Endodontics(root fillings)

The preservation of badly damaged teeth

You may wonder why there can be so much difference in costs of root fillings from one dentist and another. In essence, you get what you pay for. Our stance is that if we are to do it, it should be carried out properly, and if a person is unwilling to pay the amount required then it is better we don't do it. We don't look for short-cuts, we aim to remove infection to allow healing.

Although a tooth may not be painful, a chronic infection can affect other parts of the body, and improperly completed work leaves you vulnerable to effects perhaps years later.

How do we know when to root fill?

Sometimes there is doubt and we may have to monitor a tooth for several months, before we can make a definite decision that it is required.

Teeth generally give us early warnings such as discomfort on pressure when biting or brushing. At this stage magnification available on digital x-rays may allow us to detect changes in the supporting membrane of a tooth and narrowing of the nerve canals. When we see this a diagnosis of 'irreversible pulpitis' may be made. This means the damage is irreparable without our help, even though you may not have intense pain.

This is the best time to treat, because damage hasn't spread into the bone around the tooth, so success is almost assured. There is one exception to this and that is where a tooth has split, and this may only become apparent as the root filling is progressing. Unfortunately, the only certain treatment for this is extraction.

Leaving a tooth to worsen may result in abscess formation, swelling of the face, increasing difficulty getting the tooth numb, and greater risk of treatment failure. Our advice is to treat as soon as the diagnosis is established.

Root-filling is one of the most skilful areas of dentistry

It is interesting that the NHS doesn't pay general practitioners to root fill teeth, yet expects them to do so. It pays for the filling on top, but no extra for the root filling, and yet general practitioners are expected to do the root filling if clinically necessary. This is a recipe for disaster, where little time is allocated for their completion and short-cuts are common.

We can only assume that the NHS system is encouraging dentists to extract teeth rather than save them. Such an approach protects general health, but long term dental health and function may be affected, and this may take dentistry back to that of the 1940's and 50's.

Root filling is one of the most intricate and time-consuming procedures in dentistry, and accordingly costs more than most others except implants. If not carried out properly the chance of long-term failure is dramatically increased.

The minimum time we take for the simplest single root filling is one hour. We hear of cases where a small number of unscrupulous dentists complete these in ten to fifteen minutes, but this is impossible, because eradication of bacteria by the disinfectants used takes at least 30 minutes. The 30 minute disinfection cycle starts when we are about 1mm from the tip of the root. To help you appreciate the sizes we are dealing with, if you imagine bacteria are enlarged to our size, then one millimetre is the equivalent of 550 metres. It takes time for the disinfectant to soak through, and we know some will survive even this, so we use a second liquid disinfectant , and usually ozone gas.

The ozone, which is unavailable at any other local practice, as far as we aware, has two effects, firstly as a strong disinfectant bursting any bacterial cell walls it comes into contact with, and secondly it changes to oxygen in the tissues around the end of the root. The high level of oxygen combines with protective iron collected from us by bacteria, leaving them vulnerable to the effects of our immune cells, thereby increasing our healing capacity beyond the root tip, probably increasing the success of the operation.

To achieve the quality we are seeking the stages we carry out are:

Pre-treatment digital x-ray of tooth, which is used to estimate the length of the tooth.
Topical anaesthetic is applied to the injection site for two minutes to minimise the discomfort of injection.
Local anaesthetic is slowly administered to allow painless treatment.
The tooth is opened to expose the pulp chamber, and the openings to the root canals identified.
Where appropriate, rubber dam is applied to isolate the tooth and make treatment easier.
Sodium hypochlorite is applied regularly during the procedure to dissolve fragments of dead tissue and kill bacteria.
Ethylene diamine tetra-acetic acid (EDTA) is applied frequently when root canal instruments are introduced into the canals, to lubricate and interact with the hypochlorite to bubble and loosen debris.
Chlorhexidine gel is introduced into the canal to destroy certain nasty bacteria.
Use root canal instruments to shape the canals ready to receive the root filling materials.
An electronic apex locator is used to assess when the root tip is reached.
The size of the canal is measured to assess the root filling required.
With the measuring instrument in position a digital x-ray is taken to confirm the position.
Once satisfied that the canals are ready, HealOzone is applied for two minutes to destroy remaining bacteria. If not possible to attain a seal for HealOzone, then we use photo-activated disinfection.
A lubricant is placed into the canals, and the softened root filling material, gutta percha is slid and gently compressed into the canal. Alternatively, we may use a resin based filling material.
The positioning is confirmed with another digital x-ray.
The biting surface of the tooth is then restored with a medium term restoration. Once we are sure healing is satisfactory the tooth should be restored with a crown to prevent cracking of the tooth, because it becomes brittle, having no blood supply inside. Generally a crown should be fitted within 12 months.

