Brent’s Board Review.

Endodontic Literature by Topic

Table Of Contents (Page # may be aprox.)

1. Evidence Based Endodontics………………………………………………………………………………3

2. History……………………………………………………………………………………………………..……7
3. Microscope……………………………………………………………………………………………………..8
4. Diagnosis………………………………………………………………………………………………………..9
5. Radiographs………………………………………………………………………………………….……….17
6. Topical Anesthesia…………………………………………………………………………………………..23
7. Needle Size/Breakage………………………………………………………………………………………23
8. Local Anesthetics…………………………………………………………………………..……….……….24
9. Local Anesthesia: Mandibular Teeth………………………………………………….…….……………29
10. Local Anesthesia: Maxillary Teeth……………………………………………………….……………….33
11. Type of Injection Technique: IANB………………………………………………………….…………….35
12. Duration of Pulpal Anesthesia for IANB………………………………………………………………….36
13. Injection Technique………………………………………………………………………………………….36
14. Local Anesthesia: Supplementary Injections…………………………………………………………..36
15. Local Anesthesia: Nerve Injury following IAN………………………………………………………….37
16. Local Anesthesia: Bu ering……………………………………………………………………………….38
17. Local Anesthesia: Other……………………………………………………………………………………39
18. Con rming Pulpal Anesthesia…………………………………………………………………………….42
19. Local Anesthesia: Max Dosage………………………………………………………………………..….43
20. I & D/Trephination/Sinus Tracts…………………………………………………………………..……….43
21. Dental Dam……………………………………………………………………………………………..…….46
22. Straight Line Access……………………………………………………………………………………..…47
23. Cleaning and Shaping (pre- aring)…………………………………………………………………..…..47
24. Working Length with Root ZX…………………………………………………………………………….48
25. Preparation Techniques……………………………………………………………………………………51
26. Glide Path/Patency File/Hand File……………………………………………………………………….52
27. Preparation Length………………………………………………………………………………………….54
28. Cleaning and Shaping (in presence of NaOCl)…………………………………………………………55
29. Cleaning and Shaping (Crown Down Technique)……………………………………………………..56
30. Cleaning and Shaping (hand les)……………………………………………………………………….56
31. Purpose of Instrumentation……………………………………………………………………………….58
32. Cleaning and Shaping (NiTi Rotary)……………………………………………………………………..60
33. Apical Preparation Size…………………………………………………………………………………….67
34. Irrigation………………………………………………………………………………………………………69
35. Irrigation (EDTA)…………………………………………………………………………………………….73
36. Irrigation (Final Rinse EDTA + NaOCl)…………………………………………………………………..74
37. Irrigation (Final Rinse MTAD)………………………………………………………………………….….74
38. Irrigation (QMix)……………………………………………………………………………………………..75
39. Irrigation (CHX)………………………………………………………………………………………………75
40. Irrigation (removing Ca(OH)2 )…………………………………………………………………………….77
41. Endoactivator…………………………………………………………………………………………………78
42. Ultrasonics…………………………………………………………………………………………………….78
43. Smear Layer…………………………………………………………………………………………………..79
44. Calcium Hydroxide / Intracanal Medicament…………………………………………………………..81
45. Sealer…………………………………………………………………………………………………………..85
46. Sealer Extrusion……………………………………………………………………………………………..88

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 47. Obturation Technique…………………………………………………………………………………….…89
48. Gutta-Percha Overextension………………………………………………………………………………95
49. Lateral Canals…………………………………………………………………………………..……………96
50. Primary function of root lling materials………………………………………………………………..97
51. Gutta Percha………………………………………………………………………………………………….97
52. Bioceramics…………………………………………………………………………………………………..98
53. Temporization………………………………………………………………………………………………..99
54. Coronal Restoration………………………………………………………………………………………..101
55. Coronal Seal/Microleakage………………………………………………………………………………104
56. Ori ce Barrier……………………………………………………………………………………………….106
57. Nanoparticles.………………………………………………………………………………………………106
58. Why 1 year Recall…………………………………………………………………………………………..108
59. One Vs Two Visits…………………………………………………………………………………………..109
60. Prognosis/Success Rates………………………………………………………………………………..113
61. Outcomes: initial treatment………………………………………………………………………………120
62. Retreatment…………………………………………………………………………………………………126
63. Apical Barrier/Apexi cation……..……………………………………………………………………….136
64. Surgery……………………………………………………………………………………………………….140
65. Pulp Cap/Pulpotomy……………………………………………………………………………………….167
66. Implant vs Endo…………………………………………………………………………………………….172
67. Flare-ups………………………………………………………………………………………………….….176
68. Misc Treatment Outcomes………………………………………………………………………….…….178
69. Analgesics/Pain Control…………………………………………………………………………………..180
70. Anxiolytic Therapy………………………………………………………………………………………….187
71. Antibiotics……………………………………………………………………………………………………188
72. Misadventures/Procedure Errors………………………………………………………………………..198
73. Pain……………………………………………………………………………………………………………206
74. Endo Perio Lesions…………………………………………………………………………………….…..223
75. Post and Post Space Preparation…………………………………………………………………….…224
76. Focal Infection Theory/Hollow Tube Theory/Etc……………………………………………………..230
77. Oral Pathology………………………………………………………………………………………………232
78. Root Morphology…………………………………………………………………………………….…..…239
79. Anomalies/More Morphology/Anatomy…………………………………………………………….….242
80. Tooth Extrusion……………………………………………………………………………………………..253
81. Endo - Pedo……………………………………………………………………………………………….…253
82. Endo - Ortho…………………………………………………………………………………………………254
83. Response To Caries…………………………………………………………………………………….….255
84. Bio lm……………………………………………………………………………………………………..…258
85. Pulp Biology………………………………………………………………………………………….……..261
86. Microbiology…………………………………………………………………………………………….….270
87. Immunology/In ammation….………………………………………………………………………..…..282
88. Trauma……………………………………………………………………………………………………..…292
89. Decoronation……………………………………………………………………………………………..…310
90. Resorption……………………………………………………………………………………………..…….314
91. Bleaching……………………………………………………………………………………………….……326
92. Regen Endo…………………………………………………………………………………………….……327
93. Vertical Root Fractures/Cracks..……………………………………………………………….………..340
94. Pulp Necrosis in teeth prepared for crowns……………………………………………….………….349
95. Smoking and Endo……………………………………………………………………………………..…..349
96. Systemic Disease/Medically Compromised Patient……………………………………………..…..350
97. More In ammation……………………………………………………………………………………..…..370
98. Facial Spaces……………………………………………………………………………………………….375
99. Other……………………………………………………………………………………………….…………386

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 Evidence Based Endodontics
• Evidence-based dentistry, as de ned by the American Dental Association, is “. . . an approach
to oral health care that requires the judicious integration of systematic assessments of
clinically relevant scienti c evidence, relating to the patient’s oral and medical condition and
history, with the dentist’s clinical expertise and the patient’s treatment needs and
preferences.”
• Torabinejad, Bahjri 2005: JOE. Essential Elements of Evidence-Based Endodontics: Steps
Involved in Conducting Clinical Research.
• Finding evidence begins with a speci c, well-built clinical question. Once a speci c
question is framed, the validity and relevance of the evidence need to be appraised. The
best levels of evidence can then be used to inform decisions regarding care. The
purpose of this paper is to discuss the history of evidence-based treatment and to clarify
the process of conducting a systematic review.
• The rst step in performing a systematic review is framing an important and well-
de ned question that is relevant to patient care. Framing a question in proper format
requires special skill and plays an important role in the outcome of a systematic review.
A well- formulated research question identi es four crucial “ PICO ” elements. These
elements are: (a) the Population or patient type; (b) the Intervention; (c) the
Comparison; and (d) the Outcome. By properly stating a problem, the criteria to
include or exclude primary studies become evident. The balance between well-de ned
criteria that limit bias, and the criteria that are not narrow enough to introduce the risk of
chance, is a very critical part of the initial task of conducting a systematic review.
• RCTs: A randomized controlled trial (RCT) is an experimental study among patients with
a particular disease (clinical trials) or disease-free subjects ( eld trials) in which the
individuals are randomly assigned to either an experimental intervention or a control
group to determine the ability of an agent or a procedure to diminish symptoms, to
prevent recurrence or to decrease risk of death from the disease during a follow-up
period. Well-controlled RCTs that are frequently referred to as the “gold standard of”
research can provide the strongest evidence of causation. This is primarily because of
the fact that since the subjects are allocated in a genuine randomization manner, this
minimizes or eliminates unequal distribution of known and unknown confounding factors
that in uence clinical outcome between the groups. Thus, randomization as well as
blinding make the groups comparable and minimize bias and confounding. Another
strength of an RCT is that the exposure level is also under the researcher’s control.
Nevertheless, RCTs have a number of potential weaknesses that make them
inappropriate to be conducted for some studies. Among the weaknesses is that they
raise some ethical concerns. The treatment or procedure tested should show potential
bene t for the exposed subjects; at the same time it should not show a large enough
bene t that it becomes unethical not to offer it to the control group. RCTs are also
usually very costly and time consuming to implement. Because of strict eligibility criteria
and loss to follow-up, RCT sample size requirements are dif cult to attain and maintain,
and eventually result in limited external validity of results for the general population
• Questions regarding diagnosis, prognosis and causation may be best addressed by
observational (sometimes called “epidemiological”) studies. Observational studies,
which are frequently undertaken in dentistry, can be more challenging to design and
execute in terms of controlling bias. Following are the most common types of
observational studies.

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 • Cohort Studies: A cohort study is an observational study that follows an exposed
cohort compared to an unexposed cohort to determine the incidence of a given
outcome. This can be prospective (concurrent) by following subjects from study
initiation to sometime in the future. Cohort studies can also be retrospective in that
the subjects are followed from some time in the past to the future. These studies
are referred to as retrospective or nonconcurrent cohort investigations. Well-
designed cohort studies offer a clear and appropriate temporal sequence from
exposure to outcome, providing strong support for causation. Nonconcurrent cohort
studies are relatively weaker because they rely on existing records. However, they
offer great bene t in situations when the expo- sure is extremely rare. Cohort
studies also allow multiple outcomes as a result of a given exposure to be
investigated within the same study as well as a direct measure of incidence of the
outcome. Among the disadvantages, however, is that these studies require large
sample size especially when assessing chronic diseases resulting in a loss to either
follow-up and/or increased cost. The length of these studies might also result in
misclassi cation of exposures because of changing exposure status of subjects or
misclassi cation in outcome status because of ongoing changes in scienti c
knowledge of the outcome under investigation. Thus, continuous assessment of the
exposure and outcome status is required during the follow-up period.
• Case-Control Studies: Case-control studies are observational studies wherein
cases with a particular outcome and controls that do not have the same outcome
are rst selected, and exposure assessment is done retrospectively. These studies
are quick, relatively inexpensive, and appropriate in studying rare diseases. They
also allow assessment of multiple risk factors for a particular disease within the
same study. Unlike cohort studies, case control studies do not ordinarily allow direct
assessment of incidence of disease. However, direct assessment is potentially
possible if a study is appropriately designed, or if the cases are obtained from an
existing cohort study, giving rise to what is known as a nested case control study.
Several important biases are associated with case control studies resulting in the
relative weakness of these studies. These include the dif culty in identifying
comparable cases and controls resulting in selection bias. Differential recall and
report biases can also result as the information on prior exposure and other
confounding variables are obtained. These studies are also inappropriate where
rare exposures are involved. Unless they are appropriately designed, case control
studies have limited use in establishing a cause and effect relationship.
• Cross-Sectional and Ecological Studies: Cross sectional and ecological studies
are observational studies that assess the relationship of a particular disease with an
exposure at the same time. In addition to being quick and inexpensive, these
studies give rise to potential relationships between the exposure and outcome, but
no causal inference could be made because researchers can’t be fully assured that
the exposure resulted in the outcome, or was a con- sequence of the outcome.
Therefore, these studies are usually used before other analytical, observational or
experimental studies when little knowledge is available about the association of the
particular out- come with the exposure under investigation. The difference between
cross sectional studies and ecological studies is that ecological studies are
conducted at the group level, while the unit of analysis in cross sectional studies is
individuals. A major weakness of the ecological studies is called “ecological fallacy,”
that is, the assumption that the association holds true at the individual level if it
shows to be true at the group level

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 • Case Report and Case Series: These two types of descriptive observational studies that
document unusual occurrences of outcomes constitute the most common types of
articles in medical journals. They usually represent the rst clues of new diseases or
adverse effects of exposures. Case series are an extension of case reports, in that they
are a description of a small number of individuals that have a similar experience with
regards to a particular outcome and disease, rather than a documentation of just a single
case as seen in case reports. In both descriptive evaluations, however, there are no
control groups, and so one cannot conclude with reasonable con dence that the
observed outcome is because of the given exposure.
• RCTs vs Observational Studies: Despite their methodological strengths and
acceptance as the gold standard, RCTs have some shortcomings. Because RCTs
examine interventions under ideal conditions, they may not represent their effective-
ness in uncontrolled situations. Also, because RCTs are usually set up with some very
stringent ethical limitations, certain populations are eliminated from these studies.
Finally, because of the presence of strict inclusion and exclusion criteria, it is dif cult to
know if the results of these studies are applicable to excluded groups. Therefore, RCTs
represent average outcomes for those who met the inclusion criteria. The biggest
challenge of an observational study is the lack of comparability of groups before any
intervention or exposure. As a result, the number of confounding variables can become
signi cant in observational studies. In addition, the researcher has little or no control
over the quality of the experiment and has to work the existing data. Because of the
inability to control variables in observational studies, they do not prove a cause and
effect relationship. Despite these weaknesses, well- designed observational studies can
report on rare diseases and novel, interventions, prevent unethical allocation of
treatments, and their ndings can be closer to representation of the general population
• Gutmann, Solomon 2009: JOE. Classi cation Criteria
• Level 1
• Randomized Controlled Clinical Trial – high level
A clinical study in which participants are randomly (ie, by chance) assigned to either
an experimental group or control group. The experimental group receives the new
intervention, and the control group receives a placebo or standard intervention.
These groups are followed up for the outcomes of interest.
• Systematic Reviews of Randomized Controlled Clinical Trials
• Level 2
• Randomized Controlled Clinical Trial – low level
A clinical study in which participants are randomly (ie, by chance) assigned to either
an experimental group or control group. The experimental group receives the new
intervention, and the control group receives a placebo or standard intervention. These
groups are followed up for the outcomes of interest.
• Cohort Study – high level A clinical study that has 2 groups (cohorts) of subjects, one
that did receive the exposure of interest and another that did not, and that followed
these cohorts forward for the outcome of interest.
• Systematic Review of Cohort Studies
• Level 3
• Case-Control Study – high level A clinical study that involves identifying subjects with
a clinical condition (cases) and subjects free from the condition (controls) and
investigates whether the 2 groups have similar or different exposures to risk
indicator(s) or factor(s) associated with the disease or condition.
• Systematic Review of Case-Control Studies

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 • Level 4
• Case Series A report on a series of cases with an outcome of interest. No control
group is involved.
• Retrospective Studies
• Cohort Study – low level
• Case-Control Study – low level
• Level 5
• Case Reports, Animal Studies, Bench Research, Biological Plausibility, and Expert
Opinion
• High Quality versus Low Quality
• Torabinejad et al 2005: JOE. Systematic Review. Levels of evidence for the outcome of
Endodontic treatment.
• The purpose of this systematic review was (a) to search for clinical articles pertaining to
success and failure of nonsurgical root canal therapy, and (b) to assign levels of
evidence to these studies. Based on these ndings, it appears that a few high-level
studies have been published in the past four decades related to the success and failure
of nonsurgical root canal therapy. The data generated by this search can be used in
future studies to speci cally answer questions and test hypotheses relevant to the
outcome of nonsurgical root canal treatment. Despite the absence of evidence at the
highest levels, the long-term healing of periradicular pathosis and the preservation of
millions of teeth every year underscore the success of the current modalities of root
canal therapy. Conducting research projects at the highest levels of evidence (when
possible) will strengthen current data.
• The criteria that have been used for success and failure studies in root canal therapy
have been more stringent than those applied for the outcomes of implants. When
survival rate (functional teeth with or without radiographic lesions) for endodontically
treated teeth is used instead of the traditional criteria, the success rate of endodontically
treated teeth by endodontists is equal or better than the long term outcome of implants.
Treatment options following unsuccessful root canal therapy are retreatment and/or
endodontic surgery. In contrast, the treatment option for a failed implant is its removal
and the possible placement of another implant. Because of these differences and ethical
issues, it is very dif cult to design clinical studies that would, in a randomized fashion,
examine the success rate of root canal therapy compared to alternative treatment
modalities such as implants.
• Evidence Level Strati cation of Relevant Study Designs
• Level 1: Randomized Control Trials. Systematic Reviews of RCTs
• Level 2: Low-quality RCTS, Cohort Studies, Systematic Review of case control
studies
• Level 3: Case Control Studies, Systematic Reviews of case control studies
• Level 4: Poor-quality cohort and case control studies, Case Series
• Level 5: Case Reports, Expert Opinion without explicit critical appraisal, Literature
reviews.

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 History
• Ingle 1961: Proposition of standardized le sizes to improve instrumentation and ll of canals
• AAE/ABE:
• 1943 AAE begins (Clyde Davis-1st president)
• 1963 Endodontic specialty recognized by ADA
• 1956 ABE begins
• 1965 1st ABE board exam
• 1st in Endodontics:
• Hermann (1930): Introduced Ca(OH)2 - vital pulp cap; Frank: Apexi cation
• Coolidge (1919): Introduced NaOCl as tissue solvent (Dakin’s Solution)
• Nygaard Ostby (1957): Introduced EDTA for dentin softening; idea of REGENDO
• Imperial Chemical Industries (1940s): Introduced CHX
• Barnum (1864): Introduced concept of Rubber dam
• Bowman: Introduced GP for obturation, Rubber dam forceps
• Koller: Proposed Cocaine as anesthetic
• Einhorn (1906): Procaine (novocaine) introduced
• Maynard: Developed broach
• Arthur: Introduced barbed broach
• Harry B. Johnston 1928: Created term “Endodontia”; 1st Endodontic Of ce
• Clyde Davis: 1st president of AAE
• Otto Walkhoff: 1st dental radiograph, CMCP as pulpal antiseptic
• Ingle (1961): Standardization of GP and instruments
• Miller; Hunter: Introduced Focal Infection Theory, Billings: Introduced Focal
Infection Theory to USA
• Pfaff: Introduced pulp capping
• Codman: Concept of secondary dentin in pulp cap healing
• Buckley: Developed Formocresol for pulpal antiseptic (“Buckley’s solution”)
• Jasper: Silver points
• Hudson: 1st to obturate canal (gold)
• Hill: Introduced Hill’s stopping (GP, carbonated lime, quartz) for obturation
• Perry: 1st carrier based obturation (Goldwire/GP for obturation), see also Wm Ben
Johnson: Therma l
• Callahan: Introduced chloropercha technique for obturation

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 Microscope
• Rubinstein, Kim 1999: Microscopy serves to aid the practitioner in the location of normal
anatomic structures during nonsurgical and surgical endodontic therapy
• de Carvalho, Zuolo 2000: The use of DOM increases the number of root canal ori ces
located
• Buhrley et al 2002: The use of magni cation leads to an MB2 detection rate three times that
of the non-magni cation group. The use of no magni cation results in the detection of
signi cantly fewer MB2 canals. No signi cant differences were noted between the use of a
microscope vs loupes. In some instances, the most important factor in locating the MB2 canal
is not the magni cation but the persistence of the operator.
• Rampado et al 2004: DOM is bene cial for access preparation.
• Setzer, Kim et al 2012: meta-analysis. Found more favorable outcomes for molars using the
surgical operating microscope vs loupes.
• AAE Position Statement 2012: the microscope is an integral part and important part of
performance of modern endodontic techniques.
• Khalighinejad, Aminoshariae, Kulild, Mickel et al 2017: Retrospective. The aim of the
current investigation was to assess the effect of the use of a dental operating microscope on
the outcome of nonsurgical root canal treatment (NS RCT) while treating the mesiobuccal
(MB) root of the maxillary rst molar. Microscope n=83; no microscope n =112. The MB root
was 3 times more likely to present with a PAR at the time of retreatment if the initial NS RCT
was performed without the use of a microscope (P < .05, odds ratio = 3.1). There was a
signi cant association between a missed MB2 canal and an MB PAR in the group in which
the initial NS RCT was performed without the use of a microscope (P < .05, odds ratio = 5.1).
However, in cases in which the initial NS RCT was performed using a microscope, a missed
MB2 canal was not associated with the presence of an MB PAR. With proper education,
dentists can gain further insight into recognizing limitations in treating cases that require
advanced training and advanced optics such as a microscope. Based on this strategy, it
would appear that the outcome of NS RCT can be improved.
• Kim S and Kratchman 2006: JOE. The operating microscope provides important bene ts for
endodontic microsurgery in the following ways:
• The surgical eld can be inspected at high magni cation so that small but important
anatomical details, e.g. the extra apex or lateral canals, can be identi ed and managed.
Furthermore, the integrity of the root can be examined with great precision for fractures,
perforations, or other signs of damage.
• Removal of diseased tissues is precise and complete.
• Distinction between the bone and root tip can easily be made at high magni cation,
especially with methylene blue staining.
• At higher magni cation the osteotomy can be made small (3-4 mm) and this results in
faster healing and less postoperative discomfort.
• Surgical techniques can be evaluated, e.g. whether the granulomatous tissue was
completely removed from the bone crypt.
• Occupational and physical stress is reduced since using the microscope requires an
erect posture. More importantly, the clinical environment is less stressful when clinicians
can clearly see the operating eld
• The number of radiographs may be reduced or maybe eliminated because the surgeon
can inspect the apex or apices directly and precisely.
• Video recordings or digital camera recordings of procedures can be used effectively for
education of patients and students.
• Communication with the referring dentists is improved signi cantly.

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 Diagnosis
• Sources of Pain in the Maxillofacial Region
• Dental Pain: Pulpal/endodontic, Dentinal hypersensitivity, occlusal, periodontal
• Unilateral
• localized pain
• sensitive to temperature
• pain qualities: dull, sharp, throbbing
• lesion or caries present
• resolves with dental procedure
• Non-Dental Pain: muscular, sinus, headaches, neurpathic, atypical facial,
neurovascular, cardiac, joint, psychogenic
• pain to jaw movements
• bilateral
• multiple pain sites
• poorly localized
• not necessarily associated with a thermal stimulus
• pain qualities: burning, electric, stabbing, dull ache
• no lesion or caries
• AAE Glossary: Diagnostic Terminology
Pulpal Diagnosis:
• Normal Pulp: pulp is symptom-free and normally responsive to pulp sensitivity testing.
• Reversible Pulpitis: subjective and objective ndings indicate in ammation should resolve
and the pulp should return to normal.
• Symptomatic Irreversible Pulpitis: subjective and objective ndings indicate that the vital
in amed pulp is incapable of healing; symptoms include lingering thermal pain,
spontaneous pain, or referred pain.
• Asymptomatic Irreversible Pulpitis: subjective and objective ndings indicate the vital
in amed pulp is incapable of healing; no clinical symptoms but in ammation is present and
attributed to caries, caries excavation or trauma.
• Pulp Necrosis: indicates death of the dental pulp; pulp is usually non-responsive to pulp
sensitivity testing.
• Previously Treated: tooth has been endodontically treated, and the canals are obturated
with various lling materials other than intracanal medicaments.
• Previously initiated therapy: tooth has been previously treated by partial endodontic
therapy, such as pulpotomy or pulpectomy.
Periapical Diagnosis:
• Normal apical tissues: teeth not sensitive to percussion or palpation testing; the lamina
dura surrounding the root is intact; and the PDL space is uniform.
• Symptomatic Apical Periodontitis: in ammation usually of the apical periodontium
producing clinical symptoms; including a painful response to biting and/or percussion or
palpation; it may or may not be associated with an apical radiolucent area.
• Asymptomatic Apical Periodontitis: in ammation and destruction of the apical periodontium
that is of pulp origin, appears as an apical radiolucent area, and does not produce clinical
symptoms.
• Chronic Apical Abscess: an in ammatory reaction to pulpal infection and necrosis
characterized by gradual onset, little or no discomfort, and the intermittent discharge of
pus through an associated sinus tract.

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 • Acute Apical Abscess: an in ammatory reaction to pulpal infection and necrosis
characterized by rapid onset, spontaneous pain, tenderness of the tooth to pressure, pus
formation and swelling of associated tissues.
• Condensing Osteitis: diffuse radiopaque lesion representing a localized bony reaction to a
low-grade in ammatory stimulus, usually seen at the apex of the tooth.
Adjunctive Diagnostic Terminology
• Fractures: craze lines, fractured cusps, cracked tooth, split tooth, vertical root fracture
• Periodontal-Endodontic Lesions
• Pulp Polyps: characterized by a proliferation of the dental pulp tissue from the exposed
pulp chamber that lls the cavity with a pedunculated or sessile, pinkish-red eshy mass,
usually covered with epithelium.
• Resorption: internal root resorption, external in ammatory root resorption, invasive cervical
root resorption, replacement resorption, pressure resorption.
• Traumatic Dental Injuries: crown fractures, root fractures, alveolar fractures, luxation
injuries, avulsions.
• Additional Diagnostic Information:
• Sensitivity is the ability of a test to correctly identify those with the disease (true + )
• Speci city is the ability of the test to correctly identify those without the disease (true - )
• Thermal tests: merely identi es the presence of pulp nerve tissue that is capable of
responding to a change in temperature
• EPT gauges the ability of nerves in the pulp to respond to electrical stimulation. The
nerves in the pulp responding to EPT are A-delta nociceptors and do not transmit
electric, thermal, touch or proprioceptive sensations to the CNS, but only pain. EPT
gives the clinician no information on the status of in ammation in the pulp or the health
or disease of the vasculature system.
• Endo Ice (1,1,1,2 - tetra uoroethane): -50 deg F (Fuss, Trowbridge, Bender 1986)
• CO2 Snow - 78 deg F (Ehrmann 1977)
• Heat sensitivity following RCT
• Keir, Walker 1991: Two cases of thermally induced pulpalgia in teeth previously
endodontically treated are presented. Reproduction of the patient's chief complaint was
the key to identifying the teeth involved. In both cases, the pulpalgia was stimulated by
heat. After locating and treating an un lled canal, the teeth have remained
asymptomatic. Possible explanations for this occurrence are discussed. Missed MB2.
• Tidwel, Witherspoon, Gutmann, Sweet 1999: Case Reports. The problem of thermal
sensitivity following non-surgical root-canal treatment is explored and case reports are
presented. Possible causes for post-treatment discomfort from endodontic and
restorative etiologies are discussed, as are the mechanisms to explain the patients'
painful experiences. Treatment of this problem may vary from the simple replacement of
a defective restoration to a more extensive non-surgical retreatment of the case, despite
radiographic evidence of an acceptable root lling and normal periradicular tissues.
• Patient pain localization
• Friend, Glenwright 1968: An experimental investigation into the localization of pain from
the dental pulp. Only 37% of patients could accurately identify the correct tooth. 3.4% of
teeth referred pain to the opposite Jaw (mand to max); 1.5% pain referral across midline.
• McCarthy, McClanahan et al 2010: The presence of periradicular pain increases the
accuracy of pain localization. The results show that patients presenting with odontogenic
pain can localize the painful tooth 73.3% of the time. Patients experiencing periradicular
pain can localize the painful tooth (89%) signi cantly more often than patients with pain
without periradicular symptoms (30%, p < 0.0001).

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 • Van Hassel, Harrington 1969: Classic: localization is poorest in mand post (60%
discrimination between two teeth). Pulps have wide two point discrimination threshold.
Most of the time patient can tell between quadrants.
• Thermal Testing
• Bender 2000: Odontogenic pain can refer discomfort to neighboring teeth and between
jaws. Pulp sensitivity testing leads to uid changes causing A-delta ber stimulation.
• Heat leads to inward uid movement
• Cold leads to outward uid movement
• EPT leads to ionic changes
• Fulling, Andreasen 1976: Classic: cold tests are more reliable than EPT in immature
teeth. (Compared responses of children's and adults teeth). EPT was not accurate in
immature teeth due to late development of the responsive A delta nerve bers
• White, Cooley 1970: Recommend Endo Ice based on convenience and demonstrated
its superiority over a cold-water bath or ice stick. Of the cold tests studied, skin
refrigerant produced a greater thermal change than either an ice water bath or an ice
stick. Of the heat tests studied, hot water (from the tap) ooding the tooth produced a
greater thermal change than hot gutta-percha stopping, a hot burnisher, or a Burlew
wheel.
• Cooley: normal: respond w/i 5-8 secs, returns w/i 15 secs; Reversible: immed, sharp,
subsides w/i 15 secs; Irreversible-severe, long-lasting > 1min
• Trowbridge 1980: Cold testing relies on outward hydrodynamic uid ow to stimulate A
delta bers. Response to cold or hot stimulus occurs before the temperature change
occurs at the pulp. Mechanoreceptors, not thermoreceptors must be involved. Supports
Brannstrom’s hydrodynamic theory. (Response time measured in vivo, then tooth
extracted and that time was compared to the time it tooth for thermal changes to be
detected by a thermistor in the pulp)
• Fuss, Trowbridge, Bender, Rickoff 1986: CO2 Snow and dichlorodi uoromethane
(DDM) more effective at eliciting response than ice and ethyl chloride. EPT, CO2 and
DDM were equally reliable in teeth of Adults, but not in immature teeth
• Rickoff, Trowbridge, Fuss, Bender 1988: Heat and Cold tests do not cause
in ammatory changes in the pulp. Safe to use for assessing vitality. (tested teeth. later
extracted and examined histologically). No pathologic changes in the pulp as a result of
cold or heat testing. Heat testing is generally a second-line pulp sensitivity test or when a
patients chief complaint includes heat sensitivity.
• Jones 1999: reported that a large cotton pellet produced the largest temperature change
in the pulp chamber compared to a small cotton pellet, a cotton-tipped applicator and or
cotton roll.
• Jones, Rivera, Walton 2002: Endo ice produces a pulpal response faster than CO2, but
both are equally effective. (anterior, unrestored teeth only)
• Peters, Baumgartner 1994: Cold is best felt on the cervical 1/3 of tooth. It is much rarer
to have a false positive to cold vs EPT. If no response in an adult untraumatized tooth to
cold and EPT almost certainly necrotic. False negatives to cold increase with age. False
negatives to cold AND EPT are rare. False negatives to cold increases with age. Cold
is best felt in cervical third.
• Miller et al 2004: Found refrigerant sprays to be the superior method of cold testing in
teeth restored with full-coverage porcelain-fused-to-metal restorations. (In conclusion,
application of TFE on a saturated #2 cotton pellet was the most effective method for
producing a temperature reduction at the PDJ of intact teeth and those restored with
gold, PFM, and all-porcelain when testing for less than 15 seconds.)

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 • Berman, McClanahan et al 2012: Found that a special tip on a system b endodontic ll
device with a reservoir to heat a small piece of gutta percha was the most consistent and
safe method of heat testing.
• Jespersen et al 2014: Endo Ice was 90% accurate. EPT accuracy was 75%
• Texeira: Reliability of pulp tests. Recommends using both cold and EPT to increase
accuracy.
• Petersson, Soderstrom: Reliability of pulp tests. overall accuracy: Cold 86%, EPT
81%, Heat 71% probability the neg.=necrosis: cold – 89%; EPT – 88%; hot – 48%
probability the pos.=vital: cold – 90%; EPT – 84%; hot – 83%
• Jafarzadeh, Abbott 2010: The article mainly focused on pulp sensibility tests such as,
cold/ heat and EPT. Such tests only test the state of the pulp and do not test the vitality
of the pulp, because they cannot assess the vascular state of the pulp. In addition, A-
delta bers have lower stimuli threshold, thus they are the rst bers to respond to
stimuli compared to C bers. Both set of bers respond according the hydrodynamic
model. This means that a temperature at the DPJ causes the liquid inside the dentinal
tubules to move and activate the nerve bers. The article also, covered the test results
expected under each pulpal condition, from healthy pulp to reversible pulpitis to necrotic
pulp. Review of Pulp sensibility tests. Part I. Pulp sensibility test: thermal test, EPT, test
cavity, to determine alive or necrotic pulp (responsiveness of nerve bers.Pulp vitality
test: LDF, pulse oximetry, tooth temperature measurement, to assess pulp blood ow
(vascularity)
• Electric Pulp Tester (EPT)
• Mumford: Discussed that the speci c numbers on EPT machines are not important. All
relative. no relationship with value and pulp pathology; density important: incr surface
area requires incr current to produce sensation (all or none response)
• Nahri: EPT stimulates A beta and A delta bers; no C bers
• Ketterl 1983: Reported that EPT might be more useful than thermal testing in calci ed
teeth due to loss of uid needed for hydrodynamic A-delta ber stimulation.
• Bender, Trowbridge 1989: Incisal edge is the most sensitive to EPT. Gingival 1/3 gives
false reads at 60-80. Exposed dentin results in an even lower threshold. (EPT of
anterior teeth)
• Wilson, Baumgartner 2006: Landmark study demonstrating EPT’s and EAL’s had
absolutely no effect on performance of implanted cardioverter/de brillator’s (ICD’s) and
implanted cardiac pacemakers (ICP’s). (ICD/IPT pt’s hearts and devices were monitored
during EPT and EAL testing)
• Jespersen et al 2014: Endo Ice was 90% accurate. EPT accuracy was 75%
• Texeira: Reliability of pulp tests. Recommends using both cold and EPT to increase
accuracy.
• Petersson, Soderstrom. Reliability of pulp tests. overall accuracy: Cold 86%, EPT 81%,
Heat 71% probability the neg.=necrosis: cold – 89%; EPT – 88%; hot – 48% probability
the pos.=vital: cold – 90%; EPT – 84%; hot – 83%
• Jafarzadeh, Abbott 2010: Review of pulp sensibility tests. Part II. EPTs can be a
valuable aid when evaluating pulpal status, but they should always be used in
combination with more reliable thermal pulp tests, radiographs, clinical information and
patient medical and dental history. Test cavities to assess pulpal status are not
warranted in modern dentistry, as it is an invasive and irreversible procedure.
• Correlation between diagnostic tests and clinical symptoms
• Ricucci, Siqueira 2014:

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 • The clinical diagnosis of normal pulp/reversible pulpitis matched the histologic
diagnosis in 57 of 59 (96.6%) teeth.
• Correspondence of the clinical and histological diagnosis of irreversible pulpitis
occurred in 27 of 32 (84.4%) cases.
• Infection advancing to the pulp tissue was a common nding in teeth with
irreversible pulpitis but was never observed in normal/reversibly in amed pulps
• Ricucci, Pitt Ford, 2006: 57 ext’d teeth
• You can NOT use a radiograph to diagnose cyst/granuloma/abscess. radiopaque
lamina doesn’t matter.
• No correlation found between the presence of a radiopaque lamina and the
histological diagnosis of cyst.
• The generic term “periapical radiolucent lesion” should be used rather than
“granuloma” or “cyst” when examining radiographs. The differential diagnosis of
periapical lesions cannot be made based on radiographic appearance, but requires
histological examination of serial sections.
• Seltzer, Bender 1963: Classic: No reliable correlation between diagnostic pulp tests and
histological ndings. Showed that a positive percussion test was important for detection
of partial or total pulp necrosis. – Percussion pain was present in all cases of partial or
total necrosis of the pulp (Sectioned human control and teeth in pain after extraction).
• Mitchell, Tarplee 1960: Evaluated subjective and objective ndings and compared
these to histologic ndings. Subjective complaints of pain due to intake of hot and cold
foods or drinks are indicative of pulpitis, but they are not as reliable as careful testing by
the clinician. Additional microscopic ndings indicate that all of these in amed, vital pulps
had involvement at site of exposure with extension of the in ammatory zone varying
from a tiny area of the pulp horn to an area extending into one or more root canals. No
clinical tests studied differentiated between such cases. 3 teeth which were
asymptomatic but considered likely to have pulpitis were tested and sectioned. The
results of the objective tests indicated pulpitis and the microscopic ndings supported
this diagnosis. 7 teeth had in ammation extending into root canals. In no instance was
in ammation evident within the apical third of the root canal. Yet, 22 of these teeth were
tender to percussion. Each of the 5 teeth with a periapical radiolucency were tender to
percussion. (Patient’s subjective description should only be used as a guide rather than
a basis for diagnosis. Teeth with painful pulpitis are generally vital, hypersensitive to
temperature and many times exhibit sensitivity to percussion. Diagnosis by radiograph
alone is generally not possible, although it is helpful for suggesting possible potential
pulp exposure. Pulp in ammation is greatest immediately next to the pulp exposure, but
it can extend into the root canal.)
• Mumford: 142 pts with pain. No correlation between histology and clinical symptoms.
• Barthel, Trope 2004: It may be concluded that there are relationships between
radiologic and histologic signs of in ammation in human root canal-treated teeth. There
appears to be a tendency that the radiologically determined quality of the coronal seal
has an impact on the histologic state of the root- lled tooth. No relationship was detected
between un lled lateral or accessory canals and the status of in ammation at the
periapex (51% in amed, 49% unin amed).
• Caliskan et al 2016: IEJ. Retrospective study.
• Neither radiographic size nor presence of an associated radiopaque line alone was
suf cient to determine the type of lesion.
• Histological examination is required in order to reach to a de nitive diagnosis.

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 • 93 specimens. 72% Granulomas. 21.5% Radicular cyst. 4.3% Abscess. 2.2% Scar
tissue.
• Periapical granulomas were determined when the lesions were predominantly
in ltrated with lymphocytes, plasma cells or macrophages, with or without
epithelial remnants, and had a surrounding capsule of collagen bers.
• When a mass of polymorphonuclear leucocytes dominated the granulomatous
tissue as a collection of pus (dead and dying neutrophils), the lesion was
classi ed as a periapical abscess.
• Lesions with a dense, collagenous connective tissue and lack of in ammatory
cells were established as scar tissue.
• If there was a layer of strati ed squamous epithelium along a surface of
conjunctive tissue to indicate a delineated cavity and surrounded by a slight
brous capsule, the lesion was diagnosed as a periapical cyst.
• Percussion, Palpation, Biting tests
• Seltzer, Bender 1963: Classic: No reliable correlation between diagnostic pulp tests and
histological ndings. Showed that a positive percussion test was important for detection
of partial or total pulp necrosis. – Percussion pain was present in all cases of partial or
total necrosis of the pulp (Sectioned human control and teeth in pain after extraction).
• Seltzer & Bender 1965: Percussion tenderness may result from endodontic disease
beyond the apex. Biting tenderness can indicate extension of endodontic disease
beyond the apex. Palpalation tenderness may indicate endodontic disease or alveolar
damage.
• Iqbal et al 2007: Sharp pain was more likely associated with pulpal pathosis, whereas
dull pain was more likely associated with periapical pathosis. Percussion and palpation
tests were powerful in differentially diagnosing between pulpal and periapical conditions
• Ehrmann 1977: Limitations of pulp testing: Clinicians must remember that pulp testing is a
very archaic method of assessing the vitality of the dental pulp. These tests only establish
whether vital nerve tissue is present. It does not tell us whether the circulation within the
dental pulp is still intact. Additionally, these tests are subjective and depend upon the
cooperation from the patient. Pulp vitality tests are not reliable when assessing the pulpal
state of traumatized teeth. Traumatized teeth may also discolor. This does not necessarily
indicate RCT. This is only correct when trauma is severe and has occurred in a tooth with a
normal apex. When the apex is open the circulation may re-establish and the tooth may be
vital while at the same time discolored. Signi cance: Good treatment starts with a good
diagnosis. Pulp testing is essential to the diagnosis of pain and interpretation of radiolucent
areas. Each test must not be used alone; instead each pulp test must be used in conjunction
with other tests, radiographs, clinical ndings, dental history and clinical experience.
• Robinson et al 1989: Recommended BWs to access coronal pulp anatomy.
• Abou-Rass 1982: (Pulps respond to CUMULATIVE injury. Use to justify prophylactic endo.
Logic is there, but science is not.) The stressed pulp condition: an endodontic-restorative
diagnostic concept. The stressed pulp condition is a clinical concept that describes pulps that
have received repeated previous injury and survived with diminished responses and lessened
repair potentials. Before performing restorative dentistry the dentist should conduct a
comprehensive pulpal health evaluation on teeth to be restored. This evaluation should
include (1) traditional pulp-testing methods and (2) a review of the past, present, and planned
future treatment of the tooth. This analysis will usually identify teeth with stressed pulp
conditions. Teeth with stressed pulps should be treated before complex restorative dentistry.
• Klausen et al 1985: reported a combination of signs and symptoms yielding a correct
diagnosis of pulpal degeneration in 82% of cases including constant pain, sensitivity to

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 temperature changes, an extruded feeling in the tooth, impaired mouth opening, mobility, and
tenderness to palpation in the apical area. These signs and symptoms in various
combinations were highly accurate predictors of disease
• Glickman, Carranza 1990: From Text Book
• Furcation classi cation: Class 1 just noticeable, Class 2 not quite through and through,
Class 3 through and through.
• Mobility classi cation: + 1 Just beyond physiologic, + 2 < 1mm horizontal movement, + 3
> 1mm horizontal movement, possible rotation or depressible
• Brown et al 1995: Talks about using anesthetic localization to diagnose oral and dental pain
• Bender 2000: Odontogenic pain can refer discomfort to neighboring teeth and between jaws.
Pulp sensitivity testing leads to uid changes causing A-delta ber stimulation. Heat leads to
inward uid movement; cold leads to outward uid movement; EPT leads to ionic changes.
• Amir, Gutmann, Witherspoon 2001: No need to do endo just b/c calci c metamorphosis.
Only 1-16% of CM teeth develop necrosis
• Abbott 2004: Clinical examination and periapical radiographs do not provide suf cient
information to enable clinicians to accurately assess teeth that have been previously restored
and have pulp and/or periapical pathosis. All existing restorations should be removed before
endodontic treatment in order to address the most common causes of pulp and PA disease
(caries, marginal breakdown, and cracks), and to assess restorability and prognosis.
• Nair PN 2006: Review of persistent apical periodontitis. There is evidence (Penick 1961,
Bhaskar 1966, Seltzer et al. 1967, Nair et al. 1999) that unresolved periapical radiolucencies
may occasionally be due to healing of the lesion by scar tissue that may be misdiagnosed as
a radiographic sign of failed endodontic treatment.
• Gopikrishna et al 2007: Ef cacy of pulse oximeter vs EPT and thermal. Showed pulse
oximeter is an effective method of evaluating pulp vitality.
• Krell, Rivera 2007: Crowning a cracked tooth with reversible pulpitis may be enough to save
the tooth. Mand 2nd and 1st and Max 1st molars have highest incidence of cracked tooth.
Treatment of visually cracked tooth with reversible pulptis was crowned and after 6 months
only 21% of these needed RCT. Crack propagated in only 4%. (Treatment of cracked teeth
with RP using crown. Followup for 6 yrs, but de nitive dx done within 6 months).
• Iqbal et al 2007: Sharp pain was more likely associated with pulpal pathosis, whereas dull
pain was more likely associated with periapical pathosis. Percussion and palpation tests were
powerful in differentially diagnosing between pulpal and periapical conditions
• Mejare, Kvist, Bergenholtz et al 2012: Diagnosis of the condition of the dental pulp: a
systematic review. The aim of this systematic review was to appraise the diagnostic accuracy
of signs/symptoms and tests used to determine the condition of the pulp in teeth affected by
deep caries, trauma or other types of injury. The overall evidence was insuf cient to assess
the value of toothache or abnormal reaction to heat/cold stimulation for determining the pulp
condition. The same applies to methods for establishing pulp status, including electric or
thermal pulp testing, or methods for measuring pulpal blood circulation. In general, there are
major shortcomings in the design, conduct and reporting of studies in this domain of dental
research.
• Bastos et al 2014: A temporary loss of sensibility was a frequent nding during post-
traumatic pulpal healing, especially after luxation injuries. All sensibility tests presented low
accuracy shortly after trauma. The electrical test provided the best support for pulpal
diagnosis after long-term follow up. The clinician must be aware of additional signs of crown
discoloration and radiographic changes before initiating endodontic treatment.
• Read, McClanahan 2014: Ibuprofen can mask pain responses to cold, palpation, and
percussion but doesn’t mask biting pain.

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 • Fowler, Reader, Drum 2014: showed that combo of acetaminophen and hydrocodone had
no effect on cold testing in patients with symptomatic irreversible pulptitis.
• Harrington 1979:
• isolated deep probing —> suspicion for VRF increases.
• wide periodontal pocket —> suspicion of periodontitis increases.
• PradeepKumar, Kishen et al 2016: Dx of VRF. (197 teeth. Retrospective Clinical Study.) It
can be concluded that the mean postoperative time period before the presentation of VRFs in
endodontically treated teeth with crowns and without posts is 4.35 (+/-1.96) years. Pain on
palpation/percussion, the presence of deep, narrow periodontal pockets and halo-shaped
radiolucency are strongly suggestive of VRFs in crowned endodontically treated teeth.
Posterior teeth, female patients, older patients (>40 years), and over lled canals are all
potential risk factors for the presentation of VRF within 5 years postoperatively. Mandibular
molars had the highest incidence of VRFs (34%) followed by maxillary premolars (22.8%).
The characteristic clinical ndings in teeth with VRFs were pain on percussion (60%), pain on
palpation (62%), presence of a deep/narrow pocket (81%) and sinus tract/swelling (67%). The
most common radiographic presentation was a “halo” type radiolucency (48.7%) followed by
thickened periodontal ligament space (23.4%). It was also observed that the obturation
technique followed in all the teeth was lateral compaction technique using gutta percha.
• Miller 1950: Miller Index for mobility. Class I: rst distinguishable sign of movement greater
than normal. Class II: movement of the tooth as much as 1mm in any direction. Class III:
Movement of the tooth more than 1mm in any direction and/or depression or rotation of the
tooth.
• Hill 1986: Fiberoptic illumination. loss of tooth translucency is reported to be an accurate
indication of pulpal health or disease.
• Cameron 1973: discussed using beroptic illumination for crack detection in teeth.
• Kulild: From Ingles. Diagnostic ndings: pain to percussion/mastication and thermal
sensitivity, are pathognomonic for cracked tooth.
• Ingolfsson & Tronstad: discuss how laser dopler owmetry is more accurate than EPT
• Wilcox & Johnson: Discuss pulse oximetry.
• What causes pain while ying / diving?
• Ferjentsik – Barodontalgia - Navy study found 86% with faulty restorations
• Senia – in amed vital pulp tissue major cause
• Kollman – 0.26% incidence in German soldiers
• Zadik 2009:
• Vital Pulp Tissue is major cause. Pain on ascent = pulpitis. Pain on descent =
necrosis.
• Baradontalgia is an oral (dental or non-dental) pain caused by change in barometric
pressure. SCUBA divers sometimes refer to it as “tooth squeeze”. Barodontalgia is
currently classi ed into 4 categories: I Nonreversible pulpitis (Sharp momentary pain
on ascent), II Reversible Pulpitis (Dull throbbing pain on ascent), III Necrotic Pulp (Dull
throbbing pain on descent), IV Periapical pathosis (severe persistent pain on ascent
and descent). A healthy pulp is not affected by barometric change. Good oral hygiene
is a key factor to prevention. Following dental treatment, 24-72 hrs of “grounding” is
an effective way to prevent barodontalgia. If pulp compromised advised to intial RCT.
• Glickman Furcation Classi cation System:
• Grade I: incipient lesion when the pocket is supra-bony involving soft tissue and there is
slight bone loss.
• Grade II: Bone is destroyed on one or more aspects of the furcation but a probe can only
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 • Grade III: Intra-radicular bone is completely absent but tissue covers the furcation.
• Grade IV: a through and through furcation defect
• Lin, Langeland 1984: Always do the proper pulp testing steps regardless of the extent of the
PA lesion and remember that nerve bers can persist even in the presence of severe
in ammation. The purpose was to clinically and histopathologically investigate the pulp
tissues biopsied from cariously involved teeth displaying periapical radiolucency. .
• In most cases the size of periapical radiolucency was related to the extent of bacterial
invasion and the degree of tissue destruction in the canal. Teeth associated with large
periapical radiolucencies may but usually do not respond to pulp testing (Their pulps
often show extensive necrosis).
• Teeth associated with small periapical radiolucencies may respond to pulp testing and
their pulps usually reveal only the coronal necrosis.
• Periapical in ammatory changes often develop before total in ammation or necrosis of
the pulp occurs. Intact nerve bers can persist in pulps having severe in ammation and
partial necrosis.
• Lalonde, Luebke 1968: 800 periapical lesions. 45.2% Granulomas, 43.8% Radicular Cyst,
0.4% Periapical Scar. Can expect 9/10 periapical lesions will be periapical granulomas or
radicular cysts.
• Simon J 1980: JOE. small sample teeth. 35 Teeth. Incidence of true cysts (not connected to
teeth) is low (8.6%). True cysts may not heal with nonsurgical endodontic therapy. The bay
cysts may heal with nonsurgical endodontic therapy because they may have extensions of
epithelial granulomas. Bay Cyst: an apical in ammatory lesion with epithelium lining a cavity
but interrupted by the apex protruding into the cavity. True/Apical Cyst: an apical in ammatory
lesion with epithelium completely lining a cavity with no opening or connection to the apical
foramen and root canal.
• Music
• Nasso et al 2016: This study shows the effects of music therapy on vital values and on
subjective perception of anxiety during endodontic therapy. Music and medicine always
work together; the soothing effects of sounds and musical frequencies make this union an
extraordinary tool of synergistic care. Music therapy is a valid nonpharmacologic adjuvant
to anxiety perception in endodontic therapies.

Radiographs
• Radiation Dosages (micro sievert, µSv):
• Ludlow, Ivanovic 2008: One Periapical Radiograph (Digital) 2-8 µSv
• Pauwels et al 2012: One Panoramic Radiograph (Digital) 14-24 µSv
• Ludlow et al 2015: One Limited FOV CBCT 5-652 µSv
• Ludlow et al 2015: One Large FOV CBCT 46-1073 µSv
• Ludlow: Small FOV unit scans (Accuitomo/Kodak) equivalent to about 3 digital PAs
• Patel: NSD in 180 vs 360 scans using Acciutomo 3D in detecting arti cial AP lesions & less
radiation
• Venskutonis et al 2014: small volume CBCT equivalent to 2-7 PAs
• Radiographic Features important to PA pathosis
• Kaffe & Gratt – continuity & shape of lamina dura; width & shape of PDL
• Strindberg - PDL width and contours normal, lamina dura intact
• Bender 1982: 7% loss of mineral is needed to make lesions visible. Mineral loss, not
size, causes radiolucencies. Cortical plate must be involved before PARL seen.
• Lee & Messer – Lesions in cancellous bone detected if lamina dura is affected

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 • Bender, Setzer 1961: Introduced the concept of anatomical noise to endodontics. They
showed that periapical lesions con ned to cancellous bone cannot be seen because of
the projection of overlying anatomy. Therefore they recommend taking multiple angles to
compensate.
• Periapical Index (PAI) –
• Orstavik/Kerekes (1986)
• Radiographic Assessment of Apical Periodontitis:
• 1 – Normal – No Periapical bone loss evident
• 2 – Small bony changes periapically, not pathognomic for AP
• 3 – Bony changes with Mineral Loss, characterisitic of AP
• 4 – AP with well de ned RL area
• 5 – Severe AP with radiating expansion of bony changes
• Cone Beam CT Periapical Index (CBCT PAI) –
• Estrella (2008)
• CBCT Assessment of Apical Periodontitis:
• 0 – Normal – No Periapical bone loss evident
• 1 – PARL: >0.5 – 1 mm E – Expansion of Periapical cortical bone
• 2 – PARL: >1 – 2 mm D – Destruction of Periapical cortical bone
• 3 – PARL: >2 – 4 mm
• 4 – PARL: >4 – 8 mm
• 5 – PARL: >8 mm
• Technique
• Robinson et al 1989: Found that bitewing radiographs provide an accurate
representation of the location and size of the pulp chamber and can aid in the design of
the endodontic access preparation
• Forsberg: Paralleling is more accurate in length determination vs bisecting angle
• Brnoff 1970: For improved diagnostic accuracy recommends taking multiple angled
radiographs. She found that accuracy improved from 74% to 90% when using one vs 3
radiographs taken from multiple angles. (in a 1967 study Brynof demonstrated that
histologic in ammation can be present in the absence of radiographic changes).
• Radiograph Reliability/Interpretation
• Goldman et al 1972: “Who’s reading the radiograph”. We INTERPRET radiographs.
Severe disagreement in terms of interpreting radiographs as a means of determining
success and failure. 6 examiners: only 47% agreement among 253 cases reviewed.
Upper molars gave the greatest percentage of disagreement.
• Goldman et al 1974: Reliability of radiographic interpretations. Same examiners from
previous study were asked to reexamine the original radiographs 6-8 months later. The
examiners agreed with themselves 72-88% of the time. Radiographic interpretation is a
questionable process at best and is very subjective.
• Tewary: with digital found similar numbers to Goldman; 25% inter-observer and 68%
intra-observer agreement
• Radiographic vs Histologic Findings
• Ricucci, Pitt Ford, 2006: (You can NOT use a radiograph to diagnose cyst/granuloma/
abscess. radiopague lamina doesn’t matter. 57 ext’d teeth). No correlation found
between the presence of a radiopaque lamina and the histological diagnosis of cyst. The
generic term “periapical radiolucent lesion” should be used rather than “granuloma” or
“cyst” when examining radiographs. The differential diagnosis of periapical lesions
cannot be made based on radiographic appearance, but requires histological

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 examination of serial sections. Granulomas 35/57 (61.4%), Cysts 10/57 (17.5%),
Abscess 12/57 (21%).
• Caliskan et al 2016: IEJ. Retrospective study. Neither radiographic size nor presence of
an associated radiopaque line alone was suf cient to determine the type of lesion.
Histological examination is required in order to reach to a de nitive diagnosis. 93
specimens. 72% Granulomas. 21.5% Radicular cyst. 4.3% Abscess. 2.2% Scar tissue.
• Barthel, Trope 2004: It may be concluded that there are relationships between
radiologic and histologic signs of in ammation in human root canal-treated teeth. There
appears to be a tendency that the radiologically determined quality of the coronal seal
has an impact on the histologic state of the root- lled tooth. No relationship was detected
between un lled lateral or accessory canals and the status of in ammation at the
periapex (51% in amed, 49% unin amed).
• Radiographs for Working Length
• Woolhiser et al 2005: The accuracy of digital radiographs for endodontic working length
determination is comparable to conventional analog radiographs. Digital radiography
includes its inherent advantages such as lower radiation exposure, instant image
production and elimination of chemical waste.
• Goodell, McClanahan: Comparing WL measurements. Kodak > schick or conv. for size
10 & 15 les
• Lamus, Katz: Comparing WL measurements. NSD between shick & conv.
• Yilmaz, Senel et al 2017: All CBCT images obtained at different FOVs with voxel sizes
less than 0.3 mm3 performed similarly and better than intraoral periapical radiography in
the determination of endodontic working length measurement. Apex locator
measurements were better than CBCT and periapical images, and they correlated highly
with actual length measurements. (Apex Locator > CBCT > PAs)
• Ustun et al 2016: JOE. Conclusions: In teeth with large periapical lesions and persistent
intracanal exudate, measurement of the root canal length by using CBCT (NewTom 5G,
voxel .125mm) was as reliable as measurements that used apex locators (Propex Pixi,
Raypex 6).
• Digital vs Conventional Radiographs
• Soh et al 1993: Showed that digital radiographs reduce radiation doses to patients
because they require 22% less radiation exposure than traditional radiographic lms.
• White, Pharoah: Oral Radiology Text. 75% reduction in radiation when using digital vs
conventional.
• van der Stelt 2008: Review of advantages of digital radiography compared to
conventional lm-based radiography. (requires less dose, can be altered/enhanced,
measure distances. Disadvantages: more digital radiographs usually taken).
• Mistak, Loushine: NSD between digital, transmitted digital & conventional radiography
for PARL identi cation
• Folk: NSD between shick (cmos) & trophy RVG ui (ccd)
• Nair: conv. lm displayed the highest % of PARL detection (vs. ccd & storage phos.)
• Arkdeniz: enhanced digital superior than original digital, E or F speed lm
• Hadley 2008: All ve digital radiographic systems were signi cantly better at lesion
detection compared with D-speed lm.
• Can a radiographic radiolucency be seen in a patient with irreversible pulpitis?
• Yamasaki: rat study. demonstrated PARL prior to pulp necrosis
• Suzuki, Skinner: PARL w/ IP; 11/24 healed with IDPC
• Bergenholtz: 16% of vital teeth had lesions (nerves more resistant to necrosis)

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 • Abella: CBCT detected add’l 10% (13 vs 3) of PA lesion in IP teeth, Sig more AP lesions
in sym vs asym IP
• Caliskan 1995: IEJ. The favorable results of this study demonstrate that pulpotomy
treatment in teeth with cariously exposed vital pulps and with periapical involvement may
be an alternative treatment to root canal therapy.
• Linsuwanont et al 2017: JOE. Teeth with clinical signs of irreversible pulpitis showed
successful outcomes with pulpotomy. A periapical radiolucency lesion does not always
correlate with pulp necrosis. Teeth with the presence of radiolucency could be treated by
MTA pulpotomy with a high rate of success of 76%. 84% of teeth with clinical signs of
irreversible pulpitis were treated successfully.
• Lin, Langeland 1984: Always do the proper pulp testing steps regardless of the extent
of the PA lesion and remember that nerve bers can persist even in the presence of
severe in ammation. (The purpose was to clinically and histopathologically investigate
the pulp tissues biopsied from cariously involved teeth displaying periapical
radiolucency. In most cases the size of periapical radiolucency was related to the extent
of bacterial invasion and the degree of tissue destruction in the canal. Teeth associated
with large periapical radiolucencies may but usually do not respond to pulp testing (Their
pulps often show extensive necrosis). Teeth associated with small periapical
radiolucencies may respond to pulp testing and their pulps usually reveal only the
coronal necrosis. Periapical in ammatory changes often develop before total
in ammation or necrosis of the pulp occurs. Intact nerve bers can persist in pulps
having severe in ammation and partial necrosis.)
• CBCT
• Systematic Reviews:
• Dutra, Haas et al 2015: Systematic Review/Meta-analysis. Diagnostic accuracy of
CBCT vs Conventional radiography on Apical Periodontitis. Periapical radiographs
(digital and conventional) reported good diagnostic accuracy on the discrimination
of arti cial AP compared to no lesions, whereas CBCT imaging showed excellent
accuracy values.
• Chang et al 2016: Systematic review assessing CBCT in detecting vertical root
fractures (VRF). Only review solely dedicated to assessment of endodontically
treated teeth. Only 4 relevant studies included in analysis, with a total of 130
patients. Currently insuf cient evidence for reliability of CBCT for detecting VRF.
• Lofthag-Hansen et al 2007: Reported identi cation of signi cantly more lesions by
CBCT vs 2D radiographs.
• Low, Van Arx et al 2008: When compared with CBCT, traditional radiographs missed
34% of lesions in the posterior maxilla.
• Estrela 2008: CBCT is more accurate in identifying apical periodontitis when compared
to pano or periapical radiography. Care should be taken during interpretation with the
presence of metallic objects. Other limitations include cost and radiation doses.
• Moura, Estrela et al 2009: Apical periodontitis is detected more frequently when CBCT
is used. Although this cross-sectional study could not show the relation between ROC
and success/failure of RCT, over lled samples showed more frequent incidence of apical
periodontitis.
• de Paula-Silva et al 2009: No difference in speci city was found, but there was a higher
sensitivity using CBCT compared to digital radiographs (de Paula-Silva et al. 2009),
meaning that PR and CBCT were equal in identifying healthy teeth, whereas CBCT
identi ed more of the teeth with apical lesions (Dog study. Veri ed histologically)

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 • Patel 2009: Showed that CBCT images could detect lesions con ned to cancellous
bone. (essentially replicated Bender and Seltzer’s work from 1961). (28% more lesions
vs digital radiographs)
• Peters C, Peters 0 2012: Endo Topics. Review of CBCT and other techniques to detect
the presence and resolution of periapical periodontitis. The success rate determined by
CBCT appears to be 10-40% lower than diagnosed by evaluation of periapical
radiographs. More PA lesions discovered with CBCT. PA bone defects calculated on PA
radiographs were roughly 10% smaller than on coronal sections of the radiolucency as
viewed by CBCT.
• Tsai, Torabinejad 2012: Lesions must be greater than 1.4mm in diameter for adequate
detection on CBCT
• Bornstein: Used CBCT to study the sinus membrane. Found that the sinus membrane
was thicker near roots with AP vs w/out AP.
• Abella, Patel et al 2012: The present study highlights the advantages of using CBCT for
detecting AP lesions, especially in teeth with symptomatic irreversible pulpitis. Three
hundred seven paired roots were assessed with both PA and CBCT images. A
comparison of the 307 paired roots revealed that AP lesions were present in 10 (3.3%)
and absent in 297 (96.7%) pairs of roots when assessed with PA radiography. When the
same 307 sets of roots were assessed with CBCT scans, AP lesions were present in 42
(13.7%) and absent in 265 (86.3%) paired roots. The prevalence of AP lesions detected
with CBCT was signi cantly higher in the symptomatic group compared with the
asymptomatic group (P < .05). An additional 22 roots were identi ed with CBCT alone.
• Venskutonis et al 2014: CBCT imaging should be considered in situations in which
information from conventional imaging systems may not yield an adequate amount of
information to allow the appropriate management of endodontic problems. The radiation
dose of a small-volume CBCT, which is generally suggested for endodontic imaging, is
similar to 2-7 standard periapical radiographs. (However, variation among machines).
• Kruse et al 2015: It can be concluded that although there is a tendency for a higher
accuracy for periapical lesion detection using CBCT compared to two-dimensional
imaging methods, no studies have been conducted that justify the standard use of CBCT
in diagnosing periapical lesions. In addition, it should be considered that, at the present
time, the ef cacy of CBCT as the diagnostic imaging method for periapical lesions has
been assessed merely at low diagnostic ef cacy levels.
• Weissman et al 2015: Reported detecting an apical radiolucency by using PA
radiographs in 57% of cases, while it was detected in 79% of cases using CBCT.
• Ozuk: CBCT reliability in detecting root fracture. Accuitomo 93% accurate in identifying
VRFs, con rmed via retx or surg
• Costa: presence of metallic post sig inhibits accuracy of fx diagnosis w/ CBCT (beam
hardening)
• Cotton, Schindler: CBCT uses in endo. Endo appications: 1) Dx endo path, 2) assess
pathosis of non-endo origin, 3) root fx, 4) Resorption, 5) pre-surgical planning. Cons: 1)
incr radiation, 2) cost, 3) availability, 4) medico-legal
• Uraba, Okiji et al 2016: 178 teeth. Retrospective. The overall periapical lesion detection
rates of PR and CBCT imaging were 31.5% and 52.2%, respectively (P < .0001). The
ability of CBCT imaging to identify periapical lesions that were not detected by PR was
statistically signi cant for the maxillary incisors/canines (P < .0001) and maxillary molars
(P < .005). Conclusions: Within the limitations of this investigation, it can be concluded
that CBCT imaging is effective at detecting periapical lesions that cannot be detected on
PR, particularly in the maxillary incisors/canines and molars. Our ndings suggest that

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 the in uence of structural noise in the maxillary anterior region and maxillary posterior
region should not be overlooked during the interpretation of PR images.
• Vaz de Souza, Patel, Mannocci et al 2017: CBCT imaging is superior in detecting ECR
lesions and their location on the tooth when compared to PA images. In addition, ECR
lesions can be classi ed, based on the Hiethersay classi cation, more accurately using
CBCT scanning as compared to PA radiographs. Highlights the importance of CBCT
imaging in the diagnosis and therefore treatment planning of external cervical resorption
lesions and compares the diagnostic ability of 2 widely distributed CBCT scanners. Used
Carestream and J. Morita.
• Rodriguez, Patel et al 2017: JOE. Our ndings suggest that more diagnostic
information can be obtained from a preoperative CBCT image than from a preoperative
PA radiograph and that this information can directly in uence a clinician’s treatment plan,
particularly in high dif culty cases. CBCT imaging has a substantial impact on
endodontic decision making among specialists, particularly in high dif culty cases. After
viewing the CBCT scan, the extraction option increased signi cantly. The examiners
altered their treatment plan after viewing the CBCT scan in 27.3% of the cases.
• Kanagasingam, Mannocci, Patel 2017: IEJ. CBCT had signi cantly higher diagnostic
accuracy in detecting apical periodontitis compared to periapical radiography, using
human histopathological ndings as a reference standard.
• Rodriguez, Patel, Abella et al 2017: JOE. CBCT imaging directly in uences endodontic
retreatment strategies among general dental practitioners and endodontists.
• CBCT AAE/AAOMR Joint Position Statement 2015: CBCT should be used only when the
patient’s history and a clinical examination demonstrate that the bene ts to the patient
outweigh the potential risks. CBCT should not be used routinely for endodontic diagnosis or
for screening purposes in the absence of clinical signs and symptoms. Clinicians should use
CBCT only when the need for imaging cannot be met by lower dose two-dimensional (2D)
radiography. For most endodontic applications, limited FOV CBCT is preferred to medium or
large FOV CBCT because there is less radiation dose to the patient, higher spatial resolution,
and shorter volumes to be interpreted. If a clinician has a question regarding image
interpretation, it should be referred to an oral and maxillofacial radiologist
• Recommendation 1: Intraoral radiographs should be considered the imaging modality of choice in the
evaluation of the endodontic patient.
• Recommendation 2: Limited FOV CBCT should be considered the imaging modality of choice for diagnosis
in patients who present with contradictory or non- speci c clinical signs and symptoms associated with un-
treated or previously endodontically treated teeth. (CBCT imaging has the ability to detect periapical pathosis
before it is apparent on 2D radiographs)
• Recommendation 3: Limited FOV CBCT should be considered the imaging modality of choice for initial
treatment of teeth with the potential for extra canals and suspected complex morphology, such as mandibular
anterior teeth, and maxillary and mandibular premolars and molars, and dental anomalies.
• Recommendation 4: If a preoperative CBCT has not been taken, limited FOV CBCT should be considered as
the imaging modality of choice for intra-appointment identi cation and localization of calci ed canals.
• Recommendation 5: Intraoral radiographs should be considered the imaging modality of choice for
immediate postoperative imaging.
• Recommendation 6: Limited FOV CBCT should be considered the imaging modality of choice if clinical
examination and 2D intraoral radiography are inconclusive in the detection of vertical root fracture (VRF).
• Recommendation 7: Limited FOV CBCT should be the imaging modality of choice when evaluating the non-
healing of previous endodontic treatment to help determine the need for further treatment, such as non-
surgical, surgical or extraction.
• Recommendation 8: Limited FOV CBCT should be the imaging modality of choice for non-surgical re-
treatment to assess endodontic treatment complications, such as overextended root canal obturation material,
separated endodontic instruments, and localization of perforations.

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 • Recommendation 9: Limited FOV CBCT should be considered as the imaging modality of choice for pre-
surgical treatment planning to localize root apex/apices and to evaluate the proximity to adjacent anatomical
structures.
• Recommendation 10: Limited FOV CBCT should be considered as the imaging modality of choice for
surgical placement of implants.
• Recommendation 11: Limited FOV CBCT should be considered the imaging modality of choice for diagnosis
and management of limited dento-alveolar trauma, root fractures, luxation, and/or displacement of teeth and
localized alveolar fractures, in the absence of other maxillofacial or soft tissue injury that may require other
advanced imaging modalities.
• Recommendation 12: Limited FOV CBCT is the imaging modality of choice in the localization and
differentiation of external and internal resorptive defects and the determination of appropriate treatment and
prognosis.

Topical Anesthetic
• TA anesthetic should be applied for at least one minute and before each injection to
demonstrate that we are doing everything possible to prevent pain.
• Cho et al 2017: JOE. Investigate the effects of topical anesthesia on needle insertion and
injection pain in the labial mucosa of the maxillary central incisors of patients awaiting apical
surgery and to assess the relationship between patients’ anxiety and pain scores. Topical
anesthetic application signi cantly reduced both insertion-and injection-related pain. Injection
pain was signi cantly higher than insertion pain throughout the experiment.
• The topical anesthetic was highly effective for both insertion and injection pain during
in ltration anesthesia in the maxillary central incisors.
• Highly anxious patients reported higher pain scores; however, topical anesthetics
reduced the effect of anxiety on increasing pain.
• Nusstein & Beck 2003: Demonstrated that 20% benzocaine was helpful in the maxillary
anterior region when applied for at least 1 minute. They reported TA signi cantly increased
the odds of patients experiencing no needle pain during maxillary anterior in ltration. No
difference in pain in maxillary posterior in ltrations and IANB.
• Martin et al 1994: Found that if patients thought they were receiving topical anesthetic,
whether they did or not, they anticipated less pain.
• Parirokh, Abbott et al 2012: Use of topical anesthesia had no signi cant effect on pain
during either needle penetration or injection. Pain during injection had no signi cant effect on
the success of anesthesia. (Effect of Topical Anesthesia on Pain during in ltration injection
and success of anesthesia for maxillary central incisors. )

Needle Size/Breakage
• Fuller et al 1990: Found no signi cant difference in the perception of pain produced by 25, 27
and 30 gauge needles in retro-molar fossa
• Flanagen et al 2007: Found no signi cant difference for injection pain between 25, 27 and 30
gauge needles in 930 injections for IANBs, maxillary buccal in ltrations and palatal injections
• Pogrel 2009: most needle fractures occur when giving the IANB often with a 30 gauge
needle and in children who have moved suddenly. Recommends do not bury needle to hub,
avoid using 30 gauge needles for IANB, avoid bending needles at the hub before insertion.
• Aghahi et al 2017: JOE. n=60. Maxilliary teeth w/ supraperiosteal injections. Pain felt during
dental injections is dependent on dental anxiety. Patients feel increased pain if anxiety in the
treatment environment is high, and therefore it is important to reduce anxiety during treatment
to reduce pain. The purpose of this study was to compare pain and anxiety levels
experienced during injections using a newly invented telescopic-coated dental needle that

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 covers the conventional needle and also has the capability of applying topical anesthesia
through its unique design with the conventional dental injection needle. A total of 25 men and
35 women with an age range of 19–55 years participated in this study. Pain levels reported
during the injection using the telescopic-coated needle were signi cantly lower than those
using the conventional needle, with statistically signi cant differences between the 2 groups
(P < .05). Patients experienced signi cantly lower overall postinjection anxiety (P < .05) and
had more positive overall experience ratings with the telescopic-coated needles. Conclusions:
A new telescopic-coated dental needle was superior to a conventional injection system in
pain perception and in reducing postinjection dental anxiety.

Local Anesthetics
• Malamed:
• Local Anesthetic agents are used in the practice of dentistry to prevent the transmission
of pain impulses from peripheral neurons to the brain.
• These agents achieve their effect by blocking sodium channels in peripheral neurons,
thus preventing depolarization of the nerve and the propagation of the action potential.
• The properties of the local anesthetic depends on several factors.
• pKa: The speed of onset depends on the logarithmic acid dissociation constant
(pKa), with a lower pKa causing a more rapid onset of action.
• Lipid Solubility: The potency of the drug results from its lipid solubility. More lipid
soluble anesthetics diffuse more quickly through the neural sheath.
• Metabolism: Most commercially available local anesthetic drugs are amides and
are metabolized in the liver. Articaine has an additional ester linkage, thus
permitting its metabolism by plasma esterases in additional to normal liver
metabolism (Oertel et al).
• Duration: In uenced by protein binding and the presence of a vasoconstrictor. The
duration of action depends on the diffusion of the local anesthetic away from the
site of action and is in uenced both by the ability of the anesthetic to block sodium
channels and the presence of a vasoconstrictor in the local anesthetic solution.
• All local anesthetics are vasodilators, thus vasoconstrictors like epinephrine are
added in solution to slow diffusion from the site of action.
• While allergies to local anesthetics are rare, allergies to sul te preservatives in
solutions containing epinephrine are more common.
• Additional issues with epinephrine are encountered in patients under the care of a
physician for cardiac disease.
• Though maximum dosage of epinephrine in a healthy patient is 0.2mg, the
maximum dosage that may be used in a cardiac patient is 0.04mg, according to
Haas.
• Max Recommended Dosages
• Articaine 7 mg/kg, absolute max N/A
• Bupivacaine absolute max 90
• lidocaine 7 mg/kg, absolute max 500mg
• mepivacaine 6.6mg/kg, absolute max 400mg
• prilocaine 8 mg/kg, absolute max 600 mg
• Schwartz 1974: Review.
• Uncharge basic form (RN) penetrates nerve membrane, ionizes (RNH+), binds to
voltage-gated Na channel and blocks the in ux of Na ions preventing depolarization.
• 1st LA was cocaine.

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 • Inactive nerve cell membranes have a constant charge difference of -70mV across the
membrane with the interior being negative to the exterior. When a stimulus occurs there
is a depolarization until a ring threshold is reached and the cell reaches a potential
difference of + 35mV relative to the exterior.
• When depolarization occurs, the cell membrane increases in permeability to Na+ ions,
and the positively charged Na+ ions ow into the nerve cell. In the presence of Ca++, LA
agents reduce the nerve cell membrane permeability to Na+ ions, and thus, interferes
with depolarization and impulse conduction.
• Epinephrine increase the intensity and duration of the effect of the LA. Vasoconstrictors
decrease systemic toxicity of the LA, allowing absorption to keep pace with metabolism.
Vasoconstrictors reduce local hemorrhage during surgical procedures.
• Ester type LA (Cocaine, benzocaine, procaine) pose a higher risk of allergic dermatitis
compared to amide type LAs (lido, articaine, burpivacaine, mepivicaine).
• Haas DA 2002: An update on local anesthetics in dentistry.
• 1. Biotransformation of amide LA occurs in the liver. Reduced hepatic fxn does not
increase duration of anesthesia but predisposes to toxic effects. Use reduced dosages.
Ester local anesthetics undergo extensive hydrolysis in the plasma by
pseudocholinesterase enzymes
• 2. Methemoglobinemia is associated with articaine and benzocaine
• 3. Articaine and prilocaine are associated with increased paresthesia.
• 4. Malignant hyperthermia occurs with exposures to inhalation anesthetics, not local
anesthetics.
• 5. Lido and prilocaine are preg category B; others are C
• 6. 7mg/kg is max lido dose. (4.4mg/kg is Malamed/conservative)
• Moore PA 2002: Adverse drug reactions to local anesthesia.
• Local anesthesia toxicity: Initial symptoms include tremors, muscle twitching, and
convulsions.
• Respiratory depression, lethargy, and LOC may follow.
• Cardiovascular depression and hypoxia secondary to respiratory depression can rapidly
produce serious outcomes including cardiovascular collapse, brain damage, and death.
• Methemoglobinemia: caused by metabolites of prilocaine, with symptoms occurring 1-3
hrs after treatment.
• Cyanosis without respiratory distress may be apparent when met-Hgb levels reach
10-20%.
• Vomiting and headache have been described, as has dyspnea, seizures, stupor, coma,
and death at levels higher than 20%.
• Methemoglobinemia is a disorder characterized by the presence of a higher than normal
level of methemoglobin (metHb, i.e., ferric [Fe3+] rather than ferrous [Fe2+] hemoglobin)
in the blood. Methemoglobin is a form of hemoglobin that contains ferric [Fe3+] iron and
has a decreased ability to bind oxygen.
• Jastak, Yagiela 1983: Vasoconstrictors Review.
• EPI stimulates alpha & beta adrenergic receptors.
• EPI’s predominant effect in oral mucosa, submucosa and periodontium is that of alpha
stimulation (vascular contraction).
• It can lower mean arterial pressure by substantially decreasing peripheral resistance
because of its potent dilating effect on skeletal muscles arteriole (beta receptors).

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 • Advantages of vasoconstrictors: enhancement of LA, reduction of peak plasma conc. of
LA, control of bleeding. Lido and procaine are strong vasodilators and therefore are an
incompetent pulpal anesthetic w/out a vasoconstrictor.
• Site of injection greatly in uences drug uptake and the effect of vasoconstrictors.
Injection of LA will cause vasodilation in skeletal muscle, but little or none in
subcutaneous tissue.
• Adverse drug interactions:
• Tricyclic agents inhibit uptake of adrenergic amines; it pressor effects of epi are
increased 2-3 times.
• Beta 2 receptor drugs; pressor effects of epi enhanced.
• Adrenergic neuron blocking agents; enhances vasoconstrictive effect.
• The use of LAs w/out vasoconstrictors is advised in patients with severe and poorly
controlled ischemic heart disease, certain arrhythmias and uncontrolled
hyperthyroidism.
• Kim, Trowbridge 1984: Results of this study show that local anesthetic injections of 2% lido
w/ 1:100k epi are capable of reducing pulpal blood ow signi cantly in teeth that are in the
area of or distal to the injection site. Intraseptal method produces greatest decrease in blood
ow. Plain lidocaine increased pulpal blood ow, the decrease in pulpal blood ow can be
attributed to epi.
• Hargreaves, Keiser 2000: Review LA Failures.
• 1. Anatomical Causes
• try Gow-Gates or Akinosis to overcome accessory innervation.
• 2. Acute Tachyphylaxis of LA
• reduced responsiveness of LA, not proven.
• 3. Effect of In ammation on local tissue pH
• in amed tissue is more acidic, more LA trapped in acidic form and can’t cross
membrane.
• Try 3% mepivacaine or buffering LA. uncharged base crosses membrane; charged
acid blocks Na channel. Low pH causes LA to be trapped in the charged acid form
that can't cross membranes. Mepivacaine is more resistant to ion trapping due
to it's lower pKa (7.6 vs 7.9 for lidocaine). Problem with this theory: pH change is
restricted to area of abscess.
• 4. Effect of in ammation on blood ow
• more blood ow, more absorption of LA. try block.
• 5. Effect of in ammation on nociceptors
• may be less sensitive to LAs.
• In ammation affects nociceptors by activation and sensitization- Bradykinin
activates unmyelinated C bers. PGE2 causes sensitization, reducing the threshold
for ring, so that gentle stimuli (heartbeat) can now activate a neuron. Nerves
sprout and grow into areas of in ammation, increasing the size of their receptive
eld. In ammation causes increased neuropeptides (SP, CGRP). TTX-resistant Na
channels are more resistant to lidocaine. TTX-R Na channel activity doubles after
exposed to PGE2.
• 6. Effect of in ammation on central sensitization
• exaggerated CNS response to gentle stimuli.
• Psychological Factors
7.
• apprehension causes reduced pain threshold. manage by establishing trust etc.

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 • Managing: 1. Supplemental Injections. 2. Adjunctive Drugs or Techniques (NSAIDS,
steroids can decrease pulpal nociceptor sensitization and mitigate resistance to LA). By
alleviating in ammation and anxiety will help LAs effectiveness.
• Fouad: 6 fold increase in TTX-resistant sodium channels in IP cases.
• Malamed 2006: LA update. Bupivacaine: only long-acting anesthetic; good for managing
post-op pain. Articaine: Little to no evidence exists that it is superior to other LAs. There is no
scienti c evidence to demonstrate greater risk of paresthesia w/ use of articaine (all reports
are anecdotal).
• Yapp, Hopcraft, Parashos 2011: Articaine Review. A unique amide that contains a
THIOPHENE ring, instead of a benzene ring, which allows greater lipid solubility and potency.
Only amide anesthetic containing an ester group. Amide linkage undergoes biotransformation
in the liver, however, it is additionally inactivated by serum esterases. Lower systemic toxicity
allows a 4% conc., although 2% vs 4% demonstrated no signi cant difference. Supplemental
buccal in ltration of articaine after IANB has shown signi cantly higher success rates. Teeth
w/ irreversible pulpitis: Articaine has be shown to be superior to lidocaine in max post. teeth
during endo procedures. However, no diff between articaine and lido/mepivicaine in mand.
post. teeth during endo procedures. Literature supports the safe and effective use of articaine
for all ages. Since there is no evidence of superiority over other LAs, the choice is based on
personal preference and experience.
• Common Anesthetics
• 2% Lidocaine w/1:100K epi = 34mg lido w/ .017mg epi
• 3% mepivicaine (carbocaine, polocaine) = 51mg mepivicaine
• 4% articaine w/ 1:100k epi = 68mg articaine w/ .017mg epi
• 0.5% bupivicaine (marcaine) w/ 1:200k epi = 9mg marcaine w/ .009mg epi
• Epinephrine action:
• alpha-1 (blood vessels) —> Predominate in oral mucosa & periodontium —> Vasoconstriction
• beta-1 (heart muscle) —> increase cardiac output
• beta-2 (blood vessels) —> predominate in skeletal muscle —> vasodialation
• Epinephrine Drug interactions
• Tricyclic Antidepressants (amitriptyline, doxepin)
• Nonselective beta blockers (Nadolol, propranolol)
• Recreational drugs (cocaine)
• Nonselective alpha adrenergic blockers (chropromazine, clozapine, haloperidol)
• Digitalis (Digoxin)
• Thyroid hormones (Levothyroxine)
• MAO inhibitors
• Contraindications to Epinephrine
• 1. Untreated Congestive Heart Failure
• 2. Uncontrolled HTN (180/110 or >)
• 3. Severe Recalcitrant Arrythmias
• 4. Digoxin – Anti-Arrythmia/CHF drug
• 5. Unstable Angina
• 6. Recent MI (within 6 months)
• 7. Recent CABG (within 3 months)
• 8. Recent Stroke (within 6 months)
• 9. Uncontrolled Hyperthyroidism (Grave’s disease, Pituitary adenoma)
• 10. Pheochromocytoma – adrenal tumor EPI/NorEPI
• 11. Sickle Cell Anemia (limit 2 carps in surgery) – vasoconstrictionCrisis
• 12. Severe Asthmatics – possible sul te allergy – no reported incidents
• 13 Sul te Allergy

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 • 14. Recent Cocaine or Methamphetamine use (within 48 hrs)
• 15. PRONJ – Post-radiation osteonecrosis of jaw; >6000 cGy radiation
• Malamed:
• pKa —> determines the onset of action, the lower the pKa the more rapid the onset
• Lipid solubility determines the potency, permits anesthetic to penetrate the membrane
more easily
• protein binding is responsible for the duration of action. Duration also increased with
vasoconstrictor which decreases blood ow and systemic absorption.
• amide LAs are metabolized in the liver and excreted by the kidneys. Articaine is
metabolized in both the kidneys and plasma
• Mechanisms of Action
• L.A. alters the resting potential and increase excitation (A.P.) threshold of the nerve by
binding to sodium channels and preventing sodium in ux
• pKa of anesthetic determines amount of acid and base forms of anesthetic present:
• decrease in pKa = increase in Base form present extraneuronally = Faster Onset of
L.A.
• Base form of anesthetic crosses neuronal membrane and converts to acid form
• Acid form (NH+) of anesthetic binds to sodium channels to prevent AP transmission
• Finder & Moore 2002 DCN
• 1. LA Toxicity –
• a. Initial symptoms - Tremors, muscle twitching and convulsions
• b. Later ndings – Respiratory depression, lethargy and loss of consciousness.
• c. Final ndings – Cardiovascular depression and hypoxia secondary to respiratory
depression can rapidly produce serious outcomes including cardiovascular
collapse, brain damage and death.
• 2. Vasoconstrictor Overdose –
• a. Initial signs - Palpitations, increase heart rate and elevated BP
• b. Anxiety, nervousness and fear are often found as well
• c. Severe overdose - Arrhythmia, stroke and MI are possible
• Prevention: Good technique, watch for drug interactions, avoid high doses, get good
medical history
• 3. Management from Little & Falace
• a. Protect patient during convulsive phase, consider IV Valium (Diazepam)
• b. Monitor and record vitals (BP, Pulse)
• c. Supportive therapy
• i. Supine position
• ii. O 2 10 L/min, Monitor O2 with Pulse Oximeter
• iii. Maintain BP
• iv. Treat Bradycardia w/ IV Atropine 0.4 mg
• v. EMS
• d. CPR if unconscious
• Haas 2002 DCNA – Recommended Emergency drugs: O2, Epi Pen, Nitro, Injectable
antihistamines (diphenhydramine or chlorpheniramine), albuterol, aspirin, oral
carbohydrates, and corticosteroids.
• LA Overdose from Malamed Lecture: A seizure is the classic expression of a LA
overdose. head tilt and chin lift —> Use if seizure to help maintain airway. most LA
seizures last less than 1 minute. Patient will recover; patient will be ne
• Kim S and Kratchman 2006: Mechanisms of Vasoconstriction by Epinephrine

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 • Epinephrine binds alpha-1, alpha-2, beta-1, and beta-2 adrenergic receptors located on
the vascular smooth muscles.
• The alpha-1 receptors are adjacent to sympathetic nerves that innervate blood vessels.
• The alpha-2 receptors are distributed throughout the vascular system and are generally
bound by circulating catecholamines.
• When epinephrine binds to the beta-1 adrenergic receptors in the heart muscle, the
heart rate, cardiac contractility, and peripheral resistance increase.
• When the drug binds beta-2 adrenergic receptors in the peripheral vasculatures,
vasodilation results.
• The beta-2 receptors are prevalent in blood vessels that supply skeletal muscles and
certain viscera but are relatively rare in mucous membranes, oral tissues, and skin.
• Ideally, for the purpose of endodontic microsurgery, an adrenergic vasoconstrictor would
be a pure alpha-agonist. Fortunately, the predominant receptors in the oral tissues are
alpha-receptors, and the number of collocated beta-2 receptors is very small. Thus, the
drug’s predominant effect in the oral mucosa, submucosa and periodontium is
vasoconstriction. Because virtually all adverse effects associated with epinephrine are
dose and route dependent, clinicians should use the appropriate dose with an aspirating
syringe.
• Receptor types in the oral mucosa: 95% alpha receptors, 5 % beta receptors

Local Anesthetic: Mandibular Teeth

• Aggarwal et al 2016: JOE. RCT. n = 153 premolars.
• The MINB and IANB gave 53% and 47% anesthetic success rates, respectively, with no
signi cant difference between them.
• Adding an IANB to MINB signi cantly improved the success rates to 82%.
• Conclusions: A combination of MINB and IANB can provide improved local anesthesia
for symptomatic mandibular premolars.
• Fernandez, Reader, Beck, Nusstein 2005: IANB. duration of anesthesia: 2% lido w/1:100k
epi 2h 24min pulpal and over 3hrs soft tissue. 0.5% bupivacaine w/1:200k epi 3-4 hrs pulpal
and over 8hrs soft tissue.
• Stanley, Reader et al 2012: Mandibular teeth with irreversible pulpitis had a statistically
signi cant increase in the success of the IAN block when supplemented with 30-50% nitrous
oxide sedation. w/N2O: 50%, w/o N2O: 28% (Sig. Difference)
• Kung, McDonagh, Sedgley 2015: Systematic Review/Meta Analysis.
• In patients with symptomatic irreversible pulpitis, articaine is as effective as lidocaine
when used for mandibular block or maxillary in ltration anesthesia.
• In cases of persistent pulpal pain despite successful mandibular block anesthesia,
supplementary in ltration with articaine instead of lidocaine has 3.55 times greater
likelihood of achieving successful anesthesia.
• Kanaa 2012: Mand. Molars with Irreversible Pulpitis. After a failed IANB, additional articaine
in ltrations provided successful anesthesia 84% of the time, intraosseous anesthesia 68% of
the time, PDL injections 48% of the time and repeat IAN blocks 32% of the time.
• Investigated the ef cacy of different supplementary local anesthesia techniques
following failure of initial IANB. It was concluded that IANB injection alone does not
always allow pain-free treatment for mandibular teeth with irreversible pulpitis.
Supplementary buccal in ltration with 4% articaine with epinephrine and intraosseous
injection with 2% lidocaine with epinephrine are more likely to allow pain-free
treatment than intraligamentary and repeat IANB injections with 2% lidocaine with

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 epinephrine for patients experiencing irreversible pulpitis in mandibular permanent
teeth.
• Nuzum, Reader et al 2010: Mandibular Anterior teeth. The labial plus lingual in ltration
signi cantly improved the success rate (no response to 2 consecutive 80 readings with the
pulp tester) to 98% when compared with a labial in ltration of a cartridge of the same
articaine formulation (76% success). The combination labial and lingual in ltrations did not
provide pulpal anesthesia for an hour. (Normal pulp - 4% Articaine w/1:100k epi – B inf (1.8
mL) + L inf (1.8 mL) vs. B inf (1.8 mL) only. Success: B+L – 98%, B only – 76%, Duration:
B+L improved duration 4th-58th minute)
• Ef cacy of different concentrations of epinephrine
• Yared 1997: JOE. An evaluation of 2% lidocaine with different concentrations of
epinephrine for inferior alveolar nerve block. No statistically signi cant differences in
success and failure were found among the 1:50,000, 1:80,000, and 1:100,000
concentrations of epinephrine
• Mason, Drum, Reader et al 2009: JOE. A prospective, randomized, double-blind
comparison of 2% lidocaine with 1:100,000 and 1:50,000 epinephrine and 3%
mepivacaine for maxillary in ltrations.
• Anesthetic success and the onset of pulpal anesthesia were not signi cantly
di erent between 2% lidocaine with either 1:100,000 or 1:50,000 epinephrine and
3% mepivacaine for the lateral incisor and rst molar. Increasing the epinephrine
concentration from 1:100,000 to 1:50,000 in a 2% lidocaine formulation
signi cantly decreased pulpal anesthesia of short duration for the lateral incisor but
not the rst molar. For both the lateral incisor and rst molar, 3% mepivacaine
signi cantly increased pulpal anesthesia of short duration compared with 2%
lidocaine with either 1:100,000 or 1:50,000 epinephrine.
• Berberich, Reader, Drum et al 2009: JOE. A prospective, randomized, double-blind
comparison of the anesthetic ef cacy of two percent lidocaine with 1:100,000 and
1:50,000 epinephrine and three percent mepivacaine in the intraoral, infraorbital nerve
block.
• The intraoral, infraorbital nerve block was ine ective in providing profound pulpal
anesthesia of the maxillary central incisor, lateral incisor, and rst molar. Successful
pulpal anesthesia of the canine and rst and second premolars ranged from
75%-92% by using 2% lidocaine with 1:100,000 and 1:50,000 epinephrine.
However, pulpal anesthesia did not last for 60 minutes. The use of 3%
mepivacaine provided a shorter duration of anesthesia than the lidocaine
formulations with epinephrine in the canines and premolars.
• Wali, Drum, Reader et al 2010: JOE. Prospective, randomized single-blind study of the
anesthetic ef cacy of 1.8 and 3.6 milliliters of 2% lidocaine with 1:50,000 epinephrine for
inferior alveolar nerve block.
• By using 1.8 mL of 2% lidocaine with 1:50,000 epinephrine, successful pulpal
anesthesia ranged from 33%-50%, and when using 3.6 mL of 2% lidocaine with
1:50,000 epinephrine, success ranged from 40%-60%. When using 1.8 mL of 2%
lidocaine with 1:100,000 epinephrine, success ranged from 40%-60%, with no
signi cant di erence among the 3 anesthetic formulations. CONCLUSION:
Increasing the epinephrine concentration to 1:50,000 epinephrine or increasing the
volume to 3.6 mL of 2% lidocaine with 1:50,000 epinephrine did not result in more
successful pulpal anesthesia when compared with 1.8 mL of 2% lidocaine with
1:100,000 epinephrine by using the IAN block.
• McEntire, Nusstein, Drum, Reader, Beck 2011: Anesthetic ef cacy of 4% Articaine w/
1:100k epi vs 4% articaine w/1:200k epi for primary buccal in ltration in mandibular rst
molar. 1:200k epi comparable to 1:100k epi for buccal in ltrations.

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 • Ef cacy of different anesthetics… ie Articaine vs Lidocaine
• Kung, McDonagh, Sedgley 2015: Systematic Review/Meta Analysis.
• In patients with symptomatic irreversible pulpitis, articaine is as effective as
lidocaine when used for mandibular block or maxillary in ltration anesthesia.
• In cases of persistent pulpal pain despite successful mandibular block anesthesia,
supplementary in ltration with articaine instead of lidocaine has 3.55 times greater
likelihood of achieving successful anesthesia.
• Brandt et al 2011: Pulpal anesthetic ef cacy of articaine vs lidocaine. Meta-Analysis.
• In ltration Anesthesia: articaine superior.
• Mandibular Blocks in teeth w/ IP: articaine or lidocaine can be used.
• Mandibular blocks in healthy teeth: articaine superior.
• Claffey, Reader: NSD between 4% articaine and 2% lido w/ IANB & IP (24%, 23%)
• Mikesell, Nusstein, Reader, Beck, Weaver 2005: Found that the anesthetic ef cacy of
2% lido and 4% articaine were not signi cantly different for IANB.
• McLean, Reader, Beck et al 1993: JOE. Found no difference between 3% mepivacaine,
2% lidocaine or 4% prilocaine in success rate of IANB.
• Fernandez, Reader, Beck 2005: Found no advantage of using 0.5% bupivacaine over
2% lidocaine in achieving success with IANB.
• Whitworth et al 2007: in healthy teeth, 4% articaine is more effective than 2% lidocaine
in achieving anesthesia of the mandibular rst molar
• Visconti et al 2016: Mepivicaine vs Lido in SIP. Mepivacaine resulted in effective pain
control during irreversible pulpitis treatments. The success rates with either solution
were not high enough to ensure complete pulpal anesthesia. All patients tested reported
lip anesthesia after application of either type of inferior alveolar nerve block. Pulpal
anesthesia success rates measured by using the pulp tester were satisfactory for both
solutions (86% for mepivacaine and 67% for lidocaine). Success rates according to
patient report of no pain or mild pain during pulpectomy were higher for mepivacaine
solution (55%) than for lidocaine solution (14%). The differences between mepivacaine
and lidocaine were statistically signi cant.
• Reader, Drum et al 2014: In theory, using 3% mepivacaine initially for an inferior
alveolar nerve (IAN) block would decrease the pain of injection, provide faster onset, and
increase anesthetic success. However Reader (JOE, 2014) stated that the combination
of 3% mepivacaine plus 2% lidocaine with 1:100,000 epinephrine was equivalent to the
combination of 2 cartridges of 2% lidocaine with 1:100,000 epinephrine in terms of
injection pain, onset time, and pulpal anesthetic success for the IAN block.
• McLean, Reader JOE 1993 – Compared 4% Prilocaine, 3% Mepivicaine and 2%
Lidocaine w/ 1:100,000 epi. Vital pulps. NSD in onset, success or failure between any of
the 3 solutions used. Molars = 43-57% Success
• Buccal In ltrations
• Nydegger, Reader, Drum et al 2014: JOE. Anesthetic comparisons of 4%
concentrations of articaine, lidocaine, and prilocaine as primary buccal in ltrations of the
mandibular rst molar: a prospective randomized, double-blind study.
• The success rate for the 4% articaine formulation was 55%, 33% for the 4%
lidocaine formulation, and 32% for the 4% prilocaine formulation. There was a
signi cant di erence between articaine and both lidocaine (P = .0071) and
prilocaine (P = .0187) formulations. CONCLUSIONS: A 4% articaine formulation
was statistically better than both 4% lidocaine and 4% prilocaine formulations for
buccal in ltration of the mandibular rst molar in asymptomatic mandibular rst
molars. However, the success rate of 55% is not high enough to support its use as
a primary buccal in ltration technique in the mandibular rst molar.

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 • Robertson, Nusstein, Reader, Beck, McCartney 2007: Anes. ef cacy of articaine in
buccal in ltration in mand. post. teeth. Clinical trial. 4% Articaine w/1:100k epi
signi cantly better compared to 2% lido w/1:100k epi in achieving pulpal anesthesia
(higher % of pulpal anes., faster onset). Although fast onset, anesthesia declined
steadily for both articaine and lido over 60 min. Lip numbness should not be considered
an indicator of pulpal anesthesia.
• Currie et al 2013: JOE. Found that local in ltration in the molar area works via a
combined mental and incisive nerve block.
• Dressman, Nusstein, Drum, Reader et al 2013: JOE. Found that a single in ltration of
4% articaine in the mandibular premolar region provided successful pulpal anesthesia
80-87% of the time. When an additional in ltration was added success increased to
92-94%.
• Corbett 2008: 4% Articaine in ltrations (buccal + lingual) on lower rst mandibular
molars had similar EPT testing anesthesia as IANB (~60-70% rate of anesthesia).
Subjective tooth numbness was more with IANB.
• McEntire, Nusstein, Drum, Reader, Beck 2011: Anesthetic ef cacy of 4% Articaine w/
1:100k epi vs 4% articaine w/1:200k epi for primary buccal in ltration in mandibular rst
molar. 1:200k epi comparable to 1:100k epi for buccal in ltrations.
• Buccal In ltration Supplemental to IANB
• Fowler, Drum, Reader, Beck 2016: JOE. The purpose of this retrospective study was to
determine the anesthetic success of the inferior alveolar nerve (IAN) block, and
supplemental articaine buccal in ltration after a failed IAN block, in rst and second
molars and premolars in patients presenting with symptomatic irreversible pulpitis. For
patients presenting with symptomatic irreversible pulpitis, the success rates for the IAN
block and supplemental buccal in ltration of articaine of the molars and premolars would
not be high enough to ensure profound pulpal anesthesia.
• Rogers et al 2014: JOE. RCT. n = 100.
• Supplemental BI with articaine was signi cantly more effective than lidocaine.
• Ef cacy of articaine vs lido as supplemental buccal in ltration in mand molars with
irreversible pulpitis. For mandibular molars with IP, the IANB success rate after 1
carpule of 4% articaine with 1:100,000 epinephrine was comparable to previous
reports for 2% lidocaine. As a supplemental BI, 4% articaine was signi cantly more
effective than 2% lidocaine. The superiority of articaine was most clear in second
molars.
• Cold testing is a reliable indicator of pulpal anesthesia after a 4% articaine
supplemental BI. After the IANB give BI with articaine. If symptoms are still present
use IO
• Kanaa 2012: Investigated the ef cacy of different supplementary local anesthesia
techniques following failure of initial IANB. It was concluded that IANB injection alone
does not always allow pain-free treatment for mandibular teeth with irreversible pulpitis.
Supplementary buccal in ltration with 4% articaine with epinephrine and intraosseous
injection with 2% lidocaine with epinephrine are more likely to allow pain-free treatment
than intraligamentary and repeat IANB injections with 2% lidocaine with epinephrine for
patients experiencing irreversible pulpitis in mandibular permanent teeth.
• (After a failed IANB, addtional articaine in ltrations provided successful anesthesia
84% of the time, intraosseous anesthesia 68% of the time, PDL injections 48% of
the time and repeat IAN blocks 32% of the time).
• Matthews, Reader 2009: JOE. Prospective study. n = 55. B in ltration supplemental to
Failed IAN B – Sym. Irreversible Pulpitis, 4% Septocaine w/1:100k epi, Success: 58%

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 • Concluded that when the IAN block fails to provide profound pulpal anesthesia, the
supplemental buccal in ltration injection of a cartridge of 4% articaine with
1:100,000 epinephrine would be successful 58% of the time for mandibular
posterior teeth in patients presenting with irreversible pulpitis. Unfortunately, the
modest success rate would not provide predictable pulpal anesthesia for all patients
requiring profound anesthesia.
• Haase, Reader, Nusstein, Beck, Drum 2008: JADA. Anes. ef cacy of articaine vs
lidocaine as a supplemental buccal in ltration of mand. 1st molar after IANB. Articaine
was statistically signi cantly better. 88% vs 71%.
• Kanaa 2006: Demonstrated that a cartridge of 4% articaine w/1:100k epi was
signi cantly better than a cartridge of 2% lido w/1:100k epi for a primary buccal
in ltration of the mandibular rst molar following IANB 4% articaine w/1:100k epi.
• 1 vs 2 Cartridges
• Fowler, Reader, Beck 2015: 2 cartridges admin for IANB had fewer failures in symp.
and asymp. teeth. Administration of a cartridge volume was signi cantly better than
administration of a cartridge volume in both asymptomatic subjects and patients
presenting with irreversible pulpitis.
• Fowler, Reader 2013: Retrospective. 1 vs. 2 carps 2% Lidocaine w/1:100,000 epi –
Symp. Irreversible Pulpitis, Success: 1 carp: 28%, 2 carps: 39% (No sig difference)
• Albazarpoor 2015: stated that increasing the volume of articaine provided a signi cantly
higher success rate of IANBs in mandibular rst molar teeth with symptomatic
irreversible pulpitis, but it did not result in 100% anesthetic success.
• Aggarwal 2012 – 1 vs. 2 carps 2% Lidocaine w/1:200,000 epi – Symp. Irreversible
Pulpitis, Success: 1 carp: 26%, 2 carps: 54% (Stat. Sig.)
• Vreeland, Reader – Compared 1 carp 2% Lido w/1:100k epi vs. 2 carps 2% Lido w/
1:200k epi vs. 1 carp 4% Lido w/1:100k epi, Vital pulps. NSD in degree or duration of
anesthesia. Molars = 43-60% Success
• Jensen, Drum, Reader, 2008: JOE. Repeating the intraosseous injection 30 minutes
after an initial intraosseous injection will provide an additional 15 minutes of pulpal
anesthesia.
• Mikesell, Drum, Reader et al 2008 – 2 carps vs. 1 carp 2% lido w/ epi – Inc duration
lateral, 1st pm, 1st m. The 3.6 mL volume provided a statistically longer duration of pulpal
anesthesia for the lateral incisor, rst premolar, and rst molar.
• Dressman, Nusstein, Reader et al 2013: JOE. Found that a single in ltration of 4%
articaine in the mandibular premolar region provided successful pulpal anesthesia
80-87% of the time. When an additional in ltration was added success increased to
92-94%.
• Pabst, Drum, Reader et al 2009: Anes Prog. A repeated in ltration of a cartridge of 4%
articaine with 1:100,000 epinephrine given 25 minutes after an initial in ltration of the
same type and dose of anesthetic signi cantly improved the duration of pulpal
anesthesia, when compared with only an initial buccal in ltration, in the mandibular rst
molar.

Local Anesthetic: Maxillary teeth

• Kung, McDonagh, Sedgley 2015: Systematic Review/Meta Analysis.
• In patients with symptomatic irreversible pulpitis, articaine is as effective as lidocaine
when used for mandibular block or maxillary in ltration anesthesia.

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 • In cases of persistent pulpal pain despite successful mandibular block anesthesia,
supplementary in ltration with articaine instead of lidocaine has 3.55 times greater
likelihood of achieving successful anesthesia.
• Askari, Abbott 2016: The effect of maxillary 1st molar root length on the success rate of
buccal in ltration anesthesia. This study focused on 1 of the variables that may in uence
anesthesia success after in ltration injections for maxillary molar teeth with irreversible
pulpitis. Results showed signi cantly higher anesthesia failure in teeth with longer palatal and
distobuccal roots. Used 2% lido w/1:80k epi. In conclusion, maxillary molars with longer root
lengths may have more anesthesia failure compared with teeth with shorter roots.
• Pfeil, Drum, Reader 2010: showed that for the maxillary rst molar, the 3.6 mL volume of the
lidocaine formulation provided a statistically longer duration of pulpal anesthesia than the 1.8
mL volume.
• Brandt et al 2011: JADA. Pulpal anesthetic ef cacy of articaine vs lidocaine. Meta-Analysis.
In ltration Anesthesia: articaine superior. Mandibular Blocks in teeth w/ irreversible Pulpitis:
articaine or lidocaine can be used. Mandibular blocks in healthy teeth: articaine superior.
• Sherman et al 2008: Found no difference between articaine and lidocaine in max in ltrations
• Srinivasan et al 2009: Compared 4% articaine and 2% lidocaine with 1:100k epi, for max
posterior buccal in ltrations in patients experiencing irreversible pulptitis in terms of success.
They found the articaine formulation was more successful than lidocaine (small sample size)
• Aggarwal et al 2011: Teeth with irreversible pulpitis.
• No difference noted between in ltrations and posterior superior alveolar nerve blocks in
their ability to anesthetize maxillary rst molars.
• No difference was found between buccal in ltrations alone or when combined with
palatal in ltrations (palatal anesthesia does not appear to increase anesthetic success
rates)
• Guglielmo, Reader, Drum, Nusstein, Beck 2011: Found that anesthesia success rates did
not signi cantly improve when palatal in ltrations were added; however the duration of local
anesthesia increased. (showed the success rates were 88% for the buccal in ltration and
95% for the buccal plus palatal in ltration. The difference was not statistically signi cant. The
buccal plus palatal in ltration signi cantly increased the duration of pulpal anesthesia from 21
minutes through 57 minutes.)
• Evans, Drum, Reader 2008 – (Articaine superior to lidocaine in anterior but not posterior).
2% Lidocaine w/1:100k epi vs. 4% Articaine w/1:100k epi (1 carp) – B In ltration Max
Laterals/1st Molars: Max Laterals: L: 62%, A: 88% (Sig. Difference), 1st Molars: L: 73%, A:
78% (NSD)
• Mikesell, Reader et al 2008 – 2 carps vs. 1 carp 2% lido w/ epi – Inc duration lateral, 1st pm,
1st m. The 3.6 mL volume provided a statistically longer duration of pulpal anesthesia for the
lateral incisor, rst premolar, and rst molar.
• Kanaa 2012: RCT. showed that there was no signi cant difference in ef cacy between 4%
articaine with 1:100,000 epinephrine and 2% lidocaine with 1:80,000 epinephrine in achieving
anesthesia in maxillary teeth with irreversible pulpitis after buccal in ltration.
• Forloine, Drum, Reader et al 2010: JOE. A prospective, randomized, double-blind
comparison of the anesthetic e cacy of two percent lidocaine with 1:100,000 epinephrine
and three percent mepivacaine in the maxillary high tuberosity second division nerve block.
• The high tuberosity approach to the maxillary second division nerve block with both
anesthetic formulations resulted in a high success rate (92%-98%) for the rst and
second molars. Approximately 76%-78% of the second premolars were anesthetized
with both anesthetic formulations. Both anesthetic formulations were ine ective for the
anterior teeth and rst premolars. The use of 3% mepivacaine provided a signi cantly

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 shorter duration of pulpal anesthesia than 2% lidocaine with 1:100,000 epinephrine in
the molars and premolars.
• Yapp 2011: BDJ. Review. Articaine superior to lidocaine in posterior maxilla
• Berberich, Reader, Drum et al 2009: JOE. A prospective, randomized, double-blind
comparison of the anesthetic e cacy of two percent lidocaine with 1:100,000 and 1:50,000
epinephrine and three percent mepivacaine in the intraoral, infraorbital nerve block.
• The intraoral, infraorbital nerve block was ine ective in providing profound pulpal
anesthesia of the maxillary central incisor, lateral incisor, and rst molar. Successful
pulpal anesthesia of the canine and rst and second premolars ranged from 75%-92%
by using 2% lidocaine with 1:100,000 and 1:50,000 epinephrine. However, pulpal
anesthesia did not last for 60 minutes. The use of 3% mepivacaine provided a shorter
duration of anesthesia than the lidocaine formulations with epinephrine in the canines
and premolars.
• Broering, Reader, Drum et al 2009: JOE. A prospective, randomized comparison of the
anesthetic e cacy of the greater palatine and high tuberosity second division nerve blocks.
• Both techniques resulted in a high success rate of pulpal anesthesia (95%-100%) for
rst and second molars. Around 70%-80% of the second premolars were anesthetized
with both techniques. Both techniques were ine ective for profound pulpal anesthesia
of the anterior teeth and rst premolars.
• Mason, Drum, Reader et al 2009: JOE. A prospective, randomized, double-blind
comparison of 2% lidocaine with 1:100,000 and 1:50,000 epinephrine and 3% mepivacaine
for maxillary in ltrations.
• Anesthetic success and the onset of pulpal anesthesia were not signi cantly di erent
between 2% lidocaine with either 1:100,000 or 1:50,000 epinephrine and 3%
mepivacaine for the lateral incisor and rst molar. Increasing the epinephrine
concentration from 1:100,000 to 1:50,000 in a 2% lidocaine formulation signi cantly
decreased pulpal anesthesia of short duration for the lateral incisor but not the rst
molar. For both the lateral incisor and rst molar, 3% mepivacaine signi cantly
increased pulpal anesthesia of short duration compared with 2% lidocaine with either
1:100,000 or 1:50,000 epinephrine.
• Scott, Drum, Reader et al 2009: J Am Dent Assoc. The e cacy of a repeated in ltration in
prolonging duration of pulpal anesthesia in maxillary lateral incisors.
• A repeated in ltration of 1.8 mL of 2 percent lidocaine with 1:100,000 epinephrine given
30 minutes after the initial in ltration signi cantly improved the duration of pulpal
anesthesia in the maxillary lateral incisor.

Type of Injection Technique: IANB

• Glick, Drum, Nusstein, Reader, Beck 2015: The purpose of this prospective, randomized
study was to evaluate the anesthetic ef cacy of the Gow-Gates and Vazirani-Akinosi
techniques using 3.6 mL 2% lidocaine with 1:100,000 epinephrine in mandibular posterior
teeth in patients presenting with symptomatic irreversible pulpitis. Results: Subjective lip
numbness was obtained 92% of the time with the Gow-Gates technique and 63% of the time
with the Vazirani-Akinosi technique. The difference was statistically signi cant (P = .0001).
For the patients achieving lip numbness, successful pulpal anesthesia was obtained 35% of
the time with the Gow-Gates technique and 16% of the time with the Vazirani-Akinosi
technique. The difference was statistically signi cant (P = .0381). Conclusions: We concluded
that for patients who achieved lip numbness neither the Gow-Gates technique nor the
Vazirani- Akinosi technique provided adequate pulpal anesthesia for mandibular posterior
teeth in patients presenting with symptomatic irreversible pulpitis. Both injections would
require supplemental anesthesia.

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 • Montagnese, Reader 1984: Gow-Gates vs IANB. Clinical study. No signi cant difference
noted between two techniques.
• Haas 2011: Review of Gow-Gates and Akinosi-Vaziraini techniques vs IANB. No difference in
pain experienced by patients in any of three techniques. No evidence that one technique will
have a higher success rate than the other two. However, good to know all three techniques.
• Goldberg, Reader, Drum 2008 – No difference in anesthetic success of IAN vs. Gow Gates
vs. Akinosi. Faster onset of pulpal anesthesia with IAN B.
• Malamed: Suggests Gow-Gates superior to the standard block
• What nerves are anesthetized?
• Akinosi: inferior alveolar, incisive, mental, lingual, mylohyoid. 25 or 27 ga long needle,
insert in soft tissue overlying the medial border of the ramus directly adjacent to the
maxillary tuberosity at the height of the mucogingival junction. This injection is below the
gow gates area but above the inferior alveolar area.
• Gow gates: place needle at MP cusp tip max second molar on a line between the tragus
and the corner of the mouth aiming for the neck of the condyle; picks up IAN, mental,
incisive, lingual, mylohyoid, auriculotemporal and B (in 75% of Pts).

Duration of Pulpal Anesthesia for IANB

• Fernandez, Reader, Beck, Nusstein 2005: IANB. duration of anesthesia:
• 2% lido w/1:100k epi 2h 24min pulpal and over 3hrs soft tissue.
• 0.5% bupivacaine w/1:200k epi 3-4 hrs pulpal and over 8hrs soft tissue.
• 4% articaine w/1:100k epi at least 60 min pulpal (soft tissue not studied)
• McLean, Reader, Beck, Myers 1993: 3% mepivicaine plain at least 50 min pulpal and over
3hrs soft tissue

Injection Technique
• Kudo 2005: Measured injection pressures of dental injections. Injecting with low pressures
signi cantly reduced pain and anxiety.
• Kanaa 2006: Found slow IANB injection (60 sec) was more comfortable and more successful
than a rapid injection (15 sec).
• Aggarwal 2012: in another study assessed the effect of injection rate on success of
anesthesia. It was found that Rate of injection has no effect on anesthetic success of IANB,
but slow injections were more comfortable than rapid injections.

Local Anesthetic: Supplemental Injections

• Webster, Drum, Reader, Fowler, Nusstein, Beck 2016: The supplemental intraseptal
injection (.7mL 4% articaine w/ 1:100k epi) achieved profound pulpal anesthesia in 29% of
patients when the IAN block failed in patients with Sym Irr pulpitis. This injection would not
provide predictable levels of anesthesia for patients requiring emergency endodontic
treatment for symptomatic irreversible pulpitis in mandibular posterior teeth.
• Schleder, Reader, Beck, Meyers 1988: PDL injection: comparison of 1) 2% lido plain, 2) 3%
mepiv., 3) 1:100K epi, 4) 2% lido w/1:00k epi. The PDL injection using 2% lido w/1:100k epi
effective for anesthetizing mandibular 1st molars (pulpal anes during 20min). It anesthetized
adjacent teeth mesially and distally. 3% mepivicaine less effective. 2% lido plain not very
effective. No anesthesia with epi. The addition of epi to 2% lido increased the success and
duration of anesthesia.

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 • Childers, Reader, Mist, Beck, Myers 1996 : Clinical study. Supplemental PDL injection
following IANB increased incidence of pulpal anesthesia for the rst 23 minutes. (2% lido w/
1:100k epi used)
• Dunbar, Reader, Mist, Beck, Myers 1996: Anesthetic ef cacy of intraosseous injection after
IANB block in mand. teeth. Clinical trial. The additional of IO injections following IANB can
improve pulpal anesthetic success and speed up onset.
• Gallatin, Nusstein, Reader, Beck Weaver 2003: IO injection. X-tip vs Sabident in mand.
posterior. Clinical Trial. Both provide quick onset of anesthesia (w/in 2 min) and initial high
rate (93%) of anesthesia success.
• Remmers, Glickman et al 2008: 30 teeth with irreversible pulpitis. Intra Flow intra- osseous
injections had 87% success EPT 80/80. IAN block had 60% success EPT 80/80.
• Moore, Cuddy, Cooke 2011: Review of PDL and IO injection techniques. Alt. approaches.
Useful when IANB has failed.
• Kanaa 2012: Mand. Molars with Irreversible Pulpitis. After a failed IANB, additional articaine
in ltrations provided successful anesthesia 84% of the time, intraosseous anesthesia 68% of
the time, PDL injections 48% of the time and repeat IAN blocks 32% of the time.
• (Investigated the ef cacy of different supplementary local anesthesia techniques
following failure of initial IANB. It was concluded that IANB injection alone does not
always allow pain-free treatment for mandibular teeth with irreversible pulpitis.
Supplementary buccal in ltration with 4% articaine with epinephrine and intraosseous
injection with 2% lidocaine with epinephrine are more likely to allow pain-free treatment
than intraligamentary and repeat IANB injections with 2% lidocaine with epinephrine for
patients experiencing irreversible pulpitis in mandibular permanent teeth.)
• Walton 1986: PDL is primarily intraosseous and when used with operative procedures. Can’t
be used to anesthetize one tooth; adjacent teeth are affected.
• Walton, Garnick 1982: PDL injection needs back pressure.
• Walton 1981: Mandibular molars required supplementary anesthesia more frequently than
other types of teeth. PDL injecting under strong back pressure was important; the greatest
frequency of success was attained when injecting under pressure. Onset of anesthesia was
generally very rapid, usually immediate. The length and gauge of needle were unimportant in
attaining anesthesia. The overall frequency of success in attaining anesthesia with this
injection was 92%. This rate included situations in which the injection was administered more
than once.
• Rosenburg 1975: intrapulpal anesthesia produces effect via pressure
• Kim: said that PDL injection (vasoconstrictive) cuts down blocked blood supply to the pulp up
to 60 mins. Vasoconstriction is mechanism of action.
• Torabinejad: PDL injection has no long-term deleterious effects on pulps of human
premolars.
• Discuss Intraosseous anesthesia success and side effects?
• Replogle & Reader – 67% had an increase in heart rate – ok with healthy pts; consider
mepivicaine (28.8 BPM vs 4 BPM); normal within 4 minutes; most perceived incr w/ lido,
none with Mepivicaine
• Nusstein - Stabident with 2% lidocaine – 88% effective for IP
• Reisman - Stabident with 3% mepivicaine for IP– 80% successful x1 injection; 98% x2

Nerve Injury following IANB

• Haas, Lennon 1995: Retrospective study. Five-fold increase in paresthesia when articaine
implemented for IAN blocks compared to lidocaine.

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 • Pogrel, Thamby 1999: Parathesia: Lingual nerve is affected in 70-79% patients. Inferior
alveolar nerve is affected 21-30%.
• Pogrel, Thamby 2000: Parathesia: < 0.05%. Incidence is between 1 in 26,762 (< 0.025%)
and 1 in 160,571 (< 0.000006)
• Malamed 2006: There is no scienti c evidence to demonstrate greater risk of paresthesia w/
use of articaine (all reports are anecdotal).
• Pogrel 2007: Evaluated patients referred with diagnosis of damage to the inferior alveolar
and or lingual nerve that could only have resulted from IANB. 57 cases. 35% from lido. 30%
from articaine. 30% from Prilocaine. He concluded there was not a disproportionate nerve
involvement from articaine. Use of lidocaine may not be safer with regard to nerve damage.
• Gaffen & Haas 2009: Found a 5 fold increase in paresthesia when articaine was
implemented for IAN Blocks
• Garisto, Haas et al 2010: Occurrence of Parathesia after LA admin. in US. 4% Prilocaine
and 4% articaine are more highly associated with development of paresthesia than other LAs,
which may be due to their 4% formulation (greater potential for neurotoxicity). Most cases
(94.5%) involved the IANB with the lingual nerve being affected in 89%. 3.6 times in articaine,
7.3 times higher in prilocaine. dentists should consider these results when assessing the risks
and bene ts of using 4 percent local anesthetics for mandibular block anesthesia.
• Pogrel 2012: Permanent nerve involvement has been reported following inferior alveolar
nerve blocks. This study provides an update on cases reported to one unit in the preceding
six years. Lidocaine was associated with 25 percent of cases, articaine with 33 percent of
cases, and prilocaine with 34 percent of cases. It does appear that inferior alveolar nerve
blocks can cause permanent nerve damage with any local anesthetic, but the incidences may
vary.
• Pogrel- 15% prolonged paresthesia after IAN w/ articaine, of this 81% spont heal w/in 2 wks,
add’l 10-15% heal w/in 8 wks. If paresthesia lasts more than 8 wks, unlikely to completely
heal, but might get better, surgery not a good option for injection paresthesia, good for
over lls (compress injury)
• Paresthesia following root-end surgery.
• Kim, Rubenstein 2001: As long as complete severance of a major nerve bundle has not
occurred, normal sensation should recur in approximately 4 weeks, or in rare cases,
within a few months.
• Wesson and Gale 2003: reported transient parathesia is a common complication in
mandibular molar surgery, with 20% of patients experiencing some sensory disturbance.
The majority of patients experienced resolution over time, as only 1% of patients
reported a permanent de cit.
• Hillerup: 5 fold higher chance of parathesia w/ articaine vs lido
• 4% Septocaine is most common anesthetic involved in NSDs (neurosensory disturbances)
– 60/96 NSDs reported over 12 yr period in Denmark
• Mechanism of injury – Neurotoxicity of 4% Solution – Axonal degeneration. Not mechanical
due to under representation of other solutions
• Pogrel: Mechanisms of neurosensory disturbance (NSD):
• 1. Mechanical injury – penetrating neural sheath with needle
• 2. Mechanical injury – intraneural hemorrhage, granulation tissue, scar formation
• 3. Neurotoxicity – axonal degeneration
Local Anesthetics: Buffering
• Saatchi, Haghighi et al 2016: The administration of a buccal in ltration injection of 0.7 mL
8.4% sodium bicarbonate before an inferior alveolar nerve block injection can be helpful for

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 clinicians to improve the ef cacy of the anesthesia in mandibular rst molars with
symptomatic irreversible pulpitis. (Results: The success rate after the buccal in ltration of
sodium bicarbonate was 78%, whereas without the buccal in ltration of sodium bicarbonate it
was 44% (P < .001).)
• Shurtz, Reader, Drum, Fowler, Beck 2015: RCT. Buffered articaine did not provide any
advantage over nonbuffered articaine for anesthetic success, anesthesia onset, or pain of
injection for a primary buccal in ltration of the mandibular rst molar
• Herreld, Fowler, Drum, Reader, Fowler, Beck 2015: RCT. Buffering a 4% lidocaine
formulation did not signi cantly decrease the pain of in ltrations or signi cantly decrease the
pain of the incision and drainage procedure when compared with a nonbuffered 4% lidocaine
formulation in symptomatic patients with a diagnosis of pulpal necrosis and associated acute
swelling.
• Schellenberg, Drum, Reader, Nusstein, Fowler, Beck 2015: RCT. For mandibular posterior
teeth, a 4% buffered lidocaine formulation did not result in a statistically signi cant increase in
the success rate or a decrease in injection pain of the IAN block in patients with symptomatic
irreversible pulpitis.
• Balasco, Drum, Reader et al 2013: JOE. Bu ered lidocaine for incision and drainage: a
prospective, randomized double-blind study.
• The addition of a sodium bicarbonate bu er to 2% lidocaine with 1:100,000 epinephrine
did not result in signi cantly decreased pain of in ltrations or signi cantly decreased
pain of the incision and drainage procedure when compared with 2% lidocaine with
1:100,000 epinephrine in symptomatic patients with a diagnosis of pulpal necrosis and
associated acute swelling.

Local Anesthetic: Other

• Drum, Reader, Beck 2011: OOOOE. Long buccal nerve block injection pain in patients with
irreversible pulpitis.
• Intro: The purpose of this study was to determine the pain associated with needle
insertion (with or without topical anesthetic) and solution deposition for the long buccal
nerve block injection in patients with irreversible pulpitis. Initial pain and any di erences
by age and gender were also studied. RESULTS: Moderate-to-severe pain occurred
from 41% to 46% of the time with the long buccal nerve block. The use of topical
anesthetic did not statistically decrease the pain of needle insertion. CONCLUSIONS:
In conclusion, 41% to 46% of patients presenting with irreversible pulpitis have the
potential for moderate-to-severe pain with the long buccal nerve block.
• Hutchinson, Reader, Drum et al 2011: JOE. A prospective, randomized single-blind study
of the anesthetic e cacy of frequency-dependent conduction blockade of the inferior
alveolar nerve.
• We concluded that the stimulation of nerves in the presence of local anesthesia
(frequency-dependent nerve block) did not statistically increase the success rate of
pulpal anesthesia for an IAN block.
• Droll, Drum, Reader et al 2012: JOE. Anesthetic e cacy of the inferior alveolar nerve block
in red-haired women.
• Intro: The exact reasons for failure of the inferior alveolar nerve (IAN) block are not
completely known, but red hair could play a role. The genetic basis for red hair involves
speci c mutations, red hair color (RHC) alleles, in the melanocortin-1 receptor (MC1R)
gene. The purpose of this prospective randomized study was to investigate a possible
link between certain variant alleles of the MC1R gene or its phenotypic expression of
red hair and the anesthetic e cacy of the IAN block in women. Results: Women with
red hair and women with 2 RHC alleles reported signi cantly higher levels of dental

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 anxiety compared with women with dark hair or women with 0 RHC alleles. No
signi cant di erences in anesthetic success were found between any of the groups for
any of the teeth. CONCLUSIONS: Red hair and the MC1R gene were signi cantly
linked to higher levels of dental anxiety but were unrelated to success rates of the IAN
block in women with healthy pulps.
• Perry, Drum, Reader et al 2015: JOE. E ect of operator and subject gender on injection
pain: a randomized double-blind study.
• No signi cant di erences were detected between male and female participants on the
Corah Dental Anxiety Scale. For all 4 operator-gender combinations, no signi cant
di erence was found in reported pain for needle insertion or placement. A signi cant
di erence (P = .0357) was found during the solution deposition phase among female
subjects receiving injections from male operators. CONCLUSIONS: Gender had a
statistically signi cant e ect for solution deposition pain when a male operator
administered the injection to female subjects.
• K r, Tsesis, Metzger 2017: IEJ. When EALs are used, local anesthesia may not be required
for root canal treatment in teeth with necrotic pulps and retreatment cases associated with
periapical lesions. (40 retreatment cases, 40 necrotic pulp cases. In all 80 cases no patients
experienced pain)
• Bultema, Fowler, Drum, Reader, Nusstein, Beck 2016: RCT. n=95. Studied liposomal
bupivacaine (Exparel) in managing post op pain with endo tx. Although liposomal bupivacaine
had some effect on soft tissue anesthesia, it did not reduce pain to manageable clinical
levels. Therefore, we cannot recommend the use of in ltrations of liposomal bupivacaine or
bupivacaine to control postoperative pain in patients presenting with untreated, symptomatic
irreversible pulpitis. (Not approved for block anesthesia)
• Glenn, Drum, Reader, Fowler, Nusstein, Beck 2016: For symptomatic patients diagnosed
with pulpal necrosis experiencing moderate to severe preoperative pain, a 4.0-mL in ltration
of liposomal bupivacaine (Exparel) did not result in a statistically signi cant increase in
postoperative success compared with an in ltration of 4.0 mL bupivacaine. (RCT. n=100)
• Parirokh, Abbott et al 2012: JOE. Patients who received bupivacaine as the anesthetic
agent for single-visit endodontic treatment of irreversible pulpitis in mandibular molars had
signi cantly less early postoperative pain and used fewer analgesics than those who had
lidocaine as the anesthetic. (RCT. n = 60. 0.5% bupivicaine 1:200k vs 2% lido w/1:80k epi)
• Does accessory nerve innervation affect anesthesia?
• Frommer – mylohyoid nerve may supply accessory innervation
• Pogrel – cross innervation of Mand incisors
• Clark, Reader - mylohyoid injection did not sig enhance pulpal anesthesia
• Stropko - (From Lecture). Foramen Coli. Located lingual of lower 2nd molar in apical
area. Can be source of additional/accessory innervation of mandibular teeth. Only in
some patients.
• Reversal of soft tissue anesthesia
• Fowler, Reader 2011 – Reversal of soft tissue anesthesia following admin of (oraverse)
phentolamine in asymptomatic endodontic patients post IAN B and Maxillary In ltrations.
Statistically signi cant decreases in time for return of normal lip sensation: Maxillary – 88
min decrease, Mandibular – 47 min decrease.
• Elmore, Reader 2013 – Reversal of soft tissue anesthesia in normal patients following
admin of (oraverse) phentolamine 30 min or 60 min post IAN block. Phentolamine
signi cantly reduced duration of both pulpal and soft tissue anesthesia. 30 min post IAN
admin was 24 mins faster (75 mins vs. 90-100 mins) for reversal effect than 60 mins
post IAN admin

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 • Laviola 2008: Phentolamine mesylate (OraVerse, Septodont) acts as a vasodilator and,
when administered, can reduce the duration of local anesthesia.
• Malamed 2001: Articaine hydrochloride: a study of the safety of a new amide local anesthetic
J Am Dent Assoc, (2001): The chemical composition of articaine contains a unique thiophene
ring instead of the benzene ring found in lidocaine and other amide local anesthetics. This
difference increases lipid solubility, thereby increasing diffusion through the lipid membrane of
the epineurium, which purportedly explains its faster onset and higher success rate when
compared with lidocaine
• Willett, Reader, Drum, Nusstein, Beck 2008: Anes ef cacy of Diphenhydramine and
dyphenhydramine/lido for IANB. Diphenhydramine gives very poor success rate of pulpal
anesthesia and causes moderate to severe injection pain and continued pain on pos op days
when compared to lidocaine. The combination of DPH and lidocaine gives less success than
lidocaine alone and causes more pain on pos op days.
• Becker 2007: Epi interacts with digitalis
• Aggarwal V et al 2012: Increasing the volume of 2% lidocaine to 3.6ml improved the success
rates as compared with 1.8ml. 54% success with 3.6ml VS 26% success with 1.8ml.
• Yadav et al 2015: RCT. To compare preoperative oral medication (ketorolac) on anesthetic
ef cacy of IANBs and buccal and lingual in ltration with articaine and lidocaine in patients
with irreversible pulpitis.
• Premedication with ketorolac signi cantly increases the anesthetic ef cacy of articaine
IANB/in ltrations in mandibular molars with irreversible pulpitis.
• A supplemental in ltration of articaine is superior to lidocaine in ltration.
• Ketorolac is a non-steroidal anti-in ammatory drug (NSAID) in the family of heterocyclic
acetic acid derivatives, used as an analgesic. Ketorolac is indicated for short-term
management of moderate to severe pain
• Rodriquez-Wong et al 2016: IEJ. The combination of mepivacaine-tramadol achieved similar
success rates for IANB when compared to mepivacaine 2% with 1:100k epi. There was no
signi cant difference in the anesthetic ef cacy between the control and experimental
solutions and none of the solutions were completely successful.
• Shetty et al 2015: In mandibular posterior teeth diagnosed with symptomatic irreversible
pulpitis, preoperative administration of 1 mL magnesium sulfate USP 50% resulted in
statistically signi cant increase in success of IAN block compared with placebo.
• Akhlaghi, Abbott et al 2016: Ketorolac buccal in ltrations can increase the success rate of
anesthesia after IANB and BI with articaine 1:100k epi in patients with acute irreversible
pulpitis.
• Fullmer, Drum, Reader 2014: JOE. E ect of preoperative acetaminophen/hydrocodone on
the e cacy of the inferior alveolar nerve block in patients with symptomatic irreversible
pulpitis: a prospective, randomized, double-blind, placebo-controlled study.
• The success rate for the IAN block was 32% for the combination dose of 1000 mg
acetaminophen/10 hydrocodone and 28% for the placebo dose, with no statistically
signi cant di erence between the 2 groups (P = .662). CONCLUSIONS: A combination
dose of 1000 mg acetaminophen/10 mg hydrocodone given 60 minutes before the
administration of the IAN block did not result in a statistically signi cant increase in
anesthetic success for mandibular posterior teeth in patients experiencing symptomatic
irreversible pulpitis.
• Reader 2010: The purpose of this prospective, randomized, double-blind, placebo-controlled
study was to determine the effect of the administration of preoperative ibuprofen on the
success of the inferior alveolar nerve block (IAN) in patients with irreversible pulpitis. The
success rate for the IAN block was 41% with ibuprofen and 35% with placebo, with no
signi cant difference (P=.57) between the 2 groups. For mandibular posterior teeth, a dose of

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 800 mg of ibuprofen given 45 minutes before the administration of the IAN block did not result
in a statistically signi cant increase in anesthetic success in patients with irreversible pulpitis.
• Aggarwal 2010: Comparative evaluation of effect of preoperative oral medication of ibuprofen
and ketorolac on anesthetic ef cacy of inferior alveolar nerve block with lidocaine in patients
with irreversible pulpitis: a prospective, double-blind, randomized clinical trial J Endod (2010):
Statistical analysis with nonparametric chi2 tests showed that placebo gave 29% success
rate. Premedication with ibuprofen gave 27%, and premedication with ketorolac gave 39%
success rate. There was no signi cant difference between the 3 groups. Preoperative
administration of ibuprofen or ketorolac has no signi cant effect on success rate of inferior
alveolar nerve block in patients with irreversible pulpitis.
• Do pre-oper NSAIDs help success of anesthesia?
• Yes:
• Parirokh 2010: 150 pts w/ Sym. Irreversible Pulpitis, IAN B Success: 600 mg Ibuprofen
78%, Indomethacin 62%, Placebo 32% - Preop (1 hr) Ibu & Indo Signi cantly Success of
IAN B in Symptomatic IP patients)
• Ianiro, Eleazer 2007 - 40 pts w/ Sym. Irreversible Pulpitis, IAN B, Success: 600 mg Ibu/
1000 mg Aceto 76%, 1000 mg Aceto 71%, Placebo 46%. NSD but trend towards more
success with pre-op analgesic
• Yadav et al 2015: RCT. To compare preoperative oral medication (ketorolac) on
anesthetic ef cacy of IANBs and buccal and lingual in ltration with articaine and
lidocaine in patients with irreversible pulpitis. Premedication with ketorolac signi cantly
increases the anesthetic ef cacy of articaine IANB/in ltrations in mandibular molars with
irreversible pulpitis.
• Akhlaghi, Abbott et al 2016: Ketorolac buccal in ltrations can increase the success rate
of anesthesia after IANB and BI with articaine 1:100k epi in patients with acute
irreversible pulpitis.
• No:
• Simpson, Reader 2011 – Combination of 1000 mg Acetominophen/ 800 mg Ibuprofen
did NOT signi cantly improve success of IAN b in Symptomatic irreversible pulpitis
cases; Preop Ibu + Aceto did not Inc. success of IAN
• Aggarwal 2010 – Sym. Irreversible Pulpitis, IAN B Success: 300 mg Ibu 27%, 10 mg
Ketorolac 39%, Placebo 29% - NSD; Preop (1 hr) Ibu or Ketorolac did NOT Inc. success
of IAN B (pain during procedure)
• Oleson, Reader 2010 – Sym. Irreversible Pulpitis, IAN B Success: 800 mg Ibuprofen
41%, Placebo 35% - NSD; Preop Ibu did not Inc. success of IAN
• Hagai 2015: Pregnancy outcome after in utero exposure to local anesthetics as part of dental
treatment. Results suggest that use of dental local anesthetics, as well as dental treatment
during pregnancy, do not represent a major teratogenic risk
• Buckley J Perio 1984: Study indicated signi cant reduction in blood loss using 1:50 vs
1:100k epi (50% less blood loss)
• Lindorf OOO 1979: This study discussed the rebound effect (reactive hyperemia) after
injections with epi.
• Frommer: Mylohyoid nerve may supply accessory innervation
• Pogrel: Cross innervation of mandibular incisors
• Clark, Reader: Mylohyoid injection did not signi cantly enhance pulpal anesthesia
• Wilburn-Goo, Lloyd 1999: When patients become cyanotic: acquired methemoglobinemia. J
Am Dent Assoc 1999. Methemoglobin normally is present in the blood at levels <1%. Levels
may become toxic as hemoglobin is oxidized to methemoglobin after local anesthetics such
as benzocaine and prilocaine are administered. Overdoses occurring in dental practice are

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 rare, accounting for 9 of 100 overdoses. Such cases have prompted maximum recommended
dose changes for prilocaine (4mg/lb max). Benzocaine doses of 15-20mg/kg may cause
methemoglobinemia, and a 1 second spray of 20% topical benzocaine delivers 60mg.
Symptoms may develop hours after administration. Patients at increased risk include those
with heart disease, anemia, G6PD de ciency, children<2, and elderly.

Con rming pulpal anesthesia

• Kitamura 1983: reported EPT was 99% accurate when testing teeth determined to be vital
(con rming pulpal anesthesia)
• Dreven et al 1987: Showed that the absence of patient response to an 80 reading with the
EPT was an assurance of pulpal anesthesia in vital, pain-free teeth
• Miller et al 2004: Once the patient is experiencing profound lip numbness, the cold
refrigerant (endo ice) is sprayed on a large cotton pellet help with cotton tweezers. If no pain
is felt, it is likely that pulpal anesthesia has been obtained. They demonstrated that pulp
testing with a cold refrigerant is effective when tooth has a gold, PFM or all-ceramic
restoration.
• Reader’s Group: 2 EPT readings of 80
• Rogers et al 2014: JOE. RCT. n = 100. Mandibular Molars with IP
• Supplemental BI with articaine was signi cantly more effective than lidocaine.
• Cold testing is a reliable indicator of pulpal anesthesia after a 4% articaine supplemental
BI. After the IANB give BI with articaine. If symptoms are still present use IO
• Cohen: lip anesthesia is not a reliable indicator of pulpal anesthesia. The use of DDM (endo
ice) is a reliable method of determining true pulpal anesthesia. 92% effective.

Local Anesthetic: Max Dosage

• Haas 2000:
• Maximum dosage of epi in healthy patient is 0.2mg (.2/.017=11.6 carts lido)
• the maximum dosage of epi that may be used in a cardiac patient is 0.04mg
(.04/.017=2.3 carts lido).
• Epi is subject to a number of drug interactions: tricyclic antidepressants (amitryptiline,
doxepin), nonselective beta blockers (propranolol, nadolol), cocaine, general
anesthetics. Also it interacts with digitalis (according to Becker 2007).
• Moore: rule of 25 = 1 cartridge for every 25 pounds of weight
• Max dosage of Anesthetic According to Malamad (and manufacturer)
• 2% Lido —> 4.4mg/k or 2mg/lb, 300 mg max, (7.0mg/kg or 500mg max)
• 3% Mepivi plain —> 4.4mg/kg, 300mg max, (6.6mg/kg or 400mg max)
• 4% Septo —> 7mg/kg or 3mg/lb, 500mg max, (Same)
• 0.5% marcaine —> 1.3mg/kg or 90mg max, (Same)
I&D, Trephination, Sinus Tracts
• Bene ts of Incision and drainage: (O) Oxygen, (I) increase circulation, (D) decrease
bacteria count, (P) promotes healing, and (P) decrease pressure.
• Slutzky-Goldberg, Tsesis et al 2009: Quintessence. Odontogenic sinus tracts: a cohort
study.
• Sinus tracts while most frequently found on the buccal aspect can be found relatively
commonly on the lingual aspect of gingiva as well.

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 • Sinus tracts originated mainly from maxillary teeth (63.1%); only 38.9% originated from
mandibular teeth.
• Chronic periapical abscess was the most prevalent diagnosed origin (71.0%).
• Broken restorations were highly associated with the presence of sinus tracts (53.0%).
• The most frequent site of ori ces was buccal (82.4%), followed by lingual or palatal
(12.0%).
• Ori ces on the lingual aspect of the gingiva were observed in mandibular molars. There
was an 86.8% correlation between the occurrence of an apically located sinus tract and
apical rarifying osteitis (P<.01).)
• Gupta, Hasselgren 2003: chart review. Prevalence of odontogenic sinus tracts in pts referred
for endo therapy. 1/5 teeth with periradicular in ammation have a sinus tract.
• Huttler: talked about decompression of cellulitis.
• Farber: Multiple sinus tracts are a good indication of VRF.
• Kelly, Ellinger 1988: JOE. Case Report. Always trace sinus tract. Pulpal and Periradicular
pathosis causing sinus tract formation through the sulcus. “Sinus tract formation frequently
occurs secondary to pulpal-periradicular disease. Although sinus tracts usually exit through
the gingiva or the mucosa, they may also drain extraorally or through the gingival sulcus of
the involved or an adjacent tooth. Those opening through the gingival sulcus may traverse a
pathway directly through the periodontal ligament, or they may leave the alveolar housing and
dissect subperiosteally to the osseous crest where they subsequently enter the gingival
sulcus”.
• Larson: suggested to trace sinus tract with GP #25.
• Johnson: presented ve cases of facial lesions that were initially misdiagnosed as lesions of
nonodontogenic origin. The correct diagnosis in each case was cutaneous sinus tract
secondary to pulpal necrosis and suppurative apical periodontitis. All facial sinus tracts
resolved after the patients received nonsurgical root canal therapy. They concluded that if the
sinus track is originating from odontogenic infection, the sinus track will be healed following
NSRCT.
• Nusstein, Reader, Beck 2002: The purpose of this retrospective study was to determine the
effect of drainage upon access on postoperative endodontic pain and swelling in symptomatic
necrotic teeth. n = 124. Obtaining short-term drainage upon access (average of 1.85 min) did
not signi cantly (p > 0.05) reduce pain, percussion pain, swelling, or the number of analgesic
medications taken for symptomatic necrotic teeth with periapical radiolucencies.
• What are sinus tracts lined with?
• Baumgartner 1984: (most sinus tracts are not lined with epithelium throughout their
entire length. Microscopic examination of 30 sinus tracts revealed that 100% were lined
with epithelium at the surface mucosal interface. Twenty of thirty (67%) sinus tracts did
not have epithelium deeper than the surface mucosal rete ridges. The remaining
extension of the sinus tract was lined with granulomatous tissue. Ten of thirty (33%)
sinus tracts had epithelium extending down the tract to the periapical lesion. The
periapical in ammatory lesions that the sinus tracts communicated with were
microscopically diagnosed as abscesses, granulomas and cysts.
• Harrison, Larson 1976:
• Most sinus tracts are not lined with epithelium and 9 out of 10 are lined with
granulation tissue.
• Sinus tracts that extended from periapical lesions to the alveolar mucosa were
surgically removed and examined microscopically. The results indicate that sinus
tracts may be lined with strati ed squamous epithelium. More commonly, however,
these tracts are lined with granulation tissue.

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 • Apical Trephination/Apical Patency
• Foraminal Enlargement —> More Post-Op Pain
• Yaylali et al 2017: JOE. RCT. Foraminal enlargement of necrotic teeth with a
continuous rotary system causes more post-op pain on the rst 2 days after an
endodontic treatment. 1 visit endo.
• Saini et al 2016: IEJ. RCT. Enlargement of the apical foramen during root canal
treatment increased the incidence and intensity of postoperative pain in teeth with
pulp necrosis and apical periodontitis. Pain was higher in the FE group than in the
NFE in the rst 6 days. 2 visit endo.
• Foraminal Enlargement —> Little or No Post-op Pain
• Cruz Junior et al 2016: JOE. Reported that foraminal enlargement created with a
reciprocating system led to a low incidence of pain.
• Silva et al 2013: JOE. RCT. Indicated that FE created in anterior teeth with hand
les did not signi cantly increase the pain.
• Apical Patency on Post-op Pain
• Arora M 2015: IEJ. Randomized clinical trial study- Maintenance of apical patency
during chemomechanical preparation had no signi cant in uence on post-operative
pain in posterior teeth with necrotic pulps and apical periodontitis.
• Reader et al 2001: Effect of apical trephination on postoperative pain and swelling
in symptomatic necrotic teeth. J Endod 2001: The purpose of this study was to
evaluate postoperative pain and swelling after performing apical trephination in
symptomatic necrotic teeth with apical radiolucencies. The apical trephination group
took signi cantly less acetaminophen with codeine tablets. Although the
trephination procedure seemed to have some effect, there was no signi cant
decrease in reduction of pain, percussion pain, or swelling and therefore its routine
use is not recommended for symptomatic necrotic teeth with radiolucency.
• Arias, de la Macorra et al 2009: JOE. This study compares the incidence, degree,
and length of postoperative pain in 300 endodontically treated teeth, with and
without apical patency, in relation to some diagnostic factors (vitality, presence of
preoperative pain, group, and mandible of treated tooth). Of the questionnaires
received back, apical patency was maintained during shaping procedures with a
#10 K- le in one group (n = 115) and not in the other (n = 121). There was
signi cantly less postendodontic pain when apical patency was maintained in
nonvital teeth. If pain appeared, its duration was longer when apical patency was
maintained in teeth with previous pain or located in the mandible. Maintenance of
apical patency does not increase the incidence, degree, or duration of
postoperative pain when considering all variables together.
• Overinstrumentation
• Georgopoulou, Sykaras 1986: IEJ. showed a signi cantly higher incidence of pain
after over-instrumentation of canals during preparation.
• Torabinejad, Kettering 1988: JOE. Unintentional over instrumentation did not
affect post op pain
• Siqueira, Barnett 2004: Endo Topics. Increases risks of interapppointment pain as
result of mechanical injury to periradicular titles, usually coupled with apical
extrusion of debris and microorganisms.
• Jahde & Himel 1987: A small amount of in ammation and localized bone necrosis
occurs with le overextension .

