Root Canal Treatment

Root canal treatment is the procedure of the removing infected pulp, cleaning and shaping the root canals, and filling them with a root canal obturating (filling) material.  

The innermost soft part of a tooth is your tooth pulp. The pulp is a soft tissue which contains nerves and small blood vessels. It is present in the crown (the white visible portion of your tooth) as well as in the root canals (small tubes present in the roots of your teeth which are not visible in a healthy mouth). When the outer two layers of your tooth are lost due to bacterial attack or a fracture, it exposes your pulp to the outer environment. This causes inflammation and infection of the tooth pulp. At this point, you need a root canal treatment which is abbreviated as RCT.

In adults

From the tooth pulp, the infection can also make its way down to your jaw bone which may make your condition severe. Your tooth pulp can get exposed if you have deep dental cavities, a half-broken tooth, or during a dental procedure. In such cases, you are required to get the infection removed and the root canal filled. Other reasons which make it necessary for you to undergo RCT involve the presence of extensive fillings which can make the tooth weak, and getting a tooth bridge (artificial teeth) to replace missing teeth (in such cases, you may need to get RCTs of the teeth on which the bridge will be placed).

In babies

Many times, milk teeth may not require an RCT. In cases of extensive decay, the tooth of your baby is removed from the tooth socket by your dentist. This is because mostly, a milk tooth is soon replaced by an erupting permanent tooth. However, in some cases, your child might have an extensive tooth decay way before it’s time for its successor tooth to erupt. That is when your baby’s milk tooth requires an RCT.

Please note that if a decayed tooth is not treated, its pulp dies over a period of time and can also infect your jaw bone causing a dental abscess (infection with pus formation).

When to see your dentist?

Following are a few symptoms that need you to see your dentist as soon as possible:

• Unbearable pain, which is not relieved in spite of taking medicines (painkillers). 
• Pain on consuming hot/cold/sweet or any other form of solid or liquid food.
• Swelling with or without pain, which may also cause difficulty in opening your mouth.  

In any of the above-mentioned condition, it is strongly recommended that you should not delay and consult/visit a dentist immediately.

RCT is a multi-step procedure and usually requires more than one visit to your dentist. It can be done by a general dentist as well as an endodontist (a dentist with specialization in root canal therapies). Following is the stepwise procedure for your root canal treatment:

History
Your dentist will take a detailed history of your current health status to avoid any emergency during treatment. The dentist may ask you the following questions:

• Blood pressure and blood sugar levels.
• Whether you are currently suffering from breathing problems, heart diseases, liver diseases, kidney diseases, mental disorders etc.
• Past or current experience of seizures, tuberculosis (TB) or any other recent infection, blood disorders, problems in blood clotting etc.
• Any known allergic reactions to medicines.
• If you are currently taking any medicines.
• Past surgeries and any complications related to them
• Any other dental treatment that you might have undergone in the past.

Note: If you have high blood pressure, high blood sugar, had heart surgery (pacemaker insertion, prosthetic valve, heart defects, or heart transplant), had tuberculosis in the past, undergone or undergoing treatment for blood thinning, your dentist may not start the procedure till your physician gives clearance in writing that it is safe for you to undergo this treatment.

Hence, it is important for you to inform your dentist about all the medications that you are on in order to prevent any complication during treatment.

This is because certain medicines and ongoing treatments may cause disruption or hindrances in dental procedures such as RCTs.

X-ray
Your dentist might either advise or take an X-ray of the affected tooth in the clinic itself before starting the procedure. This will help in understanding the condition of the tooth and evaluating the extent of infection in the surrounding jaw bone.

Anesthesia
If you have never received anesthesia in the past, your dentist may do a small test on your forearm to check whether you are allergic to it. Anesthesia is given to make your tooth numb while your dentist is carrying out the procedure. This makes the procedure painless and comfortable for you as well as for your dentist. Within a few minutes, you may experience numbness or tingling sensation in your lip, tongue, and face on the same side where the injection is given. There is nothing to worry about. This happens because of the fact that one nerve supplies to many structures on the same side. Hence, numbing one part in the middle will also make other areas numb. Sometimes, when the pulp is dead, you may not even require anesthesia.  

Isolation of the tooth
In this procedure, your dentist will keep your tooth dry and isolated from the rest of your mouth using cotton rolls or a rubber sheet known as rubber dam. This will prevent any further contamination of the canals with saliva while cleaning and filling them.

Access opening
It is the next step after isolating your tooth. Your dentist will use a powered instrument with water spray to make way through the hard tissues of your tooth to the tooth pulp. This will take out all the damaged portions of your crown. Hence, it will not only help in accessing all the root canals in your tooth roots, but it will also prevent the transfer of infection in deeper areas. After this step, your dentist might use a hand instrument to remove the upper wider part of the pulp from the crown portion of your tooth.

