In the centre of each tooth sits the blood supply and nerve supply to the tooth, otherwise known as the pulp of the tooth. One could consider this to be the heart of the tooth which is essential to keep the tooth healthy and alive. Occasionally the pulp of the tooth can become inflamed and give rise to an excruciating sharp shooting pain, often with hot and cold stimuli. This pain is the human body’s way of telling you something is wrong and requires some attention. In most cases this kind of pain is due to decay in the tooth, leaking restoration or a recent trauma or injury. If diagnosed and treated early, the inflammation can be reversed before any lasting damage on the pulp. In many cases this may not be possible and the pulp becomes irreversibly inflamed, leaving only two options, which is to extract the tooth or complete root canal treatment.
Some teeth with large fillings, recurrent decay or extreme trauma may result in necrosis (death) of the pulp tissue. This will often result in an infection associated with this tooth which is characterised by a dull ache or throbbing pain, pain on biting and in many cases sleep disturbance. Teeth that have had previous root canal treatment and have become re-infected can also present with similar symptoms. In both of these situations, the treatment options involve root canal treatment, repeat root canal treatment or extraction of the tooth.
Root canal treatment and retreatment avoids the need to extract an irreversibly inflamed or infected tooth and has a high success rate, if carried out in the right setting. It involves cleaning out the pulp and root canal space, disinfecting it and then sealing it with an inert filling material. Following the completion of the treatment, the tooth no longer has any life or feeling but can be retained to avoid a gap and maintain function and aesthetics.
In some patients further advanced forms of endodontic procedures may also be necessary, involving a surgical approach to treat dental cysts and infections that persist after multiple attempts at root canal treatment. This is often known as an apicectomy, apical surgery or surgical endodontics.
Root canal treatment and associated surgical endodontics are skilled and time-consuming procedures and the time required to complete the treatment will vary between each tooth. A specialist will often have more advanced equipment including an operating microscope and vast experience which will help to achieve higher success rates. Before embarking
on this treatment, it is important to have a consultation where the tooth can be thoroughly assessed. There is no point in trying to carry out root canal treatment on a tooth that subsequently cannot be adequately restored with a good prognosis. The consultation will also allow the specialist to identify any factors that may compromise the outcome of the treatment or make the treatment more complicated. These findings will be presented to you which should help make an informed choice regarding the best course of treatment for your symptomatic tooth.
In every case the primary choice of treatment should always be to try and save the tooth however, in some cases this option may not be a good long-term solution or the complexity of the case may mean the outcome is unpredictable. In these situations, the best option may be to consider extraction of the tooth and a suitable replacement with a denture, bridge or dental implant retained crown. A specialist in restorative dentistry who has expertise both in endodontics and prosthodontics can discuss both options with you, present the advantages and disadvantages of each and help you make a choice based on what is right for you.
Periodontics is a branch of dentistry that is concerned with the structures surrounding and supporting the teeth, often referred to as the periodontal tissues. These tissues include the bone, gums and a ligament that connects the teeth to the bone. The two most common periodontal problems are gingivitis (inflamed gums) and periodontal disease/gum disease (inflamed gums with bone loss). Whilst these are the most common there are a whole range of other problems and conditions that may be associated with the periodontal tissues. A specialist in periodontology can help to assess, diagnose and manage these conditions.
The primary cause of gingivitis and periodontal disease is poor oral hygiene resulting in a build-up of plaque around the junction between the teeth and gums. Dental plaque is a collection of bacteria and microorganisms which matures with time and if left long enough will mineralise into a harder structure, known as calculus/tartar. This is somewhat similar to how limescale forms. The more mature the plaque and calculus, the more damaging it can be to the underlying periodontal tissues. It is therefore recommended that twice daily brushing and interdental cleaning to remove the plaque and disrupt the biofilm is absolutely necessary to maintain good gum health. If left to turn into calculus then this can only be removed by a dentist or hygienist with a scaler.
The build up of plaque releases toxins from the bacteria within it, which in turn irritate the underlying periodontal tissues. The tissues and the body reacts in an attempt to fight the bacteria and its toxins through an inflammatory reaction. This results in swollen and bleeding gums (gingivitis). As part of the inflammatory reaction, the body sends enzymes via the bloodstream to fight the bacteria and its toxins. Unfortunately, if this process goes on long enough the battle between the bacteria and the body’s defence enzymes can result in bone loss (periodontal disease). There are many risk factors that may contribute to the development of gum disease in the presence of plaque. The common ones are smoking, uncontrolled diabetes, crowding of teeth and poorly restored dentition where fillings, crowns, dentures etc are acting as a plaque trap. A specialist in restorative dentistry can not only look at the periodontology aspect of the problem but is also in a good position to assess the whole dentition and identify other contributing factors from a prosthodontic and endodontic perspective as well. This allows a fully informed discussion as to the treatment required to address the problem. For some patients, this may involve treatment over multiple specialties.
Interestingly, periodontal conditions do not usually cause pain or discomfort and therefore go unnoticed until a late stage, especially in patients who are irregular attenders with the dentist. Clinical signs of gingivitis include red swollen gums that bleed on eating, brushing or even spontaneously. Periodontal disease often presents with teeth becoming loose, the gums receding, gaps forming between teeth and teeth drifting, in addition to the signs noted in gingivitis. If the condition is not managed the end result will be multiple loss of teeth.
Unfortunately, chronic periodontal disease like any other chronic condition cannot be fully cured. The bone loss often noted around periodontally involved teeth in most cases can also not be brought back. The main aim of treatment is to work with the patient to identify and control risk factors, provide tools and techniques to improve plaque control and stabilise the inflammation through non surgical and surgical periodontal treatment to prevent further bone loss and progression of the disease. Once stabilised the patient will embark on a life long journey of maintenance, monitoring and supportive therapy. In patients who show long term sustained stability more advanced periodontal procedures can be considered such as bone regeneration in suitable sites.
A periodontal specialist may also see patients who do not have gum disease but require other forms of treatment, such as soft tissue grafting to cover root recession defects on teeth and manage sensitivity. Some patients may also have a gummy appearance to their smile and a periodontist may be able to help by carefully surgically repositioning the tissues. This can be carried out around multiple teeth or around one single tooth to expose some more of the tooth to help restore it with a crown. These procedures are often referred to as mucogingival surgery, periodontal plastic surgery or crown lengthening procedures. A periodontist can also help to manage problems with inflammation and bone loss noted around dental implants. This condition is known as peri-implantitis and is similar to periodontal disease around teeth.
If you have any problems or concerns related to your gums or periodontal tissues around teeth or implants, then a consultation with a specialist would be advised. Some patients may not have any problems but may be advised to see a specialist by their dentist or hygienist, as they have identified a problem during a routine visit. Early diagnosis and intervention can have a better outcome then leaving it to a stage where the condition is more advance.
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