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Contents

Part 1 Fourdatiors of Endodontology 1

1 Introduction to endodontology 3
ClaesReit, Glnnar Bergenholtzand PrebenIltrsted-BindslelJ
2 Diagnosis of pulpâl and periapical disease
ClaesReit,KeÆtinPeterssonand OlaoMoben

Part 2 The \4tâl Pulp L9

3 The dentine pulp complex rcsponsesto adverse influences 21
Leif Olgatt a1li Guwrr Bergenholtz
4 Dentinal ând pulpal pain
Mtltti Nîirhi
r rne mlrrûorsclpl]nâry nârure or pam
IlanaEli
6 Vital pulp iherapies 66
PrebenHorstedBindsleï and GunnarBergenhoLtz
7 Endodontics in p.imary teeth 92
Ingeqefi Mejàrc

Part 3 The Necrotic P1dp 109

8 The microbiology of the necrohc pulp ln

ElseTheilade
9 Apical periodontitjs 130
RistoPekkt Happonenand G nnar Beryenholtz
10 Systemiccomplications of endodontic inJections 145
Nils Sk 8
11 Treatmeni of the necroiic pulp 156
Paul Wesselinkînd G ntur Bergenholtz

Paft 4 The Root Filled Tooth 175

12 The root filled tooth in prosthodontic r€consiruciion 177

EckzhardKnstkaanàlem-Fnnçois Rotlet
13 Apical and coronal lealage
Willian P. Sûunderc
14 Faciors influencing endodontic retrearment
Cldrs Reit

Part 5 Clinicat Methodologies

15 Radiogrâphicexamnùlion
Ib Pûul Setntin
16 Root cânal instrumenration
W,11ta!11
P.Soùnd,t ûad LlFakt\ Sau,1d.,,
17 Rooi cânal filling marerials
Gotlfried Scht@lz
18 Root filling teclùi+les

19 Non-surgicàl retreatmeni
Pierre Mnchtuu ind Claes Reit
20 Surgicalretreaiment
Preface
Tcxtbook of Enàodontalogy is intended to serv€ the
educational n€eds of dentai studÊnts, as well as of dental
prâctiiioners seeking updates on €ndodontic iheories
ând techniqùes. The primary âim hâs been to Provide an
undelstmding of the biologicâl processes involved in
pulpâl and periapical pathologies md how that knowl-
edge impinges on clinicâl management, ând to Present
that inJormation in an €asily accessibl€ form Therefore,
we have supplemented the core te\t with numerous
figures md photogrâphs, as wel âs with boxes tugh-
lighting key fa.ts, importmi clini.al procedues aJrtdkey
research. Case studies are given at the end of some chaP-
teIS in order io tu*her illusirate toPics descibed in the
text- Lr ihese vârious wâys, the book Provides infolmâ-
tion both at a fomdation level, md at a morc detailed
level for tlrc grâdùating student and practitioneL
The key infornation boxes are coloûr. coded as an
easy-to-use nâvigaiionâl aid {or readers. Corc concepts
afe coloured pink, while advanced concePts are PurPle
Clini.al prccedures arc coded green and key literâture
This book is also intended to stimulate ihe reader to
delve into the mdodontic literâture and the research
methodology ihat forms ou current knowledge base. To
aid the reader, a seleciive rcference list is Provided ând
coments have been added io €speciâlly weighty or
useful r€ferences. Important and intercsting investlga-
tions are pr€sented in ihe core and âdvanced con ept
boxes, and we hope that these feaiures will encourage
the rcader io do his or her own r€search
This book woûld not lÉve been Possible withoùt
ihe dedicâted support of our co authors - 18 hi8Ny
iespected cliniciâns and sientists, who, in addilion to
the editors, hâve contlibllted 1() this book We thank
them all sinc€rely for theii time, effort and endûrance
dùing the ediiing process.
A&nar Bergenholtz, PrebenH sted Billdslm
and Claes Reit
Contributors

Gunnal Bergenholtz Depaltment o{ Endodontology ànd Oral Diâgnosis, Faculty of Odoniology, SaHgren-
skâ Acâdemy, Gôteborg Universitt Sweden

Preben Hsrsted-Bindslev Dcpdtmeni of Dental Paihology, Operâtive Dentistry âncl Endodontics, Royâl Denrâ]
Co eg€, University o{ AârhÙs, Denmark

Claes Reit Department of Endodontologl, and Oral Diagnosis, Facùlry of odoriology, Sahlgrcn
skâ Acâdemy, Gôteborg Unjversity, Sweden

Ilânâ Eli Deparhneni of Occlùsùn md Behavioial Sciences,The Mâurice and Gâbrjela Cold-
schleger School of Dental Medicnrc, Tel Aviv University, Israel

Risto-Pekka Happonen Depârtment of Oral and Maxjllofâcjal Surge$., Insiiluie of DentisLrr University of
Turk! Finlând

Eckehard Kostka Depârtnent of Operâtive ând Preventive Dentistry ând Èndodontics, School of Denial
Medicine, Charité, Medicâl Facuky of the Bcrlin Humboldt Univelsity, Gemany

Piere Machtou DepaÉment of Endodontics, uaris 7 University, Francc

Ing€serd Mejàre Eastman Dental InsiiLuic md Facùl\' of Odo11to1ogy,Cent€r for Oral Sciences, Malmô
Universiiy, Sweden

Olav Molven Departrnent o{ Odontology Endodontics, Univcrsitlr of Berger! No lay

Matti Nârhi Depaiiment of Physiolog, University of Kuopio, Finland

LeiI Olgad Division of Phalmàcology, Kârolinskâ Institute, Stockholn, Swedm

Department of Endodontics, Malmô Univerciq., Swedcn

Iean-Flançois Roulet Deparhnent o{ Operative and Preventive Dentistry ajrd Endodontics, Chaité, School of
Denral Medi.ine, Medical laculL.r, of the Berhl Hûmboldt University, Ge.man)'

Elisabeth Saundels The Dental School, University of Dundee, Scoilmd

Williâm P. Saùnders Thc Denial School, University of Dùnd€e, Scotlând

Gottfried Schmâlz Dcparhnc.nt of Operative D€ntistry and P€dodontology, University of ]tegensbù8,

Ib Paul Sewedn Depaùnert of Oral Ràdioiog,T, School of Dentistry, Faculiy of Health Sci.r.es, Univer
sity of Copenhâger! Denmark

Nils Skaug Department of Odontology Oral Microbnnogy, Faculiy of Dentistry, University ot

Eergen,Norway

Else Theilade Depaltment of Orâl Biologt Royâl Dental College, Universitv of Aârhus, Demark
viii contribuiors

Clinic for Periodontologt Ëndodontology and Cariologt Center of Dentistry, Univer-

sitv of Bâsel,Switzerland
Paul wesselink Depatment of Cariology, Endodontology and Pedodontology, Acâdemic Center for
Dentisuy Amsterdam (ACTA), The Netherlands
 Foundations
of endodontology
performing procedures oneself, and reflecting on what
has been learnedare all important.
Phronesis
According to Aristotle, phronesis is the ability to think
about practical matters. This can be translated as ,prac-
tical wisdom' (5) and is concernedwith why we might
decide to act in one way rather than another. \4/hen
thinking about the 'right'action or making the ,right,
decision we enter the territory of moral philosophy. The
person who has practical wisdom has good moral judg-
ment. Modern ethical thinking has been influenced
significantly by ideas that originated during the enlight-
enment. Morality is concerned with human actions and
there are certain principles that can separate ,right, from
'wrong'
decisions. Jererny Bentham (2) and the utilitari-
ans launched the utility principle and Imnanuel Kant
(6) invented the categorical imperative, each creating a
tradition with great impact on today's medicaLethics
and decision-making.
Aristotle, on the other hand, believed that there are
no explicit principles to guide us. FIe understood prac-
ticai wisdom as d combination of Lrnderstandinsand
e\perience dnd the dbility to read individual situations
correctly. He thought that phronesis could, be learnt
from one's own experience and by imitating others who
had already mastered the task. He stressed the cul-
tivation of certain character traits and the habit to act
wisely.
The clinical situation demands that the dentist exer-
cises practical wisdom, 'to do the right thing at the right
moment'- In order to develop phronesis, theoretical
studies of moral theory and decision-making principles
might be helpful. Neoaristotelians such as Martha Nuss-
baum (7) have suggested that reading literature should
be part of any academic curriculum, the idea being that
it increasesour lnowledge and undersldnding of other
people. However, the essenceof phronesishas to be learnt
from practlce.
Conceptsof endodontology
From the above it can be concluded that endodontology
encompasses not only theoretical thinking but also the
practical skills of a craftsman and the practical thinking
needed for clinical and moral judgment. Unfortunately,
through the years, undue prestige has been given to
theoretical-scientific thinking and this has hindered the
development of a rational discussion of the other t!,ues
of knowledge. The serious student oI endodontologv
has lo invesljgate dll three aspects,but, as argued aborié,
there are limits to what can be communicated within the
covers of a textbook.
The dawn of modern endodontology
It all started with a speech at the Mccill University in
Mon treal.ln the mornirg of October3, I q 10,Dr Witiam
Hunter gave a talk entitled 'The role of sepsis and arrti-
sepsis in medicine'- Hunter said that:
'h my
clinical expedence septic infection is without
exceptionthe most prevalent infection operating in med-
icine, and a most important and prevalent cause and
complication of many medical diseases.Its ill-effectsare
widespread and extend to all systemsof the body. The
relationbetweentheseeffect:and the seDsisthat iauses
them is constdntlyoverlooLed,becausethe e\istenceof
the sepsisis itself overlooked. For the chief seat of that
sepsis is the mouth; and the sepsis itselt when noted, is
erroneously regarded as the tesult of various conditions
of ill-health with which it is associated- not as it really
ls, ân rmpottant causeor complication.
Gold fillings, gold caps, gold bridges, gold crowns,
fixed dentutes, built in, orL and around diseased teeth,
form a ve table mausoleumof gold over a massof sepsis
to which there is no parallel in the whole realm of
medidne or surgery. The whole constitutes a perfect gold
trap of sepsis.'
The cited text was published it the Lancet in 1911 but
Flunter's words were also rapidly spread and inten-
sively discussed among laymen and were given balner
headlines in the newspapers. Essentially, Hunter pro-
posed thd t micro-organ isms from a Focusof in fection can
spread to other body compartments and cause serious
systemic disease. The waiting rooms of the dentists
became filled with individuals who thoueht that their
illnesseswere causedby oral infections.Theseillnesses
were often chronic or of ud<nown origin and teeth were
removed in enormous numbers.
Although not directly stated by Hr.rnter, teeth with
necrotic pulp were seen as one of the main causes of
'focal
infection'. Laboratory studies had disclosed the
growth of bacteria in the dead pulp tissue. In the 1920s,
dental radiography came into general use and radiolu-
cent patches around the apices of necrotic teeth were
detected. If such teeth were extracted and cultured,
micro-organisms were often recovered from the
detached periapical soft tissue. It was generally held that
pulpally diseased teeth should be removed.
Reflecting on this period in the history of dentistry,
Grossman (4) wrote: 'The focal infection theorv promul-
gated by William Hunter in 1ql0 gave deniistry in
general, and root canal treatment in particular, a black
eye from which it didn'l recover foi about 30 years.'
However, in hindsight this period can also be regarded
as the dawn of modem endodontology. Researchers
staded to question and oppose the clinical consequences
 Foundations
of endodontology
response may be destructive and result in total break-
down of the tissue.
An irreversibly inJlamed or injured pulp ideally
should be removed and replaced with a root filling
because otherwise an infection may develop in the
root canal system. This removal procedure is called
pulpectomy. A pulpectomy is carried out under local
anesthesia by the use of specially designed root canal
instruments. These instruments remove the diseased
pulp in its entirety and prepare the canal system so
that it can be filled properly. The filling prevents
microbial growth and multiplication in the pulpal
chamber.
Exposure of the pulp may occur after clinical excava-
tion of caries or after a traumatic insult or iatrogenic
injury. If the pulp is judged to be injured reversibly it
may not have to be removed. Simply by treating the
open wound with a proper dressing ald protecting it
from the oral environment (so-called pulp capping),
healing and repair are often possible.
The necroticoulD
As mentioned above, injury to the pulp may lead to
complete breakdown of the tissue (Fig. 1.3). The non-
vital, or necrotic, pulp is defencelessagainst microbial
invasion and will allow indigenous micro-organisms to
reach the pulp chamber, either along a direct exposure
or uncovered dentinal tubules or cracks in the enamel
and dentine. Lateral canals exposed as a result of pro-
gressive marginal periodontitis may also seNe as path-
ways for bacteda to reach the pulp.
Areas of important Endodontictreatment
knowledge concepts
Root canal
treatment
Periapicaltissue
reactions
Fig.1.3 Thescope lhenenotkpulp.
of endodonlology:
The specific environment in the root canal, character-
ized by the degrading pulp tissue and lack of oxygen,
will result in a microbiota dominated by proteolytic,
anaerobic bacteria. Via the apical foramen, microbes and
their by-products may reach the periapical tissue and
elicit an inJlammatory response. This response induces
resorption of the surrounding bone, which often is
visible in a radiograph as a localized periapical radiolu-
cency. The inflammatory reaction may also stimulate
epithelial cells in the periodontal membrane to prolifer-
ate and form a periapical cyst.
Treatment of the necrotic pulp is by root canaltreatment
(RCT) and is focused on combating the intracanal infec-
tion. The canal is cleaned with files in order to remove
rnicrobes as well as their growth substrate. F{owever,
owing to the complex anatomy of the root, instruments
canlot reach all parts of the calal system and additional
antimicrobial substancesare usually needed to disinfect
the canal. In order to avoid reinfection and to prevent
surviving microbes from growing, the canal is then
sealed with a root filLing.
The root filled tooth
Pulpectorny and RCT do not always lead to a successful
clinical outcome. For example, a tooth may continue to
be tender or periapical hllamrnation may persist. Such
treatment 'failures' are often associated with defective
root fillings which allow organisms from the initial
microbiota to survive in the root canal or new bacteria
to enter the pulpal chamber via coronal leakage (Fig.
1.4).
Areasof important
knowledge
Reasonsfor
treatment"failure"
Fig.1.4 Thescopeof endodontologyr
the rootfilledtooth.

The root canal may be retreated using either a non-
surgical or a surgical approach. In non-surgicalretreat-
ment tl:.e root filling is removed and the canal is
reinstrumented. Antimicrobial substancesare applied to
kill the surviving microbes and the spaceis reobturated.
Crowns, bridges and posts may mean that it is some-
times not feasible to reach the root canal in a conven-
tional way. In such cases, a surgical refreatffient is
appropdate. A muco-pedosteal flap is raised and
entrance to the apical part of the root is made through
the bone. Surgical retreatment may also involve cutting
of the root tip and retrograde preparation and filling of
the root canal.
The diagnosticdilemma
The diseaseprocessesin the pulp and periapical tissues
take place in concealed body compartments that nor-
mally are not available for direct inspection. Instead, the
clinician has to rely on indirect information to assessthe
condition of the tissues and reach a diagnosis. The
interpretation of this information entails the risk of
making false-positive and false-negative diagnoses. For
example, the patient's report of pain has been shown to
be an unreliable sign of pathology becausemost inflam-
matory episodes within the pulp or periapical bone pass
by without symptoms. Furthermore, the discriminatory
ability of the intrapulpal nerwes is not perfect, which
means that if a patient has toothache due to pulpitis
there is a high risk that he or she may 'point out the
wrong tooth'. Besides anamnestic information, vitality
testing of the pulp and interpretation of periapical radi-
ographs are the prime diagnostic sources of data. Such
data have to be handled with utmost care and with in-
depth knowledge of possible errors and the factors that
infl uence diagnostic accuracy.
The tools of treatment
To many dentists, RCT can best be described by using
Winston Churchill's words on golf: 'An impossible
game with impossible tools'. The complexity of root
canal anatomt the relative stiffness of root canal instru-
ments, being unable, often, to visualize the area prop-
erly, and the lack of space in the mouth provide
substantial challenges to the skill and patience of the
dentist. Intracanal work is exceptionally difficult; this
is clearly demonstrated by radiographically based epi-
demiological suweys, which repeatedly report that many
root fillings do not meet acceptable technical standards.
Because clinical outcome is strongly related to the
quality of treatment, the high frequency of substan-
Introduction
to endodontology
dard perfornance is a subject of great concern to the
profession.
The last decade has seen a tremendous technological
development that hopefully will increase the overall
standard of endodontic treatment. For example, the
advent of superflexible nickel-titanium alloy has made
it possible to fabricate instruments that follow much
more easily the anatomy of the root canal and therefore
produce good quality canal preparations. Furthermore,
systems have been developed that allow the instruments
to be maneuvered by machine rather than by hand,
improving fine-scale manipulation and decreasing
operator fatigue.
The microscope has brought light and vision into the
pulp charnber and root canal (Fig. 1.5). Working under
high magnificatiorç it is now far easier to remove min-
eralizations, locate small root canal orifices and control
intracanal procedures. Flowever, high quality micro-
scopes are expensive and, thus fat the technology has
been adopted mostly by dentists specialized in
endodontics.
In the midst of this technological boom it must not be
forgotten that endodontics is basically about controlling
infection. Luckily, there are few medical therapeutic pro-
cedures that can be carried out as aseptically as RCT.
Shielding the operation field with a rubber darn is one
of the oldest and still most effective ways to ensure that
the area remains sterile, thus improving clinical success
(Fig. 1.6).
Conclusions
Pulpal pain can be beyond endurance and pulpal infec-
tions can destroy supporting bone. To manage these
Fig.l.5
 Foundations
of endodontology

tomatc and healthy, and capable of maintaining its func-

tional place in the oral cavity.

References
'1.
1 . Aristotle (Iruin, ed.\. Nicomacheat?Eflics- London:
Hackett Publishing, 1988.
Beîlhai1J. Introduction to the PùnciPles of Morûls and Legis-
Iatiotl (L789) (B11rIrsJH,Hart DLA, eds). London: Methuen,
1982.
Chalmers AF. Wlraf is this Thing called Sciet.e? Buckingham:
Open University, 1999.
Grossman LI. Endodontics 1776-1996: a bicentennial
history against the background of general dentistry. ,fADÂ
Fig.1.6 1976;93t 78-87.
5 . Hughes GJ. A/lsfofle or1Eti?ics.London: Roudedge, 2001.
6. Ka tI. Foundationsof the Metaphllsicsof Morals (1785).lltài-
clinical problems the dental profession has been forced anapolis: BobbrMerrill, 1959.
to develop diagnostic skills, explore the microbial flora, -lhe
7. Nussbaum M, Poetic Justice. litefiry imTgination and
investigate pharmacology and biocomPatabiliiy of public life. Boston:. Beacon Press, 1995.
medicaments artd matedals, in addition to developing a PolanyrM. PersonalKxowledge:Towardsn PostcriticalPhilos'
broad range of specially designed tools. This combined oplry.London: Routledge, 1958.
knowledge concentrates on rendering the tooth as).rnP- 9. Ryle C. The Concept of Mizd. London: Penguin, 1949.
Chapter2
of pulpaland periapicaldisease
Diagnosis
ClaesReit,KerstinPetersson
and OlauMoluen
Introduction
To diagnose diseasesof the pulp and pedapical tisssues
is often a very demanding and sometimes ftustrating
procedure, e.g. when patients are in severepain. Because
the reactions mostly take place in concealed parts of
the body, the disease picture frequently must be made
'visible' by indirect methods and tests.The clinician also
must learn to navigate with a very limited diagnostic
armamentadum at his or her disposal. In this situation,
besidespersonal experience and intuition (which cannot
be leamt from a textbook), the accuracy and correct
hterpretation of diagnostic information are all impor-
tant. Evaluation and re-evaluation of data have to be
carried out in a continuous process.
From textbooks, students normally learn about diag-
nosis through studying the various diseases.Expected
symptoms, signs arrd test results of, for example, pulpal
inflammation, are presented, the diseasesare given and
their clinical, radiographical and laboratory expressions
are discussed.However, such a learning procedure is the
reverse of what happens in the clinical situation. People
rarely know what they suffer from and instead they
present with certain symptoms, signs and test results.
Suspicions often can be raised in several directions and
the task of the clinician is to look through a wealth of
information to find the right 'signal' or diagnosis. This
chapter thus will stad with a discussion on how diag-
nostic information may be evaluated.
Evaluationof diagnosticinformation
Making the right diagnosis is very often a complex task
and clinicians easily may draw different conclusions.
Many studies have demonstrated how physicians and
dentists vary in the way they practice their profession,
regardless of whether they are defining a disease,
making a diagnosis or selecting therapeutic procedures.
For example, in a study on microscopic investigation of
biopsies from the uterine cervix, 13 pathologists were
asked to read 1001specimens and to repeat the readings
at a later time. On average,each pathologist agreed with
him or herself only 89% of the time (intraobserver agree-
ment) and with a panel of'senior'pathologists only
87% of the time (interobserver agreement).Looking only
at patients who actually had cervical pathology, the
intraobserver agreement was only 68% and the inter-
observer agreement was 51% (29).
Many similar studies on various signs and symptoms
'observer
have been caffied out and the literature on
vadation' has been growing for a long time (7, Key lit-
erature 2.1). From a diagnostic point of view it has been
found that, in general, observers looking at the same
thing will disagree with each other or even with them-
selves 10-50% of the time (8).
Many authors have regarded the diagnostic process
'Traditionally,
more as an act of art than of science:
the process of diagnosis was left undefined, a natural
art, or explained as a process of intuition. Despite re-
cent advances, this is still too often the case' (10). In
'diagnosis'is defined
Dorland's medical dictionary (6)
'The arf of distinguishing one disease ftom another'.
as
However, dudng recent years clinical reasoning has
been the subiect of substantial research, and both
descriptive and normative models have been proposed
(1s).
Diagnostic
accuracy
Let us assume that the question of whether or not a
person has a certain disease D in a clinical situation can
be determined only by a test T. It is possible to obtain
two test {esults: one indicating that the patient has D (a
positive test, T+) and one suggesting that the patient
does not have D (a negative test, T ) (see Core concept
2.1). Unfortunately, T has the drawback (which it shares
with almost all tests and procedures) that it cannot com-
pletely separate persons who have D and those who
have not. Two types of error are possible. A person who
has D can be informed that he or she has not (a false-
negative diagnosis) and another person cdn recei\e a
l0 toundations
of endodontology

propoftion of persons withoLit D correctly identifiecl as

Keyliterature
2.1 Observer
variation
in negative.
periapical
radiographic
diagnosis In order to determine the sensitivity and specificity of
a diagnostic test a comparison r,vith some sort of ideal
In â studyby Reit& Hollender (27)the radiographs
of 119endodon- 'gold
ticallytreatedrootswereexaminedby six observers.
standard'hasto be made.Theremust be some test-
Eachroot was
visibleon two separate radiographs.Threeof the examiners were
iudependent u'ay of making a definiti\.e diagnosis of
specialistsin endodontics andthreein oralradiology. Theobservers \\'hether the patier,t is diseased or not. P|eferablv suclr
wereaskedto distinguish between'normal periapical conditions'. a gold standard is creatcci by means of a biops),, but
'increased 'periapi- olten another test normallv not clinically available
widthof the periodontal membrane space'and
calradiolucency'. In theopinionof oneor moreobservers, 82 of the becauseof high costs or ser-ereaci-erse effectsmay scrve
I19 rootspresented normalperiapical conditions.
However, onlyat this purpose. In most casesin\.estigatorshave to use
33 (37%)ofthese rootswasthedecision shafedbyallsix.The diag- gold standards that are belou"24 carats'.
nosisof increased widthof the periodontalmembrane space'was Tn the clinical situation the most interesting questions
madein agreement in only 9% of 65 recorded cases. Periapical are formulated in a slightly different wa\. When the test
radiolucency was reportedat 37 of the roots,and at 10 of these
indicates that the patient is diseased(T+), \ ùat is the
(27%)all observers agreed. Thisstudyserues as an illustrationof
the difficulties
probability that he or she rcally has D? Ancl if the patient
in definingand maintaining criteriâin radiographic
evaluation of the periapicaltissues. gets a negative test (T ), rvhat is the probability tl,at
D js not present? These probabilities are given in the
so-called poslfft,cprctlictitc'oaluc (PPV) and the /1qqdfir.
p reLlictirtc .toI ue (NPV ).
Tr'rcontrast to sensitivity and specificity, PPV ancl NPV
Coreconcept2.1 Measures
of diâgnostic are dependent on the prevalence of the clisease.Let us
accuracy assume that a test has 90% selrsitivity and 95'li, speci-
ficity for a certain discase. lf the prevalence of the
Testresults diseasc is 50%, then the PPV will reach 95!/n.This means
T + T that if a patient receivesa positive test there is 95%,prob-
D+ TP FN ability that he or she is discascd. lf the prevalence is L0').,
Actualstate (Truepositive) (False neqâtive) thc PPV will clecreaseto 67%; if the prevalence is 1')i,,the
D_ TN PPV is only 15'1,.This matlrematical exercisetells us that
(Falsepositive) (Truenegative)
tests do not work r'r'ell u'hen plevalences are low.
T+ = positivetest result Accordingly, in a clinical situation, tests should not be
T = negative testresult used on a routine basis. Bv history takit, g and oral ex-
D+ = disease present aûlination the clinician selects paticnts in which a spe-
D = disease absent
ciiic test may be used. Wrat he or she actually does js to
Sensitivity= the proportion patients(D+)correctly
of diseased il'rcrcasethe prer-alenceof the strspectec-l disease!
identified (TP/TP
as positive + FN).
Speciïicity= the propoftionof non-diseased
patient'(D ) correctly Receiver (ROC)analysis
operatingcharacteristic
identified
as negative (TN/TN + FP).
Tf ratcs of true-positive response (TPII) and false
Positive predictive value = the proportionof positivetests(T+)
positive response (FPR) are calculated fol different deci-
that aretruepositive(TP/TP+ FP).
sion criteria (cut-offs), the obtaincd pairs of vaitres mav
Negative predictive value = the proportionof negativetests be plotted in a simple graph r,r'ith the TPR placed vcrti-
(T ) that âre true negative(TN/TN+ FN). cally and tl.re FPR horizontally. Various cut-off points
may be obtained in many ways. For erample, in racli-
ographic diagnosisof periapicallesionsthe level of con-
fidence of the obsen'er often is used. Iloth the TPR and
positive test although he or she cloeslrot l.raveD (a false the FPR arc calculateclfor five decision critcra: clefinitelv
positive diagnosis).Of coursethere are also two types of a lesion; probably a lesion; uncertain; probabJv no lesion;
correct outcomcs of the test: truc-positive and true- dcfjnitely no lesion. The plotted points form u.hat is
negative diagnoses, rcspectively. The proportions of called the ROC curve.
these four possible outcomes can be used to express the The position of the ROC curYe will te1l us hou' good
diagnosLicvalue aitachedto the test.Sensitivity- or the a test is.rt discrin.rinating between people (or teeth) 1\4ro
true positive ratio - is a measure of the proportion l'rave the diseasefrom those rn'l'rodo not. The ROC crrrve
of patients n'ith D corrcctly identified as positi\-e. of the perfect test coincides with the axes, whcreas the
Specificity the true ncgative ratio is a measure of the cun'e of thc lvorthlesstest lies along Lhc:15"diagonal.
 of pulpalandperiapical
Diagnosis disease 1 1

TPR(%) TPR
100 1.0

conventionalradiography
D D R o, r i g i n ailm a g e
DDR,processed
image

o s' o o.2 0.4 0.6 0.8

or*1"7.3
Fig.2.1 In radiographic of periapical
diagnosis truepositive
lesions, rates
[PR)andfalsepositive rates(FPR)
canbecalculatedforfivedecision
crite-
ria:(a)definitely (b)lesion
a lesion, probâble,
{c)lesion (d)proba
uncenain,
blynolesion,(e)definitely
nolesion.
We can measure the discriminatory power of a test by
how close its ROC curue is to the axes and how far it is
ftom the diagonal. More precisely, the discriminatory
power is measured by the area under the curve, which
is 100% for the perfect test and 50% for the wortNess
test. An ROC analysis demonstrates that changing the
cut-off point will rof influence the discriminatory power
of a test, it just moves its position alons the curye.
Howevet different cut-off points can have momentous
clinical consequencesfor those affected by the judgment,
and a strategy for deciding the position to be taken on
the curve must be developed (seenext section).
Receizter operating charncteristic (ROC) analysis
of p eri ap ic al r adio gr aphy
In a study by Kullendorff et û1. (16\ the aim was to
compare the observer performance of direct digital radi-
ography, with and without image processing, with that
of conventional radiography, for the detection of peri-
apical bone lesions. For 50 patients a conventional peri-
apical radiograph using E-speed film was taken and
then a direct digital irnage of the same area was made.
The images of 59 roots were assessedby seven observers
using a five-point confidence scale: definitely no lesion;
probably no lesion; uncertain; probably a lesion;
definitely a lesion. A gold standard was created by
,ll
of periapical
Fig.2.2 RoCanalysis râdiography
showing
observer
decisions
(16).
for59radioqraphs
independent readings of 73 films by two experienced
radiologists. Only images where they agreed (totalling
59) were included in the study. The ROC curves were
established and mean values of the observers'
decisions are shown in Fig. 2.2.
Conventional film radiography came out slightly
better ftom the study than direct digital radiography.
Image processing did not improve the observer
performance.
Diagnostic strategy
The diagnosis is not a goal in itself but only, in the words
'a mental resting-place' for prog-
of a Scottish clinician,
nostic deliberation and therapeutic decisions (33). One
of the main concerns for this deliberation is of course the
fact that no diagnostic method has peffect sensitivity
and specificity, which means that false diagnoses cannot
be avoided completely. Also, from ROC analysis we
'costs'. If we
learn that diagnostic decisions always have
want to be sure that all casestreated are really diseased,
we have to take a low position on the ROC curve. The
cost for this will be a number of missed cases.ln con-
trast, if we want to treat all diseased patients (or teeth),
a high position on the ROC curve is needed and the cost
will be a number of healthy cases being treated. lf
an analysis of an actual clinical situation results in a
strategic decision to avoid overheatment (low ROC
 Foundations
of endodontology
position), then the clinician should signal for disease
only when he or she is absolutely certain that it is
present. If the problern is to avoid false-negative diag-
noses, the best consequenceswill be obtained if disease
is reported at the slightest suspicion of it (high ROC
position). It is important to notice that a decreaseof one
type of error will lead to an increase in the other
On which grolurds should a certain strategy be
chosen? This is a complex problem and an in-depth
analysis is beyond the scope of this chaptel However,
certain important factors may be identified: the conse-
quences of untreated disease; risk of complications or
adverse effects of instituted therapy; economic costs;
and personal values.
In a situation where untreated disease will not lead to
any serious complications of the general health or well-
being, one normally wants to avoid overtreatment. The
diagnostic process will be directed towards the avoid-
ance of false-positive diagnoses and a low position on
the ROC curve is taken. If untreated disease will lead to
serious complications it is important to iclentify and find
all or most of the diseased individuals. From a stratesic
point of view, false-positivediagnosesmusl be accepted
and we have to move higher up the ROC curve.
It is obvious that if the available cure also implies
great risk of severe complications or serious adverse
effects you do not want to perform any unnecessary
treatments. The price to pay for accepting false-positive
diagnoses will be too high. In contrast, the diagnostic
position should be moved higher up the ROC curve if
treatment is simple and without any considerable risk.
All rnedical and dental care is associated with eco-
nomic costs and thus resources must be resarded as
limited. Didgnosisand treatment hare to be iost-etfec-
tive and if the ar ailable therapy is very erpensive you
want to be certain that you do not start treatment on a
false-positive diagnosis. For example, you may stad a
non-surgical retreatment of a root filled tooth on a slight
suspicion of apical periodontitis if the procedure is
easily carried out in a tooth without complex prostho-
dontic restorations. But ifyou have to remove crown and
post in order to reach the root canal, you probably want
to be absolutely certain that this is the right thing to do
and, accordingly, you will move to a lower position on
the ROC curve.
Personal values have to be included in a decision strat-
egy. Faced with the same clinical situation, people will
not evaluate the benefits and risks of a treatment proce-
dure in identical ways. This means that the position of
the diagnostic cdterion has to be discussed with the indi-
vidual patient. Will the patient take a false-positive diag-
nosis before a false-negative diagnosis, or the other way
arourrd? Attempts have been made to measure patients'
values in order to incorporate them in various decision
models (28). These possibilities are discussed in more
detail in Chapter 14.
of pulpaland
Clinicalmanifestations
periapicalinflammation
The clinical manifestations of inflammatory processesin
the pulp and periapical tissues cover a broad range of
expressions.Patients' experienceof dentalpainmay vary
from a barely noticeable discomfort to an unbearable
torment, from the odd attack of short duration to a lin-
gering continuous suffering. Patients may also disptay
discolored teeth, fistulas, swellings and raised body tem-
perature. In Core concept 2.2 the most commom symp-
toms and signs associatedwith pulp inflammation, pulp
necrosis and periapical pathosis are collected and dis-
played. Strangely, howevet patients most often are free
of symptoms and the majority of pulpal inllammations
in need of endodontic treatment are unveiled during
operative procedures (26). Periapical inJlammations are
detected in most casesonly by radiographic means.
Collectingdiagnosticinformation
In.ferencesregarding disease processesin the pulp and
periapical tissues have to be made with the help of a
rather limited diagnostic armamentarium. The main
sources of information are the patient's report on pain
and other symptoms, the clinical examination of the
tooth and surrounding structures, and the radiographic
examination (Core concept 2.3).
The problem for which the patient seeks dental care
(chief complaint) is the natural point of departure for the
diagrostic process.If the patient is in acute distress, the
examination and diagnosis must be focused on solving
that problem as fast as possible and a complete exami-
nation and establishrnent of a definitive treatment Dlan
will be postponed until later. A quieter situation will
allow the examiner to expand on the present dental
illrless. The patient's report on character, intensity, fte-
quency, localization and extemal influence of the symp-
toms will often give clues to a tentative diagnosis. This
initial notion may be strengthened or refuted by pene-
trating the dental history, including information on such
things as recently placed restorations, pulp cappings
and potential bruxism.
When reviewing the medical history the endodontist
will focus on illnesses,medication and allergic reactions.
Consultation with the patient's physician is recorn-
mended when physical or mental illness is expected to
interfere with diagnosis and treatment. There are no
systemic disease conditions for which endodontic treat-
 14 Foundations
of endodontology
usually associatepathology with pairr and a pain-free
situation with non-disease. However, studies have
pointed at a low correlation between pulp pathology
and Patients' s).rnptoms (1,30). In most cases inflam-
matory reactons in the pulp and periapical tissues will
not give rise to pain. Thus, the sensitivity of pain as a
diagnostic critedon of endodontic disease is very low
The clinical picture is even more complicated. Studies
have shown that when a patient reports spontaneous
dental pain and locates the origin of symptoms to a
certain tooth, the clinician cannot act on only this infor-
mation. The discriminatory power of the pulpal nerves
is not perfect. I{tren healthy teeth were stimulated elec-
trically, Mumford & Newton (23) fouad that orùy 46% of
subjects correctly identified the right tooth. Friend &
Glenwright (9) reported that 73"/" of subjects made a
correct area localization (one neighboring tooth on each
side included). In these studies electric pulp testers were
used, which stimulate mostly A-delta Ébers.When pain
is elicited by pulp inflammatiorL nerve impulses will
originate mostly from C-fibers. Those fibers have a lesser
discriminatory ability, which means that the chance of
conect patient identification in a clinical situation will
decreasefurther. Thus, pdtients mdy experience pain in
one tooth while the pathosis is to be for_rnd in anothel
This phenornenon is called referred pain (11, 31). Pain
may be referred to teeth also from pathological processes
in the ear, salivary glands, maxillary sinus and mas-
ticatory muscles (13). Even organs outside the head
may generate an experience of'toothache'. Bonica
(4) reported that patients with angina pectoris rather
frequently referred the pain to their teeth.
In order to find the right source of the pain, the most
ifformative diagnostic move is to try to provoke or
extinguish the s1'rnptoms. Pulpal pain may be triggered
or aggravated by applying cold or hot stmuli to the
tooth. In cases with continuous pain that is hard to local-
ize, it rnay be very helpful to inject anesthetics system-
atically and find the site where the symptom can be
relieved,
A lot of important diagnostic inlormation can be
found in the patient's description of the pain. Pulpal
pain has a wide experience range: from a slightly
increased sensitiveness, to intraoral temperature
changes,lo very intense,almost Lrnbearable
pàm. tn "
typical case the pain comes in attacks often elicited by
hot or cold food (Advanced concept 2.1). Initially, with
such a provoked attack a sharp pain is felt (A-delta
fibers). After the stimulus is removed, the pain lingers
on for varying amounts of time (seconds to hours), often
described as deep, dull and throbbing (C-fibres). Para-
doxically, in some cases,taking a solid dose of ice water
into the mouth may relieve the symptoms. This obser-
vation is mostly made when pain is continuous and very
Advancedconcept2.1 Temperature
changes
and
pulpalpain
ïhe hypothetical explanationto thephenomenon thattemperature
changes inlluencepulpalpainis that suchchanges influencethe
tissuepressure insidethe pulpalchamber with its rigiddentine
walls.Because ol low compliance in the pulpalchamber. even
modest changes inpulpalfluidvolume willberefleded inthetissue
pressure (20).An increased pressure in the pulpaltissuedueto
increased temperaturq for examplqwouldstart a painattack
because thebiochemical inllammatory mediatorsalready maintain
subclinical painsignalsanda decreased painthreshold. Congruent
to this reasoning. a significant decrease in temperature would
decrease thetissuepressure andthusalsothepainsensation. Tooth-
relaledpainin patients subjected to pressure changetcalledbaro-
dontalgia, is sometimes experienced by airborneor divingpeople
andis important asan indicator of pulpalinflammation.
intense and is held to be a sign of excessive and irre-
versible pulpal infl ammation.
As soon as the inflammatory reaction spreads out of
the pulp chamber or root canal to involve the periodon-
ta1 membrane, the tooth may be tender to percussion,
palpation and chewing. Pain associated with periapical
inflammation is mosù continuous and described as dull
in character. The synnptoms will not be inlluenced by
changes in the temperature and thus may not be provoked.
Assessment
of pulp vitality
Traditionally, pulp vitality has been determined by
investigating its sensitivity. Because this is an indirect
methodology the clhician has to work with hypotheses
of the relation between the test result and the reality.
Two main assumptions about this relation usually are
made:
(1) If the pulp is sensitive, it is vital.
(2) If the pulp is sensitive and the patient has no symp-
toms, the pulp is healthy.
There are three t'?es of pulp vitality test:
o Mechanical
r Thermal
o Electrical.
The rules for the use of viiality tests are given in Core
concept 2.4.
Mechanical tests
Probing exposed dentine in a cavity or cervically at the
neck of the tooth often results in a sensitive reaction in a
vital tooth. Pulp sensitivity also maybe disclosed during

Core concept 2.4 Guiding rules for the clinical
use of vitality tests
. theprocedures
Explain to thepatient.
a Donotrelyononlyonetest;usecombinations.
. with otherteeth,preferably
comparisons
l\4ake contralaterals
butalsowithneighboring teeth.
a withdoubtfulreactions,
In cases repeatthetestsin a ditferent
thesuspicious
order,'hiding' tooth.
removal of caries or defective fillings. It is sometimes rec-
ommerlded to drill a small test cavity, especially in teeth
with full crown restorations. Such test cavities can be
used also for thermal and electrical tests. Mechanical
stimulation is generally considered to have a high sensi-
tivity and specificity. However, scientifically obtained
data on the diagnostic accuracy seem to be lacking.
Thermal tests
Cold ait water or a cold object may elicit a sensible
response when placed at a tooth surface covering denti-
nal tubules. The temperature changes will influence the
flow of dentine liquor, u'hich leads to movcment of
the odontoblast process and subsequent mechar1ical
stimulation of the pulpal nerves. A common method
is to apply a cotton pellet soaked in a fast evaPorating
fluid, such as ethyl chloride or dichlorodifluoro-
methane. Dry ice sticks - made by filling empty cylin-
drettes with water and placing thern in the freezer - also
can be used.
Application of heat to the tooth surface also has been
recommended for vitality testing, conveniently carried
out by using temporary stopping. A gutta-percha bar is
heated in an open flame for a few seconds until it
softens. It is then placed on the br-rccalsurface of Lhe
tooth, away frorn the gir1giva. The bar is removed as
soon as the patient signals a reaction. Because studies
indicate that the diagnostic accuracy is r.ery lo$' (25,
Advanced concept 2.1, Key literature 2.2), heat should
not be used as a single test of pr- p vitality.
Electrical test
An electric pulp tester sends a weak electric current
through the tooth, which stimulates the pulpal nerves.
An electrode coated with a conducting medium is
placed on a tooth surface away from the gingiva. In
order to avoid transduction of the current to its neigh-
bors, the tooth to be tested should be isolated with
rubber dam or plastic strips. The current is slowly
increased. Electric pulp testers should not be used in
individuals wiih cardiac pacemakers.
of pulpalandperiapi€al
Diagnosis disease 1 5
2.2 Diagnostic
Keyliterature of thermal
accuracy
and electricalpulp tests
Ina studybyPetersson eta/.(25),thepulpalstatusof 75teethwas
investigatedby cold(ethyl heat(hotguttapercha)
chloride). and
(Analytic
electricity Technology PulpTester). Truepositive,
fâlse
positive,true-negativeand false-negative test resultswere calcu'
lated for each methodcomparedwith a gold standard.The gold
standardwasestablished by directpulpinspection(59teethin need
of endodontic treatment) and by judgingradiographs (16 intact
teeth).Twentv-nine teeth (39%) were judgedto be necroticThe
authorsfound that an insensitivereactionrepresented a necrotic
pulDin 89% with the cold test, in 48% with the heat test and in
SBoo with thp Êleclricaltest.A sensitive
reactronwasfoundio cor
respondto a vital pulp in 90% with the coldtest,in 83% wjth the
heattest and in 84% with the electricaltest.
Vjtality testing by electrical stimulation has good
diagnostic accuracy (21, 25, Advanced concept 2.1) but
its use is often prohibited if metallic restorations cover
most of the tooth structure. To overcome this problem,
Pantera el a/. (24) suggested the use of a bridging tech-
nique. The tip of an explorer coated with toothPaste u'as
placed against an exposed Part of the tooth surface and
the pulp tester then was placed against the explorer.
Studies have shown that tl.re pain threshold is influ-
enced by the placement of the electrode. Several authors
registered the lowest threshold values wher.r the pulP
tester was placed on the incisal tip (3). At this part of the
tooth the enamel layer usually is very thin (the enamel
than the dentine) and tl.re
has greater electrical resistar.rce
concentration of sensory nerves is highest in the pr"rlpal
holns (17).
Infcrprelqtion of the lpsl rcsulfs
The outcome of a sensitivity test is the result of an intel-
action between the given stimulus ar.rdthe Patieni's re-
action to it. Accordingly, a failing correlation bet\^'een
sensibility and vitality may be either stintuLtLsor retcflotr
dcpcndctrt.The forrner situatiot.rmay be illustrated by an
electric irnpulse that does not reach a vital pulP tissue
owing to, for example, excessiveamounts of reParative
clentine. False recordings also may be obtained if the
pulp js necrotic and the impulse reacl.resnerve fibers in
the pedodontal mernbrane or in a neiShboring tooth.
Such possibilities have been discussed in detail by
several authors (12, 22). Sometimes a vital pulp carurot
respond to stimulation owing to a traumatic ir.ljury of the
intraclental nerves. The accuracy of the test also may be
impaired by the patient's behavior. He or s1.remay be
anxious or feeling uneasy and thus have difficulty in
giving a correct report. Therefore, $'hen test results are
16 Foundations
of endodontology

donbtful and difficult to interpret, a combination of

methods must be used (Core concept 2.4). Coreconcept2.5 Clinicaldiagnoses
of the pulp
and periapicaltissues
Interpretationof periapicaI radiographs Pulpasana: positively
thetoothreacts to vitality
testing
andthe
pulpiscovered byhealthy,
harddentine.
Noclinical
or radiographic
Becauseinflamrnatory reactions of the periapical tissues
signsof inflammation
arepresent.
often proceed without any clinical symptoms, casesare
frequently diagnosed by radiographic means only. The Pulpitisrthepulpreacts positively
to vitâlitytestingandsubjedive
sensitivity of periapical radiography has been studied or objective
signsof inflammationarepresent.
by numerous investigators and a common approach has Necrosis
pulpaerthe
pulpis insensitive
anddoesnotbleed.
been to create artificial bone lesions in cadavers and
Periodontitis
apicalis thepulpisnon-vital
chronica: andthereare
determine the minimum amount of bone loss that will
radiographic
and/or
clini(al
signs periapical
ofchronic inflammation
result in a visible radiolucency. A now classic study was (e.9. Thepatient
fistulâ). hasnosymptoms.
set up by Bender & Seltzer (2), who reported that a bone
lesion was not visible until the cortex or the interface Periodontitis
apicalis
acutatthepulpis non-vital
andthereare
between cortical and cancellous bone was involved. clinical
signs periapical
ofacute inflammation(pain,
swelling,
ràised
bodytemperature).
They also stated that bone destructions were always
larger than that suspected from studying the radj-
ographs. In a study of human autopsy material, Brynolf
(5) compared the radiology and histology of periapical
areas of upper incisors. She reported a high frequency diagnostic system must be based on clinicnlly aaailable
of radiographically undetected inflammatory lesions. information only. Therefore, in an attempt to distinguish
Several later investigators have confirmed the findings clearly between clinical and histopathological diagnosis,
of Bender & Seltzer (2) and Brynolf (5), and pointed out the present book always refers to the former in their
ihe high risk of false-negative recordings, which in turn Latin forrn (Core concept 2.5).
will influence the sensitivity of the test.
Clinicians arrive at false-positive diagnoses mainly by
ertoneous interpretation of normal anatomical struc- Pulpasana
tures. Major blood vessels and spaces in the bone There are situations when teeth with healthy pulps are
marrow, for example, might simulate the image of an treated endodontically. These cases are not unveiled
inflammatory periapical lesion. The specificity of the through a pulp diagnostic procedure. The barrier func-
radiographic diagnosis is also influenced by other tion in the tooth may be violated through operative pro-
disease processes that might cause periapical bone cedures by penetrating the dentine and exposing the
lesions, such as marginal periodontitis and cementoma. pulp tissue. Occasionally root canal retention is needed
In such cases,sensitivity testing of the tooth is decisive. when the possibilities for coronal retention are il]suffi-
When testing of the pulp vitality is not possible, as in cient. Hemisection of multi-rooted teeth also initiates the
root filled teeth, the risk of making false-positive diag- need for endodontic treatment of the healthy pulp.
noses increases.For example, casesin which healing has
not resulted in periapical bone-fill but in scar tissue
formation might be classified as 'failures'. Pulpitis
As mentioned above, findings from numerous studies
indicate that the presence or absence of clinical symp-
Diagnosticclassification toms provides little information about the true condition
of tlre pulp (7,18,79,30,32). However, becausethe car-
The end of the diagnostic process is the formulation of dinal symptom of pulp inflammation is pain, the mag-
a diagnosis. The collected information has to be related nitude of the experience is used to try to distinguish
to a disease entity. In the literature, several classification between cases in need of pulpectomy (irreversible
systems have been suggested and various terms used inflammation) and those that are not (reversible ir.rflam-
to denote disease processes in the pulp and periapical mation). To make this important distinction, the pres-
tissues.At first glance this situation may appear confus- ence or absence of pulp exposure is an informative
ing to the reader but a closer look will disclose that the finding. The severe inflammatory reactions often
systems express rather small variations on a common observed, even in symptom-free teeth with carious pulp
theme and 'translations' between them are not as diffi- exposures (14), in combination with the broken dentine
cult to carry out. It is important to recognize that a useful barrier rnake the prognosis of pulpal healing doubtful.

From a practical point of view it is helpful to regard
excavation of caries and rernoval of fillings as part of the
diagnostic process, and painful pulps found to be
covered by dentine are provisionally regarded to be
reversibly inflamed. Such cases should be treated tem-
porarily by filling the cavity with ZOE cement, lor
example, and only when pain persists should a pulpec-
tomy be performed. Thus, the diagrosis of'pulpitis'
covers a broad range ofpathological situations and cases
will receive different clinical monitodng. As in most
endodontic diagnostic and treatment decision situa-
tions, underdiagnosis and undertreatment are preferred
to overdiagnosis and overtreatment.
pulpae
Necrosis
A failing reaction to a vitality test is not sufficient infor-
mation to act on this diagr1osis.FIowever, in combina-
tion with a discolored crown or periapical radiolucency,
an accesspreparation to the pulp chamber is justified
and the diagnosis is confirmed with the finding of a non-
bleeding pulp.
Periodontitis
apicalischronica/acuta
Pathological processesof the periapical tissues are most
often asymptomatic and the diagnosis is verified only by
radiographic examination. Sometimes,in clinically acute
situations, bone resorption may not have reached the
level at which radiolucency is detectable in the radio-
'periodontitis apicalis'
graph. The clinical diagnosis of
makes no attempt to differentiate between various
histopathological situations such as granulomas and
cysts.
References
1. Baume LJ. Diagnoses of diseases of the pulp. O/dl Sr.//9.
1970;29: 102-1.6.
2. Bender IB, Seltzer S. Roentgenographic and direcl obser-
vation of expedmental lesions in bone. /ADA 1961; 62:
150-60,708-'t6.
3. Bender IB, Landau MA, Fonsecca S, Trowbridge HO.
The optimum placement-site of the electrode in electric
pulp testing of the 12 anterior teeth. /ADA 1989;11E1
305 10.
4. Bonica JJ. The Maruqeflcnt o/ Pain. PhiladeJphia: Lea &
Febiger 1953.
5. Brynolf I. Histological and ioentgenological study of peri-
apical region ofhurnan upper incisors. Odontol. Reuy1967;
18i suppl. 11.
6. Dorland's lllL$trated Medical DicLiolxtty. Philadelphia:
Saunders, 1965.
7. Eddy DM. Variations in physician practice: the rcle of
ujnceftajj'rty. Health Affairs 7984; 3:7Ç89.
of pulpalandperiapical
Diagnosis disease 17
Feinstein AR. A bibliography of publications on observer
variability.,f.Chron.Dis.1985;38:619 32.
9. Idend LA, Glenwright HD. An experimental investiga-
tion into the locâlizâtio11o{pain from the dental PulP. O/al
Sutg. 1.968;25: 765-74.
10. Gale J, Marsden P. MeLlical Diastlosis:frotl1 Sfudenf to
Clûtician. Oxford: Oxford University Press, 1983.
'19(,2)
11. Glick DH. Locating referred pulpal pain. Oml Surï.
15: 613 23.
Himmei VT. Diagnostic procedures for evaluating pul
pally involved teeth. Curr Opitti. Dent. 799L 2:72-7.
Ingle JT,Click DH. Differential diagnosis and treatment of
dental pain. h Eflàodoiltics(Ingle Jl, Bakland LK, eds).
Plriladelphia: Williams & Wilkins, 1994; 52449.
14. lzumi T, Kobayashi l, Okamura K, Sakai H. lmmunohis-
tochemical study on the immunocompetent cells of the
pulp in human non carious and carious teeth. Archs. Oral
Biol. 1995;40, 609-74.
Kassirer JP, Kopelman RJ. Leatnittg Clitlical Reasotlitlg.
Baltimore: Williams & Wilkins, 1991.
16. Kullendorff B, Peterson K, Rohlin M- Direct digital
radiography for the detection of pedapical bone lesions:
a clinicàl study. Etldotlont.Deûf. Traunntol. 1,997;L3: 183-
9.
L7. Lilja J. Sensory differences between crown and root
derltine in human teeth. Acta Odotltol. S.a?ld. 1980; 38:
285-94.
18. Lundy T, Sianley HR. Correlation of PulPal histoPathol
ogy and clinical symptoms in human teeth subjected to
experimental irritation. Oral Pathol. 1969;27: 187 20'1.
79. Mitchel DF, Tarplee RE. Painful pulpitis. A clinical and
microscopic stlldy. Oral SrrS. 1960;38: 1360-81.
Mjôr I, Heyeraas K. Pulp-dentine and Periodontal
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1.998;941.
21. Mumford JM. Evaluation of gutta percha and ethyl chlo-
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Mumford JM. Toothacheand Orofacial Pain. Londot
Churchill Livingstone, 1976.
Mumford JM, Newton AV Convergence ir the trigeminal
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BioL.1.977;76: 1.08997.
Pantera EA, Anderson RW Pantera CT. Use of dental
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Endodotlt.1,992;1,8t37 3.
Petersson K, Sôderstrôm C, KianiAnaraki M, Lévy G.
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Etldollotlf. Dent. Tra natoL. L986;2: 624.
27. Reit C, Hollender L. Radiographic evaluation ofendodon-
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Reit C, Kvist T. Endodontic retreatment behaviour: the
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Etldodont.I. 1998;31: 358 63.
18 of endodontology
Foundations
29. Ringsted J,Amtrup C, Asklund P,BaunsgaardHE, Chris-
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Seltzer S, Bender 18, Ziottz M. The dynarnics of pulp
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846-77.
3 1 . Sharav Y Leviner E, Tzuked A, Mccrath PA. The sPatial
dishibutiory intensity arld rnPleasantness of acute dental
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Wafvinge J, Bergenholtz G. Healing caPacity of hurnan and
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OxJord: Blackwell Science,2000.
Part2
THEVITALPULP
Chapter3
Thedentine-pulpcomplex:responses
to
adverseinfluences
Leif Olgart and Gunnar Bergenholtz

lntroduction The denrinal fluid selves às â vehicle for the transport

The extent to which the denral pulp i\.i11sustainimpân
ment in the clinicâl environmcni dcpcnds on its poten
tial to oppose bact€riat châllengesdnd withstànd iniury
by varioùs forms of tfaumâ. To understand ilrc biologi-
cal events th.t operate and mosl ofien prcvcnt the Pùlp
from sufiering tr pernanent breakdown, the spcciJic
biologicâl frnctions of both dentine ând pulp under
patlùplrysiological conditions $'iI be âddressed in this
ùaptcr. Thcsc two tissue components ol the tooth lofm
a functional unit that oftcn is rcfcrred to âs ihe dcrtlrlc
putpcanpter (Fig. 3.1).
Basalfunctionsof the dentine-pulp
comprex
Dentineand dentinâltubules
Undei normâl con litions, $'hen dentine is co\-ered by
enâmelând cementum, flri.liJr the dentinal tubules can
.ontraci or cxpa1d to imphge on the cells in the pulp in
rcsponseio ûermâl stimuli âpplied on the tooth surfa.e.
Hence, dentine of the intàct tooth cù lransfon exter
nal siimuli hto a1 appropdaie message to cells ànd
ncNcs in tlÉ pr p a feâiurc thâr is useful clinicâlly to
test iis Yiial tunctions (seeChâpter 2).
\4/tren enamel and cemeniùm arc lost for âny reâsor!
the exposeddeniina I tubules provide diffusbn cha lels
frcnr the sûrface to the pulp (Fig. 3.2). Ir thc pcdph€1y
there âre about 20000 tubules per squarc millimeter,
eâchha\,ing a diâmeter of 0.5!tm. At the plrlpal ends thc
tubulai apertures occup,\rà greaier surfacc arca because
ihe tubules coN.crgc ccniraly and becone \^.i.ler (2.5
3 Um) (25).Thus, ât tlrc inn€r su#âce of dentine there arc
nore thâr 50000 tubù1esper square millimeten In root
deniinc, cspccially bwârds the apex, the tubules Lrecome
more $'idelv spaced.Also, in ilÉ pulpal portion of root
dentine they âre thirùer ed assume a lesser diâmeter
of ca- l.spm. There are cxicnsive branches betrveen the
tubules that alloû' intercommunicaii(ù.
of pârticulaic maiter and mâcromolecules in cither
djrection. From thc pr p, plâsmâ proteins mày enter thc
tubules, especialy {ollo'|illg ân injury (a2), whch
rcsùlis in disrllption of the tight jm.iions betrleen the
odontoblâsts (iJo).Sirnilarly, Iollolvhg exposure to ihc
orili enl.ironment, bacicrial mâcromolecules may penc-
trâte the tubules and provokc âr nrîâmmato{' response
in th€ pûlp (7; see further below).
Tlrc pcmeabiliiy of the dentinal tubulcs is normarv
grcad)' restricte.l by a variety of iissùe structures,
includfig collâgen fibers ând cellular proccsses. The
odonioblasis rormally extend c)'toplasmic processes
inio the iubules of the innermost pari (0.5 lmm) of the
dentine (23, 1E). Somc believe *Ët these processes
extend âll the e'ay to the dentine enâmel or.loliine
cemenrum julciion. A large nùmber of the tubules âlso
contâin ner\-e terminals (Fig.3.3). Furthermore, cells
bèlonging to the imnunosurvcilance syst€m ofthe pulp
extend dendites into the iubr cs of th€ predentine lâyer
(s9). Consequently,the spaceavailable in th€ tubules for
thc tra$port of pârticllate mâtter a1d ma.romolecùles
The dent ne pù p cômpl€x
Fig.3.1 Sotrl$ue of the pulp sutrounded
by deôriûeând enameand
.ementum.Insêt
depktsihe interface denriôe
between âôdpùlp.
22 lhe vjtalpulp

is normaly much smêller thân the tubular sPâcel€r se

(67).This is especiallytlue at their pulpal ends.

Primêryodontoblasts
The primary odonioblasts that line the Periphery of the
pûlp (Fig. 3.4) are highly differcntiated cells They
produce pnmâry denrine boih during rooth develoP
mflt and after completion of root formâtion (Core
concept3.1).Inlratubùlar cellular processesmake ihe
primary dentine tubulâr in nât!Ûe. Owing to the.oniin-
ued fmction of the odonioblasts,the pulpal spâcegrad-
ually narrows over time md in old individuals become
so small that endodontic teaLrnent becomes difficult
(seeChapt€r16).
The râie ai which tubular dentine forms in the adult
tooth is low and seems to be influenced by sensory
nerves in the putp, becauseit has been sho 'n uui the
absenceof nerve supply to mimal teeth slows down
dentine formation (33). Homonal fâctors also iifluence
the secretory activity of the odonioblasts Thus, high
J.rêm c do-"ge,of, ortico.leroid"grrénfor imauro-
suppiession in o!8m-iransplânted Patients, strongly
stimulâte dentine produciion (57). lùbueslnvarlous
Fig,3,2 DeBityol dentinal porriôns
oflhecrownrêglon
The pdmary odonioblasis may also produce new Lthâ!bêen
inleerh, estmated a.ealâkên
riâtthêsurfa(e byûo${uttubÙles
deniine at an increasedrate in rcsponseio mild stimuli: bùtiêarthepulp$e dentinaLtubules
isca.2 l% ln theperlphery a$ùme
.a.2s%ofthes.râc dêa(67).

oI ôdontoblâsE,
exlensions
Fig.3.3 CÊLlu!âr neruè,
and@lso{ thêimmune svsrem(dendtk (elt $at
Dendriti"eL occupvlhepopalends es.
ofthedeniinaltubu

*: nainedwlth hemalôxyin
Fig.3.4 li$ue secdon ândeosinshôwingdentine,
ândpulpt$ue properwilh odonlôbâstslininqthe pêrphery
predêûtine
 Thedentjie pulpcornplexi to adve6€nTllences 23
responses

't'
LOreconceptJ, I vànoutlermsuseoTol
' differenttypesof dentinogen€sis a
'o led ovo'n"rr ooo lobl"
P,î",r d€"rfe:o.nLine
: Âepa€tùedertire:dentine Iormedin rcsponseto injurybyether
'.
primêryor s€condary odontobasts(reparing odonloblênt..'
.. Equivalent rermscommon y usedarcnrcgulatse.ôndary dentine,:
.4.3flôhdà.r..àëfi r6.io.\ dà.tirê.
\ole -h"I or nàryd" | ê "no .p'onod1o"nin" " " .È n\ 'on"
--
i Umesueedto designâte dentine formedby pimaryodontobasls
' beforeandaftertermination orrootdev€Lopment,rcsp{liley.con' .
. sequenty, thetermtertiâry dentine hasemerged to denoledentine,
' formed in responseto lrritationor inlùryrh€cùrcmtufi makesno i
r' suchdlstlnciion. a'

e.g. dùring initial prccavitaicd stages of o1amel câdes

(u); by slowly progrcssing caries in gel1erâl (13), oI
during a shâliow pieparariù for rcsbrative puryoses. Fig-3.5 M cophoioqraph showshàrdlirsùerepâiriolowinqa cavilyplepa
tus is sometimes termed reaciionâry dentine (73). 6tôi Gftow).ûe cif. e ndcatestlre bulkol newdeiiinebeirglomed.

Secondary odontoblâsts

Foloù,ing n!ur)' or iritâtion (e.g.indÙced bt, . restora-

live procedure or rapicllt' progfessing caries), primary
odontoblasts mây die. Becausc ilrcsc cclls are poshniiotic
cels, thcy arc ùablc to ægen€rate by c€I] division.
^lthough ilt origh of the repâiring cells has been the
subject of mùch debate, mesenchvùal c€lls in the plrlp
tissûe f./ s. hâve Lreenimplicâied as iheir likcly sourc€
(24).lt is plausible thatthese repâiring odonioblasis rep-
resenta popu lation of p u lpa I stem cellsrhat arc rccruited
to the site of inju{r. Following their upregulation, a
mnrer,:lizing mâtrlx is lâid do$'n on tlrc dcntinal
$.a11.Iiepâir by secondat' odontoblasts is also possible
against ân âppropriat€ !\'oûnd healing agent âpplied ro
tr€atdireci exposrrc ol the tiss! e (seeChâpter 6). Hencc, Fig.3.6 Clinicalpholoqraphof anleriorlowerteelhshowing
extensivelo$
â new generation of odontolrlast Like cells, capable of ol lôôthstructure
dueto loothweai Repararivê dênlneiormedin the pup
making ncw dùinr bcally, can evolve in the pu lp upon haspievênted dirè.texposureoTthetissuetorheoralenvifônnent.
injul),.
Secondaryodontoblasts produce dentine àt à râte that
is dependent on ihe extcnt and durâLion of th€ injtry
The developmeni of this hard iissuc lcads to a compen e\.âporâtive stimùIi (15, se€ i:lso Chaprer 4). Yci, the
satory in.rease in dcniinc thickness (Figs 3.5 and 3.6). qualiiy of dr nes har.l tissue is noi al$-a)'s as good .rs
ft should be noted thât dentine formed b,v secondary ihat of prilnâry dentine. Whcn formed ât â râpld pâce,
odontoblâsts becomes more irre8ùlar and amorylûus tissue inclùsions arc formed, rendering it a hiSNy
a^d contalns less dentinâl tubules (15). Thcsc tubules porous configurainù. Similarl), hârd tisslre repair of
lvill not n€cessadl_v be in direct line û'ith the rùbutcs of pulpâl wounds may occasionally sholt' substantjal
ihe Primâry dentnæ Fig. 3.7).Conse$ently, a complex dcfects,which mâkes it h ighl), perDlcableto bâctet a a n d
of primâry and reparative d€ntine b€comes Lessperne- bactc'rial elements. The.efore, hard iissue repair in the
able to extemally dern ed matter. It âlso follob's rhat pulp, alilloùgh âdding to th€ dcfcnce pot€ntiâl of the
such dùiirc is lcss sositile to thelmal, osmotic and tissuc in certâin aspects,should be vicwcd âs â scàr.
24 Thevita pulp

Nerves

Pulpal ncrvcs moritor pân]Jul s€rùations. By \iftue ol

thcir pc?tidc contùt they also mediâte a !aliet), of bio
logical funcin!É, includfig the control of dentine
flm-. r,rr\ .\.rr- d,d r'.n, r.pdir
(Fig.3.8).
Thcrc arc ilvo types of nerle fiber thât mediâte the
sensationofpâin: A fibr€s condûct rapid àncl shâry pàin
sensàtionsând belongtolhe myelinaied group, ryhcrcas
C fibres âre involved in dull âchhg pain and are ihinrr
ând unmyelinated. The A fibres, mainly of ihe A-delta
t),pe, âre preferential\' located in the periphery of the
\ pulp, \rhere they âre in close âssociation {'ith the odon
toblâsis âI1d extencl fibers to many but not âlL dentinâl
;\ tubulcs. Th€ C-fibres t)'picâ1l)' terminâie in the pù1p
tissùe pcl s., eidÉr as frce nerve endnlgs or âs brânches
a r o u n d b l o o d v e s s e l s( 6 1 ) .T h e n a t u r eo f A a n d C f i b r e s
and their rcspccù.c rolcs in pain hansrnFsron are
Fig.3.7 Iissuese.rionof an interta(ezonebehveen primarydentineand
repâÊtive denlineàsindi.arêd by arows Notetlratthedentinatubue5are
rcvicwcd in Chaptcr 4.
le$ nûmùôùsiô the se.ondary dentinethan in the primarydentineto lhe Ncrvcs bcl(ùging io t]t aùtù1omic nervoùs syst€m/
LeTt.Alsô,lewofthetùbulesare n direcrlinewiththoseoftheprmarydentine, such as sympâlhetic vâsoconshictor fibers, arc also
thusnâkng the enrnecomplexe$ permeabe. PupailÈsueand nu.e of present (52). They enter the pulp rogether rviih blood
odontôbâsts areto the ri9hr.(Coùrte5y
of Dr LaEBiorndaandwth permis. vesselsand sensory axons. Histochemicàllt they can be
,ion of CârlêsRereâr.h,
Karge.) traced in the puLp vja their content of norâd renaline and

NKA

rmpu6e propagaûon

Fig.3.8 A Large ponionof the sNory lbùs, ndudinqC libùs andsomeA deta fbets,containvasoa.tive
neuropeplde5 50(has (aciloninqenejelated
peptde{cCRP),!bnan@P(5P)andnemkininA(NKA)(83) desarepoducedin thetriqeminal
Ire neuropepl .el bodiesandaretran5ponedvia aronallow
rorheneiveterminasinthepup,wheretheyarestored.naddilontotheireffecronpupalbloodTowandve$elpqmeabity,5PandCGRPex
tôryefie.lsôn lhegrowlholpulpal@ls,ach 6fibrob6c {79),andrepairodontoblaslsTheyareal50adlveln the rccruitmenr
oI immuno.ompetent.el s in
rêsDoôlestu bà.terialinie.ton.
 the denllnelulpcomplex:
responses infuênc€s
lo adverse 25

neuropepride Y Upon felease these substmces exert Vasculârsupply

contraction of tha smooth-muscle sphincters in dteries
ând smâll arterioles apical to d within the pulp (63).
A parasympathetic vasodilator conhol implies thai
autonomic neNes, upon renexogenic activâtion, release
the clâssical transmitter âcebr'lcholine ând the co stored
vasoâctive intesiinal polFcptide (VIP). Both trâns-
mitters have been foùd in the pulp of mâny species and
they have vasodilâior âctions (62). Às yet, ther€ is little
evidence thât this rcmote blood flow control p1âys an
important role in the local defense of the pûlp.
Cment knowlcdge of the vasculù ar.hitecture of the
plrlp has been iliûenced g€âtly by the use of the
microvascular rcsin castmethod (Fig.3.9) (76).This tech-
ni$le allows resin io fill up even the smallast caPillaries
of the pulp. A vascùlar .ast is then oblâjned, which, fol
lowing coÛosion of sunounding iissùe structures, cân
be cxanined in the scâming clechon micloscope.
In â[ developmental stages the crown pulp shos's a
large1 vascular neiwork dùn the rooi PLrlP, whêre rhe

Fig,3,9 serlesofmkrophorographsôfthevâscuarnetworkinthepupoltelh G)lntheyounlJ toolhof dog5rhêÈsadenselermina capillarytelwoftin

lhepulÈdentine bordqzone(b)rnesuperfciâ .ap larynetwork rcgonln a viewpspendku
intheodontoblàst d tô ùe pulpa$rf&e.k) Boodve*ehin
aryevenules
thedistaroorcanalolamaruredogprefrôlârTheçuperfcialcapilariesdraindnêcrlyinto (V).Inlhemàrurê tôoth,continuous
denllneiorûâtion
andna(owing ofrhepulpcviryleâdto remodeling (d)rheu(lar netlvork
ofthevasculartree. of anaduI humân 1ôoih.Witha narowapicalorâmen,the
number oI arterioles
is rcducêd
ro 5i andvenulesto2-3 (41).1lle
nùmbù oTmain veselranerioes andvenulesin lhecentrapulpare redu.edandthe
also
haielnloops
typical ofùe temlnalGpillary
network becomess pronouncd.(counsyol DrK.Takahashi.)
26 Tlr€vral pulp

ctrplllary neiÉork is mùch denser th.n in i11ol€ central

portions of thc pr p. /hasbmosis bciwccn inconing
and origoing blmd vesscls has beù obsen cd in ihc
ccntral pulp of adull aniùâl i€eth (43) and seems lo bc
in the apical pulp thân in t1le crown
pulp (39). Shunt connections betNeen supplying ând
draining pulpal vessels hàve âlso beetr found just
outsidc thc apical foraùc.n in thc pciodontal ligam.nt
(77).It is reasonableto assume that theseshûnts pro\,ide
control of blood perfusion throùgh the pulFÀl tjssue.
I lence, in the caseof n loctrl if flammtrtory event causin€t
. r ' .r F d . e J ê . i - . L n . . . . p I p . r h l o . d . r r ' r i o p r u r .
shunts mây comeinto play and rcdircct incoùing blood.

Lymphatics
Both morphological and fùlciional sLudi.s ù anDnals
shos' the existence of lvnrphatjc vessels in the pulp
(12, 27). Thcse vessels are importani to adjusi tor
celsGtanedbrown)with
Fig.3.10 lks0esedonihownqdendrltic n lhe
incrcascd colloid osmoiic pressur€sexerted b,v protehs odontobasti( layeimmùnohisro.hemi.a
andsubodontobasti( nanngwâ3
and macrorndecules .ccLrmLrlating extrâcellularl), in .aûiedoutwith0x6-anubody, ca$ lltMNamoêcùlês.
whch s a markerfor
inflamed arcÂs.Another important fnnction is to serle
as pâthwâys to the l€gionâl lymph nodes for àntigen
They occur h rnost body compartments ând ar€ chârac
presenting ce1ls.

. HigN)' denddtic noryhology

Ce{lsof the immunesystem
. Higlr âûroûnts of Cl.ss ll nolecules on ilrcir ccll
The ctenrâl pulp is equipped i!'ith the necessàry.ells
io iriiiatc and mainiain immune responscs.Hc'ncc, T- . HiSh notility
lymphocytcs a1d antigcn-prcscntng cclls (^PCs) of . LiDiicd phagocytic câpâcilv
v â r i o l r sk i n d s h â v e â 1 1 b e e n i d e n t i f i e da s r e s i d e n t so f i h e . Efficient activaiion of naile T-cells.
nofm.l dental puLp (36). D cells, on the other hànd, will
Thc Class II molecule €xpressjirg acroph.ge is the
not appeâr in the pùlp ûssue pcr s. unless there is ân
oùcr profcssional APC of ih€ norrlal, non inflâmed
intlâmlnatory event.
pulp. Thcsc macmphâges âre .{istdbuted in a rcnârk'
The APC is à cell thâtcârries stnnùlàtor) nolecules ol
âbl), high nmbcr in ihe pulp and s€e to form â dense
importdnce for T .ell âctivdtion of its sùrfÀce.The Class
nctwork together with pulpal dendritic cells (35). As in
l1 molecule is one strch molecule ànd is â gene product
other conn€cti\.e tissues, macrophagcs in dr pulp are
of dæ major histocoùpatibiliiy complc\ (MHC). Ii is
heterogeneous in icrms of phenotyPe ând tunction.
â b F i ô d . f l r ) r . g r n ê ' t ' " ff ' r É r , ' r . . ê r u r " . u i r r :
Hence,lherc arc rcsidcnt mâcrophâges(hjstioc\'tes)thât
tion by T cells. Together with oûer co stimulâto , mo1
do not carrvClass II molcculcs. ïÈse ce11s àrc prim,rril,\r
cculcs, Class iI Dlolccr cs arc found on all so-callcd
1ocàted perivasculârlv Other macrophages erpress
profcssiiùâl APCS.
\ àrioùs combinations of cell surface markcrs, includhg
Thcre are ta'o types of professional APCS in thc
Class II nolecules.
normal pùlp. One type has à prcnounced dendritic con-
Tlrc normal pr p àlso hârbols a limited numbcr of T-
f i g r m t i o n a n d m o s t l i k e l y f e p r € s e n t tsh e d e n d r i t i cc e l l s ,
hclpù and T cytotoxic cells. These cells ma,v reprcscnt
w h i c h c o n s t i t l t i r e l y . à r r y C l â s s l l M L I C m o l e c d e so n
c i r . r l a t i n g m e m o r y c e l l s( F i g .3 . 1 2 ) .
their ccll surfac.. Tlrsc dcndritic cclls arc stratcgically
posjhofed ;Jl the pedphery of th€ pnb, $'here foreign
antigens àre most likely to €nter the tissue (Fjgs 3.l0 ând
Basalmaintenance
3.11).H€re, thel compete for àvailâble spâ.e \,'ith the
odoDioblasls and thus mal<ccontaci lvilh ihcsc cclls via
Bloodflow
thcir cytoplasmaiic proccsscs(59).
^s lviih all i\.hitc bknd cclls, dcndritic cclls dcrn,c Thc bknd flow ihrough tlle )'oùng adlrlt pulp during
from thc hematopoietic slem cell in the bone marroal resiin8 conditi(Ds is.e1âti!e1y high cornpared $.ith
 Ire dentine-pulp
complex:
responses
to àdverse
influences 27

sensory
nerves Boodvessêl Lymph
vessel

Fiq,3,11Connituents
ofprimary
sigôif6nce
inihedefense
I
ofthepulpagainst
foreign
ffi
substânces,
including
Macrophage
Classll

bacteial
elemenrs,
make
Macrophage
Non-classll

IiEt line
uptheinnate
MemoryT-cell

ô
4

Fis.3.12 Antigen{pecilic T-ce iôihepuipfollowing

lsae developed primàry{l)andseondary(ll)antigen
exposur6 alonsdentinaltubules.
Dendritk
cells
(1infigure)@pture protein
aûligen Torproe$ingto peptide
fràgments
àndcarry{2)andpresent
peptide inthecontext
fraqments llmole.u16
ofùe Clasç on
theircellsùrfâcêto nai've ymphnods(3:primary
Tcel5 intheregional lmmune.esponse).
Followingdoiâl*pânsion,lhesecelkênter (4in
lhecirculation
Tigue).tollowlnq lheirpatbllinqoftissues
asmemoryTcells jn se.ondârylmmune
theymayparticipate responses eg-inthepulp(5inTigure),
at localsites,
iI exposedio theappropriate
aniigen bylo@APC(6ln19rc),ftis routeconstitutes pathogeftspdfic
adapiive immunity.
 Thevit pulp
that of other oral tissues (54). In dÈ aduli dog, blood
flow per 1009 of tissue is ca. 40m1/min in teeth with â
ful1y formed âpex. By compaison, in the gjngiva it is câ.
30 nll/min.
Localcontrol
The le\t.el of the resting blood flow in the pulp is to a
greai extenl controlled by the neuropeptidcs, subsiance
P (SP) and calcilonin gene related peptide (CGRP).
Both CGR? and SP maintain a continuous relâxation of
feeding arteiioles (11). This continùous hfluen€e on the
blood supply to the pdp depends on a basal releaseo{
the peptides withoût âppareni neNe activation.
Nitric oxide (NO) â short-lived gâs moleclrle that is
produced enzymatically in the endothelial cel lining of
the vessels also serves to maintain â physiological
blood perfusion of the pulp (38). It has a powerful
vasodiiâtor action md, ùnike neuropetides, exerts
relaxation of the draining venules jn the pulp ùnder
physioloÈca1 conditions (11). (See Advânced concept
s.1.)
Remote control
The regulatorycontrol of pùlpal blood flow also
invot\-es autonomic nen'es. This remotc system influ-
ences blood cir.ùlaiion in ihe pulp as we as in âdjâcent
tissues within the same imerahon ten itory
Although pârâsympaùeiic vasodilalor nerves clo not
seem to play a significant role, there is tum evidence for
sympatheiic vasoconstrictor conhol in the denial pùlp.
The system does not seern to be âctive ionicâlly and may
noi suPport local moment to moment demands of the
tissue. However, physical ând mentâl shess trigger sym-
patheiic vasoconstriction in the oral region, inclùding
the pulp, as part of the general fight ard flight rea.tio11
(63).
Advanced concept3.1 Mechônisms
regulating
pulpalbloodflow
Thephyslologka rcgulation of bloodTlowandtissuepressures
the pulphasbeenstudiedin somedetailin ênimalteeth.For
exampl€, ùeatment withânlagonists to neu.opeptidei
Leading to deg€neration olthe sensory inneruâtion, almonhaves
r h ep - p a lb o o df i o w . n dF d u ( p .I p i n r q i d I u r dp , ê s s uirne
thepulp.Pharrnacolog câlblocking ol N0 production
bloodTlowbu1,at rhesamelime lnûeâses lissuepressure.
ûren rhFp\ysiologi'dl drio o N0 i, nùr. tow resisÈncê
drainingvess€ls islow(dilated veses),â owingappropriate
foW volum€ andtissu€presureln lhe pulp(11).
In general terms, both the s]'mpathetic ând the
pâfas]'mpaihetic systems operâte at the general or
segmental 1evels ând tend to ignore ihe needs of an
individul tissue such âs the pulp. Therefore, ihe localy
âcti\,e mechanisms most favorably meet the nutritional
demands of the healthy pùlp. Suitable adjustmeni of the
resthg blood flow in the pùlp is mairny the result of a
balance between the locally govened rclaxing lactors
and a certain myogenic constrictive tone of th€ vessels.
Appropriateresponses of the healthy
pulp to non-destructive
stimuli
Functionally, the rmique dentine-odontoblast unit acts
as a trâisducer of vaious cxternal siimuli of moderale
inrensity. This enâbles dæ iissue comtituùts of ihe
peripherâl pulp to be alertecl appropriatel)r. Thus, in ihe
inta.t healdly tooib a Limited .old stimulus or elâstic
deformation of ddlinr dùe to a sudden hea\.y load on
thÊ iooth is hansformed to minute and rapjd move
menrs ot the dentinal l'luid (12 82). Such movements
excite adjacent nelves, resûlting in â râpid reflex with-
d.awal reactioni this is inmediately fo owed by â
briet sharp pah, âlefting the individtal io further with-
drawâl. This is ân import.nt â1âransystem protecting the
rooth from overload by masticàtion forces for example.
In parallel there is a transienl increâse in blood per-
fusion in the pulp (53). This is pan of m instant local
defense rcâctio11 ând is brought âbout by the fine temi-
nâl branclrcs of sensory neNes supplying both cells in
the odonioblast region as well as srnall feeding artedoles
deeper in ihe pulp. Excitation of the most terrninal
branches in the peripheral area of the pulp resuns in a
reflex pfopagation of impulses in âdjâcent nerve temi
nals belongin8 ro the same neNes (axon reflex) (6a, 82).
Because thesc neNes contain vasodilahng neuropep-
tides (66,52), jt tâkes only a few seconds for a short-
lasring (< L0 nin) inc'ۉse in blood pefusion of the
pulp. The CGRP is the dominating mediâtor of this
response. As a rcsuli of dÈ transient incrcase in local
blood volume, pùlpal tissue pressùrc increases. (See
Advanced concepi 3.2.)
Collectivelt thc rcflex s'ithdrawal, the pâin and ihe
in local blood flow increase ùe judged as being appro'
pdâte ad esseniial responses for ihe proieciion and
or axotomy naintenànce of nor111âlfunction o{ ihe pulp.
alsoreduces Effectsof intermittent and
thus,
in
longstandingirritâtion
blood
Episodes of sustâhed and iteiated irritaiion of ilÈ intact
tooth or an exposed dentinc surface caùse exiended
 the dentln€pulpcomplex:responses
to adveneinluences

Advanced of
concept3.2 Spread;ng
vascular
reactions
a transientn(easein pLrlpalb oodfow È produced bye ectnGl
or noxious stimualion of adjacenitissu€sandteeth,as demon
nEledin ansthetiz€d anmals(71,62).IhBpinching of rnsertron
oTaninlection needlein thevestibulâroGl mucosa anddelivery ol
â sho trêinofeecticâ impulses to theliporadjacentleelh qivê
riseto a bloodIlow inoease severaminutes lông.Thsphenone-
nondemonslrates theextemive bÉnchlng of semory nervesin and
around t€€thandiheirwidereceptivelieldt impyinglhat sprcad
ingôf neuroqenic vascularreaclionsmaytâkeplaceb€hveen dû
Ierentoraltjssueswlthlnthesamenerueteiritory

pulpài reâciion and motrilize elements il1 a p'olnllâm-

matory response.The predisposltioû ofthe pulp io rcact
with inore comple\ blrt hansient cascadesof events js
shred by most peripheral tissucs and is an important
function to maintain and iegain hcalih As tar âs the
pulp is concemed, there are soûe unique featurcs thâi
affcct its abiliry to srsiâin hjûr,v:
. The encasemenl within rigid hard tissùe \^.alls
r€stlicts e.lemtr formâtion and expansbn. In other
1'ords, the pulpàl tissue is confined to a lo-r1,
c.rtplian(. slstrn.
. The lack of collateràl blood supply in one-rooied
ie€û limiis the supply and dfâinage of b1æ,1.
Both of thes€ factors ha\.e implicatbns for the $'ay in
which inflâmnato{r fesponses de\.elop in thc pr p âl1d
may/ on severe châllenge, be contributory b pulpâl
Restorativeprocedures
Resiorativc procedùes undertaken ir dentistry to
nalage cades, fractùres ând tooth losses camot nor-
mally be undertaken lvithort generating damagc b the
plrlp. It is pdmarily ihc cutting procedure that causes
pulpal irritâiior! related pimarily to the r€leàseot tric-
tional heat trom the use of roiary instnùnents. Because
the thermâl conducti\-iiy of dentinc is low, it is pdma
dl,\r dehi'drating elfects thât âre damaging, ùis \till be
the case with insufficienl waiù irrigatioi (Fig. 3.13).
Dire.i hcat iniury does not normâlly occur unless the
procedû1e is câûied out close to the pulp. ^.lso, the
toeqùent ior.hing of the tooth strlrclure by improperly
ccntered insh'ûments mây câuse tEumatic effects. À11
ihese injudcs causc ncurovâscùl respons€sol a nâture
similar to thosc dcscibed abole.
Apr€?aration hauma with rotâry instruments is likell
io injùre the odontoblast layd (80). Oi{ing to dehtrdra-
Fig.3.13 Prêparlnll geûerâ1ês
teethforrestorations ficuonalheat,which
.auses
dêhydratjon
âM tissuedamaqe torhepùp.sù.hinjurys le$ened
by
proper
waterirrigauon
durlngthe.utringprôcedore
Lion of the tubular content, odontoblâsts ma]' cven be
srcked into the denttuâl tubules- This particulâr featu'e
is icrmcd odoTrfoûldsf dspildrid, and cân be observectin
tissùe sections by the presence o{ tlleir nucleàr piofilcs
rvithin thc dentinàl tubules.
Injuryby prcparation trauma to the odonioblast la t€r
opens ùp path$'ays for â peripherâ]ly dirccted flot{ of
tissue fluid alonE the tùbùles. The flLrid floi{ is Possibie
due to the higher tissue pressùre jn the pulp ih.n èrtèr
nallv Under normal coiditions it is 5 l0rnmHg highel
in the pulp (21. This colfesponds fairly well with the
tocâl blood pressure. Under inflâ]r]mation, the pu\l
tissue pressure incrcases.B), contrast it ma,vbc reduced
dûring flight'and-fight reâ.tions, âpprehension (9) and
in th€ ùs€ of ànestheiic solution contâining vasocon-
stricbr (82).
Potentialprotectiverolesof the dentinâlfluid
Providcd dùt ânestheslawith a vasoconsuictor is not
used ard às long às a dcntine exposure remâins oper,
there will be a slow .ontinuous outlvard t]ow of fluid
along the dentinal tubù1es(O.afl/min/cm2) (Fig.3.14).
It hâs been estimated thâi ûe individual iùbule câr1b€
cmptied âncl refilled lel iiDes a.tay (15).
Both the continuolrs and ihe stimulus induced dcnti-
ml flnid flow mây seNc to limit if\.asive thrcats.
Follo('n1g exposure of denihc b tlle oràl envi ronmeni,
30 Thevitalpup

Fig.3,14 Wlrenexposed dsntines dred (1 iû fgûe)

orsubjeded to a painlùstimulus çuchâsâ bLanoicon
pre$edair or (aping wth ân èxporeithe oùlward
movement of rhe dênrinâïuld is râpdy â(eleruted
Th5 re5uhsn neivenimulation (2iô ri9ufê)and a rcrue
m e d a t e d i n o e à s e o r pbullôpoàd f l ô w (n3l q u r e ) . c o n
sêqùenty, manyve$eL,wh chdùrln!lrenin9 (onditons
wereonlypartlyb ôôdfi ed,nowl lup and n(€s the
voiumeol T lèd boôd veses n the pup. Ths n lurn
o,.o*- reqùrerroomlor expamon(4 n fisure)Be.aùse the
spà.elor theen.âpsulaled pùp s rênrftd, theinstant
I up of vè$eh pronpl5an ln@asen rhe nterniral
tirse prs!re (28).Therellrant lor.e enhan.es lhe
o u t w a rfdi l r a u o n r a l l u i d( 5 n f i g m e ) ( 9 , 5 1 ) .
o fd e nn

bâcterial elements mây enter the pulp akDg thc tubr cs

by diffusion. Hoa.ever, a peripheral llorv of denihal a^rô .nn.ônr L
Ituid boih diluics md opposcs sùch minward transPort
. . N€urovascularreac(ontncludinq vasodilatonând ndeased
of elel,I1enis.Thùs, freshl) e\posed dentine sùbjected - ve$e perrneabllty in fesponse b errerna,reativeyInnocu
to a painfll stimulus hâs some capacity to flush the ousstimull,areprolnfl:mmatory events
tubules, a'hereby dlffusion of h.rmful agents is coun- . Iheyarereversibe inthenormapulpandserueto suppolhe
terâcted (81, 1).Itneeds to be rc.ognized, however that tissuein overcominqpotenti:lthreats.
the pedpherâl flo\r of flùid càrnoi completely prevent . Ihe responsesareslgnfcântbeca6e:
the ins,ard diffusion of ba.terial el€ments (8). A1so, chaenqedce s arcdependent onoptimanutriton;
ulder periods ofnegatile tissuepressurenonoùs âg€nts deârance of harmruproducts lromthe affededtissLre
on thc surfacc of dentinc, by virtuc of ihe fluid, mây c0mpartmeni B auqmentedi and
be dmi{n into the pulp and aggravate a pùlpal lesion â moderate ncrease n issuepre$ure rendsto limit nva
(82,9). s onofnoxioW elements a onqpateûldentinâtubuesby
increængihe peripherâ flowofdentinalflud.
Nevertheless, ihe protecti\-e eifeci of thc flùid is likclv
to bc cnhaNcd during pulpal inflammaiion and n'ray
contdbute io ilÈ proccss of pùlpal lrca]ing and repâir
seen follo('ing bacteriâ] challenge of denrine (51, 81, 8).
A l o n g w i t h t h e j n c r e a s eo f p l a s a p r o t e r n s i n t h e
Blood flow <hanges
extravÂscûlarhssue corlpÂrtment, the content ofplasma
proteins will increasein the dentùal fLujd as $'ell. This Preparalion of dcntfie br rotary instrumenis results
m€.ns that â vâriet)' of ântinùcrobiàl elements, such as instantâneouslv ir incrcased pulpâl blood flow (l-ig.
imlnunoglobûlnr and conplenent Îâctors, arc câried 3.15).Acii\-ation of the peptide contâinjl1g sensofy nerve
to the periphery oI dentine and may bind to bacicria aùangen'renL described àbove, mediates this rcsponse
a1d bactedal macromolecules. Such â bindhg is Likely (seeCore concept 3.2).
io imp€de drir furûer penetration to the pdp. The ln deep cavity or cro$.n prcparations, a direct elfect of
incrcascd coNcntration of plasma prohnÉ further no.lerâte heât on pulpâlcells and vessclsalso augments
âffects the viscositv of the fluid ând makes ii less pcNi- putpal blood Ilow. Excessivegenerâtion of hcat rcpre-
ous. Thus, severâl fâctors âssociatedirith the deniinal scnts an inappropiâte operative procedure and camoi
fluid mây aid in limiting threais that ma,v folloi\. cxpo- bc abated by rhe locâl protective mechansms, ihùs
s u r c o f d e n t i n et o t h e o f a Le n v i r o n m e n t . potcntiailv causingsedous dànâge tothetisslre. For this
 I.d.' F r ' et o " d . " " i r f J " . -
' " p r l p . o m p l " .p: o

(t
t-

Fig.3.15 Prep3ràrion ol dentlnefor reloralon.ausesan n.reased pupa bloodflowlhal resutsn accumularon olluid andma.romolÊ.ulÊs ourside lhe
e a k n g v e $ e sn .t ù r n , l h s w l.l a û s ea 5 u l an e di n o e a s ne n l r a p pu a lp r e $ u r w
e ,h i . hm a yb ed o u be t h a t n i h e n o r n ap ù p ( l l ) . T h e l ù d p r e $ ù r e p r o m p l y
GùsèsâôêihâncedoutwarddÊnrnallùdlowinexpose.lderinelhe nle6tiriafluidâ..umulàrons,howevêr, imiredbyrhÊ.ountera.ring preerê iûcrêâse
andbyrèmovâlôlrhe proteins vià ymphve$elsThesurpuslud i5 dowyùanspofted arvaybyabsorpron và nla.rvenues n adjacnlrjçsùe.ômpdrmênts
( 2 8 ) . A d j a @y m p h a n d b o o d v e $ e s a s o . o n r r i b u r e r o r h e . e a

ftasor! it is csscntial thât â proper wàter cooling svstenl .nd their primarv fun.tion is to kill bactclia. If ihcrc is
is ù cficct (hcn cuitin8 leeth s.ith rotary instruments. no or little bacterial €xposurc in coûunctnn s,ith tlr
Preparâtion in vit,rl dentnl€ usllâlly makes th€ use ot injur\', e.g. âfter a pr€par-ationtfaumn, th€ infjltraiion of
locâl .nesthetics fecessàrl'. As .i l€sùlt, the appropdâte neuùophils rvi be limited Ànd ihey l{ill dis.ppeâr
ner.e meclinted vâsûlù l€sponses to ihe PrepârâLion { idnil a fe$. dà),s.orL bàct€riâl cl]dllenge ii conjunction
tf.umâ \^.ill b€ attenuâie.{ for à whil€. This is noi re wiù leâkl- restoràtions,n€utrophils inâ,v acclrmulâte in
garded âs à serioùs problcm bccarNc pr pal ncrvcs arc largc numb.rs a1d cntd the pulpàl ends of ih€ deftinâL
only blocked for,: few minutes àfter iûection. Ho{,ever, trtrules (Fig. 3.16).In srch .j positio]l they conn-ibuteto
whcn a lasoconstri.tor (àdrcnâline/eprlephrife) is fulf.l protection b,1rblocking both the diflusioD of bac-
!sed, there rlill l,e a long-lasting pcriod of rcduciidl of tcdal macroDrclccùlcsas wrl as dÈ n1vâsionof b.r.t€r'
basal blood flow: infiltration ancsthcsia in thc ûpp.r ial orsanisms (E). (SeeAd!âice.t concept 3.3.)
front tooth region mâ) lotr cr bknd pcriusn)n of tlt pulp Pcriphcral blùd mono.ytes âlso inlilhâte the sit€ ol
'l'hese
n adjacùt tccih b,v 70 80"1,for > lh (65, 2ô, 58). injur). Onc€ in the iissue, ùonocyics bccomc a.trvated
changcs arc noi as prominent s.ith â mandibul.f block and turn into màcrophàges$.ith a mL tjiudc ot impor-
trut dr pulp is likely to be vulnerâLrleto the clinicâLpfo tânt functions, such âs:
ccdures directed to the tooth strlcture. lt is therefore
. Bacicdal killing
advisàble to aroid catecholamine!âsoconstriciors when
. ClcdÉng tlt tissue of cellular delrris
prcparng for restorations in teeth n ith vit.l prlp.
. Anhgen Fresentât'on
. Tissue repàir bv stimulaiing an8iogcncs$ and
l\4i9râtionof inflammâtorycells f ibroblast proliferatjon.

A local nlurr to the pùlp activaics thc migration of

inflàmmâtory cclls. lollol.ing the injurl., a varietv ol Effectsof potentiallydestructivestimuli
solùLte chemoiaciic iack)rs are formed thât prompt
neûtrcphils, ùonocyics and T- and B-cells to l€.rve lhe ln ihc clirical dlvironncni a ladciy of poientiall\'
vasculaturc. Thc neulrophils.tri\-e in l.rge numhers destiarctive elements, priùrârili of a bactcrral naturc,
32 Thevita pup

Advànced(oncept3.3 l\,lediators
of
ouloalinllàmmàtion

!n .once[ numerous oGllyproducdnediatorof nflammaton, ]

I n . d r q È o . d o i o È .i , r o . n ô o n o " u o p " pi d a , p p o r ' -
, inJêmmatory pro.ess andthesubsequent repanphase. BothCGRP
a and5Pexenchemotac(c attradionon eukocytes, induæexFres.l
':
sionoI adhesion nrohcLr es ôn vssel wâ s neces:ryfor exltof ,
' ê 4 i ê r o ô i u ô d on o d , , " l r p o ) . . v :, b 8 l 5
'r n manyànimalmodes, n(eaædp astkty oI pupâ inneruallon
I hasbeenobserved.Wilh n 48h alterexpsimental exposurc of the
I p u p l o t h e o r a l e n ! r o n m e n t , n e û o pnedput d i di n
e !sS, P a n d C G R P
: âreinûesedintheneùeiermina s c oseto the nllammdro,y zuÉ
il n additlon, there s extens ve bran.hng and sproutngoi rne
.l p e p t i d e { o n t a n i n g n e r u e t e r m i n a s i n t l r e b o r dneiraznorn e o l t h e
.l matoryproce$(78,40) ftis outgrowtlr ol peptdecontain ng
1 nerves is paftor ana.uiedelense resporoe rhatisïu y developed
. wilhn 48h alterinluryand â5l3for êç Long6 the û t:uon per .
i sÉts.Thealocâ phenom€na arego!€rned by llre trioemna .ell
,: bodesviaperipheral infuences. Theactivatinq siqna s conveyed
': bya neurotrophin:nerue growthTactor (NGF) (50).rlEsubstân.e
w i
:
s normay Iormed
maintain
ata low eveln pulpaflbroblans
thejntegrity oI th€perlpheral nerueendings
andseNesto
(49)andto
i êcelùatetisaerepar (47).Consequently, the n(easedlocal nner
* vàtonànd ncreased levesoI neropeptdes support themôbiÊê
:r
ntr tion and acrvatjonoI cellsnecessary Ior an optnrâ defense

ffi t'ry
Fig.3.16 to owinltâ badùlâl .halèngeôl expôseddenlineneuûophh
mayenterthetubùesoTrheaJlecteddèninear thepùpâ ùd Gncir.ed)ând
preventlhed
$ên nalônôI bârreralê emêôrstô thepùp.(ftomBergeûholtz dctcctcd onlv follo\ring plâque r€moval and âir drying.
c cndan8cr the continued vitàl function of the pulp.
Also, d ental pro.edures and variorÉ fonN of accidental
traumâ rnây câuse iijury leading to p!lpal breakclo(r.
Caries
Càdes is a most commor cârÈe of lracteria]prolocation
of the pu1p. In ûe Processof destroying the tooû siru.
hrre, a lariety of subsianccs arc produccd that cvokc
nrîaùmaiory hsnns. Mosi oficn ilt pulp is ablc h)
slrsiàin tlle irritation, especialy rlhen cad€s is.onfiied
to pfimàrr dentine onh,: By contràst, once into '€pârâ
ftc dùiùt or rhe pulp tissue propea severe inflamma-
torv involvcmcnl usually emerges (69, 45) thât may
jeopàrdize the continued \-itÂl f!nction of the tissLre.
Caries is defined às ,,lrldi ffner às long às the process
has not rcsûlte.l jn macroscopic destuùction ot the
en.mel (cavitâtion). h reuliqr dentine is often imoh'ed
eârl"v on, in spite of the fâct thâi the lesioi mâv b€
CoDscqucnil)r the pr p becom€s àlerted nfd pronrptecl
to rcspond b cari.s at a lery eàr\' phâse (l'1, 16, a5).
Thc progrcssnD of câries iends to be intemrittent,
vith peûods of rapid dcstruction inierchânge.l ù'ith
pcrbds whcrc caries advaLes at d slolv pâce. Some
times it mây be stopped temporâril]' or perùancntly
(arrested .âries; Fig. 3.17). Thc character of ùe càries
lesion in thcsc rcspccts influences the .tegree of pulpal
jnfl amùratory inrdvcmcnt.
Pùpal rcsponses to cdries .onfined to
Gn en the n.itùre of the ctrfious process, inflamrnai)rv
tissûe changesâs well âs repair phefomenà cân b€ secn
il1 th€ pulp nt dll stages of ân âcfie lesion. Thc cxicnt
of the response depcnds on thc quanLi\' of bâcteiâl
iûitants thai rcach tlÈ pulp ât a gi\ en point. lt is àLsoà
funciidl of distare. C.,nseqùent1y,$'hile still in the
pefiphefi., bacieria s'ill rdcasc substaices that s,ill hà\'e
to travel much fufther than in a lcsidl closc b thc pulp.
H o s . \ - . \ e d i - r, a . , , , 1 ^ i . e , r r , l \ ' f ' * . , "
nificance lvhen reâcti\.eprocesscsin tcrns ol nrlatubu
lar mineràtizâtion (de,ltirdl s.le,îsts) ha\-e emcrgcd.
 Ihe denllnepulpcoffplex:responses
to âdveneinfuences 33

Fiq,1.17 Cliricâlphorographdemonsrratlng
extensve cariesln the (efri
.a regonof a lowef.ânne Pàrtollhe leson5eems to be arcsted,aslndi
catedbythe pgmènted,earheÊlke appêarànce
at tlre bu.cala5pec(Ai ihe
nesa 5urfacetherek p âqûeâc.ùmulaton andrhêleson is sonto probinq,

D? titrtl scle1osis
In relativcly deep carious Lesions the.lentine t11ay
bccomehvpefmjnerâlized \,vithir1a limitcd arca pulpallv
toihe âdvancing dennneralizainn froni, including âreâs
within ihe zone of denineraiizatun (Iig. 3-18).Depend
ing on th€ siz€ ând rate of pcnctration of the câfies
lesion, the formation of denlinal sclerosis can be
explained in tlre followfig marorr: thc transmission of
bactcrial irritânts tàkes pl;rce (;n iritial cades) dùough
the demineÊlized prccavitaled enamel ând m.ry caùse Fig.3.13 (a) cênlra pàrtoJàn à.lve.àfiÈs esionn à môlar(b) tMi.m
6dôgrâph shôwsradiopà.rieswilhn the deminera izeddentine,wh.rr,
. l , , l p d l e . l u r - l f l ' . 1 1 . , J p r r r ' ' - " e r o . i -. \ ê .
toward,the pulpânped, k bùdûed by a rimo{ hypermiûêrâlizêd
dèntlne.
belbre evidence of mhcral loss in dentine. Conse (coùnesyof Dl L.Bjomdàlwithpùm$ion olcdies Raed.h, Karger)
quently, hvpcninerâlizâtion mÀy be ân efiect of
enh.Ncd $owth of peritubuLârdentine (14),which nay
continuc in particulà r on slolvl,vprogl€ssing caies. Such
derltinc recei\.es a tftrnsparent and glass-Likc appcar- alizâtions continue to be dissoh.ed and nes. prccipitâtes
ancc. Ar leâst temporÀrjl)', .lentinal scl.rosis may block m â v d p p e â r i n t u b u l e se v e n c l o s e rt o t h e p u l p . I l e n c e ,
Lrr redùcc the permeâbiliq of the nrvohed cleniine to a carics lcsion in dentine is a dynamic process thal
illclù.tes e\ el1tsof breakdown and rcmineralization n1
At a ceftin point cludng nlitial caics, ùe enamel a.ill differcnt pârts of the tooth structure \r'her€ cârjes 1s
bc deminer.lized throrlgh the entirc ùaùel layer thick' a c t i v e( 7 2 )( F i g .3 . l 8 ) .
ness and the imtial dcrtfial sclerosisi{ill be dissolved. Dentinâl sclerosis can âlso occùr iI1 the abseice of
The pâttem of sclcrosis irom this point 'it1 inchcle câdes.Itis a coùmoD changc associaicdlviih agcfig and
reprecipiiatior of crystals of vâriolrs lb.ms ànd com delelops succcssivcly in a coronal dircction from thc
position of hldrox),apaLite ùr the c.rries proc€ss. Upon apical rcgion of thc botb asindniduals groiv oldcr (56).
lr rrh' | ..d\.'n', -' nr of ll F . r|e. p'^. ê.- hr.- *iJl.l Itmay also dcvelop al thc peripheral ends oi ihe tubules
34 Thev tal pulp
subs€quent to their orâl exposure by âbfasion and
cervicâl erosion. After a p€riod of time, minertrl salts
âfe deposited, $/hich will l€duce ûe sensiti\ ity of the
Mechanisns and nnture of the p lpsl rcsponse
It is importânt to understand thât, âheady dùû19 its
initiâl penetràtion of deîtnre, câries e\-okes inflâmma
tory rcsporÉcs in ihc pulp long before bacleria in ùc
câri€s process lÉvc rcachcd thc pulp. Sùpport for ihs
!ie$, has bc.r gaincd from cxpcdmcntal studics in
humans and animals where known conponents ofbâc'
teriâ in denial plaque rvere topicâlly Âpplied to freshly
c u t d e n t i n e( 1 0 , 7 ) .W i t h i n h o u f s ,â n d i n a s s o c i a t i o bn ' i t h
the pulp.l ends of the challenged dentnr€, trn acute
inflammatory r€sponse developed in the pùlp. Th€s€
experimenis suggest th.t dentinàl tublles in.lee.i .re
perùeabl€ to bacterial clcmcnis ùd supporr thc vrcw
thât elen a small cades lesion when just penetràting
the enamel is able to provoke ân hîàmmàiory pulpâ1
lesion (16). In this aspect, however, it should be men
tioned that thc pùlpal rcsponsc, inclùdhg clùngcs in tlr
odonnrblasi-prcdentine region, hâs sholvn a ùore pro-
nounccd paitcmin active hitial caries lesions comparcd
r.ith similarlv sized slobl,\r progressing lesions, hereby
indicatjng the r€versible nâtrre of the eafly pulpâl
During growth and cell deâth of micro orgânisms in
the câries process,elements ar€ llberâteclthÂt m,rv initi
are pulpal rcsponses by different mechânjsms. These
( 1 ) R e l e â s €o f i n f l a m m a t o r y m e d j a t o r s f f o m p u l p â l
cells, including odontoblasts (pfostâglandins,
leukotrienes ând prcinflanmatory ci,tokin€s).
(2) Irenetr.tion of bâcterial .omponents, whjch act as
I r ' r " . . 'r I r , r . \ ô P J r i m L r e n . p . r . p
Thc fi$i cclls b cncounlcr the bact€rial châllen8e arc
the periphcrally locatcd odontotrlasis and dùdriiic
cclls. Both arc capable of activaling â varielv of efiecior
c e l l so f i n n â t eâ n d specitic i m m u n
dendfitic cells, aftef obtainLng pfoteh fragmefts, É'ill
- e o pÈ^,,|\'pl-.,.lF- 'lJ illi'..r t',nd,\
il]rlmune fespons€upon $,hich there \,yil be recruitment
of Àntigen specific T cells (seeFig. 3.12).
N e u t r o p h i l s û - i l l n o t n o f l r a l l , v i n Ê i l t r â t et h € p u l p
durng carl]' dcniinal carics. tnstead, the infiltratc is
most ofien conRrosed of macrophagcs, T-cclls a1d
plâsnà cells. These moDonuclear ccll hliltratcs cal be
se€n cithcr in clustcrs or dispersed in the pulp tissue
propcr underne.lth the caries lesion.
^lso, ihe number of Class Il molecule expressingcells
is nlcrcased (37), represented by an accumulation ot
dendritic cells and Class II 1noleculeexpressing
A
à
"â
i.
Fis.3.19 k) Numqosc6s mo{u ê expre$ins G s GÎaned bown)
accumu à superfi.
atedundernearh à1.àresLesion,
exrend
nginrôrhêdêôtne
ora hùmànrooth(dark upps 9hi).(b)Extemion
stâin, ofdmdrtei intolhe
tubues.(Coutesy
of Drr 0kji)
macrophagcs (Fig. 3.19). Thesc cells pâlticipate in the
secondàrv immlrne responsc takinE placc fi the pr p
and âre likely to enhânce the defense capaciiy of tlt
Although the inflalnmâtorf reâction may bc pro-
l]ol'nce.l on râpidlv prog!€ssing câries in a yount ttxfll
rvher€ the distânce to the pulp is shori, ii is lcss disLin.t
in a maLurc tooù ùhere câdes is progressnrg sloi{l}'
(Fig.3.20).In fâct, in the 1âtterth€ i.flammatory àctivity
is limited and sometim€s the only e\.idence oi bâcterial
irriiati{)n is thc cmcrgcncc of â smâ1l rim of repafâtive
denline (13). Thc nunbcr of Class II nole.ule express
ing cells is also decrcascd,suggesting that the inflùx of
infl.mmâtogenic substanccsin ihcsc lcsions is r€duced
or inhibited (37).The fà.tthat the tjssue changc b.cones
so limited is likely to bc cxplaincd by the preliousl!
dcscdbed reactive prccessestÂlifg place in.lentine. The
formation of fepàfâti\-e dentine also coniributcs to a
fed!ction of dentine pefmeabili[. Yci, in thc pcriphery
of th€ caries lesion where nei{ dentinal tubulcs trccome
i t y .T h e h i g h l v j n o t i l e ù\'o1ved, inflammàto{'/i inùnologjc.l responsesand
subsequent repâir phenomellâ conthue to emefge.
In teeth vl]1erecaies hâs pros'€ssed at a slo$' pàce,
pulps display nrreased {ibrosis àt the expense of the
ncnous and vascùlar supply. Intrâpùlpa1 nrin€râlizà
tions also may develop. Thus, tissue chânges of this
nâtûrc renderthepulp tissue less celllllar and t.ss rcsNt-
ânt to iterâtec1injulv
Respo se to deep cari$
Once th€ câries leslon r.ith its bâcteùll ironl has pcrlc-
tràted the prim.rry deftine and âd\.ânced to reparativc
.lFr.irednd ,'r lo \e pr t ,i--Jef-ôp.- ., In'-."
mobilization of the inflâDmatofy fesponse will tâke
 | " d"1 F pJtp o nprp.:r.po .! roàd\ê.ê fJ" ."( 35

Fig.3.20 (a) M crophôlôgraph qvnq overuiewof à sowly pro

qresng câriou,lÈsônwiih a tota arræ. breàkdoM (b) Mi(o
Édiographc vlev/shôwsttrbularreparàrvcdenrinÊn the adia@nt
pup. k) Pupa tiiae is lee oT nflammarory
nfhràtcs.(cordesyol

Advanced
concept 3.4 Nitricoxidein thepulpal
response
to a carious
exposure
n a(ut€pulpalinTammatory eslorothefornral on oTn lric oxde
(N0)s dramatkally n(eased (46)Endotox nslromGranrneqatve
bacteria andq,tokines, suchasintereukn 1,tumornecrosi5lôc1or
and ntederon ganrnra, âfetypicalactlvâtoE triqqeflnq a fapidpfo
d ù i o o f \ 0 p o d | | q - , , È ? d . T i 5 o . .. b o t 1 - . n "
ce s ând n vâs.ùârendothe um n arêâscloseto ândâroundan
nflàmmatory slte{55)Althouglr thefun.tonalmportance of this
nrassive andlonqlanlnqN0 Iornrâtion hasnot beenspêcfkây
âddre$ed fôr thepup, N0 s regarded âçâ .entrâcômponent in
r'rJ """ ,, n,"f"dd" | ? g n"drql ool
qanisms Hence, N0canincrcale theb aodf orvandreôxthedrêin
F i g . 3 . 2 1H n o l o q i .sae d o no f a p u ps p em
. e nd e m o n i r â t l nnl il .âr ô n9 vessos, thefeby suppon nq appropriate oufow êndpressure
âb5.esà$o.iared wirha care5expo5u e.Notethâttheremanderol the a d j u s 1 m ê n t (ô1ar d
) .d l t a n
N 0n â ye x e rât n tb â . i ê r iâa.l tv i t ya n d
pùp shows a lairlynormààppeùarce (Counsy of DrNola tutrrn.) hasaninhibiloryetfecton nÊuirophinfiftration n theâcutephâse
oI nTlammâton {44) n fac1, the flnaldestruction of mûaôrg:n
n p L d q o, / e d b , n d r o p d 9 " dFro',J0 o.ihôôrl ' t
c es p r o d u G
largae n o u n tosf N 0 I h 6 , N 0m a ys s n r m o d i y
pLa.e(.t9, .r5) {Fig. 3.21).A ùost conspicuous fcahlrc is nqth€a.uteinlêhmàtôfy rêspônsê
th! aggrcgalion of neutrofhils. allten n Loc,rl.rbscessLàs Ex.e$or Nq â thorghbeneri.iê|, mayàlsoprovdedenrudve
d c v c l o p c d ( I i g . 3 . 2 2 ) . C l i n j c â l h t L ] p o f € x c . r r n t i o no f effe.tsft .àn reacrwithrreeoxygen rada s produced duringthe
caics, a droplet of fus rnâv sofietimes tlpp€àr tfLrn the nflàmmalory pro.essto formtheitabe peroxynitrle P€roxynitrle
s â çirongoxidant thâl .auses t$ue njury(5).Th6,a thorgh N0
Althougr shot 1iled hân acutc inl-lammabry lcsnù, suppons thedefenre rerfoNein modefate tissùeinlammêt on, n
neutrophils rele.rsetissue destrùctivc clcmcnts, irrlud- severe rea.tions su.hasthat uponGrè5 exposure of the pup t
ifg oxi'g€n ràdic.rls, hsosomal cDzvncs and cx.es' maybe.ome averey toxi.ênd.ontrbuteto thebr€êkdown ot the
sive I olrnts of nir*ic ondc. Collcctilclv ihcsc aBents
contribùte to degrâ.l.tior1 of thc pr pal tissuc (scc
,A.dvarcd con.cpt l.,l). There rvill nlso be ren€l\e.l
à1rctfitense imrunoloEical aclivit),, às expressedbr ân l n f l . m n a t o r y r c s p o n s e ,t h e t u l p m â ! r e t â r n \ 1 1 . r 1
âc.lûnulâtion of Class II molcclrle expressing cells functions ior â period of time, àlthough sunr\.al rs
(dcndriii..ells ând mac,.ophÀges)(37).Collecti\'€\, this
ncans ih.t the micrcbiâl loaclon the pulp has rncrcaser:r
dramatically and the vit.l fùnctions of ûe pr p at this N I u ro7.1
n sc1t I a r cr e1I t s
staEcare clearly threatefed (Fig. 3.22).Nevertlrless, nl Besides the accunulation of neutrophils anLi irnmuno
spite oi th€ ff.ssi\'€ bâctedal attack and thc inicnsc compctcnt cclls ncar thc ca cs lcsion, llt hflarnmabr\'
 in the pulpto
coreconcept3.3 Tissuechanges
canes
Câ es confinedto dentine
. Drng itscourse towards thepulp,caie!comphtely delroys
dentine and1Ênsforms it intoê mushymâ$ of decomposed
tissue containing anâbundânce of bacterialelements thatcan
prolokenflammatory changes r thepulp.Yet, owingto reâc-
tive processes in dentine(dentinâlscerosis)and derense
responses ot the pup,the vila functions of the tissueare
s d o l É n d à n g q aê sdl o . Sd 5 . d e , i ' , o n r ê d r o o r n d 1

. Theinfammalory andmedium-
nlovem€ntwith superticial
deepGriesin dentlneisnormay limited
to thesupefcalpor
tionsof the pup. Infammatorycelh,primêrlly
mononudear
leukocytes(macrophaqes,
plasmacelhândT{elh),infltratethe
sigNof repair(e.9.thelorma
ussuebuito â limiteddegrce.
tlonof reparative
dentine)ùe often,butnotalwaytâ prom

. ôr p in reerhûlL ong d di_q d,d/o, \lowlyp ogP$i 9

cariesmaydisplay fibrosirredu.ed
increased neruousand
vas
culârsupplyandintrapulpal
mineralizztions.

