Textbook of Endodontology

Cover
Textbook of Endodontology
Title Page
Copyright
Contents
List of contributors
Foreword
Preface
About the companion website
1 Introduction to endodontology
	Endodontology
		Episteme
		Techne
		Phronesis
		Concepts of endodontology
	The objective of endodontic treatment
	Clinical problems and solutions
		The vital pulp
		The necrotic or infected pulp space associated with apical periodontitis
		The endodontically treated tooth
	The diagnostic dilemma
	The outcome dilemma
	The tools of treatment
	References
Part 1 The Vital Pulp
	2 The dentin–pulp complex: structure, functions, threats, and response to external injury
		Introduction
		The odontoblast and the dentin–pulp complex
			The primary odontoblast, dentinal tubules, and branching
		The dental pulp
			Cellular composition of the pulp
			Extracellular matrix
			Nerves
			Vascular supply and blood flow
			Lymphatics
		Immune responses in the dentin–pulp complex
			Inflammation, a crucial prerequisite for repair and regeneration
			Vascular events and inflammation
		Responses of the healthy dentin–pulp complex to nondestructive stimuli
		The dentin–pulp complex and responses to external injuries
			General response pattern
			Dental treatment procedures
			Restorative procedures
			Protective roles of dentinal fluid
			Preparation trauma – a catastrophic threat?
			Bacterial leakage
			Effects of restorative materials
		Summary
		References
	3 Dentinal and pulpal pain
		Introduction
		Classification of nerve fibers
		Morphology of intradental sensory innervation
		Function of intradental sensory nerves
		Sensitivity of dentin: hydrodynamic mechanism in pulpal A-fiber activation
		Responses of intradental nerves to tissue injury and inflammation
			Peripheral neural changes affecting pain responses in inflamed teeth
			Neurogenic vasodilation and inflammation
			Inflammatory mediators
			Morphological versus functional changes of pulpal nerves in inflammation
		Local control of pulpal nociceptor activation
		Dentin hypersensitivity
			Central nervous system mechanisms
		Pain symptoms and pulpal diagnosis
		References
	4 Clinical pulp diagnosis and decision-making
		Introduction
		Evaluation of diagnostic information
		Diagnostic accuracy
		Diagnostic strategy
		Clinical manifestations of pulpal and periapical inflammation
		Collecting diagnostic information
		Diagnostic methodology: assessment of pulp vitality
			Mechanical tests
			Thermal tests
			Electrical test
			Interpretation of test results
		Diagnostic methodology: evaluation of reported pain
		Diagnostic methodology: provocation/inhibition of pain
			Differential diagnosis of pulpal pain
		Diagnostic methodology: evaluation of tooth discolorations
		Diagnostic classification
			Diagnostic terms
		References
	5 Caries pathology and management in deep stages of lesion formation
		Enamel lesions without clinical cavitation
			Understanding the topography of the enamel–dentin lesion
		Progressive stages of enamel–dentin lesions without surface cavitation and exposure of dentin to the oral environment
			The superficial enamel lesion and the early odontoblast response
			Dentin hypermineralization prior to demineralization of dentin
			Dentin demineralization
			Why is demineralized dentin discolored?
			Tertiary dentinogenesis and lesion activity
		Cavitation of the dentin lesion
			Lateral spread along the enamel–dentin junction and toward the pulp
			Bacterial invasion and innate and adaptive immunity
			Caries-induced inflammation in dentin differs from soft tissue inflammation
			Carious activity may change in the environment of an untreated deep lesion
			Radiographic definitions of deep and extremely deep carious lesions
			Histological picture of pulp inflammation in deep caries
			Histological picture of pulp inflammation in extremely deep caries
		Concluding remarks on the natural history of dental caries
		Strategies for the management of deep caries
			The need for updated terminology
		Detailed treatment protocol for deep caries management
			Evidence in support of stepwise caries removal
			Evidence in support of selective caries removal
			Managing deep caries and clinical pulp diagnosis
		References
	6 Treatment of vital pulp conditions
		Introduction
		Indications and treatment concepts for preserving vital pulp functions
		Protocols for treatments aiming to preserve the vitality of the exposed pulp
			Pulp capping
			Pulpotomy
		Factors of importance in preserving vital pulp functions
			Type of injury
			Age
			Size of the pulp exposure
			Clinical procedure
			Integrity of permanent restorations
			Postoperative recall
		Capping materials and healing patterns
			Calcium hydroxide
			Dentin-bonding systems as pulp capping
			Hydraulic calcium silicate cements
		Tissue–biomaterial interaction and pulp healing
			A problem to solve–the loss of dentin-producing cells following pulp exposure
			Classical wound healing patterns
			Use of bioactive capping materials
			Future attempts to promote wound healing patterns
		Pulp-preserving treatments–a controversial treatment?
