The Toxic Tooth: CHAPTER NINE: ALTERNATIVES TO ROOT CANAL TREATMENT Some Healthy Options

 

CHAPTER NINE: ALTERNATIVES TO ROOT CANAL TREATMENT

Some Healthy Options

Several options exist to help out the patient who has had one or more root canal-treated teeth extracted, or to the patient who just elects to get an infected tooth extracted first before even proceeding to a root canal treatment. These options include bridges, partials or full dentures depending on the remaining mouth anatomy, implants, and doing nothing. Doing nothing is not a good option in many circumstances, but it can sometimes be the best option when the back molar is missing but chewing is not compromised.

It goes without saying that a healthy mouth that is free of cavities and free of periodontal disease is ideal. However, even with the most diligent home care regimen, tooth decay can sometimes occur which may eventually lead to pulp infection. In addition, damage to teeth caused by trauma can be the indication for a root canal procedure or tooth extraction. The question, then, is: What are the restoration options when the tooth pulp becomes infected, and the tooth is extracted rather than given a root canal procedure?

When the infected tooth needs to be extracted, the restoration options include:

1. Leaving the space empty

2. Restoring the missing tooth or empty space(s) with a removable

   partial denture (RPD)

3. Restoring the empty space(s) with a permanently cemented fixed

   bridge

4. Restoring the space(s) with dental implant(s)

However, because the ADA has unequivocally stated that root canal- treated teeth are 100% safe and can pose no systemic health risks whatsoever, patients will likely be led towards having a root canal

procedure instead of an RPD, fixed bridge, or dental implant. Considering the ADA’s position on the root canal procedure, the encouragement to go in this direction is completely understandable.

To further complicate matters, if a patient decides to have a fixed bridge and somewhere down the line one of the abutment (anchoring) teeth becomes non-vital, the patient will have to make the choice to have a root canal procedure on that abutment tooth or to have that tooth extracted which necessitates removal of the entire bridge. After paying a sizable price for the fixed bridge, many people would be reluctant to remove the entire bridge that could have been “saved” with just a root canal procedure. Now the patient faces additional expense for a new bridge or dental implants. So the treatment decision is definitely not an easy one for the patient, especially when considering all of the expenses involved.

The decision to have a root canal procedure should be made by the individual patient who has been completely informed about all of the risks and benefits of the procedure.

As all root canal-treated teeth remain infected, the ability to tolerate a root canal-treated tooth varies widely from individual to individual, as does the degree of tooth toxicity. Extensive work by Dr. Boyd Haley did not find a single extracted root canal-treated tooth that did not have significant toxicity. And Dr. Haley tested over 5,000 consecutive extracted root canal- treated teeth. How these toxins will impact the health of any given individuals could vary greatly based on some known factors—such as genetic predispositions, immune status, antioxidant status, age, and general health—as well as by a future health status that cannot be known. Therefore, the final treatment decision should always rest with the completely informed patient.

Now let’s address in more detail the treatment options to restore the empty space after extraction.

“Do Nothing” Option

The first option is to do nothing. This may be an acceptable permanent option if the tooth that was extracted is a second molar. Most of the chewing is done from the first molar forward so it is very unlikely, functionally speaking, that this tooth would ever be missed. The only

downside of leaving the second molar space vacant is the continued eruption of the opposing tooth. If there is no opposing tooth, or if there is partial occlusion of the opposing tooth by the first molar, then continued eruption of the opposing tooth will not occur.

Removable Partial Denture Option

If the extracted tooth is any other tooth besides the second molar or a wisdom tooth, then the empty space should be restored both for aesthetic reasons and, more importantly, to maintain the stability of the dental arch and the ability to chew optimally. The least invasive restoration to replace missing teeth is a removable partial denture (RPD). A RPD rests on the gum tissue and hooks onto the remaining teeth with various types of clasps. A RPD is completely removable so it is easily taken out of the mouth to clean.

Figure 9-1: A partial denture as a replacement for 5 lower molars. This appliance is removable for cleaning.

Fixed Bridge Option

Another option to replace missing teeth is a fixed bridge. A fixed bridge uses the teeth (called abutment teeth) on either side of the empty space as supports for crowns to fill in the space. The abutment teeth are prepared for crowns in the same way as for a regular crown procedure. Then, a one-piece restoration is fabricated where a tooth or teeth that are to fill in the empty

space are connected to the two abutment crowns and the entire unit is fitted and cemented permanently in place. The major downside of this procedure is that a lot of natural tooth structure must be removed in the crown abutment preparation, which can sometimes lead to death of the pulp tissue. If both of the abutment teeth already have very large dental restorations in them, then only slightly more natural tooth preparation will be necessary and this option becomes more attractive.

Figure 9-2: A fixed bridge is permanently anchored to a tooth on either side. The anchor teeth must be filed down to accomodate the caps that hold the replacement tooth.

Figure 9-3: A surgical post screwed into the jawbone becomes the anchor for the replacement tooth in a dental implant.

Dental Implant Option

Dental implants have become a very predictable and reliable long-term solution to replacing a missing tooth. This procedure involves the implantation of a sterile titanium post as an abutment in the extraction site.

The implant serves the same supporting function as the natural tooth or the root canal-treated tooth prepared as the support for a single crown or fixed bridge without the negative health impact delivered by bacteria and toxins leaking out of the root canal-treated tooth.

When placed in healthy, well-healed bone a dental implant can provide many years of function without the need to place crowns on teeth adjacent to the empty space in order to place a fixed bridge. Depending on the particular situation, an implant can be used to replace a single tooth or as an abutment for a bridge.

When performed as outlined below, a dental implant is always preferable to a root canal-treated tooth because a root canal-treated tooth can always be expected to negatively impact health substantially more than an implant, especially if it was properly-placed. Indeed, a properly-placed implant should have no discernible negative impact on general health.

Although some dental implants are placed immediately after extraction and are sometimes immediately restored, it is recommended that a dental implant procedure should not be started until new healthy bone has filled the extraction site. This important healing process requires a minimum of three months.

Unless bone grafts or sinus augmentation is needed to create more bone volume, the implant procedure is a painless and relatively straightforward procedure for a dentist trained in implant dentistry. Once the bone at the implant site is carefully measured, both by physical exam and X-ray evaluation, the dentist will select the appropriate implant size. An incision is made in the gum tissue to expose the top of the bone. Then a series of increasing diameter drills create a hole in the jawbone, and a sterile post made of titanium alloy is firmly screwed into place. When the top of the implant is flush with the bone crest, the gum tissue is sutured closed. The implant remains untouched under the gum tissue for three to six months as the bone heals and matures and essentially locks the implant into place.

After sufficient healing time the restorative process begins by reopening the gum tissue and an implant abutment is inserted onto the exposed implant. This implant abutment acts the same way as a natural tooth that has been prepared for a crown. At this point the restoration proceeds essentially the same way in which a crown is placed on a prepared natural tooth.

It is very important that the gum tissue around the implant be kept very clean, as the gum tissue does not insert fibers into the implant abutment like a natural tooth does to prevent bacteria from reaching the underlying bone. However, if this gum tissue is kept clean and plaque-free, it will keep a firm seal around the implant abutment, and it is likely that no bacteria will migrate into the bone.

The goal of this book is not to eliminate the root canal procedure per se . The goal is to state scientific research, to interpret it logically, to stimulate further objective and unbiased research into the safety of root canal-treated teeth, and to allow dental patients to make their own best treatment decisions.

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