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 • Gonzales Sanchez 2012: overinstrumentation created an oval-shaped major
foramen. ProTaper Universal and ProFile Vortex les were used in their study. Both
le systems are nonlanded.
• Hu, Sedgley, Svec 2014: Landed, nonlanded and nonlanded reduced shape
memory les all produced transportation of the apical foramen when
overinstrumented 0.5 mm in severely curved canals. There was no difference
between these le systems with regard to the degree of this effect. (looked at
ProFile ISO, ProFile Vortex or Vortex Blue)
• Cortical Trephination
• Dorn SO: In the absence of swelling, trephination is the surgical perforation of the
alveolar cortical plate to release from between the cortical plates the accumulated tissue
exudate that causes pain. Its use has been historically advocated to provide pain relief in
patients with severe and recalcitrant periradicular pain
• Moos HL: A comparison of pulpectomy alone versus pulpectomy with trephination for
the relief of pain. They concluded that trephination was not effective in SAP.
• Reader et al 2000: OOOOE. The majority of patients with symptomatic necrotic teeth
had signi cant postoperative pain and required analgesics to manage this pain. The use
of a trephination procedure with an intraosseous perforator, les, and a spoon excavator
did not signi cantly reduce pain, percussion pain, swelling, or the number of analgesic
medications taken in symptomatic necrotic teeth with periapical radiolucencies (P >.05).
We cannot recommend the routine use of a trephination procedure, as used in this study,
for relief of pain in symptomatic necrotic teeth with radiolucencies.
• Houck, Reader, Beck, Nist, Weaver 2000: RCT. Effect of trephination on post-op pain and
swelling in symptomatic necrotic teeth (trephinatation ~ mid root). Following RCT,
Trephination at the conventional site of an intraosseous injection (not the periapex) does not
provide more post-operative pain relief or reduce analgesic medication taken by patients who
present with symptomatic, necrotic teeth with periapical radiolucencies.
• Nist, Reader, Beck 2001: RCT. Following RCT, apical trephination performed. No signi cant
reduction in pain, percussion pain, or swelling resulted. Therefore, cannot not recommend the
routine use of an apical trephination procedure, as used in this study, in symptomatic necrotic
teeth with radiolucencies.
• Simon, Warden, Bascom 1995: Gen Dent. Needle aspiration: An alternative to incision and
drainage. (Not able to nd abstract yet)

Dental Dam
• AAE Position Statement 2010: Standard of care. The American Association of Endodontists
is dedicated to excellence in the art and science of endodontics and to the highest standards
of patient care. The accumulated clinical knowledge and judgment of the practitioner
supported by evidence-based scienti c research is the basis for endodontic treatment. Tooth
isolation using the dental dam is the standard of care; it is integral and essential for any
nonsurgical endodontic treatment.A dental dam is a latex or nonlatex sheet with a hole
punched in the material to allow placement around the tooth during the endodontic
procedure. One of the primary objectives of endodontic treatment is disinfection of the root
canal system. Only dental dam isolation minimizes the risk of contamination of the root canal
system by indigenous oral bacteria. The dental dam also offers other bene ts, such as aiding
in visualization by providing a clean operating eld and preventing ingestion or aspiration of
dental materials, irrigants and instruments.
• Cohen, Swartz 1987: Use of a rubber dam is the standard of care to prevent aspiration or
ingestion of instruments and subsequent lawsuits.

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 • Cochran et al 1989: The rubber dam is the only device capable of preventing contamination
of the root canal system with oral ora during treatment.
• Lambrianidis, Beltes 1996: Case report on swallowed instruments. Safety and it is the
standard of Care
• Ahmad 2009: Aids in visualization during treatment and reduces risk of aspiration of irrigants
and instruments.
• Goldfein et al 2013: Rubber dam use during post placement in uences the success of root
canal-treated teeth. 204 teeth. 174 w/o RD (73% success) and 30 w/RD (93% success) (174
vs 30 not a great comparison).
• Lin et al 2014: Effect of rubber dam usage on the survival rate or RCT. 3.43 year survival:
90.3% w/RD, 88.8% w/out RD (**30k extracted not taken into failure). Additionally, 29,219
teeth were extracted of the ~500k. Survival probability of endodontically treated teeth was
signi cantly enhanced by rubber dam isolation.

Straight Line Access

• Ove Peter: Ingles Text. Initial Access. It is suggested that only the initial entry point on the
occlusal table should be based on a standardized protocol but once the pulp chamber has
been found, the cavity should be tailer made (prep should re ect pulpal anatomy).
• Ove Peters: Ingle’s Text. Straight line access describes a preparation that provides a straight
or outwardly ared, unimpeded path from the occlusal surface to the apex. This allows the le
to reach the apex with minimal de ection. SLA involves the selective removal of the outer
canal tooth structure to protect the furcal surface.
• Mannan 2001: SLA provides a better chance of debridement of the entire canal (done on
extracted anterior teeth, their straight line access was through the incisal edge)
• Schroeder, Walton 2002: results showed negligible length changes occurring during the
aring of coronal canal preparation and that straight-line access and coronal aring may be
performed either before or after working length determination. Severe curvature had a slightly
greater, signi cant effect on the amount of change. Tooth type had no signi cant effect.
Changes in working length from SLA and CF, although statistically signi cant, were very small
and clinically unimportant.
• Krasner, Rankow 2004: Anatomy of the Pulp-Chamber oor. Law of Centrality: the oor of
the pulp chamber is always located in the center of the tooth at the level of the CEJ. Law of
Concentricity: the walls of the pulp chamber are always concentric to the external surface of
the tooth at the level of the CEJ. Law of CEJ: CEJ is most consistent, repeatable landmark for
locating the position of the pulp chamber. Law of Color Change: Color of pulp chamber oor
is always darker than the walls. Ori ces of the root canal are always located at wall/ oor
junction.
• Robinson et al: Recommends BWs to assess coronal pulp anatomy
• Plotino et al 2017: JOE.
• The purpose of this study was to compare in vitro the fracture strength of root- lled and
restored teeth with traditional endodontic cavity (TEC), conservative endodontic cavity
(CEC), or ultraconservative “ninja” endodontic cavity (NEC) access.
• Teeth with TEC access showed lower fracture strength than the ones prepared with CEC
or NEC. Ultraconservative “ninja” endodontic cavity access did not increase the fracture
strength of teeth compared with the ones prepared with CEC. Intact teeth showed more
restorable fractures than all the prepared ones.

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 • Rover et al 2017: JOE. In uence of access cavity design on root canal detection,
instrumentation ef cacy, and fracture resistance assessed in maxillary molars. It was possible
to locate more root canals in the TEC group in stages 1 and 2 (P < .05), whereas no
differences were observed after stage 3 (P > .05). The percentage of noninstrumented canal
areas did not differ signi cantly between the CEC (25.8% ± 9.7%) and TEC (27.4% ± 8.5%)
groups. No signi cant differences were observed in the percentage of accumulated hard
tissue debris after preparation (CEC: 0.9% ± 0.6% and TEC: 1.3% ± 1.4%). Canal
transportation was signi cantly higher for the CEC group in the palatal canal at 7 mm from
the apical end (P < .05). Canal preparation was more centralized in the palatal canal of the
TEC group at 5 and 7 mm from the apical end (P < .05) and in the distobuccal canal of the
CEC group at 5 mm from the apical end (P < .05). There was no difference regarding fracture
resistance among the CEC (996.30 ± 490.78 N) and TEC (937.55 ± 347.25 N) groups
(P > .05). The current results did not show bene ts associated with CECs. This access
modality in maxillary molars resulted in less root canal detection when no ultrasonic troughing
associated to an OM was used and did not increase fracture resistance.

Cleaning and Shaping (Pre- aring)

• Coronal aring has several functions. It provides straight line access to the apical portion of
the canal (Schroeder et al) and allows the apical foramen to be reached more consistently
when read with EALs (Ibarrola et al). Further more, Roland et al found that pre aring
decreases the incidence of rotary instrument separation. However, this process leads to
change in WL measurements; although, according to Schroeder et al, this change is
clinically insigni cant.
• Ibarrola 1999: Effect of pre aring on Root ZX apex locators. An in vitro study was designed
to determine if pre aring of canals would facilitate the passage of les to the apical foramen
by eliminating cervical interferences and to see what effect this would have on the
performance of the Root ZX apex locator. Results of this study suggest that pre- aring of
canals will allow working length les to more consistently reach the apical foramen (p =
0.015), which in turn increases the ef cacy of the Root ZX apex locator.
• Roland, Torabinejad 2002: .04 taper NiTi les were far less likely to separate in pre- ared
canals.
• Stabholz, Rotstein, Torabinejad 1995: The ability to determine the apical constriction by
tactile sensation was signi cantly increased when the canals were pre- ared (p < 0.0001).
• Schroeder, Walton 2002: Our results showed negligible length changes occurring during the
aring of coronal canal preparation and that straight-line access and coronal aring may be
performed either before or after working length determination. Severe curvature had a slightly
greater, signi cant effect on the amount of change. Tooth type had no signi cant effect.
Changes in working length from SLA and CF, although statistically signi cant, were very small
and clinically unimportant.
• Iqbal 2010; Baumgartner 2002: Over instrumentation can be minimized by completing
coronal aring before WL determination due to change in the WL. (loss of working length
during instrumentation)
• Shovelton: Pre aring remove more microorganism and reduce the bacterial load in vital
cases because they are more in the coronal part in vital cases.
• Tan, Messer 2002: Pre aring rst led to a more accurate master apical le size determination
(a larger MAF was able to be placed to WL when pre aring was done).
• Borges et al 2016: The in uence of cervical pre aring on the amount of apically extruded
debris after root canal preparation using different instrumentation systems. Results:

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 • K- les produced signi cantly more debris than all of the other systems (P < .05).
• For all systems, cervical pre aring reduced the amount of apically extruded debris when
compared with no cervical pre aring (P < .05).
• The apical debris extrusion occurred independent of the instrument used.
• Full-sequence rotary systems promote signi cantly less apical extrusion of debris than
reciprocating systems.
• The cervical pre aring was associated to a lesser amount of apical debris extrusion.
• Vasconcelos et al 2016: JOE. Lab. Changes in root canal length at different stages of
preparation evaluated with Root ZX II. Demonstrated a precision of > than 96.5% +/- 0.5mm.
The authors concluded that the RCL of the teeth presented signi cant reduction in extent
during the chemical-mechanical preparation, making it necessary to perform electronic
measurements not only after cervical preparation but also as soon as instrumentation has
been completed. The accuracy of Root ZX II presented no change considering the time
interval when the electronic measurement was made. the authors concluded that during
endodontic treatment, the extent of the RCL was reduced, thereby jeopardizing control of the
apical limit during instrumentation and/or obturation. The RZX was extremely accurate in all
evaluated stages.

Working Length with Root ZX

• Custer 1918: First report of EAL with alcohol or dry canal. Measures resistance.
• Suzuki 1942: reported that PDL and oral mucosa have a constant electrical resistance of
~6.5 kOhms. dogs.
• Sunada 1962: Classic: Credited as being the rst to develop EAL (Suzuki 1942 demonstrated
technology in dogs). Measured electrical resistance between canal and periodontal
membrane to accurately locate the apex. The patient’s age, shape, or type of teeth and the
diameter of canals showed no in uence. No difference in vital vs necrotic cases.
• Kobayashi 1994: Developed technology for Root ZX. Measures impedance values that
represent a ratio of resistances
• Accuracy/Precision of EAL
• Shabahang 1996: Accuracy of Root ZX 96% +/- 0.5mm
• Pratten, McDonald 1996:
• Apex locator was more reliable in determining the position of the apical constriction
compared to radiographs. Cadavers.
• EAL tends to overestimate WL.
• Radiographs tend to underestimate WL.
• Welk, Baumgartner, Marshall 2003: The ability to locate the minor diameter (+/- 0.5
mm) was 90.7% for the Root ZX and 34.4% for the Endo Analyzer Model 8005.
• Tselnik, Baumgartner, Marshall 2005: Both apex locators were within 0.5mm of the
minor constriction 75% and within 1mm of the minor constriction 90% of the time. This
indicates that EWL determination by Root ZX and Elements Diagnostic would provide
accurate readings if used as indicated (by the manufacturer) under the clinical condition.
• Vasconcelos et al 2016: JOE. Lab. Changes in root canal length at different stages of
preparation evaluated with Root ZX II. Demonstrated a precision of > than 96.5% +/-
0.5mm. The authors concluded that the RCL of the teeth presented signi cant reduction
in extent during the chemical-mechanical preparation, making it necessary to perform
electronic measurements not only after cervical preparation but also as soon as
instrumentation has been completed. The accuracy of Root ZX II presented no change
considering the time interval when the electronic measurement was made. the authors
concluded that during endodontic treatment, the extent of the RCL was reduced, thereby

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 jeopardizing control of the apical limit during instrumentation and/or obturation. The RZX
was extremely accurate in all evaluated stages.
• Piasecke 2016: JOE. Micro CT Study of Apex ID vs Root ZX
• The “0.5” mark can be used to determine the WL with high precision. Some
anatomic variations may in uence the accuracy of EALs. The accuracy of EALs to
determine the RCL can be negatively affected by the lateral position of the AF,
whereas their accuracy to determine the WL can be affected by the AF–AC
distance.
• Root ZX and Apex ID are equally precise in determining the RCL and WL.
• The average AF diameter was 0.45 mm (0.24– 0.66 mm).
• The average AC diameter was 0.31 mm, (0.2 and 0.5 mm).
• The average AC–AF distance was 0.59 mm, (0.12–2.25 mm).
• The accuracy of the EALs to determine the AF was reduced in the presence of
accessory canals. However, the results were not statistically signi cant (P > .05).
• It was negatively affected by the lateral positioning of the AF.
• The "APEX/0.0 mark" - 0.5 mark was less precise in determining the WL than RCL-
0.5 mm, but not statistically signi cant.
• The accuracy of the EALs when using the 0.5 mark was affected when the AC–AF
distance was more than 0.5 mm.
• The 0.5 mark on both EALs can be used to determine the WL rather than
subtracting 0.5 mm from the measurements obtained at the APEX/0.0 mark.
• Does apical status, resorption, irrigant or type of le in uence EAL.
• Tsesis 2015: JOE. Systematic Review & Meta Analysis. The precision of electronic
working length measurement depends on the device used and the type of irrigation and
is not in uenced by the status of the pulp tissue.
• Dunlap et al 1998: There was no statistical difference between the ability of the Root ZX
to determine the apical constriction in vital canals versus necrotic canals.
• Piasecki et al 2011: The Root ZX II device was accurate in locating the apical foramen
regardless of the presence of Apical Periodontitis.
• Jenkins et al 2001:
• Irrigant solution does not affect Root ZX reading. 7 irrigants tested.
• The present data indicate that the Root ZX electronic apex locator reliably
measured canal lengths to within 0.31 mm and that there was virtually no difference
in the length determination as a function of the seven irrigants used. These results
strongly support the concept that the Root ZX is a useful, versatile, and accurate
device for the determination of canal lengths over a wide range of irrigants
commonly used in the practice of endodontics.
• Elayouti 2009: Inconsistent readings associated with obliterated canals
• Goldberg et al 2002: (Root ZX accurate in presence of root resorption). The Root ZX
was 62.7%, 94.0%, and 100.0% accurate to within 0.5 mm, 1 mm, and 1.5 mm of the
direct visual measurements, respectively. The purpose of this in vitro study was to
evaluate the accuracy of Root ZX apex locator to determine the working length in teeth
with simulated apical root resorption.
• Thomas, Hartwell 2003: Stainless-steel and NiTi les can be used interchangeably
during the course of root canal therapy for length determination without compromising
the WL reading. Smaller les tended to give lower than actual true length readings,
whereas larger les gave higher than actual true length readings. (Used Root ZX).
• Angwaravong, Panitvisai 2009: To evaluate whether root resorption of primary molar
teeth affects the accuracy of the Root ZX apex locator and to compare the Root ZX at

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 different meter readings with direct canal measurement. The Root ZX was 96.7%
accurate to within +/- 0.5 mm of the apical foramen when compared with the actual canal
length of primary molars with root resorption. (extracted primary teeth)
• Wilson, Baumgartner 2006: EALs (Root ZX) and EPTs (Endo Anayzer) are safe for patients
with Implanted cardiac pacemakers or cardioverter/de brillators
• Williams et al 2006: when the le is short it is actually closer to the apical foramen than it
appears radiographically; when it is long it is actually longer than it appears radiographically.
• Martins et al 2014: JOE. Systematic Review. Compared the radiographic and electronic
methods. It was concluded that the apical locator reduces the patient radiation exposure and
also that the electronic method may perform better on the working length determination. At
least one radiographic control should be performed to detect possible errors of the electronic
devices.
• Ibarrola 1999: Results of this study suggest that pre aring of canals will allow working length
les to more consistently reach the apical foramen (p = 0.015), which in turn increases the
ef cacy of the Root ZX apex locator.
• Ustun et al 2016: JOE. Conclusions: In teeth with large periapical lesions and persistent
intracanal exudate, measurement of the root canal length by using CBCT (NewTom 5G, voxel
.125mm) was as reliable as measurements that used apex locators (Propex Pixi, Raypex 6).
• Oliveira, Vasconcelos et al 2017: JOE. The aim of this study was to evaluate the accuracy
of 5 electronic apex locators (EALs): Root ZX II (RZX; J Morita, Tokyo, Japan), Raypex 6
(RAY; VDW GmbH, Munich, Germany), Apex ID (AID; SybronEndo, Orange, CA), Propex II
(PRO; Dentsply Maillefer, Ballaigues, Switzerland), and Propex Pixi (PIXI, Dentsply Maillefer)
when used in the following protocols: (1) −1.0, insertion up to 1.0 mm below the apical
foramen (AF); (2) 0.0/−1.0, insertion until the AF and withdrawn 1.0 mm short of the AF; (3)
0.0, insertion until the AF; and (4) over/0.0, insertion until “over” and withdrawal to AF.
Considering the suggested protocols, the lowest mean error values were observed in 0.0,
0.10 mm (RZX), 0.13 mm (RAY), 0.16 mm (AID), 0.23 mm (PRO), and 0.10 mm (PIXI),
without a signi cant difference for over/0.0 (P > .05). Comparing the results obtained in 0.0
with those found in −1.0 and 0.0/−1.0, signi cant differences were observed for most EALs
(P < .05). For the comparison between EALs, signi cant differences were observed only in
protocols −1.0 and over/0.0 (P < .05). Under the conditions of the study, it was concluded
that, regardless of the mechanism of the device, the best results were found when electronic
RCL measurement was performed at the AF; furthermore, the electronic withdrawal did not
offer any additional advantage over the reach of the AF.

Preparation Techniques:
• Ingle: Standardized Technique (uses the same WL for all instruments introduced into the
canal and therefore relies on the inherent shape of the instruments to impart the nal shape
to the canal. Also called, “single-length technique
• Coffae, Brilliant; Clem; Weine: Step Back, serial prep (pre-curved les w/ incremental
instrumentation for root canal enlargement)
• Torabinejad: Passive Step Back
• Marshall: Crown Down Pressure-less
• Abou Ras: Anticurvature Filing (involves using precurved les cutting only on outward stroke
away from furcal surface but it is not effective beyond curvature - O. Peters).
• Roane: Balanced Force
• Goerig: Crown Down/ Step-down
• Reciprocation

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 • Yared 2008: proposed a new preparation technique with only 1 ProTaper F2 in a
reciprocating motion. Reciprocating motion is an evolution of the balanced force
technique that proved to maintain the curvature with minimal distortion of the root canal
shape. The risk of cyclic fatigue is reduced because it is presumed that counterclockwise
rotation of reciprocating motion diminishes the torsional stress exerted on the le. The
reduction in the number of les may also lead to the assumption that the apical extrusion
of debris and release of neuropeptide could be decreased.
• Grande, Cohen 2015: Current Assessment of Reciprocation in Endodontic Preparation: A
Comprehensive Review: Reciprocation movement (RM) is de ned as a repeated backward and
forward (CW/CCW) movement; this reciprocal movement can be applied to many endodontic
les, and it has been extensively used in endodontics for many years. There are many variations
of RM, including complete reciprocation (oscillation), partial reciprocation (rotational effect),
and hybrid reciprocation (combined movements). Hybrid reciprocation can be xed or exible
(ie, they can shift from one type of reciprocation to the other in the canal based on mechanical
resistance and torque).
• Canal preparations effect on tooth
• Sedgley: Vital dentin 3.5% harder; biomechanical properties are not signi cantly altered
after root canal treatment and teeth do not become more brittle after RCT. It is the
cumulative loss of tooth structure that weaken the tooth.
• Reeh: Reduction in tooth stiffness as a result of endodontic and restorative
procedures? Endodontic procedures have only a small effect on the tooth, reducing the
relative stiffness by 5%. This was less than that of an occlusal cavity preparation (20%).
The largest losses in stiffness were related to the loss of marginal ridge integrity. MOD
cavity preparation resulted in an average of a 63% loss in relative cuspal stiffness.
• Zelic 2015: IEJ. Mechanical weakening of devitalized teeth: three-dimensional Finite
Element Analysis and prediction of tooth fracture: Teeth with two-surface composite
restorations that underwent root canal treatment are less resistant to high occlusal load,
but the main contribution to their weakening arises from access cavity preparation. Canal
enlargement does not contribute to this process substantially.
• Awawdeh, Al-Omari et al 2017: JOE. The difference in the maximal bite force was
signi cantly higher in root canal–treated teeth, which is consistent with the function of
dental pulp as a highly sensitive sensor. Therefore, the reduction in the sensitivity of teeth
to an applied load after pulp removal may increase the risk of overloading. This may, in
turn, increase the frequency of tooth damage after root canal treatment. (This is a
comparative cross-sectional study of 124 patients who received root canal treatment.
Treated teeth were compared with vital teeth on the contralateral side.)
• Bayram, Celik et al 2017: JOE. n=40 mandibular premolars. The aim of the present study
was to evaluate the frequency of dentinal microcracks observed after root canal
preparation with ProTaper Universal, ProTaper Gold, Self-Adjusting File, and XP-endo
Shaper instruments using micro–computed tomographic (CT) analysis. The PTU system
signi cantly increased the percentage rate of microcracks compared with preoperative
specimens (P < .05). No new dentinal microcracks were observed in the PTG, SAF, or XP
groups. Root canal preparations with the PTG, SAF, and XP systems did not induce the
formation of new dentinal microcracks on straight root canals of mandibular premolars.
• de Oliveira et al 2017: JOE. n=60. This study aimed to compare apical microcrack
formation after root canal shaping by hand, rotary, and reciprocating les at different
working lengths using micro–computed tomographic analysis. Root canal shaping with
ProTaper Universal for Hand Use, HyFlex CM, and Reciproc systems, regardless of the
working length, did not produce apical microcracks. Neither the root canal preparation

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 techniques nor the instrumentation lengths tested in uenced the production of apical
microcracks.
• Plotino et al 2017: JOE.
• The purpose of this study was to compare in vitro the fracture strength of root- lled and
restored teeth with traditional endodontic cavity (TEC), conservative endodontic cavity
(CEC), or ultraconservative “ninja” endodontic cavity (NEC) access.
• Teeth with TEC access showed lower fracture strength than the ones prepared with CEC
or NEC. Ultraconservative “ninja” endodontic cavity access did not increase the fracture
strength of teeth compared with the ones prepared with CEC. Intact teeth showed more
restorable fractures than all the prepared ones.
• Sigurdsson, Kim et al 2017: JOE. The aim of this study was to evaluate the effect of
different pecking depth on the stress generated by the screw-in forces of a rotating
endodontic le in simulated canals. No signi cant difference in SF was found between the
2 groups of pecking depths. However, the longer pecking depth (4-mm group) showed a
signi cantly larger cumulative screw in force CSF compared with the shorter pecking depth
group (P < .05). The shorter pecking depth may generate lower overall stresses for the root
dentin as well as the instrument

Glide Path/#10 Patency File/Hand Files

• Patino 2005: Use stainless steel hand les to prepare the apical 1/3 of curved canals before
introducing rotary les, to reduce the incidence of le breakage. (K3, ProFile, ProTaper)
• Izu 2004: 5% NaOCl prevents inoculation of periapical tissues w/ patency le.
• Vera, van der Sluis 2012: patency le #10 decreased vapor lock and allowed irrigants to
reach the apical foramen better
• Peters: no protaper instrument fractured when glide path was created
• Goldberg: Recommends using a small le for patency; big les cause transportation (61% of
#25 les caused apical transportation, 25% of #10 les caused apical transportation)
• Sanchez 2010: Small patency les extended 1mm beyond the apical foramen found no
transportation.
• Izu et al 2004: JOE. Showed that small les used as patency les are unlikely to carry
bacteria past a reservoir of NaOCl.
• Berutti et al 2014: JOE. ProGlider to reduced stress in ProTaper Next X1 during shaping
through a glide path and preliminary middle and coronal pre aring.
• Elnaghy, Elsaka 2014: JOE. ProGlider/PTN instrumentation method revealed better
performance with fewer canal aberrations when compared with instrumentation performed
with PathFile/PTN or PTN only.
• Ajuz et al 2013: JOE. This study compared the incidence of deviation along S-shaped
(double-curved) canals after glide path preparation with 2 nickel-titanium (NiTi) rotary
path nding instruments and hand K- les. Findings suggest that rotary NiTi instruments are
suitable for adequate glide path preparation because they promoted less deviation from the
original canal anatomy when compared with hand-operated instruments. Of the 2 rotary
path nding instruments, Scout RaCe showed an overall signi cantly better performance.
• Ozyurek et al 2017: JOE. The used glide path les’ Number of Cycles to Failure (NCF) was
lower than the new ones; however, this difference was not statistically signi cant (P > .05).
The cyclic fatigue resistance of the used and new PathFile #2 les was statistically
signi cantly higher than that of the ProGlider les (P < .05).
• Arora, Tewari et al 2016: IEJ. RCT. Maintenance of apical patency during chemomechanical
preparation had no signi cant in uence on post-operative pain in posterior teeth with necrotic
pulps and apical periodontitis.

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 • Paleker, van der Vyver 2017: JOE. Glide path preparation times with the rotary instrument
groups (ProGlider, G-Files) were signi cantly faster than with stainless steel manual K- les.
• Bahcall, Skidmore 2005: (The causes, prevention, and clinical management of broken
endodontic rotary les.)
• Dentist can best prevent this occurrence ( le breakage) by using hand les before rotary
les, creating a straight- line (glide path) access into a canal, and pre aring the coronal
portion before using rotary les in the apical third of the canal.
• Complications can occur during many dental procedures. The prepared clinician
responds by either correcting the problem during treatment, or, ideally, preventing the
problem from occurring in the rst place. In endodontic treatment separated rotary Ni-Ti
les are a common procedural problem. Through understanding that the main causes of
le breakage are cyclic fatigue and torsional stress, a dentist can best prevent this
occurrence by using hand les before rotary les, creating a straight-line (glide path)
access into a canal, and pre aring the coronal portion before using rotary les in the
apical third of the canal. In addition, using an up and down motion with the electric slow-
speed handpiece (not allowing the le to bind within the canal) will signi cantly reduce
the incidence of le breakage. If a le does break, successful removal primarily depends
on the location of the le in the canal rather than the speci c technique employed for
removal. A case does not necessarily fail if the separated le cannot be removed. The
prognosis when le separation occurs can still be favorable, especially if care was taken
to reduce the critical concentration of canal debris with hand instrumentation and
chemical irrigation prior to rotary le insertion. In addition, the introduction of a new CS
le design will help the dentist increase the chance of removing the le in the event of
breakage.
• Kim et al 2017: JOE. The aim of this study was to evaluate the changes in the surface pro le
of rotary nickel-titanium (NiTi) les designed to prepare a glide path and conventional
stainless steel (SS) hand les when used in extremely narrow canals both in clinical and
experimental conditions. This study showed that PathFiles had signi cantly less surface
defects compared with SS les after the preparation of narrow canals, indicating their
possible bene ts when establishing a glide path in extremely narrow canals. PathFile can be
used multiple times in extremely narrow canals.

Preparation Length
• Sjogren et al 1990:
• Vital or Necrotic teeth w/out AP have 96% success; with AP have only 86% success
• Success of Cases with pulp necrosis + AP is affected by length of obturation.
• 94% 0-2mm short
• 68% +2mm short
• 76% long.
• Cases with previous RCT and AP: 67% 0-2mm, 65% >2mm, 50% long
• The rate of success for cases with vital or nonvital pulps but having no periapical
radiolucency exceeded 96%, whereas only 86% of the cases with pulp necrosis and
periapical radiolucency showed apical healing.
• Kuttler 1955: Distance between AC and AF
• 0.5-0.6mm between minor (AC) and major foramen (AF)
• 0.525mm 18-25y/o, 0.659mm >55 y/o
• Burch, Hulen: avg .59mm from occlusal of major diameter to apex
• Green 1956: AC to AF 1mm in Anterior
• Green 1960: AC to AF 0.75mm in Posterior,

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 • Chapman 1969: AC to AF 0.5mm - 1mm. Diameter of AC = 0.13-0.17mm
• Tamse & Littner 1988: apical foramen was positioned 0.8mm from tip of the root
• Stein, Corcoran 1990: AC to AF = .72mm, Apical Constriction/CDJ = .19mm, avg cementum
width .492mm (increases w/ age)
• Piasecke 2016: (Micro-CT study of Apex ID vs Root ZX) The average AF diameter was 0.45
mm (0.24– 0.66 mm). The average AC diameter was 0.31 mm, (0.2 and 0.5 mm). The
average AC–AF distance was 0.59 mm, (0.12–2.25 mm).
• Wu, Wesselink, Walton 2000: Extension of the root lling material in uenced the treatment
outcome. Prognosis is decreased with over- ll and with signi cant under- ll. Instrumentation
or obturation should not extend beyond the apical foramen. Apical Terminus location of root
canal treatment procedures.
• Termination Point with a Vital Pulp: Terminate instrumentation 2-3mm, rather than
0-2mm from the apex.
• Termination point for infected/necrotic canals: terminate instrumentation at or within 2mm
of radiographic apex (0-2mm). Success rate drops if short of 2mm or apex or beyond
apex.
• Termination point for retreatment: recommend instrumenting to the AF/radiographic
apex, but ll short (1-2mm of the AF to con ne irrigants, obturants etc).
• Blaskovic-Subat 1992: 76% of foramina deviates from apex. Quotable for direction of
deviations (B in anterior teeth and D in posterior teeth). AC-AF (occlusal aspect) is 0.99mm
(almost twice as kuttler)
• Chugal N, Clive, Spangberg 2003: The instrumentation level (mean +/- SEM of the working
length) for successfully treated teeth/roots with normal preoperative pulp and periapex was
farther away from the radiographic apex (1.23 +/- 0.13 mm) than for teeth/roots with an
unsuccessful outcome (0.20 +/- 0.09 mm; P <.005). However, successfully treated teeth/roots
with pulp necrosis and apical periodontitis had working length levels closer to the
radiographic apex (0.55 +/- 0.12 mm) than did teeth/roots with unsuccessful outcomes (1.73
+/- 0.30 mm; P<.001). In teeth/roots with apical periodontitis, a millimeter loss in working
length increased the chance of treatment failure by 14%
• Davis & Joseph 1971: Teeth that were fully instrumented, but lled short of the radiographic
apex had best healing. ALSO: Seltzer & Bender 1963 &67 (human and monkey study with
healing eval at 3 months; over ll = persistent in ammation)
• Langland: Most favorable prognosis was obtained when procedures were terminated at the
AC, and the worst prognosis was produced by treatment that extended beyond the AC.
Procedures terminated more than 2 mm from the AC had the second worst prognosis
• Instrumentation and obturation should terminate at the CDJ (Ricucci 1998), as
overinstrumentation and over lling cause periapical in ammation (Seltzer et al 1973)
• Arslan, Doganay et al 2017: JOE. Traditionally, the protection of the working length from
deviations can be achieved manually by observing the stopper and coronal reference points.
The Gold Reciproc motor allows for simul- taneous length control during instrumentation with
auto-stop function. According to the results of the present study, simultaneous length control
during root canal preparation is a bene cial tech- nique to prevent postoperative pain.

Cleaning and Shaping (w/out NaOCl)

• Peters O, Zender 2005: Lubrication of root canals using aqueous solutions decreased torque
and force. Paste-type lubricants are less bene cial and lead to increased forces when used
with ProFile rotary les.

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 • Shuping, Orstavik, Trope 2000: Mechanical debridement with and without 1.25% NaOCl.
Signi cantly better results with NaOCl. Instrumentation with NaOCl irrigation was superior in
bacterial reduction to instrumentation with sterile saline (28% reduction) and resulted in
61.9% of canals becoming free of bacteria. An increase in le size was shown to be important
in allowing the NaOCl to be an effective antibacterial irrigant. The addition of calcium
hydroxide as an intracanal medication for at least 1 wk produced 92.5% of canals void of
bacteria.
• Instrumentation + Saline = 28% Reduction
• Instrumentation + NaOCl = 61.9% Reduction
• Instrumentation + NaOCl + Ca(OH)2 1 week = 92.5% reduction
• Bystrom et al 1985: Demonstrated bacterial reduction with mechanical instrumentation and
saline. Showed that we need NaOCl to obtain further bacterial reduction.
• Peters et al 2001: IEJ. At least 35% of canal walls are untouched regardless of technique
used.
• Rodrigues, Orstavik, Rocas, Siqueira et al 2017: JOE. This clinical study evaluated the
in uence of the apical preparation size using nickel-titanium rotary instrumentation and the
effect of a disinfectant on bacterial reduction in root canal–treated teeth with apical
periodontitis. Forty-three teeth with posttreatment apical periodontitis were selected for
retreatment. Teeth were randomly divided into 2 groups according to the irrigant used (2.5%
sodium hypochlorite [NaOCl], n = 22; saline, n = 21). Canals were prepared with the Twisted
File Adaptive (TFA) system (SybronEndo, Orange, CA). Bacteriological samples were taken
before preparation (S1), after using the rst instrument (S2), and then after the third
instrument of the TFA system (S3). In the saline group, an additional sample was taken after
nal irrigation with 1% NaOCl (S4). DNA was extracted from the clinical samples and
subjected to quantitative real-time polymerase chain reaction to evaluate the levels of total
bacteria and streptococci
• S1 from all teeth were positive for bacteria. Preparation to the rst and third instruments
from the TFA system showed a highly signi cant intracanal bacterial reduction
regardless of the irrigant (P < .01). Apical enlargement to the third instrument caused a
signi cantly higher decrease in bacterial counts than the rst instrument (P < .01).
Intergroup comparison revealed no signi cant difference between NaOCl and saline
after the rst instrument (P > .05). NaOCl was signi cantly better than saline after using
the largest instrument in the series (P < .01).
• Irrespective of the type of irrigant, an increase in the apical preparation size signi cantly
enhanced root canal disinfection. The disinfecting bene t of NaOCl over saline was
signi cant at large apical preparation sizes.
• The larger the apical preparation size, the greater the bacterial reduction.
• NaOCl was superior to saline only at large apical preparation sizes.
Cleaning and Shaping (Crown Down Technique)
• Morgan, Montgomery 1984: The crown-down pressureless technique was rst suggested by
F.J. Marshall and J.B. Pappin to minimize the extrusion of canal contents. This technique
involves early canal aring with Gates Glidden drills, followed by the incremental removal of
canal contents and dentin proceeding from the canal ori ce to the working length. Straight
les are used in a larger to smaller sequence with a reaming motion and no apical pressure
once the instrument beings to bind in the canal.
• Al-Omari, Dummer 1995: Evaluated 8 types of instrumentation techniques on debris
extrusion. Crown-down pressureless technique and balanced force resulted in least amount
extruded.

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 Cleaning and Shaping (Hand Files are occasionally needed)
• I use the balance force lling technique according to Roane 1985: 1/4 turn clockwise, push
apically and counterclock wise 180. (“intentionally controlled reaming”)
• What are the advantages of the balanced force technique?
• Wu, Wesselink: produced cleaner apical portion of canals vs other hand techniques
• McKendry: extruded less debris
• Sepic: less apical canal alteration in curved canals vs step back technique
• Southard: Up to size 40 able to maintain canal curve 80% of time
• Patency File as above
• Vera, van der Sluis 2012: Patency #10 le allowed irrigants to reach the apical foramen
better
• Endo Files classic review
• ISO Files: Tip Dimensions: 0.06mm - 1.40mm. Taper: + 0.02mm diameter/ 1mm length.
Dimensions: D 0 - D 16mm. Error of +/- 0.02mm (ie #35 could be a #33 or #37). Helical
Angle/Pitch is the angle of the cutting edge relative to the le. Most les are triangular.
Ground les are more exible than twisted les. Flex-R les have a modi ed transition
angle to help with ledge prevention.
• Webber, Moser, Heuer: Triangular instruments more ef cient initially, but lose sharpness
quickly. Square had greater retention of sharpness
• Pliet, Sorm 1973: triangular instruments cut more ef ciently than square les
• Chernick: Torsional tests and scanning electron microscope examination revealed that
endodontic les twisted in a counterclockwise manner were extremely brittle compares to
those twisted in a clockwise manner. This study is opposite to Roan study which shows
separation is more likely on the clockwise rotation
• Miserendino 1985: Signi cantly greater cutting ef ciency occurred with the newly
designed S le and traditional hedstrom les over other types of hand instruments. The tip
geometry of the le has the greatest impact on cutting ef cacy of the le compared to ute
design.
• Kazemi 1995: It was shown that all les evaluated rapidly deteriorated when machining
dentin. This decline in ef ciency was signi cant but different within, as well as, among
brands. It was suggested that endodontic les be disposable.
• Seto: Machined les exhibit less ductility than twisted les prior to fracture and may be
more susceptible to torsional failure clinically.
• Tepel, Schafer: Compared different manual hand instruments. Best instrument results
were obtained by exible instrument with noncutting tip. Also they found that SS K- le have
better cutting ef cacy than NiTi.
• Yucel, Henry: Never cut the canals dry. Lubricant increases ef ciency by 200%. Water and
2.5% sodium hypochlorite solutions have equivalent lubricant effects. The most common
breakage of le happens with hedstrom. Plastic deformation is the main cause of loss of
cutting ef ciency.
• Walia et al 1988: The First publication/description on the invention of NiTi hand les. Nitinol
(Naval Ordinance Lab). 2-3 times more exible than SS les.
• Haikel: Talked about properties of NiTi: NiTi has 2 phases: austenite (A crystalline unstressed
phase of stainless steel and nickel titanium alloy) and martensitic (In nickel titanium alloy, this
more exible form occurs as the result of thermal changes or the application of stress). The
ability to cycle between these 2 states is due to NiTi having the property of super elasticity
and shape memory. Phase transition occurs with rapid stress on the le, therefore use at a
constant speed. Files are weakest during phase transition and may fracture at this time

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 (cyclic fatigue). Radius of curvature was found to be the most signi cant factor in determining
the fatigue resistance of les. Cyclic fatigue as a major cause of failure.
• Transporting: 3 studies of 1) Esposito 2) Schafer&Tepel 3) Kuhn: talked that there is a less
chance of transportation using NiTi and they maintain the original shape of the canal
compared to SS K les.
• Pettiette, Trope 1999: Less deviation of canal with NiTi les vs SS. Less procedural errors
with NiTi les vs SS. Maintaining the original canal shape after instrumentation leads to a
better prognosis of endodontic treatment. (dental students)
• Yoldas: compared the effect of hand les and rotary les on dentin after canal preparation.
They concluded that rotary instruments caused more dentinal defects, such as craze lines
and cracks, which possibly could develop into fractures after restorative treatment.
• Shuping, Orstavik, Trope 2000: JOE.
• Instrumentation with NaOCl irrigation was superior in bacterial reduction to
instrumentation with sterile saline (28% reduction) and resulted in 61.9% of canals
becoming free of bacteria. An increase in le size was shown to be important in allowing
the NaOCl to be an effective antibacterial irrigant. The addition of calcium hydroxide as
an intracanal medication for at least 1 wk produced 92.5% of canals void of bacteria.
• No diff in bacterial removal (rotary vs hand le). 1) There was no detectable difference in
colony-forming unit count after NiTi rotary or stainless-steel hand instrumentation. 2) NiTi
rotaries are not more effective for microbe elimination than hand instrumentation. Pro le
and 1.25% NaOCl decreased bacteria 62%, 1 week CaOH2 decreased bacteria 93%.
• Ove Peters: If a Broad Distal Canal - circumferential ling with hedstrom or treat as two
canals in term of mechanical and chemical irrigation. best with treat as two.

Purpose of Instrumentation
• Endodontic instrumentation serves to:
• remove debris (Dalton, Orstavic, Trope 1998)
• permit irrigant penetration to the apex (Salzgeber and Brilliant)
• prepare the canal for obturation (Schilder 1974).
• Commonly described instrumentation techniques
• Step-down —> Goerig
• Step Back —> Weine
• Passive step-back —> Torabinejad
• Anticurvature ling —>Abou-Rass
• Balanced force —> Roane
• Crown-down —> Morgan and Montgomery
• Peters et al 2001: Endodontic instrumentation leaves 35% of canal walls untouched.
• Purpose of endodontic instrumentation
• Permit Penetration of Irrigants
• Khademi 2006: #30 w/ .06 coronal taper allowed penetration of irrigants to remove
smear layer
• Albrecht, Baumgartner 2004: #20 0.10 taper allowed similar cleaning as
#40/04,06,08 taper
• Salzgeber, Brilliant 1977: Found that a minimum MAF size of a no. 30 K le allowed
penetration of irrigants to the apex.
• Reduce Microbial Load/Remove Debris
• Bystrom, Sundqvist 1981: 100-1000 fold reduction in bacteria with mechanical
instrumentation w/ saline

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 • Shuping, Orstavik, Trope 2000: JOE. Instrumentation in presence of NaOCl
decreases bacteria by aprox 60%.
• Dalton, Trope 1998: Progressive decrease in CFU, No diff between hand or .04 NiTi
• Siqueira 1999: E. faecalis reduced over 90%
• Peters O 2001: All instrumentation techniques left 35% or more of the canal’s surface
area unchanged. (4 instrumentation techniques looked at w/ micro CT scanner).
• Creates a tapering preparation/Prepare canal for obturation
• Walton 1992: Permits better debridement of apical preparation, reduces
overinstrumentation of the foramen, and improves ability to obturate.
• Schilder 1974: Instrumentation serves to prepare the canal for obturation. 1.
Continuously tapering funnel. 2. Cross-section diameters should be narrower at every
point apically. 3. “Flow” with the original shape of the root canal. 4. Apical foramen
should be in its original position. 5. Apical foramen should be as small as practical.
Biological Principles: 1. Procedures con ned to roots. 2. No necrotic debris forced
apically. 3. Remove all tissue from canal space. 4. Suf cient space for internal meds
and irrigation created.
• Ove Peters: Ingles Text. Root canal preparation serves two main objectives: mechanical
and chemical elimination of intracanal tissue and pathogens, aided by antimicrobial
substances and by optimized root canal llings.
• Can instrumentation cause bacteremia?
• Baumgartner, Harrison 1976: JOE. Part I. In non-surgical endodontic procedures when
endodontic manipulations were con ned to the root canal system, a bacteremia could
not be detected. Only when instrumentation was extended beyond the apical foramen
did a bacteremia occur. The root canal system was con rmed as the source of the
blood-borne microorganisms.
• Baumgartner, Harrison 1977: JOE. Part II. Tooth extraction produces an extremely high
incidence of bacteremia (100%). Surgical endodontic therapy produces an extremely
high incidence of bacteremia. Re ection of a full mucoperiosteal ap causes an
extremely high incidence of bacteremia. Curettement of the periapical tissues produces
a signi cant incidence of bacteremia, but a lower incidence than ap re ection.
Nonsurgical endodontic therapy produces a very low incidence of bacteremia.
• Schilder 1974:
• Mechanical objectives 1) Root canal preparation should develop a continuously
tapering shaping (CTS) from the root apex to the coronal access cavity
2) The cross sectional diameter of the preparation should be narrower at every point
apically and wider cervically 3) Root canal preparation should ow with the shape of
the original canal 4) The apical foramen should remain in its original spatial
relationship both to the bone and to the root surface. 5) The apical opening should be
kept as small as practical in all cases. 6) Outline of the funnel in the apical portion of
the root canal should be round in all cases, but in the middle and cervical third it may
or may not be desirable 7) Cross sectional diameter has to be narrower at every point
apically and wider at every point coronally 8) The sole exception to this principle is
incases of internal resorption where absolute adherence to this rule would grossly
weaken the remaining tooth structure 9) Foramen transposition most commonly takes
2 forms – development of an elliptical or teardrop foramen, and outright root
perforation 10) Apical foramina are usually found slightly short and to the side of the
radiographic apex. 11) Tapering funnel preparation from the root apex to the coronal
access cavity. 12) Greatest problem lies in the apical portion of the canal, and the

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 greatest care must be taken to maintain the direction of the canal curvature.There are
2 cautions –
• 1. No straightening is permitted in the apical few millimeters
• 2. Unconscious straightening is dangerous
• Position of the foramen should remain in its original shape, foramen transportation
should be avoided, tear drop foramen
• Biologic objectives of cleaning and shaping:
• Con ne instrumentation to the root canals
• Beware of forcing necrotic material beyond the foramen during canal preparation.
• Remove all tissue debris from the root canal system
• Try to complete the cleaning and shaping of single canaled teeth in one visit and,
whenever possible, prepare multi-canaled teeth one at a time
• Create suf cient space during canal enlargement to receive intracanal
medicaments and to accommodate small amounts of periapical exudates
• Clinical Principles common to all canal preparation
• 1. Irrigation is abundant
• 2. Never skip instruments
• 3. Never skip to the next instrument until the previous one ts loosely in the canal
• 4. When the next le doesn’t t to the apex, consider using a cut off le of the
previous of the previous le size as an intermediate instrument
• 5. In general, the narrower and more curved the canal, the more it must be
shaped with les rather than reamers
• 6. Reamers and les that shows sign of irregularities should be discarded
immediately
• 7. Loss of canal patency, blocked canal is regained by irrigation, use of
precurved le
• 8. Partially calci ed canal can be negotiated successfully
Cleaning and Shaping (NiTi Rotary)
• Love 1996: Bacteria can invade up to 150-250 micrometers into dentinal tubules. Con rmed
by Sen (1995): bugs grow 150um into tubules. Thus, Yared & Bou Dagher 1994 advocate
apical preparation to 0.3-0.5 mm larger than original size (and width of CDJ is often 0.19mm
(Stein & Corcoran 1990).
• Tanalp 2014: IEJ. Review. Apical extrusion of debris and irrigants.
• Hand les extrude more than rotary.
• More apical extrusion with apical enlargement.
• Less extrusion when working length is kept 1mm short of the apex.
• No difference in extrusion in canals with or without curvature.
• Files with short pitch have less extrusion compared to les with long pitch.
• Side vented needle has less extrusion compared to conventional needle.
• Full sequence rotary instrumentation associated with less debris extrusion compared to
reciprocating systems.
• Cruz Junior et al 2016: JOE. RCT. The aim of this prospective study was to evaluate the
postoperative pain that followed root canal treatments performed with a single- le
reciprocating system on asymptomatic uniradicular necrotic teeth with and without foraminal
enlargements (FEs). FEs during endodontic treatments of asymptomatic necrotic, uniradicular
teeth that were performed in single visits using the Reciproc R40 reciprocating le resulted in
a low incidence of pain. After 24 hours, the FEs resulted in more patients reporting mild pain
compared with the control group, but no differences were observed at 72 hours or 1 week.

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 • Acosta et al 2017: JOE. The fatigue resistance of new controlled memory instruments was
higher than conventional NiTi les. After fatiguing to 3/4 of their fatigue lives, CM les
decreased their torsional resistance.
• Zuolo et al 2017: JOE. n=40.
• None of the preparation systems induced the formation of new dentinal micro-cracks.
• The aim of the present study was to evaluate the percentage frequency of dentinal
micro-cracks observed after root canal preparation with TRUShape and Self-Adjusting
File (SAF) systems by means of micro–computed tomography imaging analysis. A
conventional full-sequence rotary system (BioRace) and a single- le reciprocation
system (Reciproc) were used as reference techniques for comparison because of their
known assertive cutting ef ciency.
• Reciprocation vs. Continuous Rotary Systems
• Tanalp 2014: IEJ. Review. Full sequence rotary instrumentation associated with less
debris extrusion compared to reciprocating systems.
• Adiguzel, Caper 2017: JOE. WaveOne Gold instruments, which have advanced
metallurgy, were more resistant to cyclic fatigue than WaveOne instruments (P < .05).
• Topcuoglu et al 2016: IEJ. All instruments (Vortex Blue, K3XF, ProTaper Next,
Reciproc) were associated with apical extrusion of debris. VB and PTN les were
associated with less debris extrusion compared to the other systems.
• Silva, De-Deus et al 2016: IEJ. All systems (PTU, PTN, WaveOne, Reciproc) were
associated with apical debris extrusion when canals were prepared to a large apical
size. The PTU system was associated with more debris extrusion. No signi cant
differences were found between PTN, WO and R systems (P > 0.05)
• Ferreira et al 2017: IEJ.
• Reciprocating motion can extend the life of the le.
• When reciprocating and continuous motion are compared an extended lifespan of
the le and higher cyclic fatigue resistance was observed if using a reciprocating
motion.
• The fracture of instruments used in continuous rotary motion has been attributed to
torsional stress or cyclic fatigue. Torsional fatigue occurs when the tip of the
instrument binds in the root canal whilst the le continues to turn. Cyclic fatigue
occurs when the instrument does not bind in the canal but rotates freely in a
curvature whilst being subjected to repeated cycles of tension and compression,
which disintegrates its structure and consequently leads to fracture. Cyclic fatigue
primarily occurs in acutely curved canals with short radii of curvature. Mechanical
stress of NiTi les is mainly reported to occur because of the root canal curvature
and dentine hardness, but it is also related to cyclic fatigue and to the torque of the
motor during root canal preparation. Reciprocating movement NiTi instruments
have been developed as a means of increasing performance and safety. The lower
stress induced by reciprocating motion enables dentists to use a single NiTi
instrument to prepare the entire root canal.
• Ahn, Kim, Kim 2016: JOE. Systematic Review of in vitro studies. Instruments with
reciprocating systems presented higher cyclic fatigue resistance in comparison to that of
continuous rotating systems. The use of reciprocating systems resulted in less canal
transportation; however, neither system was clinically signi cant. Controversies remain
regarding extrusion of apical debris and dentinal defects.
• Tokita, Okiji et al 2017: JOE. used 30/06 taper ProFile instruments. This study
examined the dynamic frac- ture behavior of nickel-titanium rotary instruments in
torsional or cyclic loading at continuous or reciprocating rotation by means of high-speed

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 digital video imaging. Conclusions: The dynamic fracture behavior of NiTi rotary
instruments, as visualized with high-speed digital video imaging, varied between the
different modes of rotation and different fatigue testing. Reciprocating rotation induced a
slower crack propagation and conferred higher fatigue resistance than continuous
rotation in both torsional and cyclic loads.
• Kherlakian et al 2016: JOE. RCT. Indicated no signi cant difference in postoperative
pain between reciprocating and continuous rotary systems.
• Capar, Arslan 2016: IEJ. Review. (Systematic?)
• Debris Extrusion: Similar for rotary and reciprocating.
• Cutting ef ciency: Similar for rotary and reciprocating.
• Cyclic Fatigue: the greater the reciprocating range of the le the better the cyclic
fatigue.
• Dentinal Crack Formation: Similar for reciprocating and rotary.
• Transportation and Straightening: Con icting ndings.
• Higher speed: generally more ef cient and no increase in cyclic fatigue.
• Retreatment: Reciprocating maybe better than rotary?
• Torque controlled vs non-torgue controlled motors: no difference. In non-torque
controlled generally you will increase the torque which results in more ef cient
cutting.
• Lubricant: liquid better than viscous.
• Nekoofar, Dummer 2015: Full-sequence rotary instrumentation (ProTaper) was
associated with less debris extrusion compared with the use of reciprocating single- le
systems (WaveOne) and suggested that this factor could be associated with less
postoperative pain.
• Neves, Siqueira et al 2016: JOE. In Vivo Study. Reciproc vs BioRaCe with 2.5%
NaOCl. DNA samples before and after. Both reciprocating single-instrument and rotary
multi-instrument systems were highly effective in reducing the counts of total bacteria
and streptococci in root canals of teeth with apical periodontitis. Regardless of the
system used, approximately one half (~50%) of the teeth still had detectable bacteria.
• Alves, Siqueira et al 2016: JOE. The rotary multiple-instrument system was more
effective and faster than the reciprocating single-instrument approach in removing
previous root canal llings. As for the Reciproc group, it was observed that the larger
instrument promoted signi cantly better results. The adjunctive nishing instrument XP-
Endo Finisher signi cantly improved lling material removal.
• Rossi-Fedele, Ahmed 2017: JOE. Systematic Review. The application of different
instrumentation protocols can effectively, but not completely, remove the lling materials
from the root canal system. Only hand instrumentation was not associated with
iatrogenic errors. Reciprocating and rotary systems exhibited similar abilities in removing
root lling material. Retreatment les performed similarly to conventional ones. Solvents
enhanced penetration of les but hindered cleaning of the root canal. The role of irrigant
agitation was determined as controversial.
• Borges et al 2016: (The in uence of cervical pre aring on the amount of apically
extruded debris after root canal preparation using different instrumentation systems.)
Results:
• K- les produced signi cantly more debris than all of the other systems (P < .05).
• For all systems, cervical pre aring reduced the amount of apically extruded debris
when compared with no cervical pre aring (P < .05).
• The apical debris extrusion occurred independent of the instrument used.

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 • Full-sequence rotary systems promote signi cantly less apical extrusion of debris
than reciprocating systems.
• The cervical pre aring was associated to a lesser amount of apical debris extrusion.
• Yaylali et al 2017: JOE. RCT. To evaluate whether foraminal enlargement (FE) with a
continuous rotary system during endodontic treatment causes more postoperative pain
than nonforaminal enlargement (NFE). A signi cant difference was noted in
postoperative pain in the rst 2 days; the FE group experienced more pain than the
conventional NFE group (P < .05). FE causes more pain on the rst 2 days after an
endodontic treatment.
• ProTaper Gold
• Arias, de Vasconcelos, Peters O 2017: JOE. Evaluated Torsional performance of
ProTaper Gold during shaping of small root canals after 2 different glide path
preparations (path les, progliders). Under the conditions of this study, differences in the
torsional performance of PTG rotary instruments after 2 different glide path preparations
could not be shown. The different geometry of glide path rotary systems seemed to have
no effect on peak torque and force induced by PTG rotary instruments when shaping
small root canals in extracted teeth.
• Plotino et al 2017: PTG is more resistant to cyclic fatigue than PTU at operating
temperatures. Intracanal temperature in uenced the cyclic fatigue resistance of
instruments produced with traditional nickel- titanium, whereas it did not in uence the
fatigue life of instruments produced with gold heat treatment. Gold heating treatment
enhances the resistance to cyclic fatigue of ProTaper instruments.
• Elnaghy 2016: IEJ. PTG vs PTU.
• PTG instruments had a sig. higher resistance to cyclic fatigue & exibility than PTU.
• PTU instruments were associated with higher resistance to torsional stress and
microhardness than PTG instruments.
• The PTG instrument had improved resistance to cyclic fatigue and exibility
compared with PTU.
• PTU instruments had improved resistance to torsional stress and microhardness
compared with PTG.
• Hieawy, Haapasalo 2015:
• PTG les were signi cantly more exible and resistant to fatigue than PTU les.
• PTG exhibited different phase transformation behavior than PTU, which may be
attributed to the special heat treatment history of PTG instruments.
• PTG may be more suited for preparing canals with a more abrupt curvature.
• The fatigue life of size S1 and S2 was signi cantly longer than that of sizes F1–F3
les.
• Uygen et al 2016: IEJ. PTG show the greatest Cyclic Fatigue resistance. (PTGold vs
PTNext vs PTUniv.) PTG were most resistant 5 and 8 mm from the tip; however, at 8mm,
there was no difference between the PTG and PTN. The PTU les had the lowest CF
resistance at all levels.
• Gagliardi 2015: PTG and PTN produce less transportation and maintain more dentin
than PTU.
• NiTi vs SS Hand Files
• Short, Baumgartner 1997: NiTi rotary systems better centered in canal than SS hand
les. NiTi signi cantly fasters.
• Zmener 2011: NiTi rotary les (TiLOS, PTU) combine with irrigation of 5.25% NaOCl,
17% EDTA produced cleaner root canal walls than the hand les (although no technique
produced completely clean canals)

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 • Transporting: 3 studies of 1) Esposito 2) Schafer&Tepel 3) Kuhn: talked that there is a
less chance of transportation using NiTi and they maintain the original shape of the canal
compared to SS K les.
• Pettiette, Trope 1999: Less deviation of canal with NiTi les vs SS. Less procedural
errors with NiTi les vs SS. Maintaining the original canal shape after instrumentation
leads to a better prognosis of endodontic treatment. (dental students)
• Yoldas: compared the effect of hand les and rotary les on dentin after canal
preparation. They concluded that rotary instruments caused more dentinal defects, such
as craze lines and cracks, which possibly could develop into fractures after restorative
treatment.
• Shuping, Orstavik, Trope 2000: No diff in bacterial removal (rotary vs hand le). 1)
There was no detectable difference in colony-forming unit count after NiTi rotary or
stainless-steel hand instrumentation. 2) NiTi rotaries are not more effective for microbe
elimination than hand instrumentation. Pro le and 1.25% NaOCl decreased bacteria
62%, 1 week CaOH2 decreased bacteria 93%.
• Siqueira 1999: Instrumentation (hand and rotary) and irrigation w/ saline can
mechanically remove 90% of bacteria (E. faecalis) from root canal. Apical size increase
signi cantly reduced bacteria, 40 being the most.
• Dalton, Trope 1998: Instrument technique does not effect bacteria reduction. Neither
technique able to remove bacteria completely. Fewer bacteria when larger les used.
0.04 NiTi Rotary and hand les used (saline irrigation).
• Pettiette, Trope et al 1999: JOE. NiTi vs and stainless steel K- les. Found less canal
transportation and fewer gross preparation errors such as strip perforations with NiTI.
• Trope: Rotary les no more effective at removing bacteria than SS hand les
• Rotary Properties/Reasons for failure
• Torsional Failure: Distal End of le becomes locked in place (edges imbedded into
dentin), shaft keeps rotating. May happen by advancing to rapidly.
• Taper Lock: Similar to torsional failure but a longer portion of the le is locked into the
canal by friction. May happen by advancing too far with a single le so too great a length
of the canal exactly matches the shape of the le.
• Cyclic Fatigue: Instrument failure due to repetitive stress. Essentially bending the le
back and forth repeatedly until micro-cracks form, they propagate and the le breaks. No
part of the le is stationary. If a le free rotates in a curved tube, it can fail due to cyclic
fatigue.
• Smaller diameter more susceptible to torsional failure. Large diameter more susceptible
to cycle fatigue.
• Haikel et al 1999: Cyclic Fatigue. Statistically demonstrated that as instrument size and
taper increased—> fracture time decreased (fractures prematurely). Decreasing radius
of curvature decreases time to fracture (radius of curvature is most signi cant parameter
in terms of prediction of instrument failure)
• Kitchens et al 2007: # of rotations not speed determine fracture time. Larger Taper,
fractures sooner.
• Shen et al 2013: NiTi alloys cycle through several temperature dependent crystalline
structures, including the stiffer austenite phase, the intercrystalline R phase and the
more exible low-temperature martensite phase. New instruments are fabricated from
controlled memory wire, a heat-treated NiTi substance in which the austenite nish
temperature is higher than body temperature, thus keeping the instrument in the more
exible martensite and R phases. (Heat treated wire is more resistant to fatigue failure,
but less resistance to torsional failure.)

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 • Haikel: Properties of NiTi Files —> 55% Nickel/45% Titanium; 2 phases: Austentite &
Martensite - cycling between the two phases allows for super elasticity and shape
memory; radius of curvature is most important factor for cyclic fatigue, causing failure.
• Yared: NiTi les can be used up to 10 canals (2-3 cases)
• Hicks: NiTi les can go through 10 cycles of heat sterilization without an increase in
chance of fracture
• Cunningham: Sterilization effect on NiTi. Neither the number of sterilization cycles nor
the type of autoclave sterilization affects the torsional properties, hardness, and
microstructure of stainless steel and NiTi les.
• Pruett, Clement, Carnes 1997: Cyclic fatigue testing of nickel-titanium endodontic
instruments. NiTi instruments fracture within their elastic limit and without any signs of
previous permanent distortion. Rotation subjects NiTi to both tensile and compressive
forces in the area of the canal curvature; this produces a very destructive form of
loading.
• Thompson 2000: IEJ. NiTi exists reversibly in two conformations, martensite and
austenite, depending on external tension and ambient temperature. While steel allows
3% elastic deformation, NiTi in the austenitic form can withstand deformations of up to
7% without permanent damage or plastic deformation. Knowing this is critical for rotary
endodontic instruments for two reasons. First, during preparation of curved canals,
forces between the canal wall and abrading instruments are smaller with more elastic
instruments, hence less preparation errors are likely to occur. Second, rotation in curved
canals will bend instruments once per rotation, which ultimately will lead to work
hardening and brittle fracture, also known as cyclic fatigue. Steel can withstand up to 20
complete bending cycles while NiTi can endure up to 1,000 cycles.
• Peters et al 2013: Heat-treated les with high martensite content typically do not have a
silver metallic shade but are colored due to an oxide layer, such as gold or blue. It is
important to note that Controlled Memory les frequently deform; however, with a
delicate touch, cutting is adequate and often even superior to conventional NiTi
instruments
• Berutti et al 2003: JOE. As a general rule, exible instruments are not very resistant to
torsional load but are resistant to cyclic fatigue. Conversely, more rigid les can
withstand more torque but are susceptible to fatigue. The greater the amount and the
more peripheral the distribution of metal in the cross section, the stiffer the le.
Therefore, a le with greater taper and larger diameter is more susceptible to fatigue
failure; moreover, a canal curvature that is more coronal is more vulnerable to le
fracture.
• Instrumentation with and without irrigation
• Shuping et al 2000: Mechanical debridement with and without 1.25% NaOCl.
Signi cantly better results with NaOCl.
• Bystrom, Sundqvist 1981: Mechanical instrumentation with saline irrigation reduced
bacteria
• Lim et al 2016: JOE. Lab study. In hydrated roots, instrumentation with hand,
reciprocating, or rotary NiTi instruments did not result in residual micro-strain
concentrations. Instrumentation of non-hydrated roots caused localized micro-strain
concentration and diminished stress relaxation, but this did not result in detectable
dentinal micro-defects. This study highlighted that the response of root dentin to root
canal instrumentation was in uenced by the degree of hydration. Root canal
instrumentation with hand, rotary, or reciprocating instruments did not produce residual
microstrains or microdefects in hydrated root dentin.

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 • Peters O 2001: All types of NiTi rotary les left 35% or more of canal surface area
unchanged.
• Chan, Parashos et al 2016: IEJ. Autoclaving was effective in the sterilization of sponges and
endodontic instruments. Endodontic sponges should be autoclaved before clinical use. For
clinical ef ciency and cost-effectiveness, rotary NiTi instruments can be sterilized in
endodontic sponges without removal of rubber stoppers.
• Arora, Tewari et al 2016: IEJ. RCT. Maintenance of apical patency during chemomechanical
preparation had no signi cant in uence on post-operative pain in posterior teeth with necrotic
pulps and apical periodontitis.
• Metzger 2010: showed that protaper rotary les leave 44.6% of the canals untouched.
• Rotational Speed
• Gabel, Hoen: ProFiles run at 333rpm separated 4 x more often as les at 167 RPM
• Gambarini: Recommended electric low torque or right torque motors. K3 & ProTaper at
300 RPMs
• Li et al 2002: JOE. a lower rotational speed (~250 rpm) results in delayed build-up of
fatigue
• Yared et al 2001: IEJ. a lower rotational speed (~ 250 rpm) results in reduced incidence
of taper lock
• Gonzales Sanchez 2012: overinstrumentation created an oval-shaped major foramen.
ProTaper Universal and ProFile Vortex les were used in their study. Both le systems are
nonlanded.
• Hu, Sedgley, Svec 2014: Landed, nonlanded and nonlanded reduced shape memory les all
produced transportation of the apical foramen when overinstrumented 0.5 mm in severely
curved canals. There was no difference between these le systems with regard to the degree
of this effect. (looked at ProFile ISO, ProFile Vortex or Vortex Blue)
• Karatas et al 2016: (study may be biased) Purpose to assess the effect of root canal
preparation using ProTaper Gold, ProFile Vortex, F360, Reciproc and ProTaper Universal on
dentinal crack formation. Results: all experimental groups, except F360 produced signi cantly
more cracks than the control group (p<0.05). No sig diff observed among groups at 6mm and
9mm levels. The ProTaper Universal group produced signi cantly more cracks than control,
ProTaper Gold, ProFile Vortex, F360 and Reciproc groups at the apical section 3mm
(p<0.05). (The tip design of rotary instruments, cross sectional geometry, constant or variable
pitch and taper, and ute form could be related to crack formation. Even though (Yoldas et al.
2012) have shown that the cross sectional geometry has an effect of the formation of micro
cracks, based on the result of the present study it seems unlikely that the differences in crack
formation might be explained by the differences in the cross-sectional design of the
instruments. In contrast, the tapered les are reported to cause increased stress on canal
walls . Thus, the taper of the les could be a contributing factor in dentinal crack formation. All
the systems that were tested produced dentinal cracks. The PTU group was associated with
more dentinal crack formation than PTG, PV, F360 and Reciproc groups at the 3 mm level.
Moreover, there was no signi cant difference between the control and F360 groups in terms
of dentinal crack formation. )
• Peters O: As the TRU Shape rotating it makes an actual envelope of motion that is larger
than nominal le size. The S curve in true shapes help this envelope of motion greater than
the actual nominal size of le. This system follows the hooks law of spring. It was shown that
there is up to 36% better dentin preservation with TRU shape compared to standard le
with the same tip and taper (20/06) and less apical transportation.
• Fracture mechanisms:
• Torsional failure (forcing the instrument into a narrow canal space and rotating it).

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 • Cyclic Fatigue failure (overusing an instrument by prolonged rotation in a curved canal).
• Corrosive failure (combination of torsional and fatigue failure of an instrument with signs
of corrosion).
• Manufacture defect.
• Baumgartner, Harrison 1976: Unable to detect evidence of bacteremias in patients
undergoing nonsurgical root canal therapy when instrumentation was con ned to the tooth.
(Best paper to use to support keeping instrumentation within a canal. Instrumentation within
a canal does NOT cause bacteremia. Long instrumentation RARELY causes bacteremia, but
only in necrotic teeth. (Blood sample and culture for: one pre-op and one 5 mins after most
injurious part of a given appt. Groups tested: A inst short with vital teeth. B inst long in
pulpless teeth. C inst short in pulpless teeth. D obturation of group A. E obturation of group
B and C. )
• Jahde & Himel 1987: A small amount of in ammation and localized bone necrosis occurs
with le overextension .
• Ruddle 2005: Endo Topics. Almost all current rotaries are non-landed, meaning they have
sharp cutting edges, and they can be used in lateral action towards a speci c point on the
perimeter. This “brushing” action allows the clinician to actively change canal paths away from
the furcation in the coronal and middle thirds of the root canal but may create apical canal
straightening when taken beyond the apical constriction. Circumferential engagement of
canal walls by active instruments may lead to a threading-in effect but contemporary rotaries
are designed with variable pitch and helical angle to counteract this tendency.
• Cheung et al 2007: JOE. Material imperfections such as microfractures and milling marks
are believed to act as fracture initiation sites .
• Herold, Johnson B et al 2007: JOE. Material imperfections after manufacturing can be
removed by electropolishing but it is unclear if this process extends fatigue life.
• Aksel et al 2017: JOE. in vitro study
• Purpose: to evaluate the effects of different root canal instrumentation techniques and
preparation tapers on the amount of apically extruded bacteria.
• Using a 0.02 taper in a crown down manner results in the least amount of bacterial
extrusion.
• Instrumentation technique did not seem to affect the amount of bacterial extrusion when
0.04 and 0.06 taper instruments were used for cleaning & shaping the root canal space.
• Crowning Down and Full-length linear instrumentation techniques showed similar
bacterial extrusion regardless of taper.
• The preparation taper had no effect on the number of CFUs when a FL instrumentation
technique was used (P > .05). There was a statistically signi cant difference in the CFUs
between FL and CD techniques when the preparation taper was 0.02 (P < .05). There
was no statistically signi cant difference between the 0.04 and 0.06 preparation tapers in
any of the instrumentation techniques (P > .05).

Apical Preparation Size

• Chapman 1969: Diameter of AC 0.13 - 0.17mm
• Pinada, Kuttler 1972: The apical foramen is located laterally in 78% to 93% of cases.
• Stein, Corcoran 1990: Apical Constriction 0.19mm
• Salzgeber, Brilliant 1977: Found that a minimum MAF size of a no. 30 K le allowed
penetration of irrigants to the apex.
• Ram 1977: Effective irrigation requires apical preparation. Rec prep size of #40 to get
effective delivery of irrigants. The irrigants can only progress 1mm beyond the tip of the
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 • Khademi 2006: Based on the results, it appears that the minimum instrumentation size
needed for penetration of irrigants to the apical third of the root canal is a #30 le, w/ .06
coronal taper. (looked at #20,25,30,35)
• Mickel 2007: Suggested that MAF size should re ect the size of the apex. They found that by
using a crown-down technique to asses apical size, followed by an increase in 3 le sizes to
nal instrumentation, greater bacterial reduction was noted than if only one le size greater
than the initial was selected.
• Saini 2012: Outcomes were signi cantly improved when the MAF was 3 sizes larger than the
rst apical binding le and that further enlargement beyond 3 sizes did not provide any
additional bene t. (RCT. n = 167.)
• Usman, Baumgartner, Marshall 2004: 40/06 results in cleaner canals than 20/06.
• Albrecht, Baumgartner, Marshall 2004: Results suggest that debris is more effectively
removed using.04,.06, and.08 ProFile GT instruments when the apical preparation size is
larger (size #40) compared with size #20 apical preparations. When a taper of.10 can be
produced at the apical extent of the canal, there is no difference in debris removal between
the two preparations sizes. They conclude that overall taper and shape can compensate for
the small apical size.
• Sedgley 2005: Canal preparation size signi cantly in uences the chemo-mechancial ef cacy
of irrigation. Ef cacy of irrigation signi cantly reduced in canals prepared to size 36 compared
to size 60 but with no advantage after that. In addition to canal size other factors can play a
role (proximity of needle tip to apex, larger volume, longer exposure time etc)
• Brunson 2010: Effect of Apical Preparation Size and Preparation Taper on Irrigant Volume
Delivered by Using Negative Pressure Irrigation System. The data demonstrated that an
increase in apical preparation size and taper resulted in a statistically signi cant increase in
the volume of irrigant. In addition, an apical enlargement to ISO #40 with a 0.04 taper will
allow for tooth structure preservation and maximum volume of irrigation at the apical third
when using the apical negative pressure irrigation system.
• Silva et al 2013: performed randomized clinical trial on the effect of apical enlargement on
the post operative pain. The foraminal enlargement and non-enlargement techniques resulted
in the same postoperative pain and necessity for analgesic medication. This may suggest that
the use of foraminal enlargement should be performed for endodontic treatment without
increasing postoperative pain.
• Aminoshariae, Kulild 2015: Systematic Review. Microbial reduction. With the limited
information currently available, the best current available clinical evidence suggests that
contemporary chemo-mechanical debridement techniques with canal enlargement techniques
do not eliminate bacteria during root canal treatment at any size.
• Aminoshariae, Kulild 2015: Systematic Review. healing outcomes. With the limited
information available, the best current available clinical evidence suggests that for patients
with necrotic pulps and periapical lesions, enlargement of the apical size would result in an
increased healing outcome in terms of clinical and radiographic evaluations.
• Card, Trope: Larger apical prep size showed increased reduction in CFU counts
• Ruddle 2002: (apical gauging) suggested that canal width can be determined by passing a
series of K les to WL to gauge.
• Schilder 1974: Apical foramen should remain in its position and not be enlarged.
Recommends con ning shaping procedures to the canal space.
• If we compare the apical size preparation between classic and current literature, we can
notice a signi cant decrease in the recommended size of apical preparation for effective
irrigation. Also there are more emphasis on taper size in current literature for effective

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 irrigation. Based on current literature it might be conclude that "overall taper and shape can
compensate for the small apical size” (Matthew Brunson)
• Rodrigues, Orstavik, Rocas, Siqueira et al 2017: JOE. This clinical study evaluated the
in uence of the apical preparation size using nickel-titanium rotary instrumentation and the
effect of a disinfectant on bacterial reduction in root canal–treated teeth with apical
periodontitis. Forty-three teeth with posttreatment apical periodontitis were selected for
retreatment. Teeth were randomly divided into 2 groups according to the irrigant used (2.5%
sodium hypochlorite [NaOCl], n = 22; saline, n = 21). Canals were prepared with the Twisted
File Adaptive (TFA) system (SybronEndo, Orange, CA). Bacteriological samples were taken
before preparation (S1), after using the rst instrument (S2), and then after the third
instrument of the TFA system (S3). In the saline group, an additional sample was taken after
nal irrigation with 1% NaOCl (S4). DNA was extracted from the clinical samples and
subjected to quantitative real-time polymerase chain reaction to evaluate the levels of total
bacteria and streptococci
• S1 from all teeth were positive for bacteria. Preparation to the rst and third instruments
from the TFA system showed a highly signi cant intracanal bacterial reduction
regardless of the irrigant (P < .01). Apical enlargement to the third instrument caused a
signi cantly higher decrease in bacterial counts than the rst instrument (P < .01).
Intergroup comparison revealed no signi cant difference between NaOCl and saline
after the rst instrument (P > .05). NaOCl was signi cantly better than saline after using
the largest instrument in the series (P < .01).
• Irrespective of the type of irrigant, an increase in the apical preparation size signi cantly
enhanced root canal disinfection. The disinfecting bene t of NaOCl over saline was
signi cant at large apical preparation sizes.
• The larger the apical preparation size, the greater the bacterial reduction.
• NaOCl was superior to saline only at large apical preparation sizes.

Irrigation
• Zehnder: The ideal irrigant:
• possesses broad antimicrobial properties
• is highly effective against anaerobic and facultative microogranisms
• dissolves both vital and necrotic tissues
• inactivates LPS, and either prevents the formation of the smear layer during
instrumentation or dissolves it once formed.
• GentleWave
• Sigurdsson, Garland, Le, Woo 2016: JOE. This multicenter, prospective, nonsigni cant
risk clinical study evaluated healing rates for molars 12 months after endodontic therapy
using the GentleWave System. Eighty-nine patients needing endodontic therapy who
met the inclusion criteria consented for this clinical study. All enrolled patients were
treated with a standardized protocol consisting of conservative access, shaping of
canals to #20/.07, GentleWave treatment, and warm vertical obturation. Seventy- ve
teeth in 75 patients were evaluated at 12 months with a follow-up rate of 84.3%. The
cumulative success of endodontic therapy was 97.3%. The success rates of necrotic and
irreversible pulpitis were 92.9% and 98.4%, respectively; 3.8% of the patients
experienced moderate postoperative pain within 2 days and no incidence of pain at 14
days, 6 months, and 12 months of initial therapy. In this 12-month prospective
multicenter clinical study, the GentleWave System showed a high level of success after a
12-month follow-up

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• Irrigation Needles/Tip Design
• Tanalp 2014: IEJ. Review. Apical extrusion of debris and irrigants. Side vented needle
has less extrusion compared to conventional needle.
• Vinothkumar, Kumar et al 2007: JOE. Looked at in uence of irrigation tip design in
removing bacteria. Safety-ended needles with a single side port are ef cient in
mechanically removing the bacteria from the instrumented root canals. Analysis: Safety
needles with the single side port work ne for irrigation.
• Abou Rass 1982: Demonstrates that needle must be placed close to the debris
intended for removal (deeper the better). Debunks effervescence, because it made no
difference in debris removal. (Like Sedgley who showed irrigation depth important with
bacteria). Prepped to size 25 and 40 and used different needle diameters. The deeper
the needle penetration, the more debris was removed.
• Sedgley 2005: Deeper needle penetration results in more removal of bacteria (Like
Abou-Rass who showed the same thing with debris). Flushed out uorescent bacteria at
5mm and 1mm. Canals were prepped to size 60.
• Kumar 2007: Safe ended needle with one side port shows best irrigation ef cacy vs
safe-ended needle with double side port and hypodermic needle.
• Boutsioukis 2010: discussed the effect of needle insertion depth on irrigation pattern.
Irrigant replacement reached the WL only when the side-vented needle was placed at 1
mm; therefore, it seems reasonable to suggest that this needle should be positioned
within 1 mm from the WL if possible. Additional safety against irrigant extrusion in case
of binding in the root canal is provided by the blind end of the side- vented needle. On
the other hand, the at needle and probably also similar types like the notched or the
beveled needle should not be placed at 1 mm because of the high apical pressure
developed. This pressure is likely to be even higher when the root canal is smaller and
no safety feature like a blind-end needle is available to prevent forceful extrusion in case
of binding. The further the needle is positioned away from the WL, the less apical
pressure is developed, but then the irrigant exchange is also less ef cient and wall shear
stress is lower. A reasonable compromise would be the 2- or 3-mm position, which still
ensures adequate irrigant exchange.
• NaOCl:
• Dissolves necrotic tissue (Baumgartner)
• Dissolves vital tissue (Rosenfeld)
• removes organic component of smear layer (Baumgartner)
• Kills planktonic bacteria (Haapasalo)
• kills bacteria in established bio lms (Del Carpio-Perochena et al)
• kills bacteria in dentinal tubules (Wong and Cheung)
• Lacks ability to dissolve the mineralized component of the smear layer
• Additional:
• hypochlorus is the active antibacterial property of NaOCl
• bactericidal, bleaching agent, lubricant, deodorizer, inexpensive, can help stop
bleeding, champagne effect for an extra canal.
• Coolidge 1919 was the rst to introduce NaOCL sodium hypochlorite.
• Daiken: Daiken Solution: WW1 Walker 1936: introduction of sodium hypochlorite
as a root canal irrigant.
• Chlorine, which is responsible for the dissolving and antibacterial capacity of
NaOCl, is unstable and consumed rapidly during the rst phase of tissue
dissolution, probably within 2 minutes. Continuous replenishment of the irrigant

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 is essential. Most AAE members report using NaOCl at concentrations of 5.25% or
greater (Dutner et al)
• Hurst: NaOCl has a pH of 11; hypochlorus is the active antibacterial property of NaOCl; it
disrupts oxidative phosphorylation and other membrane activities
• Harrison, Baumgartner: 5.25% is safe for clinical use and does not increase postop pain.
• Senia, Marshall F 1971: One of the rst in-tooth study to evaluate NaOCl tissue dissolving
ability (NaOCl better than saline).
• Cvek 1976: Antimicrobial effect of root canal debridement in teeth with immature root. A
clinical and microbiologic study. After the length has been con rmed radiographically,
depending on the thickness of the remaining dentinal walls either a very light ling or no ling
is performed with copious irrigation with 0.5% sodium hypochlorite. A lower strength of
sodium hypochlorite is used because of the danger of placing it through the apex of immature
teeth. The lower strength of sodium hypochlorite is compensated by the volume of the irrigant
used
• Harrison, Svec T 1978: The clinical toxicity of 5.25% NaOCl is no greater than the clinical
toxicity of normal saline soln when used as an endodontic irrigant.
• Butler, Crawford 1982: Lab/Animal Study. Demonstrated that NaOCl 5.25%, 2.7% and
0.58% were all equally able to completely detoxify small levels of endotoxin. Larger amounts
of endotoxin are not detoxi ed by even strong concentrations of NaOCl.
• Pashley 1985: 5.25% NaOCl is very effective at dissolving soft tissue and disinfecting canals
but must be used with caution (caustic/cytoxic). (tested NaOCl w/ blood, intradermal
injections w/ rats, in rabbit eyes)
• D’Arcangelo 1999: 0.5% = 1% = 2.5% = 5% NaOCl for antimicrobial effectiveness (11 strains
inc E. faecalis; in fac aerobes -anerobes, microaerophiles, obligate anerobes). IMPORTANT
POINT: Best when use at least 10 min contact time.
• Harrison, Hand 1981: 5.25% NaOCl was the most effective antibacterial agent against the
test microorganism. Dilution of 5.25% NaOCl signi cantly inhibits the antibacterial property of
this chemical agent.
• Hand et al 1978: found 5.25% NaOCl was most effective at dissolving necrotic tissue
• Senia et al 1971: Found 5.25% NaOCl was best concentration for removing vital tissue
• Harrison, Baumgartner et al 1981: Found 5.25% NaOCl was safe for clinical use and did
not increase post-op pain
• Morgental, Ove Peters et al 2013: Found 5.25% NaOCl was more effective than either CHX
or QMix at erradicating E. faecalis.
• Siqueira, Rocas 2000: Demonstrated you can use lower concentrations of NaOCl. 1%-5%
NaOCl have equally effective antibacterial effect (pairs with Baumgartner's smear layer
removal study). Canals infected, then irrigated and sampled. But, if you are going to use a
lower concentration of NaOCl a frequent exchange and larger volume of irrigant is needed to
maintain the antibacterial effectiveness of NaOCl.
• Clegg, Vertucci 2006: 6% NaOCl was the only irrigant capable of both rendering bacteria
nonviable and physically removing the bio lm. (lab study. looked at 6% NaOCl, 3% NaOCl,
1% NaOCl, 1% NaOCl followed by MTAD)
• Nguy, Sedgley 2006: JOE. Instrumentation and apical enlargement of root canal systems
with increasing root canal curvatures may facilitate the ef cacy of endodontic irrigation.
Increasing the apical preparation size to 46 with .04-tapered les signi cantly improved
irrigation ef cacy in root canals with curvature. A straight line access for the irrigation needle
might allow more effective ow of the irrigant to mechanically ush bacteria from the root
canal system in canals with curvature. Looked at 27/04, 36/04, 46/04 in straight roots and
roots w/ curvature using biolumiscent bacteria.

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 • Retamozo, Shabahang, Torabinejad 2010: The only NaOCl concentration and irrigation
time that consistently eliminated E. faecalis 100% was 5.25% and 40 minutes, respectively.
(irrigation with 1.3% and 2.5% NaOCl for this same time interval was ineffective in removing
E. faecalis from infected dentin cylinders. High concentration and long exposure to NaOCl are
needed for elimination of E. faecalis contaminated dentin. )
• Cullen et al 2015: We evaluate the effect of 8.25% sodium hypochlorite on pulp dissolution.
We test the effect of sodium hypochlorite on dentin exural strength and modulus. Dilution of
sodium hypochlorite decreases its pulp dissolution capacity. Sodium hypochlorite had no
signi cant effect on dentin exural strength or modulus.
• Baumgartner 2010: Compared apical extrusion of NaOCl Using the EndoVac or Needle
Irrigation of Root Canals. This study showed signi cantly less extrusion risk using the
EndoVac system compared with needle irrigation.
• Ahmad, Pitt Ford, Crum 1987: The cleanliness of the canals appears to be more related to
the irrigant rather than the instrumentation technique.
• Haapasalo 2010: regarding the penetration of NaOCl. Depth of penetration increased with
increasing hypochlorite concentration, but the differences were small. Within each time group,
depth of penetration with 1% NaoCl was about 50%–80% of the values with the 6% solution.
Temperature, time, and concentration all contribute to the penetration of sodium hypochlorite
into dentinal tubules.
• Vouzara et al 2016: CHX was signi cantly more cytotoxic than NaOCl and EDTA. NaOCl was
signi cantly more cytotoxic than EDTA. The combined action of irrigants did not produce a
signi cant increase in their cytotoxicity. The tested irrigants were cytotoxic in dose- and time-
dependent manner. (Lab - cultured human lung broblasts used)
• Zandi, Rocas, Orstavik, Sequeira et al 2016: This study compared the antibacterial effects
of 1% sodium hypochlorite (NaOCl) and 2% chlorhexidine digluconate (CHX) during
retreatment of teeth with apical periodontitis. Conclusions: NaOCl and CHX both reduced
bacterial counts and the number of infected canals. Intracanal medication with calcium hy-
droxide reduced the number of canals with persistent infection but resulted in overall larger
bacterial counts in the cases positive for bacteria. The effectiveness of antimicrobial treatment
can be in uenced by the initial bacterial load.
• Cheng, Yu et al 2016: JOE. Under the conditions of this study, strong acid electrolyzed water
(SAEW) showed a similar antibacterial effect to that of 5.25% NaOCl against both the ow
and static E. faecalis bio lms. Our results indicate that SAEW might be a potential root canal
irrigant for root canal disinfection. Basically no difference between the two.
• Ruiz-Linares et al 2017: IEJ. Overall, 2.5% NaOCl proved to be the most effective solution
for dissolving and killing bacteria, when used against polymicrobial mature bio lm on human
dentine. Cetrimide improved the antimicrobial activity of chlorhexidine and alexidine. (To
evaluate the antibio lm activity of 2.5% sodium hypochlorite (NaOCl), 2% chlorhexidine
(CHX), 2% alexidine (ALX) and 0.2% cetrimide (CTR) alone and in combination on mature
polymicrobial root canal bio lms on human dentine using confocal laser scanning microscopy
(CLSM).
• Tawakoli, Zehnder et al 2017: IEJ. Under the conditions of the current study, sodium
hypochlorite displayed several unique features amongst the tested endodontic irrigants at
their clinical concentration. The NaOCl solution broke glycosidic bonds. It dissolved
glycoconjugates in the bio lm matrix. It also lysed bacterial cells. NaOCl-treated specimens
showed signi cantly lower matrix and bacteria volumes compared to all other groups. The
bio lm structure was almost entirely dissolved after 1 min of exposure to 5% NaOCl.
• Bukhary, Balto 2017: JOE. Solutions were compared for their antibio lm effect against
Enterococcus faecalis bio lm. 5.25% sodium hypochlorite was signi cantly more effective

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 than all other solutions. 1% alexidine and 2% chlorhexidine had low antibio lm activity.
Octenisept was more effective than either chlorhexidine or alexidine.
• Hulsmann, et al 2009: Endo Topics.
• Sodium hypochlorite: Effective against a broad spectrum of bacteria, has good tissue dissolution
properties, concentrations are still being debated, and is toxic to vital tissue (resulting in
hemolysis, skin ulceration, and necrosis).
• EDTA: Used to soften the root canal dentin and dissolve the smear layer. It is cytotoxic but safe
when used carefully. No reports on adverse effects during clinical use have been published so far.
• Citric acid: Proposed for smear layer removal and has shown good biocompatibility.
• CHX: Good antibacterial, antifungal, and antiviral properties but does not dissolve vital or necrotic
tissue. It is highly cytotoxic to human periodontal ligament cells and human broblasts. The
clinical relevance of these ndings has yet to be proven.
• Iodine-potassium-iodide: Proposed and used as an endodontic disinfectant due to its excellent
antibacterial properties and low cytotoxicity. However, it causes staining and may be a severe
allergin.
• Alcohol: Used for drying canals.
• MTAD: In combination with 1.3% NaOCl, it shows tissue-dissolving activity and removes smear
layer. It is less cytotoxic than calcium hydroxide.
• The endodontic literature contains several case reports on complications during root canal
irrigation, including inadvertent injection of sodium hypochlorite or hydrogen peroxide into the
periapical tissues, air emphysema, and allergic reactions to the solutions. Most of the cases
occurred because of incorrect determination of endodontic working length, iatrogenic widening of
the apical foramen, lateral perforation, or wedging of the irrigating needle.
• In case of an irrigation incident, the dentist should immediately inform the patient of the cause
and the nature of the incident. In many cases, no or only minimal intervention is necessary. To
reduce the acute pain, local anesthesia may be helpful along with the prescription of analgesics.
Antibiotics are recommended in cases where there is a high risk of the spread of infection; they
are not necessary in minor cases. The patient should be informed that healing will take some
days, or even weeks, and that symptoms in most cases will resolve completely. When the acute
symptoms have resolved or diminished, endodontic treatment may be completed in most cases.
The use of a mild, nonirritating irrigation solution (sterile saline, CHX gluconate) is recommended
in such cases.
• Sjogren et al 1997: ~ 40% of teeth remained infected with use of 0.5% NaOCl
• Siqueira et al 1997: ~ 40% of teeth remained infected with 4% NaOCl
• Shuping et al 2000: ~ 40% of teeth remained infected with biomechanical debridement with
1.25% NaOCl. The placement of calcium hydroxide for at least 1 wk rendered 92.5% of the
canals bacteria free.

Irrigation (EDTA - ethylenediamine tetraacetic acid)

• Ethylendiamine Tetraacetic Acid: Chelating agent; collects Ca ions in dentin making it softer;
removes inorganic portion of smear layer. EDTA works by replacing Ca ions with Na and
make the dentin softer . Nygaard-Ostby 1957 introduced EDTA. Schilder: EDTA is self
limiting after 7hrs
• Grawehr, Zehnder 2003:
• EDTA solution maintained its calcium-chelating ability and its antimicrobial effectiveness
when combined with NaOCl.
• NaOCl lost available chlorine and therefore its tissue dissolving effectiveness when
EDTA was added.
• Calt & Serper 2002: JOE. EDTA chelates calcium ions, effectively targeting dental hard
tissue debris. Found that a 1-minute rinse with EDTA removed the smear layer in its entirety,
although a 10-min application resulted in excessive dentin erosion.

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 • Dai et al 2011: JOE. Found that QMix was as effective as 17% EDTA in removing the smear
layer.
• Clarkson et al 2011: JOE. Found that the active chlorine content of NaOCl was reduced
when mixed with EDTA.
• de Almeida 2016: EDTA detaches 99% of cells from bio lms, but has only a 12%
antibacterial ef cacy.

Irrigation (Final Rinse: NaOCl + EDTA)

• Baumgartner, Madder 1987: Combo of NaOCl and EDTA used alternative removed the
smear layer from the instrumented root canal surfaces as well as the pulpal remnants
(organic) and predentin (mineralized) from the uninstrumented surfaces. It also caused the
exposed calcospherites on uninstrumented surfaces to have an eroded appearance. The use
of both EDTA and NaOCl is required to debride the canal of both organic components and the
inorganic components of the smear layer caused by instrumentation. The use of EDTA
throughout the procedure in combination with NaOCl can lead to excessive erosion of dentin.
Found NaOCl dissolves necrotic tissue (good to get rid of smear layer as it has pathogenic
bacteria in it)
• Yomada, Goldman 1983: THE classic for justifying nal rinse! 10 ml of 17% EDTA then 10ml
5.25% NaOCl is the best for removal of debris and smear layer. Final ushes with different
protocols involving NaOCl, EDTA and citric acid.
• Bystrom, Sundqvist 1985:
• Combined use of EDTA + 5% NaOCl more effective than NaOCl alone.
• Found no diff in antibacterial effect between 0.5% vs 5% NaOCl.
• Bacteria surviving instrumentation and irrigation rapidly increased in number between
appointments when no intracanal med used.
• Grawehr, Zehnder 2003:
• EDTA solution maintained its calcium-chelating ability and its antimicrobial effectiveness
when combined with NaOCl.
• NaOCl lost available chlorine and therefore its tissue dissolving effectiveness when
EDTA was added.
• It may be clinically advisable to copiously rinse root canals with NaOCl after each EDTA
irrigating step to wash out the remaining EDTA and guarantee good effectiveness of the
hypochlorite solution. (This study corroborated the nding that the tissue-dissolving
potential of NaOCl is mainly a function of free available chlorine.)
• Kho, Baumgartner 2006: This study demonstrated that there is no difference in antimicrobial
ef cacy for irrigation with 5.25% NaOCl/15% EDTA versus irrigation with 1.3% NaOCl/Biopure
MTAD in the apical 5 mm of roots infected with E. faecalis.
• Baumgartner, Marshall 2007: the results of this in vitro investigation showed consistent
disinfection of infected root canals with 5.25% NaOCl/15% EDTA. The combination of 1.3%
NaOCl/BioPure MTAD left nearly 50% of the canals contaminated with E. faecalis.
• Calt: > 1min EDTA causes excessive peritubular and intertubular erosion.
• Schilder: EDTA Self limiting after 7 hrs.

Irrigation ( nal irrigation: MTAD)

Mixture Tetracycline Acid Detergent - doxycycline, citric acid, tween 80
• Shabahang, Torabinejad 2003: MTAD more effective in disinfecting root canals in extracted
human teeth vs 5.25% NaOCl.

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• Torabinejad, Shabahang 2003: MTAD possesses superior bactericidal activity compared
with NaOCl or EDTA when tested against E. faecalis.
• Newberry, Shabahang, Aprecio, Torabinejad 2006: The purpose of this investigation was to
determine the antimicrobial effect of MTAD as a nal irrigant on eight strains of Enterococcus
faecalis and to measure the minimum inhibitory concentration (MIC) and the minimum lethal
concentration (MLC) of MTAD. The results showed that this treatment regimen was effective
in completely eliminating growth in seven of eight strains of E. faecalis. The MIC/MLC tests
showed that MTAD inhibited most strains of E. faecalis growth when diluted 1:8192 times and
killed most strains of E. faecalis when diluted 1:512 times.
• Tran, Torabinejad 2013: Pulverization is a superior method for sampling/detecting bacterial
in canals and dentinal tubules when compared to sterile paper point sampling. Irrigation with
1.3% NaOCl/MTAD reduces E. faecalis load in the apical 5mm of single canal roots more
effectively than irrigation with 5.25% NaOCl/17% EDTA.
• Baumgartner, Marshall 2007: the results of this in vitro investigation showed consistent
disinfection of infected root canals with 5.25% NaOCl/15% EDTA. The combination of 1.3%
NaOCl/BioPure MTAD left nearly 50% of the canals contaminated with E. faecalis.
• Tay et al 2006: Under the same experimental condition, 17% EDTA and MTAD completely
remove the smear layer when used as the nal irrigant. MTAD is comparably more
aggressive in demineralizing intact Intraradicular dentin. Yet, No erosion was observed in
neither of the irrigants because NaOCl was not used as the nal rinse.
• Malkhassian, Basrani, Friedman 2009: Conclusion: The nal rinse with MTAD and
medication with CHX did not reduce bacterial counts beyond levels achieved by canal
preparation with NaOCl.

Irrigation (QMIX)
• QMIX is made of Polyaminocarboxylic Acid (chelating agent), Bisguanide (anti-microbial), a
surfactant and deionized water. QMIX contains EDTA, CHX. Studies have shown 99.99%
bacterial reduction rate but it doesn’t have tissue dissolution. QMIX is a nal rinse and is
capable of disinfecting and removing smear layer
• Dai et al 2011: JOE. Found that QMix was as effective as 17% EDTA in removing the smear
layer.
• Haapasalo et al 2012: QMiX and NaOCl were superior to CHX and MTAD under laboratory
conditions in killing E. faecalis and plaque bacteria in planktonic and bio lm culture. Ability to
remove smear layer by QMiX was comparable to EDTA.

Irrigation (Chlorhexidine Gluconate/CHX)

• CHX is able to permeate and denature the cell wall or outer membrane and attacks the
bacterial cytoplasmic or inner membrane of the yeast plasma membrane Activity is greatly
reduced in the presence of organic matter. Wide antimicrobial spectrum, effective against
both Gm- and Gm+ bacteria and yeast. Not effective anti-viral. In direct contact with human
cells, CHX is cytotoxic. It is a xative agent.
• Emilson CG, Ericson: Uptake of chlorhexidine to hydroxyapatite. it seems that residual
antimicrobial activity of CHX in the root canal system remains for up to 12 weeks.
• Jeansonne, White 1994: 2% CHX is as effective as 5.25% NaOCl as an antimicrobial irritant.
But, NaOCl also dissolves soft tissue and CHX does not. Consider with NaOCl allergies,
perfs and open apices.

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 • Heline 1998: Chlorhexidine is effective in dentin infected with E. faecalis (ie chlorhex =
NaOCl). Can survive prolonged starvation (Figdor)
• Okino, Siqueira et al 2004: CHX lacks the ability to dissolve organic substances, namely
necrotic/vital tissue
• Basrani, Friedman 2002: Proves substantivity of CHX 2% on root dentin (Unfortunately 0.2%
CHX did not perform much better than controls. Ca(OH)2 has no substantivity). Roots
incubated with solutions, rinsed, cultured, then shavings were taken and cultured. Tested
against E. faecalis.
• Rosenthal 2004: CHX is retained in root canal dentin in antimicrobially effective for up to 12
weeks. CHX has no tissue dissolving properties.
• Clegg, Vertucci 2006: This study assessed the effectiveness of different concentrations of
sodium hypochlorite (NaOCl), 2% chlorhexidine (CHX), and BioPure MTAD. Intracanal
contents were collected from 10 patients diagnosed with chronic apical periodontitis. The
samples were cultured on hemisections of root apices to generate a polymicrobial bio lm.
Each bio lm was separately immersed in 6% NaOCl, 3% NaOCl, 1% NaOCl, 2% CHX, 1%
NaOCl followed by BioPure MTAD, and sterile phosphate buffered solution (PBS). SEM
analysis showed 6% NaOCl and 3% NaOCl were capable of disrupting and removing the
bio lm; 1% NaOCl and 1% NaOCl followed by MTAD were capable of disrupting the bio lm,
but not eliminating bacteria; 2% CHX was not capable of disrupting the bio lm. Viable
bacteria could not be cultured from specimens exposed to 6% NaOCl, 2 % CHX, or 1%
NaOCl followed by BioPure MTAD. These results indicate that 6% NaOCl was the only
irrigant capable of both rendering bacteria nonviable and physically removing the bio lm.
• Kisen et al 2008: Collagen exposure can enhance the adherence of E. faecalis to dentin.
Endodontic disinfectants such as NaOCl remove exposed collagen and subsequent irrigation
with CHX signi cantly reduces the adherence of E. faecalis to dentin. Since the combination
of NaOCl and CHX can lead to toxic precipitates care should be taken not to mix them.
• Malkhassian, Basrani, Friedman 2009: Conclusion: The nal rinse with MTAD and
medication with CHX did not reduce bacterial counts beyond levels achieved by canal
preparation with NaOCl. In summary, the relative plateau observed in the antibacterial effect
exerted by the endodontic treatment regimen used in the present study con rmed the critical
role of canal preparation—instrumentation and irrigation with NaOCl—in achieving
disinfection. Beyond this critical step, it remains questionable whether additional procedures,
if any, add a signi cant antibacterial advantage.(Antibacterial ef cacy of MTAD nal rinse and
2% CHX gel medication in teeth with apical periodontitis: A Randomized double-blinded
clinical trial.) Methods: Canals in 30 teeth (single-rooted and multi-rooted) were prepared by
using 1.3% NaOCl, rinsed with MTAD or saline in random sequence, medicated with CHX for
7 days, irrigated with 1.3% NaOCl, and lled. Bacteriologic root canal samples were obtained
by aspiration before (1A) and after (1B) canal preparation, after the nal rinse (1C), after CHX
was ushed (2A), and after nal irrigation (2B). Bacteria were enumerated by
epi uorescence-microscopy (EFM) by using 2 staining methods and by colony-forming-unit
(CFU) counts after 14 days of incubation.
• Du, Haapasalo 2014: To evaluate the antibacterial effectiveness against E .faecalis bio lms
in dentin canals of shor term and lon term exposure to 2% chlorhexidine (CHX) and 2% and
6% NaOCl (3, 10, and 30 minutes). Signi cantly more bacteria in infected dentinal tubules
were dead in each experimental group with long exposures (10 or 30 min) than after 3 min (P
< .05). 6% NaOCl (53%–88% killing) was the most effective antibacterial agent after
exposures of 3, 10, or 30 minutes (P < .05). The speed of killing was greatly reduced after 3
minutes and even more so after 10 minutes of exposure. Limited penetration depth,
inactivation of the solutions by dentin and microbial mass, and resistant subpopulations

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 (‘‘persister cells’’) of bacteria in the bio lm may be reasons for the incomplete killing even
after 30 minutes of exposure. The antibacterial effect of NaOCl and CHX depended on
exposure time and concentration.
• Böttcher 2015: The results of their study indicate that 2% CHX solution was detected for 48
hours and 7 days with a low percentage of viable cells.
• Rocas, Sequeira 2016: Disinfecting effects of rotatary instrumentation with either 2.5%
NaOCl or 2% CHX as the main irrigant. After chemomechanical preparation (50 single rooted
teeth) with BioRaCe using either 2.5% NaOCl or 2% CHX, 44% (NaOCl) and 40% (CHX) of
the root canals still had detectable bacteria. No signi cant difference was observed for the
clinical antibacterial effectiveness of rotary preparation using either 2.5% NaOCl or 2% CHX
as the main irrigant.
• Zandi, Orstavik, Rocas, Sequeira et al 2016: In conclusion, irrigation protocols with either
1% NaOCl or 2% CHX effectively reduced both the number of positive root canals and the
counts of total bacteria, streptococci, and E. faecalis in root canal treated teeth with apical
periodontitis with no signi cant differences between them. Although the amount of positive
root canals decreased after intracanal medication with calcium hydroxide dressing, bacterial
counts in the positive cases increased signi cantly. Finally, a signi cant association between
the initial bacterial counts and achieving bacteria- free root canals after chemomechanical
preparation was observed.
• Basrani 2010: CHX and NaOCl precipitate to form parachloroanaline
• Dametto, Gomes: 2% CHX better than 5.25% NaOCl in reducing CFU of E. faecalis for 7
days
• Gomes 2001: CHX in all concentrations killed E. faecalis in 30 seconds, while only 5.25%
killed E. faecalis in 30 seconds, all other concentrations took much longer.
• Gomes 2003: CHX killed E. faecalis as an intra-canal med better than Ca(OH)2 or mix of 2
• Portiner, Haapasalo 2002: Total loss of CHX by bovein serum albumin (in ammatory
excudates is rich in albumin-weaken the effect of CHX?)
• Trevino, Hargreaves, Diogenes 2011: JOE. Irrigation with 17% EDTA best supported cell
survival (89% viability; P < .001 versus all other groups), followed by irrigation with 6%
NaOCl/17% EDTA/6% NaOCl (74%; P < .001 versus the 2 groups containing 2% CHX).
Conversely, protocols that included 2% CHX lacked any viable cells.

Irrigation (removing Ca(OH)2)

• Alturaiki 2015: The purpose of this study was to evaluate the effectiveness of different
irrigation systems on removing calcium hydroxide from the root canal by using a scanning
electron microscope. Techniques used: MAF, EndoVac, EndoActivator, ProUltra systems. All
groups irrigated w/ 3ml EDTA and 3mL 1% NaOCl for 1 minute. Conclusion: None of the
investigated techniques removed the Ca(OH)2 dressing completely. However, the
EndoActivator System showed better results in removing Ca(OH)2 in each third of the root
canals in comparison with the other techniques.
• Yaylali, Kaya et al 2015: Systematic Review. JOE. The aim of this systematic review was to
summarize the outcomes of in vitro studies comparing ultrasonically activated irrigation
versus other irrigation techniques for removing calcium hydroxide (Ca[OH]2) from the apical
third of root canals.
• Ultrasonically activated irrigation was found to be superior to syringe irrigation and apical
negative pressure irrigation, but insuf cient evidence was found to indicate its superiority
over the other irrigation techniques such as sonically activated irrigation, the Self-
Adjusting File, and the RinsEndo.

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 • Lambrianidis: The removal of Ca(OH)2 is frequently incomplete, resulting in a residue
covering 20% to 45% of the canal wall surfaces, even after copious irrigation with saline,
NaOCl, or EDTA. Residual Ca(OH)2 can shorten the setting time of zinc oxide eugenol–
based endodontic sealers. Most notably, it may interfere with the seal of the root lling and
compromise the quality of treatment.
• This nding is in agreement with KIM study In uence of calcium hydroxide intracanal
medication on apical seal. Int Endod J 2002. The Ca(OH)2 groups showed signi cantly
more dye leakage than the non-medicated control group.
• However, Baumgartner said that CaOH can be effectively removed using NaOCL or
EDTA.
• Kim questioned study of Kontakiotis who said CaOH2 dressing does not effect the seal
of the permanent root canal lling. Questions whether methylene blue is useful for
CaOH2 studies. CaOH2 decolorizes methylene blue. This study used the uid transport
method for measuring leakage.

EndoActivator
• Caron, Machtuo 2010: EndoActivator and Manual Dynamic activation were signi cantly
better at removing the smear layer (using NaOCl and EDTA) in the apical 1/3 of curved roots
of mandibular molars.
• Blank-Goncalves, Machado 2011: Sonic (EndoActivator) and ultrasonic irrigation resulted in
better removal of the smear layer in the apical third of curved root canals than did
conventional irrigation.
• Mancini et al 2013: JOE. The purpose of this study was to evaluate the effectiveness of
different irrigating methods in removing the smear layer at 1, 3, 5, and 8 mm from the apex of
endodontic canals. Conclusion: In our study, none of the activation/delivery systems
completely removed the smear layer from the endodontic dentine walls; nevertheless, the
EndoActivator and EndoVac showed the best results at 3, 5, and 8 mm (EndoActivator) and
1, 3, 5, and 8 mm (EndoVac) from the apex.
• Alturaiki et al 2015: The purpose of this study was to evaluate the effectiveness of different
irrigation systems on removing calcium hydroxide from the root canal by using a scanning
electron microscope. Techniques used: MAF, EndoVac, EndoActivator, ProUltra systems. All
groups irrigated w/ 3ml EDTA and 3mL 1% NaOCl for 1 minute. Conclusion: None of the
investigated techniques removed the Ca(OH)2 dressing completely. However, the
EndoActivator System showed better results in removing Ca(OH)2 in each third of the root
canals in comparison with the other technqiues.
• Jensen et al 1999: JOE. Sonic activation offers debridement equivalent to passive ultrasonic
activation

Passive Ultrasonic Activation

• Archer, Reader, Nist, Beck, Meyers 1992: In vivo. Histo. Ultrasonics produces better
cleaning of canals and isthmuses at 1mm, 2mm, 3mm
• Gutarts, Reader, Nusstein, Beck 2005: the 1 min use of the ultrasonic needle after hand/
rotary instrumentation resulted in signi cantly cleaner canals and isthmuses in the mesial
roots of mandibular molars.
• Burleson, Nusstein, Reader, Beck 2007: Ef cacy of ultrasonic-activated NaOCl vs needle
irrigation following 3 instrumentations techniques. US-activation of NaOCl for 1 minute sig
improves cleanliness of canal.

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 • Ahmad, Pitt Ford, Crum 1987: “Acoustic streaming” using (smaller) ultrasonic les to
remove smear layer. Degree of cleanliness of canals more a function of the type of irritant
rather than the technique used. Most of the bene ts of ultrasonics are due to acoustic
streaming rather than cavitation.
• Ahmad, Pitt Ford, Crum 1988: larger les create “Cavitation”, 135 um, might result in pitting,
not signi cantly cleaner canals.
• Jiang, van der Sluis, Wesselink 2012: Continuous Ultrasonic Irrigation was the most
effective technique in dentin debris removal from the apical irregularities, and syringe
irrigation alone was the least effective. Manual Dynamic Activation technique with GP was
more effective with a tapered GP cone than with a nontapered one.
• Paragliola et al 2010: The use of ultrasonic agitation increased the effectiveness of the nal
rinse procedures (penetration of irritants into the dentinal table) in the apical 1/3 of canal wall.
• Levy 1987: Ultrasonics did not produce better cleaning of canals at neither 1mm, 3mm
• Mayer, O Peters: Ultrasonically activated irrigants did not reduce debris or smear layer
scores.
• Jensen, Hutter: 3 min passive sonic or ultrasonic following hand instrumentation produced
cleaner canals
• Gutarts: US produced cleaner canals and isthmuses than after hand/rotary instrumentation
alone
• Haidet: US improved canal debridement at 1mm level and isthmuses
• Sjorgren, Sundqvist: US were better than hand instrumentation at bacterial removal
• Cunningham, Martin: Combo of US and high volume irrigation better than traditional
methods
• Richman: First described ultrasonic in endodontics.
• Liang 2013: performed randomized clinical trial investigating the effect of ultrasonic activation
of irrigant on radiographic healing after RCT. It was found that root canal treatments with and
without additional ultrasonic activation of the irrigant contributed equally to periapical healing.
• Haapasalo 2010: The Synergistic Antimicrobial Effect by Mechanical Agitation and Two
Chlorhexidine Preparations on Bio lm Bacteria: The combined use of mechanical agitation
and chlorhexidine had a more pronounced antimicrobial effect against the bio lms than either
one alone.
• Yaylali, Kaya et al 2015: Systematic Review. JOE. The aim of this systematic review was to
summarize the outcomes of in vitro studies comparing ultrasonically activated irrigation
versus other irrigation techniques for removing calcium hydroxide (Ca[OH]2) from the apical
third of root canals. Ultrasonically activated irrigation was found to be superior to syringe
irrigation and apical negative pressure irrigation, but insuf cient evidence was found to
indicate its superiority over the other irrigation techniques such as sonically activated
irrigation, the Self-Adjusting File, and the RinsEndo.
• Munoz , Camacho-Cuadra 2012: JOE. Conclusions: PUI and EndoVac are more effective
than the conventional endodontic needle in delivering irrigant to WL in mesial root canals of
mandibular molars.
• Blank-Goncalves, Machado 2011: Sonic and ultrasonic irrigation resulted in better removal
of the smear layer in the apical third of curved root canals than did conventional irrigation.
• By creating acoustic streaming patterns (Ahmad, Pitt Ford, Crum 1987), Passive ultrasonic
activation improves the cleanliness of both the main canal and isthmuses (Gutarts,
Nusstein, Reader et al 2005). It is more effective than syringe irrigation in removing debris
from depressions in the canal space (Malki et al 2012). PUI is also as effective as a nal
rinse with CHX in eliminating bacteria (Beus et al 2012. RCT). Grundling et al 2011,
however, asserted that bacterial elimination during PUI is a function of the irrigant rather than

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 the activation. Liang et al 2013 (RCT) found no signi cant difference in periapical healing
when this technique was employed (vs standard needle irrigation).

Smear Layer
• Articles alerting us to its presence outside of Endo.
• Brannstrom 1984: Bacteria was present under facial restorations with smear layer
present. When antiseptic detergent used (smear layer removed), bacteria was absent.
• Pashley 1984: Bacteria diffuses through smear layer into dentinal tubules. Smear layer
is a liability because it can harbor bacteria.
• 1st to Describe in Endo
• McComb & Smith 1975: JOE. 1st described in endo. found that all standard
instrumentation techniques produce this layer, Used NaOCl and REDTA to remove.
Found REDTA removed most of the smear layer.
• Moodnik, Dorn, et al 1976: JOE. 2nd article to describe smear layer. A layer of “sludge”
covered all instrumented canal surfaces where the le came into contact with the
dentinal wall. Many specimens showed areas where the root canal instruments never
contacted never contacted the canal walls.
• What is the smear layer made up of?
• Sen: Smear layer made up of organic & inorganic debris (pulp, bacteria and byproducts).
Found that it blocks the disinfecting properties of NaOCl and chlorhexidine.
• Baumgartner, Mader, Peters: 2 layers - (layer one on canal wall, layer two deeply
packed into the dental tubules) 1-2 microns thin layer on canal wall; up to 40 microns in
tubules
• How do your remove it?
• McComb & Smith 1975: JOE. 1st described in endo. found that all standard
instrumentation techniques produce this layer, Used NaOCl and REDTA to remove.
Found REDTA removed most of the smear layer.
• Baumgartner 1987: Alternating EDTA (inorganic) and NaOCl (organic) removes smear
layer, tissue and pre-dentin
• Teixeira et al 2005: In this limited laboratory study, canal irrigation with EDTA and
NaOCl for 1, 3 and 5 min were equally effective in removing the smear layer from the
canal walls of straight roots.
• Crumpton, McClanahan: to remove smear layer —> 1mL 17% EDTA for 1 min, followed
by 3 mL NaOCl
• Yamada , Goldman 1983: The most effective way to remove organic and inorganic
components of smear layer is 10 ml 17% EDTA and then 10ml 5.25% NaOCl.
• Recommends Removing it.
• Gutmann 1993: removal enhanced adaptation of GP and sealer
• Orstavik, Haapasalo 1990: Presence of smear layer impeded the effect of intracanal
medicaments.
• Abramovich, Goldberg 1976: absence of smear layer allowed better sealer
penetration.
• Gettleman, Messer 1991: Adhesive strength of sealers (especially AH-26) will increase
in the absence of smear layer.
• Timpawat et al 2001: JOE. Bonding to dentin without smear layer removal was too low
to be measured.
• Saunders, Saunders 1994: JOE. Removal of smear layer reduces coronal leakage.

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 • Ng, Gulavivala: Recommend smear layer removal. In prospective study removal of
smear layer = more success.
• Kokkas 2004: SEM. Smear layer obstructed all sealers from penetrating dentinal
tubules. In contrast, smear layer removal allowed the penetration of all sealers to occur
to a varying depth. AH plus and Apexit penetrated further than Roths.
• Foster, Kulild 1993: Removal of smear layer facilitates diffusion of Ca(OH)2 to kill
bacteria.
• Jeansonne: less coronal leakage with smear layer removal (AH 26)
• White, Goldman (1984): smear layer removal improves the sealer penetration into
dentinal tubules. Least sealer penetration occurs in the apical third. Also Astrit Kuçi
(2014, JOE) con rmed these ndings. They stated that greater sealer penetration could
be achieved with either the MTA Fillapex–cold lateral compaction combination or with the
AH26–warm vertical compaction combination. Smear layer removal was critical for the
penetration of MTA Fillapex; however, the same did not hold for AH26.
• Torabinejad, Handysides, Bakland 2002: Recommend smear layer removal. Removal
decreases bacteria and improves adaptation of obturation
• Morago et al 2016: JOE. The presence of the smear layer reduced the antimicrobial
activity of 2.5% NaOCl. The combination of 2.5% NaOCl/9% etidronic acid (HEBP)
exerted antimicrobial activity that was not reduced by the smear layer.
• Recommends Keeping it.
• Walton, Drake: Recommend leaving smear layer as it blocks bacteria entry into tubules.
Teeth with smear layer had less bacteria than those without it. Smear layer may inhibit
bacterial colonization or root canals.
• Timpawat et al 2001: JOE. Removal of smear layer caused more variability and more
microleakage.
• Evans, Simons 1986: JOE. Presence or absence of the smear layer had no signi cant effect
on apical seal.
• Barkhordar 1997: Looked at removal of the smear layer using Tetracycline (Genco 1978. A
periodontist rst recommended tetracycline for perio therapy).
• Blank-Goncalves, Machado 2011: Sonic and ultrasonic irrigation resulted in better removal
of the smear layer in the apical third of curved root canals than did conventional irrigation.
• Orstavik: talked about dentinal tubules E. faecalis & Strep sanguis grew 300-400um into
slabs of bovine dentinal tublues after 14-21 days. Presence of a smear layer delayed, but did
not prevent, antimicrobial effects of medications.
• Taylor & Jeansonne (1997): Coronal leakage cumulatively reduced by removal of smear
layer, use of AH26 and vertical compaction. Madison also Evans and Simon reported that
removal has no effect on apical seal. However, Cergneux (IEJ) studied apical seal following
EDTA or ultrasonic/NaOCl used. Found that a better seal occurred when smear layer was
removed with EDTA. Smear layer removal improves the apical seal.
• Ozdemir (2012, JOE) One of the questions regarding the irrigation protocol is that can age
and sclerotic dentin affect the ef cacy of irrigation and time required for smear layer
removal!? Ozdemir concluded that treatment with EDTA + NaOCl for 1 minute appeared to be
the best experimental combination in both young and old dentins for different reasons. In
young dentin, extending the treatment time of EDTA + NaOCl over 1 minute does not
signi cantly alter the chemical and ultramorphologic structure and thus appears to be
unnecessary. In old dentin, extending the treatment time of EDTA + NaOCl over 1 minute
leads to excessive demineralization and erosion and thus should be avoided.

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 Calcium Hydroxide/Intracanal medicament
• The purpose of an intracanal medicament: to aid in disinfection and prevent recolonization of
the root canal space with bacteria.
• CH has a basic pH between 11 and 12 and diffuses into dentinal tubules, causing an increase
in the pH of out root dentin after 2 to 3 weeks (Nerwich et al). These effects do not extend
into cementum or the adjacent PDL space, indicating that the cementum may act as a buffer
(Tronstad et al). The most effective means of delivering CH into the root canal space is the
lentulo spiral, followed by injection and K les (Sigurdsson et al). CH eliminates the majority
of bacterial species in the root canal system, though some anaerobic species (Sjogren et al
1991) and E. faecalis may be resistant to its effects (Siren et al). Passive ultrasonic irrigation
(Capar et al) or rotary instrumentation (Kenee et al) are more effective than syringe irrigation
at removing CH from the root canal system.
• Bystrom, Sundqvist 1985:
• Combined use of EDTA + 5% NaOCl more effective than NaOCl alone.
• Found no diff in antibacterial effect between 0.5% vs 5% NaOCl.
• Bacteria surviving instrumentation and irrigation rapidly increased in number between
appointments when no intracanal med used.
• Ruparel, Diogenes et al 2012: CH is favored for REGEN. It is less cytotoxic than antibiotic
pastes or CHX against apical papilla stem cells
• Calcium hydroxide is used widely as an intracanal medicament in root canal treatment to
reduce residual bacteria (Messer). It has been used in endodontics in various clinical
situations. It inhibits osteoclastic activity (Safavi), degrades bacterial lipopolysaccharides
(Safavi), dissolves soft tissues (Hasselgren), and promotes apexi cation. Even though the
use of Calcium Hydroxide has now subsided with the use of mineral trioxide aggregate and
similar biomaterials, such as bioceramics, it is a traditional pulp capping material used in vital
pulp treatments
• CHX Gel
• Often suggested as an alternative to CH. Like CH, it possesses broad antibacterial
abilities.
• Wang et al: found that 2% CHX gel is an effective root canal disinfectant.
• Waltimo et al: Found it is effective against gram + and gram - bacteria, both aerobic and
anaerobic species and fungi.
• Buck et al: It exhibited greater antibacterial activity against E. faecalis than CH.
• Oliverira et al: Like CH, CHX gell also reduces intracanal LPS.
• Tavares et al: Reduces pro-in ammatory cytokine expression in the periapex
• Leonardo et al: More favorable healing of PA lesions was noted with CHX gel vs CH.
• Herman 1920: introduced CaOH as an intracanal medicament in necrotic teeth
• Heithersay 1975: CaOH kills most bacteria due to its pH of around 12.5
• Sjogren, Sundqvist 1991: minimum use of CaOH for 7-10 days to eliminate bacteria that
survived instrumentation. (found that a thorough disinfection of the root canal system required
7 days of treatment with calcium hydroxide, and bacteria were not suf ciently eliminated after
10 minutes or 24 hours of exposure to the medicament.
• Sathorn, Messer 2007: Systematic Review & MA. 1 vs 2 visits. Calcium hydroxide has
limited effectiveness in eliminating bacteria from human root canal when assessed by culture
techniques.
• Siqueira 2001:
• Ca(OH)2 mechanism of action
• pH (12.5) alters enzyme activity/cellular metabolism Hydroxyl ions create free
radicals destroying components of bacteria cell membranes.

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 • Hydroxyl (OH-) ions created in aqueous environment: Highly Oxidative Free
Radicals (H.O.F.R.s):
• Cell Membrane Damage: OH- ions Remove H+ from Unsaturated Fatty Acids –
Generating free lipid radicals and destroying phospholipids – key components of
cell membrane
• Protein Denaturation: Alkalinization induces breakdown of ionic bonds maintaining
tertiary structure of proteins = Loss of activity of the enzyme and Disruption of the
cellular activity
• DNA Damage: OH- ions react with bacterial DNA and induce splitting of strands.
Inhibits DNA replication and cellular activity.
• Free radicals (hydroxyl ions) react with bacterial DNA inhibiting DNA replication and
cell activity. Increased pH (12.5) alters enzyme activity disrupting cellular
metabolism and structural proteins. Ca(OH)2 effective when in direct contact with
bacteria which may not always be possible such as bacteria located in dentinal
tubules or int he center of bacterial colonies. pH in tubules is increased, but only up
to 8-11 (Tronstad). Certain bacteria such as enterococci tolerate high pH levels of
9-11. Vehicle used to deliver Ca(OH)2 must not alter the pH signi cantly
• Bystrom, Sundqvist:
• Cleaning & Shaping —> 20-40% reduction in bacteria
• C&S + 0.5% NaOCl —> 40-60% reduction in bacteria
• C&S + NaOCl + 24hrs Ca(OH)2 —> 90% reduction in bacteria
• C&S + NaOCl + 7 days Ca(OH)2 —> almost 100% reduction in bacteria.
• Sjogren 1991: 100% of canals dressed with Ca(OH)2 for one week were sterile, 50% of
canals treated for 10 min were free of bacteria.
• Safavi, Nichols 1993: Lab. Inactivates LPS. Evaluated effect of Ca(OH)2 on bacterial LPS.
This study suggests that calcium hydroxide-mediated degradation of LPS may be an
important reason for the bene cial effects of inter-appointment calcium hydroxide treatment.
• Weiger 2000: No bene ts using Ca(OH)2 between appointments, outcomes the same.
• Hasselgren 1988: Completely dissolves porcine muscle tissue over time
• Turkun – Pretreatment with CaOH2 enhanced tissue dissolving ef cacy of 0.5% NaOCl to the
level achieved with 5% NaOCl. CaOH2 causes tissues to swell and become more accessible
to the NaOCl.
• Wadachi 1998 – Bovine teeth, SEM analysis of remaining pulpal tissue: NaOCl >30 s,
CaOH2 -7 days showed signi cantly lower debris scores compared to shorter time intervals;
Combination of NaOCl + CaOH2 signi cantly enhanced the tissue dissolution effect compared
to either NaOCl or CaOH2 alone (Synergistic effect)
• Haapasalo 1989: Clinical study: Bacterioides spp in dental root canal infections.The success
rates of the 3 penicillin groups (0, 1 and 12 weeks) showed no difference at 1 year control.
The result supported the current practice in endodontic treatment where antibiotics are not
routinely prescribed. Bacteriological samples taken at the second appointment showed that
Ca(OH)2 effectively disinfected the canal.
• Peters, Wesselink 2002: No signi cant difference in healing of periapical radiolucency was
observed between teeth that were treated in one visit (without Ca(OH)2 ) and two visits with
the inclusion of calcium hydroxide for 4 weeks. The presence of a positive bacterial culture at
the time of lling did not in uence the outcome of treatment.
• Sundqvist 1998: Certain facultative anaerobes maybe resistant to Ca(OH)2 even after 1
week

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 • Estrella 1999: Ca(OH)2 demonstrated NO antimicrobial effect at 2, 3, & 7 days against E.
faecalis, S. aureus in infected dentinal tubules (suggests antimicrobial effectiveness is due to
concentration of [OH] and time of exposure).
• Siqueira 1999: Literature review. The primary function of calcium hydroxide as a routine
intracanal medicament is to provide antimicrobial activity. However, the mechanisms of
antimicrobial activity of calcium hydroxide are not well known. Physicochemical properties of
this substance may limit its effectiveness in disinfecting the entire root canal system. In
addition, calcium hydroxide is not effective against all bacterial species found in root canal
infections. Association with other medicaments may enhance the ef cacy of the intracanal
medication in eliminating residual bacteria in the root canal system.
• Gomes 2003: CHX killed E. faecalis as an intra-canal med better than Ca(OH)2 or mix of
• Evans, Sundqvist 2002: Survival of E. faecalis in calcium hydroxide appears to be unrelated
to stress induced protein synthesis, but a functioning proton pump is critical for survival of E.
faecalis at high pH.
• Khan, Hargreaves 2008: Ca(OH)2 leads to substantial reduction in detectable levels of
endogenous in ammatory mediators
• Simcock 2006: Complete instrumentation before medication is what enables good ll, not CH
delivery technique. (injection system, lentulo spiral, reverse hand le and reverse NiTi le all
used to introduce CH into minimally prepped and fully prepped canals. All performed equally
poorly with minimally prepped (25.04) and all performed very well in completely prepped
(40.04) canals.)
• Basrani, Friedman 2003: CHX works better than CH as a intracanal medicament against E.
faecalis. (Did the same thing as 2002 study with Gorduysus, except rst they inoculated
THEN they incubated for 7 days. Canals rinsed then dentin shavings taken and cultured.
Basrani is the CHX root shaving guy, demonstrated substantivity of 2% CHX in dentin.)
• De Moor, De Witte 2002: Extensive extrusion of Ca(OH)2 into the periapical tissue does not
appear to compromise periapical healing. Despite this nding, the deliberate extrusion of
dental materials into the apical tissues is not advocated.
• Law 2004 – Review - CaOH2 remains the best medicament available to reduce residual
micro ora beyond instrumentation effort.
• Foster, Kulild 1993: The results demonstrated that Ca(OH)2 diffuses from the root canal to
the exterior surface of the root and that the removal of the smear layer may facilitate this
diffusion.
• Mickel 2003 : JOE – Thin mix more effective antibacterial than thick mix
• Vera/Siqueira 2012 JOE – 2 visit w/ CaOH2 = Bacterial counts in main canal, dentinal
tubules, isthmuses, apical rami cations, lateral canals (DIAL) = Improved histobacteriologic
status
• Xavier/Martinho/Oliveria 2013 JOE – 2 visit w/CaOH2 were more effective at reducing
bacterial endotoxins (LPS) than 1 visit protocols (98% vs. 86%)
• Orstavik: NaOCl canal irrigation reduced the bacteria level by only 61.9%, but use of
Ca(OH)2 in the canals for 1 week resulted in a 92.5% reduction. These researchers (Shuping,
Orstavik, Trope) concluded that Ca(OH)2 should be used in infected cases to more
predictably obtain disinfection. Superior antimicrobial effect of CaOH when used long term.
However, Sathorn (IEJ) found that Calcium hydroxide has limited effectiveness in eliminating
bacteria from human root canal when assessed by culture techniques
• Tronstad: Ca(OH)2 effective when in direct contact with bacteria which may not always be
possible such as bacteria located in dentinal tubules or in the center of bacterial colonies
( Same nding was shown by Bystrom) pH in tubules is increased, but only up to 8-11. He
mentioned that CaOH might be effective in resorptive case by inhibiting osteoclastic activity.

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 • Tronstad – pH is decreased during resorption. Teeth lled with CaOH2 have increased pH in
the surrounding dentin. (7.4-11) The pH of cementum/PDL is not effected by CaOH2 in the
canal. Increased dentinal pH may be the mechanism for stopping resorption.
• Andreasen: Recommended use of CaOH < 1 month. Long term use of CaOH increase risk of
root fracture (in sheep). Trope rec 6 months use for internal resorptions. Tamse: 2 weeks
• Safavi and Nichols: CaOH inactivates LPS. CaOH is ineffective against E. Faecalis.
• E. Faecalis is resistant to Calcium Hydroxide due to proton pumping. Resistant up to pH
11.5. Above that it kills it. Evans: E. Faecalis proton pump resists high pH of calcium
hydroxide.
• Rosenberg 2007 – In vitro, maxillary incisors, CaOH2 placed 7, 28, or 84 days and compared
with control (GP/Sealer). Signi cant in Dentin Fracture strength from 28-84 days w/ CaOH2.
Long term use of CaOH2 decreases microtensile dentin fracture strength.
• Bystrom/Sundqvist – Bacteria rapidly repopulate the canal without intracanal medicament.
Negative culture following instrumentation + NaOCl + EDTA + CaOH2.
• Sigurdsson, Madison: Ca(OH)2 placement. lentulo > injection > k le
• Estrella: Ca(OH)2 not effective unless touch canal walls
• Lambrianidis: The removal of Ca(OH)2 is frequently incomplete, resulting in a residue
covering 20% to 45% of the canal wall surfaces, even after copious irrigation with saline,
NaOCl, or EDTA. Residual Ca(OH)2 can shorten the setting time of zinc oxide eugenol–
based endodontic sealers. Most notably, it may interfere with the seal of the root lling and
compromise the quality of treatment.
• This nding is in agreement with KIM study In uence of calcium hydroxide intracanal
medication on apical seal. Int Endod J 2002. The Ca(OH)2 groups showed signi cantly
more dye leakage than the non-medicated control group.
• However, Baumgartner said that CaOH can be effectively removed using NaOCL or
EDTA.
• Kim questioned study of Kontakiotis who said CaOH2 dressing does not effect the seal
of the permanent root canal lling. Questions whether methylene blue is useful for
CaOH2 studies. CaOH2 decolorizes methylene blue. This study used the uid transport
method for measuring leakage.
• Porkaew 1990 – CaOH2 medicated teeth demonstrated less apical leakage (dye) than non-
medicated teeth. This may be due to temporary occlusion of dentinal tubules by the CaOH2
paste or incorporation into the sealer.
• Hosoya 2004 – Effect of CaOH2 on various sealers: ZOE, Ketac-Endo, Sealapex. Signi cant
reduction in working time, Faster setting
• Hosoya 2001 – Optimal Time Needed for Ca(OH)2. Optimal peak pH (periapical tissues):
Aqueous mixture (CaOH2 powder/distilled H2O) - 14 days; CaOH2 powder alone - 49 days;
Time required for opt. intracanal CaOH2 activity is at least 2 weeks
• Nerwich/Figdor/Messer – hydroxyl ions derived from a calcium hydroxide dressing diffuse
through root dentin. 1-7 days elapse before pH began to rise in the outer root dentin,
peaking at pH 9.3 apically after 2-3 weeks.
• Zancan et al 2016: the aim of this study was to analyze the in uence of vehicles on OH /Ca
ion release, solubility, and antimicrobial action of calcium hydroxide pastes against bio lms.
The highest OH ion release values were found in 3 and 30 days. Ca releases were greater in
CH/ CMCP. CH/P and CH/CMCP showed a higher percentage of volume loss values. CH/
CHX presented the greatest antimicrobial action.
• de Freitas, Weckwerth et al 2017: NSAIDs and Antibiotics combined with CH. The
association of NSAIDs and cipro oxacin increased the antimicrobial action of CH paste. The

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 use of NSAIDS instead of antibiotics associated with CH paste would avoid the topical use of
antibiotics, which could encourage the growth of resistant strains.

Sealer
• The sealers are responsible for the principal functions of the nal root lling: sealing off of the
root canal system, entombment of remaining bacteria and the lling of irregularities in the
prepared canal. (Why use sealer? Binding agent for RC core lling material, Fills voids and
discrepancies in canal walls, Prevents leakage, Acts as lubricant for ll )
• Louis Grossman 1976: Ideal Sealer: Radiopaque, Bacteriostatic, Adhesive, Short setting
time, Biocompatible, Non-staining, No Shrinkage, Resorbable, Soluble in common solvents,
Hermetic Seal.
• Wiemann and Wilcox: No matter which sealer is selected, placement can be completed with
K les, lentulo spirals or GP cones with no effect on ll quality.
• AH Plus:
• An epoxy-bis-phenol- resin & adamantine based sealer.
• 4 hr working time. 8 hr setting time. Excellent radiopacity. Biologically Inert.
• Paste/paste system for fast, easy mixing and dosage control
• Supposedly has no formaldehyde release. Bisphenol past A/amine past B
• De Silva 2013: Advantages: Good ow, low solubility, good dimensional stability, good
adhesion to dentin and gutta percha. Disadvantages: cytotoxic up to 2 weeks, irritating
to periradicular tissues, delays healing if extruded.
• Pulp Canal Sealer (Kerr EWT)
• Zinc oxide eugenol-based. Setting reaction by formation of Zinc Eugenolate
• Powder Component: Zinc oxide, silver, resins, thymol iodide
• Liquid Component: Eugenol, Canada balsam
• Working time: 30 min, Setting time: 15-30 min
• De Silva 2013: Advantages - Excellent lubricating properties, germicidal, resorbed if
extruded. Disadvantages - cytotoxic up to 1 week, irritating to periradicular tissues,
solubility
• Grossman’s sealer/Roth Sealer:
• 42% ZnO - ller, antimicrobial (Barkholder)
• 27% resin - gives body, coherence, good setting time
• 15% Bismuth Sub carbonate - accelerates setting time
• 15% Barium sulfate - radiopacity
• 1% Borax- retards setting time
• Sealapex:
• Base: Ca(OH)2 25% ZnO 6.5%
• Catalyst: Barium sulfate 18.6% Titanium dioxide 5% Zinc stearate 1%
• Wilcox: Methods of sealer placement: NSD between coated master cone method, lentulo,
US or MAF
• Spangberg: Talked about cytotoxicity of sealer, proposed that cytotox of ZnOE sealer can be
reduced by replacement of eugenol with fatty acids.
• Mickel, Wright 1999: compared Roth sealer vs calcium hydroxide (sealapex) showed
antimicrobial effect. Grossman showed shrinkage of Roths sealer following sealer setting.
• Leonardo 1999: The objective of the present study was to evaluate two different types of root
canal sealers: AH Plus (an epoxy resin-based sealer) and Fill Canal (a zinc oxide-eugenol
based sealer). A total of 34 root canals with vital pulp from dogs' premolars were used. After
instrumentation, the root canals were lled with gutta-percha and AH Plus or gutta-percha

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 and Fill Canal sealers using a classical technique of lateral condensation. After histological
processing, the sections were stained with hematosylincosin or Mallory's trichrome stain.
In ammatory cells or areas of necrosis were not associated with AH Plus. Hard tissue
formation apically to the material was observed in 14 specimens. The Fill Canal sealer
presented an in ammatory response of moderate intensity in the periapical region, mainly
adjacent to the material.
• Leyhausen 1999: AH 26 cytotoxic but not seen with AH plus (Resin sealers have a long
history of use, provide adhesion, and do not contain eugenol. AH- 26 is a slow-setting epoxy
resin that was found to release formaldehyde when setting. AH Plus is a modi ed formulation
of AH-26 in which formaldehyde is not released. The sealing abilities of AH-26 and AH Plus
appear comparable. AH Plus is an epoxy-bis-phenol resin that comes in two tubes. Powder:
Silver Powder: 10% Bismuth Oxide: 60% Hexamethylenentetramine 25% Titanium Oxide 5%
Liquid: 100% Bisphenoldiglycidyl ether )
• Siqueira et al 2000: AH Plus and Kerr Pulp Canal Sealer EWT are antibacterial and ow
values signi cantly superior to other sealers tested (Grossman’s sealer, Thermasealer, Sealer
26, Sealer Plus). All root canal sealers tested showed some antimicrobial activity against
most of the microorganisms.
• Siqueira, Rocas 2001: AH plus apically seals as wells as Kerr EWT, AH 26 and ThermaSeal.
Evaluated apical sealing ability of 5 endodontic sealers. The results showed that Grossman’s
sealer exhibited signi cantly more leakage than the other sealers, except ThermaSeal.
• Orstavik 2001: AH plus expands 0.9% (not much), ZOE base shrink
• Saleh, Haapasalo 2004: AH plus and Grossman’s were effective in killing E. faecalis in
dentinal tubules. (Ketac-Endo, Apexit, RK, Ca(OH)2 not very effective)
• Kayaoglu, Orstavik 2005: AH Plus, Grossman’s sealer, MCS were effective in reducing the
number of cultivable cells of E. faecalis. Calcium hydroxide-based sealers, Sealapex and
Apexit were ineffective in this short-term experiment.
• Du, Haapasalo 2015: The placement of root canal sealer after NaOCl treatment enhanced
antibacterial effects against E. faecalis in the dentinal tubules. Little additional effect was
obtained after 30 days of exposure to sealers. Looked at AH Plus, Endosequence BC Sealer,
or MTA Fillapex
• Azar et al 2000: Cytotoxicity of the AH-plus was con ned to the early period of experiment
and was no longer detectable after 4 hr of mixing. (compared to AH 26 cytotoxic for 1 week,
and ZOE 5 wks)
• Dahl 2005: Review of cytotoxicity. Most sealers exhibit a cytotoxic effect, but only for a
limited time. (Cytotoxicity reigned in the literature for a decade)
• Smadi et al 2008: Most sealers exhibited antibacterial activity when freshly mixed that is lost
over time. Evaluated the antimicrobial activity 9 root canal sealers
• Eriksen, Orstavik, Kerekes 1988: No difference in outcomes when using ZOE, resin (AH26)
and chloroform (KlorperkaNO) sealers. (One of the ONLY well-controlled clinical outcomes
studies). 3-year recall of 571 teeth lled with three sealers. PAI used to evaluate
• Orstavik 1993: No difference in outcomes when using resin (AH26) and chloroform
(KlorperkaNO) sealers. Prognosis affected by PARL status and ll being 1-3mm from apex.
(One of the ONLY well-controlled clinical outcomes studies). Similar study design done as
Ostavik 1987, except this study compared two sealers at two schools (Oslo and Arhus)
• Orstavik 1987, 1988: Zinc oxide sealers are cytotoxic and the effect can be long lasting.
Resin based sealer elicit initial severe in ammatory reaction and subsides after.
• Gutmann, Tay et al 2010: JOE. This in vitro study compared the cytotoxicity and osteogenic
potential of an experimental calcium silicate-based sealer with an epoxy resin-based sealer
(AH Plus; Dentsply Caulk, Milford, DE) and a zinc oxide-eugenol-based sealer (Pulp Canal

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 Sealer; SybronEndo, Orange, CA). All sealers exhibited severe toxicity after 24 hours, after
which toxicity decreased gradually over the experimental period except for Pulp Canal Sealer,
which remained severely toxic. Toxicity of the extracts derived from the sealers was
concentration dependent, with those derived from the experimental sealer being the least
cytotoxic at a 1:10 dilution. Minimal alkaline phosphatase activity and no bone formation were
seen with Pulp Canal Sealer. The production of alkaline phosphatase was less intense for the
experimental sealer at 7 days. However, both AH Plus and the experimental sealer did not
inhibit mineralization of the extracellular matrix after 28 days. The experimental calcium
silicate-based sealer may be regarded as minimally tissue irritating and does not interfere
with bone regeneration even when it is inadvertently extruded through the apical constriction.
• Candeiro et al 2016: IEJ. To compare the characteristics of bioceramic endodontic sealer
Endosequence BC sealer with those of AH Plus sealer. Bioceramic-based sealer had less
cytotoxicity and genotoxicity and similar antibacterial effect against E. faecalis in comparison
with AH Plus sealer. Endosequence BC sealer had signi cantly smaller antibacterial activity
than AH Plus sealer up to 1 h of direct contact (P < 0.05). On other exposure times, both
materials had similar antibacterial effectiveness (P > 0.05). The antibacterial effect of the bio-
ceramic sealer may be due to the combination of high pH and active calcium hydroxide
diffusion and hydroxyapatite formation. Study appears to be biased in favor of BC Sealer.
• AlShwaimi, Majeed 2016: JOE. The purpose of this systematic review was to summarize the
outcomes of in vitro studies of root canal sealers for their antimicrobial effectiveness against
Enterococcus faecalis on the basis of direct contact test. The evidence indicated positive
antimicrobial activity of freshly mixed sealers against E. faecalis. Antimicrobial ef cacy was
lost as the material set, with no bacterial growth inhibition by 2-day to 7-day set sealer
samples. However, the studies included in this review presented medium to high risk of bias.
This review demonstrated that resin-, ZOE-, and CH-based sealers were among the most
commonly tested root canal sealers. Other types of sealers used included calcium silicate-/
MTA-, silicon-, and GIC-based sealers. In all categories, freshly mixed sealers showed some
type of positive antimicrobial effect against E. faecalis except silicon-based sealers. However,
the ability of freshly mixed sealers to improve the success of root canal treatment by
preventing the growth of microorganisms left in the rami cation of the root canal system after
chemomechanical preparation and intracanal dressing requires further clinical investigations.
• Evans, Simon 1986: JOE. Indian Ink. Thermoplasticized GP/Lateral Cond w/ and w/out
sealer. Only the sealer had signi cant effect on dye leakage. Obturation method and
presence/absence of smear layer had no effect.
• Wu, Wesslelink 1994 &1995: IEJ: sealers show less leakage when mixed thinner. The
results after the second measurement showed that every sealer produced the best seal when
the sealer layer was the thinnest. AH26, Ketac-Endo and Tubli-Seal showed a reduction in
leakage over time and gave signi cantly less leakage than Sealapex (P<0.005). Sealapex
showed signi cantly more leakage after storing in water for 1 year (P<0.005). Therefore, the
long-lasting seal of sealer may, among other in uencing factors, depend on the layer
thickness and the solubility of the material. These ndings indicate that the thickness of the
sealer layer in uences the sealing ability of a root canal lling.
• Barkin, Cohen et al 1984: Presented a case of severe allergic reaction to eugenol in an
endodontic sealer
• Generali et al 2017: JOE. Sealer penetration into dentinal tubules is not affected by the
irrigant delivery and/or agitation systems studied. Therma l with TopSeal technique achieves
complete sealer perimeter integrity in all groups. Fifty single-rooted teeth with round-shaped
root canals were distributed in 5 homogeneous groups characterized by the different
cleansing system used: conventional endodontic needle irrigation, EndoActivator, Irrisafe,

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 Self-Adjusting File, and EndoVac. After instrumentation, all teeth were lled by Therma l
obturators and rhodamine B dye labeled TopSeal sealer.

Sealer Extrusion
• Ricucci, Rocas, Siqueira 2016: Apically extruded sealers: fate and in uence on treatment
outcome. Not all extruded sealers were predictably removed from the periradicular tissues.
Treatment outcome was not signi cantly affected by the type of extruded sealer. A signi cant
better outcome was observed for teeth with no lesion in comparison with teeth with apical
periodontitis. When in contact with tissues and tissue uids, zinc oxide eugenol-based sealers
are absorbable while resin-based materials typically are not absorbed
• (do not agree with the previous observation from Augsburger which reported that given enough time
postoperatively all extruded sealers would be removed. This may be true for the zinc oxide eugenol–based
sealers, but only 15% of the AH Plus cases and one third of the Apexit cases showed complete removal of the
extruded material in periods longer than 4 years. In the majority of cases in which these sealers were not
removed, they remained apparently unchanged on radiographs, even after long periods ranging from 10 years.
Also they reported that as for the in uence on treatment outcome, there were no statistically signi cant
differences between type of extruded sealers at all follow-up periods and also extrusion of sealer does not
affect the healing outcome. )
• Seltzer et al: associated with chronic in ammation
• Torabinejad, Bakland 1979: No systemic antibody formation or delayed hypersensitivity
reaction to Grossman’s sealer or AH 26 (after 7 days of intentional extrusion of sealer in dog
teeth).
• Sari 2007: A radiographic 4 year f/u of extruded AH plus. No signi cant difference between
healing in cases with extruded sealer and those w/out. It did delay healing some. (49 pts, age
9-15, 100% recall).
• Augsburger, Peter 1990: (ZOE sealer) Did not prevent healing; removed over 6 year period.
(The radiographic appearance of lling material extruded into periradicular tissues during
obturation of root canals was studied over time. Recall radiographs for up to 6 1/2 yr were
compared with immediate postoperative lms. Consistently, less material was evident at
successive postoperative periods. This study indicated that given time, the two zinc oxide and
eugenol-based sealers studied will be removed from periradicular tissues. It also indicated
that sealer is removed from periradicular tissues more rapidly than gutta-percha.)
• Silveria et al 2011: Rat study. Looked at Epiphany, AH Plus, Pulp Canal Sealer (zinc oxide
eugenol based), Sealpex (Ca(OH)2 based). All created some in ammation when extruded,
usually more intense at 7 days and more mild by day 30. The outcomes of the present study
showed that the sealers presented acceptable biological compatibility after 30 days, except
for Pulp Canal Sealer.
• Huang 2010: JOE. suggested that inhibition of alkaline phosphatase (ALP) expression might
play an important role in the pathogenesis of root canal sealer–induced periapical bone
destruction. They showed that AH26 sealers can signi cantly reduced the amount of
expressed ALP and probably increase the rate of bone destruction following sealer extrusion.
• Spangberg 1974: The formaldehyde containing N2 formulation (Sargenti paste) produces
extensive tissue necrosis. Since the paraformaldehyde in N2 will not be resorbed, must sx
remove Sargenti material expressed beyond apex.
• Serper 1998: Paraformaldehyde pastes are neurotoxic.
• Generali et al 2017: JOE. Sealer penetration into dentinal tubules is not affected by the
irrigant delivery and/or agitation systems studied (conventional, endoactivator, irrisafe, SAF,
endovac).

