Endodontics
All root canal treatments (endodontics) in our clinic are performed in accordance with the guidelines of the German Society of Endodontics (DGEndo).
All treatment procedures are carried out under the operating microscope with the highest level of precision. Infected tooth nerve tissue is completely removed in order to preserve the healthy tooth root for a long time.
Endodontics: Course of treatment
Although root canal treatments often have a bad reputation among patients, they are not painful if done conscientiously and correctly. Rely on the expertise, empathy and experience of our specialist Dr. Basel!
If Dr. Basel can identify the tooth affected without a doubt, she will anaesthetise it as well as its surrounding area. It goes without saying that phobic patients can undergo this treatment under sedation or intubation anaesthetia. She will then cover the relevant tooth by means of a coffer dam, and she will seal it. This is to ensure that neither bacteria nor saliva can contaminate the area. The other reason is that none of the liquids necessary for disinfection will be able to reach the oral cavity of the patient.
Then Dr Basel proceeds – with the help of the magnifying capability of a dental microscope – to gaining access to the nerve system of the toot. This is done by drilling a little hole into the chewing surface of the tooth. Following this Dr Basel cleans out the root canal system by using rotating files and a tailor-made combination of disinfectants until she reaches the root apices.
This is a very lengthy process because it is crucial to the success of the root treatment. To make sure you do not become bored, we provide video glasses. These allow you to watch films or television series of your choice.
The length of your root canal is determined by using an electronic length gage (endometrics). The electronic resistance reading used in this process allows us to determine the exact length of your root canal. This helps us avoid doing additional X-rays. Following preparatory treatment Dr Basel will proceed to cleaning the nerve canals a second time by using a specially developed file (SAF system). This step is aimed at killing bacteria and at removing tissue remnants.
Depending on the severity of the inflammation and the complexity of the patient's root canal system, most treatments of this nature require only one visit to the dentist (”one visit” principle). After Dr Basel has conscientiously and carefully prepared and disinfected the root canal, she seals it with a thick root filling. This is to prevent renewed entry of bacteria. The material we use for this is called gutta-percha, and it has proven to be very reliable.
In the area of the posterior teeth crowns or partial crowns should be used after this treatment. This is to prevent tooth fractures or reinfection. The prosthetic treatment stabilises the tooth in such a way that the tooth will be twice as well protected against fractures than would be the case with a natural tooth free from tooth decay.
FAQ Root Canal Treatment
In a root canal treatment living (vital) or dead (devital) dental nerve tissue is removed from the root canal. The root canal itself is mechanically and chemically cleaned. The aim of this treatment is to keep a tooth the dental nerve (pulp) of which has become irreversibly inflamed or that has died altogether. The infected tooth material around the root canal (root dentin) is also removed. The gaps resulting from this are then filled with a biologically very well compatible material (gutta-percha).
Not only does root canal treatment allow us in most cases to keep the tooth but this treatment also prevents the inflammation from spreading further throughout the body. If left untreated the latter can lead to severe internal conditions. The tooth treated will probably be sensitive for a few days following root treatment/root filling.
Endodontologists are specialists for root canal treatments. Endodontologists carefully and safely remove the inflamed nerve in patients suffering from tooth aches. This means that even after having suffered damage due to an accident (following dental trauma) or decay the tooth can usually be kept. This way endodontologists make your tooth ache go away predictably and fast. In 90 % of cases endodontologists can save a tooth even in very severe situations (extremely severe destruction of the tooth or extensive inflammation). State-of-the-art diagnosis and therapy, such as 3D X-ray and treatment using surgical microscopes are a vital part of this. Dr. Julia Basel’s key to success consists of having excellent technical equipment, but her experience and diligence are no less part of this. So is having enough time. Our Munich-based Dental Clinic offers modern endodontology with the aim of keeping your teeth for a long time and permanently.
More often than not tooth ache points to damaged dental nerves. There are two different types:
- Ringing, piercing and radiating pain
- Dull, pulsating pain
What do these different types of pain mean?
1. Ringing piercing pain - The vital nerve has become inflamed
A vital dental nerve may become inflamed when the waste products of bacterial metabolism reach it (e.g. as a result of deep-reaching tooth decay). The body reacts to this by activating its defence mechanism. The dental nerve is then increasingly supplied with blood, and it starts swelling. Due to the fact that the tooth is surrounded by dentin and due to the fact that the tooth can only be nourished through a small opening at its bottom tip, the swelling cuts off oxygen supply. This means that, at that point, the cells in the dental nerve can no longer be nourished (self strangulation).