The costs of this treatment

This should be weighed against the alternatives of course. The full cost of saving a badly damaged tooth includes the cost of root filling and subsequent crowning and it's better to budget for both, although crowning can be put off for while if you need to, but this isn't the best course of action. Remember teeth are different, with front teeth generally having a single nerve canal, whilst back teeth have 3,4, 5 or even more, and more difficult and time-consuming therefore. The prices are guides and subject to individual variation.

Saving a front tooth (total time involved 3 to 4 hours)

Excellent quality root filling about (time 1 to 2 hours)...£300

Aesthetically excellent crown (time 2 hours)...............£550

Total.....................................................................£850

(compared to cost of an implant £2000, or bridge £1400)

Saving a molar tooth (total time involved 4 to 5 hours)

Excellent quality root filling (time 2 to 3.5 hours)..........£650

Strong tooth coloured crown (time 1.5 hours).............£415

Total.....................................................................£1065

(compared to cost of an implant £2000, or bridge £1400)

What are the chances of success?

When carefully carried out, root fillings have a success rate around 90%. This would be higher if people attended as soon as problems develop.

Ray Steggles has a particular interest in endodontics and during the last ten years has root filled over 2000 teeth (about five per week). The number that are known to have failed, requiring extraction, has been fewer than 20. So his personal success rate is well above the generally accepted level at about 99%. The main reason for this is the determination to maintain high quality by allocating sufficient time and the most advanced techniques and equipment.

Despite the success rate, success in your case cannot be guaranteed, and all we can do is our best. There are failures where the reason cannot be determined, but in cases of initial failure, we can sometimes succeed by re-treatment. Should you require re-treatment within two years Ray Steggles will carry this out without additional charge to you, but this promise does not include other treatment to the tooth, such as extraction, or the cost of re-treatment by another dentist. If you comply with the conditions for guarantee of advanced treatment, then this all encompassing guarantee will apply once a crown has been fitted.

Why should we preserve such badly broken down teeth?

Because we have the technology to predictably save apparently hopeless teeth.
To maintain the arch of teeth. Teeth work in unison and the loss of one or more can badly affect the functioning of the rest of the team.
A preserved natural tooth is better adapted to your body than the best artificial replacement, currently an implant, which would cost in the region of £2000- £3000.
To provide support for crowns, bridges, or dentures.
To prevent the movement of other teeth leading to altered function, trapping of food, and ultimately the loss of further teeth.
To maintain youthful appearance, and hold back the signs of ageing.

Does root filling hurt?

Root filling is carried out under local anaesthetic, so the procedure should be pain-free.

After the procedure you may have some after-pain, but ordinary pain killers should be sufficient to calm it down. About 50% of people get some after pain which they describe as ranging from soreness to intense pain, and they say this lasts from a few hours to several days. The other 50% say they are unaware that anything has been done.

The reasons for after pain seem to include the oozing of minute amounts of root filling material through the tip of the tooth. The success of the root filling is not affected by this, because your body will remove this material.

You may be aware that the tooth feels 'different' for several months or even a year or two. Again the tooth functions correctly, and this sensation is probably to do with the healing process, and is not an indication that the root filling is failing.

Failure of root filling is indicated by:

An increase in pain after apparent healing of the tooth.
Loosening of the tooth
Development of swelling around the tooth.
Where a lump appears near the tooth and you can squeeze pus from it.
Worsening appearance on x-ray.

The last four may occur without any pain. Should you notice any of these developments, it is important to let the dentist know, so that there is a greater chance of finding the reason and dealing with it before damage is so severe extraction is necessary.