This issue comes up a lot in all dental practices but more so in biological dental practices because many patients who attend our offices have done their research and do not want to have a root canal treatment (see resources on our website for more information about root canals). Indeed, I spend a lot of time removing root canal treated teeth that have failed.
So how do we handle the situation where a patient requires a ceramic restoration (‘crown’ or onlay) or any restoration for that matter, to restore a heavily damaged tooth and where there is always a risk of the tooth needing RCT? There are two issues here, one of consent and one financial, since investing in a lab fabricated ‘crown’ or onlay on a tooth is significant relative to a plastic filling.
With regard to the consent issue, there is always the possibility of ANY tooth being restored may require RCT, regardless of the best biological techniques and procedures provided by the dentist. The bacterial load and host response (robustness of the immune system) are the primary factors that will determine if the ‘pulp’ (consisting of a nerve and blood vessels) can muster the appropriate immune defense to neutralize bacteria that will inevitably infect the vital root canal and invoke inflammation. Certain biological methods, such as ozone and lasers, can reduce the bacterial load and help with the immune response but there are no guarantees. I wish I could reliably predict which teeth will heal well from the stresses of restoration from those that won’t.
Some teeth that have been restored or need restoration are already non-vital , meaning the nerve and blond vessels have ‘died’ and are necrotic. Often the teeth are asymptomatic, meaning the patient is unaware they are dead. If these teeth end up needing further restoration RCT is needed to preserve the roots of the teeth before they can be restored. Dead, abscessed, necrotic teeth should not be left untreated as they can compromise the immune system and spread infection to other areas of the body. If the teeth have single roots and are not abscessed, which is detectable with an X-ray, the vitality of the nerve can be tested with an electronic device (vitalometer), in office. If the tooth has multiple roots, such as a molar, the situation can be more difficult to diagnose, even with a vitalometer. In these cases if the patient is concerned that a root canal may be necessary we can refer to an endodontist, a root canal specialist, who can determine and possibly provide a three dimensional assessment (cone beam radiograph)of the tooth to get a better look at the roots and ligaments that surround them in the bone. At this point the patient can decide whether to undergo either RCT or have the tooth extracted if the nerve is dead or compromised. If the tooth is deemed vital, the risk of compromising the nerve while performing restorative treatment, especially if there is a lot of damage, is significant. However, RCT’s can be performed on teeth that have crowns by accessing the canals through a small hole which is filled afterwards with a resin. This occurs more frequently than we like. There are no guarantees with biological systems and the acceptance of risk including the financial responsibilities that come with that risk lie with the patient. If a tooth deemed vital has a crown placed and later dies and needs either extraction or RCT that is the risk the patient must accept as well as the fact that further treatments have additional costs. After all, the damage inflicted on teeth is under control of the patient. We are lucky to have the profession of dentistry which can mitigate suffering and restore function.
Teeth are living, ‘breathing’, organs that are an integral component of our health and require special care and attention. It is important that we understand their role in health so they may serve us well for a lifetime.