Hard work-for what reward? (Root Canal Treatment / Endodontic Therapy)

Member Name: Squiddly450

Product:	Root Canal Treatment / Endodontic Therapy
Date:	19/02/09 (424 review reads)
Rating:

Advantages: You get to keep your tooth (probably)

Disadvantages: It's hard work!

How exciting, another dental treatment I have done myself AND been subjected to!

In my dental centre, Root canal treatment (RCT or endodontics) is done for one of two reasons. The first is "Traumatic exposure" where one of my patients has broken a tooth and the nerve is exposed. This is fairly rare (I've done it twice in three years) in my experience, and often we can treat the tooth so that we don't have to remove the nerve. The other reason we do it is when a patient presents with Chronic Pulpitis, periapical periodontitis, or a periapical abscess (can be acute or chronic). These conditions are usually caused by dental decay but can be caused by trauma-I had to have RCT after breaking my front tooth in a fight with my brother mediated by the kitchen door, a periapical abscess developed three years later- and in some cases, the cause is dental treatment.

In order to explain RCT more fully, I'll delve into some tooth anatomy.
The hard, outer surface of the tooth is made of enamel (the hardest substance in the body), under this is dentine which is softer and made of microscopic tubes (tubules) underneath this is the "pulp", where the nerves and blood vessels live.

When a tooth begins to decay, millions and millions of bacteria attack the enamel, this has often been weakened by sugar, and form a hole. Once the defensive layer of enamel has been broken, the bacteria get into the dentine which is like a massive orgy for them. The dentine is easily digestible and is porous, meaning the bacteria can whizz in and out as they please. Even if the actual decay has got nowhere near the pulp, often the bacteria will have caused the pulp to become inflamed because they have got down one of the tubules that leads to the pulp.

Sometimes, this means a patient will present with pain such as a throbbing ache that lasts 10min or more, keeps them awake at night, arrives spontaneously but is worse with hot, maybe relieved by cold, isn't touched by painkillers and generally makes them want to do anything to get the tooth out. (More on this later).

Other times, the patient will present with a hole in their tooth, or pain on hot, cold, or sweet. So we will do a simple filling and next week the patient returns with an abscess saying "It was fine til I had the filling". As I mentioned, when there is a hole, the bacteria can get in and out as they please. Once we have sealed the hole up with a smashing filling, we have trapped the bacteria inside the tooth. Sometimes they die, sometimes they don't. If they don't, they start to multiply and (as with any infected body part) the pulp tries to swell. It can't swell because the tooth is rigid and the pressure causes severe pain. Hope that makes sense.

Anyway, once there is bacteria inside the root canal system (this is quite a complicated system with up to six nerve canals in one tooth, they often divide and join again and have branches going off left right and centre), the entire tooth is infected. The dentine (which is porous) also becomes infected as the bacteria can travel down the tubules.
Now this has happened, the only real way to relieve the pain is to "extirpate" the tooth. This means removing the pulp and putting an antibacterial dressing inside the tooth. Antibiotics are sometimes given but there is no evidence that they work other than having a "placebo effect" (which is better than no effect at all!!).

As I mentioned in an earlier review, once teeth are infected, the local anaesthetic just doesn't work as well. This is a nightmare scenario, patient already in pain, trying to treat the tooth to get rid of the pain but causing more in the short term- I hate it!!

Not all people who need RCT will present in pain, sometimes a chronic abscess is an incidental find on x-ray or they get a sinus (where the chronic abscess drains through the gum-nice) or the tooth simply changes colour. The pain isn't always horrendous either, my toothache was just annoying.

So, once the acute pain has been fixed, the patient will (should) come back to finish the treatment. This is always difficult-patient sometimes thinks "pain has gone, I don't need to spend my hard earned cash getting the treatment finished".
Unfortunately, now the nerve and blood vessels have been removed (or died) the tooth has no immune system of its own, so any bacteria that are chancing along in your blood stream or bugs that get in through the top of the tooth, can get in and have a party. Causing more infection, abscess, nasty taste etc etc.

