Root Canal

Root Canal (a.k.a Endodontic therapy)

Endodontic therapy is a sequence of treatment for the pulp of a tooth whose end result is the elimination of infection and protection of the decontaminated tooth from future microbial invasion.

Pulpal problems (Root Canal Problems)

What happen if you leave a tooth with cavity untreated? The cavity will get bigger and bigger, spreading from the surface enamel layer to deeper dentin layer, then eventually into the pulp space. Does it hurt as the cavity spread, you may wonder? It may or it may not! Many patients with cavity that affects the dentin layer will experience sensitivity when they eat sweet stuffs or when they drink cold liquids. However, equally many patients presented to me with huge cavity, which has affected the pulp, did not have any pain or any symptoms at all! Why different people response differently? I don抰 know. It may be related to the strength of the immune system the individual has or it may depend on how an individual responses to pain. Many people have the idea that if nothing bothers me now, why should I go to see the dentist? This is one of the reasons why you need a regular checkup, as cavity may not give you any symptoms. As I mentioned earlier, if cavity just affects the enamel and dentin layer, a direct restoration (a filling) usually suffices. However, if cavity has got so big or so deep that it affects the pulp, a filling will not be enough. Why? It is because the pulp has the blood vessels and nerve. When the pulp is affected, it will go into a chain of reactions what we call inflammation. Think about when you hurt your finger by carelessly stabbed it with an object and it got red, swelling, pain, and quite hot around the area. That is inflammation. When inflammation happens, blood supply to that area will increase, so you抣l see red and hot area (because of the blood), swelling because blood and body liquids accumulate, which builds up pressure (that gives you pain). Now let抯 bring the picture of inflammation in the dental pulp environment. When you just remove the cavity and filled the hole with a filling, while the pulp chamber inside the tooth core has inflammation. Blood is gushing into the pulp but it has a limited space! Pressure will go up, and up, and up until the pressure is so high that it pinches onto the nerve in the pulp. That is why dental pain can become so excruciating! Sometimes it is less painful if the cavity is bigger that it actually creates a big hole to let the pulp communicate with the surface of the tooth.

Procedure of Root Canal Treatment:

So now, what are the treatment options? One is to take out the tooth completely (extraction) as so commonly practiced in the third world countries or poor populations because it is the cheapest and quickest option. The other option is to carry out a procedure called root canal therapy. How do dentists perform root canal therapy? In brief, they drill a hole from the surface of the tooth into the core of the tooth where the pulp is located. Once they get an access to the pulp, they can clean up all the tissues there, including the nerve, the blood vessels. Now the pulp space becomes hollow and clean, ready to be filled with some rubbery material called gutta percha.

You can imagine that once the root canal therapy is finished, the tooth is devoid of blood supply and nerve supply, what dentists call a non-vital tooth (non-living). Why my dentist tell me I need root canal therapy even though the tooth does not bother me at all?
As I mentioned earlier, sometimes the tooth has cavity deep into the pulp but the patient can experience no pain at all. What will happen to the tooth if this situation goes on? The tooth responses to cavity in a different way. Rather than going into inflammation, the pulp just silently dies out. Now the tooth becomes non-vital because the blood vessels and nerve gradually shrink and become necrotic (rotten in a sense). This rotten pulp can be there for quite some time until the tooth comes to haunt you again. How can you tell one tooth is non-vital and has a rotten pulp? You can抰! But your dentist can tell when he/she carries out some specific tests on the tooth. One of the tests is to put some very cold object onto the tooth and ask the patient if he can feel the coldness from that tooth. A healthy tooth normally can tell the coldness but as long as the object is put away, the coldness disappears. A tooth that goes into inflammation will sense the coldness in a dramatic way and the coldness or discomfort can linger for a few minutes, sometimes for hours, when the object is put away. For a non-vital tooth with necrotic pulp, the patient will not feel the object to be cold at all. Same is for the tooth that has had root canal therapy, because in both situations, the tooth is non-vital (non-living). But there is a fundamental difference between the two. The root canal treated tooth has a clean and filled pulp space, while the tooth with a necrotic pulp has rotten tissues inside to harvest the bacteria. In other words, now the pulp is infected even thought it does not bother the patient at the moment. What if the tooth is left untreated in this situation? The bacteria will keep growing inside the pulp space in a situation similar to a covered garbage can with all the rotten stuffs inside. You cannot sense (feel) the foul smell (the infection) yet, but this situation will not last too long. Gradually, the infection will spread beyond this garbage can (the pulp space) to the environment (the alveolar bone that anchors the tooth). Again when this happens, the body responses differently among different people, or even among different teeth in the same individual. Some tooth will give you severe pain when you now touch the tooth or when you bite down or just pain constantly. Some tooth in this situation will not give you pain, at least not yet for now, but it will cause the surrounding alveolar bone which next to the tooth抯 root tip to dissolve. Why? Because now a balloon-like structure will start forming around the exit of this garbage can (at the root tip) which displaces the bone in its way. This balloon-like structure is called a cyst or a granuloma (a small tumor).

