A Concise Guide To Endodontic Procedures (9783662437292)

A Concise Guide
to Endodontic
Procedures
Peter Murray
123
A Concise Guide to Endodontic Procedures
Peter Murray
A Concise Guide to
Endodontic Procedures
Peter Murray
Department of Endodontics
Nova Southeastern University College
of Dental Medicine
Fort Lauderdale, FL
USA
ISBN 978-3-662-43729-2 ISBN 978-3-662-43730-8 (eBook)

DOI 10.1007/978-3-662-43730-8
Springer Heidelberg New York Dordrecht London
Library of Congress Control Number: 2014949160
© Springer-Verlag Berlin Heidelberg 2015

This work is subject to copyright. All rights are reserved by the Publisher, whether the whole or part of
the material is concerned, specifically the rights of translation, reprinting, reuse of illustrations, recita-
tion, broadcasting, reproduction on microfilms or in any other physical way, and transmission or infor-
mation storage and retrieval, electronic adaptation, computer software, or by similar or dissimilar
methodology now known or hereafter developed. Exempted from this legal reservation are brief excerpts
in connection with reviews or scholarly analysis or material supplied specifically for the purpose of being
entered and executed on a computer system, for exclusive use by the purchaser of the work. Duplication
of this publication or parts thereof is permitted only under the provisions of the Copyright Law of the
Publisher's location, in its current version, and permission for use must always be obtained from Springer.
Permissions for use may be obtained through RightsLink at the Copyright Clearance Center. Violations
are liable to prosecution under the respective Copyright Law.
The use of general descriptive names, registered names, trademarks, service marks, etc. in this publica-
tion does not imply, even in the absence of a specific statement, that such names are exempt from the
relevant protective laws and regulations and therefore free for general use.
While the advice and information in this book are believed to be true and accurate at the date of publica-
tion, neither the authors nor the editors nor the publisher can accept any legal responsibility for any errors
or omissions that may be made. The publisher makes no warranty, express or implied, with respect to the
material contained herein.
Printed on acid-free paper
Springer is part of Springer Science+Business Media (www.springer.com)

Contents
1 The Differential Diagnosis of Endodontic Disease . . . . . . . . . . . . . . . . 1

Talking to Patients About Saving Their Teeth . . . . . . . . . . . . . . . . . . . . . . 1
Patient Consent and Record Keeping. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
Talking with Patients to Diagnose the Cause of Pain . . . . . . . . . . . . . . . . 2
Endodontic Examination . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
Facial Examination . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
Dental Examination. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
Radiographic Examination . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
SOAP Framework for the Differential Diagnosis
of Endodontic Disease . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
Subjective Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
Objective Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
Assessing Information to Reach a Diagnosis . . . . . . . . . . . . . . . . . . . . 5
Plan/Procedure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
Dental History . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
Medical History . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
Dental Pulp Vitality Diagnosis. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
Dental Pulp Sensibility Testing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
Electric Pulp Tester . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
Cold and Heat Tests . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
Palpation Testing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
Percussion Testing. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
Cavity Testing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
Experimental Dental Pulp Sensibility Tests . . . . . . . . . . . . . . . . . . . . . 11
Exploratory Surgical Flap . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
Anesthesia Test . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
Transillumination . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
Crown Examination Prior to Treatment. . . . . . . . . . . . . . . . . . . . . . . . . . . 12
Tooth Structure Needed for Restorations. . . . . . . . . . . . . . . . . . . . . . . . . . 12
Root Aspect and Periodontium Examination Prior to Treatment . . . . . . . 12
Examination of the Apical Aspect of the Root and Apical Bone . . . . . . . 13
Detecting Additional Canals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
Angulated Multiple Radiographs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
v
vi Contents
Root Canal Working Length . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14

Electronic Apex Locators . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
Limitations of the Radiograph . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16
Diagnostic Criteria . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
When to Treat . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
When Not to Treat. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
Medical History . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18
Reversible Pulpitis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18
Irreversible Pulpitis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19
Periapical Pathosis Without a Radiolucency . . . . . . . . . . . . . . . . . . . . . . . 19
Periapical Pathosis With a Radiolucency. . . . . . . . . . . . . . . . . . . . . . . . . . 20
Fistula and Sinus Tract. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20
Swelling . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20
Periapical Lesions of Nonpulpal Origin . . . . . . . . . . . . . . . . . . . . . . . . . . 21
Endodontic-Periodontic Lesions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22
Endodontic Lesion Diagnosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22
Classification of Endodontic-Periodontic Lesions. . . . . . . . . . . . . . . . . . . 22
Endodontic Lesions. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23
Primary Endodontic Lesions with Secondary Periodontic
Involvement. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23
Primary Periodontic Lesions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24
Primary Periodontic Lesions with Secondary Endodontic
Involvement. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24
True Combined Lesions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24
Periapical Diagnosis. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25
Diagnostic Complications Due to Radicular Anomalies . . . . . . . . . . . . . . 25
Etiology of Root Defects . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26
Diagnosis of Root Defects . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26
Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27
Diagnosis of a Cracked Tooth . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27
Etiology of Cracked Teeth. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27
Diagnosis of a Cracked Tooth . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27
History of a Cracked Tooth . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28
Radiograph of a Cracked Tooth . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28
Bite Test for a Cracked Tooth . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28
Transillumination for a Cracked Tooth . . . . . . . . . . . . . . . . . . . . . . . . . 28
Responsive Testing of the Pulp . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28
Restoration Removal and Dye Test . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28
Surgical Exploration . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29
Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29
Emergency Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29
Restoration . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30
Root Canal Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30
Standards for Patient Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31
Summary of Pulp, Periapical, and Bone Status . . . . . . . . . . . . . . . . . . . . . 31
Contents vii
Quiz for the Topics Covered in Chapter 1 . . . . . . . . . . . . . . . . . . . . . . . . . 33

Appendix 1.1. Example of a Patient Consent Form. . . . . . . . . . . . . . . . . . 35
Bibliography . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38
2 Dental Traumatic Injuries, Pain Management,

and Emergency Treatments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39
Traumatic Dental Injuries . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39
Patient Care Immediately Following Traumatic Dental Injuries . . . . . 39
Differential Diagnosis of Traumatic Dental Injuries. . . . . . . . . . . . . . . 39
Subjective Information About the Traumatic Dental Injuries. . . . . . . . 40
Objective Information About the Traumatic Dental Injuries . . . . . . . . 40
Assessing Information to Reach a Differential Diagnosis . . . . . . . . . . 41
Plan/Procedure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41
Root and Crown Fractures. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41
Tooth Fracture Diagnosis by Radiographic Examination . . . . . . . . . . . 42
Tooth Fracture Diagnosis by Clinical Examination . . . . . . . . . . . . . . . 42
Tooth Fracture Diagnosis by Patient Report . . . . . . . . . . . . . . . . . . . . . 42
Identification of the Type of Traumatic Dental Injury . . . . . . . . . . . . . 42
Types of Traumatic Dental Injuries. . . . . . . . . . . . . . . . . . . . . . . . . . . . 44
Diagnosis of Traumatic Dental Injuries . . . . . . . . . . . . . . . . . . . . . . . . 45
Emergency Care for a Traumatic Dental Injury . . . . . . . . . . . . . . . . . . 46
Diagnosis and Treatment Modalities for Dental Trauma . . . . . . . . . . . 51
Treatment Planning for Dental Traumatic Injuries . . . . . . . . . . . . . . . . 51
Treatment for Dental Traumatic Injuries . . . . . . . . . . . . . . . . . . . . . . . . . . 52
Avulsed Tooth Replantation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52
Treatment for Replanting Avulsed Teeth . . . . . . . . . . . . . . . . . . . . . . . 53
Evaluating the Success of Replanted Avulsed Teeth. . . . . . . . . . . . . . . 53
Delaying Treatment to Traumatically Injured Teeth . . . . . . . . . . . . . . . 53
Local Anesthesia for Traumatically Injured Teeth . . . . . . . . . . . . . . . . 53
Repositioning and Stabilizing Traumatically Injured Teeth . . . . . . . . . 56
Prognosis of Traumatically Injured Teeth . . . . . . . . . . . . . . . . . . . . . . . 56
Orthodontic Movement of Traumatized Teeth . . . . . . . . . . . . . . . . . . . 56
Patient Home Care Instructions for Traumatically Injured Teeth . . . . . 57
Antibiotics and Tetanus. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57
Root Resorption . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 58
Differential Radiographic Diagnosis of Root Resorption . . . . . . . . . . . 59
Treatments for Root Resorption . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 59
Anesthesia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 60
Pain Management for Trauma and Endodontics . . . . . . . . . . . . . . . . . . 60
Local Anesthesia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61
Inferior Alveolar Nerve Block . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 62
Accomplishing Profound Local Anesthesia . . . . . . . . . . . . . . . . . . . . . 62
Selecting Local Anesthesia by Type and Dose . . . . . . . . . . . . . . . . . . . 62
Injecting Local Anesthesia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 63
Failure to Accomplish Pulpal Anesthesia . . . . . . . . . . . . . . . . . . . . . . . 64
viii Contents
Tips for Accomplishing Pulpal Anesthesia. . . . . . . . . . . . . . . . . . . . . . 64

Reversal of Local Anesthesia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 65
Tooth Whitening Procedures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 65
Causes of Tooth Discoloration . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 65
Whitening or Bleaching Teeth Without a Pulp . . . . . . . . . . . . . . . . . . . 66
Summary of Dental Traumatic Injuries, Antibiotics, and Anesthetics . . . 66
Bibliography . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 69
3 Treatments for Traumatized and Diseased Immature Teeth:

Pulpotomy, Cvek Partial Pulpotomy, Apexification,
Apexogenesis, and Regenerative Endodontics. . . . . . . . . . . . . . . . . . . . 73
Saving Traumatized and Diseased Immature Teeth. . . . . . . . . . . . . . . . . . 73
Diagnosing the Health of the Pulp in Traumatized and Diseased Teeth . . 73
Treatments for Traumatic Injuries and Caries Decay to Immature Teeth . 74
Endodontic Terminology for Treatments for Immature Teeth. . . . . . . . . . 75
Apex Size and Stage of Tooth Maturity. . . . . . . . . . . . . . . . . . . . . . . . . . . 76
Age, Health Status, and Compliance of Patients . . . . . . . . . . . . . . . . . . . . 77
Root Canal Disinfection. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 78
Dental Materials in Contact with Vital Pulp and Tissues . . . . . . . . . . . . . 79
Endodontic Sealers in Contact with Vital Pulp and Tissues . . . . . . . . . . . 79
Apexogenesis and Cvek Partial Pulpotomy . . . . . . . . . . . . . . . . . . . . . . . . 80
Apexification . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 81
Alternative Treatments to Apexification . . . . . . . . . . . . . . . . . . . . . . . . . . 84
Revascularization of the Root Canal . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 85
Regenerative Endodontic Treatments . . . . . . . . . . . . . . . . . . . . . . . . . . . . 89
Comparison of Treatments on Root Length. . . . . . . . . . . . . . . . . . . . . . . . 93
Tooth Avulsion and Root Canal Revascularization . . . . . . . . . . . . . . . . . . 93
Test Questions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 94
Bibliography . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 94
4 Oral Pathology and Imaging. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 99

Digital Radiographs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 99
Radiation Dosage and Avoiding Incidental Radiation Exposure. . . . . . . . 99
X-Rays and Radiographs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 100
Types of Radiographs. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 100
Bitewing Radiographs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 100
Periapical Radiographs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 101
Occlusal Radiographs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 101
Full Mouth Series of Radiographs . . . . . . . . . . . . . . . . . . . . . . . . . . . . 102
Panoramic Radiographs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 103
Cone Beam Computed Tomography . . . . . . . . . . . . . . . . . . . . . . . . . . . 104
CBCT Field of View . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 105
CBCT Diagnosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 106
CBCT Detection of Apical Periodontitis . . . . . . . . . . . . . . . . . . . . . . . . . . 106
Contents ix
Radiographic Description of Oral and Maxillofacial Pathology . . . . . . . . 107

Radiolucent/Radiopaque Lesions of the Jaws. . . . . . . . . . . . . . . . . . . . 107
Periapical Cyst or Radicular Cyst . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 108
Dentigerous Cyst or Follicular Cyst . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 109
Keratocystic Odontogenic Tumor . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 109
Lateral Periodontal Cyst . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 109
Ameloblastoma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 110
Central Giant Cell Granuloma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 111
Odontoma. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 111
Ossifying Fibroma or Osteofibrous Dysplasia. . . . . . . . . . . . . . . . . . . . . . 111
Cementoblastoma. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 111
Focal-Osseous Dysplasia or Cemento-osseous Dysplasia . . . . . . . . . . . . . 112
Odontogenic Myxoma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 112
Solitary Eosinophilic Granuloma. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 113
Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 113
Bibliography . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 115
5 Endodontic Access Considerations Based on Root

Canal Morphology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 117
Access Preparation. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 117
Criteria for the Root Canal Access Preparation. . . . . . . . . . . . . . . . . . . . . 118
Aging of the Dental Pulp . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 118
Removal of the Dental Pulp . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 118
Identifying the Shape and Position of the
Cement-Enamel Junction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 119
Law of Root Canal Centrality . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 119
Law of Root Canal Concentricity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 120
Tooth Angulations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 121
Distance from the Cusp Tip to the Floor of the Pulp Chamber . . . . . . . . . 122
Positioning the Root Canal Access . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 122
Access Modification. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 122
Root Canals by Tooth Type . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 123
Mandibular First Molar Teeth . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 123
Mandibular Second Molar Teeth. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 124
Maxillary First Molar Teeth . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 124
Maxillary Second Molar Teeth . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 124
Bur Size for a Root Canal Access . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 124
Technique for Root Canal Access . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 125
Step 1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 125
Step 2 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 125
Step 3 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 125
Law of Dentin Color Change . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 126
Orifice Number and Location . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 126
x Contents
Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 127
Bibliography . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 129
6 Instrumentation (Techniques, File Systems,

File Types, and Techniques) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 131
Cleaning and Shaping of the Root Canals . . . . . . . . . . . . . . . . . . . . . . . . . 131
Root Canal Instrumentation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 132
Tooth Length Measurement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 133
Final Instrumentation and Shaping the Root Canal . . . . . . . . . . . . . . . . . . 134
Cleaning and Shaping to the Root Apex . . . . . . . . . . . . . . . . . . . . . . . . . . 136
Size of Apical Enlargement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 136
Shape and Size of the Instrumented Root Canal . . . . . . . . . . . . . . . . . . . . 136
Endodontic Hand File Geometries. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 137
Endodontic Instruments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 137
Using Hand Files and Instruments to Shape the Root Canals . . . . . . . . . . 138
Anti-curvature Filing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 139
Accessory Canals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 140
Steps for Instrumenting the Root Canals . . . . . . . . . . . . . . . . . . . . . . . . . . 140
Culturing and Medication of Root Canals . . . . . . . . . . . . . . . . . . . . . . . . . 141
Perforation Repair . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 141
Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 142
Bibliography . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 144
7 Irrigation of Root Canals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 149

Irrigating the Infected Root Canal . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 149
Functions of Irrigating Solutions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 150
Types and Dilutions of Irrigating Solutions. . . . . . . . . . . . . . . . . . . . . . . . 150
Functions of Chelating Agents. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 152
Activation of Irrigating Solution and Chelating Agents . . . . . . . . . . . . . . 155
Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 156
Bibliography . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 158
8 Root Canal Obturation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 163

Root Canal Sealers. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 163
Selecting Obturation Materials . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 164
Gutta-Percha Obturation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 165
Summary of the Root Canal Obturation Technique. . . . . . . . . . . . . . . . . . 167
Alternative Root Canal Obturation Materials . . . . . . . . . . . . . . . . . . . . . . 169
Silver Point Obturation of Root Canals . . . . . . . . . . . . . . . . . . . . . . . . 169
Pastes to Obturate Root Canals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 170
Composite Resins to Obturate Root Canals . . . . . . . . . . . . . . . . . . . . . 170
Contents xi
Posttreatment Patient Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 170

Posttreatment Instructions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 170
Treatment of a Flare-Up. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 170
Considerations for Restoring Endodontically Treated Teeth . . . . . . . . . . . 171
Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 171
Bibliography . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 173
9 Periradicular Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 177

Surgery in Endodontic Practice . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 177
Types of Surgeries . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 178
Restorative and Occlusal Factors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 180
Guidelines for Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 180
Surgical Flap . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 180
Complications of Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 181
Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 181
Bibliography . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 183
Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 185
The Differential Diagnosis
of Endodontic Disease 1
Talking to Patients About Saving Their Teeth
Millions of teeth are extracted every year and most dentists are doing everything pos-
sible to save teeth. But many patients feel that having a painful tooth extracted is the
most economical way to solve their problem. It is not economical for the patient if
they subsequently decide that they need to replace the tooth [1]. Patients need to be
told that if root canal treatment and restoration can be used to save the tooth and that
getting the treatment is preferable over the long term to maintain their quality of life
and ability to chew food [2]. Root canal treatment is not always the appropriate solu-
tion for every painful tooth [3]. When a tooth can be saved by root canal treatment,
the 10-year success rate for healed teeth can vary between 73 and 90 % [3, 4]. Teeth
are healed after endodontic treatment if they do not have clinical or radiograph symp-
toms of disease [5]. The information that you need to give patients is summarized as:
1. Prosthetic teeth in a denture or bridge do not allow patients to chew food as

effectively as natural teeth.
2. Insurance plans often cover the cost of endodontic treatment, but not dental
implants.
3. Postoperative pain after having teeth extracted is commonly much more severe
for a patient than if they had been given a root canal treatment.
4. Expensive dental implants, denture, or a bridge can be avoided and root canal
treatments often require fewer visits to a dental office.
Patient Consent and Record Keeping
Gaining patient confidence, cooperation, and consent for a dental examination and
further consent for treatment is essential. Patients need to have all their treatment
options explained to them, their benefits, risks, and costs. For young or old patients
© Springer-Verlag Berlin Heidelberg 2015 1

P. Murray, A Concise Guide to Endodontic Procedures,
DOI 10.1007/978-3-662-43730-8_1
2 1 The Differential Diagnosis of Endodontic Disease
who cannot comprehend or communicate consent for treatment, the guardian or par-
ents of the patient may need to provide consent on their behalf. Performing endodon-
tic treatment to high standards may not be enough to prevent the treatment from
failing or an adverse health event from occurring, but effective treatment is better
than a patient suffering without any treatment. Complete written documentation,
electronic documents, radiographs, specialist reports, and signed informed consents
for every patient must be organized into the patient record and be kept securely. The
patient’s record must include a record of their visits, your diagnosis, and treatment
planning agreement. An example of a patient consent form is included in Appendix 1.1.
Talking with Patients to Diagnose the Cause of Pain
The patient’s own description of their pain is an important diagnostic aid. Let the
patient explain in their own words why they have come to see you. After listening
to the patient’s own explanation of their pain, you should consider the following
criteria to diagnose their type of pain:
1. Pain characteristics: Is the pain sharp, dull, lingering, and throbbing? Can the
pain be localized to a tooth or is it diffuse?
2. Origin: Does the pain begin for no apparent reason, or is it affected by heat, cold,
or biting pressure?
3. Reproduction: Can you reproduce the pain or alleviate it?
4. Timing: Is the pain continuous, or does it come and go?
After listening to the patient’s answers to your pain questions, you will be
directed to check for a fractured tooth, or to check pulp vitality and periodontitis, or
for caries or a pulp exposure as shown in the flowchart (Fig. 1.1).
Does your tooth Does biting presure

hurt all the time Check for
give a sharp pin point
and keep you fracured tooth
pain?
awake at night?
Is your tooth Check pulp vitality

sensitive to hot or and for
cold? periodontitis
Check for caries

and pulp exposure
Fig. 1.1 Flowchart for using the patient’s description of pain to check for dental problems
Endodontic Examination 3
The dental history and the chief pain complaint are subjective information that
you can elicit from the patient. The following paragraphs explain how you can col-
lect more objective information.
Endodontic Examination
A comprehensive endodontic examination not restricted to a hot tooth should be

performed on all new and existing patients according to the following criteria:
1. Facial examination
2. Dental examination
3. Radiographic examination
4. Pulp sensibility testing and endodontic treatment planning using the SOAP
framework [6]
Prior to beginning the exam, make sure that all the safety protocols regarding
sterilization of instruments, covering of surfaces, and that overalls and masks are
worn to protect your health and the health of the patient, as shown in Fig. 1.2.
Facial Examination
At each visit, the patient must have all their facial tissues examined to check their
face for any asymmetry, skin color changes, and the overall complexion. Check for
signs of disease, lesions, infections, traumatic injuries, and facial scars. Gently
touch the patient’s face to identify any swelling and bilaterally palpate the subman-
dibular nodes to check for lymphadenopathy. If the symptoms of any disease
conditions are identified, the patient should be referred to a medical specialist.
Fig. 1.2 Create a safe

environment to protecting
your health and the patient
Dental Examination
At each visit, the patient must have a dental examination that inspects the oral
mucosa, oral pharynx, tongue, teeth, gingival, and floor of the mouth for any abnor-
malities. If any abnormalities are detected that you are unable to treat, the patient
should be referred to a dental specialist.
Radiographic Examination
The ideal radiograph will show the crown and cervical aspects of the tooth. The
x-ray beam should be angled parallel to the tooth. In some situations, it may be
necessary to use a bitewing radiograph to see a more complete tooth definition. The
clinical features must be diagnosed in order to determine the etiology of the tooth
condition and the necessity of endodontic therapy. The following features should be
considered:
1. Pulp horn proximity to a restoration or caries

2. Prior pulp-maintenance efforts to save the tooth, such as a pulpotomy or a pulp
cap
3. Pulp chamber evaluation for the presence of retrogressive changes, including
recession, resorption, or pulp stones
4. Periodontal evaluation and checking for the presence of calculus
5. Evaluation of restorations
6. Evidence of a fracture or trauma
7. Presence of a periapical lesion or pathology
A radiograph does not reveal structural cracks. If a dark line appears on an x-ray,
the line by definition is a fracture line.
SOAP Framework for the Differential Diagnosis

of Endodontic Disease
An accurate diagnosis of the vitality of a dental pulp is needed to ensure that a tooth
is given the most appropriate endodontic treatment. The diagnosis of dental pulp
vitality should use the SOAP criteria [6]:
1. Subjective information
2. Objective information
3. Assessment information
4. Plan for treatment
SOAP Framework for the Differential Diagnosis of Endodontic Disease 5
Subjective Information
Subjective information should be gathered by talking with the patient about their
health and the tooth causing the problem. The types of questions to ask patients are:
1. Has there been any changes to your health since your last dental visit?
2. Have you taken any pain killers for the toothache?
3. Has the tooth bothered you until recently?
4. When did the toothache start?
5. Do you have any health problems or diseases?
6. Do you take any medications?
7. Do you feel lingering toothache with hot or cold drinks?
Objective Information
Objective information should be gathered about the patient’s condition from 12

sources:
1. Results of cold, hot, electric, or percussion testing

2. Asking the patient to point to the painful tooth
3. Identification of caries, fracture, track, or a pathway of infection
4. Non-endodontic pathology
5. Dental checkup
6. Root development status
7. Root resorption
8. Radiographs taken from different angulations or a cone beam computed tomog-
raphy image of the root canal of a painful tooth
9. Oral health status
10. Patient’s dental history
11. Palpation tenderness, swelling, and purulence
12. Periapical abscess
Assessing Information to Reach a Diagnosis
The assessment of objective information should be used to reach a diagnosis.

The assessment should include a checklist:
1. Pulpal diagnosis and periapical diagnosis

2. Identifying the pathway of infection into the root canal
3. Restorability of the tooth
4. Need for continued root development to strengthen the tooth

5. Symptomatic and asymptomatic periodontitis
Plan/Procedure
The diagnosis of the dental pulp viability and assessment criteria used for treatment
planning include a checklist:
1. Apexification
2. Root amputation, hemisection, bicuspidization
3. Revascularization and regenerative endodontics
4. Endodontic-periodontic lesions
5. Nonsurgical root canal obturation
6. Apexogenesis
7. Surgical root canal obturation
Dental History
Investigate the patient’s dental history using a checklist:
1. Previous treatment that could affect the current condition of the pulp, such as a
deep restoration or a pulp-capping procedure
2. Periodontal and orthodontic consultations or treatments that have been
performed
3. Any unfavorable responses the patient may have had to a previous dental treat-
ment, such as allergies to drugs, medicaments, or anesthetics
4. The status of a radiolucency by comparing it to previous radiographs
5. History of trauma or injury
Medical History
Ask the patients about their medical history using a checklist:
1. Anemia
2. Bleeding disorders
3. Cardiorespiratory disorders
4. Drug treatment and allergies
5. Endocrine disease
6. Fits and faints
7. Gastrointestinal disorders
8. Hospital admissions and attendances
9. Infections
Dental Pulp Sensibility Testing 7
10. Jaundice or liver disease

11. Kidney disease
12. Likelihood of pregnancy or pregnancy itself
Dental Pulp Vitality Diagnosis
The diagnosis of the vitality of the dental pulp is essential to plan the most suitable
endodontic treatment for the tooth. Cold testing is the most commonly used PAIN
diagnostic method.
1. Pulp with irreversible pulpitis will eventually become necrotic. The patient
reports a lingering pain when cold is applied to the tooth for symptomatic irre-
versible pulpitis. A patient, who has a tooth with asymptomatic irreversible pul-
pitis, will have a history of trauma, caries extending into the root canal, or past
treatment.
2. A dental pulp with reversible pulpitis is responsive to cold testing and the patient
will often report a lingering pain.
3. Ignored cold applied to the tooth for 5 s indicates the dental pulp of the tooth is
completely necrotic. This is the easiest dental pulp diagnosis to identify.
4. Normal, healthy, vital dental pulp is responsive to cold testing and the patient
will report an immediate non-lingering sensation.
The diagnosis of dental pulp viability based on patient responses to cold testing
is summarized in Table 1.1.
Dental Pulp Sensibility Testing
Sensibility tests for assessing the vital, inflamed, or necrotic status of the dental pulp
are an essential diagnostic aid. No single pulp vitality testing technique can reliably
diagnose all pulp conditions [7]. The most common dental pulp sensibility tests
Table 1.1 Dental pulp vitality diagnosis based on patient responses to cold sensibility testing
Pulp vitality diagnosis Patient response to cold sensibility testing
Normal, healthy, and Patient senses a pain which stops immediately once the cold is
vital removed
Reversible pulpitis Patient senses a pain which can linger briefly, in the affected tooth
compared to adjacent and contralateral teeth
Symptomatic Patient senses a lingering pain, compared to adjacent and contralateral
irreversible pulpitis teeth
Asymptomatic Patient senses a more severe pain compared to adjacent and
irreversible pulpitis contralateral teeth which may or may not linger; the tooth has a history
of pulpitis, trauma, exposed pulp
Necrosis Patient reports no sensation even when cold is applied to the tooth for 10
No Normal, healthy vital pulp
Immediate Asymptomatic
Yes Pain Check
pain does reversible
occlusion
not linger pulpitis
Yes
Tooth Lingering Symptomatic Pulp becoming
responsive pain irreversible necrotic because of
to cold pulpitis caries or trauma
Do control No Necrotic pulp

teeth have
No Negative is
the same Retest with
responses? Non- necrotic pulp
Yes electric pulp
responsive tester
Positive is
vital pulp
Fig. 1.3 A flowchart for using sensibility testing to diagnose the status of the dental pulp before
endodontic treatment
include thermal and electric tests, which extrapolate pulp health from a sensory
response. Sensibility tests indirectly assess the vitality of the dental pulp by asking
the patient if they can sense the tooth response to cold applied by ethyl chloride fol-
lowed by electric pulp testing (EPT), or less commonly sensibility to a heat test with
gutta-percha. Ideally, cold testing should be used in conjunction with an electric
pulp tester so that the results from one test will verify the results of the other test.
The patient’s sensibility responses can be used to interpret the vitality of the dental
pulp according to the flowchart shown in Fig. 1.3.
Cold testing and EPT can accurately diagnose pulp vitality in over 80 % of
cases [7]. In a controlled study of sensibility testing comparing the results with the
root canal contents [8], the probability of a sensitive reaction for a vital pulp was
90 % with cold, 83 % with heat, and 84 % with an EPT, and in nonvital pulp, it was
89 % with cold, 48 % with heat, and 88 % with the EPT. This indicates that cold
and the EPT are reliable to a similar extent in the diagnosis of vital and nonvital
pulps [8].
If a mature, nontraumatized tooth does not respond to either EPT or cold, then
the tooth may be considered to be nonvital. However, caution is needed when test-
ing multirooted teeth, as they may respond positively to cold, even though only one
root actually contains vital pulp tissue. The results of dental pulp sensibility tests
need to be carefully interpreted and closely scrutinized as false results can lead to
misdiagnosis which can then lead to incorrect, inappropriate, or unnecessary
treatment.
Electric Pulp Tester
The EPT does not measure dental pulp vitality; its readings mean that neural tissue
is capable of responding to the electric signal. The interpretation of the findings is
critical. The specific readings for a tooth are not as important as the comparison of
Fig. 1.4 Electric pulp tester

for dental pulp sensibility
testing
readings to those of adjacent and contralateral teeth; an involved tooth may have a
significantly different reading than other teeth. Care must be taken to place the
probe in an area that will give a true reading shown in Fig. 1.4. False readings can
occur from placing the probe on enamel without underlying dentin or on a restora-
tion. Placing it too high on the incisal edge may give a false-negative reading, and
placing it too low may give a false-positive reading from the gingiva. Basically, the
pulp tester should be placed in a position where the current will pass through enamel
and dentin to the pulp without interference. The EPT should be used to confirm the
results of the cold or heat sensitivity tests. The EPT is not reliable when used on
teeth with extensively restored teeth or with crowns.
Cold and Heat Tests
Cold and heat tests are the most reliable and commonly used tests for determining
pulp viability. A normal dental pulp will respond to heat or cold, and the pain will
disseminate quickly after the stimulus is removed. A necrotic or inflamed pulp may
not respond comparably; there may be no response to either heat or cold, or the
response may be exaggerated or prolonged. The cold stimulus can be applied
directly to the tooth by means of ethyl chloride crystals on a cotton pellet, as shown
in Fig. 1.5. The cold test can be used to differentiate between reversible and irrevers-
ible pulpitis. If the patient feels a lingering pain, even after the cold stimulus is
removed, a diagnosis of irreversible pulpitis may be reached. Conversely, if the pain
subsides immediately after stimulus removal, a diagnosis of reversible pulpitis is
more likely. The responses should be interpreted by taking into consideration the
patient’s history of pain on lying down and the duration of pain. The diagnosis of
reversible/irreversible pulpitis is only a clinical diagnosis and may not correlate
with a histological diagnosis. The heat stimulus is most commonly applied using
heated gutta-percha or a heated instrument. Vital teeth must never be excessively
heated or cooled because it can injure the dental pulp.
Fig. 1.5 Cold test to assess

dental pulp sensibility
Fig. 1.6 Palpation of tooth

apex to identify a fluid mass
from an infection
Palpation Testing
Palpitation is the touching with fingertips of the tissues over the apex of the involved
tooth and neighboring teeth. If the tissue feels soft or spongy, it can indicate under-
lying bone involvement. If there appears to be a fluid mass shown in Fig. 1.6 that
moves or drains, it indicates an infection. When a sensitive apical area is palpated,
the patient will report that it is painful.
Percussion Testing
Percussion is the tapping of a tooth with a finger or an instrument by the dentist or

endodontist. If the patient reports pain in response to percussion testing, it usually
indicates inflammation in the periapical area and/or the tooth has suffered a
traumatic injury. The latest advance in percussion testing is to perform quantitative

percussion diagnostics using a perimeter quantitative percussion system, which can
test the stability of dental implants [9].
Cavity Testing
When the cold/heat, palpation, and percussion tests have proved to give inconclusive
results on fully crowned teeth, a cavity test can be prepared. A small shallow cavity is
drilled into the lingual surface of anterior teeth or the occlusal surface of posterior teeth,
without anesthesia. A necrotic or inflamed pulp will not yield a pain response. A tooth
with a vital pulp will feel painful as the bur cuts into the dentinoenamel junction.
Experimental Dental Pulp Sensibility Tests
The most common standard of care is to use the cold test to test dental pulp sensibil-
ity, for the diagnosis of pulp vitality, and then to use the electric pulp test to confirm
the cold test diagnosis. The experimental noninvasive pulp tests which may be opti-
mized for use in the future are laser Doppler flowmeters which measure blood flow
in the pulp tissue and pulse oximeters which measure the pulsatile blood circulation
and oxygen saturation in the pulp tissues. There are also devices which can measure
the apical properties of the involved tooth using photoplethysmography, spectro-
photometry, transmitted laser light, transillumination, or ultraviolet light photogra-
phy [10]. Some experimental devices have also been developed to measure surface
temperatures of a hot tooth as an indirect measure of pulp vitality.
Exploratory Surgical Flap
The periodontal tissues and bone may have to be opened by cutting a surgical flap
to visually confirm the diagnosis of a traumatized tooth with a fractured root.
Anesthesia Test
Some patients find it difficult to localize the source of dental pain. The source of pain
can be precisely determined by anesthetizing a single tooth or a quadrant of teeth.
Transillumination
Transillumination with fiberoptics can be an aid to diagnosing cracked or fractured

teeth. Placing the fiberoptics probe on lateral surfaces may aid in the visualization
of a crack.
Crown Examination Prior to Treatment
After the pulp diagnosis, the coronal aspect should be examined prior to treatment.
The location, anatomy, and size of the pulp chamber in relation to the crown must
be evaluated to determine the initial access opening. Caries and defective restora-
tions have to be evaluated to determine whether they need to be removed and to
establish pretreatment considerations to assist in placing the clamp and rubber dam.
Tooth Structure Needed for Restorations
Not all teeth are restorable if there is not enough tooth structure to retain the syn-
thetic crown. The ferrule effect is derived from the Latin term to mean a ring or cap
usually of metal put around a slender shaft to strengthen it or prevent splitting. Most
dentists believe a minimum of 5–6 mm of exposed tooth structure above the osseous
crest is needed to ensure that the tooth is restorable after endodontic treatment.
However, there are techniques to increase the amount of tooth structure to retain a
synthetic crown, such as:
1. Forced eruption of the tooth in question using the adjacent teeth as anchorage
2. Osseous recontouring and gingival displacement
3. Orthodontic extrusion
4. Lengthening of the crown by periodontal surgery
The greater the compromise of the crown/root ratio, the more it lowers the tooth
mechanical fulcrum, which increases the likelihood of fracture. Some crowns will
need to have posts placed inside the root canal to retain them. The indications for
posts are:
1. Core retention with a post is necessary if there is a weak cavity wall.

2. Anterior teeth do not need posts, unless they are severely destroyed.
3. No post is needed if the axial walls are present and are more than 1mm thick.
Root Aspect and Periodontium Examination Prior to Treatment
The root aspect must be carefully examined in the mesiodistal dimension to deter-
mine the relationship of the canal, or canals, to the crown. At this time, the position
of the access opening should be considered in order to decide upon the best approach
to the canals and their apices.
Since the canals separate at the root aspect, there is more chance that the addi-
tional canals can be radiographically detected here. Examination of this area is
indispensable in evaluating the condition of the periodontium and the presence of
furcation involvement, calcifications, and resorption.
Detecting Additional Canals 13
Examination of the Apical Aspect of the Root and Apical Bone
The apical aspect of the root should be examined for the following information:
1. Separated roots.
2. The direction and degree of root curvature.
3. The position of the canal within the root.
4. The dimension of the root structure mesial and distal to the canal.
5. The location and type of radiolucency. A lateral radiolucency may indicate a
large accessory canal. If it appears to be a teardrop radiographic lesion, a linear
fracture may be suspected.
6. The location of the apical foramen, if apparent. Be well aware that it may not
coincide with the radiographic apex.
7. Root pathology, such as calcifications, resorption, and fracture.
8. Apparent intracanal aberrations resulting from previous treatment, such as ledg-
ing, perforations, and instrument fragments.
9. Periapical pathology, including osteosclerosis, condensing osteitis, or
hypercementosis.
Detecting Additional Canals
Every effort must be made to locate and to obturate all canals. All teeth can have
additional canals and roots. Never become complacent and be falsely secure once
the “normal” number of canals has been located.
Angulated Multiple Radiographs
A canal extending to the full length of the root does not automatically indicate that
only a single canal exists. There may be a second canal superimposed. Its presence
may be seen in the angulated radiograph, for which the direction of the central beam
is horizontally shifted from the straight-on approach to a mesial or distal angle. This
approach may be the only manner in which multiple canals will be radiographically
separated. The off-angle radiograph is also indispensable in establishing whether
multiple canals have a common or separated apex.
When in a straight-on radiographic approach the canal outline ends abruptly as it
approaches the apex, it should be presumed that this canal is branching into addi-
tional canals. This may be verified by an angulated radiograph, and a radiograph
taken from the same angle could be used to separate the canals after treatment in
order to evaluate the quality of the root canal filling.
In the angulated radiograph, it also becomes possible to identify the roots.
A simple rule to assist in this identification is to direct the x-ray bean from the
mesial aspect. The buccal root will appear to the distal side of the radiograph.
Normal anatomical landmarks may often emulate periapical pathosis when their
radiographic images appear superimposed on an apex. Additional radiographs taken
at different angles will show these landmarks to change their position in relation to
the apex. If, in fact, periapical pathosis exists, its radiographic image will not change
from its apical position in various radiographs. Do not make the error of making
all-conclusive diagnostic decisions based on the one original radiograph. The lack
of an apparent canal does not positively imply that a canal does not exist. The off-
angle radiograph is also indispensable in disclosing a possible perforation.
Root Canal Working Length
Prior to root canal treatment, undistorted radiographs are required to assess canal
morphology. The apical extent of instrumentation, debridement, and the final root
filling have a role in treatment success and are primarily determined radiographi-
cally. The working length of the root canal is most accurately measured with a hand
file inside the canal and by using a radiograph to check the proximity of the file tip
to the apical foramen, as shown in Fig. 1.7.
Checking the exit of the file in multiple-canal roots is important to see if they exit
separately or as a common apex. Be suspicious of a second superimposed canal if a
dark shadow borders the file. The degree of canal curvature must be assessed to
assist in the canal preparation. The off-angle radiograph is used to check for addi-
tional canals. Look at the relationship of the file buccolingually to the center of the
tooth. If the file appears in the radiograph to be more mesial or distal, there is a
strong possibility that another canal exists. Take care not to depend on a radiograph
Fig. 1.7 Measuring the root canal working

length with a file inside the root canal using
a radiograph
Root Canal Working Length 15
Fig. 1.8 Detecting the

a
openings of root canals.
(a) Probing the floor of the
pulp chamber to uncover
additional root canals.
(b) Additional root canal
detected
alone to count the number of canals in a tooth. Look at the prepared access for open-
ings and use a sharp hand file to probe the floor of the pulp chamber to uncover the
openings of other canals, as shown in Fig. 1.8.
Electronic Apex Locators
Electronic apex locators (EALs) or electronic apex locaters reduce the number of
radiographs required and assist where radiographic methods create difficulty. The
use of EALs alone without a preoperative and postoperative radiograph is not rec-
ommended. The EAL may also indicate cases where the apical foramen is some
distance from the radiographic apex. The EAL can be used to detect a root canal
perforation. They have become more popular because of new technology which has
increased their accuracy. Many EALs can give accurate measurements of the root
canal working length even when filled with conductive fluids such as saliva, blood,
or irrigating solution. The accuracy of EALs can vary between 80 and 96 %, which
is similar to a radiograph. When the maximum length of the root canal is reached,
the EAL will signal via beep, buzz, flashing light, or all of those shown in Fig. 1.8.
It is not recommended to depend on the EAL alone to determine the root canal
working length because it could give inaccurate measurements if the apical foramen
is complicated or is still maturing and has blunderbuss morphology, as was shown
in Fig. 1.7.
Limitations of the Radiograph
Do not assume there will be radiographic changes in a painful tooth. Soft tissue
changes of the pulp cannot be seen on a radiograph. Likewise, not all periapical
lesions are discernible in a radiograph. A periapical lesion is not likely to be visible
if it only involves cancellous bone; it must involve the cortical plate to be visible on
a radiograph, as shown in Fig. 1.9. Once a periapical lesion is visible on a radio-
graph, the actual area of infection and the amount of bony destruction are always
greater than the extent shown on the radiograph.
Fig. 1.9 Periapical lesion

involving the cortical plate.
(a) Failing root canal
treatment with a periapical
lesion. (b) Healed periapical
lesion following root canal
treatment
Diagnostic Criteria 17
Diagnostic Criteria
Diagnosis is a critical aspect of treatment planning, without an accurate determina-

tion of the problem; even the best quality of treatment can be useless. The basic
concept is to determine the underlying causes, or etiology, of a patient’s complaint.
To diagnose accurately, you should:
1. Distinguish between normal and abnormal conditions

2. Realize the limitations of testing procedures
3. Interpret test results
4. Not assume any missing information
5. Know pathology
Diagnosis is part science and part experience. The diagnostic pitfalls to

avoid are:
1. Beginning treatment, even though the diagnosis has revealed that nature of the
problem is unclear.
2. Relying on someone else’s opinion, test results, or radiographs to reach your
diagnosis.
3. Assuming all the tests and patient history variables will give you one obvious
diagnostic conclusion. There may be several connected or independent problems
that need treatment.
4. Invite problems by failing to refer the patient to a specialist or more skilled
dentist when it will be more beneficial for the patient.
5. Neglecting to look for etiologic factors.
When to Treat
There are four situations when endodontic treatment should be performed:
1. Pulp removal is needed as a preventive measure, such as when teeth are in the
path of radiation therapy.
2. After the tooth is diagnosed as having irreversible pulpitis or when no pulp is
present.
3. Needed as part of periodontal therapy, including root amputations and
hemisections.
4. Tooth cannot be properly restored without removing the pulp.
When Not to Treat
There are five situations when endodontic therapy should not be performed; this is
because:
1. Mobility of the tooth is beyond normal limits and appears to lack periodontal
ligament or bone to maintain it.
2. Instruments, files, or equipment that is needed is not available.
3. Not enough tooth structure is remaining to restore it.
4. The operator’s clinical skills are not commensurate with the task.
5. Status of the patient’s medical conditions makes endodontic treatment too risky
for them.
Medical History
Prior to every treatment, the patient’s complete medical history must be reviewed to
ensure they are healthy enough to undergo endodontic treatment or to determine
whether the treatment plan must be altered in some way. Pay careful attention to:
1. Precautions that must be taken

2. Identifying radiographic and clinical manifestations of a systemic disease
3. The risk of complications to endodontic treatment
Although there are few absolute contraindications for performing endodontic

treatment, good judgment is needed to identify situations in which it is not reason-
able to provide treatment. For example, although patients taking high doses of ste-
roids are not a contraindication for endodontic therapy, the depression of their
immune system gives them an increased risk of a secondary infection developing.
At each patient visit, a complete up-to-date history is mandatory both for medical
and legal reasons and, because a patient had a “negative” health history in the past,
is not a predictor that the state of their health has not changed.
Reversible Pulpitis
Endodontic therapy may not be indicated if reversible pulpitis is indicated by the

following criteria:
1. When the pulp is not exposed following excavation of caries.

2. Electric pulp tests are the same or slightly higher in the involved teeth as those
for adjacent and contralateral teeth.
3. Pain from a tooth that does not linger.
4. Pain that is not severe.
5. The sensation disappears as soon as the cold or hot test is removed.
The WEPPT situations suggest a possible reversible pulpitis, because the

responses are only to stimulation. The WEPPT situations may indicate the need for
pulp-maintenance therapy.
Periapical Pathosis Without a Radiolucency 19
Irreversible Pulpitis
The borderline between reversible and irreversible pulpitis pain is considered

crossed, when irreversible pulpitis pain is indicated by:
1. When the patient states that the pain begins for no apparent reason and
lingers.
2. Adjacent and contralateral teeth give sensibility test results which are noticeably
different from those for involved teeth.
3. Severity of pain is becoming more severe.
4. Pain remains after the thermal stimulus is removed. On occasions, the pain can
be so severe that warm or cold water is required to alleviate the pain.
The critical difference between reversible and irreversible pulpitis lies in

whether or not the pain is stimulated or unstimulated in origin. In the case of
unprovoked pain that cannot be localized, the patient’s cooperation is required.
It may be necessary to wait for the localization of the symptoms before a dif-
ferential diagnosis can be made. In these cases, the patient is told to call the
office immediately if there is any change in the symptoms. The other indications
of irreversible pulpal changes are more definite. Severe continuous pain or
throbbing that persists without stimulations and sensitivity to percussion are
indications of the need for root canal therapy. Pain resulting from thermal
changes, from either heat or cold, which lingers or comes at unpredictable times,
indicates irreversible pulpal damage. Total pulpal necrosis is usually indicated
by a lack of sensibility responses. Do not diagnose the pulp sensibility by the
electric pulp tester alone; always verify the results with cold sensibility testing
procedures.
Periapical Pathosis Without a Radiolucency
Sometimes, there will be a periapical pathosis, but no radiolucency is apparent.

