If you’ve ever experienced tooth pain, you’ll agree that the pain caused can be almost as bad as any other physical condition. But why is this? How can something as small as a tooth cause so much pain? And perhaps more importantly, how can it be prevented or treated? The structure and function of a tooth is well known to dentists, and especially endodontists who specialize in this area. Their job is to treat diseased or damaged dental pulp – the soft tissue found inside a tooth often referred to as the nerve.


  • Each individual tooth has divisions called root canals
  • An individual tooth can have between one and four root canals
  • The result of dead or dying dental pulp is pain


But, what exactly causes this pain?


A tooth has a thin but strong outer layer called enamel. There is only a very small opening into the supporting jawbone is present, deep within the bone. So, when a tooth’s dental pulp is diseased, dying, or dead, the flow of blood increases – but there is nowhere for the pressure to be released except into the supporting jawbone.


This causes the pain usually associated with toothache. Occasionally, the infection inside the tooth can spread into the jawbone and come out into the soft tissue of the gums. This usually takes the form of pimple-like projection commonly referred to as a ‘gum boil’.


There are many causes of dead or dying teeth, and many ways they can be treated. Let’s take a closer look at these:


What you feel or see

Conditions, signs or symptoms related to endodontics


  1. Pressure causes pain

You experience pain when chewing with the affected tooth, or when pushing on it or tapping it with an object. Sometimes there are periods when there is no pain at all, and antibiotic therapy will usually reduce or eliminate the pain for a short while.


Tooth pain when pressure is applied can indicate:

  • A dead or dying tooth
  • A cracked tooth, or
  • A tooth that has had recent heavy chewing, or ‘bruxing’ on it


If your dentist finds your tooth is dead or dying, you will usually have two options:

  1. Root canal therapy
  2. Tooth extraction


  1. Heat causes pain

If hot foods or beverages cause significant pain in a certain tooth, it normally indicates that the tooth is dead or dying. In this case, you usually have two options:

  1. Root canal therapy
  2. Extraction of the tooth


  1. Red, pimple-like projection on the gums

If you have one or more red, pimple-like projections on the tongue side or cheek side of your gums near an affected tooth, this usually indicates the tooth is dead and the infection has broken out though the bone. When this happens, it usually creates a fistula, or canal, through end of the tooth root though the gums. Sometimes, yellow pus will come from the red projection, often without much pain, but will return until the condition has been completely treated.


Therapies for this condition may include:

  • Endodontic (root canal) therapy alone
  • Root canal therapy and an apicoectomy (root tip amputation and root tip filling) if the defect is large
  • Hemisection (amputation of one or more roots) if the disease is persistent and involves just one of a multi-rooted tooth
  • Extraction of the tooth


  1. Tooth with a previously treated root canal has pain or a pimple-like projection

The good news is that 95% of root canal therapies are completely successful. However, the remaining 5% can be problematic and cause pain or other complications.


After discussing these issues with your dentist, you will usually be presented with several alternatives:


  • Redo the root canal therapy
  • Apicoectomy (root amputation and filling of the root-tip)
  • Hemisection (amputation of one or more roots)
  • Extraction of the tooth


  1. Tooth with a previously treated root canal has darkened in color

It is not unusual for small amounts of blood or other debris to be inadvertently during a root canal therapy. Although this is not harmful, the pigments from the blood or debris can cause the tooth to become dark, which is undesirable for most people.


Several options are available for patients whose teeth have darkened after root canal therapy:


  • The tooth can be bleached by a dentist to restore the color
  • A crown (cap) can be placed on the tooth to match the color of the healthy teeth
  • The affected tooth can be left as it is (but most people do not want a darkened tooth)
  • The tooth can be extracted and replaced with a replacement tooth, such as a dental implant


What Your Dentist or Endodontist Can Do

Treatments available for dead or dying teeth


  1. Root canal therapy

If a tooth’s pulp (nerve) is diseased, traumatized, or dead, it must be removed to save the tooth, and then replaced with a root canal filling. The materials used for filling range from the most popular, rubber-like gutta-percha, to sterling silver and other metals, plastic, and various cements.


A root canal procedure, which usually requires one or two appointments, is typically not painful but patients may experience some discomfort during treatment and healing. In most cases, the procedure is not complete once the root canal has been completed because the tooth is now much weaker. To treat this, a strong, reinforcing post is placed into the tooth. Sometimes a tooth may still be too weak or unpleasant looking, so a crown (cap) is needed to make the tooth both functional and more pleasant-looking.


The minimum therapy to remedy a dead or dying tooth is a root canal only. However, if parts of the tooth are missing due to decay (caries) or from an old filling, then the most accepted form of therapy is:

  1. A root canal
  2. A post, and
  3. A crown (cap)



  • Advantages of root canal therapy


The biggest benefit is that the affected tooth remains in your mouth, pain free. The cost of root canal therapy can be significant, but the cost of replacing the tooth is typically much higher.



  • Disadvantages of root canal therapy


This type of procedure is time consuming, often requiring multiple appointments. The root canal procedure itself usually consists of one or two appointments, with one or two additional appointments needed to restore the affected tooth with a crown (cap). The time and costs involved is usually significant, but almost always well worth it.



  • Risks of root canal therapy


Although root canal therapy is a low-risk procedure, the risks that do exist are:

  • The tooth may have more divisions of the root canals than the dentist expected, which they may inadvertently miss during the procedure. This results in a failure of the root canal therapy, continued pain, and the need for further treatment
  • Occasionally, the fragile tools and instruments used for the procedure can break, resulting in complications in successfully completing the therapy.
  • Around 5% of root canal treatments fail for no specific, observable reason, and subsequently require either retreatment or extraction of the affected tooth.



