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Root Canal PDF Print E-mail

Root canal

Root canal procedure: unhealthy tooth, drilling, filing with endofile, rubber filling and crown
Root canal procedure: unhealthy tooth, drilling, filing with endofile, rubber filling and crown

Root canals are the long passages full of soft tissue deep within the dentin of a tooth, adjoining the pulp chamber. In dentistry, a pulpectomy is an endodontic treatment to cure an infection of the root canal; informally a root canal. A root canal, coupled with internal tooth bleaching, is also used to fix teeth that have blackened because of infiltration of decayed soft tissue into the dentin in the teeth, most often seen in incisors ( a type of front tooth) that have been injured through a sudden impact.

Contents

  • 1 Tooth structure
  • 2 Root canal treatment
  • 3 Innovation
  • 4 Failure
  • 5 Systemic issues
  • 6 Advice for patients requiring root canal treatment
  • 7 List of root canal irrigants
  • 8 References
  • 9 See also
  • 10 External links

 

Tooth structure

At the center of a tooth is a hollow area that houses soft tissue, known as pulp. This hollow area contains a relatively large space towards the chewing surface of the tooth called the pulp chamber. This pulp chamber is connected to the tip of the tooth root via thin hollow pipe-like canalshence, the term "root canal". Human teeth normally have one to four canals, with teeth toward the back of the mouth having the greatest number. These canals run through the centre of the roots like pencil lead runs through the length of a pencil. The tooth receives nutrition and sensory function through the blood vessels and nerves traversing these canals. Occasionally, a cavity on the outer surface of the tooth may cause this soft tissue to become inflamed or infected. Left untreated, a serious jaw infection can result. The infection and inflammation is very painful in most cases. Treatment is available and should take place before this happens.

 

Root canal treatment

In the situation that a tooth is considered so threatened (because of decay, cracking, etc.) that future infection is considered likely or inevitable, a pulpectomy, removal of the pulp tissue, is advisable to prevent it. Usually, some inflammation and/or infection is already present within or below the tooth. To cure the infection and save the tooth, the dentist drills into the pulp chamber and removes the infected pulp by scraping it out of the root canals. Once this is done, the dentist fills the cavity with an inert material and seals up the opening. This procedure is known as root canal therapy. If enough of the tooth has been damaged, or removed as a result of the treatment, a crown may be required.

The standard filling material is Gutta-percha, a thermoplastic polymer of isoprene, which is melted and injected to fill the root canal passages. Barium is added to the isoprene so the material will be opaque to X-rays, allowing verification afterwards that the passages have been properly completely filled in, without voids.

Lower right first molar (center) after root canal therapy and crown: right-most two nerves have incomplete root canal and may need further therapy.
Lower right first molar (center) after root canal therapy and crown: right-most two nerves have incomplete root canal and may need further therapy.

For patients, root canal therapy is one of the most feared procedures in all of dentistry; however, dental professionals assert that modern root canal treatment is relatively painless because the pain can be controlled. Lidocaine is a commonly used local anesthetic. Pain control medication may be used either before or after treatment. However, in some cases it may be very difficult to achieve pain control before performing a root canal. For example, if a patient has an abscessed tooth, with a swollen area or "fluid-filled gum blister" next to the tooth, the pus in the abscess may contain acids that inactivate any anesthetic injected around the tooth. In this case, it is best for the dentist to drain the abscess by cutting it to let the pus drain out. Releasing the pus releases pressure built up around the tooth; this pressure causes much pain. The dentist then prescribes a week of antibiotics such as penicillin, which will reduce the infection and pus, making it easier to anesthetize the tooth when the patient returns one week later. The dentist could also open up the tooth and let the pus drain through the tooth, and could leave the tooth open for a few days to help relieve pressure.

At this first visit, the dentist must ensure that the patient is not biting into the tooth, which could also trigger pain. Sometimes the dentist performs preliminary treatment of the tooth by removing all of the infected pulp of the tooth and applying a dressing and temporary filling to the tooth. This is called a "pulpectomy". The dentist may also remove just the coronal portion of the dental pulp, which contains 90% of the nerve tissue, and leave intact the pulp in the canals. This procedure, called a "pulpotomy", tends to essentially eliminate all the pain. A "pulpotomy" may be a relatively definitive treatment for infected primary teeth. The pulpectomy and pulpotomy procedures eliminate most all pain until the follow-up visit for finishing the root canal. But if the pain returns, it means any of three things: the patient is biting into the tooth, there is still a significant amount of sensitive nerve material left in the tooth, or there is still more pus building up inside and around the infected tooth; all of these cause pain.

Lower right first molar (center) after root canal therapy, this time complete and without crown
Lower right first molar (center) after root canal therapy, this time complete and without crown

After removing as much of the internal pulp as possible, the root canals can be temporarily filled with calcium hydroxide paste. This strong alkaline base is left in for a week or more to disinfect and reduce inflammation in surrounding tissue [1]. Ibuprofen taken orally is commonly used before and/or after these procedures to reduce inflammation.

After receiving a root canal, the tooth should be protected with a crown that covers the cusps of the tooth. Otherwise, over the years the tooth will almost certainly fracture, since root canals remove tooth structure from the tooth and undermine the tooth's structural integrity. Also, root canal teeth tend to be more brittle than teeth not treated with a root canal. This is commonly due to the fact that the blood supply to the tooth, which nourishes and hydrates the tooth structure, is removed during the root canal procedure, leaving the tooth without a source of moisture replenishment. Placement of a crown or cusp-protecting cast gold covering is recommended also because these have the best ability to seal the root canaled tooth. If the tooth is not perfectly sealed, the root canal may leak, causing eventual failure of the root canal. Also, many people believe once a tooth has had a root canal it cannot get decay. This is not true. A tooth with a root canal still has the ability to decay, and without proper home care and an adequate fluoride source the tooth structure can become severely decayed without the patient's knowledge since the nerve has been removed, leaving the tooth without any pain perception. Therefore it is very important to have regular X-rays taken of the root canal to ensure that the tooth is not having any problems that the patient would not be aware of.

