By Mark Malterud, DDS — Founding Member, Academy of Biomimetic Dentistry
In thirty years of practicing dentistry in Saint Paul, I have come to believe that the question “do I need a root canal?” is one of the most consequential questions a patient can ask — and one of the most poorly answered in modern dentistry.
The honest answer, in many cases, is: maybe, maybe not. It depends on how the tooth is diagnosed, what tools are available, and how the dentist thinks about preservation versus replacement. A tooth that one dentist sees as a root canal is, in another office, a candidate for a bonded biomimetic restoration that keeps the nerve alive. A tooth that one dentist would extract is, in another office, treatable with ozone therapy and a same-day repair.
This is not a fringe view. It is the working philosophy of minimally invasive dentistry — the field I have spent my career in, and the one I teach other dentists across the country and internationally.
If you have been told you need a root canal, or if you have a tooth that’s been bothering you and you’re not sure what to do, this guide is for you. I will walk you through when a root canal is genuinely necessary, when it can often be avoided, and what to ask before you sit in the chair.
First, an honest note: sometimes a root canal is the right answer
Before we talk about avoiding root canals, I want to say plainly: root canals exist for a reason, and they save teeth every day. We perform root canal services at our practice when they are warranted. A tooth with an irreversibly inflamed or necrotic pulp — meaning the nerve and blood vessels inside the tooth have died or are dying — cannot heal on its own. In that situation, the choice is between a well-performed root canal and an extraction. There is no third option.
So the question is never “are root canals always avoidable?” The question is, “in this particular tooth, on this particular day, is there still a path that preserves the nerve?”
In my experience, that path is available more often than the average patient is told.
Three categories of teeth that can often be saved
Not every painful tooth needs a root canal. Here are the three clinical situations where, with the right diagnosis and the right tools, the nerve can usually be preserved.
1. Deep cavities that haven’t yet reached the nerve
Traditional dental training treats deep decay almost like a switch: if the cavity is deep enough that the nerve is exposed or nearly exposed, the standard recommendation is a root canal to “protect” the tooth from future infection.
But modern research and biomimetic technique tell a different story. When decay is removed carefully — using slower, more selective tools like air abrasion or dental lasers instead of a high-speed drill — and when the remaining tooth is treated with ozone therapy and sealed with a bonded biomimetic restoration, the nerve often stays alive and healthy. This approach is called pulp capping or partial pulpotomy, and the success rate in carefully selected cases is well over 90%.
The key word is “carefully selected.” Not every deep cavity is a candidate. But many are, and many patients are never offered the option.
2. Cracked teeth caught early
A cracked tooth is one of the most common reasons a root canal gets recommended. The reasoning is reasonable on its face: a crack can let bacteria into the pulp, and if the crack is deep enough, the nerve is at risk.
But cracks live on a spectrum. A surface craze line is harmless. A vertical root fracture is unsalvageable. Most cracks fall somewhere in between — and the right move depends on exactly where the crack is and how deep it goes.
With 3D cone beam imaging and high-magnification visual exam, we can map a crack with much more precision than a traditional 2D X-ray allows. In many cases, a cracked tooth that would have been root-canaled a generation ago can be stabilized with a bonded onlay or full-coverage restoration that distributes chewing forces away from the crack and lets the nerve recover.
3. Teeth diagnosed as “questionable” on imaging alone
This is the category that frustrates me most as a clinician. Sometimes a routine X-ray shows a small dark area at the root tip — a possible apical lesion — and the recommendation is a preemptive root canal.
But not every shadow is a problem. Some are anatomical variations. Some are old, healed lesions that are not active. Some are early changes that may resolve with conservative treatment of the underlying cause, like a clenching habit or a leaky filling.
Tools like DEXIS CariVu cavity detection and 3D imaging let us evaluate these findings in much more detail than a flat X-ray. The result is fewer reactive root canals on teeth that did not need them.
“A tooth that one dentist sees as a root canal is, in another office, a candidate for a bonded biomimetic restoration that keeps the nerve alive.”
