Root Canal Treatment

Normal tooth cut in half

A Root Canal Treatment (RCT, Root canal therapy, Endodontic treatment) is a dental treatment for saving the tooth from being extracted. The tooth is decayed deep into a pulp chamber causing the nerve to expose to an oral cavity and infection process begins inside the root canals and drains at the root apex.

Root canal treatment helps remove infected or diseased pulp (blood vessels, nerves, and connective tissue) from the pulp chamber and the root canals inside a tooth. Failure to treat an infected or diseased pulp has several potential consequences such as acute and chronic dental infection that ultimately lead to the loss of the tooth.  After root canal treatment, the tooth becomes weaker, and a dental crown (cap) is required to protect the crown portion of the tooth from breaking.

Some dentists may determine to do root canal treatment when the decay is very deep and close to the pulp even if the tooth is vital and no indication of infection. This decision is made based on the risk of exposing the dental pulp that the dentist may encounter while excavating of the decay.  As a patient, you may want to know if there is any other way to avoid taking the risk of exposing the pulp and having the root canal treatment in a vital tooth. 

According to the California Dental Association Journal published in January 2016, the use of Silver Diamine Fluoride (SDF) has been found to arrest and prevent dental caries.  Therfore; if the dentist apply SDF at the deepest part of the decay without removing all the decay, the silver kills the bacteria and stop the decay, while fluoride hardens what is left through remineralization.  SDF has been approved by the U.S. Food and Drug Administration in 2014. Consult with your dentist if this application can be applied to you.

Root canal treatment includes:

• Remove decayed materials and re-shaped each canal
• Fill the canals with root canal fillers (gutta-percha) and root canal cement. 

Terminology

Enamel - the white outermost of tooth structure
Dentin -  The second layer next to enamel, consist of small tubules
Pulp chamber - The inside of the tooth crown where blood vessels and nerves innervated, it provides nourishment and sensory to the tooth
Ligament - the tissue that support tooth structure to a bone
Root apex - The end of the root where nerve and blood supply entrance

When decay penetrates a pulp chamber, the infection spreads inside the tooth (pulp chamber and root canals), and form an abscess at the root tip.  Without root canal treatment; the abscess enlarges, more bone is destroyed at the root tip area, accompanied by severe pain, and swelling of the gums adjacent to the abscess.  A root canal treatment will bring relief to the infected tooth.

"Endodontist" is a specialist who performed a root canal treatment. Root canal treated tooth is brittle.  To protect the tooth from future fracturing, the dentist places a crown on the tooth. In children, before age 18, a temporary crown such as stainless steel crown is recommended.  Additional pins and post may be needed to strengthen the restoration.

Locate an Endodontist:
U.S from American Association of Endodontists,  
The United Kingdom go to British Endodontic Society 

Side effect of root canal therapy

1. Paresthesia related to root canal treatment (burning, aching, tingling, numbness and itching on the face) caused by nerve injury. The most common nerve affected by root canal treatment is the inferior alveolar nerve.  The inferior alveolar nerve runs inside mandibular canal in the lower jaw, close to the root tips of lower teeth; allowing the mechanical or pathological origin to affect the nerve.

Causes of paresthesia related to root canal therapy

• One or more of root canal procedure extends beyond root apex (apical foramen, root tip) and irritate the nerve. For example; excessive preparation of the root beyond the apex, extreme pressure during irrigation, and  extrusion of root canal filling (gutta-percha) and root canal sealer
• Accumulated purulent exudation around a root tip, creating pressure to the nerve
• Injection to the nerve during local anesthesia, causing injury to the nerve
• Injection of a contaminated anesthetic agent such as alcohol.

Note: other factors that may cause paresthesia are:

• Systemic factors: Leukemia, Multiple Sclerosis, Lymphoma, and viral infection.
• Local factors in dentistry (not related to root canal treatment) such as fractured jaw bone, cyst, benign or malignant tumor, impacted tooth, local infection from implants, anesthetic injection, orthodontic surgery

An accurate patient history, oral exam, radiography (periapical, panoramic, computed tomography scan), and the variety of tests are required to determine the cause and evolution of paresthesia.  Paresthesia may last for months or years.

