Does having root canal therapy hurt?

- Root canal treatment has a reputation for being painful but this page explains why that notion isn't necessarily deserved.

Page Graphics
Link to Numbing Your Tooth section.

When discussing the topic of procedure discomfort, the subject of root canal therapy needs to be broken down into subcategories. That's because the pain issues involved with each one are different.

Subcategories:

  • Regularly scheduled appointments. - (Managing discomfort while performing the steps of the procedure.)

    For the average person and average case, experiencing root canal treatment isn't all that much different from having other routine dental procedures performed (like having a filling placed). Here's information and statistics about what you can expect and why.

  • Post-operative pain. - (Managing after-visit problems.)

    While it's not the norm, there is the possibility that a patient will experience some degree of discomfort after having root canal work performed.

    Use this link for an explanation of the causes, treatment solutions and statistics associated with post-op issues.

  • Emergency visits. - (Managing the discomfort that has signaled the need for treatment, or retreatment.)

    Some people will experience an acute tooth flare-up during which they experience mild, moderate or even excruciating pain.

    When these types of situations occur it can be a challenge for a dentist to painlessly treat the severely inflamed tissues involved. This link explains why and what can be done.


1) There's no reason to expect that regularly scheduled appointments will hurt.

When it comes to having root canal performed, what you've heard may not necessarily be accurate.

As evidence of the level of misconception that abounds, a survey conducted by the American Association of Endodontists (root canal specialists) found that people who had actually had root canal therapy were 3 times more likely to say the process was painless as opposed to those who had never had a tooth treated. (AAE 1995) (Reference sources.)

Yes, for the majority of people, having endodontic therapy is a routine dental event (see Statistics section below).

For simple cases, it may not seem all that much more involved than having a relatively large dental filling placed. And when compared to a tooth extraction (the only other alternative to having this procedure), while it does take longer it's certainly a more civilized process.

Comfort management.

Your dentist is just as eager for you to have a pleasant experience as you are. Toward this goal, here are some of the things they can do to help to insure that that happens.

a) The timing of your appointment.

Regular visits (as opposed to emergency ones) are generally targeted for a period when your tooth is expected to be relatively "quiet" (having no or just minimal symptoms). That's because this time frame offers a window during which the tissues involved with your treatment will respond most predictably.

For people whose tooth has never been bothersome, this point isn't much of an issue. But if a recent flare-up has occurred, the dentist will want to wait until a point when the inflamed tissues involved have had a chance to settle down substantially.

b) Numbing your tooth.

A dentist giving a dental injection.

Of course, your dentist will numb up your tooth for its procedure (that involves giving you a "shot"). And so you don't feel the pinch of the rubber dam clamp that they'll place, they'll also need to anesthetize the surrounding gum tissue too.

The good news is that once this has been accomplished the remainder of the appointment should be easy going (see Statistics section below), even to the point of being boring.

Things to know.

Of course, getting shots can be an issue in itself. And in an effort to be complete, we should mention the following points.

  • It will likely take giving you more than one injection (stick of the needle) to adequately anesthetize everything that needs numbing. (One or more for the tooth itself and one or more for the surrounding gum tissue.)
  • The injections used to numb the gums on the palate side of upper teeth do tend to pinch, that's just life. (Why some dental shots hurt more than others.)
  • Numbing lower teeth is usually more of a challenge than uppers. But even so, the routine techniques used with lower teeth generally have a 75 - 90% success rate right off the bat. (Rosenberg 2002)
  • Anesthetics tend to be less effective when used with inflamed tissues (Rosenberg 2002). That's one reason why your dentist will want to give your tooth some time to settle down before initiating its procedure.

Statistically speaking.

We found a study (Segura-Egea 2009) that specifically evaluated the issue of pain experienced by patients during their root canal procedure.

Its findings were that 54% felt no pain. Of the remaining subjects, 34% experienced slight, 9% moderate and 3% felt intense pain. No cases involved unbearable discomfort.

All of the cases in which subjects reported intense pain involved teeth that were acutely inflamed (the tooth was painful before the procedure was begun). Of the cases involving teeth that had no symptoms, very few patients experienced moderate and none reported intense pain.

c) Anxiety management may help to improve your experience.

Different from pain management is the issue of patient management.

Research has shown that there is a relationship between pain experienced and the level of stress, anxiety or pessimism that the patient holds. The higher the level, the more likely the patient is to interpret the sensations they feel as pain.

That means you need to be up front with your dentist about your concerns. Doing so will give them a chance to figure out a solution. Here are some of the things that can help.

