I. What is Root Canal Treatment?

Root canal treatment (RCT) is a treatment method that is aimed at retaining teeth with irreversible pulpal damage. Pulp here refers to the collection of blood vessels and nerves that lie in the ‘roots’ or ‘legs’ of a tooth. Bacteria invade the space within the root canals of the tooth deep inside. Through RCT, doctors create a cavity to reach the interiors of the root canals, clear the space of the infecting microbes (using anti-bacterial solutions called irrigants to wash the space) and then fill the space with a solid filling.

A root canal is a common dental procedure that can save your natural teeth and prevent tooth loss because tooth loss would require a dental implant (or dentures) to fill this space. RCT safeguards the functional role of a tooth in the oral cavity.

II. Procedure for RCT

In the endodontic treatment there are, broadly the following phases:
 The opening of the pulp chamber.
 Then comes the shaping of the affected tooth- this is done either by hand or by using rotary instruments;
 The cleaning phase, where irrigants are activated and enhanced and a temporary filling material is placed;
 The obturation phase, where a permanent material called gutta percha is placed and the access cavity is sealed with a temporary filling material.

Of course, the treatment must be concluded with a permanent sealing material i.e the post-endodontic restoration.
Let us look at these in detail:

1. Numbing:First and foremost, the dentist will, through local anesthesia numb the area around the infected tooth.

2. Forming/generating the access cavity: In order to perform the procedure, the dentist will require creating a hole to access the nerve space. This hole is called the “access cavity.” The dentist will drill the tooth from its surface to make an opening that will go down up to the pulp chamber. The dentist will perform his treatment through this access cavity. For front teeth, the cavity will be made on the rear side of the teeth.

The dentist clears away any tooth decay or any brittle portions of the tooth while creating the access cavity.

3. Measuring the length of the tooth:For the dentist to perform the RCT, he must measure the length of the ‘nerve space’ or ‘root canal’ of the tooth. This is vital because if the treatment goes to an area beyond the nerve space it might lead to post-operative pain. If the dentist uses an apex locator (an electronic device), a beeping sound will be heard as soon as the file reaches the canal’s end (tip of the root), when the dentist slides the file into the root canal.

The dentist will have to measure the length of each of your tooth’s root canals. A tooth can have more than one root canal.

A dentist can use two methods to take these measurements:

a. By taking an x-ray: Conventionally, dentists have determined length measurements by way of taking an x-ray after positioning a root canal file in the root canal. Files look like tapered straight pins whose surface is rough. As root canal files are made of metal, they show up clearly in an x-ray. The actual calculation is made by studying the markings on the file. The x-ray is simply used to ensure that the file is positioned properly (extending to the full length of the tooth).

b. Recent discoveries have made available apparatus that facilitate measurement of the root canal with the help of electronic apparatus.

4. Cleaning the tooth and shaping the root canals: The next step in the root canal process is the “cleaning and shaping” the inside of the tooth (its pulp chamber and each of its root canals).

• The cleaning is directed at removing or doing away with nerve tissue (live or dead), as well as any bacteria, toxious deposits and other debris housed in the inside of the tooth.

• Shaping refers to a process where the root canals are made spacious to enable the dentist to do the ‘filling and sealing’ that follows. Care must be taken by the dentist to remove only so much internal tooth structure so that the integrity of the tooth is not compromised during the treatment.

• The shaping and cleansing are done with tools called files. The files are used up and down, with a twisting motion. Some files may be operated by hand and some usingmechanized or automated rotary endodontic instruments.

• Tooth irrigation is another significant part of the cleaning and shaping process: While performing his work, the dentist will periodically irrigate (flush out) your tooth to wash off debris and contaminants.

• If a patient finds it difficult to keep the mouth open for long, dentists put a rubber prop (a “bite block”) between the patient’s teeth.

5. Sealing the tooth: After the interior of the tooth has been thoroughly cleansed and properly shaped, it must be sealed with its hollow interior filled in. The most commonly used material to fill the root canal is a rubber compound called gutta percha. It comes in cone shapes to match the size and shape of the root canal files. The dentist must ensure that the cone extends to the whole length of the canal to completely fill it forming a solid mass inside the canal.