		Indications and treatment concepts for treating the irreversibly inflamed vital pulp (pulpectomy)
			Objective
			Treatment principles for an effective pulpectomy
			Inter-appointment dressing with calcium hydroxide
			Wound healing after pulpectomy
		Postoperative considerations
		Choosing between pulp-preserving vital pulp therapies and pulpectomy
			Irreversible pulpitis
		Concluding remarks on the avoidance of pulpectomy by vital pulp therapies
		Revitalization and/or regenerative endodontic procedures
		References
Part 2 The Infected Necrotic Pulp and Apical Periodontitis
	7 Apical periodontitis
		Introduction
		The nature of apical periodontitis
		Interactions with the infecting microbiota
			Bacterial elimination
			The bacterial front line
			The formation of the lesion
			The equilibrium between bacteria and host
			The endodontic flare-up
		Treatment and healing of periapical lesions
			Treatment of periapical lesions
			Healing of periapical lesions
		Persistence of periapical lesions
		Clinical manifestations and diagnostic terminology
			Normal periapical conditions
			Asymptomatic apical periodontitis
			Symptomatic apical periodontitis
			Acute apical abscess
			Chronic apical abscess
			Cellulitis
			Condensing osteitis
		References
	8 Microbiology of the inflamed and necrotic pulp
		Introduction
		Historical background
		Clinical evidence
			Routes of microbial entry to the pulpal space
			The inflamed pulp
			The necrotic pulp
		Infections in root-filled teeth with persistent apical periodontitis
			Surviving in starvation
			Microbiology in failed root-filled teeth
		Microbial pathogenesis of apical periodontitis
		Association of signs and symptoms with specific bacteria
		Biological evidence
			Biofilms in root canals
		Extraradicular biofilms
		Ecological determinants for microbial growth in root canals
		Microbial interactions in biofilms
		Microbial resistance to antimicrobials
		Antibiofilm strategies
		Concluding remarks
		References
	9 Clinical diagnosis of pulp necrosis and apical periodontitis
		Introduction
			Diagnostic procedures
			Microbial infection and host response
		Clinical features of pulp necrosis and root canal infections
			Pulpal necrosis
			Clinical features of root canal infection
			Clinical procedures for assessing pulpal and periapical status
		Radiographic features of apical periodontitis
			Bone tissue response
			Radiographic methods
			Interpretation of images
			Methods for follow-up and epidemiology
		A strategy for the formulation of a periapical diagnosis
			Combining the anamnestic, clinical, and radiographic data
		Diagnostic challenges during treatment
			Inter-appointment pain and emergencies
		Special cases of endodontic infections
			Root fractures and dental trauma; dens invaginatus
			Endodontic–periodontal lesions
			Root resorptions
			Maxillary sinus involvement
			Differential diagnoses
		An integrated approach to endodontic diagnosis
			Clinical–radiological features and extent of infection
			Diagnosis and treatment options
		References
Part 3 Endodontic Treatment Procedures
	10 Endodontic emergencies
		Introduction
		General diagnostic considerations and emergency principles
		The etiology and pathogenesis behind emergency scenarios
			Acute pain from pulpitis
			Acute pain from apical periodontitis
			Symptomatic pulpitis–vital pulp
			Symptomatic apical periodontitis with or without acute abscess
			Posttreatment emergency
		Non-endodontic tooth pain–conditions of differential diagnostic interest
			Marginal (periodontal) abscess
			Referred pain from other teeth or nondental structures
			Idiopathic or neuropathic tooth pain
		Management of patients with acute dental pain
			From a psychological perspective
			Antibiotics
			Analgesics
		References
	11 Controlling the environment–the aseptic working field
		Background
			History and evidence
		Preparing teeth for rubber dam isolation and the development of an aseptic working field
			Access preparation
		Rubber dam isolation
			Rubber dam clamp
			Punches and forceps
