Why Have I Been Referred?
While many dentists do not perform any endodontic treatment and refer all patients to endodontists, a few general dentists may perform some endodontic (root canal) treatment. However, patients are often referred to an endodontist when it has been determined that your case may be complex or requires the attention of a specialist. endodontists are specialists with advanced training and knowledge in this field. A sharp general dentist often identifies potential challenges in advance, and refers to an endodontist to avoid encountering difficulty in order to give you the best treatment outcome. It is important to recognize that you have been referred because your dentist has your best interest at heart and wants you to receive the finest endodontic care possible.
Common reasons for referral include: molar teeth or difficult canal anatomy, elusive pain diagnosis, previously root canal treated teeth, fractures, pediatrics, and trauma.
At Pomerado Endodontics, we work in close partnership with your dentist to ensure that you receive optimal care. We serve as an extension of their dental team and maintain close communication and detailed documentation of your care.
Do I Need Treatment?
Not all patients referred to us will need a root canal treatment. We will do a thorough evaluation as a proper diagnosis is utmost important. Our doctor’s expertise and state-of-the-art technology will help to determine if you need treatment. Oftentimes, we find that patients do not need root canal treatment. However, when they do need root canal treatment, we offer the most gentle and the highest quality of care as we strive to exceed expectations and ensure the best treatment outcome.
Signs and Symptoms
Common signs and symptoms may include one or more of the following: a toothache, radiating pain, prolonged sensitivity to heat or cold, discoloration of the tooth, sensitivity to biting, swelling or tenderness of the gums. Occasionally there are no symptoms and endodontic disease is detected by a loss of bone on radiographs (x-ray images). Signs and symptoms can often progress to severe intensity that requires an emergency evaluation. If patients wait too long to be seen, the tooth may go beyond saving. If you suspect that you may have an endodontic problem, it is best to seek care early before signs or symptoms have a chance to progress.
Why Would I Need Endodontic Treatment?
Endodontic treatment is necessary when the pulp becomes irreversibly inflamed or infected. The most common reasons for this are deep cavities (caries), repeated dental procedures, tooth cracks, or trauma. If irreversible pulp inflammation is allowed to progress untreated, it will inevitably progress to an infected tooth, which ultimately progresses to an infected abscess in the surrounding jawbone. Only endodontic treatment or extraction can stop this process.
How Can Endodontics Help Me?
Endodontic treatment allows you to keep a tooth that otherwise would need to be extracted. Endodontic treatment can also provide substantial relief from pain, swelling, or other symptoms. The endodontist removes the inflamed or infected pulp, carefully cleans and shapes the canal system and then seals the prepared space. Most treatment is now performed in a single appointment ranging from 30-90 minutes (depending on the number of canals). Patients can expect immediate relief after a root canal treatment but some may still have mild discomfort up to two weeks after the procedure as the tooth structure takes time to heal.
Common Treatment Types
Root Canal Treatment
A root canal is one of the most common dental procedures performed. This simple treatment can save your natural teeth and prevent the need of dental implants or bridges.
To understand root canal treatment, it helps to understand the anatomy of a tooth and its surroundings. Within the core of every tooth are hollow spaces and channels containing a soft tissue organ called the pulp. The pulp is sometimes referred to as "the nerve". Pulp tissue is largely comprised of blood vessels, nerve endings, and connective tissue. The blood vessels and nerves enter the pulp tissue through tiny openings at the tips of each root. A thin membrane called the "periodontal ligament" surrounds the entire root surface of the roots and connects the tooth to the surrounding jawbone.
The pulp is a very vulnerable tissue and can easily become diseased for a variety of reasons. Symptoms can range from none to excruciating pain. In the early stages of pulpal disease, the pulp tissue is inflamed and sensitivity to cold or hot is often the hallmark symptom. The ligament is often also inflamed causing pain when biting or chewing. Irreversible inflammation progresses to necrosis (death) and infection of the pulp. The process of necrosis often causes spontaneous pain and toothache. Infection spreads into the surrounding bone and gum tissues through the root openings, forming an "abscess". Since the blood supply no longer functions in a necrotic pulp, bacteria thrive within the confined space, safe from antibiotics or the immune system. For this reason, a tooth that has a diseased pulp should either be extracted or receive root canal treatment to eliminate this inevitable source of infection.