6. Temporary filling: After sealing of the tooth, the dentist will place some type of provisional (temporary/not permanent) filling to close the access cavity created at the beginning of the procedure. This ensures that the treatment rendered so far is protected.

7. Wrapping up the treatment: Once the access cavity is thus sealed, it ends the root canal process. However, there is still some treatment left and that is a permanent restoration must be done. Subsequently, after a few weeks, the dentist will finish the treatment by placing a ‘crown’ on the top of your tooth. If a permanent restoration is thus placed, then, the endodontic therapy performed will last long and strong. Ideally, this permanent restoration has to be placed within a reasonable timeframe according to the instructions of the dentist, else the treatment did so far will be prone to damage.

III. Tests needed before an RCT:

It is common for us to pose the question- ‘When do I need a root canal treatment?’ Determining whether a tooth requires endodontic therapy isn’t always an easy job. Some common symptoms of tooth decay can be a visible injury or swelling of the gums, excessive sensitivity to hot or cold liquids or food or pain/bleeding in the tooth and gums, discoloration of the teeth, pus formation, tenderness, cracked teeth, soft tissue asymmetrical changes etc.

These are not all. At times, the symptoms of infection may not be obvious but there will be a persistent feeling of discomfort. At such times, an examination by the trained eyes of a dentist is warranted. The dentist will collect information from various sources and will have a chat with you regarding the type of discomfort, location, duration etc. Based on this, he will arrive at a finding as to whether the tooth requires a root canal treatment.

Types of tests: The types of tests employed to ascertain whether an RCT is needed are a thermal test (hot and cold), percussion, electric pulp testing and yes, the x-rays.

It’s only after studying patients’ dental and medical history, symptoms visible, tooth testing and a clinical examination that a dentist can ascertain if a root canal procedure is appropriate.

IV. Advantages and Disadvantages

Root Canal Advantages:
• The tooth is not extracted, it is resurrected and retained.
• The bone around the tooth is not lost and the structural integration is protected.

Root Canal Dis-advantages:
• It is not a total foolproof treatment.
• It has to be undertaken by hands trained at it.

V. Measures to be taken before and after RCT

Before RCT
• The patient must be mentally prepared to undergo the RCT
• Ideally, he should get plenty of rest
• Eat regular meals before an appointment unless he is under I.V sedation
• Get the x-rays given to him by his general dentist

After RCT
• The patient should avoid eating anything until the numbness in his mouth is no longer there, lest he should bite his cheek or tongue.
• He should not chew or bite on the treated tooth until he has it restored by his dentist.
• Keep a track of his oral hygiene and follow certain sanitizing tips to maintain his oral care
• Be sure to brush and floss his teeth as he normally would.
• It is possible that a thin layer will fall off in bits if the opening in his tooth was restored with a temporary filling material. If the wearing off happens in large amounts that seems unusual, it is recommended to see the dentist.
• He should contact his dentist right away if he develops any of the following: a visible swelling inside or outside of his mouth; an allergic reaction to medication, including rash, an itching sensation, his original symptoms; or his bite does not feel normal.

VI. Preferred Age, Gender, etc. for RCT

Both young and old can undergo a root canal treatment. However, for younger patients (in their early teens) the treatment should be approached with care as eruptive movements may result in alignment issues.

VII. Advancements in RCT

Endodontics is undoubtedly a field that is constantly evolving albeit in a quieter way as compared to other speciality areas.

The advancements in RCT have been summed up by Dr Raju Srinivas, Cosmetic Dentist, Endodontist and Implantologist, He says, “root canal treatment has got hi-tech recently, making the procedure as easy as possible for both the patient and the dentist. Thanks to the recent root canal advancements, without invasive dental surgery with modern dental instruments and resources, we can complete root canal treatment successfully and the patient can have the procedure done in just one sitting and virtually painless”.

The advancements majorly are in the following areas:

(i) Advanced anesthesia

(ii) Equipment and ultrasonic instruments used in RCT- New and sophisticated state of the art equipment is currently the order of the day in the root canal procedure.