The goal of periapical diagnosis is to determine whether or not the periapical tis-
sue is infected and inflamed. If the periapical tissue is involved, it is then neces-
sary to determine whether the pathosis is of pulpal origin. A radiograph with a
lack of periapical pathosis does not ensure that the apical tissues are not involved
in the inflammatory process because studies have shown that with a minimum of
pulpal inflammation, the pathology of the periapical tissue can be involved.
Infection and inflammation of the periapical tissue can occur before visible radio-
graphic changes, such as a radiolucency taking place. A periapical pathosis may
or may not be symptomatic to percussion or palpitation, and it may exist in the
presence of a vital but altered response to cold or hot testing, and the electric pulp
tester.
Periapical Pathosis With a Radiolucency
When a periapical pathosis is visible as a radiolucency on a radiograph, the next

step is to determine whether or not it is of pulpal origin by assessing pulp vitality
using sensibility tests. If the radiolucency is of pulpal origin, the sensibility tests
will prove to be negative, indicating the pulp is necrotic. Negative sensibility tests
do not always indicate the pulp tissues are completely necrotic; some vital tissues
may exist in the apex of some canals. A positive response to the pulp sensibility test
is a strong indication that the periapical pathosis with a radiolucency was not caused
by infection originating from a necrotic pulp.
Fistula and Sinus Tract
A fistula is an abnormal pathway between two anatomic spaces or a pathway that

leads from an internal cavity to the surface of the body. A sinus tract is an abnormal
channel that originates from a chronic abscess and ends in one opening. In the litera-
ture, the terms fistulas and sinuses are often used interchangeably. An orofacial fis-
tula is a pathologic communication between the cutaneous surface of the face and a
suppurating chronic abscess. Orofacial fistulas are not common, but intraoral sinus
tracts due to chronic dental infections which caused an abscess are common. Fistulas
and abscesses require immediate disinfection and treatment to prevent the condition
from spreading. Dental infections, salivary gland lesions, neoplasms, and develop-
mental lesions cause oral cutaneous fistulas, fistulas of the neck, and intraoral fistu-
las. Chronic dental periapical infections or dentoalveolar abscesses cause the most
common intraoral and extraoral fistulas. These dental periapical infections can lead
to chronic osteomyelitis, cellulitis, and facial abscesses. Infection can spread to the
skin if it is the path of least resistance. Fascial-plane infections, space infections,
and osteomyelitis can cause cutaneous fistulas. Fascial-plane infections often begin
as cellulitis and progress to fluctuant abscess formation. Compared with the other
conditions, fluctuant abscess formation is more likely to result in cutaneous fistulas.
A gutta-percha point should be inserted into the fistula or abscess tract, and a radio-
graph should be taken to confirm the origin of the fistula, as shown in Fig. 1.10.
Usually, the origin is fairly obvious, but occasionally, the opening of the fistula may
be several teeth away from the involved tooth.
Swelling
A soft and fluctuant swelling of oral tissues shown in Fig. 1.11 is often caused by
inflammation and an infection of the dental pulp or periodontal tissues. A firm, hard
swelling is an indication that the lesion is not inflammatory and not of pulpal
origin.
Periapical Lesions of Nonpulpal Origin 21
Fig. 1.10 A gutta-percha

point indicating the track of a
fistula
Fig. 1.11 A swelling of oral

tissues
Periapical Lesions of Nonpulpal Origin
Periapical tissues are susceptible to infection from the root canal, in addition to
lesions with an osteogenic source. The bone lesions can be classified as develop-
mental, inflammatory, reactive, dysplastic, and neoplastic. It is important to deter-
mine if the lesion is of nonpulpal origin. This is done by carrying out pulp
sensibility tests and by observing signs and symptoms. In the presence of radio-
lucency, and with the pulp sensibility tests all responding within normal limits,
the radiolucency is probably not of pulpal origin. If the signs and symptoms of
pulpal involvement are present, these are also used to diagnose the lesion differ-
entially. The two symptoms that cannot be ignored are spontaneous numbness and
tingling. If a patient presents with these complaints, a malignancy must be ruled
out first.
Endodontic-Periodontic Lesions
When the periodontium is involved in endodontic lesions, a question of etiology

arises. It must be determined whether the condition was caused by an endodontic
infection or a periodontic infection, or a combination of the two. This diagnosis
determines both the treatment sequence and the prognosis.
Endodontic Lesion Diagnosis
Periodontal lesions caused by an endodontic infection can be diagnosed following

the sensibility testing of the dental pulp. A tooth with normal responses and a vital
pulp can be ruled out as the source of the periodontic lesion. If the dental pulp is
necrotic or partially vital, then it is either the cause of the periodontic lesion or a
contributing source of infection. Teeth associated with periodontic lesions can
exhibit sensibility responses and have symptoms across the whole spectrum of
pulpal pathology. In radiographs, an endodontic etiology is suspected when one
portion of the root is involved or if the furca is radiolucent though the mesial and
distal crestal bone is intact. If the defect can be probed, it is usually (but not always)
a narrow fistula or sinus defect, as compared to the wider periodontal disease
defect.
Lesions caused by a periodontic infection can be diagnosed by gingivitis, peri-
odontitis, and, in advanced cases, bone resorption around the roots of teeth. If,
upon probing, an extensive plaque or calculus buildup is encountered and the
defect is diffuse and craterlike, periodontal treatment is required. If the defect is
entirely of periodontic origin, the tooth sensibility tests will probably be within
normal limits.
In combined lesions, where signs and symptoms of gingivitis, periodontitis, and
pulpitis or necrosis are present, both the treatment and prognosis change. The end-
odontic root canal treatment should be completed first or concurrently with peri-
odontal therapy. The reason why endodontic treatment must be first is to increase
the chances that the lesion will heal; if the periodontal treatment is accomplished
first, the defect may not heal. Assuming that the endodontic therapy is successful,
the prognosis is dependent on the periodontal therapy. If there is sufficient bone
remaining and the periodontal area can be adequately treated, the prognosis is favor-
able. If the periodontal condition is untreatable, root redesigning may be required.
Classification of Endodontic-Periodontic Lesions
There are five combinations of endodontic-periodontic lesions that can be identified

by their radiographic appearance:
1. Endodontic lesions
2. Primary endodontic lesions with secondary periodontic involvement
Classification of Endodontic-Periodontic Lesions 23
3. Periodontic lesions
4. Primary periodontic lesions with secondary endodontic involvement
5. Endodontic-periodontic combined lesions
Endodontic Lesions
Endodontic lesions may have drainage from the gingival sulcus area or with swell-
ing in the adjacent gingiva. This may cause minimal discomfort to a patient, but it
is not very painful. These lesions may appear to have a periodontic origin, but they
are fistulas passing through periodontic tissues and are caused by dental pulp infec-
tion. Bone resorption may be apparent on radiographs, depending on the severity
and duration of infection. A spreading infection from the dental pulp may have a
fistula that passes from the root apex through the periodontium, along the mesial or
distal root surface, to exit at the cervical line. The fistula may occur on any maxil-
lary or mandibular tooth and can be observed as a radiolucency along the entire
root length. A fistula can also develop from the root apex into the bifurcation area,
which can create the radiographic appearance of periodontal involvement. A simi-
lar radiographic appearance may result from chronic pulpitis through an accessory
canal that opens into the bifurcation area. When making a diagnosis, be suspicious
of a pulpally induced lesion when the crestal bone level on the mesial and distal of
the involved tooth appears relatively normal if only the bifurcation area is radiolu-
cent. Another possibility is that fistulization can occur through an accessory canal
some distance from the apex on the mesial or distal aspect, which may resemble an
infrabony pocket.
It must be pointed out that if fistulization occurs on the buccal or lingual aspect
and is superimposed over the tooth root, the radiolucency may not be visible. This
could be true also of upper molars for which the palatal root screens the view of the
trifurcation area. Thus, it is imperative that a gutta-percha or silver cone be inserted
into the fistulous tract and x-ray films be taken to determine the origin of the lesion.
When the pulp does not react to responsive testing, it may be necrotic. In addition,
on probing, these defects are discovered to be narrow, tubular, and limited to one
aspect of the tooth. They are not periodontic lesions but rather fistulas of endodontic
origin, and they may heal with endodontic therapy alone.
Primary Endodontic Lesions with Secondary Periodontic

Involvement
If after a period of time a primary endodontic problem remains untreated, it may

then become secondarily involved with periodontal breakdown. Plaque may begin
to form at the gingival margin, which could result in periodontitis. When plaque or
calculus is encountered with a probe or explorer, the treatment and prognosis of the
tooth are altered; the tooth now requires both endodontic and periodontic therapy.
The prognosis depends on the periodontal therapy, assuming the endodontic
procedures are adequate. With endodontic therapy alone, only part of the lesion may
heal, which may indicate the presence of secondary periodontic involvement. In
general, healing of the endodontically induced areas may be anticipated.
Primary Periodontic Lesions
Primary periodontic lesions are caused by periodontal disease. Periodontitis may

gradually progress unchecked along the root surface until the apical region is
reached. Occlusal trauma may or may not be superimposed in these lesions.
Diagnosis is based on the usual periodontic test procedures. Probing usually reveals
calculus for varying lengths along the root surface, and the pulp responds within
normal limits to endodontic testing procedures. The prognosis in this situation
depends wholly upon the efficacy of periodontal therapy. The diagnostician must
also be aware of the radiographic appearance of periodontal disease associated with
developmental radicular anomalies.
Primary Periodontic Lesions with Secondary Endodontic

Involvement
As periodontal lesions progress toward the apex, lateral or accessory canals may be
exposed to the oral environment, which may lead to necrosis of the pulp. In addi-
tion, pulpal necrosis may result from periodontal treatment procedures in which the
blood supply, through an accessory canal or the apex, is severed by a curette.
These primary periodontal lesions with secondary endodontic involvement may
be radiographically indistinguishable from primary endodontic lesions with second-
ary periodontal involvement. Teeth undergoing periodontal therapy that do not
respond as anticipated should be responsively tested. It may be that the previously
vital tooth is now necrotic. Again, the prognosis depends on the periodontal therapy
once the endodontic therapy has been completed. Periodontal treatment alone will
not suffice in the presence of a pulpally involved tooth.
True Combined Lesions
True combined lesions occur where an endodontically induced periapical lesion

exists on a tooth that is also periodontally involved. The radiographic infrabony
defect is created when the two lesions meet and merge somewhere along the root
surface. Ultimately, the clinical and radiographic picture is indistinguishable from
that of primary endodontic lesions with secondary periodontic involvement or pri-
mary periodontic lesions with secondary endodontic involvement. Periapical heal-
ing may be anticipated following successful endodontic therapy. The periodontal
tissues then may heal following periodontal treatment, if the severity of tissue
Diagnostic Complications Due to Radicular Anomalies 25
damage was not extensive. A vertically fractured tooth may also have a radiograph
showing an intrabony defect. If a fistula is present, it may be necessary to create
a flap to visualize the etiology of the lesion. A root fracture that has exposed the
dental pulp, allowing infection and necrosis, may also be labeled a “true” combined
lesion and yet not be amenable to successful treatment.
Periapical Diagnosis
There are five common periapical diagnoses plus one other diagnosis for special
cases. The checklist for the five common diagnoses is:
1. Chronic apical abscess

2. Acute apical abscess
3. Normal apical tissues
4. Non-endodontic lesions, which applies to special cases when a periapical lesion
or cemental dysplasia is associated with a tooth that responds normally to cold
testing
5. Asymptomatic apical periodontitis
6. Symptomatic apical periodontitis
The periapical diagnosis is based on patient responses to percussion and radio-

graphic appearance as shown in Table 1.2.
A flowchart for diagnosing the status of the dental pulp and periapical tissues is
shown in Fig. 1.12.
Diagnostic Complications Due to Radicular Anomalies
Some cases of chronic periodontitis do not heal following fistulas that have a verti-
cal developmental radicular groove anomaly. These developmental anomalies allow
the ingress of bacteria, which infects the periodontal tissues.
Table 1.2 Periapical diagnosis based on patient responses to percussion and radiographic
appearance
Patient response
Pulp vitality diagnosis to percussion Radiographic appearance
Normal, healthy, and vital None Periodontal ligament and lamina dura
are uniform in width and intact
Asymptomatic apical periodontitis None Periapical lesion
Symptomatic apical periodontitis Pain Any
Acute apical abscess Severe pain and No
swelling
Chronic apical abscess Little or no pain Periapical lesion
Is tooth
tender to
percussion?
No Yes
Widened periodontal
ligament or periapical Is there swelling?
radiolucency
No Yes
No Yes
Is the tooth
Normal necrotic? Symptomatic Acute
periapical periapical
No Yes periodontitis abscess
Sinus tract
Lesion of non- present?
endodontic origin
No Yes
Chronic Asymptomatic
apical apical
abcess periodontitis
Fig. 1.12 A flowchart for diagnosing the status of the dental pulp and periapical tissues
Etiology of Root Defects
A tooth which develops with an anomalous root defect has the potential to allow the
ingress of bacteria causing an infection in the periodontal tissues. The chronic infec-
tion can cause adjacent bone resorption. This can be visualized radiographically as
a periapical radiolucency. Unfortunately, anomalous root defects often do not heal
following periodontal treatment.
Diagnosis of Root Defects
The clinical diagnosis of this condition is all important. The patient may have the
symptoms of a periodontal abscess or a variety of endodontic conditions, or he may
be asymptomatic. If the condition is purely periodontal, it can be diagnosed by visu-
ally following the groove to the gingival margin and by probing the depth of the
pocket. This pocket is usually tubular in formation and localized to this one area, as
opposed to the generalized periodontal problem. The tooth may be responsive to
endodontic testing procedures. Bone destruction or a radiolucent area that vertically
follows the groove may be apparent radiographically. If this entity is associated with
an endodontic problem, the patient may present clinically with any of the spectrum
of endodontic symptoms.
The appearance of the grove in the tooth crown may be altered by a prior access
opening or an amalgam filling. The appearance of a teardrop-shaped area on the
Diagnosis of a Cracked Tooth 27
radiograph should immediately arouse suspicion. The development groove may

actually be visible on the radiograph; if so, it will appear as a dark vertical line. This
condition must be differentiated from a vertical fracture, which can give the same
radiographic appearance.
Treatment
In essence, since this is a self-sustaining infrabony pocket, periodontal therapy is

inadequate. Although the acute nature of the problem may be alleviated initially, the
source of the chronic or acute inflammation cannot be eradicated except by extrac-
tion. If the groove does not extend apically too far down the root surface, the tooth
may be retained, with occasional exacerbation of the symptoms, if the area is kept
clean. Otherwise, extraction is the only alternative.
Diagnosis of a Cracked Tooth
Structural cracks deep in the dentin, close to or involving the pulp, are a perplexing
cause of dental pain. This pain may be difficult to diagnose because of the absence
of obvious causes and the possible deviations from the usual symptoms of pulpal
pathology. This situation is quite prevalent and deserved more attention than it has
received in the past.
A structural crack is defined as a break or split in the continuity of the tooth sur-
face without a perceptible separation. The line cannot be wedged, separated, or seen
on a radiograph, although it may be a precursor to a fracture.
Structural cracks should be differentiated from craze lines, cuspal fractures, or
vertical fractures. Structural cracks, by definition, involved the dentin approaching
the pulp. They may be symptomatic or asymptomatic clinically—the dentist cannot
determine the proximity of the crack to the pulp or the extent of root involvement.
Etiology of Cracked Teeth
The exact etiology of the cracked tooth phenomenon is difficult to establish based
on clinical evidence. The primary factors include occlusal or accidental trauma and
restorative procedures.
Diagnosis of a Cracked Tooth
The diagnosis of a cracked tooth can be determined by the tooth:
1. History
2. Radiograph
3. Bite test
4. Transillumination
5. Sensibility testing of the pulp

6. Restoration removal and dye testing
7. Surgical exploration
History of a Cracked Tooth
Patients with cracked teeth usually report a long history of uncertain diagnosis and
inconclusive consultations. The pain is erratic, occurring inconsistently upon masti-
cation. The patient is unable to describe the complaint clearly or precisely.
Radiograph of a Cracked Tooth
A radiograph does not reveal structural cracks. If a dark line appears on an x-ray
film, the line by definition is a fracture line, and the tooth is fractured rather than
cracked. The radiograph is effective, however, in examining alterations of the pulp
chamber or canal.
Bite Test for a Cracked Tooth
For the bite test, a small rubber wheel is positioned over the cusp of a tooth sus-
pected of having a crack, and the pain is evaluated during closing and releasing of
the bite.
Transillumination for a Cracked Tooth
Fiberoptics are extremely useful in the detection of crack lines. The tooth should be
cleaned of plaque, calculus, or caries prior to transillumination test.
Responsive Testing of the Pulp
Responsive testing, including the use of thermal or electric stimuli and percussion,
should be performed in order to determine the need for root canal therapy.
Restoration Removal and Dye Test
The diagnostic procedure may require the removal of a sound restoration, especially
if the cusps are not restored, in order to examine the tooth structure for crack lines.
The use of disclosing dye may be necessary to stain and visualize a suspected crack.
Treatment 29
Fig. 1.13 Exploratory

a
surgery to rule out possible
cervical resorption. No
further treatment was
indicated (The case is
courtesy of Dr. Jamie Ring)
Surgical Exploration
If a crack or fracture of the root is suspected in a tooth that has been restored with
full coverage, surgical exploration may be advisable. Often, exploration can detect
untreatable situations, sparing the cost, time, and effort of endodontic or restorative
treatment. In the case shown below (Fig. 1.13), exploratory surgery was conducted
to rule out cervical resorption.
Treatment
Emergency Treatment
The occlusion should be reduced to relieve occlusal stresses in centric and lateral
relationships. This is accompanied in order to reduce the pain and to prevent the
progression of the crack.
Restoration
The restoration must include and protect the cusps: the onlay or full crown is
mandatory.
It is important to keep the operative trauma to a minimum. Overpreparation,
excessive generation of heat, and the use of irritating chemicals should be avoided
and careful attention must be given to the occlusal contour and relationship.
Root Canal Therapy

Teeth with structured cracks should be given special consideration during root canal
therapy. Excessive condensation should be avoided and the use of post restorations
is not advised.
Root Canal Treatment
1. Obtain patient consent for treatment.

2. Check if the patient is healthy enough for treatment by checking blood pressure
and health status.
3. Profoundly anesthetize the involved tooth.
4. Isolate the involved tooth with a rubber dam.
5. Use a microscope to help visualize treatment.
6. Prepare the access opening. It is important that the opening be in the correct pro-
portion to the canal size to allow for canal instrumentation and filling procedures.
7. Establish an accurate root working length using an apex locator and by taking
a radiograph with the file or reamer in place.
8. Use hand files to find and enter the root canal spaces.
9. Use rotary files to clean and shape the root canals as far as the radiographic
apex.
10. During instrumentation, irrigate the canals with 6 % sodium hypochlorite
(bleach) to remove all the necrotic tissue.
11. Dry the canals with paper points
12. Use a chelating agent, normally 17 % EDTA for 60 s with ultrasonic irrigation,
to remove debris from the root canal.
13. Dry the canal with paper points.
Summary of Pulp, Periapical, and Bone Status 31
14. Flush the canal space with a final rinse of irrigating solution (6 % sodium
hypochlorite).
15. Apply sealer to the root canal walls.
16. Obturate the root canal space with gutta-percha cones (lateral condensation).
17. Place a temporary restorative material to seal the root canal access.
18. Place a crown or restorative material to restore the tooth within 3 months.
Standards for Patient Care
To reduce the risk of litigation following endodontic treatment [11], you must main-
tain the highest standards of patient care, which includes:
1. Protect the health of the patient, and avoid causing them injury or suffering.
2. Making an accurate diagnosis of the patient’s condition.
3. Delivering treatment which is supported by an evidence base and uses instruments,
materials, and medicaments according to label and manufacturer instructions.
4. Avoiding accidents and mistakes, such as rushing the treatment and cutting out
steps, causing a root perforation, breaking instruments, not properly isolating the
tooth, by treating the wrong tooth, or by spilling sodium hypochlorite irrigating
solution without using adequate suction to remove it.
5. Giving adequate instructions for home care.
6. Providing emergency care and rectify a treatment failure to avoid patient suffering.
Summary of Pulp, Periapical, and Bone Status
The diagnosis of pulp, periodontal tissue, and dentin status should follow a consis-
tent and logical order that includes all the SOAP criteria. The accurate and complete
diagnosis of the disease state of the pulp, periodontal tissues, and dentin is neces-
sary to develop a treatment plan which will benefit the patient and provide them
with the highest-quality longest-lasting endodontic care. Dental traumatic injury
and resorption are described in Chap. 2. The diagnosis of the tissues should use the
following uniform terminology shown in Table 1.3.
32
Table 1.3 Summary of the diagnosis of pulp, periodontal tissue, and dentin status
Cold sensibility Percussion, palpation,
Tissue type Tissue status Patient complaint Radiographic observations Tooth history testing and mobility
Pulp Normal vital None Normal Variable Normal Not used for pulp
Reversible pulpitis Cold and hot Normal Variable Intense non- diagnosis
sensibility lingering pain
Symptomatic Lingering cold and Normal to wide Spontaneous pain Intense more
irreversible pulpitis hot sensibility periodontal ligament lingering pain
Asymptomatic None Normal to wide Asymptomatic Normal
irreversible pulpitis periodontal ligament
Necrotic pulp Variable pain Normal to wide Variable No response
1
and sensibility periodontal ligament

Periapical Normal vital None Normal Variable Not used for Normal
Symptomatic apical Chewing discomfort Normal to wide Recently treated periapical diagnosis Sensitive with excess
periodontitis periodontal ligament mobility
Asymptomatic apical None Normal to wide Asymptomatic Asymptomatic with
periodontitis periodontal ligament excess mobility
Acute apical abscess Pain and swelling Periapical lesion Microleakage from Sensitive with variable
restoration mobility
Chronic apical abscess Bad taste in mouth Periapical lesion and Asymptomatic Nonresponsive and
possible sinus tract normal mobility
Dentin Normal None Normal Variable Not used for dentin Normal
Internal resorption Pink tooth Loss of dentin inside Traumatized diagnosis Normal
root canal
External resorption Excessive tooth Loss of dentin outside Replanted or Normal to excessive
mobility root surface traumatized mobility
The Differential Diagnosis of Endodontic Disease
Quiz for the Topics Covered in Chapter 1 33
Quiz for the Topics Covered in Chapter 1
1. Endodontic treatment is always the most appropriate treatment to save a painful

tooth?
(a) False
(b) True
2. Having a painful tooth extracted is always the most cost-effective treatment
planning approach for patients?
(a) True, if the patient does not plan to replace the missing tooth
(b) False, if the patient wants to replace the tooth
3. The 10-year success rate of root canal treatment can reach 90 %?
(a) True
(b) False
4. Teeth are healed after endodontic treatment if they do not have clinical or radio-
graph symptoms of disease?
(a) True
(b) False
5. Postoperative pain after having teeth extracted is commonly much more severe
than if they had been given a root canal treatment?
(a) True
(b) False
6. Obtaining patient confidence, cooperation, and consent is required before root
canal treatment is performed?
(a) True
(b) False
7. Complete written documentation, electronic documents, radiographs, specialist
reports, and signed informed consents for every patient must be organized into
the patient record and be kept securely.
(a) True
(b) False
8. A tooth which is not painful all the time but which produces a sharp pinpoint
pain with biting pressure is likely to be fractured?
(a) True
(b) False
9. A tooth which is painful and sensitive to hot and cold is likely to have caries or
a recent pulp exposure?
(a) True
(b) False
10. A tooth which is painful and not sensitive to hot and cold is likely to have
pulpitis and/or periodontitis?
(a) True
(b) False
11. At each visit, the patient’s face and dental tissues must be examined for
diseases?
(a) True
(b) False
12. If you discover that the patient has a probable disease that you cannot treat, the
patient must be referred to see a specialist for diagnosis and treatment?
(a) True
(b) False
13. The ideal radiograph will show the crown and cervical aspects of the tooth?
(a) True
(b) False
14. The SOAP framework is used for the diagnosis of endodontic disease?
(a) True
(b) False
15. Cold testing and electric pulp testing can accurately diagnose pulp vitality in
over 80 % of cases?
(a) True
(b) False
16. Every effort must be made to locate and to obturate all canals.
(a) True
(b) False
17. A fistula is an abnormal pathway between two anatomic spaces or a pathway
that leads from an internal cavity to the surface of the body.
(a) True
(b) False
18. Primary periodontic lesions are caused by periodontal disease.
(a) True
(b) False
19. The exact etiology of the cracked tooth phenomenon is difficult to establish
based on clinical evidence.
(a) True
(b) False
20. It is important to keep the operative trauma to a minimum.
(a) True
(b) False
(All answers are true.)

Appendix 1.1. Example of a Patient Consent Form 35
Appendix 1.1. Example of a Patient Consent Form

Appendix 1.1. Example of a Patient Consent Form 37
Bibliography
1. Torabinejad M, Anderson P, Bader J, Brown LJ, Chen LH, Goodacre CJ, Kattadiyil MT,
Kutsenko D, Lozada J, Patel R, Petersen F, Puterman I, White SN. Outcomes of root canal
treatment and restoration, implant-supported single crowns, fixed partial dentures, and extrac-
tion without replacement: a systematic review. J Prosthet Dent. 2007;98:285–311.
2. Bortoluzzi MC, Traebert J, Lasta R, Da Rosa TN, Capella DL, Presta AA. Tooth loss, chewing
ability and quality of life. Contemp Clin Dent. 2012;3:393–7.
3. Berman LH. Failing before starting: when not to do endodontics. Gen Dent. 2010;58:529–33.
4. Engström B, Segerstad LH, Ramström G, Frostell G. Correlation of positive cultures with the
prognosis for root canal treatment. Odontol Revy. 1964;15:257–70.
5. Kerekes K, Tronstad L. Long-term results of endodontic treatment performed with a standard-
ized technique. J Endod. 1979;5:83–90.
6. Fleury A, Regan JD. Endodontic diagnosis: clinical aspects. J Ir Dent Assoc. 2006;52:28–38.
7. Lin J, Chandler NP. Electric pulp testing: a review. Int Endod J. 2008;41:365–74.
8. Petersson K, Söderström C, Kiani-Anaraki M, Lévy G. Evaluation of the ability of thermal and
electrical tests to register pulp vitality. Endod Dent Traumatol. 1999;15:127–31.
9. Dinh A, Sheets CG, Earthman JC. Analysis of percussion response of dental implants: an
in vitro study. Mater Sci Eng C Mater Biol Appl. 2013;33:2657–63.
10. Chen E, Abbot PV. Dental pulp testing: a review. Int J Dent. 2009;2009:365785.
11. Cohen SC. Endodontics and litigation: an American perspective. Int Dent J. 1989;39:13–6.
Dental Traumatic Injuries,
Pain Management, 2
and Emergency Treatments
Traumatic Dental Injuries
Traumatic dental injuries (TDIs) are caused by sudden impact forces to teeth gener-
ated by falls, fights, sports-related injuries, and traffic accidents. School children have
a 25 % risk of suffering TDIs and 33 % of all adults will suffer TDIs [1]. The most
common TDIs in adult teeth are crown fractures [2], while children are most likely to
suffer a protrusion or retrusion of a tooth causing lateral luxation [3]. All TDIs, even
if apparently mild, require a dental exam. Sometimes, the neighboring teeth can suffer
an additional, unnoticed injury that can only be detected by a thorough dental exam.
Patient Care Immediately Following Traumatic Dental Injuries
When the patient or their parent/guardian telephones and describes tooth trauma,
arrange to see the patient immediately. Check that the trauma is limited to the teeth; if
the injuries to the face are more extensive, the patient must be directed to visit an acci-
dent and emergency center for treatment prior to seeking dental treatment. If the patient
has an avulsed tooth, tell them to wash it and replant it quickly. When the patient arrives
at your office following an accident, you should wash blood and dirt from their face
with soapy water. Tell the patient to rinse their mouth with mouthwash or saline.
Differential Diagnosis of Traumatic Dental Injuries
An accurate diagnosis of the type of TDI is needed to ensure the tooth is given the
most appropriate treatment. The diagnosis of trauma should use the following
criteria [4]:
1. Subjective information
2. Objective information

DOI 10.1007/978-3-662-43730-8_2
40 2 Dental Traumatic Injuries, Pain Management, and Emergency Treatments
3. Assessment
4. Plan
Subjective Information About the Traumatic Dental Injuries
Subjective information should be gathered by talking with the patient about their
injury. The types of questions to ask patients are:
1. How do you feel? Did you become unconscious or confused?—Judge if the

patient appears confused and needs medical assistance, or if their condition is
stable and they are healthy enough for dental trauma care.
2. How long ago did the injury occur?—Knowing the amount of elapsed time is
important for replanting teeth and treatment planning.
3. How did you get injured?—Crashing in a car or bicycle will likely cause greater
injury forces than those associated with a fall onto the pavement or being
punched to the mouth.
4. Have you taken any pain killers for the pain?—Assess if the trauma symptoms
are being masked by pain killers.
5. Have you had any previous difficulty to control pain with local anesthesia?
With taken any pain killers for the pain?—This will help determine if a longer
waiting time or supplemental anesthesia is needed before you can start
treatment.
Objective Information About the Traumatic Dental Injuries
Objective information should be gathered about the patient’s condition from the
following criteria:
1. Palpation tenderness and swelling.

2. Examination of the injured tooth.
3. Radiographs taken from different angulations or a cone beam computed tomog-
raphy image of the root canal of an injured tooth.
4. Cold, hot, electric, and percussion sensibility test results.
5. A sking the patient to point to the painful tooth, if it is not obviously
injured.
6. Identification of trauma type.
7. Dental and medical history.
8. Soft tissue lesions should be palpated to identify any tooth fragments or foreign
bodies. If the lip is lacerated, a radiograph of the lip is needed to identify any
tooth fragments or foreign bodies.
Traumatic Dental Injuries 41
Assessing Information to Reach a Differential Diagnosis
The assessment of objective information should be used to reach a differential diag-

nosis of the type of dental trauma. The assessment should include the following
criteria:
1. Avulsion of the tooth from its socket

2. Displacement and loosening of the tooth
3. Mobility of a single tooth or several teeth as a unit
4. Intrusion, protrusion, and retrusion of the tooth
5. Tenderness to percussion
6. Signs of root and crown fracture
Plan/Procedure
The differential diagnosis of dental trauma and assessment criteria are used for
treatment planning:
1. Regenerative endodontic treatment for teeth with immature roots, which have
symptoms of a traumatized irreversibly injured pulp.
2. Antibiotics can protect the patient from infection following TDIs. There is none
or limited evidence that antibiotics are beneficial for saving teeth or for healing
TDIs.
3. Discarding teeth which should not be replanted, replanting avulsed teeth, and
repositioning loose and luxated teeth back into their sockets using splinting to
neighboring teeth. Splinting should reposition a loose tooth in its correct position
and be comfortable.
4. Apexification treatment for teeth with mature roots which have symptoms of a
traumatized irreversibly injured pulp.
5. Root amputation, hemisection, bicuspidization.
6. Surgical intervention needed to restore facial appearance and function.
Root and Crown Fractures
Root or crown fractures should not condemn the tooth so that it should automatically
be considered for extraction. Root fractures can be vertical or horizontal and can occur
at any level. Many teeth with root fractures can be saved by endodontic treatment and
restoration of the crown. The type of and amount of treatment needed to save the
injured tooth are dependent on the type and severity of TDI. If the extent of the frac-
ture is linear from the crown to the root, replanting the tooth is not recommended
because of the high risk of treatment failure caused by infection through the fracture.
Tooth Fracture Diagnosis by Radiographic Examination
Several angulated radiographs are needed to identify root fractures, particularly in

the mesiodistal plane, and incomplete or oblique fractures. These fractures are the
most difficult to identify. Radiographs should be carefully examined for the follow-
ing information if a fracture is suspected:
1. Degree of fragment separation

2. Apex and root development
3. Root resorption, fracture lines, and presence and location of radiolucencies
4. Evaluation of periodontal tissues
Tooth Fracture Diagnosis by Clinical Examination
The dental examination should identify the movement of a tooth following TDI,
such as coronal displacement, tooth discoloration, and mobility. It may include the
following criteria:
1. Soft tissue evaluation

2. Periodontal probing
3. Occlusal evaluation
4. Responsive testing
5. Exploration by lifting a surgical flap
Tooth Fracture Diagnosis by Patient Report
The patients’ description of their TDI will help diagnose the type and severity of the
injury. It may include the following criteria:
1. Swelling and treatment history

2. Pain history
3. Injury description
4. Time elapsed since injury
Identification of the Type of Traumatic Dental Injury
The SOAP, PERCACIDS, ADMITS, RADARS, DARE, SPORE, and SPIT cri-
teria are used to differentially diagnose the type and severity of TDI. The starting
point is always to assess if the tooth has been completely avulsed from its socket
and replanted. If the tooth has not been avulsed, the displacement of the tooth and
its mobility beyond normal limits should be tested. If several teeth move as one unit,
it is characteristic of an alveolar fracture. If a single tooth moves and a fracture can
been seen in a radiograph, it is characteristic of a root fracture. If no root fracture
Yes Avulsion
Tooth Yes Mobile Several teeth

No displace Yes move as a unit Alveolar fracture
-ment?
No No
Single
tooth Radiograph Yes Root fracture
Loose?
moves root
fracture No
No Extrustion
Protrusion or retrustion
Lateral luxation
Avulsion
of tooth Intrusion
Percussion
from its tenderness Intrusion
socket
Yes
Subluxation
Yes
Concussion
No Fracture ? Uncomplicated
No
Above Exposed crown fracture
gingiva pulp?
Complicated
Yes crown
fracture
Below Exposed
gingiva pulp? Uncomplicated
No crown-root
fracture
Complicated
Yes crown-root
fracture
Minimal
incomple
Infraction
None
No injury
Fig. 2.1 A diagnostic flowchart to classify traumatic dental injuries
can be identified in a radiograph, it suggests that the tooth has had an extrusion. A
tooth which appears to be in an abnormal position because of protrusion or retrusion
has suffered from lateral luxation. A tooth which is abnormally located by intru-
sion out of its socket into alveolar bone has suffered from intrusion. If the tooth has
not been displaced, but is loose, it has suffered from subluxation. If the tooth has
not been displaced, but is not loose, and has percussion tenderness, it has suffered
concussion. If the tooth has not been displaced, is not loose, and has no percussion
tenderness, it has suffered concussion. If the tooth has not been displaced, is not
loose, has no percussion tenderness, and has suffered a fracture above the gingiva
which exposed the pulp, the tooth has suffered a complicated crown fracture. If a
tooth has a crown-root fracture that has not exposed the pulp, it has suffered an
uncomplicated crown fracture. If a tooth has a crown-root fracture that has
exposed the pulp, it has suffered a complicated crown fracture. If the extent of the
fracture is so minimal that no tooth structure has been lost, the tooth has suffered an
infraction. If the tooth has no discernible symptoms of trauma, then it can be
assumed that the tooth has no injury. A diagnostic flowchart to classify TDI is
shown in Fig. 2.1.
Types of Traumatic Dental Injuries
The accurate use of TDI terminology is essential to communicate in dental records

and between dentists. The TDI terminology can vary slightly among organizations
and authors [5–13]. The six types of luxation injuries are:
Avulsion—The complete displacement of the tooth out of its socket.

Concussion—An injury to the tooth-supporting structures without increased mobil-
ity or displacement of the tooth, but with pain to percussion.
Extrusion—Partial displacement of the tooth out of its alveolar socket. Characterized
by a partial or total separation of the periodontal ligament resulting in loosening
and displacement of the tooth. The alveolar socket bone is intact in an extrusion
injury as opposed to a lateral luxation injury. Apart from axial displacement, the
tooth will usually have an element of protrusion or retrusion. In severe extrusion
injuries, the retrusion/protrusion element can be very pronounced. In some cases,
it can be more pronounced than the extrusive element.
Lateral luxation—Displacement of the tooth other than axially. Displacement
accompanied by crushing or fracture of either the labial or the palatal/lingual
alveolar bone. Lateral luxation injuries, similar to extrusion injuries, are charac-
terized by partial or total separation of the periodontal ligament. However, lateral
luxations are complicated by a fracture of either the labial or the palatal alveolar
bone and a compression zone in the cervical and sometimes the apical area. If
both sides of the alveolar socket have been fractured, the injury should be classi-
fied as an alveolar fracture (alveolar fractures rarely affect only a single tooth).
In most cases of lateral luxation, the apex of the tooth has been forced into the
bone by the displacement, and the tooth is frequently nonmobile.
Intrusion—Displacement of the tooth into the alveolar bone. This injury is accom-
panied by crushing or a fracture of the alveolar socket.
Subluxation—An injury to the tooth-supporting structures with increased mobility,
but without displacement of the tooth. In acute trauma, bleeding from the gingi-
val sulcus confirms the diagnosis.
The eight types of tooth and bone fracture injuries are:
Alveolar fracture—A fracture of the alveolar process, which could involve the
alveolar socket. Teeth with alveolar fractures are characterized by mobility of the
alveolar process; several teeth typically will move as a unit when mobility is
checked.
Complicated crown fracture—A fracture through enamel and dentin which caused
a loss of tooth structure, but which exposed the dental pulp.
Complicated crown and root fracture—A fracture through the enamel, dentin,
and cementum which caused a loss of tooth structure, but which did not expose
the dental pulp.
Enamel fracture—A fracture confined to the enamel with loss of tooth structure.
Enamel infraction—An incomplete fracture or crack in the enamel without a loss

of tooth structure.
Root fracture—A fracture through the dentin and cementum which exposed the
dental pulp.
Uncomplicated crown and root fracture—A fracture through the enamel, dentin,
and cementum which caused a loss of tooth structure, but which did not expose
the dental pulp.
Uncomplicated crown fracture—A fracture through the enamel and dentin which
caused a loss of tooth structure, but which did not expose the dental pulp.
The three main types of injuries to the gingival or oral mucosa are:
Abrasion—A superficial bleeding wound caused by the rubbing or scraping of tis-

sues with an object or surface
Contusion—A bruise of the gingiva or oral mucosa caused by a blunt object often
associated with an adjacent bone fracture
Laceration—A wound in the gingiva or oral mucosa caused by a penetrating sharp
object
Diagnosis of Traumatic Dental Injuries
Avulsion—The displacement of the tooth from its normal position in the socket is
an indicator of the direction and amount of injury sustained by the tooth. If the
tooth has been completely avulsed, the percussion test and sensibility tests are
not used to diagnose pulp sensibility since these tests are unreliable for replanted
teeth. It is important to check radiographs of the involved socket for intrusion
and alveolar fracture.
Alveolar fracture—The displacement of several teeth from their normal position,
or the movement of several teeth as a unit when mobility has been checked, is a
symptom of fractured alveolar bone across the periodontal ligaments or septum.
These teeth will be tender to the percussion response and usually have no
response to the pulp sensibility test.
Concussion—A tooth which has no visible or radiographic abnormalities, except
that the percussion test causes a pain response, is probably suffering from con-
cussion. If there is a normal response to the pulp sensibility test, the pulp has a
lower risk of becoming necrotic.
Crown fracture—A tooth with a visible fracture through the enamel and dentin
above the gingiva which caused a loss of tooth structure. Uncomplicated—a
fracture which did not expose the dental pulp and has a lack of response to the
percussion test. The pulp responds normally to the pulp sensibility test.
Complicated—a fracture which exposed the dental pulp and has a tender or
painful response to the percussion test, and also an abnormal response to the pulp
sensibility test.
Crown-root fracture—A tooth with a visible fracture through the enamel, dentin,
and cementum, below the gingiva which caused a loss of tooth structure.
Uncomplicated—a fracture which did not expose the dental pulp and has a lack
of response to the percussion test. The pulp responds normally to the pulp sensi-
bility test. Complicated—a fracture which exposed the dental pulp and has a
tender or painful response to the percussion test, and also an abnormal response
to the pulp sensibility test.
Extrusion—A tooth which is partially displaced out of its alveolar socket. The
tooth is loose and has greater than normal mobility. The radiograph shows there
is an increased periodontal ligament space at the root apex. The involved tooth is
tender in response to percussion and is likely to have an abnormal response to the
sensibility test.
Infraction—A small fracture contained within the tooth enamel without any loss of
tooth structure. The involved tooth has a no pain response to percussion and no
increased mobility and a normal sensibility response is an indicator for a low risk
of necrosis.
Intrusion—A displacement of the tooth into the alveolar bone accompanied by a
fracture of the alveolar socket. This involved tooth causes no pain in response to
percussion, but it creates a metallic sound. The tooth has no increased mobility
and no response to the sensibility test. The radiograph shows a reduced periodon-
tal ligament space.
Lateral luxation—A displacement of the tooth other than axially accompanied by
a fracture of either the labial or the palatal/lingual alveolar bone. This involved
tooth causes no pain in response to percussion, but it creates a metallic sound.
The tooth has no increased mobility and no response to the sensibility test. The
radiograph shows an increased periodontal ligament space.
Root fracture—A root fracture is seen on the radiograph of the tooth. The involved
tooth evokes a pain or tender response to percussion; it has more mobility above
the site of the fracture. A normal sensibility response indicates a low risk of pulp
necrosis.
Subluxation—A tooth with injured supporting structures and often bleeding from
the gingival sulcus. The involved tooth evokes a pain or tender response to per-
cussion; it has increased mobility. A normal sensibility response indicates a low
risk of pulp necrosis.
The diagnoses for traumatic dental injuries are summarized in Table 2.1.
Emergency Care for a Traumatic Dental Injury
The priority of emergency care is to relieve pain and provide evidence-based treat-
ment to save the tooth. This involves giving anesthetics, suturing soft tissue lacera-
tions, and the repositioning and stabilizing of bone and the involved teeth. If pain
and mobility are not present, a definitive diagnosis and treatment plan should be
delayed until healing has had a chance to occur. The immediate lack of pulp
Table 2.1 Diagnosis of traumatic dental injuries
Percussion Increased Radiographic
Description Representation Symptoms response? mobility? Pulp sensibility? observations
Avulsion Teeth are completely Not indicated Yes Not indicated Check socket for
displaced out of their intrusion and alveolar

socket fracture
Alveolar fracture Several teeth move as Tender Several teeth Abnormal A fracture can be seen
a unit when mobility move as a unit along the periodontal
is checked ligaments or septum
Concussion Injured tooth is not Pain No A normal No abnormalities

displaced response indicates
a low risk of
necrosis
(continued)
47
Table 2.1 (continued)
48

Crown fracture Lost crown structure None Crown—yes Normal Fracture visible in
(uncomplicated) without an exposed Root—no crown
2
dental pulp
Crown fracture Fractured crown Tender Crown—yes Abnormal Fracture visible in

(complicated) structure with an Root—no crown
exposed dental pulp
Crown-root fracture Fractured crown-root None Crown-root— Normal for apical Fracture not visible in
(uncomplicated) structure without an yes pulp apical area
exposed dental pulp Apical root—no
Crown-root fracture Lost crown-root Tender Crown-root— Abnormal Fracture not visible in
(complicated) structure with an yes apical area
exposed dental pulp Apical root—no
Dental Traumatic Injuries, Pain Management, and Emergency Treatments
Extrusion Injured tooth is Tender Yes A normal Increased periodontal
partially displaced out response indicates ligament space at root
of its socket a low risk of apex
necrosis
Infraction An enamel fracture None No A normal None

without any loss of response indicates
tooth structure a low risk of
necrosis
Intrusion Intrusion of the tooth None, metallic No Abnormal Reduced periodontal

axially into alveolar sound ligament space
bone
Lateral luxation Injured tooth is None, metallic No Abnormal Increased periodontal

displaced other than sound ligament space
axially and fractures
alveolar bone
49
(continued)
50
2

Root fracture Injured tooth has a Tender Yes—above A normal A root fracture is
root fracture fracture response indicates visible
a low risk of
necrosis
Subluxation Bleeding from Tender Yes A normal None

gingival sulcus but no response indicates
tooth displacement a low risk of
necrosis
Dental Traumatic Injuries, Pain Management, and Emergency Treatments
sensibility response should not indicate that the pulp is necrotic and root canal treat-
ment is needed, since the test may be unreliable owing to the temporary neural
paresthesia. The patient should be recalled immediately if they experience pain or
after 3 months have elapsed and be evaluated for the following criteria:
1. Change in tooth color.

2. History of pain and swelling.
3. A radiographic evaluation should also be performed.
4. Mobility beyond normal limits.
5. Pulp sensibility response.
6. Soft tissue changes.
Diagnosis and Treatment Modalities for Dental Trauma
The steps to diagnose and deliver treatment for dental trauma are:
1. Clean and inspect all aspects of the TDI.

2. The SOAP, PERCACIDS, ADMITS, DARE, SPORE, and SPIT criteria are
used to differentially diagnose the type and severity of TDI.
3. Give local anesthesia to relieve pain at the site of the TDI and make the patient
comfortable.
4. Use the flowchart in Fig. 2.1 and Table 2.1 to determine the type of TDI.
5. Use RADARS criteria to plan the treatment.
6. Use CHAMPS criteria to monitor the healing and success of the treatment.
Treatment Planning for Dental Traumatic Injuries
The treatment decision-making steps for dental traumatic injuries using the
criteria are:
1. Decide to give immediate treatment with appropriate pain relief or delay treat-
ment and monitor the tooth until a treatment is indicated and necessary. Check
the pulp sensibility; if the pulp sensibility response is altered to cold and electric
pulp testing, or the tooth is painful, suggesting a necrotic pulp or a pulp with
irreversible pulpitis, then root canal treatment is indicated.
2. Reimplant avulsed teeth if they will be able to heal or discard the tooth.
3. Examine all lacerations and abrasions, to ensure that all tooth fragments, dirt,
and foreign material have been removed.
4. Suture any lacerations after checking the wound is clean and disinfected with
saline or chlorhexidine.
5. Splint loose teeth with resin to immobilize them in their correct position to
neighboring teeth for 2 or 4 weeks.
Treatment for Dental Traumatic Injuries
Avulsed Tooth Replantation
Avulsion injuries are considered one of the most complicated and detrimental
displacement injuries of teeth. The maxillary central incisors are the most fre-
quently avulsed teeth. Avulsion frequently involves a single tooth; but multiple
avulsions are occasionally encountered. The most common age group for avul-
sion injuries is children between the age of 7 and 10 years, when the permanent
incisors are erupting. The loose structure of the periodontal ligament favors com-
plete detachment and avulsion of the tooth as opposed to a crown or root fracture.
Damage to both the pulpal and periodontal tissues is a common sequel of tooth
avulsion injuries. Immediate replantation of a permanent avulsed tooth is the
most critical of all factors that impact the prognosis of that tooth. Failure to prop-
erly handle, transport, and store the avulsed tooth in addition to delaying its
replantation may lead to permanent irreversible destruction of both the pulpal
and periodontal tissues and inevitably reduce the success of any replantation
attempts.
The replantation of avulsed permanent teeth has been the subject of several
in vivo research studies using animals. Normal healing is characterized by complete
repair of the periodontal ligament (PDL) and is radiographically characterized by
no signs of resorption. In a clinical study of 110 replanted teeth, 90 % of teeth
replanted in less than 30 min showed no resorption [10]. The replantation of avulsed
teeth can be a very successful therapy over the long term; however, many replanted
teeth fail. Replacement resorption is the most detrimental of the periodontal liga-
ment responses that occur following replantation of an avulsed tooth with long
extra-alveolar time [14].
Avulsed baby teeth should not be replanted. The following are considerations for
replanting avulsed permanent teeth:
1. Replant the avulsed teeth as quickly as possible, preferably within 30 min.

The longer the teeth are outside the oral cavity, the less favorable is the
prognosis.
2. Alveolar fractures can complicate healing. Avulsed teeth with an extensive root
and crown fracture should not be replanted.
3. Intact periodontium is essential for replant success.
4. Necrosis of the pulp is likely because of the interruption in blood flow. A fully
mature tooth will need a root canal treatment no later than 2 weeks following its
replantation. An immature tooth with an apex open more than 1.1 mm will need
a regeneration treatment if the root canal walls are thin and will be prone to frac-
ture. An immature tooth with thick walls will need an apexification treatment.
These treatments are discussed in the next chapter.
5. Younger patients may need to have avulsed permanent teeth replanted temporar-
ily to allow full tooth maturation and dental development. The cosmetic and
psychological needs of all patients should be considered.
Treatment for Dental Traumatic Injuries 53
Treatment for Replanting Avulsed Teeth
Once a decision has been made to replant an avulsed tooth, the following factors
should be considered:
1. Store avulsed teeth in milk or saline, if the teeth cannot be replanted immediately
following avulsion.
2. Endodontic treatment is needed to prevent the spread of necrosis from the pulp
into the periapical tissues surrounding the replanted tooth. If the tooth has not
been replanted within 30 min, resorption can be expected to occur.
3. Antibiotics and anti-tetanus therapy may be considered.
4. Leave the periodontal tissue; it should not be scraped, as much tissue as possible
should be maintained.
5. Splint the tooth with resin to adjacent teeth to stabilize it for 2 –3 weeks. More
lengthy periods of rigid splinting may predispose the tooth to ankylosis and may
negate success.
Evaluating the Success of Replanted Avulsed Teeth
Replanted avulsed teeth are considered clinically successful if they meet the follow-
ing criteria:
1. Mobility matches the non-replanted teeth.

