Marat Tselnik DDS

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Endodontic Basics

What is endodontics?

Endodontics is the branch of dentistry which is concerned with the study of the causes, diagnosis, prevention and treatment of the diseases of dental pulp (‘nerve’ tissue inside the tooth ) and periradicular tissues (structures around the tooth). Endodontics is one of nine dental specialties recognized by the American Dental Association

Who are endodontists?

Endodontists are specialist dentists who have completed a minimum of two years of additional training in the field of endodontics. In addition to performing a wide variety of endodontic procedures, endodontists are also trained to investigate and diagnose the cause of oral and facial pain not directly related to root canal disease (e.g. sinusitis, migraines and other headache types, neuralgias, etc). Most endodontists in the United States are specialist members of the American Association of Endodontists. Although your general dentist can perform basic endodontic treatment, patients are often referred to a specialist endodontist for more complex cases.

What does it mean if your endodontist is a Diplomate of the American Board of Endodontics?

The purpose of the American Board of Endodontics is to assure the public that the endodontists it certifies have demonstrated exceptional knowledge, skill, and expertise in the specialty of endodontics. By achieving Diplomate status, the endodontist shows great motivation and exceptional commitment to continuing professional growth. To become Board Certified the endodontist has completed ADA accredited postdoctoral program and demonstrated high moral, ethical and professional qualifications. In addition, the endodontist passed a three-step arduous examination process:

  • The Written Examination tests a broad range of fields, including anatomy, biochemistry, pathology, immunology, microbiology, pharmacology, radiology, statistics, clinical endodontics and related disciplines.
  • The Case History Examination requires submission of documentation of a variety of cases from the endodontist’s own practice. The cases must be diverse and complex enough to demonstrate exceptional knowledge, skills, and expertise in the full scope of the field of endodontics.
  • The final phase of the Board Certification process is an Oral Examination. In the Oral Examination, a team of experts question the endodontist about a variety of endodontic diagnosis and treatment situations. Through the extensive interviews, a high level of skill in problem solving, decision making, analysis, creativity and evaluation must be demonstrated.

What is endodontic (root canal) disease?

To understand endodontic treatment it helps to know something about the anatomy of the tooth. The bulk of tooth structure is composed of dentin. The crown part of the dentin is covered by a white hard layer of enamel. Inside the dentin is a soft tissue called the pulp. The pulp extends from the crown of the tooth to its root tips and it contains blood vessels, nerves and connective tissue. The pulp creates the surrounding hard tissues of the tooth during development and is very important during tooth growth. However, once a tooth is fully mature it can survive without pulp.

Endodontic treatment is necessary when the pulp becomes inflamed or infected. The inflammation or infection can have a variety of causes: tooth decay, tooth cracks, trauma, or repeated dental procedures on the tooth. If pulp inflammation or infection is left untreated, it can cause pain or lead to an abscess, and, potentially, a loss of the tooth. Signs of pulp damage may include prolonged sensitivity to cold or heat, tooth discoloration and swelling or tenderness in nearby gums. Sometimes, there are no symptoms

What is a non-surgical root canal treatment?

Once the need for endodontic treatment has been ascertained via a thorough diagnostic evaluation, the endodontist will numb the area with local anesthetic. After verifying that you are completely numb, a small protective sheet called “dental dam’ is placed over the tooth to isolate it from bacterial contamination from saliva. The endodontist will then make an opening through a chewing surface of the tooth to gain access to the pulp tissue inside the canal spaces. Very small instruments are used to remove the pulp from the pulp chamber and root canals, and to shape the space for filling. Various disinfecting solutions will also be used during the cleaning process to improve the cleansing and disinfecting of root canal spaces.

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 coated with an adhesive cement to ensure complete sealing of the root canals. In most cases, a temporary filling is placed to cover the access opening. The temporary filling will be removed by your dentist before the tooth is restored.

After the final visit with your endodontist (endodontic treatment may infrequently require a second visit), 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 this is not done within a few weeks of the root canal treatment, the treated tooth may break and it may need to be extracted.

What is a non-surgical root canal retreatment?

With proper care, most endodontically treated teeth can last as long as other natural teeth. In some cases, a tooth that has receive endodontic treatment fails to heal, or becomes diseased months or even years after successful treatment. This may occur for a number of reasons: narrow canals or complicated anatomy not cleaned out during initial treatment, delayed placement of the permanent restoration after initial treatment or the permanent restoration not preventing salivary contamination. Also, new decay, tooth cracks, or loose or broken fillings can expose the root canal filling material to bacteria, causing a new infection in the tooth

As with the primary root canal treatment, the tooth will be numbed and the rubber dam placed. In many cases, complex restorative materials – crown, post and core – must be removed to permit access to the root canals. After removing the canal filling, the endodontist can disinfect the canal spaces and carefully examine the inside surfaces for any additional canals, perforations, fractures and decay using microscope magnification and fiberoptic illumination. If the tooth is deemed restorable (no catastrophic fractures or decay), the root canals are filled and the treatment is finished in the same fashion as during the primary endodontic treatment and the access is sealed with a temporary filling. As with the primary treatment, you must return to your dentist as soon as possible to have a crown or other restoration placed on the tooth to protect and restore it to full function.

