INTRODUCTION TO THE TOOTH ANATOMY

A tooth is a vital structure and requires a constant blood supply to live. The biggest proof of the tooth being a vital structure is that we experience pain, sensitivity, and pressure. Nerves are responsible for all these sensations. The center of the tooth, known as the pulp, is filled with nerves and blood vessels. When the pulp gets involved in tooth decay, it results in continuous pain. Sometimes when we visit the dentist and he points out a newly formed superficial cavity, which we are not aware of, as the pulp is not involved as yet. Once the pulp gets involved, that is when we start feeling pain and discomfort.

The pulp is protected by the topmost hard white layer known as the enamel and the second layer known as the dentine. These two layers protect the pulp. When we start feeling pain, the tooth decay has made its way through the enamel and dentine already, and now the trouble starts. However, this situation can be controlled if we practice good oral hygiene and visit our dentist regularly. The dentist would be able to detect a carious (decayed) tooth even before you start experiencing pain.

Visiting the dentist regularly is much cheaper than getting a root canal done. It is because of our negligence that we are forced to pay a big hefty amount for our dental treatments. Even a filling costs much less than a root canal.

WHAT IS A ROOT CANAL TREATMENT?

Simply put, a root canal treatment (RCT) is a dental procedure in which some dental structure is carefully removed to gain access to the infected pulp. With the help of pin-like instruments, the pulp is removed and the tooth is saved. The purpose of removing the pulp is to remove the decay that has reached the nerves and vessels and is causing pain to the patient. The pulp continues done to the roots of the tooth too. The pulp that continues into the roots is known as canals, hence the name Root Canal Treatment.

FILLING AND ROOT CANAL? WHAT’S THE DIFFERENCE?

It depends on the involvement of pulp. If the cavity is away from the pulp, then a filling can be done to save the tooth. Filling just involves the removal of that tooth structure that is decayed. Once that is removed, the hole can be filled with filling material, following the actual anatomy of the tooth.

However, if the pulp is involved, then the infected pulp has to be removed and that is only possible with an RCT. The involvement of the pulp is verified on an X-Ray and by the symptoms reported by the patient. These symptoms have been discussed below:

1. Symptoms reported by a patient who needs a filling

The classical symptoms reported by a patient who needs filling include the following:

 
—Slight pain or discomfort
—Food getting stuck
—Pain while chewing food or drinking
—Pain only lasts for a few seconds
—Pain subsides when the stimulus is removed
—Sensitivity
—Dark brown or black spots are seen on the tooth
—Never felt the need to take a pain killer

2. Symptoms reported by a patient who needs an RCT:

The classical symptoms reported by a patient who needs RCT induces the following:

 
—Constant pain
—Salty discharge
—Pain aggravates on lying down
—Severe pain on chewing and drinking that lingers on for a while
—Gums around the tooth are swollen
—Pain does not go away when the stimulus is removed
—Tooth is very sensitive to touch and percussion
—Pain killers did not help much

RCTs are not just needed in the case of tooth decay; they are even indicated in the case of trauma to the tooth. Sometimes, RCTs are used to help in replacing missing teeth. The two teeth around the missing space are root canal treated and instead of having two individual crowns, three joined crowns are made. Two crowns cover the root canal-treated teeth, while the middle one helps to replace the missing tooth. This is called a bridge.

RCT PROCEDURE

An RCT can or cannot be performed right away, depending on the state of infection around the tooth. RCTs are not performed if there is too much swelling and pus discharge. This aggravates the pain for the patient two folds. Therefore, the infection should be treated first.

1. Consultation

The dentist looks at the tooth clinically, asks you some questions, such as does your tooth hurt more when you lie down?, takes small focused X-Rays (Periapical X-Rays), and makes the final call for a filling or RCT. In case of an infection, the dentist usually prescribes antibiotics along with some pain killers and calls you back in the office after a few days to start the procedure. If the infection is not that bad, with no pus discharge or swelling, then the dentist might start right away. Sometimes the swelling can even spread above the upper lip and cheek area (if it is an upper tooth) and spread down to the chin and neck area (if it is a lower tooth).

