There's More to the Story: Root Canal Edition

 By: Nick Sienkiewicz, DPT, CSCS

Although it is not likely that everyone reading has received one, we have all heard the term “root canal.” Furthermore, chances are high that you know at least one person with one or more “root-filled” teeth, as around 12% of adults in our country have received a root canal. Basically, root canal treatments are performed with such regularity that it has become common practice for “dead" teeth, an increasingly familiar condition in today’s world. A root canal filling is often the gold standard recommendation for this situation of a dead tooth; when the inner workings of the tooth, known as the pulp, become infiltrated by decay and subsequently infected. The pulp houses the nerve and blood flow to each tooth. Once the pulp is infected, an abscess will form. This is known as irreversible pulpitis. Pulp necrosis follows, where the pulp of the tooth dies. This can trickle over into the surrounding bone of the jaw, a condition known as apical periodontitis. Infectious organisms can even travel through the tooth’s blood supply, getting into systematic circulation. Essentially, many significant problems can arise from pulp necrosis, so something needs to be done to avoid potentially severe repercussions. Root canals are the go-to intervention in this regard. If you are unfamiliar with the root canal procedure, it is the process of shaving down the top of the tooth to access the pulp, at which point it is filled and sealed closed. Then, a crown is placed on top of the mold to reshape the surface of the tooth. Root canals sound fitting in theory, and are absolutely a timely option. We are given the impression that once a root canal is performed, everything is corrected and reversed. However, it is imperative to understand that like many other modern practices, there are trade-offs. There is assuredly more to the story! 

Before we get deeper into the discussion, let’s address the elephant in the room. I am unfolding something this week that is a bit outside my lane, yet I know is extremely pivotal to health. I have attained this knowledge through personal experience and self-directed learning rather than working with patients or clients in this regard. Obviously, I am not a dentist; nor do I claim to be a “specialist” when it comes to the teeth and oral health. I do often bring up their importance in an educational context with my own patients, but if I believe further assessment and/or interventions may be warranted, then I will refer out. As it relates to my personal situation, I won’t get too deep into details. However, I can tell you that I am undergoing a tooth extraction in a few weeks. A root canal was initially recommended to me, but I pursued more information and guidance from experts in the field (mainly biological dentists) after learning of the trade offs for root canals on my own. Thus, the combination of knowledgable providers and my own personal critical analysis directed me toward a tooth extraction rather than a root canal filling to afford the best possible outcome for myself. This does not mean it would be the right decision for you. Nonetheless, it is crucial that you know and understand this information in order to arrive at the most suitable treatment plan for your unique situation. Some of the following is from research, blogs, podcasts (check out our In the Rack episode with biological dentist, Dr. Michael Mayr), but much of this information has been directly learned from dentists in the trenches navigating these scenarios everyday. Let’s dive in:

• It is virtually impossible for a root canal to clean out and fill all of the nooks and crannies of the pulp: The enamel on the exterior of our teeth is strong and impermeable. It is not until the enamel is traumatized, whether through physical damage or acidic decay from bacteria, that holes form in the enamel. The dentin (middle layer) and pulp are much more soft and porous. This creates a series convoluted channels and tunnels throughout the interior of the tooth. Even with more modern high-tech equipment like lasers and antimicrobial UV lights, it is unfeasible to perfuse and fill all of these caverns. These spaces left behind offer a great place for microbes, like bacteria, to reside. Once the root canal procedure is finished and a crown is placed, these remaining gaps are transformed into dark, moist homes that are perfect for these pathogens to survive and reproduce. Since most pulp necrosis leads to apical periodontitis, or a lesion in the adjacent jaw bone, it its clear that these infectious organisms being harbored in “root rooms” of the dead tooth can easily creep into the surrounding tissues.    
• Reinfection rate is extremely high (and/or complete resolution of the infection(s) may be impossible in the first place): The description in the bullet above explains much of the reasoning for this occurrence. Even though it may seem like a sealed off dead tooth wouldn’t be a great place for microbes to thrive because of lack of oxygen and food sources, this has been shown to be a fallacy. This study discovered that glycoproteins can still get into a root filled tooth, providing plenty of sustenance for unfriendly invaders. Moreover, many of the pathogens that infect root canals are anaerobic bacteria, meaning they survive in oxygen-deprived environments. Unfortunately, these are also usually the bacterial strains that are resistant to antibiotics and other conventional treatments. This makes for an added layer of complexity when it comes to addressing these root canal-derived infections.  
• You wouldn’t leave any other dead tissue in the body: If you were to experience a burst appendix or gallbladder, surgery is necessary to not only clean out the contents from the ruptured tissue, but to remove the remnants of that particular organ. It would be considered malpractice if a surgeon were to operate, clean up the mess, but leave the remainder of the unsuitable organ’s tissue just sitting in the body. That is because that particular tissue would essentially just rot inside the body and create massive problems, including more infection. This is fundamentally the same scenario as a root-filled tooth. The blood supply to the tooth has been disrupted to the point of necrosis, meaning the tissue within the tooth is actually dead. Leaving the dead tooth in the mouth is analogous to the scenario above of leaving behind an appendix or gallbladder after it has burst.
• Extraction, although not ideal, typically offers a better overall solution for the high rates of reinfection: The situations described in the points above generate a cesspool for microorganisms to thrive. Just as it is common practice to remove the appendix or gallbladder following rupture to avoid further repercussions (like sepsis), extracting a dead tooth seemingly offers a less risky long term solution. There have certainly been advancements in endodontic practice that have improved outcomes with root canal procedures, but it has been shown that even the modern interventions fail to fully disinfect the root canals within the tooth. Additionally, this same study illustrates how these microorganisms secrete endotoxins from within the tooth, further triggering immune reactions and leading to increased inflammation. Due to these issues and the inability of the conventional root filling procedure to fully address them, extraction may be a better option for most. Obviously, a root canal is still an option. However, the individual should understand these concepts and be willing to assume these risks in that case. Just like anything else with our health, we need to do an appropriate risk-reward analysis on our unique situation. 
• Furthermore, root canal filling (or extraction for that matter) does not address the underlying root cause(s): As with any health issue we face, identifying and addressing root causes is imperative. This could obviously be its own series of newsletters. The things I discuss each and every week are some of the big rocks though; nutrition, toxin exposure, metabolic health, microbiome/internal ecosystem balance, etc. As it relates to the root causes of my upcoming tooth extraction, I’ve had a long history of oral issues dating back to adolescence. Part of these reason I’m so passionate about health and wellness now is because I truly came from a place of dys-health. I had terrible nutrition, inconsistent sleep habits, and sub-par oral hygiene. Furthermore, I was a chronic mouth breather and dealt with rather significant immune system imbalance (I’ve discussed my Th2 dominance in past newsletters) in conjunction. On top of all that, I endured pretty significant oral trauma in high school when I took a shoulder to the mouth during a soccer game that avulsed 4 of my teeth (aka knocked them out of their sockets). The teeth were quickly put back in, but I lost a substantial amount of gum tissue during the injury. All of these factors combined equate to my root causes (at the ones I’ve been able to identify). Steadily, I’ve been addressing these root causes in recent years, with the one caveat being my oral injury history. That cannot be changed unfortunately, and less gum tissue means less protection for your teeth, especially the roots. Gum grafts are an option (I’ve had one), but of course, there’s risks and rewards associated with those procedures too.   
• Root canal procedures have been linked to many other health issues: The health of the oral cavity has a profound impact on overall bodily health. This is now very well known, as it is being shown over and over again in the literature. Many studies, like this one, illustrate a strong relationship between root canal treatments and subsequent cardiovascular disease that is seemingly triggered by the intimate vascular connection between the periodontal region and heart tissue. This study demonstrates that the bacteria residing in root canals of teeth are linked to the development of not only oral cancers and cancers of the head and neck region, but also contributory to colorectal and pancreatic cancers. Other studies have linked periodontal disorders that often result in root canal procedures to the evolution of breast cancer as well. Some researchers have even exhibited a connection between root-filled teeth and depression, largely due to the brain being bombarded by endotoxins secreted by the microbes that tend to park themselves inside the cavernous spaces of the dead tooth. These are just a few examples, but unquestionably serious concerns. This is absolutely not to say that these conditions are guarantees post-root canal procedure. Nevertheless, you as the individual potentially considering root canal filling have to be aware of these realities in order to make the best possible decision for yourself and your family.  

This is a bit of a heavy topic, as I’m sure there are many reading this newsletter who have already undergone a root canal procedure in their life. If this is you, please do not panic. The best thing you can do is to start by working with a biological dentist, as they will view you as a whole bio-individual body and not just a mouth with teeth. Further testing to determine the status of that root filled tooth and the surrounding tissue will likely be warranted, but a holistic provider will help guide you in this process. Please reach out if you have any further questions on this topic!