Procedure of a root canal treatment
A correct diagnosis is crucial for successful treatment. The diagnosis for endodontia requires a very exact determination of the state of the disease. Normally the restorations (for example, crowns) need to be removed. A caries free access to the pulp chamber (pulpakavum) is possible, and in the case of tooth vitality, a local anaesthetic (anaesthesia) will be given. A sheet of latex called the “cofferdam” will be placed around the tooth to isolate it, hence keeping it clean and dry during treatment. Depending on the variable anatomy inside the concerned tooth, an opening of the pulp chamber will be made and a straight access to the canal entrance or to the canal entrances will be created. The entrances of the root canals can be found and explained with the aid of optical magnifying aids (loupe glasses or a surgical operating microscope).
With a tiny instrument the dentist moves carefully up to the root apex (physiological apex) while inspecting this by means of radiogram; alternatively the dentist may work using a electric-metrical canal length determination, which is not covered by the German statutory health insurance.
According to the geometry of the canal the whole canal system is prepared: the aim is to remove the whole pulp tissue in the canal and not to leave any infected tissue behind. Between and during the preparation the canal system is disinfected with different solutions.
Only in few cases the whole root canal treatment can be concluded in one session, usually several sessions are required. In acute cases medication will be placed in the opening to allow a complete regeneration. The insertion of medication should be stopped (the German statutory health insurance pays three times for a replacement of the inserted medication) – when the tooth is free of symptoms and canals are completely prepared and dry.
There are many methods of filling the canal system (obturation). The canal system needs to be filled properly up to the root apex by a filling without bubbles and the material needs to be well tolerated. The standard filling material is gutta-percha.
After the filling of the root a check-up is always indicated. There is no alternative to the radiography. After about four weeks a further check-up is required. If the patient is without symptoms, the treatment should be finalized.
If there is an irreversible inflammation (pulpitis), the nerve has died or become infected, the root apex has already been affected and, perhaps, has already reached the surrounding tissue (Periapex) and not to be forgotten, what was the cause of the fall of the nerve …. Although cavities are a trigger, the incorrect restorations or periodontal phenomena (infection through deep gingival pockets) are also possible. In the case of an infection of a deep gingival pocket, a sole root canal treatment might not be sufficient and then only a therapy of both clinical pictures will eventually succeed.
After a temporary filling, the tooth should eventually be restored solidly. An adhesively anchored (= glued) filling may be able to stabilise a root canal tooth better than a conventional prosthetic solution (e.g., crown). The stabilisation probably needs to be done through a post construction in which adhesively fastened (= glued) variations (e.g., fibre posts) seem to be more suitable than metallic posts. Fibre post constructions are the most similar to natural teeth, but the costs are not covered completely by the German statutory health insurance. To achieve the best long term prognosis for your natural tooth, an adhesive plastic construction is also essential if a crown is placed on the tooth later.
In most cases the repetition or revision of the root canal treatment is sufficient. This is not covered by the statutory health insurance scheme. Nevertheless, in rare cases a root end resection is the last resort for saving the natural tooth. Here the gum is lifted to uncover the underlying bone and the root end of the tooth. The damaged root end is removed by minor surgery.
Nevertheless, such a treatment is considered as a routine operation which is usually completed successfully with the preservation of the tooth. The prognosis can be improved by a microsurgical preparation of the root from the root end side which will afterwards be filled with special cement. The costs of this therapy are not covered by the statutory health insurance.