2. Ankylosis resorption is not evident on radiographs of the periodontal ligament.
3. Normal supporting tissue, free from a fistula or swelling.
4. No apical or periodontal lesion.
5. Asymptomatic and functional tooth.
Delaying Treatment to Traumatically Injured Teeth
If a tooth is diagnosed as suffering from concussion, it will not need endodontic

treatment unless the pulp comes painful and is diagnosed as being necrotic or hav-
ing irreversible pulpitis. Teeth which do not need immediate endodontic treatment
should be monitored at routine dental visit intervals. The types of teeth suffering
from TDI which need monitoring and/or endodontic treatment are summarized in
Table 2.2.
Local Anesthesia for Traumatically Injured Teeth
Local anesthetics must be used to block pain from painful TDIs. There are several
types of local anesthetics and local anesthetic nerve blocks that can be used. These
include the inferior alveolar nerve block (IANB), Gow-Gates nerve block, Akinosi
Table 2.2 Treatment for traumatic dental injuries

Patient home
care and
Description Treatment plan Prognosis instructions
Avulsion Clean with saline or CHX Good if immediately Soft-food diet
Reimplant tooth if less than replanted and then the Use soft
30 min or not already pulp responds toothbrush
reimplanted normally
Suture any laceration CHX rinse daily
Apply a flexible splint for
2 weeks
After 2 weeks if the apex is
closed or sensibility is altered,
give root canal treatment
Alveolar fracture Give local anesthesia Good if alveolar Soft-food diet
Reposition teeth back to fracture repositioned Use soft
original location quickly toothbrush
4 weeks
If pulp sensibility is altered,
Concussion Monitor Good if the pulp
Soft-food diet
If pulp sensibility is altered, responds normally
Use soft
give root canal treatment toothbrush
CHX rinse daily
Crown fracture Restore tooth structure Good if the pulp Soft-food diet
(uncomplicated) If pulp sensibility is altered, responds normally Use soft
give root canal treatment toothbrush
CHX rinse daily
Crown fracture Temporary treatment is to bond Endodontic treatment Soft-food diet
(complicated) fragments together is needed
Remove coronal fragment, Use soft
perform endodontic treatment, toothbrush
and restore the tooth with a
post and crown
If that treatment is not CHX rinse daily
indicated, give orthodontic
extrusion, surgical extrusion,
and decoronation or extract the
tooth
Crown-root fracture Remove fragments with forceps Good if the pulp Soft-food diet
(uncomplicated) and restore tooth structure responds normally
Clean with saline or CHX Use soft
toothbrush
(continued)

Patient home
care and
Crown-root fracture Temporary treatment is to bond Endodontic treatment Soft-food diet
(complicated) fragments together is needed
Remove coronal fragment, Use soft
perform endodontic treatment, toothbrush
and restore the tooth with a
post and crown
If that treatment is not CHX rinse daily
indicated, give orthodontic
extrusion, surgical extrusion,
and decoronation or extract the
tooth
Extrusion Clean with saline or CHX Good if the pulp Soft-food diet
Reposition tooth back to responds normally Use soft
original location toothbrush
2 weeks
Infraction Seal marked infractions with Good if the pulp None
resin to prevent discoloration responds normally
Intrusion Clean with saline or CHX High risk of root Soft-food diet
Reposition tooth back to resorption Use soft
2 weeks
Lateral luxation Give local anesthesia Good if the pulp Soft-food diet
Reposition tooth and displaced responds normally Use soft
bone back to original location toothbrush
4 weeks
Root fracture Clean with saline or CHX Good if the pulp Soft-food diet
Reposition tooth back to responds normally Use soft
4 weeks
(continued)

Patient home
care and
Subluxation Clean with saline or CHX Good if the pulp Soft-food diet
Apply a flexible resin splint for responds normally Use soft
2 weeks toothbrush
If pulp sensibility becomes CHX rinse daily
altered, give root canal
treatment
nerve block, and intraorbital nerve block. In addition to the supplemental anesthetic
blocks, which include: buccal infiltration, intraosseous infiltration, intraligamentary
infiltration, and intrapulpal infiltration. The use of local anesthetics is subject to
clinical experience.
Repositioning and Stabilizing Traumatically Injured Teeth
Teeth which have been subject to extrusion, intrusion, and lateral luxation need to
be repositioned often without anesthesia into their original position within the tooth
socket using light finger pressure and do not use forceps or instruments to reposition
teeth as their grip could easily slip and increase the trauma to the tooth. On most
occasions, it is appropriate to split the loose teeth to neighboring teeth with a resin
splint or a wire composite splint for 2–4 weeks, as shown in Table 2.2.
Prognosis of Traumatically Injured Teeth
The prognosis of injured teeth is favorable if the vitality of the pulp can be main-
tained and this has been diagnosed by a normal response to cold sensibility testing
and electric pulp testing. The teeth which do not have a vital pulp response will need
endodontic treatment to prevent the spread of necrosis and subsequent damage to
surrounding dental tissues.
Orthodontic Movement of Traumatized Teeth
Traumatized teeth must be evaluated carefully to ensure the injuries have completely
healed and have radiographic evidence of healing prior to beginning or continuing
orthodontic movement. Teeth with an injured vital pulp which have orthodontic
treatment before healing is complete are more likely to develop pulp necrosis and
root resorption. Orthodontic forces on the roots of teeth are a common trigger for
root resorption [15]. Root resorption is most likely to occur in teeth with a damaged
cementum and/or periodontal ligament. A guide for all injured teeth with a vital pulp
is that a minimum of 3 months to a 1-year wait is recommended prior to beginning

or continuing the orthodontic movement of injured teeth. A 3-month wait is recom-
mended before the orthodontic movement of teeth with a vital pulp can begin after
an uncomplicated crown fracture, concussion, subluxation, and extrusion. A longer
wait is needed if the crown fracture was complicated by pulpal exposure. If the peri-
odontal ligaments have suffered moderate or severe trauma, a wait of 6 months is
recommended before orthodontic tooth movement can begin. Teeth which have sus-
tained root fracture should not begin or continue orthodontic tooth movement for
1 year. Teeth which have had endodontic root canal treatment, provided there is no
injury to the periodontal ligaments, can have orthodontic tooth movement if there is
radiographic evidence of healing. Injured teeth can have successful orthodontic
movement if light intermittent forces are applied without prolonged tipping forces
which force the root into the buccal or lingual cortical plates [16, 17].
Patient Home Care Instructions for Traumatically Injured Teeth
Following TDI, the goal is to make the patient comfortable and to accomplish heal-
ing of the injury by protecting it from further damage. The patient must avoid par-
ticipation in contact sports until healing is complete. For periodontal pain, ice or a
popsicle can be applied to the injured area for 20 min. The injury pain can be man-
aged by instructing the patient to use pain medication, such as acetaminophen,
Tylenol, ibuprofen, Advil, or Motrin as need for up to 7 days according to the label
instructions. To prevent pressure on the injured teeth, the patient should be instructed
to eat a soft-food diet for 3–14 days and to avoid putting chewing pressure on the
tooth for weeks following the injury. If the patient was given sutures to an oral
wound, spicy food, salty food, popcorn, and straws should be avoided to prevent
injury for a week. The patient should use a soft toothbrush for twice daily oral
cleaning. Then, the patient should use a chlorhexidine gluconate (CHX) rinse as a
mouthwash for 7 days to reduce the bacteria in the mouth and prevent tartar buildup.
The patient should be instructed to call the dental office for a dental visit if any of
the following occur:
1. Toothache worsens and becomes severe.

2. Teeth become more sensitive to hot or cold drinks and foods.
3. Teeth become a darker color.
Antibiotics and Tetanus
The overprescription of antibiotics should always be avoided to reduce the risk of

creating bacteria which have developed resistance to antibiotics. Most clinical stud-
ies have not demonstrated that antibiotics are beneficial to healing following
TDI. Nevertheless, systemic antibiotics such as amoxicillin, penicillin (Pen V), or
tetracycline for 1 week could be beneficial to reduce infection if the patient has an
unhealthy medical status and injuries that appear prone to infection. The placement
of topical anesthetics on sutured wounds, such as minocycline or doxycycline at
1 mg per 20 ml of saline for 5 min, can also be considered to help reduce the risk of
wound infection. Patients may need to have a tetanus booster if the injuries involve
dirt and soil or if the tetanus coverage of the patient is uncertain.
Root Resorption
Pressure or injury to the root surface from TDI, ectopic teeth erupting in the path of the
root, infection, excessive occlusal loading, tissue lesions, and tumors can cause root
resorption. The root resorption of permanent teeth is an inflammatory response which
causes the destructive breakdown and loss of the root structure. If root resorption is left
untreated, it will destroy the affected teeth. Root resorption is often a consequence of
replanting avulsed teeth which were not replanted quickly enough or from severe
TDI. Root resorption occurs because odontoclasts resorb the root surface cementum
and underlying root dentin. Early resorption can be seen in radiographs as microscopic
pits in the root surface and advanced resorption can devastate the whole root structure.
Severe root resorption is very difficult to treat and often requires the extraction of teeth.
The root resorption process caused by TDI should not be confused with the natural
process of deciduous root resorption which allows the exfoliation of the primary teeth
to make way for the permanent adult teeth. A common cause of root resorption is the
orthodontic forces applied to teeth. The key structure protecting the root from osteo-
clast resorption is healthy cementum. When the cementum is missing, injured, or com-
pressed, the loss of its protection can permit osteoclast root resorption.
Root resorption can be broadly classified into external or internal resorption by
the location of the resorption in relation to the root surface. Internal root resorption
is a relatively rare occurrence compared to external root resorption [18]. The accu-
rate classification of external or internal root resorption poses diagnostic concerns,
because it is often confused with external cervical resorption. The incorrect diagno-
sis of the type of root resorption might result in an inappropriate treatment plan
which does not cure the resorption. The two types of internal and external root
resorption according to the cause of resorption [19] can be remembered as:
Internal Root Resorption

The internal root resorption of teeth can occur because there is a:
1. Pulp infection and/or periradicular infection
External Root Resorption

The external root resorption of teeth can occur because there is:
2. Avulsed teeth that have been replanted. It is thought the stimulus for the resorp-
tion and ankylosis of the tooth is related to damage to the periodontal ligament
due to too long a time out of the mouth or lack of adequate storage before
replacement.
3. Tissue injury may also be caused by whitening/bleaching teeth.

4. Infection of the periodontal ligament causing an injury to the pericementum.
5. Orthodontic tooth movement causing tipping pressure on the roots of teeth or
root surface pressure caused by impacted teeth. This can occur because the teeth
are impacted or because they were laterally luxated, infractioned, or extruded
and have been repositioned in their socket, which has damaged the periodontal
ligament.
Differential Radiographic Diagnosis of Root Resorption
Two radiographs are needed to distinguish internal or external root resorption, the
first taken perpendicular to the tooth and the second taken mesial to the perpendicu-
lar on the same horizontal plane. This is the mesial buccal distal (MBD) rule, where
objects closer to the source of radiation will shift distally in relation to objects fur-
ther from the source. If the lesion is an external root resorption, the image will shift,
and the root canal system can be clearly seen in the films superimposed on the
external lesion. If the lesion is internal resorption, the lesion will not move in rela-
tion to the root canal system. In these cases, the root canal system will enlarge at the
site of the root resorption [20].
External resorption at the root apex will change the natural shape of the root,
making the apex appear shortened, blunted, or square, with a ragged or irregular
lesion appearance. The lesion can appear superimposed over the root end. An inter-
nal resorption lesion within the root canal system will appear as an enlarged area.
The margins of the internal lesion will be clearly defined, with a smooth regular
appearance. A resorptive lesion in the mid-root or near the crown will appear more
sharply defined compared to a carious lesion. In addition, all carious lesions prog-
ress from the outside in, and their margins are less clearly defined [21].
A case of replacement resorption courtesy of Dr. Sonia Chopra is shown in
Fig. 2.2.
Treatments for Root Resorption
The first step is to identify the source of the infection or injury lesion causing the
root resorption. Knowing the cause will lead to a diagnosis and it will also direct the
treatment, because the stimulus for resorption must always be removed to prevent
further root destruction. The use of internal tooth whitening/bleaching agents can
cause a chemical injury to the cervical tissues which stimulated resorption. Peroxide
is especially harmful after it has been heated to force it into the dentinal tubules. It
is safer to use the less toxic sodium perborate for internal tooth bleaching. A pulp
infection can trigger internal root resorption and also external root resorption, by
damaging the cementum and periodontal ligament tissues to the extent that they
have no protection from osteoclastic activity, leading to internal resorption or exter-
nal apical resorption. In these cases, a root canal treatment can disinfect the root
canal and remove the stimulus for root resorption. It is recommended to obdurate
Fig 2.2 Replacement resorption of a root canal-treated tooth following avulsion and replantation
the root canal with calcium hydroxide for 2 weeks to halt the resorptive process and
promote mineralization. A periodontal infection can cause external root resorption
due to an injury to the pericementum. In these cases, periodontal treatment includ-
ing scaling, root planing, and localized antibiotics can be used to remove the infec-
tion source and stop the root resorption. Pressure from orthodontic movement,
impacted teeth, or a tumor, cyst, or lesion can cause external root resorption.
Releasing the orthodontic pressure on the tooth, extracting the impacted teeth, and
removal of the tumor or lesion are necessary to stop the root resorption. External
root resorption in the cervical region of teeth can be treated by reflecting the gingi-
val tissues, disinfecting the resorptive lesion, and restoring the lesion with a tooth
repair material such as mineral trioxide aggregate (MTA) or Biodentine. Some root
resorptions can be so severe that the teeth cannot be saved and need to be extracted;
for this reason, early detection and immediate treatment for root resorption are
recommended.
Anesthesia
Pain Management for Trauma and Endodontics
Most patients fear that the treatment for a traumatized tooth and/or a root canal
treatment will be extremely painful. The patient’s fear and apprehension of experi-
encing intense pain could focus their attention to detecting pain, thereby lowering
Anesthesia 61
the pain threshold and making the pain sensation more difficult to block. A good
dentist or endodontist will always counter patient fears with patience, understand-
ing, and reassurance that every effort will be made to make the visit comfortable.
The ability to minimize patient discomfort depends largely upon the use of clinical
judgment and using effective analgesics when they are needed to accomplish pro-
found anesthesia. The minimization of pain requires good communication with the
patient; this involves following a checklist:
1. Some patients will ask not to have any anesthesia, but having patients suffer
through a root canal treatment with blocking the pain is not an acceptable stan-
dard of care.
2. Tell the patient to raise their arm to stop the treatment because they feel the pain.
When the patient signals to stop the treatment, respect their wish immediately.
Continue with treatment if the patient has become comfortable or after more
anesthetic has been effective to block the pain.
3. Relaxing the patient by gaining their trust and confidence. A phobic patient may
need to have general anesthesia and not be able to cope with local anesthesia.
Never plan a local anesthesia treatment for a patient whose behavior is likely to
prevent the completion of root canal treatment.
4. Avoid talking about “pain” too much, but do warn the patient that they will feel
a “sting,” before the injection of anesthesia, before placing the clamp to hold the
rubber dam in place, and prior to accessing the root canal.
5. Not commencing with treatment, until profound pulpal anesthesia has been con-
firmed by cold pulp testing or electric pulp testing. Lip numbness is not a good
indicator of anesthesia effectiveness.
6. Do not allow the patient to take the pain relief into their own hands through
drugs, alcohol, acupuncture, natural/herbal remedies, or meditation; the use of
experimental pain relief remedies is not an acceptable standard of care.
Local Anesthesia
A study of general dentists found that 13 % had experienced a failure of local anes-
thesia in the previous 5 days, causing 10 % of dental treatments to be abandoned
[22]. The most common technique to accomplish pulpal anesthesia prior to root
canal treatment is to use the inferior alveolar nerve block (IANB): the injection of
local anesthesia, 3.6 ml of 2 % lidocaine with 1:100,000 epinephrine or 4 % artic-
aine with 1:100,000 epinephrine into the mandibular lingula or foramen. There is no
statistical difference between the effectiveness of articaine or lidocaine to accom-
plish a successful IANB [23]. When local anesthesia fails, this can be managed
effectively by modifying the conventional IANB techniques to overcome anatomi-
cal problems such as variations in the location of the mandibular foramen [24] or the
use of “high” blocks such as the Gow-Gates [25] or Akinosi techniques [26, 27].
These latter methods also help to counter any accessory nerve supply from sources
such as the mylohyoid nerve which may not be anesthetized by standard approaches
[28]. In addition, there are also supplementary intraoral techniques available for
administering local anesthetics to provide pulpal anesthesia when conventional
infiltration and regional block methods prove unsatisfactory.
Inferior Alveolar Nerve Block
The inferior alveolar nerve block (IANB) is the most widely used technique for
blocking a pain signal from the hemi-mandible. It is routinely used in everyday
dental and endodontic practice. When the IANB is successful, it provides anesthesia
of a wide anatomical area. This includes all ipsilateral mandibular teeth and gingival
tissues and anterior two-thirds of the tongue and floor of mouth. The injection of
local anesthesia should be in the mandibular lingula or foramen. The needle of the
syringe should be level with the occlusal plane of the mandibular teeth. The expected
depth of needle penetration is 20–25 mm. Some patients with a tooth exhibiting
symptoms of irreversible pulpitis have found success (mild or no pain upon end-
odontic access or initial instrumentation) with the IANB alone between 19 and
56 % of the time [23]. Therefore, these studies would indicate that profound anes-
thesia is often difficult to achieve in a tooth with irreversible pulpitis using only the
IANB. The rare complications of the IANB are the risk of giving an intra-arterial
injection or causing nerve injury. Paresthesia is a very rare event, with only 14 cases
reported per 11 million injections [29].
Accomplishing Profound Local Anesthesia
Lip numbness is not a good guarantee that the pulp is anesthetized [30, 31]. A
patient’s failure to respond to having a sharp explorer touch to the tooth mucosa
can’t accurately be used to indentify an anesthetized pulp. Profound pulpal anes-
thesia must be confirmed using cold pulp sensibility testing followed by electric
pulp testing to confirm the cold test response. Lip numbness usually occurs
5–9 min after the anesthetic injection and pulpal anesthesia usually occurs
15–16 min after the anesthetic injection [30–32]. In the mandibular teeth of
19–27 % of patients, a slow onset of pulpal anesthesia may be observed taking
longer than 15 min; in 8 % of patients, the pulpal anesthesia may take more than
30 min [30–32].
Selecting Local Anesthesia by Type and Dose
A cartridge of either mepivacaine or prilocaine will be as effective as 2 % lidocaine

with epinephrine for pulpal anesthesia for 50–55 min [33]. Clinically, this is an
important finding because when medical conditions or drug therapies suggest cau-
tion in administering epinephrine-containing solutions, plain solutions can be used
as an alternative for the IANB. It is a mistake to assume that increasing the volume
Anesthesia 63
Table 2.3 Local anesthetics for adults

Duration of anesthesia
effectiveness to block pain
Total allowable in pulpal tissues (min)
Local anesthetic formulation dose (mg/kg) Mandible teeth Maxilla teeth
4 % articaine hydrochloride with 7 (500 mg) 90 60
epinephrine vasoconstrictor at 1:200,000
or 1:100,000
0.5 % bupivacaine hydrochloride with 1.3 (90 mg) 240 90
2 % lidocaine hydrochloride with 4.4 (300 mg) 85 60
or 1:100,000
3 % mepivacaine hydrochloride without 4.4 (300 mg) 40 25
epinephrine or vasoconstrictor
2 % mepivacaine hydrochloride with 4.4 (300 mg) 150 60
levonordefrin vasoconstrictor at 1:20,000
4 % prilocaine without a vasoconstrictor 6 (400 mg) 55 20
4 % prilocaine with epinephrine 6 (400 mg) 65 45
vasoconstrictor at 1:200,000
Please follow the label instructions for using anesthetics
of local anesthetic by using two cartridges of lidocaine [20, 21] and that increasing
the epinephrine concentration from 1:100,000 to 1:50,000 will provide more pro-
found pulpal anesthesia for a patient who reports pain upon treatment. Increasing
the volume of anesthetic by using two cartridges at a time, or repeating the IANB,
or increasing the epinephrine concentration does not help accomplish faster or more
profound anesthesia. Some dentists may believe the second injection is providing
additional anesthesia; however, in slow-onset anesthesia, the first injection is still
becoming more effective and the effectiveness of the second injection still has a
delay to become effective [32]. The common local anesthetics used to block pain in
pulpal tissues are shown in Table 2.3.
Injecting Local Anesthesia
Studies using ultrasound [34] or radiographs [35] to accurately locate the inferior
alveolar neurovascular bundle or mandibular foramen revealed accurate needle
location does not guarantee successful pulpal anesthesia. Even though profound lip
anesthesia is achieved, patients do not always achieve pulpal anesthesia, but it is
NOT the fault of the clinician for giving an inaccurate injection [36]. The orienta-
tion of the needle bevel (away or toward the mandibular ramus) for an IANB does
not affect anesthetic success or failure [37]. A slow IANB injection for 60 s causes
less injection pain and results in a higher success rate of pulpal anesthesia than a
rapid injection of 15 s [38].
Failure to Accomplish Pulpal Anesthesia
A failure to accomplish pulpal anesthesia occurs in approximately 17 % of first

molars, 11 % of first premolars, and 32 % of lateral incisors [36], even though all these
patients had profound lip numbness. Therefore, a failure of pulpal anesthesia is higher
in the incisor teeth than the molars and premolars. The failure to accomplish anesthe-
sia can be explained by the central core theory. The theory hypothesizes that the anes-
thetic solution may not diffuse into the nerve trunk to reach all nerves and produce an
adequate nerve block on the outside of the nerve bundle supplying the molar teeth and
on the inside of the nerve bundle supplying the incisor teeth [36, 39, 40].
Tips for Accomplishing Pulpal Anesthesia
After local anesthetic delivery, its effectiveness as a nerve block must be tested by
asking the patient if they have lip numbness. After the patient reports lip numbness,
a cold sensibility test or the electric pulp tester should be used on the tooth to be
treated to ensure it is not sensitive prior to beginning a clinical procedure [40]. The
electric pulp tester is more difficult to use than a cold sensibility test, but the cold
sensibility test may not always indicate pulpal anesthesia in teeth with irreversible
pulpitis [41]. If the patient has sensibility in the tooth to be treated after waiting
15 min, supplemental injections may be needed to achieve profound pulpal anesthe-
sia. A patient who has had a previous difficulty with anesthesia is more likely to
experience unsuccessful anesthesia [42]. It is a good clinical practice to ask the
patient if they have had previous difficulty achieving clinical anesthesia or have an
allergy to anesthetics. Some common reactions that can be misinterpreted as aller-
gies to anesthetics are syncope and tachycardia. If the nature of the reaction is
hypersensitivity related, such as rash, pruritus, urticaria, or dyspnea, then it can be
characterized as a true allergy. If the anesthetic causing the allergy to the patient is
known, select an alternative amide, free of vasopressor so that no sulfites are pres-
ent. Otherwise, refer the patient to an allergist, for testing of sulfites and exemplary
local anesthetics such as lidocaine, mepivacaine, and prilocaine [43]. If the patient
has had unsuccessful pain management experiences, supplemental injections should
be considered. A supplemental buccal infiltration with a cartridge of 4 % articaine
with 1:100,000 epinephrine after an IANB can significantly increase the success of
profound pulpal anesthesia by up to 88 % [44]. A supplemental buccal infiltration
of articaine following an IANB is only 58 % successful in accomplishing the pro-
found anesthesia of a tooth diagnosed with irreversible pulpitis [45]. An intraosse-
ous injection of local anesthetic solution directly into the cancellous bone adjacent
to the tooth to be anesthetized following DTI or as a supplement to the IANB can
provide a quick onset of profound pulpal anesthesia for up to 60 min [46–48]. The
intraligamentary injection of anesthetic to supplement the IANB is approximately
75 % successful. Reinjection of the periodontal ligament with anesthetic can
increase the ability of the anesthetics to accomplish short-term profound pulpal
anesthesia by up to 95 % [49]. The IANB and repeated supplemental injections of
anesthetic are still not able to accomplish profound pulpal anesthesia in
Tooth Whitening Procedures 65
approximately 5–10 % of mandibular posterior teeth with irreversible pulpitis. If

pain persists when the pulp is entered, an intrapulpal injection is initially painful,
but can be effective immediately if given under back pressure [50].
The routine anesthetic blocks for pulpal anesthesia prior to endodontic
treatment are:
1. Inferior alveolar nerve block (IANB)

2. High blocks: Gow-Gates and Akinosi techniques
3. Intraorbital nerve block
The supplemental anesthetic blocks for pulpal anesthesia prior to endodontic

treatment are:
1. Buccal infiltration
2. Intraosseous infiltration
3. Intraligamentary infiltration
4. Intrapulpal infiltration
Reversal of Local Anesthesia
Patients often report that the soft tissue anesthesia which lingers 3–5 h after the
IANB is uncomfortable and children often risk inadvertently biting their lips,
tongue, and cheeks. Phentolamine mesylate (PM) accelerates the clearance of local
anesthetic and accelerates the recovery from soft tissue anesthesia. A study of PM
in children after 2 % lidocaine with 1:100,000 epinephrine found that it increased
their tongue sensory recovery time by 60 % to 60 min compared to 135 min for
children who had no PM [51]. A disadvantage of PM is that it is expensive and so
may be most advantageous for special needs patients who are at highest risk for
posttreatment lip and tongue injuries.
Tooth Whitening Procedures
Causes of Tooth Discoloration
The causes of tooth discoloration are:
1. Pulpal hemorrhage into the dentinal tubules as a result of trauma, direct pulp
capping, or partial pulpotomy. It is advisable to irrigate the root canal often dur-
ing treatment.
2. Materials, medications, and sealers. Materials should match the esthetics of
teeth, such as using white MTA rather than gray MTA. Some medications and
antibiotics, such as minocycline and tetracycline, can stain teeth. Some endodon-
tic sealers can also discolor teeth. It is recommended to check the label of the
materials for their ability to discolor teeth prior to use.
3. Inaccessible pulp horns can harbor necrotic remnants which can discolor teeth.
To prevent this problem from occurring, the pulp horns must be included in the
access preparation.
4. Staining foods and tobacco can penetrate cracks or craze lines after prolonged use.
Good oral hygiene and regular prophylaxis are needed to prevent discoloration.
5. Fluorosis.
Whitening or Bleaching Teeth Without a Pulp
The old term for whitening teeth was bleaching; today, more dentists are using the
term whitening. It is recommended to slightly over-whiten or overbleach the tooth,
since it will darken over time. All the endodontic whitening techniques are based on
the use of oxidizing agents that release oxygen. Superoxol—a 30 % solution of
hydrogen peroxide—and powdered sodium perborate are the most readily available
oxidizing agents. They can be used independently or in combination. Teeth should
not be whitened if they have:
1. Structural defects, such as cracks, fractures, hypoplasia, or grossly undermined

enamel
2. Insufficient tooth structure to retain a permanent restoration
3. Require a porcelain crown restoration in the near future
4. Poorly condensed gutta-percha, silver points, or paste sealers because the whit-
ening agent can leak through the root canal into the periapical tissue
The techniques which can be considered are the following:
1. Walking bleach technique is so called because the bleaching takes place between
appointments 3–7 days apart. The root canal is cleaned and dried with chloro-
form or xylene to well below the gingiva. The chamber is then filled with a thick
mix of sodium perborate and superoxol and sealed with a pledget of cotton and
Cavit.
2. Thermocatalytic procedures use a variety of heat sources to release the oxygen
from the 305 hydrogen peroxide.
3. Vital bleaching for endemic fluorosis uses a mixture of hydrochloric acid, hydro-
gen peroxide, and ether for a light reduction of the superficial stained enamel.
Summary of Dental Traumatic Injuries, Antibiotics, and

Anesthetics
A patient with a dental traumatic injury must be given immediate treatment and the
type of injury be determined by a differential diagnosis to ensure the tooth is given
the most appropriate treatment. Avulsed teeth must always be cleaned and be re-
implanted immediately back into the tooth socket. Waiting to reach a dental office
for the dentist to replant an avulsed tooth could condemn the replantation of the
tooth to fail. Local anesthetics are used to create nerve blocks to relieve the pain
from traumatic dental injuries. Teeth moved by extrusion, intrusion, or lateral luxa-
tion need to be placed back into their original position and be splinted to adjacent
teeth. The over-prescription of antibiotics should be avoided, and most clinical stud-
ies have failed to demonstrate any healing benefits of antibiotics for dental trau-
matic injury, nevertheless systemic antibiotics could reduce the risk of an infection.
Patients who had a traumatically injured tooth should be recalled if the tooth changes
color, becomes painful, or has soft tissue swelling.
1. Dental traumatic injuries are caused by sudden impact forces to teeth?

(a) False
(b) True
2. A patient with a dental traumatic injury should be given an immediate appoint-
ment to relieve the pain, get a complete dental exam, and be provided with
evidence-based treatment to save the tooth?
(a) False
(b) True
3. If someone telephones seeking advice about an avulsed tooth, they should be
told to wash it and replant it into its socket immediately?
(a) False
(b) True
4. An avulsed tooth has been completely removed from its socket?
(a) False
(b) True
5. The movement of several teeth as a unit indicates an alveolar fracture?
(a) False
(b) True
6. The movement of a single tooth and a fracture seen in a radiograph is charac-
teristic of a root fracture?
(a) False
(b) True
7. If a single tooth has abnormal movement but no fracture, it can indicate the
tooth has had an extrusion?
(a) False
(b) True
8. A tooth in an abnormal position because of protrustion or retrusion has suffered
from lateral luxation?
(a) False
(b) True
9. A tooth in an abnormal position by intrusion out of its socket into the alveolar
bone has suffered from intrusion?
(a) False
(b) True
10. A loose tooth which is not displaced has suffered from subluxation?
(a) False
(b) True
11. A tooth which has not been displaced, but is not loose, and has percussion
tenderness has suffered from concussion?
(a) False
(b) True
12. A tooth which has not been displaced, is not loose, has no percussion tender-
ness, and has a fracture above the gingiva with an exposed dental pulp has suf-
fered a complicated crown fracture?
(a) False
(b) True
13. A tooth which has not been displaced, is not loose, has no percussion tender-
ness, and has a fracture above the gingiva which has not exposed the dental pulp
has suffered an uncomplicated crown fracture?
(a) False
(b) True
14. A tooth with a minimal loss of tooth structure has suffered an infraction?
(a) False
(b) True
15. A tooth with no discernable signs of trauma likely has no injury?
(a) False
(b) True
16. A tooth diagnosed with concussion, does not need endodontic treatment unless
the pulp becomes painful or diagnosed as being necrotic or having irreversible
pulpitis?
(a) False
(b) True
17. Teeth moved by extrusion, intrusion, or lateral luxation need to be placed back
into their original position and be splinted to adjacent teeth?
(a) False
(b) True
18. Local anesthetics can be used to create nerve blocks to relieve the pain from
traumatic dental injuries?
(a) False
(b) True
19. The over-prescription of antibiotics should be avoided, and most clinical stud-
ies have failed to demonstrate any healing benefits of antibiotics for dental trau-
matic injury, nevertheless systemic antibiotics could reduce the risk of an
infection?
(a) False
(b) True
Bibliography 69
20. Patients who had a traumatically injured tooth should be recalled if the tooth
changes color, becomes painful, or has soft tissue swelling?
(a) False
(b) True
(The correct quiz answers are all (b). True)
Bibliography
1. Glendor U. Epidemiology of traumatic dental injuries – a 12 year review of the literature. Dent
Traumatol. 2008;24:603–11.
2. Andreasen JO, Andreasen FM, Andersson L. Textbook and color atlas of traumatic injuries to
the teeth. 4th ed. Oxford: Wiley-Blackwell; 2007.
3. Kramer PF, Zembruski C, Ferreira SH, Fedens CA. Traumatic dental injuries in Brazilian
preschool children. Dent Traumatol. 2003;19:299–303.
4. Fleury A, Regan JD. Endodontic diagnosis: clinical aspects. J Ir Dent Assoc. 2006;52:28–38.
5. Frank A, Simon JHS, Abou-Rass M, Glick DH. Clinical and surgical endodontics. Concepts in
practice. Philadelphia: J.B. Lippincott; 1983.
6. Andreasen FM, Andreasen JO. Diagnosis of luxation injuries: the importance of standardized
clinical, radiographic and photographic techniques in clinical investigations. Endod Dent
Traumatol. 1985;5:160–9.
7. Bakland LK, Andreasen JO. Examination of the dentally traumatized patient. J Calif Dent
Assoc. 1996;24:35–44.
8. Andreasen FM, Andreasen JO, Tsukiboshi M. Examination and diagnosis of dental injuries.
In: Andreasen JO, Andreasen FM, Andersson L, editors. Textbook and color atlas of traumatic
injuries to the teeth. 4th ed. Oxford: Blackwell; 2007. p. 255–79.
9. Flores M, Andersson L, Andreasen J, et al. Guidelines for the management of traumatic dental
injuries. I. Fractures and luxations of permanent teeth. Dent Traumatol. 2007;23:66–71.
10. Flores M, Andersson L, Andreasen J, et al. Guidelines for the management of traumatic dental
injuries. II. Avulsion of permanent teeth. Dent Traumatol. 2007;23:130–6.
11. Flores M, Malmgren B, Andersson L, et al. Guidelines for the management of traumatic dental
injuries. III. Primary teeth. Dent Traumatol. 2007;23:196–202.
12. American Academy of Pediatric Dentistry. Guideline on management of acute dental trauma.
http://www.aapd.org/media/Policies_Guidelines/G_Trauma.pdf.
13. Andreasen JO. Dental Trauma Guide website: http://www.dentaltraumaguide.org/Examination.
aspx.
14. Andreasen JO, Hjorting-Hansen E. Replantation of teeth. I. Radiographic and clinical study of
110 human teeth replanted after accidental loss. Acta Odontol Scand. 1966;24:263–86.
15. Topkara A, Karaman AI, Kau CH. Apical root resorption caused by orthodontic forces: a brief
review and a long-term observation. Eur J Dent. 2012;6:445–53.
16. Malmgren O, Malmgren B. Orthodontic management of the traumatized dentition. In:
Andreasen J, Andreasen F, Andersson L, editors. Textbook and color atlas of traumatic injuries
to the teeth. 4th ed. Ames: Blackwell Munksgaard; 2007. p. 669–716.
17. Duggan D, Quinn F, O’Sullivan M. A long-term follow up of spontaneously healed root frac-
tures later subjected to orthodontic forces – two case reports. Dent Traumatol. 2008;24:231–4.
18. Patel S, Ricucci D, Durak C, Tay F. Internal root resorption: a review. J Endod. 2010;36:1107–21.
19. Tronstad L. Root resorption–etiology, terminology and clinical manifestations. Endod Dent
Traumatol. 1988;4:241–52.
20. Toto PD, Restarski JS. The histogenesis of pulpal odontoclasts. Oral Surg Oral Med Oral
Pathol. 1967;16:172–8.
21. Gartner AH, Mack T, Somerlott RG, Walsh LC. Differential diagnosis of internal and external
root resorption. J Endod. 1976;2:329–34.
22. Kaufman E, Weinstein P, Milgrom P. Difficulties in achieving local anesthesia. J Am Dent
Assoc. 1984;108:205–8.
23. Claffey E, Reader A, Nusstein J, Beck M, Weaver J. Anesthetic efficacy of articaine for infe-
rior alveolar nerve blocks in patients with irreversible pulpitis. J Endod. 2004;30:568–71.
24. Afsar A, Haas DA, Rossouw PE, Wood RE. Radiographic localization of mandibular anesthe-
sia landmarks. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 1998;86:234–41.
25. Gow-Gates GA. Mandibular conduction anesthesia: a new technique using extraoral land-
marks. Oral Surg Oral Med Oral Pathol. 1973;36:321–8.
26. Akinosi JO. A new approach to the mandibular nerve block. Br J Oral Surg. 1977;15:83–7.
27. Meechan JG. Supplementary routes to local anaesthesia. Int Endod J. 2002;35:885–96.
28. Heasman PA, Beynon AD. The role of the mylohyoid nerve in mandibular tooth innervation.
J Dent. 1986;14:80–1.
29. Haas DA, Lennon DA. 21-year retrospective study of reports of paresthesia following local
anesthetic administration. J Can Dent Assoc. 1995;61:319–20.
30. Vreeland D, Reader A, Beck M, Meyers W, Weaver J. An evaluation of volumes and concen-
trations of lidocaine in human inferior alveolar nerve block. J Endod. 1989;15:6–12.
31. Hinkley S, Reader A, Beck M, Meyers W. An evaluation of 4 % prilocaine with 1:200,000
epinephrine and 2 % mepivacaine with levonordefrin compared to 2 % lidocaine with
1:100,000 epinephrine for inferior alveolar nerve block. Anesth Prog. 1991;38:84–9.
32. Nusstein J, Reader A, Beck M. Anesthetic efficacy of different volumes of lidocaine with
epinephrine for inferior alveolar nerve blocks. Gen Dent. 2002;50:372–5.
33. McLean C, Reader A, Beck M, Meyers WJ. An evaluation of 4 % prilocaine and 3 % mepiva-
caine compared to 2 % lidocaine (1:100,000 epinephrine) for inferior alveolar nerve block.
J Endod. 1993;19:146–50.
34. Hannan L, Reader A, Nist R, Beck M, Meyers WJ. The use of ultrasound for guiding needle
placement for inferior alveolar nerve blocks. Oral Surg Oral Med Oral Pathol Oral Radiol
Endod. 1999;87:658–65.
35. Berns JM, Sadove MS. Mandibular block injection: a method of study using an injected radi-
opaque material. J Am Dent Assoc. 1962;65:736–45.
36. American Association of Endodontists. Taking the pain out of restorative dentistry and end-
odontics: Current thoughts and treatment options to help patients achieve profound anesthesia.
Chicago: Winter; 2009.
37. Steinkruger G, Nusstein J, Reader A, Beck M, Weaver J. The significance of needle bevel
orientation in achieving a successful inferior alveolar nerve block. J Am Dent Assoc.
2006;137:1685–91.
38. Kanaa MD, Meechan JG, Corbett IP, Whitworth JM. Speed of injection influences efficacy of
inferior alveolar nerve blocks: a double-blind randomized controlled trial in volunteers.
J Endod. 2006;32:919–23.
39. Strichartz G. Molecular mechanisms of nerve block by local anesthetics. Anesthesiology.
1976;45:421–44.
40. Dreven L, Reader A, Beck M, Meyers W, Weaver J. An evaluation of the electric pulp tester as
a measure of analgesia in human vital teeth. J Endod. 1987;13:233–8.
41. Nusstein J, Reader A, Nist R, Beck M, Meyers WJ. Anesthetic efficacy of the supplemental
intraosseous injection of 2 % lidocaine with 1:100,000 epinephrine in irreversible pulpitis.
J Endod. 1998;24:487–91.
42. Milgrom P, Weinstein P, Kaufman E. Student difficulties in achieving local anesthesia. J Dent
Educ. 1984;48:168–70.
43. deShazo RD, Kemp SF. Allergic reactions to drugs and biologic agents. JAMA. 1997;278:
1895–906.
Bibliography 71
44. Haase A, Reader A, Nusstein J, Beck M, Drum M. Comparing anesthetic efficacy of articaine
versus lidocaine as a supplemental buccal infiltration of the mandibular first molar after an
inferior alveolar nerve block. J Am Dent Assoc. 2008;139:1228–35.
45. Matthews R, Drum M, Reader A, Nusstein J, Beck M. Articaine for supplemental buccal man-
dibular infiltration anesthesia in patients with irreversible pulpitis when the inferior alveolar
nerve block fails. J Endod. 2009;35:343–6.
46. Dunbar D, Reader A, Nist R, Beck M, Meyers W. Anesthetic efficacy of the intraosseous injec-
tion after an inferior alveolar nerve block. J Endod. 1996;22:481–6.
47. Guglielmo A, Reader A, Nist R, Beck M, Weaver J. Anesthetic efficacy and heart rate effects
of the supplemental intraosseous injection of 2 % mepivacaine with 1:20,000 levonordefrin.
Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 1999;87:284–93.
48. Stabile P, Reader A, Gallatin E, Beck M, Weaver J. Anesthetic efficacy and heart rate effects
of the intraosseous injection of 1.5 % etidocaine (1:200,000 epinephrine) after an inferior
alveolar nerve block. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2000;89:407–11.
49. Walton R, Abbott B. Periodontal ligament injection: a clinical evaluation. J Am Dent Assoc.
1981;103:571–5.
50. VanGheluwe J, Walton R. Intrapulpal injection—factors related to effectiveness. Oral Surg
Oral Med Oral Pathol Oral Radiol Endod. 1997;19:38–40.
51. Tavares M, Goodson JM, Studen-Pavlovich D, Yagiela JA, Navalta LA, Rogy S, Rutherford B,
Gordon S, Papas AS, Soft Tissue Anesthesia Reversal Group. Reversal of soft-tissue local anes-
thesia with phentolamine mesylate in pediatric patients. J Am Dent Assoc. 2008;139:1095–104.
Erratum in J Am Dent Assoc. 2008;139:1312.
Treatments for Traumatized
and Diseased Immature Teeth: 3
Pulpotomy, Cvek Partial Pulpotomy,
Apexification, Apexogenesis,
and Regenerative Endodontics
Saving Traumatized and Diseased Immature Teeth
Adults who have root canal treatments to save fully mature permanent teeth with a
diseased necrotic or irreversibly injured pulp can benefit from a success rate of over
90 % over 10 years [1]. Younger aged patients with developing immature permanent
teeth present special problems to save their teeth following dental traumatic injury
(DTI) or caries decay. The DTI of children’s immature teeth damages the pulp; in
the case of luxation injuries, the trauma can rupture the neurovascular supply at the
level of the apical foramen, whereas in a root fracture, the rupture can occur at the
level of the fracture [2]. A disruption to the blood supply to teeth can cause tissue
asphyxia, which will lead to necrosis and a loss of pulp vitality [3]. The traumatized
pulp can suffer irreversible pulpitis, which will eventually lead to liquefaction
necrosis [4]. After the pulp loses its vitality, the normal development of the teeth is
stopped [5]. The immature teeth can have very thin fragile dentinal walls making
them prone to fracture [6] after a conventional root canal treatment. The endodontic
treatments for traumatized and immature teeth with a necrotic pulp can vary. Some
dentists remove the necrotic tissues and obturate the root canal with gutta-percha
(rubber) [7], composite resin, or mineral trioxide aggregate (MTA) [8]. The problem
with all these obturation procedures is that they can halt the growth of the tooth at
an immature stage of root development.
Diagnosing the Health of the Pulp in Traumatized

and Diseased Teeth
Lack of toothache pain is not always a good indicator for pulp vitality in traumatized
teeth. Pulp necrosis can be non-painful, whereas irreversible pulpitis can be associ-
ated with episodes of lingering toothache pain in response to hot or cold drinks and
food, or even asymptomatic pain [9]. Teeth with a necrotic pulp are nonresponsive

DOI 10.1007/978-3-662-43730-8_3
74 3 Treatments for Traumatized and Diseased Immature Teeth
to cold and electric pulp sensibility testing. Teeth with irreversible pulpitis will have
a greater lingering pain in response to cold sensibility testing and electric pulp sen-
sibility testing compared to adjacent and contralateral teeth. Sometimes the results
of the cold and electric pulp sensibility tests are difficult to interpret for diagnosing
pulp vitality because there can be varying degrees of necrosis and inflammation
within the teeth with multiple canals [10]. The interpretation of the pulp vitality or
necrosis and pulpitis should include the SOAP framework [11]: subjective informa-
tion, objective information, assessment, and a plan for treatment.
Treatments for Traumatic Injuries and Caries Decay

to Immature Teeth
Endodontic treatments for traumatized immature permanent teeth with an exposed

pulp can vary considerably among dentists. Periradicular inflammation and pulpitis
following trauma can initiate the resorption of dentin and bone. Normally, an intact
tooth is resistant to resorption, even if pulpitis and periradicular inflammation are
present. However, when an injury damages the protective layer of cementum, pulpi-
tis, or periodontium, it can allow root resorption to occur [12]. Resorption of the
dentin surface by dentinoclast activity from the center to the periphery can occur.
Most of these cases are asymptomatic, but over the long term, pink spots can be
observed where advanced internal resorption has taken place. To prevent resorption
and spread of necrosis and infection, some dentists will debride the necrotic pulp or
tissues with irreversible pulpitis and obturate the root canal with gutta-percha [7],
similar to the conventional treatment provided to fully mature adult teeth, whereas
other dentists will obdurate the root canals with composite resin, calcium hydroxide
[13], or mineral trioxide aggregate (MTA) [14]. These procedures can be successful
to save immature teeth with thick dentin walls and with low levels of necrosis or
infection, because these teeth do not need continued mineralization or disinfection
for their survival. Most immature teeth with a necrotic pulp or irreversible pulpitis
will benefit from stimulating mineralization within the apical root canal to close the
apex and to help disinfect the root canal with calcium hydroxide and/or MTA using
an apexification procedure [15–22]. The apexification procedure is the most com-
mon and highest standard of care for immature teeth with a necrotic pulp or irrevers-
ible pulpitis. However, the development of the teeth will cease at an immature stage
of development; thus weak dentinal walls and short roots will remain. For teeth with
very thin dentinal walls which are likely to fracture and need strengthening, a revas-
cularization procedure can be used to disinfect the root canal with antibiotics and
revitalize new tissue formation [22–33]. The revascularization procedure is so
called because it accomplishes tissue formation within the root canal by blood
revascularization from the periapical tissues through the open apex. Alternatively,
the necrotic and irreversible pulpitis tissues can be debrided, the root canal disin-
fected, and a scaffold placed inside the root canal to promote tissue formation in a
regenerative endodontic procedure [34–37]. The new tissue formation can miner-
alize the dentin and continue root development and maturation. The continued
Endodontic Terminology for Treatments for Immature Teeth 75
Traumatized
or diseased Provide root canal
immature No treatment and trauma care
permanent as needed
tooth with
open apex Is injury or
disease limited Yes Cvek partial pulpotomy
Yes to superficial
coronal pulp
No Apexogenesis
Vital
Yes pulp Root canal
No walls are thick Yes Apexification
enough to
withstand No
fracture Yes Revascularization
Multi-visit
root canal
disinfection Regenerative
with No endodontics
antibiotics
Fig. 3.1 Flow chart of treatments for traumatized or diseased immature teeth
formation of dentin and development of the roots in weak immature teeth should
help prevent the loss of these teeth to subsequent fracture. Very few endodontic
revascularization procedures have been performed on severely traumatized teeth
where resorption is expected. It is not yet clear if MTA apexification is more benefi-
cial for severely injured teeth than a regenerative endodontic procedure.
Traumatized or caries-affected immature teeth with a vital pulp which does not
have irreversible pulpitis or necrosis can continue their root development and den-
tinal wall thickening after the removal of damaged coronal pulp tissue in a proce-
dure known as apexogenesis [38, 39] or where 2 mm of coronal pulp tissue is
removed in a Cvek partial pulpotomy procedure [40–43].
A flow chart of the suggested protocols for endodontic regeneration treatments
according to the status of the pulp and the need to save the teeth are shown in
Fig. 3.1.
Endodontic Terminology for Treatments for Immature Teeth
The terminologies for the endodontic treatments for immature teeth are:
Necrotic pulp—Death of the cells of the dental pulp.

