Services

Your Endodontic Consultation

When you visit our office for the first time, there are several things we require to best address your specific needs:

Your personal information, including any insurance information and a health questionnaire that we will review with you.

Consent to report back to your referring dentist our findings and any treatment rendered.

After we have gathered this information (all forms are found in this site) we will take a digital x-ray of the area in question and Dr. Shackleton will talk to you about the history, onset, symptoms, etc. of your specific condition.Following this, Dr. Shackleton will perform some quick, easy tests on the teeth and gums in the affected area in order to come to a diagnosis. The diagnosis is the result of.

  1. The information you provide (subjective)
  2. The information on the x-ray
  3. The information from Dr. Shackleton's diagnostic tests (objective)

Each of these steps is critical in reaching a correct diagnosis which in turn will result in appropriate treatment and prognosis. Treatment may be rendered on the same day as your consultation or another day, depending on scheduling, complexity of treatment, existing condition, etc.You can expect this appointment to take approximately 20 minutes.

Root Canal Therapy (for patients)

These are scary words to many of us: Root Canal! You tell friends, co-workers and loved ones that you need one and you are met with looks and comments ranging from sympathy to horror - "Bummer! Let me tell you about my root canal…."

While I'm sure the guy in the next cubicle or your aunt Gertrude were well-intentioned when they gave you the gory details of a root canal gone bad, that story is not what I would call a representative sample - that is, it may be the exception instead of the rule. It is also possible that it may be embellished just a little for effect. So, let's de-mystify what a root canal is, how they work and how they sometimes do "go bad."

People need root canal therapy for lots of reasons: infection, runaway inflammation after a crown or filling, cracks, broken teeth, deep cavities and so on. The list is seemingly endless, but these are the major reasons that bring people to my office each day. So, whatever the reason, lets say you need a root canal - Great! What follows is a step-by-step explanation of what happens each day in my office.

  • The first thing is Anesthesia - Profound Anesthesia! We want you very frozen so you can be relaxed and have a good experience at our office, so for that reason, you may feel like we are giving you a lot of anesthetic - that's because we are. After we freeze you up, we'll let it go for a few minutes and make certain you're numb before we start.
  • Next we have to isolate the tooth. That is, I need to make sure your pesky tongue, lips, cheeks and saliva don't get in my way. So, we isolate the tooth with a rubber dam. This is non-negotiable. No rubber dam, no root canal. I consider it below the standard of care to perform root canal without a dam for 3 reasons: 1) I don't want any saliva to get into you tooth - it's full of bacteria and will re-infect your tooth. 2) I rinse your tooth out with bleach (I use Javex) and I don't want any of it going down your throat. It won't kill you but, gross! 3) I clean out your roots with long, sharp instruments called files and if I were to drop one and it went down your throat, well, you can imagine what the result would be. The good news is that I use a small dam that is designed specifically for root canal, so it's a bit less obtrusive than many others.
  • After your tooth is isolated, I do a little drilling to get to the nerve of the tooth. This only takes a minute or two and feels just like getting a filling. If your tooth has a crown, it may take several minutes as porcelain and metal are very hard to get through.
  • Next is finding the nerve canals. When we drill to the "nerve" (it's actually called pulp, because it contains many things: the nerve, blood vessels, a drainage system, cells that make tooth structure, cells that fight infection, structural cells and so on) we drill down to a "chamber". This is located in the part of the tooth that is above the gums. Extending out from the chamber and down the roots are the "canals." These canals are where I spend most of my time and since they are canals located in roots, we call procedure "root canal." Front teeth typically have 1 canal, premolar teeth 1 or 2 (rarely 3) canals and molar teeth will have 3 or 4 canals (sometimes 1, 2 or 5).
  • Once the canals have been located, which can take a few seconds (most of the time) to over an hour (rarely) we begin the process of "cleaning and shaping." That is, I clean (i.e. sterilize) the canals with bleach and I shape the canals with those long, sharp files. This will feel like I'm scraping out the inside of your tooth - again, that's because I am. This is a cycle of cleaning, shaping, cleaning, shaping, etc, until I am satisfied that all the infection/pulp tissue is out of the tooth all the way down to the root tips.
  • Once I finish cleaning and shaping the canal, I will either fill the canals with a rubber material and a clove oil based cement or I will place a paste of Calcium Hydroxide in the canals. In the case of infection or root canal retreatment, I will typically place the Calcium Hydroxide with a temporary filling tooth and we will leave it for a period of about 4 weeks. The Calcium Hydroxide paste simply creates a very inhospitable environment for any remaining bacteria making it possible to finish at the next visit.
  • As was mentioned, to fill the canals we place rubber and cement in them. We place this rubber with heat so as to fill, or "obturate" all the little nooks and crannies located in your roots. Once completed, I will either place a permanent filling in your tooth or a temporary if you are going back to your family dentist within 2-3 weeks of your root canal appointment.

