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Endodontics - 4th - Ed
Endodontics - 4th - Ed
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Foreword
Fifty years ago, when we were young dental students, the treatment of found the clinical discipline most satisfying and, when correctly applied,
dental, pulpal and periapical disease was taught in a disciplined fashion we were able to achieve predictable clinical outcomes. During this period
according to the principles of G.V. Black and Louis Grossman. Our uni- of our development, we benefited greatly from the tutelage of the late Fred
versity teachers were greatly influenced by these pioneers of dental learn- Harty, who not only encouraged us to learn more about endodontology but
ing and consequently, we were introduced to treatment modalities in stages also supported our efforts to disseminate our knowledge as widely as pos-
following the natural history of the disease process. This was done in a sible, all at a time when endodontics was not defined as a speciality in the
very practical and mechanical way. We were brought to graduation on a UK, and the British Endodontic Society was in its infancy.
diet of hollow tubes, apical seals, culturing techniques, and potent topical Endodontics has now come of age and has become an important aspect
drug therapy. Endodontics was presented as an adjunct to the restorative of patient care. The biological basis for the subject is understood and
aspects of dental care, and at that time, it was delivered as a small part of research into the pathological processes and clinical outcomes of treatment
the overall interests of Departments of Conservative and Operative Den- have led to clearly established evidence based therapies. It is pleasing to
tistry. The reasons for this are probably historical. Conservative techniques see the rise in numbers of specialists in this area of clinical activity. The
were used to deal with the destructive outcomes of dental caries, tooth establishment of dedicated departments and professorial positions to
surface loss, and trauma. This loss of coronal integrity of teeth allowed progress the subject and to maintain essential standards is also applauded.
the invasion of micro-organisms. Endodontics involved the treatment of Kish and Paula are to be congratulated for their hard work in producing
ensuing infections. It was natural to consider endodontics as a component this 4th Edition of Endodontics. They have presented a well re-organised
of Conservative Dentistry. and richly illustrated text that unifies modern evidence-based thinking. It
Postgraduate study at the Eastman Dental Institute improved our under- will be of value to all students, practitioners and specialists, who possess
standing and refined our performance in the delivery of restorative care. an enthusiastic interest in endodontics. It is with great pride that we
We realised that there was an essential need to base our clinical work on commend this work to readers.
the cornerstones of Endodontics, Periodontics and a reliable working
knowledge of Occlusion. Endodontology, the science that underpins endo- Chris Stock
dontics, took on a primary role in our appreciation of dental diseases. We Dick Walker
Preface
The first edition of this book (1988), “A Colour Atlas of Endodontics”, updates and enhances its evidence-based and rationalized clinical approach,
was published under the editorship of Jack Messing and Chris Stock and whilst upholding the richly illustrated perspective, to serve the visually-
consisted of 21 short, practical chapters. A wonderfully illustrated book, dependent learning framework of many aspiring endodontists. The book
it met the needs of the time. Endodontics was still in the early stages of is significantly re-organized into four sections: section 1, establishing the
gaining recognition as a specialized discipline in the UK. A realization was scientific and clinical rationale; section 2, prepares the reader for the pre-
dawning that experts with deep knowledge and advanced skills could make requisites of treatment; section 3, describes the core treatment details; and
a unique contribution to patients’ needs. The book focused on techniques section 4, discusses the interfaces between disciplines, as the growth of
and “how to” questions, with lots of useful practical tips. The final, single specialisms has altered the dynamics between clinicians who have devel-
page chapter on “The Way Ahead”, alluded to the lack of evidence-base oped higher skills and knowledge in defined areas. The approach also
in endodontics, the rise in demand for complex treatment and the need for demanded the incorporation of new material and chapters to ensure a
general dental practitioners to improve their skills, despite the develop- comprehensive coverage of subject matter.
ment of specialisms. This proved a prophetic vision. The endodontic service needs of the UK population is currently deemed
The second edition (1995), “Color Atlas and Text of Endodontics”, was to be best met by three levels of expertise: the general dental practitioner
led by Chris Stock with three newly enlisted editors (Kishor Gulabivala, serving the core needs; the dental practitioner with enhanced endodontic
Dick Walker and Jane Goodman). The book retained its practical and skills to manage the moderately complex cases; and finally, the specialist
technique-oriented approach through its 17 chapters, but started with a tier serving the needs of patients with more complex problems. It is hoped
more robust scientific, biological and clinical rationale, reflecting the that this book will serve practitioners at different levels of service delivery:
growing maturity of the discipline in the UK. The approach met the chang- (1) inspire the advanced undergraduate dental student about to enter prac-
ing needs of the general dental practitioner, who faced more challenging tice; (2) help the general dental practitioner to consolidate their knowledge
cases as informed patients sought and demanded higher levels of service. and skills after graduation; (3) form the basis of advancement for the
The editors embraced the pictorial story-board concept to convey the practitioner with enhanced skills; and (4) lay the preliminary foundation
message to its readership in a simple, coherent style. for the aspiring specialist. Whilst the evolution of this book is described
The third edition (2004), “Endodontics” (editors: Stock, Walker, Gula- in the context of the UK healthcare system, various streams of evidence
bivala), retained its richly illustrated essence and was more emphatically (endodontic journals, epidemiological data, international conferences and
founded in scientific and clinical rationale. The maturity of the book global perspectives of health sciences) suggest that the same process of
reflected the evolving needs of the general dental practitioner, who was evolution is endemic across the globe, making the text relevant wherever
seeking to acquire greater sophistication about endodontics. The discipline endodontic practice prevails.
had finally gained recognition as a specialty in the UK in 1998. In parallel, The editors recognize that book-learning alone cannot enhance technical
the commercial sector recognized the potential in the growth of endodontic and clinical skills, however practical the information. Theory must be
service provision and fueled their research and development wings to assimilated into working knowledge through vigilant and reflective prac-
innovate and supply a burgeoning number of instruments and materials. tice. Rare individuals are able to make this transition independently but
Along with the technical revolution came the need for clinical experts who most require various levels of hands-on instruction, coaching and mentor-
could explain and disseminate the proliferating plethora of new techniques ing. Advanced endodontic skills are developed through parallel and inte-
utilizing the emerging products. It was therefore, challenging to describe grated cognitive, visual, technical and clinical effort and discipline. The
all the techniques in a book, there were simply too many. Instead, the refinement of personal discipline, conscientious attitude and detailed atten-
editors appreciated the need to distil the principles, allowing dentists to tion necessary for successful endodontics, happily create the right attributes
learn the core essence, which they could apply to any technique. The for life-long personal development and fulfillment. This philosophy was
editors had been privileged enough to ride the crest of the wave of these also embodied by Aristotle who is quoted to have said:
exciting developments in endodontics, as they nurtured masters and spe- Excellence is an art won by training and habituation.
cialty training programmes, as well as having ran specialist endodontic
We do not act rightly because we have virtue or
clinics in hospital and practice settings.
This fourth edition (2014), retains one of the previous editors (K Gula-
excellence, rather we have those because we acted
bivala), Chris Stock and Dick Walker having taken a well-earned retire- rightly. We are what we repeatedly do. Excellence
ment from their illustrious careers, and includes a new co-editor, Yuan-Ling then is not an act but a habit.
(Paula) Ng. The latter, a long-serving clinician and teacher, has been We hope that this book will be only the beginning of the reader’s journey
instrumental in helping to advance the clinical evidence-base for endodon- of development in this fascinating field.
tics through research, as well as being the programme director for the
endodontic masters programmes at the Eastman Dental Institute. This Kishor Gulabivala
latest book will continue the tradition established in previous editions. It Yuan-Ling (Paula) Ng
Acknowledgements
The editorship and authorship of this book has changed over the last three In addition, the following have contributed various images in the past:
editions, during which time the concept and content of the book has evolved
through constant feedback and various contributions. The presented version Professor Ramachandran Nair, Mr JF Roberts, Mr FJ Hill, Late
in this edition is significantly updated but still carries the vestiges of previ- Professor GB Winter, Professor Paul Speight, Dr John Bennett, Mrs
ous authors and editors’ contributions. The editors would like to acknowl- P Barber, Dr Nicky Mordan, Mr J Morgan, Dr Elisabeth Saunders,
edge and thank the following for their previous contributions: Professor Michael Tagger, Professor Paul Dummer, Late Professor
Thomas Pitt Ford, Professor Callam Youngson, Dr Margaret Byers,
Dr Christopher JR Stock Dr Melody Chen, Professor Ivor Kramer, Late Dr Jakob Valderhaug,
Professor Richard T Walker Dr Lars Laurell, Miss Noushin Attari, Miss Angela Christie, Dr Michael
Dr Jane Goodman RN Collins, Dr Peter Endo, Dr David Dickey, Dr Ben Johnson, Dr Paul
Dr Jackie E Browne King, Dr Koos Marais, Dr Joe Omar, Dr Paul O’Neilly, Dr Alistair
Dr Ian Cross Spiers, Dr Peng Hui Tan, Dr J Woodson.
Dr Carol Mason
Dr Shahrzad Rahbaran The editors gratefully acknowledge the effort of various Masters level
Dr John D Regan postgraduate students whose research projects have contributed images to
Professor Paul R Wesselink this book. They are:
The editors would also like to thank J van der Meer for providing
images, Jeffrey Chan for his photographic expertise, Dr William Cheung
& Associates, Robert Ng’s surgery for the use of his practice and equip-
ment as an example, and Rahul Goria for use of his surgery as an example.
Prof Ian Eames for the use of images on irrigation from Computational
Fluid Dynamics.
Contributors
Ian Alexander BDS, MSc Farhad B. Naini BDS, MSc, PhD, FDS RCS, M Orth RCS, FDS
Senior Clinical Teaching Fellow Orth RCS, GCAP, FHEA
Coordinator of Diploma in Endodontic Practice Consultant Orthodontist Kingston & St George’s Hospitals, London;
UCL Eastman Dental Institute, London, UK Honorary Senior Lecturer Craniofacial Anatomy, Biology &
Proof-reading of chapters 8 & 9 Development St George’s Medical School, University of London,
London, UK
Ulpee Darbar BDS, MSc, FDS RCS Provided intellectual content for chapter 13
Consultant in Restorative Dentistry & Clinical Director
Department of Periodontology Murray Saunders BDS, MGDS RCS, MSc
UCLH Trust, London, UK Honorary Lecturer in Endodontology/Specialist in Endodontics
Provided intellectual content for chapter 12 Coordinator of Short Course Modules
UCLH Trust, London, UK
Proof-reading of chapters 6 & 9
Rachel Leeson BDS, FDS RCS, PhD, FHEA
Senior Clinical Lecturer in Oral Surgery
Morgana Eli Vianna BDS, MSc, PhD, FHEA
Director of Masters Programme in Oral Surgery
Clinical Lecturer in Endodontology
UCL Eastman Dental Institute, London, UK
Coordinator of Masters Programmes in Endodontology
Provided main intellectual content for chapters 16 and 17
UCL Eastman Dental Institute, London, UK
Provided figures 3.5, 3.27, 3.28, 3.48; tables 3.3 & 3.5; and
Alyn Morgan BChD, MSc proof-reading of chapter 3
Senior Clinical Teaching Fellow
Coordinator of Diploma in Endodontic Practice Wicher Joerd van der Meer BDS
UCL Eastman Dental Institute, London, UK Teacher, University Hospital of Groningen;
Proof-reading of chapters 8 & 9 Staff Member, Centre for Special Care Dentistry, Assen;
Honorary Research Associate
Alexander Mustard BDS, MFDS RCS, MSc UCL Eastman Dental Institute, London, UK
Teacher in Endodontology Provided intellectual content for section on CBCT for chapter 4;
UCL Eastman Dental Institute, London, UK generated and provided 3D images in figures 1.40, 2.9, 3.1, 3.5,
Provided main intellectual content for chapter 15; proof-reading of 3.8, 3.11, 4.64, 4.65, 4.66, 4.67, 8.55; tables 4.12, 4.13; proof-
chapters 4 & 10 reading of chapter 15
Introduction to endodontology and endodontics
TOOTH DEVELOPMENT regions of the maxillary and mandibular processes proliferate and then
spread towards the midline where they become continuous into horseshoe-
Many readers approach human embryology with a view to satisfying aca- shaped bands. These bands are not evident on the surface but project into
demic test requirements and may even believe such academic knowledge the underlying mesenchyme and are called the primary epithelial bands.
to be far removed from clinical practice. Yet this book begins with this During the seventh week of embryonic life, the primary epithelial band
fascinating subject, not merely to lay an academic foundation for the divides on its deep surface into two processes; the outer, thicker one
knowledge of endodontics but because contemporary practice recognizes becomes the vestibular lamina (responsible for the later separation of lips/
that these biological processes hold the key to future therapeutic strategies. cheeks from gums) and the inner, smaller one becomes the dental lamina
Regenerative treatment approaches depend upon insight from develop- (which later gives rise to the teeth) (Fig. 1.3). As the dental lamina grows
mental processes to engineer the growth of new tissues to replace those in length, it penetrates deeper into the mesenchyme; at the front of the
that are diseased or damaged. The ultimate may even be to grow whole mouth in a lingual direction, to form a shelf-like projection and at the back
replacement teeth on demand, in situ or for implantation. Among the clini- of the mouth remaining more vertical (Fig. 1.4). It is not known whether
cians involved should be endodontists in whose field of knowledge and this results from active invagination of the lamina or upward proliferation
practice these procedures should lie. Any clinician involved in delivering of the mesenchyme.
procedures that even border on regenerative techniques should have a basic
understanding of tooth development and its associated structures. ENAMEL ORGANS
The “intelligence” or “activating force” that directs the precise coordi-
nation of multiple cell line activity, growth, migration, induction, fusion A short while after formation, the dental lamina thickens into small rounded
and disintegration with such control and symphonic grace, still eludes us. swellings, involving the whole thickness from free edge to the base of
In our current state of knowledge, we are left merely to describe the attachment to the oral epithelium. These are the enamel organs of the
observable and timed changes gleaned through various biological studies. deciduous teeth with four in each quadrant (2 incisors, canine and first
Experimental studies also give us some insight about the genomic and deciduous molar) (see Fig. 1.4). The dental lamina continues to grow
proteomic involvement in the process, even though the picture is far from backwards, giving rise to further enamel organs for the second deciduous
complete. Yet there is already sufficient intuitive knowledge to enable the molar (10-week embryo), and the permanent molars (first permanent molar
culture of tooth tissues and whole teeth in the laboratory, albeit in a neo- at 16-week embryo; second and third permanent molars after birth). At 10
phytic way (Fig. 1.1). weeks of embryonic life, the enamel organs and dental lamina conform to
a catenary curve. As the tooth germs grow, the spacing between them is
reduced. There is at this early stage no indication of the successional per-
EARLY DEVELOPMENT OF TEETH manent teeth, which develop later by budding off from the lingual aspects
The primitive mouth cavity is evident as a slit-like space lined by ectoderm of each deciduous enamel organ.
in the 3–4-week-old human embryo. It is located under the surface of the
brain capsule and above the pericardial sac where the heart forms. The DENTAL PAPILLA
mouth cavity is still separated from the primitive pharynx by the oropha-
ryngeal membrane. The mandibular processes grow ventrally on each side The mesenchymal tissue surrounding the developing enamel organ
of the head to meet gradually in the midline, where they form the lower responds by proliferation to form a dense mass of cellular tissue. This gives
border of the mouth opening. The maxillary processes arise from the upper rise to the dental papilla (primitive pulp) and the follicular sac for each
surfaces of the origin of the mandibular process and likewise grow towards tooth bud. The enamel organ in the “bud” stage appears as a simple, spheri-
the midline, to form the upper border of the mouth below the brain capsule cal to ovoid, epithelial condensation that is poorly morpho- and histo-
(Fig. 1.2). The maxillary and mandibular processes are essentially exten- differentiated. The epithelial component is separated from the adjacent
sions of mesenchyme tissue covered by ectoderm. The ectoderm is a layer mesenchyme by a basement membrane. The combination of enamel organ,
of low columnar epithelial cells, resting on a basal lamina which separates dental papilla and follicular sac are collectively known as the tooth germ
them from the mesenchymal tissue, which originates from the neural crest (Fig. 1.5). The enamel organ becomes concave on its papillary surface and
cell line. In some regions, such as the tooth-bearing part, the epithelium begins to grow at the rims so as to encircle the dental papilla, which, at
has a more superficial part, which consists of 2–3 layers of flattened cells. this stage, is partly capped by the enamel organ (hence “cap” stage) (Fig.
At this stage, the maxillary and mandibular processes do not show separate 1.6) and progressively embraces a greater volume of it, to be called the
lip or gum regions; the development of the lips, cheeks and gum regions “bell” stage (Fig. 1.7). At the cap stage, the centre of the concavity devel-
is closely associated with the development of the dental lamina, from ops a projection of epithelium called the enamel knot (Fig. 1.6), which
which teeth arise. soon disappears by programmed cell death (apoptosis) and seems to con-
tribute cells to the enamel cord. The enamel knot represents an important
regulatory signalling centre during tooth development by producing bone
PRIMARY EPITHELIAL BAND, VESTIBULAR BAND AND morphogenetic proteins (BMP-2, BMP-7), fibroblast growth factor (FGF–
DENTAL LAMINA p21 cyclin-dependent kinase inhibitor), sonic hedgehog (Shh), WNT and
The first indication of formation of tooth development structures becomes transcription factors. These signals regulate growth and development of
evident at 6 weeks of embryonic life when the oral epithelium in the lateral the epithelial folds that correspond to the cusp pattern of the mature tooth.
Enamel niche
Enamel organ
Vestibular band
Tongue
Maxillary process
Mandibular process
Enamel niche
Cardiac sac
Fig. 1.2 Maxillary and mandibular processes in the head of human embryo
(approx. 5 weeks)
Mesenchyme
Tongue Mesenchyme Dental papilla Enamel organ Bone
involved in the process, by which the cap stage is transformed into the bell
stage or that it is a focus for the origin of stellate reticulum cells.
VESTIBULE FORMATION
Concurrent with the enamel organ development, the vestibular band
growth continues apace. At around the time of the cap stage, a vertical
cleft becomes established in the vestibular band, separating the formative
lips and cheeks from the formative gums (Fig. 1.8). As for the dental
lamina, the vestibular band development progresses backwards.
Vestibular band
Dental lamina CHANGES TO AND FURTHER DEVELOPMENT OF
DENTAL LAMINA FOR PERMANENT MOLARS
Fig. 1.3 The dental lamina
As the enamel organ is reaching the cap stage, so the dental lamina length-
The primary enamel knot also determines the position of the secondary ens and divides into buccal and lingual parts, though the function of this
enamel knots corresponding to the site of the future cusps. The enamel is unknown. By the time the enamel and dentine formation begins during
cord is a strand of cells seen at the early bell stage of development. When early bell stage, the dental lamina connecting the tooth germs to the oral
present, it overlies the incisal margin of a tooth or the apex of the first epithelium starts to degenerate leaving a network of strands and clumps
cusp to develop. It has been suggested that the enamel cord may be of epithelial cells. At the same time, the dental lamina continues to grow
4 TOOTH ORGANOGENESIS, MORPHOLOGY AND PHYSIOLOGY
Enamel organ
Tongue
Dental lamina
Enamel
Vestibular band
Dentine
Dental papilla
Mylohyoid muscle
Bone
Fig. 1.8 The formative lips and cheeks separated from the formative gums at
the advanced “bell” stage
DEVELOPMENT OF SUCCESSIONAL
PERMANENT TEETH
The enamel organs for the successional teeth arise so differently from the
permanent molars that it raises the question of whether the permanent
molars should actually be regarded as part of the deciduous series. During
Enamel septum External enamel epithelium the fourth month of fetal development, an epithelial process appears on
the lingual aspect of each enamel organ; this becomes the lamina for the
successional teeth (Fig. 1.9), giving rise to tooth germs in like manner to
the deciduous teeth.
Enamel
DIFFERENTIATION OF DENTAL PAPILLA, DENTAL
FOLLICLE AND SHEATH OF HERTWIG
Dentine
Permanent successor
During the above differentiation of the enamel organ, there are concurrent,
although subtle changes in the dental papilla. The loosely packed cells of
the papilla, which are derived from the neural crest (ectomesenchyme)
become infiltrated by delicate fibres, capillaries and nerve fibres during the
bell stage in preparation for the formative task ahead. The innervation
remains simple until birth, after which there is a conspicuous increase in
this system.
As the enamel organ envelops the dental papilla, a mesenchymal cellular
condensation appears around the outer aspect of the external enamel epi-
thelium, which is continuous around the dental papilla beyond the rim of
the enamel organ. This is the primordium of the dental follicle or sac. The
follicle becomes innervated as soon as it appears during the cap stage. The
role of the dental follicle is to provide nutrition and blood supply for
the enamel organ, maintain relationship to the oral mucosa, control the
form and size of the bony cavity, in which the developing tooth germ lies
and, finally, to give rise to the periodontal membrane when the tooth is
erupted. It also contributes to differentiation of cementoblasts and the
formation of cementum.
Once the enamel organ has mapped out the entire form of the clinical
crown, further growth at the cervical loop is geared towards development
of the root. From this point onwards, the internal and external enamel
epithelia are not separated by the stratum intermedium and stellate reticu-
lum but grow as a two-layered epithelial wall, which is now called the
sheath of Hertwig. The sheath of Hertwig maps out the shape of the root(s)
(see Fig. 1.10). It is disposed in a simple tube for a single root, and in a
Dental papillae Bone
more complex form for multiple roots. This is achieved by the inward
Fig. 1.9 The enamel organ for the successional tooth growth of horizontally directed processes of epithelium.
Dental
classification of the malformations and a brief summary of the presenting
Dental lamina Ectoderm Placode Bud Cap features, which may or may not affect endodontic management. Given the
variation in degree of severity, each case must be judged on its own merits
as far as management is concerned.
Bell Late bell Failure to understand the root form and root canal anatomy of the teeth
that we treat is rather like setting out on a long journey without a road
Enamel map. The technical execution of endodontic procedures demands a thor-
ough understanding and knowledge of tooth and root canal system mor-
Dentine
phology. If performance of the procedural elements of endodontic treatment
Pulp were likened to sport or crafts, then knowledge of the tooth anatomy would
be akin to knowledge of the sports playground, court or pitch, or the craft
Bone medium.
Endodontic treatment involves controlled manipulation of dentine,
forming the bulk of the tooth, in order to shape or sculpt, scrub or clean,
Fig. 1.11 Schematic model of the molecular regulation of tooth development. fill and seal in a controlled way. It is the terrain of the endodontic “sport-
Signal molecules (BMP: bone morphogenic proteins; FGF: fibroblast growth
sperson” or the medium of the endodontic craftsman.
factors; Shh: sonic hedgehog; TNF: tumour necrosis factor) mediate the
interaction between epithelial (green) and mesenchymal tissues (blue) and Insight about tooth and root canal morphology should, therefore form
regulate the expression of genes in the responding tissues (shown in boxes). the foundation of endodontic management and requires dedicated study.
Signalling centres (red) appear in the epithelium reiteratively and secrete An understanding of the pulp–space anatomy of teeth is a prerequisite
locally many different signals that regulate morphogenesis and tooth shape. to the delivery of high-quality root-canal treatment. Many of the problems
(Adapted with permission from Thesleff I (2003) Epithelial-mesenchymal attributable to failure in endodontic treatment relate to an inadequate
signalling regulating tooth morphogenesis. J Cell Sci 116(9),1647-8) understanding of the three-dimensional nature of the pulp space. In treat-
ment, it is important to develop a visual picture of the likely location and
number of root canals in a particular tooth. It may be necessary to take
more than one preoperative radiographic view to gain as much information
ameloblasts; the thickness of the enamel being determined by the extent as possible about the nature of the pulp space before proceeding with the
of migration of the ameloblasts. Dentine is laid down between the mesen- therapy.
chymal surface of the basal lamina and the inwardly migrating dentine-
forming cells, the odontoblasts, which originate from the dental papilla.
The thickness of the dentine is determined by the distance migrated by the TOOTH AND ROOT SHAPES
odontoblasts. The continual formation of dentine leads to progressive
reduction in the size of the pulp cavities and root canals of the teeth. VARIATION BY TOOTH TYPE
Cementum is laid down on the surface of the dentine that is not covered Every dentist is familiar with the characteristics of tooth shape and should
by enamel after the Hertwig’s sheath starts to break up. be able to identify each tooth type if confronted with extracted teeth, by
type and quadrant. Anterior teeth are genetically evolved to help incise
MOLECULAR REGULATION OF TOOTH DEVELOPMENT food; they have incisal edges and single roots to guide excursive mandibu-
Tooth development is a very complex process involving many growth lar movements. Posterior teeth are evolved to crush and grind food; they
factors and transcription factors that help ensure an ordered and controlled have cusps and multiple roots to support biting loads. The incisive edges
development of individual tooth germs, as well as the entire dentition. of the anterior teeth are in line with the buccal cusps of the posterior teeth.
Epithelial–mesenchymal interactions require signalling between the two The lingual cusps of the posterior teeth decrease in size towards the front
major components of the tooth germ. Bioactive molecular signals (i.e. and are represented in the anterior teeth by the cingulum (Fig. 1.20). The
transcription factors, growth factors, cytokines) are produced in a specific canines form the junction or buttress between the anterior and posterior
spatial and temporal sequence, such that the cascade of events results in a teeth, often taking the majority of the lateral guiding forces, reflected in
tooth with the appropriate tissues and shape. A model of the molecular their longer and bulkier roots.
regulation of tooth development from initiation to crown morphogenesis
(Thesleff, 2003) is given in Figure 1.11. VARIATION BY RACE
The development of the dental tissues is genetically driven. The growth
ANATOMICAL ANOMALIES and migration of the internal and external enamel epithelium in defining
the crown and root forms of teeth is particularly heritable. Familial and
Tooth characteristics such as size, shape, number and structure are geneti- racial traits affect the three-dimensional spatial configuration of the tooth
cally determined as evident from the above section. The most stable teeth and pulp space. As roots continue development after eruption and when
in the human dentition, showing minimum genetic variation are the under functional load, root form may be influenced by functional factors.
canines, central incisors and first molars. The most variable teeth are the Most human populations are of very mixed origins, although some com-
maxillary lateral incisors, the second premolars and the second and third munities have remained isolated. Genetic and functional influences have
molars. Malformed teeth may display bizarre pulp-space configurations. led to the development of characteristic traits in certain populations (Table
Most commonly this occurs in invagination, evagination, talon cusps, 1.3). The Australian aborigines and the Eskimos have the largest teeth,
dilacerations and gemination (Fig. 1.12). Table 1.1 below gives a while the Bushmen of South Africa and the Lapps have the smallest teeth.
TOOTH ORGANOGENESIS, MORPHOLOGY AND PHYSIOLOGY 7
A B C
D
E
F
Fig. 1.12 Pulp-space configurations in teeth with developmental anomalies: (a–c) Tooth invagination, (d) tooth evagination, (e,f) Talon cusp, (g) dilaceration (h,i)
gemination
Fig. 1.13 Fusion Fig. 1.14 Radiograph of malformed maxillary Fig. 1.15 Tooth evagination
canine (Talon cusp)
Fig. 1.17 Dens invagination Type 2 Fig. 1.18 Dens invagination Type 3a Fig. 1.19 Dens invagination Type 3b Fig. 1.20 Occlusal view of maxillary
teeth
The external form and size of the tooth is clearly fixed at formation but
the internal surface continues to change throughout life, even after root
Table 1.4 Eruption times of adult teeth
maturity, as secondary dentine is laid down continuously and maybe
supplemented by tertiary dentine in response to caries, tooth surface
Year Tooth loss and occlusal wear. With the passage of time, the pulp volume
6–7 16/26/36/46 31/41 therefore decreases (Fig. 1.21). This process can occur at different rates in
7–8 11/21 32/42 different teeth.
8–9 12/22 In premolar and molar teeth, laying down of dentine at the roof of the
9–10 13/23 33/43 pulp chamber is less than that at the floor of the pulp chamber. In addition
10–11 14/24 34/44 to this decrease in the height of the pulp chamber, there is also a decrease
11–12 15/25 35/45 in the mesiodistal width of the pulp chamber; however, canals do not
12–13 17/27 37/47 become completely occluded or sclerosed. Even though the coronal portion
17–22 18/28 38/48 of the canal system may become obliterated, the apical portion usually
remains patent. Such canals can be difficult to locate and treat when the
remaining pulp becomes infected (Fig. 1.22).
Fig. 1.22 Radiograph of sclerosed Fig. 1.23 Cleared Fig. 1.24 Weine’s classification of canal morphology
root canal in maxillary lateral incisor mandibular molar
Type I (1) Type II (2-1) Type III (1-2-1) Type IV (2) Type V (1-2) Type VI (2-1-2) Type VII (1-2-1-2) Type VIII (3)
over 20% of the dentine in the form of tubules. In disease, the space
Type (2-1-2-1) Type (3-1) Type (3-2) Type (2-3) Type (3-4)
becomes the province of microorganisms.
The pulp space is complex and bears little resemblance to the stylized
diagrams that are often used to explain the traditional terms used in
describing the anatomy of the pulp. It has to be appreciated that the out-
lines, shapes, and positions of pulp chambers, root canals and pulpal–
periradicular foramina are highly variable. Canals may branch, divide,
rejoin and present forms that are considerably more involved than many
textbooks of anatomy depict for simplicity; yet these simple forms serve
to convey the essential canal structure found in teeth. The complex nature
of the pulp space is typified by the appearance of an extracted molar ren-
dered transparent (Fig. 1.23).
Despite this complexity, it is useful to describe the patterns of root canal
Fig. 1.26 Gulabivala’s additional canal morphological groups
system found in human teeth. Few have tried because of the degree of
variation evident. Weine et al. (1969) used a four-group classification to
describe the canal systems in the MB roots of maxillary molars (Fig. 1.24),
which was believed could be applied universally. Zillich & Dowson (1973)
CHARACTERISTICS OF THE PULP SPACE
used an eight-group classification, which does not appear to have found A number of generalized observations can be made on the characteristics
favour. Vertucci (1984) produced a more complex and extensive classifica- of the pulp space that have a significant bearing on the practice of
tion (Fig. 1.25) to which Gulabivala et al. (2001, 2002) added a number endodontics.
of further groups (Fig. 1.26). These have been more frequently adopted In cross-section, root canals tend to take on the shapes of the roots.
for application in other studies. Where roots are wide in a buccolingual direction, the pulp space tends to
12 TOOTH ORGANOGENESIS, MORPHOLOGY AND PHYSIOLOGY
A B
Fig. 1.27 Sectioned roots of a Fig. 1.28 Proximal canal complexity in (a) an incisor, (b) a molar Fig. 1.29 Buccal and approximal
mandibular molar views of a central incisor
Fig. 1.30 Cleared maxillary molar Fig. 1.31 Cleared maxillary premolar Fig. 1.32 Buccal radiograph of Fig. 1.33 Approximal radiograph of
mandibular first premolar the mandibular first premolar
take on similar proportions to the outline of the root or there may be more
than one root canal (Fig. 1.27).
Roots and root canal systems display simple forms in the mesiodistal Table 1.5 Roots of teeth with two canals (%)
dimension, giving a simple radiographic projection; however, this masks
great complexity and curvatures in the buccolingual dimension (Fig. 1.28), Tooth Maxillary Mandibular
which is not revealed by conventional radiography. Roots and canals are Incisor Rare 41
rarely straight even when they appear so in a normal clinical radiographic Canine Rare 14
projection (Fig.1.29). Cleared specimens further reinforce the complex First premolar 84 (62 with 2 roots) 30
anatomy (Figs 1.30, 1.31). As a result, the volume of the pulp space is Second premolar 40 11
much greater than the normal buccal view might suggest. First molar 71 (MB root) 87 (M root)
Single roots do not necessarily have single root canals. Even when 38 (D root)
clinically there appears to be a single opening into a root canal, separation Second molar 3 roots/3 canals 2 roots/3 canals
can lead to two distinct canals (Figs 1.32, 1.33). Table 1.5 shows the fre- Root fusion common Root fusion common
quency of two canals in various tooth types. Typically, maxillary anterior
TOOTH ORGANOGENESIS, MORPHOLOGY AND PHYSIOLOGY 13
0–3mm B
C
D
F
Fig. 1.34 Pulpal fin in central incisor Fig. 1.35 Approximal Fig. 1.36 Relationship between root tip, apical Fig. 1.37 Cleared
radiograph of maxillary foramen, and apical constriction: A = root apex; mandibular first
canine with pulpal B = apical constriction; C = root canal; premolar
cervical bulge D = cementum; E = dentine; F = apical foramen
A B
teeth possess the type 1 canal system (single central canal following Fig. 1.40 Classification of apical constrictions: (a) traditional single
the shape of the root), while the mandibular anterior teeth may possess constriction; (b) tapering constriction; (c) parallel constriction; (d)
type 1 or other configurations (types 2, 3, 4 – see Weine classification) as multiconstricted (Reproduced from Dummer et al. 1984)
the frequency of two canals is between 40 and 50%. Maxillary first and
mandibular second premolars tend to have a type 1 canal system, while 3 mm from the root apex (Fig. 1.36). There may of course be more than
the maxillary second and mandibular first premolars can possess more one apical foramen (Figs 1.37–1.39). Dummer et al. (1984) described four
complex systems. The mesiobuccal roots of maxillary molars and the types of constriction in anterior and premolar teeth (Fig. 1.40).
mesial roots of mandibular molars tend to possess complex canal systems
Lateral, secondary and accessory canals
(types 2–4 etc), while the palatal and distobuccal roots of maxillary molars
tend to possess the type 1 canal. The distal root of mandibular molars Lateral communications arise when the pulp is supplied by collateral vas-
may frequently have either a type 1 or type 2 canal system. Characteristics culature anywhere along the length of the root and vary in size from a few
in the form of fins (Fig. 1.34) exist in oval roots with two canals, while microns in width to the size of a main canal. Such lateral communications
cervical bulges (Fig. 1.35) may occur on the palatal aspect of maxillary have been demonstrated in histological sections (Fig. 1.41), cleared teeth
canine teeth. (Fig. 1.42) and clinical radiographs (Fig. 1.43). The blood vessels passing
Generally, the diameters of root canals decrease towards the apex of the through these canals (Fig. 1.44) allow interchange of inflammatory break-
root where they tend to be narrowest, 0–1.5 mm from the foramina. The down products between the pulp and the periodontal tissues, which may
term used to describe the narrowest point is the apical constriction, which influence the outcome of endodontic treatment and periodontal health.
may be oval, round or irregular. From this point, the canal widens into the De Deus (1975) defined lateral canals as extending from the main canal
foramen, which may open onto the root surface anywhere between 0 and in the middle third of the root (body) to the periodontal ligament; the
14 TOOTH ORGANOGENESIS, MORPHOLOGY AND PHYSIOLOGY
Table 1.7 Diameters (mm) of apical foramen by tooth and root type
Table 1.8 Mean volume and standard deviation (SD) of dental pulp cavities
Maxillary Mandibular
Tooth type Mean volume (mm3) SD Mean volume (mm3) SD
Central incisor 12.4 3.3 6.1 2.5
Lateral incisor 11.4 4.6 7.1 2.1
Canine 14.7 4.8 14.2 5.4
Fig. 1.44 Minor blood First premolar 18.2 5.1 14.9 5.7
vessels entering lateral Second premolar 16.5 4.2 14.9 6.3
canals (courtesy of Prof. First molar 68.2 21.4 52.5 8.5
I Kramer) Second molar 44.3 29.7 32.9 8.4
Third molar 22.6 3.3 31.1 11.2
Fig. 1.45 Buccal radiograph of Fig. 1.46 Radiograph of lateral Fig. 1.47 Radiograph of lateral Fig. 1.48 Congenital grooving in a
central incisor and proximal incisor with two roots incisor with an invagination maxillary lateral incisor
radiograph of central incisor with
lateral canal
Fig. 1.49 Radiograph of malformed Fig. 1.50 Radiograph of extracted mandibular Fig. 1.51 Approximal groove Fig. 1.52 Specimen
maxillary lateral incisor incisors on mandibular incisor root maxillary canine
irregular triangular (base facing labially) or oval cross-section cervically, separate apical foramina is 5.5%. The canal configuration maybe type 1,
which also gradually becomes round towards the apex. Generally, there is 2 or 3, in that order of frequency. When two canals are present, the labial
very little apical curvature in central incisors and, where it is present, it is is straighter, with the division in the cervical third.
either distal or labial. It is extremely rare for these teeth to have more than In teeth with a single root canal, the canal is normally straight but may
one root or root canal. It has been suggested that up to 60% of central curve to the distal (and less often to the labial) side. The grooving found
incisors have accessory canals (Fig. 1.45). on the mesial and distal surfaces of the roots of these teeth (Fig. 1.51)
The lateral incisors are smaller, following the same pattern but the apex makes them susceptible to perforation if over-instrumented.
is often curved, generally in a distopalatal direction. Extra roots and second
canals are more likely to be found in lateral incisors (Fig. 1.46), as are MAXILLARY AND MANDIBULAR CANINES
developmental grooves and invaginations (Figs 1.47–1.49).
These teeth tend to be the longest of all. The root is wide and irregularly
tapered labiopalatally and regularly tapered mesiodistally. The canal is
MANDIBULAR INCISORS type 1 and has an oval shape cervically and begins to become round in
These teeth have a single root which is narrow mesiodistally and wide cross-section in the apical third, where there may be a distal curve. The
labiolingually. Over 40% of these teeth have two canals, which usually canal often has a bulge on the palatal aspect in the coronal third (Figs 1.52,
join in the apical third (Fig. 1.50). The highest recorded figure for two 1.53). It can very rarely present with two roots (Fig. 1.54).
16 TOOTH ORGANOGENESIS, MORPHOLOGY AND PHYSIOLOGY
Fig. 1.53 Specimen Fig. 1.54 Maxillary Fig. 1.55 Radiograph of extracted mandibular Fig. 1.56 Mandibular Fig. 1.57 Radiograph
maxillary canine cleared canine with 2 roots canines canine with two roots of mandibular canine
with two roots
Fig. 1.58 Radiograph of extracted maxillary first Fig. 1.59 Cleared Mongoloid Fig. 1.60 Radiograph of extracted maxillary
premolars maxillary first premolar second premolars
The mandibular canine resembles the maxillary canine, although its molar configuration, although the buccal canal sometimes starts as a single
dimensions are smaller (Fig. 1.55); it is the longest mandibular tooth. The canal in the pulp chamber.
root is narrow mesiodistally but wide labiolingually; it rarely has two The maxillary second premolar tends to be single-rooted with a single
roots. The canal configuration is type 1, 2, or 3 with up to 20% having canal (85%), which is wide in a buccolingual direction (Fig. 1.60). The
two root canals (Figs 1.56 1.57). The type 1 variant follows the cross- canal configurations are type 1, 2, 3, or 4 in that order, although the last
sectional shape of the root, while the others have a rounder cross-section variety may be more common than thought. Where there are two canals
after the division. they tend to converge apically. The remainder (15%) has two roots, each
with a single type 1 canal configuration. The cervical canal configuration
MAXILLARY PREMOLARS is variable as in the first premolar, from oval to figure eight.
Fig. 1.61 Radiograph of mandibular first premolar Fig. 1.62 Extracted specimen Fig. 1.63 Cleared root of Fig. 1.64 Radiograph of extracted
with two roots of mandibular first premolar mandibular first premolar mandibular second premolar
Fig. 1.65 Right Fig. 1.66 Maxillary first molar with Fig. 1.67 Four canal orifices in Fig. 1.68 Groove in the floor of a
maxillary first molar two mesiobuccal canals maxillary first molar maxillary first molar
configurations are type 1, 2 or 4 (Figs 1.62, 1.63). Three canals appear in curves buccally in the apical third. The mesiobuccal root often curves
less that 2% of the teeth. The existence of C-shaped canals has also been distopalatally in the apical third of the root (Fig. 1.65). The tooth usually
reported in these teeth. has four root canals, the additional canal being located in the mesiobuccal
The mandibular second premolars tend to be single-rooted with a single root (Fig. 1.66).
centred type 1 canal, which is wide in a buccolingual direction (Fig. 1.64). The pulp chamber floor has a quadrilateral shape, although it is some-
Two canals occur in 25% of cases, when the floor of the pulp chamber times described as triangular. All the orifices of the canals lie mesial to the
extends well below the cervical level with canal configurations of type 2, oblique ridge, allowing it to be maintained intact during access prepara-
3 or 4 in that order. About 1% may have three canals with two buccal and tion. The orifice of the palatal canal is the most prominent and lies beneath
one lingual. the mesiopalatal cusp. The orifice of the mesiobuccal canal is located
beneath the mesiobuccal cusp. The minor mesiobuccal (or mesiolingual or
MB2) and distobuccal canals are located by their relation to the main
mesiobuccal canal; the distobuccal canal is not related to the distobuccal
MAXILLARY FIRST MOLARS cusp. The distobuccal canal lies 2–3 mm to the distal and slightly to the
The maxillary first molars are three rooted, two buccal and one palatal. palatal aspect of the mesiobuccal canal. The mesiolingual canal (MB2) lies
The mesiobuccal root is broad in the buccopalatal plane and narrow in on a line joining the major canal and the palatal canal orifice, 1.82 mm to
the mesiodistal plane, similar to a maxillary premolar root configuration. the lingual on average (Fig. 1.67). As both the canals lie on the buccopala-
The root generally exits the crown mesially and can abruptly curve tal plane, they are often superimposed on the preoperative radiograph. The
distally. The distobuccal root is the smallest and can vary in cross-section presence of a groove on the floor of the pulp chamber may be an indication
from round to oval with the narrow dimension oriented mesiodistally; of the likelihood of a second mesiobuccal canal orifice (Fig. 1.68), which
it can curve mesially in the apical third. The palatal root is the bulkiest, may be only fully exposed after the removal of dentine in the area (Fig.
oval, with the widest dimension oriented mesiodistally, and generally 1.69). The mesiobuccal root can have canal configurations of type 1, 2, or
18 TOOTH ORGANOGENESIS, MORPHOLOGY AND PHYSIOLOGY
Fig. 1.69 Mesiobuccal canals Fig. 1.70 Buccal Fig. 1.71 Maxillary Fig. 1.72 Maxillary Fig. 1.73 Maxillary
evident following removal of the curvature of a palatal first molar with an second molar with second molar cleared
groove root of a maxillary first extra root buccal root fusion
molar
Fig. 1.74 Extracted Fig. 1.75 Cleared two-rooted Fig. 1.76 (a) Three-rooted mandibular molar (b) five-rooted mandibular molar
mandibular first molar mandibular first molar
Fig. 1.77 Mandibular first molar Fig. 1.78 Radiograph of mandibular first molar Fig. 1.79 Cleared mandibular
with three canals with four canals first molar with five canals
Fig. 1.80 Clinical radiograph of mandibular Fig. 1.81 Mandibular Fig. 1.82 Clinical radiograph of mandibular Fig. 1.83 Buccal
second molar second molar with second molar radiograph of
fused roots extracted second molar
The single distal canal (type 1) is usually larger and more oval in cross-
section (sometimes kidney shaped) and has a tendency to emerge on the
distal side of the root surface short of the anatomical apex. More than 25%
of the distal roots have two canals, half of which have separate apical
foramina (type 2 or 3 configurations) (Fig. 1.78). The frequency of second
distal canals appears to be higher in Mongoloid teeth, and specimens with
five canals have been observed (Fig. 1.79). When a second distolingual
canal is present, it tends to curve towards the buccal. There have been case
reports of five and six canals and the presence of a third mesial canal.
MANDIBULAR SECOND MOLARS Fig. 1.84 Approximal Fig. 1.85 Lingual view Fig. 1.86 Cleared
radiograph of the of extracted specimen specimen
This tooth can have many morphological variants, although in general, the
extracted second molar
most common type has the same pattern as the mandibular first molar. In
Caucasoid mandibular second molars, the mesial root has two (occasion-
ally one) canals and the distal root usually has only one canal (type 1 teeth with C-shaped roots do not always have C-shaped openings. Those
configuration) (Fig. 1.80). The prevalence of canal configuration is differ- with C-shaped orifices do not always have continuous C-shaped canals.
ent in the mesial root compared to the first mandibular molar; in this case,
type 2 is more common than type 3. The roots tend to be closer together
and may fuse (Fig. 1.81). Rarely, only one canal is present when both roots
MAXILLARY AND MANDIBULAR THIRD MOLARS
are fused (Figs 1.82–1.86). In Mongoloid teeth, the fusion of roots is The root form and canal anatomy of maxillary third molars is highly vari-
common and where roots are incompletely separated interconnections are able. It may possess three roots (Fig. 1.88) but more often fusion occurs
likely, giving rise to the C-shaped canal (Fig. 1.87). It would seem that and only one or two canals are evident (Fig. 1.89).
20 TOOTH ORGANOGENESIS, MORPHOLOGY AND PHYSIOLOGY
A B A B
Fig. 1.87 C-shaped canal in Fig. 1.88 (a) Maxillary third molar (b) Fig. 1.89 (a) Maxillary third molar (b)
mandibular second molar maxillary third molar cleared maxillary third molar cleared
A B A B
Fig. 1.90 (a) Extracted mandibular third molar Fig. 1.91 (a) Extracted mandibular third molar
(b) cleared mandibular third molar (b) cleared mandibular third molar
The roots and root canals of the mandibular third molars tend to be short
Fig. 1.92 Radiograph of mandibular
and poorly developed (Fig. 1.90). The anatomy tends to vary and where
incisors with root canal division
there is root fusion the canals also fuse (Fig. 1.91).
C
A
A
B
Buccal lamina
Enamel niche
Enamel organ
fibres and a complex network of blood vessels and nerve fibres (Fig.
1.106). The ground substance contains the fibroblasts responsible for pro-
ducing the proteins and carbohydrates that form the viscous substance of
the matrix. The ground substance accommodates humoral and immune
cellular infiltrates produced during inflammatory responses. Lymphatic
vessels help to clear away exuded fluid and macromolecules and return
the tissue to status quo.
Biological or chronological ageing may reduce the cellular and neurov-
ascular elements and thereby reduce the ability of the aged pulp to respond B
to injury. The pulp tissue has a rich neurovascular supply that reaches it
via arterioles and nerve bundles through the apical foramina and lesser
accessory supplies via lateral canals in the root. These allow an exchange
of tissue fluid between the periodontal and pulpal tissues, otherwise the
cementum is impervious to macromolecules (a feature that makes survival A
of the tooth by root canal treatment feasible).
The structure of the mineralized dentine is depicted in (see Fig. 1.102).
There may be up to 65 000 tubules per square millimetre at the pulpal end
and 15 000 tubules per square millimetre at the dentine–enamel junction.
Fig. 1.110 Irregular deposition of secondary dentine (A) due to caries (B)
The diameter of the tubules is about 3 μm near the pulp and less than 1 μm
peripherally. The dentinal tubules account for 45% of the surface area near
the pulp and 1% of the total surface area near the dentine–enamel junction. on of dentinogenesis at the termination of tooth formation. Irregular sec-
The dentinal tubules, which are interconnected by lateral tubules (Fig. ondary dentine, as the name implies, is laid down unevenly at a rate of
1.107) make up 20–30% of the volume of dentine. Primary dentine formed about 3 μm per day, in response to noxious external stimuli, such as dental
during the development of the tooth is laid down at a rate of 4 μm per day. caries, attrition, and abrasion (Figs 1.105, 1.109, 1.110). It is laid down by
Secondary dentine is laid down by the same odontoblasts that formed the newly differentiated odontoblast-like cells replacing those damaged by the
teeth but after they are fully developed. It is laid down at the much slower noxious stimuli; therefore, the tubules and processes are not continuous
rate of about 0.8 μm per day and is formed evenly over the entire pulpal with primary and secondary dentine.
surface; it is also known as physiological or regular secondary dentine. It The name peritubular dentine is given to the tissue laid down by the
may be distinguished from primary dentine by the slight and sudden odontoblast process within the tubules. It is 40% more mineralized than
change in the direction of the tubules (Fig. 1.108). This change in direction intertubular dentine (mineralized tissue between tubules) and lacks a fibril-
and rate is thought to be due to the switching off and then switching back lar matrix (Fig. 1.111). The formation of peritubular dentine is thought to
24 TOOTH ORGANOGENESIS, MORPHOLOGY AND PHYSIOLOGY
B
C
A B
Fig. 1.111 Cross-section of dentinal tubules: Fig. 1.112 SEM images showing (a) mineralized tubules contrasted with (b) demineralized tubules
A = peritubular dentine; B = interbutular dentine;
C = odontoblast process
Supply
Supply arteriole
capillary
network
Terminal
capillary
network
THE VASCULAR SUPPLY branches, which terminate in a supply network of capillaries (Figs 1.115–
The arrangement of the vascular system in the pulp is uniquely developed 1.118). It consists of ascending and descending branches, which are ori-
and organized to help overcome the problems of its non-compliant encap- ented perpendicular to the dentine surface. They supply and drain the
sulation within the rigid dentine shell. The structure of the vascular archi- terminal capillary network, which reach the odontoblastic layer where they
tecture alters and adapts according to metabolic needs as the tooth develops. divide extensively to form a plexus below (Fig. 1.119) and within (Fig.
It may be visualized as consisting of: (1) the main supply arterioles; (2) 1.120) it. This is oriented parallel to the dentine surface in the crown, is
the supply capillary network; (3) the terminal capillary network; (4) the 400–500 μm wide and diminishes in width towards the root. The venous
venular network (Fig. 1.114). return is collected by a network of capillaries that unite to form venules,
The main supply arterioles, usually 5–8 in number are branches of the which primarily course down the peripheral part of the pulp and drain into
dental arteries that enter through the apical foramina, pass centrally through the main venules (2–3) in the central portion of the pulp (Fig. 1.121). Some
the pulp and arborize. Some branches of these vessels run along the root minor vessels may enter through lateral canals but these cannot provide
canal wall as they advance towards the coronal pulp giving off lateral sufficient collateral circulation (Fig. 1.122).
TOOTH ORGANOGENESIS, MORPHOLOGY AND PHYSIOLOGY 25
A B
Fig. 1.115 A transverse section through the root pulp (P) of a human
mandibular premolar. The rectangular demarcated area in (a) is magnified in
(b). Note the numerous nerve fibre bundles (NB), some of which are closely
associated with blood vessels (BV) to form neurovascular bundles (inset in b). Fig. 1.118 Relationship of arterioles Fig. 1.119 Capillary plexus adjacent
OB = Odontoblasts. Magnifications: (a) ×55, (b) ×130, inset ×225. and capillaries in the pulp to dentine to the dentine (courtesy of Prof.
(Reproduced with permission from Nair PNR, Schroeder HE (1995) Number (A) (courtesy of Prof. I Kramer) I Kramer)
and size spectra of non-myelinated axons of human premolars. Anat Embryol
192, 35-41)
Fig. 1.120 Capillary
(A) from the
subodontoblastic plexus
Fig. 1.122 Minor blood vessels entering lateral Fig. 1.123 Localized inflammation Fig. 1.124 Lymphatic vessel in feline dental pulp
canals (courtesy of Prof. I Kramer) of the pulp (arrowed) (from Bishop & Malhotra, 1990)
and blood cells back to the circulation. The mean velocities of vascular
fluid are approximately 1.5 mm/s in the primary feeding arterioles, decreas-
ing to 1 mm/s in secondary arterioles, 0.5 mm/s in terminal arterioles, and
0.2 mm/s in the capillary bed. It then increases to 0.4 mm/s and then
0.6 mm/s in the collecting and final venules, respectively. One feeding
arteriole may supply 100 capillaries.
The vasomotor tone controlling the flow of blood is moderated by sym-
pathetic nerve fibres and chemical and humoral mediators, which may be
both vasodilators and vasoconstrictors. In contrast to most tissues, reactive
hypoxaemia and functional hyperaemia are not observed in the pulp.
Occlusion of the external carotid arteries produces reactive hyperaemia in
oral tissues but not in the pulp. The response of the pulp under vascular
stress is therefore to shut down, in marked contrast to other tissues.
Fig. 1.126 A magnified view of the demarcated area in Figure 1.129 showing
detail of non-myelinated axons, variation in size of the non-myelinated axons.
(AN = myelinated axons, SC = Schwan cells). Magnification: ×9110.
(Reproduced with permission from Nair PNR, Schroeder HE (1995) Number
and size spectra of non-myelinated axons of human premolars. Anat Embryol
192, 35-41)
Fig. 1.129 Immunocytochemical section showing CGRP-IR nerve fibres
branching extensively in the coronal pulp and entering into dentine for up to
Fig. 1.127 Plexus of 0.1 mm but avoiding reparative dentine (RD). (Reproduced with permission
Raschkow from Byers MR, Taylor PE, Khayat BG et al (1990) Effects of injury and
inflammation on pulpal and periapical nerves. J Endod 16, 78-84)
sensitivity may, therefore be increased by opening up the dentinal tubules Fig. 1.130
by acid etching; conversely, blockage of the tubules, such as by potassium Hydrodynamic theory: A = nerve plexus; B = odontoblast; C = dentine; D = Aδ
nerve fibre; E = odontoblast process; F = dentinal tubule; G = fluid movement
oxalate crystals prevents fluid flow and leads to desensitization of dentine.
stimulates Aδ nerve fibre
Blockage of the dentinal tubules by sclerosis over time would also lead to
desensitization.
During electric pulp testing, the Aδ fibres are stimulated first because not activate the C fibres unless some element of damage occurs to the pulp
they have a lower stimulation threshold. Increase in stimulus intensity is tissue, such as raising the pulp temperature to about 44°C. Similarly,
conveyed by an increase in the frequency of firing and by the recruitment extreme cold temperatures reaching the pulp may stimulate the C fibres.
of more Aδ fibres; if the stimulus becomes noxious, C fibres may also The C fibres are thought to play an important role in the development
be stimulated giving rise to a strong unpleasant sensation. The relative of the dull and poorly localized symptoms associated with pulp
unreliability of electric pulp testing of young teeth with immature roots inflammation.
may be explained by the scarcity of Aδ fibres in their pulps at this stage The third type of nerve called the Aβ fibre is myelinated and has the
of development. fastest conduction velocity. They are thought to respond to non-noxious
The C fibres may be activated by thermal, mechanical or chemical mechanical stimulation of the intact crown and may be important in the
stimuli reaching the deeper parts of the pulp. Dentinal stimulation does regulation of mastication and loading of teeth. They do, however, also
28 TOOTH ORGANOGENESIS, MORPHOLOGY AND PHYSIOLOGY
B
A
A
B
A
B
C
C
C
Fig. 1.135 Cementum; dentine, periodontal Fig. 1.136 Healing of periapex with cementum Fig. 1.137 Gingival, transeptal and alveolar crest
ligament and alveolar bone: A = periodontal formation (arrowed); A = periodontal ligament; fibres – longitudinal view: A = gingival fibres;
ligament; B = acellular cementum; C = dentine; D B = root canal; C = alveolar bone (courtesy of Prof. B = transeptal fibres; C = alveolar crest fibres
= alveolar bone T Pitt Ford)
A B
PERIODONTAL LIGAMENT
Periodontal ligament is a dense fibrous connective tissue which supports
and attaches the tooth to its alveolar socket (see Fig. 1.131). Its principal
component is collagen, which is embedded in a gel-like matrix. The fibres
are arranged in specific groups with individual functions. These include
gingival, trans-septal, alveolar crest (Fig. 1.137), horizontal, oblique (Figs
1.138, 1.139) and apical fibres. Another important component is the oxyta-
lan fibre. Functional adaptation may take place in the broad zone known C
as the intermediate plexus (Fig. 1.140). The main cells are fibroblasts and
occasional defence cells. The root sheath of Hertwig, which helps in the B
formation of the root, does not involute completely after completion of
root formation but degenerates into what resembles a perforated bag of Fig. 1.140 Intermediate plexus: A = dentine; B = intermediate plexus;
epithelial cells (Fig. 1.141), called the rests of Malassez (Fig. 1.142). The C = alveolar bone
30 TOOTH ORGANOGENESIS, MORPHOLOGY AND PHYSIOLOGY
Fig. 1.141 “Perforated bag” appearance of epithelial Malassez cells Fig. 1.142 Rest of Malassez
Fig. 1.145 The tooth in Figure 1.148 Fig. 1.146 Disused periodontal
following crown placement. Premature ligament. Note the lack of proper
Fig. 1.143 Vascular communications Fig. 1.144 Normal periodontal occlusal contact caused overloading orientation of fibres in a narrow
at the root apex ligament and widening of periodontal ligament ligament
perforations are quite large and the intercommunicating strands of epithe- Nerve supply
lial tissue may not all be seen in a given histological section. These cells
Nerve bundles enter the periodontal ligament through numerous foramina
can proliferate when stimulated by inflammation to form a cyst. They also
in the alveolar bone. They branch and end in small rounded bodies near
produce cytokines and participate in the apical defence response.
the cementum. The nerves carry pain, touch and pressure sensations and
form an important part of the feedback mechanism of the masticatory
Blood supply apparatus.
Blood supply to the periodontal ligament originates from the inferior
Functions
dental artery. Arterioles enter the ligament near the apex of the root from
the lateral aspects of the alveolar socket and branch into capillaries within The ligament has a proprioceptive function and acts as a viscoelastic
the ligament in a polyhedric pattern along the long axis of the root (see cushion by virtue of its fibres and hydraulic fluid systems (blood vessels
Fig. 1.139). The collagen fibres run through the polyhedral spaces. The and their communications with vessel reservoirs in the bone marrow and
blood vessels are located closer to the bone than to the cementum. Com- the interstitial fluid of the ligament). The ligament has great adaptive
munications between the vasculature of the pulp and periodontal ligament capacity. It responds to functional overloading by widening to relieve the
may be evident, especially near the root apex and furcation (Fig. 1.143). load on the tooth (Figs 1.144–1.147). The radiographs in Figures 1.144
Venules drain to the apex or through apertures in the bony wall of the and 1.145 show the same tooth before and after placement of a crown with
socket and into the marrow spaces. a premature occlusal contact: in Figure 1.145, the periodontal ligament
TOOTH ORGANOGENESIS, MORPHOLOGY AND PHYSIOLOGY 31
Fig. 1.147 Overloaded periodontal Fig. 1.148 Alveolar bone Fig. 1.149 Trabeculae in spongy bone
ligament with oblique fibre
orientation and resorption of bone
space is noticeably wider. Figure 1.146 shows a histological view of a Fig. 1.150 Osteoclasts
disused tooth with a lack of proper orientation of fibres in a narrow liga- (arrowed) in Howship’s
ment. Figure 1.147 shows the periodontal ligament of a tooth under normal lacunae
heavy occlusal load, with evidence of adjacent bone resorption causing the
ligament to widen; this widening should be distinguished from that which
occurs in response to pathological irritation. The periodontal ligament also
plays an important part in the eruption of teeth and healing, for example
following surgery or trauma. Vascular channels between the pulp and peri-
odontium form pathways for transmission of both inflammation and micro-
organisms between the tissues.
ALVEOLAR BONE
Fig. 1.151 Relationship
Alveolar bone is that part of the maxilla and mandible which supports the between alveolar bone
teeth by forming the “other” attachment for fibres of the periodontal liga- and cemento–enamel
ment (Fig. 1.148). It consists of two plates of cortical bone separated by A junction in health:
spongy bone (Fig. 1.149). In some areas, the alveolar bone is thin with no A = cemento–enamel
spongy bone (Fig. 1.148). The alveolar bone and the cortical plates are junction; B = alveolar
thickest in the mandible. The spaces between the trabeculae of the spongy bone
B
bone are filled with marrow, which consists of haematopoietic tissue in
early life and of fatty tissue later (Fig. 1.149). The shape and structure of
the trabeculae reflect the stress-bearing requirements of the particular site.
The surfaces of the inorganic parts of the bone are lined by osteoblasts,
which are responsible for bone formation: those which become incorpo-
rated within the mineral tissue are called osteocytes and maintain contact the cemento–enamel junction (Fig. 1.151) but, in periodontal disease, it
with each other via canaliculi; osteoclasts are responsible for bone resorp- may lie much more towards the apex of the root.
tion and may be seen in the Howship’s lacunae (Fig. 1.150). Cortical bone
adjacent to the ligament gives the radiographic appearance of a dense
white line next to the dark line of the ligament (see Figs 1.144, 1.145). REFERENCES AND FURTHER READING
Bone is a dynamic tissue, continually forming and resorbing in response Bishop, M.A., Malhotra, M.P., 1990. An investigation of lymphatic vessels in the feline
to functional requirements. In addition to such local response to needs, dental pulp. Am J Anat 187, 247–253.
bone metabolism is under hormonal control. It is easily resorbed under the De Deus, Q.D., 1975. Frequency, location, and direction of the lateral, secondary, and
accessory canals. J Endod 1 (11), 361–366.
influence of inflammatory mediators at either the periapex or the marginal Dummer, P.M., McGinn, J.H., Rees, D.G., 1984. The position and topography of the
attachment. In health, the crest of the alveolus lies about 2 mm apical to apical canal constriction and apical foramen. Int Endod J 17 (4), 192–198.
32 TOOTH ORGANOGENESIS, MORPHOLOGY AND PHYSIOLOGY
Fanibunda, K.B., 1986. A method for measuring the volume of human dental pulp Thesleff, I., 2003. Epithelial-mesenchymal signalling regulating tooth morphogenesis.
cavities. Int Endod J 19, 194–197. J Cell Sci 116 (9), 1647–1648.
Gulabivala, K., Aung, T.H., Alavi, A., et al., 2001. Root and canal anatomy of Burmese Vertucci, F.J., 1984. Root canal anatomy of the human permanent teeth. Oral Surg Oral
mandibular molars. Int Endod J 34 (5), 359–370. Med Oral Pathol 58, 589–599.
Gulabivala, K., Opasanon, A., Ng, Y.-L., et al., 2002. Root and canal anatomy of Thai Weine, F.S., Healey, H.J., Gerstein, H., et al., 1969. Canal configuration in the
maxillary molars. Int Endod J 35, 56–62. mesiobuccal root of the maxillary first molar and its endodontic significance. Oral
Hess, W., Zurcher, E., 1925. The anatomy of the root canals of the teeth of the Surg Oral Med Oral Pathol 28, 419–425.
permanent and decidous dentitions. William Wood & Co., New York. Zillich, R., Dowson, J., 1973. Root canal morphology of mandibular first and second
Morfis, A., Sylaras, S.N., Georgopoulou, M., et al., 1994. Study of the apices of human premolars. Oral Surg Oral Med Oral Pathol 36, 738–744.
permanent teeth with the use of scanning electron microscope. Oral Surg Oral Med
Oral Pathol 77 (2), 172–176.
Oehlers, F.A.C., 1957. Dens invaginatus (dilated composite odontome): I. Variations of
the invagination process and associated anterior crown forms. Oral Surg Oral Med
Oral Pathol 10 (11), 1204–1218.
2
Section 1 Rationale for disease management
Biological and clinical rationale for vital pulp therapy
K Gulabivala, Y-L Ng
The aim of this chapter is to outline the biological basis for prevention and vicinity of the exposed tubules reduces their threshold and leads to hyper-
management of pulp disease. A rational approach to the treatment of algesia or hypersensitivity. In addition, it also allows stimulation of the
disease requires an understanding of the pathological process, which in higher threshold C fibres that are responsible for the deep-seated, less
turn, demands knowledge of the normal anatomy and physiology of the localized, duller, throbbing pain associated with pulpitis. Stimulation of
involved tissues (see Chapter 1). Given the low-compliance encapsulation proprioceptive Aβ nerve fibres may forewarn the owner of impending
of the pulp and its apparent fragility as a tissue, it was once believed that overloading of the tooth.
relatively minor events could precipitate pulp necrosis and infection. Yet, In addition to sensory defences, the inflammatory response of the pulp
the pulp shows remarkable resilience and ability to repair and survive an contributes to recruitment of the full array of non-specific and specific
aggressive oral environment and generally unsympathetic dental interven- immunological responses (see Chapter 3). This system protects the pulpal
tions. Clearly the pulp–dentine complex is adapted for such survival and soft tissue against external molecular or microbial assault. An extremely
this chapter explores the interplay between host mechanisms and restora- important function of the pulp–dentine complex, which often works simul-
tive factors that determine the direction of the outcome. taneously with inflammation, is secondary (reactionary) or tertiary (repara-
tive) dentine formation (Fig. 2.2) together with dentinal tubule sclerosis
(calcification) (Fig. 2.3) to block off further ingress of noxious factors. It
FUNCTIONS OF THE PULP
is likely that severe inflammation may interfere with the dentinal response
The functions of the pulp are stated to be formative (dentine) and defensive by disturbing the odontoblastic function.
(through the pulp–dentine complex, inflammatory and immune responses). Reparative processes within the pulp–dentine complex mimic develop-
Once the tooth is fully formed, the pulp mainly serves a defensive function. mental processes. During tooth formation, molecular signals (growth
The pulp is not a vestigial organ, as indicated by the definite change in the factors) between epithelial and mesenchymal cells control the induction
rate at which dentine is deposited once tooth formation is complete. Hypo- of odontoblast differentiation. The growth factors have a profound effect
thetically, if secondary dentine deposition continued at the rate of primary on various cellular activities and are found throughout the body. A subclass
dentine formation, the almost complete obliteration of the pulp would of these molecules, called the transforming growth factor-beta (TGF-β)
result in a tooth with very different mechanical properties. By inference, family, is responsible for signalling odontoblast differentiation. The dif-
the raison d’être of the pulp and dentine must be to provide a tooth with ferentiated odontoblasts synthesize and secrete the TGF-βs together with
the resilient characteristics necessary for withstanding masticatory load. other growth factors and sequester them into the dentine matrix, which
Note that the tooth is considered the hardest structure in the body and then becomes calcified. The subsequent dissolution of the dentine matrix
referred to as a non-compliant environment from a fluid dynamics perspec- as a result of caries, tooth surface loss or restorative procedures releases
tive. Yet, from a mechanical perspective, dentine can flex at a microstrain these molecules again to exert their influence on healing. TGF-β molecules
level, detectable by sensitive strain gauges. This microscopic deformation released by mild dentine–pulp injury diffuse along a concentration gradi-
of the tooth under occlusal load must, by the principle of homeostatic ent down the dentinal tubules, against the outward flow of dentinal fluid,
mechanisms, be detectable by proprioceptors in the pulp; however, direct and stimulate viable odontoblasts to lay down reactionary dentine. Injury
evidence for the existence of proprioceptors in the pulp is absent. The that is severe enough to damage odontoblasts irreversibly requires their
presence of Aβ fibres, which serve a proprioceptive function, offers an replacement from the pulpal mesenchymal cell pool. This is a lengthier
attractive, if partial, explanation for the apparently greater susceptibility and more complex process requiring the migration and differentiation of
of pulpless teeth to fracture. new cells followed by secretion of a new matrix. The resulting dentine is,
Defence reactions are essential for the survival of the pulp. The most therefore less well organized and known as reparative dentine (see Fig.
obvious and widely described defence reactions include: the initial inflam- 2.1). An important factor that may interfere with the reparative process is
matory response in the pulp; blockage of the involved dentinal tubules by a continuing microbial challenge as a result of coronal leakage, as well as
large molecular substances in the transudate; the sclerosis of the dentinal the toxicity of any restorative material, which would both intensify the
tubules by mineral deposition and formation of peritubular dentine; and, inflammatory process (Fig. 2.4).
finally, the laying down of secondary and tertiary dentine (Fig. 2.1).
The pulp–dentine complex has been thought of as a sensory organ that CAUSES OF PULP INJURY
warns against developing disease (e.g. caries or other forms of surface
tooth tissue loss) by eliciting pain. In this role, the warning system is not The pulp may be injured in a variety of direct and indirect ways. These
effective given the proportion of teeth whose pulps become irreversibly are summarized in Table 2.1 (Figs 2.5–2.7). The pulp may be injured
inflamed apparently without prior pain. The recently exposed dentine may either by interference with its blood supply or by damage to, or through,
become sensitive over a few days but, thereafter, as the pulp recovers, the the pulp–dentine complex. Direct interference with the blood supply
sensitivity too would subside. may occur in acute (impact) or chronic (occlusal) traumatic injuries.
The first line of sensory defence involves stimulation of the low- Injuries through the pulp–dentine complex may occur by: (1) induction
threshold cutaneous-type Aδ nerve fibres, responsible for the sensation of of cracks or fractures in the tooth structure (through acute or chronic
the characteristic sharp, lancinating dentinal pain elicited by stimulating traumatic injuries); (2) exposure of dentine through natural (attrition,
dentine by probing, air blast, hyperosmotic fluids, extreme temperatures abfraction), dietary (attrition, erosion), parafunctional (attrition, abrasion),
or occlusal loading (in the cracked tooth syndrome). Inflammation in the habitual (attrition, abrasion), pathological (caries, resorption) or iatrogenic
Fig. 2.1 Primary (A) and irregular Fig. 2.2 Secondary dentine Fig. 2.3 Sclerosed dentinal tubules Fig. 2.4 Bacteria in dentinal tubules
secondary (B) dentine deposition caused by caries and its (arrowed) (low-power view)
treatment
Fig. 2.5 Effect of attrition on dentine Fig. 2.6 Effect of caries on the pulp: A = inflamed Fig. 2.7 Effect of cavity preparation on the pulp
pulp tissue
(operative or cosmetic) processes; or (3) direct exposure and damage to of microbial stimulants would eventually lead to chronic inflammation and
the pulp. pulpal demise. The mechanism for such progression may begin with an
Exposure of dentine through any of the mentioned processes would accumulation of polymorphonuclear leucocytes (PMNs) at the boundary
induce direct physical injury to odontoblastic processes and the cell body. of the pulp–dentine complex with migration of these phagocytic cells into
The disruption would cause the tight junctions between odontoblasts to the dentinal tubules. Observation of this phenomenon was originally mis-
separate and be pushed away centrally into the pulp; this would allow interpreted as “aspiration of odontoblasts”. This would be followed by
pathways of fluid flow from the pulp to open up. Equally, the pulp would migration of macrophages, particularly if an irritating or allergenic mate-
then be open to stimulation by microbial factors by diffusion, albeit against rial had been deployed.
the tide of outward flowing dentinal fluid. The degree of such exposure to These would then be followed by the specific response, including T and
flowing or diffusing substances would be dependent on the surface area of B lymphocytes. The chances of pulp necrosis may be enhanced when the
exposure, permeability of the dentinal tubules and depth of dentine damage. accumulation of PMNs is profuse.
The permeability of dentinal tubules is affected by several factors, includ- Protection of the pulp–dentine complex is, therefore dependent on cov-
ing involvement in the carious process, physiological response, pathologi- erage of the exposed dentine using restorative materials. Such coverage
cal response, exposure to acidic oral environment, calcification, and may simply aim to provide a protective layer or simultaneously replace
coverage by restorative materials. The rate of damage to the dentine, the missing tissue, restoring form, function, aesthetics and speech. The
whether carious or non-carious, may also influence the ability of the pulp complexity and invasiveness of the restorative procedures may in turn also
to defend itself. The dentine reputedly has a strong buffering capacity induce further damage to the pulp, but this is seen as a necessary calculated
against the inflow of bacterial substances by binding them to the walls of risk in order to afford the final protection, just as it is in any elective
the tubules. surgery. It is, however, important to appreciate the damaging effect of
The physiopathological mechanisms in place, namely, inflammation, restorative procedures. A key initial problem is the manner by which the
outflow of dentinal fluid, temporary blockage of tubules by protein mol- material is attached to the tooth structure; whether this involves mechani-
ecules, followed later by mineralization (dentinal sclerosis) and formation cal or chemical retention, each has its advantages and disadvantages.
of reactionary dentine help to close off the avenues of direct pulp exposure, The relative importance of the different factors causing pulp injury,
in time. If such closure were not possible because of a precompromised when restorative procedures are employed, has been debated at length and
pulp unable to generate the reparative response, then the unrelenting inflow the emphasis has changed from one set of factors to another. In the 1950s
BIOLOGICAL AND CLINICAL RATIONALE FOR VITAL PULP THERAPY 35
A B
Fig. 2.10 Incandescence caused by Fig. 2.11 Bacteria (a) lining the surface of cut dentine (high-power view), (b) in dentinal
dry cutting of dentine tubules
A B
Fig. 2.15 (a) Pulp chamber containing vital pulp tissue; (b) radiograph of the
same tooth, showing periapical area around palatal root before opening into
the pulp
A B
rest of the pulp is not fully understood. It is presumably related to the of subsequent infection of the necrotic pulp. Such pulps have been shown
ability of the pulp to close off dentinal tubules by the action of replacement to remain uninfected for up to 6 years.
odontoblasts from undifferentiated mesenchymal cells. If this fails to wall
off the source of inflammation, then it would become persistent and
chronic. It can be envisaged that the greater the number of adjacent den-
DYSTROPHIC PULP CALCIFICATION
tinal tubules involved and the greater the degree of odontoblast injury, the A common finding in the pulp in all age groups is the presence of dys-
larger the volume of pulp tissue affected by inflammation. The localized trophic calcification or pulp stones. These are more common in teeth with
response may or may not progress to more severe inflammation depending diseased pulps but may also be found in unerupted teeth. The precise
on stemming of the provoking factors. Progression of the inflammation stimulus for calcification is unknown but may be presumed to be mediated
may produce a range of histological pictures, including areas of chronic via the mechanisms stimulated by growth factors and leading to odon-
inflammation coexisting with microabscesses, gross PMN accumulation togenesis from mesenchymal cells. A recent theory suggests a role for
and partial necrosis (Fig. 2.14). Unfortunately, all these histological pic- nanobacteria or particles but this remains far from widely accepted so far.
tures of pulp disease have a poor correlation with clinical signs and symp- There are two types of calcifications; those which are smooth and rounded
toms; in 50% of cases, the pulp remains asymptomatic. This makes clinical are formed by concentric laminations and found commonly in the coronal
diagnosis of the state of the pulp extremely difficult as the tissues are pulp (Fig. 2.16a), whereas the irregular calcifications without laminations
hidden from direct view and examination. Adding to the complexity of are found more commonly in the radicular pulp (Fig. 2.17a). These may
this diverse picture is the finding that, in some cases (usually young sometimes take the shape of rods or leafs. The laminated stones grow in
patients), even in the presence of vital healthy pulp tissue in the roots size by the addition of collagen fibrils to their surface (Fig. 2.16b), whereas
(Fig. 2.15a), there may be radiographic evidence of periapical change the irregular type of pulp stones form by calcification of pre-existing col-
(Fig. 2.15b) associated with coronal pulp inflammation. A reasonably clear lagen fibre bundles (Fig. 2.17b). Some regard the calcifications as a dys-
distinction between different states of the pulp can only be made between trophic change, but these calcifications are not always found in association
vital (albeit inflamed) and completely necrotic pulps using currently avail- with degenerative changes. The main clinical significance of pulp calcifi-
able pulp tests. cation lies in the technical difficulty it can cause during root-canal treat-
Under the specific condition of traumatic impact injuries, sudden sever- ment. Sometimes the calcification may be extensive enough to almost
ance of the blood supply can result in total necrosis of the pulp without obliterate the pulp space (Fig. 2.18). These changes may make the location
any intervening infection, inflammation or subsequent radiographic peri- and negotiation of canals difficult. Furthermore, dislodged stones may be
apical change. Such change would then only become evident in the event pushed apically to cause a blockage. Irregular calcification in the canal
38 BIOLOGICAL AND CLINICAL RATIONALE FOR VITAL PULP THERAPY
surface loss, acute traumatic injury or cavity preparation. In each case, the at repair may create a calcific barrier but may not possess the structural
operator has to estimate the pre-existing state of the pulp, the extent of integrity or full defensive ability of a normal pulp–dentine complex. Such
pulp injury and the degree of microbial contamination. In the case of an deficient barriers may eventually succumb to the effects of microbial colo-
acute or chronic (tooth surface loss) traumatic injury, the hard tissue wound nization, whereas a fully functional pulp–dentine complex would eventu-
is clearly seen and its history will reveal the extent of damage at the ally lead to an inflammation-free pulp. Judging the outcome (regeneration/
surface. The nature of the acute injury will give an indication of the prob- repair/non-healing) is somewhat subjective, with opinions varying about
able damage to the pulp and its chances of success. When dealing with a the amount of time given from 6 weeks to 6 months.
deep carious lesion, the picture is less clear as the extent of the carious
lesion in its proximity to the pulp will not be obvious. Its acute or chronic REGENERATIVE PULP THERAPY
nature will provide some insight into the degree of pulp injury as judged
by loss of odontoblasts and inflammation. Estimation of the degree of This is a relatively newly tried approach with a limited evidence-base. It
damage is made by a number of clinical assessments. The first assessment is supported only by case reports/series, many of which have involved
is to judge the histological state of the pulp. This judgement is made on mandibular premolars devitalized by occlusal wear or breach of a dens
the history of pain, examination findings, pulp tests and radiographs. The evaginatus, leaving the root incompletely formed. The cases involved have
poor correlation between the histopathology of the pulp and clinical signs periapical lesions and sometimes even suppuration. The proposed manage-
and symptoms leaves the operator with an educated guess. Despite this, it ment consists of conventional access under rubber dam isolation, flushing
has often been stated that teeth exhibiting no history of pain or signs of of the root canal using a dilute sodium hypochlorite solution, followed by
periapical disease and a positive response to pulp tests stand a good chance dressing with a mixture of antibiotic (ciprofloxacin, metronidazole, mino-
of success following vital pulpal therapy. Conversely, teeth exhibiting cycline) or calcium hydroxide paste within the coronal half to three-
severe throbbing, spontaneous pain, made worse by hot stimuli and keeping quarters of the canal. The latter helps to control the infection without
the patient awake may not fare well using this approach. The second damaging any mesenchymal stem cells in the periapical tissues containing
assessment is to estimate the proximity of the carious lesion to the pulp the residue of the formative dental papilla. Once the infection is controlled,
and, lastly, to guess the extent to which the superficial pulp may be necrotic the paste is removed and the canal debrided. Bleeding is then induced by
and contaminated by bacteria (Fig. 2.19). over-instrumentation of the periapical tissues or the residual dental papilla,
The aim of the treatment is to remove as much of the infected hard or to encourage the influx of stem/mesenchymal cells. The tooth is then
soft tissue as possible and to restore the tooth with a bacteria-tight restora- dressed with mineral trioxide aggregate (MTA) over the blood clot and
tion in order to preserve the health of the residual pulp tissue, leaving it permanently restored. Follow up of such cases has demonstrated resolution
inflammation-free. of the periapical lesion, thickening of the root walls internally, as well as
The differences between the procedures labelled indirect pulp capping, continued root growth with evidence of continued deposition of hard tissue
direct pulp capping and pulpotomy reside mainly in the depth and extent within the root. However, the outcome of continued root development is
of injury to the pulp and, consequently, the burden of recovery. Each more not as predictable as increased thickening of the canal walls. Crown dis-
radical procedure confers greater damage on the residual pulp calling upon coloration produced by the minocycline is an undesirable outcome. Histol-
higher tissue regeneration demands for recovery. In the case of the indirect ogy on dog teeth undergoing this procedure suggests that, in some cases,
pulp cap, by definition, the dentine should be intact, even if it is thin. There the new tissue is dentine-like and, in other cases, it is cementum-like with
may be damage to the odontoblasts but the potential for recovery of the the invasion of bone and periodontal ligament into the root canal. The latter
pulp–dentine complex should be the highest. In the case of the vital pulp are not pulp parenchymal tissues, suggesting that the outcome is not
therapies, the essential dentine barrier is missing, so the emphasis is on an always tissue regeneration but wound repair.
adequately healthy, albeit inflamed pulp, to regenerate the dentine barrier
through stimulation and differentiation of pulp stem cells to secrete and ASSESSMENT OF SUCCESS OF VITAL PULP
mineralize a new functional tertiary dentine layer. In successful cases, the THERAPY PROCEDURES
newly formed pulp–dentine complex may be almost indistinguishable
from the remaining dentine (Fig. 2.20). If the pulp is too inflamed or All cases of vital pulp therapy should be followed up to determine outcome.
fibrotic, there may be insufficient capacity to regenerate, in which attempts An initial assessment at between 6 and 12 weeks is recommended,
40 BIOLOGICAL AND CLINICAL RATIONALE FOR VITAL PULP THERAPY
A B
Fig. 2.23 (a) Complete root formation following pulpotomy; (b) elective
devitalization following completion of root formation
of sealants for occlusal caries were partially or totally lost and 7.5% of
those sealants retained had caries progression underneath.
A B
Atraumatic restorative therapy (ART)
Fig. 2.22 (a,b) Root formation continues after successful pulpotomy
According to a recent meta-analysis (de Amorim et al., 2011), the pooled
survival rates of single-surface ART restorations using high-viscosity glass
ionomer in permanent teeth were 85% (95% CI: 77%, 91%) and 80% (95%
followed by 6- and 12-monthly reviews. At each review, a history of CI: 76%, 83%) over the first 3 and 5 years, respectively. The pooled one-
symptoms is obtained and an examination carried out to assess tenderness year survival rate for multiple-surface restorations was 80% (95% CI:
to palpation of adjacent soft tissues, tenderness to pressure and percussion 76%, 83%).
of the tooth, signs of radiographic pulpal and periapical changes and
Indirect pulp capping (one-step versus
responses to pulp tests. However, pulp tests may not be as fruitful in pul-
step-wise excavation)
potomized teeth. In the case of pulp capping and pulpotomy, additional
tests include checking the presence and integrity of the calcific barrier A clinical trial (Bjorndal et al., 2010) including only adult permanent teeth
(Fig. 2.21) radiographically and by removal of the dressing and direct reported pulpal exposure to be a complication during the final excavation
probing. Although an initial examination at 6 weeks has been suggested, in 18% of cases, and 74% of carious teeth undergoing a step-wise excava-
this can be modified by the radiographic assessment. If there is no evidence tion procedure remained vital and free of periapical disease at one year
of a complete bridge formation, the treatment is considered to be a failure postoperatively. The age of patients, presence of preoperative pain and
and conventional root canal treatment must be considered. In addition, in pulpal exposure during excavation were significant prognostic factors.
the case of incompletely formed roots, there should be radiographic evi-
dence of progressing root formation (Fig. 2.22). Once root formation is Direct pulp capping
complete, some believe that it is desirable to carry out root-canal treatment A systematic review (Aguilar & Linsuwanont, 2011), including 10 studies
in order to avoid the complications of continued calcification of the root- published between 1971 and 2010, reported the pooled success rates of
canal system, which may render the procedure more difficult at a later direct pulp capping using calcium hydroxide or MTA as the capping mate-
stage (Fig. 2.23). This is not, however, a universally accepted axiom and rial in permanent teeth with cariously exposed pulps to be as follows: 88%
many consider that the residual pulp would be healthy (see Fig. 2.20) and at 6 months to 1 year, 95% at 1–2 years, 88% at 2–3 years, and 73% at 3
should only be removed if restorative requirements for restorative reten- years or more, postoperatively. MTA was found to be superior to calcium
tion dictate so. hydroxide and teeth with immature apices were associated with signifi-
cantly more successful outcomes.
PROBABILITY OF SUCCESS OF VITAL PULP Pulpotomy
THERAPY PROCEDURES
A systematic review (Aguilar & Linsuwanont, 2011) reported that partial
CONSERVATIVE MANAGEMENT OF CARIES (six studies) or full (seven studies) pulpotomies using calcium hydroxide
or MTA in permanent teeth with carious pulpal exposure achieved a more
Fissure sealing of occlusal caries
predictable outcome than direct pulp capping, and sustained high pooled
The approach of sealing occlusal caries appears to be at least partially success rates: 98–99%; 93–99%, respectively. The outcome was not influ-
successful; a recent study (Bakhshandeh et al., 2011) reporting that 7.4% enced by the capping material or the maturity of the root apex.
BIOLOGICAL AND CLINICAL RATIONALE FOR VITAL PULP THERAPY 41
The most important factors affecting the outcome of vital pulp therapy are:
the maturity of the root apex, pre-existing health of the pulp; adequate
removal of infected hard or soft tissues; careful operative technique to
avoid damage to residual pulp tissues; and elimination of microbial leakage
around the final restoration. It can be difficult to gauge the health of the
residual pulp as it is a matter of subjective assessment and relies on experi-
ence in pulp diagnosis. The degree of pulp bleeding upon exposure is a
more reliable tool to judge the status of the pulp than the preoperative
clinical signs and symptoms. Continued bleeding after 10 minutes, even implantation; scaffold implantation; injectable scaffold delivery; three-
after rinsing with sodium hypochlorite solution, may suggest that the dimensional cell printing; and gene delivery.
residual pulp was still heavily inflamed and a complete pulpectomy may The ultimate would be the in vitro growth of teeth and their implantation
be a more effective treatment modality. Removal of infected tissue is a into the mouth to order, however, this seems decades away.
matter of subjective experience but may be aided by various dyes. The
final factor is reliant upon the correct choice of restorative material and its
REFERENCES AND FURTHER READING
adequate manipulation to prevent leakage.
Aguilar, P., Linsuwanont, P., 2011. Vital pulp therapy in vital permanent teeth with
Factors, such as age and health of the patient, size and nature (carious cariously exposed pulp: a systematic review. J Endod 37 (5), 581–587.
or traumatic) of pulp exposure, and its duration of exposure to the oral Andreasen, J.O., Andreasen, F.M., 1994. Text book and colour atlas of traumatic injuries
environment (up to 48 hours) do not in themselves compromise outcomes to the teeth, 3rd ed. Mosby, Munksgaard, Denmark.
Bakhshandeh, A., Qvist, V., Ekstrand, K.R., 2011. Sealing occlusal caries lesions in
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Innovation should by definition recognize the flaws and potential in current Dent J 31, 251–260.
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predictors are: (1) the preoperative health of the pulp; (2) elimination of Bergenholtz, G., Cox, C.F., Loesche, W.J., et al., 1982. Bacterial leakage around dental
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Section 1 Rationale for disease management
Biological and clinical rationale for root-canal treatment and
management of its failure
K Gulabivala, Y-L Ng
3
Uncontrolled pulp disease (inflammation) spreads from the pulp chamber an absence of periapical disease, while showing 18 out of 19 teeth associ-
and main canals via the intercommunicating lateral canals and apical ated with periapical disease to yield positive cultures.
foramina to the periradicular tissues (Fig. 3.1); channels which normally
serve to feed the pulp tissue with their neurovascular supply. While this Bacterial products
apparently simple event of the inflammatory border passing the threshold Bacterial products, such as sialic acid, M protein, various enzymes, cell-
of the tooth boundary may not seem that important, clinically, it is associ- capsule and cell-wall constituents, and particularly lipopolysaccharide
ated with a reduction in the success of root-canal treatment by 10–20%. It (LPS), have all been implicated in initiation of periapical disease. A posi-
may well be that the critical boundary is that of the associated microbial tive correlation between the presence of LPS and periapical lesions and/
front. Root-canal treatment is a therapeutic procedure used to prevent apical or symptoms has been confirmed in many studies.
periodontitis when pulpal disease is considered too advanced to manage Although bacteria have been the most common microorganisms consid-
by vital pulp therapy but apical periodontitis is not yet established. Root- ered in root-canal infections, other domains of extracellular (Eucharya and
canal treatment is also a therapeutic procedure used to cure apical periodon- Archaea) or intracellular (Viruses) life have also been associated with
titis when pulpal disease has advanced to its sequela, apical periodontitis. periapical disease.
The details of the treatment procedure are covered in Chapter 8, suffice
it to say that it is a technically demanding protocol requiring a mastery Fungi
and integration of tactile, spatial and cognitive senses. In a busy general The presence of fungi in root canals has been reported in numerous studies
practice, therefore, the performance of this feat holds sway over biological (Table 3.1) and has been considered to be a potential cause of endodontic
considerations in the dentist’s mind. The prevalence of apical periodontitis failure in root-filled teeth but definitive evidence is lacking. Various fungi
and the need for such treatment, worldwide, has underpinned the com- (Candida, Aspergillus, Penicillium, Fusarium, Aureobasidium, Exophiala,
mercial development of instruments, materials and techniques to make Eurotium, Cladosporium) have been isolated from root canals.
root-canal treatment more efficient and putatively effective. However, the
outcome data on periapical healing demonstrate that such technical and Archaea
technological advances have not been matched by improvements in success
Archaea, the third domain of life, which are found in a wide variety of
(Fig. 3.2). As pointed out by others in the field of endodontology in the
environments, and in close association with eukaryotes including metazoa,
past, true advances cannot ignore biological considerations, either in the
have been implicated in human health and disease via syntrophic and
design of treatment strategy or its execution in practice.
antagonistic interactions with bacteria. Members of the genus Methanogens
A three-dimensional conceptualization of the dynamic interplay between
are the only archaea detected in the human body in primary and secondary
infection, inflammation and healthy tissue may help to improve visualiza-
root-canal infections by amplification of the mcrA gene. The low diversity
tion of how treatment procedures might influence biological events and
of archaea in root canals, with only two phenotypes identified (Methano-
thus aid periapical disease control. An understanding of the process of
brevibacter oralis, “phylotype 3” mcrA gene) may imply a limited role.
spread of infection and inflammation, their establishment in the periradicu-
lar tissues and treatment must begin with knowledge of the normal struc-
ture and physiology of the involved tissues. HOST FACTORS IMPLICATED
Periapical disease is the result of interaction between bacteria (or their
AETIOPATHOGENESIS OF PERIAPICAL DISEASE products) and the host defences. Both the non-specific and specific branches
of host defences are recruited to defend against the threat of invasion of
AETIOLOGICAL FACTORS IMPLICATED the body by bacteria. The periapical lesion is, therefore, the retreat of the
bone tissue away from the source of infection, creating space for the body’s
Initial uncertainty about the bacterial origin of periapical disease gave room defensive elements to migrate into the immediate vicinity of the infection
for other theories to become established, including stagnant tissue fluid to counter it (Fig. 3.3).
and necrotic pulp tissue. The former theory was conclusively disproved Knowledge of the composition of periapical lesions is based on histopa-
by Goldman and Pearson (1965). Histological studies have also shown thology of samples of long-standing lesions of unknown activity and often
growth of connective tissue and cementum-like hard tissue on root-canal undefined clinical status. Nevertheless, the full range of immune mecha-
walls after a 7-month exposure of apical tissues to necrotic pulp tissue. nisms has been implicated in the development of the periapical lesion (Figs
3.4, 3.5).
Bacteria
The clinical course of the periapical lesion varies giving many presenta-
The credit for demonstrating a definitive causal association between bacte- tions that have been classified into: acute apical periodontitis; chronic apical
rial infection and periapical lesion development is extended to Kakehashi periodontitis; acute periapical abscess or suppuration (without sinus tract);
et al. (1965), who compared the pulpal and periapical reactions to experi- chronic periapical abscess or suppuration (with sinus tract); and radicular
mental pulp exposure in germ-free and conventional rats. The teeth in the cysts. The relative contribution of the normal inflammatory and immune
former case exhibited healing, while the latter showed pulp necrosis and responses varies in these clinical variants. The essential nature of the lesion
periapical lesion development. The causal relationship between root-canal (except in the incipient lesion) is chronic inflammatory (or granulomatous)
infection and periapical disease was further consolidated when Sundqvist tissue, meaning that the two principal elements, inflammation and attempts
(1976) recovered no cultivable bacteria from traumatized, intact teeth with at healing are coexistent. Depending on the state of the lesion there may be
Buchbinder (1941)
Castagnola & Orlay (1952)
Grahnen & Hansen (1961)
Engstrom & Lundberg (1965)
Harty et al. (1970)
Heling & Tamshe (1970)
Cvek (1972)
Werts (1975)
Adenubi & Rule (1976)
Heling & Shapira (1978)
Jokinen et al. (1978)
Kerekes (1978)
Kerekes (1978)
Barbakow et al. (1980)
Cvek et al. (1982)
Boggia (1983)
Klevant & Eggink (1983)
Pekruhn (1986)
Bystrom et al. (1987)
Halse & Molven (1987)
Safavi et al. (1987)
Akerblom & Hasselgren (1988)
Sjogren et al. (1990)
Murphy et al. (1991)
Cvek (1992)
Ried et al. (1992)
Peak (1994)
Friedman et al. (1995)
Calisken & Sen (1996)
Peretz et al. (1997)
Sjogren et al. (1997)
Lilly et al. (1998)
Ricucci et al. (2000)
Weiger et al. (2000)
Chugal et al. (2001)
Peak et al. (2001)
Benenati & Khajotia (2002)
Cheung (2002)
Hoskinson et al. (2002)
Peters & Wesselink (2002)
Chugal et al. (2003)
Huumonen et al. (2003)
Field et al. (2004)
Khedmat (2004)
Chu et al. (2005)
Moshonov et al. (2005)
Aqrabawi (2006)
Doyle et al. (2006)
Gesi et al. (2006)
Conner et al. (2007)
Molander et al. (2007)
Sari & Duruturk (2007)
Chevigny et al. (2008)
Cotton et al. (2008)
Penesis et al. (2008)
Siqueira et al. (2008)
Witherspoon et al. (2008)
Hsiao et al. (2009)
Tervit et al. (2009)
Liang et al. (2011)
Ng et al. (2011)
Ricucci et al. (2011)
Liang et al. (2012)
Combined
Fig. 3.2 Forest plot showing pooled and individual studies (1941–2012) probability of periapical healing following primary root canal treatment based on strict
criteria
BIOLOGICAL AND CLINICAL RATIONALE FOR ROOT-CANAL TREATMENT AND MANAGEMENT OF ITS FAILURE 45
apical foramina, as part of sinus tracts (Fig. 3.7a) or as the lining of devel- granulomas and apical scar lesions. T lymphocytes are the predominant
oping cysts (Fig. 3.7b). Other tissue elements found in the periapical lesion lymphocytes in periapical granulomas, while B lymphocytes and plasma
include endothelial cells and fibroblasts, both being found where there are cells may occur with greater frequency in “advanced” periapical lesions.
attempts at healing. T cells may also be more numerous in refractory periapical granulomas,
The three-dimensional distribution of these cellular elements is thought while B cells may be relatively more numerous in periapical cysts.
by some to fall into zones (Fig. 3.8), based on an animal model of bone Plasma cells have been demonstrated to be actively producing antibod-
infection, but others refute this concept, believing the cellular distribu- ies in peripical lesions. Members of the tumour necrosis factor family of
tion to be too random for discrete zonal partition. Perhaps both views are receptors and ligands, receptor activator nuclear factor kappa B (NF-κB
correct, with zonal organization more evident in the pure chronic lesion or RANK), ligand (RANKL) and osteoprotegerin (OPG), which are
and zonal disorganization brought about by repeated acute exacerbations. involved in bone metabolism, are found in increased levels when T and B
Earlier studies concentrated on the proportions of different cell types in lymphocytes and macrophages infiltrate chronic periapical lesions. The
the periapical lesions to gain insight into the types of reactions prevalent relative ratio of RANKL/OPG may be a key determinant of RANKL-
but there is a limit to the inferences that can be drawn. Later studies mediated bone resorption (see Fig. 3.5).
focused on the phenotypic evaluation of cell surface markers (CD recep- The neural and immune systems also interact in controlling the non-
tors) using monoclonal antibodies to define the relative proportion of cell specific and specific defensive responses and it is also possible that micro-
subsets giving insight into their activity and roles in the progression of the organisms participate in this regulatory function. The ultimate goal is to
lesion. The periapical lesion is T lymphocyte dominated, although B lym- decipher the mechanisms involved so that a model can be constructed
phocytes are also present. The relative proportions of T and B lymphocytes describing the entire sequence of interactions between the cellular (micro-
may be dependent on the nature of the lesion; the T/B cell ratio is reported bial and host) and neural components leading to the progressive develop-
to be significantly higher in lesions containing radicular cysts than ment of the stable (in size) yet dynamic (in activity) periapical lesion. This
Fig. 3.3 Gross structure Monocytes
of a periapical lesion. PMNs Blood vessel
Note zonal distribution Macrophages
of cellular types
PMNs
PMN
Macrophage
Infected root canal
IL-1
IL-11
TNF-α
Bacteria Bacteria
requires synthesis of information from human and animal studies at both possible role of CGRP, which has been implicated both in the response to
cellular and molecular levels. The mechanisms coordinating all these ele- pulp and periapical injury (Fig. 3.9).
ments have not yet been fully elucidated, although it is known that some
Viruses
of them function as cascades.
