I need to go to a root canal specialist?

Dr. David Alfaro, Beer, Pizza, Dental Implant, Vancouver, Unicorns, Dentist

Pretty much at least once a week I have someone present on an emergency basis with concerns about severe tooth pain, a broken tooth, or some sort of swelling. Unfortunately, in many cases these symptoms are the result of a tooth that is necrotic (dead pulp), or well on its way to it. To save a tooth like this, a "root canal" is often required. Now this is a treatment that every dentist had to learn in order to graduate dental school, but some of us refer to specialists.

I refer all of my root canals. It often takes some convincing, but in the end, my patients always understand why I do.

Let us talk about referring out "root canals".

Why would someone need a "root canal"?

There are various components to the tooth. The outside of the tooth is enamel (or cementum at the root), which covers the dentin, which then surrounds the inside of the tooth, which is called the pulp. The nerves and blood vessels that feed the tooth enter the pulp via the tips of the roots, where they travel to the pulp chamber via the root canal system.

When a tooth is injured by tooth decay, trauma, or excessive heat, cold or chemical attack, the cells inside the pulp die, including the immune cells that are constantly fighting off bacteria. Once dead or dying, the tooth can no longer defend itself, and the bacteria make themselves a nice little home inside the pulp chamber. They live there quietly until the toxins they make work their way down the root system and out of the tip of the roots, where they irritate the bone and cause a localized inflammatory/immune response. This is when people usually show up at the office, because that type of pain and pressure is often unbearable.

At this point, a "root canal" is needed. To complete a root canal, the dentist must cut a hole into the top of the tooth in order to access the pulp chamber. Once the pulp chamber is cleaned up, the dentist must find the beginnings of the root canal systems in order to be able to disinfect them. After the root canal system is cleaned and disinfected, it is filled with a rubber based material. The coronal portion is then restored, often with a core and crown.

If you learned how to do root canal fillings, why would you refer?

Root canal filled teeth are notorious for breaking, and once a tooth is broken it often needs to be removed. Different dentists will tell you different reasons for why root canal treated teeth are prone to breakage:

"the tooth dries up and becomes brittle"

"the patient can't feel the tooth so they bite harder"

"the root canal filling process puts pressure on the roots"

All of these are possible explanations, but what is a more accepted reason is that a tooth requiring a root canal filling is often very damaged in the first place. The more that you remove material from a tooth, the weaker it is, and the more likely that it will break. Conservation of tooth structure is therefore paramount in every procedure we do.

And this is why I refer.

It is tricky to find the openings to the root canal systems, so often a big hole is made in the top of the tooth in order to see things, and to get the instruments in. Many dentists therefore perform root canal fillings with the help of magnification, thanks to "loupes". But there is a better option: microscopes.

The use of microscopes has completely revolutionized root canal therapy because it allows the dentist to be as conservative as possible when trying to find the access points to the root canal systems. It is no longer necessary to make a big hole in the tooth for a root canal filling.

Learning to work with microscopes, however, is not an easy task, and takes years of training to get comfortable with. Dental schools are implementing microscopes into their programs, but realistically the students are just learning how to drill with direct vision, and how to work in inverse with hand mirrors and dental loupes; throwing in a microscope is another challenge that is difficult to master in the short time that dental school really is.

Dr. David Alfaro, Beer, Pizza,Dr. David Alfaro, Beer, Pizza, Dental Implant, Vancouver, Unicorns, Dentist

Endodontists are dental specialists who spend two to three years, and thousands of hours of clinical time, training how to use microscopes for their craft, all while tackling complex cases. Yes, a general dentist can work with a microscope too, but realistically it would take years, if not over a decade, to accumulate the amount training that endodontists spend working with microscopes during their residencies. Then throw in the fact that they spend all day every day treating root canals, and have customized their offices to allow themselves to provide the best care they can, there is no question in my mind that when my patient shows up with a throbbing molar, that they are getting booked with the first available endodontist.

And my patients often complain about the referral. Why can't you do it? But it is so expensive! My insurance only covers a small portion! Can't we just pull it? Can I so somewhere that they do everything?

No. Go to the specialist. Please.

And eventually they do.

I always follow up with my patients after their treatments, and review the report that I get from the endodontist with them. I show them the photos (like the ones below) so they understand why I sent them to a specialist. More often than not, they are that happy I did.....well, with a little grumbling about the price....but quality work does not come cheap.

It is hard to understand what conservative endodontics is until you see it. Let me explain on a couple of pictures:

Here you see that the entrances to the canals are not very visible, so there has been a large hole made in the top of the tooth. This tooth has been significantly weakened due to this procedure.

Compare the picture above to this one below. A tiny hole has been made to access the canals. This would be virtually impossible to do without a microscope. (Courtesy: Dr. Ellen Park)

Microscopes also allow for the completion of treatments in a novel manner. The usual "access" for a canine is a large hole in the back of the tooth. This case was completed via a tiny access on the tip of the tooth, significantly conserving tooth structure. (Courtesy: Dr. Mark Parhar)

Here we can clearly compare a root canal access that was completed without a microscope, to one that was completed under a microscope. These are supporting teeth for a bridge; the access on the right is much more conservative and can improve the chances of the bridge remaining in place.

(Courtesy: Dr. Joel Fransen)