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Dr. George McKee
Dr. George McKee, Dentist
Category: Dental
Satisfied Customers: 1396
Experience:  Licensed dentist with 30 years clinical experience in general practice and cosmetic reconstruction.
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Can a tooth that has suffered nerve damage be restored to a ...

Customer Question

Can a tooth that has suffered nerve damage be restored to a vital condition? Once deemed to be non-vital, can a tooth heal itself by removing the affected infectious tissue and killing the source bacteria? Can infected pulp be cleaned or rid of infection and bacteria without performing a pulpectomy? How is the degree of infection assessed such that pulpectomy is determined to be the only remaining option for keeping the tooth?
Submitted: 6 years ago.
Category: Dental
Expert:  Dr. George McKee replied 6 years ago.

Dear XXXXX,

Thank you for your question. The nerve of a tooth is a unique situation in the body. The hollow space inside every healthy tooth contains tissue, a blood supply and a nerve. This live tissue communicates with the rest of your body through a small opening at the root tip. The entire blood supply to the tooth comes in to this enclosed chamber through this tiny opening.

The key for any diseased tissue to heal is the body's ability to bring white blood cells to the area to destroy any bacteria and dead tissue. If a tooth nerve has suffered injury through a bacterial invasion (decay) or trauma, as long as the blood flow to the tooth is healthy, the body attempts to resolve the situation with it's own natural defenses. The problem is, when the nerve is inflamed, it swells up as any tissue would. This inflammation, restricted by the hard chamber it occupies, puts pressure on the tiny opening through which the blood supply comes in and cuts it off. At this point the entire nerve tissue dies. An analogy would be placing a tight tourniquet on your wrist and leaving it there for days. The blood supply would be cut off, and your hand would become irreversibly necrotic, requiring amputation. The same happens to a tooth nerve. You cant bring the dead back to life. Without a blood supply, no repairing of the tissue can be made. A root canal then has to be performed to seal this area off from the rest of the body, preventing a tissue rejection attempt. I hope this answers your question. If you have any concerns that I have not addressed regarding this matte, please let me know and I will get back to you with more information.

Sincerely, XXXXX XXXXX

Dr. George McKee, Dentist
Category: Dental
Satisfied Customers: 1396
Experience: Licensed dentist with 30 years clinical experience in general practice and cosmetic reconstruction.
Dr. George McKee and 2 other Dental Specialists are ready to help you
Customer: replied 6 years ago.
Thank you for your informed answer. Just a little follow up and I think I will have a satisfactory understanding.

How is it determined that the blood supply to the tooth has been cut off? that the nerve of the tooth is really "dead" and not just wounded? Using your analogy, if the tourniquet is relieved in time, the wrist could still survive, even if numbness had set in. As regards XXXXX XXXXX can the wounded nerve tissue be revived? How do you determine if the point of irreversible harm has been reached?

Assuming a pulpectomy is the appropriate dental response, do the infected gum and bone tissue have a chance to regenerate afterwards? Where significant bone loss has been experienced on one side of the tooth, for example, would a bone graft be appropriate or could a bone graft even be performed?

Finally, would the presence of such bone loss present an impediment to survival of the tooth and lasting success of the pulpectomy or root canal?

Thank you again.
Expert:  Dr. George McKee replied 6 years ago.

Dear XXXXX,

We use the patient's symptoms and a radiograph to determine the health of the tooth. If a tooth is sensitive to just cold, that indicates a reversable situation. The nerve is inflamed but can be reversed with decay removal and sedative filling placement. If the pain of the cold stimulus lingers on for more than about 15 seconds after the stimulus is removed, then the health is borderline. Any sensitivity to heat is an indication that the nerve has died and decomposed. Methane gas, a byproduct of tissue decay, is present in the nerve space and expands upon the application of heat, putting pressure outside the small opening at the tip of the tooth and causing pain on the nerves outside the tooth.

If the radiograph shows bone loss around the tip of the root, then the nerve is necrotic and the body's natural defenses are detecting the bacteria and necrotic byproducts that start spilling out of the small opening in the tooth. Sometimes, this stage of the process can be painless and can go on for years without the patient being aware that anything is wrong. The white blood calls are busy devouring the bacteria as fast as they spill out of the tooth and can keep the small chronic infection from getting any larger. Eventually, however, the bone loss around the tooth progresses and the corralled infection gradually enlarges and creates and acute situation typically manifesting as an abscess.

Once the root canal is completed, the contents of the nerve chamber cleaned and sealed with a biologically inert material. The white blood cells eliminate the remaining bacteria and the bone loss from the infection gradually is replaced with new bone. The larger the bone loss around the tip of the tooth, the longer it takes to regenerate. We can't bone graft a situation like this. The body regenerates the bone. Presence of this bone loss before performing a root canal has nothing to do with the root canal's success. This is determined by the skill in which the dentist properly cleans, disinfects and seals all the canals in the tooth.

I hope this helps.Please let me know if you need more information.

Sincerely,


George McKee DDS

Customer: replied 6 years ago.
Thank you again for your authiitative answers to all of my questions. I hope you will remain available for additional follow up that I may require.

Best regards,
Customer
Expert:  Dr. George McKee replied 6 years ago.

