A Possible Alternative to Root Canal Treatment:
Many of the emails I get are questions about root canal treatment. There seems to be a lot of confusion and anxiety about that subject and many of you want to know if there is any alternative - other than extraction - to root canal treatment. Well, the answer is yes ..... and no.
The most common scenario is the case of decay that has gotten so deep into the tooth that on the x-ray it looks like it's already reached the nerve of the tooth. The dentist tells you it looks like you need a root canal....
Sometimes the dentist will see "a shadow" at the tip of the root. That indicates bone loss that results from the changes in chemistry that happens when a tooth has already abscessed (is infected) and the nerve has already been dead for a while (probably several months or longer). In that case there is no choice other than extraction or root canal treatment (RCT).
But often there is no clearly defined shadow at the end of the root so determining whether it needs a RCT or not is a bit of a puzzle and the dentist has to be a kind of detective putting many clues together. Many times the clues point to RCT for sure, but sometimes it's still a puzzle. In those cases the dentist has to drill out the old fillings and decay and see how deep the decay goes. If he drills carefully he can sometimes get a all the decay out and still see that the nerve has not been reached. That's good - just a filling should fix it.
Sometimes after getting all the decay out there will be a small spot where the nerve has been reached and that spot will normally bleed a little. That's called "an exposure". The text-book thing to do is RCT, but if the exposure is small, and if the bleeding is slight and the color of the exposure looks like pretty healthy tissue, the dentist can opt to do a pulp cap.
A pulp cap just means trying to sterilize the area as well as possible, stopping the small bleeding, and placing an appropriate filling over it. In the past the technique was to place calcium hydroxide over it and then a normal filling (usually amalgam). Modern pulp-capping is mostly done using a bonded composite technique* (see note added April 2009 below ) right over the exposure - with NO calcium hydroxide layer.
When they are done well and in the right situation , pulp caps have a very good chance of working for a long time. The key here is picking the right candidates and doing it well. Exposures that do not fit into the narrow slot of suitability for pulp capping should be considered candidates for extraction or RCT.
Teeth that are already abscessed should never be pulp-capped. It's just for those teeth in the in-between stage where the nerve is irritated but still alive and healthy enough to repair itself given a reasonable chance. The pulp-capping gives it a chance by getting rid of the decay and the bacteria that are in the decay, and by creating a clean dressing over it with the filling. It's not unlike cleaning out a dirty cut or scrape on your skin and placing a clean bandage over it.
Pulp-capping has been done in different ways for a very long time. It's not new, but the technique has evolved with the new techniques and products available to dentists.
So, yes there is an alternative ..... sometimes. I hope this helps and doesn't just make you more confused!
Note: added April 2009
These are signs that while "not written in stone", do serve as general guidelines indicating that a tooth is probably NOT a good candidate for pulp-capping.
pain is caused by exposing the tooth to heat, like hot coffee or soup
the pain lasts more than an instant.... it lasts a few minutes or more
tapping or biting on the tooth causes pain
pain sometimes starts for not apparent reason ( like it starts when you're not eating or drinking or chewing anything...or maybe it wakes you up during sleep )
These are all general indicators of what is called "irreversible pulpitis", which simply means that the nerve is irritated beyond its ability to repair itself.
*Also, research has shown that while calcium hydroxide cements ( Dycal, for example) are still not indicated for pulp-capping, there are other materials that might be even better than bonded composite.
2010: John Kanka, DDS, who is a lecturer I greatly respect, has recently shown that a certain kind of dental cement that has been around for many years, known as polycarboxylate cement, may be the best choice for pulp-capping. Perhaps the most common trade name for this cement is Durelon.