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Actually taking dental treatment may be the last option for some people. They only go to the dentist when they are backed into a corner and no other option is available. So when is it that root canal treatment cannot be further avoided?

A lot of people delay dental treatment till the very last minute possible and this ends up being to their detriment. As a general rule of thumb, any medical or dental treatment taken earlier in the disease’s progression will be less time consuming, less expensive, less invasive and, more successful [1].

In the case of root canal treatment, the most common reason for requiring root canal treatment is due to tooth decay [2]. It usually begins as a small cavity which can be taken care of with a filing and then slowly progresses further. There are quite a few occasions when the dentist has to try and take a call whether a deep filling may still be possible or whether starting root canal treatment is the only option [3].

Let us see the signs, symptoms, and clinical situations where avoiding root canal treatment is no longer an option.

When is root canal treatment absolutely unavoidable?


There is no bigger motivator than pain to finally seek dental treatment. There are several qualities of pain that help indicate what stage of progression tooth decay has taken. If the pain is severe and sustained in nature for a prolonged period of time then it could indicate irritation of the nerves inside the tooth.

Typically, in a tooth needing root canal treatment, the pain can be referred to different parts of the face. An upper tooth could cause a headache, pain near the eyes, in the cheeks, while a lower tooth could cause ear pain, headache, or discomfort in the neck [4].

Referred pain to unaffected parts of the head and neck is one of the strongest indicators that the tooth requires root canal treatment and just a filling will not be sufficient anymore.

Pain that arises in the tooth at night during sleeping without any other stimulus is also a very good indicator that tooth decay has reached the nerve of the tooth. When we lie down, the blood flow to the head and neck can increase and actually increase the sensation of pain [5].

Dead Tooth

A painful tooth is tangible enough to understand but a tooth that is not painful but requiring root canal treatment is rather more difficult to wrap your head around.

A lot of times, teeth inside our mouth can die. When we say die, we mean that their blood supply has been compromised and their nerves have stopped responding [6]. The tooth will not be painful but it could very well be infected.

Some of the things that help a dentist determine whether a tooth is dead or not include x-rays, pus formation, change in color, and response to temperature vitality tests [7].

If a tooth or teeth are determined to be dead then the only way to disinfect them and protect them from falling out over a period of time is with a properly performed root canal treatment procedure.

Cracked tooth

Sometimes, a tooth may be perfectly healthy and non-infected but it could develop a crack. The most common reasons for developing a crack include falls, sports injuries, automobile accidents or biting on something hard [8].

There can be different classifications of cracks depending upon their depth but if the crack is near the nerve of the tooth, then the only way to save the tooth is by performing a root canal procedure [9].

Some symptoms that can be seen in a cracked tooth include pain, tenderness, difficulty in applying pressure to the tooth, or actually fracturing a part of the tooth. Characteristically, a cracked tooth may be more painful while relieving pressure on the tooth rather than while applying on it.

Cracks can also be quite difficult to detect radiographically and may require a CBCT to confirm [10].

The aim of the treatment here is to perform the root canal treatment to relieve the pain and to protect the tooth with a crown to increase its longevity.

Medically compromised patients

There are some patients in which extraction of a tooth may not be an option at all. Patients who are undergoing chemotherapy or radiotherapy are asked to avoid extractions at all costs. The blood supply to the teeth is severely compromised in such cases and an extraction wound could be left gaping non-healing for a long time. Such a condition is called osteoradionecrosis [11] and can even be life-threatening.

For such patients, root canal treatment is the only choice if tooth decay has reached the nerves at the center of the tooth. There is literally no other alternative.


Generally speaking, it is pretty clear when you need to get a root canal done. In some cases where tooth decay is very close to the nerve and the clinical symptoms are not too severe, the dentist can try to fill the tooth rather than performing root canal treatment.

In most cases, the only way to avoid root canal treatment is by getting the tooth extracted and that is not something that is advisable.   

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