. Nerrto lbebacterial
frontth€resacc0nulâllon
ofneutrophils
andtssuedelrucnon.
. Inadjoiningarcasthereisl
mmune ce â.livâtion ând aomuktion of

- contain
branchingand sproutinqol neuropepiide ng

inteNevaKularadivty and localized

lncreased
tissue

ofthepulpmaydevelop
Tolalnecross aftera periodoi time.

In the process, severe painJul sympbms mây or l,Ilay

not appear (seeChâpier 4). Tlrc locally increased tissue
plessurc as a rcsûlt of vascular leakage mây lead to
Fig.3.22 (a)Radogrâph showing a deep,mesio leslonthat siasisand local ischemia, thus contriblrting to ihe skof
o.clusalcaries
hæâdvancd lo lhepulpin a lowermolarHiçto olJkaexamnation of the
pulpin lheerûadedtoothrevea s pârtalpupalbreakdown at lhebreak' Thc previous âssumption that incr€âsedpulpal iissuc
throu!,h
oflhe.aries (b)lireapicalpulp
leslon. displays
a normalappedamq pressure as a dominânt fâctor would compress thin-
(c)Anintenieinflamnatorylniilrateextendsintotheorif(eof lhemesia
in a drâmatrc
@ol@na.(d)rhepupti5$ of thedistalrootcanalshows esslêuko.yre walled veins in a vicious circle re$ifing
inlitrarioô
wilhan iôràdodontoblàst.ell layer(Côurtesy
oI Dr Domenico rcduciion of pulpâ1 blood flos' ând possibl)' pùlpal
necrosis (strângulâtion theor]') is misleadnlg and has
found no support in rcccni literature (67). Thus, ihe
clearânce of excess fluid and prot€ins via blood and
resporÉe âlso fivolvcs cxtcnsive neùiolasftlâr rcâ.- lymph vessels (28) in the vicinjty of the rcaciion zone, âs
iioff. Thcse rcsponses consisi of brmchfig and descdbed âbove, gives the pulp relief and mai' allos, it
sprouring of neuropeptide-.ontaining ncrvc tcrlrÙals, to surlne for â pedod of time.
incrcased pulpat bhod flos', increased vascular perane- A sûnmâry of the tissue changes rr rhe pùlp as a
abilitv ând exliâvasâtion of fluid and plasma proieins. rcsporoe to câries can be found in Core concepl3.3.

Fig.3.23 MicrophotogÊph ôl â pùp pôyp dlend ng nom the pùp ôf â
youngtoorhbrokêndôwôbycâries. Norerhedensoinlammarory nliltateiô
lhe prolilerallng
lissuè.(Courtesyot
ù DorêncoRkù(j.)
Responseof the periapicûl tiss e
Theinflarnmatoryresponseof the pulp to ân openexpo
sure bv cades is often confined to the site of break
through, r?iih the àpicàl portion of the pûlp remàining
non inîâmed. The lesion in certain casesmây be exten
siv€ âJrtdinvolve the periâpical tissue âdjâcent to apicâl
forâminâ.Thesechangesinclude mobilizâtionof APCS
(60),cdcma formaiion ùd somebone resorplior! ('hich
mat' be visible radbgraphically (Clùpiers 9 md 15).
When the pulp chÂmlreris $'ide, Âsin young individu'
als,cariesmay initiateâ proliferativeresponseand câuse
what is termedâ ,rlp polyp(Fig.3.23).A prerequisiteis
thât the roof of the plrlpâl châmber has been tota y
destroyed.The tissueproliferationis ân expresslonof
ihc rcparati\-c phaseof the pulpal responseand is madc
possible by ihe fact thât the process no longer occùrs
within à close.l system. Subseqrcntlt pulpâl polyps
mal' becone epithellâlized upon mâkhg contact $'ith
the gil1gival tissuc.
Dentaltreatmentprocedures
The primâry objective of dentâl treatnent pfocedures is
to climinaie inJectious a8ents in the healment ol cancs
and pedodontal disease and io restol€ tooth function
and aesthetics, bùt these procedures cân seLdo be
carried out 'ithout causing pulpal injury. In the short
tefm, most irritâtion occurling in ihis context is sustâin
âb1eby the pùlp. It is only follolring advanced disease
ând the ûse of too damaging or nùppropriatc proce-
dûres i]Ét the Ijsk of severe nlury is immineni.
Common ilNats to ihe pulp relate io:
dentln€ pulp cornplex:responses to adve6einfuences
llllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllre 37
. Thc damagé nûicted in conjunction with the use of
rotary instruments.
. Leakageofbacieriâl elemenis from ihe oral environ-
ment along margins of resioratioN that show poor
âdâptation to the remaining tooth siructure.
. Toxic effects of medicamenis and componcnts of
màteriâ ls ù sed to restore câviiies and cement crowns
It is feasonâbleto âssumethai prcparaiion hâumas,bac
terial influences and maierial ioxicities in combhation
câuse a cumulâtive effect and are thus mora deLrimental
to the pûlp than eâch of these factors alone (br.
Prcpantion tu.u!rul
A cutting pfocedure b)i roiary instrlnolis will ûot nor-
mâlly cause damage io ihc cxicnt dùt ihe vital function
of thc pulp is jeopârdized. Prepârâtio'1for restorâtion
closeto the pulp mat howe\.er,generâtesubstùtial ftc-
tional heat to cause â significani and dctimmtal tem-
perâturc incr€asein the pulp. Repairwill usùaly cnsue,
but the fornation of reparative dentine can be extensrve
ald rcnder the pulp vulrcrâb1e to repeated injury. tn
fa.i, clinical Iollow-ups of teeth restored with câst
resrorations (tul] crowns ând teeth included as abut
ments in bidgeworks) have sholvn ûat pulpal necrosis
may occù with a Iaequencyof 10 15% over a period of
r10 yeârs (E). Often one will find thât the .oronal
portion ofthe pulp in such teeth is obliicratedby repar
J,i\e Jenl'r e Jl nB cnd d.'nh l\rrap! prrdnous
Another complicâtjon to caviiy and crosn prcparâ-
tion is internâl bleeding. ln rarc casesit may be so exten-
sive thât pûlpa1necrosis occurs âlrnost instanrâneously
The iooth structure of such teeth mÂv tufn red and laler
l , r. p i l e o I . L , b - r . i r l e [ f o 1 ,ô \ e r l f e ! , J r - l J D , . r ù \ '
restorative materials, including rcsin composites, and
the techniques for their use, the shnnkage of these mat-
edâls âfter setting is criticâl (75,21).Shfinkage builds ùp
strains irl *È filling thât lâter may result jn gaps ât the
tooth/restoration interfâce.This may auow bactena ând
bactcrial clements in the orâ1 environment to affect the
pulp. The icrm ùr.t./irl /crftdgcis used io imply this form
of pulpal irritâtion.
Reseârchin recentyeârs hâs indeed demonstrated ihai
bactefial leakagein resroration margfis is a mâjor threat
to the vital functions of ihe pulp sùbsequent to 1esio1â
tive therapies (8, 67). In particulâr on deep and exten-
si! e exposûresof dentine, the infectious load on the pulp
c be subst.ntiâl (Fig. 3.24).
In pùlcip1e, the inflâmmatory events of the pulp in
rcsponsc to thesebacterial exposùresar€ similâr to those
38

Keyliteratufe3.1
Lundyandsranhy(51),in ân exp€rimenral studyln lruman!, pre
paredsmaLbutdeepdenlin€ GvitksinteethrheduhdTorextcc
tion Thecavtes wereeft unrestor€d to thearâ environfirent for
vùous periodsoI tme to observe and corr€âtepup tÈsue
resporoes to thedeqree ot o(u nq pâinfûlsymptoms. Theintal
respôBe ôf ihe pup afterI 2 days.onsÈted oJseverent trates
of neutrophils. Fowever at subsequent obseruatons therewasno
breakdown olthe pulpseveniTlhe remaninqdentnewâ tothe
p u l p w a s t h jnns. t e a d , r e d u c e d l n T L a m m a t o n a n d e v d e n c e o r r e p a i
wereæenas earyas 9 daysaflerdentine exposufe. Weeks ênd
months afterllre inliaton oI ora expofure, nonralpupatslue
àndthe formation oJr€paEtvedentin€wereFen ln tlre krqe
m a j o r i toyl s p € c m e n ' 0 nt e s t n gI o r l e n s l i v q l,e e t hb e c a m e
inoesinglypainiulover theIirnlew daysThese synrptoms subse
quently ibsded, a on! wlthrecovery ofthepulpFindlnqs.onfirm
the pôtentiâôI the pulpto wihlând bacterial .hâ engeslvhen
thereisst a wa of dentneseparatin! tre pulpfromtre oralenvi
Fig.3.24 Incontradonqâpsor altern.ompele coveraleoî dentiùe
lo ronnentBothreduced or b ocked denline pernêâbltyând nflam
lowlng procedures,
renoràtive baderaleements n theoralcavilrmaygaf maroryand rnnrunoloqlca respoNes n the pulparem{hansms
ac(e$topulpalonqthe
exposed
dentina tubues.Thiss fegarded
asa seirous thal de kelylo mpede furtherbacter êl irttaton.Expeflments in
tothepup be(ause
threat lmayindu@parlu symptons aM inTanmârory bothhumatrandprimates empoyngchaenges ofcarousdentine
or a minureoJbadsa products corroborate thele{indinqs (48,
84)

det.iled for càries, L11ltthere àr€ some distinct diffe1

cnccs. Neutrophils plâl an impodant rcle in the initiàl
responsesowing to tlt rnorc sùddcn and cxlcnsivc bac-
t€rial €xpos11l€thâI1 that in ihe relatilcly sldlly pro
;'...S,..:.. 1....rtr.-... l'...| .r',. r'.r'
of the pùlp that corrcspond to ihe involved dcniinal
iubùlcs. Chcùrciaciic stimuli also prompt neutrophils to
nigraic inio thc ûbules. l h is is p robâbl,vthe most sign i
ficalt dcfcnsc iacior ihat, in addition to the protective
cffects of the dentinâl fluid (des.ribed âLrove),helps to
block fùrihcr pcnetration of bâcteriâ ànd bàcteriâl ele
_" , | u . \ r l r l l a u l l . . l \ .1 . l " -
likel,v to explain i{h} pùlp.rl repair ifd heâlirig.ire stjll
possible even s.hen â restoratio. .1oesnot comFletely
s e â l j l s m à r g i n ( i j , K € v l j t € f a t u f e3 . 1 ) .
Co,ltrârl to câdes, occlusion of dcntfial tubulcs bv
Dinerùl deposits sel.lom occrDs undcnrath fillings.
T\.,1,r.h.r r. -J|'L.l.Jl\ ,,,
permeâble and scnsiiivc ùnlcss rcparaiivc dentrnc has
becn forncd in thc pulp.
Toai. elTe.ts o1 rcstonttizJe niteriils
In additjon ro the trdumà ironr preparing t€eth for
rcstoratiù and the subsequent leàkage of bactefi.l ele
ments, constitu€nts ot r€storâtivemâteriâls màl, ha\e à1
.dverse influence on the pu1p. For Diany years tnc toxr
citv ot restor.rti\ e mâteriâls \{as ft'gardcd as ihc maior
. r-eJl .,J.. .. p rlp, tu,.. r, r.lu. h\. p J .
durcs. Horv.vcr, rcs.arch in recent leàrs his shown
ihat, contrarv to prelious beliets, toxi. coûfonents in
rcstorâLi\e materiàls àre â lesser thrent to tre flilp th.n
prcvn)usljr anticipatcd (8). This has been best .temon
straied in erperimcnlal siudics rvhrc d.ntal matedals
| -.19. m /r . pl .' pl,,.' . .. I
resin composites)rvcre applicd dirccil)' on pulpal tissue
nn.l Nhere the surface oi ihe resloration a,as scalcd
bàcterial tight (19,2{)).thescexpclirnollsdcmonshatc.l
11ùl dr Pr p around s.aled restorations often resuûed
â h€.ltlry st,rte,bùt $.itho!t â bacterial tight surlâce seal
the Lrdct€riar.ere presemtàt the pulp/fesh)ratLon ntcr-
fâ.e and selere lrflamm,rtion deleloped in lhe pulp.
Thc dsk of selere pùlpâl complication is even less
wllcn a dùûr banier remâins. Dentin€ seemsto s€Fre
.1 , .1 asadcb fyfig tissuc,in that higld) to\icmât€riatsnrav
bc aLrsorbcdk) thc inncr walls of the dentinâl hrbl es
(3(l). lt h.rs been sho\ln also that dcntine brffers the
cffccls of acids and bases (31).It needs io b€ recogrliTed
thêt erpeliments t, .ltf. (32) â.d nr .ir. have .lemon-
strnted thât cytotoxi. components of rcsin monom.rs
tfieth,vlene gl\-.ol dimeihacrvlaic lTlcDlvll\) and 2-
h) droxfeth)'l m€th,rcrylâte (H!MA) readilv penelraie
tNn dcntine rvalls ùpon toFicàl apFlicâtjon. The efieciot
such lcakage is not '!e1l unclerstood.Ho evea obs€^.a
60rù fi anmah suggest that ihe toxi. efect on the plrlp
 Ihe dentife pu p complexi to adveEeinl u€nces
responses 39

Core(on(epL1.4 Pulpàlresponse to bà(teridl

leakaoe
at tooth/restoration
interfaces
Leâkaqeofbacteria a pfoducts
andbacler n toolh/resloiêiion
interfa@s
induces
infêmmatary ln lhe pulpacroes
esions thê

Athough theseresponse!donotnôrmây eâdto pûpa break

down,lhey maycause panrulsymptoms andpulpal(a6
C niciànsârêcautoned noito leâvedentine
expo5uresLrnpro
tecredorwlthpooryllitedrertoratons.
Ihûe is a vaî dinùen@in the lnïe.tio6loadon the pulp
whenâ ârgeareaoTden!neis uncovered, e.q.nafullcrown
prepârêuon incomparsontoa emalland preFa
shallowcavity
raton.Fence, on !uchexposuresprotectve arepar
nreasures
Fig.3.25 Sèiles ol radiographs a lurationnjuryat
ofâ tooththatsuffered
â youngâgeUard tirsue
issu..esslvey deposlted
n tlrepulp.Arow nd.àles
chânge r stalusbelween the15.year Iolowupradogràphs.
and2o-year n
lheradlographtotheriqhra pÈrlàpi.al.àdio
ù.en.ysseen,suggening pùpà
(ftomRobertçôn
nfe.rion. el r. 00) wilh pùmsionoTthe,rouûar or

of these .gents ls short lâsting. It hrs been sho\^.n,f!f

lFrro_p tl.l mo.l l.."l.bl. -rb.t,r'F. Jî re-.
compositesàre leleâsed v'ithh ihe tust few davs after
plâcementand tltn litilc s,ill bc dischargcd (22).Thcrc-
fore, thc thrcat to thc pulp in conjunction wil:ll rcsbra-
tne proccdurcs docs noi seen lo be as mùch rclatcd nl
ihemateriâls pers. âs it is to the impfopef seâlthatoften
results (Corc conccpt 3.,1).
Dentaltrauma
Tr.umatic injurjes to teeth include fractures an.l luxÂ
tions or.omtrinâtions of fiactures and 1uxâtions (2).
Luxâtion is an iûùry $4Ére t]1e t(!th has bccn lmsencd
trom its àheolùs. Luxation may or may not bc associ
ated with varioùs dcgrccs of dislocaûr1. A traumatic
r:njury,rcgardlcss of whcthcr tlrcrc is loss of iûrth stluc-
ture, 'rày hâle sedous implicatioDs for drc \'ital fulc
lions of rhe pulp both in the shoft ând the long term.
Mosi siFificant is whether or not the nelùo\-ascular
\upply of thc tissuc has bccome sc\-e.ed.Thcrc arc ttro
mechanjsms for sùch an jnjurvl
(1) Thc hauùa nay havc rcsr tcd in scvcrc ntcnal
blccding duc to rupture of lùc larger blood vcsscls
sùpplring ihe pulp. The bleeding reàctjon, ii erten-
si\-e,malr càuse the brcâkdonm of the entlfe tissue
sithjn a rcry shorl pcriod oi time.
(2) Separâtion of t]È tooih hom the alveolus follos,ing
dislocâtion nray hâve s€\.er€.ithe blood vesselsand
the nerves at the apicalfordrnen to d compl€te ces
sation of th€ nuhitionâ1 pply of the pùlp. Nùtri
i u n I ' o m r o i r , m L . \ I ' r r r . .l rpn-.' r
in conjunction s,iih inhusnrn injurr: If thc bknd
supplt is not restorcd, thcsc coùplications ùa!
rcsul l in sù.ccssivc dcgradâtion .,f the pulpâl tissue
by aun)l,vsis.
Alollg cràcks n1 the enânel (innâctions) of âlong
direct exposuresof dentine, bà.teriâ may sooncr or latcr
a.ccss ih. nccrotic iissù. d infcct it (6). Phagocltosis
and rcplaccmcnt of ùe necrotic tissue jn the pulpàl
chambd $,iih cofiecti\'e iissùe hom th€ pefiodontâl
tissue is possiblc onll if thcrc is a wide apicâl t'or.rmen
in . young tooth (8a, 4). Olhen{isc, rl.crotic tissue will
remâin âseptic until becoùing inicci.d.
ln teeth suffering a Iracillrc, r'hcthù limiicd to the
cro\an or extensive ând involvlng ihe pulpal tissuc,
p!lpâl necrosisis â much less conmon outcomc than rn
a luxatcd iNlh (2, 3). Pulp ùost often surviv€s afLl
renains vital e\'en though the loss of tooth slruciurc
mar- àllorv the oral mlcrcbiot. to âf{ect ihe pr pal iissuc
se.ondâd\r The r€sponsepatt€nr to the microbial chal-
lcngc is sinilar to ihât âssociàtecllvith cilrjes nnd dentâl
proccdllrcs and shall not lre detâi1e.l fùrther.
LuxatidÉ may cause a temporârv ischeûic injûry to
r r p u f l l . l d , ' - " i r . ' , - . r i \ l ê â dr , n . , . . i -
llowever, sùch ân intury may trigg.r pr pal cells to
rîspond Niih an acccl€rated hârd tissue deFosition,
lea.ting t., rnore oi less conrplete obliteràtion ol lhe
Fulpdl chamber (3a).This type ofprLlp.ll rcacLionis par-
ticu tuly common in trâunlatiz€d leeth oi young fidi-
lidLrals (Fig.3.2s). Over a perlod of ls 20 years âbol,i
209" of thcsc tceth na) dele1oP pùlpal necrosis an d root
canal infcction, as fidicat€.t by the appeâf.nce ol n peri
apical lcsn,n (34, 70).
40
Coreconcept3.5 Pulpalresponse
to traumâ
. Traumatk injuries
to teethmayresutin bothimmediate and
lateeffedsonthepulp.
. lf pulpsurvives
the tfauma,inlammalory responses
develop
dueto the tissu€danageindu@d anddue10anymcrcbial
iûtanBthalaccessed thepulpsubsequently.
. h.hemkinjurymâydevelop in the pup dueto moreor les
extensiveinternalbhedngor ruptureof the neurôvas.ulêr
supplyai th€ apex.lïis compkationmay ead lo pupal
. ispossible
R€pair inyoungteethwithopenapices.Suchfepêir
frcquently
is accompaniedby hardtissuerepair,
resulting
in
moreor lesscompete olthe pulpâchâmber
obliteration
For a summaryof the pulpal responseto hâûmâ,see
Core concept3.5.
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Y
ii Thedentin€p! p compex:fesponses
to adve6einl uenc€s 41

li 2l H.ycra.s KI. Pulpal hennrdynani.s àûd iûtcrstiti.l 11,,ù axôtàlsprorLtnr8.

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i
i
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'faintor
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O r û l B 1 o lM
Th. p.t.ûttdl hù.ùtu]sfot th. ptlttt|r rsiiry a,ûpa'tr n\11
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n i r l . 1 9 9 6 , . 1 1l l:2 1 3 1 .
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S.i. 115,.1
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LN' r\, Baù'ngàr.1nerK, \'1.ll.r 5, GelùartG Lo.àtrz.tro.
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era.r' d l. .r'' ..- 1".'rl\ '' . p i,l ' i
àtcd s'lrn woun.l heàlùg. Ëqr M,l P,tlDl. 1985;.13:271
48. Lcn il< f, illjin lA. !!à11û tjon oI lechnntuesfor the rnd !.
iion 01 tuLpltis.I Biol. Êt.. 1977i4: L311.1A.
49. Lci'in GR, lvietulell LNI. Ncrvc SrNlh la.tor ànd noci
cepln)n. ?,"rrs N.rD..i. 1993;16 353 9.
Lindsà! R\4,l.ockert c, sternbergJ, Wi'rt.f I. NÊùropep
tid. .ap.essnrn in .ult!rcs ôi a.h t sensory .curcns:
modùlaùù oi substôfcc P ân.l calcituùr gcnc{.late.1
teptid€ LevelslJi ncrvc goçth factor Nt!f.s.(,.. Lqii9;
33:s}art.
5 1 . I-!nd_rT, olpulpâlhstopaùologl
st nLeyH. Coûclnlion
.nd clinicâl slnptorns in l,umân reelh Nbje.t.d to crPe.
mùtal iûtâtion. Od s,ri. 1969;27: 187 201.
52 I-uthman J, Luthmm D, TJôllelt l O.curret.. and disL
butnD of.lifferenl ncuro.nemical mârle.s ir) tlrc hunan
.lentdl pûlp. lr.l Otul Bi.t 1992,37i 193 208
5 t . Mâtt|ea s E, Vongs.lan \. I.r€mctions betl!.cf n.,'ril
.'r'd \'| d , oull
Ar./r O/rl !iol. 1991,39 (Suppl.): E7S 95S.
5.1. Meler NIt{. Pulpal bL(n)d flôù,: tsc oI ra.iio labelled
nricn)spheres.Lt. Ërl.L'1. I te93i 26: 6 J
55. Moncada S, Palmcr RI4, Higgs !4. Nitri. oaide: Phvsnn
ogy pathophJislolo$t an.l fhalft.ologir P/r,,,,ft'/. &.
| 9 9 1 ; . 1 31: 0 9- 1 2 ,
\ . , t o . , . t, | . o r -.| . . , o .ê . I q . l F . , r i. ,, ,
changes in root denrin€ of hllûin tcctn .bseNed b!
otticâl .nd xrav mi.ros.ofir /. D.,t. ^.s. 1960, 39:
Nâsstrôû K,Iorsb.rE B,l'eterssonA, \'Vcst.ssonI'L Ntù
rowùg of ùc dcntal pu\r .hànbct jn patients û]th
rcnal diseàses.Or4l Su.q. 1985,59:242 {
J E , (ldo. TNl, Piti Ford fR,lll.Donald f. Adr.niline 'n lo.:ù
rnaesthesi.r:thc ctfc.r of concentràtion of dcnlal PulFrL
circul.rtion and rnaesth€sia. ItddiLrl. D.nt. ltlùltrtnl.
199,1;:10: 167 73
42

59. Ohshima H, Maedâ 'f, 'fakùo Y The distiibutiôn md smith Al, CassidyN, Perrv H, Bcgu.-Kjfl C, Ruch lY,
ultàshxctue of class II MHc-positive .e]ls in hunan LesotH. Reactionarv dcntinogenesis. Irt. /. Dea Blol.1995;
ddtal pulp. Ce11TÈri.^s. 1999;295: 1sl s. 39i 273+0.
Ohji T, Kawasl,ima N, Kosàkà T, Kobâyashi C, Sùda H. Stuehr Dl, Cho I{, Kwon NS, Weise MI, Nàthàn CÈ
Disûitrutio,l of Ia antigcn-cxpressing nonlymph{rid cells Pùrificatiofand ctiaracterization of the cytokine-induced
in vdiôû stagesof induccd pedapi.àl lesiore nr .at macrophagc nitric onde synthaser d FAD' ând FMN
nôIas.I. Ehdodont. \99+;2A:27i3l. containingr'lavoprotcin. Pfoi. Nril. Acad.S.i. USA 1991;
O l 8 . ' r l l . ' o , ln - J " , , n ' . r d . , J t t | . t \ 1 . i . n AA:n71 7.
ol Pdinaad ûMlgesiccalhpùûrdrlBÊe.slr RF,Botrctt EC, 75. S,vifttij Jt I'erdigaoJ, HeymaN Ho. Bondin8lo enâmel
ecls).Nelv Yo.k Ravc. Press,1979,2E594. and de.tinc: a bricfnistol.,rànd stàt€of the ùt. Q4irtc$.
62. Olgàrt L. Neuùgenic componcntsof pulpàl innâûna ] ] 1 . 1 9 9 5 ; 2 69i5 l l 0 .
tion. tn P/oæcd;rgJ of the lttematiovl Ca"t'eft r o,l " l " t d - \ iK K ' - l Y K . ( \-dM B.lcdronnrro-
Dentjne/l\tlp Cùntptu 199t Chibà, tàpù1 (Shimonô M, scopestudy of thc blood vesselsof dog pllp using.oûo
Màeda T, Suda H, Tal<ahashiK, eds).Tokyo, Japan:Qunl siof resif casts i Erdodori.1982;8:131 5.
tesseû.el'ublishnr&1979,16975. TâkanasniK, Sakai S. Regllation mechànisN of pulpâl
Olgdt L. Nèural control ol pulpal blood flos. Ctt. Ra1 bkDd flos' oulside thc dcntal pulp. In Dùttine/Pult)
Orcl Biô1.Med.t996j7:1a9-7\. co,ryler (Shinono I4 Takahishi K, eds). Tokyo. Iàpâ11:
R.ri.u tapet d$d ibiuS næhûaisÆ grærhihg prlpùl Quhtesse.cePublisnin&1996;15È61.
Iàylôr l'8, ByèrsMR, RÊddPE. Slùouling of CGRPnen e
64. Olgart L, Edù.allL, GazcliusB. lnvoh,ementof afie.ent fibers in rcsponscto dentineùiûy ù1 ràt ûolâis. Brdi,
ncrves in pxlpâl bl{x,.Iflow reactjonsin resporue to tcs. 19881 461:371 6.
clinicaland experimenialprccedùresin tfc cat.âr.1,.Ordl 79_ Irdkrr l& MesserHH, Birner R. The cffccts of ncu-
n i o l .1 9 9 1 , 3 6 : 5 7{ 5
i. ûrpepfi.tes(calcitoninSene-related pcptidcand substance
Olgàrt L, Gâzèlius B. Effectsoi adrcnàline dd felypressin P) on cùlturedfuma. pulp.clls..l. Ddri. R.s. 1995;74:
(o.tnpressin)ôn bl@d flo{'and scNory nerle à.tivity in 1oiiG7l.
the tooth.A.ld Olùnfdl 5.at1t1.1977' 35,69 75. 80. Tùner Dl, Mârturt CE Saliclb.rg C. Dcmonstrâtion of
OlgàrtL, HôlJêlt T, Nilssonc, Pcrno$'B.Locàlizahonol physiologicâlbarrierbch{ccnpulpal odontoblasts d.1 1ts
substù.e P lil<e nnnùnoreactivjty in neNes ù1 ùe tooth pe.turtiâtionlolloa'ing routinciestoratilepro.€dures:A
pr)p. Pail1977)4: 1539. hoNerâdishpe.ondaseL.a.ingsludy in ure rat. i. D.al.
67. PashleyDH. Dynami.s of the pulpo dÊntinecomple\. Rds.1989;68::12:162 8.
Crit. Rd. Atdl tsiôI.Mù1 1996,7: 104 33. 81. VonEsa\-an N, Matthe('s B. Thc pc.ûeabilill ol .ùt
Catttth.tsbe tùitu ùh t'un.tion5ûnt1Esto sesôf th. dendne in vivo and ln vilro. ,,irc/? Atal Biol. 199\) 36:
ddtin -pulp corytlertô iltj|ti.ùs dot.nk.
68. Pavnn BG, Brewster DR, (loetzl EI. Sp€cin stiûulàtion of VonEsavan N,Mallhe{'s E. Chrngesinpulpalblood floiv
humd T lvnphocytesby slbstanceP I. Imrrrol. 1983; " , d i r ' l r i df l . . \ h r c u s l d " r n . p r o I r . o b v . r r o . o . ,
133:326065. and sensorlne^e stimulalionin ùccat. Prc..f/rr, Derl.
Rccv€s& Stànley Hlt The rclaliofsh ip of bacteriàl pene Sd..1992;88(Suppl.1):.r917.
tration ùd pulpal pathosisin carioust€eth.O/r/ Srr.t WakisakaS, Akâi M. lmmunohistochcmical obs€tration
1966;22:5965. on nèurcpeptides a.ornd thebloodvesselin Ielinedental
Robe.tsonA, Andreasenl-M, ller6erùo1lzc, Andreasen pulp,.I Ërdodorl.1989;15:413 16.
lO, Norén JC. lrcidence of pllp necrosissubseqreûttô wa.ivnl8e l, Bergenhorrz G. Heâringcapâcityof h!flan
plrlp canalobliteràtionturm tEumâ of pcrma.ent in i- ànd monl<èy deûtal pr ps f.nlowing expÊ.imentalhr
sors.I Endadont. 7996'2: 5574a. hdû.ed pultritis. Endotlo l. Dcnt. Tturtuûtù| I9n6j 2:
7 L . SâsanoT, Kuriwùdâ S, ShôjiN, SanjoD,Izlmi H, Kadtn 25642.
K. Axonreflexvâsodilatâti{D i. caLdenlalpulp elicitedby 85 Ohmd A. Healing and sensitn'lq.to pain in young
noriols stimulationôf the 6nrgiva.i. D.rl, Rrs,1994,73: replântedtèeth.An experimen tal,clinicala.d histologicai
1797-402. siùrly. Otlonlù|.Tidskt 1965j73: 165 22E.
72. Schiipbach R Cuggeûhènn B, Lùtz L Histopaihology
of root surfa.e.àlies./. D.rr. R.s. 1990;69i ll95-204,
Chapter4
Dentinaland pulpalparn
Matti Ntirhi
Introduction
The dentâl pulp is exceptionally ri.hly imcrvaied by
trigeminal âfferent âxons (7, 10) thai seem io subseNe
mostly, if not exclusively, nociceptive function (23, 31,
35). Accordingly, they rcspond to stimuli dui indùce or
theaten to incluce injury to the pulp iissùe, and their
â.livation mây induce defensive, withdrawal-tpe
rcflexcsin ihe masticatory muscles (30,35,41). The pain
responses jnduced by c'xicrnâl siimùli can be extfemely
inten-se. The dense imcrvahon of t]rc pûlp ând clentine
gives â morphological basis for ihc sensitivity of thes€
tissues. tn addition lC) ihe afferent seNory nerles, the
dental pulp is imeNated by autonomic s),mpathetic
efferents thât plây a role h the regulârion of the blood
flo$'in the pulp (39). The exisience and fmciional
significânce of parasympâthetic imeration are stjll
controversiâl (39).
Classification
of nervefibers
Neres .an bc divided into different groups according
to axon size and structure, $'hich determine thc con-
duction velocities oflhe individual fibers (17) (Tâble4.1).
ln the nen ous sysiem ihe diffcreni-sized fibers are dis
tdbuted in a functionally meaningtul manner, nâmely
thick myelinated fibers jn those nerve trâcis where fast
conduction is denanded ând fine-caliber fibers in ilûse
hacts ,he1e the speed of conduction is noi as critical.
for exâmple, t}rc effercnt Ac[ motoneuJons, which irans-
mit ner!.e impulses io ûe skeletâ1muscles, hâve rhick
myehlated âxons and conduction velociries ofup io 120
m/s (14. rhe âfferent Ap+ype sensory dons (s'ith
conduchon velocities of 30-70m/s) trânsmit touch ând
pressuresensaiionsand, usùaly, thei re.:eptolsrespond
to light mechanicâl forces, i-e. ihey have low stimulation
thresholds (17).
Pâin is conducted by two d ifferent sets of neuroÈ: thin
myelinatedAô fiberswithconductionvelociiies oI12 30
m/s and neurons with unmyelinâted âxons with con-
dùciion vc'locitiesof 0.5 2.5m/s. BecaNc oI this orgâni
zaiior! dÈ sensâtion perceived in response to noxious
stimulâtion consists of t\^'o discrete ând differ€nt com
ponenis: fi$tshâry andl{'ell locâlized pain mediatedby
Aô-fibers ând then delayed, dull pain fiatis rnediated by
C fibers and can radiaie to a wide areâ surromding the
âlTected tissue (31). Under experimental condiiions, ilrc
temporal discrimination ând the quâljty differ€'n es of
ilrc two pain components.anbe demonshated clearly in
rcsponse to stimulâtion of extrcmiLies (31). The sâme
dichotomy in the quality of pain can be shown when
stimulâting teeth (23),although iemporâl dis.rimination
is nor as obvious becâuseof the short disiance between
the brain âJIIdthe slte of stimulation.
Morphologyof intradental
sensoryinnervation
The sensory neurons of the dcntal pûlp ha\-e their cell
bodies h the tdgeminal ganglbn (7,10). The teeth of the
ùpper jaw are innelvated by neuroro of tlrc max;llary
and ûose of the lower jaû-by ncurons of the mândibu-
lar di sion ofthe ldgeminalrcrve. The pulpal axons de
locâied in ihe alveolar branches of the ncNe and finâlly
enter thc pulp tlrrough the apical foramen or multiple
forâmina of the root apex in close proximity to the
intradental blood vcssels (Fig. 4.1).
Severâl hundred axons per tooth entef the pulp at drc
root âpex; for premola$, dns number is close io a ùou-
sâJrtd(7, 19,22). The nen-c fibers enter the tooth pulp in
multiple bûndles that contair boih myelinared and
ûnmyehrated âxons (Fig.4.2) (7,19,22). rhe majoiiy of
the âxoN (70-80%) âre uninyelinared (Z 19,22).
In speciesas vaded as humù, cat, dog, monl€y and
ferreL it appears that therc are no gross differences in
jntradenial innervation (7, 10). Rat molars also hâl'e
similar inneNaiion but in the incisors, û-hich de con
tinuously erupiing, th€ inn€flàtion is spârse ald of â
different struciurc. For example, these teeth lack denti
nâl nen'e fibers (Z 10).
43
 44 Thevitalpulp

Fig4l s'hematcdrawng presentinq

theinneruatonofthedenralpùlp.
severà bran.hes
tromrheaveotàrnerue enrerrne âprcatareâ
otrhetôorh.
a pârt
oftheneruêbundesinneruârê
theperlodontâtissues
MullDhbundesenterthêpup ir ctoseproximtyrothebtoodve$es ihroùqhtheâpicatiorâmenj
rhêy
brân'hturtheron
thèrwavtorhetoôthcrownMonolthêintradenralâxon5hâverheûtetui;as n rl. prrpla"ntr"r,.j*, *".orona pulp, wh.h isthe
hetissueG).inqe âÈ rewùneryeendnss in thecerv.aarea(b)anjthepuprdentne uordern rheroorpup isspareiy

Table4.i Exâmpejol dtflerenr

nere fibertype,rheirfûn.rion,dameteu On1),a small proporrion of the pr pal afferenrsrc,rmj
nate m the roor. Mosr of th€ ne|ve bundles extend to
I'e.or,rdl pJlp brr th;rg nn the. hJ) ,t
Diaûeter Condu.rion d 4I,
l h e l " r - n r l b r d n . Fe n d h g - d r ê t ô . d ê d m o { t ) I n I n , .
$ttrm) velocily(m/s)
pulp/dentuc bordcr arcâ of the coronat pulp (Fig. 4.3).
Ào Moroneuron5 1 22 0 7A-120 A dense netwofk of fine Nrve {ilaments, known as rne
Mu(e âttererenr nervc plexus of Raschkon-,is formed ctose ro ore ooon_
A]} trlediarjon
of1ou.han.l t0-70 ioblasts. A numbù o{ mrve ierminâts atso cnrer ihe
pre$uresen5arions odontoblêst layer and many of them exrencl nro fl1e
Aô Mediâtonof pâin, 2 5 12-30 d.ntinâl tubules (Z 10) (FiS. 4.3). Both morphologicâl
remperârure
androuch ând functional studi€s indicâtc rhat the fine nene fita
C Môsrtymedarion ol pa n 041.2 05-2.5 mcnis in rhe clerrinat tubules are mostlyterminâls of the
mvelinated intra denial axons (2,10,32,35). A parr or the
r . ô n - J l . o , . - m i 1 â ' . . r t t - , . J . c D , . p. â , . o , t t - , . p . r t p
' . r e nI r o . e f o \ ù n i 1 . o t h e p r t p . I o t o ù J \ e - n . t - . d . d
thev may have a significanr role in thc mediaiion of
pulpal blood l:loû, responses ro extelnat iûndûoû, as

Fig.4.2 A schematic drawing showingâ neruêbundLe
enterlng
chambs in theapkalûea of thet@th.Theneryebundle
andmyelinâted
unmyelinared àxo6ol varhbhsizs.
Fig.4.3 Inneryatiônofthepup/dentine
border
lnthecoronal
lbe6 enterinslhe areâform a deBe networkknownâs ihe plexusol
Raschkow.Ihelibùs fôm fræ nerueendlnssinhe pqipheÊlpùlpandindre
odontoblan lâyerMânyneryeteminahareal5olodtedin the dentinal with the ceNical dentine Gee s€ction
lubues.somelibeubranch lo inneryatethe
adiacntblood
andpulpalpain
Dentinâl
well as in plrlp tis$re inflanrmation and r€Pair (9, 10,39,
40i see also Châpter 3).
The terminal branching of the plr]lPal nefle fibers is
e\ten'ive (î. lndr\ idual mleùndted aion5 ma) imer-
vate morc than â hundrcd dentinal tubûles. Accordingl,
irmelîation of the pulp/dentine border ]s exhemely
d€nse. Both myelimt€d aJrtdurunyelinâted fibe$ termi-
nate as free nerve endings. Thes€ are the rccePtors or
nociceptors, which respond to various external stimùli
in normal te€th and to the environmental changes and
various inflammatory mediato$ ihat ocdir ûnder
paihologicâl conditions.
As in other tissrcs, the sensory ne{ves of the dentât
prip contain neÙropeptides such as stbstânce P and cal-
citonin gen€-related peptide (CGRP) (8-11) Anumber of
dil'ferenl neuropeplidec ha\ebeen identified in \Jfiou"
parts of the nei.r'ûts system (16, 27) ftat act as neù13-
mediators or modulâtoF md have significmt rcgùlatory
efferts on jmpulse transmission in ihe cenhal neûoùs
system. Many oI them also have be€n shown tô tun iion
in pedph€ral tissues as, for example, mediator
substmces in the effector organs of the attonomic
slanpathetic and paraslmpathetic nerves (27). The
sensory nelrropeptides in ihe âffer€nt neres Plây
thepulp an important role in the initial stâ8es of the inflarnma-
both lory prcce." tneùrogenic iJll'lffdtion)
contains Iouowing iniu'v
iî the peripheËl tissues (39, 40) and also seem to
regulâte the later siages of inlamation and rePair
(8 11).
The tocation of the nerve teminals in dentine is
limited to the irmer 150-200 ltm of the tubules (7, 10). Th€
outer lâye$ of dentine are not inneffated. It shouid be
noied âlso that iftrervâtion of the dentine is densest 1Il
the €oronal pan, especialy in ttte pulp tips ûnder the
cusps, whel€ about 50% oI ihe tubûles have be€n shown
to .ontain neNe fibers (7). Mâny tubules conialn several
nerve endings (Z 21). InneNation of dre pulp/dentin€
boder becomes less dense towards the ceNical arcas
and the number of innerated tubules becomes consid
erably lower (Z 10). In additio& the distance thât the
neffe fibers penetrate into the tubules is much shorter
compared with the coronal areas. In ihe root. the imÊr-
vation of the peipheral pulp and dmtine is sParce (7)
In this respect the struchrial organizaiion of inhadental
imeNation seems io be Poorly coFelated to the sensF
tiviiy of different dentine areas in the clinical situation,
namely, ihai exposed cetrical dentine seerns to be esPe-
cially sensitive. However, this obvious discrePân€y can
be due to differcnces in the time the dentine hâs been
pulp.
Thenerye exposed ard in the responses of tlrc
PulP-dentine
iûitation in the coroml dentine comParêd
complex to
on dentine h}?er-
ve$els(see
ten sensiti\.ity below). The vadation in dentinal inneration
in differcnt pârts of the tooth may ex?lain the different
t-vpes of pain response induced in tIrc coron.l versûs ilrc
root denhne in humân teeth (2s). Advan(edconcept4.1 Electrophysiologi(al
Some afferent neNe fibers may branch to innen-ate methods of pulpnerveactivity
for the recording
bolh the dental pulp ând th€ adjacmt iissues or multL
Twodifferent methods havebeenêpplied in theeleclrcphysologl
ple leeth. Such organizâtion may, io some exient, con-
' J F o , d i _ q . o _ p -ppw p t u, l i o n . R - o r d i n s l o n dr eF r ) p e l
tribute to the poor 1ocâlizationof denlâl pain and may
rorm€dby piâcn9the ele.trodes in dentinâcâvilles(43).Thû
also âllow neurogenic vasodilation ad inJ]alrmaiory method allowsthedis( mlnation ol theacdonpot€ntiab orfaster
reactions to occur in ân ârea of tissue wider dùn i]ùt conducting A fbeE the activity of theCfiberscannotber€corded
affected by drc original irr.sult. Correspondingly, $,ithin andda$ fcationortheindividual nerue fibeuwithrespect ro ther
the dentâ1 prlp the terminal branching of the nen'e conduction veocilesandel€clrkâthresholds is noi posible.fte
fiberc may conhibuie io ihe spread of the infiammâtory recordings wereperlormed initallyon.êt Gnineteeth(41)butlt
l€âctions (36). is mponâfito notethatthe method hasbeenapplied to human
teethaswe ândthoseexperim€nts haveshownthat ntradenial
neweadivityisreâtedto pâinsensâtions percivedbythesubjecis
Functionof intradentalsensorynerves in response to the external stlmuliapplied, showinq thêt pulpal
nerues âreâbleto conduct nockeptive infomâtion (15).Inihe cat
under normalconditions ieeththe recordlnqs fromdentjne haveshownthatpupalA-Iibùs
respônd to mechân calandosmotcstimuationof denlne(38)and
tu obleJ8e of -hê I ra'hun o r l-JJprrJ aene- i. areactivated or sensitized bycenâninflammatory mediators ând
mostly bâsed on electrophysiologicai recordings per- lreatlnjury(1,37,40).lt wasa so shownthattheacrivilyot th€
formed on experimental .nimals (32, 35, 36, 38). Com- intrad€ntal AJbe6 is greatlyaffe.redby changsin th€ pulpal
pa rison of the nerve rcspolrses to the sensations induced
hom human teeth wiih ihe same stiml i, as $'e11as io In singejiberrecordlngs the indvidualfibeu inneruatingth€
the clinicât cases of denrâl pain, has given insight to th€ examnedteeth aredissecred
lromth€âveolêrnerue andârciden
contribrtion of the diffefent intradentâl ne,e fibe1 tiriedbye edrkalnimulatjon olthe toothûown(32).Ihemethod
gloups to different dental pàin sensâtions.Thc appar- hasbeenusedin dog,Gt andJ€tretteethandjt allowsdetaiied
eruy simild str-ucture ând function of the imervation in funcrionalc assirication
oI theexamined n€ruefbeu with resped
the diÉerent species cxmined (man, monket dog, cat to theirelectrkalthresholds,
conducton velocitierreceptive
fieds
(theêreâin the dentine or pulpwher€ân indviduâfibercn be
d r d f ê r r e r )g i \ e . J r e d . o r â b l êb d , . l . - u i l , \ n r p J - ! o n !
activared)
andsensitivitytoa vadetyofstimu appli€dtothedenral
(Advanced concept 4.i).
hârdtissues or to thepulp(32,35).
As already mentioned, the pulp ând dentine are mner'
vated by t\^'o different groùps of afferents: A ând C
fibers (23, 32, 35). Thc fmciionâl classification is bâsed
on the conduction vclocihes o{ the axons âJld corr€
sponds to i]rc morphological findings sho\^'ing the exis- for the sensiiivily of deniine and may give the first
tence of both myelinated ând unmyelinated nerle fibers warning signals a.hene\-er dentine is exposed, whereas
jn the pulp (7, 19,22). i]É C-{ibers mat, be activatcd mostly under parhologi.al
Intradental A- ând C fibres are furtionally differenl
(10, 23, 35, 36). The A-fibers respond to vârions 'hydro- Discrete receptive fields ofihe intfadental netre fibers
d)'namic' sLimuli applied to dentine, such as drilling, can be locaied in eiiher the pulp or dentine (23, 32, 36,
p1ob g, air-drying and hwertonic chemical solùhons 50). ïhe receptive fields of C fibers arc found in the pulp
(32, 3a, 35). The mechânism of the ncrve fiber acli\.âtion pfoper ând for ihek 1ocâtion the pûlp ijssrc has to be
in response to the dïfereni stimuli seems to be common. exposed. Also, â pâû oI the A'fibers, mostly s1owly con-
This hydrod'îànic mechânism wil be desciibed and ducting, hâve their receptive fields h ihe pdp âJrtddrùs
discussed in detail later in this chapter. The pulpal C câniot be âctivated by dùtnd stimdatbn (36, 50). On
fibers âre poll.rnodal, which means that rhey L€spond to the other hand, ûe rcceptive fields of those A-fibers dùi
se\-eral different stimlrli $,hen thcv rcach ihe pulp are activated by hydrodynâmic siimulation of dentine
proper (23, 32 35). The fibers hâve high thresholds and cm be located by probing the exposed .teniine slrrfâce
ar€ âctivâted by iniense thermal (heat and cold) and (36, 50). In normal teeih the rccephve fields are usually
mechanicâl stimutahon (23,32, 35). They âlso respond to small spois ofâ few mm diameter (Fig.4-a). Some fibers
such inlammâtory me.liators âs bradykinin and hista- m ay have two or e\.en thrce sepârate rccepti\'€ fields thât
mine (32,35),which are both formed md/orrcleased in can be locâted ât a considerable distânce from eâch
rcsponse to tissue injlûy and associated inflamalory other jn the coronal dentine ând ceNicâ1 area in some
Iuactions.Thus, the results from tlrc electmphysiologicâl cases (50). Twicâ1ly, the receptive fields of individu.l
stùdies indicate thât intradental A-fiberc are responsible fibers overlap extensivelt meannlg thât stimulâtion of a
v
D e n t i f âal n dp up a p ê i n 47

l.rtencv compârcd h'iih C fibers, which is in accordance

I rvith theif âctiv.tbn ncchanism (s€ebelow).

Compàdsof of the âbovc-dcscdbe.t ferle rcsponses
to t]t pain sensationsinduccd fton hunûn te€th Lrn.i€r
sirnilar siimuldtion conditions has reveàled how difier-
RF1 ent intradcrtal n€rve ilb€r gfoups may contdbute to the
diff crcnt .lent.rl pnin cond iù)ns. f or e\anpie,'h,v.l f o
dlnamic'stimuli, $.hich aciivate ofh pulpâl A fibcrs,
indu.e slurp pain h'hen aFplied to d€nunc in hrNrn
subiecls (31, 35). Intense theflnâl stimulati(n of hrùn.lIr
r q t l 1 . . \ ' j - " 1 1 r , i ' J . r e . r, r . l \ . p t . , .
sàtiolr follo$.ed b,v dclavcd dùl1ànd lingering pâfiif ihc
stilnlllâtion is continucd (23). Sniil stlnr!l.tion oi trc
cat cànnr€ tooth indù.cs a brict short laterlc! firinB of
inbâ.{-.ftâ A fibers ldlnlcd b} à long lâtenc! .ciiva-
ûn of C fibers (23, 32, l5). CorÉequeitly n gogenic
RF], (pâj11prodûciig) agenis, 'vhich rcii!nte se!e.trvclt
either A- or Cjibcrs nl erpeûnenlal anirnals (32, 35),
indu.c sharp of dùll .nd lingcring pafi in hùmnn sûb
jccis (2). Altogether, the âLu'c rcsulis irl.licat€ thât
jnrradcntal ^-fibers medi.rte the sharp dcntal pain serl
satlons ând arc responsible fot detrtine scnsiti\ itl,
Fig.4.4 s.rÊmar.dràwngshorv ngthereceplve Teld5 of lenindividuà wherens Gtibcrs Dlcdiaie the drll pulpal pain or
p! p nerve fibeEonrheexposêd dentlne s0{a.eThereceptive Ie dsarêol
tooth.rcheconne.icd with Pulpitis.
variabe shape andôvenàppiô9, andln a nonnâltoolh areralher 5màLTlre
Inspit€ ofthe type otsthr ùs âpplied to n toolh,paùl
r E r n i nbar a n . h n g ô T t h r c e n ê ù è t b ù s { l b s 5 l ,n2tâl rnedpl )u p / d e n t n e
border ontherlqhtsideoi thelqureandthe.orcsponding re.eprive le d5 is ih€ of lv sensation indùccd jn resPonseto âct'valton
(RF,RF2andnF3)ôn thedênrinÊ surla.e areshown aseraûpiès.The RFot of the tulpal scnsory ncrves, âccor.ling to most stÙ.llcs.
ea.hndvdùàI ber(oirêspôôds 1otheareaI ihepupldentne border nnef l'hc onll cxccptior is lorv intensih clcctri.al stiin u lation
varedby ihe part(ularaxonand.onnected to lhÊrc.eptive led on lhe (31,35), whicl can induce so-callcd plep.)iû sensâtions
deirne5urfa.e bylhedentina rubules thai prob.ibly r€sult frorn liN-lcvcl (lininâl) actil.it)' ir1
thc pùlpal nocic.'pti\ e nft€rents. Considcrfig àn) cLinl
cal situâti()ns {'hcn an electric tulp testcr is used, it is
i r
s m à l l â r e a d e r l t i n €o f f u l f c i n a c t n a L cm u l t i p l c n c r \ e lûrportant tr) nolc t]ùt the initiâl sensali(ù1al thrcshold
fibers; this is an jnrport,rnt factor, considcring thc intei €r.el is uslralh noiPainful. \\ hen the srimulus intensitv
sit)' of the pàin fespoises indlced by exiern.rl stimrlla- is ifcreâsed, the scnsatiorl beconres pâinful and anl
tjon. These fun.tional fin.lings are in accordancc with ' l _- -r_ | ', ,,i'l- h. ..1 i ,dJ.. t l
the structure oi iùrcrvaliù oi thc pulP/deriife border allhough its qùâlity nâv l.ary in rcsponse io ditfefent
arca, with ihe extensile ..d oçeflâpping lerminal stilnùli. The vàriatiù is due to .liffe.ences in tlt ncrvc
branching ol the ilrdr!i.11lil .rofs (seeâbo!e) (Iis. .1..1). responsepâtterns and lhe acti\'âtio. of differcni tvpcs of
TM intra.lentâ1C t'ibersar€ nctivated b) à difc.tcffc.t ne 'e libers (35).
of the applicd sinruli on ihc ner\ e endings (23, 32, 35).
l,or erâmple, in thcrùal stimulatidl the l€sponse laten
cjes âre rath€r lùg and dr ncrvc firhg does not b€gin Sensitivityof dentine:hydrodynamic
until the temperallrre wiùnr ùc pûlp hâs ch.tnged by mechanismin pulpalA-fiberactivation
selefâl degreescentjgrâde (2:1, 32). Sù larl\r actr'àtiof
of the most slon'ly condùcting ^ô fibers seeûs tir r€suLt Tlr'hldrod)rânric hypothcsis' cxPlainhg the sensiti-
fron a dircci efiect of ihe stimuli on the ner\-e endints \ it)' of dentine rlas iirst prelented b,v Gl'si (lll) irl 1900.
( 3 6 , 5 0 ) . I tà l s os e e n s t h d t t h e f u l p â l C ' I i b c $ a n d s l d v l v Todây it is$'idcly acceptedth.tthe sensiiivitv ofdentùe
c o n . t r c t i n g A ô Ê b € r sâ r € ' s i l e n t ' i n n o r m a l h c a l t h v t c c t h is L)as€don h)'drodl-namic nctivâtion oi tlt irtradentâl
and ma) bccomc âciile onh in câsesol pllp injùrv and A lib€rs (FiB.4.5). This concept is supported Lr)'a cor
innamùuliù. On i]r contrar!, ùe A tibefs (mosily sider.ible nnolnt of 'r !l/rd and tu ttird dat;r irom boih
fastcr conductng) rcsponsible for the sensitivlh .)1 humân md nnimàl expcrNcnts 15,6, 32, 3,r, 36). lt lras
dcntinc rcspond rcadill rvkne\ er dentife is expose.1. shown iû the €. rlv I 960sand in a number of làter stu.lrs
Ihe nen'€ âctivation is hmcdiatc or oi â letv shoft that stimuli nrduclng pâin whcn âpplie.l to human
48 lïe vita pulp
Tissue
deformatiôn
\l ,ç-
t--
.;;:: :€
.'- "€'
.
1
/,.
' Nerve
êctivêtion
rig, 4,5 ûe hydrodynam. mdansm of pùipnerueà.rivâlon Any ttrbules, owing to iheir high osmotic pressure,resuliing
stimu us.apab eofremov nqfluidlromtheourêrends
oTthedentina tubùês
a(tvates hydrodyûâmi.lu d movement.Ire
ostfùidisreplà.edbyanimme- (5,6). Sc\.eralstùdies have sho n ûat dæ capability of
dlaleoutward flowdûero rhehiqhcaplllary To(esin thêdenrinàltùbule5. hypcrtonic solutions to induce pàin jt1 humâr tecù (3,
Ihe fluidfow causes me.hancadstortonol thetkrùêwkn trre,'e've 5, 6) and to âctivate inhâdentâl nerles in cxpcdmental
endinq5 inlhepùlp/dentine borda
clentineâre able to indlLcefluid flow in dentinal tubuLes
itl 1.|itrc(5, 6). The strong câpilary forces in the lrie
tubules .ause thc hydrodynamic fluid flow ln BenerâI,
dcsiccâting or er'âporaiivc slimuli ar€ the most effectivc
becaùsc ihe capillary forc€ coniributes to the out\rârcl
mov€nc.nts of the tubûle contents. Il is much more .liJ
ficult to induce inwârd fluid flow (6, 42). The fluid flow
causes echânical distortion of the iissue in ihe
pulp/denthe bordcr area a'here most of thc nene
endings are lo.ated (Figs 4.1 ând 4.3 4.5). Accordingly,
with a hvdrodlaumic stimuti the final factor inducing
activâtion of the Derve en.iings or receptorsis amechân,
ical etreci. The iesults from singlepulp nen'e r€cordings
showing thai individual nerve fibe$ rcspond ro se\.erâl
dilTerent hydrodynaoic stimuli âre fi line a.ith this
c o n c € p t( 3 2 , 3 s , 3 6 ) .
The fluid flow in the denûùl iubules mlst tre râpid
enough to indLrcesufficient mcchanicâl effect for âcti!a-
tioD of the nen'e €n lings jn the pulp/dentine border
Although there is contfiùous, slow outwald flo$, in the
tubules ofexposed dùtine due to the high câpilary and
tissuc fluid pfessure in the pulp, such a low is 11otsùt,
ficient to causcnen e âctivàtion (42,49).As already men
lionec1, stimùli that are able to renov€ fluid from the
tubule apertures, €.9. evaporati\-eor desic.aûE, are the
most ei1èctivc in activating the pi pal nociceptors
because thc capillarv forces conrribùle ro their effecr,
resulting in an immecliate lapid outward llow (5,6).
Thennal siimulâtion àlso is ablc ro induce hydrocli,
namic ner\-e actjvation because iemperature chdnges
cause volûme ùanges in ihc dentine and tlrblle con
tents. Howevcr, thc remperature chÂnge must be lapid
€nough io cause sufficient fluid flo$' for the nerve acti-
vation. ln generâ], cold js
becaùse ii induces outward
(r1€ effective than hat
fluid movement (6). If
htcnse enough, thermal stimlrlation (both hcat and
cold) is able to indtrce hydrodlnamic nerve activaiion in
âJt il1ttacttooth wiihoul anv dentine exposlirc (23). In
cases of pûlpal inflâmùation, thc iniradental nocicep
torc nây become sensitized ârd aciivaied by â .lirect
effect of heat or cold (35,36), resûlthg in a significant
increâsein the dærmal sensiii\.itv of the affecied teeth.
Vâdous hypcri.ùric solutions can induce pain ûh€n
applied to human dentine and activate inhadental
n€n'es in expcdmcntal animals (3, 5,35). This action is
based on th€ir ability to extract fluid from dÈ dùûùl
in àctivâtion ol the câpillary forccs md fluid mo\.ement
ânimâls (35) is rclated to thcir osmotic presslrre rather
thân to the chemicâl compositun of ihe âpplied solution.
Such results give turther support io the view that the
intràdentâl nervcs arc actir'âied by the hydrod]'namic
The expeliment.l induction of pain with hypertoîjc
soluiions corresponds to a clinicâl siiuaiion: irhcn a
pâtient complains of dental pah in connection s,ith
eâting si{ccts (irhich form à saturÂted sucrosesoluhon
lvhen mixed lvjth the sâ]ivâ on the tooth surface), ihis
indicâtes that clentine $'ith patert iubulcs is exposed in
a tooth or teeth. The exposure can bc found on \-isible
occlusal or ce icâ1 surfâces but also in ihe margins of
leak)' fitlings.
A mâjof char,rcteristicof s€nsiiivc humù dentine is
dùt thc dentinal tubules âre pÀtent (5,6,33,34). Thc
hydraulic conductancc of dc.ntine an.l the àmount and
speed of the dentil1al fluid flos- arc, to â greàt extent,
dependent on the d€ntinc having open or blocked
iubdes (6, 42). In practice, this means that à11exposed
dentjùc is not sensiti\.e. ljor the induction of hldrodv-
mùic fluid flor- by câpillary forces, 1€moval of nuid
ftom the tublrle apertures is €ssentiâ1.Blockng of ihc
tubùle openings pre\.ents or reduces thc rcrnovar or
d€nûù]fluid bv the âpplied hydrodynannc sÉmuli ald
thus lecluces d€nûr sc.nsitiviil.
The efiect of the condition of dcniinc on iis sensiii\.ity
hâs been show:n in â number of human and animal
expedments. Fo1 examplc, after drilling, the denhne
su#a.e is covcrcd lvith a smear layer (ddlling debds)
and the iubulc openings are blocked by ihe sme plugs.
Etûing of thc cxposed slrrfâce with âcid is âbl€ to
removc ilrc smear ând open the tubules, thus increasing
 andpulpalpain
Dentinal

the seNitiviiy of the dentine to a great exient (5, 6, 32,

34, 35). Blocking oI the deniinâl trbules, e-9. with Advanced as
concept4.2 odontoblasts
oxâlaies or resins, iedùces or âbolishes the pulp neNe r€ceptoraells?
rcsponses in experimental mimâls (32, 34, 35) and
Thepossibe function oI odontoblanswilhtheircellprocesses ln
desensitizes dentine in humal sùbjects (6,34). ti has - as receptor celhhæ beendiscused lor a
the d€ntinâiubules
been repofied also that a significmt positive coÛelahon longtime(4,29,32) h hasbeensuqgested thâtthesecelhhave
€nsts between the densily of thc open dentinàl tubules membrane propenles likethos€of excitab e ce s andthuswould
and the inreNity of thc pain responses induced from beableto respond to extenal5timulation bycreating â receptoror
exposed cervical dentine surfaces(33).In addition tô thè generâtôr potential (29)Thispotentiawouldth€ncause Propagâ
suface .onditio& chânges occu.ring deeper in dentine, tionoI actonpotentiah, whkhwouidbetransmitted Iuftherinthe
such as intrâtubul mineralization md sccondâry or nerue fibe6.How€ver evidence suppofting theideaor receptor cell
irriiâtion dc.ntine formation in the pulp, may affcci the function ôf the odontoblâns is controversiâ. Allhough the mem
hydrauiic condù.tance of dentin aJrtdthus its sensiiiviLy braneproperti€s with the châÊderstlcs oI th€ on channes ând
(6,42). consequent elecÙlca esponses of the ællspô$es someproper
tiessimilarlon€uronalsatellilece s(14),theirelecrrophysologka
The resulis of ihe siudies listed âbove give strong bui (14,29).
responses do not resembe thos€of sensory rec€ptoE
still only indireci evidencc supporting the idea that the morphologkal studies havebeenunable lo identilyany
lvoreover,
sensiliviiy of deniine æd inhâdental A fiber âctivation cellcontacG betlve€n odontôb astsandlhe adlaceni nerue tibers
are based on the hydrodynamic mechanism. Re.ently, whkhwouLd belypcalrorsynaptic connedions ore ectriccouPlinq
Vongsavan and Matthea's (49) have sho$'n a dit€ct rela- oTrhetlvocelk(7,10,29)A(ordlngto morphologkal nudies, the
tionship between the measurcd dentinal fluid flow and odontoblast process islimited to rhelnnerlhnd orhalfofthedenti
inhâdertal neffe activjty in response to hydrostâtic naLtubule (7,21)andthusmlqhtnol contribute to tlresensiuvity
prcssûre changes in cât teeth. of th€ periphera dentine Aso,studjes ôn humanieethândeec
Othcr suggested mechânisirs of plrlp nen-e activâtiol'r trophysiologkal record ngsonexperimentêl anjmas havelndkated
inclùde the possibility of direct activation of the noci- thatdentine canremainsensiuve êndthe intradental nervelbeE
ârcactlvated evenwhentheodomoblêst layerhasbeendenroyed
ceptors when dentine is stimulated. However, such â
(5, 6, 2o).In conclusion, on the basisor the curentlyavallable
mechmism docs not fit wiû the findings regardin8 ihe
evidence the proposed r€.eptor cellfunclion of th€ odoniôb âsts
rcsponse prcperties of intradental nenc fibers and However, odontobasts may hzveimporlant
seemsinrprobâble.
sensory responses in human subjecis, showing that fundioNassupponing celkTortheTine neryeterminals andln the
âlgogenic agenis are rrmble to induce neNe activity or - q . l d r i o l o . h " F n ? . o n n " n % l , o n o i . lo nl u. d ' n$ge c o rp o ' i
pain when applied ro pcripher.l dentine (32,37). More- rionolrhedentinâland llssuelluid aroundthe nerveendngt(10).
over, âs described earlier, neuroanatomicàl studies have Suchenvrcnmental chânges may modilythe sensitivity oi th€
shùwn ihat peripheral dentine is noi imc ,ated (7). The
possible role of the odontoblasis in pain impulse trans
mission has been discussed and sludied but the e\+
dencc sùpporting such â view is \-ague (see Adv ced
concepi 4.2). is exposed, activation of the hydrodynmic forces cân
It can be concluded that the s siLivity of dentine is intmsify ùe effects of the exicnal stimùli io â Sreat
based on hydrodynanic âctit'ation of inlradcntal A- exteni. This alloa's aciivâtion of the inrradenial A-fibers,
fiber and, because patent dentinal tubules arc the most mediÂting sharp dcntinâ1pâin. The intensiiy of the pâin
importali factor for nerve âctivation, blocknlg of i]rc is most often still mild or, at greatest, moderate and con
tubules would be the meilûd of choice to abolish or siderâbly weli locâlized. Such initiâl pair! rcsponsesafter
prevent dentinal pâin sympions. deniine exposure can be regaded as â warning si8nal
indi.athg that dentine is exposed ând there are Patdlt
denrinal tubù1es that form a come.tion between ihc
Responsesof intradental nervesto pulp and the dentine surface. In additiort the plotective
tissueinjury and inflammation or withdrawâl rcflexes induced by ihe pulPâl A-fibcr
acti\'âtion in the jaw muscles can modify the masticâtory
Ir normâl nlhct teeth quite intense exiernal stimû]i arc tunction ând contribùte to the prevention of excess tooth
needed for the induction of any activity in i]rc pulpal wear or, in some extrcme câses, even cracking ot the
nocicepiors. They stây mostly 'silent' becaùse their tooth crown (30, 35, 41).
thresholds io vaious stimûli are high ;tnd they are also In inflamed teeth, exierml stimuLi that are not paiiJul
well proiected by ihe dentâl hârd tissues. As a resuli, hot in heâlthy dentition cm induce exhemely intense parn
or cold foods and drùks do not cause any significant rcsponses. For examplc, patients with pulpiiis ofien
disconfort or pain in a healthy dentition. When dentine complain that temperature chalges câused by hoi or
50 Thevita pu p
coid foods or drn*s induce pain. Also, sponraleous
pajn withoùt any obvioùs cxternal i itâtun may be
prcsent. Sùch strmptoms indicate thàt the pulpal noci
ceptors have been seDsitized,which Dlcans rhat their
thrcsholds to heat, col.t a1d other stimuli are uecreds€o.
The seNitizâtion câ]1bc induce.l by â number of inflam-
,:tory mcdiators thât arc releasedând/or formed i11the
pulp as â rcsr t of the hsult (32,35,36,38). Orving to
thc cnvironmental chânges ând ihc activation of diffcr-
ent mcdiators, intradentâ] A and C,fibers may bc
affectcd diÈerentiâIy during the progress of the nrîam-
mation (32, 3s, 36), which may explain th€ chmges in
ihe t,vpe of pain symptoms found in clinical cases or
pulpihs.
Peripberalneurèl(hdngesèffe(ting pain
responses
in inflamedteeth
Às in other tissues, injur). to the pulp rcsrllts D ân
iû]ammatory rcaction, \^'hich is an initial promorer of
the heâhg and repâir processes.Stimulâtiù ofexposed
deniine is able to jnduce inj!l]', \rhich includes disloca
tion of the odonioblasts into the dcnlinal tubules âs
s h o w n i n h i s t o l o g i c a ls t l r d ; e s ( 5 , 6 , 2 0 ) . A l s o , n e r l e
cndings locât€d in the tubules or adjacent to the odon-
bblasts b€comc damâged (10, 26). Such morphological
chmges âfe promincnl âftef dehydrating stjmuli ànd
cleârly shoir the efûcàcyof i]rc hy.lfodynânnc Lnk in ihe
mecliâtion of the stimûlâtion cffects from tl1e ocnone
sudace to ihc pulp. Thus, €\'en a light stimulus such as
an ân blasi cân, ijll fâct, bc noxious to the prllp owing to
the amplifying effe.i of the capillâry ând hydro.lynamic
forces. In spite of tlrc mofphologicâl changes with
destruction of the odonbblâst laver ând dentinal nelve
€ndings, the erposcd dentine su#acc .cmains s€nsitile
in hman subjecis (5,6,26) and intrâdental neNe fibers
i ' F ' p ' l ' . . , I r ' û r d l -I n d r r i I r h e i r - . p , , , . r . ,r , . -
\v
, \ /
\ - *
\l stimutus
to denûù] stimu lation (20). Thus, dentine seisiLivity is
not dependent on the existenceof intâct odontoblasis or
ncrve enclingsin the dcntnrâl tubûles.
Neurogenicvasodilationênd inflammation
Wheneler Àn insult causesâct;l.âtion of ihe intfàdental
' ù ' i . . f , . r . ' r r ei t u . i . lr , - . | . n i 1 h e a r p i , . u c ' - n ê ,
rogeni. \,asodilation nediâted by ihe telm;Jtals of ihe
aftetent rcNc fibers (Fig. ,1.6).Th prcpagâted âctbn
potentials arc conducted over thc entire cell membrane
of dr neuron. As à resûlt of ortodromic cordùchon the
impulses reach the trigrminâl nuclei ând then higher
brain centres, jncluding ihe cortex, to e\îke â pain
sensarion.Antldroùlic hansmission along tlE collateral
tcrminâl brânches of the axons results in the reteaseof
CGRP and substi:ûce P, wHch induce vasodilaiion and
ân nrcreÂsein ihcpermeàbilitv of thc bloo.l lessel walls.
Because the responses arc evoked by the propâgàted
nervc impulses, they are induced immediârely b,v exrer
nal irritâtion. Thus, this initial compon€nt of thc jniam
matory feaction is dependc.nl on àfferent nerve fitrers
and is câlled neurogenic inflâmmâtioû.
The extensive brârching of the pulpal âfferents also
allolvs a spread of the n€urogenic effectsin a wid€r area
oi the pùlp than i{as oiginally strnulàt€d.It is also pos,
siblc that âctivation of axons imervàti.g the pùlp ald
the surroùding structures mây r€sulth a spreâd of the
neLrrogedc inflamâtort. r€Âctions behvccn the adja
cent tissues in rather eârly stâg€s of hîaùmation (39,
10).
lnf lammatorymed;ators
^s outlined jn Chàpter 3, manv different rnediàtors dc
activatcd at diffefent stâges duing the inflammatory
r€.ction and Lissuc repaif, originâting from nurnerous
2
Fig, 4.6 S.hemari.drawingpresenung ihe indùûon
3 ol neuroqenic vasodilat
on ând inlammatlonin the
pùp/denlne borderAdvâtioû ôJ the nocceptoEby
extemalstimulation resuts n nêrueimpuse (ondudon
alonqal colalerulendngsoI ihs sameaxon someof
rhê endinqs are o(aredàdjâ@nr ro the broodve$es.In
responseto ther adivation,
thè terminasrelêase sensory
ôèùrop€ptdes,wh ch nducevasodiâtionând n.rease tlre
permۈbi ry oflheve$e wa L

sources,e.g. various tissue components of the plrlp,
mi$ating inflâmmatory cells and the circûlating blood.
Th€semediâtors lÉve imporimt effects in ilrc regrhrbn
of the inflammâtory reaction ad iissùe repair The neù-
rogmic fâctors inieiaci closely with othcr mediaiors (40),
e.g. sensory neùropepiides cm induce the releâse of his-
tamine. Autonomic ncres also seem io be involved and
it has beer snggested i]Ét sympathetic nere cndings
form contacts with the affercnt nociceptive terminals to
preveni the release of sensory neu ropeptid es by a preter
min:t inlrih+ôrv êffp.r /4n\
After heat injury intfâdental nefles are sensitized and
show ongoing firing ând increased responses to tlrcrmâl
stimulation (1). The fâct that ihe hduced activaiion is
inhibited by âJlti iniâmmâtory drugs indicates thât the
sensitizâtion is mediated by prostaglandins (1). Sero-
tonin hâs been shown to ser1sitize pr pal A-{ibers (35,
37).After locâ] applicâtion of serotonin into deep denti
nâl cavities, th€ responses of A-fibeB ro hydrodlromic
stimulation of dentine âre ernùnccd md they show
ongoing âctiviiy (35). Bradykinin and histamine achvaie
pulpal C-fibers (32, 35). The ditferentiâl sensitivity of the
iDiradenial A- and C-fibers to vadous inflammatory
nediaiors mây give an explanation to the chânges in
the i}?e and jntensity of the pain symptoms dûring the
progress of pulpâ1 hflammarion. The .ondiiions rn the
pulp iissue, such as alterations in the blood flow êJtd
consequently dÉ amoùt of a\-ailable oxygen, my also
play â role. In generâL tlrc trlrlnye]nùted C-{ibers de
more resistânt than ihe myelinated A-{ibers againsi
r€duced oxygen pressure (17), and single-fibei record-
ings in cais sùggesi a similar difference in the intraden-
tal nen-es (35).
Nlorphological
versusfunctionalchangesof
pulpàlnervesin inflammation
Laâddition io the nen'e impulsetransmissiontherc rs
ùoiher, slower type of signaUing between the nefle ter
minals in the pedpheral tissues aJld the soma of the
neuron via axonal transport. This process is bidirec-
tional, inchding both antero- ând retrogradc bans-
portation of varioils cytoclÈmical si8naling agenis. Ii
âIows tuansmission of inJormation regarding the condi-
tions of the tissues aromd the ner\.e endings to the soma
of the neuron (10). An injury to the ncNe tcrminals and
other tissue components in the pûlp results in metabolic
âclivation of ihe neùons in the trigeminal ganglion- As
â rcsult, varbus signaling molecules, receptors, media-
tors md modulators are synthesized and transported to
the ne|ve endings in the injured tissue, where they take
part in regulâtion of the hJlaûmaiory process ând hssùe
repair (E, 10). Also, profound moryhological .lÉnges
take place in the pedpheral nelve teminals (11).ïÈse
Dentna andpulpalpâ n 51
changes âre regulâted by gro 'th {âctors and other sig-
nâLin8 molecules activated dudng Lhe process (8, 10). lt
slùuld bc noied also that the action of potential firing
ând the iræport oI sigml molecùles into the centr.l
neNoùs system rcsuli in discrete cyiochemicâl chânges
in ihe second-order neùrons of the trigeminal pain pâth-
ways (12).
The seNory neuropeptides, CGRP and snbstanc€ P
present in the âfferent nerves of normal healthy tissues
(E 11) seem to be confined to the fine-caliber pain-
mediating afferents (10, 16). It is also indicated thai
the neuropeptides arc prcdominantly located in the
ûrmyelinated C-fibers ând that some small A&fibers are
CcRP-inrmunorcâctive (24 28, 40).
MorpholoBical d1ânges shown to take plâce in
responsc to injùry md hiammâtion in the intradentâl
nerve endings inclûde ân hcrease in thei neuropeptide
cohtent ând sprouting of the îeNe teminals (8, 9)- As
already meniioned, the seNory neuropepiides æ able
io indùce vasodilation æd an increase in the perme-
ability of the \-essel walls (39, 40). Such vascular reac-
tions are an essentjalpart of the inflammatory reaciion
and are necessâri' to satisfy the nutdtional needs related
to the increâsed metàbolic activity in connection with
tissue repatu âJrtd healing. The âbove describecL struc
turâi neual responses arc probably nnportant for tissue
repair becâuse ihey allow rnore effective regulatory
function of the nerve termimls in rhe healing proccss
(11, Key literature 4.1). Also, i]rc time course of ihe mor
phological chânges jr1 ilrc nerve ierminals indicates that
ihey are an essential pari of the tissùe r€sponses. They
are obvious a'ithin â couple of days after the insult in
the fat molars and they disâppear concomiimily wiih
tissue repair and resolution of ihe insull in reversible
cases(8, e).
The experjmentâl Ëndings regârding the functional
conelaies of the moryhological chùges in dÉ pùlpal
nociceptors described above are limited. Considering
the extent of ihe changes, they may have inportânt
Keyliterature4.1
Bye6andTayor(11)cornpared theresponses âTter pulpexposure
in denervated andnonia y inneruated rat molâuandfoundthât
the âbsence of fie sensory nerues affected lhe tssuer€spons-"
signilicanlly sixdâysâftefoccusalpulpexposure, thedenervated
reel'showed rure àdvan(ed p-lpnecoss a_dlers'enèrnrqvds
culâr, vltâlpuptissue comparedwllh thecontroteethwithnormal
sensory innetuâtion Tlreresuts indkate thâttheexistence oilntad
- - o l i l e r v di o -w i , ri . F s p o < e s .roi s s unej t _ fyt y b e i n p o r
tântJor€gulation oJtheinfammatory response andconsequenty
T olrh et s s u ed e ï ê n saen dr e p a ri re a d l o nnsi h e p u p
52 Th€vitê pup
In.reaeedover ap/
increasedsênsitvlty
tig. 4.7 Scherurcdràwlngshowngreceptive fieldsof the çme ntrâden
tal nefrefibe6 as piesenred iô u9. 44 TemnalsproltingoI threèlbe6
(fibe6l, 2 andl) in the pùp/dentineborderis sholvnonrhê rght ândcon
5equenrlylhe re.eptveIê dr (Rt, RF2andRfl) on thedentiôêsùria(ehave
expanded âôdshowin.reased overapkt Fig.44)
effccts on the tooth sensitivii). Electrophysiological
studics fidicate that the recepiivc fieltls of single
intradental ner\e fib€rs in inflamed dog teeth âre wider
comparcd i{iih rlninflâmed controls (36) (Fig. .1.7).Such
a chànge corrclaies with the morphologi.al findnrgs
showing sproùtn1g ol the â\on i€nninals (8, 9). Along
$,ith th€ erpànslon, o\.erlap of dÉ rec€ptiçe lields of
single âfferents in dentiie is nlcreâsed, rcsultng iI1 ail
incrcâsein tl! nunber offibers âcti\-atcdby stnnùlâtion
of âny pâriicùlar areâ h dentine (Fig. 4.7).^ccordingl,v,
sLr.h cnânges mâv coniribùte to increased denrnt sen
sitivit)' in il1flalned teeth (34,36).
ElechophysioLogicalexperirncnts hâv€ shoa.n thai in
inflamed teeth the propo rrjon of ^-fibels that respon.l to
dentinal sthlùlation is incfeâsed signiJi.antl) (36),espe-
cially in slowly condrciing A-à fibers (36).Many oiihcsc
'silent' undcr nolanâl conclitions but seem io
fib€rs àre
become a.iivc as â resùlt of the inflammatory l€d.tion
(36). The change mâr b€ câused bv sprouting ând con
sequent forùration of ner! n€|ve endings and âlso by
sensitizâtion of the orignùl neNe tefminals by tlt
ift1âmmÀtor,v mediators. ^cti\ âtion ol the'silent' noci
ceptors m,ry significantl,v nlcrease the sensitivity of the
Localcontrolof pulpal
nociceptoractivation
A puzzlinS clinical Éndnlg is thai pu\ritis mây otten
r€sù1t in totâl pùlp necrosis s'ilhoùt ôr'\- symPtoms
Rcceit studies hâlc rc!eâ1ed a number of locàl mediâ-
t.rrs in the periphcral tisslres thât rcgulaie the nlflam-
,intory proccss and consequenily ihe sensltivity oi thc
nociccpiors (.r0, 47). ln the dentnl puiP, for cxdnple,
peripheral endogenous opioids, somâtostaiir an.i totà
drenalin€ hâ\'e been sugEeste.lto possesssuch eftects
( 10,36, :10).It is indicnted that ihe releàseof rhe rncdia
tors js closcll h1ke.l to sPecific steps in the inr:l.nrm.-
tor,v prccess ùd is legulated b,v a negâtive feedback
loop (a0).The idnbitory fdctors may be ne€.led to attcn-
uate the inflarnmatory reâction and at the same timc
l l . \ , r l _ r b r ' l l - . . n h . .dr l o l , r ' p r l r ' l 1 o , i F l ' . r ' .l n
addiLion, environmenial chânges due to alk'râhôns in
| ,È,u,. l.lôoJ l. h r. trlel. m.JrI\ r\L rc-r'^, .i\ê-
ness ol the intradcntal n€Nes (3,-,38).
In âddition to the dcscrib€d local factors in tlrc Pulp
tissùe itsclf, â lârge nunbcr of che icâl â8eûs releàsed
ffom carbus lesions in decavcd ie€th and diffusing ftom
the deninr su#àce thrcugh patent tubuLesmay modtl
lâte the nervc acti\'ity (38). Thus, nuneroûs local mc.h-
nnisms may aif€ct the âcti\-ation of the iniradoltal
nerv.s and contribute b thc wide variàbilit,v of pulpitis
Dentinehypersensitivity
Dentine hwe$cnsitilit)' is a pain coD.lition that d€!el-
ops follorving cxposure of dentine surfâces The condi-
ii(ù is nlost often located in the cera.icalarca of the tooih
(6, 31, .12)ând can b€ à considerablc clini.dl F'obl€m
TypIcà]I,v,paiLalts complain oi a shâry or shooting Pan'r
thai is intûced by cold foods or drinks, both cleaning
or even à light touch of ûe exposed dùtine surface (34,
.12).The pain symph)ms cân be extremcty intense, con-
tinue for te.rrs and lhus hâle grcat imPact on the
parieni's cvert.lày life. The condition and ùain tealur€s
, , r . . r { l r \ . 1 1 ,r . h e . r - ' , e l , - l l . l ' y . l r o J . n ' ' , c r . c
àctivâtiùr ùcchânism as the basis for dentine sensiti!it)t
hà\.e been dcscribed in det.lil in an eàrlier seclidl on
dentine scrÉitivitv The followng text r.ill focus on ùe
facbrs that mây Prolong the con.lition, csPeciillv the
role ol irflàmmabry mechânisms and neurâLeltects
In favomble cases the repâir reactiol1sol the PUIP-
dcntin€ complex h response io dcntiie exposure
usualll lca.l to n grâdual tubùle block b)' intrâLubular
mineralization âncl/or iûitâtion dentine iornation to
protect th€ pù1p, leâding to naturai desensiiizatiof of
dentine. Horve!er, sometimcs th€ d€ntinâ] tlrbulcs màv

sta)'op€n ànd the sensiti\.itvof dentine is mahtanrd (6,
31,12).Such â vâdâiion in the local responsesin dcntinc
is poorll undcrsnrod. It mar be .lue to a compromiscd
defensecapabilir)* of i]t pùlp tisslre or too intense ând
coniinuous cxicnal irritaiion. Possibledilferences In û,c
repàif reàciions n ihc.oronal versus ceNical pulp
dentjne complex mav cxplah i{h} persistent s,vmptoms
oi dcntinc hypc$ensiiivit! âre otten lolrnd in the cervL
câl and root âreâs brt rârely in the coronal dùûr
42). lf this respectthe simcture of thc intradentâl l]l,.el
ratiof is intefesting, shoa.ing a dcnsc nch{ork of ne|ve
€ndjngs in the crown (7). Namel,v,the affcrcnt ncrles
may play .r1 importànt role in the refair and dcfcnsc
r.actnDs oI ihe pu\r (11). Also, the time course of thc
dcntinc exposure ln.rl, be significtrnt. Gin8i!âl recess n
in the ccrvical arca ùay cause mucf fâster exposure
compared with that câùsed by âttrition on the occlùsal
or ircisâl tooth sudaces ànd thus noi alow sufficieft
iime for favorablc rcpair reacLionsto t.rke plâce In the
pulp. If i]t dcntinal fubul€s remâù op€n, it ffay result
in .n inl'lâmmalory rcaction in the Pulp (6) .1ncli more
or less persistent l.in con.lition.
T h e m € t h o d o f c h o i c e i n t h e t r e a t m e n l o fd c n L i n a l p a i n
wonld tre trlocking of the p.tent tubl cs. The âction
ncchânism of â number of products markcicd for
hypersensitive dentine is b.rsed on this principlc bùt in
sone câses deiitine sensitiyit] may reman cvcn when
the tubules have bccn blocl<cdcompletely (3'l). This mà)'
tre an indication of pulpâl inflamm,rtion and consequent
'lhus,
scnsiiization of the inhàdeniàl no.iceptors.
prodlrcts used jn the clinic for the h€atment ot .lentrne
hrpersensitivitv mat in soDlc cascs, hâ\'e diâgnostlc
v,rlu€ h the discrimination of inllamcd te€tI1.
Exposed dentineNith palenl txbulcs is sensiti\'e ifthe
Lmdell),hg pulp is \-itâI. The detinition'hypersùsitile
dentine' wolld impli.àie thai dcntinc ca1 be more
sensitiv€ than nonMl a1d it is tempting to siàte this,
considedlg how extremelv intense the dcntinal pain
responsessometimes cân be (3a). In iact, thc €lecho
physiological and mofphologicâl sludics prcscnted
treforc givc support to this concept. Namel]',locâl appli-
cition of scrobnjr in heâlthy teeth cân increasethe s€n-
siti\.itv of intradcntal A-fibers to dentinâl slimulâtion
(3a, 35). Morcovca norphological and functionâ]
changesshoû-ing sprouring of tlrc pulp ne e t€nnnlals
(il 11), expansi.D of t1rc rc'ceptive fields ot pr|lpàl A-
'silent' nociceplors (36)
fibcrs (10, 36) and âctivàtion of
mày contriblrte to an incrcâse in dcntinc scnsitivitl il]
inflàmed teeth. Accordingl,v,in teeth with hvpersensitive
del1til1e,pulp.il infl.1ûmatory r€.ctions mây plai' a sig
nificali roh fi the development ând ir a i ntenânce of ilrc
pain syDrpt(ùns.It shoùld be noted, hos-ever, thal ilr
abovc ncural changes âre rcrel1sible. They can bc
resolved if ihc pulpal irritâtion cân be âbolished ind
Dentina
ânl dp up a p a i n 53
corseqLrenllv thc inflammàtory r€âction aticnuaied (8,
9). ThtS, effective tubùlc block mât contribùtc io the
by reduc-
rcdùction of dentine senlsiiivit)'both .lirect!,1.,
ing lhe htdlaùlic conduciancc, and ùdire.tLl, bv allo$-
ing resolution of the pulpal ncùral chànges induced b,v
systemmechanisms
CentralnervoLrs
(34,
Both strucLural Jn.l fuuctionàl changcs in th€ c€ntral
ner\-ous systcaù take place following periph€ràl foci
ceptor activâiiùl in rcsponseto tissue iniury and fiflâm
mâtion. These changcs becone mofe promincni in
long làsting pâin ànd may rcsùlt in p€rsistent.lrêr.tiofs
in those pârts of th€ pafi pâfir\'âys that pârticipatc in
the regulation of pâin iùplllsc trânsmissior from the
periphel,v to the higtrer ccntcrs of ilre brah.Itesùlis tuom
psvchophysiological stùdies ànd neuophysiologicil
cxpcriments indicâte that ccnhal regulàtjon is also
importait in i'ârjous dental pain conditions.
Tlrc humâr1 €xFeriments of Sigurdsso and \4aixner
(.16)shor\.ed lhat radiàtion ol the pain in pulpiLis is vitl
secondâry hypcralgesiâ dùe to centràl sensitization. By
conditioning paùrJr stnnùlâtion of the ann, t]È sec
ondâry h,vperâlgesiacould b€ àbolished and the prnnary
soùrce of the pain ùorc accurately locâlized.
Electfoptrysnnogicalstùdies hà\-eshos.n tb. t nd\nrrs
slimulation of teeth results ir.liscrete cliochemical
rcsponsesin the second-ordcr neurons of the trigeminal
ùc brainstem nlclei mediatng orofâciàlpâif (12, 13).Tltsc
Dn)rphologicâl chÀngesare obvn)us s'iuin a fèr. hours
âfter slimulation of the peripheral nociccpiors . d mny
rcprcsent ilrc first signs of initiàl sensiiization ol the
central pain paihtr,àys. lnjuries to tlt dentâl ne es
caLrsedby tooth criractions ,rl]d pulpotomics lùve been
shob'n to induce long 1ôstingfunctional L:hangesif the
irigcminal br.iinst€m neurons (45). T1È neurons shoa.
nlcredse.l sponiancorÉ aclivity ând e\pansion of their
pefipheral reccptive fiel.ls, indicâting thai i]Èy hâre
forrned connecin)ns to pedpheral neurons that do not
normàl,v acti\.âtethem.
In sulnmâry, it is indicatcd ihât infln|rmàtion an.1
nlrlry in the Feripheràl tissucs may result jn changesitl
thc impulse trdfsmission in thc c€ntrâl pain pâthr\.ays.
lt is nor knos,l1 exd.tly to Nhât exicni the.entrÀl mech-
anisms plây À role in the denial pain conditions btrt lh€v
mÀi/ be signifi.ânt, cspecially in cases ol lon8-lasting
pàin.
Painsymptomsand pulpaldiagnosis
At its rvorst, pulpitis can cause extre el)' intense panr
On ihe other hând, it is a conimon clirtcal finding llùt
 a lârge number of teeth develop rotal pulp necrosis $'ith pulpâl ntlmDâtion are of diagnosrjc vâlue and
s lhôu'bein8 pJirùrl dr d wirl- .o -\înp-om- ,br. Ar may gi1.e some indicâtion of the pulp,s condjtion.
der rrbed abor e. locat meLha | .m. ,Jflê.img no( , ,.ptor However, it must be uiderlined again that rhe correlâ-
âctivation in the pulp (10,3t 40) ând rcgulation of rhe tion betweù the symptoms and histopaihologicât
impulse bansmission in the ceniral nervoùs sysrem (46) chmges in pulpitis is poor and detemination of ihe type
have signi{icant modulatory êffects on rhe devetopment md extent of the hiammatory changes on ihe basis of
of pâin in pulpitis. The poor coffelation betw€en rhe the symptomology is imccurate.
pâh symptom and rhe actual condition of rhe pûlp in
intlamed teeth has been esrablishedin histoparhological
studies (6, 4a). From â diagnosrjc poinr of view, rhe grear References
vadation of s)'mptomology in pl pal inflâmmation is
rmporimi to nore (see chapters 2 and 6). 1. AÀlberg KL Dôse dependent inl,ibitiôn ôf sensory nerve
The nerve {ibers iJl the pulp may maintain iheir struc- à.tivity in ùe feli.e dentâl putp bv mriinflalrûatory
I t r â l ' d e n l : t \e \ e r i n â d \ J r , e d p u l p i l : . . h o s i n g a , ù n - d r L E . . I , r y r r 1 / . , d / t " 7 q :t 0 2 { t a r 0 .
siderâble destruction of rhe other components of rhe 2. Al'lquisl ML, ftanzen OG, Edwalt LGA, Fois UG,
pulp tissue (48). lt is not known iJ the remajning axons Hâegersiam GAL Quality of pâin sensadonsfoloù,ing
are capâble oI impulse transmission ùnder sucn condL locàl âpplicationof algogenicagenrsôn uG cÀposeo
hùman tôoth pulp: à psychophysiological dd etectro
tions bui clinical experience shows rhât pain cân be
physiologicôl study. In Âdrar.cs ifl thjn R6.a/ch and
evoked in comection with rhe endodoniic treahneni of
ndrapy (Fields HI- ed.), vol. 9. Nes- york Raven press,
teeth where most of ihe prlp iisslre is necroric. Com 1985;3519.
panson of the elech.ical thresholds of single inhadental 3. Anderson DJ. Chenical dd osmoric ex. ar$ ù pan
nerve fibe$ and those of hman teerh also indicares rhât in humâ,r dentine. I. Sdtsoty M(honÀhs in Dûnine
activâtion of only a Iew inrradentâl axons is sufiicienr to (Ande$on Dl, ed.),Oxford:PÊrgamon prêss,I963,88 93.
evoke prepâin or pajn sensaiionsin huDan reerh(31,35). a. Avery IK, Rapp Ii. An investigatio. of rhe mechdism of
With pûlp diagnosis such results are significmt becâuse neurâl impulsedânsmissionin humd teêth.O/rt SrS.
they indicâte that a {ew swiving nere fiber5 q a purp 1959;12:190-98.
s-ith advùced iissue necrosis may give a positive 5. Briirns1lôn M. A hvdndynami. mechanismin dre rds
semory response to dental stimulation. Thùs, evoked mission of pâin prod u.ing srnnùli ttrough rhc dentnrc. h
Sensat!Me.hanislkr in Dan;flc(AndeFonDJ,ed.).Oxford:
sensairons in response to elecricâl stimularion with â
Pergàhon Prcss,1963173-79.
pulp tester do not necessadly mean thâr ihe pulp is
6. Br;imsbôm M. Dertjre o Pttp in ReÂtantjbeDentiitty.
heâlthy. In fact, deniine cân be sensitive in spte of con Nà.h, Swcden: Dêntal TherâpexticsAD, 1981.
siderable tissue damâge in the underlyirg purp rssue. This boùksir5 M e ensiæ dèr.r9tion of diluqi hye6
A1l ihese Iindings indicate ilùr the coÛelêtion between regardik{ theresponysal th. pulflentùLe coxlptrr h ctinicrt
the dentâl sensory responses and rh€ condirion of rhe pracedufts.Dmtite sehsltirit,! and dentalpnin in tmerot at
pulp hssue is poor Accordinglt ir should be nored .lisctsetlin tl.tailjhreldtio tô pulp tbsu.fta.tirnsûfldpulu
tlùt pâlII symptoms are noi â reliable bÂsis for pulp
diâgnostics. 7. llyeN MR. Dental sensory .eceptors. trr. Rco.Neutubial
In inl]ammatory lesions, mediâtors such as histâmine I 9&4,25:39-94,
'fhis
md bradykinin âctivate C-fibers (32 35). After redlrction is a ftli.u papù dentibiry the st cture of the ddtal
tmnatlon. The ùaryholog! ol both prtpdt ûû petindnntal
of the pùlpal blood llow by periapical adrenaline injec-
hûrer dktl tteptars is presentedand dis.u*et1 in tetationto
tions they maintain thei functionat capaciiy bener rtùn
thefuictiDnal osprts.
A fibers (3s), where the implrlse conduction is blocked, 8. Byers MR. Eftect of inflamtion on dental sensory
probably be.ause of hFona in the pûlp tjssue. This nerves ùd vice eena. Pr@. Finh. D@t. S... 1992, BB
m È d n \ t h à r d u r i n g t r e D r o F e . . o . o u l p r i i 5 .p r t p r t ( (Suppl.1):as9-506.
l r b . r - T è v m J i n t a i nd e i r . à p r o i l i l \ f o ' n e ^ e i - p u . e 9. Bycs Mli. Ncuropeptide imuoreactivjty jn denirl
conduction longer t1ùn A fibers. In fa.t, they cân sosory nervès: variation rclâled to primarl- odontoblast
become e\.en more active in the advânced srâges or fun tion and sûvivâi. In Dentin.putp Cotlptà gniûûô
pr pâl ituqammâtion owing ro their susceptibility to M, Màeda T, Suda Ft Tâkâhashi K, eds). Tokyo, Japû:
inflammatory mediaiorc. Qùnrtessence, 1996;124 9.
The ftmctionâl properties of rhe iwo pl p ner1 e fiber 10. Byers M& Nârhi M. Dèntâl jnjlrl, models: expe.rnenrar
tools foi understânding neminflammatory nreracùos
groups may explâin the changes in the qùatity of rhe
and polymodalno.icèptor tun.riôn. cril. À4. o/at Diol.
pain symptoms during pulpftis: Êom rarlrc. shârp or
M.d. 1999;10:,Ê39.
\ h o o t ù 8 J n d q u t e h ê l l l o c J l n ê d .r o d r J t à r d I r g ê r , n g . 'Ihis
rypt ptesmtsû .oihptehensbetdieu an naryhùLogical
Thus, ihe q?e and durahon of the symptoms ur pan€.fts âta functi.nûL oirccts of .lcûtat na.ireprots.tfl phtti.rtal,