The molecular components implicated include: cytokines (including inter- The role of viruses in the pathogenesis of periapical disease has been
leukins, tumour necrosis factors and colony-stimulating factors); interferons; investigated with a focus on their effect on symptoms, suppuration and
arachidonic acid and metabolites; matrix metalloproteinases; adhesion mole- epithelial and cystic proliferation. As intracellular residents in host cells,
cules; kinins; complement system; fibrinolytic peptides; vasoactive amines; their presence may modify the host response. The viruses investigated and
lysosomal enzymes; prostaglandins; leukotrienes; and neuropeptides. found include the Herpes simplex (HSV-1/2), varicella zoster (VZV),
The neuropeptides implicated in this process are calcitonin gene-related Epstein-Barr (EBV), human cytomegalo- (HCMV), human herpes-6
peptide (CGRP), substance P, vasoactive intestinal polypeptides, dopamine (HHV-6), human herpes-7 (HHV-7), and human herpes-8 (HHV-8) and the
hydrolase, and neuropeptide Y. The most interesting among these is the human papilloma (HPV) viruses.
48 BIOLOGICAL AND CLINICAL RATIONALE FOR ROOT-CANAL TREATMENT AND MANAGEMENT OF ITS FAILURE
B C
Fig. 3.10 (a) Monkey’s oral cavity used in experiments by Valderhaug (1974); (b) monkey model of apical
D periodontitis (Valderhaug, 1974); (c) apical progression of root canal infection and establishment of apical
granuloma (Valderhaug, 1974); (d) localization of apical infection by a well-defined granuloma
F-Met-Leu-Phe that constitutes the amino terminus of many bacterial well as that of the cellular infiltrate, which is more diffuse and spread into
proteins, and other pathogen-associated molecular patterns (PAMPs) the trabecular system. These histological pictures translate into radio-
including components of lipopolysaccharides, mannose and teichoic acids. graphic views of well circumscribed, smaller, and better-demarcated peri-
In a previously exposed host, these activate the innate immune response apical radiolucencies compared to more diffuse and extensive lesions,
by interaction with different receptors known as pattern recognition recep- respectively. The acute response may be accompanied by the usual clinical
tors (PRR). The PRR, such as the family of Toll-like receptors (TLRs), are signs of pain and tenderness on percussion of the tooth, which may feel
present mainly on macrophages, neutrophils, and dendritic cells (DCs). elevated in the socket, but it may also be too transient and minimal to be
Other receptors present on phagocytes with an important role in the noticed. So far, little bone resorption is likely to have taken place and little
immune response are those for complement, cytokines, interleukins, and obvious radiographic change would be discernible (Fig. 3.11a).
immunoglobulins. Since the bacteria and their products are not removed, because of their
Phagocytosis of accessible bacteria and their products begins with adhe- seclusion in the root-canal system, a delayed immune response is mounted
sion of the phagocyte surface receptors to bacteria or immune-coated cells; and the specific immune response commences. These responses are medi-
they are internalized in phagosomes and digested by respiratory bursts and ated by direct stimulation of the host cells by the bacteria and their prod-
generation of reactive oxygen species (ROS). ucts, as well as cascade triggers from subsequent responses. Unlike the
The initial exudate will also bring with it any circulating specific anti- innate response, the adaptive or acquired immune response depends on
bodies that may be present. The PMN migration would also then be further activation of the lymphocyte; it involves specificity with a wide spectrum
stimulated by activation of complements C3b and C5a via antigen– of diverse recognition patterns, memory, self-restraint, and tolerance to
antibody-complex formation. The overall effect of pre-existing immunity components of the organism itself. Although the main cells involved in
is better confinement of the bacteria to their source (apical foramina), acquired immune response are lymphocytes, antigen-presenting cells
requiring only a sparse cellular infiltrate to deal with them and a fibro- (APCs) play a key role in their activation, presenting antigens associated
encapsulation of the rich granulation tissue (see Fig. 3.10d). In contrast, with molecules of the major histocompatibility complex (MHC) to T
lack of pre-existing immunity results in poorer bacterial confinement as lymphocytes.
50 BIOLOGICAL AND CLINICAL RATIONALE FOR ROOT-CANAL TREATMENT AND MANAGEMENT OF ITS FAILURE
palpation but it soon becomes apparent (Fig. 3.14a). There would be no dynamism and an array of histological variations in cell composition
demonstrable radiographic periapical change (Fig. 3.14b). Subsidence of (described above) and epithelial proliferation with or without cystic
the pain is accompanied by the appearance of a periapical area and the change.
transition of the inflammation to a chronic state.
EPITHELIAL PROLIFERATION AND CYSTS
CHRONIC PERIAPICAL INFLAMMATION The epithelial rests of Malassez may be stimulated to proliferate by
The histological picture of this entity is as described in detail above. It is inflammatory mediators. The pattern of proliferation is variable, with
clinically asymptomatic and presents as a radiographic periapical radiolu- the formation of strands, arcades or rings of epithelial clusters at the
cency (Fig. 3.15). The asymptomatic radiographic image masks a quiet junction of the uninflamed connective tissue and granulation tissue
52 BIOLOGICAL AND CLINICAL RATIONALE FOR ROOT-CANAL TREATMENT AND MANAGEMENT OF ITS FAILURE
A B C
F E D
(see Fig. 3.7b). Proliferation may also occur within the body of the granu- if conventional root-canal treatment fails to resolve it. This supposition
loma, where it presumably helps to plug the apical foramina and limit remains to be proven.
egress of bacteria and their toxins (see Fig. 3.13). In some instances, these The exact aetiology and mechanisms of cyst formation are not clear.
epithelial plugs bulge out into the periapical lesion, forming a sac con- The epithelium may surround an abscess or granuloma, cutting off the
nected to the root and continuous with the root canal, termed a “Bay tissues within from their nutrient source and causing their degeneration.
or apical pocket cyst” (Fig. 3.16a,b). In these cases, microorganisms from The molecular mechanisms that stimulate proliferation of epithelial cells
the root canal have direct access to the “cyst” cavity and may invade it considered crucial in generating the cyst have not yet been elucidated.
(Fig. 3.16c). Several endogenous regulatory mediators (cytokines, prostaglandins,
A true cyst has been defined as a separate pathological, epithelium-lined interleukins, keratinocyte growth factor, epidermal growth factor) contrib-
cavity usually containing fluid or semi-solid material. It does not com- ute to cell proliferation. In an established periapical cyst, the basal cells
municate with the root canal or any other opening (see Fig. 3.16a,d) and of the lining epithelium retain the potential as unipotent stem cells capable
develops in periapical lesions. It was once believed that large circum- of cell division on inflammatory stimulation. The cyst can persist and grow
scribed radiolucent lesions with a sclerotic border were likely to be cysts in size; proliferation markers (e.g. ki67) in the lining epithelium and Notch
but such a correlation has not been proven. However, lesions of the size signalling (which also regulates embryonic development, adult tissue
shown in Figure 3.16e are likely to show cystic change. The bay cyst homoeostasis, stem/progenitor cell maintenance, differentiation, and pro-
should by inference heal by elimination of the bacterial contamination of liferation) are involved in the activation of epithelial cells in periapical
the root canal. Successful treatment of the true cyst may require surgery cyst walls.
BIOLOGICAL AND CLINICAL RATIONALE FOR ROOT-CANAL TREATMENT AND MANAGEMENT OF ITS FAILURE 53
An alternative theory for genesis of cysts is that dividing epithelial cells host cells without either side gaining the upper hand. The accumulation of
grow until the central cells are starved of their nutrient source, causing dead cells and the consequent release of lysosomal enzymes results in the
their degeneration. formation of pus. This is usually conveyed to the nearest body surface by
The method of cyst enlargement is also speculative. Theories involve the formation of a sinus tract, which over time, becomes lined by epithe-
selective absorption of fluids and an active biochemical interaction between lium (see Fig. 3.7a). Clinically, there may be a draining sinus tract, which
the cyst wall and adjacent tissues. Whatever the final explanation, it is may sometimes be raised to form a “gumboil” (Fig. 3.17a) or rarely may
clear that cysts tend to grow and may be considered an independent patho- drain extra-orally to the skin (Fig. 3.18). The patient may complain of bad
logical entity within another pathological entity, the granuloma (see Fig. taste in the mouth but rarely pain; there may sometimes be some mild
3.16d). The relative proportions of granulomatous and cyst tissue may discomfort especially on palpation adjacent to the involved tooth. The
vary. Although the reported prevalence of cysts among apical periodontitis radiographic picture (Fig. 3.17b) would be similar to the previous category,
lesions varies from 6% to 55%, meticulous serial sectioning and strict however, the sinus tract presents the opportunity for placing a gutta-percha
histopathological criteria show the actual prevalence of the cysts to be well point in it, to trace its source if there is any doubt (Fig. 3.17a).
below 20%. As such, it could be argued that while the granulomatous
lesion may be treatable by removal of the aetiological agents from the ACUTE PERIAPICAL ABSCESS/CELLULITIS
canal, the cyst, having become independently established, may continue
to flourish until specifically inhibited or disrupted. This entity may arise from any of the other categories described so far.
When it arises directly from acute periapical inflammation without any
other transition, it is an exquisitely painful condition. The pain usually
CHRONIC SUPPURATIVE PERIAPICAL INFLAMMATION subsides as soon as a periapical lesion forms and pressure is relieved.
In some cases, the conflict between the bacteria and the defence cells, Opening access to such a tooth is difficult and is aided by applying
which are primarily the PMNs, results in the death of many bacteria and pressure to the tooth with a finger while drilling, as vibration from the
A B
Fig. 3.14 (a) Tenderness to palpation over maxillary left lateral incisor and canine; Fig. 3.15 Radiographic appearance of chronic
(b) definite evidence of radiographic periapical change is lacking periradicular inflammation
Fig. 3.16 (a) Bay and true cysts: A = true cyst; B = bay cyst; C = granuloma;
D = epithelium; E = alveolar bone; F = dentine; G = root canal; H = cementum;
I = periodontal ligament. (b) Histological section showing a bay cyst (A):
A
B = granuloma;
A
B
B
54 BIOLOGICAL AND CLINICAL RATIONALE FOR ROOT-CANAL TREATMENT AND MANAGEMENT OF ITS FAILURE
D D C B A
hand-piece causes the discomfort. The abscess is caused by an influx of pathological cavity filled with pus and lined by a pyogenic membrane,
large numbers of bacteria into the periapical area that overwhelm the which consists of granulation tissue. Clinically, there would be various
defences (see Fig. 3.12). This causes a rapid influx of large numbers degrees of swelling and pain (Fig. 3.19a,b) and the tooth would feel ele-
of PMNs. The rapid death of large numbers of cells and the release of vated in the socket. If severe, and accompanied by an allergic response,
lysosomal enzymes causes an accumulation of pus called an “abscess”. there is a large exudative component leading to a build-up of fluid pressure
The highly acidic environment causes the further death of surrounding (Fig. 3.19c). The position of the swelling depends on the tissue planes
tissues and may lead to further exacerbation. Classically, it consists of a (themselves determined by muscle and fascia attachments) through which
BIOLOGICAL AND CLINICAL RATIONALE FOR ROOT-CANAL TREATMENT AND MANAGEMENT OF ITS FAILURE 55
A B
A B
pus spreads and accumulates (Fig. 3.19e–g). The lymphatic system is commence leading to the formation of bony sequesters. The patient’s
frequently involved in dental infections and gives an indication of the temperature is elevated, lymph nodes are swollen and pain is severe.
pattern of spread. Lymphadenitis, which comprises an enlargement and The teeth may be loosened but there may not be obvious swelling in the
tenderness of the lymph nodes (Fig. 3.19d) may be present, as well as early stages. Untreated, the acute osteomyelitis can progress to a chronic
lymphangitis, characterized by an inflammation of the lymphatic vessels. stage, which is less symptomatic but just as serious and merits prompt
The viable bacteria, cellulitis and pus may spread through the lymphatic treatment.
system and along tissue planes formed by mucles and fascia, causing a
spreading cellulitis with pyrexia, and the patient to feel unwell. The tissue PERIAPICAL OSTEOSCLEROSIS OR
space compartments where pus and exudate gather are described in detail CONDENSING OSTEITIS
in Chapter 10. Spreading cellulitis, typical of streptococcal microorgan-
isms, manifests as a diffuse firm swelling and can lead to life-threatening Information is scarce on this relatively common presentation. It is thought
conditions. If a maxillary tooth is involved, cavernous sinus thrombosis to be a low-grade response of the body to mild irritation. A subdued
may develop where infection of the tissues of the face may spread intrac- response is caused by the buffering effect of intervening healthy tissue,
ranially via the interconnecting venous system, probably via the facial vein for example, when the coronal part of a pulp is necrotic and infected while
to the cavernous sinus. If a mandibular tooth is involved, Ludwig’s angina the apical portion is still vital. The intervening pulp tissue reduces the
may be a risk. Prior to the antibiotic era, the mortality for Ludwig’s angina potency of the infection and its molecular products and, therefore, their
exceeded 50%, since the antibiotic era, and along with improved imaging direct impact on the periapical tissues. The effectively lowered dose stimu-
and surgical techniques, mortality for the condition currently averages at lates bone deposition as opposed to resorption causing increased bone
8%. Patients with Ludwig’s angina (Fig. 3.19h,i) become seriously ill, with density with mild chronic inflammation in the marrow spaces. Clinically,
marked pyrexia, and swallowing, speaking and breathing difficulties. If the lesion is asymptomatic and presents as various grades of radiopacity
the glottis becomes involved the patient may die within 12–24 hours. The surrounding a severely widened periodontal ligament space (Fig. 3.20). In
condition should be identified early and the patient referred urgently for rare instances, the inflammation is sufficient to cause apical root resorption
medical attention (see details in Chapter 10). at the same time (Fig. 3.21). The condition should not be confused with
other radiopaque lesions, such as caused by benign tumours or dysplastic
changes; 60% of radiopaque lesions are of periapical origin.
PERIAPICAL OSTEOMYELITIS
This is a very rare but serious progression of a periapical infection. Chronic
osteomyelitis of the jaws is usually due to mixed anaerobic infection. NATURE OF THE PERIAPICAL LESION ASSOCIATED
The local infection spreads in a diffuse manner through the medullary WITH TREATED TEETH
spaces causing the necrosis of bone or, more specifically, the cells that
line the mineralized bone (osteoblasts and osteoclasts) and fill the medul- Much of the research on human periapical tissue has been conducted on
lary spaces (haematopoietic or fatty cells). The spread may be limited undefined samples, that is, it is not known whether the sample was associ-
or extensive. PMNs fill the medullary spaces and destroy osteoblasts ated with treated or untreated teeth. Many investigators have assumed that
lining the bony trabeculae, allowing the process of bone resorption to the responses would be the same. Only a few studies have focused on
56 BIOLOGICAL AND CLINICAL RATIONALE FOR ROOT-CANAL TREATMENT AND MANAGEMENT OF ITS FAILURE
Maxillary anterior
Labial exit
Palatal exit
A Maxillary posterior
Mandibular
Fig. 3.19 (a) Right facial and infraorbital swelling associated with maxillary canine; (b) intraoral view of swelling in (a); (c) spreading submandibular swelling;
(d) localized submandibular swelling (arrowed); (e–g) line diagrams showing the pathways of spread of infection; (h,i) treatment of Ludwig’s angina
BIOLOGICAL AND CLINICAL RATIONALE FOR ROOT-CANAL TREATMENT AND MANAGEMENT OF ITS FAILURE 57
Palate
Oral cavity
Masseter
Tongue muscles
Dermal tissues
Parotid gland
Mandible
Medial pterygoid
muscle Masseter
Pathways of
infection spread
Buccal space
and buccal I
H
pad of fat
specified tissue samples, either from treated teeth or untreated teeth. A destruction in the centre and PMNs aggregated at the periphery, possibly
quantitative comparison of lymphocytes and their subsets in periapical as a result of sodium hypochlorite extrusion.
lesions harvested from treated or untreated teeth has shown differences in Periapical lesions persistent over a longer term may represent persistent
the inflammatory infiltrate and relative proportions of T, B and TH cells. chronic inflammation as a result of residual intraradicular infection (Fig.
The short-term (7–14 days) response of apical tissues to different root- 3.22), established extraradicular infection (Figs 3.23, 3.24), a foreign body
canal treatment procedures may result in atypical lesions with total cellular response (Fig. 3.25) or a radicular cyst (Fig. 3.26).
58 BIOLOGICAL AND CLINICAL RATIONALE FOR ROOT-CANAL TREATMENT AND MANAGEMENT OF ITS FAILURE
A B
Fig. 3.20 Periradicular condensing Fig. 3.21 (a) Apical resorption associated with condensing osteitis;
osteitis associated with 35 (b) access cavity into the same tooth shows vital but inflamed pulp tissue
B C
A D E
BIOLOGICAL AND CLINICAL RATIONALE FOR ROOT-CANAL TREATMENT AND MANAGEMENT OF ITS FAILURE 59
A B
B C D
becoming more anaerobic and Gram-negative without increase in total cell To account for the possible contribution of unsampled or uncultivated
numbers. bacteria in the pathogenesis of lesions, eleven isolated strains (including
In classical studies in a monkey model, uninfected teeth did not develop eight strains from one tooth, representing its total cultivable infection)
periapical lesions while most of the infected teeth developed periapical were inoculated in freshly necrotized monkey teeth, in various combina-
lesions. They found that the proportion of facultative anaerobic species tions, but always in equal proportions. After 6 months, the “eight-strain
decreased and strict anaerobic species increased during the experimental collection” (Prevotella oralis [formerly Bacteroides oralis], Fusobacte-
period. The ratio of obligate anaerobic to facultative anaerobic bacteria rium necrophorum, Fusobacterium nucleatum, Streptococcus milleri,
increased from 1.7 (7 days) to 3.9 (90 days) to 6.5 (180 days) and finally Enterococcus faecalis [formerly Streptococcus faecalis], Peptostreptococ-
to >11.3 (1060 days). The major site of infection was the main canal fol- cus anaerobius, Actinomyces bovis and Propionibacterium acnes) was
lowed by dentine and then the apical part of the canal. The apical micro- recovered from all teeth but in the same proportions in which it had been
biota is the most likely to influence changes in the periapical tissues by recovered from the original tooth. This strongly suggested that selective
virtue of its proximity. pressures were at play in the root-canal system to reproduce the “same
BIOLOGICAL AND CLINICAL RATIONALE FOR ROOT-CANAL TREATMENT AND MANAGEMENT OF ITS FAILURE 61
A B
C D
infection”. Other combinations did not survive as effectively, while some In summary, periapical disease is caused by a polymicrobial infection
species were not recovered at all, suggesting that the cultured isolates were of the root-canal system with a direct relationship between the size of
the main core of the functional microbiome. periapical lesion and diversity of infection.
Periapical destruction was consistently associated with the mixed infec- Despite several species being implicated by association with sympto-
tions but not with the single-strain infections, where some periapical matic apical periodontitis (Table 3.2), a cause–effect relationship remains
inflammation was evident depending upon the extent and type of bacteria elusive. Black-pigmented Gram-negative anaerobic rods (Black-pigmented
surviving. Of the single strains inoculated, only Enterococcus faecalis Bacteria; BPB), especially Prevotella melaninogenica (formerly Bacter-
survived in every case. Prevotella oralis (formerly Bacteroides oralis), oides melaninogenicus), as well as Parvimonas micra (formerly Pepto-
which dominated all mixed infections, did not survive as a monoinfection. streptococcus micro) were originally implicated in purulent infections. The
Inoculation of Staphylococcus aureus, Streptococcus sanguis, Pseu- presence of black-pigmented Gram-negative anaerobic rods does not,
domonas aeruginosa and Bacteroides fragilis as monocultures in root however, consistently result in acute abscesses. Other species have also
canals could also elicit periapical responses. become associated with the presence of symptoms, including Actinomyces
62 BIOLOGICAL AND CLINICAL RATIONALE FOR ROOT-CANAL TREATMENT AND MANAGEMENT OF ITS FAILURE
Fig. 3.26 (a) Longitudinal radiographs of a periapically affected left central incisor of a 37-year-old woman over a period of 4 years and 9 months of clinical
management. Note the large eccentrically located apical radiolucency observed before (a) and immediately after (b) root filling. The lesion did not show any
reduction in size in control radiographs taken 14, 28, 40 and 44 months (c–f) after endodontics. Apical surgery was performed (g) and the periapical area shows
distinct bone healing (h,i) within 1 year of surgery (from Nair et al., 1993). (b) Axial section through the apical biopsy removed from the radiolucent area visible
in (a) & (g). The large lesion is encapsulated with a narrow rim of dense capsular connective tissue (CT) and contains a distinct lumen lined with stratified
squamous epithelium (EP). Note the vast number of cholesterol clefts (CS) concentrated in the connective tissue at the distocervical aspect of the lesion. The
luminal centre contains pale staining necrotic tissue (NT) and the rest of the lumen is filled with dark staining erythrocytes, among which cholesterol spaces can
be seen. The large rectangular demarcated area is further magnified in (d) (from Nair et al., 1993). (c) Section of a true apical radicular cyst. (d) Presence of vast
numbers of cholesterol clefts (CS) in the lesion. The cholesterol spaces are surrounded by multinucleated giant cells (GC), of which a selected one is magnified in
the inset. Note the large number of nuclei (NU). Original magnification ×98 (inset ×322) (from Nair et al., 1993)
species, Finegoldia magna (formerly Peptostreptococcus magnus), non- severity and clinical presentation. The most abundant phyla in acute infec-
pigmented Prevotella and Porphyromonas species, Peptococcus species, tions were Fusobacteria with predominance of the genera Fusobacterium
Eubacterium species, Propionibacterium species, spirochaetes; and Fuso- and Parvimonas.
bacterium species (Table 3.2). Given the ecological basis for infections, it
is likely that the cause of symptomatic exacerbation is complex and related NATURE OF THE ROOT-CANAL MICROBIOTA
to the number of bacterial cells, strain variants, nature of interaction
between species/strains, and other as yet unknown microbial factors. Since The picture of the root-canal infection has continued to evolve as new
the outcome is also dependent upon interaction between the microbiota research methods have revealed more of the “hidden jigsaw puzzle”. The
and the host, compromising factors such as viruses could conceivably play polymicrobial nature of the root-canal infection may be defined by its
a part, as may other immune burdens. Although the true basis for acute diversity; which in turn is made up of species richness (number of unique
exacerbation of periapical lesions is still unclear, molecular studies com- taxa within a niche) and species evenness (the relative abundance of each
paring acute and chronic infections have suggested that some strains are taxon within the niche). Few studies have determined the true diversity of
associated with acute cases more than chronic cases. More recently, pyro- the root-canal environment; the majority of studies were based on root-
sequencing, which allows massive parallel sequencing, has suggested the canal sampling, microbial isolation, their identification by biochemical
existence of specific consortia related to location in root canals, disease expression or gene sequencing (Fig. 3.27).
BIOLOGICAL AND CLINICAL RATIONALE FOR ROOT-CANAL TREATMENT AND MANAGEMENT OF ITS FAILURE 63
C D
Table 3.2 Symptomatic primary apical periodontitis and its association with specific taxa
1
Former Bacteroides spp.
64 BIOLOGICAL AND CLINICAL RATIONALE FOR ROOT-CANAL TREATMENT AND MANAGEMENT OF ITS FAILURE
A B C D E F
G H I J
K L M N
Fig. 3.27 Schematic diagram showing sampling, culture, isolation and identification. (a) Selection of a suitable case; (b) access cavity after rubber dam isolation
and decontamination of the working field; (c) microbial sampling using sterile paper points at full length of the root canal; (d) placement of the paper points in
a transport medium. In a microbiology laboratory; (e) 10-fold serial dilutions are performed; (f) aliquots of the serial dilutions are plated on blood agar plates;
(g) plates are incubated for 24–48 h under aerobic and 7–21 days under anaerobic conditions (Anaerobic work station; Don Whitley Scientific Ltd, West
Yorkshire, UK); (h) example of a plate with microbial growth originated from a primary root canal infection (dilution 1 : 10); (i) colonies are isolated according
to their morphological characteristics on agar plates; (j) subdivided into two and plated on two blood agar plates and incubated under aerobic and anaerobic
conditions; (k,l) the pure colonies are stained and observed under microscopy. A catalase test is also performed. (m) According to these preliminary tests,
biochemical tests are selected for microbial identification (example of a biochemical identification kit for anaerobic bacteria: Rapid ID 32 A from bioMérieux,
Craponne, France); (n) the clinical isolates can also be submitted to molecular identification techniques by DNA/RNA techniques and comparison to a collection
of sequences from several sources (i.e. Genebank). (courtesy of Morgana Vianna)
Different approaches to sampling and novel sequencing approaches a range of anaerobic bacteria). As strict anaerobic culture techniques
(pyrosequencing of DNA) may extend the list of taxa further. So far, the improved, many more strains and species were isolated and identified,
main contribution seems to be in the refinement of the taxonomic assign- although identification often lagged behind isolation. Most of these species
ments at different levels (phyla, classes, orders, families, and genera) originated from the oral cavity and some from other parts of the body or
rather than identification at species or strain level. the general environment. The unique milieu of the root-canal system only
allows the survival of select bacterial species, giving rise to different pro-
portional composition of the microbiota compared to oral and periodontal
SPECIES RICHNESS OR QUALITATIVE ANALYSIS niches. Molecular techniques, such as polymerase chain reaction (PCR)
OF MICROBIOTA (Table 3.3) and its derivatives, for detection and identification of bacteria brought the
Studies before the 1960s, lacking the advantage of advanced anaerobic next major advance in resolution of the picture of microbial diversity
culture techniques, found mainly aerobic and facultative organisms with implicated in root-canal infections. This was mainly because detection was
some strict anaerobes (streptococci, lactobacilli, Gram-negative cocci, and not reliant on being able to culture bacteria; yet unculturable bacteria are
BIOLOGICAL AND CLINICAL RATIONALE FOR ROOT-CANAL TREATMENT AND MANAGEMENT OF ITS FAILURE 65
Table 3.3 Representative taxa in untreated root canal infections associated with apical periodontitis (courtesy of Morgana Vianna)
Fig. 3.28 (a) General molecular tree of life (ToL) based on rRNA sequence
Bacteria comparisons. The diagram compiles the results of many rRNA sequence
acteria
comparisons. Only a few of the known lines of descent are shown.
ria
Firmicu
(Reproduced from Pace NR (2009) Mapping the tree of life: progress and
acte
Chlorobi
Ve Th
Acidob
rru ria t prospects. Microbiology and Molecular Biology Reviews 73(4), 565–76.
nob
erm
Ge co cte plas
WS
tes
mm mi
oto Copyright © 2009, American Society for Microbiology. All Rights Reserved).
Acti
a
cro ob oro ia
7
atim
6
an chl acter
ga
TM
on bia y (b) The hierarchy of biological classification’s eight major taxonomic ranks.
e
ad C b dria
ete teo Mitochon (c) Phylogentic tree built of enviromental sequencing data as representative
Bac
tero s Pro
idet 1 phyla found in infected root canals as reported by Özok et al. (2012)
es OP1
Chlorofl
exi BRC1
s
ll ate
Fungi
ge
ls
fla
ima
a no
An
C ho lga
e
Origin dA
Re
ts
Plan
s
Stramenopile
Crenarchaeota Alveolates
Acan
tham
Archaea oeba
e
Eug
Euryarchaeota leno Vertebrates
zoa
He
Urochordates
ter
olo
Angiosperms Gymnosperms
BOL
Tric
bo
BAQ1
omo
a
nad
Eucarya
s
A Slime molds
Arthropods
Echinoderms
Table 3.4 Quantification of bacterial load by culture and real-time CULTURE STUDIES
quantitative PCR (qPCR)
Morphological studies do not give the identity of bacteria and so require
Year of supplementation by cultivation or in situ hybridization studies. In common
Study publication Type of study with the morphological studies, these also focus on the coronal–apical
Kantz and Henry 1974 Culture 107 bacteria/mL of sample distribution of bacteria in root canals and the penetration of bacteria into
Zavistocki et al. 1980 Culture 107.7 bacteria/gm of sample dentine. The earliest studies on infection distribution were interested to
Byström et al. 1987 Culture 101–107 bacteria/mL determine the existence of infection in periapical tissues because of the
Ando and Hoshino 1990 Culture 103 bacteria/gm of sample controversy caused by the focal infection theory. The chronic periapical
Sato et al. 1993 Culture 101–106 bacteria/mL lesion can remain sterile even when the root canal is infected. The fact that
Brauner and Conrads 1995 Culture 105 bacteria/sample
the majority of periapical lesions heal upon tooth extraction suggests that
Dougherty et al. 1993 Culture 101–106 bacteria/mL
only rarely do infections properly become established extraradicularly.
Vianna et al. 2006 Real-time PCR 4.6×104–6.7×107 gene copy
numbers/mL Cultivation of bacteria from apical (5 mm) samples similar to those
Blome et al. 2008 Real-time PCR 2.6×105–2.6×107 bacterial described by Nair (1987) in his light and electron microscopy study
counts (described below) showed the presence of Actinomyces, Lactobacillus,
Saito et al. 2009 Real-time PCR 2.8×105–2.09×109 cells/ black-pigmented Bacteroides, Peptostreptococcus, non-pigmented Bacter-
samples
oides, Veillonella species, Enterococcus faecalis, Fusobacterium nuclea-
tum and Streptococcus mutans. The majority (68%) were strict anaerobes.
The microbiotia invading the deep layers (0.5–2.0 mm) of dentine in
cultivable species per tooth is currently estimated at 1–12 with mean root canals of carious teeth is mostly (80%) composed of strict anaerobes.
ranges from 2.0 to 5.7 per tooth. According to culture quantification, the The predominant bacteria are Gram-positive rods (68%) and Gram-positive
total concentration of aerobes and anaerobes is nearly equal. In contrast, cocci (27%). Lactobacillus (30%), Streptococcus (13%) and Propionibac-
teeth undergoing root-canal treatment have a residual microbiota with a terium species (9%) are dominant. A similar study of teeth with undefined
cell concentration of between 101 and 103 CFUs per sample. There is a coronal status but evaluating the full thickness of dentine found a more
general trend towards later studies showing higher numbers of species per diverse microbiota consisting of a mix of Gram-positive and Gram-
tooth but this is not universally true. The numbers probably reflect better negative types including Prevotella, Porphyromonas, Fusobacterium,
cultivation and identification techniques. Peptostreptococcus, Actinomyces, Streptococcus, Propionibacterium,
Studies using culture-independent techniques reveal the overall diver- Lactobacillus and Bifidobacterium species. The presence of Gram-negative
sity of root-canal infections to be much higher than findings using culture- bacteria in the inner layers of root canal dentine has been confirmed by
dependent techniques. The mean total number of gene amplicons by the finding of lipopolysaccharide in dentine up to 300 μm in depth.
real-time PCR (qPCR) in infected teeth is estimated to range from 104 to Cementum from apical portions of roots harvested during apical surgery
109 gene copy numbers per root-canal sample. The discrepancy with CFU may show the presence Prevotella, Fusobacterium, Peptostreptococcus,
counts may be explained by the fact that each bacterium may have multiple Eubacterium and Campylobacter species. This observation can be recon-
copies of a gene. Pyrosequencing reveals the mean number of species/ ciled with previous studies if the teeth are associated with sinus tracts.
phylotypes in apical root samples to range from 13 to 130. Some researchers have investigated the penetration of bacteria and their
products into cementum from the periodontal surface but the positive find-
DISTRIBUTION AND PHYSIOLOGICAL STATUS ings remain controversial. The reason is that they imply that such bacteria
OF INTRARADICULAR MICROBIOTA could coexist with vital, perhaps healthy pulps and others have shown that
vital pulps resist invasion by bacteria.
Insight about the distribution and physiological status must be synthesized
from different study sources as a single research method is not available
to lend comprehensive evidence.
MICROSCOPY STUDIES
It is intuitively evident that bacteria gain access to the root-canal system Several microscopy surveys (light, dark-field, fluorescent, confocal, TEM
by a number of routes. The commonest is through the crown by means of and SEM) of teeth have shown the pattern of bacterial invasion and associ-
a carious exposure, through open dentinal tubules in the crown or root, ated pulp necrosis. A “synthesized view” is presented below based on the
through lateral canals either before devitalization via blood vessels com- observations from these studies.
municating with the periodontium or after exposure to the oral environ- Bacterial invasion usually begins in the coronal part of the tooth and
ment due to periodontal disease. Cracks in the tooth (enamel and/or root and is concentrated there (Fig. 3.30). The distribution from here into
dentine) also allow root-canal infection. Another less common route is by the canal system is associated with two factors: the presence or absence
anachoresis; a term used to denote infection of a chronically inflamed area of pulp chamber exposure; and the presence or absence of a periapical
by a blood-borne infection or a bacteraemia. For this condition to be ful- lesion. As a rule, bacteria are evident lining the canal wall in biofilms,
filled, the pulp must be intact but chronically inflamed, it is unlikely that which are discontinuous (covering 30–50% of the surface area) and vari-
a necrotic canal would be infected in this way. The point of entry of the able in thickness (Fig. 3.31), with thinner and less coverage in teeth with
bacteria is likely to dictate the nature and distribution of the subsequent intact pulp chambers. The biofims may also extend along other surfaces,
infection within the tooth. such as necrosing pulp tissue (Fig. 3.32) and degenerating vascular chan-
Studies on the nature of microbiota in root canals far outnumber those nels. Bacteria appear in smaller numbers in the root canals as the apical
seeking to reveal the distribution of bacteria. Our collective knowledge is terminus is reached in teeth with intact pulp chambers (Fig. 3.31) but
based on light, dark-field, fluorescent, confocal and electron microscopic where the pulp chambers are cariously exposed, the canals are more evenly
(scanning electron microscopy [SEM], transmission electron microscopy coated with a bacterial plaque. Even then, the plaque is not continuous
[TEM]) studies, cultivation studies and analysis of distribution of bacterial over the entire surface (Fig. 3.33). In teeth without periapical lesions, vital
toxins. pulp tissue may be present apically and, if so, the intensity of the infection
68 BIOLOGICAL AND CLINICAL RATIONALE FOR ROOT-CANAL TREATMENT AND MANAGEMENT OF ITS FAILURE
components. Examples of in situ hybridization labelling of bacteria in pathogenesis. This suggests that the Streptococci are initial colonizers and
root-canal sections include gold labelling of bacterial cell surface antigens that perhaps with biofilm maturity they are outnumbered by other species.
(Fig. 3.49), gold labelling of 16SrRNA probes (Fig. 3.50), fluorescent in The technique should enable the dissection of the local niche ecology in
situ hybridization (FISH) of universal bacterial 16S rRNA probes (Fig. combination with insight about bacterial physiology. Figure 3.52 shows a
3.51), FISH of spirochaetes (Fig. 3.52), FISH of streptococci (see Fig. typical ecological picture with different morphotypes clustering in pat-
3.35). The technique is able to help depict the distribution of bacteria over terned format around some part of the dying pulp, from which one species
the canal surface, as well as the distribution of specific species such as is deriving nutrient directly, while other morphotypes appear to be arranged
streptococci. The streptococci specific biofilm was always a smaller per- around the primary species (interpretation by Prof Bill Costerton).
centage of the overall biofilm coverage; the percentage of streptococci In summary, the overall picture of the intraradicular microbiota is a
generally decreased as exposure to the external oral environment reduced. crude one of a variable distribution of bacteria within the root-canal system
The level of Streptococus infection in exposed teeth with periapical patho- and dentine. The state at any given time may represent the stage of infec-
sis was less than that of samples with exposure but no perapical tion with bacteria extending up to and sometimes beyond the apical canal
70 BIOLOGICAL AND CLINICAL RATIONALE FOR ROOT-CANAL TREATMENT AND MANAGEMENT OF ITS FAILURE
A C
B D
Fig. 3.33 Canals evenly coated with a discontinuous bacterial plaque in a Fig. 3.35 Bacterial colonization concentrated in the coronal and apical
tooth with exposed pulp and apical periodontitis. Bacterial distribution (in red) portions of root canal. Bacterial distribution (in red) as revealed by in situ
as revealed by in situ hybridisation using universal (EUB) and streptococcal hybridisation using universal (EUB) and streptococcal (Strep) rRNA probes.
(Strep) rRNA probes. Attempts 1 & 2 are separately stained sections Attempts 1 & 2 are separately stained sections
Fig. 3.34 Vital pulp tissue present in the infected canal of a tooth without
periapical lesion. Bacterial distribution (in red) as revealed by in situ
hybridisation using universal (EUB) and streptococcal (Strep) rRNA probes. Fig. 3.36 Different bacterial morphotypes in biofilm seen under TEM
Attempts 1 & 2 are separately stained sections
terminus. The depth of penetration into dentine is also variable but gener- remains controversial because of the difficulties of obtaining an uncon-
ally appears to be confined within the area close to the root canal and is taminated sample. In the majority of chronic periapical lesions, no bacteria
probably dominated by Gram-positive bacteria, mostly streptococci. In may be found, although bacterial invasion of the periapical tissues is a
rare instances in chronic lesions, the bacteria may proliferate beyond the common event in acute exacerbation where, for unknown reasons, the
apical foramen and into the periapical lesion. Mainly anaerobic bacteria root-canal bacteria overwhelm the local periapical defences.
have been demonstrated in the periapical tissues, perhaps associated with
foreign or dead (cellular or dentinal) material, to which the defence cells
have no or limited access. The bacteria may also be found embedded in
IMPORTANCE OF MICROBIAL ECOLOGY
an extracellular plaque-like matrix covering the external surface of the
AND BIOFILM PHYSIOLOGY IN THE TREATMENT
root. The bacteria in this plaque have been observed to be mainly cocci
OF ROOT-CANAL INFECTION
and rods but fibrillar forms may be present too. The main species impli-
cated in periapical tissue invasion include Actinomyces species and Pro-
MICROBIAL ECOLOGY
pionibacterium propionicum. Many others from the root-canal microbiota Periapical lesion development is dependent upon the nature of the mixed
have also been implicated but their true presence in the periapical tissues infection, the succession of bacterial species within it and its ultimate
BIOLOGICAL AND CLINICAL RATIONALE FOR ROOT-CANAL TREATMENT AND MANAGEMENT OF ITS FAILURE 71
Dentine
Bacterial
biofilm
Dentine
Bacterial
biofilm
PMNs PMN
layer
B
A C
Fig. 3.39 PMNs (a = light microscopy, b = SEM) lining the biofilm on the canal wall and (c) actively phagocytosing the intracanal bacteria
Fig. 3.40 Cocci attached to the filaments giving a Fig. 3.41 Massive apical biofilm filling the entire Fig. 3.42 Apical root resorption with multilayered
corncob appearance circumference of the canal of a tooth associated bacterial plaque embedded in an extracellular
with acute apical periodontitis matrix
72 BIOLOGICAL AND CLINICAL RATIONALE FOR ROOT-CANAL TREATMENT AND MANAGEMENT OF ITS FAILURE
Root
Dentine Cementum
Fig. 3.43 Extraradicular extension of bacteria Fig. 3.44 Bacterial cells attached to collagen fibres
in dentinal tubules
A B C D
Fig. 3.45 (a) Adequate root filling demonstrated on radiograph; (b) periapical surgery and root resection of the tooth shown in (a) (arrowed) shows stained root
dentine; (c) resected root showing stained/infected dentine (2.82); (d) histological view of the root end shown in (c), showing infected dentinal tubules (S)
Fig. 3.46 Bacteria in survival. It is influenced by, as yet, undiscovered ecological factors in the
tubule with evidence of root-canal system. Studies, have therefore, focused on the nature of bacte-
cell division rial interactions with their environment.
Interactions between microorganisms and their biotic (living) and
abiotic (non-living) surroundings are important in enabling their survival.
The restricted nature of the root-canal microbiota suggests selective pres-
sures. A study of associations between bacteria in root-canal systems by
isolating all cultivable bacteria from a large number of root canals associ-
ated with periapical disease and calculating the likelihood of pairs of
bacteria occurring together has confirmed:
Hybridization
Probe
Fluorescent dye
Ribosomes
Target (16SrRNA)
Fluorescently labelled
oligonucleotides (probes) Washing & Drying
Fig. 3.48 Schematic digram showing in situ hybridization procedures for bacterial identification (courtesy of Athena Iacovidou & Morgana Vianna)
micros); Porphyromonas endodontalis, Selenomonas sputigena and The positive and negative associations are thought to be due to nutri-
Wolinella recta; Prevotella intermedia and Parvimonas micra; tional interactions (Fig. 3.53), local physiological conditions (Eh, pH),
Peptostreptococcus anaerobius and Eubacterium species bacteriocins and bacterial coaggregation or physical attraction and binding.
• negative associations between other species: Propionibacterium Microbial interactions within communities enable them to evolve,
propionicum, Capnocytophaga ochracea and Veillonella depending on the local environmental variations, thus supragingival and
parvula. subgingival plaque only a few millimetres apart develop vastly differently
74 BIOLOGICAL AND CLINICAL RATIONALE FOR ROOT-CANAL TREATMENT AND MANAGEMENT OF ITS FAILURE
Dentine
Biofilm
Canal lumen
Fig. 3.49 Gold labelling of Prevotella cell surface Fig. 3.50 Gold labelling of Fusbacterium Fig. 3.51 Fluorescent in situ hybridization (FISH) of
antigens 16SrRNA using rRNA probes universal bacterial 16S rRNA probes
Fusobacterium
Capnocyto-
eubacterium Strepto-
phaga
prevotella coccus Veillonella
Eikenella
peptostrepto- actinomyces
corrodens
coccus
NH4 lactate
Necrotic
tissue succinate CO2
formate menadione
haemin H2
acetate
Fig. 3.53 Nutritional interactions between some common root canal pathogens
treatment procedures (mechanical and chemical) essentially interfere with Growth and reproduction rates, as well as metabolic rates, may vary
the environment, killing some bacteria and, by a domino effect, indirectly within a biofilm depending upon its composition and activity. Local varia-
killing other species by altering the nutritional, physiological and toxic tions in such aspects can result in concentration and electrostatic gradients.
balance. The surviving bacteria are usually those physiologically “hardy” As cells reproduce, the colonies change shape and develop into stacks, the
enough to resist changes in the environment induced by the treatment and size and extent of which are controlled; water channels between the stacks
capable of living independently of other species in the unique nutrition- serve as a primitive circulatory system to transmit messaging molecules.
depleted conditions. That is, the organisms are “hardy” because of their Some cells develop slow metabolism and take on the role of persisters,
capacity to adapt. This means that a poor first attempt at root-canal treat- others may become detached from the biofilm and may become transiently
ment may result in a more recalcitrant infection to eradicate at the next planktonic to achieve dissemination. In this way, a highly specialized and
attempt. It is, therefore biologically most sensible to launch the most cooperative community develops, akin to a multicellular organism, capable
comprehensive effort at eradicating the infection at the first attempt. of sensing its environment and responding to changes within it.
The size, shape and composition of the colonies are variable and depend-
BIOFILM AND PLANKTONIC PHYSIOLOGY ent on the physiological activity of the community. They are partly dictated
by the relative proportion of extracellular matrix (ECM), the composition
Aggregations of microorganisms in communities at surface interfaces, of which is generally described as polysaccharide but varies according to
exhibiting well-defined structures, organization and cooperation, division the nutrition available, as well as its function. The ECM is a store-house
of labour, succession and specialized survival strategies have become
known as biofilms. Bacterial cells can live a nomadic existence, drifting
for finding nutrition and suitable environments for growth, reproduction Plasma
membrane Cell wall
and survival (Fig. 3.54); this is known as a planktonic existence. The same
Ribosomes Capsule
species may also live a sedentary existence by locating a suitable environ-
Plasmid
ment, in which nutrition is plentiful and safety is assured for growth,
Pilli
reproduction and survival; such an existence is known as a biofilm exist-
ence (Fig. 3.55). The latter existence is difficult to find, particularly for
single species, but may be engineered by cooperation between multiple
species with collective properties enabling a more effective and efficient
utilization of available resources. Such cooperation leads to the formation
of the most primitive, yet in its own way a sophisticated community. As
in any community, such cooperation requires communication, which
occurs in the form of chemical messaging, known as quorum sensing. The
messaging molecules are released into the environment by multiple cells,
if a sufficient amount of the messaging molecule is produced, a critical
threshold is exceeded to trigger a variety of changes and events. This
Bacterial flagellum
includes the switching on and off of key genes to facilitate growth, repro-
duction, secretion of and control of the nature of the extracellular matrix, Cytoplasm
expression of virulence genes, etc. The same species may be planktonic Nucleoid material (circular DNA)
or biofilm producing; simply as a function of the genes expressed despite
the relatively simple genomes they possess. Fig. 3.54 Schematic diagram of a planktonic bacterium
Dentine
Tubules
Fig. 3.55 Schematic diagram of the classical five stages of biofilm formation
76 BIOLOGICAL AND CLINICAL RATIONALE FOR ROOT-CANAL TREATMENT AND MANAGEMENT OF ITS FAILURE
or “junk-yard” for excreted molecules, including DNA, which forms an Effective treatment techniques should recognize these problems and be
important element of it. The relative proportion of cell to ECM varies sufficiently efficacious at the first attempt (visit) to prevent the infection
according to physiological activity and nutritional availability and can from becoming dominated by the surviving, more resistant strains.
range between 30% and 70%.
The first reliable, in situ, observation of the root-canal microbiota that
revealed both attached biofilms and planktonic bacteria suspended in fluid,
PREVENTION AND TREATMENT OF PERIAPICAL DISEASE
came from Nair as late as 1987. Since then other evidence has emerged.
It is not known whether the “suspended” bacteria were in fact suspended
BIOLOGICAL AND CLINICAL PERSPECTIVE
in fluid or matrix-embedded. If suspended, it was not clear if they had
ON A TECHNICALLY DRIVEN
simply been shed from the root-canal surface or were growing independ-
CHEMOMECHANICAL PROCEDURE
ently. The relative distribution of biofilm and planktonic phenotypes in the Based on the fact that periapical lesions develop as a result of the interac-
root-canal system is not yet known but these may dictate the properties of tion between bacteria (and their products) and the host defences, it is clear
the infection, in particular those that allow biofilm persistence after treat- that their prevention or resolution depends upon preventing or terminating
ment. The concept of the root-canal microbiota as a biofilm is a relatively this interaction.
recent one in the endodontic literature, although it was described in the Prevention of apical periodontitits applies to the clinical situation where
second edition of this book in 1994. it is judged that the pulp is irreversibly inflamed to the point that vital pulp
Root-canal infection then is essentially a bacterial biofilm coating the therapy would not resolve the problem and requires pulpectomy. By defini-
dentine surface, including the tubules to variable depths and extending to tion, apical periodontitis has not yet become established implying an
the apical foramina and sometimes beyond. The biofilm is usually patchy absence of bacterial colonization of the apical root-canal anatomy and the
and discontinuous (see Figs 3.31–3.35); different populations of bacteria probable presence of vital, healthy pulp tissue. The purpose of the chemo-
may communicate with each other through fluid films or fluid columns by mechanical treatment then would be to extirpate the pulp and prevent
the medium of molecular messengers. Individual cells within this coopera- infection becoming established as the natural defence system of the pulp
tive may respond to their immediate surroundings and neighbours by is sacrificed. The implication is that the procedure demands asepsis as
switching on or off relevant genes for survival. Nutrition depletion may a prime requirement. The technical aspects of the protocol may not be
slow their metabolism and allow some to enter a dormant state. This may so important and are focused principally on removal of the pulp tissue
also make them uncultivable if sampled. The bacterial population may, (Fig. 3.56). This is validated by the fact that the success rates (judged
therefore be diverse in terms of species and phenotypes (both biofilm and by conventional radiography) are high (90–99%) regardless of protocol
planktonic). This inter-reliance of the bacterial species is both therapeuti- (Fig. 3.57a).
cally useful, as well as potentially problematic. Once the periapical lesion has become established, variation in the
The relative mount and composition of ECM in biofilms within technical delivery of the chemomechanical protocol makes a greater
root-canal systems are currently unknown. It is, however, important to impact (see Fig. 3.57b). Overall, the challenge is a different one because
determine this property because it would play a major role in biofilm the purpose now is not merely to prevent infection but to remove the bacte-
eradication. rial biofilm and effect a switching-off of the host response. The challenge
Given the complexity of the root-canal anatomy, it is highly unlikely seems to be greater still if the periapical lesion is larger as it is associated
that bacterial killing agents would reach all aspects of the root-canal with a more diverse infection. A number of approaches have been used to
system and biofilm in adequate concentration. Reliance is placed on using achieve this general aim.
adequate concentrations of antibacterial agents so that sufficient dosage is The healing process after root-canal treatment has not been deeply
achieved along a diffusion gradient to effect killing or an ecological shift. researched but can be conceptualized using “Fish’s zones” (see Fig. 3.8)
It is probably because of the inter-reliance and inter-dependence among in a chronic inflammatory lesion. The removal of bacteria and their prod-
bacteria that the more fastidious species are killed in a chain sequence akin ucts should result in the reduction, if not (ideally) elimination of the zones
to a domino effect because of deprivation of their nutrients and stimulants of infection and contamination. This allows the macrophages in the zone
(such as quorum sensing) from their neighbouring partner species. Root- of irritation to invade the areas previously occupied by the zones of infec-
canal treatment, therefore probably works by a combination of direct and tion and contamination in order to remove dead cells and debris. This
indirect killing effects. The importance of indirect killing is probably process also makes way for the osteoblasts and fibroblasts, together with
underestimated in modern endodontics and is why knowledge of biofilm new in-growing blood vessels and nerve fibres from the outermost and
physiology may be therapeutically advantageous. active zone of stimulation to proliferate into the zone of irritation. In this
Conversely, biofilm existence also confers a range of defensive survival way, gradual healing takes place from the boundary of the lesion inwards
strategies. If a sufficiently effective attempt is not made to eradicate the until a normal periodontal ligament is established. Provided that the
biofilm, then its innate tendency would be to detect the changes and adapt pluripotential cells in the periodontal tissues, in particular, have not been
to launch events to facilitate survival. Recognition that root-canal infection irreversibly damaged, ideal healing would eventually result in regeneration
is an “intelligent”, multicellular-organism-like biofilm, is important in and the formation of cementum over the apical terminus, isolating the
devising strategies for treatment because bacteria in biofilms are more root-canal system completely from the periapex (Fig. 3.58) but this is not
resistant to killing. This is because: an inevitable end result. Incomplete removal of the infection would reduce
but not eliminate the inflammatory area and, in fact, this is generally the
• the exopolysaccharide in which the bacteria are embedded may case (Fig. 3.59). This implies that residual infection in the apical anatomy
restrict diffusion of the antibacterial agents to the cells is the norm following completion of root-canal treatment and that an
• different layers of cells may similarly act as barriers to diffusion ongoing interaction beyond the end of treatment, between the residual
• slower-growing bacterial cells, persister cells, metabolically infection, root filling material and host defences plays a definitive role in
inactive cells or dormant cells are more resistant to killing determining the final outcome. This explains several clinical observations
• cells may exhibit specific resistance mechanisms about periapical healing outcomes. It explains why, despite variations and
• biofilm phenotypes may be inherently more resistant. changes in the technical aspects of the chemomechanical protocol, the
BIOLOGICAL AND CLINICAL RATIONALE FOR ROOT-CANAL TREATMENT AND MANAGEMENT OF ITS FAILURE 77
Isthmus Dentine
Pulp tissue tags
in the isthmus and surface Pulp
on canal walls tissue
Rarely observed
odontoblastic
processes
being pulled out
of their tubules
Residual pulp
tissue apically
Virtually intact
Residual pulp tissue
extirpated pulp tissue
partially torn apically
Combined
Fig. 3.57 Forest plots showing (a) pooled and individual studies’ (1976–2012) probability of periapical healing following primary root-canal treatment in vital
teeth based on strict criteria;
78 BIOLOGICAL AND CLINICAL RATIONALE FOR ROOT-CANAL TREATMENT AND MANAGEMENT OF ITS FAILURE
Auerbach (1938)
Buchbinder (1941)
Castagnola & Orlay (1952)
Heling & Tamshe (1970)
Cvek (1972)
Werts (1975)
Adenubi & Rule (1976)
Heling & Shapira (1978)
Jokinen et al. (1978)
Barbakow et al. (1980)
Cvek et al. (1982)
Boggia (1983)
Pekruhn (1986)
Bystrom et al. (1987)
Halse & Molven (1987)
Safavi et al. (1987)
Akerblom & Hasselgren (1988)
Sjogren et al. (1990)
Murphy et al. (1991)
Friedman et al. (1995)
Calisken & Sen (1996)
Peretz et al. (1997)
Sjogren et al. (1997)
Lilly et al. (1998)
Weiger et al. (2000)
Cheung (2001)
Hoskinson et al. (2002)
Peters & Wesselink (2002)
Chugal et al. (2003)
Huumonen et al. (2003)
Khedmat (2004)
Chu et al. (2005)
Aqrabawi (2006)
Doyle et al. (2006)
Conner et al. (2007)
Molander et al. (2007)
Sari & Duruturk (2007)
Chevigny et al. (2008)
Cotton et al. (2008)
Penesis et al. (2008)
Siqueira et al. (2008)
Hsiao et al. (2009)
Mente et al. (2009)
Tervit et al. (2009)
Ng et al. (2011)
Ricucci et al. (2011)
Liang et al. (2012)
Combined
Fig. 3.57 Continued (b) pooled and individual studies’ (1938–2012) probability of periapical healing following primary root canal treatment in non-vital teeth
with periapical radiolucency based on strict criteria
Fig. 3.58 Low-power view of healing success rates of root-canal treatment have not improved over the last
by cementum formation when century (Fig. 3.60). It explains why the success rates are so sensitive to
Sealapex is used. (Black particles are the apical length of root-canal debridement (Fig. 3.61). It further explains
residual Sealapex and root filling
why the periapical lesion can take so long to heal after termination of the
material) (courtesy of Prof. M Tagger)
treatment procedure (Fig. 3.62).
• access to the pulp chamber through the crown of the tooth (coronal
access)
• location of all canal orifi in the pulp chamber floor
BIOLOGICAL AND CLINICAL RATIONALE FOR ROOT-CANAL TREATMENT AND MANAGEMENT OF ITS FAILURE 79
Fig. 3.59 Residual bacterial biofilm present in the apical portion of root canals following root-canal treatment (Nair et al., 2005)
• obtaining access to all apical canal termini by sensitive negotiation observation, culture test/bacterial presence test outcome) and
of the canals facilitate decision on need for further debridement or obturation
• determining the length of the instrument path to the canal • in the presence of continued signs and symptoms or positive
termini culture test/bacterial presence test, the root-canal system is
• maintaining access to all canal termini while also maintaining the reassessed to evaluate whether some part of the anatomy has been
canals centred in the root as they are progressively shaped to a missed; the chemomechanical step is repeated
regular taper (radicular access) to facilitate delivery of the • in the absence of signs and symptoms and a negative culture
antibacterial irrigant and ultimately the root filling material to the test/bacterial presence test, the root-canal system is filled to the
entire root-canal system canal termini (obturation).
• chemical treatment of the entire root-canal system surface
and space to facilitate removal of the bacterial biofilm and The stages prior to root filling are usually sufficient to achieve periapical
residual pulp tissue (a process dominated by control of fluid healing (Fig. 3.63). The purpose of root filling is said to be to fill the root-
dynamics) canal system with an inert material (usually gutta-percha and a sealer) to
• continued chemical treatment to control residual bacterial biofilm seal off the periapical tissues from the canal system and, in turn, from the
between visits (the coronal access is sealed and the tooth left for a oral environment. It also helps incarcerate residual infection in the root-
period of at least a week) canal system. The permanent access cavity restoration or the permanent
• re-entry to the root-canal system at the next visit to assess tooth restoration provides the definitive coronal seal preventing reinfection
response to debridement (signs, symptoms, intraradicular of the root-canal system.
80 BIOLOGICAL AND CLINICAL RATIONALE FOR ROOT-CANAL TREATMENT AND MANAGEMENT OF ITS FAILURE
Combined Combined
0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 1 0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 1
Probability of success - strict (studies published before 1960) Probability of success - strict (studies published in the 1960s)
Combined Combined
0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 1 0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 1
Probability of success - strict (studies published in the 1970s) Probability of success - strict (studies published in the 1980s)
0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 1 0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 1
Probability of success - strict (studies published in the 1990s) Probability of success - strict (studies published in the 2000s)
Fig. 3.60 Forest plots showing pooled and individual studies’ probability of periapical healing following primary root-canal treatment based on strict criteria by
decades of publication
The culture test during root-canal treatment has fallen out of favour in The use of cone-beam computed tomography (CBCT), which may be more
contemporary practice for a variety of reasons. The issue, though, remains sensitive to detection of periapical healing, may give healing rates and
controversial and there are some who still practise it. The outcome meas- durations that are longer but would not alter the factors affecting treatment
ures at the end of root-canal treatment are absence of clinical signs and outcome.
symptoms of persistent periapical disease and, curiously in the mind of
the practitioner, the radiographic appearance of the root filling (its shape
and homogeneity). The definitive outcome measure (in conjunction with
EFFECT OF CHEMOMECHANICAL AND OBTURATION
absence of signs and symptoms), however, is periapical healing, since the
PROCEDURES ON BIOLOGICAL EVENTS
treatment is aimed at resolution of the periapical disease (Fig. 3.64). Numerous studies have evaluated the effect of different stages of root-
Although the majority of periapical lesions heal within one year, healing canal treatment on the intraradicular bacterial flora, both qualitatively and
can take anything up to 4 years or longer (see Fig. 3.62) as measured by quantitatively. Some studies merely report positive culture tests whereas
sequential conventional radiographs, which follow the diminution in the others have identified and quantified intraradicular bacteria before and
size of the periapical radiolucency until normal architecture is restored. after various stages of treatment.
BIOLOGICAL AND CLINICAL RATIONALE FOR ROOT-CANAL TREATMENT AND MANAGEMENT OF ITS FAILURE 81
Combined Combined
0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 1 0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 1
6 months 36 months
Combined Combined
0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 1 0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 1
12 months 48 months
Combined Combined
0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 1 0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 1
24 months 29+ months
Fig. 3.62 Forest plots showing pooled and individual studies’ probability of periapical healing following primary root-canal treatment in non-vital teeth with
periapical radiolucency based on strict criteria by duration following treatment completion
A B A B
Fig. 3.63 (a,b) Periapical healing by cleaning Fig. 3.64 (a,b) Delayed healing caused by extruded filling material from the
alone distobuccal canal of a maxillary second molar (arrowed)
BIOLOGICAL AND CLINICAL RATIONALE FOR ROOT-CANAL TREATMENT AND MANAGEMENT OF ITS FAILURE 83
gradual abandoning of the culture test in clinical practice. One criticism Fig. 3.65 Fibrous
was that numerous factors could potentially account for treatment outcome healing (histological
but were not all considered in these studies. One large study (Seltzer et al., view)
1963) in particular contributed to the demise of the culture test but even
their study showed a 10% difference in success in favour of the negative
culture test when periapical disease was present. The outcome is even
worse when a positive culture test result combines with the presence of a
periapical lesion.
The bacteria in preobturation cultures include Enterococcus, Streptococ-
cus, Staphylococcus, Lactobacillus, Veillonella, Pseudomonas, Fusobac-
terium species and yeasts. Some studies have found no relationship
between individual species and treatment failure but others have. While
the overall failure rate for cases with positive cultures was 31%, that for repair with fibrosis (Fig. 3.65) or persistent chronic inflammation. Only
teeth with Enterococcus species was 55% and for teeth with Streptococcus time and acute exacerbation will identify the latter, whereas the former
species was 90% (Frostell, 1963); in another study, good quality root-canal should remain asymptomatic.
treatment on 54 teeth with asymptomatic periapical disease gave an overall A systematic review and meta-analysis of the factors affecting root-
success rate of 74%, but teeth with Enterococcus faecalis had a success canal treatment outcome revealed the following: the mean success rate is
rate of 66% (Sundqvist et al., 1998). These associations cannot be regarded 83% when a vital pulpectomy is carried out as there is no established
as cause–effect and a relationship should also be sought between numbers infection; this reduces to 72% when the root-canal treatment procedure is
of bacteria and treatment outcome. The success rate for teeth with no aimed at eradicating an established infection associated with a periapical
bacteria was 80% while that for teeth with bacteria in the canal before lesion.
obturation was 33%. The factors having a major impact on root-canal treatment outcome
A more recent monkey-model study (Fabricius et al., 2006) used the were:
same 4- or 5-strain infection model to test the effect of debridement
and obturation procedures on outcome. When bacteria remained after • presence and size of periapical lesion
chemomechanical debridement, 79% of the root canals were associated • apical extent of root-canal treatment in relation to radiographic
with non-healed periapical lesions, compared with 28% when no apex
bacteria were found to remain. Combinations of several residual bacterial • outcome of culture test
species were more frequently related to non-healed lesions than were • quality of root-canal treatment judged by radiographic appearance
single strains. When no bacteria remained at the end of chemomechanical of root filling
debridement, healing occurred independently of the quality of the • quality of the final coronal restoration.
root filling. In contrast, when bacteria remained, there was a greater The factors having minimal effect on root-canal treatment outcome
correlation with non-healing in poor-quality root fillings than in techni- were:
cally well-performed fillings. In root canals where bacteria were found
after removal of the root filling, 97% had not healed, compared with • age of patient
18% for those root canals with no bacteria detected upon removal • gender of patient
of root filling. The study emphasizes the importance of reducing bacteria • general health of patient
below detection limits before permanent root filling in order to achieve • treatment technique (preparation, irrigation and obturation material
optimal healing conditions for the periapical tissues. It also reinforces the and technique) other than length control.
view that obturation does indeed play a role when there is residual The improvements in techniques of mechanical and chemical canal
infection. preparation have not resulted in increases in success rates over the last
Regardless of the technique for obtaining a culture, the use of a century (see Fig. 3.60).
negative culture test results to inform progress of treatment has a It is notable that all the factors having a strong influence on
positive impact on treatment outcome. The association of specific species treatment outcome are associated in some way with root-canal infection.
with treatment failure is not well established but the identity of the small Further improvements in root-canal treatment outcomes may, therefore
group of species isolated from positive cultures is relatively constant and be obtained by understanding the nature of the root-canal infection (espe-
may hold answers to treatment resistance and failure. It is, however, cially apical) and the manner in which the microbiota is altered by
important to account for the other factors that influence root-canal treat- treatment.
ment outcome.
CAUSES OF ROOT-CANAL TREATMENT FAILURE
FACTORS AFFECTING OUTCOME
OF ROOT-CANAL TREATMENT When guideline standard root-canal treatment is performed, the failure rate
is 10–20%. When the treatment is technically substandard, as described
Clinical judgement of the outcome of treatment is based on the absence
for a high proportion of root-canal treatments performed in general prac-
of signs of infection and inflammation, such as pain, tenderness to percus-
tice across the world (Fig. 3.66), the success rates are lower.
sion of the tooth, tenderness to palpation of the related soft tissues, absence
The causes of root-canal treatment failure may be summarized as
of swelling and sinus and radiographic demonstration of healing of the
follows:
periapical lesion (if sufficient time has lapsed), with a completely normal
Microbial (persistent periapical inflammation)
periodontal ligament space.
Absence of signs and symptoms of periapical disease but a persistence • intraradicular (persistent or new infection)
of a periapical radiographic radiolucency may indicate either healing by • extraradicular (pre-existing or precipitated by treatment)
84 BIOLOGICAL AND CLINICAL RATIONALE FOR ROOT-CANAL TREATMENT AND MANAGEMENT OF ITS FAILURE
70.00%
60.00%
50.00%
40.00%
30.00%
20.00%
10.00%
0.00%
S es la 7)
or L el e . (2 )
po tus l. 3)
& en e l. (1 1)
rav e e (1 )
De ius e l. (1 8)
Pe sso t al. 986)
on l. 7)
ng l. 9)
Ho che al. ( 00)
pk Pe ez e al. (2 1)
Pa t al. 02)
Du s e (20 )
ba u e (2 )
Si & Ab l. (2 5)
Ts eira ott 05)
Ec eish t al. 005)
Su et . (20 )
)
Gu e (2 )
hi l. (2 )
al. 8)
8)
ter Im s (1 0)
Bu De son ld 91)
Ra n e (19 )
na S Tro . (19 )
ed ikk (1 )
Sa Ha en 95)
Llo We rs et (19 )
yd ige al 96)
tne (19 )
Ch s e l. (2 )
Er ngb l. (1 1)
az t al 003
da lt al. 8
ga ka 02
na al. 05
ur al. 07
lsa t a 007
e g 3
y & t al 95
far o pe 95
de el 95
Bj sjo 89
ga t a 03
om l 5
rq iva 199
go of t a 00
ley le a 9
Si chu et (199
ic t a 99
ss t a 98
va et a 199
-R up mm r et 200
k t a 00
et 00
00
s 9
iks er 99
Sp t 99
rb t a 00
ck C e (19
Du wlic (20
qu b 0
To et (20
9
& on 9
un r tw (19
ou et (20
0
et (19
& de (19
G t 9
ow gu t 0
ter e (1
ter n e (1
a & r e (2
e (2
(2
& r e (1
un e (2
ke i e (2
(
Pe tröm vist
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.
å a
f e
t
rg lmq
rke r
y
e
er
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u
s
s
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Mo
Ge
cz
lta
Bo
Non-microbial (persistent periapical inflammation/pathosis or new untreated teeth, treated teeth appear to contain few mixed cultures, often
inflammation/pathosis) only three, two or one cultivable species are found with a mean of only
1.7 species per tooth. Teeth with poor root fillings have the highest bacte-
• true cyst
rial counts (103–105) with a maximum of 3–6 cultivable species per canal
• foreign body reaction to: cholesterol crystals, extruded dentine
and a diversity that resembles that of untreated teeth, perhaps reflecting
chips, extruded calcium hydroxide, extruded sealer, extruded
poor treatment technique. Enterococcus faecalis is the commonest species
gutta-percha filling material, extruded amalgam, or extruded
and, when it is present in small numbers in the primary infection, it is
cellulose components from paper points, cotton wool, or pulses
easily eliminated, but if it infects in large numbers it is difficult to
eradicate.
INTRARADICULAR MICROBIOTA ASSOCIATED WITH Although specific bacterial species have not been implicated as being
FAILED ROOT-CANAL TREATMENT resistant to treatment in longitudinal studies, the presence of specific
groups of bacteria in root-treated teeth suggests that other than being
Microbial species recovered from root-treated teeth with persistent periapi-
survivors from the pre-existing infection they may be contaminants intro-
cal disease are presented in Table 3.5, which shows a different spectrum
duced during treatment. This may be due to:
compared to that in untreated teeth. The microbiota is dominated by Gram-
positive bacteria (Fig. 3.67), many of which are coccoid facultative anaer- • inadequate tooth isolation
obes. The retrieval of bacterial samples from obturated root-canal systems • poor asepsis
is compromised by the need to remove root-filling material first, which • leakage of the access dressing
may kill the bacteria present. The most frequently identified species are • access cavity being left open for drainage.
Enterococcus faecalis, Propionibacterium species, Streptococcus species,
Lactobacillus species, Peptostreptococcus species, and yeasts.
The species recovered from root-treated teeth reside in accessory canals
EXTRARADICULAR MICROBIOTA ASSOCIATED WITH
(see Fig. 3.22), in dentinal tubules (see Fig. 3.47) or in the main canal
FAILED ROOT-CANAL TREATMENT
alongside the root filling (see Fig. 3.24). They are a subset of those found Obtaining a sample from the periapical tissues without contamination is
in untreated teeth though the diversity and quantity is reduced. Unlike notoriously difficult. Approaches include either sampling through the root
BIOLOGICAL AND CLINICAL RATIONALE FOR ROOT-CANAL TREATMENT AND MANAGEMENT OF ITS FAILURE 85
Table 3.5 Representative taxa in treated teeth with persistent apical periodontitis (courtesy of Morgana Vianna)
canal or directly through the soft tissues, either method being susceptible A. israelii is a repeated culprit in therapy-resistant cases and is by far
to contamination. Many studies that have obtained periapical tissue have the most common species involved in actinomycosis. A. israelii is the most
taken scrapings, which may include microorganisms from the apical part prevalent Actinomyces species isolated from human abscesses; however,
of the root canal. Actinomyces gerencseriae (formerly A. israelii serotype II) is also preva-
The bacterial front may extend beyond the apical foramen and into the lent, found in 56% and 25% of human abscesses, respectively. Using
periapical lesion. It is possible that establishment of infection in this site checkerboard DNA–DNA hybridization analysis of root-canal samples
may lead to its change to adapt to the new site. Such a periapical infection from teeth diagnosed with periapical abscesses, A. israelii and A. gerenc-
may then seed new infection into the root-canal system and become a seriae have been reported in 14.8% and 7.4% of samples, respectively;
source of treatment resistance. This has been a topical area of research however, the role of A. gerencseriae in persistent infection after root filling
interest and controversy. The problem of its study is compounded by the is unknown. Recently, a new Actinomyces species, Actinomyces radiciden-
assertion that extraction of teeth causes pumping motion that may move tis, was found to be involved in post-treatment disease. Using PCR-based
the bacterial front and artificially alter the morphological relationships detection, it has been shown to be present in untreated root-canal infections
existing in vivo. Therefore, not only can periapical tissues be contaminated and root-filled teeth with chronic apical periodontitis, although its preva-
from the root canal but the root canal may be contaminated from the peri- lence in both types of infection was low.
apical tissues. Such movement of bacteria due to bulk flow of fluid caused
by pressure changes could indeed occur but is less likely when the coronal
part of the tooth is intact.
Periapical abscesses associated with untreated teeth appear to be domi-
CYSTS AND THEIR MANAGEMENT
nated by Streptococcus, Peptostreptococcus and Bacteroides species, a The cyst is an independent pathological entity within a granuloma (see
finding consistent with the presence of these groups in root canals of teeth Figs 3.16d, 3.26c). The granulomatous component of the lesion may
associated with symptoms. The profile of bacteria found in periapical respond to removal of the aetiological agents from the canal but the cyst
tissues in cases of “extraradicular infection” is somewhat different (Table component may survive (see Figs 3.26a,b). Cholesterol needles, which
3.6). In addition to the above groups they include Actinomyces, Propioni- leave the so-called cholesterol clefts in histological views (see Figs
bacterium, Fusobacterium, Prevotella and Staphylococcus species; these 3.26b,d) may be associated with a foreign-body type response. Successful
groups overlap considerably with those observed in teeth with symptoms. treatment of the cyst may require its enucleation, decompression by punc-
Some regard the two main groups of bacteria involved in extraradicular ture or induction of acute inflammation in the vicinity. Enucleation has
infections to be confined to Actinomyces (see Fig. 3.23) and Propionibac- been reliably tested without significant recurrence but the effectiveness of
terium species. the decompression method is less well documented. Healing can vary from
86 BIOLOGICAL AND CLINICAL RATIONALE FOR ROOT-CANAL TREATMENT AND MANAGEMENT OF ITS FAILURE
being rapid to slow and unpredictable, and the approach allows no proper non-surgical root-canal treatment, this approach is the preferred method
opportunity for biopsy. However, it is a valuable means of reducing the of first treatment of all periapical lesions associated with necrotic and
cyst’s size before surgical enucleation. The last method, of inducing acute infected pulps. If upon follow up, a technically adequate root-canal treat-
inflammation in the cyst’s vicinity, requires instrumentation through the ment does not lead to resolution, then a surgical approach should be
apical foramen as advocated by Bhaskar (1972). This rather unpredictable considered.
procedure has not gained wide support. Despite the overall lack of clarity
about the pathogenesis and approaches to treatment of cysts, the therapeu-
tic regimen for all periapical lesions associated with compromised pulps
FOREIGN BODY RESPONSE AND ITS MANAGEMENT
is clear. In view of the inability to differentiate diagnostically a granuloma In a small proportion of cases following treatment, and sometimes preced-
from a cyst clinically and the high rate of success of conventional ing it (if the tooth has been left on open drainage), foreign material may
BIOLOGICAL AND CLINICAL RATIONALE FOR ROOT-CANAL TREATMENT AND MANAGEMENT OF ITS FAILURE 87
Fig. 3.68 Needle used by a patient in trying to Fig. 3.69 Cellulose extruded into periapical tissue Fig. 3.70 Pulse granuloma
keep the canal clean
find its way into the canal and is then displaced into the periapical tissues, Fig. 3.71 Delayed
either by the patient in trying to keep the canal clean (Fig. 3.68) or by the healing associated with
dentist. Examples of foreign matter found in periapical tissues include extruded amalgam
needles and wires (Fig. 3.68), cotton wool or paper points (Fig. 3.69),
pulses causing a pulse granuloma (Fig. 3.70), dentine chips, root-filling
materials, including sealer (see Fig. 3.64), amalgam (Fig. 3.71), gutta-
percha (Fig. 3.72) and other materials, such as talc on the gutta-percha
(see Fig. 3.25) and calcium hydroxide (Fig. 3.73).
If the material is causing persistent pathoses or symptoms, it should be
surgically removed. The biopsy would reveal a picture of a frustrated
attempt by multinucleated giant cells derived from macrophages to engulf
and phagocytose the foreign material. Small amounts of extruded material
are normally removed by the body without problem (Fig. 3.74).
88 BIOLOGICAL AND CLINICAL RATIONALE FOR ROOT-CANAL TREATMENT AND MANAGEMENT OF ITS FAILURE
A B C A B
Fig. 3.72 (a–c) Delayed healing associated with extruded gutta-percha Fig. 3.73 (a,b) Delayed healing associated with extruded
calcium hydroxide
B A
Fig. 3.74 (a,b) Extruded sealer resorbed by the host Fig. 3.75 (a) Radiographic and (b) histologic images showing fibrous tissue repair
following surgical endodontic treatment in the maxillary left lateral incisor associated with
a preoperative large periapical radiolucency
FIBROUS HEALING (TMJ) dysfunction, sinusitis, other non-odontogenic causes of pain, peri-
odontal disease, lateral periodontal cysts, normal anatomy presenting as a
The outcome of healing of tissues damaged by inflammation and necrosis radiolucency (mental foramen, incisive foramen, maxillary sinus, etc).
as might be caused by a periapical lesion, is either repair or regeneration.
In the majority of cases, the final outcome would be regeneration. However,
it is possible that root-canal treatment may lead to healing by fibrous tissue MANAGEMENT OF FAILED PREVIOUS TREATMENT
repair, particularly in the case of large lesions that damage both cortical AND OUTCOME OF ROOT-CANAL RETREATMENT
plates (Figs 3.65, 3.75).
When root-canal treatment fails to resolve periapical disease, it is often
considered appropriate to retreat the tooth using conventional approaches,
INITIAL MISDIAGNOSIS
especially when the previous treatment is technically deficient (Fig. 3.76a).
This is of course not a true cause of failure of root-canal treatment but is This requires removal of the previous root-filling material and any other
a failure to manage the original problem correctly. At secondary referral material placed for restorative reasons. Correction of any iatrogenic pro-
centres, this is not an uncommon presentation. Common causes of misdi- cedural errors may also be required, if possible. All material must be
agnosis of pulpal/periapical disease include temporomandibular joint removed in its entirety to ensure delivery of antibacterial agents to all
BIOLOGICAL AND CLINICAL RATIONALE FOR ROOT-CANAL TREATMENT AND MANAGEMENT OF ITS FAILURE 89
A
B C
would then inflict additional trauma to the site and change the picture
Grahen & Hansson (1961)
altogether. The procedure would hopefully remove the causative factors
Bergenholtz et al. (1979a&b) leaving a complicated wound to heal by a process that is different from
Molven & Halse (1988) the one in response to conventional root-canal treatment. The healing
Sjogren et al. (1990) essentially involves epithelial and connective tissue resolution processes
Friedman et al. (1995) that are interdependent. The first step is the formation of an epithelial seal,
Sundqvist et al. (1998)
which matures with the nutrient support from the developing underlying
Hoskinson et al. (2002)
Farzaneh et al. (2004)
connective tissue. Reattachment of the mucoperiosteal flap may be com-
Gorni & Gagliani (2004) promised by the presence of periodontal disease. Further connective tissue
Caliskan (2005) healing consists of removal and organization of the clot into periosteum,
alveolar bone, cementum and periodontal ligament. The apical root resec-
tion creates a surface of exposed dentine with a root-canal outline, which
0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 1 is large and filled with a material of variable toxicity. The exposed dentinal
Probability of success for retreatment on teeth with apical periodontitis surface may become covered with cementum (see Fig. 3.58) if the tubules
are not infected but none forms over the root canal over which fibrous
Fig. 3.77 Forest plot showing pooled and individual studies’ probability of tissue develops. If a retrograde filling material, such as mineral trioxide
periapical healing following root-canal retreatment on teeth with apical
aggregate (MTA) is used, its osteogenic potential may allow better cover-
periodontitis based on strict criteria
age of the root-end by regeneration of tissues as opposed to repair.
surfaces of the root-canal dentine (Fig. 3.76b&c). The success rates of
retreatment are generally perceived to be lower compared to primary treat- FACTORS AFFECTING THE OUTCOME
ment because of: OF SURGICAL RETREATMENT
Meta-analysis of prospective data on the outcome of surgical endodontic
• obstructed access to the apical infection and/or
treatments on teeth with periapical radiolucency performed by a modern
• a potentially more resistant bacterial flora.
technique (using magnification, root-end resection with minimal or no
The outcomes from a range of studies shows that the mean weighted bevel, retrograde cavity preparation with ultrasonic tips, and modern ret-
success rate is 66% (Fig. 3.77), about 6% lower than in the case of primary rograde root-canal filling) revealed complete healing in 30–93% of cases
treatment on teeth with apical periodontitis. The factors affecting outcomes with a pooled success rate of 92% (95% CI 86%, 95%). Another meta-
of root canal retreatment are otherwise identical to those affecting primary analysis reported the pooled success rate of treatment using a microsurgi-
root canal treatment; a separate and further consideration is therefore not cal (94%; 95% CI 89%, 98%) was more favourable than traditional
given here. root-end surgery (59%; 95% CI 55%, 63%). However, the studies included
in the latter meta-analysis differed in design, case selection, duration after
PERIAPICAL SURGERY AND RETROGRADE SEAL treatment when outcome was assessed, and preoperative non-surgical
treatment. The difference between the microsurgery and traditional
In a proportion of cases, the conventional chemomechanical approach
approaches may, therefore have been exaggerated.
alone does not resolve the problem either because it may not allow access
The factors having a major impact on surgical retreatment outcome
to the infection or the cause is non-microbial. In the case of microbial
were:
causes of failure, the infection site may be in the apical canal anatomy (see
Fig. 3.22), in the apical dentinal tubules (see Fig. 3.45a–d) or extraradicu- • presence and size of periapical lesion
lar (see Fig. 3.23). In these instances, a surgical approach to the periapex • loss of cortical plate
may be required in addition to the conventional approach (see Fig. 3.45b). • quality of the pre-existing root-canal filling judged
Extraradicular infection cannot be diagnosed before primary treatment. It radiographically
is rather a differential diagnosis arrived at by initial conventional treatment • placement of root-end filling
of the intraradicular infection. The healing process in such cases may • quality of the coronal restoration.
follow a more complicated pathway. Initially, there may be attempts at
The factors having minimal effect on surgical retreatment outcome
healing if the primary intraradicular source of infection is also a major
were:
component of the lesion, so there may be a reduction in the size of the
periapical lesion. The persistent extraradicular infection would, however, • age of patient
frustrate attempts at complete healing. If the extraradicular infection is the • gender of patient
major source of the problem, there may be no change after treatment. • general health of patient
The surgical procedure consisting of the incisional and dissectional • tooth type
wounds concluding with the apical resection of the root (see Fig. 3.45c) • preoperative signs and symptoms.
90 BIOLOGICAL AND CLINICAL RATIONALE FOR ROOT-CANAL TREATMENT AND MANAGEMENT OF ITS FAILURE
Fig. 3.78 (a) Extrusion of filling material into the inferior dental
canal; (b) zones of anaesthesia (inner) and paraesthesia (outer)
A B
ALTERNATIVE APPROACHES Blome, B., Braun, A., Sobarzo, V., et al., 2008. Molecular identification and
TO ROOT-CANAL TREATMENT quantification of bacteria from endodontic infections using real-time polymerase chain
reaction. Oral Microbiol Immunol 23 (5), 384–390.
Bogen, G., Slots, J., 1999. Black-pigmented anaerobic rods in closed periapical lesions.
It is unfortunate that even in these times of evidence-based practice, some Int Endod J 32 (3), 204–210.
alternative practices persist. The philosophy adopted by some operators Brauner, A.W., Conrads, G., 1995. Studies into the microbial spectrum of apical
has been that the root-canal system anatomy is so complex that adequate periodontitis. Int Endod J 28 (5), 244–248.
Byers, M.R., Taylor, P.E., Khayat, B.G., et al., 1990. Effects of injury and inflammation
biomechanical debridement is impossible and time-consuming. Conse- on pulpal and periapical nerves. J Endod 16 (2), 78–84.
quently, they advocate the use of chemical agents to fix the organic pulp Bystrom, A., Claesson, R., Sundqvist, G., 1985. The antibacterial effect of camphorated
tissue together with any bacteria with a reduced emphasis on asepsis and paramonochlorophenol, camphorated phenol and calcium hydroxide in the treatment
of infected root canals. Endod Dent Traumatol 1, 170–175.
mechanical preparation. A variety of materials (e.g. N2), all containing Bystrom, A., Happonen, R.P., Sjogren, U., et al., 1987. Healing of periapical lesions of
formaldehyde as the fixative agent, has been used. When used together pulpless teeth after endodontic treatment with controlled asepsis. Endod Dent
with some degree of mechanical preparation, and the material is confined Traumatol 3 (2), 58–63.
Bystrom, A., Sundqvist, G., 1981. Bacteriologic evaluation of the efficacy of mechnical
within the root-canal system, the technique may, in some instances, provide root canal instrumentation in endodontic therapy. Scand J Dent Res 89, 321–328.
successful results. However, there is no scientific body of evidence to Bystrom, A., Sundqvist, G., 1983. Bacteriologic evaluation of the effect of 0.5% sodium
substantiate this practice as a predictable procedure. Furthermore, it has hypochlorite in endodontic therapy. Oral Surg Oral Med Oral Pathol 55, 307–312.
Bystrom, A., Sundqvist, G., 1985. The antibacterial action of sodium hypochlorite and
been demonstrated that the fixed pulpal tissue is antigenically altered and EDTA in 60 cases of endodontic therapy. Int Endod J 18, 35–40.
can stimulate an immune response on its own, whereas unfixed necrotic Conrads, G., Gharbia, S.E., Gulabivala, K., et al., 1997. The use of 16S rDNA
tissue cannot. directed PCR for the detection of endodontopathogenic bacteria. J Endod 23,
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When such material is inadvertently extruded (Fig. 3.78a), there are Dahlén, G., Bergenholtz, G., 1980. Endotoxic activity in teeth with necrotic pulps.
serious consequences. The toxicity of the material can cause necrosis and J Dent Res 59, 1033–1040.
can alter nerve function. The clinical manifestations of these include Dahlén, G., Fabricius, L., Heyden, G., et al., 1982. Apical periodontitis induced by
selected bacterial strains in root canals of immunized and non-immunized monkeys.
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4
Section 2 Preparation for delivery of endodontic treatment
Diagnosis of endodontic problems
K Gulabivala, Y-L Ng
Primary (actual)
Pain (spontaneous or stimulated by eating or drinking)
Cannot eat/drink (cannot bite, take hot or cold)
Table 4.4 Simplified classification of endodontic conditions
Swelling/infection
Discoloured tooth
Dentinal pain
Broken tooth/filling
State of the pulp
Tooth/gum does not feel right/feels different
State of periradicular tissues
Bad odour/taste
Tooth cracks/fractures
Iatrogenic problems Secondary (fear of)
Resorption Anxiety about
Anatomical anomalies Disease and its effects
Non-endodontic conditions Treatment
Mimicking pain Cost/loss of earnings
Mimicking periapical disease Appearance
No
Disease disease
No
Disease disease
A B
DIAGNOSIS OF ENDODONTIC PROBLEMS 95
HISTORY TAKING sound knowledge and experience. The patient should be allowed to relate
the details of their problem in their own words (as iterated by Wilfred
Wilfred Trotter on listening Trotter) but the process should be managed to make it ordered, systematic
the power of attention, of giving one’s whole mind to the and free of digression. If necessary, the clinician should be prepared gently
patient without interposition of anything of one’s self. but firmly to redirect the patient’s thoughts and memory if the information
Although a patient attends the dentist to identify and resolve their presented is incomplete.
problem, they will often have a preconception about the origin of the The purpose is to get the patient to relate their experience as accurately
problem, which may result in them limiting the scope of information as possible. The difficulty in achieving this in endodontic patients is poten-
they may be prepared to share with the clinician. There may be a need to tially multilayered. The patient’s experience of their problem may have
break the preconception first so as to enable the patient to be more open affected their state of mind due to anxiety, loss of sleep, loss of appetite
and free with the sharing of their experience and insight. The importance and a general feeling of malaise. In addition, the patient may not have the
of the detail for obtaining a resolution for the patient should not be vocabulary to describe their experience or the memory to recall it. While
underestimated. the dentist is trained to receive information in a particular order and has a
Another curious problem in free information sharing is the patient with set vocabulary for what may be experienced by the patient, they may not
an “intellectual ego”, who becomes very defensive when asked a basic have personal experience of the problem. Conversely, the patient is not
question, such as “can you describe the pain?” They may respond with, trained to describe their experience, especially using the “set” vocabulary
“Well, it is just a toothache”; suggesting that they somehow feel it beneath and order, in which the dentist is trained to receive it. Information exchange
themselves to share such basic insight with the expert whose responsibility would be significantly enhanced by dentists acquiring personal experience
they believe it is to identify and resolve their problem. The real problem of the full range of problems that they have to deal with (but this may
often is that they find it difficult to articulate their experience and feel prove impractical or unethical!). The challenge is therefore one of inade-
diminished by not being able to do so. They may be pacified to learn that quacy of information exchange.
toothache comes in many forms and it can indeed be very difficult to Listen carefully to the patient’s explanation of their condition and use
describe for most people but that attempting to do so would help to identify the patient’s own words to record it. Obtain a detailed description of any
their problem. Such grudging compliance may sometimes also hide other pain: its nature or character (sharp, dull, aching, throbbing, radiating);
issues, to which the dentist should be alert. continuous or intermittent; initiating, exacerbating or relieving factors;
To capture the patient’s attention and confidence requires many things, duration; frequency; association with time of day, events, cycles (e.g.
including a confident approach by the dentist, which in turn, demands menstrual), habits, eating, drinking, physical or mental activity, etc, should
all be noted; the effectiveness of analgesics should be recorded.
MEDICAL HISTORY
Table 4.6 Sources of the presenting complaints
Tooth structure problems
A medical history is taken to find out whether the patient has any health
Tooth structure problems Sources of inflammation
problem or is taking medication that could affect the treatment. The most
Caries State of the pulp convenient way of recording such information is to use a checklist that is
Tooth surface loss State of periapical tissues
kept in the patient’s file, such as that shown in Table 4.8.
Dental resorption Periodontal disease
There is no medical condition that specifically and definitively contrain-
Tooth cracks/fractures
Tooth/root perforation Non-endodontic conditions dicates endodontic treatment, however, if there is any doubt, it is best to
Anatomical anomalies Mimicking periapical disease
consult the patient’s medical supervisor. Conditions such as diabetes mel-
litus, bleeding disorders, anticoagulant therapy, blood-borne viruses,
Sources of pain immunosuppression or epilepsy may affect treatment. The incidence of
Dentinal pain infective endocarditis in patients with cardiac abnormalities is increased
Pulpal pain with diabetes mellitus, immunosuppression, alcohol dependence, haemo-
Periradicular pain dialysis and intravenous drug abuse. In the UK, guidelines published by
Non-odontogenic pain
the National Institute of Clinical Excellence do not recommend the pre-
scription of antibiotic prophylaxis for infective endocarditis.
Diagnosis Pain H/C Pain TTP Pain Drink Can’t bite Swelling Discoloured tooth Bad taste Bad odour
Dentinal √ X √ √ X √ X X
Pulpal √ √ √ X X √ X X
CTS √ √ √ √ X X X X
Periapical √ √ √ √ √ √ √ √
Vertical root fracture √ √ √ √ √ √ √ √
Resorption √ X √ X √X √ √ √
Periodontal √ √ √ √ √ X √ √
No Yes Details
Have you had rheumatic fever or a heart murmur?
Have you had heart trouble or high blood pressure?
Do you have antibiotic cover for dental treatment?
Do you tend to bleed excessively or bruise easily?
Do you suffer from asthma, TB, bronchitis or any other chest conditions?
Do you suffer from renal (kidney) disease?
Have you had liver disease (jaundice or hepatitis)?
Do you suffer from epilepsy?
Do you have any allergies to medicines or latex?
Are you pregnant?
Have you ever had depression or mental illness?
Are you currently taking any medicine?
Are you currently receiving treatment from you General Practitioner or any other specialist?
Have you ever been admitted to hospital?
Do you smoke? If so how many and how long?
Do you drink alcohol? If so how many units per week?
Do you have any other illness we should know about?
The initial consultation is most effectively carried out beside a desk with
both patient and clinician seated; patients find this less stressful than
immediately being asked to sit in a dental chair (Fig. 4.2).
I Olfactory Ask the patient to smell and identify something familiar (e.g. vinegar)
II Optic Observe for visual reflexes by shining a pen torch into one eye and check for pupil constriction
III Occulomotor Ask patient to follow your finger with their eyes and ask if they experience double vision during upward or inward eye movement.
Observe for ptosis (drooping of the eyelid), and mydriasis (pupil dilation)
IV Trochlear Ask patient to follow your finger with their eyes and ask if they experience double vision during downward eye movement
V Trigeminal Sensory branch: Lightly touch the face with a piece of cotton wool and then a blunt probe on the forehead, cheek and jawline. Lightly
touch the cornea with cotton wool and observe for corneal reflex
Motor supply: Ask patient to clench their teeth and observe and palpate the bulk of the masseter and temporalis muscles; ask patient
to open their mouth against resistance; gently tap the patient’s chin and observe for jaw jerk reflex
VI Abducent Ask patient to follow your finger with their eyes and ask if they experience double vision during lateral eye movement. Observe for
the affected eye turning inward
VII Facial Ask patient to raise their eyebrows, close their eyes against resistance and puff out their cheeks and show their teeth
VIII Vestibulocochlear Test for hearing loss by clicking your fingers next to the mastoid process
IX Glossopharyngeal Test for gag reflex by touching the soft palate
X Vagus Ask the patient to say “aah” and observe the movement and any deviation of the uvula
XI Spinal accessory Ask patient to shrug their shoulders and turn their head against resistance
XII Hypoglossal Ask patient to stick their tongue out and observe for any signs of wasting, fasciculations or deviation of the tongue
Intraoral
The purpose of the oral examination is multifold. The first remit is direct
visual detection of any variation from normal. The direct visual examina- Fig. 4.9 Loose bridge
tion is facilitated by drying the tissues, use of good illumination, transil- abutment with caries
beneath
lumination and magnification. This is secondarily followed by tactile
manipulation of the affected part to decipher any further variations
from normal. Finally, direct stimulation (by air, fluids, touch, pressure,
percussion or electrical current) of affected parts may be used to reproduce
or elicit the complaint or symptoms. Local anaesthesia may also be used
to aid further location of pain by selectively abolishing sensation.
The intraoral soft tissues, oral hygiene (Fig. 4.7), general periodontal
condition (Fig. 4.8), presence of caries (Fig. 4.9), missing or unopposed
teeth (Fig. 4.10), quality and quantity of dental treatment (Fig. 4.11), tooth
surface loss and faceting (Fig. 4.12) should all be assessed.
