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Cohen’s TWELFTH
EDITION
PATHWAYS
of
the
PULP
EDITORS
LOUIS H. BERMAN, DDS, FACD
Clinical Associate Professor
Department of Endodontics
School of Dentistry
University of Maryland
Baltimore, Maryland
Faculty
Albert Einstein Medical Center
Philadelphia, Pennsylvania
Private Practice
Annapolis Endodontics
Annapolis, Maryland
Diplomate, American Board of Endodontics
Web Editor
ILAN ROTSTEIN, DDS
Associate Dean of Continuing Education and Chair
Division of Endodontics, Orthodontics, and General Practice Dentistry
Herman Ostrow School of Dentistry
University of Southern California
Los Angeles, California
ELSEVIER
3251 Riverport Lane
St. Louis, Missouri 63043
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Notices
Knowledge and best practice in this field are constantly changing. As new research and experience
broaden our understanding, changes in research methods, professional practices, or medical treatment
may become necessary.
Practitioners and researchers must always rely on their own experience and knowledge in evaluating
and using any information, methods, compounds, or experiments described herein. In using such
information or methods they should be mindful of their own safety and the safety of others, including
parties for whom they have a professional responsibility.
With respect to any drug or pharmaceutical products identified, readers are advised to check the most
current information provided (i) on procedures featured or (ii) by the manufacturer of each product to
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tion, and contraindications. It is the responsibility of practitioners, relying on their own experience and
knowledge of their patients, to make diagnoses, to determine dosages and the best treatment for each
individual patient, and to take all appropriate safety precautions.
To the fullest extent of the law, neither the Publisher nor the authors, contributors, or editors, assume
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contained in the material herein.
Printed in Canada
Louis H. Berman
Dr. Berman received his dental degree from the University of Maryland School of
Dentistry and his Certificate in Endodontics from the Albert Einstein Medical Center. He
is Clinical Associate Professor of Endodontics at the University of Maryland School of
Dentistry and a Clinical Instructor and Guest Lecturer at the Albert Einstein Medical
Center. He has lectured internationally in the field of endodontics and has published in
several peer-reviewed international dental journals as well as co-authoring textbook
chapters on numerous topics in various endodontic textbooks. He is past president of
the Maryland State Association of Endodontics and is a member of the Journal of End-
odontics Scientific Advisory Board. A Diplomate of the American Board of Endodontics
and Fellow of the American College of Dentistry, Dr. Berman has been in full-time
private practice in Annapolis, Maryland since 1983.
Kenneth M. Hargreaves
Dr. Hargreaves is Professor and Chair of the Department of Endodontics at the
University of Texas Health Science Center at San Antonio. He is a Diplomate of
the American Board of Endodontics and maintains a private practice limited to
endodontics. He is an active researcher, lecturer, and teacher and serves as the
Editor-in-Chief of the Journal of Endodontics. He is principal investigator on several
nationally funded grants that combine his interests in pain, pharmacology, and
regenerative endodontics. He has received several awards, including a National In-
stitutes of Health MERIT Award for pain research, the AAE Louis I. Grossman
Award for cumulative publication of research studies, and two IADR Distinguished
Scientist Awards.
Ilan Rotstein
Dr. Rotstein is Professor and Chair of Endodontics, Orthodontics, and General Practice
Residency and Associate Dean at the Herman Ostrow School of Dentistry of the Univer-
sity of Southern California in Los Angeles. He is on the Executive Leadership Team of the
School of Dentistry and an ambassador member of the University of Southern California.
He has served in leadership roles for various dental organizations, including Chair of
the International Federation of Endodontic Associations’ Research Committee; as a
committee member of the American Association of Endodontists and European Society
of Endodontology; and as a scientific reviewer for international endodontic and dental
journals. He has also served as President of the Southern California Academy of Endo-
dontists, Israel Endodontic Society, and International Association for Dental Research—
Israel Division and as Chair of the Israel National Board of Diplomates in Endodontics.
Dr. Rotstein has published more than 150 scientific papers and research abstracts in
the dental literature as well as chapters in international endodontic textbooks, includ-
ing Pathways of the Pulp, Ingle’s Endodontics, Endodontics: Principles and Practice, Seltzer
and Bender’s Dental Pulp, and Harty’s Endodontics in Clinical Practice. He has lectured
extensively in more than 25 countries throughout 5 continents.
iii
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Dr. John Ingle
The development of every edition of Cohen’s Pathways of the Washington Study established proof of outcome for endo
Pulp, for all of its editors and contributors, is a journey into dontic treatment and remains a seminal work in the
both the future and the past of endodontics. What we as literature for our field.
clinicians know today and the care that knowledge enables New fields offer many new challenges to their pioneers,
us to provide to our patients are the result of the curiosity, and Dr. Ingle soon turned his attention to the development
dedication, and commitment of the teachers, researchers, of standardization of endodontic instruments. His work
and clinicians who have come before us. Dr. John Ingle, resulted in the metric measurements and the 0.2 taper of
who contributed to the science, practice, and teaching endodontics files that were established in 1957.
of endodontics for more than 7 decades, is one of those In 1965, Dr. Ingle brought together his experience
extraordinary pioneers. as both a clinician and an educator in the publication of
Dr. Ingle began his career as an educator at the Univer- his foundational textbook Ingle’s Endodontics. Now in its
sity of Washington in Seattle, where he taught periodon- sixth edition, Ingle’s Endodontics has provided an essential
tics. While teaching, he became interested in the new field evidence-based reference to students and clinicians for
of endodontics and, perhaps drawing on the example of more than 50 years.
his pioneer great-grandfather, Daniel Boone, he entered While Dr. Ingle’s many accomplishments are known and
a specialty program in endodontics at the University of admired, the attributes of his character are equally revered.
Michigan to explore this new discipline, earning graduate Dr. Ingle was modest about his many contributions to end-
degrees in endodontics and periodontics. odontics and was unfailingly generous in his support and
As an educator and clinician, Dr. Ingle knew the impor- encouragement of others. The compassion and empathy
tance of evidence in establishing the efficacy of endodontic that motivated his work were experienced by all those he
treatment as a new specialty. To meet this need, he evalu- touched throughout his long and exemplary career and life.
ated the results of endodontic treatment in 3000 patients It is with profound gratitude and appreciation that we
and presented his findings to the annual session of dedicate this twelfth edition of Cohen’s Pathways of the Pulp
the American Association of Endodontists in 1953. The to Dr. John Ingle, a scholar, a leader, and a gentleman.
v
Contributors
Abdulaziz A. Bakhsh, BDS, MClinDent, Nicholas Chandler, BDS (Lond), MSc (Manc),
MEndo (RCSed) PhD (Lond), LDSRCS (Eng), MRACDS (Endo),
Endodontist FDSRCPS (Glas), FDSRCS (Edin), FFDRCSI, FICD
Department of Restorative Dentistry Professor of Endodontics
Faculty of Dentistry Faculty of Dentistry
Umm Al-Qura University University of Otago
Makkah, Saudi Arabia Dunedin, New Zealand
Bettina Basrani, DDS, PhD Gary S.P. Cheung, PhD, BDS, MDS, MSc, FHKAM,
Program Director FCDSHK (Endo), SFHEA, FICD, FAMS, FRACDS,
MSc Endodontics MRACDS (Endo), FDSRCSEd
Department of Endodontics Clinical Professor
University of Toronto Division of Restorative Dental Sciences
Toronto, Canada Associate Dean of Undergraduate Education
Faculty of Dentistry
Ellen Berggreen, PhD University of Hong Kong
Professor Pokfulam, Hong Kong
Biomedicine
University of Bergen Till Dammaschke, Prof, Dr Med Dent
Head of Research Dentist and Assistant Medical Director
Vestland County Department of Periodontology and Operative Dentistry
Bergen, Norway Westphalian Wilhelms University
Münster, Germany
Louis H. Berman, DDS, FACD
Clinical Associate Professor Didier Dietschi, DMD, PhD, Privat-Docent
Department of Endodontics Senior Lecturer
School of Dentistry School of Dental Medicine
University of Maryland Department of Cardiology and Endodontics
Baltimore, Maryland University of Geneva
Faculty Geneva, Switzerland
Albert Einstein Medical Center Adjunct Professor
Philadelphia, Pennsylvania School of Dentistry
Private Practice Department of Comprehensive Care
Annapolis Endodontics Case Western Reserve University
Annapolis, Maryland Cleveland, Ohio
Diplomate, American Board of Endodontics
Anibal Diogenes, DDS, MS, PhD
George Bogen, BS, DDS Assistant Professor
Senior Lecturer Endodontics
Department of Endodontics University of Texas Health Science Center at San Antonio
School of Dentistry San Antonio, Texas
University of Queensland
Brisbane, Australia Melissa Drum, DDS, MS
Diplomate, American Board of Endodontics Professor and Advanced Endodontics Director
Endodontics
Ohio State University
Columbus, Ohio
vi
CONTRIBUTORS vii
Conor Durack, BDS NUI, MFDS RCSI, James L. Gutmann, DDS, Cert Endo, PhD, FICD,
MClinDent (Endo), MEndo RCS (Lond) FACD, FIAD, FAAHD, FDSRCSEd, Dipl ABE
Specialist Endodontist and Practice Partner Professor, Chair, and Postdoctoral Program Director
Riverpoint Specialist Dental Clinic Endodontics
Limerick, Ireland College of Dental Medicine
Nova Southeastern University
Bing Fan, DDS, PhD Davie, Florida
Professor and Chair Professor Emeritus
Endodontic Center Restorative Sciences/Endodontics
School and Hospital of Stomatology College of Dentistry
Wuhan University Texas A&M University
Wuhan City, China Dallas, Texas
Adjunct Professor Honorary Professor
Department of Endodontics Stomatology
Dental College of Georgia School of Stomatology
Augusta University Wuhan University
Augusta, Georgia Wuhan, China
The radiographic interpretation of odontogenic and non Science Topics, and Part III: Advanced Clinical Topics. The
odontogenic lesions is exactly that: an “interpretation.” twelve chapters in Part 1 focus on the core clinical con
This new twelfth edition boasts a completely new chapter cepts for dental students, while the chapters in Parts II and
entitled Lesions That Mimic Endodontic Pathosis that eluci III provide the information that advanced students and
dates and differentiates lesions that may appear as endo endodontic residents and clinicians need to know. In addi
dontic origin. This is a perfect adjunct to the chapters on tion, three additional chapters are included in the online
Diagnosis and Radiographic Interpretation. version.
The chapter on Managing Iatrogenic Events has been The new organization better reflects the chronology of
completely rewritten to include an expansive section on endodontic treatment.
injury to the inferior alveolar nerve.
Damage to the inferior alveolar nerve secondary to endo
dontic treatment is an avoidable dilemma. There is now Digital Content
specific content elaborating on the avoidance and manage
ment of these types of injuries. New features included on the companion site include:
Root resorption and root fractures can be some of the n Three chapters found exclusively online:
most difficult defects to clinically manage. The Root Resorp n Chapter 26: Bleaching Procedures
tion chapter on these subjects has been completely updated n Chapter 27: Endodontic Records and Legal Responsi
and will prove beneficial to the clinician and academician.
bilities
This edition updates all of the previous chapters to reflect n Chapter 28: Key Principles of Endodontic Practice
the changes in the literature since the last edition.