r.ttû| tustDûs.sto injùttt arll infLrnmti.r an .ar.trd Th.
rctil\xiù txchùtilnsûnd ûfftnlt lu ncl iort ùf th. itnrdLlùnûl
h.t!.! ih tht neaintian olra.ic.ttit ttforhtttion to th. Ltûitj
rte /1!tnted.'rh. nle.l tht, aoci..ptas ir tguhtiôr ol !h.
i1t|ùtrùtùttùrtaùd repan r.dio,t ,, r,,d t!4, iNa. ô ,ts.
tl.lrfibeti. th ùlLlitiaù, thL us..l inlnA.rkl nùir 4itrtlûlinu
rs ùtùiù ùLtltlaùt1 tht aTli.rti.n.fth. d.rhn iltjtw rûd.ls
tt) studr the t.lrttnlùl ûa.iæptot fundian nnd n.utui.ni.
in|1ùnnùt.t! ffidiaÆ k discrsîd.
1 t LtteN I1R, TarLr)fPL. Lfl.d of scrsorv dc.ervntion or th.
respotue ol rat molar pu lp toexpo r. inj!r1,./. nd,r R$.
1993,72: 6:13 18.
1 2 Chattipàkoû SC, Light AR, l,Mllcockson HH, Nârhi NI,
\ l . , , { - - i . G a r' . - 1 . . . , ! . .
the trigennnâl brain stern conrtlcx prod(c.d lr.' prlpàl
' l r ' u l - r u r i r ,r L - 1 , . r a
t 3 . Coimlrà È Coimtrra À. Dental nolious nput r.nch.s th€
nLbrû.leus .àu.lalis of lhe l.iEenrinâl conrplcx n thc r.t,
as sfoi'n ly cjos expression upon thennâl or nechani
.àl stimulation Nartuci. Lctt. 1991;173: 2011-]1.
Dividson R\'L N Èùràl foml of loltaliÊ d ep€ndenLsodI u nr
cùrcnt !n humnn .ultlred dêntal pulp cells 7ùû. a)rdl
Bld. 1994;39: 613 20
l5 Edwrll L, Olgart L A new LÊch.ique lo- rcco d:nt of
iitradental sensor) ner\e â.tivity in mâ.. Pdi, lt77) 3i
r2t 6.
This is the llÆt t.tùtt ùù jnttûlcntn! nnt nntdfu: ir
huirrr ll,itts. ]tu r.tiarl potentiû!\ 1ttr. ntd.d ltau
de"tji\.. Th. û.t.. t.spersts tùdekttrl\titûthtia uLî klatld
tu yin r$p.nst: tct.tttd by tl'. s!ùj..rs. 1l'. rni /r! s/rr0
lhnl irtnd.rtrl hùres ùt rblL ta candu.l noti..ttnt
IËn.o{cr.ccdà A, Henl<e H, Lundbery lNl, I'etem,ar.
lB, Ilôkfelt T, lis.her lA. Calciloin, Eenc rclâLcd
pL.piide (CGIÙr) in .aFsâicln sensiri\.e sulslan.c P-
mùunolea.h!e
distrib(tion ùd eleàse bI caFsâicin. Pettida\ 19E7i n:
399 110.
ll Cuf]]ron ^C, H.rll lE. lirtl,..t .l ùLtliatl Phy!ùt$lt.
|hLadelPni., PA: 1,V.B. 5.!n.lcrs, r996
CysiA.Aû àttemû to erFlaù the sensitirenessoI d.nti.c.
Br /. D.,/. 5.i. 1900,.13:E65 8.
'fJ.
Hi^ one. A q uantlt,rtiv. .Lctron mi.ros.opi. àn:ù! sis
ot the aaons rl thc ù|cx of th. .ànhe tooth pulp n th-"
dog.,,ldd Ârrt. 1987i 128: 13f9.
l 0 Hinonci T, Niirhi M. The effe.t of dentinal rtnnùLâr,on
on pùlt ncrc fun.tion.ùd prh norphology in the do8
/ l r d , r . R 6 . 1 9 E 6 , 6 51: 2 9 0 3 .
2 1 . Holland CR. Odontoblàsts ànd reryÉs; jurt hiends. r,ru..
Fn,r D.rt Sr.. 1986,821 : 7989.
22. Hollth.l GIl,ltotrinson Pt The numbcr.nd sizc or.xons
at ttic.pcx of tfc cat's .aninÈ tôoth. !rrt. l{r!. 1983;205
215 22.
23 Jr\àsjâNi lr, Kniffki K-D. Cold stim|làfioû ot te€ur â
.omparisonbct$'e€nthe respotuesôf cât inh.dental A
and C fibrcs ind hurln setuàttun./. l/r/si./ 1987,391
193247.
2.1 L.wson SN. Pcplidcsand cutnn.o$ polymodâlDo.icep
nr. neuron.s.Pr.r,: !ûir, À.s. 1996;:l:13369 E6.
pd
Dentinalân u l p apl an 55
25 Lllja I. S"nsorv differ.n..s b.lirecn .rowû àtu1rooi .lenhn
jl hlûàn t.eth. A.ra Od.rr.l. -s.rrd 19E0;3E: 285 91.
26. L,ljà l, Norde,r!àll K l, LlriintutrômN1 Dentùresensrh!
ùt, odontoblàsts ànd rer!ès under desic.âtedôr ùte.te.l
e\periùentàl .à!ities. Sr,.d.Dù't. /. 1982;6: rr3 103.
27. L | d b . r i ' v t - F p . dô r . , ^ , o f r ' F , . . { J , . F .
lation slstemir the orofà.iàlregion.l/... Itrl. Dù,t. Sd..
1 9 8 9 , 8 5 : 2 3590 .
Mâggi CA, Meli A. The senso$efferenl luncùon .l
.àpsâicins. sitire sensortneurous.C.n.l'lrrrr4.!1. 1988;
r9:1 43.
29. I4agloirc lI, Virurd II, Toffrc ^. llc.trophvsiologi.ùl
propertiesof hrmin d.ntil pult cÈlls.I. Ëi.1.Ërù 1979;
7:251 62.
30. Ilitthews B, Bà\tù L t\htts S. SeNory ànd reflex
rcspons.sto tooth pùlp sûmulntionin rnn. Ër"ir! Â.s
1976;113:E3 !r1.
Illnïo.d JNI,Eohrn.r D lnin ùrd plodropnti.sqrsibil'
it} A r€LieNa'itn pa.ti.uhr relcren.cto t.etn. Pdû 1976,
12. Nàjh MVO. Thc chaf,ictcrjstics of lntrad.nt,n scnsory
unilsand Lncirr.sponscstostinrul.iio../. D.,1. R.5.1985,
6.1:564-71.
Nàrh M, Konl ri-\ârhi \i Scùsitilitr ind sùrf.rcecond!
tion of d.ntir à SENtrepli.astldy (àbstri.t).l D&l À.s.
1991j73:\22
Nij,t \T, Kontturi'Nârhi \| Iliivoncn T, NgassùpaD
Ncuroplysiologicalme.hanjsmsof dùltin hvpers.nsidr'
lty. Pro..Finn.Ddtt. 5...1992,88 (S!ppl. l)i 15 22.
35. Nârhi M, JrràsiâNi E, Virtânen A, Huopaùerni T,
Ngassnp.D, Tlirvoncn'f. Roleof irtrad.rtal ,\- ..d C-
lvp. .crvc librcs in dc.tâl pâ n mcclr.nisnrs.P,i.. Fnu
D d t s , . 1 9 9 2 ; 8 (8s x p p Ll.) i 5 0 7 1 6 .
36. Nà,t \T, Yam.rnolo H, Ngassnfa D funclion of
jntrad.ntil no.iccptorsin norûul and inflan.d tccth.In
Dt ùnrlPrll Cautkt lshimono M, M.cdi T, Suda H,
Takanâshi K,.ds).Tol<vo,Iapâ.:Qu nt.sscnccPublishif g,
I996,136-1.10.
37. OlSaft L. tra.itation of intmdental sc.s.L". u.ils bv
phannacological agents. A.n, lirrsidl 5.ùûd I97q 92:
.18-55.
38 Olgafl L. The tule of L{r.aLlacl{ns nr dentù .nd puLp nr
nrba.lental Fain rne.haùsrns. /. D.,t. lt's 1985;6.1:572
()l8a.r L. Neu.al .onr.ol ot pxipal bk\rd llow. crr R4
ù a l B i t nM . d . 1 9 t 6 , 7 :1 5 97 1 .
()18a.1L. NÊurosenic.onrponents olpulp inflanrmation.
ri Dentina/Pu!t1c.np!.r (shnnono rvr, MaÊd.'f, sxtla H,
Takâhadri K, eds).ftkyo,Iapâ.: QùinLessen.efrLnishnrg,
1996;la,9 7r.
Th. ûljaùn Rcn.ptkr flûi| fibùs ûlsa hrr. nttaûrrt .ff.t
utt lin.tit, tn th. ncunSLùi. rÈttkiin i the inJlan,,n|t,ll
nhd tupnjt rerLtiùû: in thèit td(.t rirjLcs. T,À ,?rdr frf.,
,7cs.rilr.! f/,ci irtlùîtîhtotlt rxchùtiùrs, it.lttLirlg tht
.11 ()l8a.t L, (laTelius B, Su.dsLrônr fi lnlfidcntâl .crvc
a.tiviN a.d iaw .pe.ins refLeanr responseLomeciâ.i.ar
.l€form.tnrn 01 .al tÊeth. ,4.r" /rtv5rnl. S.,,d. i988; 133:
 Th€vitâlpulp
Pashley DH. Mcdunism of dentine sæitiviqa D.,r.
Cltu. Nùtth An. 799U 34: 449J3.
S.ott D J., Tempel TR. A stûdy in the er.itation of dental
pulp nene fibres. In Sdsary Mechinisns in Dùttitt
(Anderson DJ, cd.). OxJord:PergamonPress,1963;27-46.
Seltær S, Bendcr IB, Ziôntz M. The dF1âmics of pulp
infl:tll]mtion: correlàtiotu bet('æn diâgnostic datâ and
actuâl }ntopaûological findings nr $e pulp. O/al Sûd.
Onl Med. O1alPtthal. 1963;1tt: 969 77.
In the eûrlt:t196Asthe resenth St.ut oJ Dt Seltzetand Dr
Beûer defnitelltshaoeda poot.ùtrclationb.ttueen thèclini
caLpnn sytuptônsand theactualhGtopûthalagical cakditiùhol
the pult. Thepreseit papetis oneal theî slillii,unt sîirs ol
studiesftgûrding tulp diign6ti.r.
SessleBJ. The ne@bioloEy of facial ùd dental paif:
present knowledgc, tuture directions. .L De,t. ,,t?s.1987;
66. 962 ar
Sigûdsson A, Maixner W Effets of expe.imenral clini.âl
nonôùs colnteriûitants on pâin perception.lan 1994;57:
26t75.
47. stèin C. Peripheràl mehùisms of opioid mlgesiâ.
Anesth.AnaLg. 1993)76:182 91.
It hns bed thaught thût opioitis,e.g. ùaryhûe, hau otll!
anntl glects. This papt presehtse]i.lcn e that thev Ml
ithibit no.i..ptar aclixttian it th. puiph*hl tissLes.
48. Torneck CD. Chânges in the fi.c struct@ of human
ddtal pulp sùbscqudt to .àries exposurc..l. O/rl Paiàol.
1977j6: 82 95.
49. Vongsavd N, Mâtihc$'s B. The relationship beiween nuid
flow in dentinc ed the dischârge of iltrad€ntâl nen ès.
Ath. Ad Biol. 1994;39: 1405.
50. Yâhamoto H, Narhi M. Fù.rion of newc fibres xulcr
vâting difiereni parts of den6ae.Ar.h. Otal Bbl. 1994j39:
14:LS
Chapter5
Themultidisciplinary
natureof pain
IlanaEli
Introduction
Pain is a complex expedence of a mûltidisciplinary
nature that is âlways sùbjective and âssociâted with
emotional md cognitive factors. Todây it is widely
accepted that the mere âctivity in the nociceptor and
nociceptive pâthways of the neflous system clicited by
a noxious siimulus does not represent pâin. Pain is
alwâys â psychological stâte and cm be reported âlso in
ûe âbsm.e of tissue damâge or any likely pathophysi-
Pain is often L\e pimary motivator for pâtients to
se.k health carc in general and dental h.eatment in
paftict ar Dental treâtment is closely âssociâted with
pain. Mosi dental pâtients expect to experien e some
de8ree of pain duing dental treatment ând dcntists
olten use pâin as a diagnostic tool. Self-repolts of
pain seNe the praciitioner to locate possible pathology
and to arive ai conclusions regarding diagnosis âJld
h€âtment, e.g. the use of tooth pulp stimulahon âs
a diâgnosii. tesi for pulp vitaliiy (50). Hoù-evea pain is
ân ùn]eliable jndicator o{ paûology (2a). h fact, liit1e
co elation exisis beta'een the âmouli of lissue desûuc
tion and the reported presence or âbsence of pain,
wheiher derived pulpâlly, pcriodontâlly or periâpicaly
(s4).
It is impossible to view pâin as only a unique sensory
reaction, thercfore pâin js defined âs 'an unpleasmt and
emotional expedenceassociatedwith âciual or poiential
tissue damage, or described in tems of such damage'
(26).Thus, pâh is alwâys subjective ând unpleasant and
not necessdily related to â stimulùs or direct tissue
damage. It is an emolional and cognitive experience
affected by stress, anxietJ, expectation, focus of âtten-
tior! gendd md culture, in oiher words, a mùltidisci
plinâay experience (Core concept 5.1).
Unlike many other sensaiions that are evoked by
external events (seeing, hearing), pain can be classiJied
âmong rhe bodily sensations that are evoked by internal
evenis (so-called'need siates'such as hunger ând thirsi).
Like other need states, pâin js affecied by distraction,
Coreconcept5.1
lvlanypeoplereportpainin theâbsenc€ of tissu€damageor any
liGlypathophysiologkal cause.
ft€re is nowaytô distinquishths
experiencelromlhat of tssuedamaqe andit shouldthererorebe
acceptedaspan.acrvityinduced inthenociceptorândnockeptve
patlrwaysby a noxiousstimuusis not pain.Painis alwaysa psy
srggestior! culture and learning and is âssociâted widl
â predictable behâvior
In many acutc pain situations, including pulpitis,
;Niety mây not orily low.r the pâin threshold but
my, in facL leâd to the perception dùi nomally non-
painful siimuli are painftrl. Althoùgh the cxplanaiion
for such a phenomenon is not a1wâys fully understood,
it is essential thât the treating dentist accepts the fact
that for the pâtient the expeience is similâr to that
caused by ddlling in a non-ânesthetized tooth. In â
similar maruær, pcople differ in their pâin perception
and rcaction âccording ro iheir culture, social environ-
menl gender ând individùal cogniiive ând eootionàl
fâcto$. Moreo\-er, the same individuâl mây rcact in a
differcnt mamer to similù stimulations ûider different
conditions (CoÊ concept 5.2).
Pâ may produce immediâte beluvioral manifes-
taiiorB, such as instantàneous withdrawal ftom the
siimulus- It can also bring about long+crm behavioral
consequences, jncluding the development of dental
Coreconcept5.2
Painresearch
distinguish€s
betweenpêinthreshold
andpâintoler
ance.Botharedefined
in temsof a subjective
sef report:
. Painthreshold zabe pa:nexperence
È theleastrccogn
. Paintôleranc€
isihegreâtestleveofpainihaton€isprepared
57
anxiety and phobiâ, which in turn coi d leâd to avoid-
ance ând severe neglect of dental .âre. Proper ulder-
standing of ihe pain phenomena enables the use of
non-pharmacological modes for pain management
and leads to better dental care ând palient mana8ement
in ilrc imediâte ând long term. The various psycho
logical faciors that affect pâin experience ând their
importance in dental ireatmmi are addressed in ihis
Psychologicalfactors affecting
pain experience
Affective factors
tnpact of sress,feÛ and nnxiet!
It is widely believed that aùiety is associated with
incrcased pâin report (9). A tense and uioùs patimt is
more lnclined to report pain during ireaiment tllan a
relaxcd one, because anxiety createsthe expectâncy for
future pain. Therefofe, ân anxious patient who ârrives
for treahment with former pain memory is likely to
expect pain d udng the tr€atment. This câûses the pâtient
io filter selectively âny inJormâtion given pdor to ù€ât
meni and 1() focus on stim li that can lesenble or be
associated with pain. Thc slightest pressure on ihe iooth,
for example, can be inierpreted as pain and initiate â
pain reaction. Arousâl câused by anxiety may âlso leâd
to increased slmpathetic activiiy and muscle iension,
which nay cause additional pain.
Denral anxiety is â prevâlent obstacle that aftects
human behavior in the dental setting (i5). Among all
dental siiuations, the one causing the highest levels of
siress md ;ùieiy are oral surgical procedures and
endodontic therapies (5, 1Z 52, 60). Thùs, there is a high
probâbility thât patients who arive for endodontic tfeâi
menl are anxious and expect to experiencesome degree
of pain during treatment. This may prompt patients to
report pain during treatment even when there is no
pâthophysiologicâl basis for such a rcport (c.9. drilling
in a tooih with non-vital pulp). Somctimcs thc achcvc-
ment of pioper local mcsihesia is extremely difficult
md thc paiient coniinues 1() complâin of pain in spiie
of sel,€ral âitempts at drsihesia. Such situaiions arc
closely associatedwith patienis'{ear of dentâl treatment
(27,58).
Becausepain by definition js always subjective,there
is no r{ay to distinguish between pâin due to psycho-
logical reasons and pâin originaiing ftom actual tissue
stimulation. In both câses it is regârded ald reported by
the patient as pain ârld shoirld be accepted and referæd
to âs such (Key literaturc 5.1).
Keyliterature5.1
In anextensive
revewregafding painandanxi€ty ln d€ntêlproce
Litl(36)Toundthal
dures, in acutepaln situationr
anxletyand pain
pâinlhresh-
maybeindistinquishable.
Anxiety notonlylowerslhe
od, but mayactuay leadto the perception that nomâllynon
painfulstimulare pâinful(e.9.vibÉtlonoI the d ll feh on an
Mood, especiâlly depression,inlluences pâin perception
and pain tolcrance. Ther€ is a clos€ re1âtion betw€en
chronic pain staies and depression(53). It has b€en
hFoihesized ihai chronic pain and depression âr€
closcly rclated, owing io similar neurochemicalmecha
nisms in both disorders. Another reâson for depressed
mood is the wây in which chronic pain jnrcrferes with
importani fuctioning in e\.eryday life (e.9. decline in
socialactil.itiesand socialrea'ards)(51).
Moo.l caJrtâffect pain perception also in short-term
acute pain situations, such as dental heatment. For
exalrnple, weisenberg et lr/. (59) obseNed that acute
pâin per.epiion wâs âffected by a film induced mood
condiiion. In thât study 200 subjects \^'ere exposed to
three diff€rcnt t)'pes of films: hùmorolr s, a holocâusr ând
a neutral. Before wârching the film, immediarcly aJier
md 30min laieaeachsùbjectwas clÉllengedwith a trial
of cold pressùrepain. The r€su1tshdicated that subjects
who watched the humorous film iolerâted thê pain chal-
lenge better lhan any of the other subjecis.This obser-
vation suggeststhat psychologicalapproachescould
have a significant e{fect on ihe sensory dimensions of
pâin and thât pain tolerancein patjents can be increased
substantiêllywithrâthersimplemeâsures, includingthe
showing of hmoroùs films in the waiting room.
Cognitive factors
Pain is one of the most potent foms of stress.The €x
perience of pain in lud€s an actual confrontation with
harm, which can be physical (e.9.injùry), psychological
(e.9.loss of control) or intcrpcrsoml (e.9.slùIne). As
such, jt is affected by both the potency of the stimulus
ând by the individual's abiliry to cope with the shessful
event(49).
Attentio oersus distrlrction
Alrnost any situation that athâcts â sufficient degree
of hiensc, prolongedatiention(e.g.sports,batu€) cân
provide conditions for other stimûlation to go ûnno
iiced, inclùdnE wounds thât woÙld .ause considerâble
sutreing under normal circumstances(39).
 nalureot painmanagement 5 9
fte multidisciplinêry

Broâdly defined, distraciion is directing one's atten-

iion from ihe sensaiions or emotional reactions prod uced Coreconcept5,3
by a noxious stimulus. Generally, dishaction reduces
Anambiguous sensation canbepercivedase tlrerpeasurâble or
pâin compared $'ith undistracted conditions (38).
pêinful, bâsed onindividuai cognitions andexpectatlons. ïherefore,
Denlists cân apply distraction techniques while treât p . . e ni p ' p at di o - i n l . p n ( ". h " e d i , 9o f p d : -o rn op à : -
ing their patients, e.g. by using background mûsic or
râlking to the pâtient. Several âdvanced methods have
been described as being effective i. the dentâl clinic,
such âs momting a ielevision monitor near the .eilin8
ând âsking the pâtieni to plây â video game 'agailrst Keyliterature5.2
the house' (8). Disira.tioll teclùriques ihai require
àncrlionêl .dpd.il) d-e erle.f\e in -edu.rng pd r- ln â studyby Dworkin andchen(12),subjects served asth€rrown
r€lâted disiress, and even the simplest distraction tech- controlwhentoothpùlpshocks weredelivered eiiherin a labom
toryor in a c inkalsetting.A substântiâldecrease in lhe subjects'
niquc isbeneficial inredrcing â patient's stressand pain
thresho dsfof sensationândpain,and n palnto erance wasiound
whenpati€ntrwerechâllenged in the dinca ættlng.Fromthis
studyit canbeconcuded that in thedenlaloTTk€, patienfsamc
pationof ihreatândthê âssoclâted ânxiety arepotenrcognitiv€
Reseârchhas shown that shess, coping mcchanisms md mediato6ofpain b€havloL
Inotherwords responses to painstlmuli
reaclion to pain are alïected by the degree of conirol thât c r â l q êè ( o d , q m ù e l i t u à i o - ac o n r e ^I n
r whrr Dâr I
patienls feel they have over the stimuli that can induce
pajn (3, 35). For exâmple, pâtients who were provided
with inJormâtion on N,O ânâlgesia shoived highcr pajn
tol€rance ill]esholds to iooth pulp siimulaiion thm
paiientswho wer€ noi infomcd (13).Becauseihe fear of dentâl trearmenL this increases the liketihood for pain io
uncontroiled, sùdden, acuie pâin is â primary concern be perceived (Core concept 5.3).
for most patimts (33), conlinuous informarion regârding ln stressful situations, behâvior, tholrghls ând emo-
forthcoming procedùes md ihe dcscription of the likely tioml reaciions are influenced noi only by the stimulus
sensâtions are important in order to provide pâtients as such bui also by i]rc individual's perception of 'self
wiù some sense of control or involvement. Thereby, efficacy', i.e. one's belief in ha\.ing the lelevant and nec'
&iety and pain le\-els associated $'jth dentâl proce essâry coping ski s (2). lf â patient believes that he or
durcs can be reduced (56). she cân sùccesstul1y cope with the ânticipated pain, then
rhis perception increases the pân1 tolerance, and vice
Pain beliefs and expectitio'ts r-ersa. Cenerallt those who avoid denial care be.aùse of
Reaction to a stimulus, whether âcute or chronic, is fear and anxiety perccive ihcmselves âs being reliâbly
âlwâys âffected by drc meaning ihat ihe individual less able to tolerate pâin. Such paiients often clam to
attâches to it. For exalrnple, the paiient ca1 interyret an hâve an 'exceptionally low pah tlæshold' or rcpoit
p p i " o . l po " r u n e ç e c t e d a n d t m e \ p l à h e d p d h . e n themselves as 'completely unâble to endure pâin'. Sùch
sâiion dudng ireatmeni as a sign of insufficieni a low self efficâcy further lowers their pain tolere.e
professional skill on thc part of the dentist. This in turn level d uring treatment ând increases ihe probability ihat
cân develop mishust and make the patieni assùme pain $.ill be experienced (29,30, Key liieraiurc 5.2).
that any turiher minor stimulus is a threat ând evokes â
pain reâction. Conversely, when mutual trust exists Pain prediction and memory
and when the patient has complete faith in the necessiq, Usuâly, memory for the generâ1 intensity of pain is
of the treatment, ch incidences are beârable and less good. However, ûe level of pâin remembered by pa
Lnr- r"tsddn{ pe\ioJ" denlêl hrâlmêntri- morr
In a classicexperiment (l), subjectswere re$ested to .losely associâted with theù expeciations of pain rather
toudl a vibnting sùfa.e for ls. Some were leci to thân to their real pâin experience (2E).Furthemore, mood
believe that the sûfâce would caÉe pain, others tlÉi it md affective staies inflùencc ilÉ memory of pain (19).
{ o J l d o r o d . r e p e d - r r ê i n d r h " f t - m d i n o é rh c , É i \ c n Whm denial patienis experience recurrent pain
no hint on whai the vibrations would eniâil- As pre- dufing ireâtment, their recall of the expedence has an
dicted, thê'pain sùbjects'usuâlly reported the \-ibratjons increasedmagnjtude. This maylead tojncreased anxiei),
to be paintul, the'pleasure subjects'as pleasurable and âncl increased pain perception. As time elapses, ihe
the 'conLrol subjecis' as neutral sensâtions.This experi- pâiiîul expedencestend to gain negative impact, pfob-
ment shows tlui if a patient expects pain to occu| dùring âbly due to reconstruction of memoljes to make them
60 Thevtàlpulp
consistent with the existing level of anxieiy. The vicious
circle is enhânced by feelings of shame due to ihe inabil
ily io cope û,ith the situalion- Other defensi\-e adj6t-
ment mcchârisms, sùch as sùpprcssion ('I don't evcn
h , n l l " l ù l o f l h a t) . J e r i d l , I h " r È - n o t h i r g \ 1 , n t s
with my recih') or projection ('I simply hate dentisis'),
further coniribute to the pâtient's inability to cope with
the siLuaiion and increâses thc probability of pain duing
treâtinent (15).
Memory of past pain experience also depends on the
intensity of ihe pr€sent pain. When rhc pain htensjty
is high, patients remember the levels of their plior pâin
as being more severe than odginâlly recorded (14).nns
situaiion is occasionâlly secn among pâtienls û'1û ex
pericnce postopertrtive pain after their first sessbn of
endodontic therâpy. Postoperative pâln causes Pahùis
to r€member former ireatmeni âs more PâinfLLl than in
fact was oliginaly expedenced. This, in ium, leads to
highei siress, higher expecrâiion of pâin ând loa'er tol-
erancc of pain in the next encounier s'ith the dentist.
Environmental
factors
Direct and i'tdbect lealning
Part of off behâvior resùlts from tife experiences. The
.onc€pts ând coping sirategies of valious liJc events
(n1clûding pain) arc contintally âffecred by leaming
processes.For a leamed behavior to d€velop, exposûrc
to tlrc stimulus in q estion must occur, resulting in a
response pattem (conditioning). Fûrther rejntorcement
of the responsê pattem (positive or ne8âtive) leads to the
acquisition of new behaviors.
Unfortunâtely, the dentàl situation prolides nùmer-
ous opportunities for negâtit'e conditionin8 and the
acqdrement ot maladapiive behaviors. The most com
mon stimulus in this respect ls pain. ^lthongh acute
pain during dental trۉtmenl cm be avoided in most
cases, there âre srill many adults who hâve expenencecl
it during treatment in the Past. A dental praciitioner who
acts without perseverance to$'ard an aPPrehensit'e
patient seNes to rcinforce ihe nc8âtive behavior, thcreby
decreasing the pâtient's tolerm.c io pâin. Reactions of
'difficult io handle'
impâiiencc towârd the Patient, as-
sociaied wiih unconscious punishment (heatmeni aP-
plied in ân impatient ând harsh mamer), reinlorce the
negative bchâvior of the pâtient md lowers his or 1Ér
Numerous learned behâviors associatedwithpajn âre
bâsed on negali\.e rciiforcement somcthing ûncom-
fortable or fearful thâi shoùld be âvoided. This t}?e of
(to
leaming includes escâpe and avoidânce avoid or
prevdli tlrc ùnpleasânt situation before it occùrs). One
example is that of patienrs who reâct with symPtons
of pallor, nâusea, s$'cating, dizziness oi even lainiing
during administration of local anesthesia. In many
iîstances, sympioms originate n1 the patienfs feàr of
pâin .ather thâJlt being due to pathophysiologicâl
câuses-The sitùation can resùli in signjficânt shessto the
dentist, who occasionâ]lychoosesto PostPonetr.âthènt
to the nexi appointnent. Once the symPloms have
seNed thc patient as ân adequate meâns io avoid the
stressful situàtion, it mây seNe as a rcinforcement to
increas€ the probabiliiy of recurence dûring subsequeni
confrontâtions. Patients develop a'fâintjng Prone'
'protects' ûem from the need to face treai-
behavior that
menl. The negatil.e paiten is further rehJor.ed by the
dentist's rcluctânce to ireai pâtients with such â medical
history'
In some cases fts rn alâdaptive Pattern is further rein
forced by secondaly gai$, sùch as slmPâthy and ât1en
iion from the environment, â\-oidmce of unPleâsmi
work of dutics, etc. Reinforcement of pain behavior can
âlso occur with pain medication. For some, ihe effects
of pain medication reinforce pain behavior due io the
development of physiological ând psychological addic-
t i o r . n r e . ê i n d i L ' d u d. . o n . h J e r . " p r i n b ê h a \ o r r e -
essary ând sllfficieni to leâd to delivery of nedication,
even aftcr the original rcciceptive stimulus has r€solved
Iror lcaming to take place, pâtients d o noi lùve to hâve
â direct experience.Ii cân also be a rcsùlt of observalion
(vicàrious leannng). This meaÉ that one sees wtÉi
hâppen-sio another indi\-idual and assumes thâr ône's
own fate wot d be similar jr1 nature. For ex.mple, â
child who accompanies his or her pârcnt to the dentist
and ù'âtches a pain-lelated behavior mây laier, in a
similâr situation, irniiate that behavior. Indeed, observ-
ing oth€rs respond to pâhful siimulâtion could eiiher
provoke or reduce ihe pah response of the obsen'er (47)
Vicârio s leaming cân Àlso oriSinate through identifi-
cation (e.9. a parcnt a'ho comtântly comPlaitu âbo1rt
pâin from â tooth or denial treârment) or through in-
dircci suggestions.For â pàrent who brings his or hcr
child to the deniisi and reâssuresin a hembling \-oicê
'.
that . . there is no reâson to worry . . - it will not hurt ai
â11...', ihc non verbal sùggestion may oltèn bè the
reverce and cause increâsed pain sensitivity
'stressor',
ln conclùsnù, as with any other Pain is âlso
influ€nced by indnidùally le.med lesponses Respon
dent and opcrani conditioning, indirect leârning i]ùough
mode]nlg and suggestions, as well as sociâl leârning
have a significant impact on the pain expeience (6)
socialand culturalfactors
The inÎùence ol social cnvironinentâl factors and the
level of approval gi\-en by different societies for ihe
 Ihe multidiscipl
narylrâtureof lain mânagemeni 61

public cxprcssnn of pain lùvc a significant impact on

painbehavior Ar-arietyofstudies in the 1950sand 1960s Keyliterâlure
5.3
i n t h e U S i o u n d d i f f e r e n c e si n c l u d i n g d e n i à l o f p r o b -
Eliel al (l6) invenigêted therelatonships of gend€ranxktyand
l e m s ,s o c i â l l v i t h d r â i { a l â n d f e w e r c o m p l â i n t s i n c u l '
pan n the dentalseting.In the ludy, 32 womenand32 men
tur.l gfolps thât tend to be more rcsered, ând more undeNentdiâqnoli.loothpulpnimuLation by an electrcpulp
dr..ratlc responsesto pnh, grcnter expfessi\.€ness.nd iesterAthôuqh therewasnod rectimpact olgendef ontre vanous
. n e e cflo f s o c i â ls u p p o r t i n t h o s €. u l t ! r a l g r o ! p s w h e r e pân me6ûes(sens tivtythreshold, pan thresho d,pan to ecnce),
expressjonof emotion is more âccepted (61, 62, 63). th€reweresltniTkant diIIùences n therelalonship between pân
lhe culhùal significancc aitdbuied io pafi, synbols toleranæ andthêsubledive evaluation orthepainfulexper€nce by
of panl and situations àssociâtecl ,ith pâin màk€ therr bothgendeBInwom€n, thereatioNhp ws negar ve{thehiqher
à.c€ptâbleor àvo àb1eregàldless of the à.tuâ1 intensity theone,the owertheother), whercas in menit waspositve(the
of the s.rsâtion. For cramplc, acccptance of pain h q h e r t hoen et,h eh i l h e r t ho€t h ù ) .t w a s c o nu. d e d t h a
wto m e n
idictcd durjng thc adminisiration ofl()cal ancsthcsh as wereaflededmorebytheoblectve.haract€ristics oi tlrenimuus,
whereas menwerealroâflededby ts psy.lrologka signIkan@
scrving a positivc purpose, rc'jectionof pan causcd by a
Proper understanding of thevarabesthatafi€ctindivdualpain
nccdlc puncturc ù the fingd as symbolizing injury Tlr
assessment n menand womenis imponanibe(auseit may
accepranceofpain does not mean thâttheieelirrg qlLalitI pfôduce emotiona responses that.an nAuenccomplknæ
oi ihc sdùatjon has changed. Ihe scnsation is alwavs
tùipleasanL but ùe unpleasanhess is blerated r!he.
cultural trâ.litions câll for its âcceptânce.
UJlrileethnic groups differ Nith regard to factors that
i n f l u e n c er e s p o n s e st o p â i n , s i m i l â f i t i e se x j s t i n t h e i r affcctcd by sociocr hrrâl fâctors and the percei\-edposi-
leport of the response.For €xâmple, â mor€ recentstudv tiur of mcn and womcn in socieiy.EmbaûâssDent in.y
br Lipton (34) fould thât r€sporses, âitihldes ànd ' . r J - p m ê r l o ' r , r r _ , ' p J i l u , î l ' . i l I r . r . . - . - i r . ê \c
descriptions trere relatilely similar in fàcid pân1 ity ând inieifcrcs a.ith i{ork. Min nzhg pâil1 ûdy be
pati€nts toom a w e vadctt of cultural backgrormds.
consistent i{ith sociâl and culLural norms tlùt consi.{er
Most of thc itcms for lvhich intcrctlnic diJfcrcnccs wcrc insensiti\-ity to pain and pain cndùrance as attribut€s of
found con ene.t emotions (stoicism vs expressileness) virilifi'.
in responseto pâin, àn.1 interfefence in dàily function There à1€ consiclerâblediffercnces befi{ccn irpcs of
jng aliribulcd io pair.
chlicâl pàin (22). Expefimentâl pain, produccd ulder
Furilrcr cvidcncc cxists lhat somc dimcnsi()ns ot pain controlled cofditjons bv briet noxbus stnruli, differs
(time, intensitl., location, quàliq., ciuse ând curâbilily)
tuom proct'dural and postsurgical pâin. These kinds of
are unilersal, rvhile others are cûlture specjÊc (,10,41). pan havc diffcrent me.Jlings ànd make the stud,v of
pain rnorc complex (KeI literàttr€ 5.3).
Apparùil} (rcmcn ând men mâke cliffefent assess-
Genderând pain ments oi proccdrùal pain and ma) thus be affected dif
fcrcnily by i]È exp€rience.ln â study regârding clinical
Cen.ier differences in responseto pdirr siimuli àre con- pâif in the dentâl office (18), it b'as shosn lhai men
hov€rsial. Som€ claim ùai rvonen exhibii greater sen expert to expcricncc morc pafi preoperàtivelv than
sitilitt io no\ioùs stimuli ihân nen (20), whereàs others s.omen buL rcmcmbcr lcss pain posioper,rtivell It i{às
show onll slight gend€r differencesin râtings of chrunic conclucled thai cognitiYc pain perception il1 clinicâl sit
and cxpcrimcDtal pain, pain-rclaicd illrcss trciùvbr and . r , l . n - d i f e r . t r p. p e . E pr , r ^ . - : . . | . l - l 1 . , \ J l :
pcrsonaliiy (7). nâte in Fsychosociâl fàctors such as cxpcctcd g€nder
In an cxtensive reviea. concefning gender lariatiiù in
clùicâl pain experience,Unruh (,55)reports ihat a.omcn
âre more likely thân men to experience à variety of
recurrent pains. ]n most strL.liesb'omen reporl morc Psychological to pain
approaches
se\ere levels oi pain, more tucqucnt pafi and pain of
longer dur.rtion thân men. Wornen mny be nt gfeater risk
management
of pâin relatecl djsnbitit,v thtrn m€n, but lvomen also
Treatmentstrategies
r€spond morc àggressn'e1y to pai11 throilgh heâlth
related actilitics. Rcgarding psychosocial faciors, the Sysiamatic aticmpts to treât pâif hdv€ been closely
review shorls that mcn may bc morc cmbarrassed bt aligncd wiih hos, pain is conceptùalize.l ând e!âLuâie.1
pain ùan vromen a1d that thc mcaning of pain nay be (21).Tradiinùall)', the focus in l11edicjre(and clentistrv)
62 llre vltâlpulp
has been on the câuse of the pâin reported, lviih tlÉ
assunption that there is â somatic bâsis for thcpain and
once it is identified the soùce can be blocked by med ical
or operative intervcniidl. In ihe absence of physical
basis, the sitùation was labcled as psychogenic pain'.
Todat it is widûly accepied that such a dichotomous
view is incomplcic and inadequate. There is no question
that physical factors cùliribute to pain symploms, or
ihai psychological factors plây a part in pain reports.
Thereforc, m increâsing range of psychologicàlly based
hterventioN is conlinuously incoryorâted in pân1
Treatment ot acute pâil1 inclùdes sirategies based on
information, distraction, relaxation and h}?nosis.
Generally, prepadng the pâtient with coping skills
such as hformâtiory disiraction md relaxaiion helps to
reduce the discomfort of potertially panrJul dùial pro-
cedurcs. Palients who âre properly prepared show less
anxiety ând prcsert reporis of low pâin. Such non-
phâr acologicâ1strâiegiesfacilitaie acuie pain manâge-
ment ând are felâtivÊly casy to leam and perform. They
shoûld be part of the professional training of every
dentist in general, âs rvell as of speciàlties,especia y n1
Effective treatment shategies for ûe mâllagemeni
of proionged chlonic pâin conditions (e.9. temporo-
m d , d r b u l r r L l i , p ,. ê ) i n , u J ê o p e r d n .c . n d i t i o n i n Ë .c ù B
nitivebehavioral ihcrapt psychodynamic therâp).,
group tLrerapy,biofeedbâck, rclâxation and hypnosis.
Rob of hypnosis tts !:tnoile for pûin ha\dgeneftt
In spite of iis ancient roots, hypnosis has been âccepted
only recendy as a scieniific and medical tool. Hypnosis
hâs been suûounded by myths ând mystery for so long
thâi even today vadous populâr mlsconceptions exist.
There is no doùbi that ii is a poa'erful therapeutic tool
(Core concept 5.4)- From 1982 to 1985 alone, over 1000
ârticles s'ere pùblished on hypnosis (46), hdicâting â1,l
endùing willhgness on the ptrrt of the scientific com
munity to Âccept it as a legiiimate topic for clinical and
researchinvestigation.
The use of hypnosis fo1 alesihciic purposes dates
back to the 19th century and is atLributed to Recamier in
1821.In dentist{,, Oudet uscd h}?nosis as an anesthetic
âgent to extract a tooth in 1837(48).Today, hypnosis has
becn described in the deîtal literature as having a dra-
matic effect s'lrcn used as â sole anesthetic. Hilgard
ând Hilgârd (23) summarized nl,merous case reports
$'here procedures such as extractions, pulpotonies and
pulpeciomies were performed ûnder hypnosis s,ithoùt
other deslhetic agents.
Hypnosis is used in endodontic treatment (42 44) and
in other dental procedures (32, 57) to âllow trcaiment
Coreconcept5,4
Potential
appcations
of hypnosis
in dentistry
ndude:
. Patienls
whosufferfronrdentalfear, anxetyor phoba.
. Pati€nls
withexcessive gagginq rcfex.
. Acut€andchroncpan conditlons.
. Enhancement of patientcompliznce withdentâhygiene.
. Enhancement oI patientadaptatlonto dentures.
. Toinduælocalanesth€sia in patientswilh
specilkfearsand
n
treâtingpâiientswiih true(orsuspected)hypersensitivty
!o
oca ânesthetic
âqent!.
without shess or pain. For example, it câJrtredlrce both
the srrength and uîpleasantness of electricâl tooth pulp
siimulation (25). The use of hlrrnosis to induce locâl
anesthesia is especia y effective for medical)' compro-
mised patients (37), for patienis $,ith specific feals (i.e.
clental syinge, needle or nlections) (a) and in ircâting
patienis with irue (or sùspcctcd) h'?ercensitiviiy io
hcal anestheiic agent-s(45).
\'lûnagiq adùprse rca.lion lo Iocûl ûne'lheiia
Occasjonally, pâtients may present wlth ê history ol
hypcrseNitiviiy to local ânestheiic agents. The symp-
tons usùally in lude hmediâte r€actions to ihe
injection proced!rc (dizziness, shoû1ess of brcath,
iâchycardia, etc.). Although the true incidence of local
ân€sthetic alergy is lo$', such â history often involves
both the patient's a'Id i]rc dentist's eiety rcgardfig ihe
J- uI ll FdrutsinqLr'hon.Hrp|on'.drt.'\ d Indjùr
roh n1 conholling pafi and ilÉ associated disiress.
In many cascs, advcysc rcaciions io local anesthetic are
ps),chogenic in naLure. Fear of injection, or of dolial
treÀtment in general, col d lead to sone of the
mosi frighiening 'allergi.' reaclioN - tâchycardiâ ùd
vasodc?rcssor syn opc. E1.cr patimis with a former
diagnosis of allcrg)' may noi bc allergic ai all (10).
Pâtients frightened by the use of local or general
anesthesiÂ,of those djagnosed Âs auergic, may suffer
from se\.ere adverse consequences.Pâtients correctly
or inconectly labele.l as 'allergic' tend to postpone
rontine treatment ûntil pah is intolerable, whidl causes
detedoration of their dentâ1 cofdition (11). Agàjû
hypnosis may be used as ân efficient tool to m.luce
ânalgesia/ânesdrcsia a1d to eDable rouLine dental care.
Generally, the hypnotic r€sporse is eâsil], achieved
bccaùsc of illc patient's high moiivation and because the
meihod is solely used to âchieve ânalgesia- Conse
quenll).,pâtients do not expect any 'psychological' inter
\.eniion ând thereforc hâve less need ro mobilize
psychological defenses(31).

Casestudy
Generally, aùieiy incr€âses i]rc percepiion of noxioN
events as pâinful. F€ar ând dùieiy æ ofien encoul-
tered in ihe dental situation. Therefore, ii could hâve
a najor effeci on the patient's Éport of pain and con-
comitàntly on the diâgnosis (and trealnent) of vârious
dental paihologies, inclùding endodonti€ lesions.
A 16-year-old girl suffe.ing from dental phobia
aûived at a dental clinic for a routine examination.
Owing to high dentâl ânxiett the patient hâd prei'iorsly
rcceived treatment under generâl anesthesia. On eùter-
ing the clirtic, she manifested a high degee of appre-
hension but a$€ed (with âppârent shess) to undergo
'initial'
exâmination.
Examination reveâled a râdiolucent lesion between the
roois o{ t€eth 12 and 13. SeNibiliiy lests peiformed on rhe
teeth âdjâceni to th€ lesion evoked a clear pain respolse,
suggesting a non-endodonii. eiiology. To avoid possible
misdiâg1losis, the iesis were repeated severâl times by
tNo independent dentists with identical result. Con
tralaierâl ieeth reacted in a simiiar manner. The pâtient
was rcferred for further consultation to an Oral Surgery
Clinic. Outcome of sensibility tests was .onsistent with
previous results. Each time a cold or electricâl stimulus
was applied to ihe teelh in question, the pâtient reacted
with pain coupled with âpprehemion.
References
:1. AidêÉon DB, Pmebâker lW Pain and pleasure: aRer
native interpretàtions for identical stimulâtion. Err .1.Soc.
Pst!.hô|. 79AAi lO: 2Q7 12.
2. Bùdùâ A. Sèlf efficacy. Towâd a unlying ûeorv of
belDvior .l'.nge. Psycldl. ltd. IL)77i u: t9 | 215.
3. Bmdûà A. Sod"l lorrddtian afThaaghtdndA.tiùh: û So.1nl
Caghitiae Theot!. En8lewoo.l Cliffs, Nl: Prentice-Hall,
1986.
4. 8.,tu4 q\4. È,lJ\diiùn ., EEr.b, , drd h}? n- . ,
dennsxy. Pedialr Dent. I97L ll:72 5.
5. Brdd Ht Cortzak RéiTh, PalmeÈBouva CC& Abraham
RE, Abralaû-lnpijn L. Cardiôvas.uld
docine responsesduring acutc strcss induc€d by diffeF
ent types of dèntal tr€atment.l"t. D.Dr..1.1995;45:45 .9.
6 Burdette BH, Gâ]e EN. Pâin âs â lemed rêspôn*: a
reliew of belDviorâl fâ.tors in dboni. pàin. /. ,4r. Ddrt.
Âssd.. 1988;:l:16:881 5.
7. Bush FM, Hârkins SW, Hâ.rin8ton WG, P.icÊ DD. Analy
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presentâtion in tempoN mddibular pâin. Prir 1993; 53:
73S0.
Themuliidirciplinàry of painmanagement 63
nalLrre
It was decided to perfo1Ïn an €xcision biopsy of Lhe
le.rnr Jnd' r ge r rdl dé-.he.rd. Os hB lù lhe pro\im
iiy of the lesion to thc apex of tooth 12, it wâs assumed
that following the biopsy a possible devitalizâtion of the
tooth would occur. To avoid this complicahon md
fùnher trauma, pr.'ventive endodontic treaturcnt was
sùggested prior to biopsy.
When the p lp of tooth 12 wâs opened, â non-viial,
necrotic tissue was revealed.The canal was clemed and
seâled without funher intervention. Six months laier
the lesion had resolved ând no turther treahnent was
Pâin is olien a poor indicator of the cause of a condition.
In ihis pariicùlar case, patieni ara\iety, siress ând
anhcipation of pain may lùve led to subjective inter-
pretation o{ the applied stimuli as paintut md ro a
clinical reaction ihat suggested the presence of â viial
pulp. In Lhe diagnosis of endodontic pathology, pain
often sefl,'es as an important parameter of evaluahon-
The high incidence of feâr and ânxiety âmong dental
p à r i e n t - .à n d i r i n n L e n ,e o I r n \ i e r y o r l h e p , i n e \ p e -
rience, call for a resered frame oI mind 10 individuals'
8 . Colah NL, Gale EN, Illing Sl. Psychological shtss
reductiondlrint denialprocedù.es. /. Dc,r. R?s.:1979;58:
134751.
CÉig KD. Èûotionâl asp{ts of pain. In ?lli,oo/. o/ Prnl
(2nd edn). (wall PD, Melzack & eds). London: chxrh l
:10. deslEzo ltD, Nèlsôn HS. Ai âpproa.h to the pâtidt Mth
" \ i . 1 . I ù i l ô . . ! x 1 e 5 t 1 ' êrbl i.f e ! e F h \ , r ) s p e e n . e
with 90 patients./. Â//c/SyClin.tnnunô|. 1979;63:387
11. Dole r,A, GoepfÈd Sl. An âllèrgy to lo.âl desùeti.s?
The .onsequÊncêsof a misdiâgnôsis..1.D.rt. Cl,rd. 1989,
5 6 : 1 0 36 .
Dworkin SI, Chen AC. Pàù in clini.al dd laboratory
contcxts..1.D.rl. ^es. 1982,6l i Z2-4.
13. Dworkin 54 Chen ACN, Schubef MM, Clàrk DW Cog
nitive modiJi.âtion ôf pain: infomàtion in comblnàtion
w i t h N , O .P r i t 1 9 8 4 1 9 : 3 3 95 r .
Eich E, ReevesJL, JaegerB, Gmff liadfôrd SB.Mèûôry of
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Pdin l9a5i 23: 375 9.
t5. Eli t. PsychDphlsiology: Sr"ss, Pdin aîd Èeha.jarn1Ddtnl
Catu.BocaRabn, !L: CRC Press,1992.
64
Eli L Bâr Tal Y Fussz. Korff E. Effectof bjologicalsex
differenceson the perception of acute pain stjmulation in
the dental settjng. Pai, ^æ . MnMg. 199O| 2A14.
1 7 . Eli I, BaÈTalY, Iuss Z, Silberg A. Effect of intended treat-
ment on anxieç and on Eaction io elcctric pldp stimula-
l i o ' ' d e l L p d re n r - I E d a d a r t1 . o 72 1 6 0 4 - 7
Ninety h@ potimts uha @ercûboullo undcrgowriors denlal
tftdtflehts (.û\cr|tb ttuotô|, Jilliry, tuot uml b.atnent ûtu[
ertractio) tuùe&olunted,conpnnq thendehtolanriet! dnd
pain eryc.tatianfrcù tlx ùttendedtreatnren!antl theî reactian
to electfirûl tôôth pulp srimulatian. the dttd indi.ate thdt
pûtientsdilet in theit dtuitL! lerels oid theit et?e.tatiôhta
exptien.e pûin ûccotdingta thefo|@inS hierarchlJ: extractior,
tôôt canalfreatment,111ù9,calculusrc otal. Dettal antie4J
de.reæet1 thesenFation lhreshaldol rylients tuhaeryectetleaskr
tftatnents kûlculus tetrû|,lifiitg) bat incrcaredth. thrcsh
ôld ùf trûse1trh.expectetl ore rtrcssful beatùerts lendodon-
t1ctQdttuent, eùtu t1ôn).
18. Eli L B.nt & Kozlovsly A, Simon H. Effe.t ôf gdder on
acutepainprediclionandmemoryin periodontâlsurgery
E n / . O r d lS . i . 2 0 0 0 ; 1 0 8 : 9190 3 .
r9. r \ l r e A \ 4 ô 4 e )( . 1 ' - à , . ê < . V F T o) I u p " i r : i , - r ' - s .
]]99Ai
Pdjn 4l:255 ns.
20. litlingim RB, Mainer W. Gender diffe.ences ln the
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2L. Gâtchèl RL Turk DC. Ps!.hôlo|i.al ApptuaclEs ta Paln
Mdrdscftcrl, Nêw'lork The Gùilford P.ess,1996.
22. Hârkins SW Discussion on 'Long term remory of âcùte
post-sûgi.àl pâin' by Sisk, A.L., èt tl. I. Otal Maxill'.fùc.
5!/8. l99l;,19i358-9.
23. HiLgard E& Hilgdd lR. irypnùsis i" thePeliefaI Pûin. Los
Altos, CA: Williâh KaxJmam lnc., 1975.
24. Hoiowitz LG, Kehôê L, iâ.obe E. Multjdis.iplinâry
pâtidtcarê inpre\entivedentistry:idiopâthicdentâlpain
È.ônsidÊrcd.Cli,. Pt". Dent.7991j13:239.
Hôulè N! Mccrâth P4 Morân G, Ganet Ol. The efôcâcy
of hypûosis dd relaxation induced ânalgÊsia on two
dimensionsof pain for .old pæsso.ând elechic tooth pulp
stimulation.P4l, :1988;33: 24:L51.
T@eru-eigh! subiects uercstbtuittedta taathpult stinulûtian
û tl coLdptsôt stihulntlùn ùI the .farû n ...arding ta a
spaifed pntocol. The trcdtnùt cônditioîe incltuledprogtes
siæ nlusckrelaxatiotandhwflati ifldtctiofluith gg5tiafls
fu Malgsia. Both hytîosis ontt fttdxdtjan sigflifc,ntt!
reduæd thesneflgthandtheunpleùsdnthess Dftaathprlp nin
tlation,btt afll! theMtkrsnfltflessdinenrionôf.old ptssot
pri1t.AuthôÆcondtulethdt the quùlit! ôf the cognitiæ bûsed
thùapks Æedrd esflôt only occôûing tô srbjects chatuctet
isticsand th. 4JicacyoJthe ihteaentionbut alsonccaftlingto
thenûtureal th. roxioùsstittuli.
26. LA.SPSubcomittee on Tùonony. Pain terN: a lisl with
definitions md notes on $age- Pain 1979:6: 249 52.
27 KalJnan E, WeinsteinP,Milgrom P Diffi.ulties in â.hiev-
ing local desihesiâ. i. ,ttr. Ddr. A$d.. 1984, 108: 205
28 Kent C. Memoly of dèntâl pain. lrdin I9a5j 2l: 187 94.
'I]t pôssibility
thot patie t nlenûry fot rcùe pdin is ftcofl
sttuctedûù tit uas t?stedbtj conpating the degteeôf panl
tuflmbetd 3 rlonths ifet o deîtal rppointnent @ith both
eryc.tetlûnd eryûirn.èd pûit, ds rèpotted innlediately biate
aid allet the ûppùintttunt. Thete tÆ a c\ôset dssocjdtlofl
bchuen ronenbnd and crpè.tet1pain thûn befileehftften
b.retl anrl et?erjen ed pnii1, pdtti.Llût4t Iùt pdtjehts uith high
29. Keni G. SelÊefficacious .ôntrol over rèpôried physiol-
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âNieba A./rd. Rc!. Tler :1987;25:341 7.
K e n . C C b b o n - R < . l h r i i 'à 1 " n d h e c o a r r o o
l rdn.i^u.
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dental-ælâted behavioral dysfmctions in â consultâtile
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1985,28:4.r.
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I i p l ô , 'l A M r , b r . L I l . r . l n . r y ù d . h Èp J n F , p e n o c r
SD..Sd. Med.1984;19:127998.
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149 60.
36. Litt MD. A modè] ôf pâin dd ûiet), 6sociated with
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This is ùh erteîsive @ieu rtticl. that discuss.sthe natrre
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pte!fiE tha dispôsitionll and sittûtiôndl factaÆ that con-
ttibùte to tle pùdption af rfl dcrte stressotos au$ioe. m.
dttick pÆeflts a nôdel illusttoti]ry how the utiaus lactos
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Melza.k R. The Puzzleaf Pdn,. New York: Bâsic Boots,
1973.
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Cultral perccptionsof pain ând pâin coping among
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45 Morse D& Schooi RS, Cohen BB. su.gjcal ând non
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49 RoskiesE, Lazarus RS.Coping theory ûd the teaching of
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51 Rudy TE, Kems RD, Trk DC. Chionic pain md depree
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of painmânâgêmênt 6s
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Themuhidisclplinary
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399102.
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Chapter6
Vital pulp therapies
and Gunnar Bersenholtz
PrebenHarsted-Bindslezt
lntroduction
A multihrde of hârmtul elements, alone or in coùbinâ-
tion, may ûnder clinicàl conditions cause âdve6e reac-
tions in the dental p lp (Fig- 6.1; see also Chapter 3). If
not properly managcd dÉy may result in:
(1) I'aintul pulpitis.
(2) Pulpal tissue breâkdown (pulpal necrosis).
(3) Rooi cânal infection, leading io pedapical ifflârn-
matory lesion (apical pedodontitis).
These effects are the resulr of inÎamâtion and âssoci
ê t e d t j - - . r ed e - . r ! . 1 ' o r . T i - " u e d e , _ r u .t ' , r , p a . , i . r n e c
essary featur€ of infla mmâiion ir general and is reqùired
by the host to carry out al effective defense àgainst
foreigl matter, includnlg bactefia and bâcterial clc-
menis. Howeve4 às far as the pulp is concerncd it can
be devâstâting âJrl.l result in total breakdown of dæ
Infeciion and intlamlation in the periapical tissue
(see Chapier 9) ftcqùcntly follow such ân event, tefmed
pulpal necrosis.Vital pulp therapy involves clinicalpro-
. Relieving pâinful symptoN of pùlpiiis.
. fr.\. rin8 lhr dr\ Flop_cn. oi r de-,ac,ive , cur-
of pulpâl hllairnmâtion.
ln the current chapter the rationalcs for th€ clinicâlpro
cedures employed ând the techniques and materials
applied to attâin these objectives are described.
Clinicalscenarios
Anli direct exposure of the pulp to i1É orâl environment
involves the isk oI desbuctive ntlâmmatory break-
down (Fig.6.2).Ii shoùld be noied thât a pulpal $'ound
has little self-healing capacit].unlcss propeù heated. ln
contrâst to the skin and mucosal iissues, wheie .ùts or
woundsnormâlly healwithin a short period of time, the
pub hâs no epithelia that cân bidge thc defect. This
meâns that even â smâll exposure mây preseni the bac-
66
terjal flofa of rhc oral carity $'ith the poleniial to câuse
â destfuctive and iûeversible (non healing) inflamma
Exposure of the pulp may reslrlt from ca.ies,liactùe,
crack ând inadvcrtert deep cavity ànct crown prepârâ
rion. Altlûûgh cades progresses ai a fanly slow pâce, the
other bjuries cause a sudden ând immediate exposurc
of the tissue. This is significait ftom a therapeulic pojni
of vie$'. For example, after a longstânding exposure to
caries tlæ pûlp may aheady be in a compromised stâte
such tlùi lÈa1ing and repair are not possible, making it
necessary Ior radical removal. On thc oiher hand, on a
recent tuâcturc or deep càviqv and croM prcparâtion a
fâiflv healtlry pulpal dssue is challenged md dÉ poten
tial for a conseNative tissue-sa\.ing procedurc is olten
promishg. This is espccialiy true if the inj ry is heaicd
$'ithout delâ)aIf an cxposùre by crâck, frâciure or deep
cavity is left unircated or ûndiagnosed, an acutc int-lâm
Inalury red.ti.n pr.ue-. slù.h *tv re-Llt in , a^r-
hcah€ bsion.
Pulpâl inflâmmatory lesions of a destructive nature
may also âppearwithout direct cxposûre of the tissue to
ihe oral c.nvnolrlrnent. S ch cases can be seen in con
junction with à restorali\.e ircaLment, which olten is
carried out within a fairly short period ot time (i{ceks,
months) pdor to the debut of rhe symptoms. The càuse
may bc rclâted to the injury induced in ilrc pulp by the
restorativc procedure and leakage of bacteriâ1elements
in gaps along ihc margins of the restorâiion (scc ClÉPrer
3).
Inflammato{' clùnges of ihe pùlp may or may not
occnr with pain- The pain symptoms vary and in then
end stàgesprior to pùlpal br€akdown can be excrucrai-
ing, requiring imediâte attention- Sympiom sug
Besiivc of a ùore or less severe pùlpal inflânmatory
involvement àre summâiized in Core concept 6-1-
Treatmentoptions
ln cases û-hcrc the pulp hâs become directly exposed to
th€ oral enviromùt, ihe clinician may consider one of
 Vtal pulptheapies 67

two beatment strâtegies-One apprcach is consefl,'ative tissue is radicaly remov€d and replâced with a root
dd aims to preser,,e Lhe pulp and re-establish non- cânal {illing (Fig. 6.5).
painful and healthy conditions in the long term (Figs 6.3 Prior io a definitive ireaiment, a preoperahve emer-
and 6.4). The other is a pro.edue wlrcreby the entire gency tieaimenl may have to be cârried oui. Sùch a treat-
ment is usually caled for to alleviaie a severely pairJul
tooth or to majntain an accidental pulpal exposure until
Caries/ traumâ/ iâtrôgenicinjury a definiiive treâiment cân be caiiied où1 (see p. 85).
Viial pùlp therapies in lude:
. Indirect pltlp cnpptn& which refcrs io a pro.edure
whereby câries is excavaied in â stepwise fâshion in
order io preveni iairogeni€ pulpal exposure. This
p r o ( e d u r em J ) b e u i e d i n - i l u J l i o n 5 o f d e e p L . r r i e s
without signs o{ irrcversible inflammatory changes
in the pulp (seeChapter 7).
. Direcr p lp capping/|1t:rtkL pllpoto y. These proce
d res are airned at rnaintaining the pulp after it has
become exposed to ihe oral enviromenl (Fig. 6.3a).
The open exposlre is seal€d off by ihe use of aJrt
appropriate wound drcssing. The puryose of the s€al
is to prcvent a.cess of bâctedâl orgânisms in the oral
caviiy and to promoie soft-tissùe healing and hârd-
li+ue repù of tl-ee\po-ed rred. lr pulp.dppmg
thc-e r" no -e-.\dr oI pulpal fs-ue. h\êrêr. in d
patial pulpotomy some pulpal tissue is removed ât
ihe exposure site to a depth of 1 2mm (Fig. 6.3b).
This measurc is carried oùi to clem the woud of
inJected tissue and to prepar€ a space for the $,oûnd
pulparcaction
Fiq.6,l Adverse to.arles,
trâoûâôr ârrogenic
injùry drcssing so thât it cân be applied securely ({or a

Fig,6,2 Examp esof clnl.â .onditions

requninsvita pulp lhsapy:(â) pupai
t $uedireclly
exposed byG esi(b)pupal
t$ue directly
exposedbytraumâi{d noô
exposedpupbutloothpresenls withpain
ândrhÊreis a cracklineon the in!,ual;
(d)iôlôwiôgcmovalor $e rllinq,lhe
dâ.kseems tlrepulp.
to enter
F i g . 6 . 3( a ) c l i n i . a l p h o t o g r a p h o l a p u l p e x p o l ce ad vr ôi ltyhf e
ool or w
ô ingairauma.Pulph6beendp6êdlor
âpproiirârêy 1 dây.(b)Ihê{perlkiâlporton ofthepulphâsbeenremoved to prepare
thes rerorà pârtiapulpo

of the rooi portion vitâl and tunctioning so thât root

Cor€con(ept6.1 development câjlrbe completed (sce also Chapbr A.
The têl]Il âpexogenesis is somehmes used for this
PËinsymptorns
commonly with â pulpâlnflâmmatory
associat€d
procedure. In ftil1y developed leeih, pulpotomy is
often canied out as â temporary measure o11an emer
. nûeased sensltivjlye kltedby expolreto colddrinksfood gency basis until time is available for prlpectomy.
andairortouchoJanexposed dentine suffaceareearLysiqns . Pulpectamyis âI.n|asive procedure where ihe pulp
oI pupa in{lammation. These symptoms ar€usually nôtsug tissue is removed in totâl by root canal instmments
gestiveof ân âdvânced esion.In the contexloTa r€c€nt
and subsequently replaced with â root filling (Fig.
or periodonta!
restorative treatmentsuchsymptoms may
6.5). A more delailed description of the procedurcs
emerge shonlyalterthe prccedure but oftensubslde along
with recoveryol the tissue.
. sho( intermitt€nt periodsoI lingerlngpain Gecond,to
minutes)by exposure to cod drinks,foodandairmaybesigns
ofa pulpalnTlammatory lesionin progress.
Neverthelesssuch Fâctorsinfluencingchoiceof therapy
symptoms maypGvailforlongperiods oftime(months, yea6)
wlthoutresuhing in pulpalnecrosis. It is â most intdcate task for â clinician to advocate the
. Longstanding (hou6)severcpain,spontaneous or ntermrt- proper thenpy when a pùlp is exposed (r1 when clinicâl
tenty provoked by €xt€rnal stimu, including hot {oodand signs ând symptoms suggest a isk for pùlpal necrosis.
drink, s ân aarminqsiqnsuqq€stive (non'
of an irrev€rsible A conserative measure saves elTort, time md monet
heallnq)pulpâlcondilon.
û'hereas a pulpeciomt especially in the posterior tooih
fegion, is oficn a technicaly demanding md time-
consuming procedure. This is why direct pulp capping
detailed description of the techniqùe, see turther hâs enjoyed some poputa ty over the years tor the man-
below and Chapier 7). âgement of pùlpal expos1rfres:it is non-invasive, casy to
P ltotomy is a term ùsed for partiêl removâLof dis- caûy ont aJrd normâl]y does not rcquire ân elaborate
eâsed pulpâl tissue. The procedure is often caûied dental restoration âfterwards. Nevefiheless, a pulpec-
out in teeth with incomplete root formation, where tomy is the treatmeni of choice ù'hen the prognosis lor
pûlpeciomy for this reason cannot be cârried out. pùlpal survivâl is deemed queshonable. If the pûlp is
Pulp is normaly cui level with the cânal oriJices in assrned io be in an irrcversible condition, a pulpe.tomy
two- md mùlti-rooied teeth, or as deep âs necessary is always io be preferred in a fully developed tooih. The
in iceth s'ith a single root canâl (Fig. 6.4). The treaiment is fie most predictâble ând elimimies the risk
remaining pùlp tissue is co\-ered with wound dress for subseqùent irLqâmmatory brcakdown of the tissùe
jng. The aim of dris procedure is to mâintâin the pulp md associaiedhJections and painful evenis. If a tooth
 69

Fig,6,4 Pupotomys a partà removalolpu pall sùe,à sorermed

puLpaûputârlônTherirsùe iç nomaly cut lèvelwiththe rootcana
in two andmullirootedleelh.Inteeihwlth oneiootcanàl,
orilices
tissuemaybe removed to the eve of the (ementoenameljumton
G). Radiogmphs show .oronafradurein toolh l1 wlth in(omplete
root formation(b);depositol calciumhydoxldeaner removalor
corom pup k)rrool flLinqafts.ompletionol the root.Ingeneral,
ihepupotomized toolhÈ folowedradioqraphically anda roorI ling
s notrequiredunie$exce$ive(a cili(atlonoccu6,or pronhodôntc
recomlructionis needed(d) (courlesyol Dr M. cvê[.)

Coreconcept6.2 Treâtment
optionsfor
purpar
€xposure

opronsIôr pâiniùcondition5
Treatmenr

Wait ahd see leûpatary

Fig.6.5 Râdiogràphs showing:G) an innrunenrin the rootGna oi an rcstatatron
upper àteia! n.isor n.onjùôdon wrh a pùp{romy pb.edûe; (b) the
instrumenred
.analthathàsbeennlhd. pùtpôtôny
 70 fte vitalpulp
is incompletelydeveloped,putpecromyis precarious
and pulpotomy servesas rhe alrernarjve û€ahnenr (Fig.
6.4, Core con ept 6.2).
ln young individuâls with nrompletety developed
roots/preservaiionof as much pùlpal tissueas possibte
is essential.This mâles way for continued deveropmenr
of the iooth structure. A pulpe.romy, by eliminating rhe
soft tissùe of the pulp, prevenrs furrher growih ârd
leaves â weakened tooth thar is vulierable to fracrure.
Cvek (13) reponed ihât there is a close linear reraûon
ship between the degree oI roor ctosûre in teerh wher€
the prlp is lost and the rare of intra-atveolâr fracture
over time. In very immâture roors the frequency of frâc-
iure $,âsâs high as 80%wirhin 3 4 years âJterroot câial
Pùlpectomy not only eliminates the pûlp bur rcquircs
the sacifice of hard tissue as wel. Often rhe toss hâs
to be largd ihâ. tlÉr initiâied by the injury itself. This
LSDecausethe lreatmenr requircs âccess to the roor
canâl system md sufficient removal of the canat walls
to allow proper filling. Ineviiably this wil reduce
the resistânce of the tooth b fracture by mâsticarion
forces(57).It Âlsomeansthar after completion oI rhe pro-
cedufe â râther extensive restorâtion is needed (see associated\^'ith an advânced inflâlnmaiory
Chapter12).
In conclusion, the time, effort, sacrificeof roorh struc-
ture and costsfor a pulpecromy arc grearerthan rhar for
a pûlp capping o! partial pu lpotomy procedure.yei, crit-
icât to rhe choice of therapy is how the case presenis
itself and how ihat js deemed ro affecr rhe potenrial
for pulpâl survivâl upon a consefl,,ativetissue-saûng
m - d , u r eT h e r e f o .têh e d e c i r , , n , o c ê r r y o u it ad \nJ - i v e
procechraeor not must be based on â careful anâlysjs of
ihe clinicâi inJormation thar cân be gained from rhe
diseasehistory ând clinical exâmimiion of the parLeru.
Assessmentof the preoperative condition of
t h ep u l p
Diagnostic criteda of ân iûeversibly injured pup are Dy
no m€ansdear-cut. In fâcL there are no objeciive meâns
âvaiiable, at present, by which the rrue condition of ihe
pulp .an be decidedbt for example,a btood or rissue literaturc6.1).
sâmple. Esseniialy there âre iwo conditions ûâr are
us€dto guide the clini.iânl
(l) The presenceùd characrerof paintul putpat becomesincreasingly more sensirive ro €old air or cold
(2) The presenceand type of pdpal exposure.
Core concept6.1summâizes the rypical pâin slîproms
associaiedwith pulpâl inuarnmarion. Alrhoùgh tinger-
mg pai4 provoked by exrernal stimuti, ofren is used ro
suggest an ireversible conditio& studies ha1.e faited
to find a strong con€larion of such a symprom comptex
Keyliterature6.1
In lrisclaskâlsludyNyborg (40)prospeclivety
Tolowedê seûes of
225cârF.rrdr 'âd b""n ortp caoped duero o-tpJ ",po$,e ir
conjunction wth excâvarion of cari€s.
Thefottowup peiodvaied
ftom10monthsto 13yea6.Atfollow up,leerh wereexaminedboth
dinkâllyand radiôEâphkally lor evidenceof pùtpatbreaKoown
(paiilulsymptoms of apicâlperiodonliris
and/orrêdiographk€v-
denceol apkalpeiodonlris). Eighryonereethwerea$esedhis-
tolôgkally.0Jthe t€€ththatdidnordisplay painfutsymptomsatthe
timeoi lr€âtment, thesuccess rarewassubslaniiattyhigh€r(95%)
thânii patientshadexp€rienced pân priorro capping.
OJrhetaner
category only9 ol20 teethweredeemed to havea h€atihy
putpat
theÎnâl followup.fte srudyrevealed rhêrmanyteethrhatwere
dinically w thoutsigns ofpulpâpathology dispayedsevereinftâm
maiorychanges on lr nologkalexarninatlon.
with the tne condihon of the pulp (2, 59). In these
stucliespulps hâv€ been exâminedhisidogically aJier
recording pain hisiory and exiraction of ihe teerh.Ii was
found thât repori of severe pêjn was nor ne.essârity
breâkdo$,n
of thepu1p,ând viceversa.Hence,a nther severcpulpal
condiiior.oLld hrve appcrreJrrirlout bFinBd.com
panied by pâin. Converselt severe pulpat pain wâs
sometim€s present on râther modest rissùe changes.
Consequenily,comparaiive studi€s have shown pajn to
be a rather weak predicror of the conditioll of itre pu1p,
whether rcvercib1yor ir.reversibly irùflâmed.
Nevefiheiess,the existenceof â hisrory of pain and rhe
characiù of the pain presentaiion are cruciâl ctinical
mânifesiations because the ner€ presence oi pain
prompts a th€rapeutic decision. If combined with deep
cades, .racked tootb frâcture or recent rcsiorâtive pro-
cedure, a progressing infiammâiory pulpâi lesion mây
be iminent and an nlâsive therapy by pdpecromy
would be required. This vies- is suppofted by rhe obser
vation that pulp capping of cârious exposureswas less
successfulin patients displalng painfl s],îpioms rhan
in patienls without pain at the time of treârment (40,Key
A typicâl scenario suggestive of â progressing in-
flammatory condition of the pulp is when a rooth firci
drinks and food producis, which subsequenrly tlms
into shorter or longer periods of Lingeringpain elicired
by the sÂme stimuli. The inrermittenr châracter of rhe
pain experienceis a û.Lrlycharâcterisiic feâture and is a
differcntiât diagnostic toward otlÉr painJul .onditions
(seealso Châpters2 and 4). In ihe mosr selere cases,
excruciâtmg pain may linger for hours. pâin mây occur
spontaneously or be provokedby hot or cotddrinls d
 Vitâlpulptherêpies 7 1

Coreconcept6.3
. A pulpectomyprocedureshouldbecarrledoutwhena pulpal
.ondition
È d€€medirrevelsibh.
. A pup capping/paidâl
pupotomyproc€dure maybecanied out
whenanexposed pulpis heathyorrev€rsibly
lnllamed.
. thecutotrpointbelween
underdinicalconditions nreveFibly
ândr€vedblyinflamed
n{lanred isoftenhardto identit

cut-oflpointfor pupedômyl

Fig.5.6 RâdioEâph
,hôwlng ex1ênsivêcaries
in thecrownof toodr16,
Althôûgb ihepup isnllvita andlunctioning.
inlâmed, Periapically
lhereaG
widenedapka3paces
aibothrootsanda sclerosÈ
a$o.làrêdwithrhemesâl

food- In ihe end siages, prior to complete breâkdown of (2) Exposedin conjmction with excavationo{ ca:riesor
the pulp, patients mây find ihat cold wâter may âlle\ri hemisection in periodontal therapy.
ate the symptoms. The report of severe pain may be the
{lliimately the prccedures aim io preservethe vital func
only presenting symptom. Tenderness io percussion of
tions of the pûlp. AlLhough not necessaryfor a success
the offending tooth and even of the neighboring ieeth
ful oùtcome, it is considered advântageousthât woùnd
rnay or may nor be obsered in the final siages of pûlpal
heahlg rcsults in hârd-iissùe repair of the open expo-
s1lreto enlunce pulpal protection to secondâryharmtul
Pulpd hnaûmatory lesions may cause the presenia-
evenis(Fig.6.4.
don il1 radiographs of loss of lamina durâ" small ped-
âpicalradiolû.ency and/or pedâpical sclerosis(Fig. 6.6).
These findings in themselv€s aie not necessârily indicâ Historical perspectives
tive of an irreve$ible condiiion bùt èan be helpful toIn 1883Hùier (26) claimed thât 'Even though ihe pulp
idenlib lhe offending too r n d pd nJul ca.p. mây be suppuraiing and the pus welljng up in volumes,
I shâl savejt'and he prêsseda mixturc of sparrow drop-
In conclusion, clinicâl and radiographic signs are less
than decisive diagnosti. measæs to deiermine the pings onto ihe exposedpulp ând achievedsuccess'tu]ly
spread of pùlpal inflanrmâtion n1 a given câse, and yel
equal ro 98 per cent'.
they âre ihe or y signs currenrly avâilable for diagnosisSinceHunter so dJastically inbodllced pulp cappinS,
in clinical practice. The decision io carry out an invâsive
the treatment procedùre has been vigorously disputed
procedure often has to be taken on the basis of the exis
in the dentâl profession and is still a matter of contlo-
tence ând the character of tlrc pâin symptoms (Core versy. The discussion often has been polarized, bodr as
concept 6.3). io when to do it, if at all, and as to whât capping mat
erial should be preferred. The râdicals have clâimed thât
the long iime percpective of the treatment is unprc
Managementof exposedpulps by direct diclable and is doomed to faiiure, therefore the more
pulp capping/partialpulpotomy invasive pulpotomy or pulpectomy must be carried out
when the plrlp is exposed. The conservatives, on the
Objective other hând, hold that successcân be achieved, even
when made in teeih folowing lârge and Iongstanding
?ulp capping and pârtial pulpotomy are procedures
carior.lsexposures,and they contend that pulp capping/
to consider when ih€re is no hisiory of lingedng pain
partid pdpotomy indeed is worthwhile because if it
to external stimuli and when the pulp lùs been:
fails then foot câJrlaltherapy cm be caÛied out.
(1) Accidentaly exposed to the oral environment by The rcason for the dispute hasbeen ihe dclactorncer
cavit/ preparation and haumâtic injury. tainty, aheady descdbed, about ihe prcoperaiive ând
72

Fig,6.7 Dired pulp (appnq:{a) expo$reto bleednqpulp ol a moa.;

{b) hard-t$ue lormation ( masecourtesy
or the exposure (.)
or ù B.Klaiber);
hislooqka secrionshowinghard-t$ueTormaton90 daysJo owingêxperi
mentalpupcappingwlrh Pùpâll $ùe displâys
a a.iùm hydroxide.emenl â

postoperative diâgnosisof the pulpâ1condition. Both âre
dûe to insufficient clinicâl meâsùresto evaluate the hue
statusof the pu1p.Becâusemâjor iiflammâtory .lù1nges
mây be present without.oncomitant clinical svmptoms,
a pulp capped tooft may prevail for years wiihoùt
presenringclinicâl symptoms, even though rhere is
extensive intlmaiory breakdown (40; see also Ke)'
literature 6.2). A turther rcason has been a mediocrc
understanding of ihe healing poiential of the pulp.
Lrlammation in the pulp is a dynâmicprocesstrnd tor
previously unaffected puLpthat is hoûsed in â large pùlp
chamber,especially in ihe young, the heâ1ingpotential
is substantial. Even âfter exposurc to the orâ1envinn
ment for â pedod of time, heâ1ingis possil,le(6, 10,2,1).
Contraryro previousbeliefs,infiârmâtory chângesiJt
one pari of i1rc pùlp will noi ine\-ilâbly leâd ro pulpal
necrcsis âJrtdma)' heal if the proper measurc is iakcn io
sustâin ând optimize the lrca]nrg poteniial.
Factorsof importance for a successfuloutcome
As indicaiedin the text above,healjngand repair ot Ân
exposed pulp depend initiâl1y on the preoperative con
dition of the tissue. Consequently, if inflâmmâtion has
reâclæd ân nreversible state, no heâtment can remedy
the condirbn ad a failure \{'ill show up as pulpal necro
sis. This ma)' ol may notbe preceded by pa intul events.
Fâctors recognized âs lmportânt for the long-term sù-
f.iyal ofthe pulp to capping/partial pulpotomy âre now
rvpe oï inj ry
AJrtâccidental puLpâlexposure throughinlâctdentine
occurring dùring cavity âjrd crown preparation has
ilÉ greâtestpotentialfor a successfuloutcome.ln this
situâtion the pulp mây be heâlthy ând ihe bacterial
contâminâtion limiied, therc'forc the imnediate col1dL
iion for healing is opûnal.
ln a haumaLic injury, where the pùlp hâs be€n
exposed by a blos- or fall rhe hcaling conditions are
fÂvourable even though the pulpal wound may havc
been exposed to the oral enviionment for a period of
tjme. Both clinical and experimental studies (6, 10, 11,
 Vlràpulpth€rèples 73

tive stimuli (4).In ihc studyby Hôrsredtral. (29),PulPal

Keyliterature6.2 sùrvi\'âl 5 yeârs after pulp câpping \a.as70% for 50 80
yeaH)lds but 85% for 30-50-)'earolds and 92% for
cvek(10)Iolloweda seresof60youngleeth over5 yeâ6thatwse
10-30-year-olds.
treatedwith panialpulpotomy subsequent to pulpalexposur€ by
(97%)cappings
traumaFifty'eight weredeemed su(6sful,e.g.
teerhwerecom{ofiabe andwithoulc nka or radioqraphic sgns Size a d loc!:'tionof the p lpal oryosure
olpulpalbreakdown.Aludher indcaiionôf pulpalvilalitywæcom 1rhâslongbe€nh€lclthat cappingsshouldbe considered
p etonoI rootdevelopmentin teethwithincomplete rootclosure. only when rherc is exposureof an occlusâlor mclsal
n thestudytherewasno dilJerence n success râte regardless
ol portion of the pùlp, becâusecâppingof a more c€Nical
rhetimethepulphadbeenexposed to theorêlenvironm-"nl Gome exposureis rhoùghtio be lessslrccesstul due to possible
teethhadrecelvedtreatmentTirnafterseveml weekt,theskeoI circulatorydisturbâncesand necrosiso{ tlrc corcnally
expoareorthenageoTrootdosure. locatedportjon of thc tissue(21)(Fjg.6.8).Laiea it l\'âs
shown thât cen'icalexposùresmay heal wiihoùt com
promising the rest of ihc pùlp provided thâi a gende
heatmentprocedureis used (6,7, 47).
24) have demonstrated that bâcterial coniminâtion o{ Thc high srccess rale in c]nncal âJrldrâdiographic
the wound site becomes negligible (Kc']. literature 6.2). folow up studlesâfterpârtialpùlpotomy(10,18,38)hâs
rollowing proper dishJcction and delrridement, heâling lL 1lef fur l^ lJc.l ùr lhe ,é1.\r1 e .f.' n..ure.ir. ".
and lùrd-tisme repâir have been shoû'n io occur ât a a significant pâfàmeter tt lvas once believed thât caP-
vcr)' high râie (10, 18,38). pings slûÙld b€ reser\-edonly for pin point exposurcs.
Ir cxposùres by .aries, on the other hand, thcre mây Current kro\rledge sùggestsihat the totâl volu me of ihc
be a massive penetration of bactedâ] organjsns to the fLlp l'.{ e rr r' ldliun,o -he.r/eôf t\' . \po.urei- mo-e
tissue. This has usually rcsulted h â localzed acute
iniârnmation of the pûlp, oft€n as ân abscess (see
Chapter3). The healing poiential oI such lesions is there' Cli ical proceà rc
fore ûnpredictable. The proc€durc of.aies excava The proceduleto cany out pt p ctlPpinS/Partialpt
tion, in âddition, may exaccrbate the lesjon by forcing potorny is simplc. Successessentiallydcpendson the
infecicd dùihe chips jl1to the hssue. Neverthelcss, cap
ping of câdous exposùr€s may be considcred if s)'mp
toms of pÛlpitis âre absent. Ir is generally atreed that
the most favoiable prosrosis exists when perforation is
made during rhc vet' finâl excâvation of the de€Tcst
part ot the caries lcsion and when therc is only â small
erposuie. An ovcralls-year pùlpâl sun'jrâl fate of 80%
'!vas folrnd in 510 cases and no statistical differences
' J e r eo b . ê n " o b c t u " i ' r r i u u - d n d r J 1 , . r i o u - ê \ f . -
sures (29). This {inding is in âccor.tânce s.ith dÉ 931/.
successrâte after 2 yeârs reportcd for pârtiâl pulpotom),
caried out in cârious mola$ of teenagers(5,38, 72).

Ag"
Althoùgh not consistentlj, obseLl.ed(3), it scems that the
proslosis for capping âJlrdpartial pulpoiomy is beiter n1
,\roung than old hdividuals (29, 72). The fact thât the
pulp of young t€edl is rich in cells and blood vcssels
makcs it prone to reâct fa vorabl), to miciobiologicâl and
haumâtic challenges. On the othcr hând, in àn aged
tooth and/or iooth cxposed to previoûs injur)' the pùlp
is often poor in c€'Is, fiber-rich âJrtdpartly mineralizcd,
thereforc it is likely to be more vulierâble ând less able
to sûirvive a càpping procedure. Thc size of the puLpâl Fig. 6.8 Hi(ôlôgkalsectionof a pupal erposurccappedwith .àlciud
spâce in âr1old tooth js âlso much smaller, thus provid hydroxidecêment.
Tle capplng
matêràl(c)hâs beenpu5hednto the pulp,â
ing â great€r risk fol plrlpal breakdowr upon destruc o(rred (b)andrhe incisalpùLp
majorbleêding lisle b(ame netut c (n).
 74 fte v tal pulp

e\tent to s-hich thc h'ound site .an be mâlntaincd free

ofbacteri.l prolocations in both rhe shorr rcrn ano rn€ procedure
Clinicàl 6.1 Pulpcapping
rù8 rerm (chical Pro.e.lùrc 6.1).
Pulp càpphg is regardcd âs âpprop are fof irù (1) Remove anyb ooddot w th a sharpeKavalorln ihecaseof
mc.irâte mùor cxposures,r'hcreds pârtial putpotoinv is tmeâq between exposure
andtrearmenr.
(2) Estabsh hernonasis by applyinqlenrk pre$ùfean the
more apt for wounds that have been exposed to micro,
woundwth a .ottonpelet moienedwth chlorhexidino,
bial challengcs for a pernrd of ttiùe, nrtuding làrgc
sterile
salineor anaqes.solution.Renewthecononpe ei if
carxùs exposurcs. The recomnenddrion is Lrase.l ori nece$ary andwât iôr complete hemolâsÈ.
the results of e\Fernncntâl studics sholving thar atier (3) centyapplycapping mêteraltô thewoundw rhourfirm
pÉs
a.cidenial crposure ihc inlectioi rcùâins superlicial
o\-er the fi$t 2;rh (6, 11, 25). Over longcr periods, hfcc- (4) Coverthewound dr€ssing
withâ hardsetrlng
@m€nt ach as
tion usually lùs nlvolved .leepcr âreas of thc putp a gÉs ron0mercmenr.
ând ihcreforc pâriial plrlpotony is adlisâbtc in rh€s€ ( 5 ) RestoreandsealtlæGvitywitha reloration.
(6) Alter1 week,evauat€thepresence or absen@ ofsymploms.
A partiâ prlpobmy ( 7 ) Atter6 monihtevaluarel
offers ùe ad\àntagc ihât ir
reno\-es the supcrficial . d poientiatly inf.cre.l lâyef of
. reaction!to tlre.mal
5tmuli âb5enr,srort,proonqed
the pr p. Sone suuoun.ling dcntine is reûrovcd as s.ell,
. sens pulptesting pôsirve/regar
tivty to êlectric ve
s4rich crcales â well dcfiIed spâcefor p]âcement of thc
. perâpcaËdiographi. chênqes
capping nàtedal (seeFig 6.3b).The prepararion sholrld . ËdiogËphkallyvûilied'brdge formarlon
bc carried oùt 1 2in111 dccp 1!ith a1 en.1cltting Basedon the rindings,continuefecâs ar do roor Gnal
diamond burr h an trû turbine undfl copnrus1\-.t€r iûi-
g.tion in order to reducc the tràuma on rhe tissue (sce (7)at yearyintefras.
{8) nepeat
lufther Chaptef I. Thc operâtion is normillly simplc in
à tfâùmaiize{l incisor but more dcmanding m a nr)lâr
where, ou.in g to fic gcnernI l' 1ârgcr.ou I d càlit\r bleed
inEimav be diÊficult to stop.
A most critical step in pulp câpping ânLl putponrmy
proce.llrres is to stop blecdin8 ând to cinnin.re ùajor
blood clots prior to plâc€ment oi the w.,und dressing.
Blood clots ser\e asbâcteriâl substràte and may support
thc gro\vth of contaminath8 or.l micro{)rginisms. If
bleedtug cannot be .oDtrolled propcrl]t f ltpectony
sholrld be carried oùt. Arothef lmportanr.onsiclerari(ù
is to applv a gentle t€clùique to avoid dil.cerâtion and
.lisplàccDcnt of capping material k) lhe cleep Porrions
ol the Fulp (27).

Integrit! ûf the pÛ n t t restoratiolr

It€sults oi clinlcal studics ân.t €xpcrnnents in hboraror),
ânnnals suggest ihat the jrtc8rily of ûe pcrman€tt
resh)ration is of vitàl imporiance for thc successful
outcome ot th€sc procedùres (3, 7, 29,40). |\,cn rhough
thc wound .lrcssùrg inây erhance hàr.l,tissùe reptrir of
@
thc exposurc, the hard tissue often becoùcs poroùs and
. l . '\ - . . l . r i l . r B J , . . t . . , - r e , d t ,i l , . J rr r E . . * ,
to it (FiB. 6.9). hr ihcir erpeijmenial srrdi, Cox fr "1. (7)
obse^,ed that inflâmnatory pulpâl lcsions uere trc-
quent ul1.lcneâth rePancd pulpàl woùnds and ihar
these lesi()ns corelatcd with the con.omttânt prcscnre
ot bâctcrià in the n.any formed hard rissu€. TM orgaf
isms con.eir.Àbly originâted from lhe oràl en!ironmeft
dfter pcnetràting spacesàt the nargins ofihe per!,dnen!
.r 75
I
I
I
I
I
II Fig. 6.9 N4icrophotographsûom an expea
menla nudy cared out by cox et a/. (7),

II showinqan nlàmmarory6ion ùnderneath

haidtis5uerepair1l nonthsalrerpùp.apping.
(à)ire poroùsnarureol lhè hârdl$ue beinq
fDrmed is obvoù {b)stâinabhba.tù àl or9àn

I
isms,sÊenà5 à purpe mast lrâvepènetrated
thecappiigâ9ent(bâckùatera ), n thÈ .àre
â hârdsetting.a(um hydroxlde compound

p!lfoioml Calcium hydroxide suspcnsions ànd pastes

Coreconcept6,4
| ê 4 r i o o ô . o o u o o p o o o à L o l p o r o , \ .o , d - r "
Iadual conditonsthât prcvâ, i.e. wheTrertrey act n Iavor or
againstâ successlùoutcome
. Degreeof hemolass that canbe obtained
. Tie potentalto prcvde â pemênentrelorat on of ong term
Thc sigl1ifi..ùce of the permancnt rcstoration is âlso
fifcrred by the observation oI thc dcchnng ràte ofp!lpâl
sùrvi\.al olcr ùne br Hiirsted .:t di. (29) (IiE. 6.10).The
use of adhcsi\c tc.hniques for th€ bondin8 of dcntâl
restoràtions io thc boù structùre, or ol any olher
r€storatne that rcsults iI1 â proper seal ol its margins,
should ,viel.l better l)ng-tcrm rcsults (Core concept 6.4).
câpping materialsand healingpatterns
Cdlciuln h!àroxide
Smce the 1930s calcium hl,drori.le w.tef slurrv and
commerciâl hard-sct conipounds based on calcrulr
hydfoxide hale bccn the prim€ mâtefials tor conscrva'
''i
t r F l È 1 ^ p J l r , n r , , . r r L l .b \ n u l o . t t i . c ' l
ârc ch.ràcterizcd br- tlreif inhercni high pH. When
àpplied to an e\posed ptrlp, .alcium hydro\ide walcr
slunl (pH 12.5)câuterizcs ihe tissùe ànd câuscs super
ficial recrosis. Onc lvould àssunrethât such a heàtûent
is detrirneniàl lo ihc pulp, it js detfimoltal, but only to
a minor extent. Indeed, cxperience has shoa,n thât, in
conpadson wjth màny othcr cotnpoùnds, healing is
prcdictable witf this malclial (Fig. 6.lL). lt lras cvcn
originallv beliered that thc Decrotic zone rras a Pre
i€Ltuisile for hard iissle repâir nr be orgdnized. Laicr
sirLdicshavc den]onstràted that tlis is not necessarilyso
and thâthnrd tissue rcpair cù develop in a lcss alk.hle
efvironmcnt n,ithout â distinct zonc of ne.rusis (16, {i1,
63).
llârd-lissuc rcpàir of tulpâ] wounds is fot uniLluc to
càlcir r hyd roxidc but can occu r s'ith a numb€r ot other
nâtedâLs (8, 12,,15) and trith a vàri€ll oi biologicnLly
actile nâtfices and molecùl€s (67). Evcn so, câlciÙm
hvdrcx e has rcmaincd the mât€rià] of choice, Pdllr
adlv due to the solid clinical doftnrentàtion. Thc mât
crial is likely to b€ importdlt also frcm an antimicrobiâl
point of \.ier. lcw oral micro-orgdlisDls sùr!i\.e in thc
high alkaline environment ihat tlis mnteriâl Providcs,
ând ùcrcfore àny microbes contâninÀting the a(trùd
site stânLllitilc chànce of impairing heâling (a).
Wo nd hcalin:l pitretlts to calti nl hqdrotide
ReFnlr Lryhard tissue of a pulpâl wound is â nrultLrâc-
torial process involvnH à \tid€ r.nge of cclls, extrâcel
76 the vi1âlpulp

100

13 6 12 24 36 48 60 124
nme (montht

Fig.6.10 n a rêtrospê.rivê of pulpcâppiûgs

lolowupsrudy eir/. (29)it wasloundthai arhough
ln 510teethbyUoreted lsoNvâlÊtèât 5 yea6
rheovêrâ
wasashigbàs82%,rhê pulpâsùruiva
dêclircd
ôvertime.

3). Thcsc cells âre recruited from echtomesenchymal

' e l l - , - i e m . . 1 1 . , r '' d l ê d r r r h . p r L p . I o l o t r i a 8 . , . e r i p -
of DNÀ replicaiios, drcse ce11snigrâte to the sile of
injùrt- ald differentiate illto elongâied and polaized
odontoblastllke cells (17).Thc haling sequencefollow
ing tfeatment of a wound in a healthy ptllp ancl where
pure câlcium hydroxide or câlcium hydroxide coniain-
ing .ements werc applied with a gcnilc operâtive tech
niqùe mâ'' be summarized as tollows:
. One day afier cappn'Ig *rcre will be a supe.ficial
laver of lissue necrosis and inflâminâtory cell infil
trates (55,71). In rcsponse to câ1cium hydroxide
cemmr, which provides 1ov,'er pH, Fjtzgerâld (16)
obse,ed no necrosisbut signs of blceding md ody
a slight infiltrale of leùkocytes.
. Durjng the fiisi fc'w days dæreâfter, blood clots
are resolved ând the hssue is in â process of
r€organtz ahon.
. The fitlairnmâtory r€action is graduâlly reduced ad
a collagen-rich matrix is forned in close relation to
Fig.6.11 rclluar hard-tÈsue reparof a pup prevousycapped
wlth the necrotic zone (r1 directly a.ljacent to the capping
akium hydroxide (+). A oevi(ecanbe p,obedàlonsrhÊrim or the
exposure,whi.hmàyindi.are rhàrrhehardrissue
hâçbeenlômedbelowa . in ûe {o1lo$'n1g a'eelt minerâlizahon ot the âmor
superfcia layerof necroiic
tissue phous tissue starts (Fig. 6.12).

