Why does pain occur during root canal treatment?

The more a person is afraid of dentists, the more closely he eventually has to interact with them and the longer the dental treatment will be for him - a simple and banal truth, but, unfortunately, not all people take note of it. If caries treatment is not carried out in a timely manner, the infection gradually spreads “inward”, capturing more and more new territories and reaching the pulp chamber. Pulpitis develops - an extremely painful and unpleasant disease, which is popularly called “inflammation of the dental nerve.” This is where most people don’t just go to the dentist, but run – because the pain prevents them from sleeping, eating, or working normally. And if the patient has already begun to have inflammation of the tooth canals, treatment will require quite serious and lengthy treatment: cleaning the tooth canals from infected and dead tissue, their special antibacterial treatment, careful filling of both the canals themselves and the dental crown with the cavity.

Almost everyone knows about such a dental procedure as treatment and filling of dental canals, and many people have encountered it from personal experience. But most people usually don’t know the intricacies of the process, how exactly such treatment takes place, why it is needed and what it gives in the end. So what are the standards for filling canals, why and how exactly is this procedure carried out, and what can a poorly filled canal threaten a patient with? Dentist-therapist at the 32 Dent clinic Larisa Aleksandrovna Kravtsova will help you get reliable answers to all these questions.

What is a root canal?

Each tooth, except for enamel and dentin, has an internal space - a pulp chamber, communicating with thin cavities running along the entire length of the roots of the teeth - root canals. Different dental groups have different numbers of roots, and, accordingly, canals. The front group has 1 channel, the side ones - from 2 to 4.

Narrow, winding, thin tubes with many branches - this is how to characterize the root canals of teeth. The entrance to them is located at the apex of the tooth root, it is called the apical foramen. Through it, through each root canal, passes neurovascular tissue, which is responsible for the blood supply and innervation of the tooth.

Endodontic treatment is a procedure for removing infected, inflamed or dead neurovascular tissue, followed by cleaning and disinfection of the resulting space, and completely sealing the dental canals.

Indications for root canal treatment in permanent teeth:

• acute and aggravated pulpitis;
• chronic pulpitis;
• caries of enamel and dentin (medium and deep stages);
• acute and aggravated periodontitis;
• chronic forms of periodontitis;
• tooth trauma with opening of the cavity and exposure of the nerve [1].

Filling can be carried out as planned, when the patient himself comes to the doctor as damage is detected, or as an emergency, as a result of acute pain.

Successful restoration of tooth shape and function with composites requires strict adherence to a number of steps:

1. Preparing the patient for restoration. The dentist assesses the degree of tooth destruction, the condition of the periapical tissues, functional load, and the need to use an intracanal pin.
2. Preparing the tooth for restoration. The doctor selects the colors of the restoration and removes tooth formations.
3. Preparation of a carious cavity. The dentist selects a filling material, opens the enamel prisms, isolates the tooth from saliva, drys the cavity, applies a medical lining (if necessary), creates a hybrid layer from a moisture-resistant adhesive substance, applies the adhesive, introduces a composite material into the cavity, modeling the filling and final highlighting.

The criterion for a high-quality restoration is compliance with the shape of the tooth, the absence of overhanging edges of the filling, and the transition between the filling and the tooth tissue does not have a noticeable boundary.

“As the results of clinical trials have shown, endodontic manipulations in one root canal take from 40 minutes to 2 hours, depending on the condition of the canal.
Most of the time is spent on its mechanical processing. Filling one canal using the lateral condensation method without correction of the working length requires an average of 12 minutes Lutskaya I.K., Doctor of Medical Sciences, Professor, Head of the Department of Therapeutic Dentistry of the Belarusian Medical Academy of Postgraduate Education [2]

Diseases that require endodontic therapy

Treatment of tooth canals is performed only if there are strict indications, since as a result of the intervention, the tooth is deprived of the vessels and nerve endings that feed it, which makes the dental tissues less durable and more susceptible to destruction. Indications for intervention include inflammation and infections accompanying caries or traumatic tooth damage:

• Pulpitis is inflammation of the pulp (neurovascular tissue) - soft, fibrous tissue, including blood and lymphatic vessels, nerve endings and connective tissue.
• Periodontitis is inflammation of the tooth root and surrounding tissues (periodontal tissue).

These diseases are usually accompanied by the following symptoms:

• Acute, throbbing or aching pain in the tooth, increasing at night or intensifying with load on the tooth.
• Swelling, discoloration of the gums, formation of ulcers and fistulas on it.
• Putrid odor from the mouth.

In some cases, there are no pronounced symptoms and the development of pulp necrosis is detected only during a doctor’s examination. Only a specialist can accurately determine whether endodontic treatment will solve the problem and select the most effective therapeutic regimen.

Methods of treatment of dental canals

Not so long ago, arsenic paste was used for endodontic treatment. The dentist opened the dental chamber, put the paste into it and, after the pulp died, removed it from the tooth. Next, the tooth was filled and considered cured. The resorcinol-formalin method was also widely used - a resorcinol-formalin mixture placed in the cavity slowly hardened, stopping the disintegration of the partially removed pulp.

