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Root Canal Treatment Choices

 

First this Statement !!!!!  There's so much confusion and anxiety about root canals and I get emails - literally from all over the world about  "my dentist  is against root canals ...and YOU [me, Dr. Goldman] are for root canals.  Please help me to know what to do...." or some question similar to that. So let me say this:

I am neither FOR nor AGAINST root canals....   My position is that there is NO PERFECT SOLUTION at this time  to a root canal problem  and so  taking a black or white position for or against root canal treatment  seems  to me to be a mistake in judgment.  My feeling is that each situation needs to be seen and evaluated on its own merits.

If extraction makes sense in a specific situation, fine.  If not, then   perhaps there are some things that  could be done - perhaps just a little differently - to make the  root canal treatment  less likely to become a problem later.

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As Paul Harvey used to say on the radio:
And now for the rest of the story...

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Root-Canal Treatment .......
                       an "alternative, alternative" viewpoint !

by Michael C. Goldman, DDS
           

FAQ 1: My dentist says I need a root-canal.  Should I have it   done or Extract the tooth?...and   What are the consequences?

FAQ 2: I have  been told it's dangerous to keep my old root-canal treated tooth.  Is that true?   What should I do?

 

There is a line of thinking among many dentists in the holistically oriented community that root canals are necessarily "bad" and should be removed if you have them  and never done if you need one...  Well, that's fine if there's some reasonable alternative.  Sometimes there is.... and sometimes there is not ! 


Before you let any dentist remove any of your teeth - possibly making you a dental cripple - check out what treatment  options are  being offered following the tooth (or teeth) removal and see if what is offered makes sense to you.....Always remember, it's YOUR body, and only YOU can decide what's right for it !  Don't wait until AFTER the teeth are extracted to find out that you don't like the options!!!!  It's too late then!


Get a good understanding of the issues so you can make an informed decision about your body !!!!!


******If you are dealing with root-canal issues, please read my other root-canal article "Root-canal Treatment -  Exposed" .  It will explain what the "holistic" controversy regarding root-canal treatment is all about.  Once you understand that, this article will help put it in perspective [at least as I see it ], to help you make a more informed decision for yourself. Your body deserves that much...  It talks about issues raised by Dr. Weston Price and by Dr. George Meinig's scary and sensational book "Root canal Cover-up Exposed!" ............ If you've read it, no wonder you are scared and worried and confused about what to do!!!

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Note [this really just happened ! ]  :-(
As I'm in my office writing this section, the phone rang. A young woman wanted an appointment for a consultation about getting a partial denture (removable bridgework..."like her grandparents wore"...). She had all the molars extracted on the lower jaw on one side....


Her "holistic" dentist had told her she had infections and cavitations...and the teeth had to come out. No options were offered. He scared the "stuff"  out of her. And so...as often happens ... she went along. She never thought about   "...then what?".


.........Never having experienced several missing teeth before, she had no idea how devastating it might be or feel. I felt very, very sad for her.
She was now in touch with her anger about having been told to take out those teeth. She said she would never have done it if she really understood the implications...


She said she had no intention of going back "to him" to have the rest of the treatment finished. She was sick about it....and so was I. I'm not totally 100% convinced about how big a problem she might have had with the infections and cavitations she was told she had..., but I am 100% certain she's really got a  problem now for sure !!!!


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Please understand, her decision   was neither right nor wrong...it's just that she was not given enough information to make that decision from a position of mental comfort and balance. It's what is legally called "informed consent". Don't ever allow yourself to be pressured or intimidated into a course of treatment!   If after considering her options, she still wanted to have the teeth  removed, well, even if I think it's the wrong decision, it's her body and her right to to what she wants with it.

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Some of the frequent questions that I get asked are about existing root canals.... What to do about old ones?... What to do if one is now needed?   While a lot has been said about potential problems with root canals - and I agree with much of that - little has been offered for patients who need to make real-world,  hard, practical choices, not in the abstract, but about their own bodies.

I recently had this discussion with a very aware woman who was concerned about issues raised in Dr. George Meinig’s book discussing Dr Price’s research of root canal problems and treatment. That book , of course is "Root Canal Cover-up Exposed!".