98 DIAGNOSIS OF ENDODONTIC PROBLEMS
Fig. 4.10 Missing and unopposed Fig. 4.13 Soft tissue examination
teeth
BACK FRONT
Fig. 4.15 Example of BPE score grid and criteria for coding
1 0 3
2 2 4*
Code Criteria
0 No pockets >3.5 mm, no calculus/overhangs, no bleeding after probing (black band completely visible)
1 No pockets >3.5 mm, no calculus/overhangs, but bleeding after probing (black band completely visible)
2 No pockets >3.5 mm, but supra- or subgingival calculus/overhangs (black band completely visible)
3 Probing depth 3.5–5.5 mm (black band partially visible, indicating pocket of 4–5 mm)
4 Probing depth >5.5 mm (black band entirely within the pocket, indicating pocket of 6 mm or more)
* Furcation involvement
Both the number and the * should be recorded if a furcation is detected - e.g. the score for a sextant could be 3*
(e.g. indicating probing depth 3.5–5.5 mm PLUS furcation involvement in the sextant).
SOFT TISSUE EXAMINATION Hard and soft swellings should also be recorded on diagrams for extent,
site, size, texture, consistency (bony, firm, fibrous, soft), mobility, fixity
The soft tissues, consisting of the cheek mucosa, tongue, floor of mouth, and fluctuance. Soft swellings should be palpated with two fingers to detect
palate, sulcular fold, and those overlying the alveolus should all be fluctuance. One finger is placed at either end of the swelling and pressure
assessed, after wiping with gauze, by direct visual observation for signs applied; if the swelling is fluctuant, movement of the fluid beneath the oral
of inflammation, sinus tract openings, induration, swellings, fibroepithelial mucosa will be felt.
growth, ulcers or discoloration (Fig. 4.13).
The purpose of tactile stimulation is to determine whether the tissues
are allodynic, hyperalgesic, tender or normal. A light touch may be applied,
PERIODONTAL EXAMINATION
such as with a cotton bud to see if pain is elicited, indicating neuropathic A general periodontal examination should be performed to characterize the
changes. An increasing degree of force is applied by finger palpation to periodontal status as part of the overall treatment plan, resulting in a basic
determine the presence of tenderness, which the patient is asked to confirm. periodontal examination (BPE) score (Fig. 4.15). The purpose is to deter-
The areas of altered sensation should be mapped on a diagram in the mine and segregate any problems arising from marginal periodontal prob-
records (Fig. 4.14). lems. More specifically, it is essential to exclude local, deep, isolated
DIAGNOSIS OF ENDODONTIC PROBLEMS 99
Fig. 4.16 Mobility Fig. 4.17 Use of fibreoptic light Fig. 4.18 Mandibular molar with
showing tooth fracture distal fracture
A B C
Fig. 4.19 (a) Burlew disc; (b) wood stick; (c) tooth slooth
Using an impact force rather than graduated pressure, allows a different presence or absence of a viable blood supply (laser Doppler, pulse oxime-
sort of assessment as the tooth moves differently in the viscoelastic peri- try) but these instruments have not yet been developed for routine clinical
odontal ligament. Gentle tapping with a finger (both vertically and later- use. Contemporary pulp testing can quantify neither disease nor health,
ally) and then with an instrument will locate a tender tooth but it is a and should not be used to judge the degree of pulpal disease. Pulp tests
harsher test and usually gives a slightly different result to a pressure test are best used to determine the existence of pulp necrosis and all are prone
(Fig. 4.20). If ankylosis of a tooth is suspected, tapping with an instrument to false positives and negatives. Each type of pulp test works through a
handle in the long axis of the tooth will confirm the diagnosis: an anky- slightly different mode of stimulation and, therefore, it is prudent to use
losed tooth has a distinctive high-pitched ring. all of them to triangulate a consensus.
D
E
DIAGNOSIS OF ENDODONTIC PROBLEMS 101
Fig. 4.22 Application of hot Fig. 4.23 Running a rubber wheel on Fig. 4.24 Flooding the isolated tooth
gutta-percha stick on tooth surface the tooth site with hot water
A B
Fig. 4.27 Ice stick applied to tooth Fig. 4.28 (a) Apparatus required for carbon dioxide pulp testing; (b) carbon dioxide stick
Fig. 4.29 The bevel of • remove a restoration to examine the floor of the cavity for
the needle should point a fracture
away from the tooth
• control temporomandibular joint (TMJ) and muscle pain
• remove a post to assess feasibility of orthograde root-canal
retreatment
• open a pulp chamber to assess feasibility of locating a sclerosed
root canal.
OCCLUSAL EXAMINATION
Part of the role of tooth examination is to establish tooth mobility,
tenderness on pressure or percussion, as well as structural damage from
parafunction. As these may all be influenced by occlusal contacts, it is
a quadrant of teeth with several possible candidates is to block individually appropriate to establish whether the pattern of static and dynamic occlusal
their nerve supply to see if the pain is abolished. The problem is that such contact relationships may have contributed to these findings or would
precise localization of anaesthesia is difficult and the technique relies on contribute to the planning and management of the restoration of the
precise delivery of the local anaesthetic agent. The pain is first provoked involved tooth.
and then an infiltration injection of local anaesthetic may be used to iden- This is done by recording the static occlusal relationship in maximal
tify the tooth. An intra-ligamental injection localizes the effect of the intercuspal position, the retruded contact position and the slide between
analgesic better, although the proximal teeth may still be affected. Note the two. The excursive guiding contact surfaces should be noted (in pro-
that the bevel of the needle in Figure 4.29 points away from the tooth to trusive and left and right lateral excursions). Most importantly, the pres-
allow easier penetration into the periodontal ligament. For mandibular ence of any non-working or working side interferences, as well as fremitus
posterior teeth, nerve blocking may begin with infiltration, proceed to on the involved teeth should be noted as these may be the cause of mobility
mental block and then inferior dental nerve block. or tenderness.
This is also a convenient time to note occlusal space requirements for
Cutting a test cavity any restoration and whether there has been loss of occlusal space due to
As a last resort, a test cavity may be cut in a tooth which is believed to be caries or loss of restoration or tooth attrition.
pulpless. In the authors’ experience, this test is not reliable because a posi-
tive response may be obtained from a tooth with a necrotic pulp due to
vibration effects. IMAGING TECHNIQUES
Further tooth evaluation Imaging technologies have been developed in medicine to aid non-invasive
visualization of the hidden tissues under investigation. The perfect tool is
On occasion, it may be necessary to carry out a preliminary procedure
not yet in existence. Any departure in their ability to detect disease or
before the final treatment plan can be made. For example:
health is measured by their sensitivity or specificity, respectively. The
• crowns and bridge retainers should be assessed for cementation perfect imaging tool would have 100% sensitivity and specificity; that is,
failure; the retainer should be firmly depressed apically and then it would detect disease or health without fail. Commonly used imaging
pulled axially, repeatedly to elicit bubbles at the margin as a sign techniques in medicine include, radiography, its computerized variant
of decementation (computed tomography), which allows three-dimensional rendering,
DIAGNOSIS OF ENDODONTIC PROBLEMS 103
magnetic resonance imaging and ultrasound imaging. In dentistry, the indicate to the operator the cause of the problem and the probable ease of
imaging techniques are confined to conventional radiography and cone- treatment. In Figure 4.32, the radiograph shows a maxillary first molar
beam computed tomography (CBCT). with horizontal and furcation bone loss, possible inflammatory resorption
of the distobuccal root and a gutta-percha point passing into the furcation.
CONVENTIONAL RADIOGRAPHIC ASSESSMENT The tooth should be extracted. Figure 4.33 shows two maxillary premolars,
the first of which has a periapical radiolucency and an inadequate paste
This is of the utmost importance. Preoperative periapical radiographs root filling, the second showing gross caries in the coronal portion of the
should be taken using the paralleling technique (Fig. 4.30). If a patent sinus root canal. The first premolar was root filled (Fig. 4.34) and the second
is present preoperatively, a radiograph may be taken with a size 30 gutta- extracted and replaced with bridgework.
percha point in place. The point should be inserted into the sinus and gently Accurate dental radiographs are an essential requirement for the prac-
teased by rolling the tip back and forth between the fingers until resistance tice of endodontics. High-quality periapical radiographs improve initial
or discomfort is encountered (Fig. 4.31). diagnosis and assist greatly in success of treatment. Operators should
If endodontic treatment is being considered, the following should be endeavour to achieve high technical standards in order to ensure accuracy
assessed on radiographs: shape, curvature and number of roots; presence and minimize the number of film exposures needed to complete a clinical
and morphology of root canals; size of pulp chamber; type and size of procedure. It is important to have a clear understanding of the materials,
coronal restoration; presence of periradicular disease; periodontal bone equipment, techniques and safety standards governing this discipline.
loss, internal or external resorption; and root fracture. If the tooth has been The reader is referred to a specialist book on radiography for such
treated previously, it should be possible to assess the type of root-filling knowledge.
material used and the presence of any procedural errors, such as perfora-
tion, untreated canals or a fractured instrument. The radiograph will often Conventional films versus digital image recording
The fastest films available, consistent with satisfactory diagnostic results,
Fig. 4.30 Radiograph should be used. F-speed film is replacing E-speed film as the fastest avail-
taken with parallel able, saving a further 20–25% on exposure compared with E-speed film
technique
when processed optimally. Size 0 films (34×22 mm) are suitable for chil-
dren and for anterior teeth, size 2 films (40×30 mm) for posterior teeth
and adults.
Digital radiology (DR) offers many potential advantages in dental and
endodontic practice. The detectors for DR exist in two forms: solid-state
detectors (sensors) and photostimulable phosphor plates. DR sensors use
miniature TV camera charge-coupled devices (CCD) or complementary
metal oxide semiconductor (CMOS) chips that are sensitive to light in
combination with a scintillator layer that converts X-rays to light. The
CCD/CMOS sensor is connected to a computer to display the image on a
A B C
Fig. 4.31 (a) Gutta-percha in sinus; (b) depth of insertion of gutta-percha; (c) gutta-percha point placed in sinus visible on radiograph
Fig. 4.34 First premolar root treated. Second Fig. 4.35 RVG imaging system Fig. 4.36 Schick intraoral sensors
premolar due for extraction
monitor. Direct conversion DR detectors have also been described in other technologies, there are a number of factors to consider. The spatial resolu-
fields of medical imaging and may play a more important role in the future. tion can be used to characterize the image sharpness and is expressed
The first digital imaging system was radiovisiography (RVG; Trophy in line pairs per millimetre. In a study that compared conventional film
Radiologie, Vincennes, France). It eliminated the time spent processing (F speed film), PPP and DR sensors, the highest spatial resolution was
X-ray films and possessed a zoom function, which allowed the magnifica- found for the conventional film even though a few DR sensors were able
tion of selected areas to try to improve diagnostic performance (Fig. 4.35). to match this resolution. In the same study, the highest contrast resolution
Digital image quality has improved with the further development of these was achieved by most of the DR sensors. The widest range of exposure
intraoral sensors and is now comparable with that of E-speed film (Fig. and the highest dosages permitting a diagnostic image were obtained with
4.36). The advantage of DR sensors for endodontic treatment is the imme- PPP systems and a few DR sensors. This contradicts the common belief
diate availability of the image. The disadvantages are the high cost and that digital radiography will always lead to dose reduction. Longer expo-
thickness of the sensor. sure times may cause blooming artifacts with most DR sensors (Fig. 4.38)
Phosphorescent screens or photostimulable phosphor plates (PPP) are but will leave the radiographic contrast of PPP largely unchanged. This
sensitive to X-rays and generate a latent image that is scanned with a implies that the clinician should make sure that the lowest possible expo-
laser scanner and converted to a digital image. The image can be erased sure time for the DR system is chosen.
from the phosphor plate by exposing the sensor to intense white light, As the computer hardware seems to double its performance every
thus making the sensor reusable. The advantage of PPP is that they have two years (Moore’s Law), concomitant improvement in the number
roughly the same dimensions compared to conventional radiographs and of pixels per DR sensor area, the signal to noise ratio and reduction in
that the sensor plates are relatively inexpensive. amount of radiation required to generate an image would be expected in
Due to the development of wireless technology such as “bluetooth” for the future.
other applications, the first wireless CMOS sensors have already been
introduced, such as the Schick CDR® wireless system (Fig. 4.37). Even Film holders
though these sensors have a tiny battery pack as power supply, they have
about the same dimensions as the corded equivalents but are more Film holders are devices designed to hold the film in a stable position
expensive. within the patient’s mouth, avoiding the need to hold the film by hand.
The advantages of digital imaging are the instant availability; secure Many incorporate beam-aiming devices to prevent “cone cutting” and
storage and archiving of the digital data. The images can be accessed from some also include a device for rectangular collimation (Fig. 4.39). Their
different computers in a network, as well as transmitted as necessary. use improves the diagnostic quality of the image and allows the position
of the film and beam to be reproduced during subsequent recall
Comparing the different technologies assessment.
Film holder systems include:
The traditional film can be regarded as the gold standard. It does, however,
come with certain disadvantages related to storage and processing: The • modified Spencer-Wells forceps
film package needs to be unpacked in a dark or safelight environment; • Rinn XCP system including anterior and posterior film holders
the chemicals used for processing (developer and fixer) are a burden to (Fig. 4.40)
the environment; the development procedure is sensitive to temperature, • Masel precision film holders (Fig. 4.41)
development time and concentration of the chemicals. The film, once • RinnEndoray film holder – a holder designed for taking paralleling
developed, needs inspection with the aid of a magnifying glass. All the technique radiographs in the presence of endodontic hand
radiographs need to be stored and archived physically. All these issues are instruments (Fig. 4.42). The film holder incorporates a “basket”,
solved when employing digital radiography. Even though PPP need to be which fits over the crown of the tooth and endodontic instruments,
scanned after exposure, this can be regarded as an automatic process and on to which the patient bites lightly. The X-ray beam may be
that almost eliminates human error. When comparing the different aligned with the handle and centred through a centring ring.
DIAGNOSIS OF ENDODONTIC PROBLEMS 105
Fig. 4.42 Rinn Endoray film holder with basket Fig. 4.43 Film/sensor holder and Fig. 4.44 Thermoluminescent
beam-aiming device in use dosimeter
Radiation safety and regulations is in operation. It extends for a distance of 2 m around the tube head and
patient (for tubes operating at up to and including 70 kV) and for a distance
The Ionizing Radiations Regulations 1999 and the Ionizing Radiation
along the primary beam until it is attenuated by a radiopaque wall or shield
(Medical Exposure) Regulations 2000 (IRMER) lay down requirements
of suitable thickness.
for the safe use of radiation in the workplace and for the protection
of patients, staff and the general public. It is the responsibility of all Operators and other staff
staff to be familiar with legislation relevant to them. The dangers of
excessive radiation are minimal, provided simple precautions are observed. All staff involved in dental radiography should understand the dangers of
Four categories of personnel are identified under the IRMER 2000 radiation and be conversant with the precautions necessary for proper
regulations: handling of equipment and patients. Every practice should appoint a Radi-
ation Protection Supervisor (RPS) from within the dental staff to oversee
1 the referrer who requests the radiograph day-to-day radiation safety, and a Radiation Protection Advisor (RPA) – a
2 the practitioner whose responsibility is to decide if the radiograph qualified medical physicist – to advise the practice on radiation protection
can be justified measures and to carry out equipment checks. Local rules relating to radia-
3 the operator who carries out any aspect of the exposure procedure tion protection in the practice should be conveniently displayed. Only
4 the employer (legal person) who takes responsibility for the people adequately trained for their role should take part in dental radiog-
radiation installation and staff working within it. raphy and no one under 16 years should be allowed to work with ionizing
In dental practice, the dental surgeon may fulfill several or all of these radiation.
roles. The most important decision any practitioner should make is whether Several units are used for measuring radiation:
the use of X-rays is clinically necessary. Safety considerations of radio- 1 The exposure is a measure of the energy of the X-ray beam
logical techniques fall into three areas: emitted by the X-ray tube. It measures ionization per unit mass of
1 the patient air and is expressed in units of coulombs per kilogram (C kg−1)
2 the operator 2 Radiation absorbed dose (D) is the amount of energy absorbed
3 the equipment. from the X-ray beam per unit mass of tissue. It gives the absorbed
energy in joules/kg and is expressed in Grays (Gy) and milliGrays
(mGy)
Patients 3 The effective dose (E) is a measure that considers the relative harm
To justify any radiograph, the risk to the patient from an X-ray exposure of the radiation emitted and the relative sensitivity of the tissues
must be outweighed by the benefit of the diagnostic information given by exposed. This then allows doses from different investigations of
the radiograph. The risk must be minimized by reducing the dose as far different parts of the body to be compared, by converting all doses
as possible. Techniques should be used which avoid exposures passing to an equivalent whole body dose. It is expressed in Sieverts (Sv)
towards the patient’s body and gonads. Paralleling technique for periapical and milliSieverts (mSv)
radiographs is preferred for this reason. Lead aprons are no longer recom- Staff exposure to radiation should be closely monitored, using
mended for routine dental radiography since the use of such techniques film badges or thermoluminescent dosimeters (Fig. 4.44) if an
with modern, high kilovolt equipment, rectangular collimation and fast individual’s workload exceeds 150 radiographs per week or if an
films produce less scatter towards the body and are more effective at reduc- X-ray tube is relocated. Radiation dosage is reduced if the
ing dose. following precautions are observed:
Exposures need to be set to the minimum exposure time possible. ▸ the operator must stand outside the controlled area
Patients should not hold the film packet in position with their fingers; film ▸ the operator should never hold the film, tube housing or patient
holders or forceps should be used (Fig. 4.43) and no one other than the during the exposure
patient should be within the controlled area during the exposure. The ▸ when not in use the X-ray machine should be disconnected from
controlled area is an exclusion zone around the X-ray tube head when it the mains to prevent inadvertent exposure
DIAGNOSIS OF ENDODONTIC PROBLEMS 107
Mounts molar area, but it is usually possible to align the tooth parallel with the
Radiographs should be named, dated and filed systematically. They may film with a small separating distance. A separation of object and film
be stored in the patient’s clinical records but should ideally be mounted to creates magnification of the object, but this is overcome in the paralleling
protect the film during examination, storage or referral. It is usual to place technique by the use of a longer focal spot to object distance (ffd), creating
radiographs in labelled pouches or to laminate them between two sheets a more parallel beam.
of acetate (Fig. 4.46), either by stapling the sheets together using adhesive A film holder with a beam-aiming device is necessary to support the
transparent “sticky-back plastic” or by using a heat-sealing laminating film upright in the mouth and to ensure accurate alignment of the colli-
machine. mated beam. Figure 4.47 shows a paralleling periapical radiograph of the
central incisors being taken using a Rinn film/sensor holder and localizing
Radiographic techniques ring. The resultant digital radiographic image is also shown (Fig. 4.48).
Paralleling periapical projections The advantages of paralleling technique are:
The ideal imaging geometry for a radiograph would place the object and • greater geometric accuracy (e.g. Fig. 4.49)
film close together, with their long axes parallel. The X-ray beam would • reproducibility
then be directed at 90° to the long axes of these two structures. It is rarely • fewer retakes (films held securely and technique less prone to
possible to achieve this ideal positioning in the mouth, except in the lower errors)
108 DIAGNOSIS OF ENDODONTIC PROBLEMS
Fig. 4.50 Parallel image of maxillary molar roots Fig. 4.51 Use of forceps to position intraoral film Fig. 4.52 Principle of the bisecting
(see Fig. 4.55 for bisecting angle view) angle periapical projection
Fig. 4.53 Bisecting angle periapical projection of Fig. 4.54 Image produced by Fig. 4.55 Superimposition of the zygomatic arch
maxillary central incisors misplaced film in bisecting angle in bisecting angle technique (see Fig. 4.50 for
technique parallel view)
• lower radiation dose (beam not directed towards the body trunk, and easy to use with rubber dam in place and is relatively comfortable for
finger not holding film and, therefore, not irradiated, use of high all patients, even those with small mouths. It is, however, difficult to avoid
kilovolt modern machines) distortion and an accurate image can never be guaranteed. Other faults
• superior images of maxillary molar roots (zygomatic buttress such as displaced or bent films and “cone cutting” are more likely than
projected above the molar apices (Fig. 4.50) with film/sensor holders (Fig. 4.54). Anatomical structures such as the
• superior image of bone margins zygomatic arch are frequently superimposed over the apices of the upper
• superior images of interproximal regions (the positioning is closer posterior teeth and the relationship between roots, other anatomical struc-
to that of bitewings, therefore interproximal caries may be tures and alveolar bone may be distorted (Fig. 4.55). It is also difficult to
assessed). reproduce a periapical view for review and recall purposes.
Inevitably, this technique has some limitations, being more difficult to
achieve ideal positioning in patients with shallow palates, with a pro- Parallax techniques
nounced gag reflex or with rubber dam in place. Alternatives involve the Horizontal and vertical parallax techniques are most useful in endodontics
use of forceps (Fig. 4.51). in the diagnostic and treatment phases. The principle works on the basis
that a set of objects distributed in three-dimensional space, although having
Bisecting angle periapical projections fixed and unique relative relationships, will appear to have altered relative
In this technique, the film is placed against the tooth and the angle between relationships depending on the viewing perspective. As an analogy, when
the long axis of tooth and film is visualized and bisected. The X-ray beam driving along a highway through countryside, trees closer to the highway
is centred on the apex of the tooth, transecting the bisecting line at 90° “move” in the opposite direction of travel, while those in the distance
(Fig. 4.52). In the lower molar region, the film and tooth may be almost appear to “move” in the same direction of travel. Applied to X-ray images,
parallel but, in the upper anterior regions, a considerable angle may result if two images are obtained from two different horizontal angles, the appar-
between the tooth and the film causing a pronounced angulation of the ent shift in position of an object (relative to a reference object) in the
beam downwards towards the body (Fig. 4.53). opposite direction to the X-ray tube signifies that it is closer to the tube
The bisecting angle technique may be performed without film/sensor (i.e. on the buccal aspect), while an object exhibiting an apparent shift in
holders (although the patient must then hold the film with forceps), is quick position in the same direction, will be further away from the tube (i.e. on
DIAGNOSIS OF ENDODONTIC PROBLEMS 109
Fig. 4.56 Horizontal parallax used to Fig. 4.57 Horizontal parallax used to Fig. 4.58 Horizontal parallax used to Fig. 4.59 Horizontal parallax used to
identify perforated post and post identify perforated post and post identify perforated post and post identify perforated post and post
preparation preparation preparation preparation
the lingual aspect). This principle is enshrined in the SLOB rule, which
stands for “Same Lingual, Opposite Buccal”. Horizontal parallax can be
used to indicate the position of intradental structures in relation to the
external surface of the tooth. This is very useful in the identification of
location of perforations (Figs 4.56–4.61). Both horizontal and vertical
parallax can be used to good effect selectively to image individual roots
of a multirooted tooth (Figs 4.62, 4.63).
Fig. 4.64 The principle of the CBCT is a cone- Fig. 4.65 The CBCT dataset is reconstructed to images that can be viewed in different planes: axial,
shaped beam projecting X-ray source and a sagittal and coronal (courtesy of Dr WJ van der Meer)
reciprocal image receptor that rotates once around
the head of the patient (courtesy of Dr WJ van der
Meer)
Fig. 4.66 The CBCT machines are available for scanning lying down, standing up or sitting down Fig. 4.67 For endodontic purposes a small FOV
(courtesy of Dr WJ van der Meer) is usually required. Even though many CBCT
machines are able to reduce their FOV in a vertical
direction (B), a machine that is also able to reduce
360°. The computer reconstructs these images to a 3D volume (Fig. 4.65). the FOV in a horizontal direction (C) will greatly
Algorithms for this reconstruction have been available since the 1980s, reduce the effective dose for the patient. These
but the computer power of commercially available computers at that machines are best suited for endodontic
time was insufficient for these kinds of calculations. At present, the recon- diagnostics (courtesy of Dr WJ van der Meer)
struction of up to 600 exposures to the corresponding images in three
orthogonal planes (axial, sagittal and coronal) only takes a couple of to movements of the patient during the scan. Ideally, a scan should be
minutes. The CBCT machines are available for scanning patients lying acquired with a high resolution, a short scan time with a low effective dose
down, as in traditional CT scanners but also for scanning patients sitting for the patient. As some of these factors impose conflicting requirements,
down or standing up (Fig. 4.66). The machines also differ in the size of a balance needs to be found between the parameters. For endodontic diag-
the field of view (FOV) and the options for adjusting this FOV (Fig. 4.67). nosis, a small FOV should suffice, reducing the effective dose and the
As a rule of thumb, it can be stated that the larger the FOV (and thus the anatomical area to be examined. The importance of this lies in the fact that
sensor), the higher the price of the machine. For endodontic diagnostic the clinician is responsible for the dataset, including anatomy outside the
purposes, a small FOV equivalent to the size of several teeth, is usually oral cavity. This implies the need to ensure correct reporting from a quali-
sufficient. fied radiologist on such radiographic data.
The effective dose for a patient is determined by the X-ray source When comparing the CBCT datasets with traditional 2D radiographs,
(continuous or pulsed), the kilovoltage and amperage used, the amount of the CBCT datasets reveal 38% more periapical lesions than traditional
filtering, the FOV and the resolution needed for the dataset (Table 4.12). radiographs. When comparing measurements made on traditional radio-
Higher resolution images will require more images and, therefore, a longer graphs and CBCT datasets the latter seem to be more accurate and the
exposure time. The disadvantage of higher resolution exposures is not only errors seem to be small and clinically insignificant.
the higher effective dose for the patient but also the extended rotation time. The UK Health Protection Agency’s Radiation Protection Division
A longer scanning time will increase the chances of motion artefacts due (2009) and the Joint Position Statement of the American Association
DIAGNOSIS OF ENDODONTIC PROBLEMS 111
Model Field of view (mm) Voxel size (mm) Scan time (s) Reconstruction time kV Effective dose (microSv)
Ewoo (Vatech)Pax Uni3D 50 × 50 0.2 8 18 s 50–90 25–60
(2 models) 80 × 50 mm 17.5–20 25 s
Ewoo (Vatech)PaX Duo3D 50 × 50 to 120 × 85 0.12–0.2 15–24 32–59 s 50–90 25–60
Ewoo (Vatech) PaX Reve3DS 50 × 50 to 150 × 150 0.12–0.25 15–24 27–105 s 50–90 25–-60
Ewoo (Vatech) PaX Zenith3D 50 × 50 to 240 × 190 0.08–0.3 15–24 10–221 s 50–120 25–60
Ewoo (Vatech) Master3DS 160 × 70 0.2–0.25 15–24 9–51 s 50–90 25–60
240 × 190
Ewoo (Vatech )PicassoTrio 120 × 70 0.2 15–24 25 s 50–90 25–60
Gendex/KaVo/Icat 130 × 170 0.12–0.40 5, 8, 9 of 25 120 s 96–120 68
Illuma 140 × 180 0.09–0.40 20–40 2–4 min 120 58–300
Kodak 9000 3D 50 × 37 0.076–0.200 13.9 <2 min 60–90 Not available
Kodak 9500 90 × 150 0.200 2 min 60–90 Not available
184 × 206
Morita 3D Accuitomo170 40 × 40 0.080,0.125 5.4–30.8 1–4 min 60–90 22 (40 × 40);
170 × 120 0.160, 51 (60 × 60)
0.250
Morita Veraview epocs3De 40 × 40 0.125 9.4 4 min 60–90 30 (40 × 40)
40 × 80
Morita Veraview epocs3D 40 × 40 0.125 9.4 4 min 60–-90 30 (40 × 40)
40 × 80
Newtom 5G 60 × 60 to 18 × 16 0.075– 0.3 18–36 Less than 1 min 110 Not available yet
Newtom VG 150 × 110 0.3 18 Less than 1 min 95 50–100
Newtom VGi 120 × 75 to 150 × 150cm 0.15–0.30 18 Less than 1 min 110 50–100
PlanmecaProMax3D 80 × 80 to 40 × 50 0.160 × 0.160 × 0.160– 18 30–150 s 84 50–80
0.320 × 0.320 × 0.320 μm
Planmeca Proma x3DMAX 50 × 55 to 220 × 170 0.100 × 0.100 × 0.100– 18–30 30–150 s 96 50–80
0.400 × 0.400 × 0.400
Planmeca Promax3DS 50 × 50 to 50 × 80 0.100 × 100 × 100– 18 30–150 s 84 50–80
0.200 ×0.200 × 0.200
Scanora 3D 60 × 60 to- 0.133 3–6wer-kelijke 1–2in 60–85 29–38
130 × 145 0.35 best ra-ting)
Sirona Galileos Comfort 150 (spherical diameter) 0.15–0.30 14/2–6 2.5–4.5 min 85 70*
Sirona Galileos Compact 150 × 120 (ellipsoid) 0.15–0.30 14/2–6 4.5 min 85 45*
Pulp Root
chamber canal
Cancellous
Lamina bone
dura
Periodontal
Periradicular ligament
radiolucency space
Lamina dura
This is the name given to the white line forming the lining of the tooth
socket seen on radiographs and represents the margin of the socket. This
feature is less critical than the PDL space in determining the presence of
apical pathosis.
Fig. 4.72 Superimposed incisive Fig. 4.73 Large maxillary antrum, which may be Fig. 4.74 Maxillary lateral incisor
canal cyst giving impression of loss confused with a cyst with a periradicular lesion – maxillary
of lamina dura around the apex of a central incisor with superimposed
maxillary incisor incisive canal
Fig. 4.75 Inferior dental canal, which may be Fig. 4.76 Radiographic appearance of a mental Fig. 4.77 Inferior dental canal and
confused with periradicular lesion foramen mental foramen, which might be
confused with periradicular lesion
Incisive foramen be close to or coincident with the roots of the lower molar and premolar
teeth. Here it may be mistaken for a lesion (Fig. 4.75).
This circular or oval radiolucent shadow of the incisive foramen may be
superimposed over the apex of a central incisor and be mistaken for a
periapical lesion (Fig. 4.74). Mental foramen
The mental foramen is situated below and distal to the apex of the man-
Inferior dental canal
dibular first premolar (Fig. 4.76). Occasionally, the angulation of a periapi-
The mandibular or inferior dental canal runs from the mandibular foramen cal radiograph may result in superimposition of the structure on the apex
on the medial aspect of the ascending ramus of the mandible to the mental of one of the premolars. The foramen may then be confused with a per-
foramen in the premolar region. It is seen as a radiolucent band that may iradicular lesion (Fig. 4.77).
114 DIAGNOSIS OF ENDODONTIC PROBLEMS
LESIONS INVOLVING THE PERIODONTAL relation to the main X-ray beam (Fig. 4.86). If the beam does not pass
LIGAMENT SPACE through the fracture, it may well remain undetected.
Periradicular lesions
PERFORATION LESIONS
These are the most common apical radiolucencies. Long-standing lesions
Perforations (Fig. 4.87a) can lead to rapid bone loss, the diffuse appearance
and those from a chronic inflammatory process are usually well defined
of the radiolucency reflecting the more acute inflammatory process initi-
(Fig. 4.78) and may even develop a radiopaque margin of reactive bone
ated. The presence of a post-retained restoration in a tooth with a large
(Fig. 4.79). Early lesions are identified by thickening of the periodontal
diffuse lesion involving more than just the apical region should arouse
ligament space (Fig. 4.80) – these can progress to discrete areas of radi-
suspicion of a perforation or fracture (Fig. 4.87b).
olucency (Fig. 4.81) and may, at a later stage, become larger and more
diffuse in appearance (Fig. 4.82).
SCLEROSING OSTEITIS
Lateral periradicular lesions
This appears as a zone of peripheral radiopacity (Fig. 4.88) and is indica-
Widening of the periodontal ligament space and formation of radiolucen- tive of a long-standing, low-grade apical infection, which gives rise to a
cies unrelated to the apex (Fig. 4.83) are associated with infection within circumscribed proliferation of the periapical bone. It is usually related to
the lateral canals. These canals may become visible only after canal obtura- a pulp that is in the process of degeneration. The condition is often
tion (Fig. 4.84). symptomless.
Fig. 4.78 Maxillary lateral incisor Fig. 4.79 Mandibular molar with periradicular Fig. 4.80 Periodontally involved maxillary molar
with well-defined periradicular lesion lesion with radiopaque margin with widening of the periodontal ligament space
of the mesiobuccal root
Fig. 4.81 Discrete periapical radiolucency Fig. 4.82 Mandibular molar with large diffuse Fig. 4.83 Central incisor with lateral
periradicular radiolucency periradicular radiolucency
DIAGNOSIS OF ENDODONTIC PROBLEMS 115
Fig. 4.84 Central incisor with Fig. 4.85 Diffuse radiolucency Fig. 4.86 Maxillary central incisor
obturated lateral canal related to fractured maxillary incisor with horizontal root fracture
Idiopathic osteosclerosis
Areas of dense bone may frequently be encountered within the trabecular
Fig. 4.89 Periodontal spaces and may represent a developmental anomaly or, occasionally, a
lesion associated with compensatory response to abnormal stress. The radiographic appearance
mandibular molar may closely resemble that of sclerosing osteitis. However, the tooth reacts
normally to vitality testing (Fig. 4.90).
Fibro-cemento-osseous dysplasia
Fibro-cemento-osseous lesions present in their early stages as radiolucent
areas, commonly in relation to the apices of the mandibular incisors known
here as periapical fibro-cemento-osseous dysplasia (Fig. 4.91). These
lesions mature over a 5- to 10-year period with gradual infill of dense
cemento-osseous material to create radiopacities. The teeth remain vital
and endodontic treatment is not required.
116 DIAGNOSIS OF ENDODONTIC PROBLEMS
Fig. 4.90 Dense bony trabecular Fig. 4.91 Fibro-cemento-osseous-dysplasia related Fig. 4.92 Extensive radiolucency produced by a
pattern around the roots of vital to a mandibular molar lesion of non-endodontic origin
teeth
Other local and systemic pathosis months. The tooth should be checked at regular intervals until the pulp
tests return to normal; root-canal treatment should only be considered in
Many inflammatory, cystic and neoplastic lesions may arise in the jaws
conjunction with a second sign of pulp necrosis and infection, namely,
which are not of endodontic origin (Fig. 4.92). These are capable of
periapical change.
destroying or remodelling neighbouring bone and of displacing or resorb-
ing teeth. In many cases, the teeth remain vital if the lesion originates
outside the periodontium. The clinician should always be alert to the pos-
REVERSIBLE PULPITIS
sibility of non-dental causes of bone destruction. Hot or cold stimuli will cause a quick sharp pain, which may linger for
The origin of such lesions may be divided into: seconds after the stimulus is removed as a dull aching sensation. The pain
does not radiate and the tooth is otherwise symptomless. The radiograph
• infections (localized and spreading)
shows no periapical radiolucency.
• trauma
• cysts (odontogenic and non-odontogenic)
IRREVERSIBLE PULPITIS
• tumours (benign and malignant)
• giant cell lesions The pain encountered in this condition may vary – from none to spontane-
• fibro-cemento-osseous lesions ous intermittent paroxysms or continuous pain; it has an aching, throbbing
• metabolic and endocrine lesions quality and may radiate from the maxilla to the mandible or vice versa.
• idiopathic lesions. Pain commonly occurs at night, when it may be worse than during the day
because lying down increases the intrapulpal pressure; the pain will typi-
DIAGNOSTIC CATEGORIES cally disturb sleep. The throbbing is due to a hyperalgesic or allodynic
neural response, which is intermittently stimulated by the rise and fall in
Once the patient has been assessed, the information from the history, clini- vascular and tissue pressure, synchronous with the heart beat. In the early
cal examination and tests is integrated into an overall decision about the stages, the patient is unable to locate the affected tooth but, as pulpal
nature of the problem. The main diagnostic categories with their classical inflammation spreads and toxins pass out through the apical foramen, the
presentation features are described below. It is important to bear in mind tooth may become painful to touch. Involvement of Aβ nerve fibres may
that these descriptions represent the central and commonly presenting also begin to localize the pain. Application of heat or cold will generally
findings; the actual presentation may vary. start the pain, which gradually increases in intensity and severity, then
slowly dies away and may last for a few minutes up to several hours. Pain
will typically be worse with hot than cold stimuli, in fact, as the pulpitis
NORMAL PULP
becomes advanced, cold stimuli may begin to relieve the pain. Radio-
This will be asymptomatic and give only a mild, transitory response to graphs will show changes associated with the root apex when the pulpitis
stimulation with thermal or electrical tests. Percussion and palpation do is advanced enough to make the transition to incipient apical periodontitis;
not cause pain. Radiographs show a definite pulp chamber and canal which occasionally apical rarefaction will occur at an earlier stage during pulpitis,
will be smaller and narrower in the older patient. The width of the peri- particularly in younger patients. Figure 4.93 shows a mandibular first
odontal ligament is normal, with no evidence of resorption. molar with coronal caries. The patient was experiencing episodes of pain
Dentinal pain may be experienced when the dentine is exposed to the particularly at night and the tooth was tender. There is a widened periodon-
oral cavity, with thermal changes or exposure to sweet food or drink. The tal ligament space around both the mesial and distal roots. There is a halo
pulp is not normally affected. of condensing osteitis around the distal root.
Fig. 4.93 Irreversible pulpitis of mandibular first Fig. 4.94 Mandibular second molar with well- Fig. 4.95 Posterior abutment to a bridge with
molar showing a widened periodontal ligament defined periradicular area early radiographic changes
space around both apices
Fig. 4.96 Bridge removed showing Fig. 4.97 Carious exposure with
gross caries hyperaemic pulp
Fig. 4.101 (a,b) The maxillary first molar with a crack was
associated with severe pain on biting, which was
subsequently resolved and replaced by apical and periodontal
ligament pain
feeling like an itch or irritation around the tooth, which is relieved by FURTHER READING
pressure. American Association of Endodontists; American Academy of Oral and Maxillofacial
Acute periodontal conditions can also cause more severe and character- Radiology, 2011. Use of cone-beam computed tomography in endodontics Joint
Position Statement of the American Association of Endodontists and the American
istic pains but, as these have become less common, they are more easily Academy of Oral and Maxillofacial Radiology. Oral Surg Oral Med Oral Pathol Oral
midiagnosed. Radiol Endod 111 (2), 234–237.
Dummer, P.M., Hicks, R., Huws, D., 1980. Clinical signs and symptoms in pulp disease.
NON-ODONTOGENIC PAIN Int Endod J 13 (1), 27–35.
Holroyd, J.R., Gulson, A.D., 2009. The radiation protection implicationsof the use of
The dentist’s role is to be familiar with and identify causes of dental pain cone beam computed tomography (CBCT) in dentistry – what you need to know.
Health Protection Agency, Centre for Radiation, Chemical and Environmental
but they must be familiar with and vigilant in detecting pain that is not Hazards, Radiation Protection Division, Didcot.
of dental origin. Patients will often display tell-tale signs of uncharac- Seltzer, S., Bender, I.B., Ziontz, M., 1963. The dynamics of pulp inflammation:
teristic presentations. The problem is as prevalent as 12% of patients correlations between diagnostic data and actual histologic findings in the pulp. Oral
Surg Oral Med Oral Pathol 16, 846–871, 969–977.
referred to a tertiary referral centre and so is dealt with in greater detail in Whaites, E., 2007. Essentials of dental radiography and radiology, 4th ed. Churchill
Chapter 16. Livingstone.
5
Section 2 Preparation for delivery of endodontic treatment
Treatment planning
K Gulabivala, Y-L Ng
Decision
making
Endodontist
Assessment
Delivery
Dentist Planning of
Treatment
Human being
Fig. 5.1 Hierarchical importance of knowledge Fig. 5.2 Interrelationship between assessment and Fig. 5.3 Orthopantomogram (OPG) of difficult
context decision making, planning and delivery of problems
treatment
In general dental practice, where a patient has often been under long-term
care by a particular practice or dentist, the majority of interactions with
the patient are part of continuing care. A plan of management will have
been established at the first encounter at some point in the past and, in the
simplest cases, requires no more than a review (recall) to evaluate a change
in overall status and provide motivation for maintenance. Under these Fig. 5.6 (a)
Symptomless 25 has
circumstances, the sudden precipitation of a pulpal or periapical problem
been reviewed for some
may be managed in isolation as long as there are no complex restorative time and now has a
implications (Fig. 5.4). Where there are such complex restorative implica- sinus; (b) the same 25
tions, the lack of insight or desire (on the part of the dentist) to tackle them has been retreated and
may influence outcome of the endodontic problem (Fig. 5.5). It is therefore is now under review to
important that a rational analysis of the situation is performed conscien- assess healing before
tiously and difficult restorative decisions taken promptly as necessary, making a decision
about restorative
rather than procrastinating to another time when the situation is likely to
options
be worse. Recognition of personal limitations in knowledge and skills, or
seeking appropriate referral, is the key to finding a solution. A
It is not uncommon and perfectly valid for patients on long-term recall,
to have the supervising dentist place individual teeth on probation to
review their status at a subsequent time because of uncertainty about a
diagnosis or the progression of a lesion (Fig. 5.6a). A number of potential
problems, not causing current difficulties will, therefore have been identi-
fied but a mutually agreed decision made between patient and dentist to
leave the tooth/teeth alone and periodically review them. Such a plan of
action is not uncommon both in unrestored mouths and in those that are
heavily restored and on the borderland of catastrophic transition to a dif-
ferent, perhaps partially edentulous state. The latter situation describes the
not uncommon condition of an ageing or restoratively ravaged dentition, B
where one further change could precipitate a radical review of the overall
TREATMENT PLANNING 123
dental strategy for the patient, with major implications of time and cost.
Table 5.1 Weighing of prognosis and relative cost of endodontic and
Small changes to the situation may be managed by minimal intervention restorative options (based on average figures)
and a “patchwork” approach but this also demands a more vigilant rather
than complacent review strategy. The situation, however, must be clearly Relative
Treatment option cost Prognosis (% survival/years)
recognized and understood by both the patient and dentist using the
so-called informed consent approach. The tooth in Figure 5.6a has been Root canal treatment 1.0 Difficult to determine as
dependent on individual
retreated (Fig. 5.6b) and placed on continuing review until a mutually Conventional retreatment 2.3
prognostic factors
and new post retained
agreed decision can be reached with regards to which of the previously restoration
discussed restorative options to pursue. Each case has to be weighed
Surgical endodontics 1.5 independently
It is not unheard of that, under some circumstances, with the passage of
Extraction/leave unrestored 0.2
time, the mutually agreed plan may be forgotten or fades from memory,
Extraction/denture 1.4
particularly where detailed medical or dental records are not maintained.
Extraction/bridge 3.8
Under these circumstances, the precipitation of a pulpal or periapical Extraction/implant 4.3
problem and even worse multiple problems that occur in rapid succession
may cause the need for a radical review of the options. The sudden accu- NB: the relative cost may change depending on contemporary and local trends.
mulation of such unfavourable events may prompt the patient to seek a
second opinion. The nature of this next encounter, in all likelihood with
somebody with a different philosophical perspective, may raise different root resection or extraction). The last option also requires a consideration
opinions about the previous management. The precise nature of the previ- of the alternative restorative options. Apart from feasibility, the cost and
ous mutually agreed treatment plan might not be fully appreciated in the long-term priorities of the patient have to be weighed.
absence of accurate and detailed records. The vagaries and subtleties that A cost–benefit analysis should be performed to aid the decision-making
lead to differences in management approach may cause patient dissatisfac- process as illustrated in Table 5.1. The outcome of such an analysis,
tion, which sometimes (and in contemporary society increasingly fre- though, is likely to be different depending upon the exact details of the
quently) leads to legal action. It is therefore considered best practice to situation. A recent health economic study using a Markov model evaluat-
keep detailed records of initial findings, option appraisals, discussions, ing the cost-effectiveness of clinical intervention over the life-time of an
rationale for decisions and informed consent for treatment. adult patient revealed that root-canal treatment is highly cost-effective as
a first line intervention for a maxillary central incisor. Orthograde retreat-
ment is also cost-effective, if a root-canal treatment subsequently fails, but
FACTORS INFLUENCING TREATMENT PLANNING surgical retreatment is not. Implants may have a role as a third line inter-
vention if root canal retreatment fails.
Treatment planning may be categorized into a very broad spectrum of As an example, consider the various presentations of an endodontic
complexity from simple isolated problems to those multiple problems problem associated with a maxillary central incisor in an otherwise intact
requiring complicated multidisciplinary management. At its most complex, dental arch.
treatment planning is a challenging, complicated and rewarding decision-
making process for both the clinician and patient that involves a two-way
SCENARIO 1
dialogue (interrogation and negotiation), leading preferably to short-,
medium-, and long-term goals for the management of the patient’s denti- Consider the not uncommon scenario of the pulp in a maxillary incisor of
tion. Difficulties are often caused by the contradictory desires, require- an otherwise intact dentition becoming compromised by a severe traumatic
ments and perceptions of both dentist and patient. The ways in which these injury in a young, mature adult (Fig. 5.7a). The options of vital pulp
may be resolved are numerous, even forming the basis for practice- therapy or root-canal treatment may be considered. The choice will centre
marketing strategies. The factors influencing the decision-making process on the prognosis of each treatment (based on biological factors) and the
are many and can be classified into general patient factors, professional long-term benefit to the patient. If the tooth is not restoratively compro-
background and philosophy of the dentist, general oral and dental condi- mised and the root is mature, the high prevalence of pulp necrosis in such
tion, and local factors related to the problem tooth (teeth). Factors that may cases may lean the decision towards root-canal treatment and the appropri-
confound the process include differences in perception and expectations ate restoration as having a high chance of success (Fig. 5.7b,c). Other
between the dentist and patient. The dentist must be aware of the potential restorative factors may not come into the equation at this stage but will be
for such problems and be prepared to take appropriate action to circumvent discussed with the patient.
them.
This hypothetical yet familiar illustration of operator and patient per- SCENARIO 2
spectives, which many will identify with, illustrates some sources of prob-
lematic communication. Clear and effective communication is the key to If, under the same circumstances, the patient was younger with an incom-
arriving at a mutually satisfactory treatment plan. pletely formed root, the decision may now lean towards the more con-
The vagaries of decision making are further defined and explored by servative vital pulp therapy (Fig. 5.8a) in order to aid completion of root
examining different case scenarios based on a relatively simple problem. formation and improve the long-term restorative prognosis (Fig. 5.8b). In
the event that the traumatic injury in such circumstances is accompanied
by severe coronal tooth fracture, the restorative prognosis may be further
ILLUSTRATION OF FACTORS AFFECTING TREATMENT jeopardized (Fig. 5.9). Consideration of early replacement may have to be
DECISION MAKING USING MAXILLARY INCISORS AS tempered by the psychological need to avoid loss of the tooth, as well as
AN EXAMPLE to delay permanent replacement during the growth phase of the individual,
The options available to treat endodontic problems include dentine and especially if an implant-retained crown is a possible alternative. The com-
pulp protection, vital pulp therapy, root canal treatment, root canal retreat- promised tooth may, therefore, be retained as a suitable space maintainer
ment or periradicular surgery (including root-end management, root repair, until a more definitive solution can be executed.
124 TREATMENT PLANNING
A C
Fig. 5.7 (a) Traumatized maxillary incisor; (b) maxillary incisor following endodontic treatment. (c) maxillary incisor restored
A
A
B B
Fig. 5.8 (a) Traumatized maxillary incisor with an open apex, receiving pulp Fig. 5.9 (a) Maxillary central incisors with root-canal treatment to control
therapy; (b) traumatized maxillary incisor root filled following root closure apical periodontitis and inflammatory resorption following traumatic injury;
(b) same teeth affected by replacement resorption, were subsequently
replaced with implant-retained crowns
SCENARIO 3
Consider an identical scenario but where a traumatized, intact, mature, the discoloration. In this scenario, there is an increasing number of uncer-
maxillary central incisor has been left untreated for years as the pulp tainties as outcomes are less predictable. The decision-making now has to
slowly succumbs and the patient seeks attention either because of an acute be aided by weighing the relative chances of success of the different endo-
infection or the discoloration caused by secondary dentine formation and/ dontic options and, finally, also the restorative/aesthetic outcome.
or pulp necrosis (Fig. 5.10a). On radiographic examination, it is found that
the canal is sclerosed (Fig. 5.10b) and only evident in the apical third of
the root associated with a periapical lesion. Now other considerations
SCENARIO 4
come into play, including the potential for successful outcome by conven- Consider that the same scenario presents many years later but this time
tional or surgical means, as well as the desire for correcting the discolora- without having caused the patient any symptoms, the sole concern being
tion. In the matter of the former problem, it has to be established whether tooth discoloration. The intact tooth will in all probability give negative
the operator is confident of locating the canal using a conventional coronal pulp test responses and may or may not be associated with a periapical
approach (Fig. 5.10c), which would improve the chances of success (Fig. radiolucency. In the case of a periapical radiolucency, the decision is
5.10d). If not, injudicious dentine removal may result in compromised easier, as it would be reasonable to recommend root-canal treatment,
restorability of the tooth. A surgical approach may stand a better chance of bleaching (Fig. 5.12) and, if necessary, a porcelain veneer to mask residual
finding the canal but may not help eradicate the major part of the infection discoloration caused by increased thickness of sclerosed dentine. The
in the root-canal system, compromising the chances of successful healing morbidity of treatment, that is, the potential of an acute flare-up, should
(Fig. 5.11). In addition, the absence of access to the pulp chamber also also be considered since about 10–15% of teeth associated with asympto-
compromises the chances of internal bleaching of the tooth to help correct matic periapical radiolucencies, without sinus tracts, become acute on
TREATMENT PLANNING 125
Fig. 5.10 (a) Discoloration of tooth following trauma; (b) radiographic evidence of
D pulp calcification and dentine sclerosis; (c) example of sclerosed canal in maxillary
incisor; (d) canal successfully negotiated and obturated
B
A C
commencement of root-canal treatment. The decision is even more diffi- treatment failure. The causes of failure include persistent intraradicular
cult in the absence of a periapical radiolucency because of the potential to infection, new intraradicular infection, extraradicular infection, cyst,
infect a necrotic pulp and precipitate further problems. If the pulp chamber foreign body reaction, healing by scar tissue and radicular fracture. It is
and canal space is obliterated, locating and accessing the canal for root- virtually impossible to predict which of these factors may be the prime
canal treatment may be problematic. External bleaching may be considered causative factor in the absence of other clinical clues. The presence of
as the sole treatment. acute infection may narrow down the options. The presence of an unin-
strumented apical canal space may suggest persistent infection whereas, a
recently decemented and recemented post crown may suggest a newly
SCENARIO 5 established infection or root fracture. If intraradicular infection is impli-
Consider another variation on the above scenario, where the tooth has cated, then conventional retreatment may be the treatment of choice. In
already been root treated and restored with a post-crown. The patient now this case, the restorability of the tooth, the retrievability of the post-core
presents years later with a periapical lesion (Fig. 5.13a). This confronts and root filling should be weighed up, as should the potential for root
the dentist with additional endodontic and restorative dimensions that must fracture during post removal. The natural consequence of this will also be
be considered. The endodontic question to address is the reason for the need for revising the root-canal treatment and placing a new post
126 TREATMENT PLANNING
Fig. 5.12 (a) Central as a possible indicator of bone after extraction for an implant and, finally,
incisor requiring the occlusal relationship with opposing teeth. The prognoses of each of
endodontic treatment these options, as well as their cost, should be considered.
and bleaching; (b)
bleached central incisor
SCENARIO 6
Consider a further variation on the above scenario where two central inci-
sors had received crowns to engineer aesthetic correction of a severe class
2 division 1 malocclusion. The patient was happy with the result but, over
time, suffered some gingival recession and the beginning of repeated epi-
A sodes of swellings and pus discharge associated with the gums above these
teeth. The maxillary right central incisor had been root treated and restored
with a post-crown, while the left central incisor just had a ceramic crown.
The two teeth are now associated with a very large periapical lesion (Fig.
5.14a). Despite the aesthetic compromise, the patient’s priority was pre-
serving the teeth. The quality of the root-canal treatment in both was
suspect. Given the restorative uncertainty, the previous operator had
decided on a surgical approach and felt decompression of the lesion may
be useful given the size of the lesion. Having tried this for some months,
it was apparent that the approach was not going to work and referred the
patient for further care.
B It was now clear that conventional root canal retreatment plus surgery
would be required. Treatment commenced first with the left incisor without
the post (see Fig. 5.14b); after conventional debridement, there was mar-
ginal resolution of symptoms but persistent swellings continued. It was
decided to remove the crown and post from the right central incisor, which
proved extremely challenging because the core and post were almost at
right angles, revealing the extent of aesthetic correction, which the patient
had forgotten. Both teeth were opened and debrided with continuous drain-
age of a straw-coloured fluid from the right central incisor (see Fig. 5.14c).
It was noticed, however, that irrigation in one tooth resulted in outflow
from the other tooth and vice versa (see Fig. 5.14d). The two teeth were
clearly connected by a common cystic lesion, a diagnosis obvious in con-
trast to the previous scenario. After repeat debridement, there was no
abatement in the exudate and through and through surgery would be
inevitable.
A new indirect customized post-core was constructed of gold alloy in
readiness for a single visit obturation and surgery. The teeth were opened
A B and debrided, the exudate, although reduced, was still ongoing from the
right incisor. The left incisor was therefore obturated (see Fig. 5.14e).
Fig. 5.13 (a) Post-crowned incisor with periapical lesion; (b) retrograde Surgical access was obtained to the periradicular area of both incisors, the
apical treatment of post-crowned incisor
lesion curetted and the crypt temporarily filled with gauze to control bleed-
ing. The right central incisor was root filled using a through and through
crown. The chances of success using this approach should be weighed technique and the new post-core was cemented (see Fig. 5.14f). The peri-
against a surgical option where the existing crown is preserved (assuming apical aspects were then cleaned and the root filling burnished in retro-
good pre-existing margins, contours and aesthetics) and retrograde apical grade fashion (see Fig. 5.14g). Postoperative healing was uneventful and
treatment considered (Fig. 5.13b). This has the advantage of correcting there have been no further episodes of swellings; healing is progressing
causes of failure other than intraradicular infection. It must be remembered favourably. This case illustrates that multiple factors need to be accounted
that if a conventional approach is selected and the cause of the problem for and some bravery is required in pursuing treatment goals, based on
turns out to be extraradicular infection or a cyst, surgical correction may first principles tempered with experience. Implant therapy may be selected
still be required in addition. Under these circumstances, the decision- by some but, with the extent of bone loss, that was not a realistic option
making process is therefore more complicated. If it is found that the root to begin with, even with socket preservation. It was necessary to achieve
length is short or that the restorative management is compromised by the periapical healing with regeneration of bone to give the patient a future
existing canal shape, size and length, extraction and prosthetic replacement chance with implants. In the final analysis, the patient was free of signs
should also be considered. and symptoms of disease and had new aesthetic crowns.
Under these circumstances, further assessments have to be made for
alternative replacements. The options include leaving alone, a denture,
bridge or implant. A number of factors now need to be considered, includ-
SCENARIO 7
ing the size and shape of the vault of the palate (for a denture), the restora- The superimposition of a medical condition, such as diabetes or a history
tive status of the adjacent teeth, including their size for the purposes of of IV bisphosphonate treatment may sway the balance of the decision
adhesive bonding, the quality and quantity of bone in the site at present depending upon the predictability of the outcome. The type of endodontic
TREATMENT PLANNING 127
C
B D
E G
Fig. 5.17 Radiograph of root-treated molar with Fig. 5.18 Patient requiring extensive treatment
evidence of canal transportation
Fig. 5.19 Very carious, periodontally involved Fig. 5.20 Provisional sedative restoration in a Fig. 5.21 Endodontic treatment
mandibular molar molar commenced in painful fractured
molar
other teeth or in different arches. Where multiple teeth are involved, each patients in pain of pulpal or periradicular origin need not be anxiety-
should be independently evaluated initially and then the interacting aspects ridden or time-consuming, and can assist in building the reputation of a
considered. It will often be intuitively obvious when the simple solution practitioner.
should take precedence over extravagantly complicated efforts to preserve The treatment required for the immediate relief of pain may be obvious
teeth at all costs. − for example a very carious, periodontally involved, unrestorable tooth
Once the treatment options have been selected, the next phase involves may be extracted (Fig. 5.19).
the planning of the sequence of delivery of the treatment. In the case of Where a tooth has recurrent caries, treatment of the provoked pain may
single teeth, this is straightforward because it is purely tooth-related, but only require the removal of caries, placement of an indirect pulp cap with
becomes increasingly complicated with involvement of multiple teeth, of calcium hydroxide, and the placement of a provisional sedative restoration
which some may be symptomatic and others may require temporization. (Fig. 5.20).
Where the appropriate treatment is not quite so obvious, as in some
cases of post-restorative pain, interim relief may be achieved by correction
THE SEQUENCE OF TREATMENT DELIVERY
of occlusal interferences and inadequate or excessive approximal contacts,
Figure 5.18 shows the case of a patient with multiple restorative and to allow the stressed pulp to recover from the restorative episode.
endodontic problems. Cracked teeth with symptoms of irreversible pulpitis may require endo-
There are three stages in the planning process. These are: dontic treatment for the relief of symptoms before making a definitive
decision about the restorative future of the tooth. For example, endodontic
● planned initial treatment treatment may be commenced in a painful tooth with a suspected fracture
● planned definitive treatment before undertaking further investigations to establish the true prognosis
● planned review. (Fig. 5.21).
Teeth with established intraradicular infection may present with severe
PLANNED INITIAL TREATMENT pain and/or localized or diffuse swelling (Fig. 5.22a). Treatment in these
situations is based on the need for the establishment of drainage (Fig.
Immediate relief of symptoms
5.22b), thorough disinfection of the tooth and, where necessary, the pre-
The immediate relief of pain is a valuable service and should precede scription of analgesics and antibiotics. The use of antibiotics alone in the
other forms of treatment. The provision of emergency endodontic care for relief of acute symptoms is inappropriate.
TREATMENT PLANNING 129
This approach is crucial for the long-term prevention of dental caries and
periodontal disease.
Effective planning should always incorporate prevention. In addition to
the identification of the aetiology of the dental disease present, patient
education becomes the basis of any preventative regimen. This may
include dietary advice, home oral-health measures, and the use of fluoride
B
supplements.
A A
B
B
Fig. 5.26 (a) Molar requiring restoration with
Fig. 5.25 (a) Elective root canal treatment for
questionable vitality; (b) molar endodontics
mandibular canine; (b) overdenture in place
completed prior to restoration
Fig. 5.28 Tooth defending the need for a free-end
saddle
Periodontal support
Active periodontal disease is a contraindication for embarking on root-
canal treatment unless symptoms demand otherwise in a tooth with pre-
dictable periodontal prognosis. Conversely, loss of periodontal attachment
on its own is not a contraindication for endodontic treatment. Provided a
tooth has, or can be made to have, a healthy albeit reduced periodontal
apparatus, endodontic treatment may be carried out (Fig. 5.29). History of
periodontal disease may complicate root-canal treatment due to dystrophic
calcification (see Chapter 12).
Implants
The apparent success of single-tooth implants has prompted extravagant
claims in some quarters to the effect that the treatment modality may spell
B
the end of endodontics. This has proved to be unfounded as originally
predicted. Implants are just one of several tooth replacement options and Fig. 5.30 (a) Clinical image of implant-retained
nothing more. They have good fixture survival rates but suffer from pros- crowns; (b) radiograph of single tooth implants
thodontic complications rather more frequently (Fig. 5.30). Most patients
will wish to retain their own natural teeth and extraction must be a con-
sidered decision based on exhaustion of all possibilities to save them
TREATMENT PLANNING 131
within a reasonable time and cost frame. A cost–benefit analysis of the Access to the tooth and root-canal system
options showed retention of the tooth to be a better option (Moiseiwitsch
Access to the tooth is a prime consideration and may be affected by mouth
& Caplan, 2001), but this will be a changing comparison as the cost of the
opening, as well as the nature of the occlusal plane (Fig. 5.33). At least
treatment changes.
two fingers width opening is required at the incisors as a general rule.
Patients with a history of radiotherapy or submucous fibrosis may have
Restorability of teeth
restricted access (Figs 5.34, 5.35). Access may also be compromised in
Following endodontic treatment, it should be possible to restore a tooth to maxillary molars with distobuccal orientation; opening the mouth leads to
function and health. Particular attention needs to be given to the support translation of the coronoid process forwards over the occlusal surface of
that can be provided for a coronal restoration and the position of finishing the tooth compromising access.
margins, which should preferably be maintained supragingival. Restorabil- Together with mouth opening, the ability to maintain the mouth open
ity should be assessed at the outset (discussed further in Chapter 13). If for a reasonable period of time should also be considered. Some patients
the prospects of providing a predictable restoration seem remote, extrac- with temporomandibular joint (TMJ) or masticatory muscle problems
tion should be considered (Fig. 5.31). may find this difficult. The use of mouth props may be considered (see
Good treatment strategies should also take into account possible failure. Chapter 4).
By planning for failure, operators and patients are placed in a much better Some patients cannot tolerate rubber dam; given the importance of
position to cope with outcomes that are not as originally hoped for. Through airway protection, it may need to be considered whether root-canal treat-
informed consent, compromised teeth may be maintained for up to 10 ment should be considered without rubber dam. It should rarely be neces-
years with plastic restorations (Fig. 5.32). sary to do so.
C
A
A B
A
B C
Fig. 5.32 Compromised tooth (a) Fig. 5.33 (a–c) Access to the tooth is affected by limited mouth opening and the nature of occlusal
maintained up to 10 years with an plane; attempts to access the 46 are affected by the hand-piece pivoting on the incisors
amalgam restoration (b)
132 TREATMENT PLANNING
Canal anatomy
Bizarre root forms and root-canal anatomy, congenital grooves and dilac-
erations may all present difficulties if root canal treatment is attempted
(Fig. 5.39). These unusual forms may affect the outcome of treatment.
Teeth with complex root canal systems demand additional forethought and
planning to anticipate difficulties. Different strategies may be used to
prepare canals or to deliver the irrigants and obturating materials.
Sclerosed canals
Root canals that are not visible radiographically may be difficult to locate
and negotiate if root canal treatment is necessary (Fig. 5.40). However, in
many cases they are possible to locate and treat (Figs 5.41, 5.42). It is
impossible to prejudge the ability to locate the canal until an attempt has
C
been made to locate it. Location demands knowledge of anatomy more
than magnification; in single-rooted teeth the goal is to drill dead centre,
Fig. 5.35 (a–d) The so the skill is in maintaining hand-piece orientation; experience allows
tooth in Figure 5.34 location without deviation. Teeth with a history of trauma experience
was accessed from the progressive narrowing of the pulp space. Such teeth should be reviewed
buccal surface radiographically and, if there is evidence of sclerotic change, endodontic
treatment should not be contemplated until there are radiographic per-
iradicular indications of necrotic change occurring within the canal.
Amalgam restoration
Distolingually
deviated
access
preparation
Pulp chamber
Prepared and filled canals outline
Fig. 5.37 Access compromised by lingual
orientation of 46 tooth
Fig. 5.38 Access initially malaligned almost leading to perforation (Fig. 5.37)
A
Fig. 5.39 (a) Mandibular premolar
requiring treatment; (b) irregular root
form of the premolar; B
B (c) complex canal anatomy of the
premolar Fig. 5.40 (a,b) Sclerosed pulp chamber and canals in multirooted teeth
space free of microorganisms. When considering whether to complete anaesthetic. Patients with medical histories that require the administration
treatment in one visit or more it is worth thinking about the possible advan- of antibiotics for treatment also benefit from receiving care in a single visit.
tages and disadvantages of both the single and multiple visit approach. When dealing with a long-standing infection in a tooth with a large
Where root-canal treatment is being performed on a vital tooth, the bac- periapical radiolucency, swelling or with a sinus tract, it may be wise to
terial content of the tooth is minimal and a single-visit approach is favoured, consider the disinfection of the tooth over more than one visit. This
thus reducing the possibility of bacterial entry into the tooth through approach allows greater time and the use of a medicament to supplement
coronal leakage of the provisional restoration. The single visit also allows the chair-side irrigation and disinfection procedures. Retreatment cases
for immediate and intimate knowledge of the canal anatomy of the tooth lend themselves to a multivisit approach because of the time required to
and all important reference points. Patients also favour single visits because remove restorations and root fillings, and the presence of resistant bacterial
there is less time spent in the dental office with less anxiety and local strains.
134 TREATMENT PLANNING
C
B
A
A Fig. 5.42 (a) Sclerosed root canal in mandibular premolar; (b) drilling to locate canals; (c) canal in
mandibular premolar located and treated albeit initially deviated
A B
restoration (Fig. 5.44). In any case, the dentist must first decide whether
Previous root-canal treatment
any iatrogenic problems evident are surmountable to regain access to the
The decision to retreat a previously root-filled tooth (Fig. 5.43) should be apical anatomy. Consideration should be given to remaining tooth struc-
based on clear criteria; retreatment may be initiated because of clear signs ture, the thickness of roots, the width of previous canal preparation, pres-
of previous treatment failure (symptoms, sinus tracts, persistent or devel- ence of canal transportation, presence of perforations, evidence of missed
oping radiolucencies) or to improve the technical quality of the root-canal root-canal anatomy, the presence and type of separated instruments, and
treatment (as judged radiographically) prior to a new permanent their location in relation to canal curvatures (Fig. 5.45). Although it is
TREATMENT PLANNING 135
A
B
Fig. 5.44 Maxillary molar requiring treatment Fig. 5.45 (a) Mandibular molar with silver points requiring technical revision; (b) mandibular molar
revision prior to restoration following retreatment
A B
never clear what features may be correctable before entering the root-canal for failure. It does not, however, allow treatment of extraradicular infection
system, an attempt should be made to predict the outcome based on experi- or other biological and causes. Conversely, a retrograde surgical approach
ence. The practitioner should always assess their ability to improve on the addresses the extraradicular infection or biological cause, and preserves
existing situation. If this ability is in doubt, referral to a colleague special- existing restoration, but fails to address any coronal leakage and does not
izing in this area should be considered. enable thorough canal system cleaning (Fig. 5.46).
The management of symptom-free periradicular radiolucencies in previ- In cases involving retreatment of teeth with large periapical radiolucen-
ously root-treated teeth seems to give rise to considerable management cies, the use of decompression (Fig. 5.47) to reduce the lesion size and
variation. The inclination of a dentist to propose endodontic retreatment biopsy techniques to establish a clear diagnosis, should be considered.
is variable. There does not appear to be a definite retreatment criterion for
stable symptomless periradicular radiolucencies. The judgement may be
decided by an estimation of future problems based on restorative needs. DECISION-MAKING PROCESS FOR ROOT CANAL
The replacement of coronal restorations in endodontically treated teeth RETREATMENT, SURGERY OR EXTRACTION
can occasionally give rise to symptoms, but why this should be so is not
fully understood. It has been suggested that coronal leakage, altered occlu- When failure of the previous root-canal treatment is confirmed and retreat-
sal loading, the effects of post-space preparation and restoration cementa- ment is indicated, the general and local factors (Box 5.3) affecting the
tion hydrostatic pressures may account for the problems. Previously prognosis and feasibility of non-surgical versus surgical retreatment should
root-treated teeth requiring new restorations should be examined with care be assessed carefully. The patient should be informed about the prognosis
and, if the adequacy of the sealing of the pulp space is in doubt, retreat- of the tooth and the available treatment alternatives and participate in the
ment should be considered. choice of treatment. The operator should make a decision about the point
Where post-retained restorations exist in teeth requiring endodontic at which the case should be better managed surgically, the tooth should be
treatment, a choice has to be made regarding the approach to treatment. better extracted and replaced with a prosthesis or the patient referred to a
Conventional retreatment is likely to damage the restoration, and post specialist based on complexity index (Fig. 5.48), the set-up in the dental
removal might precipitate a root fracture; but it gives a better opportunity practice, his/her/their experience and capability, as well as the patient’s
to clean the canal system and eliminate coronal leakage as a possible cause inclination and medical condition.
136 TREATMENT PLANNING
B C
Cause of failure
Vertical root fracture Adequate
Symptomatic Asymptomatic RCT and
Perforation at cervical level
antibacterial
Inadequate RCT medication used
Fig. 5.48 Hypothetical decision-making algorithm for root canal retreatment that may vary with dentist’s ability
Alveolar mucosa
Mucogingival junction
Alveolar bone
Attached gingiva
Periodontal ligament
Free gingiva Palatal mucosa
Cementum
Gingival sulcus Gingival fibres
Pulp
Dentine
Bone
Enamel
Epitheluim Submucosa Periosteum
Fig. 5.49 Diagrammatic section of periodontium Fig. 5.50 Diagrammatic section through mucoperiosteum
138 TREATMENT PLANNING
because the patient did not allow extraction. On the other hand, the dentist
Root resorption
could be accused of being unjustifiably optimistic in the illustrated case
of an attempted splinting of the horizontally root fractured tooth with a The loss of tooth structure due to resorption may lead to fracture (Fig.
dowel (Fig. 5.61). Horizontal root fractures may also occur in premolars 5.64). The prognosis for teeth affected by internal resorption is better
(Fig. 5.62) and molars (Fig. 5.63), usually through traumatic episodes. because of a more limited communication with the periodontium. The
Crown-root fractures passing through the attachment apparatus and process may be arrested by pulp removal and, provided the remaining
involving alveolar bone require careful assessment to establish accurately tooth substance is strong enough, the tooth can be retained (Fig. 5.65).
the endodontic and restorative needs of the remaining tooth substance. Treatment of resorption arising on the external surface of the root is less
Posterior teeth with fractures involving the floor of the pulp chamber have predictable (Fig. 5.66). External inflammatory resorption associated with
poor long-term prospects. root-canal infection is treatable and responds to root-canal treatment. The
treatment of other types of external resorption is unpredictable. Defects Factors that may lead to secondary failure of a previously successful
can be repaired surgically (Fig. 5.67) and also made supragingival. There root canal treatment include recurrent caries and coronal leakage (Fig.
is, however, a tendency for this type of external resorption to continue. 5.72), caries extending into the root canal (Fig. 5.73) or furcation, root
Cone-beam computed tomography (CBCT) may be used to assess the fracture (Fig. 5.74) or perforation (Fig. 5.75).
three-dimensional distribution of the tooth structure loss before deciding In conclusion, all dental treatment should be undertaken applying the
on management (Fig. 5.68). principle of continuous review. Endodontic treatment provides definite
indications for scheduling review appointments and should be looked upon
PLANNED REVIEW as an integral part of treatment planning.
Reassessment and re-evaluation of the status of dental health of patients Fig. 5.68 (a,b) CBCT
is an integral part of the planning process. It involves examining the patient aids assessment of the
again; often taking elements of the history again, re-establishing a diag- 3D distribution of tooth
nosis, and formulating a new treatment plan for whatever new or residual structure loss
problems are encountered.
Clinical and radiographic follow up, at regular intervals for an indefinite
period, are essential for the assessment of endodontic treatment. Observa-
tion periods of at least 4 years are desirable (Fig. 5.69). Endodontic treat-
ment should be assessed annually.
Indications of success are absence of pain, swelling, sinus tract, other
symptoms, no loss of function, and radiographic evidence of a normal
periodontal ligament space around the root.
The outcome of treatment is considered uncertain if a radiographically A
evident radiolucency has remained the same size or diminished in size
without complete regeneration (Fig. 5.70).
Treatment is considered to have failed if a previously normal periapex
now exhibits a radiographic radiolucency or a pre-existing radiolucency
has increased in size (Fig. 5.71), or there is conflicting evidence with
respect to symptoms and radiographic evaluation. For example, a tooth
may have persistent low-grade symptoms and yet appear healthy clinically
and radiographically. It has been found that such symptoms are consistent
with a healing lesion and will resolve spontaneously within one year. In
some cases, such mild discomfort persists, particularly when palpating
over the root apex. This may be because bone remodelling during healing
results in the root apex being palpable through the mucosa. This is simply
a mechanical problem rather than a biological one and does not require
treatment, merely reassurance.
B B
TREATMENT PLANNING 141
B
A
Fig. 5.70 (a) Postoperative radiograph of lesion;
(b) lesion remains static Fig. 5.71 (a) Pre-existing lesion; (b) lesion increasing in size
REFERENCES AND FURTHER READING Pennington, M.W., Vernazza, C.R., Shackley, P., et al., 2009. Evaluation of the
cost-effectiveness of root canal treatment using conventional approaches versus
Kvist, T., Heden, G., Reit, C., 2004. Endodontic retreatment strategies used by general replacement with an implant. Int Endod J 42 (10), 874–883.
dental practitioners. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 97 (4),
502–507.
Moisiewitsch, J.R.D., Caplan, D., 2001. A cost–benefit comparison between single tooth
implant and endodontics. J Endod 27, 235.
6
Section 2 Preparation for delivery of endodontic treatment
Pre-endodontic management
K Gulabivala, Y-L Ng
Endodontics can be one of the most satisfying aspects of dental practice, cervical trays without hand-piece and 3-in-1 cord fittings will also allow
provided it is performed in a well-managed working environment. Consid- instruments to be approximated to the tooth being treated.
eration should be given to specific organizational requirements, which Customized carts have been favoured among endodontists since they
affect the operator, the staff, the patient and, ultimately, the tooth to be provide easy and ergonomic access to a range of hand-pieces, including
treated. The practice of endodontics has become very gadget-oriented and air-rotors, slow speed motors, reducing speed/controlled torque hand-
may demand a vast array of small instruments and equipment, depending pieces, ultrasonic or sonic instruments, irrigation devices and obturation
upon the operator’s preferences, as well as large adjunctive equipment, devices (Fig. 6.3). Some believe that the development of cordless devices
such as the operation microscope and X-ray machine. Nurses may grow may obviate the need for cart or mobile systems. However, given the pace
to abhor endodontic cases if they are not fully engaged or involved in the of change in equipment and material available demands flexibility and it
management of the patient. Nurses may also find preparation for an endo- seems the best way to achieve this is not to have fixed worktops but
dontic case laborious in comparison to other procedures. The growth of mobile, multilayered systems providing an increased area within easy
specialized equipment and materials for various disciplines has enor- reach (Fig. 6.4). The mobile systems may be stored away in a separate
mously complicated the management of ergonomic practice. Endodontic area where they can be replenished and be ready for use in any surgery.
procedures also rate highly on the list of medico-legal challenges posed to The trend may be toward having separate mobile units for different
defence organizations. It is well to consider, systematically and thoroughly,
the clinical operatory, nurse support, operator and medico-legal aspects,
patient and finally, the tooth. Fig. 6.1 Example of a
sub-optimally designed
operatory
THE CLINICAL AREA
Fig. 6.3 (a) Well-designed operatory; (b) with customized endodontic cart
(courtesy of R Goria)
Fig. 6.5 Work surface in high contamination zone covered with sterilized
impervious disposable coverings (green)
microbial load and prevent the build-up of biofilm. Specific agents, such
as Alpron (Fig. 6.7) are now available to eradicate biofilms in dental unit
A water lines (Fig. 6.8).
The basic instrument pack to the pulp chamber. These are used for scooping out the remains of the
pulp and excess gutta-percha; also for flicking away pulp stones. The flat
A presterilized basic pack (Fig. 6.9) is required for all routine root canal
plastic assists in placement of inter-appointment provisional restorations.
procedures. The pack contains:
The ruler is used to measure and set instrument lengths. The nurse can
● front surface mirror provide initial measurement but the operator may wish to use a finger-ring
● two endodontic locking tweezers held ruler for checking or fine adjustments.
● canal probe
● Briault probe Operation microscope
● long-shanked excavator There are many brands of Dental Operating Microscopes available on the
● endodontic pluggers market. They vary by the optical system; a continuous zoom versus series
● gutta-percha gauge of steps of magnification (3.4×, 5.1×, 8.5×, 13.6×, 21.3×); fixed versus
● flat plastic inclinable binoculars; halogen, Xenon or LED illumination; and manual
● metal ruler versus foot pedal for hands-free operation. Installation of video camera
● mixing spatula and monitor or assistant scope could facilitate four-handed endodontic
● Mitchell’s trimmer. practice. The former set-up would allow the dental assistant to carry out
Use of the front surface mirror overcomes the problems associated with other tasks and for documentation purposes. The type of microscope and
double images, which are produced when the reflecting surface is beneath installation (ceiling mounts, wall mounts, floor-stands, custom-mounts)
a layer of glass. The endodontic locking tweezers allow small items to be may be limited by the size of the dental surgery and the quality of the
gripped safely and transferred between assistant and operator (Fig. 6.10). ceiling and walls. An optimal mounting arrangement would facilitate easy
They are particularly useful when handling gutta-percha points, paper access and positioning, as well as make best use of the available surgery
points and cotton-wool pledgets. The tips of the beaks should be blunt and space (Fig. 6.13).
grooved. A Mitchell’s trimmer may be used to remove cement and either X-ray machine
temporary or permanent crowns. The canal probe or DG 16 should be
long, fine, sharp and strong. It is used to feel the floor of the pulp chamber All medical devices, including X-ray machines, purchased for use in
when locating canal orifices. A Briault probe is used to feel for overhangs countries within the European Union should have acquired CE (stands for
when removing the roof of the pulp chamber and to check the internal Communauté Européenne, i.e. European Community) marking according
margins of any restorations. Two other probes, although not included in to the Medical Devices Regulations 2002. The wiring must comply with
the basic kit, are useful in periodontal assessment: the explorer EXD3CH BS 7671: 2008, 17th edition. Each newly installed X-ray machine must
(Fig. 6.11) (used to examine restorations, such as bridges), furcation probe receive a Critical Examination (IRR99 reg 31) by the installer confirming
with markings (for measuring the extent of periodontal furcation involve- the correct function of safety systems, leakage exposure rates and in-beam
ment in posterior teeth); and a pocket measuring probe with a fine shank, dose. An acceptance test must be performed prior to clinical use and,
blunt end, and millimetre markings (as illustrated in Chapter 11). Long- thereafter, routine tests at suitable intervals.
shanked excavators (Fig. 6.12) come in a range of designs to allow access Current dental X-ray machines are normally microprocessor-controlled
digital devices with touch contact keyboards to set the exposure time and
area to be exposed. The tube voltage of most current machines is 70 kV
Fig. 6.9 Presterilized and must comply with a suitable British or international standard for con-
basic instrument pack struction. Most current machines are suitable to be used with conventional
and digital radiographic techniques.
A
B
C E
Fig. 6.19 (a) Steiglitz and (b) endodontic fine-beaked forceps, (c) instrument removal
system (IRS), (d) Cancellier tubes and cyanoacrylate glue, (e) ultradent tubes as an
alternative to Cancellier tubes
A B
Fig. 6.18 (a) Ivory miniature post puller; (b) Eggler post puller; (c) Ruddle
post-removal system; (d) Gonon post-removal system
148 PRE-ENDODONTIC MANAGEMENT
A B
A
Fig. 6.28 (a) Needle holder; (b) suture scissors
Fig. 6.26 Retractors
Fig. 6.27 (a) Micro-Apical Placement (MAP) System (Dentsply-Maillefer, Ballaigues, Switzerland); (b) Messing gun;
(c) Dovgan carrier; (d) MTA block and Lee’s carver; (e) retrograde pluggers
it arrives in a presterilized pack; this trend is also increasing but the 2009) recommends endodontic files and reamers should only be reused on
sizes that are presterilized are limited. Many dental instruments are now the same patient on condition that the instruments are marketed as reusable
available for one use only and are presented in presterilized packs. It is and the dental practice’s registered manager is satisfied that the tracing and
important to note that the Department of Health, UK (Health Technical audit procedures used are such as to exclude error in identifying the
Memorandum 01-05: Decontamination in primary care dental practices instrument(s) and associating them with the correct patient.
150 PRE-ENDODONTIC MANAGEMENT
(optional, dependent
upon space and layout)
Ultrasonic cleaner
(optional)
Rinsing Washing
Inspection and Inspect and where sink sink
Instrument flow storage Sterilizer applicaple, pack Deliver
Airflow
Notes
1. The use of an ultrasonic cleaner is optional. Where such a cleaner is not provided, handling difficulties will be reduced by siting the washing sink
near to the rinsing sink or by combining both sinks through the installation of a double-bowl sink assembly.
2. Practices may increase the number of sterilizers if capacity and service continuity dictates.
Fig. 6.29 Example layout of essential quality requirements (from Health Technical Memorandum 01-05)
PRESTERILIZATION CLEANING
Used instruments may be heavily contaminated with body matter which
harbours and protects microorganisms. The instruments should be cleaned
thoroughly before being sterilized. Whenever possible, cleaning should be
undertaken using an automated and validated washer-disinfector (Fig. the bath, not a disinfectant. Washer-disinfectors are the most reliable way
6.31) in preference to manual cleaning, as a washer-disinfector includes a of presterilization cleaning but must not be used as a substitute for steri-
disinfection stage that renders instruments safe for handling and inspec- lization (Health Technical Memorandum 01-05: Decontamination in
tion. Manual cleaning should be considered only where the manufacturer primary care dental practices, Department of Health, UK 2009).
specifies that the device is not compatible with automated processes
(including ultrasonic cleaning) or when the washer-disinfector is temporar- STERILIZATION
ily unavailable. Exceptionally, where local experience indicates that pre-
washing may be helpful (for example in the removal of tenacious dental Pressure steam (autoclave) sterilization is the preferred method for the
materials), such action may be appropriate before automated cleaning. sterilization of most instruments used in the clinical setting. It is effective
Manual cleaning should be performed using a long-handled brush with and has a reasonably short cycle (3 min at 134°C). The effectiveness of
soft plastic bristles, warm water (45°C or lower, a higher temperature will autoclaving wrapped instruments in sterilizing chambers that are not evac-
coagulate protein and inhibit removal) and a detergent specifically formu- uated has been called into question and steam-sterilizers with a vacuum
lated for manual cleaning of instruments. Chlorhexidine handscrub, phase are generally recommended. However, this type of sterilization has
washing-up liquid, cleaning creams or soap should not be used as these the disadvantage of causing corrosion and dulling of sharp instruments and
agents, in particular chlorhexidine, make proteins adhere to steel. Gross is unsuitable for sterilizing cotton wool and paper products.
debris is removed from small files by stabbing them into sponges impreg-
Checking successful sterilization
nated with detergent. The person cleaning instruments should always wear
protective gloves to avoid inoculation with debris. Ultrasonic baths may Successful sterilization depends upon the consistent reproducibility of
be used to enhance removal of gross debris. A detergent should be used in sterilization conditions. Autoclaves should therefore be validated before
PRE-ENDODONTIC MANAGEMENT 151
use and their performance monitored routinely. Correct operation of the INFECTION CONTROL
autoclave must be checked every day that the autoclave is used. This can
be achieved by recording the readings given as printouts or readings on Each practice must have an infection-control policy. This describes the
the instrument panels. The readings should be compared with the recom- practice policy for all aspects of infection control and provides a useful
mended values. guide to the training necessary for each member of staff. Clinical staff
should be vaccinated against the common illnesses shown in the list below.
The immune status of staff must be checked for rubella and hepatitis B.
STORAGE All dental staff should have an appropriate hepatitis B immunization
The most convenient storage systems for endodontic instruments involve record, which is recorded and updated. At the time of writing no dentist
the use of trays, and boxes. Many autoclavable metal containers for endo- in the UK who was HIV seropositive was legally entitled to practice clini-
dontic files are available but the move towards single use for presterilized cal dentistry, however, from 2013, the Department of Health in England
root canal files would suggest these metal boxes are obsolete. announced that dentists with HIV can practice providing they can prove
that they are taking antiretroviral drugs and are being monitored. (Dentists
File holders and stands who are hepatitis B positive can continue to practice normally.)
There are several file holders on the market; they carry enough instruments Recommended vaccinations for dental staff:
for one treatment or part of the treatment (Fig. 6.32). This simple stand ● diphtheria
for files closes flat to prevent the instruments falling out in the ● hepatitis B
autoclave. ● pertussis
Files may be placed in a foam insert held in a file stand or by an Endor- ● poliomyelitis
ing (Fig. 6.33). This finger-held device allows the operator or nurse to have ● rubella
both hands free. A ruler lies in front and small cups may be placed at the ● tetanus
side, for example EDTA paste. The foam insert has been specially devel- ● tuberculosis.
oped so that files placed in it may be sterilized in an autoclave. The foam
inserts are one use only and provide a convenient way of disposing of the Fig. 6.34 Rack for
instruments into a sharps container after use. Using the insert in this way endodontic syringes
reduces the chance of a needle stick injury.
During the history taking, patients might disclose that they are HIV or ANTICIPATION
HBV carriers. HBV carriers and patients with HIV who are otherwise well
may be treated routinely in dental practice, but patients with HIV who are One of the greatest assets a dental nurse can possess is the ability to antici-
in ill health or who have oral manifestations of the disease should be pate the needs of patient and operator. The nurse should be aware of the
referred for expert advice. Confidentiality should always be preserved and aspects of care that optimize a patient’s comfort, safety and protection.
the obligation to provide care realized. Refusal to treat these patients is Dental nurses should be encouraged not to adjust the patient’s chair until
illogical – undiagnosed carriers of infectious disease pass undetected the medical history has been established – and certainly not before explain-
through practices every day. Operators who are HBV- or HIV-positive ing what is about to happen – because sudden chair movements may
should seek appropriate advice. frighten patients unnecessarily. Particular attention should be paid to the
Dental interest in Creutzfeld–Jakob disease (CJD) and prion-related angulation of the chair and the head position. It is wise to ask the patient
conditions centres on the risk of their transmission from human to human if they are comfortable.
during dental treatment. There is no known case of this happening. The patient must wear spectacles, to protect their eyes, and a disposable
However, those patients suspected of being infected require special waterproof bib (Fig. 6.36). These items protect against splashes, dropped
infection-control procedures. “Prions”, the infectious agents that cause instruments and spillage of sodium hypochlorite.
CJD and related conditions, are much more difficult to destroy than con- With the patient supine, the assistant should sit slightly higher than the
ventional microorganisms. Suspected cases should be referred to hospital operator to allow adequate visibility (Fig. 6.37). Adjustment of the light
for dental treatment. In the UK, the government banned the reuse of root- is the nurse’s responsibility.
canal instruments because of the risks involved. If patients spend long periods lying supine, the chair should be returned
All staff should understand the modes of transmission of infections, to the upright position slowly on completion of treatment, and the patient
sterilization and infection-control requirements, the proper use of protec- asked to sit for a moment or two before leaving the chair – this will prevent
tive clothing and equipment, the remedial actions to be taken in the event problems arising from postural hypotension.
of accidents, the importance of general hygiene and of keeping immuniza- In order to provide effective operator support, the nurse must anticipate
tions up to date. the actions of the operator. Clinical procedures should be understood and
Inoculation injuries are the most common route for transmission of learned thoroughly and a rationalized work sequence developed between
blood-borne viral and other infections in dentistry. Great care should be the operator and nurse. Use of arranged spoken and unspoken signals
taken when handling all sharps and specially designated bins should be improves the efficiency and flow of working movements (Fig. 6.38).
used in their disposal. Needle-protection devices are available and should
be used for re-sheathing. Each practice should have a policy to record and CLOSE SUPPORT
manage inoculation injuries promptly and appropriately. The specific operations involved in endodontics are generally delicate and
require a high level of concentration on the part of the operator. Control
THE DENTAL NURSE of the operating field is one of the main aims of close support. The operator
and nurse control visibility and illumination, soft tissues, moisture and
The dental nurse should be well trained and hold a relevant qualification. saliva, instruments, water coolants and contaminants.
In a specialized field such as endodontics, advanced in-house training is In endodontics, the greatest aid in achieving this degree of control is a
also necessary to ensure that the nurse fully understands the various tech- dental (rubber) dam. Isolation using a dental dam can greatly improve
niques employed and how they can support and facilitate the delivery efficiency by gaining time normally lost by patients rinsing, dentists con-
of care. Emergency and resuscitation training requirements should also tinually changing wet cotton rolls and assistants struggling with saliva
be met. ejectors. According to the European Society of Endodontology guidelines
Fig. 6.36 Rubber dam, eye protection and Fig. 6.37 Nurse seated slightly higher than Fig. 6.38 Example of hand signal indicating
waterproof bib operator transfer of file
PRE-ENDODONTIC MANAGEMENT 153
Fig. 6.40 Close support aspiration Fig. 6.41 Surgical tip used for the aspiration of
sodium hypochlorite
(2006), root-canal treatment procedures should be carried out only when Fig. 6.45 Instrument
the tooth is isolated by rubber dam to prevent salivary and bacterial con- transfer to foam insert
tamination, prevent inhalation and ingestion of instruments and prevent
irrigating solutions escaping into the oral cavity.
INSTRUMENT TRANSFER
This should be smooth, safe, and unobtrusive and require a minimum
amount of movement on the part of the operator. Transfer of instruments
should take place in the so-called transfer zone, which lies over the
patient’s neck at chin level. Instrument exchange becomes important
during the preparation and obturation phases of root-canal treatment, when
the system of parallel transfer can be employed to advantage as it allows
the alternate exchange of instruments to be accomplished speedily.
A dental nurse can be of considerable help during rubber dam placement the nurse who spears the instrument into the sponge. This simple move-
(Fig. 6.39), instrument transfer, canal irrigation, and suction procedures. ment reduces the chance of needle stick injury.
Figure 6.40 shows the nurse holding the aspirator tip close to the tooth
without hindering the operator’s access. Similarly, a small surgical tip is THE OPERATOR AND MEDICO-LEGAL CONSIDERATIONS
placed close to the tooth (Fig. 6.41) so that sodium hypochlorite may be
removed efficiently without obstructing the operator’s view. Paper points A letter from a solicitor alleging that a patient has been treated negligently
and gutta-percha points are exchanged between operator and nurse effi- has a dramatic and lasting impact on any dental practitioner however
ciently using endo-locking tweezers with the parallel technique. Figure experienced or well qualified. Unfortunately, these letters are arriving with
6.42 shows the nurse removing a paper point and placing a new paper ever-increasing frequency, in line with the increasing frequency of claims
point in the operator’s hand (Fig. 6.43). Notice that the instruments lie against health professionals. This section is designed to help the dental
parallel to each other during transfer. practitioner, particularly when carrying out endodontic treatment, to reduce
The nurse should also be able to judge the length of hand instruments the risk of receiving such letters.
required and set working lengths precisely when instructed (Fig. 6.44). A Although the section has been written from the English law perspective,
quick and efficient method of transferring an instrument after use to the it should be emphasized that some of the recommendations given may
nurse is shown in Figure 6.45, the operator holds the instrument towards differ in other jurisdictions. While the law may differ slightly between
154 PRE-ENDODONTIC MANAGEMENT
countries, there is no doubt that, provided a dentist carries out endodontic Digital radiographs are acceptable dento-legally, but care should be
treatment to the best of his/her ability, explains the treatment to the patient, taken to ensure that the software system prevents tampering with the
keeps careful records, and maintains good communication at all times, the images. Similarly, computer-held records are acceptable dento-legally,
chances of litigation will be greatly reduced. provided the software incorporates suitable safeguards to protect the integ-
According to the insurers and indemnity organizations during recent rity of the data. Digital data should be backed up to prevent loss in the
years, endodontic treatment is a common source of claims for compensa- case of damage or theft of computer equipment.
tion, and of allegations of professional misconduct to dental regulatory Clinical records should include the following:
bodies.
The main type of complaints received by defence bodies include: ● patient’s complaints and symptoms
● relevant medical, dental, and social histories
● poor communication ● clinical signs and examination findings
● unsatisfactory treatment ● special tests, such as pulp tests, radiographs, and radiographic
● failure to make an appropriate diagnosis findings
● incorrect or unnecessary treatment ● diagnosis and treatment plan
● fee dispute ● local analgesia type and amount given
● post-treatment complication. ● working-length measurement(s)
● instrumentation and preparation
NEGLIGENCE ● type of root-filling materials used
● number of radiographs taken
A dentist assumes a duty of care under common law when a patient is
● temporary restorations
accepted for treatment. If the dentist is negligent and infringes that duty
● any complications or mishaps.
of care, with the result that the patient suffers avoidable harm, the patient
is entitled to be compensated for the loss and damage sustained. To succeed
in an action for negligence, the patient must prove, on the balance of prob- CONSENT
abilities, that the dentist owed them a duty of care, breached that duty by
Dentists must obtain valid consent from their patients prior to treatment.
some act or omission, and that, as a direct consequence of the breach of
It is very common nowadays for a dissatisfied patient or their advisor to
duty, some loss or damage followed.
criticize a dentist not only in the performance of the endodontic treatment
To prove the practitioner acted negligently, the patient must prove he/
itself, but also in having failed to obtain valid consent.
she departed from what is considered to be standard practice by a respon-
The need to obtain consent is an ethical/professional duty, as well as a
sible dental body. If the dentist has acted in accordance with an accepted
legal duty. The General Dental Council’s guidance to dentists Maintaining
view on endodontics then it is unlikely that he/she will be found negligent.
Standards states:
However, one of the problems in dentistry, and in particular in endodon-
tics, is that there may be more than one responsible body and each may A dentist must explain to the patient the treatment proposed, the risks
hold a different view. It is the responsibility of the dentist to keep up-to- involved and alternative treatments and ensure that appropriate consent
date with advances in endodontics and to be aware that the view they are is obtained.
following is current.
If a general anaesthetic or sedation is to be given, all procedures must
be explained to the patient. The onus is on the dentist to ensure that all
DENTAL AND MEDICAL RECORDS necessary information and explanations have been given either
A dentist must always obtain a medical history from a patient before com- personally or by the anaesthetist/sedationist. In this situation written
mencing treatment and check the history for any changes at subsequent consent must be obtained.
visits. Full contemporaneous records are also a prerequisite for responding
constructively to a complaint, or successfully defending a disciplinary The three principles of consent are:
action or negligence claim. If, for example, a patient alleges that the treat-
● giving the patient adequate information
ment was unnecessary or inappropriate, the patient records, including
● competency/capacity of the patient (i.e. his/her understanding of
X-rays, will almost invariably prove essential to refute such an allegation
the information supplied)
by confirming the investigations leading to the decision to undertake
● non-coercion of the patient into giving the consent (i.e. the consent
endodontic treatment. Likewise, radiographs may be essential to refute
must be given freely).
allegations of unsatisfactory treatment.