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 Obturation Technique
• Torneck: Root canal failure is due to poor debridement rather than poor root canal lling
• Sabeti 2006: (dog study) The noteworthy nding of this study was that there was no
difference in healing of apical periodontitis between the instrumented and obturated and
instrumented and nonobturated root canal system. The success of endodontic treatment
ultimately depends on the elimination of the microorganism, host response and mechanical
closure (coronal seal) of treated root canals that may provide a potential for future bacterial
contamination.
• Yared, Dagher: Displacement of GP apically is more in vertical (1mm) condensation than
lateral (0.5mm). They also reported that there is less chance of overextension and less apical
leakage in smaller apical preparation (size 25) compared to larger (40) following vertical
condensation.
• Walton 1981: Less leakage occurs with deeper spreader penetration (w/ in 1 mm, or 2mm w/
master cone), Tug-back is not a good indicator of canal adaptation. D11 more damage than
nger spreader.
• Brothman 1981: Vertical compaction demonstrated TWICE the number of lateral and
accessory canals and denser ll.
• Kayat, Lee, Torabinejad 1993: Found that obturated root canals that were not sealed and
exposed to the oral environment were recontaminated in less than 30 days. No diff in method
of obturation (cold lateral vs vertical condensation techniques).
• Buchanan 1994: Continuous wave of condensation technique.
• The continuous wave of condensation technique uses the System B Heat Source with
the choice of four different-sized pluggers. The main advantage of this obturation system
is that the downpack of gutta-percha can be achieved in one continuous motion with one
heated plugger. The temperature of the heat source can be adjusted, but the
recommended setting is a temperature of 200°C. It is also recommended that the
pluggers be used 4 to 6 mm short of working length. It is believed that heat is conducted
to the tip of the master gutta-percha cone.
• Lea et al 2005: Results demonstrated that the continuous wave of condensation technique
resulted in a signi cantly greater density compared with cold lateral compaction. Warm
vertical compaction using the continuous wave of condensation technique in acrylic blocks
resulted in a greater gutta-percha ll by weight compared with standard cold lateral
compaction.
• Sequeira et al 2000: No obturation technique predictably produces bacteria-tight seal of root
canal after direct saliva challenge.
• Goldberg, De Silvio 2001: (Continuous wave lled more lateral canals vs lateral) A greater
number of simulated lateral canals were obturated when Ultra l, Therma l, and System B +
Obtura II were used, in comparison with canals obturated with the hybrid technique, Obtura II,
or lateral compaction of gutta-percha. This difference was statistically signi cant (p < 0.05).
No statistically signi cant differences were found between results obtained in the obturation of
simulated lateral canals in the different thirds of the root (p > 0.05).
• Bowman, Baumgartner 2002: The deeper the downpack with System B, the more GP lls
the lateral canals. Split tooth model down. Downpacked to 5, 4, 3mm from apex. Downpack
to 3mm lled grooves at 3mm
• Jacobson, Xia, Baumgartner, Marshall 2002: Continuous wave and lateral condensation
perform equally well in bacterial leakage regarding incidence of leakage, but continuous wave
performed better with time to leakage (10 vs 20 days). Teeth prepped and lled with 1)
continuous wave with/without sealer 2) lateral with/without sealer. Leakage model with K.
pneumonia for 12 weeks

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 • Orstavik 2005: Endo Topics 2005. Obturation Review.
• Primary Functions of the root lling —> Filling and Sealing
• Grossman's requirements for an ideal obturating material.
• It should be easily introduced into the canal
• It should seal the canal laterally as well as apically
• It should not shrink after being inserted
• It should be impervious to moisture
• It should be bacteriostatic or at least not encourage bacterial growth
• It should be radiopaque
• It should not stain tooth structure
• It should not irritate periapical tissue
• It should be sterile or quickly and easily sterilized before insertion
• It should be easily removed from the root canal if necessary
• Sundqvist & Figdor assigned 3 primary functions to the root lling:
• sealing against ingrowth of bacteria from the oral cavity
• entombment of remaining microorganisms
• Complete obturation at a microscopic level to prevent stagnant uid from
accumulating and serving as nutrients for bacteria from any source.
• (Schilder talked about difference between underextension, overextension, under ll and
over ll. Over- ll = 3D obturation with some GP beyond apex; Over-extension = excess
GP beyond apical foramen, but no implication of 3D obturation).
• The sealers are responsible for the principal functions of the nal root lling: sealing off
of the root canal system, entombment of remaining bacteria and the lling of
irregularities in the prepared canal.
• Schaffer, White, Walton 2005: Determining the optimal obturation length. (3 groups: 0-1mm
from apex, obturated past apex, obturated > 1mm short). Obturating material extruding
beyond the radiographic apex correlates with a decreased prognosis. Better success rate is
achieved when tx includes obturation short of the apex.
• Peng 2007: The ONLY Systematic Review and meta-analysis of obturation. Cold lateral
condensation and warm gutta percha (ie therma l, no continuous wave compaction)
performed EQUALLY between obturation quality, post-op pain, long term outcome.
Overextension more likely in in warm GP techniques.
• Sahni et al 2008: This study demonstrated that the continuous wave group achieved
signi cantly more gutta-percha occupying the canal space than the Endo-Eze system at all
levels. The percentages of gutta-percha and sealer were indirectly proportional. A warm
technique like continuous wave produces a greater amount of gutta-percha occupying the
canal when compared with a single-cone technique. The mean percentages of voids were
signi cantly larger at 6 mm and 12 mm for the Endo-Eze group compared with the Pro le
Series 29 and continuous wave group. Both rotary and reciprocating instrumentation were
unable to clean and shape elliptical canals consistently. In the majority of sections, the warm
vertical group possessed less debris than the Endo-Eze group, but this was not statistically
signi cant. Since the rotary instruments produce only circular preparations, portions of
elliptical canals will be left untouched. A continued effort to make an instrument that prepares
ribbon-shaped canals more effectively is needed.
• Reader C et al 1993: JOE. (NSD in ll quality; more lateral canals obturated with warm
technique). The three-dimensional obturation of the root canal system is widely accepted as a
key factor for successful endodontic therapy. The purpose of this study was to evaluate the
obturation of lateral canals and the main canal using three gutta-percha sealer techniques:
cold lateral condensation, warm lateral condensation, and warm vertical condensation. Sixty

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 epoxied blocks with ve lateral canals placed at varying angles from the main canal were
used. Each experimental group was treated by a board-certi ed endodontist with training and
clinical experience in that obturation technique. There was no statistically signi cant
difference (p < 0.05) between the obturation techniques in the ratio of the void area to the
gutta-percha-plus-sealer area for the main canal. There was signi cantly (p < 0.001) more
sealer in the lateral canals for the two lateral condensation techniques. The warm obturation
techniques had signi cantly (p < 0.001) more gutta-percha in the lateral canals.
• Clinton, Van Himel 2001: Gutta-percha using Therma l was better able to ow into lateral
spaces, had fewer voids, and replicated the surface of the root better. It also, however, was
extruded out the apical foramen more than in the lateral condensation group.
• Farzeneh, Friedman 2004: A 10% higher healing rate was also reported with WVC versus
CLC for teeth with previous apical periodontitis ( ared preparation and vertical compaction,
90%; step-back preparation and lateral compaction, 80%). Toronto study.
• Collins, Kulild 2006: (Continuous Wave of condensation was signi cantly better at
replicating defects than cold lateral condensation) A split-tooth model with arti cially created
intracanal wall defects was used to compare three gutta-percha (GP) obturation techniques,
cold lateral, warm lateral, and warm vertical (continuous wave techniques). The techniques
were evaluated and compared based on defect replication quality as a function of defect
location and size. The obturations were evaluated on an ordinal scale, 0 to 4, based on how
much each defect was replicated. There was a statistically signi cantly better result with both
warm techniques compared to cold lateral obturation, while there was no signi cant difference
between the warm obturation techniques.
• Venturi et al 2002: The use of the System-B Heat Source on root canals maintained at a
constant body temperature by a thermostatic bath revealed that the increase of temperature
of the gutta-percha at the apical third of the canal was negligible and that the compaction of
the mass of the gutta-percha close to the apex was performed at body temperature. Minor
changes in temperature of the outer surface of the root canals occurred, suggesting no
danger for the periradicular tissues.
• Gutmann: 10 degrees C temp change will damage the PDL cells; temps never reached
this high. However, Baumgartner J Endod 2001 showed that at no time did the System B,
the Obtura II, or ultrasonic delivery of warm gutta-percha exceed an increase of 10 degrees C
at any thermocouple level on the external root surface.
• Sweatman, Baumgartner 2001: Exterior root temperatures using System B, Obtura II or US
delivery of GP never exceeded 10 degrees C. In vitro study with extraradicular
thermocouples.
• Eriksson et al 1983: It is generally accepted that a 10°C rise above normal body temperature
can cause damage to the tooth’s surrounding structures
• Romero: System B at 200 C only produced 1 degree C increase on exterior root surface at
apex and 2 degree C increase at 5mm from apex (Eriksson & Albrektsson: > 10 degree C
is threshold level for bony necrosis)
• Davis 1971: Teeth that are fully instrumented that are lled short have best healing
• Bogen, Kuttler 2009: Unsuccessful root canal treatments compromised by microleakage,
inadequate cleaning and shaping, poor quality obturation, and large PA lesions can
demonstrate superior healing rates when this osteoinductive and cementogenic material is
used to ll the root canal system. It appears that teeth obturated with MTA might not only
increase their fracture resistance with time, but bacteria might be effectively entombed and
neutralized in severely infected teeth. Supports complete MTA obturation of whole root canal
system.

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• Ricucci, Siqueira 2010: Is lling lateral canals relavent to tx outcome —> not really.
Conclusions: Condition of tissue in main canal re ects the condition of the tissue in the lateral
canal. Radiographic appearance of lled LCs does not indicate disinfection or seal. Overall,
the belief that lateral canals must be injected with lling material to enhance treatment
outcome was not supported by literature review or by our histopathologic observations. It
appears that strategies other than nding a technique that better squeezes sealer or gutta-
percha within LC/AR should be pursued to effectively disinfect these regions. In cases in
which lateral canals appeared radiographically " lled," they were actually not obturated, and
the remaining tissue in the rami cation was in amed and enmeshed with the lling material.
• Wong: warm vertical placed larger mass of GP into canal than lateral condensation
• Hale, Gattie, Glickman, Opperman 2012: Retrospective clinical outcomes study. Compares
lateral vs carrier based obturation. No signi cant difference noted in success rate: LC 81%,
CB 83%. (Performed by dental students)
• Walton: Therma l leaked most possibly due to stripping of GP off carrier; at 1mm from apex
only 5% were completely covered with GP - complete encasement of carrier over entire canal
was never seen.
• Baumgartner: There is NSD in the apical leakage between vertical and lateral condensation.
However, therma ll leaked the most due to stripping the carrier.
• Chu et al 2005: Therma l vs lateral. 3 yr recall. No sig difference in treatment success rate
between therma l (81%) vs lateral condensation (79%). Therma ls take less time. Type of
post-endodontic restoration had a signi cant association with the presence of post-treatment
disease.
• Chugal N, Clive, Spangberg 2003: The risk of failure was higher for a fair/poor density of
obturation than for a good density for all diagnoses of periradicular status. (presence of
chronic apical periodontitis, level of lling and density of lling affects the outcome. )
• Tamse: Lateral condensation more prone to VRF (look up article)
• Siqueira, Rocas 2009: -Role of obturation: to eliminate or reduce space for reorganization of
the community by surviving bacteria and prevent further nutrient supply.
• Lateral Condensation
• Joyce: NiTi spreader induced less stress and decreased risk of VRF
• Allsion, Walton: Less leakage with deeper spreader penetration (within 1-2mm)
• Berry: NiTi spreader penetrated sig greater depth than SS in curved canals
• Custom Cone Technique:
• Keane: 1 sec dip in chloroform gave best adaptation and less leakage; less chloroform =
less leakage
• Knapp, Marshall: master apical impression technique, use a cone a couple sizes larger
• Increased GP density leads to fewer voids and theoretically a better apical and coronal seal.
The more GP in the canal will limit the space lled by sealer. Gutta-percha, a polyisoprene-
based polymer, will be more resistant to hydrolytic degradation than sealers, which are
typically zinc-oxide eugenol or calcium hydroxide. A resultant obturation with more GP and
less sealer should provide better long-term results.
• Compare lateral compaction and warm vertical technique?
• Jacobson, Baumgartner – NSD in bacterial leakage (continuous wave vs cold lat)
• Reader C – NSD in ll quality; more lateral canals obturated with warm techniques
• Wong- warm vertical placed larger mass of GP into canal than lat con
• Peng – Systematic Review w/ Meta analysis of lat con vs Warm vert, NSD in post op
pain, obt quality or success
• Farzeneh, Friedman 2004: A 10% higher healing rate was also reported with WVC
versus CLC

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 • Kayat, Torabinejad: NSD
• Baumgardner, Walton et al: Carrier based lling materials results in lls that leak
signi cantly more than laterally or vertically condensded GP.
• Newton: Problem with sargenti paste. demonstrated 6m & 1 yr cytotoxicity; contains
paraformaldehyde; leads to destruction of tissues, intractable pain and paresthesia of nerves
• Tay, Pashley et al 2005: Show how resilon is no good. As Resilon is susceptible to alkaline
hydrolysis, it is possible that enzymatic hydrolysis may occur. Biodegradation of Resilon by
bacterial/salivary enzymes and endodontically relevant bacteria warrants further investigation.
• Schilder 1974:
• Described 5 design objectives for cases obutrated with GP. 1. The shape should be a
continuously tapering funnel from the apex to the access cavity. 2. Cross-sectional
diameters should be narrower at every point apically. 3. The root canal preparation
should ow with the shape of the original canal. 4. The apical foramen should remain in
its original position. 5. The apical opening should be kept as small as possible.
• 4 Important biological objectives: 1. Procedures should be con ned to the roots
themselves. 2. Necrotic debris should not be forced beyond the foramina. 3. All tissues
should be removed from the root canal space. 4. Suf cient space for intracanal
medicaments and irrigation should be created.
• Klevant 1983: IEJ. Chemomechanically debrided RC systems of 86 human teeth and left un-
obturated for 2 years. Radiographic exam showed signi cant decrease in PARLs in C&S-
unobturated and C&S-obturated teeth. Thus, reject “hollow tube” theory for breakdown of
tissue uid inducing PA lesion. (Should point out that even though C&S produced signi cant
radiographic healing of AP, better healing was observed in C&S-obturated group. Also
reported by Donnely 199, Weine, and others (see Klevant for refs)
• Wu, Van der Sluis, Wesselink 2006: OOOOE. The aim of this study was to measure long-
term leakage along single cone (SC) llings. The apical root lling in all 60 canine roots did
not show leakage either at 1 week or at 1 year. All 10 positive controls showed gross leakage
(>20 muL/h). In no case gutta-percha extruded through the apical foramen. Sealer extruded
apically in 88% of the roots where a gutta-percha cone was used to introduce sealer, whereas
in 28% of the roots where a bidirectional spiral was used to introduce sealer (by chi-square
test, P < .05). CONCLUSION: In wide and straight canals, SC llings with RoekoRSA sealer
prevented uid transport for 1 year. Using bidirectional spiral to place sealer reduced sealer
extrusion under the conditions of this experiment.
• Iglecias, Gavini et al 2017: JOE. Micro CT Study. This study evaluates the quality of
obturation of mesial canals of mandibular molars obturated by means of single-cone
technique and continuous wave of condensation. We show that both obturation techniques
are similarly ef cient to ll the root canal space. The percentage volume of voids was similar
in the 2 groups and was in uenced by the obturation technique only in the cervical third.
• Resilon
• Barborka, Woodmansey, Glickman et al 2017: JOE. Retrspective case-control study.
• Within the limitations of this study, teeth obturated with RS had 5.7 times greater
chance of failure compared with teeth obturated with GP.
• One hundred teeth treated at Texas A&M University College of Dentistry between
2007 and 2012 were included; 50 teeth were obturated with RS and 50 with GP.
The average recall time for RS was 5.8 years and 6.6 years for GP. Fifty-six percent
of RS-obturated teeth were classi ed as successful at recall compared with 88% of
GP-obturated teeth. RS had 5.7 times greater odds of failure compared with GP
(P < .001). When periapical radiolucencies were present, they tended to be larger

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 and involve multiple roots in the RS group compared with GP group. None of the
prognostic factors examined were found to have any signi cant effect on outcome.
• Tay, Pashley et al 2005: Show how resilon is no good. As Resilon is susceptible to
alkaline hydrolysis, it is possible that enzymatic hydrolysis may occur. Biodegradation of
Resilon by bacterial/salivary enzymes and endodontically relevant bacteria warrants
further investigation.

Gutta-Percha Overextension
• Spangberg 1969: GP has low toxicity
• Schilder: GP is inert “Gutta Percha won’t hurt ya”
• Seltzer 1975: Initial acute response in rats. 15 days for brous encapsulation
• Sjogren 1995: GP in small pieces is extremely in ammatory. (Large pieces of GP are well
encapsulated in collagenous capsules, but ne particles of GP induce an intense, localized
tissue response, characterized by the presence of macrophages and giant cells)
• Bergenholtz 1979: JOE. 2 year recall of re-treatment cases. Better healing and outcome if
no overinstrumentation or over ll (Spring 2017)
• Sjogren 1990: 76% healing with overextension of GP. 94% healing lled 0-2mm.
• Davis 1971: Best outcome if instrumented long and lled short of radiographic apex
• Pascon 1991: Over ll induced a foreign body reaction.
• Serene & Vesely 1988: GP activates C3 complement which may induce bone resorption.
• Ng et al: Extrusion of gutta-percha root lling did not have any effect on tooth survival (HR =
1.1; P = 0.2) within the rst 22 months but signi cantly increased the hazard of tooth loss
beyond 22 months (HR = 3.0; P = 0.003).
• Extruded gutta-percha is associated with delayed healing of the periapex (Strindberg 1956,
Seltzer et al. 1963, Kerekes & Tronstad 1979, Nair et al. 1990b, Sjogren et al. 1990)
• Baumgartner 1983: Extrusion of sealer or gutta-percha was associated with increased pain.
Overall incidence of postobturation pain was 47.6%.
• Nair: large pieces of GP were encapsulated and free of in ammation; ne particles evoked
in ammatory response (macrophages and multi-nucleated giant cells)
• Ricucci, Langeland 1998: IEJ. The results of an in vivo histological study involving apical
and periapical tissues following root canal therapy after different observation periods
demonstrated the most favorable histological conditions when the instrumentation and
obturation remained at or short of the apical constriction. This was the case in the presence of
vital or necrotic pulps, also when bacteria had penetrated the foramen and were present in
the periapical tissues. When the sealer and/or the gutta-percha was extruded into the
periapical tissue, the lateral canals and the apical rami cations, there was always a severe
in ammatory reaction including a foreign body reaction despite a clinical absence of pain.
• Moreno 2013: Canals lled up to 0–2 mm short of the apex had a signi cantly higher number
of teeth rated as healthy than over lled or under- lled cases. Regression analysis showed
that the quality of endodontic treatment was the most signi cant factor in uencing the
periradicular status (P < .001).
• Gomes AC et al 2015: assessing the in uence of endodontic treatment and coronal
restoration on status of periapical tissues: A Cone-beam Computed Tomographic Study.
• It is 4.68 times more likely to nd healthy teeth when the apical extension of the lling is
0–2 mm short compared with teeth with over lling.
• The odds ratio allowed the conclusion that it is 0.6 times most probable to observe a
healthy periapical condition when you have the presence of coronal restoration when
compared with an absence of coronal restoration.

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 • Regarding the apical extension of the lling, the best results were observed for canals
lled within to 0–2 mm short of the apex, with a statistically signi cant difference over
teeth with over- or under lling. It is 4.68 times more likely to nd healthy teeth when the
apical extension of the lling is 0–2 mm short compared with teeth with over lling. The
apical extent of the lling >2 mm short from the foramen also displays an odds ratio of
2.024, which corresponds to a signi cantly higher possibility of nding healthy teeth
compared with over lling. The odds ratio shows that it is 2.5 times more probable to
have periapical health when there are satisfactory periapical endodontic treatments than
when this treatment is unsatisfactory. When there was adequate endodontic treatment
and coronal restoration was present, it was categorized as healthy 59.44% of the time.
This condition showed a signi cantly better outcome than the others did (P < .0001).
Teeth with inadequate treatment and absent restoration yielded the highest prevalence
of disease (77.14%).
• The quality of the endodontic treatment, the presence of coronal restoration, and apical
extent of the root canal lling were signi cantly associated with healthy apical tissues.
• Langland: Most favorable prognosis was obtained when procedures were terminated at the
AC, and the worst prognosis was produced by treatment that extended beyond the AC.
Procedures terminated more than 2 mm from the AC had the second worst prognosis.
• Walton 2005: (JOE. Meta-Analysis of literature) Obturating materials extruding beyond the
radiographic apex correlated with a decreased prognosis.
• Large pieces of gutta-percha are well encapsulated in collagenous capsules, but ne particles
of gutta-percha induce an intense, localized tissue response characterized by the presence of
macrophages and giant cells (Sjogren et al. 1995)

Lateral Canals
• Barthel, Trope 2004: It may be concluded that there are relationships between radiologic and
histologic signs of in ammation in human root canal-treated teeth. There appears to be a
tendency that the radiologically determined quality of the coronal seal has an impact on the
histologic state of the root- lled tooth. No relationship was detected between un lled lateral or
accessory canals and the status of in ammation at the periapex (51% in amed, 49%
unin amed).
• Ricucci, Siqueira 2010: LC/AR were observed in about 75% of the teeth. Looked at 493
teeth planned for ext or apical surgery. Overall, the belief that lateral canals must be injected
with lling material to enhance treatment outcome was not supported by literature review or
by our histopathologic observations. LC/AR were observed in about 75% of the teeth. In
clinically vital teeth, vital tissue was consistently found in LC/AR. In teeth with periodontal
disease, the whole pulp became necrotic only when the subgingival bio lm reached the main
apical foramen. In teeth with pulp exposure by caries, the tissue in LC/AR remained vital as
far as the pulp tissue in the main canal did so. When pulp necrosis reached the level of the
LC/AR, the tissue therein was either partially or completely necrotic. Chemomechanical
preparation partially removed necrotic tissue from the entrance of LC/AR, whereas the
adjacent tissue remained in amed, sometimes infected, and associated with periradicular
disease. Vital tissue in LC/AR was not removed by preparation. In cases in which lateral
canals appeared radiographically " lled," they were actually not obturated, and the remaining
tissue in the rami cation was in amed and enmeshed with the lling material.
• Vertucci 1984: Accessory canals are minute canals that extend in a horizontal, vertical, or
lateral direction from the pulp to the periodontium. in 74% of cases they are found in the
apical third of the root, in 11% in the middle 1/3 and 15% in cervical third.

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 • Cutright, Bhaskar 1969: Accessory canals contain CT and vessels but do not supply the
pulp with suf cient circulation to form a collateral source of blood ow. They are formed by the
entrapment of periodontal vessels in Hertwig’s epithelial root sheath during calci cation.
• DeDeus: 27% over incidence of lateral/accessory canals; found most often in the apical area
(63% are in the apical 3mm).
• Kim, Krachman: 98%
• Ruboc and Michell
Primary Function of Root Filling Materials
• Sundqvist & Figdor 1998: Assigned three primary functions to the root lling:
• sealing against ingrowth of bacteria from the oral cavity
• entombment of remaining microorganisms
• complete obturation at a microscopic level to prevent stagnant uid from accumulating
and serving as nutrients for bacteria from any source.
• Grossman 1978: Criteria for for ideal root lling material: 1. It should be easily introduced
into the canal. 2. It should seal the canal laterally as well as apically. 3. It should not shrink
after being inserted. 4. It should be impervious to moisture. 5. It should be bacteriostatic or at
least not encourage bacterial growth. 6. It should be radiopaque. 7. It should not stain the
tooth structure. 8. It should not irritate periapical tissue. 9. It should be sterile, or quick and
easily sterilized before insertion. 10. It should be easily removed from the root canal if
necessary.
• Orstavik 2005: The sealers are responsible for the principal functions of the nal root lling:
sealing off of the root canal system, entombment of remaining bacteria and the lling of
irregularities in the prepared canal.
• Siqueira, Rocas 2009: -Role of obturation: to eliminate or reduce space for reorganization of
the community by surviving bacteria and prevent further nutrient supply.

Gutta-Percha
• GP composition described by Friedman: 65% ZnO (antimicrobial activity), 20% GP, 10%
metal sulfates (radiopacity), 5% waxes/resins. According to Friedman the more GP, the
stronger and more rigid. ZnO increase the brittleness and decrease the ow.
• Schilder:
• GP exists in beta-semicrystalline state; undergoes change to alpha phase upon heating
(42-29 C); The transformation temperatures of dental gutta-percha compounds are
42c-49c for the beta to alpha transition and 53c-59c for the alpha to amorphous
transition, depending on the speci c compound. compactable not compressible.
• Gutta-percha is a polymer found in two distinct crystalline forms, alpha and beta. Most
gutta-percha cones available are in the beta form. The alpha form of gutta-percha is
brittle at room temperature, but becomes gluey, adhesive and highly owable when
heated. The beta form, on the other hand, is stable and exible at room temperature.
When heated, it is less adhesive and owable than the alpha form.
• Most commercial GP is beta, including dental, and the alpha form occurs in the tree. If
the alpha form is heated above 65°C, it become amorphous and melts. If this amorphous
material is cooled extremely slowly (0.5°C/hr), the alpha form recrystallizes. If it is cooled
more rapidly, the beta form recrystallizes. If the beta form is now reheated, the polymer
becomes amorphous at 56°C. There are no mechanical differences between alpha and
beta GP, but there are thermal and volumetric differences.

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 • Sequeira: Disinfect GP w/ NaOCl before use….5% are contaminated from the manufacturer.
• Guttman: Gutta-percha is generally manufactured in the beta form. When it is heated to 46°C
to 48°C it changes from the beta form to the alpha form
• Senia 1975: JOE. sterilize GP by 1min immersion in 5.25% sodium hypochlorite
• Ludlow: can sterilize GP by 1 second exposure to NaOCl
• Costa et al 2001; Orstavik: As GP is chemically close to rubber, care should be used in
patients with severe type I allergy to latex.
• Gazelius et al 1986: Presented a case report of con rmed allergy with GP in a pt with latex
skin allergy, resulting in prolonged pain following obturation that resolved once the offending
GP was removed.
• Goodman, Schilder 1985: 1) GP thermal study: beta to alpha phase at 46-48C and GP in
alpha phase to amorphous phase at 56-62C. A small volume reduction occurs when cooling
to 37C (so be sure to vertically condense). 2) Compaction not compression happen following
GP so there is no spring back ability of GP particles to assist in the sea. 3) Thermal
penetration limited to 4-6mm GP.

Bioceramics
• Wang et al 2015: Endo Topics.
• Biodentine contains tricalcium silicate, calcium carbonate, zirconium oxide, and a water
based Liquid-containing calcium chloride as the setting accelerator. Zirconium oxide is
the radiopaque agent allowing identi cation on radiographs. According to the
manufacturer‟s instructions, Biodentine is a fast- setting (around 10-12 minutes, shortest
among tricalcium silicate cements) calcium silicate-based restorative material. One of
the advantages of Biodentin over MTA is that it exhibits clinically perceptible color
changes. The pH value of the Biodentine has been reported to be 11.7 after 1 day
immersion in Hank‟s balanced salt solution. Biodentine showed a higher level of calcium
ion release than MTA, EndoSequence BC Sealer and IRM.
• EndoSequence BC is a premixed bioceramic endodontic sealer that contains zirconium
oxide, tricalcium silicate, dicalcium silicate, colloidal silica, calcium silicates, calcium
phosphate monobasic, and calcium hydroxide. Zirconium oxide is added as the
radiopaci er. The radiopacity value of BC Sealer is signi cantly lower than AH Plus.
• MTA is a mixture of dicalcium silicate, tricalcium silicate, tricalcium aluminate, gypsum,
tetracalcium aluminoferrite, and bismuth oxide. The pH value of MTA is 10.2 after mixing
and rises up to 12.5 after 3 hours Meta-analysis studies have concluded that MTA has a
high clinical success rate, provides an adequate seal, shows excellent biocompatibility
and promotes tissue regeneration.
• MTA Angelus is composed of 80% Portland cement and 20% bismuth oxide. The setting
time of MTA Angelus is approximately 14 minutes, which is considerably less than WMTA
and GMTA
• EndoSequence root repair material (ERRM) is a new bioceramic material delivered as a
premixed moldable putty or as a preloaded paste in a syringe with delivery tips for
intracanal delivery. Both materials are composed mainly of calcium silicates, zirconium
oxide, tantalum oxide and calcium phosphate monobasic.
• MTA Fillapex was created in an attempt to combine the physico-chemical properties of a
resin-based root canal sealer with the biological properties of MTA. Studies have
reported signi cant reduction in cell viability, which may be caused by lead released from
the set sealer.

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 • EndoSequence BC gutta-percha is subjected to a proprietary process of impregnating
and coating each cone with bioceramic nanoparticles. Not enough studies are not
available yet.
• MTA Plus is a ner powder, lower cost product that has a composition similar to tooth
colored ProRoot MTA, and can be mixed with a liquid or a gel. This tricalcium and
dicalcium silicate-based material can be used as a root canal sealer when mixed with
gel, which also improves the handling properties and washout resistance.
• Haapasalo, Shen et al 2015: EndoTopics. Bioceramic materials are generally antimicrobial,
biocompatible and have excellent long term sealing capabilities. Staining of tooth structure
and slow setting times have been some of the potential downsides of the bioceramic
cements, depending on the clinical situation. New BC materials seem to show improvement
with regard to these challenges. Clinical Uses of Bioceramic Materials: Retrograde
Obturation, Root Perforation Repair, Furcal Perforation Repair, Internal Resorption in root or
pulp chamber, Invasive Cervical Resorption, Orthograde obturation, Teeth with open apex ,
Pulp Capping, Regenerative Procedures
• Taha et al 2016: JOE. The aim of this study was to evaluate the subcutaneous connective
tissue response to EndoSequence root repair paste compared with mineral trioxide aggregate
(MTA). EndoSequence was signi cantly more irritating than MTA and control at 1 and 3
weeks in terms of severity and extent of in ammation. After 6 weeks it displayed more
biocompatible characteristics.
• Chen, Setzer, Kim 2016: JOE. The purpose of this study was to investigate odontogenic and
osteogenic cell adhesion, proliferation, and survival on the surface of a newly developed
bioceramic material (EndoSequence Root Repair Material [RRM]; and compare it with
mineral trioxide aggregate (gray MTA). A potential role of extracellular signal-regulated kinase
(ERK) signaling in the RRM/MTA-induced cellular activities was also investigated. Bottom
Line: MTA and RRM are both biocompatible and promote cell proliferation and survival in an
ERK- dependent manner.
• Beatty, Svec 2015: JOE: Biodentine and Endosequence discolor bovine tooth structure to a
perceptible degree. At 8 weeks, this was signi cantly more than ProRoot MTA.
• Kohli, Setzer, Yamaguchi et al 2015: The purpose of this in vitro study was to evaluate
coronal tooth discoloration induced by bioceramic materials, EndoSequence RRM, and
BioDentine in comparison with other materials used during endodontic treatment such as
gray MTA, white MTA, triple antibiotic paste, and AH Plus sealer. Bioceramic-based materials
BD, RRM, RRMF, and AH+ did not induce perceptible color change in the tooth structure
when left in the pulp chamber for extended periods of time (6 months). Coronal tooth
discoloration caused by TAP, GMTA, and WMTA was statistically signi cant. Clinical studies
are needed to further con rm these ndings.
• Also see Apical Barrier section for more info on bioceramics

Temporization
• Many Temporary restorations and root canal cements contain Eugenol
• Eugenol is a clove oil derivative.
• It alters neurotransmission (Kozam) via increased potassium permeability and
decreased sodium in ux in nerves, thus decreasing the rate at which action potentials
re (Trowbridge et al). Furthermore, Eugenol blocks the expression of neuropeptides
associated with in ammation (Trowbridge). Lastly, it decreases the vasoconstriction
response to epinephrine (Mjor).

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 • Wilderman 1971: Cavit is composed of Zinc oxide, calcium sulfate, glycol acetate,
triethanolamine, polyvinyl acetate, polyvinylchloride acetate, red pigment. It is Hygroscopic
(absorbs moisture from environment).
• Webber 1978: Minimum 3.5mm of cavit is necessary for adequate seal
• Lamers et al: Showed that Cavit leaked after 42 days
• Anderson, Powell, Pashley 1988: Cavit and TERM provided better seal than IRM which is
not signi cantly. The microleakage allowed by three temporary endodontic restorative
materials was measured and evaluated. Endodontic access preparations were made in 30
noncarious, nonrestored crowns of extracted human incisors, canines, and premolar teeth.
Three groups of 10 teeth each were restored with either Cavit, IRM, or TERM. Microleakage
was measured by a uid ltration technique at various time intervals. Cavit and TERM
provided leakproof seals while IRM demonstrated signi cant microleakage at 7 days and after
thermal stress.
• Deveaux 1999: Cavit is superior to IRM or TERM against bacterial leakage. Cavit has good
sealing properties for up to 21 days when used in simple endodontic access cavities, and
seal quality is only slightly affected by thermocycling.
• Bobotis, Anderson, Pashley 1989: The results indicated that Cavit, Cavit-G, TERM, and
glass ionomer cement provided leakproof seals during the 8-wk testing period, while leakage
was observed in 4 of the 10 teeth restored with zinc phosphate cement. IRM and
polycarboxylate cement were the least effective of the materials tested for preventing
microleakage.
• Moller 1981: 3mm of cavit effective against resisting bacterial penetration up to 6 months.
• Barthel 1999: GI or GI/IRM only materials able to withstand 1 month bacterial leakage.
Superior to cavit. Cavit/GI was worst (dual layer). Cavit and IRM leaked signi cantly more
than GIs.
• Beach, Hutter: 3 wk bacterial leakage test: no leakage w/ Cavit. (Clinical Study)
• Pashley: Cavit, TERM, GI provided leakproof seal for 8 wks. (Pashley a big microleakage
guy)
• Kampfer, Zhender et al 2007: the 4 mm application of Cavit prevented leakage of E. faecalis
signi cantly better than the corresponding 2 mm application
• Balto et al: found that all of the provisional materials they tested in post-prepared root canals
failed to prevent coronal leakage when used for an average of 30 days. Similarly, delayed
placement of the de nitive restoration had an impact on the prognosis of ETT.
• Teplitski: Thermal variation does not affect the cavit ability to maintain seal.
• Zmener et al 2004: There was no statistically signi cant difference in marginal leakage be-
tween Cavit, IRM, and Ultratemp Firm (p > 0.05). All materials leaked at the interface
material-dentin, whereas some IRM specimens absorbed the dye into the bulk of the material.
• Doagel, Sweet 2008: Tempit UltraF provided a better seal than IRM and Cavit, but no
difference was found between Tempit UltraF and Tempit and between Tempit, Cavit, and IRM.
The fact that there was no signi cant difference in leakage between IRM and Cavit is
consistent with some other leakage studies. All materials tested were shown to leak. Tempit
UltraF leaked signi cantly less than Cavit and IRM. (Tempit Ultra-F is a non– eugenol-
containing, light-activated diurethane dimethacrylate resin micro lled with 30% silicon dioxide
and marketed as an IRM designed to last up to 1 year. )
• Pai et al 1999: talks about a double seal with temp materials and how it is better
• Naoum et al 2000: Review of Endo Temporaries. As a hygroscopic material, Cavit possesses
a high coef cient of linear expansion resulting from water absorption. Its linear expansion is
almost double that of ZOE, which explains its excellent marginal sealing ability. The sealing
ability of Cavit has been tested in many studies, both in vitro and in vivo, with generally

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 favorable results. In in vitro studies, Webber et al. tested the thickness of Cavit required to
prevent methylene blue dye leakage. Clinically, Cavit and its relatives have the advantages of
ease of manipulation, availability in premixed paste and of being easily removed from access
cavities after setting. A double seal using Cavit as an inner layer and IRM as an outer layer
has been recommended to compensate for the undesirable physical properties of Cavit.
• Jensen, Abbott 2007: JOE. The purpose of this study was to design an experimental model
that allowed extensive endodontic interim restorations to be tested for dye penetration while
under simulated masticatory load. Extracted premolar teeth had standardized mesio-occluso-
distal cavities prepared, and the root canals were instrumented. A cotton wool pellet was
placed in the pulp chamber, and the cavities were restored with Cavit, IRM, Ketac-Fil Plus,
Ketac-Silver, or composite resin (Z100). They were subjected to the equivalent of 3 months of
clinical load while exposed to methylene blue dye. Results of this study could not support IRM
as a suitable interim endodontic restorative material to use in extensive cavities. The dye
penetration in the Ketac-Fil Plus and Ketac-Silver specimens was not predictable, and the
results suggested Cavit and Z100 composite resin require further investigations as potentially
useful materials for this purpose.

Coronal Restoration
• Ray, Trope 1995: Use for justifying retreatment if coronal caries is present. Coronal
restoration was signi cantly more important than the endodontic treatment for apical
periodontal health.
• Tronstad 2000: The technical quality of the endodontic treatment as judged radiographically
was signi cantly more important than the technical quality of the coronal restoration when the
periodical status of endodonically treated teeth was evaluated. Good Endo + Good restorative
best result.
• Ng et al 2010: Systematic Review. Demonstrated that both the presence of a full-coverage
crown and the presence of mesial and distal contacts positively in uence success rates.
• Gillen, Looney 2011: Systematic Review/Meta-Analysis. Impact of good restoration vs good
endo. The odds for healing of apical periodontitis increase with both adequate root canal
treatment and adequate restorative treatment. (On the basis of the current best available
evidence, the odds for healing of apical periodontitis increase with both adequate root canal
treatment and adequate restorative treatment. Although poorer clinical outcomes may be
expected with adequate root lling-inadequate coronal restoration and inadequate root lling-
adequate coronal restoration, there is no signi cant difference in the odds of healing between
these two combinations. )
• Toure’ et al 2011: JOE. Analysis of Reasons for Extraction of Endodontically Treated Teeth: A
Prospective Study. Mandibular rst molar without a crown was the most extracted tooth.
Periodontal disease (40.3%) was the most frequent. Other reasons included endodontic
treatment failure (19.3%), vertical root fracture (13.4%), nonrestorable cuspid and crown
fracture (15.1 %), non-restorable caries 5.2%, iatrogenic perforations and stripping 4.2%,
prosthetic 0.8%, and total crown destruction (1.7%). 119 teeth included.
• Moreno, Roccas, Siequeira 2013: Found that the quality of the root canal was more
in uential on the periapical status than the quality of restorative care.
• Aquilino & Caplan 2002: teeth without crown lost at 6X higher rate. The nal Cox model
showed that endodontically treated teeth not crowned after obturation were lost at a 6.0 times
greater rate than teeth crowned after obturation
• Gomes AC et al 2015: JOE. 1290 teeth. Assessing the in uence of endodontic treatment and
coronal restoration on status of periapical tissues: A Cone-beam Computed Tomographic
Study. The odds ratio allowed the conclusion that it is 0.6 times most probable to observe a

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 healthy periapical condition when you have the presence of coronal restoration when
compared with an absence of coronal restoration. The quality of the endodontic treatment, the
presence of coronal restoration, and apical extent of the root canal lling were signi cantly
associated with healthy apical tissues.
• Are endodontically treated teeth more brittle?
• Helfer - 9% less moisture content in pulpless teeth vs vital teeth
• Papa, Messer – NSD in moisture content
• Sedgley – Vital dentin 3.5% harder; biomechanical properties are not signi cantly
altered. Commutative effect of tooth structure loss causes weakness.
• Reeh, Messer & Douglas – RCT reduces cuspal stiffness by 5%; Occl cavity prep.
20%; MOD 63% (exclusively related to access opening)
• Gutmann - shear strength of endo tx teeth lower than vital tth (14%); altered collagen
structure
• Craveiro, Fontana 2015: JOE. In uence of coronal restoration and root canal lling quality
on periapical status: clinical and radiographic evaluation. Using either a radiographic or
clinical assessment alone was not a reliable method to ascertain whether restoration quality
could be correlated with postoperative periapical status. Poor root canal lling quality was
a prognostic determinant of endodontic treatment failure, whereas coronal restoration
quality had a lesser impact on the outcome of the endodontic treatment.
• Pratt, Aminoshariae, Mickel et al 2016: JOE. 8 yr retrospective study. Posterior teeth. This
study demonstrated that timing of the crown placement after root canal treatment can
signi cantly affect the survival rate of endodontically treated teeth. (Results: Type of
restoration after RCT signi cantly affected the survival of Endodontically Treated Teeth (P =
.001). ETT that received composite/amalgam buildup restorations were 2.29 times more likely
to be extracted compared with ETT that received crown (hazard ratio, 2.29; con dence
interval, 1.29–4.06; P = .005). Time of crown placement after RCT was also signi cantly
correlated with survival rate of ETT (P = .001).
• Teeth that received crown 4 months after RCT were almost 3 times more likely to get
extracted compared with teeth that received crown within 4 months of RCT (hazard ratio,
3.38; con dence interval, 1.56–6.33; P = .002).
• Conclusions: Patients may bene t by maintaining their natural dentition by timely
placement of crown after RCT, which otherwise may have been extracted and replaced by
implant because of any delay in crown placement.
• The overall 8-year survival rate of ETT regardless of the type of restoration was 79%.
The 8-year survival rate after RCT was 84% with full coverage crowns, 71% if only a
core build up only, and 58% if no permanent restoration was placed.
• This difference was statistically signi cant between groups. ETT that received composite/
amalgam buildup restorations were 2.29 times more likely to be extracted and those
without a permanent restoration were 4 times more likely to be extracted compared with
those that received crowns.
• Mannocci, Pitt Ford 2005: Operative Dent. RCT comparison of endo treated teeth restored
with amalgam or with ber posts and resin composite: 5 yr results. n = 109. Premolars with
class II carious lesions were selected.
• No statistically signi cant difference was found between the proportion of failed teeth in
the two experimental groups.
• Signi cant differences were observed between the proportion of root fractures (p=0.029)
and caries (p=0.047), with more root fractures and less caries observed in the teeth
restored with amalgam at the ve-year recall.

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 • Within the limits of this study, it can be concluded that restorations with ber posts and
composite were found to be more effective than amalgam in preventing root fractures
but less effective in preventing secondary caries.
• Mannocci, Pitt Ford 2002: J Prosthet Dent. The aim of this study was to evaluate the clinical
success rate of endodontically treated premolars restored with ber posts and direct
composite restorations and compare that treatment with a similar treatment of full-coverage
with metal-ceramic crowns. There was no difference in the failure frequencies of the 2 groups.
The results upheld the research hypothesis that the clinical success rates of endodontically
treated premolars restored with ber posts and direct composite restorations after 3 years of
service were equivalent to a similar treatment of full coverage with metal-ceramic crowns.
• Gargiulo et al: Biologic width. 3mm from crown margin to alveolar crest. Comprises the
combined gingival sulcus, epithelial attachment and CT attachment. Violations of this width
lead to periodntal in ammation and bone loss.
• Juloski et al: Ferrule refers to a 1.5-2 mm circumferential vertical wall of tooth structure
encompassed by full-coverage restorations. A ferrule decreases the fracture rate of
endodontically treated teeth by providing both retention and resistance of crown to
displacement.
• Sorensen and Martinoff 1985: To evaluate endodontically treated teeth as abutments.
The greatest failure rates were noted in teeth without crowns (24.6%). Abutments for FPDs
and RPDs that were endodontically treated had signi cantly higher failure rates than single
crowns. Single crown 94.8% success, FPD 89.2% success, RPD 77.4% success.
• Sorensen and Engelman 1990:
• Ferrule design for endo treated teeth. One millimeter of coronal dentin above the
shoulder signi cantly increased the failure threshold. The preparation of the coronal
walls should be parallel for maximum resistance form. The contrabevel design at ether
the tooth-core-junction or the crown margin did not improve the failure. The axial width of
the tooth at the crown margin did not signi cantly increase the fracture resistance or
alter the failure threshold.
• Effect of post adaptation on fracture resistance of endo treated teeth. Maximum
adaptation of the residual root structure with a tapered post signi cantly increases the
fracture resistance of endodontically treated teeth, but upon failure renders the tooth
nonrestorable. Taped posts resulted in fractures that were directed more apically and
lingually. Parallel-sided posts had a lower frequency of fracture upon failure, involving
less tooth structure. Parallel-sided posts surrounded by large amounts of cement had no
signi cant effect on failure loads.
• Schwartz and Robbins 2004: JOE. Post placement and restoration of endo treated teeth: a
review. 1. Avoid bacterial contamination of the root-canal system 2. Provide cuspal coverage
for posterior teeth 3. Preserve radicular and coronal tooth structure 4. Use posts with
adequate strength in thin diameters 5. Provide adequate post length for retention
6. Maximize resistance form including an adequate ferrule 7. Use posts that are retrievable.
• Schwartz and Fransman 2005: JOE. Procedures for restoration of endo access cavities.
• Prevent contamination of the root canal system. Restore access cavities immediately
when ever possible. Use bonded materials. The 4th generation (three step) resin
adhesive systems are preferred because they provide a better bond than the adhesives
that require fewer steps. The “etch and rinse” adhesives are preferred to “self etching”
adhesive systems if a eugenol containing sealer or temporary material was used. “Self
etching” adhesives should not be used with self-cure or dual-cure restorative
composites. When restoring access cavities, the best esthetics and highest initial
strength is obtained with an incremental ll technique with composite resin. A more

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 ef cient technique which provides acceptable esthetics is to bulk ll with a glass ionomer
material to within 2 to 3 mm of the cavo-surface margin, followed by two increments of
light-cure composite. If retention of a crown or bridge abutment is a concern after root
canal treatment, post placement increases retention to greater than the original.
• Baba, Goodacre, Daher 2009: Restoration of endo treated teeth. Fiber-reinforced resin
posts should be used with caution until more long-term data are available. Crowns should be
placed on most endodontically treated posterior teeth to enhance their longevity. Posts
weaken endodontically treated teeth rather than enhance their clinical longevity. 5 mm of
apical gutta-percha should be retained. Short posts should be avoided. The potential for root
thinning, perforation, and root fracture increases with large-diameter posts. A cervical ferrule
should engage tooth structure to prevent root fracture
• Dawson et al 2017: JOE. In conclusion, this study revealed a low frequency of nonsurgical
retreatment and root-end surgery in the 5 years after root lling and restoration. Extractions
were more common. There were signi cantly fewer nonsurgical retreatments and extractions
of indirectly than directly restored teeth but slightly more root-end surgeries. Teeth with direct
restorations required signi cantly more additional restor- ative procedures; 30.3% underwent
at least 1 further direct restoration, whereas the corresponding percentage for indirectly
restored teeth was 6.4%. The results imply a better outcome for teeth with indirect resto-
rations during a 5-year perspective. However, this may be a result of se- lection bias; thus the
results should not be extrapolated to support a general recommendation that root- lled teeth
should be restored with indirect restorations. Regarding the choice of coronal restoration of a
root- lled tooth, little is known about the dentist’s decision-making process(Indirect = Crown?)

Coronal Seal/Micro Leakage

• Based on bacterial and endotoxin leakage studies of Torabinejad, Khayat, Alves & Trope ,
you should consider re tx leaking NSRCT case if open > 3 weeks.
• Swanson, Madison 1987: (3 days). A signi cant amount of microleakage is evident after 3
days of exposure to arti cial saliva. Evaluated microleakage following exposure of gutta-
percha and sealer to arti cial saliva for various time periods.
• Madison, Wilcox 1988: (3 days). Emphasized importance of coronal seal. 3 day dye
leakage.
• Torabinejad, Ung, Kettering 1990: (19 days for staphlococcus) (42 days for Proteus
species) Found that without a coronal protection seal of the canal obturations, it took only 19
days for staphlococcus organisms placed in a coronal access cavity to reach the apex in half
test cases and 42 days for the same percentage of Proteus samples.
• Magura et al 1991: (3 months) Saliva penetration at 3 months clinically signi cant.
recommends retreatment of obturated canals that have been exposed to the oral cavity for at
least 3 months. (used IRM)
• Khayat, Lee, Torabinejad 1993: (30 days) Found that obturated root canals that were not
sealed and exposed to the oral environment were recontaminated in less than 30 days. No
diff in method of obturation. Used human saliva.
• Trope, Chow, Nissan 1995: (21 days) Endotoxin, a component of the cell membrane of gram
negative bacteria is a potential in ammatory agent that, due to its smaller size may be able to
penetrate obturated canals faster than bacteria. In this study, endotoxin demonstrated
contamination in all teeth within 21 days.
• Alves, Walton, Drake 1998: (20 days) Found that bacterial endotoxins could reach the apex
of obturated canals in as little as 20 days if not protected by a coronal seal

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 • Sequeira et al 2000: No obturation technique predictably produces bacteria-tight seal of root
canal after direct saliva challenge.
• Wolanek et al 2001: in vitro bacterial penetration of endodontically treated teeth coronally
sealed with a dentin bonding agent. Results: The coronal barriers were signi cantly better in
preventing coronal microleakage. The presence of eugenol in the sealer had no signi cant
effect on the sealing ability of resin adhesive. (Defend composite core or barrier)
• Swartz, Fransman 2005: 3 step bonding systems work ne if using eugenol sealer. (JOE
2005)
• Dawson et al 2014: Non-root lled teeth. There was no signi cant difference in the
frequency of apical periodontitis (AP) between teeth restored with resin composite or
amalgam (1.3% and 1.1%, respectively). The frequency of AP for teeth restored with
laboratory-fabricated crowns was signi cantly higher (6.3%). Regression analysis showed no
association between AP and resin composite restorations but a signi cant association with
laboratory-fabricated crowns. The results indicate that the risk of damage to the pulp-dentin
complex from exposure to resin composite material and dentin bonding agents shown in
experimental studies is not re ected in the clinical setting. However, in the study sample, AP
was diagnosed in a signi cantly higher proportion of teeth restored with laboratory-fabricated
crowns.
• Dawson et al 2016: Cross-sectional study. Root lled teeth. This study did not indicate any
association between apical periodontitis and resin composite restorations in root- lled teeth. If
the quality of the coronal restoration is adequate, neither the type nor the material seems to
be of signi cance for periapical status. Looked at teeth with composite, amalgam and crowns.
The results did not indicate any association between AP and resin composite restorations.
Neither the type nor the material of the restoration was of signi cance for periapical status as
long as the quality was adequate.
• Cox, Bergenholtz 1987: Monkey Study. Demonstrated that a good seal is important to keep
bacteria out and pulp protected. Healing of dental pulp exposures is not dependent on the
effect of a particular type of medicament that provides calcium or hydroxyl ions such as
calcium hydroxide, but on the capacity of the capping material to prevent bacterial leakage.
(Tested, silicate cement, zinc phosphate cement, amalgam, composite —> Material didn’t
matter as long as it is sealed it was well accepted by the dental pulp tissue and do not impair
wound healing on a short-term basis.)
• Vire 1991: (JOE) 59.4% cause of tooth loss is due to coronal microleakage. 32% (1/3) due to
periodontal disease (do periodontal examination before RCT) and 8.6% RCT problems which
is mostly due to vertical root fracture from lateral obturation using spreader (Endo failures
usually happen quickly in 2 years and perio 5 years). Blames everyone else for failing endo.
• Song et al 2011: 493 teeth were analyzed for the cause of failure in root canals treatment
done under microscope when examined under a microscope during endodontic microsurgery.
Cause for failures were: 30.4% leakage around the root lling material, 19.7% Missed canal,
14.2% Under lling, 8.7% anatomical complexity, 3% Over lling, 2.8% Iatrogenic defects,
1.8% apical calculus, 1.2% cracks.
• Ravanshad, Torabinejad 1992: Coronal dye penetration of the apical lling materials after
post space preparation. Forty canals of palatal and distal roots of molars were cleaned and
shaped with the use of a step-back technique. Thirty canals were obturated, 10 each with
lateral, vertical, and therma l techniques. Five root canals were obturated without a root canal
sealer and served as positive controls. Another ve root canals were obturated, and their
coronal half was sealed with sticky wax and served as negative controls. The apical 5 to 6
mm of the lling materials were exposed to india ink for 48 hours. The depth of dye
penetration was measured in all groups and statistically analyzed. The apical plugs in the

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 therma l group had the highest degree of coronal leakage. The ANOVA test showed a
signi cant statistical difference between coronal dye leakage between this group and those
found in canals lled by lateral or vertical condensation techniques. The results indicate that
the apical lling materials obtained by lateral or vertical condensation leak less than those
obtained by therma l.

Ori ce Barrier
• Saunders, Saunders 1990: Suggested placing Vitrebond glass ionomer material over canal
ori ce and pulpal oor to minimize coronal microleakage.
• Roghanizad, Jones 1996: JOE. talked about intraori ce barrier / 3 mm of the coronal gutta-
percha was replaced by either Cavit, TERM, or amalgam with cavity varnish. After thermo
cycling and 2 wk of immersion in dye, the amount of dye penetration was measured. The
results showed that amalgam with two coats of cavity varnish sealed signi cantly better than
Cavit and TERM. However, Cavit and TERM were still signi cantly better than a positive
control group.
• Pisano, McClanahan et al 1998: JOE. 74 extracted teeth. Evaluated Cavit, Intermediate
Restorative Material, and Super-EBA as intraori ce lling materials to prevent coronal
microleakage. The teeth were suspended in scintillation vials containing trypticase soy broth,
and human saliva was added to the pulp chambers. Microbial penetration was detected as an
increase in turbidity of the broth corresponding to bacterial growthAt the end of 90 days, the
results showed that 15% of the Cavit- lled ori ces leaked, whereas 35% of the Intermediate
Restorative Material and Super-EBA- lled ori ces leaked. The gutta-percha obturated root
canals that received an intraori ce lling material leaked signi cantly less than the obturated,
unsealed control group--all of which leaked in < 49 days.
• Wolanek JOE 2001 – Clear l (composite) barrier showed no leakage, No barrier group
showed positive bacterial penetration in 15 to 76 days. NOTE: Eugenol containing sealer
had no effect on the bonding agent. ( in vitro bacterial penetration of endodontically treated
teeth coronally sealed with a dentin bonding agent. Results: The coronal barriers were
signi cantly better in preventing coronal microleakage. The presence of eugenol in the sealer
had no signi cant effect on the sealing ability of resin adhesive. (Defend composite core or
barrier)
• Galvan, Liewehr, Pashley 2002: JOE. At 7 days, IRM, AElite o, and Pal que leaked
signi cantly more than Amalgabond or C&B Metabond. Amalgabond consistently produced
the best seal of all the materials throughout the duration of the study.
• Mavec, McClanahan et al 2006: JOE. 40 teeth. Bacterial microleakage of the remaining
gutta-percha in teeth prepared for post space with and without the use of an intracanal glass
ionomer barrier was evaluated. In clinical situations of teeth with compromised crown-root
ratio that require a post and core, 1 mm of Vitrebond over 2 or 3 mm remaining gutta-percha
could reduce the risk of recontamination of the apical gutta-percha.
• Nagas et al 2016: JOE. Alkali resistant glass ber incorporation into calcium silicate– based
cements (ProRoot MTA, Biodentine) is a viable choice to improve the reinforcing effect of
intraori ce barriers in root- lled teeth. This nding might indicate that ber reinforcement of
the tested intraori ce barriers may help withstand large amounts of stress before transmitting
the load to the root.

Nanoparticles

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 • Carpio-Perochena, Kishen et al 2017: JOE. The aim of this study was to evaluate the
ef cacy of chitosan nanoparticles (CNPs) and ethanolic propolis extract (EPE) incorporated
into a calcium hydroxide paste (Ca[OH]2) to kill bacterial bio lms. All experimental pastes
were able to signi cantly reduce the E. faecalis colony- forming units (CFU) after 7 or 14 days
(P < .05). However, the CFU reduction was signi cantly improved when CNPs were
incorporated into the Ca(OH)2 paste (P < .05). Conclusions: Incorporating CNPs into pastes
of Ca(OH)2 could potentially be bene cial when using interappointment intracanal
medications because of their ability to kill bacteria in short- and long-term exposure.
• Shrestha, Kishen 2016: Antibacterial nanoparticles in endodontics: a reveiw. The application
of nanoparticles in the form of solutions for irrigation, medication, and as an additive within
sealers/restorative materials has been evaluated to primarily improve the antibio lm ef cacy
in root canal and restorative treatments. In addition, antibiotic or photosensitizer
functionalized nanoparticles have been proposed recently to provide more potent
antibacterial ef cacy. Conclusions: The increasing interest in this eld warrants sound
research based on scienti c and clinical collaborations to emphasize the near future potential
of nanoparticles in clinical endodontics. Most of the nanoparticles tested for root canal
disinfection depend on contact-mediated and time-dependent antibacterial activity. Thus, the
incorporation of various nanoparticles into sealers or root lling materials signi cantly
improved the antibacterial ef cacy by inhibition of bacterial bio lm formation on the surface as
well as the resin-dentin interface.
• Pankajakshan, Bottino et al 2016: This study was designed to (1) investigate the
antimicrobial ef cacy of triple antibiotic–containing nano bers against a dual- species bio lm
and (2) evaluate the ability of dental pulp stem cells (DPSCs) to adhere to and proliferate on
dentin upon nano ber exposure. Triple antibiotic–containing polymer nano bers led to
signi cant bacterial death, whereas they did not affect DPSC attach- ment and proliferation
on dentin. Nano ber-based drug delivery systems are a more cell-friendly disinfection
strategy than the currently used triple antibiotic paste, which, in turn, may contribute to better
and more predictable regener- ative outcomes. (Recent research has shown that the use of
TAP (metronidazole, minocycline, cipro oxacin) interferes with growth factor release from
dentin because its removal is challenging, leading to the interpretation that paste blocks
dentinal tubules preventing growth factors from leaching out, which might also have limited
the growth of DPSCs on TAP-treated dentin. Also, TAP is acidic (pH=2.9) and its prolonged
use has been shown to reduce dentin microhardness. It is established that the clinically
recommended dose of TAP (1 g/ml) is very toxic to dental stem cells and PDL broblasts. TAP
can also cause crown discoloration.)
• Kishen, Shrestha, et al 2008: JOE. This experimental investigation highlighted the potential
advantage of using ZnO-NP and Chitosan-NP to inhibit bacterial recolonization in root canals
and to improve the antibacterial capabilities of endodonitic sealers. All the nanoparticulates
tested showed bacterial killing, and the rate of killing depended on the time and concentration
used. The ow property of the sealer increased signi cantly after the incorporation of
nanoparticulates at a nanoparticulates/sealer powder ratio of 15%. Zinc oxide-eugenol sealer
had a strong antibacterial activity. With the addition of ZnO-NP and CS-NP to the sealer, the
number of viable bacterial cells decreased further.
• Shvero et al 2013: IEJ. Available endodontic sealers modi ed using insoluble antibacterial
nanoparticles demonstrated an antibacterial effect against E. faecalis, which was maintained
for 4 weeks. Incorporation of IABN into endodontic sealers reduced signi cantly E. faecalis
bacterial counts. These durable antibacterial properties, plus the non-cytotoxic effect
previously reported, may be useful in designing endodontic sealing materials.

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 • Qi, Jiang et al 2004: These studies show that chitosan nanoparticles and copper-loaded
nanoparticles could inhibit the growth of various microorganisms markedly and exhibit higher
antibacterial activity than chitosan itself or doxycycline.
• Barros, Silva, Rocas, Alves, Siqueira et al 2014: evaluated the effects of 2 endodontic
sealers (AH plus, Pulp Canal Sealer), unmodi ed or loaded with QPEI nanoparticles at 2% w/
w concentration, on bio lms formed by 2 Enterococcus faecalis strains. The addition of
quaternary ammonium polyethylenimine (QPEI) nanoparticles improved the killing ability of
Pulp Canal Sealer against both E. faecalis strains and the effects of AH Plus on the biomass
of bio lms from the ATCC strain.
• Wu, Fan, Kishen, Gutmann 2014: JOE. evaluated the antibacterial ef cacy of silver
nanoparticles (AgNPs) as an irrigant or medicament against Enterococcus faecalis bio lms
formed on root dentin. The ndings from this study suggested that the antibio lm ef cacy of
AgNPs depends on the mode of application. AgNPs as a medicament and not as an irrigant
showed potential to eliminate residual bacterial bio lms during root canal disinfection.
• Shrestha, Kishen 2014: JOE. tested the interaction/uptake of rose bengal-functionalized
chitosan nanoparticles (CSRBnps) with monospecies bacteria/bio lms and assess their
antibio lm ef cacy on a multispecies bio lm grown on dentin. CSRBnps interacted and
adhered to the bacterial cells surface, damaging the membrane, and resulting in the release
of cellular constituents. The positive charge, af nity to bacterial cell membrane, inherent
antibacterial property of chitosan, enhanced dispersibility, and higher reactive surface area
because of the nanosize of CSRBnps could have attributed to the damage to the membrane,
increased membrane permeability, and subsequent intracellular leakage. These physical
properties also resulted in increased uptake of CSRBnps into the bio lm structure, which led
not only to greater interaction with bacterial cells, but also the negatively charged polymeric
matrix of the bio lm structure. Conjugation of the photosensitizer (RB) with a cationic
molecule (chitosan) allowed photosensitizer molecules to enter the cells, resulting in
increased killing ef ciency at a lower concentration. Importantly, the CSRBnps used in this
study are nontoxic to eukaryotic cells.
• Bernardi et al 2017: IEJ. To evaluate the effect of its adding nanoparticulate calcium
carbonate (NPCC) to MTA on setting time, dimensional change, compressive strength,
solubility, and pH. The addition of Calcium Carbonate nanoparticles to MTA Angelus
accelerated the setting time by 16 minutes, reduced compressive strength, resulted in higher
solubility and pH, and resulted in a lower dimensional change after 30 days. The addition of
NPCC to MTA made it more workable.

Why 1 Year Recall

• Yu, Messer et al 2012: In conclusion, a speci c interval alone should not be used to
conclude that a lesion will not resolve without intervention. Available data suggest that
asymptomatic lesions should be monitored further, especially if the lesion has reduced in size
since treatment. Clinically, endodontists and their patients must often make retreatment
decisions without the bene t of access to radiographs taken at the time of treatment. The
basis for a decision to re-treat is restricted to evidence from the current radiographs, clinical
signs and symptoms, and patients’ informed consent. In view of the nding that a majority of
persistent lesions have reduced in size since treatment and are asymptomatic, this raises an
important question: to what extent is it possible to judge purely from current lesion
characteristics (radiographic plus clinical data) whether the lesion is healing or deteriorating?
The data from this study suggest that a lesion that is >5 mm in diameter and present for more
than 10 years since treatment is likely to be deteriorating. Also, the presence of clinical signs

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 such as biting pain or a sinus tract and/or history of postobturation are-up strongly indicate a
deteriorating lesion. More data are needed before a de nitive answer can be provided.
• Reit 1987: (1 year and annually for 4 yrs) Best recall at 1 year, recall up to 4 years for
questionable cases
• Orstavik 1996: 76% of AP lesions that develop post-op occur in one year. 1 yr; peak
incidence of healing/CAP occured @ 1 yr; may take 4 years
• Pirani et al 2015: Survival rate was 84.6% and healing rate was 79% (10-19 years). 240
teeth. The 6-9 months evaluation appears to be an indicator for the nal outcome of primary
root canal treatment both in the presence and in the absence of IAP. An initial radiolucency
associated with an unsatisfactory quality and extent of root canal lling signi cantly.
diminishes the possibility of achieving long-term radiographic success. Retrospective study.
(Odontology 2015)
• Seltzer/Bender 1966 – Evaluation of success should occur after 6 months – 2 years. May
take up to 2 years for radiographic healing or signs of persistent disease to present clinically
or radiographically
• Orstavik and Pitt-Ford 1998: The goal of RCT is to prevent and cure apical periodontitis.
Also they suggested Periapical index for periapical assessment: 500 teeth, follow up 1, 2, 4
years, PAI scoring. Follow up recommendation of vital cases: 1year. Most cases of failures
were detected within 1 year. 70% of new CAP will appear in 1 year. 90% in 2 years. Full CAP
healing: 50% in 1 year, 80% 2 years, 90% 3 years Partial healing of CAP 90% in 1 year. 76%
of apical periodontitis lesions develop post are seen in 1 year. Therefore, follow up of 1 year
predict long term success.
• Rud, Andreasen 1972: Watch periradicular area for 1yr. If healed or healing at 1yr, then
healing is ok. If not, then re-tx.
• Andreasen, Rud 1972: Recall after 1 year and continue recall for 4 years. Wait 4 years
before considering uncertain and incomplete cases a failure. It is dif cult to determine if a
large PARL is scar tissue or in ammation in the healing periapical surgery area. It is more
common in Max anterior
• Endodontic Microsurgery - the 5-year prognosis can be predicted from the 1-year assessment
with an accuracy of 91% (Halse, Movlen 1991) and 95% (Jesslen et al 1995). Moreover, a
recent study by (Song et al JOE. 2014) found that there was no signi cant difference in the
clinical outcome after EMS between the follow-up at 1 year and that at 4 years or more.
Therefore, the 1-year follow-up may have been suf cient to predict the long-term outcome of
apical surgery in our study.

One vs Two Visits

• Regarding Single Vs. Multiple visits it can be noticed that most of the classic literatures
emphasize the importance of multiple visits using intra canal medicaments. However, in more
recent articles it has been con rmed that there is no signi cant difference regarding the
success rate and post op pain between single and multiple visits. This might be attributed to
the fact that in recent studies more advanced technologies like rotary les and irrigation
systems are used which enhance the antimicrobial properties of chemo mechanical
preparation.
• Most arguments focus on: In uence on prognosis, capacity to disinfect, effect on post-tx pain.
• Moreira et al 2017: JOE. Endodontic Treatment in Single and Multiple Visits: An Overview of
Systematic Reviews.

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 • The results indicated that single and multiple visits showed a similar repair and success
rate. The apical periodontitis subgroup showed a slight trend toward decreased
incidence of postoperative complications.
• The main characteristics including healing rates, success, and clinical complications
during and after endodontic treatment were extracted from the SRs. From the 20 SRs
initially identi ed, 8 were included in the analysis. Of these, 6 SRs showed low to
moderate risk of bias and were suitable as strong clinical evidence on the topic.
• Overall analysis indicated that single and multiple visits showed similar repair or success
rates regardless of the precondition of the pulp and periapex. The apical periodontitis
subgroup showed a slight positive trend toward a decreased incidence of postoperative
complications and a higher effectiveness and ef ciency for a single session. Based on
the risk of bias, the current level of evidence for this clinical approach is high.
• 1 vs 2 visits: Post-Op Pain
• Eleazer et al: NO DIFFERENCE in post op pain of necrotic teeth in single visit
compared to multiple visit. Oliet con rmed these ndings.
• DiRenzo 2002: No signi cant difference in post op pain between 1 and 2 visits for either
vital or non-vital cases. About 20% from both groups needed to take medication.
• Yoldas et al 2004: Incidence and level of post-op pain in RCT retreatment: single vs two
visit. 2-visit endodontic retreatment with an intracanal medication (Ca(OH)2) reduces
postoperative pain in endodontically retreated symptomatic teeth and decreases the
number of are-ups in all retreatment cases compared to 1-visit endodontic retreatment.
• Figini et al 2007: Cochrane Systematic Review. No Difference, but one visit may have
more swelling and more analgesic use.
• El Mubarak et al 2010: No difference. In terms of post-op pain with conventional RCT
• Su et al 2011: Systematic Review. Single better - lower post-op pain. No signi cant
difference was observed in the healing rate between single- versus multiple-visit root
canal treatment, as well as the incidence of medium-term post-obturation pain. As to the
short-term follow up, the prevalence of post-obturation pain was signi cantly lower in
single-visit than in multiple-visit group. (However, because the number of studies
included in this review was limited, it might be preliminary to conclude that there is no
difference between single- and multiple-visit root canal treatments in terms of
postoperative complications for teeth with infected root canals)
• Pekruhn 1981: Defend single visit endo: no difference in number of “pain days”
• Maddox, Walton 1977: Defend Single Visit Endo: Classic: intracanal medicament does
not make a difference in pain (it’s not what you put in, but what you take out). Obturation
= less pain.
• Wang et al 2010: IEJ. Under the conditions of this randomized controlled trial, no
signi cant difference in post-obturation pain was found between one-visit and two-visit
RCT on teeth with vital pulps.
• 1 vs 2 visits: Success/Healing
• Weiger 2000: The paper for arguing one appt endo. Success of PARL 92-93% for both
single or two visit endo with 5 year recall. (From a microbiological perspective, one-visit
root canal treatment created favorable environmental conditions for periapical repair
similar to the two-visit therapy when calcium hydroxide was used as antimicrobial
dressing. One-visit root canal treatment is an acceptable alternative to two-visit
treatment for pulpless teeth associated with an endodontically induced lesion.)
• Figini, Gorni, Gagliani 2007: Cochrane Systematic Review. No Difference, but one visit
may have more swelling and more analgesic use.

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 • Manfredi, Figini, Gagliani, Lodi 2016: Cochrane Systematic Review. Update to 2007
article. There is no evidence to suggest that one treatment regimen (single-visit or
multiple-visit root canal treatment) is better than the other. Neither can prevent all short-
and long-term complications. On the basis of the available evidence, it seems likely that
the bene t of a single-visit treatment, in terms of time and convenience, for both patient
and dentist, has the cost of a higher frequency of late postoperative pain (and as a
consequence, painkiller use).
• Penesis, Johnson B et al 2008: RCT. No Difference. The choice of one-visit versus
two-visit root canal therapy for necrotic teeth with apical periodontitis is a source of
current debate. Both groups exhibited equally favorable periapical healing at 12 months,
with no statistically signi cant differences between groups.
• Paredes-Vieyra, Enriquez 2012: Two year prospective study. No difference. Found no
difference between single and multiple visit therapy for necrotic teeth with apical
periodontitis. The reported success rates were 96% for single visit therapy and 89% for
two visit therapy.
• Witherspoon et al 2008: Obturated teeth with open apexes in either one or two visits
with MTA. One visit: 93.5% healed; two visit: 90.5% healed. (78/144 teeth available for
recall 1-5yrs).
• Su et al 2011: Systematic Review. Single better. No signi cant difference was observed
in the healing rate between single- versus multiple-visit root canal treatment, as well as
the incidence of medium-term post-obturation pain. As to the short-term follow up, the
prevalence of post-obturation pain was signi cantly lower in single-visit than in multiple-
visit group. (However, because the number of studies included in this review was limited,
it might be preliminary to conclude that there is no difference between single- and
multiple-visit root canal treatments in terms of postoperative complications for teeth with
infected root canals)
• Sathorn, Messer 2005: conducted a systematic review of single- versus multiple-visit
endodontic treatment of teeth with apical periodontitis. Does single-visit root canal
treatment without calcium hydroxide dressing, compared to multiple-visit treatment with
calcium hydroxide dressing for 1 week or more? They found that, on the basis of current
best available evidence, single-visit root canal treatment appeared to be slightly more
effective than multiple-visit treatment (6.3% higher healing rate). However, the difference
between these two treatment regimens was not statistically. This is a complicated issue
because the inability to detect differences between groups might also be due to
variations in research methodology, including sample size, duration of follow-up, and
treatment methods.
• 1 vs 2: Microbiological Point of View
• Weiger 2000: The paper for arguing one appt endo. Success of PARL 92-93% for both
single or two visit endo with 5 year recall. (From a microbiological perspective, one-visit
root canal treatment created favorable environmental conditions for periapical repair
similar to the two-visit therapy when calcium hydroxide was used as antimicrobial
dressing. One-visit root canal treatment is an acceptable alternative to two-visit
treatment for pulpless teeth associated with an endodontically induced lesion.)
• Kvist 2004: No difference. RCT: Microbiological eval of 1 vs 2 visit endo. Concluded
from a microbiological point of view, treatment of teeth in two appointments were not
more effective than the investigated one-visit procedure. 62% of 1 visit cases had
cultivable bacteria vs 64% of 2nd visits (with Ca(OH)2). Also, the micro ora changed
from anaerobic-dominated before treatment to facultative-dominated after treatment.

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 • Sathorn, Messer 2007: Systematic Review & MA. 1 vs 2 visits. Calcium hydroxide has
limited effectiveness in eliminating bacteria from human root canal when assessed by
culture techniques.
• Vera, Sequeira, Ricucci et al 2012: 2 visit better. However, very low sample size (13)
and difference minimal between the two. recommend intra-canal medicament to reduce
bacteria.
• Sjogren/Sundqvist 1997 : IEJ– 94% success w/ -culture; 68% w/ +culture; regardless,
they state modern anaerobic culturing techniques are not readily available, nor are they
required.
• Seltzer and Bender- no diff: 84% (- culture) vs 81% (+ culture)
• Peters, Wesselink 2002: The 2nd paper to use (aside from Weiger) to support 1-visit
endo.
• 100% survival (those that were not "successful" had a reduction in lesion size).
• Complete radiographic healing was observed in 81% of the cases in the one-visit
group, and in 71% of the cases in the two-visit group.39 roots (very low n). The
probability of success increased continuously over time for both treatment groups.
Seven out of eight cases (87.5%) that showed a positive root-canal culture at the
time of obturation healed.
• Within the limitations of this study, no signi cant differences in healing of periapical
radiolucency was observed between teeth that were treated in one visit (without)
and two visits with inclusion of calcium hydroxide for 4 weeks. The presence of a
positive bacterial culture (CFU<10(2)) at the time of lling did not in uence the
outcome of treatment.
• Xavier/Martinho/Oliveria 2013 JOE – 2 visit w/CaOH2 were more effective at reducing
bacterial endotoxins (LPS) than 1 visit protocols (98% vs. 86%)
• Molander, Kvist et al 2007: JOE. RCT. 2 year f/u. Necrotic teeth with AP. The present
study gave evidence that, given a meticulously instrumented root canal, a one-visit
antimicrobial treatment including 10 minutes of dressing with 5% iodine-potassium-
iodide is as effective as a two-visit procedure using CH.
• Fava L: If a canal has been entered, the clinician should be committed to removing all tissue.
Partial instrumentation (i.e., leaving tissue remnants in the canal) may result in increased
post-treatment pain.
• Nair 2005: Microbial status of apical root canal system of human mandibular rst molars with
primary apical periodontitis after "one-visit" endodontic treatment (2005). The results showed
(1) the anatomical complexity of the root canal system of mandibular rst molar roots and (2)
the organization of the ora as bio lms in inaccessible areas of the canal system that cannot
be removed by contemporary instruments and irrigation alone in one-visit treatment. These
ndings demonstrate the importance of stringent application of all nonantibiotic chemo-
mechanical measures to treat teeth with infected and necrotic root canals so as to disrupt the
bio lms and reduce the intraradicular microbial load to the lowest possible level so as to
expect a highly favorable long-term prognosis of the root canal treatment.
• Southard, Rooney 1984: Even in the presence of acute periapical abscess can obturate in 1
visit
• Sjogren/Sundqvist: Favor 2 visit w/ Ca(OH)2
• Trope, Delano, Orstavik 1999: JOE. The additional disinfecting action of calcium hydroxide
before obturation resulted in a 10% increase in healing rates. When baseline PAl scores were
controlled for, the calcium hydroxide group showed the most improvement in PAl score (3, 4,
or 5 to 1 or 2), followed by the one-step group (74% vs. 64%).

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 • Schwendicke and Gostemeyer 2017: JOE. Cost-effectiveness of 1 vs 2. There were no
differences in cost-effectiveness between single- and multiple- visit endodontic treatment in
both single-rooted and molar teeth
• Schwendicke, and Gosteyere 2017: BMJ Open? Systematic Review and Meta-analysis.
There is insuf cient evidence to rule out whether important differences between both
strategies exist. Risk of complications was not signi cantly different in single-visit versus
multiple-visit treatment. Risk of pain did not signi cantly differ between treatments.
Risk of are-up was recorded by 8 studies (1110 teeth) and was signi cantly higher after
single-visit versus multiple-visit treatment; very weak evidence.

Prognostic Indicators
• Criteria Used to Judge Success/Failure, Healed/Healing etc
• The widely accepted de nition for endodontic success and failure by Strindberg
embraces both radiographic and clinical ndings. Friedman and Mor preferred the
terms healed, healing, and diseased instead of success and failure because of the
potential of the latter to confuse patients. The “healed” category corresponds to
“success” as de ned by Strindberg, whereas “healing” corresponds to “success” as
de ned by Bender and colleagues
• Board Exam Prognosis Terms: Favorable, Unfavorable, Questionable
• Orstavik 1986: Proposed use of PAI (periapical index) to evaluate radiographic
success by comparison to 5 standard images (healthy = 1; bad=2-5).
• Strindberg 1956:
• Strindberg success criteria: Absence of radiolucency, PDL not more than 1.5
times normal, lamina dura intact, no symptoms, no swelling, no sinus tract, no
pain on percussion or palpation, absence of PARL. Healing in some cases took
until 10 years to heal. Recommendation of 4 year follow up for necrotic cases
Vital cases had 95% success; Necrotic had 71% success after 4 years, if
extended to 10 years 85% success. Lower success rate if there is a lesion.
• Success: No signs or symptoms, Normal PDL Radiographically
• Uncertain: Ambiguous Radiograph, Extracted prior to 3 year f/u, reason not endo
• Failure: Signs or symptoms, PARL decreased, but not resolved, PARL increase,
New PARL, Broken/poorly de ned lamina dura
• Bender et al 1966:
• Clinical Success: absence of pain swelling; disappearance of stula; no loss of
function; no evidence of tissue destruction
• Radiographic Success: an eliminated or arrested area of rarefaction after a
posttreatment interval of 6 months to 2 yrs
• Friedman & Mor 2004:
• Healed: Clinical (normal presentation), Radiographic (normal presentation)
• Healing: Clinical (normal presentation), Radiographic (reduced radiolucency)
• Diseased: Radiolucency has emerged or persisted w/out change, even when the
clinical presentation is normal OR clinical signs or symptoms are present even if
the radiographic presentation is normal
• When Should patient’s be recalled?
• Orstavik – 1 yr; 76% of AP lesions that develop post-op occur in one year. peak
incidence of healing / CAP occurred @ 1 yr; may take 4 yrs

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 • Rud/Andreasen – 1 yr; wait 4 yrs for uncertain healing cases
• How long does it take a lesion to heal?
• Murphy – Avg. rate is 3.2mm/mo.; >70% require >12mo
• Yu, Messer et al 2012: In conclusion, a speci c interval alone should not be used to
conclude that a lesion will not resolve without intervention. Available data suggest that
asymptomatic lesions should be monitored further, especially if the lesion has reduced in
size since treatment.
• Pirani et al 2015: Survival rate was 84.6% and healing rate was 79% (10-19 years). 240
teeth. The 6-9 months evaluation appears to be an indicator for the nal outcome of
primary root canal treatment both in the presence and in the absence of IAP.
• Seltzer/Bender 1966 – Evaluation of success should occur after 6 months – 2 years.
May take up to 2 years for radiographic healing or signs of persistent disease to present
clinically or radiographically
• What factors may be detrimental to a successful outcome?
• Crump 1979: (POOR PAST AM): Perforation, Obturation; Over ll, Root canal missed,
Perio disease, Another tooth, Split tooth, Trauma, Anatomy complex, Microleakage
• Friedman: Toronto study:
• NSRCT – Pre-op lesion
• RETX – Pre-op lesion, perforation, ll quality, restoration
• S RCT – lesion > 5mm quadrupled risk
• What are reasons for continued thermal pain following RCT?
• Keir- missed canals
• Tidwell- 1) inadequate C&S, obturation, 2) missed canals, 3) silver cones in contact with
coronal restoration, 4) metallic GP carriers in contact with oral/pulpal/periradicular tissue,
5) broken metallic instrument in contact with apical vital tissue, 6) Defective coronal
restoration, 7) Referred pain from another tooth
• Do radiographic healing correlate to histologic healing
• Byrnolf – No; only 7% demonstrated no in ammation
• Green, Walton – Yes; 74%
• Is bacterial culturing indicated? Does it in uence healing?
• Sjogren & Sundqvist 1997: IEJ. 94% success w/ -culture; 68% w/ +culture; regardless,
they state modern anaerobic culturing techniques are not readily available, nor are they
required
• Seltzer and Bender- no diff: 84% (- culture) vs 81% (+ culture)
• Molander- 80% vs 49%; removal of bacteria important but not # of appts
• Peters & Wesselink – found NSD between 1 or 2 visit, or between + and – cultures
• Weiger 2000: The paper for arguing one appt endo. Success of PARL 92-93% for both
single or two visit endo with 5 year recall. (From a microbiological perspective, one-visit
root canal treatment created favorable environmental conditions for periapical repair
similar to the two-visit therapy when calcium hydroxide was used as antimicrobial
dressing. One-visit root canal treatment is an acceptable alternative to two-visit
treatment for pulpless teeth associated with an endodontically induced lesion.)
• Kvist 2004: No difference. RCT: Microbiological eval of 1 vs 2 visit endo. Concluded
from a microbiological point of view, treatment of teeth in two appointments were not
more effective than the investigated one-visit procedure. 62% of 1 visit cases had
cultivable bacteria vs 64% of 2nd visits (with Ca(OH)2). Also, the micro ora changed
from anaerobic-dominated before treatment to facultative-dominated after treatment.

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 • Vera, Sequeira, Ricucci et al 2012: 2 visit better. However, very low sample size (13)
and difference minimal between the two. recommend intra-canal medicament to reduce
bacteria.
• What are reasons for failure of NS RCT?
• Intraradicular infection – Nair – main reason for failure is microbes persist in canals
• Extraradicular infection – Siqueira –rare / Nair – Actinomycosis
• Foreign body rxn – Nair – root lling materials
• Cysts – Nair – possibly with cholesterol crystals
• Nair et al 2006 - IEJ. 1) intraradicular infection persisting (fungus, E. faecalis), 2)
Extraradicular infection (Actino, viruses), 3) Extruded RC lling or other exogenous material
that cause foreign body rxn, 4) Accumulation of cholesterol crystals (18-44%), 5) True
cysts, 6) scar tissue
• Crump 1979 – POOR PAST (Perf, obturation inadequate, overextended, root canal
missed, perio dz, another tooth, split/fx tooth, trauma) also microleakage
• Does the level of root canal ll in uence success/failure?
• Seltzer & Bender – Over ll decreased success (71%); ush/under ll had no in uence
(87%, 87%)
• Ng – meta-anaylsis shows w/in 2mm of apex improved success
• Schaefer and Walton - meta analysis: 0-1mm best, >1-3 mm; both better than long
• Sjogren - 0-2mm 94%, > 2mm 68%, long 76% (vital or necrotic pulp, no lesion)
• Is 1 or 2-visit treatment more successful?
• Peters & Wesselink – NSD
• Weiger, Rosendahl & Lost – NSD for teeth with AP treated in 1 visit or with 1 wk
Ca(OH)2
• Figini- meta analysis: NSD; 1 appt more post-oper pain meds and swelling
• Sathorn/Messer- sys rev w/ ma: NSD; 1 appt had 6% more success
• Success differences between GPs and Endodontists?
• Alley - endodontists had 10% higher success rates
• Lazarski – similar success rates, but endodontists had sig harder cases, GPs had sig
more failure of surg RCT
• Ramey, et al 2017: JOE. Results: A total of 2262 RCTs were examined, with 1960 RCTs
meeting inclusion criteria for at least 1 evaluation category. For RCT obturation quality,
1810 RCTs were evaluated, and 96.0% were considered adequate. For cuspal coverage
restorations, 1856 RCTs were evaluated, and of these 2.7% were inadequately restored.
Healing of periapical pathosis was 91.5% and 85.7% for Air Force and referred civilian
providers, respec- tively. Survivability was 94.4% for endodontists, 95.3% for AF general
dentists with additional training, 87.9% for AF general dentists without additional training,
and 78.4% for civilian general dentists. Overall, survivability was 94.1% for a follow-up
period ranging up to 47 months, with a mean of 27 months. Conclusions: In this
retrospective, radiographic analysis, evidence- based practices as followed in the Air
Force Dental Service and accredited postgraduate training resulted in improved
treatment outcomes.
• What may affect prognosis of NS RCT?
• Fouad- DM decreases success, more are-ups
• Polycarpou- chronic pain 8.6X risk factor for post endo pain
• Marending- conditions affecting immune response (DM, renal insuf ciency, breast cancer),
pre-oper lesion (PAI score), quality of ll all factors leading to decreased success

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 • Ng, Gulabivala- Age assoc with decreased healing; Improved outcome of NSRCT:
absence of pre-op PARL, root ll with no voids, root ll w/i 2 mm of apex, good coronal seal
(ie crown), M/D contacts
• Chen- HTN decreases healing
• Nasstrom- high doses of corticosteroids lead to signi cant PCO and pulp calci cations
• Galili- PCO assoc with hemodialysis
• Eleazor- pulp stones assoc with atherosclerosis
• Gillen – Sys Review on coronal restoration, GE/GR has 3x more success
• Wang et al 2011:
• Setzer, Kim s et al 2011: clinical attachment loss negatively impacts root canal therapy
outcomes.
• Karabucak, Setzer et al 2016: Teeth with a missed canal were 4.38 times more likely to be
associated with a lesion.
• Materials used in non-surgical root canal treatment (Nair et al. 1990b, Koppang et al. 1992)
and certain food particles (Simon et al. 1982) can reach the periapex, induce a foreign body
reaction that appears radiolucent and remain asymptomatic for several years (Nair et al.
1990b).
• Friedman S: Prognostic factors in root canal treatment. Many studies have investigated the
outcome of root canal treatments and there are some factors which might affect the results of
these studies. We should always consider these factors while interpreting the results:
• Type of teeth in study
• Number of subjects that considering many confounding factors (200 is too small)
• proportion of teeth with apical periodontitis and retx cases
• Criteria for case selection that affect the success rate (Ingle)
• Operators
• Asepsis and use of rubber dam
• Intracanal medicament and
• procedures Post RCT restoration.
• Generally, when reviewing articles which have assessed the success rate of RCT, Prognostic
factors have been divided to 3 main groups:
• Pre-operative Factors
• Apical periodontitis: success rate is 10-25% lower.
• Lesion size: some studies indicate a better prognosis for apical periodontitis lesion
2-5mm than for larger (Friedman, Strindberg). However, some studies did not nd
signi cant difference (Sjogren).
• Pulpal status: The success rate of vital teeth is shown to be higher or comparable
(Freidman, Kerkes &Tronstad).
• Periodontal statues: does not affect the success rate (Sjogren).
• Age, gender showed no effect on the success rate.
• Intraoperative Factors
• Apical extent of canal instrumentation and lling: Extrusion of lling materials
beyond the root-end generally result in poorer treatment outcome (Bergenholtz,
Seltzer and Strindberg). However, Sjogren believed that extrusion just impaired
the outcome in infected cases.
• GP is well tolerated by body per se therefore its extrusion can not affect the
success rate per se. However, extrusion of GP is usually followed by

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 overinstrumentation and extrusion of bacteria which in case impair the healing rate
(Sjogren).
• It has also been reported that extrusion of lling materials is totally or partially
removed by the surrounding tissue (Augsburger).
• Studies correlated short root lling (more than 2mm) with reduced success rate.
However, Sjogren found that short llings are just associated with reduced healing
rate in infected cases.
• Friedman showed that llings 0-2mm from the apex show higher success rate than
short or over lled.
• Apical enlargement: Yared & Budahger and also Orstavik proposed that apical
enlargement promotes effective disinfection of the apical portion of the canal.
• Treatment sessions: debate in Endo
• Materials and techniques: Strindberg found no difference in the success rate using
different sealers.
• Friedman Found higher success rate using ared technique and vertical
condensation compared to standard step back and lateral condensation.
• Void in obturation and Sealer extrusion: Friedman found no effect on success rate
• Post-operative Factors
• Restoration
• Aquilino & Caplan 2002: teeth without crown lost at 6X higher rate. The nal
Cox model showed that endodontically treated teeth not crowned after obturation
were lost at a 6.0 times greater rate than teeth crowned after obturation
• Moreno 2013: Canals lled up to 0–2 mm short of the apex had a signi cantly
higher number of teeth rated as healthy than over lled or under lled cases.
Regression analysis showed that the quality of endodontic treatment was the
most signi cant factor in uencing the periradicular status (P < .001).
• Keep in mind that in many studies evaluating the quality of the RCT and
prevalence of periodontitis or out come of RCT there are 3 parameters which
have been considered in most of the articles: They are
• 1) apical extension of root lling 2) quality and homogeneity of root lling and
3) taper ( Hasselgren, 2007 IEJ ; Tavares 2009 JOE ; Santos 2010 JOE ; Yu-
Hong Liang 2011 JOE). The following chart from Santos et al (JOE, 2010)
study can be a clinical guide for root canal quality assessment. Santos et al
found that a pre-op lesion and taper were most important for predicting
success.

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 • Liang 2011: study showed that different factors in PA assessment and CBCT
assessment can affect the outcome of root canal treatment. When ndings from PA
were analyzed density and apical extent of root lling were identi ed as predictors (p<
.05). When ndings from CBCT were analyzed, density of root lling and quality of
coronal restoration signi cantly in uenced treatment outcome (p ≤ .001). This might
be explained by the fact that 80% of root llings which were considered over in PA
were actually ush llings (0-2 mm of apex) on CBCT images.
• Gomes 2015: A signi cant difference was observed when comparing the treatment
outcome for teeth with and without coronal restorations. The odds ratio allowed the
conclusion that it is 0.6 times most probable to observe a healthy periapical condition
when you have the presence of coronal restoration when compared with an absence
of coronal restoration. Regarding the apical extension of the lling, the best results
were observed for canals lled within to 0–2 mm short of the apex, with a statistically
signi cant difference over teeth with over- or under lling (P < .0001). The analysis of
the odds ratio showed that it is 4.68 times more likely to nd healthy teeth when the
apical extension of the lling is 0–2 mm short compared with teeth with over lling. The
apical extent of the lling >2 mm short from the foramen also displays an odds ratio of
2.024, which corresponds to a signi cantly higher possibility of nding healthy teeth
compared with over lling.
• Victoria Soo Hoon Yu 2012: assessed the lesion progression in post-treatment Endo
lesions. Recall lesion size greater than 5 mm in diameter posed the highest relative
risk (RR) at 2.9 times (95% con dence interval [CI], 1.9–4.6; P < .0005) compared
with lesions less than 2 mm in size. The presence of biting pain at recall indicated a
1.8-times increase (95% CI, 1.2–2.6; P = .002) in the risk of lesions not improving. A
history of a are-up any time after obturation increased the risk of lesions not
improving by 1.5 times (95% CI, 1.1– 2.0; P = .014). A root lling without an ideal
working length was 1.4 times more likely (95% CI, 1.0–2.0; P = .046) to be associated
with a lesion that did not improve over time.
• Eleazer 2010: Comparison of Classic Endodontic Techniques versus Contemporary
Techniques on Endodontic Treatment Success: This study compared the survival
rates of endodontic treatment performed by using classic techniques (eg,
instrumentation with stainless steel hand les, alternating 5.25% NaOCl and 3%
H2O2 irrigation, mostly multiple treatment visits, and so on) versus those performed
using more contemporary techniques (eg, instrumentation with hand and rotary nickel-
titanium les, frequent single-visit treatment, NaOCl, EDTA, chlorhexidine, H2O2
irrigation, warm vertical or lateral condensation obturation, use of surgical
microscopes, electronic apex locators. Of the 459 teeth in the classic group, there was
an overall survival rate of 98% with an average follow-up time of 75.7 months. Of 525
teeth in the contemporary group, there was an overall survival rate of 96%, with an
average follow-up time of 34 months. Considerably more treatments in the classic
group were completed in multiple appointments (91%) than in the contemporary group
(39%). More teeth in the classic group underwent post-treatment interventions (6.7%
vs 0.9%, respectively).
• Sjogren 1997: reduced success when bacteria are present during obturation (94% vs 68%).
They suggested three negative culture before obturation increase the success rate. In
contrary to Bender and Seltzer: Culturing didn’t affect outcome
• Studies showing reduced success of NSRCT with apical periodontitis:
Success (%): Sjogren (1990) 96% vs 86%; Friedman (1995) 93% vs 69%

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• Hoskinson SE, Ng YL, Hoskinson AE 2002: In this study the presence of a pre op lesion
was the biggest prognostic factor; success rates decreased by 18% for every 1-mm increase
in size of a pre- operative periapical lesion.
• Ricucci, Siquiera 2010: Bio lms and apical periodontitis: Study of prevalence and
association with clinical and histopathologic ndings. Larger lesion —> increase in bio lm.
The size of the periapical lesion was one of the factors that had a negative in uence on the
prognosis.
• Chugal 2003: in teeth with necrotic pulp best outcome was observed with root llings at 0.55
mm short from radiographic apex. In teeth/roots with apical periodontitis, a millimeter loss in
working length increased the chance of treatment failure by 14%. The risk of failure was
higher for a fair/poor density of obturation than for a good density for all diagnoses of
periradicular status.
• Karabucak, Setzer et al 2016: Teeth with a missed canal were 4.38 times more likely to be
associated with a lesion. CBCT eval of missed canals of RCT-ed teeth.
• Strindberg 1956: Histological success most dif cult to achieve!!
Strindberg success criteria: Absence of radiolucency, PDL not more than 1.5 times normal,
lamina dura intact, no symptoms, no swelling, no sinus tract, no pain on percussion or
palpation, absence of PARL Healing in some cases took until 10 years to heal.
Recommendation of 4 year follow up for necrotic cases Vital cases had 95% success;
Necrotic had 71% success after 4 years, if extended to 10 years 85% success. Lower
success rate if there is a lesion.
• The following variables appear to have potentially a negative affect on endodontic
treatment outcome:
• Pre-Operative Factors
• Presence of Periapical Radiolucency
• Sjogren, Sundqvist et al 1990
• Pirani et al 2015
• Santos, Costas et al 2010
• de Chevigny, Basrani, Friedman et al 2008
• Ng et al 2008
• Akerblom, Hasselgren 1988
• Van Nieuwenhuysen et al 1994
• Gorni, Galiani 2004
• Imura et al 2007
• Strindberg 1956
• Chugal et al 2003
• Panitvisai, Messer et al 2010
• Presence of Periodontal Disease
• Setzer, Kim S 2011
• Ng et al 2011
• Size of Periapical Lesion
• Sjogren, Sundqvist et al 1990
• Sundqvist, Figdor, Sjogren et al 1998
• Ricucci, Siqueira 2010
• Tooth Type
• Ng et al 2010, 2011 (pt 1 & 2)
• de Chevigny, Basrani, Friedman et al 2008

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 • Imura et al 2007
• Orstavik et al 2004
• Iatrogenic Perforations/Anatomical Alterations (ReTx)
• Ng et al 2011
• de Chevigny, Basrani, Friedman et al 2008
• Gorni, Galiani et al 2004
• Imura et al 2007
• Pontius et al 2013
• Systemic Disease?
• Fouad, Burleson 2003: Concluded that patients with diabetes have increased
periodontal disease in teeth involved endodontically and have a reduced likelihood of
success of endodontic treatment in cases with preoperative periradicualar lesions.
• Bender and Bender 2003: evaluated diabetes and concluded that when diabetes
mellitus is under therapeutic control, periapical and other lesions heal as readily as
non diabetics.
• Ng et al 2011: reported patient factors that play a signi cant role in outcome include
history of diabetes and systemic steroid therapy
• Wang et al 2011: concluded that an increased risk of tooth extraction after root canal
therapy is signi cantly associated with diabetes mellitus, hypertension and coronary
artery disease individually
• Suchina et al 2006: retrospective. Found that despite obturation de ciencies and the
immunocompromised state of the patients, endodontic therapy has a relatively high
degree of success in the majority of HIV/AIDs patients. HIV and aids should not be
considered a contraindication to endodontic therapy in this patient population
• Intra-Operative Factors
• Speci cally, Level of Obturation
• Sjogren, Sundqvist et al 1990
• Pirani et al 2015
• Santos, Costas et al 2010
• Liang, Wesselink, Wu 2011
• Moreno, Alves, Rocas, Siqueira 2013
• NG et al 2008
• NG et al 2011
• de Chevigny, Basrani, Friedman et al 2008
• Van Nieuwenhuysen et al 1994
• Nair, Sjogren, Sundqvist et al 1990
• Davis et al 1971
• Schaeffer, Walton 2005
• Ricucci, Langeland 1998
• Chugal et al 2003
• Gomes et al 2015
• Root Canal Quality (Length, Density, Taper)
• Santos, Costos et al 2010
• Liang, Wesselink, Wu 2011
• NG et al 2008
• Chugal et al 2003
• Gillen, Looney, Pashley et al 2011

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 • Craveiro et al 2015
• Gomes et al 2015
• Interappointment Complications
• de Chevigny, Basrani, Friedman 2008
• NG et al 2011
• Imura et al 2007
• Pantitvisai, Messer 2010
• Apical Patency/MAF
• NG et al 2011
• Saini et al 2012
• Aminoshariae, Kulild 2015
• Post-Operative Factors
• Coronal Restorations
• Salehrabi, Rotstein 2004
• NG et al 2010
• Aquilino, Caplan 2002
• Liang, Wesselink, Wu 2011
• NG et al 2008
• Gillen, Looney, Pashley 2011
• Craveiro et al 2015
• Pratt, Aminoshariae, Mickel et al 2016
• Gomes et al 2015

Outcomes: Initial Treatment

• Ng 2010: Systematic review.
• 2-10yr survival ranges 86-93%.
• 2-3 years (86%), 4-5 years (93%), 8-10 years (87%).
• Factors affecting survival: Restoration with crown, both M and D contacts, not
abutments, non-molars
• Torabinejad, Goodacre et al 2007: Systematic Review.
• Showed that both root canal and implant treatments resulted in a very high survival rate
(97% at more than 6 years), compared to only 80% for a xed dental prosthesis (3-4 unit
bridge). Different criteria are used for implant and endo. Endo much stricter success
criteria.
• Survival: 97% for implants, 97% for RCT, 82% FPD
• Success: 95% for implant, 84% for RCT, 80% FPD
• Ng 2008: IEJ. Outcome of primary root canal treatment: systematic review of the literature.
• Part 1. Effects of study characteristics on probability of success.
• The reported mean success rates ranged from 31% to 96% based on strict criteria or
from 60% to 100% based on loose criteria
• The estimated weighted pooled success rates of treatments completed at least 1 year
prior to review, ranged between 68% and 85% when strict criteria were used.
• It would be desirable to standardize aspects of study-design, data recording and
presentation format of outcome data in the much needed future outcome studies.
• Part 2. In uence of clinical factors.
• The authors concluded that four conditions were found to improve the outcome of
primary root canal treatment.

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 • pretreatment absence of a periapical radiolucency
• root lling with no voids
• root lling extending to 2 mm within the radiographic apex
• satisfactory coronal restoration
• They went on to note that the results of the review “should be interpreted with
caution and cannot be considered to give de nitive conclusions because of the
retrospective and heterogeneous nature of the data. It does, however, provide
strong clues about the factors likely to dominate outcomes and inform the design of
future randomized trials.
• Pirani et al 2015: Retrospective study. 240 teeth. (Odontology 2015)
• Survival rate was 84.6% and healing rate was 79% (10-19 years).
• The 6-9 months evaluation appears to be an indicator for the nal outcome of primary
root canal treatment both in the presence and in the absence of AP.
• An initial radiolucency associated with an unsatisfactory quality and extent of root canal
lling signi cantly diminishes the possibility of achieving long-term radiographic success.
• Sjogren 1990: Diagnosis Drives Prognosis or Prognosis is driven by Diagnosis. 356 patients
were recalled 8-10 yrs later.
• Vital or nonvital with no PA radiolucency: >96%.
• Necrotic Pulp + PA lucency: 86%.
• Retreatment + PA lucency: 62%.
• Salehrabi, Rotstein 2004: 8 year epidemiological study.
• 97% survival with nonsurgical endodontic treatment.
• 85% of the extracted teeth had no full coronal coverage.
• De Chevigny et al 2008: Toronto studies. Found that after 5-10 years….
• 88% of endodontically treated teeth were radiographically healed
• 94% of teeth were clinically functional.
• If no lesion: 93% success, 97% survival.
• If lesion: 82% success, 94% survival.
• Doyle et al 2006: (196 implants vs 196 RCTs, 1-10yr recalls).
• Outcomes were as follows for implants and NSRCT outcomes, respectively:
• Implant success 73.5%
• RCT Success 82.1%.
• At 6.5 years RCTs 89.5% survival.
• The results of this study show that the endodontic and implant therapies resulted in an
identical number of failures, but the implant group had fewer successes and survivals,
independent of location. The implants had a signi cantly higher fraction of patients
classi ed as surviving with the requirement for subsequent treatment, equivalent to
clinical complications. Additionally, the implant group had a longer time-to-function than
the endodontic group. The location of the restorative treatment was not a signi cant
factor when comparing the two treatment groups.)
• Friedman et al 2003: Toronto Study. 4-6 year outcome of initial RCT.
• 97% Overall Survival.
• 81% Overall healed.
• 92% healed w/out apical Periodontitis.
• 74% healed with apical periodontitis.
• The "healed" rate (81% overall) was signi cantly higher for teeth treated without apical
periodontitis (92%) than with apical periodontitis (74%). Poor Recall (51%)
• Akerblom and Hasselgren 1988: JOE. Non-negotiable, obliterated teeth
• 89% overall success.

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 • 98% success with no PARL.
• 63% success with PARL.
• Obliterated teeth not patent for more than 1/3 the root length included.
• Weiger 2000: IEJ. The paper for arguing one appt endo.
• Success of PARL 92-93% single or two visit endo (High success for PARL.)
• From a microbiological perspective, one-visit root canal treatment created favorable
environmental conditions for periapical repair similar to the two-visit therapy when
calcium hydroxide was used as antimicrobial dressing. One-visit root canal treatment is
an acceptable alternative to two-visit treatment for pulpless teeth associated with an
endodontically induced lesion. 73 patients (low n). Strong 92% recall with 5 year recall
(similar to Sjogren, Figdor, Persson, Sundqvist)
• Peters, Wesselink 2002: IEJ. The 2nd paper to use (aside from Weiger) to support 1-visit
endo.
• 100% survival (those that were not "successful" had a reduction in lesion size).
• Complete radiographic healing was observed in 81% of the cases in the one-visit group,
and in 71% of the cases in the two-visit group.39 roots (very low n). The probability of
success increased continuously over time for both treatment groups. Seven out of eight
cases (87.5%) that showed a positive root-canal culture at the time of obturation healed.
• Within the limitations of this study, no signi cant differences in healing of periapical
radiolucency was observed between teeth that were treated in one visit (without) and
two visits with inclusion of calcium hydroxide for 4 weeks. The presence of a positive
bacterial culture (CFU<10(2)) at the time of lling did not in uence the outcome of
treatment.
• Molven, Halse, Fristad 2002:
• Asymptomatic cases with lesions can continue to heal up to 27 years!
• 50% PARL at time of treatment --> 17% at 17yrs --> 6% at 27yrs.
• Overall 95% 27-yr radiographic success rate.
• The percentage of cases with normal periapical ndings at the nal follow-up was
86.4%, whilst 8.7% were recorded with increased width of the apical periodontal space.
Followup of cases done by pre-doc students Longer term follow-ups can increase
success rate!
• Yu, Messer, et al 2012:
• A speci c interval alone should not be used to conclude that a lesion will not resolve
without intervention. Available data suggest that asymptomatic lesions should be
monitored further, especially if the lesion has reduced in size since treatment.
• Clinically, endodontists and their patients must often make retreatment decisions without
the bene t of access to radiographs taken at the time of treatment. The basis for a
decision to re-treat is restricted to evidence from the current radiographs, clinical signs
and symptoms, and patients’ informed consent. In view of the nding that a majority of
persistent lesions have reduced in size since treatment and are asymptomatic, this
raises an important question: to what extent is it possible to judge purely from current
lesion characteristics (radiographic plus clinical data) whether the lesion is healing or
deteriorating?
• The data from this study suggest that a lesion that is >5 mm in diameter and present for
more than 10 years since treatment is likely to be deteriorating. Also, the presence of
clinical signs such as biting pain or a sinus tract and/or history of postobturation are-up
strongly indicate a deteriorating lesion. More data are needed before a de nitive answer
can be provided.

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 • Setzer F, Kim S 2011: Long-term prognosis of endodontically treated teeth: a retrospective
analysis of preoperative factors in molars. The only preoperative factors signi cant for the
prognosis of restored endodontically treated molars were related to periodontal prognostic
value and attachment loss. It can be concluded that it may be dif cult to predict the prognosis
of molars in need for endodontic treatment and restoration from prognostic factors not related
to periodontal disease.
• Systematic Reviews
• Ng 2010: 2-10yr survival ranges: 86-93%. 2-3 years: 86%, 4-5 years: 93%, 8-10 years:
87%. Factors affecting survival: Restoration with crown, both M and D contacts, not
abutments, non-molars
• Torabinejad, Goodacre et al 2007: Showed that both root canal and implant treatments
resulted in a very high survival rate (97% at more than 6 years), compared to only 80%
for a xed dental prosthesis (3-4 unit bridge). Different criteria are used for implant and
endo. Endo much stricter success criteria.
• (Survival: 97% for implants, 97% for RCT, 82% FPD)
• (Success: 95% for implants, 84% RCT, 80% FPD)
• Iqbal and Kim 2007: found similar results in another systematic review when they
compared the survival rates of restored endodontically treated teeth with those of
implant-supported restorations.
• Ng 2008: The estimated weighted pooled success rates of treatments completed at least
1 year prior to review, ranged between 68% and 85% when strict criteria were used. The
authors concluded that four conditions (pretreatment absence of a periapical
radiolucency, root lling with no voids, root lling extending to 2 mm within the
radiographic apex, and satisfactory coronal restoration) were found to improve the
outcome of primary root canal treatment.
• The NSRCT success rate for necrotic teeth vs vital appears equivocal
• Smith 1993: reports reduced success with necrotic cases
• Kerekes & Tronstad 1979: reports same success
• Strindberg 1956: reports increased success with necrotic cases
• Sjogren 1990: Same if no PA lesion >96%
• NSRCT Outcome Studies:
• Friedman: 92-98%, 74-86% w/ AP
• Washington Study 1994 (Ingle, Glick): 92%
• Sjogren: 96%, 86% w/ AP
• Seltzer, Bender: 92%, 76% w/ AP
• Molven & Halse 1988: 91%, 68% w/ AP
• Akerblom, Hasselgren 1988: 98%, 68% w/ AP (obliterated canals)
• NSRCT Epidemiological Studies
• Salehrabi, Rotstein 2004: 97% functional success @ 8 yrs (1.5 million)
• Lasarski, Hargreaves 2001: 94% @ 3.5 yrs (110,000)
• Chen 2007: 93% (1.6 million) @ 5 years
• NSRCT Length of Obturation
• Seltzer, Bender: Flush 86.5%, Under ll 87%, Over ll 71%
• Sjorgren: 0-2mm short 94%, over ll 76%, > 2mm short 68%
• Schaefer, Walton: 0-1mm better than 1-3 mm short; both > long
• Etiology of Non-healing initial endodontic Therapy
• Nair et al 2006: IEJ. Apical periodontitis is a chronic in ammatory disorder of periradicular
tissues caused by etiological agents of endodontic origin. Persistent apical periodontitis

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 occurs when root canal treatment of apical periodontitis has not adequately eliminated
intraradicular infection. Problems that lead to persistent apical periodontitis include:
inadequate aseptic control, poor access cavity design, missed canals, inadequate
instrumentation, debridement and leaking temporary or permanent restorations. Even when
the most stringent procedures are followed, apical periodontitis may still persist as
asymptomatic radiolucencies, because of the complexity of the root canal system formed
by the main and accessory canals, their rami cations and anastomoses where residual
infection can persist. Further, there are extraradicular factors -- located within the in amed
periapical tissue -- that can interfere with post-treatment healing of apical periodontitis. The
causes of apical periodontitis persisting after root canal treatment have not been well
characterized. During the 1990s, a series of investigations have shown that there are six
biological factors that lead to asymptomatic radiolucencies persisting after root canal
treatment. These are: (i) intraradicular infection persisting in the complex apical root canal
system; (ii) extraradicular infection, generally in the form of periapical actinomycosis; (iii)
extruded root canal lling or other exogenous materials that cause a foreign body reaction;
(iv) accumulation of endogenous cholesterol crystals that irritate periapical tissues; (v) true
cystic lesions, and (vi) scar tissue healing of the lesion. This article provides a
comprehensive overview of the causative factors of non-resolving periapical lesions that
are seen as asymptomatic radiolucencies post-treatment.
• Ng et al 2011: Part 1 and 2.
• Success based on periapical health associated with roots following 1°RCTx (83%) or
2°RCTx (80%) was similar, with 10 factors having a common effect on both
• Investigated the probability of and factors in uencing tooth survival following primary (1°
RCTx) or secondary (2° RCTx) root canal treatment. The 4-year tooth survival following
primary or secondary root canal treatment was 95%, with thirteen prognostic factors
common to both. See below for 13 indicators.
• Seltzer, Bender 2003: JOE. “Cognitive Dissonance” Reprint from OOOOE 1965. It has long
been held that if the three basic principles—the so-called “endodontic triad”—are followed
faithfully, the end result of endodontic treatment must be successful (2). These three
“principles” are (a) thorough debridement of the root canal, (b) sterilization of the root canal,
and (c) complete obturation of the root canal. Put down as a simple formula, it would be a + b
+ c = endodontic success. However, even when followed, sometimes we still have failure. We
believe that it is time for the endodontic community (especially teachers) to become more
realistic and to stop informing the dental profession that endodontic treatment is a sure- re
method which almost always succeeds. Endodontists themselves must be willing to stop
ignoring the dissonance and admit that their treatments sometimes fail, for there can be no
attempt at solution of a nonexistent problem.
• Chercoles-Ruiz A, Sanchez-Torres A, Gay-Escoda C. 2017: JOE. Systematic Review. To
compare survival rate of RCT, RCRT, and/or apical surgery with implants.
• Success rate of endodontic treatment varies from 42.1% - 86% after 2-10 years
• Endo retreatment success varies from 84.1% - 88.6% after 4-10 years
• Apical surgery success ranges from 59.1% - 93% after 1-10 years.
• Implant survival varies from 91.8% - 100% after 1-10 years (no studies on success rate).
• No important differences between treatments (endo vs. implant) can be observed until
after 8 years of follow-up.
• Only 1 study detected a higher survival rate for implants because survival and survival
with intervention rates were grouped in this category. Survival with intervention included
endodontic retreatment or peri-implantitis treatment.

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 • The authors found that implants had more postoperative complications requiring
intervention.
• Because the different treatment options are comparable in terms of success and
survival, treatment should be agreed upon in accordance with patient preferences and
realistic expectations. Studies on dental implants are less demanding than those studies
on endodontics because the majority of them only provide information on survival and
not success rates.
• As observed by Doyle et al., implants have more prosthetic complications than
endodontically-treated teeth.

Retreatment
• Commonly sited factors in uencing the reported outcomes of nonsurgical retreatment: initial
treatment quality and apical periodontitis. Others include iatrogenic perforations and
anatomical alterations.

• RCT Outcome Studies

• He, et al 2017:
• 90.4% success. n=63. 2yr recall. Mand 1st molars. Resilon in 1/2 cases.
• Torabinejad, White 2016: JADA. Review of Systematic Reviews.
• The rst treatment option after failure of root canal treatment is not extraction of the
tooth and replacement by using a xed prosthesis or a single-tooth implant. There
is value in retaining an otherwise sound natural tooth.
• Endodontic treatment options for failed initial root canal treatment include:
• nonsurgical retreatment (93- 95% success)
• endodontic surgery (94% 2-4 yrs, 88% 4-6 yrs)
• replantation (88% mean survival)
• and transplantation (good prognosis).
• Results of systematic reviews regarding the outcomes of these treatments show
high survival rates for these procedures. Nonsurgical retreatment and apical
surgery are particularly effective when performed using contemporary techniques to
address the cause of any remaining unhealed periapical disease appropriately.
Therefore, these procedure options should be considered before extraction of teeth
initially treated by means of nonsurgical root canal treatment.
• The rst-line treatment option after failure of initial root canal treatment is
nonsurgical retreatment. Endodontic surgery, intentional replantation, and
autotransplantation should be considered before extraction and replacement by a
single-tooth implant.
• Comprehensive case assessment, evaluation of all endodontic options, and risk
assessment for caries and periodontal disease are always necessary when
choosing the optimal treatment for a patient when initial root canal treatment has
failed to heal.
• Torabinejad, Corr, Handysides, Shabahang 2009: Systematic Review.
• A signi cantly higher success rate was found for endodontic surgery at 2-4 years
(77.8%) compared with nonsurgical retreatment for the same follow-up period
(70.9%; P < .05).
• At 4-6 years, however, this relationship was reversed, with nonsurgical retreatment
showing a higher success rate of 83.0% compared with 71.8% for endodontic
surgery (P < .05).

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 • Endo surgery has more favorable results initially, but nonsurgical retreatment offers
a more favorable long-term outcome.
• Ng, Mann, Gulabivala 2008: IEJ. Outcome of secondary root canal treatment: a
systematic review of the literature. The pooled estimated success rate of secondary root
canal treatment was 77%. The presence of pre-operative periapical lesion, apical extent
of root lling and quality of coronal restoration proved signi cant prognostic factors with
concurrence between all three strands of evidence whilst the effects of 1 degrees RCT
history and 2 degrees RCT protocol have been poorly investigated.
• Ng et al 2011: Part 1. Periapical Health. 2-4 yr F/U
• 83% Success RCT
• 80% Success RCT ReTx
• Success based on periapical health associated with roots following 1°RCTx (83%)
or 2°RCTx (80%) was similar, with 10 factors having a common effect on both
• Eleven prognostic factors were identi ed.
• preoperative absence of a periapical lesion
• in presence of a periapical lesion, the smaller its size, the better the treatment
prognosis;
• absence of a preoperative sinus tract
• achievement of patency at the canal terminus
• extension of canal cleaning as close as possible to its apical terminus
• the use of ethylene-diamine-tetra-acetic acid (EDTA) solution as a penultimate
wash followed by nal rinse with NaOCl solution in 2°RCTx cases ONLY
• abstaining from using 2% CHX as an adjunct irrigant to NaOCl solution
• absence of tooth/root perforation
• absence of interappointment are-up (pain or swelling)
• absence of root- lling extrusion
• presence of a satisfactory coronal restoration (P ≤ 0.001).
• Ng et al 2011: Part 2. Tooth Survival.
• 95% Survival for RCT and RCT ReTx
• The 4-year tooth survival following primary or secondary root canal treatment was
95%, with thirteen prognostic factors common to both.
• 13 prognostic factors were identi ed.
• Signi cant patient factors included history of diabetes and systemic steroid
therapy.
• Signi cant pre-operative factors
• narrow but deep periodontal probing depth;
• pain;
• discharging sinus;
• iatrogenic perforation (for 2°RCTx cases only).
• Signi cant intra-operative factors
• iatrogenic perforation;
• patency at apical terminus;
• extrusion of root llings.
• Signi cant post-operative restorative factors
• presence of cast restoration versus temporary restoration;
• presence of cast post and core;
• proximal contacts with both mesial and distal adjacent teeth;
• terminal location of the tooth.

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 • The presence of pre-operative pain had a profound effect on tooth loss within the
rst 22 months after treatment with a lesser effect beyond 22 months. Patency at
the apical terminus reduced tooth loss within the rst 22 months after treatment but
had no signi cant effect on tooth survival beyond 22 months. Extrusion of gutta-
percha root lling did not have any effect on tooth survival within the rst 22 months
but signi cantly increased the hazard of tooth loss beyond 22 months
• Bergenholtz 1979: n=660. Re-tx due to PARL or technical reasons
• 2-yr success of re-tx technical indication only 94%.
• Don't retreat just for technical shortcomings!
• Re-tx success of PARL 78% success (elimination or shrinking of PARL).
Retreatments carried out because of technical inadequacies alone were successful
in 94% of the cases. It was concluded that renewed endodontic treatment whenever
possible is the method of choice when treating defective endodontic llings
complicated with pathologic processes periapically.
• van Nieuwenhuysen 1994: Use of rubber dam makes re-tx more successful. ~6yr
recall 91% success (including uncertain). Monitored lesions: Only 3% got worse. Only
2% got better. 95% remained unchanged. 612 teeth retreated, 420 asx roots monitored.
(The initial size of the lesion, use of RD, obturation technique, and level of obturation
signi cantly affected the retreatment outcome. In cases were lesions or broken
instruments were involved, almost 95% remained unchanged when they were observed
for 6 months or more. When teeth are asymptomatic or have only small apical lesions,
95% of the time no change occurs.
• Sundqvist, Sjogren et al 1998: Case series - Bacterial analysis of failed RCT and ReTx
outcomes.
• 75% Success.
• Two factors that were shown to have a negative in uence on the prognosis are the
presence of infection at the time of root lling and the size of the perapical lesion.
• It also showed that periapical healing was rather slow in some cases; requiring 4-5
years for full resolution.
• The common recovery of E. faecalis from the root canals of teeth in which previous
treatment has failed is notable. E. faecalis appears to be highly resistant to the
medicaments used during treatment.
• Bacteria found in root- lled teeth was predominantly gram-positive microorganisms,
with approximately equal proportions of facultative and obligate anaerobes.
• Teeth with infections of an untreated canal typically have a polymicrobial ora with
approximately equal gram-negative and gram-positive bacteria and are dominated
by obligate anaerobes.
• Demonstrated that 75% of cases with previous RCT and persisting PA lesions can
be successfully managed with endodontic retreatment.
• The initial size of the periapical lesions appeared to have an in uence on the
outcome of treatment. The mean size of all initial lesions was 4.2 mm (range, 2–13
mm). The initial mean size of the lesions that healed was 3.7 mm (range, 2–6.5
mm); the initial mean size of the lesions that persisted was 5.6 mm (range, 2.5–13
mm). The difference in size between the lesions that healed and those that did not
heal was statistically signi cant at p = 0.034. Teeth with larger lesions had a poorer
prognosis than teeth with smaller lesions.
• Of the 50 cases that could be followed-up, most (37) were lled within 0.5 to 2 mm
from the radiographic apex. Nine were lled ush with the apex, and four had root-

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 lling excesses of less than 1 mm. There was no statistical difference in outcome
with respect to the root- lling level.
• Fabrio, Gorni, Gagliani 2004: (2-yr success evaluated on 452 teeth).
• Overall success for Root canal morphology respected (RCMR) was 86.8% and 69%
for Root Canal Morphology Altered (RCMA).
• For single canal teeth, success was 83% for RCMR and 48.7% for RCMA.
• For premolars, 87.2% for RCMR and 50.3% for RCMA.
• For molars, 87.1% for RCMR and 44.1% for RCMA. Teeth without PA lesions had a
success of 89.5%, while those that had a lesion had a success of 61.7%.
• In the RCMR group, teeth with lesions showed a slight but not statistically
signi cant difference. In the RCMA group, teeth with lesions had a signi cantly
lower success than teeth without lesions.
• 47% success If canal anatomy has not been respected (zipped, transported,
ledged)
• 87% success If the anatomy has been respected
• Fristad, Molven, Halse 2004: IEJ.
• 85% success at 10-17 yrs.
• 95% success at 20-27yr.
• Late periapical changes, with more successful cases, were recorded when a 10-17-
year follow-up after root canal treatment was extended for another 10 years.
Persistent asymptomatic periapical radiolucencies, especially those with over ll,
should generally not be classi ed as failures, as many of them will heal after an
extended observation period.
• Farzaneh, Abitol, Friedman et al 2004: Toronto Study Phase I and II: Orthograde
Retreatment:
• 4-6 yr outcome. 34% recall.
• This study suggested that apical periodontitis, although a strong predictor, was
secondary to preoperative perforation and root lling quality, and to postoperative
restoration, in predicting the outcome of retreatment.
• 93% of the entire study samples were asymptomatic or fully functional.
• 81% were classi ed as healed. 19% were classi ed as diseased (20 teeth).
• de Chevigny, Basrani, Farzaneh, Abitbol, Friedman 2008: The Toronto Study Phase 3
& 4: Orthograde retreatment.
• 82% 4-6 yr success rate (94% survival) of re-tx.
• The quality of the previous root lling, presence of a perforation, and apical
periodontitis/PA radiolucency were identi ed as outcome predictors.
• 41% recall rate.
• IF no AP: 93% success, 96% survival.
• IF AP: 80% Success, 93% survival
• Salehrabi, Rotstein 2010:
• 5-year SURVIVAL rate of re-tx is 89% (similar to the Delta Dental studies on
NSRCT by Salehrabi & Rotstein 2004 and Lazarski 2001). n = 4744
• Anterior teeth: Of 964 anterior teeth, 896 (93%) were retained, 122 (13%) had
additional procedures, whereas 842 (87%) did not undergo any additional
procedures after orthograde retreatment
• Premolars: Of 858 premolar teeth, 762 (89%) were retained, 129 (15%) had
additional procedures, whereas 729 (85%) did not undergo any additional
procedures after orthograde retreatment

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 • Molars: Of 2922 molar teeth, 2565 (87%) were retained, 439 (15%) had additional
procedures, whereas 2483 (85%) did not undergo any additional procedures after
orthograde retreatment
• Hepworth, Friedman 1997: Ortho retreat combined with retro retreat success 20%
higher than surgery alone. Combining apical surgery with retreat is about 81%
• Kvist, Reit 1999: JOE. RCT. The purpose was to observe any systematic difference
between orthograde and retrograde retreatments by random assignation to a cohort of
endodontically "failed" cases. At 12 month recall signi cantly higher healing rate was
observed for surgically retreated cases. At the 48 month recall no difference was found
in the healing rate. Surgical RET seems to result in more rapid periapical bone ll, but
also may imply a higher risk of “late failure”
• Kvist, Reit 2000: Signi cantly more patients reported discomfort after surgical
retreatment than after nonsurgical procedures. Patients were found to be more subject
to postoperative discomfort when teeth were retreated surgically as compared with
nonsurgically. Swelling and discoloration of the soft tissues were the main reasons for
patients to be absent from work, a behavior only observed after surgical retreatment.
The indirect costs are higher if cases are retreated surgically rather than nonsurgically.
• Yoldas et al 2004: n=218. Eight patients from the 1-visit group and 2 patients from the
2-visit group had are-ups. There was a statistical difference between the groups (P \
.05). Two-visit root canal treatment was more effective in completely eliminating pain
than 1-visit treatment of previously symptomatic teeth (P \ .05).Two-visit endodontic
treatment with intracanal medication was found to be effective in reducing postoperative
pain of previously symptomatic teeth and decreased the number of are-ups in all
retreatment cases.
• Gutta Percha Removal
• Comparin, Souza, Silva et al 2017: JOE. The aim of this randomized clinical trial was
to evaluate the in uence of rotary or reciprocating retreatment techniques on the
incidence, intensity, duration of postoperative pain, and medication intake. No
statistically signi cant difference was found among the 2 groups in relation to
postoperative pain or analgesic medication intake at the 3 time points assessed
(P > .05). Multivariate analysis showed a signi cantly higher incidence of pain after
24 hours when preoperative pain was present and a signi cantly longer duration of pain
for men than women independently of the retreatment technique used. The reciprocating
system and the continuous rotary system were found to be equivalent regarding the
incidence, intensity, duration of postoperative pain, and intake of analgesic medication.
• Jorgensen et al 2017: JOE.
• This ex vivo study aimed to evaluate the ef cacy of retreating GuttaCore and warm
vertically condensed gutta-percha in moderately curved canals with 2 different
systems: ProTaper Universal Retreatment and WaveOne. Eighty mesial roots of
mandibular molars were used in this study.
• The WaveOne Primary le underwent more separations and was unable to remove
gutta-percha as ef ciently as the ProTaper Universal Retreatment les. Also, canals
obturated with GuttaCore were retreated more ef ciently and with fewer le
separations than the canals obturated using continuous wave of warm gutta-
percha.
• Yilmaz, Ozyurek 2017: JOE. We compare the amount of debris extruded from the apex
during retreatment procedures with ProTaper Next, Reciproc, and Twisted File Adaptive
les. Within the limitations of this in vitro study, all groups were associated with debris
extrusion from the apex. The RCP le system led to higher levels of apical extrusion in

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 proportion to the PTN le system. In addition, there was no signi cant difference among
groups in the duration of the retreatment procedures.
• Martins et al 2017: JOE. Micro-computed tomography study. The aim of this study was
to evaluate the effectiveness of ProTaper Next and Reciproc systems in removing lling
material from oval root canals using sonic or ultrasonic irrigation as additional cleaning
methods. None of the retreatment protocols completely removed the lling material from
the root canals, and there was no signi cant difference between the instrumentation
systems or between root thirds assessed in terms of the average volume of remaining
lling material (P > .05). Likewise, no signi cant difference was observed between the
additional cleaning methods in any of the root canal thirds assessed (P > .05). The
ProTaper Next and Reciproc systems were equivalent with respect to effectiveness in
removing lling material regardless of the additional cleaning method used. The
additional cleaning methods were also equivalent and did not improve the removal of
lling material signi cantly.
• Alves, Siqueira et al 2016: JOE. The rotary multiple-instrument system was more
effective and faster than the reciprocating single-instrument approach in removing
previous root canal llings. As for the Reciproc group, it was observed that the larger
instrument promoted signi cantly better results. The adjunctive nishing instrument XP-
Endo Finisher signi cantly improved lling material removal.
• Rossi-Fedele, Ahmed 2017: JOE. Systematic Review.
• None of the protocols investigated was able to fully remove root canal lling
materials.
• Reciprocating and rotary methods have a similar ability in removing root lling
material.
• Only hand instrumentation was not associated with iatrogenic errors.
• Hybrid protocols are likely to improve cleanliness.
• Root llings are never fully removed. The mean percent total valued of residual
material ranged from 43.9% to 0.02%, with the vast majority of studies reporting
values less than 10%. When comparing retreatment les versus conventional les,
no advantages were found for the former, whereas the use of hybrid techniques and
larger diameters of preparation likely improve cleanliness. Hand instrumentation is
the only technique not associated with iatrogenic errors. Rotary and reciprocating
techniques exhibit similar abilities in removing root lling material. Solvents could
enhance root canal penetration of les but may hinder cleaning. The role of
irrigation agitation is controversial.
• The application of different instrumentation protocols can effectively, but not
completely, remove the lling materials from the root canal system. Only hand
instrumentation was not associated with iatrogenic errors. Reciprocating and rotary
systems exhibited similar abilities in removing root lling material. Retreatment les
performed similarly to conventional ones. Solvents enhanced penetration of les but
hindered cleaning of the root canal. The role of irrigant agitation was determined as
controversial.
• Canakci, Ustun et al 2016: JOE. This study evaluated the amount of apically extruded
debris in the retreatment of curved root canals using different nickel-titanium (NiTi)
systems: the ProTaper Universal Retreatment, Mtwo Retreatment, D-Race Retreatment,
R-Endo Retreatment, and Reciproc (VDW) systems. In the retreatment of curved root
canals, the Reciproc system extruded signi cantly more debris than the rotary
retreatment NiTi systems. In addition, the ProTaper and Mtwo retreatment systems

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 extruded signi cantly more debris than the R-Endo and D-Race systems. The Reciproc
system was signi cantly faster than the rotary retreatment systems.
• Dincer, Canakci 2015: IEJ. Compare the amount of debris extruded apically during root
canal retreatment using ProTaper, Mtwo and Reciproc instruments with hand H- les.
Use of the reciprocating single le system resulted in the extrusion of signi cantly less
debris compared with the full-sequence rotary NiTi instruments and hand ling. Use of
the ProTaper and Reciproc instruments required less time for retreatment procedures
than use of the Mtwo or H- le.
• Colaco, Pai 2015: Evaluated the ef ciency of manual and rotary GP removal.
techniques. Rotary techniques were more ef cient than manual techniques in GP
removal. Overall, d-RaCe retreatment system was most ef cient, whereas manual use of
H- les and system B was least ef cient. All techniques showed GP remnants in the
canal and radiographs failed to show these remanants.
• Topcuoglu, et al 2014: JOE. The aim of this study was to evaluate the amount of debris
extruded apically during the removal of root canal lling material using ProTaper, D-
RaCe, and R-Endo nickel-titanium (NiTi) rotary retreatment instruments and hand les.
All retreatment techniques caused the apical extrusion of debris. Hand les produced
signi cantly more debris when compared with ProTaper, D-RaCe, and R-Endo rotary
systems (P < .05). There was no statistical difference between the ProTaper, D-RaCe,
and R-Endo retreatment systems (P > .05). The ndings showed that during the removal
of root canal lling material, rotary NiTi retreatment instruments used in this study
caused less apical extrusion of debris compared with hand les.
• Wilcox, Krell 1987: All methods of removal leave debris in the canals. Sealer accounts
for the greatest percentage of the debris. You can’t get all GP out of the canal.
(Chloroform and les with US le attachment didn't remove all of the AH26. Roth's 801
easier to remove.)
• Wilcox & Juhlin: It may be prudent to use mechanical means to remove as much of the
Therma l gutta-percha as possible before a solvent is used in retreatment.
• Takahashi 2009: All teeth have GP remnants during retreatment. Re-tx with ProTaper
without chloroform was faster. (As opposed to Ferreira with pro les, but that was with
curved roots)
• Bernardes et al 2016: Used micro-CT to quantitatively evaluate the amount of residual
lling material after using several techniques to remove root llings with and without
ultrasonic activation and to analyze the cleanliness of the root canal walls and dentine
tubules with scanning electron microscopy (SEM).3 groups: Reciproc Rotary, ProTaper
Un Retreatment Files and hand les/gates-glidden used. Conclusion None of the
instrumentation methods were able to completely remove root lling material. Ultrasonic
activation improved the removal of root lling material in all groups.
• Wilcox 1987, 1989: Examined RC walls after heat, les, chloroform, US for Roths 801
vs AH26. All techniques incompletely cleaned walls; AH26 more dif cult to remove than
Roths.
• Wilcox 1991: Since re-instrumented canals usually enlarge in the same direction as the
rst instrumentation, retreating one’s own failure is unlikely to debride areas previously
undebrided. if you go to the same angle you won't x the problem in the retreatment and
always try to get straight line access.
• Metzger 1995: JOE. Removal of overextended gutta-percha root canal llings in
endodontic failure cases. A procedure for the removal of an overextended root canal
lling is presented. First, the gutta-percha is softened and removed to a distance of 2 to
3 mm short of the apex. Second, the remaining gutta percha is removed by a Hedstrom

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 le. The le is extended 0.5 to 1.0 mm beyond the apex, rmly engages the gutta-
percha and is slowly removed.
• Removing GP: Ultrasonic, Safe End Burs, Touch and Heat, Retreatment les,
Chloroform. Try to remove the GP mechanically before using chloroform. Using
chloroform following 1 ml syringe technique (Donnelly) After adding chloroform use
paper point to resorb the dissolved GP.
• Post Removal
• Glick 1986: rec use of 3 Hedstrom les to braid around post
• Krell 1984; Ngai 1986: rec use of ultrasonic les to enlarge canal space around post/Ag
points/separated instrument. Key point- often need to rst start with 1/2 round bur (or
Muller Pulp Chamber Bur with extra long shaft) or hand le prior to US les
• Berbert & Filho 1995: Ultrasonics can reduce force needed to remove posts
• Johnson & Leary 1996: Ultrasonic removal of Paraposts takes 16 min
• Chloroform Use
• McDonald 1992: Okay to use chloroform (Vapors below OHSA levels, FDA has not
proven that chloroform is a human carcinogen. Review on the safety of chloroform as it
is used in dentistry
• Edgar, Marshall, Baumgartner 2006: Chloroform has antimicrobial properties against
E. faecalis. Matched teeth prepped, infected, obturated. Then Saline irrigant used in one
and chloroform in the other. Positive cultures were more in saline group for S1 (after GP
removal) and S2 (after apical enlargement).
• Kaplowitz: tested 5 solvents; only chloroform dissolved GP completely
• Tamse 1986: GP Solvents: chloroform > xylene >> Endosolv-E (Tetrachloroethylene) >
orange turpene oil, Halothen, eucalyptol.
• Carpenter 2014; showed the ef cacy of chloroform in dissolving MTA based sealers like
MTA Fillapex and regaining patency in retreatment cases lled with MTA sealers.
• Hansen 1998: Relative ef ciency of solvents used in endodontics. Eucalyptol,
eucalyptus oil, orange oil, chloroform, and xylene were used to remove gutta-percha and
several different types of sealers. Only chloroform removed AH-26.
• Chutich: Chloroform safe for patients. Risk assessment of the toxicity of solvents of
gutta-percha used in endodontic retreatment. Compared chloroform, xylene, or
halothane and it is proposed that the use of any of the aforementioned solvents used in
the retreatment of root canals would pose negligible risk to the patient.
• Silver Points
• Seltzer 1972: All silver cones removed from failed RCTs were moderately to severely
corroded. Silver cones corrode and are cytotoxic. corrosion products of silver sul des,
silver sulfates, silver carbonates, and silver amine sulfate amid hydrates are cytotoxic;
sulfur comes from sulfur containing amino acids. Silver points are soft and should not be
touched directly with US
• Goldberg: no correlation of corrosion and failure; poor chemomechanical debridement
• Techniques to remove silver points
• Krell: ultrsonics with hedstrom
• Ruddle: ultrasonics with IRS
• Can US post removal cause any problem
• Davis, Gluskin, Chambers 2010: 20 sec dry US to post can cause 10 d C or more
increase in root surface temp. Injurious heat transfer during post removal with
ultrasonics in 20 seconds! Air or water or endo ice equally effective at cooling at rest. It
takes less time to cool than heat. (10sec on, 10sec off) (10degrees C is injurious per

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 Eriksson1983 rabbit study). Teeth with posts mounted in thermal baths with
thermocouple.
• Dominici, Eleazer: > 15 sec caused high root surface temps
• Huttula, McClanahan: irrigate with ultrasonics reduced temp well below that which can
cause bone damage
• Therma l carrier removal
• Betrand: C-soln and hand les/hedstroms
• Baratto: Pro les at 300rpm
• Wolcott, Hicks: System b 225 deg and hand instruments
• Royzenblat and Goodell: rotary instruments
• Russian Red
• Gound: Resorcinol-Formaldehyde resin: 10% sodium hydroxide cause polymerization
• Krell: Use US
• Hartwell: no solvent works; NaOCl works best
• Stabholtz, Friedman: Before doing re-tx there are couple of questions you should ask: 1) Is
it worth damaging a successful restoration in order to gain access to the root canals? 2) Is it
necessary to retreat a case just because it seems radiographically unsatisfactory and 3) what
are the chances of improving the lling by retreatment? 4) What are the chances of success
in cases where previous treatments failed, especially when no apparent reason can be
suggested for failure?
• Stabholtz, Friedman strategies for retreatment: 1) In case of non properly lled cases you
can use hand les to remove the gutta percha. 2) The more condensed the root lling, the
more dif cult it is to remove it. 3) Restorations of poor quality, particularly those with poor
marginal adaptation or secondary caries, should be removed for retreatment to be later
remade. A satisfactory restoration should be retained, being either perforated, with
subsequent repair, or removed, with subsequent re-cementation. 4) In curved roots the gutta
percha should be dissolved to allow resistance-free negotiation of the curves and prevent
ledging or perforating the root canal. In straight roots gutta-percha can be removed with
rotary endodontic instrumentation. 5) In root canals that were prepared and lled considerably
short of their apices, particularly the curved ones, it should be assumed that ledges may have
formed at the apical end of the preparation. To prevent carrying the ledges further in such
cases, forceful removal of the gutta-percha should be avoided and it should be dissolved 6)
Coronal ends of silver cones that extend into the pulp chamber should be preserved and
used as handles to pull out the cones. They are visible in radiographs, except with amalgam
cores. You can use grasping pliers (steiglitz), le and solvent and indirect ultrasonic. 7) In
removing hard cement use ultrasonic and vibration or drilling with surgical bur half round bur
8) Dissolving gutta-percha is advocated whenever it is well condensed and in curved roots,
particularly when the obturation terminates short of the apex and at the curve 9) The use of
solvents eliminates the need for excessive force during the negotiation of the gutta-percha
obturated canals. Such force can lead to undesired transportation of the canal space. 10)
Removal of gutta-percha with rotary instruments is indicated only in straight canals and those
in which the gutta-percha appears to be well condensed. 11) The removal of the material
should not result in a change in the canal morphology, so that the objectives of endodontic
therapy can be maintained.
• Stamos 1988: Use ultrasonic tips to remove ZnPO4 cement
• Bergenholtz 1979: Group being re-tx for prosthetic indication (ie, not failing) still had 6%
failure rate
• Metzger 1995: described removal of overextended GP cone by careful engagement with
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 • Feldman & Solomon 1974: Describes use of Trephan burs, beroptics and hollow needles to
remove separated instruments from the canal
• The highest rate of success in retreatment cases is when the failure is due to missed canals
which can be cleaned and shaped
• Therma l Carrier Removal
• Therma l is an endodontic obturator consisting of a solid carrier coated with alpha-phase
gutta-percha. After heat softening the gutta-percha and inserting into the root canal, the
carrier is sectioned and becomes incorporated into the gutta-percha. The carrier was
originally made of metal, but plastic carriers are used in the current product.
• Ben Johnson 1978: Developed therma l technique
• Ibarrola: removal of therma ll in retreatment cases is easy using K le and chloroform.
• Hayakawa 2010: ProTaper Retreatment Files are useful for removing Therma l Plus
plastic carriers. Among them, the D1 instrument has an active cutting tip that facilitates
initial penetration into a gutta- percha lling. The greater taper of this instrument (9%)
may also facilitate prompt binding to the carrier and canal wall. These design features
may favor ef cient removal of the carrier. It was also suggested that removal of carrier is
easier in cases with smaller tip and taper.
• Wolcott, Himel & Hicks 1999: Used System B HeatSource (faster than chloroform):
Use heated System B plugger (225C) to insert 10- 15mm for 5-8 sec. Then insert #50
and #55 NiTi les on B & L sides of Thermo ll obturator (while GP is still
thermoplasticized). Apply rm apical pressure and CW rotration, remove les and carrier
together. (Be careful: melting point of plastic carrier =300C)
• Tulsa: Work down obturator as far as possible with small les and chloroform. And then
insert #20 or #25 Pro le .04 taper at 2,000 RPM to spin down further and hopefully
withdraw the obturator
• Bertrand 1997: Hand les with chloroform can remove Thermo ll obturators
• RCT ReTx Outcomes Summary
• Ng et al 2011: 80% Success RCT ReTx , 95% survival at 4 yrs (equal to to initial RCT)
• Friedman: IF no AP: 93% success, 96% survival. IF AP: 80% Success, 93% survival
• Salehrabi: 89% survival at 5 years
• Torabinejad: 83% success at 4-6 years (systematic review and M/A)
• Gorni, Gagliani: 87% if RC morphology respected, 47% if not
• He, et al 2017: 90.4% success. n=63. 2yr recall. Mand 1st molars. Resilon in 1/2 cases.
• Success of ReTx
• (Moven, Halse 1988; Sjogren 1990; Friedman 1995 (n=569) )
• No PARL: 89-100%
• PARL: 56-71%
• If initial RCT or RCT ReTx not healing what could be the cause?
• Nair, Sjogren, Figdor, Sundqvist 1999: OOO. This report describes 6 cases that
demonstrate persistent periapical radiolucent lesions after conventional root canal
treatment. Six teeth that had conventional root canal treatment or re-treatment with
nonresolving periapical radiolucencies underwent periapical surgery. Biopsies were
obtained and analyzed descriptively by correlative light and transmission electron
microscopy for general features and microbial ndings. Three ndings were identi ed:
periapical lesions with persisting infection in the apical root canal system (2 cases); a cyst
(1 case); and periapical healing by scar tissue formation (2 cases). Conclusions. These
results con rm previous observations that associated factors in the failure of endodontic
treatment include persistent intraradicular infection and periapical cysts. In addition,

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 unresolved periapical radiolucencies may occasionally be due to healing by scar tissue,
which may be mistaken as a sign of failed endodontic treatment.