Let me set the groundwork this way. I am a general dentist and I do many root canals in my practice, which I like to characterize as a holistically oriented, mercury-free, caring practice, centered in what I like to think of as a "healing environment". I have read an am familiar with the controversies regarding root canals as raised by Dr. Price, Dr. Meinig and others. I agree with many of the issues they raise!..... Nevertheless, I feel there is more to the story and when it comes to making practical, real-world decisions, people need practical options.

Here’s how I have reasoned through this difficult and very confusing issue.

First, to re-familiarize readers with the issues raised against root canal treatment let me do a quick review.  Root Canal Cover-up Exposed  was published by a dentist named George Meinig centering on the research done around 1920 to 1930 or so,  by a remarkable dentist named Weston Price. Dr Price did a lot of very interesting research relating to root canal infection and treatment spanning a period of about twenty-five years with some amazing results.

The basic notion behind his work was the idea of focal infections which was a very big deal in medical thinking at that time. It is the idea that an infection someplace in the body - tonsil, gums, toenail, ear, or root canal - might be able to spread to another perhaps far remote part of the body. There was the feeling that was largely accepted that a gum infection, for example, might be able to end up somehow in the heart or other part of the body, and result in a dangerous or even life-threatening infection there. That idea, while never disproved, just sort of faded away by and large (although it keeps making small and sporadic comebacks ).

What happened was that with the advent of penicillin and other wonder-drugs to combat infection, concern for where the infection was coming from was suddenly less important than just which particular germ the infection was. The identity of the germ bacteria dictated which particular wonder-drug antibiotic was needed and that, in a nutshell, was that! "...Next patient!" We got away from treating the cause to treating the symptom .

If the way Dr. Meinig describes it in his book is accurate, the political debate among medical/dental leaders at the time must have been pretty hot and heavy! No doubt the pharmaceutical companies had their input, too... As with any new wave of thought, those that held to old ways were labeled old-fashioned and reactionary, whereas those that promoted the new were seen as modern and with it. As is often the case, the new way won the day. Some ground was gained, no doubt, but something may have been lost in the process.

Re-enter Dr. Weston Price. He took infected teeth or extracts of ground up infected extracted  teeth from patients suffering from a wide range of serious "medical" problems. He implanted these under the skin of laboratory animals....Guess what happened? The laboratory animal quickly came down with the very same disease ! I might have expected that an infection from a tooth might go somewhere. Like if ten animals had parts of an infected tooth implanted, that one might get an infection in the brain, another in the heart, and another somewhere else and so on...that seems reasonable. But that's not what Dr. Price reportedly  found at all!   What he reported was that if a patient had infected kidneys and his infected tooth was ground up and implanted in several lab animals, essentially all the animals quickly developed infected kidneys!   I don't think contemporary medical wisdom can explain that.

Moreover, Dr. Price claimed to have found that 95% of focal infections started in the teeth and tonsils! Part and parcel in with this is the idea that harmless bacteria normally found in the mouth get trapped in infected teeth (and tonsils) and somehow mutate into a dangerous form. The new mutated bacteria and /or the toxic poisons they create travel through the blood stream and lymphatic system to remote body parts and cause damage.

As if that were not bad enough, Dr. Price goes on to report  that even when root canal treatment was  done according to accepted modern principles of the time [early 1900's]...and even when the follow-up x-rays showed good healing of the bone around the root (which has been thought to prove that the infection is gone) - that even then, the mutant bacteria and their toxins are often still there spreading their poison! This is a very different scenario from what I was told in dental school and in all the years up to now! All I can say is that I read the book with an open mind and with the ability to challenge allegations by virtue of my training and 25 years or so of experience and I have to say it was compelling.

The anatomy of a tooth is like this. There is a hollow space running down the center of each root. That is the nerve canal. It can have curves and small offshoots or branches to make it more complex than a straight "tube", but in all, that total space is the nerve- or root-canal space. In a healthy tooth the nerve and small blood vessels mainly occupy that space. When root-canal treatment is done, that canal is cleaned out to render it empty. Medications are usually used to "sterilize" that space...to kill any bacteria that might be remaining after physically cleaning it out. Then it is filled up with various techniques and materials to obliterate the space.

