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Can a root canal treatment be re-done a second time?

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Dr. Hall,
I have a tooth with a root canal that has been redone once, nine years ago. the tooth is bothering me again. Can the root canal be redone more than once?
– Jodie from Ohio

Jodie,
A root canal treatment can be re-done twice, three times, whatever, but that’s not the question. The question is whether or not that makes sense as a treatment.

Root canal treatment is one of the less predictable treatments in dentistry. It is accepted that even when the dentist has done everything right, there could be a failure rate of 5-15%, maybe more if the dentist is less skilled at this procedure. Let me explain the reason for this.

The living tissue inside your tooth is the pulp. There is a pulp chamber up in the crown of the tooth and a pulp canal that conducts the blood supply and the nerve to this pulp chamber. When the pulp becomes infected, the chamber and the canal have to be cleaned out and sealed against any bacteria re-entering the tooth. The problem is that the pulp canal can have branches and twists and turns inside the tooth that can, in some situations, make it difficult or even impossible to full clean out and seal. For example, in a molar, the standard number is three canals—one for each of the three roots. But often there is a small, difficult-to-find fourth canal. Furthermore, sometimes some of the canals can split off into branches at right angles. The dentist has tiny, highly flexible files that he or she inserts into the tooth and cleans out the infected tissue. There is no way this file can be manipulated to enter a side branch that comes off at a right angle.

Now these anomalies occur in a small minority of teeth, so the large majority of root canal treatments are successful. If a root canal treatment fails, re-treatment can remedy the situation, but only in somewhere around 50 to 75% of the cases. But if that re-treatment was done by a dentist skilled in root canal treatment and didn’t work, there’s a pretty slim chance that it will work if tried again.

There is another option, and that is root canal surgery. The dentist, most likely a root canal specialist, will make an opening in the bone and cut off the root tip of the infected tooth, and probably do a small filling at the end of the tooth to help ensure that it is sealed. This is called an apicoectomy and retrofill. If a root canal re-treatment has failed, this is usually the next best option and will be successful again in somewhere around 50 to 75% of the cases. Furthermore, some roots of some teeth are not surgically accessible or are in locations that would make surgery very risky, such as near the nerve that goes to the lower jaw and lip.

Another option is extraction. This isn’t the first choice, for sure, but some teeth are simply not savable.

– Dr. Hall

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About David A. Hall

Dr. David A. Hall was one of the first 40 accredited cosmetic dentists in the world. He practiced cosmetic dentistry in Iowa, and in 1990 earned his accreditation with the American Academy of Cosmetic Dentistry. He is now president of Infinity Dental Web, a company in Mesa, Arizona that does advanced internet marketing for dentists.

Root canal re-treatment isn’t working

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Dr. Hall,
I had a root canal re-treatment on my front tooth 3 weeks ago, by an endodontist specialist. I had the tooth checked just over a week ago and although I was still having pain around the tooth, he said that there was no swelling and it would all settle down. However, it is still very sore and sometimes the gum throbs, particularly if I am active, which surely tells me there is inflammation still. I am unable to take ibuprofen or aspirin and take paracetamol when needed.

I had gum swelling around the tooth before the root canal re-treatment, which was treated by erythromycin and this was finished about a week before the treatment was completed.

My question is what should I do next? It does not seem to be settling and I am worried if the bone around the tooth is infected and if it could spread. Should I wait more time to see if settles or see if the dentist will prescribe more antibiotics?
– Diane from Ashfield, UK

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Diane,

It doesn’t look good for your front tooth. Your instincts are correct – after three weeks it should be feeling better. Am I correct in assuming there is no improvement in the tooth? Residual tenderness in a tooth after any root canal work isn’t that unusual, but there should at least be some gradual improvement which you should be able to notice after three weeks.

I would not do any more antibiotics. Antibiotics won’t get at the source of the infection in a tooth – they only assist your body in fighting off the infection. Yes, the tooth would feel better for a while but then when you quit taking the antibiotics, since you haven’t eliminated the source, the pain will come back and now you will have an antibiotic-resistant infection.

There is no significant risk of the infection spreading at this point. You aren’t having an increase in pain, from what you are saying, and there isn’t any serious swelling.

Something is still wrong with the tooth that wasn’t fixed with the root canal re-treatment. Re-treatments don’t always work and it appears that yours isn’t. After initial root canal failure, which you experienced, the chances for success for re-treatment are somewhere in the range of 50-80%, depending on the nature of the problem that led to the failure.

