Why Are You Visiting Our Endodontic Practice?

1) Root Canal Therapy

Pain is not the reason you are having a root canal, but it is a great motivating factor! The reasons for having a root canal would be:

1. A cavity that has reached the center or nerve of the tooth. Once bacteria reach the nerve of the tooth, the nerve will become infected, secondarily inflamed, and need to be removed.

2. The tooth has been traumatized. When a tooth is traumatized, the blood flow to the tooth is compromised. The tooth may darken over time. Also under trauma comes other categories; a filling, a few fillings, a crown (cap) preparation, braces, periodontal work, a crack, grinding or clinching of your teeth. All can be cumulative effects to a nerve dying in the tooth.

3. The general dentist may need the root canal done to complete further work on the tooth. There may not be enough tooth structure to place a proper crown (cap) on the tooth. The tooth has to be built up. The surface area in the root will be used to cement a post. Not enough tooth structure means a cap that repeatedly comes off

Teeth may have one or several roots. The center of each root is hollow. The center would be the canal that contains the pulp. The pulp is made up of the nerve and blood vessel. Once bacteria reach the nerve canal from a cavity, the nerve will start to become infected, inflamed and die. The bacteria are free to live in the tooth, multiply, and spread out into the jaw bone through the opening in the end of the root.

The Endodontist will clean and sterilize the canals. The infected nerve tissue and bacteria are removed. The canal is sterilized. The sterilized and empty canal will be filled with a biocompatible material, a rubber-like material called 'gutta-percha."

Point 1: Once bacteria are living in the tooth, the inflammation destroys the blood vessel in the tooth. Neither your body nor any antibiotics can get into the tooth to defeat the bacteria. The antibiotics can appease the infection in the bone, alleviating some pain, but can not cure the problem in the tooth. Once we have sterilized the inside, the gutta-percha seals it off like a cork in a bottle.

Point 2: The gutta-percha has three dimensions just like the cork. It has to fill up the whole nerve canal to the end of the root.

2) A Failing Root Canal

How do you know that the root canal is failing?

1.You may have increasing pain at some point in time.

2.You may have developed a pimple on your gum that may come and go. You may have no pain.

3.Your dentist may have noticed a "shadow" at the end of the root while looking at your x-rays. You may have no pain.

4.You may have some swelling.

Why is the root canal failing? There are still bacteria in the tooth coming out, infecting the bone.

Wait a minute! If the nerve was removed, why am I having pain? The pain is coming from the nerves that attach to the outside of the tooth in the surrounding jaw bone.

Where in the tooth are these bacteria? Not all teeth are created equal! There may be an extra root or canal hiding. Something could have gone a stray with the original sterilization process of the root canal. There could be an accessory branch to a canal, like a tributary in a river, containing bacteria.

What are my options?

I.Retreat the Root Canal

II.Root Canal Surgery (Apicoectomy)

III.Extract the Tooth

I. Retreat the Root Canal

This procedure entails going back into the tooth. The root canal filling is easily removed. The inside of the root is properly sterilized. A root canal filling is properly placed back into the root. There are pros and cons to be considered. Take the time and consult with our Endodontic staff. Remember, it is not whether it is easier or harder, longer or faster, but what will give you the best prognosis (outcome) for the tooth to be tested by time.

II. Root Canal Surgery (Apicoectomy)

This procedure entails making a cut (incision) in the gum area near the end of the root. The very tip of the root is removed. A small filling is placed into the end of the existing root to seal it off.

Why would I want to consider this? If you can not retreat the tooth conservatively, this would be your second option. Now, depending on where the tooth is, this may not be an option. Molars are more difficult, and may have a decreased prognosis or chance of success.

Rule of thumb: The farther you go back in the mouth, the more the difficulty increases and prognosis decreases. Take the time and consult with our Endodontic staff, along with your periodontist, oral surgeon and dentist.

III. Extract the Tooth

Out of sight, out of mind! Sometimes a tooth becomes so structurally compromised from all the work involved over a life time that it is not sound any more. The tooth can be removed (extracted). Remember, once it is gone, it is gone! The most important step that you can do is to be informed of what to do with the space before the tooth comes out. Have a treatment plan, (game plan) with all your options laid out by your dentist. You may need to be consulted by the oral surgeon or the periodontist. The tooth can be replaced with an implant or a bridge. This may be a more sound treatment plan. How much will it cost to replace the tooth? Can the tooth be replaced?