But such technologies have significant disadvantages:

• Arsenic and formalin saturated with resorcinol are very dangerous, toxic substances that can accumulate in various organs.
• These substances cannot always kill the nerve completely, which contributes to severe pain when trying to extract the pulp.
• Infected neurovascular tissues that are not completely removed become a source of repeated inflammation.

These methods were used because there were no sufficiently strong anesthetics that would allow removal of the affected pulp painlessly. Today they are completely irrelevant - modern dentistry treats tooth canals using a completely different technology.

Modern methods of dental canal treatment

There are two main methods of treating tooth root canals:

• Therapeutic (biological) in which the entire pulp or part of it is preserved. Manipulations can be carried out directly - the dentist puts a medicinal product into the dental cavity, separates the pulp chamber with an insulating gasket and installs a temporary filling. Or drugs can be delivered through the dentin, using antibiotic dressings, etc. Such drug therapy is effective only at the initial stage of inflammation.
• Surgical (pulp extirpation) - removal of all neurovascular tissue, cleaning, disinfection and sealing of dental cavities. Root canals are treated in one of the following ways: classic filling of tooth canals - filling the voids with filling material.
• Vertical condensation by injection of thermoplasticized gutta-percha.
• filling using thermophiles - hot gutta-percha on a carrier.

In some cases, endodontic treatment requires resection of the root apex - in the presence of granuloma, fibroma, cyst, perforation and other problems near the root apex.

Causes of pain during root canal treatment

The most common and most unpleasant complication of endodontic treatment for patients is pain after filling the root canals of a tooth. This is not always considered a pathology, since during the first 7 days the persistence of a slight aching soreness is normal and may be an individual reaction of the body. Severe pain indicates that treatment has not been successful. The reason for this may be:

• non-compliance with pulpitis treatment techniques;
• perforation of the tooth root;
• overestimation of the filling during restoration;
• poor cleaning of the root canal and pushing of infected tissue beyond the apical foramen;
• tool fragments in the channel;
• use of materials that cause irritation, allergic and neurotoxic reactions of periapical tissues;
• incorrect diagnosis [3].

Concomitant diseases of the patient increase the risk of complications after filling. For this reason, dentists always take a medical history to assess their general health and are more attentive to people who have diabetes, hypertension, hemophilia, etc.

Pain is possible even with an “ideal” x-ray picture. The severity of the pain syndrome can vary from slight pain when biting on a tooth to intense pain, comparable to pain in acute periodontitis, since the inflammatory process occurs in a very limited and enclosed space.

Stages of treatment

• Diagnostics

If damage to the dental canal is suspected and in order to detect a pathological focus, an X-ray examination (orthopantomogram, CT) or a study of the patient’s existing images is performed. Based on the examination results, the endodontist selects the appropriate treatment method.

• Pulpectomy

After anesthesia, the dentist opens the tooth, removes all damaged and necrotic tissue, gives the canal the required shape and rinses it with an antiseptic.

• Canal filling

Open channels are hermetically filled with filling material. For this purpose, plastic (gutta-percha, paste), hardening (cement group) and hard materials (pin structures) are used. The most progressive method is filling the canals with hot gutta-percha.

• Restoration of the crown part of the tooth

The correct anatomical shape of the tooth is restored using direct (filling) or indirect (crown, inlay) restoration.

Where is the tooth canal located, how is it structured

Human teeth have almost the same anatomical structure, including three main parts: crown, neck and root. Inside the tooth there is a pulp chamber, from which canals originate and extend all the way to the root. The pulp chamber contains the pulp or nerve of the tooth, which is a bundle of nerve fibers and blood vessels. Nerve fibers and vessels also pass through the entire internal space of the dental canal. The shape of the tooth canals can be either straight or curved, and their number varies depending on the type of tooth. Thus, the canines and incisors of the upper jaw have one canal, the canines and incisors of the lower jaw have two. There may be two or three canals in molars, and the maximum number of canals is observed in wisdom teeth - from three to five. The exact number of dental canals is determined using radiographic examination.

As mentioned above, the shape of the canals can have bends and turns, which complicates the process of their high-quality cleaning and treatment. Meanwhile, when treating canals, it is important to thoroughly clean their internal space - otherwise it will not be possible to stop the inflammatory process and save the diseased tooth.

Features of root canal treatment under a microscope

Modern dentistry cannot be imagined without the use of innovations that take root canal treatment to a new level. One of the most advanced methods of root canal treatment is the use of a dental microscope. Powerful optics allow you to increase your view by 32 times, given that the diameter of the channel is usually no more than 1 mm, it is simply impossible to process it efficiently without the help of optics.

Advantages of dental treatment under a microscope:

• The endodontist sees in detail the mouths of the canals, the features of their structure, each branch, depth and direction. This is especially important if the tooth canal has a complex, convoluted shape.
• The microscope makes it possible to remove only diseased and dead tissues without damaging healthy ones.
• Thanks to the targeted effect on the tissue, the best result of the intervention is ensured, eliminating the likelihood of perforations, as well as other problems and complications.