Treatment of paresthesia 

1. Infection-related, paresthesia subsides after removal of the cause through root canal treatment
2. Injured by needle, paresthesia resolves itself after approximately eight weeks
3. Surgery improves long-term paresthesia

Prolong contact to an overfilled root canal filling and sealer, nerve fiber laceration from the needle, and prolonged pressure on the nerve may cause long-term or sometimes permanent paresthesia due to nerve fiber degeneration.

2. Pain due to recurring infection and swelling; resolves by re-do root canal treatment or sometimes extraction.

3. Tooth discoloration; resolves by placing a crown or internal bleaching (usually done on a single tooth)

Before and after tooth bleaching

4. Tooth and root fracture

5. Affect tooth growth in children

Why some patients experience pain or discomfort after root canal treatment?

During a root canal treatment, the dentist removes the nerve and blood supply from the pulp chamber inside the tooth; therefore the tooth itself doesn't have any sensation. But the sensation comes from the outside of the root, some of the tissues and nerves at the root tip may have been inflamed or infected during the procedure. This inflammation can make the tooth become discomfort or even painful after the root canal treatment.


Some other causes of pain are:

• Irritation caused by overflow of root canal filler to outside of the root canal
• Incomplete of root canal treatment
• Cracked tooth due to large opening inside the canal weakens the structure of the tooth
• The filling over the post is too high

Root Canal Treatment Procedure (see illustration below):

1. Instrumentation stage; the dentist uses different file sizes to remove all decayed materials, nerves, and other infected materials from the tooth and the root canals and re-shape the canals to specification


2. Irrigation; the dentist uses 0.5-6% hypochlorite (NaOCl) as an endodontic irrigation to clean and remove debris from the canals.  Hypochlorite helps killing bacteria and dissolve necrotic organic tissue inside the root.


3. Drying; the dentist dries the root canal with paper points.


4. Filling; the dentist fills the canal with gutta-percha and root canal sealer and fills the pulp chamber with temporary filling


5. The dentist waits until there is no infection before placing post-core and crown over the treated root canal tooth to strengthen the tooth.

Without root canal treatment; certain bacteria harbor in the infected root tips can travel to other parts of the body including the heart valve. The infection at the root tip builds up pressure that can push the tooth out of its socket causing bite disharmony, toothache.

Without root canal treatment, the remaining abscess inside a jaw bone may constantly feed live and dead bacteria and its toxin into the bloodstream. Taking herbs, vitamins, or even antibiotics prescription may temporarily solve the problem. The correct treatment is to perform root canal therapy or a dental extraction to remove the bacteria-harboring place.

The illustration of root canal treatment

1. Position rubber dam over the tooth and stabilize with rubber dam clamps to prevent contamination from saliva and keep the area clean during the treatment.

2. Remove blood vessels, infected tissue and decayed material inside crown.

4. Clean and shape the root canal walls with different size of files

5. Dry the canals with paper points.

6. Fill the canals with gutta-percha: a root canal filler. The gutta-percha seals the canals, prevents bacteria and fluid to enter the root canals.

7. Clean the excess gutta-percha inside pulp chamber(crown), prepare the root for the dental post to strengthen the tooth structure if needed.

8. Place the filling material over the post to re-build the crown, re-shape the filling, remove excess material, and check for a high spot.

9. Take X-ray to confirm the root canals were treated properly.

Place the permanent crown on the root canal treated tooth within one year or sooner to prevent the tooth from breaking.

Apicoectomy

In some chronic infection teeth; abscess forms at the root tip that cannot be removed or drain through the crown of the tooth or an infection develops or persists after root canal treatment. The dentist will do a surgical procedure called apicoectomy.  The procedure includes; making a small incision at the gums adjacent to the root tip, remove infected tissue and the tip of the root.  The area is cleaned and sealed with a root- end filling.

Root Amputation

In a multi-rooted tooth, even after a root canal therapy, one or more of the roots become infected or have severe bone loss around the root.  The dentist may surgically remove the infected root (amputate), leaving the serviceable root intact.

Pregnancy and Dental Health

Dental Health During Pregnancy
 

Does a woman lose calcium from her teeth during pregnancy?

Many people believe while being pregnant the calcium baby requires developing healthy teeth obtains from mother's teeth. In fact, the calcium in mother's teeth is not affected. However, the calcium she takes in does have an excellent impact on the development of the newborn teeth. The mother should eat dairy products as part of a proper pregnancy diet and take dietary supplements as guided by the obstetrician.