			Rubber dam frame
		Application of the rubber dam
			Winged technique
			Wingless technique
		Disinfection of the working field
		Aseptic working procedures
			Radiographic images and rubber dam
			Coronal sealing
		References
	12 Access and canal negotiation: the first key procedural steps for successful endodontic treatment
		Introduction
		Principles of tooth development and tooth anatomy
		Individual analysis of the tooth, preoperative radiographs, and additional CBCT scans in complex cases
		Rubber dam isolation
		Access cavity preparation
			The concept of minimally invasive access cavities
			Difficulties accessing teeth with mineralized pulp chambers
			Access as a diagnostic step
		Canal negotiation
			Pre-flaring the superficial part of the canal (phase 1)
			Coronal flaring of the coronal half to two-thirds of the canal (phase 2)
			Negotiation to the canal terminus and determination of working length (phase 3)
		References
	13 Root canal instrumentation
		Introduction
		Principles of root canal instrumentation
		Root canal system anatomy
			Root canal(s) versus root canal system
			Root canal curvature
			Cross-sectional shape and diameter
			Apical configuration
			Physiologically and pathologically induced changes
		Anatomical variations in teeth
			Maxillary anterior teeth
			Maxillary premolars
			Maxillary molars
			Mandibular anterior teeth
			Mandibular premolars
			Mandibular molars
		Procedural steps
			Preassessment
			Aseptic working
			Coronal and radicular access
			Initial root canal preparation
			Methods to establish working length
			Final root canal preparation
		Endodontic instruments
			Traditional systems
			Engine-driven Ni-Ti instrument systems
		Instrumentation techniques
			Hand instrumentation
			Engine-driven nickel–titanium instrumentation
		Limitations of root canal instrumentation
			Engine-driven nickel–titanium versus stainless-steel hand files
			Limited reach versus unwanted dentin removal
			Risk of instrument fracture
		Preventing procedural mishaps
			Blockage
			Stripping
			Ledging
			Zipping
			Perforation
			Instrument fracture
		References
	14 Irrigation and disinfection
		Introduction
		Eradication of microorganisms from the root canal system
		Microbial reduction by instrumentation
		Root canal irrigation
			Sodium hypochlorite (NaOCl)
			Hydrogen peroxide (H2O2)
			Chlorhexidine digluconate (CHX)
			Iodine potassium iodide (IKI)
			Combination products for canal irrigation
		The apical root canal–a special challenge for irrigation
			Apical pressure: positive versus negative
		Activation of irrigant flow
			Syringe-needle irrigation
			Sonic and ultrasonic cleaning
		Use of lasers in irrigation
		Wide-spectrum sound energy for cleaning the root canal system
		Intracanal medicaments
			Calcium hydroxide (Ca(OH)2)
			Chlorhexidine digluconate (CHX)
			Antibiotics as intracanal medicaments
			Phenolic compounds
		Concluding remarks
		References
	15 Root canal filling
		15.1 Root canal filling materials
			Introduction
				Purpose of filling root canals
				Classification
				Limitations
				Selection
			Requirements
				Technical properties
				Biological properties
				Handling properties
				Biocompatibility
				Leakage/sealing
			Evaluation of specific materials
				Cones of gutta-percha and other materials
				Sealers/cements
				Materials for retrograde fillings during root-end surgery and intentional reimplantation
				Materials for regenerative endodontics
			References
		15.2 Root canal filling techniques
			Introduction
			Clinical objectives and in vitro investigations
			The root canal filling–dentin interface
				Dentin conditioning
			Root canal filling techniques
				Cold techniques
				Techniques requiring heat
				Techniques for wide open apical foramen
			Concluding remarks
			References
Part 4 The Endodontically Treated Tooth
	16 The root canal-treated tooth in prosthodontic reconstruction
		Introduction
		Fracture predilection of root-treated teeth
		Occlusal loading
		Root canal-treated teeth as abutments