The {irst mnlerâ1ized tissue is irregular in miure and

luld nolecules ând physicochenicâl interâctions (67).
Aldrough dre exaci nlechânism by which câlcium
h)'drcxid€ initiâtes lÉrd-tissue 1epail of a pùlpâl expo
sùr€ is not full)' ùrderstood, it is cle thât in the process
sccondary odontoblasts arc crucial (32, 71) (see Clmpter
conianrs many cel1 inclusions. Subsequenily a more
deniinelike tissùe with tubules is fo ned. Odontoblast-
like cells iine ihe tissue. It is a comlrnonfeature that also
the more regularjoned lÉrd tissue contâins cell inclu-
sions ând tunnel defects, rendering it permeable to

noxious €lernents in lhc oral cà!ity (Fi8. 6.9).Alrcqùent
'.lentinc bddge'.
term uscd for the hafd tissuc rcpâir is
This dcsignation is misleading, how€v€r, becâusc thc
tissue oftcn becones highlv pcncatrle io b.rctefraancl
bàctefial clcm€nts. In f.ct, ii is often less alte than
priinârl, denlinc io protect the plrlp ftoù !u.h elemenis.
Ilence, ihcrc triI âlsdys be .1risk for Pt'lpâl int€cùù
from possible sùrfàce seal brcal<down.
Other niteliû|s lor cnppitrg
Maiedâ1s other th.n caicnrm hydroxlde mal also a1lorv
hard-tissue rep.ir oi pulpal rloùnds. This has gilen
somc sûengdr to the theory thaiproFer fnrtection of the
sl)und duiirg th€ heâling phase is jlst âs, o. moLe,
important tlùn lhe choice oi a spccific .iPping maiclial.
^c.ordhgl),, denrin€ bonding slstems halc rccenu)
been àdvocatc.t for directFulp càppings trccauseihefor'
mation oi a hlbrid làver and subseqrlent restorainn
with rcsDrcomposite is believcd n) resùlt in leâkagc-trcc
festor.lilcs. In so]]le reports the successrâte h.s becn
similar to thai ith .a1ci11mhydroxidc (9, 36). Other
studies har.e sho(r that the use oi â denlinc bonding
agent.loes not ncccssarilr"result in â Permantùt bi.ter
'bddgûlg' o{ lhc woulde.l
ial seâling of the ca!ii)' and
arca (56). Pulpâl inllarnmatiorr ând {orcign tro.ly
re.r.tions àgainst disPlaced resln pa|iiclcs hâle ireen
descritrcd (14, 19, 23,.16,{t6).lhcrcfore dentine bon.ling
natcrials should not bc considered unless furlher
documdltàtion feveàls rcsùlis comPâfnbLelo calciut11
hvdroxidc (4, s6).
Ilecent intcrcst hâs focrsed furlltr on the lse oi
lr,vdroryâpaiiic, ldcalciùm phosplutc and m eràl tri-
Fig.6.12 Mi.rophotoqraph5fionrhenudybyFilzgeral.l(16)sholvingt$uereorlaniaror5dayraiiercappingolsheâthypu
oTdenunechipsUntesnÔÎ nfectedthesechipsdo not ihpa I but rathÊrsrppôrlrhe repaûpro.e$ àôda so be.oneÊn.lDsèd
rhe d spacèment
daysâI1ù.appinq,new odonrobanshâveappeâred at the woùndsi1èand startedro ay dolvna mlneraiznqmâtrlx(atrowsln b) (aoùnesy of Dr M
V t a l p u l pt h e r à p l e ! 7 7
oxidc aggr€gate .s potentiâl .aPPing naterinls (22,'18)
lloi{clcr, iJ hnfd iissuc sùbjtlcenl io hvdrox,vapaiitc
occurs,it has beef descriLrcdas irr€gulâr and nto]nplete
ànd th€ usc of tricnlcium phosphdte seems b be nrost
eflèctivc if.alciun h,vdroxideis àdde.l (31,62). lvlinerâl
hioxide àggrcgate (MlA) natcûâ1 s€eDrst{) Prodùc€
â tissue rcsponse similâr tt) lhat of calcium hydroxide
(61'l)and offers, in âddition, the àdvaniagc of s€tting
hard with less risk of dissolution o\er tine. So far,
chlicàl.locumcntation on the efficacl.oi this maLcrialis
Bioacti!e noleclrlcs, kno\|'ll to be siflificmt to the tcr-
minal differcftlation of odonbLrlàsts, have been Pro-
poscd as âltemâl€ ay to êchie\-ehcalfig ol pulPàl
w o u n d s ( 5 3 , 6 7 ) f a t h e r t h a n . . ! s t i c m a t c r i a l ss r c h â s
Ca(OlI)r and NITA. Allhoùgh proinisirlS in imal
expcrimcnis, corlsi.ierablc r€s€rrch ând de\ elopment
has to be cà11-ie.l outbefore bioactivc moiecules i{ill fmd
cljf icâl applications.
In conclusion, solid expcriment.l and clùical docu
merltâtron accumrlâted ovcr manv veirrs suPPrÉ rn€
use of culcium hydrox € in pL p capping and PulPo
trùn) procedures. Predictnble fePa ôi.l h€âling of
pulpal wounds canbc expected Pft)vided thnt the lrcat_
ùrcnl is rmdeftàken on ihe bnsis of prop€r diâSnosis
and bv ih€ use of a proper techniquc (scc Core concePi
6.4).It is lik-plythal cal.iûm h,vdroride rvill Lrereplaccd
in the futurc bv otlreï less caustic mdtefials that stinù
lite rcg.ncration oi dcniine rnther than repair with
a porous h.rL<1tissue. Urltil fù.ther docunentntion 's
âvâiiable, calcium hvdroxidc-based cotrPotnds remtljn
the mnteriâls oi choic€ for dircct càFplng and Partiàl
Nloplneà n o n G y { a )
n i1.NinP
7a

Coreconcept5.5
w
@
Proædreror dincalfoliowupof pup cappng/partial
pulpotomy
shouldinclude
checks
oI Common reêsonsfor p!lpec.ômy

. History
of spontaneous
pan or ljngering
pâinontemperaiure

. Reacdon to €l€cùicpulptester Electivetrêâtment in

. Stôtusol tlre restoration
prosthodontictherâpy
. RadiogËphc
evidence
of hâd tissuerepajl
Notethat infammatory
present,
.hêngesand pulpaln€oosismay be
desptehard.rsueformâtion,
in an olheMis€sympro-

Postoperativerecall
Bc.ause of the inlrcrent dsk for pulpal hJ€ction and
necrosjs,clirectprlp capping /pa rtjai pulpotomy should
be followed cljnically and radiogaphically. The post-
operâtive conirol cân be seenas â ts,o-phaseprocedurcl
the initial phase entâils an e\'â1uâtionof wheihe. healing
and asympromatic conditions havc been âttained; and
the subscquenr phase refers to ihc.ontinued folloif up
on â yearly basis. The lâtter is prompted by ihe prevàil
ing risk of pulpâl brcakdown thât mà), occrtrr several
years alter treÂtment/ dùe to nrJeclion along â defective
During the first i{ceks, minor sensations of sponia-
neous panl of short duration mav ocrur. Such symptoms
âre expected to disappeâr. However, if symptoms get
worse, indi.âting an irreversible inll lmak)ry condi-
tion, pulpobmy or pulpectomy should bc considered.
A 6 monù rccall is considered approp atc for the
fi6i folloû' up. Th€ tooth should be examined chncal]y
àccolding to rhe procedûrc oudined in Core concept 6.5.
ll there is no hisiorv of spontaneoùs pain, a positive reac
tion to elechical pulp testing âl1d a normal periapicâ]
.ondition in radioglaphs, tltn treatment js consideled
successful. Apposition of hard tissue may of lnay not be
sccn radiographically. Thc resioration nrtegdtv shoùld
be checked for deficient margins, becâuse mâlginal ftac-
lures or bulk ftâcLurcs facilitate penetfâtion oI micro-
organisms to the woùnd sitc-
Pulpectomy
Pdpecbmy is primadly cârricd out to prevent the
developmenlof a clestructivecourseof pulpal inflam
mâtion, which may resnlt in rooi canal infectionand
âssociatedpainful events (Fig. 6.13).This meâns tl1ât
rTr
Fig,6,11 Common lôi pupe.tomy.
rèâsons
r[i
pùlpectomy maybe considered in an), câs€ lvhere ùere
are clinical signs ndicaring irrcversible inflanmatory
chùges in the pûlp of a given iooth of tk pcrmanenr
dcntiiion. A pr€requisite is that root development is
complcie. Hence, the treatment may be periormcd
regârdless of whether the tissue is dircctly exposed to
the orâl en\-ironment or not. Pulpeciomy is âlso the
treahrent ol choice for y dircct exposure of the tissue,
when strict hdications {or dircct pulp capping or partjal
pulpotomy âre not tulfilcd. Moreol.ef, pu]pectorny may
be carfied out follownlg h.'miscciion in periodontâl
thcrapy, ând when rctentil.e measur€s are needcd ir
prosthodortic thcrapy. In these lâttef situations, the
treatment is eleciive, which means that it is not prom
pted by a diseasccondition of ihe tissue.
Objective
Pulpectomyseeksto estâb1isha condition *4rre ihe
looth, following completion of treaLmeni md after a
folloa-up period, is a'ithout clinical and radiographical
signs of rooi can.l inJcction (l.ig. 6.14).ln âddition, the
fillingofthe càna] should be oI sùch a qùaliiy that bacte-
ria and bâcteliâl elemeûts in thc oral eN.ironment âre
unàble to penciratc the pulpal chamber and cause â
periapical inflammâtory lesion. The expectation is that
such a ltaling resuli lâsrspermanently ancl for the dura-
tion of thc patieni's life. This objective is c1eârlyattâin
ablc provided thattreatme.t is callied out properly and

Fig.6.14 series
orGdiosGphs nga succe$tu
demonstrâi outcomeoIâ pùLpe.iomy
ît ofthe.ânâttoproper
taken4yeâÉaftercompetiôn
tenglbk) Gdiogrâph
periapiGinTlammation (counesy
rôd 6na infection.
indicaling of DrA,Gêsi.)
with due consideraiion of the potentiâ1 Iisk of bacterial
contâmination both dûring ând after the procedure. It
needs to be understood thai although ihe treatment on
many occâsions involves r€moval of diseased and, to
some extent, infected tissùe, most of the tissue is not
irJected. This is pârticularly tru€ for the apical portion
of the pulp. An importânt objective of the b€ahnent is
therefore to maintain the stedle condiiions of the root
Criticalprocedural stêps
Pulpectomy involves two principâl steps:
(1) Removâlof L\e connective tissua of thê pulp in its
(2) Filling ihe root canâl spacethus oltained
The tissueis removed by specially desi8nedinstruments
that cânbe used to dean alrd widen the root .mal sPace,
both by hand aJrtd by rotary iNtrumentation. The
various instruments ùd iechniques by which they ûay
be used in ihis coniext are comprehensivelydes.ibed in
Chapier 16 al11dwill not be dealt wiih her€. The tech
nique Ior filling inshtmented root canalsis presentedln
Chapter 18-
ln order to achieve a predictable and successtul
outcome of pulpectomt dÈ folowing critical measurcs
are considered in some detail:
. Aseptic techrlique
. Accessând pr€pâraiion of ùe root canal space
. Location and mânagementof the apicâl woùd.
Pûlpectomy is â highly pahiul procedûre ûât should
not be carded out withoùi proper anesLhesiâ.Roù-
tine procedures, including local infiltration or regioMl
blocks, are to be followed and are most often slrJficient.
79
G)deep
ina owq molar: ca esmsialyintôôth36;(b)therinadeNe
ol aeatment
Tooih
ls æyûpiomatkanddrerearenoÈdiogÉphkalsignsoJ
Howevea pulpal ânesthesia sometim€s fails and one
may {ind that the tissue can stil be very sensftive md
.annot be touched wiihoui câLlsing intense Panr, even if
the injection has been given prcperl). This complication
is morc common in mândibular posterior ieeth than in
mdillary teett! where h{iltration anesthetics norma y
are etrective (49). It js a common clinicâl finding, esPe-
cially in pâtients with painfùl pûlpitis, that comPleie
anesthesia can be difficult io reach. Prcvided that the
injection is given adequately and at ihe proper dosages,
several me.hânisms cân be held r€sponsible:
(1) Afferent nerve fibers deriving from jnflaûed tissùe
sites may have chmged resting poieniials and
lowercd excitâbiliiy thr€sholds, which not only
are Éstricted locally but extend throughout the
alT€cted nerve. Anesthetic agent is therefore unable
to prevent total impulse transmission (35, 69)
(2) Pâtienis under sû€ss and :ùiety hâve a lowered
pain threshold (seeChapter 4).
(3) Accessory nrnelvâtion, e.A. ntftus lllyLohyoideLs,
may send branches to mmdibular molars. The he-
quency has befl estimâted to be âpproximately
20% (s8).
In the câse of insuflicient pulp anesthesrâ, one or
several supplementary measures may be undertâken:
'l) R e p ê â l n i e c t i o n. , n d w d I a l o l h e r 5 l 0 m i a
(2) If noi effective, combine regional block anesthesiâ
with iililtration. For exmple, on mandibùlar
blocks combine a'ith infilhation at the botiom of
the mouth disially to the tooth, to numb a potential
extra nere supply of flefpus nrylohyoideus.Conbi\e
infiliration of the maxillary incisor with a deposit
deep inio ihe nâsopalatine dùct to catch nerve
(3) If stil not effeciive, supplement wiih so-câlled ped
odontal ligament ùjection or intraosseous injection
(Clndcal procedurc 6.2).
 80 Thevitalpulp

Such a material would fix drc lissue and render ir

Clinicalprocedure
6.2 necrotic witHn 1 week. Thereupon ân endodontic pro-
Inthemonheadstrong
cÉs wh€repulpalanesthesia
cedure woùld ensue. This met\od is not used now
isdifficutrto
oblâin,suppl€mental
anenh€saof differcnrmodesmay be becauseof rhe strong risk of leal(âge along ihe rempo-
rary filling to the marginal periodontim, a,here serious
tissned€sirùctioncould result (seeCasestudy).
Inthligamentary
injedion
. Plâceshodneedle
Aseptic techniqrc
intheqingivalsukur
mesiaor distâttothe
Asepsis relates to meâsùr€sundcrtaken durin8 sùrgical
. ooe dhon. to p'È\" rr rl-e dccê". oi e\lraleoL. -i(ro
Advance inlotheperlodonral
ligamem unriiresisrance
is m€1.
. slowlyjnject0.2m oI anenheftsolution,
whkhwi penerrate orgânisms to a giver wound sitÊ. In endodonric ihera
thecanc€llousbonetothe pup. pics, including pùlpectomt poienrial sources of bacierial
conrâmination of the pulpal chamber ar€ ftom:
lïis technique
shouldnot be 6ed in reethwth marginapùi
. hJecied debds
. Sali1'a ând gngival exudate
lntlaosseous
iniection . Non-sterile irÉLruments.
. Useintitration
anesthesla
olsoftrissue
covering
footâpex
and Hencc, asepsisin endodontics involves procedures rhàt
afe àimed io control these sources of inJecrion.
. Pertom1efie
p€riapkalcorricalbonewirha soidne€d,c
unven
bya conrra-ângl€ Initially, prior to any attempt to enter root canâ1swirh
hândpie@.
. Inseda shortneedle
in rh€drilledcanat. instruments to exthpate the tissûe, carjes shoutd be
. Inject0.5m1of non-vasopressoFconrâ
ning,fâstpenerrating removed totally by careful excâvaiion. Otherw$e, rnere
aneslhelc,
e.g.ânkâin,whichis the anenhesja o, cnorce is ù obviolls ûsk that during canal iîstrumenration
(37,39). hJecied dentine is brought to rhe apical porrion of the
canal whefe it may induce ard maintain ân inflamma-
tory lesion. Sinilarly, the tooihshould be cleaned ofany
. Applya cottônpellersaiùrâredinanelheticro
theputpâtfloor. calculus ând dental plaque. A defective fi11ing is anorher
. R€move an€sthetizeddentine wirh a slow{peedhandpiece. so1'rce of bacierial contaminâtion and should be elimi-
Repeât anaenhesiaof dentine il necessary. naled âJtd rcplaced before ihe initiation of treatmenr
. Makeê smallp€rfoÉtion of thepulp,aimingara snugft of (Fig.6.15a,b).
then€€deii theperforarion Ploper asepsis in endodontics cmot Lre aftained
. Inject0.5m]of anenhelkinrolhe pup underfim prcssure without ihe use of a rubbef dâm. Apart from providing
. Repeat procedureif n€cessryror eachioorcânaTottowing ân aseptic field ofopcraiion, â rubber dâm facilitates rhe
r€movâl oTthecoronalpulp. procedure ancl prevents instrumenis being dropped,
which may be swallowed or aspirated inro the tungs.
Also, a nbber dâln prevents leâkâge io rhe oral environ-
ment of tissue-irdtâting medicaments used drring rhe
(4) As a final, desperate move one may be forced k)
givc an inje.tbn directly inro the putp (inûâpr pa] On intact teeih or teeth ûiih only minor loss of
mjection) (Clinical procedure 6.2). Ii is imporiant tooih substance/ â rubber dâln normally cân be applied
ihat such a meâsûr€ is caried out only wirh ful without nuch effort. However, teeth wiih substantiâ1
compliaNe of the patient. ln an apprchensive or substance loss mây reqùire differert build-Lrps (Fig.
severely anxioûs patient the procedure shoùld be 6.15b), inclùding the plâcemenr o{ ortlrcdoniic or copper
avoided. It is then advisable ro posFone treâtment bands. OdÉr mea rcs to optimize ftbber dam applica-
ând reschedùle the patient with a prr--scription tion inclùde gingiveciomy and crown,iengrhening
ror premedi.ation. Ditrerent regimens mây be prâc-
tised, including â combination of orat adninistrâ- Following the placement of a rubber dam ir shouid be
tion of non steroidal alti-inflâmmatory tested for leâkage. This is best done with hydrogen per-
d.ugs ând
diazepam in proper dosages. oxide (30olt, which js carefully âpplied io the nârgins of
the rubber dâln. Leakage of sah.a or gingival exudate
Formerly, when pain control could not be obtajnecl in will show up as â more or less intense foaming âction
these extreme situations, pulpâl devitalizarion was used. (FiS.6.16b).
The procedure involved applicaiion onto rhe exposed To control leakage, the dam may be righiened to
pulp o{ â highly tissùe toxic âgent, e.g. iormâldehyde. the tooth structure by dental lape. The iechnique is ro
 Vtàlpulptherapies

i5oationof a toothwithâ rubber

Fig,6,15 Proper uteprerequisile
dàmisanabso to oblan ânaseptklieldo{opûâuon.
Defective beê jmi
filingsshouLd
mÈdriEtG)andrepla@d with,Iorexamp e â glâsionomêr (b)orâny
cement orher
restorative
that
cai p@Êni leâkàqe
olellvaandsinsiva tô $e
exudate
rool(analdunslheprocedure. (d R,rbbùdamânddâmp.

Fig.6.16 ciii.âl pholoEâphsshowing rubbsdamâppLjction

on uppqinciso.G)
prcperdâmpk le(êdi(b)swabwilhhydrogen pùoxide(30%)sho$
Ioamins
acdonthât
needsâttemiôn(+); k) dÈinleuôn
withiodinetin.iure.

brin8 Lhe tape throqh the tooth contacts and tie it
undemeath the clamp. Also, various forms of sealing
âgents mây be used for the purpose of excluding orâl
fluid .ontmination. Fimlly ihe dm, the tooth aJrtdthe
pulpâl wolrrtd should be disinfected with either an
iodine tinctul€ solution (s 10%) or chlorhexidine in
alcohol(Fig.6.16c).
An important st€p in ih€ aseptic chain is io use sterile
jnstruments. Insiruments for root..ml pr€paration âre
best maintained in boxes,which can be aùtoclâved (Fig.
6.17).Dudng the operation, care shoùld be exercisedto
avoid contâminÂtion of the part of the lnstlument that
goesinto the canâ1by,tor exmple, finger toudl or odrer
A.cess a d preparation oî the rcot caflal space
Teclnicalt pulpectomy can be quite â demanding
microsurgicâl operâtion. This is paticularly Eue in pos-
terior, multirooted t€eth, whel€ pl1]per accessto the root
cânal system often is diffil:irlt io attain. Pulpectomy also
may be precâious in naraow and severely cuFed root
canals.Other complications include:
82 Thevltâlpulp

. Overlooked root canâls chânicàl hsùumentâtion âre cdtical. For À detailed

. Incomplete ehninâtion of pr pal tissu€
. Lâteralând apical overins Lrumcntatidl
. l n r o - p ' l ' I l l r n S , ' l h r' . " r . , r . r . p r . .
Tl . ôb\ ioLr. h.rl Lrder lhe-e.onJ tion. tl-.p ognu-i-
for a successftrloutcome is lessened,becâuse miclob€s
eiiher brolrght into the pulp châmber during the prcce
dure or penctrating the pùlp chamber afier its comple-
tion mà)i find conditiorù for groirù d mûltiplication
in the root cànàl system.
To opiimize the .onditions for a succcssful oùtcomc,
proper âcccss b all root canals and thoroùgh biome-
Fig,6,17 Endodonlk
instrunents ândftriized in â.âsètte pdor
âûânged
âccoù1t of the proc€dures âssociâted with opening i:nd
hsLrumcnLing iccth for cndodontic t]Ërâp),, the reâder
is referred to Chaptcr 16.
To bc complctcd successtul, a pulpeciomy also
requires sufficienl rime. It must noi bc rushed bccaùsc
of ihe iminent risk of lcaving iissuc clcmcnts behjnd
(seeFis. 6.18).In oiher words, a pu\rectomy shor d b€
c o m p l e t e dn r o n e a n d t h e s a m e s i t t i n g â n dt h e c â n a l t h e n
should be enlârged so thât il cân r€ceive erther a
ternporary or permânent root filling.
Location .tnd fiatûgeflrent of the apical zooM1d
Clinicâ], râdiographic and hisiological sludies have
shown thât conttrining instfumeniation and foot filling
within | 2mm from the ànatomical àpex provide ihe
best condiiions for healing folloi{ing pulpc.lomt
wlæreas api.âl ovÊliirstrumentâtion âncl overfilling
hal'€ a negative e$ect on the result (50). ltadiogrâphic
folo$' rp studies hâve also sholvn thât leavnrg more
tlÉn aboùt 3mm of the apical pûlp redrces the chânce
of succcssfulouiconc (33,34). Severalpoints ar€ shong
ârguments for the view that pulpcciomy slûuld be per-
formed slightly shori of thc anabmical apcx:
. The apical region of th€ loot cânàl is '€àsonàbly wel I
vascularized by virt!e of its close felâtionship to the
periapical tissuc and to ramiJicatioN of dr cDal n1
thc apical rcoi stru.ture. This provides sufficient
conditions for healing, âs oppos€d to â more coronal

Fig,6.18 ft is impoftantto recognizê rhàr non

lnsl.umented lÈsuen overlooked.ana s andl$ùe
remnants left on cana walt in fns and in other
cana ûrequarites,seryeas potenrals teslor ba.
teria qrowtlr n addilon,r$ùe remnants prevenr
the esràblÈhmênt ol à properroorfi ing lhar .an
sealoff the instrlmented canà.{à) DemneÉized
se.ton ol ùppêrin.Èor Rootfillng màbriâ (d iç
seêûô.cupylng rhe êfrpartofthe(ana,aM a mud
ofdenlinashavlngs andti5sue remnànts ln rhêrlghr
part somelnllàmmàtôry cê s âre locâiedin the
residùâlpùlp tjsùe (b) DeninûalÊedsdlon of
ù p p ù n c k û I h er c o tf i i n g { r f ) i s n o l f o w n g t h e
mân cânà Remnânts ol root flLng mateûâand
pùpâ risluede seênn â là1eÊlGnâl(c) lnfan-
malory.elk anddentinâçhavinqs areseenlatera
lo lhe rootTihd main.ana!(e).

U A il U U l,
iir;r;ï".nîixiïirîrïrîrîfîî:1
l onsof the aoicalforamen.
le\-el of ihe rooi caial that is normâlly without col-
lateral blood circulaiiù (42).
As the pulpâl tissue and thc dentin€ in this apicâl
rcgion most often are noi infecicd, ali]rctgh it l,llay
be infiltrated with inflammaiory cells, removâl of the
tis e and antimicrobial treâtment arc redtmclânt.
Instrumentation ihrough thc api.al foramen may
dâmage ihe root shuciure to the exteît that â proper
seâl of drc apical portion of rhe cmal is jeopardized.
Often aJrtoverirutrumented cânal results in ovelfill
ing and a poor seal to the detriment oI a sù..essÊrl
outcome. Root filling materials are not inert md
overfilling may caEe tissue deshuction" jnflamma-
tion and forcign body reâction in the periapical
region (see Chapter u). Ideal\, the apical wound
sho ld be slightly shoft of the âpicâl foramen, a'here
the canâl is at iis narrowest point. At this site mmy
carals âre almost circulâr ând the woùd sùlace câJrt
be kept to a minimum, leaving Iair .onditions lor
heâling of the woundr This poini is ofien iermed the
apicâl constdction. However, siudies of ihe ânatomy
of the root âpex have shown thât ihe levcl of i]rc
apical conshiction vâries, although il is most olien
within 1 mm short of the apical foramen (15). In addi-
tio& the apical forâmen often exists at â distance ftom
thc anatomicâl apex (Fig. 6.19). Because of these
reâsons it is logica I to place rhe âpical wound short of
the ânatomical apex and ât â safety distance of about
1-2 mm from its level. The proper level is delermincd
by placing an instnùnent in the cânal to the assumed
co ect length ând assessing ilrc remaining distance
to the anatomicâl âpex in a radioglaph. This proce-
dure is termed û'orking-length determination by the
u - e o f â t r i d l f l e . W o r I n g l e n g r \ d é l ê r m i n , t i o r rc d n
âlso be carried out electronically (seeChapter 16).
Furthermore, confining ihe levcl of exti4'ation to 1 2
mm off ihc ap.'x favors a shaphg technlque rhat is
aimed at creating a step in the caMl againsi whidl
ûe root fil1ing can be condensed. Àccordinglt the
chanca of a tight fit between the filljng and ihe canâl
wâlls increases,md the dsk of ovednstn'menration
and displacement oI ihe root Élling material jnto ihe
periâpicâl tissùe and bone decreases.
Vitalpulptheraples 83
or temporaryroot {illingâfter
Permanent
pulpectomy?
Pro\.ided that ihe c'xtirpation procedurc cal be com
pleted without complicâtions, ân immediatc permanent
canal filting js appropriâte iJ therc is sufficieni time
âvailable lor the filling procedure. If not, or if i1Ére is
bleeding that is difficult to stop or concen about the
teclùical outcome of rhe procedùre in general, a tempo-
râry root filling is advocaied. Leâving the cânal ùIfilled
is inappropriate becausc it may facilitâte ihe Srowth
of contamnlating micro-organisms. Câlcir.lm hydroxide
is then ihe mâteriâl of choice- The rationale for its use is
(1) It fills p the canal space ând prevents rhe multi
p l i . â t i o n o l , r ! . o n r d m r ' â t u ' gb d c t e r u ro r g d n i ' m - .
(2) It aids in siopping bleedings.
(3) Ii nccrotizes any ussue remnts on the canal wâlls,
whid! upon a subsequcri siiting, caî be elimimied
by instrumentâiion md ûe use of NâOCI irriSation
(20).
(4) It favoùs the formâtion of hard tissue at the apicâl
end of tlÈ root cânal and ât arry cui laterâl canals
(60) (Fig. 6.20).
Wound healingafter pulpectomy
T]rc heahlg pâttem following pdpe.tomy is charâcter-
ized by an initial inflammatory reâction in ihe aPical
r ' . r r ê d u e t o h e l " r , m r I n d u c e db y l h e . u f i i n g p ù . e
dure. Tnc residual pulp is often lacerated aJrldmay even
be losi in tlÉ process (41). If, by âccident, tlrc root canâl
instrument has been pushed through the aPicâl foramen
durjng working-length determination or irutrumenta-
tion of the cmal, ûe âpical terminaiion of the pre
parâtion slùuld sti11be confined to 1-2nrm flom the
anatomical âpex to rcduce ihc risk of periâpicâ] surylus
of root filling maierial. In the âbsence of wound infec
tior! reorganizâtion soon occnrs. This involves iePlace
ment of Lhe injured tissua by connective tissùe dêrived
from ihe pedapicâl region (28,43). In the process, somc
iniemal or extemal rool resorytioll mây develoP ilùi
larer is repâired (Key lfteraturc 6.3).
 Thevitalpulp
Fis.6.20 G) Mdophotosraphs
showingapkaihardtissue
repair
inloolhsubjeded ro pulpectomy
I momhsearier{b)Nighmasnilication
shows
hàd-iissuetormârion
n rclarion
ioiherootlil:ngmarsiàl(+)anddenlitutshavinss
Patients mây èxperi€nce some tenderness imedi-
ately following the procedùe. These slrnptoms disâp-
peâr in a few dâys' time, along with recovery of the
apicâltissue.
Matedâls ûsed to fill root canâlsrnay compromisethe
nolanal healing pattem, owing to their irritating capac-
ity, ând r€sult in a longstânding inflanrmatory lesion. In
particular, this is the câse when rcot filling material is
extruded into the residral pùlp and dre periapicâl tjssrc,
or into uninstrumented apical rèmifications (51).InJlam-
matory cells accurrûlate closeto ihe root filling material
and remain for æ long as toxic componots are r€leased.
Eventually the mât€rial will be lined off by a Iibrous con-
nective tis e. Th€se lesions usually go on ûmoticed
without causing much discomJoft to ihe patient. On
ove#i s exiending into the periapical hssue, a radiolu
cent areacm be found to circlrmscribeth€ material, thus
reflecting the tissue irritâtion that is going on. The
process of phagocytosis mây eliminate the excessroot
andlilingwirhâ cakium+ydroxide-conlaininq
cement
(3).
fig. 6.21 Resoelion of s€er: (a) rool
liLlingwith gùttapêr.hapointsand a
côciumhydroxide sealerâftû pulpeciômy;
(b) resoryuonor djssolutiônof $e nron
apicalparrofthebotfilirgâIterl0 monti'
(counsyof DrÀ.Buûard.)
filling mâterial or occasionâly also material inside the
cmal (Fig. 6.21). Hence, ttre rcsponses to root filling
mâterial may remain for years and prevent complete
healing. ând yet root Iiling excessesdo not câuseexten
sive lesions and on more prominent Iesions a bacterial
etiology should be suspected.
It is noi mcommon Ior dentine chips rcmoved ftom
drc clml wals during the instrumentation to be dis-
plac€d inio or packed agâinst the residud pinp Gig.
6.22).Unless infected, this is usualy rcgârd€d as b€nefi-
cial becaùsedeniine chips:
(1) S€parâtethe root filling matedâl from the apical
(2) Are instrumental in buildin8 up a hard tissue
bÂrrier(6a).
It shoÛldbe emphasiz€dthat neither the packed dentine
chips nor the apposition of hard tissue onto displâced
d€ntine chips is impermeable to bacteria and bactedal
 a5

Keyliterature6.3
Inanexpem€ntêlstudy, deliberateapicâl wâs
overinstrum€ntation cells.Hardtksuewa5d€posit€d onlhe canâlwâlsin areâsof previ
perforrnedbyHô6tedandNygâard-ostby (28)in 20 maxillâry
inci- ousinternal rootresoption (b).
sorsandcanines schedùled {orêxtradion.Ihe pulpswerc dinkally lïe authoB concludedthâtunint€ntionalremovâlof the€ntircvitêl
Theâpkâlpulplksuewasremov€d
healthy. or dllaceËted andthe pup to the periodontal membÊn€ doesnol nece$itêie subsequenl
lndkatorfile wasrakenthrough thêapicalforamen (â). flling oI the entirecanalprcvid€d thât strictasepsisi5 maintained
Tostudythe châracterof the subsequenl tissueresponse,iinal duing the lreatment, Thut if unintentional
overinnrumentanon 6
shaping,filirg ândrcot{illingwasmadesubstântially shoftofthe experienced, the rcot ca.al instrum€nt shooldbe withdÊwnand
radlogÉphk AftefenÉdinglhet€€th6 10 months
{ofamen. Laler, lurthershaping andfilingshouldbercstricledto theoriginalworking
hktologiGl examinêtlonrevealed a cellrichwell-vasculariz€d
con lenqthin orderto facilitatea tightfit oJlhe root{illingandavoid
necliv€tissuewithinthe âpkalpartoTthecênal.ltis tksuebor- surplus rootfillingmaterial.
deredthelootfillingmaterialand harboredonly a Tewinflâmmalory

elements (5a), therefore ftrrther treatmeng e.g. a laier
accessto the canâl to prepar€ for a post space,must be
peformed ùder asepii. conditions.
Emergencytreâtment
Emergency ireatnent is primarjly carried out io giv€
relief from painful symptoms. lt mây â]lsobe driven by
an ûnJoreseencomplicaiion thai is not associâtedwith
pain but that requires temporâry treatment until a d€fin-
itiv€ treatment cân be conduct€d. As Ior teeth with vitâl
plrlps, emergencytrearmeni may occrû due to:
(1) PâhJûlpûlpitjs.
,2, rJlp e\poslrrebecduseof , d,iês. iaroSeniciniu)
or trauma in ân othetrise non-painful tooth.
(3) Mid-treâtment or post-treatm€nt pâin subsequent
to pùlpectomy.
Time often sets limits for what ù possible to achieve.
Time conshaints may be due io ùscheduled appoint-
ments in beiween rc8ulaÙ schedùled patierts in the
clinic, or because a complication occured ai the end of
a scheduled ireatment session. This meaff that ân eme.-
gency treatment, by its v€ry natur€, ofien is â compro-
mise. Nevertheless, the operaiion hês io be câûied out
and should be directed to either alleviate or prcvent the
develop ent of â painful condition or my other âdveme
sequel. This pârt of the dupter describes procêdùF thât
may b€ undertalen to meet such objectives as far as the
viial pulp is concemed.
Pêinfulpulpitis
In ân emefg€ncy situation one mây be faced with
pâtients in different degrees of pain and thus of dif-
ferent urgency for treatmenl. Àlthou8h severely dis-
comforting to ihe patient, it mây just be an enllanced
sensitivity to thermâI, osmotic and tactile stimùli, which
disâppears upon removâl of the pain stimulus. In yet
other casesthe condition js severcand lingering and the
urgency for ûeahnent i.shigh (seeCore €oncept 6.1).
86
Fig.6.22 Denrine chipsiemovedfromthe.analwalsdurinqinsrrumentâ
t l o na r e p a . [ Êadg a n n t h eâ p i . ap u p t È s u A
e b o u t 2 m o n r ù f o l o w irnogô t
lillng rhercs a n gft nfâûmâtoryreacuon ofthe1i5sue.osero rhedentne
.hips and resorption oi the canalwa 5 but normalappeàran.e ol lbrous
t $ u e a n d . a ô aù m e nl u r i h ear p i . a l y
Also, thc causemal \'âry. Most often teeiù in pain are
associaicd with à deep carious lesion or rcsnrration
penetraiing cithù to the ïicinity or straighi k) the
puLp. There may also bc a cracked or tunctlred iooth,
rvhere either lârB€ afcas of dcntine or à frdnk exposlrrc
of the pulp has eùcrgcd. Paticlts thât nore or less
recently have been expos€d io pcriodoital thertrpv 'r.y
âlso present n'ith episodic trursts of mor€ of less
lingering pain to crlcnal stilrlûli, nldicâting painfr
ldentifynrg the offending trxnh is an iûpodânt
pdnâr,v task and vet it may rcprcscnt â most clenand'
ing diagnoshc châl]enge (see àlso Chaptcr 2). The
pdmar)' rcasonis thât stmptoms other than thc patient's
r€pori oi pafi are rârelt prcseft. This mcans that if
therc is not an olert d€ep caries lesion, vhich is the
most common causc of panrful pulpitls, the clinician
màv be faccd sith ilL' dilemmù of dssessings'hich ott
of scvcral teeth is âffected.
M sn.rsenent pr itrc ip Ies
Paijcnis with pulpal pâin mây require â pL pcctorn]-
procedure bui ihis d.cision shoùld be tâken onlv aftcr
câreful considcration of the cà1ls€snnd the exrnr u
which thc pan condiibn cân be .llevi,rted bjr a morc
con ser\-. tive âpproach. Dctcrmining th€ ufgency fo r onc
or the other mode ol treâtment is fllrther cornplicàted
b)'the taci thâi paticnts in pain âre oftcn u'Ider greât
stress àn.l mây leel fcar and .ùxiety for thc trcain€nt
(scc Châpter 5), thercforc a con.iitjon ma) appcar more
., ."|| ini."|J||\ -d Irh.prô t'. m r'iî '
sivc proce.llrc than is nccd.d.
Cases r|here rhe pulp is not exposed ând l.hcrc the
pairful condition is atroùt hypersensiiiviiy or ofl)r
short lingcing pânr to external siimuli are esPeciâll,\r
âmenabl. to â cofsen'âtive, or wait ànd see, kind oi
treatmcni. A recent festorativc proce.lur€ or reccnt
p€fiodontal thcrapt belof g to thesecascs.Oftenfereihe
symptoms âre of a tcmporà[' nature ând will disàt]Peâr
o!er d feu $.eeksiliihout active trcahreni.If sr"mFioms
a1€ pronounced or hav€ persisted for sornc tine, rc
ùolal of the restoraii(D a1d replacement of it ùiù à
new of temporary rcskrratjon mày takc c.re ôf the
problcm. Hoùelea root exposurc subsequ€.t to P€ri-
odontâ1ib€rap,vor looth sear is not mànaged as casily
and requn€s some form of thertrP€ltic â8ent thât.rn
block tl1epermeabilily of tM inlo1ved dentinal tubules
so thai ihe hydrod-vnamic mcchanisn for p.in trans-
mission al(ng dentin€ is set of{ (scc Chapter 4).
ln cascswùere the conditjon of thc pulp is deeme.l to
be oi ân irrcvc$ible nâturc, the iirsi sicp in the ejner
gencv trcâtrncnt is to exFosethe PulP. If thcre is a carles
lesion, all carions dentine should be e\câvated lirsl
and then sevefâl opiidls are â!âildble, âlthough hme
pressure often dccidcs the choice of treaim.nt. Sev€râl
studies hâ\-e indicated thàt pulpeclonl Niih comPlete
dcbrid€ment of the root canâls is tlre emergcncy heàt
rrcnt wiù the fighest probabiliiy of Faif reliei (44, 65).
Howcvea sùfficient time oilcr is noi â!àiLâbLeto connrrt
thc acute pâtient bv this procedure ând theref(rc it
shor d noi be ùndertaken. An alicrl1ative lâstef treat-
mcntwiihâ high râte oisucccss is pulpototll., s.hcrc the
cotun.rl pulp is rcmol.cd (21,aa) (Clinicâl proccdure 6.3).
The fastcsl and simplest treatmcnt, but the leâst Prc-
diclablc, is to .o!er the pulpal cxposùr€ with â cotktl
clinical procedure 6.3 Emergency pulpotomy
(1) Prepare a..es op€nlng t0 ihe pup andrenovethe corona
p u p w t h a b un a na i H o t o t
(2) lr gat€withcopioFamoùnts or0l%.lr orhexdiôeor 0 5%
Na0C
(3) controlhemotrhage by prcssùre wth nerile.ottonpe ets.
Inthecaseol profuse bhedlng, soakpelktsn 3% hydroqen
penxideor anaqueoLrs mixtûre of ca(oF),.
(4) Appya smallnùllecottonpe et lo thepupa woundat the
(5) Restore a(e$ Gvitywitha têmponry rilling.
(6) Perform pupectomy assoonn po$ibe.

pellet ând â iemporâry filling. Whcrc pùlp is exposed
after caries remorâl in ân asymptomaiic tooth, ihis pro-
cedure is normâly sl1fficient until the patieni can be
scheduled for plrlpectomy.
Special co siderctions
Ii '\,âs plel,iously held that â sedâtive or antibâcteriâl
drcssjng sùch as eugenol, camphorâted phenol or
steroids a'as a necessary adjùci to obiain pain relief.
Comparaiive studies have shown t]Ét there is no addi
iional effect ftom ùsing agents of ihis nature over what
is gained by ihe placement of a sicile dry cotton pellet
(21, 70)- The cotton pellei also may be omiitcd because
Its function is me.elytoeâse the location of ihe canal od-
lices at the next sitting upon removal of the temporary
tlling. Tlle pellet must be smâll to permit a Lsmm
thick lâyer of temporâry filling mâterial (e.9. zinc oxide-
cugcnol ccmeni) to prevent mi.robiological leakâge ànd
contâninâtion of the pulp between sittings.
Aithoùgh pulpectomy has shown the hi8hesi sù..ess
rat€ of pàin reli€t pulpotomy has given totâl or parhâl
pain rclie{ in âboui 95% of cases in clinicâl follo$' ûps
(30, 44). In situatioùs where pain relief is not âccom
pl .h.Ll bi pulpùrùmy. puJpe.rumr .roud be per
fomed and ihe paiient shoùld bc mâde âwa1e thât
some postoperaii\.e iendeness or a slighi dùll pâin in
ihe affectcd region is to be expecied {or a couple of days
afiel the emergency procedure. If continuing to be
severe,the patient should be ad\.ised to call and ask for
â new appointment.
Pulpalexposureby trauma or cêriesin
a non-painfultooth
Ir ihe cascof pùlp exposureof ân âsymptomaticpulp
by lrarùna or câries,direct pulp càpping or pârtiâl
pulpotomy may be consideled (seep. 71). Eilher ireat-
ment should be gi\.s as soon as possible following
injury md thÊn a permanent filling to preclude bâc
tedal contaminâtion should be cârried ort. ff proper
conditions for câpping or pùlpoiomy do noi exist, ilrcn
pulpectomy is the lreaiment of choice and may be
scbeduled for a later appoinlment. In ihis case pulpal
exposure should be manâged by a temporary drcssing
âs described above.
Mid-treatment or post-treatment emergency
A pâhJu1 conditionmay remain after emergency
pulpectomyor arjsefol1o$,ingpûlpectomyof âninitially
non?ainJul iooth. Thc latid condiiion is termed
endodoniic flâie-up. The caùsc is likely to be of bâcter
iat odgin combined with an inadcquaic teclmicâl proce
dlrre- Contaminalion due to noi applying a rubbei dâm,
Vltalpulpthe6pies 87
an unsâtisfaclory temporary lestolation, displâcement
of câdous dentjne and bacterial plaque into the canal
have been identified as key faciors (1, 30, 52, 70). h]
combhation with inappropriaie intracalal medicatio&
incomplete instrumentation, non-instrumenied cânals
md apicâl overhstrumentâtion, it is easy to compre
hend that conditions for bacterial mùltiplication are
created in the root canal system. It slûuld be eûpha
sized that compli.aiiorÉ of ihis nâture should be rare
ând only occùr ai a low rate in properly mânaged clini-
ca1practicc (30,65,Core concept6.6).Cracked tooth sub-
stance ând traumaii. occlusion âre other fâctors ihat
should be taken inlo coNideraiion when examinjng
patients for causesof an endodonii. fla1e-up.
To aleviâte a painful condiiion âfter pulpectomy,
ûe first step is to assessthe need io carry oui a re entry
p1ocedurc. This is pârticularly rclevant if the iooth is
àlreâdy permùcntly filled. Many ùmes the .ondition
is self-healing ând may be controlled simply by over
the-counter pain medication ùd a Éduction of the
fmctionâl cusps. lf re entry is deemed nôcessârt tlrc
endodontic procedure shonld follow the same stdct
routine as des.ibcd above, which includes proper
rubber dâm applicaiion ând dishJection. lf necessary,
the âccessopening should be adjusted to gain optimal
entry to the root canal system. It is advantageous
to enter rvithoui ancsdÈsiâ for rhe controlof âny missed
canals or incomplete removâl of pulpâ] iissuc. Of co1[se,
the conhol should be cârried oui s,ith greât câre uncier
gentle probing of poleniial c al orifices and root canals-
Special notice should be given io drc high ftequency
of maxillary molars û'ith two mesiâl cânals, the one
that is most often missed is the mesiolingual carù1].In
lower molars ilrc distâlrootmây âlso harbor two canâls.
Copious irigation and re inshumentation of the canals
should rhcn follow, iJ necessary under local ancsilæsia.
On cârrying out the prccedure, ensù proper working
length and tempoize dÈ cânal with a drcssing ot
cÂlcim hydroxide. Ir order to secure a bacieria-tight
tenporary filling of $ifficient strength, a mix of a zin
ondÈ eugenol cement or similâr compoûnd should be
âppli€d over the calcium hydroxide dressing, lollo'\'ed
by a sudace seâl of hâid-setiilg cement.
An endodontic flâre-up may be associâted âlso $'ith
m overliled root cânal. Normâlly, â small exirusion of
Cor€concept6,6
p nclples nduding aseptklreât
Adh€renceto bâskendodontk
pulpaltissueandrillingof
nent,comphleremoval of accessible
canato properlenglh favolspâinrc iefandpredudesendodon
88 Thevitalpulp
root filling material does not cause more tlÉn slight ten
deness, if at aI, o\.er a coùple of days and subsidcs over
the following days. Hoa'e\-er, if a severe pain condition
has developed along \rith apicâl tenderness and some
sa'elling, often therc is a bacteriâl cause where, along
with the root filling material, micro organisms hâve
been pushed jnto the peliodontal tissues âs a.ell. Cross
o\.erfills may cause quite severc tissue responscs duc to
â sirong toxic reaction.
Casestudy
Seqrelae following the use of toxic endodontic
A patient appeared jn the denral clinic a.ith pain and
sû-elling related io ihe firsi righi mandibular molaa a
reduced capability of opening the mouth and paresthe-
siâ of the dght lower lip. Root câJrlalheatment had
been hitiâted by anoihef dentisr some tim€ previoùsLy
âJrtdparaform used as a deposit between sittings. The
intraoral exâminâtion reveâled exposed corticâl bone
bet$,ee11the molâr and the second prenolar (â).
Renovâl of a temporary filling in the molâr releâsedâ
sirong smell of camphoraied paramonochlorplÉnol
tuom a cotion pcllci and rcYcalcd devitalized pulp tissue
drd r m, .idl p, l,rJh, r ùf lt. pJlt . hdmbc
The pulp châmber and the root canals û-ere irrigaied
\a'ith copious amounts of stefile saline and the canals
A rare but se\.ere complication is associat€d with root
filnlg mâtedâl being forced into the madibûla1 cânal.
Tlns is esp€cia11)' true if a paraform-releasing paste hâs
bccr used (se€Châpter 17).ln such instancesthepaticnt
may be numb for â few days, a.hich later leads io a
sel.cre pain conditioll due to neuritis. Such a painful con-
dition may lasi for w€eks or months and cânnotbe cûred
by slùgicâl inte entjor.
lvere funher clcancd ând shaped, follo$'ed by an
i " t r . r . J n , l . l p p c { tc I r . J . u _ f r d . o \ i d ê - L r s p c n - i o r
Àntibiotics lvcre prescribed.
Surgical rcmo\-âl of the necrolic tissuc ihc followil1g
da), reveâled a mesial pcrforation of the molar (b).
The s$'elling a.as resolvcd and ûe paresthesia û'as
reduc€d aft€r 1 week.
One month lâter a bone sequesterwas removcd and â
dccp periodontâlpock€t was prcbed mesiâlly and in thc
turcâiionarea (c, d), àft€rwhichitwas decided to extract
the molar. Pari (e) sho$'s the mesial âspect of the
cxtra.tcd tooth, $,ith perforation and âpicâlremants ot
dl€ peliodontâl membrane. An implâni a'as irucrted lat€r.
The case emphasizes ilrc problenatic use of highly
toxic endodoniic medicamenis, which under ad\.erse
circumstanccs may leach to the suûounding periodon-
tal tissues,resulting in serious dcstruction. (Courtesy of
Dr K. Brôndum.)
 Vitêlpulptherapies 89

References :19. Gwimet AL TàyFR.Edly and intcrmed iate time response

of thè dentâl prlp to d a.id etch tedùique i. vivo. ,'1'r.
1. Abbott PV laclors associated Nith contnruing pain in ./. Dcrt. 1998,l:l: 535-!4.
e.dodontics. ,4ast. D.al. i. 1994,39: 157-61. HassèlgrênG, Olsson B, Cvek M. Effecis of calcium
2. BaùmÊ LI. Diagnosis of diseasesof ltle px1p. Or"i 5,r9. hydtuxidè dd sodim h'?ocNorite on the dissolûtion
:1980,29: 102 16. of nècroti. pôr.lne ûus.le tissue.I. Errodori. 198E,14:
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pulp capping.lrr. Dcrt. /. 198113:L:25160. 2 t . Hàsselgren C, R€itC. Emcrgcncypùlpolony: pâin rcliev
,1. Bergenholtz C. Evid€nc€ for ba.teriàl causation of adversc ,g,'lN h,hd'orirl^ur Lhr.-! J .. ddii\- ù-* nE .
pulpal respo$es in resin based dental .Êstorations.Crt. I. EntLotlo t. I98r't5:25].{.
lle!. Onl BD/. Med. 2000; ll: 467 80. Seaehty thÆ tit|nts veking dnerycn..!treatn nt be.dusè
5. Câlùkân MK. Pulpotomy ôf .dioùs vitâl teèth with peri ôJ "ctt? p"lpnl piu uùe subi.ikd Lo ttlpotni4. Altèt
âpical involvemot. lri. Er1ùdnnt l. 1995i 28: 1724. t h o t l . l t h " a . n a tt a . a . I t t L p " ] oa . o t r t p 1 1
6. Cox C4 Bergenholtz G, litzEerald M, Heys DR, Heys RL tuaisteked uiith cûnpharated phù1o|,.ugewl, cresatin ar 60
Avery lK. Câpping of tlrc dental pulp nechmically tDnicsalihe,ôt snnplya dry pdkt, rvs tlûæd ar the Enaû
èrposèd tô the oral microflora â 5 wÊek obçrvation of id" patp , d t . ta\a r ' 1. -t \ttn-a lu. .4
wound heahg in tlrc nonkey../. Otal Pûthù!. t9a2i II: oxide+ugenol cenehtuds plûed dnectlyon thepr\al tirsuc,
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Heys RI. Pllp cappinS of dental }rùlp me.hanically ptlptctonies ùJlet the aflesth.ti. .f..t had dGnqedrd. The
eyosed to oràl mi.roflorà: a 1 2 ),ed obseNâtiôn of wôrd resilud 7A patkth had na ptin 1 da,! aller the eùèryen!
heôling in the montey. l. Onl Pathol. 19E5' I4: 15Ç64. tleatrert, ilr.spe.tioe al ahetht û tnednaùùit !ûs rtu1
8. Cox C4 Keàll Cl, Keall Hl, Ostro E, Bergenholtz G. ot Nt. IIE cotu an useofsetlatbedrcf irys sent thùstù hùe
Biôcoûpâtibility ôf surfâcè sèâlèd ddrtal natè|iâL flo pdifl tli."itg tlfect. The inpotanl pnrt ol the enleryencu
âgaitut erpôsèd pulps. /.l,tosthrt. Dcnt.I9A7i 57:1 a. neatn@t is rctraul af th. iîitants ord the ùast iiL)qand
9. Cox CI, Hàfez AA, Akiûoiô N, Otsuki M, Suzùl<i S, Tarir l,itt of th. pùlp tiss"e,t'allouedby n bûclùiû titht tempamt!
û Bo,onlrlb,l,) r p,,m-, ddl--{\, 'd ,ê.in..n lttiflg.
Posite systèhs on nôn exposèdand exposedpulps of non HàyàshiY Imâi M, YànagiglchiK Viloria lL, lkeda lL,
human pdmates. Âr,. /. Da'|. 1998;11:S5É3 IÀcd Tlldi'l p" ie"pplie.d l di,r'rp.,lp.dpp,'E
10. Cvek M. A .linical report on pârtial pulpotomy ând medi.ine s bsiitutes for osteodentin.I. Erdodorf. 1999,25:
.àpping with .àlcium hldtuxidè in pemanent nc$ors 225 9.
with .omplicàted crown fn tur€. I. Etdadaî|. 1974; 4l 23. IleblingL Ciro EMA, deSouzaCoslacA. Bn compatitril
232 7. iq of an ad|esne system applied t., expôsedhumdl
11. CvekM, Cleâton
lonesPE,AustinlC,Andreâsen
IO.Pùlp ddtàl pulp. .1.Ërdddrrl. 1999)Zal 676-82.
r€â.tions to exPosureafter èxperiheûtâl crô$a1lrâ.t@s Heide t KerekesK. Delayedpartial pulpotomyin per
on grùding in àdult ûônkeys. I. Etltodont. t982:9: 3L)I: . mnent in isors of monkcys. hr. Endodant.I. I9n6, 19:
12. Cvek M, Grùàth L, Cleàtôn JonesIl Ausiin l. Hàrd tissue 78 89.
bàrier formâtioi in pxlpotoûized môtkey teeth càpped 25. Heide t Mjôr IA. Pulp rcactio.sto erperimentalexpo
$'ith cyanoa.ryiàte oi .àLiû hydroxide for 10 ùd 60 nûcs in young permânentmonkeyteelh.lt,. E dodDnf. /.
minutes.,LD.,r. R.s.1987,66:1166_7,1. 1983,t6: 11 19.
13. Clek M. Prognosisof luatèd non vitâl ûdillùy in.isors 26. Hûter lA. Saving pulps. A queer process.Ir.'6 o/
trcalcd s'iù caLim hydroxide ànd fi]led with gutta' talercrl1881,352.
percna.A rctrospcctivccljnical study, Etdodonl.Dml. Horsled l', El Atta. K, Lmgèland K. Câppiig of mo*ey
Trûutwtal.I99L a: 45-55. pulps wi$ qral and a Câ eugènol.ernent.Orl S!/g
14. de Souza Costa CA, Lopes do Nâscimento AB, Teixeira 19E1;52:531-53.
HM, Iontanà Uf. RespoNe of humd pûlps .npp€d with 2E. Horetcd B Nygaard Ostb_r.. B. Tissueformattun in thè root
a scrf'ctch|ng adhesi\e system. D.tt. Matù. 2007. 77: canalaftertolâl pùlpectoml'and partial rcot fi]ling. O/rl
23È40. Sury,197E)16:275{ 2.
15. Dummer PM, Mccim IH, R€esDC. The position of 29. HoEtcd q SondergaardB, Thylshrp A, El Attâr K
topograplU of dre apical canal constrictionâ.d apicâl FF,.l.\ u. A ,.r' p, . .ruJi ol d É. I r.ulp. 'pr'iÈ
foramen.rrt. Enl..idrr. / 1984 17::1924. rvith .nLiû hydJoxidc compounds.Endadont.Dent.
I 6. IitzgcraldM. Celular mechMicsof d€.ntinilbddgerepair 'fraunat l. 1985,L:29 34.
usingrH-lr,ymidinc./. po!t. RF. 1979;58:219È206. 30. Imura N, Zuolo ML. Iactds âssociâtedù,ith endodonhc
u. Iitzgerald M, Chiego D, Hcys DR. ^uloradiographjc r'lare{ps: a prcspectiye stuC,y.lnt. EndDdont.I. 1995)2E:
rnalysis of odontoblast repla.eûdt follo$'ing pûlp expo- 261-5.
surc in primate te.th. Âr.l . Ad Bial. 199ù 35: 747 15. 31. JabcfL, MascrèsC, DonohùewB. Electronnn.ros.ôpe
18. Fuks AB, Gar6 S, ChosackA. Long+em follow up of characteristicsof dentin repair after hydroayâpâtite drre.t
baùmalizedincisorstrcatcdby prrtial pulpotomy.P.dlah pulp câppinghinrats./. Otûl Prthù|.Med. t99t:2t: 502
D . a l .1 9 9 3 ; 1 5 : 3 3 4 - 6 . 8.
90 Thevitê pulp

32 KàrdosTB,Hun terAR, Hnnlin SM,Knk ElI. Odontolrrasi 5 1 Ri.ucci D, LângclândK. -{picallnnit of rôot..nâl nrchr,
differertiatior: a .espôûseto cnvironnentàl càlcium? rcnlâ tnn ând obtu.ation,Pàrt2,^ histdlogi.alstud! rt
Eûdodont. Denl.Trsu"lttô1. 1998;14:105 u. Ërd./.rr.l. 199E,3l : 394--10e.
il3. KerekesK, TronsladL. Long term resullsof endodo.lic Rq,otpÈn,,ts llstolryi.il dbsùrûtiansoJttu dlnd artl lùi
beàhndl tcrformed \rith i st.rndâr.1ized te.lujquc l. ryi.a1 tisre Jron 11 roùt ftlledhuwn tèèth Iqhnlnntot1/
Etxladaut.1979,5: n3 90. tissrètùctia s n.rt sLti 1û y wûrsijlù ..t.p|.tion .f tuot
34 Ketterl\'V.KriLÊrienfùr det ErfolEder vitâlexstnPâtion Jilliry in.ùs* ûiLh èrttù\iùflaf ûoLlIin[ nnt.tial int. 1l
Dl.ch.Zahnnntl.Z. 1965;24:4Q7L) petnttitl ti-.srt,'ùhù"ùsth. 'Nstlaûh1bk histata|iûLûùdt
35 Kin{rerll CL, EycF MR. infl.ùm.tion oI rat rnôl.r tiors1rtr..bterr.d tLltn.bLutstiùnturnjn.tl at at sh.tt af lh.
prh.',J.ri^, i,,, J,,-".' F".-c r'ir"ineên
rlùtcd peptideând axotàl sprcuù19.Âtri. R.. l 9E8;222: P , Bâbi.kt'1,S.hctrze.L, Lèung^ Theertè.r
52 Rosentrerg
2E9 300. of occlusalrcductnn on pain afte. èndodonticinstni
KitàsâkoY I.okosli S, Tagimj J. Effectsof dircct resnl mentâttun.i Irrlol.rr. 1998;24:'r925
pùlp câppjng techniquesor snort terrn responscol Ru$erf(trdD,IitzgeràldNl.A ne$'biologi.âlàpprcachk)
rne.lrùicalry exposedpulps.I. Dent.r999i27:257-63 vitâl pllp theràpyCfir.l{... Anl IJio!Mùl 1r)9r6:?1BtL)
37. lvlalmcd S. H,tdÙookof Local^nethcsio(4th cdn) St Safari K, Ho6lcd P,l'asconE^, Langelùd K. Biologi.al
cvaluâûn of thc apicâi ddtin cniP Plug l rxdo']ùtr'
38. M.j;rc l, cv€k Nl.l'àrtiâl pultotomy ù totûg PcnnânHrt 1985,11:1È2.1.
tÊeLhs,ith deep.. riouslesia\s.Endodott.Dent T1ûtr|ût.t schrôdcrU. Effectsof ..lcitnn h),.1ro\ntùcontainûg P!lP
1993'9i 238J.12. .âpping agentso. pulp .ell migr.tion, Prclifel$ion, and
'fhe efticà.yof nn inlraosseous injectionsïstem diffeÈntiatio.. /. D.rt. À.s, l9E5;611: 541r1
39. I,Ircr SL.
of deh'erhg io.àl ànestnctic. ,'lrr.
./. Dùrt. A$oc.1995;126: 56 SchuuN AHB, Gruythuyscn RJM, Wessclink PR PUIP
capping rdtl âdhèsile resi.-bâsê.l.omposite Yersus
Nvborg H. Cappingôf the pult. The processes lnvorled caLciumhydroxi.le:a Èview Entlôtlot DIl T'nr",dt.l
.md thcjr oulcotn€.ArePortoftne ftnlù! ups of . clini.âl 2000;:16:24 50 .
s.ri.s. O/,,nt. Trlsh 195E) 66i 296 {r4. 5 7 . Sedgle), CNI, McssÊr HH. Arc cndodonti.àlly rrcâLedtPèt1
\)o^r". 'rll ' d.'1. o r . * . - - . L - r ' morc brittle? /. E"dddo',t. 1992;lE: 332 5.
e
tion. An expÊrinentàlsttdy oI 17 leetll.Odortt Tiirkl 58 SillinpàM,Vloriv, LehtinenR The mlohyoid .ervÊ'nrl
1 9 6 5 , 7 3 : 4 3- 0
46. mardiLrdaranesthesin.Irr.i ord/ r!4rtill.r{a.sx/S 1988,
42. NygaàrdÔstbl' B. r,rui!.tr!, nr Xd.r.tttB. Oslô:Uni
versitcts{o.1aget, 197:1. 59 SeltzerS, Bc.der lB, Zionrz M. Th€ dynnnri.s ol PulP
NvgaârdOstbl Ll,Hjotdal O. Tissuefomitlon in thrrôôt ùfl.rlùatio.: .orelàtions behleen dia8noslicdata ù.1
.inal lolknsùg pnlp rcmo\.al.Sùtltl.I. Dùn. Res t971,i79: actuàlhislobgic findingsn, ûe pulp. Onl S!rg. 1963,16i
333+9. 8,1671.
Oglmtcbi BR, Deschepp€rEL Tayld TS, Whit. CL, Pink spângbergL, FnEshilmB. S1!dieson root cafal medr.â-
ro\.pe,"r,-p ',c''F - | " ' F Jo.l.'l' nenis lL C)1oloai. eftectol nredicaments used nr rôôt
emergcncyheatdent of svmPlonàti. pulpitis.O/al 5,/3 fiuùrg.,4.tr Oddrtol. SLrrd. 1967;25: :lE3 6.
I99L 73: 479 n3. 6 i . sLanle), HR,I-und,vT. Dycàl tl,erâp' ior pulP exPosures.
Ogunt€LriB& HeâvenT, ClafkAE, ]]ink fE Quantitârivê Anl Sury 1972i31: 818-27.
assessment of d.nLin trddge fomation krllo$,i]1gPulP 62. SiibayRKAs.iS. UumanPubàl rcsPonse to hrdroxyaP
càtping nriniâturesllnc. i. Entlotlùht.1991 21:79 a) , , r 1 . J r d J , , l 'i , r r ' ) r ' ' d n d r ' d 'r " "oJ 'È

46 PameijÊrCH, Stùrley HR. Tfu disastrols eff€ctsôt th. ag€nts.O/a/s,/9. 1993;76:'18s92.

'Tolal Et.h'techniquc nr vitai pulp capPinEin
Prinrât.s. 63. IronsiadL. Rèâ.tionoI LheexPos.dPulP lo DycaltreaL
Arl. /. D.rr 1998;11:S4F5.r. ûdt. Or,/ Sùry.1974;3E1945 53.
'rissuereàctionsnnldving aPicaL
47. P.rcirâ Ic, StânleyHR. Pùlp .appitlg: influcnce .t thê 64. TrônstndT.. Pluggingof
cxposlrre siie ôn pulp healing histologic .nd râdi- the root ca nal $'ith dentin ciiPs in nonlcY te€th suLrj€clcd
ographicstud),in dogs' pùlp. I. EndotlotL198t 7:213 tô pnlpcctoml O/dlsrls. 1978)45:297-344
23. 65. liop€ \4. rla.e uP ratc of singlevisit endodônri.s.rnt
Pirt lofd Tlt, lbràbifcl.d M, Atredi Im, Bakland LK, Endatlort.l. \99t 24:2ç7.
Kâiyarvàsm SP Usnl8 nineràl trioride .ggrcgàteàs à 66. lÈlncda Y Hayakis'. T, Yanàtoto H, lketni I, Ncmokr
pûlp-cipping nateiâ]. / ,4r" Ddtt. Ass... 1996i 7271 K A histoP.ttioloEical stu.ly ol directPulP càPPûg$ ith
1.191-!. adhesn c esins. Ofùd D.,i. :1995;20: 223 9
Potomik 1, Batotic È lalLurc of ûJerior ah'eolar t€n'. 67. fzinf.s D, Smith AJ, Lcsot H. Designingnrù' treôtnrent
brockhinendôdontics.llxd,dùht. De t. Ttirnatô!.1999;15: strategjcsin vitàl pulp iheraPl /. D.rr. 2000;28:77-92
247-41. 68. Tziàfas D, Pàntèldou O, Ahânou ^, EelibasakisG,
50. Ri.ucci D Api.àl limit of root canalinstrlmcnL.b.n ànd fapà.limiirioù The d.ntinogeni. àctiviry .i min.r.l
otnu.aùrn,pàrtL.Litcrâtu.e.Êvie$.Irl.ErdtLtr'l 1 9 9 E , tdoù'lc (M'fA) ù1 short'tenn capping cxPeriûdts. ful
L:
3 184 93. E dodont. l.2o02i 3a:245 54.

69. Wallace JA, Michdowicz AE, M@dell RD, Wilson EG.
A pilot study of the .Lini.al prcblm of regiomny mee
thetizing the pulp of an acutely inflmed rr@diblld
molaL Onl Surg. 1981 59: 51721.
70. Wâlton P! Fouad A. Endodontic inteiappointment flæ
upsr a prcspective study of incidence md related tâctois.
l. Endodoflt.199L 1A.172J.
Vitalpuiptherâpiês 91
7t. YoshibaK YGhiba N, Nâlamura It Iwâku 14 Ozawâ H.
Iûmmolocâlization of fibronectin during rêpârâtive
ddtinogoesis in h1lmn teeth after pûlp cappinA with
calciû hydrofde. .1.Derr. R6. 7996j75: 159097.
72. ZlbFtun U. V*s E cdrnd- rr. l-d,ridl prlprrom) in
cdious permeat mola.6.4,1' .1.DdL t989;2:147
50.
Chapter7
in primaryteeth
Endodontics
IngegerdMejàre
Introduction
The need lor endodontic treatment in primâly teeih
is usuâtly related to câries in molars, with tlre mrn
obje.tive being to mintain space in order io prcvent
crowding of the permânent teeth. Normally, the mosl
important time period is before the firct permanenl
mo1ârs ha1'e reached occlusion. The special features of
the primry molar, such as i]rc complicated root
.miomy and close relahon io the permùent tooth ge1Ïn
md its rcsiricied iime of fmction, make the beaiment
principles partly different from those of permmênt
teeth- These principles willbe reviewed in this chaptcr
The normalpulp
The histologicâ1 âppearafte of the normal pûlp in a
pimary tooih is [o dïf€rent ftom that of the permanent
tooth. ?hysiological agehg occurs in botlr although the
time span during which this occurs is shorter in primâry
leetl_.A , omîor m.uder+ddrng F lhdl lhF primà\
tooih is not as seNible to pail as i]É pelmanent tooth
ând that operative treatment thercfore wouLd noi re-
quire local anesthesiato ihe sme extmt. Even though it
has been obsered ihai ihe qùmiiry of nerve fibers is
snalier in the pulp of pimary teeth (41), there is no
proof thât the primary tooth woùld not be equally sen-
sible to pâin. The only exception wol d be just before
exfoliatior! when the number of nerves within the pulp
Pulpinflammation
Even ihoùgh thcre has been some contfoversy in ihe lit
erature as io the capacity of ihe pulp of pdmaly teeft to
respond to €aies by forning reparative d€nhne, several
histological studies have demonstrâted  frequent ocor-
rcnce of repârâtive dentine jn primary molârc with dccp
cades (19,39,42, s1). Mâgnusson and S[nde]l (28) found
92
a significantly lower tuequency of pulp exposure with â
stepwise excâvation procedure compaï:d with dir€ct
.omplete ex.âvâtion ol deep caries in primary molârs,
suggesting thât the pulp has good poieniial to produce
repamtive dentine-
The moryhology o{ the pdmary molâr implies that the
clinical symptoms of pûlp tissue rcaclions to damâge
may differ hom those of permanent teeth (Core concept
7.1). Thus, owing b the relatively smâ1l distance fron
the coronâl pulp floor to the biturcation and the û€quent
presence of accessory canals thrcugh the plrlpal floor
pulp infl nnation by caies in pdnary molârs morc
often rcsults in pathological chmges in ihe interradicu
1 area. Fistulâ and abscessesdue to p1rlp infection also
are seen more often in plimâry teeth, probâbly because
.f tl-' relêt\.ly thin bu.,.rl .nrri.dl b.ne in roung
children.
Internal root resorytion is the most common seqùel to
inflammaiion after pulpotomt the odgin of which is not
underslood. It may be due to ihe different way in which
the pulp iissùe in primâay ieeth reâct to irritating âgenis.
Thus, it has been shoM thât ilrc physiological process
of shedding oc.urs in areâs lâcking predentine, which
has been shown to incrcase the risk of iniernal resorp-
tion (34, 55)- Ey using calcirm hydroxide as a dlessing
material atte! pulpotom)., the presence of a rernaining
blood clot bet\ reen the dressing and the wound sudace
hâs been $rggested to enhance the intenal root resory
iion process (52).
Healing
A proper preop€rative pulp diagnosis is decisive for
successful endodonric tueahrdli in primary teeth. Pre-
supposing ihat rhe .aùse is rcmoved, the exteni io whidr
inflanmation can be present in the pulp while ihe pùlp
recovers ând undergoes repair âJtd heâling is not
k1own. In other words, the siage at which the hllam
matory process is irreversible is mce âin but essentiâI,
because endodontic treâtmeni in pdnary ieeth focuses
mairny on vital puip therapy.
 n pnnràry
Endodontc r€eth 93

(22). lhercforc, meticûloùs cleansing of the cxposcd

Coreconcept7.1 Special of thepulp
features p.rl , a , . r , l l . ' n . . r .r v s ' e ' t . r g . , o J i - È
of primarymolarsin
ândroot morphology t e c h f i q u e s( 2 1 ) .
with permânent
comparison molârs Repair and he.ling âft€r pulpotom)r r|her€ the ampu
tâtion site is situâted ai thc o fices of the root cânâls,
. Themolarhêspracrcay no rootsocle
depend on \^.hether or noi prcopcratile rnflànrmntory
. The.oronâ pulpchambùs comparati!€y àrgeandwideand
reactiois .rlso involve th€ root pulp, on the oFerative
the dnanceto the surface ol tlretootlrÈ sma, bothin the
ocusalandapproxima dnec{ois. tecfnique àn.l on thc characterisLicsof the \!'ound.lress-
. Ihe pulphorn5arereativeyarge,bothin the o(Lusaand ing uscd. furthcrmore, nrfection dueto bâctcrial lcakage
àpproximà diredons, making lhetoothvunerableto meclran is a pimc tlùeât to both rcpair ând hcaling (4), and ù€
kalandario6 exposure. importance of à bacteriâ tiSht seal camot hè ôver
fte distan@ lromth€ pupa Iloorto the blfurcatons shott
andrh€areabehveen th€pulpfloorandthebiiu(àtionolten
.ontêins a..€ssory.anas. B€cause olthisanda po$ibe ess
we -mneralized denlin€ntbisarea, anint€ûadku arw dened Diagnosis
psiodontamembrane with los or laminaduE or boneoss In ord€r to .ssess ihe cxlcnl of pulp inflàlnmâtion, filo
s a commonradographksign oI extens ve intammâ1ory
di.gnostic terms arc ofi.n ùsed: .htouic Frtial pulpitis,
chanqes or necrosis ofthe pûlp1Èsue
designatcd for teeth n,ithout prcoperarivc clùncal
Therootsareoftenfaredandbentandth€n(onlerqnq n trre
a p c a l p a r t a nndd o s er e l a l otno t h ep e m r a n e n t t o o
n t h .e d/or iadiogràphic s),mptoms of pulp nriàmmation;
coronal pârttherootcanals arereêlonably wideanda(es- aftl .hnni( tatûl pllpiLit, dcsitalat€d for teeth with pre
be whseasin the apkal pafr theyoftenshowintfcâte opelati\'€ symFtoms of pulp hflammàtion ext€ndnlg
moryhoogy with narcw,rbbonshâped ând curvedcanas. ink) tl1c ioot pr p (7,8,5l). For th€ sakc of s lplicit),,
Instrumentat onmaylher€fore bediTlcut, pdtku arlyin upper tlt tarms parLial ând totâl plrlpitis s.ill be uscd hcre.
Allhough cssentiàl for the olrtcome of the t]caimcnt,
ihere is at prcscrt no neans of prcciselv determinhg
clini.âll)' 1ùchisblogicâl stutùs ofthe pulp. Teeihjudgcd
lobc witlûut signs oftotnl pulfitis might halc proiould
Pr pàl nifl,rnmàtion. The proportion of correctly clirg
nosed pulps in lisblogical terms jlrdged trom prc-
) " oferàtive clinical fhdings hâs been inv€stigàted, wiih
resl ts \.trrylng trom 56 k) 81'". Most investiSators
have reported a poor correlaiiiù bcillcen chncâl d
hisiologicâ1 tu.1hgs (7, E, 23, 39,.12), i{hereas oihers
havc foturd a relatjvely high agrccrrolt of aboùt 80'),'
(24, 51). Severâlof these studies suff€r fron a r€latively
small nurber of teeth and it is oficn not siaied how
the teeth i{ere select€d.Ovcrall, it seems that, generâlh,t
itesults irom r€cent clinical shrdics on clirect or the probabiliiy of arriving at à histologically correci
- r c f t r i ,- . . . . . ,r . " d " . . d r " . . l . - r .' - r ' \ u . , g pulp diagnosis basecl on clinical sympbms is rârh€l
permanent tcelh and partial pulpotoDl) of càrio1lslv
erpos€d pulps in both primâry and young pcrmdLrt ln the clnic, ii may be suffici€nt to knoN bùethcr ihc
teeth suggestthatthe pulp hàs good porential kr rccov.r pulp is treâtable i{ith vital pulp therap,v or not, an.i rl
once the irrjtants are rcmo\.ed (21, 26,30,,19, 64). Thus, has been suggestcd ihat if ih€ ie€th âre divided ink)
'tretltable' (= partial
i o r ê \ L m p l . a. 1 0 0 . l i , , r l . r d r d , g a t l - r . ' , - two treitment caicgorics only, i.e.
r . , . .n d . - b . ê \ ' J I , r - F p n . - ! . ' \ d l . n i i . . , r n F pù1pjhs, vitâl pulp treatmcnt) or'not treatàble' (- totâl
perman€nt nolais with deep c.rious lesionsâ{ier obscr- pulpltis or necrosis;cxbaction), the agreetlent beti{een
vâtion perio.is of at least 2 years. Inportani prerequi cljnical ùd histologicâl finclings i{iLl inpro\-c (8, 21).
sitcs for a successful h€aiment \fere th€ absefce of Howe!er, these studies also suffd fron a snall miûber
clinical and/or radioglàphic paihologicàl syDptoins. of select€d âterials ând in oùc (8), the diilerence
Thc opcrativc icclùigùc rùust bc ponlted out âs trn bciwcen the i\\'o groups lvas not siatisiically significânt.
importani iactor for successful cndodonti. trcaLment. In the orhcr (24),tlÈ bâsis for grolrp ing the ieelh focuscd
Thus, it has been shown thai prcsumatrly fiJected on the characicr of the bleeding of the exposcd pu\r
dentine frâgmenis uninl€nrionally lcft bchind in t]È combined wiih ihe chârâ.ter of pai., a \.âriablc ihat is
pulp tissue cause widespread inflammabry rcactnDs difficult to make uncqui!ocal ând reLlable.
94 Thevitâlpulp
Coreconcept7.2 Clini(alsignsof total pulpitis
. RadlogÉphc patholoqkachangersuchâs widenedper-
odontal membÉn€ with lossof lamlnadurâ,nterradku ar or
periapical rcsoetiveperiodontiis (owlnqto superlmposed
' r,u u,ê..rddoqi.phr chànqes nèy bedi"ic-lrrod ffiv4 in
. Abnormaibotlrmobility.
. or pe6içtent
spontaneous pain,particularly
at nighi
. sigNoJckilcationsin thepulpchamber.
Radiographk
. Darkiedand/orth ck-v106 bleedingolthe exposedpulp.
. Pulpexposedafterremovaior necrotkdentin€ arg€pulp
. Prolusebleeding
orlheexposedpulp.
. Painfromperusionand/orpre$ure(oftendiffkultto inter
pret partkulary
in younger
childr€n)
Thus, although there are no clinical mcans io deier-
mine accûrately the extent ârd sevcdty of pulp inJlam-
mâiior! a number of clinical svmptoms can be used to
erhance the probability of ârfivjng at a proper pulp
diagnosis (Corc concepl7.2)-lthasto be realized though,
ftat teeth with deep carious lesions without âny of these
symptoms and accordingly classiJiedas pârtiâl prlpitis
mâ\ b" 'ld-.iJcd.^*e. l) 'r hi-olosicd lerm. in no
more thân 60 70% and ai best in 80% of cases.
Importantly, it is less difficûlt to pr€dict total pulpitis
from clinical symptoms than it is to predict a healû)'
pulp or â pulp with partiâl pulpitis (Z 8,23,39), and the
obvious presence of my of the listed symptoms (âpart
from pain from perussion and/or prcssure, which is
often difficlrlt io interprct) indicaies iotâ] pulpitis. Par
ticûlar notice shoùld be gi1.en to radiographic pâtho
logical changessuch as widened ând diffusely outlined
lâmina dura ând the presenceoI spontaneouspain, pâr-
iicùlarly at nighl, both of whlch strongly suggest total
pùlpitis. Se\-eresymptoms such as swelling, fistultr or an
âbscesssuggesi pulp necrosis.
Wound dressings- characteristics
and
modesof action
The ldeâl dressing mâterial Ior either ulcxposed or
cxposed vitâl pulps should be bâciedciclal, enhance the
repair âl1d healing of t1rc pùlp and promote the fornra
tion of rcpârâtive dmtine or, in the câse of an exposed
pdp, t]1eformation of a hard-tissue ballier. The ù€ss
ing also shor d be bjocompatible ànd noi nlterfere widl
thc ph)'siological process of root rcsorption. UnJorLrl-
naielt ihe ideâl dressing js still to be discovered Meân-
while, a \-ariety of dfessing naterials are uscd. A
detailed list of .linical sùccess rates obseNed for dif-
fercnt ircahnent proccdurcs with different drcssing
maierials is presenled in Table 7.1.
Presentedbelow are the mostconmonly used a.ound
dressings: calcium hydroride, formocresol (FC), ghù
taraldehyde, Ledermixo, zinc oxide €ugenol cement and
Calciumhydroxide
Câlciumhydroxide,usedàsâ dressingmàterialon both
uiexposedâJrtd
exposedpulps,is a strongalkaline.om-
pould with a pH of aboùt 12 thai causes a sùperficial
nccrosis of aboùt 1.5-2m in ihe area underneaih its
placemcnt. AJicr ihc initial irritation of the mderlying
tissue, ihe pulp produces new collagen and thereâfter a
bone-Iikc hard tissuc. Avoidance of m exirapulpal blood
clot is pârticularly essential nhen ushg câlciùm hydrox-
ide as a wound dressing,becaùseits presencemay inter'
fere wiih pulp healing (52). Therefore, il is impoltant
to trSea gentle technique, implying clrtting with high
speed equipment and .liamond bûrs folowed by irrigâ
tion with $'âter or sâLine in order to achieve hemostasis.
The fomâtion of a hard tissue banier, although
seldom compleie, prote.ts the pûlp mechatcâl1y d
partiâlly from bacterial infe.iion (Fig. 7.1). Ii shoùld be
noted though that ihe presence of such a bârrier, often
considered a criterion of slLccessftrltreâtment is no
guaralice of a hcalrhy rcsidùal pulp (37, 50).
Unsuccessfulouicomes ofpr poiomics using calcium
hydroxide as a wound dressing have been aitributed io
a blood clot leftbehind befia'eenthe dressing and wound
surface (52). An i, r"tfo laboratory study showed thât
blood and serum substântially lowered ihe pH of
calcium hydroxicle âJrldthercby reduced its bactedcidâl
effect (29). The presence of bacterla combined \a'ith a
blood clot mây iherefore be an imporimi cause of
fâilurc. Beca6e the blood clot probâbly serves âs a
bûffea it also prevents calcium hydroxide ftom exeftins
its superficial necrotizing effect on the pulp tissue.
Alother reason for failure coÛld be ân incorrect pre-
operative pulp diagnosis. Thus, it has becn suggesied
ùai calcirm lrydroxidc lÉs no othcr cffcct bcsidcs pro-
moting i]1c formahon of a lùrd-hssuc barrier and therc-
fore camoi be used successfully on ân inîùed pulp
tissùe (52). Thc laiter suggcstion is, howcvcr, not con-
sistent ù'ith recent r€ports on rclatively high rates of suc
cessful treatments using pârtial pulpotomy in cariouslli
exposed pulps (30,49).
After pulpotomy with calcium hydroxide as â wound
dressing, reported successrâtes vâry betwe€n 31 and
59%. Using the same diagnostic cdteria, the successrates
âre higher when câlcium hydroxide is used as â dress-
lng after pârtiâl pùlpotornt/ (78-83%) (Table 7.1). As
 in prlmary
Endodontks teeih 95

Table
7.1 Reponed clinca succe$
rates pro.edures
ofvitalpuprreatment ôIprmâry
molats
withdeep.arious
lesions, oIwôuôd
alongwitrypê drc$ing,
numberofteethn lhestudvandTollow-uD
tme'

Follow-up
lime su(e* ,âiê(%)

71 23-16mo 60
20 51
(51)
S.hdder 93 83
JA ft
khddù (50) 33 zyts 59
Vja(62) 103 2yu t1
164 1,5y6 89
(12)
l\4elàrc 2,5y8 55"
98 7A
2yts
125 93
smirh
eta/.{54) 242
93
29 91
shumâyr khandAdenub(51) 61 J4
I s a i e t a{i 6. 0 ) 150 19
a2
15-3.5y6 96
101 3yu
79
55
\7

| 61%ol thênolâ6hâdobvious peoperarive

cliô.a slgmoi$ta pupitis.
( Ihêi(es râteafter2 3 yeâ6was81%(n= s7)ândâfter>3 yêa6 r wd 74% = ll),
{,
' Conlâtu a syithetc con.osteroidândtedermycn"
"su(ce$fulisdefnedaslundoning,.èteèthwthradograph.evdemeolnlemâLrcotrcsorptionwerelncudedlnsucce$luGses{15%).

judg€d from these studies, ii seem tlùi t]æ pârtial

pulpotomy technque is more favorable. Howevet
prospeciive raldomiz€d studies comparing these two
techniques are nêc€ssary to .onfirm this âssumption-

Formocresol
Formocrcsol (FC) is used as a dressing mâiedâl âfter
pùlpotomy. The originât compound, Bù.kley's FC, con-
tâins concentrated formalin (19% formaldehyd€), cresol
(35"1t ùd glycerol (7%) in an âqûeous solù hon, the mâin
active componellt being formaldehyde. Nowadays,
Buckley's formù1â is often diluted to one-fifth of its odg-
inal sirengrh- Depending on the concentration and iime
Fig,7,l Hard-tÈsue ina prlmarymolarformed
baûier polomy
afterpu uslng of exposu re to formâldc'hyde, part of the root pulp tissue
asa wounddr6sins(u & E,x40).(couftsyoI M.Cvek.)
aciumhydroxide is devitâlized. Importantlt it has be€n shown that not
even aftef prolonged applicaiion of ihe full concentra-
tion of FC r'âs the enlire pulp devitalized (33, 45).
96
The most common hisiological appearânce û-hen
using FC as a wound dresshg is d€vitalized pulp iissuc
in the upper pârt of the root canÂ1, ;nflammâtory
changes with intcmal root resorption and apposition of
hârd tissue in dÉ middle section, with the most apical
pârt usually showing normâi pulp tissue (4s) (Fig. 7.2).
Thus, ihe use of FC does not result in repair âl1d lrcâ1ing
in histologicâl terms, and a hârd tissu€ bârrier under-
neaih ihe dressing is not formed. Tl1is makes fte tood'r
vulnerable to contamhâtion from bacterial lcakage and
emphâsizes rhe importance of â bâctedâ tight seâl wher
restoing thc tooth.
As sho$'n in Tâble 7.1, in most studies on pulpoiomy
the clinical successrâtes using Buckley's formuta arc
higher than those obtâined witl câlciun hydroxide as a
dressing mâterial (78,25, 32, 47,50, 62). Also, when
d i l u . ê ldo l : c l r . l u , " J - , r , . p - , r , l e . ol (l , r e c o n
siderably higher ihan ilui ofcalcium hydroxide (13,35).
Fû1Gând Bimsiein (13), reporting a clinical successrate
of 94% after 2 yea$ of observation, recommended the
1lse of ihe diluied formùla of l'C insteâd of Buckley's FC.
The most probable ieason for thc relativcly high
clinical successrate with FC âs a dressnlg mâtedâl is
that, as long as the devitatized tissne does not becom€
infected, the tooth usually stays âsymptomatic. Furiher-
more, becâuse of drc more exicnsi\-e de\-ilâlization of the
p lp compâred s,ith calcium hydroxide, the use of FC is
notâs sensiiive to a coûeci prcoperative diagnosis of the
inflammatory staLusoI the root pulp as when calcjurn
moaLPup lissue
Fig,7,2 Paatalrootof uppersecond reactrons
ater
pulpolomy withBuckleysfomocresol 2.5yea6postopera-
asdressinq,
(u & E,x25);(b,
lively:k)overuiew c)mldde panortheroot(H& E,x60).
hydroxide is used. The clinical successrate when using
Bù.kley's FC on molars with obvious .linical sigff of
total pùlpitis amounted to 82% âfter 1.5 yeârs of obser
vation bùt dropped to s0% âfter 3 yeârc (32).
Glutaraldehyde
Gluiâraldehyde (GA) a dialdehyde - has gained
incieasing attëntion âs â possible sùbsiiiute for FC as a
womd dressing, ihe suggestion bcing less pulp dcvital-
izaLion but similar clinical r€sults. Glutaraldehyde hâs
nôl beFl p'odr.pd co-mprriall) )er. ll'e -rin red-on
bein8 iis insiabiliiy, even when reftigeraied.
Like FC, CA cm caus alûgic skin rcactions, md
hand dermatitis has been reportcd in denial assFimts
aftef using the disinfecting agent Cidexo (36). There âre
no unequivocâl indicâtions of mutÂgenic properties of
GA. The cvtotoxicities to human fibroblasts of the full
concentration or â 1r5 dilution of FC \^'ere 2 3 times
more ioxic than2.57. GA (20).In another studt however,
llttle dilference in the relative toxicities was observed
beh{een formaldehyde md CA whm the daia s-crc
câlculated in ierms of molar concentrâtions iaûer thân
diluiion (58). Interesthgly, GA appeâred more toxic to
rai nasal epithelium than FC (57). Owing to cross-
linking, CA is less penetrâtir-e than formâldehyde and
consequently causes less immediate damâge 1o pulp
tissue. Hoû-ever, in â study on monkeys GA did not
result in repat and heirling in histologicâl terms (59)and

it camot be ruled oùt thât, ûider a nâlIow zone of
fixation, partiâ1ce1ldamage d/or a slow death ofcells
deeper wirhin ihis zone may lcad io chronic cel injury
(58).
Studies rc?orting on the chncal success râte of GA às
â s'ound dressing are listed in Table 7.1. Using 2 or 5?â
GA" the su.cess rates vary ftom 74 io 96%, the pedods
of observation befig between 1 and 3.5 years (1, 12, 14,
53, 60).
lt has been suggested thât rhe buffered CA solution
is more effeciive than the unbuffered soluiion. Thc
concentrâtion ând time of exposure to the tissue show a
shong interaction (58), implying that GA needs a rela-
tively long contact time $,ith the plrlp tissue to âchieve
oplimal fixâiion. lrcther this problem cân tre circum
vented in the clhic by nisfig dæ concentration is debât
âble. Thrs, the optimal shength of GA is yet uncefiain
ând there âre also vârying opinions about whcihcr it
shoùld bc includcd in dÉ permanent dressing of zinc
oxide+ugool cement or not. Additionâl studies on the
possible opiimal use of CA as a a.ound drcssing there-
lore seem necessary
Cort;costeroids
The concept behind using corticosteloids âs â wound
dressing is to suppress ând, ideally, ieverse any ilJldn-
matory Éactions in dr pdp tissue.ledermix' the only
conrmercially avâilable dressing mâtedâ1 for this
p1ûpose is a s)'nthetic glucocorticoid with some
Te d e - m yi,r , r d . m c ù ) l . l r l , , l . f r d . ) . l r n " )à d d e d l o i l ,
mixed wiih câlcium hydroxide, zinc oxide and eugenol
There is a great deal of coniroversy associated widl the
efficacy of corticosteroids and ihef capaciiy, s'lÉn used
localiy, to reversepulp inRâmmalion. Thus, Hæcn (17)
- h ^ b e d h J i l h e . , . h \ e' c m p n r n l o I T " d r r t \ w à .
decomposed after 18 days. It hâs been argued also thàt
any anti inflammatory effect is restricted to the contact
;rrea between the dressing and the pulp tissùc (2).
Furthermore, ibe dressjng d oes not induce the tormahon
of a hârd iissue barrier, â charâcteristic considered to be
important n1 protecting the pulp of pdmary m ola rs rfom
bâcteriâl leâkage and subsequent infection. These factors
nay cxplain why Lederm has not gâined anv wide
sprcad popularity as a drcssing mâterial.
Hâisen.t i?1.(16) compâred zinc oxide eugenol with
leJermi\ r-, bolnddr"--in8JLp-pLp.ro \ û,d -
ousl,\r exposed pulps md fomd lcss severe intemal rooi
resorptions ùd inflammatory rcactioÈ in teeth where
Ledermjx was Lrsed.Although a lenient material û iilûut
âny observed side effects, only â few studies report on
the success rate with a corticosteroid âs the wound
dressing. In à small stu.lj, of 30 molars and varying
obseflation times, Hansen cf dl. (16) reported a success
in prmdryte€th
Endodontics 97
raie of 79%. In â 3-ye study with 101 molars, Gerdes
et i]1.(15)reported a sùc.essrate of 76% (defined as tunc-
tioning teeth ând inclùding 12 teeth $'ith internal rooi
resorytions and 4 teerh wiih radiogrâphic and clinical
symptorns). r"iom ihesc siudi€s it might be expected thâi
corticosteroids are superior to calcium hydroxide as a
dressing materiâl (see Tablc 7.1). Howev€t beca se ol
the lâck of rùdomizcd prospective clinicaI studies using
diffcrent woû1d dressing materials, ii is not possible to
propose the best matefial.
Zincoxide eugenolcement
Zinc oxide{ugcnol cem€nt, probâbLy nor so often uscd
today as a drcssing matedal âlone after pulpotomt
results in a high pcrcoltâge of intemal rcsorptions and
rcpo ed clinical successrâtes arc loa' (55 57%) (16, 27).
Ferricsulfate
Ferric suuate(Fe,(SO").)in â 15.s%solution hâs been
b ê d d - a , o " g L r" l i \ e J n . l h e ' * i J h . J g F n . h . r o s ' r
and bridgework. Blood proteins aggluiimie when they
are expos€d to the ferric and sulfate ions but the exâct
mcclùnisms of âction ârc still debated.
IMÉ.n used âs â {'oûnd dressing âfter pùlpoiomy, a
ùetal protein blood clot forms at ihc siie of pdp expo
sure. Ferric slllfate mixed $,ith zinc oxide €ugenol has
been in esiigatcd as â possible alternative to FC (10, 11,
51)- The rc?orted clinicâl success rates âie similar io ihat
of diluted FC and vary ftom 74 to 97'l.. ln the reiro-
spective studyby Smiih pl al. (54) the clnncd successrate
wàs 74'l" a{ter 3 years of obscNation (1r= 242); Fei rt,/.
(10) feported a 97'1,successrate âfte1 3 12 months (n =
29), and tuks cf dl. (11) found a successrate of 93% âfter
obseNation times \.ârying ftom 6 to 34 months (, = 55).
Overall, the rcports ar€ fes', the number of ieeth de
smal and most observâtion limes are short. Thereforc,
it stil remâins ncerlain whcilÉr fe1aic sulfate will
replace FC as â more biological and equally clinically
effectivc *,oùnd dressing.
Objectivesof pulp treatment
Strictly, thc objectiles of pulp treâtment are rc'pair and
heahlg of the residual pulp iissùc in hisiologicâl telms
and â $'ell functioning t{nù until normal exloliation-At
present, calcium h)droxide is the only dressing thaL
theoreticallt has the poteniial b tuÏil tlrcse crit€ria.
However, becâuseofthe low clinical successrâte âft€r
pùlpoiomy using calciurn hydroxide as a woùd dress
ing ad because of the restricted lifetimc of the prnnary
tooib less sirict.riiedâ for the successof pulp ireâhrent
98 Th€vita pulp

Advan(edconceDt aboutthe useof

7.1 Concerns Keyliterature7.1
in primaryteeth
âs a wounddressing
formocresol
n theetudybyLeks€etai. (26),theprevêhnce oI pulpexposure
(F()
Theuseof formoûesol asa wounddressinq aftefpulpotomy afÈf stepwise veÉus direct compkie excvation o{ permanent pos
ln prlmary moa6 hêsbeendtcally revewed(40,61) Besid6its teriorteethwilh deepcâriou!esiomwasas6æd ln 127ieeth
cytotoxkity the maln.oncems ùe po$ibecârcinoqencty, mùta- from116pâti€nls aged6 16years(meân - 10.2year).Included
genkityandlhe lad thatIormaldehyde È a pôtentâ eryen. were teeth wth radioqraphs revealing Grous lesions to sucha
(CN,o),
FormaLdehyde the mainâctiveagenlof FC,is a smêll, depth that pu p exposùe cou d be expected fdirect comp et€€xca
hlghy readivemoeculerhat rapldly converts 10waterandcabon vationwaspeformed, butteethwithclincalsymptoms otherthàn
dloxde.li s .ylotoxkandcusesdevitalizatlon whenapplied to transient pan shony before treatmentwere notaccepted.Theteeth
pulptssuetheextentof whichis doseandtimedependent (33). were Èndomly sehcled for eithertreatment procedure
Damage to the permanent succssor dueto possib ed ffusion or Fc stepwis€ excavatlon rnplied removalolthe buk oI caroustssue
throuqh thepupalfoof hæ notbeenobserved, however (11,44) andappkâtionof cakiurnhydroxde, roLowed by sealing ol tlre
animalstudi€s haveshownthat Iormâldehyde hasmutâgenic cavltywth zincoxidFeuqeno cement. Aftera perlodof 8 24
ândcarcinogenc ellectsCa(inomain mandu€io formaldehyde weekrtherestofthecarious dentine wasremoved ândlhecâvity
exposure r however, extremeyrare (56) and the Grcnogenic seaed wth cakium hydroxde, zinc oxide+ugenol and a renora
potential froma slnqeapplkation of Fc to the pulptissueoI a tive malerial. Directcomplete excavaton entailed reûrovaof:ll
. r m â l d e h y d e i s a m u l a g e n l n l r u m a nGr
p r m a r y t o ost hn e q j i g i bfef o ! , ousdentine followed byraling,asmentoned aboveLnthecase
thenweare n seroustroube because nrono{ 6lnhah formade' of pulp exposure, a pu p treatment wâs performed.
hydedaily,majnlyIfomcars,woodenprcducts, textlles,perlum6 fte pulpwas€xposedn 40%or th€ teetlrtreatedby difear
andothercosmetks andburninq wood. compere excalation Thecoresponding IigureIorthosetrcatedby
anyinc€ase in positive reactions to patchtestsin .h drenwho lepwiseexcavâtlon wa! 17.5%fte d ffer€nce wâsnatisically sig_
havehada preliousFCpulpotorny couLd not beround (46),but tl nirkant. the teeth with no pulp exposure alter dlrect or nepwis€ i,
a ergkreadions to Iormaldehyde aflerrootcanal ireâtment have :, excâvation showed normal clnical ând radio!raphk conditiom ât
b€enobserved inadults(6,9).Therc ârenoknownstudies ona pos r f p d r . h o , \p r n â â n - 4 1 nl oL l .
' IncondWion, stepwseex.êvation.an prevent pup expoaren
sibelmmune responselrom appyinganântigen G lergen) diredly
to expoedpulptksue.Athouqhpotentiêl âmlqen pr€sentjng ce s i teeth with deep cârious lesions and the resuts indlcate thâtths ,
F d n q I o , o ( e d . r . . u . . ô . u ù o \ ' o . dr - à - -o oêopqdrivp
mediatng theimmune reeponse arepresent n pulptissue, tseems
veryunikelythêta slnge doseof FCapplkddifecty onpulpl$ue l j n p b I o rp , l pi l d I
wouldænsilzea pe6on.mmunoq obulinEmedlâted sensitivtyto
Iomaldehyde a soseems to berâre(6) Incontras! contact a eruy
Iromthehandlinq oTthemedlcament isolmaior.oncem tordema
folowing operaii\.c trcaiment options are avai]âble (see
Fortheabovementioned reasons andthe âckor heang prop Core concept 7.3):
eniet Fc isIarIromldeaiasa wounddre$lngandellortsto Iind
aneffcentsubstitute forformaldehyde conlalning wound-dre$ing . Stepwise excavàtion
mareriasn pedatrcdenlislry areimporiant. . Ilulp capping direct, indireci
. Partial pulpotoay
. Pulpotoriy
. Pulpectomy md root canal treâtmcnt

are âccepted h many countfies, i.e. besidcs ro gen€ral

harm, no danage should be inflicted to the permancnt
tooih and ihc primary tooth should be symptomlcss
until normal exfoliaiion. Formocresol is considered by
ûâny to meet ilÉsc criieria ând, owing to the compara-
tirely high clinicâl successratc, is still â commonltr Lrsed
drcssing mateiial, alihoùgh healhg ilt bjstologicâl terms
docs not occu (Adv ced concept 7.1)-
Operativetreatmentprocedures
lndicâtionsênd clinicalsuccess
Based on clinical and radiogaphic symptoms ând other
possibleconsidefations for decidjng thc best therâpy,the
Stepruise excaoatioll
Tfu puryose of steplvise excalation is to pre\-ent Pu4r
exposure by intermittent removal of câdous denline. By
compalnrg tlrc number of pulp cxposures nom stepa.isc
erca\-ation ù,ith those ffom direct comPlete exca\.âtion,
it 1ùs been clemonstratedboù jr1 pdmary and pcrna-
nentmolârs that pulp exposûÎes oft-"n canbc pre!entecl
by stepwise cxcalation (26,28, Ke)' literature 7.1)
It has been assumed that by placing calciuln hlrd rcx-
ide temporarily on tlÉ remaining innermost layer ot
cadous dentine, the pulp iissue is stiûulated to produce
repaiatil'€ dentine, allowing complete er.av,tiôn
\riilùui pulp exposurc io be câûied out ât a subsequent
trcabnent occasjon.Ii is alsopossible thât byâlle\-iatug

Coreconcept7.3 Deepcariousl€sions
Pulptreâtmentprocedurcs
Indkations:deepGriouslesiontwherc
the bulkof n€croti?eddentine
hasnot
yetreached thê pulp;no dinkaland/or
Gdiographk sigNol pathologJa
suchæ
persistentpain,widenedperiodoftal
membrane orinteûâdkulêr orpeiapkal
Indicâtion:âs fôr stepwiseexcâvâtion
(nodinkaland/or s gnsof
radiogrâphic
pathoiogy),butdiffeBinthattheinneÊ
mostayeror Giou5dentine isdeliber
atey andpermanenty eft behind.The
indkationis only when,Ior practkai
reasons srepwreex.avanon cannorDe
ndkallon: addental or pinpoint
caiouspup exposure
of a symptomle$
Indkations:
traumatkexposure of pulp
exposuredueto cries; no clinkalor
sigNol pathoogy.
radiographk
ndicaton:
c nka and/orradjogfaphc
symptomsindkating coronal pulp
Pulpedonylrcoteanaltteatnent
Indkations:inlammationextending
into the root pulp,pulpneûosisand
wherespeciâconcern makesthetooth
ln primary
Endodontlcs teeth 99
dÉ ba.terial load, pulpâ1 heating and repair are fâcili-
iated. Other mechanisms ch âs remineralzation of the
remâining dentine may be involved but if and to whai
extent they coniribute io i1æ lower frequency ot pulp
exposures following stepwise excavation is not known.
Based on animal studies, Berg€nholtz (3) suggested
that the heâling capaciiy of ihe pdp could be substan-
lial once the iritating âgents are removed. This assump-
tion was confirmed by the favorable results of ihe >90L
chlicâl ccess râte when stepwise excâvalion was used
to h]eat deep cadous lesions in young permanent pos
têrior teeth (26). Although there âre no cljnical studies
conlirming ihe value of stepwise excâvation in primdy
teeih, ihere is no reâson to believe that this procedue
should not be favorâble also in pdmary mola$. Step-
wise excavation is ùerefore rccommended {or deep
carioE lesions i11 pdmary molârs, presupposing ihai
thel€ âre no or only minor preoperaiive subjective
sympionrs and no radiographic signs of paihology (i.e.
no signs of irreversible pulp i]ll1âmmation).
ln iirect pulp cappirlg
Il1dil€ct pulp capping is simild io siepwise excavation
brt differs in the sense thai the imerTnosi lâyer of
carious dentine is deliberately and pemmently left
behind. This is not an ideal siiuâtion, because the
amount of cades left behind will remain rmklown, and
the indi.ation should therefore be when, {o! pracii.al
reasons, stepwise excavation camoi be performed.
Direct pltlp capping
Direct pulp câppingmears that a minimal pulp expo-
surejsjust cleânedmd.overed wiih a wound dressing,
prcferâbly calcium hydioxide. Reported clinicat success
rates âfter direct pulp capping are low (5, 38) aJrtdtlrc
procedur€ should therefore be restricted to an acciden-
tal or pinpoint caiolls exposur€.
Partial p lpotolnlJ
Partiâl pulpotomy implies rcmovâ1 of only the most
sùperficiâl part of the pulp tissue âdjaceni io ih€ expo
sùre, and is indicated for a haumatic pulp exposul€ or
a pulp exposrûe ftom â deep cafous lesion. Important
prereqùisites for â favorable result are the same as for
stepanseexcavation, i.e. no of only minor preoperaiive
subjeciive symptoms, no radiogrâphic sigN of pâthol-
ogy and nomal bleeding of ihe exposed pulp tissue.
Two studies rcport on the .linical successrate in pdmary
molârs, varying from 78 to 83% after 1 "1 years of
obseflâtion(21,49).
Pulpotomy
The indicâtions for pulpotomy (implying removâl of the
€ntire coronâl pulp) âre the same as for pdtiâl pulpo-
tomy, i.e. te€th with cârious exposureswiih no or only
100 T r ev i t a l p u l p
mjnor preoperative subjertive symptoms, no râdi-
ogaphic sigîs of pathology and normal bleeding of
the exposed pulp tissue. Pulpotomy has been ih€ most
commorny ùsed vital pùlp thempy and numerous
1€ports lÉve been presented on ihe success iates-
Depending on the status of the pu1p,the operâtive tech-
nique, s-oùd dressing ed obserâiion time, success
Ëtes vary beiween31 md 98%(Table7.1).
A ùough rJndomizedprospe,tjve -tudiescompâring
partial pulpotomy and pulpotomy afe lacking, the rela
tively high successrates reported for partial pulpotomy
suggestthat pulpotomy may be restricted to borderline
cases,i.e. when clinicâ1 and/or radiographic findings
are not easily inierpreted and possibly indicate ire-
versible inflâmmation in the coronâl pùlp tissue.
P lpectomy and root canal treattnent
Usuâlly, â primâry tooth with clinicâl and/or ladi
ographic symptoms indicahng tolal pulpitis or pulp
necrosis should be extracied. However, if the tooth is
considered of special imponânce (e.9.when the pefma
nent successoris missing) or if the child âltd the pârents
appreciatethis twe of sefl,'ice,plrlpectomy or root cânal
heatment can be performed. The size and shape of the
root canals âre ofien consider€d a hindrmce bui root
canal instrumentation might be perfoimed iJ the ,:aiâls
are considered accessible.In order not to damage the
tmderlying pemæent tooth, broachesand fi]es musi be
hândled with extr€me cde and a resorbabtemedicament
such as calcillm hydroxide should be plàced in the
Generally, clinicâl ând/or mdiographic sigîs of totâl
pulpitjs or plrlp necrosissuggestexbâction of the iooth.
This is pariicularly importa.t jn a child with â tustory ol
severeacute or chronic illress, be.aNe ihe .hild shoùld
not be subjected to the possibfity of furt]rcr infection
resulting from pulp therâpy.
Howto do it - procedures
and
importantpoints
StepwiseercûL,ation
Prccedure:After locâl ânesthesiâ,â penpheral caries,
the bulk of necrolic Ând part of the demineralized
dentirc are removed. A layei of calcium hydroxide is
placed on the rcmaining carious dentine and covered
with zinc oxide +ugenol cement. After 6 5 \'eeks the
rest of the carious dentine is removed and the bottom of
ihe cavity is again covercd with a câlciûm hydronde
layer A layer of slow setting zinc oxide eligenor cement
or a fast-settingcâlciûm hydroxide containing cemeni is
placed and the câviq/ is permanendy restored (seeCâse
study 1). Aliemativel, ânother intermediate excâvation
ParLial p lpotony
Ptoccdwe:Local ânesthesia and a rubber dam arc
âpplied. À11 caries is removed md 1-1.5m of the
exposed pulp tissue is removed wiih a sphericâl
dimond bùr and high-speed e+ipment (with water). It
is not critical to use sterile saline but a coolant with
an-Ipleflow js important. Remove all carioùs .lenbne
adjacent to the pulp exposure before cutting the pùlp
tissue. Jeppesen (21) emphasized the importmce of
câr€ful cieansingof possibly injected dentine chips from
ûe area of âmplrtation before âpplying the womd
dressing. Bleeding is siopped by nrigation with sterile
saline or water. Dry gently with stedle cotton pellets. A
lâyer of calciûn-Ihydroxide is applied and gently pressed
in contaci wiih the woûid surface. A layer of slow-
settin8 zinc oxide-.€ùgenol cement or â fast-setting
cêlcium-hydroxide-containing cement is ptaced and the
P lpotony sing a ci n hyAloride
Procedurc:Local ênesthesia and a tubber dm aie
applied- Access io the pulp chmber is gained. The
coronâl pulp js removed with a spherical diâmond
bur and high-speed eqùipmeni. Th€ wo1ù'rdsurface is
iûigâted with saline or water Bleeding is siopped by
applying cotton pellets using slight pressure. Àfter
hemostâsis,the wound sudacesat the orifices of ih€ root
canâls are covered by a layer of gently pressedcalcium
hydroxide.A layer of slow settingzinc oxide-eugenol
cernentcovered with a fasÊselting cement is placed md
rhe cavity È restored. The restoration is c11lcialand a
crown is probâbly the most effective for
stainless-stee1
prc\'enting bactedâl leâkage.
P lpotoît! lrsitlg fonioûesol (FC)
Pncedwe: Loîal anesthesiâ âJrtd a rubber dam are
applied. The coronâl pulp is rcmoved with a sphericâl
bur and high-speed eqûpmeni. The woûnd sl fâcesat
the orilices of the rcot canalsâre iûigated with saline or
water. Bleeding is stopped by applying cotton pellets
using slighi pressùe. AJter lÉmostasis, â coiton pellet
soaked in.FC is applied io each womd surface and left
in place for 3smin. Full-strength FC (19% formalde-
hyde) is recommended if signs of total pulpilis are
present, otherwise a one fifth dilution is sufficieni. The
pelets âre removed and a pasteof one drop of FC mixed

a.iih zin oxid€-eligenol is plâced on the $'omd surfâce.
Avoid plâcing ilÈ pelets on the pulpâl floor. A iaycr of
slow se$ing zinc oxidcrugerol cement covered with a
fast setting cemenl is placed and the câf ity is lestored
(seeCâse study 2).
Pulpotom! sing gl tûtaldehlde
Prccetlut": Locàl anesthesia and a rubber dam are
applied. The operalive proccdure is in pdnciple rhe
sâme trs for È-C.Pellers soaked in a 2% buffercd freshly
prepâred glutaraldehyde soluiion are plâced on the
woùd surfacesând left in place for 3-5mfi. The pelets
arc removed and a slo('setting zinc oxide-eugenol
cement covercd with a fast setting cement is p]âc€d ând
the caviiy rcstored.
FoIIoTu-up Winciptes
Clinicâ] and radiographic follow ups should be donc
6 months postoperatively ând then at yearly inten als,
in general, primary tceth sùbjected to endodontic treat-
m€nt should be observed until cxfoliation.
Long ierm follolv ups are essential (21, 48). In most
sludies, successor fâilure has been jùdged ftom clinical
- r d r i d i o S f t p l - i .. \ d m i n . l i o n . o r ) . H ' . s e \ e r h d
study b)' Jeppesen (21) on parriâl pulpoiomr 43/76
clinicâlly successful cases were judged histologically
âfter 4 years of observation dd were considered io be
successfulin 88%. ïns is of great importance fton the
\-ies- of folbw-ùp plocedures. Thus, after â follow-ùp of
4 years, the risk of additional fâilures wâs small but drc
potentiâl for new failures was siill present.
Tâb1€7.1 gi1.esân orerall pi.iure of pdpal sun'ivâl
âssessedby clinical means subsequcnt to different treat-
ment procedlrres of cârjous pulp exposures. Reported
datâ differ nr the diagnostic criteia for pulp heatrnent,
lvith folloa-up periods and cdteria for successfultleai-
mùi making dircct compadsons impossible. Ii appears,
l , o s " ' ê r .r h . t d i J e . lp r r p . d p p i r B J n d p L ' p ù r o* \ r - i r l g
câlcium hydroxide or zinc oxide-eùgcnol âs dressing
maierials rcsult in the lowest ctinical successraics. It is
notewofihy that vcry few rândomized st!| d ies hâve bcen
performed with i1rc aim of compâring differenl procc-
The clinical meam for reveallng àn unsuccesstul heat
ment include clinical inspection and râdiographic
exâmination. The earliesr signs of failurc are most
often radiogrâphicaly detected internal root rcsorption
and/or interradicutâr bone 1oss,û'ith subjective symp-
roms such as pain being u rsuâ1.Pârticulârly in small
children, clcctric pûlp testing is often unreliâble ald
if primary
Endodontlcs teeth 101
insteâd carcful nlspection of the tooth and the sur-
roûjrding oral mùcosâ shoûld be made. Pathological
tooth mobility, sweling or fistula consiitute 1âte ancl
definite signs of an unsùccesstul trcatment.
As mentioned earlicr, the fomâtion of a hard'tissue
baÛier wh€n using calciùn hydroxide as a woùnd
drcsshg is no pLoof of læaling (37), bùt failùre to
produce hârd tissuc at ihe amputation site always
means markcd pathologicâl chdges hisiologicailli (21)
(Fig. 7.3).
Radioyaphic signs of faihffi
Inltrlû| rcot rcsarytiotl:This is thc most common com-
plication after pulpotomy in prhary ieeth, particularly
Âfter pulpotomy with zinc oxidecùgenol or calcium
hydroxide as wound dressings. \\læn znlc oxtcie
eugcnol $,âs ûsed (27) il was obseNed in 1iJla0 (15%)
teeth within â followup time of 3 yeârs, $'lÉreâs it was
found in 11133 (33%) âfter 2 years with câlcium hydro-
xide as wound dressing (s0). The prevâlence was con-
siderably lower whcn ûe pârtial pulpotomy te.hnique
was used 4/93 (,1%)(49) - âlthough the follow-up time
in that srudy wâs only 1 ycar leppesen (21), âlso ùsjr1g
thc partial pulpotomy iechnique, did not repori any fail-
ures due io iniemal root resorption âfter âLmost 4 years
of observâtion.With calciumhydroxide as a'otnd dæss-
Ing. nro-r in ernJl r... den.ine rê.ôrp'i"n. .erc
obser\-ed$'ithh ûe first yea. afier pulpotomy (50).
tnternal root dentine .esorptun occurs also afier
pulpotomy using FC, glutataldehydc or Ledermix" as
wornd dressings (Fig. 7.4). In a study by Mejàre (32),
Fig.7.3 Unsuccesful pulpotoûy ùçingckium hydroxided dresinq
mâleria:k) remnantsol hardrissuebadel (b) heawinflr.àtônw]th
nflammatory(elsjk) ntsna rootre$etion{u & E,x40).(coùrtesy
ol
't02 Thevita pu p
Fig. 7.4 Lower eft 16l molarwilh Ëdioqraphic
evideû.eol inrêrnaroot rêsofption
(â)ât lhe rimêol trætment;(b)18 monthspodoptrâtwlyr k) 3 yea6pôsrôperâr
16/71 (22%) molars with FC as drcssing shos-ed inter-
nal root resorytions after 2.5 years of obser\-at1on,
whereas the prevalence u,âs only 1/70 (1%) when the
diluted formula of FC was used âfter 2 years of obser-
vation (13). With glutaraldehyde âs a dressing,6/50
(12"1t showed nltem.l tuot rcsorytion âftef 2 years of
observation (12). The use of Ledermix rcsulted in hter
nal roor rcsorprions in 18/101 (1E/o) âfrer 3 yeârs of
observaû,n (15).
As menhoned earliea the reason fo1 the emergenccof
intemâl root resorytion after pulpotomy is noi clear
Concernin8 calcium hydroxide, ithas bccn suggesledto
be ihe rcsuli of either preoperative pulp inflâûùation nl
the root pÙlp or al cxrrapulpâl bloo.t clot left behild
between the dressing ând thc remajning pulp tissue.
Regarding FC or glutarâldehydc, ihe reason is prcbably
the irritating effects of the medicaments.
Interratlicllltlrptriûdûnlitis: This was a common caus€ of
fâilùre âftcr FC pùlpotomjes using Bnckley's formûla
(32, 17) and was found in 29174 (39%) teedl fi a siudy
by Mejàre (32) (Fig. 7.s).lt shoùld be noted, though, thât
in thjs study morc ihù hâlf of the teeth hàd ob\'lous
clinicâl signs of total pulpitis ai the iime of Lrcaiment,
indicaiing a poor pulp condition and thus probably
rcdùcing the prerequisites for successful trcaiment.
When using the one-{ifth dilution of FC or gluiafal-
dehyde, inteÛadicûlâr pcriodoniiiis has been less com
mor y obseNed: 3-4% (12, 13).
Periapical pctiodojlLitis:This was the most common
leason for fâilure aJier parhal pulpoiomy ând occurred
in 10/93 (11%)teeth 1year postoperativcly in one siudy
(49) but only in 2/7E (3%) teeth dufing a follow,lip time
of âlnost,1 years in ânother study (21).AJter 3 yeârs of
obseNaiion with Ledermix âs a dressing, pcriapical
periodontjtis was observed h 9/101 molals (15).
Pulp oblitention: This hâs beo obseNed mosrly àtter
pulpotomies using FC or glùtâraldehyde as a wound
afterpulpotomy
wth Buckey'sIormocresol
a5 d.esslngmateria:
vely.
Fig.7.5 Lôwe.rghl se.ôndfrolarwlh radiog.aphic
evden.eol inrer
rad.ularosteth 2.5yèa6afterpulpotony
withBkkley's
formoûeso6
dressing (Fig. 7.6).Thus, râdiographic evidence of pulp
obliteration was seeû in 62-80% oI molars pùlpoiomizcd
using Buckley's Iormula of FC (18,32,47, 63). whcn ihc
diluted formùla was used (13), pulp obliteration was
obscNcd jn 20170 (29%)âfter 2 yea6 of follow-up. With
glutaialdehyde, pulp obliieration occurred in 20/50
(40%) âfter 2 yeârs of obsen'âtion (12), whereas Tsâi
.f nl. (60) reported a loa'er pre1.âlenceof 261150 (17'lt
after 3 ycars of obseNaiion.
The reason for pulp obliieraiion is probably a
responseto the irritating effectsof these agents,paticu
larlt the vâsc1 ar dâmage inflicted upon the remàining
vital pùlp. Thus, it wâs sho('n that the {ormaldehyde
component of FC is rapidly hânsported through the vas-
culâr sysiem, causing severe thrombosis and hemor-
rhâge atvaryirs and see,rirgly ûnpredictâble distânces
from the womd surface (31).As â consequence,remote
pârts of the odgnd pulp tissuc arc damagcd and may
reâct by prodûcing hdd iissùe. Similar rcactions prob-
ably occù with glutarâldehyde âs a a'ound dressing. It
should be noted thâtthis commonreaction following FC
and ghrtâraldehyde pulpotomies implies that vital
tissue remains in the root canals. ln most ciinical studies
thjs complicâtion is not judged às a fâilure.
 in primàry
Endodontks teeth

evden.eoi
tig. 7,6 Radiographic
pulp obliteration
n â lower right
se.ondmôâr followingpupotomy
wth Buckley's asd.esitg
fomocrcsol
maierial (b)2yeas
h) ppôperâtvelyi

Prcmstureexfolittion: This complication is not consict

ered as a lailure bui deseryesto be mentioned. Thûs, Advânc€dconcept7.2 Newbiological
exJoliation of molâis my o,:clr] faster thm their to vital pulptherapy(fromRutherford
ôpproaches
antimeres both after FC ând glùtârâidehyde pûlpo (43))
ândFitzgerald
tomies- It has been sùggested that glutâraldehyde is prcteinmolècules
Bonemorphogenetk
perior to FC in this respect, becauseit resùlted in a
lower percentage of premature exfoliation: 15 versus Newtechniqu€s Iocuson blologkâapproâches to vilâl pulp
47% with Buckley's FC and 39% with the diluied therapy.Eêsed uponthe natureof thewounddressjng, bioogkal
âgents compounds synlhesizedin andbyb ologkalsystems are
formr â (12).Arftough not properly evâluareô drc clini-
io câclumhydroxid€
in conrrast Torexample whichcanbelooked
cal significance oI a possible prcmaturc exfoliation ot at
uponasa non-bioLogicl mâterial.At presenlûe monpromising
most, 6 months is probably of minor importance. âpproâch s withinmoleculâr
biology,whichprovid€s opponunties
to developnew slrategiesfor the l]eatmentoI exposedpulps
Amongthe newagentthighlypuriried proeinshav€gâinedpar
lndicationsand contraindicationsfor ticuarinrer€stândê numberofexperirnentaldùdies suggenthal
pulp treatment in primary teeth bane naryhogeneticprotein nalecùlescan inducereparâlive
denilnogensis in hurnâns.
0bseryalions fromanimalexpêimenls
The most important reasonfor keepnlS a primary tooth indkat€that reliable
therapeuticinduction dentn0_
ol reparative
genesisandthepreservâtionof pulpvitalitywouldbeposslble even
until exfoliation is to prcseffe the space to prevent
ln diseasedanddamaged pulps.
crowding in the permanent dentition. Concemhg the
molars, normally the most importânt iime pedod is treatment
Trânsdentinal
before the lirst permanent molars have reach occlusion.
Other imporimt reasons are to mâintâin masLicatory ft€ slepwise
excavationpmcedure, wherecakium hydrcxideisused
functions, to prevent tongue habits and to prcsefl/e aes- to induce
repêrâtivedentife,is anexample ol transdenlinaltreaË
ment.Ihenewtransdentinalappmach jmplies
th€useof biologkal
theiics. Iurthermore, t might be important io keep ihe
agentstocontrolpulprcsponselhrough anexisting
layeroIdentine
primary teeth for psychologicâl reasons md the age
A lâyerof rcpaËtive deitne d€€pwithinthe renrâlning dentine
ând/or mental condition of the child may reqùire speciar wouldprcvideexlraprotectionfrom€xtemalirritantsTher€duced
handling and considerâtions.W'lrcn the permanent tooth permeabiliiyof lhis reparâtiled€ntineprovides an additionaL
is missin& the pdmary tooth may be importânt to keeP protectionofthe pulpfromthennaland mechânical a
chall€nqes.
foi m extended period of time. conrrolledamountol repaÉuv€dentineimmediatey following
Th€ folowing conditions generâlly contradict pulp extensive
dentine Lo$withoutpulpexposurewoud bea desirable
Lrertmenl dd lhê loolhshouldbe e\rrdclêd: dinkalgoa.
Athoughno materials arepresently available
to satisiythesê
. Presence of clinicaland/or mdiographicsymptoms c4terià,h4.êdrp inoicàl,ons l "l oênlinpnàl it p'oiPin\dp
indicating severe iniammatory rtactions in the potentially
capableofworkingn thisdlr€ction.
pûlp, pulp necrosis,swelling, fistula or abscess.
. Medically compromised childrer! pârticularly those
with a lowered rcsistanceio inJectiory e.g. children
with sever€cardiâc conditions-
. An restorable tooth or less than two-thirds of the
root is present,i.e. the remâining functioll time of the
104 Thevitalpulp
Futuredirections
The degree a nd extent to which ân existing pulp inflam-
mâtion c.n be treate.l successfully using vital pulp
therâpy has still not been determnæd and thcre F no
precise definition of $4ùt 'nrc!.crsible' pulp infam
mâtion means. In order i{ords, rhe capâci5 of the
inflamed pulp to recoler is lârgely u*nown. Bccausc
endodontic tr.aimenl in primàry teeth {ocus€son vitâ]
pulp therâpy, ihis is an cssentiâl future feseârch field.
ln this respect, prospcciivc randomized studjes whefe
the partial pùlpolomy technique is compàrcd \rith
ihc pr potoDy techniqu€ âre of litd nùportarc.
Anothcr impoÉânt task js to tu1d better assays for tlr
clinician to decide the status of ihe pulp from clinical
Furthennor€, the fundâmentâl biologicâl processes
leâdjng to repârâtive dentinogenesisâre not fully under
siood, nor is it clârified how the mechânisns behind
t i s s u er e g e n e r a t i oânn d h e â l i n g w o f k .T h i s j s e s s e n t i a l i n
order to understand nei{ efforts in biologicaI approa. hes
b viial pulp iherapy (43) (Ad\-ùced concept 7.2).
Acknowledgement
Thc author i\ould likc io ihank Nils Pyk for providing
somc of thc illustraLionsfor Lhischapier.
Casestudy 'l
Stepwiseexcavationin a s-yeaFold
Hisiory
A healihy 5 year old boy presentswith a deep caious
lesio11in the upper right se.ond molâr. There is no
complainhg of toothache other than sporadic pain in
connectionwith meals and no visible pâihological
periapi.alchmges.
Ln order to a\.oid mesial driJiing of the first permaneni
molar, it is important to ke€p the second pdmary molar
at least miil ihe fi$t permânenr molar has reâched
occlusion. Because ihere arc no clinical or râdiographic
symptoms indicating irreverible prnp inflâmrnation,
the diagnosis is chroni. pârtiâl pulpitis and stepwise
excavâtion is the therapy of choice.

