Are root canals uncomfortable to have?

Most of the time they are not. If the dentist achieves a good level of local anesthesia, patients undergoing an endodontic procedure experience little or no pain. Yesterday I had my first root canal treatment. My colleague, Stan Lenkowsky, started a root canal on a molar that I had cracked years ago and had become nonvital and was symptomatic. Although, I had suspected that it needed a root canal, I, like many of my own patients, procrastinated because I was worried about how uncomfortable the experience might be. This is especially ironic because I have personally performed hundreds of root canals and most patients have reported little or no discomfort during the procedure.

Stanley, an experienced endodontist in Manhattan who has a great bedside manner, made the experience a comfortable and pleasant one. He was both thorough and gentle and the slight discomfort I did experience was tolerable ( he elected not to give me a palatal injection since it can be uncomfortable and in my case he felt it would be unnecessary).

Although I had no discomfort afterwards, some patients do have some soreness after a root canal procedure and their tooth can be sensitive to biting pressure (this is the reason, often dentists relieve the occlusion of a tooth when performing a root canal). Usually Ibuprofen or Aspiring does a good job of relieving the transient discomfort that patients can have after a root canal procedure.

What is a medicated filling?

Usually when a dentist says he is placing a medicated filling he means a filling that will release medication to the tooth. Most often dentists are referring to a temporary filling that has eugonol in it since it is a natural abtundant and has a sedative effect on irritated pulps. In my practice I use IRM for my 'sedative' fillings since it releases eugonol but it also is strong enough for long term use. It also seems to have antimicrobial properties and helps prevent teeth from experiencing recurrent decay prior to the placement of a permanent restoration.

Other types of 'medicated' fillings that dentists use are Glass ionomer based, since they tend to release fluoride over time. In my practice I make frequent use of a modified glass ionomer cement aptly named Miracle Mix since it is strong and seems to have properties that definitely inhibit recurrent decay adjacent to these restorations. Miracle Mix is made by taking the powder from amalgam capsules(sans mercury) and mixing it with glass ionomer powder to create a new hybrid cement restorative. The metal fillings from amalgam have copper,and silver and other metals that most likely provide additional antimicrobial protection above and beyond normal glass ionomer formulations. It has only one real drawback. Miracle Mix fillings are grey in color and can not be placed in areas where esthetics is important.

Dentrix Integration problems?

My integration of Dentrix Management software with my Dexis digital Xray software is not as seamless as I expected. We have been using Dexis digital imaging for storing our radiographs for the last year and a half and most of our patients have X-ray images stored in this software. We recently installed Dentrix and were promised that the integration would be 'seamless' with Dexis. Not our experience so far.

During our second training session,Daryl Kerker, our trainer, tried gamely to show us how to register new patients. Each time she did, Dentrix would give us a disturbing prompt--to either rename a patient stored in Dexis to the new patient's name or dump their radiogaphs in a general comm folder. After a couple hours of aborted training and several calls to support, it turns out that in our case the two will not play nice together. Our best option for now was to disengage the two programs. Perhaps later, when we have registered most of our patients in Dentrix we can try again to integrate the two programs. At the moment, I am neither impressed nor happy. John Giarraputo ,my Schein Technology Specialist/Salesman, seemed unaware that this would be a problem and hasn't yet offered any satisfactory solution.

Dexis support isn't sure how I should best handle the integration in the future, but one cumbersome solution was to wait until I had manually entered all the patients in Dentrix and then manually assign new numbers to all my patients in Dexis. This sounds time consuming to me. So much for the flawless integration.

If any dentists reading this have had a similar experience and might offer any good solutions I would be happy to hear from them. At this point I am looking for solutions to these integration issues. If anyone has experienced a similar problem and has a good solution I will be happy to hear it.

How should the area under a pontic be cleaned?

The area under a pontic can be cleaned by using floss. This can be accomplished easily either by using a "floss threader" or by using Oral B Superfloss. A floss threader is a plastic loop with a flexible but stiff plastic leader that can be pushed between pontic and the adjacent abutment. Floss is placed through the loop and then pulled through the proximal area. Once this is done the pontic area can be cleaned using the floss.

Often Superfloss can used to do an even better job. It is a three in one floss. The end is dipped in parafin so that it is stiffened, the middle is 'fuzzy' and thicker(almost like a soft pipe cleaner) and the end is regular floss. The parafin coated tip can be pushed through the interproximal contact and the fuzzy part can be used to clean under the pontic.

When do you prescribe an antibiotic after a root canal treatment?

The use of an antibiotic in adjunct with a root canal treatment is based on the judgement of the dentist treating a patient. In my practice, most patients whose pulps were nonvital(necrotic or no longer living) are given antibiotics to take after root canal treatment. My thinking is that the contents of the root canal system are most likely contaminated with bacteria and the patient will benefit by taking an antibiotic after being treated. A small percentage of non vital cases 'flare up' after root canal instrumentation. These flare ups can involve periapical swelling and pain and a worsening of the infection. Antibiotic may help prevent the flare up,lessen any that occurs and will most likely help with the resolution of any infection already present.

For vital cases(teeth with living, non infected pulps)most times antibiotic is not prescribed. After a root canal treatment of a vital tooth there also can be some periapical tenderness and even some slight swelling, but antibiotics are not prescribed unless I suspect an infection may have developed.

Should a tooth thats broken to the gum line be fixed?

This is a situation most dentists face every week. A patient comes in with a broken tooth (either with or without prior root canal treatment)and would like their tooth fixed. This poses a dilemma for dentists. Most are aware that teeth do not have enough exposed tooth available to safely hold a crown are more likely to fail than teeth that have do have sufficient 'ferrule'(sound tooth structure around the base of the tooth that can be used to anchor crowns). In my experience, it is extremely desirable for teeth to have at least 1.5 mm of ferrule in order for me to fabricate a predictably long term restoration.

What should a dentist do if a patient wants his tooth fixed and it doesn't have sufficient ferrule? First he or she must make the patient aware of this issue and its ramifications. The fact is that if a crowned tooth has insufficient ferrule, it is more likely to fail. The remaining tooth structure is much more likely to fracture and can even lead to the loss of the tooth. With this fact in mind what should a dentist do?

Ideally a patient who wants this sort of tooth restored has two good options. The first is the road least travelled. It involves having the tooth orthodontically extruded and after it stabilizes having a crown lengthening procedure. This will allow for an aesthetic result and a more predictable restoration since the resulting restored tooth will have the desired amount of ferrule.

Another option is to for go orthodontic extrusion and just perform a crown lengthening procedure ( removing bone and gum from around the tooth in order to expose more tooth structure). This can work well but can result in removing supporting bone from adjacent teeth and can cause aesthetic problems, since the resulting tooth can look too long and appear to have experienced gingival recession and 'black holes' interproximally(missing papillas).

Often patients offered either of these two options are hesitant to give approval to either and are insistent that the tooth be fixed as is. Although dentists sometimes go along with this request, it can lead to the eventual loss of the the tooth. How long such a restoration will last varies, but it is not a gamble that patients should take, if they want to keep a tooth long term.

Still another option, not yet mentioned, is that some broken teeth should be extracted and have bone grafting and an implant placed, while there still is sufficient bone available at the site. Implant restorations can be extremely predictable when placed in good candidates with the proper amount of bone support.