The patient will, in this case, experience piercing pain radiating into the back of their head. The patient will also be very sensitive to cold or hot food and drink in their mouth. If tooth ache occurs without any outside influence, and if it lasts for ten minutes or longer, chances are that the dental nerve has been inflamed. At this stage the patient might not be able to tell with certainty which tooth is aching. This is because neighbouring teeth tend to hurt as well. Another indication of an inflamed dental nerve is the feeling that the tooth affected appears to be “higher” than the teeth next to it.
2. Dull, pulsating pain - When a dead tooth is hurting
If an inflamed dental nerve is left untreated, it will fall apart eventually, and its interior will no longer have the strength to defend itself. Bacteria can now enter the defenceless root of the tooth, and they will slowly spread to the root apices. Coming from the root apices the bacteria are now up against the body's own immune defence. An inflammatory reaction will follow, and the bone material around the root apices will decompose. The endodontologist will be able to identify the bone inflammation from the X-ray. The inflammation will show as a dark, round shadow surrounding the root apices.
Sensitivity testing, which involves cold being applied to the tooth, can be used to determine this. This is because dead dental tissue will no longer be able to pass on temperature stimuli. Following the stage of acute root apice inflammation with strongly piercing pain, the next stage is marked by duller pressing pain in the area of the bone. This may lead to dental abscess and fistula formation. In this scenario there is a risk of bacteria spreading to the entire body.
In either scenario an endodontologist must perform root canal treatment in order for them to be able to preserve the tooth.
The main reasons for tooth aches may be one or more of the following: tooth decay, trauma (punch or hit), cracks in the tooth, untight fillings or crowns, differences in pressure (e.g. when flying or diving), and chemical or thermal stimuli (hot and cold / sweet and sour). In rare cases tooth aches lasting for a week or two may be the result of a cold. Tooth aches caused by colds or changes in pressure initially only need to be observed. If needed we can cover sensitive tooth necks with small fillings. Root canal treatment should only be undergone when the tooth that is the source of the pain has been identified without a doubt.
When the inflammation of the dental nerve (pulpitis) leads to uncontrolled dying off of the nerve, this inflammation may spread to the surrounding periodontium and the bone (apical ostitis). Endodontologists will be able to see this in an X-ray. It usually shows as a dark spot at the tip of the root. This is because minerals, such as calcium and magnesium, are released from the bone as a result of the inflammation. This also means that X-rays can more easily get through the bone. They expose (blacken) the X-ray film more than they normally would. In the more advanced stages of this condition the inflammation might break through the bone, and a pus-filled cavity might be formed (abscess). When it gets to this stage patients tend to suffer very severe pain.
When this abscess empties by way of the periosteum, the bone skin, and the gums into the oral cavity, this results in what is referred to as a dental fistula (purulent fistula). This is when the pain stops. Once the inflammation reaches chronic stages, dental cysts can form. In most cases this may not lead to any pain. However, the tooth affected should be treated in any case. This is to prevent the inflammation from spreading.
Dental trauma is most common among children and young people. Falling off a bicycle, slipping and tripping by the swimming pool or a sudden strike or hit of a hard object are among the most common causes. If a piece of the tooth breaks of or the tooth is knocked out altogether (complete luxation) in an accident, it is best to immediately make your way to an endodontologist. The tooth should be kept in a specially designed tooth rescue box, in saliva or in UHT milk. If the tooth can be treated, endodontologist differentiate between three different scenarios:
- If only part of the tooth is broken off without the dental nerve being affected, the fragment can be glued back on. Alternatively, the missing part of the tooth can be completed by using a filling or a veneer. Vitality of the tooth should be checked over the coming years.
- If a huge chunk of the tooth has broken off and the dental nerve has been exposed, the endodontologist will first of all perform root canal treatment. Depending on where the tooth is in terms of its growth stage, procedures may differ. In the early stages it may be possible to preserve the vitality of the tooth and to promote natural conclusion of the growth of the dental apex. The missing fragment can be glued back on or it can be completed by means of a filling, a veneer or a crown.
- If the tooth has been knocked out but it was stored correctly, it can be put back in place. In this case, too, an endodontologist must first of all perform root canal treatment. This is because the dental nerve was most likely torn off as a result of the trauma, and the dental nerve may have died off. The tooth replaced will then, for a duration of three months, be aligned with the teeth on either side. It is vital to observe the tooth since root problem frequently occur.