Fig. 1. (â) Preôpùâlive

cliricâlviewoI thê
upper moar (b)Bltewlnq
iqht se.ond radlograph
showiigrhedeplholrhe.ariouslesion.

Fig,2, k) Clinkalviewafts excavallon dentine(b) Caciumhydroxide

ofthe bulkoi necrotic wasappiedandlhe.avltywæ Tihd witha s ow settingzin.
oxde-euqeno@menl.k) fte GdioqGph showsno slsnsofpûkpl@ pathologkal .hânges.

Fig,3, Atthesecond
vslt8 weeksaterthetooli iswithour (â)therâdog€phshows
symproms: (b)theclinicàlvjèw
nopâtholoqkalchanqes; aftêrrêopen-
ngandrcmovalolthe
lemporaryfi ling;k) theclnl@vewafterÈmôÉloftheremanlngcarious hydrôx
dentneAnewlayerofcalcium dewâsâppliedto
toedeepspansolthe a layerol lasrsedng.àkumhydrôxidewâ,
e5ion, plâ.ed withqa$ onomer.eûeôt
andthetoolhwasrcstored

Fig.4- 0nèyearàterthètooths without

k) p*iapkalcondltiom
æcordjnq
to rheradioqraph
prmarymoarplâys
inwhi.hthesecond
symptoms:{a)c inkalview;(b)birewing
radlogaph
showng ofthecoronapulpto lherestoration;
thêrelâtion
arewithouianypalhoogca
NoiethatrheI6t pêrmanent
changes. molârisln a pre-eruptive
posirion,
animportànr
rcleasa spa.Ê mânlâiôer
106 Thevitalpllp

Casestudy 2
Pulpotomy ffiing formocresol in a s-year-old
History
A \erllh) q yedr old bo) pre-enl. wilh a deep,âroLs
lesion in the lower righi second primary molar There is
no history of pain oi]rcr ihm o..asiomlly after sweet
food intâke. There âre no signs of swe ing of the gingi\,â
or fistu1â âJrld the tooth mobility is normâL The râdi
ogrâph reveâls a deep carious lesion md ihe inteûâdic-
u1âr ar€a shows a widened peiodontal membrme md
a diJtusely oùtlined lmina dura. Ai caries excâvatio4
necrotic dentine r€aches the pulp dumber md the
bteeding ai pulp exposure is profuse and dalk.
In orcler to avoid mesial drifting of ihe firsi permnent
molar it is important to keep the second pdmary molar
ât least until the firct permanent molar hâs reach€d
occlusion. In this case there are ob\.ious signs of toial
pulpitis, such âs necrolic deniine rea.hing the pulp
tÈsùe, dark protuse bleeding ât exposll]e ând
pernadicdar pâthologicâl signs, âs judged radiogrâphj-
ca1ly. With the pulp diagnosis being total pulpitjs, the
prognosis ùsing calciùn hydronde as a wound dressing
after pulpotomy would be poor An âltemaiive to extrac-
tion is to use formocresol as ihe womd dæssing. In this
case pulpotomy was carried oùt and full-strengih
formocresol wâs chosen as the û'ound dressing.

Fig. 1. Preoperativeradiographrevealinqa deep Fig,2, G) tormoqsolhæ beenappiedto the roolcanaloifi.êsJor5 minuresatd rhê bleêding
has
caioùs lêsionin iie lower ghr sêcondprimàry stopped (b) Ilre lormocresolcôntaiiiig wôûrd dre$ing has been appled to the rcot @nal
molaiNotethepositlon of thelowerTirstpemaneni orlfices.
Notethalthe pupalfoor is nol coveied
wlththe dre$ nq,
molarwithitsanglederupting direction,

Fig.3. Radiogrâphs
râkên6 monihspôrlopeGïvely.
îie rightimâge
showsfie inleûâdkuârârcâ Fig,4, Radiograph laken2 years
portoperatively.
towârdsthêmêsiâlrôôtsliL
+owsa difiusely
outlined
amina dura, thepic.ure
athough isnoreâsiy Ihse æ noobvioW orperiradkular
signs patho
lntêmreied.
oiheNserhêlôôthissvûoromêss. o!,y,the toothis clinely symplomessandthe
Tiutpermanent mola.haserupted andreached

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1 5 . Gerdes l, Ravn JJ,Ldbjêrg Hæen H. Vitâl pldpotomy
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H d ! n H r . R " \ | r ' . U L n . lD^ . v . J p u l p o r o m IJn p r n r ^
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Kisling E. Histologiske undersôgelscraf mælketændenes
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21. Koch G, Nyborg H. Coirelationbetwæn clinicaland his
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Endodontics 1O7
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I. Dttt Child. 1,956;23:4W\
26. Leke]l E, Ridèll K, Cvek M, Mcjàre L Pulp exposure âfter
stepû'ise vêrsus direct complele excavation ol .leep
ca.ious lÊsiotu in yoûg permanent posteùor teeil1.
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27_ Mâgrusson B. Therapeùtic pulpotoûy in primary molars
.liùcal md histôlogn.l follo$-up. Znrc oxideêugenol
as * oùd dressing. Odortol. R@. r971i 2: 4151.
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7917)8:36'll.
The aiû tudsto ûssss pô*ible benejts (aûidiits pllp ètposure)
ol steptuiseexcdutian oJdeeptriors teriô6 i, pinùy ftottts.
A tôtdl ôf 110 ftolus uith deeperies uithôrt synlptans ôl
puhitis tuet nfldonllJ selectetllar citlEt itulnetliûte nîd .on-
plete excautiot of all catiaus .le,itine or û st.ptuise exu'aliM
prccerlùt uhetb! a thin lqtel of remininE .ûies clase ta the
palp tuts co?elùl uith colciuù hldtùride dnd the cdtitlt seokd
uith zinc oxid.augenol ce"xnt. AItèt I 6 uæks the cûlity u^.
@pefled dfltl dll rcûaini]tg carits tuds reftored. In the yatl
inlrlediatel:/ ifld ûrLpktel! excooat.d, ttu ïeqrcflcy af pulp
eqùsurs uas 53% rtsus 15'/,,fot teeth.t duted bv the stE-
tuise ptucedure. Tuo teeth in the sttpttise dt?qtion \rcup
'rhfte
ddelôped ptlpitis ûflt1 rærc .ttrûcted. teeth ifl the m-
ûedidte èiautiotl grarp and ane in ttu steptuiseexcautian
gtuap hdd rccratic t\lps. Tht dutho$ côflclude that st .puis.
.tt@tion .an re.lte the prcblùns causùl W the im1leqtu.! ùf
.ufte,tt tuthads of pùlp treatudt in ptihrry teeth.
29. Mejàre B. Bactericjdal effect oI .alcium hydroxide on
enterc.o.ci in blood and ærun. /. Deri. Àes. 1986; 65:
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teêth wiù dæp cârious lesio\1s.Etdôd.h L Denl. Ttatnatot.
IL)L)3j9: X8 !\2.
31. Mèjàre L Ldsson À. Short-term .eactuns of hûan dental
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Âes. 1979;67: 208 :16.
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Dûn. P€s.1976jU:29 36.
Mjôr lA. Dentjne ûd pù]p . \n Pcactinn Pattùns ii HLnûh
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Cantdct Detnal, 1988) 1E: 193.
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38. Pritz W. Erfanrungen nit CâL!y] zt ptlpenùbe.kappmg.
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108 T l r ev 1 a !p u l p
l9 I'bphet AS,I4iller I. Th. etrcctof carieson thede.iduôus
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40 RanlyD\4. FomocÉsoltoii.iry CurrcntknowledEe.
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(iiù SD,ed.) ^l.banra: UnireNitl, ol -{]âbàmàPress,
l 9 6 E ) : 1 0391 .
RaInerJA, SouthâûJC.Pulp chingcsin decldùrusteeth
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43. Rutherfo ll, fitzgeràldM. Àncw biologicâ|apprôr.hnr
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29.
l { J l lÉ I - o ' " r < f o . o n - ^ l t ' l L ' . { \ ' l o n . 1
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Ofrl Sr€. 1976;'r2i518 28.
RôlLing I, Thllin Il. ^llcr€y LesLsâganÉt fùmldeh)'de,
cresolùal ergenol in chlldrcn {'ith krmo.rcsol ptlpo-
toûized priûàry te€th,S.4,d.I. Ddlt. Rts.1976:a4 345J.
47. Rôlling I, Th)'lstrup.^ 3-ycârchrl.aLhnL{N uP study ot
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4E -u:' < ' r ' , . , 1f p . Ë . , p . J l ' p , , I n , . , n
teeth../Dcrr Cr,ll. 1963,30:141 S.
19. S.hrôd€rU, Szpri.gcFNodzak M, Iani.ha J,n'à.inskaM,
Budn_r- L MlosckK. A on€ r'ea.frnl{N up oipàrtiàl pllpo'
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Ehtlôtlôrt.Dett. Tlatnûtol.1.987;3:3016
50. SchôderU. A 2-yearfolloa''up oI primarymola*, pulpo'
torized witha gendctc.n n iqucand cappÊds,ith.àl.nm
hydroxide.s.rrd. .L D.rl. Rcs 1978,86,:173{.
5t Sdùôder U. Agr€ementbcnvccn clnri.aLmd histologi.
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D.Dr R.r. 1977;85:583 7.
52. Sch.ijderU. !ffè.t ofà. cxtn-pxlpal bl{ut dotonh.tling
folLo i.E ÊxFerirnentalpulpolon,y an.l .àpPing wrth
,4.rt .alcjum hydtuxide.Odo,,tol. R.r,! 1973)24:25769.
53. Shuma\-ikh NM, Adenulii IO. Clnlnal evàluaton ot
glulârsldehrde $ith .nl.l!m nydrcide ând ghtù61-
d, j.Frir '. v. Jp. p. o'i, J. o i . o prin 1
nio1a6.Eùtltnlahl. Dtrt. Tnrrûkn.1999) 15:24964
Snith NL, Su€ Scnlc N, NuN ME. ferric sllfale nl
pdm!r_r"molà6. A rei.ospectnesttLd).P.dtdlrD.,t. 2000;
22:192 9.
SoskoLne !\A, DimsteiÎE. A nislomorphologi.àlstudl oI
| - , 1 / o , ' . É f ' o , , . ô u , ' i , i J u , - r p . 1. . , ' ' o ' ,
chronological dàges.,,lr./r.ClralBul 1977'22:33I 5.
56. SquireRA, CarnefonLL.tur analysisof pot€ûtiàl.àrcro-
gc.ic risk tunn forràld€,1ya1..RtSu!.TDti.ù|.lhttw.al.
198.1,4: 107 2'r.
5 7 St Clair Mts, GrossEA, N{organKT. l'athologl ùrd ccll
prnileration indu.€d bl i.rra nasalirotillàtion ol alde
hldes in tnc ral: .ompaisôn of glllaraldehyde and
lonnaldehyde.?natdl Prll,l 1990;18:353,61.
5E, sun Hw,leigal RL McsserHH. Cltotoxi.irv of gl"rârâl
dÊhldÈànd formôldchydeû Èlâtiot to timc oleaposure
and con.entration. Irdlrh Dc,t. :1990; :12:3037
59. Tâg8erE, TaggerM. lulpal and penapicâlieàctionsto
glùtaraldehtdedd pirùformaldehydepuhotomy drcss
i.g in monkeys.i Erdorlo,t.1984,l0 364 71
fsai Tf, Su HL, TsengLH. GhtàmLdehydepreparations
a.d pulpotomy û primary motars.Or, s!€ 1993,76:
3!1650.
r^ , h.J-F 1l. n.|.' n J , ' l , F' 4 r i- I r i ' L ' r
pul|ltony ùedicàmcnts: a rÊvie$. Ëtddd.rl. Dr'l
rtùù1nrtù|.199, 11:147 62.
62. ViarW lvàlûtion of decidùousmolùs treatcdby pûlpo
loml, and .âlcnû hyd roxide./ ,'trl D.r l. ,lssr. I 955;50i
34 -13.
63. uli llârdRM. Radiogriphic ch.ngesfollowingiornrocreûn
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15.
-
/ / i b - r r, r V n . . . \ " d rH llr|ôr,,l;,.
.àrious peflnanentnolàrs. Att.I D.nL.79812: 147aA
Part3
PULP
THENECROTIC
Chapter8
The microbiologyof the necroticpulp
ElseTheilade
Historicalbackground
Micro-organisms cohnizn'g the necrotic pulp have long
been established âs the.aùse o{ acute ând chronic
periapical inflâmmation. Thc tust obser|ation of these
micro orgânislns was by Antony vân Leeuw€nhoek,
$'hose home'mâde microscopc also enabled tum to
mâke ihe first dnivings of dentâl plàque bacteriâ in
1683.However, jt took about 200 years beforc rootcanâ1
micro organisms came under bnnogical investigâtion,
namely by the lather of oral microbnrhg, Willoughby
D. Miler (18s3 1907).
Millcr in 1890 described the clinical effecis of
'gan-
g r e r . ' u . r ' ' . r \ - p rl p . :rfe,l,or' \, riing
from hardl)' per.eptible pedâpical inflammahon kr
. r m p l u * - .omel:me- e\er
ç\ere lô.Jl rrd gcr' rJ
s'ith fatal out ome (Key literâtrr€ 8.1).He cultured and
characterized bacteria liorn the necroiic pulp md
st1rdied their pâthogenic potcniial jn animâl e\Teri
nents (45).
With the publication in 1911oI william Hrmter's book
'Orâl Sepsis âs a Câuse o{ Diseâse' (ciied in Ref. 15),
interest .entered àroùid the theory of focal nrfcciion, the
concept thât inJected teeth might cause infcciions in
oiher parts of the body and also many oiher systcmi.
discascs.Hunter accused dentists of producing masscs
of oral sepsis with their p.ocedures for fillings, crowns
and bridges, which ofien caused pulpitis, pûlp necrosis
ùd pcdodontal disease. A more sultable name for
'coroeNative dentistry' wonlcl be'septic dentistry'. His
publicâiions (35) led to ûe view thât a[ teeth suspected
of infection should be extract€d. This resulted in mass
exhâctions and probabl)' a dclay in ilrc development ol
endodontic theraB., but e\.entually âbo nl biologically
soûltd treâtment principles, including thc elinnnâtion of
Essential in
role of micro-organisms
endodonticdisease
Animal experiments
Someeârly authors suggcstedthat decomposiiionôf
ncciotic pulp tissue or stagnant tissue fluid mjghr câuse
apical pedodontitis er-cn ir dre absence of bactcria.
Hoa.e\-er, it was demoûstrâted thât sùbcuiâneous
implantation il1 experimental anmab of empty t!'bes or
sicile deâd tissue causedonly a Lransientinflammâtion
thâi did not prevent healing, whereas necrctic tissue
contâminâied widl bâcteda caused intcnse inflâmma
tion ând often abscessfomation (42, 72).
Aclassical stud)' in germ ftee and con\.eniional iats ln
1965 (36) demonsbaied the essential role ot micro-
orgànisns in the pâihogeresis ofperiapicâl lesions (Key
literatue 8-2). In aer€ement û'ith this, asepiically necro
tizcd pulps that $'eÎe seâ]ed ând rdnanled sterjle for 67
months in experimental monkeys did not induce inJlam-
matory reactions in ihc periapical tissues- ln conhast,
pulps 1âceratedby jnstrumentainrn ând contaminated
wilh oral florâ ca6ed clinicâ], radio$aphic âJrt.lhisto-
logical signs of pedâpical inflâmmiion (48).
Humanstudies
Stùdies n1 hurnâns ha\.e shown that PedaPicâl inflam-
mation is comecicd $,ith the pr€senceof bactc'nain ihe
rcot canâl. Dcmonstration 01 micro-organisms in root
cânats btr culiurc has mâny pitfâlls and ôlder studies
âre not very reliable. Ii was greâtly impro\-ed with drc
studies in 1966 (47) of Mô[er, who .leveloped meihods
for sâmpling, transpori ad.ûlture by taking into
accoul1lt the fastidiolrs and often obligate anaerobic
natùe of ûe micro orgânisms. Cùliurâl siudies of non-
vitâl prlps of teeth a.ith clos€d necrosis after irauma
have demonshaicd i]rc abselrce ol Srowih ir câses
withoui radiographic signs ot periapical iniâmmat1on,
111
112 pulp
fte n€crotic

Keyliterature8.1 Citations
fromclassics Keyliterature8.2
'....
tookthisstufloutoI thehollows
in theroots,andmixedit pulpexposur€s
Expùimental madeby drillinqa holethouqhthe
withceânrainwaterandsetit beforethemagnitinggla$ sos odusa thkknesof enamel anddentine
of maxillary frst molals
to seeiilherew€reasmanylivinqû€atures in it asI hâdaforetim€ n germ{reeandconventionaratsshowedihatiheabsenceorpres
dscovered; andI mustconress thêtth€wholes1uffseemed to m€ en@ora mkrobalflo€ isth€majordeterminanl of healinq versus
deveopmem of p€riapkal
lesions.
s (inthepres€nce
n conventionalanima orbaderia) theexposed
AntonyvânLeeuwenhoek,
1683,
pups be.êmenecfôtic,
and periapkâlqranulonras or ab(ess€s
c t€dfrcm(l5)
'Thevulgêr
andevencenainauthoEhavebe evedandnillbelieve n tlregermJreerats(inthe abs€nce
oI baderia),
the exposed
thattoothache
ândcariesar€cêused by dentalwormsandihese pupshealed wh e nonecrotcpulprapkal
wth denlinalbridging
woms gnawawaylitte by litte the tissueof the bonyIbeE or granuomas or ab(6ses devêop€d in spit€ of grosslood

Pietre
Fauchard,1721, FJ 1955(16)
râlehalh5 SraneyHF.Fitzgùald
citedlrom {15)
'n lhemo0thweJind
certan condtions whkhar€presemed byno
otherpartofthehumanbody,in thâiâ directway isïumishedlor trâuma thât severs its blood srppl),, will have excellent
parâsiles
thrcughthe mediumol the root canalsznd dÈeas€d condiiions for grorvih there-ln thecase ofbacteria enter
tooth-pulps
nlothedeeper parts... . ing a vital pulp, their sun ivâl a'ill depend on their
InI€clions
lhroughgangrenous tooth-pups are to be rank€d number and virulence as opposed to the defense
êmongth€ mostfrequentpyogenic nfectlons
of thehumanbody; mechanisms of L\e pulp.
th€yby no meansâ wâyshavethe hêrme$ .hôfacter commonly
Dentalcaries
Apkalinfections exhibita ùaNitionslrom â hardyperc€ptible
reactonto the mostdangerous phlegmonoùs lnflammationt \Mrenâ deepcarieslesionreâches
thepulp (Fig.8.1),
the
arcmpânied by geneËlsyrnptomr suchas highfeverchilltet.. massivc ba.ierial invasion will cause pulpal inflâmma
which,asmanyinstances showmayleadto meningitraswellto tion followed by necrosis and pcriapical inflâmmation.
o r æn . é n d< " p t k æ npi ! o L p "5, w i h " r d l ê r r n J o n . . In such cases the bacteda gâhing access wil be the
smallparticles ofsuchpulpsbrought underthesk n ormcq o(a complex microflora o{ deep cades dominated by ânâer-
sionedn the majorily of casesdlâmmation andswelling. . . At
obic, Grâm positir.e bacteriâ (19, 33). It is generâly
theendof ih€ second or th rd daya smallâbs.eswasgenerally
found.. . . n 36.8per centlhe nle.tlonswerea(ompaniêd acc€pted ihat bâcteria do not normally reach ihe pulp in
by
\ôvdp n 7 pq ,ônr , ê di,êd5p !\ rtêd dtdly .
significant nûmbers as long as it is covered by clinically
vnprolt
sound dentine. By microscopy and anaerobic culture,
W loL,ghby 1890(45)
D N,lilh,. nNestigators hâr'c demonsirated bâcteria in a few of the
dentinâl iubules in front of the carious lesion. Small
numbers of bacteria can even enter uncxposcd, \.ital
{4æreas most cases a'ith such lesiorÉ gavc gro('ih pulps ftom deep caries (34),but such bacteriâ nornâlly
(9,17,63). $,iI be eliminatcd by the immue system o{ the pulp.

Entryof micro-organisms
into
the root canal
ln some cases of infccied necrotic pùlp, a ù,ide open
patha'â)' {or the entry of bacieriâ is found chicaly in
the fom of pulp exposure due to cades or ftacture. On
the other hând, nrJeclion and apical pedodonhtB occur
âlso in câses of closed necrosis, even in appar€ntly iniact
teeth. As rc'viewed below severâl ways of entry seem
possible and have been drc subject of much reseÂrch
ând cven more speculation bui few firm conclusions
(Fig.8.1) (for reviews, see Refs 11 and 50). Ëven a Ie$'
bacteda enterjng à p1 p ilÉt is necrotic, e.g. following à
Trâumâ
Pulp exposùie due kr bauma will give accessto oral bac-
tedâ (Fig.8.1).In humms, as in animal experimenis (36,
48), this will caùsebacterial invasion and pulpâl inflam
mation followed by infected necrosis ând periapical
hJlammation (Key litcrature 8.2). In âddiiion, there is
clinical el.idence tlÉt bactedâ mav enter ihe pulp in
casesof cracked-tooth strndrorne,i.e. initiâl incomplete
fraciure (Fig. 8.2) (23). Labortrtory experiments indicâte
that bacteria c enter through even mil1or cracks in
enâme1 ând dentine following hauma (41). Àlso, ih€
dentinâ1tubules exposedby tooth Êacture during cavity
and crown preparation or under reskrraiions wiih mar-
ginâl leâkâge âr€ a poiential parhway (7). Futhermore,

Pulp exposuredue to Dentinaltubulesexposeddue to
Fig.8.t Dràwing lhepalhwa,s
illusiraring ol enrry
lormicrooqânisms
intotheroot€na.obvious
pâdrwais
Potential areca*s in enamelanddentlne dûeto t€ùma,aôddentinaltubules
leàkage
around or rootplaning.
JillingtrcolrcsoQtion Frôm periodontal
pockeltpoiential
rubules
orviab oodvsæ s in the@æof lraufrâ. Dûingbâcrsemia,b ùd-bomebaderià màycolonize
iJ ilrc periodontium is traumatized, ba.teria from the
gingival crevice or pocket may rcach the pulp ûroûgh
s€vered blood vessels (24. I\4rct}rcr or not bacteria
eni€iing by these routes caJrl Nive Ând multiply
dependson the stateof lhe plrlp. They will often be elim-
inated md fùrther enby prevented by the dentine pulp
complex(10).
Periodontal disease
Lr the pres€nce of Èeriodontal pockets, severâl enhy
routes (Fig. 8.1) seem possible for the complex subgin-
gival miûoflora, which are atso well suited for $owth
in the necrotic pulp. The microflora (43, 61) âre pre
dominantly anaercbic ând compnse many diffe1€nt
Gram-negative rods, spirochetes and varioùs Gra]1I-
po-itjve rodi and Lo(,i. dll of hlùch dF.onrmon il
necroiic pulps. ln fa.t ihe similârit/ of the endodontic
md p€riodontal microflofâ and even dre presence of
identical dones âre impoftant argumentsfor ihe €ntry of
bacteia from deep pockets into non-vital pulps of non-
câfous teeth (26,34.
From subgingiwalplaquê, ba.teria and their prodncts
can enter through accessorylâte!âl and furcal canals,or
ultimately duough the apical foramen. Fûrthermorc,
Themicrobiology pulp
ofthe necrotic 113
by anachoresis
root pLanrng
exposeo
dentinal
root.esôrPtion êxposed
accessory
waysôIêntryàrcpulpexposures
duelo câiesortÊùma.
by6ies fracture
exposed cavivor crownprepârâtion.
maryinal
pahways
arêviaexposed â(e$ory(anal'viâexposed dentinal
àôinfàmed pulpGn&horesis).
ornecroiic {seetext
dentinal tubÙles exposed due to root câiies, 8âps in
cementum formation in the ceNical area or by removal
of the cementum by rcot resorption or root planing
colrld be a path of entry (1). Inllammatory reactionsand
sometimeseven Iocal necrosishave been demonstrated
histoiogicaly in pulp tissùe adjacent to such potentiâl
entry pathways (38, 55). However, in other histologicâl
studies no .orElation beween periodontal diseaseand
pulp tissue changeshav€ been Iound (71).In a study of
experimentaly induc€d marginaf periodontiiis in
monkeys (12), it was demonstrated that neither peri-
odontal d€stniction (limited to ihe cervical haÏ of the
xoots)nor pla+e accurnulation on ex?osedroot dentine
causessevereaiterâtions in ùe pu1p.A.slong as the PulP
is vital and fuctioning the bâcteria usualy will be e.Lim-
inated, followed by healing of tlÉ dentine-pùlp .omplex
(10), bùi they will become established if the pûlP is
Anachorêsis
Anachoresis(Greek retreating) is a phenomenonknol'n
for mmy years by which blood-bome bactedâ or other
mat€riâls are prcferentially localted in âreasof inflam-
maiion (Fig. 8.1) (for a rcview seeReL 54).Animal exPer-
114 Theneûotk pù p
im€nts hâve sholln that baclcria nlcctcd fitrâlenous y
coù1.{b€ demonstrited in a lafge proportbn of pu1}rs
thai were inflam€d due to the prepafation of dc.p
cavities ând chemicàl irritatjon (l:1,24,5:t). It is a wcll-
csiablishd fact thât trônsieni bâctefemia is not un-
comnon in hunans (seeChapter 10). Depending on the
soùrce of the bâcteri.t,slrch bâcteremiàscould bring non-
ornl às well às orâl bà.teriâ to ihc root cdrls. Oral bâc
teriâ trom dental plaqùc or j ccted root canÀls cân be
r€trieved tuom vcnous bhod ninediâtely after tooth
extrÂction, pefiodonlâl surgcryr scaling, endodontic
treahnent, toothbfushing and even chea'ing (8, 18, 31,
5.1).Anâchoresis is therefore a possible explanation for
the inJ€ctioll jf sofre clinical câsesof closcd pulp necro
sis, although bàcterià âre normally râpidl)' eliminatcd
Conclusion
Therc arc nllmcrous possible pàthrvâys fof eniry ot
micro organisms into thc root canals, even nr the
absenceof clinicâlly obvious pL p cxposure lrom canes
o.Irr ' p,'j.'. l.')r'lb,.r'1.' . rJ\|Jm."'.r.
lesions ând perlod ontâI pockets, can gainacccssthroùgh
crâcks in enarnel and dentine, exposed dcntùal Lubùles
of accessory.ànâls. uood-bornc oral as ilell as eitrd
oral tractcria nay .nter the cânils in the ..se of bâc-
terenia. No dâtà âre àrailÀble concefning the rclahvc'
hequencl of these entry routes in the clinical siillaLion.
Thc iùtact doliim pr p compl€x is a highly efficieni
detense s,vstcù oftcn capablc of prelenting €ntry an.]
eliminàiing aDr cntcing ùicro{rgdnsns. Tfe necrotic
pulp, on illc othcr hand, giv.s cxcellent gro$'th condi
tionsior mi.ro ofgànisms.
Fig.8.2 cra(kedroothsyndromeh) nonpeleLy netured
max arymolarj (b)highùmagniT.âl
ônoitheùâ.k.Beneath
theamalqan restoiarion, lo lhepup.kom:
theûâ& extends
CeurtsenW lrrl Periodo"rnêJtor
Dent1992j12:195 40s
(23)
in
Locationof micro-organisms
endodontic infections
The pres€nce of micro{rgansms is geferâlly .lenon-
stratcd by the cultlre of necrotic pu4r tissue or fluid
froù the cânâl (se€beloiv). Spc.ial sanp]nrg techniques
as \r€ll ds histological and ultrastrùctur.l studi€s arc
needed to claify fie locâtion of micro{rganisms (Fig.
8.3),$'ltther nl ihe necroticpulp, on tlt mot can.llwâll,
in thc dcntinal trlbùles, on the rooi ccmcnLùrnor in peri-
âpical soft-tissuc lcsions (for r€viea.s, see Rcfs 50 ân.l
6,t).
Necrotlc pulp tissuc is d1e nàjor location of bacteriâ
câusnrg periapic.rl hsn,ns (Fig. 8.3). Necrotic tisslle in
root cànâLscan support thc gro\tth of nrany microbial
speci€s. Nli\ed mi.robial màsses consisiing ot cocci,
ro.ls, iilaDlùtous bâcteria, spirochetcs and yeasts ha\.e
been deûonstràted in n.croiic pulps in studies using
light microscop,voI histological tissu€ se.tions, as rvcll
as by hânslnission elcciron ni.roscoty of rillr,fhif
secti()ns and scànnifg electron Dicroscopr of root
f r à g n c n i s ( 2 , 3 9 , 4 9 ,s 2 , 5 7 ) ( F i g .8 . 1 ) .
Cencrall\r Dricro organisms also adhrc to soûe âre.s
of the (xn canal wâi1s, elther as dcnsc aggregàtes or
ns thin, singlc- or n'[ tilâyered condcnsations (Figs
. . - lÀ . r 1 s. u | , . l r r . . l , -c. .r .",. i1 , ô
scveral morpfologlcal l-".pcs,soùetirnes s.ith filam.n'
to1Éfofnrs ànd chaDù of coc.i peryend icular to tlt cânâ]
'a 1 a biofilm raùcr siùil to d€ntal plaqlrc fi struc
hù€ (19, 57). When thc pulp is necrotic ând infectcd,
micro{)rgdnsms nlso gro$' into some of the dentinal
tubulcs for â \'âiabL€ distâncc (fig. E.5), in one stud,v
mcasured to 10 150!m (57) and ùsuallr confined to the
'rrrr,rd.ro.tf , . . . . o f p p . f , . . 1 1 . * r . , nm- , r ô
 of the neootk pulp
Th€mkrobiology 115

Location of micraorgânisnt in endadontic infections

tig. 8.! Drawln!,lunratinlJ lhe oca- :]:

tioN oJendodonti.micro-orqan sms.Ire
maloroGiioN ae intrdadkuar:inthe
necrotc pulpI $ue, adhernqto the rool
.anàl wals ànd in lhe innêr part ol
denrnâltobues.Extrarad culâr mcrù
orgànismsmaybêprêsêntin periodonlai
pâqùeôn the rôotçu â.e,in rêsorption
lâonâèând n periapkalçofttiçsue (see periâpical soft periodonta p aqle
Advancêd concêpt8.1 andthe text.) tissùe les ôns on the root surface

organisms ârc. They have been demonsiiated mâ v in

Advâncedaoncept8.1 Micro-orgânisms
in cases with acùte slmptoms or fistulac, or in câses
periapicâl
lesions not r€sponding to previous ddodoniic heâttieît.
Extraràdicular micro-organisms àrc liable to removal b]'
The ongstêndingideâthat solidgranulomas
andtrueedkuar
host dcfcnse nechanisms ùnless they find proicciion in
cyslsdo notgenerây harbormkro-organisms
is nill!alid
ExtGradcularmkrobes mayberound: a btufiLn on â solid surfÂce.
hr ultrastrucLurâl strldies,micro orgânisms are gencr-
. i abscessed (usuâlly
lesions syrnptomatk) alltr not folrnd in ihc soft-tissuelesion in casesof chronic
. n perlapkaactlnomycosis àpical periodoniilis (apical grânù1oma)or in periapicâl
. n inlected
radkular paftkuarlythosewithcavl!esopen
cysts,
tlue clrsts (when the caviiy is conpletely encased 11
to theroolcânal(periapica
pocket
cysts)
ân epithelial lining so thai no communication to the
. on piec€sof rootdentine intothepeiâpex.
displaced
root canal exisis) (50). Àn exception to this rule is the
f N R , 1 9 (9570 )
NaiP occasional finding of typicâl actinomyces-containng
I \ e , ei s e vd e r c eo ' b è n e r à pl - ' p n - | p q r d d ( , l d r h u " ' I n colonies in grarulomas and in mdicul cvsts and
asympiomatcêpicêl periodontitÈ pe6stngafterrootfillir, abscesses(29, 5l). In casesof pcriapicâl âbsc€ss!\'ith or
(62) rvithout sinLrs (fistula), varùus bacteliâl forms and
Sund€
PT, erai.,2000
GatriJl,etri.,2000 ycâsts may be present jn the lesion, sometimes iiside
Q2)
phagocyies (Fig. 8.3 and Advanced conccpt 8.1). A1so,
radicular cysts mây coftâjn nicro-orSânisms, parhcu
lafll ihosc with the cyst cavity open to thc root canâl
organsms are always fo1ÙIdù thesehtrâràdicu1âr locâ (Ad!ânced conccpt 8.1) (50).
iions, often $'a1led off by neutrophil granulocytes or ân In conLrast to dÈ âbove stâtements, bacicrial DNA
epitheliàl plug ât the apical forâmen (a9). coùld be demonstràted û-iih a sensitile molecular
Pciapical bacicdal plaque has be€n demonstrâted by genetic technique in periapical tisstes removed duiing
scaronng clcciron ùncroscop)' as a coating of !àrioûs surgical treâtmcnt of asymptomâtic aplcÂl perio.lontitis
microbial forms embedded in a shuciurcless nâtedal on persisting âftef rooi filling (Advânced concept 8.1) (22,
the outer root surface, gen-"râlly near ihe main apical 62). The location of these (\-iable or non-viaue) bâcteria
foramen (Fig. 8.7). In resorption lâcunae bactefa and i. n . cleâr il .ou J be In h. ' f.-l -{ " lê.ion r o.1
t-eastcells sometimes coutd be delecled (40,50, 73). It is ihe rooi sudàce ând the risk of sample contaninâtion
r o t c L e a rh o l \ e . l r . r' J d ( ( , r m | . 1 - during the operâhon cannot be rùled oui.
116 pulp
Thenecrotic

'
, ,t.-
. +'

'' j'

,::];

Fig.8.4 Thèendodanrk microlloGin rheapicalroor (GR).The

canàloIâ hùmantoothwilh apicalperlodonttis eeâsinnebvænlhe uppêrtwoandthe lower
rwô drôwh€ds in (â) de mallnlried y. Notêthe densebaderiaasqiegàl6(BA)nckn!, (in b) lo the denrinâl(D)wallandas
in (b) and k), respê.rive
remaining
rrpendedamongneulrophiic . srânùocytesappearto tom
qÉnuo.yr6 (Nc) in the fu d phaseof the root.ana .ôôtenr{in c).Theneutrophi
a delemlvewal, aqansi lhe advan.ingbacreralIrônt. A transmisslon e edion microscopkv ew (d) of the pulpodêitnalinteQhase5hos
baderlal.ondensation
onthesurface oJthedÈnlnaldâll,fomlnqa thicklayered (â)x46;(b)i600i O x]i0;(d)x2350.tromrNaûPNR
p aque.[,]àgôif.auon:
Peiadantology
20A019911 t3: 1214a l\Al.

Methodsto study the
root canal microflora
The microflora of necrotic prlps hâve been studied for
morc thal 100 yۉrs, mair y by direct microscopy a1d
cultivaibn (45). Much knowledge has been gained
tlùough rcseârch into the composition, ecology ând path'
ogenic potentiâl of the microflora. In clinicâ] practice,
root canal culturcs mâ)' be used to determine the nicro
bioLogical siatus ud to assessthe efficacy oI the treat
ment prior to rooi Êlling. In caseof persisicni inJ€ciion
âJter root fill ing, irJormation on the micro-organisms ând

Fig.8.5 a.olony.onsstingol cô..1ândrodsin an ecoogka nicheonihe
bôtGialwâl.Ihê aggreqaled baderlaahoshowsomepeneiration
denlinalubule5.
5canning ele.rronml.ros.opy,magnilicatiot
!5000. Bom:
sênBH,PisklnB,DemirciT.Endodoht. Dent.ltaunarol. 1995t11: 64 \51),
Fig,8.6 Yeast celsaongroorcna wallin themddethirdoi theroot. the root canâls,and samplesâre t ken with sterile PaPer
ThÊy fôrû sepâbte jn the rootcna. Notcetheirafiachmenls
colonjês
io the canalwith fiamentous slructurcs.
Scanning
eleclron
mcroscop,
magnlfication
x750.From: SenBH,PhkinB,DemrciT. E dodontDent
ftaùûa|ô|.1995:11:6 9 157).
their aniibiotic sensitiviry paitems may b€come useful.
There ale, however, s€veral meihodological problems in
sâmpling ând cultivation to over.ome, owing to the loca
lion of the micro organisms ând the complexity of rhe
microflorâ (Fig. 8.3, Core concepi 8.1).
Fof many years, the methods for smpling, trarsport,
cultivation ând ideniification were râiher inadequaie for
Lhe m l fa"fidiob. olten ânaerobi. ffiLro or8Jrj.m.
preseni. Therefor€, fâlse-negative cultures (no grorfth in
spite of micro-organisms living in the root canal) a'ere
common. False-positive .ûltures, i.e. growth of contami-
Themkrobiology pulp
oI the necrotic 117
Core(onc€Dt8,1 Problems
in rootcanalcultures
sampling: Inaccessibleocarlon
TraNport deathoTmicro-oqanisms
overgroMhof othe6
Cultivationi m€diânotâdequate
anaerobiosis
notâdequat€
'unculuvatable
organi5ms
ldentifkationrilmeconsuming
expensive
taxonomynotyetdefined
culture-independenl, genetic
molecular cansolvesome
techniques
intothe
nating micro-organsms not present in the rooi calal,
were also a comn-Ion event. Of course, optimal tecll
niques to minimize such fâlse results md to securethe
growth of all members of the mi\ed microflora are
essential (47, 63, 64). Methods for microbial idenhfica-
tion with and withoùi cultùing are rapidly developinS,
âJlldthe namesand iaxonomic position of many bact€ria
changewith the acquired knowledge (Core concept8.r).
Sampling
For clinical indi.ations and proceduresfor microbiologi
cal sâmpljng,seeChâpier11.Sirict asepsisis necessary
during sampling to avoid contâminâtion from ieeih
(plaque or caries),oral mucosa, salivâ, fhgers md
inshuments. Therefore, cdies shoûld be excavated,fill-
ings, crowns, plaque and calculùs iemoved, a rubber
dâm appliedand rhe tooih md rubberdam disinfected.
Stedle brrs ând irotruments are used to gain â..êss iô
pohts. The cânâl mây coniain m intlaûmâtory exudaie,
bùt iJ not it is necessâryto introduce a small amount 01
sterile fluid. By slight inshumentation with a smal1fi1e,
necrotic tissue and mâterial from the cânal wall are dis-
persed in ihe tlùid, which is then absorbedwith a sùJfi-
cient numb€r of paper points to soak up all the fluid. The
paper points shoùld be hansferred immediâiely to a
tûbe of prereduced transpoû medium (47) desiSned to
kæp dÉ orgânisms alive a'ithout growing (ârd without
changil1g thejr proporhons) durnlg hânsport to the
1âboratory(Coreconcept8.1).
Microscopy and cultivation
The micro-orgafisms must be dispeÉed in the fluid,
e.g. by vigorous minng with glass beads, befofe
118 T h en e c r o tpc u l p
ii
ri
j
culiivâtion and preparation of sljdes for nicroscopy.
By dircct obscNation wiih phase'conhast or dârk
field micloscopt sc.'ming eleciron mcros.oPy or
microscopy of Gram-stained smcars, a1l mo4rhological
types present may be noiiced but some of ihcm
(e.g. spirochetes)may not be re.overed in cûlturcs (17)
The prescn.e of speciJic bacteria mây be .ssêssed n
smeârs siained with the indircct immunofluorescent
technique (3).
For culiivâtion, dilutions of the disPeËed san-IPle a]€
spreâd on agar mediâ, wHch âre ihcn incubatcd long
Fig. 8.7 lrlassivêbaderlalpaqùè at the
periapex of a humàntoothwrh â.uteapical
periôdonutis orgln. Notethe
ol endodontic
mirêdbacteriaïora consisriôg ot numetôùs
dividinqcod, rôds(lowerinçt),llamenl5(F)
and spnochd6 (5 uppù inset).Rodsons
reveaà Gram-negarivê cellwall {G!!, lower
C,(ementum;
insêt). D,dentine.Mâqnticaron:
x2680; upper insetrx19200; lower nset
136400.trom:Nar PNRP€r/odoniology2000
1997;13 121-48(50).
cnongh (10-14 days) to alloa' êven slow growers to folm
colonies. In a broth cultùre, the Iastest growhg bacteda
$,i11 overgrow the others and rnembers of ' nixed
microflorâ will be missed (64) Non-selective agâr medn
contahing hemolyzed blood (Fig. E8) fu1fill manv
spccial nuhiellt requirements and âre bcst sûited to
culture the many bâcteriâl q?es as $'eU âs yeasts (32)
Fol scientific puryoses, selective mediâ mây be
inclùdcd, e.g. SaboÙrâud agâr lor ycasts, mtjs sâli\-âr-
ius agai for streptococci,or RogosâSL âgâr selê'live tor
1âctobâcili. Special media are required for the Srowth ot

Fig.8.8 Agarpateof non{electivemedium .onràining hemôyzêdbood
ino.ulâred
withdiuredsuspension
ofpaperpointsamp e lrômfôotcanalwitb Fig-8.9 Anâerobkbox for proce$ingôI ml.robioogca
c pulpAfleranaerobic
ôecrot arl7'c lor l0 dâytseverâ
in(ubalion colony
areseen,ndi.àring
rype5 a mixed (Couftsyoi
inlecriôô. L Kruse.)
mycoplasms and spirochctcs,but only some ofthe latter
are cr tivâtable even when spccial t€clùiques àrc used
(32) (Corc concept 8.1).
The micro orgâr1ismscolonizing fooi canals arc facl -
tativ€ ând obligâte ânaerobes, therefore eacrobic
iechniques for lÉndh1g ând incubâtion of cultures arc
€ssentialfor accurate resûlts (47, 63). This 'pquiremcni
.an be fulfilied by nlù,bÀtion in anaerobi. jds or, even
bettei, by an anaerobicbox in which work with samples
and culiures as a'cll as incùbatio11âre carried out in
.n oxygen-tueeahrosplÉre (Fig. 8.9). In order to fâcili-
tate the identification of facultativc ânâerobic and
capnophilic (carbon dioxidelo\.ing) bactcria, a set of
âg plâtes is incûbated i n a ir supplementcd with cârbon
dioxide. G€nerà1\', one or two colonies of cach type are
subcùliured for identificàtion. Eecause differeni bacte.iâ
mây have similâr colonies, for somepùrposcs it is better
to isolate â ]ârge nmber of colonies, e.g. 50, tuon â
samplc (79).
Methodsfor identification
Preciseidentificaiidl, at i]É species1evel,of endodontic
isolâtes is very iimc-consulnng and cosutr and some-
times not even possible becausemâny nemb€rs ot the
orâL microflorâ âre nol yer sufficioltly charâctedzed.
Some âre eren nnpossiblc to culture (Core colrcept E.l).
Dctailed id€ntiJication of micro olgânisms F essmhal
il1 research, e.g. concerning the etiolo$' of differcnt
p€liâpical diseasestates ând the rolc of certain bâctedâ
or microbiâl combinàtions in diseâse progrcssion and
treatmcnt outcom€.
Bacterial isolates câi simply be $ouped on ihe basis
of charactcrs such as colony moryhologlr and pigmcn-
tation, cell morplûlog,v, motility or not, Gram staining
fte mkroblology pulp
ofthe necrotic 119
(utuies in an
orygeniêe (counesy
âtmôsphere. ol L. Kruse.)
reaction and fâcûltative or obligate anaerobe. Cenus or
species idcntification in addilion requires severâl bio-
chetnical tesls for €nzlme âctivjties and cnd ploducts,
possibly by comrcrciâ1 test kits (13, 59, 63, 76).
Unlno\^.n isolaies must be compa.ed a'ith reference
strains of defined spccies. In rcsearch, similarities
beiween strains cân bc €xâmin€d wiih advanced
methods such as DNA DNA homology analysis or
protein profil€s of cell extrâcls by polyacryiâ ride 8el
clcctrophoresis (,:1,18).
\ 4 ù d ' r r m o e . . r h r g e r l ' r ' . h r n a u cl .f o " . 1 \ i . s .
see Rcf. 77) hold greât promise âlso for exâmjnâhon
'herâlding â
of endodontic sâmples because the]' ar€
ne(', cultùc-independent erâ of medical miclobiology'
' { u o e d t n ' m R . f 7 l ) L i m r n ,l . o r ^ r l r r ê c d t o r , u l -
tudng means ihai the (probably numeroùs) Ùn.ûltivât
able bacreria can be included. One such medrcd (16) is
a 165 IDNA dilected PCII (polymerase chain reâction)
âpplicable ât differeni levels (bâcterià in 3ùera1, bacie
rial ofdeF or famil)'-sp€ci{ic, species-specific ànd
subspecies- or virulence factor specific). As the 165
RNA D\A oJ.,h.nl. d'qr r. rdpidl\ ra'n .rn{
nmbers of relerence sequcnces, s1lch rnethods '!ill
bccome Inore ùselul.
In medicai nicrolrjology, diagnostic kits are commcr-
ciâlly available for qujck exâminaiion s ithout c!'lturing
for some specilic pathogers, c.g. for hemolytic strepto-
cocci in thfoât samplcs. Similar ûrethods âre d.veloPed
l^ e\ rm rc p. ùd.rlâ. oo..er- r^. .' f.h .oe,ie-
deened io be of speciâl intetesi. Sudl tests cân be
based on specific antibodies applied in various ELISA
(enzyme linked immûnosorbant àssa"v)strstemsfor bac
tedal antigen deteciion. The DNA DNA hybidization
techniques ûsing DNA probes for specific b'.r.riâ âre
atso applicâble (for a re\-icw, see R€f.77). Wiih the
1ZO pulp
Thenecrctlc

'checkerboard' DN
A DNA hybridization method, DNA
extracted ùom endodontic sâmples hâs been reâcted Cor€concept8.2 Themicroflora
of the
with DNA probes ftom up to 40 bactcrial species, widl necroticpulp
r e s u l t s. n d i . â r h s r l ' e p r " - n . " o f q d r y , ' l r l - e . e. p e . r " -
(22, 58, 62). Srch methods designcd io deieci specifi. Ura y a mixtre of seveEloralbacteralspecies
ako lound n
dentalplaqueperiodontâlpockets
andcâ oushs ons.Dominated
bâcieriâ are only reliablc if appropriaie specific DNA
probes arc âvâilable, and ilrcy seem less suitable for MostTrequenlly
foundarespecies
ofl
endodontic microbiology, where the presenceof any oI
a largc number of oral âs well âs non oral speciesis of

Compositionof
the endodonticmicroflora
The fesident orâ1 microtlorâ .ompdse morc than 300
speciesof cultivable bacteda êJld an unknown number
of species that r-e cmot groû' with preseît methocls.
ProbabLymost o{ these can be prescnt in ihe necroti.
pulp, where also yeasts ând several bactcria of exira-
oral origin mây be found (Core concepr 8.2).The special
environment in the rooi canal (and our methods of
stud],), however, selecisceriain speciesto be foûnd most
fi€quenily (13, 59, 64, 75, 76). GeneËlly, â mixture of
several (1-16) species has been cultured Êom samples
ialen ftom necrotic pulps at the start of heatmeni (25,
63,76).
Oral bacteriain the necroticpulp
ln the field of orâ1 bâcieiology na$' species are con-
tinuously being described,and new knoa'ledge leads to
changes nr classificaiion and names. Therefore, the same
bactedâ may hâve diffcrent names in older ând nelver
articles (43, 66). AlihoùBh recent techniques alow very
precise identification, c.g. based on DNA sequences,
naming ls f less reliable in older studics using a more
or less cxtcnsi\-e series of t.aditional tests.
The micro-organisms in root cânal sanrFles from
deciduous as wen as permânent teeth âre predominantly
ihc same bacteria as those fomd in dental plâqùe, peli-
odontalpockets and cadous lesions (19,26,33,32 43,56,
61). The majority of isolâfts n1 initiâl cùltures arc obli-
gate anaerobic bâctedâ. These constituicd 91% of thc
isolates ftom closed necrosis (69), 90% of isolates tuom
necrotic pulps of deciduous teeth (56) md 68% ftom thc
apical part of necroii. putps in carious teeth (5). A lârge
proportion of the anac'robesare asaccharol'tic, peptide-
and âmino acid-degrading bacieria (56, 64).
The mâny ganera and species currently identifi€d in
root canal samples comprise obligate mâerobic ând
Iacuriari\.e amerobic ofÂl Lracteria(Tâb1e8.1) (3, 4, s, 9,
13, 77, 25, 69, 76, 78). Among the streptococci,speciesof
the ânginosus group (S. dtrgi ast,l,s. intctnedilts, S. con
Yea$s (moncommonly candidiaibican,andbâcteriâofextraora
orlgin(rotablyEnteroco.cur ako mâybepresenl
faeca16) initially
bul aremorecommon in sâmpestakenaterduringplolonqed
tfeatment,ôr in cases
oTrêtreatmênt
of fâ edrootfillings.
sfrllirtnt ând mitis group (5. t1Litis, S.on:rLi.,S.gotdonii,S.
sutlguis, S. pdnsangLlls) ar€ common, and in carious teeih
also S. urrfrts. Ii s'as sùggested (44) that S. sr"&?s and
S. srlirrl;ff often occù in rooi canal cultùes duc io con-
iamination with sâli\'â or invasion ilùough leakirg
iemporary fillings. Laciobacilli âre mainly fomd in leeih
with carics. ,4.f;totiyccs is/,1rli;(as s'ell as other,4cttro
rrvccr species)may be present, ând sometirnes actino
mycotic periapicât lesions de\-elop (29,51).
Black-pjgmented bacteria of the genera porptiyrondms
and Pmtatella (previous\r clâssified in the genus B/r.
fcloidl]s) hâv€ âttracted much attention as potentiâl
pathogens in endodontic as ùre âs n1pedodontal micro
biology (6, 28, 69). These ânâerobic, Gram negâtive rods
arc vcry .ommon jsolates hom necrotic pulps before
l r e 4 f m e r l .e . | e ( i ê l l ) r r r er r ' o r , l / a- p c . i . . l ' , a i s a . " r . .
Pr. inten editl,Pr. tatnerae,PLtnelaninogenica, PL denticola
d L l f L b t ( . t : i . r. , h . .,lr P , T l y t o n o t a , p e .e '
P. eltdodôl1tllismd P.gir.gi?dlis. Oth€r orâl bâcteria
commonly fould arc spccics oï Peptostreptococcus,Eltbttc
leriun, Veillanelln,Fusobû.leriun, Selelo,ûnûs, CrmW-
loùdcrer(previously Woltnella),Neisseria,Cdpnoortûphûgû,
Eikene\a anà Treponena,the latter generâll), demon-
strated bi, direct microscopy. Some species such as
Treponenta de ticoltt and Bactctoiles rù,sytà&s, whlch
ale dlfficult to culture, hâve been demonstrâted wiih
DNÀ reclùiques applicd dircctly to rooi canai samples
(16,s8).
pulp
Oralyeastsin the necrotic
Yeasts of ihe genus Cnt?d;d, and someiimes othcr fmgi
members of thc resident oral microflora
(43). Yeâsrs have also been obser\-ed by elecbon

Table8.1 Côhfrôngeneràin nfê.tedrootcanals.
nicroscopy in root canals tlÉi had been cxposcd to ihe
oral .â\-ily (Fig. 8.6) (40, s7), aJtd in biopsies ftom root
filled ieeth wilh therapy resistântpedâpical lesions (52).
In mâny older culturâl studies, yeâsts alone ()1 iogethcr
with bâcteda are reported in ùp io 17ol, of cases (1or a
review see Ref. 75). ln a rccc'ni study of 967 samples
cultured from ûnJiled root canals with iherapy-resislânt
n{e.tion (75), yeasis were found in 7%, sometjmes jn
pure culture but mor€ oficn together with bacteria (Co!e
concept 8.2). Most isolates ^,ere Candida albic1ns and
the rest wcrc idenrified as C. glûbnta, C. Suilliermowlii,
C. incanspicua atùf, Geottichltltl cûndiàun. A srtptisingly
high prevalence (40%) of yeasts (in most casestogether
with bacteriâ) was demonstrated in pus from den
toalveolâr abscesses ftom deciduous teeth in childrcn
with nursing bottle caries, â condition kno$,n to favor
ihe growth of yeasts in ihe mouth (70).
Bacteriaof extra-orâlorigin in
the necroticpulp
Faclrltâtively ânaerobic, cntedc bacteda are frequently
found in rcot canals, sometimes in initiâ] samples but
especially in samples taken later cluring ircàhneni in the
case of poor response or dudng reûeâtment of fâiled
root fillings (5, 46, 53, 59, 66, 68, 79). By far the most
common species in this gronp is EnterccoccusfuecIlis
Thernicrobioogy pup
ofthe necrotic 121
(fomerly Streptdcdccrslàecrlis), which is the only isolare
ftom many of these cases. Other enteric bactedâ isolated
comprise species of EntcrabucteLAcinetobactl:r,Prcte s,
Klcbsitlla d1d Pscullitnot1ds.It is not cleâr wheiher ihese
bactcia are present initially to become predominmt
dùring heabnent, or entcr ihe canals later due io failûres
in aseptic iechniquc and tcmporary seals (Core concept
8.2). Stdphllacaccus species âre also ânong the bâctedà
occasiolally plesent ln root canâl cultures, in some cases
probably as â contâminânt ftom ihe skin.
Ecologyof the neffoticpulp and
the root cânal
Colonizationof the root canal
Apicâl periodontitis is âr1 hflainmâtory reâchon to a
polymic.obial infection of necrotic pulp tissue ând root
( . , n J ' w " l l . . V ' c r o b i J , n m m u r r i e , B e n e r Jl ) c o m p r i *
ing several species (Table 8.1) grow as dense aggregâtes
in the necrotic tissue and, in âddition, adhere to the
dentinal wâ1ls in dense mâsses similâr io denral plâque,
invade dentinal tubines âl1d sometimes colonize ped
apical ccmentum (Figs 8.4-8.7) (49, 57). The microfloras
enicling ihc rcot cmal diffcr in ikir odgin: f]om deep
dentinâ] caries, predomnlânily Gram positi\,e obligâte
ânâerobesj from pedodontal pockets, mâny obligâiely
ânaerobic, Grâm-negahve rods md spirochetes in addi-
tion to Cram-posiiive cocci ând rods, and from saliva
ând pragingivai plaque,lârger proportions of faculta-
tive anâerobes and sometimes yeasts and non orâl bac
tedâ (33, 37, 43, 61). Bâcteda of extra oral origin could
â1so enter Àl)m bâcteremia originâting from the intes
tinâl traci, for exâll1ple.
The ecologicâl determinants deciding the success or
failuie of the groNth of micro-organisms enteiing ihe
root canal environmert (Core concept 8.3) compdse
microbial adhesioll and coâggregatioi! low oxygen
concenhâtion ând oxidation/redûction potentiâl, nutri
iion available from the hosr md slnergistic as wcll as
ântagonisiic relations between the micro-organisms (sec
below). With time, a climax communiiy is established
.' .ooper.rlinB Jrd .o-peling mLro-orgrni-m, In
balâncewith each other and the local environment. The
objective of endodontic ireatment is to elimnate or ai
least disLurb ùis comunity with meclÉnicâl debride
rent dnd ârtimi. robidlâEenls \ew mi.fo org"ni-nb
mây, however, enter the cânals, mainly throush leaking
temporâry fillings or due to failûe of the aseptic
Thc dcvclopmmt ovcr timc of thc microflora in
necrotic pulps in hman tecth is noi known. Some indi-
cation may, howe\-er, be derived from experimenial
 'l22

Percentâgeof tôtal f ora

Cor€concept8.3 Ecological
determinants
of the Fâ.ultativelyanaerobi. bacteriâ
endodontic
microflora
M1060
Adhesion
to rootcânatissues 1060D
of popuations
Coaggregation
Lowoxygenconcentraton

tis5ue
lluidandexudâte

mechankal
d€bridement

monkey studics (21, a8) where pùlps were mechanicâlly

trâ u m atized md exposed to the oral flora for L week ând
thereâfter scated for up to 3 years (Figs 8.10 ând 8.11).
Samples taken 7 days âfter sealing shoa'ed âbour 50%
facultâtive and 50'1, obLigate anacrobes, û'hereâs the
ùncroflora cultured aJtù 9i), 180 ând 1060 davs had
8 q o 0 5 ô . n d a 8 o ù o ù g - r ê, " ' e " 0 . " ,e.,'.,r'r"r.
with incrcasing predomfiancc of cram negâtive rods.
U&' npure.Ul.Lre.,'loJcre-'.lâ . lJ 1 . i n d l ) . r i n . o m
binations, r,rere inoculared jJtrtotramaiized pulps of
monkevs (20) or mice (60), pùre cùlrures of obtigate
anaerobesoften failed to colonize, whereâs mixturcs of
lacultâtiv€ md obligate anâeiobcswere nore sûccesstul.
lnhefent propcriies of the resident oral florc âre the
ability of some microbial species to adhcrc io host
sùrfâces and the tend€ncy of ditrerent species to torm
coaggregaics(i.e. stick together), so thâtdense mâssesof
Âdhedng micro-organisms ârc fomed (Core conccpi
E.3).These processesarc cssentialfor the coloùzaibn ol
oral mucosa ând teeth. On the hard, non-shcdding sur
faccs of teeth and dental mâierials they âre rcsponsible
Ior ihe formation of denlâl plaque, i.e. â polymicrobjal
biofilm resistani to eliminàtiori (for revicws, see ltefs 43
" , d r i l l . l r r o u .c d d t r . i e - \ . 4 8 7 r - i . r u - u r g J n i , - .
âÎe prcseDt not only as aggregaiesjn the necrohc rissùe
bùr also âdhenng torhe hard tissuesas dense aggregates
and siJrgle or multilayefed condc.nsations on cânâl
'!vâlls,in dcntinal tubules and sometimes
on periapical
cementum (2,39,40,49, 50,52,57, 73). This modc of col-
onizatbn produces nùcrobial commùnities wltrc ihe
membcis benefit from each oiher Âs well as compere
(Corc concept 8.3). Ii also hampers ch..mical and
mechdncal elimination of the endodorltic microt'lora.
obl 9ârely anaerobicbâderia
I ffi
l I
Fig. 8.10 Mêân pe(entaqeoT oblqatey âid fâ.ùhativeyanaerobic
bâcterâln root.anals ln lhree expeimenral monkeyi1Mq0,[,4130and
M1060)at d ïlercnlrimes(7,90,180and1060dayt afterseâlingrhe canals
followinqme.hàni.àremovalofthe pup andexporùre to thêora mi..olora
i o r l w e e k . F r o m : F a b r i c i u s l - e t à l J . à . d r D e1r t9Â8e2J; 9 0 : 1 3 4 - 4 4 ( 2 0 ) .
The predominantly obligatcly anaerobic microtlola
(Figs E.10ând 8.11,Table 8.1), with only a {ew perceni
tâcultâtiv€ anacrobcs and râre occurrcnce of obligaie
aerobes, rtflccts the low oxygen tension and rcdùced
redox potential in the necrctic pûlp ând thc root canal
microflora (Core concept 8.3).As i11dental plaque, ânv
olrgen eniernlg, e.g. rvith sali\-â, !!il1 presrnably be
coNumed by the facultative maerobes ând these have
cnzymes to remove toxic oxygen producis. In the dense
microbial aggr€gâtes,1owoxlgen lcvels and a lowredox
p o l e n t i J l . L i r d b fFo o o i B J l ^ r n , e " o b ew. : l l p r e \ f ; l
Nutritionof the endodonticmicroflorê
The nutri€nts arailable for the endodontic microflora
(Core conc€pt 8.3) arc deri\.ed from degradâtion of t1r
 ofthe necrctkpr p
Themicrobioogy 123

Percentageôf rotâlflorà The de$âdâtion of large molecules such Âs glycopro

Fâcutativelyanaerobic bacteriâ teins occûrs exiracellûlarly, probably by the concerted
90D 180D a.inD of cnzymcs hom diffcrent species n1 the poly-
CanaL Dentlne Apex Cana Dentine Apex microbial commmiiy, and ihc mino acids md small
50 amounts of sugars libcratcd may serve as nuirients for
all. In general ihe limited supply of nutri€'nis restricts
growth, especially in ihe deeper layc6 of thc microbial
aggregatcs. The siluatioD in many rcspe.ts is similar to
l o.lê,- / o|e\ ieb-. -ee
l l ' r l n f p l d q r F i n p F r i o d o , l r dp
Refs 43 and 61). Fof the micro organisms in dentâl
pla$e there Âre mâny examples of intermicrobial food
châhs, whele metâbo1ic products (e.9. hemh, vitamin
K, H, CO, NH, folmâie, aceiate, succinate) of one
speciesscNe as csseniial nuLiienis for others

Microbialsynergismand antagonism
In addition to slrppling iutrients, food chains â.e âlso
useful for the removâl of wasie prodùcts tlùi oiherwisc
might inhibii microbial growth. Such food chains krr
food webs comprising several species)also seem io be
important for the nutdtion of the microbial community
in the root canàl and the bàlânce between its members
(Core concept 8.a) (for reviews, see Refs 43, 64 and 6s).
All fte irùabitalts in the dense microbial aggregâtes
colonizing root cânâls (Figs 8.4 8.7) may benefit also
from the àbiliq' of some speciesto inâchvate host resisl
obligâtelyanaeroblc bacteria ùce mechùisms by degrading antibodies and killing or

n n hhibiting plùgocyics. In thick biofikns the micro-

organisms are also largely inaccessible to the ântinicro-
E I bial agents applied in iherâpla
Fig.8.11 Meanpercenlage
Antagonistic reiations also exist between the different
of obigaieyandfacullativelyanaerobic
bâcte-
la fromd ffereôtpàrtsol rhe rootcanalsystemin Tnalsamples in experi populations present (Core concepr 8.4). Thev are not
nentâ monkeys {lr/90âôdM180)90 and180daysaftersealnqthe ana s only cooperating b u t also competing for nutrients, space
Iolowingme.hancalremoval ol thepup andexposurc to theora microflora êJrl.lattachment sites. Some of their metâbolic products
torl week.From:tabclusL,eral.kahd.I DenIRe\.193219a:11444 \2a) (e I H,O, fâtty acids, sulfur compounds) mây accumu-
late in concùirations ihat arc inhibitory or toxic io
othel species. Bâctedocins are bâctericidâ] compoùnds
necroiicpulp tissueand by tissuefluid and inflamna produced by some species that are âctive âgainst
iory exudateenteringfrom thepedâpicâltissues(56,64). other species or other clones of the same species, so that
These sourcessupply the ne.essary nutric'nts: noi orly competing miclo-orgânisms can be suppressed (43, 61).
the basic requirements oI all bacicia for sources of Srch complcx synergishc and aniagonisiic fitera.iions
carbor! energy, nitioger and nrcrganic iolls, but also bctwecn mcmbcrs play a roh h ihe estâblishment ârd
m \ -pe.ial ',lLit?m,nr. 'cr gl!.nproter,. dmirn regulation of lhe climax communiy in an infccted root
âcids,fâtty âcids,vitamiN, hemin,purines and pydm
ldines of the various fastidioùs oral bacteda ihai are pre-
domimnt membersof the endodontic microt'lora. In this
enviromùt, growth of micro-organisms requiringcar Pathogenicpotential of endodontic
bohydraiefor energyis limited, whereasasâccharolytic
and proiein- and amino acid degrading bacteria âre
micro-organisms
fa\.ored (56,65). The nuhients âvâilable ând the slightly
Opportunistic pathogens
âlkâline pH resulting from the ânâerobicdegrâdation o{
amino acids pfomote the $owth of Peptostrcptococcus, The resideni oral microflora live in commensal associa-
EubacTeium,PrewteLk,Potphyronondsùd Fusôbaùerlutn r r ^ r r v ' r \ l h e l - I m J n m o u h . u - u " l l ) c o e ' i + i n g p e J r e -
124 Thenecrotc pulp
Coreconcept8.4 Microbialinteractions
in a
polymicrobial
cotnmunity
. coêgqregaton
. Mâinrenance
of ênêerobicenvironrnenr
. Enzyme.omplementâtionfor conæneddeqradation
ot
. Compeiiton ior space
andrutents
. Inhibitory
meiâbolic producls
fully É'ith its host. Ther€ is a certâjr mcasurc or mlrtu-
aljsm (reciprocâl benefit), e.g. ilÈ lrcst benefits from the
colonization rcsistance of the oral microflora agajnst
nltroduced pathogens and agai nst overgro lvth of micro
orgâJti$ns normally preseni in small nuinbers. On the
oihcr lùnd, ihe relation may also turn into parâsitism
whcn ihe micro-orgânisms ùnder certâh conditions
become harntul for ihe host and causedisease.In othel
words, the orâ1 micro organsm arc opportunistic
(polenrial) pathogens. They will always cause diseascif
they colonize a location such âs â fooi canâ], which is
normâl]y sterile. When ihc putp is necrotic the mrcro-
orgânisns âre located in thc necroiic lissue, on the canal
wàlls and in the dcntinal iubu]es (]-ig. 8-3). ln this
situâtion the hosi dcfc'nscsare se\-erely conpfomised
ând u ,Jb, 1,,,l mirJ e lhe mi.-oorg"ri-m-Erowi1S
outside thei reach, md cven foming dense âggregates
ân.t imperûeable biofilms on hard-tissuc surfaccs (Figs
8.4+.6). ^ny micro-orgânisms thât invade or are intro
dùced into the pcriapical connective tissùe mây câuse
clinicâl symptoms of acute inflarnmation (Core concept
8.5).Theywill, on the other hdnd, generâll)'be killed and
removed by the innate ând adaptive immule sysicms
ope.ating in the inflàmmatory processu ess thcy fon
a biofilm on a solid sûfâc€ (Fig. 8.7).
Virulencefactors
Any microfloia sùccccdjng in colonizing the root canàl
seem to produc€ morc or tcss severedisease.There is no
single or unque pâthogen. The presence of different
complex mixiures of micro orgânisms in the root canals
is typical o{periâpical diseas€.The sum of severâlviru-
lcncc factors produced by the consortiâ of nncro
orgânisms present will determine th€ degrce oI patho-
Coreconaept
8.5 Polymi.robial
oppo|tunistic
inf€ction
Apkal periodontitis i! a poymkrobia,opportunstcinfecuon
causedby resdentorâl microorqanisms becominq pathoqenc
whentheycolonDe thenecrotkpulp,rootcanalwalk,
dentineand
cementum, .e.in o.atonswherehostdefense me.han smsare
unable to eliminaterhem.
thereisnoslnge orunquepathoqen. severapotentialv
ruen.e
Tâctorsôfth€vârious specespresent
mây.ontribute10ihe co ec
t vepêthoqen c ty ôf th€endodontic
mcrofofa.
genicity of the €ndodontic microflora (Ad\.anced
concc?t 8.2). lnfonnaiion on vin ence faciors is limited
to examples in celtàin oràl speciesthât hâve attracted
atiention, mâinly as potenlial pâthogers in periodonial
d.êJ.ê (rt 4l) <o^ e ôf I rp,p rp dl-c .ômmcn r
endodontic samples ând similar pathogenic mecha-
nisms are likely to be àctive in p€riapical diseâse (64 56).
Host .lefense mechânisms âre unâble to remove
nncro orgânisms located ouisid€ their reâch in the
rccrotic pulp âr,Id on the \ral1s of tlrc root canrl (Figs
8.4 8.7). hl addition, some micro-organsùs can impan
host defense, with enzymes degrâding p1,:sûà proteins
such âs immùoglobulins, complement factors, pro-
tcinasc jnhibito$ and protcirù imolvcd in ilt cknÉn&
fibinolyiic and kinin systcms (43, 66). Such enzymes
havebeen demonstrated ii Pot'phyrûronasand preùûttlkr
speciesând malr offer pfotection to the a.hole microbial
community, not onLy to the producers. Irhagocytosisis
of paramount jmportance in host defense. Although
leukotoxin producing (phagocyte kil1hg) bâcteda arc
rare ln the endodontic micfoflorâ, seve.âl ofthe bâcteria
colrmoily found can cvadc phagocyiosis or rcsisi inha-
cellular killing in vâious ways. One such mecha snl
is the âbove mentioned degràdâtion of plasrna proteins
essentiâl for opsonizâtion, and ànother is the presence
of a capsule arould some bacieda (61,66).
Dircci damagc io i]t pcriapical comective tissu€ ârd
bone ma]' be causcd b,v cxiraccllùld bactcrial enz)'mes
such âs proteâses,collagenase,hyaluronidasc and chon-
droitin sulfâtase.Such enzymes are produced by several
spccics isolatcd from rooi canals, notably Pr"c?otclln,
Porphvtona trs, P.ptastn'ttacôc.us, Eubicteriu l nwl'trc
porerTd species (30). The endodontic microflora also
pfoduce cltotoxic metâbolites, which mây damâge
t h e t i " - . r . . r j l d , ) u - e i J t l l d m - r t i o n d r n m o r i d ,d m r n e . .
hdole, hldrogen su1fide, methyl nercaptân, butl'ràt€,
pmpionate, succinâie ând others (43, 61, 64, 66). Anothel
groûp of cytotoxic sûbstânces are ilrc lipopol)rsacchadde
ùdoioxins of Cram-ncgaiivc bactcria. Tlty act as anti-
 Themicrobioloqy pulp
ofthe necrotic 125

Table8.2 o(ureme ôf syûpÎôms in 31 cases periodontits

ol apical in
Advanced conc€ot8.2 som€mi(robialvirulence whiclrbackpigmeûted
bâ.teria(37stÊins)wêrekolâted fromthe root
", ftom:Haapaiaio
elâ/.,1986(28).
in periapical
factorsimplicated diseas€ cana

colonlzation
of rootcanal
. Surfac€components lor adhesion
andcoaggregation
. Enzym€s to getnutrients
. l'/lkrobiafoodchains
Evasion
of hon delenses
. lmmunoglobulin-degradingproteases
. Complemem-degradingprcteæes
. Inhbilonof phagocyles
. Proteæes ândotherenzymes
. produds
cfrotoxicmetâbôlic
. Llpopolyschùideendotoxins
Indirect
tissue
damage
dueto inlammatory
response
ro themlcro-
. Proleâses
andotherenzymsIromhon celk
genic and toxi. compomds, which cause inflammalion
and indûce bone resorption.
MâJrty virulence fâctors of the endodontic microtlora
can indfte inflamaiior! md this ('ill lead indirecily
to hosi iissue dmaging itselt (Advanced concept 8.2).
Alihoùgh the inflâmmatory process is protective for ihe
hosL aiming at elimination of the nicro-o.ganisms and
iheir products, it also câuses degradation of periapical
comective ti.ssue fibefs and exrrâcellulâr matrix, ân.i
osteoclasts are acLivatcd to bonc æsorption. In addiiion,
dorûant epithelial rests may be stimulated to prolifer
aie (50).In these intdcate processesrnanycell q?es patr
ticipate, notably neutrophil granulocytes, mâcrophages,
l]'mphocytes, plâsma cells ând tis$e cel1s. Among the
mâny biologicall), aclive substân.es âre cyiokines
released by inflâmmâtory cels a1d tissue cels, comple-
ment faciors, antibodies, and eMymes rcleâsed toom
neutrophils, macroplùges drd iissue cells.
Associationof signsand symptoms
with specificbacteria
Although pedapical inîdmmâtion is usuâ1ly chfonic
with no subjective symptoms, it cân also become âcute
with symptoms such as tendemess to pressll]e on the
tooth, exudate in the canâl, spontaneoùspairr swelling,
6"
Paryhyrcna nas enda.iontaIis 2
tuevat eIIa inteme did| ôigft < ehs 10" 5
3 9
l l
baderiapresenl'
B a.k-p!gmenied 9 22
No black.pigmented
bac@ria' 2 29
' Ba.kpgmenied badê a werc(liuredlrcml1 ol62rêêù.
' n thfee6es Po.ginglval,J
wasloùndroqerherwilh Pr i,t€mêdialniqrercnr
' o(mrêmeoJsymploms 1 weekàfterinila lieahenlwhielhe badera were
Coreconcept8.6 Associationof signsand
symptomswith specilicbacteria
Thereis no absolute
conelation
belween thepres€nceof sp€cifk
baderiaandsignsandsymptoms oTacuteinTlammation.
Thereir however;an increæ€dncid€nceoJpain,swelling
and
abscessln caæswith mixedinfection
comprisingmanyanaerobrc
specierespeciây in the pr€senc€
oI certainspecies
oi Porphy-
rcnonas,Prcvatelh,andlotPeptostrcptococ.ut.
abscess formaftù, and sometimes sprcad of the infec
h ^ r b r t l _f e \ . r T r . l u g i . d l l ù 4 . \ r " ê l h r l . o m e m , r o
organisns (Table 8.1) and .ertain mixtures are morc
virulent ilùn othcrs ad therefore more likely to cÂuse
aote symptoms, and there is in fact some evidence for
thls hypothesis. However, ihe largc individual variation
ând the smâll number of cases studied prevent fiûn con
clusions, and no absolute conelaiions hâve been estab
lished (6, 20, 25, 28, 30, 60, 63, 67, 69, 79).The dsk of acute
symptoms is increased in case of large queiities of
mi.ro-organisms in the cânal and in the presence of mix-
lures of se\,erâl, mâiniy ânaerobic species. Furthermorc,
in somc studies Potph!rcmanas, PrcI)oteLla,Peptastrcptli-
coccus,FtLsobacteriunt à 'J €rrdctrt,n specieswere asso-
ciated with ân increased incidù.e of slmpioms (Tâble
8.2; Core concept 8.6) (25,28, 63, 69,79).
'I]tre
Potpllllnntanas and PmlatelLa species forming
black colonies on blood agar (previously caled b]âck
pigmented Edctero;des or bpb) have atira.ted special
attention in endodontic as well as peft)dontal microbi-
olog-v.The importânt role of bpb in mixcd anâerobic
infections hâs been known for more than 35 years ald
126 pulp
Thenecrotic
for some of theù s,as colrJiraned in à studv ol experi
mental infections inducêd h gûinea pigs by subcuta-
neous injections of combinaibns of root cânâ1bacteriâ
(67). Persistent abscessesmd transmissibb hfections
could only be produced with mixtùes compising Po.
endodontiLisot Pr. interngdia/nigrcscù1s. (These stùdies
$'ere before 'Bi?creloidrstntelu.dnrs' was divided n'rto ?/.
int.rnedid àùà Pr niyescells.)
Studies of black pigment€d bacterlâ in casesoi peÈ
apicâ1inflâmmation with and without âcute symptoms
(28, 69) suggest that the presence ot Pû. t1ldt',1.'ntnlis,
Pa. gingkltrlis or PL intetltLedia/nigrescerc in the mi\ed
micronora increases the 1isk of clinical symptoms and
abscessformation. Ir one o{ dæse studies o{ 62 casesof
apical perùdontiiis (35 âcute and 27 clinically asympto-
mâtic câses), 37 strains of 'black-pigmenied Bactclotdes'
b . r c i , ^ J l c d I r . _ 1 1 ' c 0 " " ' o l ' ê l . e l l ' .J b r ) . r n .
nixed anâerobic nicroflorà (28). These bacteda wcre
cultured from both symptomaiic and asymptomàtic
teeth, ând there were also scveral sympiomâtic cases
from which they weie noi isolatcd. Howevel, the prot€
o\,tic species Po. ginsiwlis and po. ,rdodorfrl;s s'ere
present only in acute jnfections, whereas lx ;rf.,/r?c-
dia/nigrescens wâs found in both symptomatic ald
asymptomâtic casesârld P,: dcrtl.old occurred mosily in
asymptomâLic root cânâls (Tàble 8.2). Especially if the
canal contâjns blâck pigmented bacteria,the mcthod of
cânâl instrumentation is an imporialt determinant â lso
in ihe dc'vc'lopment of post-treaùnent abscess becaùse
thcsc bacteia are likely to cause acute s]'rnptoms if
pushed out apically.
Olle study (25) suggests thai statisiically significant
associations exist between individùal endodontic
symptoms and pa.ticular combinations of specific
bâcteda. Thus, pain was associated wiih mixtuæs of
ânaerobes comprising PeptB!Êptococcllsûd PrclJotelld
species. Swellilg was particulârly âssociated û'ith
lsolatlo]] of EubacteriLLt, Peptostreptacaccusor Prtrotella
species, ând even more strongly a'ith a combnùiion of
Peptostreptococcusênd P/e-rorell, species. Exudate in the
canal s,as significandy âssociate.l with combinations of
Pttliotella,Eubdctctiuît species dnd Peptostreptacaccts/
Ellbactetirm species.
In some cascs the rooi cânal infection seems resistanl
to treatment, as indicaied by persisiing exudate in the
ceal ad/or other syùrpiolns. Cultures from such cases
âfter severâl trcatment sessions often show strepiococci,
enterobacteriaând yeâsts.Thesc mayhave beenpresent
ffom the starl and be rclatively rcsistani to beatment. It
seems, howe\.er, âs if their presence is ofien dùe io con
tâminâtion of câJrtals lelt opef or inadequâtely sealed,or
to orher fàilures in aseptic technique (59, 75). In studics
of root fi1led teeth retreâted due to persistin8 periapical
lesions, the nùcroflorâ crdtured differed markedly from
that of ùrtreated teeth. lt consisted mostly of one or tr(.o
species of main\' Crâm positil.e bacteia, and the most
common isolaic wâs Ërterccoccus fnecatis{.16,68).
Conclusion
tleseâich inio dÉ microbiology of apical pciodontitis
h r - d " m u r - t r d . e dr \ e e , . ê rI J l J l c . m i , r o o r g " r i - n .
n1 ihe necrotic pulp and the root canâ1for the de\.elop-
ment of periapical irîalrmâtion. The micronora is
generally â mixture of several oral species dominated by
obligaie ânâerobic bacteria wiih smallcr Proportions ol
fâcultaiive ânâerobes.Orâl yeâsls and mteric bâcteria
may also be presenti these often become predomnant
during prolonged treahnent in câses of persistent
ilJe.iion, and they are common in rebcaicd câses du€
to failure of ple\-ious root fillings. Infonnâtioû on the
endodontic microt'lora is ân impottant pâit of thc scien
titic bâsis for the developmeni of modern treâiment
principles. The ireatment àims at eliminâiion ot ùncro'
orgânisms located noi only in the necrotic pulp iissue
but â1soon the root canal walls ând nlside the denrinâl
tubules. This requires mechmicâl instrumentation ând
locally applie.l antimicrobial agents under the mâinte-
nance of aseptic techniques,as wcll as an adequâte seâl
to pr€vent contâminâtion during ând bet\^'een treatment
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33. Hoshino E Prcdomjna.i obligâleânae.obesin hund
.àrious d€ntin.i. Dd't. À.s. 1985,64:1195S.
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35. Hunter 1{i. The role of sepsis rnd of anlisepslsin
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.onventionallatrontory râts.Orrl Sxrg.1965,20:3.10-9.
, I b d , r-. n , 37. KobàyàshiT, Hàyashi A, YoshikawàR, Okrdâ K, Hârâ K
The microbial lloû from root canâlsand perùdontâl
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I|n. EndôdaûtI. ]99A)23:100-6.
38. Ldgelànd K, RodriguesFI, Dowde. w Pedodontar
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'1974'
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39. LinL, L.mgelàndK. Liglt ànd clectronmicroscopic study
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292 316.
Lomcôli C, Scn BÉT,Cànkâya H. Sca ing €lectron
microscopicobse.vâti{rrsof api.al roôt surfà.esof teeth
with apicalpeùrdontitis.Entlùtlant. D.fl|. Ttnrrtalal.7996;
I2t 70-6.
41. Love RM. Bacteriâlpenetrâtnnof the root.anâl of inta.t
incisoftccti atterâ snnuhted trâunari. injùy Erdodo,,t.
'frau'nûtL.1996,12249 93.
Deû|.
'fhoden van Velzèn Sr! Wèsselink PR.
]2 Mal*cs PC,
Rcôctionsof the lirnns o.ganismn) deâdând fixed dead
ti,ssne. I. EnAadùùt.
l97A:4:I71L
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lvright,l999rlÈ15, U 32,416,5H0,91 2"106 17,12736,
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ssrynis,Stteptù.Dr.ùr ttù tansând Steploco..lssdi?rnustn
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45 Miller lvD. flr. Mrrù Orgrrûrf of the Htktafl Motth
(ùnâllered rep.int of the ôriginâl r'ôrk pubLishedin 1E90
if Piiladelptiiâ).Bâsel:S.KârEer,1973;969,285 95.
128 Thenecrotc pulp
Molànder ^, Reir C, Dâhlén C, Kvist r Micrcbiôlogi.al
status of rcot litlcd teeth sith âpi.nl pcrio{lontitis. It .
End.dant. I. 1998;31: 1J .
Môller ÂIR. Ml.nri.l.j,.,l E|ûniflatian oJ RootCùndlr aM
P.tirtiûl T6itF .l Hutntn |t:eth.M.ltto.lob\iûl Strdks.
Côteborg: Akad emi tijrlaget, :1966.
Môlle. ÀJR, Fâbricius L, Dalnd C, Ôhman AE, Hevden
C. Influence on pèriàpi.àl tissues oi hdigenous oraL
bacteria ùd ne.rotic pulp tissue in monkc-vs. 5.4,d. /.
D . n i . R d s .1 9 8 1 , 8 9 : 4 7 54 4 .
Thetrl\ureasèpti.ù|1! flecrotiz.d.ht 26 teeththellLr.rek Pl
sk t ik I'y ralin{ ûh1!52 tuùe i J.cted ûi th on! Jl ott. Afte r 6 7
nôrths, th. k.th tnd pùidpicûl tissrs tm è nnd. Tht
nr inJ.ct.d toot.aiâLs ûetu r11st.ril. and lhc nL.tDtt. tirstL
dd tut nldùæ pù1api.ùlitflnnnrtiot Ttî Leethujth ttf?ct.d
n . ntic Li$ue*ùtuù! ttlûntttat ian c1i|i.aL\ 112/52tùth) nrd
trtliog/athi.aIu (47/52 teeth). All itle.ted tèèth era nd
hjstol%i.all| lhD|tu] nt)tg ltriûtnat iiÛt!ûûtnûtirn .
Nâir I'Nlt. Light and clÊcifon micros.oPi. studies ofroot
.!nal flo.a and peiapi.àl lesjons. /. Ërddrùrr 1987, 13:
29 39.
50 Nâir FNIi. Api.àl periodo.tilis: a dynàûic cncounter
bctween root .ml infcction and host resporse.
Pûiodontologlt 2AAA1997| 13: 121-18.
5 1 Nlir PNR, Scbroédèr HE. Pcriapical actinôûy.osis .1.
f,rdoLlDnt.19n1j l0: 567 70.
52 Nair PNR, SjilEret U, Krey C, Kah.berg K E, SmdqvjsL
C. lnLracmâl bà.teria and lungi in root flllcd,
asymptomàti. hum.. teelh with theraPyjesistant
p. o l'. n:"l-d F r nl , - l n J
scopic ioLlùv up study. l. Erdod.,t. 1990;16: 580 8.
t" r n d/ / t t ô "tl ,,"1ù
thtûp1J Bnntn nltd asynllonùti. hùftdt tùit1pi.al lesiLrls,
atlLkhuere ftûùbù! ts blackbiotsicstluing jtgi.dl t@tttot .
'rh.
fndinf rùgg.st thù nL th. naiorit! oJtDDtfrlled t.eth uilll
Lh.tW tcsistùnt petiapicûl ksions, ûtj.to orya ts s pùs1st
ùt the ûpi.ûl toot cnflal ûnd nlall pluy ù rigllifcûnt rctu û1
. ndodanti. tft ùtfl eht Jailuts
Peciuliène V, BalciunienÊ I, Edksèn HM, Haapâsalo M.
lsolàtion of E,icro.o..,s /darlô in prcviousiy tuot 6lled
canals in a Lithuàniàf populatnrn. / Ërdodori. 2000;26:
593 5.
Robinson HBC, Bolnrg Llt. th€ dachoretic
pulpitis. L Bàcteriolotic stùdies. /.,4r,. Dtrl ,4$... 1941;
2n: 264 {2.
55. Rutrâch WC, Mitcfcll Dn Pern)dontàl diseasc,a.cesso.y
.mals ànd pû]p patfosis. / Petjotlo t. \965i 36:34-a
5ar. Sanr 1, Hoshino E, Ucmâtsu H, Nodà T. Prcdomnrmtly
obliEate dàerobcs in nec.(,tic Pubs of huûan deciduoùs
te.th. Mkrah. Eû!. Hùlth Dû. 1993;6:26È75
57 Sen BH, Piskin B, Dernri'f. OlrsÊrvationofbactcria and
ftùgi in inJected rool canâls and dentinal xùrlles by SEM.
Lfltlodoflt.Dml.lralmatù|. l99at lI:6 9.
5u Siqùe]rùIf, RocaslN, Sout{)It, de Uzeda M, Col,)mbo AP
Che.kerboàrd DN -DNA hybridization
ddodonti. iiJc.tio.s. Oml Sr,1. 2000; 89: 7,1-1-8.
59. Sird EK, I laa pasalo MPP, Rmta K SàlmiP, Kemnrc ËNJ.
\ . 1' r o b o o g r . ind j. " 'J .
durès in endodontic câses sele.ted fo. microbnnogicâl
i N € s t i g a t i o n .l , f E i d o t l ù t . I . I 9 9 7 i 3 0 : 9 1 5 .
64. Sotrrinno^PR, BâN)s MHM, Ni.oli JR..t dl. ExpcnmÊn
lal rôot .ùnal jnfectn)tu in convcnÙonal ând g€mjree
mi.e.I E,rd.dorl. 1998124, 405 E.
Socrânsky SS, Halfajee D. Microbiology of pedodonlal
disease. In Cl,,i.,l Pùiùdartùlog! antl ttlphnt DenListt!
(3rd edn) o.nrdheL Karrnrs r, Lùg NP, eds)
Coperùràg€n: 1997,13888.
MùnLsgaàrd,
sûde PT, TrnÉtàd L, Eribe ER, Lind PO, Olsen I
^ssessmdt of pcrindicr âr ni.robioia bï DNA DNA
hybridizntjon. Erddrldrt. D.rt 7ia, ,tol.2000; 16: lqr r;
Sûdqvist G. Er.tùitagical Sludie! ùJ N(totic I)t.htl
Prlps. Unreâ, Sù edet: Uncâ Unn,ersity Odontob8lcâl
Dùsedàtiof s, 1976,no. 7.
'tuth
a'ith inlnct .rùûhr xiet seht..l and rhicl r.cûuli.nr
û[ùinst .aûlan]inntij trk t. Ana.nbit cùflditians ûtu
ntnùsin d jb\tûplin., tnnspût and .rltiutian. Na hnrh'
tjr coùld b. isatatd ftùtt afl! sarryt.s Jiù1t 13 t.eth ltt fun1
t)et iryicnl d.s t | û tiùfl . l' tu tt 1I /1 9 teeth 1ri th 1,.r inlical ottei t$,
1 12 sttùihr of l)ackhriûuere ùtltùtd, th. MatDritubeihgr*
ùetub.s,T..th uith ù.rte slllrttonis hel o .onryLt dnnetubt.
lrf, conpfÀtts'Da.teroidcs meldinogenicus"
Slndqvist C. Endodontic micrôbiologl In ErPttil"r tdl
E,idodorti.s (Spângberg LSW ed). Bôca Raton, FL: CRC
ar5. Sûdqvjst G. Asso.i.rtions bctween ni.robial sPec'€srn
dental rool cànal infe.tions. Onl Mitùbiol. Iru\un.l L992)
7:257-62.
Sundqrisl G. Taaonoty, ccology andpàthogcnlciLy ôt trÈ
root canal floû. OralS,ry. 1994;7E:522-30
srùdqlist C, trckerbom MI, Iarsson AB Sjôgrcn trl
Càpac $ of anaèrobi. b.cie.iâ hotn ne.rotic dental puLps
'' to indùce puruLent nrlections. ltle.t Intniun 1979:24:
685 91.
6 8 . Sundqvlsl G, Iigdor D I'e$son S, Siô8rn s
Microbiological màlysls of LÊeL\lvith failcd endodônti.
tre.tmen|and out omc of conservâtivelc+rea rment O/al
5!rS. 1998;85:8G93.
Erftylbù rùùtllled teethrri|t tùsistih I pùiapicatLcsi.ùstuùe
setected,t tttût cnt. .\llet tuhoul af th. root fLLi118,ca ak
1r.rc sdflpkd Iryncnn\ af ùd.rn..d n nrubi'laii.ûl t.chriql.\'
'nL
mi.rolDtù u.r. nai ltt siù81. srycies .I Pt?dùt nnlttLy
Gtaù t)Dsitiu arganÀtù!. irnterococcus faecalis ort rltd
etie.t in spixs ntust .oniîûnly t.col|ttt. The suc.e$ nk .l t.IEar
mdt'ûns 74"i:60'1, ht .dss uith nryatirt .ùltrft priar to
fLlin& ûtsrs 33'l' lor cù\esûith pasitir. .uit1ùe
Sundqvist G,Iohansson E, Sjô8?enU. Prevâlenceôf blacl'
pigmented Brctù.tlcs spe.ies in rool canâ] inJe.tions. .l
E,ddd.rr. 1989,1;i 13 :19.
70 Terheyden H, Knospe Hl, D6sche A, Meunier D
KeimsPcktrum odontogener ^bszesse ùn Milcnselriss
Dts.h. Zahnnt.tl. Z.1997' 52:124 5.
'fo.abnel.rd
71 M, Kiger RD. A hrstoloSi. evàluâhon ol
.lentàl pulp tisùe of à patienl ù,ith p€rlodontal
disèâse.O/rl Sr/3. 1985;59: 19E-200.
analysis oj 72. Tonreck CD. Rcaction of rat connective tissue to
pol],ethylÈne tubc implants. Part TL O/"/ Sr,'.! 1967, 24:
674 43.
73. 'fronstàd L, Earnett r, Cervonc L Peiapi.àl ba.leriâL
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Endnrlôrl. D.n t. Trùut1dlal. 1990; 6: 73 J .
 The microbiologyof the nemtk pulp 129

71. Wâde WC, Spralt DA, Dymock D Weightme AJ. Mole- 76. Weiger R, Manncke B, Werne. H, Lôst C. Micrcbial flora
cùla. deteciio! of novel anaercbic speciesin dentoarv€o- oi sinus tracts ùd rooi canals of non'vi tal teeth. Eddddrl.
lâr abscesses. Clir. IrrÉct.Dis. 1997,25(Suppl 2): 5235{. Dent. Tnuflotal. 7995) 11: 15-L9.
75. Waltimo TMT, Sirén EK Torkko I:ILK Olsen I, Hâapasalo 77. Williams RC, Paquette DW. Del{t,on of pùtâtive
MPP lungi in therapy-resistalt apical pcriodontitis, Irt. pathogens. tn Cht."l Pmodontolog! md tmplûnt Dehtistty
Edodont. I. 1997;30: 96-101. rrrLr pJn ,L 'dle J r..a" rg tdrg \t cd-'.
Atnrng 967 mi.rcbiologicalsanplestaken by gtPlal pncti- Copenhagen:Munrsgaard, 1994 403-7.
tionùs fon pùsistènt endùdùnticinJe.tions,692&ne gtuuth 7E Xia T, Baumgarher JC, David LL. Isolâtion ùd
aû yeastsuùe isalotedhon 17 (7%) ôf th6e. Theyeaststuùe iddtifi.âtion of Ptaotella taflnaae fiom ododonhc
fôtnd in pùreclltlre in 6 (L3%) dnd taqetherroith bacteririn i n f r , ' i o r . O ' , r \ / l o ù : o /1 4 , . , , o . a 0 n 0 j1 4 2 7 1 s .
4 t / 8 d o \o I t t l p . a ) p t , . t h . a , , d . p a n l t r y b a . t , . ar ù , 79 Yoshida M, Iukushnna It Ymmoto K, Ogawâ K, Toda
ftostl! stftptocoocjdnd ôthù GtM pôsitibe.fâculktiee ân T, Sagas'âH. Conelâtion betwêd clinicâl syrptôûs dd
ætuba. tn sùhÉ rases,obtlsat. anaerobestuereJattd in micro-organsns isolaied f.om .oot cmals of teeth with
pe.iapical pathosis. .1.Efldod.nt. 7987,13: 24 3.
Chapter9
Apicalperiodontitis
Risto-Pekka
Happonen
andGunnarBergenholtz
Introduction
In theprocess of pùlpal necrcsis,bacteda,bactcdal prod-
ucts ân.l inllammâiory mediators àccuDulatein the rooi
canal sysiem ùd may spreâd beyond apicâl forimnr
and elicii lesions in the periodontâl tissucs. Becaùse
these lesions typically âre inflammâio1y in naiure and
most often hcaied neâr the tip of roots, collecti\.ely they
â1€ termcd âpicâl periodontiijs. Periodontâl lesiolls of
endodoniic origin mây also d.'velop in a juxtaposition
âlong ihe lâreral aspecis of thc roois. ln these instan es
tk causative agents are rclcased along lateral or âcccs-
sory canals (Fig. 9.1). Proper rerms for these lesions
rvould be juxrârâdicular or lateral periodontitis. In this
text we use i]É tcrms apicâ | periodoititis and mdodon-
tic lesion to describe the inflânrnatory proc€ssesof the
periodontal tissrcs dlat are initiated and mâintânrcd by
an endodontic source of irritants.
Apical peû)dontitis sen'es ân important protective
tunction ad seeks to prel'ent the spread of bâcterià
and bacterial elements to other body compartments.
Yet, ùe process occasionaly may be âssociated \^,ith
severe clinical symproms and lnay also, alihough rare,
be a life threate ng condition. Pdirr iendencss md
${,ellings often bring ihe pâtient to ihe dentist (Figs 9.2a
ând 9.2b). For ihe most pârt, âpical periodontitis stàvs
âs]'mptomatic ând is thus 1ârgelyinconspjclLousto the
paiienL to be reve.led ody by routine ràdiogrâphic
cxamination (Fig.9.2c). The microbial load ârd the
siate of the host defensc are important pârâmetcrs that
determine the clinical presentâtion. In this chapter ihe
pathogenesis ând ihe various clinicâ1 ând microscopic
fcatures of apical p€riodontitis arc dealt wiû (Core
concePt9.1).
Etiologicalfactors
Apicâl pcdodontitis primarily cvoh-es as â response io
a bâcterial châllenge enanating from an infected,
necroLic pulp. Bacteria hJect pulps subsequent to injûry,
130
most commonly by c.ries/ dental irama or iâtrogenic
injuf), (see ftrrther in Chapter 3). Ii needs to be recog
nized that âs early as duing ilrc advancement of pulpal
hflammation, e.g. in respons€ to a caious exposùre,
pedâpical tissue respoNes energe. Sometines thesc
early fesponsesmanifesi ihc'mselvesradiographcaly bv
the loss of lâmiiâ dura and ihc de\-elopment of  smâI
râdiolucent âreâ, bùt ovefi lesions âs presented in Fig.
9.2 âre jnvariably not clinicâlly evident udess th€re is a
necrotic pulp where Lracteriahave nlvaded ihc pùlp
chmbcr and multiplied jnto lârge nûmbers.
Apical periodontitis may âlso appear or prcvail afier
ùdodontic theràpy, due to treatneùt failing io prevent
bâcteda frcm infecring the rcot cânâl system or failing
to dd ân already establishcd bfeciion (see Chapters 6
and I l).
In conjunction $'ith endodontic thcrapy, apical peri
odontitis ma)' be initiatcd by iatrogenic injury. ldtrogcfll.
lnjrly is ân injùy caused bv the dentist. Inâdvertani
extrusion of cytoi.rxic or allergenic medicaments âll1d
root I lù rd -nr. rJl, r- or e e\ ,-p F of idlro8a'i. hjr ry
ïns oftcl causes â cvtotoxic response brt mây also
result il1 hype$ensitiviiy or foreign body reâctions
(13, 3,r, 35; Châpter 17). Root pcrforation ù artificiâl
comnunication beiù'een the root cân.l spâce and thc
periodonial tissues is another example that may occur
during nr.shumentation of root cânâ1sin endodontic
iherapy of in conjunction \riih prcparaiion for a
p o . l - p . . e i n p r n - u h o dror i c l l c . , p \ . S u r r ,d , c m u r i
cation may se 'e âs à pathway for bactc'rialelements to
enter the periodontal tissûe and sustain an endodontic
Core concept 9.2 summâdzes the faciors associaied
\tiù apical periodontitis.
Whercâs medicamc.nts md root filling matedâls often
cause clinical lesins of limited durÂtion, bâctedâ y
induced lcsioN prevail ând remain as â non-selflæâ1ing
proccss. The reâson for non heahg js that ilrc host
dcfcnse is unable to reach sufficiendv far hto ilrc rooi
cmal space to kill the bâctedal in\,â.lers. CoÈcqùentlt
an ùireated root cànal infeciion, oncc established,
 Apkalperiodontitis 131

rcmains as a chronic process and exposesthe olgânism
conhnuouslyto bacteriâlelements.
SpecificTeâturesof the infecting microbiota
In an unheated tooth miciobial infection is an absolùle
prerequisitefor apical pedodonhtjs (16, 28). It needs
to be emphâsized that necrotic plrlpal tissue â1oneis
ûnable to sustain frark inflmâtion and only initiates
a phâgocytic response.However, repair is seldom pos'
sible be.ause the openhg of th€ apicâ1forâmen is often
too small to albw peiodontal tissùe io repla.e dæ
necrotic tissue. Therefore, if noi infected concomitætly
ôr .\^rrl) dftpr drp injur). J re. -oh, pJlp r.mdn. r
rargei for mi.robial colonization. Studies ha\.e shown
thal ihis will oi lâter (2, 42) because
necrotic tissue attraciive subsirate for
certain oial micio-oiganisms (Chapter 8).
The course ând the severity of the tissue response
to root cânal infection depend on the state of the

Coreconcept9.1

Even lhoughapcalpsiodontitk mayca6€svercdinkalreadions,

it baskay seûesa protective lunctionbecauset issetuparleast
to confineif notto kiil,the infecrion
to theroot.ânâlspaceand
preventit Ircmspreading. apcalperodontitis,
Tlrercfore although
oftenrefened to âsa leson,shouldbereqarded âsan impofiant
proiectivelnTlammaiory buTferzone(39).

y::!::_*___""-_ .
Apcalperiodontltis
mâybeasso.iated
with:
(1) Extenslveinfammatory or a vitalpulp.
lesion
(2) Inïectedpulpnercsis.
(3) Failed endodontktreâtment.
(4) latrogenicinjuryfromextrusiono{ medicaments
and rcot-
leslônsn rhe periodonr
Fig,9,1 Polentiâlo(âtonsoJendôdonlic um, Jillingmaleal.

