Apicoectomy, When Root Canal
Therapy Isn’t Enough

By Catherine M. Fascilla, D.D.S.

Sometimes the infection of an abscessed tooth cannot be eliminated with routine root canal therapy. The canals within a tooth are very complex with many small branches off the main canal. Sometimes, even after root canal therapy, infected debris remains in these tiny microscopic branches. This can prevent healing or cause re-infection later on. Large abscesses and longstanding infections are particularly resistant. Your dentist or endodontist (root canal specialist) may choose to remove the infected area at the tip of the root (apex) with a procedure called an apicoectomy.

This type of endodontic surgery is performed by making an incision in the gum at the end of the root. The gum is gently pushed away and a small opening or window is made in the bone covering the infected root tip. A portion of the root tip (apex) is removed and the periapical region or area around the end of the tooth is cleaned with a small spoon-like instrument and with ultrasonic instrumentation. The procedure is usually done under a special microscope. The seal of the root canal filling material is examined. Steps are taken to make sure the root canal filling is tightly sealed at the end of the root. Sometimes it may be necessary to place a small filling at apex opening to seal the tooth. A biocompatible material is used. This is called a retrograde filling.

The procedure is usually done with local anesthetic and takes 30 to 90 minutes to perform. Most patients return to normal duties within 24 hours. Over the counter medications are typically recommended for three to five days following treatment. Discomfort usually subsides in a couple of days but may last as long as a few weeks improving gradually over time.

Treatment involves finding correctable causes if possible. In many cases, it is not possible to correct xerostomia and treatment focuses on relieving the symptoms and preventing cavities. Careful attention should be paid to oral hygiene. The use of decongestants and antihistamines and excessive mouth breathing should be avoided. Frequent sips of water, alcohol-free oral rinses, gels, sugar-free chewing gum, and mints all help. Using a humidifier at night is beneficial. Minimizing caffeine and alcohol consumption is recommended. Artificial saliva is not well-liked and does not last. Pilocarpine HCl can be prescribed to increase salivary gland function but the side effects of that medication (sweating, vasodilation, headaches and urinary frequency) often decrease compliance.

The overall success rate that the tooth will last for ten years is about 80%. A ten-year success will most likely continue to hold up. The alternative to apicoectomy is tooth extraction and replacement with an implant, bridge or removable prosthesis.

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