The minimally invasive techniques that make this possible
None of what I just described is theoretical. It is everyday clinical practice in offices that have invested in the diagnostic tools, materials, and training that minimally invasive dentistry requires. Here are the specific tools and techniques that change the equation.
Better diagnosis
You cannot avoid an unnecessary root canal if you do not know what is actually going on inside the tooth. We use:
- DEXIS CariVu — a transillumination device that catches cavities at the earliest stages, often years before they would show up on a traditional X-ray. Earlier detection means smaller treatment.
- Cone beam 3D imaging — full three-dimensional view of the tooth, root, jaw, and surrounding bone, which catches details that flat X-rays simply cannot show.
- High-magnification visual exam — every operative procedure is performed under magnification so we can see what we are working on at the cellular level.
- Pulp vitality testing — direct testing of whether the nerve is alive, dying, or dead, rather than guessing from imaging alone.
Gentler decay removal
How decay is removed matters enormously. A high-speed drill removes everything in its path — healthy and diseased tissue alike. The alternatives we use:
- Air abrasion — fine particles of an inert powder remove only the soft, decayed parts of the tooth. Healthy enamel is preserved.
- Dental lasers — a precisely tuned laser energy targets diseased tissue and bacteria, leaving healthy structure intact.
- Selective drilling — when a drill is the right tool, we use the smallest, slowest bur that will do the job.
Ozone therapy for disinfection
Ozone therapy is one of the most powerful tools we have for avoiding root canals. Ozone is a gas that kills bacteria, fungi, and viruses on contact, without harming healthy tissue. When applied to a deep cavity before placing a filling, ozone disinfects the dentin so completely that bacterial recolonization is dramatically reduced. Many of the deep cavities that would have flared up into root canal territory under a traditional filling never do under an ozone-treated, biomimetically restored tooth.
Biomimetic restorations
Biomimetic dentistry is the practice of restoring teeth with materials and techniques that mimic the natural strength, flexibility, and behavior of enamel and dentin. A biomimetic restoration is bonded directly to the tooth, distributes chewing forces the way a natural tooth does, and seals the underlying tooth structure against bacteria. This is the difference between “plugging a hole” and “rebuilding a tooth.”
Properly performed biomimetic dentistry can keep teeth alive that would have required root canals a generation ago. That is not marketing language; it is clinical reality, and it is taught at the postgraduate level by groups like the Academy of Biomimetic Dentistry, of which I am a founding member.
Have you been told you need a root canal?
We offer complimentary second-opinion consultations for patients considering root canals. We will give you our honest evaluation — including when we believe a root canal is the right answer.
What to ask if your dentist recommends a root canal
If you have been told you need a root canal, you are entitled to ask questions before you commit. Here are the ones I would want a patient to ask me — and the answers I would want to hear from any dentist.
1. “What is the specific diagnosis?”
Not “the tooth is bad.” The specific diagnosis. Reversible pulpitis? Irreversible pulpitis? Pulp necrosis? Apical periodontitis? Each of these has a different prognosis and different treatment options. A dentist who cannot give you a specific diagnostic name has not finished diagnosing the tooth.
2. “What did the pulp vitality test show?”
If your dentist has not tested whether the nerve is alive, that is a question worth pressing. A simple cold test or electric pulp test takes seconds and gives critical information. Many “recommended” root canals are recommended on imaging alone, without confirming whether the nerve is actually compromised.
3. “Have you considered pulp capping or a biomimetic restoration?”
This question signals that you know there are alternatives. The answer should be specific and clinical — not dismissive. If the answer is “that doesn’t work” or “we don’t do that here,” you are entitled to a second opinion from a dentist who does.
4. “What is the failure rate of the proposed root canal on this tooth?”
Root canals have widely varying success rates depending on the tooth, the operator, and the diagnosis. A first molar with a good prognosis is a very different procedure than a re-treatment on a previously root-canaled tooth. A dentist should be able to give you a realistic estimate.
5. “What happens if we wait and watch?”
Sometimes the answer is “the tooth gets worse.” Sometimes the answer is “if symptoms develop, we treat then.” The watch-and-monitor option is not always available, but when it is, you should know about it.
