What are the Alternatives? What if I don’t have the Root Canal Treatment?
If the nerve has been affected inside, to the point at which it can no-longer recover (irreversible pulpitis), or has already died, then there are only three choices:
Let’s look at our alternatives in more detail:
- Do nothing
If the tooth isn’t currently giving you problems (which means an area around a root on a tooth with a deep filling was most likely discovered by accident on an X-ray, you may decided to leave it. This is your right and if it has been silent for many years, then I can understand your point of view.
However, it is worth commenting that leaving any infection in your body is probably not a good idea and if the balance for some reason is tipped in favour of the bacteria, pain and an acute abscess will result.
Unfortunately there is no saying when this might occur, so it may be better to be proactive, but this is of course your decision. If you are already experiencing some pain and decide to leave the tooth and do nothing, it is likely that the pain will get more frequent and severe, until eventually you have to resort to one of the options below.
Sometimes as the nerve is dying it can be very painful, then suddenly… Relief! In these circumstances, the tooth is likely to have been experiencing irreversible pulpitis, which is painful until the point at which, the swelling inside the nerve is sufficient to cut off its own blood supply to the tooth and the nerve dies and the pain disappears. This may stay silent for a while, but then follow a similar course to that discussed above.
There are some circumstances where it is advisable to remove a tooth, or it is not possible to perform a root canal- these are discussed in more detail below. Removing a tooth can have a number of negative consequences, these include:
1. Aesthetic problems– obviously this is personal and up to you, but having a space where your front tooth is will have significantly more impact than a space right at the back of your mouth.
2. Problems chewing
3. Speech problems (very rare)
4. Worsening of periodontal disease– because the remaining teeth are now taking more pressure or tooth movement has created areas that are more difficult to clean.
5. Sensitivity of the roots- relating to the teeth next to the space- as the bone in the extraction site shrinks down
6. Tooth movement:
(i) Teeth next to the space may tilt inwards, similar to when you remove a book from a shelf of books- the ends tilt in.
(ii) Teeth opposing the space may over erupt. Teeth maintain the ability to erupt, so when a tooth is removed and they are no-longer balanced, it can erupt further, providing a cosmetic problem- areas that trap more plaque and sensitivity from the exposed root, which are now above the gum.
Changes in your bite can result in problems of the jaw joint, See -TMDS, though this is relatively rare.
Whilst all these consequences happen in varying amounts, most patients in my experience who opt to remove the tooth and not to fill the gap learn to adapt to their new mouth without too much trouble. Are you best to fill the gap? Of course! It is the best way to avoid the problems, but I am conscious that some dentists may over emphasize these issues and push patients towards expensive replacements. See- Missing teeth, for more information.
Tooth movement commonly occurs following an extraction and if you leave this over a long period, it may be much harder to put something in the space without moving the teeth first.
Extraction is the cheapest, fastest and simplest option to get you out of pain, but not if you wish to consider filling the space it leaves. The price of a getting a denture would be similar- which begs the question why extract it in the first place- you get to keep your tooth as before and don’t have to take the denture in and out. If you already wear a denture then adding a tooth to it is a cheaper option.
A bridge, or implant to replace the tooth will nearly always exceed the cost of the root canal, so where your intention is to seek a replacement, it is better where the prognosis for the tooth is good, to have a root canal treatment and keep the tooth.
Am I Suitable for a Root Canal?
There are circumstances in which root canal treatment is not advised or indeed not possible:
- Inadequate access. Using the little files and a drill to access the canals requires space and if you have very limited opening or a very small mouth it may not be possible.
- General medical conditions. If a patient is not physically or mentally able to understand and accept treatment or cannot remain still for extended periods then complex root canal therapy may not be appropriate.
- Poor prognosis- unrestorable tooth. If the tooth cannot be restored properly to health and function following a root canal it may be a waste of time and money. For example, if the decay extends below the crest of the bone supporting the tooth, an extraction may be a better choice.
- Poor periodontal support. If the tooth has very little bone holding it in and has mobility that suggests that the prognosis is not good and it may be lost shortly anyway, extraction should be considered. If the tooth has healthy periodontal tissues or they can made healthy, a root canal can be performed.
- Unopposed tooth. If the tooth doesn’t have another tooth opposite it to chew on and is of little functional use, i.e. it doesn’t support a partial denture or provide any value to the mouth then extraction should be considered.
- Strange anatomy. If the tooth in question has complex curved roots,or is dilacerated(the angle of the root doesn’t match the crown), this could affect the prognosis. Though most specialists would be able to handle most situations.
- Root fractures. Fractures of the root that communicate with the mouth have a poor prognosis, as they provide a stream of bacteria, which will re-infect the root canal. The extent and site of the fracture line will determine whether the tooth can be saved or not. Vertical fractures that extend low under the gum are difficult to save, but a superficial horizontal or diagonal fracture confined to the crown of the tooth, has a much better prognosis.
- [[il|70|Failed root canal treatment]].If a root treatment has failed, the prognosis second time round is less favourable. It is important to consider why the root treatment has failed – is the anatomy unfavourable? Was the root inadequately sterilized last time? Is there an undetected root fracture or perforation that has prevented healing?
Would Extraction be a Better Option?
There are a number of considerations here- some related to the tooth and some related to more general matters.
If you can afford to save a tooth and it is a useful tooth with a good long-term prognosis, then the best thing to do is to try and save it.
Some questions to ask yourself are?
- Is it affordable?
Root canal treatments cost a lot of money. If we take cost out of the equation, most of the time I would say go to whatever lengths necessary to try and keep your teeth, as there is no substitute for the real thing. As money is nearly always a factor, we may have to ask more considered questions.
As a patient, I would be asking myself- is my money best spent in this way? Here ,I am not talking about whether I would rather buy an i-pad, though we all have different priorities- I mean taking into account the likely success, usefulness of the tooth etc. Would it be preferable to spend for example $3000 on a molar root canal and crown or would I be better off extracting it and filling up some of the other spaces I have with a partial denture? Every case is unique and different and must be assessed that way.
- Where is the tooth?
The nearer to the front the tooth is and the more prominent in the smile, the more likely you are to opt for a root canal. Patients often have the attitude that if you can’t see it then it will be fine, but having back teeth is much more than just about the look. The back teeth support the cheeks and muscles providing structure to the face and surface for chewing, protecting and reducing the wear on the front teeth.
Also, check your smile in the mirror to see if the gap is going to be an issue from a cosmetic standpoint.
- Do you have other missing teeth?
If you extract the tooth… what are you going to do with the space? As I mentioned previously, the options that exist are a denture, bridgebridge or implant. If you already have a denture and are used to wearing one, then depending on the denture construction, a tooth can most often be added. It is however important to assess whether removing the tooth will negatively affect the support and grip of the denture.
For example, if it is the last remaining molar in the upper jaw that has a clasp around it, then it is helping to hold the denture in place. Removing it may mean the denture doesn’t remain in place as well as it might- it may move slightly during chewing. In these circumstances, it would be advisable to save the tooth.
However, if the tooth was already next to a space and not the key tooth that was providing support, extraction is unlikely to affect the wearing of the denture.