Irreversible pulpitis—Chronic inflammation of the dental pulp which cannot be
reversed to heal the damaged tissues, thus the prognosis is that the pulp will
become necrotic.
Apexogenesis—A vital pulp procedure which debrides the coronal injured pulp
from a root canal. The removal of the superficial injured pulp will allow the
remaining vital pulp to continue the maturation and physiological development
of the roots.
Cvek partial pulpotomy—A vital pulp procedure which debrides 2 mm of coronal

injured pulp from a root canal. The removal of the superficial injured pulp will
allow the remaining vital pulp to continue the maturation and physiological
development of the roots.
Apexification—A necrotic pulp and irreversible pulpitis procedure which debrides,
disinfects, and obturates the root canal of immature teeth. The obturation of the
root canal with calcium hydroxide or mineral trioxide aggregate (MTA) will
induce a calcified barrier to help save the tooth.
Revascularization—A necrotic pulp and irreversible pulpitis procedure which dis-
infects the root canal with antibiotics or/and antimicrobial agents. The periapical
tissues are instrumented through the open root apical foramen to cause bleeding
into the canal to revascularize it, thereby promoting tissue formation within the
root canal for the continued deposition of mineral to strengthen dentin and grow
the roots of immature teeth.
Regenerative endodontics—A necrotic pulp and irreversible pulpitis procedure
which debrides the tissues from the root canal, disinfects the root canal, and
instruments the periapical tissues through the open root apical foramen to cause
bleeding into the canal to revascularize it. In addition to adding a scaffold or
biological procedure within the root canal to promote vital tissue formation
which will continue the deposition of mineral to strengthen dentin and grow the
roots of immature teeth.
Root canal treatment—A necrotic pulp and irreversible pulpitis procedure for
mature teeth which debrides the tissues and disinfects the root canal by cleaning
and shaping.
Apex Size and Stage of Tooth Maturity
When the pulps of fully mature adult teeth with a closed apex become traumatized
and necrotic or have irreversible pulpitis, their debridement followed by root canal
obturation with gutta-percha is an extremely successful procedure [1]. In immature
teeth with an open apex, the apexification procedure removes the necrotic pulp,
which is often successful in alleviating toothache pain and for preventing the spread
of necrosis and infection into periapical tissues [15–22]. Nonsurgical endodontic
treatment is not ideal, because instrumentation could further weaken the thin walls
of immature teeth and make them more prone to fracture. Traumatized immature
teeth with a necrotic pulp could benefit from revascularization [22–33] and regen-
erative endodontic procedures [34–37], whereas traumatized immature teeth with a
mostly vital pulp could benefit from Cvek partial pulpotomy [40–43] and apexogen-
esis [34, 36–40] to promote the continued maturation and root development of the
teeth. The size of the root apical foramen is a critical factor to consider when decid-
ing which endodontic procedure will be the most beneficial to save the tooth. In
teeth that are almost fully mature, a small apical foramen will limit blood flow into
the root canal. Teeth with a restricted blood flow are not likely to revascularize and
regenerate, because it is not sufficient for new tissue development inside the root
Age, Health Status, and Compliance of Patients 77
canal. It has been found that an apical foramen diameter of 1.1 mm or wider is
needed to successfully accomplish revascularization of tissues within the root canal
space [44]. The formation of tissues inside the root canal following revasculariza-
tion is believed to occur by the delivery of mesenchymal stem cells [45] which form
new vital tissues. If the apical foramen is less than 1.1 mm, it is not recommended
to attempt root canal revascularization or pulp regenerative endodontic procedures.
It is also not recommended to attempt to instrument the apical foramen to make it
wider for the purpose of revascularization or regeneration, since this could weaken
the roots of the immature teeth and make them more susceptible to fracture.
Age, Health Status, and Compliance of Patients
The endodontic treatments for immature teeth with vital pulps and necrotic pulps
have been mostly limited to children and adolescents, between the ages of 6 and 17
years. There have been some patients who were 44 years of age at the time of pulp
revascularization [46]. After 18 years of age, all the teeth of patients, except third
molars, can be expected to be fully mature with long roots, thick dentinal walls, and
a closed apical foramen. In some rare instances, the teeth in older aged patients can
still have a wide-open apical foramen because of developmental anomalies or because
of past trauma or a caries infection which halted the development of the teeth.
Regenerative endodontic procedures should never be used to preserve deciduous
(baby) teeth. If deciduous teeth become traumatized or injured, they should be
maintained by restoration. If restoration is not a suitable treatment, the deciduous
teeth should be extracted. The reason for not using regenerative procedures to pre-
serve deciduous teeth is because of the risk of retaining these teeth and disrupting
the eruption of the permanent adult teeth. Given these age restrictions, it is not
advisable to deliver regenerative endodontic procedures to patients younger than 8
years or older than 16 years of age.
There have been no studies of patients who had genetic diseases, severe medical
conditions, or a compromised immune system, which could impair the dental revas-
cularization and regeneration responses. Until evidence becomes available, it can be
assumed that patients who have a compromised ability to heal will not be good
candidates for regenerative endodontic procedures. This is because the success of
regenerative endodontic procedures is dependent on the ability of the tissues to heal
in the root canal [34]. If the ability of patients to heal is doubtful because of their
medical history, endodontic procedures which do not rely on regeneration should be
provided, such as apexification instead of regenerative endodontics to save trauma-
tized or caries-affected teeth.
A retrospective study of 30 endodontic regeneration cases found only two cases
(6.7 %) with minor complications restricted to discomfort or discoloration. The
complications were minor and restricted to discomfort or discoloration [48].
However, there have been cases were regenerative endodontic treatments have
failed, and the teeth had to be saved using an apexification procedure. The reasons
why some cases have failed are still under investigation, but patient compliance is a
factor. There have been some patients where the regenerative endodontic procedure
Patient does
Patient
not have a Compliant
aged 7 to
systemic patient
17 years
disease
Tooth not
avulsed and Immature Not
replanted within necrotic primary
30 minutes tooth tooth
Regenerative
Normal endodontic
No crown-
mobility and proceedures
root fracture
is restorable may be
considered
Fig. 3.2 Case selection criteria for regenerative endodontic procedures
was initiated but was not completed because the patients failed to attend recall visits
to complete the treatment. If a patient has a poor record of attending appointments,
it is not recommended in the delivery of a multiple-appointment endodontic treat-
ment which is unlikely to be completed, because the patient will fail to return to
complete the treatment.
The degree of trauma and extent of caries decay must be checked prior to initiat-
ing endodontic treatment that the tooth damage is within restorable limits to use a
crown or dental materials to restore the tooth. Some complicated crown fractures
and root fractures may be restorable using revascularization and regenerative thera-
pies. However, if the fracture is complicated and involves the crown and root, that
tooth is not acceptable for revascularization and regenerative therapies because of
the high risk of microleakage through the fracture. If the tooth has greater than nor-
mal mobility, the damage to the tooth-supporting structures may cause the tooth to
be lost. Revascularization and regenerative therapies should only be delivered to the
teeth which have a healthy periodontal ligament to retain the tooth. A summary of
the patient and case selection criteria that need to be considered prior to delivering
endodontic therapies are shown in Fig. 3.2.
Root Canal Disinfection
Sodium hypochlorite is the most commonly used endodontic disinfectant and irri-
gating solution [48]. Sodium hypochlorite is highly toxic, and it can kill dental pulp
stem cells and prevent them from attaching to the surfaces of root canals [49].
Endodontic Sealers in Contact with Vital Pulp and Tissues 79
The survival of stem cells within the root canals is an essential step to accomplish
tissue regeneration; if the cells are destroyed by a toxic root canal environment, they
will not form tissues. In addition, because of the wide-open apical foramen, there is
no barrier to prevent sodium hypochlorite from leaking out from the root canal
space and injuring the periapical tissues. To reduce the level of intracanal toxicity to
optimize cell vitality and risk of harm to patients by sodium hypochlorite leakage,
sodium hypochlorite must be diluted for use as an endodontic irrigant in the root
canals of immature teeth; spillage of the sodium hypochlorite will then cause less
injury. Sodium thiosulfate can be used to help neutralize the toxicity of sodium
hypochlorite within root canals and reduce any lingering toxicity. Some alternative
endodontic irrigating solutions have been developed for reduced toxicity; these
include Aquatine EC and noni juice. Alternative irrigating solutions to sodium
hypochlorite have not proved popular because of their high cost and lack of evi-
dence for their effectiveness. At the present time, it is recommended to dilute the
sodium hypochlorite to 1.25 % for use in regenerative procedures in vital teeth with
a wide-open apical foramen.
Dental Materials in Contact with Vital Pulp and Tissues
The regeneration of tissues is sensitive to the environmental conditions within the

root canal. The intracanal environment must be sufficiently biocompatible to allow
cell survival, cell attachment [49], and new tissue formation. Adhesives, condition-
ing agents, and acids are toxic to vital tissues and must never be allowed to be in
contact with vital pulp, because they can cause tissue necrosis [50]. Most restorative
dental biomaterials are not formulated for direct contact with pulp tissues, blood
clots, or developing vital tissues. Consequently, restorative dental biomaterials
should only be used to restore teeth after a thin protective liner of mineral trioxide
aggregate (MTA), Biodentine, or calcium hydroxide [51] has been placed in contact
with the coronal pulp tissue, root canal blood clot, or regenerating tissues. The
placement of MTA will also help prevent the microleakage of bacteria into the root
canal. The presence of intracanal bacteria can cause necrosis of pulp tissue and
treatment failure.
Endodontic Sealers in Contact with Vital Pulp and Tissues
Endodontic sealers are needed to obturate root canals after cleaning and shaping to
prevent the microleakage of bacteria through the root canal system. Endodontic
sealers must never be used as part of regenerative endodontic procedures because
they are highly toxic to cells [52] and were never formulated to be biocompatible to
soft tissues. The toxicity of endodontic sealers will impede cell survival and tissue
regeneration in the root canals and is not suitable to be used in conjunction with
regenerative endodontic procedures.
Apexogenesis and Cvek Partial Pulpotomy
Apexogenesis and Cvek partial pulpotomy procedures are similar and so are dis-
cussed together. The continued root maturation and development of the teeth fol-
lowing superficial coronal trauma, where the pulps are still vital, are suitable
candidates for a Cvek partial pulpotomy procedure [40–43]; if the degree of pulp
injury exceeds 2 mm from the pulp horn, an apexogenesis procedure [38, 39] is
more suitable. Both these procedures remove the coronal pulp to prevent pulpitis
and injury from spreading and affecting the whole pulp. Most of the pulp and root
canal surface are not touched as part of these procedures, because the intention is to
allow the natural maturation and development of the tooth using the remaining vital
pulp tissues. Prior to MTA becoming available, calcium hydroxide powder was used
to fill the root canal space, and some dentists still use calcium hydroxide mainly
because it is less expensive. The space formerly occupied by the injured or diseased
pulp tissue is obturated with MTA or a similar biocompatible material. The steps to
accomplish apexogenesis and Cvek partial pulpotomy are shown in Table 3.1
Table 3.1 Steps to accomplish apexogenesis and Cvek partial pulpotomy

Case selection for root revascularization treatment
1 The traumatized or caries-infected teeth must have a vital pulp that responds normally to
cold sensibility testing and is not suitable for other endodontic treatments
2 The tooth must have thin walls that will benefit from a continued development of the root,
so that it can become stronger and less prone to failure in later life
3 The patient must be aged 7–16 years and have parents/guardians willing to take them to
attend multiple appointments
First treatment visit
4 Check the patient’s health history and that they are healthy enough for endodontic
treatment
5 Take a pretreatment radiograph and conduct a radiographic examination of the tooth and
surrounding tissues
6 Check for swelling and lesions. Probe around the tooth margins to locate defects or tracks;
if any are identified, they must be restored to seal access to the root canals
7 Check tooth sensibility using cold sensibility testing and electric pulp testing. If the tooth
has abnormal sensibility and is injured, the treatment plan will have to change to an
apexification. If the tooth responds normally to sensibility testing indicating good pulp
vitality, continue to the next step
8 Use a local anesthetic block to anesthetize the involved teeth
9 Isolate the involved tooth with a rubber dam
10 Prepare the access opening. It is important that the opening be in the correct proportion to
the canal size to allow for canal instrumentation and filling procedures
11 Use a cervical pulpotomy technique to remove the coronal 2 mm of injured or diseased
pulp tissue with a file for the Cvek partial pulpotomy procedure. Remove more pulp tissue
that appears injured or diseased until healthy bleeding is observed for the apexogenesis
procedure
12 Disinfect the coronal root canal space by flushing it with sodium hypochlorite diluted to
1.25 %. The sodium hypochlorite is diluted to 1.25 % reduce its toxicity. The sodium
hypochlorite is delivered and immediately suctioned to minimize extrusion through the
vital pulp tissues
Apexification 81

13 Do not instrument the coronal dentin because it will weaken the tooth
14 Place white MTA to fill the empty root canal space. It is optional to place a moist cotton
pellet above the MTA for 1 week to ensure that it sets. If you do not have MTA, you can
use calcium hydroxide
15 An endodontic sealer is not biocompatible for apexogenesis or Cvek partial pulpotomy
and should not be used
16 Overlay the white MTA with a temporary material such as Cavit or glass ionomer cement
17 Take a postoperative radiograph
Second treatment visit
treatment
19 Take a radiograph and check for any changes since the previous visit. If a periapical
radiolucency has appeared or increased in size, oral antibiotics may need to be given. The
tooth may need an apexification procedure if the tooth has become painful
21 Do not waste time checking tooth sensibility
24 Remove the cotton pellet and restore the teeth with a resin-modified glass ionomer to help
prevent microleakage, with a composite resin overlay restoration, or full-crown
replacement depending on the severity of crown damage
Follow-up visits
25 If the patient is reporting pain and/or a tissue swelling flare-up is observed, an
apexification treatment or other endodontic treatment must be considered
26 The quickest that radiographic changes to root thickening, root lengthening and the
resolution of periapical lesions can be observed is 6–12 months
27 Recall the patient every 6 and 12 months for at least 5 years
Apexification
The closure of the open apical foramen of an incompletely developed tooth has tra-
ditionally been accomplished through an apexification procedure. Apexification is a
method of inducing a calcified apical barrier or continued apical development of an
incompletely formed root in which the pulp is necrotic [15–22]. Apexification can
involve a single [22] or multiple monthly appointments to place calcium hydroxide
(100 % powder) inside the root canal to eliminate the intraradicular infection and
to stimulate calcification to close the apex. After monthly appointments, the tooth
should be stronger to allow the root canals to be obturated with gutta-percha [18].
A problem with calcium hydroxide is that it can alter the mechanical properties of
dentin and render these teeth more susceptible to root fracture [17]. The traditional
use of calcium hydroxide to accomplish apexification is gradually being replaced
by MTA as a one-step technique [19]. The MTA can be placed as an apical plug
with calcium hydroxide [53, 54] or even as a root canal obturation material [55].
Although effective, the obturation of whole root canals with MTA is expensive.
A developing consensus approach to accomplish apexification is to instrument root

canals to remove the necrotic tissue and to place MTA in the root canal apex, with
the remainder of the canal obturated with gutta-percha [21, 56, 57].
Some long-term studies of apexification with MTA have reported root apexifica-
tion and periapical healing [21, 56, 57]. The apexification failure rate of an MTA
apical plug with a single placement of calcium hydroxide for immature permanent
teeth was 7.1 % over 2 years [22]. Over the longer term, the rate of apexification
failures is difficult to predict. Among 200 case reports, some variable success rates
have been reported for apexification with calcium hydroxide with evidence lacking
about its adverse events or long-term effects [18]. Apexification with calcium
hydroxide has not always been successful in completing the root formation of
immature teeth or for healing persistent periradicular inflammation and tenderness
to percussion [19], avoiding root resorption [53], and there is no clinical evidence
that its use may help avoid root fracture. Apical MTA plugs are more effective for
accomplishing apexification [56] and for strengthening the roots of traumatized
immature permanent anterior teeth [58], but it is not clear whether these MTA
apexification procedures are as effective as regenerative endodontic procedures.
Some dentists place calcium hydroxide in the root canal to promote calcification
and apexification [17], but calcium hydroxide can also weaken the tooth structure
and lower its fracture resistance [17], again making the tooth prone to fracture even
after treatment. Ideally, the immature tooth should have a treatment procedure
which will promote the continued development of its root, resulting in a stronger
tooth which is less prone to fail in later life. A root fracture can affect up to 7 % of
permanent teeth, and the weakest teeth are the most prone to fracture [59]. The use
of calcium hydroxide to accomplish the apexification of an immature tooth of a
10-year-old boy with a necrotic pulp is shown in Fig. 3.3.
a b c d e
Fig. 3.3 Radiographs of an apexification treatment case in a 10-year-old boy with a necrotic pulp.
(a) Non-vital pulp diagnosed. (b) +1 month calcium hydroxide. (c) +1 month calcium hydroxide.
(d) +1 week MTA cotton pellet. (e) +3.5 months obturation with MTA
Apexification 83
Mineral trioxide aggregate (MTA) is used after calcium hydroxide, or instead of

calcium hydroxide as a root canal obturation material in immature teeth following
positive treatment outcomes [33]. The most current approach to accomplish apexi-
fication is to instrument root canals to remove the necrotic tissue and to place MTA
in the root canal apex, with the remainder of the canal obturated with gutta-percha
[60, 61]. There have been few long-term studies of apexification with MTA, but the
few studies that have been published have reported pulp and periapical healing [60,
61]. The steps to accomplish MTA apexification are shown in Table 3.2.
Table 3.2 Steps to accomplish to accomplish MTA apexification

1 The traumatized or caries-infected teeth must have a nonvital pulp that responds
abnormally to cold sensibility testing and is not suitable for other endodontic treatments
2 The tooth must be permanent and immature with a wide-open apical foramen. The tooth
must have thick walls that do not need strengthening to avoid fracture
3 The patient must be aged 7–16 years and have parents/guardians willing to take them to
attend multiple appointments
treatment
surrounding tissues
has normal sensibility but is injured, the treatment plan will have to change to an
apexogenesis. If the tooth responds abnormally to sensibility testing, continue to the next
step
11 Disinfect the entire root canal with 10 ml of sodium hypochlorite diluted to 1.25 % for
1 min. The sodium hypochlorite is diluted to 1.25 % reduce its toxicity. The sodium
hypochlorite is delivered and immediately suctioned to minimize extrusion through the
open apical foramen
12 Dry the canals with paper points
13 Measure the working length of the canals with a file inside the canal using a radiograph
14 Do not rely on an apex locator to measure the root canal working length of immature
teeth; it is not reliable in teeth with a blunderbuss apex
15 Instrument the root canal to remove necrotic pulp, but avoid weakening the root canal
dentin by excessive instrumentation
17 Etch the root canal walls with 17 % EDTA for 1 min
19 Flush EDTA from the root canals with sodium hypochlorite diluted to 1.25 % for 30 s
(continued)

21 Use white MTA to fill the empty root canal space. It is optional to place a moist cotton
pellet above the MTA for 1 week to ensure that it sets. If you do not have MTA, you can
use calcium hydroxide. If the root canal was obturated with calcium hydroxide, it will
need to be changed each month, for up to three months
22 An endodontic sealer is not needed because the MTA has sealed the root canal
treatment
26 Take a preoperative radiograph and check for any changes since the previous visit. If a
periapical radiolucency has appeared or increased in size, oral antibiotics may need to be
given. The root canal will have to be disinfected again and/or have more calcium
hydroxide placed in the canal for another month
if any are identified they must be restored to seal access to the root canals
31 Remove the cotton pellet and restore the tooth with a resin-modified glass ionomer to help
Follow-up visits
32 If the patient is reporting pain and/or a tissue swelling flare-up is observed, an
apexification retreatment or other endodontic treatments must be considered
33 The tooth is not expected to develop longer roots or thicker walls or mature past the stage
that the apexification was performed
Alternative Treatments to Apexification
The use of the apexification procedure can save the teeth with thick root canal walls
which do not need further root canal maturation to strengthen the walls. In order to
get immature teeth with a necrotic pulp to continue their root development and be
less prone to fracture, two alternative treatment procedures have been developed:
the first is “root canal revascularization” which involves the disinfection of the pulp
followed by stirring the tissues with a file to cause bleeding through the apical fora-
men [22–33]. The second is “regenerative endodontics” which attempts to regener-
ate the tissue on a scaffold inside the root canal and relies on bleeding through the
apical foramen to revascularize the root canal [34–37].
Revascularization and regenerative endodontic research is mainly limited to case
reports, and further research is needed to identify which of these types of proce-
dures is the most beneficial to revitalize an immature tooth to promote the develop-
ment of its roots, and thereby makes it more resistant to fracture later in life. To save
the teeth with very thin dentinal walls, the endodontic treatment must promote
Revascularization of the Root Canal 85
mineralization within the root canals to strengthen the teeth, and so makes the teeth
less prone to fracture [7]. If the teeth fracture, they can be non-restorable, leaving no
option to save them because they need to be extracted. Therefore, the purpose of
revascularization and regenerative endodontic treatments for immature teeth are to
alleviate the pain of toothache and to save the tooth for the lifetime of the child.
Revascularization of the Root Canal
Revascularization procedures must only be used to treat necrotic incompletely

developed teeth, which are likely to benefit from stronger dentinal walls and longer
roots. Prolonging patient suffering by providing them with an endodontic proce-
dure, which might ultimately fail and provide no benefit, must be avoided. Root
canal revascularization procedures have been used since the early 1970s [46] but
were disregarded because they were only effective in teeth without an infection or
necrotic pulp. The placement of Hoshino’s triple antibiotic paste, containing a 1:1:1
ratio of ciprofloxacin, metronidazole, and minocycline inside a root canal for 1
month, can disinfect it [62]. The disinfection of the root canal prior to evoking
bleeding from the apical foramen to fill the root canal with blood became what we
know as the revascularization procedure [23–26]. Some clinical trials are underway
to investigate the use of the antibiotic paste without minocycline because it can
cause tooth discoloration. In some other teeth, calcium hydroxide (100 % powder)
proved to be equally as effective as Hoshino’s triple antibiotic paste at promoting
root lengthening and thickening [63]. The success of revascularization depends on
the adequate disinfection of the root canal prior to revascularization. Some root
canal disinfection can be accomplished by irrigating the root canal with sodium
hypochlorite, but the need for the almost complete disinfection supports the need to
use antibiotics, calcium hydroxide, or other disinfectants. The revascularization
procedure evokes bleeding into the root canal, which delivers undifferentiated mes-
enchymal stem cells into the root canal space. The mesenchymal stem cells are
multipotent, meaning that they can differentiate into a variety of cell types, includ-
ing osteoblasts (bone cells), chondrocytes (cartilage cells), and adipocytes (fat cells)
[64]. In the dog root canal, the mesenchymal cells are responsible for new tissue
formation that has been described as fibrous connective tissue and intracanal cemen-
tum [65]. It has a similar appearance to the tissues regenerated in the root canal of a
human tooth (Fig. 3.4). A rare case report is shown in Fig. 3.4 of new tissue forma-
tion in the root canal after performing the endodontic revascularization procedure
on an avulsed and replanted tooth. This case suggests that avulsed and replanted
immature permanent teeth with an open apex that develop symptoms of necrosis
can benefit from using a regenerative revascularization procedure. It is not recom-
mended to attempt the revascularization procedure on replanted deciduous teeth, or
teeth with a closed apex, as these are unlikely to revitalize or benefit.
In a review of 24 case reports [66], there were 118 immature teeth (excluding
dropouts) with a necrotic pulp with an apical pathosis, which healed or reduced, and
another 7 had questionable healing. This suggests the healing rate for apical pathosis
a b c d
Fig. 3.4 Case of an avulsed replanted tooth and tissue formation in the root canal following a
regenerative endodontic procedure. (a) Preoperative. (b) +9 months postoperative calcium hydrox-
ide. (c) +1 month postoperative revascularization MTA. (d) +4.5 months tooth avulsed could not
be replanted taken for histology. (e) Histology of the lack of tissue formation within the root canal
of a human tooth following revascularization 4.5 months previously. This case was treated by Dr.
Shiju Cherian, a former postgraduate resident of endodontics at NSU College of Dental Medicine,
Fort Lauderdale, Florida, USA. A 9-year-old female avulsed her #8 and #9 teeth in an accident;
they were replaced after 2 h and had a poor prognosis due to replacement resorption.
Revascularization was attempted after apexification with calcium hydroxide had been attempted,
but had a poor prognosis. The calcium hydroxide was changed every 3 months and was inside the
canal for 9 months. No antibiotic paste was used. A blood clot was initiated by stirpating the apex
to cause bleeding into the root canal. The canal was irrigated with saline and flushed with
EDTA. Amoxicillin was prescribed. Unfortunately, the patient fell again and avulsed the #9 tooth,
but it was fractured through the root and could not be replaced. The avulsed tooth was collected
for histology. The histology shows little tissue regeneration, and there are mostly red-blood cells
is 94.1 % following revascularization or regenerative endodontic procedures. In a

review of 24 case reports [66], the root lengthened in 94 teeth, and it was not deter-
mined or did not lengthen in another 29 teeth. This suggests that root lengthening can
be seen radiographically in 76.4 % of teeth following revascularization or regenera-
tive endodontic procedures. In a review of 24 case reports [66], the thickness of the
root canal walls increased in 97 teeth, but no increase was measured in a further 27
Revascularization of the Root Canal 87
teeth. This suggests that root canal wall thickening can be seen radiographically in
78.2 % of teeth following revascularization or regenerative endodontic procedures.
A variable which can affect these results is the time elapsed following the treatment.
At least 6 months to 1 year is needed to see any increase in root length or root canal
wall thickness following revascularization or regenerative endodontic procedures.
The steps to accomplish root canal revascularization are shown in Table 3.3.
Table 3.3 Steps to accomplish root canal revascularization

abnormally to cold sensibility testing and is not suitable for apexification or root canal
obturation treatments
2 The tooth must be permanent and very immature with a wide-open apical foramen wider
than 1.1 mm and have an injured or exposed pulp. The tooth must have thin walls that will
benefit from a continued development of the root, so that it can become stronger and less
prone to failure in later life
3 The patient must be aged 7–16 years, in good health, and have parents/guardians willing
to take them to attend multiple appointments
4 The patient/parents/guardians must be told that the endodontic treatment is experimental,
and there is a risk that it may fail; if revascularization does fail, the tooth can have an
apexification procedure to save it
treatment
surrounding tissues
step
12 Disinfect the root canal with 20 ml of sodium hypochlorite diluted to 1.25 % for 1 min.
The sodium hypochlorite is diluted to 1.25 % reduce its toxicity. The sodium hypochlorite
is delivered and immediately suctioned to minimize extrusion through the open apical
foramen
14 Measure the working length of the canals with a file inside the canals using a radiograph
15 Do not rely on an apex locator to measure the root canal working length of immature
teeth; it is not reliable in teeth with a blunderbuss apex
16 Deliver Hoshino’s triple antibiotic paste as a 1:1:1 ratio of ciprofloxacin, metronidazole,
and minocycline (or omit the minocycline) to fill the canal from the apex to the cement-
enamel junction using an amalgam carrier or Lentulo spiral
17 Seal the root canal access with a temporary material such as Cavit or glass ionomer
cement
(continued)

treatment
given, and more Hoshino’s triple antibiotic paste may need to be given for another month.
If the periapical radiolucency is large, revascularization may not be indicated and the
treatment plan will have to change to an apexification
21 Look for swelling and lesions. Probe around the tooth margins checking for defects; if any
defects or tracks are identified, they must be restored to seal access to the root canals
23 An anesthetic without a vasoconstrictor (3 % mepivacaine) should be used when
attempting to induce revascularization (bleeding) into the root canal. A carpule of
mepivacaine may need to be given every 20 min
25 Remove Hoshino’s triple antibiotic paste by flushing the root canals with 10 ml of 17 %
EDTA. Do not leave the EDTA inside the tooth for more than 2 min in total because it can
weaken the tooth structure
27 Flush the canals with 10 ml of sodium thiosulfate for 1 min in a ratio of 1/2 the
concentration of sodium hypochlorite that was used. For 1.25 % sodium hypochlorite
concentration, a 0.63 % concentration of sodium thiosulfate should be used. If you do not
have sodium thiosulfate to neutralize the toxicity of sodium hypochlorite, you can flush
the root canals with sterile saline
29 Stir the pulp with a file, if there is hay-colored fluid; this means the root canal is not
disinfected enough and that Hoshino’s triple antibiotic paste needs to be placed for another
4 weeks. If the root canal is disinfected, bright red blood can be seen
30 Do not instrument the dentin because it will weaken the tooth
31 Mark a file 2-mm longer than the working length, and use it to stir the tissues 2 mm
beyond the apical foramen to cause bleeding in the root canal. Allow 5 min or more for
the blood to pool in the root canal up to the cement-enamel junction. If you cannot obtain
bleeding into the canal, add 17 % EDTA at the root apex for 15 s. Dry the EDTA with a
paper point. If sufficient bleeding into the canal cannot be obtained, revascularization will
not be successful and the treatment plan will have to change to an apexification
32 It is optional to place a collagen plug inside the root canal that is filled with blood to be
used as a scaffolds
33 After the blood clot has filled the root canals up to the cement-enamel junction, place a
2-mm thick layer of white MTA directly above the blood clot. Then place a moist cotton
pellet for one week. If you do not have MTA, you can use calcium hydroxide
34 An endodontic sealer is not biocompatible for regeneration and should not be used
Third treatment visit
treatment
given, and more Hoshino’s triple antibiotic paste may need to be given for another month.
If the periapical radiolucency is large, revascularization may not be indicated and the
treatment plan will have to change to an apexification
Regenerative Endodontic Treatments 89

Follow-up visits
42 If the patient is reporting a toothache and/or a tissue swelling flare-up is observed, an
apexification treatment is indicated
43 Tooth sensibility tests are expected to be negative for at least 1 year and may always be
negative because of the crown restorations masking a vital pulp response
44 The quickest that radiographic changes to root thickening, root lengthening and the
Regenerative Endodontic Treatments
Most endodontists are willing to incorporate regenerative therapies into treatments

[35]. Regenerative endodontic procedures include root canal revascularization as
part of the procedure and also include a scaffold, growth factors, or stem cell ther-
apy to stimulate tissue regeneration within the root canal to restore the normal phys-
iologic functions of the pulp-dentin complex [34]. Regenerative endodontics can
use Hoshino’s triple antibiotic paste over multiple visits to disinfect the root canal
and then use revascularization to fill the root canal with a blood clot containing cells
to establish new tissue formation. Alternatively, the single-visit regenerative end-
odontic procedure will remove the necrotic tissues and disinfect the root canals with
sodium hypochlorite without using an antibiotic paste. If the necrotic contents of the
root canal are removed, a collagen scaffold is placed inside the root canals to pro-
mote new tissue formation from the stem cells within the revascularized blood from
the periapical tissues. A comparison of the single-visit versus the multiple-visit
regenerative procedure is shown in Fig. 3.5.
The success of regenerative endodontic procedures is dependent on the wide-
open apical foramen to allow the ingrowth of vasculature from the periapical tissues
[47]. The vasculature also delivers mesenchymal stem cells into the root canals [45].
The constriction of the apical foramen is a limiting factor for root canal revascular-
ization: the smaller the width, the less revascularization is possible. The width that
is needed to make revascularization possible is around 1.1 mm in diameter or
greater. Roots with a diameter less than 1.1 mm are much less likely to revascularize
[47]. Some animal studies have shown that periapical tissues can grow into the root
canal space and form fibrous connective tissue and intracanal cementum [65]. None
of the regenerated or replacement tissues forming inside the root canals resemble
the natural dental pulp, except in rodent studies. It has been suggested that fully
mature teeth can have their apical foramen instrumented to 1.1 mm obtain
Fig. 3.5 Flow chart comparing single-visit regenerative endodontics versus multiple-visit regen-
erative endodontic procedures. The left side of the flow chart shows a single-visit regenerative
endodontic treatment which removes necrotic tissue from the root canal and fills the root canal
with collagen scaffolds for tissue regeneration. On the right side, the use of an antibiotic paste is
shown to disinfect the root canal for one month prior to revascularization
revascularization of the root and regeneration of tissue to revitalize teeth. A problem

with attempting the revascularization and regeneration of older teeth is that the
blood supply is much reduced when compared with young immature teeth, and so it
is more difficult to restore the revascularity of the root canal. In addition the stem
cells which flow into the revascularized root canals are likely much less numerous
in older patients. In the future, it may be possible to revascularize and regenerate all
immature and mature teeth very reliably. At the current time, it is the standard of
care to deliver the most successful evidence-based endodontic treatment for teeth.
For mature teeth with a closed apical foramen, the most successful treatment is
conventional endodontic root canal therapy and obturation with gutta-percha. The
problem is that conventional root canal therapy does not allow immature teeth to
develop and make stronger dentinal walls and longer roots. Therefore, there is a
need to restrict regenerative endodontic procedures to children and adolescent
patients for the treatment of immature teeth with a necrotic pulp. In a review of 24
case reports of revascularization or regenerative endodontic procedures [66], the
healing rate for apical pathosis was approximately 94.1 %; the root lengthening was
seen radiographically in 76.4 % of teeth; the root canal wall thickening was seen
radiographically in 78.2 % of teeth. A variable which can affect these results is the
time elapsed following the treatment. At least 6 months to 1 year is needed to see
any increased in root length or root canal wall thickness following revascularization
or regenerative endodontic procedures. All of the regenerative endodontic proce-
dures include revascularization, but the steps can vary according to the scaffold
used; it can be made from biodegradable polymers or protein-rich plasma from
patient blood [36]. The steps to accomplish endodontic regeneration with a biode-
gradable polymer are shown in Table 3.4:
Regenerative Endodontic Treatments 91
Table 3.4 Steps to accomplish regenerative endodontics

Case selection for regenerative endodontic treatment
abnormally to cold sensibility testing and is not suitable for apexification or root canal
obturation treatments
2 The tooth must be permanent and very immature with a wide-open apical foramen wider
than 1.1 mm and have an injured or exposed pulp. The tooth must have thin walls that will
benefit from a continued development of the root, so that it can become stronger and less
prone to failure in later life
3 The patient must be aged 7–16 years, in good health, and have parents/guardians willing
to take them to attend multiple appointments
4 The patient/parents/guardians must be told that the endodontic treatment is experimental
and there is a risk that it may fail; if revascularization does fail, the tooth can have an
apexification procedure to save it
treatment
surrounding tissues
step
9 An anesthetic without a vasoconstrictor (3 % mepivacaine) should be used when
attempting to induce revascularization (bleeding) into the root canal. A carpule of
mepivacaine may need to be given every 20 min
12 Measure the working length of the canals with a file inside the canal using a radiograph
13 Do not rely on an apex locator to measure the root canal working length; it is not reliable
in teeth with a blunderbuss apex
14 Lightly instrument the necrotic pulp to remove it. Use 10 ml of sodium hypochlorite
irrigating solution diluted to 1.25 % for 1 min with each instrument. Deliver and
immediately suction the sodium hypochlorite to minimize extrusion through the open
apical foramen
15 Do not instrument the dentin because it will weaken the tooth
17 Flush the canals with 10 ml of sodium thiosulfate for 1 min in a ratio of 1/2 the
concentration of sodium hypochlorite that was used. For 1.25 % sodium hypochlorite
concentration, a 0.63 % concentration of sodium thiosulfate should be used. If you do not
have sodium thiosulfate to neutralize the toxicity of sodium hypochlorite, you can flush
the root canals with sterile saline
19 Flush the root canals with 10 ml of 17 % EDTA. Do not leave the EDTA inside the tooth
for more than 1 min because it can weaken the tooth structure
(continued)

21 Mark a file 2-mm longer than the working length, and use it to stir the tissues 2 mm
beyond the apical foramen to cause bleeding in the root canal. Allow 5 min or more for
the blood to pool in the root canal up to the cement-enamel junction. If you cannot obtain
bleeding into the canal, add 17 % EDTA at the root apex for 15 s. Dry the EDTA with a
paper point. If sufficient bleeding into the canal cannot be obtained, the lack of
revascularization will not allow regeneration to occur, and the treatment plan will have to
change to an apexification
22 After the blood clot has filled the root canals up to the cement-enamel junction, pack the
bloody root canal with a sterile collagen scaffold (CollaCote) cut into a cone shape or into
1-mm strips to match the working length
23 Place a 2-mm thick layer of white MTA directly above the blood clot. Then place a moist
cotton pellet for 1 week. If you do not have MTA, you can use calcium hydroxide
24 Check the position and seal off the white MTA within the root canal using a radiograph
and pack or move the MTA into a better seal position as necessary and recheck with
another radiograph
25 An endodontic sealer is not biocompatible for regeneration and should not be used
26 Seal the root canal access by overlaying the white MTA with a temporary material such as
Cavit or glass ionomer cement
treatment
given and the canal reaccessed to be packed with Hoshino’s triple antibiotic paste for a
month to disinfect the canal. If the periapical radiolucency is large, regenerative
endodontics and revascularization may not be indicated, and the treatment plan will have
to change to an apexification
Follow-up visits
34 If the patient is reporting a toothache and/or a tissue swelling flare-up is observed, an
apexification treatment is indicated
35 Tooth sensibility tests are expected to be negative for at least 1 year and may always be
negative because of the crown restorations masking a vital pulp response
36 The quickest that radiographic changes to root thickening, root lengthening, and the
Endodontic regeneration can be accomplished through the activity of the cells

from the pulp, periodontium, vascular, and immune system [67]. Most therapies use
the host’s own pulp or vascular cells for regeneration, but other types of dental stem
cell therapies are under development. Because of the increasing activity of dental
stem cell banks, we can expect stem cells from baby teeth to be implanted into
mature teeth to accomplish regeneration [68].
Tooth Avulsion and Root Canal Revascularization 93
Percentage change in root length (%) 10

9
8
7
6
5
4
3
2
1
0
Apexification Apexogenesis Revascularization
Fig. 3.6 Changes in root length following endodontic procedures
Comparison of Treatments on Root Length
A radiographic comparison of the effects of 30 cases of apexification, apexogen-

esis, and regenerative endodontic treatments after an average of 1.7 months found
there was very little root lengthening following apexification (0.5 %). The roots of
immature teeth with a necrotic pulp which had revascularization increased by 9.9 %.
The roots of immature teeth with a vital pulp which had apexogenesis increased by
8.7 %. These results indicate that apexification does not permit the growth of roots in
immature teeth. The apexogenesis of teeth with a vital pulp indicates that the natural
growth of the roots over 1.6 months increased their length by 9.9 %. The results
show that regenerative endodontic procedures for teeth with a necrotic pulp can revi-
talize the teeth with new tissue which can promote root length similar to the natural
growth rate of the roots following apexogenesis. The results are shown in Fig. 3.6.
Tooth Avulsion and Root Canal Revascularization
The common age group for avulsion injuries is children between the age of 7 and 10
years, when the permanent incisors are erupting [69]. Avulsed intact teeth with no
fracture through the root should be washed with water, saline, or chlorhexidine to
remove any contamination and be replanted immediately [70]. The removal of
coagulum and cleaning of the socket is not regarded as being beneficial [71]. If the
tooth has an extraoral dry time of 60 min or more, replantation is usually not recom-
mended [47]. The most severe pulp damage is seen in the coronal pulp in mature
replanted teeth with a closed apex, whereas teeth with an open apex healed more
rapidly [44]. The likelihood of natural revascularization after replantation of an
avulsed tooth is influenced by the extra-alveolar time and the stage of root develop-
ment, which is reflected by the diameter of the apical foramen. An open foramen
>1.1 mm is beneficial, with natural revascularization occurring in approximately
18 % [47] to 34 % [44] of teeth with immature roots. Successful periodontal healing
can be improved if the pulp is extirpated within 14 days [72]. There is little evidence
to support the use of an endodontic revascularization procedure on an avulsed and
replanted tooth, but it could strengthen the root canal walls of immature teeth and
save them from being unrestorable following a fracture.
Test Questions
Which of the following treatments (a to e) would you give the following teeth?
(a) Traditional root canal obturation

(b) Regenerative or revascularization endodontics
(c) Apexification
(d) Apexogenesis
(e) Extract tooth
1. A mature tooth with abnormal pulp sensibility and a closed apex. The tooth has
thick dentinal roots. The patient has a routine health history and the tooth is
restorable?
2. A mature tooth with abnormal pulp sensibility and a closed apex. The tooth has
thick dentinal roots. The patient has a routine health history and the tooth is
non-restorable?
3. A immature tooth with abnormal pulp sensibility and an open apex more than
1.1 mm. The tooth has thick dentinal roots. The patient has a routine health his-
tory and the tooth is non-restorable?
4. A immature tooth with normal pulp sensibility and an open apex more than
1.1 mm. The tooth has thin dentinal roots. The patient has a routine health his-
5. An immature tooth with abnormal pulp sensibility and an open apex more than
1.1 mm. The tooth has thin dentinal roots. The patient has a routine health his-
Correct answers: 1a, 2e, 3c, 4d, 5b
Bibliography
1. Salehrabi R, Rotstein I. Endodontic treatment outcomes in a large patient population in the
USA: an epidemiological study. J Endod. 2004;30:846–50.
2. Tsilingaridis G, Malmgren B, Andreasen JO, Malmgren O. Intrusive luxation of 60 permanent
incisors: a retrospective study of treatment and outcome. Dent Traumatol. 2012;28:416–22.
3. Jacobsen I. Criteria for diagnosis of pulp necrosis in traumatized permanent incisors. Scand J
Dent Res. 1980;88:306–12.
Bibliography 95
4. Andreasen FM. Histological and bacteriological study of pulps extirpated after luxation
injuries. Endod Dent Traumatol. 1988;4:170–81.
5. Chala S, Abouqal R, Rida S. Apexification of immature teeth with calcium hydroxide or
mineral trioxide aggregate: systematic review and meta-analysis. Oral Surg Oral Med Oral
Pathol Oral Radiol Endod. 2011;112(4):e36–42.
6. Katebzadeh N, Dalton C, Trope M. Strengthening immature teeth during and after apexifica-
tion. J Endod. 1998;24:256–9.
7. Dummer PM, Davies J, Harris M. Automated thermatic condensation of gutta-percha root
fillings in teeth with open (immature) apices. J Oral Rehabil. 1985;12:323–30.
8. Moore A, Howley MF, O’Connell AC. Treatment of open apex teeth using two types of white
mineral trioxide aggregate after initial dressing with calcium hydroxide in children. Dent
Traumatol. 2011;27:166–73.
9. Zero DT, Zandona AF, Vail MM, Spolnik KJ. Dental caries and pulpal disease. Dent Clin
North Am. 2011;55:29–46.
10. Chen E, Abbott PV. Evaluation of accuracy, reliability, and repeatability of five dental pulp
tests. J Endod. 2011;37:1619–23.
11. Fleury A, Regan JD. Endodontic diagnosis: clinical aspects. J Ir Dent Assoc. 2006;52:
28–38.
12. Fernandes M, de Ataide I, Wagle R. Tooth resorption part II – external resorption: case series.
J Conserv Dent. 2013;16:180–5.
13. Wilkinson KL, Beeson TJ, Kirkpatrick TC. Fracture resistance of simulated immature teeth
filled with resilon, gutta-percha, or composite. J Endod. 2007;33:480–3.
14. Desai S, Chandler N. The restoration of permanent immature anterior teeth, root filled using
MTA: a review. J Dent. 2009;37:652–7.
15. Barker BC, Mayne JR. Some unusual cases of apexification subsequent to trauma. Oral Surg
Oral Med Oral Pathol. 1975;39:144–50.
16. Wechsler SM, Fishelberg G, Opderbeck WR, LoMonaco CJ, Skribner JE, Shovlin
FE. Apexification: a valuable and effective clinical procedure. Gen Dent. 1978;26:40–3.
17. Andreasen JO, Farik B, Munksguard EC. Long term calcium hydroxide as a root canal dressing
may increase risk of root fracture. Dent Traumatol. 2002;18:134–7.
18. Rafter M. Apexification: a review. Dent Traumatol. 2005;21:1–8.
19. El-Meligy OA, Avery DR. Comparison of apexification with mineral trioxide aggregate and
calcium hydroxide. Pediatr Dent. 2006;28:248–53.
20. Sarris S, Tahmassebi JF, Duggal MS, Cross IA. A clinical evaluation of mineral trioxide
aggregate for root-end closure of non-vital immature permanent incisors in children-a pilot
study. Dent Traumatol. 2008;24:79–85.
21. Nayar S, Bishop K, Alani A. A report on the clinical and radiographic outcomes of 38 cases of
apexification with mineral trioxide aggregate. Eur J Prosthodont Restor Dent. 2009;17:
150–6.
22. Mendoza AM, Reina ES, García-Godoy F. Evolution of apical formation on immature necrotic
permanent teeth. Am J Dent. 2010;23:269–74.
23. Iwaya SI, Ikawa M, Kubota M. Revascularization of an immature permanent tooth with apical
periodontitis and sinus tract. Dent Traumatol. 2001;17:185–7.
24. Banchs F, Trope M. Revascularization of immature permanent teeth with apical periodontitis:
new treatment protocol? J Endod. 2004;30:196–200.
25. Thibodeau B, Trope M. Pulp revascularization of a necrotic infected immature permanent
tooth: case report and review of the literature. Pediatr Dent. 2007;29:47–50.
26. Petrino JA. Revascularization of necrotic pulp of immature teeth with apical periodontitis.
Northwest Dent. 2007;86:33–5.
27. Jung IY, Lee SJ, Hargreaves KM. Biologically based treatment of immature permanent teeth
with pulpal necrosis: a case series. J Endod. 2008;34:876–87.
28. Cotti E, Mereu M, Lusso D. Regenerative treatment of an immature, traumatized tooth with
apical periodontitis: report of a case. J Endod. 2008;34:611–6.
29. Thibodeau B. Case report: pulp revascularization of a necrotic, infected, immature, permanent
tooth. Pediatr Dent. 2009;31:145–8.
30. Shin SY, Albert JS, Mortman RE. One step pulp revascularization treatment of an immature
permanent tooth with chronic apical abscess: a case report. Int Endod J. 2009;42:1118–26.
31. Ding RY, Cheung GS, Chen J, Yin XZ, Wang QQ, Zhang CF. Pulp revascularization of imma-
ture teeth with apical periodontitis: a clinical study. J Endod. 2009;35:745–9.
32. Reynolds K, Johnson JD, Cohenca N. Pulp revascularization of necrotic bilateral bicuspids
using a modified novel technique to eliminate potential coronal discolouration: a case report.
Int Endod J. 2009;42:84–92.
33. Trope M. Treatment of the immature tooth with a non-vital pulp and apical periodontitis. Dent
Clin North Am. 2010;54:313–24.
34. Murray PE, Garcia-Godoy F, Hargreaves KM. Regenerative endodontics: a review of current
status and a call for action. J Endod. 2007;33:377–90.
35. Epelman I, Murray PE, Garcia-Godoy F, Kuttler S, Namerow KN. A practitioner survey of
opinions toward regenerative endodontics. J Endod. 2009;35:1204–10.
36. Torabinejad M, Turman M. Revitalization of tooth with necrotic pulp and open apex by using
platelet-rich plasma: a case report. J Endod. 2011;37(2):265–8.
37. Torabinejad M, Faras H. A clinical and histological report of a tooth with an open apex treated
with regenerative endodontics using platelet-rich plasma. J Endod. 2012;38:864–8.
38. Chueh LH, Huang GT. Immature teeth with periradicular periodontitis or abscess undergoing
apexogenesis: a paradigm shift. J Endod. 2006;32:1205–13.
39. Nosrat A, Asgary S. Apexogenesis treatment with a new endodontic cement: a case report. J
Endod. 2010;36:912–4.
40. Cvek M. A clinical report on partial pulpotomy and capping with calcium hydroxide in perma-
nent incisors with complicated crown fracture. J Endod. 1978;4:232–7.
41. Karabucak B, Li D, Lim J, Iqbal M. Vital pulp therapy with mineral trioxide aggregate. Dent
Traumatol. 2005;21:240–3.
42. McIntyre JD, Vann Jr WF. Two case reports of complicated permanent crown fractures treated
with partial pulpotomies. Pediatr Dent. 2009;31:117–22.
43. Abarajithan M, Velmurugan N, Kandaswamy D. Management of recently traumatized maxil-
lary central incisors by partial pulpotomy using MTA: case reports with two-year follow-up. J
Conserv Dent. 2010;13:110–3.
44. Andreasen JO, Borum MK, Jacobsen HL, Andreasen FM. Replantation of 400 avulsed perma-
nent incisors. 2. Factors related to pulpal healing. Endod Dent Traumatol. 1995;11:59–68.
45. Lovelace TW, Henry MA, Hargreaves KM, Diogenes A. Evaluation of the delivery of mesen-
chymal stem cells into the root canal space of necrotic immature teeth after clinical regenera-
tive endodontic procedure. J Endod. 2011;37:133–8.
46. Nygaard-Ostby B, Hjortdal O. Tissue formation in the root canal following pulp removal.
Scand J Dent Res. 1971;79:333–49.
47. Kling M, Cvek M, Mejàre I. Rate and predictability of pulp revascularization in therapeutically
reimplanted permanent incisors. Endod Dent Traumatol. 1986;2:83–9.
48. Garcia-Godoy F, Murray PE. Recommendations for using regenerative endodontic procedures
in permanent immature traumatized teeth. Dent Traumatol. 2012;28:33–41.
49. Ring KC, Murray PE, Namerow KN, Kuttler S, Garcia-Godoy F. The comparison of the effect
of endodontic irrigation on cell adherence to root canal dentin. J Endod. 2008;34:1474–9.
50. Pameijer CH, Stanley HR. The disastrous effects of the “total etch” technique in vital pulp
capping in primates. Am J Dent. 1998;11 Spec No:S45–54. Erratum in: Am J Dent 1998;11:148.
51. Murray PE, García-Godoy F. The incidence of pulp healing defects with direct capping materi-
als. Am J Dent. 2006;19:171–7.
52. Al-Hiyasat AS, Tayyar M, Darmani H. Cytotoxicity evaluation of various resin based root
canal sealers. Int Endod J. 2010;43:148–53.
53. Oktem ZB, Cetinbaş T, Ozer L, Sönmez H. Treatment of aggressive external root resorption
with calcium hydroxide medicaments: a case report. Dent Traumatol. 2009;25:527–31.
54. Ghaziani P, Aghasizadeh N, Sheikh-Nezami M. Endodontic treatment with MTA apical plugs:
a case report. J Oral Sci. 2007;49:325–9.
Bibliography 97
55. Bogen G, Kuttler S. Mineral trioxide aggregate obturation: a review and case series. J Endod.
2009;35:777–90.
56. Erdem AP, Sepet E. Mineral trioxide aggregate for obturation of maxillary central incisors
with necrotic pulp and open apices. Dent Traumatol. 2008;24:e38–41.
57. Park J-B, Lee J-H. Use of mineral trioxide aggregate in the open apex of a maxillary first pre-
molar. J Oral Sci. 2008;50:355–8.
58. Yildirim T, Gencoglu N. Use of mineral trioxide aggregate in the treatment of large periapical
lesions: reports of three cases. Eur J Dent. 2010;4:468–74.
59. Deshpande A, Deshpande N. Flexible wire composite splinting for root fracture of immature
permanent incisors: a case report. Dent Traumatol. 2012;28:358–63.
60. Juriga S, Marretta SM, Weeks SM. Endodontic treatment of a non-vital permanent tooth with
an open root apex using mineral trioxide aggregate. J Vet Dent. 2008;25:189–95.
61. Oliveira TM, Sakai VT, Silva TC, Santos CF, Abdo RC, Machado MA. Mineral trioxide aggre-
gate as an alternative treatment for intruded permanent teeth with root resorption and incom-
plete apex formation. Dent Traumatol. 2008;24:565–8.
62. Sato I, Ando-Kurihara N, Kota K, Iwaku M, Hoshino E. Sterilization of infected root-canal
dentine by topical application of a mixture of ciprofloxacin, metronidazole and minocycline in
situ. Int Endod J. 1996;29:118–24.
63. Bose R, Nummikoski P, Hargreaves K. A retrospective evaluation of radiographic outcomes in
immature teeth with necrotic root canal systems treated with regenerative endodontic proce-
dures. J Endod. 2009;35:1343–9.
64. Nardi NB, da Silva Meirelles L. Mesenchymal stem cells: isolation, in vitro expansion and
characterization. In: Wobus AM, Boheler K, editors. Stem cells, Handbook of experimental
pharmacology, vol. 174. Berlin/New York: Springer; 2006. p. 249–82.
65. Wang X, Thibodeau B, Trope M, Lin LM, Huang GT. Histologic characterization of regener-
ated tissues in canal space after the revitalization/revascularization procedure of immature dog
teeth with apical periodontitis. J Endod. 2010;36:56–63.
66. Law AS. Considerations for regeneration procedures. J Endod. 2013;39:S44–56.
67. Andreasen JO, Paulsen HU, Yu Z, Bayer T, Schwartz O. A long-term study of 370 autotrans-
planted premolars. Part II. Tooth survival and pulp healing subsequent to transplantation. Eur
J Orthod. 1990;12:14–24.
68. Arora V, Arora P, Munshi AK. Banking stem cells from human exfoliated deciduous teeth
(SHED): saving for the future. J Clin Pediatr Dent. 2009;33:289–94.
69. American Association of Endodontists. Recommended guidelines of the American Association
of Endodontists for the treatment of traumatic dental injuries. Chicago: American Association
of Endodontists; 2003.
70. Andreasen JO. The effect of removal of the coagulum in the alveolus before replantation upon
periodontal and pulpal healing of mature permanent incisors in monkeys. Int J Oral Surg.
1980;9:458–61.
71. Öhman A. Healing and sensitivity to pain in young replanted human teeth. An experimental
and histological study. Odontol Tidskr. 1965;73:166–227.
72. Miller SA, Miller G. Use of evidence-based decision-making in private practice for emergency
treatment of dental trauma: EB case report. J Evid Based Dent Pract. 2010;10:135–46.
Oral Pathology and Imaging
4
Digital Radiographs
Dental radiographs created by x-rays are used to visualize the internal structures of
the teeth, bones, and soft tissues to help diagnose pathology. Dental radiographs can
show hidden dental structures such as cavities, anomalies, malignant or benign
masses, impacted wisdom teeth, periapical lesions, and bone resorption that cannot
be seen during a visual examination. Dental radiographs are an important diagnostic
aid and are routinely taken preoperatively and postoperatively to monitor the out-
come of endodontic treatment. Radiographs should only be taken when they are
necessary for diagnosis and treatment. The amount of radiographs that should be
taken of patients should be as few as reasonably achievable to limit their exposure
to radiation.
Radiation Dosage and Avoiding Incidental Radiation Exposure
The dosage of x-ray radiation received by a dental patient is typically 0.150 mSv
for a full mouth series of radiographs [1]. The dental radiation dose is equivalent
to a few days’ worth of background environmental radiation exposure. Newer
technology has reduced the amount of radiation needed to obtain radiographs by
increasing the speed of the x-ray film. It is recommended to always use the fast-
est radiographic film (E or F film speed) and to reduce incidental patient radia-
tion exposure by using lead protective aprons to shield the abdomen and thyroid
when taking radiographs. Before a radiograph is being taken, all personnel
should leave the room or stand behind lead shielding to limit their incidental
radiation exposure.