But I am in pain now! Tooth pain is easily controlled with medication. This will allow you the time to make a decision without being influenced by the pain factor. Replacing a tooth may involve work on other surrounding teeth and be more costly, even though it is out of sight for the short term; it may not be out of mind for the long term.

3) Tooth Trauma

The tooth has sustained some type of injury. The blood flow and nerve to the tooth has been compromised. The nerve may or may not be exposed. The tooth may or may not discolor over time.

Point 1: Just because a nerve is exposed or traumatized, doesn't mean you have to take the nerve out immediately. There are many variables that come into consideration when evaluating tooth trauma:

1.The age of the tooth and patient at the time of insult.

2.The type of trauma.

3.The degree of trauma.

4.The part of the tooth that is traumatized.

5.The time of treatment from when the trauma occurred.

Most dental injuries occur in the first two decades of life, with the ages of 8-12 being the most prone. Remember, kids are like magnets! Their mouths attract everything and anything from sporting objects to the floor.

Some of the injuries that we see are:

When the crown of the tooth (the part that we see) is fractured, the pulp (nerve) is not exposed, the tooth can be bonded. When the nerve is partially exposed, the exposed portion can be medicated; the remaining nerve kept in tact, and then bonded. Both situations should be followed very closely for a minimum of one year with regular visits. By keeping the nerve in tact in young teeth, still allows the root to keep growing.
The tooth sustains a traumatic injury. The crown of the tooth appears fine, but the root can be fractured or cracked. This would be the part of the tooth under the gum we do not see. Depending on where the fracture is positioned, makes a difference on the outcome of the tooth. The best advice that we can give is to get an x-ray of the tooth and have watched closely. This is the situation were over a period of time you start noticing that the tooth slowly discolors.
A tooth is knocked out. The key factor here is speed and cleanliness. I think the worst place to go is the hospital. Dentists are not typically on staff in the emergency room. If you have ever visited an emergency room, as hard as the staff tries, it is a wait. These emergencies always happen after hours. The best thing to do is immediately call your family dentist, endodontist, orthodontist, oral surgeon, pediatric dentist. The bottom line is that you need to get to someone ASAP. Your family dentist will not be insulted if they happened to be out of reach at that particular moment, it does happen. Hold the tooth by the crown, rinse it off. Have the individual rinse out their mouth; place the tooth back in the socket. If you are reluctant, place the tooth in milk, you want to keep the tooth from drying out while you are on your way to the dentist. The tooth should be followed very closely by our Endodontic staff for a minimum of a year.

Typically, injuries that happen at school, from car accidents, sporting events, fights, or even at home may need an accident report. Reports should be very detailed. The report should encompass a thorough history, and all possible complications and costs that the patient may incur in the future.

4) Facial Pain

Guess what? It's not always a tooth. Facial pain comes in two categories: (1) Tooth Pain and (2) Non-tooth Pain.

1. Tooth Pain: Tooth pain from a bad nerve can be very specific. You can put your finger on the tooth and say "This is the tooth that hurts!"

We also may have what we call "Referred Pain". A bad tooth can send radiating pain to other distant sites. This would include another tooth, skin of your face, your eye, ear and your sinuses. Lower teeth tend to send pain to the ear. Upper teeth tend to send pain to those "Headache" areas.

Some of your symptoms (What you tell us) will be:

I have pain to cold, and the pain lingers after the cold is gone.
I have pain to hot, and the pain lingers after the heat source is gone.
I get a sharp pain every time I bite a certain way.
It woke me up last night.
The tooth hurt while I was exercising.
The tooth hurt while I went on a plane flight.
It just throbs all the time.
The Advil was working, but now I take a bottle a day and it is not helping anymore.

Point: Referred pain never crosses the midline of your face! A toothache on the bottom jaw can make your ear or upper teeth hurt, but only on that side. Pain will not refer from right to left or left to right, only up or down.

2. Non-tooth Pain: It feels like it is in the tooth area, but it is not from the tooth. This type of pain may not be as specific, shorter duration, diffuse and not consistent. So where is it coming from? There are many avenues:

Periodontal problems- The gum and surrounding bone tissue can get infected and make a tooth hurt.
Neuralgias- The nerve that goes to your teeth, also travel to the other facial structures. There may be a "trigger point" on the gum or cheek. Touching the spot gives you a pain episode that can be sharp and last a few seconds. There are viral infections (cold sores, shingles) that may set off a neuralgia typical situation.
Ear infections- Pain can be referred to the jaw area from an infection stemming from the middle ear. Positional changes of the head may make the tooth feel worst.
Sinus - The roots of your upper teeth can be right next to your sinuses. How close? Blow up a balloon, now place your fingers into the balloon, this may give you some idea. Sinus problems come from infection and allergies. The pain can be dull to severe; can last for hours and days. Head positioning can make it worst. Also a key symptom is that you are "stuffed". Typically you will not be telling us of temperature sensitivity and sharp pain from a stimulus.
Headache pain- Migraines and cluster headaches. The pain from this is severe; pain can last for minutes to hours. The pain in your teeth or jaw may change due to head position, and room surroundings.
Heart- Left posterior jaw pain is not uncommon with heart conditions, angina, and carotid artery problems. Pain may last for minutes and can be associated with exercise or physical situations. In these situations it is important that there is good communication between patient, dentist and physician.
TMD/TMJ - This pain tends to be low grade, and go on for a long time, months. The two joints the open and close your jaw located in front of your ears can be damaged from arthritis, accidents, trauma, grinding and prolonged opening of your jaw. The muscles that open and close your jaw attach to the bone surrounding your teeth. You may have a dull ache in the posterior of the jaw.
Neoplasia and benign growths- Things that can grow in your jaw that encroach and push on teeth and nerve endings in the jaw. Many cancer and non-cancer growths can occur in the jaw.

5) Bleaching a Discolored Tooth

I have noticed my front tooth has darkened over the years. Why did this happen?

Your tooth has had the following happen:

1.If there are no fillings in the tooth, the tooth has been traumatized. The nerve and the blood vessel are necrosed (dead).

2.The tooth had a root canal in it a long time ago.

If the tooth was traumatized, the nerve and blood vessel was damaged. It will die right away or over a period of time. The red blood cells contained in the blood vessel will disintegrate over time. It is just like the red hamburger patties that sit out for awhile, and turn to grey. When the light hits the tooth, it does not travel through the same. It appears grey or yellow.

My root canal was done a long time ago, and now it has gotten grey. There is some dead nerve tissue left in the crown.

Teeth that discolor this way can be bleached. The tooth needs to be bleached from the inside. You can not achieve it from the outside. If the tooth does not have a root canal, it will need the root canal first. If it had a root canal already, the filling in the back of the tooth can be removed and bleached placed inside.

6) Root Canals on Baby Teeth

Don't be so quick to be contributing to that tooth fairy! That money is still better of in your pocket then hers. Baby teeth help keep the shape of your child's arch, facial features, and help guide the adult teeth into place. Otherwise they can drift. This may increase those years of orthodontics, making it more costly and difficult for you. Keeping the baby teeth, will help to enhance chewing, nutrition, speech, and gives a psychological plus for both child and parent.

From the age of 6-12 years old, you child will have both baby teeth and adult teeth. Having decayed or missing baby teeth in the same environment as the adult teeth, starts your child out at a disadvantage. The pulp tissue (nerve) is easily removed and medicated in baby teeth. The teeth are restored with a simple filling or sometimes a stainless steel crown. Speak to your orthodontist, pediatric and family dentist. Start the kids out early. It is all about putting a fun spin on the dental experience. Remember, kids are great listeners and you are their first teachers. Do not talk negatively about the dentist; you will be surprised as to what they hear, fear and remember.

7) Consultation / Second Opinion

A consultation is a great time for both the patient and our practice to ask a lot of questions. The following objectives should be accomplished:

For us to understand your expectations
For you to understand our expectations
For us to answer your questions
For you to answer our questions
For you to understand what you treatment will entail
For us to try and put your worries aside
For us to fill in the gaps and pull the pieces together for you

Every situation and tooth is different. There are so many variables. It is difficult to compare one person's situation to yours and visa versa. The advantage of having more then one Endodontist in our practice is teamwork, and having another set of eyes to review your case.

When coming for a consultation, it is always best to have your questions written down. If there is a history, please prepare an outline or notes for us. Any previous dentals records or x-rays are a great help.

Patients are referred to our practice not only from the dental community, patients and friends, but from Cardiologists, Orthopedic Surgeons, and Oncologists. Physicians scheduling their patients for surgery and radiation therapy want their patient's teeth infection free. When time is a factor, we strive to get you complete.

8) Consultation by the Web

We can provide to you a consultation based on radiographic review and history for a nominal fee. You can send us your x-ray (radiograph) by mail or email (if digital). We will send to you a questionnaire and history form to fill out and return.

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Brian P Trava DMD, SuJean Oh DDS and Alison Petix DMD: Endodontists - Providing services in endodontics and root canal dentistry to the areas of North Jersey (NJ).

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