The root canal procedure. -

An outline of the steps a dentist follows when they perform root canal treatment (endodontic therapy). | Cleaning and shaping the canals. | Sealing the root canal system. | What is each step like for 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 endodontic therapy.

The following is an outline of the steps a dentist follows when they provide conventional root canal treatment for a tooth. (The basic procedure most frequently performed for teeth.)

Other terms for this procedure are "non-surgical" and "orthograde" endodontic therapy. Both of these names indicate that the procedure is performed through an opening made in the tooth's crown (the portion that lies above the gum line), as opposed to accessing the root directly via some type of surgical procedure.


Step 1 - Placing the rubber dam.

After numbing you up, your dentist will first "isolate" your tooth by way of placing a rubber dam. A dental dam is simply a sheet of "rubber" (actually, latex in most cases) that's pulled over your tooth so it pokes through (see picture below).

As diagrammed on our What is a rubber dam? page, because the portion of the tooth that sticks through the dam now lies in a region where its environment can be controlled, it can be kept contaminant-free during its procedure.

Why is tooth isolation so important?

  • One of the fundamental goals of root canal therapy is removing contaminants from within the tooth.
  • The barrier created by a dam aids with this goal by preventing saliva (a source of bacteria and debris) from gaining entry into the tooth while its work is being performed.

Note: Placing a dam is part of the "standard of care" that any and every dentist must responsibly provide. If your endodontic procedure doesn't involve using one, you should be asking questions because in the vast majority of cases, it's use is considered absolutely essential.

Section references - Ingle

A tooth with a rubber dam in place.

A rubber dam creates a controlled environment where successful endodontic therapy can be performed.

What's this step like?

For you, the patient, wearing a dam should be a non-event.

  • Since you've been numbed up for your procedure, there shouldn't be any discomfort involved as it's placed or while it's worn.
  • What you may feel is the pressure of the clamp that's used to hold the dam in place on your tooth.

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

 
 

Step 2 - Creating the access cavity.

As a start point for actually beginning to perform your tooth's work, your dentist will need to create an opening to its nerve space. This step is called creating the "access cavity."

An access cavity in the chewing surface of a molar.

The hole through which the dentist performs their work.

  • The process itself is simple enough. Your dentist will just drill into your tooth, not terribly unlike when a filling is placed, but deeper into it.
  • As shown in our picture here, with back teeth the opening is characteristically made on the tooth's chewing surface. With front ones, it's made on their backside (like in our picture above).

There are a number of specific goals and objectives that the shape and extent of an access cavity must meet. We discuss these issues in detail on our page: Endodontic access cavities.

A common question is what becomes of a dental crown if an access opening is made through it. We discuss this matter on our page: Issues involved when treating teeth that have dental crowns.

What's this step like?

As alluded above, dental anesthetic doesn't inhibit your sense of pressure. So, when your dentist starts drilling your tooth's access cavity, you'll feel the minor vibrations of their drill. But these mild sensations are really all you should notice.

You shouldn't experience any pain. However, if you find differently, either at this point or during the remainder of your appointment, just indicate to your dentist so they know. (Establishing an agreed-upon hand signal with your dentist at the beginning of your appointment makes a good plan.)

Once they realize that a problem exists, they can then determine what steps are needed to control your discomfort.

Step 3 - Identifying all of the tooth's root canals.

Once the entrance into the interior of your tooth has been made, your dentist will need to identify each of its root canals. (How many canals does your tooth have?)

An important aspect of endodontic therapy is that each one is identified and treated. Falling short of this goal will lead to case failure.

A surgical operating microscope may be used.

It's become increasingly common that the floor of your tooth's pulp chamber will be examined using a surgical operating microscope.

These instruments aid the dentist in discovering all of the tooth's root canals by way of helping them to identify the openings of minute canals that might otherwise be overlooked by the naked eye.

 
Takeaways from this section.

Your dentist searching for the openings to your tooth's root canals should be a non-event. Pain should not be a factor. They'll typically use a pointed hand instrument, or root canal file (see below), to feel around inside your tooth until each one is located.

In cases where a canal's location isn't immediately apparent, your dentist may need to trim away additional portions of your tooth's interior to expose them. If so, at most you should just feel the vibrations of your dentist's dental drill as it's being used.


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

And that means that 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. So while it's commonplace that an endodontist (root canal specialist) will have one in their office, it's less likely that your general dentist will.

Step 4 - Measuring the length of the tooth.

Your dentist's goal will be one of treating the entire length of each of your tooth's root canals but not beyond. Doing so is not only important for creating treatment success but also helps to minimize complications with post-operative pain.