DOI 10.1007/978-3-662-43730-8_4
100 4 Oral Pathology and Imaging
A fundamental principle for diagnostic radiology is to limit the patient exposure

to radiation using ALARA, as low as reasonably achievable by FOOD:
1. Following appropriate radiograph selection criteria after taking a history from

the patient and then a clinical evaluation.
2. Only properly trained and credentialed personnel should take radiographs.
3. Optimal radiographic techniques should be used, including beam projection
geometry, beam energy, collimation, and filtration.
4. Detector must be the fastest available to obtain a radiographic image of adequate
diagnostic quality.
X-Rays and Radiographs
X-rays were first called invisible rays and were discovered by W. Conrad Roentgen
in 1895 [2]. X-rays are a form of high-energy electromagnetic radiation. A radio-
graphic image is formed by a controlled burst of x-ray radiation which penetrates
oral structures at different levels, depending on varying anatomical densities, before
striking the film or sensor. The teeth appear lighter because less radiation penetrates
their dense structure to reach the film. If some of the structure of the teeth or bone is
missing because of dental caries, infections, resorption, and lesions, these areas of
pathology appear darker because the x-rays more readily penetrate these structures.
Dental materials for tooth restoration with filings and crowns or root canal obtu-
ration and sealing can appear lighter or darker depending on the density of the mate-
rial. Most dental materials contain a radiopaque material such as barium sulfate to
help visualize the material in radiographs.
The ability to accurately interpret radiographs is essential to identify and diagnose
oral diseases. Reaching an accurate diagnosis takes training, skill, and good-quality
imaging. Poor angulation and poor geometric configuration of the tooth onto the x-ray
sensor can lead to poor-quality images which can cause substantial errors in interpre-
tation. Most routine endodontic radiographs display sufficient resolution and image
details to allow the diagnosis of problems and for treatment procedures to be planned.
Dental radiographs are commonly taken by placing the radiographic film or elec-
tronic sensor inside the patient’s mouth. A decision-making flow chart for taking
radiographs is shown in Fig. 4.1.
Types of Radiographs
The following types of dental radiographs are common.
Bitewing Radiographs
The name bitewing refers to a small tab of plastic situated in the center of the x-ray
film. The patient bites on the tab which holds the x-ray film in a position to visualize
the crowns of the posterior teeth and the height of the alveolar bone in relation to the
Types of Radiographs 101
Do you Yes Bitewing radiographs

Do you
have a full need to
Yes check for
mouth Do you
series of tooth decay need to
radiographs Periapical
No check for
for the radiographs
endodontic
patient problems?
within the
past 3
Do you need
years? Take a full mouth Occlusal
No to check for
series of radiographs radiographs
pathology?
Fig. 4.1 Flow chart for taking radiographs
cement-enamel junctions, which are the demarcation lines on the teeth which sepa-
rate the tooth crown from the tooth root. The bitewing radiographs are routinely
used to detect tooth decay and recurrent caries under existing restorations. When
there is extensive bone loss, the films may be situated with their longer dimension
in the vertical axis so as to better visualize their levels in relation to the teeth.
Because bitewing views are taken from a more or less perpendicular angle to the
buccal surface of the teeth, they more accurately exhibit the bone levels than do
periapical views. Bitewings of the anterior teeth are not routinely taken.
Periapical Radiographs
The periapical radiograph is taken to visualize the root apex, periapical tissues, and
bone surrounding the teeth that a patient is complaining of being painful and/or has
swelling and/or the symptoms of infection. The periapical radiograph is the most
common type for determining the need for endodontic therapy as well as to monitor
the outcome of endodontic therapy. Periapical radiographs are useful in detecting
impacted teeth and hyperdontia or presence or absence of supernumerary teeth.
In order to create a high-quality periapical radiograph, the central x-ray beam
must pass through the alveolar crest or root apex. There are two projection tech-
niques for taking periapical radiographs:
• The paralleling technique, also called the long-cone technique: The periapical
film is stood parallel to the long axis of the teeth, and the central is aimed at the
right angles of the teeth and the film (Fig. 4.2a).
• The bisecting-angle technique: The periapical film is stood as close as possible
to the palatal/lingual surface of the teeth. The film and the teeth form an angle
with its apex at the point where the film is in contact with the teeth. Central ray
is directed at apex of the teeth [3] (Fig. 4.2b).
Occlusal Radiographs
The occlusal radiograph is taken to visualize the skeletal or pathologic anatomy of

either the floor of the mouth or the palate. Sometimes, the occlusal film is used to
Fig. 4.2 (a) The paralleling a

technique; (b) the bisecting-
angle technique
X-ray film
X-rays
X-rays
X-ray film
detect soft tissue anomalies and conditions. The occlusal view is not included in the
routine full mouth series of radiographs.
Full Mouth Series of Radiographs
A new dental patient may need to have a complete set of radiographs taken of their
mouth. The full mouth series (FMS or FMX) or complete mouth radiographic series
(CMRS) is discouraged because it involves taking 18 radiographs, many of which
may not be necessary for the patient’s treatment. The full mouth series comprises of:
Four bitewings:
• Left and right molar bitewings

• Left and right premolar bitewings
Eight posterior periapicals:
• Left and right maxillary molar periapicals

• Left and right maxillary premolar periapicals
• Left and right mandibular molar periapicals
• Left and right mandibular premolar periapicals
Types of Radiographs 103
Six anterior periapicals:
• Left and right maxillary canine-lateral incisor periapicals

• Left and right mandibular canine-lateral incisor periapicals
• Maxillary and mandibular central incisor periapicals
Panoramic Radiographs
Panoramic radiographs are occasionally taken using extraoral films and show a
broad view of the jaws, teeth, sinuses, nasal area, and temporomandibular joints and
anatomic structures (Fig. 4.3).
Panoramic radiographs are useful in detecting impacted teeth, bone abnormali-
ties, cysts, solid growths (tumors), infections, and fractures but have limitations for
assessing periodontal bone loss and tooth decay. Panoramic radiographs of children
are useful in detecting developing teeth (Fig. 4.4).
E NS NC SN
EL HP MS
MT ANS SP
DOT N
EOR IF
MA MC
IBOM MF SF
Fig. 4.3 Panoramic radiograph with marked anatomic structures. ANS anterior nasal spine, DOT dor-
sum of tongue (shadow), EL ear lobe, E epipharynx, EOR external oblique ridge, HP hard palate, IF
incisive foramen, IBOM inferior border of mandible, MA mandibular angle, MC mandibular canal, MC
mandibular condyle, MS maxillary sinus, MT maxillary tuberosity, MF mental foramen, NS nasal sep-
tum, NC nasal cavity, N nasopalatine canal, SN sigmoid notch, SP soft palate, SF submandibular fossa
Fig. 4.4 Panoramic radiograph of a child with developing teeth

Cone Beam Computed Tomography
Digital radiographs are an acceptable first choice for the diagnosis and treatment of
dental pathology. Cone beam computed tomography (CBCT) imaging is becoming
a complementary technology and in many instances can provide 3-dimensional oral
pathology information that might have been overlooked on 2-D images. CBCT
avoids the superimposition seen on 2-dimensional radiographs and avoids the geo-
metric distortion of radiographic structures. CBCT must not be used routinely for
endodontic diagnosis or for screening purposes in the absence of clinical signs and
symptoms that require imaging. A patient’s history and clinical examination must
justify the use of CBCT in addition to routine radiographs. Several different views
are possible of patients with CBCTs as shown in Fig. 4.5.
Computed tomography was invented by Hounsfield in 1974 [4]. The first CBCT
unit was approved in the USA in 2001 [5]. Since then, the technology has become
Fig. 4.5 A selection of CBCTs showing the different views which are possible
CBCT Field of View 105
standard in dental schools and hospitals. CBCT uses a rotating gantry with an x-ray
source and detector. A divergent pyramidal or cone-shaped source of ionizing radia-
tion is directed through the middle of the area of interest onto an area x-ray detector
on the opposite side of the patient. The x-ray source and detector rotate around a
fixed fulcrum within the region to be imaged. During the exposure sequence, hun-
dreds of planar projection images are acquired of the field of view (FOV) in an arc
of 180°. In a single rotation, the CBCT can generate accurate 3-D radiographic
images. The limitation of CBCT is the artifacts caused by scatter and beam harden-
ing around high-density structures including enamel, metal posts, restorations, and
root obturation materials. Another common problem is artifacts caused by patient
movement during the CBCT scan. Dentists must be responsible for interpreting the
entire CBCT image and can be liable for missed diagnosis, even if it is outside of
endodontics; thus, specialist referral of CBCT or routine checking of CBCTs in
universities and hospitals by specialists is recommended.
CBCT Field of View
The CBDT dimensions of the field of view (FOV) also known as the scan volume
are dependent on the detector size and shape, the beam projection geometry, and
the ability to collimate the beam. Collimation of the primary x-ray beam limits
x-radiation exposure. The field size limitation ensures that an optimal FOV can be
selected for each patient based on disease presentation and the tissues to be
imaged. In general, the smaller the scan volume, the higher the resolution of the
image and the lower the effective radiation dose to the patient. As the earliest sign
of a periapical radiographic finding suggestive of pathosis is discontinuity in the
lamina dura and widening of the periodontal ligament space, it is desirable that
the optimal resolution of any CBCT imaging system used in endodontics does not
exceed 200 μm—the average width of the periodontal ligament space [5]. The
principal limitation of large FOV cone beam imaging is the size of the field irradi-
ated. Unless the smallest voxel (volumetric pixel) size is selected in these larger
FOV machines, there will be reduced resolution compared to intraoral radiographs
or limited-volume CBCT machines. For endodontic use, limited or focused FOV
CBCT is preferred over large volume CBCT. There is often an extra charge to
patients for CBCT images, but the advantages of CBCT over other types of radio-
graphs are:
1. Images of tissues which are located on axial, coronal sagittal planes can be seen
more easily. The anatomical area of interest is focused and it reduces the area of
responsibility.
2. No magnification or distortion problems, and saves some time, because of the
smaller volume to be interpreted.
3. Superimposition of tissues is eliminated.
4. Easy planning of the placement of dental implants.
5. Cyst and tumor density can be measured.
6. Tissues with different densities can be more easily distinguished. Resolution is

increased to improve the visualization of calcified/accessory canals, root canal
curvature, missed canals, root fractures, luxation, and tooth displacement and
differentiate odontogenic from nonodontogenic pathology, discontinuity in the
lamina dura, widening of the periodontal ligament space, root resorption, and
periapical lesions.
The disadvantages of CBCT over other types of radiographs are:
1. Higher radiation exposure.

2. A contrast agent is necessary to image soft tissue.
3. Degradation of images by metallic objects, dental crowns, and fillings.
CBCT Diagnosis
The pathology in and around the individual teeth can be more easily diagnosed by
the high-resolution images of CBCT. The periodontal ligament is approximately
0.2 mm in diameter; the high resolution allows the assessment of periodontal dis-
ruptions from apical periodontitis, periapical pathology, fractures, and other pathol-
ogy. CBCT has fewer limitations for identifying periapical pathology, which can
only be seen on standard radiographs if the bone loss is more than 35 % and it per-
forates the cortex [5]. CBCT also shows lesions in cancellous bone that could not be
detected by radiographs [6]. The advantage of CBCT is that it allows developing
lesions to be identified more quickly before bone deterioration has escalated. A
study of the images of more than 1,500 teeth with endodontic disease found that
CBCT can detect periapical pathology more accurately than periapical films or pan-
ographic radiographs. The prevalence of periapical pathology visible on radiographs
was 17 %, panographs was 35 %, and on CBCT it was 63 % [7]. The results dem-
onstrate the impact that CBCT imaging can have on improving the accuracy of
endodontic diagnosis.
CBCT Detection of Apical Periodontitis
CBCT can detect radiolucent findings at initial stages of development before they
can be visualized on conventional radiographs. Some periapical lesions in cancel-
lous bone cannot be detected radiographically [8]. Some lesions in the cortical bone
can only be detected radiographically when there is a perforation of the bone, ero-
sion from the inner surface of the bone, or extensive erosion or defects on the outer
bone surface. CBCT can allow bone defects of the cancellous bone and cortical
bone to be seen separately. The ability to visualize early stages of apical
Radiographic Description of Oral and Maxillofacial Pathology 107
periodontitis is significantly better when using CBCT, in comparison with periapi-

cal radiographs [9]. The healing information gained by a CBCT evaluation of peri-
apical repair following root canal treatment was comparable to histological analysis,
whereas conventional radiographs underestimated the size of the periapical lesion
[10]. One study showed that 34 % of the radiolucencies detected with CBCT were
missed with periapical radiography in maxillary premolars and molars [11]. It was
concluded that the detection of apical periodontitis was considerably higher with
CBCT than with periapical radiography [9]. Thus, CBCT was found to be a more
sensitive diagnostic method to identify apical periodontitis.
Radiographic Description of Oral and Maxillofacial Pathology
Radiolucent/Radiopaque Lesions of the Jaws
Odontogenic cysts and tumors present problems of diagnosis, radiology, and histo-
pathology. In general, their differential diagnosis requires radiographic clinical
data, since many of them possess similar histological characteristics. Radiologic
appearance of jaw cysts and odontogenic tumors varies considerably. The common
lack of physical findings and the development of most of these lesions within the
confines of the bone make radiologic investigation and interpretation uniquely
important. Radiographs are also important in treatment planning for surgical
removal. They can evaluate encroachment on vital structures, extent into soft tissue,
size of the lesion, and requirements for reconstruction. Radiography allows for cre-
ation of a radiologic differential diagnosis [12].
The radiopaque lesions of the jaws are:
1. Cementoblastoma
2. Odontoma, osteoma, or osteochondroma
3. Fibrous dysplasia (late stage)
4. Torus
The radiolucent lesions of the jaws are:
1. Dental granuloma
2. Incisive canal cyst
3. Simple bone cyst
4. Central giant cell granuloma
5. Ameloblastoma
6. Odontogenic keratocystic tumor
7. Odontogenic myxoma
8. Radicular cyst
9. Dentigerous cyst
The mixed radiopaque/radiolucent lesions of the jaws are:
1. Chronic osteomyelitis
2. Cemento-osseous dysplasia
3. Osteosarcoma
5. Ossifying fibroma
4. Metastasis
5. Early stage fibrous dysplasia
Periapical Cyst or Radicular Cyst
The most common odontogenic cysts of the jaws are periapical cysts, also called
radicular cysts, root end cysts, periodontal cysts, apical periodontal cysts, and dental
cysts; they are most commonly seen in patients aged 20–60 years old. These cysts
are caused by pulpal necrosis secondary to dental caries or trauma. The cysts appear
as a well-defined radiolucency around the apical foramen of a tooth (Fig. 4.6) and
are slowly progressing and painless if not infected or until they cause expansion of
the cortical plates. Once the infection enters a tooth, it can cause an abscess and
painful swelling. Larger cysts can involve a complete quadrant causing some bone
resorption, mobility of teeth, and necrotic pulps. These cysts can persist even after
the extraction of the associated tooth and are called residual cysts. Enucleation is the
normal treatment for a small or medium radicular cyst, while larger cysts may need
to be treated by marsupialization [13–15].
Fig. 4.6 A CT scan showing

a periapical cyst eroding the
right anterior wall of the
maxilla (GNU Free
Documentation License)
Lateral Periodontal Cyst 109
Dentigerous Cyst or Follicular Cyst
The second most common odontogenic cysts of the jaws are dentigerous cysts,
sometimes called a follicular cyst. These cysts are thought to be of developmental
origin, and they are commonly seen surrounding the crown of an impacted tooth,
mostly the mandibular third molar, and are caused by the accumulation of fluid
between the enamel and epithelium. These cysts are usually asymptomatic, but they
can become inflamed and produce swelling and pain. Dentigerous cysts are seen on
radiographs as a unilocular radiolucency with well-defined sclerotic borders, asso-
ciated with the crown of an unerupted tooth. The borders of an infected cyst can be
ill defined. Small dentigerous cysts are removed surgically; larger cysts are treated
by marsupialization or decompression.
Keratocystic Odontogenic Tumor
The keratocystic odontogenic tumor (KCOT) accounts for 10–20 % of all develop-
mental odontogenic cysts; it was formerly known as the keratinized primordial cyst
[16]. The tumor most commonly occurs in the mandible growing within the medul-
lary cavity of the bone, but without causing any bone expansion. An unerupted
tooth is involved in the development of 25–40 % of these tumors. Multiple tumors
can be seen in a patient with Gorlin syndrome who has nevoid basal cell carci-
noma. KCOTs are associated with genetic mutations in the gene PTCH which is
part of the hedgehog signaling pathway (patched drosophila). The tumor has a
well-defined radiolucent area with a smooth corticated margin. Large lesions in
posterior body and ascending ramus of the mandible have a multilocular radiolu-
cency. The treatment for this tumor is its removal by enucleation and curettage;
however, the tumor has a tendency to recur due to the formation of new “daughter”
cysts from dental lamina [17].
Lateral Periodontal Cyst
Lateral periodontal cyst is a rare asymptomatic lesion that arises from the epithelial
rest of Malassez which is a remnant from odontogenesis. It is seen mainly in the
mandible in canine-premolar bicuspid region. It is usually seen by chance in routine
radiographs. Radiographically, it appears as a well-circumscribed radiolucent area
located laterally to the roots of a vital tooth. Occasionally, this cyst appears as mul-
tilocular (poly cystic) named botryoid odontogenic cyst. The affected tooth is usu-
ally vital and has no indication for root canal treatment unless it has a non-vital or
necrotic pulp diagnosis following sensibility testing. The treatment for the cyst is
surgical enucleation [13].
Ameloblastoma
Ameloblastomas are rare but are the most common tumors of the mandible as seen
in Fig. 4.7. Ameloblastomas arise from the ameloblast cells which form enamel
during tooth development. Most ameloblastomas are benign. The most common
site for an ameloblastoma to develop is the ascending ramus and proximal body of
the mandible. Ameloblastomas can be divided into three subtypes: unicystic, mul-
ticystic, and peripheral based on their radiological appearance. Multicystic amelo-
blastomas account for approximately 85 % of all ameloblastomas and occur
between the ages of 30 and 70 years. On radiographs, it is typically seen as rounded
and cyst like; the radiolucent area can appear multilocular. There is often a marked
buccolingual cortical expansion with internal osseous septae, giving rise to a “soap
bubble” appearance. Tooth displacement or root resorption may occur. Unicystic
ameloblastomas occur in a younger age group and tend to be noninvasive. They
present as a well-circumscribed, unicystic, radiolucent lesion, mostly in the region
of the mandibular third molar [18]. While chemotherapy, radiation therapy, curet-
tage, and liquid nitrogen have been effective in some cases of ameloblastoma, sur-
gical resection or enucleation remains the most definitive treatment for this
condition [13].
Fig. 4.7 Ameloblastoma seen in a CT scan (left) and after resection (right) where the ameloblas-
toma initiated at the third molar. These images are taken from Wikipedia commons and are the
work of Berto1286 a dental student at UCLA
Cementoblastoma 111
Central Giant Cell Granuloma
The central giant cell granuloma (CGCG) is a benign condition of the jaws. It is
twice as likely to affect women and is most likely to occur in 20–40-year-old peo-
ple. CGCGs are most common in the anterior part of mandible with a tendency to
cross the midline. The CGCG manifests as a small unilocular lucent lesion and it
develops into a multilocular with fine trabeculae. CGCCs are defined as nonaggres-
sive and aggressive; the aggressive form grows rapidly and can absorb the roots and
the cortical plate. Brown tumor of hyperparathyroidism can mimic CGCGs radio-
logically as well as pathologically; however, the patient’s age, radiological changes
in other bones, and biochemical findings help in differentiation [19]. The treatment
for CGCG is thorough curettage. The recurrence ranges from 15–20 %.
Odontoma
Odontomas are considered to be a hamartoma of odontogenic origin rather than a neo-

plasm. The average age of a patient with an odontoma is 22 ± 9 years, and it is associated
with an interrupted tooth [20]. Radiologically, it is seen as a radiopaque mass surrounded
by thin radiolucent space. The compound odontomas are composed of multiple well-
formed teeth, whereas the complex odontomas appear as an irregular calcified tissue. A
related but very rare lesion is ameloblastic fibro-odontoma. Most cases occur in young
males involving posterior jaws and may expand into the ramus. The amount of radiolu-
cent internal structure exceeds the odontomas component [19, 21].
Ossifying Fibroma or Osteofibrous Dysplasia
Ossifying fibroma is rare and is also known as an osteofibrous dysplasia. It is a rare,

benign nonneoplastic condition with no known cause, although it is considered a
fibrovascular defect. An ossifying fibroma has a slow expansile growth, and it can
expand the cortices and displace adjacent structures. True benign tumors of mesen-
chyme have a strong predilection for tooth-bearing sections of the jaw. Most patients
are females aged 20–40 years. The early ossifying fibroma appears radiolucent in
radiographs, and mature lesions appear more opaque. Small ossifying fibromas can
be removed by enucleation and curettage. The ossifying fibroma can grow very
large, and these will require removal by local resection. Recurrence of the lesions is
rare [13, 22].
Cementoblastoma
Cementoblastoma, or benign cementoblastoma, is a benign neoplasm of the cemen-

tum of the teeth and is derived from ectomesenchyme of odontogenic origin [23].
The cementoblastoma is very rare and accounts for less than 0.69–8 % of all
odontogenic tumors. The cementoblastoma occurs mostly in males under the age of
25 years, and it forms a mass of cementum and cementum-like tissue on the roots
of the teeth, usually the mandibular first molar. The involved tooth normally has a
vital pulp in the early stages of the cementoblastoma; in the later stages, root
resorption, toothache, and tooth mobility may be observed. In radiographs, the
cementoblastoma appears as a well-defined radiopaque mass with a round or sun-
burst appearance [24]. The cementoblastoma is removed with the tooth if it is
resorbed by surgical excision, and curettage is recommended to reduce the high
recurrence rate [25].
Focal-Osseous Dysplasia or Cemento-osseous Dysplasia
Focal osseous dysplasia (FOD) or cemento-osseous dysplasia, or florid cemento-

osseous dysplasia, is the most common benign fibro-osseous lesion of the jaw
bones. It is believed that FOD originates from the fibroblasts within a periodontal
ligament. FOD is mostly seen in females and occurs more frequently in African-
Americans. Radiographically, FOD has a variable appearance and can appear as a
radiolucent to radiopaque lesion that can be clearly or poorly defined. FOD biopsies
contain fragments of bony trabeculae within fibrous stroma. The main differential
diagnosis is with ossifying fibroma, which is neoplastic, while FOD is considered a
reactive process. Most patients with FOD may be followed clinically without surgi-
cal intervention, and treatment can be considered if the FOD transforms into
cement-osseous dysplasia [26].
Odontogenic Myxoma
Odontogenic myxoma is a rare benign tumor arising from the connective tissue
associated with tooth formation [27]. The myxoma consists mainly of spindle-
shaped cells and scattered collagen fibers [28]. The myxoma is most common in the
mandible, between the molar and premolar of patients aged 25–35 years of age. The
patient notices a painless swelling of the jaw with tooth loosening or displacement.
A maxillary myxoma can enlarge into the sinuses, and a mandibular myxoma can
enlarge into the ramus. The myxoma can appear in radiographs as a unicystic, mul-
tilocular, or pericoronal radiolucency with ill-defined borders. The septae visible in
the myxoma are thin and straight or curved and course causing a honeycomb appear-
ance, resembling a soap bubble-like radiograph of an ameloblastoma. Small myx-
oma tumors can be treated with enucleation and curettage followed by chemical
bone cautery. Large myxoma tumors require resection of the tumor and surrounding
bone. Multilocular myxoma tumors exhibit a 25 % recurrence rate and, therefore,
must be treated more aggressively to completely remove the tumor and reduce the
risk of recurrence [27, 28].
Solitary Eosinophilic Granuloma
Solitary eosinophilic granuloma of the jaws is a form of benign Langerhans cell his-
tiocytosis [13] that occurs mainly in adolescents and young adults. The etiology of the
granulation is unknown. The granuloma is most commonly seen in the mandible, and
it can cause painful swelling and bone destruction. In radiographs, the lesion is circu-
lar and gives the appearance of teeth floating. The granuloma is treated with curettage.
In some cases, the granuloma will spontaneously regress and it can reoccur.
Summary
Patients are worried about the radiation from x-rays, even though the amount is very
low; care must always be taken to reduce your own and the patient’s exposure to
radiation. Having a low exposure to radiation can help reduce the risks of develop-
ing cancer later in life. But do not be afraid of retaking radiographs that are needed
to diagnose pathology and to decide on an accurate treatment plan. It is better to
have good-quality radiographs than have to interpret poor-quality radiographs that
are out of focus and angled incorrectly.
1. Dental radiographs can show hidden dental structures such as cavities, anoma-
lies, malignant or benign masses, impacted wisdom teeth, periapical lesions,
and bone resorption that cannot be seen during a visual examination.
(a) False
(b) True
2. Dental materials for tooth restoration with filings and crowns, or root canal
obturation and sealing can appear lighter or darker depending on the density of
the material. Most dental materials contain a radiopaque material such as bar-
ium sulfate to help visualize the material in radiographs.
(a) False
(b) True
3. Bitewing radiographs are routinely used to detect tooth decay and recurrent
caries under existing restorations.
(a) False
(b) True
4. Periapical radiographs are taken to visualize the root apex, periapical tissues,
and bone surrounding the teeth that a patient is complaining of being painful
and/or has swelling and/or the symptoms of infection.
(a) False
(b) True
5. Occlusal radiographs are taken to visualize the skeletal or pathologic anatomy

of either the floor of the mouth or the palate.
(a) False
(b) True
6. Panoramic radiographs are occasionally taken using extraoral films and show a
broad view of the jaws, teeth, sinuses, nasal area, and temporomandibular joints
and anatomic structures.
(a) False
(b) True
7. Digital radiographs are an acceptable first choice for the diagnosis and treat-
ment of dental pathology.
(a) False
(b) True
8. Cone beam computed tomography (CBCT) imaging is becoming a comple-
mentary technology and in many instances can provide 3-dimensional oral
pathology information that might have been overlooked on 2-dimensional
images.
(a) False
(b) True
9. Odontogenic cysts and tumors can be identified using radiology, clinical diag-
nosis, and histopathology.
(a) False
(b) True
10. The most common odontogenic cysts of the jaws are periapical cysts, also
called radicular cysts, root end cysts, periodontal cysts, apical periodontal cysts,
and dental cysts; they are most commonly seen in patients aged 20–60 years
old.
(a) False
(b) True
11. The second most common odontogenic cysts of the jaws are dentigerous cysts,
sometimes called a follicular cyst.
(a) False
(b) True
12. The keratocystic odontogenic tumor (KCOT) accounts for 10–20 % of all
developmental odontogenic cysts; it was formerly known as the keratinized
primordial cyst.
(a) False
(b) True
13. The lateral periodontal cyst is a rare asymptomatic lesion that arises from the
epithelial rest of Malassez which is a remnant from odontogenesis.
(a) False
(b) True
14. Ameloblastomas are rare but are the most common tumors of the mandible.
(a) False
(b) True
Bibliography 115
15. The central giant cell granuloma (CGCG) is a benign condition of the jaws. It
is twice as likely to affect women and is most likely to occur in 20–40-year-old
people.
(a) False
(b) True
16. Odontomas are considered to be a hamartoma of odontogenic origin rather than
a neoplasm.
(a) False
(b) True
17. Cementoblastoma is a rare benign neoplasm of the cementum of the teeth and
is derived from ectomesenchyme of odontogenic origin.
(a) False
(b) True
18. Patients can worry about the radiation from radiographs, even though the
amount is very low; care must always be taken to reduce your own and the
patient’s exposure to radiation.
(a) False
(b) True
19. You should not be afraid of retaking radiographs that are needed to diagnose
pathology and to decide on an accurate treatment plan.
(a) False
(b) True
20. It is better to have good-quality radiographs than have to interpret poor-quality
radiographs that are out of focus and angled incorrectly.
(a) False
(b) True
(The correct quiz answers are all b. True)
Bibliography
1. American Dental Association, Healthy Mouth, Chicago, IL, USA, 2013.
2. Berk RN. Eugene W. Caldwell Lecture. The American Journal of Roentgenology: past, pres-
ent, and future. AJR Am J Roentgenol. 1995;164:1323–8.
3. White SC, Pharoah MJ. Oral radiology: principles and interpretation. 5th ed. St. Louis: Mosby
Inc; 2004. p. 25.
4. Seynaeve PC, Broos JI. The history of tomography (In Dutch). J Belge Radiol.
1995;78:284–8.
5. Ludlow JB, Ivanovic M. Comparative dosimetry of dental CBCT devices and 64-slice CT for
oral and maxillofacial radiology. Oral Surg Oral Med Oral Pathol Oral Radiol Endod.
2008;106:106–14.
6. Scarfe WC, Levin MD, Gane D, Farman AG. Use of cone beam computed tomography in
endodontics. Int J Dent. 2009;2009:634567. http://hindawi.com/journals/ijd/2009/634567.
html. Accessed 26 Oct 2010.
7. Estrela C, Bueno MR, Leles CR, Azevedo B, Azevedo JR. Accuracy of cone beam computed
tomography and panoramic and periapical radiography for detection of apical periodontitis.
J Endod. 2008;34:273–9.
8. Cotti E, Campisi G. Advanced radiographic techniques for the detection of lesions in bone.
Endod Top. 2004;7:52–72.
9. Patel S, Mannocci F, Wilson R, Dawood A, Pitt Ford T. Detection of periapical defects in
human jaws using cone beam computed tomography and intraoral radiography. Int Endod
J. 2009;42:507–15.
10. Paula-Silva FG, Wu MK, Leonardo MR, da Silva LA, Wesselink PR. Accuracy of periapical
radiography and cone beam computed tomography scan in diagnosing apical periodontitis
using histopathological findings as a gold standard. J Endod. 2009;35:1009–12.
11. Low K, Dula K, Burgin W, von Arx T. Comparison of periapical radiography and limited cone
beam computed tomography in posterior maxillary teeth referred for apical surgery. J Endod.
2008;34:557–62.
12. Escobar E, Godoy L, Peñafiel C. Odontogenic cysts: analysis of 2.944 cases in Chile Germán
Ochsenius. Med Oral Patol Oral Cir Bucal. 2007;12:E85–91.
13. Cawson RA, Odell EW. Cawson’s essentials of oral pathology and oral medicine. 8th ed.
Edinburgh: Churchill Livingstone; 2008. p. 145–6.
14. Samuels HS. Marsupialization: effective management of large maxillary cysts. Oral Surg Oral
Med Oral Pathol. 1965;20:676–83.
15. Şahin S, Saygun NI, Çanakçı CF, Öngürü Ö, Altug HA. Root canal treatment failure mediated
lateral radicular cyst: case report. T Klin J Dental Sci. 2009;15:214–9.
16. Madras J, Lapointe H. Keratocystic odontogenic tumour: reclassification of the odontogenic
keratocyst from cyst to tumour. J Can Dent Assoc. 2008;74:165–165h.
17. Mendes RA, Carvalho JF, Van der Waal I. Characterization and management of the keratocys-
tic odontogenic tumor in relation to its histopathological and biological features. Oral Oncol.
2010;46:219–25.
18. DelBalso AM. An approach to the diagnostic imaging of jaw lesions, dental implants, and the
temporomandibular joint. Radiol Clin North Am. 1998;36:855–90.
19. Altug HA, Altug H, Sari E, Sencimen M, Altun C. Diagnosis and surgically management of
supernumerary teeth in both the primary and the permanent dentitions. J Gazi Univ Fac Dent.
2010;27:77–82.
20. Miki Y, Oda Y, Iwaya N, Hirota M, Yamada N, Aisaki K, Sato J, Ishii T, Iwanari S, Miyake M,
Kudo I, Komiyama K. Clinicopathological studies of odontoma in 47 patients. J Oral Sci.
1999;41:173–6.
21. Weber AL. Imaging of the cyst and odontogenic tumors of the jaw. Definition and classifica-
tion. Radiol Clin North Am. 1993;31:101–20.
22. Ortakoğlu K, Aydıntuğ YS, Altug HA, Okçu KM, Günhan Ö. Benign fibroosseous lesions.
Turk J Dent. 2006;65:132–6.
23. Sankari LS, Ramakrishnan K. Benign cementoblastoma. J Oral Maxillofac Pathol.
2011;15:358–60.
24. Sumer M, Gunduz K, Sumer AP, Gunhan O. Benign cementoblastom. A case report. Med Oral
Patol Oral Cir Bucal. 2006;11:e483–4855.
25. Huber AR, Folk GS. Cementoblastoma. Head Neck Pathol. 2009;3:133–5.
26. Summerlin DJ, Tomich CE. Focal cemento-osseous dysplasia: a clinico-pathologic study of
221 cases. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 1994;78:611–20.
27. Lin Y-L, Basile JR. A case of odontogenic myxoma with unusual histological features mim-
icking a fibro-osseous process. Head Neck Pathol. 2010;4:253–6.
28. Lahey E, Woo S-B, Park H-K. Odontogenic myxoma with diffuse calcifications: a case report
and review of the literature. Head Neck Pathol. 2013;7:97–102.
Endodontic Access Considerations
Based on Root Canal Morphology 5
Access Preparation
The endodontic access is a convenient, direct preparation used to locate and enter all
root canals. The access position and design are determined by the size of the pulp
chamber, the age of the tooth, the previous restorative efforts, the long axis of the
tooth, and the root curvature. In the past, access cavities tended to be standardized
depending on tooth type; however, with modern endodontic techniques, a dental
operating microscope, and loupes providing magnification and better illumination,
an access cavity is now mostly dictated by the individual pulp chamber morphology
of the tooth being treated (Fig. 5.1).
A well-executed access is necessary for proper endodontic therapy to uncover
and locate all canals, biomechanically remove infected tissues, disinfect the remain-
ing tooth structure, and completely obturate and also seal the root canals. Unless the
access preparation to the canal orifices and the apical foramina is sized and posi-
tioned properly, achieving the goals of high-quality endodontic treatment will be
Fig. 5.1 A straight-line

access preparation into the
root canals

DOI 10.1007/978-3-662-43730-8_5
118 5 Endodontic Access Considerations Based on Root Canal Morphology
Table 5.1 Root canal access preparation

1 All defective restorations and caries should have been removed to solid tooth structure
2 The surface of the root canal should be visible, and all canal orifices should be identifiable
3 The root canal should be totally cleared of all overhanging enamel and dentin. The root
canal chamber should blend continuously with each canal orifice
4 The access preparation should provide as direct an approach as possible all the way through
to the apical foramen of the root canal
5 Weak, unsupported cusps should be relieved from occlusion to reduce the possibility of
accidental fractures accompanying the consequent change in tooth measurement to reduce
pain from hyper-occlusion
6 The access design may also be modified during root canal preparation to minimize
instrument torque or root perforation and stripping.
7 A severely curved root may require that the access be relocated in the opposite direction to
facilitate anti-curvature filing
8 In calcified teeth, the pulp chamber diameter is usually minimal, and the canal orifices are
difficult to locate. To reduce the danger of root perforation, remove the rubber dam for
better orientation. A radiograph may also be helpful at this point to check the progress of the
access preparation
difficult and time-consuming. Achieving adequate access to the root canal is the key
to accomplishing endodontic success [1].
Criteria for the Root Canal Access Preparation
The completed access should demonstrate all the eight characteristics described in
Table 5.1.
Aging of the Dental Pulp
The odontoblast cells within dental pulp create the roots of the teeth through a pro-
cess of dentinogenesis during tooth development [2]. The dental pulp initially occu-
pies the root canal space within each root of a tooth. The root canal space containing
dental pulp reduces in volume throughout life, because of dentinogenesis, which is
the continual calcification and mineralization process of odontoblasts [3]. As a
patient gets older, their root canals become more calcified and narrower, and in old
age the root canals of teeth can be completely calcified with no apparent dental pulp
remaining [4]. The changes that occur in vital teeth between the ages of 10–30 years
and 51–60 years are a reduction in root pulp width by 75 %, and increase in root
dentin thickness by 46 % is shown in Table 5.2.
Removal of the Dental Pulp
The cells of the dental pulp are not essential to the maintenance or survival of fully
mature teeth or for the survival of immature teeth that are almost fully developed
and which have strong roots [5]. Many teeth can be maintained for the lifetime of a
Law of Root Canal Centrality 119
Table 5.2 Age-related changes in vital teeth

10–30 years 51–60 years Percentage
Variable Premolar aspect mean mean change (%)
Dentin thickness (mm) Crown 1.3 1.7 +31
Root 1.1 1.6 +46
Pulp width (mm) Crown 2.1 0.9 −57
Root 1.6 0.4 −75
Pulp area (mm2) Crown and root 14.2 9.9 −30
Pulp cells (odontoblasts per mm pulp Crown 253 298 −16
dentin border) Root 258 147 −43
patient without a dental pulp [6]. The dental pulp must be removed or be disinfected
if it is painful, necrotic, infected with bacteria, and/or irreversibly inflamed [7].
Removal of the entire necrotic dental pulp requires adequate access to the root canal
space. Removal of the dental pulp begins with an analysis of the anatomy of the
tooth that needs endodontic treatment and the tooth-supporting tissues. In order to
remove the dental pulp, the location of the coronal pulp chamber and the pulp within
the roots must be visualized.
Identifying the Shape and Position of the Cement-Enamel

Junction
Prior to accessing the root canal of the teeth, the physical identification of the shape
and position of the cement-enamel junction (CEJ) should be determined. The circum-
ference of the CEJ should be explored using a periodontal probe as shown in Fig. 5.2.
After the CEJ has been visualized, an access penetration location on the occlusal
surface can be selected which will give a straight-line access for instruments into the
root canal(s) as seen in Fig. 5.3.
Caution is needed when a tooth has a prosthetic crown. This is because the crown
center is not always centered over the CEJ.
To help visualize the location of the dental pulp, there are laws to be used to help
position the access and find the orifices to root canals:
Root canal centrality

Root canal concentricity
Dentin color change
Symmetries 1 and 2
Orifice locations 1 and 2
Law of Root Canal Centrality
The law of root canal centrality means the root canal space containing dental pulp,
or which once contained dental pulp, is located at the center of the tooth at the level
of the cement-enamel junction (CEJ) [8]. The center location of the root canal space
can be seen in Fig. 5.4.
Fig. 5.2 Visualizing the CEJ

by probing the margins
of the tooth
Fig. 5.3 An access that

allows instruments straight-
line access into the root
canals
The law of root canal centrality is a useful guide for positioning the bur and
directing it toward the center of the CEJ when preparing the root canal access.
Preparing the access can often mean ignoring the physical direction of the crown or
restored crown of a tooth and checking radiographs and roots to aim for the imag-
ined center of the CEJ [9]. Do not assume that oversized prosthetic crowns are
centered over the CEJ, most are not, and this can distort the mental image of the
location of the CEJ center [10].
Law of Root Canal Concentricity
The law of root canal concentricity states that the walls of the pulp chamber are
concentric to the external outline of the tooth at the level of the CEJ [10] as shown
in Fig. 5.5.
Tooth Angulations 121
Fig. 5.4 The law of root

canal centrality shown in a
molar
Fig. 5.5 The concentric

walls of the root canal at the
level of the CEJ. The
double-sided arrows shows
equal dentin thickness
The law of concentricity is useful to estimate the location and size of the root
canal access preparation [11]. If there is an external bulge of the CEJ root surface,
there will also be an internal bulge of the root canal that corresponds to the same
direction as the bulge. A tooth which narrows externally will also have a narrow root
canal internally corresponding to the same direction as shown in Fig. 5.6.
Tooth Angulations
After deciding where the root canal access should be located to pass through the
center of the CEJ, the next step is to determine the angulation of the tooth so that
the surfaces of the canal are aligned with the access. The angulation of the tooth
can be estimated from radiographs, CBCT, and less easily by clinical
observation.
Fig. 5.6 The narrow

concentric walls of the root
canal at the level of the CEJ.
The double-sided arrow show
equal dentin thickness
Distance from the Cusp Tip to the Floor of the Pulp Chamber
Prior to preparing the root canal access, the distance from the cusp tip to the pulp
chamber floor should be measured from a radiograph as shown in Fig. 5.7. The bur
for preparing the root canal access should be shorter than that distance to prevent the
bur from causing a perforation in the furcation [12]. The perforation of the root
canal is less likely if the bur is directed toward the center of the CEJ parallel to the
long axis of the tooth.
Positioning the Root Canal Access
The starting position of the root canal access should only be decided after the CEJ
perimeter, the angulation of the long access of the tooth, and the distance to the floor
of the pulp chamber have been determined [13]. This is because the precise location
of the root canal access on the occlusal surface of the tooth is dependent on all of
these factors. Do not relocate the access location to a pit or fossa, as these are not
necessarily helpful access locations.
Access Modification
In order to prepare a straight instrumentation path to the apical one-third of a tooth,

it may be necessary to sacrifice some of the sound coronal tooth structure. Moreover,
the initial access may have to be widened to obtain access to all the root canal sur-
faces. When the access is cut too small, it is difficult to find all the canals. The
removal of tooth structure concept may be difficult to reconcile with the conserva-
tion of tooth structure. However, to lose a tooth because of inadequate cleaning and
shaping of the root canal resulting from insufficient access cannot be considered to
be conserving the teeth. Alternatively, access cavities that are too large increase the
risk of perforation and tooth fracture.
Root Canals by Tooth Type 123
Fig. 5.7 Measurement of the

distance between the cusp tip
to the floor of the pulp
chamber using a radiograph
Anatomical variations and situations that may dictate such modifications may
include the following:
1. Teeth in lingual version

2. Overlapped teeth
3. Deep cervical erosion
4. Altered coronal anatomy in restoration
5. Severe incisal abrasion
Root Canals by Tooth Type
Mandibular First Molar Teeth
Mandibular molar teeth normally have two roots in which there are commonly three
or four root canals. The mesial root nearly always has two mesial canals (mesiolin-
gual and mesiobuccal) linked by a developmental groove. The mesiobuccal root
canal orifice is usually located under the mesiobuccal cusp tip, and the mesiolingual
canal will be slightly to the buccal of the mesiolingual cusp tip.
Approximately 60 % of distal roots have only one canal, and the remaining 40 %
have two canals (distolingual and distobuccal). Approximately 5 % of mandibular
molar teeth have three mesial canals; the third mesial (middle mesial) canal is usu-
ally located along the developmental groove between the mesiobuccal and mesio-
lingual canals. Approximately 5 % of molar teeth have a third (distolingual) root
which can be seen on a preoperative radiograph, and careful widening (buccolin-

gually) of the distal canal may reveal a second distal canal orifice [14].
Mandibular Second Molar Teeth
The anatomy of second molar teeth is more varied than that of first molars, and the
incidence of two distal canals in second mandibular molar teeth is less than in first
molars. The pulp chamber volume and canal entrances are smaller compared to first
molars. In a few mandibular second molar teeth, the roots may be fused resulting in
one main C-shaped canal (in cross section) once preparation has been completed [14].
Maxillary First Molar Teeth
Maxillary molar teeth normally have three roots, with three or four canals. The pala-
tal and distobuccal roots each have one canal. Approximately 90 % of maxillary
first molar teeth and 45 % of second molars have two mesiobuccal canals (MB1 and
MB2) in the mesiobuccal root. The palatal canal is the largest of the canals, and its
orifice is located in the middle of the palatal half of the tooth.
The mesiobuccal root is flatter (mesiodistally) resulting in the mesiobuccal canal
entrances being ribbon shaped. Care must be taken to prevent the mesiobuccal canals
being over prepared mesiodistally. The MB1 canal is located just palatal to the
mesiobuccal cusp tip. The MB2 canal orifice can be challenging to locate and ideally
should be identified once the first three canals have been prepared. It is usually
located within 2 mm of the MB1, between the MB1 entrance and the palatal canal
entrance. The canal entrance is usually covered with a ridge of dentin which has to
be removed before the MB2 can be identified. Ultrasonic tips and/or small rose head
burs (LN Burs) are ideal to gently remove this ridge of dentine covering the MB2
canal entrance. The MB2 opening will feel sticky when probed with a DG16 [14].
Maxillary Second Molar Teeth
The roots of second molars tend to be very close together or even fused together;
hence, the canal orifices in second molar teeth tend to be located more closely to
each other. It is common to find all three or four root canal entrances lying along the
same line between the mesiobuccal and palatal canals [14].
Bur Size for a Root Canal Access
The most common mistake is to select a bur that is larger than necessary. The use of
burs larger than a #2 round for anterior and premolar access, or a #4 round for molar
access, increases the size of the final cavity preparation, as well as significantly
Technique for Root Canal Access 125
increasing the potential for tooth perforation. Once the bur has dropped into the pulp
chamber, it has accomplished its purpose to cut the initial access, and it is replaced
with a tapered diamond bur.
Technique for Root Canal Access
Step 1
All defective restorations and caries decay should be removed, prior to preparing
the root canal access. This is to prevent the microleakage of bacteria into the root
canals from leaky restorations and the recurrence of caries lesions which causes
tooth decay.
Step 2
The selection of bur type, bur size, and bur shape to prepare a root canal access can
vary between dentists [15]. The most commonly used burs are a #4 carbide bur or a
round diamond bur or a #557 taped fissure bur. Metal-cutting fissure burs may be
needed to remove prosthetic crowns. The bur should be positioned on the occlusal
surface at the point determined by the pre-access factors:
(i) Cement-enamel junction perimeter