The use of apex locators is now well established in endodontics, but To satisfy the first principle, the dentist must ensure that the patient has
pre- and post-treatment radiographs are still necessary to demonstrate both adequate information and fully understands the intended treatment:
the tooth and supporting tissues and the quality of the final root canal
treatment. The European Society of Endodontology guidelines (2006) ● the purpose
suggest that, even if an apex locator is used, the working length should be ● the procedures involved
verified by a dental radiograph during the procedure. ● how the procedures will be carried out
In the absence of such adequate clinical records to corroborate the den- ● the feasible options such as osseo-integrated implants, given their
tist’s account of events, the courts may be more likely to accept the long-term success rates, where this is a viable and reasonable
patient’s evidence than that of the dentist. This is because the court may choice – equally, if extraction alone, or in combination with some
well consider the patient’s recollection of a single event or a limited other form of prosthesis, is a reasonable option the patient should
number of consultations to be more reliable than that of the dentist, who be informed, so they can make a balanced judgment
may have cared for many hundreds or thousands of patients during the ● the significant risks and
interval since the treatment in question. ● the prognosis.
PRE-ENDODONTIC MANAGEMENT 155
The provision of adequate information in relation to the risks that must REFERRAL FOR TREATMENT
be highlighted to a patient has seen a shift in recent years in many jurisdic-
tions throughout the world. The previously held (and still held in certain The responsibility for obtaining consent to endodontic treatment rests with
jurisdictions) “professional standard” was that the patient should be fore- all treating dentists. If the patient is being referred to an endodontic spe-
warned of all substantial risks as deemed appropriate by responsible and cialist, some responsibility for the consent process remains with the refer-
relevant bodies of professionals. In many countries, including the USA ring dentist.
and Australia, this has moved towards a “patient standard”, by which The requirements of the dentist depend on the reason for the referral. If
practitioners should forewarn of all risks that might influence the patient’s the patient is referred for an opinion only, the referring dentist needs to
choice not to consent to a specific procedure. Accordingly, if one is in ensure that the patient understands the reasons for the referral. If the patient
doubt as to whether to warn about a potential complication or risk, it would is referred for treatment, the referring dentist should explore other treat-
be sensible to err on the side of caution and so inform the patient. Further- ment options with the patient and explain the endodontic treatment prior
more, the giving of such warnings should be noted in the records. to referral.
If the treatment proposed is complex, and arguably all endodontic treat- It is the duty of the referring dentist to provide the endodontist with
ment is complex, or if several treatment options are available, the discus- information concerning the history of the tooth, investigations and inter-
sions with the patient should be clearly documented in the records. Indeed, ventions carried out, as well as general information about the medical,
the General Dental Council requires a written treatment plan and fee esti- dental and social histories of the patient. Relevant radiographs should be
mate for all expensive and/or extensive treatments. The advice is to issue made available to the endodontist.
a patient with the treatment plan in duplicate and ask the patient to sign Likewise, the endodontist should communicate with the referring
and return one copy, confirming agreement to the treatment and fees. The dentist, if appropriate following initial assessment, and always upon com-
signed copy of the plan should be retained in the records but always be pletion of treatment. Details of the findings, diagnosis and treatment
aware that the signed plan will only be one piece of documentary evidence together with a final radiograph, type of temporization, recommendations
that may help to prove that consent was obtained. It should not be used as for final restoration and any follow up should be sent to the referring
a substitute for a two-way dialogue with the patient and notes of such dentist.
discussions in the records.
Note that written consent is required by the General Dental Council for THE PATIENT
any treatment under any form of sedation or general anaesthesia.
EDUCATION AND INFORMATION
TREATMENT COMPLICATIONS All treatment should be fully explained to the patient before any is carried
out. Patients who understand the treatment that they are about to undergo
Separating an endodontic instrument during treatment and leaving a
will be less anxious, easier to handle and more appreciative. Information
portion of the instrument in situ, or creating a perforation may not be
may be made available in the waiting room – patients are most receptive
negligent. However, with few exceptions, it is negligent not to recognize
in the few minutes before their appointment – in the form of leaflets pro-
the complication, to omit to inform the patient, and not to make arrange-
duced by the practice or commercially available (Fig. 6.46). In the clinical
ments for remedial treatment/review. Patients are entitled to a prompt,
area, the dentist may use models (Fig. 6.47), which make the procedures
honest explanation of any mishap or complication. Arrangements should
easier to explain: a patient will understand the radiographs better if he or
be made to remedy the situation, in so far as is possible, and any referring
she is given a basic knowledge of anatomy. Digital radiography, which
dentist or other dentist involved in the patient’s treatment, should be
shows an enlarged image of the patient’s tooth on a monitor, is helpful in
informed. Patients are entitled to receive, and should be offered referral
providing an explanation of the treatment.
for, a second opinion or specialist opinion/treatment where appropriate.
All actions in relation to a mishap or complication should be recorded in
the clinical notes.
Fig. 6.46 Patient information
PROTECTION OF THE PATIENT
If a dentist should fail to protect the oropharynx from ingestion of foreign
bodies, such as inhalation or swallowing of an endodontic instrument, it
is likely that any resultant claim will be indefensible. It is the dentist’s
duty to protect the patient from such harm/injury. The patient’s profes-
sional advisors may well plead that the “action speaks for itself” – res ipsa
loquitur – and the burden of proof will shift from the patient to the dentist.
Accordingly, the dentist will have to prove that he was not negligent and
that he used all adequate precautions to prevent the damage. This may
prove difficult because all responsible endodontic opinion advocates the
use of a dental rubber dam as the only adequate and effective measure to
prevent ingestion of endodontic instruments. Therefore, if small instru-
ments are swallowed or inhaled, the precautions taken were inadequate
and the dentist may be successfully sued with all the attendant stress and
publicity that this would entail.
Similarly, it is recommended that all patients undergoing treatment
should wear protective spectacles, and that their clothing should be pro-
tected from spillages.
156 PRE-ENDODONTIC MANAGEMENT
Surgical retreatment
In surgical endodontic procedures, good haemostasis is an absolute require-
Most (if not all) patients attending the dental practice for the first time
ment especially during root-end preparation and root-end filling and in
will be nervous. A calm, pleasant manner, showing that you are concerned
corrective procedures. Good haemostasis allows for clear inspection of the
about the patient’s welfare, will make treatment easier for both patient and
resected root surface and facilitates placement of a root filling by providing
operator.
a blood-free environment (Fig. 6.48).
Vasopressors such as adrenaline (epinephrine) in a local anaesthesia
ANAESTHESIA AND ANALGESIA carpule exert their influence on blood flow by stimulating α1-adrenergic
Pain control is a most important aspect of endodontic procedures: the receptors found on the smooth muscle cells of the microcirculation in the
patient’s confidence will be gained if they undergo a painless procedure. alveolar submucosa. It is important to avoid injection into skeletal muscle,
Analgesia removes pain sensation without loss of tactile sense. Anaesthe- as the predominant receptor type here is β2-adrenergic, stimulation of
sia results in complete loss of all sensation, and may be induced locally which results in vasodilation. This would cause an increase in local blood
or generally (when the patient will lose consciousness). In dentistry, anal- flow, more rapid removal of the analgesic agent with concomitant loss of
gesia is usually all that is required because we wish merely to remove pain; profound analgesia, and a loss of haemostasis control.
occasionally, with an injection, we may achieve anaesthesia, but this is Problems arising during and after surgery are frequently encountered
surplus to requirements. Local anaesthesia is more accurately described as with patients with bleeding disorders. It is therefore imperative that
local analgesia. In dentistry, local analgesic agents are usually combined any patient with a history of bleeding disorder or those taking anticoagu-
in a single carpule with vasopressors. The function of the vasopressor is lant medications should be referred to their medical practitioners for
to provide local haemostasis and to delay the absorption of the analgesic further assessment and adjustment of their medications. If necessary, a
agent. This, in turn, prolongs the duration of action of the analgesic. number of haematological tests can be used to assess the patient’s
Adrenaline (epinephrine) is the most effective, potent and frequently used status, and these are readily available in many centres in most communi-
vasopressor. In healthy patients, the influence of the adrenaline (epine- ties. These screening tests include platelet count and function tests, acti-
phrine) injected with the local anaesthetic tends to be minor in most vated partial thromboplastin time (APTT) and international normalized
patients provided the injection is administered slowly and avoids a direct ratio (INR) formerly known as the prothrombin time (PT). The INR
intravascular bolus of adrenaline. This is true of all concentrations of allows for the interpretation of PT with respect to variations among
adrenaline (epinephrine) available in combination with local analgesic. laboratories.
Absolute contraindications to the use of adrenaline (epinephrine) include
cases where the patient has uncontrolled hyperthyroidism. Administration Anxious patient
of exogenous adrenaline (epinephrine) could provoke a “thyroid storm” or
Gag reflex
“crisis”. Other conditions that require special consideration prior to admin-
istration of vasopressor agents include unstable angina, cardiac arrhyth- In mild cases, once the rubber dam is applied treatment may be carried
mias, history of myocardial infarction, hypertension and uncontrolled out routinely with local analgesia as the patient has an effective barrier
diabetes. Although not absolutely contraindicated, caution should also be and is unaware of instruments or fingers in his or her mouth. In the more
exercised in patients on tricyclic antidepressants. severe cases, intravenous sedation or relative analgesia will control the
Before treatment begins, the type of analgesia or anaesthesia must be reflex.
chosen. Guidelines for this decision are given below.
Relative analgesia
Routine root-canal treatment
This is a safe, easy technique using varying quantities of a mixture of
Regional or infiltration local analgesia is all that is necessary. nitrous oxide (N2O) and oxygen (O2) administered via a nasal mask.
However, difficulties may arise in that the nosepiece may hinder the opera-
Acute hyperaemic pulp
tor in root treatment and endodontic surgery in the maxillary incisal region.
Regional or infiltration analgesia is usually adopted, followed by addi- Other disadvantages include the set-up costs and the possible hazards of
tional local analgesic (see Chapter 10). air “pollution” within the surgery environment.
PRE-ENDODONTIC MANAGEMENT 157
A C
B
Fig. 6.52 (a–c) Staining of cotton wool caused by leakage around residual restorative material
In the case illustrated (Fig. 6.51), the bridge must be removed. More subtle
signs of leakage should be sought, including marginal discoloration of the
tooth or staining of the restoration, both from the external aspect, as well
as from within the access cavity when it is judged that the existing restora-
tion is sound enough to keep and work through. Even at the second visit
of root-canal treatment, the cotton wool placed in the access cavity partly
(to prevent the temporary restoration from blocking the canals) should be
examined for signs of staining (second function) caused by possible
leakage around residual restorative material (Fig. 6.52). This in itself is a B
good reason for using a cotton wool barrier, it is not placed for preventing
leakage as some believe and on this basis criticize its use.
A Fig. 6.53 (a,b) A tooth that is not
predictably restorable
ASSESSMENT OF RESTORABILITY OF TEETH
Large plastic restorations (amalgams and composites) and crown or bridge
retainers make it difficult to assess the long-term restorative prognosis of
teeth without their removal. Such restorations should usually be removed
PROVISIONAL RESTORATION OF
and an assessment made of the residual tooth tissue in the context of a
BROKEN-DOWN TEETH
future predictable restoration so as to avoid the embarrassing situation The most important reason for placing provisional restorations in/on
of satisfactorily root treating an unrestorable tooth (Fig. 6.53). It is broken-down teeth is to protect and retain the occlusal and proximal space
difficult to give clear guidelines for restorability but an attempt is made in that will be occupied by any future restoration. A common problem is that
Chapter 14. neglect of such space preservation allows occlusal and/or mesial tooth
PRE-ENDODONTIC MANAGEMENT 159
drifting with consequent loss of space rendering the tooth unrestorable Fig. 6.57 Cutting a copper band
without complicated orthodontic intervention.
Broken-down teeth should be restored to meet space protection criteria,
as well as to allow the placement of a rubber dam. More definitive restora-
tion of the tooth before root treatment is unnecessary, time-consuming,
and may jeopardize the final restoration. The best possible view of the
floor of the pulp chamber is seen in severely broken-down teeth (Fig. 6.54),
although such rampant access cavity preparation is not recommended!
It is usually possible to place a clamp on a broken-down tooth but, on
rare occasions, some build up or a crown lengthening procedure is required Fig. 6.58 Trimming a copper band
to remove excess gingival tissue and expose the margins of the tooth. using a stone
If a clamp cannot be placed because of significant loss of tooth sub-
stance, the tooth may be built up with a restorative material, such as a
light-cured composite to allow clamp placement and temporary filling
(Fig. 6.55). Another option is to fit and cement a copper band or steel
orthodontic band around the tooth with glass ionomer cement. The band
must fit accurately otherwise the attachment apparatus will be damaged
and at subsequent visits confuse the judgement of progress of treatment,
the tooth under treatment and its neighbour is poor, consideration should
as the patient may report the tooth to be tender on pressure. Where pos-
be given to its replacement with one that has a better contact relationship
sible, the band must be left clear of the gingival margin. The case illus-
in order to protect the periodontal tissues. This is especially important in
trated (Fig. 6.56), shows a first mandibular molar with a fracture line in
periodontally susceptible patients.
both the distal and buccal walls of the crown. A copper band was selected,
Periodontal probing defects around teeth scheduled for endodontic treat-
cut (Fig. 6.57) and trimmed with a stone to fit (Fig. 6.58), cotton wool
ment should be measured in detail using continuous point charting (as
placed in the pulp chamber with softened stick gutta-percha over the top,
shown in Chapter 12) and recorded; in molars, exposed furca should also
and the band cemented.
be properly characterized. These provide a baseline for assessment of the
Where the tooth tissue loss is great enough to prevent easy placement
effect of endodontic treatment.
of a rubber dam clamp, the predictable restorability of the tooth must be
questioned. Alternative options should be carefully considered before pro-
gressing further. ISOLATION USING RUBBER DAM AND
OTHER DEVICES
PERIODONTAL TISSUE MANAGEMENT Rubber dam isolation is the single most useful procedure for making den-
tistry and in particular endodontics easier. It has many advantages, which
There are several reasons why the periodontal tissues should receive atten-
can be listed as follows:
tion before root-canal treatment, including removal of excess tissue to
allow the placement of a rubber dam. The periodontal health around the ● Safety: Rubber dam undoubtedly provides the best protection for
tooth margin is examined, any inflammation pointed out to the patient and the oropharynx and should be used during root canal treatment
oral hygiene instruction given. Inflammation-free gingival tissues make (Fig. 6.59). They further protect the soft tissues of the mouth and
for easier and cleaner tooth isolation. Furthermore, any discomfort caused lips from the potentially caustic effects of any root canal irrigants
by local gingival inflammation will be eradicated before commencing or medicaments.
root-canal treatment and enable confusion-free evaluation of the tooth as ● Prevention of cross-infection: Rubber dam acts as a barrier and
treatment progresses. If a surgical procedure is planned, gingival tissues prevents aerosol formation from the mouth when air-driven or
free of inflammation provide the best tissue texture for surgical manipula- ultrasonically activated instruments are used in the mouth. Not
tion and provide a predictable outcome in replacement of the tissues. only is the risk of cross-infection from such aerosol eliminated but
Root-canal treatment of molar teeth will be often followed by a permanent the patient is also protected from the surgical environment. Perhaps
restoration, often a crown whose accurate margin placement is reliant upon most importantly, the barrier prevents salivary microorganisms
good gingival health. When the proximal contact between a restoration in from entering the root canal environment.
160 PRE-ENDODONTIC MANAGEMENT
Fig. 6.59 Rubber dam protecting a patient’s Fig. 6.60 Rubber dam punch
oropharynx
● Comfort: Contrary to popular belief, rubber dam confers a Fig. 6.62 Rubber dam
comfortable working environment for the patient, dentist and nurse. and plastic frame
It is very rare that a patient may find a rubber dam to be
uncomfortable. The reasons are usually feelings of claustrophobia,
breathing difficulties, activation of gagging reflex or latex allergy.
Each of these may be appropriately addressed and it is rare that a
patient cannot be convinced of the benefits of a rubber dam. In
fact, once used to it, most will demand its use for treatment. Latex
allergies appear to be on the increase and non-latex rubber dam is
available as an alternative.
● Controlled operating field simplifies procedures: Rubber dam
provides retraction of the lips and facial tissues and also helps keep
the tongue out of the field, although the extent of retraction is
determined by the manner in which the rubber dam is framed. A
number of options are available and discussed later. It also Fig. 6.63 Clamps from
improves visual and manual access and provides a clean and left to right – 14, 13a,
controlled operating field. It reduces the need for the patient to W8a, 1
rinse, although they should still be able to swallow and
communicate reasonably well. All of this contributes to an
improvement in overall efficiency of treatment.
(Figs 6.64, 6.65). Having ensured that the clamp is stable on the tooth, a
single hole is punched in the dam if the clamp is wingless and, if winged,
a larger hole is made (by punching a second hole beside the first one or
selecting a larger punch), the dam is then stretched over the clamp bow
and the tooth (Fig. 6.66). The second method is to insert the wings of the
Fig. 6.70 The lower (dependent) edge of the
clamp into a hole punched in the dam, then carry the dam and clamp to rubber dam is folded up to create a pouch to
the mouth and place them over the tooth (Fig. 6.67); the dam is then capture fluid overspill from handpiece water-
slipped off the wings so that it lies around the neck of the tooth. coolant and irrigation when suction fails to
In both these situations, the rubber dam may not have sufficient oppor- control it.
tunity to slip through the contact points to a stable position at the gingival
margin around the entire circumference of the tooth. As a consequence, crevice. When the mat surface faces away from the patient’s face, the
the dam may allow some seepage of saliva around its margins. This may inverted dam surface facing the tooth is also mat and this facilitates the
be conveniently stemmed with a commercially available gasket, such as stability of the dam as it is held in position by friction. Although applica-
Oral Seal. This is a paste that is applied to the margin of the dam in small tion in this way is a little more time-consuming, it is worth the time spent
quantities. It absorbs moisture and stems the passage of saliva. because of the moisture-free isolation it provides. The rubber dam clamps
A less commonly used method of rubber dam application but one that are then applied to hold the sheet in place.
gives a better seal is that used in operative dentistry when several teeth In the anterior part of the mouth, the dam may be fitted without clamps
are isolated together. In this method, the clamp(s) is/are preselected as (Fig. 6.68) using rubber or wooden wedges. In those cases where the tooth
described. The rubber dam is prepared by punching holes designed to is severely broken down, there are two options either use the split-dam
match the size and distribution of the teeth so that the sheet is positioned method (Fig. 6.69) or build a retaining wall on the tooth being treated (see
centrally over the operative site, to cover the mouth completely without Fig. 6.55).
unequal tension on any side when the frame is applied. The rubber dam is The rubber dam frame may be applied to the front of the dam or to the
applied by stretching the rubber at selected holes to thin it down. The edges back depending on preference. When applied to the front, an additional tip
are then “knifed” into contact between the teeth. This ensures that the is to create little pockets at the bottom corners to collect waste irrigant
rubber dam lies at about the same level around the circumference of the from the tooth and to prevent it from spilling onto the patient (Fig. 6.70).
tooth. The dam is inverted, after drying the teeth with a triple syringe, by This is particularly useful for single operators working without continuous
employing a flat plastic to insert the edge of the dam into the gingival nursing support.
162 PRE-ENDODONTIC MANAGEMENT
OTHER DEVICES Department of Health, 1990. Principle recommendations of the report of an expert
working party on general anaesthesia, sedation, and resuscitation in dentistry. HMSO,
Many other devices are used to protect the oropharynx but none of them London.
Department of Health, 2001. Guidance notes for dental practitioners on the safe use of
are as effective as rubber dam. x-ray equipment. National Radiological Protection Board 2001: Information Services,
Chilton, Didcot, Oxon OX11 0RQ [information@nrpb.org.uk].
Department of Health, 2009. Health Technical Memorandum 01-05: Decontamination in
primary care dental practices. DH, London.
REFERENCES AND FURTHER READING General Dental Council, 1997. Maintaining Standards – Guidance to Dentists on
Abbott, P.V., 2004. Assessing restored teeth with pulp and periapical diseases for the Professional and Personal Conduct [and subsequent amendments]. GDC, London.
presence of cracks, caries and marginal breakdown. Aust Dent J 49 (1), 33–39. Nelson, C.A., Hossain, S.G.M., Al-Okaily, A., et al., 2012. A novel vending machine for
Bolam v Friern Barnet Hospital Management Committee, 1957. 1 WLR 582. supply of root canal tools during surgery. J Med Engin Technol 36, 102–116.
7
Section 3 Delivery of endodontic treatment
Vital pulp therapy
Y-L Ng, K Gulabivala
The aim of this chapter is to outline the technical and clinical elements of
TECHNIQUES OF PULP THERAPY
prevention and management of pulp disease. The rationale was established
in Chapter 2. The general principles of disease management covered previ- INDIRECT PULP CAPPING
ously apply equally well to the primary and secondary dentitions as will
be evident from Chapter 1. However, primary teeth bring special chal- Carious lesions should usually be fully excavated before teeth are restored.
lenges of management and are covered here first before describing the A clinical dilemma may be presented by the finding of deep caries in an
management of secondary permanent teeth. asymptomatic tooth exhibiting no clinical or radiographic evidence of pulp
disease in a child whose cooperation or attention span would preclude
progress to pulpotomy. Indirect pulp capping may be used in such instances.
MANAGEMENT OF THE PRIMARY DENTITION
Its success relies on the observation that the advancing carious front is
almost free of cariogenic bacteria. Provided that the overlying infected
Retention of the primary dentition until the time of natural exfoliation is
dentine is removed, a small amount of softened dentine may be left in the
important for several reasons. Primary teeth have important roles in mas-
deepest part of the cavity and covered with a thin layer of setting calcium
tication, appearance, speech development and space maintenance for the
hydroxide and then zinc oxide eugenol or reinforced glass ionomer cement.
permanent successors. Therefore, there are clear psychological advantages
The tooth should then be definitively restored to achieve an optimal
of conserving rather than extracting such teeth.
coronal seal with an adhesive or preformed metal restoration. The tooth
Endodontic treatment of primary teeth differs from that of permanent
may then be reviewed clinically and radiographically to ensure that pro-
teeth for three main reasons – tooth morphology, physiology and pathol-
gression of pulp disease does not lead to periapical involvement. This
ogy. Techniques and medicaments used in primary teeth differ due to these
avoids a second operative visit, which is an obvious advantage for
factors and because of the processes of physiological root resorption and
children.
exfoliation.
Fig. 7.1 Comparison of adult and primary molars Fig. 7.2 Caries and intraradicular bone loss in Fig. 7.3 Resorption of primary molar roots
(arrowed) primary molars
Fig. 7.4 Abscess associated with Fig. 7.5 Internal root resorption Fig. 7.6 Caries removal
primary molar
Fig. 7.8 Prior to access preparation Fig. 7.9 After removal of roof of pulp chamber Fig. 7.10 Removal of pulp chamber contents
Fig. 7.11 Pulp stumps remaining Fig. 7.12 Removal of cotton wool Fig. 7.13 Pulp stumps appear dark brown
followed by thorough rinsing and soaking up of excess moisture with Fig. 7.14 Zinc oxide
a slightly moist cotton pledget. Diluted (0.5%) sodium hypochlorite restoration
solution may also be applied to achieve haemostasis; persistent
haemorrage at this stage indicates residual pulp inflammation and
pulpectomy or extraction should be followed.
5 On removal of the cotton wool, the radicular pulp stumps should
appear bright or dark red without haemorrhage (Figs 7.12, 7.13).
6 Once haemorrhage has been arrested, MTA mixed with sterile water
to a “wet sand” consistency is then applied over the radicular pulp
and the tooth definitively restored with glass ionomer cement and a
stainless-steel crown (Figs 7.14, 7.15).
Fig. 7.16 Stainless-steel crowns Fig. 7.17 Stainless-steel crown being fitted
Fig. 7.18 Resin crown formers in place Fig. 7.19 Resin crowns Fig. 7.20 Turner hypoplasia
When a primary tooth has been endodontically treated, it must be regularly • erupting molars
reviewed clinically and radiographically. The primary tooth may develop • deep pits and fissures and
signs and symptoms of acute or chronic infection. These may manifest as • existing unsatisfactory restorations requiring replacement.
sensitive and, therefore, need greater care in placement. Deep cavities, restorative material and tooth tissue. For successful adhesive restoration
therefore, should preferably be lined with calcium hydroxide and overlaid of teeth, the restoration must deform in phase with the tooth under all
with zinc oxide/eugenol. This may limit the opportunity to use composite loading conditions. Unfortunately, so far no material is able to meet these
resin in posterior teeth, which is ironic considering the irrational restric- demands for long periods, consequently, all adhesively retained materials
tions imposed on use of amalgam in some countries. While mercury has fail at some point in time after placement and allow microbial leakage.
toxic properties, there is little evidence of its toxic effect on the health of While much emphasis has been placed on reduction or elimination of
patients or dentists when used in amalgam using modern dispensing, the gap at the tooth/restoration interface to reduce microleakage, little, if
mixing and placement methods. Care should equally be directed when any, emphasis has been placed on the reduction of microbial leakage,
removing amalgams for replacement by tooth-coloured restorations. specifically. The closest approach is the use of zinc oxide/eugenol as a
Resin-modified glass ionomers should be sublined with calcium hydroxide base under amalgam restorations, though the effect of this material if
and their direct contact with dentine in deep cavities avoided. placed directly against the pulp must be considered. Eugenol is strongly
Reactionary dentine response is important in increasing the dentine antibacterial and has neurotoxic and anodyne properties but is toxic to pulp
thickness postoperatively and is positively related to the size of the cavity, tissue, and therefore, must be lined by calcium hydroxide. Unfortunately,
remaining dentine thickness, acid etching and microbial leakage. The the material cannot be used in conjunction with composite (aesthetic)
greatest reactionary dentine response is seen in cavities with remaining restorative materials because of its potential to interfere with their setting
dentine thickness between 0.25 and 0.5 mm and especially in the presence reaction. Another option is to use a resin-modified glass ionomer as a
of microbial leakage. It may be that this depth is optimal for the stimula- sublining but over a layer of calcium hydroxide. The durability of the
tion effects of solubilized growth factors released during restorative pro- antibacterial effect of zinc oxide/eugenol has been questioned, however, it
cedures and able to reach the pulp. However, when dentine thickness is need only last as long as the pulp–dentine complex takes to lay down a
reduced further, the damage to odontoblasts also increases, thereby result- defence (dentinal sclerosis and secondary dentine formation) against
ing in a reduced reactionary dentine response. Restorative material plays further ingress of bacteria and their products. It could be argued that the
a minor role in stimulating reactionary dentine but, for obvious reasons, same applies to adhesive techniques. The crucial point is that the principle
its effect is enhanced by reduced dentine thickness (especially below of this approach assumes that the defence of the pulp–dentine complex is
0.5 mm). Calcium hydroxide dressing produces the maximum response fool-proof and not compromised by pre-existing inflammation, the depth
and zinc polycarboxylate cement no response; this effect is probably medi- of cavity or the restorative material. The potential inability to block off all
ated via the stimulation of odontoblasts. dentinal tubules is the weak link in the ability of the pulp to survive, and
The approaches to prevention of microbial leakage may be divided therefore, perpetuate its life to resist further onslaughts.
into two:
1 those seeking to reduce the gap between the restoration and the SMEAR LAYER AND ITS MANAGEMENT
tooth (including attempts at adhesion)
Dentine or, more specifically, hydroxyappatite has the natural characteris-
2 those using the antibacterial properties of materials to inhibit
tic that when it is cut or ground with metal, a deformed smear layer is
microbial leakage.
generated; in dentine this consists of organic and inorganic matter (Fig.
Predictable reduction of the restoration/cavity gap is dependent upon 7.21a). Although the smear layer prevents good adaptation of restorative
the properties of the material and its optimal manipulation, taking into material in the cavity, it may be best to retain it to protect the pulp from
account the resilience of teeth and the interfacial interaction between the effects of microbial leakage. A reasonable compromise is to remove
A B C
E
D
168 VITAL PULP THERAPY
the smear layer partially so that the surface layer is removed leaving the dentine has been reached, a bur may be used to complete the preparation
dentinal plugs intact (Fig. 7.21b). Use of 3% hydrogen peroxide may be as the advancing carious front is irregular. If considered necessary, the
sufficient for this purpose in most instances. Newer generations of dentine surface of dentine may be scrubbed with 3% hydrogen peroxide to remove
adhesives dictate what happens to the smear layer. In some cases, it is only the superficial layer of the smear layer; the smear in the dentinal plugs
retained and reinforced, in others, it is partially removed and, in others, it would remain intact. A sublining of setting calcium hydroxide should be
is removed completely using acids, such as ethylenediamine tetra-acetic placed to facilitate repair and kill any residual bacteria in the dentine, as
acid (EDTA) (Fig. 7.21c) or phosphoric acid (Fig. 7.21d). It is intended
that the resin enters the surface layer of dentine to form what has become
known as the hybridized layer (Fig. 7.21e).
Fissure sealant
PRACTICAL APPROACHES TO MANAGEMENT OF Fluid-filled
Early enamel
CARIES AND RESTORATION OF TEETH caries tubules
The initial enamel white spot lesion (Fig. 7.22) only requires non-operative Translucent
treatment and preventive management. If caries has progressed into the dentine
dentine with demineralized dentine evident on radiographs or extending
through half of the thickness of dentine (Fig. 7.23), operative intervention
with a minimally invasive approach is required to prevent and avoid pulp
exposure. Pulp
The most conservative operative treatments include sealing of the
carious lesion or atraumatic restorative treatment (ART). Sealing of carious Fig. 7.24 Schematic diagram of sealing of carious lesion
lesions involves rubber dam isolation of the tooth, etching of the affected
tooth surface with 38% phosphoric acid, rinsing with water spray, air-
drying, and application of resin sealant (Fig. 7.24). ART involves removal
of soft carious dentine using hand instruments and filling the cavity with
an adhesive restorative material (Fig. 7.25).
Caries
Conventional management of carious lesions involves excavation of
carious dentine, placement of a layer of base material and restoration of
the cavity with amalgam or adhesive restorative material.
In treating a carious lesion (see Fig. 7.23), the following principles
should give optimal results: a conservative cavity should be cut to access
and remove softened, carious dentine (Fig. 7.26a), ensuring that all periph-
eral caries is removed (Fig. 7.26b). This may be achieved with a diamond Excavation of caries Removal of undermined enamel
bur in an air-rotor to breach the enamel. Subsequent removal of the carious
dentine may be facilitated by an appropriate sized stainless steel round bur
in a slow hand-piece and water spray. Very carious dentine tends to smear
and will clog the bur. Use of a sharp excavator may be efficient. Once hard
A B C
D E
Fig. 7.26 (a) Removal of carious dentine in Figure 7.23; (b) completed preparation; (c) sublining with calcium Fig. 7.27 Incompletely formed root
hydroxide; (d) lining with zinc oxide/eugenol; (e) placement of amalgam
well as to reharden it (Fig. 7.26c); a subsequent lining of zinc oxide/ advocate vital pulp therapy is in the treatment of a tooth with an incom-
eugenol should then be placed to prevent the effect of microbial leakage pletely formed or immature root (Fig. 7.27).
on the pulp (Fig. 7.26d). Finally, a well-adapted amalgam restoration Proponents of vital pulp therapy, on the other hand, would offer success
should be placed to ensure an absence of marginal leakage (Fig. 7.26e). rates of 85–90% for these procedures if the cases are properly selected and
executed and they would counter the evidence for pulp calcification and
significant internal resorption. In addition, in its strong favour, a tooth
TREATMENT OF THE DEEP CAVITY AND with a preserved vital pulp may be considered to be less susceptible to
“COMPROMISED” PULP fracture.
As long as the pulp–dentine complex remains physiologically intact and Procedures designed to preserve the pulp have been labelled, indirect
functional, the pulp is likely to maintain its ability to recover after restora- pulp capping, direct pulp capping and pulpotomy. To this traditional list
tive procedures. The pulp, therefore, becomes compromised when the may be added the new category of “regenerative pulp therapy” in the
pulp–dentine complex is damaged beyond functional repair or is anatomi- future. The rationale for these was covered in Chapter 2.
cally breached with severe damage to the underlying pulp tissue. The A potentially compromised pulp may present in various ways: including
treatment of the pulp compromised by exposure or near exposure, due to with a frank breach in the pulp, or nearly breached. The cause may be
deep caries or trauma may either involve attempts at its preservation by caries, tooth surface loss, acute traumatic injury or cavity preparation,
vital pulp therapy or elective sacrifice by pulpectomy and root-canal treat- regardless of which, the operator must estimate the pre-existing state of
ment. The choice of approach is based on the operator’s perception of the the pulp, the extent of pulp injury and the degree of microbial contamina-
chance of success and long-term prognosis given by the options. This tion. The aim of the treatment is to remove as much of the infected hard
decision is also likely to be significantly influenced by the overall treatment- or soft tissue as possible and to restore the tooth with a bacteria-tight
planning considerations. A single tooth in an otherwise intact arch, to be restoration to preserve the health of the residual pulp tissue.
restored with a plastic restorative material provides opportunity for con-
Indirect pulp capping
venient review and correction and lends itself to a conservative approach.
A tooth scheduled for a cast restoration, on the other hand, provides more This clinical procedure (Fig. 7.28) has drawn some controversy in recent
limited scope for convenient correction and root-canal treatment is often years. The technique is used when excavation of all the carious dentine
considered more pragmatic. from the pulpal surface might risk a traumatic breach in the pulp through
In a case where there are no overriding restorative considerations, the the thin but sound dentine overlying the pulp (Fig. 7.28a). When such an
choice between preservation of the pulp or its extirpation is guided by the eventuality is predicted clinically, some of the carious dentine over the
clinician’s preconceptions about vital pulp therapy derived from their pulp (not peripherally) is left (Fig. 7.28b) and dressed with calcium
teachers and early clinical experience. In this respect, two schools of hydroxide to kill residual bacteria and to encourage remineralization and
thought have arisen: one believes in the viability of the pulp and its pres- dentine repair (Fig. 7.28c). This is followed by the application of a layer
ervation and the other in its inherent susceptibility to long-term failure. of zinc oxide/eugenol to prevent microbial leakage (Fig. 7.28d). The tooth
Members of the latter school of thought argue that the success rates of is then restored with a permanent material that excludes microbial leakage
primary root-canal treatment on teeth with vital pulps are higher (95%). so that the lesion does not become reactivated (Fig. 7.28e). If an adhesive
They further state that irregular calcification and internal resorption in the composite material is to be used, then resin-reinforced glass ionomer
canal treated by vital pulp therapy might render root-canal treatment more cement may be more suitable. Neither zinc oxide/eugenol nor resin-
difficult at a later stage. They would further claim that the potential for reinforced glass ionomers should be applied directly to deep dentine
pulp death and infection could reduce the chances of success of delayed because of their potential to cause odontoblast and pulp injury. After this,
root canal treatment to 85%. The only circumstance in which they would if there are no clinical symptoms and the tooth shows signs of continuing
170 VITAL PULP THERAPY
B
A C
D E
Fig. 7.28 Indirect pulp capping: (a) initial caries lesion; (b) caries removal; (c) calcium hydroxide dressing; (d) zinc Fig. 7.29 Necrosis of pulp, due to
oxide/eugenol sub-lining; (e) final amalgam seal microleakage
Development of tertiary dentine Further excavation of caries New calcium hydroxide dressing over
over the pulpal surface pulp covered by zinc oxide-eugenol
and then definitive restoration
A B C
D E F
Fig. 7.31 Direct pulp capping: (a) initial caries lesion; (b) cavity preparation; (c) caries-free cavity with pulp Fig. 7.32 Profuse bleeding from
exposure (arrowed); (d) exposure dressed with calcium hydroxide; (e) zinc oxide/eugenol sub-lining; (f) final hyperaemic pulp
amalgam seal
There does not appear to be a relationship between the size of the an absence of microbial leakage that could compromise healing by causing
exposure and the success rate, even though it was firmly believed at one inflammation.
time that the larger the exposure the poorer the prognosis. It may be
expected that carious exposures would have a lower success rate but
Pulpotomy
studies indicate that in the absence of previous pulpal symptoms, success
rates may be similar to those of traumatic exposures. The key elements of This is the term applied to the removal of coronal pulp tissue when the
successful outcome are good pre-existing potential for replacement of exposed pulp (Fig. 7.33a) is believed to be too severely contaminated by
odontoblasts and a good reparative dentine response in conjunction with bacteria or inflamed to give a satisfactory prognosis.
172 VITAL PULP THERAPY
A B C
D E F
Fig. 7.33 (a) Pulp exposure, due to traumatic fracture; (b) removal of superficial necrotic pulp; (c) irrigating the pulpal
wound; (d) haemostasis; (e,f) application of calcium hydroxide; (g) zinc oxide/eugenol dressing
The extent of pulp tissue removal is not strictly defined. In the case of consistency (Fig. 7.33g). Some operators advocate cutting a step in the
fractured teeth with exposed pulps, the pulp surface may exhibit one of cavity to support a plastic or Teflon disc on which is placed the zinc
two reactions: oxide/eugenol dressing. As before, an alternative is a sub-base of resin-
reinforced glass ionomer cement if a composite material is to be used.
• proliferation of the epithelium covered pulp (pulp polyp) where the
As for direct pulp capping, MTA has become the material of choice for
inflammation is limited to a depth of 2 mm, or
pulpotomy in the last decade. If MTA is used, a moist cotton pledget is
• superficial necrosis with inflammation of the pulp penetrating
placed over the material to facilitate its setting. The cavity is then tem-
several millimetres from the exposure site.
porarily sealed and then re-accessed in the next appointment to check the
The principles of therapy are identical to direct pulp capping except setting of the MTA before placement of a permanent restoration. Discol-
that the exposure is larger and the calcium hydroxide is applied deeper ouration associated with the use of MTA is a major side effect for teeth
into the root. The aim of the procedure is to remove superficial necrotic in the aesthetic zone.
pulp tissue to reach healthy tissue. Success of the procedure is therefore
Regenerative pulp therapy
reliant upon the removal of necrotic and inflamed tissue. It is believed
that this is best and most atraumatically achieved with an abrasive diamond This is a relatively newly tried approach with a limited evidence-base.
bur used at high speed with adequate water cooling in an intermittent It is supported only by case reports/series and should not be used as a
light stroking approach to minimize implantation of dentine chips into routine procedure without properly consenting the patient with all risks
the exposure (Fig. 7.33b). All debris must be removed to achieve a clean and potential benefits. The latest literature should be consulted for an
wound (Fig. 7.33c). After haemostasis is achieved as described above up-to-date procedural guideline. The principles were covered in Chapter
(Fig. 7.33d), calcium hydroxide is gently applied without pressure (Fig. 2. Figure 7.34 shows schematic drawing of regenerative pulp therapy
7.33e,f) and is covered with a layer of zinc oxide/eugenol mixed to a thin procedures. The procedure has been accepted by the ADA.
VITAL PULP THERAPY 173
FURTHER READING
Tooth exhibits continued root
Following debridement and formation with increase in length Bjørndal, L., 2008. Indirect pulp therapy and stepwise excavation. J Endod 34 (Suppl. 7),
S29–S33.
antibiotic paste dressing, and wall thickness
Duggal, M.S., Curzon, M.E.J., Fayle, S.A., et al., 1995. Restorative techniques in
Apical papilla associated blood clot is induced in root
paediatric dentistry. Martin Dunitz, London.
with immature tooth with canal by apical over- Duggal, M.S., Gautam, S.K., Nichol, R., et al., 2003. Paediatric dentistry in the new
necrotic pulp instrumentation millennium: 4. Cost-effective restorative techniques for primary molars. Dent Update
30, 410–415.
New pulp Fejerskov, O., Kidd, E., 2008. Dental caries: the disease and its clinical management,
tissue 2nd ed. Blackwell Munksguard Ltd, Oxford.
Fuks, A.B., 2008. Vital pulp therapy with new materials for primary teeth: new
Blood directions and treatment perspectives. J Endod 34 (Suppl. 7), S18–S24.
clot Nadin, G., Goel, B.R., Yeung, C.A., et al., 2003. Pulp treatment for extensive decay in
primary teeth. Cochrane Database Syst Rev (1), CD003220.
Rodd, H.D., Waterhouse, P.J., Fuks, A.B., et al., 2006. British Society of Paediatric
MTA Dentistry. Pulp therapy for primary molars. Int J Paediatr Dent 16 (Suppl. 1), 15–23.
Coronal
seal
PRINCIPLES OF ROOT-CANAL SYSTEM MANAGEMENT • shape the radicular access to a predefined taper, sufficient to allow
antibacterial agents and root-filling materials to be delivered to the
The treatment of choice for management of periapical disease is the elimi- full extent (all surfaces) of the root-canal system in a controlled
nation of microorganisms and their products from the root-canal system. way.
Microorganisms may be found in suspension in the root-canal system in The precise shape and size is therefore determined by the requirements
the apical part but they mostly colonize canal walls and dentinal tubules for irrigant delivery and root-filling placement.
to a variable degree up to the apical foramina. A microbial biofilm with a These goals should be achieved by controlled removal of intraradicular
variable thickness and properties coats the dentinal wall (Fig. 8.1); where dentine such that the original shape and curvature of the main root canal(s)
the pulp chamber is exposed, the coverage is continuous but, in teeth with are retained (Fig. 8.5). This together with a relatively conservative final
intact pulp chamber walls, the coverage is patchy. Bacteria penetrating the preparation size helps to ensure that the root is neither excessively weak-
dentinal tubules may be considered to be extensions of the main canal ened nor perforated. In narrow uncomplicated canal systems, the mechani-
biofilm resulting in a three-dimensional form that may resemble a “hairy cal preparation alone may be sufficient to effect almost complete removal
worm”! In addition to the biofilm, there is also a variable penetration into of the microbial biofilm (Fig. 8.6). However, this is a rare achievement
the tubules of bacterial products and toxins, such as lipopolysaccharide. even in anterior, single-rooted teeth (Fig. 8.7). The truth is that there is
The complex three-dimensional form of root-canal systems adds to the always a variable proportion (30–50%) of residual non-instrumented
difficulty of the task of decontaminating its surface. surface in the root-canal system (Figs 8.3, 8.8, 8.9). This finding suggests
It is in fact impossible to sterilize the root-canal system with available that it is not necessary to file or plane all surfaces of the root-canal system
equipment, materials and techniques. It is therefore fortunate that sterility for a successful outcome; therefore, the adjunctive chemical preparation
is not a precondition to successful outcome of root-canal treatment. Root- must play the important role of reaching all surfaces.
canal treatment procedures work because the reduction in microbial and
microbial product content of canal systems together effect a collective
diminution in their pathogenicity, which promotes periradicular healing. PRINCIPLES OF CHEMICAL INTRARADICULAR
The part played by altered pathogenicity in periapical healing is demon- PREPARATION AND INTRA-APPOINTMENT
strated by the presented case, in which despite lack of direct access to the ROOT CANAL IRRIGATION
apical part of the root-canal system, almost complete periapical healing
was brought about (Fig. 8.2). The precise mechanisms leading to complete In order for the chemical agent to reach all surfaces of the root-canal
biofilm eradication are not fully understood, but it is clear that both the system, a sufficient path must exist and the flow of the fluid irrigant must
mechanical and chemical components of canal preparation play a role. be facilitated. This requires that obstructions in the path have to be cleared.
Root-canal system management may, therefore be thought of in Prior to mechanical preparation, the root-canal system may have pulp
terms of: tissue in various states of disintegration, dystrophic pulp calcification or
pulp stones, and bacterial biofilm coating walls and disintegrating tissue
• Mechanical intraradicular preparation (see Fig. 8.1). The process of mechanical preparation would disrupt and
• Chemical intraradicular preparation displace such contents as the canal was being enlarged by dentine removal.
1 intra-appointment medication The dentine chips generated from the shaping process would add another
2 interappointment medication element to the canal content. This heterogeneous mass of organic and
• Root-canal system obturation. inorganic tissue needs to be flushed out of the canal system.
Pure flushing action is restricted by the viscously-dominated environ-
ment of the root-canal system, so a key element of irrigation is fluid
PRINCIPLES OF MECHANICAL dynamics. Strategies for delivering, mixing and replacing the irrigant must
INTRARADICULAR PREPARATION be effective. In addition, pure flushing action is only effective for loose
The purpose of the mechanical aspect of intraradicular preparation is to debris; most of the contents are likely to be attached or adherent, and must,
create access to the root-canal system. The aim of this extension of the therefore be loosened by agitation or chemical solvent action. Therefore,
coronal access cavity or to name it by its function, the radicular access the act of flushing must be prolonged, repetitive and occur in parallel or
cavity (conventionally known as canal preparation) is to obtain and main- in alternation with mechanical preparation.
tain “patency” to the apical part of the root-canal anatomy (Fig. 8.3). The Once the mechanical shaping is completed, a final effort can be made
shape of the radicular access cavity is a general tapering form that may to reach all instrumented and, particularly, uninstrumented surfaces to
have a circular (Fig. 8.4a) or slightly eccentric cross-sectional (Fig. 8.4b) allow chemical “scrubbing” of the entire root-canal wall to remove biofilm
configuration. The final form depends on the initial shape of the root-canal from the uninstrumented surface and any contaminated smear layer from
system and the form imposed by the mechanical preparation, which is the instrumented surface.
dictated by the instruments and the manner in which they are manipulated. The process of bacterial biofilm disruption by antibacterial fluids and
The mechanical preparation typically involves using metal instruments of dressings is complicated by two problems:
graded sizes to:
1 the challenge of delivering the irrigant to the narrow and distant
• negotiate instruments of sufficient size to the apical terminus of apical anatomy, as well as all the ramifications diverging off along
the root-canal system without losing patency the length of the root-canal system (Fig. 8.10)
A B
Fig. 8.2 (a,b) Periradicular healing despite inability to negotiate full length of
canals
Fig. 8.1 (a) A microbial biofilm covering the canal wall; (b) CLSM images
(×40) of biofilm stained with Pisum sativum lectin, showing the distribution
of extracellular polysaccharide matrix from cross-sectional and surface
perspectives
A B
E
F
A D
B
Fig. 8.5 (a–f) Controlled removal of intraradicular dentine with original shape and curvature of main root canal(s) retained (courtesy of Imran Azam)
A B
A B C
Fig. 8.7 (a) Irregular wide-root canal in maxillary canine; (b) wide, “blunderbuss” canal in an incompletely formed root; (c) sectioned teeth showing variable
canal system shape
NON-SURGICAL ROOT-CANAL TREATMENT 177
A B C
A = before preparation
B = after mechanical preparation
C = after chemomechanical preparation
A B C
Fig. 8.8 These diagrams are reproduced from the cleared tooth Fig. 8.9 (a–c) Cleared teeth showing root filling material penetrating into non-
shown in Figure 8.3; (a) before preparation; (b) after mechanical instrumented anatomy
preparation; (c) after chemomechanical preparation
A B C D
undebrided
mechanically debrided
B chemically debrided
A
Fig. 8.10 Ramifications Fig. 8.11 (a,b) Effect of narrow and widely tapered preparations on complex canal anatomy:
diverging off along the length (A) before preparation; (B) after narrow-taper preparation; (C) after wide-taper preparation;
of the root canal system (D) after mechanical preparation and use of irrigant with ability to dissolve debris and destroy
(courtesy of Michael Jones) bacteria
A B
of mechanical and chemical cleaning is more efficient than either method Fig. 8.15 (a,b) Root
alone, and allows a more conservative canal preparation as reliance treated tooth with only an
on dentine removal for decontamination (a forlorn hope) is reduced. apical “seal”
This is the so-called “chemomechanical” method of root-canal system
preparation.
Canal preparation in teeth requiring pulpectomy, that is, vital pulp
removal, has similar but not identical aims. The concern in such teeth is
to remove not microorganisms but pulp tissue which may, in due course,
become necrotic and possibly infected (Fig. 8.14). In the case shown, the
uninstrumented apical portion of the distal canal has resulted in the devel-
opment of incipient periapical disease. It is therefore useful if the selected
irrigant both dissolves organic tissue and destroys microorganisms.
To summarize, irrigation may be thought of as serving several functions; A B
each of these functions dominates one of three distinct phases of irrigation
during preparation:
Phase 1 – during canal negotiation and apical enlargement – the 5 Be able to induce regeneration of periapical tissues
main requirements are to lubricate the smooth penetration of the 6 Not affect the physical properties of the temporary access cavity
instruments in the tight channels to the apical terminus and flush out restoration or be able to diffuse through the temporary seal
generated debris 7 Be easily placed and removed
Phase 2 – during mechanical shaping to a final taper – the 8 Be radiopaque
requirement is mainly to flush out generated debris and to dissolve 9 Have anodyne properties
attached and adherent organic fragments and to facilitate their 10 Not stain or weaken the tooth.
flushing out
Phase 3 – after mechanical shaping is complete – the main
requirement is to deliver the chemically active irrigant to all canal PRINCIPLES OF ROOT-CANAL SYSTEM OBTURATION
surfaces through active or dynamic irrigation. Following debridement and medication of the root-canal system, it would
be logical to prevent migration of microorganisms from the oral cavity or
root-canal system to the periradicular tissues. The purpose of obturation
PRINCIPLES OF CHEMICAL INTRARADICULAR of the root-canal system and placement of an adequate coronal restoration
PREPARATION AND INTERAPPOINTMENT is to prevent such recontamination by establishing a continuous barrier to
INTRACANAL MEDICATION the passage of microorganisms and their products.
The main rationale for using such intracanal medication between appoint- In the past, the main emphasis was placed on establishing an apical
ments is to help complete the aim of root-canal system preparation, that “seal” (Fig. 8.15). However, in recent years, the importance of the coronal
is, to degrade residual microbial biofilm and organic tissue and to kill seal has been appreciated more fully. The purpose is therefore to “seal”
remaining bacteria that have escaped primary debridement. The medica- the entire root-canal system, including the coronal entry. Cases have been
ment should, therefore, also prevent bacterial recolonization of the root- reported which demonstrate that it is possible to achieve resolution of
canal system, from either those bacteria left behind after preparation or periradicular lesions following root-canal preparation and coronal seal
new invaders through lateral communications or the coronal access. In alone or even spontaneous resolution of a lesion following caries removal
addition, it would be useful if the medicament possessed a range of other and placement of a coronal restoration (Fig. 8.16)! Therefore, obturation
properties that would suppress pain and facilitate apical healing. A root- of the root-canal system should begin with the root-canal filling and
canal medicament should therefore ideally: finish with an integrated, well-designed and executed coronal restoration
(Fig. 8.17).
1 Be able to kill all root canal bacteria with a long-lasting
The aims and objectives of obturation therefore are:
antibacterial effect
2 Not be inactivated by the presence of organic material • to establish a barrier to the passage of microorganisms from the
3 Be able to help degrade residual organic material, including pulp oral cavity or root-canal system to the periradicular tissues
tissue or microbial biofilm • to “entomb” or “incarcerate” and isolate any microorganisms that
4 Not be irritating to periapical tissues or have systemic toxicity may survive the shaping and cleaning process
NON-SURGICAL ROOT-CANAL TREATMENT 179
A B
A
C
B
A B
A
Fig. 8.23 (a) Conserve tooth substance; (b) access cavity too large
Fig. 8.26 Judging access cavity Fig. 8.27 (a) Calcified tissue and
CUTTING THE CORONAL ACCESS CAVITY depth pulp remnants; (b) pulp chamber
Initial penetration into dentine is made with a tungsten-carbide, domed- thoroughly cleaned and canals
prepared
fissure, cross-cut bur aimed towards the largest part of the pulp chamber.
When penetration to dentine is through a porcelain crown or enamel, a
round diamond bur is used to cut through these brittle materials first before
changing to a tungsten-carbide bur to cut through the metal or dentine Younger, immature teeth have large pulp chambers and probably should
beneath (Fig. 8.25). Once the roof of the pulp chamber has been pene- not have their entire roof removed to avoid unnecessary weakening of the
trated, a safe-ended, tapered, diamond bur, or similar-shaped tungsten- tooth (Fig. 8.28). Thought must be given to the type of permanent restora-
carbide bur, is used to reduce the risk of damaging the pulpal floor while tion that will be used afterwards as this will alter the shape and approach
the roof is removed. The depth of penetration can be judged by holding to cutting the coronal access cavity. For example, in the case of an onlay,
the hand-piece containing the bur against the parallel view preoperative the walls of the access may be reduced before the canal-root treatment is
radiograph, or using the measuring tool available on digital radiographic, carried out or, in the case of an anterior tooth which is to be crowned and
systems (Fig. 8.26). Older teeth have smaller pulp chambers and, therefore is lingually inclined, consider access from the labial aspect (Fig. 8.29).
require a smaller access cavity. Additionally, the floor may have calcified Radiographs (Fig. 8.30) show that straightline access can be just as effec-
pulp tissue attached and care must be taken to remove it (Fig. 8.27). tive from the buccal aspect as from the lingual.
NON-SURGICAL ROOT-CANAL TREATMENT 181
OUTLINE SHAPE and shape of the cavity is dictated by the size and shape of the pulp
chamber and will therefore, tend to be smaller in older patients.
The outline shape of coronal access cavities is dictated by the shape of the In anterior teeth, straightline access into the canals of incisors and
pulp chambers which, in turn, follow that of the tooth in cross- or longi- canines requires that the cavity must be cut high up on the tooth near the
tudinal section (Fig. 8.31). The standard shapes of coronal access cavities incisal edge. This type of access cavity will leave the cingulum intact,
for different tooth types are given in Figures 8.32–8.39. The actual size which provides the maximum retention for a full crown later. At the same
time, it is important not to breach the labial enamel and dentine, as doing
Fig. 8.28 Incomplete removal of pulp so, may predispose the tooth to develop cracks in the enamel in the future.
chamber roof in an immature tooth
The shape of the pulp chamber and, therefore, the coronal access cavity,
still allowing straight-line access to
the canals
of the maxillary first molar is rhomboid due to a widening over the palatal
canal orifice. The second and third molars show a mesiodistal flattening
of the pulp chamber, which also lies nearer the mesial aspect of the tooth.
The access to the mandibular first molar is also rhomboid in shape
because the distal canal is either broad buccolingually or because there are
two separate canals. The second and third molar access cavity is more
triangular as there is usually only one distal canal.
A B A B
Fig. 8.29 (a,b) Buccal access in mandibular anterior tooth Fig. 8.30 (a) Buccal view of mandibular anterior teeth; (b) Approximal view of
mandibular anterior teeth
A B
182 NON-SURGICAL ROOT-CANAL TREATMENT
A
A B
B C B
Fig. 8.32 (a,b) Maxillary incisor Fig. 8.33 (a,b) Mandibular incisor; (c) mandibular incisor viewed Fig. 8.34 (a,b) Maxillary canine
from the incisal edge
A B A B A B
Fig. 8.35 (a,b) Mandibular canine Fig. 8.36 (a,b) Maxillary premolar Fig. 8.37 (a,b) Mandibular premolar
A B A B
Fig. 8.38 (a,b) Maxillary first molar Fig. 8.39 (a,b) Mandibular molar
NON-SURGICAL ROOT-CANAL TREATMENT 183
X-Ray tube
A B C
foramina in all cases with necrotic pulps and to clean the canal system to
this/these point(s). It is safest to clean to the apical termination of root
canals even in cases where the tooth is vital but failure to do so will not
jeopardize success in such cases. However, it is crucial to ensure that Projected image from
instrumentation and treatment materials do not extend beyond the root- distal curvature
canal system as this may reduce the prospects of a successful outcome.
Distal root curvature
Projected image from
CLINICAL LOCATION OF THE ROOT-CANAL SYSTEM buccal curvature Buccal root curvature
TERMINUS/TERMINI
Root-canal systems have been classified in different ways, including by Fig. 8.41 Line diagram showing radiographic views of file in a root that
the number of termini they exhibit (see Chapter 1). Locating the apical curves distally or buccally
termini of the root-canal system exactly is an art rather than a precise
science. Several methods are used to triangulate the terminal point(s) of
the root-canal system, they include:
• radiography
• electronic apex locators
• tactile sense
• paper point.
Each of the methods is analysed independently first and then a way of
combining them offered.
Radiographic method
The first problem is that the root-canal system often ends in an apical delta
so that there is not just one but several apical foramina. The diagnostic
endodontic file will pass into only one of these (Fig. 8.40).
The second problem is that the radiographic view with a file in the canal
provides a two-dimensional picture of a three-dimensional root-end, in
A B
which the file may be disposed in any plane within a 360° circumference
(Fig. 8.41). Unless a single root-canal system exit is disposed at exactly Fig. 8.42 (a) Preoperative parallel view radiograph; (b) periapical radiograph
right angles to the X-ray beam and film, the radiographic technique can with diagnostic files
never estimate the position of the apical terminus accurately.
The traditional protocol for canal length determination using radio-
graphic technique alone is as follows. An estimate of the approximate
length of the tooth is made from a preoperative parallel radiograph (Fig.
8.42). A file is placed in the root canal about 1 mm short of this estimated Fig. 8.43 Angled
length, ensuring that a coronal reference point is selected that is reproduc- periapical radiograph
with diagnostic files
ible, stable and durable. The file should be large enough to be visible on
the radiograph (e.g. size 10 but size 08 may also suffice). It is best not to
commence apical instrumentation before understanding the location of the
canal terminus, as irreversible damage is easily incurred at the early stages.
A parallel radiograph is then taken (Fig. 8.42b). In teeth with multiple
canals, diagnostic files should be placed in all canals and a single view
taken to minimize exposure to radiation (Fig. 8.43). Canals may exit on
the root surface at a variable distance and position from the root tip and it
is impossible to judge the three-dimensional distribution of apical foramina
satisfactorily from radiographs (Fig. 8.44). This pair of images shows three
184 NON-SURGICAL ROOT-CANAL TREATMENT
A B
A B
A Fig. 8.46 Relationship 2 In some cases, the file may be longer than the radiographic apex, in
between root tip, apical
0–3mm B which case the distance between the file tip and a point 1 mm short of
foramen, and apical
constriction: A = root apex;
the radiographic apex should be measured (Fig. 8.48). Subtracting
C B = apical constriction; this figure from the length of the diagnostic file will give the length
D C = root canal; of the canal.
F
D = cementum;
E = dentine; F = apical Electronic apex-locator method
E foramen
The reliability of contemporary electronic apex locators (EALs) has
increased to a point where many clinicians rely almost exclusively on them
although they do not give 100% reliability. The European Society of
Endodontology guidelines state that having used the apex locator, a con-
firmatory radiograph should be taken.
roots, with files that appear flush with the radiographic root tip but which
Electronic apex locators (Fig. 8.49) in theory enable the location of the
are actually extended past the apical foramina. Figure 8.45 shows a case
true position of the apical terminus, utilizing the fact that root canals, in
taken from a clinical study, in which a cemented file that is apparently
common with other tubes with one end immersed in an electrolyte solu-
flush with the root tip is actually extended well beyond the apical foramen.
tion, exhibit certain electrical characteristics that are relatively constant.
An average distance of 1mm short of the radiographic apex is widely
The parameter of importance is the abrupt change in impedance of the
accepted as a reasonable estimate of the terminal position of the canal, but
root canal as the terminus is approached and bypassed. The impedance in
this may be inaccurate by up to 3 mm (Fig. 8.46).
question is measured between a point along the length of the root canal
Once a parallel view periapical radiograph of the tooth with diagnostic
and the oral mucosa (Fig. 8.50). Introduction of electrolytes into the root
file(s) in the canal has been obtained, working length is calculated taking
canal causes the impedance to drop and the gradient of impedance along
account of image distortion by comparing the actual and radiographic
the canal to decrease. The impedance value at the apical foramen, that is,
distance between the tip of the file and the reference point indicated by
between the periodontal ligament and the oral mucosa, measured via the
the rubber stop.
root canal is a relative constant. This value is used to calibrate commercial
1 In most cases, the tip of the file will be short of the radiographic EALs, but the impedance characteristics of the canal coronal to the apical
apex. This is often accepted as the length of the canal if the foramen are not factored in. EALs should therefore always be used to
distance is within 1 mm (as in the lateral incisor: Fig. 8.47a). If the achieve the “zero” reading for greatest accuracy and not any point short
discrepancy is greater than 1 mm, then the distance between the of this.
file tip and the radiographic apex should be measured and 1 mm EALs work by applying an alternating current between two electrodes,
subtracted from this measurement (as in the central incisor: one of which is attached to the file and the other via a clip to the lip or
Fig. 8.47a). This residual discrepancy is added to the length of the cheek mucosa (Fig. 8.51a,b). The frequency of this current, which also
diagnostic file to give the estimated length of the canal (Fig 8.47b,c). influences impedance, is usually fixed in a given make of instrument but
NON-SURGICAL ROOT-CANAL TREATMENT 185
1mm
4mm
B C
A Fig. 8.47 (a) Diagram reproduced from Figure 8.42b. Correct length in 12 accepted. Short length in 11 is
corrected; (b,c) adjusted diagnostic files and final root fillings
1mm
1mm
60
Mean resistance (k ohms)
40
A A
30
Fig. 8.48 (a) Overextended file; (b) diagram reproduced from (a) shows corrected 20
length 10
0
0 1 2 3 4 5 6
Distance from apex (mm)
A B C
D
E
Fig. 8.51 (a,b) Connection of electrodes to file and cheek; (c–e) apex indication in different apex locators; (f) file placed to length indicated at “zero” by apex
locator
differs between makes. As the file is passed down the canal, the EAL and capacitance separately rather than the resultant impedance; it then
measures the impedance and compares the value with its calibrated stand- putatively searches for comparative values in a lookup matrix generated
ard. A countdown scale indicates a “zero” or “apex” reading when the from in-vivo studies. The Raypex® 5 (VDW) (Fig. 8.53), which also uses
calibrated value is matched (Fig. 8.51c–e). All currently available conven- multiple frequencies, claims to be a fifth generation apex locator with
tional EALs use this principle but display the information differently. The greater accuracy.
current generation of EALs has overcome the problem with electrolytes The accuracy of different models of EALs has been tested clinically and
in root canals by measuring the impedance at multiple current frequencies. shows slightly variable results for the same EALs in different studies and
The Root ZX (J Morita, Kyoto, Japan) (see Fig. 8.49) compares the ratio for different EALs in the same study. These differences may be attributed
of impedance at two frequencies to derive the apical position. The Apex to many factors, including conditions of use and calibration of the instru-
Finder AFA (Discontinued) claimed to derive the information from five ment. Each instrument requires practice in use to become familiar with its
different frequencies. The Elements Diagnostic Unit (SybronEndo) (Fig. idiosyncrasies before it can be used with confidence. EALs are reliable but
8.52) claims to be a fourth generation apex locator measuring resistance should not be relied upon in all circumstances. If there is any doubt about
NON-SURGICAL ROOT-CANAL TREATMENT 187
Fig. 8.54 (a) Apical root resorption: histological view; (b) apical root
resorption: SEM view
A B C D
Fig. 8.55 Patterns of apical constriction: (a) classic, (b) tapered, (c) parallel and (d) multiple (adapted from Dummer et al (1984) – images courtesy of WJ van der
Meer)
the reading, a radiograph must be taken. Potential problems in use include can aid apical foramen location in some cases, it is unreliable by itself
short-circuiting if the file touches a metal restoration, if the canal contains because of seepage of exudate or blood into the canal and by capillary
excessive moisture, or if the size of the file is too small. Clinicians should, action along the paper point.
having used the EAL to obtain a “zero” length reading, take a check radio-
graph (see Fig. 8.51f). The greatest advantage of the EAL, is that having Combined method for determining position
obtained and confirmed this base-line reading, the working length and of canal terminus
patency may be monitored continuously throughout canal preparation with None of the methods described so far are infallible. The recommended
each file placed to length or just short. This confers tremendous confidence approach to location of the terminus of the root-canal system is first to use
to the clinician during the procedure. an EAL to obtain the “zero” reading. The diagnostic file should not fit too
loosely in the canal otherwise a less accurate reading will be obtained. The
Tactile method length of the file at this reading is recorded from a stable reference point
Some clinicians claim that it is possible to gauge the apical constriction on the crown. The file(s) is replaced to the same length and a radiograph
of the root-canal system by tactile sense. There are several problems with taken using a parallel view radiograph. The file should appear to be within
this claim. First, not all teeth possess an apical constriction due to the the confines of the root apex, although sometimes, the radiograph shows
presence of apical resorption caused by apical periodontitis (Fig. 8.54). the file to be extruded, while the EAL indicates a consistent reading; this
Second, the ability to gauge the apical constriction relies on the pre- may be because the root thins out sufficiently for it to be invisible at the
existence of a natural canal taper that has a minimal constriction only at apex. In any case, if the file appears to be longer, the EAL reading should
the termination of the canal; Dummer et al (1984) observed four distinct be rechecked for consistency. A final judgement should be made about the
patterns of apical constriction (Fig. 8.55). Third, the tactile detection of true position of the canal terminus by triangulation of the lengths from the
the apical constriction relies upon the selection of a file size that will first different sources, as well as tactile sense and paper points.
bind only at the apical constriction. Given that the size and anatomy of
the apical constriction varies considerably, this method is reliant upon DETERMINATION OF WORKING LENGTH
several preconditions, as well as the fortuitous selection of the correct The working length is the length to which each instrument is used in the
instrument size. Taking these factors collectively, it is highly unlikely that root canal. It is not necessarily the same length as that of the canal from
tactile sense alone can be used to gauge the position of the apical terminus, the reference point to the canal terminus. Some instruments may be used
although it has been shown that the chances are improved by a step-down to the full length of the canal, while others may be used at various prede-
preparation approach. termined lengths short (step-back) or long (patency) of it.
Once the length of the canal has been determined, it is necessary to
Paper-point method
decide whether the series of root-canal instruments will be set to that
Another recommended method is the use of a sequence of paper points length or short of it. Many factors dictate the length to which instruments
that show the position of the apical foramen by virtue of the junction of will be used in the canal. The goal of the negotiation phase of canal prepa-
tide-mark of the blood-wetted and dry tip of the paper point. Although this ration is to enlarge the canal to at least size 30 (ISO) just short of the canal
188 NON-SURGICAL ROOT-CANAL TREATMENT
terminus. That is, to preserve the original size of the apical foramen as far 3 When in addition to the narrow roots they also exhibit a sudden
as possible. If the canal is to be prepared to a wide non-ISO taper (0.06 apical curve (Fig. 8.57), small flexible files may be used to the full
plus), then it is considered that preparation to size 20 or 25 may be suf- length but larger files (above size 25) should be used to shorter
ficient. The optimal size of the apical preparation is size 30. If the operator lengths.
is very meticulous, the length to which the canal is prepared can be con-
Different files may therefore be used to different (working) lengths. All
trolled to within 0.25 mm and the files may be set to 0.25 mm short of the
of this, of course, presumes that the operator has exceptionally good
canal length. If, on the other hand, the operator has poorer control it may
control of the instruments, is conscious of the attention to detail necessary
be prudent to set the instruments up to 1 mm short of the canal length. The
in measuring the files (up to 0.25 mm) and of problems, such as “rubber
former is always preferable and good endodontists will strive for such
stop slippage” and parallax in judging the position of the file in relation
accuracy. In addition, the following factors may further affect the decision
to the coronal reference point. Lack of adherence to these basic principles
to modify the length to which the canal is instrumented:
is a common fault exhibited by inexperienced operators.
1 When apical root resorption is evident, the canal terminus may be Displacement of the (rubber) stops on the files, which designate length,
“blunderbuss” shaped and, therefore, allow extrusion of endodontic is a problem that must be prevented by selecting tightly fitting stops. Some
materials (see Fig. 8.54). One school of thought suggests that stops are more susceptible to displacement than others (Fig. 8.58). Loss
instrumentation should be shorter. Another suggests that the of the reference point is another important cause of error. It may occur
resorption is caused by microbial infection in the site and so either because of lack of care in properly recording it in the medical notes
requires vigorous apical preparation up to the full length or because the original reference has been lost due to breakage of tooth or
2 When the root tip is very narrow there may be a risk of root restoration. In either case, the length must be re-established before pro-
perforation if the root is prepared to a significant diameter to the ceeding further. Once again, having used an EAL at the outset makes
full length (Fig. 8.56) redetermination of the length is easier.
A B C A B
Fig. 8.57 (a,b) Sudden apical curve in root canal; (c) risk of apical perforation in narrow Fig. 8.58 (a,b) Different types of stops
root tips
NON-SURGICAL ROOT-CANAL TREATMENT 189
A B C
undebrided
mechanically debrided
B chemically debrided
A
Fig. 8.61 (a,b) Simple tubular canals encompassed by tapered canal preparation:
A = before preparation; B = after mechanical preparation; C = after chemical
irrigation with sodium hypochlorite
RELATIONSHIP BETWEEN THE RADICULAR ACCESS, more desirable as they do not compromise root strength (Fig. 8.60). Based
ITS DIMENSIONS AND ROOT-CANAL ANATOMY on the irrigation requirements of the root-canal system, teeth may be
divided into simple or complex canal systems.
Historically, the mechanical preparation of root-canal treatment had been
considered the most important aspect of bacterial debridement. There has
been a paradigm shift in the way that mechanical preparation is now
viewed; it can now be regarded as no more than an extension of the coronal
SIMPLE CANAL SYSTEMS (TYPES A, B AND C)
access cavity into the root, that is, it is a radicular access cavity. This is In simple canal systems with narrow circular cross-sections (Type a),
principally because of the relative proportion of the canal wall surface that preparation to a regularly tapered radicular access cavity may entirely
remains uninstrumented; up to half of the surface must be cleaned by encompass the original canal system (Figs 8.61–8.63). In such cases,
means other than instrument planing. cleaning may be achieved almost wholly by mechanical preparation with
It has traditionally been held that canals should be prepared by control- little reliance on the irrigant.
led dentine removal so as to produce a regular taper with the minimum In contrast, in simple canal systems with wide non-circular but regular
diameter at the apical constriction or canal terminus and the maximum cross-sections (Type b – such as canines, some premolars, distal and
diameter at the coronal end; at the same time, maintaining the original palatal roots of molars, teeth with C-shaped canals), preparation to a regu-
shape of the canal as far as possible to preserve the strength and integrity larly tapered radicular access cavity may not allow complete debridement
of the root. Its original shape, therefore, also dictates the overall shape of solely by mechanical preparation (see Figs 8.7, 8.64–8.66). C-shaped
the prepared canal. canals could be treated as broad distal canals in lower molars that may
The apical diameter or degree of taper, to which the canal should be result in two separate or overlapping tapers (Figs 8.67, 8.68a,b) prepared
prepared has been a subject of much debate. The choice is usually based to allow sufficient access for irrigation. Alternatively, if filing is used then
on personal preference and individual clinical experience rather than on a continuous coronal shape may be created (Fig. 8.68c,d). Access for
sound scientific rationale. Widely tapered canals may allow better irrigant irrigation is excellent in such teeth and, therefore, only minimal filing of
penetration, better debridement and probably better obturation if using the the canal walls is usually required. In simple canal systems with narrow
cold lateral compaction or warm vertical compaction techniques, but these circular cross-sections but minor fins and ramifications extending off them
benefits are achieved at the expense of root strength and possibly long-term (Type c), mechanical preparation would remove most microbes and organic
survival of the tooth. Advocates of narrowly prepared canals argue that tissue except from the uninstrumented accessory anatomy (Fig. 8.69).
a taper that allows irrigant penetration using narrow needles is sufficient Examples of such anatomy may be drawn from all tooth types (Fig. 8.70),
for debridement and that obturation of such canals can be satisfacto- showing root-filled teeth, in which the main canals have been prepared to
rily achieved with thermoplasticized gutta-percha techniques. Narrowly a taper and filled but the accessory anatomy may remain undebrided if a
tapered preparations, if they allow adequate cleaning and obturation, are proper irrigation regimen is not used.
190 NON-SURGICAL ROOT-CANAL TREATMENT
A B
A B
Fig. 8.63 (a,b) Regularly tapered radicular access cavity preparation almost
encompassing the original canal system; Type A system
A B
A B
NON-SURGICAL ROOT-CANAL TREATMENT 191
C
A B
Fig. 8.68 (a) C-shaped root; (b) C-shaped canal in mandibular second molar; (c) C-shaped canal in
mandibular second molar with diagnostic instruments in place; (d) C-shaped canal obturated to reveal
continuous single canal (courtesy of Dr Yea-Huey Melody Chen)
Fig. 8.70 (a–c) Root-filled canals showing instrumented and uninstrumented canal
walls (Example of Type C system)
192 NON-SURGICAL ROOT-CANAL TREATMENT
A B
A B
Fig. 8.72 (a,b) Effect of mechanical and chemical cleaning on complex irregular
canal systems: A = before preparation; B = after mechanical preparation; C = after
mechanical preparation and sodium hypochlorite irrigation
C D
A B
Fig. 8.73 Effect of mechanical and chemical cleaning on complex irregular canal systems:
A = before preparation; B = after mechanical preparation; C = after mechanical
preparation and sodium hypochlorite irrigation
Fig. 8.75 Kerr K-reamer No. 25 Fig. 8.76 Kerr K-Flex file No. 25 Fig. 8.77 Micro Mega Hedstroem No. 25
Rotary motion
In rotary motion, the instrument cuts best when the cutting edge is oriented
almost parallel to the long axis of the instrument, such as in the reamer
(Fig. 8.75). The progressive decrease in the pitch of the flutes by making
the twists in the metal shank tighter renders the cutting edges at a greater
angle to the long axis and closer to the perpendicular of the long axis, as
in a file (Fig. 8.76). This means that the latter instrument is suitable for
both rotary use, as well as push–pull filing. The closer the cutting edges
are to being perpendicular to the long axis of the instrument, the better
suited it is to use for filing or push–pull action (Fig. 8.77). In addition to
the orientation of the cutting flutes, the manner in which the edges engage
dentine and cut it is different in the two motions.
In rotary motion, cutting is reliant upon engaging opposing walls of the
canal dentine by screwing and apical feeding. The file engages dentine
much in the same way as a screw may engage wood (Fig. 8.78). The
threads or cutting edges wind into the dentine. No lateral forces are
involved, only torque. The operator has only to gauge the torque required
to engage the dentine. The amount of dentine engaged depends on the
relative mismatch in the diameter of the instrument and that of the canal
Fig. 8.78 Threaded screw Fig. 8.79 Deformed hand instrument
and the degree to which it is screwed into the canal. Therefore, the amount entering a piece of wood
of dentine engaged is a function of the degree of apical feed of the instru-
ment. In a perfectly circular canal whose taper is almost matched with that
of the instrument, apical feed and lateral engagement of the dentine may
be almost proportional. However, in reality, canals are irregular, with the
files only contacting intermittently at selected opposing points. There is,
therefore, a mismatch between rotational motion, apical feed and apical
advancement. Many technique manuals erroneously give instructions on
the degree of clockwise or anticlockwise rotation without any mention of
the degree of apical feed or torque that should be used. As a consequence,
rigid pursuit of such instructions may lead to procedural errors, particularly
where the file tip is unconstrained. The operator must balance the degree
of apical feed with the degree of torque required and this insight can only
be acquired by vigilant practice. To understand how the instrument cuts
dentine in rotary motion, imagine a screw being rotated clockwise into a A
matching hole in a piece of wood (Fig. 8.78). As it screws in, it engages
the substrate. Rotation in the anticlockwise direction will allow it to
unscrew back out of the wood along a path identical to the screwing-in
motion. If, however, apical force is applied while the screw is rotated
anticlockwise, instead of backing the screw out, the wood engaging the
threads is fractured. This is the principle of the balanced force technique.
Its correct practice requires an understanding and a “feel” for the torque
forces that the instrument and dentine can tolerate. In unpractised hands,
there is a potential for overstressing the metal instrument with its conse-
quent deformation (Fig. 8.79) or fracture (Fig. 8.80). Alternatively, by the
laws of physics, an equal and opposite force is imposed on the dentine, Fig. 8.80 (a) Fractured K-Flex tip;
which may also fracture if its breaking threshold is exceeded, which can B (b) instrument fracture due to torsional
easily occur when there is thin apical dentine. However, the common fatigue
194 NON-SURGICAL ROOT-CANAL TREATMENT
A B A B
Fig. 8.81 Ledging and excessive dentine removal Fig. 8.82 (a,b) Thread cut into dentine Fig. 8.83 (a,b) Thread cut into dentine (arrowed) by
(arrowed) by screwing instruments into root screwing instruments into root canal
canal
outcome is that dentine is removed in an uncontrolled fashion resulting in the lateral force will be greatest at the handle and progressively reduce
procedural errors (Fig. 8.81). Another problem is that in circular, narrow towards the tip. A file that is too flexible will simply tend to bend away
canals, the entire circumference of the instrument may be engaged and from the dentine surface on application of a lateral force. The advantage
with progressive apical feeding result in a considerable length and, there- of the reducing lateral force apically is that a natural taper will be created.
fore, surface area of the instrument becoming engaged with dentine simul- This poses an interesting dilemma when a curved canal has to be instru-
taneously. As this happens, a progressively greater force is required to feed mented; on the one hand, flexible instruments are required to negotiate the
the instrument in further, imposing greater and greater force on both the canal without producing procedural errors but, on the other hand, some
instrument and dentine; the ultimate result is what is known as “taper rigidity is required to control application of lateral force. Very flexible
lock”. Screwing instruments into the root canal in this fashion will impose instruments, such as those made from nickel–titanium are not effective for
enormous stresses both on the instrument and the root; it may also result filing techniques, yet are better for a rotational approach. It is therefore
in a thread being cut into the dentine (Figs 8.82, 8.83). more effective, when using a push–pull filing technique to control the
The surest way of reducing the amount of force applied in torque is to actions of the apical portion of the file by preshaping the coronal part of
limit the degree of apical feed and, therefore, the amount of dentine the canal first. This enables the tactile sensation of preparing the apical
engaged. The file is only fed in until slight resistance is met, then the file part to be discerned without coronal hindrance. In order to control dentine
is turned anticlockwise with or without apical force. Rapid cycling clock- removal along the entire length of the instrument, the interfacial force must
wise and anticlockwise without heavy torque in a stem-winding or watch- be controlled over its entire length. Other strategies to overcome this
winding motion enables the gentle negotiation and enlargement of the problem are discussed below.
canal without risk of procedural errors. This works best in canals where
the instrument does not bind simultaneously around its entire circumfer- Design of hand instruments
ence; conversely, in narrow, tight canals, this technique can be demanding A skilled operator must understand and know the tools(s) he/she uses. The
on finger-strength and endurance. It is the sort of instrument manipulation manner of manipulation has to be based on the cutting properties of
that causes finger calluses; it is interesting though that the formation of the instrument. The mode of manufacture, orientation and sharpness of
calluses, far from reducing sensitivity to touch increases sensitivity. As in the cutting edges, as well as the response to use and to sterilization on the
all rotary techniques, the flutes of the instruments should always be cleaned cutting properties, should be aspects the operator should be familiar with.
frequently to facilitate adequate cutting. The root-canal instruments available may be manufactured from metal
wires of different alloys (stainless steel, carbon steel, titanium, nickel–
Push–pull filing
titanium), cross-sectional shapes and diameters. These alloys have differ-
In contrast, in push–pull filing, the entire circumference of the instrument ent physical and chemical properties: carbon steel is the most brittle, rigid
can rarely be engaged for more than one stroke. In this method of cutting, and susceptible to corrosion; stainless steel is more resilient; titanium is
the sharp edges are ideally oriented perpendicular to the direction of file more flexible; and nickel–titanium is the most flexible. The cross-sectional
movement. Other than in the situation where the file is rotated into engag- shapes of instruments may be square (K-file – Fig. 8.84), triangular
ing the dentine and then pulled (also a valid approach to cutting), push–pull (K-reamer – Fig. 8.85), rhomboid (K-Flex-file – Fig. 8.86), circular (Hed-
filing requires the application of a lateral or interfacial force to enable the stroem file – Fig. 8.87) or S-shaped (Unifile).
file to engage dentine. This is akin to using a wood-file on a piece of wood. These shapes have a bearing on the physical properties of the instru-
A wood-file held lightly against the wood will remove few wood shavings. ments. The cutting edges may be generated by twisting the metal shaft
Pressing on the wood-file harder will allow it to engage the wood surface along its long axis or by machining it. When twisted, the square blank
more effectively and remove more wood shavings. In the same way, an produces the most rigid instrument; the triangular shape is more flexible
endodontic file is more effective when it is rigid enough to engage dentine and the rhomboid more flexible still. When machined, the depth of cut
when lateral interfacial force is applied. In contrast to a wood-file, the used to produce the flutes dictates the flexibility and strength of the instru-
lateral force on a root-canal instrument cannot be applied directly to the ment. The helical angle thus produced, influences the optimal mode of use
file but is exerted on the handle in the hope that this will be transmitted (rotational or push–pull). Machined instruments generally tend to be more
along the length of the file. As the instrument is tapered towards its tip, susceptible to fracture, unless they have been specifically heat-treated.
NON-SURGICAL ROOT-CANAL TREATMENT 195
Fig. 8.84 Kerr K-file No. 25 Fig. 8.85 Kerr K-reamer No. 25 Fig. 8.86 Kerr K-Flex file No. 25
D16 D0
D16 D3 TIP
75º
D0
3mm
16mm
D16 16mm D0
Fig. 8.87 Kerr Hedstroem No. 25 Fig. 8.88 Dimensional formula for files and Fig. 8.89 Dimensional formula of an H-type
reamers: D = diameter instrument (ANSI specification No. 58:
D = diameter)
devices have been introduced onto the market through the years, with
reciprocal, vertical, and random movement and both sonic and ultrasonic
oscillation. Nickel–titanium rotaries (non-ISO taper), since their introduc-
tion in 1995, have taken an increasing share of the market. There are many
advantages to these instruments and many improvements have been made
since their early advent; universal acceptance though is still prohibited by
their expense. The reason for choosing nickel–titanium is that it is five Fig. 8.94 The
times more flexible and more resistant to fracture when compared to stain- alternating cutting edge
less steel. in a RaCe instrument
The final radiograph of a root filling in a nickel–titanium rotary prepara-
tion looks smooth and shows a gradual even taper; this may, in part, be
due to the action of the rotating instrument packing debris into the crevices
and accessory anatomy. The importance of removing microorganisms and
debris is paramount, so a system that uses both a reciprocating and oscil-
lating movement may be more appropriate. Such a movement may
be able to clean the asymmetric shapes found in root canals more
effectively.
Table 8.1 shows the advantages and disadvantages of rotary over hand
instrumentation.
A B
Fig. 8.95 Non-end-cutting or safety tip Fig. 8.96 (a) Profile GT – side view; (b) this instrument has been based on the original ProFile so it
shows wide radial lands
A A
A
B B B
Fig. 8.97 (a) The Quantec – side view; (b) the Fig. 8.98 (a) The K3 – side view; (b) the K3 shows Fig. 8.99 (a) The Hero – side view; (b) Hero 642
Quantec has two radial lands, which are relieved three radial lands in cross-section, two of which – the numbers relate to the tapers. The coronal
to reduce friction against the root canal wall are relieved. The flutes increase in depth towards and middle portion of the canal is prepared to 06
the top of the shank, the shallower flutes near the and 04 taper respectively and the apical portion to
tip impart additional strength to the instrument. 02. Note narrow radial lands
The radial lands are spaced at varying distances
apart reducing the pull-in effect
Safety tip and better-shaped canals. The tactile skills required are different from
The majority of nickel–titanium instruments have been designed so that those required for hand instruments. Which automated device is “best” is
they do not cut at the tip (Fig. 8.95). It is obvious that if the tip had an a matter of personal preference.
aggressive cutting action the instrument would tend to cut into the wall of
the root canal when a curve was reached. Unconventional instrument design
Figures 8.96–8.101 show both side views and cross-sections of Profile, A novel instrument design has been marketed recently, called the self-
Quantec, K3, Hero, Pro Taper, RaCe, nickel–titanium rotary instruments. adjusting file (Fig. 8.105). It is machined from nickel–titanium and resem-
The latest instruments WaveOne (Fig. 8.102), Reciproc (Fig. 8.103), and bles a mesh formed into a cylinder. The single instrument is compressible
Twisted file (Fig. 8.104) are also shown. and may be inserted into any canal shape with a minimal size equivalent
Initially, the disadvantage of automated instruments is the loss of tactile to ISO size 20; this means the canal must be prepared to a minimum glide
sense but with time and practice this can be acquired to an extent. It has path of this size first. Its advantage is that when it is activated with a vibra-
been demonstrated that experience results in fewer instrument fractures tory push–pull action, it conforms to the shape of the canal and enlarges
198 NON-SURGICAL ROOT-CANAL TREATMENT
A A
B B
Fig. 8.100 (a) Pro Taper – side view; (b) the Pro Fig. 8.101 (a) The RaCe – side view; (b) RaCe
Taper is similar to the Hero in cross-section. It has stands for reamer with alternating cutting edge.
a variable taper along the shank. The cutting The alternating cutting edge reduces the tendency
action is fairly aggressive for the instrument to be pulled into the canal. The
instrument cuts aggressively and may make a
clicking sound when being used Fig. 8.103 Reciproc
A B C
Fig. 8.106 (a) File fitting tightly in the canal; (b) circumferential filing: anticurvature filing: 3× on B, Fig. 8.107 Ledging
M, L; 1× furca; (c) file fitting loosely in the canal with preferential points of contact
A B
Fig. 8.108 Zipping Fig. 8.109 (a,b) Transportation of the apical foramen
stroke and thereafter with each subsequent stroke, the file becomes pro- These problems may be overcome by:
gressively looser and a lateral force has to be applied to the file in numer-
ous different directions (traversing 360°) as the file is moved • reducing the restoring force with which straight files lean against
the curved canal
circumferentially around the canal, while conducting a push–pull motion
(Fig. 8.106b). Once the file is loose in a curved canal, however, its natural • reducing or controlling the length and surface area of the file that
is actively engaged in cutting at any given time.
tendency to straighten up will only allow preferential contact at certain
points along its length (Fig. 8.106c). These points are predictably at the
outer aspect of the major curve apical to the curve, on the inner aspect of Reducing the restoring force
the curve at the height of the curve and either at the inner curve or outer This can be achieved in a number of ways:
curve coronal to the curve, depending upon the direction in which the
1 Precurving the file – the restoring force may be reduced by
lateral force is applied. The contacts result in procedural errors, such as
achieving a closer match in the curvature of the instrument with
ledging (Fig. 8.107), zipping (Fig. 8.108), transportation of apical foramen
that of the canal. Assuming that an accurate match is obtained, this
(Fig. 8.109), and perforation (Fig. 8.110). Strategies to avoid such uneven
match is true only in one position (Fig. 8.111). The greater the
preferential contacts involve ways of reducing them.
amplitude of the filing stroke the greater the mismatch at the
There are two elements to such uncontrolled forces and dentine removal:
extremes of the filing stroke. Therefore, the amplitude must also
1 the tendency of the file to straighten to its normal shape be reduced. Files may be precurved by using a cotton wool roll or
2 the tendency of the file to cut along its entire length and using commercial devices (Fig. 8.112). The curve perpendicular to
surface area. the X-ray beam is estimated from the radiograph and any curve in
200 NON-SURGICAL ROOT-CANAL TREATMENT
A B
B C
B A
Fig. 8.112 (a,b) Commercially available devices for Fig. 8.113 (a) Use of small file as explorer; (b,c) curvature (in two planes) of file removed from the
precurving files mesiobuccal canal in (a)
the planes parallel to the X-ray beam must be estimated by tactile Fig. 8.114 Files are
sense and the curvature on initial explorer files (Fig. 8.113). Files precurved at different
that are to be used at different lengths in the canal relative to the levels depending on the
curvature should be appropriately precurved (Fig. 8.114) depth of insertion into
the canal
2 Use of flexible files – the restoring force in more flexible files is
naturally lower. Some makes of instrument are more flexible by
virtue of their cross-sectional shape (Fig. 8.115) or material of
construction, such as nickel–titanium
3 Greater use of smaller files – smaller instruments (size 20 and
below) are more flexible and so their use until larger instruments
are able to negotiate without force may reduce adverse dentine
removal (Fig. 8.116)
4 Use of intermediate sized files – The transition from one file to the
next can also be made easier by the use of half sizes, e.g. sizes 12,
17, 22, 27 and 32 (Fig. 8.117). This reduces the force required to
negotiate the files apically and also the probability of procedural
errors.
NON-SURGICAL ROOT-CANAL TREATMENT 201
B B A B
Fig. 8.115 (a) Maillefer “Golden Medium” No. 27; Fig. 8.116 (a,b) Loss of length caused by forcing Fig. 8.118 (a,b) Preflaring allows more direct
(b) Girofile No. 25 large instruments into canals too early apical access
A B C
Fig. 8.119 (a) Severe strip perforation; (b) furcal view of mesial root of extracted tooth; (c) cross-section of a mesial root. Ideal removal of dentine during
preparation (shaded area): B = buccal; M = mesial; L = lingual
Reducing or controlling the length or area of file actively potential perforation (Fig. 8.119). This method, which involves
engaged in cutting filing the buccal, mesial and lingual walls of the root canal
This can be achieved in a number of ways: with more strokes than the furcal wall by a ratio of 3 : 1, is
effective (see Fig. 8.106b). However, simply following the
1 Modified canal preparation techniques – preparing the coronal prescription without regard for tactile feedback, flexibility of
part of the canal first in a corono-apical or crown-down approach the file and controlled manipulation of the file will render it
removes coronal binding and allows more controlled preparation ineffective. The technique does not work with files that are
of the apical part of the canal with the apical part of the file too flexible and a degree of straightening may be inevitable
(Fig. 8.118) (Fig. 8.120)
2 Modified manipulation of instruments – the manner in which the • Modified use of files – files may be used in such a way that
instruments are manipulated can allow a restricted part of the canal their area of contact is reduced. For example, in the crown-
or instrument to be engaged, increasing the control over dentine down-pressureless technique, only the tips of the instruments
removal are used for cutting. The file is placed in the canal until it binds
• Anticurvature filing – denotes filing preferentially away from (Fig. 8.121) and is then rotated twice without apical pressure to
the inner curve or furcal aspect of the root canal, the site of remove dentine at this binding point.
202 NON-SURGICAL ROOT-CANAL TREATMENT
Fig. 8.120 Mild straightening Fig. 8.121 Modified use of files: Fig. 8.123 Loss of
despite anticurvature filing A = circular movement of file; canal curvature in
B = only the tip of the mesiobuccal root of
instrument engages and cuts maxillary molar using a Fig. 8.124 Mesiobuccal canal with narrowly
dentine rotational technique tapered radicular access using rotational
manipulation
3 Modified instruments – the idea of only using the apical part of Fig. 8.125 Example of
instruments has been extended by the development of instruments widely tapered radicular
that have cutting edges only in their apical part, such as Light access using rotational
manipulation
Speed (Fig. 8.122). These instruments are particularly useful for
gauging the apical size of the canal.
A B C
A
A
A
B B B
Fig. 8.127 (a,b) Radiographs of treated cases Fig. 8.128 (a,b) Straightening coronal curve in the Fig. 8.129 (a,b) Straightening apical curve on the
where the natural canal contour has been distal root mesial root
maintained
additional curve as an unaccounted resistance to file manipulation. There- technique will achieve the desired result (Figs 8.132, 8.133). The size of
fore, when the filing technique is used, the undetected curve may be the taper may have to be limited, placing greater reliance on the chemical
straightened and, if the root dentine is thin, it may result in a strip perfora- preparation.
tion in the furcation. The use of a gentle rotational technique is more likely
to retain the curve. Preparing a regularly tapered radicular access and
Sometimes the double canal curvatures will be evident in the same gauging it
radiographic plane. These are difficult to maintain using a filing technique
The ability to prepare a well and regularly tapered radicular access is based
alone. Either the coronal (Fig. 8.128) or apical curve (Fig. 8.129) may be
on two factors:
straightened. The preparation of such curves with automated nickel–
titanium rotary instruments is only possible if the curves are gentle and 1 knowing when to stop using a given instrument. Under-use of an
the canal already wide (Fig. 8.130). Otherwise, there will either be damage instrument may leave the taper too narrow and over-use, too wide
to dentine or the file will fracture (Fig. 8.131). When more severe curves 2 knowing how to gauge the canal taper (or “feel” the diameter at
in two planes are present, only hand instrumentation with a rotational specified lengths using the tips of equivalent sized instruments.
204 NON-SURGICAL ROOT-CANAL TREATMENT
A B C
Fig. 8.130 Curvature in opposite Fig. 8.131 (a–c) Damage to dentine and file separation during preparation
directions in the same plane of canal with double curvature without appropriate glide path
A B
Fig. 8.132 (a) Diagnostic radiograph of severe curves in two planes; (b) successful Fig. 8.133 Successful treatment of the maxillary
treatment of the severe multiple curves right second premolar with severe multiple curves
Gauging the canal taper is the most underrated aspect of learning to 2 coronal–apical techniques (e.g. step-down, double flared, crown-
prepare canal systems to a consistent and predictable shape. Unlike the down-pressure-less techniques) (Fig. 8.135).
taper of a crown preparation, that of the canal is not visible until the canal
These simply describe the direction in which canals are progressively
is filled and radiographed, which is too late for any modification. The taper
enlarged; either starting coronally and then progressively enlarging towards
can, however, be felt using a series of diameter-graded instruments.
the apex (coronal–apical); or, starting at the apex and progressively enlarg-
Gauging a radicular access cavity, therefore, means placing accurately
ing the entire canal with the emphasis on segmentally stepping back from
measured instruments into the prepared canal to the precisely judged
the apex to the coronal part (apical–coronal). Normally, the mechanical
coronal reference points and feeling their tightness (or looseness) at their
preparation of the radicular access is divided into four phases:
appropriate lengths. In order to prepare a regular taper, it is essential that
each instrument, at its respective length (whether 1 mm or 0.5 mm step- 1 Preparation of coronal flare to the beginning of the first canal
back), exhibits precisely the same degree of tightness or looseness. curve or to two-thirds the estimated length of the canal if there is
The design of the Light Speed instrument lends itself very well to canal an absence of a curve
gauging because only its tip can bind to the canal wall. 2 Determination of canal length to apical terminus by negotiation
The advent of non-ISO taper nickel–titanium instruments with a prede- of small instruments (ISO size 08, 10) to full length with precise
termined taper has meant that a single instrument, that is, the one used to length establishment as previously described
finish the entire radicular preparation, can be used to gauge the canal taper. 3 Negotiation and enlargement of the canal to the accurately
However, if the same instrument is overused, particularly with a brushing confirmed length using hand instruments in a rotational mode of
motion, the same problem of loss of taper control may arise even with manipulation, preferably a gentle stem-winding technique to at
these instruments. least ISO size 30
4 Final shaping to achieve a regular taper.
RECOMMENDED APPROACH TO PREPARING THE
RADICULAR ACCESS Coronal preflaring
There is an almost infinite number of techniques to prepare the radicular The benefits of coronal preflaring are:
access cavity. Various strategies have been devised to help dentists prepare
root canals. The techniques have been divided into two groups: • it allows early debridement of the coronal part of the canal that
contains the bulk of organic and microbial debris, reducing the risk
1 apical–coronal techniques (e.g. standardized, step-back techniques) of carrying this material to the apical end and its extrusion through
(Fig. 8.134) the apical foramina
NON-SURGICAL ROOT-CANAL TREATMENT 205
Coronal access
and preflare
Working length
determination
Apical enlargement
Canal enlargement after
apical negotiation
• early coronal widening enables better and deeper penetration of Negotiation to the full length of canal and
its apical enlargement
irrigant earlier in the preparation, reducing the risk of blockage of
apical foramina with dentine “mud” (viscous mix of dentine debris The apical part of the canal should now be negotiated with a series of hand
and dissolving pulp tissue) instruments of progressively increasing size up to ISO size 20–30, to the
• preparation of the coronal portion of the canal tends to remove full length without deviating from the canal curvature. Again a number of
interferences, smoothens access and shortens the effective canal approaches are available but the safest way is to use a gentle stem-winding
length; determination of canal length after such enlargement technique that does not remove excessive amounts of dentine. The instru-
reduces the problem of changing canal length as it is prepared ments may be used in a corono-apical (Fig. 8.139 ) or apico-coronal (Fig.
