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 PROCEDURES

Introduction

As an endodontic patient, what should I expect?

A comprehensive examination to diagnose orofacial pain and pulpal injury and determine if the tooth is a good candidate for endodontic therapy.

Non-surgical treatment to eliminate the diseased pulp. This injured pulp is removed and the root canal system is thoroughly cleaned and sealed.

Under certain circumstances, microsurgery may be indicated. We are experts in performing this procedure, and utilize sophisticated equipment to ensure the best result.

Non Surgical Root Canal Treatment

What is a root canal?

A root canal (endodontic treatment) is one of the most common dental procedures performed, with more than 14 million performed every year. This simple treatment can save your natural teeth and prevent the need of dental implants or bridges.
 

At the center of your tooth is the pulp. The pulp is a collection of nerves and blood vessels that helps to build the surrounding tooth during childhood.  Once the tooth is fully mature, the pulp merely serves as a surveillance system for problems i.e., cracks, cavities etc.  Infection of the pulp can be caused by trauma to the tooth, deep decay, cracks and chips, or repeated dental procedures. Symptoms of the infection can be identified as visible injury or swelling of the tooth, sensitivity to temperature or pain in the tooth and gums.

How is a root canal performed?
If you experience any of these symptoms, your dentist will most likely recommend non-surgical treatment to eliminate the diseased pulp. This injured pulp is removed and the root canal system is thoroughly cleaned and sealed. This therapy usually involves local anaesthesia and may be completed in one or more visits depending on the treatment required. Success for this type of treatment occurs in about 95% of cases, in our office. If your tooth is not amenable to endodontic treatment or the chance of success is unfavourable, you will be informed at the time of consultation or when a complication becomes evident during or after treatment. We use local anaesthesia to eliminate any discomfort.

The Endodontic Procedure "root canal" involves the following stages:

1. The endodontist examines the tooth and x-ray films. Once the need for treatment is confirmed, local anesthetic is administered. After the tooth is fully anesthetized (numb), the endodontist places a small, protective sheet called a "dental dam" over the area to isolate the tooth and keep it clean and free of saliva during the procedure.

 

2. An opening will be made in the crown of the tooth. Very small instruments are used to clean the pulp from the pulp chamber and root canals and to shape the space for filling.

 

3. 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 placed with an adhesive cement to ensure complete sealing of the root canals. In most cases, a temporary filling is placed to close the access opening.

The temporary filling will be removed by your dentist prior to placing the final restoration.
If the tooth lacks sufficient structure to hold the restoration in place, your dentist or endodontist may place a post inside the tooth. Ask your dentist or endodontist for more details about the specific restoration planned for your tooth.

 


4. After the final visit with your endodontist, you must return to your restorative dentist to have a crown or other restoration placed on the tooth to protect and restore it to full function.

 

 

Endodontic Retreatment - A second chance to save your tooth

With the appropriate care, your teeth that have had endodontic treatment will last as long as other natural teeth. Yet, a tooth that has received treatment may fail to heal. If your tooth has failed to heal or has developed new problems, you have a second chance. Another endodontic procedure, called retreatment, may be able to save your tooth.

Why do I need another endodontic procedure?


As occasionally happens with any dental or medical procedure, a tooth may not heal as expected after initial treatment for a variety of reasons:
  • Narrow or curved canals were not treated during the initial procedure.
  • Complicated canal anatomy went undetected in the first procedure.
  • The crown or other restoration was not placed soon enough after the procedure.
  • The restoration did not prevent saliva from contaminating the inside of the tooth.

In other cases, a new problem can jeopardize a tooth that was successfully treated. For example:

  • New decay can expose the root canal filling material to bacteria, causing a new infection in the tooth.
  • A loose, cracked, or broken crown or filling can expose the tooth to new infection.
  • Trauma causing root fracturing.
  • Coronal leakage.



What will happen during the endodontic retreatment?
First, the endodontist will discuss your treatment options. If you and your endodontist choose retreatment, the endodontist will reopen your tooth to gain access to the root canal filling material.

In many cases, complex restorative materials - crown, post, and core material - must be disassembled and removed to permit access to the root canals.

After removing the canal filling, the endodontist can clean the canals and carefully examine the inside of your tooth, searching for any additional canals or unusual anatomy that requires treatment.

After cleaning the canal(s), the endodontist will fill and seal the canal(s) and place a temporary filling in the tooth. Post space may also be prepared at this time.