Cleaning and shaping of the root canals
Cleaning is done in order to take out the infected tooth pulp from your narrow canals. Dentists use various types of needle-like instruments which have cutting edges for this procedure. These are known as files and the technique is known as filing. These files have stoppers to prevent slipping of the file beyond the expected length of your tooth root. Files can be used manually (hand-operated) or with a powered device. They engage the tooth pulp and the underlying affected hard tissue and remove it from narrow areas of the canals. Once it is done, these files are used with increasing diameter to shape your canals. The length of each root is identified either by taking an X-ray with files in all the canals or by using an apex (the tip of a root) locator (a device which locates the apex and tells the root length). Shaping is important to make your canals more accessible and easily fillable.

Disinfection
This is a very important step in root canal treatment. Your dentist will wash your root canals every once in a while with sterile (germ-free) water and with disinfecting chemicals. It is of utmost importance that all the debris flows out of your root canals and isn’t further pushed down towards the bone while filing.

Medicaments
The above procedures are done on your first visit to the dentist. After cleaning and shaping, your dentist might fill your canals with an antibiotic paste (intracanal medicaments) to kill the remaining bacteria as well as to prevent their spread till you come for your next visit. Over this paste, they will put an antiseptic-soaked cotton and a temporary white filling. This temporary filling will prevent the entry of bacteria from saliva in your root canals. It is advised that you do not drink anything for one hour after leaving the clinic. You are also advised not to chew anything from the treated side for the next 24 hours. Between your first and second visit, your dentist may prescribe and advise you to take some antibiotics and painkillers to make the infection, pain and the swelling to subside.

Filling (Obturation) of root canals

In permanent adult teeth

On your second visit, your dentist will take out the temporary filling, the cotton, and the antibiotic paste from your canals. After cleaning them, your dentist will do a final assessment to check if there are signs of bleeding or any pus discharge. If there are bleeding and pus discharge, you may have to come for a third visit for final treatment after taking the medicines prescribed on the second visit.

If the root canals are free of blood and pus, your dentist will give a final wash to the tooth and its canals, take an X-ray with a cone (conical-shaped filling material) in each root canal to ensure that the filling will not fall short. After washing, small tube-like rolled papers (paper points) are used to dry the canals completely. A paste which seals the filling material with the inner surface of the root canal (a sealant) is applied. After the sealant is applied, your dentist will fill all the root canals with the filling (obturating) material. Thereafter, a permanent filling is placed in the crown portion of your tooth. The height of the tooth is slightly reduced so that it does not come in contact with the opposite tooth. This prevents the application of chewing forces on the treated tooth and helps it heal faster.

In milk teeth

Milk teeth are filled with a filling material which is available in paste form. The paste comes in injection-like tubes. These make it easier to fill the root canals of the baby teeth. Over this paste, a permanent filling material is placed. The paste sets and hardens over a period of time.   

Emergency access opening
This is a very painful condition in which you might experience severe pain in the tooth, with or without associated swelling in the same area. This happens when there is severe inflammation (swelling) of your tooth pulp which causes pressure to build up in your tooth. Since a tooth has an outer hard structure, there is no place for the swelling to expand and it results in severe pain. In such a case, rush to your dentist, or a nearby dentist immediately. The dentist will give an injection on the affected side to make the area numb and will perform an access opening of the affected tooth. This procedure is slightly painful because the action of anesthesia is not as strong when there is a swelling or pus associated with the affected tooth. However, getting an access opening done will release the pressure and relieve your pain. The dentist will prescribe antibiotics and painkillers to make the symptoms subside. Later on, you will have to get your root canal treatment completed to prevent further spread of infection.

Pain during RCT

For most people, RCT is not painful. However, some people do experience severe pain which depends on many factors.

During treatment
Pulp is a complex tissue. Sometimes, you may experience pain even after receiving anesthesia. This can happen when the whole pulp is not dead. Some of it may remain vital (alive) which does not get numb because the anesthesia is not able to reach it. Other times, the tooth pulp tissue may be resistant to anesthesia. Such a tooth does not get numb even after receiving two shots of anesthesia. This tooth is known as a hot tooth. If pus formation (a dental abscess) has occurred in the jaw bone, it will hinder the action of anesthesia on the tooth nerves.  

After treatment
After completion of the treatment, you may experience pain for a while. This happens as a normal reaction of the body after any treatment. There is nothing to be worried about. Take your medications on time and follow the instructions given by your dentist. The pain usually subsides in one to two weeks. If it does not go away even after fifteen days of medication, go back to your dentist for a further check-up.  

Did you know?

