Textbook of Endodontology

The Editors Lars Bjørndal, PhD, is Associate Professor in the Section of Cariology and Endodontics, Department of Odontology, Faculty of Health and Medical Sciences at the University of Copenhagen in Copenhagen, Denmark. Lise-Lotte Kirkevang, PhD, is Associate Professor in the Department of Dentistry and Oral Health at Aarhus University in Aarhus, Denmark and Professor of Endodontics, at the Institute of Clinical Dentistry, Faculty of Dentistry, University of Oslo in Oslo, Norway. John Whitworth, PhD, is Professor of Endodontology/Consultant in Restorative Dentistry in the School of Dental Sciences at Newcastle University/Newcastle Hospitals NHS Foundation Trust in Newcastle, UK.

• List of contributors xiiiForeword xviiPreface xixAbout the companion website xxi1 Introduction to endodontology 1John Whitworth, Lise-Lotte Kirkevang, and Lars BjørndalEndodontology 1The objective of endodontic treatment 2Clinical problems and solutions 2The diagnostic dilemma 6The outcome dilemma 6The tools of treatment 6References 7Part 1 The Vital Pulp2 The dentin–pulp complex: structure, functions, threats, and response to external injury 11Lars Bjørndal and Alastair J. SloanIntroduction 11The odontoblast and the dentin–pulp complex 11The dental pulp 17Immune responses in the dentin–pulp complex 22Responses of the healthy dentin–pulp complex to nondestructive stimuli 25The dentin–pulp complex and responses to external injuries 25Summary 29References 293 Dentinal and pulpal pain 33Inge Fristad and Matti N¨arhiIntroduction 33Classification of nerve fibers 33Morphology of intradental sensory innervation 33Function of intradental sensory nerves 36Sensitivity of dentin: hydrodynamic mechanism in pulpal A-fiber activation 38Responses of intradental nerves to tissue injury and inflammation 40Local control of pulpal nociceptor activation 44Dentin hypersensitivity 44Pain symptoms and pulpal diagnosis 45References 464 Clinical pulp diagnosis and decision-making 49Kerstin Petersson and Claes ReitIntroduction 49Evaluation of diagnostic information 49Diagnostic accuracy 50Diagnostic strategy 51Clinical manifestations of pulpal and periapical inflammation 51Collecting diagnostic information 52Diagnostic methodology: assessment of pulp vitality 53Diagnostic methodology: evaluation of reported pain 55Diagnostic methodology: provocation/inhibition of pain 56Diagnostic methodology: evaluation of tooth discolorations 58Diagnostic classification 58References 595 Caries pathology and management in deep stages of lesion formation 61Lars BjørndalEnamel lesions without clinical cavitation 63Progressive stages of enamel–dentin lesions without surface cavitation and exposure of dentin to the oral environment 65Cavitation of the dentin lesion 67Concluding remarks on the natural history of dental caries 72Strategies for the management of deep caries 72Detailed treatment protocol for deep caries management 74References 766 Treatment of vital pulp conditions 79Lars Bjørndal, Helena Fransson, and St´ephane SimonIntroduction 79Indications and treatment concepts for preserving vital pulp functions 80Protocols for treatments aiming to preserve the vitality of the exposed pulp 81Factors of importance in preserving vital pulp functions 87Capping materials and healing patterns 89Tissue–biomaterial interaction and pulp healing 91Pulp-preserving treatments – a controversial treatment? 92Indications and treatment concepts for treating the irreversibly inflamed vital pulp (pulpectomy) 93Postoperative considerations 96Choosing between pulp-preserving vital pulp therapies and pulpectomy 96Concluding remarks on the avoidance of pulpectomy by vital pulp therapies 97Revitalization and/or regenerative endodontic procedures 97References 98Part 2 The Infected Necrotic Pulp and Apical Periodontitis7 Apical periodontitis 103Zvi Metzger, Anda Kfir, and Itzhak AbramovitzIntroduction 103The nature of apical periodontitis 103Interactions with the infecting microbiota 107Treatment and healing of periapical lesions 114Persistence of periapical lesions 115Clinical manifestations and diagnostic terminology 117References 1198 Microbiology of the inflamed and necrotic pulp 123Luis E. Ch´avez de PazIntroduction 123Historical background 123Clinical evidence 124Infections in root-filled teeth with persistent apical periodontitis 126Microbial pathogenesis of apical periodontitis 128Association of signs and symptoms with specific bacteria 129Biological evidence 131Extraradicular biofilms 133Ecological determinants for microbial growth in root canals 134Microbial interactions in biofilms 134Microbial resistance to antimicrobials 136Antibiofilm strategies 137Concluding remarks 138References 1389 Clinical diagnosis of pulp necrosis and apical periodontitis 143Dag ØrstavikIntroduction 143Clinical features of pulp necrosis and root canal infections 144Radiographic features of apical periodontitis 147A strategy for the formulation of a periapical diagnosis 153Diagnostic challenges during treatment 153Special cases of endodontic infections 154An integrated approach to endodontic diagnosis 162References 165Part 3 Endodontic Treatment Procedures10 Endodontic emergencies 171Peter Jonasson, Maria Pigg, and Lars BjørndalIntroduction 171General diagnostic considerations and emergency principles 171The etiology and pathogenesis behind emergency scenarios 171Non-endodontic tooth pain – conditions of differential diagnostic interest 181Management of patients with acute dental pain 182References 18311 Controlling the environment – the aseptic working field 185Merete Markvart and Pia Titterud Sunde Background 185Preparing teeth for rubber dam isolation and the development of an aseptic working field 186Rubber dam isolation 187Application of the rubber dam 189Disinfection of the working field 189Aseptic working procedures 190References 19212 Access and canal negotiation: the first key procedural steps for successful endodontic treatment 195Ove A. Peters and Ana AriasIntroduction 