Fig'9,2Dffelentc|incâ|plesên1àtÔnsolapcaper]odontti5duetoan]nTected,nemtcpUpk)eXtra.oÊ]5welinginther]ghl(heeklegion;(b
brokenlowerpremoa)j (c)apG y posilioned
vstibuù swellingG*o.iârêdwirhrhêseverely fupperriqht,(anneincisor).
Édioluæmarea
 132 Theneootk pu p
F i g . 9 . 3P o t e n t l a l p o s i l o n s ô l t h el o
bnà tdtenrai n
aecrornpup:(1)insjde
theroot.aôaàr a smalldistân.è fromrheapcalorâmen;(2) ariheapG
loramen; (3)wrhlnthe esion pelf.
indivicluâl's dcfense poteniial and the $ràlitv and rhe
number of micro-orgairisms of the infecting microbiorâ.
Th us, â lesn)n may becomc s€'\.er€Ând deh.imentà| rn an
indnidùal rvith a poor gcneral health coùdftion. Acùte
and scvere lesions may nevefthelessdcvclop in healthy
i rd \ d J , l . . n d o f , r . ^ . o d . ê . , ) . ' , S e . $ h . e
micro{rgânisms have rapldLy hcreased in numbers and
wltrc the loca1tissuc defenseis noi )'ct flLllv orgàniz€d.
The prcsc.nce of .ertain, pàrticularly parhogeîi.,
organisms âlso scems to play an import,rft rolc. Thus,
organisms belonging to the gencra of Porphytoutôlns,
Ptcrûtll1û, F1lsobûctlr;Ln
d Pcpr"slrct,rococ.rrsare
more oftei associated s,iih syrnptomati. and pâinfll
lesions than are other typcs of o€anisms (.7,8,12f.;!01).
Neverthelcss, âll btrcteria that colonize roor canâ]s are
considered pathogens but most ot them arc associat€cl
with silùi lesions.
Bâcte1iârcsponsibl€ for apical pedodontitis are not
r ' " r ' n ,) , b l . t " . - r . , b ' . , l - - - . , r , . r r ' e t . . i , , , .
(29).Thcrcason is thatbacleria âttempLingro invade tl-ie
tissue effcciivel,vare heldback ând,rre eliminated bv the
h o . l o , fi , e l , e r . u r . . , o r . r o . . o u . , r t r . r - n o r m , t )
initiaicd and maintained by the rcleâse of bacrerial
elcmcnis produccd during growth and djsn-Ltegraibn
of bacteria \^'ithin ihe confines of rhe root canât spacc
(Fig. 9.3), bui thcre are excepûr$.
In purulent lesbns (periàpical abscesses) bacteria may
be found lviihnl thc exrdate. This can be confirmcd
either by direct nricloscopy of snrearsor by cultufe of
pus (50). Oncc the acute phasc hàs subsided, rhe host
defens€nomrally eliminâies thcse ofganisms. Occasjon
alltr such lcsions continuc and Âre .Linically discernible
by a perbdic fe1€âseof pus into the oral €nvironmenr
âlong a fistulous trâct (sce belor,).
Certair bâcteriâ in root canal infectnùN may invàde
ând sur\.i!e long tcrm i{ithin ihe lcsion sit€ àn.l nav
Nerts ol A.tnomy.er
Fig.9.4 Baderiamayoc.urln thê lesond eithq a lilm or the eitùmi
rootsùda.eor àsnesls,
asln thisèxâmpe.
comPrcmisc lhe poteirtiàl for a successful outcome ol
erdodontic tr€atment. There arc two possibjlities for ihis
kind of nrfection (Fig. 9.4):
(l) II1 spitc of iàe host .l€{ensc,bacteriâ ma\, prolif€r-
âte from the root canàl spacc and iornr â tràcreial
film on the extenàl root surface (aS).
(2) \rarious ldir(rry.cs-rclaled species, especiall,v
. ? ., . r d f , . o û b . " . . , p t .
t,
.ni.utL, ùa:" invade the lesion site and produce
colonies of bâcierial masses or n€sts rhar cscâpe
phagocytosis ànd dcsbuciion (9). Su.h lesbns are
desjgnâte.t p.r',apl.r/ actitLotrLvcDsis and àre clur
trctedzed by the râc1iâ1aûangcDlent of thes€
Clram Positive Il.mentous organsms.'l'he histofy
of such lcsbns is usL],rllyâssociatcd $.ith clidcàl
exâccrbaii.Ds and poor rcsponses to efdodontic
treàtment. frn.f/ùrtion is a tern olten used to
denote the suddcn change frcm a silent to an a.ute
lesion a.ith o\-ert cl;nical s)'mptoms of pàin and
swelhlgs. Ar su€eri', i,ellos,ish suuuf gr,inùles
charactcristic of actjnomycoiic infections oft€n can
bc foùnd a.ithin the soft-tissuelesion.
Tissueresponses
and reactionpatterns
'r.,\e
temporâl evcnts oi lhe neurulascular and.ellùlàr
rcsponscsi'r àpical pedodoDtitjs are not vdstly diffcroli
ftum those of inflâinnator) processes in comecrivc
tissue and bone tissue elsei{hcrc. Its chrcitc ndmre aDo
spccilic location in a bone tissue compàrhncnt never
thcless necessitat€an accolrnt of the orgânization of the
tissue lesion atboùcarly and estâblishedstagcs.Sinilâf
to perjodontal .liseasc,ihe inflamûràtor), process is not
in resporLseto a sngle bàcteriâ1 orga sm but to à

. perlaplcâlabs(es
. periapicâlgranuloma
. radicularcyst
. osteomyelitis
ol periàpicâltksue
Fig.9.5 Overuiew lo IoôtcanaLlnfecdon
responses
lafge variety of combinahons of different organisms.
This means tlÉt, depending on the pathogenecity of the
mic.obioia, ihe tissue lesion may hâv€ â differeni clini
cêl preseniation ir1 tems of exieni ad severity
The rcspoNe of the periodonial tissùestothebactcrial
challenge involves differeni phases (Fig. 9.5). The ea{y
stageof âpicaLperiodoniitis shows â distinct âcute châr-
drler ârd i- raprdl! e\pand rS. Th. mo.r , on'Pi'uôù
feâture is bone resorytior! which gives sPâce 1or an
inllammâtory soft-tissue lesion at ihe rooi end ln this
early stage of the process, frânk clinical PFsèntâtion
mâ)' or mây not âpPear On very râre occâsionsth e ihfe.-
tion may tâke ân adverse course âJrtclspread far inio the
adjacentbone to câuse osteomyelitis (seebelow).
AJier iermiration of the acûte phâse, the Process
eniers jnto â balùced host tissue response.The condi-
tion is th€'n charactedzed by a continùous combar ofbâc
teriâl invad€rs at the same iime as lhe host aiiempts to
reorganize and repair the tissue dâmâge. Oû'ing to the
consistent releasc of bacteriâ] elemenis, heâling camot
occû and the dcfense reâction continues ând enters
into a chronic slâge of iniammation that may last for
yaars. A common ierm for ihis condiiion is periapicâ]
granulomâ, which refers to the $anulâtion tissue thal
is fomed in the process.It needs lC)bc recognized rhat
apicâ] periodontitis is notân autonomic processbccause
il is entircly dependenr on the constant releâsc of bâcte
rial elements ftom the root canâl space.
On a long-term basis a pedaPicâl grânuloma mây
eventually develop into â radiculâr cyst. AradicuLar cyst
is a closed, flùid-filled sâc thai is Lincd with ePithelium
It expands md may eventually cause considerâble
destruction of âlveolâr bone (seebelow).
Api.alPeriodontitis 133
Earlyevents
As in any irJlalnmatoly reaction to microbiai infection,
early events in apicâl periodontitjs include:
o Neurovascularresponses.
. MigrÂtion ând accumulation of inflânrnatory cellsof
borh ihe innâte ând ihe âdâptive imnune sysrem
. Tissue destruction.
To plo\.ide sufficient spa.e for the inflanrmâtory lesion,
the periodonial ligameni ad the adiacentalveolarbone
are initiatly broken down. Scveral local and systemic
l d . r u r ' ; n " c o n . . T l e dd , t i o r P d t i c ; p â t ei r t h i ' o r o c e " -
ùd include both bacterially dc'nved comPonents and
pro-ntlammâtory host derjved sùbstaices The lâtter
refer to âràchidonic â.id derivarives, componc'nis of
ihe kâllikrein kinin system, .''iokines, free râdicâls,
metalLoproieinâseenzymes, as well âs antigen antibo.ty
comptc'x formations and âssociâied .omplement aciivâ
tion (21, 24,32, 39). Aldrcùgh bacterial components slicl1
as enzymes ând cell wâll constituqlts cân shmulâte
tissue desiruction (inclùding bone resorPtion) dircctly, it
is their indirect stimulation throngh host-derived medi-
ators that is likely to be the most significant mechanism
The processof bo11eresorPiion is carried ouiby osteo-
c1âsts(Fig.9.6). R€sorptive cybkil]es (e.g interlelrkin l)
and prostaglandiN stimulâte thesc cells ln dre caÙ
phases of apicÂl pcriodontitis, osieoclâstsare .bùûdânt
md outpedorm bone forming osteoblasis Conse
quenily, the net result is loss of bone tissue a'ithin a
1im ited arca, which will rcmain for âs long âs the infld-
mâtory lesion prevâi]s. This resulls in an imPortant
diagnostic feâhl]e, because apical perbdontitis in radF
ographswill show up as a radiolucent area (seeFig 9 2c
ând Chapter 15).
Along wjth the proc€ss ot bone resorPhon, some
apicâ1 parts of tlÈ root will be lost as wcll However,
ioot rcsorpiion will be mùch less Pronounced and is
often vjsible only in microscopic seciiorÉ, seldom in
radiogrâphs (20)-Yet, root tiPS may sometimes bè forc-
shortened to the extent that the oi8inal confiSuration of
the apical canâl ùaiorny is alrered.
Of the inltammaiory ceils thar âPPear inilially, the
polymorphonucleu leukocyte (the ncotrophil) Plays a
cenhal role and forms the first line o{ defeme These
cells meet the bactedal front ald hold it back through
phagocytosis and intraccllular killinS Thercby, ihe
spreâding oI bâcterial or8âldsms is most otten Prc-
vented. The bacteriâl hont is then kept inside the root
calal or ât the foramen (Fj8. 9.3). Effective neuhophils
furthermorc help to limit ihe diseâse process (Key liter
aiure 9.1). Yel, when caused io âcclrmulate ln large
numbers, an acuie abscessis formed that, undd prcs
134 Thenecrotc pulp

Fig.9.6 Bonêresôeronsan mportânt featureoTtheeary lnflammatoryresponse lnihecaseshownnG),bone sresorbedwlthin

in âpicalpeiodontilis
a laiy largearêâ ôùtçidê$e root ilp wherethe nflammatoryesionappeaEiô be çpreadng.IhÈcaseaso displâysloreshortenng ol lhe root
tp duero resorprion.oneôdanic â.tviiês areseenwlhln a bonemarow 5pace5 in (b)ând{.) nêarthe roottp of a toolhwirhprôEe$ingàpicalperiodon.
ttis. Mi.tophorographs
ârêlrôfr ûnpublkhed expermentalmaleria in nonhumanprimares.

Keyliterature
9.1
n an€xperjmenta studystæhenko eta/.(40)inducedendodontc
lesionsin ratsby leaving bû exporresoTpulpuncovered to the
oraLenvronment for up 1o20 days.A groupof animakreceved
bothbeforeândperiodkay êfterthe njurya boloqkarcspons€
modiri€r (PGGguGn),whkh upregulates lrostdelense m€clra
nsms.Ihis drugenhances primùilyrhenumber ofc rcuatingneu nfe.ted necroticussue
trophlsândmonoryter aswellaslheirphagocytk Gpâb ty.Ih€re
weresignilicanty l€ssteethwth compete pulpalnecrosÉin P66
treatedânimas compared w th controlan
mals.also,
theseanmas
hêd e$ a veolarbonedenructon andpeiapkalsoTl tssuelesion,
implkatlng tlre signllkamroe oI neLrtrophils
and monocyles in
ljmitn9thed sease process.
to roorcânainfedlon,
tig. 9.7 n response pre5eût
thetÈsueesion df
atvarousd nan.eslromtheroottp.
fùentleatures

surc, will creâie pâthwâys {or drâinage into either thc
oral caviiy or the maxillâry snlusesand âlso, but rarely,
extrâ-orâ y (seeturther below).
The châràcter of the tissue lcsion chmges over
time and with disimcc from the root end. Although
neuirophils rvill dominate the lesion siie next to the
bâcteriâl front, macrophages and oihcr mononucleâr
leukocytes (i.e. nacrophages and T- and B-.clls) with
distinct immunologjcal functions come io prcdominâte
in more peripherâl areas and operale io rcsist turther
the sp1€ad of bà.teriâl elernents (Ad\.ânced concc'pt
9.1). Mixed to a l.arious cxient i{ith th€ inflâmmaiory
ccls are {iblovasculâ r elemcnts representing attempls io
r€pair. Thjs arcâ of ihc lcsion is often leferred io as dÉ
exudati\.e zonc (Fig. 9.7). More periphcrally a mûch
shongcr exprcssion of tissue rcpair develops l'herc
therc is fibloblâstic âctivit,v ând ilÉ fomation ol new
vessels. This areâ of ihe lesion appeâ6 similâr to the
grânulation tissùe ihat is formecl pfior to normal tissue
repÂii However, rcpair wil not be compleied as long as
th€re is egressof baciedâl substancesfrom thc root cânal
 Aplcalperiodonrltis135

Advanaed concept9.1 Recruitment of

inflâmmâtory.ells in developing
apicalperiodontitis
_
ft€ complement synem,a component of the innateimmunity, is
importantforthe recruitrnent
of n€utrophils
to the esionsile.asa
rilsl lineoI deJenseir is adivateddiecty by mkrcbialelements
wil\ott thepFsenleo dn.ibodie,. wl ù ldle' becoftsàniruol
iant d€fense mechanÈm. Activation
of complement resulls;n the
rormêtion of c3b bindingto thê suda.€of ba.leria, whichleads
to opsonization ândlysk.Complement acrivationako generâtes
chemotacti. fâctorr e.g. C3â and Csa ânâphylaroxins, which
stimulate themlgration of neuùophih.
Dendritkce s(Dcs)ândsomemacrophages Geechapter3)pre-
sentin thetissue areactlvêtedaftermaking contactwith lre bâc- Fig,9,8 Epilhe ina periapicalgrâiùlomâ
ialstrands ihaiseem
to attâch
to
teial e ements. Withinhou6theyproduce ê vaiietyof cytokines
including chemokiner whkh attractneun'ophib nacrophager T-
celkandmatureDCstoiheesionste.ThutDCsandmâcrophaqes
serye ânimponênt roe asgâtekeepeG ândâmplileuol theinnâte
with protecli\.e elements io limit the bâcterial exposur€
V d r ue D C !F g u l o . reh e . p e , i i i r m u re e p o t ê . o ( ( j ' i g of the hosl organism.
duringthe initialphases ofapicl peiodontitis.The activation phâse
ndudesdoningin regionalymphnodesof ântigen{pecilic ym-
phoc),tes (r-cells),
Epithelialproliferation
whichsoonâppearât the lesionsiteandlat€r
become a dominant ce lypein the lesion(41).Duringthe ea y Occâsionaly strânds of epithelial cells are encorteftrd
activ€phaseheper T-celk(CD4+)predominate overcytotoxkT' within the lesion site (Fig. 9.8). These cells are thoùghi
celLs(CD8+), whercas inthemoreestablish€d chronicphase theet- to origirùie ftom the rests of Mâlassez in the periodon-
uationis reveE€d (41).Thsfeature sugqens ùat helperT{elh âre tal ligâlrnent. Dûring the process of periapical inflam-
êdiveduingexpansion ofihe inïlammatory process.Ihut theyêre
mation, cltokines md growth faciors âre released that
likelyto be involved in the boneresolptlve proce$by activaling
ma(ophages to produce bone-r€sorptjve mediatoE. bring ihese epithclial cells to divide and proliferate. Yet,
B-ces are essabùndânt thanTrellsin the earlteventsbui noi every lesion irill contah epitheliâl shânds: it has
becomean importantconstituent in the enablished reson. been estimated thâi no more tlÉn ca. 50% of longsiand
Activated B-celLs become plasmacellsand prcduce a vùety of ing lesions contain epithelium (31, 32).
immunogobu ns,of whichlgC is the mon domlnant da$ (35). On obser\.ing tissue sections, epithelial cells seem to
Recent obseryations suggest that anlibody-mediated mechânisms tâke a rândom course ihroùgh ihe lesion. Sometimes
bya variety ofadion' ncludlng opsonzation andactivation ol the they appeâr to âttâch to the root surface (Fig.9.8). ln
compement system, areo{ greaiimportance in confiûlng the root other hstances epithelium mây block rhe exit of the root
canainfedionandprcventtTromspreadng (14).
canâI, thus appeaing to form anoLher defense bârrier
against ûe bacterial mass in the root cmal space (33).
I11 the âss of epiLhetial cells, neutrophils frequently
appear (12).
At incrcnsing distânces ftom the root tip there are
decreasingnumbers of inflammatory cels. Conversely,
Radicularcyst
the volûme of fibroblasts. gloûJlld substanceand col1a
gen is increased. Yet, .lûsiers of mononucleâr innam Radicular asa sequelto apicalpedodon-
cysidevelops
maiory cells may prevail in bone maûow spa.es next to titis ànd is the mosl comon of all cysis in the jâws and
the sofftissue lesion. the orâ1 tissue. À cyst is a câviiy with epithelial ljning
Dense,collagenrich tissueusuâlly becomespromi- filed by fluid or senisolid materiâl surrouded by a
nent ai ihe \-ery peiphery of the processand separaies dense connective tissue (Fig. 9.9).
the soft-tissue lesion ftom ihe sùounding alveolâr R a d i c r l a r c ) - t " c , n l o . à ' e d t d r y r o u r l F b " â r i n 8a ê a
bone. This tissue responseseemsto be yet anoiher of the jaws, bnt the ânterior maxilla appeds to be a
meansby which the processis localized(19). predilection siie. They are âs]'mptomatic unless second-
ln conclusion, the tissue lesion in âpical periodontitis, dily infected or so large that they become clinically
wtrich on a molecùlar and celular level consists of â discemiblc from fteir expânsion (Fig. 9.10). They may
complex sedes of events, balânces tissne deshuction peforate the corticâl bone and on pâlpation will be
136 T h en e o o t l pc up

'.{ ..
'ë
'.:

Fig. 9,9 k) A Gdkuar cystattachêd lo

lhe apca endof an erûadedrool s seen.
Eptheum (E) and a (onneclivei$ue
G p s ue ( c ) a r c u n d t h e . y nu m e n(.b ) P r o
feratinqcystepilheiumin a qpicalàr.âdê
ke config0ration à..ompànied by nlençe
inlammarory.einlhÊtes.

Fig,9,10 Dlflerentclnkapresentaiion5 ofradca .yns aredspayed.Radiograph5 (à)and(b)dem06lrâtê two çpàrâleradiolucent areas.0ne È a$oclàled
w th toothll andone a$er esions a$ociated wlthroothl4 andhà5expanded n a disral.orôôâdirè.tion.Alhoughthes zeandshapeol a esionarenor
defnitivecriterlafor cyl formation,lhere
areothertealures ol radi.ùar.yn. 0n opeôiû91ôoth
suqqestve 33lor eModonti.treatmenl, ( earexudale5 drew
off lrom the rcorcnàl k). r wasnorpo$lblêro nop exudarionândthus.ompletion oT.oôvêntônalendodontc therapywasprevented Al rhê bu..aiand
distâlâspêcr,ôf lÔôthl4 therewâsâ dÈriû.tprôn nen.ethârwâshardand nontenderto palpation (d).0n cÈing à lap lor enKlearioô, the expànçive
proæ$ s moreclearlyvùibleG).Thn bonetis5ueimiledthe luldji ed procÈsar the sùrfà.eHisrologi.al exaniûaron ol a tissuespe(imen confirmedthe

noticcablc as a lluctuaiing ihoùgh not parii.ularly The epitheliâ1 lining of radicular cysts derivcs ftom
paintul arca. Some indil.iduals appear to be morc proDc the prolifelation of the epithelial rests of Malasscz and
th othcrs io d.'vclop radicular cysts on root cdù1 is iegârded âs benlg a djrect effect of the inflammaiory
infection, for reasonsihal have yei to be established. proccss (45, 19). On the basis of histological serial
 137

Advânced andgrowth
concept9.2 Pathog€nesis
of radicular
cysts
TheIactorsthat iniliâteproiferationof the epitheal rêslsor
I\/alassez arenôtwellknown. Bothbâcterialendoloxins aswe as
c)4okines of infammatory celkhavebeenimpkat€d(26).There k
ako evidence lhat €pjdùmalgroMhlactorsareinvolved in this
prcces(22,23,47).Oncenarred,epitheliâ prolileration will con
ïnueforas ongasstlmulêllng faco6 arepresent.
th€ mechânsm behndthe deveopmeni of the ryslcavllyhs
beenrheroc6 ol muchspeculation. Twohypoth6es stilLprevail
(32)Oneslaiesthatwhentheepitheliâl massncreases in size,the
centralc€lLs wi undergo degeneËlon ândnecrosÈ dueio lackoI
nutrilonalsupply.fte ne(otk materâlin turnattracts neutrcphilt
whkh,together with lksueexudâte, rcsultln the formation o{
mcrocavites thêt eventua y coaesc€to forma radkuar.yst.
Anorher theoryisbuiltontheassumpton thatepitheliêlce s grow
brorm anepithelial lningonlhelnnerâspedoranabsce$ cavi\.
A k o r ê ê \ à - r ê . h a n . n o . h ê . , b \ p q t e n . s l o_wf l p d ' ê
In
th€sizeof theradkular cystshasnotreceveditsfna explanaton.
Fig.9.11 Radlculâr.ysts
mayappearin hvo(onfgurations:
a poclet.yn somebelievethatincreâsedosmoticpressureinthecystcavity sâ
k)whûelhereisdired.ommunlction the(yst(avty andthêrôôt
betlveen keyelement (38).Increased osmos s l€adngto thepæsage oflluid
nosuch(ommunlaton
cMlsp&e;anda ûuecrit (b)where exists. tromthesnoundin!tissueinlothe cystlumenis Lk€lyto o(ur
dueto breakdown ofepirhelialând infammâtory celh.Funh€rmore,
cystexpâmion k reLated to the releâse of bonercsorbing factoE
frommononu.lear leukoc),tes preæntn th€ rysrwall,indudng
inierl€ukin, mastceLllryptaseand prostagandins(10, 25,6,46).
sections tâker through cystic lesions, a proposal has
been made lor the subdivision of radiculd cysts into
true cysts md pocket cysts (31). In a pocket cyst there is
a direct continuity bets,een the cyst câvity ând the fooi
canal spâce, whel€âs no such direct communication is Keyliterature9.2
present wiih the hue cysi (Fig. 9.11).
A radicular cyst may rcmain within the bône âftel n ê c asi. experment in primales, Vaderhêug (49)removed the
exhâction of the tooih (ieeth) involved. Such â cyst is pup tissu€in teethandl€fttherootcanasopento theora envi
termed a residual cyst- Residùal cysis may remâh stâ rcnment rorupto 360days.
tionâry or slowly expând ovef time. arrhouq n i t y e v q p i f a r r a t o l a i o . . i n - d ig n i g à
In microscopic examinâtions, non-conifying strâiiJied tionor epilhelalcellrwereseenin theêpicalarea,it tookmor€
than200daysbeforecystrormation developed. Theobseruation
squamoùs epithelium of varying ùick1less is typicâlly process periodont
suggens tharrheinfammalory n theâplcâL um
- e e l ' o n t h e i n n e r . r û f a , e o r l h e ( ) . 1 c J \ i r y G ê er i g . o . o l
is capabhoI induclngprolifeÉtlon oI the epltheliarens of
The epitheliâl lining often shows â folded, dcade-like [4ala$ez andthatradkuarcystsmayresuhir âpicalperlodontitÉ
configuration. Eoth the cyst epithelium md the outer is l€ftuntrealed Tora ongperlodoltime.
comecii\.e tissue câpsûle vâdably are infiltrated by
mononuclear leukocyies âJrtd nenh]ophils. The epithe-
lirn may bc disrupted or even complet€ly missing as â
resùli of secondary infection of the cyst wâ11.sometimes crysrals.Rûshton's bodjes are .ircùlar or polycylic
mucous cels or ciliâted cells cm be noted on the sùrfâce bodies often consisting of concentric amorphous lam€l
of the epithclial lining. lae. Aldûugh the source so far remains obsclre, they
civen the pâthogenesisof radi$lâr cysts (Ad\.anccd hâve been proposedio be either of hematogenousor
concept 9.2, Key literâture 9.2), epiilrclial growth ceases odontogenicepitheliâlodgin (3, 27).
when the stimulating factorc æ climinaied. Subse Often, bùi (d from âlways, both the cyst capsÙleand
quently L\e epithelium lining becomes thin, as is o{ien the cyst cavity conrain .holesterol, which foms shary
the câse in a residual cyst. Inflammatory inIilEâies of ihe needle like crystals-In tissue se.tions they are not seen
cyst wâll .lso become scânty. but appeâr as typical tissue clefts from the dissolution of
Other hisiological feâtures of radicular cysts include the cholesteroldudng tissueprocessing.The crystals are
thc prrserre of Rushion's hyaLin€ bodies and cholesterol formed in the connectivetissue of drc cyst capsule and
138 Theferctic pulp

Bucca space betw€en

b!ccinator mus.le and
Fig.9.12 Common pathways oiâ pùlapi
.âl àb(e$. llre route dependson rhê
ocâriôôol the roots ln reation to thè
âbove mylohyoid musc e 3u(ôundngànàromical 5tructures: {1) sub
l n g u a l s p alcnet h es u b i n g u a l r i sas bu oe v e
lhe myohyodmuscle;{2) rbrândibuld
spacebelow the myohyod m6cer (l)
paata absces;(4) bù(al spa.ebetween
b u c ( n a t om i u ( e a n dô r e r y n gs [ i n ;( 5 )
bê ow my ohyod muscle m a x l l a ys i n 6 r( 6 ) v 6 t b ùe .

âre graduâllv moved towards and into thc cyst câviti..

Thcy attrâct nultinuctcar giant cels of rlt foreign body
iype ând thus elicit a foreign body rcsponse In the con
necii!-c tissle (30). Tlt crystâls are ûoughi lo .lefive
frorn disfitegrating red blood cells d\ring !L Lirsc
numberc n-Lâpicalperioclontitis in sta8nant lessels of the
lesion. lnflammabry cells clving in large nuffbers in
ipicat pernrdonljtis ând circulating pl.sna tipi.ls arc
other proposed so!'rces (1,37).

Periapical
abscess
H) percmia, edenrdârd dr aggregâtion of nriaùmatorv
' pll. i r . r p,r "p,. r'*" '" *'r'.. .r
f t,.a t. |'" r.
a pcriâpical absc€ss.Such à lesion is .ommonly âsso.i
d.rc h I h -.\er- o ' r ,. -\ell rS. dl lm"r .,,. -.r-.,
direci sequel to the fifccLion and breâkdown oi â vitaL 7'
pulp before th€ pciapicâl tissue defcnse is fullv ofgân 't,,1;yl.:r
ized. Ireriapical abscessesmây also develop folloù/ùg
ex.cerbâtion of an established, clinically sileft lesion.
The caûse ihc! is often related n) an endodontic treai-
ment. In conjunction \riih heatment, bacteda and Fig.9.13 Potentia
deveopmênls ofa periap.aabsce$Ina subperonea
bacterial elemcnts mâv ]]dre b€cn forced inadrertenily pushasa$embedundemûrh
abscêst thepûoneum(a).n à ubm(os
ouisi.le the âpical foraùen. It mây àlso bc ihat pârticLr ab(as {b),prsh8 brokenrhroughthepeiosteumandà.cumu aredn rhe
larl), vin cnt ûricro olganisms wer€ fdlored by ihc pro, mù.osalrissue
Theatterisofteraso.âredwirha distinderra.orat$ue
cectllle,c.g. bv apictrl o!eiNtrumentatjon thât efhanced
their nuiitional supplv. Such a lesion is knos.n .s an
endodontic fiarc up (sce fùrther nl Chaptcr 11). arc dclicate bundles of collâgdr and bone resorption ls
Microscopicâlly, a periâpjcal àbscessis charâcteflze.l ongofig (Fig. 9.6). Here, ûe nlflammaiory infilh.ate
by tissue .ecrosis and an atnmdancc of dead aJr.l bccomes more mononuclear fi naturc. As bone fesory
active nelrtrophils in the center. At ttrc peripherv there tion advânces,pus collectcd r.ithin the pe ritrpicà1tissue

Fig.9.14 CtinicatphotographsdemonstraringdifêrenrprèsentaiiomofJisrulo6ùâdsG)and(b)showtypi.al
o r âl i d u l a i i o n a r r h e a n g t e o t r h e n o s ê . B y r n c i n q t b e p a r h w a y w i t h a g u f t a p e r . h a . o n e t h e o r i q i n w a s d â
(d).maqes (c)and(d)counsyôrù F.Frkk.
compâriûrent may peneirate surrou nding bone ând seek
iis way furiher along the analomical pathwâys and
dùough the anaiomicâl structùes with the leâst resisi-
ance (Fig. 9.12). T]lis will result il the de\-elopment of
a localized abscess i11the âdjâcent soft tjssrc. Cellditis
is a feaiùre s€en in ihis context represeniing diJtuse dis
seminâtion of inflamatory exudâte in the soft tissùe.
Cellditis is a term thai rcIers to ân acute diffuse sPread-
ing of inflammation within ihe tissue ând should be dis-
tinguished from â swelling due to an âbscess, which
replesents a localized collechon of pus.
Usua y abscessesmanifest themselves as a tender
swelling that may lÉve accûmulated either under dæ
periosteum a subperiostealabscess(Fig. 9.13â) or in
the mucosa âfter breatthrough of the periosteum (Fig.
9.13b). ùr palpation the latter lesion fluciuates, whel€as
a subperiosteal abs.ess often feels hard and veiy iender.
In its mosi severe forms the patient may have idsmus,
fevef and difficulti€s in swâllowing. Because ihis cân
be a lifelhreatening condition, prompt relellal to m
Apicalperiodontitls 139
(d)
nùaoralfistulatons, h k)$deis anextra-
e trêêrraml u
i npeipndecbfEy o
Érd i o g r a p h y
oral and maxillofacial surgeon for proper diagnosis ând
treahneni is necessary Any ùrtrcâted periaPical abs.ess
with overt clinicâl mùiJestations should be considered
a potential healù ttueat thaL in ùy given circumstance,
mây lead io a serious condition induding orofâcial
abscesses, .ellûlitis, deep cervicâl hfections and cav-
emous sinus thrombosis.
A much less severe manifeslation of a PedaPical
âbscessis a sinus ira.t or {istula (Fig.9.14).A sinus trâci
is defined as a passage of pus from an abscess câvity to
an extemal environment tlrrough â tissue membfane
such âs the oral mucosâ or the skin (Fig. 9.1s). DePend-
ing on the dùtomicâl locâtion of the tooth ape>; lisiù-
loùs trâcts may spreêd nor oily to the oral caviiy or skin
but also to mâxillary sinuses and cause odoniogenic
s r n u . r ' t l \ c Ê p L t o r s r n u . r ù - e r i i o n -l h e - e e . i , ' t u a r e
not normâlly associâted with seveie symPtoms of Pain
or swellings but mây cause tendeness and pâtient dis-
comfort- A most conspicuous featùe is that they recur
and release pùs periodicâ]Iy.
140 Thenecrolcpulp

Osteomyelitis not been conJincd is the most common càuse of acute

ostcomi'clitis of ihe jala-s.Often â mixed inJ€ciion bui
Osteomyelitis is a diffuse iriflammâtory proccss that
also single organisms such as Sirtl,y1.r..r..,./s
nrl.rs and
expdn.ts withh bone tissue. In the ja$,s, osieomyelitis
enterobâctefia may be âssociâied with this condition.
may âdse ftom odontogenic infections or any type of
In chronic forms, includlng clùoric suppurati\.e
tfâumâ such as bone ffÂctule ând surgical procedlrre
osteomyelitis, â càusati\,€ organism is ofi€n hard to
(18). Thc condftion is rare brt morc
esiabiish. The diâgnosis and treahncni of acute ând
mâ'rdible ùan in the mârillâ. Systemic discasesuch âs
chronic forms of osteomyelitis should be left to spccial-
immunologicâl and nutritional .leflciencies, as well as
ists oral and maxillofacial surgerv. Treatment \,âdes
impaircd blood circulation in bone, predisposes to
clependhg on the cljrical icaiures ând nay incLude
long term ântibiotic tkrap)', surgicâl treatment .lnd
Ostcomyeljtis occurs in acùte and chrcnic forms. A
hypelbaric oxvgc.ntherâpy (15).
pcriapictrl âbscess ivhcre the root cânàl infecûù has

Condensing
osteitis
Condensing osteitis is also knoù,n as focal sclerosing
osicomyclitis (rrig.9.16).This is a conditior that does not
Fose much of a dùcat to patients and does îot iequire
lreaiment. Tl?ica lly these l€sions are asympiomalic and
are seen âs radiopaque mâsses often affccting molârs
of the mandibr legion The les n consisis of dense
sclerohcbone formed in ihc responseto â longstânding,
to$'grâde nriaùmak)ry process,e.g. âpulpallesion (1).
l r l . r n m d . u r . , ' l l - J , , . J , 1 ) . . J rr ) l h ê . - l e . i r n - m à \
or n1àynot disappeâr after endodontic theràpy or tooih

Epidemiology
Periâpicâl in{lammâtory lesions arc frcqucni manriestâ-
iions. Althorgh epidemiobgical daia are limited, it is
(â) obrious thât lesions are comnon in populâtions where
|,IougJi cariesis prevalent. There is also a link io age.The elde.l].,
\' \o I ê. uêrr \ r, ,\. ,J I, r.d de r, ,l iljr ri+ b) , rri+ .r
Fig.9.15 Exanps ol va.iousdirêc.ionsihat a TstuoûstÉcr mayrakel rcstorâtive procedrues, sholv 5-10% of their teeth to be
G)ù,oùgh àlveod boneto the oÊl envronmmtr(b)alonsthe pùodonta affected (5, 17, 5i). Populâtion studi€s havc also fomd
ligament
to the orà environmenr. thât endodonLic trcalments of less thân optimài qùalitr

Fi9.9.16 k)A arqesclerotcbonerea.tionis a5sociated

withthe dstâlrôoroia màndibular moafThetoothh asymptomâtic pulpvirài!'
ândrèspôndsro
tests.(b) DeNe(hrol. bonedevôd ol nlammaloryce s is a typcâ h çô ôg.à I ndnq n (ondens
nq osreirÈ.

prcsent with higher ftequencies of lesions than those
whereendodonticswas adequâte1y performed(s0,5,17,
sccalsoChapter14).
The prevalence of .adlcular cysts has been estimatect
from biopsy specinens after penapicâl surgeriesas i{ell
as from sections of soft-tissùe lesions that have beol
rccovered in conjunction with extraction. Dâta trcm
Casestudy 1
The radiograph in (a) is from a 37-year-olcl woman
$'ho wâs referred for ireaiment because of o..asional
pâin episodes on tlÈ left rnandibuld area. On clini'
cal cxamn1atio11, a fluctuating swelling was fotnd lin-
gual1-v Radiological examinâtion reveâled a round
cystic lesjon âssociaied with the first premolâr tooth
Endodontic treaiment had been given sevefal years
earlier to the tooth that was cln1icâlly ûobile. The
I
Apicalperjodonlltis 141
numerous studies vary considerably and rePorted inci-
dences among Âpical irLqammatory lesiolls subjected k)
analysis vary Êom 5 to 55%. Variation most Likely dePends
on the cdtcria used for ihe designâtion of.ysts ân.l the
population in focus for ihc siudy. When vcry strict cri
tedâ were used Nâir et ll/. (31) reported ân in idence ot
15%, of which true âplcal cysts made uP the maiolity.
cyst ând the toodl $'ere removed surgically in one
A cyst associatedwith the aPical area ol the rooi is
confirmed on hisiologicâ1 examination (b)
Higher magnificaiion shows thât the cyst is noi
diæcdy in conrâd wiù the âpex of ihe root (c). A chronic
inflâmmâtory cell inliltrate is secn jr1 the cysr capsule on
the ight side of the root.
Thin cyst epithelium lÉs a coûugaied orthokeiâ-
tinized surface (d).
D;dsnosls:Kerâtocyst, orihokerâtinized \-anânt
142

Casestudy 2 testing. The lesions were considered to be associated

wiih secondary hperparathyroidism. No heatment wâs
A 4l-year-old woman sù{Tedngfrom diabetes melliiùs, given.
Meniel€'s disease, chronic pyelonephritis resulting in Radiographic examination 3 years lâter shows
renal failure and secondary hyperparathlaoidism dis- complete resolution of the periapical lesions (b). Kidney
played multiple pedâpical radiolucent lesions (teeih 3Z transplantaiion had been performed 1 year earliea
36,34, 33, 32, 43, 41, and 47) on orthopantomographic rcsÙlting in improvemflt of imbalmce in the .alcirD
exminêtion (a). The patient was dialysis dependent. metabolism.
Therc were no cljnical symptoms.All ihe ieeth exceptfor Dûsrosis: Bone deshuction dûe to secondary hyper-
tooth 47 werc found to rcspond as vital on sensibility pa rathyroidism.

Casestudy 3
An âslmpiomatic cystic lesion was fomd il1 râdiologi-
cal exminâtion ât the periapical areâ of mândibular
frcnt teeth in a 31-yeâr-o1d woman (â). The pulps of the
teeih involved were found to be viial. The lesion was
rcmoved $rgicallla
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6 : 2 6 57 2 .
Chapte1
r0
Systemiccomplicationsof
endodonticinfections
NiIs Skaug
lntroduction
tnfectious processes associated with the root cânal
syslem of tecth may give rise to vàrio1's complicâiioff
that not only result in locâlmânifesiations but may also
produce lesions in other body siies. As oùtlined in Fig.
10.1,there âre three means by which a root canal intec-
tion may cause metastatic inJections:
(l) Through an âcuie pcdapicâ1 âbscesswhereby pus,
micro-organisms and their piodrcts âre spread.
(2) Ey an endodoniic treatment procedure where
micro organisms are disseminated to other body
conpartments along thc circùlatory system.
(3) By thc rclease of bacteriâl products ùd pro-
iniammâtory mediators from a .hronic penâpicâl
hllâmmâtory lesion.
The clinical sjgnificance of ihese spreâding mechânisms
âs well as the measures to be mdcriaken to pre\€nt
sysiemic complicatjons in oiherwisc hëalthy patients
or pâtients comprornised by a systcmic disease are
discùssed in this chapter.
Acuteperiapicalinfectionsas origin of
metâstaticinfections
Acuie maniJcsiaLions of endodontic lesions involvc
the foimahon of abscessesin the pedâpical tissues.
Although ihese lesiom most often become confined io
the oral region, they may extend to both nearby and
distant body compârtments along anâtomical pathways
(fâcial plmes md spaces).Hence, a peiapicâl âbscess
may spread and reâch the mâxillary sinuses, the bnin,
the câvemous sinus, the eye or ihe mcdiastinum. Need
less to say, some of these conditions are huly life threat-
ening. In addition to the direct sprcad of pus and
ba.icial elements, brain êJlldlung abscessesalso may be
caùscd by septic emboli. Rrthermore, oral bacteria
involved in endodontic infections may be aspnaied
inio ihe lmg and caùse sedous infections. Acùtc
osteomyelitis is yet another condition ihat can arise from
ân endodonhc hJection (see Chapier 9). Before the
antibiotic era, â11ihese non-oral irlfeciions causcd by dis
seminating oral bactcriâ were often fâial. ln .ontrâst to
the stalus in dev€loping countries, complicâiions of this
mlure are no\{ rare in the ind6trialized world. Yet,
when occurring, they still represent  thrcatening siluâ
tion that demânds propcr dentâl and medicâl aitention.
spreadof oralmicro-organisms
by
the circulation
IN'àsion of the circùlationby bacteriâ ànd rhcir dissem
hation by t]È bloodstream throughoùt dÈ body is
called bacteremlà. Eâcteremiasmay occur as â result of
surgical ând other invasiv€ procedures.They arc gener
â[y âs]'mptomâtic and trânsient (duration <15-30min)
because the numlrer of bacterial cells in the blmd
usùany becomeslow (<10 colonyjorming ûnits per ml).
The host's reticuloendothelial system ând the humoral
immunc rcsponse, turthermorc, rcadi1y eliminate ihe
orgânisms. Ther€fore, in healthy indiliduâls trârsient
bacieremias arc usùally of no clinical significance and
asymptomatic. Howevcr, in individuâls who lack
nolnal protection against infeciio$ (conPromised
hosts) the bacteda mây start ro multiply in the blood
reslrlting in sepsis, â sedous infection, local or bâc-
ieremic, that is accompaniedby systemic maniJesiations
of inflamrnation. In compromised hosrs (e.9. patients
with cânceÎ, unregulatcd diâbetes or imunodefi
ciency), sepsis may procced io a generâl fatal inf.'.tiôn
Oral micro organisms may gâin accessto the bknd
aJter loss of orâl mucosal integrity from rrâûmâ .1
mânipulation. In co lection with endodonLi. trâhnent
procedurcs, {or exâmple, the placcment of a rubber dam
clmp olten câuses transient bactercmiâ. Bacteremias
may also fdlow instrumentation of root canats (see
below). Bâcteremiacân occul spontaneously as well as
in conjunction with various twes of professionâl dental
treâhnents md other orâl manipulâtions, including oral
health procedures and mastication (Tâble 10.1).
145
146

(b) Ovêrinstr!mentation

Fig.10.1 a periàpi.alab(e$at a roottip (â),â rôor.analoverlnsriùmenrarion psiâpG jnTâmmârôry

(b)andanestabliihed hson k)

Table 10.1 Frequèncy

oI treatment.indu(ed
and selfndked ùâNent procedures (41). The incidencc ald ùagnitude oi bac-
teremiâs of oral oriEin have been found to be djrcctl,v
proportnùal to ihe degree of orâl inflammâtion and
fiJectnn (10, 9) and occur more frequently in persons
$,ith high dentâl plâque scores and gingivitis thân nl
fidividuals prâctising àdequate oral hvgiene (46).
nt.àligamenta
anenheri. I6-97 45
Bflcterenia a à endodolttic tueahne11t
I0-94 23 Ihe âctu.l numbef of Dicro orgànisns in ftrced fi the
1638 t3 bloodstream depencls ûpon the size of ihe âpical
8-80 t3 fofâmen, the degr€e of inJectionof thc rooicanal and ihe
l method of rooi cânal ireahncri (3). ^ \-arieir of oral bâc'
31-54 15 terià, .md speciesthai arc fould n infective endocardi-
0-5 5 tis, hâve been isolâtcd from infccicd root cânals ând
53 42 pedapical hsions (25), yet ùere âre relàti\.elv fer.
t3
rcports n1 dæ literalurc dcscibing how ofien bâctererniâ
l,laÎrixbàndwirhwedge 32 oc.urs lirlloi{'n1g endodontic thera}ry ùd ferv provide
bacicriological fhdings (Table 10.2)-
t0 30 Studies pcrformcd during ihe 1960sa'erc not âble to
Rubbqdam.lampp acment 29 demonsLratc posiiir.e blood cultlrres e\-en if the root
24 canat svstem had been instru ented vigorouslv in the
tTt6 t0 presence of salira. Ho\^.ever,when cànâls were instnL
Routine
daiy ora a.tivities nented beyoncl the root âpex, there rvâs a 25 30?" inci-
058 t8 dence of bactercmia (E). Bàungàrtner cf l?/.(s) uscd an
Chêwin9 13 aseptic te.hnique to cùl ù€ the blood of20 paticnis and
7-50 I3 registerc.l bâctercmiain only one casewlæn a root cânal
50 19 had bc.n olcrirEtrumenied. Llebeliàn ft ,/. (i4), on the
2040 9 other hând, found a comparatiYcly hi8h frequenc,v of
a-26 18 bâcieremias subsequcnt b cndodontic Lherap) (a2",t,
particr arly so in cases r.here the endodontic lnstrll
mcntation had been delibefately cârri€cl out beyord
It is important b note thât bâcteremià occurs hc- ihc apical iorâmen (7/13 vercus 4/13 for non
qlentlv lrom routinc dail\. oral activjties. in faci, bac, ovcrinstrmenied cases).In this Latterstûcl"vanâerobes
ter€miâs âre 1000-800(ltinres more lile1y to bc causcd were freqlrently isolated frcm the positive blood cul-
b,v dâilv oral manipulalions thân by dental tr.armcnt tures, as oppose.l io previols stû.lies \^,herefâcultative
 Systemlc of endodontk
compications infedions 147

Tabler0.2 Srùdie!
showlng
bâcrerlâ
kolated
frombloodsamples withnoôçùrgkaorsurqi.al
obtanedinconiurcton endodonti.
therapy.

No.ofteeth/ Procedure of positive

Frêquêncy Numberof isolatês(i)

56156 Periphsal
bloodemplesw{e 6 Æ 6( 1 0 % ) vnidans
'ûeptoca.(ùs ln = 1)
obtained prior1o
asepticaly sp.lô = 1)
carynebactetith
apicoedomyand3,6 andI
minposloperàrively.
B ood
sampeswere.ullvatedaerobicaly
femehtuûln = 1)
La.tabatil!ù\
sP.{n= 'l)
PePtdrtæPto.o..lr
Bloodsampiês wêreobtained 4124\20%)
in Vâ.u1â
asepri.ally ne/ tubes
beloreduriô9andafter nlracana hafnaniiln = 1l
côrynebactùium
endôdontc instrumentât
on At@r
ysisJinâiôn,$e bloodsmphs Vûldans (n= 4)
Eoupnreplo(oc(
wereincubatedanaerobi(ally
lor Anaerobl( (n= 1)
nrepto.oc.

era/.(14)
Debelan 26t26 B oodsâmpeswereobtâlned 11126
\4210) Prevôtelkintenedtaln = 3)
âsepti.â
ly dùringâûdôftêr Fùsobadetiun nuclearuû(n= 1)
the endodonricpro.edurê. PtôpiohiheteiuûKnesIn = 1)
5eeïurùq Hemdahetr. (24) stÊptôro@Jt termediue {n= I)
Steptôro@JJânglr (, = 1)
attihôhûillùs In=11
istàelii
se.hdonyrs .ercviriae(, = 1)
(rungùt

orgal]isms had predominâted. These authors laiÊr verj. of oralvirdansnreplo(occa$o.aredwnh

Table10.3 Relatvefreqùêncy
fied that, for each patient in whjch a positive blood rrom19441o1983(48).
inrediveendo(arditisâttheNêwYorkuospitâ
culiure lÉd been formd, there was phenotypic ând geno-
typic homology between the bacteliâ isolated liom the
rooi canal and the blood, srggesting thât L\e blood bac-
1341
teria originatcd from the ireâted root c.nals (15). lnter 1147
csiinglt in one patient drc fungls Si7ccturonyces 5 3
crreïisidc wâs recovered hom both ihe root cânal ând thc 3-10
blood sample. (Advmced conccpt 10.1.) 't2
6 1
Infectioe endocaùitis 1 3
ilacteremia is considered a risk facior for t]le develop
ment of endocarditis. Bacteriâl endocarditis is a bacie-
dal infection of the hea rt vâlves and the epithelial lining
(endocardinm) of the heaft. The lerm infeciive cndo- effects, circulâting micro{,rgar1isms aJltd local and
cârditis hâs rccendy been proposed to emphasize ihc systemic host clefense facto$. In mny .oûntries it is a
fâct tlùt microbes other than bâcteria also may cause relatively uncommon life-t]ùcatunhg disease(approxi
endocarditis (23). According io new teminology, inJec mately 50 cascs a.e officially rcgisteied in NoM'ay
ti.e endùcdrdil:s b rulned aher Jrc -nfeLli\ e mi,roor- and 300 in Denmârk per year). Infective docarditis
ganism, e.g. streptococcâ1endocarditis, staphylococcal u-u"I) ocrrr- h idi\idu-1, b i l l - r d é r l \ ing con
endocarditis or frngal endocârditis (Tâble 1û.3). geniial or a.qdrcd structural cardiac defects who
Although cunenily rermed ective endocârditis, bac develop bacieremia with bâcteda prone to causing endo-
teriâl endocardiiis is still ùscd by many aùthors in the cârditis. Symptoms of endocarditis generally start
dental and medical liicraturc. within 2 weeks of the incited bâcteremia, allhoùgh ihe
Jntectiveendocardiiis resulis from a complex ùierâc time to diagnosismaybe shorter or longer (48).A longer
tion bet$'een rhe endocardium, local hydrodFÉmic in' !b.jfi^r pe.inJ drdr 2 we"I. be.u cen | 'e 'nvJ.i\c
148

heârt vah'es.Aprerequisite is often a prùr fijrùy wh€re

Advanaedconcept10.1 Accuracy
of testingblood fibr and plâtelets ha1.e been releâsed, which cân
samples presence
for bacterial capturc circulating microbes. Multiplication a.ithin thc
vegelâiions lcads to discharges of the infecting orgal'
WhendÉwlngbloodbyvenipuncture for cuturingcr.ulatingoral
ism(s) back k dr circL âtion, producing a constanibac-
baderla, thereis âlwêys â rsk of contâm natingthebloodsample
withskincommensa presence inbloodcuLture5 ollypcalskln teremia that gives multiple positive blood cultures. The
s.The
baclerla, rch ascoaguiase{egatlve staphy ococc,corynebactena clinicâl sympioms, including embolizafior toorgans, arc
o r p r o p i o n b a d e r i a , i n d k a t e s c o n i a m n a t i o n l r o m t h € s k l na. B
dirc.i
e æ n result
tly of this mechânism.
it wasçhownthâtskn disinfection wth acohoilc chorhexidine is A ivide r'âriety of bacteria havc been isolâted from
moreenkacious lhanskinprepaËtjon with aqueous provdonF blood of patients $.ith irJcctive endocarditis. Viridans
iodlnein r€ducing contaminaton ol bloodculiures (36).How€vet streptococciarethe mosi common (50 63%) followed by
bê.teria knownæ skincommensalsêlso maybeprernt intheora -.'ph,lo,o.ci 12. 'o".\ r'0. q0r.Vd "L. ol'e mi\ro
microbiota, therefore t hâsbeenhardto t€llwhether suchbacre- organisms âccount for less than 10'1, (33). Among the
ra, whenpresent in blood.u turet originâte fromlhe skn or the oral viridans sùeptococciassociâtedwilh inJeciivecndo'
ora Gvity Re@ntly developed mole.uaridemiricalon techniques idldirir \rirlro o i, , t . t 1 d S t t ? t ù t u r ,ù . a n e , r :
. ô ô | ! u d jl r q ro nb o i l êô n i o
I d j o , q , o m "l h . p o b l ê Fr ' ) 1 A
domirùic md â.coûni for more than ta'o-lhirds of thc
followingloGl anenhetkinjedioNin childrenshow€dblood
cullurewirh bacterla growthin8%ofrhechldren prlortotheinjec
tionsBothcoâgulase negative stâphylo.od(adominant member The reâson a'hy f.iridùs strcpiococci ar€ nore likely
oI the .onnafi skjnJlora)andthe oËl baderium streptococ.us than othcr iyp€s of sheptococci to cause endocarditis
sanguir wercisolated fromth€seprenj-"ction b oodcultures. Brown relaies b thcir r€leaseof extlâcell lar polysacchâridcs,
et a/. (10)e iminat€d fromtheirbâcterem â stLrdy patienls who a'hich provides tlrcm with dJrl exceptional âdhesion
demonstËted bood cultuLês posltiveIor coagulase negative mechanisn. Other adhcsnÉ hke lipoteichoic acid,
staphy ocod, corynebacteria and propionibacter a becusethey fibdnogen bjnding proiein, fibronectin-bindhg protein
werethoughtto be lndcâtiv€ of skincontamination. In thestudy ând p1Âtelet interactive molccules are putative virulence
byDebeanetà/.(15),homoosywasfoundbetlveen Propionibaê fâcto$ of bacteria associaledû'ith cndocarditis (20). lt
tetuDa.nesisoatedin boththebloodÉmpl€sandtherootcana was sùggest€clrecently thât the majoriil. of ected root
s a m p e s s u g g e s t i nn g tl h a
e rs e c a s e s t h e o r g a n i s m w a s n o l a s k i n
cânals co.tain bâcteria tlùi may have the poteniial to
causebactcrial infectile endocarditis (a).
Thevoumeorbloodusedforcultu|ing, theconcentration oI bac
teriain theblood,thetypeo{bloodculturlng synenandtlreiden Stnphylococcus aurcus is another imporimi pathogen
tiTkation procedure ernployed delerm nethefr€quency of positive ùat nay odgnlate from the orâl cavilv, alihough tllere
bloodcuLtures with respedto typeandnumber oI species. With . r o , , r r ri r i r e , . \ ' d e n . e t h " t o r . r s t J p h ' l ô . o . . i . r
improv€d bloodcuhure pro@dures andimprovements ln theisoa c J u - e i . ' e . a ' , , r d u . dd i l . r ; l ) . T h i - o _ g ,n i - m ' -
tionolanaerobkand fastidous mkroorqanisms Iromblood,recov capâble of infccting even structuràlly no.mâl heârt
eryoI mkroorganisms Iromlranslent baderemiâs hasmarkedly \ /l\ e- , nd F ll_, mur \o _nror ) i-olrleli o|!,r'.
i r , " o ê d d .i , 9 F , p ny p d . . . r hoq!". - o o J r i g L q f " q F n c a hfective endocârditis of intravoûùs drug âbusers (50).
of bacteremia but ako morespecies and a hqh€rnumberot I reed. lo l-' r"' ùgrù/éd rtÈ. ordl mi ro orb 'i'\n -
midoorgân smsare expecied whenthe resulisof morerecent presumcd to cause ective endocà.ditis in a givcn case
nudiesarecompar€d withthoseofnudiesperlormed decades âqo.
are not normally specific io thc oral cavity oril\. FL'r
thermore, the incubâtion pciod (th€ time between â
procedufe resulting in bacteremia ând the onset of
symptoms) is often È'ell outside thc accept€d time
procedûre and the onset ol sy ptoms significântly ftame, $,hid1 should be lvithin l0 14 days, dep€nding
i€ssens the litelihood of the procedure to be the proxi. on the câusative orsanisû (29). This rn€ars thai it is
mâte câuse (2e). oftù hard to estâblish the origin of a givcn heârt
The symptoms ar€ non-speciJic ând include fever,
mâlâise, anorexià, càrdiac muûnûrs, splenomegal,v,
ùemiâ ùd weight loss- Before the ùlibiotrc cra the Caûillc conditiofls aflrl dentdl treatme t pro.eàwes
mortality ofbactcdal endocdditis lvas 100%,âJrtdir still as nsk fû.tors for infectioe endocaûitis
is if not trcat€d adcquaiely. hesenily/ th€ death râte is Ceitain cardiac conditions are thoûght to predisposc
less than 10'1,for viidans (alfa-hem(ùtic) sircpto.occât individuals for infectivc endocarditis more often than
endocarditis (51,20) and 30'1,for staphylococcal endo- others. Most at risk are ihose patients with à priof
cârdtis (20). history of infective endocârditis and ihose $,ith a pros
The organism(s) in the circulation câusing lhe diseasc thetic heart valve. In line with this knowle.tge, the
adhercs to Ând forms vegetations in a focal area of ihe Amedcân HeâIt Association (AHA) (12) lù1s detued
 Synemic
complcatlons c inTectons 149
oI endodont

high risk and modefate fisk categories for infcctilc shoulcl be regàrded as dangerous to individuals i\.ith
c'ndocarditis (Core concept 10.1). Thls body hâs also
dcfincd dcnial d oral ti€ahn€nt proce.lûres thàt âre Ab.,J. 0 ".Idl1-nte.ti eerJ,..rd r. ,.P. I in
likely to causc hazardous bacteremiâ in these hro inlec paiients without previouslv idenlificd dsk fâciors. It hâs
1i!c cndocarditis caiegori€s (Cor€ concept 10.2).llence, bccn cstimated thàt 20". of càsescan bc rclâted to dental
a \.ariet] oi iN-asivc dcnial procedrùes are felt to pose a treahneni procedures or jnfections (20) but the v.st
risk for infcctn c cndocarditis, alihough the.rssociations majoriiy arc dùe to orâl orgânisms and are nôi relâte.j
have nevcr be€n fiù l' docùmeft€cl. Yet, endodontic io dcntal proce.lûres (,10).
s1lrgery,including incision and drairagc oi abscesses Even if the oral iocal inJecftin theortr (seebelon, no
and instrumentâtion beyond ilt knth ap.'x, belong to longer enjoys ividcspread âcceptânce,it has rctained its
the dental procedùies that, accordjng to the AHA, position wh€n ii comes to the etiolog,vofinfcctivc endo
c.inlitis. This is in spiic of tlÉ lack of firm eviderlcc for
a câuse effect relationship. Thcr€fore, to.letermine the
cause of à given case of €ndo.arditis, physicjans often
r. Coreconcept10.1 Currentdelinitions
of the ask patients if they hâve reccivcd dentâ1 treatment in
American
HeartAssociationasto conditions rccolt monûs.If the ânsi{ef is ves, thc d€ntâl tre.rtment
representing
highor moderateriskof infe(tive is usuâ]ly blâred fof the condiiion (51) Yet, ihere aF
'l endocarditis
in combinâtion
with dentalrisk : on ly rs'o $.ell-conirollcd shrdies of d entàI risk factors for
treàtmentinvolvingbacteremia hfeciivc en.tocarditis (26, a9). Onc sLudy foun.j no
incrcascd dsk âsso.iated rvith denial procedùres h the
preccdins 90 da],s (26), ;rLthough bordcrline increased
. Proslhelic valveç,
cardiac incudinqblprosthetc
andhomogmlt risks were noicd for eidodoftic treahneni aDd dentâl
scaling. In ânoth€r largc, popl ation based,casc-conhol
. bacierial
Prevlous endocârdtis. study (a9) none of thc dentàl pfoce.lures that \Lcre
. compexcyênoliccongenila (e.9.
heândisease singleventrKle observed, excepr possibli' for tooth ertrâciion, *'as
ofthegredânerles,
stales,lransposition tetraLogy
of Fallol). I.Lrl.l .o be. '. fl t. Tlr. v -, u.
Surgcallyconstructed
synemic pumonary
shuntsor conducts, 'lvhefe there i\.crc ulderlying car.iiac vah'r ar
abnormalities (prosthetic vâlves, prcvious hisiory of
riskcàtegory
, Ivlodêrâte .ndocârditis). The study did conJirm, hoa.e\-er, the
,. . Congen oiherihanthosemenr.nen
talGrdlacrnalTormatlons impoûance ot these heart abnormâlities as flsk t.1.iors
f or infcctile endocârditis.
. A . q - i r e rod h . d f . n . i o " . 9 . h p r d r i f ê à 1 d , ) " c4 very rcccntl), ih€ AHAissued the follù{jng stâtement
. Hypenopn. .ar0romyopamv.
: . 'Cood oral health is important jr rcducnrij tlie risk for
r!1irra vaveproapæwth vavularregurqtauon ând/ôrth ck-
a.u ic .ardiovasculardiseàsèsuchas bactcrialendocàrdi
tls. Thcrc is limited ànd iû.oncluslrc clidcnce thât oràl
tra.teri! may plry à role in.hronic ciûioàsculàr disor-
dèrs srL_hàs coronary iriery diseàsÈ.uhether this rcla
tionship lvill evenb.ll), prove tob€ signilicaDt,!s one ot
thc manr fa.tors in the developmcnl of cafdiorâsculâr
disease,or of no signiric,rncels prcs€n y unrno\\,n.
Theamerlcan Heart
A$ociationrecommendsantbloticprophylaxis
rilk for infediveendo' .
n Grdiacpatentsat hiqhaid modefat€ Regrlù prolèssionaland hone dentâl .ar€ can rcdu.e
' r ' , - . . r J n \ . - . u r - r . . ' I r ^ ' a i , . ô . 1 9 .i - n . :
.ardtiswlrenundergoing dentalrsktreatments:
theIollowinq
neithet rortine nor cxlraordinar) dentâl treâtmcnl Pro
| . Dentaexlract
ons.
ce.]!res hà!è been documcnbd to pr€! e,1t.hrom. .oro'
n llono . roqr ' . no .nd rool
fnry lreàrt.liseàsèTh.1997 American Heàrt Association
: plàning, problng andrecallmantenance.
gûidelifts for th. pr.rcDnof ofbà.terid endo.ardiÛsnr
., . D e n t a l l m p a n t p l a c e n r reeni tm
apûL
d â n t aolfoanl us e d t e e t h, ,.
, . Endôdonti. (rootGna) indrumentation (onlywhen beyond rhe . ùt-risl.lcntal patientsremàin in eticci as recomnretdèd.'
I ap€x)andsurgery Thereforc,cver if dentâl pfocedur€s havc noi b€en corl
. \.oq qib pd"," o d,ooi. r'b- .nd rp'
r r m . . . , n . l l , r , ' r -ù r r f d I \ . p r d o , ,r d r i . . r . ' . d r e
. lnitl; plâcemeû or ortho.lontk ban.lsbutnotbra.kets
' . often infected wiih micr(lorgânisûs common to lhc oral
ntr:ligamentêry locaLansthetk inledons.
I . Prophyadi. ceanng of teethor impantswhse beedingi5 nicrobiota (49) ànd trdÉient bacteremiâsdue io dùtal
tr€àtrnent procedures caNoi be ex.lùded as causative
fâctors. Consequenrll., dcniisis must àIr\'.rys be obscr-
 150 Thene(otk p! p

vant of the poteniial risk of denrât infecrions and deirtal

proccdures, ard fo11ow estàbtished guidetines for

Preventivemeasures
Cltftent r.coin'nendations on aîtib iotic
prcuntio of ba.terenin sequelae
The AH^h.s issucctrvidely acceptedrccommerdatrofs
siating dùt ântibioiics should be given io prevenr cndo
cardjtis rvhen tr pâtient is ûrdergoing denral dsk heat i s k r n d v i d u aAs n u b i o t p
c r o p h y a xr sh r e l o r es h o u do e
rnent d i{h€n quaiifying for the moderate orl1igh fjsk
hmunocompfomised pârknls(indivduak wirh qftnutoc),re
category (Core concept 10.1). Dentat fisk trcarrnent is
.ount <3500,hûkemcpatienEbonematrowtrânsptant
defincd âs à treâtment procedùc rhat is kroa'n to patientswithl€ukema)arear highrÈkoI badùemiànduæd
p foduce bactercmiâ, r^'hich includes endodonric su.g€r), inte.tions.
Antbioti.prophyaxsis neededand shoutaoe
âl-Ldroot câna1 'nsùuDentÀtion (Cofe coNept 10.2). determined n consûltation
wirhrhepâtienrtphyskiân
becauæ
C€rtain p roceduresth at arc not recommen.led for ântibi unive6alguide nesêrenotavailabh.
otic plophvt.xis mav nevcrlheless cause significanr Re.ipen$or orgânrranspantç ândcancer parients,
athough
blecding in patients vlilh poor oral hygicne. rf such at increâsed
sus.€pibiliiy
to nledions,
donornormatty requre
câsesprophvlaxis is âlso appropliaie. Conscquenthr thc roulineântbioticprophylaxis n .onjuncronwirh denral
deniist is always responsible for rh€ finàl decrsronâs k)
ùhether aniibiotic proph\,.taxissho! .1bc instinlted. See
Core conccpt 10.3 for gûi.lelines on mLibiotlc prophy
laxis ând isk tlssessmeit of patients. . ThevastmalorlyoI nle.riv€ endocardirs
câses
ar€notdso
Prophylaxis is most effeciive $hcn given prcopera ciaiedwth dentaltr€armenr procedures.
tiveiy in doses rhar are sufficient b ensure adeqlate . Phcem,"nt of rubberdam. êmps,roorcanalinstrunenrarion
antibiotic concentraiions h rhe bloùt during ând 10h beyônd th€apca foranren andendodoniksrgery areâ$oc-
âfter the proccdure. To minimizc the dsk of anàph),tac- atedw th transentba.teretrlâs
andrequire prophy
anribiorc
laxisn parentsâi riskol nfecrive
endocardiris.
tic leactions ând antibioric resistare, rhe AHA rccon1
men.ls orâl r€gimens âs ihe standard roure. A stngle
dosc of 2g (AHA) or 3g (British Socieh of Ànrim icrobial
Thcrapy, BS^C) (2,27) amoxi.nlin in adr is shoull:t ihc,n i . Anyus€ofantibori.prophyaxk musttakeinto.onederaron
be gi\.en orally Il-L bcfore the dental tlearmenr. In ihe .r theadverse eII€dsof ânibiotkloxkiryandallergy, setecion
I ol resistantnrkroorgan sm!,supdnJedions ândeffec onme
r r ' . o I f ê | , r l l ' , r t ' .e \ .
t , . ê f , n . n ' ,, " , r a j r r.,- I mûobialecoogy.
damvcin is recommcnded às a1âlteûrtive. Amoxicillin '. U n d earn yc r c u m n a n tchee,d e f t n i s u t i m a t erl ye s p u n s D e
when gi\'en in the rccomm€ndcd .loses is prcfeûed to
. Torthe linal de.isonas ro wherherantbiori.prophytaxis
other penicillins becausc it enslùcs adequatc anribiotic shouldbeinnirured andrhesele.ronofdruq.
,
concentrationsin the serûm for 10h posiopefÀrn eti. Fof
palients who âfe u1able to iakc or absorb oral nedicâ d_roô-.( orop'\ro 1â/ gpndorô.dôrd.

ûnr, 2g of ampicilfi sodiun ad n inistercd inlramuscù

lâfly or intravenouslv within 30mh of ih€ proccdurc is

If thc ptrtient h.s forgotten to rake the

Prescfjbed
antibioiic prior to the treaiment, thc medicâtion can sti
be effcctlve if gi\.en fi.onjlincrion $-ith tlt ptuceour.,
but not lâier thù 2h âfrer ii iras staded. The rdnorare
is that thc antirnicrobial effcd plirrarity is.lùc ro
inhibjtion of b.cterial gfo.rrth on the damàged lÉa
\,alvcs and noi, as drought before, to rhe colonizari(ùr
pcl s. or to dre killing of micro-organisms in rhe btood
siream (22).
It is lvcll docuDented thar Àntibioric prophytaxts,
accofcling to the recornmeildcd regimens, mây setcctfoï
i . r o u r g J ' , ; . * t. h , t d r , . - r - l , r t . , . t - - d , , d R F - ; -
tànce is likelynot io persist for mofe than 9-t.r dâys aftcr
terminâiion of prophylâctic treâtment, tlrcrcfore denial
tfeâûrcnts reqriring an ârLtibiotic umbretla should bc
sche.luled ('ith àt least 14 dâv intcr\.âls. If a shorter
irtcn-il is necded, an altcrnâtive âlliibiottc shoutd be
sclccted (Tâblc 10.a).Ifâ siLuationwerc to emerge where
antibiotic prophl.lâxis is requiled ra.ice withh â shorr
time intcrvâl (12 24h), it is unlikely thàr a significani
selection of resistânt micro organsms has occun€d. In
- J . i l i t u rI r e - l l r F u - . i h e . ) - , p r
l t \ , . . t . r p gm . -
 synernic of endodoitkinfections
complications 151

T a b l el O , 4 r i e A m e f t a n H e a n a s 5 o c i à t i o ô ! r e . ô h m e n d a l j o n s o f l 9 9 T o n a n t i m c r o b i a p r o p h y l a x i s n p a r i e n t s â t m o d e r a t e a n d h i g h r È k o f n l ê . t
(ardilisunderqoing denlallreatment knownlô gve highlevelba.tercmia.

general
standard prophylaxis A d u r s i z , 0 g ; c h i l d r e n : 5 0 m 9 / kb9eofroârleyp1rhc @ d û e
unable
to takeoralmedlGtons a d ù l r s : 2 . 0 g i n t E m 6 0 l a roy,(i M
ô r)r â v e n o B l y ( l v ) i c h l l d r e n : 5 0 m g / k s
lM orlVwlthinl0minbêIore procedurc
orully
Adults:600m$.hldreû:20mg/kq proceduê
l h before

cepha
exin"orcefadroxll" Adùl1s:2
0ç.h drcn:50m9/kg prô.edûe
oGllyI h belore

Ælthromycin
or Ca thomycin Aduft'500û9;chidren:rsmg/kg p@@duÈ
oralyl h berore
A d u t s : 6 0 0 m 9 ; c h i d r e n i 2l V
0mw igt /hki g
n30minbeToreprocedure
unabe
to takeora medications
Aduts:1.0g;chiLdreni
25mg/kg
lMor
procêdure
lVwilhinl0minbelore

" Cephalosporins
ihoud nûtbêurêdin ndivduâ
s wrh immediâte (ê.9.urlkâria,
to peôicilns anqoedema
or ànaphylaxt.
rypehyperensirivlry
ieaclions

Antibiotic fophAlo$is in coîtplolnised hosts far. Root cmal iruhumentation beyond ihe tooth âpex
The aniibiotic prophylâxis reghens of the AHA and should âlways be avoided âJrld any antibioiic proPhy-
BSAC seem to be appropdate for the prevenrion of bac- laxis pdor to penapicâl $rgery should be determined
teremia il1 cancer chemotherâpy patients but might be in consùliation wiih ihe pâtient's physician.
inappropriate in pâtients with suppressed grân loc)-ie An expert pânel of dentists, orthopedic slrrgeoN md
couJrtt(<3500per mm" blood),leukemic pârients or bone infechous disease sp€{ialists recently conclùded that
maûow transplùl palienis. ln the latter caiegory of antibiotic prophylaxis is not rouiinely indicâted for rnost
paiimis more effcciive agents agaiist Gram negâtive dentâl patients wth lotal joint rePlâcements, nor is ii rec-
orgmism are required (40). This is because the oral flora omnended for denial patients with pins, plâtes md
of such immunocompromised patients can be different scres's (1). Antibiotic prophylaxis for the pr€venhon oi
tuom that of norrnal individuals and includes Gram- systemic infections is not recomended in hemodialy
negative bacteriâ (e.9. Klebsiella pneunoniae, Entercbacter sis paticnts, heârt hânsplant patienis or splenectomizeci
cloane, Escherichia col?l that are higNy resistant io dæ patienis, nor to pre\-ent brain abscess (40).
b ê . , rl a . . d m a n t i b i o ù . . . d m i n o g l ) , o . r d e . . \ , r c o m ! , i n Surgical intervention in ân infected area is sometimes
and fluoroquinoienes. The most obvious risk for bone necessary. In addition to ihe risk for bacter€mia, locâ1
marlow irùsplant pâiients with leukemiâ is, howevea spreâd of nicro oigâni-sms will always ocûr and may
septic shock câûsed by viridans sheptococci (a0). Hence, present a dsk for metastatic infection. Yei, surgical
the lâtter authors recommend that dentâl paiients wiih ânhbiotic prophylâxis is only justified in ilrmunocom
low $anulocyte counts should be treâted only on m promised paiients .nd should begin 2h before and
emergency (non-ele.tive) basis. Becâ6e of significant be termjnated when the surgery is finjshed and no
interindividùal difiercnces in the orâ1 microflora of lâter thân 24 .18h âfter the sugery (for reterences, see
immùocompromised patients ând the lack ot con Ref. 40).
holled clinical siudies, andbbii. prcphylaxis in Lhese It needs to be recognized thât in order to achieve â sâi-
patients sholrld be based on microbiological evâluâtlon isfâ.tory dsk benefit ratio any ùse of antibiotic prophy-
d d I n . o l l r b o r d l o n q I l , i } c p d . i c n l. p h ) s i . i a n . laxis mrst take inro consideration the adverse effects of
Patients in need of organ (e.9. heart kidney, li\-er) antibiotic toxi.iiy and a ergy, the selection of rcsistant
hansplantation shouLd have â preiransplmt dentâl micro-orgâdsns, superinteciions md effects on the
evalûation. All required endodontic treaimcnt should microbiâl ecology (40).
be completed in due time pdor to the transplantation
because of the incrcâsed dsk of infection thât these Are the cffirent ttlttibiotic prophylûxis
patients wil1be exposed io due to the immunosuppres- r econrfi efiil ati ons npp r opri &t e ?
sion. Antibiotic prophylans in such pâtients still has m The most important rationale for antibiotic prophylaxis
empincal basc and no guidelines hâve been issuecl so has been to prcveni infective endocarditis because this
152 p! p
Thenecrotic
diseâsecarries high mofbi.liry ând mortalit),. Studies in
expcrimentâl anjmâls hâve indccd demonstrâted that
aliibiotics can pr€vent infcciive endocarditis (16) ân.{
that penicillin is the drug of choice in the câs€ of \'id
dans str€ptococcâlbâctcrcmia. Yet, ihe effecti\-enessof
antibiotics to prev€nt jnfcctive endocarditis in hunans
hâs nol been proven and probably ne\.ef will be b€càuse
it is a rare .liseasednd conLrollcd siudies.ânnot be con
ducted for cthical reâsons (16). In the Shom.t ,?1.(a9)
stud]', a minoritl, (<10%)of the caseshàd received antitri-
otic prophylâxis bùt ihe risk for jnfectlve endocârditis
remâined ihc same regafdless of $4æihcr prophylactic
ântibioiics had been taken or not.
Thelackoffi.m evidence thâtdcnial treaiment is â fre
qùent causc of infective endocarditis, thc report of('ell
documented cases $'here aniibbiic prophylâxls |l.ls
fàiled b prevent lnfectile €ndocarditis (29), the los'
conpliâice wiih lhe current guidelines for antibiotjc
prophylâxis, the ur{avorablc cost benefit and risk
bcncfit relationships and thc isk for selection of anti
btulic resistancehâ\,e initiaicd qualified qu€stions as to
the appropdâtercss of ihe cufrent guidehes for pro,
phtrlaxis against infective endocarditis b€forc dcntal
treatment. It has been proposecl that antibiotic prophy-
laxis should br given onlv to pâtients with prosiheihic
heârt valvcs or pre\.ious histoû ofendocarditis and only
in conjunction with procedures gjfing high-levcl bac-
tcremiâs (extrâctions and gnrgn al suLgef)', includhg
implmt surgefy) (14. However, dcniists shouid con
tinùe hr follor- the 1997AHA guide]nrs ùrtil a re\-ised
document has Lreenissred. Bccauseinfective endocardi
iis ot oral odgh is Dlorc likely ro be due to poor oral
health and hi,giene thù dental tre.tmentfcrsf, pâtients
lvith cârdiàc âbnormaliiies should be encourâged to
majntâin a high lcvel of ofal heÂith (29).
Thesigdficance of thc coniribution of âcute orâl iifec
ûoN ro prostheticjoint nrJectioDslùs been.liscussed lor
yeârs. Th€ currcni view is thât it is Likely thar bac-
teremiâs âssociatcd with sùch nrfections can, and do,
câuse implani infcction. l'hefefore, eliminâtion of thc
source of n ecrion (e.9. endodontic thcrapv or tooth
extra.tDn) is requircd in these paticnts (1).
chronicperiapicalinfectionsas origin
of metastaticinfections
Systemic effectsof chronicdental inïections
Ftom 'oril sepsis'to 'fo.!11illfection'
'Goitl
fUi|gs, gotd caps,Sotdltr idgLs,goltl crcunr, I kd dtli-
turcs,btLiltin, on, ûùd atuu,1.ld)sctiscLl
tecth,formn rietitûblt
nrusotcln af g.'td ûùù a "tass of scpsisto uhich the : is t1t)
psnllel in the Lahalercil)t1of nedicinc ot sùttc t.
tt is thercJoretn,ot
n itnttct oJ te,:thû|d dcntishr, it is û
alLitrryortn t nntter of ecpsisdnd antiscpsis.'
Sir Williùn Hulter, 1861 1937
The belief that n cctcd icctharethecâuseofcertâin s\.S
tcmic discascs (c.9. arthritis) emerged at the begiming
of thc 19th ccnlur\t but ihe notion mây be trâcked back
to âncient Limesand Hippocratcs (39). On the basis ol
his studies of the oral |ricrobiotâ, the American oeno$
W D. Miller drei{ attention to the possibl€ ùrterrelâ
inDship behveen orâl infectiofs and syst€mic .liseases
(3a,35). At the tum of the century the Englishphysicim
W. Hunter intro.tuced the tern oral scpsis. Ii implied
thât in addition to dissemnùûù of bacleria irom the
oral câ\'itlr pârticulârl)' ftom hng-tcrD oral infeciions of
lor! grâde, oral bactcria act specifically ând selecti\.ely
on ditferent târget orgals by libcraiing loxins, therebl
producing âdvefse svsteric eff€cts (41). Accordmg to
Hrnter's tlrcor\t thc moulh s.âs the most importa.t
septic focus and oral scpsis ihe most common source of
sepsis.Hc allcgcd ihar conservàij\.e dentistry wâs s\'1l
orryùous ('ith septic dentistry.
hr l912theAmericanphvsicianF. B ljt1gsreplaced thc
lerm oràlsepsis with localinfeciion (39,41).Focal infec'
tion occurs when micro olgânisms dissem atc from a
locàlized areâ of nlfection (focus of hfc.tion) and csiab-
lish theDselres elsewhere h the bodv âs â secondary
infection. \ n]cn aloral irJ€ciion is the sou.ce of focâl
infection, the terù oral focal fiJcction is used. Dental
focill infeciion implies thât ân infectcd kxnh is ihe focus.
Figûre 10.2 shows hoù'dental ûrfection $'as once
thoùght io bc rcsponsible for dental sepsis and vadous
corulcctcd sysiemic conditions. Common to these con
diii(rrs, at ihal iiDe, vâs thât no câuse oiher thân oft1
Fig.10.2 A.coldngto lhedentalfo.àinlediontheory,
a varietyolsynemi(
affednqthe brân,êyet ung,heâd,liver,joinrsandrhe sklnaE
diseases
causedby dentalsepsis,involvingdjrsemiûatôn
oT bacteraand bàcreràl
producrs
fromchronnperiapca andmarqjnalpeôdonrits.
 Synemkcomplkations
of endodontlc
lnfectiofs 153

local infection could be found. Therefore,e\.en the products, pârticrilârly lipopolysacchârides md pro-
extaction of healthy teeth becamejustified to prevent inflamaiory .ytokines, hduced locâlly in responsc to
systemicinfections and diseases.As a consequence, oral infections, enicr the bloodstreâm ànd may subse-
endodontic therapy nearly disappeâred in the USA for quently activaie systemic rcsponsesil1 certain suscepti-
many years (11).Fel1owcolleagueseven naintainecl that ble individuals. Ii is not yet knor,{n whether these
dentists who performed root cânâl tlrcrâpy shoûld be rclationships are causal or consegùentiâL
consider€d criminals ând b€ sentenced to 6 months ot
hard laboul (41).Latea the true etiology of many of the Deliberations iî rccent Vedrs
infeciious condilions thât were associaieda'ith oral fo.i Spurcd by epidemiological findings in lâr8e paticnt
was dischsed. It becameobvious that over ihe yêars populations, a renewed interest has emerged jn rcccnt
mmy healihy tceih lÉd bec'n rcmoved for no good years on tle role of ctuonic orâl infections in certain sys-
reason.The dentalfocal infectiontheorythereforegrad- temic diseâsessù.h as coro11a1y heart diseâse.Data from
uallylost its influence.Howeverowingto the continued Finland, for example, havc demonsirated â significant
r€leaseof new casereportswith clâimsthat pâtientshad âssociationin male paticnts to dental infections (31, 32,
beencured for arth.ritisor other chronicdiseasesafter 47) and primarily 1o periodontal disease(21). Evidence
exhâction of their infected or root filled teeth, and in f r J r l l _ el i . e r J . r r r eJ . ô . u 8 g e - l - l l u | h ê t \ ' , \ â r ' â \ . o . i
spiteof lackofscienuËcer.idence, the dentâlfocâ1infec- àtion between sel.ercpcdodontâl infections ând sponta-
neous preterm birth (52). It ls now believed thât systcmic
inflâûmations have common bnnogical higgering
Potential nechanisns by Tohicho chro ic mechanisms (lL 10, lL-6, TNF-.I, PGE2) and that they
inflammatory periopicol lesio may occû more frcquently in individuals wiih hypcrinflam-
cdusendoerse syster ic effects maiory monocyte phenotype (MO+) than in individuals
The denial focal inJection theory acquired a new dimcn- with normal monocyte pherotype. The inonocytes ot
sion when immùopaihological mechmisms wcre the former phenotype secrete three to tenfold greaier
addedto disseminatedbacteriaand microbiâltoxins as amounts of ihese mcdiaiors in response to lipopotysac-
causativefactorsof systemicdiseâses(Fjg.10.3).Receni chârides ihan tlrcsc of dÈ normâl monoqae phenotype
data sùggesi that c]ùonic subclinical infeciioff (c.9. (6, A. Demonstration of DNA îrcm Actnobacillusûctil1o-
chronic pedodontal inJections), as indicated by râised tLtyo:tenænitins, Poryhyrcnaùnsgingimlis aÀ PtclJotelL:L
val!eswithin the normalrângeofC reactiveprotein(33) i tffmeàia it âtheromas shongly indicates â role for
and other acutephase proteins (53), may induce these orâl bacteriâ Lr athemsclerosis(6). Although they
systemic hîainmâtion leading to such conditions as âre known âs pedodontal pâthogens, ihey arc also in-
athelos.lerosis, cardiovasculârdisease,.erebrovascûlar volved in endodontic infections. Activated macrophages
diseâse or preierm low-bnihweight d€h,ery. These in pedâpical hfections produce the pro-iniammatory
observâtionslÉve led to a paradigm shift in olir irjtder cytokines (IL-lÊ and TNF o) (38). uhether ihcrc is
.rdrding ui lhe pdil-ôbrôlo$ ol lher'.ompl, ' d*.. d-
a rclatioNlip beiween the MO+ onocyte phenoiwe,
tions. It is no( rcalized ihat oral bacieria .nd i]rcir chronic pedapical infection and syslemic inflammation
is cllrently not known (37). The labsr revie$' papers
concernnrg possible relationships between periodonial
discase,tooû loss ârld câfdiovâsculâr diseâseconclùdc
that therc is no such scientific evidence ioday, and that
the previously demonsirâted pedodontitissystemjc
disease associations arc, in part, confor.mded by
smoking.

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27. l r . t l . r W . \ 4 . l - ' ôn. D \ < r n - o 'n a r " g . . a . -
ô r ' ' . r l " r i ô r -b . r r ' ' , ) , l i | p r . p ,l " i . {IF
vention of eidô.àrditis. British Sôciety foi Antirni.robiàL
Clrcoothcraty Endocaditis WbrknrgParç lj,d, 1997,
350:1100.
2E. LockhartPB. ^n analysisof bactcrcmiasdlring denral
extractions. Arcft.Irt. M.d. 1996,156:513-20.
29, Lockhart PB. Th€ risk for cndo.irditis in d.ntil practicc.
Pùiodottalagy20002000)23: 127-35.
30. Lofùus iE, Waki MY Iolko\-sky DI-, Otono'Corgcl J,
N ' h n , " \ . I F n n r e T B ' . l . n n l o l l o rl e . r b e r e-
v.l itrig.tion and scaling..d root plâning.L Pùrrdo,rrl.
L99l, 62: 642 , .
31. MattilaK,Ni.nin.nMS,Voltoncn W RâsivqKàsanlcml
Y,Sy4àlàST.,rl"1.Associâtionbeh{eendenlalhÊâllhând
acùtenryocârdialinfectior.Bf, Mat1. J.I989i 29a:779m.
D.sigrcda.unùlatiu s.ôrcsttsLcn based rryn th. rrnlaa al
cariôus ksiaÆ,th. rttmt aJtdiadarlil to.ketj|9, th. trer.ace
ird nrgûi1rdeafpiatinl lesio$dndLtur.s.n...r abs.nc?
olp.d.aturiLÈlor conrlationto rorcna\lheûrtdiseûse.
32. Mattila KJ, Vùrtoncn Va, Nicùlncn M, Huttunen JK.
Dêntal inlecLionând the .isk of rc( corùary Êr'entsl
prcspectivesûdy of patientswith docuûented.oroturry
rrtcry discrsc.Clnr.tu/.,r1.DN. 1995,20:aE892.
33. MendallM, PatetP,BallâmL, StrachanD, NorthJiel.lT. C
rÊâctive protuû ùd it! relatiôn to cardiôvas.ulâr i*
fa.brs: a popùlatnmbasedcrossse.bnal sh,dy'Ër r\4td.
i. 1996;312 1 :0 6 15 .
14. Miller UID. The hùnan mouth as a fr).G of inl'ection
D.,i. C,st os I891r33:689 95.
35. MillÊr wD. flr. M;c/. ./gdriri$ ilt theHrnû,t MDtth Ihe
La.al antl ç.nù.1 Disesseswhich ar. Cnr\td b! Thrù1.
Phnad€lphia, PA: S. S.White,:1890;274 3!l:1.
16, Miûoz O, Kaifl A, Me.cai ^, CosscronM, falissârdB,
ta.ke. r., cr al. Chlùhexidine compâred s'ith providone
iodnr assknl prepdation bef.ùeblood a hùe. A rùdot
ized,controlledtrial. Arr. l tetn.Med 1999jI3I:831 7.
37. Mlrrray CA, sâLm.lersWP Root cânal t.eâtnent ùd
generalhealthi a reriew of the litÊratu.e.l,r Erdddotr.
/. 2000;33::L 18.
Nair fNR. Apical pertudontitis:â dynmic encôunter
beh{eenroot canalnrlectionand host.esFonse. P.ttorio,
tù|ùitvaAAA1997, 13:L2L4A.

39 O'ReiIy PC, Clâffey NM. A history of ocl seps,sâs a
câuseof diseâse.P.todortolùEy 20002004)2311,3-78.
40 PaIæ.h TJ, Slots I. Antibiotic prophyhns md the med-
i.llly .ompromiæd pàtidt . Ptiadafltalagy 2AAA7996i 10:
107 38.
D ' , , t i b . , t st 4 " p , : t t , p t . a l , n b : a t , p
, nplJa' . | . ,,ns
bactftnliû, discussingraiaus aspectsal nfecti"e cndacdlitis,
iaclutlirg dettist antl phlsici'n .anpliance, dnil indi.ûting
pmpet usc aI anfibiDti. ptùphyktis in prtit,lts ûith sdetl!
inpit d Fsistahceto inf.ctians.
41. Palla{h Tl. Thefocalinfectjontheory:appraisalând reap
praisal.Cal'l Ddl. Asso../.2000,2E:194200.
42. Reidrddt R, Bolton & mava G. Effeci of non ste.ile
versus steiile wàter iriigation with ûltrasonic scaljnt ind
postoperative bâcteremias.J. Ptiadantal. l9a?i a3:96-9.
,13. Ralù R, Shah PM, scâfer V Frenkel G, Seibold K.
Bakteriëmie nach chirurgish endodontischen Ejngritren.
zWR 198296:903-7.
RobertsGL Hoizel HS, Suy MR, Simmôns NA, Gddnel
q Longhurst P Dental bacteremiâin children. Pcdt,rx
CardioL1997j 78: 24-7.
RobÊrts,GJ, Simmons NB, Lon8hat P, Hewitt PB. Bâc
teremiafollowing local anest|eticinjectionsin .hildÊn.
Br. Dent.l. \998;\85:295â.
Sconyers IR, Cra$'tord ll, Moriarty ID. Relationship 01
bacleremia10loothbrushjngin patientswith pe.iodonti
ns.J.An. Ddt. Assac.\973j87:61622.
SeymourRA,StælelG.Is t|e.e â link belaveen
tâ1diseæeand coronaryheâIt diseasê?
184:33 {.
Synem
ic complications infectiôns
of endodontk 155
48. Stdkèbàm M, DracN D Beeson P Thè 'ii.ubâdon
periôd' ôf ba.terial endocardjtis. YnleJ. Biô|.Med. 1977' 5Ol
49 58.
49 Strom BL, Abtut_vnE, Bedin IA, Kinnân JL, Seldmd RS,
Skrley PD, .t al. Dotal md cardiac risk factors for inJè.
tive èndo.àrditis. Apopulation-baæd, ca<onhll study.
Ann. Intetfl. Med. 1998; 129.76\-9.
ThispaprlrtioÈbaæd,.aiHantrol strdll cahclades thrt .lmtrl
ttihnèrL sems nùt tô bed tilk fuctot fat infectiv. mdacar.il
ti!, euh ih pitieîtr uith ulrrlat abnonnlities. convqwttly,
th! I'oliciest'at a tibiotic ptophykris in sù.h pdtièntsshotld be
Tunl@l AR, Mmdell CL. Infecling micro orgdisms. In:
lnfectiae Endôcarditis.(Kaye D ed.). New York Râvd
Prêss,199185 97.
5 t . Wdn MI. Myths oI dcntal-induced endocâditis. Coltp.
Cont.Etllc. Dent.I99q 75.]1AA-\\9.
52. Williams CECS, Davenporl ES, Steûe IAC,
Sivapathasundaram v, Ieamè lM, Cùtis MA. Mecna-
nism of risk ii preterm low-birthweight infmts P,r;
ôdantalo*/ 2AAA20OO) 23: 142 54.
53. Williams RC, Offenbacher S. Pèriodôntâ] medi.ine thc
energoce of a new branch of pènôdontology. Pel,oddr-
talô.y 20002040)23: 9-12.
Yohessi OL Walker Dl4 Ellis q Dwyer DE. lâtâl Stoply
lo.occrsarrrs inf(t,ve endoca.ditis. The dèntâl implicà-
Tion. Ad Sutg.EndodMt.1998, 85:168 72.
penodon
Bl Dctl. l. 199E,
C h a p t e r1 1
Treatmentof the necroticpulp
Paul Wesselinkand Cunnnr Bergenholtz

lntroduction also demands thàt âny |adiographic evidcnce of apicâl

periodoniitis thàt exjsted prior b trcatment shot d
This chaptcr dctails the procedùres €mployed to carry resoh-cand result in complete reorgan izarion of ilt pe|i-
out coiservatile root câl1âltherâpy (RCT) of teeth û'ith apical tissue (Fig. 11.3).
necrotic pulps. Thetreâtment maybe performed rcgard-
lcss of whthcr tlrc root canal system is hfected or Historicalperspective
noi. If noi infccted, thc rationale for d1e tfeâûnent is
Oler the years, different approach€s to combât
to prevent microbial colonization and multipli.ation n1
endodontic infections hâv€ been in \.ogue.In ihc b€gin-
the pulpal space and subseqlrent symptomaiic or non-
ning of lhe last cciliury, fol1o\^'ingthe disco\-ery of ihc
syinptomtrtic presentationsof apical periodontiiis (4, 46)
role that bacieria play in diseàse processesin general
(Chapter 9).In mostinstÂnces, hoa'ever,ltCT is curative
and apical perbdontitis il1 pârticulâa emphasis was
ând initiâted to eliminâte â root canâl jnfection, ther€by
plâced on the use of strong antiseptics.Such agentswere
remedying periapical hJlâmmâtortr tisslre lesions (Fig.
phenol deri\.âii\-es ald their nnxtures, e.8. methylacre-
ll.1a, b). Tleatment is also essentiâlto impede the spread
svla.ctatc and camphorâtecl monochlorophenol, and
of root cmal bacteria to distant orgdÉ (Chapter 10).
fomaldehyde and its derivativcs, e.g. foûnocresol and
^lihoùgh cxtraction of the tooth in question solves the
pârâformaldehyde (10). Aniiscpiic âgents were to be
inJection problem, it is a radicâl plocedurc not usually
administered either to the orificc or to dæ nltenor or roo!
âcceptâbleto pâiients. Thus RCT offc$ a rcalistic âlter
canah h pâst€ or liquid foln1. By evaporaiion, bâctedal
nâti\-e, pro\.ided thât the tooth is resiorablc. Hence,
organisms wouldbe ki11edt-ithour â cleaning procedure
if properllr conducted, ltCT of teelh a.ith nfccted
or filling of the root cânal system (53).In yer oi]tr modes
pulp necrosis enjoys a hish rale of success a1d can
of treatmcnt strong ânhseptics werc combincd with
b€ expected to result in compLete resolution of apical
mechanical irÉLrumentâtion, followed by filling the
periodontitis in four out of five cases(22,43).
hstrumented cân,rl(s)wlth à paste .ontaining a strong
;ntiseptic àgent. Bv in orporating antisepticsin the root
fillirg mâterial, it was felt thât where bàcteria $.erc noi
obiectivesand general
killed by thc inbacânâl procedl're a continuous rcleas€
treatment strategies of antiseptic woùld prevent sûrvi\.al irnd regroa'th
of the remaining organisms. Indeed, snch treatment
Thc overall objective of RCT is to exclude the root canal
âpproaches gained gieai popùlarity and âre practisecl
. ) . . ' m J . J - ù u r . . , f b d .r ' r i . , l" . p u - r ê ù f t h eo g a n i - m
even to.lay jn mâny countdcs. However, the use oi
Tlrcrcforc a prhary iask includes efforts to rid bàcteria
shong antisepticsin efdodoniics €niails sev€ral seriolls
resideni in the root cmal sysicm (Fig. 11.2a d).Asecond
charge is to provide measures to €nsure thàt root canal
infection will not recur The procedrrc includes several (1) Alt]ûùgh they âfe eflectivc against nicrobes,
phâses, of $'hich cleâning a.ith root canal instruments strong ântiseptics caùsc substântiâl cell and hssue
(Châprer 13) and disinfection arc cdtical. To prevent damage, particr arly if behg exhuded to the peri
reinfection, a filling js sulrsequentlyplaced jn ihe inshu- âpicàl tissue en\'ironment(45) (sccâ1soChâpter u).
menied root cânâl(s) (Fig. 11.1b). (2) Thcs€ dishJectànts, also in dilùted form, have ihe
If successtully conducred, t€eth with cljnicaL symp- disad\,ântâge of sensibilization and h)'pcrseisitiv
tons of apical periodontitis (tendemess,Fain, swelling, iiy responses (Chapter l7). Some chcmicals even
IisLulae)becone non-symptomâtic. Sùccessfulheatment cart' car.inogenic dnd mutagenjc risks (24).
156
 Treatment pulp
ofthe necrotic 157

Fig.11.1 Thereasonfor.arryin!,oul root cana therapys eitherFevêntveôr.ûallve. RâdioEaph(a) showsa ôwersêcondmolarwith peiapi.aL
an infededpup necrôsis
fâdolu.en.yaso.iaredwlh borhroob,indicaiinq ândapi.a periodontitis. (b)shôwsthepetmânenïy
Radiograph filledroolcaoàLs
tolowlnqroolcanâtherapy.