After a thorough examination, the endodontist, we will administer local anesthesia to eliminate discomfort. In addition, we will provide nitrous oxide analgesia or oral conscious sedation, if indicated. After the tooth is numb, a protective sheet called “dental dam” is placed over the area of interest to isolate the tooth and keep it clean and free of saliva during the procedure. This dental dam acts as a protective barrier to prevent any root canal cleaning solution or instruments from dislodging into the oral cavity. Once the plastic shield is firmly in place, the root canal procedure will begin with the access or opening of the crown portion of the tooth on the biting surface. Various small endodontic instruments are used to clean the pulp chamber and shape the root canals prior to filling the canal systems.
Root canal treatment involves the meticulous removal of diseased pulp tissue and debris. The canals are mechanically shaped and the remaining pulp spaces are chemically disinfected. Once the diseased tissue or infection is removed from within the tooth, the tissues around the tooth can heal.
After the canal systems are cleaned and shaped, the canals are sealed off with a root canal filling material called gutta-percha in order to prevent salivary bacteria from contaminating the disinfected root canal spaces. Gutta-percha is a rubber-like material that is solid at body temperature but is moldable when heated or compacted. This allows the material to form a custom seal in the root canals, and prevent the percolation of bacteria, contamination, and secondary infection.
What Happens After Treatment?
When your root canal therapy has been completed, a temporary material will be placed in the access hole of the crown. Your restorative dentist will receive a record of your treatment and radiographs. The root canal treated tooth needs to receive a permanent restoration within 2-3 weeks, a period of healing, to prevent any bacterial leakage into the recently root canal treated tooth. During this time the tooth has a temporary restoration. Please contact your restorative dentist to schedule a follow-up appointment for permanent restoration. Your restorative dentist will decide on what type of permanent restoration is necessary to protect your tooth. It is rare for endodontic patients to experience complications after routine endodontic treatment or microsurgery. If a problem does occur, however, we are available at all times to respond. To prevent further decay, continue to practice good dental hygiene. With proper root canal treatment and restoration of the tooth, healing can occur and the health of the tooth can be maintained.
Root Canal Re-Treatment
Endodontic (Root Canal) Retreatment (non surgical)
With the appropriate care, your teeth that have had root canal treatment will last as long as other natural teeth. Occasionally, a tooth that has received treatment may fail to heal or pain may continue to exist. Sometimes, the pain may occur months or years after treatment.
Common cause for failure of root canal treatment or improper healing are:
- Complicated canals or hard to find canals were not identified and treated during the initial treatment.
- Curved or narrow canals were not thoroughly cleaned.
- The crown or restoration was not placed within the appropriate amount of time following the procedure.
- Leakage of salivary bacteria contaminate the root canal due to poorly sealed root canal, cracked or poor fitting crown or filling, or through an area of new decay.
These types of issues can usually be corrected with proper retreatment (redoing root canal procedure). Part of an endodontist's evaluation is to identify the specific sources of a dental problem and to assess whether or not they will be able to correct it. Often a 3-dimensional image, or CBCT scan, is extremely useful in assessing teeth with previous endodontic treatment. The CBCT scan can detect canals that were missed, lesions, and fractured teeth not readily identifiable with traditional 2-D imaging.
The objectives of retreatment are the same as with initial root canal treatment. They are to:
- Mechanically remove debris, tissue and infection from within the canal spaces.
- Chemically disinfect the spaces and return them to a clean state.
- Seal off the spaces within the tooth with a root canal filling so that recontamination does not occur
When retreatment has been selected as a solution to your problem, the doctors will reopen your tooth to gain access to the root canal filling material so existing restoration and previous root canal needs to be disassembled. This might include removing or making an access opening through an existing crown, removing existing posts and cores, and removing previous root canal filling materials, so all canal spaces can be cleaned, disinfected, and thoroughly examined. Once all identified canals are cleaned and disinfected, the doctors will fill and seal the canals and place a temporary filling in the tooth.
At this point, you will need to return to your dentist as soon as possible in order to have a new crown or restoration placed on the tooth to restore full functionality. If the previous restoration is damaged or leaking, it will need to be replaced. A well-fitting final restoration is essential for the success of root canal treatment.
Apicoectomy (Surgical Retreatment)
Why Would I Need Endodontic Surgery?
