- Inadequate anesthesia: The stigma associated with the question “OMG, you are having a root canal?” is rather unfortunate. Pain management is achievable today in the right hands. It should be a very rare occurrence that root canal treatment is a painful, nightmarish experience. On the contrary, with the right skill-set and ability, the dentist who understands and implements “pain management skill” should be able to perform root canal treatment without causing the patient the kind of pain associated with the stigmatized memory that many patients currently carry…
- Weakening of the tooth: So often I redo root canals that demonstrate the unfortunate undermining of good tooth structure due to aggressive and indiscriminate access openings into the pulp chamber. This results in the irreversible weakening of the tooth with obvious negative consequences. There are two main reasons for this. Firstly, most root canal treatment is performed by dentists who have not fully developed the skill-set needed to do these procedures at the highest level. The second reason is that the surgical microscope is not used; the level of magnification and illumination produced by the microscope helps the dentist see with incredible accuracy thus reducing the chance for “gouging” and weakening of the tooth.
- Missed canals: This is a huge problem and the cause for a vast majority of root canal failures. It is one of the main reasons my practice is filled with patients who need root canals retreated. Again, the surgical microscope is absolutely critical in locating and fixing these missed canals. With correct training, skill, commitment and the surgical microscope, the chance of missing canals is reduced tremendously.
- Short fills: The second biggest reason for root canal failure is the multitude of inadequately filled root canals. It is so much easier and quicker to fill root canals short. This is because the most complex part of the root canal system is usually the last few millimeters of the root. This is where most of the time and expertise is needed to do the job right. This is the area most neglected by the operator leading to long-term failure in so many cases.
- Inadequate disinfection: A human being can do so much and no more to clean and shape a root canal. After that, we need to rely on chemicals to get into all the nooks and crannies of the root canal system. The technical term for that is “chemical debridement”. Many root canals are filled as soon as the dentist feels he has done the work of cleaning and shaping. As a result, tissue remnants and infection can be left behind in the root canal system. This serves as a source for failure long-term. The science has evaluated and demonstrates the importance of “soak time”. We clean and shape and only then, once there is space available to hold a volume of the disinfection agents, do we begin to count the soak time. It should be obvious to you now that “extreme attention to detail” is a key element in the nuanced procedure called “Root Canal Therapy”.
- The One Shot Root Canal: Most root canals are done in one visit; the so called “One Shot Root Canal”. This is the incorrect approach in most cases and it takes a judicious and objective understanding of the literature to appreciate this. This is a hotly debated topic in this field and too complex to discuss here. Bottom line: be aware of root canals done “quick” and in “one visit”. They might sound enticing as it gets you out of the chair fast, but tissue remnants and bacteria remain in key areas that can result in post-operative problems including pain and reinfection over time. Feel free to contact me any time to discuss this further!
- The use of old filling techniques: We use a more modern technique called “Warm Vertical Condensation”. This procedure results in hydraulic forces that fill the canal system in three dimensions causing the materials to flow into areas of the root canal space called accessory/lateral canals, with a higher level of predictability than the old “cold lateral condensation technique”. Be aware of this as the old techniques, used by so many dentists, could leave you with a compromised result.
- Neglecting the presence of the smear layer: The bottom line is that dead tissue and bacteria remain behind in the smear layer that blocks canals and compromises results. We use chelating agents to remove it.
- Completing a root canal without sealing it right away: Coronal leakage is “the silent killer”. When a root canal treatment is completed, a coronal seal should be placed immediately over the root canal filling material. This procedure should be the standard of care but its importance has not yet hit the mainstream dental community resulting in many freshly filled root canals re-infecting within the first few weeks of completion. There is excellent scientific evidence of this but most don’t follow it. Scary isn’t it? What do we use to seal? We bond a composite material over the root canal material that we have tested and know seals extremely well, reducing the risk of root canal reinfection. We have been doing this for many years now. Hopefully someday soon this will be a routine procedure thereby saving thousands of patients a year the added torment of root canal reinfection and failure over time.
- Misdiagnosis: One of the biggest challenges can be root canal diagnosis. The problem is that we rely too heavily on patient symptoms and the ancient technology of x-rays. X-rays were invented by Rontgen in 1895 and the technology has remained pretty much unchanged since! The issue is that we rely on a two-dimensional film to evaluate a three-dimension object. This has huge shortcomings and often results in misdiagnosis.
I often speak about “our love-affair with asymptomatic”. The problem here is that medicine and dentistry is way too reliant on patient symptoms in order to diagnose disease.
You need to realize that by the time the human brain has detected the pathosis, the disease process has usually reached a very progressive phase.
As a result, we as doctors spend most of our careers treating medium to end stage disease. In our field, the consequences of this approach usually are not as dire as in medicine. Nevertheless, our goal should always be to optimize the situation at hand. For me this means accurate, early diagnosis and a logical preventative approach wherever possible. Diagnosis, with all its challenges, is best done by a clinician who understands the scientific nuances and has the foundation/experience to deal with this.
It should be obvious to you now that extreme attention to detail is a key element in the nuanced procedure called “Root Canal Therapy”.
It takes a depth in knowledge and wisdom through experience to be able to consistently follow a path of excellence in diagnosis…