Author Archives: rgangwisch

Restoring Root Canal Teeth

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Once a root canal has been completed, it is extremely important that the tooth be properly restored. If not, then there would be a good chance that the tooth could be lost permanently. The reason for this is the dental pulp which houses a collection of nerves and blood vessels in the center of the tooth will bathe the inner tooth layer (the dentin) with fluid, allowing the tooth to flex under load. Once the source of the moisture is gone, the tooth becomes very brittle. I always recommend that all chewing teeth have a crown placed soon after a root canal has been completed. I have even had the unfortunate experience of needing to extract a tooth only weeks after root canal treatment due to the tooth fracturing through to the root because it had not been properly restored yet. Some front teeth, if they have adequate remaining tooth structure, can be restored with just a filling.

Crown Over Root Canal Tooth

To place a crown on a back tooth, usually a crown buildup needs to be done. A crown buildup is a core of filling material that is used to replace the tooth structure that was lost in the root canal process and due to decay. This core may need to be retained with pins or a large post that is placed in one of the canals. With a quality, well-timed final restoration covering and protecting a root canal tooth, that tooth should give decades of future service.

Mouthguards

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The use of mouthguards in athletics has significantly reduced accidental fracturing of teeth, reduced morbidity of many orofacial injuries and even possibly lessening the number of concussions. Mouthguards were first mandated for boxing in the 1920s. By the 1960s, their use became mandatory for high school and college football.

Mouthguard

Mouthguards are currently made with polyvinyl chloride or polyurethane. They can be custom made by a dentist or at home with the “boil and bite” variety. The NCAA currently requires mouthguard use in four sports: ice hockey, field hockey, lacrosse and football. The American Dental Association recommends mouthguards for 29 sports. Studies have shown that the frequency of orofacial injuries and fractured teeth in individuals who do not wear a mouthguard is from 1.6 to almost 2 times higher. As far as concussion prevention, the studies are inconclusive because concussions can happen without a blow to the jaw. However, it would be very logical to think that the cushioning effect of a mouthguard could reduce the number of concussions involving mouth trauma.

Root Canal Complications

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Most root canals can be done with little or no discomfort and will usually heal uneventfully. Unfortunately, there is an occasional poor soul who has post-operative complications. The most common of the complications is pain. Most pain is caused by inflammation. I always recommend that my patients who have undergone root canal treatment take an NSAID (non-steroidal anti-inflammatory) such as ibuprofen right after the procedure. Getting the anti-inflammatory into the bloodstream before the inflammation sets in is the key to preventing most post-operative pain. Infections can be the other main reason for post-op pain. A root canal is usually done on a tooth that is already infected. Through the root canal process, most of the infectious bacteria are removed. But there is still the possibility that some bacteria could be left at the tip of the root. Normally, the bioburden is greatly reduced from the root canal procedure, however, sometimes the body’s defenses can still be overwhelmed. Most infections can be handled with a single regimen of antibiotics. If you experience pain and/or swelling that is present for more than a couple of days after a root canal, you should contact your dentist immediately.

Dentally Related Headaches

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There are a wide range of causes of headaches and tooth and jaw problems are on that list. A toothache can refer pain up toward the ear, onward toward the temple, then eventually to an old-fashioned headache. The more common dentally related cause of headaches is pain from the temporomandibular joint (jaw joint) and the related muscles of mastication. Inflammation in the joint itself can cause pain that can radiate to the head. When the surrounding muscles go into spasm, the constantly contracted muscles choke off the blood vessels reducing the blood flow. This causes a buildup of lactic acid. It’s the same discomfort we get when we start exercising after an extended layoff. It’s a malady called myofascial pain dysfunction syndrome. The muscle spasms will start with the chewing muscles, but then will get the other muscle groups involved. When these head and neck muscles begin to spasm, we call that – a headache. Although different from the migraine, it is nonetheless – a pain. Your dentist can help you with diagnosing and treating many headaches. Once serious problems, for example, brain tumors, have been ruled out, then the dentist can try a TMD splint, basically a mouthpiece, to take the pressure off the jaw joint, and will many times alleviate the pain.

Osteoporosis

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Osteoporosis is one of the scourges of old age. The bone density of sufferers decreases with time, many to the point that the bones become very susceptible to fracture. As many as 10 million Americans are affected by the disease and as many as 34 million others have a high risk of getting it. There have been a number of studies that have shown an increase in tooth loss in those who are afflicted with osteoporosis. The alveolar process, the portion of the jaw bone that holds the teeth, can be affected by the loss of bone density, thus contributing to tooth loss. Women are affected three times more than men. Periodontitis is a chronic infection that affects the gums and jaw bone. An interaction between toxins coming from the bacteria that reside on the teeth and the body’s immune system will cause the bone to break down. Research is beginning to point to a relationship between the less dense bone of osteoporosis victims and a quicker breakdown of the supporting bone leading to tooth loss. To help combat osteoporosis, there are a number of medications that are currently on the market. They can be a big help in reducing bone loss, but they come with a potentially serious side effect called bisphosphonate osteonecrosis (BON). BON can cause bone death after surgical dental procedures. These areas of dead bone can be extremely difficult to get the mucosal covering to heal properly. It is extremely important that patients tell their dentist that they are taking these medications.

