Endodontics

endodoncjaIn many cases, a patient visiting a dentist with a toothache hears this: “We need to perform root canal work.”  In fact, every tooth is a small organism with its own innervation and vascularization.

When a tooth loses its stability, e.g. due to a deep cavity, the result is pulp inflammation that causes pain. The pain itself may be of greater or lesser intensity.

Endodontic treatment involves removing the infected internal tooth tissue and cleaning its channel, followed by disinfecting and tightly sealing the tooth with the proper materials.

For this purpose, in our clinic we use cutting-edge equipment (including OPMI pico ZEISS microscope) and materials: nitinol machine tools and hot gutta percha. Electronic measurement of the root canal length and the distance from the root apex is performed using highly-accurate Morita endometers.

When processing the root canal, we often use endodontic microengines with rotary instrumentation systems, as well as ultrasonic instruments for root canal processing.

Digital radiovisiography is very important in the course of treatment. In the most difficult cases, we use a CT scanner to radiologically control the whole course of root canal work. Minimization of radiation has turned imaging into a safe procedure.

Frequently Asked Questions:

It is a treatment that removes infected tissue and bacteria from the inside of the tooth (from the pulp chamber and canals). It is important in the course of treatment to properly shape and widen the canals in order to properly clean and disinfect the area and then to fill the canals with biocompatible materials. The reconstruction of the tooth is also very important because, not only a properly performed root canal treatment is a guarantee of the full success of the treatment, but also a tight seal and strong reconstruction.

In many cases, root canal treatment can be completed in one visit which significantly optimizes the procedure and reduces the risk of complications such as a tooth crown fracture.

In some cases, previous root canal treatment does not bring the expected therapeutic results. The most frequently occurring indications for further treatment are inflammatory changes with underfilled root canals visible on a radiological photo or carious defects or leaky fillings that cause repeated infections of the filled canals.

Re-treatment consists of removing the material that fills the tooth canals, finding, restoring, cleaning, and widening all possible canals, then filling them with biocompatible materials. In re-endo treatment, as in the case of regular root canal treatment, a tight seal is an equally important aspect of strong restoration of the tooth crown.

Clinical and radiological visits are important after root canal treatment because the healing process of inflammatory changes can last up to 12 months.

It should be remembered that re-root canal treatment is a treatment carrying some risk. The degree of tooth destruction, the progress of inflammatory changes, the possibility of maintaining the tooth in the oral cavity, and the risk of complications should all be analyzed.

Sometimes a sick tooth cannot be saved. It is worth mentioning that the risk of complications increases if the root canals are characterized by a complicated structure (for example, if they are curved), run an unusual course,  or are clogged.

Often during root canal treatment, an infected tooth is found to have an unusual anatomical structure.  The root canals can be narrow, curved, or obstructed or there can be an obstacle in the root lumen (e.g. a broken tool, a crown-root insert).

In such cases, we use a MICROSCOPE which enables and facilitates precise treatment in a small treatment area. The advantage of microscope use is due to the magnification and illumination of the treatment area. It helps in identifying previously undetectable structures, allows visualization of root canals, and detection of narrowings, pulp canal obliteration, and other irregularities.  The microscope is used primarily to find and treat root canals which are often not visible to a dentist in traditional treatment. It also allows the removal of broken parts of tools from the canal, hard cement filling canals, or crown-root inserts.

Thanks to the endodontic microscope, it is possible to treat cases that are difficult, atypical, and initially doomed to failure.

We have 3 microscopes (Zeiss) with the best optics in our facility.

World guidelines for root canal treatment require the use of a dental dam, an isolating material used in dentistry.

A dental dam, sometimes called Cofferdam, is a thin rubber sheet in which there is a hole through which the selected tooth or teeth are isolated. A clamp, depending on the size of the tooth, is placed on the rubber sheet to hold it in place.

ADVANTAGES OF TREATMENT WITH A DENTAL DAM:

  • greater visibility of the treatment area
  • protection of canals against infection from bacteria in saliva
  • protection of patient against irritation by rinsing agents or swallowing tools
  • moving the tongue and cheeks away from the work area
  • keeping the mirror steam-free
  • shortening the time of the procedure

We currently use modern thermal systems that utilize the malleable properties of GUTTA-PERCHA, which is a biocompatible material used with a sealant to fill the canals after they have been cleaned and widened. When heated, the material becomes plasticized. Thanks to that, we can precisely introduce the material into the canal condensing it well in order to obtain the tightest seal and uniformity of the filling within the whole root canal.

X-ray diagnostics is an extremely useful diagnostic method in the case of root canal treatment.

Minimal radiation doses allow us to take several intraoral photographs during one visit – without any impact on the patient’s health.