		Distribution of remaining tooth structure and restorability
		Principles of restoration of root-treated teeth
		Timing of restoration after endodontic treatment
		Approach to restoration of anterior teeth
			Relatively intact teeth
			Teeth with proximal cavities
			Teeth with inadequate retention or resistance
		Characteristics of posts
			Post materials
			Post shape
			Post length
			Post diameter
			Surface configuration
			Diaphragm
		Preparation of the post space
			Cementing posts
			Clinical outcomes for posts
		Approach to restoration of posterior teeth
			Relatively intact teeth
			Teeth with proximo-occlusal cavities
			Teeth with MOD (mesio-occluso-distal) cavities
			Teeth with inadequate tissue for retention without auxiliary aids
		Core materials
			Composite
			Ceramics
			Cermets
			Cast cores
		Modes of restoration failure in root canal-treated teeth
			Loss of retention
			Structural mechanical failure
		Conclusions
		References
	17 Clinical epidemiology: measuring endodontic disease and treatment outcome
		Introduction
		Defining a “successful” outcome
			Measuring outcome
		Study designs commonly used in endodontic research
			Cross-sectional studies
			Cohort studies
			Experimental studies
			Systematic reviews–meta-analyses
		Treatment outcome and risk factors
			Treatment outcome
			Patient-related outcome
			Person-specific risk factors
			Tooth-specific risk factors
		Concluding remarks
		References
	18 Endodontic retreatment–the decision-making process
		Introduction
		Why might the initial treatment be unsuccessful?
			Intraradicular infection
			Extraradicular infection
			Canal complexity
			Nature of periapical disease
			Technical aspects of the primary treatment
			Patient-related factors
			Operator-related factors
		When may further intervention be considered?
			New or persistent symptoms
			New or nonhealing apical periodontitis
			Risks of local or systemic disease
			Questionable foundations for restoration
		Decision-making–the dentist's perspective
			Medical history
			Dental history
			Clinical examination
			Special tests
			How signs and symptoms influence decision-making and treatment plans
			Indications for operative intervention
		Decision-making–the patient's perspective
		References
	19 Nonsurgical retreatment
		Introduction
		Indications
			Persistent or secondary apical periodontitis
			Preventive retreatment
			Access opening through crowns and restorations
			Removing crowns and bridges
			Removing cores and posts
			Access to the apical area
			Removing gutta-percha
			Removing sealers, cements, and pastes
			Removing silver cones
			Removing metal or plastic carriers
			Removing broken instruments
		Instrumentation of the root canal
			Reshaping the root canal
			Apical obstructions
			Ledges
			Missed canals
			Perforation repair
			Antimicrobial treatment
		Prognosis
			Periapical healing
			Tooth survival
		Summary
		References
	20 Surgical endodontics
		Introduction
		General outline of the procedure
			Treatment planning
		Local anesthesia
		Flap design, incision, and raising the flap–general considerations
			Flap designs
			Incisions
			Flap elevation and retraction
		Access to the root tip
		Root-end resection
		Curettage of the soft-tissue lesion
		Management of bleeding
			Local anesthesia (see also Chapter 21)
			Proper and gentle operation technique
			Suctioning
			Obstruction by mechanical means
			Chemicals
			Resorbable agents
			Electrocoagulation
		Root-end preparation
		Root-end filling
		Repositioning and suturing of the flap
		Postoperative measures
		Follow-up after surgery
			Bone healing
		References
Part 5 Additional Considerations
	21 Local anesthetic considerations
		Introduction
		Fundamentals of local anesthetic action
		Common local anesthetic agents in endodontics
			Lidocaine
			Articaine
			Mepivacaine
			Prilocaine
			Bupivacaine
		Standard methods of local anesthesia for endodontics
			Maxillary teeth
			Mandibular teeth
		Failure to secure anesthesia
		Why may teeth be difficult to anesthetize?
