The root canal procedure. -

An outline of the steps a dentist follows when they perform root canal treatment (endodontic therapy). | Also, what is having each step like for you the patient?

Cleaning
the tooth.

Link to root canal cleaning section.

Sealing
the tooth.

Link to root canal filling and sealing section.

The steps of the root canal procedure.

Step 1 - Placing the rubber dam.

After numbing you up, your dentist will "isolate" your tooth by way of placing a rubber dam.

A dental dam is simply a sheet of "rubber" (latex in most cases) through which your tooth receiving treatment pokes up and through (see picture below).

As explained on our rubber dam page, because your tooth sticking through the sheet lies in a region where its environment can be controlled, it can be washed, dried and kept contaminate-free.

Why is tooth isolation important?

  • One of the fundamental goals of root canal therapy is removing contaminates from within the tooth.
  • Since saliva contains bacteria and other debris, a rubber dam acts as a barrier that helps to keep the tooth isolated (clean, dry, contaminate-free) during its procedure.

Note: Placing a dam is a part of the general "standard of care" that any and every dentist must responsibly provide. If your treatment doesn't involve using one, you should be asking questions.

 

A tooth with a rubber dam in place.

A rubber dam sets the stage so treatment can be successfully performed.

What's this step like?

For you the patient, having a dam should be a non-event. Since you'll be numb by this point, there's no discomfort involved.

We have an entire page that's dedicated to rubber dams, including how they're placed, what it's like to have one, and why the use of a dental dam during your procedure is so important.

 

Step 2 - Creating the access cavity.

As a starting point for performing your tooth's treatment, your dentist will need to gain access to its nerve space. This step is called creating an "access cavity."

An access cavity in the chewing surface of a molar.

The hole through which the dentist performs their work.

  • Your dentist will use their dental drill to make a hole that extends through the surface of your tooth to its pulp chamber.
  • This is the opening through which they will perform their work.
  • With back teeth, the access cavity is made right through the tooth's chewing surface (as shown in our picture).
  • With front ones, it's made on their backside.
  • When creating the access cavity, the dentist will also remove all tooth decay, and any loose or fragile portions of the tooth or its filling.

Related page: Issues involved when treating teeth that have dental crowns.

What's this step like?

By this point, you're numb, the rubber dam is in place, and everything is set for your work to begin.

As mentioned above, dental anesthetic doesn't significantly impair your sensation of pressure. So, when your dentist starts drilling the access cavity, you'll feel the vibrations of the drill. But these mild sensations are really all you should notice.

You shouldn't experience any pain. If you find differently, either at this point or during the remainder of your appointment, just indicate to your dentist so they know. Once they realize there's a problem, they can administer more anesthetic.

[Our sideshow contains pictures of access cavities.]

A surgical operating microscope may be used.

Once entrance into the interior of the tooth has been made, it's increasingly becoming the accepted standard of care that the floor of the tooth's pulp chamber is examined using a surgical operating microscope. These instruments aid the dentist in searching for the openings of minute root canals that might otherwise be overlooked by the naked eye.

Takeaways from this section.

The use of a microscope increases the likelihood that all of the tooth's canals will be found and treated, which generally translates into increased treatment success.

And that means that especially with cases where the need to identify very minute canals might be expected (molars, premolars, lower incisors, teeth with calcified pulp chambers and root canals), the use of one could be considered important.

These instruments have a price tag associated with them. And while it's commonplace that an endodontist (root canal specialist) will have one in their office, it's less likely that your general dentist does.


Step 3 - Measuring the length of the tooth.

Your dentist's goal will be to treat the entire length of your tooth's nerve space but not beyond. Doing so is not only important part of the treatment process but also helps to minimize post-operative pain.

To be able to work within these confines, your dentist must measure the length of each of your tooth's root canals. This measurement is typically calculated to the nearest 1/2 millimeter (about 1/50th of an inch).

Measuring the length of a canal via x-ray.

Slide series - Measuring the length of a canal.

How does a dentist make this calculation?

A dentist has two methods they can use to take measurements.

a) By taking an x-ray.