Mother's dental health and her overall oral health have a great impact on her baby.  If the mother neglects her dental health and develops dental decay or gingival problem, not only she will not be able to eat nutritious foods, she will transmit harmful bacteria to her baby. So keep in mind that a healthy pregnancy will create a healthy child.

It is critical to consult the obstetrician before considering any dietary supplements. If the mother's dietary calcium is not sufficient, your bone will provide calcium to your body or the baby. Most of the time the obstetrician will recommend supplements to help ensure adequate calcium your body need.

Will X-ray (radiation) harm pregnant women?

In some emergency dental cases, x-ray exposure to a pregnant woman is required. The dentist has to consider the risk of a pregnant woman to wait until the baby is born without any dental treatment and the threat of spreading infection from her teeth or gums to her baby. In some cases, dental care might be essential to preserving the well-being of the mother and child.

Even though radiation level from dental x-ray procedure is weak, every x-ray radiation safety precaution should be implemented to reduce the radiation exposure. A leaded apron a leaded thyroid collar can safeguard the baby and the thyroid gland from the radiation exposure. Dental x-rays are not contraindicated if you are breast-feeding.

Pregnancy and Gum Disease

One of the pregnancy symptoms is during the second to eighth month of pregnancy, your body's hormone progesterone level changes considerably.

The increased level of the hormone causes gum tissue to be more sensitive to plaque deposit on the tooth at the gum line. Results in gum disease as in gingivitis. Without proper treatment for gingivitis, the condition becomes a periodontal disease. Periodontal disease causes swollen, tender red gums and bone loss in severe cases.

Pregnancy tumors

Pregnancy tumors are the overgrowth of gum tissue develop between the tooth in some pregnant women during the 2nd trimester. Pregnancy tumors are not cancerous. The cause of Pregnancy tumors believed to be a severe inflammation reaction to food and plaque accumulation at the gum line. Pregnancy tumors bleed easily, and their appearance resemble red mulberry surface.

Sometimes “Pregnancy tumors” disappear on their own after the baby is born or can be surgically removed by the dentist if they did not disappear.

There is one more reason to maintain excellent oral health while being pregnant.  Research finds that most women with severe gum disease are prone to deliver premature babies.

Baby's teeth during pregnancy

The baby's teeth are developing during the period of twelve to twenty-four weeks of pregnancy.  During pregnancy, the variety of vitamins, nutrients and supplement from the mother will reflect on the well-being of the baby's teeth formation.  It is important that pregnancy woman's diet and supplements are monitored carefully by the obstetrician.

Proper care of Tooth While being pregnant

In the 2nd trimester, a pregnant woman should see a dentist. When visiting the dental office, let the dentist know you're pregnant and how far into the pregnancy you presently are. It helps the dentist assess conditions that commonly show up in an oral cavity while being pregnant and a precaution not to perform an x-ray unless it is necessary.

Home care of pregnant woman's teeth is essential. Flossing 2-3 times a day, brushing at least 2-3 times a day with fluoride toothpaste, rinse with non-alcohol mouthwash are recommended

Studies have shown that pregnant women with several decayed teeth and advanced periodontal disease may cause the babies to be born underweight or prematurely. Cigarette smoking while being pregnant is a health risk by itself, but most women frequently don't know the effects of smoking to the tooth and the baby. The tooth enamel is softer in those that smoke.

Is there a link concerning diet and dental health of the infant while being pregnant?

It may be necessary to eat a vibrant food through your day-to-day life.  It is vital to supply the proper amount of the standard prenatal multivitamin nutritional supplements to nurture both you and your baby when in pregnancy state.

Your baby's tooth begins to grow between 3rd and 6th month of being pregnant. It's important that you consume a sufficient amount of nourishment for the baby to develop strong and healthy teeth.

Some dietary necessary for pregnancy woman:
1) Folate or folic acid is needed to support the improving mother's blood quantity as well as lessen the risk of baby Neural Tube Defects (NTD). During pregnancy, diet plan on its own won't be possible to offer adequate folate. Women need to start a regular folate dietary supplement of 0.4 mg in 3 months prior to conceiving.  Continue this dose through the entire first 3 months of the pregnant state.