Apical Barrier/Apexi cation

• Treatment aimed at barrier creation is referred to as apexi cation.
• What materials can be use as apical barrier?
• Torabinejad: MTA
• Andreasen: suggested 4 mm MTA
• Weisenseel: CaOH: 2mm thickness for creating barrier
• Frank; Cvek: CaOH
• Tronstad: Use of dentinal shavings
• Yoshida: Dentin powder and bovine bone
• Jeeruphan, Hargreaves et al 2012: Better outcomes with MTA vs CH. Also looked at
REGEN methods which had a better outcome than MTA and CH.
• MTA
• MTA: 75% Portland Cement, 20% bismuth oxide, 5% gypsum. White MTA has less iron,
aluminum, magnesium. Portland cement: tricalcium silicate, tricalcium aluminate,
dicalcium silicate, tetracalcium aluminoferrite.
• Bartols et al 2017: JOE. n=4 teeth. The aim of this study was to elucidate whether the
use of mineral trioxide aggregate (MTA) in endodontic therapy in human teeth leads to
the same regeneration of the apical tissues as observed in animals. Histologic healing of
the human periodontium to MTA corresponds to the healing pattern shown in animal
studies. Cementumlike tissues were formed on the surface of MTA, which proves
regeneration of the periodontal ligament.
• Parirokh, Torabinejad 2010: MTA is composed of calcium, silica, and bismuth oxide. It
has a long setting time, high pH, and low compressive strength. It possesses some
antibacterial and antifungal properties, depending on its powder-to-liquid ratio.
Disadvantage: potential staining. Conclusions: MTA is a bioactive material that
in uences its surrounding environment.
• Pace et al 2014: case series. Using MTA as an apical plug in necrotic, immature teeth
with open apices can have an almost 100% success rate after 10 years. In immature
teeth, since mechanical debridement is minimal, a short-term application of Ca(OH)2
could improve disinfection without reducing root strength. However, if periapical drainage
through the canal can be controlled and the canal dried during the rst visit, the use of
Ca(OH)2 can be avoided. In immature teeth with thin roots, MTA does not negatively
impact dentin and it has a slight positive effect on root strength. Extrusion of MTA in this
study did not affect the healing outcome. 94% success at 10 yrs. The difference between
5 and 10 years was not signi cant.
• Mente 2013: The success rates of teeth with open apices in this study suggest that the
orthograde placement of MTA apical plugs is an appropriate treatment option for open
apex teeth. The presence of preoperative apical periodontitis was identi ed as the most
important prognostic factor, and success rates remained consistently high, even after
follow-up periods of more than 4 years. (Teeth without preoperative periapical
radiolucencies showed an overall healed rate of 96% compared with 85% for teeth with
preoperative periapical radiolucencies. )
• Shabahang, Torabinejad, Boyne 1999: Mineral trioxide aggregate produced apical
hard tissue formation with signi cantly greater consistency (compared to Ca(OH)2 and

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 osteogenic protein-1). Based on the results of this investigation, placement of an apical
barrier using MTA is an alternative to conventional long-term calcium hydroxide therapy.
( rst proposed MTA as a barrier, used OP1 and Ca(OH)2, 13/14 MTA plugs developed a
barrier, created PA lesions in Dogs, used OP1 bone morph protein)
• Moore et al 2011: Provides clinical data that white MTA can be successfully used as an
apical barrier. Compares ProRoot vs Angelus. Provides the rst report that white MTA
can cause staining even if placed apically. Purpose: To investigate the clinical and
radiographic success of apical barrier placement, using white MTA ProRoot and white
MTA Angelus in children with non-vital, immature permanent incisors. The mean follow-
up time was 23.4 months. There were no statistically signi cant differences in clinical or
radiographic outcomes between the two groups. The overall clinical success and relative
radiographic success rate was 95.5%. Statistically signi cant reduction in periapical
pathosis was shown over time in both groups (P < 0.05). A signi cant relationship was
identi ed between non-divergent apical anatomy and ideal positioning of the MTA plug in
all teeth (P = 0.04). Interestingly, coronal discoloration was observed in 22.7% of teeth
following white MTA placement. Conclusions: Apical barrier placement using both white
MTA ProRoot® and white MTA Angelus after an initial calcium hydroxide dressing
showed similar favorable clinical and radiographic outcomes.
• Witherspoon 2008: MTA can be used as an apical barrier. One appt has same success
as when pre-incubated with Ca(OH)2. so you can do one visit with MTA. No diff was
found between 1 and 2 visits with MTA. High success rate. 93.5% 1 visit. 90.5% 2 visit.
• Holden, Schindler 2008: The use of MTA as an apical barrier results in high success,
similar to long term Ca(OH)2 apexi cation. However, it can be accomplished in fewer
visits, and the tooth can be restored/reinforced much sooner. High success rate.
• Belobrov, Parashos 2011: JOE. This case report describes the treatment of tooth
discoloration caused by white MTA (WMTA) used for the management of a complicated
crown fracture. Upon access, the WMTA was completely discolored. After it was
removed, a signi cant color change was observed in the tooth crown, which was further
improved with internal bleaching. The tooth remained vital, and a dentin bridge was
con rmed clinically and radiographically. The recommendation to use WMTA for vital
pulp therapy in the esthetic zone may need to be reconsidered. Should discoloration
occur with the use of WMTA, the technique described may be used to improve the
esthetics.
• Silujjai, Linsuwanont 2017: Success of MTA apexi cation and revasc were 80.8% and
76.5% To evaluate clinical and radiographic outcomes of MTA apexi cation and
revascularization in terms of success and continued root development and to analyze
factors in uencing outcome. MTA apexi cation and revascularization provide reliable
resolution of disease and tooth retention in necrotic, immature permanent teeth, but
neither provides satisfactory and predictable further root development.
• MTA vs Endosequence Root Repair Material
• Sedgley 2011: JOE. compared different root repair materials. Endodontic repair
materials are used for various procedures that include pulp capping, apexi cation, root-
end llings, and perforation repairs. Successful placement of the materials is facilitated
by optimal access to the repair site and trouble-free handling properties. Of the repair
materials available, mineral trioxide aggregate (MTA) possesses several advantageous
properties that include good sealing capability, biocompatibility, and antibacterial activity.
EndoSequence Root Repair Material (ERRM) is a bioceramic material delivered as
premixed moldable putty (ESP) or as preloaded syringeable paste (ESS) with delivery

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 tips for intracanal delivery of the material. Sedgley found that MTA and ERRM have
similar antibacterial ef cacy against clinical strains of E. faecalis.
• Chen: MTA and Brasseler Root Repair Material contain calcium silicates which were
shown to to promote cell differentiation, to have osteoconductive effects, and also to
reduce in ammation of human dental pulp cells (hDPCs)
• Herschberg, Hartwell 2013: OBJECTIVE: To compare the sealing ability of ProRoot
mineral trioxide aggregate (MTA) to the sealing ability of EndoSequence Bioceramic
Root Repair Material (ES-BCRR) putty using a bacterial leakage model.
Results: the ES-BCRR group 93% of samples leaked, compared to only 20% of samples
in the MTA group. There was a signi cant difference in leakage between the
experimental groups (P < .0001). Also there were no signi cant differences between the
negative control group and MTA group and between the positive control group and ES-
BCRR group (P = 1.00).CONCLUSION: Samples in the ES-BCRR group leaked
signi cantly more than samples in the MTA group.
• Antunes, Rocas, Siqueira 2015: MTA and BC-RRM Putty had similar sealing ability.
• Tran, Glickman 2016: No differences were observed among the other 3 materials.
Conclusions: All materials showed comparable marginal adaptation at the anatomic apex
when used for orthograde obturation of open apices. Application of BC Sealer before the
delivery of BC RRM-FS Putty enhanced the quality of adaptation coronal to the apex.
Comparative analysis of calcium silicate-based root lling materials using an open apex
model. Intro: Many new calcium silicate–based root lling materials have emerged in the
market; however, their performance in the orthograde obturation of an open apex has
not been evaluated. The purpose of this study was to compare the marginal adaptation
of ProRoot MTA, NeoMTA Plus, and Endosequence BC RRM-Fast Set Putty (BC RRM-
FS; Brasseler USA, Savannah, GA) after orthograde placement in roots with open
apices. M&M: Palatal roots used. 6mm of materials placed. 3mm of root resected.
ResultsThere were no signi cant differences in marginal adaptation among the 4 groups
at the level of the anatomic apex (P = .175). BC RRM-FS + BC Sealer had a signi cantly
smaller gap size after 3-mm root end resection compared with the other 3 groups
(P < .01).
• Taha, Alwedai 2016: Biocompatibility evaluation of endosequence root repair paste in
the CT of rats. Results: EndoSequence provoked severe in ammation after 1 week,
which was signi - cantly different from MTA and control (P < .05), with fragmented
particles and foreign body reaction. MTA showed tissue-tolerance features almost
comparable to control. Conclusions: EndoSequence was signi cantly more irritating than
MTA and control at 1 and 3 weeks in terms of severity and extent of in ammation. After 6
weeks it displayed more biocompatible characteristics.
• Chen, Setzer, Kim 2016: JOE. The purpose of this study was to investigate odontogenic
and osteogenic cell adhesion, proliferation, and survival on the surface of a newly
developed bioceramic material (EndoSequence Root Repair Material [RRM]; and
compare it with mineral trioxide aggregate (gray MTA). A potential role of extracellular
signal-regulated kinase (ERK) signaling in the RRM/MTA-induced cellular activities was
also investigated. Bottom Line: MTA and RRM are both biocompatible and promote cell
proliferation and survival in an ERK- dependent manner.
• Beatty, Svec 2015: JOE: Biodentine and Endosequence discolor bovine tooth structure
to a perceptible degree. At 8 weeks, this was signi cantly more than ProRoot MTA.
• Kohli, Setzer, Yamaguchi et al 2015: The purpose of this in vitro study was to evaluate
coronal tooth discoloration induced by bioceramic materials, EndoSequence RRM, and
BioDentine in comparison with other materials used during endodontic treatment such as

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 gray MTA, white MTA, triple antibiotic paste, and AH Plus sealer. Bioceramic-based
materials BD, RRM, RRMF, and AH+ did not induce perceptible color change in the tooth
structure when left in the pulp chamber for extended periods of time (6 months). Coronal
tooth discoloration caused by TAP, GMTA, and WMTA was statistically signi cant.
Clinical studies are needed to further con rm these ndings.
• Holland: removal of debris is the most important phase of apexi cation treatment.
• Frank 1966: Described apexi cation techniques with Ca(OH)2. Nonvital immature teeth
treated with CaOH developed four different types of apical barrier formation. Was the 1st to
describe technique. 4 repair types: 1- periapex closes with de nite recession of the root
canal. 2- obliterated apex develops without any change in canal space. 3- no radiographic
evidence of development in canal or apex; an apical stop is evident clinically. 4- calci c bridge
forms coronal to apex that is detectable radiographically.
• Katebzadeh N, Dalton BC, Trope M. 1998: Strengthen the cervical portion of immature teeth
with composite during apexi cation to prevent fracture. Also found metal posts, opaque posts
and resin bonded posts improved fracture resistance over unrestored teeth.
• Cvek 1972: Tx necrotic teeth with incompletely formed apices with Ca(OH)2. 95% success
for apical closure.
• Pace et al 2014: found that 94% of immature teeth treated with MTA apexi cation were
healed 10 years post op
• Alobaid et al 2013: Found apexi cation and REGENDO treatments provide statistically
equivalent results.
• Eleazer : Root contains enough moisture to help with set of MTA
• Mente et al 2013: reported that success rates for apexi cation are lower in the presence of
preoperative apical periodontitis. Also, mentioned that success rates were less favorable if
treatment were performed over several visits.
• Yates: If you replace the CaOH early you will have better result for apexi cation. The mean
barrier formation time was 9 months. The presence of infection did not affect the barrier
formation but the width of the open apex was a determinant factor.
• Trope 2008: Ingle’s Text book. MTA has been used to create a hard tissue barrier quickly
after disinfection of the canal. Calcium sulfate can be pushed through the apex to provide a
resorbable extraradicular barrier against which to pack the MTA.
• Felman, Parashos 2013: JOE. All teeth discolored when restored with wMTA, which was
most prominent in the cervical third of the crown. The presence of blood within the canal
adjacent to the setting wMTA exacerbated the discoloration (P = .03). CONCLUSIONS:
wMTA induces the gray discoloration of the tooth crown, and the effect is compounded in the
presence of blood. (it was placed in the coronal aspect of the root)
• Apexi cation Outcomes
• Pace et al 2014: 94% at 10 years with MTA
• Cvek: 96% Ca(OH)2 long term
• Witherspoon & Ham 2001: 93.5% 1 visit, 90.5% 2 visit; MTA
• Jeeruphan, Hargreaves et al 2012: (looked at survival. CH/MTA risk of cervical
fracture) Outcomes for teeth treated with apexi cation methods are in uenced by
presence of preop periodontitis and number of tx visits)
• CH Apexi cation: 77%
• MTA apexi cation: 95%
• REGEN: 100%
• Options to manage open apex in immature permanent teeth:
• Proposed Apical Barriers:
• Tronstad;Holland: Dentin Chips

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 • Weissenseel: Ca(OH)2
• Hicks, Pelleu: Ca(OH)2
• Torabinejad: MTA
• Witherspoon: MTA 93% 1 visit, MTA/Ca(OH)2 90.5% 2 visit
• Holden: MTA/GP 85% healed, 100% functional success
• Knapp, Marshall: Master apical impression
• Branchs, Trope: Regen
• Ree, Schwartz 2017: JOE.
• This case series evaluated the long-term clinical outcome of nonvital immature teeth
treated with mineral trioxide aggregate (MTA) as an apical barrier and an adhesive
restoration with or without a ber post. Eighty-three teeth in 72 patients were treated by
the rst author with an apical MTA plug and an adhesive restoration of composite resin
and in 45 of the 83 teeth 1 or more ber posts. All of the patients had been referred to
the rst author’s private endodontic practice with at least 1 immature tooth with signs of
pulpal ne- crosis and subsequent apical periodontitis that had been caused by a variety
of traumatic dental injuries. Three teeth presented had dens invaginatus.
• Of 83 teeth, 69 teeth in 60 patients were available for follow-up after 5 to 15 years (recall
rate = 83%). The mean follow-up time was 8.29 years.
• No teeth were lost because of a root fracture.
• Ninety-six percent (66/69) of the recalled teeth were characterized as healed.
• Based on periapical radiographs and clinical examination, 96% of teeth treated with the
MTA barrier technique and adhesive restorations were characterized as ‘‘healed’’ and
were in function after 5 to 15 years (mean = 8.29 years).
• These results indicate that this is a viable and predictable treatment approach for the
long-term success of nonvital immature teeth.
• Mozynska et al 2017: JOE. Systematic Review. The results indicated that some materials
showed a strong potential for staining, including gray and white MTA Angelus (Londrina, PR,
Brazil), gray and white ProRoot MTA (Dentsply, Tulsa, OK), and Ortho MTA (BioMTA, Seoul,
Korea). Individual study results showed that Biodentine (Septodont, Saint Maur des Fosses,
France), Retro MTA (BioMTA), Portland cement, EndoSequence Root Repair Material
(Brasseler USA, Savannah, GA), Odontocem (Australian Dental Manufacturing, Brisbane,
Australia), MM-MTA (Micro Mega, Besancon Cedex, France), and MTA Ledermix (Riemser
Pharma GmbH, Greiswald-Insel Riems, Germany) were materials with the smallest staining
potential. This review clearly showed that some calcium silicate–based cements have a high
potential for staining hard tissue. On the other hand, some showed only a small change in
color, which was nearly invisible to the human eye (ΔE <3.3). However, more long-term
clinical studies are needed.
• Cicek, Bilgin et al 2017: JOE. Effect of mineral trioxide aggregate apical plug thickness on
fracture resistance of immature teeth. lab study. The negative group showed the lowest
fracture resistance compared with the other groups. The 3-mm apical plug group showed the
highest fracture resistance (P < .05). No signi cant differences were found between the 3-mm
and 6-mm apical plug groups (P > .05). MTA should be used as an apical plug instead of root
canal lling material to increase the fracture resistance of immature teeth.

Surgery
• Iqbal et al 2007: Surgical endodontic therapy seeks to resolve periapical pathology when
orthograde endodontic treatment is not feasible.

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 • Guttman. Harrison. Kim : indication of Surgery: IF YOU CAN NOT SOLVE THE PROBLEM
OR RETREATMENT IS IMPOSSIBLE; THEN SURGERY MIGHT BE INDICATED.
• Abou-Rass: Surgical endodontics is avoided unless retreatment is rst attempted or the
quality of previous root canal therapy is acceptable or the canal obstructed
• Molven, Halse 1991: Used to support retreatment before apical surgery. (All failures in this
study were associated with retro lled teeth as opposed to NSRCT then surgery)
• Surgery case selection based on Arens text book: In case that canal is not negotiable, there
is an extrusion of material, severe curve, severe calci cation, extraradicular bio lm. In these
case you may consider surgery before re-tx. In case of Root is excessively short, Tooth is
non-restorable don’t consider surgery.
• Rud, Andreason 1972: Developed radiographic criteria to evaluate healing after apical
surgery.
• Baumgartner, Harrison 1977: JOE. Demonstrated bacteremias in patients undergoing
surgical root canal therapy. (Tooth extraction produces an extremely high incidence of
bacteremia. Surgical endodontic therapy produces an extremely high incidence of
bacteremia. Re ection of a full mucoperiosteal ap causes an extremely high incidence of
bacteremia. Curettement of the periapical tissues produces a signi cant incidence of
bacteremia, but a lower incidence than ap re ection. Nonsurgical endodontic therapy
produces a very low incidence of bacteremia.)
• Dragoo 1996: J of Perio and Rest Dent. Recommends Geristore for submarginal restoration.
The ideal subgingival restorative material should be biocompatible, dual-cure, have
adhesiveness, uoride release, radiopacity, compactness, surface hardness, insolubility,
resist microleakage, low coef cient of thermal expansion, and low cure shrinkage. All
materials showed biocompatability with adjacent tissues. Although none of the material met
all the criteria Geristore was the most favorable.
• Dragoo 1997: Clinical and histo study in humans. It is possible to get epithelial and
connective tissue adhesion, during wound healing, with resin-ionomer restoratives such as
Dyract, Geristore, and Photac-Fil.
• Hirsh et al 1979: Through-and-through lesions and the absence of a retro ll are the most
important factors for healing subsequent to apical surgery. Maxillary anteriors, patients <35,
lesions ≤5mm, and intact buccal bone also play a positive role in prognosis. Granulomas
seem to heal better than cysts, but this may be due to the fact that in general, granulomas are
correlated with smaller bone destruction.
• Marshall, Pappin 1985: Methylene blue dye can be a useful aid in endodontic surgery. The
differential staining of methylene blue outlines roots, delineates root dentin from bone,
demarks isthmuses between two canals in a single root, and outlines cysts for enucleation.
• Kim 2011: One of the challenging situations following a failed RCT tooth is that a tooth should
be retreated nonsurgically or surgically, or should the tooth be extracted and replaced with an
implant-supported restoration or xed partial denture. In a cost-effectiveness analysis by Kim
(JOE, 2011) it was mentioned that Endodontic microsurgery was the most cost-effective
approach followed by nonsurgical retreatment and crown, then extraction and xed partial
denture, and nally extraction and single implant–supported restoration. A single implant–
supported restoration, despite its high survival rate, was shown to be the least cost-effective
treatment option based on current fees. Kim and Solomon: Surgery is more cost effective
than nonsurgical retreatment.
• Moiseiwitsch, Trope 1998: Never jump to surgery if retx is applicable
• Wesson and Gale: Sensory disturbances of a variable duration in the lower lip is evident in
aprox 20% of all patients following mandibular molar surgery. Only 1% of pts retain a
permanent defect.

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 • Jannson et al 1997: After an observation time of 1 year, 85% of the healing patterns were
classi ed as successful or uncertain. Teeth within the surgical area showed a signi cant loss
of clinical attachment during the observation period. The mean clinical attachment loss in
teeth with an unsuccessful healing was 0.85 mm and differed signi cantly from successfully
healed cases (mean 0.15 mm).
• Kim S and Kratchman 2006: JOE. 20 page review on endo surgery. Winter 2017. Topics
include, local anesthesia, pre-op & post-op surgical hemostasis, bone wax, epinephrine
cotton pellet, ferric sulfate, thrombin, bevel, root-end resection, Isthmus, mental foramen
managment, sinus management. The advantages of microsurgery include easier identi cation
of root apices, smaller osteotomies and shallower resection angles that conserve cortical
bone and root length. In addition, a resected root surface under high magni cation and illumi-
nation readily reveals anatomical details such as isthmuses, canal ns, microfractures, and
lateral canals.
• Suture Removal: 2-3 Days
• Microscope is key to endodontic microsurgery
• To completely see all the critical anatomical details of the root surface it has to be
stained with methylene blue.
• In endodontic surgery, however, local anesthesia has two distinct purposes:
anesthesia and hemostasis. Thus, a high concentration of vasoconstrictor containing
anesthetic, e.g. 1:50,000 epinephrine, is preferred to obtain effective vasoconstriction.
Currently recommended maximum dosage of epinephrine 1:50,000 in local
anesthetics 2% lidocaine for adults for good hemostasis is 5.5 cartridges to reach 0.2
mg
• Epinephrine binds alpha-1, alpha-2, beta-1, and beta-2 adrenergic receptors located
on the vascular smooth muscles. The alpha-1 receptors are adjacent to sympathetic
nerves that innervate blood vessels. The alpha-2 receptors are distributed throughout
the vascular system and are generally bound by circulating catecholamines.
Fortunately, the predominant receptors in the oral tissues are alpha-receptors (95%),
and the number of collocated beta-2 receptors is very small (5%). Thus, the drug’s
predominant effect in the oral mucosa, submucosa and periodontium is
vasoconstriction.
• Hemostatic Agents:
• Bone Wax: Not frequently used in endo surgery. The hemostatic mechanism has
essentially a tamponade effect. The wax, when placed under moderate pressure,
plugs all vascular openings. The plug is formed partly of blood and partly of bone
wax, which prevents further bleeding. The method of action is purely mechanical
and does not affect the blood clotting mechanism. Following root-end lling, the
wax should be removed. Studies have shown that bone wax causes a foreign
body reaction if left in the surgical site
• Epinephrine Cotton Pellet (Racellets): Racellet #3 contains .55mg epi. Racellet
two contains 1.15mg epi. The combination of both epinephrine and pressure has
a profound effect that usually results in immediate and profound vasoconstriction.
Epinephrine causes local vasoconstriction by acting on the alpha-1 receptors
present in the blood vessels wall, and the pressure aug- ments this hemostatic
potential. The epinephrine cotton pellet also pre- vents debris from getting lodged
into the bone crypt during root-end preparation and root-end lling.
• Ferric Sulfate: (Viscostat, Astringedent). The agglutinated proteins form plugs
that occlude the capillary ori ces. Thus, in contrast to traditional hemostatic
agents, ferric sulfate affects hemostasis through a chemical reaction with blood.

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 Care must be taken, however, not to leave ferric sulfate solution in the bone
because it has signi cant adverse effects on osseous healing
• Thrombin: It is a potent dry powder that acts rapidly in an intrinsic fashion to clot
the blood brinogen directly.
• The once popular semilunar ap design and the Lüebke-Ochsenbein ap design are
no longer recommended. With the current method the base of the ap is as wide as
the top, and the vertical incisions follow the vertical blood vessel alignment. This
facilitates nearly scar-free healing while still providing more than adequate access to
the surgical site. In the sulcular full-thickness ap design, the main disadvantage is
recession and shrinkage of the papilla. Velvart proposed the PBI for the marginal
mucoperiosteal ap to prevent or minimize loss of interdental papillary height.
• With the microsurgery technique, mono lament sutures are removed within 48 to 72 h
for best results. This is enough time for reattachment to take place and the suture
removal is easy and painless. After 72 h, the tissues tend to grow over the sutures,
especially with mucosal tissues, and thus removal of sutures may be more
uncomfortable. The 5 0 and 6 0 sutures are ideal for microsurgery and polypropylene
sutures (6/0 or 7/0) are also popular. The use of 4 0 silk sutures is no longer
acceptable because the silk is braided and causes accumulation of plaque causing
delayed healing or secondary in ammation
• the smaller the osteotomy, the faster the healing
• A major purpose of using the microscope during the osteotomy is to clearly distinguish
the root tip from the surrounding bone. The root has a darker, yellowish color and is
hard, whereas the bone is white soft, and bleeds when scrapped with a probe
• Elimination or minimization of the bevel angle is one of the most important bene ts of
microsurgery.
• Root resection: Our anatomical study of the root apex shows that at least 3 mm of the
root-end must be removed to reduce 98% of the apical rami cations and 93% of the
lateral canals
• Apical surgery entails not just the removal of the diseased tissue or the root tip, but
most importantly resealing of the root canal system.
• The isthmus is most frequently observed between two root canals within one root.
Thus, the majority of posterior teeth contain an isthmus. At the 3-mm level from the
original apex, 90% of the mesiobuccal roots of maxillary rst molars have an isthmus,
30% of the maxillary and mandibular premolars, and over 80% of the mesial roots of
the mandibular rst molars have one
• The ideal root-end preparation can be de ned as a class 1 cavity at least 3 mm into
root dentine, with walls parallel to and coincident with the anatomic outline of the root
canal space. Ultrasonics tips also made cleaner and deeper root-end cavity
preparations, aiding retention of the root-end lling material and disinfection by
removing infected dentin.
• Root end lling materials. MTA: the main ingredients are tricalcium silicate (Ca3Si),
tricalcium aluminate (Ca3Al), and tricalcium oxide (Ca3O2).
• Mental Foramen Management: Generally, the mental foramen is located below and
between the apices of the second premolar and the mesiobuccal root of the rst
molar. More precisely, its most common location is inferior to the crown of the second
premolar (62.7%) (107), and it is always larger than it appears on the radiograph. It is
also essential that the vertical releasing incision is long enough to expose the mental
foramen after a careful dissection. Once the foramen is identi ed, a retractor is placed

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 to protect the foramen and under the microscope, a horizontal groove is cut just above
the foramen
• Sinus management: step is to prevent any solid particles, such as cotton pellets, root-
end lling materials, and so forth, from entering the sinus cavity. The sinus is capable
of ushing away large amount of uid but not solid materials. Thus, ushing of the
sinus with saline poses no problem. If the size of the sinus perforation is very small, a
cotton pellet tied securely to a suture can be used as a barrier. If the perforation is
large, however, a thin iodine gauze strip can be inserted into the sinus, leaving the
end outside for ready retrieval, before continuing the surgery. The postoperative
preparations should include a prescription of an antibiotic, such as cipro oxacin or
amoxycillin for 1 wk, postoperative instructions to sleep with the head slightly
elevated, to avoid nose blowing and to expect possible nose bleeds.
• Classi es cases: A through F.
• Pain and swelling can expect to be minimal.
• Craig, Harrison 1993: JOE. Demineralization or resected root ends with citric acid enhances
cementogenesis, the key to dentoalveolar healing, by removing the smear layer barrier and
exposing the organic component (collagen brils) of resected cementum and dentin.
• Oberli, Bornstein, Von Arx 2007: OOOOE. Retrospective study. Conventional periapical
radiographs cannot be used as predictors for perforation of the maxillary sinus during
periapical surgery. However, radiographs with a speci c distance between the periapical
lesion and the sinus oor point toward a very low risk of accidental sinus perforation during
periapical surgery.
• Forouzanfar, Van der Waal et al 2008: RCT. n = 100. Conclusion: Ice compression and
compression are superior in reducing postoperative pain and discomfort after surgical third
molar removal when compared with no treatment. Compression and ice compression were
not signi cantly different in terms of reducing post-surgical pain. Bottom Line: The application
of ice and compression for 45 minutes after apical surgery may decrease post op pain.
• Hargreaves, Khan 2005: Endo Topics. Review of anesthesia & hemostasis in surgery.
• Anesthetics can be safely used to reduce both peri- and post-operative pain. Anesthetics
including lidocaine and articaine can be used to obtain effective anesthesia of the soft
and hard tissues. Post-operative pain can be effectively reduced for up to 48 h after
surgery by the administration of long-acting anesthetics.
• The control of hemostasis begins with the preoperative assessment of the patient’s
medical history and current medication usage. Effective intra-operative hemostasis often
requires the slow in ltration injection of one to two cartridges of local anesthetic
containing 2% lidocaine with 1:50000 epinephrine and waiting for tissue blanching as a
sign of effective vasoconstriction.
• Excellent surgical skills including careful design of aps, handling of tissues, positioning
of retractors, etc, to reduce trauma to the tissue. Hemostasis in the surgical crypt can be
managed by any of several techniques, including resorbable sponges containing
epinephrine or direct application of ferric sulfate. Treatment with epinephrine appears to
have minimal systemic effects and avoids the potential delayed wound healing that
might occur if not all of the ferric sulfate is removed. A reasonable alternative, particularly
for patients at cardiovascular risk, might be the local application of a calcium sulfate
paste on the surgical crypt.
• Good tissue approximation with appropriate suturing techniques combined with 5–10min
of wound compression is effective for promoting post-operative hemostasis in otherwise
healthy patients.

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 • Many NSAIDs are recommended for post-operative pain control. As NSAIDs (including
aspirin) might in uence post-operative bleeding via inhibition of cyclooxygenase, it is
reasonable to consider whether NSAIDs alter post-operative hemorrhage. Although data
for endodontic surgical procedures are not available, a systematic review of the effect of
NSAIDs on post- operative bleeding after tonsillectomy concluded that non-aspirin
NSAIDs have no signi cant effects on clinical bleeding, whereas aspirin does
signi cantly increase post-operative bleeding.
• Surgical Healing
• Harrsion 1991: JOE. Review. Healing progresses through several stages, including
clotting and in ammation, epithelial healing, connective tissue healing, maturation and
remodeling.
• Kramper, Heuer et al 1984: JOE. Animal Study. Evaluated the clinical and histological
features of healing of three common types of surgical ap designs used in periapical
surgery. Conclusion: In ammatory changes persist for longer time in the semilunar and
intrasulcular incisions than in the submarginal incisions. This chronic in ammation
delayed healing of the incisional wounds. When compared with the submarginal incision,
the semilunar and intrasulcular incisions demonstrated a delay in histologically
observable mature collagen bers and its realignment with adjacent tissues. Entrapped
epithelial islands were observed in the intrasulcular incisions. Loss of alveolar bone,
accompanied by gingival recession or an increase in the length of the epithelial
attachment, will occur with the intrasulcular incision. Scar formation occurs with the
submarginal and semilunar incisions, while very little, if any, visible scarring occurs with
the intrasulcular incision. From the evidence presented, it would appear that the
submarginal incision is the ap design of choice in periapical surgery when not
contraindicated by the anatomical location of the lesion or by insuf cient attached
gingival tissue (2mm minimum). However, this study was carried out under
nonpathological conditions.
• Harrison, Jurosky (Summary: incisional + Disectional)
• Day 1: Thin epithelial seal. Blood clot evident. PMN the predominant in ammatory
cell. Periosteal necrosis.
• Day 2: Multilayered epithelial seal. Type III collagen production. Macrophages the
predominant in ammatory cell.
• Day 4: Clot replaced by granulation tissue, Type I collagen production. Osteocyte
proliferation from endosteum.
• Day 14: Normal Sulcular epithelium. Woven bony trabeculae occupy the wound.
New periostium
• Day 28: Maturing bony trabeculae occupy the wound.
• Harrison, Jurosky 1991: Wound Healing (incisional). Sulcular incision leaves perio
tissue attached to cementum which speeds up repair and prevents epithelial down
growth. Few differences between sulcular and submarginal healing. Submarginal design
showed less predictable results (marginal epithelial barrier forms at 48-72 hrs, so
remove sutures in about 2-3 days)
• First 24 hrs: clotting and in ammation: brin clot/PMNs, then macrophages
• 2-3 days: epithelial healing: 4 d for intrasulcular incision vs 2-3d for vertical incision
• 3-5 days: CT healing; broblasts
• 5-7 days: Maturation and remodeling: Collagen
• Harrison, Jurosky 1991: Wound Healing (Dissectional). (Tissue tags in dissectional
wound okay to leave b/c there is no surface necrosis of bone. If removed, prevents early
reattachment of apped tissue to cortical bone). * Scaling of root attached tissue and

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 tags on the cortical bone should be avoided to allow rapid reattachment. Cortical
retained periosteal tissues exert some protective in uence which prevents necrosis of
surface lamellae in underlying cortical bone. * The elevated periosteum does not survive
the ap re ection, its cambium layer do not survive but becomes depolymerized and
reforms laters. * Crestal bone osteoclastic activity occurs following submarginal and
rectangular aps. However osteoblastic repair occurs and crestal bone height is not
altered.
• Day 1: have clot present;
• Day 2-3: have PMNs, macrophages, broblasts.
• Day 4: Type I collagen in new BV, broblasts predominate, osteoclasts.
• Day 14: have brous CT, new periosteum, no loss of alveolar crest
• Day 28: have completely normal tissue
• Harrsion, Jurosky 1992: Wound Healing (osseous excisional). No osteoclastic activity
in excisional wounds. The endosteal tissue play the major role in osseous excisional
wound healing. Periosteum does not function in bone repair until crypt lled with woven
bone
• Day 1-3: Coagulum lls defect (macrophages, PMNs, broblast-like cells)
• Day 2-4: Outgrowth of granulation tissue from PDL, in ammatory cells (PMNs,
macrophages replaced with broblasts)
• Day 4: endosteal tissue proliferation into coagulum (macrophages/PMNs replaced
by broblasts)
• Day 14: new periostium forms; osteoblastic activity; new woven bone trabeculae
occupy 80%. (proliferating granulation tissue replaces coagulum, woven bone,
osteocytes, dense brous CT separates ap from bone)
• Day 28: lesion lls with maturing new trabecular bone (and a functioning periosteum
was active in repair of cortical plate)
• 4-5 months: Maturation/remodeling complete
• *(Periosteum does not survive ap re ection; don’t curette cortical retained tissue;
crestal bone levels will reduce following surgery)
• Prognositic Indicators
• Ultrasonic vs Bur Preparation; Magni cation; Retro ll Material; Periodontal Status; Initial
vs Revision Surgery.
• Setzer, Kim S et al 2011: preop attachment loss negatively impacts surgical outcomes.
• Von Arx et al 2012: found that mesiodistal bone levels were a signi cant predictor of
surgical outcomes.
• Song 2013: demonstrated that a buccal cortical plate height greater than 3mm
signi cantly improved clinical outcomes.
• Lui et al 2014: Periodontal probing depth, in addition to bone height was shown to
in uence outcomes, with probing depths of less than 3mm associated with more
favorable outcomes.
• Kim, Song, Kim S et al 2008: found that isolated endodontic lesions had signi cantly
better outcomes, with a success rate of 95%, compared with endodontic-periodontal
lesions, which had a success rate of 78%.
• Second Surgery/Surgery Revision
• Song et al 2011: Found that revision surgery had a 92% success rate if modern
techniques were used during the revision procedure
• Gagliani, Gorni 2005: 5 yr longitudinal study. Found 59% success rate in revision
surgery. (1st time surgery 86% healed)

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 • Peterson and Gutmann 2001: IEJ. Systematic Review. Found that revision surgeries
had 39% success rate
• Von Arx et al 2007: JOE. 1st time surgery 84% success (n=173), 2nd time surgery
77.8% success (n=18)
• Sutures/Suture Removal
• Kim – remove after 2-3 days (after epithelial healing occurs). mono lament, gauge 5 x 0
or 6 x 0 to provide rapid healing
• Stropko: recommends suture removal at 24-48hrs (from lecture)
• Harrison and Jurosky: epithelial seal at 2 days, epithelial healing occurs 4 days for
intrasulcular incisions, 2-3 d for vertical
• Selvig - rapid increase of collagen content of granulation tissue at day 4
• Selvig 1998: braided sutures attract more bacteria than mono lament. rapid increase in
collagen content of granulation tissue at day 4 (remove sutures after 4 days). (Braided
sutures conduct bacterial migration to a greater extent. Gore-Tex showed less bacterial
ingrowth. Epithelial ingrowth was unexpected, but was presumable stimulated by the
lack of a tight t between the suture thread and the surrounding tissue (contact inhibition
not allowed to function). Silk elicits an extensive tissue reaction and bacterial ingrowth.
Gore-Tex exhibited less in ammation and more advanced repair than silk and Vicryl.
Tissue response intraorally is distinct from that at other sites due to the presence of
moisture and bacteria. Conclusion: Bacterial invasion of suture track is common,
regardless of the suture material. This is more prominent for silk. Synthetic mono lament
suture (Gore-Tex) elicited mild in ammation. Sutures placed intraorally produce a
prolonged tissue response likely due to continual in ux of bacteria. Chromic gut is
absorbed rapidly and unpredictably in an environment characterized by moisture and
infectious potential.)
• Becker: Vicryl (polyglactin) sutures produced little in ammatory response compared to
polypropylene, silk or gut.
• Harrison: Sutures immobilize the surgical ap and promote healing by primary intention
• Velvart and Peters:
• Flaps should be re-approximated without tension to avoid impairment of ap
circulation.
• Mono lament synthetic sutures are recommended for this purpose, as they are less
traumatic, discourage in ammation and promote less bacterial adhesion than
multi lament sutures.
• Smaller suture gauges, particularly the 6-0 and 8-0 sutures, are recommended to
avoid tissue necrosis and minimize scarring.
• The suture technique selected, either simple-interupted or continuous, should be
appropriate for the clinical situation.
• Sutures should be removed 48-96 hours following surgery.
• Exposure of Surgical Site/Flaps
• Velvart, Peters 2005: Endo topics. Excellent review on ap design, incision, elevation
and retraction. (winter 2017)
• Intrasulcular incisions extend through the gingival sulcus and expose the entirety of
the root structure for inspection.
• Submarginal incisions (oschenbein-luebke technique) require a minimum of 2mm of
attached gingiva and do not expose the cervical third of the root.
• Semilunar aps incise into the alveolar mucosa and expose a minimal amount of
root structure for visualization; consequently, they are infrequently used in
endodontic surgery.

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 • horizontal incision may cause slight shrinkage along the gingival crest that leads to
recession.
• Vreeland and Tidwell: For submarginal incisions, scalloping is often recommended to
provide landmarks during ap closure.
• Velvart 2002: IEJ. To prevent scarring by submarginal ap designs developed papilla-
based incisions recommends atraumatic handling of soft tissue as a required note for
success of this ap design. This technique involves two incisions at the base of the
papilla: one a shallow incision to a depth of 1.5 mm through epithelium and connective
tissue and a second incision directed to the crestal bone. This method prevents thinning
of the coronal aspect of the ap, which is important for healing. Velvart states that the
papilla-based incisions not only prevent recession of papilla, but also cause minimal
scarring.
• Kramper, Heuer et al 1984: Intrasulcular incisions are associated with more post op
recession and scarring than other incision types. Scalloped submarginal incisions are
associated with better epithelial closure than submarginal or semi lunar incisions but do
pose a risk for scar formation. reported the loss of alveolar bone of approximately 0.5 to
1 mm with intrasulcular incisions.
• Sargolzaie et al 2013: RCT. showed signi cant decrease in gingival margin height using
a full thickness ap compared to a papilla-based technique at a one-month recall.
However, no statistical difference was present in bleeding on probing, attachment loss,
probing depth, or the gingival index between the two approaches.
• Von Arx 2007: compared 3 ap designs in 185 patients. Full thickness intrasulcular,
submarginal (oschenbein-leubke) and Papilla Based Incision. PBI was superior in
regards to scarring and loss of papilla, intrasulcular had most recession, submarginal
had most scarring. showed the loss of papillary height to be greatest with a sulcular
incision compared to papilla-based or submarginal incisions.
• Velvart, Ebner 2004: (papilla based incision represents a modi cation of the
intrasulcular technique and permits visibility of the entire root surface, while mitigating
the risk for recession by preserving the interdental papillae). Comparison of long-term
papilla healing following sulcular full thickness ap and papilla base ap in endodontic
surgery. In the short as well as long-term the papilla base incision allows predictable
recession-free healing of the interdental papilla. In contrast, complete mobilization of the
papilla displayed a marked loss of the papilla height in the initial healing phase although
this was less evident 1 year postoperatively. In aesthetically relevant areas the use of
PBI is recommended, to avoid opening of the interproximal space, when periradicular
surgical treatment is necessary.
• Taschieri et al 2016: The aim of the present controlled clinical trial was to compare 2
incision techniques, papilla base incision (PBI) and sulcular incision (IS), evaluating
changes in papilla and recession height over a 12-month period. The PBI and IS
approaches in endodontic surgery showed similar results in terms of papilla height
preservation and recession changes. Papilla preservation aps could safely be applied
to endodontic surgery procedures. The results obtained (12 months after surgery) with
this approach in terms of papilla height changes and gingival recession are expected to
be similar
• Moiseiwitsch 1995: JOE. For surgery on mandibular premolars he suggests placing the
vertical incision distal to the surgical site so that good access is achieved without
stretching the content of the mental foramen
• Kim S 2001: suggests placing a vertical incision mesial to the rst premolar when
performing a surgery on the mandibular rst molar. The reason is to avoid the mental

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 foramen and also to avoid the muscle attachment at the second premolar, which heals
poorly if damaged. The rectangular ap is advantageous in the anterior area (especially
when the roots are long) and provides better access than the triangular ap. Since the
vertical incisions are parallel to the larger vessels, the blood supply is minimally
disrupted. Argues against making the ap wider in the base (i.e., trapezoidal ap design)
due to inadequate supporting evidence and also due to the cutting of the blood vessels
obliquely rather than parallel to them.
• Harrison, Jurosky 1991: Did not nd any difference in the healing of intrasulcular and
submarginal incisions.
• Tarnow et al 1992: J Perio. Described the relationship between crestal bone height and
the interdental contact point. They examined 288 human papilla and discovered that if
the distance between the contact point and the crestal bone was 5 mm or less, the
papilla usually lls the embrasure space 100% of the time. At distances of 6 mm and 7
mm, the percentage decreases to 56% and 27%, respectively.
• Membrane barriers/Bone Grafts/Guided tissue regen
• Garrett, Hartwell et al 2002: For the majority of apical surgical procedures with the loss
of only one cortical plate, the use of membranes or grafts provides no advantages over
traditional surgical techniques.
• When are membrane and grafts bene cial:
• Lin et al 2010: Membranes and grafts may improve outcomes for treatment of
through-and-through lesions
• Tsesis et al 2011: Large periapical defects
• Douthitt, Gutmann, Witherspoon 2001: apicomarginal defects
• Tsesis et al 2011: For these indications (through and through lesions, large
periapical defects, apicomarginal defects) resorbable membranes are favored over
nonresorbable membranes and bone grafts may not be necessary except to hold
the membrane in place.

• Bashutski and Wang JOE 2009:

• Grafts fall under several broad categories. Graft Activity:
• Osteogenic grafts contain cells capable of depositing bony matrices (Intrinsic
capabilities for bone regeneration).
• Osteoinductive grafts release mediators that signal the host to induce new
bone formation (induce surrounding tissue to deposit bone).
• Osteoconductive grafts serve as a scaffold on which bone host cells can grow.
• Grafts can be further categorized by source.
• Autogenous grafts are derived from the host.
• Allografts from a genetically dissimilar member of the same species.
• Xenografts from another species altogether.
• Alloplasts: inert materials that serve as a scaffold for new bone.
• Bone grafts are often used with membranes (resorbable and nonresorbable)
• Caffesse and Quinones 1992: The combined use of bone graft and membrane is
referred to as guided tissue regeneration, a procedure that facilitates tissue regeneration
to its original form. Effective in perio surgery of 2 and 3 wall intrabony deffects and class
II furcations.
• Apaydin, Torabinejad 2004: The results indicated that placement of calcium sulfate in
osteotomy sites after periradicular surgery does not signi cantly affect periradicular
healing.

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 • Lin, Chen, Ricucci, Rosenberg 2010: (Purpose: to provide a better understanding of
the use of membrane barriers and bone grafts in PA surgery. Molecular and cellular
biology not fully understood. Membrane: prevents apical migration of gingival epithelium
and CT cells. No conclusive evidence that membrane placement has better long-term
outcome than control group. Just b/c a hole doesn’t necessarily need a bone graft. Blood
clot best thing to ll the space.) A review article on tissue regeneration: Tissue
regeneration by using membrane barriers and bone grafting materials in periapical
surgery is an example of tissue engineering technology. Membrane barriers and/or bone
grafts are often used to enhance periapical new bone formation. However, the periapical
tissues also consist of the periodontal ligament (PDL) and cementum. For regeneration
of the periapical tissues after periapical surgery, one of the important requirements is
recruitment and differentiation of progenitor/stem cells into committed pre-osteoblasts,
pre-PDL cells, and pre-cementoblasts. Homing of progenitor/stem cells into the wounded
periapical tissues is regulated by factors such as stromal cell–derived factor 1, growth
factors/cytokines, and by microenvironmental cues such as adhesion molecules and
extracellular matrix and associated noncollagenous molecules
• Tsesis 2011: Guided tissue regeneration techniques have been suggested as an adjunct
to endodontic surgery in order to promote bone healing. Tsesis (JOE, 2011) in a meta
analysis declared that GTR techniques may improve the outcome of bone regeneration
after surgical endodontic treatments of teeth with certain lesions.
• Would you consider guided tissue regeneration?
• Pecora & Kim – If > 10mm; through & through; endo-perio defect
• Tsesis – M/A showing GTR sig better for through & through lesions and trending
better for > 10 mm diameter lesions
• Suda – Calcium sulfate was effective in bone regeneration
• Sotosanti- 80/20 mix of DFDBA/CaSO4
• Von Arx- membrane NOT enhance new bone formation compared to ap
readaptation alone
• Replantation
• Cho et al 2017: JOE. This retrospective study aimed to assess clinical outcomes after
intentional replantation of teeth with periodontal involvement and to explore potential
predictors of outcomes.
• Cumulative improved rates declined from 89% at 1 year to 68% at 4 years. A Cox
proportional regression model identi ed the patient's age (P = .049; hazard ratio,
2.552) and the number of preoperative periodontal pockets with a depth
≥6 mm (P = .041; hazard ratio, 2.523) as predictors of outcomes in the replantation
of periodontally involved teeth.
• Periodontal involvement is not an absolute contraindication to intentional
replantation. The teeth with 1 preoperative periodontal pocket ≥6 mm and the
subjects aged ≤40 years had 2.5 times and 2.6 times lower probability of failure,
respectively, than the teeth with 2 pockets and the subjects aged >40 years.
Therefore, these factors need to be carefully considered for intentional replantation.
• Bender and Rossman: Reported a success rate of 81% for 31 intentional replantation
cases.
• Torabinejad et al 2015: The rst systematic review comparing the survival of implant-
supported crowns and intentionally replanted teeth. The survival rate of implant
supported crowns is 97%. The survival rate of intentionally replanted teeth is 88%. The
survival of intentionally replanted teeth was by no means too low, and it should be

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 considered as an alternative treatment modality in selected cases for patients who like to
save their natural dentition.
• Cho, Friedman et al 2016: This prospective cohort study of contemporary intentional
replantation suggested a cumulative 12-year retention rate of 93% and healed rate of
77% after 3 years. Healing occurred 1.7 times more frequently in teeth replanted within
15 minutes. Although most complications occurred within 1 year after replantation,
follow-up should extend for at least 3 years to capture late complications. 159 teeth.
• Jang et al 2016: The purpose of this study was to investigate the prognostic factors for
the clinical outcome of intentionally replanted teeth with a C-shaped canal. The
cumulative survival rate of intentionally replanted teeth with a C-shaped canal was
83.4% at 4 years and 73.0% at 11 years postoperatively. extraoral time (#15 minutes vs
>15 minutes) and retro lling material (ProRoot MTA [Dentsply, Tulsa, OK] vs others)
were signi cantly associated with tooth survival (P < .05). Conclusions: Extraoral time
exceeding 15 minutes and the use of ProRoot MTA as a retro lling material were
signi cantly associated with a lower survival of intentionally replanted teeth with C-
shaped canals. With improved clinical procedures based on an understanding of the
prognostic factors, intentional replantation would be a favorable treatment option for
treating teeth with a C-shaped canal.
• Kratchman S. 1997: Intentional replantation. Dent Clin North Am 1997. Best review of
this procedure. Success rates of 80-85% should be seen: 1. It used to be advocated
always to curettage the socket after removing the tooth. Now clinicians know not to
touch the walls of the socket and only to aspirate gently the apical region if needed. 2.
After removal, the tooth used to be held in gauze, desiccating viable PDL cells. Now the
tooth is kept bathed in an emesis basin lled with HBSS, which maintains the viability of
the PDL for 30 minutes. 3. All clinicians were able to do was visual inspection; now the
microscope is used to illuminate and magnify the working area. 4. Splinting was done on
every case; now clinicians rarely splint after replantation. 5. Narcotic pain medication
was prescribed routinely; now clinicians premedicate with chlorhexidine rinse, anti-
in ammatory medication, and sometimes antibiotics, rarely using narcotics. With
increased understanding of the periodontium and improved techniques, replantation
should no longer be viewed as a treatment of last resort, but rather a successful
treatment alternative. (Key tx recommendations for this procedure include atraumatic
extraction, minimal handling of the root surface, an extraoral time of less than 10 min,
biocompatible apical lls and non rigid postoperative splinting.)
• Autotransplantation: provides a replacement option for missing teeth under proper
circumstances. This technique is often used to replace lost teeth in the early permanent
dentition (Cardona et al). Frequently, mandibular premolars are selected as donor teeth
due to favorable anatomic features (Jonsson and Sigurdsson). Ideally, the donor tooth
should have a partially developed root with an open apex (Lundberg and Isaksson). For
successful autotransplantation, one must atraumatically extract the donor tooth to
preserve the Hertwig epithelial root sheath and maintain the PDL cells for the recipient
site (Andreasen et al). Successful autotransplanation permits development of the donor
tooth and continued growth of the alveolar bone and associated soft tissue (Lundberg
and Isaksson).
• Kim et al 2016: Autotransplantation of a mature premolar to a molar site is a viable
treatment option showing successful results. The selection of a functional donor tooth,
adequate surgical procedures, and timely application of orthodontic forces may have
contributed to the favorable prognosis. 2 cases. 7 year follow up.

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 • Torabinejad et al compared the survival rates of autotransplanted teeth with those of
implant-supported single crowns. Meta-analysis of available data showed a weighted
mean survival rate of 89% (95% CI, 81%–94%) for autotransplanted teeth. (Article in
preparation)
• Zu a et al 2017: JOE. Case Report. Autotransplantation of mand. 3rd molar with buccal
cortical plate to replace vertically fractured mandibular second molar.
• Andreasen et al 1990: The purpose of the present investigation was to determine the
long-term prognosis of autotransplanted premolars with respect to tooth survival and
pulpal healing. The material consisted of 195 patients aged 7 to 35 years, with a total of
370 autotransplanted premolars with observation period ranged from 1 to 13 years.
Teeth transplanted with incomplete and complete root formation showed 95 per cent and
98 per cent long-term survival respectively: Pulp healing as evaluated by sensibility
testing and radiographic signs of partial pulp canal obliteration was usually veri ed 6
months after transplantation. The frequency of pulpal healing (versus pulp necrosis),
appeared to be closely related to stage of root development at time of transplantation.
Teeth transplanted with incomplete and complete root formation showed 96 per cent and
15 per cent pulp healing respectively. Another and associated factor which could equally
well predict pulpal healing was the diameter of the apical foramen of the graft. Finally, in
teeth with completed root formation, the use of bursa with internal cooling and no extra-
alveolar storage prior to transplantation seemed to increase the chance for pulpal
healing. The present study indicates, that the size of the apical foramen and possibly the
avoidance of bacterial contamination during the surgical procedure are explanatory
factors for pulpal healing.
• Hemostasis
• Scarano A 2012: Calcium sulfate was found to provide effective hemostasis. The aim of
this study was a clinical evaluation of the hemostatic effect of CaS hemi-hydrate
(CaSO4), commonly known as plaster of Paris, in endodontic surgery. Calcium sulfate
(CaS) is a simple, biocompatible material with a long history of safe use in different elds
of medicine. CaS is a rapidly resorbing material that leaves behind a calcium phosphate
lattice, which promotes bone regeneration and hemostasis. Antonio Scarano (JOE,
2012) showed the higher ef cacy of hemostasis w/ CaS compared to ferric sulfate.
• Kim: The best method of controlling hemorrhage is to establish hemostasis before ap
re ection. This is accomplished by injecting lidocaine with 1:50,000 epinephrine at
various sites in the alveolar mucosa and near the root end. The slow injection of the
solution in numerous sites within the localized operative eld should be accomplished
even with block anesthesia because the localized effect of the vasoconstrictor is more
pronounced.
• Witherspoon & Gutmann 1996: IEJ. general review on hemostasis: 3 phases: vascular
phase, platelet phase, coagulation phase
• Macphee & Cowley 1981: Vertical incisions bleed less since most vessels run parallel
to long axis of tooth
• Malamed 2012: the use of norepinephrine causes marked tissue ischemia,( it should not
be used in surgical endodontics for the purposes of hemostasis. )
• Petruson 1974: Anxiety can increase bleeding via stress-induced inc BP and inc
brinolysis
• Davenport et al 1990: J Perio. RCT. reported that homeostasis was judged signi cantly
better in 1:100,000 epinephrine containing local anesthetics compared to 1:200,000
epinephrine containing local anesthetics
• Buckley 1984: J Perio. Use lido w/ 1:50k epi. 1/2 the blood loss as lido w/ 1:100k epi

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 • Ibarrola et al 1985: Bone wax and Surgicel left in situ greatly inhibited osteogenesis and
cause a foreign body reaction. Gelfoam slowed repair of osseous defects at early
postsurgical intervals in this study but did not have any chronic effects on osteogenesis.
When Gel-foam was left in situ, complete resorption of the material was observed in two
of three 120-day specimens. (Bone wax causes an in ammatory response so not used
much anymore)
• Witherspoon and Gutmann: Need to review medical history including meds and
supplements. Can use CollaCote or Gelfoam or cellulose based products like Surgicel.
• Gutmann: Epinephrine is an effective hemostatic agent via its interaction with blood
vessel alpha receptors, producing vasoconstriction.
• Gutmann, Harrison 1994: stated that loose cotton bers left in the surgical site may
affect the root-end seal by becoming trapped between the root-end cavity preparation
and the root-end lling material. They also note that cotton bers may serve as foreign
bodies in the surgical site and may delay wound healing.
• Lindorf 1979: OOO. Can get rebound effect (reactive hyperemia) on blood ow after
injection with vasoconstrictors
• Witherspoon & Gutmann 1996: Bone wax interferes with healing, so it is
contraindicated
• Souto & Oliver 1996: Pts on coumadin tx were safe for oral sx using normal coumadin
regimen and local tranexamic acid (a potent anti - brillar
agent) post-op for 2 days
• Vickers et al: Racellet hemostatic cotton pellets containing 0.55mg of racemic epi per
pellet promote surgical hemostasis w/out risking cardiovascular effects.
• Vickers et al: Ferric sulfate also produces excellent hemostatis in surgical eld, but
must be removed or will cause a foreign body rxn (Jeansonne et al).
• Vickers, Baumgartner, Marshall 2002: The hemostatic ef cacy, as well as the
cardiovascular effects, of two hemostatic agents currently used during endodontic
surgery was examined. Use either of the agents to achieve adequate surgical
hemostasis. The hemostatic agents used were epinephrine pellets (Racellet pellets) or
20% ferric sulfate (Viscostat). Patients were assigned to one of two experimental groups.
Blood pressure and pulse rate were recorded pre- and postoperatively and at three
additional times during the surgery (root-end resection, root-end preparation, and lling).
The adequacy of hemostasis was rated by the surgical operator. Results indicated that
there is no signi cant change in cardiovascular effects when using either of these
hemostatic agents. Except in one case where ferric sulfate was the agent, both agents
produced surgical hemostasis that allowed for a dry eld for root-end lling.
• Vy, Baumgartner, Marshall 2004: the results suggest that CollaCote collagen sponges
saturated with 2.25% racemic epinephrine provide excellent hemostasis with no evident
changes in blood pressure or pulse rate. N = 48. Results showed no signi cant
difference in blood pressure or pulse rate between the experimental and control groups.
• Messer 1987: Blood loss during surgery - avg 9.5 mL/cc, which is similar to tooth
extraction. Time/duration of surgery is biggest factor.
• Lemon, Steele, Jeansonne 1993: Ferric sulfate hemostatis: effect on osseous wound
healing if left in surgical site. Signi cant adverse effects on osseous healing occurred
when ferric sulfate solution was left in situ.
• Jeansonne, Boggs, Lemon 1993: Ferric sulfate hemostatis: effect on osseous wound
healing if curettage and irrigation. When adequately curretted and irrigated from the
surgical site prior to closure, ferric sulfate did not cause persistent in ammation or delay
osseous repair in comparison to controls.

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 • Menendez-Nieto et al 2016: Hemostatic agents in periapical surgery. The outcome was
better in the aluminum chloride group than in the gauze impregnated in epinephrine
group
• Kim, Kratchman 2006: JOE. Calcium sulfate has been recommended as a hemostatic
material during periapical surgery. It serves as a physical barrier and plugs vascular
channels. It is a resorbable material
• Witherspoon, Gutmann 1996: IEJ. Ferric Sulfate is a necrotizing agent with a pH of 0.8
to 1.6. Ferric sulfate causes agglutination of blood proteins and plugging of the capillary
ori ces. When it comes in contact with vital tissues, it immediately causes color change.
Because of its low pH, this material is very cytotoxic and must be used with caution.
• Osteotomy
• Osteotomy is the removal of cortical and cancellous bone covering the root end(s) at the
site of surgery. Proper osteotomy provides access to the periapical aspects of a tooth.
Osteotomy should be performed with light stroking motions and copious saline irrigation
to maximize cutting ef ciency and minimize heat generation.
• Yu et al 2014: The use of CBCT is essential to determine the location and size of
periapical lesions, their relationship to the vital structures, and thickness of cortical bone
plates.
• Kim S and Kratchman 2006: Smaller is better and heals quicker.
• Rubinstein, Kim 1999: Microsurgical techniques currently used in surgical endodontics
allow the operator to create a signi cantly smaller-sized osteotomy compared to the
traditional technique of periapical surgery. Keep osteotomy small. state that small lesions
heal faster than large lesions.
• Boyne 1966: compared different bur types and shapes and reported a No. 6 or 8 round
bur produces smoother cut surfaces, less in ammation, and shorter healing times
compared to using a ssure or diamond bur.
• Eriksson, Albrektsson 1983: reported that the threshold for irreversible damage to the
bone is between 44°C and 47°C for one minute. During osteotomy, the use of saline
coolant is imperative to lower the temperature of the cut tissues.
• Matthews, Hirsch 2013: Conducted cadaver studies and examined the effect of
incremental and constant drilling. They found incremental drilling resulted in effective
temperature reduction and reduction of generated debris.
• Resection and Retroprep
• The purpose of root-end resection is to remove anatomic variations, correct operator
errors, evaluate and create an apical seal, and reduce fenestration of root apices. Root-
end resection involves beveling the apical portion of the root end. Root-end resection
removes the untreated apical portion of the root and enables the surgeon to determine
the cause of failure. It also provides a at surface that allows the operator to create a
root-end cavity preparation and place a root-end lling material.
• Gilheany, Figdor 1994:
• Increasing the depth of the retrograde lling signi cantly decreased apical leakage;
there was also a signi cant increase in leakage as the amount of bevel increased
(aim for 0 degree bevel).
• Studied relationship between bevel angle of root resection and required depth of
retroprep to minimize leakage: 0 degree bevel: minimal retroprep depth of 1 mm. 30
degree bevel: minimal retroprep depth of 2.1 mm. 45 degree bevel: minimal
retroprep depth of 2.5 mm. They conclude with a recommendation of 3.5 mm
retroprep depths (thus, the retroprep depth should extend coronal to the pulpal
terminus of the tubules)

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 • Green 1956: 400 Anterior Teeth. Accessory foramina 1.0-2.2mm from apex. Justi es
resection of 3mm during surgery. Distance from AF to AC: 1mm.
• Green 1960: 700 Posterior Teeth. Accessory foramina up to 2mm from apex. Justi es
resection of 3mm during surgery. Distance from AF to AC: 0.75mm
• Kim, Kratchman 2006: by resecting 3mm of root end —> 98% of apical rami cations
and 93% of lateral canals are removed. They recommend little or no beveling of the root
during root-end resection.
• Weller, Niemczk, Kim 1995: 4mm root resection of MB root of Max 1st molar will
expose a complete or partial isthmus 100% of the time; so we prep all roots between the
two canals.
• Kim S 1997 & 2005: Isthmuses.
• The isthmus is most frequently observed between two root canals within one root.
• Thus, the majority of posterior teeth contain an isthmus. At the 3-mm level from the
original apex:
• 90% of the mesiobuccal roots of maxillary rst molars have an isthmus
• 30% of the maxillary and mandibular premolars
• over 80% of the mesial roots of the mandibular rst molars have one.
• This high incidence of isthmuses in premolars and molars is an important
consideration when performing apical surgery. This is one of the reasons why
apicoectomy alone, without root-end preparation and/or root-end lling, especially in
molar teeth, usually fails.
• Baumgartner: 3mm prep with diamond coated ultrasonics —> no crack seen and
minimal bony crypt required.
• Wuchenich, Torabinejad 1994: Ultrasonics gave more parallel walls, deeper preps,
followed canals better and provided cleaner walls compared to burs.
• de Lange et al 2007: US retropreps are associated with a more favorable outcome
compared to burs.
• De Lange et al 2007: RCT. Ultra sonic pre vs bur prep. n = 399. the overall success rate
in teeth whose roots were prepared with ultrasonic tips was 80.5%. is dropped to 70.9%
when the roots were prepared with conventional burs. This clinical study showed a
signi cantly better outcome when ultrasonic tips were utilized to prepare deeper and
cleaner preparations and address anatomical dif culties. the advantages of ultrasonic
techniques outweigh the unknown clinical signi cance of the occurrence of
microfractures.
• Gorman et al 1995: JOE. reported that the root-end cavities prepared with ultrasonic
instruments showed signi cantly less smear layer compared with those made by
conventional burs.
• Layton, Marshall, Baumgartner 1996: JOE. Lab. root-end cavities prepared by
ultrasonic tips can increase the number of micro- fractures signi cantly compared to
roots that only had root-end resections. e study suggested that lower power settings may
reduce the number of micro-fractures. (Lab studies on extracted teeth. Teeth are
probably dried out and crack easier compared to teeth in a human)
• Gray et al 2000: JOE. conducted a study in cadavers and found an insigni cant number
of cracks with ultrasonic preparations.
• Tawil 2016: This clinical study evaluates the effect of ultrasonic root-end preparations
on dentinal defect creation and propagation. Conclusions: This periapical microsurgery
study showed that ultrasonic root-end preparations are safe to use on intact roots.
Eighty-four teeth were treated with periapical microsurgery using a modern microsurgical
protocol in a private practice setting. Preexisting dentinal defects can be propagated by

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 ultrasonic root-end preparations. Through the use of light-emitting diodes, dentinal
defects can be detected, special root-end management can be implemented, and more
predictable outcomes may be achieved.
• Mannocci, Pitt Ford 2005: Justify prepping M root isthmuses even if you don’t see them
b/c 50% of 2-foramen M roots have an isthmus at 3mm (only 17% have isthmus at 1mm,
so keep going)
• Andelin, Torabinejad et al 2002: Found that resection of set MTA does not diminish its
sealing ability
• Abedi, Torabinejad 1995: The results showed a signi cantly higher incidence of crack
formation in the walls of root-end cavities prepared by ultrasonic tips compared with
those made by the bur.
• Carr 1997: Dent Clin North Am. introduced retro-shaped ultrasonic tip design.
• Harrison and Todd 1980: Resection of root ends with well-condensed GP does not
adversely affect the seal, though the same is not true for silver points.
• Kaplan et al: Advocated GP llings should be burnished after resection.
• Retro lling
• Gartner, Dorn 1992: The purpose of a root-end lling is to establish a seal between the
root canal space and the periapical tissues. An ideal root-end lling material should be:
1) able to prevent leakage of bacteria and their by-products into the periapical tissues, 2)
non-toxic, 3) non carcinogenic, 4) biocompatible with the host tissues, 5) insoluble in
tissue uids, 6) dimensionally stable, 7) unaffected by moisture during setting, 8) easy to
use, 9) radiopaque, 10) nonstaining, and 11) bioinductive (promote cementogenesis)
• Torabinejad, Pitt Ford et al 1995: The main ingredients of MTA are tricalcium silicate,
tricalcium aluminate, tricalcium oxide, and silicate oxide
• Von Arx et al 2014: 5 yr f/u. n= 271. (initial n = 339) MTA vs Adhesive Resin composite.
The overall rate of healed cases was 84.5% with a signi cant difference (P = .0003)
when comparing MTA (92.5%) and COMP (76.6%). The results from this prospective
nonrandomized clinical study with a 5-year follow-up of 271 teeth indicate that MTA
exhibited a higher healing rate than COMP in the longitudinal prognosis of root-end
sealing.
• Christiansen 2009: IEJ. n = 52. The results from this RCT emphasize the importance of
placing a root-end lling after root-end resection. Conducted a RCT of the success of
smoothing GP vs MTA retro ll. 1 year followup : 52% for GP smooth, 96% success for
MTA retro l
• Torabinejad: Why MTA as retro l —> biocompatible, demonstrates the least leakage;
substrate for osseous and cementum growth, sets in the presence of moisture/blood.
MTA has been evaluated extensively for microleakage (dye penetration, uid ltration,
and bacterial leakage), marginal adaptation (SEM), and biocompatibility (cytotoxicity, tis-
sue implantation, and in vivo animal histology). Sealing ability of MTA has been shown to
be superior to that of Super-EBA and was not adversely affected by blood
contamination. Its marginal adaptation was shown to be better than that of amalgam,
IRM, or Super-EBA. MTA has also been shown to be less cytotoxic than amalgam, IRM,
or Super-EBA. Its pH, when set, is 12.5 and its setting time is three hours and 45
minutes, which is much longer than that of amalgam, IRM, or SuperEBA. e compressive
strength of MTA is reported to be 40 MPa immediately after setting, which is less than
that of amalgam, IRM, and SuperEBA, but increases to 70 MPa after 21 days, that is
comparable to that of amal- gam, IRM, and SuperEBA. Unlike other root-end ll- ing
materials that do not tolerate moisture, MTA requires moisture to set. Hydration of MTA
powder results in a colloidal gel that solidi es into a hard structure.

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 • Song & Kim 2012: 95% success for MTA vs 93% success for Super EBA. In a
prospective randomized controlled study mentioned that there is no signi cant difference
in the clinical outcomes of endodontic microsurgery when Super EBA and MTA were
used as root- end lling materials.
• Apaydin, Shabahang, Torabinejad 2004: JOE. Animal Study. (Fresh better than set
MTA). The purpose of this study was to compare the effect of fresh mineral trioxide
aggregate (MTA) with set MTA on hard-tissue healing after periradicular surgery. The
results indicated that although freshly placed MTA resulted in a signi cantly higher
incidence of cementum formation (12 of 12 versus 8 of 12, p = 0.028), there is no
signi cant difference in the quantity of cementum or osseous healing associated with
freshly placed or set MTA when used as root-end- lling material. (higher bone ll with set
mta, higher cementum with fresh)
• Gilheany, Figdor 1994: Increasing the depth of the retrograde lling signi cantly
decreased apical leakage; there was also a signi cant increase in leakage as the
amount of bevel increased (aim for 0 degree bevel). Studied relationship between bevel
angle of root resection and required depth of retroprep to minimize leakage: 0 degree
bevel: minimal retroprep depth of 1 mm. 30 degree bevel: minimal retroprep depth of 2.1
mm. 45 degree bevel: minimal retroprep depth of 2.5 mm. They conclude with a
recommendation of 3.5 mm retroprep depths (thus, the retroprep depth should extend
coronal to the pulpal terminus of the tubules) (This study evaluated the apical leakage
associated with various depths of retrograde llings placed in root apices which had
been resected at one of three different angles. Leakage was assessed with a hydraulic
conductance apparatus. Teeth were divided into groups corresponding to the angle of
apical resection (0, 30, and 45 degrees to the long axis of the root) and apical leakage
was determined following incremental increases in the depth of the retrograde lling
(Ketac Silver). Both the permeability of resected apical dentin and microleakage around
the retrograde lling material had a signi cant in uence on apical leakage.)
• Kim, Kim, Song et al 2016: This study identi ed no signi cant difference in the 4- year
success rates of MTA and Super EBA as root-end lling materials in endodontic
microsurgery. A total of 182 teeth were examined at the 4-year follow-up. The success
rate was 91.6% for MTA and 89.9% for Super EBA. (1yr/4yr outcome of MTA & Super
EBA as root-end lling materials in endodontic microsurgery. 182/260 were examined at
4 yr recall. 1 year recall: MTA 95.6% success rate, Super EBA 93.1% success rate. 4
year recall: MTA 91.6% success rate, Super EBA 89.9% success rate. Overall/combined:
1 yr 94.3%, 4 yr 89.5%. No sig diff noted between MTA and Super EBA in 4 yr success
rates.)
• Von Arx 2010: Clinical Results with Two Different Methods of Root-end Preparation and
Filling in Apical Surgery: Mineral Trioxide Aggregate and Adhesive Resin Composite.
The overall rate of healed cases was 85.5%. MTA-treated teeth demonstrated a
signi cantly (P = .003) higher rate of healed cases (91.3%) compared with Retroplast-
treated teeth (79.5%). Within the MTA group, 89.5%–100% of cases were classi ed as
healed, depending on the type of treated tooth. In contrast, more variable rates ranging
from 66.7%–100% were found in the Retroplast group.
• Compared to newer materials, amalgam is associated with more leakage (Torabinejad
et al 1995), poorer biocompatibility, more in ammation (Baek et al 2010) and poorer
outcomes (Setzer et al).
• Fischer et al: MTA provides a marked improvement over older materials. It provides a
better apical seal than amalgam, IRM or Super EBA, even in the presence of blood
(Torbeinjad et al 1994).

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 • Chong, Pitt Ford, et al 2003: The use of MTA as a root-end lling material resulted in a
high success rate that was not signi cantly better than that obtained using IRM. MTA
84% after 12 months, 92% after 24 months. IRM 76% after 12 months, 87% after 24
months.
• Baek et al 2005: MTA promotes cementum and bone coverage unlike amalgam or
Super EBA.
• Torabinejad, Kettering, Pitt Ford 1995: lab study. MTA had better adaptation/smaller
gaps compared with amalgam, Super-EBA, and IRM.
• Torabinejad, Pitt Ford, Abedi et al 1997: JOE. Monkey study. It appears that amalgam
is an unsuitable root-end lling material and its use should be discontinued because it
does not prevent microleakage and does not allow regeneration of the dentoalveolar
structure. The results of this study support the use of MTA as a root-end lling in man.
The periradicular tissues of all roots with amalgam as the root-end lling material had
moderate to severe in ammation, while only one root that had been lled with MTA
displayed in ammation, which was severe. Cementum formation was observed over the
dentinal surface of the resected root ends for both groups, but it was not seen over any
of the amalgam root-end llings. In contrast, a thick layer of cementum was present over
ve of six MTA root-end llings; an incomplete layer had partly formed over the other.
The cementum showed incremental lines; in some places periodontal bers could be
seen inserted into the new cementum.
• Frank, Glick, Weine 1992: JOE. Cohort Study. n = 96. Amalgam retro lls have a less
than ideal long term success rates. Only 57.7% success.
• Baek, Setzer, Kim S 2010: JOE. The purpose of this study was to determine the bone
regeneration potential to different root- end lling materials by evaluating the distance
between the materials and newly regenerated bone after root-end surgery. MTA showed
the most favorable periapical tissue response. From the center of the resected root
surface to the bone, the MTA group had the closest distance. The periodontal ligament
(PDL) thickness in the MTA group of our study could be considered a normal average
PDL thickness. The gap between the SuperEBA and the amalgam groups were two
times and three times wider, respectively, than in the MTA group, suggesting that MTA
promotes bone and PDL regenerative ability.
• Shinbori, Nicole et al 2015: JOE. The use of EndoSequence-BC RR as a root-end
lling material resulted in a high healing rate of 92.0% (94/113) in endodontic
microsurgery at a minimum 1-year recall examination. This evidence suggests that ES-
BCRR is a suitable root- end lling material to be used in endodontic surgery. Future
studies with a larger sample size are needed to con rm the ndings and to identify
potential prognostic factors that may impact the treatment outcome.
• Dorn & Gartner 1990: Retrospective study. 6 mon - 10y f/u. Success Found: 75%
Amalgam vs 91% IRM vs 95% Super EBA.
• Is a retro- ll required? What do you use and why?
• Christiansen – RCT of success of smoothing GP vs MTA retro ll at 1yr f/u: 52% vs
96% for MTA
• Kim – Super EBA showed success rates 91% at 5-7yrs
• Chong/Pitt Ford- success at 2 yrs 92% for MTA, 87% IRM
• Setzer – contemporary tech with EBA, IRM or MTA was 94% at 1 yr
• Andelin, Torabinejad et al 2002: Found that resection of set MTA does not
diminish its sealing ability
• Discuss MTA as a retro- ll material?

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 • Torabinejad – biocompatible; demonstrates the least leakage; substrate for
osseous and cementum growth, sets in presence of moisture/blood
• Baek – MTA promoted better PA tissue healing vs. Super EBA or am
• Why use MTA?
• 1) Successful (Chong-92%), 2) Biocompatible (Kaiser-less toxic to PDL cells than
EBA, Baek and Torabinejad-substrate for osseous and cementum), 3) Least
leakage (Torabinejad), dry or in blood
• Damas et al 2011: Endosequence root repair material similar to MTA should in vitro.
Composed of calcium silicate and calcium phosphate.
• Ma, Haapasalo et al 2011: Endosequence root repair material similar biocompatibility to
MTA in vivo.
• Zhou, Huang et al 2017: JOE. Prospective RCT. 12 month follow-up.
• These results suggest that iRoot BP-RRM is comparable with MTA in clinical
outcome when used as root-end lling materials in endodontic microsurgery.
• Success rate in the MTA and BP-RRM groups was 93.1% (81/87 teeth) and 94.4%
(67/71 teeth).
• Three signi cant outcome predictors were identi ed: quality of root lling, tooth
type, and size of the lesion
• Anatomical Concerns: (see anatomy section)
• Wang, Tiwari, Peng et al 2017: JOE. CBCT Analysis, n=204
• The purpose of this study was to investigate the relationships between the location
of the mental foramen (MF) and the mandibular canal (MC) and the surgical access
line (SAL) of the mandibular posterior teeth using cone-beam computed
tomographic (CBCT) scans.
• The average vertical distance between the MF and the SALs showed signi cant
increases sequentially from the rst premolars to the distal roots of the rst molars,
and the shortest average distance of 2.74 mm was obtained for the rst premo-
lars. The SALs of the second premolars were the closest to the MF in the horizontal
direction with an average distance of 1.5 mm. In 19.9% of the cases, the vertical
and horizontal distances between the MF and the SALs of the second premolars
were less than 2 mm. In addition, the MF was located superior to the root apices in
6.62% of the cases. The majority of the SALs were located at a vertical distance
from the MC that was more than 2 mm. Men and women exhibited signi cant
differences in both the horizontal distance from the MF to the SALs of the rst
premolars and the vertical distance from the MC to the SALs of the second
premolars.
• To improve the success of endodontic microsurgery, adequate knowledge of the
anatomic relationships between the location of the MF and MC and the SAL of the
mandibular posterior teeth is indispensable to surgeons.
• Carruth 2015: Regarding location of mental foramen, 53.7% of the foramen were
located mesial, 45.3% distal, and 1% coincident to the apex of the mandibular second
premolar.
• Grotz et al 1998: Overextension of lling material into the mandibular canal after root
treatment in the lower jaw is a rare but serious complication. Mechanical compression,
chemical neurotoxicity and local infection may cause irreversible nerve damage. If
neurological complaints appear after root lling in the lower jaw, a nerve injury due to
root lling material should be ruled out. In cases of over lling, immediate apicectomy and
decompression of the nerve with conservation of the tooth is often the treatment of

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 choice; the tooth may be pre- served and the best chance of avoiding permanent nerve
damage is provided.
• Kovisto 2011: assessed the proximity of IAN canal to mandibular molars using CBCT
Root apices of the mandibular second molars are closest to the mandibular canal than
other teeth. The mesial root of the second molar was closer to the nerve in female
patients compared with male patients. Root apices in younger patients (<18 years) were
generally closer to the mandibular canal than in older patients.
• Weller, Kim S 1995: JOE. were among the rst to point out the signi cance of the
isthmus in surgical endodontics. In mesiobuccal roots of the maxillary rst molar with two
root canal systems, they reported the highest incidence of an isthmus occurred in the
apical 3 to 5 mm, and that an isthmus was present 100% of the time at the 4-mm level.
• von Arx 2005: IEJ. an isthmus was found in 76% of mesiobuccal roots of maxillary rst
molars with a 3 to 4 mm apical root resection. In maxillary rst molars, 76% of resected
mesio-buccal roots had two canals and an isthmus, 10% had two canals but no isthmus,
and 14% had a single canal. All disto-buccal and palatal roots had one canal. In
mandibular rst molars, 83% of mesial roots had two canals with an isthmus. In 11%,
two canals but no isthmus were present, and 6% demonstrated a single canal. Sixty-four
per cent of distal roots had a single canal and 36% had two canals with an isthmus.
• Mannocci et al 2005: IEJ. an isthmus was found to be present 85% of the time in the
mesial root of the mandibular rst molars evaluated.
• Jin et al 2005: JOE. Asian Pop. The greatest mean distance between a root apex and
the buccal cortical plate reported in the two studies was for the distal root of the
mandibular second molar with a mean distance of 8.51 mm. e tooth with the root apex
closest to the buccal cortical plate was the maxillary canine (mean = 1.64 mm) in one
study and the buccal root of the maxillary rst premolar (mean = 1.63 mm) in the second
study.
• Ericson et al 1974: in 314 apical surgical procedures performed on maxillary canines,
premolars, and molars in 276 patients that oroantral communication occurred in 41
cases (13%). Sinus communication did not impair healing, as there was no difference in
the success rate between those cases with or without sinus exposure.
• Eberhardt, Torabinejad 1992: MB root of 2nd maxillary molar is closest to the sinus
(0.8mm) and furthest from the buccal cortical plate (4.5mm); buccal root of maxilliary 1st
premolar is closest to buccal cortical plate (1.6mm) and furthest from the sinus (7mm).
5% of posterior maxillary roots protrude into the sinus. The root apices of the maxillary
second premolar and the mesiobuccal and distobuccal root of the maxillary rst molar
were all approximately 2.8 mm from the oor of the sinus.
• Phillips, Weller: mental foramen located 60% the distance from the buccal cusp tip of
the 2nd mandibular premolar to the inferior border of the mandible; exits posterior-
superiorly; radiographically 3mm below and slightly mesially the apex of 2nd premolar
• Denio, Torabinejad, Bakland 1992: Mandibular canal is S-shaped. found that the root
apices of the mandibular second molar (mean = 3.7 mm) and the mandibular second
premolar (mean = 4.7 mm) were closest to the mandibular canal. The mesial root apex
of the mandibular rst molar was found to be furthest from the canal (mean = 6.9 mm).
• Lavasani, McClanahan et al 2016: CBCT Analysis of anatomy in posterior maxillary
teeth. 1. Buccal bone was thinnest over the buccal root of the 2-rooted rst premolar
(0.66mm) and the mesiobuccal root of the rst molar (0.84mm) and thickest over the MB
root of the 2nd molar (1.91mm). 2. The palatal bone was thinnest over the palatal root of
the maxillary rst molar (1.24mm) and thickest over the single-rooted second premolar
(3.26mm). 3. The longest distances to complete resection were found for the 2-rooted

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 rst and second premolars (8.81mm and 9.14mm, respectively) and the MB root of the
second molar (7.4mm). 4. The MB root of the second molar had the closest proximity to
the sinus oor, with an average distance of 0.66mm.
• Aminoshariae (JOE, 2014) in a critical review assessed different methods used to
locate the mental foramen (Following table): (CBCT favored)
• Hazani et al 2013: Technique - palpation. Location of MF - the origin of the mentalis
muscle. Bene t - no equipment or radiation needed. Risk - not precise.
• Guo et al 2009: Technique - Anatomic landmark. Location of MF - 23.34 +/- 2.39
mm below the cusp tip of the second mand. premolar. Bene t - no equipment or
radiation needed. Risk - occlusal wear can cause errors.
• Kquiku et al 2011: Technique - Direct Visualization. Location of MF - between the
rst and second mandibular premolars. Bene t - exact location of the MF is
determined. Risk - potential tissue/nerve injury
• Phillips et al 1990: Technique - periapical radiograph. Location of MF - the position
was 3.8 mm mesial to the apex of the second premolar. Bene t - equipment present
and small amount of radiation required. Risk - magni cation, and failure to detect
MF it is located below the apical edge of the lm.
• Jacobs et al 2004: Technique - Pano. Location of MF - detected in 94% (n=545) but
it was distinct in only 49% of the cases. Bene t - relatively small amount of radiation
and the entire orofacial structure is included. Risk - large degree of mangi cation
and failure to detect MF when it is not clearly visible.
• Jacobs et al 2002: Technique - Computed Tomography. Location of MF - MF was
detected in 100% of the cases (n=230). Bene t - magni cation free 3D
visualization. Risk - larger amt of radiation.
• Parnia et al 2012: Technique - CBCT. Location of MF - MF was detected in 100%
of the cases (N=96). Bene t - Magni cation free 3D visualization. Risk - ionization
radiation but less than conventional CT.
• Chau 2009: Technique - MRI. Location of MF - each assessor identi ed the MF on
278 and 298 obligue images of CBCT and MRI respectively. Bene t - no ionization
radiation required and MRI detected mandibular nerve better than CBCT. Risk -
very expensive equipment and image.
• Mahmoud et al 2010: Technique - Ultrasound. Location of MF - consistently
detected in dry mandibles. Bene t - no ionizing radiation and real-time identi cation.
Risk - Equipment not readily available
• Sinus Exposure Management
• Lin, Langeland: Avoid nose blowing,Prescribe decongestants, antibiotics only if sinusitis
develops
• Ericson: Sinus exposure (13%) has no bearing on successful healing. No nose blowing,
prescribe decongestant and antibiotics
• Kim, Rubinstien 2001: Recommend antibiotics
• Kim, Kratchman 2006: When the sinus is perforated, the most important step is to
prevent any solid particles, such as cotton pellets, root-end lling materials, and so forth,
from entering the sinus cavity. If the size of the sinus perforation is very small, a cotton
pellet tied securely to a suture can be used as a barrier . If the perforation is large,
however, a thin iodine gauze strip can be inserted into the sinus, leaving the end outside
for ready retrieval, before continuing the surgery. Once the surgery is completed, the
cotton pellet or the iodine strip must be removed completely. The postoperative
preparations should include a prescription of an antibiotic, such as cipro oxacin or

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 amoxycillin for 1 wk, postoperative instructions to sleep with the head slightly elevated,
to avoid nose blowing and to expect possible nose bleeds.
• Lin et al; Rud and Rud; and Walton: Do not recommend antibiotics
• Tataryn, Torabinejad, Boyne 1997: Sinus perforations tend to self-repair, regardless of
size, with a limited bony covering and a brous scar. The use of resorbable membranes
does not appear to improve osseous repair.
• Postoperative Management
• Chong and Pitt Ford: Discomfort following surgery is often of short duration, with its
maximum intensity in the early postoperative period. For a large number of patients,
nonprescription analgesics are adequate and effective for management of post op pain.
• Tsesis et al 2003: Pre-op pain is correlated with post op pain
• Hargreaves and Keiser: A long-acting postoperative anesthetic, such as bupivacaine,
can markedly reduce postoperative discomfort in the initial period.
• Antibiotics are not believed effective in managing post op discomfort.
• Kim et al: To aid in soft tissue healing after surgical procedures —> use of both pre-op
and post op CHX rinses to reduce soft tissue in ammation
• Shahan et al: advised avoidance of CHX for 48 hrs immediately post op as it may
reduce broblastic attachment to root surfaces and negatively affect tensile wound
strength.
• CBCT Related
• von Arx, Bornstein et al 2016: To compare 2D with 3D radiography in assessing the
treatment outcome 1 year after periapical surgery. CBCT images showed in nearly a
third of the evaluated cases a worse situation than PA. There is a need to de ne criteria
to assess the ‘radiographic healing’ in CBCT following periapical surgery.
• Kim et al 2016: The purpose of this study was to examine the size, volume, and other
parameters of preoperative periapical lesions measured from cone-beam computed
tomographic (CBCT) images as potential prognostic factors in endodontic microsurgery.
Within the limitations of this study, the volume of the lesion had a signi cant effect on the
outcome of endodontic microsurgery; periapical lesions with a volume above 50 mm3
were signi cantly associated with failures (> 5-6mm mesio-distal). With regard to the
treatment of large periapical lesions, the use of graft materials could be considered.
Ninety- ve cases were evaluated after a period of at least 1 year, and 2 were extracted
before the 1-year follow-up.
• Kovisto et al: recommends CBCT to evaluate proximity to mandibular canal
• Schloss, Setzer et al 2017: JOE. n=51. The aim of this study was to compare the
assessment of healing after endodontic microsurgery using 2-dimensional (2D)
periapical lms versus 3-dimensional (3D) cone-beam computed tomographic (CBCT)
imaging. CBCT analysis allowed a more precise evaluation of periapical lesions and
healing of endodontic microsurgery than periapical lms. Signi cant differences existed
between the 2 methods. Over the observation period, the mean periapical lesion sizes
signi cantly decreased in volume. Given the correct indications, the use of CBCT
imaging may be a valuable tool for the evaluation of healing of endodontic surgery. The
healing classi cation in 3D (CBCT) analysis was signi cantly different from 2D
(periapical radiography) analysis. The use of CBCT analysis may be a valuable tool for
the evaluation of healing of endodontic surgery if indications are given
• Decompression
• Mejia, Basrani 2004: Use of a vacuum system to apply negative pressure to large apical
lesions enabled rapid removal of the periapical exudate through the root canal in teeth
with immature apices. This technique respects the basic principles of endodontic

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 therapy, in that the source of bacteria is eliminated through the root canal, the access
cavity is kept closed during the whole procedure and the apical foramen is kept intact
without altering its position or size.
• Freedland 1970: Conservative reduction of large periapical lesions. Oral Surg Oral Med
Oral Pathol 1970. Describes decompression using polyvinyl tubing for access and
irrigation of large PA lesions. Indication of marsupialization: Devitalization of adjacent
teeth Damage to anatomic structures (ian, sinus), Loss of bony support, Parasthesia,
Elderly pts where surg is risky
• Neaverth, Burg 1982: Decompression of large periapical cystic lesions. The removal of
extensive periapical cystic lesions by surgical enucleation frequently causes postsurgical
sequelae, such as devitalization of adjacent teeth, patient apprehension and discomfort,
loss of bony support and, on occasion, paresthesia. An alternative approach is
presented, whereby a tube is inserted into the cystic cavity. This tube is then periodically
reduced in length as the lesion heals.
• When would decompression be considered and discuss different approaches?
• Neaverth and Burg - Large lesions in order to avoid: devitalizing adjacent teeth,
damage anatomical structures, paraesthesia or risky surgery (elderly)
• Freedland – used polyvinyl tubing and daily irrigation
• Hoen – Aspiration & irrigation
• Summary of Survival and Success Rates
• Rubinstein, Kim 2002: 7 yr F/U. 92% Survival. 92% Success rate
• Chong et al 2003: 2 yr F/U. 95% Survival. 90% Success rate
• Tsesis et al 2013: Meta-analysis. 1 yr. F/U 89%
• Taschieri et al 2008: 2 yr F/U. 94% Survival. 91% Success rate.
• Taschieri, Del Fabbro 2009: 2 yr F/U. 93% Survival. 91% Success rate.
• Taschieri et al 2011: 4 yr F/U. 91% Survival. 88% Success rate.
• von Arx et al 2012: 5 yr F/U. 87% Survival. 76% Success rate.yrs (SR & M/A)
• Torabinejad 2009: Systematic Review. 77.8% at 2-4 years; 72% at 4-6 years
• Torabinejad 2015: Systematic Review. Overall with modern techniques.
• Survival: 94% at 2-4yr; 88% at 4-6yr.
• Success rates: 90% at 2–4 years and 84% at 4–6 years
• Chong, Pitt Ford et al 2003: MTA 84% after 12 m, 92% after 24 m. IRM 76% after 12
months, 87% after 24 months.
• Song et al 2012: 6 yr f/u. 93.3% success. (97/104)
• Setzer, Kim 2010: Endo Microsurgery success: 94% vs Traditional: 59%. (does not
mention length of time. Did a Meta Analysis)
• Von Arx et al 2014: 5 yr f/u. n= 271. (initial n = 339) MTA vs Adhesive Resin composite.
The overall rate of healed cases was 84.5% with a signi cant difference (P = .0003)
when comparing MTA (92.5%) and COMP (76.6%).
• Outcome/Prognosis etc
• Different studies have evaluated the prognostic factor that affect the outcome of surgery.
Age of the patient, existing root- lling length, preoperative lesion size, and apical and
coronal seal are the main factors mentioned in different studies. This inconsistency may
be caused by the differences in the technical quality of periapical surgery as well as case
selection, sample size, the observation period, and methodology (Friedman,
Rahbaran). In a recent study by Song (2011, JOE) age, sex (female), tooth position
(anterior), root- lling length (adequate), lesion type (endodontic lesion), root-end lling
material (mineral trioxide aggregate and Super EBA; Harry J. Bosworth, Skokie, IL), and
restoration at follow-up appeared to have a positive effect on the outcome.

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 • Wang et al 2017: JOE. Prospective Cohort. n=98 teeth. The aim of this study was to
investigate the outcome of endodontic microsurgery using a microscope and MTA and
analyze the prognostic factors. The combined rate of complete and incomplete healing
of teeth 12 to 30 months after endodontic microsurgery was 90.5%. The use as an
abutment may have a negative effect on treatment outcome. A predictably high healing
rate (complete and incomplete healing) 12 to 30 months after treatment can be achieved
using endodontic microsurgery with a microscope and MTA.
• Wang, Friedman et al 2004: 4-8 yr Treatment outcome in endodontics—the Toronto
Study. Phases I and II: apical surgery. Analysis indicated an increased odds ratio for
disease persistence for teeth with larger pretreatment lesions and pretreatment root
canal lling of adequate length. Pretreatment lesion size and root- lling length were
signi cant predictors of the outcome of apical surgery.
• Torabinejad, Corr, Handysides, Shabahang 2009: A signi cantly higher success rate
was found for endodontic surgery at 2-4 years (77.8%) compared with nonsurgical
retreatment for the same follow-up period (70.9%; P < .05). At 4-6 years, however, this
relationship was reversed, with nonsurgical retreatment showing a higher success rate
of 83.0% compared with 71.8% for endodontic surgery (P < .05). (Endo surgery has
more favorable results initially, but nonsurgical retreatment offers a more favorable long-
term outcome).
• Tsesis et al 2013: 89% at 1 yr. A meta-analysis was performed to assess the 1 year
success rate of surgical Endodontic treatment performed by modern techniques
(MICROSCOPE, NON BEVELED ROOT END PREPARATION). With proper case
selection and use of modern techniques, surgical endodontics provides patients with a
predictable means of eradicating periapical pathology. From the meta-analysis of the 18
studies, the pooled percentages of success (complete healing and incomplete healing),
uncertain healing, and failure at the 1-year follow-up were found to be 89.0%, 4.6%, and
6.4%, respectively. MTA was signi cantly associated with better treatment outcomes
than other retro lling materials. The use of IRM provided signi cantly worse outcomes
compared with MTA (P < .05) or EBA (P < .05) in the low risk of bias studies but not in
the high risk of bias studies (P > .05). Finally, the use of EBA was associated with less
favorable outcomes compared with the use of MTA in the high risk of bias (P < .05).
• Mente J 2015: JOE. evaluated the treatment outcomes of nonsurgical retreatment after
a failed apicoectomy clinically and radiographically. It should be considered that in the
included cases, apical surgery had been performed instead of regular retreatment in
failure cases. Based on the result, twenty teeth (87%) were classi ed as “success,” and
3 teeth were considered (17%) “failure after non surgical retreatment following failed
surgery.
• Filipowicz 1984: 13% 5 yr survival rate of root amps with no RCT. So do RCT before
root amp!
• Setzer, Kim 2010: Endodontic Microsurgery success: 94%. Traditional root-end surgery:
59%. The use of microsurgical techniques is superior in achieving predictably high
success rates for root-end surgery when compared with traditional techniques.
• Song et al 2012: 6 yr f/u. 93.3% success.(97/104). 91/97 completely healed, 6
incomplete healing.
• Setzer, Kim et al 2012: meta-analysis. Found more favorable outcomes for molars using
the surgical operating microscope vs loupes.
• Von Arx, Friedman 2012: found that mesiodistal bone levels were a signi cant predictor
of surgical outcomes. assessed the success rate of apical surgery in two intervals of 1
and 5 years (JOE, 2012). It was found that a total of 129 of 170 teeth were healed

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 (75.9%) compared with 83.8% at 1 year. Two signi cant outcome predictors were
identi ed: the mesial-distal bone level at ≤3 mm versus >3 mm from the cementoenamel
junction (78.2% vs 52.9% healed, respectively) and root-end llings with ProRoot MTA
versus SuperEBA.
• Song, Kim et al 2013: demonstrated that a buccal cortical plate height greater than
3mm signi cantly improved clinical outcomes. (suggested that the height of the buccal
bone plate was the only signi cant predictor (P = .040) of the healing outcome,
suggesting that teeth with a buccal bone plate >3 mm presented a higher success rate
than teeth with a buccal bone plate that was ≤3 mm high (94.3% vs 68.8%,P < .001).
• Lui et al 2014: Periodontal probing depth, in addition to bone height, was shown to
in uence outcomes, with probing depths of less than 3mm associated with more
favorable outcomes.
• Torabinejad et al 2015: Systematic Review. At 4–6 years, single implants had higher
survival rates than teeth treated with endodontic microsurgery.
• Survival Rates: Single implant (SI) survival rates varied from 96% at 2–4 years to
98% for 6+ years; This indicated that implant losses primarily occurred before 2
years, with few being lost thereafter; a steady state was approached within the
times studied. Teeth treated using endodontic microsurgery (EMS) had survival
rates of 94% at 2–4 years and 88% at 4–6 years, indicating that teeth treated with
EMS tended to be lost at low rates over the time studied. Teeth treated using EMS
substantially lagged the survival of SIS at the 2- to 4-year time interval. Survival
data for 6+ years were not identi ed.
• Success Rates: A comparison between SI and EMS success rates was not
appropriate because the success criteria for the different treatment modalities were
qualitatively different. SI success rates varied from 98% at 2–4 years to 97% at 6+
years;. Implants that had been successful at 2–4 years tended to remain as
successes for the duration of the period studied; a steady state was attained. Teeth
treated with EMS had success rates of 90% at 2–4 years and 84% at 4–6 years; the
CIs barely overlapped, suggesting a tendency for teeth treated with EMS to become
unsuccessful over time. EMS success data for 6+ years were not identi ed.SI
success rates did not differ from SI survival rates for each of the 3 time periods
studied. In contrast, EMS success rates were lower than EMS survival rates for
both time periods studied.)
• Von Arx 2010: performed a meta-analysis regarding the prognostic factors in apical
surgery: With regard to tooth-related factors, the following categories were signi cantly
associated with higher healed rates: cases without preoperative pain or signs, cases
with good density of root canal lling, and cases with absence or size ≤5 mm of
periapical lesion. With regard to treatment-related factors, cases treated with the use of
an endoscope tended to have higher healed rates than cases without the use of an
endoscope.
• Molven, Halse, Grung 1996: Lateral incisor most often found with scar tissue. The
ndings support the conclusion that cases clearly showing features of incomplete
healing (scar tissue) at the regular follow-up 1 yr after surgery can be regarded as
successes. They need not be recorded for further systematic control.
• Rubinstein, Kim 1999: 96.8% at 1 yr. Using scope, ultrasonics and Super EBA
(reinforced zinc oxide cement; its liquid contains 32% eugenol and 68% ethoxy benzoic
acid): n=94 cases (2/3 posterior & 1/3 anterior): 97% radiographic success at 3-12m
follow-up with mean healing of 7.2m (criteria = restoration of lamina dura). 85%

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 granuloma and 15% cysts with no difference in time to heal. Isthmuses were found in
25% of the cases.
• Rubinstein, Kim 2002: 7 yr F/U. Survival rate: 92%. Success rate: 92%. 59 roots were
evaluated.
• Gagliani, Gorni 2005: conducted a study to monitor the outcome of periradicular
surgery in teeth that had previously undergone surgical treatment. 59% healed
completely, 17% were considered to have incompletely healed and 23% were
associated with post-treatment disease. Surgical retreatment of teeth previously treated
with surgery is a valid alternative to extraction. However, association with post-treatment
disease was greater than after a primary surgical approach.
• Halse, Molven, Gung 1991: 1 year follow up will provide a valid diagnosis for the
majority of cases.
• Kvist, Reit 1999: JOE. Looked at retreatment vs surgery. The outcome of the
procedures was clinically and radiographically recorded, and followed for 4 years. At the
12-month recall, a statistically signi cant (p < 0.05) higher healing rate was observed for
cases surgically retreated. At the nal 48-month examination, no such difference was
found. These ndings may be explained by (a) slower healing dynamics in the
nonsurgical group and (b) the event of late "failures" in the surgical group. Within the
latter category, four cases classi ed as healed after 1 yr failed at the nal follow-up.
Conclusively, this study failed to show any systematic difference in the outcome of
surgical and nonsurgical endodontic retreatment. Surgical retreatment seems to result in
more rapid periapical bone ll, but also may imply a higher risk of "late failures." From a
scienti c point of view, the length of the follow-up period is very important and may
strongly in uence the conclusions made.
• Kim S et al 2008: 2 yr recall. 73% recall. The successful outcome for isolated endodon-
tic lesions was 95.2%. In endodontic-periodontal combined lesions, successful outcome
was 77.5%
• Updated Techniques/Microscope
• Setzer, Kim S et al 2012: found more favorable outcomes for molars using the surgical
operating microscope vs loupes.
• Setzer, Kim S et al 2010: found a 59% success rate when traditional techniques were
employed vs 94% success rate when modern techniques were implemented.
• Retreatment following failed apical surgery
• Mente J 2015: JOE. evaluated the treatment outcomes of nonsurgical retreatment after
a failed apicoectomy clinically and radiographically. Based on the result, twenty teeth
(87%) were classi ed as “success,” and 3 teeth were considered (17%) “failure after non
surgical retreatment following failed surgery.
• Perforation Repair Outcome
• Mente: 86% at avg 3 yr
• Main, Torabinejad: 100% w/ MTA
• Intentional Replant Outcome
• Torabinejad: 88% (at 6yrs - check)
• Bender, Grossman: 81%, 80%
• Kratchman: 80-85% should be expected
• 2nd Surgery: Surgical Outcomes
• Gagliani, Gorni 2005: 59% (86% 1st surgery) at 5 yrs (complete healing)
• Song/Kim 2011: 92% if modern techniques were used. (1st surgery failure associated
with history tech/materials)

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 • Peterson & Gutmann 2001: Systematic Review. found that surgical revisions achieved
a success rate of only 36%
• Persson 1973: When performing a surgery for a second time the success rate is
dramatically reduced (36.4%). If the lesion was greater than 5mm a even less favorable
result can be expected. A follow up of about one year is enough to determine success of
treatment. Factors (in uencing the prognosis) such as clinical symptoms, tooth-group
and the patient's age appeared to have no effect on the late results of reoperation.
• Root Amp Outcome
• Fugazatto: 97% survival at 13 yrs, D root of man molar was worst 75%
• Root resection outcome
• Langland: 62% at 10 yrs

Pulp Cap/Pulpotomy (Vital Pulp Therapy)

• Vital pulp therapy serves to maintain the vitality of the radicular pulp tissue in cases of
trauma, deep caries, iatrogenic damage or in the presence of developmental anomalies.
Maintaining pulp vitality, particularly in permanent teeth with open apices, is the treatment of
choice as it promotes completion of root development. This process is often referred to as
apexogenesis (AAE Glossary). Pulp cap, partial pulpotomy, full pulpotomy fall under the
umbrella of vital pulp therapy.
• Linu et al 2017: JOE. Treatment outcomes following direct pulp capping using bioceramic
materials in mature permanent teeth with carious exposure. MTA group n=15, biodentine
group n= 15. The patients were reviewed at 1, 3, 6, 12, and 18 months after treatment. Four
cases (2 each of MTA and Biodentine) were lost to follow-up. MTA and Biodentine groups
showed success rates of 84.6% and 92.3%, respectively, with overall success rate of 88.5%.
Radiographically visible dentin bridge formation was observed in 69.2% (9/13) and 61.5%
(8/13) of cases done with MTA and Biodentine, respectively. The cases done with MTA
showed coronal discoloration on review. Diffuse calci cations of the pulp chamber were
observed in 1 (7.7%) case done with MTA and 3 (23.1%) cases done with Biodentine. The
advent of bioceramic materials with better biocompatibility and sealing properties can make
the outcome of DPC technique in mature permanent teeth with carious exposure more
predictable.
• Taha, Khazali 2017: JOE. n=50. This study aimed to assess the outcome of partial
pulpotomy using mineral trioxide aggregate (MTA) compared with calcium hydroxide (CH) in
mature cariously exposed permanent molars. MTA partial pulpotomy can be considered
appropriate long- term management for symptomatic carious exposures of mature teeth with
>80% success after 2 years. CH is not a suitable alternative for these cases (43% at 2yrs).
• Meraji, Camilleri 2017: JOE. Dentin replacement materials are necessary in large cavities to
protect the pulp and reduce the bulk of lling material. These materials are layered with a
composite resin restorative material. Microleakage caused by poor bonding of composite
resin to underlying dentin replacement material will result in pulp damage. The aim of this
study was to characterize the interface between dentin replacement materials and composite
resin and to measure the shear bond strength after dynamic aging.
• Results: The Biodentine surface was modi ed by etching. The Theracal LC and Fuji IX
microstructure was unchanged upon the application of acid etch. The Biodentine and
glass ionomer interface showed an evident wide open space, and glass particles from
the glass ionomer adhered to the Biodentine surface. Elemental migration was shown
with aluminum, barium, uorine, and ytterbium present in Biodentine from the overlying
composite resin. Calcium was more stable. The bond strength between Theracal LC and

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 composite using a total-etch technique followed by self-etch primer achieved the best
bond strength values. Biodentine exhibited the weakest bond with complete failure of
bonding shown after demolding and thermocycling.
• Qudeimat, Hasan et al 2017: IEJ. 16 patients. 23 permanent molars. In children, MTA was
associated with high clinical and radiographic success as a pulpotomy agent in permanent
teeth with clinical signs and symptoms suggestive of irreversible pulpitis.
• Katge & Patil 2017: JOE. Clinical Study.
• According to split mouth design, these patients were then divided into 2 groups,
Biodentine group (right side) and MTA group (left side). The pulp-capping procedure was
performed by using Biodentine and MTA in 58 asymptomatic bilateral permanent molars
with pulp exposure.
• The study reported 100% success rate with both Biodentine and MTA at baseline and 6-
and 12-month follow-up on the basis of clinical and radiographic parameters. These
ndings were statistically nonsigni cant (P < .05) between both groups (Biodentine and
MTA).
• Radiographically, dentin bridge formation was not evident with both groups at baseline,
but it was evident after 6- and 12-month follow-up. These ndings were statistically non-
signi cant (P < .05) in both Biodentine and MTA groups.
• Taha et al 2017: IEJ. MTA Angelus full pulpotomy is a successful treatment option for
cariously exposed pulps in mature permanent molar teeth. n = 52.
• 1YR: 100% Clinical Success; 97.5% radiographic success.
• 3YR: 92.7% clinical and radiographic success.
• Clinical signs and symptoms suggestive of irreversible pulpitis were established in 44/52
teeth, and periapical rarefaction was present in 14 teeth.
• (To assess the outcome of complete pulpotomy in mature teeth with carious exposures
demonstrating variable pulpal conditions using MTA Angelus over a 3-year period. Over
a 3-year follow-up, MTA full pulpotomy was highly successful both clinically and
radiographically in symptomatic permanent teeth with carious exposures. Teeth with
signs and symptoms clinically suggestive of irreversible pulpitis may still have the
potential to heal following full pulpotomy as it is likely that the radicular pulp is at worse
reversibly in amed. Longer-term observation may con rm the future bene ts of this
treatment option. )
• Linsuwanont et al 2017: JOE. 55 teeth.
• Teeth with clinical signs of irreversible pulpitis showed successful outcomes with
pulpotomy.
• A periapical radiolucency lesion does not always correlate with pulp necrosis.
• Teeth with the presence of radiolucency could be treated by MTA pulpotomy with a high
rate of success of 76%.
• 84% of teeth with clinical signs of irreversible pulpitis were treated successfully.
• Success Rates by time period < 1 yr: 87.9%; 1 to < 2 yr: 100%; 2 to < 3 yr: 95.8% ; 3 to
< 4 yr: 96%; > 4 yrs: 86.7%
• Torabinejad and Parirokh: Healing of pulp tissues following pulp-capping procedures with
MTA or CH. Pulp cap placed —> Coagulative necrosis of adjacent pulp tissue —> hard tissue
bridge formed. These responses are similar likely b/c MTA forms CH upon setting. (Better
bridge formed with MTA)
• Nowicka et al: Found that biodentine-capped pulps had a similar histological appearance to
those treated with MTA.
• Pulpotomy: pulp amputation, or pulpotomy, is de ned as a procedure in which part of an
exposed vital pulp is removed, usually as a means of preserving the vitality and function of

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 the remaining part. The rationale is to remove the portion of the pulp tissue that has
undergone degenerative and irreversible changes and to leave behind healthy and vital tissue
(Langeland 1987). Pulpotomy is essentially indicated as a treatment of normal pulp or
reversible pulpitis associated with a carious lesion or after traumatic pulp exposure in primary
teeth (Fuks 2008) and immature permanent teeth (Witherspoon 2008). In mature permanent
teeth, full pulpotomy is actually only indicated as an emergency (routine) procedure before
root canal treatment (RCT) (Hasselgren, Reit 1989) (Oguntebi et al 1999).
• Witherspoon 2008: Vital Pulp therapy in permanent teeth. Summary: Pulp necrosis in
immature teeth subsequent to caries has a major impact on long-term tooth retention. The
aim of vital pulp therapy is to maintain pulp viability by eliminating bacteria from the dentin-
pulp complex and to establish an environment in which apexogenesis can occur. A
complicating factor in treating immature teeth is the dif culty predicting the degree of pulpal
damage. The ability of the clinician to manage the health of the remaining pulpal tissue during
the procedure is paramount. Currently, the best method appears to be the ability to control
pulpal hemorrhage by using sodium hypochlorite. Mineral trioxide aggregate (MTA) currently
is the optimum material for use in vital pulp therapy. Compared with the traditional material of
calcium hydroxide, it has superior long-term sealing ability and stimulates a higher quality and
greater amount of reparative dentin. In the medium-term clinical assessment, it has
demonstrated a high success rate. Thus, MTA is a good substitute for calcium hydroxide in
vital pulp procedures.
• Fuks 2008: Vital Pulp Therapy in primary teeth. Summary: Vital pulp therapy aims to treat
reversible pulpal injury and includes 2 therapeutic approaches: (1) indirect pulp treatment for
deep dentinal cavities and (2) direct pulp capping or pulpotomy in cases of pulp exposure.
Indirect pulp treatment is recommended as the most appropriate procedure for treating
primary teeth with deep caries and reversible pulp in ammation, provided that this diagnosis
is based on a good history, a proper clinical and radiographic examination, and that the tooth
has been sealed with a leakage-free restoration. Formocresol has been a popular pulpotomy
medicament in the primary dentition and is still the most universally taught pulp treatment for
primary teeth. Concerns have been raised over the use of formocresol in humans, and
several alternatives have been proposed. Controlled clinical studies have been critically
reviewed, and mineral trioxide aggregate and ferric sulfate have been considered appropriate
alternatives to formocresol for pulpotomies in primary teeth with exposed pulps. In most of the
studies reviewed, the caries removal method has not been described. The use of a high-
speed handpiece or laser might result in an exposure of a “normal” pulp that would otherwise
not be exposed.
• Asgary and Eghbal 2010: Found that pain relief following pulpotomy treatment was greater
than with a full pulpectomy in vital cases. However, this treatment is not w/out risk. Cvek
found that common postop complications include calci cation, internal root resorption, and
complete pulpal necrosis.
• Cvek: Pulpotomy facilitates continued root development in immature teeth
• Tronstad 1972: DPC of carious exposure had less than 50% success rate.
• Cvek 1978: Partial pulpotomy and capping w/ Ca(OH)2 in permanent incisors w/ complicated
crown fracture. The size of the pulp exposure and the time between accident and treatment
are not critical for healing of healthy pulps. 96% success (58/60).
• Fairbourn, Charbeneau 1980: Indirect pulp cap reduces CFU count
• Gutmann 1981: Types of treatment for vital, immature teeth depends on the severity of the
in ammation/presence of bacteria: indirect pulp cap, direct pulp cap, partial pulpotomy,
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• Cvek, Andreasen 1982: Pulpal in ammation limited to 2mm of defect in fractured, vital teeth
(remove 2mm before repair of fractured teeth)
• Cvek 1983: Histo appearance of pulps after exposure by a crown fracture, partial pulpotomy,
and clinical diagnosis of healing. Histological observations con rmed the clinical diagnosis of
healing, and it was, therefore, concluded that the routine use of pulpectomy after partial
pulpotomy treatment of exposed vital pulps in crown-fractured teeth does not appear justi ed.
• Cox, Bergenholtz 1986: Pulps have the capacity to heal after CH pulp capping of 24hr pulp
exposures. Demonstrates histologic success (but no long term success)
• Caliskan 1995: IEJ. Vital teeth PARL’s are sometimes capable of repair. 10-24 yo patients
had carious exposures. Pulps were tested normal to EPT and no symptoms of irreversible
pulpitis. The favorable results of this study demonstrate that pulpotomy treatment in teeth with
cariously exposed vital pulps and with periapical involvement may be an alternative treatment
to root canal therapy.
• Pitt Ford, Torabinejad, Abedi, Bakland 1996: Using MTA as pulp capping material vs
Ca(OH)2 in monkeys. All the pulps capped with MTA showed dentin bridge formation and all
but one were free of in ammation. No bacteria observed on cavity walls in MTA group. Only 2
teeth pulp capped with Ca(OH)2 showed dentin bridge formation. Demonstrated MTA is
suitable as a pulp-capping material during vital pulp therapy.
• Barthel 2000: Pulp capping of carious exposure. 5yr success 55%. 10 yr success 20%. A
paper against pulp capping. Poor recall rate (30%). Not a well controlled study
• Aeinehchi 2002: MTA forms thicker bridge, less in ammation, less necrosis than CH (but
only vital teeth and short, 6 month recall). (Human molars mechanically exposed then capped
with MTA or CH).
• Swift, Trope 2003: Found that 90% of teeth treated by pulpotomy using eugenol were pain
free at 6 months postoperatively.
• Bogen, Bakland 2008: Over an observation period of nine years, the authors followed 49 of
53 teeth and found that 97.96 percent had favorable outcomes on the basis of radiographic
appearance, subjective symptoms and cold testing. All teeth in younger patients (15/15) that
initially had had open apexes showed completed root formation (apexogenesis). MTA can be
a reliable pulp-capping material on direct carious exposures in permanent teeth when a two-
visit treatment protocol is observed. (Diagnosis was no more severe than Irreversible pulpitis)
• Ansari 2010: MTA is equally as effective as formo in primary teeth pulptomoties. (Primary
teeth pulpotomized and compared for healing 2 years after).
• Mente 2010: Multiple analysis showed that teeth that were permanently restored ≥ 2 days
after capping had a signi cantly worse prognosis in both groups. MTA appears to be more
effective than calcium hydroxide for maintaining long-term pulp vitality after direct pulp
capping. The immediate and de nitive restoration of teeth after direct pulp capping should
always be aimed for.
• AAE Recommends avoiding formocresol and other products containing formaldehyde or
paraformaldehyed as they are both unsafe and ineffective.
• Gruythuysen 2010: Indirect pulp capping of teeth with large carious lesions. 3 year success:
primary molars 96%. Mature pulp caps 93% success. (Pulptomomy done with 2/3 the dentin
thickness was carious per BW radiograph. Pulpotomy done in the event of pulp exposure).
• Asgary 2010: RCT vs Calcium Enriched Mixture (CEM) pulpotomy in teeth with irreversible
pulpitis. Same 5 year success rate for RCT (94%) and CEM pulpotomy (91%). n = about 200
per group
• Bjorndale et al 2010: Treatment in adults. Success rate for vital pulp therapy was between
32-35%.

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 • Aguilar, Linsuwanont 2011: Systematic Review. The success rate of vital pulp therapy,
particularly on carious exposures, was between 73-99%. Current evidence does not outline
factors in uencing success of pulp capping and pulptomy. Partial or full pulpotomies are more
successful than pulp capping.
• Mente et al 2014: Reported that the long-term success rates for direct pulp caps with calcium
hydroxide were 58% and with MTA was 80%. compared the long term success of direct pulp
cap using MTA versus CaOH. It was found that MTA provides better long-term results after
direct pulp capping compared with CH. Placing a permanent restoration immediately after
direct pulp capping is recommended.
• Li, Fan et al 2015: Meta analysis. In clinical trials, mineral trioxide aggregate (MTA) showed a
higher success rate than calcium hydroxide (CH). MTA resulted in less pulpal in ammatory
response than CH. MTA was superior to CH in terms of dentin bridge formation.
• Nowicka: Calcium hydroxide has been a material of choice for pulp capping since 1930
because of its antibacterial activity, ability to release calcium and hydroxyl ions, and low
potential for irritation of the traumatized pulp tissue and . However, it has major
disadvantages including high solubility, dissolution in tissue uids, and poor sealing ability
• Schwendicke 2014: We found both direct pulp cap and RCT suitable to treat exposed vital,
nonsymptomatic pulps. DPC was more cost-effective in younger patients and for occlusal
exposure sites, whereas RCT was more effective in older patients or teeth with proximal
exposures. These ndings might change depending on the health care system and underlying
literature-based probabilities. Despite requiring follow-up treatments signi cantly earlier, teeth
treated by Direct Pulp Cap (DPC) were retained for long periods of time (52 years) at
signi cantly reduced lifetime costs (545 vs 701 Euro) compared with teeth treated by RCT.
For teeth with proximal instead of occlusal exposures or teeth in patients >50 years of age,
this cost- effectiveness ranking was reversed. Although sensitivity analyses found substantial
uncertainty regarding the effectiveness of both strategies, DPC was usually found to be less
costly than RCT.
• AlShwaimi 2016: assessed the application of betamethasone/gentamicin (BG) cream as a
pulp capping material. It was shown that MTA resulted in a signi cantly better pulpal
response, with less in ammation and a thicker dentin bridge at 8 weeks.
• Nowicka: reported that Biodentine had a similar ef cacy in the clinical setting and may be
considered an interesting alternative to MTA in pulp-capping treatment during vital pulp
therapy.
• Gruythusen 2010: in a retrospective survival analysis study estimated that survival rate was
96% for primary molars (mean survival time, 146 weeks) and 93% for permanent teeth (mean
survival time, 178 weeks) following (Indirect Pulp Treatment) IPC, liner, GI and permanent
restoration. This study shows that IPT performed in primary and permanent teeth of young
patients may result in a high 3-year survival rate. Sixty-six uncooperative children (4-18 years
old) with at least one tooth with clinically diagnosed deep caries were included.
Radiographically, the lesion depth was greater than two thirds of the dentin thickness.
Incomplete excavation was performed leaving infected carious dentin at the center of the
cavity. After placement of a layer of resin-modi ed glass ionomer as liner, the teeth were
restored. A 3-year survival analysis (Kaplan-Meier) was performed. Failure was de ned as
the presence of either a clinical symptom (pain, swelling, or stula) or radiologic abnormality
at recall. In total, 86 of 125 (69%) treated primary molars and 34 of 45 (76%) treated
permanent teeth were available for both clinical and radiographic evaluation.
• Raedel et al 2016: IEJ. Insurance data bases. A total of 148 312 teeth were included. The
overall success rate was 71.6% at 3 years. The overall survival rate was 95.9% at 3 years.
Material used not speci ed. In the present study, teeth of the youngest and oldest patients

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 performed best whilst teeth of patients between 18 and 64 years of age performed slightly
below average by seeing a slight positive trend with higher age. These results are in contrast
to studies describing a better outcome at a younger age (Dammaschke et al. 2010, Cho et al.
2013).
• Marques, Wesselink, Shemesh 2015: JOE. DPC. The overall success rate was 91.3%. The
success rate in occlusal caries was 100% and 89.7% in proximal caries. The success rate in
initial caries was 94.7% and 88.9% in secondary caries. The success rate in patients younger
than 40 years was 100% and 80% in patients aged 40 years or older. Direct pulp capping with
MTA after pulp exposure during excavation of deep caries could maintain pulp vitality in
permanent teeth when a 2-visit treatment protocol is observed. wMTA used. Healthy or
reversible pulpitis.
• Barthel et al 2001: Pulp capping of carious pulp exposures. Regardless of material used,
45% of teeth became necrotic after 5 years and 80% after 10 years.
• Mente et al 2014: reported long term success rates for direct pulp caps. CH 58% vs MTA
80%. this study indicate that MTA provides better long-term results after direct pulp capping
compared with CH. Placing a permanent restoration immediately after direct pulp capping is
recommended.
• Aguilar and Linsuwanont 2011: Systematic Review. Overall, the success rate of vital pulp
therapy was in the range of 72.9%-99.4% with carious exposure. Vital permanent teeth with
cariously exposed pulp can be treated successfully with vital pulp therapy. Current best
evidence provides inconclusive information regarding factors in uencing treatment outcome,
and this emphasizes the need for further observational studies of high quality.
• Indirect Pulp Cap Outcome
• Mertz-Fairhurst: 70% at 10 yrs
• Marchi: 89% with dycal/SBMP/cmpst; 93% w/ vitremer
• Thompson: Meta-analysis: advocated IPC
• Direct Pulp Cap Outcome
• Barthel: 55% at 5 yrs, 21% at 10 yrs (carious exposures)
• Haskel, Stanely: 87% at 11.7 yrs
• Bogen: 98% w/MTA at 9 years
• Aguilar (meta-analysis): MTA 90%, Ca(OH)2 71% (SS), open apex 94%, closed 69%
• Marques, Wesselink, Shemesh 2015: JOE. The overall success rate was 91.3%. The
success rate in occlusal caries was 100% and 89.7% in proximal caries. The success
rate in initial caries was 94.7% and 88.9% in secondary caries.
• Cvek Pulpotomy Outcomes
• Cvek: 96% (young incisors)
• Fuks: 94% success ( Ca(OH)2 )
• Witherspoon: 95% w/ MTA
• Aguilar (meta-analysis): Ca(OH)2 94%, MTA 87% (SS)

Implant Vs Endo
• Chercoles-Ruiz et al 2017: JOE. Systematic Review. The aim of this systematic review was
to answer the following clinical question: Which is the best treatment option for a pulpally
involved tooth: Endodontics, Endo ReTx and Apical Surgery vs Ext + Implant.
• The survival rate of single-tooth implants was greater than the success rate of the
distinct conservative treatments. However, among comparative studies, no important
differences between both treatments were observed until at least 8 years later.

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 • The endodontic treatment and the implant placement are both valid and complementary
options for planning oral rehabilitation. Although a level B recommendation can be
stated, these results come from retrospective comparative studies because there is a
lack of randomized clinical studies comparing both types of therapeutic options.
• Endodontic treatment and implant placement have comparable survival rates.
• The majority of studies on dental implants report only survival rates.
• The treatment should agree with the patient’s preferences.
• Setzer, Kim 2014:
• If a positive outcome for teeth was de ned as retention without symptoms, regardless of
the periapical status, the survival of endodontically treated teeth is as high as that of
implants.
• Long term outcome of both treatment options is similar. Yet, they need to be done by
experienced clinicians in order to have high survival rate.
• Both implants and endodontically treated teeth demonstrate signi cant outcome rates if
the treatments are appropriately chosen and rendered. However, a missing tooth is
irreversibly gone, and a tooth should be removed only after worthwhile deliberation.
There is no lifetime guarantee for either a natural tooth or an implant. Both options
should be seen as complementing each other, not as competing, and should serve the
overall goal in dentistry, the long-term health and bene t of the patient, being least
invasive and incorporating function, comfort, and esthetics. To achieve these goals, it is
important for clinicians to be fully aware of true long-term outcomes of both implants and
endodontically treated teeth.
• Torabinejad et al 2015: The rst systematic review comparing the survival of implant-
supported crowns and intentionally replanted teeth. The survival rate of implant supported
crowns is 97%. The survival rate of intentionally replanted teeth is 88%. The survival of
intentionally replanted teeth was by no means too low, and it should be considered as an
alternative treatment modality in selected cases for patients who like to save their natural
dentition.
• Torabinejad et al 2015: Systematic Review. Although, both have a high survival rate, At 4–
6 years, single implants had higher survival rates than teeth treated with endodontic
microsurgery.
• Survival Rates: Single implant (SI) survival rates varied from 96% at 2–4 years to 98%
for 6+ years; This indicated that implant losses primarily occurred before 2 years, with
few being lost thereafter; a steady state was approached within the times studied. Teeth
treated using endodontic microsurgery (EMS) had survival rates of 94% at 2–4 years
and 88% at 4–6 years, indicating that teeth treated with EMS tended to be lost at low
rates over the time studied. Teeth treated using EMS substantially lagged the survival of
SIS at the 2- to 4-year time interval. Survival data for 6+ years were not identi ed.
• Success Rates: A comparison between SI and EMS success rates was not appropriate
because the success criteria for the different treatment modalities were qualitatively
different. SI success rates varied from 98% at 2–4 years to 97% at 6+ years;. Implants
that had been successful at 2–4 years tended to remain as successes for the duration of
the period studied; a steady state was attained. Teeth treated with EMS had success
rates of 90% at 2–4 years and 84% at 4–6 years; the CIs barely overlapped, suggesting
a tendency for teeth treated with EMS to become unsuccessful over time. EMS success
data for 6+ years were not identi ed.SI success rates did not differ from SI survival rates
for each of the 3 time periods studied. In contrast, EMS success rates were lower than
EMS survival rates for both time periods studied.)

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 • Hannahan, Eleazer 2008: JOE. Implants were placed by periodontists in a group practice,
whereas the endodontic treatments were performed by endodontists in group practice. Charts
of 129 implants meeting inclusion criteria showed follow-up of an average of 36 months
(range, 15-57 months), with a success rate of 98.4%. One hundred forty-three endodontically
treated teeth were followed for an average of 22 months (range, 18-59 months), with a
success rate of 99.3%. No statistically signi cant differences were found (P = .56). When
uncertain ndings were added to the failures, implant success dropped to 87.6%, and
endodontic success declined to 90.2%. This difference was not statistically signi cant (P =
.61). We found that 12.4% of implants required interventions, whereas 1.3% of endodontically
treated teeth required interventions, which was statistically signi cant (P = .0003). The
success of implant and endodontically treated teeth was essentially identical, but implants
required more postoperative treatments to maintain them.
• Iqbal, Kim 2007: Concluded in their systematic review that there was no difference in the
survival outcome between either of these treatment modalities. Therefore, the decision to
perform endodontic or implant treatment should be based on factors other than treatment
outcome. The results of this systematic review indicate that the decision to treat a tooth
endodontically or replace it with an implant must be based on factors other than the treatment
outcomes of the procedures themselves. Both nonsurgical root canal therapy followed by an
appropriate restoration and single-tooth implants are excellent treatment modalities for the
treatment of compromised teeth.
• Torabinejad, Goodacre et al 2007: Systematic Review. 6 yrs.
• Survival 97% for implants, 97% for RCT, 82% FPD
• Success: 95% for implant, 84% RCT, 80% FPD.
• 97% at 6 yrs. showed that both root canal and implant treatments resulted in a very
high survival rate (97% at more than 6 years), compared to only 80% for a xed dental
prosthesis (3-4 unit bridge). Success rates for ISCs were higher than for RCTs and
FPDs, respectively; however, success criteria differed greatly among treatment types,
rendering direct comparison of success rates futile. Long-term survival rates for ISCs
and RCTs were similar and superior to those for FPDs.
• Doyle et al 2006: This study suggests that restored endodontically treated teeth and single-
tooth implant restorations have similar failure rates, although the implant group showed a
longer average and median time to function and a higher incidence of postoperative
complications requiring subsequent treatment intervention. Outcomes were as follows for
implants and NSRCT outcomes, respectively: success 73.5% and 82.1%. At 6.5 years RCTs
89.5% survival. (196 implants vs 196 RCTs, 1-10yr recalls). (The results of this study show
that the endodontic and implant therapies resulted in an identical number of failures, but the
implant group had fewer successes and survivals, independent of location. The implants had
a signi cantly higher fraction of patients classi ed as surviving with the requirement for
subsequent treatment, equivalent to clinical complications. Additionally, the implant group had
a longer time-to-function than the endodontic group. The location of the restorative treatment
was not a signi cant factor when comparing the two treatment groups.)
• Doyle et al 2007: Factors affecting outcomes for single-tooth implants and endodontic
restorations.
• Initial root canal therapy and implant placement are both common treatment modalities,
and, as such, prognostic factors that in uence the treatment outcomes of these two
restorations should be identi ed. In a retrospective chart review, 196 implant restorations
and 196 matched initial nonsurgical root canal treated (NSRCT) teeth in patients were
evaluated for four possible outcomes-success, survival, survival with intervention, and
failure. Results showed that smokers had fewer successes and more failures in both

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 groups (p = 0.0001), whereas NSRCT outcomes were affected by periradicular
periodontitis (p = 0.001), post placement (p = 0.013), and over lling (p = 0.003).
Outcomes for both groups were not signi cantly affected by diabetes, age, or gender.
Implant group outcomes were not affected by implant length (from 10 to 16 mm),
diameter (from 3.25 to 5.5 mm), or an adjacent endodontically treated tooth, nor were
NSRCT outcomes affected by the number of appointments for the procedure.
• Age, sex, and diabetes do not affect the outcome of endodontic or implant treatment.
Smokers have a lower treatment success in both groups. For endodontics, presence of
PA radiolucency, over lling, and post placement decreased success. The number of
treatment appointments was not signi cant for the endo group. For implants, the
presence of adjacent endodontically treated teeth, implant width, and implant length did
not in uence the outcome.
• Sussman 2007: Implants may fail due to endodontic infection from a nearby tooth (case
report)
• Pennington et al 2009: IEJ. Modeling the available clinical and cost data indicates that, root
canal treatment is highly cost- effective as a rst line intervention. Orthograde re-treatment is
also cost-effective, if a root treatment subsequently fails, but surgical re-treatment is not.
Implants may have a role as a third line intervention if re-treatment fails.
• Shabahang, Torabinejad 2003: Dog Study. Teeth with periradicular lesions DO NOT
adversely affect adjacent titanium implants. Implants osseointegrated and neighboring tooth
infected
• Torabinejad, Lozada et al 2014: JOE. Patients perceive both treatments with high degrees
of satisfaction with minimal pain and complications.
• Laird et al 2008: JOE. The purposes of this study were to determine success and survival
rates for implants and teeth adjacent to implants and the incidence of endodontic implantitis
(E-I) (endodontic involvement in adjacent teeth causing implant failure) and implant
endodontitis (I-E) (implant placement causing endodontic failure). The data were from 233
single-tooth implants placed in 116 subjects by postgraduate periodontal students with recall
radiographs taken >or=9 months after implant placement. Three groups were analyzed: group
A, implants with no adjacent teeth (n = 90); group B, implants with nonendodontically treated
adjacent teeth (n = 123); and group C, implants with endodontically treated adjacent teeth (n
= 20). The success and survival rates for implants were both 92.2% in group A, 98.4% and
99.2% for group B, and 85% and 95% for group C, respectively. For adjacent teeth, they were
both 99.4% in group B compared with 75% and 90% in group C. However, after case review,
none of the implants or adjacent teeth in group B were considered to have E-I or I-E, and one
(5%) of the implants in group C had E-I and two (10%) of the adjacent teeth may have had I-
E. The results of the present study agree with previous research, which suggests that
endodontically treated teeth adjacent to single-tooth implants are usually successful and
should be maintained.(Loss of implants due to endodontic implantitis or loss of RCT'd teeth to
implant endodontitis low, so no need to ext RCT'd teeth prior to implant placement.)
• Iqbal 2008: Implant studies lack standardized success criteria and often sponsored by
manufacturer
• Implants Vs RCT
• Torabinejad 2007: Systematic Review. NSD - 97% survival at 6 yrs
• Doyle: NSD - 94%, implants 5 x more post-op interventions
• Iqbal, Kim: MA. Systematic Review/Meta analysis – NSD implant/crn 96%, RCT/crn
94% NSD survival or success; implants more surg
• Hannahan, Eleazor: intervention (12.4%implant vs 1.4% endo) Implants less max biting
force, chewing ef ciency

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 • Pogrel, Ruggerio 2017: Successful dental implants can fail when patients start taking
bisphosphonates. This article reports a type of localized osteonecrosis that can occur in
patients who have had successful osseointegrated implants for many years and then
commence anti-resorptive therapy. Eleven female patients were identi ed who had successful
implant insertion, but who were placed on anti-resorptive therapy (bisphosphonates or
denosumab) several years later and developed osteonecrosis around the implants. In each
case, the osteonecrosis occurred only around the implants and not around the patient's
remaining teeth. The implants of eight patients were removed with a sequestrum of bone
tightly adherent to the implant. This is different from the normal pattern of implant failure.
Implant failure can occur when patients with successfully integrated implants are later placed
on anti-resorptive therapy, and the osteonecrosis takes a particular form where a sequestrum
forms that remains adherent to the implant. Why the adjacent remaining teeth are not affected
is unclear.

Flare-ups
• De nition
• AAE Glossary: An acute exacerbation of periradicular pathosis after initiation or
continuation of root canal treatment.
• Walton 2002: Increase in pain or swelling, usually within a few hours to a few days
following treatment, that prompts an unscheduled visit to the treating clinician.
• Treatment
• Seltzer, Naidorff 1985: Analgesics and antibiotics may be used to control a are-up
once initiated.
• Walton 2002: Endo Topics. Psychologic management to reassure the patient that the
condition is treatable and should not affect the prognosis, localized treatment to re-clean
and medicate the canal or incise and drain swelling and pharmacologic management.
• Dunksky and Moore 1984: Long acting LA, such as bupivacaine
• Others have proposed: analgesics, steroids, antibiotics when indicated.
• Harrington, Natkin: Midtreatment are-ups: The principal modality for managing
swelling secondary to endodontic infections is to achieve drainage and remove the
source of the infection.
• Other options
• Adjust occlusion to reduce post-op pain (Cunningham; Rosenberg)
• Re-enter RC system and debride
• Open vs Closed (Seltzer & Naidorf; August)
• Establish Drainage: (Harrington)
• Evaluate for Analgesics: 3-D Strategy (Hargreaves)
• Evaluate for antibioitics (Harrison; Baumgartner)
• Evaluate for Steroids (Marshall and Walton)
• Seltzer: Endodontic are-ups may occur because of a variety of reasons, including
preparation beyond the apical terminus, over-instrumentation, pushing dentinal and pulpal
debris into the periapical area, incomplete removal of pulp tissue, overextension of root canal
lling material, chemical irritants (such as irrigants, intracanal medicaments, and sealers),
hyper-occlusion, root fractures, and microbiologic factors.
• Torabinejad et al 1988: Retrospective.
• Risk Factors: Pre-op pain was an excellent predictor, females 40-59, no or small PA
lesions, mandibular premolars or anteriors (tooth type), pts with allergies, pre-op
analgesic use, no sinus tracts, retreatments.

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 • Factors associated endodontic interappointment emergencies of teeth with necrotic
pulps. I. Patients in the 40- to 59-yr range are more susceptible to develop IAE than
other age categories. 2. Female patients had more IAE than their male counter- parts.
Furthermore, women over the age of 40 had signi cantly higher rates of IAE than their
male or female counter- parts. 3. Mandibular bicuspids followed by the mandibular
anteriors were the most problematic teeth after cleaning and shaping of their root canals.
4. Highly signi cant association exists between the frequency of IAE and the presence of
allergies. 5. Patients with preoperative complaints are highly susceptible to IAE. 6. The
frequency of IAE was signi cantly higher in patients with no or small periapical lesions
than in those with larger lesions. 7. The patients who were taking medications
postoperatively had signi cantly fewer IAE than those on no medications. 8. Retreated
cases had a higher incidence of IAE than those that received initial treatments. 9.
Presence of sinus tract stomas signi cantly reduces the frequency of IAE. 10. Presence
of systemic diseases, use of intracanal medication, and penetration of the foramen with
small instruments had no signi cant effect on the frequency of IAE.
Patients under 20 had lowest incidence of are-ups. Higher number of are-ups in females
especially over age 40. A higher frequency of are-ups after cleaning and shaping the root canal
system in mandibular teeth. A higher incidence of are-ups in teeth w/out apical radiolucencies
and lower incidence in teeth with large radiolucencies. A higher incidence in patients with
allergies. No difference in patients with systemic disesase vs no systemic disease. Pre-op pain a
good predictor of are-up. Associated are-ups with retreatment therapy and history of allergies.
By using long lasting anesthetics, completely cleaning the shaping the root canal system,
administering appropriate medications and psychologically preparing patients with pre-op
complaints may reduce number of are-ups. Use of analgesics resulted in signi cantly fewer
cases of interappointment emergencies. Lower incidence of are-ups (p=.05)in patients who
received antibiotics compared to those who did not. Higher incidence in retreatment cases.
Intracanal medications had no effect on are-ups.
• Trope 1990: No areups in teeth with no PARL. Flare-up rate in asx necrotic teeth is 2.5%,
4% w/ PARL or re-tx. Intracanal medicaments have no effect on are-up rate.
• Trope 1990: Flareups occur 3/22 in re-tx, BUT pre-op symptoms were not recorded in this
study!
• Iqbal et al 2009: The presence of a periapical lesion was the single most important predictor
of are-ups during NSRCT. 9.64 X greater chance if PA lesion.(opposite Torabinejad). There
was no statistically signi cant difference in are-ups between one and two visits NSRCT. The
odds of developing a are-up increased 40 fold when NSRCT was completed in three or more
visits.
• Harrington, Natkin 1992: suggested that necrotic teeth are more likely to have are-ups;
especially if debris is extruded. This nding was also con rmed later by Siqueira (2005).
Remember Crown-down (Ruiz-Hubbard & Gutmann 1987 JOE) and balanced-force
(McKendry 1990 JOE) extruded less debris than step-back instrumentation.
• Walton, Fouad 1992: Endodonitc interappointment are-ups. Overall incidence: 3.17%.
Overriding factor to predicting are-ups: Presenting Conditions (signs, symptoms, diagnosis).
Greater occurrence in females. Age not a factor. Patients initial symptoms (pain, swelling)
were associated with higher incidence of are-ups. Teeth with vital pulps resulted in relatively
few are-ups (1.3%). Teeth with necrotic pulps had a 6.5% incidence (statistically signi cant).
The periodontal diagnosis of acute apical abscess was signi cantly greater in areups. Sinus
tract = 0% areups. Number of visits not signi cant. Obturation correlated with signi cantly
fewer post treatment areups. No sig diff between intial tx vs retreatment. Dental students
had fewer areups.

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 • Pickenpaugh, Reader, Beck, Meyers, Peterson 2001: RCT: effect of prophylactic
amoxicillin on endodontic are-ups in asymptomatic, necrotic teeth. Prophylactic amoxicillin
does not signi cantly in uence the occurrence of endodontic are-up. Has no effect on the
incidence of are-up.
• Alacam, Tinaz 2002: Interappointment emergencies/ areups in teeth with necrotic pulps.
Overall incidence of are-ups 7.17% (9.4% sympotomatic cases, 5.9% in asymptomatic
cases). Signi cantly more painful are-ups in mandibular teeth than in max teeth. There were
no signi cant differences in the incidence of are-ups attributable to gender, age, presence/
diameter of lesions, taking analgesics, or pre-operative symptomatic or asymptomatic tooth
diagnoses.
• Kerekes, Tronstad 1979: (Root canal done by undergraduate, hand le and lateral
condensation): No change in prognosis for success if case has are-up (opposed to Ng
study). Roots without periradicular radiolucency prior to treatment showed better success rate
than those with radiolucency. No difference in success between vital and necrotic pulps, or in
teeth with are-ups during tx. Adequate seal and the apical level of the root lling were
signi cant factors for the success of tx.
• Walton 1977: compared the effect of three intracanal medicaments (Formocresol, Ledermix,
and calcium hydroxide) on the incidence of post-instrumentation are-ups. 2.5% are ups
were seen. No signi cant difference was found in the are-up rate among the three intracanal
medicaments.
• Segura-Egea, Cisneros-Cabello 2009: Pain associated with root canal treatment Int Endod
J (2009): There are no signi cant differences in relation to gender or age groups. Mandibular
teeth had a signi cantly (P < 0.05) higher percentage incidence of pain in comparison with
maxillary teeth. Pain was absent in 63% of anterior teeth compared with 44% in posterior
ones (P < 0.01). Interventions shorter than 45 min resulted in a signi cantly higher
percentage of pain absence (P < 0.05). Root canal treatment was signi cantly (P < 0.05)
more painful in teeth with irreversible pulpitis and acute apical periodontitis compared to the
group with necrotic pulps and chronic apical periodontitis (P = 0.049).
• Bence & Meyers '80; Simon '82; Seltzer & Naidorf '84 : leaving teeth open between
appointments is not recommended due to bacterial recontamination, food debris, blockage of
canals and higher chance are-ups. Also Weine (1975 OOO) showed that teeth left closed
had fewer exacerbations.
• Haapasalo 1997: If root canal had been unsealed at some point between treatments, enteric
bacteria were found more frequently. This indicate the importance of good seal between
different appointment. Also the higher the number of appointments the rate of enteric bacteria
would be higher.
• Siqueira 2003: Review: Micobial causes of Endodontic areups. Incidence: 1.4 - 16%.
Causes: debris extrusion, changes in microbiota and environmental condition, secondary
infections (new bacteria possibly introduced into root canal), increase of oxidation-reduction
potential. Flare-up Preventions: one of the best predictors of are-up occurrence is a history
of preoperative pain and/or swelling, especially necrotic cases. Clinicians should: select
instrumentation techniques with the least debris extrusion, complete chemo-mechanical
instrumentation in one visit, use antimicrobial medicaments between appointments, not leave
teeth open for drainage, maintain aseptic environment during treatment. Flare-ups have no
signi cant effect on the outcome of treatment.
• Seltzer & Naidorf 1985: Causes of Flare-ups: overinstrumentation, overmedication, debris
forced into periapical tissue, incomplete removal of pulp, recrudescense of CAP. over-
irrigation, hyperocclusion, root fracture, another tooth, pasteur effect (over growth of
facultative anerobes)

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 • de Chevigny, Basrani et al 2008: Though uncomfortable, are-ups have not been
associated with treatment failures (Toronto Studies).
• Tsesis, Fuss et al 2008: Meta-analysis. Flare-up frequency 8.4%. Insuf cient evidence for
in uencing factors. Authors propose etiology is likely multifactoral, compromising chemical,
mechanical and microbial factors inherent in the endodontic disease and treatment. No
consensus on causation.
• Yu, Messer, et al 2012: 5.8% incidence of are-up after initiation of RCT on teeth with
persistent periapical lesions.
• Do prophylactic antibiotics help decrease are-ups:
• Akbar 2015: Prophylactic use of Amoxicillin in asymptomatic non vital teeth before root
canal treatment had no effect on the incidence of are-up.
• Reader:
• Pen VK did not decrease are-ups with irreversible pulpitis
• Amoxicillin did not decrease are-ups with necrotic, asymptomtic teeth
• Pen VK did not decrease are-ups with necrotic, symptomatic teeth
• Walton: Pen VK had no signi cant effect on incidence of are-ups
• Brennan: No difference in infection, pain or adverse events following use of PCN
• Abbott et al 1988: Reported a reduced incidence in tx of asymptomatic, necrotic teeth.
However, study * awed, as it used an outside control group.
• Endo Emergencies: Open or Closed
• Weine 1975: OOO. Teeth left closed had fewer exacerbations.
• Simon 1982: JOE. leaving teeth open can lead to foreign body reaction of material
forced into periapical tissue
• Seltzer & Naidorf 1984: JOE. Reasons why not leave tooth open include additional
bacterial contamination, contamination with food debris or
blockage of canals, unnecessary follow-up appts to close the tooth
• Sundqvist 1976: REMEMBER: Apical periodontitis can only be detected in teeth with
bacteria present in canal systems. Open cases will become infected. Necrotic, but sterile
teeth have no signs of PARL. In contrast, necrotic and infected teeth showed PARLs.
Also, probability of pain increased with # bacterial species (esp when >6); suggests
bacterial synergism is important virulence factor.
• August 1982: OK to leave teeth open. Reported 46% of teeth closed had to be re-
opened. Teeth left open can be completely instrumented and closed (95% remain
closed).