Traditionally, dentists have established/confirmed/documented length measurements by way of taking an x-ray after a root canal file has been positioned in a tooth's canal. (Since root canal files are metal, they show up distinctly on an x-ray.)

The actual calculation is made by reading markings etched on the file. The x-ray is simply used to confirm that the file is positioned properly (extends the full length of the tooth).

b) Electronic measurements.

In recent decades, electronic length-measuring devices have come into common usage.

  • The dentist will clip one of the unit's wire leads to a root canal file that has been inserted into the tooth. They'll then tuck its second lead inside the patient's lip, so to make a complete electrical circuit.
  • As the dentist slides the file further and further into the root canal (an area insulated by the tooth's root), the unit measures changes in electrical resistance as it's tip passes ever closer to the conductive tissues that lie beyond. A digital readout or a beeping sound indicates when the file has finally reached the canal's end (tip of the root).
  • Once again, the measurement itself is read from the markings on the file. The electronic unit simply indicates when its tip has reached the proper position.

c) Several individual measurements may be needed for a tooth.

A separate length measurement will need to be made for each of the tooth's individual root canals. (Teeth can have several canals and/or roots.)

What's this step like?

The development of electronic devices to aid with this step really has made performing/having root canal treatment quicker and simpler.

If an x-ray measurement is taken, the dentist has to disassemble the rubber dam (so the film or sensor can be placed in your mouth next to your tooth), take the picture and then put everything back together again.

With an electronic unit, a measurement can be taken in less than a minute. And no, even though they are electronic in nature, when one is used you won't feel a thing.

[Our slideshow explains more about taking length measurements.]

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Step 4 - Cleaning and shaping the tooth's root canals.

The next step of the root canal process involves "cleaning and shaping" the interior of the tooth (the tooth's pulp chamber and each of its root canals).

In regard to this step:

  • Its cleaning aspect removes nerve tissue (live and/or dead), as well as bacteria, toxins and other debris harbored inside the tooth. (Here's more detailed information about why this is needed.)
  • Shaping refers to a process where the configuration of a tooth's canals are enlarged and flared, so they have a shape that's ideal for the procedure's filling and sealing step.

The whole process is a balancing act. One where the dentist seeks to accomplish the goals above without removing so much internal tooth structure that the integrity of the tooth is compromised.

Endodontic files.

The parts of a root canal file.

a) What tools does a dentist use?

For the most part, a tooth is cleansed and shaped using root canal files.

Files look like tapered straight pins but on close inspection you can see or feel that their surface is rough, not smooth. These instruments literally are miniaturized rasps.

 
Inserting a file into a tooth's canal.

Slide series - Using files inside a tooth.

b) How are files used?

  • A dentist will work a file up and down, with a twisting motion.
  • This action scrubs, scrapes and shaves the sides of the canal, thus cleaning and shaping it.

c) Your dentist will use several files.

This same motion will be used with an entire series of files (probably at least six or more), each of which has a slightly larger diameter.

  • The idea is that each of the files, when used in order, slightly increases the dimensions of the root canal.
  • Since some canal contaminates are embedded within a canal's walls, this enlargement process not only produces a shaping effect but a cleaning one too.

d) Your dentist may have a handpiece that can manipulate the files for them.

At least some of the root canal files that your dentist uses in your tooth will be worked by hand. But they may also have a specialized dental drill (handpiece) that files can be placed in which generates the motion for them.

Nickel-titanium files.

Nowadays these endodontic handpieces are usually used with special files made of nickel-titanium alloy and that's a big deal.

The very flexible nature of these files combined with the mechanized motion created by the handpiece typically means that a tooth's root canal system can be cleansed and shaped much more rapidly than in the past.

Tooth irrigation is an important part of the cleaning and shaping process.

While performing their work, your dentist will also periodically irrigate (flush out) your tooth. This carries off and washes away debris and contaminants.

While a number of different solutions can be used for this purpose, sodium hypochlorite (bleach, Clorox) is the most common one. An added benefit of using bleach is that it's a disinfectant.

What's this step like?

For the patient, the cleaning and shaping portion of their tooth's treatment is the most boring part. And the time when they're most likely to fall asleep.