What Dr. Price and Dr. Meinig reported  is that it is more complex than that. Not only is there this large central nerve-canal space to worry about, but, rather, that there are millions of little tunnels coming off the central nerve-canal space radiating through the body of the tooth root to the exterior surface of the tooth root. The tooth root surface is in contact with the blood stream and then bone. The "little tunnels" or dentinal tubules, as they are correctly called comprise literally miles of tunnels into which bacteria from the nerve-canal space can go and hide, well away from the physical and chemical efforts of the dentist. This has been shown more recently and confirmed by the electron-microscope!

What does all this mean? What are the implications?

Well it seems to me there are several. First, it seems ever more important to do the root-canal treatment as early as possible. In addition to making the treatment easier for you, it minimizes the opportunity for infection to develop inside the tooth which might be able to subsequently hide in the tubules and from there spread havoc around your body.  Early root canal problems are about badly INFLAMED nerves. Over a period of time it changes from INFLAMED to INFECTED.

Second, there is one medication which is generally agreed to be found capable of really killing most of even the most resistant bacteria inside the tooth, calcium hydroxide. [ See page 197 of Meinig’s book, 1993 edition ] Calcium hydroxide (Note:   This is NOT...NOT...not Biocalex, which  is now sold under a new name which I believe is Endo-Cal)  is recognized to be more effective than other more "modern" medications, but is only infrequently used by the root canal specialists and usually only for special situations, not consciously related to the issues raised here. There is no reason why it could not be routinely used and for a long enough time period to do the job (about a month). The norm today among general dentists as well as root canal specialists is to either finish the treatment in one appointment or perhaps in two appointments a week apart. Little real effort is apparent to sterilize the canal, probably again because of the "modern" thinking that if an infection is still there, we'll just knock it out with one or another antibiotic later.

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Why on earth, then,  would I ever recommend doing root canal treatment?

So with all that having been said, why on earth would I ever recommend doing root canal treatment? It really hinges on the question of what are you going to do if you already have root canal treated teeth or if you have a tooth in need of root canal treatment?

If you just take out a tooth or teeth how are you going to replace it? Well, you may just say "I won’t replace it." That’s ok, how about if it’s a front tooth? You could choose to not replace it, but realistically most people would want to replace it.

Back teeth that "don’t show"?   If you leave missing teeth missing, you may develop problems with your gums, problems with your bite (TMJ), and / or cranio-sacral, or chiropractic problems, not to mention lowered chewing ability. I should add that in some situations, teeth can be left not replaced and everything may be fine. But that’s the exception to the rule. The fact is that most of us will want the teeth replaced for a variety of reasons.

Teeth can be replaced with removable, "clip-in" partial dentures - bridges you take in and out. Most people find them unaesthetic and unhygienic. Workable, but not very satisfactory..... Dentally, they work... but not well. Usually patients want teeth replaced in a way that is closer to "natural".

That means the teeth must be replaced with an implant or a fixed bridge with caps. Implants are metallic posts implanted into the jawbone to mimic lost tooth roots. They are complicated and expensive and require a surgical procedure. Mostly (but certainly not always) they work pretty well. But what of having a metal plug directly in the bone ? Is it a problem? We really don’t know.

From a regular western dental point of view they seem ok, but from a more subtle point of view, who knows! Maybe after years of observation we’ll have some idea, but I don’t think anybody really knows for sure at this time. I wonder if the metal of the implant interferes with acupuncture meridians which flow through the bone where the implant has been placed. We know each tooth is normally related to meridians.  Now that so many implants have been done, we are beginning to see that some [a small percentage] of the patients are having allergic reactions to their implants.  That can be for both titanium and the newer zirconium implants.

If implants are out, then the other possibility may be to cap the teeth on either side of the space and have a "dummy cap" attached to those caps so the "real" caps hold the "dummy cap" in the space. That’s good old dentistry as it’s been done for years. While we have some options now about what the caps can be made of so that it is possible to make caps without metal in them, that is not always an option. It depends on the specifics of you and your mouth. But, what if you don't have teeth on  either side of the space to hold a "fixed bridge", or if the teeth are not suitable  for use?  What if they are not strong enough?

And what if capping these other teeth causes so much trauma to those teeth that the nerve breaks down in them ...and then they need root canals? That probably won’t happen, but be aware that it can and does happen! And not necessarily through any fault of the dentist, either. Finding a really good dentist will minimize that possibility, but it will not eliminate it....

So then what do you do? That’s the problem. If there were a perfect solution, I’d be first in line for it...but, unfortunately, there is not a perfect solution at this time.