Meeting this goal means that your dentist must measure the length of each of your tooth's root canals. This measurement is typically calculated to a tolerance of/has an accuracy of 1/2 millimeter (about 1/50th of an inch). (Hargreaves)

Setting the parameters for this measurement.

You might be surprised to learn that there's considerable controversy about just where in a canal its endodontic therapy should terminate.

  • Some studies suggest that treatment should extend all of the way to the root's apex (tip). Others seem to have concluded that a point 1 to 2 mm shorter gives a better chance of case success. (Hargreaves)
  • To confuse matters even further, other studies have concluded that the endpoint chosen should be influenced by both the current status of the tooth's pulp tissue (i.e. necrotic, vital, inflamed), and the degree to which the tooth's pathology has affected its surrounding bone tissue. (Hargreaves)

Obviously, choosing the treatment terminus will simply be a judgment call that your dentist will need to make.

Section references - Hargreaves

Graphic illustrating the measurement of the length of a root canal via x-ray.

Measuring the length of a canal.

How does a dentist make canal length calculations?

There are two methods that a dentist typically uses to measure a canal.

a) By taking an x-ray.

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

b) Electronic measurements.

In recent decades, the use of electronic length-measuring devices has become commonplace. These units are referred to as "electronic apex locators." (The word "apex" refers to the tip of the tooth's root.)

We discuss the steps associated with both processes on our "Measuring the 'working length' for root canal file use" page. And explain the strengths and weaknesses of both methods too.

Several individual measurements may be needed for a single 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?

Neither method poses any risk for you feeling anything.

As we discuss on our "Measuring the working length" page linked to above, using the electronic method is quick and simple and is easily worked into the normal flow of the procedure.

In comparison, the dentist having to stop to take a radiograph tends to interrupt the flow of their work. But the information that an x-ray picture can provide for them can be a great asset to their treatment of your case.

With most cases, both measurement methods are used.

Step 5 - Cleaning and shaping the tooth's root canals.

The next step of the root canal process involves "cleaning and shaping" the tooth's root canal system (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 contours of the tooth's canals are enlarged and flared, so they have a shape that's more ideal for the procedure's filling and sealing step.

The whole process is a delicate balancing act. One where the dentist seeks to accomplish the goals above, without removing internal tooth structure to an extent, or in a fashion, that might compromise the integrity of the tooth, or the outlook for its completed work.

Section references - Tronstad

Endodontic files.

Root canal files.

a) What tools does a dentist use?

For the most part, a tooth is cleaned and shaped (its walls rasped and planed) via the use of root canal files.

What do they look like?

Files look like tapered straight pins but on close inspection you can see, or feel, that their surface is grooved, not smooth. While files come in a couple of different designs, in general terms, they can mostly just be thought of as miniaturized rasps.

Related information - If you'd like more details about files, we delve into this subject much more extensively on our What are root canal files? page.

 
Animation of the filing action of a root canal file inside a tooth.

The primary cutting action of a file is on the upstroke.

b) How are the files used?

Filing motion.

A dentist will generally work a file with an up-and-down motion, combined with some type of twisting action. The specific way a file is manipulated depends on both its design, and what the dentist is trying to accomplish.

Aids to the filing process.

As an adjunct, your dentist will probably coat each file with EDTA paste or gel (ethylenediaminetetra-acetic acid) before it is used.

  • EDTA is a chealating agent, and as such softens the mineralized walls of the canal so the file's action will be more effective.
  • Additionally, its thick, wet consistency serves as a lubricant for the filing action.

Both of these functions are especially helpful in aiding the dentist in negotiating and enlarging narrow root canals.

Section references - Ingle

c) Your dentist will use several files.

The same general routine will be used with each member of an entire set of files (probably at least six or more), each of which has a slightly larger diameter.

Each file is worked for a number of repetitions (until it starts to feel loose in the canal). The dentist then inserts the next larger size file and continues the process.

Animation showing how the size of the tooth's canal is enlarged by the cleaning and shaping process.

Cleaning and shaping enlarges and flares the canal.

The idea is that each of the files, when used in order, gradually increases the dimensions of the root canal (diameter and flare). This is important for a couple of reasons:

  • Enlarging the canal has a cleansing effect by way of removing the surface layer from its walls. (This layer has often become impregnated with debris and contaminants.)
  • A wider canal can be irrigated more effectively (see next section).
  • It gives the canal a shape that's better suited for the sealing process (discussed below).

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 handpiece (dental drill) that can be used for this purpose. We discuss aspects of rotary-file endodontic systems here.

