Root Treatments
What is a Root Treatment?
Infection
Root treatments are required when the nerve in a tooth dies due to decay, trauma from a filling or sometimes due to gum disease. If left untreated, bacteria get into the tooth and start an infection which can progress to become an abscess. A boil on the gum is usually related to an abscess that has been present for some time. This process can be painful, or sometimes there is little or no pain at all. Dental abscesses can be life threatening if left untreated.
Disinfection
The aim of a root treatment is to clean out the dead nerve and the bacteria that have got into the core of the tooth. The nerves of teeth live in thin canals and different teeth have varying numbers of canals. When a root treatment is carried out, the goal is to find all the canals and disinfect them all the way to the end of the root. Special instruments and disinfectants are used during this process and it takes time to do a thorough job.
Root Filling
Once the canals are cleaned and disinfected, the canal system is filled up with sealer material. this stops the canals filling with bacteria after the treatment has been competed. It also seals off any bacteria that may have escaped the cleaning process, which is possible as the canal systems are highly complex. The tooth then needs to be properly restored to prevent leakage of saliva and bacteria back into the root canals, which would start the infection again.
Whats Makes Root Treatment Successful?
The Tooth
The tooth must be in a good enough condition to allow for a high quality filling, both during and after treatment. This will allow a seal to be created. If the tooth is very broken down and has edges far under the gum, filling materials generally fail, which allows leakage of fluids and bacteria from the mouth into the canal system and allows for a repeat infection.
The Root
If the root canal anatomy is very complex, or if there is a blockage for some reason, it becomes impossible to fully clean the inside of the tooth and the canals. This can lead to spaces deep in the root where bacteria continue to survive and the keep infection going.
The Treatment
How the treatment is carried out is very important. Magnification through high powered dental telescopes can make a big difference as the tiny canals are more easily seen. Rubber dam is a protective sheet that goes around the tooth and separates the patient from the disinfectants, but also stops bacteria re-entering the tooth during treatment. Taking time to allow the disinfectant to work properly and access all the spaces in the canals is very important. Finally, a high quality seal finishes the treatment and allows for the best chance of success.
Re-Treatment
Re-Root Treatment
If a tooth has already had a root treatment and gets an infection, it is often possible to re-root treat the tooth. This is more difficult and time consuming than the first root treatment, but is worth pursuing if the tooth is still in a good enough condition. The alternative would be an extraction Sometimes however, a tooth is too damaged to have a re-root treatment and the chance of success is too low for the investment required to save it.
Post Removal
A post is a form of anchor that helps hold the crown of a tooth on when it is very damaged. Posts are cemented into the root canal and act as a stump that replaces the natural tooth that is missing. If a tooth has a post, it should also have had a root treatment to clean and disinfect the root canal. If there is an infection, or the post breaks, the post will need to be removed for the canal to be disinfected again. This can be challenging and time consuming, so only worth undertaken if the tooth has a good long term prognosis.
Fractured Instruments & Perforations
An unfortunate risk of root treatments is the possibility of a file instrument fracture, or perforation of the tooth. Root treatments are carried out with delicate, specialised instruments that access the tiny canals in the tooth. They can occasionally break and get stuck. If they cannot be retrieved, they cause a blockage that can effect the outcome of treatment.
A perforation is when the outside of the tooth is damaged from the inside. These can be repaired, but the larger they are and the longer they have been there for affects the outcome.
Magnification and the right equipment can remove some fractured instruments and repair perforations to give the tooth a chance.
Dark Teeth
Internal Bleaching
Dental trauma can cause the nerve in a tooth to die. When this happens, blood enters the tooth and causes it to discolour. Once a root treatment has been carried out to remove the damaged nerve, dental bleaching can be carried out inside the tooth and remove the darker appearance. This is less invasive that crowning the tooth to change the colour.
Crowns for Protection
Once a tooth has had a root treatment, there is usually a significant amount missing, which can lead to fractures in the long term. If there is a large filling in the tooth as shown in the picture, a crown can hold the tooth together. This returns the strength to the tooth and protects the tooth after the root treatment. If the tooth is not treated in this way, it is at more at risk of a catastrophic crack or split that results in loss of the tooth.
Dental Trauma
Knocked Out Tooth
If a tooth is ever knocked out, the best management is to put it straight back in. This is because the tooth root has a special lining that dries very quickly and if severely damaged, has a big impact on whether the tooth should be put back in or not. Less than an hour out of the mouth is usually the cut off. If the tooth is dirty, rinse it in milk or use saliva to clean it. Tap water can be damaging but better than nothing. Once the tooth is back in position, it needs to be held in place. Stabilisation by a dental professional is required, but gently holding the tooth in position is the best thing to do until this can be achieved. Gently biting on gauze can help as long as it is not pushing the tooth out of place. The tooth will need a root treatment at around 7 days, as the nerve will have died in most cases.
Never try and put a Child’s milk tooth back in. This is only for adult teeth.
Broken or Traumatised Teeth
Broken teeth that do not involve the nerve can be rebuilt with composite materials. It is best to attend a dentist as soon as possible to make an assessment. A temporary filling will be placed to protect the nerve from further trauma. If the nerve is exposed, the tooth will almost certainly need a root treatment. In addition, traumatised teeth can change colour over time and either go more creamy in colour or darker. Creamy is a natural response and the nerve is often still alive, whilst dark colours usually mean the nerve has died and needs a root treatment.
Traumatised teeth can be very tender and sensitive for weeks or months afterwards. They require regular follow up to check on the nerve and make assessments as to the treatment that might be required in the future. Traumatised teeth that have moved generally need a root treatment and can undergo a form of resorption that eats away at the root. sometimes this stops over time, but it can also result in the loss of the tooth.
Resorption of The Tooth
Internal Resorption
Internal resorption is a process whereby the nerve tissue inside the tooth starts to eat into the root of the tooth. This can be seen on an X-Ray as a bubble shape or is seen in the mouth as a pink glow through the crown of the tooth. Usually due to some form of trauma, it can be treated if caught early by a root treatment. unfortunately, if it is caught late, the tooth cannot usually be saved.
External Resorption
External resorption is when the tooth is dissolved from the outside going towards the centre and is usually caused by trauma. Occasionally it can be caused by other factors or has no clear reason at all. Some cases start then stop, with no symptoms and no active treatment required, whilst others continue to eat away at the root until the tooth is lost. Early detection with mild or moderate damage can sometimes be treated with surgery. This removes the cells that are eating the tooth and places a special filling in the cavity. If there is considerable damage, the tooth may be lost. Some forms of resorption result in a change of the root to bone as it is turned over by the body. There is no treatment for these cases and the tooth could last a few months before it is lost, or several years, depending on the speed of the process.