While non-surgical retreatment can usually be utilized to address failing primary treatment, there are some situations where proper retreatment cannot be accomplished with a desired outcome. These include:

  • Complex restorations with large posts may not be amenable to removal without fracturing the root. Thus access into root canals cannot be gained
  • Complex internal anatomy prevents adequate disinfection of root canal spaces
  • Retreatment has been completed without desired healing.

In those situations, endodontic surgery may save the tooth.

What is a surgical root canal treatment?

Surgery can help save your tooth in a variety of situations.

  • It may be used to remove anatomy at root tips which could not be adequately cleaned during non-surgical treatment due to blockages
  • It may aid in diagnosis of a problem not immediately apparent on your x-rays (root fractures or accessory canal spaces)
  • It may aid in treating damaged root surfaces and surrounding bone.

Although there are many surgical procedures that can be performed to save a tooth, the most common is called apicoectomy or root-end resection. When inflammation or infection persists in the bone around the root tip after a root canal procedure, an apicoectomy may need to be performed.

In this procedure, the endodontist opens the gum tissue near the tooth to remove any inflamed or infected tissue. The root end is also removed and the resected root surface is examined for fractures. A small filling is then placed to seal the end of the root canal and sutures are placed to help the gum tissue heal properly.

Do cracked teeth need endodontic treatment?

Nowadays, people are living longer and more stressful lives, often exposing their teeth to many more years of crack-inducing habits, such as clenching, grinding, and chewing on hard objects. Cracks through the outer hard tissues of the tooth introduce a pathway for bacteria from saliva to encroach upon the pulp and irritate it. If the cracks are not discovered and treated promptly and the pulp is irritated repeatedly, it may become damages to the point that it can no longer heal itself. The tooth may not only hurt to chewing, but also become sensitive to heat or cold and, in time, develop an infection.

There are many different types of cracks and the majority of them initiate in the crown part of the tooth. These include craze lines and fractured cusps. The craze lines are very common defect in outer enamel layers and do not require any treatment. Fractured cusps rarely damage the pulp, so the root canal treatment is seldom needed. The tooth will usually be restored by your dentist with a full crown.

Crown-root fractures are cracks that originate in the crown and may extend into the root. The pulp often gets damaged in these situations, requiring root canal treatment. If the crack extends below the gum line, the tooth may not be restorable and require extraction.

Other types are fractures may begin at the root tip and extend towards the chewing surface. These are called vertical root fractures. They usually show minimal signs and symptoms and may therefore go unnoticed for some time. Vertical root fractures are often discovered when the surrounding bone and gums get infected. Treatment usually involves extraction of the tooth, although the tooth may be saved sometimes with surgical removal of the fractured root portion.

Unlike a broken bone, the fracture in a cracked tooth will never heal. A cracked tooth that is not treated will progressively worsen and may be lost eventually. Early diagnosis and treatment are important in saving these teeth. Once treated, most cracked teeth will continue to function for years to come.

Do trauma to teeth require endodontic treatment?

Treatment depends on the type, location and severity of each injury. Any dental injury, even if apparently mild, requires examination by a dentist or an endodontist immediately. Sometimes, neighboring teeth suffer an additional, unnoticed injury that will only be detected by a thorough dental exam.
The most common type of tooth trauma results in a crown chip or a fracture. If the pulp is not exposed, the tooth can be restored with a tooth colored filling or a crown. Root canal treatment is usually not necessary. However, root canal treatment may be necessary if the pulp is exposed or damaged after a crown fracture on most fully formed adult teeth.

During an injury, a tooth may be pushed sideways, out of or into its socket. Your endodontist or general dentist will reposition and stabilize your tooth. Root canal treatment is usually needed for permanent teeth that have been dislodged and should be started a few days following the injury. Children between seven and 12 years old may not need root canal treatment since their teeth are still developing. For those patients, an endodontist or dentist will monitor the healing carefully and intervene immediately if any unfavorable changes appear. Therefore, multiple follow-up appointments are likely to be needed. New research indicates that stem cells present in the pulps of young people can be stimulated to complete root growth and heal the pulp following injuries or infection.

If a tooth is completely knocked out of your mouth, time is of the essence. The tooth should be handled very gently, avoiding touching the root surface itself. If it is dirty, quickly and gently rinse it in water. Do not use soap or any other cleaning agent, and never scrape or brush the tooth. If possible, the tooth should be placed back into its socket as soon as possible. The less time the tooth is out of its socket, the better the chance for saving it. Call a dentist immediately!

If you cannot put the tooth back in its socket, it needs to be kept moist in special solutions that are available at many local drugstores (such as Save-A-Tooth). If those solutions are unavailable, you should put the tooth in milk. Doing this will keep the root cells in your tooth moist and alive for a few hours. Another option is to simply put the tooth in your mouth between your gum and cheek. Do not place the tooth in regular tap water because the root surface cells do not tolerate it.
The nature of the injury, the length of time from injury to treatment, how your tooth was cared for after the injury and your body’s response all affect the long-term health of the tooth. Timely treatment is particularly important with dislodged or knocked-out teeth in order to prevent root resorption.
Resorption occurs when your body, through its own defense mechanisms, begins to reject your own tooth in response to the traumatic injury. Following the injury, you should return to your dentist or endodontist to have the tooth examined and/or treated at regular intervals for up to five years to ensure that root resorption is not occurring and that surrounding tissues continue to heal. It has to be noted that some types of resorption are untreatable.

All images on this page were reproduced with permission from the American Association of Endodontists