What does revision (repeated treatment) mean in connection with existing root canal treatments?
Even if a tooth has been treated in root canal treatment, this tooth might still become reinfected. The patient will usually notice returning dull pain, and the general feeling will be that “something is not right.”
More often than not the tooth in question is not the cause of pain or other such effects. Moreover the inflammation may not be visible until the area is looked at in an X-ray. The area affected, the root apices, will show on the X-ray as a dark spot.
Complications following root treatment: This is when will revision be necessary
If, following root treatment, bacteria have remained in the canal system or if they have returned after the treatment, renewed inflammation may be the result. This is when renewed treatment, retreatment, is necessary. Common causes may include:
- Canals have been overlooked or they have not been treated in their entirety, i.e. in their entire length or breadth
- Cleaning out the canal system could not be done sufficiently due to the complex anatomy of the patient’s root canal
- Tooth decay, untight fillings or late treatment with a crown may have resulted in bacteria entering the root canal system for a second time eingedrungen
How is a revision carried out?
In the event of renewed inflammation we removed the previous root filling in its entirety, and we will clean out thoroughly the entire root system, including any root canals that might have been overlooked. Following this filling and sealing are done as was the case during your first treatment.
Retreatment is more complex and lengthy than your primary root canal treatment since the old root filling, remaining tissue and maybe even foreign materials (e.g. bits of broken off tools) will need to be removed. If retreatment is not as successful as we would have desired, apicoectomy is the last option we have. If it becomes clear that the inflammation in the posterior tooth is going away, the retreated tooth should be replaced with a prosthesis.
Success rates for retreatment, meaning when root canal treatment is repeated, are around 60 to 85 % on average. During your initial treatment we will give you an estimate of the likeliness of success for your individual treatment of your own tooth.
The last resort for unhealthy teeth - apicoectomy
Apicectomy is a way of saving unhealthy teeth in cases where retreatment did not result in the desired success.
At our specialist practice PD Dr Harder and Prof Dr Mehl use magnifying glasses or microscopes to perform apicectomy treatment. First of all the entire area is anaesthetised, using local anaesthesia. It goes without saying that phobic patients will be given the option to undergo the surgery under sedation or general anaesthesia.
Apicectomy: What happens during treatment?
Through a tiny cut made into the gum, we remove the inflammation (or the cyst as the case may be) along with the last three millimetres of the root. We then seal the infected root canal from the side of the tip of the root, using biological cement (MTA), and the cavity may be refilled with artificial bone material if you so wish. In some cases the tooth will be sealed with a membrane or a gum transplant.
In micro surgical apicectomies we remove no more than the tip of the root through a tiny passage. Bone augmentation or sealing are not part of this treatment. With most surgeries the patients will not have massive swelling or pain.
The apicoectomy: Root resection after root canal treatment
What is internal bleaching (Walking Bleach)?
Insufficient root treatments, trauma or dead nerves are the number 1 cause for a change in the colouring of a tooth. Due to internal bleaching the tooth can be whitened with the help of hydrogen peroxide.
However, we only perform internal bleaching if the root filling is sufficient and the tooth is free from inflammation. We remove part of the root-filling material to and seal the top part of the root canals. The cavity is then filled with a bleaching agent and sealed. Five to seven days later we check the result. Should the treated tooth still be darker, we will repeat the process. Generally speaking a total of two to three appointments is needed in most cases. If the desired colour of the tooth has been achieved, we neutralise the bleaching reaction. We seal the tooth with a composite filling and/or a dental crown. This depends on the situation. The result achieved will remain the same for many years to come.
Process of internal bleaching
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The anterior teeth have been damaged in a physical conflict due to a punch. The right anterior tooth shows bleeding of the nerve. This is leaking into the tooth and changes its colour.
2
Following provisional treatment of the fractures by using plastic fillings and root treatment of the right anterior tooth, bleaching gel is introduced into the tooth in the area in which the nerve used to be. The tooth is then sealed.
3
Here you can see how the discolouration has become must lighter following a week of the bleaching gel having been inside the tooth. Upon this appointment the bleaching gel was replaced.
4
The treatment is finished off with definitive plastic fillings.
5
The patient was happy, and hopefully, he will soon forget all about his encounter with that fist.
Beautiful teeth thanks to internal bleaching.
