Textbook of Endodontology

The third edition of Textbook of Endodontology provides lucid scholarship and clear discussion of endodontic principles and treatment to dental students and dental practitioners searching for current information on endodontic theories and techniques. 

• Completely revised and updated new edition
• Features six new chapters
• Provides pedagogical features to promote understanding
• Includes clinical case studies to put the information in the clinical context
• Illustrated in full color throughout with clinical images and detailed diagrams
• Offers interactive multiple-choice questions on a companion website
  
  

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 xiii

Foreword xvii

Preface xix

About the companion website xxi

1 Introduction to endodontology 1
John Whitworth, Lise-Lotte Kirkevang, and Lars Bjørndal

Endodontology 1

The objective of endodontic treatment 2

Clinical problems and solutions 2

The diagnostic dilemma 6

The outcome dilemma 6

The tools of treatment 6

References 7

Part 1 The Vital Pulp

2 The dentin–pulp complex: structure, functions, threats, and response to external injury 11
Lars Bjørndal and Alastair J. Sloan

Introduction 11

The odontoblast and the dentin–pulp complex 11

The dental pulp 17

Immune responses in the dentin–pulp complex 22

Responses of the healthy dentin–pulp complex to nondestructive stimuli 25

The dentin–pulp complex and responses to external injuries 25

Summary 29

References 29

3 Dentinal and pulpal pain 33
Inge Fristad and Matti N¨arhi

Introduction 33

Classification of nerve fibers 33

Morphology of intradental sensory innervation 33

Function of intradental sensory nerves 36

Sensitivity of dentin: hydrodynamic mechanism in pulpal A-fiber activation 38

Responses of intradental nerves to tissue injury and inflammation 40

Local control of pulpal nociceptor activation 44

Dentin hypersensitivity 44

Pain symptoms and pulpal diagnosis 45

References 46

4 Clinical pulp diagnosis and decision-making 49
Kerstin Petersson and Claes Reit

Introduction 49

Evaluation of diagnostic information 49

Diagnostic accuracy 50

Diagnostic strategy 51

Clinical manifestations of pulpal and periapical inflammation 51

Collecting diagnostic information 52

Diagnostic methodology: assessment of pulp vitality 53

Diagnostic methodology: evaluation of reported pain 55

Diagnostic methodology: provocation/inhibition of pain 56

Diagnostic methodology: evaluation of tooth discolorations 58

Diagnostic classification 58

References 59

5 Caries pathology and management in deep stages of lesion formation 61
Lars Bjørndal

Enamel lesions without clinical cavitation 63

Progressive stages of enamel–dentin lesions without surface cavitation and exposure of dentin to the oral environment 65

Cavitation of the dentin lesion 67

Concluding remarks on the natural history of dental caries 72

Strategies for the management of deep caries 72

Detailed treatment protocol for deep caries management 74

References 76

6 Treatment of vital pulp conditions 79
Lars Bjørndal, Helena Fransson, and St´ephane Simon

Introduction 79

Indications and treatment concepts for preserving vital pulp functions 80

Protocols for treatments aiming to preserve the vitality of the exposed pulp 81

Factors of importance in preserving vital pulp functions 87

Capping materials and healing patterns 89

Tissue–biomaterial interaction and pulp healing 91

Pulp-preserving treatments – a controversial treatment? 92

Indications and treatment concepts for treating the irreversibly inflamed vital pulp (pulpectomy) 93

