Monday, 9 September 2013

When in dOUBT ...

They say... When in doubt, Cut it OUT !! Extension for prevention has always been a way round doubtful circumstances in the healthcare industry. Fortunately,  things have changed over the decads from barbaric gory procedures to minimally invasive interventions. 

In the world of dentistry today, the technology advancement allows everyone to have the luxury of saving their teeth. Each one of us have a choice of keep our infected  tooth rather than it being extracted. Conventional treatment for badly decayed or broken tooth would suggest the latter. Given the choice today, root canal treatment is a better  and smarter choice. Nothing comes close to chewing food with your own original teeth. The luxury of retaining your real teeth rather than removing and replacing them with false teeth is

The common dilemma among many of us these days  is NOT whether to save, or not to save the tooth, but saving the tooth in the most minimally invasive method possible. That brings us to ponder upon the efficacy of a root canal treatment. Understanding what a root canal treatment is, how it works, and how effective is it is important. A root canal treatment is basically removal and debridment of infected nerves and tissues in the roots of the tooth. Our tooth comprises of three layers,

Enamel - outer most layer, strongest substance in 
                  the body 

Dentin - comprises most of the tooth substance, 
                 lying under the enamel, forming the roots
                 and body of the tooth, and the roof/base/
                 walls of the nerve plexus
Pulp - the center containing nerve plexus

Most of the time, caries development goes undetected. It progresses over time, setting of different symptoms and sensation as it infests deeper into the tooth. The right question we should be asking here is, HOW do we know if we have a cavity infesting in our "healthy" dentition? Well for a start, your reaction towards cold drinks and food would indicate if there are any activities going on in your teeth.

INITIAL CARIES ( early stage )


LATE STAGE CARIES ( with pulp involvement )

These are just indications to the severity of the decay. A thorough dental examination followed by proper digital imaging usually helps in diagnosing existing cavities, and as well as initial caries lesions. Initial caries lesions are usually reversible ( provided no cavitation are present ), and are treated by practicing good oral hygiene together with fluoride therapy. Advanced caries simply means there is a sign of cavitation and the decay has progressed beyond the enamel into the dentin, without breaching the pulp chamber. At this stage, the tooth can still saved by doing a filling in order to restore its function back to normal. However a late stage carious tooth could not be restored with a filling, the reason being the nerve plexus ( the pulp chamber ) has been breached and requires further treatment. This is when the dentist usually advices the patient to do a Root Canal Treatment.

At many occasions, deep cracks (complicated fractures) or gum disease involving the pulp (nerve plexus) would require a root canal treatment as well. RCT usually requires 2 or more clinical visits, unless it is a prophylactic endodontic treatment on a sound (healthy) tooth, in which it can be done in a single visit. 

During the 1st visit, a through examination is carried out based on the patients chief complain. An investigation is done on the patient's medical history, followed by an extraoral and intraoral examination, and finally studying the problematic tooth itself. A good Periapical radiograph or  panoramic imaging (OPG, X-ray) is done to aid in the diagnosis. When the final treatment plan is done, the root canal treatment (if indicated) is then carried out. This is after analyzing all the circumstances and factors influencing the
prognosis of the tooth. A good diagnosis and treatment plan will determine a good outcome of the treatment. This one of the most crucial stage in determinating the fate of the tooth.

A good local anesthesia is administered to numb the tooth and the surrounding tissues. Next, the pulp chamber of the tooth is accessed in order to carry out pulpectomy (removal of the nerves) and debridment of any discharge or infected tissues in the root canal. The canals are cleaned and shaped using rotary and hand instruments to remove any infected debris or tissues within the canal. It also helps widen the diameter of the canal, to aid disinfection and filling of the canal later on. By the end of the 1st visit, the dentist would have placed an intracanal medicament and sealed the canal orifice with a temporary filling material. 

At the 2nd visit, the seal is removed and intracanal

medication washed out. The canal, if not presenting with any sign or symptom of infection, is then filled with an obturating material (gutta perca). The final restoration is then placed, awaiting a prosthesis to further strenghten the tooth. 

The entire procedure is carried out under local anaesthesia. To treat a tooth with RCT requires few  considerations :-

a) the degree of tooth fracture - vertical fractures respond poorly to RCT due to bacterial 

    invasion beneath the gums
b) extend of decay - severe decay extending below the alveolar bone level might 

    compromise root canal treatment
c) exisiting sinus tract - how severe
d) existing chronic periapical abcess
e) pathological lesions - cyst, ameloblastoma,OKC
f) tooth mobility - Grade 3, poor prognosis of survival
g) periodontal disease - perio-endo lesion, causing periodontal abcess
h) other limiting factors , such as limited mouth opening, very poor oral hygiene, root caries, 


A RCT is only carried out once all pathological influence is removed. The fundamentals of a good root canal treatment is to do it under asepsis method, where a good isolation of the tooth (infection control) using proper and specific instruments is needed. The use of proper irrigation material and procedure together with good intracanal medication is necessary. A good root canal treatment done could determine the fate of the tooth treated. The chances of reinfection of the tooth depends on how well the tooth was treated, medications and irrigation system used and above all identifying and treating the causative factor of
the infection within the tooth. Early evaluation on the condition of the tooth, together with a good dental history has a big role in treating the source of infection. 

Having known now all the considerations before carrying out a root canal treatment, it is crucial that the root canal treatment is then performed optimally to ensure a high success rate. The astute dental clinician has to have enough knowledge and expirience in order to carry out the treatment efficiently and successfully. For further inquiries regarding root canal treatment,  please email Dr. Yogesh at

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