This structure will stay the same size or get bigger gradually in the course of time until one day; there comes a severe pain from that tooth. This is often when the person will go to see a dentist for treatment because the pain has become so intolerable. What is the treatment for now? The same as before: either root canal therapy or extraction of this tooth. However, the success rate of root canal therapy in this situation will become slimmer. In other words, the chance of saving this tooth will be less and often the tooth will be painful for a while even after the attempt of root canal therapy. Therefore, the patient normally has less motivation of saving the tooth because they experience more pain during and after the root canal treatment.

In some extreme situations, the patient with a necrotic tooth will not give you the above picture. The infection gradually spreads into an extensive area in the jaw bone and the adjacent tissues silently at first. Then one day, the patient’s face will swell up with severe pain that he/she will be admitted to the hospital as an emergency. This situation can become life threatening if not managed promptly. In this situation, the troubled tooth will be extracted. Sometimes the swelling is so bad that the patient cannot even breathe normally and open his/her mouth for the caregiver to extract the culprit. As an emergency treatment, the physician may need to make some incision on the patient抯 throat or cheek to get access.

Regular checkups can prevent root canal therapy and expensive bills:

I hope none of my patients will ever get to any of these stages. Theoretically, if preventive dentistry is implemented, root canal therapy should never be needed (I should never say never, someone told me). Whenever a tooth has started a cavity, if detected early enough, a simple filling is all what it needs at most. Simple direct filling is much, much cheaper and less time consuming than extensive restorations such as root canal therapy and crowns and bridges. My patients too often tell me that they did not come earlier for checkup cleaning because they are not lucky enough to have dental insurance coverage like other people. What is my answer? I will say just because you do not have dental insurance coverage, the more you need to have regular dental checkup and cleaning so that no expensive dental treatment you will ever need! How much will it cost you, if you do not have dental insurance, to have a checkup and cleaning once a year in a dental office? About $200 to $300. You may need one or two fillings now and then, which costs you another $100 or $200. But this won’t happen every year if you have a reasonable oral hygiene at home. How much for an average person spends in hair salon for taking care of his/her hair? I don’t you. But my guess would be about $200-$300 per year. Think about those people with dental insurance, how much they normally pay for premium each month for coverage? Probably $30 at least (that is $360 a year!). They may not notice this amount because normally their paychecks have already been deducted with the dental insurance premium. They are not much luckier than you. What if you don’t go to see a dentist for 5 years, how much you have saved? $200 times 5 equals $1000. But after five years, now you have an emergency because the tooth is hurting you. How much will this tooth cost you if you want to save this tooth? Root canal therapy and a crown equals to $2000 dental bill! And the tooth is not as good as the one with no filling or just a small filling in it. How about you have two teeth now need these expensive treatments? How about if you have gum disease because your mouth has not been cleaned for 5 years and is now full of plaque and calculus (tartar)? You now need a full mouth deep root cleaning (called root planing), which can cost you at least $1000 to $1500 and you may need three to four cleaning appointments, and often local anesthetics (needles) is required for this treatment!

Sometimes, money cannot make up what you have lost!

I have not included the costs of having a severe toothache one day and the loss of works because of it. I have not included the costs of forfeiting yourself the pleasure of enjoying a sense of wellbeing in your dental health and the confidence of a beautiful smile! Do you get my point?

However, most people do not see my point. They will argue that not everyone who does not go to see a dentist will have gum problems, or severe decayed teeth. The problem is that you don’t know whether you are or will be the lucky one! Let me ask you: do you buy life insurance? Disability insurance? Car insurance? House insurance? Why do you still pay money for these if you may be the lucky one that never needs to claim for these insurances? Do you know the chance of you to claim for any of these insurances is much smaller than the chance you will get a cavity in your mouth in the coming year? How do I know? Because scientific studies have shown that cavity is the most prevalent infectious disease in humankind!

Some people may argue that even if they visit their dentists every year, they still need a crown or root canal therapy from time to time. There are two main possibilities to explain this phenomenon:

  1. You have some teeth that have had big fillings before and now these fillings have served their time. Remember I mentioned earlier that direct fillings are not long lasting as crowns? In this case, you are just paying the prices for your dental neglects in the past, where cavity was not prevented when it started small in the first place.
  2. Your dentist did not diagnose cavity early enough when the tooth just needed a small filling. Misdiagnosis or negligence in diagnosis of a dental problem can be due to incompetence of your dentist, his/her practice philosophy (that is not emphasizing prevention dentistry) or lack of use of updated dental equipment (for example taking enough but necessary dental x-rays). Sometimes it is the objection from patients to let the dentist take enough dental x-rays for appropriate diagnosis. More often, it is due to oversight of the dentists themselves. In this case, it may be time for you to switch to a better dentist.