The way antibiotics were used in your case seems strange to me. You said you had erythromycin before the treatment, and this was finished a week before doing the re-treatment. That would just give the infection a chance to come back before starting the re-treatment. If antibiotics were needed, I would have started them, done the re-treatment after they had taken effect, and then continued the antibiotics for a couple of days afterward. I just mention that because it’s strange – that’s not why your tooth isn’t getting any better.

Your options at this point are limited. You could have root canal surgery, but I’m skeptical about the chances for success of that treatment in your case, since, based on what you’re telling me, your endodontist isn’t inspiring me with a lot of confidence. You could maybe try that if you get outside your UK National Health Service. Your other option would be to have the tooth extracted and then replaced with whatever options they give you in the UK.

Dr. Hall

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About David A. Hall

Dr. David A. Hall was one of the first 40 accredited cosmetic dentists in the world. He practiced cosmetic dentistry in Iowa, and in 1990 earned his accreditation with the American Academy of Cosmetic Dentistry. He is now president of Infinity Dental Web, a company in Mesa, Arizona that does advanced internet marketing for dentists.

A smile makeover over a fractured tooth spells trouble for Aaron

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Dr. Hall,

I had a traumatic fall 12 years ago fracturing 2 front teeth and my smile was restored with root canals and Procera crowns by my family dentist. With age and time, I didn’t like the way my adjacent natural teeth looked with the Procera. Also, I had one left upper molar that had a pretty deep filling and was giving me trouble. I am 38 years old and that filling was almost 30 years old. I decided that it was time for a smile makeover. So I went to a cosmetic dentist here in Lexington who gave me a combination of porcelain crowns and porcelain veneers.

I love my new smile. After the restoration however, my #9 front fractured tooth began giving me trouble. It was tap and pressure sensitive, so I went back to my cosmetic dentist and she told me I need to get an implant and another restoration. I had a gum pimple at the time and was referred to a periodontist.

root fracture on tooth in a smile makeover

The x-ray of Aaron’s front tooth.

I went on a course of antibiotics immediately (Amoxicillin 500 mg). I saw a periodontist last week and he confirmed that extraction of my newly restored tooth was needed. I requested my x-ray, showed it to my family dentist, and he doesn’t necessarily agree that extraction is warranted. He is contacting the West Virginia University, University of Kentucky, and University of Louisville dental schools to see if this tooth can be saved by periodontics or endodontics. I really do not want to lose #9, especially after a $1500 crown was placed, and not to mention IT IS MY FRONT TOOTH. Wish me luck. Please feel free to comment. I have attached the x-ray.

– Aaron from Kentucky

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Aaron,

I actually have a couple of problems with your smile makeover. Not with its appearance. You also sent a photograph of your smile and it looks great! But it leaves me wondering if your dentist took x-rays before doing this smile makeover or, if she did, if she fully comprehended what she saw or gave it proper weight.

Root fracture on tooth #9

Your tooth #9 doesn’t look good at all. I have a fair amount of expertise in x-ray diagnosis and taught x-ray technique at the University of Minnesota, and I’ll tell you what I see. Right in the middle of the root there is a horizontal radiolucent line that looks like an old fracture. This must date from back to your original accident. The root canal filling crosses this fracture line, so the dentist who did the root canal either didn’t see the fracture or figured he or she could navigate through it, remove all the necrotic soft tissue, and hopefully get healing. And it looks like this happened to some extent, at least. The end of the root looks healthy. But just above the fracture line, the tooth looks moth-eaten. It appears that some of the root canal filling material is gone. If the pimple on your gum traces to that area, that spells trouble. And my guess is that it does. The moth-eaten appearance suggests that there is infection eating away at the root of your tooth. If this is the case, the tooth is unrestorable.

Does tooth#8 need root canal re-treatment?

If this weren’t enough, the other front tooth is suspicious. If I had done this case, I would have addressed the problem with #9 before starting, but I would have also recommended re-doing the root canal treatment on #8, because the root canal filling stops several millimeters short of the end of the tooth. Now that the crown is on that tooth, I wouldn’t do anything more than wait to see if it flares up. There aren’t any signs on the x-ray of any infection here, just evidence of a situation in which infection could develop.

So yes, I think you’re going to lose tooth #9. From everything I can tell, your dentist is an excellent cosmetic dentist, so I would have her stay with this case and finish it. But I think she missed the diagnosis here and should make concessions on the fee to get this fixed right. If I had made this mistake, I would ask you to pay for the extraction and the implant but then not charge you anything for the implant crown. That would make it so the total fee you pay would be equal to what you would have paid had the tooth been extracted in the first place and an implant placed, which is what should have been done.