			Anatomical considerations
			Physiological considerations: inflammation
		Measures to preempt or overcome challenging local anesthesia
			Local anesthetic agents
			Mandibular nerve blocks
			Mandibular infiltrations
			Maxillary nerve blocks
			Maxillary infiltrations
		Supplementary injections
			Periodontal ligament injections
			Intraosseous injection
			Intraseptal
			Intrapulpal injection
		Sedation
		Complications of local anesthesia
		References
	22 Complex orofacial pain conditions
		Introduction
		Overview of pain mechanisms
			Transient pain
			Inflammatory pain
			Neuropathic pain
			Functional pain
		Diagnostic process
		Complex orofacial pain conditions
		Painful posttraumatic trigeminal neuropathy
			Pain management
		Persistent idiopathic facial pain
			Pain management
		Atypical odontalgia/persistent dentoalveolar pain
			Pain management
		Trigeminal neuralgia
			Pain management
		Trigeminal autonomic cephalalgias
			Pain management
		Migraine/neurovascular orofacial pain
			Pain management
		Temporomandibular disorder pain–referred pain
			Pain management
		Summary
		References
	23 Endodontic complications after trauma
		Introduction
		Common dental injuries
		Dental trauma and its consequences
			Traumatic injuries and the pulp
			Fractures
			Luxations
			Obliteration of the pulp space by mineralized tissue
		Consequences of pulp breakdown and infection after trauma
			Inflammatory bone resorption
			Inflammatory (infection-related) root resorption
			Internal inflammatory root resorption
			Non-inflammatory root resorption
			Arrest of dental development
		General considerations in the management of dental trauma
			Immediate management of patients with dentoalveolar trauma
			Immediate and long-term management of patients with dental trauma
		Diagnostic quandaries: to remove or review the pulp after trauma?
			Pulp regeneration–the dawn of a new era?
		References
	24 Medicolegal considerations
		Introduction
		Ethical considerations–the concepts of beneficence and nonmaleficence
		Defining best practice
		Endodontic procedures as complex interventions with scope for imperfection, oversight and error
		Examples of errors and accidents
			Wrong tooth or wrong diagnosis
			Unexpected pain
			Perforation during access cavity preparation
			Fractured instruments
			Swallowed or inhaled instruments
			Medicament accident
			Technical aspects of the root filling
		Do errors always lead to legal action?
		Professional indemnity/malpractice insurance
		Managing risks
			Careful diagnosis
			Discussing treatment options and risks with patients
			Duty of candor in the event of an accident or error
			Working within the limits of your skills and knowledge
			Offering referral for specialist care
			Acting in the patients best interests when accidents or errors arise
			Taking patient concerns seriously and having an effective complaints procedure
			Good record keeping
			Learning from complaints and mistakes
		Conclusion
		References
	25 Emergencies in need of urgent referral
		Introduction
		Neurological injuries resulting from endodontic procedures and materials
			Local anesthetic-related neuropathies
			Neuropathies caused by endodontic instruments and materials
		Neurological injuries resulting from periapical inflammation
			Preventing neuropathy associated with periapical inflammation
			Management of neuropathy associated with periapical inflammation
		Chemical tissue trauma
			Prevention of chemical tissue injury
			Management of endochemical tissue injury
		Severe odontogenic infections that may compromise systemic health
			Management of severe spreading odontogenic infection
		Suspicion of locally aggressive or neoplastic lesions
		Severe or persistent pain
		Inhalation or aspiration of dental instruments or materials
			Preventing of aspiration of dental instruments or materials
			Management of acute aspiration
		Allergic responses that may compromise systemic health
		Reporting adverse events
		Summary
		References
	26 The transition to independent practice
		Introduction
		The challenge of transition
		Learning: explanations and strategies
			Learning as self-directed
			Learning as motivation to succeed
			Learning as acquiring knowledge versus becoming competent
			Learning as developing an identity in a community
		Conclusion
		Acknowledgment
		References
Index
EULA