After the final visit with your endodontist, you will need to return to your dentist as soon as possible to have a new crown or other restoration placed on the tooth to protect and restore it to full function.

If the canals are unusually narrow or blocked, your endodontist may recommend endodontic surgery. This surgery involves making an incision near the end of the root to allow the tip of the root to be sealed.


What are the alternatives to retreatment?
For some patients considering retreatment, endodontic surgery is also an option. This surgery involves making an incision near the end of the root to allow the tip of the root to be sealed. Endodontic surgery may be recommended in conjunction with retreatment or as an alternative. Your endodontist will discuss your options and recommend appropriate treatment.

The only other alternative is extraction of the tooth. The extracted tooth must then be replaced with an implant, bridge, or removable partial denture to restore chewing function and to prevent adjacent teeth from shifting. Because these options require extensive surgery or prosthetic procedures on adjacent healthy teeth, they can be far more costly and time consuming than retreatment and restoration of the natural tooth.

No matter how effective modern tooth replacements are - and they can be very effective  nothing is as good as your natural tooth. You've already made an investment in saving your tooth. The payoff for choosing retreatment could be a healthy, functioning natural tooth for many years to come.

Endodontic Microsurgery

Why would I need endodontic surgery?

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

  • Surgery may be used in determining a diagnosis. If you have persistent symptoms but no problems appear on your x-ray, your tooth may have a tiny fracture or canal that could not be detected during non-surgical treatment. In such a case, surgery allows your endodontist to examine the root of your tooth, find the problem, and provide treatment.
  • Sometimes calcium deposits make a canal too narrow for the cleaning and shaping instruments used in non-surgical root canal treatment to reach the end of the root. If your tooth has this "calcification," your endodontist may perform endodontic surgery to clean and seal the remainder of the canal.
  • Surgery may also be performed to treat damaged root surfaces or surrounding bone.
  • Surgery may be needed to treat fractured or perforated teeth.
  • Surgery may be recommended due to complexity within the root canal system.
  • Surgery may be recommended due to iatrogenic obstructions within the root canal system.

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 bony area around the end of your tooth after a root canal procedure, your endodontist may have to perform an apicoectomy.

What is an apicoectomy?

In this procedure, the endodontist opens the gum tissue near the tooth to see the underlying bone and to remove any inflamed or infected tissue. The very end of the root is also removed or resected.

A small filling may be placed to seal the end of the root canal, and a few stitches or sutures are placed in the gum to help the tissue heal properly. Over a period of months, the bone heals around the end of the root.

Are there other types of endodontic surgery?

Other surgeries endodontists might perform include dividing a tooth in half (called hemisection), repairing an injured root, or even removing one or more roots. Your endodontist will be happy to discuss the specific type of surgery your tooth requires.

These procedures are designed to help you save your tooth.

Will the procedure hurt?

Local anaesthetics make the procedure essentially painless and very comfortable. Of course, you may feel some discomfort or experience slight swelling while the surgical site heals. This is normal for any surgical procedure. Your endodontist will recommend appropriate pain medication to alleviate your discomfort.
Your endodontist will give you specific postoperative instructions to follow. If you have questions after your procedure, or if you have pain that does not respond to medication, call your endodontist.

Can I drive myself home?

Yes you can, the procedure is performed under local anaesthetic so you will not experience any drowsiness associated with sedation.

When can I return to my normal activities?

Most patients return to work or other routine activities the next day. Your endodontist will be happy to discuss your expected recovery time with you before and after the procedure.

How do I know the surgery will be successful?

Your dentist or endodontist is suggesting endodontic surgery because he or she believes it is the best option for you. Of course, there are no guarantees with any surgical procedure. Your endodontist will discuss your chances for success so that you can make an informed decision.

What are the alternatives to endodontic surgery?

Often, the only alternative to surgery is extraction of the tooth. The extracted tooth must then be replaced with an implant, bridge, or removable partial denture to restore chewing function and to prevent adjacent teeth from shifting. Because these alternatives require surgery or prosthetic procedures on adjacent healthy teeth, endodontic surgery is usually the most cost-effective option for maintaining your oral health.

No matter how effective modern tooth replacements are - and they can be very effective nothing is as good as a natural tooth. You've already made an investment in saving your tooth. The pay-off for choosing endodontic surgery could be a healthy, functioning natural tooth for the rest of your life.

 

Cracked Teeth

Because people are living longer and more stressful lives, they are exposing their teeth to many more years of crack-inducing habits, such as clenching, grinding, and chewing on hard objects. These habits make our teeth more susceptible to cracks.