F i g . ' 1 1 . 2( a ) A n e x t r a c l e d t o o l h w r h a t t a c h e d i n f a m m a r o i y s o f t t $ u e l e l l o n . 0 n û a . k i n l l t h e l o o t h o p e n ( b ) a nodrôkb, sd ê) û
nnt hget h
( aêni nntneg
eleclonm aoscope, various foms of bacteralmorphotypês maybeldêntifedonlhe rootcanalwalls, incuding{iâmenttspirocheles, rodsandcocci. rlriskindof
infection isthetarlletforrootana thqapy.Fisrs (b) (d)dê lrômMovenéit. (27)andpublÈhed wilhpe.mission ôTMùnkgaad (coun6yof Dr0. Môven.)
158
(3) In Iiquid foms, chemicals are rapidly inactivated
by iniammatory endat€ and therefore provide
antibacterial etrecis only of a short duratior! thus
becoming inactive within hours or a few days (13).
(4) Antiseptics included in root filing materiâls can
.atse tjssùe i itation and they eventua y lose then
âniibacteriâl activity (17). If canâls were improperly
filed ând/or poorly sealed coronally, infection can
In rccent decades the teâiment sûategy for necrotic ancl
inJected pulps has changed in the move to find melhods
that are biocompatible. Thoroligh biomechanical instn-
mentation wiih the use of minimaly toxic ând allergenic
disinJecimis is now emphâsized âl1d will be detailed
Fig,ll.3 A series of radioEaphs demonsùating
the successfuloutcome of rcot 6nâl therêpyln a
.lowêrin.isor{à)A.oot@nalinslrument pacedin
the .anal,whichk usedto cleânihe cânâland
determinethe engthof inslrumenialion in rclaiion
to rhêÉdiographi. apex. Notetheapkal.adiolu-
âpi.apeiodontitis.
.eô.y,indi.aling (b)ïheinslru,
mented cnalhasreeived a slightyoverextended
rcorlilliig.k)A.adlosGph taken2y&E lalei(d)
RadioEâph râk€n6 yeâtslater, showing complete
resouùonoTihe prcviôos hsior.IherÔôrhnow
reslson â hêâlthypêriodortiûn âtd rhercareno
symptoms (tendemesr pain,swellings) lqg6ting
ongoing rootcanalinfeclion.
Schemefor a routine procedurein RCT
To a€hievean optimâl fesult, severalcritical stepsin RCT
(1) Assessing,prior to trۉtment the technical diffi-
culties i1ùt may be encounteredduring ih€ proce-
dure in terms of being able to negotiaie the c.ml
anatomy(seeChapter13).
(2) Opening ihe iooth io be teated in order to lo€al
ize all canals,so{alled âccessopening preparation
(Fis.11.4â).
(3) Providing an aseptic field of operation (Fig.
11.4b).
(4) Ca ying out mechadcâl iruhumentation of the
canâl intedor (Figs 11.3a,11.4l:).
 of the nerctk pulp
Treatment 159

procedûre
Fig,l1,4 A rourine for.ombâtng in root@naltheÊpyjnvoves
infedlon severaimpor
(b)
tanlneps:{a)acc6sro rhêrôôtGnaLsynem; rubber damisolatlônânddisinfect
onik) biome
chankalprepararion;
(d) iûigationj dre$insi(I) temporary
(e)anlimicrobial renodionbetween
appointmenti(g)rôôicanafiling.
160 pu p
Thenecrotic
(5) Irrigating thc cmal system to remove debris ând
pro\-ide chemical disinlectjon (l-ig. u.4d).
(6) Plâcing ân antimicrobial dressing until the next
âppointment (FiS. 11.4e).
(7) Closing the root canÀ1system between appoint
ments (Fig. 11.4f).
(8) Assessingthe fesult of the initial treâhn€nt.
(9) Carrying out root canal filling (Figs 11.1b, 11.3b,
11.4S).
(10) Recalling the patieit in 6-12 monils io assess
long term outcome (Fig. 11.3c,d).
Access opening (Fig. 11.,1â)
Once a dccision for ircaimenthas been taken alrd the dif
ficulties assessedâs to the presence of canàl obstacles,
length of canals and extent of curvâtures, an access
opening sholrldbe pr€pared. Thc purposc of such a siep
is to uncover â11the canal orifices present to be able to
carrv oul an unobstructed mechânica1prcpàràtion o{
each root canÂl (see further Châpter 13). It is often
advantageous to enter the tooth intcior pnor to thc
placement of a rbber dam to rcducc the risk of gonrg
in the wrcng dnectior and causc a perforaiion to the
pedodontal Ligâm.'ntspace.Alig ngthedirection ofthe
bur to the loùg axis of the iooth facilitâtes the p roced u fe.
This is pârticulârly important in ihc tecth of elderly
patienls, where the pulpal châmber often is redùced l,y
pulpal mineralizations and is then difficult to find.
Aseptictechnique(Fig.11.4b)
Even though teeth with necrotic pulps most oficn arc
infected,RCT requires an âseptic teclmique of opcratnù.
Asepsis is mâintân1ed first of all b cxclude contami-
nâtion with orgânisms that hâve greater resistare to
ircatment lhan members of the root câfâl miclobiotâ.
Common contamjDants, difficull to manage, belon8 to
the fàcultâtive Grâm-positivc scgnc.nt, mosi notably
enterococci.But other €nteicbactcria and yeastsmay be
broùdrt hio thc canal system dùe to the fa ilu re to main
iain proper asepsis. Other sources of contâ inating
orgmisms are along leâky te porary restorâtions
applied behveen sessionsand Lrylۉving canals open to
ihe oral câvity for drainage (4i, s1). Therefol€ eliminâ
tion of micro-organisms from root canÀls nâturally
reqdles the prevotion of oral contamhâtion. As stâted
in Chapter 6, procedures in this context includ€ rcrùoval
of plaque ând calcuius, .lefective f lnrgs ard crorvns
and cârious dentine pdor to Lhc iniiiaiion of treatment.
For fie stbsequc'nt RCI proper rubber dâm âpplicarion
is indispensablc and also ihe use of sterile bùrs and
M e c h a n i c a l i n s t r u m e n t a t i o n ( F i g -1 1 . 4 c )
Clcaning thc calal intcdor ù ith lÉnd and roiary iishu-
ments is a mosi important iool b rcmovc lhe majorbùlk
of ihc inJeciing bacicrial nass ald iis nubitional supply.
The instrumentaiion, if possiblc, should bc camed out
throughout the entire exlension of each root canal ed
ideally end ai its cxii or slightly short of the apical
folamen. The procedure âims to:
. Physically rcmovc as much as possiblc of thc bacie-
. Remove sources of substrâte for bacterial regroa'th
ând multiplicâtion, includjng necrotic trssue and
tissûe brcakdown products.
. Remove the in|er portion of the root cânal rvâlls,
\^'here dentine is most heâvi1y hfected.
. Provide access lor ifligâtion solutions to âll pàrts
of ilt rooi cmal sysi.m for .lcanng md chemical
. Create a cleân âl11dproperl'' shâp€d cânal thàt fâcil
itatcs ihc inscriion of â well-seâ]n1groot filling.
T\' J, i.r.'. d|,rJ Jr. \or ùr \ d. m\'o-
orgdnsùs locaicd in the main canal(s) (Fig. 11.2) but
ihey s'ill also enter any spacc and ramificaihn availablc
to them, including dentinal tubulcs (33), isthmuscs and
latcral canals (Fig. 11.5).This makes dÈ cleârnng .nd
disinfection procedûrc precarlous âswellas demànding.
ln thiscontext itneedstobe L€cognizedihatcrevices and
lateral âreâs of oval-shâped cânals (Fig. 11.5) are espc-
cially difficult to reâch. If untouched by the instru nents,
boih substrate ând bâctedâ1 organisms mày renam in
such 1ocâtions and if .Io$'ed â pàthway to the àpica1
envirolrment a fâi1ure may ensue. In fâct, stùdies exam
i ng the cxtent to which root canâls âre rendered cleân
âfter instrumentation ofien find remnants of necrotic
tissùe ând debris on the cânâl i\'âlls, especially in o\.âl-
slùpcd canals (56). Bactcria lodged in deniinâl tubules
Narrow, partiâlly blocked cânâls ând cânais in sev
erely curved roots fufiher complicaie thc insirumùta-
tion procedure (Fig. ll.6a,b)- Inslrumentâtion is also a
demanding râsk a.here canâls âre extremely wide, e.g.
intolrng irn mâtu L€teeth (Fig. 11.6c).One reason for this
is thàt the ârmâmeftârjum normâlly is designed for
teeth a'ith complete root development. Anolher is that
insimnùlation in such cases has io be Limited owing to
the âlrcâdl thin loot structure. Thereforc, the combat
of hJ€ction in srch root cânàls hàs to rely morc on
chemical dishJectiorl and p1ope1 loot filling thâl1 the
mechanical insirumc.ntaiion pu' se. Howcvcr, thc fill-
ing of incompl€tely devclopcd roois, duc b thc open
forder! is a fomidablc task and it is oficn not possiblc
 Treatnreni pulp
of ihe necrotic 161

Coreconceptll.1

Workingengths a termusedforlhe enqthol me.hâni.ànstru

mentatonn reâtionto theanâtom ca apexin a gi!€nroot.anal.
Two methodsara currentyin use to det€rmine this length:
ràdogEphcdse$nrentby nsêrtinq a tfla file ntothe.analto
t h e v i . i n l y o J t h e : p e x G e1e1F3gà )a;n du sn 9a ne e c t r oc n

Fiq.11.5 Cr!$ se.lôna .ut rhrorgha roor.ana party fi ed w th guna

pè|.hâ.Notelhè!ûtlLedâûâ dretrioB (aftowhùdsl,wh.h mayprôvde
coreconcept
11,2
spa(efor baderal!lrowthaM leakaqeoJbererâ eLenents lo the perâpi
overextens with RCIis ê
on of tlreapl.a foràm€nn conjundon
serouscompcationbecaùse:
. Bê.tera organrnsand nrededdebrismaybeextruded ntô
the perapl.atissueandcâ6e â lare up of a non.painful
t o à t t à i n . n à c c e p t a b l er e s l l t ù n l e s s a n i l p i c d l b l o c k i s esion, :gqravâle a panfu esionand/or perpetuate apicaperi
o d o n t l tosna l o n gt e r mb a s s
Yet, the instrumentation procedrire is â Hghll impor . ll mayresut n enhân@d nutritonalsupplyof anyremanin!
tânt Phase of RCT. Bt cnlarging and prcparing cdrls orqanisns ândboosttheirgroMhto .aus€endodontc 1àre
Jnd givfig ihcn shapc for acccsshr chcmical disinicc- up!and/orlonqtermfêilure.
r . . . r d I r , . 1. ..rbJlt.'I' . lt enhânces thersk or overf ng.
. Thepotenl:lto.ârryoutâ perman€nt rootT ng,whkrrs€aB
bnna is phvsically .emoved (5 8). Th€reiore rhe trme
t h êa p c â l p o r t iboand e r a l t q hol ,f t € ns i m p a i r e d .
spcnt in clcaning and shaping rool canals accordint
to ùe prficiples dcscribcd in Chapicr 13 is tr€l]

Col1si iletutiotls ift ro uti1|e cflses
Tl-- i 1 m . r t d o r . . . l r i t r F r ' o , , r ' r ' r .1 - i r
$hen the càl1àlârLâiom) is within â fâiriy norùràl rànge
jn t€rms of {idth, length and cur!âture (Fig. 11.1),is
no .{iffefent to thât cârried ort in coûrmction rvith pr
pectoù_v-(Chaptcr 6). Yci, lltrc arc ccrtain prccallLions
thni n€ed to be ùnderiàken to dlojd primàrih tlrree
( l ) B l o c k i n gt h e c a n . l p a t € n c \ .
( 2 ) C à u s i n ga n e n . l o d o n t i cf l . r e ! , f , .
(3) t\'erext€ndingtheapicâ1foràmen.
Block"rg th! cnnal falen.! cân occur bv frâcturing ân
ûrstrumeno t r b v c â u s i n gà l e d g e .B o t hc o m p l i c à t i o n â
s rc
p â r t j c u l . r l v c o ù m o n j n n a r f o ! v a f d c ! r v e d c a n â l sa n c l
.re often the resu t of improper t€chnique. altrviousl}',
eff€cti\.e rcmoral (]1 the infecting microbiot. is ham
pere.t bl, such errors, thcrcforc it is importani ùat
the jnsh'rirnentàtiorLprocedure follo\rs à \r€ll proven
schem€ of steFs (seefurther Chàpter 13).
To rc.luce tl1crisk ofcaushg an .r'loddrrl,.lrl. ,t and
oac'.rttnsiait oJ thc apittllorr,,!r, propcr dclcrmùrarron
oi thc lcngdl of nstruncniatn)n h{orkin8 lcngth)carrics
spccial imporiancc n RCT (Corc conccpi ll.l). This
mcasure is undcrtakcn pdmàrilf to ensûr€ th,rt the
€ntjrc length ofeâch cânâl is ircatcd, if possible.lf n1stn1
]nentâtion ls cailied out too shori, sutrslantial amounts
of bâcterjdl o|gânisms mày be leil bchind and continue
o J . r . . . ' p , . t p , . l o rl r r - . T , . 1 , .l d' - r - " ..iur
cause of fàilùre nr RCT (22,.$).
Câreful working length dctcrminaiion is also ùn
portant to prc\.crl instrrimentation belotd the àpical
foranen, other{ise ,r set ol conrplicâtions mav cnsuc
(Core concept ll.2). One compljcation relaics nr thc isk
of cxirudhg bâcterià ând infected dentine d.bds jrllo
thc pcriapicat tissuc. If especiàll) \.irlrleft, such ofgàn-
isms m.r,v aggravaic a periapicâ1 inflârnnatofy condi
tion and causc ilt dcvclopment of pâinfûl s,vmptoms,
including ân apical absccss (cndodontic flâr€ up).
Fxtiarded inaected dcbris mal' also pe+rehùt€ âpicâL
periodontiiis, dcspitc complete elirnination of bâcteriàl
organisrns in ih€ cânnl svstem p./ s3.
Overnlstrlmentâtion ilso cxtcnds ihc apical forà
1l]en .nd promotes entry to the canal of hflamrnàtor)
cxrldâte. O ing to its content ot serun p(ncins, tlt
growth of proteol)'tic org.nisns is likel! to be boosted.
This lalicr mcchanism mar- àlso t€a.l to an endodoniic
162 pulp
llrenecrotic

Fig.11.6 ExamplesoJcalsdkplayingva.lousdegreesof dif

Tkulty:(a)apartallyblo.kencnaldue to prdiousmineraliza_
lon procesesin the pulp; (b) à tooth with severlycuryedrool
canalanatomy, the mesialroo! (c) â tooth with
espe.iàlly
incomphte rootdêvelopmeôï (d)a supemuûêrary toothwlth
a dens ,vagratûr fusedto lhe pemaneni incisot (e) buc@l
spect (i linsualasped. F.lowinglnstunenlâiionandllling
only(9),lheperiapl@lesionrcsoived
ofthe invasinatlon (h)
Thetoothresponded lo àn eLedric pulpteît andcold,indi
6tlnq rhatthê ôtherponionhada vùalpùlp.

Another grave complicâtion of overpreparâtion is so
called apical zipping (Chapter 13). This is when the
cânal orifice hâs beel1 noi only enlarged bui also trans-
ported h â laterâl direction. Similar kr an jn ompleiely
developed root, such canâls are extremely difficult io fi]l
properly. Except for dÈ risk of overfiling, often ihe root
filling is rûâble to piovide an apical scal (55). In facL
unfilled spâces (pockets) often remain along the apical
portion of the rooi filling, where bâcteriâ may contin e
to groit and maintain apical periodontitis (29).
Coltttoqing paiî d ting instranentatiotl
Usùally trealment of a necrotic pulp does not rcquire
anesihesiâ. However, even in the presence of â radioh-
cency, functional sensory nelve fibers mây prevail in tlrc
àpicâl portion of the cànâl (25). On.e canâl irÉhuments
iouch these fibers, â pain response is idtiated. Th11s,for
coûpletion of heahnent, mcsthesia may be required.
Some patients may âllow the necessâry instmentation
a'ithout anesthesia, but this should not be condùcted
unless complete agreement with ihe patient has been
sought. Usliâlly âfter instrumentaiion with one or two
file sizes, pain is gone.
It should be recognized ihat a pain response during
instnmùtaiion of a neciotic pulp mây indicâte that the
formen has been inadvertently pierced and that the
working length should be reassessed. This shoùld be
cùried out in spite of whât appears to be a con€ctly
rccorded working length. Distinction between nerve
fibe. remânts and overprepârâtion is not âlways
obvious and to ensûrc proper length of instrmentahon
(1) Take a conrrol radiograph under a 20'distâl or
mesial angle with a fi]e in plâce to obtâin â good
image of the buccal or linguâl âspect of fte root
(such a radiograph shows more cleafly than an
orthogonal pictlû€ iJ the tip of dÉ file extc'nds into
the periodontium).
(2) Carry out additionâl electricâl measûr€ments.
(3) Insert paper points to the prcsumed working lengrh
and observe s,hether moisrure (bleeding or exuda-
tion) is pick€d ùp.
Hence, because of the sometimes-deviani exit of the
apicâl foramen into the periodontiûïr, it is advalta-
geous io cârry out RCT in the absence of ânesthesia
because ihis draws aitoiion 1o ihe risk of o\.erinstlu-
menting the canâI. How€ver, ihe comfori of the paiieni
should be given the highest prioniy.
lrrigationand chemicaldisinfection(Fig.11.4d)
Medrânicâl inshumentation of root canals needs to be
supportcd by frequent irrigation. Therc arc severâl
of the necrotkpulp
Tr€atment 163
importalt pûr?oses of such a measure, primarily to
clean oùt debds and dentinal shâvhgs âJrtd to keep
cmals moist so that irÉLruments can be run smooiNy. It
is also considered cdii.al that tlrc iÛigating sohtion
excris antibacieial cffects. Such a view is supported by
clinical lrials where baciena frequc.nily wcre rtcovered
from teeih ireaied with mechaical imhumentaiion ând
$,aFr nrigaiion âlone (5). To au$nent ihe efficacy of the
lnstrumentaUon procedure, ân irri8aling solulion for
rootcanals should alsobe able to dissolve necroiic hssue
rcmnânts, especiâlty in areâs where mechanical insiru-
mentâtion cannot feâch, includins crevices, invagina'
tio11s and accessory canâls. Low rfâce tension is
thereby â desiral,le quality becaùse it promotes the flow
of tluid into such âreâs. To be able to dissolve Lhe smear
layer is yet another desùable property. Finalt ihe âgent
should câuse minimal tis$re damage and thus be mini
mlly reâctive in câse it is exhuded inio ihe periapical
tissue envirorÙenL However, câre should be taken
when using iraigants in order to prevent complications
arising from iheir extrusion beyond ihe apical forâmen
(Clinical procedure 11.1).
A ftrmber of irrigating solutions are avÂilâb]e, bui
none can be sâid to satjsry these requiremenls- There-
fore, during RCT h^'o or morc âgents may be combined.
11.1 Prevention
ClinicalDrocedure andtreâtment
ol complications
dueto extrusion of irrigating
solutionsbeyondthe apicalforamen
(0.4mm)and
. Usea small-diam€ler
needle inÉftnolongerthan
2 mmsho.roI thewo.kinqlenqth.Apply a rubb€fnop on the
needlefor lengthcomrcl.
. Ensurethatthe needl€
is nev€rlockedintothecana,
. U.e o F,ce'sivepess-reto flowthefl-id on o'lLlesu nqe.
. pêinresponse,
mmediate whkhmayor mâynotbefollowed
. Withlna few hourserrensive
swelling
mayorur in lip and
. Aft€rsomedayslheremaybe an exlË-orahematoma
and
someoc softtisae necrosis.
Treatment
of severesequelae
. Administernronganalg€sics. Locaanestheticmaybeadmin
isteredbut no vasoconficlion shouldbe usedin orderto
preventthedev€lopm€nt of furthertissuenecrcsi'
. Cod compresses durlngthelrst 6h maybe qivenTorsom€
164 pulp
Thenecrollc
Sodium hypochlonte
The most colnmolrly employed solution for endodontjc
iûigaiion is sodium hypochlorite (NâOCI), which unites
thrcc importani qualitics csscnLial to RCT:
(1) lt dissolves orgânic materiâI.
(2) It is a potent disintecta.t.
(3) lt is minimàlly tissue irriiating in los-concentra-
The tissue-dissolving capacity of NâOC] is wcll cstab-
lished (2, 28). Both vilâl ând necrotic tissue arc affcctcd
and dissoh.ed in excessof NaOCl. The speed of tissue
dissohtion is dependent on the extent of contact
between active sohtion and tissue. Thus, stjrring of the
use of ûltràsound, for exânple, \^'ill speed up the tissue
dissolving process considerably (28).
The effect of NâOCI is quickly ln.cti!àted in the
prcsence of oidizablc matcdal, such as d.ntine debis
ând orgânic material/ becâuse it dissociâtes into Nâ'
ândCfions (19,28).Therefore,dùû19 RC! the solution
has b bc rcplcnishcd consistcntl). Alihough NâOC1
breâks dovn collâgen, ii hardly affecrs thc canal wals
(18, 39). The âddition of surfactânt or hydrogen pcr-
oxide to NaOCI has not been proven to provide sig fi-
cânt therâpeutic effects (48).
Sodium hypochlorite is a strong ân.l fast-âcting
disi.fectant wiih a lo$. tissùe-irritating poicnLial ai low
conc€ntrations (0.5 1%) (43). It is a pot€nt tissùe irri
tânt in higher concentrations (2.s 5'/") (23, 3, 20, 3s), so
tugh concentrâtions should be either avojded or used
wiih grcai carc so thai no soLliion is drcpped inio the
cycs of the paiient or cxirudcd bc]'ond ilÉ âpi.al
foramc'r! which may causc sevcrc Lissuc nriiatior (see
Cljnical procedure 11.1).Thc dsk-bcncfit ratn) of the ùs€
of high concenirations of NaOCI can be qucstioncd
furthcr on thc basis of thc Limitcd gain in antibactedal
effect fouùd in clinicât irials (8).
E t h ! I eîe di anin et etr a acet ic û cill
Ethylenediaminetetraacetic acid (EDTA) is a calcium
binder (chelator) thataids inremoval ofthe srnear la),er
The smear 1âyeris mainly composed of dentine pârticles
embedded in an àmoryhous màss of organic material
that foms on the nrner root cânal walls dudng the
instrum€ntâtion procedùe. Sodiû1 hypochlorit€ js
unable to dissolve tlris debris,lvhich often contâhs bâc'
lerial organisms. Some contend that it is advantagcous
io icavc ihc smcar laycr iniact bccausc it acts as a phts
ical barricr for bactcia lodgcd in dcntinal tubùles ,nd
thereby locks them in. On the other hând, ihc smcar
layer counteracts djsinfectants and blocks the penetra-
tion of medicaments into the dentinal tubules. Also, ii
interferes with âdhesjon and penetration of root filling
material. Therefore, interchângeÂble irrigâtion with
NaOCI and thc dcntinc softener EDTA hâs been
âdvocat€d (37).
Othet irrig&nts
A varietl' of other disinfectânts have found applicaiion
in RCT, includhg detergents,chemotheiapeutics,acids
md combinâtions thereof. Brief comc'nis are gi!€n
here onlv on the use of chlorhcxidinc and antibiotics.
Chlorhexidinc is of irierest becâuse ot its extensive
use in othcr m€dical and dentâLcontexts. lt rs brocom-
patiblc and adheres to hydroxl-apatite, which providcs
extended aniimicrobial activity (19).So fàr the âgeft hàs
onl,\rgâined I ittle âccepianccfi cndodontics, most llkel,v
becauseof its lack of tissue-dissolvfig .apacity (31).
It conld be rcasonedihat an irrigant contâfiing ântibi
otics is logicâl to combat root canal infcciions. Conid
ering the Iimited effecii\-cncssfound jn clinicâ1 trials,
combincd with ùe risk for sefsltizrtion ând induclion
of bactedâl r€sistânce,the locâl use of antibiotics as ân
endodontic i igtrnt is not consid€red b bc appropriate.
Interappointmentdressing(Fig.11.4c)
Mechanicâl insiruneDtaLion and illigâtion !v'th ân
antimicfobial salùrion (bioncchdnicûLprepnrat)on)has
been found ro rendcr root carls free ofcultivâble orgân-
i- . il d,.f.u\ mdt,lr <0 E0' ^l I r.,.rd.r.p,rq 8.42
38, 32). In teeth whe.e bâcteria $'erc still Écovered the
number \^.asnonethelessgreatly rcdù.ed, showing that
biomechanicâl preparation, if carcfully conduct€d, is
quite ân effective meâns of bacterial renoYal fi RCr
Yct, if given spâce âJrd futrition, regrovih to origntl
numbcrs ùav soon occur.
In pinciple, there âre two approaches to rendo thê
low nmbcr of remafiing bâcieda harmless:
(l) To furthd cjnùncc baciedal eh'iinàtion before the
p€imânent root filling b,\rappl)-irg a disinfectant jn
the instrûmented cânal(s) rrci$'eù two treâûnent
sessjons.This procedurc is oftol refeûed to âs ân
int crûppointnenttlrcsso1I.
(2) To cnioml, the renaining bâcteriâ in the pcrma'
ncnily filled root cdnal space. ltoot filling is thcn
carricd out âfte1 completion of the biomechanical
preparaiiù in thc lery sane visit. lt is expect€d
that thc aniibacteriâ] activit_v of the root cùd
sealer,nr its unsetstàge, kills the orgmisms æd/or
they become deprived of nuiritional supply and
space for regrolvih if pathways ftom ând to the
periÂpical tissue âre effcciivcly blocked.
Completion of trcahrcni with a permanent root fill ing
in the sâme session as thc biomechanical instrumenta-
I\on (oneappûit1tnt11tcndôdantics)ri.àr not trh^.ays be

Coreconcept11,1 Rearon!Ior holdingthe root
fillinguntil a laterappointment
are:
' T o o b , " a er ' p o i r e ( r . l l e c l o l r r e n ê d r n l-o p - . " ' g
i'à /. pro.l. ïlua nq ô" . v Clr o "no I u1""."no o_
r lesionswherethe proqnosÈis reqarded
rêsolv ng, rênewed treatmentcan be caûed oùt wlthout
havingto remove thepsmanentrootîi nd.
a) TocontroapcalsuppuÊilon, or beeding.
exudâtion
(3) Toensure
;: (3) thâtsùnicient tjmeisavailabhror.omphrion.1ùe
: b i o m e c h â n k â p r e p a É i o n .
In shaighiforsard, non-syùptomatic ie€th, lvh€r€
lreatrn€ni can bc carricd oui wilhoùt coDlplicahonsân.l
rvithn a rcasoDableiime span, a case càn certÀjnly be
nâde foi coûpletion of RCT in one session.A one{isit
treâtment s.rvcs timc and furthcr oficrs thc advaitage
that the peculiariiics of thc canal anat(ùy (e.9. cùr!à
tufes, jrregulârities) are current b thc opcrat()r and
cdnâls are ther€fore likely to be easief to fill làan at a
secondâFpointment â week(s) or months latel l,urther-
nore, âny r€sidual orgânlsms h fins and cfelices of the
cânal or in deniinâ1 tùbûles, or both, may be efclosed
by the root fi1ling, drus offsetting Lheir pathogenetic
poieftià]. Agan$t this approach it can be ârgued ihai
root fillings .io not iN ariabl)' scal root canals hemeti
cally and anv rcsidual organisms may fjr1d both space
and nuiritnùal supply for rcgros,th, whch 111àe
l J | - P . l r o , " d . - J i l g . r ' r' ' . r \ i ' "
clhictrl folLo\^.!rp, observed th.t the ouicome of RCT of
teeth \\ ith apical periodontitis Nas significanily tcss
sûccessfuLifcultivatâbl€ bacterial organisms wercrccov-
ered at the time of filling râther than if not. Althoùgh
severâl stldies support the \-ies. that root canals aftcr
biomechanical prcparation and bcfore dÉ p€rmâI1ent
filling should be m€dicâted {ith ân âîtibactefiâl drcss-
ing to à second trcàtmeft sessjof (5 .3,50), conflicring
dâtâ exist as to the m€rit of such â measure (32, 54).
Noncilrclcss, RCT should ncver be rushed ât th€ expense
of propcr insiruùc'ntaiion and chemicâl dishJection in
order to finish ii ir onc scssbn. Furikrnore,
the disâppearanceof clirical signs of oDgoing infection
is ânother strong a€ument ior postponfig p.rmarnt
root filling b a laicr apppoinhncnt. For dÈse reâsons,
RCT ov€r tùo sessiois is, for most cnses,âdvocâte.] âs
a routilre pro.edurc (Corc concept 11.3).
Selecting 4 ifltr.tcatr&l dressing
Over the years â mr titude of antimicrobiaLagents ha\.e
bccn used for inhacanâ1 chesshg in RCT, including
pastes/\'adous foûrs of tinctures ând àqùeous solrtjons
(10, 14). hdinc potassnm fi hdide (IKI, s'/' ând 10'/4 is
ol lhe necrotkp! p
Treâtment 165
an example ofan aqueoussoluftD with âppeâling pfop
criics. It is â potent disinfectant (30) rrccaùse iodine
e \ , 1 . ' r ' , . 1 . ' rh' . ' r h . l ' F d F ' r r . l J b J l . . . \ r . -
| . . . .' . . : . . . . . . . . I
and iins ofroot canâ1s(36,30).Fufthermore, iis cvtotoxic
poteniial is lor! (45). Ho$'ever, in rooi canals the
antjmicrobial activity is of short durâtion and IKI is
to be .loubtfulff not ,
therefore unsuitable for use orer exten.led pcdods of
liùc. In fact, tl1is applies to àny liquid mcdicament
l,ecâ1rs€such .gents are rapidly inâcii\'âted in root
cânals, particulârly a.hcn ihcre is s€epâge ot exu.late
ftom ân apical inflamùanrry proc€ss.As â .onsequence,
regrowth of bactefiâ js likely k) occùr in ih€ ifterim
phasc (7, t). r fquid medicaments arc to be used
thc)' shor d ideàlly be applied only for 510nin in
an aitenpt to ki1l orgtlfisms in spaces inaccessibleio
inslrumcntation. Conse$rentlv, .s ân inierappoinhneni
drcsshg, a sùbstàncesho!ld be selecicd that is not eâsily
repld.ed by tissue fluid and lhat can r€mânl physi.âli,v
intact ovcr wccks or months.
In rcccni yca$, â sâier slûrrtr of câlcilrn hvdroxide
(Ca(OH):) has Eanrd c.,nsiderable acceptance as an
interâppointment dressin8 in en.{oclontic theràpies
becàuseit combjnes several athactive f€àtùres (40, t4).
It is â strofg alkiline substancc(pH 12.5)thàt in âqueous
solûtion .lissociâtes into calcium and hydrcxyl ions, the
latter pmviding antimicrcbiâl eficcis (7) (Advânced
concept ll.l) ând tissuc-dissolling capâcity (21). With
its fairly lo$-solubility ând meie physi.âl prcscncc,it is
uscd as an inhacânàl drcssing ovcr hng pedods of
result timc (Fig. 11.7). Its most esseniial fùrciion is then to
obstrarclbactcdal regrowih, $'hich matr occur by:
(1) Eliminating spacefor bâcterial gros,ih.
(2) Blocking nuhitional supply of inflanùâio ex1'
datcs dedvhg tuom the âpicâ] lesion.
(3) Rclcasing bactedcidâl hydroxyl ions.
It needs io bc re.ognized that becâuseof iis low solu
bility tle antibacteriâl capaciiy of Ca(OH)'is ljnited to
the neâr vicinit), of the nicro-organisms. Thereforc on€
. . . ù o l e \ p e . l l _ l i l e [ f . . h \ .) I ' i l l .o r c .r .i - m - i a n ô F
hstrumented pàrts of the rcot canal or bact€riâ loclged
ir dcntinal tubùles (30, 40) (seealso Advared concept
a âiti11g 11.2).Yct, Ca(OH),serves âs àn ideal iniracanal dr€ssùg
tor follo$'ups of treahnent effects ând thus offers con
venienr schcduling of d1epàtieljts. Thereb).,amplc tule
can bc rcscrved fo1 obse ation of lissuc hcahlg in
prosress, e.g. for lârge lesions, syùptomâtic esions or
rvhen prognosis for a successfuloùtcome in ânt olhcr
respect appeàrs qucsibnable (Fig. 11.7).
In RCT, Ca(OFI): also servcs an inportânt tunction
in conholing se€page of inflammatory exudâtes into
root canals. Tl1istype of leâkâgeis cspccially â problein
m conjrûction rvith svmptomatic pcdapicâl lesions,
whcrc srippurâiions hmper efiectivc disnlfe.tion
166 pulp
Thenecrotic

âJrtdâdhesion of root filling matenal b thc caml waUs.

Advanced
concept11.1 Theantibacterial
effect ln such instances permment rcot filling is contra-
of Câ(OH)rin
RCT indicated. By blocking the canal space for bacteriâl
mûltiplication and the associatedreleaseof inflârnmato
Calcium hydrcxide ismainyusedinsalurated aqueous suspens ons
genic substancesto the periapical tissue, healing of the
b u r d\ o h d \b e p n , o m o n " d wrrat -r y o t l e r v e - k l e" os o v e r u i e w
ee R€l14).an âqueous suspension generâtes highpH,whkhpro- aclrte phase of the lesion is promoted. Normâlly this
videsgrearcytotoxic potential êndkilk bacteiaandhostcellsby will occur within i week and RCT subsequently cân be
.ellmembraneproteindenaturatlonandDNAdâmage(40).Inspiie
of jtstksuedamaging pôtential, Ca(OH)r hâsqainedwideaccept
anceasanenecriv€ antimi.robiêlagent inendodontk therâpies.An
importânt râtionale is tharthe subnance,
Closingthe root canalsystembetween
afterall,is reasonably
lissuecompatible owingt0 ts slowwat€rsolubilily anddiffuslbil' appointments (Fig.11.4f)
it. Beca$€of these prcpertiet c!,totoxkity is limited10ther$ue To exclùde bacienâl conlâmination in endodontics,
areato whichit .onta.ts,wherea limitednecrosls normally is adeqùaie temporary seals between appointments ârc
induced hslethalelle.ts on bacterlâlce s alsoreateloitscaustk
required. Furthermore, canais should never be left
âcuonbythercl€ase of hydroxyl ions. Yet,owingto itsmnorsolu'
bilityanddifiusbiliryCa{oH), is â râthernefikientantimcrcbial open to the oral cavity for any extendedperiod of
formkroorganlsms lodged in pulpalremnants, crevices oflhecanal fme be.JL.pof ll_eri-l of inlrodu.in8oràl orgr1i.n.
and in denlinaltubùles(36,30).lt has beenshownaso that ûat are difficùlt to get nd of.
hydroxyapatile inhjbitsits antibacterial capa.iry(19) and that The first step is to fill the entire root câJrtâlspacewith
Ca(OH)r is effective ony 10a limiledsp€.ùumof the rootcanal Ca(OH),. Application €an be done folowing mixing of
i n a h i g h powder and stedle \^'âter to a creamy pâste/
m k r o b i o t a . F o r e x â i n p l e b o t h e m e r o c o d â n d y e a s t s s u s hCa(OH),
alkaline envrcnment andareableto rùruivein rootcanasmed whi.h is spirâlled inio the caùl with a Lentlrlo spinl.
katedwith Ca(oH), (41,51).These arelikelyrcasons whycontro This irrstiument is made of a fine, flexible wire spirâIed
versyhâsemerged overitsuselulness âsânantimiclobial agentn in the slùpe of a rcvers€ auger It should be iurned in a
RClAlthough sevsaclinkaltialshâveobserued thatrootcanas cbckwjse direction in â handpiece âi sloa' speed and
arerender€d freeof culrvable baderia folowng ts appkalionIof
â weekof rirore(8,38),orhe6havefound
brought to the vicinity of the working iength. Applying
thâtmicroorgânisms can
stll beecovered froma subnantiâl number of rootcanals light pr€ssure with a small cotton pellet at the cmal
{31.32).
Diff€rences in findings mayrcateto thetyp€of ieethinduded ln odËce ensures that the entire canâl is fii1ed. A disad
thesiudi€s andthe a$ocaiedeffedivene$ ofihe biomechankâl vantageof this methodis the risk of extrudingCâ(OH,
preparation, sarnpling technique andtheextentto whichCa(OH), beyond the apical foramen, and câre should be taken
was eliminated from the root cênêls prior to the sampling particularly when fiiling lower molârs, which âre close
to the mândibular canâl. Devices exist for injection of

Fig.11.7 G) su@$futreatment of looth36in ânâdurpatenrlollowing

nstrumentation
andCa(oHldressinq,
wheretheproqnosÈ
wasdeemed que!
ilônâbêa pr,o.idueto a largedistaesion (b).IhelollowupradogGphin k)w6 taken6 months
anda sion inûe ïù(âlregion afterlniliation
oTtreal-
meniî'e le5lons haveresolvedalmosl comphlely.
{cood6yoJDrc. Rei)
 'l
ofth€ necrotc puLp
Trcatnrent 167

C o r ec o n c e p t1 1 , 4 E v a l u a t i o nc r i t e r i a

su(nsru whenthereis absen@

Root.anatherapys coroid€red l
, . Painto apca papation
sympioms. su.hproblems maybea$o.iatedwiththepresence of .. . Painù tendemesstoper.ussion
unura pathogenr ie. Pseudononit Protelsândstàphy/o.ocur '
aureli.Inyetô1her instancês, the âckorthempeuti. effedmàyb€ 1.1 . swellin!
dueto a severe contam nationproben.n medkay compromsed . sigNof bonedeslrudion
RadlogÉphic
patentssetonlmmunosuppress vetherapy and n patentsâlvery . contnùousrootresorption
highriskof endocarditis or withmultpk heanvalveprostheset a
5amp e attlreintalappontmentswatrantedto determineantim
mbial arcptib ty in casۉ Ilareup or a sylernkcompkation
eEues.Ihsprecauton maybeundertaken ln spiteaf thefaclthat r€move the cemeni ù'ithoùt nûning the fisk ot c1ama8-
patentsareprcsbed antjmicrobial prophy axs andbecause nôt
ing the tooth siruciurc.
allmaoorganisms maybesuKeptbletotheprescrlption given(see
lu lrerChapter 10) Ipo$ble, t isnormally wÈetô referthelâttù
kindoI pâtienttôânendodontc speciâ Èt R o o t f i l l i n g ( F i g .1 1 . 1 g )
Colledin!a sample Jromrootcanasrequresaccess to â êbô
ratorytharcânprocess i1 Somedenlêlschôôls ênd ârgehospiials Permâneni root lilling of tccth wilh an infected necnnic
oTfer a mail n seruiceênd provide culture materaltincudinqsain- pulF sholrl.1fot be.ârricd oui rùless th€ Lriornechanicâl
p ngTlud andtransport media preparâtion is conplete and no cxudaiio]-i exists jn the
Takingà samplerequresellectlverubberdam soêuônand canal i]ùt prevents àc{herenceof ihc filling kr the root
p o p q d ' : n :i o o " / o d l u . o n oc o n L à r ' lo . , o " n , cânal a.alls. Il is also regàrded good clinical practi.e to
Thisprecuton s absolutely essenlla, otherwÈe thêinformatlon is postponc pcrmùent root filling until ihe nr)ù is free
worthe$. In linewith thesemeasures, all subsequenl pro@dùes ffom pâin and othù ch-Licâls,vmptoms oi rooi canal
mustbe under(aken with sterih nstru.irents and properâsepti. nrfection. An objcctivc means by {.hich the clinician is
technhuePriortô rmpLinq,.:nêh çhôud hale beenemptied or
assistcdio dc.ide rvhen bâcteriàLeliminaiiùlis comPlete
pâstemedcaments forseveradaystoallowth€ac.umulaton oI a
Liquid medcâmenis is noi reâdilv âvâi1àble.tt was oncc believed tlrât à bac
suIIkentnumbùoI organisms to beco ected.
usualyhaveon ihenêntimicrobâl efiedwithlna fewdays.Fol- terial sample vould bc ablc to provide guidânce in 1lis
lowngthe openinq of the canal,ânyexudate present is rir1 col- respect. Ilence, a posilivc sâmple tnken âlter biomc-
hded ontoan absorbent pont Thepont s thentrânsïered to â chani.àl prepâratlon s'oùld indicate thât it should be
v a l c o n tnai n gt r a n s p omr te d i u nl f t h ec a n a l idsr ys, â m p l nfgu i d coDûlued, '!h€re.s a negàii\.c culLure tr oul.l signâl
isaddedanda rootcanalinnrument, preferaby â Hedstrom fi!e is sù.ccsstul disinfection (Ad\-anccd conccpt 11.2).How
usedto shave oIId€ntine debris Trom therootGnâ waLsalongthe cvcr thc methodology has losi popr adtt in recent
Gna hngth.Paper pointsareused10transfer thesurpenlonor
)'ea$ and is pra.tis€cl only to â lirnitad dcgree às â
dentine Iilinqsandsâmpng frid to the trânspotmedium. Tle
empLe, â ongwiih a rilhd-inreferalrorm, shoud bemaledtothe
aboratorywithin 1 daylhe relut cênùsuây berecevedwithin1
Recâll
Palienis subjccted to RCT should be askcd b rctum for
d rccall àppointmcni within.r period ot (È12 monihs
Ca(OH)., e.g. blr meâns of â coùrmc.ciall,v available (12). Th€ purpos€ of ttùt appointnent is to ensurc,
s v r l n g ef i l L € dt - i t h C a ( O l l ) 1 . by clifical and râdiographc meâns, tlrât he.ling is in
After âpplictrtion, the excess màteriâl in ùc pulp progr€ss. Signs of a succcssful outcoûre âre thal no
chamber shorl.l be reDo\.€.1 and blotte.l dry with ihc clinicâl sl Ftoms (pàin, fisil ac, tenderness,rrcl sa.el-
end of â paper point of cotton pellet. Ihc canal odfice lings) prevâil or ha\.c appeare.t (Core concept 11.,1).
and adjacc'nipari of lhc pùlp chdnber should ihen be Inspeciior! palpatioD dr.l p€'cussion tesls.n.l .\nnri
scatcd s,ith a soft tenpolarl- cenent (e.9. Cà\-it, zin. nation of periodonial pocket probing depths (to senrch
oxide+ugenol) fotlowecl b1 â ûo1€ rigid temforàrv for fisfulae âlong th€ peflodonial ligamcni) cân coflirm
filling thai lviihstands th. weâr and pressùreby occlusal
forces (e.9. thick mixes of zinc phosphaic ccment, IRM, The râdiographc contml reveàLsthe extent io (hich
glassionomer).Thc first layer of sofi ccmcni crùures ihât â pfeoperàlir.c radtulucencv hàs disappeâred (Iig. 11.3).
a bactefial-iight scal is csiablishcd ùltil thc second visit. Alfeâdy b,v 4 6 months, râ.liographic e\âminatun na)'
An ultfisonic scâlef or spoon exc.lvator can tMn casily re\'€â| signs ol:bonc kaling in progress.Although somc
168
Fig.11.8 Insrrumentation
wasnotposslble
overiheenrneengthof$e d stalrooiin a lowermolardueto obliteÊtion
hasred(ediôsize(b).Cinkaljatheloothrerainêdwithour
inlàmmarory
symprom'
l€sions iake longer to heâ1, most hëaling lesions âre
likely to resolve with complete bone fill wiihin 1 year
(see further Chapter 1a). In câsesnith â large lesion,
whêre a self-sustaining and expmding cyst or other
prt\ologi(dl lesion ma) o, 5u,peLled.i. s recom
mended to carry out ihe rccall by 4 6 months. If heâl
ing is obviously not in progress, Â surgical prcc€dure
may be considered(Chaptei14).
Considerations
in advancedcâses
Canâl anatomy may be such that cleaning and disinfec-
tion of the root canal system can be conducted only wjth
grr:at ditriculty. Root €anals âlso mây be parily of totâ]ly
obstncied by mineralizâtion wiihin ihe pulpâl châ mber,
e.g. as a resutt of inflâmmation or previous injury by
hauma or operâtive procedure (Fig. 11.6a,b).There rnay
also be de\.elopmentâl anomâlies (Fig. 11.6d). It is highly
important to idenhfy carcfully âny potentiài difficÛlties
pdor to initiation of RCT (Fig. 11.8). Re{effal to ân
endodontic speciâlist or eipedenced colleague also may
Nevertheless, conserative management of whât ap-
peârs to be a lrcpeless case may stil be success{ul by
conventional RCT (1) (Fig. 11.8). Yet, the prognosis
shoûld b€ guarded. lf â permaneni.ast rcstoration is to
be caûied ouL restoration should be postponed ùiil
there âre clear signs of healin8 in progress.
Effectsof RCTon thê
intracanalmicrobiota
As described in Châpter 8, the microbiota of infected
neootic pùlps is normâlly dominated by anaerobes,
(a).At rêcâl2 yê8 arêrrhelesion
whercas facultatives 6uâ11y occupy a minor po ion of
the root c;tnal norâ. Ho$'ever, there is greât valatDn
and a large number of individuâ1 speci€s and combina-
tions of species cân be associated with the development
al1d continuarcc of apical peiodontitis (Chapter 8).
Therefore, one lùs found liltle support for treatment
êpprôd. h, . lhrl -ere.f\el! focu- oa spe, iJi. org"ni"ms.
Yet, findings of â dominance of facultatives, especiâ1ly
therâpy-resilicri mterococci in reireatment cases (cases
1'herc lesions have âppealed or failed to heal subse-
queni 10 endodontic therapyi 26, 44. suggest thât RCT
normaly is effective in combatins the anaerobes. On this
basis, one may speculate tllat RCT, if not properly con-
ducted, mây select th€ mosi robùst segment of the root
cânâ1 microbiota. Conseqùentlt it cù be regarded âs
important thât the besi possible effort io eradicâie micro-
orgânisms slûuld be iaken ai the initial ireÂtment
session. It seems æasonable, therefore, to câution agâirsl
a plocedùre whereby instrumentation and chemical dis-
infection is .arried out only hâU-a'ay, and to postpone
compleiion of bùmechmical inslrumenlâtion to a later
session. One may Êven eleci io rcfrain from entering
infected root canals if sufficient time is not avâilâble for
completion of the biomechanical prepârâtion in the tust
silting.
Managementof symptomaticlesions
Most lesioN associaiedwith an infected necrosisof the
pulp prcvail a'ithout acuie signs of inflammation (pain,
iendemess, fistulae, swellings). Nevertheless s)'mpto
malic lesionsmay develop spontaneouslyor be initiated
in conjunction with RCT (Fig. 11.9).This section of drc
châpter is devoted to measuresto be undertaken in srich

priorto RCT
Painfulcases
Si'mptomatic lesions maybe âssociâiedvith or without
â distinct soft tissue swelling. ln some of thcsc lesio11s,
celluLitis or â periâpicâl abscess mây ha1.c ahcady
mâtured ând manifested itself as a subperiosical or
submucosalabscesswith distinct intra-ofal or exira-oral
s$'ellings, or both (see further Chapier 9). To aleYiate
ihe condition, RCT is siill ihe treabrent of choice.
However, jr1 ûese instarces patients olten seek the
dentiston ân unscheduled âppointment, and time there-
fore may set Limiis {or whai it is possible to do. There
mây âlso be a \-arieiy of other circlùnstances that mâke
prcper RCT impossible io carry out at the time the
patient seeks ihe dentjst. Somc of th€se âre iechnically
related and include the presence of obshuctions in the
root canâl thât require subsianhal timc to rcmove before
the rest of thc canal(s) can be access€d.Examples are
Fig,11,9 A casew rh both bu..al àndpalâtàswêling, doeto an a.ute
Ilareup oI àn apicalperiôdontris.
Fig.11.10Drainage ofsubmu.ofL bytheuseora <alpe(â),bywhich
ab(ss isobiained
tics.Unive6itv
of NorlhCaroina
atChaDelUill,
of lhe necrotlc
Treatment PULP 169
hârd tis$e obliterâiions, previous root fillings and
.rowns with posts. Thus, bli its very naiure/ emergency
treaimcnt s,il1 often have to be a .ompromise, where
the primary objective is to gei ihc patieni out ot
pain. Consequelltly, âlthough a complcie instrumenta
tion and medication of the tooth is higHy desirable to
combar the iffecting microbjota, it is only a seconclâry
objectil-c at ftis point and mây ha1.e io be put on hold
until the patient cù be sccn ai â rcgularly schedùled
Genenl prccetlure
An emergency procedu.e includcs several critical steps:
(l) Ëstâblishment of a co ect diagnosis of the
(2) Assessment of the s€veriiy and a decision as io
$'heiher an invâsive RCT ând/or incision and
drainâge procedure is nccded or if the condition
can be manâged by analgesics.
(3) Emergencyheaiment.
(4) Reschedding for compleiion of RCT or endodontic
surgery if needed.
Any emergency treahneni must take into account tlt
manâgement of both ihe root canâ1 system and the peri-
apex. I{ cânàls are accessible, opening ihe root canâl(s)
gir.es Ân opportmity io obtâin drâhage of exudaie or
pus (see fùther below) and to combai ihc infecting
mi.robiota by biomechanicâl insimeniâtion (RCT).
The €mergency procedure also may in.lùde ân attempt
to drain off an âbscessby surgicâl incision (Fig. 11.10).
If canals are noi accessibleând if drainage by incision
is not deemed possible, the emergency lrcâtmeni may
have to be limited to prescription of a strong analgesic
ând postponemenr of furthel measures until a more suit-
âble time is a\.ailable within a couple of days.
pusisreeasd(b).lmags ôItheDepanmentof
couftesy Endodon
17O pulp
lhe necrouc
Emergenq RCT
In tceth that hurt becâuse of â pâinful mânifestÂtion of
apical periodontitis, even ilrc slightest pressure mây
cause pain and thereforc the root canals o{ such teeth
should be êccessedwiû high-speed burs and light prcs
sùre. Occasionâl1yitmaybenecessaryto give local anes-
thesia, bùt in a[ odÈr aspe.ls the IICT is no diffelent io
that used in roùtine non-symptomatic câses.
On spreading inflâmmatory processes(cellulitis, sub-
periosteal âbscess),drainâge of exudate or pus undcr
pressûre mây be possible âlong the rcoi câral space.
Sometimes it occurs directly in conjun.tion wrth access
to the puipal chamber (Fig. 11.11),bui in other instânces
drainage mây be obtained by carcful bypâssing of tjre
âpical foramen usjng à tlin rooi canal instrument. U
sù.h drainâge does occur, ûcrc is often immediâte pâin
,r r,t. Ti r. h Bhly i-portan. .lrdt thc âp',, I or.,mer .
not pierced with instruments of morc dùn ISO sizes
1È20, otherwise one ruB the risk of câùsing ân âpical
overprepâfâtion âJtd zipping of ihe apical forâmen, thus
making subsequent RCT precarious (seeabove). In the
fouowing, ii is sufficient to cleân the root cânal systcm
properly ând cbse it up with â dressing of Ca(oH), and
temporary ccment in the âccess opening.
WitI ân abundant drainâge of pûs that does not halt
immediarelt it is advisable to lei ihc paiient sit for
a while beforc closing the canâl system, in order io
equilibrate the apical tissùc pressure. One should not
leave canâls open to the o1al envircmenr becausetbis
may cause a severe contâmination problem. Hence,
leaving root câna1s opcn wiihout a suface seâl may
contribute to the establislùent of a microtlorq includ-
ing enteric bâcteria and yeâsts, whjch subseqriently æ
very difficr t to get rid ot (26,47,57).
If drahagc of an âbscesscan be obrained by crther root
cânâl inshumentation or incision and drainâge, pre-
scribing ântibiotics is æduldmi ùd undesirable.
Fig.11,11 Drainageoipùs àôdbloodalonqlhe rootcanauponac.e$ ol
an upperaterain.sorwithâ nÊ.roticpulpandpainfuapicalpeiodontiiir
I{ dÉre is a lack of iime ùd there is no drainage on
carctul piercing of the apical {oramen after making th€
access,one has to close the canal system ard postpone
turther biom echadcal irutrumentation until a more suit-
able occasion can be found. On mâny occasions pâin
relief ca. be obtahed simply by such a meâsùie, yci pain
mây not be alLeviatedimmediately folownlg energcrcy
RCT, and the paljent must be inâde awâre of this (Corc
concept 11.5).
PuIp necrcsis with a localizeLl llu.tutt'It s|oetittg
Wiih a locâlizcd, lluctuant, sofi-iisslre swelling indi
cating a submucosâl âbscess,an incision cl drainage
proccdue should be attempted (Fjg. 11.10).It is not
possible to stâie caiegorically wheLh€r this should be
done before or after accessins the root canâl system,
bui as a rllle of thumb it is rccommended to canl out
the procedure fi$t, if thcrc is m obvious fluctuation.
with à non flùctuânt tjssue swe i11git is advised not
to incise the tissue becÂuse concem exists âs to the
possilrjlity of ('orsening the condition ând câusing ihe
spr€ad of miûo-organisms. Conirolhrg ihe pain a'ith
ànâlgesics until fluctuaiiùr oc.urs is piobably the best
choice of treâLmenibccaùse the administration ol anti
biotics may not be effective (seebelow).
Occasionall,v, localized inrrâ-oral swellings are âccom
pânied b)' some exLra-oral distension resulling in ân
elevâted cheele s$'ollen tips and someiimes even
swolen eyelids. Usually, thesesyinptoms do not require
addiLional ireâtmenl or medication unless the sweling
rapidly djffuses.
P lp necrcsisTuithdilfuse suelling
tn the presenceof diftuseswellingthat hasrapidly pro-
$essed and is â..ompaniedby sysiemic signsincludin8
fevel (>39'C) âJt.l generâ] malâise, paiients should be
refeÛed to â hospital where intravenous ântibiotics
usuâly âre given. In ilrcse cases it is not âdvised to try
to control the nrJection by oral anûbùtics prescribed by
the generâl plactitionel
Coreconceptl l.5 Painreliel âIter emergency
RCT
Painmaynotd sppeafimmediâtely
âftû emergency
RCT,
therefore
. to thepatienl
expâintlresituation
. adjusttheodusal comads
. prescribe
a suitabeânâlgesic
. beavailabe to thepati€ntiJsevere
pajncontnues

Use oï antimisobiûls (antibioti.s)
In generâl the sl,stemic use of antibiotics is a \.aluâble
adjmct io d1eheatmeni of infectious diseases.Hoû'evcr,
ihe dsk of caushg bâcterial resistâncenakes ii neces-
sary b rcsbict iheir use n1 endodontics to those cascs
in absolute necd. Such câsesâre pùnârily those where
slmptoms of ododontic iiJection suggest màfke.l pro-
gr€ssionoi systemic involvement, or both. The pupose
ol an antib iotic prescriplion is rhcn to lÉlp io contain the
I ô(€* Jnd lo, r.d p'*.'bl, .e ù1..\-lên'i. !^n-È
quences(seealso Chapicr l0). ïns means thât antibiotic
th€râpy is not appropriâte for the treahncnt of locâlized
swellings $'h€rc drainÂge and debridement can be suc-
cesstullv cârried oût.
In ih€ exceptional câseû'hen antibiotics are to bc pre-
scribed,ân adequate .lrug an.l âccu.ate dosage shoùld
be gilen. Becâ1rse there is no û'ay of knowing which spe-
cific orgânisms are causing thc lesion, d1e prcscriptiolr
must be jriiiâted on an empidcâ1btrsis.Thus, seeing ihc
pJli.n or d dr:lr bâ.i- tJl | -he i 'Iec iôu- oro,e.. r.
containcd shoùld carefully monitor the result oftherapy.
lf a satisfâciory responsc is abs€nt wiilin t]rc next lew
days, one may consider chânging ihc antimi.robiâl. For
drug selection,âcarefulhistory of allcrgy ândd grcàc
f,on is necessa{r and one ma,\rconsult rhc proper bâck
ground literâture for possible side-effecis. Clùpter 10
lists the vârious anlimi.robials.
Managementof postoperative
pain- endodonticflare-up
Althoughpaintulcondiinrmnormallyâreprevented
or
curedby RCT,the RCT may âlso câusepâin and
${'ellings. This ma,\roccù eren in tccth that w€re hee of
pâin prior to lieatmcni. Thc inciderce of such conditions
has bccn reported to be âs high âs 20 -10"1,of treatcd
câses(15), whereas the incidence of s.'vcrc pâfi condi
tions appears to be <591(20,49,52).
The primary cause is io be soughi in tlÈ treâùnent
pro.edure, whereby bacteria and bacterial clcmcnts
hav€ been ertruded into the periÂplcal tissue compari-
mcnt and câused ân exàcerbâtion of the inflammabry
lesnù. An exacerbâtion mây also fo o$' btr inad\-etent
€rtension of the apicai foramen, which allolvs an
. , . , n '" d r u r : h o n ê l - . r p p l y l o . ' , , ) b . r e r " . r 8 r ' r . r r -
thàt sûivived the initiâL trealment. Normally drcse so
called endodonric flarc-ups have â sudden onset and
ma,\r not emerge until 1-2 days âft€r the procedure.
. m p r o p F ru - e o ' r r i p . n i . , r d - . ( ' l r r d l d r e . . i J l ! . - " \
âlso .a1lseirritation to the extent that a paintul condition
emerges.Ho('evea ifused correcrly,rooi canal drcssfigs
ând irigation do not câuseâ ny more postopcrahve pâùI
thân dæ use of salnle âs an jrrigant (20).
Treatment pulp
of the necrotic 171
11.1
Keyliterâture
Genet erri. (16).êriedouta clincalfolow upstudyof 443teetlr
ben eenpreoperàlveand
in443patients, reponngtheassociation
operativeïacto6andthe incdence of poslopeËtjvelado6 alter
thelirstv sit PostopeËtjvepaino(urredln 27%ofthe.aset of
whi.h5%wùe s€vere. A positive
corcâtiônwasseenbetween the
incidenc€of ponopeÊtive pâinând:thepres€nce of preoperauve
painin câses ôf teethwth necrotkpulps;ihe prcsenceoIa radro-
oJrootcanalstreated.
lucenry>5mmin diameterrand th€number
wôm€nmorelrequently reporled pâinthanmen.Wlreneachoi
theseïacto6wasanalysed independentlytheyrcmained statisti
calysiqnificant,suggesting
thattheeTfeds werecumuative.
Reseârch hàs shown that in over 50'X,ol Pâriênts lvh,)
expericnce Pain âftei treâtment thc pafi disâppears
withn 1 day. After 2 days 90% were 1€lie\'€d of pâin,
s'ttreâs for only 3% pain lasicd for longer than I week
(16, K€y litcrature 11.1).This meâns ihat most painful
conditions do not ne€d active treatmeni and can be
managed by analgcsics,âlthough a number of patients
experjence severc panl ând need to be sec'n agah fol
assessmentof âctrve trcahm€nt.
If the pâ in is noi scvere (can be sûpp ressed a.ith a mild
ânâlgesic) it is b€st to abstâln from further treâhnent,
rcassurethe pâtie.t ând prcscdbe â mild anâlgesicif no
a'nlgesic isbeing used ahcady. Adjustnent of occlusion
also provides comfort. If pain is severc, the therapy
depends on whether or not the prevbùs cânal prepara-
tion lvas complete or if the canâl lvas pcrmanentl), Ûlled:
. If pain de1'elops afrar incoïLpLeteinslrumlitatiotl,
dlen opening the canal ald completing the ltCT is
. If pâin p€rsisis or occûrs in sptte of co1t1tnctu bio
ncchd|icnl preprition, then rcopening the tooth io
att€mpi to drcin offpus orcxudaiesmâyâlleviaie thc
condition. After proper isolaiion with â ribber dam,
genily instnùnent the canal wiih an ISO 20 instru-
ment. If pus is discharyed, then ùsually the pain is
greât]y reduccd or disâppeafs.Leâve thc ioothâlone
until pus sropsdischârging and theniûigate, dry ând
close up rhe acccssopening. The problem jnvariablv
mâynorrcsolveby s1lcha meàstrre,particularly ifno
pùs is noticed, therefore a dccision to reopen a ProP-
erly instrumenred and medicâted root canal shoùld
be tâkef after caretul asscssmentof the câseand con-
siderâtion of prescfibing shong ânalgesics jnsiead
(11).Thc patieni should be informcd that the pain is
expecicd to subside within the nc'xt few dâvs. lf the
conditidl continues to be se\-ere,asugicâlprocedufe
mâv have tob€ carded out.
172 pu p
Thenecrotic
. Filing of ilÉ root canal seldom results in postopera-
tivc pajn (50, 20). lf, dlcr rcot cindl lilliry, a paÂlùI
condition appears, the câseis best managed by pain
medication, because the root canal is blocked for
possible drÂjnage. Futhermorc, rcmo\-al of the root
canâl ûlling mây caùsc cxtrusion oi foot filling
mâteriâL and inadverient overprepârâtion ol the
foramen. rn the càseof subp€riosteal or submucous
absc€ss, incisionmaygivethenecessârydlainage.
Api.àl surg€ry or cxrraction mây have to be câûied
out if the condiLion persisls. An experienced co1
league or cndodontic specialist mây be consulicd
prior io deciding on a possible unnecessaryrcmo\-al
Concludingremark
trâiients miy be greatly upsct or concefned about the
developmc'nt or continuaîce of pain afier RCT, cspe-
cialy when ihey have not receive.l proper prior infor-
mation thât sùch complications mây emerge.Itis crucial
thât patients be told that â tooth treatcd for an infected
pulp necrosis mây become sensitivc or even painful. lt
is also necessari' to advise i]È paiient about which
measl'resto undertâke,e.8. b call and Setan emergency
appointment. Good c'xplanationand advice prevent con
siderable concem and ùay malc pain more tole.abLe(9).
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Bystrôm A, Sûdqvist C. The dtiba.teriâ] action of
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dcnccofpreoperatn€ ând postoperàtivepàinù1en.lo.Lôn
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SK. Preoperàtiv€ ànd operàtive fâ.tors âslo.iated rlth
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saliva ind serum of the dtimicrobiâl a.tivity ot sôme
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tlaapasàlo LIK, Siién EK Waltimo TM, Orstayik q
ilaapisalo MP Ina.tivation of local root .ànàl mèdicâ
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20. Hâtrison IW Balmgaft.cr lC, Ziclk. DR. Analvsc of
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of cndodonticirligdts dd medi.àûents. l. hdo.ldrt.
l 9 E l j 7 : 2 7 26 .
2 L HasselgrenG, Ols{D B, Cvek M. Eflects of calcium
hydrcxide ând sodium hypochLoriteor i\. dlssolution
of necroticporcinc mlsclc tismc. .1.Erdodort.1988,14:
KÊrekesK, TronstadL. l-ong-lcrmrculis of cndodontic
e a e oe,irn' d .. lr .. nJ rd /.d ...hnrq(.
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Clntial tntl ùùliolmphn .t'o!loaup rtudy of palients ltûtet1 blJ
ufld.rynd@te rhderts. AJ 211 tùots ttuted fot d (tutn
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LameNAC, Van MullenrPJ,SnnonM. TissuerGcljonsto
sodiùm hypocfloritcrnd jodinc potassiumiodidc mdcr
clinicalconditionsi. mo.l<cyJ1c.1h..1. Ërdodorl.1980;6:
7nn 92.
LeivisB.Ionnâlde|yde in de.listrf a rcviea.Iortnc mil-
renniùm./. crnt. P.dmlr irciL. 1998)22: 167-77.

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periapical lcsions. Otù\ Srry. Anl M.d. Pûthal. 19Eti aI:
535 -13.
\,Ioiàndcr ^, Reit C, Dahlén C, Kvist t Nlicrobiological
stills of rooL filled teeth ù,ith !pi.!l pcriodo.tilis /,t
ErdodotL.I. \998j 3L: L J.
27. I,lolvcf O, Olsen l, Kerèkes K. S..fni.g Êlectrcn
microscopy ol ba.terià in drc aticâl pa.t of rcot cùàls in
pèrmùert teet| witlr periaFi.al lesions. frdodort. D.,1.
T'luvnlal. 1991)7: 226 9.
28. Moorer WR, nlessèlirLkPR. In.tors promotnrg lhe hssue
disnnvin8 .apabilit) of sodllrn hypochl)ritè. lrt.
F.tdodont.l. \9nL I5: \a7 96.
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C. lntrâradicula. bactedà ùd llngi in rooi filled, asyrnp
r ' - r' ' r' h iji'''ri Pi J'
lcsionsra knrg teùn light .ûd electron m icroscopicfi)ll(N
up studr /. Erddd.rt. 1990;16:580-E8.
t 0 . O$tà!ll< D,Ilaapasàlo M. Dislnfe.tion try endodortic itri
in{ected dennnal
Eints .nd drcssings of expedte.tlll]'
tubr es. lrdodori. D.rl. njlddlol 1990;6: 1.129.
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..1ndl | . 'rnb 'r rrrn h Jr " d dr * 1g Jn
" " r . " l i r ' r 'r { d . g r r r'r 'ldod o-rio
dontifis: a pilôt studt. Irt EndodotL.l.199\)24: | 7.
12. Peters LB, WèssèlinkPR. Perinpjcal heali.s of en.iodôtti
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prcsence or absèn e of bacterj! in ûre r.ot .mal. ,,1.
Lntlùdù t. I.2lDL 35: 660 67.
33 Pctcrs l.B, Wessehrk PR, Buijs Jr; vd \'Vinkcll,ôil AI.
Viable bacteriàin root denthal tlbulesof teeL\ ùith.rpicaL
pedodôrtitis..l. Erdodorl. 2QQ1 ) 27: 7Çn I
34. Ringel AM, Pltte6on 55, Ne$'ion Cw, lvliller CLI,
Mulhcm JM. tn liio evâlûation or chlorhexi.tine glû-
conâte solutiôn ând so.lium h_vpoclrloritesolution as root
canai nrigants.I. E dodont.19E2,Ei 200 204.
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rÊsponse to sodium hvpo.hloritc. /. Eùt1ùtlùht.197a: +
:140-,16.
36 Saf.vi KE, Spèngberg LS, Làngehùd K. Rool canal
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3 7 . Sen EIl, l{csselink PR, Tiirkûn M. The smcar lâ}'cr: a
phdom€ron in root canal thenpt-'.Int. Erdôt1ôrt.l 1995i
28: :14:l 8.
3 8 . Shuping CB, Orstavil D, Si8ur.lssonn, l|ope M. Rcduc-
tion of intràcafil bacte.ia using nickèl titàniuù rctarv
itutrûentàtion and rarioùs medications. i Exdorlorl.
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'fPC,
3S. Sio KnoNles lc, Ng Y L, Shelton L Cllâbivals K.
EfiÊctoi sodium hypo.blorjtc on nrcclr.nical lrruperties of
dertin. and tootn sùrlace sîaln ln t. Endodo t. I. 2001' 31:
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4U - . r " r i ' l r ' i o r I p e : \l. l'r '. ol ,lrni r.b
à.tiyitJi of .ùlciun hrd.oxi.le: a crificâl levi€$'. Irl.
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SirénEK,IlùôpasâloMr, Rantâç SâLniP,Keloslo EN.
I,Ii.robiolosical findings and .lini.àl tr€ntmcnt proce
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iN.cstigation. l',t. Ërdodorl..l. 1997,30: 91 5.
12. Sjôgrci U, Sun.lqyistC. Bactc lologic evàluàtion or ullrâ
sorjc rool canal insttuûL1rtalion. O,rl Srl8. 19E7; 63:
366-70.
43 SJôgrcnU, Hâgglund B, Sundqvist C, Wing K. ractoÉ
iffcctinS ûe long telm rcsults of endodottic tlcâtment.
. r d ù d . r r 1 9 9 0 , 1 6 i . 1 9 58 0 4 .
. 1E
Sjôg1er U, rigdor D, Persson ù Slndqvisr G. Influd.c
of infecùù at the tite ol rooL filling on the outcome 01
c.dodontic trcàtn€rt of leeth ùith âPi.àl pcriodonhhs.
lnt Entlot!ù t. I. 1997' 30: 297 3146.
Sfângb€rg L, ltrtberg M, Rldinge E. Biologic clrect or
cndodontic ântimicrolial agenLs. I. E doddri l!79; s:
166-75.
46. Sundqvist G. !t.re'iolo3ictl Studiè\DJN.ûotk Dùtttl Pt1Ps,
Odontological Dissertntion No. 7, Uni\'ersity of Umeâ,
1976.
CltÉri.nl rlrh:l papù. Atl drtcal sr Nplnt\,.L ! tiû tla, t.ch
q 'at '
lkth lrith ftcrôlk prlti iittùttl b1ln.ril. tdl trûtnù l he
.ùltttbxify rJ th. root .aùù| n1iûobiattlrrd iL5dotûitutne af
ûn,etuI).suet tu anstratù lh. studll rho sltorttl tt sttol'[
nsso.iationl).tireeû bn.L.tial tilsek? ùtn accutrùtct ol Pùt
{D.al Lsinrl t i. tu ùanm;t, ûith to btûùial tta û the
ttaiûpi.dl tissu. ttsù .d nû nddùQrry.
17. sùntlqlist G, Iigdor D, Pers()n S, Sjô91€nU. Micrctrn)
logic dalysis of tectn $'idr làiled endodontic lreatnerlt
and the ollt onc oI conservativere+rcâtment. Lr,1rl5tr,î
:t998;85:EaÈ93
sr'e. TA, Hàrrison J!\L The effè.t oi cffcNescencÊ on
o , t , J 1 r ' r . l a " p i , . ' r ' . c J nù l o . n r " i c o'-
rDted teeth. l lrdolurr. 198r; 7: 335-,10.
.19 Trcpe \4. flàr+up ratc of single ùsit cndodontics l,'t.
Endatlùkt. l. r99l 21: 21-t;.
'ftrpe
50 M, Delùo EO, (?r(avil D. Erdodontic trcatûÈnt
of teeth with npi.al pe.n)dontitis: singlc !s. ùnrltilisit
l.eàtment. J Itdrdrrl. 1999,25: 345 50.
51. Waltùno TNl, sirén Era, Tôrkko IIL, Ohen 1, Hààpasalo
MP fu.gi in therâpy r.sistant âpi.aL pedodo.titis r,t
Eûtlodo t. I. 1997j3Q:96 IAL
52. Wàlton R, fouad A. lndo.lontic interaPPùltment flarc_
ups:n prospecûe (udy of inc dence and Èlàted factors
I. Eûtlodort. 199L 18: t72 7.
tâng ZC, $'ang JD. A clù1i.âl obscrvâtnrn on exrêrsi'.
periàpi.al icsjons ol postedor tecth and their treàtmcnt
lvith resinifying the.ap rr Quiû.ss. htL.19a9i2a: U3 7.
Weigef R, Rosendahl R, Lôst C. lnfiùencÈ of .àlciunr
hydro\idc intmcanal drèssiigs on tne prognosis ô1r..th
s'ith .ndodonti.ally lnd!.cd p€daFi.al lesions i,t.
Endatlùnt l. 2aaÙ 33:219 26.
Wu M-K, fan E, Wess€LiirkIrR ]-cakageâlong àPi.ùl root
fillings in cun'ed rln.mls.lltrr l: effectsofàPi.al trâ.s
potatiof on seal of root fillings. /. Ëtl]oddnt. 2000, 26:
2:t0 16.
Wu M-K, i{tsselink I'l{ A Piimary obs€Natiotl or thc
prepàràtion and otrturâtion of oral cânals.Itr. Endodo"/.
I. 2001,l.ri 137.11.
Part4
TOOTH
THEROOTFILLED
Chapte1
r2
The root filled tooth in
prosthodonticreconstruction
EckehardKostkaand lean-François
Roulet
lntroduction
After endodontic therâpy a tooih must be rcstored to
tun iioml and esthetic demânds. Teeth serving as abut
ments in prosdûdoniic reconsiructions musl bc judged
cârefully regarding their abiliq' io cally a load higher
than the physiological one on a single tooth (Core
concept 12.1; Fig. 12.1). In most cases the remanling
tooth sbucture itill be less thal in viial tecth t €causu ù,e
most frequently occùring reason for endodontic ireai-
meni needs is dec'p caries. Addiiionally, a further loss of
tooth sirucLuretakes place during the preparation ofthe
ac.css.aviiy and thecanâ]. The â mount of cofonâ1tooth
structur€ is th€ mosi impoltant facior in the decision for
the klnd of reconstruction. It is l€sponsible for the reten
iion of ihe restorâtion and the fractùre susceptibiliq,.
\\fhen the rcmaining tooth structure does not provide
enough rctention for a core build up, the nrot cânal cân
support the retention by ûse of a post. Thus, in a sil1gle-
rooted tooth with substântiâl loss oI coronal iooth
structure, post ând cores âre ofien needed.
There is evidencc for chdges in recepior propefties in
teeth wiih non-vital pulp leading to highcr bitc forccs
than in vitâl teeth (33). This must be collsidered by esti
matjng thc fraciure susceptibility of â root fille.l tooth,
especially within a prosthodontic re.onslruction substi-
tuting somc morc teeth (Key liieraiure 12.1).
Problemsassociated with root filled
teeth as abutments
ln older to achieve long term clhical sûccess in the
prosthodontic restoraiion of root fillecl teelh it is essen-
tiâl to know the reasons for clinical failues. Somê oI
these rcasons, srich âs recurrent caries or periodontal
breâkdown, are ihc sâmc as in viial ieeth. One major
diffcrcncc io a vital toolh is the âbsenceof a vital pulp
srii r'- po-c r-idl nf rfrmmJot re..l'on cJu-ing
sympiom that act as a firsl indicâtor {of the patient. To
avoid caries and periodontal disease â proper recall
regimen should be established to ensurc adeguaie
prophylâxis.
The loss ol retention ofa crown ispossible in non-vrtar
âs well as in vital abutmenis, bùt jn ihe latier early
symptoms æ waning the patieni, rather rhan in â root
fil1ed tooth. The Iolloa'ing paËg.aphs discuss the prob-
lemstrssociatedÉ'ith the p rosthodonlic reconstruciion of
root fil1ed teeth.
Lossof retention
Reieniion loss is a failùc of the .oûlection beiween
two parts of ihe resioration or the tooth rcspectively.
À fracture eiihin ore of the materials mày result
chlicâl1y h â loss of retention âs well, but ils câuse
must be disrin8uished.
When the retenlion is lost at onc abuimmt, eii]Ér the
complet€ prosthodontic reconstruction will feel loose,
causing olrly slight symptoms in a tooth with non-utal
pulp, or it $'iI still be tunctioning sâtisfactofily and
the partialy lost rctention remains undetected by the
patieni. In these câses the diâgnosis of the rctenhon loss
is difficr t but importânt. A gap between ciown and
tooth glves accessto bâcteria,possibly caùsing.arics or
pciapical nrjlammation, depending on the locâtion of
the gap md ûe seâl of the remàining bârier behfeen
the gâp and the âpex. Frrthermorc, the forces acting
on the iemaining reconstncii.rn arc higher, with an
i ncreasing dsk of fracture or sùbsequeri loss of reiention
of the othef abutmenis. Therefore, it is of thc ùhnosi
importance not to omit the minùte check of the fii of
€very single abutnent in a prosthodoniic reconstruchon
ât every fecâlLeramination.
The marginal fit is checked with a suitable explorer by
irying to peneirate between the tooth ànd the restofation
nârgin frol11 ân apical direction. If a gap cannot be felt,
drc movcmeni of the restoration can be checked by
âpplying a rocking ând a pùsh-?ull moiion with ihe
fingers. In the case of a loosc rcskrraiion, a movement of
saliva along the cavo sùfacc margin may be observed
drrring this action. Movemeni âi the margin should bé
177
174 TherootTiledtooth

Fig.12.1 Pârt ôi a restored tooth,wlh lhe weâkpointsthat hâvêlo withnandthê âctnglôr.es.ohparêd

abulrnenl witha system
o{ chalns,

Coreconcept
12.1 Keyliteraturel2.l
Fromâ mechanka pointof viewin a pronhodonticreconslruction In 1986Randow andGlânt2 (33)câiriedoutâ dini.â experiment
al pansol rherestored âblimenttoothandthenjuncrions must olexcepiional
deslgn: inteetholtenpersons theycemented crowns
resisttheforces thatactuponthem.The strenglhofthe complete withexienslôn bâlsto thebuccatemporarily on matched pairsof
reconstrudion canbecornpared witba chainin whkheverylinkis neighboringor contrâlzterêlteeth,onebeingvitalandonercot
oneof the separat€ par6of the recoNtrudon, oJthe bioogkal filed,supponed with an individual Gst postândcore.welqha
structuresor th€ûconnections. Eachchalnis onlyâsstronqasits wereappli€d at differenteverarrnpositions untilthetestp€nons
weakest lnk. r theGseoltvvopùall€lchêint th€oveËllsft€ngth experiencedpain.Thepain oadingl€velof lhe rootllled t€eth
isashlghâsthesumofthestrengrhs of bothchâins,sowhenone wâsmorethêntwiceashighasin ihe vilalteeth. Theexpeiment
isstrongenough thereis noneedlor theotherone. wasrep€êted underlocalanesth€sla butleminatedêt a loading
Ite term'str€nglh' means boththeinternal(lensile)
strenqùof levelexc€€ding l25oloof th€ rootfilledtoothwithoutan€sthesia.
panof th€ r€construcrjon aswe asrherctentive (bond)drcngth Underth€5econdltions no difTerence in th€ reâctionevels
withinlhe par oI teethwasobsery€d, bul in oneroollilledtooth
Inthecaseof anabuhentloolhrestored witha postêndcôre a côrônâldentine frâdureô.cuûedandthecemenied pon lon its
l h el i n k o
s l t h ec h an sa r eâ ss h o winn F i g . 1 2 . 1 .
Thesercsultsshowrhat rooÈtreatedteethbehavediffer€ndyto
vitalteeth
wlthregardto lheirtadilereadivity.

viewed ûsing a magnifying glâss. In the case of a

subgingival Inargi4 this exâmination is done with a

Roùglmessof the imer sudace of the resioration

Cementingagent.
Factorsinf luencingretention
Retention of a core b ild-up
Retentionoï a ctoun
The morc the rctention of the crown takes plâce o11thê
Fâctors influencing the rctention of a crown or a pF
build-ûp, d1emor€ important is its retention at the tooth.
The build-ùp is aitached to the toolh mechanically
. Length of the prepared tooth ând/or chemically, depending on the material used. A
. Convcrgence ângle plasiic filling mâterial cân be condensed or syringed into
. Roù8lùess of ihe prepârâtion undercuts, .etention grooves or hto the cervicâl part of

the roor canal. Additionâ1ly, it cân be Êxed by means of
jntmdentinal pills or a post.
Rete tion oï a post
The retention of â posl depends on:
. Its design (iapcred, parallel, individual)
. lnscriion depth
. Mâcforetenuons (thfeàd, serralions)
. Micforereniions (surfacc rouglDest
. Cementing agùi in combjration $'ith pretreâtment
o{ the dentine surfacc.
Fractures
Cohesive fâilûre $'ithin a material occurs as a rracrtre.
Fract res of the sûperctructuft
A fracturc within the supelshùcture of â prosthesis docs
noi depend on the endodontic tfeàtment an.1 can
happ€n in a vitâl abuûnent âs \a.ell, û'ith the onl)' dif'
ference that thc rcflccLive conhol ol bite forces is rcduced
(33) due io the loss of rcccphrrs fi the pulp or â change
ir the mechânoreceptor tunciion in the pedo.lontal
Corclpost ftu.hîes
Cora The f|acture susc€ptibility of a core hild r'p
depends mostly on its dnnensiolls, the atefiâl's
strength and ilrc forccs a.ifig ùpon it. R€girrding these
forc€s,there are major differerccs bctween âJrtteiorênd
posterior te€th in the amount ând dircction of force, ilrc
râtio between length and diâmeter and thc arca of t]rc
bonded su àce.When a post is used, iis coronal end can
{,caken ûe.ore build up ând exert stress,depùding on
Posti Àpost often is tlrc most retenti\-e link in the chain
of rctention so lviil be lnorc likely to cause tracLure in
thc câseo{ overloâd. Either it breaks itself or ii fraciures
the rool dep.'ndnlg on the sbength of both. The frâctrre
susceptibility of a posi depends on the cliametet the
material and the mùùJaciuring piocess.It mâkes a Sreal
di$erence to ihe strength of the metal structure whether
it is cast or a'rought.
Fnclotsinlltt cing,trct tc tisk
(1) Mechanicalpropcftiesof notl 'oitdtdentine.Fot a Io] .g
timc cndodonii.a v treated teeth lvere thought to
be morc bittte due to â loss of moisture content.
Scvcral studies have investigated the mechanical
propcrtics of dcnûæ in vital vers$ non vital teeth
reconslruction 179
TherootTi ed toothin prosthodoftlc
12.2
K€yliteralure
sedgeyandMe$er(18)investigâted the denlnein vlialversus
pars of conlralâteralteethfreslry
rootfi ed teeth 23 matched
extracted for prosthodontkreasons weresùbjeded to difierent
mechanical testsoneof theconespondlng teethwâsvtalandthe
otherwasendodonticllytrealedl 25yea6ago{mean10.1 yeals).
lntotwo slices oI dentne0.3mmthickcutfromthe neck!ol the
teelh,hoesof l mmdiameter wûe punched n â unile6alteninq
mâchine andthe slrearstrength andtoughness werecalcuated
fromthe st€senrainclrrve. Addiionzlly,in oneoI th€ slkesthe
VickeEhârdne$wasd€tennined mldway between the rootcanal
a-o ,hêpqip_ey. ft" oronJ ool ca-a ôop ina ot h" "tuil
ngrootçwse prepared æ a seatlora coneshâped steerod,to
in anaxald redion.
Lowed byloading theteethuntilTracture
Netherthe pun.hsh€arnrcngthor loughnesnorthe oadto
ffâctredin€red signilkantly
belween vitâlandrootjill€dteeth.The
hadne$olthe ceûicadentine wæ 3.s%lowerln endodontkàlly
donotbe.om€
ftse fndingsndkatethatteeth morebrlfthfo
iowingendodont
c tfeatment.
(Key liicraiurc 12.2).Aldrough the moisture content
did vary significmt\', the comprcssion stl€ngth
and tensile sirolgth did not shol.any sig Ji.ant
difierencc (14). Othel factors may bc more respon
siblc for ùe nid€âse.l tuaciurc susceptibillt) ot
endodolrticâlly tlcaicd te€th.
(2) A1t1ônt alrel ainingtoorhtni.trrru.Thelossolinter
nal iooth sLructure in af endodonticâllv treâte.l
tooth will be more responsible for its Hghd sus
ceptibilty lo tuactùe tltan chânges in its mcclùni
câL prope ies. Tceth with nltaci marginal ddges
with only a smâll access prcparation.rê môsi
iesistânt agairBt fracture d are not si8nficdtly
weaker thm htâct teeth without any prepâràtion
(2, 10, 30, 3,1,44). From a pmsthodontic poini ot
vier', a maximum of intemal tooth stfucture should
be prcsened to minnnize th€ fracturc risk. Thùs,
dcsirâb1y the access lvould be minimal, i.e. just
largc enoùgh to gain àccessk) ùe cânal. From this
point of liew the preparation of the câial, espe'
cially in ilÈ cen'ical ârea, should bc as smâ]] as pos
sible. This prosdlodontic desire siands in conirast
10 modcm endo.lontic concepts, s,here the direct
slraight âccess to lhc ciml s,ith à wide àcccss
opening for good ovel.vielv is a general demând
ân d good ceNical flaù19 is recom mendcd io €nslire
âIr optimâl apicâl prc?ârâtion, especjally in cuned
ca1als. In more demândjng root canal treatment it
might be necessafy to sacifice sound tooth struc-
iurc. In neally straighi canals the preservâiion
of bodl strùcturc can be thc primâry goal. The
180 The oot filed tooth
(a) (b)
Fig.12,2 (a)ntadtooth(b)Forces
âctlng
onâ roofiilêdtoorhândresù
r
prosthodontic reconstruction det€lTnil1esfte for.es
actjng on the tooth. The âmount of tooth shucLure
lelt after pl€pârâtion det€rmincs its ability to carry
loàds. Which type of reconstruction is besi srit€d
for ihe remahin8 looth siructure needs to be
judged ât the very bcgironng of heatment.
When one or both of thc proximal lvalls are losi,
thc kndl is substântiâlly ('eakened as the slrpport
of ihe circumferentialmarginâl ridges (and the roof
of the pulp chambea is lost ând a hodzontal force
on â cusp acts o1.ef a long le1.er tum on the weakest
part in the cefficâl areâ, norma[]' jusi âbole dæ
ah.eolar cfest. When a force acis on rhe obli$re
nùer slopes of the cusps it rvill be divided into â
vertical ând â horizontâl component, the latier
exerting hjgh stressesh the û,eak cervical portion
(Fjg.12.2).Therefore ân effectn e bonding or cuspal
coverâg€ is necessarywltncvo a proximal wall is
lost d thc cusps are not nai due io abrasion or
anâtomical form.
Thc (tcnsile) bond slrength of ânv mâierial to
dcntine is âlways a.eaker than the (iensile) strength
of dcniinc. Therefore, the preservation of â
mâximum amoÙllt of dentine bulk slùuld be the
aim in endodontic therapy ol dn âbrtmeni tooth.
(3) 4f. o/pdsr.The q"e of post determines the âmount
ofstress. Tâperedposts, in contrâst io pârâ[e1posts,
leàd to radial forces when loadcd that arc compa-
râble to those of a wedge, and sharp cdgcs (at thc
c . r do â p . . r . â . r r . , f ) s i l l I n d r r ,
ing ûe dsk of roor fracturc (29,42,45).
ùt )1
I II
I
{ {
Fiq.12.3 5rre$peâGàr teethwirhdifiêrenr
posls.
(4) t,engthof past.Thetongera post,the betterihe dis'
tlibùtion of stresses,resulnngin redûcedshessat
ihe apical end of ihe post becâuseof leverâg€ (Fig.
12.3)(15,43). Extendingûe lengrh io tû'o ihirds
of tlÉ root l€ngth reslilts in a supedor fracture
rcsistancccomparcdi{iih slûrt posts(16).
Thele is â lack of chlical dâta regârding the
length of posls in relâtion to the level of âh.eolâr
bone, bul it seemsmore favorabie io extc.ndthc posi
below ihe ah.colar crcsi lvhcn a post carolot be
\5) Postdinnrter.The thicker a post, the thinner ând
rveâker wili be the remÂining tooth st.ucturc,
leading to increasedrisk of lracture.On the other
hârd, â post mùst be thick ând stifi enough to
trirnsnnt lateral forces to the root unlformly.
Normallt dependingon the diameterof the rool
ihe post dianeier shoùldnot exceed1.5mmând jn
ftagile roots this is less.
Perforations
hlttlgillatiotts of the eÉemal root
slttace - st/ippiflg peïforûtio11s
Roots are seldonr round and often shoû-curves, iN.agi-
nations, flutes or other \.âri€lies in shape. Thc distal rooi
of a mandibular molar is kidnet' shaped in its cross
section, so care must be tâken not to place the post
preparation in the middle of the canal but in the bulki-
est part of the root, i.e. the bûccâl or lil1guâ] edge (Fig.
12.4).
The mesial root of a loa.cr molar and thc mesiobuccâ1
root of an uppcr molar arc mosily cuved in i]rc distâ1
direciion. The mosi cenical parrs of the canalsgomostly

andight plâcementotpost
Fig.12.4 Wrong indsta rootof lowermolar
ol perforation
Fig.12.5 Dangèi in curued.ànàk.
iI1 the mesial d ection, so when this initial curve is
not removed during the access prepârâtion there is
$eât danger of stdpping perforâtion n1to the inter
radicular spacc or in ilÉ mcsial dircction (Fig. 12.s).
hoper flaring and, especiall)., anricurvaiùre filing dc
important noi oniy to gain a siraighi accessfor i]rc apical
preparaiion of the canal bui also for safe preparation or
Curaat res not perceptible in the X-tt:ty
Even if the ceryjcal part of the canal is straight a more
âpical cunâturc mâylimitthe length ofa post. The most
dangerorls crlNâtures âre il1 the plane not perceptible on
the X-rây picture. Only knowledte of dÈ ânâtomy of the
root prev€nts p€rforation duing preparation of â post
spâce, e.g. i]rc palâtal roois of upp€r bicuspids and
Therootfi ledioothin prosthodontjc
reconstruction 181
Deoiîttion of the prcparcd csnûI
Caies-Clidden drills as ('e1l as Peesoreamers uro sorre
specific ddlls for post systems hâve a non cutting self-
centerin8 tip, a'hich osures that the prepaËtion of ihe
posr spâce will noi dc\.iate fiol11 â $ddhg canal being
enlârged concenlrically. In ilÉ case of â rooi fi1led tooth,
the center of the root filling is dÈ guidhg structule.
When the root fillir€ deviâies ftom rhe odglnal cânal,
the cenier of the root filling ls no longer the cenicr of the
root. En1àrging â deviated cânal preparation concentri
cal1y can càuse â lâteral pefforaiion, dcpc'nding on ihe
amounts of deviâtio& enlargement and dentine bulk in
use of end-cutting drills
Special câre musi be takcn when usil1g the end cutting
drills pro\-idcd with many post systems. Even when
diven by hând, they can eâsily deviate from ihe canal.
Therefore, removal of tlrc root filing and prepâration ol
the canal space should be done using ddlls with a non
cutting tip prior to use of the drills for thesepost systems
(8, 31).
Erces sir e I ensthl di am eter
lMrù a post is longer ihân the sûaight portion of ihe
canal, a pcrforation is likel), to occul. Wlth increâsing
dimeter of ihe post, not onlt, the frâcture dsk but also
the risk of pe oration incrcasessigniJicmtly, therefore a
post should ala.ays bc as thin as possible, i.e. just thick
enough io gain somc guidânce ând rctentionwiihin the
Reinfection/bâcterialleakage
For l€âkagein gen€râl,seeChapter13.
Microleakdgeof .e'neîted posts
^ major aim of the rooi fi1lingis to sealthecanâliighrly
io prcvent bâcterial1eâkâge ffom the oral environn.rt
to tlæ periâpicâltissues.Prcparjngthe canalfor rccci\-
ing a post rcmoles â substantiâlàmoùit of the rooi
filling and may disiurb the seâ1of the remàjningfilling.
The subsequentcc'mcntationof postsmây àgâinseal
the canaland reducethe risk of infection(9, 49).Adhe
sivelùtjngofposts leâdsio a furthcr decrease ofleakâge
(3). Ltowever, leakagc may occur dûrhg post space
prcparation.Immediatepost spâceprepârâtionis less
than aftercompletescitingof the
lilel), to càuse1eâkage
seâ1er(32) and â root filling $'ithout iight seal of the
âccess.avity aliows leâkag€of bacteriawiihin a fcw
weeks(5,48),so the postspaceprepârâtionand the sub-
sequenrlùrjng of ihe post shouldbe estâblishedimme-
diaiely.Ascpiic conditionsare imperatived!'ring post
spacepreparaiionand ideâ1l)'â rubber dâm should be
182 TherootIi ledtooth
used. If impossible, ii must b€ substituted blr âdequaic
moisiurc control and tk post space should be irrigated
$'ith antis€ptic solutions such as sodiûi lùpochlorite,
chlorhexidine or alcohol.
Le gth of toot litLiags Lnàer posts: Ttrcrc is clinical eli
dence that leaving at least 3ùm of apical root filling
rnder posts decrcascs thc probabilit), of occûrer'c€ ol
periapicâl lesions (23). L rit? stL'dieshâve shown rhat
a remâining âpicâL root fillnrg of 5 or 7mm pre1.ùts
leakâge betrer thân one of 3mrn (2E, 32), thereiorc a
rcsidùal root fjllfig of 3lnm should b€ the âbsollrte
Kindsof corebuild-ups
core build-upwithoLrta post
It enough coronal tooih struciurc remaiis to yield r€ten
tion to  core build-up, a posr rvill notbc nec€ssa1y.The
brdl.l rp $'ill fi1] the accessca\.it,v,âny subsiancc loss
caused bl' câdes or oth€r feâso.s ând mây increasc thc
height of rhe âbutment. It lnûst be taken inio accouni
ilù1i in most .ases th€ oùtward wals of the remaining
iooih shucture will be re.trced il1 thickness or rcmoved
complerelt durjng abûtrnent prepâràtion and so will not
contrlbute to the final build-up rcicnLion. The rctention
of ihe build-ùp musi be achieved at the tooth stn'cture
that rcmains aftcr ilrc final prcpârâtionl
Modern dentine âdhesives are ablc k) rctâin.ompos
ite filings in câvitieswithoutàny reienti\-eformbut thei-
mây be oveftated in successfullybonding build-ùp and
prosthodontic reconstfuction alone. For build-ups, a
mechânicâ1 retention in addition to dentine bonding
should âlwavs be lsed to gâin â maxiDlum oYerall
The possibilities to âchieve mechânicâl retention arc
different b€tween single and mllti rooted teelh. Tlr
size of tlrc pulp chànber (inwidth and depth) in multi-
rooted tecth is oI considerâble âdlantâge for trchieving
mechanical retùiidl Undercùts are a natural propertli
of mullirooted iecth, wiil divergeni canâls thus pro
\.iding excellent mechanical rctcnLion.
Becauseforces actinB on all tecth arc differcnt and
depend on the degree of dcsiructior, fuûher mechanical
rctenlion ùay be necessaryviâ 91ooves, pà fâpulpâl phs
or posts. ln ânteriof teeth the forces âct in a morc lûri
zontal direction and their cross-seclionalarca is smaller
than h postedor teeth, resulting in unfâvorablc
lcvcr-arm rclations.
Mrcncver dre rcmânnng tooth structure and the
pulpal spacesupport sufficientletention for the bùild-
up, a posi s'ill bc dispcnsâbl€and shoùld be âvoided
bccausethe dsks with the use of psts do noi exc€ecjthe
advantagcs il1 most cases.
Postand core systems
When â post is ulavoidable there Âr€ differ€nt (ays to
Prefabicated postlplastic corc b ildary
ln .ontrast to a direct plastic build 11p,at) indirecr one
màk€s it fecessâry io rcùole ûrdercuts, so that tooih
stfllctur€ \'àluable for strengdr and retenhon are
reùoYcd. With â dircct build-ùp the acccsscâ!it)' canbe
closcd hm€diat€ly àfter root filling.If this is don€ with
a composite nl combination a.ith â suitablc adhesive,th€
risk of bacicdal leâkage compared with a provisionâl
closurc is ninnnized. An adhesi\.ebuild-up contributes
xu. .ù lf e ei, fon e nl uf rl,. luurh "r,l mi ,in i/F'
the fisk of fracillrc compâred É'jth a temporary matcnal
necessaryduring tlÈ period of manufacturing thc labo
râtoqr made post and core. These temporartr maiciâls
do not bord to the toolù siructurc, they do not hal-e th€
sbength ând it is necessaryio rcmov€ them. Whene\.er
a bùild up h'ith plastic matcrial is possible it should be
prcferred (Core concept 12.2).
Clist post and corc (directlilldirccr te.hniq e)
To fâbficate a cast posi a1d core there âre tlvo diJfcrcnt
(1) The direct techniquc - an âcrylic rcsin js used to
form a core brild up direcily in ilt mouth.
undùcuts andserveforrnoreretention.
.an remain
{2) lmmedatedosureolthe prepâred
canal.
{3) NoneedJora provsionafestomton:
ie$ dangerof bacterlâeakaqe
âvods higher Iracturc tsk during provisonal
s a v ecsh âr ç d e t m e
Inthecaæof ô composte
build-up, ae
addiîonâadvantaqes
. A d h s v e l e c h n qsuiem p layc ler v . b e

(2) The indirect technique mâking an impression and
fabricating ûe post ând core in the laboratory
The resin used h dre direct tedrnique musi be able to be
bumt out completely dudng warming up in the casiing
procedure.It canbe ân autopolymerizing .esin besi used
with a bmsh on technique, âpplying altemately liquid
and powder with a brush- A more convenieni method is
ihe use of a lighi-ùing resfi, owing to ùe individuâlly
deierûrined working time and the absence(r1monomer
vâpors. Both resinscan be prcpared with the usual rctat-
ing inshrments in sif,. They canbe used in combination
either wiih a Mought pre.ious aloy post onto which
ihe cor€part is câst,or wiih a brrm-oùt a.rylic post being
lôer in rtrp .,er nrl.pâr,rp
In the indirect tedùique there are also the two options
of using a Mought precious âlloy post io cast on or to
cast ihe compl€ie post md cor€ frcm one metâl. The
mechànicalpicpertie. of d h roLrghl merJl Jre -uperior
to a cast one owing to the âbsence of voids and the
Fig.12.6 Indicàtions
lor dilfercnt inânleiortee${a)andpGmohr
kindsol build-ups
'econ'ffu(on
Ite rool flled loo.\ ir prosd^odonric 183
mor€ homogeneousstructurc being independent of the
varying pârâmeters of i}rc câsting procedure.
I1ldiclrtionslot difrerentkinds of core b ild-ups
The kind of build up that is best suiied for Lheindivid-
ùal situation depends on:
. The rcmâining tooth shuctur€.
. The brrden of the superstructure.
The ratio oI these two fâctors influences noi only
the choice o{ bùild-up blit aiso the prcgnosis of the
In generâl, in âll caseswherê sùlficient retention carl
be gained without a post it shoùld be avoided (Fig. 12.6).
lvhether a post and core should be of plastic material
or â câst one is controversial. The plastic matedals,
especially composites, are usualy prefen€d because
iheir mechmicâl ând adhesive properties have bem
(andperiodontâlsur9ery)
$.
f.
{b) In premolar/ molarteeth
teelh(b)
/ molar
184 Th€rootfiled tooth
Bondins techniit es lor strengtheni1|g
\Mrcn a tæth with an op€n âp€x nee.ls endodontic
therap,v,both ihc cndodonLic ireatment proceclurcsând
thc final rcsbration are a chalenge. Becàusethe lvÀlls of
the root are tlin, ii is much morc susceptibl€ to ftàctur€
(47) and therciorc an c'ffcctivc rcinforc€ment is à mâjor
concern for long-term suc.ess. An effecti\-e reinlorce-
ment cân be âchieved bv filling the post-carrying partot
the footwith light-curing composite using a iransparent
ljght conducting posi. After Fmo\.al of thai post, â
prefâbdcâted nettrl post cân be cenented (Fig. 12.7),
gâinhg â tugher overâ1l fràcture resistânce thân a
.usiom-made câst post ând core, $'hich is âdapred to a
('eakened cânâl wâ11(37). B)' using light tfânsnitting
posis, a cùring depth up to 11mm c.n be achie\-ed,
d€pendhg on the diâmeter of the post (26).
The risk of frâ.ture increases from rhc bc$ronng of
cndodoniic ikrap)', so cffective protection is necessârlr
trcLwccnappointm€nts dudng â longer làsting endod on
tic lreatmc'ni aiming ai apcxificâtion of dnn n'alled
roots. The âbove described technique ca1 bc rlscd âlso
before finishing the endodontic treâtmeni, alloùing
âccessto the apical paÉ of rhe cânâ]. A srrengilrcning
effect of âJrtint€mal composite reinforcement up io 3 mDl
âpicâ1to the ce1nentoenâmeljunction hâs been verified
0 e).
t ''i
v "';i
r:'' -,illi '.':::
ï a ccramic post{ore build up is comparablc to ihâi of a
l : : l i i i \r i i j
î ifiil :i i: iitl
,."i,'ii,jI
\j T' j \,-.i \ i
Insertionol Curingwith Cehênting B ul d u p
composite lighttran!
mrrrng posr
Fig,12.7 c inicalprocedure rhinwàledroot ûseftlon
for nrenqrhening
ngwirh ighrrransmttingposr;.ementng
composire;.ui tnâlpost bùld ùp.
Corebuild-upmaterials
Amêlgam
Amâlgàm has bccn widely used for a Long time as a
pltrstic core maierial. It offers goo.l mechânicâl and
hânclling pfoperties ald has shorln its suitability for
core bùild-ups uscd sith posts, pnls of othef rêlcnft{
fcatùcs (17,25, 30,,16).Holvever, in the discussronabout
mercûy toxicity, this material has gafied a ba.t reputi'
tion h l,rtter years ând iis usc for that purPose has been
rcstdcted in some countries.
Composites
Composite is thc maicrial of choice for a pLâshccorc
build-up. h combination \\,irh dentine adhesiles it
offcrs ihe possibility of superior bond shcngih to the
tooth stfucture ov€r thc cntire surface,l€âdjng to hisher
retenti\.e strength. Its mechanicà1 properties make ]i
suitable e\-en for subsiiilliion of morc thân half of the
colonàl tooth structure. Dependfig on the kind and
amomt of fillers, its hâdness cânbe deicrmined snnihr
b ihat of dentine, fdcilitating the final abùtmcni prepa
ration. Its modulus of elâsticity should bc cqual to of
highcr ihan ilÉt of d€ntiîe, fesulring in cdùnced
rcinforcement. In anterior teeth it also has aestlætic
âdv,rntagesa'hen used in combinaiion with àll ceràmic
Ceramics
Recel1t\,,high perfofm ance ceramicss'.re inhoduce.l ês
core brLild up inâterials, especially in anteior teeth.
Thc]' lùve noi only estheuc âdvantagcs but also supe
rior strengfi. Using a suffâce prcheatmcnt ùat dep€nds
on th€ kind of ceramic, thcy arc cement€clâdhesivelt to
ihe tooib gainfig a siâbilizing effect. The rabri.ation of
cast metalpostând core, lrot onlybecausc it is also done
in the laboraiory but also becàusether€ is the opiion to
use a cefamic prcsscd aroùld a pretormed cerâmic posl
or to fabricâte the posi-cor€ build t1p in olre màterial as
glass infiltrated alumfia (20).As â ihird option, posi and
core càn be sep.rate pârts bondcd togÊther .lufing the
insertion (22).
Cements
Even ceùolts with the highest conprcssive strcngth
the metal-reinforccd glass ionomer cements ârp nof
oi sùitable âs a corc build-up mâtedal. Compared wiih
composite reshs or amalgam nl studi€s regârding frac'

a-.1 F-Y
I ra ,-' I i
I t'1 *i r i
t F - 1 f - - - t\ / F t
t r" --'i i ;
, t - -
Fig.12.8 DilfêreftVpsândshâpsof pônç
ture resistdnce, composite resins and âl11algàm always
perfoûned much better
Rcsnl-modificd glass n)nomd cemcnis and com-
pomcres, respecti\-e1y, achieve a fraciure strengrh similar
t u . r h . , . I , , , r p i \ r , . b u t r r r ^ ), r d , r g ôJ J ô n , , p r . , , r
under waier sorpiion leâding to crâcks in overlaying
ccJamic cros'ns (40). Thus, they âre likely âlso to exert
sLressto other rcstorations and iooth structurc.
Postsystemsand materials
Postsystems:
cylindrical,
tapered,
screws
In general, prefâbricâted posrs may be either cylindrical
or conical in shape, or tr combination of both. Theif
suffâce may be snootll, lough oi equipped with reten
ti\.e de\-icessuch âs groo\-esor â tap (Fig. 12-8).The tlvo
bâsic shapes have advaltages and disadvantages and
the principle of gâhing reteniion is differeni fol boih
A smooth c)'ljl1dei thai fits cxactly inb its matching
cylindrical holc has no rctention by itself because ùcrc
- 1 . L ' ' , p " r p . r d . L l , r ' o i l - F f l ' m B . u r I 'J' p n - . u , "
thc cylindcr's sùrfacc against the hole's a'all. By cemùt-
ing a cylinddcal rod into the corresponding hole, a
tcnsilc forcc onto tùe rod is chânged into a shear load
onto d1e cementing agent. The retention depends on ùe
shear bond strength between the luting àgent ând the
two surfacesand the sheâr strength ofthâtmâterial. This
meihod of force conduction is favorable û-iih respectio
the properties of the hting agents commonLy 1lsed nr
Any cone shâped rod fits exâctly into its matching
ho1e.Becauseof ûe obliqre shape of ihis rod, lerticâ1
forces are hânsformed into radial forccs actug on dÈ
hole's wâ11.The âmount of ihis force pressnlg ihe rod's
surface àgainst ihe wâlls depends on the con\.ergence
algle. This forcc incrcascs the ftiction because ftiction is
â tunction of ihc forcc pcrpendicular to the intc acc. On
ihe other hând, ihis force produces stresso\.er the entire
length in a radial direction where the root is tnost sus
ceprible to longitudinâL frÂchlre. When the retenhon is
losi in â conical post it is lost suddenly ând completel,v,
TherootTiledtooth n pronhodontic
reconstruction 185
Fr F=:1
r--7 ,-- 7
r--.' ,-'i ";\
\:1
"-; 1-;
v rsl
.,
'l
,'vl
I
)
Fig.12.9 Rerenron
oI difierent oI pous.
shapeç
in contrast to a parallel post rvhere, aficr a fiÉt dislocâ
tion, ihere is still residral rctention due to the parallcl
A parall€l posi does not stressthe root dentine at ihe
s'alls of drc post spacebrt does not match the anatomi-
cal forD of mosi of thc roots. Thus, â pàrallel post of ade
quatc diameter in the cerïicdl area and of the same
diâinetei nr the âpical area produces a potoltialpoini of
fracture at the end of thc post *4r.e ûe diam€ter of the
rool decreâses,leaving a wcak area in the rcmaining
dentine wall. When the end of thc posi is not rornded
or tâpered,the sharp edge leads âddiiionall)' to a pcak n1
d1estl€ss of this arca ancl the lisk ofperforalioN is high.
The shâpe of the post âlso has ân ilfluence on thc
inscrtion rvlul â hrting âgent hâs to flow out of the prc-
pared post hole. Although the space behveen â iapcrcd
post aîd its prepâmtion diminishes contnlùously durhg
hsc jon, a prcciscly fiitjngpâralelpost has â ve.y smàll
spacc Ior cement io escapeftom the verf beginning of
inscribn. Thus, a p.rallel post must tri$.ays have a
. e. i.B Bro.\ p fo- ' - âp' , Ll,e r rin{ fB"n.
Each shâpe has distincr disadvaniages of its own bût
by using suitâble combinations (Fig. 12.9) th€se can be
decreased.The most retentive onc of ihesé is a pârâ1lel
post $'ith â djâmetef decreâsingrr steps (righi illùsha-
tion in Fig. 12.9).
Sufacc siructure, i.e. rouglness, is of importânce for
both the post ând the post's space. Different means arc
used to âchieve sufficient surfâce roughness.Posis Da)'
bc sandblasted,whereas the post's spacemay be rough-
ened by mechanical mcaÈ or chemi.â[), prcheated to
gâin micromeclùnical rctcriion. Serlâtions of the post
i.l.l e,on'n.inrlv hr n.h nÉ, ir
la6 Therootfilledtooth
Postmaterials
Meh s
The most importantmechanicÂl
propertyof â post
nâtedal is Yoùg's modulus for stiffness ând teroile
strength, resulting in fracture sh.ength agâinst bending
l o n e . f r o m l h " l p o r n l o t | e h . t d i n l ê ! - . r e F.l. L p . n o -
to precious aloys and pure trâ niù m. Under unfavorablc
condtions, which might be thc case in the cllnical sitLl
à.ion. rah e* -leel . not rê"i'.n. "gJh-t ,orro.iôn.
Coûosion may lead to loss of rctention, sLluctûral û'eak-
enhg with subsequent post ftâcture or, most deleteri
oùs, to root frâchîe dûe to the expânsion of rhe
corrosion products. Stâinlcsssteel is therefofe no longer
Licensed in Europe. Prrcioùs alloys shor?ing no col:|o-
sion are somewhât weaker but still strong enough when
used âs awroughtpost. They âre the mâtedâls of choice
tor â câst post ând.ore. Cobaltrhromium based âl1oys
Àre an economical âlternative but they requirc irouble-
some work i11thÊ laboratory procedures.
The problenÉ associated with the câsting technology
of titânium are due to the low specifi. weighi ând the
Hgh meliing point, therefore it is necessary to check
every câsr object âgainst porosities by X rays but it
camoi be excluded thât microporosities still remàin
undetected to weâlen a casi post ând core. The mechân-
ical propefties of machincd iiianium alloy posts âre
supefor compâred \a'ith cast pure titanilm indi\.iduâl
post and cores (18).
Fib er-rcinf o rc erl r es ins
Recently, epoxy-based cârbon fiber posts wérc mar-
keted, followed by quartz and glass fiber posts. They are
luted adhesively md used in combinâtion with a com-
posite corc mate.ial. h .'/t/o studies havc shown that the
fracture resistance is loa'er compared with dùt of meial
posts- But the mode of failùe is frâcture o{ the post or
ceivi.al rooi fracture, whidl is more favorable thân the
often mùch deeper root fractures of the metal posis. Fur-
themorc, ihe fiber posts âre eâsy b remove n the case
ot reireatment (27, 39).
ln lâtter ycars new ceramics $'ith high strmgth have
come into clinical use as promising mateiâls for full
ceiâmic reconstructiors: ndcly ltrium oxide partialy
stabilizcd zirconia and glâss-infilLrared aluminium
oxide ccrmics (22). They offer high shengil! the forner
prodùced as prefabdcâied posts md ihe latter used for
cusiom m ade post ând core conslruction. Fabrication by
cultingthe shape oût of a prefabricated block is also pos-
sible with these mâterials. Àlthough a zirconia post is as
strong âs â tit.nium post and has a higher stiffness (1),
'r- u.e -hoJldbej! JSedcâ.êtuU).
t1lere",c.tU r"
term clinicâl resûlts and the rcmoval of such a posi
reheahlent shoûld become necessary mighl be i
sible, or ât leasi conducted a.ith a very time
procedure, leading b c.xcessive denline loss and a
risk of laieral rooi perforations.
Preparationtechniquesfor posts
Molneflt ol post pfeparution
After finishing the endodontic treatment it is essentlal
take precautions so ihât the risk {or bâcterial
along the remâlning root {iling is avoided- The
restorâtion thelefore should be established âs soon
po..ib e lc. 48\ Anoth"r , d{n rord I rm-edi ,'e
ration of the posi spaceis so ihai the dentist is still
iar with the individual cmal anatomy.
The sâfest mcthod of rcmoving the root fiuing ma
withoùt leaving the canal is bli hot instruments and
should be used alwâys as a first step in âchieving
post space pfepâràtion. A hot pluggei is iniroduced i
the canâj, repeatedly sofiening ând r€moving the
percha until most of ûe length is cleared. The ùse
solvent agents to sofien the Euita-percha is ob
becâusetheir action cannot be limited and ilLcre$
dencc of more leâkage âfter their use (2E).
Rotati g instuonents
The naxt st€? jn preparing the post spaceis the use
roiating insiruments. lt is essentiâl to begin with i
mêrl. eqlipped s i h r non ( LhiJl8 tip. In conh.à..
Gates Clidden drills, Peeso
preparation. The ddlls are used in âscendingdi
with lolv speed to avoid excessive heât (36). Ori
openeG can a]lsobe used. The size of the lâst Ële
an orientâtion âbout ihe appropriate dimeter for
post. As soon as the rotatnlg instrument cuts
dentine over almost all of the . cumJer€nce,dÈ
sponding dril of thc posi system is used. These
often have end-otiing tips so they must be used
carefully md only for the fiml prepâration to â1'oid
forations. Afier complehng the preparation, ân X-ra
should be performed û'iih the post jn place to ensure
proper posiiioning.
This is limited by the cuNature of the root and the
necessary root fi11ing needed to prcvent ieakâg€.Àn
âbsolute minimum of 3mm oI apical rooi filling
renain (23). T1æ length of a cylindricâl post mây
limited owing to excessivc weakening of ihe rool at tlÈ
âpicâl end of ilÉ posi.