Misc Treatment Outcomes

• Chugal N, Clive, Spangberg 2003: (Conclusion: Diseased periapex, level of working length
relative to the radiographic apex, and fair/poor density all affect the outcome of endodontic
treatment) We sought to investigate the simultaneous effect of apical periodontitis,
instrumentation level, and density of root canal lling on endodontic treatment outcome. For
this study, 200 endodontically treated teeth with 441 roots were used. A follow-up examination
was conducted 4 +/- 0.5 years postoperatively. Data were subjected to univariate and
multivariate analysis. Results: Periapical pathosis had the strongest effect on treatment
outcome (P <.0001). The instrumentation level (mean +/- SEM of the working length) for
successfully treated teeth/roots with normal preoperative pulp and periapex was farther away
from the radiographic apex (1.23 +/- 0.13 mm) than for teeth/roots with an unsuccessful
outcome (0.20 +/- 0.09 mm; P <.005). However, successfully treated teeth/roots with pulp
necrosis and apical periodontitis had working length levels closer to the radiographic apex

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 (0.55 +/- 0.12 mm) than did teeth/roots with unsuccessful outcomes (1.73 +/- 0.30 mm;
P<.001). In teeth/roots with apical periodontitis, a millimeter loss in working length increased
the chance of treatment failure by 14%. The risk of failure was higher for a fair/poor density of
obturation than for a good density for all diagnoses of periradicular status.
• Witherspoon, Ham 2001: Immature Necrotic Teeth: Found that the success rate of MTA
apexi cation treatment was 93.5% if performed in a single visit and 90.5% if performed in two
visits.
• Jeeruphan, Hargreaves et al 2012: Mahidol Study. Immature Necrotic Teeth: Looked at
survival, which measures the mere presence of a tooth in the mouth, as compared to
success, which looks at healing. They found that the radiographic survival of MTA
apexi cation was 95% whereas for calcium hydroxide apexi cation, the survival rate was
77%. However, both treatments presented a long-term risk of cervical fracture. REGEN was
100%.
• Mente et al 2013: Immature necrotic teeth. Reported that success rates for apexi cation are
lower in the presence of preoperative apical periodontitis. Additionally, they reported that
success rates were less favorable if treatments were performed over sever visits.
• Pace et al 2014: 94% of immature necrotic teeth treated with MTA apexi cation were healed
10 years postoperatively.
• Sorenson, Martinoff 1985: Endodontically treated teeth as abutments. retrospective clinical
investigation comparing 1273 endodontically treated teeth as abutments or crowns, it was
found that the success rate was higher for single crowns (94.8%) than FPD (89.2%) and RPD
abutments (77.4%).
• Main, Shabahang, Torabinejad 2004: Prognosis of perf repair - 100% 16/16 w/ MTA
• Mente: Prognosis of perf repair - 86% at 3 yr recall, perfs bigger than 3mm less success

Analgesics/Pain Control
• K. Hargreaves: principle of pain control is 3D Diagnosis, De nite dental treatment, Drugs
• Hargreaves, Keiser 2004: Management of Endo Pain Emergencies. Review. Looked at
Diagnosis, De nitive Dental Tx, Drugs. Ibuprofen 600mg and 800mg provided highest % of
pain relief.
• Hargreaves: Flexible Prescription Plan
• NSAIDS/Ibuprofen
• Max ibuprofen dose = 3200mg in 24hrs
• NSAIDs may be tolerated in patients with mild chronic liver disease, but they should be
avoided in all patients with cirrhosis because of the increased risk of hepatorenal
syndrome and the dire consequences relating to this complication. The safety of
Acetaminophen was assessed in a review study by Aminoshariae (JOE, 2015).
Acetaminophen is still the preferred analgesic in patients with liver disease because of
the absence of platelet impairment associated with NSAIDs. In general, NSAIDs should
be avoided in patients with liver disease. Although no consensus has been reached on
what is a safe dose, the total daily dose should not increase 2 g for patients with liver
damage. Acetaminophen remains the drug of choice for these patients. In patients taking
lithium NSAIDs should be prescribed cautiously due to decrease kidney excretions of
lithium and possible lithium toxicity. In this case it is better to prescribe Tylenol (Wynn,
Ragheb)

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 • Contraindications to ASA/NSAIDs
• Pregnancy (3rd Trimester only)
• Asthmatics – blocks PGE2, leads to excess Leukotrienes —> bronchoconstriction
• Sickle Cell Anemia – vasoclusive crisis (acidosis)
• Peptic Ulcer Disease – gi protection (blocking cox1), bleeding risk
• Crohn’s Disease, Ulcerative Colitis – gi protection (blocking cox1), bleeding
• Long-term Steroid use (gut mucosa – potential ulceration)
• Uncontrolled Hyperthyroidism
• Congestive Heart Failure
• Liver Disease – bleeding risk/metabolism of drugs reduced
• Chronic Kidney Disease/End Stage Renal Disease (GFR < 15 mL/min)
• Previous MI (Olson) – NSAIDs only, Naproxen ok if limited to 7 days
• Previous Stroke – Avoid NSAIDs only
• Bleeding Disorders – Thrombocytopenia, Hemophilia, von Willebrand’s
• Meds: Anti-platelet (Aspirin,Plavix), Anti-coagulants (Coumadin, Heparin), Valproic
acid (Epilepsy), Lithium (bipolar), Sulfonylureas (diabetes), Methotrexate (cancer/
AI)
• *Limit NSAIDs (< 2 wks) with Anti-HTN meds (Beta blockers, ACEI, Diuretics)
• Hargreaves 1987: Ibuprofen asserts its effect by blocking the cyclooxygenase 1 and 2
enzymes, thus preventing the production of prostaglandins.
• Taggar, Wu, Khan 2017: JOE. RCT. In endodontic pain patients, a single dose of
ibuprofen sodium dihydrate provides faster onset of pain relief and a greater reduction in
spontaneous and evoked pain compared with ibuprofen acid. (Advil lm coated tablets)
• Smith, Marshall, Sedgely et al 2017: JOE. Systematic Review/MA. A combination of
ibuprofen 600 mg and acetaminophen 1000 mg is more effective than placebo but not
signi cantly different than ibuprofen 600 mg at 6 hours postoperatively. Ibuprofen 600
mg is more effective than placebo at 6 hours postoperatively; however, there are
insuf cient data to recommend the most effective NSAID, dose amount, or dose interval
for the relief of postoperative endodontic pain of longer duration in patients with
preoperative pain. (Nonsteroidal Anti-in ammatory Drugs for Managing Postoperative
Endodontic Pain in Patients Who Present with Preoperative Pain: A Systematic Review
and Meta-analysis. As it stands, the dental literature lacks speci city in its reporting and
clarity in its results. Ibuprofen is the most studied NSAID, which at a dose of 600 mg is
more effective at relieving pain than placebo at 6 hours after endodontic treatment.
Ibuprofen 600 mg + acetaminophen 1000 mg is signi cantly more effective than placebo
at 6 hours. There is low strength of evidence to recommend ibuprofen or ibuprofen plus
acetaminophen over placebo. Based on preliminary information, ketoprofen 50 mg and
naproxen 500 mg might be more effective than ibuprofen 600 mg at 6 hours
postoperative. At this time, there are insuf cient data to recommend the most effective
NSAID, dose amount, or dose interval for relieving postoperative endodontic pain in
patients with preoperative pain.)
• Dionne, Gordon 2015: Ibuprofen is the analgesic of choice for managing acute, post-
op, in ammatory dental pain, but if additional pain relief is needed, oxy or hydrocodone
can be prescribed to supplement the NSAID. The prevention of pain onset by use of
NSAIDs either pre-op or immediately post-op to inhibit PGE2 production is one of the
most critical factors in minimizing post-op pain.
• Hargreaves 1989: Preoperative nonsteroidal anti-in ammatory medication for the
prevention of postoperative dental pain, J Am Dent Assoc 1989. Prophylactic

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 administration of a nonsteroidal antiin ammatory drug (NSAID), such as 200 to 400 mg
of ibuprofen 30 to 60 minutes before the procedure, has been shown to reduce or
prevent post-treatment dental pain.
• Cooper: For moderate to severe pain relief, ibuprofen, an NSAID, has been found to be
superior to aspirin (650 mg) and acetaminophen (600 mg) with or without codeine (60
mg). Also, ibuprofen has fewer side effects than the combinations with opioid. The
maximal dose of 3.2 g in a 24-hour period should not be exceeded. Patients who take
daily doses of aspirin for its cardioprotective bene t can take occasional doses of
ibuprofen; however, it would be prudent to advise such patients to avoid regular doses of
ibruprofen. These patients would gain more relief by taking a selective cyclooxygenase
(COX)-2 inhibitor, such as diclofenac or celecoxib.
• Mickel A 2006: Survey. It was found to be statistically signi cant that 600 mg ibuprofen
given four times per day was the preferred analgesic prescribed for patients regardless
of their perceived level of pain, endodontic diagnosis, or treatment rendered. Narcotics
were prescribed in the following conditions: postsurgical pain (28%), postoperative are-
up (31%), or severe pain associated with a necrotic pulp and acute periradicular abscess
(34%)
• Attar 2008: Pre-op 600mg ibuprofen does not signi cantly reduce post-op pain in Non-
surgical RCT
• Savage 2004: Paper to support pre-op 800mg ibuprofen for SURGERY
• Savage, Henry 2004: Lit Review of Pre-op NSAIDS. Background: Postoperative pain
following certain surgical procedures is fairly predictable, therefore, steps should be
taken to minimize patient pain and discomfort. Acute tissue injury associated with
surgical procedures not only activates peripheral nociceptors but also has a signi cant
effect on the CNS. This leads to primary hyperalgesia, which involves mostly peripheral
mechanisms and can lead to secondary hyperalgesia that involves central mechanisms.
Prostaglandins are synthesized from arachidonic acid by COX enzymes and are
involved in the sensitization of peripheral nociceptors, thereby contributing both to
development of primary hyperalgesia and subsequent secondary hyperalgesia
(in ammatory pain). PGE2 and PGI2 have been implicated in in ammatory pain.
NSAIDs not only have a direct analgesic effect, they also inhibit prostaglandin formation
by way of COX-1 and COX-2 enzyme systems. Two types of NSAIDs: nonselective
NSAIDS (inhibit COX-1 and COX-2) and speci c COX-2 inhibitors. Contraindications to
NSAID use: Short-term use of most NSAIDs pose minimal risk. Most side effects are
seen only after long-term use. There are 3 classes of antihypertensive agents that can
interact with NSAIDS: angiotensin-converting enzyme inhibitors, beta-blockers, and
diuretics. The action of all these drugs is aided by renal prostaglandins. With the NSAID
principal effect being prostaglandin inhibition, the effectiveness of these agents will be
diminished. This effect usually takes 7 to 8 days to occur. Therefore, NSAID use in a
hypertensive patient on these medications should be limited to 4-6 days. When taken
concomitantly with oral anticoagulants, NSAIDs can signi cantly increase the potential
for bleeding. This is especially true for aspirin. NSAIDs should be avoided in patients on
oral anticoagulants. NSAIDs can suppress renal function; therefore they can increase
concentrations of drugs, which are normally eliminated by the kidneys (digoxin,
methotrexate, lithium). Avoid in patients taking these medications. Avoid nonselective
NSAIDs in patients with known GI issues. They may bene t from COX-2 speci c
NSAIDs. Conclusion: Preoperative use of anti-in ammatory medication appears to be a
valid method to increase patient comfort postoperatively. It also appears to reduce use of

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 narcotics and postoperative edema. Bottom Line: If pain is anticipated a preoperative
NSAID will likely increase postoperative patient comfort.
• Flath 1987: Flurbiprofen reduces post-op pain. RCT alone signi cantly reduced pain in
patients presenting with odontogenic pain.
• Dione 1983: Pretreatment with 800mg iburprofen resulted in less post-op pain compared
to 600mg + 60mg codeine
• Parirokh: 600mg ibuprofen 1 hr pre-op in pts w/ irreversible pulpitis increased anesthetic
success (32% to 78%)
• Reader: 600-800mg pre-op ibuprofen had no signi cant effect on IAN success in pts
with IP
• Menke 2000: Prophylactic ibuprofen was more effective than etodolac. Patients with pre-
op pain are most likely to have post-op pain.
• Holstein, Hargreaves, 2002: NSAIDS are effective for treating endo pain. Most effective
combo is urbiprofen + Tramadol
• Acetaminophen
• Maximum dosage of Acetaminophen = 4 g in 24h. (3250 OTC recommended)
• Acetaminophen is a safer drug in patients who have GI problems compared to NSAID.
Acetaminophen alone or in combination with a low-potency opioid does have mild anti-
in ammatory properties and has been shown to be effective in both acute and chronic
in ammatory conditions. While acetaminophen has been considered to be the safest
non-narcotic analgesic in chronic kidney disease CKD patients, it must be cautioned,
however, that it may be nephrotoxic with chronic high dose use. With the exception of
methadone, the majority of opioids recommended for both moderate and severe pain
undergo hepatic biotransformation and renal excretion as the primary route of
elimination. The signi cant renal retention of active or toxic metabolites of commonly
used opioids including, but not limited to, morphine, oxycodone and propoxyphene can
occur among advanced CKD patients and lead to profound central nervous system and
respiratory depression and hypotension.
• Comparable antipyretic and analgesic activity with aspirin. Its utility is largely based on
the ndings that its side effect pro le is less adverse than the NSAIDs and the drug can
be used in patients for whom NSAIDs are contraindicated.
• Aminosharie 2015: New evidence suggests that, similar to NSAIDS, acetaminophen
functions in part by blocking prostaglandin synthesis through the inhibition of
cyclooxygenase 1 and cyclooxygenase 2, with additional activity linked to the central
nervous system via endogenous neurotransmitter systems
• Ibuprofen + Acetaminophen
• Derry, Moore 2013: Cochrane Systematic Review. Ibuprofen plus paracetamol
combinations provided better analgesia than either drug alone (at the same dose), with a
smaller chance of needing additional analgesia over about eight hours, and with a
smaller chance of experiencing an adverse event.
• Elzaki et al 2016: The combination of ibuprofen/paracetamol (acetaminophen), taken
immediately after initial endodontic therapy and root canal preparation in teeth (anteriors
& premolars only) with irreversible pulpitis, reduced post-endodontic pain. (better than
acetaminophen alone)
• Moore, Hersh 2013: Systematic Review. The results of the quantitative systematic
reviews indicated that the ibuprofen-APAP combination may be a more effective
analgesic, with fewer untoward effects, than are many of the currently available opioid-
containing formulations. In addition, the authors found several randomized controlled
trials that also indicated that the ibuprofen-APAP combination provided greater pain relief

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 than did ibuprofen or APAP alone after third-molar extractions. The adverse effects
associated with the combination were similar to those of the individual component drugs.
Practical Implications. Combining ibuprofen with APAP provides dentists with an
additional therapeutic strategy for managing acute postoperative dental pain. This
combination has been reported to provide greater analgesia without signi cantly
increasing the adverse effects that often are associated with opioid-containing analgesic
combinations. When making stepwise recommendations for the management of acute
postoperative dental pain, dentists should consider including ibuprofen-APAP
combination therapy.
• Menhinick, Gutmann 2004: Classic: 600mg ibuprofen + 1000mg APAP gives better
analgesia than ibuprofen alone. One of the rst to report ibu+Tylenol is great.
• Miranda et al 2006: Ibuprofen and acetaminophen are synergistic rather than merely
additive
• Wells, Drum, Nusstein, Reader, Beck 2011: The purpose of this prospective,
randomized, double-blind study was to determine ibuprofen versus ibuprofen/
acetaminophen use for postoperative endodontic pain in symptomatic patients with a
pulpal diagnosis of necrosis and an associated periapical radiolucency who were
experiencing moderate to severe preoperative pain. We also recorded escape
medication use. M&M: Seventy-one adult patients presenting for emergency endodontic
treatment with a symptomatic maxillary or mandibular tooth with a pulpal diagnosis of
necrosis, periapical radiolucent area, and moderate to severe pain participated in this
study. The patients were randomly divided into 2 groups by random assignment and
numeric coding. An emergency debridement of the tooth was completed with hand and
rotary instrumentation. At the end of the appointment, the patients randomly received
capsules of either 600 mg ibuprofen or 600 mg ibuprofen combined with 1000 mg
acetaminophen (blinded to both operator and patient). Patients also received a 6-day
diary to be completed after anesthesia wore off and every morning for 5 days. Patients
were asked to record pain, symptoms, and the number of capsules taken. Patients
received escape medication (Vicodin) if the study medication did not control their pain.
Postoperative data were analyzed by randomization test and step-down Bonferroni
method of Holm. Conclusion: There were decreases in pain levels and analgesic use
over time for the ibuprofen and ibuprofen/acetaminophen groups. There was no
statistically signi cant difference between the 2 groups for analgesic use or escape
medication use. Approximately 20% of patients in both groups required escape
medication to control pain.
• Sebastian, Reader et al 2016: Can NSAIDs/Acetaminophen combination be used to
temporarily relieve symptoms….YES. Compared debridement vs no debridement on
post op pain in emergency patients with symptomatic teeth, a pulpal diagnosis of
necrosis and a periapical radiolucency. n = 95. Group 1 received anesthesia and endo
debridement and group 2 received anesthesia but no debridement. At the end of the
appointment, all pts were given 600mg ibuprofen/1000 mg acetaminophen every 6 hrs. If
needed they could receive an escape medication. Patients receiving debridement or no
debridement had a decrease in postoperative pain over the 5 days. Debridement
resulted in a statistically higher success rate, but there was no signi cant difference in
need for escape medication.
• Mehrvarzfar, Abbott et al 2012: IEJ. RCT. A single oral dose of NSAID drugs such as
Naproxen and Novafen immediately after root canal preparation relieved postoperative pain
more than Tramadol or a placebo when there was moderate to severe preoperative pain
associated with irreversible pulpitis, in the rst 24 h after treatment. (To compare the effects of

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 single doses of three oral medications on postoperative pain following instrumentation of root
canals in teeth with irreversible pulpitis. Tramadol 100mg, Naproxen 500mg, Novafen (325
mg of paracetamol, 200 mg ibuprofen and 40 mg caffeine anhydrous). A single oral dose of
Naproxen, Novafen and Tramadol taken immediately after treatment reduced postoperative
pain following pulpectomy and root canal preparation of teeth with irreversible pulpitis.)
(However, as Hargreaves states, since they did the pulpectomy that will decrease pain,
therefore it skews the direct effect of the drugs).
• Hargreaves 1993: Comparison of oral triazolam and nitrous oxide with placebo and
intravenous diazepam for outpatient premedication. Oral Surg Oral Med Oral Pathol 1993.
Triazolam (0.25mg) appears to be a safe, effective alternative to parenteral sedation with a
benzodiazepine for dental outpatients. Benzodiazepines work by increasing the ef ciency of a
natural brain chemical, GABA, to decrease the excitability of neurons. This reduces the
communication between neurons and, therefore, has a calming effect on many of the
functions of the brain.
• Khan, Dionne 2002: COX-2 inhibitors for endodontic pain. Endodontic Topics 2002. It is now
believed that COX-1 is responsible for the immediate prostanoid response and COX-2 then
contributes as in ammation progresses. Thus, COX-1 is now thought to play a role in
in ammation. While it is clear that COX-2 inhibitors offer some advantages over the non-
selective NSAIDs in terms of a lower risk of GI toxicity with long-term use, the effects
following short-term use are still unclear. Until more data are available, COX-2 inhibitors
should be avoided or used with the same caution as conventional NSAIDs in patients with
compromised renal and cardiac function. A recent development in pain research is the
identi cation of a variant of COX-1, which has been named COX- 3. COX-3 was rst
identi ed in the canine brain and its activity is inhibited by acetaminophen as well as NSAIDs
such as ibuprofen. The identi cation of COX-3 may explain the mechanism of action of
acetaminophen. Acetaminophen is a centrally acting drug with a potent antipyretic and
analgesic effect and a weak anti-in ammatory effect. It is now clear that acetaminophen acts
by inhibiting COX-3 activity in the brain. COX-3 differs in its pharmacological activities from
both COX-1 and COX-2 and is a potential target for analgesic and antipyretic drugs.
• Marshall 2002: Endo Topics. systematic review regarding the effect of steroids in post-op
endo pain.
• Effects of glucocorticoids on in ammation: Potent Anti-In ammatory Properties.
Suppress vasodilation, migration of PMN, inhibit formation of arachidonic acid (PGs,
leukotrienes), decrease transcription of in ammatory cytokines, decrease bradykinin due
to increased ACE synthesis etc.
• Inhibit AA metabolites by inhibition of phospholipase A2
• Decreased transcription of in ammatory cytokines IL-1, 2, 3, 4, 5, 6, 11, 12, TNFa
• Decreased transcription of chemokines IL-8, RANTES
• Decreased iNOS
• Decreased COX2 transcription by monocytes/macrophages
• Decreased neurogenic in ammation by inhibiting tachykinins
• Decreased bradykinin due to increased ACE synthesis
• Glucocorticoids may have widespread effects on many organ systems but these effects
are typically only seen at supra- physiological doses given over a long-term period,
usually more than 2 weeks.
• Intraoral IM injection or an intraosseous injection is preferable over an extraoral IM
injection. Intraoral injection of steroid is preferable as no assumption about patient
compliance is required. A dose of 6–8mg of dexamethasone or 40mg of
methylprednisolone appears from the literature to be appropriate.

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• If an oral route is chosen 48mg methylprednisolone/day for 3days and by extrapolation
10–12mg dexamethasone/day for 3 days should provide signi cant post treatment pain
relief.
• Corticosteroids may be more ef cacious in attenuating pain associated with pulpal
necrosis and associated radiolucencies compared to pain associated with irreversible
pulpitis since these conditions are associated with more complex chronic in ammatory
processes.
• Antibiotics are not routinely required in conjunction with corticosteroids for the
management of endodontic posttreatment pain in the otherwise healthy patients.
• Have been used as pulp capping agents, intra-canal medicaments and systemically
(injection, oral) as a means to decrease pain and in ammation in endodontic patients.
• The use of steroids have been investigated in different routs:
• Intracanal:
• Morse showed reduced post op pain following intracanal use of dexa in vital
cases.
• Chance/Lin 1987 – Compared Intracanal corticosteroid (2.5% Meticortelone) vs.
Saline for intracanal medicament. At 24 hrs, Vital cases: Cortcosteroid sig.
reduced post op pain, Necrotic cases: NSD
• Moskow/Morse/Krasner 1984 – Corticosteroids (dexamethasone) vs. Placebo.
At 24 hrs: Corticosteroid sig. reduced post-op pain compared to placebo. Only
Vital teeth were used for the study.
• Pierce/Lindskog 1987 – Ledermix (tetracycline/corticosteroid mix) is
recommended as an intracanal medication to inhibit external in ammatory root
resorption in traumatized teeth
• Ledermix
• What is Ledermix? Corticosteroid antibiotic paste:
• 1. Triamcinolone Acetonide (1%) - Corticosteroid
• 2. Demeclocycline (3%) - Antibiotic
• 3. Water soluble cream: Triethanolamine, Calcium Chloride, Zinc Oxide,
Sodium Sulphite Anhydrous, Polyethylene glycol
• Ehrmann – LOE 1, 223 pts, signi cantly less post-treatment pain in patients
after intracanal administration of Ledermix compared with either CaOH2 or
no intracanal dressing (opposes Torabinejad, Walton)
• Bryson/Trope 2002 – Dog study, premolars hemi-sected and extracted, 60
min dry time, replanted following instrumentation + 1) CaOH2 or 2)
Ledermix. 4 month histological eval. More favorable healing and less
replacement resorption with Ledermix. Possible anti-resorptive effects of
tetracycline derivative + anti-in ammatory effects of steroid.
• Systemic:
• Reader and Marshall showed reduction in the post op pain following
administration of oral or intaosseous.
• Reader showed that intraosseous injection of Depo-Medrol reported less pain
and percussion pain while taking fewer pain medications. Clinically the
intraosseous injection of Depo- Medrol could be used to temporarily alleviate the
symptoms of irreversible pulpitis until de nitive treatment can be rendered.
• Marshall/Walton 1984 –IM Dexamethasone (4 mg) reduced severity of pain at
4hrs & 24 hrs compared to placebo. inc. Pre-op pain = inc. Post-op pain.

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 • Krasner/Jackson 1986 – Oral Dexamethasone (0.75 mg) signi cantly reduced
post-NSRCT pain at 8 & 24 hrs compared to placebo
• Glassman/Krasner 1989 – Oral Dexamethasone (12 mg q4h) signi cantly
reduced post-NSRCT pain at 8 hrs but no difference at 24 & 48 hrs
• Intraosseous
• Gallatin/Reader 2000 – Single dose of Intraosseous steroid –
methylprednisolone (Depo-Medrol 40 mg) sig. reduced pain, percussion pain,
and number of analgesics vs. placebo in patient with Symptomatic Irreversible
Pulpitis. Depo-Medrol can be used to temporarily alleveliate symptoms of
irreversible pulpitis until de nitive tx.
• Isset/Reader 2003 – Compared Intraosseous DepoMedrol vs. Placebo for
reduction of PGE2 and IL-8 in pts with Sym. Irreversible Pulpitis. At day 1,
Intraosseous DepoMedrol signi cantly reduced pulpal levels of PGE2
• PDL:
• Kaufman showed reduced pain after PDL injection of steroidal anti-
in ammatory- slow- release methylprednisolone (Depomedrol).
• More Corticosteriod Studies
• An effective way of reducing pain: 1. When there is not enough time in the day to treat all
emergencies. 2. When anesthesia fails. 3. When adequate debridement isn’t possible
due to challenging tooth anatomy. When indicate? Marshall: Moderate to severe pain
with dx of necrosis and PARL. Reader: Irreversible pulpitis if cannot due pulptomy.
Medrol Dose Pack: 21 tabs of 4mg methylprednisone; take for 6 days, start with 6 tabs
and reduce by 1 each day.
• Praveen, Thakur, Kirthiga 2017: JOE. RCT. The present clinical trial aimed to evaluate
and compare the effect of a single pretreatment dose of ketorolac (20 mg), prednisolone
(30 mg), and placebo on postendodontic pain in patients undergoing endodontic therapy
for irreversible pulpitis or pulpal necrosis using a visual analog scale. At the end of 6
hours, in irreversible pulpitis cases, the ketorolac group showed an effective reduction in
pain scores compared with the other drugs. At the end of 12 hours, the prednisolone
group signi cantly reduced the pain scores compared with the other drugs. From this
study, it could be concluded that a single pretreatment dose of prednisolone has a more
sustained effect in reducing postendodontic pain compared with placebo or ketorolac.
• Jalalzadeh 2010: investigated the effect of prednisolone premedication on post RCT
pain. This study suggests that a preoperative, single oral dose of prednisolone
substantially reduced postendodontic pain
• Bane 2016: JOE. RCT. Pulpotomy vs Corticosteroids. Patients receiving intra-osseous
methylprednisolone reported less intense spontaneous and percussion pain from day 0
to day 7 period than the patients receiving pulptomy tx. Assessed the effectiveness of
intraosseous Methylprednisolone Injection (A Reader) for Acute Pulpitis Pain in
comparison to conventional emergency pulpotomy (Tronstad) in a RCT study. It was
shown that at day 7 the patients in the methylprednisolone group reported less intense
spontaneous and percussion pain in the day 0–day 7 period than the patients in the
pulpotomy group. Methylprednisolone treatment took approximately 7 minutes (4.6–9.3)
less to accomplish than pulpotomy (or about half the time).
• Marshall J 2002: Steroids are effective as an adjunct to RCT in managing post-op pain.
• Gallatin, Reader, Nist, Beck 2000: RCT. Pulpectomy vs Corticosteroids. Over the 7-day
observation period, the subjects who received the IO injection of Depo-Medrol reported
signi cantly less pain and percussion pain while taking signi cantly fewer pain

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 medications than patients who received endodontic debridement. (Clinically the
intraosseous injection of Depo- Medrol could be used to temporarily alleviate the
symptoms of irreversible pulpitis until de nitive treatment can be rendered.) In patient
with irreversible pulpitis. Depo-Medrol administered intraosseously can be an effective
way of reducing pain when there is not enough time in the day to treat all emergency
patients, when anesthesia fails to work, and when adequate debridement isn’t possible
due to challenging tooth anatomy.
• Mehrvarzfar 2008: intramucosal dex reduces post-tx endo pain up to 24hrs in patients
w/ pre-op pain
• Liesinger, Marshall FJ, Marshall JG 1993: (IM dex reduces post-tx endo pain up to
8hrs in patients with pre-op pain and no PAP.)Eval ability of various doses of IM
dexamethasone to reduce post-tx endo pain for pts presenting with pre-tx pain. The
optimum dose of dexamethasone was 0.07 to 0.09mg/kg and a minimum of 2mg. The
rst 24 hrs after tx appears to be the period of greatest ef cacy for systemic
dexamethasone. No sig diff on incidence of pain but some effect on reduction in pain
thus resulting in patients taking less pain meds.
• Lin 2006: NSAIDs have same effect as steroid in pain reduction (etodolac vs dex)
• Tan, Tawil et al 2016: JOE. 60 pts. This study shows that a 4-mg dose of
dexamathasone administered through a local submucosal injection after periapical
microsurgery has minimal impact on pain, bruising and apparent wound healing at any
time over a 7-day interval, and the impact on swelling seems limited.
• Clark 2015: Neuropathic pain: managed with topical anesthetics and systemic meds such as
gabapentinoids, tricyclic antidepressants and serotonin norepinephrine reuptake inhibitors.
Chronic Daily Headache: managed with beta blockers, antiepileptic drugs N-methyl-D-
aspartate blocking agents. Opioids still used in ER. Fibromyalgia and widespread myofacial
pain: pregabalin, duloxetine, milnacipran, low dose opioids; currently nonpharmacologic
methods and meds best option. Osteoarthritis, Rheumatoid Arthritis: NSAIDS, corticosteroid
injections, low dose opiods.
• Benedetti 2008: THE PLACEBO Paper. Nocebo effect = placebo w/ verbal suggestion of
worsening symptoms
• Ianiro, Eleazer 2007: JOE. This study compared preoperative administration of
acetaminophen or a combination of acetaminophen and ibuprofen versus placebo for
potential increased effectiveness of inferior alveolar nerve (IAN) block anesthesia. Overall
success was 60% for all three groups. Success was 71.4% for the acetaminophen group,
75.9% for the acetaminophen and ibuprofen group, and 46.2% for the placebo group. There
was no signi cant difference between the groups; however, there was a trend toward higher
success in the medication groups.
• Mudie 2006: somatostatin and B-endorphin are located in in amed pulps
• Lin 2006: NSAIDs have same effect as steroid in pain reduction (etodolac vs dex)
• Litkowski 2005: Opiod w/ NSAID (oxy+ibu) works better than opiod with APAP
• Kardelis et al 2002: The combo of hydrocodone and acetaminophen may not affect the
reliability of pulp tests.
• Doroschak, Bowles, Hargreaves 1999: RCT. This study indicates that the combination of an
NSAID ( urbiprofen) with tramadol (opiod) provides superior short-term (24-h) pain relief,
compared with either drug alone. Tramadol alone has little effect. (Flurbiprofen + tramadol
good for post-op endo pain).
• Nevins 1994 JOE – Prophylactic use of Benedryl plays little or no role in abating post-
operative pain after instrumentation of necrotic teeth.
• Ketorolac (Toradol)

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 • Indicated for short-term management of moderate to severe pain
• Curtis et al 1994: 60mg IM injection of ketorolac tromethamine (injectable NSAID)
effectively reduces severe odontogenic pain within 40 min after administration in human
subjects.
• Yadav et al 2015: Ketorolac signi cantly increases the anesthetic ef cacy of articaine
IANB. In ltrations in mandibular molars with irreversible pulpitis.
• Akhlaghi, Abbott et al 2016: Ketorolac buccal in ltrations increased success of IANB
• Do Pre-op NSAIDS Help Success of IANB?
• Yes
• Parirokh 2010: 600mg ibuprofen, indomethacin
• Ianiro, Eleazer 2007: 600mg ibup/1000mg aceto, 1000mg acet
• Yadav et al 2015: Ketorolac
• Akhlaghi, Abbott et al 2016: Ketorolac buccal in ltrations
• No
• Simpson, Reader 2011: preop 800mg ibup + 1000mg aceto
• Aggarwal 2010: 300mg ibup, 10mg ketorolac
• Oleson, Reader 2010: preop 800mg ibup
• When are steroids indicated:
• Marshall: Moderate to severe pain with dx of necrosis and PARL.
• Bane; Reader: Irreversible pulpitis if cannot do pulpotomy (Bane) or pulpectomy
(Reader)
• Medrol Dose Pack: 21 tabs of 4mg methylprednisone; take for 6 days, start with 6 tabs
and reduce by 1 each day.
• Discuss non-opiod analgesics:
• “ exible prescription plan”
• NSAIDS – Non-selective COX inhibitors – inhibits synthesis of prostaglandins and
thromboxane Acetominophen – cannabinoid receptor agonist centrally; peripherally
blocks pain impulse; produces antipyresis by inhibition of hypothalamic heat-
regulating center
• Menhinick, Gutmann – combining APAP w/ NSAID better than ibuprofen alone in
post op pain
• Wells, Reader- NSD of NSAID/APAP vs NSAID alone is post-op pain in necrotic
cases
• Discuss opioid analgesics:
• Potency: Codeine < Hydrocodone < Oxycodone
• Activate opiate receptors in the CNS & inhibit release of excitatory pain transmitters
• Side effects: nausea, vomiting, dizziness, drowsiness, respiratory depression &
constipation
• may need to be considered in moderate to severe pain
• opioids are not anti-in ammatory —> combine with an analgesic with anti-in ammatory
properties
• opioids in combo with NSAID —> analgesia beyond the ceiling affect of the NSAID
• Activate mu receptors that inhibit the transmission os nociceptive signals from the
trigeminal nucleus to the higher brain centers and activate peripheral receptors to reduce
pain.
• studies have demonstrated NSAID + an acetaminophen-opioid combo drug provided
signi cantly greater relief than an NSAID alone
• must be aware of drug seeking patients.

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 Anxiolytic therapy
• Page et al 2002: Oral anxiolytics are easily administered and often very effective.
Benzodiazepines are commonly prescribed oral anxiolytics that work via binding to y-
aminobutryic acid (GABA) channels to assert their effects
• Linderman, Reader, Nusstein et al 2008: (JOE) Found no signi cant increase in anesthetic
success rate in those patients given sublingual traizolam prior to the administration of local
anesthetics. The success rate for the IAN block was 43% with triazolam and 57% with the
placebo, with no signi cant difference (P = .43) between the 2 groups. For mandibular
posterior teeth, triazolam in a sublingual dose of 0.25 mg did not result in an increase in
success of the IAN block in patients with irreversible pulpitis. Therefore, when using
conscious sedation, profound local anesthesia is still required to eliminate the sensation of
pain during endodontic treatment for patients with irreversible pulpitis.
• Kaufman, Hargreaves & Dionne 1993. OOOO – Triazolam (Halcion) 0.25mg appears to be
safe, effective alternative to parenternal sedation with a benzodiazepine for dental
outpatients. (Triazolam safe & effective for dental outpatients, equal to 19 mg Diazepam in
sedation quality). Also demonstrated that 0.25 mg of triazolam in combination with nitrous
oxide provides therapeutic effects but with a more rapid recovery than a 0.50 mg dose in
combination with nitrous oxide.
• Ehrich, Hutter & Dionne 1997 JOE – Oral Triazolam (Halcion) 0.25 mg is safe and more
effective anxiolytic agent than diazepam (5.0 mg) for endodontic patients.
• Dionne OOO 1997 – Sublingual Triazolam results in greater anxiolytic activity and less pain
perception than oral administration as a result of greater plasma. drug levels and may be
useful as an alternative for nonprenternal outpatient sedation.
• Berthold- greater anxiety reduction with sublingual route of admin; 28% more bioavailability
• Stanley, Reader, Nusstein et al 2012 – (JOE) N2O signi cantly improved success of local
anesthesia in mand. teeth w/ Symptomatic Irreversible patients: w/N2O: 50%, w/o N2O: 28%
(Sig. Difference)
• Carter et al 2002: Patients who are anxious have reduced pain tolerances.

Antibiotics
• AAE Position Statement 2017
• The bene ts of correct use of antibiotics include the resolution of infection, prevention of
the spread of disease and minimization of serious complications of disease. Up to 50%
of all antibiotics are prescribed or used incorrectly. Risks associated with the use of
antibiotics include nausea, vomiting, diarrhea and stomach cramps because of the
disturbances of the gut micro ora.
• Use of Adjunctive Antibiotics in Addition to Adequate Debridement and Drainage
• The key to successful management of infection of endodontic origin is adequate
debridement of the infected root canal and drainage for both soft and hard tissue. In
addition to adequate debridement of the root canal system, localized soft tissue
swelling of endodontic origin should be incised and drained concurrently.
• Fouad, Walton 1996; Reader et al 2001; Basrani et al 2003; Walton 1993; Reader
2000; Reader 2001: Adjunctive antibiotics are not effective in preventing or

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 ameliorating signs and symptoms in cases with irreversible pulpitis, symptomatic
apical periodontitis, or localized acute apical abscess, when adequate local
debridement, medication and incision for drainage, if indicated, have been achieved
• When using adjunctive antibiotics in addition to adequate debridement and surgical
drainage, such as in cases with spreading infections, the practitioner should use the
shortest effective course of antibiotics, minimize the use of broad-spectrum antibiotics
and monitor the patient closely.
• Use of Antibiotics in absence of adequate debridement and drainage
• Fouad, Walton 1996; Reader et al 2001; Basrani et al 2003: there is evidence from
randomized clinical trials and systematic reviews to indicate that supplemental
antibiotics following adequate debridement and drainage in cases of localized
endodontic infections is ineffective
• It is also the standard of care to prescribe primary or adjunctive antibiotics in
conjunction with local debridement and surgical drainage for patients who have
spreading infections, and to monitor their progress closely as these prescriptions are
made empirically and may be ineffective or insuf cient for adequate treatment.
• The literature is not clear on indications, ef cacy or duration of antibiotics for cases in
which the practitioner is not able to render local debridement and drainage at the time
of patient presentation, or in cases that are complex and the ef cacy of local
treatment may not be completed.
• Tilburt et al 2008: Many patients perceive improvement in their condition after taking
antibiotics, at least in part due to a strong placebo effect that antibiotics may have
• One strategy that may be useful is to educate the patient about the signs and
symptoms of a spreading infection and give the patient a ‘‘stand-by’’ antibiotics
prescription. The patient would only ll the prescription and call the prescriber’s of ce,
if he/ she perceives this type of infection to be occurring, prior to receiving de nitive
care.
• Comparison of the ef cacy of different types, dosage and duration of antibiotics
• Konig et al 1998: The therapeutic use of antibiotics relies on achieving at least the
minimal inhibitory concentration (MIC) of the drug, against sensitive microorganisms
in the site of infection. In the case of advanced endodontic infections, the dental pulp
tissue after succumbing to liquefaction necrosis is no longer vascularized, and orally
administered drugs are unable to reach the site of infection. Therefore, the drug
distribution is restricted to the surrounding vascularized tissues. However, in cases of
apical abscess, the presence of pus limits vascular supply, and contain cellular debris
and proteins that can bind and sequester antibiotics making these drugs less effective
in the absence of adequate drainage
• Basrani 2003; Aminoshariae, Kulild 2016: Antibiotics should only be used as
adjuvant therapies in cases with evidence of systemic involvement (fever, malaise,
cellulitis and/or lymphadenopathies) following adequate endodontic disinfection and
abscess drainage if swelling is present
• Fouad, Walton 1996; Walton 1993: In addition, patients who are
immunocompromised or have predisposing conditions such as previous endocarditis
should be medicated as a prophylactic measure.
• Segura-Egea et al 2016: Penicillin VK and amoxicillin, both beta-lactam antibiotics,
are the rst line of antibiotics chosen as adjunct therapeutic agents in endodontics in
the United States of America and Europe

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 • Wright 1999: These drugs act by binding and inhibiting the activity of several bacterial
proteins called penicillin binding proteins (PBP) involved in the synthesis of the
peptidoglycan cell wall in susceptible both gram-positive and gram-negative bacteria
• Baumgartner et al 2003: These drugs have been found to be highly effective against
isolates from infected root canal systems that are composed primarily of facultative
and obligate anaerobes
• Fouad 2017: Amoxicillin demonstrates greater ef cacy and therapeutic value
because: 1. It has broader spectrum and is more effective than penicillin VK against
certain gram-negative anaerobes due to better microbial penetration. 2. It is more
readily absorbed from the gastrointestinal (GI) tract than penicillin VK, which is poorly
absorbed and its accumulation in the GI tract is associated with depletion of
commensal ora and digestive disturbances. 3. Its absorption is not impaired by food
reaching peak plasma levels within 2 hours of ingestion. 4. Only approximately 20%
of absorbed amoxicillin is protein-bound in the plasma, being more readily available.
5. It has signi cantly greater half-life than penicillin VK requiring doses to be taken 2-3
times a day as opposed to 4 times daily for penicillin VK
• Segura-Egea 2010; Palmer 1998: The recommended dose regimen for amoxicillin is
500 mg three times a day (with or without a loading dose of 1,000 mg) for adults.
Although these doses are well established based on pharmacokinetic studies and
designed to establish maximum effective doses in the plasma, there is far less
evidence to support the duration of treatment. Most practitioners usually prescribe
antibiotics in courses of 3 to 7 days
• Lewis et al 1986, Martin et al 1987: Interestingly, some evidence suggests that
perhaps shorter courses (2-3 days) may be successfully used as adjuvant therapies
• The decision of using antibiotics for longer periods (7 to 10 days) is largely based on
studies and clinical practice of treating infections whose etiology is not fully identi ed
or the treatment of bloodstream infections in hospitalized patients.
• Lacy et al 1983: therapies lasting 7 days with amoxicillin have been shown to
increase the population of resistant strains
• Baumgartner 2003; Jungermann et al 2011; Poeschl et al 2011: if symptoms are
not improved after endodontic debridement and/or drainage, amoxicillin may be
combined with clavulanic acid (125 mg bid or tid), which is a beta-lactamase inhibitor
and increases the susceptibility of penicillin resistant strains. This combination has
been shown to be effective against 100% of cultivable endodontic bacteria, increasing
the spectrum of amoxicillin in persistent infections
• Salvo et al 2007: However, the use of amoxicillin/ clavulanic acid combinations
should not be done indiscriminately as there are potentially signi cant side effects that
include gastrointestinal and hepatic disturbances
• Although penicillin and amoxicillin are the most prescribed antibiotics, they have a
side effect pro le that ranges from gastrointestinal disturbances, hepatic toxicity to
severe anaphylactic allergic reactions. It is estimated that approximately 8% of the
population using health care in the United States of America have allergic reactions to
penicillin. There is well-reported cross-reactivity of penicillin allergy with
cephlosporins, with a total prevalence of 1% of the American population taking
antibiotics being also allergic to cephalosporins
• Clindamycin is the rst drug of choice for patients with a history of hypersensitivity to
penicillin drugs. This drug is a lincosamide antibiotic that acts by binding to the 50S
ribosomal subunit, suppressing protein synthesis. Therefore, its effects are mainly
bacteriostatic, although bactericidal effects can be achieved with therapeutic doses. It

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 has been shown to be effective against 75% of cultivable endodontic pathogens. It
has very good spectrum, with coverage against both facultative and obligate
anaerobic bacteria.
• Clindamycin is readily absorbed after oral administration, which is not impaired by
concomitant food consumption, reaching peak plasma levels in 1 hour (9 mg/ml after
a loading dose of 600 mg in adults). The drug is widely distributed in the body,
including bone. The recommended dosage for infections of endodontic origin is 600
mg as a loading dose followed by 300 mg every 6 hours, whereas in children, this
dose must be adjusted to 10-30mg/Kg (dose/ body weight) divided into 4 equal doses.
• Similar to other antibiotics used as adjuvants in endodontic therapy, there is no
agreement on the duration of the treatment and the perceived therapeutic bene t.
Also, prolonged use of this antibiotic will increase the likelihood of untoward effects
and selection of resistant bacterial strains. Despite its excellent pharmacokinetics and
moderate effectiveness against endodontic pathogens, its use can be associated with
signi cant side effects. Gastrointestinal disturbances are the most common side effect
with an approximately 8-fold increased risk of developing C. dif cile infection than the
use of penicillin
• Indications for performing culture and sensitivity tests
• As noted, antibiotics are prescribed empirically by practitioners. Occasionally, despite
adequate local debridement and antibiotic coverage, the treatment is ineffective and
the patient’s condition deteriorates. The patient may have unusual species of virulent
bacteria, multidrug resistant bacteria and/or fungal infection. He/she may also have
immune de ciency, uncontrolled diabetes, penicillin allergy and/or a history of C.
dif cile infection. In these situations, culture and sensitivity testing may assist the
practitioner in selecting the appropriate antibiotic. It is generally recognized, however,
that most oral bacterial species are commensal organisms, that about half of them are
not cultivable, and that the effectiveness of antibiotics is variable in polymicrobial
infections. Therefore, this testing may only provide additional guidance to the
practitioner, in conjunction with surgical debridement.
• Poeschl et al 2010: Aspiration of a purulent uid is the optimal sampling method, and
is achieved using a 16 or 18 gauge needle. This is taken promptly to the
microbiological laboratory to promote growth of strict anaerobes
• Baumgartner 2003; Montagner et al 2014: Studies show that beta-lactam antibiotics
are the optimal drugs for endodontic pathogens, and that there is very little bacterial
resistance to amoxicillin with clavulanic acid. These studies have demonstrated more
resistance to clindamycin, which has typically been the drug of choice for penicillin-
allergic patients. Therefore, in penicillin-allergic patients, other drugs such as
moxi oxacin or azithromycin should be considered
• Unfavorable response to empirically prescribed antibiotics following root canal
debridement and incision for drainage
• Signs and Symptoms —> Possible Condition —> Management
• Continued Pain and/or swelling —> bacterial resistance to antibiotic or presence of
inaccessible areas —> supplementing antibioitic regimen with another oral drug
such as metronidazole
• Trismus, dyspnea and dysphagia —> Spread to poorly vascularized fascial spaces
such as submandibular, sublingual, masseteric, paraphyrngeal and retropharyngeal
spaces —> Hospitalization, culture and sensitivity, together with IV antibiotics
• Vision Problems, Headache —> Cavernous sinus involvement —> Hospitalization,
culture and sensitivity, together with IV antibiotics

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 • Fever over 102 F, malaise, lethargy and increased erythrocyte sedimentation rate
—> massive systemic involvement, potential septic shock —> hospitalization,
culture and sensitivity, together with IV antibiotics
• Prophylactice use of antibiotics for endodontic surgery
• Lindeboom et al 2005: Prophylactic use of antibiotics to prevent postoperative
infections is common in general and oral surgery. Factors involved in the decision of
whether to prescribe prophylactic antibiotics, and whether to provide one
preoperative dose or a prolonged course, include the type and site of surgery, the
morbidity associated with potential infection, and the systemic health of the patient.
One randomized clinical trial compared giving 256 patients undergoing endodontic
surgery either preoperative 600 mg tablet of clindamycin or placebo. The results
were that four patients in the placebo group and two in the clindamycin group
developed postoperative infection, and this difference was not statistically
signi cant. However, the average surgical time in this study was only about 30
minutes in both groups, and the overall number of infections was low. There are no
data available for endodontic surgery that may take a longer period or are
performed in practices that have higher rates of postoperative infections.
• Nevertheless, there is evidence that antibiotic prophylaxis may reduce
postoperative infection following exodontia and surgical osteotomy extraction. In
addition, there is one study that showed that peri-operative antibiotic prophylaxis
signi cantly reduced the incidence of bisphosphonate-related osteonecrosis of the
jaw, in multiple myeloma patients on IV bisphosphonates undergoing dental
surgery.
• In cases where the biopsy result indicates periapical actinomycosis infection, it
does not appear that antibiotic treatment is indicated, as the surgical procedure is
associated with curettage of the infected tissues in these cases
• Association between adjunctive antibiotics and periapical healing
• The effect of perioperative antibiotics on long term healing of non- surgical and
surgical endodontics has not been suf ciently studied. One study compared the
healing of apical periodontitis in 62 patients who underwent non-surgical root canal
treatment (Ranta, Haapasalo 1988). There was no difference between the
penicillin and the control groups in healing. A more recent endodontic prospective
cohort study showed no association between the use of long-term antibiotics and
non-surgical treatment or re- treatment outcome (Ng, Mann, Gulabivala 2011).

• Discuss the mechanisms of commonly prescribed antibiotics:

• Cell wall inhibitors:
• Penicillins – bactericidal; inhibits bacterial cell wall synthesis
• Augmentin (Amox + Clavulanic acid): clavulanic acid binds and inhibits beta-
lactamases (produced by some bacteria) that inactivates amox resulting in
expanded spectrum of activity
• Cephalosporins – may have cross reactivity with Pen allergic pts
• Anti-ribosomal – Inhibit protein synthesis:
• Clindamycin – bacteristatic/cidal (based on dosage); inhibits protein synthesis by
binding to 50S ribosomal subunit; strong bone penetration (Vacek)
• Azithromycin, Erythromycin - inhibits protein synthesis by binding to 50S
ribosomal subunit
• Tetracyclines – inhibits protein synthesis by binding to 30S ribosomal subunit

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 • inhibitors of Nucleic Acid Synthesis:
• Metronidazole – inhibits nucleic acid synthesis; ineffective against facultative
anaerobes; added to penicillins if ineffective
• The current trend is to employ antimicrobials on an intensive basis with vigorous dosage
for as short a period of time as the clinical situation permits. Blood levels of the antibiotic
should exceed the MIC by a factor or 6-8 times to offset the tissue barriers that resist
access to the infected site. It is advisable to initiate antibiotic therapy with a loading dose
at least two times higher than the maintenance dose. Dosing intervals of oral antibiotics
should be 3-4 times the serum half-life of the drug in order to maintain therapeutic blood
levels.
• Bacteriostatic agents that effect protein synthesis and cell membrane function work
better with pulse dosing because their activity is less dependent on drug concentration.
• Bactericidal agents that effect cell wall synthesis function better with continuous dosing
because their activity is more drug concentration dependent. The bacterial ora in
common dental infections is indigenous, mixed and predominately anaerobic.
• Factors affecting clinical effectiveness of antibiotics
• Plasma protein binding (PPB) of the drug
• Only the drug that is not bound to plasma proteins is free to diffuse through tissues.
• Doxycycline = 96% PPB, Clindamycin = 80% PPB, Penicillin V = 50% PPB,
Amoxicillin = <25% PPB, Metronidazole = <20% PPB
• Surface Area-To-Volume Ratio (SA/V)
• As the SA/V decreases, the drug concentration decreases.
• Lipid solubility
• Highly lipid soluble antibiotics (macrolides, tetracycline) pass better through tissue
barriers and cell membranes than do highly water soluble agents (beta-lactams).
• Age of the patient
• Children and adult dosages of antibiotics are the same when adjusted for weight,
except in premature neonates and neonates when the dosage should be decreased
and the dosage interval should be increased. Elderly patients may require reduced
dosage or increased dosage intervals due to reduced renal/hepatic function and
reduced body mass.
• Ganda 2008: (Text book) Pencillin/Amoxicillin/Augmentin/Cephalexin —> bacteriocidal
(inhibits cell wall synthesis). Clindamycin/Azithromycin —> bacteriostatic (inhibits protein
synthesis). Metronidazole —> Bacteriocidal (inhibits DNA synthesis)
• Discuss antibiotic susceptibility:
• Baumgartner, Xia 2002: Do not need to wipe out ALL bacteria to be effective, of the 98
species of bacteria collected from endo abscess 85% were susceptible to penicillin VK,
45% to metronidazole, 91% to amoxicillin and 100% to amoxicillin/clavulante, and 96%
to clindamycin.
• susceptibility from isolated endo infections (98 bacterial species):
• Pen V – 85%
• Amox – 91%;
• Augmentin – 100%;
• Metronidazole – 45%
• Pen + Metro – 93%
• Amox + Metro – 99%
• Clindamycin – 96%
• Antibiotic of Choice

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 • Skucaita N 2010: investigated Susceptibility of Endodontic Pathogens to Antibiotics in
Patients with Symptomatic Apical Periodontitis. Streptococci and obligate anaerobes
were the predominant microorganisms in cases of primary infection. Enterococcus
faecalis dominated in cases of secondary infection. All tested microorganisms were
highly sensitive to penicillin G, amoxicillin, and ampicillin. Susceptibilities to clindamycin
and erythromycin were 73.8% and 54.7%, respectively. About 40% of the isolates were
resistant to tetracycline. More than 50% of all anaerobes were resistant to
metronidazole. All E. faecalis isolates were resistant to clindamycin. Based on the study
results, penicillin and amoxicillin are suitable antibiotics for treatment of endodontic
infection
• Baumgartner 2003: IEJ. Pen V is still AB of choice for infections. The percentages of
susceptibility for the 98 species were penicillin V (more acid stable and can be taken
orally compared to g): (85%), amoxicillin: (91%), amoxicillin + clavulanic acid: (100%),
clindamycin: (96%), and metronidazole: (45%). Metronidazole had the greatest amount
of bacterial resistance; however, if it is used in combination with penicillin V or
amoxicillin, susceptibility of the combination with penicillin V or amoxicillin increased to
93% and 99%, respectively. Clarithromycin seems to have ef cacy, but it is still
considered an antibiotic under investigation because the minimum inhibitory
concentration has not been established.
• The bacterial ora in common dental infections is indigenous, mixed and predominately
anaerobic.
• PCN- narrow spectrum, effective against g(-) anaerobes, g(+) aerobes and facultative
anaerobes, add Metronidazole if ineffective after 48-72hrs: MTN affective against g(+)
anaerobes, no aerobes
• Are antibioitics a concern with birth control pills?
• Hersch – Rifampin is only known antibiotic to inhibit bcp; discuss possibility with pt
• Bainton - effect of bacterial ora in gut (PCN)
• Little et al 2012: (Text book). Common drug interaction. Antibiotics in general —> oral
contraceptives. Beta-Lactams (Penicillin, cephalosporins) —> allopurinol, beta blockers
etc.
• DeRossi: The only known antibiotic that interfere with OCP and reduce effectiveness is
rifampin due to activation of Cytochrome P 450. Other mechanism that can affect the
OCP are interfere with absorption and OCP protein bindings. Although the only AB know
to interfere is Rifampin still we should warn female to use additional barriers for 1 week
after use of AB.
• Indications for Antibiotic Use
• AAE 2006: AAE Colleagues for Excellence. Recommends avoiding antibiotics in cases
of pain w/out signs and symptoms of infection, with an asymptomatic radiolucency, with
draining sinus tract or localized uctuant swelling.
• Pallasch 2000: Antibiotic therapy should be prescribed for the shortest duration possible
to reduce risk of toxicity and allergy but for long enough so the host defense can return
to ght the infection. Furthermore, doses need to be high enough to reach the minimum
inhibitory concentration (6-8) and should be given at intervals of 3-4 times the serum
half-life of the drug. A loading dose of 2 times the maintenance dose is recommended to
reach faster serum concentrations.
• Baumgartner & Fouad: discussed the antibiotic indications in dental infections: They
recommended that antibiotics are indicated when.
• signs and symptoms suggest systemic involvement such as high fever, malaise,
cellulitis, unexplained trismus, and persistent and progressive infections, and also

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 for patients who are immunologically compromised. In this case, it can be
concluded that well-localized vestibular abscess in otherwise healthy patients does
not need antibiotic.
• AAE 2012: AAE Colleagues of Excellence. Further recommends the use of antibiotic
therapy in cases with a fever greater than 100 degrees, lymphadenopathy, trismus,
osteomyletitis and in persistent infections. (As well as The use of antibiotics in the
treatment of endodontic disease should be limited to those infections with rapidly
increasing signs or symptoms, evidence of systemic involvement, in
immunocompromised patients, and with involvement of the danger zone. Harrison, Svec
T 1998)
• Harrison, Svec T 1998: The use of antibiotics in the treatment of endodontic disease
should be limited to those infections with rapidly increasing signs or symptoms, evidence
of systemic involvement, in immunocompromised patients, and with involvement of the
danger zone.
• Baumgartner: Indications - antibiotics are recommended in conjunction with appropriate
endo tx for progressive infections with systemic signs and symptoms such as fever (100
deg F), malaise, cellulitis, unexplained trisums and progressive or persistent swelling. I &
D is indicated for any infection marked by cellulitis ( uctuant or indurated). (Systemic
involvement,, immunocompromised and rapidly progressing)
• Yingling, Hartwell 2002: Antibiotic use by AAE members. Conclusion: When the
decision is made to use an antibiotic, it is important to adhere to basic principles of
antibiotic dosing: (a) use high doses for short durations; (b) use an oral antibiotic loading
dose; (c) achieve blood levels of the antibiotic at 2 to 8 times the minimum inhibitory
concentration; (d) use frequent dosing intervals; and (e) determine duration of therapy by
remission of disease (8). The use of antibiotics for minor infections, or in some cases in
patients without infections, could be a major contributor to the world problem of
antimicrobial resistance.
• Antibiotics for Joints
• Sollecito 2015: Evidence fails to demonstrate an association between dental
procedures and prosthetic joint infections or any effectiveness for antibiotic prophylaxis.
Given this information in conjunction with the potential harm from antibiotic use, using
antibiotics before dental procedures is not recommended to prevent PJI. Bottom Line:
While the evidence seems clear, this is a recommendation not a standard of care. It is
still wise to follow a physician’s recommendation for prophylaxis, even if it is only for
legal reasons.
• ADA, AAOS 2015: Joint Position Statement. Prophylactic Antibiotics not recommended
for patients with prosthetic joint implants undergoing dental procedures. American Dental
Association & American Academy of Orthopedic Surgeons, along with 10 other
academic associations published mutual clinical, evidence-based guidelines. No
evidence of cause-and-effect relationship between dental procedures and periprosthetic
joint infections. (Still good to consult with physician)
• Antibiotic Prophylaxis for Heart Conditions/Endocarditis
• AHA 2010: American Heart Association. Guidelines for prophylactic antibiotics for
prevention of infective endocardidis. Only recommended for 4 conditions. 1. A prosthetic
heart valve or patient has had a heart valve repaired with prosthetic material. 2. A history
of endocarditis. 3. A heart transplant with abnormal heart valve function. 4. Certain
congenital heart defects (cyanotic congenital heart dz, congenital heart defect repaired
with prosthetic material or a device for rst 6 months after repair procedure, repaired
congenital heart dz with residual defects

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 • Antibiotic Resistance
• Sedgley 2008: Interspecies exchange of antibiotic resistance genes help bugs survive!
• Pallash 1994: Up to 65% of antibiotic use is inappropriate. (Use in patients without a
bacterial infection. Improper choice of agent. Improper dose and duration. Over use for
medical prophylaxis)
• Mechanism for microbial resistance: microevolution, macroevolution, acquisition of
foreign DNA.
• Bacteremias
• Reis, Roccas, Siqueira et al 2016:
• No signi cant difference was observed in the incidence of bacteremia between
patients who received prophylactic antibiotic therapy and those not treated with
antibiotics.
• In conclusion, this study showed that the incidence of bacteremia after endodontic
treatment procedures varied from none (culture) to low occurrence (qPCR). In the
positive cases, qPCR revealed low bacterial counts per milliliter of blood.
• These ndings suggest that, for infected teeth from patients with a history of cardiac
valve disease, endodontic therapy should be the treatment of choice because the
alternative, extraction, has been associated with a greater incidence of bacteremia.
• Antibiotic prophylaxis showed no apparent in uence on the incidence and levels of
bacteremia as determined by qPCR, and further studies are required to determine
whether or not antibiotic prophylaxis is really necessary before endodontic
intervention in patients at risk of IE.
• Baumgartner 1977: Demonstrated bacteremias in patients undergoing surgical root
canal therapy.
• Baumgartner 1976: Unable to detect evidence of bacteremias in patients undergoing
nonsurgical root canal therapy when instrumentation was con ned to the tooth.
• Are antibiotics effective to reduce pain, are-ups etc?
• Keenen et al 2006: JOE. Cochrane Systematic review. Antibiotics are not recommended
for the emergency management of irreversible pulpitis. Provides evidence that there is
no signi cant difference in pain relief for patients with untreated irreversible pulpitis who
received antibiotics versus those who did not.
• Aminoshariae, Kulild 2016: Systematic Review. (Antibiotic to Tx endo infections and
pain)
• The best available evidence indicates there is no reason for prescribing antibiotics
to prevent infection either before or after endodontic treatment.
• Antibiotics do not relieve pulpitis or periapical symptoms. Effective endodontic
treatment will decrease the number of microbes and antibiotics are not necessary
for a healing outcome.
• The routine use of antibiotics in conjunction with endodontic treatment should be
discouraged and is not in line with following the principles of an evidence-based
practice. The exception would be when the spread of infection is systemic and the
patient is febrile.
• Pickenpaugh, Reader, Beck, Meyers, Peterson 2001: RCT: effect of prophylactic
amoxicillin on endodontic are-ups in asymptomatic, necrotic teeth. Prophylactic
amoxicillin does not signi cantly in uence the occurrence of endodontic are-up. Has no
effect on the incidence of are-up.
• Lindeboom 2005: Prophylactic antibiotics (Clinda) do not reduce post-op infections in
surg cases. (placebo controlled)

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 • Nagle, Reader, Beck, Weaver 2000: (PCN does not reduce pain in pts with irreversible
pulpitis). RCT: effect of systemic PCN on pain in untreated irreversible pulpitis.
Discussion: Massler & Pawlack and Torneck established that pulps of teeth with
irreversible pulpitis and without a clinical pulpal exposure contained no demonstrable
bacteria. Haldi & John and Akimoto et al. found that penicillin and ampicillin, when
administered systematically, were present in the dental pulp in the same concentrations
as in the blood plasma. However, because pulpal pain is mainly associated with the
in ammatory process and because there are rarely bacteria in the pulp in irreversible
pulpitis, antibiotics have no effective usefulness. Conclusion: Penicillin should not be
prescribed for untreated irreversible pulpitis because penicillin in ineffective for pain
relief.
• Fouad, Walton 1996: In pts with no systemic signs or symptoms with necrotic pulp and
acute apical abscess (localized periapical pain and/or swelling), Pen VK with ibu does
not help after RCT.
• Walton, Chiappinelli 1993: RCT to exam effects of prophylactic use of PCN in treating
patients with a dx of pulp necrosis/asym periapical pathosis as to posttreatment
symptoms. No sig diff (between penicillin vs placebo vs no medication) as to
posttreatment symptoms, incidence and severity of adverse side effect, incidence of
are up, incidence of pain, incidence of swelling, incidence of adverse side effects, nor
severity of pain at any time point. **penicillin does not reduce pain in pts with pulpal
necrosis and asymptomatic apical periodontitis
• Torabinejad et al 1988: May be bene cial in preventing are-up in patients with necrotic
pulp
• Henry, Reader, Beck. 2001: (post-op PCN does not affect pain or swelling in
symptomatic, necrotic teeth). RCT: effect of PCN on postoperative endodontic pain and
swelling in symptomatic necrotic teeth. PCN administered postoperatively did not
signi cantly reduce pain, percussion pain, swelling or the number of analgesic
medications taken in symptomatic necrotic teeth with radiolucencies. The majority of
patients with symptomatic necrotic teeth have signi cant postoperative pain and require
analgesic medication to manage this pain.
• Do prophylactic antibiotics help decrease are-ups:
• Akbar 2015: Prophylactic use of Amoxicillin in asymptomatic non vital teeth before root
canal treatment had no effect on the incidence of are-up.
• Reader:
• Pen VK did not decrease are-ups with irreversible pulpitis
• Amoxicillin did not decrease are-ups with necrotic, asymptomtic teeth
• Pen VK did not decrease are-ups with necrotic, symptomatic teeth
• Walton: Pen VK had no signi cant effect on incidence of are-ups
• Brennan: No difference in infection, pain or adverse events following use of PCN
• Torabinejad et al 1988: May be bene cial in preventing are-up in patients with necrotic
pulp
• Abbott et al 1988: Reported a reduced incidence in tx of asymptomatic, necrotic teeth.
However, study * awed, as it used an outside control group.
• Dinsbach 2012: Lit review of antibiotics.
• Norrington, Beck, Eleazer 2008: Bio lm growth on dentin and antibiotics. Bio lms form
quickly and antibiotics have trouble eliminating them.
• Andreasen et al 2006: Role of Antibiotics. Bacteria within the pulp space are not in uenced
by the systemic use of antibiotics. (Trauma related)

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 • In cases antibiotics are indicated; Pen 1000mg (loading dose) is starting dose and then
500mg 4 times a day for 5-6 days. If they are allergic, Clindamycin 600 mg loading dose and
then 300mg.
• Alexander 1999: Diabetics do not need routine antibiotics. Only poorly controlled diabetics
may bene t. >250mg/dL give antibiotics only in emergency situations.
• Hersh 1999: Review: drug Interactions involving antibiotics.

Misadventures/Procedural Errors
• Root perforation is a mechanical, iatrogenic, or pathologic communication between the root
canal system and the external tooth surface
• Ledge: An arti cial irregularity created on the surface of the root canal wall that impedes the
placement of instruments to the apex of an otherwise patent canal.
• Ove Peters: Ingles Text. Successful endodontic treatment originates from a well-designed
and executed access preparation. The opposite is also true; errors during root canal
treatment can often be traced back to a problem originating from an inadequate access
preparation. Errors generally stem from two access cavity characteristics: underextension and
overextension. Underextension can lead to: missed canals, increased chance of strip perf,
increase chance of le separation, transportation of apex, limits le diameter of apical
preparation size, if pulp horns remaining in anterior teeth —> discoloration. Over extension
can weaken tooth and decrease long term prognosis
• NaOCl Accident
• Guivarc’h, Cohen et al 2017: JOE. Systematic Review. Sodium Hypochlorite Accidents.
• Sudden pain, profuse bleeding, and almost immediate swelling constitute a triad of
signs/symptoms pathognomonic of NaOCl extrusion.
• 1/3 of cases indicated immediate irrigation, usually with saline. Bleeding should not
be prevented and aspiration should be utilized. Prescriptions were mostly
analgesics, antibiotics, and steroids. Post-op instructions included extraoral cold
packs on the day of the extrusion, followed by warm compresses and warm saline
rinses. NSAIDs should be prescribed in an analgesic dosage (no more than
1200mg/day for max. of 5 days) in the presence of hemorrhagic condition
associated with an increased risk of infection. The risk of spreading infection or an
impaired immune system should be the criterion for prescribing antibiotics.
• It generally took a few weeks for patients to recover from the initial S&S (pain,
edema, hematoma, and tissues necrosis). Permanent sequelae could be divided
into nerve lesions and scar tissues. Neurologic examination of the trigeminal and
facial nerves should systematically be performed once anesthesia has dissipated.
Tooth loss has not been reported as a direct result of NaOCl extrusion.
• Hulsmann & Hahn 2000:
• Potential signs: immediate severe pain, signi cant swelling/edema, bleeding in canals
instantly, hematoma/ecchymosis, tissue necrosis, bad taste and irrigation if sinus
involved, secondary infection, paresthesia
• Management: Pain Control (LA + Analgesics), Initial cold compresses for rst 24hrs
followed by warm compresses, Antibiotics if signs of infection, emergency medical
referral if vital signs compromised.
• Gluskin: Manage - give long acting LA, irrigation with saline to dilute, Amoxicillin,
analgesics, steroids, cold compresses and recalls

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 • Kleier: Diplomate survey - did not affect prognosis; women > men, necrotic with PARL
more common
• Sabala & Powell 1989: What to do: 1. reassure patient, 2. Pain control (LA block and
analgesics), 3. Saline irrigation, 4. Antibiotics, 5. cold compresses 4-6hrs, then warm, 6.
Medrol dose pack
• Matthews & Merril 2014: Presented a case of chronic neuropathic pain and long-lasting
paresthesia 7 months following a NaOCl accident.
• Reeh & Messer 1989: Describe a case where, following a NaOCl accident, the patient
developed a post-op infection and paresthesia lasting 15 months
• Instrument Separation
• Potential Factors affecting Prognosis: timing of incident, preop dx, ability to bypass
or remove the instrument fragment, adequacy of obturation following separation,
presence of perf created during attempts to remove instrument fragment.
• Panitvisai, Messer et al 2010: Systematic Review. Meta-analysis.
• If instrument is fractured, leave it! Separated instrument does not affect prognosis
(difference of 6%). If necrotic and not cleaned and shaped, then poorer prognosis.
• Overall, 80.7% of lesions healed when a periapical lesion was present, compared
with 92.4% remaining healthy when no lesion was present at the time of treatment.
• On the basis of the current best available evidence, the prognosis for endodontic
treatment when a fractured instrument fragment is left within a root canal is not
signi cantly reduced. The prognosis is lower if periapical pathology is present at the
time of treatment, but only to the extent that effective canal disinfection is
compromised.
• Iqbal et al 2006: Retrospective. 5000 cases in PENN Grad program. Reported 0.25%
incidence of stainless steel hand le separation compared with a 1.68% incidence of NiTi
rotary instruments. Rotary instruments 7 X more likely to separate than hand les.
Separation was most commonly reported in the apical 1/3.
• Ankrum, Hartwell 2004: Reported no difference in the likelihood of instrument
separation among instruments studies (ProTaper Un, ProFile and K3.)
• Spili, Messer 2005: NSD if separated NiTi Rotary les from a specialist of ce (over 8000
teeth included, 3% fracture rate but about 92% success as compared to cases w/o
separated instruments at about 95%). In the hands of skilled endodontists prognosis was
not signi cantly affected by the presence of a retained fractured instrument. (fractured
rate did not decrease with experience) no lesion + instrument 98.4%, No lesion + no
instrument 96.8%, lesion + instrument 86.7%, lesion + no instrument 92.9%. Type of
instrument (NiTi vs SS) did not in uence outcome. Mentioned the factors that affect the
prognosis of broken instrument 1) Location 2) Time 3) Diagnosis
• Strinberg et al: 19 % higher incidence of failure following broken instrument
• Grossman 1969: OOO. concluded that separated instruments affected the outcome only
when a periapical lesion was present.
• Crump, Natkin 1970: Classic: Separated instruments do not doom a tooth. (Stainless
Steel Instruments) No difference between separated and controls. (PA diagnosis not
mentioned or coronal seals). A two year recall of match pairs did not nd a signi cant
increase in failures when instruments were broken and left in teeth compared to controls.
Success depends on location and amt of debridement prior to separation)
• Fox, Moodnik 1972: No diff in success rates with les left either accidentally or
intentionally
• Saunders 2004: found in vitro that broken les (assuming apical portion is clean) do not
leak more than teeth w/o broken les. Coronal seal is important.

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• Instrument Removal
• Madarati et al 2013: Management of separated instruments. Guidelines for
management of intracanal separated instruments have not been formulated. Decisions
on management should consider the following: (1) the constraints of the root canal
accommodating the fragment, (2) the stage of root canal preparation at which the
instrument separated, (3) the expertise of the clinician, (4) the armamentaria available,
(5) the potential complications of the treatment approach adopted, and (6) the strategic
importance of the tooth involved and the presence/or absence of periapical pathosis.
Clinical experience and understanding of these in uencing factors as well as the ability
to make a balanced decision are essential.
• Options:
• Orthograde removal of separated fragment
• retrograde removal or entombment of separated fragment
• bypass separated fragment
• leave in place and monitor
• JOE. performed a systematic review on management of intracanal separated
instruments. Factors In uencing Removal of Separated Instruments are: 1) Tooth
Factors: In maxillary teeth, in anterior teeth, When the fragment extends into the
coronal third of the root canal, When the fragment is located before the root canal
curvature, When the instrument separates in straight or slightly curved root canals.
2) Separated instruments factors: It is generally believed that NiTi rotary
instruments are more dif cult to remove compared with SS ones: They tend to
thread into root canal walls because of their rotary movement, They have greater
tendencies to fracture repeatedly during removal procedures, particularly when
ultrasonics is used Clinical observation has revealed that fragments of NiTi
instruments in curved root canals tend to lie against the outer root canal wall and do
not remain in the center of the canal because of their exibility. They usually fracture
in short lengths, especially after torsional failure; the longer the fragment, the higher
the success rate of retrieval because longer fragments are usually more coronally
located.
• Ruddle: technique for removing the broken instrument (From from Madarati
JOE): “A staging platform is prepared around the most coronal aspect of the
fragment by using modi ed Gates Glidden burs (no. 2–4) or ultrasonic tips. The
Gates Glidden bur is modi ed by grinding the bur perpendicular to its long axis at its
maximum cross-sectional diameter. The platform is kept centered to allow better
visualization of the fragment and the surrounding dentin root-canal walls; therefore,
equal amounts of dentin around the fragment are preserved, minimizing the risk of
root perforation. The ultrasonic tip is activated at lower power settings, so it
trephines dentin in a counterclockwise motion around a fragment with right-hand
threads and vice versa. With this trephining action and the vibration being
transmitted to the fragment, the latter often begins to loosen and then “jumps” out of
the root canal. Other root canal ori ces in the tooth, when present, should be
blocked with cotton pellets to prevent the entry of the loose fragment. If little care is
taken and excessive pressure on the ultrasonic tip is applied, the vibration may
push the fragment apically or the ultrasonic tip may fracture, leading to a more
complicated scenario. Also, to prevent separation of the ultrasonic tip, it is important
to avoid unnecessary stress by only activating it when in contact with root tissue”
• Nevares 2010: JOE. assessed the success rate of Ruddle technique for removing
broken instruments which has been proposed as a technique for the removal of metallic

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 instrument fragments from the root canal by using a combination of Gates-Glidden burs,
microscopic magni cation, and ultrasonic tips. The overall success rate (removal and
bypassing) was 70.5%. In the visible fragment group, the success rate was 85.3%
and in the nonvisible fragment group it was 47.7%. Success rates were signi cantly
higher when the fragment was visible.
• Suter et al 2005: IEJ. Found that 87% of separated instruments could be removed, and
all cases of removal involved the use of a surgical operating microscope.
• Ward, Messer 2003: Instruments before or at the curve can be retrieved, but not
beyond. A staging platform, microscope and ultrasonic were used. Files broken beyond
the curve decreased successful removal and caused extensive damage.
• Scouter, Messer 2005: File retrieval risky in apical 1/3 and le retrieval results in loss of
tooth structure per stress test. (attempt can lead to ledge formation, over enlargement
etc)
• Fu et al 2011: JOE. Retrospective. Of 66 teeth examined (64.7% recall), 81.8% were
healed. Stepwise logistic regression analysis revealed that inadequate root canal lling
was a statistically signi cant factor in predicting failure of successful healing. The cases
with removal of broken les had a higher healing rate than those with broken les left in
the root canal, but the difference was not statistically signi cant (P > .05). There was no
signi cant difference in outcome related to presence or absence of perforation, although
the rate of healing was greater in teeth without perforation. Other factors including age,
sex, tooth type, apical status, position of segment, and type of restoration did not affect
prognosis.
• Krell 1984 & Ngai 1986: recommend use of ultrasonic les to enlarge canal space
around post/Ag points/separated instrument.
• Johnson recommended 16 min ultrasonic activation for removal of Parapost.
• Madarati et al 2008: In conclusion, when ultrasonic tips are used without coolant for
removal of separated endodontic les, the temperature rise on the external root surface
was found to be a function of root canal wall-thickness, ultrasonic tip type, power setting,
and application time. Although CPR6 tips can be safely used up to 120 seconds, CPR2
and CPR5 tips can be used up to 90 and 60 seconds, respectively, when activated at
power setting 1. Power setting 5 is not recommended for ultrasonic removal of separated
les.
• Nagai et al: reported a success rate of 73% with ultrasonic removal of broken
instruments in 99 extracted teeth. In vivo, they successfully retrieved the objects from 26
of 39 teeth (66.6%), while in 6 other teeth (15.4%), the objects were successfully
bypassed without being retrieved. The time required retrieving the objects varied from 3
to 40 min.
• Managing a separated instrument:
• Iqbal: attempt removal, bypass or obturate to fx; platforming
• Ruddle: staging plateform with modi ed gates; ultarsonic with SOM. Other
methods: endo extractor tubes with cyanoacrylate; braiding hedstroms; wire loop
and tube
• Alomairy: 80% success with ultrasonics, 60% success with IRS
• Suter: 87% of separated instruments were removed successfully (41% in apical
1/3)
• Souter: les removed in apical and middle third weaken teeth; if you can see it and
it’s not beyond the curve —> remove
• Terauchi 2013: JOE. Secondary fracture of separated les appeared to be reduced
when the ultrasonic tip was applied to the inner curvature of the canal.

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 • Perforations
• Silva et al 2017: JOE. The purpose of this study was to evaluate the in vivo response of
periradicular tissues after sealing of furcation perforations with Biodentine, mineral
trioxide aggregate (MTA), and gutta-percha by means of histopathologic and indirect
immuno uorescence analyses. Thirty teeth of 3 dogs were divided into 3 groups:
Biodentine (n = 14 teeth), MTA (negative control, n = 10 teeth), and gutta-percha
(positive control, n = 6 teeth). After endodontic treatment, perforations were made on the
center of the pulp chamber oor and lled with the materials. After 120 days, the animals
were killed, and blocks containing the teeth and periradicular tissues were processe.
MTA and Biodentine induced the formation of signi cantly more new mineralized tissue
(P < .0001) than gutta-percha, which did not induce the formation of mineralized tissue in
any case. Complete sealing of the perforations was more frequent with MTA, which
formed mineralized tissue with greater thickness and area. Biodentine and MTA exhibited
no bone resorption in the furcation region, fewer in ammatory cells, and greater RUNX2
immunostaining intensity than gutta-percha. Although MTA presented higher frequency of
complete sealing and greater thickness and area of newly formed mineralized tissue,
Biodentine also had good histopathologic results and can be considered as an adequate
furcation perforation repair material.
• Siew et al 2015: Systematic review of literature, from 1950 to 2014, on clinical outcome
of perforation repair. Success rate of >70% (pooled success rate of 72.5%) was
generally concluded for nonsurgical perforation repair. Two favorable factors were
maxillary teeth and absence of preoperative radiolucency. The use of mineral trioxide
aggregate appeared to enhance the success rate to 80.9% but the difference was not
statistically signi cant.
• Gorni 2016: JOE. 10 yr prospective cohort. Assessed the healing outcome of
perforations. 110 patients. primary healing rates of 92% (101 of 110) are particularly
encouraging. The results of the present study show that after treatment with MTA and
having obtained primary healing, the risk of progression of the in ammatory process was
very low, with a 5-year risk of progression of 18%. This was a prospective cohort study
that enrolled consecutive patients with a single dental perforation treated with MTA
(January 1999-June 2009). Patients were followed up until December 2012 for a
maximum of 13 years after treatment, with analyses carried out at 8 years. (The ultimate
goal in the management of root canal perforations is to effectively seal the area as
quickly as possible with an effective biocompatible agent to prevent in ammation and
loss of tissue attachment by preserving healthy tissues at the perforation site. Although
this study was not conducted to compare sealing agents, the high long-term success
rates achieved with MTA con rm that it is an effective and well- tolerated agent in
repairing perforations. In this age of evidence-based, personalized medicine the results
of our study provide valuable data on how to effectively manage root canal perforations
in ‘‘real world’’ clinical practice. Most of previously reported data were based on case
series or small-scale short-term trials and as such offer limited evidence-based data. Our
results provide good evidence of the combined effectiveness of experienced operators
and the use of state-of- the art materials. )
• Mente et al 2014: The treatment outcomes of 64 root perforations repaired between
2000 and 2012 with MTA were investigated. Of the 64 teeth examined (85% recall rate),
86% were healed. MTA appears to have good long-term sealing ability for root
perforations regardless of the location. The univariate analyses (χ(2) tests) identi ed 2
potential prognostic factors, experience of the treatment providers and placement of a
post after treatment (decreased success).

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• Pontius et al 2013: In a retrospective study investigating healing rates of 70 perforation
repairs performed by 6 endodontic specialists, Pontius et al reported a success rate of
90%
• Main, Shabahang, Torabinejad 2004: MTA can be used as a perf repair material. no
matrix required. 100% (16/16) success. MTA is biocompatible and caused cementum
formation; less leakage than amalgam and IRM.
• Shemesh, Wesselink, Wu 2011: Signs of prior perforation, including bone loss adjacent
to the perforation site, can be recognized pre-operatively, particularly with the use of
CBCT imaging.
• Lantz 1967: Immediate perf repair and apical location better prognosis
• Fuss, Trope 1996: Factors for perf repair prognosis: Fuss and Trope classi cation of
location (Coronal>apical>crestal), Time (immediate = better), Size (small = better).
• Detection of Performation: Apex Locator (Fuss), radiographs, blood on paperpoints,
microscope, perio probings.
• Fuss 1996: Apex locators are more reliable than radiographs for locating root perfs.
• Pitt Ford, Torabinejad et al 1995: Immediate perforation repair better than delayed
(MTA). MTA is good for furcal repairs and no internal matrix is indicated under MTA. They
described cementum formation beneath MTA followed reformation of the PDL and
normal bony architecture.
• Lee, Torabinejad et al 1993: Recommended MTA for lateral root repairs
• Nakata, Baumgartner 1998: Perf repair with MTA seals better than amalgam
• Sluyk, Hartwell 1998: MTA useful for furcation repair. MTA resisted displacement at 72hr
better than 24hr (p<.05). No difference if MTA covered by wet or dry cotton pellet
(moisture probably derived from furcal tissue). In this in vitro study, found better
adaptation of MTA to perforation walls when rst placed Gelfoam as an internal matrix
• Dragoo 1997: Recommended glass ionomers or geristore as an alternative to MTA for
sulcular perforations (as MTA can wash out)
• Potential Prognostic Factors Following Perforation:
• Perforation Size (Fuss & Trope)
• Perforation Location (Fuss & Trope)
• Time to Repair (Fuss & Trope; Pitt Ford & Torabinejad)
• Provider Experience (Mente et al)
• Post placement following repair (Mente et al)
• Ability of clinician to seal the defect (Seltzer et al)
• Prior Microbial Contamination (Seltzer et al)
• Pathogenesis of failure of unrepaired perforations (Seltzer et al 1970): Epithelial
downgroth, peridontal involvement, adjacent bone loss, bacterial contamination
• How would you manage a perforation?
• If larger, consider an internal matrix as proposed by Lemon: (used HA)
• Rosenberg – Collacote
• Alhadainey – Calcium sulfate (Capset); Vitrebond
• Frank – Ca(OH)2
• Also: hydroxyapatite, DFDBA, Gelfoam, Calcium phosphate
• Repair with MTA as proposed by Main & Torabinejad (no matrix required) – 16/16
success X1 yr; Biocompatible and caused cementum formation; less leakage than
amal & IRM
Nakata & Baumgartner – less bacterial leakage than amal. Daoudi – less dye
leakage than Vitrebond
• What’s the prognosis of perforation repairs?

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 • Harris – 88% with Cavit
• Main,Torabinejad 2004 - 100% success with MTA
• Mente 2014 – 86% at aver 3 yr recall, perfs bigger than 3mm had less success
• Gorni 2016 — 92% w/ MTA. 10 yr prospective cohort
• Pontius 2013: 90%
• Siew 2015: Systematic Review. 72.5% overall. 80.9% with MTA
• Thermal Injury
• Davis S 2010: showed that injurious heat transfer occurs in less than 1 minute during dry
ultrasonic instrumentation of metallic posts. Cycles of short instrumentation times with
active coolants were effective in reducing the probability of tissue damage when teeth
were instrumented dry. With as little as 20 seconds of continuous dry ultrasonic
instrumentation, the consequences of thermal buildup to an individual tooth might
contribute to an injurious clinical outcome
• Woodmansey et al 2009: Reported a case of osteonecrosis following osteotomy
preparation for intraosseous anesthesia without coolant. Prolonged rotation of the
perforator drills in the bone can also cause excessive heat, which can lead to bone
necrosis.
• Gluskin, Ruddle et al 2005: Suggested the use of adequate water or air coolant when
using US to prevent damaging temperature increases.
• Floren et al 1999: results of this in vitro study indicate that any temperature setting of
the System B HeatSource at or above 250 degrees C has the potential to cause the root
surface temperature to rise 10 degrees C.
• Nicoll & Peters 1998: reported that water irrigation protects dentin from temperature
increases with ultrasonic scaling. (This work was applied to surgical endodontics)
• Lee et al 1998: The critical level of root surface heat required to produce irreversible
bone damage is believed to be > 10 degrees C. The ndings of this study suggest that
warm vertical condensation with the System B Heat Source should not damage
supporting periradicular tissues. However, caution should be used with Touch 'n Heat
devic and a ame-heated carrier on mandibular incisors.
• Gutmann et al 1987: reported that thermplasticized GP was safe in terms of its effects
on the periodontium, with very little risk of soft tissue thermal injury
• Eriksson & Albrektsson 1983: Showed that root surface temperatures should not
increase more than 10 degrees Celsius to avoid injury to periodontium
• Air Emphysema
• Can occur during endodontic treatment when air is forced through the root canal space
into the periapical tissue and beyond, creating swelling and crepitus.
• Shovelton 1957: Presented 13 cases of air emphysema secondary to endodontic
treatment, including one case in which a clarinet player introduced air via an open
endodntic access.
• Falomo 1984: Air syringe into root canal can cause emphysema
• Eleazer & Eleazer 1998: Found that air syringes created signi cant air pressure in
periapical spaces in an in vitro model. (Apical diameter size 25 or greater gave a sharp
rise in pressure). Recommendations include the following: 1. Remote exhaust
handpieces should be used during all dental surgery. 2. Antibiotics are indicated if air
emphysema develops. 3. Avoid compressed air-drying of all root canals. 4. Be aware
that sudden-onset swelling may be air emphysema.
• Hulsmann & Hahn 2000: found that air emphysema was self limiting and generally
resolved without intervention. however, dramatic sequela including fatal
pneumomediastinum can result.

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 • An et al 2014: Presented a case of orbital, cervicofacial and mediastinal emphysema
following endodontic retreatment of a mandibular premolar.

Pain
• De nition: An unpleasant sensory and emotional experience associated with actual or
potential tissue damage.
• Pain Localization
• Friend, Glenwright 1968: An experimental investigation into the localization of pain from
the dental pulp. Only 37% of patients could accurately identify the correct tooth. 3.4% of
teeth referred pain to the opposite Jaw (mand to max); 1.5% pain referral across midline.
• McCarthy, McClanahan et al 2010: The presence of periradicular pain increases the
accuracy of pain localization. The results show that patients presenting with odontogenic
pain can localize the painful tooth 73.3% of the time. Patients experiencing periradicular
pain can localize the painful tooth (89%) signi cantly more often than patients with pain
without periradicular symptoms (30%, p < 0.0001).
• Van Hassel, Harrington 1969: Classic: localization is poorest in mand post (60%
discrimination between two teeth). Pulps have wide two point discrimination threshold.
Most of the time patient can tell between quadrants.
• Pain Terminology
• Algesia: any pain experience following a stimulus; the feeling of pain
• Allodynia: pain due to stimulus which doesn’t normally produce pain or which is
innocuous
• Habituation: decrease or loss of response in nn terminal after repeated stimulation
• Hyperalgesia: increased pain response to noxious stimulus
• hypoesthesia: decreased sensitivity to stimulation that feels similar to the effect of local
anesthesia
• Sensitization (De ned by anatomic location)
• Peripheral Sensitization: Decreased ring threshold and spontaneous ring of
primary nociceptor due to being sensitized. (Sensitization from SP, CGRP,
Sprouting from nn bers, increased volt gated Na Channels, A-beta bers
responding to strong stimuli)
• Central Sensitization: Prolonged nociceptive input causes alterations in
subnucleus caudalis to decrease ring threshold of second order neurons (takes
longer to stop this pain)
• Nerve Fibers
• A-Delta, C = Primary Nociceptors
• A-beta = mechanoreceptors; proprioceptors
• Bender 2000: JOE.
• A delta bers are located principally at the pulp-dentin border zone (peripheral
pulp). Fast, Rapid, Sharp, Prickling pain.
• C bers are located in the pulp proper. Slow, Dull, Crawling, Crushing Pain.
• Fried
• A-delta —> Respond to EPT and hydrodynamic stimuli
• C —> Respond to intense thermal pain (high threshold, associated w/ injury)
• A -beta —> Respond to mechanical Stimuli
• Fearnhead:
• C mostly in pulp proper.
• A-delta terminate in odontoblast layer or enter dentinal tubules up to 200 microns.

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 • 50% of dentinal tubules are innervated at cusp tip
• Allard: Odontoblasts can generate action potentials
• Byers: odontoblasts do not participate in nociception.
• Narhi elaborated the role of intradental A- and C-type nerve bers in dental pain
mechanisms: 1) A- bres are responsible for the sensitivity of dentine and thus for the
mediation of the sharp pain induced by dentinal stimulation, 2) Prepain sensations
induced by electrical stimulation result from activation of the lowest threshold A- bers
some of which can be classi ed as A beta- bers according to their conduction velocities.
Comparison of the responses of the A beta- and A delta- bers indicate that they belong
to the same functional group, 3) Intradental C- bers are activated only if the external
stimuli reach the pulp proper. Their activation may contribute to the dull pain induced by
intense thermal stimulation of the tooth and to that associated with pulpal in ammation.
•
Neuron Function Myelination Order of Signs of Diameter in conduction
Type Blockade Blockade micrometers velocity
(m/sec)

A alpha Motor - yes fth loss of 12-20 70-120

proprioception motor
function

A beta sensory - yes fourth loss of 5-12 30-70

touch, sensation to
pressure touch and
pressure

A gamma motor - muscle yes third loss of 3-6 15-30

spindles prioception
proprioception

A delta Fast, pain, yes second pain relief, 1-5 6-30

temperature, loss of
touch temperature
sensation

B pre-ganglionic yes rst increased <3 3-15

autonomic skin , temp

C slow, pain no second pain relief, .2-1.5 .5-2

loss of
temperature
sensation

• Pain theories:
• Speci c (Von Frey)
• Speci c nerves exist to perceive pain (ie nerve for itch, nerve for pain)

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 • Pattern (Schiff)
• Pain from intense stimulation of nonspeci c nerves
• Summation —> Spatial and Temporal
• Gate-Control (Melzek)
• Dorsal horn acts as gate to increase or decrease ow of nerve conduction from
primary to secondary bers.
• Large proprioceptor nn close; small open
• example: wiggle patient’s cheek
• if gate is open then pain impulses reach the brain
• gate closed by incoming impulses from large bers or from the brain; opened by
impulses from small bers.
• Hydrodynamic (Brannstrom)
• Dentin Speci c Pain
• Fluid movement in the dentinal tubules leads to activation of nerve bers around/
in dentinal tubules which causes action potentials that is relayed to the central
nervous system.
• Trowbridge
• Sensation of hot and cold occurs before actual change in pulpal temperature
• Cold = out ow
• Hot = in ow
• Pain Process Models
• Hargreaves (Behavior)
• Detection (Pulp/PA tissues)
• Processing (Medullary spinal cord (subcaudal nucleus/trigeminal ganglion)
• Perception (Cerebral Cortex)
• Lavigne, TrueLove et al 2005 (Anatomic)
• Periphery
• Injury activates free nerve endings
• Immediate —> action potentials generated in A-delta and C bers (and rarely A
beta)
• Eventually —> in ammatory mediators sensitize nerves (K, GP, 5-HT, SP)
• Spinal Cord
• Synapse in trigeminal ganglion; release of neurotransmitters (SP, glutamate) and
ascension of spinothalamic tract contralaterally
• Higher Brain Centers
• Synapses in multiple centers: limbic System (Hypothalamus, amygdala, cingulate
cortex) and thalamus
• Reaction
• Sensory response (pain) and motor response (withdrawal)
• descending inhibition (5-HT, NE interneurons)
• Overview Pain Model
• Bacterial/Chemical/Mechanical Irritant —>
• Insults to peripheral tissues leading to nn (A-delta and C)
• Release of in ammatory mediators
• direct activation of sensory nerves
• indirect activation (lower threshold) = peripheral sensitization
• Primary nn ber synapse in trigeminal ganglion
• trigeminal ganglion has main sensory nucleus and spinal trigeminal nucleus

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 • Spinal trigeminal nucleus subdivides into subnucleus oralis, interpolaris and
caudalis
• subnucleus caudalis receives input from primary nociceptors and sends to
second neurons
• Secondary neurons ascend to thalamus on (contralateral side) Via spino-thalamic,
spino-reticular, spino-mesencephalic or parabrachial tracts
• Tertiary neurons ascend to the cortex for pain perceptions
• McClanahan: talked about pain relieved by ice. Due to peripheral sensitization causing ring
of pulpal nerve actional potentials due simply to body temperature as stimulus.
• Hahn & Liewehr: Painless pulpitis due to enkephalins and endogenous opioids (produced by
lymphoctes). Stress increases sympathetic activation which causes vasoconstriction which
explains pain en route to the dentist (increases pressure in the pulp).
• Michaelson: 40% of pulp necrosis occurs without symptoms.
• Sessle (good name for referred pain)
• summation - temporal and spatial - can lead to central sensitization
• Spatial: multiple bers ring at the same time
• Temporal: one ber ring multiple times over a short period of time
• Lavigne: Descending inhibitory neurons dampen pain processing via activating opioid -
containing interneurons in the subnucleus caudalis. (Serotonin containing bers from raphe
magnus. NE containing bers from locus coeruleus)
• Referred Pain
• Sessle: Convergence of many primary neurons at similar synapse in subnucleus
caudalis is basis for referred pain (Cat model). Single subnucleus caudalis synapse had
input from cornea, maxillary skin, maxillary premolar tooth, mandibular canine and
mandibular premolar.
• Okeson; McMahon: Selective anesthesia works for referred pain; works Mn vs Mx but
not within the same arch.
• Glick: Pain (even referred) won’t cross the midline
• Binkley: Redheads have increased MC1R gene. MC1R gene is associated with
anxiety. Dental care-related anxiety, fear of dental pain and avoidance of dental care
may be in uenced by genetic variations.
• Kier: Persistent post RCT pain. Due to missed canals (2 cases)
• Lavigne: Increased pain in females vs males. Due to decreased inhibitory nerve
activity.
• Peripheral Sensitization
• Peripheral Sensitization (Hargreaves)
• Increased excitability of pulpal nociceptors due to in ammation and pro-in ammatory
mediators.
• Decreased ring threshold and spontaneous ring of primary nociceptor due to being
sensitized
• Direct Activators of Peripheral Nociceptors:
• Serotonin
• Histamine
• Bradykinin
• TNF-alpha
• Sensitizers of Peripheral Nociceptors/Primary Afferents due to:
• Prostaglandins; Leukotrienes
• increased voltage-gated Na channels
• A-beta bers responding to stimuli

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 • Sprouting of nerve bers (NGF – nerve growth factor)
• increased substance P (SP) - neuropeptide
• IL-1beta
• increased Calcitonin Gene Related Peptide (CGRP)
• vasodilation causing edema and therefore increased tissue pressure
• awakening of silent nociceptors
• Peripheral Sensitization (Triad)
• 1. Hyperalgesia = Increased/Prolonged response to noxious suprathreshold stimuli,
aka after- ring
• 2. Allodynia = Decreased threshold for AP response to non-noxious stimuli
• 3. Spontaneous pain
• Sessle 2005 – Peripheral sensitization of afferent nociceptive endings is associated
with a decreased threshold for generation of AP (Allodynia), increased responsiveness
to noxious stimuli (Hyperalgesia), and spontaneous activity
• Hargreaves 1991 – Peripheral sensitization (Hyperalgesia) is mediated by
in ammatory mediators. Results in Triad of Spontaneous APs (spontaneous pain),
Decreased threshold for AP (Allodynia), and Prolonged response to noxious stimuli
(Hyperalgesia)
• Narhi – Arterial pressure following heartbeat (non-noxious stimuli) stimulates
sensitized nociceptors to re = “throbbing” pain
• Central Sensitization (Sessle 2005/2011, Hargreaves 1991)
• Sessle: Prolonged nociceptive input causes alteration in subnucleus caudalis to
decrease ring threshold of secondary neurons and have wider receptive elds,
spontaneous ring, recruitment of wide dynamic receptor bers and sprouting of NMDA
receptors on secondary neurons. Due to: increased SP, Glutamate, A beta ber
recruitment, spatial/temporal summation, decreased descending nerve action (from
decreases in NE and 5-HT).
• 1. Central sensitization - Afferent C ber barrage secondary to peripheral sensitization/
activation may lead to an Increased Receptive eld and Recruitment of long range bers
in Medullary dorsal horn; Plasticity of central neurons – Sprouting and Unmasking of 2nd
order neurons
• 2. Trigeminal brain stem complex - somatotopically arranged: main sensory nucleus,
spinal trigeminal nuclear tract (subnuclei: oralis, interpolaris, caudalis aka Medullary
dorsal horn)
• 3. Interneurons (local circuit neurons) - inhibitory (GABA) or excitatory
• 4. Decending pathways - Down regulation by opioid pathways (Enkephalins, GABA) in
Periaqueductal Gray (PAG)/Nuclear Raphe Magnus (NRM) of brainstem
• Pain Pathways (Detection, Processing, and Perception of Pain – Trigeminal nociceptive
afferents)
• Detection: 1st order neuron - Peripheral pulpal tissue -> Trigeminal ganglion (1º cell
body) -> Medullary dorsal horn (Subnucleus Caudalis) of spinal trigeminal nuclear tract
(brainstem)
• Processing: (Trigeminothalamic tract) 2nd order neuron - Medullary dorsal horn of spinal
trigeminal nuclear tract (2º cell body) -> Thalamus (contralateral due to crossing midline
while ascending)
• Perception: (Thalamocortical tract) 3rd order neuron – Thalamus (3º cell body) ->
Cerebral cortx/higher centers
• Summary

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 • Noxious stimuli are sensed by A-delta and C Fibers (pulp and PA tissues), primary
afferent nerves with their cell bodies contained in the trigeminal ganglion. These
bers synapse on the subnucleus caudalis in the medullary dorsal horn. Second
order projection neurons cross the midline to the thalamus via the spinothalamic/
trigeminothalamic tract. Third order neurons then travel to the cerebral cortex via
the thalamocortical tract.
• Referred Pain
• Sessle 2005 – Convergence theory: Super cial and Deep 1st order neurons synapse
with the same WDR and NS 2nd order neuron cell bodies within the medullary dorsal
horn of the spinal trigeminal nuclear tract. Afferent barrage leads to increased
receptive eld/activation of long range neurons/central sensitization (central
neuroplasticity – sprouting and umasking of 2nd order neurons) and inability of higher
levels to determine pain speci c location
• Falace 1996 – (n=400) Referred pain:
• 1. Pain severity is the most reliable predictor for referred pain
• 2. intensity of nociceptive barrage, Referred pain
• 3. 89.9% of patients w/ severe pain have referred pain
• 4. Most common site = Adjacent tooth (80%)
• Hargreaves: Mechanism for Pain.
• Peripheral mechanisms that contribute to allodynia/hyperalgesia
• Bradykinin, histamine, leukotrienes, prostaglandins (these change the threshold for
A-delta and C ber ring)
• Nerve growth factor (NGF) and Substance P (these cause sprouting of nerve bers)
• Change in tissue pressure
• Incidence of Post-Op Pain
• Pak, White 2011: Incidence of Pain following RCT. Systematic Review. Pretreatment
root canal-associated pain prevalence was high but dropped moderately within 1 day
and substantially to minimal levels in 7 days. Pretreatment root canal-associated pain
severity was moderate, dropped substantially within 1 day of treatment, and continued to
drop to minimal levels in 7 days. Supplemental anesthesia was often required.
• Torabinejad: Maximal pain relief in rst 24-48hrs
• Nixdorf et al 2010a: 5% of patients have pain more than 6 months post endo,
• Nixdorf et al 2010b: of the 5% of patients that had pain for more than 6 months: 3.4% of
was non-odontogenic
• Montero J 2015: In more than 90% of patients undergoing root canal treatment, pain
was totally or partially relieved after 7 days.
• Law, Nixdorf 2014: found that 19% of patients reported severe pain following
endodontic therapy lasting an avg of 2 days.
• Nixdorf, Law 2010: meta-analysis on the prevalence of persistent pain after endodontic
therapy: In conclusion, the frequency of all-cause tooth pain at 6 months or longer
following root canal therapy of permanent teeth is approximately 5%. Higher persistent
pain estimates (>7%) likely re ect a lower limit of chronic pain frequency after
endodontic procedures *** Patients reporting "tooth" pain 6 months after RCT had a
nonodontogenic pain diagnosis accounting for some of this pain, with
temporomandibular disorder being the most frequent nonodontogenic diagnosis.
• Genet 1986: Pre-op Pain = 65% chance of post op pain, no pre-op pain = 23% chance
of post op pain. Large n, very good.
• Mattscheck et al 2001: (Pretreatment pain is the biggest predictor of post-tx pain.)
Results. There was no signi cant difference in posttreatment pain with respect to

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 patients undergoing RCT Retreatment and patients under- going Initial RCT, type of
original obturating material, or pretreatment diagnosis. Posttreatment pain levels were
signi cantly increased at 4, 8, and 12 hours after treatment. Patients reporting higher
levels of pretreatment pain (Visual Analogue Scale > 20) had signi cantly increased
posttreatment pain (P < .05) up to 24 hours after the procedure. Conclusions.
Pretreatment pain level in uenced posttreatment pain more than RCR or IRCT, the type
of original obturating material, or the pretreatment diagnosis.
• Atypical or Non-odontogenic cases of pain
• Marbach 1978: Case Reports (phantom tooth pain). Patients who have pain persistent
in the teeth and jaws that eludes successful treatment may suffer from phantom tooth
pain. Neither RCT, apico, nor ext of offending tooth renders region free of pain. Two
theories: Central Biasing (after loss of limb, dental pulp, tooth sensory bers are
destroyed, thereby decreasing the amount of input into the reticular formation and
resulting in a decrease in inhibitory in uence. The result is sustained activity, which may
give rise to sustained pain.) Pattern Generating (loss of nerve tissue produces abnormal
ring patterns that continue after stimulation has ceased).
• Rees, Harris 1979: Coined the phrase atypical odontalgia. No obvious cause can be
determined.
• Fishbain 1988: Muchausen Syndrome is a factitious disorder with physical symptoms.
Patient has a psychological need to assume to the sick role. Many times these pts work
in medical eld.
• Schnetler, Hopper 1989: Intracranial tumors presenting with facial pain. Cases. Can do
cranial nerve tests. Refer patients with unexplainable altered sensations.
• Friedlander, Runyon 1990: Temporal Arteritis, a type of neruovascular pain, is
described as a systemic granulomatous disease, often affecting the carotid arteries,
presenting with ocular symptoms, burning tongue and headache. It is often associated
with polymyalgia rheumatica, classically identi ed by an elevated erythroctye
sedimentation rate. TA is a serious disease with high potential for subsequent blindness.
• Wright 1995: Found that the masseter was the muscle that most often referred pain to
teeth and referral occurred most often to molars with a predilection for the mandible.
• Ehlers 1999: Pain is a bio-psycho-social phenomenon, not just biological
•
• Single vs Mulitiple Visit
• Maddox, Walton 1977: Defend Single Visit Endo: Classic: intracanal medicament does
not make a difference in pain (it’s not what you put in, but what you take out). Obturation
= less pain (in a subsequent study Torabinejad con rmed obturation = less pain)
• Pekruhn 1981: Defend single visit endo: no difference in number of “pain days”
• Mulhern 1982: Defend Single Visit Endo: No difference in incidence of pain (no sinus
tract) (no mention of severity of pain)
• Oliet 1983: Defend single visit endo: no difference in incidence of pain (But did not look
at post-obturation pain)
• Roane 1983: Post-op pain unrelated to tooth type and pulp status. Same post-op pain
for 1 or 2 visit endo (reason for 1 or 2 visit endo not standardized)
• Maxillary Sinusitis
• Rihani 1985: Maxillary sinusitis may be diagnosed incorrectly as TMJ pain/dysfunction
syndrome b/c of a similarity of signs and symptoms. More considerations should be
given to sinus disturbances as a differential diagnosis. (headache, facial pain that
radiates to ear and upper teeth common to both) (Absence of clicking deviation of

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 mandibule, presence of facial pain aggrevated by lower head, nasal drainage, cloud
radiograph should con rm sinusitis).
• Kretzschmar 2003: Sinusitis should be considered in differential diagnosis of pain in
post maxillary tooth.
•
• Sessle 1986: Mechanisms of orofacial pain and pain control - Described referred, or
heterotopic, pain as that arising due to convergence of afferent neurons from different areas
to the same projection neuron. Summary Article. A-Delta Fibers: Sharp, well-localized,
pricking type of pain (myelinated bers). C afferent bers: burning, poorly localized and
diffuse sensation (unmyelinated). See article for additional info
• Hasselgren 1989: Pulpotomy for irreversible pulpitis: pain not affected by presence or
absence of pulp dressing. 100% of pts had pain relief after 1 day. 96% waited at least ONE
MONTH with no dressing and the patients were FINE. (pulpal medicaments used were:
camphorated phenol, eugenol, cresatin, ZOE, saline, dry pellet)
• Brannstrom 1992: Attributed dentinal hypersensitivity to hydrodynamic effects on the
intratubular uid of the dentinal tubules, oftentimes secondary to increased tubule patency or
adjacent low grade in ammation. Thermal stimuli may cause inward or outward uid
movement resulting in A delta ber stimulation and pain, which is usually transient in nature
as long as pulpal in ammation is not progressive. Additionally, Brannstrom suggested that
eccentric occlusal loads can also result in dentinal hypersensitivity.
• Oguntebi 1992: Little difference between pulpotomy (8%) or complete pulpectomy (6%) pain,
but if you’re going to do a pulpectomy, do it properly, because partial pulpectomy gives 13%
pain.
• Walton, Fouad 1992: Endodonitc interappointment are-ups. Overall incidence: 3.17%.
Overriding factor to predicting are-ups: Presenting Conditions (signs, symptoms, diagnosis).
Greater occurrence in females. Age not a factor. Patients initial symptoms (pain, swelling)
were associated with higher incidence of are-ups. Teeth with vital pulps resulted in relatively
few are-ups (1.3%). Teeth with necrotic pulps had a 6.5% incidence (statistically signi cant).
The periodontal diagnosis of acute apical abscess was signi cantly greater in areups. Sinus
tract = 0% areups. Number of visits not signi cant. Obturation correlated with signi cantly
fewer post treatment areups. No sig diff between initial tx vs retreatment. Dental students
had fewer areups.
• Cemental Tears
• Hanney et al 1992: Described cemental tears as a complete or partial detachment of the
cementum from the underlying dentin, usually attributed to trauma from occlusion. (often
results in periodontal and occasionally periapical infection).
• Lin et al 2012: cemental tears most often found in incisors of older patients and may or
may not be associated with a vital pulp. Often, they present with a sinus tract tracing the
root structure
• Lin et al 2014: performed a retrospective analysis of 71 cases of cemental tears treated
by nonsurgical and surgical methods. Surgical approach was more often successful.
Furthermore, the location of the cemental tear was signi cant - apical or middle portion
have better outcomes.)
• Marshall JG, Liesinger 1993: (Pre-op pain and no PARL = more post-op pain). There’s a
good chance a patient will have post-op pain if they had pre-op pain and patients with no PA
lesion have a greater chance of having post-op pain.
• Torabinejad, Schilder et al 1994: Strong correlation between pre-op and post-op pain.
Positive correlation with the incidence of post-op pain and apprehension.

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 • Torabinejad et al 1994: Effectiveness of various medications on postoperative pain following
complete instrumentation.
• An association was found between the intensity of pre-and postoperative pain.
• As the intensity of preoperative pain increased, the chances for more severe
postoperative pain increased (p < 0.0001).
• In addition, an association between the presence of apprehension before any treatment
and postoperative pain was also noted (between 0.012 < p < 0.047).
• Examination of the time-effect curves for various medications in patients with no mild
pain showed no statistical signi cant difference between the effectiveness of different
medications and placebo. However, a multiple comparison of the effectiveness of
various medications and placebo on patients in moderate and severe preoperative pain
showed that ibuprofen, ketoprofen, erythromycin base, penicillin, and
methylprednisolone plus penicillin were more effective than placebo within the rst 48 h
following complete instrumentation.
• Summary. The root canals of 588 consecutive nonsurgical patients with varying levels of
pain were completely instrumented in 10 endodontic practices and 4 endodontic
graduate programs. The participants were sequentially assigned to one of nine
medications and a placebo. The severity of pain was assessed by the visual analog
scale for 72 h following instrumentation. Among all of the parameters studied, three
factors (preoperative pain, apprehension, and types of medication) were found to be
signi cant in determining post-instrumentation pain.
• Torabinejad et al 1994: Effectiveness of various medications on postoperative pain following
root canal obturation.
• Statistical analysis of the data showed that the incidence of postoperative pain after
obturation is lower than that following complete cleaning and shaping (5.83% versus
21.76%). In addition, there was no signi cant difference between the effectiveness of the
various medications and placebo tablets in controlling postoperative pain following
obturation.
• Summary. This prospective study compared the effectiveness of nine medications and a
placebo in controlling pain following obturation. A total of 588 patients who required root
canal obturation were included. After obturation of root canals, each patient took one of
the medications, salicylic acid (2 x 250 mg), acetaminophen (2 x 250 mg), ibuprofen (2 x
250 mg), ketoprofen (2 x 250 mg), acetaminophen (2 x 250 mg) plus codeine (2 x 250
mg), penicillin (2 x 250 mg), erythromycin base (2 x 250 mg), penicillin plus ibuprofen (2
x 250 mg), methylprednisolone (2 x 250 mg) plus penicillin (2 x 250 mg), or a placebo,
every 6 h for 72 h. All medications were encapsulated in identical capsules. The patients
registered their degree of discomfort on a visual analogue scale of 0 to 9.
• Houck, Reader, Beck, Nist, Weaver 2000: RCT. Effect of trephination on post-op pain and
swelling in symptomatic necrotic teeth (trephinatation ~ mid root). Following RCT,
Trephination at the conventional site of an intraosseous injection (not the periapex) does not
provide more post-operative pain relief or reduce analgesic medication taken by patients who
present with symptomatic, necrotic teeth with periapical radiolucencies.
• Nist, Reader, Beck 2001: RCT. Following RCT, apical trephination performed. No signi cant
reduction in pain, percussion pain, or swelling resulted. Therefore, cannot not recommend the
routine use of an apical trephination procedure, as used in this study, in symptomatic necrotic
teeth with radiolucencies.
• Alacam, Tinaz 2002: Interappointment emergencies/ areups in teeth with necrotic pulps.
Overall incidence of are-ups 7.17% (9.4% sympotomatic cases, 5.9% in asymptomatic
cases). Signi cantly more painful are-ups in mandibular teeth than in max teeth. .

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 There were no signi cant differences in the incidence of are-ups attributable to gender, age,
presence/diameter of lesions, taking analgesics, or pre-operative symptomatic or
asymptomatic tooth diagnoses.
• Nusstein, Reader, Beck 2002: RCT. Effect of drainage upon access on post-op endo pain &
swelling in symptomatic necrotic teeth. Obtaining short-term drainage upon access (average
of 1.85 min) did not signi cantly (p > 0.05) reduce pain, percussion pain, swelling, or the
number of analgesic medications taken for symptomatic necrotic teeth with periapical
radiolucencies.
• Tokuda et al 2004: Bacterial LPS induces increased substance P production in pulpal
broblasts, which in turn up-regulates gene expression for pro-in ammatory cytokines and
COX-2.
• Yoldas et al 2004: Incidence and level of post-op pain in RCT retreatment: single vs two visit.
2-visit endodontic retreatment with an intracanal medication (Ca(OH)2) reduces postoperative
pain in endodontically retreated symptomatic teeth and decreases the number of are-ups in
all retreatment cases compared to 1-visit endodontic retreatment.
• Koyama 2005: Pt’s expectation of pain increases the actual experience of pain
• Polycarpou et al 2005: Prevalence of persistent pain following endo tx. Retrospective
Cohort. 400 pts. The most signi cant risk factors for post treatment pain were presence and
duration of pre-op pain from the tooth. Additional risk factors for persistent pain: female, hx of
chronic pain, preop mechanic allodynia and preop pain. (predictors of chronic pain (> 3
months = chronic pain): previous chronic pain, previous orofacial pain experience, female
gender)
• Trigeminal Neuralgia
• Zakrzewska 2002: Trigeminal neuralgia (TN) review. presents with recurrent episodes
of sudden, sharp, stabbing pain in the distribution of the trigeminal nerve
• Scrivani et al 2005: Trigeminal Neuralgia Review. Trigeminal neuralgia (TN) has an
incidence of approximately 4/100,000. It occurs in both genders with a slight female
predominance, and the diagnosis is most common over age 50. The pain in TN typically
consists of lancinating paroxysms. Attacks are most common in the 2nd and 3rd
trigeminal divisions, and the right side of the face is more often involved than the left. TN
is a chronic disorder. Although temporary spontaneous remissions often occur over the
clinical duration of the illness, most patients will experience episodic TN pain attacks for
years unless appropriately treated. (paroxymal pain, maybe be prevoked by light touch,
pain con ned to trigimal distribution, pain is unilateral, clinical sensory exam is normal).
Antiepileptic drugs are used to treat. Surgery used to treat.
• Lavigne et al 2005: Review of mechanisms associated with unusual orofacial pain.
• Wadachi, Hargreaves 2006: Bacterial by-products, such as lipopolysaccharide (LPS), can
directly cause pain by binding to nociceptors of trigeminal neurons (TLR4, CD14). By
eliminating bacteria we can decrease pain.
• Caviedes-Bucheli 2008: Neuropeptide review: substance P, CGRP, NPY, VIP
• Binkley et al 2009: JADA. Results of study suggest that MC1R gene variants and their
phenotype red hair color are associated with increased dental care-related anxiety, fear of
dental pain and avoidance of dental care. Patients with red hair may require extra measures
to help manage their dental anxieties.
• Applebaum, Khan 2015: con rmed that genetic variants in COX-2 associated with post-
treatment pain after endodontic treatment.
• Segura-Egea, Cisneros-Cabello 2009: Pain associated with root canal treatment Int Endod
J: There are no signi cant differences in relation to gender or age groups. Mandibular teeth
had a signi cantly (P < 0.05) higher percentage incidence of pain in comparison with

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 maxillary teeth. Pain was absent in 63% of anterior teeth compared with 44% in posterior
ones (P < 0.01). Interventions shorter than 45 min resulted in a signi cantly higher
percentage of pain absence (P < 0.05). Root canal treatment was signi cantly (P < 0.05)
more painful in teeth with irreversible pulpitis and acute apical periodontitis compared to the
group with necrotic pulps and chronic apical periodontitis (P = 0.049).
• Barodontalgia: Pain with change in pressure (dif cult dx. scuba diving, airline ight)
• Ferjensktik: 85% cases involve faulty restorations
• Senia: can occur in endo treated teeth due to expansion of trapped air under obturation
material expanding and causing increased PA pressure (Theory only)
• Zadik 2009:
• Vital Pulp Tissue is major cause. Pain on ascent = pulpitis. Pain on descent =
necrosis.
• Baradontalgia is an oral (dental or non-dental) pain caused by change in barometric
pressure. SCUBA divers sometimes refer to it as “tooth squeeze”. Barodontalgia is
currently classi ed into 4 categories: I Nonreversible pulpitis (Sharp momentary pain
on ascent), II Reversible Pulpitis (Dull throbbing pain on ascent), III Necrotic Pulp (Dull
throbbing pain on descent), IV Periapical pathosis (severe persistent pain on ascent
and descent). A healthy pulp is not affected by barometric change. Good oral hygiene
is a key factor to prevention. Following dental treatment, 24-72 hrs of “grounding” is
an effective way to prevent barodontalgia. If pulp compromised advised to initial RCT.
• Cardiac Pain
• Kreiner et al 2010: Found that cardiac pain was more often described as pressure and
burning, rather than the throbbing and aching frequently used to describe odontogenic
pain. Cardiac pain in the orofacial area is not relieved by local anesthesia, but relief can
occur with administration of nitroglycerin in early stages.
• Harrington, Mandel 1975: Case report concerning a pt whose initial angina pain was
localized to the area of the left posterior teeth. (stated that ~18% of cardiac pain can
localize to left jaw/teeth). 1st case report of dental pain of cardiac origin.
• Sebastian, Drum, Reader, Nusstein, Fowler, Beck 2016: Purpose: compare debridement
versus no debridement on postoperative pain in emergency patients with symptomatic teeth,
a pulpal diagnosis of necrosis, and a periapical radiolucency. Conclusion: patients receiving
debridement or no debridement had a decrease in postoperative pain over the 5 days.
Debridement resulted in a statistically higher success rate, but there was no signi cant
difference in the need for escape medication. (Ninety- ve patients presenting with moderate
to severe pain were analyzed. The patients were randomly divided into 2 groups: group 1
received anesthesia and endodontic debridement, and group 2 received anesthesia but no
debridement. At the end of the appointment, all patients were given ibuprofen/
acetaminophen. If needed, they could receive an escape medication. Patients received a 5-
day diary to record their pain levels and medication taken. Both groups had a decrease in
postoperative pain and medication use over the 5 days. The debridement group had a
signi cantly higher success rate than the no debridement group. There was no signi cant
difference between the 2 groups with respect to escape drug use.)
• Arias A 2012: Predictive models of pain following root canal treatment: a prospective clinical
study. The predictive models showed that the incidence of post endodontic pain was
signi cantly lower when the treated tooth was not a molar, demonstrated periapical
radiolucencies (p=0.003), there was no history of previous pain (p=0.006) or emergency
endodontic treatment (p=0.045) and there was no occlusal contact (p<0.0001). It was also
demonstrated that the presence of a occlusal contact is a strong predictor!
• Occlusal Reduction

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 • Creech, Walton 1984: Pain related to pre-op but NOT occlusal adjustment. Not
necessary to remove occlusal contacts to prevent post-op pain. (Adjust occlusion only as
needed; prophylactic adjustment does not reduce pain.)
• Rosenberg et al 1998: RCT. Occlusal reduction would be bene cial for patients whose
teeth exhibit: pre-op pain, pulp vitality, percussion sensitivity, and no periradicular
radiolucency. WHICH RINGS THE BELL FOR SIP/SAP diagnosis. This nding was also
con rmed by Cunningham.
• Parirokh et al 2013: Occlusal surface reduction did not provide any further reduction in
postoperative pain for teeth with irreversible pulpitis and mild tenderness to percussion
compared with no occlusal reduction. (But consider in this study they did not obturate the
root canals in the rst visit)
• Gatewood, Himel, Dorn: In vital teeth in which the in ammation has extended
periapically, which will present with pretreatment pain to percussion, occlusal reduction
has been reported to reduce post-treatment pain.
• Arias A 2012: Predictive models of pain following root canal treatment: a prospective
clinical study. The predictive models showed that the incidence of post endodontic pain
was signi cantly lower when the treated tooth was not a molar, demonstrated periapical
radiolucencies (p=0.003), there was no history of previous pain (p=0.006) or emergency
endodontic treatment (p=0.045) and there was no occlusal contact (p<0.0001). It was
also demonstrated that the presence of a occlusal contact is a strong predictor!
• Keenan et al 2006: In a Cochrane Systematic Review supported the Walton ndings and
reported that there is no evidence to support the use of antibiotics for pain relief in irreversible
pulpitis. This nding was also con rmed by Reader who showed that Pen VK did not
decrease are-ups with IP. Amox did not help decrease are-ups with necrotic, asymptomatic
teeth. Pen VK did not decrease are-ups with necrotic, symptomatic teeth.
• Walton, Torabinejad 2002: reported that in intra-appointment are-ups with necrotic pulp
and no clinical swelling there might be an acute apical abscess which is con ned to bone and
not show a swelling. In this cases, patency (apical trephination) reduce the pressure and pain
signi cantly.
• Trace the pain perception originating from a tooth?
• Narhi - A- bers are responsible for sharp pain (direct dentin stimulation, osmotic,
temperature changes). C- bers are activated only if the external stimuli reach the pulp
proper and may be responsible for dull, diffuse pain (intrapulpal pressure, increase in
pulpal temperature, in ammatory mediators). Prepain sensations induced by electrical
stimulation result from activation of the lowest threshold A- bers
• Sessle: Noxious stimuli → nociceptors in pulp!A-delta / C- bers (primary afferent
bers)!inferior alveolar n (man)/max n via PSA, MSA or ASA n (max)!trigeminal
ganglion → nucleus caudalis in medullary dorsal horn of spinal trigeminal nucleus
(second order projection neuron- wide dynamic range neurons) → cross midline to the
thalamus via the spinothalamic tract (third order neuron) → cerebral cortex via the
thalamocortical tract (pain perception) Neurotransmitters: glutamate, SP, CGRP
• De ne Allodynia, Hyperalgesia, and Central Sensitization:
• Hargreaves -
• Allodynia – reduction in pain threshold so that non-noxious stimuli are painful (cold
sensitivity & chewing discomfort)
• Hyperalgesia – the response to noxious stimuli produces more pain than it would
normally (exaggerated response to endo ice)
• Central sensitization-increased excitability of central neurons (2nd/3rd order) from a
barrage of impulses from C nociceptors so that normal inputs produce abnormal

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 responses – also neurogenic in ammation can cause spontaneous depolarization of
central neurons, also incr size of receptive elds)
• Owatz- 57% pt w/ IP have mech allodynia, Pacheco showed 67%-IP, 56%-necrosis
(unpub)
• What is neural sprouting?
• Byers - Changes in neural structures occur after most dental injuries. Analysis of the
progressive stages of pulpal abscess and necrosis showed sprouting CGRP nerve
bers (a) at the retreating interface between abscess and vital pulp; (b) in periapical
areas during onset of lesions; and (c) around chronic abscesses in granulomatous
periodontal tissues. (Sprouting incr density of innervation in in amed tissue and leads
to incr pain sensitivity)
• Taylor & Byers: Injury causes neural spouting & increased release of substance
vasoactive amins like P and CGRP (Neuropeptides can cause neurogenic
in ammation), which cause vasodilation (control pulp blood ow), and release of
in ammatory agents. This nding was also con rmed by Hargreaves who declared
that Sensory nerves may thus play a role in instant defense reactions of the pulp.
Taylor also showed that innervated teeth have less pulp necrosis and PA destruction
than denervated.
• The presence and over expression of substance P in human dental pulp and
periodontal ligament when teeth are submitted to occlusal trauma shows the effect
of occlusal interferences on PDL in ammation and tenderness. Also heavy
orthodontic forces showed over expression of CGRP and pulpal in ammation.
Therefore, CGRP expression in human dental pulp increases when teeth are
submitted to severe orthodontic forces (Javier Caviedes-Bucheli, 2011 JOE).
• Discuss referred pain:
• Sessle : Convergence Referred pain caused by afferent input from cutaneous and
visceral nociceptors onto the same projection N (i.e., nociceptors from the max sinus
and max molar projecting to the same projector N in nucleus caudalis).
• Travell - Myofascial pain & Trigger zones:
• Superior belly of masseter referred to maxillary posterior teeth.
• Inferior border of masseter referred to mandibular posterior teeth.
• Wright- 3% of TMD pts had acute pulpalgia; 12% TMD pts had referred pain to teeth
• Non-Odontogenic Pain
• Pain in the head and neck region isn’t always of dental origin. Reproduction of the
patients chief complain is paramount to elucidating the organic etiopathogenesis of the
pain. (Vitality tests paramount)
• Non-Odontogenic Pain - Pillar Names
• Lavigne; Okeson; Drinnan; Nixdorf
• Types of Pain:
• Common features of odontogenic pain: unilateral, localized pain, sensitivity to
temperature, pain qualities; dull, aching.
• Common features of non-odontogenic pain: bilateral pain or multiple sites of pain,
poorly localized (appears at different locations at different times), not necessarily
associated with thermal stimulus, pain qualities: burning, electric, stabbing, dull
ache
• Nixdorf et al 2010: IEJ. The frequency of nonodontogenic pain after endo therapy is
3.4%
• Benjamin responded to Nixdorf’s article. Using the same data, based on a critical
summary assessment of the evidence/included studies, found more than 50% of

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 cases of persistent tooth pain reported at least 6 months after endo tx were
nonodontogenic in origin.
• Kuc et al 2000. OOO. 1% of PA biopsies unrelated to the pulp.
• What are some nonodontogenic causes of tooth pain?
• Hargreaves: musculoskeletal (MFP, TMD), neuropathic (TN, AO), neurovascular
(migraine, cluster HA), in ammatory (sinusitis), systemic d/o (cardiac, Herpes, tumors,
DM), psychogenic
• Myofacial Pain
• Laskan; Okeson: Myofacial pain can mimic endo pain. Increased in females.
Tenderness to muscles of the head and neck. Selective anesthesia of tooth doesn’t
resolve the pain.
• Neurovascular Pain.
• Migraine
• Alonso: Most common neurovascular pain is migraine. Pain, nausea, visual
changes. Sometimes aura is present.
• Tension type headache
• Cluster Headache
• Alonso: Same time of day. Due to stress/alcohol/vasodilators. Unilateral behind
the eye. Treat with oxygen.
• Chronic Paraoxysmal Hemicrania
• First described by Sjaastad and Dale in 1974
• Name Origin —> Daily, limited attacks, unilateral (always on the same side)
• Treatment: Indomethacin
• Diagnostic Criteria
• 50 + attacks
• attacks: severe, unilateral, supraorbital/temporal, always on the same side,
2-45 min duration, more than 5 attacks per day (at least 50% of the time)
• Giant Cell Arteritis
• Guttenberg: Severe unilateral pain due to artery being blocked. Can cause
blindness/death. F > M. > 50 y/o. Treat with steroids.
• Carotidynia
• First Described by Temple Fay in 1927
• Murray, TJ 1979: Can Med Assn.
• Unilateral tenderness of the carotid artery near its bifurcation (often enlarged).
• Often secondary to migraine (Tx of migraine will relieve symptoms if they’re
related).
• Histologic evidence of in ammatory component involved causing symtpoms
• Can be caused by carotid arteritis (a form of giant cell arteritis)
• Non-Odontogenic Pain: Neural vs Somatic
• Somatic (aka nociceptive)
• Due to noxious stimulation of somatic structures (impulses transmitted by normal
neural structures and their clinical characteristics are related to stimulation of
normal neural structures.
• Nociceptive Pain: Caused by activity in neural pathways in response to potential
tissue damaging stimuli.
• Post-op pain, mechanical lower back pain, sports/exercise injuries, sick cell
crisis, arthritis
• Neural (aka neuropathic)
• Neuropathic pain arises from abnormalities in the neural structures themselves

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 • the clinical exam shows no somatic tissue damage and the response is
disproportionate to the stimulus.
• often misdiagnosed as psychogenic
• Neuropathic pain: initiated or caused by primary lesion or dysfunction in the
nervous system.
• Post-herpetic neuralgia, neuropathic low back pain, distal polyneruopathy
(diabetic, HIV), central post-stroke pain, trigeminal neuralgia, Complex
Regional Pain Syndrome.
• 4 Subcategories:
• Neuroma: Proliferative mass of neural tissue in disorganized fashion at the
site of traumatically or surgically transected nerve. Symptoms develop after
neural tissue on the proximal stump has time to proliferate (aprox 10 days after
event). Tapping over area elicits sharp electrical pain (Tinel’s sign) similar to
trigeminal neuralgia. Unlike neuralgia, there’s no trigger zone distant to the
neuroma site. Treatment : surgical coaptation of the nerve. Most commonly in
the area of the mental foramen, lower lip, tongue, ext site, after pulp
extirpation.
• Neuralgia: Pain in the distribution of the nerve or nerves that occurs with
trigger point stimulus or uncontrollable. ie Trigeminal neuralgia.
• Black: Pulpectomy/Ext can lead to disorders resembling ipsilateral TN
• Scrivani: often spontaneous. 4 out of 1000. F > M. > 40 y/o. Associated
with MS.
• White and Sweet Diagnositic Criteria: Pain paroxysmal. Provoked with
light touch to the face. Con ned to trigeminal distribution. Unilateral.
Sensory exam normal.
• Laskin: Treatment - manage (not cure); soft diet; NSAIDs (contraversal);
benzodiazepenes; splint; relaxation techniques
• Drinnan; Okeson: Treatment- carbamazepine (Na Channel blocker),
tegretol, baclofen (antiepileptics, GABA agonist). Tx severe exacerbation
with IV lidocaine or surgery
• neuritis: In ammation of a peripheral nerve or nerves accompanied by
degenerative changes in nervous tissue (due to injury, infection - viral/
bacterial)
• Tidwell & Gutmann: HSV can mimic endodontic pain. Look for skin rash
to con rm HSV.
• Goon: HSV can cause pulp necrosis via interruption of blood ow
• Wright: VZV is in nerves adjacent to blood vessels and can in ame blood
vessels leading to decreased blood ow.
• neuropathy: Sustained, localized nonepisodic pain secondary to an injury in a
neural structure. Peripheral: affecting peripheral nerves outside CNS. Central:
affecting nerves within the CNS.
• Lavigne: Neuropathic pain due to
• Peripheral Sensitization —> Central Sensitization —> nn Sprouting ( A delta, A
beta, C bers; all of which can form connections with existing nociceptors)
• Loss of inhibitory interneurons
• C bers release SP —> increased NGF —> increase SP NN bers
• Genetic susceptibility
• Pulpectomy can lead to increased spontaneous ring of low threshold
mechanoreceptive neurons.

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 • Oshima: Nueropathic pain after RCT. 88% Mx; 81% female; 47 y/o
• Treatment of neuropathic pain
• Lavigne: Capsacin, Botulinium Toxin (BOTOX), clonazepam, gabapentin,
lorazepam, carbamazepine, TCAs, NSAIDs/Opioids (contraversal), Surgical
decompression, acupuncture.
• Sinusitis
• Radman: Recommends 5% topical swab and placed in meddle meatus; if pain
gone in 1-2 minutes it is of sinus origin.
• Laskin: Sinusitis - ache or throb worse with head positions, involves multiple teeth,
Pano to diagnosis.
• Drinnan: History of RI, chief complain of PM, M pain unilateral
• Kretzschmar: Tx with decongestants (sutafed); if no relief in 10 days add AB and
re-exmin for possible odontogenic etiology.
• Pokorny, Tataryn 2013: Maxillary sinusitis of dental origin (MSDO) should be
considered highly likely when radiographic evidence of dental pathology is
associated with maxillary sinus disease. Regardless of negative CT evidence of
dental pathology, MSDO should be suspected when unilateral maxillary sinus
disease is seen, particularly when associated with a patent infundibulum. When
MSDO is suspected, a clinical endodontic examination should be performed to rule
out or treat an odontogenic etiology.
• Dentinal Hypersensitivity
• Abir: DH Teeth = more open tubules and increased size of tubules
• Bitter 2014: Association of hypersensitive dentin and hypersensitive special senses
• Mechanism of Pain:
• Trowbridge: DH due to A-delta nn ring in DT’s from DF ow
• Diagnosis:
• Pashley: Differentiate DH from Pulpal pain
• rub Calcium chloride soaked cotton pellet over defective margin
• if pain in 30-60 sec dues to osmotic movement of DF and therefore DH
• Treatment
• Pashley: Occlude Tubules (Gluma, hurriseal, NaF, Resin Restoration). Decrease
nerve excitability (Eugenol; Nitrates (ie sensodyne)
• Nitrates:
• Markovitz: nitrates decrease DT nn ring (Na>Li>Sr>K>)
• works by hyperpolarizing nns’ transcient and needs reapplication
• Jerome: can give sustained deliver in mouthguards
• Swift: Colgate sensitive and sensodyne both contain 5% KNO3
• Pain localization: Are patients able to localize pain
• McClanahan: 75% accurate. 90% if PA symptoms
• Friend: 37% Accurate
• Brown: use of selective anesthesia to localize pain. Useful if Mx vs Mn; not useful within
the same arch.
• Sharay; Okeson: Vertical referral of pain can occur
• Glick: Pain Laws
• Pain from a tooth can be referred anywhere along the unilateral trigeminal nerve
• Pain does not cross the midline
• Maxilla can refer to mandible and vice versa
• Mn Ants —> mental area
• Mn Post —> ear; angle of Mn

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 • Mx Ant —> Frontal region
• Mx Can/PM1 —> nasolabial/infraorbital areas
• Mx PM2 —> Temporal/Mx area
• Mx M1 —> Mx area
• Mx M2/3 —> ear/upper Mn
• Does pain cross the midline?
• Steward and Wilson; Friend —> Yes
• Glick; Oliver —> No
• Cunningham & Mullaney 1992: Alleviation of existing pain is the primary objective of RCT
• Once pain starts can we expect to cease it immediately?
• Naidorf 1985: JOE. Opening the root canal introduces O2. Facultative bacteria respire
aerobically and multiply. Ag-AB complexes initiate complement. Histamine, PGs and
bradykinin are released. We can interfere with analgesics and PG inhibitors but the
process must run its course.
• Hargreaves: Pain control requires removal of peripheral mechanisms of hyperalgesia and
allodynia. This involves removal of bacterial and or immunologic factors. Often requires
pharmacotherapy interventions.
• Why do we get endodontic pain?
• It is the response of the body to bacteria that causes in ammation and the in ammatory
mediators cause pain.
• Vascular dilation and permeability result in edema and increased interstitial tissue
pressure. This leads to decreases in the threshold of neurons and concomitantly
increases the pressure on the neurons to re.
• Prostaglandins, leukotrienes, bradykinin, platelet activating factor, substance P. These
mediators indirectly and directly activate pulp/periapical nociceptors.
• Hameed; Torabinejad: Pre-op pain correlates with increased postoperative pain.
• Endodontic Pain - Postoperative
• Gulabivala: Factors associated with persistent postoperative (Chronic) pain:
• Females 85%, Males 15%
• Caucasians 81%, Asians 9.5%, Indian 4.8%, Pakistani 4.8%
• Previous Chronic Pain Problems
• Previous pain in orofacial region secondary to tx
• preop percussion pain
• 3 + months pretreatment pain
• Harrison: 20-30% of pts requires analgesia postop. 2-5% need strong analgesics.
• Pak & White: 40% have pain at 24hrs after tx. 11% have pain 7 days after tx.
• Nixdorf: 5.3% have persistent pain in the 6 months after RCT.
• Law, Nixdorf 2014: 19% of patients reported severe pain following endodontic therapy
lasting an avg of 2 days.
• Torabinejad: More pain with cleaning & shaping than obturating.
• Torabinejad; Creech & Walton: Preop pain predicts postop pain.
• Fouad; Walton; Torabinejad: Antibiotics do not decrease postoperative pain.

Endo Perio Lesions

• Endodontic lesions that create an area of drainage through the the periodontal pocket are
often dubbed “perio-endo” lesions, though in fact, these are a version of a chronic apical
abscess where the apical infection has established a pathway of drainage. Harrington et al
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 a periapical or lateral lesion and is detected as a narrow, deep probing depth. Since these
lesions arise from an endodontic source, they can be treated with endo therapy alone. Simon
et al described these lesions as “primary endo, secondary perio”.
• Vertical Root fractures or perforations may present in a similar fashion to these lesions
• Ruiz et al 2017: JOE. Retrospective Cohort. n=194 teeth w/ adequate RCT, coronal
restoration and no AP were selected. The control group included periodontally healthy
patients and the periodontal group patients with periodontal disease receiving nonsurgical
periodontal treatment. After an observation period of at least 2 years, the incidence of AP was
scored using the periapical index.
• The purpose of this study was to investigate the incidence of apical periodontitis (AP) in
endodontically treated teeth with and without periodontal involvement.
• Results: Newly emerged AP was found in 14% of periodontally involved teeth and in 3%
of nonperiodontal involved teeth (P < .05, OR = 5.19, 95% con dence interval). The
periodontal condition and hypertension were the only signi cant factors associated with
the presence of AP in the follow-up after univariate logistic regression. Adjusting for
hypertension, multivariate logistic regressions showed that periodontal status remained
signi cant (OR = 5.25, 95% CI, P < .05).
• Conclusions: The risk of developing AP in endodontically treated teeth is 5.19 times
higher for patients with periodontal disease compared with patients without periodontal
disease.
• Rotstein, Simon 2006: Endo Topics. Review
• In primary endodontic disease, the pulp is infected and non-vital. On the other hand, in a
tooth with primary periodontal disease, the pulp is vital and responsive to testing.
However, primary endodontic disease with secondary periodontal involvement, primary
periodontal disease with secondary endodontic involvement, or true combine diseases
are clinically and radiographically very similar. If a lesion is diagnosed and treated as a
primarily endodontic disease due to lack of evidence of marginal periodontitis, and there
is soft-tissue healing on clinical probing and bone healing on a recall radiograph, a valid
retrospective diagnosis can then be made. The degree of healing that has taken place
following root canal treatment will determine the retrospective classi cation. In the
absence of adequate healing, further periodontal treatment may be indicated.
• Primary endodontic disease should only be treated by endodontic therapy. Good
prognosis is to be expected if treatment is carried out properly with a focus on infection
control. Primary periodontal disease should only be treated by period- ontal therapy. In
this case, the prognosis depends on the severity of the periodontal disease and the
patient response. Primary endodontic disease with secondary periodontal involvement
should rst be treated with endodontic therapy. Treatment results should be evaluated in
2–3 months and only then periodontal treatment should be considered. This sequence of
treatment allows suf cient time for initial tissue healing and better assessment of the
periodontal condition (15, 216). It also reduces the potential risk of introducing bacteria
and their byproducts during the initial phase of healing. the prog- nosis for treatment of
primary endodontic disease with secondary periodontal involvement depends primarily
on the severity of periodontal involvement, periodontal treatment, and patient response.
• Primary periodontal disease with secondary endodontic involvement and true combined
endodontic – periodontal diseases require both endodontic and periodontal therapies. It
has been suggested that intrapulpal infection tends to promote marginal epithelial down
growth along a denuded dentin surface. The prognosis of primary periodontal disease
with secondary endodontic involvement and true combined diseases depends primarily
upon severity of the periodontal disease and periodontal tissues response to treatment.

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 • True combined diseases usually have a more guarded prognosis. In general, assuming
the endodontic therapy is adequate, what is of endodontic origin will heal. Thus, the
prognosis of combined diseases rests with the ef cacy of periodontal therapy.
• Abbott, Salgado 2009: Austrialian Dent J. In general, if the root canal system is infected,
endodontic treatment should be commenced prior to any periodontal therapy in order to
remove the intracanal infection before any cementum is removed. This avoids several
complications and provides a more favorable environment for periodontal repair. The
endodontic treatment can be completed before periodontal treatment is provided when there
is no communication between the disease processes. However, when there is communication
between the two disease processes, then the root canals should be medicated until the
periodontal treatment has been completed and the overall prognosis of the tooth has been
reassessed as being favorable. The use of non-toxic intracanal therapeutic medicaments is
essential to destroy bacteria and to help encourage tissue repair.
• Simon, Glick, Frank 1972: Discussed 5 Classi cation:
• 1. Primary Endo: Necrotic pulp, CAA drains into sulcus/furca = Narrow isolated PD;
mimics VRF, Perio Abscess
• 2. Primary Perio: Vital pulp, Wide PD defect, Angular/may involve several teeth;
Prognosis depends on Perio Tx.
• 3. Primary Endo + Secondary Perio: Necrotic pulp, CAA drains into sulcus/furca +
Plaque/calculus at gingival margin = solitary, wider PD.
• 4. Primary Perio + Secondary Endo: (Controversial) Wide PD defect extending to AF
IP/PN; Prognosis depends on Perio Tx.
• 5. True Combined: PN + Perio = Endo lesion (apically) meets perio lesion (cervically);
Extensive bony destruction, Wide defects, May involve multiple teeth; Prognosis
depends on Perio Tx.
• 6. Concomittant Endo Perio Lesion (added later): Separate and Distinct Endo and Perio
lesions w/ no in uence on either; Prognosis depends on Perio Tx
• Langeland 1974: (perio dz can cause endo dz). Pulpal necrosis occurs only when main
apical foramen is contaminated (not lateral canals). Periodontal pathology is unlikely to cause
endodontic involvement unless the periodontal lesion reaches the apex. (histo)
• Bender, Seltzer 1972: Assert that periodontitis cannot cause pulpal disease
• Bergenholtz 1978: Exposure of dentinal tubules causes only minor pulpal change
(secondary dentin)
• Harrington 1979: Do endo rst, then take care of the resulting perio defects. Review of
discerning endo from perio.
• Kobayahsi 1990: bacteria in deep pockets look like bacteria in necrotic pulps (circumstantial
evidence)
• Harrington et al 2000: Described these lesions generally as a sinus tract through the PDL
space that originates from a periapical or lateral lesion and is detected as a narrow, deep
probing depth. Since these lesions arise from an endodontic source, they can be treated with
endodontic therapy alone.
• Segura-Egea et al 2012: Chronic apical periodontitis shares important characteristics with
periodontal disease: 1) both are chronic infections of the oral cavity, 2) the Gram-negative
anaerobic microbiota found in both diseases is comparable, and 3) in both infectious
processes increased local levels of in ammatory mediators may have an impact on systemic
levels.
• Siqueira 2014: Both are polymicrobial infections sharing a common microbiota with a
predominance of Gram negative anaerobic bacteria

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• Caplan 2004, 2006: Elevated cytokine levels may be released systemically from acute and
chronic manifestations of both disease processes (chronic apical periodontitis, periodontitis),
for example increased concentrations of in ammatory mediators have been detected both in
the gingival crevicular uid of subjects with periodontal disease and in the periapical tissues
of endodontically involved teeth
• Seltzer, Sinai: (endo lesions cause perio pathology and vice versa through lateral canals).
perio lesions may be initiated by in amed or necrotic pulp through lateral canals.
• Torabinejad: Histo study showing no correlation between endo lesions and perio pathology.
• Sinai, Soltanoff: showed endo dz can cause perio dx. rat study showed pulpal disease
affects the periodontium quickly with in ammation; perio disease affects the pulp slowly with
degenerative changes
• Mazur & Massler / Czarneck & Schilder: showed perio dz does not cause endo dz. Histo
studies showed no correlation
• Wong, Hirsch: showed perio tx can affect the pulp. pulpitis was noted adjacent to areas of
root planning/scaling
• Dunlap: showed endo tx does not effect future perio tx. in vitro study found RCT does not
interfere with growth of broblasts on planed dentin surfaces.
• Euiseong Kim 2008: Endodontic microsurgery done on regular CAP cases and on Endo-
Perio cases. 263 teeth with 2 year follow up. When buccal bone was lost, Calcium sulfate
was used with CollaTape cover. Pure endo had 95.2% success. Endo Perio had 77.5%
success. It might be concluded that the combined Endo-Perio lesions can jeopardize the
outcome of the RCT.
• Setzer F, Kim S et al 2011: Molar endodontic treatments with crown placement. Information
recorded was: crown lengthening, periodontal diagnosis, attachment loss, furcation
involvement, mobility, internal resorption, external resorption, periradicular resorption. 4-year
minimum follow-up. The only preoperative factors signi cant for the prognosis of restored
endodontically treated molars (Among the mentioned factors) were related to periodontal
prognostic value and attachment loss.
• Gupta 2015: in a prospective randomized clinical trial evaluated the effect of a time lapse
between endodontic treatment and nonsurgical periodontal treatment on periodontal healing
of concurrent endodontic- periodontal lesions without communication. It was found that
nonsurgical periodontal treatment may be performed simultaneously with endodontic
treatment in the management of concurrent endodontic- periodontal lesions without
communication, and an observation period after endodontic treatment may not be required.
• Trope, Tronstad et al 1988: JOE. In periodontal abscesses the occurrence of spirochetes
ranged from 30 to 60%, whereas in endodontic abscesses the range was 0 to 10%. Thus, the
percentage of spirochetes as seen by dark eld microscopy may be of value in the differential
diagnosis of periodontal and endodontic abscesses.In abscesses diagnosed clinically as
periodontal, spirochaetes were the predominant cell (mean, 40.6±10.9%) with coccoid cells
present in eigni cantly lower numbers (mean, 19.7±10.9%). In endodontic abscesses the
reverse was true. Cocsoid cells dominated (mean, 44.3±19.7%), and only lew spirochetes
were present (mean, 5.6±4.7%).
• Gargiulo, Wentz, Orban: Biologic Width - sulcus depth 0.69mm, epithelial attachment
0.97mm, CT attachment 1.07mm.
• Periodontitis affects the pulp:
• Rubach and Mitchell
• Sinai and Soltanoff
• Giovanella et al
• Langeland (if reaches apex)

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• Periodontitis does NOT affect pulp
• Mazur and Messler
• Czarnecki and Schilder
• Bender and Seltzer

Post and Post Space Preparation

• Schillingburg: Posts enhance retention of the coronal restoration. Posts should either equal
the length of the clinical crown or measure 2/3 of the root length, whichever is longest
• Goldfein et al 2013: JOE. rubber dam isolation should be used for post placement. 20%
better outcome. Twenty-six patients (30 teeth) had a post placed with the use of an RD, and
159 patients (174 teeth) had a post placed without an RD. In the non-RD group, 128 (73.6%)
teeth were considered successful at follow-up. In the RD group, 28 (93.3%) teeth were
considered successful at follow-up. Based on the bivariate GEE model, the difference in
success between these 2 groups was statistically signi cant
• Ferrule: band of tooth structure around the tooth which is 1.5-2mm
• Juloski 2012: JOE. published a guideline regarding the ferrule effect: “The presence of a
1.5- to 2-mm ferrule has a positive effect on fracture resistance of endodontically treated
teeth. If the clinical situation does not permit a circumferential ferrule, an incomplete ferrule is
considered a better option than a complete lack of ferrule. Including a ferrule in preparation
design could lead to more favorable fracture patters. Providing an adequate ferrule lowers the
impact of the post and core system, luting agents, and the nal restoration on tooth
performance. In teeth with no coronal structure, in order to provide a ferrule, orthodontic
extrusion should be considered rather than surgical crown lengthening. If neither of the
alternative methods for providing a ferrule can be performed, available evidence suggests
that a poor clinical outcome is very likely”.
• Sorenson: Acceptable Posts should have following criteria: 1/3 MD with of root, 4mm of GP
left, half in to the bone, it should be in widest and straightest canal, it must be 2/3 of the root
or equal to clinical crown. According to Sorenson while crowns signi cantly improved the
success of endodontically treated posterior teeth, they did not do so for anterior teeth.
• Sorensen & Martinoff 1984: Anterior teeth do not require post and crown. But premolars and
molars require cuspal protection
• Guzy & Nicolls 1979: Posts do not strengthen teeth.
• Trope 1985: argued that post space preparation weakens the tooth and post do not
strengthen the tooth structure. Based on this ndings Sorenson suggested that since a post
does not strengthen an RCT tooth and the preparation of a post space may increase the risk
of root fracture and treatment failure, the decision whether to use a post in any clinical
situation must be made judiciously.
• Kane, Burgess 1991: Modi cation of the resistance form of amalgam coronal-radicular
restorations. J Prosthet Dent 1991;65: 470-4. Many endodontically treated molars do not
require a post because they have more tooth substance and a larger pulp chamber to retain a
core buildup
• Haddix & Mattison 1990: Recommended remove GP with hot instrument for post space
preparation. GG burs tend to "pull" GP and may disrupt apical seal which might affect the
long term success of RCT.
• Madison: leave at least 4mm GP when placing post.
• Madison, Zakariasen: showed that there is no difference if you prepare the post space at the
time of obturation or later regarding the seal and micro leakage.