2) Iron is essential in retaining an adequate level of blood circulation for the developing baby, as well as the placenta. Through the 2nd and 3rd trimesters, A pregnant woman should take 30mg of iron supplement. Also, eat iron-rich meals that contain

• Heme iron, e.g.,cooked mussels, clams, beef, shrimps, turkey
• Non-heme iron, e.g., cooked beans, lentils, potato with skin, asparagus, pumpkin seeds, and iron-fortified cereal products

3) Eat meals that improve absorption of iron and stay away from foods that conflict with iron assimilation.

Foods that enhance iron assimilation are meat, fish poultry, orange, cantaloupe, strawberries, grapefruit, broccoli, Brussels sprouts, tomato, green and red pepper.

Foods that conflict with iron assimilation are red wine, coffee, tea, spinach, chard, rhubarb, sweet potato, whole grain, bran and soy products.

4) Calcium, phosphorous, vitamin A, C, and D are essential during pregnancy. Consult your personal obstetrician for proper dosage.

Antibiotic Prophylaxis

What is Antibiotic Prophylaxis?

Before certain kinds of dental care, some patients that have heart problems and people with artificial joints take antibiotics. These individuals might be at risk of developing an infection in the heart or at the site of the artificial joint, respectively. Antibiotic prophylaxis may decrease the risk of an infection involving these organs.

Guidelines for People with Heart Conditions

Guidance changed - the AHA concluded that:

The potential risks of side effects to antibiotics outweigh the use of prophylaxis for many people. Side effects can vary from mild (rashes) to serious (difficulty in breathing that can lead to death).

When viewed all of the research results collectively, it was not obvious that antibiotic prophylaxis prevented infective endocarditis.

Bacteria in the oral cavity can enter the blood stream through daily activities like brushing or flossing between the tooth. As soon as bacteria enter the blood flow, it may go to one's heart. Individuals prone to an infection may be much more likely to develop infective endocarditis from routine activities than from dental care.

If physicians used antibiotics too frequently, microorganisms that cause infections may become resistance against antibiotics. For this reason, it is best to try to restrict using antibiotics.

Patient selection
The current guidelines recommend the use of preventive antibiotics before certain dental procedures for people with:

1. Artificial heart valves
2. History of infective endocarditis
3. Cardiac transplant that develops a heart valve problem
4. The following congenital (present from birth) heart conditions:

• Cyanotic congenital heart disease, including those with palliative shunts and conduit
• A completely repaired congenital heart defect with prosthetic material or device, whether placed by surgery or catheter intervention, during the first six months after the procedure.
• Any repaired congenital heart defect with residual defect at the site or adjacent to the location of a prosthetic patch or a prosthetic device.

Consult with your cardiologist if you are uncertain whether you fall under one of these groups. Individuals who required prophylactic antibiotics previously but will no longer need to have them now are individuals with:

1. Mitral valve prolapse
2. Rheumatic heart disease
3. Bicuspid valve disease
4. Calcified aortic stenosis
5. Congenital (present at birth) heart conditions such as ventricular septal defect, atrial septal defect, and hypertrophic cardiomyopathy.

Discuss with your dentist regarding how these recommendations may apply to you.

Additional resources:

American Heart Association downloadable wallet card (available in English and Spanish)

For the Dental Patient: Antibiotics and Your Heart 

Guidelines for People with Total Joint Replacements

Recommendations from the American Academy of Orthopedic Surgeons (AAOS) are intended to lower the potential risk of bacterial infections at the site of an artificial joint. They apply to those who have complete joint replacements. Patients that have pins, plates or other orthopedic hardware are not affected.  AAOS recommends that all patients who have total joint replacements should take antibiotics before certain kinds of dental care treatments.

Consult your dentist about how these recommendations may apply to you.

Regimens recommended:

Reference: JADA, vol.138, June 2007

Dental Restorations

The filling is a replacement of the hole (cavity) in the tooth structure after tooth decayed.  The dentist uses a special drill to remove all decay before filling the cavity with a different type of filling materials.  In a deep cavity, the dentist may place base material to protect the nerve. It is imperative to polish the fillings after completing the restorations to prolong the life of the fillings.  While the dentist can immediately polish the composite fillings, amalgam fillings require 24 hours before polishing.