The procedure is often complicated, depending on circumstances, and may involve multiple visits over a period of weeks. The cost is high, by local standards. In the United States, it would typically cost US$400-1,000though exceeded by the even more expensive related crown procedure, typically around US$500-1,500 with usually only 50% being covered by the dental insurer (DMO or DPO). In India, the root canal procedure would typically cost INR 1,500-4,500, when performed by an endodontist and the crown procedure, for a ceramic crown, would cost around INR 2,000-5,000.

 

Innovation

In the last ten to twenty years, there have been great innovations in the art and science of root canal therapy. Dentists now must be educated on the current concepts in order to optimally perform a root canal. Root canal therapy has become more automated and can be performed faster, thanks to advances in automated mechanical instrumentation of teeth and more advanced root canal filling methods. Dentists also possess newer technologies that allow more efficient, scientific measurements to be taken of the dimensions of the root canal that must be filled. Many dentists use microscopes to perform root canals, and the consensus is that root canals performed using microscopes or other forms of magnification are more likely to succeed than those performed without them. Although general dentists are becoming versed in these advanced technologies, they are still more likely to be used by specialist root canal doctors (known as endodontists). Dr. Arnaldo Castellucci, an Italian dentist, has recently authored a three-volume treatise on endodontics which thoroughly covers these modern concepts.

Laser root canal procedures are a controversial innovation. Lasers may be fast but have not been shown to thoroughly disinfect the whole tooth[2], and may cause damage [3].

 

Failure

Root canal treatments can fail. Patients should be educated on some of the reasons why root canals may fail. They may fail if the dentist does not find, clean and fill all of the root canals within a tooth. For example, on a top molar tooth, there is a more than 50% chance that the tooth has four canals instead of just three. But the fourth canal, often called a "mesio-buccal 2", tends to be very difficult to see and often requires special instruments and magnification in order to see it. So it may be missed, and this infected canal may cause a continued infection or "flare up" of the tooth. Any tooth may have more than one canal, which may be missed while performing the root canal. Sometimes the canal may be unusually shaped, making it impossible to fill it completely, so that some infected material is still left in the canal. Sometimes the canal filling does not extend deeply enough into the canal, or it does not fill the canal as much as it should. Sometimes a tooth root may be perforated while the root canal is being performed, making it difficult to fill the tooth. The hole may be filled with a material derived from natural cement called "MTA", although usually a specialist would perform this procedure. Fortunately, a specialist can often re-treat and definitively heal up these teeth, often years after the initial root canal procedure.

Sometimes a tool can break while it is in the tooth. If the the tip of a spiral metal file used by the doctor breaks off during the procedure, it is usually left behind and not extracted, leaving the patient with a small amount of retained metal. The occurrence of this event is proportional to the narrowness, length, and number of roots on the tooth being treated. Complications resulting from retained metal are not well studied, but the occurrence of tool breakage is well documented [4].

 

Systemic issues

An infected tooth may endanger other parts of the body. People with special vulnerabilities, such as prosthetic joint replacement or mitral valve prolapse, may need to take antibiotics to protect from infection spreading during dental procedures. Both endodontic therapy and tooth extraction can lead to subsequent jaw bone infection. The American Dental Association (ADA) asserts that any risks can be adequately controlled [5].

Recent studies indicate that substances commonly used to clean the interior of the tooth provide a low overall chance of succeeding in completely sterilizing a tooth internally [6]; however, a properly restored tooth following root canal therapy yelds long-term success rates near 97% (Salehrabi R. Rotstein I. Endodontic treatment outcomes in a large patient population in the USA: an epidemiological study. Journal of Endodontics. 30(12):846-50, 2004 Dec.).

Since 2006, two independent studies have used PCR to identify methanogenic Methanobrevibacter oralis-like species in root canal infections.[citation needed]

 

Advice for patients requiring root canal treatment

If a tooth requires root canal treatment it is unlikely that any other form of therapy (other than extraction of the tooth) will be successful in the long term.

In the short term, for controlling pain and discomfort, many over the counter NSAIDs (non-steroidal anti-inflammatory drugs) such as ibuprofen can be used.

In certain cases (if prescribed by the dentist) antibiotic therapy may be of benefit to control a severe infection of the tooth.

Despite popular belief to the contrary, modern root canal treatment can be performed quite comfortably. Avoiding or delaying the treatment can reduce the chances of a positive outcome for the infected tooth.

The most recent medium-scale (~200) patient followup study from the Journal of the American Dentistry Association was published in 1996 [7].

 

List of root canal irrigants

The following substances are used as root canal irrigants during the root canal procedure:

  • 5.25% sodium hypochlorite (NaOCl)
  • 2% chlorhexidine gluconate
  • 0.2% chlorhexidine gluconate plus 0.2% cetrimide (Cetrexidin)
  • 17% Ethylenediaminetetraacetic acid (EDTA)
  • framycetin sulfate (Septomixine)

From Wikipedia, the free encyclopedia

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Please help improve this article by adding citations to reliable sources. (help, get involved!)
Any material not supported by sources may be challenged and removed at any time. This article has been tagged since January 2007.

 

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