There’s no easy root canals in endodontics

Today I would like to focus on a statement that is often made by dentists when discussing root canals. “Oh, I don’t do molars. I only do root canals on premolars and front teeth – the easy ones.” I have thought about this comment a lot, because as an Endodontist who specializes in all types of root canals on all types of teeth, I have to disagree. Nowadays, as root canal specialists who are highly trained in anesthesia and technology, we can make the patient have a pleasant, pain-free, and easy root canal experience, but as a clinician, it is wise to remember that there is no such thing as an easy root canal.

The thing that makes root canals so interesting to root canal specialists is the fact that every tooth has different anatomy. This is both a blessing and a curse. One of the best parts of doing root canals for a living is being able to treat a wide variety of different dental anatomy. Every tooth has something special about it, and every tooth developed differently. Much like a snowflake, no tooth is the same as any other. As an Endodontist, this is my favorite part of my treatment – learning the different anatomy of the tooth as I perform the root canal. But it is also a curse, because teeth that many may consider to be “easy” can become extremely difficult.

In 1984, Vertucci studied root canal anatomy, and discovered that in the bicuspids, or premolars, there was not one single anatomy that was consistent amongst all teeth, but in fact eight different ways that teeth developed and presented. This means that every premolar has at least 8 different ways it can present when needing a root canal, which is a challenge! Eight different configurations means these teeth are actually pretty difficult, and not at all an easy root canal. This is why it is so important for root canal specialists to treat these teeth.

Recently I had a tooth that totally demonstrated this point. A young man presented to me for a root canal with a tooth #5 that was hurting him to hot and cold. The pain was waking him up at night and spontaneously hurting throughout the day. He had a large composite restoration that was close to the nerve and his dentist felt he was best served by a root canal. He had had several root canals in the past and was open to the idea of a root canal for this tooth. Based on his symptoms, and with our testing, he tested as having an irreversible pulpitis and he definitely required root canal therapy in order to treat the pain. Based on the initial x-ray, I thought the tooth looked different from a standard, “easy” root canal, but I couldn’t quite pinpoint what exactly was going on. When I got into the tooth, it became clear this tooth was anything but easy! Instead of having one, or even two canals, the tooth actually had three canals. I thought I could feel my small file catching into another canal as I was treating the buccal, but I wasn’t fully convinced until I took a cone shot that revealed an off-center canal in the buccal root with a sealer tract. As it turned out, three different nerve spaces were present in this root canal! But even more interestingly, the buccal canal split mid-way down into two separate canals, similar to a snake-tongue. Considering how root canal specialists deal in millimeters when they are working, it was very difficult to negotiate the split of the canals. I had to use an instrument that was only 6/100^th of a millimeter in diameter in order to get down the nerve space and remove the irritated nerve. Sealing the tooth was even more difficult! It took several tries to ensure the split was adequately filled and sealed properly. When I called the patient the day after his root canal to check in on him, he was feeling great, and I was feeling great knowing that we had removed all the of the irritated nerve.

Cases like these reinforce why root canals should never be taken for granted as a clinician. You never know what anatomy you are going to discover and how difficult the root canal may be. It is best to ensure you have plenty of time and are fully trained in all the techniques for identifying root canal anatomy, even when attempting a root canal you may consider “easy” – no matter what tooth it may be in the mouth.