Are all root canals necessary?
Premise: As high a number as 90% of all root canal treatments done on non-obvious teeth (those teeth excluding gross decay, severe or long standing pain or obvious radiographic abscesses) may not have been necessary at the time or necessary at all, based on long-term observation of those teeth.
A simple adjustment of interferences in the bite or function, or the removal of bacterial contamination in the dentin (the inside of the tooth), or the removal of previously done leaking restorative dentistry with decay underneath, or the fabrication of a night-time protective guard that allows these teeth to settle down may allow these teeth to survive for decades without a root canal treatment or any other problems.
The evidence for this premise has been based on the direct experiences with family members and patients representing thousands of teeth over 48 years of practice with long-term follow-up on these alternative conservative treatments. This more conservative concept or contrarian line of treatment started with a personal experience on my own tooth with a long-standing sensitivity starting in dental school.
When do you need a root canal?
For these four obvious reasons:
If you are having localized severe or persistent/long standing pain in a specific tooth.
If a long standing death of the pulp or a severe or acute infection causes a visual enlargement of the periodontal ligament space at the end of the root or the loss of bone density both displaying as a radiolucency (a dark area) on X-ray or cone bean CT (CBCT).
If the loss of tooth structure from severe decay or breakdown enters an unhealthy pulp chamber of an older tooth.
When there is a traumatic injury to the tooth.
These four conditions represent only 10-20% of the normal presentations in a general practice in an affluent area.
After routine visits, cleanings and check-ups, sensitivity in teeth is the most common reason patients come in for evaluations.
Sensitivity after dental treatments is the most common reason for follow-up appointment. This is very common because of the difficulty of checking proper bite relationships on a tired and anesthetized patient lying on their back.
Why is it some times difficult to accurately diagnosis the immediate need for a root canal treatment (RCT)?
X-rays do not always show any evidence of the dying pulpal circulation early in the process. It may take several days to a week for the bony changes from an acute pain causing infection to make the changes necessary to be visible on X-ray.
All collapsing or dying pulpal circulation systems do not have bacterial contamination or exhibit pain or discomfort.
Sensitivity alone is not a good indicator by itself for the need to do a RCT.
The most common cause of sensitivity in teeth is a bruising of the tooth from a functional interference in the bite relationship causing a swelling at the end of the root that interferes with the blood flow or circulation to the live tissue inside of the tooth.
The second most common cause is an inflammatory reaction caused by bacterial travel through the dentinal tubular system into the live tissue inside the tooth (the pulp) caused by decay, dentinal tubular contamination (the inside hard tissue of the tooth) or bacterial leakage underneath a previous done filling or restoration.
Both of these causes of sensitivity are treatable with high degrees of success and can result in the avoidance of the need for a root canal therapy.
Because of this above explanation and understanding based on decades of experience a small number of patients from this group (2-5%) may experience extreme and/or inconvenient pain. Legitimately from their perspective and the criticisms of some subsequent treaters this may seem negligent or below the standard of care. Unfortunately the benefit to the vast majority patients may out way both the doing and charging for up to 20-50 unnecessary root canals. Add in the future failures of poorly done or poorly sealed root canal treatments and this conservative approach seems both conscious and in the patients best interest.