Postoperative considerations 96

Choosing between pulp-preserving vital pulp therapies and pulpectomy 96

Concluding remarks on the avoidance of pulpectomy by vital pulp therapies 97

Revitalization and/or regenerative endodontic procedures 97

References 98

Part 2 The Infected Necrotic Pulp and Apical Periodontitis

7 Apical periodontitis 103
Zvi Metzger, Anda Kfir, and Itzhak Abramovitz

Introduction 103

The nature of apical periodontitis 103

Interactions with the infecting microbiota 107

Treatment and healing of periapical lesions 114

Persistence of periapical lesions 115

Clinical manifestations and diagnostic terminology 117

References 119

8 Microbiology of the inflamed and necrotic pulp 123
Luis E. Ch´avez de Paz

Introduction 123

Historical background 123

Clinical evidence 124

Infections in root-filled teeth with persistent apical periodontitis 126

Microbial pathogenesis of apical periodontitis 128

Association of signs and symptoms with specific bacteria 129

Biological evidence 131

Extraradicular biofilms 133

Ecological determinants for microbial growth in root canals 134

Microbial interactions in biofilms 134

Microbial resistance to antimicrobials 136

Antibiofilm strategies 137

Concluding remarks 138

References 138

9 Clinical diagnosis of pulp necrosis and apical periodontitis 143
Dag Ørstavik

Introduction 143

Clinical features of pulp necrosis and root canal infections 144

Radiographic features of apical periodontitis 147

A strategy for the formulation of a periapical diagnosis 153

Diagnostic challenges during treatment 153

Special cases of endodontic infections 154

An integrated approach to endodontic diagnosis 162

References 165

Part 3 Endodontic Treatment Procedures

10 Endodontic emergencies 171
Peter Jonasson, Maria Pigg, and Lars Bjørndal

Introduction 171

General diagnostic considerations and emergency principles 171

The etiology and pathogenesis behind emergency scenarios 171

Non-endodontic tooth pain – conditions of differential diagnostic interest 181

Management of patients with acute dental pain 182

References 183

11 Controlling the environment – the aseptic working field 185
Merete Markvart and Pia Titterud Sunde Background 185

Preparing teeth for rubber dam isolation and the development of an aseptic working field 186

Rubber dam isolation 187

Application of the rubber dam 189

Disinfection of the working field 189

Aseptic working procedures 190

References 192

12 Access and canal negotiation: the first key procedural steps for successful endodontic treatment 195
Ove A. Peters and Ana Arias

Introduction 195

Principles of tooth development and tooth anatomy 195

Individual analysis of the tooth, preoperative radiographs, and additional CBCT scans in