Using x-ray diagnostics, we can check, among other things, the state of the tooth before treatment, the presence of inflammatory changes, the extent of destruction, the patency of the canals, and the presence of obstacles in the canal (e.g. broken tool).  We can also verify the fit of the filling material or the condition after filling the root canals, documenting the course of treatment from beginning to end.

Also treatment ends (usually after 6 and 12 months), we check the course of the healing process of inflammatory lesions in a follow-up picture, comparing previous images to current ones.

Modern diagnostic tools allow excellent visualization of even small and complex anatomical structures. Computed tomography in dental diagnostics is an advanced, three-dimensional, and precise imaging technique. We take advantage of these tools in difficult cases of root canal treatment.

A classic X-ray picture, which is a two-dimensional projection, does not allow visualization of all the canals of the teeth and other anatomical details.

Thanks to the use of computed tomography, an atypical run of dental canals, a frequent cause of ineffective surgery, can be mapped. The doctor can determine the presence of additional canals, find root rupture, and picture the size of inflammatory changes.

However, a doctor should decide on the need for a CT scan.

The risk of complications of root canal treatment increases if root canals are characterized by a complicated structure (canals are curved, have an extensive root delta, i.e. a system of tiny lateral canals), have an unusual run, or are blocked. The situation is exacerbated by the presence of non-healing inflammatory lesions around the apex of the root.

In such cases, a surgical procedure, such as RESECTION, helps us to maintain the tooth in the oral cavity.

It is a procedure involving the removal and cleaning of non-healing inflammatory lesions and the top of the root (e.g. in the place of root canal obstruction).

The procedure is performed under local anesthesia, so patients do not experience any pain during the procedure.

The technique is not complicated. The gum tissue is scored at the apex of the root and the affected tissue, bone, and inflammatory lesions are removed. The wound is stitched with initial healing for about 10 days, while the bone will be regenerated in about 6-12 months. Often the root is filled at the same time, tightly filling the root canal with biocompatible materials, e.g. MTA – mineral trioxide aggregate. This is a so-called retrograde filling.

Due to surgical intervention, typical symptoms may appear after surgery, such as swelling of the surgical area, and pain or redness. Usually, cold compresses and painkillers (also anti-inflammatory) can eliminate these unpleasant symptoms, and within a few days patients return to normal.

Pathological resorption is a progressive, abnormal loss of hard tissue of the tooth or bone. Resorption occurs for many reasons. It can be caused by inflammation or by mechanical damage to the tooth – for example, as a result of an injury (with strong tooth trauma). The mechanical action initiating resorption can also be the result of orthodontic treatment.

Resorptions are often asymptomatic and pain rarely occurs. Most often they are diagnosed on the basis of an X-ray. Internal resorption occurring within the crown or neck of the tooth may appear as a pink colored tooth.

Advanced resorption destroys the bone around the tooth root which is why root canals are often filled with substances that disinfect the root, stop the infection, and facilitate bone reconstruction. The so-called bone substitute materials that help to fill cavities in bone tissue are also used (exogenous materials, e.g. Bioss, BioGuide or autogenous materials: PRF, A-PRF, CGF)

The treatment of external and internal resorption is not easy. Depending on the reason, the doctor makes decisions as to the method of treatment. In some cases, it is necessary to remove the tooth.

Causes of internal resorption:

  • Long-lasting chronic inflammation of the pulp and pulp necrosis
  • Orthodontic treatment
  • Traumatic factors: poorly fitted fillings, restorations
  • Hereditary factors
  • Other general factors

Causes of external resorption:

  • Chronic inflammation of periapical tissues (granulomas, cysts)
  • Orthodontic treatment
  • Tooth injuries
  • Replantation (intentional and post-traumatic)
  • Whitening of dead teeth
  • Pressure from neighboring teeth, tumors, cysts
  • Impacted Teeth
  • Periodontal disease
  • Systemic diseases
  • Radiotherapy
  • Idiopathic resorptions

The microsurgical treatment of tooth crown extension is performed when the tooth breaks under the gum or has deep caries, which have destroyed it below the gum line, and in particular below the bone margin of the alveolar bone. In this situation, attempts to put in a filling or a prosthetic crown are doomed to failure.

This is due to the fact that it is not technically possible to put in a filling or crown in the wet environment beneath the gums because in such conditions dental materials do not bind in properly. Not every tooth qualifies for this type of surgery;  therefore, the dentist decides about its implementation.

During the procedure, performed under standard local anesthesia, healthy tooth tissue is revealed so that it is no longer hidden under the gum and / or bone. This is related to the reduction of bone tissue 3 mm below the level of the fracture or carious defect.