Management
n Case Studies
Review Articles
New Chapter Organization n
n Review Questions
n Videos
Chapters have been reorganized and grouped into three parts:
Part I: The Core Science of Endodontics, Part II: Advanced
x
Introduction
The foundation of the specialty of endodontics is a gift from clinician, or with the augmented reality of digital microsur-
the generations of great endodontists and researchers be- gical devices? In the years to come, will we be able to truly
fore us. They guided us with the goals of treatment, the eliminate all of the canal microorganisms, biofilms, and
benefits of their advancements, and the frailties of their pulpal tissue? Will we be facilitating our canal cleaning with
deficiencies. From volumes of research, we have collectively less toxic and more directed irrigants? Once we are finally
built a virtual library of knowledge that leads us to the evi- able to totally clean and disinfect the canals to a microscopic
dence we need for mastering our clinical procedures and level, will we have an obturation material that finally satis-
benefiting our patients. As we look into our future, we fies ALL the material requirements that Dr. Louis Grossman
should be directed toward developing the necessary tools enumerated at the inception of our specialty? Will this obtu-
for maximizing our outcomes with consistency, longevity, rating material be newly regenerated vital pulp?
and, above all, patient well-being. Clearly, our endodontic future lies in out-of-the-box
Over the past several decades, we have gone from arsenic thinking, with the next generation of transformations
to sodium hypochlorite, from bird droppings to gutta- coming with collaborations not just from within the bio-
percha, from hand files to motor-driven files, from culturing logical sciences, but also in conjunction with physicists,
to one-visit appointments, from 2D to 3D radiography, and chemists, engineers, and a multitude of other great inno-
from pulp removal to pulpal regeneration. Yet still, the vative minds. The predictability of endodontics must be
clinical and academic controversies are pervasive. incontestable, not just with better technology to guide us
With patients living longer and with the inescapable toward greater success, but also to better elucidate exactly
comparison of endodontics to endosseous implants, the when endodontic treatment cannot be successful. Our fu-
demand for endodontic excellence has greatly increased. ture needs to focus on predictability and consistency, which
Surprisingly, we still base our diagnosis on a presumed and will only be achieved with disruptive technologies, rather
almost subjective pulpal status. Imagine a future in which than persisting with variations and modifications of our
endodontic diagnosis could be made more objective by current convictions. As a specialty, we have advanced by
noninvasively scanning the pulp tissue. Imagine algorithms leaps and bounds since our inception; but we are still in our
built into all digital radiography for interpreting and infancy with a brilliant future ahead of us. Since 1976,
extrapolating disease processes. CBCT has made a huge and now with 12 editions, Cohen’s Pathways of the Pulp has
impact on endodontic diagnosis, but can we enhance these always been about the art and science of endodontics, with
digital captures with a resolution that would approach an emphasis on evidenced-based direction rather than an-
microcomputed tomography, and with less radiation? Will ecdotal guidance. The dedicated contributing authors have
these 3D scans guide us not just with diagnostic objectivity, generously given their time to meticulously describe what
but also with direct treatment facilitation to guide us dur- is considered the state of the art of our specialty. We are
ing surgical and nonsurgical treatment? Truly, we are now hopeful that future editions will guide us toward enhanced
on the cusp of gaining the knowledge and technology endodontic outcomes, with the never-ending pursuit of
for accomplishing this. As for clinical visualization, will 3D endodontic excellence.
visualization and monitor-based observation change the
way we visualize and implement our procedures? Will our Louis H. Berman
procedures still be done with the fine motor skills of the Kenneth M. Hargreaves
xi
Contents
5 Case Assessment and Treatment Planning, 139 19 Management of Endodontic Emergencies, 737
PAUL A. ROSENBERG and MATTHEW MALEK FABRICIO B. TEIXEIRA and GARY S.P. CHEUNG
7 Tooth Morphology and Pulpal Access 21 The Role of Endodontics After Dental Traumatic
Cavities, 192 Injuries, 808
JAMES L. GUTMANN and BING FAN BILL KAHLER
8 Cleaning and Shaping of the Root Canal 22 Chronic Cracks and Fractures, 848
System, 236 LOUIS H. BERMAN and AVIAD TAMSE
OVE A. PETERS, CHRISTINE I. PETERS, and BETTINA BASRANI
23 Restoration of the Endodontically
9 Obturation of the Cleaned and Shaped Root Canal Treated Tooth, 870
System, 304 DIDIER DIETSCHI, SERGE BOUILLAGUET, AVISHAI SADAN,
ANITA AMINOSHARIAE, WILLIAM T. JOHNSON, JAMES C. KULILD, and KENNETH M. HARGREAVES
and FRANKLIN TAY
24 Vital Pulp Therapy, 902
10 Nonsurgical Retreatment, 343 GEORGE BOGEN, TILL DAMMASCHKE, and NICHOLAS CHANDLER
ROBERT S. RODA, BRADLEY H. GETTLEMAN, and SCOTT C. JOHNSON
25 Endo-Perio, 939
11 Periradicular Surgery, 411 GERALD N. GLICKMAN and VINCENT J. IACONO
BRADFORD R. JOHNSON, MOHAMED I. FAYAD,
and LOUIS H. BERMAN
xii
PART I
Art and Science of Diagnosis and carefully interpreting the answers. In essence, the pro-
cess of determining the existence of an oral pathosis is the
Diagnosis is the art and science of detecting and distin- culmination of the art and science of making an accurate
guishing deviations from health and the cause and nature diagnosis.
thereof.6 The purpose of a diagnosis is to determine what The process of making a diagnosis can be divided into five
problem the patient is having and why the patient is having stages:
that problem. Ultimately, this will directly relate to what
1. The patient tells the clinician the reasons for seeking
treatment, if any, will be necessary. No appropriate treat-
advice.
ment recommendation can be made until all of the whys
2. The clinician questions the patient about the symptoms
are answered. Therefore, careful data gathering as well as
and history that led to the visit.
a planned, methodical, and systematic approach to this
3. The clinician performs objective clinical tests.
investigatory process is crucial.
4. The clinician correlates the objective findings with the
Gathering objective data and obtaining subjective find-
subjective details and creates a tentative list of differential
ings are not enough to formulate an accurate clinical
diagnoses.
diagnosis. The data must be interpreted and processed to
5. The clinician formulates a definitive diagnosis.
determine what information is significant, and what infor-
mation might be questionable. The facts need to be col- This information is accumulated by means of an orga-
lected with an active dialogue between the clinician and nized and systematic approach that requires considerable
the patient, with the clinician asking the right questions clinical judgment. The clinician must be able to approach
2
1 • Diagnosis 3
the problem by crafting what questions to ask the patient and complete update of the patient’s medical history should
and how to ask these pertinent questions. Careful listening be taken if the patient has not been seen for over a year.51,52
is paramount to begin painting the picture that details the Baseline blood pressure and pulse should be recorded for
patient’s complaint. These subjective findings combined the patient at each treatment visit. Elevation in blood pres-
with the results of diagnostic tests provide the critical infor- sure or a rapid pulse rate may indicate an anxious patient
mation needed to establish the diagnosis. who may require a stress reduction protocol, or it may indi-
Neither the art nor the science is effective alone. Estab- cate that the patient has hypertension or other cardiovas-
lishing a differential diagnosis in endodontics requires a cular health problems. Referral to a physician or medical
unique blend of knowledge, skills, and the ability to inter- facility may be indicated. It is imperative that vital signs
pret and interact with a patient in real time. Questioning, be gathered at each treatment visit for any patient with
listening, testing, interpreting, and finally answering the a history of major medical problems. The temperature
ultimate question of why will lead to an accurate diagnosis of patients presenting with subjective fever or any signs or
and in turn result in a more successful treatment plan. symptoms of a dental infection should be taken.57,80,105
The clinician should evaluate a patient’s response to the
CHIEF COMPLAINT health questionnaire from two perspectives: (1) those medi-
cal conditions and current medications that will necessitate
On arrival for a dental consultation, the patient should com- altering the manner in which dental care will be provided
plete a thorough registration that includes information per- and (2) those medical conditions that may have oral mani-
taining to medical and dental history (Figs. 1.1 and 1.2). festations or mimic dental pathosis.
This should be signed and dated by the patient, as well as Patients with serious medical conditions may require
initialed by the clinician as verification that all of the sub- either a modification in the manner in which the dental
mitted information has been reviewed (see Chapter 27 for care will be delivered or a modification in the dental treat-
more information). ment plan (Box 1.1). In addition, the clinician should be
The reasons patients give for consulting with a clinician aware if the patient has any drug allergies or interactions,
are often as important as the diagnostic tests performed. allergies to dental products, an artificial joint prosthesis,
Their remarks serve as initial important clues that will help organ transplants, or is taking medications that may nega-
the clinician to formulate a correct diagnosis. Without tively interact with common local anesthetics, analgesics,
these direct and unbiased comments, objective findings sedatives, and antibiotics.80 This may seem overwhelming,
may lead to an incorrect diagnosis. The clinician may find a but it emphasizes the importance of obtaining a thorough
dental pathosis, but it may not contribute to the pathologic and accurate medical history while considering the various
condition that mediates the patient’s chief complaint. In- medical conditions and dental treatment modifications that
vestigating these complaints may indicate that the patient’s may be necessary before dental treatment is provided.
concerns are related to a medical condition or to recent Several medical conditions have oral manifestations,
dental treatment. Certain patients may even receive initial which must be carefully considered when attempting to
emergency treatment for pulpal or periapical symptoms in arrive at an accurate dental diagnosis. Many of the oral
a general hospital.93 On occasion, the chief complaint is soft-tissue changes that occur are more related to the medi-
simply that another clinician correctly or incorrectly ad- cations used to treat the medical condition rather than to
vised the patient that he or she had a dental problem, with the condition itself. More common examples of medication
the patient not necessarily having any symptoms or any side effects are stomatitis, xerostomia, petechiae, ecchymo-
objective pathosis. Therefore, the clinician must pay close ses, lichenoid mucosal lesions, and bleeding of the oral soft
attention to the actual expressed complaint, determine the tissues.80
chronology of events that led to this complaint, and ques- When developing a dental diagnosis, a clinician must
tion the patient about other pertinent issues, including also be aware that some medical conditions can have
medical and dental history. For future reference and in order clinical presentations that mimic oral pathologic
to ascertain a correct diagnosis, the patient’s chief com- lesions.13,28,32,74,80,102,107,133 For example, tuberculosis in-
plaint should be properly documented, using the patient’s volvement of the cervical and submandibular lymph nodes
own words. can lead to a misdiagnosis of lymph node enlargement
secondary to an odontogenic infection. Lymphomas can
MEDICAL HISTORY involve these same lymph nodes.80 Immunocompromised
patients and patients with uncontrolled diabetes mellitus
The clinician is responsible for taking a proper medical his- respond poorly to dental treatment and may exhibit recur-
tory from every patient who presents for treatment. Numer- ring abscesses in the oral cavity that must be differentiated
ous examples of medical history forms are available from a from abscesses of dental origin.43,76,80,83 Patients with iron
variety of sources, or clinicians may choose to customize deficiency anemia, pernicious anemia, and leukemia fre-
their own forms. After the form is completed by the patient, quently exhibit paresthesia of the oral soft tissues. This find-
or by the parent or guardian in the case of a minor, the cli- ing may complicate making a diagnosis when other dental
nician should review the responses with the patient, par- pathosis is present in the same area of the oral cavity. Sickle
ent, or guardian, and then initial the medical history form cell anemia has the complicating factor of bone pain, which
to indicate that this review has been done. The patient “of mimics odontogenic pain, and loss of trabecular bone pat-
record” should be questioned at each treatment visit to tern on radiographs, which can be confused with radio-
determine whether there have been any changes in the graphic lesions of endodontic origin. Multiple myeloma can
patient’s medical history or medications. A more thorough result in unexplained mobility of teeth. Radiation therapy
4 PART I • The Core Science of Endodontics
1. Are you experiencing any pain at this time? If not, please go to question 6. Yes No
2. If yes, can you locate the tooth that is causing the pain? Yes No
5. Please check the frequency and quality of the discomfort, and the number that most closely
reflects the intensity of your pain:
1 2 3 4 5 6 7 8 9 10 Constant Sharp
Intermittent Dull
Momentary Throbbing
Occasional
If yes, what?
If yes, what?
When eating or drinking, is your tooth sensitive to: Heat Cold Sweets
Does your tooth hurt when you bite down or chew? Yes No
Does it hurt if you press the gum tissue around this tooth? Yes No
Does a change in posture (lying down or bending over) cause your tooth to hurt? Yes No
8. Has a restoration (filling or crown) been placed on this tooth recently? Yes No
9. Prior to this appointment, has root canal therapy been initiated on this tooth? Yes No
10. Is there anything else we should know about your teeth, gums, or sinuses that would assist us in our
diagnosis?
Fig. 1.1 Dental history form that also allows the patient to record pain experience in an organized and descriptive manner.
1 • Diagnosis 5
How would you rate your health? Please circle one. Excellent Good Fair Poor
If you are under the care of a physician, please give reason(s) for treatment.
Name Address
Date
Have you ever had any trouble with prolonged bleeding after surgery? Yes No
Do you wear a pacemaker or any other kind of prosthetic device? Yes No
Are you taking any kind of medication or drugs at this time? Yes No
If yes, please give name(s) of the medicine(s) and reason(s) for taking them:
Name Reason
Have you ever had an unusual reaction to an anesthetic or drug (like penicillin)? Yes No
Is there any other information that should be known about your health?