  • Alternatives to root canal therapy


Unfortunately, there are not many alternatives currently available. You may choose to have the tooth extracted, or postpone treatment if the pain is infrequent or not present. It’s important to know that the tooth will not heal by itself, and that root canal therapy is almost always the best choice.



  • Cost of various alternatives to root canal therapy


The cost of root canals varies significantly around the world. The cost of a root canal therapy for a single-rooted tooth is much higher than having the tooth extracted, and the cost of therapy for a multi-rooted tooth is higher than that of a single-rooted tooth. Additional fees are usually applicable if the tooth needs a post, and further fees if the tooth requires a crown (cap). Essentially, the more damaged a tooth is, the higher the cost to the patient will be.



  • Result of non-treatment of a dead tooth


The longer a dead or dying tooth is left without treatment, the more it will cause discomfort, pain,  and deterioration of the jawbone around the tooth. Ultimately, these conditions will force you into seeking root canal therapy or tooth extraction.


  1. Apicoectomy

There are times when a radiograph (X-ray) shows so much disease on the tooth root that an apicoectomy (amputation of the tooth root) is required. This involves making a small incision in the soft tissue of the gums close to the root end of the affected tooth. Then, the diseased pulp (nerve) is removed,often along with a small amount of the tooth root end. After that, the resulting hole is filled with a sealing material, the soft tissue is sutured (stitched), and the sutures are left in place for several days while the area heals. Although some discomfort may be experienced, this can be alleviated with the use of medications and antibiotics.



  • Advantages of apicoectomy


Removing the diseased tissue is a relatively quick, easy, and thorough procedure, and the health status of the affected tooth can be immediately determined. Healing is typically a fast and uneventful process, and the tooth can remain in your mouth and function as normal.



  • Disadvantages of apicoectomy


There is a certain amount of discomfort involved during the healing process, and the cost of an apicoectomy can be significant.



  • Risks of apicoectomy


The risks involved during an apicoectomy can vary greatly depending on the location of the tooth. Upper and lower front teeth are typically risk-free, whereas the back teeth (molars and premolars) can be much more difficult and present a higher amount of risk.


The occasional possible risks are as follows:


  • Inadvertent contact with a nerve, causing a slight or total numbness of the area
  • Surgical contact with the sinus cavities in the upper jaw, potentially increasing the chances of sinus infection
  • Injuring or nicking teeth close to the affected tooth


You should talk with your dentist about the possible risks before undergoing an apicoectomy.



  • Alternatives to apicoectomy


You will not have many alternative if the need for an apicoectomy is indicated. Typically, the alternative options are:

  • Have the tooth extracted
  • Redo the root canal therapy
  • Wait a few week or months to see if the affected tooth responds positively without any treatment



  • Cost of apicoectomy


As an apicoectomy is a relatively difficult procedure, the cost will generally be in the same price range as the original root canal therapy.



  • Result of non-treatment


If an apicoectomy is needed but not performed, the infection will spread and cause the surrounding bone to deteriorate. However, in a very small number of cases, the infection does not worsen.


Bleaching Discolored Root Canal-Treated Teeth

As strange as it might sound, gray, brown, blue, orange, green and other colors are known to appear in teeth months to years after a root canal therapy has been completed. This discoloration would make no difference if a crown (cap) has been placed over the tooth, but if not, the resulting discoloration can be undesirable and upsetting to a patient. Thankfully, there are a number of techniques available for bleaching teeth that have become discolored after root canal therapy.



  • Advantages of tooth bleaching


    Bleaching a discolored tooth is the most conservative and least expensive solution.



  • Disadvantages of tooth bleaching


The discoloration may reappear over a period of years, but it can simply be bleached again.



  • Risks of tooth bleaching


There are no risks to bleaching a root canal-treated tooth, but occasionally the affected tooth root degenerates, resulting in the loss of the tooth.



  • Alternatives to tooth bleaching


The quickest and easiest alternative to bleaching a discolored tooth is placing a crown (cap) on the tooth. Crowns can be made to match the color of the surrounding teeth and generally last a long time. Another alternative – if the affected tooth is causing chronic, occasional pain or discomfort – is to extract the tooth. This requires the placement of a bridge (prosthesis) between two healthy, adjacent teeth. Alternatively, the tooth can be left as it is. Although the discoloration remains, this option presents no significant health issues.



  • Cost of tooth bleaching


In comparison to other alternatives, tooth bleaching is a relatively low-cost solution. For example, a crown (cap) costs more than tooth bleaching, and an extraction is more costly than a crown.



  • Result of not bleaching a discolored tooth


The only consequence of not bleaching a discolored tooth is that the tooth remains unsightly in appearance.


Other Less Frequently Encountered Endodontic Treatment

There are occasions where an affected multi-rooted tooth can have one or more diseased roots while one or more roots remain healthy. In this case, the diseased roots can be removed, leaving the remaining healthy portions of the tooth intact. This is a technique called a hemisection, and is usually called upon as a last attempt to save an otherwise healthy tooth, and is usually successful. However, this procedure usually comes with a high cost, and results can be unpredictable.


The main goal of all aspects of endodontics is to ensure a patient keeps their natural teeth. The cost of its related procedures is usually quite high, but the results are usually much more desirable than the alternatives, such as tooth-replacement procedures. Endodontic procedures aim to ensure that all of a patient’s natural teeth function naturally and effectively after a disease has occurred, and therefore are highly recommended.