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 • Karapanou et al 1996: showed that Post-space preparation can be undertaken immediately
following obturation to avoid twisting gutta-percha and breaking the seal when sealer is set.
• Kuttler: said there might be a risk of perforation using gates for post space preparation.
Dentin thickness correlates inversely to post space diameter. A no. 4 Gates-Glidden drill
caused strip perforations in 7.3 percent of the canals studied, and therefore the authors
recommend that Gates-Glidden drills larger than a no. 3 not be used in these roots. After
endodontic treatment, the furcation-side dentin thickness was less than 1 mm in 82 percent of
the teeth.
• Ravanshad, Torabinejad 1992: Coronal dye penetration of the apical lling materials after
post space preparation. Forty canals of palatal and distal roots of molars were cleaned and
shaped with the use of a step-back technique. Thirty canals were obturated, 10 each with
lateral, vertical, and therma l techniques. Five root canals were obturated without a root canal
sealer and served as positive controls. Another ve root canals were obturated, and their
coronal half was sealed with sticky wax and served as negative controls. The apical 5 to 6
mm of the lling materials were exposed to india ink for 48 hours. The depth of dye
penetration was measured in all groups and statistically analyzed. The apical plugs in the
therma l group had the highest degree of coronal leakage. The ANOVA test showed a
signi cant statistical difference between coronal dye leakage between this group and those
found in canals lled by lateral or vertical condensation techniques. The results indicate that
the apical lling materials obtained by lateral or vertical condensation leak less than those
obtained by therma l.
• Hagge MS 2002: IEJ. Investigated the effect of three root canal sealers on the retentive
strength of endodontic posts luted with a resin cement. Eugenol containing sealer, AH-26,
and Sealapex did not affect the retention of endodontic posts luted with Panavia cement;
therefore, eugenol avoidance is unnecessary when selecting sealers.
• Schwartz 1998: JOE. Effects of eugenol and noneugenol endodontic sealer cements on post
retention. The type of sealer (Roth's or AH-26) had no effect on post retention with either
cement (ZnPO4 or Panavia). Post retention was signi cantly greater with the zinc phosphate
cement than the resin cement.
• Al-Omiri 2010: reviewed the fracture resistance of tooth restored with posts. It was
suggested that fracture resistance was improved if tooth structure loss was limited, a ferrule
was obtained, a post with similar physical properties to natural dentine was used, and
adhesive techniques for post luting and coronal restoration were used. Adhesively luted resin/
ber posts with composite
• Fokkinga et al 2005: IEJ. reported that the presence or absence of metal/ ber posts did not
affect the fracture resistance and failure modes of endodontically treated premolar teeth with
resin composite crowns and no retained coronal tooth structure. Therefore, they suggested
that posts are not necessary for the restoration of such teeth.
• Wegner et al 2006: JOE. The purpose of this retrospective clinical study was to evaluate the
survival rate of teeth that were endodontically treated and restored with endodontic posts and
prosthodontic restorations. A total of 864 teeth in 360 patients were included in the study.
Dental records and radiographs of the patients were evaluated and four parameters were
documented. The mean observation time was 22.5 +/- 14.9 months. The calculated survival
rates of the abutments were statistically signi cant different for xed partial dentures (FPDs)
and for removable partial dentures (RPDs) with survival rates of 92.7% and 51.0% after 60
months, respectively. Most of the presumed factors in uencing the survival rate of
endodontically treated abutment teeth only affected the outcome in the RPD group. Teeth
restored with post and cores present a high risk for failure when used as abutments for
conical-double-crown-retained RPDs.

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 • Mohammadi et al 2009: JOE. found no difference in fracture resistance of premolars
restored with direct resin composite in the presence or absence of ber post and cusp
coverage.
• Zhou 2013: meta-analysis. compared the fracture resistance between cast posts and ber
posts. It was mentioned that cast posts had higher fracture resistance than ber posts.
• Aurelio et al 2016: IEJ. Based on the evidence from laboratory studies, root lled premolars
and molars with limited tissue loss can be restored without posts, particularly when total
coverage is planned. However, when no cusp protection is provided, post placement appears
to be bene cial in premolars. Evidence regarding the best restoration option for root lled
incisors with limited tissue loss remains controversial. When total coverage is intended,
reconstruction seems to be successfully performed by restoration with composite. However,
some reports consider that post insertion increases fracture loads. The review of clinical
studies demonstrated that survival of teeth with substantial tooth tissue is not in uenced by
the use of posts. Exceptions were found when only premolars were investigated; in these
cases, post placement was associated with greater survival rates in crowned teeth and fewer
root fractures in teeth without cusp protection.
• Stockton 1998: EDT: Rec that posts are no longer mandatory for restoring endo-tx teeth.
Alternatives include resin-bonded cores. Problems include potential root perfs, costs,
• Kurer 1977: The primary function of a post is to retain the coronal restoration.
• Abramovitz et al 2001: found that leakage was signi cantly increased in roots prepared for
posts versus inct root canal llings.
• Doyle et al 2007: Found that placement of post actually decreased the success rates of
endodontically treated teeth.
• Mattison et al: found 5-7mm of remaining GP exhibited sign less leakage than 3mm
• Eren, Yilmaz 2017: JOE. n=30. The purpose of this study was to evaluate the obturation
quality of root canals lled with different techniques and to determine whether post space
preparation had an effect on the quality of apical obturation using micro–computed
tomographic (micro-CT) imaging.
• The cold lateral compaction (CLC) and Single Cone (SC) groups showed a signi cantly
greater percentage volume of voids than the warm vertical compaction (WVC) group
(P < .05), whereas no signi cant difference was found between the CLC and SC groups
before and after post space preparation (P > .05). The post space preparation caused a
signi cant increase in the percentage volume of voids in the CLC and SC groups
(P < .05). No signi cant difference was detected in the percentage volume of voids in the
WVC group after post space preparation (P > .05).
• No root llings were void free. The WVC group presented the best obturation quality. The
post space preparation negatively in uenced the apical integrity of the lling materials in
the CLC and SC groups, whereas it had no signi cant effect in the WVC group.
• The warm vertical compaction (WVC) group presented the best obturation quality before
and after post space preparation. The post space preparation negatively in uenced the
apical integrity of the lling materials in the cold lateral compaction and single-cone
groups, whereas it had no signi cant effect on the WVC group.
• Goodacre & Spolnik 1995: J of Pros. Review
• Four to 5 mm of gutta percha should be retained apically to ensure an adequate apical
seal. When only 3 mm or less is present, there is a greater incidence of leakage.
Although studies indicate that 4 mm products an adequate seal, it is dif cult to stop at
precisely 4 mm, and additional removal can cause leakage. A conservative, safe
approach is to maintain 5 mm of gutta percha whenever possible.

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 • De nitive prosthodontic treatment should be performed on asymptomatic endodontically
treated teeth as soon as is practical after completing the endodontic therapy. If a zinc
oxide eugenol provisional restoration placed over the obturated canal is exposed to
saliva for long time periods ( = 3 months), leakage will occur that compromises the gutta
percha seal, and such teeth should be endodontically retreated.
• Both rotary and heat/hand instruments can safely be used to remove adequately
condensed gutta percha.
• Adequately condensed gutta percha can be safely removed immediately after
endodontic treatment.
• Crowns should generally be used on endodontically treated posterior teeth but are not
necessary on relatively sound anterior teeth.
• The primary purpose of a post is to retain a core that can be used to retain the de nitive
prosthesis. Posts do not reinforce endodontically treated teeth and are not necessary
when substantial tooth structure is present after teeth have been prepared. A post and
core may help prevent coronal fractures when the remaining coronal tooth structure is
very thin after tooth preparation.
• Three percent to ten percent of post and core failures are attributable to root fractures.
Threaded post forms are the most likely to cause root fracture and split, and threaded
exible posts do not reduce stress concentration during function. Cemented posts
produce the least root stress.
• When should post space be made? What technique and dimensions?
• Immediately due to familiarity to canal anatomy & setting of sealer
• Lemon – NSD with immediate or delay
• Kwan – NSD with heat or rotary removal of GP
• Sorensen & Martinoff – post = crown length
• Portell, Solano, Fan (diff papers)-all recommended immediate post space
• Johnson – max post width is 1/3 root width
• Karapanou- Roth sealer: less leakage with immediate, AH-26 no diff in immed or delayed
• Fan et al: Delayed post preps resulted in greater leakage
• Goodacre-NSD between immed and delayed; leave 4-5 mm GP (3mm minimum)

Focal Infection/Hollow Tube Theory Etc

• Focal Infection - A localized or generalized infection resulting from a dissemination of bacteria
or toxic products from a “foci of infection” (necrotic pulp or dental abscess).
• Torabinejad - chronic periapical lesions cannot act as a focus to cause systemic diseases
via immune complexes.
• Siqueira (2002) – no clear evidence that microorganisms from the RC can cause disease
in remote sites of the body
• Price 1925: Brought focal infection theory (asserts that localized or generalized infection
can result from dissemination of bacteria and toxic byproducts from a focus of infection) to
endodontics in 1925 when he inferred that bacteria trapped in dentinal tubules after root
canal-therapy could leak from the root canal space and cause systemic disease. He
advocated extraction of all diseased teeth.
• Weston-Price: First talked about the focal infection. The historical background of the connection between
dental infection and systemic diseases is related to the theory of ‘focal infection’, which was described as ‘a
localized or generalized infection caused by bacteria traveling through the bloodstream from a distant focus
of infection (Rosenhow 1909). In the years following the description of this theory, numerous reports on the
healing of systemic diseases following dental extractions and tonsillectomies were published, and in 1910,
Dr. William Hunter (ignited the theory; multitude of diseases attributed to focal infection) called tooth

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 restoration ‘a veritable mausoleum of gold over a mass of sepsis.’ (Hunter 1918). As a consequence of this
theory, physicians started to advocate the removal of teeth with necrotic pulps as an alternative to or in
conjunction with the removal of adenoids and tonsils to treat many diseases. Consequently, in the early
twentieth century, endodontic treatment (ET) lost its importance within dental education as well as in the
practice of dentistry (Grossman 1976).
• Baumgartner, Harrison 1976: Best paper to use to support keeping instrumentation within a
canal. Instrumentation within a canal does NOT cause bacteremia. Long instrumentation
RARELY causes bacteremia, but only in necrotic teeth. (Blood sample and culture for: one
pre-op and one 5 mins after most injurious part of a given appt. Groups tested: A inst short
with vital teeth. B inst long in pulpless teeth. C inst short in pulpless teeth. D obturation of
group A. E obturation of group B and C. )
• Grossman 1960: Argument against focal infection: you can extract all teeth and still have
symptoms of the suspected disease, foci of infection occur in sick AND healthy pts, and many
pts with diseases have no detectable foci of infection. This review paper is quoted in
textbooks as the defense AGAINST the focal infection theory.
• Easlick 1952: Pointed out the fallacies in Price’s research methods. He effectively refuted
associations between endodontically treated teeth and systemic disease.
• Fish 1939: Zones of Fish: Infection, Contamination, Irritation, Stimulation. Infection
(bacteria), Contamination (dead host cells, PMNs), Irritation - Normal host cells present, but
bone resorption and macrophages are here, cleaning up. Stimulation is where broblasts and
odontoblasts are laying substances to wall off infection. The work of Fish also refuted Price’s
claims. Fish described the encapsulation of infections. If the nidus of infection is removed, the
body can recover, providing a basis for the success of root canal therapy.
• 1) Necrosis / Infection – bacteria, PMNs (center of abscess)
• 2) Contamination – bacterial toxins, lymphocytes, macrophages, cell destruction evident
• 3) Irritation – osteoclasts, lymphocytes, macrophages, granulomatous zone
• 4) Stimulation – osteoblasts, broblasts (encapsulation)
• Summary of study - Cotton wool + bugs implanted into guinea pig mandibles 4-40 days.
Infection remained. Localized regardless of the duration or virulence of the organism. Rejected
the Focal infection theory.
• Rickert, Dixon 1931: Hollow Tube Theory. Suggests that hollow tubes contained within the
body, including root canal spaces, collect circulatory elements and permit in ammation to
develop (inserted metal needles in CT of rabbits). This theory was debunked by Torneck
(1966) and Wenger et al (1978), who found that open tubes, when implanted within
laboratory animals, did not cause in ammatory reactions in adjacent tissues. Dubrow
reported instances of periapical healing in patients with cleaned but un lled root canal
spaces.
• Torneck 1966: sterile empty polyethylene tubes healed in rat CT (disputes HTT)
• Goldman: no evidence of in ammation at open end of Te on rods implanted in guinea
pigs (disputes HTT)
• Wenger 1978: Polyethylene tubes sealed 1mm short with GP/Grossman’s cement
elicited little or no in ammation in rat bone (disputes HTT)
• Klevant 1983 IEJ: Chemo mechanically debrided RC systems of 86 human teeth and
left un-obturated for 2 years. Radiographic exam showed signi cant decrease in PARLs
in C&S-unobturated and C&S-obturated teeth. Thus, reject “hollow tube” theory for
breakdown of tissue uid inducing PA lesion. (Should point out that even though C&S
produced signi cant radiographic healing of AP, better healing was observed in C&S-
obturated group.

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• Nair: The concept of focal infection is built around the pathological effects of bacteremia.
However, the signi cance of this proposal is weakened by the observation that bacteremia is
found in healthy patients undergoing routine toothbrushing or ossing without adverse effects
[see also: Baumgartner '77; Hockett '77 Arch Oral Biol ].
• The theory of anachoresis, based on the work of Gier and Mitchell, suggests that blood-
borne bacteria are attracted to areas of chronic in ammation.
• The focal infection theory represents the converse of anachoresis and suggests that a
“focus” of microorganisms, like that found in a root canal space, leads to systemic
dissemination of infection. Proponents of this theory included Weston Price, who brought the
theory to endodontics in 1925. He inferred that bacteria trapped in dentinal tubules during
root canal therapy could leak into the systemic circulation and cause systemic disease. He
strongly advocated extraction of diseased teeth. In 1952, Easlick pointed out the fallacies in
Price’s research methods, including inadequate use of controls, massive amounts of bacteria
in the cases presented, as well as contamination of the endodontically treated teeth during
extraction-and refuted the associations between endodontically treated teeth and systemic
disease.
• Anachoresis is a process by which microorganisms are transported in the blood or lymph to
an area of tissue damage, where they leave the vessel, enter the damaged tissue, and
establish an infection. There is no clear evidence showing that this process can represent a
route for root canal infection. Bacteria could not be recovered from un lled root canals when
the blood stream was experiementally infected, unless the root canals were overinstrumented
during the period of bacteremia, with resulting injury to periodontal blood vessels and blood
seepage into the canal. Although anachoresis has been suggested to be the mechanism
through which traumatized teeth with seemingly intact crowns become infected, current
evidence indicates that the main pathway of pulpal infection in these cases is dentinal
exposure as a results of cracks in the enamel.

Periapical/Oral Pathology
• Lesions of Endodontic Origin (LEOS) vs Non-LEOS
• LEOS
• Lamina Dura is Discontinuous
• Associated tooth is non-vital
• well circumscribed lesion
• tear drop shaped/unilocular
• lesion is associated with the tooth on angled radiographs
• slow growing
• radiolucent
• responds to antibiotics
• swellings - associated with pain
• Non-LEOS: Actinomycosis, bro-osseous lesions (Paget’s disease, periapical cement-
osseous dysplasia, ossifying broma, brous dysplasia), OKC/KOT (keratocystic
odonogenic tumor), Carcinoma, lympohoma (hodgkin, non-hodgkin, burkitts), traumatic
bone cyst, nasopalatine duct cyst, residual bone cyst, ameloblastoma, central giant cell
granuloma, benign cemntoblastoma, central odontogenic broma, histiocytosis X
(langerhans disease), leukemia, osteomyelitis
• Lamina Dura intact
• associated tooth is vital
• lesion with indistinct borders

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 • lesion may be multilocular/unilocular
• lesion changes position with different angled radiographs and can separate from the
tooth
•
fast growing
•
may be radiolucent or radiopaque
•
not likely to respond to antibiotics
•
painless swellings possible, parathesia possible
• Marton and Kiss: Microbial spread from the pulp into the periapical tissues causes apical
periodontitis by activating both positive and negative pathways.
• Kakehashi, Stanley, Fitzgerald 1965: Demonstrated the association between bacterial
in ltration in the pulp and the development of apical periodontitis.
• Studies demonstrating associations between bacteria and development of apical
periodontiis. (Double check these)
• Kakehashi et al 1965: rats
• Paterson 1976: rats
• Moller et al 1981: monkeys
• Sundqvist 1976: humans
• Bergenholtz 1974: humans
• Korzen et al: Found more severe in ammatory responses to mixed infections than to a
mono-infection.
• Spatafore et al 1989: JOE. Case of Lymphoma presenting as a PA lesion. This case report
reaf rms the similarities between in ammation and lymphoma. The original treatment
approach seemed appropriate; however, the reappearance of the lesion prompted further
investigation which led to the diagnosis of lymphoma with appropriate therapy. Although
endodontists primarily treat in ammatory disease processes, they should be ever vigilant for
malignancies which mimic in ammation.
• Dwyer/Torabinejad & Schonfeld et al: Demonstrated a similar relationship to the
development of apical periodontitis with LPS.
• Sabeti et al: supports role of viruses in periapical pathology.
• Pulpal necrosis and infection of pulp tissues —> Spread of bacteria, LPS and viruses into the
periapical tissues —> Activation of periapical immune responses and development of apical
periodontitis.
• Torabinejad, Bakland 1978: Just as pulpal responses include both cellular and humoral
components, so do those in the periapical tissues.
• Stern et al: Lymphocytes are the predominant cell population in the development of apical
periodontitis.
• Torabinejad, Kettering: T cells > B cells
• Granulation tissue: healing tissue w broblasts, collagen, proliferating capillaries &
leukocytes
• Peripaical Cysts
• Presence of a de nitive epithelial lining differentiates cyst from granuloma.
• Torabinejad: epithelial-lined cavities that form when epithelial rests of Mallasez line a
periapical lesion.
• Ten Cate: Nutritional de ciency theory, asserting that cells in the center of the epithelial
cavity lose their nutritional source and necrose
• Nair et al: Abscess theory, suggests that proliferating epithelial cells line an existent
abscess cavity as a result of the inherent nature of epitheilial cells to cover exposed CT
surfaces.

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 • Torabinejad: Immunologic Theory, proposes that the in ammatory mediators present in
periapical responses stimulate epithelial cells to proliferate.
• Pulver: IgG and IgA are present in equal amounts
• True cyst in ammatory lesion with a distinct pathological cavity completely enclosed in an
epithelial lining. (Not attached to root canal system)
• Pocket cyst (bay cyst – Simon): lined with epithelium, but communicates with the root canal
• Abscess: acute in ammation consisting primarily of PMNs
• What are causes of persistent apical disease?
• Nair- intraradicular infection, cholesteroal crystals, true cyst, extradicular, foreign body
rxn
• Ricucci/Siquiera - 6% incidence of extradicular bio lm (100% in PARL 10mm or more
diameter)
• Is it possible to differentiate between a granuloma or cyst?
• Ricucci, Pitt Ford, 2006: (You can NOT use a radiograph to diagnose cyst/granuloma/
abscess. radiopague lamina doesn’t matter. 57 ext’d teeth). No correlation found
between the presence of a radiopaque lamina and the histological diagnosis of cyst. The
generic term “periapical radiolucent lesion” should be used rather than “granuloma” or
“cyst” when examining radiographs. The differential diagnosis of periapical lesions
cannot be made based on radiographic appearance, but requires histological
examination of serial sections. Granulomas 35/57 (61.4%), Cysts 10/57 (17.5%),
Abscess 12/57 (21%).
• Caliskan et al 2016: IEJ. Retrospective study.
• Neither radiographic size nor presence of an associated radiopaque line alone was
suf cient to determine the type of lesion.
• Histological examination is required in order to reach to a de nitive diagnosis.
• 93 specimens. 72% Granulomas. 21.5% Radicular cyst. 4.3% Abscess. 2.2% Scar
tissue.
• Periapical granulomas were determined when the lesions were predominantly
in ltrated with lymphocytes, plasma cells or macrophages, with or without epithelial
remnants, and had a surrounding capsule of collagen bers. When a mass of
polymorphonuclear leucocytes dominated the granulomatous tissue as a collection
of pus (dead and dying neutrophils), the lesion was classi ed as a periapical
abscess. Lesions with a dense, collagenous connective tissue and lack of
in ammatory cells were established as scar tissue. If there was a layer of strati ed
squamous epithelium along a surface of conjunctive tissue to indicate a delineated
cavity and surrounded by a slight brous capsule, the lesion was diagnosed as a
periapical cyst.
• Priebe – No, can’t determine from a radiograph
• Bhaskar- no correlation betw size or shape
• Lalonde- lesions > 200mm2 were cysts (0-100mm2=30% cysts, 100-200mm2=60%
cysts)
• Simon- CBCT 76.5% accurate
• Morse- electrophoresis 100% accurate (based on albumin production)
• Rosenberg – no reliable correlation b/w CBCT and histo
• What is the incidence of a granuloma, cyst & abscess?
• Spatafore 1990:
• 52% granulomas, 42% cysts, 2% periapical scars, and 4% other disorders.
• 96% of lesions of endo origin; 4% non-endo. 1659 biopsies.

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 • Overall, the most common location for lesions was the maxillary anterior, followed
by maxillary posterior, mandibular posterior, and nally the mandibular anterior jaw.
• Nair 1996 –
• 50% granuloma; 35% abscess; 15% cyst (distinguishes 6% pocket / 9% true)
• Koivisto – over 9000 lesions; 40% granuloma, 33% cyst, 27% other
• Ricuci, Pitt Ford 2006: 61.4% Granulomas, 17.5% Cysts, 21% Abscess
• Carillo 2008: 66% granulomas, 9% were cysts, 26% were scars.
• Lalonde- 44% cysts, 56% granuloma (1097 cases)
• Bhaskar- 42% cysts, 48% granuloma, 10% other (2308 cases)
• What is the composition of a PA granuloma?
• Stern- 40% broblasts, 24% macrophages, 16% lymphocytes, 7% plasma cells, 6%
vascular elements, 5% epithelial cells, 4% neutrophils
• Granuloma: chronic in ammatory tissue primarily in ltrated with lymphocytes, plasma
cells & macrophages
• Pulver et al: humoral factors are found in granulomas, IgG most frequent.
• Weiner et al: periapical granulomas composed of granulation tissue and chronic
in ammation
• Stern et al: cells found in granulomas included macrophages, lymphocytes, plasma
cells, PMNs, broblasts, vascular elements and epithelial cells.
• What are the theories of cyst formation?
• 1. Nutritional De ciency or Breakdown (Toller, TenCate) central cells of proliferating
epithelium get removed from their nutritional supply and undergo degeneration and
liquefaction necrosis; PMNs attracted, microcavities containing degenerating epith cells,
PMNs and tissue exudates coalesce and form cyst
• 2. Merging of Epithelial Strands (Lin)-as epith strands grow, they merge to form 3-D
ball mass; when CT trapped inside, ball degenerates and cyst formed
• 3. Abscess Cavity Theory (Nair/Summers)-tissue necrosis and lysis takes place in PA
in amm tissues and abscess formed; epith proliferates around abscess (an inherent
property of epith)
• 4. Immunologic Theory (Torabinejad)- immune PA rxns stimulate epithelial rests of
Malessez to proliferate resulting in cystic lined lumen formation
• Do cysts heal following RCT?
• Nair – pocket cysts should heal; true cysts, particularly large ones with cholesterol
crystals are less likely
• What are the histologic features of a sinus tract?
• Baumgartner – lined with either epithelium or granulomatous tissue; 100% lined with
strati ed squamous epithelium to level of mucosal rete ridges; 33% were completely
lined with epithelium to the PA lesion, 67% lined with granulomatous tissue
• Is condensing osteitis a LEO?
• rxn to chronically in amed pulp
• Eliasson, Halvarsson & Ljungheimer – tx successfully and resolved with RCT 85%
• Nair et al 1996: Found that periapical biopsy specimens contained granulomas 50% of the
time, abscesses 35% of the time cysts 15% of the time. Of the cysts, 61% represented true
cysts, 39% represented bay/pocket cysts.
• Carillo et al 2008: Study of periapical biopsies taken during root-end surgery. Found that
66% of lesions were histologically granulomas, 9% were cysts, 26% were scars.
• Lalonde, Luebke 1968: 800 periapical lesions. 45.2% Granulomas, 43.8% Radicular Cyst,
0.4% Periapical Scar. Can expect 9/10 periapical lesions will be periapical granulomas or
radicular cysts.

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 • Simon J 1980: JOE. small sample teeth. 35 Teeth. Incidence of true cysts (not connected to
teeth) is low (8.6%). True cysts may not heal with nonsurgical endodontic therapy. The bay
cysts may heal with nonsurgical endodontic therapy because they may have extensions of
epithelial granulomas. Bay Cyst: an apical in ammatory lesion with epithelium lining a cavity
but interrupted by the apex protruding into the cavity. True/Apical Cyst: an apical in ammatory
lesion with epithelium completely lining a cavity with no opening or connection to the apical
foramen and root canal.
• Differential Diagnosis.
• Spatafore et al 1990: JOE.
• 96% of lesions of endo origin; 4% non-endo.
• 1659 biopsies. This study found that 52% of the lesions were granulomas, 42%
cysts, 2% periapical scars, and 4% other disorders. No differences were found
between males and females in regard to age and location of lesions. Overall, the
most common location for lesions was the maxillary anterior, followed by
maxillary posterior, mandibular posterior, and nally the mandibular anterior jaw.
• Unilocular Periradicular Radiolucencies:
• PA Granuloma
• PA Cyst
• PA Abscess
• PA Fibrous Scar
• more frequent with thru & thru lesions or S RCT
• Residual/Recurrent Cyst
• Periapical Osseous Dysplasia
• Nasopalatine Duct Cyst
• max midline; > 6mm between central incisor roots
• Traumatic Bone Cyst (IBC)
• not a true cyst; trauma etiology; mand teeth
• Benign Fibro-osseous lesions (early stages)
• periapical cemental dysplasia,
• focal cement-osseous dysplasia;
• central ossifying broma
• Posterior Lingual Mandibular Bone Defect (Stafne Cyst)
• Lateral Periodontal Cyst
• man premolar area (75-80%), max lateral
• OKC, CGCG, Metastatic carcinoma
• Pericoronal Radiolucencies (no radiographic ecks). (These are present around
crown of an unerupted tooth)
• Normal Follicular Space
• Pericoronitis
• Dentigerous Cyst
• Ameloblastoma
• Squamous cell carcinoma
• Eruption Cyst (tooth fully formed and has eruption potential)
• Amelobastic Fibroma (tooth generally not fully formed)
• Pericoronal Radiolucencies (may contain radiographic ecks)
• ameloblastic bro-odontoma
• adenomatoid odontogenic tumor
• calcifying epithelial odontogenic tumor
• calci ying odontogenic cyst

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 • Multilocular Periapical Radiolucencies (MACHO)
• Myxoma
• Ameloblastoma: Aggressive neoplasm; any tooth-bearing area, but mand. most
common. peak age 30-40
• Central Giant Cell Granuloma - multi-nucleated giant cells; rule out
hyperparathyroidism
• Familial brous dysplasia
• Hemangioma
• Keratocystic Odontogenic tumor (aka OKC) -post mand most common but may
occur in any tooth bearing area; multiple OKCs associated with Basal cell nevus
syndrome
• Ragged Radiolucencies
• Chronic Osteomyelitis
• AKA chronic osteitis
• Localizes in ammation and infection of alveolar bone, consequently it will
be around teeth: generally milder
• Osteitis: in ammation of alveolar bone caused by pathogenic organisms
• Osteomyelitis: in ammation of alveolar and basal bone caused by
pathogenic organisms
• Osteoradionecrosis
• Bisphosphonate Osteonecrosis
• Primary Epidermoid Carcinoma
• Metastatic Disease
• Mixed Radiolucent -Radiopaque Lesions
• Cemento-ossifying Fibroma
• Garre’s Osteomyelitis
• Osteosarcoma
• Chondrosarcoma
• Calcifying Epithelial Odontogenic Tumor
• Calcifying Odontogenic Cyst
• Periradicular Radiopacities:
• Condensing Osteitis
• LEO, PM or M in man, no RL border
• Idiopathic Osteosclerosis
• idiopathic dense bone; vital pulps, man molar, no RL rim
• Benign Fibro-osseous lesions – mixed RL/RO;
• focal cemento-osseous dysplasia (post)
• orid osseous dyplasia
• PA Cemental Dysplasia (ant); vital pulps
• Central ossifying broma
• Cementoblastoma
• attached to root with RL rim; neoplasm of cementoblasts (man rst molar)
• Osteoblastoma
• neoplasm of osteoblasts; large osteoma (>2 cm); not attached to root
• Hypercementosis
• Odontoma
• compound (tooth like) or complex
• Osteoma
• root divergence, resorption, circumscribed sclerotic mass in body of man

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 • Solitary Radiopaque Lesions
• Tori and Exostoses
• Pontic Hyperostosis
• Idiopathic Osteosclerosis
• Osteoma
• Root Fragments
• Odontoma -- Compound and Complex
• Fibrous Dysplasia -- Monostotic
• Generalized Radiopacities
• Fibrous Dysplasia - polyostotic
• Florid Cementoosseous Dysplasia
• Paget’s Disease
• Osteopetrosis
• Chronic Diffuse Sclerosing Osteomyelitis
• Benign lesions push things out of the way; malignant lesions destroy things.
• Incidence of oral cancer?
• 4% of all cancers in US; 29,000 new case/yr
• Most common sites: lat and ventral tongue, oor of mouth, oropharynx, lower lip
• Leukoplakia- 3% invasive SCC, Erythroplakia 50% invasive SCC
• < 1% of malignancies metastasize to the jaws.
• Certain diseases may cause endodontic disease in multiple teeth without obvious dental
etiology.
• Multiple Peripaical Radiolucencies on Non-Vital Teeth:
• 1. Sickle Cell anemia (Costa et al 2013): risk factor for spontaneous pulpal
necrosis,
• 2. Vitamin D-resistant rickets (Beltes and Zachou 2012): Associated w/ defects in
enamel resulting in pulpal DZ.
• 3. Herpes Zoster (Rauckhorst, Baumgartner 2000): case report of spontaneous
pulpal necrosis secondary to herpes zoster involving the trigeminal nerve.
• Multiple Periapical Radiolucencies on Vital Teeth:
• 1. Periapical Cemento-osseous Dysplasia
• 2. Malignancy.
• 3. Neuro bromatosis.
• 4. Brown Tumor: associated with hyperparathyroidism, presents with ground glass
bone, loss of lamina dura and multiple periapical radiolucencies
• Carillo et al 2008: Study of periapical biopsies taken during root-end surgery. Found that 66%
of lesions were histologically granulomas, 9% were cysts, 26% were scars.
• Hirshberg, Kaplan et al 2003: OOO. Periapical Actinomycosis: A clinicopatholgoic study.
Typical actinomycotic colonies were identi ed in 17 of 963 (1.8%) periapical biopsy
specimens. Actinomycosis is an indolent, slowly progressive infection caused by anaerobic or
microaerophilic bacteria that normally colonize the mouth, colon, and vagina. It is most
commonly caused by the Gram-positive bacterium Actinomyces israelii. Cervicofacial
actinomycosis presents as a chronic, slowly evolving induration in the mandibular-
preauricular region, often accompanied by stular tracts to the skin that discharge typical
sulfur granules. Periapical actinomycosis is believed to be a nonresolving periapical lesion
associated with actinomycotic infection and has been suggested as a contributing factor in the
perpetuation of periapical radiolucencies after root canal treatment.
• Differential Diagnosis for Apical radiolucencies
• Periapical granuloma, Abscess, Periapical Cyst, Periapical Scar

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 •Ameloblastoma, Ameloblastic Fibroma
•Odontgenic Keratocyst (OKC) / Keratocystic Odontogenic Tumor
•Dentigerous cyst, Residual cyst
•Nasopalatine Duct Cyst, Globulomaxillary Cyst
•Lateral Peridontal Cyst
•Traumatic Bone cyst, Stafne Bone Defect
•Central Giant Cell Lesion
•Langerhans cell histiocytosis, Brown Tumor (CGCG))
•Cemento-osseous Dsyplasia (early)
•Vitamin D - Resitant Rickets
•Neuro bromatosis, Malignancy
• Multiple Periapical Radiolucencies in Nonvital Teeth
• Sickle Cell Anemia
• Vitamin D - Ristant Rickets
• Herpes Zoster
• Multiple Periapical Radiolucencies in Vital Teeth
• Periapical Cemento-osseous dysplasia
• Malignancy
• Neuro bromatosis
• Brown Tumor
• Cemental Tears
• Hanney et al 1992: Described cemental tears as a complete or partial detachment of the
cementum from the underlying dentin, usually attributed to trauma from occlusion. (often
results in periodontal and occasionally periapical infection).
• Lin et al 2012: cemental tears most often found in incisors of older patients and may or
may not be associated with a vital pulp. Often, they present with a sinus tract tracing the
root structure
• Lin et al 2014: performed a retrospective analysis of 71 cases of cemental tears treated
by nonsurgical and surgical methods. Surgical approach was more often successful.
Furthermore, the location of the cemental tear was signi cant - apical or middle portion
have better outcomes.)

Root Morphology
• Maxillary Central Teeth (100% 1 canal)
• Hess 1921: 1 canal 100%
• Vertucci: 1 canal 100%
• Todd: Case report of 2 canals
• Maxillary Lateral Teeth (100% 1 canal)
• Hess 1921: 1 canal 100%
• Chohayeb: 52% distopalatal inclination, 15% labially, 8% distally, 2% straight
• Hovland: Dens invaginatus .04-10%
• Maxillary Canine Teeth (100% 1 canal)
• Hess 1921: 1 canal 100%
• Caliskan: 2.2% two canals
• Mandibular Central & Lateral Teeth (combined ~40% 2 canals)

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 • Hess 1921: Combined. 1 canal 62%, 2 canals 38%
• Benjamin et al 1974: Combined. 41.1% had two root canals.
• Bellezzi, Hartwell 1983: Central: 16.9% 2 canals, Lateral: 20.2% 2 canals
• Mandibular Canine (22% 2 canals)
• Hess 1921: 43% 2 canals
• Bellezzi, Hartwell 1983: 4.1% 2 canals
• Vertucci 1974: 22% 2 canals, type I: 78% type II: 16% type III: 6%
• Mandibular 1st Premolar (~75% 1 canal)
• Cleghorn 2007: 1 canal 75.8%, 2 canals 24.2%, 1 foramen 80%
• Baisden, Kulild 1992: 76% one canal, 24% two canals.
• Vertucci 1978: 75% 1 canal, 0.5% 3 canals at apex
• Mandibular 2nd Premolar (91% 1 canal)
• Cleghorn 2007: One root: 99.6%. One canal 91%. One foramen 91%. Two canals ~ 10%
• Vertucci 1978: 98% 1 canal
• Maxillary 1st Premolar (~ 87% 2 canals)
• Hess 1921: 19.5% 1 canal, 79.3% 2 canal, 1.2% 3 canal
• Vertucci 1979: Coronally: 8% 1 canal, 87% 2 canals, 5% 3 canals. Apically: 26% 1
canal, 69% 2 canals, 5% 3 canals.
• Ahmad, Alenezi 2016:
• 86.6% 2 canals. 56.6% 2 roots.
• Root and Root canal morphology of Maxillary 1st Premolar. The max 1st premolars
are predominantly 2-rooted with 2 root canals. The presence of a third root is the
most common anatomic variation in these teeth. Looked at 92 studies: 1 root
(41.7%), 2 roots (56.6%). Regardless of number of roots, the vast majority (86.6%)
had 2 root canals, with type IV (2-2) being the most common canal con guration
(64.8%). The majority of the apical foramina (66.6%) did not coincide with the apical
root tip. 3 roots occur 1.7%. 2 foramina 68.6%.

• Maxillary 2nd Premolar (75% 1 canal)

• Hess 1921: 56% 1 canal, 42% 2 canals, 2% 3 canals
• Vertucci 1974: 1 canal 75%, 24% 2 canals, 1% 3 canals at apex
• Mandibular 1st Molar (M: ~93% 2 canals, D: ~70% 1 canal)
• Skidmore, Bjorndal 1971: 60% of mandibular 1st molar roots with two canals had some
form of communication. 93% of mesial roots have 2 canals. 30% of distal roots have 2
canals. 40% of mesial canals merge. 60% of distal roots with two canals merge. (45
teeth)
• de Pablo 2010: Systematic Review.
• 3 canals 61.3%, 4 canals 35.7%, ve canals aprox. 1%.
• Mesial root has two canals 94%, three canals 2.3%. The most common canal
system con guration was Vertucci type IV (52.3%), followed by type II (35%).
• Forty-one studies were identi ed including a total of 18,781 teeth. The incidence of
a third root was 13% and was strongly correlated with the ethnicity of the studied
population.

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 • Root canal con guration of the distal root revealed type I con guration in 62.7%,
followed by types II (14.5%) and IV (12.4%).
• The presence of isthmus communications averaged 54.8% on the mesial and
20.2% on the distal root.)
• The number of roots on the mandibular rst molar is directly related to ethnicity.
• Pineda, Kuttler 1972: 87% 2 mesial canals, 27% 2 distal canals (300 teeth)
• Versiani 2016: Mandibular 1st Molar Middle Mesial Canals: 18.6%. (looked at brazilian
and turkish populations). 48/258 molars. Micro CT. Most of the specimens with MMC had
3 independent ori ces (n=26; 54.2%) and 3 apical foramina (n=21; 43.8%).
• Nosrat 2015: Middle Mesial Canals. 20% incidence (15/75). More prevalent in younger
individuals.

• Mandibular 2nd Molar (M: 96% 2 canals; D: 85% 1 canal)

• Weine 1998: The C-shaped mandibular second molar has an 8% occurrence
• Weine 1988: Mesial Root: 52% (2-1), 40% (2-2), 4% (1-1). Distal Root: 85% (1-1), 9%
(2-1), 1% (2-2)
• Gorduysus 2009: Localization of ori ces in mand 2nd molars: ori ces centered around
axes of tooth. DL may be slightly more L than normal

• Maxillary 1st Molar

• Mesial Buccal Root
• Hiebert, Torabinejad et al 2017: The purpose of this study was to determine the
prevalence of the second mesiobuccal canal (MB2) in 100 maxillary rst molars using 3
independent methods and a combination method. —> 92% Prevalence of MB2 canals
• 92% (coronal plane root grinding)
• 87% (access under microscope + CBCT evaluation)
• 78% (access under microscope)
• 69% (CBCT evaluation)
• Kulild 1990: MB2 is present 96.1% of the time. MB1, MB2 merge 50% of the time. MB2
shoots sharply ML. (51 teeth)
• Cleghorn 2006: MB2 56% of time (combined all studies), 3 roots 96.2%
• Stropko 1999: MB2 93% (when microscope used) (90% negotiated to apex)
• Gilles, Reader 1990: 90% had four canals (21 teeth)
• Reis 2013: reported that older ages (51-70) are associated with fewer MB2 canals
• Distal Buccal Root (incidence of 2 DBs range general from 2-9% O. Peters, Ingles text)
• Vertucci 1984: 1 canal 100% (100 teeth)
• Ng 2001: 1 canal 94.5%, 2 canals 4.4% (90 teeth)
• Sert 2004: 1 canal 90.5%, 2 canals 9.5% (200 teeth, Turkish pop)
• Palatal Root
• Vertucci 1984: 1 canal 100% (100 teeth)
• Ng 2001: 1 canal 100% (90 teeth)
• Sert 2004: 1 canal 94.5%, 2 canals 4% (200 teeth, Turkish pop)
• Bone, Moule: 85% of palatal roots curved >10 degrees to the buccal side. S-shaped
(Bayonet) Palatal canal 13% in rst molar and 25% in second molar.

• Maxillary 2nd Molar

• Vertucci 1984: MB2 29%
• Degerness 2010: 60.3%
• Stropko 1999: MB2 60.4% (when microscope used)

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 • Kulild: 93.7% MB2
• Peikoff, Christie 1996: Max second molar anomalies: 57% (regular anatomy 3 roots, 3
canals), 23% (had MB2), 9% (merging B canals), 7% have one P and one B, 3% have
only one canal. 500 teeth used
• Christie, Peikoff: Max molars sometimes have two palatal roots (mostly in 2nd molars)
• Zuben et al 2017: JOE. CBCT study. C-shaped root canal system con guration preva-
lence may vary from region to region. From the 9 studied regions, the highest
prevalence was observed in China (44.0%), and the lowest was observed in Brazil
(6.8%). Women exhibited a signi cantly higher prevalence than men. When present, this
anatomic condition was mostly bilat- eral.

Anomalies/More Morphology/Anatomy
• Cranial Anatomy
• 1. Arterial Supply: R atrium —> R ventricle —> Pulmonary artery —> Lungs —>
Pulmonary vein —> L atrium —> L ventricle —> Aorta —> Common Carotid artery —>
External Carotid artery —> Maxillary artery —>
a. Maxillary Posterior teeth: Ptergyopalatine artery —> PSA artery
b. Maxillary Anterior teeth: Pterygopalatine artery —> PSA artery —> ASA artery
c. Mandibular Posterior teeth: Mandibular artery —> Inferior Alveolar artery
d. Mandibular Anterior teeth: Mandibular artery —> Inferior Alveolar artery —>
Incisive artery
• 2. Venous Drainage:
a. Mandibular Ant/Post teeth: Inferior Alveolar vein —>
b. Maxillary Anterior teeth: Infraorbital vein —>
c. Maxillary Posterior teeth: directly into the Maxillary vein —>
—> Maxillary vein —> Ptergyoid venous plexus —> Retromandibular vein —>
Internal Jugular vein —> Brachiocephalic vein —> Superior Vena Cava —>
Heart (via R. Atrium)
• Cranial Nerves Supply:
• Brain stem —> Trigeminal nerve (C.N. V), 3 branches of Trigeminal:
• 1. Ophthalmic - sensory only:
• a. forehead, upper eyelid, nasal mucosa, frontal sinus
• Maxillary (foramen rotundum) – sensory only
2.
• Nerve supply to the Maxillary teeth:
• Trigeminal nerve → second Div Maxillary nerve (foramen rotundum) →
• PSA → Maxillary Molars
• MSA → Maxillary Premolars (MB root Max. Molar)
• ASA → Maxillary Anteriors
• a. Lower eyelid, cheek, upper lip, maxillary teeth/gingiva, palate, maxillary/ethmoid/
sphenoid sinuses
• b. PSA - Maxillary Molars
• c. MSA - Maxillary Premolars, MB root of Max Molar (see Walton)
• d. ASA - Maxillary Canine, Incisors
• 3. Mandibular (foramen ovale) – sensory and motor
• Nerve supply to the Mandibular teeth:
• Trigeminal nerve → 3rd Div Mandibular branch (foramen ovale) → IAN →
Mandibular Molars / Premolars → Incisive branches → Canines / Incisors

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 • a. Sensory - lower lip, mandibular teeth/gingiva, chin, lower face, tongue (lingual n)
via: Buccal, Auriculotemporal, IAN, Lingual nerves (BAIL)
• b. Motor - muscles of mastication, mylohyoid, ant. Digastric
• c. IAN - Mandibular Molars, Premolars
• d. Incisive Branch - Mandibular Canine, Incisors
• Accessory/Lateral Canals
• Vertucci 1984: Accessory canals are minute canals that extend in a horizontal,
vertical, or lateral direction from the pulp to the periodontium. in 74% of cases they are
found in the apical third of the root, in 11% in the middle 1/3 and 15% in cervical third.
• Cutright, Bhaskar 1969: Accessory canals contain CT and vessels but do not supply
the pulp with suf cient circulation to form a collateral source of blood ow. They are
formed by the entrapment of periodontal vessels in Hertwig’s epithelial root sheath
during calci cation.
• DeDeus: 27% over incidence of lateral/accessory canals; found most often in the
apical area (63% are in the apical 3mm).
• Barthel, Trope 2004: No relationship was detected between un lled lateral or
accessory canals and the status of in ammation at the periapex (51% in amed, 49%
unin amed).
• Ricucci, Siqueira 2010: JOE. LC/AR observed in about 75% of the teeth (493).
• Ricucci, Siqueira 2010: Is lling lateral canals relavent to tx outcome —> not really.
Conclusions: Condition of tissue in main canal re ects the condition of the tissue in
the lateral canal. Radiographic appearance of lled LCs does not indicate disinfection
or seal. Overall, the belief that lateral canals must be injected with lling material to
enhance treatment outcome was not supported by literature review or by our
histopathologic observations. It appears that strategies other than nding a technique
that better squeezes sealer or gutta-percha within LC/AR should be pursued to
effectively disinfect these regions. In cases in which lateral canals appeared
radiographically " lled," they were actually not obturated, and the remaining tissue in
the rami cation was in amed and enmeshed with the lling material.
• Palato-gingival/Palatal Radicular Groove
• Tan et al 2017: JOE. Case Series. This is an unusual developmental deformity of
teeth mostly affecting the lingual surface of permanent maxillary incisors, particularly
the lateral incisors. Such grooves usually start near the cingulum of the incisor and
run apically, terminating at various lengths along the root. Previously, teeth with palatal
radicular grooves were usually extracted because of the complicated endoperiodontal
damage and hopeless prognosis. Over time, scholars have attempted to treat and
save these teeth by various therapeutic options, such as scaling and root planing,
periodontal regeneration, guided periodontal tissue regeneration, endodontic surgery,
and intentional replantation.
• The incidence of the condition is 2.8%–8.5%, and some authors consider that
there may be a racial relationship because the literature considered the incidence
was up to 44.6%. The exact etiology is not fully understood although some
authors have suggested that it involves minimal infolding of the enamel organ
and epithelial sheath of Hertwig during odontogenesis or the mildest form of dens
invaginatus because the pathogenic mechanisms appear to be shared
• The palatal groove is an ideal pathway for oral bacteria to invade periodontal tis-
sues and thus for the occurrence of periodontal damage, causing pulp necrosis
and/or apical periodontitis and presenting the concomitant endoperiodontal

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 deformity. The condition could manifest as a narrow and localized deep
periodontal pocket associated with the palatal gingival groove.
• In conclusion, the presence of grooves deriving from the cingulum, a radiopaque
or radiolucent longitudinal line separating the root canal in radiographic images,
and extruded root canal systems in CBCT cross-sectional con gurations are
indicative of palatal radicular grooves. CBCT cross-sectional images allowed the
best visualization of the depth of the grooves and the complications involved in
treating the condition. The key to achieving long-term favorable results in the
treatment of palatal radicular grooves is ac- curate diagnosis, elimination of
grooves, and thorough infection control. Intentional replantation is an effective
therapeutic approach for this type of deformity and can improve prognosis
estimation, particularly in type II and III grooves. Clinicians’ awareness and
under- standing of the peculiarities of palatal radicular grooves may help to avoid
misdiagnosis and improper treatment of patients with such teeth.
• Cecelia et al 1998: OOO. Case report and review. (Spring 2017)
• Kogon 1986: J Perio. 3168 maxillary lateral and central incisors were analyzed and
the anomaly was identi ed in 4.6% of the teeth.
• Withrs: incidence of lingual groove (94% in max lateral and 2.3 % in central)
• Apical Studies
• Kutler 1955: Classic:
• Distance between AF (apical foramen) and AC (apical constriction) is 0.5-0.6mm
which increases with age. AF diameter increases with age. Justi cation for lling
0.5mm short of AF per EAL.
• Avg Apical Constriction diameter: .306 mm (18-25 y/o) .274mm (>55 y/o).
• AF to AC: .502mm (18-25 y/o), .681mm (>55 y/o)
• Green 1955: Lingual Canal of Max 1st Premolar is larger. Apex of maxillary lateral
curves lingual. One of rst to mention max 1st molars having 4 canals. (microscopic
eval of apex)
• Green 1956: 400 Anterior Teeth. Accessory foramina 1.0-2.2mm from apex. Justi es
resection of 3mm during surgery. Distance from AF to AC: 1mm. (microscopic eval of
apex)
• Green 1960: 700 Posterior Teeth. Accessory foramina up to 2mm from apex. Justi es
resection of 3mm during surgery. Distance from AF to AC: 0.75mm
• Seltzer, Bender 1966: Widely quoted for anatomy of apex. AC at CDJ, but varied.
Denticles in canals. Accessory canals in 34%. Cementum thickness at apex varied
(.2-.3mm).
• Chapman 1969: 120 Anterior Teeth.
• Widely quoted for diameter of Apical Constriction (0.13 - 0.17mm).
• Justi cation for thinking that 20 le should not be patent and 15 le should
always be used as a patency le. 93% of the time the AC is 0.5-1mm from apex.
Justi cation for lling 0.5-1mm from the apex. AF = 0.3mm. Only 83% have
circular foramina. (microscope eval of apex)
• Pineda, Kutler 1972: 4183 teeth. 83% AF exit laterally up to 2-3mm from radiographic
apex (RA). More rami cations in the apical 1/3. 50% of max 1st premolars have two
foramina. (Reports on 27% of MB roots have two foramina). (reports only 14% of M
roots of mand 1st molars have two foramina)
• Stein, Corcoran 1990:
• As age increases the diameter of the major foramen/Apical Foramen increases
(same as Kuttler) and deviates due to cementum thickening.

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 • AC/CDJ appears to remain constant as age increases.
• Apical Constriction/CDJ = 0.19mm
• AC to AF= .72 vs Kuttler .5 (Justi cation for lling .5-1mm short of apex. ).
• Avg width of cementum: 0.492mm (increases w/ age)
• Blaskovic-Subat 1992: 76% of foramina deviates from apex. Quotable for direction of
deviations (B in anterior teeth and D in posterior teeth). AC-AF (occlusal aspect) is
0.99mm (almost twice as kuttler)
• Vertucci: Position of apical foramen (in all teeth) was 80% to lateral rather than
central
• Burch, Hulen: 92.4% of canal foramina did not exit at the anatomic apex (Average
deviation was 0.59 from apex)
• Gani & Visvisian 1999: JOE. studied apical canal diameter in max 1st molars. At 2mm
from apex, palatal systems are 60% circular and 30% ovoid regardless of age. At
2mm from apex, MB systems are 50-60% at (ie, ribbon, tear-shaped) and 30% ovoid
(no clear cut age effect). Interestingly, DB systems 30-60 circular. Problem is that if
C&S in at canal system for the long dimension, could perf in narrow dimension
during instrumentation
• Furcal Canals
• Vertucci 1974: 100 mandibular molars. Furcation canals or accessory canals opening
into the furcation have a relatively high incidence of 46% and may play an important
role in diagnosis and cause of treatment failure.
• Gutmann 1978: 28% of molars of have furcal accessory communication (of unknown
size). Questionable dye methodology and questionable clinical relevance b/c of
Langeland (1974).
• Burch, Hulen 1974: reported an incidence of 76% for furcal canals
• Pulp Biology
• Takahashi 1982: Classic: Dental pulp has subodontoblastic processes perpendicular
to main arterioles, arteriovenous anastomoses (collateral circulation —> resistance to
in ammation), U-shaped arterioles unique to the pulp. (resin casts)
• Johnsen 1985: Myelination of axons in pulp not complete until apex completes
development. Nerves can penetrate 150-200um. Sympathetic innervation from
superior cervical ganglion.
• Canal Classi cation systems
• Weine: Canal Classi cations. Type 1 - one canal. Type II - 2 canals 1 foramen. Type
III - 2 canals, 2 foramina. Type IV - 1 canal, 2 foramina.
• Vertucci 1984: Vertucci Canal Classi cations.
• Type 1: single canal extends from pulp chamber to apex.
• Type II: Two separate canals leave the pulp chamber and join short of the apex
to form one canal.
• Type III: One canal leaves the pulp chamber, splits in two, then merge together
and exit as one canal.
• Type IV: Two separate canals leave the pulp chamber and extend to the apex.
• Type V: One canal leaves the pulp chamber but splits short of the apex and exits
as two canals with two apical foramina.
• Type VI: Two canals leave the pulp chamber, merge in the body of the root,
divide short of the apex and exit as two canals.
• Type VII: One canal leaves the pulp chamber, divides and then joins, and re-
divides short of the apex.
• Type VIII: Three separate canals leave the pulp chamber and extend till the apex.

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 • Inferior Alveolar Nerve
• Kim, Torabinejad et al 2010: Found that the inferior alveolar nerve approached the
root apices as it moved posteriorly. On avg, the nerve structure was 4.7mm from the
2nd premolar apex and 3.7mm from the second molar apex.
• Denio, Torabinejad, Bakland 1992: (path of mandibular canal) In a typical S-shaped
con guration the mandibular canal was located buccal to the distal root of the second
molar, crossed to the lingual below the second molar mesial root, ran lingual to the
rst molar, and crossed back to the buccal apical to the apex of the second premolar.
Based on our results it appears that the mandibular second premolar and second
molar are the most likely teeth to be involved in accidental damage to the mandibular
canal during root canal therapy. (The canal was located buccal to the second molar,
lingual to the rst molar and directly inferior to the second premolar. )
• Mental Foramen/Mental Nerve
• Carruth et al 2015: Analysis of the size and position of the mental foramen using
CBCT. 106 pts. Regarding location, 53.7% of the MFs were located mesial, 45.3%
distal, and 1% coincident to the apex of the mandibular second premolar. Males had a
signi cantly greater coronal height and tangential height measurement than females.
Black patients had a signi cantly greater distal horizontal distance from the
cementoenamel junction than white patients. The mean width of the MF was 4.08 mm
(axial) or 4.12 mm (tangential), whereas the mean height was 3.54 mm (tangential) or
3.55 mm (coronal).
• Aminoshariae et al 2014: JOE. In a critical review assessed different methods used
to locate the mental foramen (Following table): (CBCT favored)
• Von Arx et al 2013: Location and dimensions of the mental foramen: a radiographic
analysis by using CBCT. 142 pts. The majority of MF (56%) were located apically
between the 2 premolars, and another 35.7% of MF were positioned below the
second premolar. On average, the MF was localized 5.0 mm from the closest root of
the adjacent tooth (range, 0.3-9.8 mm). The mean size of the MF showed a height of
3.0 mm and a length of 3.2 mm; however, individual cases showed large differences in
height (1.8-5.1 mm) and in length (1.8-5.5 mm). All mental canals exiting the MF
demonstrated an upward course in the coronal plane, with 70.1% of the mental canal
presenting an anterior loop (AL) in the axial view. The mean extension of AL in cases
with an AL was 2.3 mm.
• Phillips, Kulild et al 1990: Mental Foramen. Size, Position on 75 mandibles. The
average size of the foramen was found to be 4.6mm horizontally and 3.4mm vertically.
The outline of the foramen was generally oval and directed posterior-superiorly. 62.7%
of the time, the mental foramen intersected AB (diagram above). In terms of the
vertical position of the mental foramen, it was generally 60% the distance of AB from
the 2nd premolar buccal cusp.
• Philips et al 1990: Mental foramen: size, orientation and positional relationship to the
mandibular second premolar. Seventy- ve adult human mandibles were examined to
determine the size, orientation, and position of the mental foramen. The average size
of the foramen was found to be larger on the left side of the mandible and its usual
direction of exit was in a posterior-superior direction. The most common location of the
mental foramen was inferior to the crown of the second premolar and approximately
60% of the distance from the buccal cusp tip of that tooth to the inferior border of the
mandible.
• Phillips et al 1992: Mental foramen: radiographic position in relation to the
mandibular second premolar. Seventy- ve adult human mandibles were radiographed

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 with a paralleling technique to determine the ability to visualize the mental foramen as
well as its size and position. The foramen was seen on 75% of the horizontal
periapical radiographs examined. When the foramen was not visualized, is was
usually below the inferior edge of the lm. The radiographic size of the foramen was
smaller than the anatomical size previously reported. The position of the mental
foramen was usually mesial and below the radiographic apex of the second premolar.
• Phillips et al 1992: Mental foramen: size and position on panoramic radiographs.
Panoramic radiographs were made of 75 dry, adult human mandibles. The size and
position of the mental foramen in relation to the second premolar was determined. The
mental foramen on panoramic radiographs was slightly larger than reported on
periapical radiographs. The average position of the foramen was mesial and below the
radiographic apex of the tooth. Panoramic radiography may account for a distal shift
of the foramen and a 23% increase in size of the mandibles examined.
• Serman 1989: To examine and describe the anatomy of the mental and incisive
foramina complex. An anatomical variant of the mental foramen exists where there is
a second, separate, smaller, anteriorly-situated foramen through which the incisive
nerve re-enters the mandible after the undivided IAN exits the larger, posteriorly-
situated foramen. This mental foramina complex could not be distinguished
radiographically from other double mental foramina and in many cases, it could not be
recognized at all. A mental-incisive foramen complex that is distinct from double
mental foramina was found in 7 mandibles, with 2 cases being bilateral, making a total
of 9 cases (0.88%). (n=508)
• Moisewitsch 1998: The mental foreman was most often located between the
mandibular 1st and 2nd premolars, with verticalization averaging 16mm from the CEJ
of the nearest tooth. However, great variation was found in the vertical and horizontal
placement of the mental foramen. To avoid, take vertical PA radiographs; triangular
incision w/ D vert release; notch bone superiorly for retractor; 90% between 1st and
2nd premolar.
• Conception, Rankow 2000: Case report of a surgical case in which an accessory
branch of the mental nerve was identi ed. Recommend careful re ection to allow
proper identi cation.
• Pulp Chamber Anatomy
• Krasner, Rankow 2004: Anatomy of the Pulp-Chamber oor.
• Law of Centrality: the oor of the pulp chamber is always located in the center of
the tooth at the level of the CEJ.
• Law of Concentricity: the walls of the pulp chamber are always concentric to the
external surface of the tooth at the level of the CEJ.
• Law of CEJ: CEJ is most consistent, repeatable landmark for locating the
position of the pulp chamber.
• Law of Color Change: Color of pulp chamber oor is always darker than the
walls.
• Law of Ori ce location: Ori ces of the root canal are always located at wall/ oor
junction.
• Law of symmetry: except max molars. ori ces are equidistant from a line drawn
in a mesial-distal direction through pulp chamber oor. The ori ces of the canals
lie on a line perpendicular to a line drawn in a mesial-distal direction across the
center of the oor of the pulp chamber.
• Vigouroux, Bossan: Pulpal oor anatomy. Discussed subpulpal grooves and dentinal
cornice.

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 • Acosta, Trugeda 1978: Maxillary molars. They found the pulp chamber is located in
the center of the tooth, closely matching its outer contour and maintaining the same
distance from the mesial, distal, buccal, and lingual surfaces. It was noted that the
shape of the pulp chamber was trapezoidal, and it was therefore recommended
shaping the access preparation in the same way.
• Middle Mesial Canals
• Keles, Keskin 2017: JOE. n=85 mandibular molars with MMCs. The objective of the
present study was to measure the ori ce depth of middle mesial canals (MMCs) and
evaluate the detectability of ori ces using troughing preparation.
• It was found that 77.41% of the MMC ori ces were at the CEJ level, whereas
5.38% and 9.69% of the MMC ori ces were detectable within 1-mm and 2-mm
depths from the CEJ, respectively. Of the specimens, 7.52% had MMC ori ces
deeper than 2 mm from the CEJ. Con uent anatomy was the most frequent
con guration. No signi cant relation was detected between the ori ce depth and
MMC con guration (P > .05).
• Conclusions: It was concluded that 77.41% of the specimens did not require
troughing preparation, the remaining 15.07% would require troughing, and 7.52%
could not be accessed even with the troughing preparation.
• Tahmasbi, Nair P et al 2017: JOE.
• Purpose: 1. To identify the prevalence of a true MM canal and/or isthmus in the
mesial root of mandibular molars using a sample of cone-beam computed
tomographic images. 2. To analyze the con guration of MM canals and isthmi in
the mesial root of mandibular molars.
• Ninety limited eld of view cone-beam computed tomographic scans were
observed. One hundred twenty-two mature mandibular rst and second molars
with no previous root canal treatment, no root resorption, and intact crowns were
retrospectively evaluated.
• Of the 122 teeth, 20 (16.4%) had true MM canals. The prevalence of MM canals
was 26% in rst molars and 8% in second molars (P < .05). The frequency of
isthmi in the mesial roots was 64.7%. The frequency of isthmi was higher in
second molars, but the difference was not statistically signi cant (P > .05).
• This study showed a high prevalence of mandibular molars with MM canals or
isthmi. The detection and biomechanical cleaning of these areas during
nonsurgical or surgical root canal treatment are critical.
• Versiani 2016: Mandibular 1st Molar Middle Mesial Canals: 18.6%. (looked at
brazilian and turkish populations). 48/258 molars. Micro CT. Most of the specimens
with MMC had 3 independent ori ces (n=26; 54.2%) and 3 apical foramina (n=21;
43.8%).
• Nosrat 2015: Middle Mesial Canals. 20% incidence (15/75). More prevalent in
younger individuals.
• Baugh, Wallace 2004: Middle Mesial Canals. Case Report, review. Incidence 1-15%
in mandibular molars.
• Kazandag 2010: 18% of mand molars have MM canals, all of which merge with ML or
MB
• Weine: In 1980s published a paper that there is no MM, it’s just an isthmus
• Pomeranz, Goldberg 1981: JOE. Tx considerations for mid mesial canal in mand 1st
• Azim, Solomon 2015: JOE. Mid Mesial canal present in 46.%. n=91. Age a factor
• Dens Ivaginatus

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 • Oehlers 1957: Dens Invaginatus classi cation. Based on the extent of apical
migration of an enamel-lined invagination.
• Type I: extension stays within the clinical crown.
• Type II: the invagination extends apical to the cementoenamel junction,
terminating as a blind sac within the root canal system but not to the periodontal
ligament.
• Type III: characterized by the extension of the invagination to the apical region,
with subsequent exiting out of the root and terminating with communication to the
periapex.
• Steffen, Splieth 2005: Dens Invaginatus frequency of 0.04 -10%. Most common in
max laterals. Oehlers classi cation: Type I the invagination only extend to CEJ. Type II
the invagination goes beyond CEJ and is limited to a blind sac and a connection
between invagination and pulp is possible. Type III a form which penetrates through
the root, perforating the apical area possessing its apical exit
• C-Shaped Canals & Classi cation
• Fan 2004: C-Shaped classi cation. Category I: continuous C-shaped canal running
from pulp chamber to apex. C2: simi-colon shaped (;) dentin separates the main canal
from one mesial canal. C3: 2 or 3 separate canals. C4: only one round or oval canal.
C5: no canal lumen is observed.
• Melton 1991: C-shaped canals. Category I: the continuous c-shaped canal is any c-
canal without any separation. Category II: the semi-colon shaped canal. Category III:
simply with two or more discrete and separate canals.
• Jafarzadeh, Wu 2007: C-Shaped Canals. Asians Have more. Reports vary 0-22%.
More common in mand 2nd vs mand 1st, but can occur in maxillary molars and
laterals. Formed when hertwig’s epithelial root sheath fails to fuse on buccal and
lingual root surface. May also form by cementum deposition overtime.
• Weine 1998: The C-shaped mandibular second molar has an 8% occurrence
• Martins et al 2017: JOE. Two thousand twelve mandibular premolars were included in
this CBCT study. A prevalence of C-shaped morphologies was noted in 2.3% and
0.6% of mandibular rst and second premolars, respectively. This clinical condition
was mostly unilateral. The C-shaped con guration (C1 and C2) was found mainly in
the middle axial level. Its presence was uncommon in the apical level and null in the
coronal level; 61.5% of all mandibular rst premolar C shapes were identi ed in
Vertucci type V roots. Differences were observed among sex, teeth, and Vertucci root
con guration at P < .05.
• Mesial Root Isthmus
• Mannocci, Pitt Ford 2005: Mesial Roots of mandibular molars. Justify prepping M
root isthmuses even if you don’t see them b/c 50% of 2-foramen M roots have an
isthmus at 3mm (only 17% have isthmus at 1mm, so keep going)
• Fan, Guttaman 2010: Isthmuses in the mesial root of mandibular molars. The
incidence of an isthmus in the apical 5mm of mesial roots was 85% (combined 1st/
2nd). Mandibular 1st molars had more isthmuses with separate and mixed type
morphologies, where mandibular 2nd molars had more isthmuses than demonstrated
sheet connections.
• von Arx 2005: IEJ. an isthmus was found in 76% of mesiobuccal roots of maxillary
rst molars with a 3 to 4 mm apical root resection. In maxillary rst molars, 76% of
resected mesio-buccal roots had two canals and an isthmus, 10% had two canals but
no isthmus, and 14% had a single canal. All disto-buccal and palatal roots had one
canal. In mandibular rst molars, 83% of mesial roots had two canals with an isthmus.

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 In 11%, two canals but no isthmus were present, and 6% demonstrated a single canal.
Sixty-four per cent of distal roots had a single canal and 36% had two canals with an
isthmus.
• Kim S 1997 & 2005: Isthmuses.
• The isthmus is most frequently observed between two root canals within one
root.
• Thus, the majority of posterior teeth contain an isthmus. At the 3-mm level from
the original apex:
• 90% of the mesiobuccal roots of maxillary rst molars have an isthmus
• 30% of the maxillary and mandibular premolars
• over 80% of the mesial roots of the mandibular rst molars have one.
• This high incidence of isthmuses in premolars and molars is an important
consideration when performing apical surgery. This is one of the reasons why
apicoectomy alone, without root-end preparation and/or root-end lling,
especially in molar teeth, usually fails.
• Kim, Kratchman 2006: by resecting 3mm of root end —> 98% of apical rami cations
and 93% of lateral canals are removed. They recommend little or no beveling of the
root during root- end resection.
• Weller, Niemczk, Kim 1995: 4mm root resection of MB root of Max 1st molar will
expose a complete or partial isthmus 100% of the time; so we prep all roots between
the two canals.
• Maxillary Anatomy
• Eberhardt, Torabinejad, Christiansen 1992: A computed tomographic study of the
distances between the maxillary sinus oor and the apices of the maxillary posterior
teeth. Results: The average distance from the maxillary molars and premolars to the
oor of the maxillary sinus ranged from 0.83 mm for the mesiobuccal root of the
second molar to 7.05 mm for the lingual root of the rst premolar. The thickness of
buccal bone covering the apices ranged from 1.63 mm over the buccal root of the rst
premolar to 4.45 mm over the mesiobuccal root of the second molar. The thickness of
palatal bone covering the palatal roots of the rst and second molars and the rst
premolar was 7.01, 2.76, and 5.42 mm, respectively. Two of the 38 subjects (5%) had
roots that extruded into the sinus cavity. Conclusion: The root tips of the molars
generally lay closer to the sinus than those of the premolars. Additionally, less bone
overlies the second molars. An inverse relationship exists between the thickness of
bone buccolingually and the bone thickness superior to the apices of the teeth. The
thinnest buccal bone is found over the buccal root of the rst premolar. Palatally, the
roots of the rst and second molar were relatively close to the bone surface whereas
the lingual root of the rst premolar was relatively far from the bony surface. Bottom
Line: On the basis of the thickness of bone, access for surgery of palatal roots of the
rst and second molars should be approached palatally whereas the palatal root of
the rst premolar should be approached buccally.
• Pagin et al 2013: Found that 14% of maxillary molar roots perforate the sinus
• Beltes et al 2017: JOE. 3-Rooted Maxillary 1st Premolars study. n=53
• This study aimed to analyze the external and internal morphologies of 3-rooted
maxillary rst premolars using cone-beam computed tomographic (CBCT)
imaging.
• Three-rooted maxillary premolars exhibit heterogeneous separation of roots, with
4 possible morphologies. None of the samples exhibited 3 separate ori ces at
the beginning. On the contrary, all teeth exhibited 2 ori ces, a triangular/heart-

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 shaped B ori ce and a tear- shaped P ori ce. Below the point of separation of the
B and P roots, the B root canal bifurcated into the MB and DB canals at different
heights of the root, irrespective of the type of external tooth morphology. Three-
rooted maxillary premolars with C-shaped root canal systems are a novel nding
of the present study.
• Sidow 2000: Canal anatomy of the third molar cannot be predicted by the number of roots
• Martins et al 2016: CBCT In vivo Study of Root fusion in max/mand molars (4120 teeth).
Max 1st Molar: 7.1%. Max 2nd Molar: 25.2%. Mand 1st Molar: 0.7%. Mand 2nd Molar:
12.6%.
• Jafarzadeh 2008: Diagnosis of taurodontism is subjective. It's associated with
developmental anomalies (e.g. Down syndrome, Kleinfelter syndrome, hypophosphatasia,
rickets)
• Calberson 2007: Radix Entomolaris is DL, Radix Paramolaris is MB. RP < RE.
• Lavasani, McClanahan et al 2016: JOE. Results: (1) Buccal bone was thinnest over the
buccal root of the 2-rooted rst premolar (0.66 mm) and the mesiobuccal (MB) root of the
rst molar (0.84 mm) and thickest over the MB root of the second molar (1.91 mm). (2) The
palatal bone was thinnest over the palatal root of the maxillary rst molar (1.24 mm) and
thickest over the single-rooted second premolar (3.26 mm). (3) The longest distances to
complete resection were found for the 2-rooted rst and second premolars (8.81 mm and
9.14 mm, respectively) and the MB root of the second molar (7.40 mm). (4) The MB root of
the second molar had the closest proximity to the sinus oor, with an average distance of
0.66 mm. Conclusions: An understanding of the maxillary posterior tooth anatomy for apical
resection is bene cial to the endodontist.
• Bernick 1977: Use this paper to support existence of lymphatic vessels in the pulp
• Sabala, Benenati: Most aberrations are bilateral (60%). Most common is bifurcation in
mandibular PM. Least is seen in anterior maxillary.
• Withrs: incidence of lingual groove (94% in max lateral and 2.3 % in central)
• Teeth abnormalities
• Microdontia: teeth smaller than they should be
• Macrodontia: teeth larger than they should be
• Gemination: Single enamel organ attempts to make two teeth. Two Crowns/One Root
• Fusion: Joining of two developing tooth germs. May involve entire tooth or just
cementum and dentin. Root canals may be separate or shared. May be impossible to
separate fusion of a normal and supernumerary tooth from gemination.
• Concrescence: Form of fusion in which adjacent teeth are joined by cementum. Most
commonly seen between 2nd and 3rd molars.
• Dilaceration: extraordinary curving or angulation of tooth roots. Cause related to
trauma during tooth development.
• Dens Invaginatus: AKA Dens in dente or tooth within a tooth. Exaggeration or
accentuation of the lingual pit. Most common in lateral incisors. Oehlers-Type I-
con ned within crn, Type II-blind sac invades root (may communicate with pulp), Type
III-penetrates thru the root and bursts apically or laterally.
• Dens Evaginatus: common developmental condition affecting predominately premolar
teeth. Almost exclusively of the mongoloid race. frequently bilateral. anomalous
tuberacle or cusp located in the center of the occlusal surface.
• Oehlers-recommended DPC (30% of tubercles not have pulp horns).
• Levitan-tx recommendations: Normal pulp (mature and immature teeth/apex)-
reduce opposing occl, owable cmpst to tubercle; In amed pulp: Mature-RCT,
restore; Immature: MTA pulpotomy; Necrotic pulp: Mature-RCT, restore;

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 • Banchs & Trope: Immature-Immediate MTA apexi cation or Revascularization
• Yip- 2.2% incidence, 3.6% Chinese (PMs only-84% man, 16% max); 90%
bilateral; 26% pulpally involved
• Taurodontism: Teeth that have elongated crowns or apically displaced furcations. Pulp
chambers have increased apical-occlusal height. Associated with syndromes such as
Down’s and Klinefelter’s. High prevalence in eskimos and 11% middle east.
• Supernumerary roots: Accessory roots most commonly seen in mandibular canines,
premolars and molars.
• Enamel Pearls: Droplets of ectopic enamel. Commonly seen in the bifurcation or
trifurcation area of teeth. Max molars more common.
• Anodontia: Absence of teeth. Most common are 3rd molars then lateral incisors and
second premolars. Complete anodontia associated with ectodermal dysplasia x-linked
recessive disorder.
• Supernumerary: Extra teeth. Associated with gardners syndrome and cleidocranial
dysplasia. The anterior midline (mesioden) of the maxilla is the most common site
followed by maxillary molar are.
• Amelogenesis imperfecta: heriditary disorder of enamel formation in both dentitions.
• 1. Hypoplastic - insuf cient amount of enamel
• 2. Hypocalci ed - quantity of enamel is normal but soft and friable.
• 3. Hypomaturation. (Color range from white opaque to yellow to brown.
Radiographically dentin thin roots.
• Dentinogenesis imperfecta (hereditary) opalescent dentin
• Autosomal Dominant
• 1 .Type 1 – Occurs in patients with osteogenesis imperfecta
• 2. Type 2 – Patients have only dental abnormalities. No bone disease.
• 3. Type 3 – or Brandywine Type, similar to type 2, but includes features such as
multiple pulp exposures and periapical radiolucencies (Shell teeth w enlarged
pulp chambers)
• Clinically all three types share numerous features
• 1. Teeth exhibit an unusual translucent, opalescent appearance.
• 2. Color ranges from yellow-brown to gray
• 3. Enamel normal but fractures easily
• 4. Abnormal morphology/teeth. Tulip or bell shaped due to constriction of CEJ
• 5. Roots are short and blunted
• Radiographically
• 1. Types 1 and 2 Pulp space opaci ed
• 2. Type 3 pulp chambers and root canals extremely large
• Dentin Dysplasia
• Autosomal dominant trait
• Type 1 Radicular
• 1. Crowns normal
• 2. Teeth show greater resistance to caries
• 3. Roots extremely short
• 4. Pulps obliterated
• 5. Periapical lucencies
• Type 2 Coronal
• 1. Crowns Normal
• 2. Pulps Large (Thistle Tube)
• 3. Roots extremely short

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 • Nascimento, Pontual et al 2016: JOE. Association between Odontogenic Conditions and
Maxillary Sinus Disease. A retrospective CBCT study. 400 pts. The most prevalent sinus
diseases were the generalized and localized Mucosal Thickening, and they were the only
ones related to odontogenic conditions (periodontal bone loss and periapical lesions,
respectively). We emphasize that CBCT imaging is an appropriate method for evaluating the
maxillary sinus ndings and their associated odontogenic conditions.
• Johnson et al 2017: JOE. The purpose of this micro–computed tomography investigation
was to qualitatively and quantitatively assess and compare the morphology of contralateral
premolars in terms of length, canal width, dentinal thicknesses, accessory canals, root canal
con gurations, isthmi, C-shapes, root canal ori ces, and apical foramina. Contralateral
premolar pairs demonstrated a high degree of similarity in terms of the linear measurements
(lengths, widths, and thicknesses). The apical portion (foramina, C-shapes, and accessory
canals) did not demonstrate bilateral symmetry. Root canal con gurations and ori ce shapes
of contralateral premolars demonstrate symmetry. Contralateral premolars have a wide array
of variation in their apical portions.

Tooth Extrusion
• Huettner, Young 1955: Endo Tx and vital teeth move the same orthodontically
• Kahnberg 1988: Surgical extrusion is good alternative to orthodontic extrusion
• Malmgren 1991: Rapid Extrusion = no risk of resorption. Fibrotomy and stabilization period of
4 wks recommended
• Esteves et al 2007: No stat signi cant difference in apical root resorption with ortho or RCT
and vital teeth (although slightly greater resorption of vital teeth)
• Bauss 2008: Ortho movement of teeth with complete pulpal obliteration gives higher rate or
pulp necrosis

Endo - Pedo
• The treatment for diseased primary teeth can involve both pulpotomy and pulpectomy
treatments, depending on the extent of pulpal involvement. In vital primary teeth with carious
pulp exposures, pulpotomies are the treatment of choice.
• How do you improve the fracture resistance of immature teeth following endo treatment
• Lawley - bonded composite
• Wilkinson and Kirkpatrick - self-cured hybrid cmpst
• Schmoldt - ber post with ber reinforced cmpst was best vs MTA or cmpst only
• Mannocci - ber post and cmpst more fx resistant than cuspal coverage Amalgam
(Premolars)
• Hibbard: Primary Tooth Anatomy.
• Mandibular Incisors: 2 canals 10%
• Maxillary 1st Molars: 2 MB canals 75%
• Maxillary 2nd Molars: 2 MB canals 85-95%
• Mandibular 1st Molar: 2 mesial canals 75%, 2 distal canals 25%
• Mandibular 2nd Molar: 2 mesial canals 85%
• Sweet: Formocresol Pulpotomy Technique. Remove coronal pulp, place moist cotton pellet
until heme control, place formocresol for 5 min, ZOE cement + SSC
• Law, Lewis: FC 93% at 2 years
• Ranly: Recommends 1/5 concentration of FC

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• Pashley: Found formocresol systemically (spleen, liver, kidney) after placing in dog teeth
• Pruhs: Enamel defects noted on facial and occlusal surfaces of permament successors
• World Health Organization: Declared formaldehyde a human carcinogen. Formocresol =
19% formaldehyde, 35% cresol, dissolve in 17.5% glycerin and water)
• Fuks et al 1997: Reported a high success rates for pulpotomies with diformocresol (83%)
and ferric sulfate (93%), respectively.
• Fuks: Pulpotomy of Primary teeth Success Rates.
• FC 83%,
• Glutaraldhyde 72%,
• FeSO4 93%,
• MTA 97%
• Holan, Fuks et al 2005: Found that pulpotomies performed with MTA achieved a success
rate of 97% at 2 years.
• Peng, Li: Meta Analysis. Ferric Sulfate 92% success. NSD compared to FC, but Ferric sulfate
safer
• Maroto: gMTA 98.5% success at 42 months
• Hoshino: Triple antibiotic paste placed into canals 2mm. 95% of teeth had symptoms resolve
after 1 year
• Doyle: FC 94% success, Ca(OH)2 64% (25% of these teeth exhibited internal resorption —>
Dont use Ca(OH)2 )
• Obturation of Primary Teeth: ZOE or Ca(OH)2, (Vitapex: 30% Ca(OH)2, 40% iodoform in a
silicone lubricant)
• Coll and Sadrian 1996: 78% success with ZOE pulpectomies. Also discussed pulpectomy
risks: enamel defects, over-retention, alteration of eruption of the permanent successor.
• How long does apexi cation take with Ca(OH)2:
• Kleirer: 1 yr +/- 7 months,
• Cvek: Avg 18 months
• Concerns about long term Ca(OH)2 use:
• Andreasen: > 30 days use will weaken dentin; 1/2 strength in one year.
• Doyon: Strength not decreased until 180 days.
• Options to manage open apex in immature permanent teeth:
• Apical Barriers:
• Tronstad: Dentin Chips
• Weissenseel: Ca(OH)2
• Hicks, Pelleu: Ca(OH)2
• Torabinejad: MTA
• Witherspoon: MTA 93% 1 visit, MTA/Ca(OH)2 90.5% 2 visit
• Holden: MTA/GP 85% healed, 100% functional success
• Knapp, Marshall: Master apical impression
• Branchs, Trope: Regen
• Chen, Leggitt 2012: Endo Topics. The rst permanent molars have the highest incidence of
caries in the permanent dentition, which usually results in pulpal involvement requiring
endodontic therapy. In a young patient, however, a consideration of early extraction of FPMs
should be made as one of the treatment options if the patient meets the following criteria: (i)
Class I occlusion; (ii) premolar crowding; (iii) no missing permanent teeth; (iv) FPMs with poor
treatment prognosis; and (v) dental age of 9–11. A careful consideration and evaluation of
risks and bene ts for young patients with regards to long term treatment planning is essential
for the best outcome.

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 Endo - Ortho
• Lazzaretti, Hartmann et al 2014: It was concluded that, after 21 days, the application of
orthodontic intrusion force caused vascular changes in the pulpal tissue; it also increased the
presence of brosis and of the number of pulp calci cations. (histological eval of 17
premolars)
• Huettner, Young 1955: Endo Tx and vital teeth move the same orthodontically
• Kahnberg 1988: Surgical extrusion is good alternative to orthodontic extrusion
• Malmgren 1991: Rapid Extrusion = no risk of resorption. Fibrotomy and stabilization period of
4 wks recommended
• Esteves et al 2007: No stat signi cant difference in apical root resorption with ortho or RCT
and vital teeth (although slightly greater resorption of vital teeth)
• Bauss 2008: Ortho movement of teeth with complete pulpal obliteration gives higher rate or
pulp necrosis
• Butcher: extreme ortho forces can cause circulatory interruptions leading to necrosis
• Hamilton, Gutmann: Ortho can cause degenerative and/or in ammatory response
• de Souza: Healing of AP is faster w/o ortho, but ortho does not stop healing process
• Reitan: ortho movement too quickly —> Resorption
• Hamilton, Gutmann: endo teeth developed apical resorption less than vital teeth
• Wickwire: Ok to move endo teeth; no signs of pathologic changes
• Simon: ortho extrusion. immature bone in 2 wks, mature bone in 4 wks; PDL not tear, need
CL (1.5mm/week)
• Heithersay: ortho extrusion. Indicated for transverse root fracture 1-4mm subcrestal; 6 wk
stabilization.
• Lemon: Stabilization of extruded tooth. 1 month stabilization for every 1mm of movement
• Malmgren: brotomy may help before retention to avoid relapse
• Pontorriero: supracrestol brotomy: weekly, extrude faster in 3 weeks, stabilize 8-12 wks

Response to Caries
• Stanley 1959: Classic: Highly quoted for coolant use and light pressure with high speed
diamond. Landmark study for coolants b/c high speed handpieces were becoming popular.
(Stanley is big name in pulpal studies). Teeth cut under coolant or not, temped, then histo.
• Kakehashi, Stanley, Fitzgerald 1965: You need bacteria to develop PA pathosis in rats
(Moller showed in monkeys; Bergenholtz showed in humans)
• Brannstrom 1965: Pulp has response to caries starting even at the white spot lesion stage!
(Although this is the only study that really reports this phenomenon) Reduction in number of
odontoblasts and presence of in ammatory cell in ltrate. (Unlike Reeves & Stanley who only
see changes when bacteria within 0.5mm of pulp.)
• Langeland, Langeland 1966: Steps of crown preparation, impression, temporization have
deleterious effects on odontoblasts. (Supports cumulative effects) (Did not prove for sure
cumulative effects of all stages, b/c pre-op status not known). Teeth prepped, impressed,
temped then histo'd
• Reeves, Stanley 1966: Classic: "Signi cant" changes in the pulp occur when bacteria come
to within 0.5mm of the pulp, and "irreversible" changes occur when bacteria reach reparative
dentin (not like Brannstrom, who saw histo changes during early caries). (Carious human
teeth histo'd. Distance of bacteria to pulp measured and "degree of pathosis” ("pathosis" not
well described))

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 • Brannstrom 1968: Aspiration of odontoblasts into tubules during preparation is immediate,
but does not result in pulpal in ammation or changes to the cell rich layer. Cavity prepped
and temped then histo'd 10mins and 3months postop.
• Brannstrom 1972: Classic: The paper on Hydrodynamic Theory.
• 1. Heat causes inward uid movement in tubules.
• 2. Cold causes outward uid movement in tubules.
• 3. Concurrent distortion of odontoblastic process stimulates primary neuron at the pulpo-
dentinal junction.
• 4. Distortion leads to impulse conduction.
• Bernick 1975: Aged pulps appear more brotic only because the blood supply and nerves
are fewer, leaving behind their brous sheaths. That's why % of brous tissue is higher in
older pulps. Histo'd teeth of different ages (but reasons for extraction not noted)
• Brannstom 1976:
• The diameter and density of dentinal tubules increase closer to the pulp.
• Based on the dentinal tube density at the DEJ (~ 65K/mm2) and the pulp (~ 15K/mm2).
• Bergenholtz 1977: Pulpal in ammation results from bacterial PRODUCTS (intra- and extra-
cellular). Necrosis and PMN in ltration can occur as a rxn to bacterial products only.
• Trowbridge 1981: Classic: initial pulpal response is a CHRONIC in ammatory response.
Zones of dentin involvement adjacent to a carious lesion:
• outer zone of destruction
• zone of infected tubules
• zone of demineralization
• zone of sclerosis.
• Review of pulp response to caries. The pulp will respond with an in ammatory reaction
from caries before the bacteria from the caries actual reach the pulp.
• Stanley et al 1983: Noted that while sclerosis is observed in dentin of disease free and
attrition free teeth, there is a 95% increase in the incidence in carious teeth. Sclerotic dentin
has decreased permeability due to increased intratubular dentin and mineralization.
• Does type of restoration affect pulpal and periapical healing?
• Cox, Bergenholtz 1987: Pulpal healing does not depend on dental materials (and
probably depends on the seal). Pulp heals equally well with amalgam, composite and
ZOE. Authors assume that ZOE is the gold standard for sealing (but they do not
demonstrate this).
• Dawson et al 2014: JOE. Non-root lled teeth. There was no signi cant difference in
the frequency of apical periodontitis (AP) between teeth restored with resin composite or
amalgam (1.3% and 1.1%, respectively). The frequency of AP for teeth restored with
laboratory-fabricated crowns was signi cantly higher (6.3%). The results indicate that
the risk of damage to the pulp-dentin complex from exposure to resin composite material
and dentin bonding agents shown in experimental studies is not re ected in the clinical
setting.
• Dawson et al 2016: JOE. Cross-sectional study. Root lled teeth. This study did not
indicate any association between apical periodontitis and resin composite restorations in
root- lled teeth. If the quality of the coronal restoration is adequate, neither the type nor
the material seems to be of signi cance for periapical status. Looked at teeth with
composite, amalgam and crowns. The results did not indicate any association between
AP and resin composite restorations. Neither the type nor the material of the restoration
was of signi cance for periapical status as long as the quality was adequate.
• Laforgia 1991: Water and air spray cools the bur better than air alone

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 • Magloire, Bourvier, Joffre 1992: Review study to describe the response of odontoblasts and
the pulp to caries. Regulation of odontoblast response to caries involves factors stored in the
dentin matrix and released during demineralization. The odontoblast response involves
increased peritubular collagen synthesis and later mineralization of this collagen, leading to
sclerotic dentin formation. In established lesions in which odontoblasts have died, pulpal and
perivascular cells differentiate into odontoblast-like cells and secrete a collagenous matrix
resembling cartilage adjacent to the affected dentin. This matrix later mineralizes and is
referred to as reparative dentin, which is amorphous, disorganized, and has large tubules.
• Ten Cate 1992: In cases of injury to dentin, odontoblasts deposit collagen that is
subsequently mineralized, forming sclerotic dentin. Although odontoblasts are highly
differentiated and cannot divide, signals from predentin and damaged dentin cause
perivascular cells to differentiate into odontoblast-like cells, which again, deposit collagen
(scar formation) that is subsequently mineralized.
• Pathways of the pulp: The tubular diameter increases from about 0.6 micrometers to 0.8
micrometers close to the DEJ to about 3 micrometers at the pulp. Given that bacterial cells
are about 0.5 to 1 micrometer in diameter, it is evident that in deep cavity preparations,
particularly when total-etch procedures are employed, bacteria can migrate through the
remaining dentin into the pulp.
• Pathways of the Pulp: The formation of tertiary dentin occurs over a long period than does
that of sclerotic dentin, and its resultant characteristic is highly dependent on the stimulus.
Mild stimuli activate resident quiescent odontoblasts, whereupon they elaborate the organic
matrix of dentin. This type of tertiary dentin is referred to as reactionary dentin and can be
observed when initial dentin demineralization occurs beneath the noncavitated enamel lesion.
The resultant dentin is similar in morphology to physiologic dentin. In aggressive lesions, the
carious process may prove cytocidal to subjacent odontoblasts and require repopulation of
the disrupted odontoblast layer with differentiating progenitors. The appearance of the
resultant matrix is a direct re ection of the differentiation state of the secretory cells. This
accounts for the heterogeneity of Reparative dentin, where the morphology can range from
organized tubular dentin to more disorganized irregular brodentin.
• Pathways of the Pulp:
• Although dentin can provide a physical barrier against noxious stimuli, the pulpal
immune response provides humoral and cellular challenges to invading pathogens. It
has been shown that titers of T helper cells, B-lineage cells, neutrophils and
macrophages are directly proportional to lesion depth in human teeth. Pulpal
in ammatory response can be seen beneath noncavitated lesions and noncoalesced
pits and ssures.
• The early in ammatory response to caries is characterized by the focal accumulation of
chronic in ammatory cells. This is mediated initially by the odontoblasts and later by
dendritic cells. Odontoblasts have been shown to increase expression of certain TLRs in
response to bacterial products. Stimulated odontoblasts also release high levels of
chemokines (IL 8, CXCL8) that act in concert with the release of formerly sequestered
TGF beta-1 from carious dentin, the result of which is a focal increase in dendritic cell
numbers. The subsequent in ux of immune effect cells is composed of lymphocytes,
macrophages and plasma cells. This cellular in ltrate is accompanied by localized
capillary sprouting.
• As the carious lesion progresses, the density of the chronic in ammatory in ltrate, as
well as that of dendritic cells in the odontoblastic region, increases. Pulpal dendritic cells
are responsible for antigen presentation and stimulation of T lymphocytes.

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 • External stimulation of dentin causes the release of pro ammatory neuropeptides from
pulpal affernt nerves. Substance P, calcitonin gene-related peptide, neurokinin A,
neurokinin Y and vasoactive intestinal peptide are released and affect vascular events
such as vasodilation and increased vascular permeability. Neuropeptides can act to
modulate the pulpal immune response (chemotactic and stimulatory agents for
macrophages and T lymphocytes).
• As the carious lesion approximates the pulp, there is an acute exacerbation of the
precedent chronic in ammation. This is characterized by an in ux of neutrophils.
• Izumi 1995: discussed varying levels of in ammation. Adaptive immune response occur in
irreversibly in amed pulps separated by less than 2mm from a deep carious front.
• 1. enamel caries – increased T cells; little or no B, plasma, PMN
• 2. dentin caries – dramatic T/B cell and PMN increase
• 3. to 0.5 mm pulp – increase PMN, macrophages, plasma cells, B cells
• 4. w/in 0.5mm – micro-abscesses formed, decrease in pulp cells and loss of ECM

Bio lm
• Stoodley, Lewis: A bio lm is any group of microorganisms in which cells stick to each other
on a surface. These adherent cells are frequently embedded within a self-produced matrix of
extracellular polymeric substance (EPS). Bio lm extracellular polymeric substance, which is
also referred to as slime (although not everything described as slime is a bio lm), is a
polymeric conglomeration generally composed of extracellular DNA, proteins, and
polysaccharides. Bio lms may form on living or non-living surfaces and can be prevalent in
natural, industrial and hospital settings. The microbial cells growing in a bio lm are
physiologically distinct from planktonic cells of the same organism, which, by contrast, are
single-cells that may oat or swim in a liquid medium
• Siqueira, Rocas 2009: Topic review of bacteria.
• The Community Concept: A community is regarded as integrated populations of bacteria
that coexist and interact in a given environment. A root canal that is infected harbors an
endodontic microbial community that is composed of several populations that each
occupy a functional role (niche). These highly structured and organized communities
many times have properties that are greater than the sum of the component populations.
The bacterial composition of the endodontic microbiota differs consistently among
individuals suffering from the disease. This indicates that apical periodontitis has a
heterogeneous etiology, where multiple bacterial combinations can play a role in disease
causation.
• Bio lm can be de ned as a sessile multicellular microbial community characterized by
cells that are rmly attached to a surface and enmeshed in a self-produced matrix of
extracellular polymeric substance.
• The ability to form bio lms has been regarded as a virulence factor.
• Endodontic treatment has been fundamentally based on nonspeci c elimination of
bacteria (targets community, rather than individual species). Treatment procedures can
promote total or partial elimination of the endodontic bacterial communities. Total
elimination is not yet possible. However, partial elimination of the community represents
disturbances that can lead to death of the residual community or reorganization in
different proportion of species, which can sometime jeopardize treatment outcomes. To
avoid the latter, community reorganization, the clinician should direct his or her efforts to
maximal and broad-range elimination of the endodontic bacterial community through
chemomechanical preparation supplemented by an intracanal antimicrobial.

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 • Role of obturation: to eliminate or reduce space for reorganization of the community by
surviving bacteria and prevent further nutrient supply.
• Costerton 1999: Bio lm bacteria are also intrinsically less susceptible to antimicrobial
substances due to their slow rate of growth and adoption of a distinct bio lm phenotype,
which differs from that of their planktonic counterparts
• Bergenholtz: endo topics. A bio lm makes root canal debridement more challenging because
it is more resistant to antimicrobial agents than bacteria in planktonic form. Moreover, the
matrix is a physical barrier against disinfecting agents.
• Riccuci, Siqueira 2010: Observational study evaluating intraradicular and extraradicular
bacterial bio lms in 64 untreated and 42 treated root canals of human teeth with evidence of
apical periodontitis. Extraradicular bacterial bio lms were observed in only 6% of all their
specimens and were associated with clinical symptoms. The present study revealed a very
high prevalence of bacterial bio lms in the apical root canals of both untreated and treated
teeth with apical periodontitis. The pattern of bacterial community arrangements in the canal,
which adhered to or at least was associated with the dentinal walls with cells encased in a
extracellular amorphous matrix and often surrounded by in ammatory cells, is consistent with
acceptable criteria to include apical periodontitis in the set of bio lm induced disease.
Bacterial bio lms are more expected to be present in association with longstanding
pathologic processes, including large lesions and cysts.”
• Defour et al 2012: Endo Topics. Lit Review. A bio lm is presently seen as a community of
microorganisms held together by a self-produced extracellular matrix and associated with a
surface. 2 major bio lm related diseases: dental caries, perio disease. Quorum sensing used
by bacteria to communicate. Bio lms composed of 80-85% extracellular polymeric substance
and only 15-20% cells. Bio lms act as a protected mode of growth allowing cells to survive
challenging environments.
• Kishen, Haapasalo 2012: Endo Topics. Review. Bio lm is a mode of microbial growth where
dynamic communities of interacting sessile cells are irreversibly attached to a solid
substratum, as well as to each other, and are embedded in a matrix of extracellular polymeric
substance (EPS). The bio lm mode of growth allows the resident bacteria to survive
unfavorable environmental and nutritional conditions.
• Haapasalo, Shen 2012: Endo Topics. Review.
• Mechanical instrumentation is the core method for bacterial reduction in the infected root
canal. Rotary instruments perform comparably poorly in long oval canals because they
do not mechanically prepare 60% or more of the canal surface under these conditions.
• The bacterial bio lm on the uninstrumented surfaces is likely to remain mechanically
undisturbed and the surfaces should still be regarded as contaminated.
• NaOCl is the only irrigant in endodontics that can dissolve organic tissue, including the
organic part of the smear layer. CHX possesses antimicrobial activity, but it has no tissue
dissolving capability and therefore it cannot replace NaOCl. CHX permeates the
microbial cell wall or outer membrane and attacks the bacterial cytoplasmic or inner
membrane or the yeast plasma membrane. CHX binds to hard tissue and remains
antimicrobial (substantivity).
• 6% NaOCl was the only soln capable of disrupting and completely removing the bio lm
after 15 minutes of exposure. 2% CHX killed the bio lm bacteria but was not able to
disrupt the bio lm structure. MTAD as been shown to be effective in smear layer
removal. However, some experiments show NaOCl is better than MTAD. QMIX contains
EDTA, CHX and a detergent. Sonic activation has been shown to be an effective method
for disinfecting root canals. The antimicrobial activity of Ca(OH)2 seems dependent upon

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 direct contact with bacteria. Most sealers are only antimicrobially active during the
setting period.
• Wang et al 2012: Persistent apical lesions exhibited an extra-radicular bio lm. A
multibacterial community, including actinomyces and propionibacterium seem to participate in
the maintenance of persistent periapical pathosis. In cases with non-healing apical
periodontitis following RCT, apical surgery would be justi ed to address extra-radicular
bacteria.
• Siqueira, Roccas, Ricucci 2012: Endo Topics. Review. Bacteria are less than 10% of dry
mass. Most human diseases involve mixed bio lm communities; the virulence of the whole is
greater than the sum of its individual bacterial parts. AP is a disease caused by bio lms;
virulence factors involve a summation of structural cellular components, antigens, and
secreted substances. There is a geography related variability in community pro les.
Microbiota in apical portion differs signi cantly from more coronal aspects, but the community
is just as diverse. No correlation with bio lm presence and clinical symptoms or sinus tract.
Extraradicular bio lms are rare (6%) and almost always associated with clinical symptoms
and with intraradicular bio lm.
• Love 2012: Endo Topics. Review of bio lm development and formation.
• The bacteria-related diseases of dental caries, pulp and periapical infections, and
diseases of the periodontium are bio lm diseases.
• This community lifestyle provides potential bene ts to the microorganisms including a
broader habitat range for growth, increased metabolic diversity and ef ciency, and
enhanced resistance to environmental stress, anti- microbial agents, and host defenses .
• Initially planktonic cells in the aqueous environment of the oral cavity attach to host
surfaces, rst by physical forces though ultimately by speci c adhesive reactions
between host and bacteria molecules. Initial bacterial colonizers alter the immediate
environment and offer additional binding sites to other bacteria that cannot react directly
with the host surface. These co-aggregation reactions allow various bacterial species to
join the evolving community and participate in its development. Development of the
microbial community is also dependent on the nutritional source. Early colonizing
bacteria are adept at utilizing the immediate nutritional source at the host site, primarily
carbohydrates. With the accumulation of bacteria, nutritional demands become more
complex and proteins, amino acids, glycoproteins, and vitamins must be supplied from
either the host tissues or other bacteria. The bio lm community must co-operate to
effectively achieve metabolism of these complex molecules and perform other functions,
while other interbacterial inhibitory reactions such as bacteriocin production or quorum
sensing occur in the bio lm, in uencing the development of the bacterial community. As
such, oral bacteria do not exist independently but function as a co-ordinated, spatially
organized, and metabolically integrated microbial community.
• Kishen 2012: Endo Topics. Review. Bio lms give bacteria resistance to antimicrobials.
Resistance of bio lms can be attributed to the extracellular polymeric matrix, growth rate and
nutrient availability, and the adoption of resistance phenotype. The inability of endodontic
irrigants to penetrate the complexities of the root canal system will cause bio lms to persist in
these niches after cleaning and shaping procedures. The root canal environment makes
eliminating bacteria challenging.
• Lang et al 2012: Endo Topics. Lit review on bio lm interactions with host immune cells.
Microbial bio lm not only in uences the host immune system, but the immune system
in uences the development of bio lms. PMNs are able to recognize and attack bio lm
structures. Lactoferrin, an microbicidal agent secreted by PMNs, has the potential to prevent
bio lm formation.

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 • Du, Haapasalo et al 2014: Purpose: To evaluate the antibacterial effectiveness against
E. faecalis bio lms in dentin canals of shor term and lon term exposure to 2% chlorhexidine
(CHX) and 2% and 6% NaOCl (3, 10, and 30 minutes).
• Signi cantly more bacteria in infected dentinal tubules were dead in each experimental
group with long exposures (10 or 30 min) than after 3 min (P < .05).
• 6% NaOCl (53%–88% killing) was the most effective antibacterial agent after exposures
of 3, 10, or 30 minutes (P < .05).
• The speed of killing was greatly reduced after 3 minutes and even more so after 10
minutes of exposure. Limited penetration depth, inactivation of the solutions by dentin
and microbial mass, and resistant subpopulations (‘‘persister cells’’) of bacteria in the
bio lm may be reasons for the incomplete killing even after 30 minutes of exposure.
• The antibacterial effect of NaOCl and CHX depended on exposure time and
concentration.
• Ricucci, Siqueira, Rocas 2015:
• Most cases of pos treatment apical periodontitis are caused by persistent or secondary
intraradicular infection. However, the involvement of an extraradicular infection in some
cases cannot be discarded. Extr radicular bacteria, if present, are more frequent in
symptomatic teeth.
• When symptoms persist after adequate treatment, one may suspect an extr radicular
component of infection. Extr radicular infections can be successfully managed by
periradicular surgery.
• Du, Haapasalo et al 2015: Purpose: To evaluate the lon term antibacterial effectiveness of
NaOCl followed by different root canal sealers against E. faecalis bio lms in dentin using
viability staining and confocal laser scanning microscopy. Results: Signi cantly more bacteria
were dead when NaOCl and sealers were used in combination than when used alone. (Need
to instrument, irrigate and obturate to eliminate the most bacteria). Looked at AH Plus,
Endosequence BC Sealer, or MTA Fillapex
• De Almeida et al 2016: Purpose: To compare EDTA and modi ed salt solution in their ability
to detach E. faecalis bio lms and to evaluate their antimicrobial properties. Conclusion: EDTA
detaches 99% of cells from bio lms, but has only a 12% antibacterial ef cacy. Modi ed salt
solution (sodium chloride and potassium sorbate) detaches 94% of bio lm cells, and has
excellent antimicrobial properties, killing almost all detached bacteria.
• Liu 2010: investigated the bio lm formation of E.faecalis and its susceptibility to Sodium
Hypochlorite: Scanning electron microscopy and bio lm assay showed that starved cells were
able to form bio lm on dentin with reduced ef ciency as compared with the cells in the
exponential phase and stationary phase (p < 0.05). Bio lm grown on dentin harbored more
cells than polystyrene (p < 0.05). Bio lms of starved cells were more resistant to 5.25%
NaOCl than those of stationary cells (p < 0.05), and the impact of 5.25% NaOCl on them
decreased as the bio lm matured.
• Carvalho, Haapasalo et al 2016: IEJ. Aim To analyze the effect of commercial and
experimental gutta-percha with the addition of niobium phosphate glass on bio lm formation
by oral bacteria from human dental plaque. Additional pH and elemental release of the
materials were analyzed. None of the materials were able to completely prevent the formation
of bio lms. However, gutta-percha with niobium phosphate glass composite was associated
with a reduction in bio lm volume and had the lowest amount of viable bacteria in the bio lm.
It also had the highest pH, and a high Zn and Na release after 30 days. (Probably a biased
study as they are looking to promote a new product)
• Red Complex: The red complex is a group of bacteria that are categorized together based on
their association with severe forms of periodontal disease. The red complex, which includes

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 Porphyromonas gingivalis, Treponema denticola, and Tannerella forsythia (formerly
Bacteroides forsythus), are recognized as the most important pathogens in adult periodontal
disease. These bacteria are usually found together in periodontal pockets, suggesting that
they may cause destruction of the periodontal tissue in a cooperative manner.

Pulp Biology
• Dentin Permeability and bacterial penetration into dentinal tubules
• Brannstom 1976: The diameter and density of dentinal tubules increase closer to the
pulp. Based on the dentinal tube density at the DEJ (~ 65K/mm2) and the pulp (~ 15K/
mm2).
• Garbeoglio, Brannstrom 1976: The density of tubules and the complexity of their
branching in different regions of human dentin were different. The number of tubules per
square millimeter was 30,000 - 40, 000. More dentinal tubules in the coronal portion of
the root canal. Least in apical area.
• Armitage, Ryder, Wilcox 1983: JOE. In the infected group microorganisms were
frequently observed in the dentinal tubules at varying distances from the root canals.
The bacteria extended from a few micrometers into the dentin to approximately halfway
to the cemento-dentinal junction.
• Sen, Piskin, Demirci 1995: The bacterial penetration into the dentinal tubules was
generally as far as 50 μm , but it reached up to 150 μm in the apical 1/3 of 2 specimens.
• Peters, Wesselink, Winkelhoff et al 2001: JOE. In more than half of the infected roots,
bacteria were present in the deep dentin close to the cementum.
• Haapasalo, Orstavik 1987: Developed an in vitro model for infection of dentinal tubules.
Specimens infected for only one day revealed dentinal tubule penetration of bacteria to a
300-400 micometer depth. The main effect of prolonged infection was more tubules
became infected, whereas the avg depth of penetration of the infected tubules by
bacteria increased only slowly with time.
• Haapasalo, Orstavik 1990: E faecalis permeated the entire width of the circumpulpal
dentin after only 2 days of incubation. S Sanguis require up to 14 days to cover the
entire dentinal tubule length.
• Pathways of the pulp: The tubular diameter increases from about 0.6 micrometers to
0.8 micrometers close to the DEJ to about 3 micrometers at the pulp. Given that
bacterial cells are about 0.5 to 1 micrometer in diameter, it is evident that in deep cavity
preparations, particularly when total-etch procedures are employed, bacteria can migrate
through the remaining dentin into the pulp.
• Foaud; J Endod 2009: The mean depth of bacterial invasion in the young and the old
group was approximately 420 μm and 360μm, respectively. Bacteria penetrated the
young radicular dentin to a signi cantly deeper level than the old dentin (p = 0.033).
• Stephan 1937: Correlation of clinical tests with microscopic pathology of the dental pulp.
Conclusions: 1. The normal pulp is without painful symptoms, gives an average response to
hot and cold, EPT and radiographically normal. 2. The atrophied and degenerated pulp is
without painful symptoms, average response to electric, hot and cold stimuli but may give a
variable or no response, and radiographically normal. Cannot be reliably diagnosed clinically.
3. The acutely in amed pulp gives painful symptoms, may give average reactions to hot and
cold, but generally gives a painful response that last longer than normal. Electric is average
but may vary and radiographically normal. 4. The chronically in amed pulp gives no severe
symptoms. Food is forced into the cavity and produces a painful shock. Radiographically may
or may not show involvement. Too few cases to draw conclusions. 5. Vascular changes

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 produce painful symptoms. Too few cases to draw conclusions. 6. The necrotic pulp gives no
response to hot and cold but if contents of the canal are liquid may give a response to the
electric test.
• Patterson, Mitchell 1965: Talked about calci c metamorphisis
• Van Hassel 1971: Because of the unique encasement of the human dental pulp in a low-
compliance environment, intrapulpal tissue pressure is of paramount importance in pulpal
physiology. Tissue pressure is a local phenomenon, and the pathophysiology of pulp is
characterized not by a sudden strangulation at the apex but by a circumferential spread of
in ammation and necrosis from a site of initial injury. It is only when gross destruction of
tissue has led to a loss of structural integrity that the pulp may become an isobaric chamber
in which all areas are in hydrostatic communication. disproved the strangulation theory.
Vascular effects are localized in the low compliance environment and do not effect the whole
pulp.What is strangulation theory? As pulpal in ammation ↑, pulpal pressure ↑. With this
increased pressure, veins and lymphatics collapse at the apex and strangle the pulp -
necrosis results. Tonder in a cat study disproved this theory; localized increase in pressure
with no strangulation
• Lymph Vessels in the Pulp
• Bernick 1977: Use this paper to support existence of lymphatic vessels in the pulp
• Bishop, Molhotra 1990: Study demonstrates clearly that lymphatic vessels are present
in the feline dental pulp, (con rmed under SEM); however, the full extent of their
distribution w/in individual teeth and possible variations between different teeth remain
unknown. Lymphatics: remove excess interstitial uid from tissues
• Response to Caries
• Trowbridge 1981: Classic: initial pulpal response is a CHRONIC in ammatory
response. Zones of dentin involvement adjacent to a carious lesion: outer zone of
destruction, zone of infected tubules, zone of demineralization, zone of sclerosis. Review
of pulp response to caries. The pulp will respond with an in ammatory reaction from
caries before the bacteria from the caries actual reach the pulp.
• Hahn, Liewehr 2007: Review of caries and their role in pulpal response and
in ammation. Acidic bacteria break through the enamel allowing other bacteria to invade
the dentinal tubules. Bacterial byproducts cause pulpal in ammation, elicit an immune
response, induce anti-in ammatory cytokines and T cells, and even suppress pain
conduction. Thicker dentin is best for protecting against pulpal in ammation and as
bacteria invade the tubules become less permeable.
• Hahn, Liewehr 2007: *Review: Innate immune response of dental pulp to caries. The
dental pulp has the ability to mount an innate response to caries, which can temporarily
slow down bacterial progression. Unfortunately, the location of the caries bacteria seems
to prevent their being killed or eliminated by phagocytes. Instead, persistent infection
leads to the activation of adaptive immunity and overwhelming in ammation, which
causes edema and increased intrapulpal pressure. (Innate immunity is activated upon
initial invasion of microbes. If the innate response is unable to abolish the insult,
adaptive immunity is elicited with cellular and speci c antibody responses. Innate
immunity is not antigen speci c but uses receptors to recognize molecular patterns
common to microbes to initiate bacterial phagocytosis. Because of the unique anatomic
location of caries bacteria, classic phagocytic killing probably does not occur until the
pulp is directly in contact with the caries front. Before actual pulp exposure, the dental
pulp beneath shallow caries is capable of mounting innate immune responses to slow
down the caries invasion. A transition to an adaptive immune response will take place in
the dental pulp as the caries front approaches the pulp.) Classic Lit Autumn 2016

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 • Hanh, Liewehr 2007: *Review: Update on the adaptive immune responses of the dental
pulp. Recent advances in immunology have disclosed the enormous complexity of the
immune regulatory system. The dental pulp is equipped to mount adaptive immune
responses to caries, which include at least antigen-presenting cells, lymphocytes, mast
cells and their cytokines, and chemokines. The purpose of this review is to summarize
our current understanding of the roles of these cellular and molecular components in the
irreversibly in amed pulp. The immunopathology of abscess formation and the
mechanisms for painless pulpitis are also discussed.
• Jontell, Bergenholtz 1998: *Review: Immune defense mechanisms of the dental pulp.
(winter 2016 classic lit). Immune cells found in healthy pulp: T-lymphocytes,
macrophages, dendritic cells, lack of B-lymphocytes.
• Bergenholtz 1990: Available data seem to show that the pulp is well adapted to its
environment. It is capable of defending itself against microbial insults in a number of
ways. Dendritic cells may be associated with functions in immunosurveillance and
antigen presentation, blood vessels bring essential defense cells, macrophages with
functions for recognition, and presentation of antigens to T helper cells. Furthermore,
there are pulpal stroma cells that migrate to sites of injury, differentiate to repairing
odontoblasts, and execute dentinal repair.
• Ten Cate 1992: In cases of injury to dentin, odontoblasts deposit collagen that is
subsequently mineralized, forming sclerotic dentin. Although odontoblasts are highly
differentiated and cannot divide, signals from predentin and damaged dentin cause
perivascular cells to differentiate into odontoblast-like cells, which again, deposit
collagen (scar formation) that is subsequently mineralized. (Sclerosis represents the
earliest response to caries and corresponds to an increase in peritubular dentin
formation. The odontoblast is a connective tissue cell (a collagen-producing cell) and its
response in injury is increased collagen synthesis and scar formation. )
• Trowbridge 1981: Review of pulp response to caries. The pulp will respond with an
in ammatory reaction from caries before the bacteria from the caries actual reach the
pulp. The carious lesion of dentin is divided in four zones: Outer zone of destruction,
zone of infected tubules, zone of demineralization, and zone of sclerosis. the reparative
dentin is less tubular and more irregular compared with primary dentin. degeneration of
the pulp occurs when the number of bacteria entering the pulp exceeds the ability of the
blood leukocytes to repel the bacteria. The formation of reparative dentin represents the
defensive reaction of the pulp to caries. Sclerosis represents the earliest response of
dentin to caries
• Magloire, Bourvier, Joffre 1992: Review study to describe the response of
odontoblasts and the pulp to caries. Regulation of odontoblast response to caries
involves factors stored in the dentin matrix and released during demineralization. The
odontoblast response involves increased peritubular collagen synthesis and later
mineralization of this collagen, leading to sclerotic dentin formation. In established
lesions in which odontoblasts have died, pulpal and perivascular cells differentiate into
odontoblast-like cells and secrete a collagenous matrix resembling cartilage adjacent to
the affected dentin. This matrix later mineralizes and is referred to as reparative dentin,
which is amorphous, disorganized, and has large tubules.
• Reeves, Stanley: if caries is < 0.5mm from the pulp or if it invades reparative dentin,
there is irreversible damage; if >1.1mm then little pathosis is seen
• Pulp Vasculature
• Van Hassel 1971: Because of the unique encasement of the human dental pulp in a
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 pulpal physiology. Tissue pressure is a local phenomenon, and the pathophysiology of
pulp is characterized not by a sudden strangulation at the apex but by a circumferential
spread of in ammation and necrosis from a site of initial injury. It is only when gross
destruction of tissue has led to a loss of structural integrity that the pulp may become an
isobaric chamber in which all areas are in hydrostatic communication.
• Takahashi 1982: Classic: Dental pulp has subodontoblastic processes perpendicular to
main arterioles, arteriovenous anastomoses (collateral circulation —> resistance to
in ammation), U-shaped arterioles unique to the pulp. (resin casts)
• Kim S 1985: Review of pulp vasculature. Pulp vascular is similar to other vessels in the
body and responds in a similar manner during insult and in ammation. Pulp death
occurs gradually as a result of an alteration of microcirculatory functions from site of
injury and expands.
• Kindlova 1965: Blood supply to mucosa is by vertical blood vessels. Therefore,
horizontal incisions (for sx or IND) will bleed more than vertical incisions.
• Takahashi K 1985: Detailed analysis of 3D vascular arrangement of pulp during various
stages of development. Pulp vascular infused with resin, coated w/ gold and viewed
under SEM.
• Berneck & Nedelman 1975: Older pulps have reduced # blood vessels and nerve bers
• Kim, Trowbridge 1984: Results of this study show that local anesthetic injections of 2%
lido w/ 1:100k epi are capable of reducing pulpal blood ow signi cantly in teeth that are
in the area of or distal to the injection site. Intraseptal method produces greatest
decrease in blood ow. Plain lidocaine increased pulpal blood ow, the decrease in
pulpal blood ow can be attributed to epi.
• Takahashi K 1990: In ammation study in canine pulp. The pulp vascular consists of
three major layers. With age the pulp cavity becomes smaller and most of the terminal
capillary network disappear. During in ammation the vascular reaction primarily occurs
in the post-capillaries and venules. The disappearance of the capillary network and the
venular network with age implies that the resistance of the pulp to trauma decreases
with age. As age increases the vitality of the pulp decreases.
• Berggreen et al 2010: *Review: Pulpal blood circulation anatomy and physiology in
healthy and in amed pulp. To maintain adequate circulation in the pulp, care must be
taken to minimize in ammatory vasodilation in the gingiva, bone, and PDL during
restorative procedures. Since the main blood supply enters the pulp through apical PDL,
any tooth mobility can compress the vessels and impair circulation. Also, the epinephrine
in local anesthetics can reduce PBF and in an in amed pulp, this reduction can
compromise the immune response and have detrimental effects.
• Pulp Nerves
• Austah, Diogenes et al 2016: Purpose to evaluate the role of capsaicin sensitive
neurons in the development of pulpal and periradicular disease. Conclusion:
Administration of neonatal capsaicin caused pharmacologic ablation of TRPV1-
expression neurons and decreased CGRP concentration within the dental pulp resulting
in faster onset of apical periodontitis after pulp exposures. Bottom Line: Results
suggest that neurogenic in ammation has an early and signi cant protective role in the
development of apical periodontitis.
• Fristad, Betsa, Beyers 2010: Review: In ammatory nerve responses in the dental pulp.
Dental neural responses to injury vary according to degree of damage and duration of
in ammation. Sensory (early) and sympathetic nerve sprouting (late) takes place during
pulpal and periapical in ammation.

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 • Johnsen 1985: Myelination of axons in pulp not complete until apex completes
development. Nerves can penetrate 150-200um. Sympathetic innervation from superior
cervical ganglion.
• Fried 1992: Lit review: changes in pulpal nerves with aging. With the loss of innervation
and critical neuropeptides, there is not only a loss of sensibility but a possible loss of
capacity of the pulp to respond to insults.
• Byers et al 1990: Effects of injury and in ammation on pulpal and periapical nerves.
Injury and in ammation to pulp tissue gives rise to great sensory ber development/
nerve sprouting and uctuation which gives us some insight into patient pain and in
some instances the effectiveness of anesthesia. (Hypersensitive dentin and
toothaches: Exposed dentin activates many more nerve bers than normal with
increases in terminal branching in an episodic manner explaining transient dentinal
hypersensitivity and toothaches. Dental Anesthesia: Neuropeptides such as CGRP
were elevated in trunk axons of the trigeminal nerves that innervated in amed nerves
suggesting that those have an altered capacity for anesthesia due to cytochemical
changes extending though out the affected nerve bers. Periapical Lesions: This study
found signi cant widening of the socket and sprouting of CGRP-IR periapical bers
when vital pulp tissue was still present suggesting that neuropeptides and sensory nerve
ber branching may have contributed to lesion development.
• Johnson 1985: Nerves terminate 100um in dentinal tubules. Reason why EPT prone for
false negatives in developing teeth: C bers innervate rst and the A-delta come in later.
This was challenged by Peckham & Torabinejad 1991 (who found A delta nn during root
development).
• Wakisaka 1990: Reviews the distribution, origins, and correlation of neuropeptides in the
dental pulp.
• NEURONAL PATHWAYS TO THE PULP: The somatosensory nerves supplying the pulp
originate from the trigeminal ganglion. Upper teeth are innervated by the maxillary nerve,
lower teeth innervated by the mandibular nerve. The sympathetic nerves in the dental pulp
come from the superior cervical ganglion. There are two sympathetic neuronal pathways to
the pulp. The major sympathetic pathway leave superior cervical ganglion, run encircling
around the common and external carotid arteries and then around the maxillary artery and
nally enter the pulp with the superior or inferior alveolar artery. The other pathway is
consists of a small number of sympathetic nerve bers leaving superior cervical ganglion
and running toward the trigeminal ganglion and then toward the dental pulp along with
sensory nerve bers.
• NEUROTRANSMITER AND NEUROPEPTIDES: Neurotransmitter is a substance contained
in the nerve cells and their cytoplasmic process. Neurotransmission occurs between
adjacent cells by the release of this substance from the nerve terminal upon neuronal
stimulation. Some substances are very similar to the neurotransmitter in character but play
an assistant role in the synaptic transmitter. These substances are called neuromodulators.
Neuropeptide is a protein with the same properties. Some of them act as a neurotransmitter,
but many of them act as neuromodulator.
• SENSORY NEUROPEPTIDE IN THE PULP: There are three neuropeptides originating from
the trigeminal ganglion have been reported in the dental pulp. These neuropeptides are
substance P (SP), calcitonin gene-related peptide (CGRP) and neurokinin A (NKA).
• SYMPATHETIC NEUROPEPTIDES IN THE PULP: Dopamine β hydroxylase (DBH), and
Neuropeptide Y (NPY) have been demonstrated in the dental pulp.
• PARASYMPATHETIC (?) NEUROPEPTIDES IN THE PULP: Vasoactive intestinal
polypeptide (VIP) is another peptide reported in mammalian dental pulp. VIP-containing
nerve bers originate neither from the trigeminal ganglion nor from superior cervical
ganglion. Since VIP has been reported in parasympathetic ganglion and co-exists with

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 acethylcholine in other tissues, it seems that VIP-containing nerve bers may originate from
a parasympathetic ganglion although the existence of a parasympathetic ganglion sending
nerve bers to the dental pulp has not been demonstrated histologically.
• FUNCTIONAL ROLE OF NEUROPEPTIDES: SP, CGRP, and VIP have vasodilator
functions. Besides the vasodilator effects of neuropeptides, NPY has vasoconstrictive effect.
NPY may have some sympathetic function co-acting with catecholamines in the pulp. It has
been shown that sensory neuropeptides exist in the predentin and dentin, where there are
very few blood vessels. It is known that various external mechanical, chemical, and thermal
stimuli directed to the teeth are recognized as pain. Therefore. sensory neuropeptides in the
predentin and dentin may also participate in pain transmission mechanisms.
• Neuropeptides in the pulp
• Olgart et al 1977: First to ID Substance P in the pulp
• Uddman et al 1986: ID Calcitonin Gene Related Peptide (CGRP) in the pulp
• Wakisaka et al 1988: ID of Neurokinin A (NKA)
• Pashley 1990: Review of the permeability characteristics of dentin to learn about the pulpal
consequences of microleakage. Dentin permeability is theoretically directly proportional to the
number of exposed tubules and their diameter and is inversely proportional to dentin
thickness (thick less permeable than thin dentin). Cavity liners can decrease microleakage.
The more dentin surface exposed during tooth preparation the greater potential for
microleakage. 2-3 million tubules per cm2 of dentin. Blood ow: a normal health pulp is able
to rapidly remove bacterial substances as they enter the pulp.
• Dentin Sensitivity
• Brannstrom 1986: The hydrodynamic theory of dentinal pain. A series of studies are
described that provide evidence that the main cause of dentinal pain is a rapid out ow of
uid in the dentinal tubules that is initiated by strong capillary forces.
• Narhi et al 1992: Mechanisms of dentin hypersensitivity.
• First/fast rapid and sharp pain is related to activation of A Delta Fibers.
• Delayed dull pain is related to C Fibers.
• A bers are myelinated and fast conducting neurons.
• C bers are unmyelinated and more slowly conducting.
• A bers are responsible for dentin hypersensitivity.
• C bers are only activated if the external stimuli reach the pulp.
• Bradykinin and histamine only activate C Fibers.
• C ber activation is most limited to pathological conditions of and pulpal
in ammation.
• A bers are fast ring myelinated primary afferent nerve bers found in pulp tissue
and are mainly responsible for sharp intense pain caused by thermal or mechanical
dentin stimulation.
• C Fibers are slower ring, unmyelinated primary afferent ber found in pulp tissue
mainly responsible for more diffuse dull achy pain associated with in ammation and
pathology.
• Brannstrom 1976: Dentinal tubules density = 40-70,000/um2. At DEJ, 1% of surface =
tubules. At PDJ, 22% of surface = tubules.
• Yamasaki, Kumazawa et al 1994: (Can have a lesion exist with a vital pulp) Investigated
histologically the changes in pulp and periapical tissues after pulp exposures in rats. PA
in ammation starts before pulpal necrosis. This explains why it is possible to have a PA
radiolucency and still have some vital tissues remaining in the root canal. At rst, PA lesion
extends mesiodistally with the resorption of spongy bone as interradicular bone and then
vertically with the resorption of cortical bone and cementum.

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 • Okiji, Jontell, Bergenholtz et al 1997: Demonstrated the human dental pulp is equipped
with class II molecule-expressing perivascular dendritic cells composed of a heterogeneous
cell population
• Satchell, Gutmann 2003: review of apoptosis in relation to the pulp, periradicular disease,
and immune system. Although minor in prevalence, apoptosis does happen even in the pulp.
Although certain characteristics of apoptotic death are favorable to necrosis (e.g. an
in ammatory response is not triggered), apoptosis does not lead to pulpal regeneration.
• Kaya et al 2004: Sickle cell anemia may cause pulpal necrosis without necessarily having an
identi able etiology. SCA causes radiographically observable differences in jaw structure
especially in the mandible. Good idea to perform pulp sensibility tests to rule out pulp
necrosis of virgin teeth. SCA is caused by presence of an autosomal recessive sickle
hemoglobin gene which presents on chromosome II. Red blood cell is distorted.
• Smith 2003: *Review: Growth factors and dental pulp. Various growth factors, particularly
TGF-β family, are embedded in dentin matrix during the tooth development stages. Damage
or degradation of dentin matrix due to physical, chemical, or bacterial injury will cause the
release of these growth factors, which control the reaction of pulp, e.g. regenerative
(reparative or reactive) responses to the injury.
• Tokuda, Miyamoto, Nagoaka, Torii 2004: (Substance P plays an important role in dental-
pulp in ammation in an autocrine manner) Results demonstrate that Substance P enhances
LPS-induced expression of genes for in ammatory molecules in human dental pulp cell
cultures.
• Von Bohl et al 2012: Conclusion: A biological response of the dental pulp occurs during
orthodontic treatment in response to the applied force. Due to a lack of high quality studies
there is no conclusive scienti c evidence to establish a relationship between force level and
dental pulp tissue reaction in humans. Bottom Line: Appropriate orthodontic forces should not
affect pulpal health.
• Abd-Elmeguid et al 2013: To localize osteocalcin (OCN) in reversible and irreversible pulpitis
and to describe its possible function in in ammation. OCN is a reparative molecule commonly
expressed in response to injury of the pulp. indicate that OCN expression in reversible pulpitis
is associated with angiogenic markers, suggesting its potential use in regenerative treatment.
OCN expression is increased in pulpal in ammation and this is more so with reversible
pulpitis, which also shows a greater degree of calci cation. Therefore, OCN is important in
mineralization. OCN localization to cells around calci cations can be explained by the fact
that is considered a marker for osteoblast differentiation. In this study, markers of
angiogenesis (VEGF, PDGF, and FGF) have shown an increase in reversible stages of
in ammation, and this increase was positively correlated to OCN expression. It can be
speculated that OCN in reversible pulpitis plays a role in regulating dental pulp repair. This
role is decreased with the progression of in ammation and the expression of catabolic
molecules like IL-1α and IL-1β.
• Pettiette, Khan et al 2013: The purpose is to study the hypothesis that the systematic
administration of statins results in increased dental pulp calci cation. The systemic use of
statin may contribute to increased odontoblastic activity, which may lead to chamber
calci cation and a reduction in the vertical height of the chamber.
• Holland, Botero 2014: Endo Topics. Review of Pulp Biology. Review of pain mechanisms
and pathways. Classic Lit Spring 2016 (under immunology). Response to injury, in ammation,
immunity, and infection: the odontoblast acts as an antigen recognition cell and produces
cytokines. Blood ow and interstitial uid pressure: although the hemodynamics change
during in ammation, blood ow continues until necrosis occurs. Nociceptive mechanisms: the
pulp contains dedicated nociceptors, some of which are silent and only active during

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 peripheral or central sensitization. Stem cells, repair, and regeneration: there are several
types of dental stem cells that may be speci cally activated by appropriate therapies.
• Nair PN 2004:
• Apical periodontitis is a sequela to endodontic infection and manifests itself as the host defense
response to microbial challenge emanating from the root canal system. It is viewed as a dynamic
encounter between microbial factors and host defenses at the interface between infected
radicular pulp and periodontal ligament that results in local in ammation, resorption of hard
tissues, destruction of other periapical tissues, and eventual formation of various
histopathological categories of apical periodontitis, commonly referred to as periapical lesions.
• The treatment of apical periodontitis, as a disease of root canal infection, consists of eradicating
microbes or substantially reducing the microbial load from the root canal and preventing re-
infection by orthograde root lling. The treatment has a remarkably high degree of success.
Nevertheless, endodontic treatment can fail. Most failures occur when treatment procedures,
mostly of a technical nature, have not reached a satisfactory standard for the control and
elimination of infection. Even when the highest standards and the most careful procedures are
followed, failures still occur. This is because there are root canal regions that cannot be cleaned
and obturated with existing equipments, materials, and techniques, and thus, infection can
persist.
• In very rare cases, there are also factors located within the in amed periapical tissue that can
interfere with post-treatment healing of the lesion. The data on the biological causes of
endodontic failures are recent and scattered in various journals. This communication is meant to
provide a comprehensive overview of the etio-pathogenesis of apical periodontitis and the causes
of failed endodontic treatments that can be visualized in radiographs as asymptomatic post-
treatment periapical radiolucencies.
• Nair PN 2006: Review of persistent apical periodontitis. There is evidence (Penick 1961,
Bhaskar 1966, Seltzer et al. 1967, Nair et al. 1999) that unresolved periapical radiolucencies
may occasionally be due to healing of the lesion by scar tissue that may be misdiagnosed as
a radiographic sign of failed endodontic treatment.
• What are the cellular elements of the pulp?
• TenCate – Odontoblasts, broblasts, undifferentiated mesenchymal cells, macrophages,
Lymphocytes & Dendritic cells
• Farnoush – found mast cells in both in amed and normal pulps
• Reader – mylenated A-delta bers 28%; unmylenated C bers 72% of total
• Bernick: demonstrated lymphatics in the pulp (Bishop also showed this)
• Jontell, Bergenholtz 1985: 1st to show Dendritic cells in the pulp
• Pulver 1978: found B cells in chronically in amed pulp, none found in scar tissue
• Barhordar 1988: T cells in pulp
• Hahn 1989: mainly T cells in normal/reversible pulpitis with some B cells in
• Jontell, Bergenholtz 1998: *Review: Immune defense mechanisms of the dental pulp.
(winter 2016 classic lit). Immune cells found in healthy pulp: T-lymphocytes,
macrophages, dendritic cells, lack of B-lymphocytes.
• How far do the odontoblastic processes extend into the tubules?
• Pashley: 1/3 the length of the tubule.
• What types of collagen are found in the dental tissues & what cells synthesize
collagen?
• Pulp – type I & III; Dentin – type I (90% of organic component)
• Synthesized by mainly broblasts, but also odontoblasts, osteoblasts & cementoblasts
• Pulp Vascular and regulation of blood ow
• Takahashi, Kim: SEM showed AV anastomosis, VV anastomosis, U-shaped arterioles.

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 • Kim: pulpal blood ow increased with C- ber activation (A delta insigni cant); C bers
release substance P which increases PBF; increase in tissue pressure excites both A
delta and C bers.
• Strangulation Theory: as pulpal in ammation increases, pulpal pressure increases.
With this increased pressure, veins and lymphatics collapse at the apex and strangle the
pulp - necrosis results.
• Tonder: cat study disproved this theory; localized increase in pressure to site of
injury with no strangulation
• Van Hassel: Disagrees with theory. Tissue pressure is a local phenomenon, and
the pathophysiology of pulp is characterized not by a sudden strangulation at the
apex but by a circumferential spread of in ammation and necrosis from a site of
initial injury.
• Discuss calci c metamorphosis? Is RCT indicated?
• Pathways - Pulp canal obliteration due to trauma – resembles cementum or bone
• Andreasen – 22% of traumatized teeth undergo CM; only 8.5% developed pulp necrosis
• Walton – canal present histologically, although absent radiographically
• Holcomb & Gregory – RCT if PARL develops; only 7% require RCT
• Cvek – histo wise, most pulps had a rel normal appearance, no bacterial found, able to
negotiate 53/54 radiographically calci ed canals, so RCT can be done if needed
• What is the effect of restorative dentistry on the pulp?
• Stanley, White & McCray – tertiary dentin begins to form @ 19 days at 1.49 um/day
• Abou-Rass – consider RCT for teeth with stressed pulps
• Zach – heat is capable of causing pulp necrosis
• Dahl, Orstavik 2010: Review: Responses of the Pulp-Dentin organ to dental restorative
biomaterials. Mineralization of peritubular dentin continues with age, decreasing its
permeability. This process may be accelerated with caries or the placement of some
dental materials, notably calcium hydroxide. Mild toxic insults to the pulp result in
increased dentinogensis. Increased peritubular dentin formation (sclerotic dentin)
narrows the tubules. Tertiary dentin is formed as a repair response to pulp injury and is
either reactionary or reparative. Odontoblast survival is most sensitive to the remaining
dentin thickness.
• Cox, Bergenholtz 1987: Bench top study. Demonstrated that a good seal is important to
keep bacteria out and pulp protected. (material not important, as long as it is sealed)
• Lagorgia 1991: Benchtop study to eval temp change in pulp chamber during complete
crown prep. Intrapulpal temp should not rise when sharp diamond burs are used with
light pressure and air-water spray coolant.

Microbiology
• Bergenholtz 2015: “The culturing technique, based on samples from treated root canals, was
a common method in the past to analyze the extent bacteria persisted in the root canal
system after treatment. Although commonly taught and practiced in dental schools, the
method never gained wide acceptance in the general practice of dentistry. An apparent
reason was that culture methods are laborious to conduct, and it takes several days to weeks
to identify anaerobic bacterial species. Furthermore, many species are not cultivable under
laboratory conditions (This might explain why in most of the 70-80’s studies there is no sign of
anaerobic bacteria!!). On the other hand, culture-independent methods may identify these
organisms. Yet, DNA-based identi cation methods such as polymerase chain reaction (PCR)
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 Recently, the detection of RNA by reverse-transcriptase PCR has been assumed to be a
better alternative to DNA to measure viable bacteria. It is argued that RNAs are more labile
and possess a shorter half-life than DNA, thus providing a better indicator of viable cells.
However, the detection of viable bacteria by the reverse-transcriptase PCR method is also
cumbersome and requires multiple processing steps as well as substantial laboratory
instrumentation and setup”. “Cells in all organisms regulate gene expression by turnover of
gene transcripts (messenger RNA, mRNA): The amount of an expressed gene in a cell can
be measured by the number of copies of an mRNA transcript of that gene present in a
sample. In order to robustly detect and quantify gene expression from small amounts of RNA,
ampli cation of the gene transcript is necessary. The polymerase chain reaction (PCR) is a
common method for amplifying DNA; for mRNA-based PCR the RNA sample is rst reverse-
transcribed to complementary DNA (cDNA) with reverse transcriptase”. “DNA–DNA
hybridization generally refers to a molecular biology technique that measures the degree of
genetic similarity between pools of DNA sequences. It is usually used to determine the
genetic distance between two organisms. This has been used a lot in phylogeny and
taxonomy. DNA–DNA hybridization is the gold standard to distinguish bacterial species, with a
similarity value smaller than 70% indicating that the compared strains belong to distinct
species. In 2014, a threshold of 79% similarity has been suggested to separate bacterial
subspecies”.
• Bacteria Found in Root Canals
• Siqueria, Rocas 2009:
• Chronic Apical Periodontitis: dominated by anaerobic bacteria in a mixed
community. # of species and cells is proportional to symptoms and/or lesion size.
• Acute Apical Periodontitis and Abscesses: Mixed microbiota; dominated by
anaerobic bacteria and higher number of species compared to chronic AP.
• Root Canal: The apical microbiota is mainly anaerobic and their predominance is
higher the longer the infection has been established. The pro le of the bacterial
community in both segments shows the same amount of diversity but the mean
shared taxa is about 54%.
• Persistent and secondary infections: Although gram-negative bacteria predominate
in primary infections, gram-positive bacteria are present more frequently post-
treatment (Strep species, P micra, Actinomyces, Priopionbacterium, P alactolyticus,
Lactobacillus species, E feacalis.)
• E feacalis is the most frequently detected species in root canal treated teeth.
• Extraradicular infections: apical periodontitis is an effective immunological barrier
against the spread of infection from the root canal into the bone.
• Figdor, Sundqvist 2007:
• Primary infections consisted of an equal mix of gram + and gram - bacteria and
contained mostly obligate anaerobes.
• Secondary infections have more gram + species and have a more equal numbers
of anaerobes and facultative species.
• Baumgartner 1991:
• Strict anaerobes predominate with some facultative anaerobes.
• showed that in the root canal there are gr+ facultative and as we get close to apex
they turn to gr- anaerobic.
• Haapasalo 1993:
• Primary endodontic infections are polymicrobial dominated by strictly anaerobic
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 • Black pigmented gram-negative anaerobes are routinely isolated from endodontic
infections associated with severe symptoms such as pain, swelling, tenderness to
percussion and the presence of sinus tracts.
• Porphymonas and prevotella species are common black-pigmented bacteria. The
presence of porphymonas species increase the probability of acute symptoms.
• Gram positive bacteria play a larger role in post treatment disease (actinomyces or
E. faecalis).
• Sundqvist 1994: Fusobacterium (gr- anaerobica) , Bacteroides, Peptostrep: Correlated
highest with PA destruction. He also stated that bacterial strains can cause clinical
symptoms. Painful lesions have over 6 species of bacteria while painless lesions have 5
or less.
• Hashioka et al 1994: Canals with increased number of bacteria are more symptomatic.
• Molander 1998: Found Enterococcus faecalis in 78% of 100 failed NSRCT cases.
• Sundqvist, Sjogren 1998: The common recovery of E. faecalis from the root canals of
teeth in which previous treatment has failed is notable. E. faecalis appears to be highly
resistant to the medicaments used during treatment. Bacteria found in root- lled teeth
was predominantly gram-positive microorganisms, with approximately equal proportions
of facultative and obligate anaerobes.
• Gomes 2012:
• conducted a study to compare the levels of endotoxins (lipopolysaccharides [LPSs])
found in primary and secondary endodontic infections with apical periodontitis by
correlating LPS contents with clinical/radiographic ndings.
• They found that the median value of endotoxins found in the presence of clinical
symptoms was signi cantly higher than in asymptomatic teeth with primary
infections. A positive correlation was found between endotoxin contents and a
larger size of the radiolucent area (>3 mm).
• Teeth with primary endodontic infections had higher contents of endotoxins and a
more complex gram-negative bacterial community than teeth with secondary
infections.
• Bystrom, Sundqvist 1981: Bacteria were found in all initial specimens and 88% of the
strains were anaerobic. Demonstrated that mechanical instrumentation alone reduces
bacteria. The supporting actions of chemical disinfection are necessary for removal of
bacteria. (Justi cation for irrigation)
• Sundqvist: Review of the bacteria found in the root canal:
• gr – anaerobic rods = Prevotella, Porphyromonas, Fusobacterium
• gr – anaerobic cocci = Veillonella
• gr + anaerobic rods = Eubacterium, Aa
• gr + facultative rod = Lactobacillus
• gr + anaerobic cocci = Peptostrep
• gr + facultative cocci = Strep
• Nair: showed that the main difference between symptomatic and asymptomatic apical
periodontitis are that on average the number of different species in one canal is lower in
asymptomatic teeth.
• Shovelton 1964: claimed that the larger the periapical lesion, the farther bacteria extend
inside the dentinal tubules.
• Kakehashi, Stanley, Fitzgerald 1965: Classic study that demonstrates bacteria are required
to develop pulpal and periapical pathosis. Shows the importance of bacteria to the health or
disease of the dental pulp. Germ free rats did not develop apical periodontitis following pulp
exposure. Conventional rats with normal oral ora rapidly developed apical pathology.

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 (Similar Studies: Paterson 1976 rats, Sundqvist 1976 humans, Moller et al 1981 monkeys,
Bergenholtz 1974 humans)
• Moller et al 1981: Similar study to Kakehashi except in monkeys. All infected teeth
histologically examined showed strong in ammatory reactions in the periapical region.
• Gier, Mitchell 1968: Proposed anachoresis as a means for pulpal infection. Anachoresis is
the homing of bacteria to traumatized, unexposed pulps. Suggests that blood-borne bacteria
are attracted to areas of chronic in ammation.
• Bergenholtz 1974: Looked at bacteria from necrotic pulp of traumatized teeth. Primary
endodontic infections resulting from trauma are mixed infections with anaerobic micro-
organisms dominating. Proposed that microcracks caused by traumatic injuries allow ingress
of bacteria to infect an already compromised, in amed pulp.
• Simon 1980: Described true cyst (epithelial lined lesions that do not attach to root canal
system) and bay cysts (communicate w/ periapex).
• Delivanis et al 1981: The phenomenon of "anachoresis" in un lled root canals could not be
documented under the experimental design. Looked at cats.
• Dwyer, Torabinejad 1981: (Animal study. Endotoxin on PA tissues in cat). The radiographic
and histologic results indirectly suggest that endotoxins have a part in initiating and
perpetuating periapical in ammatory lesions in man. Response was local not systemic. LPS
or endotoxin stimulates cytokine production by macrophages, which leads to pulpal and
periapical in ammation.
• Fabricus 1982: Unlike most endo infections, Ef can survive in RC system as single organism
(rather than polymicrobial community). Con rmed in germ -free mice (Sobrinho (1998))
• Fabricus 1982: RC infections are polymicrobial. The pulps of 24 root canals, eight in each of
the three monkeys, were mechanically devitalized and exposed to the mouth ora for about 1
week and thereafter sealed. Monkey teeth were left open for 1 week and then closed at
various times. Relative # of obligate anaerobes increased over time.
• Schonfeld et al 1982: Background: A possible explanation for the pathogenesis of the
chronic periapical granuloma is that bacterial products originating in septic root canals diffuse
into the apical tissue, eliciting host response. Since gram-negative bacteria are frequent
isolates of infected root canals, bacterial endotoxin would be a likely candidate for one such
substance. Results: 75% of lesions diagnosed as granulomas were positive for endotoxin.
Endotoxin, which is present in the root canal of necrotic teeth, is also present in the PA areas
of teeth with apical granulomas. The presence of these products in PA tissue can account for
the occurrence of apical disease, even if no viable bacteria are present.
• Bystrom 1985: Importantly, E. faecalis is resistant to Ca(OH)2 tx. Con rmed by Reit &
Dahlen (1988).
• Bystrom, Happonen, Sjogren, Sundqvist. 1986: RCT to demonstrate healing of PA lesions
following root canal treatment. A high percentage of teeth with necrotic pulps and periapical
lesions will heal when bacteria are eliminated from the canal. In cases that are slower to heal,
some bacterial species, such as Actinomyces may be part of the cause. (Lesions heal,
Ca(OH)2 works)
• Haapasalo 1989: Clinical study: Bacterioides spp (are gr- strictly anaerobic rod) in dental root
canal infections.The success rates of the 3 penicillin groups (0, 1 and 12 weeks) showed no
difference at 1 year control. The result supported the current practice in endodontic treatment
where antibiotics are not routinely prescribed.
• Fukushima et al 1990: JOE. Sixty percent of extracted tooth apices with asymptomatic
periapical pathosis contained mixtures of bacteria between the lling material and the upper
part of the apical foramen. These organisms predominantly consisted of the species of
Bacteroides, Peptococcus, Peptostreptococcus, and Eubacterium which have also been in

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 symptomatic cases. Therefore, it is concluded that bacteria persisting in the apex of a class 3
lesion may have endodontopathic potential to progress to class 1 and 2 lesions (Bigger).
• Baumgartner, Faulkner 1991: (*Strict anaerobes predominate with some facultative
anaerobes. showed that in the root canal there are gr+ facultative and as we get close to
apex they turn to gr- anaerobic.). Bacteria in the apical 5mm of infected root canals.
Conclusion: The results of this study suggest that only a limited number of species of bacteria
are consistently selected out of the total oral ora for growth in an infected root canal. As
bacteria penetrate apically in necrotic canals, anaerobic succession apparently occurs
because of the compromised blood supply, the lower oxidation-reduction potential in the
necrotic tissue, and the establishment of synergistic relationships with other bacteria. Bottom
Line: Black-pigmented Bacteroides has been implicated with symptomatic infections of
endodontic origin. Other possible endopathogens include Peptostreptococcus species,
Peptococcus species, F. nucleatum, Actinomyces species, and B. buccae.
• Sundqvist 1992: Review: Ecology of the root canal ora. Endodontic treatment interferes
with this system; anaerobosis is lost when the canal is opened and biomechanical treatment
eliminates bacteria and deprives the canal of nutrients. Once the canal is re-closed, however,
anaerobosis resumes and in ux of tissue uid supports bacterial regrowth. Bacteria that have
survived, such as E. faecalis, can multiply to high numbers. Therefore, the root canal should
ideally be completely cleaned at the initial treatment when the bacteria are most vulnerable to
a disturbance of their sensitive ecology. Application of intracanal dressing is essential to
eliminate or inhibit the multiplication of bacteria that survive the initial treatment.
• Van Winkelhoff et al 1992: Review of Porphyromonas (bacteroides) endodontalis: its role in
endo infections. Signi cance: P. endodontalis appears to be involved in mixed anaerobic
infections of the endodontium. It seems to play a role in severe acute root canal infections but
it is still unclear which features are responsible. Thus, more studies to investigate the different
serotypes and the relationship between virulence, serotype, and clinical symptoms.
• Safavi, Nichols 1993: Lab. Evaluated effect of Ca(OH)2 on bacterial LPS. This study
suggests that calcium hydroxide-mediated degradation of LPS may be an important reason
for the bene cial effects of inter-appointment calcium hydroxide treatment.
• Haapasalo 1993: Review: black-pigmented gram-negative anaerobes in endodontic
infections. Primary endodontic infections are polymicrobial dominated by strictly anaerobic
species. Endodontic infections are in uenced by 3 factors: origin of infection, ecological
conditions in the infected root canal, the host defense mechanisms. Bacteria in root canal
infections originate in the oral cavity. Black pigmented gram-negative anaerobes are routinely
isolated from endodontic infections associated with severe symptoms such as pain, swelling,
tenderness to percussion and the presence of sinus tracts. Porphymonas and prevotella
species are common black-pigmented bacteria. The presence of porphymonas species
increase the probability of acute symptoms. Gram positive bacteria play a larger role in post
treatment disease (actinomyces or E. faecalis).
• Sundqvist 1994: Fusobacterium (gr- anaerobica) , Bacteroides, Peptostrep: Correlated
highest with PA destruction. He also stated that bacterial strains can cause clinical symptoms.
Painful lesions have over 6 species of bacteria while painless lesions have 5 or less.
• Gomes 1994: 1) Pain is signi cantly associated with Prevotella melaninogenica and
Peptostreptococcus. 2)Tenderness to percussion Prevotella or anaerobes and 3) Swelling
associated with Eubacterium or with Prevotella. The idea that different bacterial species are
associated with different clinical symptoms was also suggested by Miller 1980 who said
B.melaninogenicus is associated with sinus tract and pain. Other gr+ strict anaerobic
identi ed in infected root canals is Actinomycosis. Proteolytic bacteria like Prevotella,
Porphyromonas and Fusobacterium use necrotic tissue of pulp as nutrients. Prevotella and

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 Porphyromonas contain a polysaccharide capsule which can protect them against
macrophages.
• Hashioka et al 1994: (Canals with increased number of bacteria are more symptomatic.)The
object of this study was to determine the correlation between clinical symptoms and the
activity of enzymes such as collagenase, chondroitinase, and hyaluronidase produced by
bacteria isolated from infected root canals. The materials examined consisted of 28 teeth with
apical periodontitis from 25 patients. Bacteria producing collagenase or chondroitinase and
hyaluronidase were found to be signi cantly related to subacute clinical symptoms involving
percussion pain. The frequency of bacteria producing collagenase was higher in isolates from
root canals with a radiolucent area over 5 mm in diameter than in those from canals having a
radiolucent area less than 5 mm in diameter.
• Waltimo, Haapasalo et al 1997: It seems that the presence of yeasts in the root canal ora is
more common in persistent infections than at the beginning of treatment of apical
periodontitis. The occurrence of yeast in persistent infections may be the result of
contamination during the treatment. Antibiotic treatment occasionally combined with local
chemomechanical therapy is known to be ineffective against yeast and it is possible that
systemic use of antibiotics in some cases may even facilitate overgrowth of yeast.
• Fouad 1997: pulpal and periapical pathosis were independent of the presence of functional T-
and B-cells in this model.
• Foaud; J Endod 2009: The mean depth of bacterial invasion in the young and the old group
was approximately 420 μm and 360μm, respectively. Bacteria penetrated the young radicular
dentin to a signi cantly deeper level than the old dentin (p = 0.033).
• Molander 1998: Found Enterococcus faecalis in 78% of 100 failed NSRCT cases.
• Sundqvist et al 1998: Case series - bacterial analysis of failed RCT and retreatment
outcomes. -Two factors that were shown to have a negative in uence on the prognosis are
the presence of infection at the time of root lling and the size of the perapical lesion. It also
showed that periapical healing was rather slow in some cases; requiring 4-5 years for full
resolution. The common recovery of E. faecalis from the root canals of teeth in which
previous treatment has failed is notable. E. faecalis appears to be highly resistant to the
medicaments used during treatment. Bacteria found in root- lled teeth was predominantly
gram-positive microorganisms, with approximately equal proportions of facultative and
obligate anaerobes. Teeth with infections of an untreated canal typically have a polymicrobial
ora with approximately equal gram-negative and gram-positive bacteria and are dominated
by obligate anaerobes. -Demonstrated that 75% of cases with previous RCT and persisting
PA lesions can be successfully managed with endodontic retreatment.
• Baumgartner et al 2000: Found Candida albicans in primary endodontic infections.
• Love 2001: E. faecalis possesses the ability to survive long periods of time in dentinal tubules
without nutrients which contributes to RCT failure.
• Sunde, Tronstad et al 2002: Case series looking at bacteria of PA lesions refractory to endo
therapy. A wide variety of microorganisms, compromising facultative and anaerobic bacteria
as well as yeasts, remained in refractory periapical endodontic lesions after long-term
treatment with Ca(OH)2 (and systemic antibiotic tx). In this ora, 79.5% of the strains were
Gram-positive. Staphylococcus, Enterococcus, Enterobacter, Bacillus, Pseudomonas,
Stenotrophomonas, Sphingomonas, and Candida species were detected in 27 (75%) of 36
lesions. This is different from that found in asymptomatic apical periodontitis. Sulfur granules,
containing Actinomyces species and other bacteria, were detected in 9 lesions (25%), and
many of the granules were calci ed. Despite our best chemomechanical efforts: 10-20% of
PA lesions will not resolve.