2. Local Anesthesia

To help numb up the area around the tooth, the dentist injects some local anesthesia. This is an important step to help ease the pain of the patient so that the dentist can work peacefully. Local anesthesia is only effective on pain receptors but not on pressure receptors. This means that you will not feel any pain, but will feel pressure, about which the dentist cannot do anything.

3. Gaining Access to the Canals

As mentioned before, the pulp is the third layer of the tooth. To gain access, the upper layers of enamel and dentine must be removed. Once that is done, then the dentist can easily access the canals. Canals usually depend on the number of roots a tooth has. Upper poster teeth usually have 3 roots and lower poster teeth have 2 roots. The upper and lower anterior teeth usually have single roots. However, there can be variations and there can be more roots and canals in a tooth. Dentists get surprises with the number of canals all the time.

4. Removing the Pulp

The pulp is removed with the help of instruments looking like pins. They are of various sizes and are numbered and color-coded accordingly, and the dentist starts with the thinnest file to help clean, shape, and prepare the canal for the filling material. The filing can be done manually and automatically too. Lengths of the files are verified through X-Rays. These days almost all dentists do automatic filing to have saved up on time and save their backs from backache. Single rooted teeth are usually completed in one sitting only. But sometimes, the dentist might decide to finish the RCT in two or more sittings. If that is the case, then during appointments, the bulk of the tooth is filled with a temporary filling material, which is then removed when the patient walks in next.

5. Filling

Once all the infected pulp and canals have been removed, they are first filled with a root filling material. Then the bulk of the tooth is filled with filling material, either Glass Ionomer Cement (GIC) or Composite.

6. Crown Cutting and Impression

After the filling is complete, the tooth (crown) is shaped and cut to allow an artificial crown to be placed on it. Then impressions are taken and sent to the lab for fabricating a crown to help protect the RCT tooth. Since the tooth is now dead, it should be protected from external forces, hence, a crown must be placed on the tooth to prevent it from getting fractured. A temporary crown is also cemented on the tooth to protect the tooth while the permanent crown is fabricated in the dental lab.

7. Cementation

Once the crown is received from the lab, the temporary crown is removed and the permanent one is cemented. If any minor adjustments are to made, the dentist can make them in-office and then cement the crown.

MATERIALS OF CROWNS

There are mostly 3 types of materials that are widely being used in dentistry nowadays. These are:

—Porcelain Fused To Metal (PFM)
—Metal crowns
—Zirconium crowns
—Acrylic for temporary crowns

The choice of the material of the crown depends on the patient’s budget, expectations, the space available in the oral cavity, the natural anatomy of his teeth, and his habits. Zirconium crowns are the most expensive ones.

COSTING

Costing of RCTs depends on the qualifications and experience of your dentist. Also, in the area of the clinic; hospitals usually charge less than a private clinic.

BENEFIT OF A RCT

RCT helps to prevent the tooth from getting extracted and opting for options for replacing teeth. You get to preserve your natural tooth structure.

RISKS ASSOCIATED WITH RCT

Just like any other treatment, RCT has some risks of failure. You must visit your dentist for regular checkups to help maintain and monitor the RCT tooth.

The most common risks associated with an RCT are:

—Missed canals
If the pulp is not removed from canals that the dentist cannot find, then the patient will still complain of a toothache.

—File breakage
Sometimes, if the files have been used several times, the chances of them breaking while cleaning the canal are pretty high. If this happens, it is almost impossible to retrieve a broken file from the canal. The patient will complain of pain.

—Tooth fracture
Due to extra forces being applied while filing, the tooth can fracture.

—Rupturing the canal
If a file of a greater length is used, it can rupture the canal and go beyond the apex of the root, causing pain to the patient.

FINAL THOUGHTS

Regular visits to dentists can help prevent the need for more expensive and longer treatments. However, if you even ignore going to a dentist when you need an RCT, the last resort left would be an extraction. Sometimes, when the dentist prescribes antibiotics, the symptoms of the patients usually subside and then they decide to push their RCT appointment further. This must not be done as it would allow the decay to spread further. This is just sheer negligence of your oral hygiene and must not be done.