Cracked teeth show a variety of symptoms, including erratic pain when chewing, possibly with release of biting pressure, or pain when your tooth is exposed to temperature extremes. In many cases, the pain may come and go, and the general dentists may have difficulty locating which tooth is causing the discomfort. Some cracked teeth can be especially difficult to diagnose, and treatment may involve root canal treatment. That's why you have been referred to an endodontist.

Cracked tooth pain often comes from damage to the inner soft tissue of the tooth, the pulp. Endodontic treatment, also known as root canal treatment, can relieve that pain.

Types of Cracks

There are many different types of cracked teeth. The treatment and outcome for your tooth depends on the type, location, and severity of the crack.

Craze lines

Craze lines are tiny cracks that affect only the outer enamel. These cracks are extremely common in adult teeth. Craze lines are very shallow, cause no pain, and are of no concern beyond appearances.

Fractured Cusp

When a cusp (the pointed part of the chewing surface) becomes weakened, a fracture sometimes results. The weakened cusp may break off by itself or may have to be removed by the dentist. When this happens, the pain will usually be relieved. Your endodontist will determine the appropriate course of treatment. The tooth will usually be restored by your dentist with a full crown.

Cracked Tooth

This crack extends from the chewing surface of the tooth vertically towards the root. A cracked tooth is not completely separated into two distinct segments. Because of the position of the crack, damage to the pulp is common and root canal treatment is frequently needed to treat the injured pulp. Your dentist will then restore your tooth with a full crown to bind and protect the cracked tooth. At times, the crack may extend below the gum line, requiring extraction. Even with high magnification and special lighting, it is sometimes difficult to determine the extent of a crack. A cracked tooth that is not treated will progressively worsen, eventually resulting in the loss of the tooth. Early diagnosis and treatment are essential in saving these teeth.

Split Tooth

A split tooth is often the result of the long term progression of a cracked tooth. The split tooth is identified by a crack in which the distinct segments of the tooth can be separated from one another. A split tooth can rarely be saved; however, the position and extent of the crack will determine the appropriate treatment. Your endodontist will review your treatment options.

Vertical Root Fracture

Vertical root fractures are cracks that begin in the root of the tooth and extend toward the chewing surface. They often show minimal signs and symptoms and may therefore go unnoticed for some time. Vertical root fractures are often discovered when the surrounding bone and gum become infected. Treatment usually involves extraction of the tooth; however, endodontic surgery is sometimes appropriate if a portion of the tooth can be saved by removal of the fractured root.

Will my tooth completely heal?

Unlike a broken bone, the fracture in a cracked tooth will never completely heal. However, if treated appropriately, most cracked teeth can be maintained and remain in the mouth for a long period of time. Yet, in spite of treatment, some cracks may continue to progress and separate, resulting in loss of the tooth. Placement of a crown on a cracked tooth provides maximum protection but does not guarantee success in all cases.

The treatment you receive for your cracked tooth is important because it will relieve pain and reduce the likelihood that the crack will worsen. Once treated, most cracked teeth continue to function and provide years of comfortable chewing. Talk to your dentist and/or endodontist about your particular diagnosis and treatment recommendations. They will advise you on how to keep your natural teeth and achieve optimum dental health.

 

 

Traumatic Injury

Type of Injury

Chipped or Fractured Teeth

Chipped teeth account for the majority of all dental trauma. The remaining conditions represent more serious problems, including dislodged and knocked-out teeth. Treatment depends on the type, location and severity of each injury. When any dental injury occurs, the most important thing is to see your dentist or endodontist immediately. The outcome or prognosis for your specific injury often depends on how quickly you see your dentist.

Most chipped teeth can be repaired with a simple filling. Sometimes a chip will expose the pulp of the tooth, when this occurs, root canal therapy is indicated. Injuries in the back teeth often include fractured cusps, cracked teeth, and the more serious split teeth. Cracks may or may not extend into the root. If the crack does not extend into the root, the tooth can usually be restored by your dentist with a full crown. If the crack does extend into the root and affects the pulp, root canal treatment is usually necessary in an attempt to save all or a portion of your tooth.


During an injury, a tooth may be pushed into its socket. This can be one of the more serious injuries. 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, may be put inside the tooth. A permanent root canal filling will be placed over the infection at a later date. You should continue to have the tooth monitored periodically by your dentist to assure proper healing.