• it allows better tactile discernment and control over apical 8.140) sequence according to preference. Alternatively, nickel–titanium
instrumentation. rotary instruments may be used for negotiation of full length of canals
The coronal preflaring can be achieved in any one of a number of ways (Fig. 8.141). However, caution should be exercised if canals are narrow
according to personal preference. The traditionally taught approach is by or severely curved because instrument fracture through rotational torque
filing the coronal part of the canal using either Hedstroem or K-type files; or cyclic fatigue is a significant risk without creating a glide path. Newer
and then refining the shape with Gates–Glidden drills as in the step-down 02 taper rotary nickel–titanium instruments are available for creation of
technique (Fig. 8.136). It is important to maintain patency beyond the point such a glide path.
of instrumentation with a small instrument. Where the canal system is relatively wide at the outset and does not
The instrumentation may also be performed in a step-down approach require negotiation as such, the apical part of the canal should be gauged
using rotational manipulation to achieve a similar result, as in the double- to determine its size after length determination. The process of shaping
flare technique (Fig. 8.137). may then be commenced directly, bypassing the negotiation step.
Alternatively, the coronal part of the canal may be opened and flared
Final shaping of the radicular access
with nickel–titanium orifice openers or rotary instruments (Fig. 8.138).
This is an efficient and effective means of achieving this goal. This may be achieved by using hand instruments to gauge the canal taper
in a stepback filing approach (Fig. 8.142) or a stepback rotational motion
approach (Fig. 8.143). Alternatively, the instruments may be used in step-
Negotiation to the full length of canal and
down fashion.
length verification
A preferred current approach is to use nickel–titanium rotary instru-
Having preflared the canal, its full length is accurately determined as previ- ments for final shaping of the radicular access to the required final taper,
ously described. which rarely needs to be greater than 0.06 (Fig. 8.144).
206 NON-SURGICAL ROOT-CANAL TREATMENT
A B C
D E
CHEMICAL TREATMENT OF ROOT-CANAL SYSTEMS friction-free movement. Lubricants also come in the form of gels and include
AND ROOT-CANAL IRRIGATION EDTA-containing pastes, such as RCPrep and File-eze. Other agents, such
as Glyoxide or Glyde contain carbamide peroxide (an oxidizing agent).
This aspect of root-canal system preparation, although described sepa- Flushing action: A reasonably low viscosity of the irrigant should facili-
rately for convenience, is performed simultaneously with the mechanical tate flow and flushing of the root-canal space. However, the viscously
preparation and does in fact also precede and succeed it (Fig. 8.145). dominated environment of the root-canal space due to its small volume
The function of irrigants may be summarized as follows: renders the fluid relatively static. Therefore, this demands various strate-
gies to help mix and agitate the solution in the root-canal system.
• lubrication of the instruments
Degradation of pulp tissue: The best solution for degrading pulp tissue
• flushing out of root canal debris
is sodium hypochlorite (Fig. 8.146). These figures show degradation of an
• chemical degradation of residual pulp tissue
extirpated pulp over 10 minutes when the tissue is fully exposed in a large
• chemical degradation of the smear layer on the instrumented surface
volume container, where access to unreacted sodium hypochlorite is unim-
• chemical degradation of the microbial biofilm both on the
peded. In stark contrast, such access within the root-canal system would
instrumented and, more importantly, on the uninstrumented surface
be exceptionally restricted. It is therefore necessary actively to ensure that
• antibacterial action against the root canal microbiota.
unreacted solution reaches the tissue in all parts of the root-canal system.
Lubrication: This relies on the irrigant having properties that enable it to This is done via the radicular access, both during and after its preparation.
be interposed as a thin layer between instrument and canal wall, facilitating Diffusion of unreacted molecules, however, demands very frequent
NON-SURGICAL ROOT-CANAL TREATMENT 207
A B C D
Fig. 8.137 Coronal preflaring – using rotational instrument manipulation in a progressive step down approach. (a) Introduce small file (No. 10) to full WL to
establish patency: WF = without filing; (b) instrument to size 35 at about 14 mm: R = rotational motion; (c) instrument with file 30 to 1 mm deeper than size 35;
(d) instrument with size 25 to 1 mm deeper than size 30
A B
replenishment of the solution in the radicular access. Higher concentration reduces success rates. Weak organic acids, such as ethylenediaminetetra-
solutions (5%) may enable better diffusion along a gradient but its use acetic acid (EDTA) 17% may help remove the smear layer if irrigation
must be balanced against the problem of over-weakening the dentine by with it reaches and reacts with the layer (Fig. 8.149).
depleting its collagen content. Concentrations up to 3% are sufficient for Degradation of the microbial biofilm: The microbial biofilm contains an
antibacterial effect and tissue-degradation effect in most cases. Higher aggregate of microbes and extracellular polysaccharide matrix (ECPM),
concentrations may be used intermittently in the case of non-responding which are both highly adherent to the canal wall. The multiple bacterial
infections or where canal patency is compromised by compacted apical cell layers covered by the additional thickness of ECPM, which may
debris. Sodium hypochlorite is a caustic solution and has the potential to exceed the bacterial cell volume, renders biofilm removal a difficult task.
corrode equipment (Fig. 8.147), bleach clothes and cause a severe reaction Removal is certainly facilitated by organic tissue solvents, such as sodium
if extruded through the apical foramen. A good rubber dam seal must be hypochlorite and chelating agents, such as EDTA. The EDTA helps by
ensured (Fig. 8.148). It is also prudent to check prior to treatment whether chelating and sequestering heavy metal ions, which normally act as bridges
the patient is allergic to household bleach. to bond bacteria together in the biofilm. EDTA is routinely used in micro-
Degradation of the smear layer: Some operators consider this to be a biology laboratories to wash bacterial cells free of the extracellular polysac-
very important aspect of root-canal treatment because the smear layer is charide and to separate them. EDTA is likely to play an important role in
thought to harbour bacteria and prevent sufficient adaptation of the root- degrading the biofilm on the uninstrumented walls of the root-canal system;
filling material. There is, however, no definite proof that the smear layer this is therefore a more significant function than smear layer removal.
208 NON-SURGICAL ROOT-CANAL TREATMENT
R
R R
R
D
C
B
A
Fig. 8.139 Negotiation of full length of canal: using step-down rotational instrumentation (a) size 40, (b) size 35, (c)
size 30, (d) size 25, (e) size 20 at full WL. Apical enlargement may be continued to desired size by adopting another
“wave” of instrumentation starting with a larger sized instrument
Antibacterial action against the root canal microbiota: Perhaps the most surfaces free of the microbial biofilm and other debris. In order that access
significant action of the irrigant must be its ability to kill all elements of to the entire root-canal system is maintained during the radicular access
the root canal microbiota. A number of different antibacterial agents have preparation, the dentine filings, chips and pulp debris generated or dis-
been used, which exhibit a range of actions against the various bacteria placed must be flushed out of the system. During the initial negotiation
(Table 8.2). of the canal system, depending on the relative fit or mismatch between
The temptation to use multiple agents should be avoided because at best instrument and canal walls, debris occupying or attached to the canal
they may potentiate each other (although the literature does not currently system wall may be compressed, compacted, pushed and smeared into the
support this suggestion) or at worst they may neutralize each other. An accessory anatomy. As instrumentation proceeds apically through a pro-
example of the latter is the precipitate formed by mixing chlorhexidine gressively narrower channel, the potential for such displacement and com-
with sodium hypochlorite. The latter combination has been shown to paction increases and some of the debris may be ousted through the apical
reduce the success rates of root-canal treatment. foramina. It is preferable that such compaction and displacement is avoided
and that the debris is flushed out through the coronal access.
Initial preflaring of the canal allows the coronal-most debris to be
MECHANICS OF ROOT-CANAL IRRIGANT DELIVERY washed out and creates a reservoir for easier delivery of the irrigant to the
AND ITS ACTIONS apical parts of the root-canal system. In conjunction with this, the selection
The purpose of the radicular access cavity is to facilitate delivery of the of a good delivery system and good wetting characteristics of the irrigant
fluid irrigants that will help to debride chemically the uninstrumented are also crucial.
NON-SURGICAL ROOT-CANAL TREATMENT 209
F F F
F
B C D
Fig. 8.140 (a) File with size 10 to WL; (b) file with size 15 at WL; (c) file with size 20 at WL; (d) file with size 25 at WL
F
F
Fig. 8.141 The use of nickel–titanium rotary graduated tapers Fig. 8.142 (a) Stepping back by 1 mm from WL at size 30; (b) stepping back
by 2 mm from WL at size 35;
The irrigant solution has been traditionally delivered using a hypoder- faring worst of all in this property. A smaller diameter needle (Fig. 8.154)
mic needle and syringe (Fig. 8.150), particularly with the intention of and higher extrusion force (higher Reynolds numbers) may displace the
injecting it into the apical part of the root-canal system. Even assuming stagnation plane apically by a small margin only (Fig. 8.155). This means
an absence of any obstructing debris, injection of irrigant into the coronal that the only way to move the stagnation plane further apically is to posi-
part of the canal does not lead to its penetration to the apical part unless tion the needle tip further apically by using a smaller needle or enlarging
the needle is jammed into the canal (Fig. 8.151). This is because, under the preparation further; although the latter is not ideal (see Fig. 8.12). A
normal circumstances, the fluid dynamics in a root canal result in a narrow-gauge needle (27 or even better 30) is recommended for deeper
so-called “stagnation plane”, beyond which the fluid does not penetrate needle and, therefore, irrigant penetration (Fig. 8.154). Use of the narrower
(Fig. 8.152). The position of the stagnation plane is influenced by the needle may reduce the rate of injection and make control difficult because
needle design (Fig. 8.153). The stagnation plane is furthest away from the of the force required to extrude it. Some space is required adjacent to the
needle tip in the flat open-ended needle design, followed by the bevel- needle to prevent extrusion through the apical foramen (Fig. 8.151). There
ended and then the side-cut needle designs, with the side-vented needle is clearly an anatomical limit to how close to the canal terminus even the
210 NON-SURGICAL ROOT-CANAL TREATMENT
R
F R
F
C D E F
Fig. 8.142 Continued (c) stepping back by 3 mm from WL at size 40; (d) stepping back by 4 mm from WL at size 45; (e) stepping back by 5 mm from WL at size
50; (f) refining coronal flare with Gates–Glidden if necessary
R
R
R
R
A B C D
Fig. 8.143 (a) Size 25 at full WL; (b) size 30; (c) size 35; (d) size 40;
smallest needle may be placed, yet apical delivery of irrigant is most mud”. The increasingly dense dentine mud may reach such a state of vis-
important. A strategy for ensuring that irrigant replacement does occur cosity that it could be mechanically propelled apically by the piston effect
apically is called “recapitulation”. This is illustrated in Figure 8.156 . This of the sequentially larger instruments used during canal preparation,
is the single most important aspect of root canal preparation. As the canal thereby blocking the apical canal foramina. The irrigant fluid in the zone
is sequentially instrumented, each series of strokes and increment in instru- beyond the stagnation plane must, therefore, be replaced frequently. This
ment size leads to the generation of more and more dentine debris, which is achieved by using a small file, such as 08 or 10, inserted to the
will be loosely suspended in the irrigant fluid in the canal system (Fig. full working length to agitate the solution in a push–pull motion. This
8.156a). Since the stagnation plane prevents the fluid from reaching the action mixes the fresh coronal solution with the saturated apical solution
apical zone, the fluid in the stagnant zone becomes increasingly saturated beyond the stagnation plane, thereby diluting it (Fig. 8.156d). This process
with debris. In the presence of sodium hypochlorite the organic material of dilution in the zone apical to the stagnation plane is called
may begin to dissolve, thereby increasing the viscosity of the apical solu- recapitulation.
tion. The dentine debris suspended in an increasingly sticky and viscous Given that the apical anatomy may contain several apical exits in a delta,
solution, therefore begins to form what is recognized clinically as “dentine it is important that the entrance to it is not blocked. It is therefore
NON-SURGICAL ROOT-CANAL TREATMENT 211
R R
A B C
E F
Fig. 8.145 Irrigants and their functions; phase 3 consists of dynamic irrigation + = degree of activity; − = no activity
212 NON-SURGICAL ROOT-CANAL TREATMENT
A B
Fig. 8.148 Well-sealed rubber dam Fig. 8.149 (a) Smear layer formed by instrumentation; (b) smear layer removed
A B
Fig. 8.150 Hypodermic needle and syringe Fig. 8.151 Needle binding encourages extrusion Fig. 8.152 (a,b) Hypodermic needle in cleared
of irrigant canine tooth showing apical extent of needle
(A) and irrigant deposition (B)
A
B
Fig. 8.153 (a) Needle designs; (b) position of the stagnation plane for different type of needles Fig. 8.154 Different gauges of needle are
available in all types
considered prudent to pass a small file (size 08) just beyond the apical when the potential for blockage and damage is greatest. Delivery of boli
foramen to ensure its patency. This is called patency filing. It also allows of irrigant should be frequent with agitation, mixing and carriage of the
the periapical status of infection and inflammation to be gauged by allow- irrigant apically each time until the apical terminus is reached with a small
ing apically pressurized pus or exudate to be vented into the canal, where file (06 or 08) as tracked by an EAL.
it may be detected. Blocking apical foramina at the first appointment in
this manner is equivalent to a single visit obturation, even though the root
filling may not have yet been placed. Both recapitulation (within canal
DYNAMIC IRRIGATION AFTER MECHANICAL
terminus) and patency (beyond canal terminus) filing should be performed
PREPARATION OF THE CANAL SYSTEM IS COMPLETE
frequently. Once the radicular access preparation is complete, the chemical agents
Avoidance of apical blockage is academic, if the simpler task of avoid- may be delivered with a syringe and needle into the apical part of the
ing compaction of tissue, biofilm and debris in the main canal cannot be radicular access; its further penetration to the accessory and peripheral
achieved. Negotiating the main canals requires sensitive instrument anatomy may occur either by diffusion along a concentration gradient
passage combined with gentle agitation to facilitate carriage of the irrigant/ (inefficient) or bulk flow driven by agitation (efficient). Clearly, the latter
lubricant apically. Any loosened debris should either be flushed away or method is preferable but would have to be actively facilitated as mere
allowed to dissolve. Patience is required in this early and critical stage, needle delivery is insufficient.
NON-SURGICAL ROOT-CANAL TREATMENT 213
Position of 3
stagnation
plane 4
Dynamic
Mean/median
irrigation
Vol 3.3 0.0 7.6 29.6 22.4 0.01 5.5 0.0 10.7 2.0 8.1±10.2/4.4
Static
Mean/median
irrigation
Vol 0.0 1.0 0.0 0.0 1.4 0.0 0.0 0.0 0.8 0.0 0.3±0.5/0.0
B
Fig. 8.157 (a) Diagram displays fluid flow resulting from manual agitation; (b)
irrigant extrusion (bleached zone in pink agar) following gutta-percha cone
agitation of irrigant in the embedded roots
A B
As the irrigant is delivered, its contact with debris and organic material
B will rapidly deplete its oxidizing power, constant replenishment by fresh
irrigant is therefore essential. A major initial challenge is that the reactive
irrigant will have become spent by the time it reaches the peripheral site.
Frequent intermittent replenishment with fresh irrigant and its mixing is
required but is time-consuming; therefore adequate time should be allowed
for the irrigant to be replaced and to act, even if the radicular access
preparation may have been completed quickly.
The strategies for delivering, agitating, and mixing the irrigant into the
complex anatomy from the prepared radicular access have increased multi-
fold in recent years as this need became better understood. The approaches
may be classified into:
Irrisafe file
Sonic Air
UItrasonic file
Endo Activator
Vibringe
ProUItra
Fig. 8.158 Sonic agitation devices Fig. 8.159 Ultrasonic agitation devices
The simplest method is to reciprocate a gutta-percha cone to agitate the 25, 35) and tapers (0.02, 0.04) for agitation of the irrigant to avoid the
irrigant (see Fig. 8.157a). With this method, there is an increased risk of potential risks of instrument separation associated with metal files, ledge
irrigant extrusion through the apical foramina (see Fig. 8.157b). The formation and canal transportation. Preliminary data on debris and smear
optimal method for maximizing wall shear stress and reducing apical layer removal were promising. Vibringe consists of a sonically activated
extrusion is to use a gutta-percha cone that fits well apically but is slightly device attached to a syringe, which is said to create agitation as the irrigant
loose coronally. is delivered.
Activation of irrigant with sonic or ultrasonic devices involves the agita- Much higher frequencies of vibration of the working tip (in the ultra-
tion of either a syringe-delivered bolus of fluid in the canal or by simul- sonic range, 20–40 kHz) are achieved with either magnetostrictive or
taneous delivery (via a custom-reservoir) and agitation. The sonic devices piezoelectric devices. Magnetostrictive transducers produce an elliptical
available for irrigant agitation include the Sonic Air Endo Handpiece motion at the working tip, while piezoelectric transducers produce longi-
(Micromega 1500, Besancon, France), which is driven by air pressure to tudinal or transverse linear motions. In either case, the oscillations are
produce vibration frequencies of 1500–3000 Hz and which also drives damped by contact of the file with the canal wall, also reducing the acous-
stainless steel files to aid simultaneous canal preparation. The EndoActiva- tic microstreaming (Fig. 8.161). Acoustic microstreaming is enhanced by
tor® system (Advanced Endodontics, Santa Barbara, CA, USA) is electri- higher power output and greater flexibility of the file, therefore a small
cally driven and works at the much lower frequencies of 33, 100, and size is better. To maximize acoustic microstreaming, it is best to use the
167 Hz. It was designed to use polymer tips of various sizes (ISO size 15, ultrasonically energized file without contacting the canal walls; this is
NON-SURGICAL ROOT-CANAL TREATMENT 215
A B
Fig. 8.164 (a) Cresophene; (b) CMCP Fig. 8.165 Metacresyl acetate
ALDEHYDES
These materials (formaldehyde-containing preparations, formocresol, glu-
teraldehyde) have mainly been used in paedodontics. They have no role
in the treatment of permanent teeth. Formaldehyde-containing materials
have been used for their antimicrobial and fixative properties but they are
very toxic to the periradicular tissues and, furthermore, fixed tissue is
potentially antigenic. Gluteraldehyde also has the potential to cause hyper-
sensitivity reactions.
HALIDES
These include sodium hypochlorite, iodine-potassium-iodide, and a com-
bination of calcium hydroxide and iodoform preparations (Vitapex®,
Metapex®, Forendo®).
Sodium hypochlorite fulfils the most important criteria of antibacterial Fig. 8.166 Iodoform and calcium hydroxide preparations
effect and tissue dissolution, but its efficacy as a medicament is limited
because chemical reaction depletes its effect rapidly. In addition, since the
canal would need to be flooded, there may be an interaction with the
temporary filling material. crucial dental papilla in immature teeth requiring root-canal treatment.
Iodine-potassium iodide has low toxicity and good antibacterial effect Topical application of antibiotics (such as bacitracin, neomycin, poly-
in vitro. It is easily made by mixing 4 g of potassium iodide with 2 g of myxin, chloramphenicol, tyrothricin and nystatin) in the root canal
iodine and 94 mL of water. The canal needs to be flooded but its long-term remained popular with some clinicians, though with only one study from
effectiveness is not known. It has probably not gained favour because of Grossman supporting the outcomes. The substances are not toxic to the
its potential for allergic responses and tooth staining. periapical tissues, do not stain teeth and are active in the presence of
Iodoform and calcium hydroxide preparations (Vitapex®, Diapex® organic material. Since no single antibiotic is active against all the bacteria
Metapex®, Forendo®, CalPlus®; Fig. 8.166) are recently introduced found in the root canal system, a combination of antibiotics with different
medicaments with little information from controlled clinical studies. They ranges of activity is used, usually in the form of a paste.
appear to combine the best effects of iodoform and calcium hydroxide but Objections raised to the use of antibiotic pastes include the possibility
their support is currently mainly anecdotal. of developing resistant strains, possible sensitization of the patient and
development of an allergic response. Although all of these are possibilities,
and a few cases of allergic response have been recorded, there is no over-
ANTIBIOTICS whelming evidence against their use. However, their efficacy has not been
Multiantibiotic pastes were originally introduced by GB Winter and D thoroughly tested in properly controlled clinical studies. Where they have
Rule of the Paedodontic Department at the Eastman, London in the 1960s. been tested (clindamycin and penicillin), the results have been reasonably
The rationale was to achieve antibacterial effect without damaging the favourable but not comparable to calcium hydroxide.
NON-SURGICAL ROOT-CANAL TREATMENT 217
A B
The interest in antibiotics was renewed following the rise in their topical
use in localized periodontal pockets. A number of commonly used sys-
temic antibiotics were tried in combination, including metronidazole, cip-
rofloxacin and minocycline. The interest was further raised when they
were adopted for root-canal dressing in cases of pulp revascularization or
regeneration.
STEROIDS A B C
Steroids (prednisolone, triamcinalone, hydrocortisone, dexamethasone)
have been used in root canals mainly for pain relief and anti-inflammatory Fig. 8.169 (a–c) Apexogenesis
action; there is some clinical evidence of their anodyne action. These
materials have no other beneficial quality and, therefore, they may be
mixed with other antibacterial agents, such as calcium hydroxide or anti- 12–24 hours. It is for this reason that some clinicians prefer to mix it with
biotics. The commercially available paste popularly used in this manner a steroid paste. This ability to cause localized necrosis may help to form
is Ledermix® (Fig. 8.167), which also contains the antibiotic tetracycline. a hard calcific barrier at the junction with the periapical tissues. It is there-
It has been suggested that Ledermix® can stain teeth when exposed to fore a useful intracanal medicament for closure of immature apices (Fig.
light, so an alternative product (Odontopaste®), has used 5% clindamycin 8.168), apexogenesis (Fig. 8.169), intracanal perforation repairs (Fig.
hydrochloride and 1% triamcinolone acetonide instead to prevent tooth 8.170) and horizontal root fractures (Fig. 8.171) before obturation. These
staining. It also contains 0.5% calcium hydroxide with a caution that it latter actions may also be facilitated by the property of calcium hydroxide
should not be mixed in a 50 : 50 ratio with calcium hydroxide because it to solubilize the dentine matrix, releasing sequestered growth factors.
would destroy the steroid; this is a practice recommended by some for Calcium hydroxide is also readily available, inexpensive, simple to
Ledermix®. However, mixing these materials reduces the release of indi- place and relatively simple to remove from the root-canal system. It does
vidual components rather than providing synergism. The disadvantage of not stain the tooth or affect the temporary restoration. Another benefit
the use of these substances is the depressive effect they have on the host attributed to calcium hydroxide is its ability to dry weeping canals. The
defence mechanisms, including inflammation. Their use may also bring reason for this is unclear but it is probably related to the antibacterial effect
the risk of a bacteraemia. of the material and possibly the inactivation of toxins. Calcium hydroxide
has been recommended for treatment of external inflammatory and internal
resorption. Its action is probably related to its antibacterial properties.
CALCIUM HYDROXIDE Figure 8.172 shows both external inflammatory resorption (right lateral
This material had gained wide popularity and acceptance as an intracanal incisor) and external replacement resorption (left central incisor); the latter
medicament as it is effective against most root-canal bacteria and, addi- does not respond to calcium hydroxide treatment as demonstrated by the
tionally, has the ability to degrade residual organic tissue, making it more case shown (Fig. 8.173). One recently raised concern is that, in common
susceptible to dissolution by sodium hypochlorite at a subsequent appoint- with sodium hypochlorite, it may affect the physical properties of dentine
ment. The duration of the antibacterial effect is dependent upon the con- adversely, particularly when used long term. According to some early
centration and volume of the material but it has lasting effect because of studies, it does appear to make teeth more susceptible to fracture, although
its low solubility. A saturated solution effectively provides a store of unre- the effect appears to be limited to the surface.
acted ions ready to go into solution as the dissolved ions are removed. The Despite these positive features, recent literature casts some doubt on
material is quite irritating if extruded and can cause localized necrosis that the predictability of the antimicrobial effect, based on the resistance of
is self-limiting. Extrusion may be accompanied by severe pain lasting Enterococcus faecalis to calcium hydroxide because of its proton pump
218 NON-SURGICAL ROOT-CANAL TREATMENT
A B C
Fig. 8.170 (a–c) Intracanal repair of perforation in the furcal aspect of the mesial root of lower molar
A B C
A
Fig. 8.171 (a–c) Treatment of horizontal fractures where apical fragment has vital pulp tissue
A B
ZINC OXIDE/EUGENOL CEMENT liquid ratios but do not possess the same antimicrobial activity as zinc
oxide/eugenol.
The material of choice is zinc oxide/eugenol because it has proven ability
Cavit is popular because it is available in a ready-to-use form. It is
to seal against microorganisms. It is not very strong or durable and, there-
essentially “plaster”, and can give a reasonable seal over periods of about
fore, reinforced cements (such as IRM or Kalzinol) should be used. These
a week, but is not very durable. It does possess some antimicrobial effect
materials are best used to restore a conventional access cavity rather than
but is not as strong as zinc oxide/eugenol. Its so-called “self-repair” capac-
a larger defect.
ity is related to its ability to absorb moisture and expand. Because of its
To effect a good seal, proper manipulation of this sticky material is
lack of physical strength it needs to be used in adequate depth, considered
essential. It should be adapted with apical pressure from the centre of the
to be about 3–4 mm. Restoration of large cavities with Cavit results in
cavity outwards or it may pull away from the margin (see Fig. 8.180c).
cracks within it accompanied by leakage.
When mixed to a high powder/liquid ratio the material is very durable
The most recent generation of access restorative materials consist of
(Fig. 8.181a). In the case shown, the patient did not attend for 2 years after
resins. One example is TERM, which is a light-cured resin; it does undergo
placement but the IRM dressings were still intact. In the second case (Fig.
curing shrinkage and is hygroscopic but may be useful for larger cavities.
8.181b), a low powder/liquid ratio resulted in surface loss of material over
It is not recommended for use over one month.
a period of 3 months.
The only disadvantage of using zinc oxide/eugenol is its incompatibility
with composite resins. If this is likely to be a problem, a non-eugenol ROOT-CANAL SYSTEM OBTURATION
dressing may be used but would lack antibacterial effect.
“Obturate” means to block, obstruct, cork, stopper or occlude; to obturate
GLASS IONOMER CEMENTS is to occlude or fill a cavity. Historically, obturation of the root-canal
Glass ionomer cements have been recommended because of their adhesive system was viewed as the most critical part of the whole treatment. As a
properties. However, the need to use the material in bulk means that the result, extensive efforts have been devoted to the development of the ideal
setting contraction may be significant and can cause the integrity of at least root-canal filling techniques and filling material. However, it must be
part of its margin to be compromised. Resin reinforced glass ionomer stated that the success of non-surgical root-canal treatment is more depend-
appears to have good antibacterial properties. ent on the debridement of the root-canal system, with obturation playing
the secondary role of incarcerating residual bacteria and preventing recon-
tamination. The purpose is therefore to “seal” the entire root-canal system,
OTHER MATERIALS including the coronal entry. Therefore, obturation of the root-canal system
Other cements, such as zinc phosphate and zinc polycarboxylate, provide should begin with the root-canal filling and finish with an integrated, well
durable restorations and reasonable marginal integrity at high powder/ designed and executed coronal restoration (Fig. 8.182). The context of the
222 NON-SURGICAL ROOT-CANAL TREATMENT
• absence of pain and swelling Fig. 8.183 (a,b) Root Fig. 8.184 (a) Overfilling of the root canal system;
• absence of persistent exudate in the canal filling end at a point (b) overextension of the root filling – note the
• thoroughly debrided root-canal system (all canals identified, corresponding to the
canal terminus
voids alongside the silver cones (arrows)
prepared and irrigated for adequate time)
• adequate time to complete the procedure. Fig. 8.185 Arrested
Completion of the treatment in a single visit has a number of advantages root formation resulting
in an open apex
for both the patient and the clinician. These include the following:
A B
A B C
Fig. 8.188 (a) Preoperative radiograph of symptomatic lower molar tooth with prior silver cone obturation; (b) corroded silver cones removed during the
retreatment – note the black corrosion products formed on the cones; (c) case immediately after retreatment with gutta-percha
THE IDEAL ROOT-FILLING MATERIAL root-canal system. Many obturating techniques and materials were
designed and used based on misunderstandings of this morphology.
Concepts of the ideal root-filling material are changing as the role of
obturation is better appreciated. The root-filling material of the past was Solid cores
inert but it is more conceived as a bioactive material now. The required
properties of an ideal root-filling material have been defined as follows: Solid obturators, such as silver, titanium or acrylic cones were designed
to fit snugly into a canal “machined” to an equivalent dimension. However,
• it should induce or at least support regeneration of damaged the irregular nature of the root-canal system was not fully accounted for
tissues and these solid cores fitted only where they touched the irregular canal
• be antimicrobial walls. The remaining spaces were filled with cement or sealer. Over time,
• not irritate periradicular tissues tissue fluids could percolate into the canal system as the sealer is gradually
• not be toxic either locally or systemically washed out. In cases obturated with silver cones, this was deemed to
• be easily adapted to the canal walls and have capacity for self- induce corrosion products (silver sulphites and chlorides) (Fig. 8.188),
adaptation and self-sealing with dimensional fluctuations over time which were thought to provoke an apical inflammatory response.
• have good flow characteristics
• not stain dentine Pastes
• have good handling characteristics
Many “paste” materials have been formulated to “simplify” obturation and
• be radiopaque
have been recommended for use alone or in combination with a master
• be impermeable to tissue fluids
cone. As it is not possible to compact a paste, it is virtually impossible to
• be dimensionally stable
ensure complete obturation of the root-canal system with paste materials
• be cheap and have a long shelf-life
unless they expand on setting (Fig. 8.189). Expanding materials though
• reinforce, support and strengthen the root structure.
may be difficult to confine to the root-canal system. Extrusion of obtura-
Historically, a plethora of materials has been used to obturate the root- tion materials beyond the confines of the root-canal system is undesirable
canal system. Effective use requires an understanding of the properties of and, in the case of some paste materials, can result in permanent damage
the material and an appreciation of the anatomy and morphology of the to adjacent structures, such as neural tissue.
224 NON-SURGICAL ROOT-CANAL TREATMENT
50 Amorphous phase
10 Beta phase
0
0 20 40 60 80 100
Temperature (ºC)
Stereochemistry of polyisoprene Fig. 8.191 Volumetric and phase changes associated with heating
gutta-percha
CH3 CH2 Isoprene monomer
C C
CH2 H Table 8.3 Percentage composition of conventional gutta-percha points
Fig. 8.192 (a,b) Experimental root filling material A = conventional gutta-percha and sealer root
filling showing leakage (Black ink); B = experimental root filling without exposure to an aqueous
environment showing less leakage; C = experimental root filling material exposed to an aqueous
environment showing no apical leakage
A B C
disruption in an aqueous environment through precipitation of salts and Sealers (Fig. 8.193) can be divided into a number of main groups based
facilitate regeneration of apical tissues through release of growth factors. on their constituents:
Figure 8.192 shows an example of an experimental material that forms a
precipitate at the interface in an aqueous environment that enables a seal • zinc-oxide/eugenol materials (Roths, Pulp canal sealer, Wachs,
Tubliseal, Procosol)
without a conventional sealer that is better than conventional gutta-percha
and sealer (Alani et al., 2009). • calcium hydroxide-containing materials (Sealapex, Apexit, CRCS)
• glass ionomer (Ketac-Endo)
Sealers • resins (AH-26, AH Plus, Diaket, Lee Endo-Fill)
A root-canal sealer is radiopaque luting agent used, usually in combination • flexible polymers (Epiphany)
with a solid or semisolid core material, to fill voids and to seal root canals • bioceramic (Smartpaste).
during obturation. All current obturation techniques require the use of a As with all obturating materials, the ideal sealer should be biocompat-
sealer to fill minor discrepancies and voids in the obturation and to improve ible, adhere to canal walls, be radiopaque, impermeable to tissue fluids,
the seal between the core material and the walls of the canal. Sealers also dimensionally stable, antiseptic, not discolour the tooth, and be easily
act as a lubricant during gutta-percha placement and reduce leakage. manipulated.
226 NON-SURGICAL ROOT-CANAL TREATMENT
A B
Fig. 8.193 A variety of sealers currently used in endodontics Fig. 8.194 (a) SEM of smear layer formed during instrumentation of a canal
(×600); (b) SEM of canal wall following irrigation with 5.25% sodium
hypochlorite and 17% ethylenediaminetetraacetic acid showing exposure of
the dentinal tubules (×600)
A B C
OBTURATION TECHNIQUES smear layer should be removed or not. On the one hand, removal will
eliminate the bacteria contained within it and will expose the dentinal
Gutta-percha is available in many forms for use in combination with a tubules allowing closer adaptation of the obturating material. Sealer and
variety of obturating techniques. These include: gutta-percha have been shown to flow into the tubules and bonding agents
• lateral compaction can form tags in the dentine. On the other hand, opening the tubules may
• warm vertical compaction provide a passage for microorganisms into the body of the dentine wall
• thermocompaction and hybrid technique (Fig. 8.194b). The use of EDTA irrigation provides the surface with a
• thermoplasticized gutta-percha supported on a solid core negative energy that facilitates better adaptation of the root-filling
• injectable thermoplasticized gutta-percha. material.
Comparisons have been made between the different gutta-percha obtu- Dry canal
rating techniques but, despite a large body of research papers, there is no
definite evidence to support one technique in favour of another from the Moisture in the canal or in the dentine will preclude effective obturation
perspective of clinical success. Historically, lateral compaction has been but complete drying and dehydration are impossible. Some clinicians
used as a “gold-standard” to evaluate new obturating techniques; lateral prefer to use alcohol to dehydrate the surface but the benefit of this is
compaction remains the most widely taught and practised technique world- unknown. The crucial area that is difficult to dry predictably is the apical
wide. The term “compaction” is used throughout this chapter and is con- anatomy and the best attempt possible remains with paper points.
sidered more accurate than “condensation” as examination of the physical
properties of gutta-percha demonstrates that the material cannot be Controlled apical placement
condensed. This is the single most important part of obturation. Given the variability
in the anatomy of apical canal systems, and the cross-sections of apical
PRINCIPLES OF OBTURATION termini (Fig. 8.195), cone-fit is unlikely to be sufficient to effect a primary
seal. Furthermore, apical resorption or iatrogenic alterations to the apical
Preparation of canal surface
anatomy present additional challenges. It may be necessary to create an
The smear layer is a surface accumulation of debris formed on dentine apical matrix or barrier in order to prevent extrusion of the obturating
during instrumentation (Fig. 8.194a). It is composed of organic and inor- material. The matrix may be calcium hydroxide, ProRoot MTA (mineral
ganic components and forms both a superficial, loosely adherent, layer and trioxide aggregate) (Fig. 8.196) or collagen (Fig. 8.197), which can be
a deeper, tightly adherent, layer. There is some debate as to whether the placed to the established working length. The obturating material can then
NON-SURGICAL ROOT-CANAL TREATMENT 227
B C D
A B C
be packed against this matrix. An alternative is to allow healing with point is then placed into the canal noting its orientation with a mark; the
longer-term calcium hydroxide dressing prior to obturation. point is then firmly pushed to the WL; if it does not immediately sit to
A better and easier option which should be adopted routinely in every WL, a pumping motion is used progressively to seat it with continual
case, is the customization of the master gutta-percha cone, regardless of pumping. The tip should be examined to reveal the impression of the apical
the technique (Fig. 8.198). It consists of selecting a master point at least anatomy (Fig. 8.198b); this will give insight about the challenge that lies
two sizes larger than the apical preparation and should bind about 2 mm ahead. The point is left on the instrument tray to dry out. The orientation
from WL. The tip of the point (length by which it binds short of the WL) mark is crucial for reseating accurately with the sealer. Large canals can
is dipped into chloroform for 1 second only (Fig. 8.198a); the purpose is also be obturated with custom rolled gutta-percha cones, which may also
to soften the outer aspect, retaining the rigidity of the core. In a regularly be further customized by chloroform dipping (Fig. 8.199).
tapered canal, a significant length of the apical canal could be custom Apical control of root filling material also includes the placement of the
fitted. If the canal is wider and more of the outer aspect of the gutta-percha sealer, which being fluid, is obviously difficult to control. The control is
is to be softened, the point is dipped for slightly longer. The softened therefore a function of adequate viscosity, quantity and how it is delivered.
228 NON-SURGICAL ROOT-CANAL TREATMENT
Coronal seal
Once the root filling has been placed, the coronal part should be neatly
finished and a subseal placed to protect it, preferably using an antibacterial
material, such as zinc oxide/eugenol. A semi-permanent plastic material
(amalgam, GIC, composite resin) should be used to cover this subseal.
LATERAL COMPACTION
There is no compaction technique that is exclusively lateral or vertical in deform and flow under pressure (Fig. 8.204b). Following removal of the
nature. All techniques will have both vertical and lateral components. The spreader, the first accessory cone with a light coating of sealer is placed
specifically named “lateral compaction” technique involves placing tapered and compacted into place. This process is repeated until the canal is filled
gutta-percha cones in the canal and compacting them under pressure (Figs 8.204c, 8.207). The selection of the taper (of gutta-percha and
against the walls of the canal with a metal spreader (Fig. 8.202). The first matched spreader) depends on the taper of the canal at any given segmental
gutta-percha cone, called the “master cone or point”, is ISO standardized level in the canal to maximize efficiency (Fig. 8.208). It is recommended
so that it matches ISO files sizes (Fig. 8.203) and should be chosen to that finger spreaders be used as hand spreaders very easily generate forces
customize to the apical preparation size. Ideally, the customized master that may fracture roots (Fig. 8.209).
cone (as previously described) should fit accurately in the apical few mil- It is important that the spreader reaches at least to within 1 mm of the
limetres at the predetermined length (Fig. 8.204a). The customized point working length in order to ensure adequate compaction of the gutta-percha
should not be easily forced beyond the final preparation point and may against the canal walls. In addition, a regularly tapered canal contributes
demonstrate a slight resistance to removal called “tug-back”. The concept to adequate obturation (Fig. 8.210). Gutta-percha may, under the right
of apical “tug-back” has been widely cited as a requirement for a well- circumstances of matching tapers of gutta-percha, spreader and canal, be
fitting master cone and should be valid as long as the taper of the point is compacted into lateral canals (Fig. 8.211). Teeth, such as premolars and
smaller than that of the prepared canal. canines that are wide in the labiopalatal dimension will not be so well
Once master point selection and customization is complete, the canal is filled without the aid of heat (Fig. 8.212). Apical canal morphology also
dried for sealer and master point placement. Subsequent gutta-percha influences the management of the initial phase of the procedure. When two
cones are called “accessory cones”, are non-standardized in taper and canals join in the apical part, it is best to customize master points in each
match spreader tapers (Fig. 8.205). The metal spreaders can be either finger simultaneously to prevent occlusion of the unfilled canal with sealer (Fig.
or hand manipulated and are preselected by placing in the canal to reach 8.213). Accessory points are then placed alternately in each canal. If a
WL freely (Fig. 8.206) before the master cone is compacted. The spreader single canal divides into two, one canal should be obturated first up to the
should be left in place for a few seconds to allow the gutta-percha time to division and then the second (Fig. 8.214).
NON-SURGICAL ROOT-CANAL TREATMENT 229
A
C
Fig. 8.209 Root end crack produced by Fig. 8.210 Quality of properly compacted
cold lateral compaction of gutta-percha gutta-percha removed from well-tapered canal
Fig. 8.213 Obturation of Fig. 8.214 Obturation of canal that divides apically Fig. 8.215 Touch ‘n’ Heat (Analytic Technology)
canals that join apically
A B C D
Fig. 8.216 (a,b) Ultrasonic lateral compaction of gutta-percha in an extracted tooth model; (c,d) filling of accessory anatomy using ultrasonic lateral compaction
of gutta-percha (c) before; (d) after (arrowed)
NON-SURGICAL ROOT-CANAL TREATMENT 231
B C
Fig. 8.219 (a) Warm vertical compaction; (b) plugger should capture
Lateral compaction is by far the best technique for controlling apical maximum cross-sectional area of gutta-percha without apical binding;
placement of root filing material and should form the basis of any hybrid- (c) plugger binding apically may split root; (d) small plugger is ineffective
ized technique.
HC
HC
HC
A B C D E F
HC HC
B
A
G H I J K L
Fig. 8.220 Procedure for warm vertical compaction: (a) fitting master point; (b) application of heat carrier (HC); (c) plugging heated gutta-percha;
(d) reapplication of heat carrier (HC); (e) reapplication of plugger; (f) reapplication of heat carrier (HC); (g) reapplication of plugger; (h) addition of new section
of gutta-percha (3–4 mm); (i) application of heat carrier (HC); (j) reapplication of plugger; (k) reapplication of heat carrier (HC) to new section of gutta-percha;
(l) reapplication of plugger
A B C
Fig. 8.221 (a–c) Radiograph of case obturated with the warm vertical compaction technique
NON-SURGICAL ROOT-CANAL TREATMENT 233
Fig. 8.222 Electrically-operated heat carriers Fig. 8.224 Injection delivery systems for thermoplasticized gutta-percha
Fig. 8.223 Buchanan some of which combine the heat carrier and injection functions
system B pluggers (Fig. 8.224).
B A B
Fig. 8.225 (a) Disposable silver needles for Fig. 8.226 (a) Fracture of cannule due to haste
Obtura; (b) prefilled gutta-percha cannules for or inadequate heating; (b) extrusion of Fig. 8.228 If carrier is too small it
Ultrafil gutta-percha through the back of cannule may be extruded
thermoplasticized α-phase gutta-percha. This concept is widely marketed control of the flow of the thermoplasticized material is difficult and con-
as the Thermafil system (Fig. 8.227). The original commercially available stitutes a potential disadvantage of these techniques. In addition, a section
metal carrier has now been replaced with a radiopaque plastic carrier and of the core carrier obturators, such as Thermafil (Dentsply) or Softcore
is available in a series of ISO sizes from #20 to #140, as well as non-ISO (SybronEndo) needs to be removed if the tooth has been treatment planned
ProTaper shapes. Verifiers made of fluted tapered NiTi wire are used to for a post-retained restoration. Smooth round-ended burs specifically
gauge and select the appropriate size for a given canal. If the selected designed to aid removal of the plastic core have been designed by the
carrier is too small the carrier may be extruded (Fig. 8.228) and if it is too manufacturer (Fig. 8.230).
large the root-canal filling may be short. The carriers must be heated in A number of cone systems are also available on the market, including
a special oven at 115°C according to the manufacturer’s instructions. a core carrier system called SimpliFill (SybronEndo), which has been
Maximum and minimum times should be observed in order to ensure designed to overcome the problem of providing post space following
adequate heating. However, if left in the oven longer than the designated obturation (Fig. 8.231). In this technique, 5-mm plugs of gutta-percha are
time, the obturators must be discarded. A very small amount of slow- carried to the apical portion of the preparation and sealed in place with an
setting sealer is applied to the walls and the heated carriers are then placed endodontic sealer (AH Plus Epoxy Resin is recommended by the manu-
firmly and smoothly to full length in the canal. The length can be deter- facturer). The carrier can then be removed leaving the apical 5 mm of
mined in advance using the rubber stoppers on the carriers. In teeth with gutta-percha behind. The plugs are supplied in ISO sizes 35–130.
multiple canals, excess gutta-percha from the first carrier can be prevented
from blocking the orifices to the other canals by placing a temporary
obstruction, such as damp cotton pellet or paper points into these
THERMOMECHANICAL COMPACTION TECHNIQUE
orifices. Thermomechanical compaction describes the plasticization of gutta-percha
As with other thermoplasticized techniques, it is important to compen- by heat developed through mechanical friction. A well-adapted master
sate for the volumetric shrinkage that occurs when the gutta-percha cools cone is placed in the canal with a suitable sealer. A mechanically activated
by maintaining apical pressure on the cooling material. This is done by rotating compactor similar to a reverse Hedstroem file (thermocompactor)
compacting the gutta-percha around the central carrier in an apical direc- (Fig. 8.232) is introduced into the canal, which heats up the gutta-percha
tion as it cools. and thermoplasticizes it (Fig. 8.233). Accessory points may be added prior
Thermoplasticized gutta-percha has been shown to obturate the canal to commencing compaction if necessary. Disadvantages of the thermo-
system effectively and to flow very well into accessory anatomical spaces compaction technique include apical extrusion of obturation material (Fig.
(Fig. 8.229). The apical seal provided by these techniques has also proven 8.234), as is common with all thermoplasticized techniques, gouging of
to be as effective as any other obturation technique. However, apical the wall by the compactor (Fig. 8.235), excessive heating of the supporting
NON-SURGICAL ROOT-CANAL TREATMENT 235
tissues surrounding the root resulting in resorption (Fig. 8.236) and frac- Master cone customization provides the best apical control in conjunc-
ture of the instrument. tion with cold compaction, although if a sufficient length of the apical cone
(2–3 mm) is properly customized, cold compaction is not necessary. Cold
HYBRID TECHNIQUE compaction helps ensure that the apical part is properly compacted in a
safe and controlled way. This can be followed by a warm vertical approach
Each technique offers its own characteristic advantages and disadvantages. to seal the apically placed gutta-percha, which would then allow any
There is therefore considerable merit in devising hybrid techniques that rapid thermoplasticized technique to backfill with intermittent vertical
combine the best of all techniques for simple, safe, effective efficiency. compaction.
CORONAL SEAL
POST-PREPARATION/RESTORATIVE
CONSIDERATIONS
It is absolutely essential that an adequate coronal restoration be placed
following obturation of the root-canal system (see Fig. 8.182). It has been
shown that the coronal restoration is as important as root-canal obturation.
Placement of a permanent core restoration at this time would appear to be
a sensible approach to the overall management of the case. Following
obturation of the root-canal system, the tooth will never be “cleaner” as it
A B
Fig. 8.229 (a–c) Roots rendered transparent by clearing show good filling of Fig. 8.230 Post-space preparation when using Thermafil plastic carrier
accessory anatomy using Thermafil obturators; (d) molars filled with Thermafil obturators
obturators
A Fig. 8.231 (a) The SimpliFil carrier from Lightspeed Endodontics, TX, USA; (b) SimpliFil obturators (Lightspeed
Endodontics, TX, USA); (c) a SimpliFil obturator
236 NON-SURGICAL ROOT-CANAL TREATMENT
A B C D
Fig. 8.235 Gouging of canal walls in mandibular Fig. 8.236 (a) Normal periodontium; (b,c) various degrees of resorption seen on the root surface
first molar during thermocompaction (arrowed) following thermocompaction; (d) ankylosis (courtesy of Dr E Saunders)
has been soaking in sodium hypochlorite throughout the preparation stage FURTHER READING
and the rubber dam remains in place. In addition, placing the core at this European Society of Endodontology, 2006. Quality guidelines for endodontic treatment:
appointment negates the need to place a temporary restoration and reduces consensus report of the European Society of Endodontology. Int Endod J 39 (12),
921–930.
the number of dental appointments for the patient. Gordon, M.P.J., Chandler, N.P., 2004. Electronic apex locators. Int Endod J 37,
If a post space is required the root canal system should always be com- 425–437.
pletely filled and then cut back. The space created may be filled with a Gulabivala, K., Ng, Y.-L., Gilbertson, M., et al., 2010. The fluid mechanics of root canal
irrigation. Physiological measurement 31, R49–R84. http://stacks.iop.org/0967-
calcium hydroxide paste between visits in an attempt to reduce the chance 3334/31/R49.
of bacterial recontamination.
9
Section 3 Delivery of endodontic treatment
Management of non-surgical root-canal treatment failure
Y-L Ng, K Gulabivala
The aim of this chapter is to outline the technical and clinical basis for iii judgement about prognosis of different options in their hands: the
non-surgical or surgical management of root-canal treatment failure. The dentist will need to be sure that the tooth is predictably restorable
foundational knowledge and principles for this chapter were laid previ- and a viable future unit, as well as determine how each treatment
ously as follows: option could be executed together with a realistic prognosis
iv judgement about prognosis in the hands of specialist(s): if the
• the rationale for retreatment was established in Chapter 3 dentist is unsure about the prognosis in their hands, they should
• the decision-making process and planning for retreatment were offer referral to a specialist who may be able to provide the
discussed in Chapter 5 complex care with a better prognosis
• non-surgical and surgical retreatment armamentaria were described v cost of different options: the dentist will need first to visualise
in Chapter 6 the procedures virtually, in the mind’s eye, to assess the
• the general principles of non-surgical root-canal treatment were practical process, resource and time required. The better versed
discussed in Chapter 8. and experienced they are the more precise their estimation.
2 Patient factors:
i understand what is wrong with the tooth
DIAGNOSIS OF NON-SURGICAL ROOT-CANAL ii understand what can realistically be done and what their
TREATMENT FAILURE preference may be
iii understand the chances of success depending upon what is
Non-surgical root-canal treatment failure is diagnosed based on the fol-
done and who does it
lowing clinical and radiographic criteria (Fig. 9.1):
iv understand the relative costs, what is desirable and what is
• presence of clinical signs (swelling, sinus, tenderness to pressure affordable.
or percussion) and/or symptoms (pain of endodontic origin) The dentist must ensure that the patient understands the nature of the
• enlargement of existing periradicular radiolucent lesion associated problem, the chances of resolving it and the means to be deployed to do
with the tooth so. They must be clear about the dentist’s expertise to perform the tasks
• development of new periradicular radiolucent lesion associated and what other options may be available to them should they wish to take
with the tooth them. An interactive process will need to have been followed and the final
• persistence of periradicular radiolucent lesion associated with a decision preferably recorded in a mutually signed agreement. There may
tooth that had root-canal treatment at least 4 years previously. be uncertainties at play in the process and these must be clearly recorded,
for example, it may not be certain without exploration whether a crack is
It is of the utmost importance to distinguish persistent pain of endodon-
present, which may affect the direction of the decision-making pathway.
tic origin from chronic non-odontogenic, neuropathic or neuromuscular
Under these circumstances, which are common, the treatment plan
pain by adopting the assessment approaches described in Chapters 4 and
pathway may be written as being subject to conditions being met upon
16. The two-dimensional limitations of conventional periapical radiogra-
exploration.
phy may be overcome by three-dimensional cone-beam-computerized
tomography (CBCT) to increase sensitivity, if necessary, for confirmation
of the periapical status of root-treated teeth exhibiting no obvious periapi- NON-SURGICAL ROOT-CANAL RETREATMENT
cal radiolucency but associated with persistent pain (Fig. 9.2).
INDICATIONS FOR NON-SURGICAL
ROOT-CANAL RETREATMENT
DECISION-MAKING PROCESS
Non-surgical root-canal retreatment is indicated under the following three
Once failure of non-surgical root-canal treatment has been diagnosed, a circumstances:
number of important decisions need to be made between the dentist and
1 when, having confirmed treatment failure, it is judged that the
patient. A critical choice must be made between electing to retreat the
residual infection is principally intraradicular and that it is
root-canal system non-surgically, perform surgical management or select-
accessible through a conventional access, having negotiated any
ing extraction with or without a replacement prosthetic unit. The aspects
obstructions. It is self-evident that this decision presupposes that
influencing the final decision will include:
obstructions can be removed or bypassed without compromising
1 Clinician factors: the remaining tooth structure; the purpose is to treat the residual
i judgement about what is wrong with the tooth: factors to infection
decide on will include the presence of a crack, and whether 2 when a new and complex restoration is required for a tooth with a
the infection is likely to be intraradicular or extraradicular or technically poor root filling (Fig. 9.3) but which exhibits no
whether some other pathosis is at play evidence of pathoses or symptoms; the purpose is to correct the
ii judgement about treatment options and the correct choice: technical quality of the root-canal treatment, as the ownership will
factors to decide on will include whether the dentist can lie with the restoring dentist
improve upon previous root-canal treatment and, if so, in what 3 when it is suspected that a tooth with an adequate or inadequate
way; non-surgical retreatment may involve removal of root filling has been contaminated due to leakage or loss of its
restorations, retention aids, root-filling material and correcting restoration (Fig. 9.4); the purpose is to decontaminate the root-
iatrogenic problems canal system and place a new root filling and restoration.
A
C
E F
Fig. 9.1 (a–f) Root-canal treatment failure diagnosed based on clinical and radiographic criteria
A B
Fig. 9.2 (a) Periapical radiograph, and (b) proximal view captured from
cone-beam CT scan of the root treated maxillary lateral incisor associated with
persistent pain with no obvious periapical radiolucency
MANAGEMENT OF NON-SURGICAL ROOT-CANAL TREATMENT FAILURE 239
Fig. 9.5 Loupes Fig. 9.6 Microscope Fig. 9.7 Leaking crown beneath buccal margin
PRINCIPLES OF ROOT-CANAL RETREATMENT the tooth and creating new iatrogenic problems. It is critical to use some
form of magnification when required; for example, for creating a trough
The principles of root-canal retreatment are identical to those for de novo of dentine around a post or fractured instrument requires good magnifica-
root-canal treatment, with the exception of certain additional conditions: tion (Figs 9.5, 9.6), good lighting, and a steady hand. Longer appointments
1 the resident infection is likely to have been altered through are required for retreatment cases, in particular for removal of foreign
artificial selection to one with a reduced diversity, dominated by material from root canals.
Gram-positive bacteria, and a microbiota that is more difficult to
eradicate
Removal of coronal restorations
2 access to the residual infection may be compromised by the All coronal restorations should be removed prior to treatment if they are
presence of various types of obstructions, including dentine debris, either leaking or if caries is present (Figs 9.7, 9.8). This also applies to
iatrogenic errors in preparation, root-filling material, radicular full coverage crowns. If the restoration is sound it is better to leave it in
dowel and restorative material place during treatment and access the pulp chamber through the restora-
3 the tactile feel of the natural canal will have been altered through tion. It is easier to place a rubber dam and to keep the operating field dry
changes in shape, packed organic/inorganic debris, iatrogenic by cutting through an existing restoration (Figs 9.9, 9.10).
conditions, chemical treatment, impacted foreign materials. It is difficult, or impossible, to remove a crown that is seated on a near
parallel preparation and is well fitting without damaging it beyond repair.
The specific principles of root-canal retreatment are therefore to:
It is always well worth trying to ease off a crown by inserting a large
1 remove all restorative material as atraumatically as possible, where excavator under the margin and lightly twisting as it may be loose. As a
possible sacrificing restorative material rather than tooth structure; rule, the safest way to remove a cast restoration is to cut it off to prevent
the exception will be when a new and sound restoration has damage to underlying tooth structure.
recently been placed and can be excluded as part of the aetiology
2 assess the restorability of the tooth and, if deemed so (see Removal of bridges
Chapter 14), stabilize it for root-canal retreatment to prevent Any bridge that has become decemented must be removed. In most cases,
recontamination during treatment when an abutment tooth requires retreatment, the patient should be fore-
3 remove all root-filling material without sacrificing any additional warned of the possible need for a new bridge. If a new bridge is already
dentine, if possible; the exception will be only if the canals were planned then it is immaterial if it is damaged during its removal, providing
previously inadequately prepared but, even under those an adequate temporary bridge can be constructed and placed. The easiest
circumstances, avoid instrumenting dentine at this stage; it will be method for removing a bridge is to make a vertical cut through the retainer
easier to determine iatrogenic errors as belonging to the previous on the buccal aspect and then to break the cement lute with an instrument,
procedure such as a Mitchell’s trimmer by inserting it into the cut and twisting the
4 gauge the canal to understand its previous shaping and identify any blade. There are, however, many devices (see Fig. 6.17) which can be used
missed anatomy or root canals once all root-filling material has to remove bridges – most of them causing both the operator and patient
been removed and apical patency and length of canal have been varying degrees of aggravation.
determined
5 refine and modify the shape of the root-canal system as necessary Removal of posts
to deliver irrigant and root-filling material to the termini; the skills
There are many different systems and gadgets on the market specifically
of gauging come into their own in such cases
made for the removal of posts (see Fig. 6.18). The success and ease of
6 complete root-canal treatment at this stage as if it were a de novo
removal depends on the type, length, quality of fit of the posts and the
case; except if elements of obstruction could not be corrected.
cement material. Posts can be broadly classified into prefabricated or
The most common error in non-surgical root-canal retreatment is custom laboratory-made cast metal posts. Prefabricated posts include
removal of excessive dentine with the consequence of further weakening screw or cemented wrought gold, stainless steel or titanium metal posts,
240 MANAGEMENT OF NON-SURGICAL ROOT-CANAL TREATMENT FAILURE
Fig. 9.8 Poor marginal adaptation Fig. 9.9 Access through restoration with no caries Fig. 9.10 Access through well-fitting
on distal aspect of crown with signs crown
of leakage
A B
C
B
A Fig. 9.12 (a) Post fractured at canal orifice; (b) troughing cut around post with ultrasonic file; (c) loosened
post removed with fine-beaked forceps (predictble restorability may be questionable)
zirconia ceramic posts, or carbon or glass (quartz) fibre posts. Ceramic and
fibre posts are likely to be used with aesthetic ceramic crowns and have a Fig. 9.13 Post being removed using
the Ruddle post extractor
lower radiodensity than stainless steel or gold posts.
For metal posts, first attempts at removal are usually made by use of
ultrasonic vibration. The crown is first removed by cutting a vertical slot
to allow leverage and expansion of the margins. Excess cement is then
taken away. A solid curved tip is inserted in the ultrasonic hand-piece and
applied gently around the incisal edge of the core under water coolant (Fig.
9.11). The power is varied while the ultrasonic tip is in contact with the
core to achieve the desired effect. When the right power setting is reached,
cement particles may be observed vibrating at the base of the core. If this
does not loosen the post after a few minutes, a fine tip can be used to cut
a narrow trough around the post to reduce the retention (Fig. 9.12a,b). The
first step is then repeated with the blunt tip. This procedure will remove
the majority of posts (Fig. 9.12c). In the case of an excessively long, non-
threaded post, when ultrasonic vibration is not successful, one of the post-
extracting devices may have to be used (Fig. 9.13).
Ceramic posts are likely to be cemented with resin- or glass ionomer-
based cements. Well-fitting ceramic posts with resin cement are extremely
MANAGEMENT OF NON-SURGICAL ROOT-CANAL TREATMENT FAILURE 241
A B
Fig. 9.14 (a) D.T. Light post removal kit; (b) the fibre post in the palatal canal
of the maxillary right first molar was successfully removed
D E F G
Fig. 9.16 (a) Gutta-percha in distal canal; (b) orifice opener removing gutta-percha with hand-piece – speed at 700 rpm; (c) set hand-piece speed at 700 rpm
for gutta-percha removal; (d) apical portion of gutta-percha removed with Hedstroem file; (e) chloroform placed in canal entrance using a syringe; (f) file placed
in canal to mix chloroform and gutta-percha then wicked with paper points; (g) remaining gutta-percha dissolved in chloroform and wicked with paper points
difficult to remove. Fibre posts are much easier to remove than metal, they with a high-speed bur and hand excavators. A GP root filling that has been in
can be disintegrated by applying ultrasonic tips, Piezo or Gates–Glidden place for many years tends to become vulcanized and can be brittle and hard,
drills, a small stainless steel rosehead bur or specially designed drills (DT making it more difficult to remove. Ultrasonic tips, nickel–titanium orifice
Light-post removal kit, Bisco, Inc., Schaumburg, IL, USA) into the centre openers, Hedstroem files and chloroform are useful for removing gutta-percha
of the post (Fig. 9.14). (Fig. 9.15). There are three stages to the procedure:
1 A simple way to remove the coronal bulk of the GP is to use a
Removing gutta-percha narrow ultrasonic fine scaler tip or a nickel–titanium rotary
Poorly condensed gutta-percha root fillings in teeth requiring retreatment instrument (Fig. 9.16a–c)
can be easily removed by threading Hedstroem files into existing spaces 2 Most of the remaining bulk of the GP can be removed with
to engage the gutta-percha, which may then be pulled out with the file. Hedstroem files (Fig. 9.16d). The largest file that will not bind to
Well-condensed gutta-percha is a different prospect and requires creation the canal wall is placed in the canal and rotated by hand to engage
of space to insert Hedstroem files to engage the bulk of the material. Space the GP only. The depth of penetration required can be judged
creation is achieved by softening the gutta-percha using heat or solvent from the preoperative radiograph but mostly by tactile feel
and inserting the relevant file or instrument. 3 The final stage consists of “wicking” with paper points, once the
The first stage of removing well-condensed gutta-percha (GP) involves bulk of the gutta-percha has already been removed. The canal is
gaining access to the pulp chamber and clearing it. This may be accomplished flooded with chloroform from a disposable dispenser (Fig. 9.16e)
242 MANAGEMENT OF NON-SURGICAL ROOT-CANAL TREATMENT FAILURE
to dissolve remaining tags of gutta-percha adhering to the canal been cleaned out; a size 08 or 10 stainless steel file with a sharp precurve
walls. The chloroform should not overflow the pulp chamber at the tip may be used to explore for the canal opening. Once found it is
otherwise the rubber dam may be dissolved. The chloroform is threaded in and is worked gently to file away the ledge (Fig. 9.18).
then stirred using a small hand file to ensure the solution dissolves
the GP completely (Fig. 9.16f). The largest paper points that fit Packed dentine debris
into the canal are then selected and used to soak up the dissolved
The aetiogenesis of a ledge is usually preceded by blockage of the canal by
mass. Wicking is achieved by inserting several points one after the
dentine debris (Fig. 9.19a). The first challenge is to detect and diagnose the
other into the canal (Fig. 9.16g). The process is repeated until no
presence of blockage by dentine debris, which can only be achieved by tactile
further pink discoloration is discerned on the paper points. The
sense. There is no easy method for unpicking the debris blockage except by
canal is then thoroughly washed with irrigants.
the patient use of a small file in a deliberate, controlled but firm picking
motion. This is facilitated by chemical dissolution with EDTA for the inor-
Removing gutta-percha with a central core (Thermafil®) ganic component and sodium hypochlorite for the organic component; the two
As before, the gutta-percha is likely to fill the space well, therefore, there should be used alternately in copious amounts and delivered by agitation with
will be a need to create some space first using the techniques already a file or if necessary with a well-fitting gutta-percha point. Should these meas-
described. The initial goal is to remove the plastic core, using a nickel– ures fail, it may be worth trying a small precurved ultrasonically energized
titanium rotary instrument, or by braiding with Hedstroem files. The file to loosen the debris (Fig. 9.19b–d). The danger is that when the debris is
nickel–titanium instruments are run at 600–700 rpm. The size selected is packed very tightly it may be as hard as the surrounding dentine and attempts
small enough to allow the tip to engage the GP between the core and the to remove it may result in a false canal leading to a perforation.
canal wall. Once the core is removed, the residual GP may be removed by
Sclerosed canals
using the previously described Hedstroem and wicking technique. The
braiding technique consists of creating space to pass two or three Hed- Sometimes teeth requiring retreatment may have untreated canal systems
stroem files alongside the carrier distributed around its circumference. or only partially treated systems, not because of iatrogenic blockage but
Once these are in place, they are twisted around each other, the so-called because of pre-existing natural canal sclerosis that the previous operator
“braiding” and then used to pull the carrier out. It is worth noting how failed to negotiate. Natural canal sclerosis has varied aetiogenesis, including
long ago the original obturation was performed as the latest Thermafil® in elderly teeth, those that have been traumatized, had multiple large restora-
carriers have a longitudinal slot to facilitate removal during retreatment, tions or chronic marginal periodontitis. The calcification takes the form of:
while the original Thermafil® had metal carriers.
1 additional, irregular tertiary dentine, which makes the canal
narrower and the surface more irregular but retains the canal
Removing cement material
pathway for instrument negotiation
Different types of cement may be found in previously treated canals. They
Fig. 9.17 Short root filling in curved
may be zinc oxide eugenol, resin or formaldehyde resin (N2, Russian Red canal suggesting ledge present
cement) -based materials. Specific solvents, including Endosolv E and (arrowed)
Endosolv R (Septodont, Cedex, France) are available for the former two
types of cements, respectively. There is no solvent for N2 and Russian Red
cements, attempts to remove them using small long shank round bur or
ultrasonic tip may result in a false canal leading to a perforation.
Negotiating a ledge
When the previous root filling is short of the apex, there may either be a
ledge or debris packed into the canal. It may be possible to detect a ledge
radiographically if the angle is favourable (Fig. 9.17). Deviation of the
apical extent of the root filling from the centre may be suggestive of a
ledge. Ledges may be negotiated once the coronal portion of the canal has
Fig. 9.19 (a) Plastic block ledged and packed with debris;
(b) size 15 ultrasonic file used in wet canal to dislodge
debris; (c) size 10 K-file with curve at the tip bypasses the
ledge; (d) canal preparation completed using hand
instruments
B
C D
A
A B C D
Fig. 9.20 (a) Patient referred as canal could not be located (arrowed); (b) increasing resolution of radiograph showing canal is patent (arrowed); (c) canal located
and negotiated as described in text; (d) canal preparation completed and obturated
A B C
Fig. 9.23 Fractured instrument in Fig. 9.24 (a–c) Separated instrument extruded into the apical tissue during attempts to remove it
apical portion – difficult to remove
A B
Fig. 9.25 (a) Fractured instrument embedded during retrograde amalgam placement in the 12; (b) Cancellier tube fitted
D over the exposed instrument; (c) Cancellier tube tapped out with artery forceps; (d) fractured instrument successfully
removed; (e) Hedstroem file securely glued in Cancellier tube; (f) canal prepared and obturated
necessary to remove the metallic object but simply to obturate the canal fractured instrument making it more difficult to remove. Avoiding the
so that the object is embedded within the filling material. However, care silver point or nickel–titanium instrument with the ultrasonic tip requires
should be taken not to push the bypassed material, which may have been excellent vision and good magnification, as well as a steady hand.
detached from the canal wall/niche, into the apical tissue and compromise Class 3 lies beyond a curve in the canal. The majority of these metallic
periapical healing (Fig. 9.24). objects cannot be removed without excessive removal of dentine and risk
If the object cannot be bypassed, a narrow trough is cut around the of canal perforation. An attempt is made to bypass the fragment using a
embedded object with an ultrasonic tip. When the coronal 2.0 mm is fine stainless steel file with a lubricant. A small curve is placed at the tip
exposed, it can be removed using an extractor or specifically designed of the instrument to help locate a passage past the object. Canals are not
instrument removal system (Fig. 9.25). round and, therefore, there should be a gap between the metal and the wall
Great care has to be taken when ultrasound is used to remove a silver of the canal. Alternatively, it may sometimes be possible to thread an
point or nickel–titanium instrument. Silver is soft and the ultrasonic tip, instrument into a spiral flute if it is large enough and not engaged into
rather than cutting a trough around the point will cut into it; in the case of dentine. Once the instrument can be bypassed, larger instruments are used
nickel–titanium, the ultrasonic tip will shatter small pieces from the until the canal is prepared to the desired shape (Fig. 9.26).
MANAGEMENT OF NON-SURGICAL ROOT-CANAL TREATMENT FAILURE 245
A B C
Fig. 9.26 (a) Fractured instrument lies beyond a curve in the canal; (b) fractured instrument bypassed using hand instruments and then dislodged with ultrasonic
15 K-file; (c) canal prepared and obturated
A B
Fig. 9.28 (a,b) ProRoot® material (MTA) both original grey and the white material
(Dentsply, Tulsa); (b) MTA and sterile water mixed; (c) MTA placed on floor of pulp
chamber to seal perforation
was subsequently replaced with MTA prior to root filling. In some cases,
Perforations
an iatrogenic perforation located in the apical third of the canal can be
Perforations may occur due to internal/external resorption or operator treated as a separate canal and obturated with gutta-percha.
error. The success of a repair will depend on the site and size of the per- Surgical repair of a perforation is indicated when access through the
foration, and the risk or degree of contamination. Those perforations canal is impossible.
enclosed within bone housing may be associated with a favourable outcome
if the infection is controlled (Fig. 9.27); one that communicates with the
SURGICAL ROOT-CANAL RETREATMENT
oral cavity may be repaired as a normal tooth cavity with an unusual
morphology. The perforation should be repaired as soon as possible to
INDICATIONS AND CLASSIFICATION OF ENDODONTIC
prevent ongoing contamination. Many different materials have been rec-
SURGICAL PROCEDURES
ommended for repair of perforations, including zinc oxide/eugenol-based
cements, such as IRM® and EBA®, selected for their antibacterial proper- Dentistry, in its broader sense is considered a surgical discipline, so it is
ties. The contemporary material of choice for enclosed perforations is useful to define the context of the term endodontic surgery. Endodontic
mineral trioxide aggregate (MTA) (Fig. 9.28) because of its biocompatibil- surgery refers to direct access to the periradicular tissues through incision
ity and osteogenic properties. Its long setting time and, therefore, tendency of the overlying mucogingival complex. Historically, numerous reasons
to be washed away in the presence of saliva, renders it inappropriate for were cited as indications for surgical root-canal treatment. Advances
perforations exposed to the oral cavity. Under such circumstances, the in understanding and knowledge of endodontic biology have crystallized
material of choice is glass ionomer cement (GIC). Figures 9.27 and 9.29 the main indications for surgery into procedures used to resolve, through
show perforation repair using GIC as a temporary measure to allow com- direct access to the root, that which could not be achieved intraradicularly.
pletion of chemomechanical debridement of the canal system. The GIC Advances in the technical aspects of root-canal treatment and the success
246 MANAGEMENT OF NON-SURGICAL ROOT-CANAL TREATMENT FAILURE
A B D
C
Fig. 9.29 (a) Perforation visible. Endodontic probe placing glass ionomer cement (GIC) at the perimeter
of the perforation; (b) building GIC bridge without touching periodontal tissue; (c) GIC bridge completed;
(d) additional GIC placed to prevent material being pushed into periodontal tissue; (e) postoperative
radiograph
• emergency surgery
▸ incision and drainage
▸ trephination
• biopsy
• periapical surgery for root-end management Fig. 9.30 Incision and drainage Fig. 9.31 Cellulitis is a symptomatic
• corrective surgery oedematous inflammatory process
▸ perforation repair that spreads diffusely through fascial
▸ root resection planes
▸ hemisection
• intentional replantation for root-end management or corrective
surgery Fig. 9.32 Radiograph
• regenerative procedures of a mandibular molar
• decompression. showing mishap
involving perforation of
the mesial root during a
EMERGENCY SURGERY trephination procedure.
GP cone placed in sinus
Incision and drainage tract originating at
mid-root level
This procedure consists of the creation of a surgical opening in the oral
mucosa for the purpose of releasing pus and exudate (Fig. 9.30) and is a
relatively minor procedure. However, when the swelling extends to the
tissue spaces with an extraoral component, this may result in life-
threatening situations, such as occlusion of the airway. Cellulitis (Fig.
9.31) is a symptomatic oedematous inflammatory process that spreads
diffusely through the fascial planes. This infection demands immediate drainage causing intense pain; the purpose of the procedure is to aid release
treatment with both antibiotic and analgesic medication and establishment of inflammatory exudate through perforation of the cortical plate. The
of drainage if at all possible (see Chapter 10 for further details). procedure may involve the use of trephine burs or be as simple as the
puncturing of the cortical plate with a sterile finger spreader. Mishaps can
Trephination
occur with the use of burs (Fig. 9.32) and damage to the tooth may require
This is the surgical perforation of the alveolar cortical plate to release surgical correction (Fig. 9.33). These procedures are performed when
accumulated periradicular tissue exudate. This procedure is used in cases drainage through the root canal is not possible or evident. Antibiotics are
where the absence of any obvious intra- or extraoral swelling prevents required only when there is systemic involvement.
MANAGEMENT OF NON-SURGICAL ROOT-CANAL TREATMENT FAILURE 247
Fig. 9.34 Taking an excisional biopsy Fig. 9.35 Biopsy bottle containing
for histological examination during a 10% formalin and correctly
periradicular surgical procedure completed clinical biopsy request
form
BIOPSY
As a preliminary procedure for all periapical surgery, a tissue flap must
The purpose of taking a biopsy is to establish a definitive diagnosis by
be reflected. Careful and considered soft tissue management greatly
histological examination. It involves the surgical removal of a soft and/or
enhances the prognosis of the surgical procedure and improves the post-
hard tissue specimen for histological evaluation (Fig. 9.34). The value of
operative wound healing.
routine histopathological examination during endodontic surgical proce-
dures must not be underestimated. The taking of a routine biopsy during Flap design
periradicular surgical procedures has come to be accepted as the standard
of care, particularly given the reduced frequency of surgery and, therefore, The main considerations governing flap design are good access and vision,
higher chance of non-endodontic pathoses. Correct handling of the while minimizing trauma to the soft tissues during retraction. The design
removed tissue is central to the formation of an accurate histological diag- should ensure good blood supply to the flap, avoid damage to the surround-
nosis. Recovered tissue must be placed immediately in a 10% formalin ing structures and facilitate primary wound closure. The flap design should
solution and sent with complete relevant details to the pathology labora- include the tooth to be treated and, only if necessary, one or more teeth on
tory (Fig. 9.35). A biopsy request should include: either side; a balance must be struck between the risk of postoperative
gingival recession and good surgical access. It is always preferable to
• a history of the case, including patient details extend the flap further than to attempt to work in a restricted field. Factors
• a clinical description of the lesion which influence the extent of the flap include position of the mental nerve,
• a gross description of the biopsied tissue including size, location, muscle and fraenal attachments, root and bony eminences and large bony
duration, colour, texture, consistency and radiographic appearance defects. Full and limited mucoperiosteal flaps are used in endodontic
• a provisional diagnosis. surgery and differ from periodontal surgery flaps in only involving healthy
Biopsies are usually excisional or incisional. Excisional biopsy is used marginal tissue. Mucoperiosteal flaps consist of the periosteum along with
to remove the lesion in its entirety and may, therefore also be therapeutic. the overlying alveolar mucosa and gingival tissues. Flap names are desig-
An incisional biopsy is only used to establish a diagnosis and would be nated according to their shape and include triangular (Fig. 9.36), rectan-
rarely used in endodontic procedures. gular (Fig. 9.37), semilunar (Fig. 9.38), submarginal (Fig. 9.39),
papilla-base (Fig. 9.40) and palatal (Fig. 9.41). Flaps with vertical reliev-
ing incisions are less likely to produce excessive bleeding because of the
PERIAPICAL SURGERY AND orientation of the submucosal vasculature (Fig. 9.42), although this only
ROOT-END MANAGEMENT confers a slight advantage. Incision lines should always be placed so that
The periapical surgery procedure includes curettage of the lesion, root-end wound closure is on sound bone. Buccal flaps are most commonly used to
resection, root-end cavity preparation and root-end filling. gain access to the periradicular tissues; however, a palatal approach may
248 MANAGEMENT OF NON-SURGICAL ROOT-CANAL TREATMENT FAILURE
Initial shallow
incision to 1.5mm
Relieving incision line
Micro-surgical blade Fig. 9.44 Triangular mucoperiosteal
flap
Second angled
incision directed
at the crestal bone
(Fig. 9.46), where potential for recession associated with adjacent crowned
Papilla base incision
teeth is to be avoided. Rectangular and triangular flaps appear to be the
Fig. 9.40 Papilla-base flap (adapted from Velvart 2002 – Papilla base incision. most commonly taught, based on blood vessel alignment, but clinical
International Endodontic Journal, 35, 453–460) experience suggests no obvious difference in healing compared with trap-
ezoid flaps. The triangular flap has the advantage of flexibility as the flap
Fig. 9.41 Palatal flap may either be extended or converted into a rectangular one if necessary.
Incisive It is created by the use of an intrasulcular and relieving incision (Fig. 9.47).
foramen The relieving incision is started in alveolar mucosa, passes through the
attached and marginal gingivae and ends on the mesial or distal aspect of
the teeth. The gingival papillae should not be incised, this will facilitate
repositioning of the flap and prevent sloughing of the papillae. Elevation
Palatal of the flap should commence in the attached gingivae of the vertical inci-
ridges sion (Fig. 9.48). The advantages of the full flaps include provision of good
access to the root tissues (Fig. 9.49), ease of reflection and repositioning
and provision for excellent healing, usually without scarring, thereby mini-
mizing postoperative pain and swelling. The only disadvantage of these
Fig. 9.42 Vertical flaps is the possibility of postoperative gingival recession. This has been
orientation of blood shown to be minimal with the correct handling of the tissues and is more
vessels in oral mucosa likely to occur with thin marginal tissues.
B C
A B
A B C D
Fig. 9.50 (a–d) Submarginal full mucoperiosteal flaps with differently designed incision lines; NB in (c) the flap is reflected towards the crowns; (d) shows a
Leube-Ochsenbein approach
250 MANAGEMENT OF NON-SURGICAL ROOT-CANAL TREATMENT FAILURE
Incisions
A variety of incisions is used during creation of mucoperiosteal flaps.
These include:
• avoid crossing underlying bony defects Fig. 9.55 Osteotomy. Location of the root surface during periradicular surgery
• create the incision with a single firm continuous stroke usually involves removal of overlying bone unless the lesion has already
• plan the start and finish points of the incision perforated the cortical plate (see Fig. 9.57) or a natural dehiscence or
• avoid bony eminences with vertical incisions. fenestration exists
Fig. 9.56 Preoperative view showing Fig. 9.57 Perforation of the cortical
existing sinus associated with tooth plate of bone over tooth 22 by the
22 periradicular lesion
A B C D E
the cortical plate (Figs 9.56, 9.57). If the cortical plate is intact, measure- histopathological examination as sinister lesions have been identified in
ments from radiographs or from working lengths obtained during a non- the past.
surgical treatment must be used to estimate the position of the root apices.
In conjunction with copious sterile irrigation a rear-venting surgical hand- Root-end resection
piece (see Figs 9.55, 6.21) is used to remove the bone with a gentle brush- The level at which the root-end is resected and the angle of resection are
ing motion. Large round tungsten–carbide burs (Figs 9.58, 9.59) have been important considerations. The majority of the anatomical aberrations are
shown to be most suitable for safe bone removal. Excessive heating of the found in the apical region and resection at this level would eliminate a
bone via the use of excessive pressure on the rotating instrument, excessive large proportion of root-canal ramifications. As the residual infection is
depth of cutting, inadequate cooling or the use of the wrong cutting instru- most likely to reside in the anatomical complexities in the apical 3 mm of
ment can result in stagnation of the local bone circulation and eventual the root, it is often recommended that the apical 3 mm of the root-end be
tissue necrosis. Caution must be exercised at all times not to damage removed as a matter of routine. In the authors’view this may prove grossly
adjacent teeth and soft tissues. excessive because not all roots have complex anatomy in the apical 3 mm
and some short roots cannot survive such a heavy reduction. It is better
Curettage gradually to pare the apex down, while visualizing the apical canal anatomy
This has been defined as a surgical procedure to remove diseased or at the resected face; the shaving may be continued if complex anatomy is
reactive tissue and/or foreign material from the periradicular bone sur- revealed, otherwise aborted.
rounding the root of an endodontically treated tooth. Some clinicians Ideally, the root should be resected perpendicular to its long axis. Such
argue that resection of the root-end can facilitate curettage as access to a resection angle reduces the number of dentinal tubules exposed, decreas-
the palatal/lingual surfaces is improved, however, it is always better to ing the communication pathways between the canal system and periradicu-
curette first and resect later so that clear sight of the root end is obtained lar tissues. The 45° resection angle (Fig. 9.60) previously recommended
during resection. All curetted tissue must be removed and sent for was to improve access and visibility when using traditional surgical
252 MANAGEMENT OF NON-SURGICAL ROOT-CANAL TREATMENT FAILURE
A B
Fig. 9.62 (a) A 1% solution of methylene blue dye is used to stain the root
to facilitate visualization of vertical root fractures or to outline the resected
A root face; (b) application of dye with sterile sponge applicator; (c) resected
root face outlined with methylene blue Fig. 9.63 H&E of a Diaket section
micro-hand-pieces (Fig. 9.61), however, with the introduction of micro- Fig. 9.64 Masson’s
surgical instruments, this problem has largely been overcome. trichrome stained
Visualization of the root-end outline can be enhanced by staining it with section showing MTA
as a root-end filling
a 1% solution of methylene blue dye (Fig. 9.62). The root-end should be
associated with
carefully inspected for anatomical details, fractures and incomplete resec- regeneration of the
tion. Identification of the canal anatomy and, in particular isthmi, facili- periodontal apparatus
tates the correct extension of the root-end preparation.
In certain circumstances, it is not possible to remove the recommended
3 mm. For instance, a long post or reduced bone support limit the amount
of root-end removal, and close proximity of the apex to neurovascular
bundles may demand a high level of resection. As iterated, root-end resec-
tion should be started from the root apex and advance gradually coronally
up to the point where the root canal or root-filling materials are visible in
order avoid over-shortening of the root. The ideal root-end cavity should be prepared along the axis of the root,
have near parallel walls, be at least 3 mm deep and encompass the root-
Root-end cavity preparation canal anatomy. The introduction of ultrasonic root-end tips has revolution-
The rationale for preparation and filling of the root-end is to debride the ized root-end preparation (Figs 9.65, 9.66). The smaller size of the
canal system and seal off any residual intracanal infection. The rationale ultrasonic hand-piece and the angulation of the root-end tips allow better
for placement of a root-end filling is to prevent egress of any residual access. A recognized complication of root-end preparation was perforation
intracanal microorganisms and/or their products into the periradicular of the lingual aspect of the root when conventional surgical hand-pieces
tissues. The apical seal is all important in apical surgery, even more so were used in conjunction with 45° bevels. This iatrogenic complication is
than in conventional root-canal treatment. A “double seal” consisting of less likely when ultrasonically energized root-end preparation tips are used
the physical barrier provided by the root-end filling material, as well as a instead.
biological seal formed by regeneration of the periodontal apparatus over It is possible to instrument the root-canal system from a retrograde
the resected root face is the ideal outcome. This has been shown to be approach using conventional files (Fig 9.67). Bent hand files matching the
achievable with the root-end filling materials available today, such as canal length and held in a pair of haemostat forceps may be used during
Diaket (Fig. 9.63) and MTA (Fig. 9.64). debridement of the canal. The recently introduced long (9–11 mm)
MANAGEMENT OF NON-SURGICAL ROOT-CANAL TREATMENT FAILURE 253
A
B C
ultrasonic root-end tips may also be used. The closer the retrograde root Fig. 9.68 Racellets®
filling can be placed to the post or the fractured instrument, the more suc-
cessful is the treatment outcome. In line with this approach, newer ultra-
sonic tips are longer but lack the flexibility of conventional files.
Haemostasis
Adequate haemostasis is central to periapical surgery and, in particular,
root-end management. Administration of adequate amounts of vasopressor
agents contained in the local analgesic carpules will usually ensure good
haemostasis, which will be maintained throughout the procedure provided
that the procedure is completed within a reasonable time frame. After this
“window of opportunity” control of the blood flow is lost and a massive
increase in bleeding occurs due to the “rebound phenomenon”.
A number of locally applied haemostatic agents are available for use
during the surgical procedure. These include Racellets® (adrenaline (nore- placed into the bony defect may also arrest bleeding. Complete removal
pinephrine) impregnated cotton pellets) (Fig. 9.68), ferric sulphate (Fig. of the haemostatic agents is usually recommended especially when using
9.69) (e.g. Cutrol), bone wax, oxidized cellulose (Surgicel®) (Fig. 9.70), bone wax or ferric sulphate. Any of these materials remaining in the bony
gelatine-based foam (Gelfoam) and bovine-derived collagen (Collacote® crypt will usually evoke an inflammatory foreign-body reaction, which
or Collaplug®) (Fig. 9.71). Application of pressure on plain cotton pellets may prevent or delay healing.
254 MANAGEMENT OF NON-SURGICAL ROOT-CANAL TREATMENT FAILURE
A B
Fig. 9.69 (a) Ferric sulphate haemostatic agent; (b) ferric sulphate applicator
Fig. 9.72 Root resection without Fig. 9.73 Super ethoxybenzoic acid Fig. 9.74 Intermediate restorative
retrograde filling material
MTA (see Fig. 9.28a), super ethoxybenzoic acid (EBA) (Fig. 9.73), inter-
Root-end filling mediate restorative material (IRM) (Fig. 9.74), gutta-percha, Diaket (Fig.
Following root-end resection, it is usually recommended that a root-end 9.75), composite resin, and glass ionomer cement. Amalgam has been
preparation and root-end filling be placed. However, this is not always widely used in the past but it can no longer be recommended as a root-end
the case and there is some debate as to whether a better seal is achieved filling material due to new evidence demonstrating the superiority of other
by placement of a root-end filling where the canal has recently been materials and due to the long-term failure of cases where amalgam was
well obturated (Fig. 9.72). In all other cases root-end filling is used. This failure may be due to initial leakage, formation of corrosion
recommended. products and possible electrochemical reactions when in contact with a
The ideal root-end filling material should be biocompatible, antibacte- metal post. An additional problem with the use of amalgam as a root-end
rial, easy to place and remove, radiopaque, dimensionally stable, adhere filling material is tattooing of the soft tissues (see Fig. 9.52). At present,
to the root canal wall, insoluble and induce regeneration of the periradicu- the most suitable material for use in root-end cavities appears to be MTA
lar tissues. Of the variety of root-end filling materials available, none fulfils (see Fig. 9.28a); the newer Biodentine® (Fig. 9.76) remains untested in
all the above criteria. The materials currently most commonly used are this scenario.
MANAGEMENT OF NON-SURGICAL ROOT-CANAL TREATMENT FAILURE 255
Fig. 9.79 Diaket root-end filling in Fig. 9.80 MTA root-end filling in tooth #36 Fig. 9.81 Composite root-end filling
tooth #22 in tooth #21
Following its creation, the root-end cavity should be dried before the setting time (10–15 minutes). The bony crypt should be cleared of all
root-end filling is placed. This can be achieved with cut sterile paper points foreign materials, such as root-end filling, haemostatic agents or cotton
or with a short needle attached to high volume suction, such as the Stropko pellets. The surgical site is then irrigated with sterile saline. Prior to wound
device. The surgical crypt should be packed with adrenaline-containing closure, a periapical radiograph should be exposed to confirm adequate
local anaesthetic solution impregnated cotton pellets or a collagen mate- placement and compaction of the root-end filling, as well as the absence
rial, such as Collaplug (see Fig. 9.71b) during the placement of the root- of extraneous material in the periradicular tissues (Figs 9.78–9.81).
end filling. This will help maintain a dry field and, in addition, will
facilitate removal of any excess filling material at the end of the procedure. Through and through surgery
There are a number of instruments, devices and systems available to facili- This treatment approach (Fig. 9.82) is indicated when exudation into the
tate root-end filling placement (see Fig. 6.27a–e). Carriers, such as the root canal cannot be controlled by non-surgical chemomechanical debride-
MAP kit or MTA block/Lee’s carver will help transport the material to the ment. Following removal of the existing canal medicament and irrigation
surgical site and then surgical root-end pluggers, available in different of the canal system, the flap elevation, osteotomy and root-end resection
sizes and angulations, allow good condensation and adaptation of the are carried out as previously described. The root canal is then obturated
filling material to the canal walls. The root-end filling should be routinely with thermoplasticized injection gutta-percha and sealer. A flat plastic
burnished or polished except when MTA is used. This finish is not possible instrument is placed at the apex to prevent gross extrusion of gutta-percha.
with grey or white ProRoot MTA as it does not set for approximately 4 Any excess gutta-percha can be removed using a scalpel blade 11 and the
hours. MTA-Angelus (Angelus, Londrina, PR, Brazil) (Fig. 9.77) which gutta-percha surface should be burnished. Alternatively, a root-end cavity
is an alternative to ProRoot MTA contains 80% Portland cement and 20% may be prepared and filled with MTA as previously described. The access
bismuth oxide, with no addition of calcium sulphate in an attempt to reduce cavity should be sealed with a temporary restorative material and then a
256 MANAGEMENT OF NON-SURGICAL ROOT-CANAL TREATMENT FAILURE
A B C
A B
Fig. 9.86 Immediately postoperatively Fig. 9.87 Two days postoperatively Fig. 9.88 Two weeks postoperatively
sutures is also more uncomfortable for the patient due to residual postop- Fig. 9.89 (a,b) Surgical
erative pain and swelling. Therefore, suture removal is recommended at 7 repair of external
days when wound strength is assured and swelling and pain are reduced, resorptive defect on
as has been traditionally practised for decades. the mandibular first
When suturing the tissues, it is important to ensure that the flap is not premolar
under tension. The horizontal incision is usually sutured first. The tech-
nique most commonly used in endodontic surgery involves the use of
interrupted sutures. The single sling suture, vertical mattress suture and
the anchor suture may also be used. Postoperative wound healing is dem-
onstrated (Figs 9.86–9.88).
A
Wound healing
Various tissues are wounded during periradicular surgery. These are muco-
periosteal tissues (gingivae, alveolar mucosa and periosteum), periradicu-
lar tissues (bone and periodontal ligament) and radicular tissues (dentine
and cementum). Harrison and Jurosky (1991a,b, 1992) give a detailed
account of the three different types of wound healing: incisional; dissec-
tional; and excisional. To promote optimum healing, the operator must
ensure close approximation of the wound edges, encouraging healing by
primary intention. Appropriate oral hygiene measures must be established
to prevent infection of the surgical site, which may lead to wound break-
down and healing by secondary intention (scarring).
The first event in wound healing is clot formation. The function of the
clot is to provide an initial seal and strength, attach the opposing wound
edges and thereby provide a pathway for the migration of inflammatory
and repair cells. Inflammatory cells, such as polymorphonuclear leuco-
cytes migrate to the wound site (chemotaxis) and are responsible for
removal of bacteria and cellular debris (phagocytosis). Activated macro- B
phages then invade and stimulate fibroblasts to form new collagen and
small blood vessels (angiogenesis). Once an epithelial barrier has been
formed, connective-tissue healing commences. With time, the connective Caries involves destruction of dental tissues as a result of microbial
tissue remodels and matures. action. An untreated carious lesion may invade the floor of the pulp
chamber or extend along the root resulting in perforation of the root. Treat-
CORRECTIVE SURGERY ment of these perforations may require a combination of crown lengthen-
ing, root extrusion or root resection in order to retain valuable radicular
Perforation repair
segments. In must be said that the pattern of tooth destruction leading to
A radicular perforation is an artificially created communication between perforation in most cases will render the tooth unrestorable.
the root-canal system and the supporting periodontal apparatus of the Perforations resulting from procedural errors are probably the second
tooth. Perforations compromise the health of the periradicular tissues most common cause of endodontic failure and account for close to 10%
and threaten the viability of the tooth. Perforations pose a number of of all endodontic failures.
diagnostic and management problems. They generally occur through three Irrespective of the factors involved in the creation of the perforation,
mechanisms: resorptive processes (Fig. 9.89); caries; and procedural errors the management and repair will depend on three factors: (1) the location
(Fig. 9.90). of the perforation; (2) the length of time since the perforation was created;
Resorptive processes, given sufficient time, will perforate the root struc- and (3) the size of the perforation. The most important of these is the
ture. The resorptive process may be internal or external in origin and it is location of the perforation. Perforations close to the height of the alveolar
important to distinguish between them so that appropriate treatment can crest are the most difficult to repair and generally have the least favourable
be rendered. prognosis due to their communication with the gingival sulcus and the
258 MANAGEMENT OF NON-SURGICAL ROOT-CANAL TREATMENT FAILURE
A B
A B C
Fig. 9.91 (a) Perforation of the distal aspect of the mesial root of tooth 36; (b) reflected tissue flap revealing extent of the bone loss associated with the
perforation; (c) surgical repair of the perforation with MTA
A
B
microorganisms contained within it. This location has been described as • treatment of one root of a multirooted tooth that is not amenable to
the “critical crestal zone”. Coronal to this, a perforation can be repaired non-surgical or surgical treatment.
with restorative material with or without crown lengthening. Apically, a
Contraindications to root resection include:
perforation can be viewed as a secondary foramen.
The treatment of a perforation affecting the mesial root of a mandibular • fused roots
molar is illustrated (Fig. 9.91). • unrestorable tooth
Root resection • paucity of support for or attachment to remaining root(s).
A case of root resection of the mesial root of a mandibular first molar
A root resection or root amputation is defined as the removal of an entire
is presented to emphasize procedural aspects. Where possible, endodontic
root leaving the crown of the tooth intact (Fig. 9.92). Root resections have
treatment should be completed prior to root resection (Fig. 9.93a).
been performed for a multitude of reasons for many decades. Today, the
Amalgam has been placed in the root with the perforation that is due to
main indications for root resection include:
be resected. This will facilitate orientation during the surgical procedure
• treatment of a periodontal defect, e.g., furcation defect, class III and will, more importantly, seal the remaining root-canal systems from the
periodontal defect oral cavity. Preservation of alveolar bone is important but, in many cases,
• vertical root fracture of one root of a multirooted tooth removal of some bone around the root to be resected will be necessary.