195Principles of tooth development and tooth anatomy 195Individual analysis of the tooth, preoperative radiographs, and additional CBCT scans incomplex cases 196Rubber dam isolation 196Access cavity preparation 197Canal negotiation 202References 20313 Root canal instrumentation 205Lars Bergmans and Paul LambrechtsIntroduction 205Principles of root canal instrumentation 205Root canal system anatomy 206Anatomical variations in teeth 211Procedural steps 213Endodontic instruments 217Instrumentation techniques 221Limitations of root canal instrumentation 223Preventing procedural mishaps 225References 22814 Irrigation and disinfection 231Markus Haapasalo and Ya ShenIntroduction 231Eradication of microorganisms from the root canal system 231Microbial reduction by instrumentation 232Root canal irrigation 232The apical root canal – a special challenge for irrigation 236Activation of irrigant flow 237Use of lasers in irrigation 238Wide-spectrum sound energy for cleaning the root canal system 239Intracanal medicaments 240Concluding remarks 241References 24115 Root canal filling 24715.1 Root canal filling materials 248Gottfried Schmalz and Birger ThonemannIntroduction 248Requirements 249Evaluation of specific materials 253References 27215.2 Root canal filling techniques 277Amir-Taymour Moinzadeh and Hagay ShemeshIntroduction 277Clinical objectives and in vitro investigations 277The root canal filling–dentin interface 277Root canal filling techniques 281Concluding remarks 289References 289Part 4 The Endodontically Treated Tooth16 The root canal-treated tooth in prosthodontic reconstruction 295Kishor Gulabivala and Yuan-Ling NgIntroduction 295Fracture predilection of root-treated teeth 295Occlusal loading 298Root canal-treated teeth as abutments 299Distribution of remaining tooth structure and restorability 299Principles of restoration of root-treated teeth 300Timing of restoration after endodontic treatment 301Approach to restoration of anterior teeth 302Characteristics of posts 303Preparation of the post space 307Approach to restoration of posterior teeth 308Core materials 310Modes of restoration failure in root canal-treated teeth 310Conclusions 311References 31217 Clinical epidemiology: measuring endodontic disease and treatment outcome 315Lise-Lotte KirkevangIntroduction 315Defining a “successful” outcome 315Study designs commonly used in endodontic research 317Treatment outcome and risk factors 319Concluding remarks 323References 32318 Endodontic retreatment – the decision-making process 327Frank Setzer and Bekir KarabucakIntroduction 327Why might the initial treatment be unsuccessful? 327When may further intervention be considered? 329Decision-making – the dentist’s perspective 330Decision-making – the patient’s perspective 338References 33919 Nonsurgical retreatment 343Thomas Kvist and Luc van der SluisIntroduction 343Indications 343Instrumentation of the root canal 350Prognosis 357Summary 357References 35820 Surgical endodontics 361Lise-Lotte Kirkevang, Vibe Rud, and Thomas KvistIntroduction 361General outline of the procedure 361Local anesthesia 363Flap design, incision, and raising the flap – general considerations 363Access to the root tip 368Root-end resection 369Curettage of the soft-tissue lesion 369Management of bleeding 370Root-end preparation 371Root-end filling 372Repositioning and suturing of the flap 373Postoperative measures 374Follow-up after surgery 375References 376Part 5 Additional Considerations21 Local anesthetic considerations 381Nigel Foot and John WhitworthIntroduction 381Fundamentals of local anesthetic action 381Common local anesthetic agents in endodontics 382Standard methods of local anesthesia for endodontics 383Failure to secure anesthesia 385Why may teeth be difficult to anesthetize? 386Measures to preempt or overcome challenging local anesthesia 387Supplementary injections 388Sedation 390Complications of local anesthesia 391References 39222 Complex orofacial pain conditions 393Lene Baad-Hansen and Peter SvenssonIntroduction 393Overview of pain mechanisms 393Diagnostic process 395Complex orofacial pain conditions 397Painful posttraumatic trigeminal neuropathy 397Persistent idiopathic facial pain 398Atypical odontalgia/persistent dentoalveolar pain 399Trigeminal neuralgia 399Trigeminal autonomic cephalalgias 401Migraine/neurovascular orofacial pain 401Temporomandibular disorder pain – referred pain 401Summary 402References 40223 Endodontic complications after trauma 405John WhitworthIntroduction 405Common dental injuries 405Dental trauma and its consequences 405Consequences of pulp breakdown and infection after trauma 411General considerations in the management of dental trauma 416Diagnostic quandaries: to remove or review the pulp after trauma? 422References 42424 Medicolegal considerations 427Lars Bjørndal, Shiv Pabary, and John WhitworthIntroduction 427Ethical considerations – the concepts of beneficence and nonmaleficence 427Defining best practice 427Endodontic procedures as complex interventions with scope for imperfection,oversight and error 428Examples of errors and accidents 428Do errors always lead to legal action? 430Professional indemnity/malpractice insurance 430Managing risks 431Conclusion 433References 43425 Emergencies in need of urgent referral 435Tara RentonIntroduction 435Neurological injuries resulting from endodontic procedures and materials 435Neurological injuries resulting from periapical inflammation 440Chemical tissue trauma 441Severe odontogenic infections that may compromise systemic health 443Suspicion of locally aggressive or neoplastic lesions 444Severe or persistent pain 445Inhalation or aspiration of dental instruments or materials 445Allergic responses that may compromise systemic health 445Reporting adverse events 446Summary 446References 44626 The transition to independent practice 451Peter MusaeusIntroduction 451The challenge of transition 452Learning: explanations and strategies 454Conclusion 460Acknowledgment 461References 461Index 463