Sometimes a tooth is pushed partially out of the socket. Repositioning and stabilization of the tooth are usually necessary. If the pulp remains healthy, no additional treatment may be needed. If the pulp is injured, your dentist or endodontist may need to start root canal treatment. Medication, such as calcium hydroxide, may be placed inside the tooth and should be followed by a permanent root canal filling at a later date.



Avulsed Teeth

If a tooth is completely knocked out of your mouth, time is of the essence. If this type of injury happens to you, pick up your tooth by the crown, or chewing portion. Try not to touch the root. If the tooth is dirty, gently rinse it in water. Do not use soap or any other cleaning agent. If possible, place the tooth back into its socket. Go to the dentist immediately.

If you cannot put the tooth back in its socket, be sure to keep it moist, milk is an excellent storage medium.

The less time the tooth spends drying out, the better the chance for saving the tooth. Solutions to keep your tooth moist are available at local drug stores. You can also put the tooth in milk or a glass of water with only a pinch of salt, or you can simply put it in your mouth between your gum and cheek. Bring your tooth to the dentist immediately. If the tooth has been put back in its socket, your dentist may stabilize the tooth with a splint and may check for any other facial injuries.

If the tooth has not been put back in its socket, your dentist will examine the tooth to determine if it is still intact and check for other facial injuries. Your dentist will then clean the tooth carefully and place it gently back into the socket. Your tooth may need to be stabilized with a splint for a period of time. Depending on the stage of root development, your dentist or endodontist may start root canal treatment immediately. A medication may be placed in the tooth followed by a permanent root canal filling at a later date. The length of time the tooth was out of the mouth and the way the tooth was stored before reaching the dentist may influence the type of treatment you receive. You should contact your physician to see if a tetanus booster is necessary.

Root Fractures

A traumatic injury to the tooth may also result in a horizontal root fracture. The location of the fracture determines the long-term health of the tooth. If the fracture is close to the root tip, the chances for success are better. If the fracture does not result in the two pieces of the root being separated, there is also a better chance for success. However, the nearer the fracture is to the chewing surface of the tooth, the poorer the long-term success rate, regardless of whether the pieces are separated.

Sometimes stabilization with a splint is required for a period of time. If the tissue inside the tooth is damaged, root canal treatment is needed. A medication may be placed in the canal to prepare the fracture site for the eventual root canal filling.

Do traumatic dental injuries differ in children?

Children's permanent or adult teeth that are not fully developed at the time of the injury may need special attention. In an immature adult tooth, the tip of the root, called the apex, is open, and the root canal walls are thin. As the tooth develops, the apex closes and the canal walls thicken. An injured immature tooth may need one of the following two procedures to improve the chances of saving the tooth:

1. Apexogenesis

One procedure, called apexogenesis, encourages the root to continue developing as it helps heal the pulp. The injured soft tissue is covered with a medication to encourage further root growth. The apex continues to close, and the walls of the root canal thicken. If the pulp heals, no additional endodontic treatment may be necessary. The more mature the root becomes, the better the chance the tooth can be saved. However, apexogenesis is not always successful. Sometimes, a different procedure called apexification is required.

2. Apexification

During apexification, the unhealthy pulp tissue is removed. The endodontist places a medication into the root to help a hard tissue form near the apex, or root tip. This hard tissue provides a barrier for the permanent root canal filling. In spite of appropriate treatment, the root canal walls of a tooth treated by apexification will not continue to develop and thicken, making the tooth susceptible to crown or root fractures. Proper restoration will minimize this possibility and maximize protection of your tooth.

Other Injuries

An immature permanent tooth that has been dislodged may require minimal or no treatment other than follow-up until it has matured. If the tooth is severely dislodged, orthodontic or surgical repositioning and stabilization may be necessary.

If an immature permanent tooth has been out of the mouth for less than one hour, the tooth should be placed back into its socket, stabilized and watched closely by the endodontist for 3-6 weeks. During this time, your endodontist will look for changes in tooth color, pain, swelling and loosening of the tooth. If any of these problems arise, an apexification procedure may be needed. If the immature tooth has been out of the mouth and dry for more than one hour, the tooth may be put back into the socket, filled with a medication and re-evaluated for several weeks to months. The long term health of this tooth is generally poor, so your endodontist may discuss other treatment options.

What is resorption?

Resorption is a process, in which the body’s own defensive mechanism begins to reject your tooth. Resorption is the body’s response to traumatic injury. Your endodontist can evaluate your tooth for resorption and discuss appropriate treatment options.

 

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