Fig. 1.2 Succinct, comprehensive medical history form designed to provide insight into systemic conditions that could produce or affect the patient’s
symptoms, mandate alterations in treatment modality, or change the treatment plan.
6 PART I • The Core Science of Endodontics
Fig. 1.3 When taking a dental history and performing a diagnostic examination, often a premade form can facilitate complete and accurate documen-
tation. (Courtesy Dr. Ravi Koka, San Francisco, CA.)
8 PART I • The Core Science of Endodontics
Fig. 1.4 Several practice management software packages have features for charting endodontic diagnoses using user-defined drop-down menus and
areas for specific notations. Note that for legal purposes, it is desirable that all recorded documentation have the ability to be locked, or if any modifications
are made after 24 hours, the transaction should be recorded with an automated time/date stamp. This is necessary so the data cannot be fraudulently
manipulated. (Courtesy PBS Endo, Cedar Park, TX.)
1 • Diagnosis 9
Provocation or attenuation. “What produces or reduces the after the more objective testing and scientific phase of the
symptoms?” Mastication and locally applied temperature investigatory process.
changes account for the majority of initiating factors that
cause dental pain. The patient may relate that drinking Examination and Testing
something cold causes the pain or possibly that chewing or
biting is the only stimulus that “makes it hurt.” The patient EXTRAORAL EXAMINATION
might say that the pain is only reproduced on “release from
biting.” On occasion, a patient may present to the dental Basic diagnostic protocol suggests that a clinician observe
office with a cold drink in hand and state that the symptoms patients as they enter the operatory. Signs of physical limita-
can only be reduced by bathing the tooth in cold water. Non- tions may be present, as well as signs of facial asymmetry
prescription pain relievers may relieve some symptoms, that result from facial swelling. Visual and palpation exami-
whereas narcotic medication may be required to reduce nations of the face and neck are warranted to determine
others. Note that patients who are using narcotic as well as whether swelling is present. Many times a facial swelling
non-narcotic (e.g., ibuprofen) analgesics may respond dif- can be determined only by palpation when a unilateral
ferently to questions and diagnostic tests, thereby altering “lump or bump” is present. The presence of bilateral swell-
the validity of diagnostic results. Thus, it is important to ings may be a normal finding for any given patient; however,
know what drugs patients have taken in the previous 4 to it may also be a sign of a systemic disease or the conse-
6 hours. These provoking and relieving factors may help quence of a developmental event. Palpation allows the
the clinician to determine which diagnostic tests should be clinician to determine whether the swelling is localized or
performed to establish a more objective diagnosis. diffuse, firm or fluctuant. These latter findings will play a
Duration. “Do the symptoms subside shortly, or do they significant role in determining the appropriate treatment.
linger after they are provoked?” The difference between a Palpation of the cervical and submandibular lymph nodes
cold sensitivity that subsides in a few seconds and one is an integral part of the examination protocol. If the nodes
that subsides in minutes may determine whether a clinician are found to be firm and tender along with facial swelling
repairs a defective restoration or provides endodontic treat- and an elevated temperature, there is a high probability that
ment. The duration of symptoms after a stimulating event an infection is present. The disease process has moved from
should be recorded to establish how long the patient felt a localized area immediately adjacent to the offending tooth
the sensation in terms of seconds or minutes. Clinicians to a more widespread systemic involvement.
often first test control teeth (possibly including a contralat- Extraoral facial swelling of odontogenic origin typically
eral “normal” tooth) to define a “normal” response for is the result of endodontic etiology because diffuse facial
the patient; thus, “lingering” pain is apparent when com- swelling resulting from a periodontal abscess is rare. Swell-
paring the duration between the control teeth and the ings of nonodontogenic origin must always be considered
suspected tooth. in the differential diagnosis, especially if an obvious dental
With the dental history interview complete, the clinician pathosis is not found.77 This situation is discussed in subse-
has a better understanding of the patient’s chief complaint quent chapters.
and can concentrate on making an objective diagnostic A subtle visual change such as loss of definition of the
evaluation, although the subjective (and artistic) phase of nasolabial fold on one side of the nose may be the earliest
making a diagnosis is not yet complete and will continue sign of a canine space infection (Fig. 1.5). Pulpal necrosis
A B
Fig. 1.5 A, Canine space swelling of the left side of the face extending into and involving the left eye. B, Swelling of the upper lip and the loss of
definition of the nasolabial fold on the patient’s left side, which indicates an early canine space infection.
10 PART I • The Core Science of Endodontics
and periradicular disease associated with a maxillary canine be noted as swelling in the submandibular space. Further
should be suspected as the source of the problem. Extremely discussions of fascial space infections may be found in
long maxillary central incisors also may be associated with Chapter 16.
a canine space infection, but most extraoral swellings asso- Sinus tracts of odontogenic origin may also open through
ciated with the maxillary centrals express themselves as a the skin of the face (Figs. 1.9 and 1.10).2,56,64 These open-
swelling of the upper lip and base of the nose. ings in the skin will generally close once the offending
If the buccal space becomes involved, the swelling will be tooth is treated and healing occurs. A scar is more likely to
extraoral in the area of the posterior cheek (Fig. 1.6). These be visible on the skin surface in the area of the sinus tract
swellings are generally associated with infections originat- stoma than on the oral mucosal tissues (see Fig. 1.10, C
ing from the buccal root apices of the maxillary premolar and D). Many patients with extraoral sinus tracts give a
and molar teeth and the mandibular premolar (Fig. 1.7) history of being treated by general physicians, dermatolo-
and first molar teeth. The mandibular second and third gists, oncologists, or plastic surgeons with systemic or
molars also may be involved, but infections associated with topical antibiotics or surgical procedures in attempts to
these two teeth are just as likely to exit to the lingual where heal the extraoral stoma. In these particular cases, after
other spaces would be involved. For infections associated multiple treatment failures, the patients may finally be re-
with these teeth, the root apices of the maxillary teeth must ferred to a dental clinician to determine whether there is a
lie superior to the attachment of the buccinator muscle dental cause. Raising the awareness of physicians to such
to the maxilla, and the apices of the mandibular teeth must cases will aid in more accurate diagnosis and faster referral
be inferior to the buccinator muscle attachment to the to the dentist or endodontist.
mandible.77
Extraoral swelling associated with mandibular incisors INTRAORAL EXAMINATION
will generally exhibit itself in the submental (Fig. 1.8) or
submandibular space. Infections associated with any man- The intraoral examination may give the clinician insight as
dibular teeth, which exit the alveolar bone on the lingual to which intraoral areas may need a more focused evalua-
and are inferior to the mylohyoid muscle attachment, will tion. Any abnormality should be carefully examined for
either prevention or early treatment of associated patho-
sis.4,30,75,113,110,126 Swelling, localized lymphadenopathy, or
a sinus tract should provoke a more detailed assessment of
related and proximal intraoral structures.
Soft-Tissue Examination
As with any dental examination, there should be a routine
evaluation of the intraoral soft tissues. The gingiva and
mucosa should be dried with either a low-pressure air
syringe or a 2-by-2-inch gauze pad. By retracting the
tongue and cheek, all of the soft tissue should be examined
for abnormalities in color or texture. Any raised lesions or
ulcerations should be documented and, when necessary,
evaluated with a biopsy or referral.82
Intraoral Swelling
Fig. 1.6 Buccal space swelling associated with an acute periradicular Intraoral swellings should be visualized and palpated to
abscess from the mandibular left second molar.
determine whether they are diffuse or localized and whether
A B C
Fig. 1.7 A, Buccal space swelling of the left side of the patient’s face. Note the asymmetry of the left side of the face. B, Intraoral view of another patient
shows swelling present in the left posterior mucobuccal fold. C, This buccal space infection was associated with periradicular disease from the man-
dibular left first molar. Note on the radiograph the periradicular radiolucency and incomplete endodontic treatment. (B and C, Courtesy Dr. Jaydeep S.
Talim, Los Angeles, CA.)
1 • Diagnosis 11
A C
B
Fig. 1.10 A, Extraoral sinus tract opening onto the skin in the central chin area. B, Radiograph showing large radiolucency associated with the
mandibular incisors. C, A culture is obtained from the drainage of the extraoral sinus tract. D, The healed opening of the extraoral sinus tract 1 month
after root canal therapy was completed. Note the slight skin concavity in the area of the healed sinus tract.
Histologic studies have found that most sinus tracts are not
lined with epithelium throughout their entire length. One
study found that only 1 out of the 10 sinus tracts examined
were lined with epithelium, whereas the other 9 specimens
were lined with granulation tissue.55 Another study, with a
larger sample size, found that two thirds of the specimens did
not have epithelium extending beyond the level of the surface
mucosa rete ridges.12 The remaining specimens had some
epithelium that extended from the oral mucosa surface to the
periradicular lesion.12 The presence or absence of an epithe-
lial lining does not seem to prevent closure of the tract as long
as the source of the problem is properly diagnosed and ade-
quately treated and the endodontic lesion has healed. Failure
of a sinus tract to heal after treatment will necessitate further
diagnostic procedures to determine whether other sources of
infection are present or whether a misdiagnosis occurred.
Fig. 1.11 Fluctuant swelling in the anterior palate associated
with periradicular disease from the palatal root of the maxillary first In general, a periapical infection that has an associated
premolar. sinus tract is not painful, although often there is a history
of varying magnitudes of discomfort before sinus tract
1 • Diagnosis 13
clinician to the tooth involved and, more specifically, to the Once the disease state extends into the periodontal ligament
part of the root of the tooth that is the source of the patho- space, the pain may become more localized for the patient;
sis. Once the causative factors related to the formation of therefore, the affected tooth will be more identifiable with
the sinus tract are removed, the stoma and the sinus tract percussion and mastication testing.
will close within several days. Before percussing any teeth, the clinician should tell the
The stomata of intraoral sinus tracts may open in the patient what will transpire during this test. Because the
alveolar mucosa, in the attached gingiva, or through the presence of acute symptoms may create anxiety and possi-
furcation or gingival crevice. They may exit through either bly alter the patient’s response, properly preparing the pa-
the facial or the lingual tissues depending on the proximity tient will lead to more accurate results. The contralateral
of the root apices to the cortical bone. If the opening is tooth should first be tested as a control, as should several
in the gingival crevice, it is normally present as a narrow adjacent teeth that are certain to respond normally. The
defect in one or two isolated areas along the root surface. clinician should advise the patient that the sensation from
When a narrow defect is present, the differential diagnosis this tooth is normal and ask to be advised of any tenderness
must include the opening of a periradicular endodontic or pain from subsequent teeth.
lesion, a vertical root fracture, or the presence of a develop- Percussion is performed by tapping on the incisal or
mental groove on the root surface. This type of sinus tract occlusal surfaces of the teeth either with the finger or with
can be differentiated from a primary periodontal lesion a blunt instrument. The testing should initially be done
because the latter generally presents as a pocket with a gently, with light pressure being applied digitally with
broad coronal opening and more generalized alveolar bone a gloved finger tapping. If the patient cannot detect signifi-
loss around the root. Other pulp testing methods may assist cant difference between any of the teeth, the test should be
in verifying the source of infection.111,112,121 repeated using the blunt end of an instrument, like the
back end of a mirror handle (Fig. 1.15). The tooth crown is
Palpation tapped vertically and horizontally. The tooth should first be
In the course of the soft-tissue examination, the alveolar percussed occlusally, and if the patient discerns no differ-
hard tissues should also be palpated. Emphasis should be ence, the test should be repeated, percussing the buccal and
placed on detecting any soft-tissue swelling or bony expan- lingual aspects of the teeth. For any heightened responses,
sion, especially noting how it compares with and relates to the test should be repeated as necessary to determine that it
the adjacent and contralateral tissues. In addition to objec- is accurate and reproducible, and the information should be
tive findings, the clinician should question the patient about documented.
any areas that feel unusually sensitive during this palpation Although this test does not disclose the condition of the
part of the examination. pulp, it indicates the presence of a periradicular inflamma-
A palpation test is performed by applying firm digital pres- tion. An abnormal positive response indicates inflamma-
sure to the mucosa covering the roots and apices. The index tion of the periodontal ligament that may be of either
finger is used to press the mucosa against the underlying pulpal or periodontal origin. The sensitivity of the proprio-
cortical bone. This will detect the presence of periradicular ceptive fibers in an inflamed periodontal ligament will help
abnormalities or specific areas that produce painful response identify the location of the pain. This test should be done
to digital pressure. A positive response to palpation may indi- gently, especially in highly sensitive teeth. It should be
cate an active periradicular inflammatory process. However, repeated several times and compared with control teeth.
this test does not indicate whether the inflammatory process
is of endodontic or periodontal origin. Mobility
Like percussion testing, an increase in tooth mobility is not
Percussion an indication of pulp vitality. It is merely an indication of a
Referring back to the patient’s chief complaint may indi-
cate the importance of percussion testing for this particular
case. If the patient is experiencing acute sensitivity or pain
on mastication, this response can typically be duplicated by
individually percussing the teeth, which often isolates the
symptoms to a particular tooth. Pain to percussion does not
indicate that the tooth is vital or nonvital but is rather an
indication of inflammation in the periodontal ligament (i.e.,
symptomatic apical periodontitis). This inflammation may
be secondary to physical trauma, occlusal prematurities,
periodontal disease, or the extension of pulpal disease into
the periodontal ligament space. The indication of where the
pain originates is interpreted by the mesencephalic nucleus,
receiving its information from proprioceptive nerve recep-
tors. Although subject to debate, the general consensus is
that there are relatively few proprioceptors in the dental
pulp; however, they are prevalent in the periodontal liga-
ment spaces.24 This is why it may be difficult for the patient
to discriminate the location of dental pain in the earlier Fig. 1.15 Percussion testing of a tooth, using the back end of a mirror
handle.
stages of pathosis, when only the C fibers are stimulated.