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 • Baumgartner, Xia 2002: Do not need to wipe out ALL bacteria to be effective, as pen VK only
85% kill, but works! Susceptibility of bacteria isolated from abscesses: Pen V with metro =
amox (91%). Clindamycin (96%) also effective. Augmentin (100%) Resistance to penicillin
is usually by 3 mechanisms: barriers to bacterial cell wall penetration, inability to bind to the
penicillin binding proteins, and production of beta-lactamase. Penicillin V is considered the
antibiotic of choice for orofacial and endodontic infections. If patient has recently taken Pen V
or it is ineffective can prescribe Augmentin (amox/clav acid). Clindamycin was 96% effective
and recommended for those allergic to PCN. Metronidazole on active against anaerobes and
should not be used alone. Can be paired with PNC/metro (85-93%) or Amox/metro (92-99%).
In conclusion, penicillin V seems to remain the antibiotic of choice because of its ef cacy in
polymicrobial infections, relatively narrow spectrum for bacteria found in endodontic
infections, low toxicity, and low cost. Although metronidazole has relatively poor ef cacy by
itself, in combination with penicillin V the susceptibility of the bacteria in this study was
virtually the same as amoxicillin. Amoxicillin and amoxicillin/clavulanate did have greater
activity for the bacteria isolated in this study than penicillin V by itself. However, amoxicillin
and amoxicillin/clavulanate have a wider spectrum of activity than penicillin V. This spectrum
includes many species of bacteria found elsewhere in the body. Amoxicillin and amoxicillin/
clavulanate may increase the risk of selecting for resistant organisms outside of the oral
cavity. Amoxicillin and amoxicillin/clavulanate are indicated for the treatment of
immunocompromised patients, who may have odontogenic infections containing nonoral
bacteria. Amoxicillin and amoxicillin/ clavulanate may also be indicated for the most serious
infections because of their more rapid and sustained plasma levels. Clindamycin remains an
excellent alternative for patients allergic to the penicillins. Clarithromycin seems to be an
alternative for erythromycin for mild infections when penicillin cannot be prescribed.
• Siqueira, Roccas 2002: Fungal infections in radicular dentin. C. albicans was the only
species that colonized radicular dentin in this study. Candida has molecules on its surface
that mediate its adherence to tissues. (con rmed the presence of fungus in the canal.
Candida albicans is by far the fungal species most commonly isolated from infected root
canals, and this species has been considered a dentinophilic microorganism because of its
invasive af nity to dentin. C albicans has also been discovered to be resistant to some
intracanal medicaments, such as calcium hydroxide. Its ability to invade dentinal tubules and
resistance to commonly used intracanal medicaments may help to explain why C albicans
has been associated with cases of persistent root canal infections. This nding was also
con rmed by Haapasalo.)
• Evans, Sundqvist 2002: Survival of E. faecalis in calcium hydroxide appears to be unrelated
to stress induced protein synthesis, but a functioning proton pump is critical for survival of E.
faecalis at high pH.
• Distel 2002: E. Faecalis can form bio lm and become resistant to CaOH
• Baumgartner, Xia 2003: Spirochetes are part of the mixed ora found in asymptomatic
necrotic pulps and abscesses.
• Siqueira 2003: Review: Micobial causes of Endodontic areups. Incidence: 1.4 - 16%.
Causes: debris extrusion, changes in microbiota and environmental condition, secondary
infections (new bacteria possibly introduced into root canal), increase of oxidation-reduction
potential. Flare-up Preventions: one of the best predictors of are-up occurrence is a history
of preoperative pain and/or swelling, especially necrotic cases. Clinicians should: select
instrumentation techniques with the least debris extrusion, complete chemo-mechanical
instrumentation in one visit, use antimicrobial medicaments between appointments, not leave
teeth open for drainage, maintain aseptic environment during treatment. Flare-ups have no
signi cant effect on the outcome of treatment.

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 • Siqueira 2004: E. faecalis is more often associated with failed endodontic treatments than
primary infections (also shown by Gomes 2004)
• Kvist et al 2004: RCT: Microbiological eval of 1 vs 2 visit endo. Concluded from a
microbiological point of view, treatment of teeth in two appointments were not more effective
than the investigated one-visit procedure. Also, the micro ora changed from anaerobic-
dominated before treatment to facultative-dominated after treatment.
• Stuart 2006: reviewed the survival and virulence factors of E.faecalis:
• Endures prolonged periods of nutritional deprivation (Sundqvist)
• Binds to dentin and pro ciently invades dentinal tubules (Love)
• Alters host responses
• Suppresses the action of lymphocytes
• Possesses lytic enzymes, cytolysin, aggregation substance, pheromones, and
lipoteichoic acid
• Utilizes serum as a nutritional source
• Resists intracanal medicaments (i.e. Ca(OH)2)
• Maintains pH homeostasis
• Properties of dentin lessen the effect of calcium hydroxide
• Competes with other cells
• Forms a bio lm
• Figdor, Sundqvist 2007: Primary infections consisted of an equal mix of gram + and gram -
bacteria and contained mostly obligate anaerobes. Secondary infections have more gram +
species and have a more equal numbers of anaerobes and facultative species.
• Ricucci, Siqueira 2008: According to the authors, there is no clear evidence that apical
actinomycosis is an independent to intraradicular infection. Extraradicular actinomycosis
always forms a continuum with the intraradicular infection. Actinomycosis is a chronic,
granulomatous infectious disease characterized by suppuration, abscess formation and
draining sinus tract. Diagnosis of apical actinomycosis is usually achieved only after surgical
removal of the lesion followed by histopathologic and microbiologic exam of specimen.
• Kakoli, Fouad 2009: Lab. Effect of age on bacterial penetration of radicular dentin. A
signi cantly higher number of tubules were invaded by bacteria in the young group compared
with the old group (p 0.014). Also, the depth of invasion by bacteria was signi cantly higher in
the young than in the old group (p 0.033). These results suggest that bacterial infection of
dentinal tubules occur to a lesser extent in older patients. The results of this study may offer
an explanation for why some studies have shown that older individuals have a higher success
rate in endodontic therapy
• Siqueira, Rocas 2009: Topic review of bacteria. The Community Concept: A community is
regarded as integrated populations of bacteria that coexist and interact in a given
environment. A root canal that is infected harbors an endodontic microbial community that is
composed of several populations that each occupy a functional role (niche). These highly
structured and organized communities many times have properties that are greater than the
sum of the component populations. The bacterial composition of the endodontic microbiota
differs consistently among individuals suffering from the disease. This indicates that apical
periodontitis has a heterogeneous etiology, where multiple bacterial combinations can play a
role in disease causation. Bio lm can be de ned as a sessile multicellular microbial
community characterized by cells that are rmly attached to a surface and enmeshed in a
self-produced matrix of extracellular polymeric substance. The ability to form bio lms has
been regarded as a virulence factor. Endodontic treatment has been fundamentally based on
nonspeci c elimination of bacteria (targets community, rather than individual species).
Treatment procedures can promote total or partial elimination of the endodontic bacterial

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 communities. Total elimination is not yet possible. However, partial elimination of the
community represents disturbances that can lead to death of the residual community or
reorganization in different proportion of species, which can sometime jeopardize treatment
outcomes. To avoid the latter, community reorganization, the clinician should direct his or her
efforts to maximal and broad- range elimination of the endodontic bacterial community
through chemomechanical preparation supplemented by an intracanal antimicrobial. -Role of
obturation: to eliminate or reduce space for reorganization of the community by surviving
bacteria and prevent further nutrient supply.
• Siqueria, Rocas 2009: Chronic Apical Periodontitis: dominated by anaerobic bacteria in a
mixed community. Number of species and cells is proportional to symptoms and/or lesion
size. Acute Apical Periodontitis and Abscesses: Mixed microbiota; dominated by anaerobic
bacteria and higher number of species compared to chronic AP. Root Canal: The apical
microbiota is mainly anaerobic and their predominance is higher the longer the infection has
been established. The pro le of the bacterial community in both segments shows the same
amount of diversity but the mean shared taxa is about 54%. Persistent and secondary
infections: Although gram-negative bacteria predominate in primary infections, gram-positive
bacteria are present more frequently post-treatment (Strep species, P micra, Actinomyces,
Priopionbacterium, P alactolyticus, Lactobacillus species, E feacalis. E feacalis is the most
frequently detected species in root canal treated teeth. Extraradicular infections: apical
periodonttiis is an effective immunological barrier against the spread of infection from the root
canal into th ebone.
• Treasure et al 2010: case report/review. Cervical necrotizing fasciitis (CNF) is a rare
complication from a dental infection that can lead to involvement of the neck, mediastinum
and chest wall.
• Martinho et al 2010: A correlation was found between the number of gram-negative bacteria
and the levels of IL-1beta/TNF-alpha (p < 0.05). Increased levels of endotoxin were followed
by TNF-alpha release (p < 0.05). Higher levels of IL-1beta (p < 0.05) and endotoxin contents
were related to the larger size of the radiolucent area.
• Riccuci, Siqueira 2010: Conclusion: The present study revealed a very high prevalence of
bacterial bio lms in the apical root canals of both untreated and treated teeth with apical
periodontitis. The pattern of bacterial community arrangement in the canal, which adhered to
or at least was associated with the dentinal walls with cells encased in an extracellular
amorphous matrix and often surrounded by in ammatory cells, is consistent with acceptable
criteria to include apical periodontitis in the set of bio lm-induced disease. Bacterial bio lms
are still more expected to be present in association with longstanding pathologic processes,
including large lesions and cysts. Bottom Line: In symptomatic teeth bio lm are present most
of the time.
• Haapasalo 2011: E. faecalis strains from saliva and infected root canals have the potential to
recruit PMNs in the infectious sites leading to in ammation via up-regulation of PMN IL-1α,
TNF-α, MMP-8, and COX-2. PMNs can play an important role in killing of E. faecalis
• Ma et al 2011: E. faecalis strains from saliva and infected root canals have the potential to
recruit PMNs in the infectious sites leading to in ammation via up-regulation of PMN IL-1α,
TNF-α, MMP-8, and COX-2. PMNs can play an important role in killing of E. faecalis.
• Han, Wang 2013: Purpose: To describe the association of oral bacteria with various systemic
diseases and review unique virulence factors of these bacterial groups. Conclusion: Since
periodontal infection can serve as a trigger of dental bacteremia, good oral hygiene is crucial
for controlling bacterial load to prevent dissemination, especially in immune- compromised
patients. Many of the studies linking oral bacterial to systemic infections are at the stage of
association.

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 • Zhang 2015: Systematic Review. reported that E. faecalis is more highly correlated with
persistent intraradicular infections compared with untreated chronic periapical periodontitis.
(Enterococcus faecalis: gr+ facultative anaerobic diplococcic)
• Gomes, Molander: The microbial ora in canals after failure of RCT was limited to small
number of diplococcic facultative anaerobic compared to polymicrobial nature of primary RTC
composed of gr – obligate.
• Siqueira, Barnett: described the effect of LPS in postop pain. They suggest a positive
correlation between bacteria LPS and Post OP pain. The same nding was also highlighted in
Schein & Schilder (1975) found positive correlation between endotoxin levels and necrotic,
painful teeth with PARLs.
• Gomes 2012: conducted a study to compare the levels of endotoxins (lipopolysaccharides
[LPSs]) found in primary and secondary endodontic infections with apical periodontitis by
correlating LPS contents with clinical/radiographic ndings. They found that the median value
of endotoxins found in the presence of clinical symptoms was signi cantly higher than in
asymptomatic teeth with primary infections. A positive correlation was found between
endotoxin contents and a larger size of the radiolucent area (>3 mm). Also Teeth with primary
endodontic infections had higher contents of endotoxins and a more complex gram-negative
bacterial community than teeth with secondary infections.
• Viruses
• Jakovljevic, et al 2017: JOE. Systematic Review.
• Varicella zoster virus (VZV) and subsequent herpes zoster (HZ) infection have been
proposed as a causative agent of periapical pathoses and root resorption. This
review aimed to identify, synthesize, and present a critical analysis of the available
data on the association among VZV, subsequent HZ infection, and the development
of periapical pathoses and root resorption and to analyze the level of evidence of
available studies.
• Conclusions: All studies included in this systematic review had a low level of
evidence (4 and 5). Still, the potential role of VZV in the etiopathogenesis of
periapical pathoses and root resorption cannot be ruled out. Future investigations
should be directed toward the analysis of VZV pathologic effects on pulp blood
vessels, which might cause local ischemia and tissue necrosis.
• Sabeti, Slots 2003: Reported the presence of Epstein-Barr Virus and cytomegalovirus in
periapical lesions, especially larger and symptomatic lesions.
• Sabeti et al 2012: Evidence supports the role of viruses in periapical pathology. (The
present ndings provide evidence of a putative role of HCMV and EBV in the
pathogenesis of symptomatic periapical pathosis. The release of tissue-destructive
cytokines might be of pathogenetic signi cance.)
• Glick, Trope: Detection of HIV in the dental pulp of a patient with AIDS.
• Baumgartner et al 2009: Discussion: Epstein-Barr Virus is present in signi cantly
higher frequencies in irreversible pulpitis and apical periodontitis.There was no apparent
association of human cytomegalovirus, Herpes simplex virus, or Varicella zoster virus to
endodontic disease. The presence of EBV is not a predictor for the incidence of pain.
EBV are found in many but not all patients with irreversible pulpitis and apical
periodontitis. Other microorganisms may serve as cofactors of disease. Herpesvirus -
infected immune cells may release cytokines that could lead to in ammation and
exacerbation of symptoms including pain. Bottom line: EBV, but not HCMV, HS 1, or
VZV, may be associated with irreversible pulpitis and apical periodontitis.
• What causes periapical pathology?
• Bacteria:

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 • Kakahashi – lesions developed with exposed pulp in conv. rats & not germ-free
• Moller – lesions only developed in infected devitalized pulps in monkeys
• Sundqvist – bacteria were necessary to cause lesions in human teeth
*Host immune response mediates tissue and bone destruction in response to
bacteria (see in ammation section)
• Lin- bacterial needed for development of PA lesions (dogs)
• What is the general distribution of bacteria within the tooth?
• Crown = Aerobes associated with caries: Strep mutans, lactobacillus, facultative
anaerobes - Moller
• Mid-root = Mixed, Facultative species (Gram + rods/cocci): Staph aureus, Actinomyces,
Lactobacillus
• Apex = Anaerobes (Gram – rods/Gram + cocci), Fusobacterium, Porphyromonas,
Prevotella, Eubactium, Peptostreptococcus (Baumgartner, Sundqvist)
• What speci c bacteria are involved the pathogenesis of a primary root canal infection?
• Figdor, Sundqvist 2007: Primary infections consisted of an equal mix of gram + and
gram - bacteria and contained mostly obligate anaerobes.
• Siqueira – polymicrobial w/ 10-30 species/canal, predominately gram – anaerobic rods
(Porphyromonas species, T. denticola, Tannerella forysthius, Prevotella, Fusobacterium
nucleatum)
• Ribiero - 66% species uncultivable in primary lesions, Siquiera says around 50%
• Baumgartner – Prevotella nigrescens most common BPB isolated
• Fabricius - # of obligate anaerobes increase with time & nearer the apex
Gram - Anaerobic rods: Porphyromonas, Prevotella, Fusobacterium, Treponema
• Also Candida (Baumgartner) & HIV (Glick &Trope) found
• What bacteria are more likely to infect a previously treated case?
• Figdor, Sundqvist 2007: Secondary infections have more gram + species and have a
more equal numbers of anaerobes and facultative species.
• Usually 1 -5 species, generally treatment resistant gram + facultative cocci
• Sundqvist – Avg. 1.3 species;
• E. faecalis frequently isolate according to Gomes, Rocas, Sedgley
• Nair – Yeast / Candida involve in treatment failures. Gram + facultative cocci:
Enterococcus, Streptococcus, Staphylococcus
• Molander- gram + facultative anaerobes 69%; 32% E. faecalis
• Gomes- E. faecalis 78% with PA lesions
• Kaufman/Fouad- 12% w/PCR; assoc more with normal periapex than lesion
• Why are Enterococcus species resistant?
• Love — able to invade dentinal tubules and adhere to collagen in the presence of serum
• Distal – forms bio lm resistant to defense cells and antibiotics
• Evans – proton pump resists high pH of calcium hydroxide
• Sedgley — entombed in tubules; can survive a long time without nutrition
• Are any bacteria associated with symptoms?
• No:
• Baumgartner – No relationship between BPB and symptoms & signs
• Yes:
• Gomes – Association between Prevotella & Peptostreptococcus and pain
• Sundqvist – BPB associated with purulent infections
• Nakamura – Bacteroides and Poryphmonas more pain/odor
• Griffee – B melanonginacus to foul odor, pain, sinus tracts
• Discuss the bacterial ora found in acute PA abscesses?

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 • Siqueira – Polymicrobial – similar to primary infections – BPB, Treponema, Tannerella
• Sundqvist – BPB associated with purulent infections
• Ferreira/Siqueira- HHV present in 67% of AAA aspirates (role of virus unclear)
• Are bacteria present in perapical lesions?
• Yes:
• Tronstad: found extradicular anaerobes in 8 refractory lesions. anaerobic bacteria
are able to survive and maintain in periradicular tissues. (This nding was criticized
by Nair who said their ndings is due to contamination of samples.)
• Nair, Ricucci: Cysts and abscesses but not in PA granulomas
• Abou-Rass 1998: Found bacteria in 13/13 lesions.
• NO:
• Walton: dog/histo study; bacteria con ned to canal space
• Nair: histo study; said bacteria are not present in the periapical region.
In ammatory lesions seemed to resist the spread of bacteria, con ning them to the
canal. criticized Tronstad saying his samples were contaminated. Nair suggested
that bacteria are present in the PA in the following situations: 1) Abscess 2) infected
radicular cyst.
• Siqueira: SEM Study; only 1/24 cases or 4%
• Does RCT cause bacteriemia?
• Baumgartner – very low incidence if con ned to RC system – 3.3% (3%/20% if long)
• Baumgartner- 100% ext, 83% ap, 33% osseous resection (implied bacteremia short-
lived)
• Bender- 0% in canal/31% if long; NONE after 10 min
• Debelian- connected bacteremia with NSRCT (4/13 short, 7/13 long)
• Are bacteria present in traumatized teeth with intact crowns?
• Sundqvist – Yes – mixed ora with necrotic pulp; remaining had aseptic necrosis;
proposed bacterial entry through tubules and cracks (sterile necrosis)
• Does anachoresis occur?
• Yes:
• Robinson & Boling – cat study; in ammation & bacteria required
• Gier – bacteria attracted to in amed pulps (IV injection of bacteria)
• No:
• Doyle – not demonstrated through IV injection of bacteria; cat study
• Moller – non-infected pulp did not induce PA in ammation; monkeys
• Delivanis - need tissue in canals, un lled canals didn’t become infected from
bloodstream
• What is prevalence of Actinomyces periapically. How treat?
• Siqueira-up to 50% in primary infection, 3-24% in secondary infection
• Happonen- PA surgery w/ complete curettage is de nitive tx (suspect actino if persistent
sinus tracts after sound NSRCT)
• Rush-86% healed with apical surgery alone (no abx)
• Barnard-2-6 weeks abx; NaOCl and CaOH were effective
• Discuss the methods used to study endo microbioloby?
• Histology-limited to observing morphology, can’t use alone to ID species
• Culturing-not all species can be cultured, minor diff in culturing/exam can in uence
results
• Molecular method (PCR, DNA-DNA Hybridzation)-can’t distinguish betw live and dead
bacteria, very technique sensitive (contamination problems); HOWEVER can ID
microbes that are not cultivable

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 • PCR-(mid 80s)-ampli es nucleic acid sequences
• DNA-DNA (mid 90s)-hybridizes DNA samples against DNA probes; no ampli cation
so minor contaminates not likely detected but not as good detecting species in low
numbers
• Sedgley - molecular methods are more sensitive than culturing
• Martinho, Teixeira, Valera et al 2016: MMPs, TIMPs, and their complexes play a role in
apical periodontitis. Matrix metalloproteinases (MMPs), a family of zinc- and calcium-
dependent endopeptidases, are strongly associated with the breakdown of ECM and play a
major role in bone remodeling and resorption. Higher level of endotoxins present in root
canals were positively correlated with larger amounts of MMP-9 (p<.05). A positive correlation
between higher levels of MMP-1, -2, and -9 and a larger lesion and a larger area of bone
destruction was also observed.
• Alyahya, Alqareer 2017: JOE. The importance of an intact layer of cementum on the root
surface in preventing bacterial penetration into radicular dentin has not been suf ciently
investigated. The aim of this in vitro study was to determine the effect of the absence of
cementum from the root surface and the length of the infection period (2 or 4 weeks) on the
maximum depth of bacterial penetration and the percentage of sectors lined with bacteria.
The results support the hypothesis that the absence of cementum facilitates bacterial
penetration into dentinal tubules. Results also suggest that the process of radicular dentin
infection is time dependent and highlight the importance of early treatment of infected teeth,
especially in situations in which cementum discontinuity is suspected.
• Cavalli, Alves et al 2017: JOE. RCT. n=30. 24ml 2.5% NaOCl used.
• This clinical study was conducted to correlate the microbiological pro le and levels of
endotoxins found in primary endodontic infection with the presence of clinical features
and to evaluate the removal of microorganisms and endotoxins using rotary, recipro-
cating, and hybrid systems for biomechanical preparation.
• Previous pain, tenderness to percussion, and presence of a sinus tract were associated
with speci c microorganisms (P < .05).
• In conclusion, biomechanical preparation was effective in the reduction of
microorganisms and endotoxins although these were not completely removed from the
root canal. Also, it was veri ed that signs and symptoms were associated to the
presence of gram-negative and gram-positive anaerobic microorganisms.
• Alfenas, Rocas, Siqueira et al 2017: Endodontic infections are polymicrobial in nature and
are the primary cause of apical periodontitis. An acute apical abscess is a severe
manifestation of apical periodontitis and one of the most common and severe dental
infections. In conclusion, analysis of the human exoproteome in acute apical abscesses
indicates a large diversity of proteins, primarily involved in cellular processes, metabolism,
and immune response. Proteins involved in different mechanisms against infection were
identi ed, including PMN- related proteins, antibodies, complement, and iron-sequestering
proteins. Factors associated with tissue damage and protection against tissue damage were
also detected in abscesses. Knowledge of the pres- ence and function of proteins provides an
insight into the complex host-pathogen relationship, the host antimicrobial strategies to ght
infections, and the disease pathogenesis.

Immunology & In ammation

• Discuss the 4 types of immune rxns (Trowbridge & Emling 1997)
• Type I – Anaphylactic (Immediate-Type) Rxn
• IgE mediated; binds to basophils & mast cells which release in ammatory mediators
(allergic rhinitis & asthma)

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 • Anaphylaxis, hives, bronchospasm, vomiting/diarrhea
• Type II – Cytotoxic Rxn
• Autoimmunelike tissue destruction
• IgG & IgM mediated; triggers complement or phagocytosis (autoimmune hemolytic
anemia, some organ rejection & idiopathic thrombocytopenic purpura)
• Type III – Immune Complex (Ag-Ab) Rxn
• Immune Complex Formation
• Pathology due to systemic deposits
• Ag-Ab complexes activate complement; (Arthus type – large complexes within blood
vessel; serum sickness-type – small & soluble complexes which pass into the tissues)
• Type IV – Delayed-Type Hypersensitivity
• no Ab required
• cell-mediated immune memory response; macrophages and Killer T cells recognize
Ag bearing cells; Involves memory T cells;
• 4 types:
• 1) chronic infection of intracellular bacteria, viruses & fungi
• 2) contact dermatitis
• 3) graft rejections
• 4) autoimmune diseases
• T Cell
• T Cell: a type of lymphocyte (white blood cell) produced or processed by the thymus
gland and actively participating in the immune response.
• T helper cells (TH cells) assist other white blood cells in immunologic processes,
including maturation of B cells into plasma cells and memory B cells, and activation of
cytotoxic T cells and macrophages. These cells are also known as CD4+ T cells because
they express the CD4 glycoprotein on their surfaces. Helper T cells become activated
when they are presented with peptide antigens by MHC class II molecules, which are
expressed on the surface of antigen-presenting cells (APCs). Once activated, they divide
rapidly and secrete small proteins called cytokines that regulate or assist in the active
immune response.
• Cytotoxic T cells (TC cells, CTLs, T-killer cells, killer T cells) destroy virus-infected cells
and tumor cells, and are also implicated in transplant rejection. These cells are also
known as CD8+ T cells since they express the CD8 glycoprotein at their surfaces. These
cells recognize their targets by binding to antigen associated with MHC class I
molecules, which are present on the surface of all nucleated cells
• Natural Killer T Cells
• B Cells vs Plasma Cells
• Plasma Cell: fully differentiated B cell that produces a single type of antibody.
• Naive B cells which have never been exposed to antigen on encountering them
differentiate into Memory Cells and plasma cells. Memory B cells recognize the antigens
epitopes and have longer life, while plasma cells are effector cells they secrete the
antibodies and have shorter life.
• B cells, also known as B lymphocytes, are a type of white blood cell of the lymphocyte
subtype. They function in the humoral immunity component of the adaptive immune
system by secreting antibodies. Additionally, B cells present antigens (they are also
classi ed as professional antigen-presenting cells (APCs)) and secrete cytokines.
• In mammals, B cells mature in the bone marrow, which is at the core of most bones. In
birds, B cells mature in the bursa of Fabricius, a lymphoid organ. (The "B" from B cells

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 comes from the name of this organ, where it was rst discovered by Chang and Glick,
and not from bone marrow as commonly believed).
• B cells, unlike the other two classes of lymphocytes, T cells and natural killer cells,
express B cell receptors (BCRs) on their cell membrane. BCRs allow the B cell to bind a
speci c antigen, against which it will initiate an antibody response.
• Torabinejad – Ag-Ab complexes & IgE mediated rxns can initiate changes in PA tissues; type
IV rxns may be involved in PA lesion progression
• Zanini et al 2017: JOE. Systematic Review. Pulp in ammation diagnosis from clinical to
in ammatory mediators.
• Review indicates that interleukin-8, matrix metalloproteinase 9, tumor necrosis factor-α,
and receptor for advanced glycation end products expression increase at both the gene
and protein levels during in ammation.
• Clinical irreversible pulpitis is related to speci c levels of in ammatory mediator
expression. The difference in expression between reversible and irreversible disease is
both quantitative and qualitative. On the basis of our analysis, in situ quanti cation of
in ammatory mediators may aid in the clinical distinction between reversible and
irreversible pulpitis.
• Clinical evaluation does not accurately diagnose pulp in ammation severity. Biomarker
quanti cation may aid in the distinction between reversible and irreversible pulpitis. IL-8,
MMP-9, TNF-α, and RAGE expression increased in the in amed dental pulp.
• Bergenholtz 1977: Historical paper: rst to show you don’t need bugs, just antigens (in this
case BSA) to stimulate in ammation (Same monkeys used in Fabricius and Moller)
• Torneck 1977: Lymphocytes and plasma cells found in early stages of pulpal in ammation,
whereas advanced in ammation was associated with the presence of polymorphonucleur
leukocytes and macrophages. (Sections of human pulp tissue taken from the region of a
carious exposure in four young patients each having a clinical history of spontaneous dental
pain were examined with the electron microscope. All the tissues examined exhibited a
generalized edema, and an in ltration with lymphocytes, plasma cells, polymorphonuclear
leukocytes and macrophages. Varying degree of lysis of pulp and in ammatory cells were
evident. The unmyelinated nerve axons of the pulp appeared to be least affected.
Extracellular lysosomes were present in many of the necrotic areas. Edematous vacuoles
were noted in two of the pulp specimens. In some of the sections these vacuoles appeared to
be responsible for a physical distortion of adjacent unmyelinated nerve axons. It was
postulated that such distortion may be a contributing factor to the pain of pulpitis. In another
of the pulp specimens, micro-organisms were found intracellularly and extracellularly.
Intracellularly they were present within the cytoplasm of polymorphonuclear leukocytes and
macrophages and exhibited evidence of lysis. Only two morphological forms, a gram positive
rod, and a gram positive coccus were identi ed.)
• KIM (JOE, 1990): Pulp is in low compliance system. The two main mechanisms in the
in ammatory response of pulp are circulation and sensory nerve. Excitation of A-delta has no
effect on the circulation but C bers excitation cause release of substance P which can cause
vasodilation and affect the pulp blood ow. Also vasculature of the pulp contains adrenergic
receptors that sympathetic excitation can alter the PBF.
• Pulver 1978:
• PA scar tissues have no B cells (B cells only in chronic in ammation)
• IgG mostly in PA lesions (cysts have equal amounts of IgA)
• Torabinejad, Bakland 1978: Just as pulpal responses include both cellular and humoral
components, so do those in the periapical tissues.

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• Torabinejad, Bakland 1980: PGs and cytokines compose additional humoral responses in
apical periodontitis. PGs are metabolic byproducts of arachidonic acid formed via the
cyclooxygenase pathways. They hold many functions, including gastrointestinal homeostasis,
promotion of in ammation, vasodilation, chemotaxis, pain, vascular permeability and bone
resorption.
• Stern 1981: Cysts and granulomas have same in ammatory cell composition
• Stern et al 1982:
• Lymphocytes are the predominant cell population in the development of AP
• In addition to lymphocytes, macrophages/monocytes, plasma cells and
polymorphonuclear leukocytes implicated in development of apical periodontitis.
• Dahlen, Fabricius, Moller 1982: Serum Ig present when teeth inoculated, so adaptive
immunity of whole body is involved (same as Bergenholtz monkeys)
• Nilsen et al 1984: Natural killer cells, dendritic cells present in PA lesions/implicated in
development of apical periodontitis. (check this one)
• Torabinejad, Kettering 1984: The purpose of present investigation was to compare the
concentrations of circulating immune complexes (ICs), IgG, IgM, and IgE, and the
complement component C. There is a statistically higher chance of nding elevated levels of
ICs, IgG, IgM, and C3 in patients with acute apical abscess when compared to patient without
an abscess. These levels show a signi cant decrease after dental treatment is performed to
eliminate the source of infection. (An increase in circulating immunoglobulins noted in
patients with acute abscesses)
• Svetcov et al: Found an increase in circulating immunoglobulins in patients experiencing a
Flare-up
• Nevins: found higher systemic levels of IgE in patients with asymptomatic necrotic teeth
• Kettering, Torabinejad 1986: Did NOT nd higher systemic levels of IgE in patients with
asymptomatic necrotic teeth.
• Torabinejad, Kettering 1985: All cells for humoral (B) and cell-mediated (T) immunity are in
PA lesions. More T cells than B cells.
• Jontell, Bergenholtz 1987: First paper showing pulp has its own surveillance system (MHC
II dentritic cells along vessels in stroma). No B cells in healthy pulp. Conclusion The dental
pulp under normal conditions is equipped with a variety of cells associated with the immune
defense system. The large majority of cells identi ed belonged to the lymphocyte line. It
was also shown that the dental pulp contains dendritic cells, which are antigen presenting
cells of lymphoid tissue, similar to Langerhans cells in the skin.
• Barhordar 1988: Pulp has T cells, indicating pulp has adaptive immune response capability
• Hahn 1989:
• Normal/reversible pulpitis = mainly T cells (some B cells)
• Irreversible pulpitis = increased #s of T and B cells,
• (Like Reeves/Stanley 1966 in ammatory cell in ltration doesn't happen until caries is
pretty deep, within 1mm) (problem is their terminology/nomenclature is not accurate
according to Dr. Shabahang)
• Stashenko, Yu 1989:
• Helper T cells (TH) predominate during early, active phase of lesion development
• Suppressor T cells (TS) are more numerous in chronic lesions.
• Safavi 1991:
• TNF (secreted by macrophages and activate osteoclasts) found in PA lesions
• McNicholas, Torabinejad, Bakland 1991: Symptomatic lesions have a signi cantly higher
concentration of PG activity than chronic lesions or unin amed tissues.
• Baumgartner 1991: Adaptive immunity (Ig) involved in PA pathology.

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• Jontell, Bergenholtz 1998: *Review: Immune defense mechanisms of the dental pulp.
(winter 2016 classic lit). Immune cells found in healthy pulp: T-lymphocytes, macrophages,
dendritic cells, lack of B-lymphocytes.
• Bergenholtz 1990: Available data seem to show that the pulp is well adapted to its
environment. It is capable of defending itself against microbial insults in a number of ways.
Dendritic cells may be associated with functions in immunosurveillance and antigen
presentation, blood vessels bring essential defense cells, macrophages with functions for
recognition, and presentation of antigens to T helper cells. Furthermore, there are pulpal
stroma cells that migrate to sites of injury, differentiate to repairing odontoblasts, and execute
dentinal repair.
• Kettering, Torabinejad 1993:
• No NK cells were found in human periapical scar tissue.
• NK cells were found in both tonsillar tissue and in all samples of the human periapical
lesion tissues.
• The presence of these cells indicates that NK cells may play a role in the pathogenesis
of human periapical lesions. (would have been nice if they tested healthy tissue)
• Torabinejad 1994: OOO. Review Mediators of acute and chronic periradicular lesions.
(Autumn 2016)
• Lim, Torabinejad, Kettering 1994:
• The absence of I -1 Beta in the sera of patients suggests that periradicular lesion
formation and I -1 Beta production is a local phenomenon.
• Thus, periradicular lesions may in fact have the desirable characteristic of protecting the
patients from the potentially more dangerous consequences of systemic bacteremia by
creating a buffer zone between the root canal pathogens and the rest of the body.
• Are T/B Cells required for PA development
• Waterman, Torabinejad et al 1998:
• The results of this study showed no difference in the size of developing
periradicular lesions between normal rats and immunosuppressed rats at the same
time interval.
• Reduction of circulating leukocytes may not signi cantly affect the development of
periradicular pathosis in rats.
• Fouad 1997: mice study.
• Formation of PA lesion is by non-speci c mechanisms (b/c SCID mice also produce
PA lesions).
• Pulpal and periapical pathosis were independent of the presence of functional T
and B cells in this model.
• Trowbridge, Emling 1997: In ammation review. Hypersensitivity Rxn: Type I - Immediate,
anaphylaxis, hives, bronchospasm, vomiting/diarrhea, Type II - antibody - dependent
cytotoxicity, autoimmune-like tissue destruction, Type III - immune complex formation,
pathology due to systemic deposits, Type IV - delayed type, cell-mediated immune memory
response, contact dermatitis.
• Stashenko et al 1998: Periapical in ammation, its etiology etc good review (see spring
2016). W/out host you cannot have periapical disease. Bacteria by themselves are harmless,
it’s the hosts response to the bacteria that’s the problem.
• Trowbridge 1999: JOE. Good Review. Immunological Aspects of Chronic In ammation and
Repair. (Autumn 2016).
• Bone Resorption Activity (Apical Periodontitis)
• Stashenko 1992:
• T cell rather than B cell may be involved in periapical lesion pathogenesis.

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 • T helper cells predominate in actively expanding lesions, whereas T suppressor
cells correlate with chronicity.
• The bone resorbing activity is not attributable to the direct action of LPS and other
bacterial components on bone. (Kakehashi rat model was used. T Helper cells
possess several mechanisms by which they can mediate bone lysis and lesion
expansion, including the production of IFN-γ, which helps to recruit and activate
macrophages.
• Macrophages elaborate bone resorptive cytokines IL-1α, IL-1β, TNF-α, and PGE2.
TH cells produce the resorptive cytokines TNF-β and IL-1α.
• Bone resorbing activity correlated quantitatively with lesion expansion and the
activity is not attributable to the direct action of LPS and other bacterial components
on bone. This activity is rather mediated by cytokines such as IL-1α, TNF-α, TNF-β,
and PGE2, which are mainly derived from T-cells and macrophages.
• Torabinejad & Kiger 1980; Dewhirst 1990:
• ~ 60% of IL 1b bone resorbing activity is mediated by the release of prostaglandins.
• Thus, bacterial-induced release of IL-1b and prostaglandins are destructive.
• Wang, Stashenko 1993: JOE.
• Most resorbing activity present in chronic periapical lesions is correlated with the
action of resorptive cytokines IL1β and TNFβ acting through both indomethacin
dependent and independent pathways. This activity may function to prevent
reparative bone formation in the face of ongoing infection within the root canal
system.
• Kobayashi et al 2000:
• Cytokines, including IL-1, TNFa, and leukotriene promote fusion of osteoclast
precursor cells and cause consequent bone resorption.
• (Bacteria activate immune cells —> immune cells release humoral factors including
IL-1b —> IL-1b promotes fusion and activation of osteoclasts precursor cells —>
Bone resorption occurs)
• Jiang 2002:
• LPS can cause activation of osteoclasts independent of osteoblasts and cause
bone resorption
• Yamada 2003:
• Osteoclasts are derived from hematopoietic precursor cells/monocyte and
macrophage lineage
• Coon et al 2007: The role of COX-2 in in ammatory bone resorption. LPS is a potent
inducer of bone resorption. COX-2 mediated PGE2 expression is required for LPS-
induced in ammatory bone resorption and maintaining the baseline level of RNAKL and
OPG expression. Commonly used endo obturation materials do not directly cause bone
resorption but may contribute to delayed healing if extruded into the periradicular tissue.
COX-2 inhibitors could be considered as possible pharmaceutical aids to accelerate
healing of bony lesion after endodontic treatments.
• Bone resorption in apical periodontitis results from immune responses stimulated by
bacterial and viral insults. Cytokines produced during in ammatory responses stimulate
the production of a molecule called RANKL, which ultimately results in destruction of
bone by osteoclasts.
• Silva et al: Bacteria and LPS may directly activate cells, including periapical T cells to
produce RANKL, thus stimulating osteoclasts to resorb bone.
• Stashenko: IL-1 beta is the most active bone resorptive cytokine, reported to have 15
times greater potency than IL-1 alpha.

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 • Kawashima & Stashenko 1998: Used P/E selectin knockout mice (P/E ko's lack rolling
adhesion of PMNs and macrophages to endothelium): Saw signi cantly more PA bone
destruction in ko's. Thus, phagocytic leukocytes (PMNs and/or macrophages) protect
against bacterial-induced PA bone destruction in mouse model of AP.
• Stashenko 1995: If give agent which enhances PMN activity (=PGG-glucan), see 40%
reduction in PA bone destruction. Suggests that PMNs are protective in mouse model of
AP.
• Pitts & Williams 1982: Endotoxins placed on dog pulp induce PA bone resorption
• Fukagawa et al 2002 showed the periapical bone lesion formation sequence. -RANK
surface receptor on Osteoclast precursor cells. -RANKL-RANK binding --> active
osteoclast --> bone resorption. -Osteoblast when active express and secrete OPG
osteoprotegerin which act as a decoy receptor and inhibits RANKL-RANK interaction
and thus bone resorption. -Hormones and cytokines exert their effects largely by
in uencing RANKL-RANK interaction directly or by changing the ratio of RANKL-OPG
reciprocal gene expression.
• Nair: IL-1a, TNF, PG from macrophages; rapid bone resorption 7-20 days, slow
thereafter. Main resorption from pro-in ammatory host-derived substances, minimal
effect from bacterial components which is called a dynamic encounter between root
canal infection and host response. Along with bone resorption, some apical parts of the
root will be lost as well. Often just visible only in microscopic sections.
•
• Substance P
• Howles, Hargreaves 2003: Substance P levels high in irreversible pulpitis (it has
immunomodulatory function)
• Tokuda 2004: Substance P is a pulpal immunomodulator (stimulated by LPS).
Substance P plays an important role in dental pulp in ammation
• Olgart et al 1977: First to ID Substance P in the pulp
• Rosa de sa et al 2003:
• Cytokine expression varies depending on intensity of in ammation.
• Background Information: Help T subtype 2 produce I 4 and I 6. I 4 stimulates the
production of IgE and suppresses IF y dependent macrophage functions. I 6 acts in
both innate and adaptive immune responses. LT has in ammatory effects, including
endothelial and leukocyte activation. Results: All lesions stained positively for I 4, I 6,
LT. There was positive correlation between the total in ammatory in ltrate and I 4 and
between the percentages of positive cells for I 6 and L alpha.
• Ledesma-Montes et al 2004: (Mast cells are present in PA lesions).
• Intro: The cells involved in the pathogenesis of in ammatory PA lesions are
macrophages, lymphocytes, plasma cells, broblasts, endothelial cells, and MCs. T
lymphocytes are the predominant cells in these lesions. MCs are commonly found
around capillaries and contain heparin, histamine, and proteoglycans. One of their
functions is related to Ig mediated anaphylactic reactions. MCs secrete leukotrienes,
prostaglandins, and many proin ammatory cytokines. The role of MCs in the
development of PA lesions is unclear. Conclusion: Mast cells are most abundant in
chronic in ammatory PA lesions and may play an important role in the development and
perpetuation of in ammation in addition to bone resorption.
• Hahn, Liewehr 2007: Review of Innate Immunity:
• IgG, IgA and IgM involved in response to caries. Dendritic cells gather at cavity preps,
showing innate response. TGF-B important in dentinogenesis and repair. TGF-B is
initially proin ammatory, then later anti-in ammatory.

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 • Innate immune response of dental pulp to caries. The dental pulp has the ability to
mount an innate response to caries, which can temporarily slow down bacterial
progression. Unfortunately, the location of the caries bacteria seems to prevent their
being killed or eliminated by phagocytes. Instead, persistent infection leads to the
activation of adaptive immunity and overwhelming in ammation, which causes edema
and increased intrapulpal pressure.
• Innate immunity is activated upon initial invasion of microbes. If the innate response is
unable to abolish the insult, adaptive immunity is elicited with cellular and speci c
antibody responses. Innate immunity is not antigen speci c but uses receptors to
recognize molecular patterns common to microbes to initiate bacterial phagocytosis.
Because of the unique anatomic location of caries bacteria, classic phagocytic killing
probably does not occur until the pulp is directly in contact with the caries front. Before
actual pulp exposure, the dental pulp beneath shallow caries is capable of mounting
innate immune responses to slow down the caries invasion.
• A transition to an adaptive immune response will take place in the dental pulp as the
caries front approaches the pulp.) Classic Lit Autumn 2016
• Hahn, Liewehr 2007: Review of Adaptive Immunity:
• IL-10 is the MOST ANTI-INFLAMMATORY cytokine known. Stress-induced sympathetic
vasoconstriction may decrease pulpal pain.
• Update on the adaptive immune responses of the dental pulp. Recent advances in
immunology have disclosed the enormous complexity of the immune regulatory system.
The dental pulp is equipped to mount adaptive immune responses to caries, which
include at least antigen-presenting cells, lymphocytes, mast cells and their cytokines,
and chemokines.
• Khan, Hargreaves 2008: Ca(OH)2 leads to substantial reduction in detectable levels of
endogenous in ammatory mediators
• Staquet 2008: Odontoblasts attract dendritic cells better than broblasts (APC’s to periphery
of pulp)
• Baumgartner et al 2009: Discussion: Epstein-Barr Virus is present in signi cantly higher
frequencies in irreversible pulpitis and apical periodontitis.There was no apparent association
of human cytomegalovirus, Herpes simplex virus, or Varicella zoster virus to endodontic
disease. The presence of EBV is not a predictor for the incidence of pain. EBV are found in
many but not all patients with irreversible pulpitis and apical periodontitis. Other
microorganisms may serve as cofactors of disease. Herpesvirus infected immune cells may
release cytokines that could lead to in ammation and exacerbation of symptoms including
pain. Bottom line: EBV, but not HCMV, HS 1, or VZV, may be associated with irreversible
pulpitis and apical periodontitis.
• Byers & Taylor: Innervated teeth have less pulp necrosis and PA destruction than
denervated
• Akamine 1994: PMNs and macrophages are the rst cells to respond to pulpal in ammation
• Turabelidze, Dipietro 2012: In ammation and Wound Healing Review. Endo Topics 2012.
(Spring 2016)
• Immediately following injury, innate immune cells at the site of injury initiate an
in ammatory response
• The rst in ammatory cells to arrive to the site of injury are neutrophils. In the early
response, the main function of neutrophils is considered to be prevention of infection by
killing of microbes. Neutrophils are highly phagocytic, and are important to
decontamination of the wound.

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 • Mast cells are part of the resident innate immune population. They are thought to be
critical for the maintenance of tissue integrity and function. Once an injury occurs, mast
cells degranulate and release a variety of pre-stored mediators from their granules
• Macrophages have been quoted as “essential,” “indispensable,” and “most important to
a successful outcome of wound healing,” as these cells have been shown to produce
growth factors that stimulate angiogenesis and brogenesis. Macrophages, which arrive
in the wound bed just after the neutrophils and just prior to neutrophil disappearance, are
capable of inducing neutrophil apoptosis in vitro. Further, neutrophil- derived fragments
have been found in phagosomes inside of macrophages. It seems that one of the most
important functions of macrophages to wound healing is to accelerate the regression of
the in ammatory response via the elimination of neutrophils.
• T lymphocytes arrive in the wound after neutrophils and macrophages at about day 7
after injury. Their presence is at its peak during the late proliferative/ early remodeling
phase. While the function of T lymphocytes in wounds is not well understood, a reduced
level of T cells has been shown to impair healing outcomes.
• Pro-in ammatory cytokines play a critical role in wound healing. Neutrophils and
macrophages are major producers of pro-in ammatory cytokines. These include
interleukin-la (IL-1a), IL-1b, IL-6, IL-8, and tumor necrosis factor-a (TNF-a). IL-1, IL-6,
and TNF-a are up-regulated during the in ammatory phase of wound healing. Together,
cytokines prevent infection, stimulate cellular recruitment, and activate immune cells. In
addition, cytokines regulate the ability of broblasts and epithelial cells to remodel
damaged tissue.
• Chemokines (chemotactic cytokines) are small heparin-binding proteins that direct the
movement of circulating leukocytes to sites of in ammation or injury. They are active
participants in the wound healing process because they stimulate the migration of
multiple cell types in the wound site especially in ammatory cells
• Holland, Botero 2014: Pulp Biology review. Endo Topics 2014. (Spring 2016)
• Toll-like Receptors
• Martinho et al 2014; Sousa et al 2014: Endodontic pathogens activate toll-like receptor
4 on macrophages leading to the expression of IL-1beta, tumor necrosis factor, IL-6, and
IL-10.
• Mutoh, Watanabe 2007: Pulpal TLR2 increases during early infection (LTA on gram +
cells), then later TLR4 upregulated (LPS on gram - cells)
• Qin et al 2015: TNF-alpha induces the proliferation of DPSCs
• Gama et al 2016: Conclusion: The results suggest an important role of HAART in maintaining
the immune capacity in CAP for HI infected individuals, demonstrating a similar cellular
pro le and expression of immunologic markers when compared with non– HIV infected
patients. Bottom Line: HI infected patients undergoing HAART treatment will most like
present and heal the same way as n HIV infected patients.
• Cintra et al 2016: Discussion: Increased serum levels of proin ammatory cytokines in rats
with AP con rm the hypothesis that endodontic infections adversely affect systemic health
similar to periodontal diseases. Bottom line: Chronic local in ammation, e.g. periodontal and
periapical, might alter the balance of the level of serum in ammatory mediators and affect on
the systemic health.
• Faustino et al 2016: Conclusion: MM 2 and MM 9 are highly expressed in periapical
lesions of endodontic origin, with MM 2 being more expressed in periapical granulomas and
symptomatic cases. Acute and active phases of periapical lesions from endodontic origin
seem to present higher levels of MM 2 and MM 9.
• What is the role of neuropeptides?

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 • Cause neurogenic in ammation, regulate pulpal blood ow
• Byers – demonstrated “sprouting” of CGRP nerve bers after dental injury
• Caviedes-Bucheli - SP, CGRP, NKA, NPY, VIP found in pulp; neuropeptides regulate
pulpal blood ow and involved in development of neurogenic in ammation/pain;
NPY(sympathetic/vasoconstrictive) & VIP(parasympathetic/vasodilation)
• Diogenes: Protective role? Check
• Who studied LPS and what is its role in PA pathology?
• Schein & Schilder – pulpless teeth ↑endotoxin (LPS) than vital pulps; symptomatic
teeth and those with PARL have ↑LPS than asymptomatic teeth
• Martino - chemomechanical prep reduced bacterial load 99.8%, but only 60% LPS, if
remove smear layer than 98% reduction in LPS
• Schonfeld - LPS found outside canal...can account for PA dz even if viable bacteria not
present
• Martinho - 1° infect had 2x more endotoxin vs 2°; more endotoxin = more pain & bigger
PARLs
• Horiba- LPS can penetrate up to 800 um into tubules but usually only 3-400 -- why
removing smear layer is important before CaOH ll
• Diogenes- LPS can sensitize TRPV1 via TLR-4 receptors in TG neurons causing
nociceptive sensitization and in ammation
• What are cytokines and which are involved in bone resorption? Any other factors involved?
• Polypeptide products of immune cells. They modify behavior of other cells, produce
systemic effects & act as growth factors
• Stashenko (rat studies) – bone resorbing activity is due to cytokines rather than LPS
Cytokine involved in bone resorption alone or in synergistic combination: IL-1beta, TNF
alpha & PGE2;
• Wang & Stashenko - OAF: IL-1a, IL-1B, TNFa, TNFB, IL-6, IL-11 (IL-1B (60%) TNFB
most responsible)
• Torabinejad - arachidonic metabolites and the complement system play an important
role in bone resorption
• Discuss the complement cascade.
• C’ consists of some 20 interactive plasma and cell membrane proteins. Once activated
• 1. Mediate vascular responses (histamine release via C3a and C5a anaphylatoxins)
• 2. Recruiting phagocytic leukocytes
• 3. Opsonizing targets of phagocytic cells (C3b)
• 4. Directly damaging target cells (C5-9 MAC)
• Most important step is cleavage of C3.
• Classical pathway is activated by Ab coated targets or Ag-Ab complexes (IgM, IgG)
• Alternate pathway is activated by LPS, aggregated IgM or IgG, Ag-IgA complexes,
plasmin
• Serene & Vesely: GP activates C3 complement. May explain why over-extension with
GP may induce bone resorption in some pts. Also recall Sjogren (1995) small particles of
GP induce intense in ammatory response.

• Which immune components are found in the dental pulp?

• Jontell – T & B lymphocytes; Plasma cells; Macrophages; Dendritic cells; Cytokines &
Prostaglandins
• Farnoush: Mast Cells
• Jontell, Bergenholtz 1985: 1st to show Dendritic cells in the pulp

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 • Pulver 1978: found B cells in chronically in amed pulp, none found in scar tissue, also
showed IgG is present
• Barhordar 1988: T cells in pulp
• Hahn 1989: mainly T cells in normal/reversible pulpitis with some B cells in
• Olgart; Hargreaves: Substance P
• Uddman: CGRP
• Are antibodes found in the pulp?
• Nakanishi – levels of IgG, IgA, IgM, elastase & PGE2 were higher in in amed pulps
than in normal pulps
• Which immune components are found in the periapical tissues?
• Kettering, Torabinejad: NK Cells
• Nilsen – Lymphocytes, Macrophages, plasma cells Mast cells, NK cells
• Schein – Lymphocytes, macrophages, PMNs, plasma cells
• Pulver – Igs (see below)
• Stashenko – Lymphocytes (T,B,NK cells), macrophages, PMNs, plasma cells,
eosinophils, mast cells, antibodies (IgG, IgA, IgE, IgM)
• Ledesma-Montes et al 2004: (Mast cells are present in PA lesions).
• Safavi: LPS
• Which antibodies predominate in a periapical lesion?
• Pulver – IgG (70%) > IgA (14%) > IgE (10%) > IgM (4%) for cysts and granulomas; IgE
cells had degranulated mast cells nearby
• Discuss immune system
• Innate immune system provides immediate, but non-speci c response (Neutrophils,
macrophages, DCs).
• If pathogens successfully evade innate response, the adaptive immune system is
activated to improve recognition of pathogens (T and B cells – lymphocytes)
Antigen (Bacteria/virus)!Ag presenting cell!IL 12!Th1!cell mediated (PMN,
macrophages) !CD4+ T cell!IL 4!Th2!humoral immunity (B cells!Plasma
cells!Abs)
• Review: 524-529 Pathways
• Rufus, About et al 2016: JOE. The purpose was to investigate the possible role of C3a,
another complement fragment, in the early steps of dentin pulp regeneration. These results
provide the rst demonstration of C3aR expression in the dental pulp and demonstrate that
C3a is involved in increasing DPSCs and broblast proliferation, in mobilizing DPSCs, and in
speci cally guiding broblast recruitment. This provides an additional link to the tight
correlation between in ammation and tissue regeneration.
• Torabinejad, Bakland 1978: Just as pulpal responses include both cellular and humoral
components, so do those in the periapical tissues.
• Stern et al: Lymphocytes are the predominant cell population in the development of apical
periodontitis.
• Torabinejad, Kettering: T cells > B cells
• Immunoglobulins, PGs, and cytokines are involved in apical periodontitis, just as in pulp
in ammation. Immunoglobulins present in periapical lesions include IgG, IgA, IgE and IgM
with IgG predominating (Pulver et al).
• Stashenko et al: cytokines, including IL-1 beta and IL-1 alpha are produced by in ammatory
cells in apical periodontitis.
• Sabeti et al: viral infections promote cytokine production in periapical lesions.

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 Trauma
• Type of injury determines the rate of pulp necrosis. Highest is intrusion w/ a mature apex.
• Infraction: incomplete fracture of enamel with no loss of tooth structure. No tenderness, no
nding in radiographs, no need to follow up otherwise associated with luxation, 6-8 w follow
• Enamel fracture: loss of tooth structure, no pulp exposure, sensitive to cold, no
tenderness to percussion, no mobility, bonding, 6-8 weeks follow up.
• Enamel-dentin fracture: normal mobility, sensitivity, no percussion, use liner like
biodentin, Brasslerr, MTA
• Enamel, dentin, pulp fracture: In patients with immature apex try vital pulp therapy DPC
or pulpotomy. In mature RCT, 6-8 w up to 1 y follow.
• Crown-root fracture with pulp exposure: fragment removal, RCT or vital pulp therapy
• Lateral extrusion, tooth displaced labially or lingually: Metallic sound percussion, vitality
depends on the severity (displacement of tooth from its original position with out avulsion)

• AAE Trauma Guidelines: Classi cation of fractures

• Crown Fractures:
• Uncomplicated: pulp is not exposed
• Complicated: pulp is exposed
• Crown/Root Fractures
• involve enamel, dentin and cementum
• extend subgingivally
• may have pulp exposure
• Root Fractures
• may be in apical, middle or cervical thirds
• coronal portion may be displaced
• Alveolar Fractures
• may involve one or more teeth
• mobility and displacement common
• AAE Trauma Guidelines: Luxation Type Injuries
• Concussion Injuries: present with percussion tenderness but lack displacement or
mobility. Pulp sensibility testing is usually normal.
• Subluxation injuries: Present with percussion tenderness and mobility but lack
displacement. Pulp sensibility testing may initially be non-responsive, indicative of
transient pulpal damage, but is typically normal.
• Extrusive Luxation: Injuries present with outward or incisal displacement and percussion
tenderness. Pulp sensitivity testing is often non-responsive. Mobility of the extruded
tooth is often noted.
• Lateral Luxation: Injuries present with lateral displacement, oftentimes associated with a
fracture of the facial cortical bone that can be palpable. The tooth may appear immobile
or locked in bone and is typically percussion tender. Pulp sensitivity testing is often non-
responsive.
• Intrusive luxation: injuries that present with displacement of the tooth into alveolar bone,
oftentimes associated with palpable fracture of the alveolar process. The tooth may
appear immobile or locked and is typically percussion tender. Pulp sensitivity testing is
often non-responsive.
• Andreasen: Probability of Developing pulpal necrosis following luxation injuries.
• Concussion: mature teeth —> 4%; 0% in immature teeth
• Subluxation: mature teeth —>15%; 0% in immature teeth
• Extrusion: mature teeth —> 55%; 9% in immature teeth

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 • Lateral Luxation: mature teeth —> 77%; 9% in immature teeth
• Intrusion: mature teeth —> 100%; 62% in immature teeth
• Prognosis of Traumatically Injured Teeth:
According to Levin 2013, outcomes for traumatically injured teeth are a function of the extent and type of
injury, the stage of root development and appropriate treatment at the time of injury.

Injury Teeth maintain vitality (%) Reference

Crown Fracture 94% Ravn 1981
Root Fracture 78% Andreasen et al 1989
Concussion 97% Andreasen F, Pedersen 1985
Subluxation 94% Andreasen F, Pedersen 1985
Extrusive Luxation 74% Andreasen F, Pedersen 1985
Lateral Luxation 42% Andreasen F, Pedersen 1985
Intrusive Luxation 15% Andreasen F, Pedersen 1985
Avulsion (mature tooth) 0 Kling, Cvek et al 1986
Avulsion (immature tooth) 18% Kling, Cvek et al 1986

• Bergenholtz 1974: Looked at bacteria from necrotic pulp of traumatized teeth. Primary
endodontic infections resulting from trauma are mixed infections with anaerobic micro-
organisms dominating. Proposed that microcracks caused by traumatic injuries allow ingress
of bacteria to infect an already compromised, in amed pulp without direct exposure. 64% of
the time, traumatized teeth with necrotic pulps have a mixed ora with anaerobes
predominating. Trauma led to an aseptic necrosis in the other teeth.
• AAE Guidelines: In a tooth with a mature apex, the AAE guidelines consider a lack of
response to pulp sensitivity testing 3 months post trauma as an indication of pulpal necrosis,
and they advise that pulpal necrosis should be diagnosed by a least two signs or symptoms.
• AAE Guidelines: Splints. Exclusively advise the use of exible splints when splinting is
indicated, with wire diameter not to exceed 0.016 inches or 0.4mm. Also advise short
duration.
• Hecova et al 2010: Retrospective study. 889 injured teeth. Reported a higher incidence of
pulpal necrosis following traumatic injuries of mature rather than immature teeth.

• Treatment Protocols for traumatic dental injuries: Splinting & F/U

Injury Splinting Time Follow-up Times
Crown Fractures N/A 6-8 w, 1 y
Crown/Root Fractures NA 6-8 w, 1 y

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Root Fractures 4 w if apical 3rd 4 w, 6-8 w, 6 m 1 yr,
4 w if middle 3rd yearly for 5 yr
4 months if coronal 3rd
Alveolar Fracture 4w 4 w, 6-8 w, 4 m, 6 m,
1y, yearly for 5 yrs
Concussion NA 2w, 4w, 6-8w, 6m,
1 yr, yearly for 5y
Subluxation 2w 2w, 4w, 6-8w, 6m,
1 yr, yearly for 5y
Extrusive Luxation 2w 2w, 4w, 6-8w, 6m,
1 yr, yearly for 5y
Lateral Luxation 2 w; if extensive - 4 w 2w, 4w, 6-8w, 6m,
1 yr, yearly for 5y
Intrusive Luxation 2 w; if extensive 4w 2w, 4w, 6-8w, 6m,
1 yr, yearly for 5y
Avulsed tooth, mature apex 1-2w 2w, 4w, 6-8w, 6m,
1 yr, yearly for 5y
Avulsed tooth, imm apex 1-2w; if extraoral dry 2w, 4w, 6-8w, 6m,
time > 60min —> 4w 1 yr, yearly for 5y

• Treatment Protocols: Fractures

• Crown Fracture: Treat with appropriate restorative materials or rebond fragments. If a de nitive
restorative material cannot be placed, cover exposed dentin with GI or bonded resin. In
complicated fractures; it is important to preserve pulp vitality with pulp capping or partial
pulpotomy using CH or MTA.
• Crown/Root Fracture: Management depends on extent of injury. W/out pulp exposure, the
fractured segment can be removed with or wi/out a gingivectomy to restore. If pulp exposure is
present, immature teeth should be managed with a partial pulpotomy to attempt to maintain
vitality of the root pulp. Mature teeth should be treated with root canal therapy and restored
appropriately. More extensive crown/root fractures amy require orthodontic or surgical extrusion
for restoration or may even require ext.
• Root Fractures: may present with full loss of coronal segment, in which case they should be
managed as avulsive injuries. Repositioning of a displaced coronal segment should occur as
soon as possible and following radiographic con rmation of correct positioning, a exible splint
should be placed for 4 wks or as long as 4 months for cervically located root fractures. If pulpal
necrosis develops root canal therapy should be completed on the coronal segment only to the
level of the fracture with the use of CH as an intracanal medicament. (Cvek et al 2001: reported
markedly improved success rates when RCT was completed only to level of fracture than
beyond).
• Alveolar Fracture: should be management by repositioning and stabilization with a exible splint
for 4 wks.
• Treatment Protocols: Luxation-Type Injuries
• Concussion Injuries: do not require immediate tx
• subluxation injuries: may be splinted for up to 2w for pt comfort
• extrusive luxation injuries: should be repositioned immediately and splinted for 2w

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 • lateral luxation injuries: should be repositioned, which may involve disengagement from
a bony lock, followed by splinting for 2 wks or up to 4 wks for more extensive
displacement
• intrusive luxation injuries: are managed differently based on the stage of root
development and extent of intrusion.
• For luxation injuries the pulpal responsive to sensitivity and vitality testing should be
monitored for 3 months before a de nitive pulpal diagnosis and decision to initiate RCT,
unless pulpal necrosis is con rmed sooner with at least two signs or symptoms. Root
canal therapy is the treatment of choice for mature teeth with pulpal necrosis, whereas
pulp revascularization therapy or apexi cation should be considered for immature teeth.
Intrusive luxation injuries of mature teeth are likely to result in pulpal necrosis and RCT
should be initiated within 2 wks or injury with 4 wks of intracanal CH following
pulpectomy. Immature teeth with intrusive luxation injuries may escape pulpal necrosis
and should be monitored the same as other luxation-type injuries. There is currently no
strong evidence to support orthodontic versus surgical repositioning of intrusively luxated
teeth that do not spontaneously re-erupt. Clinical and radiographic followups for all
luxation injuries are recommended at 2w, 4w, 6-8w, 6m, 1 yr and yearly thereafter for 5
yrs.
• AAE Trauma Guidelines: Avulsion:
• The goal of tx of avulsed teeth is to maintain the PDL, as most complications result from
injury to this structure.
• Always replant teeth, even if poor prognosis, in order to maintain bone volume in area of
avulsion and improve feasibility of dental implant in the future
• Ideal Storage Media: HBSS, Saline, Milk
• Systemic Antibiotics are recommended.
• Speci c Tx recommendations vary according to status of root maturation, extraoral dry time
and extraoral storage media.
• Andreasen et al: the prognosis of avulsed teeth is highly dependent on status of root
maturation, time to replantation and extra-oral storage media.
• Mature Teeth Already Replanted
• Leave in place and splint 1-2 wks
• RCT w/in 7 - 10 d
• Mature Teeth Proper extraoral storage media (less than 60 min)
• reposition and splint 1-2 w
• RCT w/in 7-10 days
• Mature teeth improper storage media (greater than 60 min)
• sodium uoride soak prior to repositioning and splint 1-2w
• extra-oral RCT or within 7 - 10 days
• Replacement resorption is considered an inevitable complication with prolonged
extraoral dry time b/c of PDL cell death and decoronation according to the protocol
proposed by Malmgren is advised once the tooth is greater than 1mm
infrapositioned.
• Immature teeth already replanted
• leave in place and splint 1-2wks
• watch for pulpal necrosis. If necrotic —> REGEN or Apexi cation
• Kling, Cvek et al 1986 found an 18% incidence of revascularization following
avulsion injuries in immature teeth with apical diameter > 1mm
• Immature teeth proper extra-oral storage media (less than 60min)
• doxycycline soak prior to repositioning and splint 2 w (Cvek)

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 • watch for pulpal necrosis. If necrotic —> REGEN or Apexi cation
• Immature teeth improper extraoral storage media
• extra-oral RCT
• reposition and splint 4 w
• AAE Trauma Guidelines: Intrusive Luxations
• Immature Teeth < 7 mm intrusion
• allow spontaneous re-eruption
• if none within 3w, ortho repositioning
• Immature Teeth > 7 mm intrusion
• Surgical/orthodontic repositioning
• Mature teeth < 3mm intrusion
• allow spontaneous re-eruption
• if none within 3 w, surgical or orthodontic repositioning
• Mature teeth 3 to 7 mm
• surgical or ortho repositioning
• Mature teeth > 7mm intrusion
• Surgical repositioning and splint 2-4 wk
• AAE Trauma Guidelines: Post-op Instructions
• Soft diet 1-2 weeks
• Good oral hygiene with use of a soft-bristled tooth brush
• 0.12% CHX twice daily for 2 wks following luxation type injuries and avulsions
• contact sports should be avoided for 2 wks following avulsions
• on resuming contact sports mouth guards should be worn.
• Bakland, Andreasen 2004: Proposed division of traumatic dental injuries.
• Acute Priority Injuries that require treatment within hours: root fractures, alveolar
fractures, lateral luxation, extrusive luxation, avulsions.
• Subacute priority injuries that treatment can be delayed for several hours: complicated
crown fractures, concussions, subluxations, intrusions.
• Delayed priority where treatment can be delayed beyond 24hrs: uncomplicated crown
fractures.
• Andreasen et al 2006: Predictors for healing complications in the permanent dentition after
dental trauma. Predictors for pulpal healing/pulpal necrosis:
• size of apical foramen (bigger better)
• length of pulp that must undergo revascularization (shorter better).
• PDL can be damaged during trauma and loses ability to protects root from osteoclasts
• Most signi cant predictor for root resorption appears to be type and severity of luxation
injury, extra oral time, storage medium, root development stage etc.
• AAE Guidelines: Advise multiple angled radiographs
• Andreasen: 2 PAs, 1 Steep Occlusal. This will detect > 90% of fractures
• For pulp vitality testing —> EPT is preferred to cold as it allows more accurate monitoring
over time.
• Steelman 2013: JOE. Rapid Physical Assessment of the injured child.
• Primary Survey: Airway, Breathing, Circulation, Disability, Exposure
• Secondary Survey: Medical Hx, Last meal, events & environment leading to injury
• Focused Dental Exam: clinical examination, radiographic examination
• Ozcelik et al 2000: Histo analysis. Showed intramyelin edema, axonal swelling and partial
loss of the myelin sheath in the neurons of pulp exposed in complicated coronal fractures,
supporting the theory of neuronal injury following trauma.

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 • Andreasen 1989: Without bacterial ingress, spontaneous healing of the pulp can occur
(Kakehashi et al: pulp in ammation + bacteria = apical periodontitis)
• Andreasen FM: Dent Trauma. Tissue that has undergone coagulation necrosis ( pulp
structure still present, but no blood supply) is receptive to revascularization. Disruption of
blood supply —> coagulation necrosis (non-infected) —> Revascularization.
• Andreasen FM 1989: Pulpal healing patterns were studied in a clinical material of 637
luxated and 95 root-fractured permanent incisors followed routinely for up to 11 years. It was
found that pulpal healing patterns could generally be divided into 3 groups according to the
degree of injury sustained by the pulp: little, moderate or severe. Thus after luxation injuries,
pulp survival could be without radiographic change (PS), with pulp canal obliteration (PCO) or
nonhealing (pulp necrosis (PN]. After root fracture, similar healing patterns could be
observed: healing by hard tissue union of fragments (HT), by connective tissue union of
fragments (CT) or by nonunion due to interposition of granulation tissue between fragments
(GT) resulting from PN of the coronal fragment. In both trauma situations, healing or
nonhealing could be determined by type of luxation injury, stage of root development and type
of xation used (forceful application of orthodontic bands vs. passively applied acid-etch
xation). Pulpal healing complications (PN or GT) were based on clinical ndings (coronal
discoloration, loss of pulpal sensibility) and radiographic ndings (resorption processes of the
lamina dura at the root apex or at the level of the root fracture). However, in both injury
groups the same changes could also be seen to be intermediate steps in the pulpal healing
process. Based on ndings from these studies, hypotheses for the mechanics of pulpal
healing are proposed as well as guidelines for acute and later treatment of dental luxations,
root fractures and the diagnosis of healing complications.
• Andreasen: Most common dental injuries
• Primary dentition: Luxation
• Permanent: Crown fracture
• Trauma to orofacial region is a common nding in young patients.
• Epidemiology
• Andersson 2013: Epidemiology of dental injuries. 5% of bodily injuries in orofacial
region —> 1-3% incidence of traumatic dental injuries —> 20% prevalence in permanent
dentition, 30% prevalence in primary dentition. Factors associated with increased risk of
traumatic dental injury: <10 yrs of age, male sex, risk-related behavior. (etiology by age.
preschool: Falls, School Age: Sports incidents, Adolescents/Young Adults: Assaults,
traf c accidents, alcohol)
• Glendor 2008: Traumatic Dental Injuries: oral injuries most frequent during rst 10 years
of life, gradually decreasing with age and rare after 30. Mostly involve anterior teeth.
Multiple dental trauma episodes range fro 8-45%.
• Pulp Canal Obliteration/Calci c Metamorphosis
• Amir, Gutmann, Witherspoon 2001: No need to do endo just b/c calci c
metamorphosis. Only 1-16% of CM teeth develop necrosis
• McCabe, Dummer 2012: IEJ.
• Summary: Pulp canal obliteration (PCO) occurs commonly following traumatic
injuries to teeth. Approximately 4-24% of traumatized teeth develop varying degrees
of pulpal obliteration that is characterized by the apparent loss of the pulp space
radiographically and a yellow discoloration of the clinical crown. These teeth
provide an endodontic treatment challenge; the critical management decision being
whether to treat these teeth endodontically immediately upon detection of the pulpal
obliteration or to wait until symptoms or signs of pulp and or periapical disease
occur. The inevitable lack of responses to normal sensibility tests and the crown

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 discoloration add uncertainty to the management; however, only approximately
7-27% of teeth with PCO will develop pulp necrosis with radiographic signs of
periapical disease. Root canal treatment of teeth with pulpal obliteration is often
challenging. This article discusses the various management approaches and
highlights treatment strategies for overcoming potential complications.
• KEY LEARNING POINTS: Up to 25% of traumatized anterior teeth can develop
pulp canal obliteration; Discoloration is a common clinical nding in teeth with pulp
canal obliteration; Up to 75% of teeth with pulp canal obliterations are symptom-free
and require no treatment other than radiographic monitoring; Routine pulp
sensibility tests are unreliable in the presence of pulp canal obliteration; Teeth with
pulp canal obliteration in need of root canal treatment pose particular diagnostic
and treatment challenges.
• Robersertson, Andreasen, Bergenhotz, Andreasen JO 1996: Advised against
prophylactic endodontic treatment of teeth displaying PCO due to the relatively low
lifetime risk of pulpal necrosis. There was no higher frequency of PN in obliterated teeth
subjected to caries, new trauma, orthodontic treatment, or complete crown coverage
than intact teeth. 82 teeth w/ 7-22 y followup.
• Walton: If pulp canal completely obliterated: Canal present histologically, although
absent radiographically
• Andreasen 1972: There is always a persisting narrow pulp canal, even in calci ed
traumatic teeth.
• Andreasen: 22% of traumatized teeth undergo calci c metamorphosis (Pulp canal
obliteration). Of these 22%, only 8.5% developed pulp necrosis which need RCT.
• Andreasen & Pederson 1985: described PCO as occurring mainly in teeth with open
apices and may be a result of revascularization. PCO itself does not necessitate dental
tx as only 7% of teeth exibiting PCO developed pulp necrosis.
• Lundberg & Cvek 1980: described PCO tissues as osteoid with little in ammation or
bacterial contamination.
• Jacobson & Kerekes 1977: found PCO in as many as 40% of luxated teeth and as few
as 8% of root-fractured teeth.
• Andreasen FM et al 1987: PCO dependent upon injury. Severe pulpal injury will result
in PN, while moderate injury could result in PCO. PCO dependent upon stage of root
development. Higher frequency of PCO among luxated immature teeth than in close
apices. PCO seen more frequently in rigid xation devices. PCO generally seen after 1
year, PN after 3 months. When evaluating a traumatized tooth, it is important to
consider the severity of injury, the root development, the age of the patient (<11y/o) to
determine the probable survival of the tooth.
• Pulp Testing/Assessment
• Andreasen et al 2012: Sensibility tests will be altered w/ trauma, therefore need at least
2 signs or symptoms to diagnosis necrotic pulp. Regular follow up required to make a
pulp diagnosis.
• Levin 2013:
• Recommended pulp sensitivity testing immediately post trauma and again at 2
weeks, 4 weeks, 6-8 weeks, 6 months, 1 year.
• Thermal testing is considered the gold standard among available tests. EPT should
be considered a secondary test, as its accuracy depends on the circumstances.
• Further suggests that periradicular testing should include an assessment of
mobility, percussion and palpation testing.

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 • Single tooth mobility can assess the degree of dislodgment of the tooth from the
socket or a cervically located root fracture, whereas mobility of several teeth in
unison is often indicative of alveolar fracture.
• Percussion sensitivity in the acute presentation of trauma can indicate recent
attachment damage, whereas protracted or new percussion sensitivity at follow-up
oftentimes indicates infection or the presence of an alveolar fracture.
• A metallic tone on percussion can indicate that a tooth is locked in bone related to
lateral or intrusive luxation injury or, in late stages of healing, that ankylosis has
occurred.
• Palpation allows one to feel alveolar fractures or the dislocation of a luxation injury.
Palpation sensitivity at follow up can indicate infection or the presence of a
nonhealing alveolar fracture.
• If an alveolar fracture is suspected consider a pano.
• Ball et al 2013: Suggest CBCT may be bene cial for traumatic dental injuries as this
may provide a more reliable assessment of the extent of the injury.
• Peters, Baumgartner et al & Gopikrishna et al: (studies not necessarily trauma
related) EPT is considered most useful to con rm suspected necrosis. No EPT response
is highly predictive of necrotic pulp.
• Bhaskar, Rappaport 1973: Found vital tissue in traumatized teeth non-responsive to
traditional pulp sensitivity testing and advised a delay in diagnosis when relying on these
methods alone due to proposed transient sensory de ciencies. EPT/cold/heat testing are
unreliable following trauma. Trauma may damage nerve supply without altering blood
supply. Vitality tests give information about pulpal nerve status only and do not
evaluate pulpal blood supply.
• Fulling, Andreasen 1976: Found that EPT was not accurate in immature teeth due to
late development of the responsive A delta nerve bers.
• Gopikrishna et al 2007: Demonstrated that pulse oximetery is an effective method for
evaluating pulp vitality as compared to thermal testing and EPT. May be dif cult
clinically.
• Trope et al 2001: Laser Doppler owmeter for diagnosis of revascularization of
reimplanted dog teeth. Fairly accurate, but not clinically practical.
• Lauridsen et al: found in combined luxation–crown fracture injuries that beside the
already known variables for predicting PN after luxation injuries (ie, luxation diagnosis
and stage of root development), reaction to electrical pulp testing (EPT) at the time of
injury played an important role. Thus, teeth that did not respond to EPT had a
signi cantly greater risk of developing PN in the rst year after injury. (Combo injuries
have higher chance of PN)
• Root Fractures
• Kim et al 2016: (JOE) Within the limitations of this study, intra-alveolar root fractures
showed satisfactory healing outcomes after endodontic treatment with MTA. MTA could
be considered to be a suitable lling material for the endodontic treatment of horizontal
intra-alveolar root fractures. Obturated coronal segment with MTA (to level of horizontal
fracture.
• Andreasen, Hjorting-Hansen 1967: Examined outcomes of 50 horizontal intra-alveolar
root fractures.
• Immediate reposition and xation are the two most important features in the
treatment of horizontal root fractures.
• The apical fragment typically remains vital.

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 • Types of healing following root fracture: calci ed tissue, connective tissue (canal
obliteration common), nonhealing/granulation (pulpal necrosis), combination of
calci ed and connective tissue.
• Andreasen, Ahrensburg, Tsilingaridis 2012: Root Fractures: the in uence of type of
healing and location of fracture on tooth survival rates 492 cases.
• Apically located fractures have a much better prognosis and survival rate compared
to coronally located fractures.
• Teeth with hard tissue healing showed the best survival rate followed by connective
tissue healing.
• The present study suggests that identi cation of the healing modality should be
awaited before any de nitive treatment is planned because even cervical fractures
seem to have a good long-term prognosis if hard tissue healing occurs.
• Andreasen, Ahrensburg, Tsilingaridis 2012: 44 teeth. Mobility changes of a root-
fractured tooth appeared to re ect the healing events taking place between the fracture
surfaces. The clinical relevance is that augmented mobility immediately after splint
removal will gradually be diminished. In case of hard tissue healing over time, they
become as rm as neighboring non-fractured teeth. ( better prognosis of horizontally
fractured teeth healed with hard tissue deposition)
• Hartness 1975: Case report. A fractured root does not necessarily require treatment.
Treatment is dictated by the location of the fracture, the amount of dislocation and
mobility of the fragment, the condition of the pulp and the sequence of events during the
reparative process. If internal resorption is recognized it is recommended that root canal
tx be initiated.
• Bender IB, Freedland JB 1983: Adult root fracture. Recommended 3 radiographs with
different vertical angulations to view horizontal fracture. Apical = better prognosis.
• Cvek, Andreasen 2001: In horizontal root fractures with pulpal necrosis advise root
canal therapy only to level of fracture rather than beyond. (they found better success
when done this way. apical segment usually remains vital.)
• Cvek, Andreasen 2002: Healing and long-term prognosis of 94 cervical root fractures
were evaluated. The teeth were divided into two groups according to type of fracture:
transverse fractures limited to the cervical third of the root (51 incisors) and oblique
fractures involving both the cervical and middle parts of the root (43 incisors). Neither the
frequency nor the type of fracture healing differed signi cantly between the two groups.
In the material as a whole, healing of the fracture with hard tissue formation was
observed in 17 teeth (18%), and healing with interposition of periodontal ligament (PDL)
and, in some cases, hard tissue between the fragments in 62 teeth (66%). Fifteen teeth
(16%) showed no healing and a radiolucency adjacent to the fracture. Statistical
analyses revealed that incomplete root formation and a positive sensibility test at the
time of injury were signi cantly related to both healing and hard tissue repair. The same
applied to concussion or subluxation compared with dislocation of coronal fragment, as
well as optimal compared with suboptimal reposition of displaced coronal fragments. The
type and duration of splinting (or no splinting) appeared to be of no signi cance for
frequency or type of healing of cervical root fractures. During the observation time (mean
= 75 months), 19 (44%) of the teeth with transverse fractures and 3 (8%) of those with
oblique fractures were lost after healing. In conclusion, fractures in the cervical part of
the root had a healing potential and the predictive parameters identi ed for fractures in
other parts of the root seemed to be valid for the healing of cervical root fractures.
Transverse fractures appeared to have a signi cantly poorer long-term prognosis

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 compared to oblique fractures, apparently due to a marked post-treatment mobility,
which often led to new luxation caused by even minor impacts.
• Cvek, Andreasen 2004: root fractures. 25-30% develop pulp necrosis
• Andreasen J, Andreason F, Cvek 2004:
• Part 1: This retrospective study consisted of 400 root-fractured, splinted or non-
splinted incisors in young individuals aged 7-17 years (mean = 11.5 +/- 2.7 SD) who
were treated in the period 1959-1995 at the Department of Pediatric Dentistry,
Eastman Dental Institute, Stockholm. Four hundred of these root fractures were
diagnosed at the time of injury; and 344 teeth were splinted with either cap-splints,
orthodontic appliances, bonded metal wires, proximal bonding with composite resin or
bonding with a Kevlar or glass ber splint. In 56 teeth, no splinting was carried out for
various reasons. In the present study, only pre-injury and injury factors were analyzed.
In a second study, treatment variables will be analyzed. The average observation
period was 3.1 years +/- 2.6 SD. The clinical and radiographic ndings showed that
120 teeth out of 400 teeth (30%) had healed by hard tissue fusion of the fragments.
Interposition of periodontal ligament (PDL) and bone between fragments was found in
22 teeth (5%), whereas interposition of PDL alone was found in 170 teeth (43%).
Finally, non-healing, with pulp necrosis and in ammatory changes between fragments,
was seen in 88 teeth (22%). In a univariate and multivariate strati ed analysis, a
series of clinical factors were analyzed for their relation to the healing outcome with
respect to pulp healing vs. pulp necrosis and type of healing (hard tissue vs.
interposition of bone and/or PDL or pulp necrosis). Young age, immature root
formation and positive pulp sensibility at the time of injury were found to be
signi cantly and positively related to both pulpal healing and hard tissue repair of the
fracture. The same applied to concussion or subluxation (i.e. no displacement) of the
coronal fragment compared to extrusion or lateral luxation (i.e. displacement).
Furthermore, no mobility vs. mobility of the coronal fragment. Healing was
progressively worsened with increased millimeter diastasis between fragments. Sex
was a signi cant factor, as girls showed more frequent hard tissue healing than boys.
This relationship could possibly be explained by the fact that girls experienced trauma
at an earlier age (i.e. with more immature root formation) and their traumas were of a
less severe nature. Thus, the pre-injury or injury factors which had the greatest
in uence upon healing (i.e. whether hard tissue fusion or pulp necrosis) were: age,
stage of root development (i.e. the size of the pulpal lumen at the fracture site) and
mobility of the coronal fragment, dislocation of the coronal fragment and diastasis
between fragments (i.e. rupture or stretching of the pulp at the fracture site).
• Part 2: This is the second part of a retrospective study of 400 root-fractured
permanent incisors. In this article, the effect of various treatment procedures is
analyzed. Treatment delay, i.e. treatment later than 24 h after injury, did not change
the root fracture healing pattern, healing with hard tissue between fragments (HH1),
interposition of bone and/or periodontal ligament (PDL) or pulp necrosis (NEC). When
initial displacement did not exceed 1 mm, optimal repositioning appeared to
signi cantly enhance both the likelihood of pulpal healing and hard tissue repair
(HH1). Signi cant differences in healing were found among the different splinting
techniques. The lowest frequency of healing was found with cap splints and the
highest with berglass or Kevlar splints. The latter splinting procedure showed almost
the same healing result as non-splinting. Comparison between non-splinting and
splinting for non-displaced teeth was found to reveal no bene t from splinting. With
respect to root fractures with displacement, too few cases were available for analysis.

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 No bene cial effect of splinting periods greater than 4 weeks could be demonstrated.
The administration of antibiotics had the paradoxical effect of promoting both HH1 and
NEC. No explanation could be found. It was concluded that, optimal repositioning
seems to favor healing. Furthermore, the chosen splinting method appears to be
related to healing of root fractures, with a preference to pulp healing and healing
fusion of fragments to a certain exibility of the splint and possibly also non-
traumatogenic splint application. Splinting for more than 4 weeks was not found to
in uence the healing pattern. A certain treatment delay (a few days) appears not to
result in inferior healing. The role of antibiotics upon fracture healing is questionable.
• Andreasen JO, Hjorting-Hansen E. 1967: Intraalveolar root fractures: radiographic and
histologic study of 50 cases. J Oral Surg 1967: Described 4 types of healing following
root fracture:
• calci ed (callous) tissue
• connective tissue (canal obliteration common)
• bone/connect tissue (combo calci ed and CT tissue
• Nonhealing granulation/in ammatory tissue (nonunion).
• Location of fx did not determine success. Mobility of coronal segment is
important

• Splinting
• Andreasen et al 2012: Splint: short term, non-rigid. Splinting is used to maintain correct
tooth position, provide patient comfort and improve function.
• Nasjletie et al 1982: Found that a splinting time of 7 days resulted in signi cantly less
replacement resorption than 30 days, following experimental avulsive injuries in
monkeys.
• Von Arx et al 2001: Recommends non-rigid splinting. In studies on non-human
primates, PDL damage and replacement resorption were noted when rigid splints were
used following traumatic dental injuries. In addition to use of exible splints, shorter
splinting times were recommended.
• Resorption following Trauma
• Van Hassel, Harrington 1980: Showed that the removal of PDL (following avulsion)
resulted in severe, progressive root resorption.
• Andreasen FM et al 1986: Transient Apical Breakdown more likely occurs with
moderate injury and seems to re ect the repair process taking place in the periapical
area and the pulp after trauma.
• Bastros, Dutra et al 2014: Intro External root resorption (ERR) is a serious complication
after replantation, and its progressive in ammatory and replacement forms are
signi cant causes of tooth loss. This retrospective study aimed to evaluate the factors
related to the occurrence of in ammatory ERR (IERR) and replacement ERR (RERR)
shortly after permanent tooth replantation in patients treated at the Dental Trauma Clinic
at the School of Dentistry, Federal University of Minas Gerais, Belo Horizonte, Brazil.
METHODS: Case records and radiographs of 165 patients were evaluated for the

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 presence, type, and extension of ERR and its association with age and factors related to
the management and acute treatment of the avulsed tooth by using the logistic
regression model. RESULTS: The patient's age at the moment of trauma had a marked
effect on the ERR prevalence and extension. The patients older than 16 years at the
moment of trauma had less chance of developing IERR and RERR (77% and 87%,
respectively) before the pulp extirpation, regardless of the extension of the resorption.
The patients older than 11 years of age at the moment of trauma showed the lowest
indices of IERR (P = .02). Each day that elapsed between the replantation and the pulp
extirpation increased the risk of developing IERR and RERR by 1.2% and 1.1%,
respectively, and also raised the risk of severe IERR by 0.5% per day. CONCLUSIONS:
The risk of mature teeth developing severe IERR before the onset of endodontic therapy
was directly affected by the timing of the pulpectomy and was inversely proportional to
age. Systemic antibiotic therapy use had no effect on the occurrence and severity of
IERR in mature teeth. The occurrence of RERR before the onset of endodontic
treatment stimulates further investigations of the early human host response to trauma
and subsequent infection
• See Resorption Section for more information
• Storage Media
• Blomlof 1981: Recommended milk as a storage media for avulsed teeth. “The Milk
Man”
• Andersson L, Hedstrom KG 1983: Storage of experimentally avulsed teeth in milk prior
to replantation. Milk is recommended as a storage medium in cases when immediate
replantation is not possible. It has physiologic osmolality (280) and few bacteria. Teeth
stored up to 6h in milk had same resorption as those immediately replanted. Saliva
allows storage for up to 2h.
• Trope, Friedman 1992: Recommend saline as a storage media for avulsed teeth
• Andreasen et al 2012: Immediate replantation is best, if cannot, then tooth should be
stored in a suitable medium (milk, saline, HBSS, or saliva. avoid water).
• Antibiotics
• Andreasen et al 2012: Clinicians discretion
• Gomes et al 2016: Compared the ef cacy of amoxicillin and tetracycline in reducing
in ammation and root resorption of delayed implanted teeth in rats. Amoxicillin and
tetracycline both slowed root resorption more than the control group, but amoxicillin
controlled in ammation more and had a more positive effect on slowing resorption as
compared to tetracycline.
• Andreasen et al 2006: Role of Antibiotics. Bacteria within the pulp space are not
in uenced by the systemic use of antibiotics.
• Austin et al 1990: Topical treatment of teeth with doxycycline before reimplantation
increased frequency of pulp revascularization, reduced bacteria, reduced ankylosis, and
in ammatory root resorption.
• Ritter, Trope 2004: Topical treatment with minocycline improves the chances of
revascularization after replantation when compared to doxycycline and saline.
• Hammarstrom et al 1986: following replantation of avulsed tooth suggests a preventive
action of systemic antibiotics at time of injury but not weeks later.
• Mandibular Fractures
• Oikarinen et al 1990: Prognosis of permanent teeth in the line of mandibular fractures.
Teeth lying in the fracture mandibular line can be preserved in most cases. PN will occur
more frequently when the fracture line goes through the apex.

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 • Calderon et al 1995: Developmental Arrest of Tooth Bud after correction of mandibular
fracture. Case report. Jaw fracture lines usually pass through or in close proximity to
developing tooth buds, but extraction is not advised in these children. However, 20% of
these teeth can develop crown deformation. There is also a risk of developmental and
eruption disturbances caused by either the fracture itself or surgical treatment.
• Intrusions
• AAE Trauma Guidelines: Intrusive Luxations
• Immature Teeth < 7 mm intrusion
• allow spontaneous re-eruption
• if none within 3w, ortho repositioning
• Immature Teeth > 7 mm intrusion
• Surgical/orthodontic repositioning
• Mature teeth < 3mm intrusion
• allow spontaneous re-eruption
• if none within 3 w, surgical or orthodontic repositioning
• Mature teeth 3 to 7 mm
• surgical or ortho repositioning
• Mature teeth > 7mm intrusion
• Surgical repositioning and splint 2-4 wk
• Omar, Retamozo, Bakland 2017: Cal Dent J. Review & 3 cases. Discusses treatment
options: spontaneous eruption, ortho extrusion, surgical repositioning.
• Tsilingaridis, Malmgren, Andreasen 2012: The evaluation and prognosis after
intrusion luxations should be based on the stage of root development and the degree of
intrusion. In teeth with immature root development, spontaneous repositioning appears
to result in fewer healing complications.
• Wigen et al 2008: Retrospective study on intrusive luxations in permanent teeth. Most
frequent in 6-12 y/o. Awaiting re-eruption was the preferred treatment. Re-eruption took
place in 35/37 incisors over a period of 3-12 months. Replacement resorption (ankylosis-
related) was the main reason for tooth loss. The occurrence of replacement resorption
was signi cantly lower in teeth allowed to re-erupt than in teeth repositioned
orthodontically or surgically.
• Humphrey et al 2003: The type of crown fracture (if present) is the only signi cant factor
that in uences pulp necrosis in intrusion cases. In terms of 5 year survival of the tooth,
the amount of intrusion in mm is the only statistically signi cant factor. Treatment choice
was insigni cant. Active re-positioning should be started no later than about 2 weeks.
(found signi cantly decreased pulp survival with >6-mm intrusion compared with <3-mm
intrusion in a study of 31 intruded incisors.)
• Andreasen, Bakland 2006: Treatment for intrusions. In regards to healing (Pulp
necrosis, root resorption, defect in marginal periodontal bone healing), no repositioning
and awaiting spontaneous repositioning in teeth with incomplete root formation resulted
in the lowest number of complications.
• Teeth with immature root development—> await spontaneous eruption.
• Teeth with mature root formation and the patient having an age 12-17—> await
spontaneous eruption but monitor closely.
• Above 17 years of age—>perform orthodontic or surgical repositioning.
• Tsilingaridis, Malmgren, Andreasen, et al 2016: The aim of the study was to evaluate
the survival of intruded permanent teeth related to treatment in a large number of
patients, with special focus on development of pulp necrosis and replacement resorption
(ankylosis-related resorption). M&M: The material consisted of 168 patients (mean age

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 9.6 years) with 230 intruded permanent teeth from dental trauma clinics in Copenhagen,
Denmark, Stockholm, Sweden, and Oslo, Norway. The degree of intrusion was classi ed
as mild (1-<3 mm), moderate (3-7 mm), and severe (>7 mm). Root development was
categorized with respect to root formation and development of the apex into three
groups of increasing tooth maturity: very immature, immature, and mature. Results:
Awaiting re-eruption was the treatment of choice in 107 teeth (47%), orthodontic
repositioning in 28 (12%) and surgical repositioning in 95 (41%) teeth. Pulp necrosis was
diagnosed in 173 teeth (75%), infection-related root resorption in 57 (25%) and
replacement resorption in 50 teeth (22%). Very immature teeth, teeth diagnosed with
mild intrusion, and teeth awaiting re-eruption had signi cantly (P < 0.05) fewer
complications. In a stepwise discriminant function analysis, choice of treatment, root
development, and degree of intrusion were signi cantly (P < 0.05) associated with the
development of replacement resorption. Root development and degree of intrusion were
signi cantly (P < 0.05) associated with the development of pulp necrosis. Conclusion:
This study indicates that root development and degree of intrusion may be important for
the development of pulp necrosis as well as replacement resorption, whereas choice of
treatment only seems to in uence the development of replacement resorption in intruded
permanent teeth. Awaiting re-eruption resulted in the lowest risk for developing
replacement resorption.
• Ortho following trauma
• No consensus in the literature on the appropriate amount of time to wait to resume or
commence ortho movement following trauma.
• Kindelan et al 2008: Suggested a range of between 3 months for minor injuries up to 1
year following severe injuries, however, these recommendations are based on empirical
rather than scienti c data.
• Piera et al 2012: based on experimental work on a rat model, noted that a delay of
15-30 days should be suf cient to resume orthodontic movement following a subluxation
injury.
• Brin et al 1991: External apical root resorption (pressure resorption) is associated with
orthodontic movement of previously traumatized teeth.
• Hamilton, Gutmann 1999: IEJ. Review. A traumatized tooth can be moved
orthodontically with minimal risk of resorption, provided the pulp has not been severely
compromised (infected or necrotic). If there is evidence of pulpal demise, appropriate
endodontic management is necessary prior to orthodontic treatment. If a previously
traumatized tooth exhibits resorption, there is a greater chance that Orthodontic tooth
movement will enhance the resorptive process. If a tooth has been severely traumatized
(intrusive luxation/avulsion) there may be a greater incidence of resorption, with or
without root canal treatment.
• Complications following Traumatic Dental Injuries
• Pulpal Necrosis
• PCO
• Resorption: Internal, Invasive Cervical, External, Replacement
• Avulsions
• Gabor, Haapasalo et al 2012: Internal Resorption noted in avulsion
• Van Hassel, Harrington et al 1980: PDL damage resulting from traumatic dental injuries
as the major etiologic factor in external resorption
• Andreasen et al 2012: Update to International Association of Dental Traumatology
Guidelines. 2. Avulsions of Permanent teeth. Immediate replantation is best, if cannot,
then tooth should be stored in a suitable medium (milk, saline, HBSS, or saliva. avoid

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 water). > 60 min: the PDL cells no longer viable, RCT can be done prior to replantation,
exible splint 4 wks, antibiotics (expect ankylosis, root resorption w/ eventual loss. < 60
min: apply exible splint 2 wks, do RCT 7-10 days after replantation, if open apex may
get revascularization therefore no RCT and monitor
• Stewart et al 2008: This retrospective study proved a validity of the current IADT
guidelines regarding treatment of avulsed teeth. Unless the high chance of pulp
revascularization is expected, the early endodontic intervention should be performed in
order to reduce the possibility of in ammatory root resorption.
• Haas et al 2008: Damage and amount of remaining PDL after avulsion and severe
intrusion was similar. No matter which injury occurs a signi cant amount of PDL is
retained; replant/transplant as atraumatically as possible.
• Andreasen et al 1995: Replantation of 400 avulsed permanent incisors. 1 Diagnosis of
healing complications. Replantation of teeth is a high risk procedure that must be
monitored closely. Complete pulpal healing occured only in 8% of replanted teeth. PDL
healing in 24% teeth. 30% tooth loss. Chance of pulpal healing decreased with
increasing root development (not signi cant). The prognosis of avulsed teeth is highly
dependent of the status of root maturation, the time to replantation, and the extraoral
storage media.
• Kumar 2010: If an avulsed tooth has already had an extra-oral dry time of 60 min or
more, doing the RCT on day 0 extra-orally before replantation will not negatively
in uence outcomes when compared to doing the RCT 7-10 days intra-orally after
replantation.
• Trope et al 1995: Once resorption is initiated, recommends RCT w/ long term CH
therapy to prevent progression of the resorptive defect
• Bryson, Abbott, Trope et al 2002: following avulsion and replantation suggested an
intracanal corticosteroid, ledermix, as an alterantive to CH
• Nagaoka et al 1995: Suggested some immune protection is offered by vital pulp whose loss,
in the case of pulp necrosis, might allow ingress of bacteria via dentinal tubules. Once the key
combination of bacteria and in ammation is present in the pulp, pulp necrosis is inevitable.
• Andreasen et al 2012: Update to International Association of Dental Traumatology
Guidelines. 1. Fractures and laxations of permanent teeth. Types: Concussion, Subluxation,
Extrusive Luxation, lateral luxation, intrusive luxation. Splint: short term, non-rigid. Splinting is
used to maintain correct tooth position, provide patient comfort and improve function.
Antibiotics: clinicians discretion. Sensibility tests will be altered w/ trauma, therefore need at
least 2 signs or symptoms to diagnosis necrotic pulp. Regular follow up required to make a
pulp diagnosis. Every effort should be taken to preserve vital pulp in an immature tooth. Pulp
canal Obliteration: occurs most frequently in teeth with open apices which have suffered a
severe luxation injury.
• Malmgren, Andreasen et al 2012: Update to International Association of Dental
Traumatology Guidelines 3. Injuries in the primary dentition.
• Combination Injuries
• Lauridsen, Andreasen et al 2012: TDI is usually associated with a minor injury. The
frequency of injury types is associated with age groups. It was common to see
combination injuries when permanent teeth were involved. Concomitant crown fractures
occurred most frequently in teeth with concussion, subluxation, or intrusions. Since teeth
involved in combination injuries have a higher risk of necrosis thorough diagnostic
testing is important.
• Lauridsen, Andreasen et al 2012: Combination Injuries Part II. The risk of PN in
permanent teeth with subluxation and concomitant crown fractures. There was a strong

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 association between subluxated/enamel-dentin fractured teeth and subsequent PN in
teeth with mature and immature root development. This supports the hypothesis that
healing complications are more frequently encountered in teeth with combination injuries
than in teeth with subluxation only as each injury alone only demonstrated a low risk of
PN. Trauma-related infractions signi cantly increased the risk of PN in teeth with mature
root development. In this study, there was a strong association between no response to
EPT at initial exam and development of PN in both mature and immature teeth. (Crown
fractures should be restored and enamel infractions sealed as soon as possible to
reduce the risk of PN with subluxation, combination injuries.
• Lauridsen, Andreasen et al 2012: Combination Injuries 3. PN in permanent teeth with
extrusion or lateral luxation and concomitant crown fractures w/out pulp exposure. Teeth
that have been laterally luxated are more likely to go necrotic if the crown has been
fractured. In extruded teeth there was no signi cant difference between the risk of PN in
teeth w or w/out crown fracture. Tx should include rapid restoration to seal the infraction.
• Extrusion: Surgical/Ortho/Spontaneous Eruption
• Tsilingaridis, Malgren, Andreasen, et al 2016: Awaiting re-eruption was the treatment
of choice in 107 teeth (47%), orthodontic repositioning in 28 (12%) and surgical
repositioning in 95 (41%) teeth. Choice of treatment only seems to in uence the
development of replacement resorption in intruded permanent teeth. Awaiting re-eruption
resulted in the lowest risk for developing replacement resorption.
• Das, Muthu 2013: Systematic review. Supports successful surgical extrusion for
management of crown-root fractures in permanent anterior teeth. Authors conclude a
lower incidence of failure, good esthetics, minimum chair side time and ready
acceptance from patient. However, majority of studies were case reports or case studies
which are lower level of evidence.
• Andreasen JO, Bakland, Andreasen F 2006: A prospective study of 140 intruded
permanent teeth was examined for the following healing complications: pulp necrosis
(PN), root resorption (RR; surface, in ammatory and replacement resorption), and
defects in marginal periodontal bone healing (MA). The occurrence of these healing
complications was related to various treatment factors such as treatment delay, method
of repositioning (i.e. expecting re-eruption, orthodontic reposition and surgical
reposition), type of splint (rigid, semirigid and exible), length of splinting (days) and the
use of antibiotics. Treatment delay, i.e. before and after 24 h, had no effect upon healing.
Active repositioning in individuals with incomplete root formation (surgical or orthodontic)
had a negative effect upon the three healing parameters compared with spontaneous
eruption. In teeth with complete root formation and an age of 12–17 no repositioning was
still the best treatment in regard to MA. In individuals older than 17 years of age, cases
were not anticipated to spontaneously erupt and in these cases, the general choice of
treatment was either active orthodontic or surgical repositioning. The former procedure
appeared in this treatment scenario to slightly reduce the risk of MA complications.
However, this treatment procedure was also found to be more time demanding (an
average of 22 consultations for orthodontic repositioning compared with 17 consultations
for surgical repositioning). If a surgical repositioning was performed, the type of splint
(i.e. exible, semirigid or rigid) appeared to have no signi cant effect on the type of
healing. The same applied to the length of splinting time (shorter or longer than
6 weeks). No effect of dentin covering procedures for associated crown fractures
(enamel–dentin fractures) could be demonstrated. Likewise, antibiotics had no apparent
effect upon healing. In conclusion, in patients with intruded teeth with incomplete root
formation, spontaneous eruption should be expected. In patients with completed root

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 formation and with an age of 12–17 spontaneous eruption can still occur, but must be
monitored very carefully. In older patients (i.e. >17 years) with completed root formation,
either surgical or orthodontic extrusion should be attempted. The latter procedure
appeared to lead to a slight reduction (not signi cant) in the risk of MA complications.
The extent and direction of the intrusion may however favor surgical repositioning.
• Andreasen F et al 2015: The risk of PN increased with the extent of injury (ie,
concussion < subluxation < extrusion < lateral luxation < intrusion). Moreover, teeth
with completed root formation had a greater risk of PN than teeth with incomplete root
formation. No treatment effect could be demonstrated.

• Best follow up for traumatic cases are up to 6 months due to Ravn in Scan J Den Res who
showed that most changes occur in the rst 6 months.
• Cvek M, Andreasen JO 1982: Pulp reactions to exposure after experimental crown fractures
or grinding in adult monkeys. J Endod 1982 : Investigated the depth of in ammatory reactions
of adult monkey pulps exposed by fracture or cavity prep at different times. In ammatory
changes in the pulp exposed by cavity preparation were 3.8 mm at 48 hr, 4.4 mm at 168 hour;
increased in comparison to those in crown-fractured teeth (1.8 mm at 48 hr, 1.6 mm at 168
hr). In crown-fractured teeth with vital pulp exposures up to a period of 7 days, not
more than 2 mm of pulp beneath exposure needs to be removed.

• Management of dental traumas (Tables from Dr. Krell’s study guide):

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Management of avulsed teeth

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Decoronation
• Malmgren 2013: Review of technique in JOE.
• Recommended decoronation once infrapositioning greater than 1mm is noted.
Decoronation involves crown sectioning with splinting to the neighboring teeth for an
esthetic temporary, surgical ap and removal of any prior root canal lling material and
close observation until complete replacement with bone has occurred.
• Timing: In young patients there are advantages in retaining an ankylosed tooth for as long
as possible as a space maintainer. However, it is important to intervene before the effect of
infraposition makes a nal prosthetic solution dif cult because of the arrested alveolar bone
growth. Therefore, it is important to keep in mind that progression of infraposition varies
individually. The rate of infraposition is correlated to the age when ankylosis is diagnosed
and to the growth intensity of the face. There is a high risk of severe infraposition when
ankylosis is diagnosed before the age of 10. In these cases the ankylosed tooth should be
monitored carefully every 6 months. There is also a great risk of severe infraposition during
the pubertal growth spurt, and the time for this growth spurt varies individually. This
variation means that normal growth distribution curves in relation to chronological age are
not reliable. Annual body height measurement to evaluate the patient’s individual growth
intensity and plaster casts or photos to study the dental effects are aids for the
assessments. There is also a difference between patients with horizontal and vertical
growth of the face. The rate of infraposition is faster in vertical growers. Cephalometric
radiographs might be used for the evaluations
• The predictable success of decoronation supports the indication for replantation of avulsed
teeth in children even when the extra- alveolar conditions indicate that healing might be
compromised by ankylosis
• Earlier studies have established a relationship between infraposition of an ankylosed tooth
and growth of the alveolar bone. Infraposition is caused by local arrest of the dentoalveolar
bone, and its severity depends on the development of occlusion and facial growth. These
factors vary individually. Thus, monitoring the patient is important. In general, it is
recommended to remove an ankylosed tooth before severe infraocclusion and tilting of
neighboring teeth develop
• Malmgren, Cvek 1984: A method for preserving the alveolar ridge of ankylosed and
infrapositioned incisors and improving conditions for a subsequent prosthetic therapy is
described and evaluated clinically and radiographically. The method involves removal of the
crown and root lling from the root, which is retained and covered with a mucoperiosteal ap.
Clinically, there were no postoperative complications and after the follow-up a satisfactory
prosthetic restoration was performed in all cases, regardless of the degree of infraposition
before treatment. Radiographically, no pathologic changes were observed apart from a
continuous resorption and replacement of lost root substance by bone. Alveolar bone level
shifted only slightly between postoperative and 12-month follow-up radiographs, in a majority
of cases in a coronal direction.
• Malmgren et al 2006: Decoronation of ankylosed teeth in infraposition was introduced in
1984 by Malmgren and co-workers (1). This method is used all over the world today. It has
been clinically shown that the procedure preserves the alveolar width and rebuilds lost
vertical bone of the alveolar ridge in growing individuals. The biological explanation is that the
decoronated root serves as a matrix for new bone development during resorption of the root
and that the lost vertical alveolar bone is rebuilt during eruption of adjacent teeth. First a new
periosteum is formed over the decoronated root, allowing vertical alveolar growth. Then the

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 interdental bers that have been severed by the decoronation procedure are reorganized
between adjacent teeth. The continued eruption of these teeth mediates marginal bone
apposition via the dental-periosteal ber complex. The erupting teeth are linked with the
periosteum covering the top of the alveolar socket and indirectly via the alveolar gingival
bers, which are inserted in the alveolar crest and in the lamina propria of the interdental
papilla. Both structures can generate a traction force resulting in bone apposition on top of
the alveolar crest. This theoretical biological explanation is based on known anatomical
features, known eruption processes and clinical observations.
• Andreasen, Malmgren, Bakland 2008: preservation of even resorbing replanted teeth may
offer signi cant long-term advantages in preparation for de nitive treatment. Also, for
psychological reasons, replantation can signi cantly reduce the anxiety and despair of both
the injured child and the parents. Furthermore, decoronation of a resorbing anterior tooth will
allow it to serve as a matrix for alveolar bone formation and preserve an otherwise resorbing
alveolar process, thereby leaving an environment of bone and soft tissue that is optimal for
both single implant insertion or xed prosthesis. Finally, replantation and subsequent
decoronation, if indicated, appears to be cost-effective in comparison with non-replantation
combined with subsequent repeated prosthetic tooth replacements owing to vertical alveolar
growth of adjacent ridge areas, with eventual de nitive implant placement or a xed
prosthesis.
• Malmgren et al 2015: Abstract – Background/Aim: Decoronation is a technique developed in
1984 to remove ankylosed teeth and increase marginal bone levels in young, growing
individuals. This retrospective cohort study evaluates marginal bone development after
decoronation in relation to gender and age at treatment. Materials and methods: The study
evaluated all 95 patients with 103 ankylosed permanent incisors treated with decoronation at
the Eastman institute Department of Pediatric Dentistry during 1978–1999. Mean age of the
patients was 10.7 years (6.8–17.8) at the time of trauma and 14.9 years (9.3–22.0) at
decoronation. The mean follow-up period was 4.6 years (1.0–19.3 years). The study
evaluated development of the marginal alveolar bone level with a three-point scoring system:
1 = Unchanged or reduced alveolar bone level, 2 = A moderate increase in alveolar bone
level, and 3 = A considerable increase in alveolar bone level. The nal group for statistical
evaluation comprised 75 patients: 56 boys and 19 girls who had only one tooth decoronated.
Kappa statistics showed almost complete agreement between the two observers (j = 0.90).
Results: Bone level changes were signi cantly correlated (P < 0.05) to gender and age at
treatment. In decoronations performed after the age of 16, bone levels were unchanged or
reduced, while decoronations performed at a mean age of 14.6 years in boys and 13 years in
girls yielded a considerable increase in bone levels. Conclusion: This study indicates that age
at decoronation is an important factor for favorable development of the alveolar ridge and that
decoronation should be performed earlier in girls.
• Mohadeb et al 2016: Systematic Review. Dental Traumatology. Following decoronation,
preservation of ridge height and ridge width were both noted. To maximize the benefits of
decoronation, a timely and well monitored intervention is required. Treatment in patients, who
have surpassed pubertal growth peaks, may not yield maximum effective treatment
outcomes. (While decoronation can effectively preserve ridge height around ankylosed teeth,
its success in maintaining ridge width is slightly compromised. A slight reduction in ridge width
(1.67 mm) following decoronation is inevitable. For patients who have surpassed the pubertal
growth peak (which is individual and is earlier in girls), decoronation can do little to correct the
persistent alveolar ridge deformity and tooth infra- position. Since in those age groups, rate of
infra- position, alveolar ridge deformity or tilting of adjacent teeth is already well-established,
decoronation can only preserve remaining bone. Decoronation does not exclude possibilities

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 of additional grafts at the time of implant placement Following decoronation, xed or
removable appliances used as temporary restorations should be regularly checked so as to
eliminate dental interferences. Rate of replacement of root substance by bone deposition,
differed across studies. Even after 1– 10 years following decoronation, some studies reported
incomplete root resorption at the time of implant placement. However, insertion of implants in
contact to root substance did not hamper success of treatment.In the overall scheme,
decoronation technique to treat ankylosed teeth is associated with a favorable prognosis.
None of the studies reported any adverse events.)
• Tsukiboshi 2014: Get a collapse of the buccal ridge with replantation and decoronation. The
purpose of this report was to describe the morphological changes in the alveolar bone after
delayed replantation of avulsed teeth using three dimensional cone-beam computed
tomography in 11 during the time period 2003-2012. The radiographic observations revealed
the following: Delayed replantation results in ankylosis-related replacement root resorption;
the resorption is delayed or arrested around the cervical area superior to the alveolar crest.
The buccal bone is reduced in thickness but not the palatal bone. The buccal bone resorption
of the alveolar crest progresses approximately to the root canal space of the ankylosed root.
Delayed replantation does not completely maintain the bone volume. The buccal pro le of
alveolar bone in the maxillary anterior region is depending on teeth with viable periodontal
ligament.

Resorption
• Types:
• Internal root resorption (in ammatory, replacement)
• Invasive cervical root resorption
• External Root resorption
• Repair Related (transient)
• Infection Related (used to be called in ammatory). Bacteria present
• Ankylosis related (used to be called replacement). Physiologic process
• replacement/ankylotic resorption
• pressure resorption
• transient apical breakdown/resorption
• What is needed for resorption to occur?
• Trope; Fuss :
• 1. Loss or alteration of protective layer (precementum and predentin)
• 2. in ammation must occur to the unprotected root surface.
• It has been suggested that osteoclast just bind to RGD peptides that bound to calcium
salt of mineralized surface. Therefore, presence of predentin which is unmineralized
prevent activation of dentinoclast.
• Tronstad: For resorption to occur, loss or damage of the protective, unmineralized layers
must occur in presence of in ammation (predentin internally, precementum externally).
• Differentiating Internal vs External Resorption
• Gartner, Mack 1976: Differentiating internal vs external resorption.
• Radiographic differences: internal - symmetrical, cannot trace canal through lesions,
stays center in shift shots. External - irregular, can trace the canal through the lesion,
moves on shift shots
• Classic: Diff dx of Int vs Ext: Internal: sharp margins, canal not observed inside lesion,
symmetrical, uniform density, doesn't move on shift shot, less common, more
predictable, tx=CaOH +RCT. External: irregular margins, can see canal thru lesion,

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 asymmetrical, variable radiodensity, moves on shift shot, more common, less
predictable, tx= depends.
• Andreasen et al 1987: Analyzed resorption and provided detailed statistical methods for the
study of resorption
• Resorption Reviews
• Tronstad 1988: Review of root resorption - etiology, terminology and clinical
manifestations. (Internal resorption is maintained by RC infection coronal to site of the
lesion External root resorption caused by: trauma, periradicular in ammation, ortho,
bleaching. Classi ed resorption as transient in ammatory (surface), internal, external
(cervical, progressive external and replacement). Other than replacement resorption,
other types of resorption can generally be treated. Found that loss or damage of the
protective unmineralized layers in presence of in ammation must occur. External
in ammatory root resorption is generally endodontic or othrodontic in origin. Apical
resorption secondary to periradicular pathology is generally transient. Traumatic dental
injuries, including luxation and avulsion injuries, are associated with more extensive
injuries to the precementum and cementoblastic layer. This coupled with pulpal necrosis
and infection can result in more extensive external in ammatory resorption despite
endodontic intervention. Described replacement resorption as a secondary complication
of widespread external in ammatory resorption following extensive PDL loss as a result
of traumatic dental injuries with resultant loss of the corresponding protective
precementum and cementoblastic layers. Direct contact between cementum and bone
prevent the odontoclasts from distinguishing between bone and tooth structures, leading
to further degradation. Replacement resorption: Clinically, described a pathognomonic
metallic tone on percussion and progressive infrapositioning of the tooth as the root
structure is replaced with bone.
• Fuss, Tsesis, Lin 2003: Diagnosis, classi cation and tx. To treat resorption cases, it is
important to identify the stimulating source and remove it, if possible.
• 1. In ammatory Root Resorption: infected dentinal tubules stimulate osteoclastic
activity leading to internal/external root resorption. Tx —> RCT.
• 2. Periodontal Infection Root resorption: external root resorption may occur after
injury of the precementum, followed by bacterial stimulation originating from
periodontal sulcus. Treatment is to surgical expose defect, remove granulation
tissue and restore (geristore). Endo tx necessary only if pulp perforation.
• 3. Ortho Pressure Root Resorption: usually located in apical third of root,
asymptomatic, no radiolucency. Tx: stop ortho.
• 4. Impacted tooth or tumor pressure root resorption. Generally asymptomtic. Tx:
surgery to remove the pressure source and arrest the process.
• 5. Ankylotic/Replacement Resorption: Since no stimulation to remove, there is no
predictable treatment currently available. Prevention by minimizing periodontal
ligament damage immediately following and injury is only treatment. Soaking tooth
in uoride gel prior to replantation may possibly delay ankylotic resorption.
• Ne, Witherspoon, Gutmann 1999: summary: Tooth resorption is a common sequela
following injuries to or irritation of the periodontal ligament and/or tooth pulp. The course
of tooth resorption involves an elaborate interaction among in ammatory cells, resorbing
cells, and hard tissue structures. The key cells involved in resorption are of the classic
type, which include osteoblasts and odontoclasts. Types of tooth resorption include
internal resorption and external resorption. There are two types of internal resorption:
root canal (internal) replacement resorption and internal in ammatory resorption.
External resorption can be classi ed into four categories by its clinical and histologic

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 manifestations: external surface resorption, external in ammatory root resorption,
replacement resorption, and ankylosis. External in ammatory root resorption can be
further categorized into cervical resorption with or without a vital pulp (invasive cervical
root resorption) and external apical root resorption. Other variations of resorption include
combined internal and external resorption and transient apical breakdown.
• Radiographs and Resorption
• Patel K, Mannocci, Patel S 2016: Clinical Study.
• PRs have signi cant limitations in the detection, assessment, and treatment
planning of ECR when compared with CBCT imaging.
• A CBCT scan should be considered before the management of a potentially
restorable ECR lesion.
• Patel 2009: CBCT is superior to lms for detecting resorption
• Estrela et al 2009: In cases of suspected resorption, CBCT can greatly aid in treatment
planning and consequently, improve treatment outcomes.
• Replacement Resorption, Ankylosis:
• Campbell et al 2005: Percussion/sound test is a reliable diagnostic measure for
diagnosis of ankylosed maxillary incisors.
• Tronstad 1988:
• Described RR as a secondary complication of widespread external in ammatory
root resorption following extensive PDL loss as a result of traumatic dental injuries
with resultant loss of the corresponding protective precementum and
cementoblastic layer. Direct contact between cementum and bone prevents the
odontoclasts from distinguishing between bone and tooth structures, leading to
further degradation.
• described a pathognomonic metallic tone on percussion and progressive infra-
positioning of the tooth as the root structure is replaced with bone, particularly in
young patients.
• Malmgren B, Malmgren O 2002: The progression of infraposition varies for each
individual. Infraposition is highly likely when anklyosis is diagnosed before age 10 or the
growth spurt. In severe cases tooth is removed.
• Donaldson, Kinirons 2001: Factors affecting the time of onset of resorption in avulsed
teeth and replanted incisors in children. The risk of an early onset of resorption is
increased if a replanted tooth has a coronal fracture, visible contamination or is kept dry
for longer than 15 minutes.
• Lindskog/Hammarstrom 1985 – Removal of the damaged PDL cells may inhibit
dentoalveolar ankylosis and replacement resorption. Bone replacing the periodontal
membrane grew from the alveolus towards the cementum.
• Lindskog/Hammarstrom 1985 – Necrotic PDL cells Ankylosis between bone and
cementum due to repair confusion (osteoblasts vs. cementoblasts). 2 Types: Ankylosis
w/o root resorption (cementum-bone) & Ankylosis following in amm. root resorption
(dentin-bone)
• Hammarstrom, Blomlof, Lindskog 1989: Showed there is a relationship between the
length of the extraoral period and the occurrence of in ammatory and replacement
resorption. Avulsed teeth with an extra-oral dry time of 1 hr before replantation resulted
in extensive ankylosis and root resorption. Antibiotic treatment could only delay, not
prevent, the root resorption associated with a permanent ankylosis. Ankylosis was not a
regular nding in teeth with an extraoral period of 15 min. Presence of viable periodontal
membrane is critical.

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 • Trope 2002 – Damage to the pre-cemental layer due to traumatic injury + In ammatory
destruction of the cementum in response to dead PDL cells
• Andreasen, Kristerson 1981: If less than 20% of the root surface is involved, reversal
of resorption may occur and ankylosis may be avoided. With greater involvement,
progressive replacement resorption is considered inevitable and no known interventions
halt its progression.
• Andersson et al 1984: Tooth Ankylosis. Clinical, radiographic and histological
assessments. A high percussion sound and decreased mobility are more sensitive and
accurate signs of ankylosis than radiographically observed changes. Radiographic DX is
dependent on location of ankylosis. Buccal and lingual ankylosis can not be detected by
radiographs.
• Andreasen 1975 – Need damage of >20% of root surface for progressive replacement
resorption (vs. transient replacement resorption)
• Tieu et al 2013: Management of ankylosed primary molars with premolar successors.
Monitor spontaneous eruption is advised for 6-12 months after the expected exfoliation
time. The only indication for extraction are moderate to severe infra-occlusion, tipping of
adjacent teeth, altered or halted eruption of permanent successor, or continued ankylosis
after 6-12 months of monitoring.
• Malmgren 2013: Recommended decoronation once infrapositioning greater than 1mm is
noted. Decoronation involves crown sectioning with splinting to the neighboring teeth for
an esthetic temporary, surgical ap and removal of any prior root canal lling material
and close observation until complete replacement with bone has occurred. (deals with
replacement resorption)
• Panzarini et al 2008: Review of root surface treatments in delayed replantation. When
PDL ligament is absent or contamination is under control, the best results that may be
expected are ankylosis and replacement resorption. Although these processes will
eventually lead to failure, tooth loss will happen more slowly without loss of alveolar bone
height, which is important for future prosthetic planning. Replantation of avulsed tooth
should always be encouraged, regardless of viability of the PDL. The tooth may remain
functional for years before prosthetic treatment is required and it enables the patient to
become psychologically adapted to the loss. Root surface tx is important in delayed tooth
replantation as it may in uence the retention of the tooth for a longer period of time.
• Invasive/External Cervical Resorption
• Patel K, Mannocci, Patel S 2016: The assessment and management of external
cervical resorption with periapical radiographs and CBCT. Clinical Study. PRs have
signi cant limitations in the detection, assessment, and treatment planning of ECR when
compared with CBCT imaging. A CBCT scan should be considered before the
management of a potentially restorable ECR lesion. (results: The overall sensitivity
(0.86) and speci city (0.89) of PRs was signi cantly lower than CBCT imaging (P <
.001). PRs had a limited ability to accurately detect the size (0.75), circumferential
spread (0.60), and location of ECR compared with CBCT imaging (P < .001). PRs also
underestimated the size of the ECR lesion. Signi cant differences (P < .001) were
apparent in the treatment plans formed when PRs were assessed versus CBCT imaging.
Parallax radiographs were shown to be of no additional bene t compared with a single
radiograph.)
• Neuvald, Consolaro 2000: CEJ: microscopic analysis and external cervical resorption.
Authors propose that the probably occurrence of dentin exposure at the CEJ may cause
a focal in ammatory process that establishes ideal conditions for resorption due to many
factors such as cytokines, presence of bacteria, speci c dentin proteins and cellular

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 interaction. (Variability at CEJ leaves region susceptible to external cervical
resorption). A sample of 198 permanent human teeth was analyzed by optical
microscopy and scanning electron microscopy.
• Scanning electron microscopy showed three types of tissue interrelations:
• enamel overlapped by cementum;
• enamel and cementum edge-to-edge;
• and a gap, revealing a strip of exposed dentin.
• Using optical microscopy, a fourth type of cementoenamel junction was
observed: cementum overlapped by enamel.
• The distribution of the hard tissues found at the cementoenamel junction is
unpredictable and irregular both for any tooth type (e.g. on cuspids) and on any one
individual tooth. Based on these results and on analysis of the mechanisms
involved in cervical root resorption, it is possible to consider the cervical region as
prone to external resorption.
• Heithersay 2004: Review of invasive cervical resorption: Trichloroacetic acid (TCA),
Class I: coronal with BOP, Class II: lucency projected into crown and close to pulp, Class
III: con ned to coronal 1/3 of root, Class IV: Extends beyond coronal 1/3
• Heithersay 1999:
• For this type of resorptive defect to occur, a developmental or iatrogenic defect must
be present in the cementum/cementoid layer of the root, so that the PDL, with the
potential for in ammatory invasion, is in direct contact with dentin.
• ICRR is generally painless because complete pulpal involvement does not occur
except in advanced lessions.
• Strong association with ortho > trauma > bleaching. Distinguished class 1-4 defects;
recommends surgical access, topical 90% trichloracetic acid, curettage and GI
restoration (endo tx)
• Histologically: composed of bro-osseous and brovascular tissue associated with
clastic cells.
• Retrospective study of 257 teeth. For invasive cervical resorption to be initiated, the
normally protected cementum-cementoid layer must be de cient or damaged.
Maxillary central incisors were the predominant teeth with cervical resorption. There
appears to be a strong association between the incidence of ICR and ortho tx,
intracoronal bleaching, and dental trauma, alone and in combo. PDL acts as a
protective barrier.
• Thonen, Zhender et al 2013: Found a low incidence of ICRR at 0.9% in molars subject
to orthodontic forces, with increased associations in areas of long-duration or larger
movement. Likelihood of developing ICCR appears low.
• Frank: Tx and prognosis based on complete debridement of the defect
• von Arx et al 2009: Highlights a possible, yet unrecognized relationship between ICR
and cats with feline odontoclastic resorptive lesions. proposed a viral eiology from cats
• Heithersay 1999: Heithersay Classi cations: based on size and extent into root
structure.
• Class I: Small invasive lesion near cervical area w/ shallow dentin penetration.
involve dentin only.
• Class II: Well de ned lesion, penetration close to the coronal pulp with little or no
extension into radicular dentin
• Class III: Deeper invasion, involving the coronal dentin and coronal 1/3rd of root
• Class IV: Large invasion, extending beyond the coronal 1/3rd of the root

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 • Features of invasive Cervical Root Resorption. ICR is a relatively uncommon form
of external tooth resorption characterized by cervical location, invasive nature and
inclination to produce a pink discoloration of the crown. Generally painless as pulp
is protected by thin dentin layer. The presence of a radiolucency with a ne
radiopaque line demarcating the outline of the root canal must alert clinician to the
likihood of ICR. This radiopaque line separating lesion from root canal differentiates
it from internal replacement resorption. For invasion to occur, a defect in the
cementum/cementoid layer is a likely prerequisite. Histologically ICRR is composed
of bro-osseous and bro-vascular tissue associated with clastic cells.
• Patel et al 2009 – Review of External Cervical Resorption
• Damage to precementum or gaps at CEJ, “aseptic resorption”
• Etiology: Ortho 24%, Trauma 15%, Internal bleaching 4%, Surgery, Periodontal
Therapy (Sc/Rp)
• Most commonly: Maxillary Incisors/Canines, Mand Molars
• Histology: Hard base (Caries = sticky) profuse bleeding due to highly vascular
granulomatous tissue (Pink spot in cervical area of crown, more common than in
Internal root resorption
• Pathophys: Osteoclasts, resorption lacunae, no acute in am.cells
• Often mistaken as Internal in amm resorption, outline of canal should be visible,
ECR follows SLOB. Advocates use of CBCT.
• Treatment – Based on Heithersay Classi cations: Treat Class I, II, III lesions –
Curretage, 90% TCA, Glass ionomer restoration
• ECR is the result of a de ciency or damage to the protective cementum layer below
the epithelial attachment, which exposes the root surface to osteoclast, which then
resorb the dentin. Teeth most commonly affected by ECR are maxillary canines,
maxillary incisors and mandibular rst molars. Hx of dental trauma, ortho, internal
bleaching were most common predisposing factors for ECR. Bleaching - safer
alternatives to hydrogen peroxide are sodium perborate mixed with water. Diagnosis
of ECR is usually associated with the appearance of a pink spot in the cervical area
or as chance of nding on x-rays. The discoloration is a result of the highly vascular
granulation (resorptive) tissue within the tooth becoming visible through the thinned
out dentin. Treatment requires complete removal of resorptive tissue and restoration
of resulting defect. Heithersay classi ed ECR as I, II, III and IV. He reported 100%
success with class I an II treatment. The more cervical: poorer prognosis.
• Gerner et al 1986: Case series. The prognosis of external cervical root resorption is
poor, but sealing of resorptive defects by silver amalgam may prove to be a way of
treating and halting lesions. There are indications that grafting procedures should be
done before the eruption of the canine to reduce the chance of root resorption problems.
• Mavridou et al 2017: JOE. The data indicate that ECR is not related to patient sex. ECR
occurs most often in the maxillary central incisor. In the majority of the cases, more than
1 potential predisposing factor was identi ed, indicating that ECR may be mainly
multifactorial. The most frequently appearing factors were orthodontics, iatrogenic or
accidental trauma, and poor oral health. This information may be helpful in diagnosing
ECR at an early stage when screening patients presenting with these predisposing
factors.
• Treatment of ICRR:
• Heithersay 1999:

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 • Involves debridement of resorptive defect, placement of glycerol on the
gingival tissues, application of 90% trichloroacetic acid for 1 to 4 minutes and
restoration with a glass ionomer cement.
• To access the defect, a surgical ap is often necessary. RCT is indicated in
class 2 and class 3 defects because of inevitable pupal involvement.
Trichloroacetic acid deactivates the resorptive tissue via coagulative necrosis.
• GI cements are advised for restoration of resorptive defects because Dragoo
1997 demonstrated the ability of periodontal tissue to reattach to these
materials.
• While generally an external approach is recommended for tx, an internal
approach for repair can be undertaken for class 2 lesions and involves the use
of intracoronal trichloroacetic acid or multiple applications of CH to assure
clearance of resorptive soft tissue.
• Recommends tx only for classes 1, 2 and 3 based on poor outcomes for class
4 lesions.
• At 3 years post op reported:
• 100% success for class 1 and 2 lesions
• 78% success for class 3 lesions
• 12.5% success for class 4 lesions
• Recurrence of resorption or development of periradicular pathology were
indicators of failure in this study.
• Additionally potential methods for treating ICRR lesions include the use of guided
tissue regen, orthodontic extrusion and intentional replantation.
• internal bleaching and ICR
• Harrington & Natkin 1979: First reported the association between ICRR and
intracoronal bleaching
• Rotstein, Friedman et al 1991–
• found that superoxol (30-35% hydrogen peroxide) and heat were particularly
associated with ICRR follwing intracoronal bleaching and cemental defects found
at the CEJ provided the likely pathway of irritation.
• Internal bleaching & ECR – 30% H2O2 leakage through dentinal tubules at CEJ
with no cemental layer (Neuvald; Papadapolous – 10%) – damages dentin,
initiates in amm/resorp.
• Heithersay EDT 1997 – Hydroxyl radical was generated after thermocatalytic
bleaching w/ 30% H2O2. This radical may be one mechanism underlying PDL
breakdown and resorption after bleaching
• Internal Resorption
• Frank 1974: First described
• Gartner et al 1976: Described the classic radiographic appearance of IRR as an oval-
shaped enlargement of uniform density within the pulp space.
• Wedenberg/Lindskog 1985:
• Transient internal resorption occurs commonly following trauma, however, it will not
progress in the absence of infection.
• Progressive IRR is rare, as vital in amed tissue is necessary for continued
resorption
• Internal resorption is transient or progressive depending on bacterial contamination/
in ammation to prolong activity of clastic cells
• Dentin contains a resorption inhibitor, pre-dentin

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 • Internal resorption cannot develop unless normal pulp is replaced by a periodontal-
like connective tissue.
• Multi-nucleated giant cells/macrophages = clastic cells present
• Tronstad 1988– Tooth must be vital for Internal resorption to occur. (As a result of pulpal
injury, some degree of partial coronal pulp necrosis occurs and induces in ammation of
the remaining apical vital tissue. This in amed tissue must abut an area of exposed
dentinal tubules, secondary to loss of the protective predentin and odontoblastic layer,
for resorption to occur. If the apical tissue necroses the resorptive process stops.)
• Heithersay – Two types of Internal Resorption: In ammatory and Replacement
• Walton, Leonard 1986: Case Report. Cracks may cause internal resorption

• Patel, Ricucci, Tay et al 2010 – JOE. Review.

• Potential etiologic factors for IRR: trauma, caries, periodontal infections, excessive
heat during restorative procedures, CH procedures (pulp caps, pulpotomy), vital
root resections, anachoresis, ortho tx, cracked teeth, or idiopathic dystrophic
changes.
• Damage to odontoblastic and pre-dentin layers resulting in exposure of mineralized
dentin layer to odontoclasts. Pulp tissue: Apical to resorption is vital, Coronal to the
lesion is necrotic. 2 Types: In ammatory and Replacement (resorption + deposition
of bone/cementum-like tissues); May be symptomatic; Differentiate between IRR
and ECR with CBCT
• Internal root resorption is the progressive destruction of intraradicular dentin and
dentinal tubules along the middle and apical thirds of the canal walls as a result of
clastic activities. From a histologic perspective, internal root resorption is manifested
in one form that is purely destructive, internal (root canal) in ammatory resorption,
and another that is accompanied by repair, internal (root canal) replacement
resorption that is featured by the deposition of metaplastic bone/cementum-like
tissues adjacent to the sites of resorption. From a differential diagnosis perspective,
the advent of cone beam computed tomography has considerably enhanced the
clinician’s capability of diagnosing internal root resorption. Nevertheless, root canal
treatment remains the treatment of choice for this pathologic condition to date. For
internal root resorption to occur, the outermost protective odontoblast layer and the
predentin of the canal wall must be damaged, resulting in exposure of the
underlying mineralized dentin to odontoclasts
• Haapasalo, Endal 2006: Systematic Review.
• Internal in ammatory root resorption is a relatively rare resorption that begins in the
root canal and destroys surrounding dental hard tissues.
• Odontoclastic multinuclear cells are responsible for the resorption, which can grow
to perforate the root if untreated.
• The initiating factor in internal root resorption is thought to be trauma or chronic
pulpal in ammation, but other etiological factors have also been suggested.
• Active, expanding resorption requires vital pulp tissue and continuous
microbiological irritation, likely from the necrotic coronal part of the root canal. In its
classical form, internal root resorption is easy to diagnose. However, in many
instances advanced diagnostic methods may be required for a de nitive diagnosis.
Internal root resorption is usually symptom free, but in cases of perforation, a sinus
tract usually forms.

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 • The prognosis for treatment of small lesions of internal root resorption is very good.
If, however, the tooth structure is greatly weakened and perforation has occurred,
the prognosis is poor and tooth extraction must be considered.
• Sodium hypochlorite, ultrasonic instrumentation and calcium hydroxide are the
cornerstones of treatment of internal in ammatory root resorption. Mineral trioxide
aggregate is being increasingly used as a root canal lling material, particularly in
cases of perforation.
• Gabor, Haapasalo 2012: Found that IRR, whether stable or progressive, is a common
histologic nding in the absence of clinical or radiographic changes. They noted IRR
defects in 50% of extracted teeth with a preop dx of pulpitis and 77% of those with pulpal
necrosis.
• Gartner et al 1976: described the classic radiographic appearance of IRR as an oval-
shaped enlargement of uniform density with the pulp space. Clinical symptoms generally
do not develop until the lesion expands to create a perforation or pulpal involvement
progresses to symptoms of pulpitis or pulpal necrosis with infection.
• Mummery 1920: Clinically, a pinkish hue may be observed in cases of coronally located
IRR (generally an uncommon nding)
• Caliskan, Turkun 1997: Prognosis of teeth with internal resorption. Reported a 100%
success rate of root canal therapy of nonperforating lesions at 2 and 4 years
postoperative (16/16 cases). 25% for perforating lesion (1/4 cases)
• Haapasalo et al 2012: internal resorption was frequently detected in teeth with pulpitis
and pulp necrosis. The lesions are not likely to be detected by conventional clinical or
radiographic methods because of their small size. The development of complete pulp
necrosis stops the growth of the resorption. The high frequency of such lesions
(concavities) offers one more reason to irrigate canals thoroughly with sodium
hypochlorite during treatment. None of the 9 teeth with healthy pulps revealed signs of
internal resorption. Four of the 8 teeth with pulpitis (50%) and 10 of the 13 teeth with
necrotic pulps (77%) had internal resorption (P < .01). the present ndings do emphasize
the importance of irrigation with sodium hypochlorite in endodontic treatment because it
can be assumed that at least some of the concave lesions in the canal walls will not be
mechanically cleaned by instruments. The results suggest that even the majority of teeth
with necrotic pulps have resorption lacunae, which may contain necrotic tissue and
bio lms, both of which must be targeted by thorough irrigation with sodium hypochlorite.
• Internal Resorption Tx.
• If detected early, treatment of IRR is predictable.
• Wedenberg: Normal Pulp is replaced with periodontal-like CT.
• Caliskan, Turkun 1997:
• >90% success with non-perforating resorption using 1 wk Ca(OH)2 and warm
GP; 25% success with perforating defect
• Small sample size
• Etiologic factors: #1: Trauma, #2: Caries
• Most Common Location: Middle 1/3rd of canal, Maxillary Anteriors
• RCT w/ 1 week CaOH2 and GP obturation (warm condensation) is the
treatment of choice for non-perforating internal resorptive defects.
• If perforated, CaOH2 (remineralization) should be attempted, but surgery may
be necessary.
• Non Perforating Internal Resorption: (100% at 2-4 yrs post op) > 90% success
• Perforating Internal Resorption: 25% success
• Stamos: Recommends US to debride and warm GP to obturate

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 • Frank: without perforation - pulpectomy, obturate with GP. with perforation and no
communication with sulcus - pulpectomy, Ca(OH)2, obturate w/ GP. with perforation
and communication with sulcus: pulpectomy, obturate w/ GP, surgical repair or ortho
extrusion.
• Although no studies have been published examing MTA’s ability to treat perforating
IRR, Mente et al 2014 demonstrated that MTA can successfully repair iatrogenic
perforations.
• External In ammatory Resorption
• Vier, Figueiredo 2002: Apical resorption secondary to periradicular pathology is
generally transient. Found that 86% of cases with apical periodontitis had associated
external in ammatory root resorption due to infectious stimuli. As long as endodontic
therapy is initiated in these cases, resorption will arrest.

• Tronstad 1988–
• Progressive External In amm Resorption: Damage (Trauma, root planing) to
external root surface denudes areas of precementum/cementoblasts chemotactic
for hard tissue resorbing cells (osteoclasts/odontoclasts), Pulpal infection sustains
clastic cells.
• Generally endodontic or orthodontic in orgin.
• Traumatic dental injuries, including luxation and avulsions injuries, are associated
with more extensive injuries to the precementum and cementoblastic layer. This
coupled with pulpal necrosis and infection, can result in more extensive EIRR
despite endodontic intervention. With persistent in ammation or infection, EIRR
progresses.
• Trope 2002 – Review Root Resorption – Pulp space infection – bacteria/TEBs pass
through dentinal tubules and stimulate an in ammatory response in the PDL –
Multinucleated giant cells bind/resorb the denuded root surface and continues until the
stimulus is removed
• Gartner – Buccal object rule to differentiate external from internal resorption
• Patel – CBCT to differentiate external cervical from internal resorption
• Cwyk, Tronstad et al 1984: showed that nearly 30% of orthodontically treated incisors
had some degree of EIRR, compared with less than 5% in controls.
• Massler & Malone 1954: Reported some degree of root resorption in 86% of ortho
patients.
• Zahrowski, Jeske 2011: Systematic Review. high correlation between external
in ammatory root resorption and intrusive and rotation type ortho movements. A
predisposition to endodontic disease can also increase the risk if EIRR.
• Brin et al 1991: reported an increased prevalence of resorption following orthodontic
movement of previously traumatized teeth. Following cessation of orthodontic
movement, resorption generally ceases.
• Chen, Teixeira, Ritter, Trope 2008: Effect of intracanal anti-in ammatory medicaments
on external root resorption of replanted dog teeth after extended extra oral dry time.
Showed evidence supporting use of Ledermix and Triamcinolone in dealing with external
root resorption.
• Trope 2000: (Review) Luxation Injuries and External Root Resorption: Etiology,
Treatment, Prognosis. When a tooth sustains a luxation injury, attachment damage of
varying degrees will occur. In addition, necrosis of the pulp might result, thereby making
the pulp space susceptible to infection. These circumstances can lead to root resorption.
When the permanent tooth erupts, resorption occurs only under pathologic conditions.

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 This fact appears to be due to the anti-resorptive properties of the precementum
covering of the root that protects it in the presence of in ammation. However, if a luxation
injury removes or alters the precementum, the in ammatory response will include root
resorption with multinucleated clastic cells in addition to “usual” bone resorption. When
the injury is localized (concussion, subluxation) mechanical damage to the cementum
occurs, which results in a local in ammatory response and a localized area of root
resorption. If no further in ammatory stimulus is present, periodontal healing and root
repair will ocurr w/in 14 days. When the traumatic injury is more severe (intrusive
luxation or avulsion w/ extended dry time), involving diffuse damage on more than 20%
of the root surface, an abnormal attachment occur after healing. The initial reaction as
always is in ammation in response to severe mechanical damage of the traumatic and
concomitant injuries to the root surface. After the initial in ammatory response, the result
is a diffuse area of root surface devoid of cementum. Cells in the vicinity of the denuded
root compete to repopulate it and often cells that are precurors of bone - rather than slow
moving PDL cells - will move across from the socket wall and populate the damaged
root. Bone comes into contact with the root w/out an intermediate attachment apparatus.
This phenomenon is termed dentoalveolar ankylosis. The root is resorbed by osteoclasts
and bone is laid down instead of dentin. Ankylosis and osseous replacement generally
cannot be reversed. The tooth should be repositioned to its original location as soon as
possible and as atraumatically as possible. If splinting is necessary, it should be
performed with a functional (nonrigid) splint for 7-10 days. In teeth with closed apices,
revascularization cannot occur. These teeth should be endodontically treated within 7-10
days before the ischemically necrosed pulp becomes infected. When RCT is initiated
later than 10 days after the accident or if active resorption is observed, the preferred
antibacteiral protocol consists of chemomechancial preparation followed by long-term
dressing with densely packed Ca(OH)2.
• External In ammatory Resorption Tx
• Trope: Long term (12wks) Ca(OH)2 may be more effective than 1 wk for established
in ammatory root resorption
• Apical In ammatory Root Resorption (secondary to AP)
• Vier & Figueiredo 2002: Apical resorption secondary to periradicular pathology is
generally transient. Found 86% of cases with apical periodontitis had associated EIRR
due to infectious stimuli. As long as endo therapy is initiated in these cases, resorption
will arrest.
• Johnson: Necrotic teeth with AP had more apical resorption than those with a normal
periapex or irreversible pulpitis
• Malueg 1996: External apical resorption present in teeth with pulpal necrosis, but can
also be in irreversible pulpitis. Authors use this to justify short lls in teeth.
• Nair 2000; Trope 2002 - Dental hard tissues (dentin/cementum) are resorbed in apical
periodontitis by multinucleated giant cells (odontoclasts)
• Felippe 2009 – Apical In ammatory root resorption produces irregular apical root
surfaces and can modify the AF, changing the working length and resulting in
instrumentation beyond the AF (see Weiger – overinst. WL 0-2)
• Malueg/Wilcox/Johnson 1996 – SEM of external apical root resorption. Necrotic teeth
w/ AP had more apical root resorption than Normal or I.P.
• Laux/Abbott 2000 – Radiographic/Histo correlation apical root resorption
• Vier 2004 –75% of teeth with PARLs had apical internal in ammatory resorption, likely in
conjunction with apical external in ammatory resorption of cementum; Vital teeth had
signi cantly less resorption

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 • Nair 2000: Along with bone resorption, some apical parts of the root will be lost as well.
This nding was con rmed by Wilcox who showed that necrotic teeth with apical
periodontitis had more apical resorption than teeth with normal apical tissue. Always
consider the possibility of root end resorption and open apex in cases with large
lesions.
• Ortho Tx, Resorption and Endo
• Yamaguchi et al 2006: Compressed PDL cells obtained from patients with severe
external root resorption produced large amount of RANKL, and decreased production of
OPG and also stimulated osteoclast formation in a time and magnitude dependent
manner. These results suggest that the PDL cells subjected to compressive force may
play an important role in the occurrence of severe external apical root resorption during
ortho tx through the mechanism of up-regulating osteoclastogenesis by formation of
RANKL.
• Thonen, Zhender et al 2013: Found a low incidence of ICRR at 0.9% in molars subject
to orthodontic forces, with increased associations in areas of long-duration or larger
movement. Likelihood of developing ICCR appears low.
• Esteves et al 2007: showed that there was no signi cant difference in apical root
resorption, observed radiographically, in endodontically treated and untreated teeth
subjected to orthodontic movement. This study also agreed with data from the literature
in which practically all teeth show some degree of external root resorption during dental
movement.
• Mattison – No difference was seen in external root resorption between endodontically
treated teeth and vital teeth when subjected to orthodontic forces.
• Reitan – Ortho movement too quickly = Pressure induced in ammatory Root Resorption
(OIRR)
• Hamilton, Gutmann 1999: IEJ. Review. A traumatized tooth can be moved
orthodontically with minimal risk of resorption, provided the pulp has not been severely
compromised (infected or necrotic). If there is evidence of pulpal demise, appropriate
endodontic management is necessary prior to orthodontic treatment. If a previously
traumatized tooth exhibits resorption, there is a greater chance that Orthodontic tooth
movement will enhance the resorptive process. If a tooth has been severely traumatized
(intrusive luxation/avulsion) there may be a greater incidence of resorption, with or
without root canal treatment.
• deSouza 2006 – dog study - Ortho movement (5 months) delayed but did not prevent PA
healing in comparison to NSRCT (2 stage) teeth without ortho movement
• Zahrowski, Jeske 2011: Systematic Review. high correlation between external
in ammatory root resorption and intrusive and rotation type ortho movements. A
predisposition to endodontic disease can also increase the risk if EIRR.
• Brin et al 1991: reported an increased prevalence of resorption following orthodontic
movement of previously traumatized teeth. Following cessation of orthodontic
movement, resorption generally ceases.
• Cwyk, Tronstad et al 1984: showed that nearly 30% of orthodontically treated incisors
had some degree of EIRR, compared with less than 5% in controls.
• Massler, Malone 1954: Reported some degree of root resorption in 86% of ortho
patients, related to factors including patient age, sex and systemic conditions.
• Thonen et al 2013: The occurrence of cervical invasive root resorption after orthodontic
treatment is very low (.02%, Heithersay 1999).