The process itself is just continued cycles of: a) use some tools in the tooth, b) wash the tooth out, c) repeat the process again.

During tooth cleaning and shaping.

If your dentist uses a handpiece to manipulate the files, its noise may keep you awake. Or if your tooth is hard to get at, they may have to ask you to open really wide each time they insert a new one into your tooth.

During tooth irrigation.

Your dentist may agitate the irrigating liquid they place in your tooth with an ultrasonic tip. If so, you may hear or feel it's vibrations. Other than that, this whole process should be a non-event.

Bite blocks.

During this step (or anytime during your appointment), if you start to find it hard to stay open, your dentist can put a rubber prop (a "bite block") between your teeth.

[Our slideshow has pictures that illustrate what goes on during this step.]


Step 5 - Sealing the tooth.

Once the interior of the tooth has been thoroughly cleansed and properly shaped, it's ready to be sealed (have its hollow interior filled in).

  • In some cases, the dentist will want to place the filling material immediately after they've finished cleaning the tooth.
  • With other cases, they may feel that it is best to wait about a week before performing this step.

[ Related content: How many appointments will your root canal therapy take? ]

The gutta percha cone chosen is the same size as the last file used.

The size of the filling material and file are matched.

If the latter case is chosen, your dentist will need to place a temporary filling in your tooth, so to keep contaminates out during the time period between your appointments. (Precautions you should take with this filling.)

a) What type of root canal filling material is used?

The most frequently used root canal filling material is a rubber compound called gutta percha. It comes in preformed cones whose sizes exactly match the dimensions (diameter, taper) of root canal files.

b) Placing the gutta percha.

When performing this step:

  • The dentist will slip an initial cone of gutta percha into the tooth's canal.
  • It's important that this first cone extends the full length of the canal and fits snugly in the region of the tooth's tip.
  • Additional cones are then added, as needed, to completely fill in the canal's interior.
Placing gutta percha in a canal.

Slide series - Filling in and sealing the tooth.

In order to create a solid, uniform mass inside the canal:

  • Sealer (a thin paste) is applied to each gutta percha cone before it's placed into the canal, or else applied inside the root canal itself before the cones are inserted. It fills in any voids between pieces of gutta percha, or between them and the canal's walls.
  • The dentist may soften the gutta percha once it's been inserted into the canal by way of touching a hot instrument to it. This way it can be squished and packed down so it closely adapts to the shape of the tooth's interior.
  • As an alternative, a dentist may place gutta percha via the use of a "gun." This apparatus is somewhat similar to a hot-glue gun. It warms a tube of gutta percha. The softened material can then be squeezed out into the tooth.
What's this step like?

There's not really anything that's all that striking about sealing a tooth, other than it means you're getting close to the end of your appointment.

Your dentist may heat the gutta percha so it becomes soft and pliable. So, you may smell that. And you'll feel pressure on your tooth as it's packed in place.

Other than that, this step should be yet another non-event.

[Our slideshow has pictures that illustrate what goes on during this step.]


An x-ray showing a tooth's completed treatment and a temporary filling.

X-ray of a tooth's completed treatment and temporary filling.

Step 6 - Placing a temporary filling.

Once your dentist has finished sealing your tooth, they will place some type of temporary filling. It will seal off the access cavity created at the beginning of your procedure, therefore protecting the work that's just been completed. (Precautions you should take.)


Step 7 - The root canal process has now been completed but your tooth still requires additional work.

At this point, the individual steps of performing the root canal procedure have been finished but your tooth's treatment is not yet complete. A permanent restoration must still be placed.

Choosing an appropriate type of dental restoration, and having it placed promptly, will help to insure the long-term success of your tooth's endodontic therapy.

Takeaways from this section.

Take note of the link in Step 6. It details precautions you should take after you tooth's treatment has been completed. (For the most part, don't look for trouble. Just take it easy with your tooth.)

The link in Step 7 is important to understand too. You must have the right type of permanent restoration placed, within the right time frame. Otherwise you put your tooth and its just completed treatment at risk.


If you have additional questions ...

Use the links below to learn more about the root canal procedure.

 

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