1 • Diagnosis 15
compromised periodontal attachment apparatus. This com- the tooth, progressing in 1-mm increments. Periodontal
promise could be the result of acute or chronic physical bone loss that is wide, as determined by a wide span of deep
trauma, occlusal trauma, parafunctional habits, periodon- periodontal probing, is generally considered to be of peri-
tal disease, root fractures, rapid orthodontic movement, or odontal origin and is typically more generalized in other
the extension of pulpal disease, specifically an infection, into areas of the mouth. However, isolated areas of vertical bone
the periodontal ligament space. Tooth mobility is directly loss may be of an endodontic origin, specifically from a non-
proportional to the integrity of the attachment apparatus or vital tooth whose infection has extended from the periapex
to the extent of inflammation in the periodontal ligament. to the gingival sulcus. Again, proper pulp testing is impera-
Often the mobility reverses to normal after the initiating tive, not just for the determination of a diagnosis but also
factors are repaired or eliminated. Because determining for the development of an accurate prognosis assessment.
mobility by simple finger pressure can be visually subjective, For example, a periodontal pocket of endodontic origin may
the back ends of two mirror handles should be used, one on resolve after endodontic treatment, but if the tooth was
the buccal aspect and one on the lingual aspect of the tooth originally vital with an associated deep periodontal pocket,
(Fig. 1.16). Pressure is applied in a facial-lingual direction as endodontic treatment will not improve the periodontal con-
well as in a vertical direction and the tooth mobility is scored dition. In addition, as discussed in Chapter 22, a vertical
(Box 1.2). Any mobility that exceeds 11 should be consid- root fracture may often cause a localized narrow periodon-
ered abnormal. However, the teeth should be evaluated on tal pocket that extends deep down the root surface. Charac-
the basis of how mobile they are relative to the adjacent and teristically, the adjacent periodontium is usually within
contralateral teeth. normal limits.
Furcation bone loss can be secondary to periodontal or
Periodontal Examination pulpal disease. The amount of furcation bone loss, as
Periodontal probing is an important part of any intraoral observed both clinically and radiographically, should be
diagnosis. The measurement of periodontal pocket depth documented (Box 1.3). Results of pulp tests (described
is an indication of the depth of the gingival sulcus, which later) will aid in diagnosis.
corresponds to the distance between the height of the free
gingival margin and the height of the attachment appara- PULP TESTS
tus below. Using a calibrated periodontal probe, the clini-
cian should record the periodontal pocket depths on the Pulp test (pulp sensibility test) is a diagnostic procedure to
mesial, middle, and distal aspects of both the buccal and determine pulp status. It can be performed with electrical,
lingual sides of the tooth, noting the depths in millimeters. mechanical, or thermal stimuli, or by the assessment of the
The periodontal probe is “stepped” around the long axis of blood supply to the tooth.6 It involves attempting to make
a determination of the responsiveness of pulpal sensory
neurons.62,63 It aims to obtain a subjective response from
the patient (i.e., to determine whether the pulpal nerves
are functional), or the tests may involve a more objective
approach using devices that detect the integrity of the
pulpal vasculature. Unfortunately, the quantitative evalua-
tion of the status of pulp tissue can only be determined
histologically, as it has been shown that there is not neces-
sarily a good correlation between the objective clinical signs
and symptoms and the pulpal histology.122,123
Thermal
Various methods and materials have been used to test the
pulp’s response to thermal stimuli. The baseline or normal
response to either cold or hot is a patient’s report that a
sensation is felt but disappears immediately upon removal
of the thermal stimulus. Abnormal responses include a lack
of response to the stimulus, a lingering or intensification of
a painful sensation after the stimulus is removed, or an
immediate, excruciatingly painful sensation as soon as the
Fig. 1.16 Mobility testing of a tooth, using the back ends of two mirror
handles.
stimulus is placed on the tooth.
Cold testing is the primary pulp testing method used by cotton roll so the frozen CO2 will not come into contact with
many clinicians today. It is especially useful for patients pre- these structures. Because of the extremely cold tempera-
senting with porcelain jacket crowns or porcelain-fused-to- ture of the frozen CO2 (269°F to 2119°F; 256°C to
metal crowns where no natural tooth surface (or much 298°C), burns of the soft tissues can occur. It has been
metal) is accessible. If a clinician chooses to perform this test demonstrated on extracted teeth that frozen CO2 applica-
with sticks of ice, then the use of a rubber dam is recom- tion has resulted in a significantly greater intrapulpal tem-
mended, because melting ice will run onto adjacent teeth perature decrease than either skin refrigerant or ice.11 Also,
and gingiva, yielding potentially false-positive responses. it appears that the application of CO2 to teeth does not
Frozen carbon dioxide (CO2), also known as dry ice or result in any irreversible damage to the pulp tissues or
carbon dioxide snow, or CO2 stick, has been found to be reli- cause any significant enamel crazing.61,104
able in eliciting a positive response if vital pulp tissue is The most popular method of performing cold testing is
present in the tooth.46,98,99 One study found that vital teeth with a refrigerant spray. It is readily available, easy to use,
would respond to both frozen CO2 and skin refrigerant, with and provides test results that are reproducible, reliable, and
skin refrigerant producing a slightly quicker response.66 equivalent to that of frozen CO2.46,66,96,141 One of the cur-
Frozen carbon dioxide has also been found to be effective in rent products contains 1,1,1,2-tetrafluoroethane, which
evaluating the pulpal response in teeth with full coverage has zero ozone depletion potential and is environmentally
crowns for which other tests such as electric pulp testing is safe. It has a temperature of 226.2°C.66 The spray is most
not possible.11 For testing purposes, a solid stick of CO2 is effective for testing purposes when it is applied to the tooth
prepared by delivering CO2 gas into a specially designed on a large #2 cotton pellet (Fig. 1.18). In one study,65 a
plastic cylinder (Fig. 1.17). The resulting CO2 stick is significantly lower intrapulpal temperature was achieved
applied to the facial surface of either the natural tooth when a #2 cotton pellet was dipped or sprayed with the re-
structure or crown. Several teeth can be tested with a single frigerant compared with the result when a small #4 cotton
CO2 stick. The teeth should be isolated and the oral soft pellet or cotton applicator was used. The sprayed cotton
tissues should be protected with a 2-by-2-inch gauze or pellet should be applied to the midfacial area of the tooth
or crown. As with any other pulp testing method, adjacent
or contralateral “normal” teeth should also be tested to
establish a baseline response. It appears that frozen CO2 and
refrigerant spray are superior to other cold testing methods
and equivalent or superior to the electric pulp tester for as-
sessing pulp vitality.11,46 However, one study found that
periodontal attachment loss and gingival recession may
influence the reported pain response with cold stimuli.116
To be most reliable, cold testing should be used in con-
junction with an electric pulp tester (described later in this
chapter) so that the results from one test will verify the
findings of the other test. If a mature, nontraumatized
tooth does not respond to both cold testing and electric pulp
testing, then the pulp can be considered necrotic.23,98,141
However, a multirooted tooth, with at least one root con-
taining vital pulp tissue, may respond to a cold test and
electric pulp test even if one or more of the roots contain
necrotic pulp tissue.98
Another thermal testing method involves the use of heat.
A Heat testing is most useful when a patient’s chief complaint
is intense dental pain on contact with any hot liquid or
food. When a patient is unable to identify which tooth is
sensitive, a heat test is appropriate. Starting with the most
posterior tooth in that area of the mouth, each tooth is in-
dividually isolated with a dental dam. An irrigating syringe
is filled with a liquid (most commonly plain water) that has
a temperature similar to that which would cause the pain-
ful sensation. The liquid is then expressed from the syringe
onto the isolated tooth to determine whether the response
is normal or abnormal. The clinician moves forward in the
quadrant, isolating each individual tooth until the offend-
ing tooth is located. That tooth will exhibit an immediate,
intense painful response to the heat. With heat testing, a
B C
delayed response may occur, so waiting 10 seconds between
Fig. 1.17 A, Carbon dioxide tank with apparatus attached to form each heat test will allow sufficient time for the onset of
solid CO2 stick/pencil. B, CO2 gas being transformed into a solid stick/ symptoms. This method can also be used to apply cold
pencil. C, CO2 stick/pencil extruded from end of a plastic carrier and water to the entire crown for cases in which cold is the
ready for use.
precipitating stimulus.
1 • Diagnosis 17
B C
Fig. 1.18 A, Refrigerant spray container. B, A large cotton pellet made of a cotton roll, or a ready-made size #2 (large) cotton pellet, can be used to
apply the refrigerant spray to the tooth surface. The small #4 cotton pellet does not provide as much surface area as the #2 cotton pellet, and therefore
should not be used to deliver the refrigerant to the tooth surface. C, A large cotton pellet sprayed with the refrigerant and ready to be applied to the
tooth surface. (A, Courtesy Coltène/Whaledent, Cuyahoga Falls, OH.)
A B
C D
Fig. 1.23 Sometimes there is no clear indication of why a tooth is symptomatic. This radiograph shows a mandibular second molar with a moderately
deep restoration (A); the pulp tests nonvital. Without any transillumination, a fracture cannot be detected (B). However, by placing a high-intensity
light source on the tooth surface, a root fracture can be observed on the buccal surface (C) and the distal-lingual surface (D).
and testing, the radiograph alone can lead to a misinterpre- For standard two-dimensional radiography, clinicians
tation of normality and pathosis (Fig. 1.24). Because treat- basically project x-radiation through an object and cap-
ment planning will ultimately be based on the diagnosis, the ture the image on a recording medium, either x-ray film or
potential for inappropriate treatment may frequently exist a digital sensor. Much like casting a shadow from a light
if the radiograph alone is used for making final diagnosis. source, the image appearance may vary greatly depending
The clinician should not subject the patient to unnecessary on how the radiographic source is directed. Thus, the
multiple radiation exposures; two pretreatment images from three-dimensional interpretation of the resulting two-
different angulations are often sufficient. However, under dimensional image requires not only knowledge of nor-
extenuating circumstances—especially when the diagnosis mality and pathosis but also advanced knowledge of how
is difficult—additional exposures may be necessary to deter- the radiograph was exposed. By virtue of “casting a
mine the presence of multiple roots, multiple canals, resorp- shadow,” the anatomic features that are closest to the film
tive defects, caries, restoration defects, root fractures, and the (or sensor) will move the least when there is a change in
extent of root maturation and apical development. the horizontal or vertical angulation of the radiation
The radiographic appearance of endodontic pathosis can source (Fig. 1.25). This may be helpful in determining the
sometimes be highly subjective. In a study by Goldman and existence of additional roots, the location of pathosis, and
colleagues, there was only 50% agreement among inter- the unmasking of anatomic structures. Changes in the
preters for the radiographic presence of pathosis.49 When horizontal or vertical angulation may help elucidate valu-
the cases were reevaluated several months later, the same able anatomic and pathologic information; it also has the
evaluators agreed with their own original diagnosis less potential to hide important information. An incorrect ver-
than 85% of the time.50 This further emphasizes the neces- tical angulation may cause the buccal roots of a maxillary
sity for additional objective diagnostic tests, as well as the molar to be masked by the zygomatic arch. An incorrect
importance of obtaining and comparing older radiographs horizontal angulation may cause roots to overlap with
of the same area of the patient. the roots of adjacent teeth, or it may incorrectly create
22 PART I • The Core Science of Endodontics
Radiation
source Film or
A sensor
Radiation
source
Change
vertical Film or
B angulation sensor
Fig. 1.25 Radiographic images are only two-dimensional, and often it
is difficult to discriminate the relative location of overlapping objects.