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 • Cwyk 1984: Showed that nearly 30% of orthodontically treated incisors had some
degree of external in ammatory root resorption compared with less than 5% of controls.
Ortho resorption can occur apically or laterally, dependent on vector of force.
• Mattison 1984: There is NSD in the external root resorption between RCT treated tooth
and vital teeth when subjected to ortho force.
• Pressure Resorption
• Occurs in response to direct damage to the precementum. The dental pulp is not
involved and some outside factor must be present to create this physical damage.
• Tronstad 1988: pressure resorption can occur secondary to misaligned tooth eruption,
slow-growing tumors or cysts and orthodontic movement. For ortho related resorption,
progression will cease once orthodontic movement stops.
• Bleaching Resorption
• Rotstein, Friedman 1991: 30% hydrogen peroxide when heat resulted in external
cervical resorption. Ca(OH)2 did not protect against resorption.
• Harrington, Natkin 1979: External Root resorption associated with bleaching of pulpless
teeth. Diffusion of beaching material through the dentinal tubules might be a cause of
cervical root resorption. In order to prevent possible cervical root resorption after internal
bleaching, it is recommended to place a cervical/ori ce barrier slightly coronal to CEJ
level.
• Bastos, Silva et al 2017: JOE. To investigate the expression patterns of in ammatory
cytokines and chemokines in teeth extracted from patients presenting with in ammatory
external root resorption (IERR) and replacement external root resorption (RERR) after
replantation of avulsed teeth. IL-4 has an inhibitory effect on osteoclast formation and is
antiresorptive. Higher IL-4 with increasing age can be explained by the lower rate of RERR in
older patients. On the other hand, IL-4 did not vary in IERR. Since IERR pathogenesis is
similar to PA lesions (in ammatory), IL-4 has a minor role in suppressing infection-stimulated
resorption. TNF-α is proresorptive, especially in response to infection, and activates and
recruits osteoclasts. IERR had higher TNF-α compared to RERR, consistent with the
microbial etiology of IERR.

Bleaching
• Spasser: Described Sodium Perborate walking bleach technique
• Smith & Cunningham 1992: Recommended seal canal ori ces with 2mm Cavit prior to
walking bleach.
• Nutting, Poe: recommend superoxol + Sodium perborate for greater ef cacy; change every
week; Nutting coined term “walking bleach”
• Rotstein 1991: Sodium perborate and water just as effective as 30% hydrogen peroxide
• Tran, et al 2017: JOE. Internal bleaching of discolored teeth uses sodium perborate reacting
with water to form the active agent, hydrogen peroxide (H2O2). This study measured the
depletion rate of hydrogen peroxide from sodium perborate as a bleaching agent. The H2O2
concentration rapidly peaked within 27 hours and reached a plateau by about 3 days (75
hours). Low levels of H2O2 were evident beyond 3 days and for at least 28 days. No
signi cant differences were found between the 2 sodium perborate products. There was also
no signi cant difference in the depletion rate between the different ratios. Conclusions: Based
on the chemistry of H2O2 depletion, the minimum replacement interval for the bleaching agent
is 3 days. Frequent replacements of the perborate clinically may be unnecessary because of
the continued presence of low H2O2 levels for at least 28 days.

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• Holmstrup: Sodium perborate and water very effective at 3 yrs, no case of resorption
• Madison, Walton: Bleaching factors associated with resorption: heat with 30% hydrogen
peroxide
• Weiger 1994: no sig difference between sodium perborate mixed with 3-30% H202 and with
water. However, the whitening effect can take longer so more frequent changes may be
necessary.
• Rotstein: heating and diffusion of hydrogen peroxide through patent dentinal tubules
associate with resorption
• Rotstein: to prevent resorption —> use 2mm base material at the CEJ; also recommends
water instead of superoxol/30% hydrogen peroxide
• Gimlin, Schindler: Treatment of post-bleaching cervical resorption. remove 2mm of GP,
Ca(OH)2 long term
• Walton: Internal bleaching is effective at bleaching tetracyline stained teeth
• Abou-Rass: for tetracyline stained teeth recommends intentional RCT + internal bleaching
• Incidence of post-bleaching cervical resorption:
• Friedman- 7%
• Abou-Rass 0%
• Heithersay- 2%
• Does bleaching affect bonding of composite restorations?
• Titley & Torneck – H2O2 may inhibit resin polymerization
• Demarco – short term use of Ca(OH)2 restores bonding capabilities
• Is internal bleaching effective?
• Glockner - 5 yrs later; pts are 98% satis ed; 80% subjective success for dentists
• Abou-Rass - 7% darker at 3-15 yr follow-up, 93% satis ed 3-15 yr f/u
• Is vital tooth bleaching effective?
• Haywood – 92% experience some lightening; 66% experienced transient side effects
• Ritter – safe for the pulp up to 10 yrs post-op; bleaching effectiveness may decline
• Cohen - no harm to pulp (histo)
Regen Endo
• Regenerative endodontics refers to the biologically based procedures designed to
physiologically replace damaged tooth structures including dentin and root structures as well
as cells of the pulp-dentin complex. Techniques facilitate both disinfection of the root canal
space and ingrowth of stem cells capable of regenerating dental hard tissues.
• Traumatized teeth vs Dens Evaginatus in premolars (Dr. Bakland - states DE in premolars
has a more predictable outcome for REGEN due to remaining vital pulp attached to walls in
apical areas vs traumatized teeth that have been deprived of blood supply) (Dr. Bakland likes
the term neovascularization vs revascularization) (If there’s a little apical resorption, when
talking with referring dentists a more positive term for apical resorption is “remodeling”)
• Tong et al 2017: JOE. Systematic Review. Success rates for tooth survival and resolution of
periapical pathosis were excellent; however, results for apical closure and continued root
development were inconsistent. There are few well-reported randomized prospective clinical
studies. Reporting of long-term outcomes and late- stage effects was sparse. No study
evaluated health economic outcomes and improvements to patients’ quality of life.
Conclusions: Many knowledge gaps still exist within the studies published. Current published
evidence is unable to provide de nitive conclusions on the predictability of RET outcomes.
• Kahler, Rossi-Fedele, Chugal, Lin 2017: JOE. Systematic Review. Review of the ef cacy of
treatment approaches for immature permanent teeth with pulpal necrosis. Two fundamental
assumptions for teeth treated with regenerative endodontic procedures (REPs) are (1) that

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 the clinical outcome is comparable with the traditional techniques of calcium hydroxide
apexi cation and mineral trioxide aggregate apical barrier techniques and (2) that REPs will
result in further root maturation.
• Immature teeth with pulp necrosis treated with REPs generally show further root
maturation although the results are variable. Clinical outcomes were similar for both
groups. Patient-based criteria such as tooth discoloration, indications for changing the
treatment option, and number of treatment appointments are all important for discussion
before electing the appropriate treatment plan for the management of immature teeth
with pulp necrosis.
• REPs were associated with variable degrees of further root maturation unlike the
alternative treatment procedures. Tooth survival and clinical and radiographic healing
success rates were similar for REPs and alternative treatments. REPs may be
associated with more adverse effects.
• Ruparel, Teixeira, Diogenes 2012: JOE. Collectively, our data show that high concentrations
of antibiotics have a detrimental effect on SCAP survival, whereas lower concentrations as
well as Ca(OH)2 at all tested concentrations are conducive with SCAP survival and
proliferation. These studies highlight the clinically important point that intracanal medicaments
must be used at concentrations that are bactericidal while having minimal effects on stem cell
viability.
• Trevino, Hargreaves, Diogenes 2011: JOE. Irrigation with 17% EDTA best supported cell
survival (89% viability; P < .001 versus all other groups), followed by irrigation with 6%
NaOCl/17% EDTA/6% NaOCl (74%; P < .001 versus the 2 groups containing 2% CHX).
Conversely, protocols that included 2% CHX lacked any viable cells.
• Hargreaves 2008: rst landmark perspective paper on regendo.
• Ding 2009: one of the rst to raise issues: 1. recalls can be dif cult. 2. bleeding not always
provokable. 3. may want to consider LA w/out epi. One of the rst studies to attempt a
systematic study of regenerative technique
• Kling, Cvek, Majare 1986: Luxation injuries. The potential for revascularization depends
primarily on the width of the apical constriction at the time repositioning. If the width is 1.0mm
or more, revascularization is considered possible. The wider the apical opening is, the higher
the likelihood of revacularization.
• Historical Papers
• Nygaard-Ostby 1961: started IDEA of regendo. evaluated a revascularization method
for reestablishing a pulp-dentin complex in permanent teeth with pulpal necrosis. He
hypothesized that a blood clot could be the rst step in the healing of a damaged dental
pulp, similar to the role of the blood clot in the healing process observed in other areas
• Hermann: described the application of calcium hydroxide (Ca[OH]2) for vital pulp
therapy
• Rule, Winter 1966: published report that disinfection could be established primarily with
inter-appointment medication with polyantibiotic mixes (three different formulations used
in ve cases)
• Skoglund 1978: (historical) revascularization is feasible. Images of revascularization still
referenced. Revitalization occurs with neovascularization coronally from apex. (barium
sulfate to reveal blood ow in extracted and immediately replanted/autotransplanted
teeth in 4 month old beagles)
• Myers 1974: Monkeys. (historical only) attempts at looking at blood as a scaffold for
regendo. In monkeys with induced PARL’s
• Requirements for REGENDO

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 • Law 2013: Regen endodontics requires a necrotic pulp, an immature apex, no need for
a post and core restoration, and parental compliance. Following minimal instrumentation,
the placement of an intracanal medicament is indicated for 2 to 4 weeks.
• Langer and Vacanti 1993: Regen endo is a tissue engineering procedure that facilitates
development of hard tissue. Requirements included: stem cells, growth factors and a
scaffold.
• Stem Cells
• Chrepa, Diogenes et al 2017: JOE. Apical papilla was retrieved clinically from an
immature tooth with necrotic pulp. Apical papilla stem cells maintained vitality and
stemness despite in ammation. Apical papilla was vital despite moderate in ammatory
in ltrates. In amed apical papilla expressed high mineralization and angiogenic
potential.
• Machado, Nascimento et al 2016: IEJ. Dental pulp stem cells are found in the vicinity
of blood vessel and nerve bers, which suggests the possible existence of more than
one stem cell niche in the dental pulp. Aldehyde Dehydrogenase 1 was expressed by
isolated dental pulp cells, which has mesenchymal stem cell characteristics. ALDH1 is
an intracellular enzyme that has been used to isolate and purify different population of
stem cells.
• Lovelace, Hargreaves, Diogenes 2011: Showed that mesenchymal stem cells that
in ltrate the canal space originate in the apical papilla. It was found that there is a
substantial in ux of mesenchymal stem cells into root canals during regenerative
procedures resulting in an increase greater than 700-fold in the expression of MSC
markers. (SCAP cells are present in the apical papilla during regendo procedures (Know
that stem cells come from SCAP, SHED). Measured STRO-1, CD105 and CD 73
mesenchymal stem cell markers)
• Nakashima, Iohara, Murakami 2013: Talks about dental pulp stem cells (DPSC).
DPSCs have dentin/pulp repair and regenerative potential. DPSCs can be acquired from
discarded permanent teeth including 3rd molars, supernumerary teeth, or orthodontically
unnecessary teeth. DPSCs are self-renewing and give rise to a variety of cells types in
vitro (osteoblasts, ,chondrocytes, adipocytes, etc). In vivo, DPSCs can differentiate into
odontoblasts and induce host cells to participate in regeneration by generating a dentin/
pulp-like complex after subcutaneous transplantation (in mice).
• About 2001: Dental pulp stem cells are recruited to the site of injury following a gradient
of chemotactic agents released by resident immune cells and from the damaged dentin.
• Shi, Gronthos 2003: Dental pulp stem cells (DPSCs) can be found throughout the
dental pulp but are known to accumulate in the perivascular region and the cell-rich zone
of Hohl adjacent to the odontoblastic layer.
• Nakashima 2011: evidence that MSCs have decreased proliferative and differentiation
potential with aging
• Martin et al 2014: demonstrated that irrigation of dentin with 17% EDTA increases the
survival of stem cells and odontoblastic differentiation,
• Althumairy, Diogenes et al 2014: Found that CH promoted stem cell survival and
proliferation.
• Treveno et al 2011: CHX reduced stem cell viability
• Ruparel, Teixeira, Diogenes 2012: JOE. Collectively, our data show that high
concentrations of antibiotics have a detrimental effect on SCAP survival, whereas lower
concentrations as well as Ca(OH)2 at all tested concentrations are conducive with SCAP
survival and proliferation. These studies highlight the clinically important point that
intracanal medicaments must be

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 • Martin, Diogenes et al 2014: high concentrations of NaOCl also reduce stem cell
viability and differentiation. They found that by using a lower concentration of 1.5%
NaOCl followed by a rinse with 17% EDTA cell viability improved.
• Trevino, Hargreaves, Diogenes 2011: Finishing irrigation protocol with EDTA may
improve the survival of SCAP cells. (in vitro cultured SCAP cells placed in organotype
dentin models rinsed with NaOCl, EDTA, NaOCl/EDTA, CHX. Finishing with CHX and
NaOCl resulted in 0% viability. EDTA alone resulted in 88% viability.
• Triple Antibiotic Paste
• Mixture of Cipro oxacin, Metronidazole and Minocycline
• Hoshino, Sato 1996: THE triple antibiotic paste paper, because it demonstrates effects
on clinical samples. Explains why Cipro oxiacin, Metronidazole and Minocycline are
used in Triple antibiotic paste. (clinical cultures collected from carious lesion, pulpitis,
periapical tissue). Bacterial recovery was also reduced to zero in the presence of the
mixture of cipro oxacin, metronidazole, and minocycline, indicating that bacterial ef cacy
was suf cient with the 3mix formulation. Both bacteria from necrotic pulps and carious
lesions were reduced to zero in the presence of the 3mix formulation. Conclusion - the
mixture of cipro oxacin, metronidazole, and minocycline is an effective combination to
eliminate bacteria from infected dentin, in necrotic pulps and carious lesion. Adding
rifampicin is not necessary, but using only one of the drugs alone is not suf cient to
eliminate all of the bacteria.
• Sato, Hoshino 1996: Triple antibiotic paste works with E. coli
• Windley, Sigurdson, Trope 2005: Trope beginning his investigation in regendo.
Demonstrates ANTIBIOTIC effectiveness of triple antibiotic paste in dogs. (dog teeth
infected then disinfected with NaOCl irrigation and triple antibiotic paste. CFU reduction
noted). 70% effectiveness. Dog study.
• Ruparel, Diogenes 2012: Antibiotic pastes are effective antimicrobials, but their
negative effect on stem cell viability makes their use in regen protocols problematic.
Found CH did not reduce stem cell viability
• Nagata, Gomes et al 2014: Found no difference in bacterial reduction between triple
antibiotic paste and CH
• Jacobs et al 2017: JOE. Investigated the direct and residual antibacterial effects of
intracanal antimicrobials against bacterial bio lms obtained from infected mature and
immature teeth with necrotic pulps.
• All antimicrobials showed signi cant direct antibacterial effects regardless of the
bio lm source. Dentin pretreated with 5 mg/mL DAP provided signi cantly higher
residual antibacterial effects in comparison with all other groups regardless of the
source of bio lm. Dentin pretreated with calcium hydroxide did not show any
residual antibacterial effects.
• Tested antimicrobials showed signi cant direct antibacterial effects. Only 5 mg/mL
DAP exhibited signi cant residual antibacterial effects against bacterial bio lms
from an infected root canal of an immature tooth.
• Besides TAP, what else is used for disinfection?
• Nagata 2014: compared the long term effectiveness of two different revascularization
methods: 1) Using Tri antibiotic past, 2) CaoH as intracanal medicament.
Revascularization outcomes for traumatized patients treated with the tested protocols
presented similar clinical and radiographic data. However, TAP caused esthetic problem
leading to tooth discoloration, which can be considered a disadvantage when compared
with CaOH. Also another issue was addressed by Berkhoff (JOE, 2014) who showed
that Current irrigation techniques do not effectively remove TAP from root canal systems,

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 possibly because of its penetration and binding into dentin. However, calcium hydroxide
is effectively removed with signi cant less residual presence.
• Hargreaves: recommended minimal instrumentation and use of gentle irrigation to begin
disinfection
• Bose, Hargreaves 2009: CH can be used as an adjunct to antibiotics in disinfecting
canal. Ca(OH)2 and triple antibiotic paste when used as an intracanal medicament in
immature necrotic teeth can help promote further development of the pulp- dentin
complex.
• Nosrat et al 2013: Recommended augmentin for disinfection purposes.
• Ruparel, Diogenes 2012: Antibiotic pastes are effective antimicrobials, but their
negative effect on stem cell viability makes their use in regen protocols problematic.
Found CH did not reduce stem cell viability
• Nagata et al 2014: Found no difference in bacterial reduction between triple antibiotic
paste and CH
• Althumairy, Diogenes et al 2014: Found that CH promoted stem cell survival and
proliferation.
• Martin et al 2014: high concentrations of NaOCl also reduce stem cell viability and
differentiation. They found that by using a lower concentration of 1.5% NaOCl followed
by a rinse with 17% EDTA cell viability improved.
• Demonstrated REGENDO: Case Reports, Animal Studies, Retrospective study, 1 RCT
• Iwaya 2001: The original, rst regendo case report from Japan published in “Dental
traumatology”. (Case report of regendo on 13 y/o female w/ longstanding abscess on
#29.)
• Branchs, Trope 2004: The rst reported regendo case in the US published in JOE. (11
y/o Japanese boy treated at UNC)
• Thibodeau, Trope 2007: Dog Study. Classic, well known regendo paper. 1. First to
actually demonstrate regendo in dogs. 2. blood clot and collagen performed statistically
same, but tendency for blood clots or collagen/blood clots to perform better. Suggests
that blood clots may be particularly bene cial in regendo. (infected dog teeth, irrigated
with NaOCl, TAP, then a.)blood clot, b.)collagen and c.)blood clot and collagen placed.
All groups performed the same
• Jung, Hargreaves 2008: regeneration successful w/ or w/out intracanal blood clot.
(Case series of 4 patients in each group with and w/out blood clot)
• Bose, Hargreaves 2009: retrospective study, we collected radiographs from 54
published and unpublished endodontic regenerative cases and 40 control cases (20
apexi cation and 20 nonsurgical root canal treatments). The results showed
regenerative endodontic treatment with triple antibiotic paste (P < .001) and Ca(OH)2 (P
< .001) produced signi cantly greater increases in root length than either the MTA
apexi cation or NSRCT control groups. The triple antibiotic paste produced signi cantly
greater differences in root wall thickness than either the Ca(OH)2 or formocresol groups
(P < .05 for both). The position of Ca(OH)2 also in uenced the outcome. When Ca(OH)2
was radiographically restricted to the coronal half of the root canal system, it produced
better results than when it was placed beyond the coronal half. Conclusions: Ca(OH)2
and triple antibiotic paste when used as an intracanal medicament in immature necrotic
teeth can help promote further development of the pulp- dentin complex.
• Jeeruphan, Hargreaves et al 2012: JOE. Mahidol Study. Retrospective. In this study,
revascularization was associated with signi cantly greater increases in root length and
thickness in comparison with calcium hydroxide apexi cation and MTA apexi cation as
well as excellent overall survival rates. The survival rate of the revascularization-treated

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 teeth (100%) and MTA apexi cation-treated teeth (95%) were greater than the survival
rates observed in teeth treated with calcium hydroxide (77.2%).Clinical outcome data
and radiographs were collected from 61 cases (ie, 22 calcium hydroxide apexi cation
cases, 19 MTA apexi cation cases, and 20 revascularization cases).
• Nagy et al 2014: JOE. RCT. n = 36. The present study was performed to assess the
regenerative potential of young permanent immature teeth with necrotic pulp after the
following treatment protocols: (1) a mineral trioxide aggregate (MTA) apical plug, (2) the
regenerative endodontic protocol (blood clot scaffold), and (3) the regenerative
endodontic protocol with a blood clot and an injectable scaffold impregnated with basic
broblast growth factor. After a follow-up period of 18 months, most of the cases showed
radiographic evidence of periapical healing. Groups 2 and 3 showed a progressive
increase in root length and width and a decrease in apical diameter. The regenerative
endodontic procedure allowed the continued development of roots in teeth with necrotic
pulps. The use of arti cial hydrogel scaffold and basic broblast growth factor was not
essential for repair.
• Alobaid, Gibbs et al 2014: JOE. Retrospective study. In this study, revascularization
was not superior to other apexi cation techniques in either clinical or radiographic
outcomes. Studies with large subject cohorts and long follow-up periods are needed to
evaluate outcomes of revascularization and apexi cation while accounting for important
covariants relevant to clinical success. The majority of treated teeth survived throughout
the study period, with 30 of 31 (97%) teeth surviving (18/19 [95%] revascularization and
12/12 apexi cation). Most cases were also clinically successful, with 27 of 31 (87%)
meeting criteria for success (15/19 [78%] revascularization and 12/12 apexi cation;
nonsigni cant difference). A greater incidence of adverse events was observed in the
revascularization group (8/19 [42%] vs 1/12 [11%] in apexi cation)
• Saourd, Lin et al 2016: JOE. 3 Case reports. regenerative endodontic procedures have
the potential to be used to treat traumatized teeth with pulpal necrosis, horizontal root
fracture and in ammatory root resorption.
• Estefan, Diogenes et al 2016: It was found that revascularization procedures can be
implemented in any age ranging from 9 to 18 years; however, younger age groups were
better candidates for revascularization procedure than older ones. Regarding the apical
diameter, regeneration procedures were successful with apical diameters as small as
0.5 mm. However, teeth with preoperative wider diameters (≥1 mm) demonstrated
greater increase in root thickness, length, and apical narrowing.
• What Type of Tissue is formed/regenerated?
• Wang, Thibodeau, Trope 2010: The “regenerated” tissue really looks like cementum,
PDL and Bone. (Regendo dog teeth histologically examined and tissue characterized)
• Andreasen, Bakland 2011: We should consider what type of tissue we want to generate
in regendo procedures. (We don't know enough about what kind of tissue is generated
and how to predictably generate it in order to make recommendations regarding
procedures to make good long term prognosis)
• Nosrat, Torabinejad et al 2015: 2 case reports of extracted human premolars that
under went REGENDO w/ blood clot + MTA and were extracted 4 month later. Results:
Both patients remained asymptomatic after treatment. Radiographic examination of the
teeth showed signs of root development after treatment. Histologic examination of
tissues growing into the root canal space of these teeth shows the presence of
connective tissue, bone and cementum formation, and thickening of roots. Conclusions:
Based on our ndings, it appears that when canals of teeth with open apices are treated

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 with regenerative endodontics, tissues of the periodontium grow into the root canals of
these teeth
• Torabinejad, Shabahang et al 2014 & 2015: Pilot (21 teeth) + Animal study (Twenty-
four canine teeth from 6 immature ferrets were used.) The use of PRP or blood clots as
scaffolds results in the ingrowth of bone-like, cementum-like, and connective tissue in
the apical third of the roots at inconsistent rates.
• Reported REGENDO Techniques
• Fouad, Nosrat 2013: Review. Regenerative techniques in an infected space, where the
bacteria cannot be totally eliminated, will always have to go hand in hand with
antimicrobial strategies until the regenerated soft tissue has suf cient vascularity and
immune response to spontaneously continue its defense mechanisms. (for replanted
traumatized teeth, the probability of revascularization is found to be on average about
18%. revascularization is more likely if the apex is wider and the root development is
less. Shorter pulp length more conducive to revascularization. high concentrations of
NaOCl has shown to be cytotoxic to stem cells, and 2% CHX was the most cytotoxic to
SCAP. TAP was determined to be effective in disinfecting the canal space.
• Petrino, Bowles, McClanahan 2010: JOE.
• rst to report:
• 1. collaplug to control MTA.
• 2. Successful use of LA w/out epi to induce bleeding
• Results from this case series show that revascularization is a technically
challenging but effective treatment modality for the immature tooth with apical
periodontitis. Based on this case series, the following recommendations are made
to help with the revascularization technique: (1) clinicians should consider the use
of an anesthetic without a vasoconstrictor when trying to induce bleeding, (2) a
collagen matrix is useful for the controlled placement of MTA to a desired and
optimal level, (3) patients/parents should be informed about the potential for
staining, especially in anterior teeth when the paste contains minocycline, and (4)
patient/parent compliance with the necessary multiple appointment treatment plan
may be signi cant for case selection.
• Trope 2008: Provides a general summary on regeneration procedures and what is
known to date. Advocates the 5.25% NaOCl + triple antibiotic paste disinfection, blood
clot scaffold,and double barrier of MTA and bonded resin. However, more research is
necessary. In the unexposed pulp, the younger the pulp, the better its repair potential. In
the exposed pulp, vital pulp therapy on traumatically exposed pulps is very successful,
but less so on cariously exposed pulps. Success rates are dependent on the status of
the pulp. Another
• Trevino, Hargreaves, Diogenes 2011: Finishing irrigation protocol with EDTA may
improve the survival of SCAP cells. (in vitro cultured SCAP cells placed in organotype
dentin models rinsed with NaOCl, EDTA, NaOCl/EDTA, CHX. Finishing with CHX and
NaOCl resulted in 0% viability. EDTA alone resulted in 88% viability. (Intracanal
disinfection is a crucial step in regenerative endodontic procedures. However, this novel
endodontic treatment lacks standardization. Hargreaves (2011, JOE) assessed the
survival of stem cells from the apical papilla (SCAP) following different irrigation
protocols. Irrigation with 17% EDTA best supported cell survival followed by irrigation
with 6% NaOCl/17% EDTA/6% NaOCl. Conversely, protocols that included 2% CHX
lacked any viable cells. )
• Scaffolds

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 • Torabinejad 2011: PRP can be used as a scaffold in cases where bleeding cannot be
stimulated. (Case Report)
• Yamauchi 2011: Demonstrated that the use of cross-linked collagen scaffold and
exposure of dentin matrix combined with blood clot might provide an ef cient approach
to generate a vital support structure for the treatment of immature teeth with apical
periodontitis.
• Bezgin 2015: Current research is concerned with discovering better scaffolds for use in
regenerative endodontic treatment. platelet-rich plasma (PRP) has been suggested by
some articles as a superior alternative for Blood clot. Bezgin (JOE, 2015) stated that
PRP successfully created a scaffold for regenerative endodontic treatment; however,
treatment outcomes did not differ signi cantly between PRP and conventional BC
scaffold.
• Cavalcanti et al 2015: data suggest that self-assembling peptide hydrogels might be
useful injectable scaffolds for stem cell-based Regenerative Endodontics.
• Cavalcanti et al 2013: Under the experimental conditions described, dental pulp stem
cells survived and proliferated in a self-assembling peptide hydrogel. This class of
materials represents a promising new alternative of injectable scaffolds for dental pulp
tissue engineering.)
• Torabinejad, Shabahang et al 2014 & 2015: Pilot (21 teeth) + Animal study (Twenty-
four canine teeth from 6 immature ferrets were used.) The use of PRP or blood clots as
scaffolds results in the ingrowth of bone-like, cementum-like, and connective tissue in
the apical third of the roots at inconsistent rates.
• Huang 2008: Suggested that the scaffold and growth factors in regendo are derived
from the dentin, brin clot and sterilized pulp tissue remnants.
• Kwon, Min et al 2017: JOE. Cultured collagen scaffolds treated with Epigallocatechin
Gallate, an Antibacterial Cross-Linking Agent, promoted proliferation and differentiation
of human dental pulp cells. Elevated mechanical properties of this scaffold may facilitate
this cellular behavior.
• Diogenes et al 2017: JOE. This research provided evidence that Restylane, an FDA-
approved HA-based injectable gel, promoted cell viability, mineralization, and
odontoblastic-like differentiation when cultured with SCAP.
• Jiang, Liu, Peng 2017: JOE. RCT. The results of 40 patients (43 teeth) were included in
the nal analyses. All patients from both groups showed clinical success with complete
resolution of signs and symptoms. Radiographically, the thickness of the dentin wall at
the middle third of the root was higher for the experi- mental group than the control
group. However, other indicators were comparable between both groups. Conclusions:
The use of the Bio-Gide collagen mem- brane promoted the development of the dentin
wall in the middle third of the root in patients undergoing regenerative endodontic
procedures. The convenience of operation and the assured positioning of the sealing
material make the Bio-Gide collagen membrane espe- cially suitable for handling wide
root canals. Only 6 month recall. w/ and w/out membrane.
• Growth Factors
• Huang 2008: Suggested that the scaffold and growth factors in regendo are derived
from the dentin, brin clot and sterilized pulp tissue remnants.
• Widbiller 2016: Ultrasonic activation of irrigants increases growth factor release from
human dentine (Clin Oral Investig.)
• Tomson et al 2013: Extracellular matrix of dentine contains a rich cocktail of soluble
cytokines and growth factors which mediate wound repair of the dentine-pulp complex.

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 calcium hydroxide, a by-product of the use of MTA and Biodentine, appears to underlie
release of bioactive dentin-derived growth factors by these two bioactive materials.
• Abbott 2013: Review of dentin-pulp physiology and pathological regeneration process and to
evaluate biodenine as a pulp capping material. (Conclusion: Following traumatic injuries, the
pulp cells modify the local pulpal microenvironment by secreting growth factors that
orchestrate and induce the process required for dentin-pulp regeneration. Biodentine may
prove to be an effective pulp-capping material. )
• Cooper, Smith 2013: Bottom Line: Teeth will attempt to repair and regenerate their own hard
and soft tissues given the appropriate conditions and environment. If infection and
in ammation go unchecked they will have a signi cant impact on the natural regenerative
responses of the dental tissues.
• Hargreaves, Diogenes, Teixeira 2013:
• An update on clinical regenerative endodontics. There are many case reports of clinically
successful revascularization of a previously necrotic pulp space, and successful REP’s.
However, the predictability of continued root development and the generation of a tissue
that resembles a native dental pulp are still questionable.
• Treatment options: Biological basis of regenerative endodontic procedures. Current
approaches for treating the traumatized immature tooth with pulpal necrosis do not
reliably achieve healing of apical periodontitis, continued root development, and
reestablishment of pulpal immunologic and sensorial competency. Regenerative
endodontics has been de ned as “biologically based procedures designed to replace
damaged structures, including dentin and root structures as well as cells of the pulp-
dentin complex.” Tissue regeneration requires stem/progenitor cells, growth factors, and
scaffolds to control the development of the targeted tissue. First, stem cells are found in
the dental pulp, the apical papilla and even the in amed periapical tissue collected
during endodontic surgical procedures (which may be harvested during clinical
procedures).
• Pang 2014: In regenerative endodontics, it is believed that EDTA induces odontoblast
differentiation by releasing growth factors from the dentin matrix. Nan-Sim Pang (JOE, 2014)
assessed the effectiveness of EDTA on differentiation of dental pulp cell. Results showed that
EDTA induced cell attachment and odontoblastic/osteoblastic differentiation, which was
observed only in the group in which the DPSCs were placed in direct contact with the EDTA-
treated dentin surfaces. These ndings suggest that EDTA is bene cial for achieving
successful outcomes in regenerative endodontics.
• Li et al 2017: JOE. The present study assessed the time to resolution of clinical symptoms
and radiographic changes in root dimensions in immature permanent necrotic teeth with dens
evaginatus. All 20 treated teeth (100%) survived and met the clinical criteria for success
throughout the study period (1 yr). Complete apical closure occurred in 40% of the treated
teeth (8 of 20), and all cases showed at least a 20% decrease in apical diameter by the 6-
month follow-up visit. At 12 months, there was a 23.37% increase in root length across all the
cases in our study.
• Kontakiotis, Filippatos, Agra oti 2014: Regenerative endodontic therapy is considered to
be a safe and effective treatment option. RCTs and/or more high-quality cohort studies would
strengthen the EBD recommendations. However, the current best available evidence allows
clinicians to provide this treatment modality safely to patients. Bottom Line: Regenerative
endodontics will work most of the time. There is no harm in trying.
• It is not surprising that the rate of root maturogenesis is variable because of unique individual
circumstances. It may be that teeth with longstanding necrosis are more likely not to have
remaining viable pulp tissue and perhaps diminished regenerative capacity. Indeed, a number

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 of case reports indicate cases of traumatized incisor teeth where the regenerative procedure
failed to result in further root maturogenesis. Therefore, the many case series reporting 100%
success for regenerative procedures as tabled in Torabinejad and Faras may not re ect true
outcomes for success because it is likely that unfavorable cases are not reported. In a
prospective study by Khalar (JOE, 2014) the mean score for the presence of periapical
radiolucency in the postoperative image was 9.7%. Apical closure after treatment was
assessed as incomplete in 47.2%, and complete apical closure was recorded in 19.4% of
cases.
• AAE Clinical Considerations for a Regenerative Procedure
• Case Selection: • Tooth with necrotic pulp and an immature apex. • Pulp space not
needed for post/core, nal restoration. • Compliant patient/parent. • Patients not allergic
to medicaments and antibiotics necessary to complete procedure (ASA 1 or 2).
• Informed Consent • Two (or more) appointments. • Use of antimicrobial(s). • Possible
adverse effects: staining of crown/root, lack of response to treatment, pain/infection. •
Alternatives: MTA apexi cation, no treatment, extraction (when deemed
nonsalvageable). • Permission to enter information into AAE database (optional).
• First Appointment • Local anesthesia, dental dam isolation and access. • Copious,
gentle irrigation with 20ml NaOCl using an irrigation system that minimizes the possibility
of extrusion of irrigants into the periapical space (e.g., needle with closed end and side-
vents, or EndoVacTM). Lower concentrations of NaOCl are advised [1.5% NaOCl
(20mL/canal, 5 min) and then irrigated with saline or EDTA (20 mL/canal, 5 min), with
irrigating needle positioned about 1 mm from root end, to minimize cytotoxicity to stem
cells in the apical tissues. • Dry canals with paper points. • Place calcium hydroxide or
low concentration of triple antibiotic paste. If the triple antibiotic paste is used: 1)
consider sealing pulp chamber with a dentin bonding agent [to minimize risk of staining]
and 2) mix 1:1:1 cipro oxacin: metronidazole: minocycline to a nal concentration of 0.1
mg/ml. • Deliver into canal system via syringe • If triple antibiotic is used, ensure that it
remains below CEJ (minimize crown staining). • Seal with 3-4mm of a temporary
restorative material such as CavitTM, IRMTM, glassionomer or another temporary
material. Dismiss patient for 1-4 weeks.
• 2 Second Appointment (1-4 weeks after 1st visit) • Assess response to initial treatment.
If there are signs/symptoms of persistent infection, consider additional treatment time
with antimicrobial, or alternative antimicrobial. • Anesthesia with 3% mepivacaine without
vasoconstrictor, dental dam isolation. • Copious, gentle irrigation with 20ml of 17%
EDTA. • Dry with paper points. • Create bleeding into canal system by over-
instrumenting (endo le, endo explorer) (induce by rotating a pre-curved K- le at 2 mm
past the apical foramen with the goal of having the entire canal lled with blood to the
level of the cemento–enamel junction). An alternative to creating of a blood clot is the
use of platelet-rich plasma (PRP), platelet rich brin (PRF) or autologous brin matrix
(AFM). • Stop bleeding at a level that allows for 3-4 mm of restorative material. • Place a
resorbable matrix such as CollaPlugTM, CollacoteTM, CollaTapeTM or other material
over the blood clot if necessary and white MTA as capping material. • A 3–4 mm layer of
glass ionomer (e.g. Fuji IXTM, GC America, Alsip, IL) is owed gently over the capping
material and light-cured for 40 s. MTA has been associated with discoloration.
Alternatives to MTA (such as resin-modi ed glass ionomer [RMGI] or bioceramics [e.g.,
Biodentine®]) should be considered in teeth where there is an esthetic concern. o
Anterior and Premolar teeth - Consider use of Collatape/Collaplug and restoring with
3mm of a nonstaining restorative material followed by bonding a lled composite to the

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 beveled enamel margin. o Molar teeth or teeth with PFM crown - Consider use of
Collatape/Collaplug and restoring with 3mm of MTA, followed by RMGI, composite or
alloy.
• Follow-up • Clinical and Radiographic exam o No pain, soft tissue swelling or sinus tract
(often observed between rst and second appointments). o Resolution of apical
radiolucency (often observed 6-12 months after treatment) o Increased width of root
walls (this is generally observed before apparent increase in root length and often occurs
12-24 months after treatment). o Increased root length. o Positive Pulp vitality test
response • The degree of success of Regenerative Endodontic Procedures is largely
measured by the extent to which it is possible to attain primary, secondary, and tertiary
goals: o Primary goal: The elimination of symptoms and the evidence of bony healing. o
Secondary goal: Increased root wall thickness and/or increased root length (desirable,
but perhaps not essential) o Tertiary goal: Positive response to vitality.
• History: Based on trauma lit of avulsion (open apex w/out contamination = continued root
development)
• Nygaard-Ostby – role of the blood clot in wound healing
• Hermann: Described the application of Calcium Hydroxide for vital pulp therapy.
• Iwaya – 2001 dens evag case report using DAP (found root development by accident, pt
never came for completion of tx)
• Banchs & Trope – 2004 dens evag ( rst case report of intentional regen)
• Discuss how regenerative endo may be achieved?
• Hargreaves –
• 1. Achieved most predictably in teeth with open apices
• 2. Instrumentation with NaOCl irrigation is not suf cient to reliably create the
conditions necessary for revascularization of the necrotic tooth
• 3. Ca(OH)2 placement prevents revascularization coronal to paste
• 4. The use of (3 mix-MP” triple antibiotic paste, developed by Hoshino (consisting
of cipro, metronidazole & minocycline) is effective for disinfection of the necrotic
tooth, setting the conditions for subsequent revascularization
• Three major components of tissue engineering:
• 1. Cell source – i.e. apical papilla
• 2. Physical scaffold – i.e. blood clot or PRP
• 3. Signaling molecules
• What is the technique for regeneration?
• Banchs & Trope- First to described technique
• 1. Flush canal with 20ml NaOCl, 10 ml CHX (no ling) Can use saline in between
• 2. Triple abx paste: 200 mg cipro, 500 mg metronidazole, 100 mg minocycline (3-4
weeks); combine with sterile water for creamy mix; place in canal (lentulo)
• 3. Flush canal with 10ml NaOCl
• 4. Initiate bleeding into canal (endo explorer, large le) 3 mm below CEJ, allow
blood clot to form (15 min)
• 5. MTA, wet cotton pellet, tem access restoration
• 6. Permanent access restoration
• Do irrigants affect stem cells?
• Trevino – EDTA best, CHX worst
• Galler – nal irrigation with 17% EDTA is best
• What are the current recommended concentrations for NaOCl and TAP/DAP in regen?
• AAE recommendations 2013 – 1.5% NaOCl (lowest concentration for antibact and tissue
dissolution properties) Harrison & Hand

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 • Ruparel – TAP or DAP @ 0.01-0.1 mg/ml or Ca(OH)2 **Ca(OH)2 promotes survival and
potentiates proliferation**
• Hoshino showed antibact against endo bugs at 0.001mg/ml
• What can we do to minimize or treat staining in regen?
• Akbari – apply dentin adhesive to chamber walls prior to MTA placement
• Kim – adhesive reduces TAP staining, but does not prevent it completely
• Ilya – case report of internal bleaching after staining w/white MTA
• What else can be used besides triple antibiotic paste?
• Cheuh-used CaOH instead of trip abx paste
• Shah-used Formocresol cotton pellet instead of trip abx paste
• Bose & Hargreaves - Regen with Trip abx paste and CaOH produced sig greater
increases in root length than MTA apexi cation or NSRCT; Trip abx produced greater
wall thickness than CaOH or formocresol; depth of CaOH placement correlated to
dentinal wall thickness (54% increase if restricted to coronal half vs 3% if beyond coronal
half)
• Shin- case report of successful revascularization without use of CaOH or triple abx
paste, just MTA seal
• What are we looking for in success Regen?
• Law - Clinical and Radiographic exam:
• No pain or soft tissue swelling (often observed between rst and second
appointments)
• Resolution of apical radiolucency (often observed 6-12 months after treatment)
• Increased width of root walls (this is generally observed before apparent increase in
root length and often occurs 12-24 months after treatment)
• Increased root length
• apical closure?
• Who talked about the tissue engineering triad and what are the components?
• Nakashima – stem cells, growth factors and scaffold
• What is the source of stem cells in REGENDO?
• Huang – stem cells located in the apical papilla are viable following necrosis
• Sonoyama – identi ed SCAP as mesenchymal stem cells (STRO1) and demonstrated
ability to differentiate into odontoblast-like cells
• Lovelace – recruitment of stem cells with evoked bleeding
• What has been proposed as a scaffold.
• Thibodeau – blood clot
• Torabinejad - PRP
• Cavalcanti - Hydrogel
• Yamauchi - collagen
• Where are the growth factors and how do we access them?
• Anthony Smith’s work – TGFbeta is present in dentin, acid etching can expose TGF
beta on surface
• Galler – dentin conditioning with EDTA promoted adhesion and odontoblast-like
differentiation
• What is the characteristic of the tissue formed with regenerative Tx?
• Wang – cellular cementum-like tissue (resembles cementum, pdl and bone)
• Becerra et al: brous CT, cementum, PDL
• Yamuchi- dog study, 2 mineralized tissues formed in canal, 1 cementoid, 1 osteoid

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 • Shimizu 2012 (human histo) - odontoblast-like cells lining predentin with blood vessels
and loose connective tissue with collagen bers in the canal 3.5 weeks after
regenerative
• Iohara 2011 - Removed the pulp tissue of fully formed teeth, enlarged the apex and
implants stem cells with growth factors. By day 14, there was complete pulpal
regeneration. Used RT- PCR and histology to evaluate the tissue formed. (SDF-1 is
growth factor used to promote neovascularization) **highlights importance of tissue
engineering to promote desired tissue**
• Torabinejad: The use of PRP or blood clots as scaffolds results in the ingrowth of bone-
like, cementum-like, and connective tissue
• Do we have any outcome studies for prognosis of regen?
• Mahidol – rst outcome study 14-27 months – compares survival of regen (100%) to
MTA apexi cation (94%) and Ca(OH)2 apexi cation (77%). Succes of Tx (healed/
healing/failed) regen (80% / 20% / 0) MTA (68% / 26% / 6) Calcium hydroxide (77% / 0 /
23%). Also con rmed Bose ndings that increase in width with regen is 2x increase in
length.
• Linsuwanont et al 2017: IEJ. n=17. CBCT evaluation. up to 96 month followup. 76%
success. Conclusion: revitalization in immature teeth with nonvital pulps resulted in
unpredictable responses in terms of continued root development. Various types of root
maturation and root canal contests were observed radiographically, which were different from
typical root development
• Chaniotis 2017: JOE. 3 cases presented. Occasionally, regenerative endodontic procedures
might fail. Once they fail, alternative treatment modalities still remain. Besides apexi cation
procedures, clinicians should be aware that a second attempt of regenerative endodontic
procedures is feasible. Disinfection ef cacy seems to be the key.
• Martin 2014: JOE. Concentration-dependent Effect of Sodium Hypochlorite on Stem Cells of
Apical Papilla Survival and Differentiation; The present study aimed to assess the effect of
various concentrations of NaOCl on the stem cells of the apical papilla (SCAPs) survival and
dentin sialophosphoprotein (DSPP) expression. Authors reported that there was a signi cant
reduction in survival and DSPP expression in the group treated with 6% NaOCl compared with
the untreated control group. Comparable survival was observed in the groups treated with the
lower concentrations of NaOCl, but greater DSPP expression was observed in the 1.5%
NaOCl group. In addition, 17% EDTA resulted in increased survival and DSPP expression
partially reversing the deleterious effects of NaOCl.
• Berkhoff (2014, JOE) assessed the effectiveness of current irrigation techniques
EndoActivator (Dentsply, Tulsa, OK), EndoVac (SybronEndo, Coppell, TX), or using a
standardized irrigation protocol in a closed system in removal of TAP. It was shown that
Approximately 88% of the TAP was retained in the root canal system regardless of the
irrigation technique used (no difference among groups). Furthermore, approximately 50% of
the radiolabeled TAP was present circumferentially up to 350 μm within the dentin.
Conversely, up to 98% of the radiolabeled intracanal calcium hydroxide was removed, and
most residual medicament was found present in the initial 50 μm of dentin. This study
suggested that TAP residuals after irrigation may be detrimental for SCAP.
• In conclusion, the recent guidelines suggest: TAP and DAP medicaments should not be used
as as “thick”slurry. Instead, concentrations of 1 to 10mg/ml should be used, if required. So far,
Ca(OH)2 appears to be the most compatible antibacterial intracanal medicament for stem-cell
based therapies.

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 Vertical Root Fractures/Cracks
• Diagnosing a VRF
• Liao et al 2017: JOE.
• VRFs occurred mainly in the mesial root (20 roots, 57.14%) of the mandibular
molars (29 teeth, 44.62%).
• Clinically, teeth with VRFs usually presented a periodontal probing depth >5 mm
(44 teeth, 91.67%, P < .001) with a prosthesis (55 teeth, 84.62%, P < .001) and a
relatively intact dentition (42 patients exhibited <4 missing teeth in the dentition,
77.78%, P < .001).
• Most of the nonendodontically treated VRFs exhibited attrited occlusal surfaces.
• Radiographic characteristics of the teeth with VRFs were typically associated with
prior root canal treatment (56 teeth, 86.15%, P < .001), periodontal bone loss (62
teeth, 95.38%, P < .001), apical bone loss (52 teeth, 80.00%, P < .001), and
periodontal ligament widening (61 teeth, 93.85%, P < .001).
• The mesial roots of the mandibular molars were most susceptible to VRFs in both
endodontically and nonendodontically treated teeth.
• Walton 2017: JADA. Review and Case series of 42 teeth. Factors related to ID. The
most important ndings were that there were no signi cant, consistent signs, symptoms,
probing patterns, or radiographic changes that were conclusively diagnostic. Only ap
re ection was de nitive for identi cation; all fractured roots had overlying bony defects
lled with granulomatous tissue. Examination of the roots or resected root-ends revealed
the fracture line.
• The fracture spaces contained a combination of irritants: bacteria, necrotic debris,
sealer, and degraded in ammatory cells. Root surfaces consistently demonstrated
an in ammatory lesion adjacent to the fracture.
• VRF is an incomplete fracture in the root that may occur buccolingually or mesiodis-
tally; it may cause periodontal defect(s) or sinus tracts, and may be radiographically
evident
• VRF is invariably associated with endodontic therapy and often with apical surgery.
Frequently a post is present which can generate signi cant wedging forces. The
lateral wedging forces of gutta-percha compaction during obturation and post
placement are the initiators of stresses and strains that could result in fracture. The
VRF is more prevalent in roots with a cross-section that is narrower mesiodistally,
that is, in deep oval, attened, or hour-glass–shaped roots.
• With a suspected VRF, these diagnostic approaches have been proposed
• signs and symptoms: possibly, VRF fractures result in pain with occlusal or
lateral forces
• periodontal probing patterns: it has been suggested that the longitudinal
fracture commonly results in narrow, deep probing defects on the facial or
lingual aspect;
• radiographic ndings: the VRF is longitudinal and, therefore, tends to generate
certain patterns of resorption (Commonly, the resorptive bony defect shows an
apical-to-lateral pattern, the so-called “J-shaped” lesion; the resorption extends
around the apex and extends along the lateral surface of the root. Other
resorptive patterns have been reported, but it is unknown if these patterns are
consistent and thus aid diagnosis);

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 • treatment history: this includes whether a tooth has had endodontic treatment
and the subsequent restoration (post or no post);
• surgical exploration: ap re ection to expose the area of in ammation and
visualization of the fracture line on the root surface.
• The most important conclusion from my case series study was that the usual
noninvasive (without ap re ection) diagnostic ndings, tests, and periapical
radiographs—alone or in combination—were not reliable indicators of a VRF. Only
direct visualization of bone and root after ap re ection gave proof.
• The bottom line was that absence of symptoms, lack of radiographic changes, or
normal probing depths alone or in combination did not rule out the presence of a
VRF.
• Findings showed that when a VRF is strongly suspected, a ap must be re ected.
The nding of a bony “punched-out” defect was de nitive.
• A frequent nding, although not in all patients, was a nding or history of a
periodontal-like abscess with a probing defect and localized swelling.
• Radiographic ndings were interesting. Indeed, most showed the J-shaped lesion,
as described by Tamse. The bottom line was that radiographs were unreliable and
at best, suggestive.
• Many cases of teeth that were suggestive of VRF that proved to not be VRF.
• Observation that all VRF roots had a history of endodontic treatment, many with a
post, is consistent with the ndings reported in the literature.
• Tamse, Fuss 1999: Lateral radiolucency, a solitary pocket, and a coronally located
stula help make diagnosis. VRFs by tooth type Premolars > Mand Molars, Maxillary
Molar
• Kahler et al 2000: Aus Endo J. All symptomatic cracks in teeth extend right through the
dentin to the dentino-enamel junction, and appear to be extensively contaminated by
bacteria.
• Ailor et al 2000: JADA. Review. Initial diagnosis is directed toward determining the
presence and extent of incomplete fracture. The tooth should be assessed at this time to
determine if it can be restored. Unless symptoms are severe or the pulp has become
nonvital, it may be dif cult to assess if the pulpal response is reversible until after the
fracture is stabilized. Initial treatment is directed toward stabilizing or eliminating cusps
undermined by fractures. Since an assessment cavity is used in diagnosing most
incomplete fractures, placement of a bonded composite in the cavity is the most
common form of initial stabilization. Depending on the type and number of fractures
encountered and the time available, other methods used are occlusal adjustment,
temporary crown placement and orthodontic band placement. 8,19 Eugenol containing
palliative restorations have no place in the treatment of fractures; they do not bind
together the fractured segments, which leaves the tooth susceptible to further fracture.
After fractures are stabilized or the fractured cusps are eliminated, the tooth is observed
for pulpal symptoms. If sensitivity subsides, de nitive treatment can proceed without
endodontic treatment. If symptoms persist or intensify, endodontic treatment should be
initiated. Whenever endodontic treatment is initiated on a tooth with an incomplete
fracture, the chamber and canal walls must be inspected thoroughly for fractures that
may render the tooth non-restorable. Teeth with vertical fractures must be stabilized with
an orthodontic band or temporary crown before endodontic manipulation takes place to
guard against extending the fracture. Access cavities are re-examined after endodontic
treatment to ensure that no additional fracture has occurred. A permanent crown should
be placed as soon as possible after the pulp has either been determined to be healthy or

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 is eliminated by endodontic treatment. A crown de nitively binds fractured segments
together. Crown margins must extend apical to all fractures.
• Brynjulfsen, Fristad et al 2002: IEJ. The majority (89%) of the incompletely fractured
teeth occurred in heavily restored teeth. All fracture lines extended in the mesio-distal
direction, and in 10% of the cases they were running centrally in the tooth. In maxillary
teeth, 70% of the infractions were localized in the dentine supporting the buccal cusps,
whilst 20% were on the lingual side. In the mandible, the situation was opposite, 20%
buccally and 70% lingually. If patient reports pain and you don’t see anything, be
suspicious and look for incomplete fracture lines, specially in maxillary molars with
larger/older llings.
• Tan, Chen et al 2006: IEJ. At two years 85% of cracked root lled teeth survived.
Multiple cracks, terminal teeth, and pre-treatment pocketing were signi cant prognostic
factors for survival of root lled cracked teeth.
• Tamse, Fuss et al 2006: The “halo” (36.7%) and “periodontal” (28.6%) type
radiolucencies were the most typical appearances of periradicular areas around the
mesial roots of mandibular molars with vertical root fractures. By itself, bifurcation
radiolucency was statistically insigni cant (6.1%), however in conjunction with other
areas of radiolucency, it was signi cant (63.3%, P .0378). No radiolucency (38.5%) and
periapical radiolucency (32.7%) were predominant features in the control (nonfractured
roots). Amalgam dowel in the coronal part (1-2 mm) of the root was found in 67.3% of
the vertically fractured roots ( P .0006). De ned but not corticated (57.2%) or diffuse
(32.6%) borders were typical for vertically fractured mesial roots. The use of signi cant
variables, such as “periodontal” and “halo” bony radiolucencies, bifurcation involvement,
and the presence of amalgam dowel, has prediction sensitivity of 77.6% (VRF group)
and speci city of 82.7% (nonfractured roots).
• Opdam et al 2008: JOE. The purpose of this study was to investigate long-term clinical
effectiveness of treating painful cracked teeth with a direct bonded composite resin
restoration. The hypothesis tested was that cracked teeth treated with or without cuspal
coverage showed the same performance. Forty-one patients attended a dental practice
with a painful cracked tooth that was restored with a direct composite resin restoration.
Twenty teeth were restored without and 21 with cuspal coverage. After 7 years, 40 teeth
could be evaluated. Three teeth without cuspal coverage needed an endodontic
treatment, of which 2 failed as a result of fracture. No signi cant differences were found
for tooth or pulp survival. Three more repairable restoration failures were recorded.
Mean annual failure rate of restorations without cuspal coverage was 6%; no failures in
restorations with cus- pal coverage occurred (P .009). A direct bonded composite resin
restoration can be a successful treatment for a cracked tooth.
• Ricucci, Siqueira et al 2015: JOE. This study evaluated the dentin and pulp conditions
in teeth affected by cracks and attrition. Cracks are always colonized with bacterial
bio lms. The pulp tissue response varies according to the location, direction, and extent
of the crack.
• Tsesis, Tamse 2010: Systematic Review. Evidence-based data concerning the
diagnostic accuracy and clinical effectiveness of clinical and radiographic dental
evaluation for the diagnosis of VRF in endodontically treated teeth are lacking.
Radiographically, these fractures present with a J-shaped radiolucency extending
apically from the marginal periodontium. Clinically, they often present with a deep
periodontal probing depth that is narrow and localized as well as multiple sinus tracts
often within close proximity to the gingival margin. Most often, vertical root fractures are
noted in teeth treated previously with root canal therapy and posts.

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 • PradeepKumar, Kishen et al 2016: 197 RCT teeth w/ crown & no post. Retrospective.
• It can be concluded that the mean postoperative time period before the
presentation of VRFs in endodontically treated teeth with crowns and without posts
is 4.35 yrs (+/-1.96)
• Pain on palpation/percussion, the presence of deep, narrow periodontal pockets
and halo-shaped radiolucency are strongly suggestive of VRFs in crowned
endodontically treated teeth.
• Posterior teeth, female patients, older patients (>40 years), and over lled canals
are all potential risk factors for the presentation of VRF within 5 years
postoperatively.
• Mandibular molars had the highest incidence of VRFs (34%) followed by maxillary
premolars (22.8%).
• The characteristic clinical ndings in teeth with VRFs were pain on percussion
(60%), pain on palpation (62%), presence of a deep/narrow pocket (81%) and sinus
tract/swelling (67%). The most common radiographic presentation was a “halo” type
radiolucency (48.7%) followed by thickened periodontal ligament space (23.4%). It
was also observed that the obturation technique followed in all the teeth was lateral
compaction technique using gutta percha.
• Farber: Signs of VRF.
• 1) The repeated falling out of a coronal restoration could be due to a fracture
between the axial walls of the preparations; as the fractured segments ex or move
apart, the restoration between these segments may lose its resistance form,
become loose, and dislodge. Similarly, a retrograde restoration that has become
dislodged could be secondary to a vertical root fracture apically.
• 2) Multiple Sinus Tracts Also indicative of a vertical root fracture is the presence of
multiple sinus tracts adjacent to the tooth in question. Because the fracture may be
present on at least two surfaces of the tooth, the infected area may drain to multiple
sites, creating multiple sinus tracts.
• Keinan 2008: Quintessence. Multiple sinus tract with VRF.
• Diagnosing a Cracked tooth
• Berman, Kutler 2010: Pulp necrosis in the absence of restorations, caries or luxation
injuries is likely caused by a longitudinal fracture extending from the occlusal surface
and into the pulp. This type of presentation has been termed “fracture necrosis.”
•
• Deog-Gyu Seo 2012: Investigated the factors associated with cracked teeth. Upper rst
molar (28.0%) was most frequently cracked followed by the lower rst molar (25.2%), the
lower second molar (20.6%), and the upper second molar (16.8%). The prevalence of
longitudinal tooth fractures found in a premolar was 6.6% and 2.8% in the maxilla and
mandible, respectively. For the clinical signs and symptoms, 51% of the patients
experienced bite pain, and 82.2% respond positively on the bite test. Sixty teeth (56.1%)
were negative on the percussion test, whereas 36 teeth (33.6%) showed moderate to
severe cold sensitivity.
• Common symptoms in a cracked tooth: Thermal sensitivity, biting discomfort, history of
restorative tx.
• Always dry tooth to look for a crack. Transillumination, wedge, stain, biting test (pain on
releasing or biting) can help to detect cracks. FORESHORTENING the tooth in
radiographs after trauma makes it easier to diagnose a crack or a fracture.
• Common teeth to be cracked is mandibular second molar mesiodistally due to smaller
occlusal table than 1st Usually teeth with a small or no lling (30%). Mandibular second

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 molars have a higher incidence of vertical root fractures, followed by maxillary rst
molars and maxillary premolars.
• In mandibular molar teeth with non intact lamina dura and necrosis without any carious
or large restoration; suspect cracked tooth syndrome.
• Cameron 1964: Fractures most often involve the mandibular 2nd molar followed by
maxillary premolars and maxillary molars.
• Cameron 1971: talked about cracked teeth syndrome.
• Rivera, Walton 2015: Endo Topics. also discusses the cracked tooth, one of the ve
major classi cations of longitudinal tooth fractures: 1) craze line; 2) cuspal fracture; 3)
cracked tooth; 4) split tooth; and 5) vertical root fracture. Conclusion: If you do not look for
cracks and fractures in teeth, you will not likely nd them. If a crack is suspected, several
steps should be taken to con rm the suspicion. The tests performed and results
achieved will vary between teeth that have or have not had endodontic treatment. If the
suspect tooth has been endodontically treated, symptoms will be limited to those caused
by the affected periodontium because the tooth has no remaining vital pulp tissue. For
the tooth that has a vital pulp, the following steps will only con rm the presence or
absence of a crack. Further pulpal and periodontal testing will be necessary to develop a
diagnosis and determine the need for endodontic treatment. Remember, cracks in teeth
are ndings, not diagnoses.
• Kishen 2015. Endo Topics. Review.
• A cracked tooth is primarily described as one with cracks that originate in the
mesio-distal plane of the crown and progress toward the root. Previous
investigations have suggested that the strength of a tooth is directly related to the
amount of remaining coronal tooth structure. Hence preservation of the coronal
tooth structure has been recognized to be crucial for the successful management of
endodontically treated teeth. Endodontic procedures have been shown to reduce
the relative tooth stiffness by only 5%. This was less than that of an occlusal cavity
preparation, which reduced the relative stiffness by 20%. The largest losses in
stiffness were related to the loss of marginal ridge integrity, and mesio-occluso-
distal (MOD) cavity preparation, which resulted in a 63% loss of relative stiffness
• A vertical root fracture is described as a longitudinally oriented fracture of the tooth
that originates from the apical region of the root and propagates toward the coronal
aspect of the root. The degree of dentin loss should not be considered as a solo
factor that in uences the resistance to fracture, but should be corroborated with
other factors such root canal geometry, canal volume, and residual dentin. The
resistance of the root to ex will also depend upon the distribution of dentin material
around the canal wall.
• CBCT or PAs and VRF
• Dutra, Correa et al 2017: JOE. The VRF pathway can be accurately detected in a
non lled tooth using limited eld of view CBCT imaging. The presence of gutta-percha
generated a low beam hardening artifact that did not hinder the VRF extent. The
presence of an intracanal gold post made the fracture line appear smaller than it really
was in the sagittal images; in the axial images, a VRF was only detected when the apical
third was involved. The presence of a metal crown did not generate additional artifacts
on the root surface compared to the intracanal gold post by itself. The VRF pathway can
be accurately detected in a non lled tooth using limited/small eld of view cone-beam
computed tomographic (CBCT) imaging. The presence of an intracanal gold post made
the fracture line appear smaller than it really was on CBCT imaging or only be detected
when the apical third was involved.

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 • Talwar et al 2016: Systematic Review & MA.
• Vertical root fractures (VRFs) represent 1 of the most dif cult clinical problems to
diagnose and treat. Cone-beam computed tomographic (CBCT) imaging has been
used in recent studies with a high accuracy and sensitivity in detecting VRFs.
• In un lled teeth CBCT scans had better sensitivity and speci city compared to
periapical radiographs in the detection of VRFs, particularly when a voxel size of
0.2 mm was used.
• In endodontically treated teeth, CBCT imaging was not superior to periapical
radiographs.
• Chang et al 2016: Systematic review assessing CBCT in detecting VRF.
• Only review solely dedicated to assessment of endodontically treated teeth. Only 4
relevant studies included in analysis, with a total of 130 patients.
• Currently insuf cient evidence for reliability of CBCT for detecting VRF.
• Ma et al 2016: IEJ. Systematic Review & Meta-analysis. Con rms that CBCT images
are accurate for the detection of root fractures in non-endodontically treated teeth. The
diagnostic accuracy of root fractures in root lled teeth or teeth with posts still needs
further investigation. Voxel size does not impact the diagnostic accuracy of root fracture
in non-root lled teeth.
• Brady, Patel et al 2014: VRF in nonendodontically treated teeth.
• Suggested the use of CBCT imaging to aid in the diagnosis of VRF, but these
images do not always visualize the fractures unless the size of the fracture is larger
than the voxel size. CBCT images are most useful in the visualization of associated
patterns of bone loss.
• Found that vertical root fractures smaller than 50 micrometers were not detectable
on CBCT machines studies (3D Accuitomo and i-CAT CBCT scans). Periapical
radiographs and CBCT were unreliable for the detection of simulated incomplete
VRFs. The widths of the fractures appeared to have an impact on the diagnostic
accuracy of CBCT as the detection of VRFs of ≥50 μm was signi cantly higher than
those of <50 μm.
• Neves et al 2014: Metal posts and gutta-percha present in the root can results in beam-
hardening artifacts that can negatively in uence the diagnostic potential of CBCT
imaging in detecting VRF.
• Rud, Omnel: VRF is hard to detect on x-rays. When a vertical root fracture is present, it
is observed in a radiograph only 35.7% of time.
• Fayad, Johnson B et al 2012: JOE. Results: These 5 Findings on CBVT Exam were
Consistent with Con rmed VRF
• 1. Loss of bone in the mid-root area with intact bone coronal and apical to the
defect
• 2. Absence of the entire buccal plate of bone in axial, coronal, and/ or 3D
reconstructed view
• 3. Radiolucency around a root where a post terminates
• 4. Space between the buccal and/or lingual plate of bone and root surface
• 5. Visualization of the VRF on the CBVT views.
• Conclusion: CBVT was demonstrated to be advantageous for detection of VRFs
and valuable in providing diagnostic information to prevent possible unnecessary
treatment. Analysis: If you are suspicious of root fracture before retreat/ ap/
extraction send the patient for CBVT.

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 • Tamse 2015: Two-canal mesial roots are much more prone to VRF than 1-canal distal roots.
We suggest that VRF may occur during clinical condensation of gutta-percha in mesial roots
of mandibular molars as well as other roots with canals connected by isthmus.
• Sim I 2016: Multivariable analyses found that the presence of extension of cracks onto the
pulpal oor increased the odds of tooth loss by 11-fold (odds ratio = 11; 95% CI, 1.2–97; P =
.03) with other factors being held constant. The 5-year (60 months) survival estimate in the
absence of extension of cracks onto the pulpal oor was 99% versus 88% in the presence of
extension of cracks onto the pulpal oor.
• Zelik 2015: IEJ. Teeth with two-surface composite restorations that underwent root canal
treatment are less resistant to high occlusal load, but the main contribution to their weakening
arises from access cavity preparation. Canal enlargement does not contribute to this process
substantially.
• Rundquist 2006: How does canal taper affect root stresses? With increasing taper, root
stresses decreased during root lling but tended to increase for masticatory loading. Root
fracture originating at the apical third is likely initiated during lling, while fracture originating
in the cervical portion is likely caused by occlusal loads.
• Dang, Walton 1989: The hand spreader (D11) caused more root distortion and vertical fx
then the B nger spreaders. Therefore, VRF is more common in endodontically treated teeth.
• Tamse, Fuss: Suggested the presence of J-shaped lesions in VRF. VRF is seen mostly in
tooth with short and screwed posts. Mostly in maxillary second PM > Mandibular rst molar >
Maxillary central and lateral.
• Ozer, Unlu, Deger 2011: Case Series. Dx & Tx of endo treated teeth with VRF. Extraoral
bonding of fractured segments and intentional replantation of teeth after reconstruction
provide an alternative treatment to extraction, especially for anterior teeth. Computed
tomography-assisted VRF diagnosis is helpful in detecting fractures; however, higher-
resolution tomography units providing better image quality would be a better choice for
improved visualization of these fractures.
• Pits, Natkin: rst talked about J shaped radiolucencies in VRF Radiographic signs: Actual
separation of root fragments or fracture lines can be conclusive or suggestive evidence. If
radiopaque lling material extrudes into a fracture line it may appear on an x-ray. A halo-
like radiolucency, especially if it involves two opposite sides of a root are suggestive for
fractures. Periodontal bone lesions narrow, step-like in shape, angular in appearance are
suggestive of root fractures. Resorption along the fracture line and loosened retro- llings
suggest possible root fracture. Clinical signs: At the time of root lling - sharp cracking or
popping sounds maybe heard, the patient may feel a sharp stab of pain, pain with continued
condensation and or bleeding into the canal, all which indicate a possible fracture. Narrow,
rectangular periodontal pockets, essentially sinus tracts, have a characteristic feel when
probed different from crater-like defects of chronic periodontitis and may suggest a vertical
fracture. Visualization maybe possible if the gingiva can be retracted slightly or has receded.
Dark staining or a clicking when explored may indicate a fracture line. Transillumination may
help visualize. Surgical exposure and use of dyes con rm a vertical fracture.
• Bender: most common cause of vertical root fractures may be iatrogenic dental treatment.
Dental procedures such as the placement of posts and pins or the tapping into place of a
tightly tting post or intracoronal restoration may induce a vertical root fracture. The most
common dental procedure contributing to vertical root fractures is endodontic treatment.
• Ferrari et al: showed that 10 to 12 years after endodontic treatment, there is progressive
degradation of the demineralized collagen matrices. The aging dentin becomes sclerotic and
exhibits very limited yielding before failure. The fracture toughness is lower, and the stress–
strain response is characteristic of brittle behavior.

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 • Guthrie and DiFiore: Found that 89% of patients with cracked teeth treated with full
coverage restorations exhibited symptom elimination following placement of the temp
restoration.
• Discuss incomplete crown-root fractures
• Cameron 1964 - . First described: incomplete fracture from crown extending
subgingivally. The further apical the more likely to cause pulpal and periapical pathoses.
Symptoms: Pain on mastication, early brief pain to cold, deep probing associated with
the crack. Pulp can become in amed because of irritation from microleakage. Crack
propagation can result in irreversible pulpitis, pulp necrosis and apical periodontitis.
coined term “cracked tooth syndrome”; 1) man second Molars. 2) max rst Molars. 3)
man rst Molars; classic symptoms of biting sensitivity/cold sensitivity.
• Krell & Rivera 2007:- Cracked teeth diagnosed with reversible pulpitis:
• 20% will need RCT w/in 6 months after cuspal coverage; if last 6 mo probably won’t
need RCT.
• 21% of cases diagnosed with reversible pulpitis and a crack eventually required
RCT.
• About 15-19% of patients can be expected to need RCT after crown placement.
• The 21% in this study is only slightly higher than the 15-19% and suggests similar
incidence data. One would assume that a tooth with both mesial and distal marginal
ridge fractures is more likely to eventually require RCT. In this study, more teeth
with a single marginal ridge crack eventually required RCT. This underlines the
dif culty in predicting the eventual need for RCT in teeth with reversible pulpitis and
a cracked marginal ridge.
• Conclusion: If a crack is identi ed early enough in cases with a diagnosis of
reversible pulpitis and a crown is placed, RCT will be necessary in about 20% of
these cases within a 6-month period.
• Prognosis: The outcome of treatment for teeth with Crown Originating Fractures (COF)
has not been extensively reported. Spontaneous fracture originating in the crown and
progressing into the root in an apical direction.
• Camerom 1976 (JADA) reported a 75% success after ten years following
placement of crowns.
• Brynjulfsen et al 2002 (IEJ) achieved pain relief in 90% of their patients after
protective restorations were placed on teeth with fractures (endodontic therapy was
included when indicated)
• Tan et al 2006 (IEJ) had an 85% survival rate two years after protective crowns
were placed.
• Sim et al 2016 (JOE) reported the 5-year survival of teeth with COFs that were
restored with full coverage crowns and had root canal treatment when indicated.
They found that teeth with fractures con ned to the crowns survived at a rate of
99%, while those with fracture extensions to the pulpal oor had an 88% survival
rate.
• Kim et al 2013: JOE. Retrospective study. The treatment plan for cracked teeth depends
on the extent of the crack. A tooth with an extensive crack of long duration may be more
likely to require root canal treatment. The purpose of this study was to analyze the
characteristics of cracked teeth and to assess the outcome of different treatment
protocols depending on the pulpal and periapical diagnoses. n = 72. Cracked teeth were
treated by different treatment protocols depending on the pulpal and periapical
diagnoses. Mandibular rst molars (27.8%) were the most frequently involved teeth
followed by maxillary rst molars (25%), maxillary second molars (22.2%), and

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 mandibular second molars (19.4%). The most frequently involved ages were 40-49 and
50-59 years. Cracks occurred mainly in nonbonded restorations such as gold (26.4%)
and amalgam (12.5%), and 48.6% of cracks were found in intact teeth. In this study, 60
teeth (83.3%) were treated with root canal treatment before being restored with a
permanent crown, and only 12 teeth (16.7%) remained vital and were restored with a
permanent crown without root canal treatment. The proportion of teeth treated with root
canal treatment increased along with a deep periodontal probing depth corresponding to
the crack. The prognosis was less favorable in cracked teeth with a deep probing depth.
Early recognition can help to avoid the propagation of a crack into the pulp chamber or
subgingival level.
• Kang et al 2016: JOE. 5 yr retrospective study. Cracks were commonly found in lower
second molars and intact teeth. RCT was a reliable treatment for cracked teeth with a 2-
year survival rate of 90.0%. Deep probing depths were found to be a signi cant clinical
factor for the survival of cracked teeth treated with RCT. Most of the patients were aged
50-60 years (32.0%) or over 60 (32.6%). The lower second molar was the most
frequently (25.1%) affected tooth. Intact teeth (34.3%) or teeth with class I cavity
restorations (32.0%) exhibited a higher incidence of cracks. The 2-year survival rate of
88 cracked teeth after RCT was 90.0%. A probing depth of more than 6 mm was a
signi cant prognostic factor for the survival of cracked teeth restored via RCT. The
survival rate of root- lled cracked teeth with a probing depth of more than 6 mm was
74.1%, which is signi cantly lower than that of teeth with probing depths of less than 6
mm (96.8%). Of 38 with provisional, 11 (28.9%) required RCT
• Tan et al 2006: IEJ. 2 year survival rate of cracked teeth with RCT 85.5% after 2 years
• PradeepKumar, Kishen et al 2017: JOE. This study evaluated the prevalence, location, and
pattern of preexisting dentinal microcracks in roots of extracted teeth without endodontic
treatment in patients from 2 age groups using micro–computed tomographic imaging. Six
hundred thirty-three nonendodontically treated teeth extracted using an atraumatic procedure
because of reasons unrelated to this study were collected and divided based on the patient
age.
• Preexisting dentinal microcracks in roots of nonendodontically treated teeth occurred
more often in older patients (40–70 years) in the mesiodistal direction. They were
predominantly found in the cervical and middle thirds of root and were more likely to be
incomplete in nature.
• Preexisting dentinal microcracks show a higher predilection for nonendodontically
treated teeth in older patients.
• Preexisting microcracks occur in the cervical and middle thirds of the root surface and
are more likely to be incomplete.
• Preexisting microcracks in nonendodontically treated teeth are observed in the
mesiodistal direction.
• Yan et al 2017: JOE. There are changes in the microstructure of root dentin with age that
cause a reduction in its strength and resistance to fatigue. The greatest degradation occurs
near the apex and could contribute to the incidence of vertical root fracture.
• How do you diagnose vertical root fractures?
• Pitts and Natkin - hx of RCT, diffuse RL, isolated narrow probable defect, minimal pain,
perio abscess, dual sinus tracts (pathognomonic)
• Walton - VRF in F-L direction; crn-root fx in M-D direction
• Dang and Walton - D11 spreader > nger spreaders
• Tamse - deep pocket, sinus tract close to marginal gingiva, PA and lateral RL, CC of
pain or abscess; max 2 PM most common followed by M root of man molar

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 Pulp Necrosis in teeth prepared for crown
• Bergenholtz 1984:
• 15% incidence of necrosis in abutment teeth
• 3% incidence of necrosis in non abutment teeth
• Goodacre 1994:
• The incidence of endodontic treatment required after tooth preparation has ranged from
3% to 23%.
• Fixed partial dentures and complex prostheses had higher incidence rates than single
crowns. It has been assumed that the higher rates are because of the greater tooth
reduction sometimes required to align multiple teeth. The incidence is higher when
the prepared teeth have deep carious lesions and when periodontal disease disease
has resulted in considerable bone loss. Many pulpal problems occur after several years
rather than in the rst few years, and one study showed that 50% of the pulpal
problems occurred after 7 to 12 years. It has been suggested that “stressed pulps” are
more prone to developing pulpal disease after prosthodontic treatment.
• Valderhaug 1997:
• 2% of crowned vital teeth needed RCT after 5 years.
• 8% of crowned vital teeth required RCT after 10 years.
• 17% of crowned vital teeth required RCT at 25 years
• Cheung et al 2005: 32% of FPD abutments required RCT after cementation
• Kontakiotis 2015: A prospective study of the incidence of asymptomatic pulp necrosis
following crown preparation. 120 Teeth.
• Intact teeth had a signi cantly lower incidence of pulp necrosis following crown
placement (5%)
• Preoperatively structurally compromised (Caries, restoration or crown) teeth had an
increased incidence of pulp necrosis (13%) following crown placement.
• Imperative to recheck teeth prior to crown cementation.
• The overall incidence of pulp necrosis was 9%.
• The incidence of asymptomatic pulp necrosis of teeth following crown preparation is
noteworthy. The presence of preoperative caries, restorations or crowns of experimental
teeth correlated with a signi cantly higher incidence of pulp necrosis. Electric pulp
testing remains a useful diagnostic instrument for determining the pulp condition.
• Felton 1989: Long term follow-up of 1,000 crowned teeth demonstrated that 11% became
necrotic.
• Krell & Rivera 2007:- Cracked teeth diagnosed with reversible pulpitis:
• 20% will need RCT w/in 6 months after cuspal coverage; if last 6 mo probably won’t
need RCT.
• 21% of cases diagnosed with reversible pulpitis and a crack eventually required
RCT.
• About 15-19% of patients can be expected to need RCT after crown placement.

Smoking and Endo

• Bergstrom 2004: Tobacco smoke not associated with apical periodontitis.

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 • Krall 2006: 811 pts at VA. Smokers are 1.7 times more likely to have a root canal. There is a
statistical dose-response relationship between cigarette smoking and the risk of root canal
treatment.
• Krall 1999: Smoking exacerbates bone loss in the oral cavity
• Krall and Dawson-Hughes 1991: smoking exacerbates bone loss in the axial and
appendicular skeleton
• Ijzeerman 2003: smoking decreases the O2 carrying capacity of blood
• Segura-Egea et al 2011: Smoking & Endo. The prevalence of apical periodontitis and RCT
was signi cantly higher in smoker hypertensive patients compared with nonsmoker patients.
Lower level of evidence with confounding factors.
• Pittilo 1990: smoking causes vascular dysfunction
• Doyle: increased success of RCT and implant if a non-smoker
• Pitt Ford: Tobacco use no associated with AP prevalence
• Lopez 2012: case-control retrospective study. the relation between smoking and apical
periodontitis was assessed. It was noticed that after adjusting for age, gender, number of
teeth, endodontic status, quality of root lling, and diabetic status, tobacco smoking is
strongly associated with the presence of radiographically diagnosed periapical lesions.
• Das 1985; Tracy 1997; Frohlich 2003: smoking impairs the body response to infection

Systemic Disease/Medically Compromised Patients

• Khalighinejad, Aminoshariae, Kulild, Mickel 2017: JOE. Cross-section study. n=40
patients with matched set. The present study aimed to evaluate the prevalence of apical
periodontitis (AP) and endodontic treatment in patients with end-stage renal disease (ESRD)
as compared with patients with no history of ESRD. This investigation reported that AP was
signi cantly more prevalent in patients with ESRD, which suggests that ESRD could possibly
alter the pathogenesis of AP. Also, considering the modifying effect of AP on urea serum level,
the treatment of AP could be incorporated into the treatment planning of patients with ESRD
by health care providers. However, these ndings do not con rm the presence of any cause-
and-effect relationship between these conditions.
• Berlin-Broner et al 2017: IEJ. Association between apical periodontitis and cardiovascular
diseases. Only reviewed studies up to September 2015. Most studies found a positive
association between AP and CVD, the quality of existing evidence is moderate-low and a
causal relationship cannot be established.
• Aminoshariae, Kulild, Mickel, Fouad 2017: JOE. Association between systemic diseases
and endodontic outcome: a systematic review.
• HIV and oral bisphosphonate did not appear to be associated with endodontic outcomes.
• Cardiovascular disease and/or diabetes may be associated with the outcome.
• None of these studies can elucidate a cause-and-effect relationship.
• Although additional well-designed longitudinal clinical studies are needed, the results of
this systematic review suggest that some systemic diseases may be correlated with
endodontic outcomes.
• The overall quality of the included articles was moderate to high risk of bias. Three
articles were identi ed to report on cardiovascular disease (CVD). Eleven articles
reported on diabetes mellitus (DM). Three articles reported on human immunode ciency
virus (HIV). One article reported on oral bisphosphonate and osteonecrosis of the jaw.
• Khalighinejad, Aminoshariae, Kulild, Mickel, Fouad 2016: JOE. Association between
Systemic Diseases and Apical Periodontitis. The results of this review suggest that there may
be a moderate risk and correlation between some systemic diseases and endodontic

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 pathosis. More prospective and longitudinal research in this area is warranted to determine
greater speci city in these possible interactions to potentially decrease or minimize the effects
of systemic disease on the formation of apical periodontitis.
• ASA Classi cation (latest update 2014)
• I. A normal healthy patient
• II. A patient with mild to moderate systemic disease
• BP < 160/95 (controlled HTN), extreme anxiety, smoking, more than minimal OH,
pregnant, obese, mild lung dx
• III. A patient with severe systemic disease that limits activity but is not incapacitating
• MI/Stroke > 6 months, controlled HTN or DM, stable angina (no pain when sitting,
but perhaps pain on exertion), BP 160-99/95-144, dialysis, pacemaker, active
hepatitis
• IV. A patient with severe systemic disease and is a constant threat to life
• MI/Stroke within last 6 months, uncontrolled DM/HTN, unstable angina, BP 200+/
115+
• V. A moribund patient not expected to survive 24 hours with or without an operation.
• End stage renal disease, terminal cancer
• VI. A brain dead patient with organ harvesting planned
• Jalali, Glickman, et al 2017: JOE. The effect of rheumatoid arthritis (RA) on the healing and
pathophysiology of apical periodontitis is unknown because there is no study in the literature
evaluating the association of RA with the prevalence of periapical rarefying osteitis (PAR) and
endodontic treatment. Therefore, the goal of this cross-sectional study was to evaluate the
prevalence of PAR and root canal treatment in RA patients when compared with controlled
individuals. Full-mouth radiographs of 131 individuals with RA were examined and compared
with 131 controls that were sex and age matched exactly with the diseased group. Overall,
the prevalence of teeth with PAR was 4.0% in the diseased group and 3.5% in the control
group (P > .05). The prevalence of root canal–treated teeth was 6.2% in the RA group and
5.6% in the control group (P > .05). Controls have signi cantly more teeth than those with RA
(P = .027). The prevalence of PAR and endodontic treatment was not signi cantly different in
individuals with RA compared with control patients.
• Vitals
• Pulse:
• Normal Adult 60-100 beats/minute.
• A pulse rate greater than 100 —> tachycardia.
• A pulse rate lower than 60 —> bradycardia.
• Blood Pressure
• First beating sounds —> korotkoff sounds —> Systolic
• Sounds completely disappear —> Diastolic
• Normal Adult
• systolic BP: 90-120 mmHg
• diastolic BP: 60-80 mmHg
• Hypertension in adults: BP of 140/90 mm Hg or greater
• BP Normal < 120 systolic and < 80 diastolic
• Prehypertensive: 120-139 systolic or 80-89 diastolic
• Stage 1 Hypertension: 140-159 systolic or 90-99 diastolic
• Stage 2 Hypertension: > 160 or > 100
• > 180/110 differ elective treatment
• respiration:
• Normal 12 - 16 breaths/minute. Respiration in children higher than adults.

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• General Stress Reduction Protocol
• Open Communication about fears or concerns
• Short Appointments (preferably morning)
• Preop Sedation: short acting benzodiazepine (triazolam 0.125 -0.25mg) 1 hr before
appointment and possibly the night before the day of the appointment
• Intraoperative sedation (nitrous oxide)
• Profound local anesthesia: use topical before injection
• Adequate postoperative pain control
• Patient contacted on evening of the procedure
• Clinical Laboratory Tests and Normal Values
• Complete Blood Count
• White Blood Cells: 4,500 - 10,000/mL
• Red Blood Cells (male): 4.5 - 5.9 x 106 / microL
• Red Blood Cells (Female): 4.5 - 5.1 x 106 / microL
• Platelets: 150,000 - 450,000 / microL
• Hematocrit (male): 41.5 - 50.4%
• Hematocrit (female): 35.9 - 44.6%
• Hemoglobin (male): 13.5 - 17.5 g/dL
• Hemoglobin (female): 12.3 - 15.3 g/dL
• Differential White Blood Cell Count Mean %
• Segmented neutrophils 56%
• Lymphocytes 34%
• Monocytes 4%
• Bands 3%
• Eosinophils 2.7%
• Basophils 0.3%
• Hemostasis
• Prothrombin Time (PT) 10-13 seconds
• Looks at extrinsic Pathway of coagulation
• International Normalized Ratio (INR)
• Looks at extrinsic pathway
• The INR is typically used to monitor patients on warfarin or related oral
anticoagulant therapy. The normal range for a healthy person not using warfarin
is 0.8–1.2, and for people on warfarin therapy an INR of 2.0–3.0 is usually
targeted, although the target INR may be higher in particular situations, such as
for those with a mechanical heart valve. If the INR is outside the target range, a
high INR indicates a higher risk of bleeding, while a low INR suggests a higher
risk of developing a clot.
• Activated partial thromboplastin time (aPTT) 25-35 seconds
• looks at intrinsic and common pathway
• Thrombin Time (TT) 9 - 13 seconds
• A blood test that measures the time it takes for a clot to form in the plasma of a
blood sample containing anticoagulant, after an excess of thrombin has been
added.
• Serum Chemistry
• Glucose, Fasting 70 - 110 mg/dL
• blood urea nitrogen (BUN) 8 - 23 mg/dL
• creatinine 0.6 - 1.2 mg/dL

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 • Alcohol
• Do not sedate. Do not treat while patient is intoxicate; wait 24hrs. Drug metabolism is
altered.
• Limit to 2 g APAP/day in alcoholic
• Bleeding concerns
• 10g APAP in 24 hrs —> can lead to acute liver failure
• When metronidazole is given to some who drinks alcohol —> Disul ram RXN
• Nausea, Vomiting; can be life threatening
• Disul ram: Negative reinforcement drug to wean pts of alochol
• Disul ram-ethanol rxn is due to increased serum acetaldehyde concentrations
generated by the metabolism of ethanol by alcohol dehydrogenase in the liver.
Normally, this acetaldehyde is cleared rapidly by its metabolism to acetate via
aldehyde dehydrogenase. Disul ram blocks this enzyme, irreversibly inhibiting the
oxidation of acetaldehyde and causing a marked increase in acetaldehyde
concentrations after ethanol consumption. The discomfort associated with this
syndrome is intended to serve as a negative stimulus, but the reaction may be
severe enough to cause hypotension and death.
• Acetaminophen Metabolism
• APAP metabolized 95% by glucuronidation/sulfate and 5% by CYP2E1
• NAPQI (toxic byproduct of APAP metabolism) made via CYP2E1 pathway
• NAPQI is toxic to the liver
• NAPQI is normally conjugated with glutathione and rendered non-harmful
• When glutathione is depleted, we get increased NAPQI and this can lead to focal
liver necrosis
• Alcoholics have increased CYP2E1 and thus create more NAPQI
• Ceasing EtOH = more CYP2E1 available; BAD!
• Anemia
• De ned as either a decreased red blood cell count, decreased hemoglobin or
nonfunctional RBCs. It can also be de ned as a lowered ability of the blood to carry
oxygen. When anemia comes on slowly, the symptoms are often vague and may include
feeling tired, weakness, shortness of breath or a poor ability to exercise.
• Normal Hemoglobin levels: 14-18 g/dL for 18+ y/o M (12-15 for 18+ female)
• Types
• iron de ciency - need at least 1 mg Fe daily (2 x for menstruation)
• Hemolytic - destruction of RBC from AB’s
- Associated with Lupus and lymphoma
- lead, copper and benzene can cause
- blood transfusion often necessary
- sickle cell and thalassemia are both inherited types of hemolytic anemia
• Vitamin De ciency - B 12 - essential in Hgb production; absorbed when stomach
releases intrinsic factor to bind to B-12
• Pernicious Anemia = B-12 de ciency anemia
• more common commitant with thyroid dx/DM
• 40-80 y/o N europeans w/ fair skin
• lack of folic acid (another B vitamin derivative) can also lead to anemia which
is often found in alcoholic
• Sickle- Cell - due to amino acid substitution leading to sickle-shape of red blood
cells
• occurs under low O2 tension

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 • Kaya: can cause pulp necrosis due to microvascular interruptions
• mostly in African Americans, 0.6% of the population
• Thalassemia - due to defects in Hgb genes
• mostly in people of mediterranean descent
• minor and major forms
• major requires transfusion or bone marrow transplants
• Aplastic: Most rare; deadliest; due to bone marrow failure to produce all types of
blood cells
• Apert Syndrome
• Costa: syndactyly of hands/feet, bi d uvula, Mx crowding, open bite, prominent
forehead, hypoplastic mid-face, AD inheritance ,increases caries/periodontal dz
• Asthma
• In ammatory dz of the airways with reversible air ow obstruction and bronchospasm
• NSAIDs can cause increased production of leukotrienes which can precipitate an attack.
Exact mechanism unknown.
• Symptoms: wheezing, coughing, chest tightness, shortness of breath, worse at night and
in early morning or in response to cold air/exercise
• MoA: IgE mediated degranulation of mast cells, caused by a combination of genetic and
environmental factors
• Attack Treatment
• Oxygen
• Bronchodilator (albuterol - B2 agonist)
• Subcutaneous Epi (Epi Pen 0.3-0.5 mL 1:1000 epi q 5 min)
• Precipitators
• Anxiety
• Sul tes (LA preservative)
• Stress
• Allergens/Irritants
• Associated Conditions
• GERD
• Rhinosinusitis
• Obstructive sleep apnea
• Anxiety disorders
• APAP use - Henderson and Shaheen 2012
• Occurrence
• on the rise in the past 40 years
• in 2011, caused 250K deaths and in icted 250-300 million people globally
• Classi cation
• Atopic (extrinsic) - allergen induced
• Non- Atopic (intrinsic) - exercise/stress/chemical (not allergy though) induced
• more dif cult to manage
• chemical such as cigarette smoke, aspirin, cleaning agents or chest infection
can induce this variant of asthma via enhancing the response of the nerves in
the air passage
• Meds: Anti-in ammatory inhalant, bronchodilators, Steroids
• First Line: Beta 2 agonist
• 2nd line: oral corticosteroids
• 3rd line: long acting beta agonists or antileukotriene agents
• Diagnosis: Pattern of symptoms; spirometry

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 • Medications: Expanded
• Short acting beta-2-agonist (SABA)
• Good for attacks
• Anticholinergic medications provides additional bene t when combined with SABA
• Non-selective adrenergic agonist (epinephrine) can be used in acute attacks/status
asthmaticus
• Corticosteroids - most effective tx for long-term control; used bid
• long acting beta-adrenoreceptor agonist (LABA) good combined with steroids in
Adults
• Mast cell stabilizers - alternative to steroids; less effective
• Leukotriene receptor antagonists
• Autoimmune Disease
• Lupus is prototype
• symptoms: vague and varied; fever/abdominal pain/rash/headache
• Miller: No risk for increased infective endocarditis
• DeRossi, Glick:
• NSAIDs can precipitate lupus,
• lupus co-morbidities —> heart dz (MI), Fibromyalgia/OI
• Increased risk for infective endocarditis x 9 (systemic lupus)
• Butter y rash
• Adrenal Insuf ciency
• Rule of 2s - Add steroid if…
• Pt has taken 20mg cortisone +
• For 2 wks
• Within the past 2 years
• Steroids decrease leukocyte adhesion molecules (which decrease leukocyte diapedesis)
• also seen with EtOh use and DM pts
• Acute - death form shock/ventricular asytole b/c patient can’t handle stress
• tx: supine, oxygen, ammonia inhalant, solucortef (Steroid; 2 mL/100mg) IV, EMS
• Bacteremia
• Reis, Rocas, Siqueira et al 2016: evaluated the incidence of bacteremia after root
canal preparation in teeth with necrotic pulps and apical periodontitis. Blood samples
were taken before and 5 and 30 minutes after endodontic treatment in teeth with apical
periodontitis from individuals at high (n = 21) or no risk (n = 11) for IE. The former
received prophylactic antibiotic therapy. Bacteremia incidence after endodontic
procedures in patients with heart disease is low, irrespective of antibiotic prophylaxis.
Endodontic therapy should be the treatment of choice for infected teeth, and the need for
antibiotic prophylaxis before endodontic intervention should be re-evaluated.
• Baumgartner reported that incidence of bacteremia following RCT is very low 3.3 %
regardless of pulpal statues and if you con ne the RCT to root canal it can be prevented.
• Siqueira suggested that endo can cause bacteremia but there is no clear evidence that
this bacteremia can initiate infection or disease in far sites.
• HIV
• HIV: Destruction of helper T cells; destroys the immune system and leads to AIDS
• Meskin: 0.3% of seroconversion of HIV with percutaneous exposure
• Glick: Oral HIV lesions indicate CD4 < 200cells/cubi mm
• Cooper: no prophylactic AB in HIV pt; NSD in healing of AP w/ or w/out HIV
• de Brito 2015: Immunological pro le of periapical endodontic infections from HIV− and
HIV+ patients. Findings suggest that after reducing the root canal bacterial load in HIV−

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 individuals an anti-in ammatory response is generated whilst in + patients a pro-
in ammatory response is sustained in the periapical area (Outcome studies found no
correlation with HIV statues but immunological studies found).
• Glick, Trope: Detection of HIV in the dental pulp of a patient with AIDS
• Shetty 2006: 157 pts. No statistically differences noted in success of RCT in relation to
symptoms, antiretroviral therapy or viral load.
• Suchina, Hicks 2006: RCT has a relatively high degree of success in HIV/AIDs patients
and should not be a contraindication.
• Gama et al 2016: Conclusion: The results suggest an important role of HAART in
maintaining the immune capacity in CAP for HIV infected individuals, demonstrating a
similar cellular pro le and expression of immunologic markers when compared with non–
HI infected patients. Bottom Line: HIV infected patients undergoing HAART treatment
will most like present and heal the same way as no HIV infected patients.
• Immunode cient
• Fouad: Pts lacking leukocytes still have AP
• Torabinejad: larger size of AP if immunode cient
• Teles: no diff in AP size if immunocompromised
• Radiation; Chemo; Organ Transplant
• Radiation: 40% of H/N cancers are in the oral cavity; most are SCCs; radiation is
common tx and carries risk (mucosisitis, taste alterations, xerostomia)
• Kataoka et al 2012: Radiation therapy for oropharyngeal malignancies in doses greater
than 30-35 grays can reduce the number of teeth responding to pulp sensitivity tests.
Despite the effect of pulp vitality tests, (Faria et al 2014) showed that pulp histology is
not altered by radiation.
• Seto et al 1985: Purpose: To evaluate the applicability of endodontic therapy for treating
advanced dental disease in patients who have undergone radiation therapy for head and
neck neoplasms. No osteoradionecroses were seen in assoc with endodontic therapy in
contrast to extraction even with signi cant radiation to the jaws. In patient receiving high
doses of radiation to the head and neck, endo therapy was 100% successful in avoiding
extractions and preventing osteonecrosis
• Sakurai: Organ Transplant. Lifetime immunosuppressed; 100 x increased cancer risk;
emergency dental care only 1st 6 months; MD consult always before treatment even
when stable; emergency tx only during acute rejection
• Sung: Chemotherapy. 40% get mucositis, < platelets, < PMN
• Diabetes
• Metabolic disorders characterized by decreased pancreatic insulin production or
decreased insulin sensitivity. Increased glucose: narrowed blood vessels = ischemia =
impaired immune cell chemotaxis. Glycated hemoglobin clogs endothelial cell junctions
and decreases diapedesis. 15% Insulin Dependent Diabetes Mellitus (Juvenile or Type
1). 85% Non-insulin dependent diabetes mellitus (Type II).
• Type I: Beta Cell destruction, usually leading to absolute insulin de ciency.
• Immune-mediated: presence of islet cell or insulin antibodies that identify the
autoimmune process, leading to beta cell destruction
• Idiopathic: no evidence of autoimmunity
• Type II: Insulin resistance with relative insulin de ciency/insulin secretory defect with
insulin resistance.
• HbA1c/A1C Assay - Glycosylated hemoglobin
• long term assessment over 6-12 wks
• normal: 4-5.6%

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 • increased risk of DM 5.7-6.4%
• < 7% ok for routine dental tx
• Fasting Plasma Glucose/Fasting blood sugar
• Normal: 70-100 mg/dL
• > 126 on two occasions —> diabetes
• Hyperglycemia
• symptoms: frequent urination, thirsty, hungry, blurred vision, drowsiness, straining
on breathing, nausea, dry skin
• Treatment: No Tx; refer to MD, Tx as hypoglycemia until sure its hyperglycemia
• Hypoglycemia
• Symptoms: Shaking, fast heart beat, sweating, dizziness, anxious, hunger, impaired
vision, weakness/fatigue, headache, irritable. cold sweat
• Treatment: sugar, glucagon IM (.4-1mg)
• Hypoglycemia is more dangerous than hyperglycemia
• Liu: Metformin in rats with AP. decreased osteoclasts, decreased bone resorption,
increased insulin sensitivity, anti-in ammatory properties (decreased IL-1/6/8, TNFs)
• Fouad, Burleson 2003: JADA. Patients with diabetes and a preoperative periradicular
lesion have reduced likelihood of endodontic treatment success. Patients with diabetes
may also have increased ar ups during treatment. Diabetic patients receiving insulin
may have increased preoperative periradicular pain. A higher treatment outcome was
found in older age groups. retrospective; 6 mon f/u
• Bender, Bender 2003: When Diabetes is under control, the healing of periapical lesions
is the same as a non-diabetic patient.
• Wang: cross sectional study. DM increases 30% risk of failure (Ext) of RCT’d teeth vs no
DM
• Doyle: DM has no effect on outcome; matched case study
• Goerig: Slower, but NSD outcome of healing after endo in DM pt
• Turbelidze: Slower healing with DM due to decreased angiogenesis
• Bender: blood vessel damaged by increased atherosclerotic deposits, thicker BM of
capillaries decreases leukocyte response, decreased pulpal circulation
• Torabinejad, Shabahang: MTA pulp caps in DM rats = decreased success/increased
in ammation
• Lima et al 2013: Diabetes mellitus (DM) is one of the most common metabolic
disorders. DM is characterized by hyperglycemia, resulting in wound healing dif culties
and systemic and oral manifestations, which have a direct effect on dental pulp integrity.
Experimental and clinical studies have demonstrated a higher prevalence of periapical
lesions in patients with uncontrolled diabetes. The in uence of DM on periapical bone
resorption and its impact on dental intervention of such patients are reviewed, and its
etiology and pathogenesis are analyzed at molecular level. Pulps from patients with
diabetes have the tendency to present limited dental collateral circulation, impaired
immune response, increased risk of acquiring pulp infection (especially anaerobic ones)
or necrosis, besides toothache and occasional tendency towards pulp necrosis caused
by ischemia. In regard to molecular pathology, hyperglycemia is a stimulus for bone
resorption, inhibiting osteoblastic differentiation and reducing bone recovery. The
relationship between poorly controlled diabetes and bone metabolism is not clearly
understood. Molecular knowledge about pulp alterations in patients with diabetes could
offer new therapeutic directions. Knowledge about how diabetes affects systemic and
oral health has an enduring importance, because it may imply not only systemic

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 complications but also a higher risk of oral diseases with a signi cant effect on pulp and
periapical tissue.
• Marotta, Rocas, Siquiera et al 2012: Apical periodontitis was more prevalent in
untreated teeth in patients with type 2 diabetes
• Wang C et al 2011: An increased risk of tooth extraction after root canal therapy was
signi cantly associated with Diabetes Mellitus, Hypertension, and Coronary Artery
Disease individually. Moreover, the constellation of systemic disease burden also
manifests the importance in addition to other potential confounders.
• Tiburcio-Machado et al 2017: JOE. In uence of diabetes in the development of apical
periodontitis: a critical literature review of human studies. Discussion/Conclusions: Data
regarding the association between diabetes and AP is inconclusive because there are
very few reports on this issues. Moreover, the published studies showed methodological
limitations. Studies show that type 1 diabetes has a more severe effect on tissues. Thus,
it is inappropriate to combine the 2 types of diabetes in the same group. Confounders
such as coexistence of other systemic diseases, smoking habits, radiographic quality of
the endodontic lling, and tooth restoration can also in uence the results. Most of the
included studies only matched subject with controls based on sex and/or age, not taking
such confounders into account. Considering the studies included in this critical review,
more studies indicate an association between AP and diabetes than those that do not
nd evidence for such an association. However, studies related to this topic are still few,
especially well-designed longitudinal studies and clinical trials. Therefore, it was dif cult
to ascertain a true association, mainly due to the aws in sample size calculation,
diabetes classi cation, methods for obtaining diabetes status, blinding of the examiner,
and control for possible confounding variables that may affect development of apical
lesions.
• Arya, Tewari, Aggarwal et al 2017: JOE. Healing of Apical Periodontitis after
nonsurgical treatment in Patients with Type 2 Diabetes. Both the diabetic and
nondiabetic group depicted a signi cant reduction in the periapical score after
endodontic treatment at the 12-month follow-up (P < .05). Signi cantly less periapical
healing was observed in the diabetic group (43%) compared with the nondiabetic group
(80%) at the 12-month follow-up (P < .05). HbA1c levels in the diabetic group increased
at each follow-up after endodontic treatment. Diabetes mellitus may have a negative
impact on the outcome of endodontic treatment in terms of periapical healing.
Nonsurgical endodontic treatment did not improve HbA1c levels in patients with type 2
diabetes.
• Sickle Cell Anemia
• Costa et al 2013: The presence of sickle cell anemia is a potential risk factor for
spontaneous pulp necrosis with an odds ration of 8.3 (8.3 times more likely to
experience spontaneous pulp necrosis than a patient w/out disease).
• Kaya 2004: Sickle Cell Anemia. SCA, a genetic and systemic disease, causes pulp
necrosis. As SCA affects pulpal microcirculation, pulpal necrosis occurs without any
other etiological factor. Analysis: the take home message is that since the SCA affects
members of the black race, the pulpal necrosis without any carious lesion should not be
overlooked in the routine examination for African American patients.
• Bisphosphonates
• Pryophosphates with nitrogen backbone; oral and intravenous delivery
• Bisphosphonates are a class of drugs that prevent the loss of bone mass, used to treat
osteoporosis and similar diseases. prevent loss of bone mass; treat osteoporosis/
Paget’s/bone metastasis/MM/Hyperparathyroidism (primary)

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 • De nition. The American Association of Oral & Maxillofacial Surgeons (2007) provided a
position paper which de nes BRONJ as: ‘the persistence of exposed bone in the oral
cavity, despite adequate treatment for 8 weeks, without local evidence of malignancy
and no prior radiotherapy to the affected region in patients having been administrated
BPs’.
• other anti-resorptive medications
• DAnti-RANKL Antibody: denosumab
• OPG mimetic
• cleaved by reticuloendothelial system and not the kidneys
• inhibits osteoclast activation/survival
• Aghaloo: Case report of MRONJ in denosumab pt
• Selective Estrogen Reuptake Modulator (SERM)
• increases estrogen reuptake; decreases bone remodeling
• New term for BRONJ —> MRONJ
• Medication related osteonecrosis of the jaw
• components
• 8 + weeks exposed Mx/Mn bone with mucosal ulceration
• pain/swelling in jaw w/out evidence of dental pathology
• infection (w or w/out purulence)
• altered sensation
• Marx - 1st to publish on BP and ORN association
• Ruggiero and Edwards: recent (2014) lit review
• Sarathy: 2 case of SRCT/NSRCT as precipitators for MRONJ
• Glickman: NSD in healing of PARL in pts on BPs
• Risks:
• Mn > Mx
• IV > Oral
• IV = 0.3% risk (range .8 - 20%) ?
• Oral = 0-0.4% risk
• risk rises to .21% if > 4 yrs BP use
• Possible associated with steroid use
• combination of decreased bone turnover, bacteria, dental in ammation = MRONJ in
animal studies
• Treatment: Remove sequestra, ext teeth within exposed bone, peridex rx, antibiotics
(culture)
• Drug Holiday
• renal excretion of BP
• OC’s have 2 week lifespan so 3 months after stopping BP; the serum availability of
BP is signi cantly decreased
• Diab and Watts 2011: Do 3 month drug holiday before and after any invasive tx
• Ruggierro et al 2009: patients on oral bisphosphonates are at a lower risk of BRONJ
• McLeod, Ruggierro et al 2012: the incidence of BRONJ has been reported is between
1% and 10% in different population groups
• Hsaio, Glickman, He 2009: Patient taking long term oral bisphosphonates can expect
the same prognosis after endodontic treatment as those not taking this medication. For
severely decayed teeth, nonsurgical root canal treatment (NS RCT) is preferred over
extraction when patients report a history of intravenous bisphosphonate use or
prolonged use of oral bisphosphonates. NS RCT is less traumatic to the oral tissues and
has been reported to be associated to ONJ in only 0.8% of all cases.

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 • Moinzadeh, Shemesh, Neirynck, Aubert, Wesselink 2013: IEJ. Bisphosphonates and
their clinical implications in endodontic therapy. Review. 2 steps during endo therapy
may trigger BRONJ: damage to soft tissue and extrusion of bacteria and debris.
Recommendations: pre-rinse with CHX, Local Anesthetics w/out epi, Work under aseptic
conditions (clean tooth and clamp prior to placement), Avoid damaging gingival tissue,
Patency of the apical formaen should be avoided, Avoid techniques that over ll and
overextend the lling material, No consensus on antibiotics, In cases of necrotic
(infected) pulps in patients treated with i.v. BPs, or medicated with oral BPs for more
than 3 years with concomitant risk factors, an antibiotic single-dose prophylaxis may be
advocated, because the adverse effects of the recommended antibiotics, once allergies
have been ruled out, are minimal. As Actinomyces species are common in BRONJ loci,
amoxicillin would appear as the rst choice.
• Pathophysiology. The pathophysiologic mechanism of BRONJ remains unclear, and
current hypotheses are mainly based on histopathological observations showing
bone necrosis, in ammation, the presence of bacterial aggregates and/or areas of
thickening of trabecular bone (Favia et al. 2009, Lesclous et al. 2009, Paparella et
al. 2012). A widely accepted hypothesis considers BPs toxicity and the resulting
decrease in bone remodeling as the initial and main event in the development of
BRONJ (Sarin et al. 2008, Cheng et al. 2009, Tubiana-Hulin et al. 2009). Jaws are
characterized by high bone turnover and are highly vascularized, which result in
high local concentrations of BPs. Their action hampers normal bone turnover,
resulting in acellular bone, which can get secondarily infected, due to (micro)
trauma of the oral mucosa.
• Other contributing factors in the pathogenesis are local in ammation,
antiangiogenic effects of BPs, an interplay between bone and overlying mucosa,
direct toxic effects of BPs to oral epithelium and oral trauma
• Coagulation
• Platelet Count
• 150-300k/cubic mm
• Jolly: Platelets > 50 K for surgery
• Hgb
• 12-17 g/dl for M
• 11-15 g/dl for F
• Hematocrit:
• 40-50% M
• 37-47% F
• RBC Count
• 4.5-6 million/cubic mm M
• 5-5.5 million/cubic mm F
• WBC Count
• 4.5-11k/cubic mm
• Differential
• PMN 50-70%, Lymphocytes 20-40%, Monocytes 4%, Eosinophils 0-5%, Basophils
0-1%
• Bleeding Time
• assesses platelet function
• 1mm deep, 3mm long cut; 10 min normal
• PTT
• intrinsic clotting (factors 8,9,11,12)

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 • < 40 sec normal
• PT
• extrinsic clotting (factors 2,5,7,10)
• reported as INR
• Little, Falace 2012: If patient is taking warfarin (Coumadin), the INR should be 3.5
or less before performance of invasive procedures.
• Herman: INR > 3.5 needs dental tx postponed
• Jeske - INR < 5 ok for dental tx
• Platelets
• Functions: Plug torn vessels, activate complement, release lysozymes, increase
vascular permeability (Via PAF and PDGF)
• PDGF: mitogen for mesenchyme, broblast/lymphocte chemotaxis, prostaglandin
producer, bone resorber
• Platelet activators: endothelium damage, collagen exposed and binds to platelet
collagen receptors.
• Von Willebrand Factor strengthens the bond (released from platelets/endothelium)
• Platelet integrins interact with ECM
• Platelets make ADP, 5-HT, PAF, TXA2 to attract additional platelets
• Ca released and this activates Protein Kinase C which activates PLA2 which
modi es integrin to increase platelet adhesion
• Clot physically blocks/traps microbes
• beta-lysine released by platelets during coagulation lyses G + bacteria
• Coagulation Problems
• Hemophilia A 85%
• x linked recessive (only males)
• Factor 8 de ciency
• Hemophilia B - 15% (Christmas Disease)
• Factor 9 de ciency
• An Pin: Can give PDL injections in hemophiliacs
• PTT Increased (intrinsic Dx); but normal PT/bleeding Time/platelet count
• Sickle Cell
• Kaya - autosomal recessive; AA substitution in Hgb; RG stepladder appearance;
increased bone density as well as sporadic lucencies
• PN can occur without S/S
• PN due to microcirculation lack; Macrophage unavailable to remove bacteria
• Von Willebrand’s Dx
• Most common heritable bleeding disorder
• platelet adhesion decreased which decreases function of hemostasis
• Anticoagulants
• Coumadin
• MoA = blocks conversion of oxidized to reduced vitamin k epoxide reductase
and therefore decreases vit k clotting factors (II, VII, IX, X)
• overcome with vitamin K
• green leafy vegetables = increased vit K
• single dose lasts 2-5 days
• Hargreaves: Don’t take patients off anticoagulants prescribed by MD
• Heparin
• sulfated glycosaminoglycan
• injectable

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 •
binds to antithrombin III and activates it
•
decreases thrombin and factor Xa
•
Grif th: Chronic heparin use increases osteoporosis
•
reverse with protamine sulfate
• Plavix (Clopidogrel)
• antiplatelet; irreversible
• inhibits platelets at ADP receptor
• Aspirin
• Antiplatelet; irreversible
• platelet life span 10 days
• NSAIDs
• Antiplatelet; reversible
• Herbal medications
• Hargreaves: Garlic, Ginko, Ginger, Feverfew, Saw Palmetto, Willow Bark,
Ginsing all increase bleeding
• Antibiotics
• Hargreaves: antibioitics decrease vitamin K via alterations in gut ora which
can potentiate an anticoagulated state
• Antidepressants
• Citalopram, Fluoxetine, Fluvoxamine, Paroxetine, Sertraline can all have a
mild inhibiting effect on platelet function
• “Systemic Anticoagulants”
• HTN: increased brinolysis/decreased coagulation
• Liver Dz: Decreased clotting factors
• Alcoholism: Decreased clotting factors
• Kidney Dz: Decreased erythropoietin
• Anxiety: increased BP and brinolysis
• Staf leno: Increased bleeding with HTN, diseased tissue
• Petrusson: Anxient increases bleeding due to increased BP and increased
brinolysis
• Cardiovascular Disease
• Ischemic Heart Dz: Coronary Artery Dx, Atherosclerotic Heart Dz
• Most Prevalent CV disease
• Most common cause of myocardial infarction
• Joshipura - Creased CV dx in men who also had RCT’s
• Caplan - Association of LEO’s in pts with CV disease
• Herman -
• Urgent Care okay up to 180/110
• Hospitalization if 210/120 or greater
• diastolic usually a greater predictor for MI
• If prior MI or unstable angina, hospitalize ASAP w > 180/110
• LLU Guidelines
• No elective care if > 160/95
• No urgent care if > 180/110
• If > 200/115; ER Referral
• Antibiotic and plain LA only
• Angina Tx
• Nitroglyercin, O2, ASA 81 mg chew, repeat Nitro, EMS
• MI Treatment

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 • Nitroglycerine, O2, Morphine or Demerol (50mg IM), ASA 325 mg chew
• Contact Emergency Medical Services
• MI and Angina S/S
• sometimes be asymptomatic
• chest pain
• dizziness, faintness, N/V, fatigue
• sweating, SOB
• L side pain
• referred to L Mn
• Pasqualini 2012: Case-Control study (Notice this kind of study can not show cause and
effect relation): Coronary heart disease subjects had a higher prevalence of oral
diseases and lower compliance to oral preventive strategies than healthy controls.
Multivariate analysis showed a positive association between missing teeth, the number
of LEOs, chronic periodontitis and CHD. Chronic oral diseases may increase the risk of
CHD and may be an unconventional risk factor for CHD.
• Chen et al 2007: declared that hypertension decreases healing rate after RCT.
• AP and Systemic Disease
• Costa et al 2014: demonstrated in a cross-sectional study that patients with chronic
apical periodontitis had a 2.8 times higher risk of developing coronary artery disease
than those without chronic apical disease.
• Fouad, Kulild, Aminoshariae et al 2016: Association between Systemic Diseases and
Apical Periodontitis. The results of this systematic review suggest that there might be a
moderate risk and correlation between some systemic diseases (CVD, DM, CLD, blood
disorders, and bone mineral density) and endodontic pathosis. May of the studies had a
moderate amount of bias.
• Gomes 2013: This systematic review and meta-analysis investigated evidence to
support whether apical periodontitis (AP) can modify the systemic levels of in ammatory
markers (IM) in humans. meta-analysis revealed that apical periodontitis (AP) is
associated with increased levels of CRP, IL-1, IL-2, IL-6, asymmetrical dimethylarginine,
IgA, IgG, and IgM in humans. These ndings suggest that AP may contribute to a
systemic immune response not con ned to the localized lesion, potentially leading to
increased systemic in ammation.
• Cottie et al 2011: Suggested that low-grade chronic in ammation and associated
systemic interleukin-2 increases, like that seen in apical periodontitis, may be a risk
factor for the development of atherosclerosis because of IL-2’s ability to induce
endothelial dysfunction.
• Wang C et al 2011: An increased risk of tooth extraction after root canal therapy was
signi cantly associated with Diabetes Mellitus, Hypertension, and Coronary Artery
Disease individually. Moreover, the constellation of systemic disease burden also
manifests the importance in addition to other potential confounders.
• Thryoid
• Graves Dx - most common form of hyperthyroid
• early hyper and late hypo from the anti-TSH recepto AB in graves dz
• Hyperthyroidism symptoms
• irritable, muscle weakness, sleeping problems, tachycari, feeling overheated,
diarrhea, weight loss, skin thickening, opthalmopathy/exopthalmos (eye
protrusion)
• Hashimotos Thyroiditis: Autoimmune Dx leading to thyroid destruction causing
hypothyroidism

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 • Hypothyroidism mostly due to insuf cient iodine
• Symptoms
• Weight gain, fatigue, paleness/puf ness of face, joint/mm pain, constipation,
feeling cold, hair loss/brittleness, irregular/heavy menstruation, depression,
bradycardia
• Thyroid Storm = Similar to Epi Overdose
• occurs secondary to epi in hyperthryoid pts or secondary to hypothyryoid pts on
excessive thryoid medication
• rapid/irrigular heart beat, increased body temp, vomiting, diarrhea, mental agitation
• Tx + resuscitate, IV propranolol, IV steroid, IV barbiutat/benzo to decrease anxiety/
trembling/palpitations
• Myxedema coma: emergent form of hypothyroidism
• tx: mechanical ventilation, uid replacement, vasopressor (digoxin), warm the pt,
steroids, IV levothyroxine if pt can’t take orally, glucose containing solutions
• Tuberculosis
• caused by aerobic non-motile acid fast bacillus mycobacterium tuberculosis (slow
replication)
• mostly latent; if symptoms = bloody cough/fever/weight loss/sweating/chills/loos of
appetiti/fever etc
• active = chest xray and culturing
• latent - skin test
• if active: no tx
• if latent; obtain hx and get md consult
• tx via long-term AB (Isoniazid/rifampin)
• Kidney Disease
• Decreased renal perfusion leads to kidney release of renin which spurns ACE to convert
Ang I to Ang II which causes sympathetic activation leading to tubular Na(H20
reabsorption
• End stage renal disease = < 10% normal kidney function. Symptoms vary widely (general
ill feeling, weight loss, N/V, decrease urine output)
• chronic progression often takes 10-20 yrs
• at risk groups: diabetics; hypertensive pts; those with existing kidney dz (polycystic
kidney dz, autominnume conditions such as lupus)
• Antonellie: Renal Osteodystrophy due to decreased Ca reabsorption
• bone mineralization de ciency due to electrolyte/endocrine derangement that
accompany chronic kidney dx
• bone pain, joint pain, pathologic fracture
• loss of lamina dura
• bone demineralization
• giant cell lesions of hyperparathyroidism
• Urinalysis a good screen for kidney disease
• speci c gravity normal: 1.003-1.005
• lower = kidney function diminished
• higher = dehydrated
• Creatinine clearance
• normal: 1mg/dL; 8-12 dialysis necessary
• blood urea nitrogen (BUN)
• 5-22 mg/dL normal
• elevate = kidney dysfunction or

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 • urinary tract obstruction, recent heart attack, GI bleed, shock, severe burns,
steroids/antibiotics, high protein diet
• 50 = serious impairment
• 250= end stage renal dz
• DeRossi: Decreased pulp space in ESRG/kidney transplant pt
• Galili
• shunt doesn’t require AB prophylaxis
• bleeding risk due to heparin
• decrease LA dose
• treat on non-dialysis days
• Pen and Clinda OK; Erythro Not oK
• NSAIDs/Opiates = ok, APAP only short term
• Resistant to steroids (increase dose)
• Lymphoma
• Koivisto et al 2012: Presented several cases of periapical lesions that were revealed to
be lymphoma on biopsy. The oral cavity is cited as the location of 2-3% of non-hodgkin
lesions. According to Kemp et al, these lesions present more often in the maxilla than
the mandible.
• Spatafore et al 1989: JOE. A lymphoma which was originally diagnosed as an
in ammatory process is reported. A brief review of lymphoma's etiology, predilection for
the oral cavity, and similarities to in ammation is presented. Particular emphasis is
placed on the premise that an initial benign diagnosis may not be accurate and that
monitoring patients is essential in any disease entity whether benign or malignant.
• Liver Disease
• Liver dz tests of function
• CBC with differential
• total protein and blood albumin
• PT
• Platelet count
• SGOT/SGPT
• release of these enzymes occurs with liver damage
• SGPT = ALT = alanine aminotransferase
• SGOT = AST = asparatate aminotransferase
• Worries with Liver Dz
• Bleeding
• Decreased clotting
• altered drug metabolism
• Hepatitis
• Gilchrist (Big hepatitis name)
• HB surface antigen (anti-HBs) has been used clinically to indicate an immune
response to heapatitis and indicates protection against infection with the virus
• case report of hemophiliac hcild that received a blood transfusion and acquired HBV
despite havin gthe anti-HB marker
• assumed that the surface antigen was passively acquired and thus didn’t signify
immunity to HBV
• Cleveland: percutaneous blood exposure = 1.8% seroconverison with needle stick for
HBV
• Liver Alcohol
• Worries: bleeding, sedation additive effects, drug metabolism altered.

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 • Grawish 2013: Found that the presence of hepatitis C has been associated with coronal
dental pulp abnormalities, including inappropriate cellularity, deranged vasculature and
altered extracellular matrix proteins.
• Multiple Myeloma
• Troeltzsch et al 2014: Case report and review on multiple myeloma. Multiple myeloma
is a tumor caused by proliferation of plasma cells. It often causes punched-out lesions in
the jaw, which may resemble apical periodontitis. It has been associated with root
resorption.
• Heir, Fein 1996: Lyme disease is an infection caused by the bacteria Borrelia burgdorferi and
its interaction with the immune system. They described the occurrence of orofacial pain,
temporomandibular disorder pain and dental pain in patients with lyme disease.
• Campanelli, Walton 2008: Found that the presence of a dental abscess did not affect patient
vital signs.
• Neurological
• Myasthenia Gravis
• Autoimmune neuromuscular disease
• muscle weakness and fatigue
• circulating antibodies destroy Ach receptors at neuromuscular junction
• treated with Ach reuptake inhibitors/immunsuppresants
• Simon: case report of pt with MG who presented with trismus. Infections worsen MG
symptoms
• Parkinsons
• etiology: loss of dopamine generating cells in substranita nigra and accumulation of
alpha-synuclein into inclusions called Lewy Bodies
• leads to motor and cognitive deterioration
• Clinical Features: head bend forward, tremors to the head, mask-like facial
expression, drooling, rigidity, stooped posture, weight loss, tremor, akinesia (absence
of normal movement), loss of postural re exes, bone dimineralzation, shuf ing and
propulsive gait
• Management: drug therapy, rehabilitation, client and family education, warm baths and
massage to relax muscles, speci c drug therapy, bowel routine, self help devices to
meet daily needs, exercise to loosen joint structures, range of motion exercises to
prevent deformities
• Alzheimers
• most common form of dementia (memory loss and other intellectual ability loss that
interferes with daily life)
• progressive, worsens over years
• early onset in 40-50 y/o; most 65 +
• no cure, management only
• etiology: beta-amyloid plaques build between nerves to decrease nn transmission; tau
tangles build inside cells and their roll in the etiopathogenesis is unknown
• Pregnancy
• Khalighinejad, Aminoshariae, Kulild, Mickel 2017: JOE. Apical Periodontitis, a Predictor
Variable for Preeclampsia: A Case-Control Study. Preeclampsia (PE) is characterized by
hypertension and proteinuria after the 20th week of gestation. There is an association
between systemic in ammation and adverse pregnancy outcomes such as PE. Therefore,
for the rst time, the present study aimed to investigate the possible association between
maternal apical periodontitis (AP) and PE. AP in at least 1 tooth was found in 27 of the
mothers who developed PE (54%) and in 16 of the control patients (32%) (odds ratio [OR]

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 = 2.4, P < .05). Adjusted for the maternal periodontitis, number of teeth, and endodontic
treatment, maternal AP was signi cantly associated with the occurrence of PE (P < .05;
OR = 2.23; 95% con dence interval, 95% = 1.92–6.88). AP was signi cantly more
prevalent in the experimental group. For the rst time, this study has provided evidence
that maternal AP may be a strong independent predictor of PE. Considering the high
occurrence of PE, particularly in developing countries, it could be suggested that the risk
of PE may be reduced through comprehensive dental examinations for detecting and
treating any source of in ammation, including AP, before pregnancy.
• Sevi Burcak:
• During pregnancy:
• anemia (secondary to increased Na retention)
• increased coagulation factors (all but XI and XIII)
• hypercoagulable state
• increased DVT
• decreased lung capacity
• increased HR/CO/SV
• if hypotensive, roll on L side to move uterus off inferior vena cava
• avoid amalgam
• avoid nitrous oxide, b/c decreased DNA synthesis in animals, not demonstrated in humans
• Avoid opioids; NSAIDs ok during 1st and 2nd, APAP safest
• Although ABs, and opioids and LA can cause minimal risk to developing fetus, so can
bacterial teratogens (substances that cross the placental barrier and prevent fetus from
developing normally) and thus we must weigh risk vs bene t
• Paquin, Susin, Tay et al 2017: JOE. Case report and review of Herpes Zosters. Diagnosis of
herpes zoster is challenging when the patient does not recognize or report the prodromal
signs of the disease before root canal treatment. Focal dental pulp necrosis has been
proposed as a mechanism for dental pulps undergoing spontaneous necrosis during a
herpetic outbreak within the trigeminal nerve (23, 26). It has been speculated that the
reactivated VZV is able to travel the length of the trigeminal nerve and infect the pulpal
vasculature, leading to infarction and death (15). This emphasizes the importance of a
thorough clinical examination as well as extensive pulp testing for guiding treatment decisions.
For zoster-affected patients who exhibit irreversible pulpitislike symptoms, it may be
appropriate to delay treatment of odontalgia in the absence of other ndings such as
sensitivity to percussion, active swelling, purulent drainage, or radiographic periapical
pathology. Early diagnosis of herpes zoster is important. As soon as the diagnosis is made,
antiviral therapy with acyclovir, famciclovir, or valacyclovir is recommended. Commencement
of antiviral therapy early in the course of the disease may decrease the severity of lesions and
decrease healing time (35). Skin wounds are usually managed with open wet dressings
followed by lotions. For pain control, over-the-counter analgesics are often not adequate, so
prescription nonsteroidal anti-in ammatory agents or narcotic analgesics should be
considered. The oral narcotic oxycodone and the oral anticonvulsant gabapentin have both
been shown to be effective in reducing pain associated with acute herpes zoster. These
medications, along with tricyclic antidepressants, are also recommended for the treatment of
postherpetic neuralgia.

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 More In ammation Information
Inflammation is a protective response intended to eliminate the initial cause of cell injury as
well as the necrotic cells and tissues resulting from the original insult. Although inflammation
helps clear infections and other noxious stimuli and initiates repair, the inflammatory
reaction and the subsequent repair process can cause considerable harm.

In ammation is a bene cial host response to foreign invaders and necrotic tissue, but it is itself
capable of causing tissue damage.

The main components of in ammation are both a vascular reaction and a cellular response;
both are activated by mediators that are derived from plasma proteins and various cells.

The steps of the in ammatory response can be remembered as the ve Rs: 1. recognition of the
injurious agent, 2. Recruitment of leukocytes, 3. removal of the of agent, 4. regulation (control)
of the response, 5. Resolution (repair).

The outcome of acute in ammation is either elimination of the noxious stimulus followed by
decline of the reaction and repair of the damaged tissue, or persistent injury resulting in chronic
in ammation.

Acute in ammation is a rapid response to injury or microbes or other foreign substances that is
designed to deliver leukocytes and plasma proteins to sites of injury. Two major components:
Vascular changes: vasodilation and increased vascular permeability. Cellular Events: emigration
of leukocytes from microcirculation and accumulation in the focus of injury. The principle
leukocytes in acute in ammation are neutrophils.

Vascular Reactions in Acute In ammation: Vasodilation (induced by chemical mediators such as

histamine and is the cause of erythema and stasis of blood ow). Increased Vascular
Permeability (Induced by histamine, kinins and other mediators that produce gaps between

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 endothelial cells, by direct or leukocyte-induced endothelial injury. Increased vascular
permeability allows plasma proteins and leukocytes to enter sites of infection or tissue damage;
uid leak through blood vessels results in edema).

Leukocytes are recruited from the blood into the extravascular tissue where infectious
pathogens or damaged tissue may be located, migrate to the site of infection or tissue injury and
are activated to perform their functions.

Leukocyte recruitment is a multi-step process consisting of loss attachment to and rolling on

endothelium (mediated by selectins); rm attachment to endothelium (mediated by integrins);
and migration through inter-endothelial spaces.

Various cytokines promote expression of selectins and integrin ligands on endothelium (TNF,
IL-1), increase the avidity of integrins for their ligands (chemokines) and promote directional
migration of leukocytes (also chemokines); many of these cytokines are produced by tissue
macrophages and other cells responding to the pathogens or damaged tissues

Neutrophils predominate in the early in ammatory in ltrate and are later replaced by
macrophages.

Cell-Derived In ammatory Source Principle action

Mediator

Histamine Mast Cell, Basophils, platelets vasodialation, Increased

vascular permeability, endothelial
activation

Serotonin Platelets vasodilation, Increased vascular

permeability

Prostaglandins Mast Cells, Leukocytes Vasodilation, Pain, Fever

Leukotrienes Mast Cells, Leukocytes Increased vascular permeability,

chemotaxis, leukocyte adhesion
and activation

Platelet-Activating Factor Leukocytes, endothelial Cells Vasodialation, Increased

vascular permeability, leukocyte
adhesion, chemotaxis,
degranulation, oxidative burst

Reactive Oxygen Species Leukocytes Killing of Microbes, tissue

damage

Nitric Oxide Endothelium, Macrophages Vascular Smooth Muscle

relaxation; killing of microbes

Cytokines (TNF, IL-1) Macrophages, Leukocytes, Local endothelial activation

endothelial cells, mast cells (adhesion molecule expression),
system acute-phase response; in
severe infections, septic shock

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 Cell-Derived In ammatory Source Principle action
Mediator

chemokines leukocytes, activated macrophages chemotaxis, leukocyte activation

Plasma Protein-Derived Source Principle Action

In ammatory Mediators

Complement Plasma (produced in liver) Leukocyte chemotaxis and

activation, opsonization,
vasodilation (mast cell
stimulation)

Kinins Plasma (produced in liver) increased vascular permeability,

smooth muscle contraction,
vasodialation, pain

Proteases activated during Plasma (produced in liver) endothelial activation, leukocyte

coagulation recruitment

Arachidonic Acid (AA) Metabolites: Prostaglandins, Leukotrienes, Lipoxins

Products derived from the metabolism of AA affect a variety of biological processes, including
in ammation and hemostasis. AA metabolites (also called eicosanoids) can mediate virtually
every step of in ammation; their synthesis is increased at sites of in ammatory response, and
agents that inhibit their synthesis also diminish in ammation. They can be thought of as short-
range hormones that act locally at the site of generation and then decay spontaneously or are
enzymatically destroyed. Leukocytes, mast cells, endothelial cells and platelets are the major
source of AA metabolites in in ammation.

AA is a 20-carbon polyunsaturated fatty acid derived primarily from dietary linoleic acid and
present in the body mainly in its esteri ed form as a component of cell membrane
phospholipids. It is released from these phospholipids via cellular phopholipases that have been
activated by mechanical, chemical or physical stimuli, or by in ammatory mediators such as
C5a. AA metabolism proceeds along one of two major enzymatic pathways: 1. Cyclooxygenase
stimulates the synthesis of prostaglandins and thromboxanes and 2. lipoxygenase is
responsible for production of leukotrienes and lipoxins.

The central role of eicosanoids in in ammatory processes is emphasized by the clinical utility of
agents that block eicosanoid synthesis. Aspirin an NSAIDs inhibit cyclooxygenase activity and
thus all PG synthesis (hence their ef cacy in treating pain and fever). Glucocorticoids, which are
powerful anti-in ammatory agents, act in part by inhibiting the activity of phospholipase A2, and
thus inhibiting the release of AA from membrane lipids.

The complement system consists of plasma proteins that play an important role in host defense
(immunity) and in ammation. Upon activation, different complement proteins coat (opsonize)
particles, such as microbes, for phagocytosis and destruction, and contribute to the
in ammatory response by increasing vascular permeability and leukocyte chemotaxis.

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 Complement activation ultimately generates a porelike membrane attack complex that punches
holes in the membranes of invading microbes.

Coagulation and Kinin Systems. A central event in the generation of several circulating
mediators of in ammation is activation of Hageman Factor (Factor XII). Activated Hageman
Factor (Factor XIIa) initiates 4 systems involved in the in ammatory response: 1. the kinin
system, producing vasoactive kinins; 2. the clotting system, inducing the activation of thrombin,
brinopeptides and factor X, all with in ammatory properties; 3. the brinolytic system,
producing plasmin and inactivating thrombin; and 4. the complement system, producing
anaphylatoxins C3a and C5a.

Kinin system ultimately leads to formation of bradykinin from its circulating precursor, HMWK.
Bradykinin causes: vascular permeability, arteriolar dilation, bronchial smooth muscle
contraction and pain.

Role of mediators in Diff Reactions of Role of mediators in Diff Reactions of

In ammation In ammation

Vasodialation Prostaglandins
Nitric Oxide
Histamine

Increased Vascular Permeability Histamine & Serotonin, C3a & C5a (by liberating
vasoactive amines from mast cells, other cells),
Bradykinin
Leukotrienes C4, D4, E4
PAF
Substance P

Leukocyte Recruitment & Activation TNF, IL-1

Chemokines
C3a, C5a
Leukotriene B4
(bacterial products)

Fever IL-1, TNF

Prostaglandins

Pain Prostaglandins
Bradykinin
Neuropeptides

Tissue Damage Lysosomal enzymes of leukocytes

Reactive Oxygen Species
Nitric Oxide

Chronic In ammation is in ammation of prolonged duration in which active in ammation tissue

injury and healing proceed simultaneously.

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 Chronic in ammation is characterized by in ltration with mononuclear cells: macrophages,
lymphocytes and plasma cells. Tissue destruction: largely induced by the products of the
in ammatory cells. Repair, involving new vessel proliferation (angiogenesis) and brosis.

Features of Chronic In ammation: 1. Prolonged host response. 2. Caused by microbes that

resist elimination, immune responses against self and environmental antigens, and some toxic
substances; underlies many medically important diseases. 3. Characterized by coexisting
in ammation, tissue injury, attempted repair by scarring and immune response. 4. Cellular
in ltrate consists of macrophages,, lymphocytes, plasma cells; brosis is often prominent. 5.
mediated by cytokines produced by macrophages and lymphocytes (notably T lymphocytes);
bidirectional interactions between these cells tend to amplify and prolong the in ammatory
reaction.

Systemic Effects of In ammation. Fever: cytokines (TNF, IL-1) stimulate production of

prostaglandins in hypothalamus. Production of acute phase proteins: C-Reactive proteins,
others; synthesis stimulated by cytokines. Leukocytosis: cytokines stimulate production of
leukocytes from precursors in the bone marrow. In some severe infections, septic shock: fall in
blood pressure, disseminated intravascular coagulation, metabolic abnormalities; induced by
high levels of TNF.

Innate Immunity (natural or native immunity) is mediated by cells and proteins that are always
present and poised to ght against microbes and are called into action immediately in response
to infection. The major components of innate immunity are epithelial barriers of the skin,
gastrointestinal tract, and respiratory tract which prevent microbe entry; phagocytic leukocytes
(neutrophils and macrophages); a specialized cell type called the natural killer cell; and several
circulating plasma proteins, the most important of which are the proteins of the complement
system.

Adaptive (acquired or speci c) immunity is normally silent and responds to the presence of
infectious microbes by becoming active, expanding, and generating potent mechanisms for
neutralizing and eliminating microbes. The components of the adaptive are lymphocytes and
their products. Two types: humoral immunity (B lymphocytes), cell mediated immunity (T
lymphocytes)

Changes in Vascular Flow During Acute In ammation:

1. Vasoconstriction - (few seconds if at all), 1st event after injury, doesn’t last long
2. Vasodilation - Start in arterioles (localized to area of injury)
3. Microvascular beds open (occurs at same time as vasodilation)
4. Increased local blood ow (hyperemia) cause of warmth and redness
5. Increased permeability of Microvasculature (leaky)
6. Exudation - of protein rich blood uid into extravascular tissue
7. RBCs in small vessels become concentrated
8. Increased blood viscosity

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9. Slowing of circulation = stasis
10. Margination of Leukocytes (line up along walls)
11. Emigration of leukocytes (leave vessels, go into tissues) —> extravascular events

Classic Local Signs of Acute In ammation

1. Heat (calor) - increased blood ow and hyperemia
2. Redness (rubor) - b/c of hyperemia
3. Swelling (tumor) - exudation of uids
4. Pain (dalor) - PGE2, Bradykinin
5. Loss of Function (functio laesa)

Facial Spaces
The facial spaces of the head and neck can be categorized into four anatomic groups:
-The mandible and below
-The check and lateral face
-The pharyngeal and cervical areas
-The mid-face

Swellings of and below the mandible include six anatomic areas or facial spaces:
-The buccal vestibule
-The body of the mandible
-The mental space
-The submental space
-The submandibular space

Spread of

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Odontogentic Infection:

The mandibular buccal vestibule is the anatomic area between:

-the buccal cortical plate
-the overlying alveolar mucosa
-the buccinator muscle (posteriorly) or mentalis muscle (anteriorly)
The source of the infection:
-Mandibular Posterior or anterior tooth in which purulent breaks through buccal cortical plate
-Apex or Apices involved lie above the attachment of the buccinator or mentalis muscles

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The Space of the body of the mandible is the potential anatomic area between the buccal or
lingual cortical plate and its overlying periosteum. The source of infection is a mandibular tooth
in which the purulent exudate has broken through the overlying cortical plate but not yet
perforated the overlying periosteum. Involvement of this space can also occur as a result of a
post-surgical infection.

Mental Space
The potential bilateral anatomic area of the chin that lies between:
-the mentalis muscle superiorly
-platysma muscle inferiorly
The source of the infection:
-anterior tooth in which the purulent exudate breaks through the buccal cortical plate
-the apex of the tooth lies below the attachment of the mentalis muscle.

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Submental Space
The potential anatomic area between:
-mylohyoid muscle superiorly
-platysma muscle inferiorly
The source of the infection:
-An anterior tooth in which the purulent exudate breaks through the lingual cortical plate
-The apex of the tooth lies below the attachment of the mylohyoid muscle.

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Sublingual Space
The potential anatomic area between:
-Oral Mucosa of the oor of the mouth superiorly
-Mylohyoid muscle inferiorly
-lingual surfaces of the mandible laterally
The source of the infection:
-any mandibular tooth in which the purulent exudate breaks through the lingual cortical plate
-apex or apices of the tooth lie above the attachment of the mylohyoid muscle

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Submandibular Space
The potential space between:
-mylohyoid muscle superiorly
-platysma muscle inferiorly
-mandible laterally
The source of the infection:
-Posterior tooth, usually a molar, in which the purulent exudate breaks through the lingual
cortical plate.
-Apices of the tooth lie below the attachment of the mylohyoid muscle

**If the Submental, Sublingual and submandibular spaces are involved at the same time
(bilaterally) a diagnosis of Ludwig’s angina is made. This life-threatening cellulitis can advance
into the pharyngeal and cervical spaces,, resulting in airway obstruction.

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Swellings of the lateral face and cheek include four anatomic areas or fascial spaces:
-The buccal Vestibule of the Maxilla
-The buccal space
-The submasseteric Space
-The temporal Space

Buccal Vestibular Space (of maxilla)

The area between:
-Buccal Cortical Plate,
-overlying mucosa
-buccinator muscle
-(the superior extent of the space is the attachment of the buccinator muscle to the zygomatic
process.
The source of the infection
-Maxillary posterior tooth in which the purulent exudate breaks through the buccal cortical plate

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-Apex of the tooth lies below the attachment of the buccinator muscle

Buccal Space
The potential space between:
-Lateral surface of the buccinator muscle
-medial surface of the skin of the cheek
-(superior extent of the space is the attachment of the buccinator muscle to the zygomatic arch)
-(inferior and posterior boundaries are the attachment of the buccinator to the inferior border of
the inferior border of the mandible and the anterior margin of the masseter muscle, respectively)
The Source:
-Posterior Mandibular or Maxillary tooth in which the purulent exudate breaks through the buccal
cortical plate
-Apex/Apices of the tooth lie above the attachment of the buccinator (Maxilla)
-Apex/Apices of the tooth lie below the attachment of the buccinator (Mandible)

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Submasseteric Space
The potential space between:
-Lateral surface of the ramus of the mandible
-medial surface of the masster muscle
The source of the infection
-usually an impacted third molar in which purulent exudate breaks through the (lingual - check)
cortical plate
-apices of the tooth lie very close to or within the space

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 Temporal Space (two compartments)
Deep Temporal Space
The potential space between:
-lateral surface of the skull and the medial surface of the temporalis muscle
Super cial Temporal Space
The potential space between:
-temporalis muscle and its overlying fascia
(The deep or super cial temporal spaces are involved indirectly if an infection spreads
superiorly from the inferior pterygomandibular or submasseteric spaces, respectively.

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Swellings of the pharyngeal and cervical areas include the following fascial spaces:
-Pterygomandibular Space
-Parapharyngeal Spaces
-Cervical Spaces

Pterygomandibular Space
The potential space between:
-Lateral surface of the medial pterygoid muscle
-medial surface of the ramus of the mandible
-(superior extent of the space is the lateral pterygoid muscle)
The source of the infection:
-Mandibular 2nd or 3rd molars in which the purulent exudate drains directly into the space.
-In addition, contaminated inferior alveolar nerve injections can lead to infection of the space

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Parapharyngeal Spaces
Compromise the lateral pharyngeal and retropharyngeal spaces.

Lateral Pharyngeal Space

(Bilateral) Lies between:
-lateral surface of the medial pterygoid muscle
-posterior surface of the superior constrictor muscle
-Superior and inferior margins of the space are the base of the skull and the hyoid bone
-posterior margin is the carotid space or sheath (contains: common carotid artery, internal
jugular vein, vagus nerve)

Retropharyngeal Space
Lies between:
-anterior surface of the prevertebral fascia

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-posterior surface of the superior constrictor muscle and extends inferiorly into the
retroesophageal space, which extends into the posterior compartment of the mediastinum.

The pharyngeal spaces usually become involved as a result of a secondard spread of infection
from other fascial spaces or directly from a peritonsillar abscess.

The cervical spaces comprise the pretracheal, retrovisceral, danger and prevertebral spaces.

Pretracheal space
The potential space surrounding the trachea. It extends from the thyroid cartilage inferiorly into
the superior portion of the anterior compartment of the mediastinum to the level of the aortic
arch. Because of its anatomic location, odontogenic infections do not spread to the pretracheal
space.

Retrovisceral Space
Comprises the retropharyngeal space superiorly and the retroesophageal space inferiorly. The
space extends from the base of the skull into the posterior compartment of the mediasstinum to
the level between vertebrae C6 and T4.

Danger Space (ie space 4)

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The potential space between the alar and prevertebral fascia. Because this space is composed
of loose CT, it is considered an actual anatomic space extending from the base of the skull into
the posterior compartment of the mediastinum to a level corresponding to the diaphragm.

Prevertebral Space
Potential space surrounding the vertebral column. As such it extends from vertebra C1 to the
coccyx. A retrospective study showed that 71% of cases in which the mediastinum was involved
arose from the spread of infection from the retrovisceral space

Swellings of the midface consist of four anatomic areas and spaces:

-The Palate
-The base of the upper lip
-The canine spaces
-the periorbital spaces

Odontogenic infections can spread into the areas between the palate and its overlying
periosteum and mucosa and the base of the upper lip, which lies superior to the orbicularis oris
muscle, even though these areas are not considered actual fascial spaces.

The source of infection of the palate is any maxillary teeth in which the apex of the involved
tooth lies close to the palate. (palate superiorly, periosteum inferiorly)

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 The source of infection of the base of the upper lip is a maxillary central incisor in which the
apex lies close to the buccal cortical plate and above the attachment of the orbicularis oris
muscle. (Muscosa of the base of the upper lip and obicularis oris inferiorly)

Canine or Infraorbital Space

The potential space between:
-levator anguli oris muscle inferiorly
-levator labii superioris muscle superiorly
The source of infection:
-maxillary canine or rst premolar in which the purulent exudate breaks through the buccal
cortical plate
-apex of the tooth lies above the attachment of the levator anguli oris muscle

Periorbital Space
The potential space that lies deep to the orbicularis oculis muscle. This space becomes involved
through the spread of infection from the canine or buccal spaces. Infections of the midface can
be very dangerous because they can results in cavernous sinus thrombosis, a life threatening
infection in which a thrombus formed in the cavernous sinus breaks free, resulting in blockage
of an artery or the spread of infection. Under normal conditions, the angular and opthalmic veins
and the pterygoid plexus of veins ow into the facial and external jugular veins. If an infection
has spread into the midfacial area, however, edema and resultant increased pressure from the
in ammatory response cause the blood to back up into the cavernous sinus. Once in the sinus,
the blood stagnates and clots. The resultant infected thrombi remain in the cavernous sinus or
escape into circulation.

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Why are infections
of the midface
region dangerous?
Cavernous sinus thrombosis: Life threatening infection in which a thrombus formed in the
caverous sinus breaks free, resulting in blockage of an artery or the spread of infection.
Infections in the midface region initiate an in ammatory response. Increased pressure can
reverse the direction of venous blood ow (due to lack of valves)

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Maxillary Artery, Ptyergopalatine

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