The teeth treated as part of root treatment may change in colour as a result of the treatment. Learn how internal bleaching gives patient white teeth again.
Gallery for referrers:
Initial therapy
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Partielle Nekrose mit apikaler Ostitis 36 und 37
Check-ups
Crooked canals
Removal of fragments and pins
Special treatment cases
FAQ - root canal treatment
The signs of inflammation of a sick dental nerve vary from continued sensitivities to heat and cold, spontaneous pain (in particular at night), pain when biting, knock sensitivity to throbbing pain and swelling of the surrounding soft tissue. Sometimes a headache or jaw pain may be an indication that a root canal treatment is necessary. It is not uncommon that there is no pain at all and it can merely be seen in the X-ray image that there is an inflammation in the bone which comes from the tooth (apical ostitis).
In case of chronic forms, the infection does not involve any pain. It is not uncommon that the effects of the infection are only discovered on a radiograph in the form of a dark spot at the root tip (apical ostitis). The bone around the dental root has dissolved. This degradation is progressive and may lead to an acute inflammation with pain, swelling and purulence.
Sometimes it is no longer possible to safe the tooth by means of a root canal treatment due to the tooth’s degree of damage or due to a root fracture. Even if you do not feel any pain at that time, the tooth should be pulled because if the affected tooth remains in the oral cavity, the infection may worsen, it may result in a painful purulent abscess in the bone or it can spread into other regions of the body via the blood. After the removal of the tooth, there are different possibilities to close this gap (implant, bridge).
If in case of a root canal treatment bacteria have remained in the canal system or if they have formed again after the treatment, this may result in a new inflammation. Possible causes are:
- canals have been overlooked or have not been treated at an adequate length or width,
- the cleaning effect has been too low because of a complex canal anatomy,
- bacteria entered the root canal system again via caries, leaky fillings or because the crown was implanted too late.
In case of such a diagnosis, the old root canal filling is completely removed and the complete canal system, including any canals that may have been overlooked, is thoroughly cleaned. Afterwards, filling and closure are made in the same way as during a first treatment.
You can only treat the parts you see. Usually, teeth have more root canals than are visible to the naked eye. A lower front tooth, for example, principally has one canal; in case of 40% of the patients, however, a second canal was detected under the microscope which could also be repaired. If inflammatory tissue remains in these ignored canals, the prognosis for the tooth is not good. Furthermore, each root is different and formed absolutely individually (C-shaped, oval, L-shaped, with bulges or ramifications). In order to be able to clean them absolutely thoroughly, the treatment by means of conventional methods is not sufficient. In addition to a high-performance microscope, a time-dependent individual irrigation protocol (disinfecting irrigation of the canals) is absolutely essential. The individuality of root canals must also be taken into account with respect to the root canal filling. That is why specialists worldwide prefer the filling with warm gutta-percha. By heating the gutta-percha within the root canal, the filling material becomes soft and can be closely adjusted to the individual form of the root canal by means of microscopic control.
The treatment usually takes one and a half to two hours and is in most cases completed within one session. Sometimes, additional appointments are necessary, especially in complex cases or if the inflammation is more serious.
Unfortunately, it is not possible to save every tooth by means of a root canal treatment. This is for example the case in the event of a root fracture or if the degree of damage is too high for a successful repair of the tooth. It is not always possible before the treatment to say for sure whether a tooth can be saved. Sometimes it is only possible to make a decision in this regard after a thorough inspection of the inner tooth.
Radiographs are usually taken before the treatment and at the completion of the treatment. In some cases, for example if the course of the canal is irregular, further radiographs from different angles are necessary.
Dental dam is a small sheet made of rubber that is fixed to the respective tooth with a clip to keep the bacteria in the saliva away from the treatment area during the whole treatment.
No, a local anesthesia ensures that you will not feel anything. In rare cases it can happen that a tooth is particularly sensitive. However, due to the possibilities we have today, here, a treatment free of pain is also usually the case.