A, When the source of radiation is directly perpendicular to overlap-
ping objects, the image is captured without much separation of the
Fig. 1.24 Radiograph showing what appears to be a mandibular lat- objects. However, when the radiation source is at an angle to offset the
eral incisor associated with periapical lesion of a nonvital tooth. Al- overlapping objects, the image is captured with the objects being
though pulp necrosis can be suspected, the tooth tested vital. In this viewed as separated. B, The object that is closest to the film (or sensor)
case, the appearance of apical bone loss is secondary to a cementoma. will move the least, with the object closest to the radiation source ap-
pearing farthest away.
the appearance of a one-rooted tooth, when two roots are is correlated with the relationship of the periapex of the
actually present. tooth and its juxtaposition to the cortical-cancellous bone
In general, when endodontic pathosis appears radio- junction. The apices of most anterior and premolar teeth
graphically, it appears as a radiolucency in the area of the are located close to the cortical-cancellous bone junction.
periapex. The pathosis may present merely as a widening or Therefore, periapical pathosis from these teeth is exhibited
break in the lamina dura—the most consistent radiographic sooner on the radiograph. By comparison, the distal roots
finding when a tooth is nonvital67—or it may present as a of mandibular first molars and both roots of mandibular
radiolucent area at the apex of the root or in the alveolar second molars are generally positioned more centrally
bone adjacent to the exit of a lateral or furcation accessory within the cancellous bone, as are maxillary molars, espe-
canal. On occasion no radiographic change can be seen at cially the palatal roots. Periapical lesions from these roots
all, even in the presence of a disease process in the alveolar must expand more before they reach the cortical-cancellous
bone. This is mainly due to the fact that the disease process bone junction and are recognized as radiographic pathosis.
did not reach the cortical plate of the bone. For these reasons, it is important not to exclude the possibil-
Two-dimensional dental radiography has two basic ity of pulpal pathosis in situations in which there are no ra-
shortcomings: the lack of early detection of pathosis in the diographic changes.
cancellous bone, because of the density of the cortical Many factors can influence the quality of the radio-
plates, and the influence of the superimposition of ana- graphic interpretation, including the ability of the person
tomic structures. Variability in the radiographic expression exposing the radiograph, the quality of the radiographic
of an osseous pathosis has much to do with the relative film, the quality of the exposure source, the quality of the
location of the root of the tooth and how it is oriented with film processing, and the skill with which the film is viewed.
respect to the cortical and cancellous bone. Radiographic Controlling all of these variables can be a difficult challenge
changes from bone loss will not be detected if the loss is only but is paramount for obtaining an accurate radiographic
in cancellous bone.16 However, the radiographic evidence interpretation.
of pathosis will be observed once this bone loss extends
to the junction of the cortical and cancellous bone. In addi- Digital Radiography
tion, certain teeth are more prone to exhibit radiographic Digital radiography has been available since the late 1980s
changes than others, depending on their anatomic loca- and has recently been refined and popularized with better
tion.17 The radiographic appearance of endodontic pathosis hardware and a more user-friendly interface. It has the
1 • Diagnosis 23
ability to capture, view, magnify, enhance, and store radio- The diagnostic quality of this technology has been shown
graphic images in an easily reproducible format that does to be comparable to conventional film-based radiogra-
not degrade over time. Significant advantages of digital phy.39,73,97 The interpretation of a digital radiograph can
radiographs over conventional radiographs include lower be subjective, similar to that of the conventional film.134
radiation doses, instant viewing, convenient manipula- Factors that appear to have the most impact on the inter-
tion, efficient transmission of an image via the Internet, pretation of the image are the years of experience of the
simple duplication, and easy archiving. examiner and familiarity of the operator with the given
Digital radiography uses no x-ray film and requires no digital system.134
chemical processing. Instead, a sensor is used to capture
the image created by the radiation source. This sensor is Cone-Beam Computerized Tomography
either directly or wirelessly attached to a local computer, Limitations in conventional two-dimensional radiography
which interprets this signal and, using specialized soft- promulgated a need for three-dimensional imaging, known
ware, translates the signal into a two-dimensional digital as cone-beam computerized tomography (CBCT) (also known
image that can be displayed, enhanced, and analyzed. The as cone-beam volumetric tomography [CBVT]) or as cone-beam
image is stored in the patient’s file, typically in a dedicated volumetric imaging [CBVI]. Although a form of this technol-
network server, and can be recalled as needed. Further ogy has existed since the early 1980s,106 specific devices for
information about digital radiography may be found in dental use first appeared almost two decades later.90 Most
Chapter 2. of these machines are similar to a dental panoramic radio-
The viewing of a digital radiographic image on a high- graphic device, whereby the patient stands or sits as a
resolution monitor allows for rapid and easy interpretation cone-shaped radiographic beam is directed to the target
for both the clinician and the patient. The image appears area with a reciprocating capturing sensor on the opposite
almost instantly, with no potential for image distortion side (Fig. 1.27). The resulting information is digitally recon-
from improper chemical processing. The clinician can structed and interpreted to create an interface whereby
magnify different areas on the radiograph and then digi- the clinician can three-dimensionally interpret “slices” of
tally enhance the image in order to better visualize certain the patient’s tissues in a multitude of planes (Figs. 1.28
anatomic structures; in some cases, the image can even and 1.29).37,33 The survey of the scans can be interpreted
be colorized, which is a useful tool for patient education immediately after the scan. Various software applications
(Fig. 1.26). have been used to enable the images to be sent to other
In the past, x-ray film has had a slightly better resolution clinicians. This is accomplished either in printed format or
than most digital radiography images, at about 16 line with portable and transferable software that can be used
pairs per millimeter (lp/mm).87 However, current sensors interactively by another clinician.
offer resolutions beyond that of conventional film. Under In general, many dental applications only require a
the best of circumstances, the human eye can see only limited field of vision, confining the study to the maxilla
about 10 lp/mm, which is the lowest resolution for most and mandible. However, many devices have the ability to
dental digital radiography systems. Digital sensors are
much more sensitive to radiation than conventional x-ray
film and thus require 50% to 90% less radiation in order to
acquire an image, an important feature for generating
greater patient acceptance of dental radiographs.
80 mm
Voxel size
0.16 mm
0.08 mm
0.08 mm
0.16 mm
0.16 mm 0.08 mm
Fig. 1.29 Cone-beam volumetric tomography has the advantage of
being able to detect pathosis in the bone or associated with the teeth Fig. 1.30 The radiation source in cone-beam volumetric tomography is
without the obstruction of anatomic structures. The planes of vision conical. The receiving sensor captures the image as “voxels,” or three-
may be axial, sagittal, or coronal. (Courtesy J. Morita USA, Irvine, CA.) dimensional pixels of information, allowing digital interpretation.
provide a full field of vision for viewing more regional struc- and providing for a more accurate interpretation of ana-
tures. Clinicians should thoroughly understand the ethical tomic structures and pathologic conditions. The develop-
and medical-legal ramifications of doing scans with full ment of limited field of vision devices has also contributed
fields of view. Incidental nondental findings have been seen to decreasing the radiation and cost of these machines,
from these scans, such as intracranial aneurysms, which, making them more practical for endodontic use.41
when undetected, could be life threatening.91 Compared with two-dimensional radiographs, CBCT can
The radiation source of CBCT is different from that of clearly visualize the interior of the cancellous bone without
conventional two-dimensional dental imaging in that the the superimposition of the cortical bone. Studies show that
radiation beam created is conical in shape. Also, conven- CBCT is much more predictable and efficient in demonstrat-
tional digital dental radiography is captured and inter- ing anatomic landmarks, bone density, bone loss, periapical
preted as pixels, a series of dots that collectively produces lesions, root fractures, root perforations, and root resorpti
an image of the scanned structure. For CBCT, the image is ons.1,21,26,27,38,47,71,78,81,85,92,94,128,131,142
instead captured as a series of three-dimensional pixels, The superimposition of anatomic structures can also
known as voxels. Combining these voxels gives a three- mask the interpretation of alveolar defects. Specifically, the
dimensional image that can be “sliced” into various planes, maxillary sinus, zygoma, incisive canal and foramen, nasal
allowing for specific evaluations without a necropsy bone, orbit, mandibular oblique ridge, mental foramen,
(Fig. 1.30). One of the advantages of using a device that mandibular mentalis, sublingual salivary glands, tori, and
has a limited field of vision is that the voxel size can be less the overlap of adjacent roots may either obscure bone loss
than half that of a device using a full field of vision, or mimic bone loss, making an accurate interpretation of
thereby increasing the resolution of the resulting image conventional radiography sometimes difficult or impossible.
1 • Diagnosis 25
Several studies have demonstrated the advantages of CBCT line may directly alter the prognosis assessment for a given
in the differential diagnosis of such structures from patho- tooth and should be examined before treatment decision
logic conditions.21,29,71,137 making. Certain types of cracks may be as innocent as a
CBCT should not be seen as a replacement for conven- superficial enamel craze line, or they may be as prominent
tional dental radiography, but rather as a diagnostic ad- as a fractured cusp. The crack may progress into the root
junct. The advantage of conventional dental radiography is system to involve the pulp, or it may split the entire tooth
that it can visualize most of the structures in one image. into two separate segments. The crack may be oblique, ex-
CBCT can show great detail in many planes of vision but tending cervically, such that once the coronal segment is
can also leave out important details if the “slice” is not in removed the tooth may or may not be restorable. Any of
the area of existing pathosis (Fig. 1.31). There is a promis- these situations may present with mild, moderate, or severe
ing future for the use of CBCT for endodontic diagnosis and symptoms or possibly no symptoms at all.
treatment. It has already proven invaluable in the detection
of dental and nondental pathoses (Fig. 1.32). For a further Crack Types
review of CBCT and radiography, see Chapter 2. There have been many suggestions in the literature of how
to classify cracks in teeth. By defining the type of crack
Magnetic Resonance Imaging present, an assessment of the prognosis may be determined
Magnetic resonance imaging (MRI) has also been suggested and treatment alternatives can be planned. Unfortunately,
for dental diagnosis. It may offer simultaneous three- it is often extremely difficult to determine how extensive a
dimensional hard- and soft-tissue imaging of teeth without crack is until the tooth is extracted.
ionizing radiation.58 The use of MRI in endodontics is still Cracks in teeth can be divided into three basic categories:
limited. n Craze lines
n Fractures (also referred to as cracks)
CRACKS AND FRACTURES n Split tooth/roots
The wide variety of types of cracks and fractures in teeth Craze lines are merely cracks in the enamel that do not
and their associated signs and symptoms often make their extend into the dentin and either occur naturally or develop
diagnosis difficult. The extensiveness of the crack or fracture after trauma. They are more prevalent in adult teeth and
B
Fig. 1.31 A, This standard two-dimensional radiographic image reveals recurrent caries under the mesial margin of the maxillary first molar. However,
the patient localized pain to mastication on the maxillary second molar. B, Cone-beam volumetric tomography revealed an apical radiolucency associ-
ated with the maxillary second molar. The bone loss was obscured on the two-dimensional radiograph by the maxillary sinus, zygoma, and cortical
bone.