• caries, or a resorptive defect of one root of a multirooted tooth that Following reflection of a soft-tissue flap, root resection is performed with
cannot be managed in other ways a high-speed, tapered tungsten carbide bur starting at the most accessible
• removal of a root that has undergone an irreparable perforation coronal aspect of the root. The instrument is directed apically towards the
MANAGEMENT OF NON-SURGICAL ROOT-CANAL TREATMENT FAILURE 259
A B
E F
Fig. 9.93 (a) Preoperative radiograph; (b) clinical view following root resection; (c) placement of bone substitute Bio-Oss; (d) Bio-Oss bovine bone graft;
(e) resorbable membrane in place; (f) 5-year follow-up radiograph
A B
furcation, stopping just short of the furcation in order to avoid damage to The need for a mucoperiosteal flap is determined following each case
the adjacent root surface. The root can then be completely sectioned gently evaluation. Restoration of the remaining portions of the tooth is critical to
fracturing the remaining root material with a fine elevator placed in the the long-term survival of the tooth (Fig. 9.96). (For further discussion, see
resection line. Having removed the resected root (Fig. 9.93b), the place- Chapter 14.)
ment of a bone substitute and membrane covering further enhance healing When hemisection is performed prior to NSRCT (Fig. 9.97a), it is nec-
and resolution (Fig. 9.93c–e). A 5-year follow-up radiograph shows a essary to isolate the remaining tooth and complete the treatment in the
favourable outcome (Fig. 9.93f). Root resection should be avoided prior normal way (Fig. 9.97b,c).
to non-surgical root-canal treatment (NSRCT) (Fig. 9.94a) and it is impor-
tant to confirm that no residual root spurs remain as they can lead to
localized periodontal breakdown (Fig. 9.94b). (For further discussion of INTENTIONAL REPLANTATION
root resections, see Chapter 12.) AND TRANSPLANTATION
Intentional replantation is defined as the replacement of a tooth in its
Hemisection
socket following deliberate surgical avulsion (Figs 9.98–9.100). Trans-
Hemisection is defined as the surgical separation of a multirooted tooth, plantation of a tooth, involves replacement of a tooth in a socket other than
usually a mandibular molar, through the furcation in such a way that a the one from which it had been extracted (Fig. 9.101). This is normally
root and the associated portion of the crown may be removed (Fig. 9.95). limited to procedures within the same mouth.
260 MANAGEMENT OF NON-SURGICAL ROOT-CANAL TREATMENT FAILURE
A B C
Fig. 9.97 (a) Hemisection performed prior to NSRCT – note bleeding pulpal tissue; (b) isolated hemisected tooth; (c) completed NSRCT
Fig. 9.98 Replanted molar – note lack of NSRCT Fig. 9.99 Radiograph of intentional replantation Fig. 9.100 Radiograph of intentional replantation
– preoperative – postoperative
As a general rule, intentional replantation is considered a procedure of of the root at a later date. Root-end preparation and root-end filling are
last resort, although many successful cases have been reported in the lit- performed extraorally under a constant stream of isotonic saline or HBSS.
erature. Much is now understood about the physiology of the periodontal
ligament surrounding the root of the extracted tooth and appropriate
REGENERATIVE PROCEDURES
handling of the root will enhance the chances of success following
replantation. In 1793, John Hunter said that, “the only rational form of treatment is that
It is desirable to perform non-surgical root-canal treatment on the tooth which calls forth the recuperative powers of the body …”. More recently,
prior to replanting or transplanting. The ligament of the extracted tooth Melcher (1976) wrote a paper entitled “On the repair potential of periodon-
should be protected in the same way as that of an avulsed tooth. The cells tal tissues”, which resulted in a reappraisal of the processes involved in
of the periodontal ligament and the socket are very susceptible to damage periodontal regeneration. The emphasis following endodontic and perio-
and must be protected from trauma and from desiccation. If the tooth is dontal surgery has subsequently shifted towards regeneration of tissues as
out of the mouth for any time, it should be placed in a storage medium, opposed to repair alone.
such as Hanks Balanced Salt Solution (HBSS) or Ringer’s solution. These Regeneration of the periradicular tissues subsequent to surgery or due
isotonic solutions provide the greatest chance of ensuring vitality of the to the ravages of disease processes implies replacement of the various
periodontal ligament which will, in turn, reduce the chance of resorption components of the tissue in their appropriate locations, amounts and
MANAGEMENT OF NON-SURGICAL ROOT-CANAL TREATMENT FAILURE 261
A B C
Fig. 9.101 (a) Transplantation case. Radiographic and clinical examination revealed a hopeless prognosis for the mandibular second molar tooth; (b) bitewing
radiograph indicating relationship of maxillary to mandibular teeth; (c) NSRCT completed on unopposed maxillary third molar; (d) maxillary third molar extracted
gently and the root-ends resected; (e) root-end preparations prepared and obturated with Diaket root-end filling material. The palatal root had to be extensively
resected in order to allow the tooth to be positioned in the recipient socket; (f) transplanted tooth in recipient site (courtesy of Dr JD Regan)
relationships to each other. Repair, on the other hand, is a biological Fig. 9.102 Biomend
process by which continuity of disrupted tissue is restored by new tissues absorbable collagen
that do not replicate the structure and function of the lost ones. membrane placed over
large through and
Melcher (1976) stated that the cells that repopulate the exposed root
through defect with
surface determine the nature of the attachment that will form. If the rapidly 2–3 mm extension over
growing epithelium proliferates first, a long junctional epithelium (JE) will the osseous margins of
form. If cells from the gingival connective tissue (CT) meet the root the lesion
surface, root resorption might be the sequela. If bone comes in direct
contact with the root, root resorption and ankylosis may occur. However,
if cells from the periodontal ligament (PDL) populate the root surface first,
new connective tissue attachment may develop.
Overall, guided tissue regeneration (GTR) procedures have been shown
to improve the levels of attachment. However, histometric assessment
reveals that incomplete regeneration frequently occurs. Aukhil et al. (1986)
described three different zones of healing after barrier therapy:
to be removed during a second follow-up surgical procedure some 6 weeks
• junctional epithelium
after the initial procedure. Commercially available bioabsorbable mem-
• fibres parallel to the root surface
branes include bovine collagen, and synthetic membranes (polylactic acid,
• new CT attachment (new bone, PDL, cementum).
polyglycolic acid, polyurethane, Resolut XT/Resolut Adapt [synthetic bio-
A number of commercially available membranes are currently available. absorbable glycolide and trimethylene carbonate copolymer fiber and an
The use of membranes in endodontic surgical cases became more wide- occlusive membrane of synthetic bioabsorbable glycolide and lactide
spread following the development of bioabsorbable materials. Prior to this, copolymer], polyglactin-910 mesh with copolymer of glycolide and
the non-resorbable material, such as the expanded polytetrafluoroethylene lactide). The most common material is collagen, such as Biomend® (Fig.
(e-PTFE Gore-Tex) membrane (This product has been discontinued) had 9.102) and BioGide® (Fig. 9.103) (both collagen products). It is important
262 MANAGEMENT OF NON-SURGICAL ROOT-CANAL TREATMENT FAILURE
A B
Fig. 9.105 Perioglass® Fig. 9.106 (a,b) Capset calcium sulphate material
B
A
to place the membrane so that its edges are fully supported by 2–3 mm of At present, the evidence for routine use of GTR for apical surgery is
bone away from the edge of the crypt. Many clinicians prescribe antibiot- weak but it may be beneficial for large through-and-through lesions.
ics for their patients following placement of a membrane but there is no
evidence to support routine use of antibiotics.
DECOMPRESSION
Other substitute materials are also available as supports for membranes
or as regenerative materials aimed at supporting, if not inducing, bone Decompression or marsupialization involves the surgical exteriorization
formation. These include Bio-Oss® (Fig. 9.104), Perioglass® (Fig. 9.105) of a large periradicular lesion in order to facilitate healing of the lesion
and calcium sulphate (Fig. 9.106). (Fig. 9.107). The lesion is penetrated through the periosteum and cortical
MANAGEMENT OF NON-SURGICAL ROOT-CANAL TREATMENT FAILURE 263
plate and the patency of the opening is maintained by inserting a flanged Harrison, J.W., Jurosky, K.A., 1991b. Wound healing in the tissue of the peridontium
cannula allowing for daily irrigation of the lesion by the patient. The following periradicular surgery. 2. The dissectional wound. J Endod 17 (11), 544–552.
Harrison, J.W., Jurosky, K.A., 1992. Wound healing in the tissues of the periodontium
advantages of this procedure include reduction in the risk of damaging following periradicular surgery. 3. The osseous excisional wound. J Endod 18, 76–81.
either adjacent vital teeth or anatomical structures (Fig. 5.47). Laurent, P., Camps, J., About, I., 2012. Biodentine(TM) induces TGF-β1 release from
human pulp cells and early dental pulp mineralization. Int Endod J 45 (5), 439–448.
Melcher, A.H., 1976. On the repair potential of periodontal tissues. J Periodontal 47,
256–260.
REFERENCES AND FURTHER READING Roberts, H.W., Toth, J.M., Berzins, D.W., et al., 2008. Mineral trioxide aggregate
Atmeh, A.R., Chong, E.Z., Richard, G., et al., 2012. Dentin-cement interfacial material use in endodontic treatment: a review of the literature. Dent Mater 24 (2),
interaction: calcium silicates and polyalkenoates. J Dent Res 91 (5), 454–459. 149–164.
Aukhil, I., 1991. Biology of tooth-cell adhesion. Dent Clin North America 35, 459–467. Tsesis, I., Rosen, E., Tamse, A., et al., 2011. Effect of guided tissue regeneration on the
Aukhil, I., Pettersson, E., Suggs, C., 1986. Guided tissue regeneration. An experimental outcome of surgical endodontic treatment: a systematic review and meta-analysis. J
procedure in beagle dogs. J Periodontal 57, 727–734. Endod 37 (8), 1039–1045.
Bashutski, J.D., Wang, H.L., 2009. Periodontal and endodontic regeneration. J Endod 35 Zanini, M., Sautier, J.M., Berdal, A., et al., 2012. Biodentine induces immortalized
(3), 321–328. murine pulp cell differentiation into odontoblast-like cells and stimulates
Harrison, J.W., Jurosky, K.A., 1991a. Wound healing in the tissue of the peridontium biomineralization. J Endod 38 (9), 1220–1226.
following periradicular surgery. 1. The incissional wound. J Endod 17 (9), 425–435.
10
Section 3 Delivery of endodontic treatment
PRINCIPLES OF MANAGEMENT OF PAIN It is also worth bearing in mind that patients who have been suffering
long-standing pain may have a reduced threshold of pain perception as a
The most fulfilling aspect of endodontic treatment is the opportunity to result of central or peripheral sensitization. The zone of sensitization may
care for the patient in pain. Acute dental pain is notoriously difficult to be restricted close to the origin of the problem or expanded to various
cope with for most patients, particularly that of pulpal origin. They will distances from it. It is worth, therefore, exploring and mapping zones of
arrive in a distressed state, being anxious and irritable having had disturbed hyperalgesia (heightened response to noxious stimuli) and allodynia
sleep, eating patterns. Their psychological demeanor may be defensive, (heightened response to non-noxious stimuli), lest detected local tender-
aggressive, blaming or even dulled through fatigue and dosing on ness is in fact part of this phenomenon. Sensitization may be evident in
medication. patients with a history of chronic pain, TMJ dysfunction, fibromyalgia and
Successful management of pain is: whiplash injury.
1 preceded by sharp diagnostic and psychological insight
complemented by a confident manner
EFFECTIVE INTRAOPERATIVE PAIN CONTROL
2 accompanied by effective and efficient treatment execution,
including adequate anaesthesia and analgesia LOCAL ANALGESIC AGENTS AND THEIR ACTIONS
3 succeeded (hopefully) by patient gratitude and loyalty; and a
personally enhanced reputation for the dentist. Difficulties can often be encountered in trying to secure analgesia in
irreversibly inflamed pulps or where there is acute infection. Failure
For effective practice development, there is no greater pathway than of analgesia may be operator dependent (poor technique, choice of tech-
caring for patients in acute pain. The investment required is a moral, nique and/or solution) or patient dependent (anatomical, pathological or
human, compassionate, patient and confident approach, coupled with psychological).
understanding of the biology of the problem, as well as insight about The most commonly used analgesic solution for most endodontic pro-
pharmacological armamentaria. cedures is lignocaine with adrenaline (epinephrine) (Fig. 10.3). Providing
The majority of patients attending the dentist in pain suffer from the the analgesic solution is given slowly with an aspirating technique, then
acute consequences of pulpal or periradicular disease (Table 10.1), but the the adrenaline (epinephrine) is not a problem in most patients.
dentist must beware of confounding factors. The success rate for inferior alveolar block injections is over 90%. A
The clinician’s aim in providing emergency care is to control the infec- practitioner who regularly fails with this method should reassess their
tion and inflammation by removing the cause of the problem. However, technique. Although, it is generally considered that the sign of a successful
the response to the underlying injury will endure for the period of time it block is a numb lip, all that this indicates is that the nerves to the soft
takes for the triggered biological mechanisms to switch off. During this tissues of the lip have been blocked; it does not necessarily infer pulpal
latent period, pharmacological means may be intelligently employed to analgesia. The presence of infection and inflammation can reduce the
help control the lingering pain until the unpleasant experience subsides efficacy of analgesic solutions. In solution, the local analgesic exists in
naturally through innate physiological mechanisms. There are strong psy- two ionic forms, an uncharged anion (RN) and a positively charged cation
chological elements to pain control as evidenced by placebo effects, hence, (RNH+). Both forms of the solution are required for analgesia.
a biologically robust strategy, accompanied by effective surgical execution RNH+ ⇌ RN + H+
and a firm, confident manner is paramount. Inflammation lowers the tissue pH and, correspondingly, the amount of
the base form of the analgesic available to penetrate the nerve membrane.
DIAGNOSTIC ACCURACY Consequently, there is less of the ionized form within the nerve to achieve
analgesia. In addition, nerves arising in inflamed tissue have altered resting
Patients presenting in a dental practice suffering from orofacial pain must potentials and decreased excitability thresholds. These changes are not
be viewed from a broad diagnostic perspective. The cognitive and material restricted to the inflamed pulp but affect the entire neural membrane.
tools possessed by dentists naturally sway their management towards Articaine with adrenaline (epinephrine) (Fig. 10.4) has gained favour as
dental intervention but non-dental factors can mimic dental pain too. This a local analgesic solution to use where lignocaine appears to have failed.
is due in part to convergence of peripheral neural pathways in the central Articaine differs from lignocaine as it has a thiophene ring as its lipophilic
nervous system and in part to the patients’ inability to articulate their component rather than a substituted aromatic ring. Studies show that it is
experience in a meaningful way to the dentist. Dentists should therefore no more effective as an analgesic agent than lignocaine. However, it does
be aware of the common causes of misdiagnosis. These include non- have an increased propensity to diffuse widely, which may allow it to block
odontogenic inflammation, vascular, musculoskeletal, neurological, and accessory innervations over a broader field. In addition, the different stere-
systemic or psychogenic problems (see Chapter 16). Temporomandibular ochemical structure may also account for its apparently higher success
joint (TMJ) and muscular pain from the masseter, lateral pterygoid and rate. Unfortunately, it is also associated with a higher frequency of persist-
temporalis muscles may refer pain to the maxillary or mandibular molars, ent paraesthesia.
premolars or even anterior teeth on occasion. Such a condition may be The use of long-acting anaesthetics may provide the patient pain relief
more appropriately managed with reassurance, explanation, reduction in while the postoperative analgesics start to act. Marcaine (0.5% bupi-
muscle and joint load, stretching exercises, heat/cold therapy and lastly, vacaine with 1 : 200 000 epinephrine) when used as a regional block can
the use of an occlusal acrylic splint may help (Figs 10.1, 10.2). give soft-tissue anaesthesia of 6–8 hours. Marcaine is not available in all
countries in dental anaesthetic cartridges and, in some areas, is not licensed Akinosi techniques both attempt to anaesthetize the inferior alveolar nerve
for dental use. Dental practitioners should satisfy themselves as to the local at a higher level. Both these methods are best reserved for cases where the
rules before administering it. Other preparations of bupivacaine are avail- conventional block fails as they can produce more complications than the
able, such as carbostesin (Fig. 10.5). standard approach – the higher the needle, the closer it is to the maxillary
artery and the pterygoid plexus.
LOCAL ANALGESIC AGENT DELIVERY
Gow–Gates technique
If an inferior alveolar block fails and a repeat attempt also fails, then an
This is a true mandibular block injection that provides analgesia of all the
alternative technique should be considered. The Gow–Gates and the
sensory divisions of the mandibular nerve, including buccal, inferior alve-
olar, lingual and mylohyoid. The method relies upon the deposition of
analgesic solution adjacent to the head of the mandibular condyle
(Fig. 10.6). The patient has the mouth wide open and a line is imagined
Table 10.1 Prevalence of acute orofacial or dental pain
from the corner of the mouth to the intertragic notch; this is the plane of
Prevalence of acute approach. The needle is introduced from the direction of the contralateral
Population orofacial or dental pain Comments mandibular canine tooth and directed over the ipsilateral maxillary second
USA (National Health 14% (acute orofacial pain Most common molar (Fig. 10.7). The point of mucosal penetration is higher than for a
Interview Survey, 1989) in the past 6 months) causes: caries & conventional inferior dental block. The needle is advanced until bony
periodontal disease contact is made with the head of the condyle, withdrawn slightly, aspira-
UK (Adult Dental Health 26% (dental pain) Most cases were tion performed, and a full cartridge of analgesic is delivered.
Survey, 2009) associated with
gross caries & sepsis
Toronto, Canada (Locker & 29% (teeth with cold/hot); 50% of cases
Akinosi technique
Grushka, 1987) 14% (toothache) in the reported severe This is a simpler technique than the Gow–Gates method and is sometimes
past 4 weeks symptoms
Sao Paulo, Brazil (age 12, 26% (dental pain) Most cases were
known as the closed-mouth technique. The patient has the mouth closed
15 adolescents) (2010) associated with and a 35 mm needle is used. The syringe is advanced parallel to the maxil-
untreated caries lary occlusal plane at the level of the maxillary mucogingival junction.
or endodontic
treatment need
The needle is advanced until the hub is level with the distal surface of the
Hong Kong, China (1222 28% (tooth sensitivity);
maxillary second molar (Fig. 10.8). At this point, a cartridge of analgesic
18+ Chinese speaking 13% (toothache) solution is deposited. This technique does not rely on touching bone and
people in 2006) this can be a disadvantage. However, the Akinosi technique allows provi-
sion of analgesia in a situation where all other methods of giving an
Fig. 10.1 Splint therapy for TMJ dysfunction Fig. 10.2 Palatal view of occlusal splint
Fig. 10.10 Needle insertion for intraligamental Fig. 10.11 Intraosseous injection using X-Tips Fig. 10.12 Intraosseous guide sleeve left in situ
injection until the end of the procedure
inferior dental block would fail. Both motor and sensory analgesia are already been opened, then the needle may be advanced further into the
achieved allowing the patient to open the mouth. canal until it is wedged in place to create the backpressure. The needle
may need to be supported to prevent it from buckling. If the backpressure
INTRALIGAMENTAL INJECTIONS cannot be created, then a larger needle may be required. Buckling can be
overcome by using the shorter and finer intraligamental needles.
Intraligamental injections are used to deposit analgesic directly into
the periodontal ligament space and a number of specialized syringes
(Fig. 10.9) and small needles have been developed to facilitate this. The
INTRAOSSEOUS TECHNIQUE
needle is inserted into the mesial gingival sulcus and in contact with the The intraosseous technique allows analgesic solution to be deposited
tooth (Fig. 10.10). The needle is supported by fingers and positioned with directly into the cancellous bone around the apices of the tooth. It has a
maximal penetration between the root and crestal alveolar bone. Pressure rapid onset and has shown extremely favourable results when used as a
is slowly applied to the syringe handle for 20–30 seconds. Backpressure supplemental analgesic for the “hot” mandibular molar. The mucosa over-
has to be developed for this technique to work and blanching of the soft lying the injection site, either just mesial or distal of the tooth to be treated,
tissues would be a sign of probable success. If analgesic solution flows is anaesthetized with a small infiltration. Special kits have been developed
readily out of the sulcus then analgesia will not be achieved. Pressure is that facilitate drilling a small hole through the mucosa and cortical plate
necessary to force the solution into the marrow spaces to contact and block to allow injection of the anaesthetic solution into the cancellous bone.
the dental nerves. The technique should be repeated on the distal and X-Tips (Prestige Dental, Bradford, UK) consist of a drill to perforate the
lingual surfaces of the involved tooth. cortical plate combined with a guide sleeve. When the drill is withdrawn
the guide sleeve is left in situ. The analgesic solution can be injected
INTRAPULPAL INJECTIONS through the guide sleeve, which is designed to accept an ultra-short
27-gauge needle (Fig. 10.11). The guide sleeve can be left in place during
The major drawback of the intrapulpal injection is the need for the needle the procedure so that the anaesthetic can be “topped-up” if required
to be inserted into a very sensitive and inflamed pulp. The injection can, (Fig. 10.12). A small number of patients develop soreness at the injection
therefore, be painful. Additionally, the pulp has to be exposed to give the site and a transitory increased heart rate can occur depending on the anal-
injection and analgesic problems may have occurred prior to this being gesic solution used.
achieved. The injection has to be given under strong backpressure. In the
absence of backpressure, it is difficult to achieve analgesia. The mecha-
nism of action is the intrapulpal pressure, as the technique can work even
MANAGEMENT OF THE “HOT” PULP
with saline. One technique to create the backpressure is “stoppering” the The presence of symptomatic irreversible pulpitis (“hot pulp”) may require
cavity with gutta-percha to allow the backpressure to build up. Alterna- additional strategies to control pain and allow pulp extirpation. The
tively, a small hole can be made into the pulp chamber with a half-round problem typically affects mandibular molars. The factors to consider are
bur, through which the needle can be introduced. If the pulp chamber has accessory nerve supply and altered nerve function.
MANAGEMENT OF ACUTE EMERGENCIES AND TRAUMATIC DENTAL INJURIES 267
cyclosporins; increased serum concentrations with hydantins and lithium; the patient, as to which tooth is the culprit; even dentists with toothache
increased toxicity with methotrexate, increased blood pressure with sym- get it wrong. Pulpal pain only becomes localizable when the inflammation
pathomimetics; and increased prothrombin time with anticoagulants. is advanced enough to involve the periapical tissues and the tooth becomes
tender to touch or tap.
The dentist should seek all historical, clinical and radiographic clues to
EMERGENCY SCENARIOS
identify the cause. Sometimes, this will be obvious, such as secondary
Endodontic emergencies may be divided by temporal association into caries or crack (Figs 10.13, 10.14a) and, at other times, the patient may
preoperative, intraoperative and postoperative events, although the bound- present with a quadrant of teeth with deep restorations (Fig. 10.15), all
aries of this classification are not sacrosanct. Preoperative pain often pre- posing as potential candidates. It is not unheard of that, under such cir-
dicts intraoperative and postoperative pain but other factors may also be cumstances, several teeth end up with pulp extirpations. It is important to
involved. differentiate the causative tooth by using a combination of pulpal stimula-
tion (uncomfortable as that may be) and selective, diagnostic local anaes-
thesia. There is no local anaesthetic technique that can be completely
PREOPERATIVE EMERGENCIES confined to one tooth but intraligamental anaesthesia affords a close pos-
sibility. The principle is to choose the most likely candidate but to anaes-
Patients fall into two broad categories, those who are part of the practice thetize from the mesial to distal and maxillary to mandibular. When the
and under regular or irregular review and those who have never attended pain is abolished, the tooth is identified; effectiveness of anaesthesia may
the practice before and merely seek resolution of an urgent problem. The be tested by pulp testing.
former group of patients will have available details of dental status and The distinction between reversible and irreversible pulpitis is not clear-
previous treatment, albeit with their recent history requiring updating; cut. In both cases, there may be pain stimulated by hot, cold or sweet
whereas the latter group requires a thorough investigation to determine the stimuli, lingering for various periods of time as a dull ache, sometimes
nature of the problem, as well as the level and type of service appropriate arising spontaneously and sometimes keeping the patient awake at night.
for their needs. At times, the pain may be so severe that the patient will find it intolerable,
Inevitably, patients arrive seeking emergency treatment at a time incon- described as the worst imaginable pain and likened to being stabbed in the
venient to the busy practitioner. However, it is essential that time is made jaw with a red-hot poker or knife. The longer the episodes of lingering
to reach a proper diagnosis. Apart from the patient often not being able to pain, the more spontaneous the episodes, the greater the frequency of sleep
locate the specific tooth causing the problem, there are a number of patho- loss, the more severe the pain, the greater the response to hot rather than
logical entities that will mimic pain of odontogenic origin and, in these cold (indeed sometimes cold may relieve), the more likely it is that the
cases, endodontic procedures are obviously not indicated. pain will be judged irreversible. Indeed, severe pulpal pain of the sort
Identifiable endodontic emergencies fall into the following categories: described may sometimes be associated with a relatively normal pulp
pain of pulpal origin (Seltzer et al., 1963; Dummer et al., 1980). In the case shown, placement
emergencies of periradicular origin of cast onlays resulted in pain characteristic of irreversible pulpitis,
emergencies resulting from traumatic injuries.
Fig. 10.13 Irreversible
pulpitis in mandibular
EMERGENCIES OF PULPAL ORIGIN first molar showing a
Diagnosis widened periodontal
ligament space around
The innervation of the dental pulp consists of myelinated Aδ fibres and both apices
unmyelinated C fibres, which give rise to distinct types of pain sensations
as discussed in Chapter 4. Pulpal pain is typically stimulated by hot or
cold stimuli, however, it is important to be clear whether the pain has the
sharp quality attributable to Aδ fibre stimulation or the dull aching,
throbbing quality associated with pulpitis and C fibres. Many dentists
confuse localizable dentine sensitivity with the unlocalizable pain of
pulpal origin. Identification of the tooth is not helped by the perception of
A
B
MANAGEMENT OF ACUTE EMERGENCIES AND TRAUMATIC DENTAL INJURIES 269
A B
Fig. 10.16 (a) Symptoms consistent with irreversible pulpitis were triggered following placement of cast
Fig. 10.15 Teeth with deep restorations onlays on the mandibular molars; (b) symptoms resolved spontaneously after 2–3 months, whilst the teeth
continued to respond normally to pulp tests, remaining free of apical disease many years afterwards
Fig. 10.17 Use of fibreoptic light to Fig. 10.18 Dressed molar tooth Fig. 10.19 Mandibular molar with thickening of
illustrate the extent of an incomplete PDL space and condensing osteitis
fracture (courtesy of Dr CC
Youngson, Liverpool Dental Institute)
however, the patient was able to tolerate the pain and in time, the pain pulpitis is to remove the diseased pulp completely and to clean and prepare
resolved. Many years on, the teeth respond normally to pulp tests and the pulp canal system. Irrigating the pulp chamber with a 2.5–5.0% solu-
remain free of apical disease (Fig. 10.16). Patients unable to tolerate the tion of sodium hypochlorite ensures disinfection before canal instrumenta-
pain would opt to have the pulps extirpated, therefore, the correct term for tion. If time does not allow this, removal of pulp tissue from the pulp
the diagnosis is pulpalgia rather than pulpitis. chamber and coronal part of the root canals is often effective. The use of
Cracked tooth syndrome (CTS) may also result in pulpitis and the crack corticosteroid preparations in vital root canals has been advocated in situ-
may need additional management by placement of an orthodontic band to ations where complete instrumentation is inconvenient or impossible
prevent cuspal flexure and catastrophic fracture. The degree of pain may because profound anaesthesia cannot be secured. In the presence of severe
vary considerably, from momentary pain on encountering heat and cold to pulpal inflammation, the effectiveness of local anaesthesia is reduced as
spontaneous pain or pain on biting. The pain on biting will have a sharp discussed above.
quality, while the pain on hot and cold may vary from sharp to a dull aching In cracked teeth, dentine bonded materials may prove useful in small
quality. A fibreoptic light may be useful in locating and determining the cavities as an interim restoration before constructing a restoration giving
extent of the cracks (Fig. 10.17) but they are not always visible in the early occlusal protection (Fig. 10.20). Once a vertical crack is initiated, the
stages of CTS. treatment goal is to prevent catastrophic propagation and retain the tooth
for as long as possible; some teeth can last up to 10 years with cuspal
protection.
Treatment
Where a crack involves the pulp and symptoms suggest an irreversible
If it is judged that the pain is due to reversible pulpitis, treatment involves pulpitis, all restorations should be removed from the tooth and the extent
removing the source of dentinal or pulpal irritation. In the case of sensitive of the crack determined. If the crack has propagated to a fracture and a
dentine, patent dentinal tubules may be treated using fluoride or desensitiz- portion of the tooth is mobile it should be removed, examined, and
ing agents. Dental caries and faulty restorations should be removed and the possibility of restoring the remaining tooth substance established (see
replaced with a sedative dressing, typically containing zinc-oxide/eugenol Fig. 10.14a). Examination of the extracted fragment allows accurate
(Fig. 10.18). assessment of the restorability of the tooth. Where the fracture runs into
If it is judged that the pain is due to irreversible pulpitis, the pulp should the apical periodontal attachment apparatus, as in this case, then extraction
be extirpated (Fig. 10.19). The ideal emergency treatment for irreversible is the only option (see Fig. 10.14b,c). If the tooth is restorable, root canal
270 MANAGEMENT OF ACUTE EMERGENCIES AND TRAUMATIC DENTAL INJURIES
Fig. 10.20 Gold partial coverage Fig. 10.21 Molar tooth supported Fig. 10.22 Vertical fractures involving
restoration giving occlusal protection by an orthodontic band the floor of the chamber
treatment may commence. Should the fracture line run through the floor Camphorated Phenol Cresatin
of the pulp chamber, then it is unlikely that the tooth will respond to treat- 15 15
ment in the long term.
In cases where the tooth is cracked but is incomplete, the crown should **
Number of cases
10 10 **
be supported with a metal band (Fig. 10.21) and root canal treatment com-
menced. The long-term prognosis of posterior teeth with oblique fractures
above the alveolar crest and involving only the roof of the pulp chamber 5 5
is higher than vertical fractures involving the floor of the chamber
(Fig. 10.22). 0 0
Whether the treatment consists of a pulpotomy or pulpectomy, there 0 1 7 30 0 1 7 30
Day
should be 50–75% reduction in the severity of the pain within one day but
Eugenol Zoe
the residual pain may linger for 24–48 hours gradually reducing over the 15 15
following 24 hours (total 72 hours). It may take a further 7–28 days gradu-
ally to subside completely (Fig. 10.23). The lingering pain may be worse
10 * 10
when a complete pulpectomy with cleaning and shaping is performed. If
symptoms continue beyond this time, the presence of residual inflamed
pulpal tissue should be investigated in the root canal system in the form 5 5
of an undiagnosed canal.
If the tooth is extracted, the pain may gradually subside over the next
0 0
3 days, albeit with a changed character. 0 1 7 30 0 1 7 30
Some clinicians recommend occlusal reduction, but such an approach
should only be adopted following a proper occlusal assessment. The tooth Saline Dry Pellet
15 15
will not stay out of contact for long because of continued eruption. Occlu- **
sal reduction works when there had been previous presence of percussion
sensitivity, in vital cases and in the absence of a periapical radiolucency. 10 10
The authors do not recommend it as a routine procedure.
5 5
Medication
Antibiotics have commonly been prescribed for irreversible pulpitis but
0 0
such medication will have no effect on the inflamed pulp and is contrain- 0 1 7 30 0 1 7 30
dicated. Analgesics are a useful adjunct to manage the residual pain as Fig. 10.23 Number of cases presenting with symptoms over a 30-day period
discussed above. following root canal dressing using various materials (darkest shade = pain,
intermediate shade = discomfort, lightest shade = no symptoms; * patient did
EMERGENCIES OF PERIRADICULAR ORIGIN not attend for the 30 day clinical examination; ** patients needed further
emergency treatment) (Hasselgren, G., Reit, C.,1989. Emergency pulpotomy:
Diagnosis pain relieving effect with and without the use of sedative dressings. J Endod
15 (6), 254–256)
Inflammation and infection of the periodontal tissues may cause severe
pain. The purpose of the periapical inflammatory lesion is to restrict infec-
tion to the tooth; therefore, the seriousness of the problem escalates when Acute apical periodontitis is an acute inflammation of the periodontal
it has failed in this remit and infection is spreading to subjacent tissues ligament, generally related to pulpal inflammation but occasionally result-
and other parts of the body. ing from acute or chronic trauma.
It is important to establish whether the pain and swelling involving the An acute apical abscess (Fig. 10.24a) may develop as incipient apical
supporting tissues is of periodontal or pulpal origin. Classically, pulp tests periodontitis or from a pre-existing chronic lesion. In the incipient lesion,
will help to differentiate the origin unless, of course, there is partial necro- the tooth involved does not exhibit an apical radiolucency and will be
sis. Careful periodontal probing should supplement the examination. exquisitely painful to touch.
MANAGEMENT OF ACUTE EMERGENCIES AND TRAUMATIC DENTAL INJURIES 271
A B C D
Fig. 10.24 (a) Acute apical abscess with facial swelling; (b,c) swelling of chin associated with mandibular anterior teeth; (d) large mandibular radiolucency
related to the incisor teeth
Pterygomandibular space – via third molars or infection spread by lower eyelid (Fig. 10.26). There is risk of cavernous sinus
injection upon inferior dental nerve block posterior superior block. thrombosis
There is limited external swelling but there is severe limitation of Palatal subperiosteal interval – the palatal mucosa is closely
opening and dysphagia tethered to the periosteum, particularly at the gingival margin and
Lateral (para)pharyngeal space – via third molars; there is extreme median suture. Infections associated with the maxillary lateral
pain on swelling with limitation of opening and considerable incisor are closer to the palate and drain into the palatal aspect
pyrexia and malaise. The tonsil and lateral pharyngeal wall are separating the periosteum and producing a circumscribed fluctuant
pushed inwards but there is little external facial swelling. This is a swelling; it rarely crosses the midline but may track backwards to
serious infection and complications include thrombophlebitis of the the soft palate (Fig. 10.27)
internal jugular vein, erosion of the carotid artery may be fatal; this Maxillary antrum – the relationship between the antrum and apices
may be presaged by inequality of the pupils because of of maxillary teeth varies but most commonly second and first
involvement of the cervical sympathetic chain. molars may be close, followed by the third molar, premolars, or
even the canine. Infections arising from these generally drain
The spaces in relation to the maxilla are:
buccally or even palatally but may rarely drain into the antrum.
Within the lip – via upper incisors or canines; infection remains Usually, proximity of the apices may cause mucosal thickening in
behind the orbicularis oris which, as they take origin at the anterior the overlying antrum. Pus draining into the antrum may result in
nasal spine, results in the swelling pointing over the lateral acute sinusitis
incisors. Rarely, infection may spread to the cavernous sinus Infratemporal fossa space – this space is continuous with the upper
because the veins have no valves part of the pterygomandibular space and, in contrast to the lower
Within the canine fossa – via the canine or premolar draining space, is infected by the maxillary molars or contaminated needles
buccally. If the root is short, pus may drain below the levator during injection. Infection may spread deep to and lateral to the
anguli oris and point to the buccal sulcus. Otherwise, the pus may temporalis muscle. There may be marked limitation of opening.
travel up between the levator labii superioris and levator superioris The swelling is subtly evident as a filling out of the hollow behind
alaeque nasi to point below the medial corner of the eye. There the zygomatic process of the frontal bone. Infection of this space is
may be considerable swelling of the cheek and upper lip; serious because of the presence of pterygoid plexus of veins, which
nasolabial fold may be obliterated and there may be oedema of the communicate with the cavernous sinus
Subtemporalis muscle interval – the above infection may track
further upwards to produce this infection.
Fig. 10.26 Closure of
eye associated with Treatment
infection thought to
Emergency treatment of a periodontal abscess will involve institution of
arise from maxillary
canine drainage, debridement of the pocket and, when required, antibiotic pre-
scription. Root canal treatment of a tooth with acute apical periodontitis
should aim to ensure that the canal system is thoroughly debrided without
inflicting further insult to the apical tissues by over-instrumentation or
extrusion. Occlusal adjustment to relieve contacts may initially be helpful.
The priority for pain relief in an acute apical abscess is to establish
drainage through the root canal system (Fig. 10.28); incision and drainage
are not productive. The tooth, if tender, should be stabilized while the
B C
MANAGEMENT OF ACUTE EMERGENCIES AND TRAUMATIC DENTAL INJURIES 273
access cavity is being cut as the vibration from the hand-piece will induce If ever an extra-oral incision is called for, it should ideally be undertaken
extreme pain, despite anaesthesia. by a surgeon with insight about anatomical structures and management of
In acute exacerbation of a chronic lesion, any fluctuant swelling should such incisions. They should follow the lines of Langer and skin creases,
be incised to establish drainage. Under local anaesthesia, an incision otherwise the principles are the same. Particular care is also required for
should be made using a No. 11 blade through the point of maximum fluctu- drainage of pus from tissue compartments that are inaccessible (pterygo-
ance, parallel to the surface of the alveolar bone in the labial sulcus or mandibular, lateral pharyngeal, submasseteric, infratemporal) and where
anteroposteriorly parallel to the nerves and blood-vessels in the palate, to it may be impossible to elicit classic signs of suppuration.
liberate the contained pus. If pus has not been found, a closed blade mos- Management of an unresponding spreading infection and cellulitis that
quito artery forceps can be used to thrust through the incision and advance appears to begin to involve the floor of the mouth and upper neck or
deeper into the abscess and then open to liberate the pus. The space can towards the cavernous sinus, must involve prompt referral to a hospital
then be irrigated with saline using a wide-bore irrigation needle. The canal for emergency care involving immediate drainage of the relevant tissue
system should then be thoroughly debrided and irrigated, preferably using compartments, tooth extraction if necessary and intravenous antibiotics
ultrasonic agitation, the access is sealed with calcium hydroxide to prevent (Fig. 10.29). These patients need constant monitoring, if necessary in
recontamination. Only when there is profuse, uncontrollable drainage intensive care, to control respiratory difficulty. Maintaining airway patency
should a tooth be left open to drain for a maximum period of 24 hours. is of the highest priority because swelling makes oral endotracheal intuba-
This normally occurs when the problem is caused by an infected cyst; the tion difficult. Fibreoptic nasotracheal intubation performed under topical
exudate being clear, yellowish, and sometimes mixed with blood or pus. anaesthesia in the operating room or intensive care unit with the patient
Management of a spreading infection and cellulitis with raised body awake is preferable. Some patients require a tracheotomy. Patients without
temperature must involve establishment of local drainage through soft immediate need for intubation require intense observation and may benefit
tissues and/or root canal system and prescription of antibiotics. The age-old temporarily from a nasal trumpet.
adage, “do not let the sun set on accumulated pus” still holds true and Pus samples should be obtained, where possible, using a wide-bore
should be complied with wherever possible to achieve drainage. needle enables anaerobic culturing. Both aerobic and anaerobic culture and
Incision and drainage requires knowledge of tissue spaces, where pus antibiotic sensitivity tests should be performed to inform any required
may accumulate, and knowledge and confidence to deal with the anatomi- subsequent therapy. The approach also enables drainage of an abscess (see
cal structures. Incision and drainage are indicated where evidence of pus Fig. 10.27b, c).
is indicated by dusky redness in the general redness of a firm swelling (see Successfully controlled infection is apparent in the drop in the patient’s
Fig. 10.24c), where there is localized tenderness over the centre of a swell- body temperature, a reduction in malaise and toxaemia, relief of pain and
ing, where there is pitting oedema in the middle of a previously firm a reduction in the swelling. Initial signs include the appearance of fine
swelling. Where the clinician feels they lack adequate skill, the patient wrinkles where the skin may have been tense, red and shiny.
should be promptly referred for appropriate care. Adequate anaesthesia is
Medication
paramount and the presence of the pus and infection dictates that anaes-
thetic is deposited proximally or regionally for effectiveness. The incision Antibiotics are indicated when patients have toxic systemic effects and a
is made intra-orally wherever possible, directly over the most fluctuant raised temperature. There is currently insufficient evidence to advocate the
part, firmly and down to the periosoteum and should be wide enough to use of one regimen over another. Increasingly, short-term antibiotics are
drain the whole cavity. In general, knowledge of surgical anatomy will being used. For patients who are not allergic to penicillin, a two-dose
help avoid important vessels and nerves, for example, incision of a palatal regimen of 3G amoxicillin can be used. Alternatively, for most patients,
abscess should be performed in an anteroposterior direction to avoid divid- where drainage has been instigated, 2 or 3 days of oral antibiotics, given
ing the greater palatine vessels. Once incised, the scalpel blade is not in a high dose, will suffice for acute dentoalveolar infections; amoxicillin
required and is replaced with a pair of mosquito artery forceps to explore 250 mg every 8 hours. Metronidazole is active against anaerobic organ-
and open up locules of pus, which may be aspirated away. The site isms, which are commonly found in acute dental infections. It is often
and incision may be washed with saline. A drain, consisting of a radio- given in combination with amoxicillin with good effect. However, it has
paque non-resorbable material, such as plastic is secured with a suture for also been shown to have good efficacy in isolation, possibly because the
2–3 days. true nature of dental infections is not properly appreciated. If local patterns
274 MANAGEMENT OF ACUTE EMERGENCIES AND TRAUMATIC DENTAL INJURIES
of antimicrobial resistance indicate a high prevalence of resistance to Fig. 10.30 Young patient with facial
amoxicillin then the use of either metronidazole (400 mg 2–3 times daily) and possible head injuries
or amoxicillin in combination with clavulanic acid should be considered
as alternatives. Clindamycin remains an alternative in individuals who are
allergic to the penicillin group of antibiotics. It is advisable to review all
patients within 24 hours.
Analgesic regimens should be employed as discussed above, titrated
against the patient’s needs.
Determine those teeth that can and those that cannot be saved: the Fig. 10.31 (a) Maxillary
extent of dental damage (nature and extent of coronal/radicular incisor with complicated
fractures) should be assessed and their prognoses established. crown fracture (courtesy
of Department of Child
Efforts required to retain the teeth should be considered, in the
Dental Health, Leeds
light of the patient’s overall treatment needs (including any Dental Institute). (b)
relevant medical conditions), in order to reach a balanced decision Subsequent restoration
regarding the future of the teeth of maxillary incisor
Determine the priorities of treatment, divided into short-, medium- using fractured section
and long-term plans: a sequence will be agreed with the patient for (courtesy of Department
the order, in which hopeless teeth may be extracted, painful teeth of Child Dental Health,
A
Leeds Dental Institute)
stabilized and managed to alleviate pain (coverage of exposed
dentine or pulp extirpation), soft- and hard-tissue radiographs
taken, antitetanus and antibiotic cover provided, temporary
restorative solutions implemented to preserve aesthetics, space,
function and speech (temporary dentures, resin-retained or Essix-
retained teeth), vital pulp therapy, root canal treatment, restorative
work provided, regular review protocol established, and
contingency for longer term failure and the need for, and referral to
specialist colleagues established.
ACUTE MANAGEMENT
The principles of acute management of traumatic dentoalveolar injuries B
are as those for the management of any acute injury. They are to:
replace or approximate displaced parts
stabilize repositioned parts to allow optimal primary healing
dress or cover exposed part(s)
rest the injured part(s) or allow only physiologic movement to Root fractures
allow optimal healing.
Traumatic impact injuries may cause a variety of patterns of root fractures
These principles are applied below to facilitate immediate management which, because of the nature and direction of force, will generally tend to
of dentoalveolar injuries. be transverse or oblique but may also be vertically oriented. Transverse
Crown fractures root fractures may occur in any third of the root and in conjunction with
the level of injury to the alveolar housing will dictate the level of mobility.
Crown fractures may involve only the enamel or both the enamel and the Traditionally, root fractures below the level of the alveolar crest, unex-
dentine (Fig. 10.31a). The damaged tooth should be assessed (clinically, posed to the oral environment, have been splinted for long periods, up to
radiographically and through pulp testing) before deciding on the nature 12 weeks, to secure union of the fragments. Although, this length of time
of stabilization and protection required. Enamel may be smoothened or for splinting may only be necessary in situations where there has been
rebuilt with composite to stabilize the tooth position. Exposed dentine is displacement and considerable mobility of the coronal fragment. Where
protected with a liner and a bonded composite. It may be possible to reat- there is no increased mobility, splinting may not be required and the tooth
tach the fractured portion of the tooth as the restoration (Fig. 10.31b). should then be reviewed clinically and radiographically at 3, 6 and 12
Fracture resulting in pulpal exposure requires the additional and prior months.
consideration of vital pulp therapy to protect the pulp through dentine The degree of displacement of the coronal root fragment may also
regeneration. The emphasis on such a conservative approach is even determine the extent of damage to the pulp. Pulp testing may be unreliable
greater for teeth with immature roots, in order to encourage continued root for a period of 2 to 6 months, although recovery up to 12 months is also
development. If the exposed pulp is judged to be superficially infected and possible.
necrotic, partial removal of the pulp may be considered. Alternatively, If the tooth remains firm and the pulp remains responsive, no further
if the pulp is judged to be beyond regeneration, pulpectomy may be con- treatment is necessary. Many undiagnosed fractures remain symptomless
sidered. Details of the vital pulp therapy procedures are provided in and cause no problems (Figs 10.32, 10.33). Sometimes, a coronal level
Chapter 7. root fracture, although having increased but not increasing mobility, may
survive if allowed to for years; in the cases shown, one tooth has survived
Crown–root fractures for 30 years (Fig. 10.34) and another for 20 years (Fig. 10.35).
The treatment of crown–root fractures depends largely on their location, If the pulp response is not regained, generally (in about 25% of cases),
orientation and the degree of mobility of the coronal portion. To embark the coronal segment may become necrotic with evidence of pulp infection
on a complex and costly treatment plan, the longevity of the planned indicated by a developing radiolucency at the fracture line (Fig. 10.36b).
restorative strategy must be assured without the risk of incurring damage In others, the pulp may become symptomatic (Fig. 10.37a). In either case,
to the structures that may facilitate future restorative options, such as root canal treatment may then be performed to the fracture line. Calcium
implants. The need for surgery to expose the margins of the fracture, hydroxide is used as a long-term medicament to encourage calcification
orthodontic extrusion of the root to facilitate restorative procedures, and (Fig. 10.36b) and formation of a hard-tissue barrier, against which the
space maintenance to avoid later restorative problems should be borne obturating material can be compacted (Figs 10.36c, 10.37b). Sometimes,
in mind. the calcium hydroxide may not be effective in inducing an effective calcific
276 MANAGEMENT OF ACUTE EMERGENCIES AND TRAUMATIC DENTAL INJURIES
A B C
Fig. 10.36 (a) Horizontal middle third fracture of maxillary incisor; (b) calcium hydroxide dressing to fracture line;
(c) obturation of fractured incisor to fracture line
barrier (Fig. 10.38a–c) and allow some extrusion of root filling material, Roots of molar teeth may also be fractured through trauma, such as in
however, the apical fragment may survive with pulp obliteration this case where the patient was struck by a cricket ball, fracturing the
(Fig. 10.38d). In fact, it should be noted that pulp obliteration is the general mesiobuccal root (Fig. 10.40a). The root was removed and, as the pulp
outcome in the apical fragment (Figs 10.36c, 10.37b, 10.38d). Alterna- presented a clinically healthy looking surface, it was pulp capped and
tively, MTA can be placed apically to act as a hard tissue barrier or, indeed, restored with glass ionomer cement (Fig. 10.40b,c). After 2 years, unfor-
to act as the entire root-filling material, although the long-term effects of tunately, the glass ionomer cap became loose, the pulp was in the early
this latter approach are not known. Root canal treatment of both fragments stages of necrosis, requiring extirpation (Fig. 10.40d). The problem was
is only necessary in the case of apical changes (very rare) or if it is impos- that there was no secure means of restoring the pulp cap as there was no
sible to control file length adequately during the procedure (Fig. 10.39). cavity; the reliance being on adhesion, which failed after a time.
When the whole pulp becomes necrotic, surgical removal of the apical Sometimes, teeth with pre-existing root fillings and posts may also be
portion may be a more manageable option. traumatized and present with a fracture. The stress concentration, whether
MANAGEMENT OF ACUTE EMERGENCIES AND TRAUMATIC DENTAL INJURIES 277
due to chronic fatigue or impact injury, occurs at the apex of the post, Many types of splint are available for stabilizing repositioned, replanted
where the fracture line is or, in due course, radiolucencies may present and fractured teeth. The requirement of the splint may be to achieve rigid
(Fig. 10.41). fixation if there is extensive root and alveolar bone fracture or semi-rigid
fixation if the purpose is simply to provide stability with physiological
Treatment of luxated teeth mobility, that is, avoid accidental redisplacement. As a guide, when mul-
The nature of luxation or tooth displacement is categorized as subluxation tiple teeth have been displaced with alveolar bone and root fractures, rigid
(minimal), lateral luxation, extrusive luxation, intrusive luxation and avul- fixation may be appropriate, involving several uninjured teeth on either
sion. These terms define both the nature and extent of crushing or stretching/ side. The recommended duration of splinting is 1 month but may be
tearing injuries inflicted on the periodontal ligament. They may further be extended up to 4 months if the root fracture is near the cervical region,
accompanied by injuries to the alveolar housing, as well as the tooth while localized avulsion of a single tooth may simply merit a twist-flex
structure and neurovascular supply to the pulp. Displaced teeth should be wire attached to the avulsed tooth and one tooth on either side with com-
repositioned and stabilized. The original position of the teeth may be dif- posite (Fig. 10.42). The use of etched enamel retained composite and
ficult to determine sometimes if the teeth were previously irregularly polymethacrylate reinforced with wire or nylon has also been advocated.
arranged. Clues may be obtained from occlusal faceting caused by Reimplanted teeth are generally splinted up to 14 days.
parafunction and from pre-injury photos of the patient smiling (which are If there is evidence to suggest that the pulp of a luxated tooth has
not always available when needed). become necrotic and infected, root canal treatment should be initiated.
Completely avulsed teeth that have been replanted should undergo
root canal treatment 7–10 days following replantation. The possibility
of replacement resorption (Fig. 10.43) can neither be predicted nor
treated.
INTRAOPERATIVE EMERGENCIES
MEDICAL EMERGENCIES
It is every dental professional’s ethical and moral responsibility to ensure
that they have knowledge and skills to deal with any medical emergency
that may arise in their practice. Although rare, it is estimated that the
average dentist can encounter a medical emergency every 16 months; a
problem more likely in an ageing population. Dentists are now required
to have training in cardiopulmonary resuscitation (CPR), basic airway
management and the use of an automatic external defibrillator (AED),
A B
which is updated annually.
Fig. 10.37 (a) Maxillary incisor with middle-third horizontal fracture; Hopefully, a good medical history will have identified those patients
(b) fractured incisor following root canal treatment to the fracture line who may be at risk from a medical emergency. There are very few, if any,
D
A B
C
Fig. 10.38 (a–c) Calcium hydroxide failed to induce an effective calcific barrier at the apical end of the coronal fragment; (d) apical fragment survived with pulp
obliteration
278 MANAGEMENT OF ACUTE EMERGENCIES AND TRAUMATIC DENTAL INJURIES
medical conditions that preclude the possibility of endodontic treatment, While the treatment for vaso-vagal syncopy is to lay the patient flat,
especially as the alternative is often a tooth extraction with the entire during pregnancy, laying the patient flat can induce syncopy. Treatment is
attendant trauma. However, special arrangements may have to be in place to remove the pressure of the fetus on the vena cavae by raising the patient
to guard against possible problems. Diabetics may wish to be seen at a forward.
certain time of day so that their routines are not disturbed with the pos- Cardiovascular conditions in the mildest form would present as angina
sibility of a hypoglycaemic attack occurring. Consultation with other spe- attack, for which the patient should be able to self-medicate, although
cialists is often of benefit where the use of corticosteroids may be involved having a glyceryl trinitrate inhaler in the practice is advised, ideally with
for those patients who have adrenal insufficiency. The prepositioning of blood pressure monitoring. Patients exhibiting signs of a myocardial inf-
intravenous access would allow a quicker and possibly less-panicked arction should be given oxygen and the emergency services called promptly.
response in the case of an emergency. CPR training should be engaged as required.
One of the most serious medical emergencies in the practice is anaphy-
laxis. A patient can have an anaphylactic reaction to many materials. There
has been a reported increase in reactions to latex. The use of rubber dam
in endodontics makes this occurrence particularly important. A medical
history showing food intolerance to bananas and avocados may show a
cross-reaction to latex. Patients can develop a reaction to latex with a
number of exposures. Where patients show possible early signs, such as
tingling of the lips, then latex-free rubber dam and gloves should be con-
sidered. Where there are the signs of an anaphylactic reaction, adrenaline
(epinephrine) (0.5–1 ml 1 : 1000 intramuscularly in adults) and oxygen
should be administered as a first line of management. The emergency
services should be called immediately.
SODIUM HYPOCHLORITE
Ironically, although the chief problem of irrigation is irrigant delivery to
the apical part of the canal, it is suspected that, in most cases, there may
be some seepage or diffusion of the irrigant into the periapical tissues,
which probably causes little harm. Very occasionally, extrusion of a suf-
ficient bolus of irrigant may cause adverse reactions, particularly when
using sodium hypochlorite (NaOCl) (Hülsmann & Hahn, 2000). Acciden-
A B
tal injection of NaOCl into the periapical tissues via the apical terminus
Fig. 10.39 (a) Maxillary incisor with horizontal fracture; (b) root canal or root perforations can cause sudden sharp severe pain, immediate swell-
treatment of fractured incisor because of pulpal symptoms ing (Fig. 10.44) and profuse bleeding. A NaOCl accident would more
A B
Fig. 10.40 (a) Mesio-buccal root of the maxillary first molar with horizontal fracture. (b,c) The mesio-
buccal root in (a) was amputated and exposed pulp capped and restored with glass ionomer cement. (d)
D
The glass ionomer cap in (c) debonded after 2 years
MANAGEMENT OF ACUTE EMERGENCIES AND TRAUMATIC DENTAL INJURIES 279
likely occur when NaOCl had direct access to a soft-tissue space, such as alveolar bone had been perforated by the disease process. Extrusion of
the buccal or infraorbital, cyst or maxillary sinus rather than simply con- high concentration (5%) NaOCl may cause extensive tissue damage result-
tacting periapical tissue. This is more commonly reported in the maxilla ing in tissue necrosis. Lower concentration may increase vascular perme-
than in the mandible and might happen when the anatomic apex of a tooth ability, probably as a result of damage to the blood vessels, as well as the
naturally fenestrated through the overlying alveolar bone or when the release of chemical mediators, such as histamine, from involved tissue.
This characteristic causes immediate swelling and often profuse bleeding
through the root canal.
It must be stressed that great care should be taken when using NaOCl.
Fig. 10.41 Maxillary The bore of any needle used should be large enough to allow the free flow
incisor with an oblique of the disinfectant without the application of undue pressure. A “side-
root fracture apical to venting” needle is less prone to apical extrusion. It is always wise to check
the post and associated that it is securely fastened to the syringe and it is worth considering the
with a periradicular
radiolucency
placement of a rubber stop on the needle short of the working length. The
needle should not bind in the canal and it should be possible to keep the
needle moving within the canal. The irrigant should be expressed slowly
and irrigation should be stopped if any resistance to the plunger is felt.
The potential for extrusion when using negative pressure, sonic or
ultrasonic systems has been investigated using extracted tooth models with
pre-prepared canals. No evidence of extrusion of irrigant was found using
the negative pressure EndoVac® system but a minimal amount was
extruded using the sonic EndoActivator™. Both these techniques had
significantly less extrusion than manual dynamic irrigation (pumping of
irrigant using a matching gutta-percha point), automated dynamic irriga-
tion (RinsEndo handpiece) or ultrasonic active irrigation. There is,
however, a higher risk of apical extrusion of irrigant delivered through the
RinsEndo handpiece than irrigant delivered manually through syringe
Fig. 10.42 Twist-flex
irrigation. Ultrasonic irrigation during canal preparation was found to
wire splint (courtesy of result in significantly more extrusion than dynamic syringe irrigation.
Department of Child Limiting the extension of the needle or ultrasonic file 1 mm short of canal
Dental Health, Leeds terminus could reduce extrusion.
Dental Institute) When a hypochlorite accident occurs, the patient will report a sudden
sharp pain despite effective dental anaesthesia. The patient will be clearly
alarmed as often will the dentist. It is important for the clinician to stay
calm and reassure the patient. The canal benefits from being washed with
sterile water. Further analgesic may be administered to relieve pain. The
tooth should be monitored over the next half an hour; there may be a
bloody exudate. Drainage should be encouraged. Antibiotics should be
considered in serious cases if there is a risk of infection.
Corticosteroids assist in limiting the swelling. The use of cold com-
presses for 6 hours will help to reduce pain and swelling. Following this,
warm compresses will help to encourage healthy healing. The patient
should be warned of swelling and consequent bruising.
In the case of maxillary teeth, injection into the maxillary antrum is a
risk; the patient may report the smell and taste of bleach, in addition to
sudden pain. Likewise, in mandibular teeth, injection into the inferior
dental nerve canal is a risk, with consequent neural damage. Extrusion into
the muscle mass may lead to scarring and facial asymmetry in rare cases.
INTERAPPOINTMENT AND
POSTOPERATIVE EMERGENCIES
Patients may experience pain after canal preparation and cleaning or fol-
lowing obturation of the root canal system; it is a normal finding in almost
half of all patients. The presence of preoperative pain guarantees postop-
erative pain owing to pre-existing hyperalgesia. This can take 3–4 days to
Fig. 10.43 Replacement
subside but will be maximal over the first 24–48 hours. Other predictors
resorption affecting
maxillary incisor Fig. 10.44 Soft tissue swelling of postoperative pain are female gender, presence of necrotic pulp tissue
(courtesy of Department following a sodium hypochlorite and apical periodontitis, presence of allergies, previous history of painful
of Child Dental Health, accident treatment and manual dynamic irrigation. It is as well to forewarn the
Leeds Dental Institute) patient and give medication advice.
280 MANAGEMENT OF ACUTE EMERGENCIES AND TRAUMATIC DENTAL INJURIES
Acute apical periodontitis is common following root canal preparation drain, after which the canals should be gently instrumented and irrigated
and is due to over-instrumentation, extrusion of medicaments, and with sodium hypochlorite. A calcium hydroxide dressing should be placed
incomplete canal preparation (due to inadequate length or irrigant penetra- and the access sealed. In contrast, teeth with previously necrotic pulps and
tion) and traumatic occlusion. Teeth with pre-existing chronic lesions presence of a swelling at presentation should have incision and drainage
without sinus formation or symptoms are more prone to interappointment performed and the canal system re-irrigated. This process should also
exacerbation. It is thought that this may be explained by the altered adapta- involve a search for any missed canals and their appropriate management.
tion syndrome, where a change in the chronic balance between the micro- The access should be sealed; there are few indications for leaving teeth on
biota and host is altered; the response may be dominated by exudate rather open drainage.
than pus. A patient who is allergic to various substances, or is atopic, may Interappointment discomfort is also encountered with leaking restora-
be more susceptible; readiness with their usual antihistamine medication tions, which allow recontamination of the canal system. The area of
may prove helpful. leakage must be found and the problem dealt with. Where a pre-existing
Management of interappointment problems depends on the preoperative crown has been retained and access gained through it to complete an
diagnosis and the presenting symptoms. A tooth with a previously vital endodontic procedure, its marginal integrity should be critically assessed
pulp, treated by complete cleaning and shaping generally does not require (Fig. 10.45).
emergency attention, only reassurance. Teeth undergoing incomplete vital The probable causes of pain following obturation of the root canal
pulpectomy because of shortness of time may benefit from dressing with system are inadequate cleaning of the root canal system, extrusion of
a corticosteroid medicament; completion of root canal treatment should irritant materials (Fig. 10.46), root fracture precipitated by the filling pro-
follow swiftly afterwards. cedure (Fig. 10.47) and traumatic occlusion.
Teeth with previously necrotic pulps and an absence of swelling at Pre-informing patients about possible discomfort in the first few days
presentation should be reopened and irrigated to allow any exudate to following root canal treatment and advice regarding analgesics will reduce
the patient’s anxiety regarding postoperative pain. Where patients do
require follow-up treatment, this may involve reassurance, advice on the
Fig. 10.45 Carious use of analgesics (and possibly antibiotics), removal of the root filling and
maxillary premolar repreparation of the root canals, and surgical endodontic treatment to
remove extruded material or resection of the root. There are a few cases
where the symptoms do not respond to further therapy, in which case
extraction may need to be considered.
B
A
C
MANAGEMENT OF ACUTE EMERGENCIES AND TRAUMATIC DENTAL INJURIES 281
demands to calculate the costs, although this is likely to have been an initial priority is the epithelial seal, which occurs by mitosis and migration
exercise the dentist will have entered into with the patient. The difference of basal and prickle cells from adjacent intact tissue. The seal is formed
is that the patient’s requirements will be spread over many years and the as early as within 24 hours on the foundation of a fibrin clot. By rapid cell
costs are therefore difficult to estimate, yet the compensation boards will division, the multiple layers of the epithelium are re-established within 3
require those estimates at the outset, not many years later. The dentist days and an intact barrier is evident at 7 days.
should therefore become familiar with the literature on the natural history The initial coagulum in the periodontal ligament is replaced by a young
of outcomes of injuries and the outcomes of management approaches. This connective tissue by 3–4 days. The cells for this process, consisting
may be made somewhat challenging by the relatively limited amount of of pluripotential undifferentiated mesenchymal cells, originate from the
such data available, although it must be said that it is fortunate that some adjacent periodontal ligament and the endosteum. The cells differentiate
groups have focused on gathering such data very well. into fibroblasts synthesizing ground substance and collagen, as well as
The dentist should understand the nature and timing of healing and cementoblasts and osteoblasts that initiate new cementum and bone forma-
complications associated with various types of injuries, which should have tion. Cementoblasts begin to deposit cementoid by 10–12 days, while
a biological foundation, confirmed by clinical data. The factors to consider osteoblasts deposit osteoid within 10–14 days; new collagen fibres will be
are injuries to and healing of the dental hard tissues, dental pulp, perio- evident at 14 days. By 21–28 days, the full periodontal apparatus, consist-
dontal ligament and alveolar bone. ing of functional cementum, bone and periodontal ligament fibres will
be established.
Where the damage to the periodontal ligament is excessive, clastic cells
HEALING PATTERNS, TRENDS AND
may dominate resulting in resorption of the unprotected hard tissue surface.
SALIENT FEATURES
In the absence of inflammation, the root surface is recognized as a mineral-
Template for wound healing, repair and regeneration ized surface, which is then modified by resorption and redeposition of
osteoid. This, replacement resorption, may be evident as early as 2 months.
The process of wound healing follows a standard pattern dictated by
Where excessive periodontal ligament damage is superimposed by
molecular signalling from various cell lines. It initially involves a clearing
infection either from an inadequate or incomplete epithelial seal or from
of the dead tissue by polymorphonuclear lymphocytes (PMNs) and mac-
infection of the root canal system, the healing process becomes superim-
rophages, which are attracted to the site by release of factors signalling
posed by inflammation. This may fuel a much more aggressive resorptive
cell death and foreign matter. The PMNs dominate initially as they are
process, known as inflammatory resorption, which may be evident at 2
important in helping to control incipient infection to be replaced by the
weeks.
macrophages, which play an active role in coordinating the healing process.
As the clearance by phagocytosis and digestion gets under way, the mac-
rophages signal the influx of nutritive elements to the site by the ingrowth
Root fracture and apical development
of budding capillary vessels (angiogenesis). Circulating proteins and Root fractures may or may not heal depending upon the presence of
immune cells will be attracted by foreign material and bacterial factors. optimal conditions; lack of approximation, infection and severe inflamma-
Following closely behind are undifferentiated mesenchymal cells and tion may preclude it. Healing may be dominated by connective tissue from
fibroblasts from the perivascular tissues, which slowly but gradually come the pulp or periodontal ligament. If the pulp has survived the injury or is
to dominate the cell population. The former, depending upon the extent to revascularized rapidly enough, pulpal cells can contribute to healing by
which they are able to differentiate into local tissue cells upon chemical forming a dentine callus intrapulpally and cementum callus externally. By
attraction and stimulation, will dictate the regenerative process, while the definition, this is only likely if the two fragments are optimally approxi-
latter will aid and support healing and repair. mated by repositioning and maintained in such position (by splinting) for
The balance between regeneration (replacement with original tissue) or a period of up to 3 months.
repair (replacement with fibrous tissue) will be dictated by the relative The pulp and the apical residue of the dental papilla are responsible for
extent of tissue damage and availability and stimulation of pluripotential the ongoing development of the root. Pulp death or damage to the apical
cells. The greater the damage and the more compromised the local pres- region of the root may arrest root development. Much effort has been
ence of mesenchymal cells, the more likely it is that healing will occur by recently spent on devising ways to encourage continued root growth when
fibrous tissue formation. the pulp has been compromised. This includes efforts to regenerate the
pulp by inducing apical bleeding to invite mesenchymal pulpal stem cells
Pulp into the pulp space. Protection of the apical tissues by eliminating infection
Depending upon the nature of injury, pulp death may be almost instantane- and inflammation appears to encourage continued root growth (apexogen-
ous or drawn out over several days to weeks. The peripheral parts, coronal esis) (Fig. 10.48). In the absence of such continued root growth, the clini-
pulp horns would succumb first and may be found to be dying at about 3 cal effort is spent on inducing a calcific barrier (apexification) to prevent
days. The wound healing process described above may enable new blood apical extrusion during root canal obturation.
vessels to invade at the apical foramen by 4 days, by 10 days these will Other ways to prevent apical extrusion includes the use of MTA plug
have advanced to mid-root and by 30–40 days will have become estab- apically (Fig. 10.49).
lished in the coronal part. Nerve growth lags behind and will have advanced
into the apical portion only by day 14, slowly progressing coronally there- Alveolar bone
after. Residual populations of undifferentiated mesenchymal cells in the The healing progression will depend upon the extent of injury to the over-
pulp or in the apical papilla region may help to reinvigorate the regenera- lying mucosa, epithelial attachment, the bone itself and periosteum. As
tive potential of the pulp in the immature tooth. for any injury, the immediate aftermath is followed by the formation
of a coagulum. PMNs and macrophages will begin the clearing process by
Periodontal ligament
migrating into the coagulum from the mucosal and endosteal surfaces
Damage to the periodontal attachment may be considered in relation to and be established by the day 4. Undifferentiated mesenchymal cells and
both the epithelial attachment and the rest of the fibre attachment. The fibroblasts will migrate into the coagulum by days 4–7; these will
282 MANAGEMENT OF ACUTE EMERGENCIES AND TRAUMATIC DENTAL INJURIES
A B
A C
Table 10.4 Percentage of teeth with pulp survival after various types of injury
1 month 2 months 3 months 6 months 12 months 24 months 36 months 48 months 60 months 10 years
Concussion Closed apex 100 100 97 97 97 97 97 97 97 97
Open apex 100 100 100 100 100 100 100 100 100 100
Subluxation Closed apex 100 100 90 85 85 85 85 85 85 85
Open apex 100 100 100 100 100 100 100 100 100 100
Extrusive Closed apex 100 87 50 50 45 45 45 45 45 45
luxation Open apex 100 99 97 97 95 95 95 95 95 95
Lateral Closed apex 100 90 50 35 25 25 25 25 22 22
luxation Open apex 100 98 97 96 96 94 94 94 94 94
Intrusive Closed apex 100 60 30 3 1 1 1 1 1 1
luxation Open apex 100 90 77 55 48 48 48 48 38 38
Replantation Closed apex – 38 3 1 0 0 0 0 0 0
Open apex – 60 42 35 35 35 35 35 35 35
vival drops to 20% and if repositioned after 24 hours, pulp survival drops Extrusive Closed 80 15 5 0
luxation apex
to 10%.
Open 86 7 7 0
Table 10.5 depicts the data for periodontal ligament damage after apex
luxation injuries. Once again, teeth with open apices seem to fare Lateral Closed 67 30 3 1
better, presumably because such teeth will be socketed in alveolar luxation apex
bone that is thinner and more resilient. Young bone of such patients Open 90 7 3 0
apex
may be more prone to “green-stick” fracture. Once again, the crush-
ing injuries of lateral and intrusive luxation result in the most unfa- Intrusive Closed 0 30 40 30
luxation apex
vourable healing outcomes, with intrusive injuries being by far the Open 30 20 40 10
worst. apex
When teeth are repositioned after alveolar fracture, 10% may develop
resorption. After Andreasen & Pedersen, 1985; Andreasen et al., 1989
Table 10.6 shows the pulpal effects of superimposition of an uncompli-
cated crown fracture on various luxation injuries. Once again, teeth with
open apices fare the best for reasons already cited. However, additional
crushing injuries on top of a crown fracture inflicts progressively worse
damage on the pulp. Table 10.6 Percentage of teeth with pulp survival after various types of
injury plus uncomplicated crown fracture
Table 10.7 shows the data on root fracture healing when associ-
ated with different types of luxation injuries. Teeth with open apices Pulp survival Pulp necrosis
again show the best healing outcomes, 100% hard tissue union in
No luxation Closed apex 98 2
lateral and mild luxation injuries. In this case, in contrast to the pre-
Open apex 99 1
vious pattern, extrusive luxation fares the worst, presumably because
Concussion Closed apex 88 12
of separation between the fragments. In addition, in mature roots, Open apex 98 2
displacement of the coronal fragment resulted in pulp necrosis in
Subluxation Closed apex 50 50
25% of teeth. Open apex 80 20
Outcome data on pulp survival and periodontal ligament healing fol-
Extrusive luxation Closed apex 20 80
lowing replantation of avulsed teeth are depicted in Tables 10.8 and 10.9. Open apex 60 40
It is unsurprising that the response to complete severance of the blood
Lateral luxation Closed apex 15 85
supply during avulsion is total pulp necrosis in the mature tooth. It Open apex 70 30
is even surprising that there is some evidence of a pulp response up
Intrusive luxation Closed apex 0 100
to 6 months in such teeth. The periodontal healing response following Open apex 0 100
replantation is similar for mature and immature teeth up to 6 months, after
which differences become evident with immature teeth faring better pre- After Andreasen et al., 1989
sumably because of lesser damage to the alveolar housing and root surface
during avulsion.
Table 10.9 depicts the data on pulp survival and periodontal healing
as a function of the amount of time, for which the avulsed teeth were
stored dry prior to replantation. Mature teeth show no chance of Table 10.7 Percentage of teeth with different types of root fracture
healing in various luxation injuries
pulp survival regardless of how minimal the storage time is, while imma-
ture teeth, on the contrary, show potential for revascularization and Granulation Connective Hard tissue
regeneration, which diminishes with extra-oral time from 5 minutes to tissue tissue union
120 minutes. Concussion/ Closed apex 5 20 75
The periodontal healing is again better for immature teeth but only subluxation Open apex 0 0 100
significantly during the first 40 minutes, thereafter (40–120 minutes extra- Extrusive Closed apex 40 45 5
oral storage), the differences between mature and immature teeth diminish luxation Open apex 0 50 50
to a negligible level. Lateral Closed apex 30 55 15
These data may be used to good advantage in predicting the prognosis luxation Open apex 0 0 100
of traumatically injured teeth and formulating long-term treatment plans
and cost estimates. After Andreasen et al., 1989
284 MANAGEMENT OF ACUTE EMERGENCIES AND TRAUMATIC DENTAL INJURIES
Table 10.8 Percentage of teeth with pulp survival and periodontal ligament (PDL) healing after replantation in permanent dentition
1 month 2 months 3 months 6 months 12 months 24 months 36 months 48 months 60 months 10 years
Pulp survival Closed apex 100 38 5 2 0 0 0 0 0 0
Open apex 100 57 38 30 30 30 30 30 30 30
PDL healing Closed apex 100 90 60 48 25 25 25 25 15 15
Open apex 100 88 60 48 42 42 42 42 38 38
Flores, M.T., Andersson, L., Andreasen, J.O., et al., 2007b. International Association of
Table 10.9 Percentage of teeth with pulp survival and periodontal Dental Traumatology. Guidelines for the management of traumatic dental injuries. II.
ligament (PDL) healing after replantation following dry storage of Avulsion of permanent teeth. Dent Traumatol 23 (3), 130–136.
different durations Flores, M.T., Malmgren, B., Andersson, L., et al., 2007c. International Association of
Dental Traumatology. Guidelines for the management of traumatic dental injuries. III.
5 mins 20 mins 40 mins 60 mins 120 mins Primary teeth. Dent Traumatol 23 (4), 196–202.
Hasselgren, G., Reit, C., 1989. Emergency pulpotomy: pain relieving effect with and
Pulp Closed 0 0 0 0 0 without the use of sedative dressings. J Endod 15 (6), 254–256.
survival apex Hülsmann, M., Hahn, W., 2000. Complications during root canal irrigation – literature
Open 55 35 25 20 10 review and case reports. Int Endod J 33 (3), 186–193.
apex Khan, A.A., McCreary, B., Owatz, C.B., et al., 2007a. The development of a diagnostic
instrument for the measurement of mechanical allodynia. J Endod 33 (6), 663–666.
PDL Closed 50 28 10 10 10 Khan, A.A., Owatz, C.B., Schindler, W.G., et al., 2007b. Measurement of mechanical
healing apex allodynia and local anesthetic efficacy in patients with irreversible pulpitis and acute
Open 65 65 40 15 12 periradicular periodontitis. J Endod 33 (7), 796–799.
apex Locker, D., Grushka, M., 1987. Prevalence of oral and facial pain and discomfort:
preliminary results of a mail survey. Community Dent Oral Epidemiol 15 (3), 169–172.
After Andreasen et al., 1989 McMillan, A.S., Wong, M.C., Zheng, J., et al., 2006. Prevalence of orofacial pain and
treatment seeking in Hong Kong Chinese. J Orofac Pain 20 (3), 218–225.
Owatz, C.B., Khan, A.A., Schindler, W.G., et al., 2007. The incidence of mechanical
allodynia in patients with irreversible pulpitis. J Endod 33 (5), 552–556.
Peres, M.A., Peres, K.G., Frias, A.C., et al., 2010. Contextual and individual assessment
of dental pain period prevalence in adolescents: a multilevel approach. BMC Oral
Health 10, 20.
REFERENCES AND FURTHER READING Seltzer, S., Bender, I.B., Ziontz, M., 1963. The dynamics of pulp inflammation:
Andreasen, F.M., Pedersen, B.V., 1985. Prognosis of luxated permanent teeth – the correlations between diagnostic data and actual histologic findings in the pulp. Oral
development of pulp necrosis. Endod Dent Traumatol 1 (6), 207–220. Surg Oral Med Oral Pathol 16, 969–977.
Andreasen, F.M., 1989. Pulpal healing after luxation injuries and root fracture in the Steele, J., O’Sullivan, I., 2011. Executive summary: Adult Dental Health Survey (2009)
permanent dentition. Endod Dent Traumatol 5 (3), 111–131. The Health and Social Care Information Centre. www.ic.nhs.uk/webfiles/
Andreasen, J.O., Andreasen, F.M., Andersson, L., 2007. Textbook and color atlas of publications/007_Primary_Care/Dentistry/dentalsurvey09/
traumatic injuries to the teeth, 4th ed. Wiley-Blackwell. AdultDentalHealthSurvey_2009_ExecutiveSummary.pdf (accessed Aug, 2013).
Dummer, P.M., Hicks, R., Huws, D., 1980. Clinical signs and symptoms in pulp disease. Vargas, C.M., Macek, M.D., Marcus, S.E., 2000. Sociodemographic correlates of tooth
Int Endod J 13 (1), 27–35. pain among adults: United States, 1989. Pain 85 (1–2), 87–92.
Flores, M.T., Andersson, L., Andreasen, J.O., et al., 2007a. International Association of White, D.A., Tsakos, G., Pitts, N.B., et al., 2012. Adult Dental Health Survey 2009:
Dental Traumatology. Guidelines for the management of traumatic dental injuries. I. common oral health conditions and their impact on the population. Br Dent J 213
Fractures and luxations of permanent teeth. Dent Traumatol 23 (2), 66–71. (11), 567–572.
11
Section 3 Delivery of endodontic treatment
Management of tooth resorption
Y-L Ng, K Gulabivala
Dentine and cementum are protected from resorption by their non- INTERNAL RESORPTION
mineralized structural components (predentine and precementum) and This type of resorption has a prevalence of 0.1–1.6% in permanent teeth.
cells (odontoblasts and cementoblasts). Secretion of an anti-invasion It is initiated by damage to or loss of the predentine and odontoblast layer
factor by predentine, precementum and intact periodontal ligament is (see Table 11.1) and sustained by pulpal inflammation (see Table 11.2).
thought to prevent attachment of multinucleated resorbing dentinoclasts to Dental trauma, overheating and dehydration during restorative procedures,
dental hard tissues. Anti-invasion factor has also been found in cartilage use of cytotoxic restorative materials or dressing materials in pulpotomies,
and blood vessel walls. It is believed that the highly mineralized intermedi- and orthodontic tooth movement are factors that may injure the protective
ate cementum layer (hyaline layer of Hopewell-Smith) further prevents predentine and odontoblast cells.
external root resorption by covering the dentinal tubules, acting as a pro-
tective barrier between root-canal irritants and the periodontal ligament. Transient internal resorption
The cells responsible for resorption of dental hard tissues are multinu- In the absence of persistent pulpal inflammation, initial resorption of
cleated giant cells classified as clasts (Fig. 11.1). These cells attach them- dentine from the pulpal aspect is self-limiting with no clinical consequence
selves to the mineralized tissues by the cell membrane adjacent to the part (Fig. 11.3). It has been detected, for example, in boxers sustaining repeti-
of the cytoplasm called the “clear zone”. Resorption takes place under the tive injury to anterior teeth.
highly folded cell membrane, known as the ruffled border (Fig. 11.2) in
this zone. The membrane releases a cocktail of enzymes capable of dis- Progressive internal resorption
solving both organic and inorganic components of hard tissues. Osteoclasts
In the early stages of internal resorption, microleakage of bacteria and their
are involved in resorption of bone and dentinoclasts resorb dentine and
products via dentinal tubules and cracks sustain the inflammatory process.
cementum. The latter are smaller, have fewer nuclei and their clear zone
Eventually, the coronal pulp is invaded by bacteria and becomes necrotic.
is minimal or non-existent.
The former provides ongoing stimulus for resorption. The pulpal tissue
For dental resorption to occur, there must be damage to the non-
in the resorptive defect and apical to it is vital and provides blood supply
mineralized components (predentine and periodontal ligaments) and inter-
to the resorption area. The rate of progression of resorptive activity may
ference with the normal protection afforded by blast cells (odontoblasts,
be related to the strength of inflammatory stimulus. In the case of total
cementoblasts and fibroblasts), which allows colonization of the denuded
pulp necrosis where the blood supply is cut off, the resorption ceases.
surfaces by dentinoclasts. The causes of such damage are listed in Table
Calcified substance (osteo-dentine) similar to bone may be present
11.1. The concomitant acute inflammation during injury activates the den-
within the inflammatory tissue in the resorptive defect and this type of
tinoclasts and initiates resorption. However, this process may be transient
presentation has been classified separately as “internal replacement resorp-
in the absence of a perpetuating or persistent stimulus for the dentinoclasts,
tion”, “root-canal replacement resorption”, or “metaplastic resorption”.
allowing repair by hard tissue deposition to occur. Resorption becomes
Clinically, the early stages of internal resorption are usually asympto-
progressive if it is sustained by chronic inflammation, whether in the pulp
matic. A pink spot may be present on the crown if resorption takes place
or periodontium. The causes of persistent chronic inflammation are listed
in the pulp chamber (Fig. 11.4). The pink discoloration associated with
in Table 11.2.
internal resorption is caused by the highly vascularized inflammatory
Pathological resorption has been classified by site, aetiology and patho-
tissue undermining the coronal enamel. Vital pulp tissue is required for
genesis. The classification system presented below is based on all three
internal resorption to progress, therefore, such teeth will give positive
aspects to facilitate diagnosis and treatment planning.
responses to pulp tests. However, a negative response could not rule out
1 Internal resorption the progression of resorption because only the pulp tissue coronal to the
1 Transient internal resorption lesion may be necrotic. Progression of inflammation fuelling the resorption
2 Progressive internal resorption may result in total necrosis of the pulp and, therefore, cessation of internal
i Sustained by bacteria or their products invading the pulp resorption. The necrotic pulp may then become infected and symptomatic,
ii Sustained by cytotoxic materials used in pulp therapy discoloured and give negative responses to pulp tests (Fig. 11.5).
B B
D
A D B
Fig. 11.1 Multinucleated cells lying
in lacunae
Fig. 11.2 (a) Light micrograph of an osteoclast-like cell in close
apposition to dentine, cementum and alveolar bone (×100);
(b) electron micrograph of the osteooclast-like cell in (a) with
its ruffled border along dentine, cementum, and alveolar bone
(×5000); (c) electron micrograph showing the ruffled border of
the osteoclast-like cell in (a) along dentine, cementum, and
alveolar bone (×19 000). B = alveolar bone, C = cementum,
D = dentine
D C C B
Predentine/odontoblasts Precementum/cementoblasts
Trauma Trauma
Restorative procedures Orthodontic therapy
Use of cytotoxic materials in pulp Orthognathic surgery
therapy Periodontal therapy
Vital bleaching Dento-alveolar surgery
Pathological and non-pathological Bruxism
tooth surface loss Root-canal obturation using heated
Orthodontic therapy gutta-percha techniques or
Periodontal disease post-space preparation
(Developmental defects of dentine) (Developmental defects of cementum)
Fig. 11.5 Internal resorption affecting Fig. 11.6 Internal resorption affecting
the maxillary lateral incisor, the pulp the right maxillary central incisor
became infected and apical
periodontitis developed
A B C
Fig. 11.7 The right maxillary lateral Fig. 11.8 (a–c) Internal resorption affecting the left maxillary incisor with similar presentation as external resorption
incisor associated with extensive
internal resorption and associated
periradicular radiolucency where it
breached the distal surface (arrowed)
Radiographically, the appearance of internal resorption has been classi- Management of progressive internal resorption varies according to the
cally described as a well-circumscribed, symmetrical, oval or circular extent of the lesion, presence of calcification and perforation. Root-canal
shaped radiolucency continuous with the root canal (Fig. 11.6). The radi- treatment should be carried out immediately after detection in order to
olucency has a uniform density and the pulp chamber or canal cannot be prevent further disease progression leading to root perforation.
followed through the lesion. The position of the radiolucency remains the It may be difficult to control haemorrhage and to remove completely
same in mesial or distal angled radiographic views. However, a radiopaque the severely inflamed tissue from the resorptive defect. Therefore, debride-
mass resembling calcification may be present within the lesion or in the ment should be carried out using copious amounts of sodium hypochlorite
canal space apical to the internal resorption. A periradicular radiolucency irrigant. In addition to its antibacterial properties, sodium hypochlorite
may be associated with perforation of the root or total necrosis of the pulp also possesses tissue-dissolving ability. Use of higher concentration (5%)
in advanced cases (Fig. 11.7). This may pose difficulty in differentiation of sodium hypochlorite in combination with ultrasonic agitation has been
from external inflammatory resorption associated with root-canal infection recommended and may enhance debridement. The canal should be checked
(Fig. 11.8). Occasionally, internal resorptive lesions remain undetected and for perforation by exploring with a curved file attached to an apex locator.
may only appear incidentally on a post-obturation radiograph (Fig. 11.9). Care should be taken to prevent extrusion of sodium hypochlorite irrigant
288 MANAGEMENT OF TOOTH RESORPTION
A B
A B
through any perforation. An extensive lesion with calcification may render Clinically, the involved tooth is usually asymptomatic and the small
canal location and complete debridement of the resorptive defect impos- resorptive defects are not usually visible on radiographs. Occasionally,
sible (Figs 11.4, 11.10). Calcium hydroxide dressing should be used they may appear as small excavations of the root surface delineated by an
between appointments to prevent recolonization by bacteria and to facili- intact periodontal ligament space (Fig. 11.12b). This condition is self-
tate removal of any residual inflamed tissue within the irregular resorptive limiting and no active treatment is required.
defect. Long-term dressing with calcium hydroxide is indicated to induce
hard tissue repair if a perforation is present (see Figs 11.7, 11.11). It may Progressive external resorption without persistent
be prudent to delay root-canal obturation until complete bone healing has inflammation of the periodontal tissue
occurred to ensure minimum extrusion of filling material. This type of resorption has traditionally been described as “external
Complete obturation of the defect may be achieved by using a replacement resorption”. It is usually a consequence of luxation injuries
thermoplasticized root-filling technique, such as injection of molten gutta- or is frequently observed following replantation of avulsed teeth when
percha using an Obtura II system (see Chapter 8) after filling the extensive loss of viability of periodontal ligament and damage of cemen-
canal apical to the defect using lateral or vertical compaction technique tum of at least 20% of root surface has occurred. Synthesis of anti-invasion
(Fig. 11.11). factor and collagenase inhibitor may be affected, providing an opportunity
A surgical approach is indicated when a large perforation is present and for resorbing osteoclasts to populate the denuded root surface. It is believed
or excess root-filling material has been extruded into the periodontal tissue. that the osteoclasts cannot differentiate between cementum, which is
However, these cases have compromised prognosis and are prone to root usually protected by periodontal ligament, and bone. The osteoblasts
fracture. deposit bone where dentine and cementum have been resorbed. The
process seems akin to bone remodelling.
EXTERNAL RESORPTION Often in the dental literature, the terms “ankylosis” and “replacement
resorption” are used synonymously. However, in “ankylosis”, there is no
Resorption of the root surface is commonly seen in association with severe loss of root dentine and cementum, merely fusion or close proximity of
dental trauma, apical periodontitis or orthodontic treatment. The apical the root and bone. In “replacement resorption”, dentine and cementum are
region is generally affected but lateral and cervical aspects of the root may lost to be replaced with bone (Fig. 11.13).
also be involved. Clinically, the involved tooth is asymptomatic. Similar to ankylosis, the
high-pitched metallic sound on percussion and absence of physiological
Transient external resorption
tooth movement are the typical characteristic features. The tooth may be
Injury to precementum and cementoblasts initiates this type of resorption in infra-occlusion in a growing child.
(see Table 11.1). Where trauma is not severe, external inflammatory Radiographically, the root appears to be gradually replaced by bone.
resorption is transient and repair may follow. This has also been called The junction of bone and cementum has a mottled appearance and the
“external surface resorption” (Fig. 11.12). periodontal ligament space is not evident (Fig. 11.14).
MANAGEMENT OF TOOTH RESORPTION 289
A B
C D
Fig. 11.11 (a) Internal resorption in a maxillary central incisor; (b) calcium hydroxide dressing filling the defect incompletely and inadequately; (c) apical part of
the root canal obturated with laterally compacted gutta-percha and sealer; (d) the resorption cavity and coronal part of the canal obturated with warm gutta-
percha and sealer
A B
Management strategies should be directed towards prevention as this periradicular periodontitis (Fig. 11.15). It has been hypothesized that the
type of resorption is not treatable. An avulsed tooth should be immediately cementum at the cemento–dentinal junction apically may be too thin or
replanted or stored in milk/transplant medium to preserve the vitality of even non-existent to afford effective protection against dentine resorption.
periodontal ligaments. When inflammation is confined to a small area at the apex of the root, the
concentration of resorbing factors may be high enough to overcome resist-
Progressive external resorption with persistent ance of the root (perhaps due to hyper-mineralisation) to resorption.
inflammation of the periodontal tissue sustained by In traumatized teeth, damage to the periodontal tissues may lead to
resorption of the cementum exposing the underlying dentine. If the pulp
1. Root-canal infection is necrotic and infected, microbial products are enabled to diffuse through
In progressive external resorption with persistent inflammation of the peri- the dentinal tubules into the periradicular tissues (Fig. 11.16a,b) and
odontium, the most common sustaining factor is thought to be root-canal fuel an aggressive form of inflammatory resorption (Fig. 11.16c). Root-
infection, causing inflammation in the periodontal ligament adjacent to canal debridement and dressing with calcium hydroxide may remove the
the denuded area of root surface. Resorption may be found around the inflammatory component, reducing the resorption to a replacement variety
apical or lateral root-canal foramina in 87.3% of teeth associated with (Fig. 11.16d).
290 MANAGEMENT OF TOOTH RESORPTION
A B
Fig. 11.15 Apical resorption: (a) histological section; (b) electron micrograph
Pulp Periodontal
necrosis space
B
Inflammatory
A resorption
Fig. 11.16 (a) Diagram illustrating that microorganisms or microbial products pass through dentinal tubules
into surrounding tissues after loss of cementum; (b) light micrograph showing multinucleated cells together
with neutrophilic granulocytes at resorbed external dentine surface with microorganisms extending into
dentinal tubules on the pulpal side; (c) external root resorption after luxation and pulp necrosis; (d) 3
D months after root canal debridement of the teeth in (c). The inflammatory component removed has
reduced the aggressive inflammatory process to a slower resorption by replacement resorption
A B C
Fig. 11.17 (a) A mandibular first molar associated with apical progressive external resorption and apical periodontitis; (b,c) progressive external resorptive defect
present at the apex and mid-root level of the maxillary left central incisor
It is not known whether there is in fact a localized increase in pressure of pressure from orthodontic movement of teeth but not by root-canal
that stimulates this type of resorption; it is likely that it is mediated by a treatment.
molecular mechanism. In any case, the conceptual model seems to fit. Clinically, the involved tooth is usually asymptomatic and the pulp is
Resorption associated with orthodontic treatment has also been classified vital. Increase in mobility may be associated with a severely shortened
as “periapical replacement resorption” by Bender et al. (1997) who sug- root.
gested that pulpal inflammation might also be involved in this phenome- Radiographically, the periodontal ligaments and the surrounding bone
non. However, this type of resorption could only be arrested by removal adjacent to the resorptive defect appear normal (see Fig. 11.21a,f).
292 MANAGEMENT OF TOOTH RESORPTION
A B C D
Fig. 11.18 (a) Lateral inflammatory root resorption following luxation injury; (b) two years after chemomechanical debridement and calcium hydroxide dressing;
(c) obturation of the root canal system of the tooth in (a); (d) slow resolution of the periradicular radiolucencies
A B
C D
D E
A B
B
Table 11.3 Terms used to describe progressive external resorption
sustained by subgingival plaque
Class 1
Class 2
Class 3
Class 4
A B
Fig. 11.25 Burrowing external tooth resorption: (a) radiograph; (b) histological
section – note that the pulp cavity is not involved
A B C
Fig. 11.27 (a–c) Pink discoloration in the cervical third of the crown of maxillary central incisor associated with Class 2 or 3 progressive cervical inflammatory
resorption
A B C
F G
A B C
Fig. 11.31 (a) Pink spot in cervical region of maxillary lateral incisor; (b) extent of defect with flap reflected; (c) defect repaired with glass ionomer cement
MANAGEMENT OF TOOTH RESORPTION 297
dislodgement of the restoration during root-canal treatment. An extensive condition is suspected, the patient should be referred to a specialist for
or irregular mottled lesion with a large surface area of loss has extremely further management. No local dental treatment is indicated.
poor prognosis and no treatment is recommended (Fig. 11.32).
Progressive external resorption associated with Progressive external resorption associated with no
systemic disease obvious local or systemic disease (idiopathic)
Shortening of roots or dental resorption has been associated with some Cases of resorption where no local or systemic factors can be identified
systemic diseases (Table 11.4) and is known as “systemic resorption”. The are classified as “idiopathic resorption”. There may be a wide range of
evidence though consists mainly of retrospective case reports. The role of different presentations (Figs 11.33–11.37).
systemic diseases in dental resorption is poorly understood. When no systemic disease can be detected, the condition can only be
The clinical presentation of resorption related to systemic diseases monitored to provide palliative care to elongate the life of the teeth while
usually involves multiple teeth and is presented in Table 11.4. When this a definitive prosthodontics plan is made.
Fig. 11.32 Type IV progressive cervical Fig. 11.33 Progressive idiopathic external resorption affecting the right maxillary and mandibular teeth only
inflammatory resorption affecting the
mandibular incisors
Table 11.4 List of systemic diseases associated with shortening of root or dental resorption
A B
Fig. 11.34 (a–c) Progressive idiopathic external cervical resorption affecting the right maxillary and
mandibular teeth in a patient who also exhibits a lack of any occlusal contacts on the right side. C
There is therefore a co-existing tooth eruption disorder
A B C
Fig. 11.37 (a–c) Progressive idiopathic external cervical resorption affecting the mandibular right premolars and molars only
Lindskog, S., Pierce, A.M., Blomlof, L., et al., 1985. The role of the necrotic periodontal
REFERENCES AND FURTHER READING membrane in cementum resorption and ankylosis. Endod Dent Traumatol 1 (3),
Bender, I.B., Byers, M.R., Mori, K., 1997. Periapical replacement resorption of 96–101.
permanent, vital, endodontically treated incisors after orthodontic movement: report Ne, R.F., Witherspoon, D.E., Gutmann, J.L., 1999. Tooth resorption. Quintessence lnt
of two cases. J Endod 23 (12), 768–773. 30, 9–25.
Hammarström, L., Blomlöf, L., Lindskog, S., 1989. Dynamics of dentoalveolar Tronstad, L., 1988. Root resorption – etiology, terminology and clinical manifestations.
ankylosis and associated root resorption. Endod Dent Traumatol 5 (4), 163–175. Endod Dent Traumatol 4, 241–252.
Heithersay, G.S., 1999. Treatment of invasive cervical resorption: an analysis of results Trope, M., 2002. Root resorption due to dental trauma. Endod Topics 1, 79–100.
using topical application of trichloracetic acid, curettage, and restoration. Wedenberg, C., Lindskog, S., 1985. Experimental internal resorption in monkey teeth.