Generally, a root canal is all that is needed to save teeth with injured pulp from extraction. Occasionally, this non-surgical procedure will not be sufficient to heal the tooth and your endodontist will recommend surgery. The endodontist retreats non-healing root canal surgically from the root-end instead of retreating through the crown of the tooth.
The following are some of the reasons why surgical retreatment would be needed:
- Large recurring infections or cystic lesions,
- Infected canal spaces that are only accessible with surgery,
- Non healing (nonsurgical) retreatment
- Locate fractures or hidden canals that do not appear on radiographs (x-rays) but still manifest pain in the tooth
- Deep post, broken or fracture instruments
- Cases where retreatment could have undesirable consequences,
- Exploratory surgery for biopsy sample
- Damaged root surfaces or the surrounding bone
The most common surgery used to save damaged teeth is an apicoectomy or root-end resection.
What Is An Apicoectomy?
During apical surgery, an incision is made in the gum tissue to expose the bone and surrounding inflamed tissue. The damaged tissue is removed along with the end of the root tip, which usually contains the source of the problem. If indicated, the infected tissue may be sent to a pathology laboratory for evaluation for oral pathology lesions that are not endodontic infections. A small tunnel is carefully parepared in the root canal and a root-end filling is placed to prevent reinfection of the root. The gum tissue is closed with sutures, which are removed in 3-6 days. With the source of the infection removed, the bone naturally heals around the root over a period of months restoring to full function.
Following the procedure, there may be some discomfort or slight swelling while the incision heals. This is normal for any surgical procedure. To alleviate any discomfort, an appropriate pain medication will be recommended. If you have pain that does not respond to medication, please call our office.
Other Types of Treatment
Cracked teeth demonstrate many types of symptoms, including pain when chewing, temperature sensitivities, or even the release of biting pressure. It is also common for pain to come and go, making it difficult to diagnose the cause of discomfort.
Chewing can cause movement of the cracked pieces of your tooth, and the pulp within the tooth becomes irritated. At the same time, when biting pressure is released, the crack can close quickly, resulting in sharp pain. Eventually, the pulp will become damaged and tooth will consistently hurt, even when you are not chewing. It is possible that cracks can lead to infection of the pulp tissue, which can spread to the bone and gum surrounding the problematic tooth.
Types of Cracks:
These are tiny cracks that only affect the outer enamel of the tooth. These cracks are more common in adults. These types of cracks are superficial and are usually of no concern.
When a cusp becomes weakened, a fracture may result. The cusp may break off or be removed by a dentist. A fractured cusp rarely damages the pulp, so root canal is not necessary. Your dentist will usually restore the tooth with a full crown.
Treatable Cracked Tooth
This type of crack extends from the chewing surface of the tooth and vertically migrates towards the root. In some cases, the crack may extend below the gum line. It is possible for the crack to extend further into the root. Damage to the pulp is commonplace. In this case, root canal treatment is usually necessary. A cracked tooth that is not treated will worsen, resulting in the loss of the tooth. Therefore, early detection is essential.
A split tooth is usually the result of an untreated cracked tooth. It can be identified by a crack with distinct segments. This type of tooth can never be saved intact. Yet, the position and extent of the problem will dictate whether any portion of the tooth can be saved. Sometimes, endodontic treatment by the endodontist and restoration by your dentist can be used to save a portion of the tooth.
Vertical Root Fracture:
A vertical root fracture begins at the root and extends towards the chewing surface of the tooth. Unfortunately, they show minimal symptoms and may go unnoticed. Treatment involves endodontic surgery if a portion of the tooth can be saved by removal of the fractured root. Otherwise the tooth will have to be extracted.
Pulpotomy is a procedure that used to be reserved for primary (baby) teeth only. With new advancements in biologic materials and advanced cleaning and disinfection, we can now treat some permanent teeth with this conservative approach. In select cases, only the pulp tissue in the upper part of the tooth (crown) is inflamed, while the tissue in the roots is healthy. We can often remove only the inflamed tissue within the crown and leave the healthy tissue in the roots. We then cover that healthy tissue with a new biologic material designed specifically for this purpose. A final restoration, a filling or crown, is placed over that. The pulpotomy procedure is normally done in one visit.
Please ask if you are a candidate for this conservative treatment.