26 PART I • The Core Science of Endodontics
A C
D E
Fig. 1.33 Poorly fitting intracoronal restorations can place stresses within the tooth that can cause a vertical root fracture. A, This radiograph of a
mandibular second premolar (with a gold inlay) reveals extensive periapical and periradicular bone loss, especially on the distal aspect. B, The tooth
pulp tested nonvital, and there was an associated 12-mm-deep, narrow, isolated periodontal pocket on the buccal aspect of the tooth. After the tooth
was extracted, the distal aspect was examined. C, On magnification (316) the distal aspect of the root revealed an oblique vertical root fracture. Simi-
larly, the placement of an ill-fitting post may exert intraradicular stresses on a root that can cause a fracture to occur vertically. D, This radiograph
depicts a symmetrical space between the obturation and the canal wall, suggesting a vertical root fracture. E, After the tooth is extracted, the root
fracture can be easily observed.
these vertical root fractures may be difficult, they often be able to make a prediction as to the eventual potential of
go unrecognized. Therefore, diagnosing the existence and healing, and convey this information to the patient. A more
extent of a vertical root fracture is imperative before any detailed discussion on vertical root fractures is described in
restorative or endodontic treatment is done, as it can Chapter 22.
dramatically affect the overall success of treatment.
A patient who consents to endodontic treatment must be PERFORATIONS
informed if the tooth has a questionable prognosis. The cli-
nician must be able to interpret the subjective and objective Root perforations are clinical complications that may
findings that suggest a vertical root fracture or split tooth, lead to treatment failure. When root perforation occurs,
28 PART I • The Core Science of Endodontics
PULPAL DISEASE
Normal Pulp
This is a clinical diagnostic category in which the pulp is
symptom-free and normally responsive to pulp testing.6
Teeth with normal pulp do not usually exhibit any sponta-
neous symptoms. The symptoms produced from pulp tests
are mild, do not cause the patient distress, and result in a
transient sensation that resolves in seconds. Radiographi-
cally, there may be varying degrees of pulpal calcification
but no evidence of resorption, caries, or mechanical pulp
exposure. No endodontic treatment is indicated for these
teeth.
Pulpitis
This is a clinical and histologic term denoting inflammation
of the dental pulp, clinically described as reversible or
irreversible and histologically described as acute, chronic,
or hyperplastic.6
Reversible Pulpitis
Fig. 1.34 Physical trauma from sports-related injuries or seizure- This is a clinical diagnosis based on subjective and objec-
induced trauma, if directed accordingly, may cause a vertical root frac- tive findings indicating that the inflammation should re-
ture in a tooth. This fracture occurred in a 7-year-old child secondary to solve and the pulp return to normal.6 When the pulp
trauma from a grand mal seizure.
within the tooth is irritated so that the stimulation is un-
comfortable to the patient but reverses quickly after irrita-
tion, it is classified as reversible pulpitis. Causative factors
communications between the root canal system and either include caries, exposed dentin, recent dental treatment,
periradicular tissues or the oral cavity may reduce the prog- and defective restorations. Conservative removal of the ir-
nosis of treatment. Root perforations may result from exten- ritant will resolve the symptoms. Confusion can occur
sive carious lesions, resorption, or operator error occurring when there is exposed dentin, without evidence of pulp
during root canal instrumentation or post preparation. pathosis, which can sometimes respond with sharp, quickly
The treatment prognosis of root perforations depends on reversible pain when subjected to thermal, evaporative,
the size, location, time of diagnosis and treatment, degree tactile, mechanical, osmotic, or chemical stimuli. This is
of periodontal damage, as well as the sealing ability and known as dentin (or dentinal) sensitivity (or hypersensitivity).
biocompatibility of the repair material.45 It has been recog- Exposed dentin in the cervical area of the tooth accounts
nized that treatment success depends mainly on immediate for most of the cases diagnosed as dentin sensitivity.103
sealing of the perforation and appropriate infection control. As described in Chapter 14, fluid movement within
Among the materials that are commonly used to seal root dentinal tubules can stimulate the odontoblasts and
perforations are mineral trioxide aggregate (MTA), super associated fast-conducting A-delta nerve fibers in the
ethoxybenzoic acid (EBA) cement, intermediate restorative pulp, which in turn produce sharp, quickly reversible
material (IRM), glass ionomer cements, and composites. dental pain (Fig. 1.35). The more open these tubules are
The topic of perforations is further discussed in Chapter 20. (e.g., from a newly exposed preparation, dentin decalcifi-
cation, periodontal scaling, tooth-bleaching materials, or
coronal tooth fractures), the more the tubule fluid will
Clinical Classification of Pulpal move and, subsequently, the more the tooth will display
and Periapical Diseases dentin sensitivity when stimulated. When making a diag-
nosis, it is important to discriminate this dentin sensitivity
Many attempts have been made over the years to develop sensation from that of reversible pulpitis, which would be
classifications of pulpal and periapical disease. However, secondary to caries, trauma, or new or defective restora-
studies have shown that making a correlation between tions. Detailed questioning about recent dental treatment
clinical signs and symptoms and the histopathology of a and a thorough clinical and radiographic examination
given clinical condition is challenging.122,123 Therefore will help to separate dentin sensitivity from other pulpal
clinical classifications have been developed in order to for- pathosis, as the treatment modalities for each are com-
mulate treatment plan options. In the most general terms, pletely different.18
1 • Diagnosis 29
treatment. After all the testing procedures are complete and 9. Andreasen JO, Ahrensburg SS, Tsillingaridis G: Root fractures: the
influence of type of healing and location of fracture on tooth sur-
if it is determined that the pain is not of odontogenic origin, vival rates: an analysis of 492 cases, Dent Traumatol 28:404, 2012.
then the patient should be referred to an orofacial pain 10. Arakawa S, Cobb CM, Rapley JW, et al: Treatment of root fracture
clinic for further testing. For further information on pain of by CO2 and Nd:YAG lasers: an in vitro study, J Endod 22:662,
nonodontogenic origin, see Chapter 4. 1996.
11. Augsburger RA, Peters DD: In vitro effects of ice, skin refrigerant,
and CO2 snow on intrapulpal temperature, J Endod 7:110, 1981.
12. Baumgartner JC, Picket AB, Muller JT: Microscopic examination of
Summary oral sinus tracts and their associated periapical lesions, J Endod
10:146, 1984.
Endodontics is a multifaceted specialty, with much empha- 13. Beltes C, Zachou E: Endodontic management in a patient with vita-
min D-resistant rickets, J Endod 38:255, 2012.
sis on how cases are clinically treated. Clinicians have in- 14. Bender IB: Pulpal pain diagnosis: a review, J Endod 26:175, 2000.
creased their ability to more accurately perform endodontic 15. Bender IB, Landau MA, Fonsecca S, et al: The optimum placement-
procedures by way of increased visualization using the op- site of the electrode in electric pulp testing of the 12 anterior teeth,
erating microscope, precise apical foramen detection using J Am Dent Assoc 118:305, 1989.
16. Bender IB, Seltzer S: Roentgenographic and direct observation of
electronic apex locators, enhanced imaging techniques us- experimental lesions in bone. Part I, J Am Dent Assoc 62:152, 1961.
ing digital radiography, three-dimensional imaging, and 17. Bender IB, Seltzer S: Roentgenographic and direct observation of
more. Practices have incorporated more refined canal experimental lesions in bone. Part II, J Am Dent Assoc 62:708, 1961.
cleaning and shaping techniques by using ultrasonics and 18. Berman LH: Dentinal sensation and hypersensitivity: a review of
rotary-driven nickel titanium files facilitated with com- mechanisms and treatment alternatives, J Periodontol 56:216,
1984.
puter-assisted electronic handpieces. Many other advance- 19. Berman LH, Kuttler S: Fracture necrosis: diagnosis, prognosis assess-
ments also have been introduced with the objective of ment, and treatment recommendations, J Endod 36:442, 2010.
achieving an optimal result during endodontic treatment. 20. Bierma MK, McClanahan S, Baisden MK, et al: Comparison of
However, these advancements are useless if an incorrect heat-testing methodology, J Endod 38:1106, 2012.
21. Bornstein MM, Lauber R, Sendi P, et al: Comparison of periapical
diagnosis is made. Before the clinician ever considers per- radiography and limited cone-beam computed tomography in man-
forming any endodontic treatment, the following questions dibular molars for analysis of anatomical landmarks before apical
must be answered: surgery, J Endod 37:151, 2011.
22. Cameron CE: The cracked tooth syndrome: additional findings,
n Is the existing problem of dental origin? J Am Dent Assoc 93:971, 1981.
n Are the pulpal tissues within the tooth pathologically 23. Chen E, Abbottt PV: Evaluation of accuracy, reliability, and repeat-
involved? ability of five dental pulp tests, J Endod 37:1619, 2011.
24. Chiego DJ, Cox CF, Avery JK: H-3 HRP analysis of the nerve supply
n Why is the pulpal pathosis present? to primate teeth, Dent Res 59:736, 1980.
n What is the prognosis? 25. Cleveland JL, Gooch BF, Shearer BG, et al: Risk and prevention of
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Testing, questioning, and reasoning are combined to fracture with small-volume cone-beam computed tomography in the
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[13] Andeli-sur-Seine,—three leagues from Mantes.
[14] Pont St Pierre,—four leagues from Andeli.
[15] Harcourt,—ten leagues from Rouen, near Brionne.
[16] La Roche-Guyon,—a market-town in Normandy, three
leagues from Mantes.
CHAP. VII.
THE COUNTS OF EU AND OF ST POL TAKE BY
STORM THE NEW CASTLE OF NICORPS[17].—THE
CASTLE SURRENDERS ON TERMS.—THE COUNT DE
DUNOIS GAINS THE CASTLE OF HARCOURT.
About the middle of September, it was resolved, in the councils held
at Louviers, that, considering the great body of french chivalry, it
would be necessary to form two divisions: the one under the
command of Charles d'Artois count of Eu, Louis de Luxembourg
count of St Pol, and other captains, having with them from three to
four thousand combatants, were ordered to besiege the new castle
of Nicorps, which was held by the captain, Adam Illeton[18], an
Englishman. The french army came before it on Tuesday the 12th
day of September, and took the town by storm on the following
Thursday. The castle was then besieged,—and surrendered on
capitulation fifteen days afterward.
The other division was under the command of the count de Dunois,
lieutenant-general, having with him the counts de Clermont and de
Nevers, with four thousand veteran soldiers. On leaving Louviers,
they marched to lay siege to the castle of Chambrais[19] on the 18th
of September, of which an Englishman, called William Crinton[20],
was governor, and had under him two hundred men for its defence.
After seven days siege, it surrendered on capitulation with the count
de Clermont,—and thus was it restored to the obedience of the king
of France.
Without losing time, the lieutenant-general marched his army before
the castle of Harcourt, which is handsome and strong. It was
governed by sir Richard Frongueval[21], an Englishman, having
under him about eight score of his countrymen. The siege lasted
about fifteen days, with daily skirmishes with the garrison. Great
advances were made, in which a very valiant man at arms from the
garrison of Louviers was killed by a cannon-shot,—and an
Englishman lost his life by the shot of a culverine, on the portal of the
lower court.
A mutiny now took place in the garrison, when the governor was
disgraced, and hung by his feet under the gate,—when the French,
taking advantage of it, played their cannon so well that they greatly
damaged the walls of the lower court. The English, fearful of
consequences, entered into a capitulation to surrender, if they should
not, on the ensuing Friday, be in force to meet them in the field, and
gave hostages for the performance. When the day arrived, not
receiving any succours, they yielded up the place.
While these armies were thus employed, the english garrison of the
town and castle of Essay[22] made an excursion to fish a pond at
some distance,—which coming to the knowledge of the duke
d'Alençon, he instantly ordered his men to mount, and marched, as
secretly as he could, to cut off their retreat. He succeeded in making
the whole prisoners, and, carrying them to Essay, forced them to
deliver up the town and castle, on pain of losing their heads.
The french garrison in Dieppe, knowing that there was but a small
garrison in Fecamp, which is a sea-port, marched thither secretly,
and won it by storm.
Shortly after, arrived a vessel from England, having on board ninety-
seven soldiers to garrison the abbey, supposing it still to belong to
king Henry, whom the French suffered to land without opposition, but
instantly afterwards took them all prisoners.
FOOTNOTES:
[17] Nicorps,—a village in Normandy, diocese and election of
Coutances.
[18] Adam Illeton. Q. Elton, or Hilson?
[19] Chambrais,—a market-town in Normandy, 13 leagues from
Evreux.
[20] W. Crinton. Q. Clinton?
[21] Sir Richard Frongueval. Q.
[22] Essay,—a market-town in Normandy, five leagues from
Alençon, two from Sées.
CHAP. VIII.
THE DUKE OF BRITTANY AND THE CONSTABLE OF
FRANCE ENTER NORMANDY WITH A GREAT ARMY,
AND LAY SIEGE TO ST LO[23], WHICH SURRENDERS
TO THEM, AS DO MANY OTHER SMALL PLACES.—
THE TOWN OF CARENTAN[24] SURRENDERS ALSO.