Types of tooth restoration:

1. Pit and fissure sealants

A sealant is a plastic film used to seal pit and fissure on the posterior teeth to prevent and arrest dental caries or as a restoration in early stage of tooth decay.  The material has a low level of bisphenol (BPA), the amount that will not cause any health concern According to the American Dental Association (ADA).

2. Amalgam Filling

What is Amalgam filling? Amalgam fillings (silver fillings) have been the restorative of choice due to the affordable, simple application, durability, longevity, and bacteriostatic results for more than 150 years. Issues that may have triggered a current decrease in popularity can be ongoing concern about harmful health effects, appearance, and polluting the environment about mercury emissions in the course of preparation.

Advantages of using amalgam fillings:

1. Amalgam is sufficient for repairing molars at the back of the oral cavity where a chewing load is the greatest.
2. Amalgam is long lasting; extremely resistance against wear and it has higher durability in comparison with many other materials.
3. Amalgam is fairly low-cost compared to other substances.
4. Amalgam is simple to use with less application time compares to other materials
5. Bacteriostatic property of mercury in amalgam assists in slowing down the development of decay beneath the fillings.

Disadvantages of using amalgam fillings:

1. Dental amalgam is a combination alloy made of  50% mercury by weight, silver, tin, copper and some other metallic elements. Although dentists still use amalgam restorative material, queries have arisen concerning the safety associated with its mercury vapor continuously evolves from dental amalgam fillings. Department of Environmental Medicine at Slovak Medical University did a study related to mercury in a pregnant woman.  The study showed that if a pregnant woman exposed to the mercury, the fetus could be exposed to the mercury as well, resulted in possible subsequent neurodevelopmental disability in an infant.

Mercury gas can vaporize in the air resulted in the accumulation of mercury through inhaling. In 2009, the Food and Drug Administration (FDA) released a final regulation classifying dental amalgam from class 1(low risk) to class 2 (moderate risk).
.

2. Due to its hot and cold conductivity, amalgam fillings occasionally may cause short-term sensitivity to hot or cold foods and drinks.

3. The contrast in color between amalgam fillings and tooth makes it undesirable.

4.The dentist needs to take out more tooth
structure during cavity preparation for amalgam filling than other types of fillings.

5. Amalgam fillings can cause galvanic shock.  Galvanic shock is an electrical current that can be felt when contact with different alloys such as a gold crown, stainless steel crown, stainless steel or silver utensils in the person's mouth. (Dissimilar metals in a conductive fluid create an electric current).

6. Amalgam filling by itself cannot withstand the stress when used in large cavity or cavity that involves cusps.

3. Composite Filling

There are two placement methods of composite filling:

Direct placement composite:  the dentist place dental composite directly onto the cavity that has been clear of decay in the dental office with the aid of curing light to harden the material in the patient's mouth. Dentists often use direct composite for:

• Closing gaps between two or more teeth
• Restoring chipped tooth 
• Re-construct front teeth for aesthetic reason
• Filling small cavities 
• Sealing deep grooves and fissures to prevent the tooth from getting cavities in the future.

Indirect dental composite: the restorations are stronger and more durable than direct dental composite restorations.  The dentist fabricates restoration outside the patient's mouth before placing inside the prepared tooth. The dentists use indirect composite restorations for:

• Onlays
• Inlays and 
• Veneers

Advantages of using composite fillings:

1. Improved aesthetics due to a broad range of tooth color composites, allowing less contrast between the filling and the tooth.
2. Requires conservative cavity preparation and preserve more of tooth structure
3. Allow minor changes such as gaps, re-contour on front teeth for cosmetic purpose instantly in direct placement composite filling.

Disadvantages of using composite fillings:

1. Some composite fillings shrink after placement create a marginal cavity
2. Composite filling requires more placement time, thus more costly than amalgam
3. The color stability of composite filling can vary significantly based on personal habits People who smoke, drink coffee or tea, have their color alter quicker than non-smokers
4. Indirect composites filling require several dental office visits to complete
5. Composite fillings are not as strong as porcelain or other metal restorations.
6. Patients may experience some sensitivity after having the composite filling

4. All-Porcelain (Ceramic) Dental Materials

The advantage of using ceramic:

All-porcelain (ceramic) restorations are particularly appealing as their color and translucency is much better mimic natural tooth color than other fillings. Dentists prefer to use all-porcelain in veneer, inlay, onlay and crown restorations. The recent development of Zirconia,  a strong non-metal framework for porcelain, makes it possible to have a bridge made of porcelain.  With appropriate preparation can lead to much better esthetic and far better resistance against wear than composite filling.