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Given that, then, what can be done to respect and acknowledge the kinds of issues raised by Drs. Price and Meinig (and others), and yet treat diseased teeth?

Apparently Dr. Price did not work with all the root canal medications we have today. Calcium hydroxide is a simple salt used to make lime water. It was around in Dr. Price’s time, but it seems from Meinig’s writings (page 197) that it was not used in root canal treatment at Dr. Price's time as it has been used subsequently. Today calcium hydroxide is recognized by root canal specialists as being one of the most - if not the most - potent sterilizing agents that can be placed in the root canal space. Also, it is non-toxic and it stimulates the bone to repair around the infected root. (Note:  Calcium Hydroxide  is NOT...NOT...not Biocalex, which   is now sold under a new name which I believe is Endo-Cal)

Root canal specialists all use calcium hydroxide sometimes , but often only occasionally, for special and difficult situations. Their thinking has little to do with the issues raised here, however. Dr. Meinig discusses calcium hydroxide in his book on page 197, acknowledging its potency. He comments that it kills even the most resistant bacteria in about a minute.

Dr. Price was skeptical that anything would be able to sterilize the tiny tubules especially as they go further and further away from the main large nerve canal space outward toward the outside surface of the root. He said (as reported by Dr. Meinig on page 111, 1993 edition) that "It is practically, if not entirely, a physical impossibility to sterilize infected cementum [ the outside surface of the root ] by treating through the dentin [ that is, by placing a disinfectant inside the main nerve canal space in the center of the root structure ]. It is like trying to sterilize infection in the label on the bottle by putting disinfectants in the bottle."

There has been some very interesting research in the use of calcium hydroxide. We have learned that when calcium hydroxide is placed inside the tooth, the cementum [outside root surface] can be monitored to see the change in pH. The pH measures acidity or alkalinity, where 0=strongly acidic, 7=neutral, and 14=strongly alkaline . Calcium hydroxide is a strong alkaline and within 3 days of filling the root canal space with it, the pH measured out at the outside root cementum surface goes from about pH=7 (neutral) to pH=9. After about 18 days the pH is 10 and that pH will be maintained up to at least 120 days, which is as long as the research continued to measure it. It was found that this change in pH was observed everywhere on the root outside surface which would suggest that all the tooth structure was affected by the calcium hydroxide.  Keep in mind that Calcium Hydroxide was not used in root canal treatment until after the time of  Dr. Price's reasearch and writing.

Does this guarantee that every single tubule in the tooth was affected and that every single bacteria cell in the tooth was definitely killed stone dead? No, it doesn’t, but it suggests very strongly that it probably is so.

There are other significant benefits to calcium hydroxide. It will dissolve any tissue remaining in the root canal space. That’s important because   the mechanical technique used by dentists to clean out the nerve canal space leaves lots of bits of tissue behind, especially in the little offshoots and accessory canals which usually cannot be reached with dental instruments. So the calcium hydroxide dissolves it out chemically, provided it is left in there for a long enough time.

Additionally, the calcium hydroxide stimulates bone repair which is usually damaged if the root canal problem has been going on for more than a short time. In the mouth the calcium hydroxide disperses not only out from the nerve canal space to the surface of the root, as in the research experiment mentioned above, it continues out and goes into the ligament that holds the tooth to the bone socket, and further out into the bone itself, helping to decrease inflammation, ease pain, counteract the altered chemistry from infection, stimulate the bone repair processes and kill bacteria along the way.

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So, if a patient of mine has a root canal problem, I almost always recommend doing the root canal. When I do the root canal treatment, I use calcium hydroxide [and in recent years add chlorhexidine] as the medication inside the tooth and I leave it there for a full month. Not a week, not 10 or 14 days, but a full month. In severe cases I have re-medicated for one to several months after that before finalizing the treatment.  

 

Often when patients have been concerned about old root canals, I have re-treated them by starting over and using the calcium hydroxide technique.

Again, I cannot guarantee this is a perfect solution...

but neither can any other dentist guarantee that this or that "holistic" or "conventional" treatment is going to be perfect either!!!! and that includes extracting the tooth!