About the same period of this year, the duke of Brittany, his brother
the count de Richemont, constable of France, with other nobles and
men at arms from his duchy, amounting to a thousand or twelve
hundred lances, entered lower Normandy, to restore it to the
obedience of the king of France from the dominion of the English
(the ancient enemies of the realm), who had usurped the
government of it for nearly thirty-two years. They first advanced to
the town of Mont St Michel[25]; and the nobles and men at arms were
quartered in the villages of upper and lower Les Pas[26], Courtis[27],
St George en Gaine, Postulbanch, and thereabouts.
The duke, on quitting Brittany, had left his brother, the lord Peter, on
the frontiers, near to Fougeres and Avranches, for their defence, with
three hundred lances. On the morrow, the duke and the constable
formed their van-guard under the command of sir James de
Luxembourg, lieutenant to the constable, the marshal and admiral of
France, of five hundred spears, who that day marched to
Coutances[28], and lay before it,—while the duke and the main army,
consisting of five or six hundred lances, remained that night in and
about Granville[29]. On the morrow, the constable advanced the main
army toward Coutances, and halted opposite to the hospital; but they
were not there a day before the English in the town marched away,
and the inhabitants continued in the same peaceful state as before
this renewal of war.
The duke of Brittany next marched to lay siege to St Lo, and ordered
his van to advance and take up their quarters on one side of the
town,—while he followed with the army on the next day, and posted
himself on the opposite side. Sir William de Poitou commanded in
the place, with a garrison of two hundred men,—but notwithstanding
these numbers, he made no resistance, but capitulated with the duke
for its surrender, on being allowed to march away with his men
whither he should please. The duke and the constable, during their
stay at St Lo, won the following towns, villages and castles, namely,
le Hommet[30], Neufville[31], Torigny[32], Beuseville[33], Hambie[34],
La Motte l'Evêque[35], la Haye-du-Puy[36], Chanteloup[37],
L'Aunay[38], and many other small places round St Lo, in which city,
as well as in those captured places, strong garrisons were posted.
The van was now detached to the town of Carentan, and followed by
the main body; but the garrison held out only three days before they
surrendered, and then marched away with staves in their hands,—
and those in the town were reinstated in their possessions.
The marshal and the admiral of France now separated from the duke
and the constable, and came before Pont d'Oue[39], which having
taken by storm, they overran all the country of Coutantin, without
meeting any resistance. The government of it and Carentan was
given to Joachim Rohault. From Carentan, the above lords returned
to Coutances, and thence, in the month of October, detached a party
to Gavrey[40]. On the morrow, the duke and the constable came to
Coutances, where the duke staid that day, and before the constable
could arrive at Gavrey, the bulwark had been won by storm; and on
the morrow, sir Geoffry de Couvren, who directed the siege, having
made great approaches by his mines, attacked the castle with such
vigour that the english garrison, of about six score men, demanded a
parley, and concluded a treaty with the constable for its surrender, on
being allowed to march away in safety with their effects.
FOOTNOTES:
[23] St Lo,—a city of Normandy, on the Vire.
[24] Carentan, a town in Normandy, three leagues from the sea-
coast.
[25] Mont St Michel,—a strong town in Normandy, built on a rock,
and surrounded by the sea at high water.
[26] Les Pas,—a village in Normandy, diocese of Avranches.
[27] Les Courtis,—a village in Normandy, diocese of Avranches.
[28] Coutances,—capital of the Coutantin, two leagues from the
sea.
[29] Granville,—a sea-port in Normandy, six leagues from
Coutances.
[30] Le Hommet,—a small town near St Lo.
[31] Neufville,—a village near Alençon.
[32] Torigny,—three leagues from Coutances.
[33] Beuseville, a village in Normandy.
[34] Hambie,—a market-town near Coutances.
[35] La Motte-l'Evêque,—a barony and castle near St Lo.
[36] La Haye-du-Puy,—a market-town near Coutances.
[37] Chanteloup,—a village near Coutances.
[38] L'Aunay,—a village.
[39] Pont d'Oue. Q. Pont d'Ouilly? a market-town in Normandy, on
the Vire.
[40] Gavrey,—a town on the Seine, four leagues from Coutances.
CHAP. IX.
THE DUKE OF ALENÇON CONQUERS HIS TOWN OF
ALENÇON[41].—THE COUNT DE FOIX GAINS THE
TOWN AND CASTLE OF MAULÉON[42].—THE COUNT
DE DUNOIS TAKES ARGENTAN[43].—THE ENGLISH
RETIRE INTO THE KEEP OF THE CASTLE, AND, ON
SURRENDERING IT, MARCH AWAY WITH ONLY
STAVES IN THEIR HANDS.
The duke of Alençon, in consequence of intelligence with friends in
Alençon, advanced thither by day-break, and by their means was
admitted into the town. The english garrison retreated to the castle,
which was instantly surrounded by the duke, who had with him eight
hundred lances besides archers. There were numbers of English in
the place,—but their hearts failed them, for they made little
resistance, and surrendered the town to the duke, whose inheritance
it was. Sir Louis de Beaumont, governor of Mans, had come to his
assistance with sixty lances, and archers in proportion. During this
time, the king of France was at Louviers.
About this same period, namely, the latter end of September, the
count de Foix accompanied by the counts de Comminges,
d'Estract[44], the viscount de Lautrec his brother, and many other
knights, barons, and esquires from the counties of Foix, Comminges,
Estract, Bigorre and Béarn, to the amount of five or six hundred
lances and two thousand cross-bows, marched from his country of
Béarn through that of the Basques[45], until he came before the town
of Mauléon de Soule, to which he laid siege. The inhabitants,
perceiving such numbers, were afraid of the consequences, should
the siege be pushed to extremities, and capitulated to surrender, on
condition that no harm should be done to them.
Upon this, the english garrison retreated into the castle, which is the
strongest in all the duchy of Guienne, and is seated on a high rock.
But the count de Foix, learning that it was badly provided with stores
and provision, surrounded it with his troops on all sides; and this
coming to the knowledge of the king of Navarre, he instantly issued
his summons for the relief of the English, and marched six thousand
Navarrois, Arragonians, Gascons and English, to within two leagues
of it, to raise the siege. Finding the enemy so strongly intrenched,
and so numerous, he retreated, and sent messengers to the count to
say that he was desirous of having a conference with him, if he
would send passports for himself and what company he might
please to bring with him.
The king of Navarre, on receiving the passports, advanced with a
small company to within a quarter of a league of the count's army,
where he was waiting for him; when, after the usual salutations from
the count, (who had married the king of Navarre's daughter, and had
a beautiful family) the king said that he was much astonished,
considering how nearly they were connected together, that he had
besieged a place under his protection, his constable being governor
for the king of England, to whom he had promised to defend it
against all his enemies. The count good-humouredly replied (paying
at the same time all honour and respect), that he was lieutenant-
general for the king of France of all the countries between the river
Gironde and the mountains: he was, likewise, a relation and subject
to the king of France, and it was by his command that he had taken
the town and besieged the castle; and to preserve his honour
unspotted, and that no blame might ever be cast on him by any of
his family, he would never raise the siege until the place was
reduced to the obedience of the king of France, unless he should be
fought withal and conquered; that in every other respect he would
assist and serve the king of Navarre, the father of his wife, against all
persons whatever, excepting the king of France, his subjects and
allies, and all things appertaining to the crown of France. Upon this,
the king of Navarre returned with the troops to his own country.
The garrison in the castle, finding they had no hopes of succour, and
knowing their scarcity of provisions, surrendered it on capitulation,—
and thus was the castle restored to the obedience of the king of
France. Shortly after, the lord de Luce[46], attended by six hundred
combatants, all wearing red crosses, came and did homage to the
king of France in the hands of his lieutenant-general for the town and
castle of Mauléon, which was his inheritance. After he had taken the
oaths, he and his company returned to his mansion, wearing white
crosses, to the great astonishment of all the men, women and
children, of his country. When this had been done, the count de Foix
marched his army back to Béarn, having left a sufficient garrison in
the town and castle of Mauléon.
On the 27th of September, the lord de Blainville came with a large
force of men at arms before the castle of Toucques, strongly situated
on a rock close to the sea, and having an english garrison of sixty
men. On seeing so large a body, they did not attempt resistance, but
surrendered on having their lives and fortunes spared, and being
allowed to march in safety whither they pleased.
On the last day of this month, the counts de Dunois and de Nevers
laid siege to the castle of Yemmes[47], which the English instantly
surrendered on similar terms.
The count de Dunois then marched his army to besiege the town
and castle of Argentan. The English opened a parley, although they
had not any intentions to surrender; but when the townsmen saw
that they were only laughing at the French by these pretended
parleys, and knew their intention of holding out to the last, and that
what they were saying to the French was the farthest from their
thoughts, they called some of their countrymen aside, and bade
them have no more parleys with the English, for that they would hold
out as long as they could. At the same time, they asked for a banner
or pennon, which they would display from a certain part of the walls,
—and that when they should see it they should advance thither with
courage, and they would admit them into the town, which was done.
The English, perceiving themselves betrayed, retreated into the
castle; but a large bombard was instantly pointed against the walls,
and made a breach wide enough for a cart to pass. The French, on
this success, attacked the castle, and entered the breach,—but the
English retired into the dungeon, which they soon surrendered,
fearing to be taken by storm; and although they demanded a
capitulation, they were marched away with only staves in their
hands.
FOOTNOTES:
[41] Alençon,—a handsome city in lower Normandy, 47 leagues
from Paris.
[42] Mauléon. Q. Mauléon de Soule? a town in Gascony, eight
leagues from Pau.
[43] Argentan,—seven leagues and a half from Alençon.
[44] D'Estract. In the MS. from Du Cange's copy, it is changed to
d'Estrar. I suspect that it ought to be de la Trane; for the souldich
de la Trane was of that country, and one of Edward the IIId's great
captains. He is frequently mentioned by Froissart.
[45] Basques,—a small country near the Pyrenées, surrounded
by Spain, the ocean, Béarn and the river Adour.
[46] De Luce. Luxe.——MS. Du Cange.
[47] Yemmes. Q. if not Yesme, a village in Maine?
CHAP. X.
THE KING OF SICILY WAITS ON THE KING OF
FRANCE AT LOUVIERS.—FRESNOY[48] SURRENDERS
TO THE DUKE OF ALENÇON.—GISORS[49]
CAPITULATES.—THE CASTLE OF GALLON[50] IS
BESIEGED.
At this season, the king of Sicily came to the king of France at
Louviers, where he was very joyfully received. He had with him his
brother the count du Maine, and a long train of nobles, knights and
esquires, whose names it would be tedious to relate, to the number
of more than two hundred lances, and archers, without including
those from the army of the duke d'Alençon, the duke of Brittany, the
count de Dunois lieutenant-general, the count de Clermont, nor
those of the count d'Eu, or of the count de St Pol, who all had with
them very many men of note.
The king, seeing such a numerous and well appointed body of
chivalry, resolved to pursue with vigour the conquest of the whole
duchy of Normandy, and began his operations by ordering siege to
be laid to the castle of Gallon. This castle was very strong, and
impregnable but by famine,—for it was seated on a rock near to the
Seine, out of cannon-shot, and could not any way be won, so long as
provision for the garrison should last. The command of the siege was
given to the seneschal of Poitou and others, who pushed their
approaches toward it with great activity. The king went thither in
person.
In the mean while, the duke of Alençon laid siege to the town and
castle of Fresnoy, wherein were many English; but they made no
opposition to the prosperity of the king's affairs, and surrendered on
capitulation.
During the siege of Gallon, and about three or four days before its
surrender, sir Richard de Merbury, an english knight and governor of
Gisors, agreed to terms of capitulation with the brother of his wife, for
its surrender on the 17th day of October following. In fact, the
governor turned to the french interest, and took the oaths of
allegiance, on condition that two of his sons, John and Hemond, who
had been made prisoners at the capture of Pont-Audemer, should be
restored to him without ransom; and also that he should enjoy
unmolested the lands of his wife, which were now held by the
French, whether by gift from the king or otherwise. At the
solicitations of his wife's relations, the king granted his requests,—
and, in expectation of the services that he looked to from him and his
children, he also made him governor of St Germain en Laye, and
gave him, for his life only, all the profits and emoluments arising from
this government.