(ii) Angulation of the tooth
(iii) Pulp chamber floor distance from the crown
The bur should be advanced toward the center of the mentally imaged CEJ until
a drop is felt indicating the pulp chamber is 2-mm deep, or the head of the hand-
piece touches the cusp. Teeth with a calcified pulp have constricted canals which are
more difficult to instrument. The most difficult teeth to clean and shape should be
referred to an endodontist.
Step 3
The goal of root canal access is to remove the roof of the pulp chamber completely.
Only after the roof is completely removed should the search for orifices begin; this
is because of the danger of perforating the dentinal walls leading to a perforation.
The root canal orifices in the floor of the pulp chamber will be revealed once the
roof has been removed and access is complete.
The root canal chamber can be unroofed by using straight bur kept at a parallel
angle to the long axis of the tooth or by placing a round bur into the access engag-
ing laterally under the remaining overhang and then withdrawing the bur
occlusally.
Law of Dentin Color Change
It is not easy to know when the access is finished. Seeing a color change in the den-
tin when it is close to the pulp chamber is helpful, known as the law of dentin color
change [8]. This law states that the color of the dentin closest to the pulp chamber
is always darker than the surrounding dentin. Overhangs appear darker and should
be removed. When the access is finished, the entire pulp chamber floor can be seen
as shown in Fig. 5.4.
If is not possible to complete the access satisfactorily, the procedure should be
stopped and the tooth be temporarily restored, and the case transferred to a more
experienced endodontist for treatment.
Orifice Number and Location
Counting the roots in a radiograph can indicate the number of roots which have a
canal, and each noncalcified canal will have an orifice in the floor of the pulp cham-
ber. In addition, knowing the average numbers of roots with canals for each tooth
type and their position in the floor of the pulp chamber can help. However, the
number and location of root canal orifices can never be fully known until the floor
of the pulp chamber has been fully examined and probed.
The most effective method of finding orifices is to visualize the pulp chamber
floor and use the laws of symmetry and orifice location.
Law of symmetry 1: In all teeth, except for the maxillary molars, the orifices of root
canals are equidistant from a line drawn in a mesiodistal direction through the
center of the pulp chamber floor [8].
Law of symmetry 2: In all teeth, except for the maxillary molars, the orifices of the
canals lie on a line perpendicular to a line drawn in a mesiodistal direction
through the center of the pulp chamber floor [8].
Law of orifice location 1: The orifices of the root canals are always located at the
junction of the walls and the floor [8].
Law of orifice location 2: The orifices of the root canals are located at the vertices
of the floor-wall junction [8]. After the floor-wall junction is clearly seen, all of
the laws of symmetry and orifice location can be used to identify the exact posi-
tion and number of orifices.
The law of orifice locations 1 and 2 can be used to identify the number and posi-
tion of the root canal orifices of the tooth. Because all of the orifices can only be
located along the floor-wall junction, indentations, black or white dots, that are
observed anywhere else (e.g., the chamber walls or in the dark chamber floor) must
be ignored to avoid possible perforation. The law of orifice location 2 can help to
focus on the precise location of the orifices. The vertices or angles of the geometric
shape of the dark chamber floor will specifically identify the position of the orifice.
The dark color change at the vertex will indicate where to remove the dentin to
unroof the root canal. The law of orifice locations 1 and 2, in conjunction with the
law of color change, is often the only reliable indicator of the presence and location
of second canals in mesiobuccal roots of maxillary molars. The laws of symmetries
1 and 2 (except for the maxillary molars), color change, and orifice locations 1 and
2 are valuable when unusual anatomy is observed in radiographs.
Summary
A knowledge of tooth anatomy, combined with magnification, illumination, and

ultrasonic endodontic tips, enhances the identification of root canal orifices in molar
teeth. The most important consideration for the position, size, and shape of the
access is to gain a straight-line endodontic access to the root canals. If the access is
not adequate for endodontic treatment, it could compromise the cleaning, shaping,
and obturation of the root canals which could increase the risk of treatment
failure.
1. The odontoblast cells within dental pulp create the roots of teeth through a
process of dentinogenesis during tooth development?
(a) False
(b) True
2. Dental pulp initially occupies the root canal space within each root of a tooth?
(a) False
(b) True
3. The root canal space containing dental pulp reduces in volume throughout life,
because of dentinogenesis, which is the continual calcification and mineraliza-
tion process of odontoblasts?
(a) False
(b) True
4. As a patient gets older their root canals become more calcified and narrower, in
old age the root canals of teeth can be completely calcified with no apparent
dental pulp remaining?
(a) False
(b) True
5. The continuing mineralization processes within the root canals of teeth give
rise to alterations in root canal morphology which can present challenges for
the ideal position of the endodontic access?
(a) False
(b) True
6. The goal of the access is to locate and provide the direct access of files and
instruments into the root canals of the tooth?
(a) False
(b) True
7. The position and design of the access is determined by the size of the pulp
chamber, the age of the tooth, previous restorative efforts, the long axis of the
tooth, and root curvature?
(a) False
(b) True
8. The location and design of the access cavity is dictated by the pulp chamber
morphology of the tooth being treated?
(a) False
(b) True
9. Achieving adequate access to the root canal is the key to accomplishing end-
odontic success?
(a) False
(b) True
10. Prior to accessing the root canal of teeth, the physical identification of the shape
and position of the Cemento-Enamel Junction (CEJ) should be determined?
(a) False
(b) True
11. In order to remove the dental pulp the location of the coronal pulp chamber and
the pulp within the roots must be visualized?
(a) False
(b) True
12. To help visualize the location of the dental pulp, there are laws to be used to
help position the access and find the orifices to root canals: Root canal central-
ity, Root canal concentricity, Dentin color change, Symmetry 1 and 2, and
Orifice location 1 and 2?
(a) False
(b) True
13. The cells of the dental pulp are not essential to the maintenance or survival of
fully mature teeth or for the survival of immature teeth that are almost fully
developed and which have strong roots?
(a) False
(b) True
14. Removal of the entire necrotic dental pulp requires adequate access to the root
canal space?
(a) False
(b) True
15. Mandibular molar teeth normally have two roots in which there are commonly
three or four root canals?
(a) False
(b) True
16. The anatomy of second molar teeth is more varied than that of first molars, and
the incidence of two distal canals in second mandibular molar teeth is less than
in first molars?
(a) False
(b) True
Bibliography 129
17. Maxillary molar teeth normally have three roots, with three or four canals?
(a) False
(b) True
18. The roots of second molars tend to be very close together or even fused together,
hence the canal orifices in second molar teeth tend to be located more closely
to each other?
(a) False
(b) True
19. The most common mistake is to select a bur that is larger than necessary. The
use of burs larger than a #2 round for anterior and premolar access, or a #4
round for molar access, increases the size of the final cavity preparation, as well
as significantly increasing the potential for tooth perforation?
(a) False
(b) True
20. If the access is not adequate for endodontic treatment, it could compromise the
cleaning, shaping and obturation of the root canals which could increase the
risk of treatment failure?
(a) False
(b) True
(The correct quiz answers are all (b). True)
Bibliography
1. Spasser HF, Kahn FH. Access–the cornerstone of endodontic success. N Y State Dent
J. 1968;34:471–8.
2. Bevelander G, Johnson PL. Odontoblasts and dentinogenesis (a histochemical study). J Dent
Res. 1946;25:381–5.
3. Murray PE, Stanley HR, Matthews JB, Sloan AJ, Smith AJ. Age-related odontometric changes
of human teeth. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2002;93:474–82.
4. Allen PF, Whitworth JM. Endodontic considerations in the elderly. Gerodontology.
2004;21:185–94.
5. Lee AH, Cheung GS, Wong MC. Long-term outcome of primary non-surgical root canal treat-
ment. Clin Oral Investig. 2012;16:1607–17.
6. Fonzar F, Fonzar A, Buttolo P, Worthington HV, Esposito M. The prognosis of root canal
therapy: a 10-year retrospective cohort study on 411 patients with 1175 endodontically treated
teeth. Eur J Oral Implantol. 2009;2:201–8.
7. Garcia-Godoy F, Murray PE. Recommendations for using regenerative endodontic procedures
in permanent immature traumatized teeth. Dent Traumatol. 2012;28:33–41.
8. Krasner P, Rankow HJ. Anatomy of the pulp chamber floor. J Endod. 2004;30:5.
9. Rankow HJ, Krasner P. The access box: an Ah-Ha phenomenon. J Endod. 1995;21:212–4.
10. American Association of Endodontists. Colleagues for excellence. Access opening and canal
location. Chicago: American Association of Endodontists; 2010.
11. Raturi P, Girija S, Subash TS, Mangala TM. Unravelling the mysteries of pulp chamber. J
Endodontology 2007;19:23–29.
12. Vertucci FJ, Haddix JE, Britto LR. Tooth morphology and access cavity preparation. In: Cohen
S, Hargreaves KM, editors. Pathways of the pulp. 9th ed. St Louis: CV Mosby; 2006.
p. 149–232.
13. Deutsch AS. Pulp chamber morphology: basic research leads to clinical technique. Dent
Today. 2005;24:124, 126–7.
14. Patel S, Rhodes J. A practical guide to endodontic access cavity preparation in molar teeth. Br
Dent J. 2007;203:133–40.
15. Zelikow R, Cozzarelli-Moldauer G, Keiner S, Hardigan PC. A method to minimize complica-
tions in endodontic access cavity preparation. Todays FDA. 2008;20:17–20.
Instrumentation (Techniques, File
Systems, File Types, and Techniques) 6
The success of nonsurgical endodontic root canal treatment requires the use of files
and instruments to remove necrotic and infected tissues. The steps in this process
are to use a hand file to obtain patency in all the root canals of a tooth, to measure
the working length of the teeth, and then to use rotary instruments to shape the root
canals in preparation for their sealing and obturation. If these steps are performed
correctly, endodontic treatment can retain a tooth that would otherwise require
extraction.
Cleaning and Shaping of the Root Canals
Cleaning and shaping are separate concepts but are always performed together [1].
The goal of cleaning the root canal is the removal of necrotic pulp and infected tis-
sues. The goal of shaping the canal is to maintain the apical foramen as small as
possible in its original anatomical position [2]. A good endodontic treatment out-
come is dependent on the removal of necrotic pulp and infected tissues to a low
level that cannot cause a flare-up which will require retreatment. If the root canals
are cleaned and shared adequately, the flare-up rate can be less than 2 % of cases [3],
although there are some reports of a 10 % flare-up rate [4]. Teeth with a less infected
root canal, or which have been infected with microorganisms for less time, gener-
ally lack a periradicular pathosis, and the success of endodontic treatment in these
teeth is generally higher [5]. Teeth which have a periradicular pathosis on radio-
graphs are more infected, and these teeth are more difficult to treat [6] and have a
higher risk of flare-ups and requiring retreatment. The most significant factors
affecting the instrumentation of teeth are tooth anatomy and morphology and the
types of instruments and irrigants used for treatment [7]. Instruments must contact
the root canal tissues to debride the canal; however, it has been shown that most of
the root canal surfaces are not touched by hand files or instruments, even with the
best efforts of the dentists [8]. The reasons why most of the surfaces are not touched
are because of the ribbon, conical, or irregular shape of the canal, in addition to the

DOI 10.1007/978-3-662-43730-8_6
132 6 Instrumentation (Techniques, File Systems, File Types, and Techniques)
Fig. 6.1 Problems for cleaning and shaping root canals
presence of accessory canals, lateral canals, canal curvatures, fins, cul-de-sacs, and
isthmuses which make total debridement virtually impossible (Fig. 6.1) [9].
Because of these obstacles in accomplishing the complete debridement and total
elimination of infection inside the root canal, the goal of cleaning and shaping is to
maximize the removal of necrotic and infected tissues [3], thereby reducing the risk
of a flare-up and failure of the treatment. Prior to beginning root canal treatment, the
case should take into account all these factors for its degree of difficulty; if it is
beyond the experience and skills of the dentist, it should be referred to a specialist
for supervision or treatment.
Root Canal Instrumentation
After a straight-line access, cavity has been cut to allow direct access of the instru-
ments into the root canals, and the orifices of the root canals have been identified.
The next step is to instrument the root canals. The instrumentation process can be
simplified by dividing the procedure in a series of steps. The majority of teeth are
approximately 19–25 mm in length. Most roots are 9–15 mm, and most crowns are
10 mm in length [10]. An easy concept is to divide the root canal into three regions:
coronal, middle, and apical. Each of these regions is likely to be between 3 and
5 mm in length [10]. Dividing the root canal into three regions is a helpful strategy
for instrumenting complicated calcified root canals with a challenging morphology.
Most guidelines for endodontic associations recommend that the root canal is
irrigated with undiluted sodium hypochlorite (NaOCl) [11] at concentrations of
5.25, 6.1, and 8 %; however, many dentists dilute the concentration of NaOCl by
half to 3 %, or even more to 1.5 % [12]. The main reasons for diluting the NaOCl
are to limit the injury caused to a patient if the NaOCl spills or leaks [13].
After checking the preoperative radiographs of the tooth to be treated, the 0.02
tapered 10 and 15 stainless steel hand files are measured and curved by the dentist to
Tooth Length Measurement 133
match the length and curvature of the root canal [14]. These hand files are then placed
inside the tooth to explore the coronal and middle thirds of the root canals. When the
hand files are placed inside the canal and have been rotated to remove the tissue and
make some space, a syringe is used to deliver a small volume of NaOCl into the space.
The NaOCl can help lubricate the file and reduce the friction of the movement of the
hand files into the canals. Once the hand files have progressed through the coronal and
middle regions of the root canals, the canal maybe enlarged using the hand files prior
to instrumentation with rotary NiTi root canal shaping instruments. After the coronal
and middle thirds of the root canal are negotiated, small hand files are used to scout
the remaining apical third of the canal [10, 15]. After this stage in the instrumentation
of the root canal, it must be measured to avoid over-instrumentation.
Tooth Length Measurement
It is necessary to accurately measure tooth length in order to carry out and fulfill the
basic tenets of root canal therapy [16]. This measurement should be 0.5–1-mm short
of the radiographic apical foramen to create an apical stop within the tooth structure
in order to confine instrumentation and the filling material [10, 15]. A goal in root
canal treatment is to reduce intraradicular microorganisms to a level below that
necessary to induce or sustain apical periodontitis [17]. Prior to instrumentation, it
is essential to accurately measure the tooth working length during root canal prepa-
ration to avoid the accidental extrusion of irrigating solution and dressing or filling
material, which can lead to persistent periapical inflammation and postoperative
pain [18, 19]. The accuracy of the working length can have an impact on the out-
comes of endodontic treatments [20, 21], and optimal periapical healing can be
observed where the contact with the canal filling material has been minimized [22].
Several methods can be used to establish the working length of the tooth, such as
mathematical equations, predetermined norms of tooth length, electronic audio
measurement, tactile sense, and so on; however, the most practical approach is to
use an electronic apex locator (EAL) followed by confirmation of canal length by
placing an endodontic instrument in the tooth [23], approximating the apex and
verifying the accuracy of the instrument position with an undistorted radiograph
during root canal treatment (Fig. 6.2.).
The radiographic length is the length of the tooth as it appears on the radiograph
[24]. The estimated working length is the radiographic length minus 1 mm [25]. The
final working length is −1 mm subtracted from the anatomical apex measure from
the working length radiograph [25].
The working length should never be solely based on EALs because although they
are not prone to error with different irrigating solutions [26], their accuracy can be
influenced by the presence of a nearby metallic restoration or vital tissue, the type
of any electrolytes in the canals, the diameter of the apical foramen, an absence/
presence of apical constriction, and the size of file used [27, 28].
Once a correct working length measurement is obtained, a reference point is
established at the occlusal or incisal extension of the instrument and recorded [25].
Fig. 6.2 Radiographs of files inside root canals to measure their length
This same working length is maintained throughout all of the endodontic prepara-
tion and filling procedures: the steps for the measurement of the canal system are:
The hand file used to take the diagnostic measurement will be set to the anatomical
length using the measurement from the occlusal cusp height or incisal edge as a
landmark to the radiographic apex. All radiographs should be of good quality,
with minimal distortion and sufficient visible periapical area.
All subsequent file measurements will be set to the working length measurement
which is the radiographic apex measurement minus 1 mm [25].
Clean the apical region without blocking the apical constriction or destroying the
natural apical architecture
The purpose of using the anatomical length file is to maintain the patency of the
apical region. If a radiograph shows a file length that is 2 mm or more from the
radiographic apex, the file must be readjusted and a new x-ray taken to confirm
the diagnostic length of the root canal.
Silicon or rubber stoppers are used to measure the instrument at the occlusal land-
mark. If these stoppers move, recheck their position against the designated land-
mark as you continue to clean the canal.
Instrumentation at the working length should continue to, at least, three instrument
sizes above the file used to initially take the diagnostic measurement.
Final Instrumentation and Shaping the Root Canal
There is strong agreement that the adequate removal of necrotic and infected tis-
sues is essential to the success of endodontic therapy [17]. However, there is
seldom agreement on the optimum approach for the final instrumentation of the
Final Instrumentation and Shaping the Root Canal 135
root canal. Over the years, it has become less acceptable to redesign the root
canal space, and it should not be much larger than the original space or have a
different center and angle to the original canal space [29]. A growing trend is to
minimally alter the morphology and size of the original canal [30]. The root
canals of the teeth are all unique, but they can share common dimensions and
morphologies [31]. Once the root canal is negotiated to the apical third, a deci-
sion has to be made to continue with hand files or to use rotary NiTi instrumenta-
tion [10, 15].
At this stage the root canal has to be shaped, even if minimally altered, to facili-
tate the removal of necrotic and infected tissues and to provide space for placing the
obturating materials [10, 15]. After years of experience, it has been learned that
the best shape is one with a continuously tapering funnel from the canal orifice to
the apex [1]. The reasons why this shape is recommended is it that it decreases the
risks of procedural errors when cleaning and enlarging apically [32]. The size of
root canal enlargement is often dictated by the method of obturation. For the lateral
compaction of gutta-percha, the canal space should be enlarged to permit placement
of the spreader to within 1–2 mm of the corrected working length [33]. There is a
correlation between the depth of spreader penetration and the apical seal [34]. For
warm vertical compaction techniques, the coronal enlargement must permit the
placement of the pluggers to within 3–5 mm of the root canal working length [35].
There is a limit to the amount of shaping of a root canal, because the more that den-
tin is removed from the root canal walls, the weaker the tooth becomes [36]. The
amount of root canal shaping is determined by the preoperative root dimension, the
obturation technique, and the restorative treatment plan [10, 15]. Some narrow man-
dibular incisor roots cannot be enlarged to the same size as the more bulky roots of
the maxillary central incisors. If the restored tooth requires a post to retain the
crown, the canal space will need to be enlarged sufficiently to retain the post shown
in Fig. 6.3.
Fig. 6.3 The left tooth has

been instrumented and
restored without a post; the
right tooth has a post inside
the root canal to hold a
crown. The canal preparation
in the right tooth is much
larger to retain a post
Cleaning and Shaping to the Root Apex
The pulp and periapical tissue barrier can be determined histologically, but the barrier
is difficult to accurately determine in radiographs. Since for mature teeth there is a need
to retain files, instruments, sealers, and obturation materials within the root canal, it is
necessary to terminate the cleaning and shaping of the canals at 1 mm before the radio-
graphic apex of the tooth is reached [1, 10, 15]. The apical foramen or root apex is the
narrowest portion of the root canal furthest from the crown. The morphology of the
root apex can vary greatly from a tapering constriction to a multiple constriction, age
and root resorption can add variation, and the foramen to apex distance can vary up to
3.8 mm [37]. The problem for cleaning and shaping the canal is to get as close to the
apex as possible; otherwise, an uncleaned area of canal can harbor bacteria, but to still
confine obturation to the root canal space [38]. Extrusion of the obturation materials
must be prevented, and this must be planned at the root canal shaping stage.
Size of Apical Enlargement
Since the morphology of teeth can be highly variable, there is no generally regarded
apical canal size. Minimal enlargement of the apical preparation is advantageous to
limit canal transportation, but it can also decrease the effectiveness of the cleaning
procedure to disinfect the canal. Apical transportation can be seen in most curved
canals enlarged beyond a size #25 stainless steel file [39]. The most effective size of
apical enlargement is the one which has adequately removed necrotic infected tis-
sues. The apical root canal is the most difficult region of the canal to clean because
of its constriction to irrigation, cleaning, and shaping. Some studies indicate that
irrigating solutions are not able to reach the apical portion of the root if the canal is
not enlarged to a size #35 or #40 file [40]. When the apical region is enlarged, it can
significantly improve the disinfection of the root canal [41].
Shape and Size of the Instrumented Root Canal
The same design principle applies to both straight and curved root canals; they will
be instrumented or prepared using a tapered design that is widest at the cervical
level which gradually diminishes and ends at 1 mm before the root apex.
The taper of the prepared root canal is designed to allow the easy filling of the canal
with obturation material and to condense the apical one-third of the canal with gutta-
percha filling material [10, 15]. This taper is commonly called the “flare.” The mini-
mal size of an instrumented or prepared straight canal should be to an ISO size 40 and
a width of 1 mm. The maximum size is determined by the experience of the dentist to
remove the necrotic infected tissues from the root canal. In curved canals, the amount
of canal enlargement is determined radiographically and depends on the root direction
and degree of curvature. In addition to negotiating calcified root canals and removing
areas of resorption, the instrumentation size limitation is the mesiodistal thickness of
the root canal walls, because it is essential to maintain the strength of the tooth.
Endodontic Instruments 137
Fig. 6.4 Endodontic hand

files
Endodontic Hand File Geometries
Endodontic hand files (Fig. 6.4) are available in different lengths that are standard-
ized by the American National Standards Institute/American Dental Association/
ISO [42]. Most hand files have 16 mm of cutting flutes [10]. The cross-sectional
diameter at the first rake angle of the hand file is termed D0. One-millimeter coronal
to D0 is termed D1, while 2-mm coronal to D0 is called D2. The most shank-side cut-
ting flute is 16-mm coronal to D0, which represents the largest diameter and most
active cutting aspect of the instrument and is termed D16. Each hand file receives its
numerical designation, or file name, from its diameter at D0. Since ISO files have a
standard taper of 0.32 mm over 16 mm of cutting blades, the taper of any specific
instrument is 0.02 mm/mm. Although each file name represents the size at its D0
diameter, each of the hand files has multiple cross-sectional diameters over its active
blades. For example, The ISO size 10 file is 0.10 mm in diameter at D0, tapers
0.32 mm over 16 mm, and has a diameter of 0.42 mm at D16.
Endodontic Instruments
Nickel-titanium (NiTi) is a super elastic metal with a shape memory [43]. Endodontic
NiTi rotary instruments were introduced in 1993 [44] and have changed the way
root canal preparations are performed, enabling more complicated root canal sys-
tems to be shaped with fewer procedural errors [45]. The most commonly used type
of NiTi instrument has a taper of .04 which is good for the cleaning of various canal
types as shown in Fig. 6.5.
NiTi rotary instruments have proved to be extremely successful for cleaning and
shaping the root canals, but they should not be used when the dentinal walls are
extremely thin to avoid perforation of the root canal. More than 30 types of NiTi
instrument systems are sold, with varying designs, motors, shaping characteristics,
breakage potential, and clinical performance [45]. The advantages of NiTi
Fig. 6.5 NiTi endodontic

instrument • Small Canals
• Curved Canals
.04
• Long Canals
• Large Canals
NiTi Rotary instrument
Cutting tips before use
Cutting tips after 3 root canals
Cutting tips after 5 root canals

Vortex GTX ProTaper
Fig. 6.6 Scanning electron microscopy of the cutting tips of endodontic instruments following
repeated use
instruments are that they remain centered within the root canal space, thereby limit-
ing its reshaping size, and that they bend only once per revolution, which lowers
their risk of breaking. The manufacturers of endodontic instruments recommend
that they only be used once, because their repeated use breaks the cutting tips
(Fig. 6.6.) and lowers their cutting effectiveness.
Using Hand Files and Instruments to Shape the Root Canals
The root canal cleaning and shaping goals require that the endodontic hand files
and instruments must be used in sequential order from the smallest size first
[1, 10, 15]. Throughout the treatment, from the initial hand file to the final canal
preparation, it is necessary to maintain an accurate root working length by keeping
an apical stop on the file so that the files and instruments are always kept within the
Anti-curvature Filing 139
a b
Fig. 6.7 Computer tomography of the root canal. (a) Preoperative root canal space. (b) Post-
operative root canal space
confines of the root canal [25]. This will maintain the integrity of the tooth, avoid
perforating the tooth, avoid injuring the periapical tissue, and minimize postopera-
tive pain and discomfort for the patient. By obeying these goals, the original root
canal will be enlarged, but not so enlarged that the tooth is weakened. The differ-
ence between the preoperative root canal and the postoperative root canal volume
is shown in Fig. 6.7.
Anti-curvature Filing
Curved canals are the most challenging to instrument, because the distortion of
the files and instruments will cut into the curve to reduce its angle and place pres-
sure on the cutting tips in an opposite direction, thereby increasing the risk of
cutting a perforation [46]. The risk of cutting a perforation in curved canals
increases when larger file sizes are used [46]. To avoid perforations, the concept
of anti-curvature filing is to prepare a straight-line access through the root canal
to the apical region, by filing away the bulky root structure to create a displace-
ment space and by not touching the thin root walls which are in danger of being
perforated.
Accessory Canals
Almost all root canals contain accessory canals. The presence of accessory canals
has been a source of controversy as a cause of endodontic success or failure [47].
Accessory canals are of minimal importance to the outcome of endodontic treat-
ment, provided that the main canals are adequately cleaned, shaped, prepared, filled,
and sealed [48]. No effort is needed to locate accessory canals and to attempt to
clean them; because of their small size, it is unlikely they can cause a flare-up and
treatment failure.
Steps for Instrumenting the Root Canals
1. The straight-line access opening should allow direct and unobstructed access to
the apical region of the canal. A good access will minimize the torquing of the
endodontic instrument and help avoid the perforation or stripping of the root
canal.
2. Measure the root canal length and calculate the working length. Always use the
stop on the hand files and instruments to keep track of the root canal working length.
3. Examine radiographs to locate the danger zones where the root canal walls are
thin. Plan to avoid cutting the perforation danger zones.
4. Moisten the root canal with sodium hypochlorite or another irrigating solution
before filing. Never file a canal when it is dry. Syringe irrigating solution into
the canal with each new file or instrument, while using suction to immediately
vacuum any spillage or leakage, the irrigating solution will help lubricate the
instruments and improve their cutting effectiveness.
5. Interpret the root anatomy and morphology from the radiograph and precurve
the instruments to negotiate a path through the canals. Use each instrument only
once to obtain the best cutting effects.
6. When instruments are inside the root canal, feel the stickiness of the instru-
ments, called torquing; as the instrument binds to the root canal, avoid over
torquing as the instrument can break. Constantly clean the instruments as they
are used.
7. Remove bulky dentin from curved canals and avoid touching the canal walls
which are thin. If a root curves distally, the canal should be filed mesially, buc-
cally, and lingually to help avoid removing distal dentin.
8. If rotary instruments have been used in the canal, use hand files to smooth the
canal walls, while avoiding any perforation danger zones.
9. Dry the canals with paper points to remove residual NaOCl or other irrigating
solution.
10. Inject a chelating agent, such as 17 % REDTA or Qmix 2in1 for 1 min to remove
the smear layer from the root canal surface. Do not leave a chelating agent inside
the root canal for longer time periods as it can weaken the tooth structure.
Perforation Repair 141
11. Give the root canal a final flush with NaOCl or irrigating solution to help rinse
away the chelating agent. Note that some manufacturers do not recommend
washing out the chelating agent.
12. Dry the canals with paper points.
13. Obturate the root canals
14. Fill the root canal access opening.
Culturing and Medication of Root Canals
During the history of endodontic treatment, there was a time when it was felt essen-
tial to prove that the cleaning and shaping of the teeth had been successful to remove
necrotic and infected tissues [49]. Today, because of reliability of cleaning and
shaping the root canals, the cultures of infected tissues from the root canals have
proven to be irrelevant to the success of endodontic treatment [50]. It is widely
known that some bacteria will not be disinfected from the root canal by cleaning and
shaping but that by sealing the bacteria into the root canal space using sealers and
obturation materials, the infection can be entombed [51], so that it cannot cause a
flare-up and the need for retreatment.
Perforation Repair
Attention and planning is needed to prevent a hand file or instrument from cutting
an accidental perforation, which communicates the inside of a root canal to the
external root surface [51]. Cutting a post space is particularly dangerous for per-
forating the tooth [52]. Some perforations exist because of a caries lesion or
anomaly [53]. When a perforation occurs, it should be repaired immediately using
restorative materials, with a thin liner of MTA being placed against the vital peri-
odontal tissues or bone [54]. In the past a liner of calcium hydroxide may have
been used [55]. The prognosis of a perforated tooth depends on the size, the loca-
tion, and the time taken to repair it [56]. The perforation repair materials used to
seal root perforations are MTA [54], Biodentine [57], ceramics [58], cements
[59], freeze-dried bone [60], and Geristore [61]. The toxicity of these perforation
repair materials to L929 cells following the ISO biocompatibility standards are
shown in Fig. 6.8.
Calcium hydroxide and MTA are biocompatible to tissues and can be used to
line the vital tissue exposed by a root perforation, but they lack the physical prop-
erties to be used by themselves for perforation repair. Most dentists will use
Geristore, Biscore and Super EBA, or even Biodentine to restore root perforations
only using calcium hydroxide or MTA as liner when the size of the perforation
exceeds 0.5 mm.
60
Percentage of cell death (%)
50
40
30
20
10
0
Calcium
Hydroxide
Biodentine
Geristore
Endoseq
Paste
Endoseq
Putty
White
MTA
Biscore
Grey MTA
IRM
Super EBA
Fig. 6.8 Biocompatibility of root perforation repair materials
Summary
Root canal cleaning and shaping are the essential elements for successful root canal
treatment [61]. New file and instrument designs and metals could help avoid break-
age. The most important factor in the success of cleaning and shaping teeth is the
skill of the dentist to avoid procedural errors. If an accidental root perforation is
created, it should be immediately repaired with a biocompatible repair material
1. The success of nonsurgical endodontic root canal treatment requires the use of
files and instruments to remove necrotic and infected tissues.
(a) False
(b) True
2. The cleaning and shaping are separate concepts but are always performed
together.
(a) False
(b) True
3. The goal of cleaning the root canal is the removal of necrotic pulp and infected
tissues.
(a) False
(b) True
4. The goal of shaping the canal is to maintain the apical foramen as small as pos-
sible in its original anatomical position.
(a) False
(b) True
5. A good endodontic treatment outcome is dependent on the removal of necrotic

pulp and infected tissues to a low level that cannot cause a flare-up which will
require retreatment.
(a) False
(b) True
6. After a straight-line access, cavity has been cut to allow direct access of the
instruments into the root canals, and the orifices of the root canals have been
identified. The next step is to instrument the root canals.
(a) False
(b) True
7. The instrumentation process can be simplified by dividing the procedure in a
series of steps.
(a) False
(b) True
8. The majority of teeth are approximately 19–25 mm in length. Most roots are
9–15 mm, and most crowns are 10 mm in length.
(a) False
(b) True
9. Dividing the root canal into three regions is a helpful strategy for instrumenting
complicated calcified root canals with a challenging morphology.
(a) False
(b) True
10. It is necessary to accurately measure tooth length in order to carry out and fulfill
the basic tenets of root canal therapy.
(a) False
(b) True
11. The root length measurement should be 0.5–1 mm short of the radiographic
apical foramen to create an apical stop within the tooth structure in order to
confine instrumentation and the filling material.
(a) False
(b) True
12. The radiograhic length is the length of the tooth as it appears on the
radiograph.
(a) False
(b) True
13. The estimated working length is the radiographic length −1 mm.
(a) False
(b) True
14. The final working length is −1 mm subtracted from the anatomical apex mea-
sure from the working length radiograph.
(a) False
(b) True
15. NiTi rotary instruments have proved to be extremely successful for cleaning
and shaping the root canals, but they should not be used when the dentinal walls
are extremely thin to avoid perforation of the root canal.
(a) False
(b) True
16. Curved canals are the most challenging to instrument, because the distortion of
the files and instruments will cut into the curve to reduce its angle and place
pressure on the cutting tips in an opposite direction, thereby increasing the risk
of cutting a perforation.
(a) False
(b) True
17. The risk of cutting a perforation in curved canals increases when larger file
sizes are used.
(a) False
(b) True
18. To avoid perforations, the concept of anti-curvature filing is to prepare a
straight-line access through the root canal to the apical region, by filing away
the bulky root structure to create a displacement space and by not touching the
thin root walls which are in danger of being perforated.
(a) False
(b) True
19. When a perforation occurs, it should be repaired immediately using restorative
materials, with a thin liner of MTA being placed against the vital periodontal
tissues or bone.
(a) False
(b) True
20. The prognosis of a perforated tooth depends on the size, the location, and the
time taken to repair it.
(a) False
(b) True
The correct quiz answers are all b. True.
Bibliography
1. Schilder H. Cleaning and shaping the root canal. Dent Clin North Am. 1974;18:269–96.
2. Sabala CL, Biggs JT. A standard predetermined endodontic preparation concept. Compendium.
1991;12:656, 658, 660.
3. Alves Vde O. Endodontic flare-ups: a prospective study. Oral Surg Oral Med Oral Pathol Oral
Radiol Endod. 2010;110(5):e68–72.
4. Akbar I, Iqbal A, Al-Omiri MK. Flare-up rate in molars with periapical radiolucency in one-
visit vs two-visit endodontic treatment. J Contemp Dent Pract. 2013;14:414–8.
5. Nobuhara WK, del Rio CE. Incidence of periradicular pathoses in endodontic treatment fail-
ures. J Endod. 1993;19:315–8.
6. Siqueira Jr JF. Microbial causes of endodontic flare-ups. Int Endod J. 2003;36(7):453–63.
7. de Pablo OV, Estevez R, Heilborn C, Cohenca N. Root anatomy and canal configuration of the
permanent mandibular first molar: clinical implications and recommendations. Quintessence
Int. 2012;43:15–27.
8. Paqué F, Balmer M, Attin T, Peters OA. Preparation of oval-shaped root canals in mandibular
molars using nickel-titanium rotary instruments: a micro-computed tomography study. J
Endod. 2010;36:703–7.
Bibliography 145
9. Pujar M, Bhagwat SV. Determination of the morphological irregularities in the middle and
apical 1/3rd region of the root canal system of permanent maxillary incisors. Indian J Dent
Res. 2002;13:96–8.
10. Ruddle CJ. Current concepts for preparing the root canal system. Dent Today. 2001;20:76–83.
11. American Association of Endodontists, Colleages for Excellence, Rotary instrumentation: an
endodontic perspective. American Association of Endodontists; 2008.
12. Haapasalo M, Shen Y, Wang Z, Gao Y. Irrigation in endodontics. Br Dent J. 2014;
216:299–303.
13. Zhu WC, Gyamfi J, Niu LN, Schoeffel GJ, Liu SY, Santarcangelo F, Khan S, Tay KC, Pashley
DH, Tay FR. Anatomy of sodium hypochlorite accidents involving facial ecchymosis – a
review. J Dent. 2013;41:935–48.
14. Buchanan LS. The standardized-taper root canal preparation–part 6. GT file technique in
abruptly curved canals. Int Endod J. 2001;34:250–9.
15. Ricucci D. Apical limit of root canal instrumentation and obturation, part 1. Literature review.
Int Endod J. 1998;31:384–93.
16. Grove CJ. A new simple standardized technique producing perfect fitting impermeable root
canal filings extended to the dentinocemento junction. Dent Items Interest. 1928;50:855–7.
17. Siqueira J, Rôças I. Clinical implications and microbiology of bacterial persistence after treat-
ment procedures. J Endod. 2008;34:1291–301.
18. Yusuf H. The significance of the presence of foreign material periapically as a cause of failure
of root treatment. Oral Surg Oral Med Oral Pathol. 1982;54:566–74.
19. Georgopoulou M, Anastassiadis P, Sykaras S. Pain after chemomechanical preparation.
Int Endod J. 1986;19:309–14.
20. Sjögren U, Hagglund B, Sundqvist G, Wing K. Factors affecting the long-term results of end-
odontic treatment. J Endod. 1990;16:498–504.
21. Ng Y-L, Mann V, Rahbaran S, Lewsey J, Gulabivala K. Outcome of primary root canal treat-
ment: systematic review of the literature – part 2. Influence of clinical factors. Int Endod
J. 2008;41:6–31.
22. Ricucci D, Langeland K. Apical limit of root canal instrumentation and obturation. Part 2.
A histological study. Int Endod J. 1998;31:394–409.
23. European Society of Endodontology. Quality guidelines for endodontic treatment: consensus
report of the European Society of Endodontology. Int Endod J. 2006;39:921–30.
24. Melius B, Jiang J, Zhu Q. Measurement of the distance between the minor foramen and the
anatomic apex by digital and conventional radiography. J Endod. 2002;28:125–6.
25. Ravanshad S, Adl A, Anvar J. Effect of working length measurement by electronic apex loca-
tor or radiography on the adequacy of final working length: a randomized clinical trial.
J Endod. 2010;36:1753–6.
26. Meares WA, Steiman HR. The influence of sodium hypochlorite irrigation on the accuracy of
the Root ZX electronic apex locator. J Endod. 2002;28:595–8.
27. Fan W, Fan B, Gutmann JL, Bian Z, Fan MW. Evaluation of the accuracy of three electronic
apex locators using glass tubules. Int Endod J. 2006;39:127–35.
28. Özsezer E, İnan U, Aydin U. In vivo evaluation of ProPex electronic apex locator. J Endod.
2007;33:974–7.
29. Malterud M. Minimally invasive biomimetic endodontics: the future is here. Gen Dent.
2013;61:8–10.
30. Kim HC, Sung SY, Ha JH, Solomonov M, Lee JM, Lee CJ, Kim BM. Stress generation during
self-adjusting file movement: minimally invasive instrumentation. J Endod. 2013;39:1572–5.
31. Cleghorn BM, Christie WH, Dong CC. The root and root canal morphology of the human
mandibular second premolar: a literature review. J Endod. 2007;33:1031–7.
32. Musikant BL, Cohen BI, Deutsch AS. The evolution of instrumentation and obturation leading
to a simplified approach. Compend Contin Educ Dent. 2000;21:980–6, 988, 990.
33. Nielsen BA, Baumgartner JC. Spreader penetration during lateral compaction of resilon and
gutta-percha. J Endod. 2006;32:52–4.
34. Pérez Heredia M, Clavero González J, Ferrer Luque CM, González Rodríguez MP. Apical seal
comparison of low-temperature thermoplasticized gutta-percha technique and lateral conden-
sation with two different master cones. Med Oral Patol Oral Cir Bucal. 2007;12:E175–9.
35. Diemer F, Sinan A, Calas P. Penetration depth of warm vertical Gutta-Percha pluggers: impact
of apical preparation. J Endod. 2006;32:123–6.
36. Testori T, Badino M, Castagnola M. Vertical root fractures in endodontically treated teeth: a
clinical survey of 36 cases. J Endod. 1993;19:87–91.
37. Ivanovic V, Beljic-Ivanovic K. Determining working length or how to locate the apical termi-
nus (part I). Roots. 2009;4:30–6.
38. Aziz A, Chandler NP, Hauman CH, Leichter JW, McNaughton A, Tompkins GR. Infection of
apical dentin and root-end cavity disinfection. J Endod. 2012;38:1387–90.
39. Eldeeb ME, Boraas JC. The effect of different files on the preparation shape of severely curved
canals. Int Endod J. 1985;18:1–7.
40. Chow TW. Mechanical effectiveness of root canal irrigation. J Endod. 1983;9:475–9.
41. Card SJ, Sigurdsson A, Orstavik D, Trope M. The effectiveness of increased apical enlarge-
ment in reducing intracanal bacteria. J Endod. 2002;28:779–83.
42. American National Standards Institute/American Dental Association Standard No. 28—root
canal files and reamers, type, Chicago, 2008.
43. Tarniţă D, Tarniţă DN, Bîzdoacă N, Mîndrilă I, Vasilescu M. Properties and medical applica-
tions of shape memory alloys. Rom J Morphol Embryol. 2009;50:15–21.
44. Serene TP, Adams JD, Saxena A. Nickel-titanium instruments: applications in endodontics. St.
Louis: Ishiaku EuroAmerica; 1995.
45. Schäfer E, Bürklein S. Impact of nickel-titanium instrumentation of the root canal on clinical
outcomes: a focused review. Odontology. 2012;100:130–6.
46. Saunders EM, Saunders WP. The challenge of preparing the curved root canal. Dent Update.
1997;24(241–4):246–7.
47. Ricucci D, Siqueira Jr JF. Recurrent apical periodontitis and late endodontic treatment failure
related to coronal leakage: a case report. J Endod. 2011;37:1171–5.
48. Carrotte P. Endodontics: part 8. Filling the root canal system. Br Dent J. 2004;197:667–72.
49. Waltimo T, Trope M, Haapasalo M, Ørstavik D. Clinical efficacy of treatment procedures in
endodontic infection control and one year follow-up of periapical healing. J Endod. 2005;
31:863–6.
50. Heling I, Gorfil C, Slutzky H, Kopolovic K, Zalkind M, Slutzky-Goldberg I. Endodontic fail-
ure caused by inadequate restorative procedures: review and treatment recommendations.
J Prosthet Dent. 2002;87:674–8.
51. Tidmarsh BG. Accidental perforation of the roots of teeth. J Oral Rehabil. 1979;6:235–40.
52. Abou-Rass M, Jann JM, Jobe D, Tsutsui F. Preparation of space for posting: effect on thickness
of canal walls and incidence of perforation in molars. J Am Dent Assoc. 1982;104:834–7.
53. Sinai IH. Endodontic perforations: their prognosis and treatment. J Am Dent Assoc. 1977;
95:90–5.
54. Main C, Mirzayan N, Shabahang S, Torabinejad M. Repair of root perforations using mineral
trioxide aggregate: a long-term study. J Endod. 2004;30:80–3.
55. Bryan EB, Woollard G, Mitchell WC. Nonsurgical repair of furcal perforations: a literature
review. Gen Dent. 1999;47:274–8.
56. Roda RS. Root perforation repair: surgical and nonsurgical management. Pract Proced Aesthet
Dent. 2001;13:467–72.
57. Aggarwal V, Singla M, Miglani S, Kohli S. Comparative evaluation of push-out bond strength
of ProRoot MTA, Biodentine, and MTA Plus in furcation perforation repair. J Conserv Dent.
2013;16:462–5.
58. Aminov L, Moscalu M, Melian A, Salceanu M, Hamburda T, Vataman M. Clinical-radiological
study on the role of biostimulating materials in iatrogenic furcation lesions. Rev Med Chir Soc
Med Nat Iasi. 2012;116:907–13.
Bibliography 147
59. Tavassoli-Hojjati S, Kameli S, Rahimian-Emam S, Ahmadyar M, Asgary S. Calcium enriched

mixture cement for primary molars exhibiting root perforations and extensive root resorption:
report of three cases. Pediatr Dent. 2014;36:23–7.
60. Hartwell GR, England MC. Healing of furcation perforations in primate teeth after repair with
decalcified freeze-dried bone: a longitudinal study. J Endod. 1993;19:357–61.
61. Al-Sabek F, Shostad S, Kirkwood KL. Preferential attachment of human gingival fibroblasts to
the resin ionomer Geristore. J Endod. 2005;31:205–8.
62. Karunakaran JV, Kumar SS, Kumar M, Chandrasekhar S, Namitha D. The effects of various
irrigating solutions on intra-radicular dentinal surface: an SEM analysis. J Pharm Bioallied
Sci. 2012;4 Suppl 2:S125–30.
Irrigation of Root Canals
7
Instrumentation of the root canal alone is not sufficient to remove infected necrotic
tissues [1]. An irrigating solution is needed to reduce the friction between the instru-
ment and dentin, improve the cutting effectiveness of the files and instruments, dis-
solve the tissue, cool the file and tooth, wash the debris from the root canal, and be
bactericidal in areas of the canal which could not be instrumented [2, 3]. Few irri-
gating solutions can remove smear layer, so a chelating agent must be used after the
irrigating solution to help clean the instrumented root canal surfaces [4]. Through
experience, most dentists dilute sodium hypochlorite and use it as an irrigating solu-
tion during root canal instrumentation; then they use EDTA or another chelating
agent to remove smear layer [5]. The use of sodium hypochlorite as an irrigating
solution followed by a rinse of EDTA can produce reliable results [6]. The bacteri-
cidal effectiveness of sodium hypochlorite is because it is highly toxic and caustic
[7]. If sodium hypochlorite is accidentally spilled on the tissue, it can severely injure
a patient [8]. There are procedures in using sodium hypochlorite and chelating
agents, which can improve patient safety, and alternative irrigating solutions that
may be useful [9].
Irrigating the Infected Root Canal
Hundreds of bacterial species inhabit the mouth [10]. However, because of bacterial
interactions, nutrient availability, and low-oxygen potentials in root canals with
necrotic pulp, the number of bacterial species present in endodontic infections are
restricted [10]. These selective conditions lead to the predominance of facultative
and strictly anaerobic microorganisms that survive and multiply, causing infections
that stimulate local bone resorption, and are more resistant to endodontic treatment
[10]. Among the types of bacteria that infect the root canal, Enterococcus faecalis
(E. faecalis) is the one most commonly associated with failed endodontic treatment
[11]. In addition to bacteria, the root canal can also be infected by viruses [12] and
Candida albicans [13]. The disinfection of root canals through the elimination of

DOI 10.1007/978-3-662-43730-8_7
150 7 Irrigation of Root Canals
microorganisms is an essential step in endodontic treatment (Garcia 3) [14] to help

avoid subsequent failure (Garcia 10) [15]. Surface adherence by bacteria to form
biofilms is a good example of bacterial adaptation and one that is pertinent to end-
odontic infections. Increasing information is now available on the existence of bio-
film communities on root canal walls (Garcia 28) [16]. Unfortunately, complete root
canal disinfection is difficult to accomplish; microorganisms can remain within the
apical dentin plug (Garcia 15) [17], within the smear layer (Garcia 8) [18], and
within the dentinal tubules (Garcia 18) [19]. To maximize the removal of microor-
ganisms from the root canal, the shaping and mechanical enlargement of a root
canal must be accompanied by copious irrigation (Garcia 10,13) [15, 20].
Disinfecting the root canal to reduce the quantity of bacteria, viruses, and fungus to
low levels which cannot cause a flare-up is an important requirement of endodontic
treatment.
Functions of Irrigating Solutions
The root canal must never be instrumented dry, and an irrigating solution is always
needed to reduce the amount of friction between the instrument and dentin surface
to prevent binding and sticking [21]. The irrigating solution is needed to increase
the amount of cutting that the blades of the hand files and endodontic instruments
can perform within time constraints [22]. The irrigating solution must dissolve
necrotic and infected tissues within the canal to help clean and disinfect it [23].
Temperature increases, as low as 5 °C, can injure the tissues [24]; the irrigating
solution is needed to dissipate the heat generated by instrument friction [25]. The
irrigating solution must be able to wash the debris from inside the root canal to help
clean it [26]. The irrigating solution must be bactericidal to infected tissues inside
the canal which could not be reached by the blades of hand files and endodontic
instruments [2, 3].
Types and Dilutions of Irrigating Solutions
The selection of an irrigating solution is important to the outcome of root canal

treatment: a solution such as distilled water is entirely inappropriate for root canal
irrigation, because although it can remove loose debris, it does not have the chemi-
cal ability to disinfect the root canal or to digest the necrotic tissues. Alternatively,
many dentists will use undiluted sodium hypochlorite (6–8 % bleach), which has a
powerful disinfection and tissue digestion properties but is also highly toxic to any
tissues it comes into contact with. To minimize sodium hypochlorite accidents, the
irrigating needle should always be placed at least 1-mm short of the working length
and fit loosely in the canal. The sodium hypochlorite should also be injected slowly
to obtain a gentle flow rate. While injecting the sodium hypochlorite, the needle
should be moved up and down the canal to give better irrigation. The irrigation tips
should be side venting to help reduce the risk of forcing sodium hypochlorite
Types and Dilutions of Irrigating Solutions 151
through the root apex into the periapical tissues. In most cases, the postaccident
treatment of patients where sodium hypochlorite has been spilled is palliative care,
and observing the patient to ensure the injury does not spread, in addition to pre-
scribing antibiotics and analgesics.
Most dentists will compromise and dilute the sodium hypochlorite with water
and use a 3–4 % concentration of sodium hypochlorite for irrigating the root canal
[27], while more inexperienced dentists will dilute the sodium hypochlorite with
water to a 2–0.5 % concentration [28]. The reason why dentists dilute the sodium
hypochlorite is to reduce the amount of injury it can cause to the patient if it gets
accidentally spilled out of the root canal [8].Thus, more experienced dentists who
are more confident of not spilling the sodium hypochlorite have a tendency to use
higher concentrations, while dental students who lack confidence in their skills to
avoid spillage will tend to use lower concentrations. In addition to experience and
skill, if the root apex is open in an immature tooth, then the sodium hypochlorite
must be diluted to approximately 1.25 % with water for root canal irrigation because
of the high risk that it can leak through the apical foramen into the periapical tissues
[29]. A flow chart for deciding on the concentration of sodium hypochlorite to use
is shown in Fig. 7.1.
Sodium hypochlorite has been the most widely used root canal irrigating solution
for several decades, because it is inexpensive, can quickly dissolve infected necrotic
tissues, and is bactericidal [30, 31]. It is very toxic to tissues when undiluted and so
accidental spillage is always a concern among dentists [32, 33]. Moreover, sodium
hypochlorite by itself cannot completely clean the surfaces of root canals, and it can-
not remove the smear layer created by instrumentation [34]. A few dentists will use
alternative root canal irrigating solutions to sodium hypochlorite, and these include
chlorhexidine gluconate, an activated water called Aquatine Endodontic Cleanser, or
a natural fruit juice extract such as Morinda citrifolia.
A 2 % solution of chlorhexidine gluconate (CHX) has good bactericidal proper-
ties to disinfect the root canal [35, 36]. CHX is a bis-bis-guanide with amphiphatic
and antiseptic properties [37]. CHX is biocompatible to tissues [36] so it is less
harmful when spilled. However, the use of CHX as an endodontic irrigant is gener-
ally restricted because it cannot dissolve infected necrotic tissues. CHX can also
discolor the teeth [38], and if it is spilled a patient might experience side effects such
as loss of taste, burning sensation of the oral mucosa, subjective dryness of the oral
Comfortable using undiluted Do not dilute