When this type of set up is used, a tooth's root canal system can usually be cleaned and shaped more rapidly. That can be an important factor in making one-visit root canal treatment possible for a case.

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

While performing their work, your dentist will periodically irrigate (flush out) your tooth.

  • At a minimum, they'll use this as a means of flushing debris and contaminants from within it. Doing so enhances the effectiveness of their cleaning efforts.
  • But another important function that irrigation provides is to flush away loose debris before it has a chance of being compacted (by the up and down action of the files) into a plug or blockage.

a) What kinds of irrigating solutions are used?

A number of different types of solutions might be chosen:

  • Conceivably, just sterile water or saline solution could be used to flush out debris.
  • By far, the most frequently used irrigating solution is sodium hypochlorite (bleach, Clorox). That's because it's effective in killing bacteria and digesting organic debris (two functions that can help to disinfect the tooth's root canal system). It also happens to be quite inexpensive.
  • Because different solutions have their own set of advantages, your dentist may consider it optimal to use more than one kind of solution during your tooth's treatment.

Section references - Hargreaves

Graphic illustrating root canal irrigation.

Canal irrigation.

b) How is tooth irrigation performed?

While your dentist may have a specialized unit they use for this purpose, the process they use may be as simple as flushing your tooth out using an "irrigating" syringe.

  • This is a normal looking, smallish syringe that has a bent/curved, blunt-tipped needle.
  • The needle is rested inside your tooth and the solution is gently expressed.

    (There's nothing sharp about the needle, you are not getting a shot. Gently flushing out the tooth is the goal here, no solution pressure is generated.)

  • A normal dental suction device is used to catch any excess, or to remove the bulk of the solution from inside the tooth.
 

c) Why irrigation is such an important part of the root canal procedure.

It's easy to imagine how placing a liquid inside a tooth has the ability to seep into minute nooks and crannies, which are precisely the locations that are impossible for root canal files to access.

And especially in the case where the solution itself has properties that help to disinfect the tooth, this ability can substantially enhance the effectiveness of the dentist's work.

  • Expect that your dentist will repeatedly irrigate your tooth, seemingly ad infinitum.
  • A minimal goal is to have the tooth's root canal system exposed to the irrigant for a period of 30 minutes or longer. (Darcey)

Generally, this step is so beneficial that sometimes the process of "cleaning and shaping" a tooth is instead referred to as "shaping for cleaning," as in the tooth's root canal system is flared and opened up to enhance the volume and access of the irrigation solution used.

Section references - Darcey

What's this step like?

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

The process itself is just multiple cycles of using files in the tooth ... flushing the tooth out ... and then repeating the process again and 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 the next file into your tooth.

During tooth irrigation.

Your dentist may agitate the solution they place in your tooth with an ultrasonic instrument (its intense vibrations will help to increase the solution's effectiveness). 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.

 


Will your tooth's treatment be completed in one or two appointments?

At this point in your tooth's procedure, a potential stopping point has been reached. Its interior has been thoroughly cleansed and properly shaped, and is now ready to be sealed (have its hollow interior filled in).

  • With some cases, the dentist will go ahead and proceed with this process immediately. (One-visit endodontic therapy.)
  • With others, they may feel that it's best to wait about a week, or even two or three, before the completion of the tooth's procedure is performed. (Two or more visit treatment.)

For a discussion about how this decision is reached, use this link: How many appointments will your root canal therapy take?

In the case of two-appointment treatment:

  • As a process that further disinfects your tooth's root canal system, your dentist may place calcium hydroxide paste inside its canals and let it sit until your next appointment.

    Doing so can be especially effective, and a primary reason why a two-appointment approach is chosen.

  • They will also need to place a temporary filling that seals the access cavity opening they have performed their work through, so to keep contaminants from reentering your tooth.

    (Related: Precautions you should take with this filling.)


Step 6 - Sealing the tooth.

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

Gutta percha points come in sizes that exactly match the dimensions of root canal files.

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

The most frequently used root canal filling material is a compound called gutta percha. It has a flexible, rubbery nature, both at room temperature and even more so when warmed.

Gutta percha comes in preformed cones (often referred to as "points") whose sizes exactly match the dimensions (diameter, taper) of root canal files.

b) Placing the gutta percha.

One method of gutta percha placement that a dentist might use is referred to as "lateral condensation." When performing this process:

(Note: We describe and illustrate this process for a single-rooted tooth that has just one root canal. In actuality, teeth frequently have more than one root canal and/or roots. For those that do, this process will need to be repeated for each individual canal.)