Scaling and Root Planing

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A gum procedure called scaling and root planing has saved millions of teeth. Periodontitis (gum disease) attacks the bone that holds the teeth in place. If left unchecked, it will eventually lead to tooth loss. If the disease is detected in its early stage, scaling and root planing can be a big help in altering the course of the disease. Periodontitis is caused by an interaction between bacteria that reside on the teeth and the body’s immune system. If the bacteria is removed on a daily basis by brushing and flossing, the disease usually does not occur. However, if the home care is not good, the bacteria will wreak havoc.

Over time, the bacteria will calcify into a material called calculus (tartar). The calculus is very porous giving a safe haven to new bacteria, so even if flossing is started, it will not clean away the bacteria residing in the tartar. Scaling will remove these deposits from the teeth.

Root planing will smooth the roots and remove diseased cementum (the live covering on the root surface). Scaling and root planing will allow the body to heal the gums and give someone a fresh start. However, the disease will return if the daily home care is not done.

Crowns

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Crowns or caps have had over a century of success in saving teeth. Fillings are used to restore tooth structure lost to decay or fractures, however, they do not cover and protect the teeth from fracturing like crowns do. There are three major varieties of crowns – cast metal, porcelain-fused-to-metal, and all porcelain.

Gold Crown, Porcelain-Fused Metal Crown, and All Porcelain Crown

Cast crowns are usually made of gold. They have the longest track record and usually last the longest of the group. This is because there is no veneering surface to fracture and gold is a very tough, inert substance. I have personally observed crowns that have been in patients’ mouths for well over fifty years. The drawback is that they look like gold teeth. The other two varieties have a porcelain outer layer. Porcelain can be constructed to almost perfectly mimic teeth. And the porcelain is extremely tough and color stable. There are still quite a few crowns that I placed over thirty years ago that still look as good now as they did on the day that I put them in. The porcelain is baked onto a metal or porcelain core. The metal can be made much thinner, so it is better for crowns for back teeth. The newer porcelain cores are having very promising results and are excellent for front teeth because light can be transmitted through it giving the crown a natural life-like luster.

Root Fractures

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Root fractures can be pesky little things to diagnose. A root fracture is a crack in a root of a tooth. It can be either horizontal or vertical in direction.

X-ray of a Horizontal Root Fracture

Horizontal fractures are usually a result of trauma. The survival of the tooth is dependent on where the fracture is located. If it is located in the apical third of the root (apical being the portion toward the tip of the root), then it may be possible to save the tooth. Otherwise it is implant time. Vertical fractures can start in the crown of the tooth, which is most common, or at the tip of the root. Root fractures may or may not have symptoms associated with it. If there are symptoms, they are usually pain while chewing.

Vertical Root Fracture

When fractures are present, they rarely will show on an x-ray, so the usual course of treatment is placing a crown to keep the pieces of the tooth from wedging apart while eating. If this does not work, then root canal treatment is performed. It is, many times, only after the symptoms don’t subside after having a root canal done will a diagnosis be made of a root fracture. Other times there may be a tell-tale thickening of the black line that surrounds the root on an x-ray giving indirect evidence of a root fracture. There is no known way to repair a root fracture and with the advent of long-lasting implants, the best solution of treating a fractured root is by removal of the tooth and placement of an implant.

How is a Root Canal Done?

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Root canals are not the scourge of dentistry like they used to be. By using good local anesthesia techniques, a root canal can be performed with little to no discomfort. A root canal is done by first placing an opening into the pulp chamber.

Tooth Needing Root Canal Treatment

This is a hollow area in the center of the tooth where the dental pulp (a collection of nerves and blood vessels) resides. Once access to the pulp chamber has been obtained, the dentist will clean out any debris, whether it is live nerve tissue or dead, necrotic material. At this point, the actual root canal(s) are located. These are tiny channels that go through the root and exit at the end to communicate with the bone. Sometimes these canals can be very torturous to negotiate and many times requires a dentist with many years of experience to successfully complete the process. The canals are meticulously cleaned by a series of “files”, pin-like instruments. With each successive file, it will clean the walls of the canal, then the debris is flushed out with a sodium hypochlorite irrigating solution.

Root canal x-rays before and after

The canals are then dried and filled with a sealer and an inert material called gutta percha. The root canal has now been completed, hopefully without pain, and is ready for restoration.

 

Tooth Knocked Out On The Ball Field

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Knocked Out Tooth Splinted

Knocked Out Tooth Splinted The Day Of The Accident

Tooth Knocked Out After

Knocked Out Tooth After Healing Period Is Restored By Dr. Gangwisch With Cosmetic Bonding

In my dental career, I have had the opportunity to assist two people who have had a tooth knocked out at a sporting event. The second one was during a baseball game that I was coaching. My left fielder ran at fullspeed right into the outfield fence. He was down on the ground while the ball was in play, then while I was running out to check on him (it was a high school field, so I had to run quite a ways to get to him), he got up and came to me with something in his hand. It was his front tooth. It turns out that of the ten foot sections of the cyclone fence, he would decide to choose the few inches of pole to collide with. Needless to say, when it came to tooth versus pole – the pole won. There were no facilities at this field (it was serviced by a Port-A-John), I had him roll the tooth around in his mouth to clean it. Then, after asking his parent’s permission, I reinserted it back into the socket. He handled it very well for a 14 year old because I could tell he saw stars when I put it in. After the game, I took him over to my office, opened up the tooth and placed medicine inside and then splinted it to the surrounding teeth with braces. Later I did a root canal on the tooth and removed the braces then and rebuilt the chipped tooth. Now his smile looks as good as new.