Yes Sodium
Sodium hypochlorite? hypochlorite
No No Dilute to 3%
Tooth has
open apex?
Yes Dilute to 1.25%
Fig. 7.1 Flow chart for diluting sodium hypochlorite as a root canal irrigating solution
cavity, and discoloration of the tongue [39], and it is also less effective to dissolve
necrotic infected tissues. Generally, chlorhexidine gluconate is not a good alterna-
tive irrigating solution to sodium hypochlorite, because even at full strength, its
ability to clean the root canal surfaces is inferior to sodium hypochlorite (Yamashita
et al. 1993) [40].
In August 2006, the US Food and Drug Administration approved Sterilox
Dental’s Aquatine Endodontic Cleanser (Aquatine EC, Sterilox Puricore,
Malvern, PA, USA) for use as an endodontic irrigating solution. The active
component in Aquatine EC is hypochlorous acid (HOCl) [41]. HOCl is pro-
duced by the human body’s immune cells, through a chain of aerobic reactions
called the oxidative burst pathway, to kill invading pathogens and to fight infec-
tion (Garcia 6) [42]. Aquatine EC is produced by electrochemically charging a
low-concentration salt solution using an element reactor. HOCl is commonly
used for hospital disinfection and sterilization and in the treatment of chronic
wounds (Garcia 25) [43]. In dentistry, it is commonly used to disinfect water
lines by removing biofilms (Garcia 7,12) [44]. HOCl is biocompatible to the
tissues and antimicrobial against a broad range of microorganisms (Garcia 12)
[45]. Two in vitro studies have demonstrated that freshly made HOCI solution
can be effective as an endodontic irrigating solution (Garcia 27) [46]. However,
there are no long-term clinical trials which have demonstrated that a HOCI solu-
tion is as effective as an irrigating solution as sodium hypochlorite.
Some patients and dentists are searching for natural irrigating solutions among
plant extracts that have some bactericidal properties. Few plant extracts are suitable
as an endodontic irrigating solution because they contain natural sugars which could
feed bacteria infecting a root canal. The antimicrobial effects of natural fruit juices
and plant extracts on E. faecalis and other endodontic pathogens have generally not
been evaluated, except for the Arctium lappa plant extract, which was effective at
disinfecting ex vivo root canals (6) [47], and fruit juice from the exotic Morinda
citrifolia or noni plant (Garcia article + new article) [48, 49]. Morinda citrifolia
juice (MCJ) has a broad range of therapeutic effects, including antibacterial, antivi-
ral, antifungal, antitumor, anthelmintic, analgesic, hypotensive, anti-inflammatory,
and immune-enhancing effects (Garcia 1–3) [14, 34, 50]. MCJ contains the antibac-
terial compounds L-asperuloside and alizarin (Garcia 4) [51]. Acetone extracts
from MCJ also demonstrated some antimicrobial activity (5) [52].
While some fruit juices and plant extracts, especially from plant roots, may be
appealing to the growing patient base who wants to have treatment only using natu-
ral remedies, these compounds are expensive, and there is no long-term clinical
evidence that root canal irrigation with natural irrigating solution is beneficial.
Functions of Chelating Agents
A severe limitation of sodium hypochlorite and most other irrigating solutions

is that they are unable to dissolve the instrumentation debris on cut dentin sur-
faces, called smear layer [53]. The smear layer is a 1–5-μm-thick layer of cut
Functions of Chelating Agents 153
debris created on the surface of instrumented dentin, composed of dentin, odon-

toblastic processes, nonspecific inorganic contaminants, and microorganisms
(Garcia 5) [54]. The smear layer can harbor infected necrotic tissue, bacteria,
bacterial products, and root canal remnants [55]. The presence of smear layer
can prevent the adequate sealing of the root canal with sealers, thereby creating
pathways for bacterial leakage (Garcia 23) [6] which may lead to a failure of
endodontic treatment. The presence of smear layer on the instrumented root
canal surface and its removal with a common chelating agent are shown in
Fig. 7.2.
The removal of smear layer from the instrumented root canal walls is controver-
sial [56]. Its removal provides better sealing of the endodontic filling material to
Fig. 7.2 Scanning electron

micrographs of smear layer
and its removal from the root
canal surface. (a) Smear layer
covering the root canal
surface after instrumentation
and irrigating with sodium
hypochlorite without a
chelating agent. (b) Open
dentinal tubules of an
instrumented root canal
surface showing that the
smear has been removed by
irrigating with sodium
hypochlorite and rinsing with
17 % EDTA
dentin and will avoid the leakage of microorganisms into oral tissues (Sen et al.
1995) [57]. The infiltration of microorganisms into oral tissues must be prevented
because these often cause complications leading to treatment failure. Unfortunately,
smear layer is difficult to entirely remove from instrumented root canals, particu-
larly in the constricted apical region [4].
The most widely used chelating agent inside the root canal is 17 % ethylene-
diaminetetraacetic acid (EDTA) [58]. It has good chelating properties to remove
smear layer and clean the surface of the root canals [59]. Testing and clinical
evidence has shown that 17 % EDTA needs to be placed inside the root canal for
1 min to effectively dissolve organic components and smear layer [60]. If the
EDTA is placed within the root canal for less than 1 min, the smear layer will
not be optimally removed; if the EDTA is placed within the root canal for more
than 1 min, there is a risk that its chelating effect will weaken tooth structure. A
solution of 17 % EDTA is a very reliable endodontic chelating agent when used
fresh and at room temperature, but its chelating effects are time sensitive [61],
and it should never be kept within the root canal for more than 1 min. The EDTA
then needs to be suctioned, dried with paper points, and/or rinsed with sodium
hypochlorite to ensure it has been completely removed from the root canal after
use [62].
The BioPure MTAD Antibacterial Root Canal Cleanser (MTAD) is an alterna-
tive chelating agent to 17 % EDTA, and it is one of the newest endodontic chelat-
ing agents available on the market [63]. MTAD has the least published data
available, but it can clean the root canals, digest the tissues, and has bactericidal
properties that are equal or better than full-strength sodium hypochlorite [64].
Some other in vitro studies claim that 6 and 1 % solutions of sodium hypochlorite
were more effective than BioPure MTAD to disinfect E. faecalis biofilms from the
root canals [65]. MTAD contains a broad-spectrum antibiotic called doxycycline,
in addition to citric acid and a detergent [66]. The sustained antimicrobial activity
of MTAD is superior to CHX (AAE30) [67]. MTAD is biocompatible and can
enhance the bond strength of sealers to the tooth structure (AAE14) [68]. The
effectiveness of MTAD to remove the smear layer is enhanced when a 1.3 % con-
centration of sodium hypochlorite is used as an intracanal irrigant. One milliliter
of MTAD is placed within the root canal for 5 min, and it is rinsed with an addi-
tional 4 ml of MTAD as the final rinse (AAE33) [69]. The main disadvantage of
MTAD is that it is a more expensive alternative to sodium hypochlorite for irrigat-
ing the root canals.
The Qmix 2in1 Endodontic Cleanser (Qmix) is an alternative chelating agent to
17 % EDTA or MTAD. Unlike MTAD, the Qmix does not contain any antibiotics.
Qmix contains a mixture of a bisbiguanide antimicrobial agent, a polyaminocarbox-
ylic acid calcium-chelating agent, and a surfactant. Qmix has been found to be
effective against bacterial biofilms [70]. Qmix is as effective as 17 % EDTA, when
it is placed in the root canals for between 60 and 90 s after irrigation with sodium
hypochlorite [71].
A comparison of the removal of the smear layer from ex vivo root canals which
were instrumented and irrigated with sodium hypochlorite, followed by the chelat-
ing agents, 17 % EDTA, MTAD, or Qmix CHX, is shown in Fig. 7.3.
Activation of Irrigating Solution and Chelating Agents 155
Smear layer covering instrumented Key to root canal aspect: Apical Middle Coronal
100
90
root canal surface (%)
80
70
60
50
40
30
20
10
0
a b c d e f g h i
Groups shown in table below
# Group Irrigating Chelating Final Contamination Teeth

agent agent flush #
A PIPS with NaOCl 6% 17% 6% NaOCl E. faecalis 10
and EDTA NaOCl EDTA
B PIPS with NaOCl 1.3% Qmix 2in1 Qmix 2in1 E. faecalis 10
and Qmix 2in1 NaOCl
C PIPS with NaOCl 1.3% MTAD 1.3% E. faecalis 10
and MTAD NaOCl NaOCl
D PIPS with NaOCl 1.3% 17% EDTA 2% CHX E. faecalis 10
and CHX NaOCl
E PIPS with saliva 1.3% 17% EDTA 1.3% Saliva 4
(control) NaOCl NaOCl
F PIPS without a 1.3% None 1.3% E. faecalis 4
chelating agent NaOCl NaOCl
G PIPS with saline Saline 17% Saline E. faecalis 4
irrigation (Positive EDTA
control for effect of
laser)
H No laser treatment 1.3% 17% 1.3% E. faecalis 4
(Negative control NaOCl EDTA NaOCl
for effect of laser)
I PIPS without E. 1.3% 17% 1.3% None 4
faecalis (Negative NaOCl EDTA NaOCl
control for
contamination)
Fig. 7.3 A comparison of the effectiveness of irrigating solutions and chelating agents to remove
smear layer from the instrumented canals of ex vivo teeth when activated with photon-induced
photoacoustic streaming (PIPS)
Activation of Irrigating Solution and Chelating Agents
The process of canal preparation with files, instruments, and irrigating solutions is
usually sufficient to remove most of the necrotic and infected tissues. Some recent
articles suggest that the ultrasonic activation of irrigating solutions [72] the use of
Fig. 7.4 Scanning electron

micrograph of an instru-
mented root canal surface
with open dentinal tubules
where the smear layer and
debris have been removed.
The purple indicates where
there is smear layer or debris
still attached to the root canal
surface
highs-speed vacuum; the EndoVac system [73] and that a laser using photon-
induced photoacoustic streaming (PIPS) can improve the debridement of root canals
[74]. The effect of cleaning and shaping the root canals followed by PIPS is shown
in Fig. 7.4.
Summary
The root canals should be irrigated with sodium hypochlorite during instrumenta-
tion. Undiluted sodium hypochlorite is the most effective concentration, but it may
be diluted according to the experience of the dentist or because a tooth is immature
and has an open apex. It is not enough to use sodium hypochlorite to clean the root
canals following instrumentation. A chelating agent is also needed; most dentists
will use EDTA, although there are other effective products such as MTAD and
Qmix available. The effectiveness of the irrigation solution and chelating agent to
remove smear layer and to clean the canals can be improved by activating the solu-
tions with ultrasonics, by high-speed suction such as the EndoVac system, or by a
laser system such as PIPS.
1. Hundreds of bacterial species inhabit the mouth, because of bacterial interac-

tions, nutrient availability, and low-oxygen potentials in root canals with
necrotic pulp; the number of bacterial species present in endodontic infections
is restricted.
(a) False
(b) True
2. These selective root canal environmental conditions lead to the predominance

of facultative and strictly anaerobic microorganisms that survive and multiply,
causing infections that stimulate local bone resorption, and are more resistant
to endodontic treatment.
(a) False
(b) True
3. The instrumentation of the root canal alone is not sufficient to remove infected
necrotic tissues.
(a) False
(b) True
4. The root canal must never be instrumented dry, and an irrigating solution is
always needed to reduce the amount of friction between the instrument and
dentin surface to prevent binding and sticking.
(a) False
(b) True
5. An irrigating solution is needed to improve the cutting effectiveness of the files
and instruments, dissolve the tissue, cool the file and tooth, wash the debris
from the root canal, and be bactericidal in areas of the canal which could not be
instrumented.
(a) False
(b) True
6. Sodium hypochlorite has been the most widely used root canal irrigating solu-
tion for several decades, because it is inexpensive, can quickly dissolve infected
necrotic tissues, and is bactericidal.
(a) False
(b) True
7. Sodium hypochlorite is very toxic to tissues when undiluted and so accidental
spillage is always a concern among dentists.
(a) False
(b) True
8. A severe limitation of sodium hypochlorite and most other irrigating solutions
is that they are unable to dissolve the instrumentation debris on cut dentin sur-
faces, called smear layer.
(a) False
(b) True
9. The smear layer is a 1–5-micron thick layer of cut debris created on the surface
of instrumented dentin, composed of dentin, odontoblastic processes, nonspe-
cific inorganic contaminants, and microorganisms.
(a) False
(b) True
10. To remove smear layer, a chelating agent must be used after the irrigating solu-
tion to help clean the instrumented root canal surfaces. The most widely used
chelating agent inside the root canal is 17 % ethylenediaminetetraacetic acid
(EDTA).
(a) False
(b) True
11. A solution of 17 % EDTA is a very reliable endodontic chelating agent when
used fresh and at room temperature, but its chelating effects are time sensitive.
(a) False
(b) True
12. Testing and clinical evidence has shown that 17 % EDTA needs to be placed
inside the root canal for 1 min to effectively dissolve organic components and
smear layer.
(a) False
(b) True
13. The EDTA then needs to be suctioned, dried with paper points, and/or rinsed
with sodium hypochlorite to ensure it has been completely removed from the
root canal after use.
(a) False
(b) True
14. The process of canal preparation with files, instruments, and irrigating solu-
tions is usually sufficient to remove most of the necrotic and infected tissues.
(a) False
(b) True
15. Some recent articles suggest that the ultrasonic activation of irrigating solutions
by using a high-speed vacuum; the EndoVac system, and that a laser using
photon-induced photoacoustic streaming (PIPS) can improve the debridement
of root canals.
(a) False
(b) True
Bibliography
1. Koskinen KP. Dissolution of dentin by endodontic irrigants. Proc Finn Dent Soc. 1981;77:232–9.
2. Holliday R, Alani A. Traditional and contemporary techniques for optimizing root canal
irrigation. Dent Update. 2014;41:51–2, 54, 56–8.
3. Fedorowicz Z, Nasser M, Sequeira-Byron P, de Souza RF, Carter B, Heft M. Irrigants for non-
surgical root canal treatment in mature permanent teeth. Cochrane Database Syst Rev.
2012;(9):CD008948.
4. De-Deus G, Reis C, Paciornik S. Critical appraisal of published smear layer-removal studies:
methodological issues. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2011;112:531–43.
5. Violich DR, Chandler NP. The smear layer in endodontics – a review. Int Endod
J. 2010;43:2–15.
6. Sen BH, Wesselink PR, Türkün M. The smear layer: a phenomenon in root canal therapy. Int
Endod J. 1995;28:141–8.
7. Bajrami D, Hoxha V, Gorduysus O, Muftuoglu S, Zeybek ND, Küçükkaya S. Cytotoxic effect
of endodontic irrigants in vitro. Med Sci Monit Basic Res. 2014;10(20):22–6.
8. Goswami M, Chhabra N, Kumar G, Verma M, Chhabra A. Sodium hypochlorite dental acci-
dents. Paediatr Int Child Health. 2014;34:66–9.
Bibliography 159
9. Mehdipour O, Kleier DJ, Averbach RE. Anatomy of sodium hypochlorite accidents. Compend
Contin Educ Dent. 2007;28:544–6, 548, 550.
10. Seltzer S, Farber PA. Microbiologic factors in endodontology. Oral Surg Oral Med Oral Pathol.
1994;78:634–45.
11. Stuart CH, Schwartz SA, Beeson TJ, Owatz CB. Enterococcus faecalis: its role in root canal
treatment failure and current concepts in retreatment. J Endod. 2006;32:93–8.
12. Guilherme BP, Ferreira DC, Rôças IN, Provenzano JC, Santos KR, Siqueira Jr JF. Herpesvirus
carriage in saliva and posttreatment apical periodontitis: searching for association. Oral Surg
Oral Med Oral Pathol Oral Radiol Endod. 2011;112:678–83.
13. Rôças IN, Hülsmann M, Siqueira Jr JF. Microorganisms in root canal-treated teeth from a
German population. J Endod. 2008;34:926–31.
14. Bystrom A, Happonen RP, Sjogren U, Sundqvist G. Healing of periapical lesions of pulpless
teeth after endodontic treatment with controlled asepsis. Endod Dent Traumatol. 1987;
3:58–63.
15. Lin LM, Skribner JE, Gaengler P. Factors associated with endodontic treatment failures.
J Endod. 1992;18:625–7.
16. Takemura N, Noiri Y, Ehara A, Kawahara T, Noguchi N, Ebisu S. Single species biofilm-
forming ability of root canal isolates on gutta-percha points. Eur J Oral Sci. 2004;112:523–9.
17. Nair PN, Sjogren U, Krey G, Kahnberg KE, Sundqvist G. Intraradicular bacteria and fungi in
root-filled, asymptomatic human teeth with therapy-resistant periapical lesions: a longterm
light and electron microscopic follow-up study. J Endod. 1990;16:580–8.
18. Huque J, Kota K, Yamaga M, Iwaku M, Hoshino E. Bacterial eradication from root dentine by
ultrasonic irrigation with sodium hypochlorite. Int Endod J. 1998;31:242–50.
19. Peters LB, Wesselink PR, Moorer WR. The fate and the role of bacteria left in root dentinal
tubules. Int Endod J. 1995;28:95–9.
20. Molander A, Reit C, Dahlén G, Kvist T. Microbiological status of root-filled teeth with apical
periodontitis. Int Endod J. 1998;31:1–7.
21. Chakka NV, Ratnakar P, Das S, Bagchi A, Sudhir S, Anumula L. Do NiTi instruments show
defects before separation? Defects caused by torsional fatigue in hand and rotary nickel-
titanium (NiTi) instruments which lead to failure during clinical use. J Contemp Dent Pract.
2012;13:867–72.
22. Haïkel Y, Serfaty R, Lwin TT, Allemann C. Measurement of the cutting efficiency of endodon-
tic instruments: a new concept. J Endod. 1996;22:651–6.
23. Waal S, Connert T, Laheij A, Soet J, Wesselink P. Free available chlorine concentration in
sodium hypochlorite solutions obtained from dental practices and intended for endodontic
irrigation: are the expectations true? Quintessence Int. 2014;45:467–74.
24. Stanley Jr HR, Swerdlow H. Reaction of the human pulp to cavity preparation: results pro-
duced by eight different operative grinding technics. J Am Dent Assoc. 1959;58:49–59.
25. Zeltner M, Peters OA, Paqué F. Temperature changes during ultrasonic irrigation with different
inserts and modes of activation. J Endod. 2009;35:573–7.
26. Graziele Magro M, Kuga MC, Regina Victorino K, Vázquez-Garcia FA, Aranda-Garcia AJ,
Faria-Junior NB, Faria G, Luis Shinohara A. Evaluation of the interaction between sodium
hypochlorite and several formulations containing chlorhexidine and its effect on the radicular
dentin–SEM and push-out bond strength analysis. Microsc Res Tech. 2014;77:17–22.
27. Clarkson RM, Podlich HM, Savage NW, Moule AJ. A survey of sodium hypochlorite use by
general dental practitioners and endodontists in Australia. Aust Dent J. 2003;48:20–6.
28. Clarkson RM, Moule AJ. Sodium hypochlorite and its use as an endodontic irrigant. Aust
Dent J. 1998;43:250–6.
29. Law AS. Considerations for regeneration procedures. J Endod. 2013;39(3 Suppl):S44–56.
30. Jeansonne M, White RR. A comparison of 2.0 % chlorhexidine gluconate and 5.25 % sodium
hypochlorite as antimicrobial endodontic irrigants. J Endod. 1994;20:276–8.
31. Leonardo MR, Tanomaru Filho M, Silva LAB, Nelson Ffilho P, Bonifacto KC, Ito IY. In vitro
antimicrobial activity of 2.0 % chlorhexidine used as a root canal irrigant solution. J Endod.
1995;25:167–71.
32. Kaufman AY, Keila S. Hypersensitivity to sodium hypochlorite. J Endod. 1989;15:224–6.

33. Segura JJ, Jimenez-Rubio A, Guerrero JM, Calvo JR. Comparative effects of two endodontic
irrigants, chlorhexidine digluconate and sodium hypochlorite on macrophage adhesion to plas-
tic surface. J Endod. 1999;25:243–6.
34. Baumgartner JC, Mader CL. A scanning electron microscope evaluation of four root canal
irrigation regimes. J Endod. 1987;13:147–57.
35. Delany GM, Patterson SS, Miller CH, Newton CW. The effect of chlorhexidine gluconate
irrigation on the root canal flora of freshly extracted necrotic teeth. Oral Surg Oral Med Oral
Pathol. 1982;53:518–23.
36. Yesilsoy C, Whitaker E, Cleveland D, Phillips E, Trope M. Antimicrobial and toxic effects of
established and potential root canal irrigants. J Endod. 1995;21:513–5.
37. Carlo Ceschel G, Bergamante V, Calabrese V, Biserni S, Ronchi C, Fini A. Design and evalu-
ation in vitro of controlled release mucoadhesive tablets containing chlorhexidine. Drug Dev
Ind Pharm. 2006;32:53–61.
38. Yusof WZ, Khoo SP. Mucosal sensitivity to chlorhexidine mouthwash. Singapore Dent J.
1988;13:39–40.
39. Yamashita JC, Tanomaru Filho M, Leonardo MR, Rossi MA, Silva LAB. Scanning electron
microscope study of the cleaning ability of chlorhexidine as a root-canal irrigant. Int Endod J.
2003;36:391–4.
40. United States Food and Drug Administration, Washington. 510 k number K061689.
41. Panasenko OM, Gorudko IV, Sokolov AV. Hypochlorous acid as a precursor of free radicals in
living systems. Biochemistry (Mosc). 2013;78(13):1466–89.
42. Fang YZ, Yang S, Wu G. Free radicals, antioxidants, and nutrition. Nutrition. 2002;18:872–9.
43. Shetty N, Srinivasan S, Holton J, Ridgway GL. Evaluation of microbiocidal activity of a new
disinfectant: Sterilox 2500 against Clostridium difficile spores, Helicobacter pylori, vancomy-
cin resistant Enterococcus species, Candida albicans and several Mycobacterium species.
J Hosp Infect. 1999;41:101–5.
44. Fukuzaki S. Mechanisms of actions of sodium hypochlorite in cleaning and disinfection pro-
cesses. Biocontrol Sci. 2006;11:147–57.
45. Martin MV, Gallagher MA. An investigation of the efficacy of super-oxidised (Optident/
Sterilox) water for the disinfection of dental unit water lines. Br Dent J. 2005;198:353–4.
46. Solovyeva AM, Dummer PM. Cleaning effectiveness of root canal irrigation with electrochemi-
cally activated anolyte and catholyte solutions: a pilot study. Int Endod J. 2000;33:
494–504.
47. Gentil M, Pereira JV, Sousa YT, et al. In vitro evaluation of the antibacterial activity of Arctium
lappa as a phytotherapeutic agent used in intracanal dressings. Phytother Res. 2006;20:184.
48. Garcia F, Murray PE, Garcia-Godoy F, Namerow KN. Effect of aquatine endodontic cleanser
on smear layer removal in the root canals of ex vivo human teeth. J Appl Oral Sci.
2010;18:403–8.
49. Bhardwaj A, Velmurugan N, Sumitha, Ballal S. Efficacy of passive ultrasonic irrigation with
natural irrigants (Morinda citrifolia juice, Aloe Vera and Propolis) in comparison with 1 %
sodium hypochlorite for removal of E. faecalis biofilm: an in vitro study. Indian J Dent Res.
2013;24:35–41.
50. Brännström M, Nordenvall KJ, Glanz PO. The effect of EDTA containing surface-active solu-
tions on the morphology of prepared dentin: an in vivo study. J Dent Res. 1980;59:1127–31.
51. Crumpton BJ, Goodell GG, McClanahan SB. Effects on smear layer and debris removal with
varying volumes of 17 % REDTA after rotary instrumentation. J Endod. 2005;31:536–8.
52. Leach AJ, Leach DN, Leach GJ. Antibacterial activity of some medicinal plants of Papua New
Guinea. Sci New G. 1988;14:1–7.
53. Mozayeni MA, Javaheri GH, Poorroosta P, Ashari MA, Javaheri HH. Effect of 17 % EDTA
and MTAD on intracanal smear layer removal: a scanning electron microscopic study. Aust
Endod J. 2009;35:13–7.
54. Czonstkowsy M, Wilson EG, Holstein FA. The smear layer in endodontics. Dent Clin North
Am. 1990;34:13–25.
Bibliography 161
55. Torabinejad M, Handysides R, Khademi AA, Bakland LK. Clinical implications of the smear layer
in endodontics: a review. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2002;94:658–66.
56. Pashley DH. Smear layer: an overview of structure and function. Proc Finn Dent Soc.
1992;88:S215–24.
57. Martin H. Cleanliness, disinfection, and sterilization of the root canal. Curr Opin Dent.
1991;1:734–6.
58. Hülsmann M, Heckendorff M, Lennon A. Chelating agents in root canal treatment: mode of
action and indications for their use. Int Endod J. 2003;36:810–30.
59. Mohammadi Z. Local applications of tetracyclines in endodontics and dental trauma: a review.
Dent Today. 2009;28:95–6, 98, 100–1.
60. Uroz-Torres D, González-Rodríguez MP, Ferrer-Luque CM. Effectiveness of the EndoActivator
System in removing the smear layer after root canal instrumentation. J Endod. 2010;36:308–11.
61. Kuah HG, Lui JN, Tseng PS, Chen NN. The effect of EDTA with and without ultrasonics on
removal of the smear layer. J Endod. 2009;35:393–6.
62. Yamada RS, Armas A, Goldman M, Lin PS. A scanning electron microscopic comparison of
a high volume final flush with several irrigating solutions: part 3. J Endod. 1983;9:137–42.
63. Mozayeni MA, Zadeh YM, Paymanpour P, Ashraf H, Mozayani M. Evaluation of push-out
bond strength of AH26 sealer using MTAD and combination of NaOCl and EDTA as final
irrigation. Dent Res J (Isfahan). 2013;10:359–63.
64. Kho P, Baumgartner JC. A comparison of the antimicrobial efficacy of NaOCl/Biopure MTAD
versus NaOCl/EDTA against Enterococcus faecalis. J Endod. 2006;32:652–5.
65. Clegg MS, Vertucci FJ, Walker C, Belanger M, Britto LR. The effect of exposure to irrigant
solutions on apical dentin biofilms in vitro. J Endod. 2006;32:434–7.
66. Torabinejad M, Khademi AA, Babagoli J, Cho Y, Johnson WB, Bozhilov K, Kim J, Shabahang
S. A new solution for the removal of the smear layer. J Endod. 2003;29:170–5.
67. Shabahang S, Aslanyan J, Torabinejad M. The substitution of chlorhexidine for doxycycline in MTAD:
the antibacterial efficacy against a strain of Enterococcus faecalis. J Endod. 2008;34:288–90.
68. Johnson WT, Noblett WC. Cleaning and shaping in: endodontics: principles and practice.
4th ed. Philadelphia: Saunders; 2009.
69. Torabinejad M, Cho Y, Khademi AA, Bakland LK, Shabahang S. The effect of various concen-
trations of sodium hypochlorite on the ability of MTAD to remove the smear layer. J Endod.
2003;29:233–9.
70. Dai L, Khechen K, Khan S, Gillen B, Loushine BA, Wimmer Gutmann J, Pashley D, Tay F.
The Effect of QMix, an experimental antibacterial root canal irrigant, on removal of canal wall
smear layer and debris. J Endod. 2011;37:80–4.
71. Stojicic S, Shen Y, Qian W, Johnson B, Haapasalo M. Antibacterial and smear layer removal
ability of a novel irrigant, QMiX. Int Endod J. 2012;45:363–71.
72. Paiva SS, Siqueira JF Jr, Rôças IN, Carmo FL, Ferreira DC, Curvelo JA, Soares RM, Rosado
AS. Supplementing the antimicrobial effects of chemomechanical debridement with either
passive ultrasonic irrigation or a final rinse with chlorhexidine: a clinical study. J Endod.
2012;38:1202–6.
73. Mancini M, Cerroni L, Iorio L, Armellin E, Conte G, Cianconi L. Smear layer removal and
canal cleanliness using different irrigation systems (EndoActivator, EndoVac, and passive
ultrasonic irrigation): field emission scanning electron microscopic evaluation in an in vitro
study. J Endod. 2013;39:1456–60.
74. Lloyd A, Uhles JP, Clement DJ, Garcia-Godoy F. Elimination of intracanal tissue and debris
through a novel laser-activated system assessed using high-resolution micro-computed
tomography: a pilot study. J Endod. 2014;40:584–7.
Root Canal Obturation
8
The success of endodontic treatment is dependent on the obturation of the root canal
with gutta-percha and sealers which can seal the entire root canal, thereby prevent-
ing microleakage and the reinfection of the root canal. Over time, sealers and gutta-
percha have become the standard approach to obturating root canals. Sealers are
needed to seal the gutta-percha core material and prevent microleakage. In the
absence of sealer, gutta-percha cannot adequately seal root canals and prevent
microleakage and reinfection. Gutta-percha is most commonly used to obturate the
root canal because it can be placed relatively easily and also be removed relatively
easily if the tooth requires retreatment. The quality of root canal obturation can be
seen in radiographs and a poor quality of obturation can increase the risk of a flare-
up and treatment failure.
Root Canal Sealers
Root canal sealers are needed to adequately seal the root canal space to prevent
microleakage. The sealer fills voids and irregularities of the root canal space left
unfilled by the obturation core material [1]. Adequate sealing of the obturation
material inside the root canal is important to the success of endodontic treatment,
because up to 60 % of endodontic treatment failures are caused by the incomplete
obturation of the root canal [2]. Root canal may leak and become exposed to perira-
dicular tissue sealers; however, they are generally not very biocompatible [3–6].
Root canal sealers can vary greatly in composition and contain zinc oxide eugenol,
calcium hydroxide, glass ionomer, composite resin, silipoint, urethane methacry-
late, formaldehyde, and bisphenol A [7, 8]. The sealers are typically delivered by
auto-mix syringes to reduce the risk of operator mixing errors. The most widely
used sealers are AH Plus, Sealapex, RealSeal, BC Sealer, Apexit, and Pulpdent; the
composition of these sealers is shown in Table 8.1.
The lack of biocompatibility of these sealers to periodontal cells is shown in the
low numbers of cells which can attach to the sealers, as shown in Fig. 8.1.

DOI 10.1007/978-3-662-43730-8_8
164 8 Root Canal Obturation
Table 8.1 Composition of endodontic sealers

Product and
Group # manufacturer Component A Component B
1 AH Plus Epoxy resin Adamantane amine
(Dentsply De Trey, Calcium tungstate N,N-dibenzyl-5-oxanonane
Konstanz, Zirconium oxide TCD-diamine, calcium tungstate,
Germany) Aerosil, iron oxide zirconium oxide, Aerosil, silipoint
oil
2 Apexit Calcium hydroxide Trimethylhexanedioldisalicylate,
(Vivadent, Schaan, bismuth carbonate
FL) Hydrogenized colophony Bismuth oxide, silicon dioxide,
Silicon dioxide, paraffin 1,3-butanedioldisalicylate,
oil hydrogenized colophony, tricalcium
Zinc oxide, calcium oxide phosphate, zinc stearate
Polydimethylsiloxane
Zinc stearate, pigments
3 Endomethasone Zinc oxide, Dijodthymol Eugenol and peppermint oil
(Septodont, Barium sulfate
Saint-Maur, Hydrocortisone acetate
France)
4 Pulpdent Zinc oxide, calcium Eugenol and Canada balsam
(Pulpdent Corp., phosphate, zinc stearate,
Watertown, MA) and barium sulfate
5 Ketac-Endo Calcium-lanthane-sodium Polyacrylic acid
(3M ESPE, Fluorophosphor-
Seefeld, Germany) aluminum-silicate
6 N2 Bismuth nitrate, bismuth Eugenol
(Ghimas, Bologna, carbonate, Peanut oil
Italy) paraformaldehyde Rose oil
titanium dioxide, zinc Lavender oil
stearate, zinc acetate, iron
oxide
7 EndoREZ TEGDMA, diurethane TEGDMA, diurethane
(Ultradent dimethacrylate, dimethacrylate, bisglycerol
Products Inc., bisglycerol dimethacrylate dimethacrylate phosphate; bismuth
South Jordan, UT) phosphate; bismuth oxychloride, calcium lactate
oxychloride, calcium pentahydrate, silica; p-tolyimino
lactate pentahydrate, diethanol, phenyl bis(2,4,6-
silica; benzoyl peroxide trimethyl benzoyl) phosphate oxide
Selecting Obturation Materials
Since the late 1800s, the selection of the root canal obturation material and the
accompanying technique for its usage has been a controversial aspect of endodon-
tics. Today, the selection of material for obturation is less controversial. The major-
ity of dentists will use gutta-percha as the primary filling material in root canal
therapy [9]. Some dentists in the past used silver points for narrow and extremely
curved canals, but this is not recommended; and a few dentists will use alternative
Gutta-Percha Obturation 165
Number of periodontal cells per unit

7
6
5
area (%)
4
3
2
1
0
−)
ve
ea
en
le
pe
ex
u
l(
si
Pl
a
ls
pd
Ap
lA
Se
tro
he
ea
AH
l
Pu
a
ad
on
BC
Se
o
C
Bi
Fig. 8.1 The lack of biocompatibility of some common root canal sealers shown by the lack of
periodontal cell attachment. The best treatment was an experimental bioadhesive which is not
marketed as a sealer called bioadhesive, but it demonstrates that it is possible to formulate sealers
which are more biocompatible
materials such as GuttaCore [10], Thermafil [11], or resin-based composite [12] for
obturating teeth. In 2004, Resilon, a composite resin obturation material, was intro-
duced [13, 14]. Recent studies have demonstrated that resin composites can prevent
more microleakage in comparison to gutta-percha [13, 14] and that roots obturated
with composite resin have a greater fracture resistance [15]. The handling properties
of composite resin and gutta-percha are similar [14], and since GuttaCore contains
cross-linked gutta-percha, it also has good handling properties. GuttaCore was
developed from a Thermafil carrier system [16]. It is possible to obturate teeth with
other materials, such as MTA or cements, but the high cost can make those obtura-
tion materials prohibitively expensive for everyday use.
Gutta-Percha Obturation
The reason for the success of gutta-percha among dentists is because it is easy to
manipulate into the root canal, it is radiopaque and easily seen on radiographs, and
it can be removed from the canal and be replaced when necessary [17]. Fresh gutta-
percha has good handling properties, while aged gutta-percha can become brittle.
Gutta-percha is an isomer of natural rubber derived from the Taban tree (Isonandra
perchas). The natural chemical form of gutta-percha is 1, 4-polyisoprene [18]. It
was first used in dentistry in the late 1800s as a temporary restorative material and
then to obturate root canal systems [19]. The semi-plastic physical properties of
gutta-percha allow it to be reshaped and molded within the canal system by conden-
sation forces [20]. Gutta-percha can be softened by heated instruments and chemi-
cals such as chloroform and eucalyptol. This makes gutta-percha easy to obdurate
a b
Fig. 8.2 Obturation quality of gutta-percha in root canals. The left radiograph shows a poorly
obturated tooth because the root canals are not completely obturated. The right radiograph shows
a good quality of root canal obturation. (a) Preoperative radiograph with poorly obturated canals.
(b) Postoperative radiograph with obturated retreated canals
the root canal and easy to remove from the root canal if a retreatment is needed. An
advantage of gutta-percha is that it is inert to the periapical tissues if it should
become extruded past the root apex [21]. The quality of root canal obturation with
gutta-percha is important; if a root canal is poorly obturated, it can be associated
with nonhealing periapical lesions in up to 65 % of treatments [22], and 60 % of
endodontic treatment failures are caused by the incomplete obturation of the root
canal [2]. The difference between a poorly obturated and a retreated well-obturated
root canal can be seen in Fig. 8.2.
Some dentists prefer to insert the gutta-percha point into the canal without alter-
ing it [23], while other dentists like to soften the gutta-percha with heated instru-
ments or chemicals. The softened gutta-percha can then be condensed into the canal
using lateral or vertical condensation [24]. The separation of obturation methods into
vertical or lateral condensations is unrealistic, since it is physically impossible to
condense either laterally or vertically alone [25]. Often, the condensation procedure
to insert the gutta-percha will vary according to the shape of the instrumented root.
If the shape of the instrumented root matches the shape of the gutta-percha point,
then not much condensation of the gutta-percha is needed to get a good obturation of
the root canal. However, if the nearest size of gutta-percha point is a poor-fit, it might
need to be condensed to fit the root canal space. Gutta-percha is most difficult to
place into a minimally prepared narrow canal. Gutta-percha requires condensation
pressure be applied in the apical third region of the canal, and it can easily become
extruded through an open apex, leaving fragments in the periradicular tissues [26].
Gutta-percha filling techniques use a prefitted primary point procedure, verified
by a radiograph to fit the full length of the canal and to still fit tightly in the apical
Summary of the Root Canal Obturation Technique 167
region of the root canal [9]. Normally, if the instrumented canal has an adequate
condensation space or flare has been prepared, it is often impossible to fill the length
of the canal with a gutta-percha point that fits tightly at the root apical region. The
largest possible gutta-percha point is normally selected according to the size of the
last instrument used to the full length of the prepared canal. A radiograph of the root
canal must be taken with the gutta-percha point inserted to check that it fits the
working length of the root canal. If it does not fit, it may be necessary to reprepare
the apical aspect of the canal or to select another gutta-percha point.
The root canal must be dried with paper points prior to its obturation, as residual
irrigation fluids will leave voids [27]. The sealer is evenly coated on the prepared
canal surface, with the last instrument used to spread it throughout the canal length
using an up and down motion [28].
The fitted gutta-percha point is cut to the root canal working length, and a spreader
is used to condense it into the root canal space. A radiograph is taken to evaluate the
quality of the root canal obturation and to assess the need to reposition the point or
apply more condensation pressure. In anterior teeth, if the filling is satisfactory, the
gutta-percha should be removed to the gingival line or below it, because gutta-percha
can discolor the tooth [29]. In posterior teeth, it is advisable to have a “bed” of gutta-
percha on the floor of the pulp chamber; this can act as a guide for retreatment or to
alert the operator that he is getting too close to the floor of the crown when making a
final preparation [30]. It will also assist in the sealing of furcal accessory canals.
Because no one gutta-percha obturation technique could possibly satisfy all end-
odontic situations [31], it is necessary to consider some modifications of the basic
technique. In a root canal where an adequate apical stop or constriction is impossi-
ble to achieve, as in an immature canal after apexification, the gutta-percha point
can be custom contoured by dipping the apical 3–4 mm in chloroform and then
placing it into the canal with pressure. By the repeated placement and removal of
the apical softened point, this uses the apical canal space to mold the gutta-percha
to accomplish a good fit. Thin root canals or canals with an extreme curve are more
difficult to obturate with standard sizes of gutta-percha points. In these situations,
heated instruments or chloroform can be used to chemically soften the gutta-percha
for 5 s so that it can be more easily into the curvature and the minimally prepared
apex. All of these gutta-percha obturation techniques must be considered to accom-
plish the goal of fully obturating the root canal. A summary of the terms and tech-
niques for obturating root canals is shown in Table 8.2.
Summary of the Root Canal Obturation Technique
Situations when it is acceptable to fill the root canal:
1. The patient is relatively comfortable; mild tooth soreness is acceptable [44].

