When should we do a root canal??? This question has become repeatedly more complicated as new technologies have emerged in dentistry. However, as long term success rates of implants are now being seriously re-evaluated (ref: Dr. William V. Giannobile, Editor, Journal of Dental Research) my thoughts go back to preserving the natural dentition when possible. Therefore, I thought it was an appropriate moment to go back and review some cases where we absolutely should do the root canal. Having done extensive restorative dentistry and prosthodontics (including being Chief of Prosthodontics at multiple Air Force Bases) for fourteen years prior to Endo School, I believe that I can offer some tips in this area.
The question of “When do I do the endo?” is usually asked in reference to the old direct pulp cap vs. root canal dilemma. The overwhelming majority of endodontists believe that direct pulp caps are best utilized on young patients with minimal exposures. The increased vascularity associated with young people, and young pulps, will decidedly help the patient. Also, the new bioceramic materials by Brasseler USA and Tulsa Dentsply are very good materials to use in these cases. (I particularly like the Root Repair Material Putty by Brasseler) However, I am not an especially strong proponent of direct pulp caps on adult teeth as their success rate is much lower. However, the world of direct pulps is changing due to improved science and materials. And, in third world countries (Hate that term!!) it is a big issue. In fact, I consider it a public health issue. The unnecessary extraction of teeth World Wide still remains a Big Issue - especially the treatment of women and young girls! However, let’s get back to the discussion, at hand, and look at a few examples where we should do the endo.
Pink Teeth: Have you ever done a crown prep on a tooth, only to see it turn pink in front of your eyes? Like, … what is going on??? (This is quite common on peg laterals.) Indeed, a pink tooth looks cute but unfortunately what’s going on is …it’s cooked!! Ladies, Do the Endo!!!
Bunny Teeth: Bunny teeth are adorable and in certain cultures they are almost revered for being fabulously cute (Japan for instance). However, these teeth have really high pulp horns and you need to factor this into your crown preparation. If you get an exposure and there is, in fact, a pink halo around the defect, what do you do? Ladies, Do the Endo!!! Also, if the tooth color turns a dark brown purplish color … that means thrombosis has actually occurred in the prepared tooth! It’s done. So, what do you do Ladies?? Together now … Ladies, Do the Endo!!!
However, any discussion of endo-prosth cannot be finished without addressing the question of prosthodontic expediency. In other words, when do I devitalize a tooth purposely for the long terms success of the case? This can be a real dilemma for dentists, especially young dentists.
Here is a likely scenario. You are doing six anterior teeth (crowns or laminates) and this is a nice case. Fairly easy to do and there is a good fee associated with such a procedure. However, tooth # 10 seems close to having a pulp exposure. In fact, you may even be able to see pink through the tooth. But here’s the problem. The patient complained so much about the price of the case, that you are hesitant to tell them that they need to spend another $700 for a root canal. Big mistake. If this situation arises what should you do?? Ladies, Do the Endo!!! Here’s why.
The absolute worst case scenario is to do a beautiful crown only to have you, or an endodontist, subsequently go back in, open up the tooth, and perform endodontic therapy. Patients do not appreciate having new holes drilled into their beautiful new crown. Trust me on that one!! An even bigger nightmare, is if the tooth is part of an extensive bridge and you accidentally crack the porcelain while making your endodontic access. Nightmare!!! There goes your lab bill.
I spent 14 years in restorative / prosthodontics and then 25 years in Endodontics. I have seen this (and many other things in my lifetime) from both sides. Never, not once, did I ever have a patient who did not understand why we had to do a root canal now, to prevent further damage. No one likes to hear this; no one wants to pay an addition $700. This is predictable. But the good news is … they understand (Thank goodness for that!) However, what they will not understand, is if you have to go in fairly soon after final cementation of their “beautiful new crown” to access a root canal. They will be upset. So how can we avoid this nightmare?? In unison now … Ladies, Do the Endo!!!
Hopefully, this entry has made you think a bit more about the relationship between endodontics and prosthodontics. I am totally committed to saving teeth (when we can) and to preserving the occlusion. Saving the dentition leads to the retention of facial architecture which leads to a more youthful, vibrant look. We will address this in future blogs. Meanwhile, I would love to hear your thoughts about endo-prosth and your experiences.