After each invasive procedure, a regeneration phase is to be expected. During the natural healing process of your body, you may experience minor or moderate pain. The tissue and bones surrounding the tooth and a ligament that covers the dental root are, in most cases, inflamed before the treatment. This inflammation and the manipulation of the tissue during the treatment are the reasons for postoperative pain. As you keep your mouth open for a longer period of time during the treatment, your jaw, neck and back musculature may be slightly tense during the first days after the treatment. It can also be the case that the gums are slightly irritated for a short period of time because of the fixing of the sheet made of rubber (dental dam). The symptoms are of short duration and can usually be completely alleviated by means of painkillers, such as ibuprofen or paracetamol. We recommend taking one pill for pain therapy within the first hour after the treatment so that the effect occurs before anesthesia has worn off. A postoperative inflammation (phoenix abscess) with severe pain, swelling and fever is extremely rare. Here, the taking of antibiotics as an accompanying measure is indicated. Please contact our clinic if you should suffer such pain. After the root filling, your tooth will in general feel different than the surrounding teeth for a while.
A root canal treatment involves the following risks:
These include in particular:
- mild to severe pain shortly after the root canal treatment for several hours to days
- incomplete root canals not continuing to the end of the root tip
- incomplete effect of anesthesia
- perforation of the root or pulp floor
- swellings or abscesses shortly after the root canal treatment or later
- breaking off of root canal instruments in the root canal
- injury of the tissue at the root tip
- overfilling of root canals (leakage of filling material from the roof tip)
- stain or darkening of a tooth with root filling
- chipping, breaking off, comminution of teeth with root fillings
- continuity or recurrence of discomfort, pain or inflammation
Any complications may mean that you have to take antibiotics or that further treatments, such as an apicoectomy, are necessary or even that the tooth will be lost.
The treatment by a specialist in our clinic is carried out with the highest precision under the surgical microscope, according to the latest scientific knowledge and by means of the latest technology. Thus, we achieve success rates of up to 96%.
The chances of success, however, depend on the condition of the tooth before the treatment and on the type of aftercare. If a tooth is merely inflamed and the surrounding periodontium and bones are healthy, success rates amount to 96%. If the inflammation has already spread and led to a dissolution of the bone (ostitis apicalis) or if the tooth is not sufficiently restored after a successful treatment (partial crown, crown), chances of success decrease significantly.
As with all medical interventions regarding the human body, we cannot guarantee an absolute success. If there is no improvement, further treatment steps, such as an apicoectomy or the removal of the tooth, may be necessary.
In order to avoid an injury of the soft tissue, such as cheek, tongue or lip, please refrain from hot beverages and any food intake until anesthesia has completely worn off.
Without a restoration of the cusps, root-treated teeth may easily fracture. Therefore, please avoid any weight bearing of your tooth until such a provision has been included.
Do not change your daily oral hygiene measures.
In case the cavity of your tooth has been closed with a temporary filling, it is not unusual that a thin layer wears off between the treatment dates. If you feel that the complete filling got lost, please contact our clinic.
The completed root canal filling is only the first step to restore the functioning of your tooth. In order to ensure a long-term success, the tooth must be provided with a suitable fixed restoration. In most cases this is a provision including the cusps (overlay, partial crown, crown) that restores the full chewing force of the weakened tooth and protects it from fractures. With a good oral hygiene, the use of dental floss, regular visits to the dentist and professional dental cleaning, a sufficient restored tooth with root-filling has the same lifespan as a natural tooth. In most cases, radiographs of the tooth concerned are taken at intervals of 3, 6 and 12 months and afterwards every year up to four years after the treatment in order to monitor the healing process. In rare cases, an inflammation of the tooth does not heal even after months or the tooth continues to cause problems or even causes problems after years without any discomfort. Often, the tooth can be saved by means of a renewed root canal filling, a so-called revision.
In most cases, radiographs of the tooth concerned are taken at intervals of 3, 6 and 12 months and afterwards every year up to four years after the treatment in order to monitor the healing process.
The treatments are very complex and extend over several hours. In order to achieve an optimum treatment success, we take the necessary time. Therefore, billing for patients with statutory insurance coverage also has to be done in accordance with the German Scale of Fees for Dentists (Gebührenordnung für Zahnärzte, GOZ). However, depending on the level of difficulty, patients with private health insurance may also incur costs which are not borne by the private insurance companies.
During the initial examination, all measures and the individual course of treatment are discussed. For many patients this is extremely helpful to allay their fears and concerns. If you still prefer a treatment under sedation or general anesthetic, we are prepared.
In extremely rare cases there can be a repeated inflammatory reaction regarding the root tip that requires a small surgical procedure. During such a treatment, the inflamed root tip is removed under anesthesia and free of pain. Afterwards, the root canal concerned is cleaned from the tip onwards and filled in such a way that bacteria cannot enter. The missing bone substance regenerates. The chances of success with respect to an apicoectomy are 50%.