So, when you go back for your RCT, the dentis SHOULD do a few things to increase your confidence that she is operating within the guidelines set by our reguulatory bodies and professional dudes (like the Royal College of Surgeons and the BDA etc etc). The first is that they should use "rubber dam", this is a rubber sheet that fits over your tooth and is clamped in place.
The idea of this is fourfold-
Firstly, it is a heck of a lot easier to see the tooth properly.
Secondly, the bugs in your saliva don't get in and re-infect the tooth
Thirdly, it means we can use the strongest chemicals allowed to disinfect your tooth without worrying about you swallowing them or them getting in contact with your cheeks or tongue etc
Fourthly, the instruments we use are very fine, if one of them breaks, you won't swallow it or even worse, inhale it.

So after the rubber dam, your dentist should really be using some sort of magnification, this can range from odd looking (for odd, read sexy) glasses with extra lenses in called "loupes", to having an enormous operating microscope (worth about £15k), to help them look down the tooth. Apparently in Australia, it's illegal to do RCT without magnification.

One other issue is that all of the instrumentts used in RCT are supposed to be only used on one patient. They can be used as many times as appropriate on that one patient but never on anyone else.

If you are happy that your fang farrier has all these bases covered-let the games begin!

Anaesthetic in, rubber dam applied now we need to find all of the root canals. Upper incisors have one, as do upper laterals, upper and lower canines and lower premolars. Lower incisors have two, as do upper premolars. Upper first molars have 4-6, lowers have 3-4, second molars have 3-6 and I don't know anyone who treats third molars.
You can =/-1 canal to all of the above as there is so much variation between individuals.
The point I'm trying to make is RCT is hard, at the beginning, the canals can be as small as a hair and they can be soooooo hard to find.

Once the canals are found, the top part is shaped using a Gates Glidden (this had a walk on part in finding Nemo). This shaping allows the canal to be rinsed out with disinfectant and allows us to see as far down the canal as possible.

After this, the canal is shaped using files-these can either be in a drill or done by hand (personal preference for me is by hand), the canal is constantly washed out with the disinfectant to remove any bugs that may be lurking.
All this is hard work for the dentist and patient by the way, I have to do them before lunch as the hunger makes me more attentive.
At some point during the filing procedure, an x-ray will be taken to make sure the file is at the correct length (ie-at the end of the root), in my experience, the average is about 21mm but some are much longer.

The filing and disinfecting can often be done over two or more visits depending on a number of factors including the severity of the infection, the number of root canals and the difficulty of access.

Once your dentist is happy that the tooth is as clean as possible, and that the canals are the right shape, she can begin filling the tooth.
The filling material normally used is called "gutta percha" (GP) and is a sort of rubber. There are loads of ways to fill the tooth, some using lots of GP "points" (little sticks of the stuff that can be placed all the way to the end of the root), some using just one, some using heat to condense the GP, some using hand instruments. Again, this always comes down to personal preference of the dentist.

Once the filling is in, usually a temporary filling will be put in the tooth and another x-ray taken. This is to ensure the filling is up to scratch. Once the dentist is happy with the filling, some sort of permanent restoration will be put in place. What sort of restoration this is will depend on lots and lots of things and is something I don't want to go into on here as it varies so much.

That's a lot of work for £42 NHS pounds! Fortunately I don't have to charge my patients, even so-it's blimmin hard work!

Unfortunately, at any stage during the treatment, or afterwards, it can be decided that the treatment is not progressing satisfactorily and that the tooth would be better in the bin. Sometimes the canals are blocked, sometimes the instruments can break (not always the end of the world) or the instruments can push through the side of the tooth, I could go on and on.......

That's a lot of work for £42 NHS pounds! Fortunately I don't have to charge my patients, even so-it's blimmin hard work!

So basically, if you want to keep your tooth-be prepared for a while in the chair. Otherwise, get it taken out!

Summary: Not the end of the world, just a little investment in your gnashers!