Quintessence lnt 30, 96–110. Endod Dent Traumatol 1 (6), 221–227.
Lindskog, S., Hammarström, L., 1980. Evidence in favour of anti-invasion factor in Wedenberg, C., 1987. Evidence for a dentin-derived inhibitor of macrophage spreading.
cementum or periodontal membrane of human teeth. Scand J Dent Res 88, 161–163. Scand J Dent Res 95 (5), 381–388.
12
Section 4 Multidisciplinary aspects of endodontic management
The perio–endo interface
K Gulabivala, UR Darbar, Y-L Ng
Fig. 12.1 Initial manifestation of periodontal Fig. 12.2 Junctional epithelium Fig. 12.3 Section showing loss of
disease at the cervical aspect of the tooth marginal attachment and
(arrowed) periodontal destruction
A B C
Fig. 12.6 (a) Horizontal bone loss; (b) horizontal bone loss – 4 years later; (c) horizontal bone loss – 12 years later
B A B
Fig. 12.9 (a) Periodontal bone loss involving the mesial root of 36; Fig. 12.10 (a) Lateral periodontal bone loss of pulpal origin (arrowed);
(b) periapical radiograph of the same as in (a) (b) resolution following root-canal treatment
Fig. 12.11 (a) Early periradicular bone loss in 32 (arrowed); (b) further apical CELL PROFILES IN APICAL AND
and marginal bone loss over a 10-year period in the tooth shown in (a) MARGINAL PERIODONTITIS
Both disease processes are characterized by transition from innate to adap-
the root succumbs and further lateral and apical foramina may become tive immune responses. The precise distribution of cell proportions varies
associated with adjacent bone loss (Fig. 12.11). The size and distribution with time according to the nature of host–microbial interaction. The cell
of apical periodontitis (and thus apical radiolucency) is dictated by: types for apical periodontitis were reported in Chapter 3, and include,
• the distribution of the lateral and apical foramina PMNs, macrophages, fibroblasts, B and T lymphocytes, mast cells, plasma
• the nature and extent of the infecting microbiota cells and epithelioid cells. The same cell types are found in the developing
• the nature of the periradicular host defence. lesions of marginal periodontitis, however, the dominant cell type in the
advanced periodontal lesion is the plasma cell. Epithelial proliferation is
Periapical disease may manifest asymptomatically or symptomatically, evident in both disease processes, the junctional epithelium in periodontal
depending upon the nature of host and microbial factors involved (see disease, and the rests of Malassez in apical periodontitis, which may lead
Chapter 3 for details). Periapical lesions can remain asymptomatic and to cyst formation in apical but not marginal periodontitis.
stable in size for years. The presence and extent of periapical disease is
mainly measured radiographically (as it is not directly visible or probea-
ble) and also requires standardized radiography. The lesions of chronic
MICROBIOTA ASSOCIATED WITH APICAL OR
apical periodontitis seldom result in retrograde marginal periodontitis with
MARGINAL PERIODONTITIS
attachment loss. However, when this does occur, the probing depth and The details of the microbiota involved in apical periodontitis were dis-
bone defect is usually deep and very localized. Long-standing, untreated, cussed in Chapter 3. Both disease processes show the classical progression
marginal loss of attachment caused by root-canal infection may secondar- from an initial Gram-positive, aerobic/facultative colonizing flora, replaced
ily become established as true marginal periodontitis requiring endodontic by an increasingly diverse and complex facultatively anaerobic flora, to
302 THE PERIO–ENDO INTERFACE
A B C
In contrast, the number of investigations on the relationship between The prevalence of accessory or furcal canals in the furcation varies
apical periodontitis and systemic diseases is sparse and without any sig- between 30 and 60%. The wide range reflects the outcome of methods
nificant associations. Investigations on the effect of smoking, diabetes and used to detect them, since not all openings pass through as continuous
on cardiovascular disease have failed to note significant findings. This may channels.
also be explained by the fact that the likely surface area of exposure,
between an ulcerated periapical lesion and the resident microbiota in the DENTINAL TUBULES
root canal, is probably limited. It may, however, be argued that the selec-
tive and protective sanctuary of the root-canal system may allow privi- Under normal circumstances, dentinal tubules do not provide a communi-
leged entry for uniquely adapted strains, capable of colonizing and invading cation between the pulp and periodontium but may do so if, under condi-
body tissues; but this remains to be shown. tions of gingival recession or loss of attachment, the cementum is worn
away by professional or home root debridement (Fig. 12.16). Dentinal
tubules provide long and extremely narrow channels of communication
PATHWAYS OF COMMUNICATION BETWEEN PULP (see Chapter 1) but are perfectly capable of conveying PMNs, bacteria and
AND PERIODONTIUM their products, as well as molecular mediators of inflammation (Fig. 12.17)
(see Cementum defects).
The pulpal and periodontal tissues may communicate via natural anatomi-
cal features (lateral or accessory canals, apical foramina, exposed dentinal
DEVELOPMENT DEFECTS
tubules, developmental and cementum defects) or via acquired defects
(perforations or root fractures caused by iatrogenic factors and parafunc- Various defects, such as invaginations of the coronal or radicular tissues
tional wear and tear). The patency or permeability of the communication may occur during the development of teeth (see Chapter 1). In the majority
is determined by its morphology and dimension, as well as its content and of cases, the invaginations do not allow communication between the
fluid dynamic characteristics. tissues but, occasionally, developmental grooves, e.g. palato-gingival
groove may be deep enough to communicate with the pulp (Fig. 12.18).
LATERAL AND ACCESSORY CANALS
Lateral canals are considered to be rare in the coronal third of the root and Fig. 12.15 Lateral
arise with a frequency of ≈10% in the middle third (Fig. 12.13) and canals containing blood
≈25–35% in the apical third (Figs 12.14, 12.15) of the root. The mean vessels in the apical
third of the root
prevalence of lateral canals, derived from a number of studies as shown
(courtesy of Prof.
in Table 12.2, is ≈45%. I Kramer)
Fig. 12.13 Lateral canal in middle Fig. 12.14 Lateral canals in the apical B
third of mandibular incisor third of a mandibular premolar
304 THE PERIO–ENDO INTERFACE
CEMENTUM COVERAGE DEFECTS Another recognized condition is the cemental tear. These occur mainly
in men and may be associated with acute or chronic trauma. They can
In 10% of teeth (see Chapter 1), the cementum does not abut or overlap result in periodontal inflammation, abscess formation and deep probing
the enamel, leaving dentinal tubules open at the cervical margin of teeth. defects. The majority of involved teeth give positive pulp responses but
Equally, such defects may sometimes arise on the root surface through they may also be found in root-treated teeth with posts. Stress concentra-
abrasion or as a result of resorption. tion related to the apical extent of the post may result in a crack within
the cementum (Fig. 12.19a), as in the shown case, with associated lateral
Fig. 12.17 radiolucency that resolved upon surgical cleaning of the crack and filling
Microorganisms within with EBA cement (Fig. 12.19b,c). The tooth also had apical retrograde
dentinal tubules of root-canal treatment.
infected tooth
A B C D
Fig. 12.18 (a) Palato-gingival groove in maxillary central incisor; (b) radiograph of the tooth showing bone loss; (c) diagnostic endodontic instrument in canal
and gutta-percha points in sinus tract and periodontal pocket, respectively; (d) radiograph demonstrating some infilling of bony defect but failure due to
communication between groove and root canal system
A C
THE PERIO–ENDO INTERFACE 305
the pulp space and the periodontal ligament, which may be associated with surgery may also be compromised in the presence of root-canal infection,
healthy or root-treated teeth. resulting in attachment loss or recession. Many factors influence this,
including gingival tissue thickness (gingival biotype), alveolar bone level,
surgical trauma to the flap (or alternatively, the quality of flap protection),
effectiveness of flap repositioning and adequacy of suturing. Mean attach-
EFFECT OF PULP DISEASE AND ITS TREATMENT ment loss after periapical surgery is greater in the absence of periapical
ON THE PERIODONTIUM healing (being indicative of persistent root-canal infection).
Some periodontists may request root-canal treatment on teeth with
PULPO-PERIAPICAL INFLAMMATION AND BONE LOSS “doubtful” pulp status when regenerative surgery is planned in the site.
It is well known that pulp inflammation can be transmitted through lateral The rationale is to eliminate possible sources of infection to maximize the
communications to the periodontium, both in the furcation and apically; potential for successful periodontal outcome. The desire to eliminate
when severe, it can manifest in submarginal bone loss, especially in potential, unconfirmed root-canal infection must be tempered by the
younger patients (Fig. 12.20). Pulpitis is succeeded by pulp necrosis, root- knowledge that extrusion of root-canal treatment materials may have an
canal infection, and apical periodontitis; the latter may manifest in a equally negative impact on periradicular healing (Fig. 12.22) and, there-
number of ways in the periodontium. It may contribute to horizontal mar- fore, the prognosis of subsequent periodontal surgery. Equally, some peri-
ginal bone loss (see Fig. 12.13), vertical intra-bony defects (see Fig. odontists may request root-canal treatment on teeth with “doubtful” pulp
12.11b), or furcation involvement in multirooted teeth (Fig. 12.21). status when implant fixture placement is planned in an adjacent site.
A B
Fig. 12.20 (a) Pulpal inflammation in 16 leading to thickening of the periodontal Fig. 12.21 Furcal and apical bone loss in a
ligament space on the palatal root; (b) pulpal inflammation evident on opening the pulp mandibular molar
chamber
A B
Fig. 12.22 (a) Extrusion of root-filling material in mandibular molar; (b) delayed apical healing Fig. 12.23 Perforation in central incisor
associated with the extrusion
306 THE PERIO–ENDO INTERFACE
• an isolated, usually narrow, deep probing depth of pulpal or HISTORY OF PERIODONTAL SYMPTOMS
periodontal origin, in an otherwise periodontal disease-free mouth The duration and nature of the periodontal symptoms will help to charac-
• lesion with submarginal or intra-bony periradicular bone loss of terize the general periodontal status and should include an assessment of
pulpal and/or periodontal origin that communicates with the oral risk factors, such as smoking, stress and diabetes. The information will
cavity via a periodontal probing defect give an indication of the individual’s susceptibility to periodontal break-
• a localized deep periodontal probing defect of pulpal or down and will also help differentiate and distinguish problems associated
periodontal origin, in a mouth with other sites of periodontal with generalized periodontal problems as opposed to those associated with
disease, which may or may not be extensive. localized periodontal breakdown. This aspect of the examination is par-
These definitions do not specify the apical or marginal origin of the ticularly important in patients with generalized periodontal breakdown to
lesions, as by their nature, the origin is unknown at the time of presenta- assess the prognosis of the teeth in relation to the patient’s motivation and
tion. The key aspect of the definitions is that they represent a potentially compliance, which will affect the response to treatment.
broad range of clinical presentations with a common feature, an isolated As a rule, acute pain is not a common presenting feature of “perio–
“deep” probing defect with an uncertain (endo or perio) origin. endo” lesions because of their “open” nature. However, acute exacerba-
tions do occur and are then frequently attributed to endodontic origin but
CLASSIFICATION OF PERIO–ENDO LESIONS such symptoms can arise equally commonly from either source. It has been
suggested that dentoalveolar abscesses with 30–60% spirochaetes on dark-
Several classifications of perio–endo lesions have been proposed but none field microscopy are more likely to be of periodontal origin and those with
of them especially contributes to diagnosis or treatment. They do, however, 0–10% spirochaetes to be of endodontic origin.
serve to delineate the categories possible to encounter in practice. A simple
classification is adopted here:
SIGNS OF PULPAL OR PERIAPICAL DISEASE
1 Primary endodontic lesion (with potential for secondary
The involved and adjacent teeth should be examined carefully for evidence
periodontal involvement)
of pulpal or periapical disease. This includes performing pulp tests on the
2 Primary periodontal lesion (with potential for secondary pulpal
teeth using cold, heat and electrical stimulation, as each of these tests gives
involvement)
different clues. Each root or cusp of a multirooted tooth should be tested
3 True combined lesion of dual origin.
separately to elicit unique responses from each part of the tooth. Although,
it may be thought that pulp-test responses from a tooth would be uniform
DIAGNOSIS OF PERIO–ENDO LESIONS when applied to different parts of its surface, local variations in thickness
of enamel and dentine, as well as partial pulp necrosis can contribute to
Isolated “perio–endo” lesions in patients without generalized periodontal different responses.
disease are easily identified as such, despite their variable presentation. Root-filled teeth may also be associated with perio–endo lesions. The
The precise presentation features depend on the aetiology and its duration technical quality of the root filling, how long ago it was performed,
of existence. Localized, marked areas of attachment loss (often categorized whether it was performed under rubber dam using bleach and by whom,
as perio–endo lesions) also arise in patients with generalized periodontal should be determined. The quality of the root filling (poor or good) does
disease but the number of sites involved and their presentation are more not necessarily correlate with the presence or absence of residual root-
variable and complex. Many of these may simply reflect locally advanced canal infection. This must be gauged from other clinical signs of infection,
periodontal breakdown, defects with true uncertainty about origin are rarer namely changes in the periodontal ligament space at canal termini (apical
and more difficult to diagnose. or lateral).
Regardless of their location and number, “perio–endo” lesions continue
to challenge clinicians in arriving at a definitive diagnosis of origin because PERIODONTAL CHARTING INCLUDING THE PROBING
of the difficulty in ascertaining the pulp status, as the tissues are invisible. PROFILE OF THE TOOTH
Total pulp necrosis is relatively easy to diagnose (because of the high
A full periodontal assessment must be performed if the patient gives a
sensitivity and specificity of pulp tests under those conditions) but partial
history of periodontal disease. It should include a record of the recession,
pulp necrosis and the presence of infection pose a problem, particularly in
mobility and furcation involvement. The nature of the restorations should
multirooted teeth.
also be noted, especially on teeth designated as having combined prob-
Diagnosis is based on taking a systematic and careful history and on
lems. Teeth suspected of having perio–endo lesions should have their
clinical examination; encompassing both endodontic and periodontal com-
periodontal probing profile recorded in detail using continuous probing
ponents. The key elements, which should be considered together, include:
(Figs 12.28, 12.29).
• history of dentinal, pulpal or periapical pain Clinically, attachment loss is measured by probing the pocket from a
• history of periodontal symptoms (gum bleeding, tooth mobility fixed reference point. Ideally, this should be the cemento–enamel junction
and drifting, abscesses) (CEJ), however, due to difficulties of ascertaining the position of the CEJ,
• signs of pulpal/periapical disease (including pulp tests) the gingival margin is often used as the reference point. The probing depth,
• periodontal charting, including the probing profile around the tooth described as the distance between the gingival margin and the apical depth
• radiographic pattern of marginal and periradicular bone loss. of probe penetration, is used to characterize the distribution of the
308 THE PERIO–ENDO INTERFACE
attachment and bone loss. The accuracy and reproducibility of probing is In contrast to this, a continuous probing profile is obtained by probing
dependent upon the type of probe, applied force and position and orienta- gently along the entire circumference of the gingival sulcus of the tooth
tion of the probe in relation to the tooth. The findings are denoted by a suspected to be associated with a perio–endo lesion (see Fig. 12.12). An
6-point charting (3 points buccally and 3 points palatally or lingually) (Fig. accurate record of the continuous probing profile is maintained by dividing
12.30) of the whole mouth and is used in conjunction with standardized the tooth into sections, as shown in Figure 12.29. The probing profile will
accurate full-mouth, parallel-view periapical radiographs. help define the nature of the pocket, i.e. whether it is long and narrow or
broad and wide, and also aid monitoring of its response to treatment.
Long, narrow pockets are classically considered to be of endodontic
origin (Fig. 12.31). However, lateral endodontic abscesses may result in
“blow-out” lesions that exhibit extremely wide, as well as deep, probing
profiles (Fig. 12.32), yet respond favourably to endodontic treatment
alone. The so-called endodontic lesions with secondary periodontal
involvement should, by definition, have deep but narrower probing profiles
BUCCAL
A B
2 2 2
2 2 2
2
2 2
3 2
6 2
7
7 7
MESIAL DISTAL
7 8
12 8
12 9
12 10
9 10
10 10 10 10
LINGUAL
Fig. 12.28 (a) Three-point probing
depths palatally – distopalatal
C probing; (b) midpalatal probing;
(c) mesiopalatal probing Fig. 12.29 Charting continuous probing profile of the tooth
P
P.D 8 11 2 7 9 32 3 7 2 7 322
R 2 0 56 32 0 057 0 30
FI
M II
E E
PALATAL
P.D 4 2 3 12 10 8 5 2 2
R 0 0 24 0
FI – – –
M II
M M
THE PERIO–ENDO INTERFACE 309
A B
Fig. 12.31 (a) Probing on the distal aspect of an endodontically compromised molar; (b) radiograph of Fig. 12.32 Probing lateral endodontic abscess
involved molar
Fig. 12.33 Bone loss involving the Fig. 12.34 Bone loss
apical third encroaching on the
periapices of 15 and 17
lesion (Fig. 12.37a) is suppurative, then it may drain through a sinus tract
CAUSES OF PERIO–ENDO LESIONS AND THEIR
in the oral mucosa (Fig. 12.37b) or the periodontal ligament (Fig. 12.37c),
AETIOLOGY-BASED MANAGEMENT
as illustrated schematically (Fig. 12.38). Generally, endodontic resolution
will eliminate the pocketing (Fig. 12.37d). A lateral abscess may result in
Lesions with a higher chance of primary periodontal aetiology exhibit the
a much larger width of periodontal attachment loss. Diagnosis is straight-
following features:
forward when pulp tests are negative. When they are equivocal, because
• generalized periodontal disease of partial pulp necrosis, the diagnosis is difficult and other clues have to
• poor oral hygiene and presence of calculus be sought to arrive at a definitive diagnosis. In pure endodontic lesions,
• periodontal probing defects that are generally broad rather than even with severe bone loss, root-canal treatment alone will usually result
narrow. in complete resolution (Fig. 12.39). In cases of preoperative doubt about
the diagnosis, such a definitive response acts as a retrospective diagnostic
Lesions with a primary endodontic aetiology generally exhibit the fol-
lowing features:
Pulp
Sinus tract
through gingival
A B margin
Gingiva
Sinus tract
opening
Alveolar
bone
Periodontal
ligament
Mucosa
Sinus tract
opening
Periapical
lesion
C D
Fig. 12.37 (a) Furcal and apical bone loss associated with mandibular molar; (b) sinus tract Fig. 12.38 Pathways of suppuration spread
demonstrated in the same tooth; (c) periodontal probing before endodontic treatment; (d) periodontal
probing after endodontic treatment
THE PERIO–ENDO INTERFACE 311
A B
A B C D
Fig. 12.40 (a–b) Persistence of sinus tract following conventional root canal treatment; (c) surgical exposure reveals a labial mid-root lateral canal (arrowed); (d)
sinus resolution after cleaning and filling of lateral canal
tool. It is evident that in such a case, the wrongful selection of periodontal Cracks can arise either in the crown (vital or non-vital teeth) or in the root
root debridement as the treatment of choice may compromise subsequent (vital or non-vital teeth; mid or apical level). Sometimes they can only be
successful reattachment/regeneration of periodontal tissues. It is only on confirmed by surgical exploration. Ultimately, the management of cracks
rare occasions that conventional root-canal treatment is insufficient to will involve extraction of tooth or root and may involve a judgement about
resolve a lateral lesion caused by a lateral canal, as illustrated in this case how long the unit may be left in situ, if it is asymptomatic and functional.
(Fig. 12.40), where the lateral canal was fortuitously accessible on the Such a decision would always need to be balanced against any potential
labial surface of an incisor for direct cleaning and filling. damage to a future restorative option, such as an implant through chronic
bone loss and healing by repair rather than regeneration.
Root cracks or fractures Cracks arising in crowns of teeth with vital pulps seldom reach a point
Surprisingly, teeth with cracked roots can survive for several years without of established periodontal pocketing as the tooth is extremely painful on
catastrophic fracture. In the meantime, they produce periodontal break- biting (often in a specific way) and the patient will seek advice earlier (e.g.
down with pathognomonic probing (Fig. 12.41) and bone loss (Fig. 12.42) cracked-tooth syndrome). The crack line is often invisible in these cases.
patterns. In Figure 12.41, the long-standing crack survived with two local- By the time the crack line has become stained and visible, the pain on
ized deep probing defects on opposite surfaces of the root with mild biting is likely to have become less acute or altered in character because
symptoms and without post-crown decementation until the extraction of of pulpal involvement. Diagnosis is confirmed by cementing a well-fitting
the teeth. The staining inside the root fragments shows the extent and orthodontic band that should prevent relative movement of the tooth frag-
duration of the crack (Fig. 12.41d). The J-shaped radiographic lesion is ments and stop or reduce the pain (Fig. 12.45a). Definitive treatment
the classical sign of a long-standing root fracture, usually in the mesiodis- involves placement of a cusp-covered cast restoration (Fig. 12.45b,c).
tal plane (Fig. 12.42b). However, the precise presentation depends upon Cracks or fractures may arise in the roots of vital teeth (Fig. 12.46a,b)
the direction, extent and duration of the crack. A crack in the mesiodistal and diagnosis may initially be problematic (Fig. 12.46c,d). In this case,
plane that is prevented from progressing further apically by a crown, may pulp involvement was suspected and a fracture was only noticed later
result in an associated bone defect that is limited to the coronal part of the during treatment when bleeding into the canal could not be controlled. The
root (Fig. 12.43). The presence of a radicular post may mask radiographic tooth required surgical treatment.
signs of a buccopalatal crack (Fig. 12.44). In general, cracks or fractures Cracks and fractures more commonly arise in non-vital teeth; those
will not be visible unless their plane is within 5° of that of the X-ray beam. with root-canal infection usually progress to extensive inflammation of
312 THE PERIO–ENDO INTERFACE
A B
C B
Fig. 12.41 (a,b) Gutta-percha points used to trace localized deep probing defects on opposite sides Fig. 12.42 (a) Root-filled mandibular incisors,
of premolars; (c) periapical radiograph of the premolars in (a,b); (d) root fragments of premolars in one of which is fractured; note the widened
(c) following extraction periodontal ligament space; (b) over time, the
zone of widened PDL space developed into the
J-shaped pattern of bone loss around the
fractured incisor
A B
Fig. 12.43 Pattern of bone loss associated with Fig. 12.44 (a) Buccopalatal fracture in maxillary premolar; (b) appearance following removal of the
mesiodistal fracture in crowned mandibular molar fractured portion of root
the periodontium (Fig. 12.47), together with matching bone loss (Fig. by placing a permanent cast restoration with full cuspal coverage
12.48). Symptoms may be mild, unless there are acute exacerbations. (Fig. 12.49d,e). Cracks extending to the roots usually have a compromised
Patients may report a bad taste and odour in the mouth. Cracks commenc- long-term prognosis but, with careful and skillful restorative management,
ing in the crown (Fig. 12.49) may be visible with good lighting and may offer up to 10 years’ service. As mentioned before, there is a fine
will often respond to biting tests on individual pairs of cusps. It is impor- balance between choosing extraction or restoration; functional preser-
tant to protect such teeth from progression of the crack by placing a band vation of the tooth has to be balanced against compromise of a future
while endodontic treatment is carried out (Fig. 12.49c) and subsequently implant site.
THE PERIO–ENDO INTERFACE 313
A B C
Fig. 12.45 (a) Banded vital premolar displaying cracked tooth syndrome; (b) preparation for a MOD onlay to provide occlusal protection; (c) MOD onlay
restoration in place
A B
Fig. 12.47 Fractured premolar with post-retained
restoration
Fig. 12.46 (a) Fracture of mesial root of vital mandibular first molar; (b) root fracture (arrowed) in Fig. 12.48 Bone loss related to fracture of the
mandibular second molar; (c) surgical exposure of root fragment (arrowed) in mandibular second mesial root of a mandibular molar
molar; (d) tooth in (b) following endodontic and surgical treatment
Teeth with cracks commencing in the root may also be tender to bite on All in all, the presentation of cracks and fractures is enormously diverse
but display no differential discomfort on exerting pressure on individual in terms of pain, clinical presentation of swelling, sinus, mobility, percus-
cusps. Such a fracture only results in a probing defect once the crack line sion sensitivity, drainage, abscess and radiographic appearance.
progresses to and beyond the gingival margin. Until then, if the crack line
is superimposed on a root filling or intraradicular post, diagnosis may be
Root perforation
reliant upon surgical exploration (Fig. 12.50). The degree of pocketing and During root-canal treatment or restorative procedures, root perforation will
its width varies from a localized, narrow deep defect in an incipient frac- expose any residual infection within the root-canal system to the periodon-
ture to a wider defect in a more established and long-standing fracture. tium and consequently lay the tooth open to the development of a perio–
The treatment will usually consist of root amputation in a multirooted tooth endo lesion (Fig. 12.51). Coronal root perforations that traumatize the
or tooth extraction depending on the extent of the fracture. marginal attachment may present with wider probing defects and are
314 THE PERIO–ENDO INTERFACE
A B C
Fig. 12.49 (a) Mandibular first molar with mesiodistal crack (arrowed); (b) periapical radiograph of tooth in (a) showing periradicular bone loss; (c) periapical
radiograph following root-canal treatment and the placement of a supporting orthodontic band; (d) tooth restored with a gold veneer crown to provide occlusal
protection; (e) radiograph of the tooth 15 months after commencement of treatment showing evidence of periradicular healing
Fig. 12.50 (a) Root-filled mandibular incisor with suspected fracture; note the
characteristically widened periodontal ligament space; (b) surgical exposure of the root Fig. 12.51 Mandibular molar with a perforation
showing an open incomplete fracture not yet communicating with the oral cavity and furcal and periradicular bone loss
difficult to manage without crown lengthening procedures (Fig. 12.52). (coronally or through a periodontal communication) decreases chances of
Perforations that are more apical have a better prognosis as they can be success (Fig. 12.55a). In the case shown (Fig. 12.55), a highly motivated
treated as “iatrogenic canals” (Fig. 12.53). Immediate repair of the perfora- patient was nevertheless treated at his insistence with informed consent.
tion without allowing it to become infected gives the best outcome. Furca- Following root-canal treatment, a flap was raised and tin foil placed as a
tion perforations stand the best chance of success in the absence of a matrix (Fig. 12.55d) to repair the perforation surgically (Fig. 12.55e). As
periodontal communication (Fig. 12.54). The use of amalgam for repair the teeth appeared to have poor long-term prognosis, they were restored
of perforations has been superseded by MTA (ProRoot®). Used in com- with amalgam overlay restorations (Fig. 12.55g). The furcation defect
bination with regenerative techniques in the appropriate situation it may never healed and a through-and-through furcation morphology became
enhance the prognosis. Exposure of the perforation to the oral environment established following surgery but the patient was able to maintain it with
THE PERIO–ENDO INTERFACE 315
A B A B
Fig. 12.52 (a) Mandibular incisor with radiographic evidence of coronal-third Fig. 12.53 (a) Maxillary incisor with established lateral perforation; (b)
root perforation (arrowed) and a need for root-canal treatment; (b) radiographic appearance of the maxillary incisor following root-canal
mandibular incisor in (a) following crown-lengthening procedures, endodontic retreatment
treatment and new post-retained restorations
A B
F
D E
316 THE PERIO–ENDO INTERFACE
G H
D E
Fig. 12.56 (a) Radiograph of mandibular canine with external root resorption; (b) surgical exposure and removal of the granulomatous resorbing tissue;
(c) radiograph taken during root canal treatment; (d) radiograph of completed root canal treatment and coronal restoration; (e) minimal postoperative
periodontal probing of the restored defect
“bottle cleaner-type” brushes and the tooth has been functional for over Fig. 12.57 Class 4
10 years (Fig. 12.55h). Today, regenerative techniques may offer better progressive cervical
hope for such teeth. external inflammatory
resorption (arrowed)
Root resorption affecting the
mandibular first molar
Root resorption may arise anywhere on the root surface or even begin from
the crown. It can be classified into many types but most do not communi-
cate with the oral environment.
External cervical root resorption arises at the cervical margin as a result
of various insults to the periodontium (periodontal disease, trauma, tooth
bleaching, orthodontic treatment, surgery). The pattern of resorption may
vary according to the aetiology, type and severity. The entry point of
resorption may be confined and deep (with regular advancing front) (Fig.
12.56), confined and invasive (with irregular advancing front) (Fig. 12.57),
THE PERIO–ENDO INTERFACE 317
A B
Fig. 12.58 (a) Central incisor with broad shallow cervical defect; (b) surgical exposure and removal of Fig. 12.59 Large defect in maxillary incisor,
granulomatous resorbing tissue. The pulp is not exposed in this case and the tooth does not require due to internal resorption
root-canal treatment
B C
A B
C D
Fig. 12.62 (a) Palato-gingival groove in maxillary lateral incisor; (b) probing the
developmental defect; (c) radiograph of the lateral incisor prior to treatment;
E F (d) surgical exposure of the defect; (e) groove flattened and debrided;
(f) postoperative radiograph of the lateral incisor
THE PERIO–ENDO INTERFACE 319
A B A B C
Fig. 12.63 (a) Radiograph of maxillary lateral incisor with Fig. 12.64 (a) Fused central and lateral maxillary incisors (buccal view); (b) radiograph
two roots and a palato-gingival groove; (b) extracted of the fused teeth prior to extraction; (c) extracted fused teeth (palatal view)
specimen of maxillary lateral incisor with root division and
grooving; attempted endodontic treatment failed
A
C
A B
A B
Fig. 12.68 (a) Lateral incisor with type 3b invagination; (b) root-filled
invagination shows complete periradicular healing with maintained pulp vitality
A B
Fig. 12.73 Failure to maintain the cleanliness of Fig. 12.74 (a) OPG showing localized periodontal disease distal to 36; (b) close-up radiograph of the
a fixed prosthesis has led to localized periodontal area affected
destruction
B A B
Fig. 12.75 (a) OPG showing localized periodontal Fig. 12.76 (a) Localized gingival recession related to a mandibular incisor; (b) extensive
disease around distal root of 37; (b) periapical localized recession related to a mandibular molar with absence of probing at the gingival
radiograph of the localized destruction margin
The profiles were broad but, at least initially, restricted to one surface. Chronic periodontitis
Presentation of similar localized breakdown on the buccal surface usually
Previously termed “adult periodontitis”, this group embraces the constel-
leads to extensive localized recession (Fig. 12.76).
lation of destructive periodontal diseases, which are slowly progressive
and can be categorized as mild, moderate or severe. Disease progression
MULTIPLE PERIO–ENDO LESIONS is intermittent with periods of activity and remission influenced by bacte-
rial profile and risk factors. Individuals in this group will usually have poor
Isolated lesion(s) superimposed upon
levels of plaque control and multiple deposits of calculus, both supra- and
generalized periodontitis
subgingival. The role of general and local modifying factors should be
Any of the above isolated lesions can be found presenting as part of a considered and both smoking and diabetes (uncontrolled) are positive risk
generalized periodontal problem. The identification of some of these factors for periodontitis. Within this group, bone loss can be characterized
lesions becomes more challenging because of their occurrence together as either irregular (vertical) or horizontal. The involved teeth normally
with multiple localized sites of periodontal breakdown (see Fig. 12.7). give positive responses to pulp testing, indicating vital but not undiseased
However, careful evaluation of the presenting features along with the clini- pulp status. Teeth with extensive attachment loss of periodontal origin
cal examination may help locate those lesions with a pure endodontic have poor prognosis and should be extracted (Fig. 12.79). If such teeth
aetiology, which have a better outlook as opposed to those with a primary give a negative response to pulp testing, it will not be clear without good
periodontal aetiology (Fig. 12.77), which do not respond to root-canal insight into the clinical and radiographic history whether pulp necrosis is
treatment (Fig. 12.78) and may even accelerate their loss. The most primary or secondary to periodontal disease. In cases of uncertainty, per-
common categories of periodontitis affecting adults are chronic periodon- formance of first stage root-canal treatment followed by review of response
titis and aggressive periodontitis. will indicate endodontic origin if there is a good response (Fig. 12.80).
322 THE PERIO–ENDO INTERFACE
B C
Fig. 12.77 (a) OPG of patient with a long-span mandibular fixed prosthesis; (b) OPG Fig. 12.78 Bone loss around a non-vital mandibular
taken 5 years later with a developing primary periodontal lesion related to the mesial premolar with a localized probing defect which had
abutment; (c) surgical exposure of the periodontal defect demonstrating extensive not responded to endodontic treatment – lesion
bone loss was of primary periodontal origin
A B C
Fig. 12.80 (a) Radiograph of mandibular molar with bone loss of uncertain aetiology (courtesy of Imran Azam); (b,c) radiographs of mandibular molar indicating
the response to root-canal treatment (courtesy of Imran Azam)
A B
Fig. 12.82 Radiographs of patient with juvenile Fig. 12.83 (a) Rapidly progressive periodontitis at 29 years of age; (b) same patient at 34 years of age
periodontitis
ESTIMATION OF PROGNOSIS
The management of any clinical condition depends upon a diagnosis and
A
the nature of the presenting problem. The previous section illustrated the
problem-based management of the aetiological factors, where the cause is
clearly evident. The clinical notion of the term “perio–endo lesion”,
however, by definition often implies a lack of definitive diagnosis at the
outset. In many cases, the true origin is not confirmed until either endo-
dontic or periodontal treatment or, sometimes, both treatments have been
completed. Progress in management is, therefore, based on an initial pro-
visional diagnosis derived on the basis of an educated guess about the
endodontic contribution to the problem. The decision to embark on a
course of treatment is usually based on estimating the prognoses of the
teeth and the strategic value of each in the dental arch. In perio–endo cases,
B
it is unique that the prognosis cannot be ascertained until the origin is
known, that is, until either endodontic or periodontal intervention has been Fig. 12.84 (a) Radiograph of infected lateral periodontal cyst; (b) confirmation
completed. In some cases, both types of intervention may fail to resolve of communication with the mouth
the problem. This is classically the difficulty in the case of infected lateral
periodontal cysts that communicate with the mouth (Fig. 12.84). Lesions
presenting within a generalized periodontal problem with bone loss to the centres on whether the primary therapy should be periodontal or endodon-
root-end, grade 3 mobility, and positive pulp response, are deemed to have tic. In cases of uncertainty (even where there may be partially necrotic and
a poor prognosis. infected pulp tissue but this cannot be confirmed), the simplest and least
damaging therapy should be undertaken first; that is periodontal debride-
ment. However, it is crucial that caution is exercised in root debridement
TREATMENT OF PERIO–ENDO CASES lest the lesion is of endodontic origin and viable cells on the root surface
Figure 12.85 shows a decision-tree for aiding the planning of treatment are destroyed. In the absence of any sign of resolution after a short review
of isolated perio–endo lesions. Any acute problems (pain and infection) period (6–8 weeks) following the initial periodontal debridement, the deci-
should be dealt with first. Primarily, gentle debridement of the pocket is sion to intervene endodontically may be taken. The first stage of root-canal
the main form of treatment when present and only used in conjunction treatment may be carried out (noting the contents of the canal as healthy,
with antibiotics if there is spreading infection and fever. The issue usually inflamed or necrotic pulp) and the tooth dressed with non-setting calcium
324 THE PERIO–ENDO INTERFACE
preparation:
underprepared obturation:
overprepared underfilled
perforation overfilled positive negative
zipping poor adaptation
ledges
Fig. 12.86 The shapes of the roots Fig. 12.87 Naber’s probe
of maxillary first and second molars
root canal
is root canal retreatment feasible? perio treatment treatment
• Degree II – horizontal loss of periodontal support greater than
one-third but not encompassing the total width of the tooth
•
yes no resolution? resolution? Degree III – horizontal through and through destruction of the
OHI try OHI + debridement periodontal tissues in the furcal area.
yes no yes no Classifications based on vertical loss of bone are not in common use
resolution? resolution? due to the difficulty in assessing the level of the bone. In maxillary teeth,
check vitality again; check
if doubt, do root OHI furcation involvement is evaluated from midbuccal, mesiopalatal and dis-
yes no yes no
canal treatment and perio topalatal aspects. While in mandibular teeth, they are evaluated from the
mid-buccal and mid-lingual aspects. Furcation probing is performed with
do first stage endo,
clean and shape canals,
extract special probes, such as the Naber’s probe, which is curved to allow access
still no resolution
dress with Calcium Hydroxide into the furcation (Fig. 12.87). These clinical findings are used in conjunc-
tion with radiographic findings.
resolution? no look for other causes mentioned above Root amputations are considered when the furcation is compromised by
endodontic complications or Degree II or III involvement. Factors to be
yes final treatment options: extract, resect, hemisect
considered when deciding on root amputation are:
• Tooth-related factors
▸
Fig. 12.85 Decision-tree for management of perio–endo lesions
restorability of the tooth
▸ strategic value of the tooth
hydroxide to gauge the response. By this stage, a definitive diagnosis will ▸ feasibility of root canal treatment
be possible but some cases will fail to respond after both measures and ▸ post-treatment occlusal stability
may need either further evaluation to determine the causative factor or • Root-related factors
extraction. ▸ length of the root trunk – ideally, a tooth with a short root trunk
is a better candidate for resection. Teeth with long trunks will
Only when the pulp is clearly necrotic and infected should root-canal
have a low furcation entrance and, once established, the amount
treatment be initiated first and the tooth dressed with calcium hydroxide.
of periodontal support remaining around the roots will be poor
Periodontal treatment should follow in quick succession in the absence of
a lack of immediate healing after root-canal treatment. ▸ divergence of the roots – the smaller the divergence (closely
approximated roots), the smaller the interradicular space; these
Where the patient motivation or compliance is poor or extensive primary
teeth are poor candidates for resection
dental disease prevails, the alternative of extraction should be considered
as a first option. ▸ length and shape of roots – short and small roots may exhibit
increased mobility after resection
• Bone-related factors
ROOT AMPUTATION
▸ the residual bone around the remaining roots should be assessed
B
A
0.75
root_resect = Yes
root_resect = No
0.50
0.25
A B
0.0
0 1000 2000 3000
Analysis time (day)
Fig. 12.92 Five-year survival of root treated periodontally involved teeth with
or without subsequent root amputation
Radicular groove
C D
Fig. 12.94 Histological section Fig. 12.95 (a) The three radiographs show the retreatment of the left maxillary lateral incisor with a radiolucency
showing new attachment formation and palatal periodontal breakdown related to a palato-gingival groove; (b) surgical exposure of the developmental
using a barrier (courtesy of Lars groove; (c) groove sealed with glass ionomer cement; (d) synthetic bioaborbable barrier placed; (e) complete
Laurell) resolution of the bone defect after treatment
The following case shows the use of a barrier in the management of a narrow three-walled morphology, was debrided and all the granulation
localized perio–endo lesion associated with a deep palato-gingival groove. tissue removed. The palato-gingival groove was filled with glass ionomer
The patient in Figure 12.95 presented with a localized palatal break- cement (Fig. 12.95c) and a bioabsorbable barrier was placed (Fig. 12.95d).
down associated with the maxillary left lateral incisor. The tooth had been At follow up, healing had been uneventful with no persistent probing depths
root treated twice before, however, there was no resolution of the residual and complete resolution of the bone defect as shown in Figure 12.95e.
probing defect, which tracked along the line of the palato-gingival groove Successful outcomes with barriers require good case and site selection
(originally undiagnosed). Following referral, careful assessment and plan- (including the soft tissue assessment and the defect anatomy), as well as
ning, the patient underwent root-canal retreatment and regenerative close postoperative follow up. Early follow up helps to identify complica-
surgery. At surgery, it was noted that the groove, which was deep, gave tions, such as infection, which should be managed promptly. Although
the root a bifid appearance, tracked along the palatal aspect and terminated enamel matrix derived proteins have been extensively used in periodontal
in the apical third (Fig. 12.95b). The groove was cleaned and opened regeneration for periodontitis patients, they have not yet been applied to
slightly with a narrow ultrasonic tip. The residual bone defect, which had the combined perio–endo lesion.
328 THE PERIO–ENDO INTERFACE
REFERENCES AND FURTHER READING Rubach, W.C., Mitchell, D.F., 1965. Periodontal disease, age, and pulp status. Oral Surg
Oral Med Oral Pathol 19, 483–493.
Bender, I.B., Seltzer, S., 1972. The effect of periodontal disease on the pulp. Oral Surg Seltzer, S., Bender, I.B., Ziontz, M., 1963. The interrelationship of pulp and periodontal
Oral Med Oral Pathol 33 (3), 458–474. disease. Oral Surg Oral Med Oral Pathol 16, 1474–1490.
Bergenholtz, G., Lindhe, J., 1978. Effect of experimentally induced marginal Seltzer, S., Bender, I.B., Nazimov, H., et al., 1967. Pulpitis-induced interradicular
periodontitis and periodontal scaling on the dental pulp. J Clin Periodontol 5 (1), periodontal changes in experimental animals. J Periodontol 38 (2), 124–129.
59–73. Tamse, A., Fuss, Z., Lustig, J., et al., 1999. An evaluation of endodontically treated
Kirkham, D.B., 1975. The location and incidence of accessory pulpal canals in vertically fractured teeth. J Endod 25 (7), 506–508.
periodontal pockets. J Am Dent Assoc 91, 353–356. Vertucci, F.J., Gegauff, A., 1979. Root canal morphology of the maxillary first premolar.
Lin, H.J., Chan, C.P., Yang, C.Y., et al., 2011. Cemental tear: clinical characteristics and J Am Dent Assoc 99, 194.
its predisposing factors. J Endod 37 (5), 611–618. Vertucci, F.J., Williams, R., 1974. Furcation canals in the mandibular first molar. Oral
Lindhe, I., Lang, N.P., 2008. Clinical periodontology and implant dentistry, 5th ed. Surg Oral Med Oral Pathol 38, 308–314.
Blackwell Munksgaard, Oxford.
Lowman, J.V., Burke, R.S., Pellu, G.B., 1973. Patent accessory canals: incidence in
molar furcation region. Oral Surg Oral Med Oral Pathol 36, 580–584.
13
Section 4 Multidisciplinary aspects of endodontic management
The ortho–endo interface
K Gulabivala, FB Naini
A B A
D
C B
Fig. 13.1 Premolar undergoing orthodontic tooth movement showing progressive pulpal sclerosis Fig. 13.2 Blunt root apices, particularly affecting
maxillary incisors
Table 13.1 Optimal force levels for different types of tooth movement Table 13.2 Risk factors for orthodontically-induced root resorption
B
A
periodontal ligament space and its width. Apical root resorption is said to technically with an absence of apical pathosis) and an inert root-filling
be evident four times more commonly than lateral root resorption but it is material, exposure of dentine or root-filled pulp space would elicit a
likely that histologically, such resorption affects those surfaces under neutral response with a maintained periodontal ligament space. Likewise,
excessive pressure. Apical root resorption is more commonly manifest on in a tooth with a technically inadequate root filling but absence of apical
radiographs because the relative thinness of the roots makes the resorption pathosis (because the treatment had involved vital extirpation without root
more evident. Theoretically, it could also be because the apical cementum canal infection), it is likely that the response would be neutral. In contrast,
is more labile, although this is not consistent with the fact that root apices where the treatment had been biologically inadequate (residual root-canal
are covered by cellular cementum, which is less prone to resorption than infection) but technically sound (absence of periapical pathoses, techni-
the acellular cementum, which covers most of the root. Roots with pipette cally adequate root filling), root resorption may expose the underlying
shaped or blunt roots may be more susceptible to apical resorption. residual infection, leading to the development of periradicular inflamma-
The risk of severe localized root resorption during orthodontic treatment tion and enhanced root resorption. In the case of a technically inadequate
appears to be greater for maxillary incisors (Fig. 13.3), with 3% of teeth root-canal treatment with a residual root-canal infection (associated apical
affected compared to less than 1% for all other teeth. This risk is increased pathosis), the response to resorption would be expected to be similar to
even further, up to a 20-fold, if the roots are forced against the palatal that of a tooth with an infected root-canal system with apical pathosis, that
cortical plate during treatment. is, aggressive root resorption. Exposure of root-filling material that is not
biologically compatible may also result in some sort of inflammation-
fuelled exacerbation of the resorption. The exposed root-filling material
EFFECT OF ORTHODONTIC TOOTH MOVEMENT
may or may not be resorbed depending upon its properties and the
ON RESORPTION OF VITAL, NON-VITAL OR
host response. The scenarios clearly do not cover all eventualities and a
ROOT-TREATED TEETH
variety of responses would be expected from the continuous spectrum of
Once the cementum has been resorbed due to orthodontic forces, it was scenarios likely to exist in reality.
supposed that the response of the dentine may potentially vary according The literature mainly focuses on the comparison between vital and root-
to the pulpal status. The responses to exposure of the dentine may be treated teeth, the effect on non-vital teeth with or without periapical lesions
predicted from a knowledge of pulpal and periapical aetiopathogenesis. is ignored; the available studies on animals or humans either use radio-
It may be speculated that exposure of vital healthy dentine may have an graphic or histological outcome measures. The findings from these studies
exacerbating, reducing or neutral effect on resorption. It may be surmised have been conflicting. The majority of studies (n = 4) suggest there is no
that the odontoblasts may remain neutral towards resorption because it is difference in response between root-treated and vital teeth, a slightly
a process external to the pulp and unconnected to it. An inhibitory effect smaller number of studies (n = 3) suggest that vital teeth may resorb to a
is only manifested by the unmineralized predentine if and when this greater extent than root-treated teeth, while a smaller number of studies
becomes involved. Alternatively, it may be supposed that the odontoblastic (n = 2) still suggest that root-treated teeth resorb to a greater extent than
process is able to sense peripheral damage and respond with a defensive vital teeth. These apparently conflicting findings may be explained by the
reaction through molecular release, although there is no evidence for speculative proposals above.
such a response. Lastly, the possible initiation of pulpal inflammation
through noxious stimuli or a neurogenic response (CGRP) may result in EFFECT OF PREVIOUS TRAUMATIC INJURIES ON
an increase in resorption. The latter speculation is strongly believed in ORTHODONTICALLY-MEDIATED RESORPTION AND
some quarters. TOOTH MOVEMENT
In contrast, exposure of dentine associated with a necrotic and infected
pulp is likely to lead to a source of inflammation in the resorptively active Traumatic injuries may leave teeth with compromised but vital pulps,
periodontal ligament, which in turn, would fuel a rapid acceleration in the repaired or unrepaired crown and root fractures, repaired or regenerated
rate and extent of resorption. This would be similar to the aggressive periodontal support apparatus, ankylosis, arrested or on-going resorption
inflammatory resorption associated with traumatic injuries but is not and arrested or on-going root development. Orthodontic movement of
widely seen or reported, presumably because such teeth would normally traumatized teeth may be associated with modified responses. It may
be root treated before embarking on orthodontic treatment. become necessary orthodontically to move such teeth, either because of a
Exposure of root-treated dentine is liable to lead to a variety of responses, pre-existing malocclusion or because tooth displacement caused by the
depending upon the inner state of the pulp space. It is evident that in trauma could not be corrected manually at the time. A further cause for
a tooth with well-performed root-canal treatment (biologically and the need of orthodontic treatment precipitated by traumatic injury is that
332 THE ORTHO–ENDO INTERFACE
Fig. 13.4 Ankylosis block of bone into a new and more favourable position. This is followed
of the maxillary by fixation with wires or screwed plates. During these procedures, it is
right canine during possible that the blood supply to teeth may be directly severed, sometimes
orthodontic alignment
including the root apices. Otherwise, during longer procedures, blood
with fixed appliances
and consequent severe
supply may be restricted to the teeth. The consequence is that the neurov-
disruption of the ascular bundle would be affected, leading to loss of pulp sensitivity, rarely
occlusal plane, due to pulp necrosis (see Fig. 14.15), and sometimes root resorption. Pulp revas-
unintentional intrusion cularization may be evident but regrowth of nerve supply is less likely.
of maxillary dentition There appear to be few permanent effects from orthognathic surgery on
pulpal tissues, which may be surprising considering the proximity of oste-
otomy cuts to the teeth. This is likely to be explained by the excellent
neurovascular supply of the maxillofacial region. Research after segmental
surgery has indicated that the vascular supply of the teeth in the mobilized
segment remained intact, although unresponsive to electrical pulp testing.
tooth space is not protected by some means following avulsion or loss of In a landmark study, Bell et al. (1975) demonstrated the biological basis
teeth. The consequent compensatory movement of teeth may then need to for this phenomenon, using microangiography, which showed that dental
be corrected before restorative treatment. and osseous components receive blood from a number of sources, includ-
It is evident from the literature that traumatized teeth exhibit a range of ing the labial arteries, apical vessels, intra-alveolar vessels, the periodontal
pulpal responses, including rapid pulp necrosis, delayed pulp necrosis or plexus and the gingival plexus. It does appear, however, that the supporting
pulp survival. In the case of teeth with compromised pulps that do not structures of the teeth fare better than pulps following surgery.
manifest clinically, there is a higher chance that orthodontic tooth move-
ment may precipitate pulp necrosis. It is important to monitor for signs of
such changes through altered tooth discomfort or discoloration. EFFECT OF ORTHODONTIC TOOTH MOVEMENT ON
Teeth with repaired root fractures may be moved orthodontically without ENDODONTIC TREATMENT AND ITS OUTCOME
risk of problems, even if the fragments were previously dislocated.
However, in those cases where the repair has not occurred or is poor, root Teeth undergoing orthodontic tooth movement may occasionally require
fragment separation may occur as a result. It has been suggested that teeth endodontic treatment although, wherever possible, the need should be
that had displayed root separation at injury, albeit repositioned adequately predicted beforehand during treatment planning. Root-canal treatment
afterwards, should be observed for at least 2 years before initiating ortho- during orthodontic treatment poses a number of difficulties, not least
dontic tooth movement. during the diagnosis and treatment planning because of the problem of
Teeth with ankylosed roots may be moved if the area of ankylosis is pulpal or periradicular pain, being confounded by discomfort due to tooth
relatively small, otherwise there is likely to be no movement and, what is movement. Isolation of teeth could be complicated and novel methods can
more, the teeth providing anchorage could move in the opposite direction be used to apply rubber dam, however, it is always better, if at all possible,
(Fig. 13.4). to remove wires to allow proper application of the rubber dam. Access
Traumatized teeth do not all show a higher propensity for root resorption cavity preparation should not be compromised but it is worth remembering
following orthodontic tooth movement, however, the likelihood is greater that the tooth axis should be used for alignment, which may become con-
if there is pre-existing resorption and if the degree of trauma was greater. fused during tooth movement. Determination of the canal terminus and
A classic dilemma regarding tooth repositioning arises when deciding working length could be compromised by the apical root resorption, which
upon repositioning of an intruded tooth. Such teeth may either be allowed may be altered further by the following visit. Under the circumstances, it
to re-erupt spontaneously, be repositioned immediately using forceps or may be prudent to complete chemomechanical debridement but delay final
be orthodontically repositioned once periodontal support healing is com- obturation until after completion of orthodontic treatment, with calcium
plete. Immature teeth may be more amenable to spontaneous re-eruption. hydroxide dressing in the interim. If the dressing would be required long
If a mature tooth, which has experienced severe intrusive trauma and term, the access should be sealed with a permanent filling material to avoid
required pulp therapy for that reason, must be repositioned orthodontically, seal breakdown. It is also a further consideration that long-term calcium
resorption appears to be less likely if a calcium hydroxide dressing is hydroxide dressing may cause tooth weakening. Apical root resorption
maintained until the tooth movement is completed prior to definitive root- may complicate control of placement of root-filling material to the canal
canal filling placement. terminus. Customization of the master gutta-percha cone is therefore
mandatory.
Should teeth require caries management or replacement of fillings, it
EFFECT OF ORTHOGNATHIC/ORTHODONTIC TREATMENT
should be borne in mind that the pulpal response may be modified after
ON TEETH AND THEIR PULPS
orthodontic tooth movement. There may be a greater propensity for unfa-
vourable pulpal responses. There is no definitive evidence that the prob-
When the malocclusion is based mainly on a skeletal discrepancy, it may
ability of success of root-canal treatment is altered, however, the issue of
be necessary to correct it by orthognathic surgery, which is almost always
apical resorption and control of root filling extension may reduce success
combined with some orthodontic tooth movement. A range of established
rates indirectly.
procedures are used for maxillary and mandibular skeletal correction.
These display characteristic prevalences for pulpal and periradicular alter-
ations. These are all brought about by direct or indirect interference with ROLE OF ORTHODONTICS IN ENDODONTIC-RESTORATIVE
the blood supply for variable periods of time during and after the surgery. TREATMENT PLANNING
The surgical procedures in general demand the raising of large muco-
periosteal flaps, the sectioning of the alveolar and/or basal bone distal or Orthodontic tooth movement may be used to facilitate or enhance endo-
apical to the tooth apices before repositioning of the entire tooth-containing dontic or restorative care. The most common scenario described is that of
THE ORTHO–ENDO INTERFACE 333
the tooth with a crown compromised by tooth structure loss due to fracture, Fig. 13.5 Alveolar ridge
caries, resorption (internal or external) or tooth surface loss. Under the created by movement
circumstances, in the presence of adequate root length and attached of mandibular incisor
tooth, prior to implant
gingiva, the root may be extruded using controlled orthodontic forces (See
placement
Fig. 14.11). This process is sometimes termed forced eruption. In some
cases, subgingival fractures may extend to the level of the alveolar ridge,
making restoration of the fractured crown impossible, as any overexten-
sion of a crown margin would impinge on the biological width of the tooth
and lead to persistent gingival inflammation. As such, orthodontic extru-
sion of the fractured root coronally, out of the alveolar bone, would move
the fracture margin coronally in order that the tooth may be restored. If
enough of the tooth crown is present, it may be possible to bond an ortho-
dontic bracket and place extrusive forces via elastic traction to the root.
However, if the entire crown has fractured, leaving only the root, an attach- root of the tooth that has been moved (Fig. 13.5). Such orthodontic implant
ment may be temporarily cemented into the root canal, such as a thin piece site development may eliminate or reduce the need for a bone graft in the
of wire with its occlusal aspect bent into a loop, to provide attachment for edentulous site prior to implant placement.
the elastic traction.
Orthodontic tooth movement may also aid tooth alignment to facilitate
restorative treatment by distributing space adequately allowing properly REFERENCES AND FURTHER READING
sized and contoured crowns or by achieving adequate tooth alignment for Bell, W.H., Fonseca, R.J., Kenneky, J.W., et al., 1975. Bone healing and
bridge, denture or implant placement. Divergence of roots prior to implant revascularization after total maxillary osteotomy. J Oral Surg 33 (4), 253–260.
placement is often required, as otherwise implant placement may damage Burnside, R.R., Sorenson, F.M., Buck, D.L., 1974. Electric vitality testing in orthodontic
patients. Angle Orthod 44 (3), 213–217.
the roots of the teeth. Correcting the angulation of the teeth adjacent to a Chaushu, S., Shapira, J., Heling, I., et al., 2004. Emergency orthodontic treatment after
potential implant site by moving the roots away from one another will aid the traumatic intrusive luxation of maxillary incisors. Am J Orthod Dentofacial
the implantologist. Orthop 126 (2), 162–172.
Hamilton, R.S., Gutmann, J.L., 1999. Endodontic-orthodontic relationships: a review of
Implant placement may also be facilitated by moving teeth through bony integrated treatment planning challenges. Int Endod J 32 (5), 343–360.
defects. This may help create adequate bone thickness in extraction sites. Kaley, J., Phillips, C., 1991. Factors related to root resorption in edgewise practice.
It is possible, within limits, to move a tooth into a narrower edentulous Angle Orthod 61 (2), 125–132.
Llamas-Carreras, J.M., Amarilla, A., Solano, E., et al., 2010. Study of external root
ridge, in order to develop a potential implant site. The alveolar bone that resorption during orthodontic treatment in root filled teeth compared with their
is created behind a moving tooth will be approximately the width of the contralateral teeth with vital pulps. Int Endod J 43 (8), 654–662.
14
Section 4 Multidisciplinary aspects of endodontic management
The restorative–endo interface
K Gulabivala, Y-L Ng
Much has been written about restoration of the root-treated tooth, in part weakening, offers an attractive explanation for the apparently
because such teeth are often lacking in sufficient coronal tooth structure higher rate of mechanical failure of root-treated teeth.
and what is remaining may be compromised by cracks or altered physical
properties. They therefore, require novel and ingenious methods of restora-
tion that account for their inherent weakness. The spectrum encompassed PRINCIPLES OF RESTORATION OF ROOT-TREATED TEETH
by the pattern of distribution of remaining tooth structure is broad; attempts
have been made to devise an index to characterize it (Fig. 14.1). The dis- The same principles which govern the restoration of all teeth also apply
tribution of the remaining tooth structure may enable it to be sculpted into to root-treated teeth. However, it is important to pay special attention to
a preparation with adequate retention and resistance form for a restoration two factors to extend the longevity of tooth survival:
or it may not (Fig. 14.2). In the latter situation, various dowel systems
have been used to supplement retention and resistance form by utilizing • preservation of remaining tooth tissue
the root structure. A wide range of dowel or retention systems is available • reduction of occlusal stress and its favourable distribution within
the remaining tooth tissue.
to aid restoration but significant research to support all the claims of
manufacturers is lacking. That root-treated teeth are more susceptible to The most conservative restoration design compatible with acceptable
fracture is a widely held clinical impression and they may, therefore, aesthetics and function should, therefore, be selected in conjunction with
require different considerations when restoring them compared to vital patient consent. Occlusal loads can only be assessed subjectively from the
teeth. The high fracture rate of endodontically-treated teeth, especially history: breaking restorations or teeth; occlusal tooth-tissue loss due to
immature anterior teeth (Fig. 14.3) and those restored with mesio-occlusal- attrition; abfraction lesions, mobility and drifting; and the size and activity
distal (MOD) plastic restorations (Fig. 14.4) has been documented. Unre- of the muscles of mastication are indicators of high loads. A young indi-
stored teeth, particularly mandibular molars, may develop mesiodistal vidual with a thickset jaw, well-developed muscles of mastication and
cracks across the marginal ridges in patients with heavy occlusal loading marked faceting on occlusal contact areas is likely to exert greater occlusal
(Fig. 14.5); but maxillary molars are not immune to such damage either loads. Restoration design is dictated not only by the pattern of residual
(Fig. 14.6). The three main reasons advanced to explain the possible high tooth tissue but also by the properties of the restorative materials used.
fracture rate are: Consideration of these and the occlusal demands of the individual case
together with meticulous execution of the clinical procedures should lead
1 Altered physical properties of tooth tissue The idea that root-
to a successful and predictable restoration.
treated teeth are brittle has long been propagated as an explanation
for the apparently higher fracture rate of such teeth but no
convincing evidence has been found to support the theory. RESTORABILITY OF THE TOOTH
Dehydrated dentine is brittle and hydrated or rehydrated dentine is
viscoelastic. The water in the dentinal tubules that confers on the The restorability of the tooth should always be determined before endo-
tooth its resilience. Measures to dehydrate teeth may be dontic treatment as part of a general restorative and oral treatment plan.
counterproductive. Given that cementum is permeable to moisture, Space available should be sufficient to place an aesthetic, functional res-
it is difficult to envisage permanently dehydrated dentine in the toration with cleansable contours, which will optimize the health of the
moisture-saturated mouth periodontal tissues and adjacent teeth. Often the tooth requiring endodontic
2 Weakening due to loss of tooth tissue Many studies have evaluated treatment is severely broken down and movement of neighbouring teeth
the effect of pattern of tooth-tissue loss as a cause of tooth may result in occlusal (Fig. 14.8a) and proximal (Fig. 14.8b,c) loss of
weakening. The loss of marginal ridge integrity is probably one space, which may occasionally be corrected by orthodontic movement but
of the most important factors. The width of occlusal isthmus and this is not always a practical solution. Even when the tooth is not to be
depth of cavities compound the situation. Loss of roof of the pulp restored but used as an overdenture abutment, an assessment of the space
chamber has been considered to be an important contributory for a denture is important (Fig. 14.9a,b). A denture with thin metal frame-
factor in the weakening effect; its importance probably lies in work may fracture (Fig. 14.9c).
its contribution to the increased depth of the cavity, making the An adequate amount of remaining tooth tissue is necessary in addition
cusps “longer” and more susceptible to flexure (Fig. 14.7a,b). to space. Although it is difficult to describe strict limits, a cast restoration
Loading of such cusps may lead to unfavourable stress encompassing at least 2 mm of sound dentine around the circumference
concentration at the cervical region making the cusps prone to would make the longevity of the restoration more predictable (Fig. 14.10).
fracture (Fig. 14.7c,d) In the absence of sufficient coronal tooth tissue, it may be possible to
3 Loss of proprioception Loss of the dental pulp may deprive the gain retention from the root. Under such circumstances, it is critical to
tooth of some of its mechanoreceptive properties. Teeth without evaluate the length, width, shape and curvature of the root, to assess the
pulps have a higher “load perception” threshold and may take up potential use of a dowel. In the absence of sufficient coronal dentine, under
to twice the load of a tooth with a vital pulp before registering exceptional circumstances, it may be possible to extrude the tooth ortho-
discomfort. Although proprioceptors have not been identified in dontically. In some procedures, the supporting alveolar and periodontal
the dental pulp, there is evidence for Aβ nerve fibres which are tissues are extruded with it, which must then be recontoured surgically
reputed to serve a proprioceptive function. Despite lack of clear prior to restoration (Fig. 14.11). Rapid extrusion may allow the tooth to
evidence, this concept is plausible and, together with tooth be extruded without the periodontal supporting tissues, circumventing the
ML ML
3 0
DL
1
MB
0
A
D B
0 DB
2
A B
C
336 THE RESTORATIVE–ENDO INTERFACE
A
B C
E F
A B C D
Fig. 14.7 (a,b) Deeper proximal boxes and lack of roof of pulp chamber render cusps more prone to flexure; (c,d) photoelastic model (courtesy of Mr P O’Neilly)
showing concentration of stress increases at the base of the cusps (arrowed) when the roof of the pulp chamber is removed
THE RESTORATIVE–ENDO INTERFACE 337
A B C
Fig. 14.8 (a) Occlusal loss of space (arrowed); (b,c) proximal loss of space (arrowed)
A B C
Fig. 14.9 (a,b) Occlusal space considerations for overdenture situation; (c) fracture of denture due to thinness of framework
A B
Fig. 14.10 The margins should be
finished on sound tooth tissue
(arrowed)
C D
Fig. 14.11 (a–d) Orthodontic extrusion and periodontal surgery are necessary to make tooth tissue
supragingival for restoration
338 THE RESTORATIVE–ENDO INTERFACE
need for surgery. The long-term predictability of such teeth is not high and and, in parafunction, serve as the guiding surfaces for mandibular excur-
such a plan must be agreed with informed consent about the cost–benefit sions; they are generally not loaded axially except in class 3 malocclu-
ratio. sions. The teeth are broader in the labiolingual plane to provide greater
bulk and strength in this direction of loading (Fig. 14.13) and, therefore,
have long roots that are bulky labiolingually. Posterior teeth, in contrast,
WHEN TO RESTORE AFTER ENDODONTIC TREATMENT
serve a crushing, grinding function and have a broad rectangular base with
The decision to place expensive coronal restorations on teeth immediately multiple roots, which are likely to be broad buccolingually. They are
following completion of root-canal treatment may sometimes be difficult loaded axially, except in mandibular excursive movements when lateral
because of any uncertainty about success of root-canal treatment. It may forces may jar teeth in interference. Such interfering contacts, therefore
take at least one year, if not several years for a periapical lesion to heal incur the worst damage on posterior teeth, resulting in cracks and fractures.
but it is not practical to wait this long before a permanent restoration is Anterior and posterior teeth therefore, merit separate consideration in
placed; indeed, an early permanent coronal seal is an important final stage restorative options, not least because of their fundamentally different struc-
in the completion of root-canal treatment so as to protect and seal the tures and loading considerations.
root-canal system from recontamination and ensure success. Fortunately,
the mean success rate of root-canal treatment is relatively high (85%), RESTORATION OF ANTERIOR TEETH
therefore, it remains only for the clinician to judge whether the tooth is
Tooth-coloured composite restorative material may provide an adequate
likely to fall into the 15% failure group. Persistent symptoms and signs of
means to restore anterior teeth that have sufficient coronal tooth tissue for
infection, lack of apical patency during treatment, large periapical lesions,
adequate retention and resistance form.
extruded root-filling material, superimposed periodontal involvement and
tooth resorption may signal the teeth that may fall into this group. A small Relatively intact teeth
proportion of asymptomatic teeth with the probability to fail may be
Unrestored anterior teeth may require endodontic treatment because of
missed. It is therefore, not necessary to review the tooth for an arbitrary
pulp necrosis caused by traumatic injury (Fig. 14.14), severance of blood
period of longer than one month before providing the permanent restora-
supply during surgery (Fig. 14.15), periodontal involvement (Fig. 14.16)
tion. During this time, there should be no sinus, no tenderness to palpation
or tooth transplantation (Fig. 14.17). Restoration of such teeth would
of the adjacent soft tissues and apices or to pressure and percussion of the
normally be confined to the access cavities (Fig. 14.18) and may be
tooth. Any tooth with an uncertain postoperative endodontic status may
achieved satisfactorily with composite restorative material. In such cases,
require a longer review period prior to restoration.
“reinforcement” of the tooth by placement of a post or dowel remains
controversial (Fig. 14.19). The rationale for post placement is based on the
HOW TO RESTORE TEETH AFTER belief that the root-treated tooth is inherently weak and that the post would
ENDODONTIC TREATMENT provide a degree of reinforcement by distributing some of the stresses to
the root. The scientific support for this is equivocal. It appears that whether
Restoration of the root-treated tooth should achieve satisfactory aesthetics, a tooth is made more resistant to fracture by placement of a dowel is
form and function while preserving and protecting the maximum amount dependent on the type of loading. It is widely accepted that where a post
of tooth tissue. In any given situation, a number of design options are is not required to aid retention then it should not be placed. If one is placed
available. The choice depends on the structural integrity of tooth, aesthetic then it should be at the expense of the minimal amount of tooth tissue. The
and protective requirements. In order to place these in perspective, a need for a post is a subjective clinical assessment based on the amount
number of clinical cases have been used to illustrate the application of and distribution of remaining dentine after preparation of the tooth for the
these principles. selected restoration. In Figure 14.20, sufficient dentine cores remained
The biomechanics of anterior and posterior teeth are fundamentally dif- after crown preparation to render post/cores unnecessary whereas, in
ferent (Fig. 14.12). The anterior teeth serve an incising and tearing function Figure 14.21, loss of tooth tissue in the three teeth was variable. The gold
posts and cores supplemented residual dentine cores. The idea of “rein-
forcement” has recently been resurrected with the possibility of using
Fig. 14.12 (a,b) Line adhesive luting cements to bond posts made of materials similar in physi-
diagrams showing cal properties to dentine (carbon-fibre or glass-fibre posts). There is, as
biomechanics of yet, no long-term clinical evidence to support this concept.
anterior and posterior Previously unrestored, root-treated teeth sometimes require more exten-
teeth sive restoration than simple access filling, for example, if the crown
requires realignment or if its discoloration cannot be dealt with by bleach-
ing alone. The most conservative restoration likely to satisfy aesthetic
and functional requirements should be selected so as not to weaken
the tooth further. Such restorations may include composite or porcelain
veneers (Fig. 14.22), with or without tooth preparation, according to the
prevailing preoperative condition. The least conservative preparation is for
a ceramometal or pure ceramic crown but, even using this design, the tooth
should be prepared to review the need for supplementation of retention by
a dowel.
A B
A common clinical situation is one in which an anterior tooth has mesial
and distal cavities or restorations (Fig. 14.23). The addition of an access
THE RESTORATIVE–ENDO INTERFACE 339
A B
Fig. 14.19 “Reinforcement” of intact root-filled Fig. 14.20 (a) Adequate dentine cores remaining after crown preparation of root-filled canines render
teeth prepared for crowns is unnecessary posts or cores unnecessary; (b) buccal view of prepared left canine
A B
Fig. 14.21 As much tooth tissue should be Fig. 14.22 (a) Porcelain veneers – buccal view; (b) porcelain veneers – palatal view
retained as possible, supplemented with a metal
core as necessary
cavity leaves such a tooth with a “band” of missing tooth tissue across the
middle of its crown (Fig. 14.24). Provided that the labial enamel plate is
intact, relatively strong and unblemished by discoloration or surface
deformities, such as pitting, the tooth may be satisfactorily restored with
composite restorative materials. A crown may give a better aesthetic result,
particularly if adjacent teeth also need to be crowned, but will not neces-
sarily confer greater strength or durability on the tooth. The presence of
additional cavities/restorations or tooth-tissue loss would strengthen the
case for full coverage cast restorations.
B B
Fig. 14.25 “Rooftop” preparation Fig. 14.26 (a,b) Use of post cores to supplement Fig. 14.27 (a) Following preparation for a crown,
dentine cores and retention spicules of tooth tissue that do not contribute to
the strength of the tooth should be sacrificed;
(b) this also makes post/core construction easier
A B
D
Fig. 14.28 (a) The use of temporary post crowns may be complicated by recontamination of the root-canal system; (b) permanently cemented post, core and
temporary crown; (c,d) if surgery is required, the preparation margins may be modified after healing to avoid exposure of the crown/tooth junction
construction of a core may be sacrificed at this stage (Fig. 14.27). In this 2 A permanent post and core may be cemented permanently
way, a more conservative restoration may be constructed. following root canal treatment if there is a risk of losing the
Severely broken down anterior teeth require expeditious restoration of temporary post-crown (Fig. 14.28a), followed by placement of a
aesthetics and provision of predictable function. Three approaches may be temporary crown (Fig. 14.28b). This reduces the chances of
considered to achieve this during endodontic treatment: coronal leakage and, should periapical surgery be required (Fig.
14.28c), allows modification of the margin for a permanent crown
1 A temporary post crown may be suitable if the post has adequate once the gingival margin has stabilized (Fig. 14.28d)
length and is well fitting. Otherwise, its decementation may not 3 A temporary overdenture instead of post-crowns allows the
only cause inconvenience but also allow coronal leakage, further temporary seal to remain intact (Fig. 14.29). If the roots ultimately
compromising the prognosis of the tooth need extraction, the overdenture also serves as an immediate
342 THE RESTORATIVE–ENDO INTERFACE
Fig. 14.29 (a,b) Use of temporary overdenture Fig. 14.30 Prefabricated dowels
over abutments
Material of composition
The traditional material of construction was cast gold, which was sup-
plemented with wrought gold when conditions of stress or post dimensions Fig. 14.31 Custom-made post and Fig. 14.32 Parallel-sided
demanded. Soon, posts made of stainless steel and base metal alloys were cores or tapering dowels
also available. The most recent additions include carbon or glass fibre posts
and ceramic posts, usually made of zirconia. The rationale for these is that
they may provide physical properties better matched to teeth and are also characteristics of the two designs differ during installation and functional
deemed to be better aesthetically matched to teeth. Unfortunately, there is loading. Tapered dowels generate the least stress during cementation (Fig.
a dearth of clinical evidence to support the later additions. The best evi- 14.33a), parallel-sided dowels generate greater stress by virtue of the
dence for clinical survival exists for custom-made gold posts. hydraulic pressure developed (Fig. 14.33b). However, the parallel-sided
posts perform better in function (Fig. 14.33c) because tapered posts gener-
Shape
ate a wedging force (Fig. 14.33d). This may be alleviated if the shoulder
Dowels may be parallel-sided or tapering (Fig. 14.32). The parallel- rest is firm but this would concentrate stress at the shoulder.
sided dowels provide better retention per unit length than the tapered Although parallel-sided dowels are considered more desirable, the
dowels. An increase in taper reduces retention. The stress-distributing natural tapering shape of roots and prepared root canals mitigate against
THE RESTORATIVE–ENDO INTERFACE 343
A B C D
Fig. 14.33 (a) Tapered dowels generate least stress during cementation; (b) parallel dowels generate
greater stress during cementation; (c) parallel dowels provide better stress distribution in function;
(d) tapered dowels generate a wedging force during function (all courtesy of Mr P O’Neilly) Fig. 14.34 Dowel tapered
coronally but parallel apically
A B C
Fig. 14.36 Dentatus
Classic Post System Fig. 14.37 Selection of appropriate diameter of parallel-sided post:
B = optimum for retention and root strength
preparation of the canal to a matching shape, which can render their use
less conservative. A compromise is to select the narrowest parallel-sided
post compatible with adequate retention and strength of post and root
(Fig. 14.37).
Length
Length is as important a determinant of post retention as it is for crown
preparations. Longer posts provide better retention and stress distribution
for all types of posts in function. Unfortunately, an increase in length also
leads to greater stresses during installation, particularly of the parallel-
a dowel parallel along its entire length. Inevitably, the dowel will be sided dowels. This can be eased to an extent by ensuring that the post is
tapered in the coronal portion and be parallel-sided apically (Fig. 14.34) vented (Fig. 14.38).
but this carries a danger of apical root perforation (Fig. 14.35). One solu-
Determinants of dowel length
tion to this problem has been to taper the apical portion (Fig. 14.36).
Despite the relatively poorer retention and stress distribution characteris- 1 Root filling length The need for a minimum length of root filling may
tics of the tapered post, it has been used successfully in many cases, which limit the achievement of optimal post length in cases where the root
often makes it a more conservative choice. Parallel-sided posts require is of insufficient length to satisfy both requirements. There is no
344 THE RESTORATIVE–ENDO INTERFACE
A B
Fig. 14.40 (a) Lack of appreciation of the cross-sectional profile of the root
leads to perforation; (b) extracted tooth showing the relationship between the
post and the cross-sectional shape of the root
A B
Fig. 14.39 (a) Curved mandibular premolar prior to restoration; (b) post-
restoration radiograph indicating the influence of the position of curvature of
the root on the length of the post
A B
Fig. 14.42 (a) Decementation of unfavourably loaded long posts – note fractured porcelain on upper Fig. 14.43 Survival of favourably
right central incisor; (b) the displaced fixed prosthesis loaded short posts
B
C
Fig. 14.45 (a) Fracture of post (courtesy of Mr P King); (b) fractured post in
Fig. 14.44 Deformation of post central incisor with “roof-top” preparation; (c) displaced portion of crown
A
(courtesy of Mr P King) and fractured post
Fig. 14.46 (a) Wide posts may cause root fracture because of the
amount of dentine sacrificed; (b) unfavourable restoration designs
(such as this cantilever bridge with very wide intra-radicular post)
increase the risk of root fracture
increase (Fig. 14.46b). The minimum post diameter compatible with ade- seating and retention. Rough or uneven surfaces increase retentive capac-
quate strength and retention should be considered. ity. Threaded posts have the best retentive properties. Prefabricated posts
with a variety of thread designs are available. They may be threaded along
their entire length or only on a restricted portion. Threaded posts generate
Surface configuration
the greatest stresses, as demonstrated by the concentration of stresses
The surface of posts may be smooth, roughened, serrated or threaded and, around the threaded portion of the post shown in Figure 14.47a. The
in addition, may be modified for venting. Surface characteristics influence stresses increase when the post is loaded (Fig. 14.47b). The manner of
346 THE RESTORATIVE–ENDO INTERFACE
A B C
Fig. 14.47 (a) Higher stresses are associated with threads; (b) further increase in
stresses upon loading; (c) stresses caused by placement of a threaded parallel
post; (d) increase in stresses if the post is tightened by a quarter turn; (e)
E F loosening the post by tapping and cementing in place also reduces stresses; (f)
upon loading the stresses are considerably reduced (all courtesy of Mr P O’Neilly)
placement of the post also influences the stress generated. The stress asso-
ciated with the threads upon conventional placement is shown in Figure
14.47c. If the post is tightened by an extra quarter turn, the stress increases
tremendously (Fig. 14.47d). Upon loading, the stresses increase further,
but are proportionately much lower than those, due to over-tightening.
Removing the post and tapping the threads before replacement decreases
the stresses considerably. Loosening the fit of the post by removing and
replacing it and then cementing it in place also reduces the stress (Fig.
14.47e,f). Serrations on the posts are also associated with increased stresses
but not to the same extent as threads. Loading once again increases stresses.
The improved retention due to serrations and threads should, therefore, be
weighed against the disadvantages of increased stress concentration. The
surface of the post may also be modified with cutaway portions or chan-
nels, which act as escape routes for luting cement during installation and
allow better seating and improved retention. Fig. 14.48 Diaphragm built into Fig. 14.49 Root fracture associated
post/core (arrowed) with the tip of the post (arrowed)
Diaphragm
A diaphragm or an apron, usually placed on the palatal aspect, may help
to brace the tooth and distribute stresses more favourably (Fig. 14.48). It Relatively intact teeth
is also useful for making good lost tooth tissue. When there is inadequate Endodontic treatment is sometimes necessary on a tooth that has not previ-
coronal tooth tissue, a correctly designed and placed diaphragm prevents ously been restored or affected by caries. The pulp may become compro-
concentration of stresses around the apical portion of a post, which can mised by periodontal disease (Fig. 14.51), trauma (Fig. 14.52) or accidental
lead to horizontal or oblique fractures of the root (Fig. 14.49). severance of the blood supply during orthognathic surgery (Fig. 14.53).
Following root-canal treatment, the access cavity may be restored with a
plastic restorative material, such as amalgam or posterior composite, pro-
RESTORATION OF POSTERIOR TEETH vided there is no evidence of cracks in the tooth or signs of heavy occlusal
In posterior teeth, the plastic restorative material can serve as the tempo- loading (Fig. 14.54).
rary occlusal surface. The cores should have adequate proximal and occlu- The presence of cracks across marginal ridges or cusps (Fig. 14.55a,b),
sal contacts (Fig. 14.50). together with signs of heavy occlusal loading, indicates the need for cuspal
THE RESTORATIVE–ENDO INTERFACE 347
Fig. 14.50 (a,b) Use of amalgam cores as interim Fig. 14.51 Pulp death caused by Fig. 14.52 Trauma to the first molar
restorations periodontal disease caused by a cricket ball resulting in
root fracture
A B
Fig. 14.53 Pulp compromised by orthognathic Fig. 14.54 (a,b) Simple plastic restoration of access cavity in the absence
surgery of occlusal cracks or faceting
protection – in the short term with a cemented orthodontic band (Fig. tooth after endodontic treatment. Caution should be exercised in restoring
14.55c) and in the long term preferably using a cast partial veneer gold large cavities with this technique because of the potential for cusp defor-
restoration (Fig. 14.55d,e). The design and execution of such a restoration mation and fracture caused by curing shrinkage of the composite material
may be technically demanding because of the skills required. The problem (Fig. 14.58). Where cuspal coverage is required, it may be possible to bond
is to provide adequate retention and resistance form and to maintain the a base-metal alloy occlusal restoration to the prepared occlusal surface.
margins in the proximal areas away from contact points to enable their The use of a precious metal alloy is made possible by plating or heat treat-
direct examination and access for cleaning. The nature of proximal contact ment (Fig. 14.59). In the case shown, occlusal surfaces eroded by acid and
dictates whether it is possible to maintain the margin above the contact attrition were restored by bonding heat-treated gold castings to the occlusal
or below it: the latter effectively means cutting a minimal proximal box surfaces. Minimal tooth preparation consisted of a bevelled margin of
(Fig. 14.56). 1 mm depth around the circumference. This is a conservative and preferred
Provided that a sufficient wrap-around effect is achieved and the prepa- method for restoring relatively intact root-filled teeth.
ration is minimally tapered, a satisfactory degree of retention and resist-
ance form may be obtained. Where it is considered to be insufficient, cast
Teeth with proximo-occlusal cavity
pins may be employed to increase retention (Fig. 14.57).
Recent suggestions include the use of adhesive techniques, retaining the The case of a root-treated tooth with an existing proximal box needs dif-
composite materials by acid-etching enamel and dentine-bonding agents ferent consideration (Fig. 14.60a). The restoration in this case will depend
to increase the strength of the tooth. Although supported by laboratory on the width and depth of the box and the occlusal loading. In a tooth with
studies, the durability of such bonding remains to be clinically proven. The a moderately wide, shallow proximal box and no signs of severe occlusal
technique has been recommended as a temporary means of reinforcing a loading, a plastic restorative material may suffice (Fig. 14.60b). A tooth
348 THE RESTORATIVE–ENDO INTERFACE
A
B C
Fig. 14.55 (a) Fracture line – mesiolingual cusp; (b) radiograph of molar in (a); (c) cemented orthodontic band; (d) modified onlay preparation; (e) radiograph of
tooth with root-canal treatment completed and a restoration with occlusal coverage
Fig. 14.57 (a,b) The use of cast pins to aid retention of cast onlay
THE RESTORATIVE–ENDO INTERFACE 349
A A
600
Disp. (µm ¥ 10)
500
Buccal Cusp Strain
400
200
Buccal Cusp Disp.
100
Composite Cure B
0
248 348 448 548 648 748 848
Fig. 14.60 (a) Root-filled tooth with moderately sized mesio-occlusal amalgam
B Time (s)
restoration and absence of faceting, cracks or history of restoration fracture;
Fig. 14.58 (a) Experimental measurement of cusp deformation caused by (b) restoration of tooth in (a) using amalgam
curing composite material in a mesio-occlusal distal cavity, using an adhesive
technique; (b) strain in buccal and lingual cusps with time after curing and
displacement of the cusps (all courtesy of Prof. N Meredith)
with a similar-sized cavity but signs of heavy occlusal loading, or which
provides lateral excursive guidance that cannot be eliminated, may benefit
more from a cast partial veneer metal restoration (Fig. 14.61). A plastic
restoration would be inadequate in a terminal tooth with a wide, deep box
with signs of heavy occlusal loading but a cast metal cuspal coverage
restoration would help to reduce such stresses and protect the tooth from
fracture (Fig. 14.62, a photoelastic model representation of the situation
shown in Figure 14.7d, under identical conditions but with a cuspal cover-
age restoration). The model remains relatively stress-free even when the
load is doubled. Figure 14.63 illustrates restoration of a case with a plastic
restorative material core followed by cuspal coverage restoration. The
premolar has been restored initially using composite on the buccal wall of
the undermined cusp to prevent discoloration by amalgam and the rest was
filled with amalgam (Fig. 14.63b). The tooth was then prepared for a
partial coverage cast onlay.
A B
Fig. 14.61 (a,b) Restoration of a tooth with moderately sized mesio-occlusal amalgam with cast onlay Fig. 14.62 Photoelastic demonstration of
restoration absence of cervical stress concentration, due to
capped cusp cast onlay restoration (courtesy of
Mr P O’Neilly)
A B
C
Fig. 14.63 Restoration of root-filled mandibular premolar with capped cusp cast onlay restoration:
D (a) unrestored tooth with cavity; (b) tooth restored with core and prepared for casting; (c) cast onlay
restoration; (d) cemented onlay
A B C
Fig. 14.64 (a–c) Restoration of a severely damaged premolar and molar using capped cusp amalgam restorations
bond between the restoration and luting agent may fail allowing the buccal surface (Fig. 14.69d). On a maxillary tooth, the extent of metal
microleakage. coverage of the buccal cusp may be minimized (Fig. 14.70). Aesthetics
The most conservative option is to consider (where appropriate) is the may be improved by sandblasting the surface to reduce shine. The design
use of partial veneer onlays (Fig. 14.69a–c), which help to minimize sac- may be modified to suit the situation if additional tooth tissue is missing
rifice of tooth tissue and provide adequate cuspal protection with proper (Fig. 14.71). However, if the preparation is executed inadequately, the
design. On a mandibular tooth, the need for a functional cusp bevel and restoration will be retained poorly, resistance form will be reduced and the
occlusal shoulder on the buccal aspect means greater metal coverage of aesthetics compromised.
THE RESTORATIVE–ENDO INTERFACE 351
A A
B B
Fig. 14.65 (a,b) Clinical views of broken down Fig. 14.66 (a,b) Maxillary molar in 14.65 restored Fig. 14.67 Composite used to restore mesio-
maxillary molar with amalgam occlusal distal cavity in a root-filled premolar
A B C
Fig. 14.68 (a,b) Preparation of mandibular premolar for porcelain onlay; (c) restoration in place
A B C
Fig. 14.69 (a) Mandibular second premolar with an MOD amalgam requiring occlusal protection;
(b) preparation for partial veneer onlay; (c) gold onlay in place; (d) restoration covering the functional cusp
of the premolar
D
352 THE RESTORATIVE–ENDO INTERFACE
A B
Fig. 14.71 (a) Die for modified cast onlay preparation; (b) cast
onlay preparation on the die
A B
Hairline
cracks
A
2 mm
2 mm B
2 mm C
D
E
A B C
D
E F
Fig. 14.75 (a) Use of dentine pins to retain an interim restoration: A = amalgam; B = access restoration; C = gutta percha; D = cotton wool; E = pin; (b) pin
perforation; (c) stress-induced dentinal fractures; (d) threaded pins generated the greatest stress (courtesy of Mr P O’Neilly); (e) hand-wrench for the insertion of
pins; (f) pins placed close together cause stresses to accumulate (courtesy of Mr P O’Neilly)
The use of dentine pins is not generally recommended in root-treated • inserting the pin using a hand-wrench (Fig. 14.75e) and unwinding
teeth. The presence of a pulp chamber and root canals should provide it by at least a quarter turn so as not to engage the bottom of the
adequate opportunities for retention. Rarely, a pin may be useful to help pinhole
retain an interim amalgam restoration while root-canal treatment is being • using a threaded pin at least 4 mm long with 2 mm in dentine,
performed (Fig. 14.75a). Placement of dentine pins is associated with 2 mm in restorative material and with 2 mm of restorative material
complications, such as perforation (Fig. 14.75b) and induction of stresses above the tip of the pin (Fig. 14.75a)
in the dentine leading to cracks (Fig. 14.75c) and fractures. Induced • using pins with sharper threads minimizes stresses during
stresses are greatest with threaded (Fig. 14.75d) and friction-grip pins and installation (but these potentially increase stresses in function)
least with cemented pins but the latter require greater length for equivalent • using pins made of alloys softer than dentine, such as titanium,
retention. Stresses due to pins may be reduced by: which may induce less stress
• preparing the pinhole with a sharp drill in a speed-reducing • using only one pin per cusp because pins placed close together
result in interaction of stresses and an increased potential for
hand-piece and minimum number of passes so as not to cut the
fracture (Fig. 14.75f).
hole eccentrically
• using pins with minimal mismatch between size of pinhole The pulp space may be used for retention in a number of ways. The
and pin most conservative is the Nayyar amalgam dowel core (Fig. 14.76). This
354 THE RESTORATIVE–ENDO INTERFACE
A B
Fig. 14.76 (a) Nayyar amalgam core; (b) radiograph of the Nayyar amalgam
core
A B C
Fig. 14.78 (a) Mandibular molar with Nayyar core; (b) mandibular molar restored with cast restoration; (c) radiograph Fig. 14.79 Sectioned molar
of the molar showing the extent of the core and cast restoration with Nayyar core in place
involves placing amalgam in the pulp chamber. It was originally believed for the core. Multiple roots make it possible to place multiple posts, which
that the amalgam should extend into the root canals to a depth of about do not have to be as long as in single-rooted teeth.
3 mm to retain the amalgam but it is better to seal the coronal aspect of
the root canals with zinc oxide/eugenol and use only the pulp chamber.
CORE MATERIALS
The coronal amalgam may be designed to act as the final capped-cusp
restoration (Fig. 14.77) or the core may be cut down for placement of a AMALGAM
cast restoration (Fig. 14.78). The shortness of the dowel reduces the dis-
turbance of the root filling. Adequate remaining tooth tissue is essential Amalgam remains the material of choice for cores because of its strength,
and should be judged in terms of: versatility, availability and dimensional stability. Its one drawback was the
slowness of set, making it difficult to prepare the core for a cast restoration
• depth of pulp chamber (Figs 14.76b, 14.79) at the same visit. However, new faster- setting alloys have largely over-
• distance from floor of pulp chamber to furcation (Fig. 14.79), floor come this disadvantage. Reports of systemic problems caused by amalgam
to amelo–cemental junction (Fig. 14.79), floor to alveolar crest seem to be unfounded but environmental pollution caused by mercury is
(Fig. 14.76b) and the projected margin of the crown (Fig. 14.78) raising further concerns.
• thickness of dentine at the level of the crown margin (see
Fig. 14.10). COMPOSITE
Nayyar cores are more rarely placed in premolars. When the remaining Composite cores became popular because they could be command-set
coronal dentine is inadequate to support such a core, retention may be and were strong. However, they tend to absorb moisture and are dimen-
gained by placing a dowel into one of the canals, usually the one with the sionally unstable, eugenol temporary cements tend to soften the core,
largest and straightest root and canal; for instance, the palatal canal of a and moisture in the core may then affect the physical properties of acid-
maxillary molar and the distal canal of a mandibular molar) (Fig. 14.80). based permanent luting cements, such as zinc phosphate, glass ionomer or
The dowel and the residual coronal dentine can then provide the retention polycarboxylate.
THE RESTORATIVE–ENDO INTERFACE 355
A B C
Fig. 14.80 (a–c) Stainless steel post-retained amalgam core in mandibular molar
Where some coronal tooth tissue remains, it may interfere with the path
of insertion of the core. The canal providing the path of least resistance
may be selected for the principal post to help preserve tooth tissue and
place a partial veneer cast restoration. If a substantial amount of tooth
tissue needs to be sacrificed to provide a path of insertion for the core, it
may be better to cement preformed posts into the canals and build up a
core with plastic restorative materials.
The direct technique may also be used to construct a multiple post and
core system using preformed plastic patterns and acrylic resin (Fig. 14.83).
The method is more difficult to perform than the indirect technique but is
more suitable in some circumstances.
A B
D E
G H
K
J Fig. 14.82 (a–k) Indirect technique for the
construction of cast multipost/core
A B
THE RESTORATIVE–ENDO INTERFACE 357
A B
Fig. 14.84 Stresses are likely to be more severe on Fig. 14.85 (a) Failed anterior cantilever bridge carried by a non-vital abutment; (b) displaced
an abutment tooth fixed prosthesis with fractured dentine core (arrowed)
A B
If the crown of a tooth scheduled for root resection is intact, the only
restorations required are the amalgam seal in the canal of the root to be
by blood or food products. Removal of the cause usually removes the
resected and the access restoration (Fig. 14.87). If the tooth already has
discoloration except in the case of severe secondary calcification, which
a restoration with stable interproximal and occlusal contacts, no further
gives a dense, opaque yellow discoloration (Fig. 14.90). Options for treat-
restoration should be required. In the absence of stable contacts, a suitable
ment include:
restoration should be constructed (Fig. 14.88).
• vital bleaching
RESTORATION OF A HEMISECTED TOOTH • non-vital bleaching
• labial/buccal veneers
Teeth may be hemisected for various reasons, such as tooth fracture or • crowns.
furcal involvement. The procedure may be followed by extraction of one
of the roots and restoration of the remaining one as a premolar. Restoration VITAL BLEACHING
is made difficult by the root morphology in the furcation (Fig. 14.89a).
Rarely, both roots may be restored as independent premolar units, but the Vital bleaching may be considered for vital teeth sclerosed by secondary
procedure is fraught with difficulties mainly related to controlling the calcification. Use of home-bleaching products is regarded by some as
margin placement in the furcation (Fig. 14.89b). Successful restoration of potentially harmful and has been the subject of legal review in the Euro-
such teeth requires a high level of skill and insight about the problems to pean Union. Within the law at time of writing, dentists are able to use and
overcome. prescribe tooth whitening products containing or releasing 0.1% to 6%
hydrogen peroxide.
A B
D E
A
B
A
THE RESTORATIVE–ENDO INTERFACE 359
A B C
F
D E
Fig. 14.91 (a) Preoperative view; (b) mild improvement at the end of visit; (c) more significant improvement after one week; (d) removal of root-filling material;
(e) zinc phosphate base; (f) 30-second etching of dentine; (g) hydrogen peroxide placed with cotton pledget; (h) mixing paste of sodium perborate
chair-side by placing hydrogen peroxide in the pulp chamber. Bleaching CERAMOMETAL OR CERAMIC CROWNS
is usually performed after the pulp chamber has been prepared by remov-
ing all restorative and root-filling material to the cervical level (Fig. These are capable of providing excellent aesthetics but require an adequate
14.91d) and covering it with a layer of zinc phosphate (Fig. 14.91e). The thickness of porcelain, which means sacrificing more tissue in an already
dentine is then etched for 30 seconds with phosphoric acid (Fig. 14.91f), weakened tooth.
washed away and the cavity dried. Hydrogen peroxide is flooded into the
canal, taking care to ensure that there is no overflow (Fig. 14.91g). After EXTRACTION OF ROOT-TREATED TEETH AND
5–10 minutes, the access cavity is gently dried and a paste of sodium REPLACEMENT WITH IMPLANT-RETAINED CROWNS
perborate mixed with water (Fig. 14.91h) is applied. The access cavity is
properly sealed to prevent loss of dressing between appointments. There It is inevitable that root-treated teeth and sometimes even those that have
may be some improvement at this stage (Fig. 14.91b). One week later, not had the benefit of endodontic treatment may, at some stage, require
further improvement is seen, due to the “walking bleach” technique extraction and replacement with prosthesis. As discussed in Chapter 5,
(Fig. 14.91c). there exist a number of options but the contemporary focus is on implant-
retained crowns because they avoid damage to and interference with adja-
cent teeth.