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So what's the problem if I use calcium hydroxide?
The big question  remaining about what I have suggested here is even if the canals and tiny tubules can be ma
de totally bacteria free...which may or may not be the case.... what happens after a period of time.  A week, year...ten years?  Do bacteria come in from the outside and rehabitate the tubules? We know  it is possible, because it happens in gum disease.  If it happens that way, is it a problem? Is it the same as when bacteria are  left in there when  root canal treatment is done?  It may seem logical to think "yes"...but we just simply don't know for sure.

Can  root canals be tested somehow?
Perhaps.....There have been  dentists that   "test" teeth using kinesiology,  or acupuncture, ...or electrical acupuncture spin-offs like computerized "Voll testing".  Are they valid?    perhaps....perhaps not....  We don't know for sure.  Am I against   these  techniques?  No, definitely not.  Any indicator is helpful.   But would I take out a tooth of
m
ine based on them?....NO way!!!

Is there hope in this mess?
I think so... testing techniques are developing as more interest [and money] are beginning to surround these issues.  At present a very interesting test has been  developed by some very clever people at  Affinity Labeling Corp. out of University of Kentucky.


They have developed a very sophisticated test for toxins around teeth either from the gums or from the root canals.   Is it valid?   Maybe... But to me it looks  like the best  and most valid and most   scientifically based way to  test teeth at this time.  And that's a lot ! They have a very good website  with lots of good info at   
http://www.altcorp.com  .  If you've read all this stuff  up to here, you definitely should check them out.

NOTE: In 2010 Altcorp and Affinity testing seem to have disappeared.  I have not found any sign of them on the internet.  Perhaps that will change in the future.

 

Biocalex....

Some  have tried to get results about what happens over time with root canal teeth that are treated by conventional  means and by using the Biocalex technique.  In my personal experience with Biocalex I feel it is NOT THE WAY TO GO.  There are many well-documented problems with Biocalex including  splitting of teeth (preventing them   from ever being  saved) , post-operative pain and strange discomforts,   inability to re-treat the tooth again if needed later, and inability to see the results on x-rays after a period of time.  I HAVE USED BIOCALEX SEVERAL TIMES AND WILL NEVER USE IT AGAIN ON MY PATIENTS. 

Calcium Hydroxide on the other hand has been dependable and comfortable for many years in my hands with my patients and I continue to use it as described above. CALCIUM HYDROXIDE IS NOT THE SAME THING AS BIOCALEX.   CALCIUM HYDROXIDE IS NOT THE SAME THING AS BIOCALEX.  Note: CALCIUM HYDROXIDE IS NOT THE SAME THING AS BIOCALEX.   Have I made my point clear enough?

NOTE: I now have included a more detailed article specifically on the use of Calcium Hydroxide for root canal treatment on this website.  See Topics > Calcium Hydroxide For Root Canals.



It is my hope that this article helps readers reach more reasonable and rational decisions about their dental health decisions and root canal treatment in particular.

What I have tried to explain here is simply what I believe to be a practical and realistic approach to a difficult and all too common dental problem. It is my sincere hope and intention that it  acknowledges and respects the far-reaching and insightful observations of Dr. Weston Price so long ago and merges it with the science that has been demonstrated in the almost 100 years since his brilliant research in his time.

It is my hope that this article helps readers reach reasonable and rational decisions about their dental health.

 

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Michael Goldman DDS

3815 East-West Highway

Chevy Chase, Maryland 20815

301-656-6171

More info about the following is available  if you select  "topics".

Holism in dentistry is an approach to dental treatment, primarily  caring for  patients' health and safety from both a conventional as well as  "alternative healthcare" point of view.   It is sometimes called "biological" dentistry or "biocompatible" dentistry.  In it's fullest sense, I believe it   acknowledges and deals with  the mind, body and spirit of the patient, not just his or her "teeth".  See Topics / Info.....

Cosmetic dentistry is about doing   quality , esthetic dentistry in a way that looks natural to begin with, and furthermore,   can even  improve  one's  attractiveness through techniques such as bonding, bleaching, veneers, caps, implants and more.  It can   be like "instant orthodontics" in correcting  crooked, twisted or misplaced teeth in many instances.  Dark or misshapen teeth can be restored.   Smiles that lack youthful vigor or beauty can be revitalized! See Topics / Info..

Bleaching, veneers, bonding, caps, bridges, and implants  are cosmetic dentistry treatments that are also  discussed in  Cosmetic Dentistry, and more...located in the Bethesda, Chevy Chase, Maryland 20815 area near Washington DC.

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