All of this takes 1-1.5 hours. It usually takes 1 or 2 visits. There is typically no pain during a root canal. Below are some myths and truths about root canals:

  • All root canals get re-infected sooner or later." False. While it is true that a root canal may get infected after treatment because of poor treatment, extra, untreated canals, or leaky fillings/crowns, most reliable studies show success (i.e. no re-infection) in 90-95% of the cases. That means that 5-10% of the time they do re-infect.
  • Root canals leave toxins in my body that will cause illness in the future." False. This little myth has been around for over 100 years and has been soundly disproved again and again and again and again...
  • Root canals hurt like crazy. I should just get my tooth pulled." False. And true. While most patients will feel no pain during root canal and very little or no pain afterward, there are some (fewer than 5%) that will feel some discomfort during a root canal and moderate to severe pain afterward. This is usually managed very well with pain medication and is often very short lived. As has been noted, root canals work about 90-95% of the time, not 100% so extraction is an acceptable (often not advisable) alternative. If you extract your tooth, please follow-up with your family dentist regarding tooth replacement.
  • I should always get a crown after a root canal." False. While this is true for back teeth (premolars and molars), it isn't always true for front teeth (incisors and eye teeth). Back teeth take on hundreds of pounds of pressure when chewing and studies show that if you have a root canal on a chewing tooth and don't put a crown on it, they break about 75% of the time. This is not the same for front teeth. It is important to realize, though, that as with any procedure, each case is unique and the functional and esthetic needs for each tooth in each patient should be discussed with your family dentist and the final decision should be made between you two.
  • Root canals are expensive." True. But they are much less expensive than the cost of replacing a tooth and they are covered very well by most insurance carriers. We always provide estimates for treatment and are able to find out what coverage your insurance carrier will provide.

Apical Surgery

 

 

So, you've had a root canal and that hasn't worked. Then you had it retreated and that hasn't worked. You're at your wits end and are very frustrated with every dentist you've ever seen. Understandable. Fortunately, this situation is by far the exception, not the rule. Unfortunately, we can't apply statistics of groups to individuals and you find yourself one of the unfortunate few. Well, you have a couple of options at this point: extract the tooth and consider replacing it with a bridge, implant or partial denture. Or, you can elect to try to save the tooth by having a small surgical procedure that we do almost every day in our office. I know, I know, the word "surgery" is a little scary, but in all fairness your dentist is a "Doctor of Dental Surgery." What that means is that fillings, crowns, extractions and most else of what we do each day is, technically, surgery. Okay, so what is "Apical Surgery?" you ask. It literally is surgery at the apex of the root or in other words, it's surgery at the root tip because that's where your persistent infection is originating. Let's go through it:

  • Yep, lots of anesthetic. A little more than you get for regular root canal treatment.
  • We make a small incision in your gums (1" -2" long) and lay the gum tissue back. This exposes the infection in your bone. Don't worry, we see this every day and it will not spread to other areas of your body. It is very common. In fact, many of you reading this right now have it and you don't even know it. This is one reason we encourage you to have regular exams by your dentist so they can find these things before they become problematic.
    • We then make a small window in the bone with a specialized surgical drill. This window is about 4mm in diameter (about the width of an eraser at the end of a pencil). It's a little larger with larger infections.
  • We then remove the 3mm (approximately) from the root tip. The reason we do this is because about 98% of extra canal branches exist in the last 3mm of the root. So, we are getting rid of the infected part of the root most of the time.
  • After this, we remove the remaining infection from you jawbone. And then we use a small instrument to clean out the root canal from the bottom up and seal it all up with a mineral compound that promotes bone healing and keeps the root from re-infecting.
  • A few stitches (6 to 20, depending on the area and incision design) and you're finished. We will go through post-operative instructions with you and that's it. We like to see you about 5 days later to remove the stitches and evaluate healing and that visit takes less than 5 minutes.
  • After the surgery, you may experience a little pain and swelling and even some bruising. We will instruct you how to manage this, but we find most people require minimal pain medication.

Again, it's very important to realize that while this procedure is very successful (over 90%) it does have its failures. It can sometimes be re-done but a failure in this procedure often results in tooth loss. This is handled case by case and we will always discuss your options with advantages and disadvantages along with our recommendations.

Non-Surgical Retreatment

Root Canals work almost every time. It's true. Many studies report a success rate of 90-95% and one even reported success in over 97% of the cases! What that means is that 5-10% of the time they don't work and the original pain or infection persists. That often raises the question: "Why do they fail?" Here are some of the most common reasons:

  • Untreated canals
  • Partially treated canals (a canal not cleaned all the way to the end)
  • Broken instruments left in the canal
  • A leaky crown or filling in the root canal treated tooth

And there are many other, less common reasons. So, when we see a root canal that isn't working and we decide to retreat it, the procedure is relatively straightforward and is as follows:

  • Like a regular root canal, we give lots of anesthetic, place a rubber dam and drill a small hole down to the nerve chamber. "But I have a crown on my tooth." I hear all the time - most often we simply drill right through it. Probably half of the root canals we do are through crowns.
    • Unlike a regular root canal, when we get to the nerve chamber we don't find nerve tissue or infection, but the rubber root filling from the previous root canal. At this point, we identify whether all canals have been treated or whether there was anything missed. Depending on the tooth, we find missed (untreated) canals about 30% of the time - this percentage is a little higher in molar teeth.
  • We then remove all of the old rubber root filling, clean everything out and sterilize the canals with bleach.
    • Once the canals are cleaned and disinfected we place a calcium hydroxide paste in the canals. We do this because calcium hydroxide creates a very inhospitable environment for bacteria.
  • We then put a nice little temporary filling in the hole in your tooth and leave it for about 4 weeks. You can have a little pain during the first few days (even a few weeks) which is often managed nicely with over the counter medications - We will discuss this with you at your appointment. In rare cases, a prescription will be necessary to manage your pain or infection.
    • After 4 weeks, we finish the root canal with, you bet, anesthetic, rubber dam, drilling to the nerve chamber and cleaning everything out once again. We then fill the canals with rubber and clove oil paste. This is assuming your symptoms have dissipated - if not, you may require a re-application of the calcium hydroxide and another 4 weeks, or you may require extraction of the tooth.
  • To complete the procedure, we place either a temporary or permanent filling in the access hole in your tooth.

As with all procedures, non-surgical retreatment is not successful all the time. We find success in 80-90% of the time. This is a very high success rate, but it also means that 10-20% of the time your tooth will require additional treatment or even extraction.