The king appointed, as governor of Gisors, the lord de Gaucourt,
who had long laboured in his majesty's service: and considering his
great age, of four score years and upwards, he had lately acquired
very great honour.
FOOTNOTES:
[48] Fresnoy,—a village in Normandy.
[49] Gisors,—a city in Normandy, capital of Vexin-Normand.
[50] Gallon,—10 leagues from Rouen, about a league from the
Seine.
CHAP. XI.
THE KING OF FRANCE ORDERS THE COUNTS DE
DUNOIS, D'EU, AND DE ST POL TO JOIN HIM, AS HE
INTENDED TO MARCH TO ROUEN, WHENCE, AFTER
REMAINING THREE DAYS HE RETURNS.—SOME OF
THE INHABITANTS OF ROUEN ARE NEAR
DELIVERING UP THE CITY TO HIM.—THE DUKE OF
BRITTANY BESIEGES FOUGERES.—CONDE IS
TAKEN.
In the month of October, the king of France ordered the count de
Dunois, and the lords in his company who had subdued Argentan, to
join him: and likewise the counts d'Eu and de St Pol; for it was his
intention to march to reduce Rouen to his obedience. They hastily
complied with his orders, insomuch that their armies were soon in
the plains of Neufbourg[51], and assembled on the opposite side of
the river, toward Rouen.
The king of France departed from Louviers, attended by the king of
Sicily and his nobles, and advanced to Pont de l'Arche,—when the
inhabitants came out with great joy, to welcome him on his arrival.
He thence sent heralds without delay to summon Rouen to
surrender, that all oppressions might be avoided by a voluntary
submission: but the english garrison, aware on what embassy the
heralds came, would not let them approach the walls, nor would they
hear their summons, ordering them, at the same time, to make haste
and return, under pain of death. They reported to the king all they
had seen and heard, who, having learnt the answers the English had
given to his heralds, commanded the army to cross the bridge at
Pont de l'Arche, which was done under the conduct of the count de
Dunois, and thence to proceed to Rouen. They remained before that
city for three days with a multitude of men at arms and soldiers of all
descriptions; but during these three days, the army suffered so
greatly from the continual rains and storms that the whole was nearly
destroyed.
Notwithstanding the severity of the weather, the garrison made many
sallies, in which very gallant deeds of prowess were done; and a
french esquire, called the bastard de Forbier, was made prisoner by
reason of his horse falling under him. The french lords drew their
army up in battle-array before the walls, and sent the king's heralds,
a second time to summon the city to surrender; but as the English
would not suffer them to approach near enough to be heard by the
people, they were forced to return as before, which was quite
contrary to every rule of chivalry; for heralds are always allowed the
liberty of freely going and coming, to deliver their messages,
provided such messages do not contain any thing treasonable.
The heralds, having made their report to the count de Dunois on
their return, and he having considered that there seemed at present
no chance that the city would surrender, and that the severity of the
weather had much weakened his army, and worse was to be
expected during the winter, which was nigh at hand, marched back
to Pont de l'Arche, and quartered his men in the villages round that
town. On the day of this retreat, the king of France had come with
the king of Sicily to a nunnery within a league and a half of Rouen;
but the king of France returned to his former quarters at Pont de
l'Arche, while the king of Sicily remained until all the companies had
marched for their cantonments near to Pont de l'Arche.
Shortly after, the king received intelligence that some of the
inhabitants of Rouen had gained two towers that commanded part of
the walls, and that they would admit them by this way into the city.
On this information, the count de Dunois was ordered with the army
to undertake the business, who marched off, on the 16th day of
October, in handsome array.
On their arrival before Rouen, the army was drawn up fronting the
new castle, whence two detachments were ordered,—the one to the
gate of the Carthusians, and the gate Beauvoisienne, under the
command of the counts de Dunois, de Nevers, d'Eu, and de St Pol,
having with them many knights and esquires. The other detachment
was to take post between the place appropriated to the execution of
criminals and the walls of the city, under the command of the counts
de Clermont, de Chartres, the viscount de Lomaigne and others.
Each remained in battle-array until two hours after midday, when a
person sallied out of the city on horseback, and told the above-
mentioned commanders that some of the townsmen had gained, and
kept by force, two towers, purposely to introduce, by their means, the
king's army into the town.
Upon this, the count de Dunois, and the other lords in the
detachment before the gate of the Carthusians, ordered their archers
to march towards that part of the walls between these two towers,—
and the count and his companions instantly dismounted and
advanced to the foot of the walls, against which they raised the few
scaling ladders they had, and made all diligence to mount them.
On this occasion were made knights the count de Nevers, the lord
Concresault, Brunet de Long-champ, the lord de Pleu-martin, Pierre
de la Fayette, the lord de Graville, master William Cousinot, Jacques
de la Rivierre the bailiff of Nivernois, Robert de Hurenville, who all
exerted themselves manfully to scale the walls, so that there were
more than thirty Frenchmen who were on the battlements or within
the town.
The lord Talbot now advanced, with about three hundred men,
planting his banner on the wall, charged the French most valiantly, to
repulse those who had made good their entrance into the town.
They, however, fought well,—and great part saved themselves by
leaping into the ditches, being forced thereto by the arrows of the
english archers. Those who could not thus escape were put to death,
or made prisoners,—and the English became masters of the wall
and of these two towers. At this attack, from fifty to sixty French,
including those of the townsmen who had assisted them, were killed
or taken; and several, in attempting to escape, destroyed
themselves. A few saved themselves from the towers: others had
their legs broken by their fall, and such as remained were inhumanly
slaughtered; so that it was an abomination to see the torrents of
blood that ran in streams from the two towers.
During this time, the kings of France and of Sicily arrived at
Darnetal[52]; but when they saw that the attempt had failed, and that
the citizens of Rouen were not unanimous to assist them, they
returned, on the 16th day of October, to Pont de l'Arche. The army
was quartered in the villages on the banks of the Seine, according to
their former disposition.
On the 17th day of October, sir Richard Merbury, the english knight
before mentioned, fulfilled his engagement, and delivered the town
and castle of Gisors to the lord de Gaucourt, for the king of France.
In consequence, his children were restored to him, and all the
articles agreed on fulfilled; after which, he departed. He, however,
sent away, previously to yielding up the place, an english captain
called Regnéfort[53], who had been his lieutenant in the command of
the garrison, and in the guard of the castle.
At this period, the duke of Brittany left lower Normandy, where he
had taken many places, on his return to besiege the town of
Fougeres, held by sir Francis de Surienne, called the Arragonian.
The French, at this time, won the town of Condé sur Noireau[54]
through neglect of the guard at the gate; and therein was taken the
lady of sir Francis de Surienne, who had been driven from her lord's
own residence, and forced to shelter herself in Condé. The French
plundered every thing within the town, and also carried away the
English prisoners.
FOOTNOTES:
[51] Neufbourg,—a town in Normandy, between the Seine and
Rille, 8 leagues from Rouen.
[52] Darnetal,—a town very near to Rouen.
[53] Regnéfort. Q. Rainford.
[54] Condé sur Noireau,—in the valley of Noireau, diocese of
Bayeux.
CHAP. XII.
THE ARCHBISHOP OF ROUEN AND OTHERS OF THE
CITIZENS NEGOTIATE TO SURRENDER THAT CITY TO
THE KING OF FRANCE.—THE KEYS ARE PRESENTED
TO THE LIEUTENANT-GENERAL, THE COUNT DE
DUNOIS, WHO ENTERS THE TOWN WITH HIS ARMY.
On the 18th day of October, the inhabitants of the city of Rouen,
being greatly frightened lest their town should be stormed by the
French, and of course pillaged and destroyed, and also to avoid the
further effusion of blood, assembled with one accord at the bishop's
palace. They were much enraged at the deaths of their relatives and
friends; and had they met the lord Talbot, it was generally supposed
that they would have murdered him, as he had done their fellow-
citizens and friends.
They, however, saw the duke of Somerset, and plainly told him, that
it was expedient that a treaty should be opened, with the king of
France, otherwise they would be ruined and starved,—for it was
upwards of six weeks since any corn, wood, meat or wine had
entered the town. This language was not very agreeable to the duke,
—but looking round, and seeing that he had not more than fifty or
sixty Englishmen with him, and that there were from eight hundred to
a thousand of the townsmen, without including the remainder of the
inhabitants who were under arms in the different streets, he began to
be alarmed, and, addressing himself with much humility to the
archbishop and people, said, that he was ready to do whatever the
inhabitants of the town should wish. To appease the populace, he
went to the town-hall, where public meetings are usually held,—and,
after some discussion, it was resolved that the archbishop, with
some english knights and citizens, should attend at the gate of St
Ouen, to confer with the king, or with a part of his great council,
respecting the welfare and surrender of the city of Rouen.
In consequence of this resolution, the official of the town was sent to
the king at Pont de l'Arche to obtain a safe conduct for certain
persons therein named, to treat of peace,—which being granted, the
official returned to the archbishop and the duke. The archbishop, and
some knights and esquires on the part of the duke of Somerset,
together with certain of the townsmen, were sent to Port St Ouen[55],
within a league of Pont de l'Arche, where they met, on the part of the
king of France, his lieutenant-general the count de Dunois, the
chancellor of France, the seneschal of Poitou, sir William de
Cousinot, and some others. They had a long conference, in which
the deputies from Rouen insisted on a general amnesty being
granted, and that such as chose might depart with the English, and
all who preferred to stay should have the enjoyment of their fortunes
unmolested. It was also stipulated, that the English and their party
should have safe conducts for themselves and their effects, when
they marched away. All these demands having been agreed to by
the count de Dunois and the king's counsellors, the archbishop and
his associates promised to deliver up the town to the king's
obedience.
The archbishop and his companions then departed, to make their
report to the English and the citizens of Rouen,—but as they arrived
in the night, they could not do it until the following day. On the 18th,
therefore, the archbishop and the other deputies went very early to
the town-hall, and related every thing that had passed between them
and the ministers from the king of France, which was very agreeable
to the inhabitants, but sorely displeasing to the English, who, when
they saw the strong inclinations of the townsmen to turn to the french
interest, were greatly astonished, more especially the duke of
Somerset and the lord Talbot. They therefore left the town-hall much
discontented, and, instantly arming themselves, withdrew to the
government-palace, the bridges, and portals of the castle.
The citizens, having observed their motions, began to take alarm,
and armed themselves also. They, as well as the English, kept up a
strong guard the whole of this Saturday, and likewise during the
night; but the townsmen, anxious to expel the English for refusing to
accept of the terms the deputies had agreed to, sent a messenger to
Pont de l'Arche, who arrived there on Sunday by day-break, to
inform the king, that if he would send a force to their relief, it should
have free entrance into the town.
On this same Sunday, the 19th day of October, about eight o'clock in
the morning, the whole of the inhabitants were under arms, and on
their guard against any attempts of the English,—when they attacked
all of that nation whom they found in the streets so sharply that it
was with difficulty that they could join their companions on the
bridge, and in the palace and castle. In the pursuit, from seven to
eight English were killed,—and the townsmen gained possession, in
the interim, of the principal gates of the town.
The count de Dunois lost no time in hastening to the relief of Rouen,
but instantly mounted his horse, attended by a large company of
men at arms. In the number was Flocquet, bailiff of Evreux; but in his
hurry, he forgot to put his greaves on, and was so badly kicked by
one of the horses of his troop that his leg was broken, and he was
carried back to be cured at Pont de l'Arche, after he had given the
command of his men to the lord de Maulny.
On the arrival of this force before Rouen, those within St Catherine's
were summoned to surrender the place to the king of France, who
had, during the summons, set out from Pont de l'Arche, grandly
accompanied by men at arms and archers, to appear personally
before the walls of Rouen. He had ordered his artillery to be
charged, for an immediate attack on his arrival at St Catherine's,
although there was no necessity,—for the governor of the place,
having six score English under his orders, seeing so noble a
company, and knowing that the king was on the road, fearful also of
the event, if he made any resistance, surrendered it to the count de
Dunois, and he and his garrison marched away whither they
pleased. The bailiff of Evreux was appointed governor, until the king
should otherwise dispose of it. A herald was sent with the english
garrison of St Catherine's, to answer for their safety, and to conduct
them to Port St Ouen. On their march, they met the king, who bade
them take nothing from the poor people without paying for it; but as
they said they had no money, he gave them the sum of one hundred
francs to defray the expences,—and then they continued their march