People commonly experience pain in between their clinical visits. Sometimes your tooth might not be painful when you entered the clinic because the infection was slowly growing and did not let you suspect it. But, as soon as a treatment starts, the bacteria suddenly start multiplying in order to survive the treatment and release toxins in the canals. This is a very common symptom that you may experience after your first visit to the dentist. Since now you know the reason help yourself and the dentist to fight the bacteria by completing your treatment. The pain subsides after taking medicines on time. If you have completed your treatment and capping is also done, you may also experience pain if the cap is not placed correctly or when its height is more than that of the rest of the teeth.

Precautions to be taken after treatment

A successful root canal not only depends on the procedure and the condition of the tooth but also on how you take care of it after the treatment has been completed.

Immediate precautions
It is always important to follow your dentist’s advice and instructions after getting the treatment done.

Your dentist may advise you to take care of certain things such as:

• Do not drink or eat anything for one hour after the treatment. It allows the filling material to set completely and prevents it from falling off.
• Take soft diet such as rice, oats, milk, soft fruits, fruit juices, etc for the next 24 hours.
• You may also be advised not to eat hot and steaming food because it may worsen your condition.
• Do not chew anything from the treated tooth side.
• Do not touch the filling with fingers or a toothpick.
• Take your medicines on time.
• You may experience pain for a few days after the treatment. This pain usually goes away on medication. If you do not feel pain relief even after two weeks, visit your dentist again.

Long-term precautions
Your tooth becomes slightly brittle after the root canal treatment. Hence it is important to get capping done. Given below is a list of things you can do to make your tooth last longer after treatment:

• Brush your teeth regularly and take good care while brushing the capped tooth.
• Do not use toothpicks to clean the cap and area around it because you may accidentally chip off the material which is used to seal the cap with your tooth.
• Ask your dentist to demonstrate the correct way of brushing your teeth, the right toothbrush and toothpaste for you.
• Go to your dentist in case you experience pain in the treated tooth or any other tooth in your mouth. Early treatment will prevent your tooth from further damage.

Capping (Crown) after RCT

In milk teeth

Milk teeth have broader root canals and are more prone to fractures. However, good permanent filling provides strength to the tooth, your dentist may also advise capping till the time its permanent successor erupts. Ask your dentist what is best for your baby’s little tooth!

Note: The phase between 6 to 14 years of age is a crucial phase. During this time, your child has both types of teeth, milk teeth as well as permanent teeth. Hence, it is important to identify teeth which have cavities. If a deep cavity occurs in a permanent tooth (usually rear molar teeth which are the first permanent teeth to erupt), there are high chances that it might spread deep down the tooth roots and your child may have to lose that tooth forever.   

In permanent adult teeth

After completing the treatment, your tooth may or may not require capping. If the damage to your crown is mild, your dentist will use a tooth-coloured filling material in front teeth and silver filling/tooth-coloured material in rear teeth to fill the lost tooth structure. However, if the damage is moderate to severe, it is necessary to get capping done. Capping or crown placement provides support and strength to the treated tooth. Different types of crown materials are available and you should consult your dentist to decide the best one for your tooth.

In this procedure, the width and height of your tooth are slightly reduced using a powered device with water spray attached to it. This reduction in size (known as crown cutting) of your tooth is done in order to make space for your new crown. Before and after tooth grinding, your dentist will take an impression (a negative replica) of your tooth in order to make a mould for your crown which closely resembles your natural tooth. The crown is made in a dental lab and is matched with the size and colour of your natural teeth. Using a fixing cement, this crown is fixed on the treated tooth.

Root canal treatment does not usually have side effects. However, there have been incidences where the person has experienced certain side effects or complications such as:

Pain
You may experience a dull pain in the tooth for a long time. This usually occurs in cases where the infection was previously in the jaw bone as well.

Reinfection
Sometimes, the bacteria of the root canal are very resistant to the disinfectants used during the treatment. Hence, they either do not die or remain dormant for a long time and start reinfecting the treated tooth once the conditions are favourable to them.   

Treatment failure
When the reinfection gets severe, your treatment may fail and you might have to undergo the whole procedure again. Your tooth becomes brittle after the treatment because of loss of blood supply. As a result, in certain events when you bite hard on to something, your tooth may break or fracture.

The cost of root canal treatment differs from place to place and dentist to dentist. An expert or a specialized root canal dentist (endodontist) may charge more than a general dentist. The treatment cost varies from 2000-8000 INR excluding the cost of your cap. The cost of capping depends on the type of material with which your cap is made and also on the expertise of the dentist. It usually starts from 1500 INR and may be as high as 15000-20000 INR. However, the costs of dental procedures in government hospitals and clinics are much lower as compared to those in private hospitals and clinics.

You will recover from the treatment within a few weeks. Recovery depends on how deep your infection was initially. An infection limited to the tooth heals within four to six weeks, however, if the jaw bone was also involved, it usually takes a year to heal completely.