COMPOSITE OR PORCELAIN VENEERS Teeth may require extraction because of extensive loss of tooth structure
These can effectively mask discoloration provided that it is not severe and (through tooth surface loss, caries or resorption) or cracks and fractures.
that an adequate thickness of masking material is used. A combination of Under the circumstances and if the option of implants is to be considered,
bleaching and veneering may help if neither method alone is sufficient to the first priority is to maintain the periradicular alveolar bone. In this
eliminate discoloration. context, it may be worth considering whether this is best achieved by tooth
360 THE RESTORATIVE–ENDO INTERFACE
extraction and socket preservation/augmentation or by first providing first Hansen, E.K., 1988. In vivo cusp fracture of endodontically treated premolars restored
with MOD amalgam or MOD resin fillings. Dent Mater 4, 169–173.
stage root-canal treatment to allow periapical healing. Immediate place- Hansen, E.K., Asmussen, E., 1990. In vivo fractures of endodontically treated posterior
ment of an implant fixture into a site with previous symptomatic large teeth restored with enamel-bonded resin. Endod Dent Traumatol 6, 218–225.
periapical lesion is not considered an optimal scenario. Hansen, E.K., Asmussen, E., 1993. Cusp fracture of endodontically treated posterior
teeth restored with amalgam. Teeth restored in Denmark before 1975 versus after
The requirements of a successful implant-retained tooth, particularly in 1979. Acta Odontol Scand 51, 73–77.
the aesthetic zone, are adequate height, width and breadth of good quality Hansen, E.K., Asmussen, E., Christiansen, N.C., 1990. In vivo fractures of
bone and a favourable gingival biotype. It is paramount that the implant endodontically treated posterior teeth restored with amalgam. Endod Dent Traumatol
6, 49–55.
fixture has good primary stability on placement, demanding adequate Hatzikyriakeos, A.M., Reisis, G.I., Tsingos, N., 1992. A 3-year postoperative clinical
apical and palatal bone at the very least. For an aesthetic restoration, in evaluation of posts and cores beneath existing crowns. J Prosthet Dent 67, 454–458.
addition, there should be a good labial cortical plate supporting healthy Helfer, A.R., Melnick, S., Schilder, H., 1972. Determination of the moisture content of
vital and pulpless teeth. Oral Surg 34 (4), 661–670.
and thick biotype soft tissue. The factors influencing a favourable outcome Heling, I., Gorfil, C., Slutzky, H., et al., 2002. Endodontic failure caused by inadequate
are many and, therefore, demand a good interface with the prosthodontic restorative procedures, review and treatment recommendations. J Prosthet Dent 87,
and periodontal colleagues and specialists. The role of the endodontist 674–678.
Hommez, G.M., Coppens, C.R., De Moor, R.J., 2002. Periapical health related to the
would be to participate in helping to control the periapical infection and quality of coronal restorations and root fillings. Int Endod J 35, 680–689.
assist in bone regeneration prior to tooth extraction. Howe, C.A., McKendry, D.J., 1990. Effect of endodontic access preparation on
Once periapical healing is achieved, tooth extraction should be per- resistance to crown-root fracture. J Am Dent Assoc 121, 712–715.
Huang, T.G., Schilder, H., Nathanson, D., 1991. Effects of moisture content and
formed gently with minimal trauma to the socket walls. Bone and soft endodontic treatment on some mechanical properties of human dentine. J Endod 189
tissue grafting, as well as various substitutes may be used to augment the (5), 209–215.
socket site to help maintain the height and width of the ridge. Interdental Kantor, M.E., Pines, M.S., 1977. A comparative study of restorative techniques in
pulpless teeth. J Prosthet Dent 34, 405–412.
space maintenance is crucial and so an effective temporary restoration that Kvist, T., Rydin, E., Reit, C., 1989. The relative frequency of periapical lesions in teeth
does not impinge on the socket and prevent healing is essential. with root canal-retained posts. J Endod 15 (12), 578–580.
An implant restoration is prosthodontically driven and planning of Lagouvardos, P., Souvai, P., Douvitasas, G., 1989. Coronal fractures in posterior teeth.
Op Dent 14, 28–32.
fixture placement should be based on optimal tooth position, aesthetics and Lawson, T.D., Douglas, W.H., Geistfeld, R.E., 1981. Effect of prepared cavities on the
phonetics. These will dictate the optimal location, angulation and extent strength of teeth. Op Dent 6, 2–5.
of the fixture. Around these considerations are built the surgical demands Lewinstein, I., Grajower, R., 1981. Root dentine hardness of endodontically treated
teeth. J Endod 7, 421–422.
of grafting and regenerative approaches to ensure optimal integration and Nayyar, A., Walton, R.E., Leonard, L.A., 1980. An amalgam coronal-radicular dowel
aesthetic conditions. and core technique for endodontically treated posterior teeth. J Prosthet Dent 43 (5),
511–515.
Panitvisai, P., Messer, H.H., 1995. Cuspal deflection in molars in relation to endodontic
and restorative procedures. J Endod 21, 57–61.
REFERENCES AND FURTHER READING
Papa, J., Cain, C., Messer, H.H., 1994. Moisture content of vital vs endodontically
Bergman, B., Lundqvist, P., Sjögren, U., et al., 1989. Restorative and endodontic results treated teeth. Endod Dent Traumatol 10, 91–93.
after treatment with cast posts and cores. J Prosthet Dent 61 (1), 10–15. Petelin, M., Skaleric, U., Cevc, P., et al., 1999. The permeability of human cementum in
Burke, F.J.T., 1992. Tooth fracture in vivo and in vitro. J Dent 20, 131–139. vitro measured by electron paramagnetic resonance. Arch Oral Biol 44 (3), 259–267.
Carter, J.M., Sorensen, S.E., Johnson, R.R., et al., 1983. Punch shear testing of extracted Randow, K., Glantz, P.O., 1986. On cantilever loading of vital and non-vital teeth – an
vital and endodontically treated teeth. J Biomechanics 16, 841–848. experimental clinical study. Acta Odontol Scand 44, 271–277.
Cavel, W.T., Kelsey, W.P., Blankenall, R.J., 1985. An in vivo study of cuspal fracture. Reeh, E.S., Messer, H.H., Douglas, W.H., 1989. Reduction in tooth stiffness as a result
J Prosthet Dent 53 (1), 38–41. of endodontic and restorative procedures. J Endod 15 (11), 512–516.
Dental Defence Union, 2002. Legal position with regard to teeth bleaching. Advice Sedgeley, C.M., Messer, H.H., 1992. Are endodontically treated teeth more brittle?
leaflet GDP/014/1002. J Endod 18 (7), 332–335.
Eakle, W.S., Maxwell, E.H., Braly, B.V., 1986. Fractures of posterior teeth in adults. Sorensen, J.A., Martinoff, J.T., 1984. Intracoronal reinforcement and coronal coverage.
J Am Dent Assoc 112, 215–218. A study of endodontically treated teeth. J Prosthet Dent 51, 780–784.
Gher, M.E., Dunlap, R.M., Anderson, M.H., et al., 1987. Clinical survey of fractured Sorensen, J.A., Martinoff, J.T., 1984. Clinically significant factors in dowl design.
teeth. J Am Dent Assoc 114, 174–177. J Prosthet Dent 52, 28–35.
Guzy, G.E., Nicholls, J.I., 1979. In vitro comparison of intact endodontically treated Trabert, K.C., Caputo, A.A., Abou-Rass, M., 1978. A comparison of endodontic and
teeth with and without endopost reinforcement. J Prosthet Dent 42 (1), 39–44. restorative treatment. J Endod 4 (11), 341–345.
15
Section 4 Multidisciplinary aspects of endodontic management
The medical–endo interface and patients with special needs
A Mustard, K Gulabivala
For those patients with conditions that may become progressively debil- STROKE
itating, treatment planning will need to take into account the likely nature
and time-frame of any deterioration. This may be unpredictable or impos- Stroke is a generic term for cerebrovascular accident (CVA) resulting in a
sible for some conditions and can present the dental team with difficult sudden or rapidly progressing neurological defect, which does not resolve
long-term treatment planning decisions. within 24 hours. Stroke is the third highest cause of death in the UK, after
ischaemic heart disease and all cancer types combined, with around
150 000 people having a stroke per year.
The effects of stroke principally result in unilateral numbness, weakness
MANAGEMENT OF THE and partial or complete paralysis of the arm, leg or face on the contralateral
MEDICALLY-COMPROMISED PATIENT side of the brain. The effects, severity and recovery can be varied. Mobility
may become impossible requiring the provision of domiciliary care for
CARDIOVASCULAR DISEASE dental treatment.
Cardiovascular disease (CVD) is the commonest cause of adult death in Endodontic treatment may be affected by the provision of anticoagu-
the developed world. Hypertension is persistently raised blood pressure of lants. The patient may have difficulty accessing care, particularly if they
>140/90 mmHg. Ninety per cent of cases are “essential” with no non- are wheelchair bound. Communication may be challenging and anxiety,
lifestyle causes. A significant number of the population are prescribed fear or frustration are common emotions for patients who have undergone
antihypertensive medication via the use of diuretics, beta blockers, calcium stroke. Blood pressure should be monitored during treatment and attention
channel blockers, ACE inhibitors, sympatholytics and vasodilators. Stress, given to vasoconstrictor usage in patients who have reduced resiliency of
including as a result of dental treatment, may further increase blood pres- the cardiovascular system. Patients taking antihypertensive medication are
sure leading to a risk of stroke or cardiac arrest. Angina presents as a at increased risk of postural hypertension and this should be taken into
severe, crushing chest pain. It is the result of impaired blood flow and account following prolonged periods in the dental chair.
oxygenation of the heart muscle, usually due to atherosclerosis. Stable
angina is usually precipitated by effort and resolves with rest. Unstable
angina occurs at rest, with minimal exertion or rapidly increasing BLEEDING DISORDERS
severity. A bleeding disorder arises if there is a problem in any part of the haemo-
Dental treatment for both conditions can safely be provided under local static and clotting pathway, and can be congenital or acquired.
anaesthesia. However, unstable angina carries a serious risk of myocardial Acquired bleeding conditions occur as a result of liver disease and
infarction and elective dental treatment should not be carried out. Care platelet disorders or as the result of anticoagulant therapy. Patients with
should be given to ensure anxiety levels during treatment are minimized liver failure, alcoholism, renal failure, thrombocytopenia, and chemo-
and treatment under sedation may be a prudent option for the nervous therapy will have coagulation and clotting disorders and should not
patient. Intravascular injection of epinephrine-containing local anaesthetic undergo a surgical intervention without liaising with the physician respon-
should be avoided and the management of patient on anticoagulants is sible for their care.
discussed later in this chapter. Prophylactic glyceryl trinitrate spray has Antiplatelet therapy, such as aspirin and clopidogrel, when used in
been shown to be effective in the prevention of both hypertension and combination, have a synergistic effect impairing platelet function. However,
angina during dental treatment. Routine dental treatment should be avoided local measures should be adequate to achieve coagulation and the medica-
where appropriate for at least 6 months following a myocardial infarct with tion should not be stopped prior to a surgical procedure.
some authors suggesting treatment should be postponed for 1 year, due to Coumarin therapy is most commonly prescribed in the form of the
the risk of further infarct within this period. Acute dental problems within vitamin K antagonist warfarin. Used for the prophylaxis or treatment of
this timeframe should be managed in close consultation with the cardiolo- deep vein thrombosis, prosthetic heart valves, and people with atrial fibril-
gist responsible for the patient’s care. lation, it prolongs both prothrombin and the activated partial thromboplas-
tin time. The International Normalized Ratio (INR) is used to monitor its
effect with a therapeutic range of 2–3 for deep vein thrombosis (DVT) and
INFECTIVE ENDOCARDITIS up to 4.5 for patients with prosthetic heart valves. Patients with an INR of
Infective endocarditis is an infection of the endocardial surface of the less than 4 can undergo surgery in general dental practice without any
heart, which may include damaged heart valves, prosthetic heart valves or warfarin dose adjustment. The patient may bleed more than normal but
ventricular septal defects. In the UK, current guidelines from the National this should be controlled via local measures. Ideally, the INR should be
Institute of Clinical Excellence (NICE) recommend that antibiotic prophy- checked on the day of the procedure.
laxis is not required for at risk groups as there was insufficient evidence Special precautions are not required for non-surgical endodontic treat-
regarding the efficacy of the antibiotic regimen. The updated American ment. However, there is a theoretical risk of bleeding into the fascial planes
Heart Association guidelines (2007), on the other hand, recommend that following an inferior alveolar nerve block and, where possible, this should
antibiotic prophylaxis prior to dental procedures be administered to patients be avoided. If it is unavoidable, an aspirating technique should be used
with previous infective endocarditis, prosthetic heart valve, cardiac trans- with the injection given slowly to minimize tissue damage. Currently, there
plantation recipients with cardiac valvulopathy and some patients with are no specific published guidelines regarding the surgical endodontic
congenital heart disease (CHD). Patients with CHD are defined as those management of patients undergoing coumarin therapy. Therefore, if there
with unrepaired cyanotic CHD (including conduits and palliative shunts), is doubt regarding the management of such a patient then it would be
repaired CHD with residual defects at or adjacent to the site of a prosthetic prudent to seek advice from the patient’s haematologist prior to treatment.
patch or device, and completely repaired CHD with device or with pros- Patients who have a poorly controlled INR or an INR>4 and require
thetic material in the first 6 months following the procedure. This is multiple extractions should be treated in a hospital setting. Non-surgical
because endothelialization of the prosthetic material generally occurs in endodontic treatment should not present a significant bleeding risk.
the 6 months following the procedure. Antibiotic prophylaxis is no longer However, the clinician should maintain the highest standards of atraumatic
recommended for any other form of CHD. technique, especially with regards to soft-tissue management, apical
THE MEDICAL–ENDO INTERFACE AND PATIENTS WITH SPECIAL NEEDS 363
control (of instruments, as well as irrigants, particularly sodium hypochlo- emphysema and chronic airways disease. There are in the region of 900 000
rite) and delivery of local anaesthesia. If there is any doubt with regards sufferers in England and Wales varying from mild disease through to severe
to patient management, then the advice of the patient’s haematologist disease with respiratory failure. The majority of disease is smoking related.
should be sought prior to treatment. Diagnosis is based on history, physical examination and spirometry tests
Hereditary or congenital bleeding disorders have the potential to cause with treatment ranging from inhaled bronchodilators or corticosteroids,
severe bleeding tendencies. The most common congenital bleeding disor- through to confinement at home with constant nebulization.
der is von Willebrand’s disease, followed by haemophilia A and haemo- Most patients can cope with dental treatment safely with only minor
philia B. adjustments to procedures in general dental practice. Where possible, treat-
Patients with von Willebrand’s disease (vWD) have an extended bleed- ment should be delivered under local anaesthetic, due to the risk of respira-
ing time, due to poor platelet function and low levels of von Willebrand tory depression during treatment under sedation. It is likely that the patient
factor and factor VIII activity. will have to be treated in an upright position compromising access for
Haemophilia A is characterized by a normal bleeding time but a pro- endodontic care. Patients who require oxygen therapy should bring suffi-
longed activated partial thromboplastin time and low levels of factor VIII. cient oxygen for the duration of treatment and this should be checked prior
The rarer haemophilia B is the result of a genetic mutation leading to a to the initiation of care.
deficiency in factor IX. Both types of haemophilia typically manifest in Asthma is common, affecting up to 5.4 million people in the UK in 2008.
childhood as easy bruising and prolonged bleeding following injury. It is a generalized airway obstruction, which is paroxysmal and reversible
Most patients should be able to be managed within a primary care in the early stages. The obstruction is the result of bronchial muscle con-
setting in coordination with the patient’s haemophilia with each haemato- traction, mucosal swelling and increased mucus production leading to
logical disorder and individual patient requiring an individual approach. coughing and wheezing, and/or shortness of breath. The use of salbutamol
The goal of treatment is to minimize the challenge to the patient by restor- or beclomethasone inhalers can lead to increased caries and periodontal
ing the haemostatic system to acceptable levels and maintaining haemos- disease and patients should undergo regular dental reviews.
tasis by local and adjunctive levels. This is normally achieved through the Before dental treatment, the severity of the condition should be ascer-
delivery of coagulation therapy to raise coagulation factors to near normal tained from the patient’s history with particular attention given to any
levels within 10–12 hours of factor VIII cover and on consecutive days episodes of hospital admission. The patient should be instructed to use
for factor IX. their inhaler prior to treatment and it should be present for the duration of
It has been reported that patients with congenital bleeding disorders are the appointment. Again, local anaesthesia is the treatment modality of
often highly anxious about dental treatment and often delay treatment until choice with inhalation sedation an alternative for particularly anxious
they develop significant dental problems. In addition, patients with con- patients, due to its ability to be rapidly controlled. Care should be taken
genital bleeding disorders may have been exposed to the hepatitis C virus when prescribing non-steroidal anti-inflammatories, due to an increased
(HCV) from the use of non-inactivated replacement factor concentrates risk of allergy to aspirin, or precipitation of an asthma attack.
from pooled human blood until 1986, with the presence of HCV having
been reported in up to 70% of haemophilia patients.
LATEX ALLERGY
During endodontic treatment, whether the patient has received prophy-
lactic coagulant cover or not, care must be taken to avoid trauma. As for Latex allergy occurs in 1–5% of the general population. Workers in the
patients on anticoagulant therapy, apical control via the use of apex loca- rubber industry and healthcare professionals are at increased risk of devel-
tors and careful instrumentation is required. Rubber dam application oping a latex allergy as a result of occupational exposure. Patients with a
should be as atraumatic as possible, otherwise it can lead to gingival bleed- history of urogenital abnormalities and patients who have undergone mul-
ing, which can be particularly troublesome in patients with vWD. tiple surgical procedures are at increased risk. Atopic individuals are also
Local anaesthesia represents a more significant challenge. An inferior a risk group. However, the highest risk group are patients with spina bifida
alveolar nerve block must only be given after raising the appropriate clot- with reports of up to 67% of patients having a latex allergy.
ting factors levels via appropriate therapy as there is a risk of haematoma Patients can be classified into three groups of latex allergy risk: Group
in the retromolar or pterygoid space potentially compromising the airway. 1: people with a previous history of anaphylaxis to latex; Group 2: people
Similarly, lingual infiltrations should be avoided without the appropriate with a history of type IV contact dermatitis to latex or signs and symptoms,
factor cover as it risks a significant haematoma. Therefore, alternative including rhinitis, urticaria or conjunctivitis; Group 3: no previous symp-
anaesthesia via intraligamental or intraosseous techniques should be con- toms but fall into one of the “at risk” groups.
sidered. Buccal infiltration with Articaine may provide sufficient anaesthe- Dental management of Group 1 patients should only be undertaken in
sia for mandibular molars though not for patients with pulpitis. a “latex screened” specialist setting with the appropriately trained staff and
Any surgical procedure should be carried out with minimal trauma and equipment to manage an anaphylactic reaction. Group 2 patients can be
the use of both resorbable and non-resorbable sutures has been advocated. managed in coordination with a latex-modified environment via nitrile
Topical haemostatic agents such as tranexamic acid may provide rapid gloves, latex-free rubber dam and local anaesthetic in plastic cartridges.
haemostasis. Careful postoperative instructions should include a soft or Care needs to be taken with the use of latex-free rubber dam in endodontic
liquidized diet and the use of a tranexamic acid mouthwash regimen. retreatment cases, due to the potential of chloroform instantly to dissolve
Despite all measures, postoperative haemorrhage may still occur occa- the rubber dam on contact. Group 3 patients require no special measures
sionally and patients should be instructed to contact their local haemo- but the dental team should be alert to the patients’ increased risk. To date,
philia centre in the first instance for further clotting factor infusions. there have been no proven cases of hypersensitivity to gutta-percha root-
filling material.
RESPIRATORY DISEASE
DIABETES
Chronic obstructive pulmonary disease (COPD) and asthma are the most
likely respiratory diseases to be encountered in the dental surgery. COPD Diabetes mellitus (DM) develops from either a deficiency in insulin pro-
encompasses a collection of diseases, including chronic bronchitis, duction or an impaired utilization of insulin, resulting in altered glucose
364 THE MEDICAL–ENDO INTERFACE AND PATIENTS WITH SPECIAL NEEDS
tolerance or impaired lipid and carbohydrate metabolism. There are two BISPHOSPHONATE-RELATED OSTEONECROSIS
types: Type 1 and Type 2, with Type 2 being the most common and affect-
ing 85–95% of the diabetic population. Diabetes classically presents with Bisphosphonates are a class of drugs used increasingly to treat osteoporo-
polyuria, polydipsia and polyphagia alongside fatigue, weakness, pruritus sis, multiple myeloma, Paget’s disease, osteogenesis imperfecta and malig-
and blurred vision. In Type 2 diabetes, the symptoms develop slowly and nant bone metastases. Their efficacy in treating and preventing these
the individual may be unaware of them at the time of diagnosis. Complica- conditions has had a significant, positive impact for patients. However,
tions are a result of long-term exposure to raised glucose levels leading to there is now a significant association between their use (particularly intra-
microvascular complications, such as retinopathy, neuropathies, renal venous preparations) and osteonecrosis of the jaws.
disease and loss of peripheral sensation resulting in poor wound healing. The pathogenesis of bisphosphonate-related osteonecrosis is not yet
Macrovascular complications result in coronary heart disease, cerebrovas- fully understood and, to date, there are no reported cases occurring out-
cular disease and hypertension. with the facial skeleton. Patients most commonly present with absent or
Management of Type 1 diabetes centres on subcutaneous infusion of delayed hard or soft tissue healing after dental extractions or surgery. The
insulin with careful monitoring of blood glucose levels. Type 2 diabetes patient must have no history of radiation to the head and neck and a posi-
is controlled by diet and oral hypoglycaemic medication, which stimulates tive history for bisphosphonate medication. Patients with bisphosphonate-
the release of insulin from the pancreas. related osteonecrosis are usually asymptomatic but may develop severe
Oral manifestations of diabetes include xerostomia, burning mouth, pain as a result of secondary infection.
candidiasis, oral neuropathies and sialosis. Dental caries and advancing In patients who are currently undergoing intravenous bisphosphonate
periodontal disease generally occur in direct correlation with diabetic therapy, any dental alveolar surgery, including extractions, implant place-
control. Delayed healing presents an increased risk of oral infection and ment, periapical and periodontal surgery should be avoided as these
DM has also been suggested as a risk factor for bisphosphonate-related patients are seven times more likely to develop osteonecrosis than patients
osteonecrosis. not undergoing surgery. The relative risk of complications increases
Dental care should have a strong preventative ethos, particularly with with increased time of use for both oral and intravenous bisphosphonates,
regards to diagnosis and effective management of caries and periodontal and for co-morbidities such as diabetes. For unrestorable teeth, decorona-
disease. Patients with well-controlled Type 1 or 2 diabetes can be treated tion and endodontic treatment of the remaining roots has been advocated.
similarly to non-diabetic patients provided the normal routine of diet, It is likely that the increased use of intravenous bisphosphonates in
medication and insulin is not disturbed. A blood glucose monitoring an ageing population will increase the demand for non-surgical endo-
machine should be used where possible to monitor blood glucose levels dontic treatment, to avoid the risk of osteonecrosis following dental
before and during treatment. The dental team should pay close attention extractions.
to clinical signs of hypoglycaemia. Poorly controlled patients should be
referred to a specialist setting for dental care and treatment may have to
MULTIPLE SCLEROSIS
be delayed until diabetic control is improved.
The diabetic patient requiring endodontic treatment should be scheduled Multiple sclerosis (MS) is a complex neurological condition caused by
first thing in the morning or immediately following lunch to minimize damage to the myelin sheath of the nervous system and results in interfer-
disturbance to glucose levels. Particularly when long appointments are ence with both sensory and motor nerve transmission. MS is the most
scheduled, the patient should be encouraged at all times to report any common neurological disorder among young and middle-aged adults and
perceived changes in their condition during treatment. Anxiety levels is more common in women than men. Its aetiology is not understood and,
should be minimized whenever possible. However, sedation may mask the although a number of probable causes have been postulated, no single
signs of hypoglycaemia and should only be given by experienced causative agent has been identified.
operators. There are several different types of MS with different disease patterns.
A small number of authors have reported that diabetic patients have One in five people with MS have benign disease with no permanent
reduced periapical healing following root-canal treatment, especially in disability, whereas 15% have progressive disease that steadily worsens
insulin-dependent patients. The increased presence of periodontal disease leading to profound disability. Symptoms are highly variable between
in diabetic patients may be a confounding factor for tooth loss following individuals but often include visual disturbance, neuralgias and paraes-
root canal treatment. It has also been reported that persistent pain follow- thesia, spasticity, tremor, fatigue and depression leading to progressive
ing root-canal treatment may be a significant factor resulting in tooth loss disability. There are no specific tests for MS and diagnosis is based
possibly as a consequence of diabetic neuropathy. on neurological history and examination. There is no cure and treat-
Collapse due to hypoglycaemia may be related to anxiety, missed meals ment focuses on the prevention of disability and maintenance of quality
or inconvenient appointment times. Early signs of hypoglycaemia include of life.
pallor, sweating, facial and lingual paraesthesia, hunger, confusion, agita- Endodontic management depends on the severity of any disability and
tion and poor coordination. The dental team should be suspicious of mood it is important that treatment planning includes the history of disease pro-
changes, anger or poor cooperation in a previously tolerant patient, espe- gression and takes into account the likelihood of future problems with both
cially under rubber dam. Left untreated, a hypoglycaemic episode may accessing and delivering dental care. Appointment scheduling should take
progress from drowsiness to collapse and even coma. Management centres place during phases of good health or at the patient’s best time of day to
on prevention via the timely delivery of oral glucose or Hypostop®. If minimize stress and fatigue. Extreme fatigue is common following dental
consciousness is lost, then the delivery of intramuscular glucagon (1 mg) treatment and multiple short appointments may be necessary for root-canal
should restore consciousness within 15 minutes and the emergency serv- treatment. The use of a mouth prop may help reduce muscle fatigue during
ices should always be called if recovery is delayed. Collapse due to hyper- the appointment.
glycaemia in the dental setting is unlikely due to the slow, progressive The diagnosing clinician should also be aware that chronic pain is
nature of onset. If there is any doubt on the cause of the impending col- common in up to 50% of patients with MS and may present as paraesthe-
lapse, then oral glucose should always be given as it will do no harm to sia, hyperalgesia or allodynia. Trigeminal neuralgia occurs in up to 32%
the hyperglycaemic patient. of patients with MS and, crucially, may be the presenting symptom in
THE MEDICAL–ENDO INTERFACE AND PATIENTS WITH SPECIAL NEEDS 365
previously undiagnosed patients under 40 years of age. From the authors’ Challenges in endodontic management relate to patient access, com-
experience, patients with MS are often highly concerned about the pres- munication and delivery of treatment. Appointments should be scheduled
ence or future placement of amalgam restorations. Case-control studies for the individual’s best time of day, or when their medication has maximum
have failed to demonstrate an association between mercury amalgam res- therapeutic effect, to try and reduce tremors and random movements
torations and MS. In those patients who no longer wish to have amalgam during treatment. It is critical that the dental team take the time to com-
placed, the root-filled tooth should be restored with a gold restoration to municate with the patient in an effective manner. Namely, sufficient time
maximize longevity, especially in those patients where the replacement of should be given to allow a patient to reply to a question without feeling
restorations may become extremely difficult in the future. rushed or pressured as this will lead to frustration on both sides. The use
of yes/no questions can facilitate this process.
Tremor and random movements are the most significant physical barri-
CEREBRAL PALSY ers to delivering care. Anxiety often increases both movements, and rela-
tionship building between the clinician and the patient can significantly
Cerebral palsy encompasses a group of non-progressive neurological and
improve cooperation. Treatment under conscious sedation or rescheduling
physical disabilities developed in utero, at birth or in the first few months
to another session may also be required. Airway protection is critical, due
of infancy. The damage to the brain is mainly caused by hypoxia, trauma
to impaired swallowing reflex and the risk of pulmonary aspiration. The
and infection. It is the most common congenital cause of physical disabil-
patient should not be reclined greater than 45° and the use of rubber dam
ity and primarily is a disorder of voluntary movement.
with effective saliva ejection is recommended.
Diagnosis is made from clinical signs and there may be other impair-
ments of function, including vision, hearing and speech; epilepsy may also
be a feature. Learning disability is present in less than 50% of people with DEMENTIA
cerebral palsy. Although non-progressive, secondary complications such
as respiratory infection can cause significant morbidity. Dementia is a progressive, neurodegenerative disease that affects the
Dental features include a tapered maxillary arch, proclined incisors and ability to perform daily living activities. It encompasses a variety of syn-
a high incidence of malocclusion. Facial grimacing, dysphagia and swal- dromes and can be both reversible and irreversible.
lowing difficulties are common, as is temporomandibular joint (TMJ) Dementia currently affects in the region of 700 000 people in the UK
spasticity and the occurrence of spontaneous subluxation. Bruxism and and predominately presents in the over 65 age group. Two-thirds of people
non-carious tooth surface loss are also common. Patients are at increased with dementia are women and up to 64% of patients in care homes have
risk of periodontal disease and caries, due to difficulty in delivering effec- some form of dementia. Alzheimer’s disease is one of the most protracted
tive oral hygiene. forms of the disease and is caused by the loss of cerebral neurons. Its
Endodontic management may be extremely challenging due to uncon- prevalence increases from 5 to 10 in 100 over the age of 65 to 1 in 5 80
trolled movements, including muscle spasm or bite reflex. Anxiety man- year olds.
agement or treatment under inhalation sedation can aid access. Intravenous Diagnosis is based on recording symptoms over time and the result of
sedation or general anaesthesia may be required for those patients with cognitive/memory tests. Clinical features include memory loss, language
profound disability. deterioration, impaired visual–spatial skills, poor judgement, indifferent
attitude but preserved motor function. The type, severity, sequence, and
progression of mental changes vary widely, although Alzheimer’s disease
PARKINSON’S DISEASE is usually progressive, resulting in severe brain damage over a period of
10 years from diagnosis.
Parkinson’s disease is a progressive neurological disorder caused by Management is aimed at maintaining quality of life with medication
degeneration of dopaminergic neurons in the substantia nigra of the basal used to alleviate depression, agitation and challenging behaviour. Dental
ganglia in the brain. The resulting dopamine depletion impairs the function treatment should be carried out with a realistic approach to decision
of those parts of the brain which control movement. making and treatment planning. The ability to cope with dental treatment
The aetiology is unknown and the risk of developing Parkison’s disease varies hugely between patients, and may be hugely distressing for some
increases with age. It affects men and women equally; with a prevalence patients. In the early stages of dementia, dental treatment should plan for
of 1 in 100 people over 60 years of age. Symptoms are classified into the patient being unable to maintain their own teeth in the future and rigor-
motor and non-motor. The classical motor symptoms are dyskinesia ous preventive and oral hygiene measures should be instilled in those
(tremor or involuntary movement), bradykinesia (slow movement) and involved in the patient’s long-term care.
akinesia (muscular rigidity). Combined, these produce a characteristic
“mask-like” facial expression and a slow, shuffling gait.
Non-motor symptoms include sleep disturbance, psychoses and depres- ENDODONTICS AND PATIENTS WITH
sion. Alzheimer’s disease has been reported in up to 30% of patients LEARNING DISABILITY
with Parkinson’s disease as opposed to 10% of the equivalent general
population. A learning disability is a significant impairment of intelligence and social
Diagnosis is based on clinical symptoms and, currently, there is no functioning acquired before adulthood. Its cause may be genetic, congeni-
known cure. Treatment is aimed at controlling symptoms and consists tal or acquired.
of medication to increase the level or efficacy of dopamine within the Learning disability affects the way an individual learns, communicates
brain. Patients with Parkinson’s disease may have difficulty accessing and carries out everyday activities. The amount of support a person requires
dental care. They are at increased risk of xerostomia, resulting in burning throughout life varies according to the severity of their learning disability
mouth and root caries. Oral hygiene may become poor and patients may and whether or not they have an additional physical disability. In most
become increasingly unable to wear partial or complete dentures, due to developed countries, around 2.5% of the population have a learning dis-
poor retention as a result of xerostomia and uncoordinated or rigid facial ability equating to 1.5–2 million people in the UK. The most common
muscles. cause of learning disability is Down’s syndrome.
366 THE MEDICAL–ENDO INTERFACE AND PATIENTS WITH SPECIAL NEEDS
DOWN’S SYNDROME >50% of patients with a severe learning disability. Petit mal seizures are
brief periods of unresponsiveness or “absences”, which do not effect dental
Down’s syndrome is a genetic condition caused by a chromosomal abnor-
treatment. Grand mal seizures result in loss of consciousness followed by
mality (usually trisomy of chromosome 21) resulting in a characteristic
a tonic–clonic phase of body spasm followed by repetitive jerking of trunk
appearance, orodental features and cardiac anomalies (40%). In addition,
and limbs. Trauma from falls during grand mal seizures can cause dental
visual impairment (50%), hearing (up to 50%) impairment and a compro-
injury resulting in subluxation and avulsion of teeth, fracture and loss of
mised immune syndrome are commonplace.
vitality.
Endodontic management may be impacted by a number of factors.
Endodontic management requires no additional measures other than
Depending on the severity of the learning disability, the patient may lack
those required for the conventional dental management of the epileptic
the capacity to consent for the procedure. The consent process (discussed
patient. The clinician should seek to attain as much information as possible
later in this chapter) must be followed prior to the initiation of treatment.
at the time of diagnosis regarding seizure history. Particular attention
Patients with Down’s syndrome are at increased risk of early onset peri-
should be given to establishing the presence of any triggers, the nature of
odontal disease. Therefore, an integrated treatment plan with periodontal
the seizures, including auras, frequency, duration, management and any
colleagues is essential in the management of periodontally involved teeth
history of status epilepticus.
with an endodontic problem. Although gingival inflammation as a result
The information received should allow the dental team to avoid
of mouth breathing may be common place, widespread gingival inflam-
any specific triggers (i.e. minimizing use of the dental light in photosensi-
mation may be a presenting factor for leukaemia in patients with Down’s
tive patients) and in the event of the patient undergoing a seizure, recogniz-
syndrome.
ing what is normal for that patient, as well as abnormal. Prior to the
Congenital heart defects or mitral valve prolapse are common in adult
initiation of dental treatment, it is advisable that the patient has taken their
patients with Down’s syndrome. Although the prescription of antibiotic
routine anti-epilepsy medication, has their emergency medication with
cover for dental procedures considered high risk for inducing bacteraemia
them, has eaten according to normal routine and is not excessively tired.
is no longer recommended in the UK under NICE Guidelines, it is good
It is prudent to cancel the visit if the patient feels that their seizures are
practice to minimize any potential bacteraemia by careful delivery of care.
poorly controlled on the day of treatment, as the additional stress may
The delivery of care may be influenced by the presence of atlanto-axial
trigger a seizure.
joint instability affecting the ability of the patient to recline in the dental
During dental treatment, the use of a mouth prop (regardless of whether
chair, necessitating careful positioning, especially if dental treatment is to
this would usually be required) can provide stability and a few additional
be provided under general anaesthetic.
moments to remove dental instruments, including the rubber dam clamp if
the patient was unfortunate enough to undergo a seizure during treatment.
AUTISTIC SPECTRUM DISORDERS Following the completion of endodontic treatment, large posterior restora-
Autistic spectrum disorders (ASD) are developmental disabilities affecting tions are at risk of fracture during the tonic–clonic seizures. The provision
social interaction, communication and imagination. They are usually diag- of cast restorations has been suggested as being preferable, particularly
nosed in the first 3 years of life and persist throughout life, with manage- cast metal crowns thereby avoiding the risk of porcelain fracture.
ment centring on achieving independence and self-care through creating a In the poorly controlled epileptic patient, dental treatment may be
highly structured environment. Patients with Asperger’s syndrome will delayed until the seizures become controlled, or completed under inhala-
have normal intellect and language skills but poor social skills and a tion or intravenous sedation within a specialist setting to reduce the risk
reduced ability to show empathy. The more severe diagnosis of classical of the patient undergoing a seizure during dental treatment.
autism will encompass patients who have a cognitive impairment, which
will be severe in 40% of patients. Patients with ASD are at increased risk CONSENT
of dental caries, they may have a very restricted diet and attendance for
dental treatment may be a major challenge. Consent is a patient’s agreement for a healthcare professional to carry out
Despite looking calm, most patients with ASD have high anxiety levels treatment. Informed consent is central to all forms of healthcare and a
and combined with the sensitivity to external stimuli resulting in sensory patient’s legal and ethical right. It is a key component of high quality
overload and withdrawal. Reaction to pain can be highly variable, from services and promotes patients’ experience and provides autonomy. It is
complete insensitivity to over-reaction to the slightest touch. The dental essential for informed risk management and is one of the pillars of clinical
light, smell, taste and noise from the suction can result in an exuberant or governance.
even painful reaction. For the consent to be valid, the individual must have the capacity to
Endodontic treatment will require careful behavioural management cen- consent and be given sufficient information on the procedure (including
tring on careful preparation for each dental visit taking communication benefits, risks, additional procedures and alternatives). The individual
and behavioural factors into account. The use of clear, simple language must not be acting under duress and should feel they have the option to
with short sentences and direct requests can help. Gestures or facial expres- change their mind in the future.
sions will not be understood and it is important the dental team asks the Only a court or a proxy can give consent for a child under 16. The proxy
patient for the information they need as it is unlikely to be volunteered. is normally a parent but can be another individual given parental respon-
Routine, both before and during the appointment, can help build structure sibility via a court order. Parental responsibility is conferred automatically
to each visit and facilitate treatment with the expectation that compliance on the mother of a child irrespective of marital status. The father has
may be varied and inconsistent. A quiet waiting room with no background consent if he is married to the mother or on the child’s birth certificate. If
noise and minimizing waiting time may help reduce anxiety. not, responsibility can be appointed by the mother or the court. Children
who are able to understand information and make a decision in their own
best interest are deemed as “Gillick competent” and can consent for
EPILEPSY
themselves.
Epilepsy, which occurs in less than 1% of the general population, affects Once a patient is above the age of 18, no other person can consent for
in the region of 30% of patients with a learning disability, increasing to them regardless of their mental capacity. The Mental Capacity Act of 2005
THE MEDICAL–ENDO INTERFACE AND PATIENTS WITH SPECIAL NEEDS 367
The delivery of care via oral sedation, inhalation sedation or intravenous technique for the management of a specific anxiety, i.e. needle phobia,
sedation with midazolam may be successful in controlling anxiety levels where the inhalation sedation can be utilized only during the delivery of
and the gag reflex sufficiently to deliver endodontic care. However, in a anaesthesia and then conventional endodontic treatment can be com-
small group of patients, intravenous sedation via propofol or general menced once the patient’s initial anxiety has been controlled.
anaesthesia (delivered in an appropriate environment via a consultant
anaesthetist) may be the only method guaranteed successfully to manage Intravenous sedation with midazolam
the reflex. Midazolam is a water-soluble benzodiazepine with a short half-life provid-
ing a rapid onset of sedation with anxiolysis, anterograde amnesia and a
ENDODONTICS AND CONSCIOUS SEDATION rapid recovery (within 1 or 2 hours). It has the disadvantage of requiring
venous access and must be delivered in an appropriate setting with con-
The principle role of conscious sedation is to allay apprehension, anxiety
tinuous monitoring of oxygen saturation via pulse oximetry. It can be
or fear. It is also used to reduce the stress of a prolonged surgical procedure
extremely useful in the management of both dental anxiety and patients
or to control gagging. Additionally, conscious sedation may be used to
with a severe gag reflex. However, midazolam produces a period of seda-
stabilize blood pressure in patients with a history of hypertension, cardio-
tion of 20–30 minutes followed by a state or relaxation for a further hour.
vascular or cerebrovascular disease. The commonest forms of conscious
In a prolonged procedure, the patient may require careful titration of sup-
sedation are inhalation sedation, intravenous sedation with midazolam and
plemental doses of midazolam. Therefore, at the point of treatment plan-
oral sedation.
ning, the clinicians delivering the sedation and endodontic care must
Assessment ensure that the endodontic treatment can be completed efficiently in the
appropriate time-frame for this to be an effective technique.
A detailed discussion of every aspect of the assessment of a dental patient
prior to sedation is beyond the scope of this chapter. Essentially, the clini- Oral and intranasal sedation
cian is recording sufficient information to assess the patient’s level of
The use of oral sedation prior to the delivery of endodontic care can be
anxiety, and their medical status and suitability to undergo the sedative
particularly useful in patients suffering from mild anxiety. However, the
treatment options available. Anxiety can be assessed via a detailed history
patient will still need to be able to provide a reasonable level of coopera-
taking, communication and observation with additional measures, such as
tion throughout the procedure to facilitate treatment. It is important that
the Modified Dental Anxiety Scale or Venham Scale proving useful. A
the dose of oral sedation delivered is commensurate with the patient’s
detailed medical history is essential with attention given to respiratory,
ability to maintain cooperation particularly for the taking of intraoral
cardiovascular, liver and kidney diseases. Pregnancy, drug interactions and
radiographs. However, the effect of oral sedation can be unpredictable, due
a previous history of drug or alcohol abuse are also important factors to
to the nature of a fixed dose.
be taken into account. In addition to a comprehensive medical history,
Intranasal delivery of midazolam has a more predictable dose response
baseline recordings of heart rate and arterial blood pressure should be
and quicker onset than oral sedation. For effective delivery, the patient
noted. From these findings the patient’s fitness for sedation or general
should have an unobstructed nasal airway. It is particularly useful in
anaesthesia can be classified according to the American Society of Anesthe-
patients with a learning disability to allow sufficient cooperation for can-
siologists (ASA) fitness scale.
nulation prior to intravenous sedation. For both oral and intranasal seda-
Written consent for both the dental procedure and the sedation to be
tion the risk of respiratory depression is just as great as for intravenous
provided is essential and, for endodontic treatment, should include a treat-
sedation with midazolam. Therefore, the clinical monitoring, use of pulse
ment plan for extraction should the tooth be deemed to be unrestorable
oximetry and discharge criteria are identical to those of intravenous
once treatment under sedation is commenced.
sedation.
Inhalation sedation
The use of inhalation sedation in the delivery of dental care is a safe, reli- REFERENCES AND FURTHER READING
able technique, which is well documented in the dental literature. Nitrous American Heart Association; American Dental Association Division of Communications,
oxide has excellent anxiolytic, sedative and analgesic properties with little 2007. For the dental patient…: antibiotics and your heart: new guidelines from the
American Heart Association. J Am Dent Assoc 138 (6), 920.
or no depression of myocardial or respiratory function. It has a wide Centre for Clinical Practice at NICE (UK), 2008. Prophylaxis against infective
margin of safety and the dose can be titrated according to patient response. endocarditis: antimicrobial prophylaxis against infective endocarditis in adults and
The use of a nasal mask alongside a rubber dam can restrict access for children undergoing interventional procedures. NICE Clinical Guidelines, No. 64,
London. Available from http://www.ncbi.nlm.nih.gov/books/NBK51789/ (accessed
endodontics and a good level of patient cooperation is required for both Aug 2013).
the sedation and endodontic care. However, this can be an excellent Scully, C., 2010. Medical problems in dentistry, 6th ed. Church Livingstone.
16
Section 4 Multidisciplinary aspects of endodontic management
The orofacial pain–endo interface
R Leeson, K Gulabivala, Y-L Ng
The sensory transmission of orofacial pain is conveyed predominantly by A careful history is obtained to determine the characteristics of the orofa
Aδ and C fibres of the trigeminal nerve, which project to the nucleus cial pain, as well as any history of other generalized chronic pain condi
caudalis in the medulla. The latter is sometimes referred to as the tions. Information on comorbid anxiety, depression, sleep problems,
Eyes
Thalamus
Sinus Idiopathic
Nucleus caudalis Table 16.2 Factors determining the characteristics of orofacial pain
"Medullary dorsal horn"
Characteristics of orofacial pain
Duration and frequency – Acute/chronic
Anatomical location – Source/site
Trigeminal nerve
Symptoms and signs
Aetiology and pathophysiology
Aggravating and relieving factors
Fig. 16.1 A schematic diagram illustrating the trigeminal pain pathway
Mechanisms of pain
Table 16.5 Four primary types of pain OROFACIAL PAIN AND ENDODONTICS
Nociceptive Transient pain Endodontic patients often present because of pain, which may or may not
In response to a noxious stimulus
be associated with previous treatment interventions. The topic of endodon
Inflammatory Spontaneous pain and hypersensitivity
In response to tissue damage and inflammation
tic pain prior to any treatment intervention has been covered in Chapters
Neuropathic Spontaneous pain and hypersensitivity 4 (Diagnosis of endodontic problems) and 10 (Management of emergen
In association with damage to or a lesion of the cies and traumatic injuries). Persistent pain associated with teeth after
nervous system nonsurgical or surgical endodontic treatment has been used as an indicator
Functional Hypersensitivity to pain of treatment failure. However, pain may be experienced in a tooth or
Resulting from abnormal central processing of
normal input adjacent site in the absence of clinical or radiographic signs of dental
disease. Such diagnostic dilemmas in decision making during treatment
Woolf, 2004 planning were highlighted by Hunter as early as 1778. Failure to detect
pathological change on periapical radiographs may reflect limitations of
the diagnostic method rather than an absence of an osteolytic lesion.
Superimposition of adjacent anatomical structures over the suspect tooth
may further obscure the view. Conversely, residual periapical disease may
with sharp episodes; there may be pain on jaw movement originating either be truly absent and the pain may be nonodontogenic.
from the joints or muscles (masseter, temporalis, pterygoids and anterior Pain in a tooth site of neurogenic origin has been reported in the litera
digastric), which can be referred to the maxillary molars. Conversely, ture but only a few published studies have investigated the occurrence
muscular pain may arise from painful dental conditions and can then of neuropathic pain after dental treatment. Evidence of the association
persist as an independent entity. Characteristics of some common chronic between dental treatment and chronic neuropathic pain has been presented
nonodontogenic orofacial pain problems are presented in Table 16.4. by Marbach (1978), Schnurr & Broke (1992) and Vicker et al. (1998), who
A mechanismbased approach to pain diagnosis can be useful when reported that most patients diagnosed with atypical odontalgia related the
considering appropriate treatments. The four primary types of pain (Table onset of the pain to dental treatment, dental infection or dental trauma.
16.5) are often considered to be the acute nociceptive and inflammatory Only four epidemiological studies (Marbach et al., 1982; Campbell
pains as opposed to the maladaptive neuropathic and functional pains et al., 1990; Berge, 2002; Oshima et al., 2009) have investigated the preva
(Woolf, 2004). lence of chronic neuropathic pain after dental treatment. The study by
372 THE OROFACIAL PAIN–ENDO INTERFACE
A 69-year-old male presents with a severe toothache in the maxillary left REFERENCES AND FURTHER READING
canine, for which he requests endodontic treatment.
Aggarwal, V.R., Macfarlane, G.J., Farragher, T.M., et al., 2010. Risk factors for onset of
The pain is described as stabbing in character, “like an electric shock”,
chronic orofacial pain – results of the North Cheshire orofacial pain prospective
lasting seconds in duration. He is unable to shave or wash the face on the
population study. Pain 149 (2), 354–359.
left or even to clean the teeth, eat, drink or allow cold air to touch this area
Bender, I.B., Seltzer, S., 1961. Roentgenographic and direct observation of experimental
without triggering pain. However, pain does not disturb the patient from
lesions in bone. Part I. J Am Dent Assoc 62, 152–160.
sleep at night. Clinically, the canine is heavily restored and there are
Berge, T.I., 2002. Incidence of chronic neuropathic pain subsequent to surgical removal
extensive plaque deposits and inflammation of the gingivae in the upper
of impacted third molars. Acta Odontol Scand 60, 108–112.
and lower dental arches.
Breivik, H., Collett, B., Ventafridda, V., et al., 2006. Survey of chronic pain in Europe;
• Question: What non-odontogenic condition may the patient be suffering prevalence, impact on daily life and treatment. Eur J Pain 10, 287–333.
from? Campbell, R.L., Parks, K.W., Dodds, R.N, 1990. Chronic facial pain associated with
• Answer: Trigeminal neuralgia. (Maxillary division V2). endodontic therapy. Oral Surg Oral Med Oral Pathol 69, 287–290.
• Question: What investigations would you consider? DeLeeuw, R., 2008. The American Academy of Orofacial Pain, 2008, Orofacial Pain
Guidelines for Assessment, Diagnosis and Management, 4th ed. Quintessence
• Answer: Radiograph to exclude endodontic problems with the canine.
Publishing, Chicago.
Baseline blood tests prior to commencing medication. MRI to assess
trigeminal nerve. Dionne, R.A., Kim, H., Gordon, M., 2006. Acute and chronic dental and orofacial pain.
In: McMahon, S.B., Koltzenburg, M. (Eds.), Textbook of pain, 5th ed. Elsevier
• Question: What treatment might you consider and to whom would you
Churchill Livingstone.
refer?
Drangsholt, M., LeResche, L., 2009. Epidemiology of orofacial pain. In: Zakrzewska,
• Answer: Carbamezapine medication, referral to their General Medical J.M. (Ed.), Orofacial Pain. Oxford University Press.
Practionner, an Orofacial Specialist or Neurologist. Dworkin, S.F., LeResche, L., 1992. Research diagnostic criteria for temporomandibular
disorders: review criteria, examinations and specifications critique. J Craniomandib
Disord 6, 301–355.
Finnerup, NB., Otto, M., McQuay, H.J., et al., 2005. Algorithm for neuropathic pain
Scenario 2
treatment an evidence based proposal. Pain 118, 289–305.
Hargreaves, K.M., Milam, S.B., 2002. Mechanisms of orofacial pain and analgesia. In:
A 49-year-old female presents with a dull, burning, continuous pain in the Dionne, R., Phero, J.C., Becker, D.R. (Eds.), Management of pain and anxiety in the
upper right first premolar, with signs of allodynia and hypersensitivity in dental office. Saunders, Philadelphia, pp. 14–33.
the maxillary right maxilla. The tooth was restored then root-canal treated Koopman, J.S., Dieleman, J.P., Huygen, F.J., et al., 2009. Incidence of facial pain in the
6 months ago but the pain never subsided. Clinically and radiographically general population. Pain 147, 122–127.
the tooth in question appears to have an excellent non-surgical root-canal Macfarlane, T.V., Glenny, A.M., Worthington, H.V., 2001. Systematic review of
treatment with good apical seal. However, the patient is adamant that the populationbased epidemiological studies of orofacial pain. J Dent 29 (7),
tooth should be extracted. 451–467.
Previously, a similar pain was present in the maxillary right second Marbach, J.J., 1978. Phantom tooth pain. J Endod 4, 362–372.
premolar tooth which was restored, root-canal treated and subsequently Marbach, J.J., 1993. Is phantom tooth pain a deafferentation (neuropathic) syndrome?
extracted. Unfortunately, maxillary right first and second molars underwent Part 1 Evidence derived from the pathophysiology and treatment. Oral Surg Oral Med
a similar fate of restoration, root-canal treatment and extraction. Oral Pathol 75, 95–105.
• Question: What is your advice to the patient with regards to the Marbach, J.J., Hulbrock, J., Segal, A.G., 1982. Incidence of phantom tooth pain. Oral
extraction? Surg Oral Med Oral Pathol 53, 190–193.
Merskey, H., Bogduk, N. (Eds.), 1994. Classification of chronic pain: descriptions of
• Answer: Advise against extraction.
chronic pain syndromes and definitions of pain terms, 2nd ed. IASP Press, Seattle,
• Question: What is the most likely condition?
pp. 1–222.
• Answer: Neuropathic pain (atypical odontalgia).
Oshima, K., Ishii, T., Ogura, Y., et al., 2009. Clinical investigation of patients who
develop neuropathic tooth pain after endodontic procedures. J Endod 35, 958–961.
THE OROFACIAL PAIN–ENDO INTERFACE 373
Polycarpou, N, Ng, Y.L., Canavan, D., et al., 2005. Prevalence of persistent pain after Shoha, R.R., Dowson, J., Richards, A.G., 1974. Radiographic interpretation of
endodontic treatment and factors affecting the occurrence in cases with complete experimentally produced bony lesions. Oral Surg 38, 294–303.
radiographic healing. Int Endod J 38 (3), 169–178. The International Classification of Headache Disorders, 2nd edn (ICHDII), 2004.
Raferty, M.N, Sharma, K., Murphy, A.W., et al., 2011. Chronic pain in the Republic of Cephalalgia 24 (Suppl. 1), 9–160.
Ireland – community prevalence, psychological profile and predictors of painrelated Vicker, E.R., Cousins, M.J., Walker, S., et al., 1998. Analysis of 50 patients with
disability: results for the Prevalence, Impact and Cost of Chronic Pain (PRIME) atypical odontalgia: a preliminary report on pharmacological procedures for diagnosis
study, Part 1. Pain 152 (5), 1096–1103. and treatment. Oral Surg Oral Med Oral Pathol Endod 85, 24–32.
Schnurr, R.F., Brooke, R.I., 1992. Atypical odontalgia. Update and comment on long Wirz, S., 2010. Management of chronic orofacial pain: a survey of general dentists in
term follow up. Oral Surg Oral Med Oral Pathol 73, 445–448. German University hospitals. Pain Med 11 (3), 416–424.
Sessle, B.J., 2000. Acute and chronic orofacial pain: brainstem mechanisms of Woolf, C.J., 2004. Pain: moving from symptom control toward mechanismspecific
nociceptive transmission and neuroplasticity and their clinical correlates. Crit Rev pharmacologic management. Ann Intern Med 140, 441–451.
Oral Biol Med 11, 57–91. Zakrzewska, J.M., Hamlyn, P.J., 1999. Facial pain. In: Crombie, I.K.C.P.R., Linton, S.J.,
Sessle, B.J., Iwata, K., 2001. Central nociceptive pathways. In: Lund, J.P., Lavigne, G.J., leResche, L., Von Korff, M. (Eds.), Epidemiology of pain. IASP, Seattle,
Dubner, R.B., et al. (Eds.), Orofacial pain: form basic science to clinical management: pp. 171–202.
the transfer of knowledge in pain research education. Quintessensce Publishing,
Chicago, pp. 47–58.
17
Section 4 Multidisciplinary aspects of endodontic management
The oral medicine and oral surgery–endo interface
R Leeson, K Gulabivala
A B
C
B
A
Fig. 17.3 (a) Verrucous papilloma; (b,c) leaflet papilloma
A B
Table 17.5 Soft tissue swellings derived from haematological tissue Table 17.7 Hard tissue swellings derived from bone
B
A
Table 17.8 Hard tissue swellings derived from odontogenic origin Table 17.11 Cysts
Table 17.10 Clinical features to consider associated with radiopaque and Table 17.12 Developmental cysts
radiolucent lesions
Condition Radiographic features
Associated swelling Hard-bony, smooth/irregular.
Nasopalatine duct cyst Well-circumscribed oval or heart-
Soft- fluctuant, fluid filled, bluish colour shaped radiolucency. Located
Teeth Displacement or increased mobility anterior maxilla, mid-line, between
Non-vital/vital, infection, resorption, missing roots of central incisors
Associated pathology Sinus tract, fistula, pus exudate, pathological fracture Cysts of mucosal epithelium Well-circumscribed radiolucency, in
close proximity to but separate from
the maxillary sinus
THE ORAL MEDICINE AND ORAL SURGERY–ENDO INTERFACE 379
Table 17.18 Connective tissue odontogenic tumours Table 17.20 Malignant odontogenic tumours
FURTHER READING
Scully, C., 2010. Oral medicine at a glance. Wiley-Blackwell, Oxford.
Whaites, E., 2007. Essentials of dental radiography and radiology, 4th ed. Churchill
Livingstone.
Index
Page numbers followed by “f” indicate figures, “t” indicate tables, and “b” indicate boxes.
microbiota, 301–302
A natural history, 302 C
preceding disease states in, 299
Abscess progression, 299–301, 301f–302f Calcific bridge formation, 40f
acute apical, 117, 117f, 270, 271f, 272–273, 273f risk factors, 302, 302t Calcitonin gene-related peptide (CGRP), 47
acute periapical, 53–55, 56f–57f systemic diseases associated with, 302–303 Calcium hydroxide, 217–220, 217f–218f, 226–227
drainage, 273f Apical seal, 178, 178f paste, 39
and failed root canal treatment, 85 Arachidonic acid, 47 placement, 219, 219f
treatment, 272, 273f Archaea in periapical disease, 43 preparations, 216, 216f, 219, 219f
Abutments, 355, 357f Armamentarium, surgical, 148, 148f–149f removal and replacement, 219–220, 220f
Access cavities, coronal see Coronal access cavities Arterioles, 24, 25f tooth resorption, 287–288
Accessory canals, 13–14, 20, 303 Articaine, 264, 265f Calcium sulphate material, 262, 262f
Acellular cementum, 28, 29f Aspirin, 267–268 Calcospherites, 21–22, 22f
Acoustic microstreaming, 214–215, 214f Asthma, 363 Calculus removal, 157
Actinomyces species, 85 Atraumatic restorative therapy (ART), 38, 40, 168, Camphorated monochlorophenol (CMCP), 215, 216f
Adhesion molecules, 47 168f Canal probe, 145
Adrenaline (epinephrine), 156, 264 Autistic spectrum disorders (ASD), 366 Cancellier tubes, 147f
Akinosi technique, 265–266, 266f Autoclaves, 150–151 Cancellous bone, 112
Aldehydes, 216 Axons, 26, 26f–27f Canine fossa, 272, 272f
Alphaseal, 183f Canines
Alveolar bone, 31, 31f, 281–282 mandibular, 15–16, 16f
Alveolar crest fibres, 29–30, 29f B maxillary, 15–16, 15f–16f
Alzheimer’s disease, 365 Capillaries, 24, 25f
Amalgam, 255f, 349, 354 B lymphocytes, 45 Capset calcium sulphate material, 262, 262f
Ameloblasts, 5–6 Bacteria Carbon dioxide probes, 101, 115f
Amelogenesis imperfecta, 7t–8t biofilm and planktonic physiology, 75–76, 75f Carbostesin, 264–265, 265f
Anaesthesia, 156–157 culture studies, 67 Cardiovascular disease (CVD), 362
Analgesia, 156–157 ecology, 70–75, 74f Caries
efficacy of, 267, 267t and failed root canal treatment, 84–85, 85t, 86f, conservative management, 38, 40
intraoperative, 264–267 87t fissure sealing of occlusal, 40
local agents, 264–265 intraradicular, distribution, 67–70 optimal management, 166
actions, 264–265, 265f microscopy studies, 67–68, 68f–73f practical management approaches, 168–169,
delivery, 265–266 in periapical disease, 43 168f–169f
postoperative, 267–268, 267t persistent, effect on treatment outcome, 81–83 prevention, 38
relative, 156 root canal, 58f removal, 157–158, 158f
Anaphylaxis, 278 in situ hybridization microscopy studies, 68–70, Carts, 142–143, 143f
Angelus, 255f 74f Cast cores, 355, 356f
Angina, 362 Bacterial products, 43 Cavernous sinus thrombosis, 53–55
Ankylosis, 288, 332, 332f Balanced force technique, 193–194 Cavit, 221
Anodontia, 7t–8t Bayer Hedstroem, 195f Cavities
Anterior teeth restoration, 338–342, 339f–341f Benzodiazepines, 157, 368 deep, 169–172
Anti-invasion factor, 285 Best interest meetings, 367 principles of restoration, 166–167
Antibiotics, 157, 216–217 Bio-Oss, 262, 262f Cell-free zone, 21f, 22
periradicular origin emergencies, 273–274 Biodentine, 164t, 254, 255f Cell surface markers, 45
prophylactic, 362 Biofilms, 174–177, 175f Cellular cementum, 28, 28f
regenerative pulp therapy, 39 degradation, 207 Cellulitis, 53–55, 56f–57f, 246, 246f, 273
Anticipation, 152 physiology, 75–76, 75f Cement removal, 242
Anticurvature filing, 201 BioGide, 261–262, 262f Cementocytes, 28, 28f
Antigen-presenting cells (APCs), 49 Biomend, 261–262, 261f Cementum, 5–6, 28, 28f–29f, 303f–304f, 304
Antiplatelet therapy, 362 Biopsy, 247, 247f radiographic appearance, 112, 112f
Anxious patients, 156–157, 367–368 Bisecting angle periapical projections, 108, 108f Central tendency, 93
Apex locators, electronic, 184–187, 185f–186f Bisphosphonate-related osteonecrosis, 364 Ceramic crowns, 359
Apical abscess, 117, 117f, 270, 271f, 272–273, 273f Bleaching, 357–359, 359f Ceramometal crowns, 359
Apical constriction, 13, 13f Bleeding disorders, 362–363 Cerebral palsy, 365
Apical development, 281 Bone lesions, 374, 377t, 379t–380t, 380f Cermets, 355, 355f
Apical fibres, 29–30 Bone loss, 305, 305f, 309, 309f Cervical resorption, 292–297
Apical foramina, 13, 14t, 198–199, 199f Bone morphogenic proteins, 165 Cervical tray, 142
Apical periodontitis, 43, 61f, 63t Bone wax, 253 Chemomechanical procedure
acute, 270, 272 Briault probe, 145 biological and clinical perspective, 76–78, 77f–82f
cell profiles, 301 Bridges, removal, 146, 147f, 239 effects on biological events, 80–81
chronic, 117, 118f Broken-down teeth, 158–159, 159f technical aspects, 78–80
clinical manifestation, 299–301 Buccal space, 271 Chlorhexidine, 150, 157
measurement, 299–301 Burs, 250–251, 251f Chloroform clip technique, 227, 227f
INDEX 383
full mucoperiosteal, 248, 248f–249f Howship’s lacunae, 31, 31f Invagination, 6, 7f, 7t–9t, 10f, 317, 319f–320f
incisions, 249f–250f, 250 HPVs (human papilloma viruses), 47 Iodine-potassium iodide, 216
limited mucoperiosteal, 248, 249f–250f Human herpes virus-6 (HHV-6), 47 Iodoform, 216, 216f
retraction, 249f, 250 Human herpes virus-7 (HHV-7), 47
Flat plastic, 145 Human herpes virus-8 (HHV-8), 47
Flexible files, 200, 201f Human immunodeficiency virus (HIV), 151–152, J
Flutes, 196 157
Forceps, 147f Human papilloma viruses (HPVs), 47 Jaws, metastases to the, 375, 381t
Foreign body response, 86–87, 87f–88f Hydrodynamic theory, 26–27, 27f Juvenile periodontitis, 322–323, 323f
Foreign material irritation, 292, 294f Hydrogen peroxide, 357–359, 359f
Formocresol, 163 Hyperdontia, 7t–8t
Fractures Hypertension, 362 K
crown, 118, 275, 275f, 283, 283t Hypodontia, 7t–8t
crown-root, 275 Hypoglycaemia, 364 K3, 197f
instruments, 146, 147f Hypophosphataemia, 7t–8t Kerr Hedstroem, 195f
root see Root fractures Hypophosphatasia, 7t–8t Kerr K-file, 195f
teeth, 118, 118f, 268f Kerr K-Flex file, 193f, 195f
Front surface mirror, 145 Kerr K-reamer, 193f, 195f
Fungi I Kinins, 47–48
in periapical disease, 43
root canal, 59f–60f Iatrogenic problems, 305
Furcation probe, 145 Ibuprofen, 267 L
Fusion, 7t–8t, 9f, 317, 319f Idiopathic osteosclerosis, 115, 116f, 374
Idiopathic resorption, 297, 297f–298f Lamina dura, 112
Imaging techniques, 102–116 Lateral canals, 13–14, 14f, 20, 21f, 303, 303f
G see also specific techniques Lateral (para)pharyngeal space, 272
Implants, 130–131, 130f Lateral periodontal cyst, 377f
Gag reflex, 156, 367–368 Incandescence, 36f Latex allergy, 363
Germination, 6, 7f, 7t–8t Incision and drainage, 246, 246f, 273 Leaflet papilloma, 376f
Gingival fibres, 29–30, 29f Incisive foramen, 113, 113f Learning disability patients, 365–367
Gingivitis, 299 Incisors Ledermix, 217, 217f
Girofile, 201f mandibular, 15, 15f Ledge negotiation, 242, 242f
Glass ionomer cements, 221, 245 maxillary, 14–15, 15f Ledging, 198–199, 199f
Gluteraldehyde, 216 Independent mental capacity advocates (IMCA), Lee’s carver, 149f
Golden Medium, 201f 367 Legal considerations, 153–155
Gow-Gates technique, 265, 265f–266f Infection control, 151–152 Leukotrienes, 47, 50
Grand mal seizures, 366 Infective endocarditis, 157, 157t, 362 Light Speed, 202, 202f
Ground substance, 22–23, 23f Inferior dental artery, 30 Lignocaine, 264
Growth factors, 33 Inferior dental canal, 113, 113f Lips, 272
Guided tissue regeneration (GTR), 261 Inflammation Long-shanked excavators, 145, 145f
Gulabivala’s additional canal morphological groups, acute periapical, 50–51, 53f, 117, 117f Ludwig’s angina, 53–55, 56f–57f, 271, 271f
11f chronic, 44–45 Lumps and bumps, orofacial, 374, 375t
Gumboil, 53, 55f chronic periapical, 51, 53f Luxated teeth, 277, 282–283, 282t
Gutta-percha, 224, 224f, 224t, 254 chronic suppurative periapical, 53, 55f Lymphadenitis, 53–55
removal, 241–242, 241f pulp, 33, 36–37, 36f–37f Lymphangitis, 53–55
thermoplasticized Inflammatory resorption, 281 Lymphatic vessels, 25–26, 26f
carriers, 233–234, 234f–235f Informed consent, 94, 122–123, 366–367 Lymphocytes, 49
injection, 233, 234f Infratemporal fossa space, 272 Lysosomal enzymes, 47
Inhalation sedation, 368
Instrument removal system (IRS), 147f
H Instrumentation, 144–146 M
basic pack, 145, 145f
Haemophilia A, 363 hand, 192–195, 193f–195f Macrodontia, 7t–8t
Haemophilia B, 363 machined, 195–198, 195f Macrophages, 43–45, 48–50, 281
Haemostasis, 253, 253f–254f removal, 243–244, 243f–245f McSpadden engine-driven nickel–titanium file,
Halides, 216 transfer, 153, 153f 195f
Hand instrumentation, 192–195, 193f–195f twisted, 195 Magnetostrictive transducers, 214–215
Hard tissue swellings, 374, 377t–378t, 378f see also specific items Maillefer gutta-condensor, 236f
Healing Intentional replantation, 259–260, 260f Major histocompatibility complex (MHC), 49
fibrous, 88, 89f Interferons, 47 Mandible, spaces in relation to, 271–272
root fractures, 281, 282f Interleukins, 50 Mandibular processes, 2, 3f
wound, 257, 281, 305, 305f Intermediate cementum, 28 Mandibular teeth
Heart valves, prosthetic, 362 Intermediate plexus, 29–30, 29f canines, 15–16, 16f
Hedstroem file, 234–235 Intermediate restorative material (IRM), 254, first molars, 18–19, 18f–19f
Hemisection, 259, 260f, 357, 358f 254f incisors, 15, 15f
Hepatitis B, 151–152, 157 Internal resorption, 118, 285–288, 286f–289f, 286t premolars, 16–17, 17f
Hepatitis C, 363 International Normalised Ratio (INR), 362–363 second molars, 19, 19f–20f
Hero, 197f Interpretation, clinical, 20–21 third molars, 19–20, 20f
Herpes simplex (HSV-1/2), 47 Intraligamental injections, 266, 266f Mandibular tori, 378f
HIV (human immunodeficiency virus), 151–152, Intranasal sedation, 368 Manual agitation, 213, 213f
157 Intraosseous technique, 266, 266f Marcaine, 264–265
Horizontal fibres, 29–30 Intrapulpal injections, 266 Marginal periodontitis
Hot pulp, 266–267 Intravenous sedation, 157, 368 cell profiles, 301
INDEX 385
clinical manifestation, 299–301, 300f Mucosal lesions, 375, 381t Osteotomy, 250–251, 250f–251f
measurement, 299–301 Multiple sclerosis (MS), 364–365 Overdenture, temporary, 341–342, 342f
microbiota, 301–302 Oxytalan fibre, 29–30
natural history, 302
preceding disease states in, 299, 300f N
progression, 299–301, 300f–301f P
risk factors, 302, 302t Naber’s probe, 324, 324f
systemic diseases associated with, 302–303 Nasal sedation, 157 Pain
Masserann kit, 147f Natural killer (NK) cells, 48–49 definition, 369
Mast cells, 44–45 Nayyar amalgam dowel core, 353–354, 354f diagnostic accuracy, 264
Matrix metalloproteinases, 47 Necrotic pulp tissue, 43 history, 307
Maxilla Needle holders, 149f immediate relief, 128
radiographic appearance, 112, 112f Negligence, 154 management principles, 264
spaces in relation to, 272 Nerve fibres, 26–28, 27f non-odontogenic, 119
Maxillary antrum, 272 Neuropeptide Y, 47 periodontal, 118–119
radiographic appearance, 112, 112f Neuropeptides, 47 postoperative, 279
radiographic interpretation errors, 112, 113f Nickel–titanium rotary instruments, 196–198, prevalence, 265t
Maxillary processes, 2, 3f 196f–198f pulpal, 268
Maxillary teeth Non-steroidal anti-inflammatory drugs (NSAIDs), relief see Analgesia
canines, 15–16, 15f–16f 267 source location, 101–102, 102f
first molars, 17–18, 17f Nuclear factor kappa B ligand (RANKL), 45 Palatal flap, 247–248, 248f
incisors, 14–15, 15f Nuclear factor kappa B (NF-κβ or RANK), 45 Palatal subperiosteal interval, 272, 272f
premolars, 16, 16f Palatine torus, 378f
second molars, 18, 18f Papilla-base flap, 247–248, 248f
third molars, 19–20, 20f O Paracetamol, 267
Medical emergencies, 277–278 Parallax techniques, 108–109, 108f–109f
Medical history, 95–96, 96f, 96t, 154, 361 Oblique fibres, 29–30, 29f Paralleling periapical projections, 107–108, 107f–108f
Medical records, 154 Occlusal examination, 102 Parkinson’s disease, 365
Medicaments, 151, 151f Occlusal loading, 355 Pastes, 151f, 223, 224f
Medication, 157 Odontoblastic processes, 21–22 Patency filing, 210–212
see also specific medication Odontoblasts, 5–6, 21–22, 21f Pathogen-associated molecular patterns (PAMPs),
Medico-legal considerations, 153–155 injury, 35–36, 35f 48–49
Membranes, 261–262, 261f–262f Odontogenic tumours, 374, 381t Patient assessment, 94–102, 361–362
Mental foramen, 113, 113f Odontome, 7t–8t, 9f clinical examination, 96–97, 96f, 97t
Mental imaging, 20–21 Odontopaste, 217 dental history, 96
Mesio-occlusal-distal (MOD) cavities, 349–352, Operation microscope, 145, 145f history taking, 95, 361
350f–352f Operative emergencies, 277–279 informed consent, 94
Messing gun, 149f, 219, 219f Oral sedation, 157, 368 medical history, 95–96, 96f, 96t, 154, 361
Metabolites, 47 Orofacial lumps and bumps, 374, 375t nature of presenting complaint, 94, 94t–95t
Metacresyl acetate, 216, 216f Orofacial pain, 369–373 occlusal examination, 102
Metastases to the jaws, 375, 381t case histories, 372 pain source location, 101–102, 102f
Micro-Apical Placement (MAP) System, 149f characteristics, 370–371, 370f, 370t–371t periodontal examination, 98–99, 98f–99f, 99t
Micro Mega Hedstroem, 193f classification, 369, 370t pulp testing, 100–101, 100f–102f
Microbes definition, 369 record keeping, 94
ecology, 70–75, 74f diagnosis, 369–370 social history, 96
and failed root canal treatment, 84–85, 85t and endodontics, 371–372 soft tissue examination, 98, 98f
Microbiota neurophysiological basis of, 369, 370f tooth examination, 99–100, 99f–100f
in apical/marginal periodontitis, 301–302 prevalence, 369 Patient(s)
root canal see Root canal microbiota Orthodontic band, 311, 346–347, 348f anaesthesia and analgesia, 156–157, 156f
Microcirculation, 25–26 Orthodontic tooth movement antibiotic cover, 157
Microdontia, 7t–8t effect of trauma on, 331–332 anxious, 156–157, 367–368
Microleakage, 36, 36f, 167, 170f effect on endodontic treatment, 332 care, 361
Microscope, operation, 145, 145f effect on pulp, 329–330, 330f, 330t education/information, 155–156, 155f–156f
Midazolam, 368 effect on root resorption, 330–331, 330f–331f, with HIV/HBV, 157
Miller classification of tooth mobility, 99, 99t 330t with learning disability, 365–367
Mineral trioxide aggregate (MTA), 39, 41, 41f, 164t, effect on tooth resorption, 331 medically compromised, 362–365
226–227, 227f, 245, 254, 255f Orthodontic treatment, 320, 320f medication, 157
Misdiagnosis, 88 definition, 329 oral care, 120
Mitchell’s trimmer, 145 effect on teeth and pulp, 332 protection, 155
Mobile cabinet, 142, 142f nature of contemporary, 329 with special needs, 361, 365–367
MOD (mesio-occlusal-distal cavities), 349–352, role in endodontic-restorative treatment planning, Pattern recognition, 93
350f–352f 332–333 Pattern recognition receptors (PRR), 48–49
Molars Osteitis, condensing, 55, 58f Perforations, 114, 115f, 198–199, 200f
mandibular Osteitis, sclerosing, 114, 115f iatrogenic, 304–305, 305f–306f
first, 18–19, 18f–19f Osteoblasts, 31 repair, 257–258, 257f–258f
second, 19, 19f Osteoclasts, 31 repair instruments, 146
third, 19–20, 20f Osteocytes, 31 root, 313–316, 314f–316f
maxillary Osteomyelitis, periapical, 55 in root canal retreatment, 245, 245f–246f
first, 17–18, 17f–18f Osteonecrosis, bisphosphonate-related, 364 Periapical abscess, 53–55, 56f–57f
second, 18, 18f Osteoprotegerin (OPG), 45 Periapical disease, 44f
third, 19–20, 20f Osteosclerosis acute abscess/cellulitis, 53–55, 56f–57f
MTA block, 149f idiopathic, 115, 116f, 374 acute inflammation, 50–51, 53f, 117, 117f
Mucocoele, 377f periapical, 55 aetiological factors, 43
386 INDEX
chronic inflammation, 51, 53f Pocket measuring probe, 145 Pulp regeneration, 41
chronic suppurative inflammation, 53, 55f Points removal, silver, 243–244 Pulp space, 10–14
condensing osteitis, 55, 58f Polymorphonuclear leucocytes (PMNs), 34, 35f, characteristics, 11–14, 12f–13f
epithelial proliferation and cysts, 51–53, 53f–54f 43–45, 48–50, 281 classification of pulp systems, 10–11, 11f
host factors, 43–47, 46f, 48f Porcelain veneers, 359 dimensions, 14, 14t
osteomyelitis, 55 Post crown, temporary, 341–342 radiographic appearance, 112
osteosclerosis, 55 Posterior teeth restoration, 346–354, 347f–349f see also Root canals
pathogenesis and natural history, 48–55, 49f–52f Postoperative emergencies, 279–280, 280f Pulp testing, 100–101
prevention, 76–83 Posts/dowels electric pulp tester, 100–101, 100f
root canal microbiota, 59–62 characteristics, 342–346, 342f thermal, 101, 101f–102f
signs of, 307 composition material, 342 Pulp therapy, 163–173
treated teeth, 55–57, 58f–63f diameter, 344–345, 345f compromised pulp, 169–172
treatment, 76–83 diaphragm, 346, 346f deep cavities, 169–172
chemomechanical procedure, 76–81, 77f–82f length, 343–344, 344f–345f factors affecting outcome, 41
Periapical osteomyelitis, 55 permanent, 341, 341f future approaches, 41
Periapical pain, 307 removal, 239–241, 240f–241f primary dentition, 163
Periapical surgery, 89, 247–257 removal equipment, 146, 147f complications, 166
Perio-endo lesions shape, 342–343, 342f–343f follow up, 166
causes of, 310–323 surface configuration, 345–346, 346f pulp disease, 163, 164f
classification, 307 Pre-ameloblasts, 5–6 techniques, 163–166
definition, 307 Precurved files, 199–200, 200f tooth morphology, 163, 164f
diagnosis, 307–309 Predentine, 21–22, 21f rationale for, 38–39, 39f
management, 310–324, 324f Premolars regenerative, 39, 172, 173f
multiple, 321–323 mandibular, 16–17, 17f secondary/permanent dentition, 166–172
prognosis estimation, 323, 323f maxillary, 16, 16f caries, 166, 168–169
regenerative techniques, 325–327, 327f Preoperative emergencies, 268–277 cavity restoration, 166–169
single isolated, 310–321 Prepubertal periodontitis, 322–323, 322f smear layer, 164f, 167–168
Periodontal charting, 307–309 Presenting complaint, 94, 94t–95t success assessment, 39–40, 40f
Periodontal disease, localized, 320–321, 321f Pressure resorption, 290–292, 293f success probability, 40–41
Periodontal examination, 98–99, 98f–99f, 99t Pressure/vacuum agitation, 213, 214f Pulp tissue
Periodontal lesions, 114, 115f Prevention, 129 degrading, 206–207
Periodontal ligament, 28f–31f, 29–31 Primary dentition, 163, 164f necrosis, 43, 116–117, 117f
damage, 281, 283, 283t Primary epithelial band development, 2 Pulpal origin emergencies, 268–270
radiographic appearance, 112 Prion diseases, 152 diagnosis, 268–269, 268f–269f
radiographic interpretation errors, 112, 112f–113f Probes, 145 medication, 270
Periodontal ligament space Profile GT, 197f treatment, 269–270, 269f–270f
lesions, 114, 114f–115f Prostaglandins, 47, 50 Pulpal pain, 307
widening, 112 Pterygomandibular space, 272 Pulpectomy, 270
Periodontal pain, 118–119 Pulp Pulpitis
Periodontal support, 130, 130f anatomy and physiology of, 21–24, 21f irreversible, 116, 117f, 266–269, 268f
Periodontal symptoms history, 307 compromised, 169–172 reversible, 116, 268–269
Periodontal tissues, pre-endodontic management, 159 concussed, 116 Pulpo-periapical inflammation
Periodontitis death, 281 and bone loss, 305, 305f
aggressive, 322–323, 322f defence reactions, 33, 34f and periodontal wound healing, 305, 305f
apical see Apical periodontitis disease, 305, 307 Pulpotomy, 38–40, 40f, 163–165, 164f–165f,
chronic, 321, 322f prevention and treatment, 38 171–172, 172f, 270
initial manifestation, 299, 300f in primary teeth, 163 alternatives to, 165–166
isolated lesions superimposed upon, 321, 322f dystrophic calcification (stones), 37–38, 37f–38f Pyogenic granuloma, 375f
marginal see Marginal periodontitis effect of orthodontic tooth movement on, 329–330,
Periodontium, 136, 137f 330f, 330t
effect of pulp disease on, 305 effect of orthodontic treatment on, 332 Q
pulp communication with, 303–305 effect of periodontal disease on, 306, 306f
Perioglass, 262, 262f effect of periodontal treatment on, 306, 306f Quantec, 196, 196f–197f
Periradicular lesions, 114, 114f–115f functions of, 33, 34f Quorum sensing, 75
Periradicular origin emergencies, 270–274 hot, 266–267
diagnosis, 270–272, 271f–272f hyperaemic, 156
medication, 273–274 infection, 28 R
treatment, 272–273, 273f inflammation, spread of, 36–37, 36f–37f
Periradicular tissues, 28–31 inflammatory response, 33, 34f RaCe, 196, 196f
see also Alveolar bone; Cementum; Periodontal injury, 33–36, 34f–36f, 35t, 38–39 Race variations, 6–9, 10t
ligament nerve supply, 26–28, 26f–27f Radial lands, 196, 196f
Petit mal seizures, 366 normal, 116 Radiation safety, 106–107, 106f
Phagocytosis, 49 periodontium communication with, 303–305 Radicular access, 174, 175f, 189–190
Phenol, 215 regeneration, 281 apical-coronal techniques, 204, 205f
Phenol-based agents, 215–216 vascular supply, 24–26, 24f–26f apical enlargement, 205
Phosphoric acid, 357–359 Pulp capping, 39–40 automated devices, 195–198, 196f–198f, 196t
Photoactivated disinfection, 215, 215f direct, 38–40, 163, 164f, 170–171, 171f chemical treatment, 206–208, 211f–212f
Piezoelectric transducers, 214–215 indirect, 38–40, 163, 169–170, 170f–171f coronal-apical techniques, 204, 205f
Pink spot, 285, 292, 295f Pulp-dentine complex, 10–11 coronal preflaring, 204–205, 206f–207f
Planktonic physiology, 75–76, 75f anatomy and physiology of, 21–28, 21f in curved canals, 198–204, 199f–204f
Plaque removal, 157 reparative processes, 33 double curves, 202–203, 203f–204f
Plasma cells, 45 as a warning system, 33 full length, negotiation to, 205, 208f
Plexus of Raschkow, 26, 27f see also Dentine; Pulp hand instrumentation, 192–195, 193f–195f
INDEX 387
length verification, 205 posterior teeth, 346–354, 347f–349f sclerosed canals, 242–243
mechanical preparation, 192–215 practical management approaches, 168–169 surgical, 245–263
by automated devices, 195–198, 196f–198f, 196t principles, 334 systemic considerations, 138f–140f
and chemical treatment and irrigation, 206–208, provisional, broken-down teeth, 158–159, 159f Root canal treatment
211f–212f proximal cavities, 338–340, 340f alternative approaches, 90, 90f
in curved canals, 198–204, 199f–204f proximo-occlusal cavities, 347–349, 349f–350f analgesia/anaesthesia, 156
dynamic irrigation after, 212–215, 213f–215f removal, 157–158, 239, 239f–240f biological and clinical perspective, 76–78, 77f–82f
by hand instrumentation, 192–195, 193f–195f restorability, 334–338, 337f chemical intraradicular preparation, 174–178,
irrigant delivery and actions, 208–212, role of orthodontics in, 332–333 177f–178f
212f–213f teeth with inadequate tissue, 340–342, 341f–342f, coronal access cavities, 179–181
photoactivated disinfection, 215, 215f 352–354, 353f–355f temporary seal, 220–221
recommended approach, 204–205, 205f–211f teeth with resected roots, 357, 357f–358f coronal seal, 235–236
push-pull filing, 194, 198–202 timing after endodontic treatment, 338 effect of persistent bacteria on outcome, 81–83
rotary motion, 193–194, 193f–194f of treated primary teeth, 166, 166f effects on biological events, 80–81
shaping, final, 205 Restoring force reduction, 199–200 factors affecting outcome, 83, 83f
taper gauging, 203–204 Rests of Malassez, 29–30, 30f failure, 83–89, 84f, 86f–89f, 87t, 237, 238f
Radiography, conventional, 20–21 Retractors, 149f instrumentation, 188, 189f
bisecting angle periapical projections, 108, 108f Retrograde pluggers, 149f intracanal medication, interappointment, 178,
comparison of technologies, 104, 105f Retrograde seal, 89 215–220
conventional films versus digital image, 103–104, RinsEndo, 215 mechanical intraradicular preparation, 174,
104f–105f Rooftop preparations, 340–341, 341f 175f–177f
in diagnosis, 103–109, 103f–104f Root amputation, 324–325, 324f–326f point of termination of canal preparation, 181–183
errors in interpretation, 112–113 Root canal infection, 310–311, 310f–311f previous, 134–135, 134f–136f
film holders, 104, 105f–106f biofilm and planktonic physiology, 75–76, 75f principles, 174–179
interpretation, 111–112 microbial ecology, 70–75, 74f radicular access see radicular access
landmarks, 112, 112f tooth resorption, 289–290, 290f–291f root-canal system obturation, 178–179, 178f–179f
operator safety, 106–107 Root canal microbiota technical aspects, 78–80
parallax techniques, 108–109, 109f antibacterial action against, 208 terminus location, 183–187, 183f–187f
paralleling periapical projections, 107–108, culture studies, 67 working length determination, 187–188, 188f
107f–108f distribution, 67–70 Root canals
patient safety, 106 and failed root canal treatment, 84–85, 85t access to, 131–132, 131f–132f
quality assurance, 111 microscopy studies, 67–68, 68f–73f accessory, 13–14, 20
radiation safety, 106–107, 106f nature of, 62–67, 64f anatomy, 132, 133f
root canal terminus location, 183–184, 183f–185f periapical lesion development and, 59–62 bacteria in, 58f
techniques, 107–109 physiological status, 67–70 characteristics, 12–13, 12t
viewing and storage equipment, 107, 107f in situ hybridization microscopy studies, 68–70, combined method of determination of, 187
Radiolucent lesions, 374–375, 378t 73f–74f complex systems, 191f–192f
Radiopaque lesions, 374–375, 378t species evenness/quantitative analysis, 65–67, 66f, division, 20, 20f
Rapidly progressive periodontitis, 322–323, 323f 67t dynamic irrigation after mechanical preparation,
Rebound phenomenon, 253 species richness/qualitative analysis, 64–65, 65t, 66f 212–215, 213f–215f
Recapitulation, 209–210 Root canal obturation, 178–179, 178f–179f, 221–235 electronic apex locator determination of, 184–187,
Record-keeping, 94, 122–123, 154 advantages, 222 185f–186f
Rectangular flap, 247–248, 247f backfill, 228 fungi in, 59f–60f
Referral, 155 canal surface preparation, 226, 226f irrigation, 206–208, 211f–212f
Regeneration, 281 controlled apical placement, 226–228, 226f–228f delivery, mechanics of, 208–212
Regenerative procedures, 260–262, 325–327, 327f coronal seal, 228 intra-appointment, 174–178
Regional odontodysplasia, 7t–8t definition, 221–222 lateral, 13–14, 20, 21f
Relative analgesia, 156 dry canal, 226 paper-point determination of, 187
Replacement resorption, 281, 288 filling termination, 222, 222f–223f radiographic determination of, 183–184, 183f–185f
Replantation, 320 hybrid technique, 235 sclerosed, 132, 133f–134f, 242–243, 243f
intentional, 259–260, 260f ideal filling material, 223–225, 223f secondary, 13–14
Resilon, 224 lateral compaction, 228, 228f–230f shape of, 11–12, 12f
Resolut absorbable membrane, 261–262 pain following, 280 simple systems, 189, 189f–191f
Resorption principles, 226–228 tactile determination of, 187, 187f
root, 316–317, 316f–317f, 330–331, 330f–331f, 330t techniques, 226 terminus location, 183–187, 183f–187f
tooth, 118, 285–298 thermomechanical compaction technique, 236f working length determination, 187–188, 188f
aetiology, 285–297 thermoplasticized gutta-percha Root division, 317, 319f
effect of orthodontic tooth movement on, 331 carriers, 233–234, 234f–235f Root-end cavity preparation, 252–253, 252f–253f
external, 118, 285, 288–297, 289f–298f injection, 233, 234f Root-end filling, 254–255, 254f–255f
inflammatory, 281 warm vertical compaction, 231–233, 231f–233f, 233b Root-end management, 247–257
internal, 118, 285–288, 286f–289f, 286t Root canal retreatment, 88–89, 89f, 237–245 Root-end resection, 251–252, 251f–252f
pathogenesis, 285–297, 286f anatomical considerations, 136, 137f–138f Root fractures, 114, 115f, 118, 118f, 304–305,
replacement, 281 bridge removal, 239 311–313, 313f–314f
Respiratory disease, 363 coronal restoration removal, 239, 239f–240f healing, 281, 282f
Restorations, 334, 335f–336f, 338f–339f decision-making process, 135–140, 137f traumatic, 275–277, 276f–279f
anterior teeth, 338–342, 339f–341f gutta-percha removal, 241–242, 241f treatment planning, 136–139, 138f–139f
general considerations, 129, 129f–130f indications, 237, 238f Root perforation, 313–316, 314f–316f
hemisected teeth, 357 instrument and points removal, 243–244, 243f–245f Root planing, 306
intact anterior teeth, 338, 339f–340f ledge negotiation, 242, 242f Root resection, 258–259, 258f–259f
intact posterior teeth, 346–347, 347f–349f packed dentine debris, 242, 243f Root resorption, 139–140, 139f–140f, 316–317,
MOD (mesio-occlusal-distal cavities), 349–352, perforations, 245, 245f–246f 316f–317f, 330–331, 330f–331f, 330t
350f–352f post removal, 239–241, 240f–241f Root sheath of Hertwig, 29–30
poorly designed, 320, 320f–321f principles, 239–245, 239f Root ZX, 184–186
388 INDEX
Roots Super ethoxybenzoic acid (EBA), 254, 254f Thermafil removal, 242
characteristics, 11–13, 12t Supernumerary roots, 7t–8t Thermocompactor, 234–235
cracks, 311–313, 312f–313f Surgery Thermomechanical compaction technique, 236f
extra, 20 decision-making process, 135–140 Through and through surgery, 255–256, 256f
fractured, 114, 115f, 118, 118f Surgical armamentarium, 148, 148f–149f Tissue fluid, stagnant, 43
incompletely formed, 169, 169f Surgical endodontic procedures Tooth germ, 2–3, 3f, 5–6, 21f
shapes, 6–10 biopsy, 247, 247f Touch n’ Heat, 229
supernumerary, 7t–8t classification, 245–246 Trans-septal fibres, 29–30, 29f
Rotary motion, 193–194, 193f–194f corrective surgery, 257–259 Transforming growth factor-beta (TGF-β), 33
Rubber dams decompression, 262–263, 262f Transplantation, 320
advantages, 159–160, 160f emergency, 246 intentional, 259–260, 261f
application, 160–161, 161f indications, 245–246 Trauma
kits, 160f intentional replantation and transplantation, acute dentoalveolar, 274–275
Ruler, 145 259–260, 260f–261f clinical data for prognosis, 282–283, 282t
periapical surgery, 247–257 effect on orthodontic tooth movement, 331–332
regenerative procedures, 260–262 Trephination, 246, 246f–247f
S root-end management, 247–257 Triangular flap, 247–248, 247f–248f
Surgical retreatment, analgesia/anaesthesia, 156 Trigeminal pain pathway, 369, 370f
Safety tip, 197, 197f–198f Surgical tray, 148f Tug-back, 228
Scalpel blades, 148f Suture materials, 256–257, 256f Tumour necrosis factor (TNF), 45, 50
Sclerosed canals, 132, 133f–134f, 242–243, 243f Suture scissors, 149f Turner tooth, 166, 166f
Sclerosing osteitis, 114, 115f Swellings, 374
Sealers, 225, 226f System-B “Continuous Wave” obturation technique,
Sedation 231, 233b U
conscious, 368 Systemic resorption, 297, 297t
inhalation, 368 Ultradent tubes, 147f
intranasal, 368 Ultrafil system, 233
intravenous, 157, 368 T Ultrasonic agitation, 213, 214f
nasal, 157 Ultrasonic baths, 150
oral, 157, 368 T lymphocytes, 45 Ultrasonic units, 146, 146f
Seizures, 366 Talon cusps, 6, 7f, 7t–8t, 9f
Self-adjusting file, 197–198, 198f Taurodontism, 7t–8t
Semilunar flap, 247–248, 247f Teeth V
Sensibility testing, 100 access to, 131–132, 131f–132f
Sensitivity testing, 100 anatomical anomalies, 6, 7f, 7t–8t, 317 Varicella zoster virus (VZV), 47
Sharpey’s fibres, 28, 28f anatomy, 132 Vasoactive amines, 47
Sheath of Hertwig, 5 average lengths, 14t Vasoactive intestinal polypeptides, 47
Shell teeth, 7t–8t broken-down, 158–159, 159f Vasopressors, 156
Silver cone obturation, 223 cracked, 118, 118f Veneers, 359
Silver points removal, 243–244 development, 2–6, 3f Venules, 24, 25f
SimpliFill, 234, 235f dental follicle, 5 Verrucous cell carcinoma, 376f
SmartSeal, 224 dental lamina, 2–4, 3f Verrucous papilloma, 376f
Smear layer, 164f, 167–168 dental papilla, 2–3, 3f, 5 Vertucci’s classification of canal morphology, 11f
degradation, 207 early, 2, 3f Vestibular band development, 2
Sodium hypochlorite, 206–207, 216, 278–279 enamel organs, 2, 3f–5f, 4–5 Vestibule formation, 3, 4f
regenerative pulp therapy, 39 molecular regulation, 6 Viruses in periapical disease, 47
tooth resorption, 287–288 primary epithelial band, 2 Von Willebrand’s disease (vWD), 363
Sodium perborate, 357–359 sheath of Hertwig, 5
Soft tissue examination, 98, 98f successional permanent teeth, 4, 5f
Soft tissue swellings, 374, 375f–376f, 375t–377t tooth germ, 5–6 W
Solid obturators, 223, 223f vestibular band, 2
Sonic agitation, 213, 214f vestibule formation, 3, 4f Water supplies, 144, 144f
Splint therapy, 264, 265f discolored, 357–359, 358f–359f Weine’s classification of canal morphology, 11f
Spongy bone, 31 effect of orthodontic treatment on, 332 Work surface organization, 143–144, 144f
Squamous cell carcinoma, 376f eruption times, 10, 10t Working length determination, 187–188, 188f
Stabilization, 129 evagination, 6, 7f, 7t–8t, 9f Wound closure, 256–257, 256f–257f
Stagnant tissue fluid, 43 examination, 99–100, 99f–100f Wound healing, 257, 281, 305, 305f
Stagnation plane, 209–210 fractures, 99, 99f, 118, 118f, 268f
Stellate reticulum, 4–5 fused, 317, 319f
Sterilization, 148–152, 150f invagination, 6, 7f, 7t–9t, 10f X
Steroids, 217, 217f luxated, 277, 279f, 282–283, 282t
Storage, 151 mobility, 99, 99f, 99t X-ray machine, 145–146, 146f
Stratum intermedium, 4–5 morphology, 6 X-ray viewer, 146, 146f
Streptococci, 68–69 orientation, 132, 133f Xylocaine, 265f
Stroke, 362 pre-endodontic management, 157–162
Subgingival plaque, 292–297, 294f–297f probing profile, 307–309, 308f–309f
Sublingual space, 271 resorption see Resorption Z
Submandibular space, 271 restorability of, 131, 131f, 334–338, 337f
Submarginal flap, 247–248, 248f assessment of, 158, 158f Zinc oxide/eugenol cement, 221, 221f
Submasseteric interval, 271 shapes, 6–10 Zinc phosphate, 221, 357–359
Submental space, 271–272 strategic importance, treatment planning, 129, 130f Zinc polycarboxylate, 221
Substance P, 47 TERM, 221 Zipping, 198–199, 199f
Subtemporalis muscle interval, 272 Test cavity cutting, 102 Zones of Fish, 76–78