For example, the new operating microscope currently under use for RCT deals with complex root canal fillings. The main attribute of the operating microscope is the increased power of resolution i.e. it enables the endodontist to see distant points that are very close together thus making the human eye able to observe more details. There is also provision for a video camera to be attached to the microscope to capture images of the tooth.

Mention must be made of the ultrasonic instruments. These instruments have different types of tips that have varied kind of shapes, length and materials. The ultrasonic tips render a great cutting accuracy. As they have smaller dimensions, they allow a better view of the operating field to the doctor than the rotary instruments. (See image below):

Since the time the ultrasonic and sonic instrumentation became a part of the endodontic treatment, dentists world over are able to locate with greater precision the calcified canals, formulate root-ends in RCT, and clean the canal walls to perfection.

(iii) Digital x-rays which emit less radiation; and

(iv) Use of nickel-titanium files- Use of nickel-titanium files is a welcome development in endodontics. These Ni-Ti files bring with them a host of advantages. Dr. James Bahcall writes, “With the development of nickel-titanium for endodontic files,rotary nickel-titanium files have provided dentists with a more consistent, efficient, and effective means of performing endodontic treatment in comparison to stainless-steel hand filing” The very flexible nature of these files combined with the mechanized motion created by the handpiece ensures faster cleaning and shaping of the tooth’s root canal system. This saves the precious time of the dentists and makes it more comfortable for the patient.

In addition to the above, the following are other advances in technology concerning RCT (they have been dealt briefly without going into details)

CBCT in Endodontics: 3D Diagnosis and Treatment
Cone-beam computed tomography (CBCT) technology is the latest medical imaging technique that facilitates 3-D imaging at reasonable costs. It is a supremely useful technique compared to the conventional 2-D radiographs. Unlike a 2-dimensional (2-D) radiograph, CBCT can provide early detection of pathosis in the cancellous bone while eliminating the superimposition of anatomic structures.

CBCT cannot claim to replace the conventional digital radiograph butis an advantage over it as it ensures a 3-D field of view when required.

CBCT aids in the diagnosis and treatment of increasingly challenging and complex cases. CBCT imaging aids in the assessment of dental trauma.

CBCT imaging is exceptionally useful in the treatment of resorption. While radiographs show resorptive defects, they don’t provide elaborate information regarding the magnitude of the defect and the presence of perforations. CBCT imaging, on the other hand, provides this information with a much higher accuracy.

Recurrent pathology in previously endodontically treated teeth is best assessed with CBCT imaging.

Irrigation and Obturation
Endodontic files remove a considerable portion of the vital pulp tissue within a canal, however, it is not guaranteed that all the infected pulpal tissue is removed. Endodontic treatment is certainly more effective when the biomechanical preparation is performed with the combination of mechanical instrumentation and various irrigating solutions. Studies are in progress for the use of newer irrigating solutions.

The use of digital radiographs is increasingly becoming a practice. They help the dentist view, magnify, enhance, and store endodontic radiographic images in a format that saves them from degrading with time. A digital endodontic radiograph using a high-resolution monitor allows accurate and easy interpretation by the clinician.

Future Trends in Endodontics
As with any field, even in dental health care, technological advancements are looming large. The use of 3-D printing has revolutionized the sphere of endodontics.

Regenerative endodontics seems to be the future innovations in the field of oral healthcare. Regenerative endodontics can, in simple terms be explained as a biological procedure that replaces the hard tissue of a tooth along with cells of the pulp. The time is not far when regenerative endodontics becomes commonly applicable.

VIII. Why Dental Planet for RCT
For any oral health-related problems, Dental Planet is the ‘the’ place to be! As the name indicates, it is indeed a whole planet of dental care where every aspect of oral care is offered at affordable charges.
Ideally located at Gachibowli and Indiranagar, Hyderabad the clinics are well connected and accessible to the public.
Dental Planet can boast of an infrastructure that encompasses the latest technology and equipment with highly qualified medical fraternity consisting of dentists, dental cosmetologists and endodontists. The fee charged by the specialists is reasonable as compared to other dental clinics. Treatment is flawless with prompt and regular follow-ups!
The staff is well informed, warm, organized and exhibit a friendly attitude. All queries are addressed with patience and answered in detail