Disadvantages of using ceramic:

All-porcelain restorations except Cerec involve at least two appointments and perhaps more to accomplish.

Since the porcelain restorations are susceptible to crack when put under stress, they demand tedious work and high skill to generate a long lasting porcelain filling. If rough spots remain on porcelain, the retained rough area can easily wear off opposing natural teeth or fillings.  Therefore; it is imperative to polish the porcelain after grinding.

5. Dental veneer(also known as porcelain veneer or porcelain laminate)

Dental Veneer is a custom made of a very thin shell of porcelain to cover the tooth that is discolored, worn, chipped, or misaligned to improve the appearance.

6. Inlay

The Inlay is a customized filling, an alternative to amalgam.  The Inlay is a durable and stable material that can strengthen a damaged tooth.

7. Onlay

Onlay is a customized filling that covers the entire chewing surface including one or more tooth cusps. Onlay is a conservative alternative restoration to a crown.  It preserves more tooth structure than the crown.

The procedure for inlays and onlays are similar, typically finish in 2 visits.  The material used in inlays and onlays are porcelain, gold, or composite resin.

8. Crown (Cap)

Crown is a restoration that covers the entire tooth to the gum line. The purpose of the crown is to protect the tooth from breaking after root canal treatment, replacing large fillings that have extensive decay, and use as an abutment in bridges. The dentist removes more tooth structure in preparation of crown than another type of restorations.

Before treatment

After treatment - 4 Porcelain veneers

Materials used in Crown, Inlay, and Onlay are:

1) Porcelain-fused-to-Metal

Porcelain fused to metal is constructed with sub-layer of metal with porcelain baked on the surface for cosmetic purpose.  The metal base can be non-precious metals or precious metal.

Advantage:

The metal uses in porcelain-fused-to-metal provides strength to a crown or bridge makes this restoration more durable and cosmetically acceptable.

Disadvantage:

More tooth structure must be removed to accommodate the restoration. Porcelain restorations can wear opposing natural teeth if the porcelain becomes rough. There may be some initial discomfort to hot and cold. Some patients may show an allergic reaction to some metals used in the restoration. Sometimes the porcelain can chip off.

2. Gold Alloys

Gold alloys contain gold, copper, and other metals.  The dentists use gold alloys in inlays, onlays, crowns and fixed bridges.

Advantage: Gold alloys are strong, durable filling, highly resistant to corrosion and tarnishing. Less tooth structure is removed to accommodate the restoration. Gold alloys are also gentle to opposing teeth.

Disadvantage: The contrast in color between gold alloys and tooth make gold alloys undesirable. Due to gold alloys conductivity property, sometimes gold alloys filling can cause short-term sensitivity to hot or cold may occur.  Gold alloys fillings can cause galvanic shock; an electrical current that can be felt when contact with different alloys such as amalgam fillings, stainless steel crown,  stainless steel
or silver utensils in the person's mouth. 

3. Cerec

Cerec is an all ceramic dental restorations producing durable, high-quality restorations. Cerec restoration is processed utilizing 3D CAD software along with a milling device generates the restoration from a ceramic block. The ceramic material expands and contracts in response to alterations in temperature changes in the oral cavity. Cerec wears approximately the same as enamel. The dentist can use it for several different restorations such as inlays, onlays, crown, and veneers.

Advantages:

1. More durable than other types of restoration
2. Requires one trip to finish the restoration
3. Has numerous color of the tooth-shaded to select
4. Does not need a temporary crown or temporary fillings in the process
5.The ceramic material utilized expands and contracts as your natural teeth do; less chance to have sensitive teeth following the restoration.

Disadvantages:

1. Fee is higher than other types of restoration
2. Less aesthetic in porcelain veneer
3. Greater tooth reduction to achieve the required thickness

4. Zirconia (Zirconium Oxide)
Zirconia is a nonmetallic restoration with high tensile strength, with translucency that is a very close resemblance to the natural teeth.  The dentists use Zirconia in the crown, a bridge for anterior and posterior teeth. Since it is fairly new to the dental field, more research is needed for a longevity of this material as a dental restoration.