Why preserving tooth vitality matters
There is a broader reason to take this seriously. A vital tooth — one with a living nerve and blood supply — is more than just a chewing surface. It is connected to your immune system. It can sense temperature, pressure, and pain, which protects you from biting wrong and damaging the tooth further. It maintains its hydration and flexibility, which makes it less likely to fracture.
A root-canaled tooth, by contrast, is a beautifully preserved skeleton. It still functions, but it has lost most of its biological participation in your body. It is more brittle, more prone to fracture, and more dependent on the crown that protects it.
None of this means a root canal is the wrong choice when it is the right choice. It means that vital teeth are valuable, and worth fighting for when the fight is reasonable.
That is the heart of minimally invasive dentistry. We treat your teeth like the irreplaceable structures they are.
Frequently Asked Questions
How do I know if I really need a root canal?
The most reliable indicators are persistent pain that lingers after the stimulus is removed (especially heat sensitivity that lasts more than a few seconds), spontaneous pain that wakes you at night, or a tooth that has clearly died — gone gray and stopped responding to temperature. Imaging findings alone, without symptoms or vitality testing, often warrant a more conservative approach first.
Can ozone therapy really avoid a root canal?
In the right cases, yes. Ozone therapy disinfects deep cavities so thoroughly that many teeth that were borderline candidates for root canal end up healing fully under a properly placed biomimetic restoration. It is not a magic wand — the tooth still needs to be a reasonable candidate — but it materially shifts the odds in favor of preservation.
What is biomimetic dentistry, exactly?
Biomimetic dentistry is the practice of restoring teeth with materials and techniques that mimic the natural strength and behavior of enamel and dentin. Biomimetic restorations are bonded directly to the tooth and are designed to flex and absorb force the way a natural tooth does. Done well, biomimetic dentistry preserves tooth vitality and avoids the cycle of progressively bigger restorations that often ends in a root canal.
Is it ever too late to avoid a root canal?
Yes. Once the pulp is necrotic — when the nerve and blood supply have died — there is no biological way to bring them back, and a root canal becomes the tooth-preserving option. The window for avoiding a root canal closes when the pulp does. That is part of why early diagnosis matters so much.
If I get a second opinion and you tell me the root canal is necessary, what then?
We tell you. We perform root canals when they are the right answer, and we do them carefully and well. The point of a second opinion is not to talk you out of treatment — it is to give you a clear-eyed evaluation of your options. Sometimes the original recommendation is correct.
Does insurance cover the alternatives?
Most biomimetic restorations are billed as fillings, onlays, or crowns and are typically covered like any other restoration. Some specialty services, like ozone therapy or CURODONT Repair, may be considered elective and billed separately. We will always provide a clear cost estimate before any treatment.
If you’re considering a root canal, get a second opinion
If you have been told you need a root canal — or you suspect you might — I would encourage you to get a second opinion before scheduling the procedure. At The Minnesota Center for Minimally Invasive Dentistry, we offer complimentary consultations specifically for patients evaluating their options. We will examine your tooth, review your imaging, perform appropriate vitality testing, and give you our honest clinical assessment — including, when warranted, the recommendation that the root canal proceed.
Your teeth are worth fighting for. Sometimes that fight is best won with a root canal. Sometimes it is best won by avoiding one. The point is to know which is which, in your particular case.
To schedule a consultation, call (651) 699-2822 or contact us online. We see patients from Saint Paul, Minneapolis, Highland Park, and across Minnesota — and patients travel from around the country for specialized minimally invasive care.
— Dr. Mark Malterud, DDS
Founding Member, Academy of Biomimetic Dentistry
Member, World Congress of Minimal Invasive Dentistry
About the author: Dr. Mark Malterud, DDS, has practiced general dentistry in Saint Paul, Minnesota for over 30 years. He is a founding member of the Academy of Biomimetic Dentistry, a member of the World Congress of Minimal Invasive Dentistry, and a Board Member of the Academy of General Dentistry. He has been published in General Dentistry, the peer-reviewed journal of the AGD, and instructs other dentists nationally and internationally on minimally invasive aesthetic restorations. Learn more about our doctors.