The use of a dental microscope allows the dentist to successfully solve even the most complex clinical problem.

If your tooth aches after cleaning and filling the canals

This also happens, and the causes of this pain are quite partly physiological in nature. As a rule, when treating pulpitis, the neurovascular bundles break off, which go deep into the root through a small hole at the top of the tooth. And then the appearance is quite natural, since the nervous tissue has been injured.

When cleaning the canals during dental treatment in a dream, the dentist uses a variety of tools - this is also a kind of traumatic factor. The tissues of the upper part of the periodontium are irritated, and this mechanical microtrauma, in turn, is the cause of pain.

If the patient experiences mild pain within two to three days after root canal filling, there is no need to be alarmed: sooner or later the pain will go away. But if, soon after dental treatment under sedation or during sleep, acute pain appears that does not decrease and does not go away for a long time, then this is a serious reason to immediately consult a dentist. The doctor will conduct a thorough diagnosis, find the cause of the toothache and provide the necessary assistance. Remember: if you have serious toothaches after cleaning and root canal treatment, you should not self-medicate, otherwise you may lose your tooth and develop serious complications.

Recommendations after treatment

Endodontic treatment demonstrates high success rates. After the intervention, you must adhere to the following recommendations:

• Avoid too hot, spicy, or cold foods for several days (while teeth sensitivity remains).
• Maintain good hygiene – brush your teeth twice a day, use dental floss and an irrigator.
• Do not chew anything hard (do not chew nuts, candies, etc.), as this may result in damage to the root canals and tooth destruction.
• Undergo medical examinations with a dentist and hygienist (at least 2 times a year).

Immediately after the procedure, tooth sensitivity increases greatly. This is explained by the reaction of the tissues to the filling material. The discomfort will disappear in a few days.

Will my tooth hurt after pulpitis treatment?

The effect of the anesthetic drug wears off approximately 3 to 4 hours after the injection. The tooth sometimes begins to ache monotonously, and this pain can continue for some time. My tooth made itself felt for about two days. I stopped chewing on the left side of my jaw for several days to avoid getting hard food particles on the filled tooth, because at such moments the pain worsened significantly. These days I measured my body temperature, monitored my well-being, and was wary of complications.

My condition completely stabilized on the fourth day. I got used to the new filling, and the cured tooth stopped hurting. Now all I had to do was carefully monitor the health of my teeth and do everything to prevent deep inflammatory processes that lead to the removal of the nerve.

Surgery to remove a nerve frightens patients more with the unknown than it actually causes pain and discomfort. Toothache tends to be insidious and appear unnoticed, so I recommend everyone not to start inflammatory processes in the oral cavity, consult a dentist in time and not let the matter go to the point of removing the nerve. If indications for removal still appear, feel free to go to a professional and competent doctor. The doctor will select a good anesthetic for you, treat your aching tooth and relieve the pain forever.

Expert opinion

Lyubov Ivanovna Kopylova

dentist-therapist

Experience: more than 10 years

If you have the opportunity to go to a dental clinic equipped with an electron microscope, take advantage of it! Even the most experienced dentist works with canals without a microscope by touch. This means that there is a risk of underfilling or, on the contrary, excessive deepening into the canal, leading to perforation. The use of a microscope, when the working field is clearly visualized and the doctor efficiently cleans and seals even the thinnest and most curved canals, will allow this situation to develop.

Cost of root canal treatment in Moscow

The price of endodontic treatment depends on the number of root canals of the diseased tooth, the method used, complexity (including re-treatment) and volume of intervention, type of filling, etc. Processing 1 channel requires less work than 2 or 3, which affects the cost.

The price includes the entire list of procedures performed for the treatment of dental canals. When using a dental microscope and laser equipment in complex therapy, the cost of treatment increases.

Endodontic instruments during cleaning

To effectively clean the canal, it is necessary to use several types of instruments, usually made of strong wire. Some of them are used in particularly difficult cases when the passage of channels is difficult. The specialist, taking into account the condition of the patient’s dental passages, can select rigid devices with a square cross-section, which are durable, but are less efficient at evacuating dentine filings. Another option is triangular-section reamers, which have increased flexibility but break more easily.

Groups of tools by purpose of use:

• channel expansion. The most commonly used options: Pro File 04, ProTaper, Rasp, K-flexofile, Rotary Instrument;
• increase in the diameter of the canal mouth. : Varieties: Largo and Gates Glidden;
• facilitating passage of the canal. Types: K-reamer, K-reamer farside;
• removal of tool remains. Instrument Removal System, Masseran Extractor Kit.

Needles for expanding and cleaning dental canals

An auxiliary device is a microscope, which helps to visually zoom in on the channels and ensure high precision of the manipulations performed.

Advice! The safest instruments are considered to be nickel-titanium reamers, which bend easily and “remember” their shape after penetration into the canal.