– Dr. Hall

Do you have a comment? We’d love to hear from you. Enter your comment below.

Click here to ask Dr. Hall a question of your own.

About David A. Hall

Dr. David A. Hall was one of the first 40 accredited cosmetic dentists in the world. He practiced cosmetic dentistry in Iowa, and in 1990 earned his accreditation with the American Academy of Cosmetic Dentistry. He is now president of Infinity Dental Web, a company in Mesa, Arizona that does advanced internet marketing for dentists.

This dentist isn’t handling this infection correctly.

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Hi Dr. Hall,
So I had my root canal done a few years ago (3 or so) and just started hurting hard a week and a half ago. I saw a dentist on Tuesday last week, who saw infection on an x-ray and did root canal re-treatment and sent me home with Penicillin 500mg and Vicodin. Pain wasn’t going away after these meds so I was using 400mg ibuprofen too to get a minor relief until Saturday when I did get an hour or two no pain but everything still highly sensitive. And pain keeps coming back hard! Sleepless nights all this time!

Sunday to Tuesday it kept hurting. I feel pressure in my jaw and my tooth is kinda hurting, numb pain, constant feeling that I am trying to ignore most of the day. Not to mention headaches during the whole week and also earache Saturday thru Monday!

I saw the same dentist again to consult, and he said that some people have a longer recovery and since pain is less – it is going to be better. And if still hurts after two weeks, we can do another dose of antibiotics. I am still up at night (it’s the 9th night since he did re-treatment!!!) and taking 400mg ibuprofen and waiting for pain to stop!

I want to know is it really that my course of recovery is so long or is something else? Thanks much!!!
– Kate from New York

Kate,
I think you should see a root canal specialist. This infection should be resolving by now if the penicillin were working. I have a couple of points for you.

When you have a root canal that fails, generally a root canal re-treatment will be successful somewhere between half the time and three quarters of the time. So there is a reasonable chance that this root canal re-treatment won’t be successful.

Also, penicillin would not generally be the first choice of antibiotic for a root canal infection, especially for a situation of root canal failure, so I question your dentist’s judgment on that. And I question his judgment further if he hasn’t offered to change the antibiotic when this has been going on for a week. Penicillin resistance of infections is very common. He should have switched you to clindamycin or another strong antibiotic when you had gone a few days and weren’t seeing any significant improvement.

Also, if I am understanding what you are saying, the pain did get better but then got worse again. That’s a particularly bad sign. Clearly this isn’t working.

Ask him for a referral to a root canal specialist (endodontist), and if you get any delays, find one on your own.
– Dr. Hall

Response from Kate:
Thanks so much! I didn’t have anyone to tell me that this is not normal or that meds he gave don’t work. I really knew that something is wrong and all he said was to wait for 14 days! horrible.

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About David A. Hall

Dr. David A. Hall was one of the first 40 accredited cosmetic dentists in the world. He practiced cosmetic dentistry in Iowa, and in 1990 earned his accreditation with the American Academy of Cosmetic Dentistry. He is now president of Infinity Dental Web, a company in Mesa, Arizona that does advanced internet marketing for dentists.

Root canal tooth is infected, and I’m pregnant.

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Hello Dr. Hall,
I am 26 weeks pregnant, and I recently had a digital xray, as tooth #15 (upper left second molar) was getting sensitive. This is a tooth that had a root canal treatment before, and it also has a pile in it. The dentist said that there was an infection under the roots, and he gave me 3 options: 1. retreat the root canal 2. apicoectomy 3. extract the tooth and do an implant. I am still hesitating between 1 or 1-2 together, just to be on the safe side . He said that usually 60-70 % of the redone root canal treatments are successful, but in my case as I am pregnant what if not. As I will be soon getting in my third trimester it will be more difficult to operate. I am also worried because of the lidocaine injection, and what it might do to the baby. I know it is usually safe, category B drug, but still. My question is: 1. Does apicoectomy need more lidocain than retreating the root canal? Is the dosage bigger? 2. How fast would my dentist know if the just rootcanal would be successful? Would I feel pain in week or two if it was not successful, or not because there are no nerves in the tooth. He said he won’t know it in a year. That seems long to me, I am just talking to the redoing of the rootcanal treatment and not the apico. 3. Can apico be redone on the same tooth if it is needed? Basically if root canal would have solved the problem, having a done apico can shorten the life of a tooth if just simply cleaning up the canal would have done the trick? 4. I am also worried something may go wrong during the procedure and then I’d be in pain after and need to take drugs. Right now I am not in pain, although sometimes my tooth is sensitive. It hasn’t been lately, but I know there is no guarantee to when the infection advances and then I feel it. Thanks for your answer. Both my dentist and endodontist are basically new for me, and I wanted to have another professional opinion. I know it is not easy to answer not having the x-ray there. I appreciate it.