 Zirconia crown                            Porcelain fused to metal

Tooth Identification

First chart (Universal Numbering System)-Permanent tooth

Right = patient's right.  Left = patient's left

Universal Numbering System

The first chart is a universal numbering system adopted by the American Dental Association; the most widely used by general dentists.

In adult teeth, numbering of upper teeth begins at the wisdom tooth at the farthest upper right side (tooth #1) and ends at the wisdom tooth at the farthest upper left side (tooth #16)

In lower teeth, numbering continues from the upper, begins at lower left third molar (wisdom tooth) as number 17 and ends at tooth #32, lower right third molar (wisdom tooth).  See first chart above for easy understanding of the system.

Another method of identifying tooth is to refer to them according to their location in the oral cavity, each tooth is identified by name instead of number:

Note:
Maxillary = upper jaw
Mandibular = lower jaw 

Upper teeth

Upper anterior teeth include 6 teeth, #6 to #11
#6 refers to upper right cuspid (canine) or Maxillary right cuspid (canine)  
#7 refers to upper right lateral incisor or Maxillary right lateral incisor
#8 refers to upper right central incisor or Maxillary right central incisor
#9 refers to upper left central incisor or Maxillary left central incisor
#10 refers to upper left lateral incisor or Maxillary left lateral incisor
#11 refers to upper left cuspid (canine) or Maxillary left cuspid (canine)

Upper bicuspid (premolar) teeth include 4 teeth, #4, #5, #12, #13
#4 refers to upper right second bicuspid or Maxillary right second bicuspid
#5 refers to upper right first bicuspid or Maxillary right first bicuspid
#12 refers to upper left first bicuspid or Maxillary left first bicuspid
#13 refers to upper left second bicuspid or Maxillary left second bicuspid

 Upper molar teeth include 6 teeth, #1 to #3 and # 14 to #16
#1 refers to upper right third molar (wisdom tooth) or Maxillary right third molar

#2 refers to upper right second molar or Maxillary right second molar
#3 refers to upper right first molar or Maxillary right first molar
#14 refers to upper left first molar or Maxillary left first molar
#15 refers to upper left second molar or Maxillary left second molar
#16 refers to upper left third molar (wisdom tooth) or Maxillary left third molar

Lower teeth

Lower anterior teeth include 6 teeth, #22 to #27
#22 refers to lower left cuspid (canine) or Mandibular left cuspid (canine) 
#23 refers to lower left lateral incisor or Mandibular left lateral incisor
#24 refers to lower left central incisor or Mandibular left central incisor
#25 refers to lower right central incisor or Mandibular right central incisor
#26 refers to lower right lateral incisor or Mandibular right lateral incisor
#27 refers to lower right cuspid (canine) or Mandibular right cuspid (canine)

Lower Bicuspid (premolar) teeth include 4 teeth, #20, #21, #28, #29

#20 refers to lower left second bicuspid or Mandibular left second bicuspid
#21refers to lower left first bicuspid or Mandibular left first bicuspid
#28 refers to lower right first bicuspid or Mandibular right first bicuspid
#29 refers to lower right second bicuspid or Mandibular right second bicuspid

Lower molar teeth include 6 teeth, #17 to #19 and #30 to #32

#17 refers to lower left third molar(wisdom tooth) or Mandibular left third molar

#18 refers to lower left second molar or Mandibular left second molar 
#19 refers to lower left first molar or Mandibular left first molar
#30 refers to lower right first molar or Mandibular right first molar
#31 refers to lower right second molar or Mandibular right second molar
#32 refers to lower right third molar (wisdom tooth) or Mandibular right third molar

Universal Tooth Numbering according to the first chart

Second chart - FDI Two-digit Notation

This charting divides teeth into 4 quadrants with 8 teeth in each quadrant; using upper right and left central incisors and lower right and left central incisors as the dividers. 

• The first quadrant (1) begins at the upper right central incisor and continue toward wisdom tooth  (11-18)
• The second quadrant begins at the upper left central incisor and continue toward the wisdom tooth (21-28)
• The third quadrant begins at the lower left central incisor and continue toward the wisdom tooth (31-38)
• The fourth quadrant begins at the lower right central incisor and continue toward the wisdom tooth(41-48)