Root canal treatment. Run for cover or run to the dentist?

Today's topic to be tackled is the touchy subject of root canal treatment. 

It seems to be that whenever the notion of this is mentioned to a patient they turn pale, clammy, and leave me reaching for the medical emergency drug kit. Sadly I believe along with smear tests, the MMR vaccine and Marmite, this tooth-saving therapy has been the victim of many misconceptions and media scare mongering. 

Most often I am met with "but that hurts doesn’t it?" "my cousin/friend/that woman off of *insert American sitcom here* had one of those done and they didn't get out of bed for a year" and whilst anything that requires prolonged and/or regular contact with one of us tooth workers is never the top of anyone's bucket list, it is very far removed from the nightmare people make it out to be. 

The technical bit

Again with a little help from my friends at nhs.uk a handy definition goes a little like this....."Root canal treatment is a dental procedure to treat infection at the centre of a tooth (the root canal system). Root canal treatment is also called endodontics". Professionals in the field of root canal treatments are therefore called endodontists and there may be certain situations where you need to see one of these. 

Why you need it:

Below is an x ray of some teeth (taken from www.dentistryunited.com). Just as a side note, us tooth workers refer to x ray pictures as "radiographs" so when you hear us bandying this around thinking we sound fancy, now you can nod along. 

I have added some very technical labels as you can see. 

For some reason - usually due to decay, leaking around fillings over time or due to shoddy dental work - the nerve of your tooth becomes inflamed and infected. (You may hear the nerve being referred to by us dental folk as "the pulp")

Please note: This is just one of many scenarios that lead to the need for root canal. You may also require it for things like trauma - falling off your bike, drunken brawls etc - but the basic principles of why root canal is necessary remain the same. 

At this point you may experience some sensitivity. In some cases people experience no symptoms at all but 99% of the time the story goes something like this:

 "I was in agony for a week but then it went away so I thought it was fine"

It will never be fine. There is a reason it hurt. The reason is that your nerve is dying off. 

During the nerve's demise, a tonne of bacteria and toxic chemicals from the necrotic (fancy word for dead/dying/rotten) nerve leak out the end of the tooth and start to eat away at the bone. This causes a dark area at the end of the root on an x ray (see above) and is often what leads to an abscess, or at least it has the potential to become an abscess. 

If this area of infection is left for a period of time, you may experience a lump on the gum, which feels like a blister or a gum boil, or simply a swelling of the face. This is because the infection is trapped within the bone of the jaw and has nowhere to release itself so it causes swelling. A bit like filling a balloon with water, or a really painful spot that hasn't developed that nice white head yet. 

At this stage, when the nerve has died completely, nothing except root canal work or taking the tooth out (extraction) will solve the problem. 

Yes that's right - antibiotics will not cure the problem. They help settle the infection so we can tackle it more effectively but they will not remove the cause. No. Not even bucket loads of the things will make a difference long term.

I can also advise at this point that there is almost a 100% guarantee that the time you will realise this fact is when your face balloons up (a little akin to when the Nutty Professor's magic potion wears off and he turns from Buddy Love to Sherman Klump) on Christmas Eve/New Years Eve/before you go on holiday. Sadly at these times myself, my colleagues and our non-oversized features will be eating/drinking/sunning ourselves/laughing about that person WHO THOUGHT THEY COULD GET AWAY WITH JUST ANTIBIOTICS.

The actual (post rant) technical bit.

The root canal/canal/where the nerve lies in the tooth is where we have to get to in order to do a root canal filling. The basic principles for a successful (in the eyes of our superiors who write guidelines) root treatment is to:

1.

Remove all the infected/dead nerve and bacteria from within the tooth. This is aided using certain disinfecting chemicals. For this reason, during treatment you will have to wear one of these:

Apologies for the morbid expression on this gentleman's face, I imagine inside he is feeling pure joy. 

The green sheet/frame/silver clamp around his teeth is referred to as a "rubber dam" (referred to by my Dad for several months as "a Ramadan" - yes the famous Islamic period of fasting - because apparently "that's what it sounded like when the dentist explained it")

Wearing this device means that your mucky bacteria-containing saliva doesn't get inside the nice clean tooth and re-infect it. Similarly it means that whatever chemicals we use to make the tooth squeaky clean go nowhere near the inside of your mouth. It also makes the whole process a lot more comfortable. As you can see, you also look pretty glamorous.

2.

Shape the canal where the nerve resided to a nice even conical shape with no ledges where bacteria can continue to breed. This is done using an endodontic file. These come in many shapes and sizes. They may be held by hand, or be used in a machine.

3.

Fill the canal COMPLETELY. This is the tricky bit. As you can imagine these pesky canals are very small and in order to make sure the tooth does not become reinfected, the tooth needs to be cleaned and filled right to the end of the root. 

Maybe this picture will help. 

The picture above shows a tooth with 2 roots and 2 root canals. There are generally a set of anatomical rules for teeth and root canals however as with everything in the human body, this is open to a lot of individual diversity. 