2. After canal has been instrumented to the appropriate size and the conical shape
of the prepared canal is convenient to insert and condense the gutta-percha points
and achieve an apical stop [45].
Table 8.2 A summary of techniques for obturating root canal systems

Technique Description
Apical barrier [32] Creating an apical barrier when the apical foramen is open in immature
teeth for apexification and is important to prevent the extrusion of
gutta-percha into the periradicular tissues. A 2-mm-thick cone of MTA
or another biocompatible material such as Biodentine® can be placed
in immature teeth as the apical barrier [32]
Carrier-based A sized and fitted section of gutta-percha with sealer is inserted into the
(sectional) final 4-mm apical region of the root canal. The remaining root canal is
filled with injectable thermoplasticized gutta-percha using an injection
gun such as the SimpliFill device [33]
Carrier-based A warm gutta-percha on a plastic carrier is delivered directly into the
(thermoplasticized) canal to fill it. Some of the main carrier systems are Densfil™,
RealSeal™, Soft-Core®, and Thermafil® [34]
Chemoplasticized The gutta-percha is softened using solvents such as chloroform or
eucalyptol and is placed on already fitted gutta-percha points. The
gutta-percha points are inserted into the canal, laterally condensed with
spreaders, and the remaining canal space is filled with points [35]
Continuous wave A down-packing (vertical compaction) of core material and sealer into
the apical region of the root canal using heating devices such as a
System B or Elements Obturation Unit and then backfilling the
remaining root canal with thermoplasticized core material using
injection devices such as the Obtura Elements Obturation Unit or
HotShot heating devices [36]
Custom cone molding The outer surface of the gutta-percha point is softened using solvents
such as chloroform or eucalyptol, and then, it is inserted into the apical
region of the canal to make a mold. Gutta-percha shrinks as it hardens,
so the point is removed, sealer is placed into the canal, and then the
point is reinserted and condensed with spreaders [37]
Injection (preheated) Sealer is injected into the canal. A preheated, thermoplasticized,
injectable core material is injected to obturate the root canal using a
heating device such as an Obtura, or Ultrafil, or Calamus® system [38]
Injection (cold) Sealer is injected into the canal. A cold, flowable core material such as
GuttaFlow® is injected to obturate the root canal [39]
Lateral compaction A gutta-percha point with the same size as the final instrumentation size
is cut to the working length of the root canal. The point is coated with
sealer and inserted into the canal. The point is laterally compacted with
spreaders and other points are added to fill the remaining root canal [40]
Thermomechanical A gutta-percha point is coated with sealer and placed in the root canal.
The point is then rotated with an instrument to warm the core material
with friction. The warm core material is then compacted into the root
canal [41]
Vertical compaction A gutta-percha point with the same size as the final instrumentation size
is cut to a length of 4 mm. The point is coated with sealer, heated, and
inserted into the apical region of the canal. The point is vertically
compacted with pluggers, and warm gutta-percha points are added to
fill the remaining root canal [42]
Warm lateral A gutta-percha point with the same size as the final instrumentation size
condensation is cut to the working length of the root canal. The point is coated with
sealer and inserted into the canal, the point is laterally condensed with a
warm spreader, and warm gutta-percha points are added to fill the
remaining root canal [43]
Alternative Root Canal Obturation Materials 169
Suggested gutta-percha obturation procedure:
1. Dry the canals by inserting paper points cut to the root canal working length.
2. Fit a standardized gutta-percha point to the established root canal working
length, which is 1 mm short of the root canal length.
3. Check the fit of the gutta-percha point in a radiograph.
4. Mark the occlusal or incisal level of the gutta-percha point by pinching it with
an instrument.
5. Place a paper point into the canal that matches the size of the gutta-percha
point. Inject the sealer to evenly coat the root canal surface and spread it using
the last instrument size used in the root canal preparation.
6. Dip the gutta-percha point into the sealer, and insert it into the canal to the fitted
working length.
7. If there are any voids, add more gutta-percha to fill them.
8. Check the completeness of this initial condensation effort using a radiograph to
evaluate the extent and quality of the fill.
9. If a void or space is observed, correct it by removing the gutta-percha and
repreparing the canal for obturation. Start again by fitting a new gutta-percha
point, and then refill the tooth.
10. Once the obturation of the apical and middle regions of the root canal contains
no voids, continue adding gutta-percha or core material to obturate the root
canal up to the root canal orifice level.
11. Restore the root canal access to prevent microleakage.
12. Tell the patient to expect discomfort for a few days and prescribe analgesics as
appropriate.
Alternative Root Canal Obturation Materials
Some gutta-percha points are available with a resin coating (EndoREZ®) [46] or
glass ionomer coating (Activ GP Plus™) to be used with Activ GP sealer [47] to
attempt to improve the quality of the bond between the gutta-percha and the root
canal surface, which could help prevent microleakage [48]. There are alternative
core materials to gutta-percha for the obturation of root canals; these include silver
points, pastes, and composite resin core materials.
Silver Point Obturation of Root Canals
Silver points have been used to obdurate root canals since the 1920s. Although sil-
ver points can fill narrow canals, they are not commonly used, because they cannot
adequately seal the root canal and they can corrode leading to resorption, tooth and
tissue discoloration, and possibly pain for the patient. It is not acceptable to use
silver points, amalgam, or other corrosive metals to obturate root canals [49].
Pastes to Obturate Root Canals
Pastes have been used to fill root canals since the 1950s. Most of the pastes con-
tained zinc oxide eugenol, which is extremely toxic. The use of pastes to fill the root
canal is not acceptable [50] because they are prone to resorption, their toxicity can
trigger inflammation, and they are porous and so cannot seal the root canal ade-
quately enough to prevent microleakage.
Composite Resins to Obturate Root Canals
Composite resin materials have proved to be very successful for aesthetic restora-
tions. Composite resin has been advocated as an alternative and better core filling
material to gutta-percha to create a monoblock with the tooth structure [51]. Similar
to gutta-percha, composite resin materials such as Resilon™ can be heated or soft-
ened with solvents and used with any root canal obturation technique. Composite
resin core materials are slowly increasing in popularity, but clinical trials have not
yet shown they can be more successful than gutta-percha.
Posttreatment Patient Management
Patients can expect to experience discomfort following root canal treatment [52]. To
lessen the anxiety of the patient about the normal healing events of root canal treatment,
it is necessary to warn them to expect discomfort for days. The cause of postoperative
pain is probably the result of root canal instrumentation, the use of irrigating and medi-
cations, and slight injury to periradicular and periodontal tissues that can trigger acute
periapical pain [53]. Inflammation of the oral tissues and the associated pain are difficult
to prevent, but it can be lessened by the dentist being careful to minimize trauma, taking
care to prevent procedural accidents, and removing the root from hyperocclusion [54].
Posttreatment Instructions
Patients must be told not to chew or put pressure on the treated tooth for a few days
and to expect some pain which will resolve itself. The patient can take over-the-
counter analgesics to reduce the pain intensity and anxiety. If the pain does not
subside within a few days, they should be told to come back to the office to evaluate
the condition of the tooth, and for prescription analgesics if needed.
Treatment of a Flare-Up
See the patient as soon as possible. Remove the access material and check the root canal
for exudate. If an exudate is observed, aspirate it with suction, irrigate the root canal with
sodium hypochlorite, and instrument the canal to a larger size than was used previously.
Summary 171
Dry the canal with paper points and re-obturate it. If no exudate is observed, ensure the
core material is filling the apical region of the root canal; if it is not, remove it and irrigate
the canal with sodium hypochlorite. There is no need to instrument the canal to a larger
size if no infected fluid is observed. Dry the canal with paper points and re-obturate it.
Considerations for Restoring Endodontically Treated Teeth
The ability to restore the tooth should be considered prior to endodontic treatment;
if the tooth cannot be restored because there is too little tooth structure or because
the tooth is fractured, it should not be given root canal treatment. Teeth with exten-
sive destruction of the tooth structure may need crown lengthening or orthodontic
eruption prior to endodontic treatment.
The microleakage of bacteria into the root canal following treatment must be
prevented by placing an immediate restoration to seal the root canal access. Most
dentists will use a temporary dental restorative material, a resin-modified glass ion-
omer, or composite resin material. Delaying the final restorative treatment is not in
the best interests of the patient.
The basic principles of restoring endodontically treated teeth are:
Posterior teeth should receive full cuspal coverage restorations. Bonded restorations
may not provide enough protection for the tooth, and it could fracture before it
gets a final restoration.
Anterior teeth with minimal loss of tooth structure can be restored conservatively
with composite resin restorations.
Preserve coronal and radicular tooth structure.
If the tooth is likely to need a post to support a crown, there will need to be enough
space for the post. Posts need a ferrule minimum of 2 mm of vertical height and
1 mm of dentin thickness.
Summary
The complete obturation of the prepared root canal, by filling any voids with core
material and sealer, and attention to avoiding operator errors, such as extrusion of
sealer or core material into the periradicular tissues, are key elements for the success
of endodontic treatment. Several types of sealers are available, but they are all toxic
and should never be placed in contact with vital tissues. Although several types of
core materials are available, gutta-percha has been established as the most widely
used and successful core material to obdurate a root canal. Composite resin core mate-
rials are slowly increasing in popularity, but clinical trials have not yet shown they can
be more successful than gutta-percha. It is not acceptable to obturate root canals with
silver points, amalgam, corrosive metals, or pastes. Root canals that contain voids and
gaps have a higher risk of a flare-up and treatment failure, in comparison with root
canals that are completely obturated from the apex to the coronal root canal access.
1. The root canal must be dried with paper points prior to its obturation, as residual
irrigation fluids will leave voids.
(a) False
(b) True
2. The majority of dentists will use gutta-percha as the primary filling material in
root canal therapy?
(a) False
(b) True
3. The reason for the success of gutta-percha among dentists is because it is easy
to manipulate into the root canal, it is radiopaque and easily seen on radio-
graphs, and it can be removed from the canal and be replaced when necessary.
(a) False
(b) True
4. Fresh gutta-percha has good handling properties, while aged gutta-percha can
become brittle.
(a) False
(b) True
5. Some dentists prefer to insert the gutta-percha point into the canal without
altering it, while other dentists like to soften the gutta-percha with heated
instruments or chemicals. The softened gutta-percha can then be condensed
into the canal using lateral or vertical condensation.
(a) False
(b) True
6. An advantage of gutta-percha is that it is inert to the periapical tissues if it
should become extruded past the root apex.
(a) False
(b) True
7. Gutta-percha filling techniques use a prefitted primary point procedure, verified
by a radiograph to fit the full length of the canal and to still fit tightly in the api-
cal region of the root canal.
(a) False
(b) True
8. The largest possible gutta-percha point is normally selected according to the
size of the last instrument used to the full length of the prepared canal.
(a) False
(b) True
9. Thin root canals or canals with an extreme curve are more difficult to obturate
with standard sizes of gutta-percha points. In these situations, heated instru-
ments or chloroform can be used to chemically soften the gutta-percha for 5 s
so that it can be more easily into the curvature and the minimally prepared apex.
(a) False
(b) True
Bibliography 173
10. The success of endodontic treatment is dependent on the obturation of the root
canal with gutta-percha and sealers which can seal the entire root canal, thereby
preventing microleakage and the reinfection of the root canal.
(a) False
(b) True
11. The sealer is applied as an even coat on the prepared canal surface, with the last
instrument used to spread it throughout the canal length using an up and down
motion.
(a) False
(b) True
12. Sealers are needed to seal the gutta-percha core material and prevent
microleakage.
(a) False
(b) True
13. The sealer fills voids and irregularities of the root canal space left unfilled by
the obturation core material.
(a) False
(b) True
14. Adequate sealing of the obturation material inside the root canal is important to
the success of endodontic treatment, because up to 60 % of endodontic treat-
ment failures are caused by the incomplete obturation of the root canal.
(a) False
(b) True
15. Root canal sealers can vary greatly in composition and contain zinc oxide euge-
nol, calcium hydroxide, glass ionomer, composite resin, silipoint, urethane
methacrylate, formaldehyde, and bis-phenol A.
(a) False
(b) True
16. The quality of root canal obturation can be seen in radiographs and a poor qual-
ity of obturation can increase the risk of a flare-up and treatment failure.
(a) False
(b) True
Bibliography
1. Hammad M1, Qualtrough A, Silikas N. Evaluation of root canal obturation: a three-dimen-
sional in vitro study. J Endod. 2009;35:541–4.
2. Dow PR, Ingle JI. Isotope determination of root canal failure. Oral Surg Oral Med Oral Pathol.
1955;8:1100–4.
3. Kolokouris I, Economides N, Beltes P, Vlemmas I. In vivo comparison of the biocompatibility
of two root canal sealers implanted into the subcutaneous connective tissue of rats. J Endod.
1998;24:82–5.
4. Miletic I, Jukic S, Anic I, Zeljezic D, Garaj-Vrhovac V, Osmark M. Examination of cytotoxic-

ity and mutagenicity of AH26 and Roekoseal(RSA) sealers. Int Endod J. 2003;36:330–5.
5. Economides N, Kotsaki-Kovatsi VP, Poulopoulos A, Kolokuris I, Rozos G, Shore
R. Experimental study of the biocompatibility of four root canal sealers and their influence on
the zinc and calcium content of several tissues. J Endod. 1995;21:122–7.
6. Lodiene G, Morisbak E, Bruzell E, Ørstavik D. Toxicity evaluation of root canal sealers
in vitro. Int Endod J. 2008;41:72–7.
7. Desai S, Chandler N. Calcium hydroxide-based root canal sealers: a review. J Endod.
2009;35:475–80.
8. Kim YK, Grandini S, Ames JM, Gu LS, Kim SK, Pashley DH, Gutmann JL, Tay FR. Critical
review on methacrylate resin-based root canal sealers. J Endod. 2010;36:383–99.
9. Jenkins SM, Hayes SJ, Dummer PM. A study of endodontic treatment carried out in dental
practice within the UK. Int Endod J. 2001;34:16–22.
10. Li GH, Niu LN, Selem LC, Eid AA, Bergeron BE, Chen JH, Pashley DH, Tay FR. Quality of
obturation achieved by an endodontic core-carrier system with crosslinked gutta-percha carrier
in single-rooted canals. J Dent. 2014;42:1124–34
11. Gandolfi MG, Parrilli AP, Fini M, Prati C, Dummer PM. 3D micro-CT analysis of the interface
voids associated with Thermafil root fillings used with AH Plus or a flowable MTA sealer. Int
Endod J. 2013;46:253–63.
12. Lotfi M, Ghasemi N, Rahimi S, Vosoughhosseini S, Saghiri MA, Shahidi A. Resilon: a com-
prehensive literature review. J Dent Res Dent Clin Dent Prospects. 2013;7:119–30.
13. Shipper G, Ørstavik D, Teixeira FB, Trope M. An evaluation of microbial leakage in roots
filled with a thermoplastic synthetic polymer-based root canal filling material (Resilon).
J Endod. 2004;30(5):342–7.
14. Shipper G, Teixeira FB, Arnold RR, Trope M. Periapical inflammation after coronal microbial
inoculation of dog roots filled with guttapercha or Resilon. J Endod. 2005;31(2):91–6.
15. Teixeira FB, Teixeira EC, Thompson JY, Trope M. Fracture resistance of roots endodontically
treated with a new resin filling material. J Am Dent Assoc. 2004;135(5):646–52.
16. Beasley RT, Williamson AE, Justman BC, Qian F. Time required to remove guttacore, ther-
mafil plus, and thermoplasticized gutta-percha from moderately curved root canals with prota-
per files. J Endod. 2013;39:125–8.
17. Ring J, Murray PE, Namerow KN, Moldauer BI, Garcia-Godoy F. Removing root canal obtu-
ration materials: a comparison of rotary file systems and re-treatment agents. J Am Dent
Assoc. 2009;140:680–8.
18. Schilder H, Goodman A, Aldrich W. The thermomechanical properties of gutta-percha. I. The
compressibility of gutta-percha. Oral Surg Oral Med Oral Pathol. 1974;37:946.
19. Glenner RA, Willey P. Dental filling materials in the confederacy. J Hist Dent. 1998;46:71–5.
20. Kulild J, Lee C, Dryden J, Collins J, Feil P. A comparison of 5 gutta-percha obturation tech-
niques to replicate canal defects. Oral Surg Oral Med Oral Pathol Oral Radiol Endod.
2007;103:e28–32.
21. Fanibunda K, Whitworth J, Steele J. The management of thermomechanically compacted gutta
percha extrusion in the inferior dental canal. Br Dent J. 1998;184:330–2.
22. Hoen MM, Pink FE. Contemporary endodontic retreatments: an analysis based on clinical
treatment findings. J Endod. 2002;28:834–6.
23. Ansari BB, Umer F, Khan FR. A clinical trial of cold lateral compaction with Obtura II tech-
nique in root canal obturation. J Conserv Dent. 2012;15:156–60.
24. Naseri M, Kangarlou A, Khavid A, Goodini M. Evaluation of the quality of four root canal
obturation techniques using micro-computed tomography. Iran Endod J. 2013;8:89–93.
25. Katalinić I, Baraba A, Glavicić S, Segović S, Anić I, Miletić I. Comparison of vertical forces
during root canal filling with three different obturation techniques. Coll Antropol.
2013;37:895–9.
26. Boutsioukis C, Psimma Z, Kastrinakis E. The effect of flow rate and agitation technique on
irrigant extrusion ex vivo. Int Endod J. 2014;47:487–96.
Bibliography 175
27. Nagas E, Uyanik MO, Eymirli A, Cehreli ZC, Vallittu PK, Lassila LV, Durmaz V. Dentin
moisture conditions affect the adhesion of root canal sealers. J Endod. 2012;38:240–4.
28. Kontakiotis EG, Tzanetakis GN, Loizides AL. A comparative study of contact angles of four
different root canal sealers. J Endod. 2007;33:299–302.
29. van der Burgt TP, Plasschaert AJ. Tooth discoloration induced by dental materials. Oral Surg
Oral Med Oral Pathol. 1985;60:666–9.
30. Carrotte P. Endodontics: part 8. Filling the root canal system. Br Dent J. 2004;197:667–72.
31. Niederman R, Theodosopoulou JN. A systematic review of in vivo retrograde obturation
materials. Int Endod J. 2003;36:577–85.
32. Araújo RA, Silveira CF, Cunha RS, De Martin AS, Fontana CE, Bueno CE. Single-session use
of mineral trioxide aggregate as an apical barrier in a case of external root resorption. J Oral
Sci. 2010;52:325–8.
33. Al-Kahtani AM. Carrier-based root canal filling materials: a literature review. J Contemp Dent
Pract. 2013;14:777–83.
34. De-Deus G, Barino B, Marins J, Magalhães K, Thuanne E, Kfir A. Self-adjusting file cleaning-
shaping-irrigation system optimizes the filling of oval-shaped canals with thermoplasticized
gutta-percha. J Endod. 2012;38:846–9.
35. Stein KE, Manfra Marretta S, Siegel A, Vitoux J. Comparison of hand-instrumented, heated
gutta-percha and engine-driven, cold gutta-percha endodontic techniques. J Vet Dent.
2004;21:136–45.
36. Lea CS, Apicella MJ, Mines P, Yancich PP, Parker MH. Comparison of the obturation density
of cold lateral compaction versus warm vertical compaction using the continuous wave of
condensation technique. J Endod. 2005;31:37–9.
37. Christensen G. A custom cone technique for endodontic treatment of immature root canals.
Chronicle. 1973;36:155–6.
38. Robberecht L, Colard T, Claisse-Crinquette A. Qualitative evaluation of two endodontic obtu-
ration techniques: tapered single-cone method versus warm vertical condensation and injec-
tion system: an in vitro study. J Oral Sci. 2012;54:99–104.
39. Wu MK, Kean SD, Kersten HW. Quantitative microleakage study on a new retrograde filling
technique. Int Endod J. 1990;23:245–9.
40. Hale R, Gatti R, Glickman GN, Opperman LA. Comparative analysis of carrier-based obtura-
tion and lateral compaction: a retrospective clinical outcomes study. Int J Dent. 2012;
2012:954675.
41. Fariniuk LF, Westphalen VP, Silva-Neto UX, Carneiro E, Baratto Filho F, Fidel SR, Fidel
RA. Efficacy of five rotary systems versus manual instrumentation during endodontic retreat-
ment. Braz Dent J. 2011;22:294–8.
42. West J. Rationale and technique for vertical compaction of warm gutta-percha: the heat wave
approach. Dent Today. 2007;26:80, 82, 84.
43. Nelson EA, Liewehr FR, West LA. Increased density of gutta-percha using a controlled heat
instrument with lateral condensation. J Endod. 2000;26:748–50.
44. Bender IB. Reversible and irreversible painful pulpitides: diagnosis and treatment. Aust
Endod J. 2000;26:10–4.
45. Genç Ö, Alaçam T, Kayaoglu G. Evaluation of three instrumentation techniques at the preci-
sion of apical stop and apical sealing of obturation. J Appl Oral Sci. 2011;19:350–4.
46. Suzuki P, de Souza V, Holland R, Murata SS, Gomes-Filho JE, Dezan Junior E, Rodrigues Dos
Passos T. Tissue reaction of the EndoREZ in root canal fillings short of or beyond an apical
foramenlike communication. Oral Surg Oral Med Oral Pathol Oral Radiol Endod.
2010;109:e94–9.
47. Oliveira AC, Tanomaru JM, Faria-Junior N, Tanomaru-Filho M. Bacterial leakage in root
canals filled with conventional and MTA-based sealers. Int Endod J. 2011;44:370–5.
48. Dultra F, Barroso JM, Carrasco LD, Capelli A, Guerisoli DM, Pécora JD. Evaluation of apical
microleakage of teeth sealed with four different root canal sealers. J Appl Oral Sci.
2006;14:341–5.
49. Chana H, Briggs P, Moss R. Degradation of a silver point in association with endodontic infec-
tion. Int Endod J. 1998;31:141–6.
50. Maisto OA. Preparation and use of a slowly resorpting paste for root canal obturation.
(Spanish). Rev Asoc Odontol Argent. 1965;53:88–9.
51. Tay FR, Pashley DH. Monoblocks in root canals: a hypothetical or a tangible goal. J Endod.
2007;33:391–8.
52. Nixdorf DR, Moana-Filho EJ, Law AS, McGuire LA, Hodges JS, John MT. Frequency of
nonodontogenic pain after endodontic therapy: a systematic review and meta-analysis.
J Endod. 2010;36:1494–8.
53. Barasch A, Safford MM, McNeal SF, Robinson M, Grant VS, Gilbert GH. Patterns of postop-
erative pain medication prescribing after invasive dental procedures. Spec Care Dentist.
2011;31:53–7.
54. Jayakodi H, Kailasam S, Kumaravadivel K, Thangavelu B, Mathew S. Clinical and pharmaco-
logical management of endodontic flare-up. J Pharm Bioallied Sci. 2012;4 Suppl 2:S294–8.
Periradicular Surgery
9
Periradicular surgery is not always a necessary step toward endodontic success; it

should never be used as a cure for a poor endodontic root canal technique. Surgery
is an integral aspect of endodontic therapy when root canal therapy is not deemed
sufficient to remove the infection. Surgery is often assumed to be the most radi-
cal procedure; however, sometimes the surgical procedure becomes a conservative
effort to avoid further tissue injury and extraction of the tooth. The course of treat-
ment would be better defined as surgical or nonsurgical. The surgical endodontic
procedure must never be used as a cure-all or excuse for poor endodontic technique.
Surgery in Endodontic Practice
Unfortunately, surgery has been used in the past as a cure for an extensive periapical
radiolucency [1]. However, it has been demonstrated that a large periapical lesion
will resolve as completely as a small one if the infection from the canal has been
eliminated [2]. The extent of the periapical injury should not be a factor in deciding
to perform a surgical intervention. Surgery has been used to identify cysts [3],
because it is not possible to identify them from a radiograph alone. The pathology
of the cyst requires examination, and surgery alone cannot identify a cyst. After a
root canal treatment has failed and there is a flare-up, surgery should only be con-
sidered, if the tooth cannot be retreated to remove the infection [4]. Root canal
retreatment in itself may be adequate to resolve the flare-up and save the tooth. A
fractured instrument in the apical third of the canal is not a consideration for sur-
gery. All that is needed is future radiographs to check that there is no lesion develop-
ing around the fragment of instrument. An accidental or carious root canal
perforation was once considered to require immediate surgery for the resection of
the root to the point of perforation [5]. However, in many cases without surgery,
packing the perforation repair material from within the root canal can solve the
problem by restoring the tooth structure.

DOI 10.1007/978-3-662-43730-8_9
178 9 Periradicular Surgery
Resorption of the root canal apex was an indication for surgery to remove
necrotic tissue; however, some clinical cases have demonstrated that periapical
healing can arrest the resorptive process by nonsurgical root canal therapy [4]. An
incompletely developed apex was once assumed to require surgery; however, there
are now improved regeneration techniques for saving immature teeth. The acciden-
tal extrusion of sealer and obturation core material into the periapical tissues is the
only candidate for surgery if they cause a persistent periapical radiolucency, swell-
ing, and pain [6]. A horizontal fracture of the root apex may not require surgery, if
the apical canal fragment contains vital tissue. Only if the apical tissue becomes
necrotic, then it may be necessary to remove the apical fragment. By trial and error,
it has become clear that surgery is not always in the best interests of saving a tooth
if a nonsurgical treatment can suffice.
Types of Surgeries
Anatomical redesigning is needed as part of periodontal treatment, for root ampu-

tation, hemisection, and bicuspidization [7]. It develops a periodontally main-
tainable environment for the remaining root or roots.
Apical resection is the removal of the root end of a tooth [8]. This resection proce-
dure is used when a portion of the unfilled root needs to be removed or as a step
in the retrofill preparation.
Bicuspidization is the separation of a multirooted tooth by a vertical cut through
the furcation [9].
Diagnostic surgery can be needed after radiographs and a thorough examination
have failed to identify the etiology of a problem or pathosis [10]. In these situa-
tions, a visual examination of the root by surgical exploration is necessary and
may reveal a fracture, malformation, defect or anomaly, missed root canals
which were not cleaned, inadequately filled teeth, pieces of instruments, and
perforations caused by procedural errors. Often, diagnostic surgery will require
collecting a biopsy specimen. Although it is not common to discover a malig-
nancy or serious nonodontogenic condition, the biopsy tissue must be sent to a
pathologist for assessment and diagnosis.
Hemisection is the removal of a root and its coronal portion from a multirooted
tooth [11].
Incision and drainage is needed to release exudates from swollen soft tissues [12].
The exudate is released by incision and drainage to relieve the pressure and
reduce the pain. Often, the soft tissue swelling is indurated and has a diffuse cel-
lulitis. In these circumstances, an incision may be unsuccessful for immediate
relief and reduction of the swelling. A helpful solution is to ask the patient to
keep a warm saltwater solution in the inflamed tissue area, to try to bring the
exudate to a more fluctuant concentrated area to make it easier to drain. After
delivering local anesthesia to the surgical site to numb the tissues, an incision
should be made with a sterile scalpel blade. The released exudates may contain
blood, but this is not normally a cause for concern. If the swelling is large, a
Types of Surgeries 179
rubber-dam drain may be inserted into the incision to maintain the patency of this
surgical opening. The swelling of tissues is an indication of infection which indi-
cates the need for antibiotic therapy.
Intentional tooth replantation may be considered when no other course of root
canal treatment is possible and extraction of the hopeless tooth is inevitable [13].
The tooth is extracted, the root canal is retrofilled, and the tooth is replanted back
into the socket with care to avoid damaging the root or surrounding bone. The
amount of time the tooth is removed from the socket must be minimized to
reduce the risk of ankylosis and subsequent replacement resorption, although
these are common responses to intentional tooth replantation. The long-term sur-
vival of replanted teeth is uncertain, and this procedure can only be recom-
mended as a temporary last resort to save a tooth.
Marsupialization is a decompression technique used to reduce a massive cyst with-
out surgical curettage [14]. This is accomplished by making the epithelial lining
of the cyst continuous with the mucus membrane of the attached gingival of the
oral tissues. The reduction of the lumen takes place as the cyst epithelium
becomes part of the oral epithelium.
Periapical surgery or apicoectomy [15] has been used as the all-inclusive term
for endodontic surgery, but it does not describe all endodontic surgeries. A
periapical curettage is performed by removing the pathologic tissues sur-
rounding the apex of a tooth without disturbing the root. It can be the com-
plete treatment, or it may be the initial step in an apical resection or root
retrofill. A periapical curettage is performed to release a confined exudate or
irritant and remove periapical tissues and cysts that are not healing. A retrofill
procedure involves sealing the root canal preparation with a material. This is
done when the root canal cannot be adequately filled by nonsurgical root canal
treatment. The retrofill preparation, sometimes described as the “pot hole,”
must include the entire apical foramen, being sufficient to retain the bulk of
the filling material. A bevel needs to be cut into the root to allow the direct
access to the apical canal to accomplish its filling. In the past, sealers and
amalgam were used as common retrofill materials, but today, MTA is more
likely to be used.
Root amputation is the removal of a root from a multirooted tooth, leaving the
coronal portion of the tooth intact [16]. Root amputation, hemisection, or bicus-
pidization is indicated when removal of a root will allow for better periodontal
maintenance techniques and when a root or furcation is periodontally untreat-
able, such as in the case of obstructed canals, untreatable pathologic root defects
and resorption, procedural errors, and root fractures. The extent of periodontal
disease and bone support for the remaining tooth must be carefully evaluated
prior to root amputation surgery.
Trephination requires anesthetic and is the perforation of a cortical plate to release
the pressure of an exudate with alveolar bone [17]. This is a minimum usage
procedure, to be considered only if the pain cannot be controlled by intercanal
procedures, after antibiotics have proven to be ineffective, after rinsing with
warm saline has not affected drainage through the cortical plate. The location of
the trephination should be close to the apex of the inflamed tooth, and it must
avoid anatomical landmarks and adjacent roots. An incision is made to prevent
the tissue from being caught or wound by the bur. Only the cortical plate of bone
in the area should be penetrated; it is not necessary to reach the apex itself in
order to effect relief.
Restorative and Occlusal Factors
After amputation surgery, the patient’s occlusal contact of teeth should be evalu-
ated for problems; if there are contacts with teeth where the roots have been
amputated, those teeth may need to be supported by splinting during the healing
process.
Guidelines for Surgery
1. A surgical flap is necessary for access to tissues, visibility, and orientation of the
roots in the alveolus.
2. Removal of the overlying buccal bone may be necessary to assist in extraction of
the root.
3. Directions for root amputation: avoid gouging the remaining root.
4. Directions for hemisection: the cut is made at the expense of the root to be
sacrificed.
5. Directions for bicuspidization: Maintain the vertical direction of the cut and
remain centered over the furcation. Round off any sharp corners of the tooth.
Leave adequate space between the roots to allow for the preparation and
restoration.
6. Avoid spilling or leaving any excess materials in the alveolus.
Surgical Flap
It is not necessary to design a predetermined geometric flap configuration. There are

only two kinds of incisions that are needed to create a surgical flap. The size of the
flap must be large enough to directly access the tissues to be surgically treated. If a
radiolucency is present on the radiograph, the size of the flap must allow access to
the entire radiolucent area. The actual amount of bone destruction will probably be
larger than it appears on the radiograph. It is important that the flap be sutured over
solid bone. The position of the vertical incision is based on the need to achieve
access and to relieve tissue tension. The position of the horizontal component
depends on the condition of the periodontium and the underlying bone; it may be
made along the margins of the teeth or a few millimeters away, preferably in the
attached gingiva. The periodontal evaluation will determine whether periodontal

disease is present and the amount of attached gingiva. The gingival crevice must be
probed for pocket depth. If there are deep pockets and little attached gingiva, a full
flap may be required. If an aesthetic crown is present, a full flap may recede, which
could create a cosmetic problem.
Complications of Surgery
The patient must be informed if a fenestration or dehiscence is anticipated because

of the loss of underlying bone. Surgery to lower posterior teeth has a higher risk of
experiencing permanent paresthesia. Localized pain can be expected for a few days
after surgery, and swelling, ecchymosis, or temporary trismus may occur. After sur-
gery, a radiolucency may persist on the radiograph of the treatment site; this must
be compared to the presurgical radiograph for healing or signs of changes. If both
the buccal and lingual cortical plates were involved in pathosis or surgery, a radio-
graphic bony “defect” may remain. In reality, if the lucency is smaller than it was
presurgically, is separated from the root, and is asymptomatic, it can commonly be
diagnosed as scar tissue.
Summary
Surgery is an integral aspect of endodontic therapy for the treatment of cases when
root canal therapy is not deemed sufficient to remove the infection. Over recent
years, the amount of endodontic surgeries has been decreasing as the reliability and
success of root canal procedures have been increasing. Surgery has become a spe-
cialized field in endodontics and these cases should be referred to specialists for
treatment.
1. Surgery is an integral aspect of endodontic therapy for the treatment of cases

when root canal therapy is not deemed sufficient to remove the infection.
(a) False
(b) True
2. Over recent years, the amount of endodontic surgeries has been decreasing as
the reliability and success of root canal procedures have been increasing.
(a) False
(b) True
3. Periradicular surgery is not always a necessary step toward endodontic success;
it should never be used as a cure for a poor endodontic root canal technique.
(a) False
(b) True
4. Surgery is often assumed to be the most radical procedure; however, sometimes

the surgical procedure becomes a conservative effort to avoid further tissue
injury and extraction of the tooth.
(a) False
(b) True
5. Resorption of the root canal apex was an indication for surgery to remove
necrotic tissue; however, some clinical cases have demonstrated that periapical
healing can arrest the resorptive process by nonsurgical root canal therapy.
(a) False
(b) True
6. An incompletely developed apex was once assumed to require surgery; how-
ever, there are now improved regeneration techniques for saving immature
teeth.
(a) False
(b) True
7. The accidental extrusions of sealer and obturation core material into the peri-
apical tissues are only candidates for surgery if they cause a persistent periapi-
cal radiolucency, swelling, and pain.
(a) False
(b) True
8. A horizontal fracture of the root apex may not require surgery, if the apical
canal fragment contains vital tissue.
(a) False
(b) True
9. Only if the apical tissue becomes necrotic, then it may be necessary to remove
the apical fragment.
(a) False
(b) True
10. By trial and error, it has become clear that surgery is not always in the best
interests of saving a tooth if a nonsurgical treatment can suffice.
(a) False
(b) True
11. The types of surgery include: Anatomical redesigning is needed as part of peri-
odontal treatment, for root amputation, hemisection, and bicuspidization.
(a) False
(b) True
12. Apical resection is the removal of the root end of a tooth.
(a) False
(b) True
13. Bicuspidization is the separation of a multirooted tooth by a vertical cut through
the furcation.
(a) False
(b) True
Bibliography 183
14. Hemisection is the removal of a root and its coronal portion from a multirooted
tooth.
(a) False
(b) True
15. Incision and drainage is needed to release exudates from swollen soft tissues.
(a) False
(b) True
16. Intentional tooth replantation may be considered when no other course of root
canal treatment is possible and extraction of the hopeless tooth is inevitable.
(a) False
(b) True
17. Marsupialization is a decompression technique used to reduce a massive cyst
without surgical curettage.
(a) False
(b) True
18. A periapical curettage is performed by removing the pathologic tissues sur-
rounding the apex of a tooth without disturbing the root.
(a) False
(b) True
19. Root amputation is the removal of a root from a multirooted tooth, leaving the
coronal portion of the tooth intact
(a) False
(b) True
20. Surgery has become a specialized field in endodontics, and most surgical cases
should be referred to specialists for treatment.
(a) False
(b) True
Bibliography
1. Brugnami F, Mellonig JT. Treatment of a large periapical lesion with loss of labial cortical
plate using GTR: a case report. Int J Periodontics Restorative Dent. 1999;19:243–9.
2. Soares J, Santos S, Silveira F, Nunes E. Nonsurgical treatment of extensive cyst-like periapical
lesion of endodontic origin. Int Endod J. 2006;39(7):566–75.
3. Nikitakis NG, Brooks JK, Melakopoulos I, Younis RH, Scheper MA, Pitts MA, Al-Mubarak
H, Sklavounou A. Lateral periodontal cysts arising in periapical sites: a report of two cases.
J Endod. 2010;36:1707–11.
4. Ray JJ, Kirkpatrick TC. Healing of apical periodontitis through modern endodontic retreat-
ment techniques. Gen Dent. 2013;61:19–23.
5. Motamedi MH. Surgical management of iatrogenic root perforation following endodontic
therapy. N Y State Dent J. 2006;72:40–1.
6. Yeo JF, Loh FC. Retrograde removal of fractured endodontic instruments. Ann Acad Med
Singapore. 1989;18:594–8.
7. Green EN. Hemisection and root amputation. J Am Dent Assoc. 1986;112:511–8.
8. Cho SY, Kim E. Does apical root resection in endodontic microsurgery jeopardize the prosth-
odontic prognosis? Restor Dent Endod. 2013;38:59–64.
9. Farley JR. Hemisection and bicuspidization of molars. Tex Dent J. 1974;92:4–5.
10. Tsesis I, Rosen E, Taschieri S, Telishevsky Strauss Y, Ceresoli V, Del Fabbro M. Outcomes of
surgical endodontic treatment performed by a modern technique: an updated meta-analysis of
the literature. J Endod. 2013;39:332–9.
11. Hülsmann M, Bahr R, Grohmann U. Hemisection and vital treatment of a fused tooth–literature
review and case report. Endod Dent Traumatol. 1997;13:253–8.
12. Simon JH, Warden JC, Bascom LK. Needle aspiration: an alternative to incision and drainage.
Gen Dent. 1995;43:42–5.
13. Moradi Majd N, Arvin A, Darvish A, Aflaki S, Homayouni H. Treatment of necrotic calcified
tooth using intentional replantation procedure. Case Rep Dent. 2014;2014:793892.
14. Torres-Lagares D, Segura-Egea JJ, Rodríguez-Caballero A, Llamas-Carreras JM, Gutiérrez-
Pérez JL. Treatment of a large maxillary cyst with marsupialization, decompression, surgical
endodontic therapy and enucleation. J Can Dent Assoc. 2011;77:b87.
15. Schoeffel GJ. Apicoectomy and retroseal procedures for anterior teeth. Dent Clin North Am.
1994;38:301–24.
16. de Sanctis M, Prato GP. Root resection and root amputation. Curr Opin Periodontol.
1993:105–10.
17. Nist E, Reader A, Beck M. Effect of apical trephination on postoperative pain and swelling in
symptomatic necrotic teeth. J Endod. 2001;27:415–20.
Index
A tooth angulations, 121

Abrasion, 45 visualizing, 119–120
ALARA, 100 Cementoblastoma, 111–112
Alveolar fracture Central giant cell granuloma (CGCG), 111
diagnosis, 42, 44, 45, 47 Chlorhexidine gluconate (CHX), 151
treatment, 54 Complete mouth radiographic series (CMRS),
Ameloblastomas, 110 102–103
Angulated multiple radiographs, 13–14 Concussion
Anti-curvature filing, 139 diagnosis, 43, 44, 47
Apexification treatment, 53, 54
mineral trioxide aggregate, 81–84 Cone beam computed tomography (CBCT)
root lengthening, 93 advantages, 105–106
Apexogenesis, 75 apical periodontitis detection, 106–107
root lengthening, 93 description, 105
steps involved in, 80–81 diagnosis, 106
Apicoectomy, 179 3-dimensional oral pathology
Aquatine Endodontic Cleanser, 152 information, 104
Asphyxia, 73 disadvantages, 106
Avulsion field of view, 105
diagnosis, 44, 45, 47 usage, 104
tooth replantation, 52–54 Contusion, 45
Cracked tooth
bite test, 28
B diagnosis, 27–28
Bicuspidization, 178 dye test, 28
Bitewing radiographs, 100–101 etiology, 27
Bone fracture. See Tooth and bone fracture patient history, 28
radiograph, 28
responsive testing, 28
C restoration removal, 28
Cement-enamel junction (CEJ) surgical exploration, 28
access penetration location selection, transillumination test, 28
119–120 treatment, 29–30
access position, 122 Crown fracture
cusp tip to pulp chamber, distance complicated, 43–45, 48
measurement, 122, 123 treatment, 54
law of root canal centrality, 119–121 uncomplicated, 43, 45, 48
law of root canal concentricity, 120–122 Cvek partial pulpotomy procedure, 75, 76, 80–81

DOI 10.1007/978-3-662-43730-8
186 Index
D endodontic-periodontic lesions
Dental pulp aging and removal, 118–119 diagnosis, 22
Dental pulp vitality endodontic lesions, 23
dental materials, 79 primary endodontic lesions, 23–24
diagnosis primary periodontic lesions, 24
assessment information, 4–6 true combined lesions, 24–25
cold sensibility testing, 7 facial examination, 3
objective information, 4–5 fistula, 20–21
PAIN diagnostic method, 7 immature teeth (see Immature teeth)
sensibility testing (see Sensibility insurance plans, 1
testing) irreversible pulpitis, 19
subjective information, 4–5 medical history, 6–7, 18
tissue diagnosis, 32 oral tissues swelling, 20–21
treatment planning, 6 pain diagnosis, 2–3
endodontic sealers, 79 patient care standards, 31
pulp necrosis, 73–74 patient consent form, 1–2, 35–38
Dentigerous cyst, 109 patient’s record, 2
Dentinogenesis, 118 periapical diagnosis, 25–26
Digital radiographs, 99 periapical lesions, nonpulpal origin, 21
periapical pathosis, 19–20
periodontal tissue diagnosis, 32
E periodontium examination, 12
Electric pulp tester (EPT), 8–9 periradicular surgery (see Periradicular
Electronic apex locators (EAL), 15–16 surgery)
Enamel fracture, 44 postoperative pain, 1
Enamel infraction, 45 prosthetic teeth, 1
Endodontic disease radicular groove anomaly, 25
additional canals detection, 13–14 radiographic examination, 4
cracked tooth reversible pulpitis, 18
bite test, 28 root aspect, 12–13
diagnosis, 27–28 root canal
dye test, 28 access preparation (see Root canal
etiology, 27 access preparation)
patient history, 28 cleaning and shaping (see Root canal
radiograph, 28 cleaning and shaping)
responsive testing, 28 irrigation (see Root canal irrigation)
restoration removal, 28 obturation (see Root canal obturation)
surgical exploration, 28 restoration, 1
transillumination test, 28 treatment, 1, 30–31
treatment, 29–30 root canal working length
crown examination, 12 canal openings detection, 15
dental examination, 4 degree of canal curvature, 14
dental history checklist, 6 EAL, 15–16
dental pulp vitality diagnosis measurement, 14
assessment information, 4–6 off-angle radiograph, 14
cold sensibility testing, 7 radiograph, 16
objective information, 4–5 root defects
PAIN diagnostic method, 7 clinical diagnosis, 26–27
sensibility testing (see Sensibility etiology, 26
testing) treatment, 27
subjective information, 4–5 safety protocols, 3
tissue diagnosis, 32 sinus tract, 20
treatment planning, 6 tooth structure for restorations, 12
dentin status diagnosis, 32 traumatic dental injuries (see Traumatic
diagnostic criteria, 17–18 dental injuries (TDIs))
Index 187
Endodontic sealers, 163–164 regenerative endodontic procedure, 74–76

Enterococcus faecalis, 149 biodegradable polymer, 91–92
Ethylene-diaminetetraacetic acid cell activity, 92
(EDTA), 154 closed apical foramen, 90
Extrusion open apical foramen, 89–90
diagnosis, 43, 44, 46, 49 root lengthening, 91
treatment, 55 single-visit vs. multiple-visit, 89
root canal disinfection, 78–79
root canal revascularization, 74, 76
F apical pathosis, 85–86
Ferrule effect, 12 avulsed replanted tooth and tissue
Focal osseous dysplasia (FOD), 112 formation, 85, 86
Follicular cyst, 109 Hoshino’s triple antibiotic paste, 85
Full mouth series (FMS/FMX) of radiographs, root lengthening, 91
102–103 sodium hypochlorite, 85
steps involved in, 87–89
root canal treatment, 76
Infraction, 43, 46, 49
G
Intentional tooth replantation, 179
Gingival/oral mucosa injuries, 45
Intrusion
Gutta-percha obturation
diagnosis, 43, 44, 46
advantages, 165–166
treatment, 55
anterior and posterior teeth, 167
filling techniques, 166–167
procedure, 167–169
quality, 166 J
semi-plastic physical properties, 165 Jaws
vertical/lateral condensations, 166 ameloblastomas, 110
cementoblastoma, 111–112
central giant cell granuloma, 111
dentigerous cyst/follicular cyst, 109
H
FOD/cemento-osseous dysplasia, 112
Hand files, 137–139
KCOT, 109
Hypochlorous acid (HOCl), 152
lateral periodontal cyst, 109
odontogenic myxoma, 112
odontomas, 111
I ossifying fibroma/osteofibrous
Immature teeth dysplasia, 111
apex size and stage, 76–77 periapical cyst/radicular cyst, 108
apexification radiolucent and radiopaque lesions,
mineral trioxide aggregate, 81–84 107, 108
root lengthening, 91 solitary eosinophilic granuloma, 113
apexogenesis, 77
root lengthening, 91
steps involved in, 80–81
avulsion injuries, 93–94 K
Cvek partial pulpotomy procedure, 75, 76, Keratocystic odontogenic tumor (KCOT), 109
80–81
health status and compliance, 77–78
irreversible pulpitis, 75 L
necrotic pulp, 75 Laceration, 45
patient age, 77 Lateral luxation
pulp vitality diagnosis, 43, 44, 46, 49
dental materials, 79 treatment, 55
endodontic sealers, 79 Lateral periodontal cyst, 109
pulp necrosis, 73–74 Law of dentin color change, 126
188 Index
Law of root canal centrality, 119–121 guidelines, 170

Law of root canal concentricity, 120–122 hemisection, 178
Luxation injuries incision and drainage, 178–179
avulsion intentional tooth replantation, 179
diagnosis, 44, 45, 47 marsupialization, 179
tooth replantation, 52–54 periapical surgery, 179
concussion restorative and occlusal factors, 180
diagnosis, 43, 44, 47 root amputation, 179
treatment, 53, 54 surgical flap, 180–181
extrusion trephination, 179–180
diagnosis, 43, 44, 46, 49
treatment, 55
intrusion Q
diagnosis, 43, 44, 46 Qmix 2in1 Endodontic Cleanser (Qmix), 154
treatment, 55
lateral luxation
diagnosis, 43, 44, 46, 49 R
treatment, 55 Radiation dose, 99–100
subluxation Radicular cyst, 108
diagnosis, 46, 50 Root canal access preparation
treatment, 56 access modifications, 122
bur size, shape and type selection, 124–125
caries decay removal, 125
M CEJ
Marsupialization, 179 access penetration location selection,
Morinda citrifolia juice (MCJ), 152 119–120
MTAD Antibacterial Root Canal Cleanser access position, 122
(MTAD), 154 cusp tip to pulp chamber, distance
measurement, 122
law of root canal centrality, 119–121
N law of root canal concentricity,
Nickel–titanium (NiTi) rotary instruments, 120–122
137–138 tooth angulations, 121
visualizing, 119–120
characteristics, 118
O defective restorations removal, 125
Occlusal radiographs, 101–102 dental operating microscope and
Odontogenic myxoma, 112 loupes, 117
Odontomas, 111 dental πυλπ aging and removal, 118–119
Ossifying fibroma/osteofibrous dysplasia, 111 law of dentin color change, 126
orifice number and location, 126–127
pulp chamber roof removal, 125
P straight-line access preparation, 117
PAIN diagnostic method, 7 tooth type
Panoramic radiographs, 103 mandibular molar teeth, 123–124
Perforation repair, 141–142 maxillary molar teeth, 124
Periapical cyst, 108 Root canal cleaning and shaping
Periapical radiographs, 101–102 accessory canals, 140
Periradicular surgery anti-curvature filing, 139
anatomical redesigning, 178 apical enlargement size, 136
apical resection, 178 culturing and medication, 141
bicuspidization, 178 cutting tips, 138
complications, 181 degree of difficulty, 132
diagnostic surgery, 178 disadvantages, 132
Index 189
final instrumentation, 134–135 sodium hypochlorite, 85

flare-up rate, 131 steps involved in, 87–89
goal, 131 Root canal treatment, 1, 30–31
hand files, 137–139 Root defects
instrumented straight canal size, 136 clinical diagnosis, 26–27
instrumenting steps, 140–141 etiology, 26
NiTi rotary instruments, 137–138 treatment, 27
perforation repair, 141–142 Root fracture, 46, 50
preoperative and postoperative root Root–crown fractures
canal, 139 clinical examination, 42
root apex, 136 complicated, 44, 46, 48
tooth anatomy and morphology, 131 patient report, 42
tooth length measurement, 133–134 radiographic examination, 42
undiluted sodium hypochlorite, uncomplicated, 45, 46, 48
132–133
Root canal irrigation
chelating agents S
activation, 155–156 Sensibility testing
ethylene-diaminetetraacetic acid, 154 anesthesia test, 11
vs. irrigating solutions, 155 cavity testing, 11
MTAD Antibacterial Root Canal cold testing, 8–11
Cleanser, 154 EPT, 8–9
Qmix 2in1 Endodontic Cleanser, 154 experimental noninvasive pulp tests, 11
smear layer removal, 152–154 exploratory surgical flap, 11
Enterococcus faecalis, 149 flowchart, 8
irrigating solutions heat testing, 9
activation, 155–156 palpitation testing, 10
functions, 150 percussion testing, 10–11
types and dilutions, 150–152 transillumination, 11
Root canal obturation Silver point obturation, 169
composite resin, 170 Sodium hypochlorite, 150–151
gutta-percha obturation Solitary eosinophilic granuloma, 113
advantages, 165–166 Subluxation
anterior and posterior teeth, 167 diagnosis, 46, 50
filling techniques, 166–167 treatment, 56
procedure, 167–169
quality, 166
semi-plastic physical properties, 165 T
vertical/lateral condensations, 166 Tooth and bone fracture
obturation material selection, 164–165 alveolar fracture
pastes, 170 diagnosis, 42, 44, 45, 47
posttreatment instructions, 170 treatment, 54
posttreatment patient management, 170 crown fracture
restoration, 171 complicated, 43–45, 48
sealers, 163–165 treatment, 54
silver point obturation, 169 uncomplicated, 43, 45, 48
treatment, 169–170 enamel fracture, 44
Root canal restoration, 1 enamel infraction, 45
Root canal revascularization, 74, 76 root–crown fractures
apical pathosis, 85–86 clinical examination, 42
avulsed replanted tooth and tissue complicated, 44, 46, 48
formation, 85, 86 patient report, 42
Hoshino’s triple antibiotic paste, 85 radiographic examination, 42
root lengthening, 91 uncomplicated, 45, 46, 48
190 Index
Traumatic dental injuries (TDIs) prognosis, 56

antibiotics, 57–58 repositioning and stabilizing, 56
diagnosis, 45–50 root resorption
differential diagnosis, 39 differential radiographic diagnosis, 59
assessment, 41 external, 58–59
objective information, 40 internal, 58
subjective information, 40 treatments, 59–60
treatment planning, 41 tooth and bone fracture (see Tooth and
emergency care, 46, 53 bone fracture)
gingival/oral mucosa injuries, 45 tooth discoloration
immediate patient care, 39 causes, 65–66
local anesthesia, 53, 56 whitening/bleaching, 66
luxation injuries (see Luxation injuries) treatment decision-making, 51
orthodontic movement, 56–57 type identification, 42–43
pain management Trephination, 179–180
doctor–patient communication, 61
local anesthesia, 61–63
pulpal anesthesia, 64–65 X
patient home care instructions, 57 X-rays, 100–101

A Concise Guide To Endodontic Procedures (9783662437292)

Încărcat de

Informații document

Titlu original

Drepturi de autor

Formate disponibile

Partajați acest document

Partajați sau inserați document

Opțiuni de partajare

Vi se pare util acest document?

Este necorespunzător acest conținut?

Drepturi de autor:

Formate disponibile

A Concise Guide To Endodontic Procedures (9783662437292)

Încărcat de

Drepturi de autor:

Formate disponibile

A Concise Guide

ISBN 978-3-662-43729-2 ISBN 978-3-662-43730-8 (eBook)

Library of Congress Control Number: 2014949160

© Springer-Verlag Berlin Heidelberg 2015

Printed on acid-free paper

Springer is part of Springer Science+Business Media (www.springer.com)

1 The Differential Diagnosis of Endodontic Disease . . . . . . . . . . . . . . . . 1

Root Canal Working Length . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14

Quiz for the Topics Covered in Chapter 1 . . . . . . . . . . . . . . . . . . . . . . . . . 33

2 Dental Traumatic Injuries, Pain Management,

Tips for Accomplishing Pulpal Anesthesia. . . . . . . . . . . . . . . . . . . . . . 64

3 Treatments for Traumatized and Diseased Immature Teeth:

4 Oral Pathology and Imaging. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 99

Radiographic Description of Oral and Maxillofacial Pathology . . . . . . . . 107

5 Endodontic Access Considerations Based on Root

6 Instrumentation (Techniques, File Systems,

7 Irrigation of Root Canals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 149

8 Root Canal Obturation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 163

Posttreatment Patient Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 170

9 Periradicular Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 177

Talking to Patients About Saving Their Teeth

1. Prosthetic teeth in a denture or bridge do not allow patients to chew food as

Patient Consent and Record Keeping

© Springer-Verlag Berlin Heidelberg 2015 1

Talking with Patients to Diagnose the Cause of Pain

Does your tooth Does biting presure

Is your tooth Check pulp vitality

Check for caries

A comprehensive endodontic examination not restricted to a hot tooth should be

Fig. 1.2 Create a safe

1. Pulp horn proximity to a restoration or caries

SOAP Framework for the Differential Diagnosis

Objective information should be gathered about the patient’s condition from 12

1. Results of cold, hot, electric, or percussion testing

Assessing Information to Reach a Diagnosis

The assessment of objective information should be used to reach a diagnosis.

1. Pulpal diagnosis and periapical diagnosis

4. Need for continued root development to strengthen the tooth

Investigate the patient’s dental history using a checklist:

Ask the patients about their medical history using a checklist:

10. Jaundice or liver disease

Dental Pulp Vitality Diagnosis

Dental Pulp Sensibility Testing

No Normal, healthy vital pulp

Do control No Necrotic pulp

Electric Pulp Tester

Fig. 1.4 Electric pulp tester

Cold and Heat Tests

Fig. 1.5 Cold test to assess

Fig. 1.6 Palpation of tooth

Percussion is the tapping of a tooth with a finger or an instrument by the dentist or

traumatic injury. The latest advance in percussion testing is to perform quantitative

Experimental Dental Pulp Sensibility Tests

Exploratory Surgical Flap

Transillumination with fiberoptics can be an aid to diagnosing cracked or fractured

Crown Examination Prior to Treatment

Tooth Structure Needed for Restorations

1. Core retention with a post is necessary if there is a weak cavity wall.

Root Aspect and Periodontium Examination Prior to Treatment

Examination of the Apical Aspect of the Root and Apical Bone

Detecting Additional Canals

Angulated Multiple Radiographs

Root Canal Working Length