complex cases 196

Rubber dam isolation 196

Access cavity preparation 197

Canal negotiation 202

References 203

13 Root canal instrumentation 205
Lars Bergmans and Paul Lambrechts

Introduction 205

Principles of root canal instrumentation 205

Root canal system anatomy 206

Anatomical variations in teeth 211

Procedural steps 213

Endodontic instruments 217

Instrumentation techniques 221

Limitations of root canal instrumentation 223

Preventing procedural mishaps 225

References 228

14 Irrigation and disinfection 231
Markus Haapasalo and Ya Shen

Introduction 231

Eradication of microorganisms from the root canal system 231

Microbial reduction by instrumentation 232

Root canal irrigation 232

The apical root canal – a special challenge for irrigation 236

Activation of irrigant flow 237

Use of lasers in irrigation 238

Wide-spectrum sound energy for cleaning the root canal system 239

Intracanal medicaments 240

Concluding remarks 241

References 241

15 Root canal filling 247

15.1 Root canal filling materials 248
Gottfried Schmalz and Birger Thonemann

Introduction 248

Requirements 249

Evaluation of specific materials 253

References 272

15.2 Root canal filling techniques 277
Amir-Taymour Moinzadeh and Hagay Shemesh

Introduction 277

Clinical objectives and in vitro investigations 277

The root canal filling–dentin interface 277

Root canal filling techniques 281

Concluding remarks 289

References 289

Part 4 The Endodontically Treated Tooth

16 The root canal-treated tooth in prosthodontic reconstruction 295
Kishor Gulabivala and Yuan-Ling Ng

Introduction 295

Fracture predilection of root-treated teeth 295

Occlusal loading 298

Root canal-treated teeth as abutments 299

Distribution of remaining tooth structure and restorability 299

Principles of restoration of root-treated teeth 300

Timing of restoration after endodontic treatment 301

Approach to restoration of anterior teeth 302

Characteristics of posts 303

Preparation of the post space 307

Approach to restoration of posterior teeth 308

Core materials 310

Modes of restoration failure in root canal-treated teeth 310

Conclusions 311

References 312

17 Clinical epidemiology: measuring endodontic disease and treatment outcome 315
Lise-Lotte Kirkevang

Introduction 315

Defining a “successful” outcome 315

Study designs commonly used in endodontic research 317

Treatment outcome and risk factors 319

Concluding remarks 323

References 323

18 Endodontic retreatment – the decision-making process 327
Frank Setzer and Bekir Karabucak

Introduction 327

Why might the initial treatment be unsuccessful? 327

When may further intervention be considered? 329

Decision-making – the dentist’s perspective 330

Decision-making – the patient’s perspective 338

References 339

19 Nonsurgical retreatment 343
Thomas Kvist and Luc van der Sluis

Introduction 343

Indications 343

Instrumentation of the root canal 350

Prognosis 357

Summary 357

References 358

20 Surgical endodontics 361
Lise-Lotte Kirkevang, Vibe Rud, and Thomas Kvist

Introduction 361

General outline of the procedure 361

Local anesthesia 363

Flap design, incision, and raising the flap – general considerations 363

Access to the root tip 368

Root-end resection 369

Curettage of the soft-tissue lesion 369

Management of bleeding 370

Root-end preparation 371

Root-end filling 372

Repositioning and suturing of the flap 373

Postoperative measures 374

Follow-up after surgery 375

References 376

Part 5 Additional Considerations

21 Local anesthetic considerations 381
Nigel Foot and John Whitworth

Introduction 381

Fundamentals of local anesthetic action 381

Common local anesthetic agents in endodontics 382

Standard methods of local anesthesia for endodontics 383

Failure to secure anesthesia 385

Why may teeth be difficult to anesthetize? 386

Measures to preempt or overcome challenging local anesthesia 387

Supplementary injections 388

Sedation 390

Complications of local anesthesia 391

References 392

22 Complex orofacial pain conditions 393
Lene Baad-Hansen and Peter Svensson

Introduction 393

Overview of pain mechanisms 393

Diagnostic process 395

Complex orofacial pain conditions 397

Painful posttraumatic trigeminal neuropathy 397

Persistent idiopathic facial pain 398

Atypical odontalgia/persistent dentoalveolar pain 399

Trigeminal neuralgia 399

Trigeminal autonomic cephalalgias 401

Migraine/neurovascular orofacial pain 401

Temporomandibular disorder pain – referred pain 401

Summary 402

References 402

23 Endodontic complications after trauma 405
John Whitworth

Introduction 405

Common dental injuries 405

Dental trauma and its consequences 405

Consequences of pulp breakdown and infection after trauma 411

General considerations in the management of dental trauma 416

Diagnostic quandaries: to remove or review the pulp after trauma? 422

References 424

24 Medicolegal considerations 427
Lars Bjørndal, Shiv Pabary, and John Whitworth

Introduction 427

Ethical considerations – the concepts of beneficence and nonmaleficence 427

Defining best practice 427

Endodontic procedures as complex interventions with scope for imperfection,

oversight and error 428

Examples of errors and accidents 428

Do errors always lead to legal action? 430

Professional indemnity/malpractice insurance 430

Managing risks 431

Conclusion 433

References 434

25 Emergencies in need of urgent referral 435
Tara Renton

Introduction 435

Neurological injuries resulting from endodontic procedures and materials 435

Neurological injuries resulting from periapical inflammation 440

Chemical tissue trauma 441

Severe odontogenic infections that may compromise systemic health 443

Suspicion of locally aggressive or neoplastic lesions 444

Severe or persistent pain 445

Inhalation or aspiration of dental instruments or materials 445

Allergic responses that may compromise systemic health 445

Reporting adverse events 446

Summary 446

References 446

26 The transition to independent practice 451
Peter Musaeus

Introduction 451

The challenge of transition 452

Learning: explanations and strategies 454

Conclusion 460

Acknowledgment 461

References 461

Index 463

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