For example, upper front teeth usually have one canal and it would be very unlikely to find a front tooth that varied from this rule. However, upper first molar teeth for example should technically only have 3 root canals (one for each root) but we often find that they have 4. Similarly, for lower molar teeth, these have 2 roots but 3 root canals. 

As you are beginning to see it is quite a complicated process. 

Root filling done, what happens now

Often comes the question of what should be done with the teeth following completion of the "root canal filling" bit. Again this varies depending on which literature you read. In fact there is such debate in this field (oh yes, quite the hot potato of the dental world) that even the Cochrane review on this topic concluded "there is insufficient evidence to support or refute the effectiveness of conventional fillings over crowns for the restoration of root filled teeth". Which basically means, no one can come to an agreement. 

What cannot be refuted however, is that the tooth needs to be adequately sealed after root canal treatment (fortunately a number of scholarly people agree with this - Saunders and Saunders 1994) and in fact even way back in 1990, Torabinejad and his friends found that it only took 19 days for the entire length of the root canal to be reinfected if an adequate filling was not placed following root canal treatment. 

What this means is plain English is that you can't get away with having a root filling done and then live with a naff temporary filling for several years, or in fact months. 

If your dentist is planning on placing a crown on the tooth (which is perfectly reasonable), ensure that a good quality filling is placed, this will not be soft or crumbly. If they give you a temporary crown while your permanent one is being made, it needs to fit well, and if it falls off it should be replaced or recemented immediately. 

Finally, whilst I say this is one of the 2 options for dead (non vital in science speak) teeth it does not guarantee 100% success. This means the following:

1) If your face resembles that of the elephant man, this means there is a whopping great infection at the root of the tooth, and while we could clean it and fill it to textbook perfection, the infection means there is a reduced chance of success

2) Even if you are the "perfect" candidate for root canal treatment (e.g. an infection caught early, nice wide root canals etc) and the root filling is a thing of beauty, this does not mean the tooth will last for the entirety of your days on the planet. At best it can extend the life of the tooth for several years. Some people are very lucky and it may even outlast your human self. Others sadly find it becomes reinfected down the line however at least it buys some time so you can save up for whatever tooth replacement option you fancy. 

"Lazy dentist syndrome"

As I mentioned above, canals are very tricky to negotiate and in some cases even find. Imagine the M6 on a Friday night at rush hour/that country pub in the middle of nowhere that you thought you would try and find. 

On an x ray rather than seeing a nice black line down the centre of the tooth/root as you can in the x ray I put up earlier, you may not be able to see anything. This is due to the fact that the canal(s) have "closed off" or become blocked due to a number of things such as the natural aging process, the infection itself, previous trauma etc. We call this "sclerosis". 

In these situations a specialist endodontist would be the absolute best person to treat you and a referal to such a person can be made by your dentist. 

Sadly I have encountered several patients referred to my place of work with canals the size of the channel tunnel because apparently "no one in the practice is qualified to do root canal", I would therefore suggest you raise the question "at what point was this removed as a necessary examinable requirement OF EVERY QUALIFYING DENTIST IN THE COUNTRY".  

I am not going to go into the many clauses and stipulations of the NHS contract as it is interpretable in many ways. Each dental practice will have their own rhyme and reason for treatments they provide. They may only provide root canal therapy on a private basis however every dentist is qualified to carry it out and in my opinion should at least provide you with an honest opinion and offer to "have a go" or show you on an x ray why they believe it is not feasible for them to attempt root canal (e.g. due to sclerosis). 

Final bit of advice

As you can see, I have been rambling on for many many lines now and could continue for many more about root canal treatment (because sadly I find this all very interesting) however my final pieces of advice are:

1. Please don't wait until you are in agony to go to the dentist
2. If your filling comes out with your bacon sandwich, it will not be fine, it is never fine, please go to the dentist to have it fixed
3. Root canal fillings are an excellent treatment option and are frequently the only means of "saving your tooth"
4. They however are not 100% in any cases because your tooth is already pretty messed up from the whole rotten tooth thing
5. Therefore, please brush your teeth and keep the sugar exposures to a minimum. 

As always, ask ask ask away. If you have made it to this point I congratulate you. That's at least a years worth of lectures in one blog post. Maybe I could appeal to make it some sort of verifiable CPD......

References:

Online resource: http://www.whiterosedentalstudio.co.uk/root_canal_treatment.html

Fedorowicz Z, Single crowns versus conventional fillings for the restoration of root filled teeth.Cochrane Database Syst Rev. 2012 May 16;5

Saunders WP, Saunders EM (1994) Coronal leakage as a cause of failure in root anal therapy: a review. Endodontics and Dental Traumatology 10. 105-8

Torabinejad M. Umg B. Kettering JD  (1990) In vitro bacterial penetration of coronally unsealed endodontically treated teeth. Journal of Endodontics 16. 566