After the healing period, the tooth can be rebuilt because the gum is placed lower and allows for a tight reconstruction – its type is always decided by the physician choosing a method that will protect the tooth from being broken again. Reconstruction with a crown and root insert and a prosthetic crown is the most recommended.

Unfortunately, cases of vertical fracture of the tooth along the root, deep fractures, horizontal root rupture, or root decay are an absolute indication for tooth removal.

It should be remembered that every root canal treatment is a treatment with a risk of failure. When making such important decisions, it is necessary to analyze the degree of tooth destruction, the progress of inflammatory changes, and the prognosis, and thus the possibility of maintaining the tooth in the oral cavity and the risk of complications.

The most common factors that worsen the prognosis, as well as often the reason for qualifying the tooth to be removed are:

– destruction of the crown preventing the establishment of a tight reconstruction

– extensive inflammatory changes, resorptions actively destroying tooth tissue and bone

– massive crown-root inlays impossible to remove

– root fracture

– overly widened root canals, perforations

Although modern endodontic tools are made of increasingly durable and flexible materials (stainless steel, nickel-titanium alloy), they may undergo spontaneous breakage during the procedure.

This usually occurs when working on particularly curved or occluded canals.

It can happen when the tool gets stuck in the canal and breaks during withdrawal.

A fragment of an endodontic tool found in the root canal is one of the most common complications in root canal treatment.

It should be remembered that inflammation is not caused by the broken tool, but by dead, infected tissue left in the canal which could not be removed during root canal treatment. If the tool breaks in the initial phase of treatment, when the canal is still infected, it may worsen the prognosis due to preventing access to the canal. However, if the breakage occurs in the final phase of treatment, when the canal is already disinfected – in most cases, nothing happens.

Removal of the tool should always be attempted; however, if its position allows you to create a bypass – for example, the tool is wedged into the canal wall, then you can work on a canal next to the broken tool and leave it without any health consequences.

If the tool cannot be removed, RESECTION is a helpful procedure.

There are many ways and techniques to remove broken tools. Many companies have developed special kits. It is very helpful to use ultrasounds with a special tip to loosen the broken tool, connect it to a special needle, and remove it from the canal. Small tweezers are used when the broken tool is located close to the tooth cavity so as not to damage its deeper layers.

A few days after the root canal treatment the tooth can be tender, and the patient may experience temporary discomfort. It is the body’s natural response to the mechanical, chemical, and thermal irritation that occurs with this type of treatment. After this period, the tooth should remain asymptomatic.

Pain that appears long after treatment can be disturbing. Pain while eating, pain to the touch, and spontaneous pain may indicate an impaired healing process and activation of inflammatory process. In this case, you should immediately go to the dentist to check the cause of the symptoms.

No. All procedures are performed under local anesthesia so that the patient feels as comfortable as possible. For each tooth, we individually choose the method of administering anesthesia and the type of anesthetic. After treatment, there may be slight, temporary pain in the surrounding tissues and tenderness of the treated tooth while biting. In a few cases, chronic inflammation of periapical tissues may worsen and pain and swelling may occur. ONLY if there are general symptoms, the patient will be treated with antibiotics, anti-inflammatory drugs, and analgesics. The occurrence of exacerbation results from the virulence of bacteria living in the canals and the condition of the patient’s immune system. It DOES NOT MEAN that the treated tooth has less chance of healing.

Root canal treatment under the microscope has a high level of effectiveness. However, it must be remembered that 100% success in any medical procedure cannot be guaranteed. Even the best-performed treatment can fail to succeed because of reasons beyond the physician’s control. For teeth with no bacterial infection, the success rate in endodontic treatment is over 90%. If the tooth is infected, the odds of success decrease with the increase in the degree of inflammation.

If root canal treatment under the microscope fails, which may result in pain, swelling, fistula, or lack of healing changes visible on the X-ray, further steps will have to be taken to eradicate the infection. It may be a re-treatment, a surgical procedure (e.g. resection of the apex of the root) or removal of the tooth (extraction).

Teeth after root canal treatment in which no proper restoration has been made may break. Such a tooth is weakened by the carious process or as a result of an injury, which was the reason for the treatment, but also because the tooth pulp contains sensory receptors that protect against using too much pressure on the tooth surface. The pulp-free tooth allows us to load it with a force that can cause fracture.

If a deep root rupture occurs, this may result in the removal of the tooth.

Crown reconstruction depends on the degree of tooth tissue damage.

Possibilities of reconstruction:

  • light-cured filling (used ONLY in the case of slight destruction of hard tooth tissues)
  • inlay, onlay, overlay
  • crown-root insert and prosthetic crown (with great damage to the tooth’s tissues)

Our specialists:

Radosław RomanikEwelina LubońMonika Banaszek-RolaNatalia Lach

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