Tooth Gangrene, Root Canals, and Dental Granulomas

(Def. gan·grene: localized death and decomposition of body tissue, resulting from either obstructed circulation or bacterial infection)

A tooth is a wonder of nature. Its birth is so unique and complex that no one can really understand it in its entirety. It is the only organ in the body made up of three embryonic layers: the endoderm develops into the brain, the mesoderm develops into blood, bone, and muscles, and the ectoderm develops into the skin, nails, and hair.

Every tooth has a canal through its center that contains living tissue, bringing nerve fibers, cells, and nutrients through tiny blood capillaries to its core. This tissue is collectively called the pulp. In newly erupted teeth, the canal space that accommodates the pulp is large and has a rich blood supply. (Click on images to enlarge)

At this stage, the root tip is still not formed and continues to calcify over the next few years.

In a young adult, the canal space has shrunk but can still provide nutrition to the whole tooth.

The canal gets narrower and narrower due to aging, continuous use, cavities, dental treatment, bruxism, and trauma. This happens as cells lining the canal walls deposit dentin along the inside walls, narrowing the space available for the pulp. Because of this confined space, inflammation or infection within the pulp does not heal as a similar bruise or infection in your skin or muscle tissue would.

The damaged cells and their toxins simply cannot be evacuated fast enough, and the limited blood supply through the tiny opening under the root tip would not be sufficient to heal the damage. The tooth subsequently goes through a phase of pain (not necessarily), and the pulp degenerates.

This is essentially a micro-gangrene within the tooth. The dead tissue decomposes and becomes infected by bacteria that grow unchecked, enter the millions of tiny tubules along the canal walls, and spill their toxins into the bone surrounding the root. This is called a granuloma and appears on an X-ray as a dark shadow around the root.

This process may occur with or without pain. If it hasn’t prompted someone to seek dental treatment, it may be discovered only by chance on an X-ray.

Without pain, the patient may be surprised to learn they need a root canal. A granuloma is a focus of infection. Toxins travel to the heart lining, kidneys, and joints, contributing to disease. The immune system works overtime to counteract the damage.

An extracted, root-canalled tooth was ground down to show its cross-section through the canal, revealing the amount of dead and decomposing tissue around the root-canal filling.

Sometimes pain can be helpful by sounding the alarm. If the alarm is absent, the chronic infection will cause more damage and will grow unchecked, eating away at the bone and creating a huge void, or a “hole,” which one day WILL turn into an abscess. At that point, it will be too late to save the tooth.

The second reason to address these granulomas immediately is that the larger the bone void is, the harder it is to heal and rebuild new bone. Therefore, if the tooth were extracted, it would leave a large defect and insufficient bone to place an implant. (A-Abscess not healed; B-Untreated, failed root canal)

Granulomas also remain in teeth with an old root canal. These only need observation if they are very small, but generally, they are not desired for the same reasons. They may indicate root canal failure, toxic tissue remnants inside the canals, a root crack, or simply that the body cannot handle the dead tooth. In such cases, extraction may be a better option. After extraction, we clean out the bone and place a graft to preserve bone for a future implant.

Our first choice for restoration is a metal-free zirconia implant, which is highly biocompatible. Click on the image below to see the extraction option and subsequent restoration with a zirconia implant.

If you choose to save a tooth, you must perform a root canal procedure. For a series of illustrations explaining the root canal procedure, see the article Root Canal Treatment – The Last Resort

Doing nothing is not an option for dead teeth. In any other field of medicine, a dead or gangrenous tissue or organ would immediately be removed. Many people nowadays are opposed to root canals for various reasons and avoid the procedure. However, keeping a dead tooth in the body and avoiding a root canal is also a misconception that may have grave consequences. If a tooth is dead or gangrenous, the only other option, if you don’t want a root canal, is extraction.