Dear XXXXX,

You are most welcome. I am not always online but check this site often. If you have any follow up questions regarding this issue, I will be happy to elaborate.

SIncerely, XXXXX XXXXX DDS

(you

Expert:  Dr. George McKee replied 6 years ago.

Dear XXXXX,

You are most welcome. If you have any further questions regarding this matter, I will be happy to elaborate.

Sincerely, XXXXX XXXXX DDS

(you do not have to reply to this message)

Customer: replied 6 years ago.
The previous questions I have asked are in reference to the following matter. I will submit this as another Just Answer inquiry if that is more proper. Please let me know.

I have a tooth, molar #3, for which root canal therapy is being recommended but with reservations. Following x-rays that showed a tooth infection, the nerve was tested by applying a cold gas spray to which I did not respond positively. That is being interpreted as evidence of a compromised nerve from the infection, thus, the recommendation for root canal therapy. The reservation is that there is significant bone loss on one side of the tooth also from bacterial infection and that Insurance would deny authorization for treatment because of that condition. My understanding is that, once a healthy oral environment is created, the gum and bone tissue will be able to undergo healing and regeneration, however, it is unclear to me how much bone tissue regeneration will take place and over what time frame. I can appreciate that Insurance would be reluctant to authorize the root canal therapy because of the uncertain survivability of the tooth due to the bone loss that has been suffered but this seems to be a "catch 22". The nerve treatment is needed to cleanse the tooth of bacteria and infection which would allow the tooth environment to heal and bone tissue to regenerate which would help ensure the survivability of the tooth. However, because of the present state of bone loss, the survivability of the tooth remains uncertain and Insurance will deny authorization for treatment.

Insurance will approve extraction for this tooth but that is not a consideration for me. To replace the tooth with a dental implant that is not covered by Insurance and is 3x as costly as the root canal procedure seems quite foolish, especially when the extraction is unnecessary. How might this situation be presented to Insurance such that they would look favorably on the request for the recommended nerve treatment and be inclined to authorize root canal therapy?

Sincerely,
Customer
Expert:  Dr. George McKee replied 6 years ago.

Hi Dennis,

Thanks for the update. Do you know if the bone loss that is evident on the radiograph around #3 is due to periodontal disease or a necrotic dental nerve. These ususally have distinctive bone loss patterns. Did you dentist elaborate on this at all?

George McKee DDS

Customer: replied 6 years ago.
It appears that I have a localized periodontal condition affecting four teeth, one of which is #3. (The others are #13,, #31 and the tooth opposite #13 -- teeth in the four corners of my mouth).

The tooth #3 has suffered significant bone loss on one side from this periodontal infection, however, the tooth is not mobile at all, there is no abscess, there is no pain and the gum area is not inflamed although the pocket measued approx. 7 mm. I have read that more testing should be done to ensure that the nerve is in fact necrotic but three dentists have concurred as to its condition from the radiograph.
Expert:  Dr. George McKee replied 6 years ago.

Dear XXXXX,

A couple of things to mention. Just because the insurance company won't pay for the root canal does not mean that the tooth won't last for years and years if one is done and the periodontal status remains stable. Dental insurance companies are in the business of NOT paying claims. They are profitable business endeavors because they collect more money than they pay out. The thick booklet that comes with your initial insurance premium is a list of all the things they don't cover. Try to persuade your employer to purchase a better dental plan next year.

The other tests that should be performed to be absolutely certain of the diagnosis is:

1. Hot test

2. Electric pulp vitality tester

3. Percussion

Your dentist must also see the specific bone loss pattern around the root tips that indicates a dead tooth in addition to the periodontal bone loss. The presence of this alone is indication enough for the need of a root canal.

Sincerely, XXXXX XXXXX DDS

Customer: replied 6 years ago.
It appears that you have had your share of battles with Insurance companies and are not encouraged that they would approve such a "risky" procedure. I am meeting with an endodontist next week and should have a better understanding of this situation. If further confirming tests are not suggested then I will raise the matter myself. (One perodontist who consulted on this matter even recomended to "do nothing"- no treatment at all - because of the precarious condition of the tooth from the bone loss.) I can understand that should a root canal procedure be performed and a retreatment of that procedure be required at some point, the economics of an implant procedure would have been comparable. Maybe that is the best option now before any further infection or complications occur. I just do not know. Thanks again for your sound advise.
Expert:  Dr. George McKee replied 6 years ago.

Dear XXXXX,

Thanks for the additional information. I've been battling insurance companies for 28 years. It all comes down to the written contract of the individual plan. The employer gets what they pay for. Cheap dental plans exclude more treatment than expensive ones.

You might have an endodontic/periodontic lesion. That is a situation where an isolated area of bone loss around one root due to the periodontal condition communicates with the bone loss of the root tip. Ask the endodontist if this is the case. If so, the root canal will also improve the periodontal situation in that specific location.

We are doing some amazing things with implants these days. Because there is no periodontal space associated with an implant as there is with a natural tooth, we can "grow" bone around an implant using bone-like crystals and membranes in a surgical procedure. There are very specific situations where this works. A periodontist who keeps up with the latest technology would be knowledgeable on this topic.

I wish you well.

George McKee DDS

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