  1. The dentist will first select an initial cone of gutta percha for the canal. The size chosen will be the same one as the last (largest) file used to clean and shape the canal's full length (see picture above). This is termed the "master point."
  2. The dentist will evaluate how the master point fits inside its canal both by the way it feels as it's worked into position, and by visualizing it on an x-ray that they'll take. It's important that this first cone extends the full length of the canal, and fits snugly in the region of the root's tip.

    If it doesn't, the cone can be removed and adjusted by way of trimming it shorter. Or on occasion, the dentist may find that the next size smaller, or larger, gutta percha cone makes a better choice.

Sealing the tooth's root canal system with gutta percha.

Animation of placing gutta percha to complete the root canal treatment process.
  1. The cone is then removed from the tooth. A sealer (a thin paste) is then applied to its sides, and possibly directly inside the root canal too, and the cone is then reinserted back into position. (Frame "A" in our animation below.)

    (The paste enhances the seal that's created by way of filling in any voids that exist between the gutta percha and the walls of the canal.)

Because a master point has a snug fit in the portion of the canal that lies at the root's tip, that cone alone (its single mass of material in conjunction with a thin layer of surrounding sealer) will create the needed seal for that region.

Higher up however, usually the cleaning and shaping process has flared the taper of the upper portion of the canal significantly. And in order to create a solid (free of voids) mass inside the canal to seal it, the dentist will need to place additional cones of gutta percha in this region.

To do so:

  1. The dentist will insert a "spreader" into the canal. (This instrument's working end looks like a root canal file, with the exception that its sides are smooth. It's used as a conically shaped wedge).
Picture of using a spreader to condense gutta percha.

Working a spreader inside a root canal. (The master point is visible.)

  1. The spreader is worked laterally (side to side, hence the term "lateral condensation" for this procedure) to compact the gutta percha that's already been placed up against the walls of the canal.
  2. An "accessory point" (a gutta percha point smaller than the master point) is then dipped in the sealer and inserted into the space that's been created by the spreader.
  3. This process is then repeated until the entire space within the flared portion of the canal has been filled in (sealed). (Frame "B" in our animation.)

Section references - Tronstad

Lateral condensation technique is just one of the methods your dentist might use. But all processes are the same in the sense that their goal is simply filling in (sealing) the tooth's root canal system with a solid core of material (usually gutta percha and sealer).

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.

  • With some methods, your dentist may heat the gutta percha so it becomes soft and pliable. So, you may smell that.
  • And you'll feel the pressure of the tools being used in your tooth as the gutta percha being placed is packed and condensed.

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


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 7 - Placing a temporary filling.

Once your dentist has finished sealing all of your tooth's individual root canals (many teeth have more than one, see link above), they'll take an x-ray of your tooth so they can evaluate and document their work.

They'll also need to 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. (The filling prevents oral bacteria and contaminants from seeping back into the tooth's treated space.)

(Related: Precautions you should take with temporary restorations.)


Step 8 - 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 ensure the long-term success of your tooth's endodontic therapy.

Takeaways from this section.

Take note of the link in Step 7. It details precautions you should take after your 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 8 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.

 
 
search

Comments

Root canal irrigation

I have heard the xxxxxx xxxx irrigation system for root canal therapy is superior to conventional techniques and I’m wondering if this is so or is it just another gimmick.

* Comment notes.

Jasonw

There's nothing new about dentists agitating irrigating solutions inside a tooth with vibrating devices (hand motion/sonic/ultrasonic). And doing so is generally a positive thing because it increases the amount of contact of the solution with the canal walls.

In regard to the system you mention:

1) There is nothing new or different about the types of irrigating solutions it uses.

2) The system does remove air bubbles from the solution, so to prevent "vapor lock" (a bubble blocking flow through a tiny canal). (Implying that the solution can flow more fully through the tooth's entire root canal system and therefore be more effective.)

We searched for published studies that had evaluated the use of the system. What we found seemed generally positive but we don't have anything to say other than just that. Some of the studies were sponsored by the system's manufacturer.

A decision to use this system is a clinical one that your dentist needs to make. Can successful endodontic therapy be completed without its use? Yes. Does more effective canal cleansing aid in creating higher rates of endodontic success? Always. We'll point out that success rates for endodontic therapy are already generally high.

* Comments marked with an asterisk have either been edited for brevity/clarity, or have been moved to a page that's better aligned with their subject matter, or both. If relocated, the comment and its associated replies retain their original datestamps, which may affect the chronology of the page's comments section.

Feedback