  • Conscious Sedation. - This technique involves the use of medications (laughing gas, oral or IV sedatives) that help to place the patient at ease.

    You remain awake, in the sense that you can respond to questions and commands, you just care less about what's going on.

    As a side note, you'll still also respond to pain sensations. And for that reason your tooth and gums must still be numbed up. However, if getting an injection is the hard part for you, ask if the sedation medication can be administered first.

  • Hypnosis. - The use of hypnosis as a means of relieving anxiety has a long history in both medical and dental practice. At an extreme, the use of mediation-hypnosis has been documented as the sole anesthesia used for a root canal case (Morse 1979).
  • Information. - Knowing the details about your upcoming dental procedure can be an important anxiety reduction technique. (Looking for this type of input may be one reason why you're reading this page right now.)

    But don't just read; ask your dentist questions too. If concerns about pain are an important consideration for you, let them explain what steps they plan to take and why it's unlikely to become an issue.

  • Distraction. - Coming up with ways to take your mind off your procedure can help to alleviate anxiety and as a result minimize the level of discomfort you experience.

    As a plan, take your music player or favorite video game (and headphones please) with you to your appointment.


2) There is some potential for post-treatment pain.

We wouldn't be telling the whole story if we didn't mention that after your root canal appointment there is some potential that your tooth might hurt (it really should just be minor). We've dedicated a page to this subject: Root canal aftercare and precautions.


3) Pain management during emergency visits.

It seems likely that many of the remarks that you hear about how painful having root canal therapy is should really be attributed to those events that initially signaled that it was needed and not the procedure itself. And when this type of tooth flare-up occurs, an emergency trip to your dentist's office is indicated.

Acute flare-ups.

In some instances, the final (and possibly only) sign that a tooth needs root canal treatment is a painful toothache.

It would be dishonest to suggest that during this type of event (a time when you are stressed and your tooth and its surrounding tissues are inflamed and possibly involved with an active infection) that the steps your dentist must take to provide pain relief and to set the stage for the healing process can always be accomplished with absolutely no discomfort.

a) Problems associated with inflammation.

One big problem associated with acute tooth flare-ups is that local anesthetics are much less effective when used with tissues that are inflamed. In fact, there's an 8-fold higher failure rate as compared to when teeth are numbed under normal circumstances. (Rosenberg 2002)

Solutions.

That means a dentist must use other strategies to manage their patient's pain.

  • In some cases, simply allowing more time for the anesthetic to take effect may be all that's needed. Your dentist may ask you to arrive 20 or 30 minutes early so they can employ this technique.

    Other times the solution may lie in modifying the way the anesthetic is given or simply using more of it (although there are specific dosing guidelines that must be followed).

  • As an alternative, your dentist may employ a technique where the anesthetic is placed directly between the tooth and surrounding bone, or in the jawbone in the region of the root's tip. These methods are respectively termed intraligamentary and intraosseous injections. And while they can be, they aren't usually used to numb up teeth for routine procedures.
  • Administering a fast-acting anti-inflammatory drug may help to create an environment where local anesthetic will be more effective. Ketorolac tromethamine can be used in this fashion. (Hargreaves 2002)
  • Experiencing an acute tooth flare-up can be a stressful event. And tense and exhausted patients typically respond to pain more so than under normal circumstances.

    As discussed above, the use of sedation technique (laughing gas, oral or IV medications) can help to relax a patient and as a result decrease the amount of pain they experience.

The point here isn't necessarily what will be done with your tooth (that's for your dentist to decide) but rather to understand that a painful tooth does present challenges and that your dentist does have ways to overcome them.

b) Difficulties associated with infections.

Tooth flare-ups that involve a significant amount of swelling will complicate pain management.

  • It may be that the swelling limits your ability to open your mouth, thus preventing any type of treatment directly involving your tooth.
  • As a general rule, dentists don't inject quantities of anesthetic into areas of swelling (for fear of spreading it). With teeth that hurt, this may mean that no direct treatment is possible.

Solutions.

Even if your dentist can't work directly with your tooth, they can initiate treatment that will help your infection to clear up more quickly so later on they can.

  • Placing you on antibiotics will help to bring your infection under control more quickly.
  • If the swelling has localized, your dentist may be able to make an incision in the affected tissue that allows the trapped pus to drain.

To keep you comfortable until that time when your tooth can be worked on, your dentist will likely have you take some type of oral analgesic (pain pills), either prescription or over-the-counter.

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