Best regards,
Anna from British Columbia

Anna,
I would have the root canal treatment re-done and nothing more at this time. But I would have it done by a root canal specialist (endodontist). Specialists would be likely to have the special tools and experience that will make this treatment more predictable.

As far as the local anesthetic is concerned, you should need very little or maybe even none, because the tissue inside the tooth is dead and they will be working completely inside the tooth. Root canal surgery would require a regular dose of anesthetic. Ask the dentist to use only the minimum anesthetic required. Yes, Lidocaine is one of the few drugs that has been proven safe during pregnancy, but still, there is no need to overdo it. And another point about your pregnancy, from what you are telling me I imagine that the infection is a minor one, but it would still be better to be rid of it.

The endodontist should be able to tell right away if the treatment went well. While it is true that re-treatment is unsuccessful somewhere between 25% and 50% of the time, when it isn’t successful, it is usually because there was a difficult problem during the treatment – such as a blocked canal, a ledged canal, curves that were difficult to negotiate, or some other cause. And the endodontist will know if there were any of these difficulties. If no problems like this arose, and the endodontist feels that he or she was able to instrument the root to the very tip and got a good apical seal, the results should be fairly predictable. On the other hand, if the treatment didn’t go well, you could then make the decision to go ahead with the apical surgery (apicoectomy).

Congratulations, by the way, on your pregnancy, and good luck with your tooth.
– Dr. Hall

Read more about root canal failure.

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About David A. Hall

Dr. David A. Hall was one of the first 40 accredited cosmetic dentists in the world. He practiced cosmetic dentistry in Iowa, and in 1990 earned his accreditation with the American Academy of Cosmetic Dentistry. He is now president of Infinity Dental Web, a company in Mesa, Arizona that does advanced internet marketing for dentists.

A broken file in a root canal tooth

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Dr. Hall,
My dentist performed a root canal today and informed me that a tip of one of the metal instruments broke off in the canal. (I actually heard it and thought my tooth had broke!) He informed me that he was not going to try to fish it out. Since it was ‘sterile’ he was just going to leave it in the canal and put the post and cap on.

Is this what he should be doing? Or will it hurt me in the long run? This doctor has become notorious for not taking a lot of time with patients and overcharging, so I am nervous.

Thanks in advance for your help.
– Connie in New Jersey

Connie,
These metal files can break off easily, and that happens to a lot of dentists. And while it is best to retrieve the broken piece, that can be difficult to accomplish and can be beyond the ability of many general dentists. If your dentist can negotiate around the broken piece and seal the apex of the tooth, the root canal treatment will probably be successful. If the broken piece blocks access to the apex of the tooth, the root canal treatment could still be successful but the chances for success are greatly diminished.

If the tooth has problems later, it could end up needing re-treatment for the root canal. Cementing a post in the tooth could possibly make re-treatment impossible, depending on how many roots this tooth has. If the dental post is to be in the same canal as the broken instrument, I’d advise you not to let him put the post in the tooth.

The safest thing would be to ask to be referred to an endodontist (root canal specialist), who should have special equipment to be able to retrieve the broken instrument and fill the root canal. Depending on your relationship with the dentist and your personality, you may or may not want to do this. However, if the post is needed to help hold the crown on and if it is in the same canal as the broken root canal file and that broken file blocks the canal, I would insist on seeing an endodontist. If your dentist doesn’t refer you to one, you can seek one on your own. Otherwise the risk of losing this tooth would be too great, in my opinion. Meanwhile you could wear a temporary crown on this tooth or a temporary filling.
– Dr. Hall

Related information:
Failed root canal treatment
Root canal surgery
Dead tooth

We thank our advertisers who help fund this site.

About David A. Hall

Dr. David A. Hall was one of the first 40 accredited cosmetic dentists in the world. He practiced cosmetic dentistry in Iowa, and in 1990 earned his accreditation with the American Academy of Cosmetic Dentistry. He is now president of Infinity Dental Web, a company in Mesa, Arizona that does advanced internet marketing for dentists.

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