Traumatic injuries to teeth may cause a physical, psychological and social impact in children and adolescents. Teeth may be exposed to injuries such as fractures, loosening and displacement.
Approximately 30% of the general population experience traumatic injuries to their anterior teeth every year; the main reasons being sport activities, falls and violence. Open mouth and buck teeth are predisposing factors to dental trauma.
Prevention of traumatic injuries to teeth and early and effective treatment will save time, costs and unnecessary aggravation.
An injury to the tooth-supporting structures without increased mobility or displacement of the tooth, but with pain to percussion.
An injury to the tooth supporting structures resulting in increased mobility, but without displacement of the tooth. Bleeding from the gingival sulcus confirms the diagnosis.
Partial displacement of the tooth out of its socket.
An injury to the tooth characterized by partial or total separation of the periodontal ligament resulting in loosening and displacement of the tooth. The alveolar socket bone is intact in an extrusion injury as opposed to a lateral luxation injury. In addition to axial displacement, the tooth will usually have an element of protrusion or retrusion. In severe extrusion injuries the retrusion/protrusion element can be very pronounced. In some cases it can be more pronounced than the extrusive element.
Displacement of the tooth other than axially. Displacement is accompanied by comminution or fracture of either the labial or the palatal/lingual alveolar bone.
Lateral luxation injuries, similar to extrusion injuries, are characterized by partial or total separation of the periodontal ligament. However, lateral luxations are complicated by fracture of either the labial or the palatal/lingual alveolar bone and a compression zone in the cervical and sometimes the apical area. If both sides of the alveolar socket have been fractured, the injury should be classified as an alveolar fracture (alveolar fractures rarely affect only a single tooth). In most cases of lateral luxation the apex of the tooth has been forced into the bone by the displacement, and the tooth is frequently non-mobile.
INTRUSION - INTRUSIVE LUXATION
Displacement of the tooth into the alveolar bone. This injury is accompanied by comminution or fracture of the alveolar socket.
- Clean the fractured tooth and find the broken piece.
- Apply cold compresses on the cheek from the outside if swelling is present.
- Go immediately to the dentist.
Injuries to the mouth can cause teeth to be pushed back into their sockets. Your endodontist or general dentist may reposition and stabilize your tooth. Root canal treatment is usually started within a few weeks of the injury and a medication, such as calcium hydroxide, will be placed inside the tooth. Eventually, a permanent root canal filling will be implanted.
Sometimes a tooth may be pushed partially out of the socket. Again, your endodontist or general dentist may reposition and stabilize your tooth. If the pulp remains healthy, then no other treatment is necessary. Yet, if the pulp becomes damaged or infected, root canal treatment will be required. If left untreated, many different complications can arise. These complications can include but are not limited to: Infection of the tooth, root system or surrounding tissue, inadequate hygiene due to an inability to properly clean the dislodged tooth and the gums, and loss of the tooth.
If an injury causes a tooth to be completely knocked out of your mouth, it is important that you are treated immediately! The best chance of saving the tooth is within the first 20 minutes of the accident. If this happens to you, keep the tooth moist. Handle the tooth by the crown ONLY, do not touch the root. If possible, put it back into the socket and close the mouth with a piece of gauze between the upper and lower anterior teeth.
If a tooth cannot be replanted, immediately put the tooth in cold milk, in coconut water, or water with a pinch of salt. Your tooth can be saved if it remains moist. Go immediately to the dentist. Your endodontist may start root canal treatment based upon the stage of root development. The length of time the tooth was out of your mouth and the way the tooth was stored, may influence the type of treatment you receive.
INJURIES IN CHILDREN
An injured immature tooth may need one of the following procedures to improve the chances of saving the tooth:
This procedure encourages the root to continue development as the pulp is healed. Remove inflammed pulp tissues and leave healthy pulp tissues in the canal to encourage root development. The tip of the root (apex) will continue to close as the child gets older. In turn, the walls of the root canal will thicken. If the pulp heals, no additional treatment will be necessary. The more mature the root becomes, the better the chance to save the tooth.
In this case, the necrotic pulp is removed. The doctors place medication into the root to help a hard tissue form near the root tip. This hardened tissue provides a barrier for the root canal filling. At this point, the root canal walls will not continue to develop, making the tooth susceptible to fractures. So it is important to have the tooth properly restored by your dentist.
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