Removing
with hot
of
gutta percha
Enlârging
with
catelclidden
Final
postspace
preparation
instrument
Fig.12.10CLlnl6procêdùre
{orprcparlng â post.
andinsening
The rctmtion of a post depends more on faciols sl1ch as
shâpe, length ând su#ace rcughness than on the cemeni-
i11g agent. The cementiflg âgert has to fill the gap
between post and dentine wall and to transduce the
forces between both. The classical cementing agent for
fixed resiorations is zinc phosphate cemeni. It is still the
material of choice for metal posts in a standârd situa
iion becâuse it is uncritical in hmdling md regard-
ing denhne pretreaiment. It is removable by ultrasonic
inshumenis when retreatment is necessâr). Resin
cements are required for adhesive luting of cermc or
cârbon-fiber posts. They require m adequaie denù1e
preûeatment for removing or modifying the smear tâyer
that is always present on mechanicâlly treated dentine
sûfâces. On using dentine âdhesives the manufacturer's
instrûctions must be followed cârctuIl). Of all .esin
cemenis, the most widely ûsed and best proven contahs
active phosphaie monomers. It has superior bond
shength, especiâlly towârds metâL The curing hâs a dis-
trinct oxygen prchibiting effect so that spreâding on the
mixing pad can prolong the workn€ time.
In the cementing procedùre it is essentiâl to ensllre dry
conditions. The post space is rinsed with water and
dded with paper points. Also, in the case of ihe use
of zinc phosphate cement, removing the smear layer
s : l h e i ) l e n e d i d m i n e t e . r deâr,i c d c i dI r D T A ) i s r e . o r -
m€nded to clean Lhe canâl ând enhance retention- The
Thercotfilledtoothin prosthodontk
reconstruction 1 8 7
Prèpared
po5t5pa.e,
denti.e
Placingof
luting agent
M
preteâtment
cemeni is mixed to a creamy consislency md applied
s'ith a 1entulospirâl into ihe post preparâtion. The post
is than sealedcdetully ùntjl ii rcachesthe bottom of ihe
preparaiion and left to harden ùndisturbed.
When using fasi-setting rcsins the ûse of a lentulo
spiral mây be fâieful becauseprematuie setting mây
hinder complete positioning of the posi. When using
ihese mâtedâls only the post is coated with ihe cement
(:21).
Prosthodonticreconstruction
Single tooth
The simplest caseof prosthodontic rcconstruction is the
rcstomtion of a single iootft. Often a pmsthodontic
reconstruction can be substitut€d by â composite fiiling
(Fig. 12.11).When the composite is bonded to etched
enâmel and dentine by use of a sùitable adhesive. the
fractufe resistanceG increased considerâbly (11). As a
temporary soluiion, an âmalgam filling is also possible
(Fig.12.12).In the caseof lost proximl ndges,a cuspâl
coverageshoûld be establishedio redùceihe isk of tuac-
tùe (12 13). Sûch an amâlgâm filling can last ror some
years and allow a proper obselvâtion period. Later on,
the filling cm remain as a corebuild up ând be prepared
to receive the final cast restoration. This is aiso a cosi
benefit for the patient.
 188 Th€rcot filledtooth

Fig,12.11 Composite
renorarion.

Fig.12.12 Amagafrre5ro.auon

F i g . 1 2 . 1 sc ê r a m i c o n â y .

When the croifn preParaiion is câÛicd olrr the margin

of the preparation shuld end âs high as possible ro the
o.clusal in order not to weakei rk cervicâ1area,I,hich
is *-eâkened ftom the inside duing endodoniic iherapy
(Fig. 12.13).For ihis rcason à partial crown or ù onlav
I r B . ' l l , ^ ; l l - . rm . \ m m p r ,+ 1 . r j o r u l l J r d o o r
';,i I structure is Drcst desirâble. In an onlàr evcn minimâl
.:: I l.j cmbracing of â cusp ensures thai occlusâl forces cannot
::,,1 it âct in a holizontâl dircction (seedetail h rrig. 12.14).
i,\ t\
i'lr 1 l'i,
In the case of thin remaining r',r[s of coronal toorh
structule md esthetic demands, a full ceramic rcstorâ,
tion (Fig. 12.15) offcrs the âdvâriage of âdlÈsive
irLil
,::.:":.]r.,.,:
bondng throughoui the entire surface (35) d]1d can be
madc as . core build-up and crown restoraron m one
piecc (Fig. 12.16),which is desirablc in ihe câseof sub-
tig. I2.11 (roûn wrh d flerènrevelsof prepàràrion. stantiâl loss of nxrth stfucture (6).
 lhe roolJil€dtoothin prosthodontk
r€.onnruction 189

ûown'.
Fig.12.16 Ful ceramlc'endo w thouttêrùLe(b)Etfedof lenue.
Fig.12.17(a)Rskol ûâ.ture

principles
Prepâration
Intemal loss of tooth struct re
The reduction of internal iooth structûre tâkes place in
several sieps dudng the endodontic and rcsiorahve
. Coronâl flaring
. Preparing t]rc root cânal
. Preparing the post space (if needed)
. Remo\.iig undercrrs, if â custom cast post and core
will be established.
Although sùïicieni âccess and proper fla1ing arc neces-
sary for the sùc.ess of endodontic lreaiment, every loss
ol dedine weakeÈ the tooth (12). Thus, $,hen â tooth
seNing or going to be used as an abutment needs
endodontic lreaiment, tlrc presenation of tooih struc
ture musi be considercd durin8 the endodontic proce-
dure as wel1. When â iooth is already provided wiih a
cfown, it is higNy recommended to remove the r€con
struction before gainirg âccess to the pulp chamber. This
is done to achjeve betiei orientâtion concenhg two
aspectsr because the tooih has lost its natural shaPe, cer-
\.ical or hterrâdicula. perforaiions âre more likely to
occu4 and the amount of coroml deniine lefi is clearly
visible. After endodontic treaiment ihe decision for the
kind of build-ùp is facilitêted. Lcaving the reconstruc-
tion in place makes the determinâtion oI the amount o{
coronêl deniine impossible and alLows only a bhld esti
mation unless the reconstruction enables râdiogrâPhic
exâminaiior! as jn the case of full ceramic crowns.
Ferruledesign
Special .are must be tâken in the restorâtion of a tooth
with a minimâ1 amount ol remaining coronâl tooth
Keyliterature12.3
In 199sLibman ând Nicholls(2a)dlvided25 extra.ledhumân
centrain.iso6intoTivegroupsandprepârcd themfor complere
caslûowns.Tenteethhadcâsldowecoresfabricaled, with the
frcm0.5to 2.0nrnr
ferrue heightvarylng in0.5rnminqements.Ihe
leethdidnothave.æl dowecores.A
f veconrlol 4.0_kg loadwas
êpplied to eâ.hof therestored
cydkally teethât ênangleoI l15"
to thelongaxiso{eachtoothâta rateof 72cycles perminut€.The
loadâppli.ationpont wasprcdelemined bya waxing jigthâtwas
usedto waxâll crowns. an elecdcalresistance îrâln gauqewas
ùsedto provide eviden.€o{ preliminaryïailurc.PrcLmnary tailurc
wasdefined hereasthelossofthe seangcemenl layerben/veen
oliris nudyshowed thatlhe0.5'mm
crownandrooth.Ihercsults
and1.o-mm {erulelengths ïailedat a s gnifkandy lows number
of rydesrhanthe1 5 mmand2.0-nrm ferrul€lenglhs andcontro
struclrlr€, i.e- a.hen the comPlele clinical crown É
decayed and o y ùe root remains. In this case a Post
wi11be necessary for sufficient retmtion. Generally, with
decreasing root lengih the cro$'n length wil increase,
resulring in an un{Âvorable ratio of leverage of crown
ve$ùs root. Hodzonlal loâds âr€ supporied and tràns-
ferred by the post to the root/ resulting in extreme tensi le
stress ând thus increâsing the risk of root toacturc
drâmaiicaly. A marginàl pr€paration that embrâces the
rooi effectively participates in the hânsfer of horizontal
forces onto the root and decreases the forces transferrcd
by the posl ceni.ally on the opposite side (Fig 1217).
Such an embracjng col1 is usuany cal1ed a ferrule (Key
Liieraiure 12.3). A prere+Lisite is the establishment of a
ferrùle of 1.5 2mm (4, 14, 24,41). If this is not possible,
pli]mrily â surgical crown lengthening procedure
should be considered.
190 Therootfilledtooth
For prosthodontic reconstructions sùbsiituiing losi
teeth a higher bû rden o11toihê r€maining âbutment teeth
must be colrsidercd.
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Lo\-dahl PE, Nichols JL Pin-rctaincd amalgam cores vs.
casl-gorddower-cores. .LProstheL. Dcnt.\977 38:5Q7-\+.
26. Lùi tL. Depth of composile polymerizalion wi$in
simùlatedreotcanalsusjnglighçtransmjltingposts.Oprr
Dcnt. L991i19: 765 4.
27 Màmo.ci F,Ferâd M, ltâtson Tlj. lnierhittent loâding ôf
leethrestoredusnrgquartzfiber,cârbon-quartz fiber,ând
zinonirm dioxide cermi. tuôt cml posts./. Âdrcs. Derr.
1 9 9 9 ; 1 : 1 5{3.
28. Mâttisôn GD DeLivdis PD, Tlâcker R$T, Hâssell Kl.
Effêct of post prcpdation on the apical æal. ./. Pf.stftei.
Deht. l9a4j5L:7419.
Mdtink AGB, Creugèrs NHJ, Hoppdbuù{ers PMM,
Meeuwissd R. Quâlitâtive assessûèntof stressdishrbù
tion durhg insertiorl of endodontic posts in photoelastic
màterià].,1. Dert. 1998;26:125 3r.
30. Olivcj.âFC,Dcncn_v CE, BoycrDB. F6ctlre rsjstôncc or
èndodontically prepârcd teeth using varnrus restorative
màteriàls..1. 4m. Derl. Asoc. 1987;:l:15: 57 60.
3:t. Pilo R, T.Ne A. Residul dentine thi.l<nessin ûândibu
lar prèmolâls prêpâÉd s,ith GatesGliddd and Pârâ Post
drills./. Pfdsr/rcr. Dcrt. 2000;83:617 23.
32. PortèI I& Bèmid WE, Lôrton L, PètêrsDD. The èffect of
In-.d. ê \ F -r. Je i) -d Joi.- -pr e p -p
the intègrityof thè âpi.âl seal.I.Ehdodoflt. 1982;8:1546t.

33. Randos'K, clantz PO.On.dtilèler loàdingof viial and
noH.ital teetl. A. erperimdtâl .lhicâl study. Adr.
Odatlal.Scand,1986)44:271 7.
Reeh ES, Douglas wH, Messer HH. Stiffn€ss of
endodontrcally-lrealed teeL\ Èlated to lestontion tNh-
nique./. Dfll. ^6. 1989,68:154044.
35. Rollet JF.Benefilsand disadvdtâgesof tooth-coloured 42. Stâdtld P, rhmerehoff M, Shookoi H, Wernisch I.
ârtematives to malgû. I. Dent. 1997 25: 449-7?.
Sâundèrs EM, Sâûders UrP. The heat Seneratedon the
cxternâl root surface druing post spàceprepdâtion. tl.
Endodo nt. l. 19A9j 22: I69J3.
37. Saupe wA, Gluskin AH, Râdke RAI. A compârâtive
study of fractureresistd.e betweenmorphologicdowel
and cores and a æsin rÊinforced dowel system in the
jntraradicùlarrestorationof sh!.trâlly compromrsed
rcots.oùde$. lr1. 1996;27:4E3 91.
38. SedglevCM, MessÊrHH. AJè endôdonticâlly treatcd teelh
morebrittle?/. Erdodott.199L 18.332-5.
39. Sidoli GE, King PA, Sctcnell Dl. 4,1 in vitrc evaluâtion
oI a carbonfibeÈbas€dpost dd.ore system..l.Prcsrr.r.
40. Sindel J, F|ànldbdger & Krâmer N, PetscheltA. Crack
forûàtion of â11cermi. croMs depode.t on dillêlent
core bùild up ând luting màtedâls.I. Dent. 1999j 27:
175.31.
41. Sorenso lA, EngèLtun MI. Feûule dcsign ând toactu.e
æsistâncêof endodônti.âIy treated tæth. .1.Prosirei. Dctt.
19901 63:529 36.
Thîs strLly .taluated tle lncture resisknæ al tuethptùided
uith e castpastanrl.Dreand cruun ûith !ûtiars feftrk nesiïts
ûrd ûtùùhrs a.fcotuflaltoothstrùcturc.Ore nitLiùrtet ùJ
T 1 " ' o o rl i l l e dl o o r \ ' r p r o . \ o d o n l r c ' Ê c o n ' r L ( . o n 1 9 1
ûtunol tnth sttu.hre ûbou the shotldt pr.pmtiôn stb
stantidl4ti crcasetltheJrd.tfte Esi.taflæ.A beul oJ1 t"n dl
nn dngleof 60' at .ither thetùùth.ol?iunctianor the crc7û1
flotgjn uds nelîeclia.. Thethitknrs of dxi1l taa* nructurc ât
ttu ûoan ûryin did not apPrc.idblyiklptuae rcsistancetô
Kàftaibertragùng von vorgefdtigten Wurzelkmalstiften.
LThestÆsshmsûission of prcfâbricated root .el Postsl.
S.hueiz. Moiat$chL zahn ied. 1995,105:1418-2,r.
Stddlee lP, Capùto AA, Cô]Iârd EW Polack MH. Aftly
sis of st1essdistributiôns by endodontic posts. O/d/ Sûr8.
1972,33:952-60.
44. Steele A, Johnson BR. Ln vitro hàcture stlelgth ot
e loodon, . .lt rrcdle,lp,. n.ld,. I rtdadottt ooo ?\'
63.
Thô$teinsson TS, Yaman P, Craig RC. Stressanalyses01
for prefabricâtedposts./. Ptôsthel.Dml. 1992)67: 3a
33.
Tjd Aftl, Dûnn IR, L€e IK. lractæ resistanceof âmalEan
md compositeresin côæsretâined by varioùs intradênh
nal relentive leatures. Orn l.ss, Inl. 1993i24: 211 17-
47. Tjan AH, 1 hâng SB.Resistdce to root fractùre of dos'e]
châmels $'ith vâriou thi.knesæs of bu.cal denrne walls.
I. Plasthet.Dent. 1981 53: 196 500.
48. Torabinejad M, Ung B, Ketteiing ID. In vilro bactènâl
penetraiion of cormlly ùseâled ddodontically h€âre,i
ieeih.J,Erdodo,t.1990;16:566 9.
19 Wu MK, Pehlivar Y KontaNjotis EG, Weslelinl< PR.
Mioolèakàge àlong apical rcot filùgs rhd cenente.r
posts.J. Pr.sthet.Dènt.1998;79:26ç9.
Chapte1
r3
Apicaland coronalleakage
William P. Saunders
Apical leakage
It was long considered that there was a link between
the quality of the root canal obturation and failure. The
leakage of tissue fluids apically around inadequate root
fillings was cited as the most coûrmon cause of failure.
The hollow tube theory (46) propounded that the stasis
of fluid in the apical part of the root canal system, with
subsequent degradation and the formation of toxic by-
products, induced an inflammatory response in the
periradicular tissues. An evaluation of failures in an
extensive clinical study in the USA (22) suggesied that
over half could be athibuted to a poor apical seal of the
root filling. Several studies have shown that failure was
correlated with voids present in the root filling in the
apical part of the root canal system. Harty ef nL (20), in
a retrospective clinical study, showed that the prognosis
for success in root canal treatment was poorer when
there were voids apically in the root canal filLing. Others
attributed one of the rnajor causes of failure to incom-
plete obturation of the root canal system (1, 39, 58).
Much of this correlation between obturation and
failure was based upon an earlier ex ïiao sfJdy (13).
Extracted root-filled teeth y/ere examined for quality of
obturation using leakage with a radioisotope. Dow and
Ingte (13) found that poorly obturated root canals
allowed leakage of the isotope through the apical part of
the root canal system. This study perpetuated the
hollow-tube theory and was termed the percolation
theory. The same pdnciple was put forward; namely,
that tissue fluids enter the root canal system in cases
where there has been insufficient obturation. These
fluids then break down and leak back out into the peri-
radicular tissues to generate an in1'lanmatory response.
This process has also been termed apical leakage.
However, this would imply that all teeth that have
undergone root canal preparation but have not been
obturated would be likely to fail as a result of per-
colation, This is not the caseand a number of caseshave
been reported where healing has occurred without the
presence of a root canal filling (11, 27).
192
A number of subsequent studies have shown that
sterile tissue fluid is unable to initiate and sustain an
inflammatory reaction and it has now become well
established that periradicular periodontitis is caused by
micro-organisms or their by-products (4,31,, 54, 55, 60).
The aim of root canal treatment is to reduce the micro-
bial flora within the root canal system to allow the
body's defenses to initiaie and progress heaLing. It is a
delicate balance between host response and infective
load that affects healing. Cleaning and shaping the root
canal system dudng root canal treatment removes
necrotic and vital pulp tissue and reduces the number
of micro-organisms. Further disinfection of the system is
achieved using canal dressings that are antimicrobial.
It is important that the root caral system is protected
from ingress by micro-organisms when the root canal
treatment is complete. Obturation with gutta-percha
impedes this ingress by:
o Providing a physical barrier to the movement of
micro-organisms and their by-products.
r Possessinginierent antimicrobial activify.
Unfortr.urately the comrnonly used materials for obtura-
tion of the root canal system do not provide a complete
seal.Leakage does take place and this may be at such a level
that the host response cannot cope and failure occurs.
Micro-organisms, their by-products and the products
of tissue breakdown may leak through the apical delta
of the root canal and generate an inflammatory response
in the periradicular tissues. This also, rather confusingly,
could be termed apical leakage. The leakage may be
initiated by:
o Micro-organisms that remain in the root canal
system after preparation has been completed.
Indeed, it is probably impossible to remove all the
micro-organisms and necrotic debris from the root
canal system, especially from the apical delta, with
currently available methods for root canal treatment.
o Subsequentingress of micro-organisms from the oral
cavity. The mouth is a limitless reservoir of micro-
 Apicalandcoronalleakage

organisms and any deficiencies in the coronal part of

the tooth shucture may allow invasion by micro-
13.1
Keyliterature
organisms themselves, their by-products or nutri- studyof 1010root-
RayandTrope(44)undertook a cross-sectional
ents to sustain organisms already present in the root Iilledteeth.Theyexamin€d full-mouth periapical radiographs that
canal system or dentine. This ingress is known as hadbeenselected randomly. onlyteeththathadbeenrestored per-
coronal leakage and may eventually reach the apical manently wereincluded, andteethwithpostandcorerestorataons
tlssues. wereexcluded,The technicàlqualityof therootcanaltreatment and
thecoronalrestoration wereassessed aseithergoodor poor'The
periradicular tissueswerealsoevaluated as to the presence or
Coronalleakage absence of inflammation.
of signsin
Theresults showed thatthe overallrateoI absence
the periapical tissues was61,07%. A goodrestoration resulted in
The oral cavity provides a constant source of micro-
significantly morecases of no inllammation compared with cases
organisms, some species of which, if Siven the oPPortu-
of goodrootcanaltherapy(80%versus75.7%).conversely, the
nity, will invade the root canal system of the root-filled presence of a poor restoration resultedin more
significantly cases
tooth. Obturated root canals may be contaminated by of inflammation periapicallycompared withpoorrootcanaltreat-
micro-organisms in a number of ways: ment(30.2% versus 48.6%).The combination ol a goodrestoration
anda goodrootcanaltreatment hada rateol absence oTperi-
o Delay in placing a definitive coronal restoration after
radicular inflammation of 91.4%, whereas the combination of a
(oot canal obturation. Vadous temPorary cements
poorrestoration anda poorrootcanaltreatment hada rateof
have satisfactory sealing properties but all tend to of periradicularinflammation of 1810l0.
absence
dissolve slowly in the presence of saliva and the seal Ihe conclusion fromthisstudyisthatthetechnical qualityof the
mav be disruoted. coronal restoration wassignificantand perhaps ofeven moreimpor-
r Fracture of the coronal restoraton or the tooth. tancethanthe technical qualityof the root canaltreatment for
Cracks within the coronal tooth stlucture or across a healthof theperiradicular tissues.
restoration may allow ingress of micro-organisms.
These often occur without the knowledge of the
patient arrd may be present for some time before
treatment is undertaken. ronrrient coronal leakage took place, which, in some
o Through exposed dentinal tubules of a root where cases, extended to the full length of the root.
cementum is not present. FurLtrerstudies have demonstrated the importance of
o Caries at the margin of the restoration. Caries pro- coronal leakage in the failure of root canal treatment.
gresses painlessly in root-filled teeth and it may be Torabinejad et al. (59) examined the bacterial coronal
extensive before treatment is received. leakage of single-rooted exhacted root-filled teeth using
. Preparation of post space during preparation of a two micro-organisms. They found that 50% of the teeth
post-retained restoration, especially when an indi- were contaminated along the whole length of the root
rect technique is used (equiring the Provision of a filLing after 19 or 42 days, depending on the organism.
temPorary Post. Interestingly, the motile orgalism Proteus ?ulsaris was
Marshall and Massler (32) first brought the concePt slower to penetrate the root canal system than the non-
of coronal leakage causing failure of root canal treat- motsle StnphylococcusePidermis. Khayat el aL (26) deter-
ment to prominence. They used a radioactive tracer to mined the length of time required for the bacteria in
examine the leakage around the coronal restoration. natural saliva to penetrate root canals that had been
They speculated as to whether the overall seal of the root obturated with either vertical or lateral condensed gutta-
canal was changed if the coronal seal was broken. They percha. A1l root canals were contaminated within 30
also discussed the prognosis of root canal treatment if days whatever the obturation technique. The Penetra-
the quality of the obturation was Poor but the coronal tion of organisms in human saliva was also tested by
seal was good. It was shown that coronal leakage took }dagura et aI. (30).SaLivarypenetration was Sreater after
place despite the ptesence of a coronal dressing. Allison 3 months than four earLier study periods. They consid-
et aI. (2), when discussing the role of spreader Peneha- ered this contaminaton to be significant clinically and
tion in the quality of the root canal obturatiory also made suggested that root canal retreatment should be under-
reference to the effect that a Poor coronal seal may have taken if obturated root canals were exposed to the oral
on clinical failure. ln 1987, Swanson and Madison (56) environment for at least 3 months.
revived the concept of coronal leakage as a cause of It has been recognized that the integrity of the coronal
failure of root canal treatment. Madison and Wilcox (29) part of the root canal system is Paramount for success
showed that if root canals were exPosed to the oral envi- (44). Ray and Trope's study (44) concluded that the
194 Therootfilledtooth
quality of the coronal restoration was more imPortant
than the quality of the root canal treatment (Key litera-
ture 13.1).The same protocol for this study was aPPlied
by Tronstad et aL (61) but they found that although
the coronal restoration was important for success the
endodontic treabrient qualiry was more significant
Ricucci el di. (45) had the opportunity to examine the
periradicular status of teeth that had not been ade-
quately restored for some time after root canal treat-
ment. They concluded that a root canal system that
was well obturated may prevent sufficient numbers of
bacteria from penetrating to create a radiographically
detectable apical periodontitis. Unfortrmately this study
was probably underpowered and in their discussion
they stress that adequate protection of the coronal Part
of the root canal filling should be made to prevent
leakage. Also in this study, the quality of the root canal
treatments was good. This contrasts with the studies by
Ray and Trope (tl4) and Tronstad et al. (61), where many
of the root fillings were of poor quality.
There is therefore an important continuum between
coronal leakage and apical leakage. Micro-organisms,
toxins and nutrients enter the root canal system by
coronal leakage, and, when they reach the aPical Part of
the root canal, apical leakage into the Periradicular
tissues can ensue, creating a periradicular Periodontitis.
Saunders and Saulders (48) have reviewed the role of
coronal leakage in the failure of root canal treatment.
Coronalleakageduring root canaltreatment
An accesscavity to the root canal system provides a rel-
atively easy way for microbial invasion to take Place. It
is essential that the microbial flora is kept to a rninimum
during root canal treatment. A rubber dam provides the
most consistent way of protecting the root canal system
from r.nlecessary contamination. Ideally it should be
placed prior to gaining access to the pulp chamber The
crown of the tooth ideally should be disinfected using
30% HrO, followed by 5% KI, but a 0.5% chlorhexidine
solution is also beneficial. A temporary dressing should
be leak-proof, certainly in the short-term. Studies fu ?iflo
have demonstrated that most of the materials available
for temporary dressings, including cements and propri-
etary single-component setting Pastes, are satisfactory
in this respect, although the thickness of the material
placed is a very important factor (19,62). At least 3.5mm
should be placed to minimize the leakage risk (62). The
results of these studies are somewhat conflicting, with
one study showing that one material is leak-proof and
another that the same material performed relatively
poorly with considerable leakage.
A leakage study using a microbiological model
showed that a light-cured single-paste material Pro-
vided a better seal to Streptococcussanguis than either
Cavit or a fortified zinc oxide-eugenol cement (10). By
contrast, another study using an electrochemical imped-
ance technique showed that fortified zinc oxide-eugenol
cement gave a better seal than either a light-cured
resinous material or Cavit G (24). ln a thorough il1 ïilro
study where seven commorùy used temPorary restora-
tive matedals were tested, only four materials did not
exhibit leakage during ihe 8-week testing pedod. The
fortified zinc oxide-eugenol cement and a polycarboxy-
late cement were the least effective in preventing leakage
(3). If the temporary restoration is considered to be at
risk from dislodgement, wear or subsequent leakage,
then a two-tier dressing can be placed to give a double
seal. The floor of the pulp chamber is covered with a
small cotton pledget and the accesscavity dressed with
a zinc oxide -eugenol-basedmaterial covered by a glass
polyalkenoate cement. The former has some bactericidal
properties and the latter provides some chemical
bonding to dentine and enamel, thereby reducing
microleakage.
Coronalleakageafter root canaltreatment
Thesmearlayerand coronalleakage
The interface between the gutta-percha root filling and
the wall of the root canal is the weak lihk for leakage
after root canal treatment and is one of the reasons why
a sealer is recommended during obturation. However,
despite the presence of sealer,it has been suggested that
the sealer/canal wall interface is where most leakage
takes place (21). When the root canal wall is instru-
mented mechanically, a layer of debris forms on the
surface and extends into the dentinal tubules. This is
known as the smear layer (34). This layer cannot be
removed adequately with NaOCI or chlorhexidine irri-
gation fluids. Thus, unless specific efforts are made to
remove this layet most root-filled teeth will have a
smear layer intact. The effect that the smear layer has on
the prognosis of root canal treatment is urknown (8) but
it may be broken down by bacterial toxins and acids (35,
36). This would then allow a pathway through which
leakage could take place (41).The role of the smear layer
was reviewed by Sen et oI. rn 1995 (52).
A number of studies have shown that coronal leakage
may be reduced if the smear layer is removed, despite
the method used for obturation (15,57). InterestinSly,
if the smear layer is removed, some species of bacteria
have more difficulty in adhering to the surface of the
dentine (5). Conversely, the presence of the smear layer
may actually prevent the Penetration of dentine by
micro-organisms ('1.4,28, 38). There is still controversy
concerning the role of the smear layer in coronal leakage.
If the smear layer is removed and the root filling leaks,
 Apicalandcoronal
leakage

subsequently micro-organisms may enter the dentinal

tubules. The long-term effect that these micro-organisms procedure
Clinical 13.1 Protecting
the root
may exert is unknown but it may be presumed that if canalsin molarsfromcoronalleakage
nutrients leak into the tubules then the micro-organisms
(1) Therootcanals areobturated in theusualway{a).
may multiply and move out into the root caral system.
(2) Excess gutta-percha andsealerareremoved completely from
The use of chemically active sealers that bond to the wall
the pulpchamber the gutta-percha shouldbe seared at the
of the root canal chemically may be al important way opening of eachrootcanalwitha hotinstrument. Thecoronal
of preventing coronal leakage (43, 51). gutta-percha shouldbe condensed vertically
into the root
canal.Ihe sealeris removed with a dentalexcavator anda
Coronal leakage and molar teeth pledget of cottonwoolsoaked in alcohol.
It has been shown that coronal leakage is a significant (3) Thefloorof thepulpchamber should beinspected carefullyto
problem in multi-rooted teeth (47). The presence of ensure thatthedentine surfaceis clean.
accessory canals in the floor of the pulp chamber rnay (4) Thefloorof the pulpchamber; togetherwiththe opening of
allow the spread of micro-organisms and their toxins therootcanals, is coveredwitha layerof resin-modified glass
ionomer (b).
into the furcation area (18,53). The common practice
(5) Thetoothnowcanbe restored witha coreandextracoronal
of packing excess gutta-percha across the floor of the
resloralton.
pulp chamber should be avoided because considerable
leakage will take place (47). The use of amalgarn, glass
ionomer or cermet cement across the floor of the pulp
chamber preventsthis leakagelClincal procedures l3i
and 13.2).More recently it has been shown that a resin-
modified glass ionomer provided a good barder to
coronal microbial leakage (7).

Post-retained restorfltions anà coronal leakage

The removal of root filling to accommodate a post may
comprornise the seal of the obturation and allow leakage
to occur more easily. TÏrc retention of Smm of well-
condensed root filling apically is necessary whenever
possible and great care should be taken when removing
the existing root filling, especially if it has been present
for some time. There is a tendency for the gutta-percha
to be twisted or vibrated during removal and this may
disrupt the seal (25). The post-space preparation can be
undertaken imrnediately following obturation without
deletedous effects on leakage (42), even with the core-
carrier obturation methods (50). CLinically it seems that
failure of root canal treatment in the presence of a post-
retained restoration is a major problem (17,49). The
placement of an adequately cemented post provides as marker for varying times, are then spLit or rendered
good a barrier to coronal leakage as an intact root filling transparent and the depth of penetration by the tracer is
(e). measured. It was noted that there were marked in-
consistencies in the results produced by various
research workers; for example, aqueous solutons have
Leakagestudies been shown to penetrate further than isotopes (33). A
qualitative volumetric method of measurement was con-
There have been many research studies carded out in sidered to be a more accurate assessment of leakage.
zllro on leakage in endodontcs. Wu and Wesselink (65) These include spectrophotometdc measurements (12),
have critically reviewed these studies. A marker is an electrochemical method (23) and pressure methods
usually employed, which may be a dye radioisotope using water to determine the volume of fluid movement
or bacteda. Root canal treatment is undertaken on (9, 63).
extracted teeth and the root surfaces covered with an Microbiological models have been used in aitro in an
impervious substance, except for the apex or coronal attempt to match clinical conditions more closely (6, 16,
openings, or both. The teeth are then placed in the 40, 63). In most cases, the filled root is sterilized and the
196 Therootfilledtooth

clinicâlprocedure
13.2
cavityhasbeen
toothwhereonlytheaccess
Fortheintactanterior
cutin thecrown:
(1) Ihe rootcanals areobturated in theusualway.
{2) Excessgutta-perchaand sealer areremoved completelyfrom
thepulpchamber and1-2mmintotherootcanalitselL
(3) Iherootcanalshould glassionomer
befilledwitha light-cured
cement.
(4) A light"colored
acid-etchedcomposite should
resinrestoration
thenbeplaced strength
inaneffortto restorethe olthecrown,
particularly
at thecervical margin.
increase
Notonlywill thistechnique butthe natural
the strength
of the enamelwill not be asimpaired
translucency asit wouldif
wereleftintheentrance
gutta-percha ofthe root
canalbecausethis
intheyoungtooth,bewithinthecervical one-third Fig.13.1 Experimentalset-up €oronal
to demonstrate of bacteria
leakâge
can,particularly
through tooth.Thecloudy
a root-filled in thelowerchamber
solution (right)
of thecrown.
shows contamination.
bacterial

the periradicular tissues with consequent bone resorp-

coronal part is inoculaied with a known microorganism.
The time for the organisms to penelrdte the root canal
and enter an apical chamber, which contains a medium
that changes colour when contaminated, is recorded
(Fig. 13.1). Unfortunately most of these techniques are
not quantitative, although efforts are being made to
produce a quantitative method (37). The Presenceof the
organism Pseudomonas fluotescenswas detected using
fluorimetry The depth of penetration from the root apex
toward the crown of the tooth was measured. Using this
method Michailesco et nL (37) found no statistically sig-
nificant differences in leakage results among lateral, ver-
tical and thermornechanical condensation techniques
Despite all the shortcomings of in aitro leakage
tests, they provide a suitable initial screening of new
materials and techniques for obturation. Further work
is required in aiuo to examine further the relationship
between leakage of root fillings and periradicular tissue
reactlons.
Conclusions
The coronal leakage of micro-organisms, their by-
products and nutrients from the oral cavity may be an
important cause of failure of root canal treatment All
techniques used to obturate root canals leak over time,
therefore there must be an important balance between
the host response and the amormt of contamination,
notwithstanding the virulence of the organism. It may
be that, for the most part, the host is able to cope with
these low levels of infection. lÀ1-Lenthe ingress reaches a
certain level, an inflammatory resPonse is triggered in
tion and resultant changes that are seen radiographi-
cally. This response is influenced by various factors
concerning each individual. Therefore, it is very imPor-
tant to protect the root canal system from coronal
leakage. This can be achieved by ensuring that:
(1) Microbial contamination is avoided during root
canal treatment.
(2) The coronal asPectof the root filling is protected.
(3) A sound coronal restoration is placed immediately
following root canal treatment.
References
1. Adenubi JO, Rule DC Success rate of root fillings in
young patients. Br. Dent l 1976;14112374L.
2. Allison D, Weber C, walton R. The influence of the
method of caral prepalation on the quality of apical and
coronal obturation. .l Endodont.1979;5: 298-iO4'
3. Bobotis HG, Anderson RW Pashley DH, Pantera EA Jr A
microleakage study of temPorary restolatlve matedâls
used in endodontrcs. ] Endodont 1989;1'5:569-72
4. Bystrôm A, Sûndqvist G. Bactedologic evaluâtion of
the efficacy of mechanical root canal instrumentahon in
endodontic theraPy Scand.l. Dent Res.1981;8: 321-3'
5. Calas R Rochd T, Druilhet P, Azais JM In zrifroadhesion
of two shains of Preaotella nigrescensto lhe dentin of the
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'199q 24t 172 L5.
6. Chailertvanitkul P, Saunders WR MacKenzie D, Weetman
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Inl. Endodont.l. la96t 2q 249 5Ë.
7. Chaitertvanitkul R Saunders WP, Saunders EÀ4
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Chapte1
r4
Factorsinfluencing
endodontic
retreatment
ClaesReit
The outcomeof endodontictreatment
Essentially endodontic treatment is concerned with the
removal of diseased or infected pulpal tissue, instru-
mentation aJtd medication of the root canal system arld,
finally, the placement of a root filling. The ultimate objec-
tive is to protect the individual from a potentially
pahful and harmful infection and, at the same time, to
preserve the affected tooth in the long term. The disease
processes usually take place in body compartments
hidden from direct inspection and therefore methods of
evaluating the biological outcome of the treatment pro-
cedures are limited to observation of clinical symptoms,
radiographic findings and histopathology of periapical
biopsy specimens. Because clinical symptoms occur
hfrequently and periapical biopsies are difficult to
obtairy the presence of pathological alterations is largely
determined by radiographic diagnosis.
Evaluaton of the outcome of endodontic therapy has
a long tradition and numerous investigations based on
radiographic examination have been published. A study
with great ùnpact on subsequent researchwas published
by Strindberg in 1956 (62).Strindberg launched a system
of criteria based on the absence or presence of radi-
ographic rarefactions arormd the apex of the evaluated
root. Basically Strindberg held that a periapical radiolu-
cency diagnosed at the end of a predetermined healing
period should be considered a sign of biological treat-
ment'failure'. Although Strindberg found that complete
periapical healing sometimes did not occur until 10
years after treatment, he recommended a 4-year follow-
up period as a cut-off before a final classification be
made. The system provided a simple distinction
between healthy and diseased roots and has been widely
used as a tool to assessthe general outcome of endodon-
tic treatment but also to find factors that misht influence
postoperativehealing (Fig. 14.l ).
Investigations assessing the outcome of endodontic
therapy often are designed as so-called follow-up
studies. In these studies a cohort of patients are treated
and followed clinically and radiographically for a
certain period of time. Ideally such studies should be
made prospectively and factors of interest rairdomized,
but for ethical and practical reasons a retrospective
(looking back in files and records) non-randomized
approach more often has been used. However, this sci-
entific strategy might bias the data produced and limit
the confidence in conclusions made.
A substantial body of data have been collected from
follow-up studies through the years. The accumulation
of knowledge is impeded by the large variation among
the investigations concerning factors such as case selec-
tiorL sample size, treatment procedures, recall rate,
length of observation period and radiographic interpre-
tation. Regardless of the limitations, the studies clearly
demonstrate that endodontic treatment can be a very
reliable procedure. When teeth without apical peri-
odontitis (irrespective of the pulp being vital or necrotic)
are treated lege nrtis, a successful outcome might be
expected in as many as 957o of cases.When heatment
'fails', i.e.
periapical inflamrnation develops, it is most
often causedby micro-organisms contaminating the root
canal during heatment.
Compared with vital pulp cases, teeth with necrotic
pulp and apical periodontitis are associated with less
probability of treatment success.In such cases micro-
organisms are present initially that, owing to the com-
plexity of the root canal system, cannot be combated
successfully. However, minute cleaning, medication and
obturation of the canal will produce periapical healing
in 80-85% of cases.
Factorsinfluencing treatment outcome
Although endodontic treatment most often can be suc-
cessful, some caseswill fail and it is within the respon-
sibility of the individual clinician to minimize this
number. Therefore, knowledge of the various factors
that will inlluence treatment outcome is of supreme
importance. Such 'prognostic' factors might be found in
the situation that precedes endodontic tueatment (preop-
199
200 Therootfilledtooth

Fig.14.1 Evâluationof treatmentoutcomeaccordjng {62).(a)A 4-yearfollow-upof a filst lowermolarThepatienthasno clinicâlsymptoms

to strindberg
'success'.
(b) Ihistoothwastreated5 yearsagofor apicalperiodontitis.
Ihe
andno signsof pathologyarevisiblein the radiograph. Thecaseis classified
as a
oeriaDical
lesionhasdecreased but is stillvisibleon the râdioqraph. asa '{ailure'.
Thecaseis classi{ied

sistently has proven to influence significantly the treat-

Coreconcept14.1 Factorsinfluencing ment result is the diagnosis of apical periodontitis.
treatmentoutcome Studies have reported 1G 25% lower healing rate when
radiographic signs of periapical disease are Present
Preoperative
Tactors
compared with when they are nol.
. Apicalperiodontitis

Operativefactors
o Êxtentof canalpreparation
o of seal
Quality
a Proceduralerror
Postoperative
factors
a Coronalleakage
. Postpreparation
eratioe lactors) or rnight be associated with the treatment
per se (operatiaefactors). Also, elements of the posfopela-
,ia,e situation might exert influence on the long-term
outcome (Core concept 14.1,Key literature 14.1).
Preoperativefactors
In most studies general factors such as age, gender and
health have not been demonstrated to influence signifi-
cantly the treatment outcome. \4rhen local factors have
been considered some investigators reported that certain
teeth came out more favorable than others, but a sys-
tematic pattern among the studies and teeth has not
been found. The only preoperative factor that con-
Ooerativefactors
The apical extent of the root canal preparation is one of
the major prognostic factors. The instrumentation
ideally should be terminated at the constriction of the
canal, which normally is located 1-2 mm from the root
apex. Accordingly, Sjôger. et al. (59) reported periapical
health to be restored ln 947ô of teeth with apical peri-
odontitis when the preparation, and root filling, ended
within 0-2mm of the radiographic apex. On the other
hand, when preparations were made to a shorter dis-
tance from the apex, only 68% healed.
Overinstrumentation of the root canal should be
avoided. When the instrument passes through the aPical
foramen it may induce displacement of infected dentine
into the periapical tissues (Fig. 14.2).Within the dentine
chips, micro-organisms are protected from the defense
mechanisms of the host and may sustain inflammation
artd impair healing (69). More importantly, repeated
overinstrumentation may erùarge the apical foramen
and alter its original anatomy. Consequently, the root
canal preparation will lose its apical resistance form,
which often will result in overfill combined with an
inadequate apical seal of the canal. Overfill of the root
canal has been found to be associatedwith a decreased
healing frequency in teeth with apical periodontitis. The
 influencing
Factors retreatment
endondontic 20'l

of the rêsultsof pulptherapyon certainfactors

Keyliterature14,1 Dependence
(62)performed 'failure'whentherewasa decrease in the periradicularrarelaction,
In hisinlluentialthesispublishedin 1956,strindberg
an analyticalstudyo{ endodontic treatment resultsbasedon radi- unchanged periradicular
rarefaction anda newor an increase in the
ographic andclinicalfollow-up examinations. Thecasematerial con- initialrarefaction.
sistedof 254patients with 529teethand775rootstrealedby the Aftera follow-up periodof 4 years, Strindberg foundthat95%of
authorduringa 6-yearperiod.Theroot canalswereinstrumented cases withoutaninitialrarefadion and71%withaninitialrarefaction
bythe useof KerrlilesandHedstroem files.Vitalcases weremostly couldbeclassified as'successes'.
lf theperiodwasextended to include
completed in two sessions. Whena devitalizing agentwas used thoseobservations that he hadmadebeyondthe 4-yearpoint,the
(arsenicor paraformaldehyde paste)the treatment wasextended to healing rateamongthe latterincreased to 85%.
threeappointments. Thenon-vitalpulpswereoftentreatedin fouror strindberg's mainideawasto studytheimpact of certain
factors on
moresessions. Ihe intracanalmedicaments that wereusedvaried periapical healing.Heloundthat components suchas age,hea/th
considerably. Fivepercentchloramine iolution was usuallyem- status,nunberof interappointment dressings,treatnentflare-upand
ployedin vitalcases. casesrotationof the medicament
In non-vital tootfillingmaterialdidnot exertanysignificant influenceonthether-
(e.9,tricresolformalin,iodinepreparations, oil of cloves, creosote) apeutic Amongthe statistically
result. significant fadorshe reported
waspreferred to prevenlthe baderiafrom acquiring resistanceto periadiculatstatus,nunbet of roots,canalpreparation andtypeof
any one substance, Thecanalswerefilledwilh gutta-percha and root filrng.Healing wasfoundlessfrequently amonqcaseswith an
eitherAlytltor an 8% solutionof resinin chloroform as a binding initialperiapical radiolucency.Successful operations werecarried out
agent.AlthoughSlrindberg's treatmentmethodology lo a large moreofteninthree-rooted thanintwo-rooted teeth,whichinturndis-
extentmustbe regarded as obsolete,
hisscientific approach still is played betterresultsthansingle-rooted teeth.Where theapicalpartof
commendable, thecanalwasmechanically widened onlyto a diameter corresponding
'10 Tileno.1,a higherproportion of success wasobtained
Follow-upswerecarried outovera periodof 6 months to years. to Hedstroem
Ihe resultsof thetherapylor a panicular rootwereassessed at the thanwhenwiderfileswereused,Negative in{luences werefoundif
radiographicexaminations asa'success'when thecontour'widthand canals wereprepared to or beyond the radiographic apexandif the
strudureof theperiodontal marginwerenormalandthe periodontal rool fillingshowedpooradaption to the rootcanalor wasforced
contours werewidenedmainlyaroundthe excess filling,andas a throuoh theaoicalforamen.

periapical reaction is probably not caused by the rnat-

erial per se (guIIa-percha is well tolerated by the tissues)
but rather by intracanal microbes. Numerous outcome
studies have proven the significance of the quality of the
root fi1ling seal. An inadequate apical seal will allow
tissue fluids to leak into the root canal artd supply micro-
organisms with substrate, and also let bacterial products
seep out into the periapical tissues. On the other
hand, a defective coronal seal might provide the oral
micro-organisms with an avenue for a PostoPera-
'late' or
tive infection of the root canal, resulting in a
sustained periapical inflammation.
If negative prognostic factors are accumulated, the
chance of success will decrease substantially (15). For
example, if an apical periodontitis case is overinstru-
mented and provided with a defective seal, the prob-
ability of healing will be very low. In an epidemiological
study Bergenholtz et aL (6) lound that 55% of overfilled
roots with defective seals were associated with periapi-
cal radiolucencies. On the other hand, when root fillings
Fig.14.2 lîe negativeinfluence oToverinstrumentation. instru'
A repeated ended within 2mm of the apex and were assessed
mentationthroughthe apicalforamen will resultin a 'tear-drop'
anatomyand as adequate, oriy 12% demonstrated periapical
hindera good-quality
root-filling
seal. radiolucencies.
Procedural errors such as perforations, broken instru-
ments arrd ledge formations will not directly impede
periapical healing. However, the prognosis of the treat-
 Therootlilledtooth
provocation
Fig, 14.3 Bacterial of root-fillingseal.In the first lett upper
premolar,an âcuteperiapicallesiondeveloped 1 year after placement
the post and crown.Ihe root-{illingseâlis defectiveand microorganisms estimated to be about 2.5 million. However, the attitude
probablyhave enteredthe canalseitherviâ microleakage
procedures.
restorative
ment is decreased if the complication obstructs
cleaning of an infected canal.
Postoperativefactors
Data from recent studies indicate that the quality of the
restoration of the tooth might exert an influence on the
outcome of the endodontic treatment (46): Via defective
margins, micro-organisms may enter and colonize a
poorly sealed root canal (54) Gig. 14.3). Furthermore,
leaking saliva may dissolute the sealer and break the
resistance against reinfection (57). However, provided
that instrumentation and root fillings are carefully per-
formed, the problem of coronal leakage may not be of
great clinical importance (52).
The placement of a post in the root canal does not
per se influence the outcome of endodontic treatment.
However, the post preparation might break the root
filling seal either by disturbing the adaptation of the
mate al to the dentinal walls or by leaving too little
gutta-percha remaining. Studies have shown that not
less than 3mm should remain in the apical Part of the
canal (29).
Prevalenceof endodontic'failures'
Assessment of the technical quality and the outcome of
endodontic treatment at a population level has a long
tradition in Scandinavian countries. Studies have
reported a relatively high frequency of defective root
fillings. It has been reported consistently that 25-35% of
endodontically treated teeth are associated with peri-
apical radiolucencies (6, 13, 17,4). Similar findings
during recent years have been reported from other areas
of Europe and North America (9-71-,22,33, 55, 56).Tl:.e
most frequently adopted study design, the cross-
sectional survey, does not disclose the dlmamics of the
pedapical reactions and therefore does not provide
'failed' treat-
direct information on the frequency of
ments. However, in a follow-up study Petersson ef al.
(42) found about equal numbers of healing and devel-
oping periapical radiolucencies in a population over a
period of 11 years. Obviously there is a contradiction
between what is possible with endodontic therapy
(85-90% success)and what is actually obtained (60-70%
success).It is an important task for the Profession to try
to close this gap.
At present the number of potential retreatment
of casesis huge; in Sweden (9 million inhabitants) it can be
or duringthe to the clinical management of such caseshas been found
to vary substantially among clinicians (3,21', 43, 48,49,
60).
the
Variationin the managementof
periapicallesionsin endodontically
treated teeth
Variation in healthcare procedures was recognized early,
at the beginning of the 20th century. In a classical study
(2) of 1000 11-year-old schoolchildren in New York City
it was found that 650 children had undergone tonsillec-
tomy. The remaining 350 children were sent to a grouP
of physicians. A total of 158 children were selected for
tonsillectomy. Those rejected (182) were sent to another
group of physicians and 88 of them were then suggested
for tonsillectomy. After that, the remaining childen were
examined by a third group of physicians, and then only
65 children remained for whom tonsillectomy had not
been suggested.At that point the study was interruPted
owing to a shortage of physicians to consult. This rePort
inspired investigators to challenge the clinical consensus
of a varieÇ of medical (and dental) procedures. Trou-
bled over the results of these studies, Eddy (14) con-
'Uncertainty creeps into medical
cluded: Practice
through every pore. Whether a physician is defining
a disease, making a diagnosis, selecting a procedure,
observing outcomes, assessing probabilities, assigning
preferences,or putting it all together, he is walking on a
very slippery terrain. It is difficult for nonphysicians,
and for many physicians, to aPPreciate how complex
these tasks are, how poorly we understand them, and
how easy it is for honest people to come to different
conclusions.'
 2O3
Factorsinfluencingendondonticretreatrnent

Two main areas of research and thir.rking can be identi-

Keyliterature14.2 Variationin management
of fied: descriptive and prescriptive. DescriPtive Proiects
'failures'
endodontic aim at mapping out and explainir.rg horr" clinicians
reason and make decisions. Prescriptive, or tlormative,
Reitand Grôndahl (48)showed35 dentalofTicers fromthe Public
projccts, on the other hand, are concerned wjth how
DentalHealth0rganization in Sweden33 endodontically tleated
decisions should or ought to be made.
teethshowingperiapical radiolucencies Thecases
ol varioussizes.
werepresented with radiographsandthe sameclinicalhistory:'The
actualpatient, aged45,is in goodgeneralheallhandpresents with
no clinicalsymptoms Theplesent
fromhisteethor oralsofttissues. Clinicaldecision-making:
radiographs weretakenat a routineexamination. Rootfillingsare descriptive projects
morethan four yearsold.Thisis your first examination of the
patient,who hasno otherdentalproblems and no furtherdental In studies of clinical reasoning several models have been
treatment is beingconsidered.'For eachcasethe cliniciansmadea suggested and used (12). Sorne investigators have
choiceamongfiveoptions:no therapyindicated, wait 12 months, focused on the artistic, or intuitive, aspects of clinical
non-surgical retleatment.surgicalrelreatmentor extraction. 'jndgement analysis',
practice (45). In the tradition of
In the figureeachbar represents onecase.ln no casewasthe
researchershave tried to reveal the pieces of information
sameoptionsuggested unanimously by âll examiners. In eight 'cues' usec_lat conscious or unconscious levels
or
teethall fiveoptionsweresuggested, and in 15 câsesfour of the
alternatives. The numberof teeth selectedfor therapy(surgicalor that influence a person's decision-making policy. This
non-surgicâl fetreàtmentor extraction)had an intefexaminer approach has been applied in several domains (8),
rangeof 7-26 teeth. including judgements of third molar removal (2,1).ln a
series of innovative investigations Kahleman cf 41.
No therapy Therapy (23) explored a proposjtion that people most often rely
r F&Î:is:;. on a small number of heuristic principles to make
Periapical
decisions.
fl
_ 9urqery Attempts have been madc to explain the observed
n Extra.tion variation in thc management of periapical lesions ilt
endodontically treated teeth. Because several studies
have demonstrated large inteindividual variation in
radiographic jl'rterpretation of the pedapical area (see
Chapter 2), it has been hypothesized that variation in
retreatment decisjor.rsmight be regarded as a function of
diagnostic variation. However, studies of general prac-
n ruorherapy titioners have not supported this idea (49).The influence
n wêit12month of components including risk assessment (50), clinical
t t t t t r t r r l context (3, 60), cognitive factors (50) and overall dental
30 20 10 0 10 20 30 treatment plans (43) has been cxplored. Howevet the
Numberof observers complexity and multiplicity of factors present in each
study have rendered interpretation of the results diffi-
cult. Kvist and Reit have proposed a model to explain
endodontic retreatment behavior (27, 28, 51). ln the
'Praxis Concept' (Advanced concept 14.1)it is suggested
The large vadation among clinicians when suggesting
the treatment of endodontic cases was first demon- that dentists perceive periapical lesions of varying sizes
strated by Smith ef a/. (60). Several reports have con- as different stages on a continuous health scale, based
firmed that the mere diagrosis of a persistent periapical on their radiographic appearance. Tnterindividual
radiolucency in an endodontically treated tooth does not variation then could be regarded as the result of differ-
consistently result in suggestions for retreatment among ent cut-off points on the continuum for prescribing
clinicians (42, 43, 48, Key literature 14.2). For example, retreatment.
Reit and Grôndahl (49) found that only 39% of persist-
ent pedapical lesior.s diagnosed by practitioners were
c o m p l e m e n l e db ) . r r e l r e d t m e ndt e c i . i o n . Endodonticretreatment
Owing to theù complexity, clinical decision problerns king:a normativeapproach
decision-ma
have attracted interdisciplinary attention. In addition to
interest from health professionals, philosophers, psy- Probably tl.re most highly developed normative
chologists and economists have also contributed (12). decision-making model is the'expected utility theory'
 Therootfilledtooth
Advancedcon(ept14.1 ThePraxisConcept
Thistheoryhypothesizes thatdentists of perjapical
conceive health
anddisease notaseither/or situations
butasstateson a continu-
ousscale.on thisscalea majorlesionrepresents a moreserious
condition thana smallerone.Variation betweendecision-makers
thencouldberegarded astheresultof theindividual's
seledionof
differingcut-offpointson the scalefor prescribing
retreatment.
Placement of the cut-offoointis deoendent
on valuebut alsois
influenced byfactorssuchascosttqualityof sealandaccessibility
Non surgical
to therootcanal.
Pêrsonalvalues
- High costs - Low co5ts
- Adequate seal - Defectiveseêl
- Difficult êccess - Easyaccess
Retreêtmênt No rêtreatment
High degreê of Cut-off point Perfect heâlth
poor heâlth
(Big periapicallesion) (No periâpicallesion)
(EUT) (for a review, see Ref. 19). The philosophical folrn-
dation is to be found in classical utilitarianism, whereas
its mathematical origiru are even older The advent of
modern EUT is associated with the influential work of
von Neumann and Morgenstern (40), which made some
of the psychological assumptons of utilitarianism
redundant. The theory was introduced to medicine by
Ledley and Lusted (31) and, r.rnderthe concept of 'clini-
cal decision analysis', discussed in detail by Lusted (32)
and Weinstein and Fineberg (68). Over the last 30 years
clinical decision analysis has received increasing atten-
tion in medicine as well as dentistry (53).
Clinical decision analysis prescribes that the problem
'decision-tree', which logically
should be structured as a
displays the available actions and their possible conse-
quences. Then the listed outcomes are assessedregard-
ing probabilities and values ('utilities'). After this, the
weighed sum (expected utility) of each stuategy is com-
puted and the action with the highest sum is chosen.
Reit and GrôndaN approached the mana8ement of
pedapical lesions in endodontically treated teeth ftom a
decision analytical point of view. The problem was
graphically structured (48) and later probabiLities and
utilities were produced and 'best' actions were calcu-
lated (47,50). However, large parts of the critical infor-
mation needed for calculations are very uncertain,
therefore in the present context the decision-tree will be
used only as a rational basis for clinical deliberations,
with no explicit calculations being made.
Endodonticretreâtmentdecision-makinq
Decidenow Wait and see
Therapy No therêpy
Surgicâl Extraction
retreatment retreatment
Fig.14.4 lhe structure
of the retreatment problem.
decision-making
The structureof the decisionproblem
The structure of the decision-making problern is logi-
cally and temporally displayed in Fig. 14.4. Before
retreatment of a root filled tooth with apical periodonti-
tis is actually allowed to start, there are basically three
clirùcal questions that have to be arswered and three
choices that have to be made. \Â/hen a periapical radi-
olucency is detected the cLinician first has to question
whether the corresponding lesion might be expected to
heal or not. If there is a chance of heaLing, the case should
be followed for an additional period of time. If it is
thought that the patient will not benefit from further
expectatiorL the second question will be raised: should
the case be retreated or not? The choice is between
accepting the situation as it is or trying to improve on it.
This is the most difficult and complex of the choices that
have to be made and no simple answers are available. If
retreatment is favored there will be a question of which
clinical procedure to use. Personal skills, knowledge of
prognosis and cost-effectiveness estimations will influ-
ence this decision.
Choice1: Decidenow/wait and see
As mentioned above, endodontic treatment of teeth with
apical periodontitis has good prognosis. The majority of
tlLe cases that will succeed show complete pedapical
healing within the first 2 years of root canal treatment.
By extending the observation pedod, the healing fre-
quency will increase and single caseshave been reported
not to heal until 10 years postoperatively (62).However,
most investigators recommend the placement of a cut-
off 4 years postoperatively, a time during which the
healing curve flattens out. Thus, from a clinical point of
view, a case initially treated for apical periodontitis
might be observed for up to 4 years. If the lesion still
persists, a decision has to be made between performing
 Factors
influencing retreatment
endondontic

Radiographichêaling (%)
Coreconcept14.2 Toretreator not?
100
Factors
to consider
a Probability
of disease
a Risks
of untreateddisease
a of retreatment
Risks procedures
o Personalpreferences
a principles
Ethical

14.3 Basicretreatment
Coreconcept
principles
decision-making
1 2 3 4
Years
Firstprinciple
Fig.14.5 Healing of the periapicâl
dynamics titsuesfollowingtreatmentof A periapical
lesionin a root-filled to heal
tooththatis notexpected
vitalandnon'vitalcases. shouldberetreated.

secondprinciple

additional treatment or accepting the situation at hand is not followed.reference

(Fig. 14.s).
As a result of microbial contamination during intra-
canal treatment procedures, roots without preoPerative
signs of apical periodontitis may develop disease.Most
such casesmay be detected within 1 year of the original
'Late failures' most often are due to
treatment (41).
coronal leakage of microbes allowed to invade a defec-
tively sealed root canal. Consequently, the diagnosis of
a new periapical lesion in an endodontically treated root
normally is regarded as a sign of root canal infection.
Spontaneous healing is not expected to occur and there-
fore an extension of the observation pedod is not mean-
ingful. Together with the patient, the clinician l.ras to
decide whether retreatment is indicated.
Occasionally transient apical radiolucencies develop
around the apices of root filled teeth (62). Periapical
inflammatory reactions with subsequent bone resorp-
tion might be elicited as responsesto toxic components
of antimicrobial medicaments and root filling matedals.
Toxicity usually decreasesover time and inflammation
resolves. Clinically this possibility should be considered
if the radiolucency is associated with an overfill or is
diagnosed within the first months of comPleted root
canal treatment.
therapy
Choice2: Therapy/no
If a periapical lesion is not expected to heal, several
factors have to be considered when choosing between
retreating the root or not. For example, what is the Prob-
ability that the detected periapical radiolucer1cy repre-
sents disease?What are the general and local risks that
lf the firstprinciple mustbe madeto
respectfor patientautonomy, retreatmentriSksor retrealment
moneràry cosrs.
have to be taken if the periapical disease is not treated?
If retreatment is carried out, what are the risks of com-
plications? What is the opinion of the Patient, does he or
she have any preferences?Are there any moral implica-
tions to be considered? (Core concept 14.2.)
To decide whether retreatment should be callied out
or not is complex and each casecan be the subject of con-
traproductive overdone deliberation. In the everyday
situation it normally gives the best consequencesif a few
simple principles are followed (Core concePt 14.3).
It is assumed that the best overall consequencesare
o b t a i n e di f d e n f i ' t s ' p r i m a r l \ u 8 S e s l i o n st o P a t i e n l sâ r e
to perform endodontic retreatment. The persistent lesion
is an expression of a root canal infection and people
benefit from having their infections treated. For the med-
ically uncompromised patient the general health hazard
is probably low and therefore false-positive diagnoses
should be avoided. There is no solid scientific evidence
to distinguisll among grades of periaPical disease.
This first principle in Core concept 14.3 is quite
dogmatic and leaves no room for deliberation. It imPlies
that if retreatment is suggested and accePtedno sPecific
arguments are needed. Hot'et'et if a Persistent lesion is
diagnosed and retreatment is not selected, then sPecific
arguments have to be put forward. These are found in
the second principle.
 Therootfilledtooth
Respecting patient autonomy implies that the patient
is fully informed regarding the situation but does not
want retreatment. Attitudes to pedapical disease vary
among persons and subjectivity and personal values
must be allowed to influence the decision-making
Process.
On an individual basis, potential risks associatedwith
a retreatment procedure (e.9. root fracture following
post removal, or nerwe injury as a result of periapical
surgery) might be judged to be too high. The objectively
assessedrisks (the probability of a certain event) should
be weighed against the subjectively evaluated benefit of
retreatment. When the patient's costs for reheatment are
considered (treatment fee, drugs, loss of income, suffer-
ing), the cost/benefit ratio might be too low to be
accepted.
Probability of disease
Biopsies obtained from periapical areas showing radi-
olucencies have demonstrated the presenceof patholog-
ically altered tissue (granulomas, cysts) in about 95% of
investigated cases (Z 61). It has been demonstrated
convincingly that these reactions are mainly caused by
microbial irritalrrts present either in the root canal (30, 34,
38, 64) or in the periapical tissue (63, 67).
Risks of untreated disease
The risks of leaving a root with chronic pedapical
disease untreated are not very well known. The infected
root canal as a potential threat to systemic health is
discussed in detail elsewhere in this book. The topic
has been argued since Hunter in 1901 suggested that
oral micro-organisms could disserninate tfuoughout the
system and cause disease in other body compartments.
Cunently the evidence base is very weak and a general
risk assessmentis still very much a subject of personal
opinion (35).
From a local point of view Eriksen (16) estimated
the incidence of possible exacerbations per year to be
less than 5%. The composition of the intracanal micro-
bial flora of the root filled tooth generally varies from
that of the necrotic pulp. It is not known if ihis differ-
ence irfluences the risk.
Risks of retrcatfient procedures
Clinical procedures may injure the tooth or the sur-
rounding tissues.In order to re-enter the root canal tooth
substance, crowns or posts often must be removed,
implying risks of weakening the tooth or of causing
direct fractures. Sur#cal retreatment might, for example,
lead to mandibular nerve injury or to a visible retraction
of the marginal gingiva. Theserisks have to be presented
to the patient included in the decision-making and
accepled before retreatmen I sla rls.
Personal preferences
Personal values will influence the decision-making
process. As mentioned above, given identical inJorma-
tion and similar diagnostic findings, patients (and
doctors) will not choose the same clinical management
of a certain disease.For example, some persons will be
very eager to have a bacteria-caused periapical inflam-
mation in a root filled tooth treated whereas others will
be more reluctant.
The concept of value is multidimensional but it seems
reasonable to suppose that there is a close connection
between an individual's values and his or her value
judgements. It has been suggested that one may appre-
hend values in acts of preferring (19,40). This means that
when faced with a choice, the values of an individual are
reflected in his or her preference behaviour. To measure
'Stan-
preferences,various rating scalesor the so-called
dard Gamble' technique (Advanced concept 14.2) have
been used (65, 66).
Reit and Kvist (51) transformed the Standard Gamble
technique to suit an endodontic retreatment situation
and investigated the subjective value of periapical
health and disease among dental students as well as
endodontic specialists (27). Substantial interindividual
variations were registered in the evaluation of symp-
tomless periapical lesions in root filled teeth. It was found
that, at a subjective level, some persons will benefit
much more from endodontic retreatment thaJll others.
Ethical principles
Ethical reflection is a fundamental component of
medical decision-making. The utilitadan idea that it is
the consequences, and only the consequences, of an
action that will determine its moral value has been a
central thought in Western moral philosophy, but it is
still a very controversial one. Traditionally, dentists and
physicians have had a paternalistic approach to clinical
practice. Today, however, patient autonomy is widely
regarded as the primary ethical principle, emphasizing
the importance of determining patient values. Besides
respect for autonomy, the principles of beneficence (doing
good to patients), non-maleficence (avoiding doing harm)
and justice are often stressedin biomedical ethics (4).
l/surgicaI retreatment
Choice3: Non-surgica
The root filled tooth can be retreated using either an
orthograde or a retrograde approach to the canal. In the
orthograde or non-surgical retreatmentthe tooth is re-
entered through the crown, the root filling removed and
the canal once again negotiated before it is reobturated
Gig. 1a.6). The main objective of the non-surgical re-
treatment is to eradicate potential inhacanal micro-
organisms, thus allowing the periapical tissue to heal.
 influencing
Factors retreatment
endondontic

As an alternative to the orthograde approactç root

Gamble
14.2 TheStandard
concept
Advanced canals might be retreated from a retrograde direction' A
sursical retrmtment will include removal of the periapi-
Health state x cal soft-tissue lesiory resection of the root tip and place-
ment of a retrofill (Fig. 14.7). Using this methodology,
complete eradication of an intracânal microflora must
Health stête Y
Perfect health not be expected. Rather, if the retrofill is effective,
remaining microbes will be entombed in the root canal
and shut off from PedaPical communication.
Health state z Several factors must influence the choice between non-
Dêath surgical and surgical retreatment of a case, and asPects of
Ihe subiectis givena choicebetween two alternative courses of biological outcome, costs and risks have to be deliberated'
action.lteoptionsavailable areto (ontinue livingin thestate of Data on the outcome of non-sur8ical ret(eatment are
(health 'gamble'. most often available as part of general follow-up studies
healthdescribed in a scenario state x) or to take a
The gamble most often is some type of treatment, e.g surgery that (for a review, see Ref. 20). Reported success rates in these
mayleadto the restoration of health(healthstatey) butrisksare investigations vary between 56% and 88%. The issue has
involved andthepatientmightdie(healthstatez) Ihe probability been aàdressed specifically only by a few authors. After
(p)of attaining the best outcome of the gambl€ is systematically 2 years of observatiorL Bergenholtz e, ,1. (5) found, in a
varieduntilthesubject is indiflerent between continuing to stayin
prospective study, comPlete resolution of apical radi-
healthstatex andtakingthegamble. In thissituation thevalueor
'utility'of thetwo alternative olucencies in 487oof 234 retreated roots. Decreased size
actionsis thesame. Thismeans that
of the radiolucency was observed in a further 30%. After
theutilityof healthstatex (Ux)equals therelative sumof theutil-
will be: a follow-up period of 5 years, Sundqvisr et aI' (64)
itiesoI statey (Uy)andstatez (Uz).the formalexpression
reported comPlete resolution ir 74"" of 54 retredted
-
Ux= lp)(Uy)+ (1 pl(Uz) teeth, Irrformation on the outcome of surgical retreat-
lf perfecthealthis givena utilityof t anddeathis givena utility ment is abundant. Many methods have been adopted
of 0, thenUx= (p)(1)+ (1 - p) (0),i.e.Ux= p. and reported success rates vary between 30% and
An examplewill makeit easierto understand the method. 90% (2O). In a comprehensive review of the Literature,
lmagine thatyouhavebecome blindandhave not been able to see Hepworth and Friedman (20) tried to estimate the
for a couple ol years, A new surgical method is very promising and suc-cess rate of retreatment by rneans of a weighted
is offered to you.Theproblem is thatthereis a riskthatyoumight average calculation, reporting 59% and 66% for surgical
dieasa resulto{ the surgical procedure. In the standard Gamble
and non-surgical approaches, respectively.
thechance of survival or riskof dyingisvariedto frndthefrequency
Outcome studies have focused almost exclusively on
whenyouareindifferent betneenstayingblindor beingtreated
a person whois indifferent whenthereis either surgical o/ non-surgical retreatment procedures'
Usingtheformulaabove,
a'10%riskof dyingvaluesthe stateof beingblindto 0.90on a However, Allen (1), in a retrosPective analysis of 633
scalefrom1 to 0.Another person will perhaps beindifferent when cases where either of the two methods was used, found
thereis onlya l% riskoTdying,resulting in a utilityvalueof 0 99. no difference, These observations were coûoborated in
a prospective, randornized investigation by Kvist and

(a) ïle first lowermolarwâs treatedfor pulpitis.(b) A periapical

radiolucencydeveloped2 yearspost
Fig. .|4.6 Non-surgical endodontic retreatment.
(c)
infection. Ihe root were
canals and
re-entered to
subjected procedures
antimicrobiâl
the presence
in the mesialroot,signalling
op-eratively of an intracanal
beforetheywererefilled.
208 Therootfilledtooth
of â post and (rown, the secondupperpremolardeveloped
Fig. 14.7 Surgicalendodonticretreatmenl.Followingthe placement
apicoectomy,preparationof the âpicalpoftion of the canâlwith ultrasonic
The casewas retreatedsurgicallywith removalof the soft'tissuelesion,
ând
instruments placementof a superEBA retrofill
Coreconcept14.4 Case-related factors
influencingretreatmentchoice
of thelesion
. Etiology
a Accessto the rootcanal
o Monetary costs
a Quality treatment
of original
o PositionoTthetooth
. Personalskills
Reit (25, Key literature 14.3), who failed to show any
systematic difference in the outcome of surgical and
non-surgical endodontic retreatment
Scientific data do not support the notion ol a system-
atic difference in healing potential between surgical and
non-surgical retreatment. However, whether the recent
rapid development in technology (e.g. nickel-titanium
instruments, rotary systems,surgical microscoPes,ultra-
sonic retrotips, new retrofilling materials) will change
this situation remains to be seen.
Becausethere seems to be no evidence for a system-
atic preference for one retreatment aPProach over the
other, the choice has to be based on individual case-
related factors (Core concept 14.4).
Etiology of the lesion
'failures' the periapical
In the maiodty of endodontic
radiolucency is caused by an intracanal infection.
However, in some cases the causative agent might be
found in the periapical tissue, demanding a surgical
retreatment approach. Bacteria such as Acttnonlyces
israelii and Propionibacterilun ptopionluLm have been
found to be able to prevail outside the root canal (18, 58).
periâpicalpathosis'
Additional strains have been observed (63, 67) but the
prevalence of extraradicular microbes in chronic apical
pedodontitis is controversial.
Pedapical lesions in endodontically treated teeth may
be associatedwith non-microbial agents such as foreign
body reactions to root filling materials (37) aJtd the
development of cysts. Periapical cysts are classified as
'pocket' cysts and'true'cysts. The
Pocket cyst has the
epithelia|lined cavity oPen to the root canal and might
be expected to heal after conventional endodontic tleat-
ment (36). The cavity of the true cyst is comPletely
enclosed by epithelial lining, which might make the
dynamics of the cyst independent of any intracanal
treatment measures.Thus, traditionally it has been sup-
posed that true cysts have to be enucleated surgically in
order to heal.
Clinically it is very difficult to differentiate between
caseswitl"Ldifferent etiology of the PeriaPical reactions'
No accurate tests are available but cysts are expected to
be more prevalent among major lesions (39)
Access to the root canal
Endodontically treated teeth are often restored. In order
to re-enter the root canal, crowns sometimes have to be
perforated and posts removed. Such procedures will
increase monetary costs and the dsks for loosened
crowns and root fractures. Therefore, the more complex
the restoration, the more attractive the choice of surgical
inteNention.
Quality of originel treatment
There is a strong correlation between the quality of the
treatment (as reflected in the technical quality of the root
filling) and the treatment outcome. ln a canal with a
defective seal (short, voids), non-surgical retreatment
 tactorsinfluencing
endondontic
retreatment

Personal skills
Keyliterature
14.3 Surgical
versus
non-surgical Surgical and non-surgical retreatment procedures are
retreatmentprocedures often technically difficult aIld the results that can be
achieved are highly dependent on the personal skills of
H e ê l i n g( % )
the dentist. Therefore, complicated cases might benefit
100 from being referred to a specialist or an experienced
colleague.

Conclusion
Whether endodontic retreatment should be performed is
a complex decision situation and many factors have to
be considered. For the clinician it is important to appre-
ciate the microbiology and pathology of the non-healing
periapical lesiory as well as the technical potentials arrd
limitations of retreatment. Howevet as important
professional knowledge and skill might be it must be
6 1 2 2 4
Time(months) emphasized that the final decision is in the hand of the
informed patient. The subjective meaning of the situa-
KvistandReit(25,26)randomized 95 incisors andcanines, classi- tion will vary among individuals. Remember that the
fiedas'failures' according to the Strindberg (62)criteria,to surgÈ patient is the expert on which symptoms are tolerable,
calor non-surgicat retrealment. Threerandomization fadorswere which economic costsare acceptableand which risks are
considered: sizeof the periapical radiolucency, the apicalposition worth taking.
andthetechnical qualityoftherootfilling. clinicalandradiographic
follow-ups weremadeal 6, 12,24 and48 months postoperatively.
Toobtainidentical radiographs at consecutive interva15animpres-
sionwasobtained of thepatient's dentalarch.Theimpression was References
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Oral Sltrg. 54: 566 74.
Part 5
CLINICAL
M ETHODOLOGIES
C h a p t e r1 5
Radiographic
examination
Ib Paul Serperin
lntroduction
Radiographic exanination is essential before, during
and after an endodontic procedure (Fig. 15.1). Radi-
ographs may reveal inJormation of significance for the
assessmentof the disease status of the tooth (e.9. root
resorption processes)and the surrormding tissues (peri-
apical inflammatory lesions). Radiographs also provide
information about anatomy of importalce to guide the
clinician in his/her approach to the treatment proce-
dures (Fig. 15.2a-d). The following observations are then
critical:
(1) The number of root components and root carrals.
(2) The possible presence of supernumerary roots and
root canals.
(3) The length of the root components.
(4) The width of the root canals,
(5) Root deviatons.
(6) Potential presence of obstacles.
During the treatment per se t}]Leoperator is guided by
radiographic examination, and after treatment the final
result is controlled by radiography, immediately as well
as after a period of observation (Fig. 15.3).
In additiory radiographs show how proximal roots
are to anatomical structures such as the mandibular
canal arrd the maxillary sinuses. A bony separation
between root apices and the sinus may be absent
(Fig. 15.2e).If precautions are not taken, the risk of per-
forating the sinus mucosa and forcing medicaments
and root filling material into the sinus cavity is obvious.
ln the posterior parts of the mandible, a close relaton-
ship may exist between root apices and the mandibular
canal, which implies a risk for damaging the rnandibu-
lar nerve by overinstrumentation and overfilling (see
further below).
Techniquesin radiographic
examination
for endodonticpurposes
Basicdemands
kr order to evaluate the health status of a tooth arrd
its anatomy, depiction of the whole root complex, in-
cluding the root apex/apices, the pedodontal ligament
space, the lamina dura and a surroulding 2 mm of bone,
is mandatory. In t}re case of periapical bone loss, the
whole periphery of the destruction should be exposed.
For multi-rooted teeth and teeth that may present multi-
rooted vadations, angulated views are necessary to
display each root component.
lmagingtechniques
ConoentionaI film r adiography
Conventional radiography utilizing traditional x-ray
machines, film and processing techîiques is still the
generally used method in dental practice. However,
new alternative techniques have appeared and have
been widely tested.
Digital radiography
In recent years digital radiography has progressed.
Becausethe costs of digital radiography are still consid-
erable, the method so far has gained only limited use.
An outstanding advantage of this technique is that the
radiograph is produced immediately or within a short
period of 10-20 s. Digital imaging further offers the pos-
sibility of image enhancement, and it is also possible to
make exact measurements directly from the computer
image. However, no digital system yet has shown better
results in determining canal length and file position or
interpreting periapical lesions tJlan conventional film
imaging (11, 18, 23). In a study comparing diagnostic
performance, using conventional D-speed and E-speed
films and storage phosphor computed radiography,
no significant differences were found (12). The digital
215
216 Clinical
methodologies
Fig.t5.1 useof râdiogrâphy (a)diagnosisând
procedure:
duringendodontic
treatment
(d controlof flnâltreatment.
technique also includes subtraction programs, which
means an improvement in identfying minor lesions
and changes in radiographic density not visible by the
naked eye. ÉIowever, to be useful, identical projections
are critical.
Other im6 gin I t echni ques
Xeroradiographic images: prodtced by an electrostatic
process,these were expected to facilitate visualization of
early periapical lesions due to the edge enhancement of
the technique, but this has not been the case (21).
Multimodal narrow-beamsystems:producing sequential
tomographic images, such systems have been shown to
perform as well as conventional periapical radiography
for detecting periapical bone lesions (20), but the equip-
ment is expensive.
Microcomputedtomogruphy(Fig. 15.4): this is a fascinat-
ing new methodology because it presents accurate,
three-dimensional images of internal tooth morphol-
ogy (5, 15). The method is complicated and time-
consuming and until now has been used only for
research purposes.
planning;(b)
detemination controlof rootfilling;
ofworkinglength;(c)
In conclusion, we are at the doorstep of the digital era
in dental radiography and yet the new methods have not
totally replaced conventional radiography in the daily
practice of endodontics. Consequently, in the Present
chapter radiographic diagnosis and working procedures
are based on conventional radiographic techniques. This
chapter also is limited to radiography in relation to
endodontic treatment of the adult patient.
angleor parallelingtechnique?
Bisecting
Geometricconsidetations
Becauseexact measurements of root lengths are impor-
tant for the proper instrumentation of root canal(s) in
endodontic therapy, a radiographic technique resulting
in minimum image magnification and minimum image
distortion is crucial.
Before any treatment is started, an initial radiograph
must be taken to serve as a preliminary guide for the
procedures to be undertaken (Fig. 15.1a). Of the two
classicaltechniques for obtaining periapical radiographs
- the bisecting angle technique and the paralleling tech-
nique - the latter is recommended without reseryations.
The bisecting angle technique is maintained to secure
 examination 217
Radiographic

Fig.15.2 Unpredictable râdiographic

findingsof importance treatment(a)extraordinarily
for endodontic longrootsof tooth47 andhypercementosisof distal
rootcomponent andângulation
of mesialrootcomponent ofiooth46;(b)exïaordinarily shortrootso{ mandibular (c)likelyinaccessible
premolars; apicalregion
dueto rootcânalobturationandhypercementosis; (d)denticlein tooth13 (courtesyof DrG.Eergenholtz); (e)largemâxillâry betlveenroots
sinuswith recesses
of posteriormaxillary
teethanda closerelationship of rootsto bonywall of sinut representing sinusdurjnginstrumentation
a riskof intrudingthê mâxillary
androot fillingprocedures.

Fig.15.3 Series
of radiographs therapyof tooth11:(a) initialradiograph
with endodontic
takenin conjunctjon show;nga mesial, deepcarieslesionprompt-
(b)immediate
ingthetreâtmenl; postoperative
radiographdemonstrating takenata 2-yearrecallappointment
thedenserootcanaI filling;{c)radiograph showing
normalperiâpical
conditions
andindicating outcome(courtesy
a successful of DrA. Gesi).
214 Clinicalmethodologies

Fig. 15.4 lhree-djmensional

lransparent of the pulp
reconstruction
chamberândtherootcanals firstuppermolar(courtesy
in â permanent of
DrL.Bjorndal).

LB

exact root lengths without magnification, bui only in

theoryi for multi-rooted teeth with different distances
between the root apices and the film, distortion always
occurs (Fig. 15.5).
Forsberg and Halse (7) measured experimentally how
the size of simulated periapical lesions was projected by
the bisecting and the paralleling techniques. The bisect-
ing technique often resulted in incoffect reproductions
of the true lesion range, and reduction in size up to 50% -===tt===

was sometimes observed. It was concluded that the par-

alleling technique is far more accurate in imaging the
extent of periapical lesions. Fig. 15.5 Drawingdemonstrâting the principlesof the bjsectingangleand
The paralleling technique is based upon the use of the paralleling techniques. In the bisectingangletechnique the radiographic
film-holding devices, among which a great nurnber are film is placedin closecontactwith the toothcrown.Thispositionresultsin
imagedistortion be(âuse the film planeandthe longitudinal toothaxisfom
available (Fig. 15.6a).For radiographs taken during the
an angle.In the paràlleling technique the film is positioned (usinga film-
endodontic procedure certain problems exist, because holdingdevice)pârâllelwith the longaxisof the toothandthusminimizes
these radiographs are taken under a rubber dam and distortion.[ = linqual:B = buccal.
often with instruments inserted into the root canal.
Special film-holders allowing the presence of root canal
instruments during exposure are available (Fig. 15.6b).

(b). To give two examples: ifa is 150mm (short cone

Working length determination
The ideal depth of instrumentation and thus the final
position of the root filling must be determined with great
accuracy.Two fac{ors are in effecl:
(1) Any radiographic image will be magnified because
there is a distance between the object (the tooth)
and the film. The magnification varies with
focus-obtect distance (n) and object-film distance
technique) and û is 30 mln (typical maxillary incisor
distance), the magnification will be 20"k; iÎ q is 300
mm (long cone techdque) and û is 10mm (typical
mandibular molar distance), the magnification will
be orly 31".
(2) If the long axis of the tooth is angulated in relation
to the film plane, elongation or shortening will
appear on the radiograph. For multi-rooted teeth
with facial and lingual roots, the problem is even
 examination 2't9
Radiographic

Fig. 15.6 Film-holders for use in

endodontic (a)Devices
radiography. for
parallelingtechniquein initial radi-
ographr(right) XcP-holdingdevice;
(center)Eggenfilm'holder;(lett)Hawe
superBite.(b) Devicefor working
lengthdetermination with instrument
in the root canalduringradiographic
exposure,

more complex because angulations of the buccal

and lingual roots commonly differ in their relation
to the main axis of the tooth.

It is nearly impossible to calculate the exact length of a

root from a single radiograph, therefore working length
determination by radiography is carried out in three
steps:
(1) The initial radiograplu giving an overyiew of the
{oot anatomy, provides a rough estimate of the root
canal length. This radiograph should be taken with
the paralleling technique to secure the least distor-
tion possible.
(2) The radiograph serves as a guide for insertion of a
root canal instrument to the approximated working
length. The instrument must carry a stop, which is
placed level with a reference point on the tooth
surface (incisal edge or cusp tip).
(3) The true working length is decided from the sub-
sequent radiograptr, which will show the distance
of the instrument tip to the radiographic apex. If the
instrument ends more than 1mm shorter or longer
of what is considered to be an ideal length of instru-
mentation, then a new radiograph should be taken
for an accurate estimate.
A simplified method allowing an immediate reading of
the tooth length is to use a calibrated ruler (Fig. 15.7).
Note that bending of the film package may influence
the apparent instrument and tooth length. Bending
away from the apex will cause an elongation of the
radiographic instrument ('trial file') length compared
with the factual length (Fig. 15.8).Becausefilm bending
may be difficult to control in the moutll the use of a stiff
backing is desirable.
Another method for working length determination is
the use of electronic devices (see Chapter 16).
V e r t i c alli n e s . 1
Fig. 15.7 calibratedrulerfor !1/o*inglengthdeterm;nation (Marinal@).
A
radiographwith an instrumentof knownlengthinsertedis exposed. Any
imagemagniflcâtionand/ordistortionwill be proportional
for the instrument
andthe tooth,andthe true (previous unknown)lengthof the toothcanbe
readdirectly.
Angulated views
Three-dimensi onal int erpretati on
A single radiograph only provides a two-dimensional
perspective. Bone and dental structures then become
superimposed and it is impossible to determine their
position relative to each other, e.g. whether a structure
is facial or lingual to another structure. In endodontics
this applies to positions of roots and inserted instru-
rnents for working length determination. Taking two
projections from different angles and a logical use of the
principle of parallax enables the dentist to distinguish
these positions.
The principle is based on the fact that the position of
a structure close to the film remains more stable than a
structure that is distant to the film when both structures
 220 Clinicalmethodologies

are observed from viewing angles that are altered from
the orthogonal projection. This is the essence of the
'Buccal
object rule' and the popular 'SLOB rule, (Same
Lingual, Opposite Buccal): it appears as if a,lingual,
structure (close to the film) 'moves' in the ,same, direc-
tion as the tube, and a 'buccal' structure (distant to the
film) moves in the 'opposite' direction, when the pro-
lection angle is changed (Fig. 15.9,.
Figure 15.10shows two images of a maxillary first pre-
molar from a full moutl.r survey: an orthogonal view
(bitewing projection) shows one root filling and one
post, whereas a mesial view (canine periapical projec-
tion) reveals a buccal and a lingual root filling and,
moreover/ informs that the post is positioned in the
lingual root component.
In producing angulated views for three-dimensional
interpretation it is essential thât the film is placed in
exactly the same position for each exposure. The central
x-ray beam should be angulated 20. mesially and dis-
tally in relation to the orthogonal projection in the hori-
zontal plane. It is of great help to use film-holders with
a beam-guiding device (Fig. 15.6).

Extended use of full mouth suraeys

Fiq.15.8 Whichisthetruelength
the same,exceptthat the film packagewasbentin the apicalregionin the
dght-handimage.
In full mouth surveys, most teeth are depicted more than
once and in different views. A comparison of these views
often provides valuable information on root anatomies.
Permanent mandibular inciso{s frequently contain two
canals (6, 13). The faciolingual dimension of the canal is
always clearly larger than in the mesiodistal dimension.
A view strictly perpendicular to the facial surface pro-
vides only limited information on the morphology of
ofthiscanine?
Allexposurevariableswere the pulp chamber and the root canals compared with
angulated views. The routine canine projections often
add valuable information about root canal anatomy

$ R

Fig 15.9 Theprinciple of parallax('buccalobject rule'or'sloBr!le').In anofthogonalview(o)thetwostructures (thelargeandthesmallball)willappear

superimposedon the film.Thestructure closestto thefilm (thelargeball)k the mostttable' whenthetuvostructures
areviewedfromthe left(L)andfromthe
right(R)Thestructure distantto thefilm (thesmallbâil)will 'move'in the oppositedirectionasthe x-raysfocus.
 Radiographic
examination

Fig. 15.10 (a) orthogonalview in a bitewingradi-

ographrevealsroot filling and post in tooth 24. {b)
lvlesiâlviewrevealstvvorootfillingsandthe positionof
the postin the lingualcanal.

Fig, 15.11 Additionalinformationobtâined by

combining differentviewsfrom a full mouthsuNey:
(a) mandibular canineprojection;(b) incisorprojec-
lion. Ahhoughteeth42 and 41 showone canalin
certainview' otherviewsrevealdividedcanalsin
both.Alsonotethe dividedcanalin the apicalhàlfoI
tooth43.

of the incisors by depicting them in angulated views
(Fig. 1s.11).
Advantages and limitations of radiographs
By proper use of radiography, endodontic procedures
are facilitated and tlLe prospect for a successful result of
the treatment is improved. However, the dentist should
be cognisant of several limitatiors in the informative
yield of the radiographs (Core concept 15.1;Case study
Accessory canals, lateral branches and apical ramifi-
cations are most often so discrete that they cannot be
expected to be visible in radiographs (19). Indeed, scan-
ning electron microscopy (SEM) studies have revealed
up to 16 apical foramina in permanent teeth and a vad-
ation of 0.2-{.38mm in the distances between tps of the
apices and the foraminal openings (10), but such ramifi-
cations are rarely identified urrless they are filled by a
contrasting medium, e.g. root fijling material.
Radiographicdiagnosisof sequelaeto
pulp necrosis
of periapicald isease
Expressions
Periapical pathoses nea(ly exclusively affect interior
areas of the alveolar bone and are thus not accessible for
 Clinical
methodologies

Any lesion starts as a discrete, hardly demonstrable

Coreconcept 15.1Advantages of radiography
and radiolucency, which gradually may progress. ln some
limitations
in the interpretation
of radiographs
in cases the lesion becomes sharply demarcated, and in
endodontology other cases it appears diffuse (Fig. 15.12). The latter is
one explanation as to why there is wide inter- and
Advantages
intraobserver vadability in the diagnosis of periapical
Provides
information
regarding: lesions (8, 16, 21) (see also Chapter 14).
. Rootmorphology It is important to realize that the radiographic image
- stageof development (chjldrenandadolescents) tells us nothing about the age of a bony change or about
- number of rootcomponents its stage, e.g. whether it is progressing or heaLing or
- number of rootcanals slrnptomatic (Fig. 15.13).
- diversionsof rootcomponents, Apical periodontitis may produce various features in
o Previous
endodontic treatment the radiograph suggesting that a lesion rnay be about
- length,densiry andadaptation ol rootfilling. to progress. Such indications include widening of the
. Periapical
lesion apical periodontal space and loss of lamina dura.
- presence However, these signs are also associatedwith teeth sub-
- extenston jected to:
- position
- complications (e.9.cystformation) o Traumatic occlusion
- pathogenesis (e.9.parietalperforation). o Ongoing orthodontic treatment (Fig. 15.14)
o Rootcanalobstructions. . A previous trauma.
. Complicationsof endodontic treatment
- Hence, the identification of a widened periodontal space
fractureof instruments
- rootperforations or loss of lamina dura may or may not suggest that a
- rootfractures. root canal inJection is ongoing (Fig. 15.15).
. Adjacentanalomical structure(e.9.mandibular canal,mental
foramen,maxillarysinus). Periapical sclerosis
In certain cases of apical periodontitis a sclerosis may
Limitations appear. The sclerotic zone may either surrorjnd the
entire periapical radiolucency or occupy the whole
. lhe radiographis two-dimensional, whichmeans that:
- lesion area (Fig. 15.16).
structures
maybeobscured
- overlappingstructutes cannotbeseparated
- no conclusions canbe drawnaboutthe relationship Differentialdiagnosis
between structuresat different
distances
fromthefilm.
. Radiography is a crudemethodof examination, and radi- Periapical radiolucencies may have causesother than an
ographically
demonstrable bonelesions arealwayslessexten- infected pulp necrosis and are therefore important to
sivethanthetruelesions. identify before a treatment decision is taken. Exarnples
. Ihe radiograph is a staticimageprovidingno information include:
aboutthedynamics of disease processes. o Anatomicalstructures
. Diagnosticsensitivity
andspecificityarelow . Developmental and physiological phenomena
. Intra-andinterobserver variability
arehigh. . Periapical scar tissue
r Traumatic injury
o Tumor
o Periapical lesion of periodontal origin
o Osteomyelitis
direct visual inspection. Because clinical symptoms
r Radicular cysts.
often are absent or scarce, imaging techliques such as
radiography are therefore often the only means by Distinguishing a fully formed radicular cyst from
which periapical lesions can be detected. non-cystic lesions of apical periodontitis is another dif-
An osteolytic lesion will be visible only if there is loss ferential diagnostic issue that will be considered here.
of mineral to an extent that the difference of radi-
ographic density is detectable by the naked eye. Several Anatomicfll stluctures
studies have pointed out that cortical bone lesions are Radiolucent anatomical structures may be projected
easier to identify than lesions limited to the cancellous over the apical area of teeth and simulate apical patho-
bone. This is due to the relatively higher loss of mineral sis. This may be the case with mandibular premolars,
lesions produced in cortical bone (4). where the mental foramen may project in the vicinity of
 examination
Radiographic

Fig.15.12 Examples of râdiogrâphic of periapical

distinctness {a) sharplydemarcated
lesions: of tooth26; (b) diffusely
lesionat palatinalroot component
lesionat mesiâlânddistâlrootcomponents
demarcated of tooth46, makingit difficultto statethe extentoI the lesion.

mesiâl)
Fig.15.l4 Periapical(and attooth44 originating
radiolu€ency from
Fig.15,13 lhe râdiogrâph
tellsusnothing aboutthestageoI â lesion
{pro- orthodontic forces.
treatment
gressing, Essential
healing?). for diagnosisof theperiapical
radiolucency
of
âboutprevious
tootht2 isinlormation findings orsmaller
{larger and
lesion?)
timeof previous
treatment.
Actually,thistoolhwâssurgically
treated2 months
Deoelopmental attd phy siological phenomena
before wastaken('empty'
therâdiogrâph lumen maybea composite paste).
One simple explanation of a periapical radiolucency
may be that root formation has not terminated and the
apical foramen is still open. In the primary denttion
the root tip fig. 15.17). If the tooth through the radi- periapical radiolucencies a(e norrnal findings during
olucency displays a clear periodontal ligament space stages of physiological resorption. Around retained
around its circumference, it suggests representation of primary teeth in adulthood with slowly Progressing
the mental foramen. resorption, similar radiolucencies can be seen.
In the maxillary incisor region a pronounced incisive
fossa as well as the incisive canal may be misinterpreted Periapical scar tissue
as a periapical lesion. Even the radiolucent zone on each Surgical treatment of periapical lesions may sometimes
side of the nasal septum, representing the air-filled nos- result in the formation of scar tissue, leaving a perma-
trils, sometimes gives rise to questions on the possibil- nent defect in the bone that is visible in the radiograph
ity of periapical lesions associated with the maxillary (Fig. 15.19). Typical findings indicative of scar tissue
central incisors (Fig. 15.18). formation are, according to Molven et 41.(14):
 Clinicalmethodologies

Fig.15.15 Widenedperiodontal
spaceat tooth15.

Fig.15.17 Periapical
radjolu(ency
aroundtheapexoftooth35.Becâusethe
periodontâl
membrâne spaceappears
intact,
it canbeconcluded
thatthere
is
anoverlapping
of thementalloramen.

changes (Fig. 15.22) and extemal root resorptions that

may destroy the entire root structure.

Fig.15.16 Bonesclerosis periapical
bordering lyticlesions
at bothrootsof
tooth46.
r Reduction of the bony defect but persistence of a
widened periodontal membrane.
r A pattem of irradiating fine bone trabeculae in
contact with the root end.
. A solitary defect surrounded by compact bone but
without root contact.
Traumaticinjury
Tlpical results of acute physical traumas are luxation
injuries (Fig. 15.20). Extrusive as well as lateral (facial)
luxations will generate widened periapical spaces
withoui pulp being necrotic or hJected. The majority of
dental injuries involve maxillary cenbal incisors and
may cause horizontal root fractures (3) (Fig. 15.21).
hiured teeth should be followed radiographically to
catch later development of lateral or periapical tissue
Tumots
Radiographically one of the odontogenic tumors - the
periapical cemental dysplasia - shows a close resem-
blance to a periapical lesion of infectious origin
(Fig. 15.23). This tumor is easily distinguished from peri-
apical hflammatory lesions because the pulp wiil
appear vital and the toottr, in many cases, is intact and
without any history of trauma. In later stages, the radi-
olucent area will be occupied by mineralizations that
start in its central portion. Such lesions certainly do not
require endodontic treatment.
Osteogenic sarcomas belong to the malignancies that
may affect the jaws. If the origin of the tumor is adjacent
to root structures, widening of the periodontal space and
associated migration of neighboring teeth are t'?ical
signs. Although such a lesion is extremely rare, it should
always be considered in cases when there is a periapical
radiolucency on a tooth where the pulp is clearly vital
(see Case study 2).
Metastases from malignant tumors elsewhere in the
body may affect the jaws and also may be located in
the periapical region of teeth. Radio$aphically they are
characterized by indistinct borders. Often the compact
bone is involved,
Periapical lesion of periodontal origin
A marginal periodontal destruction may reach and
involve the periapical region. In most cases the route of
infection is obvious, but sometimes a local marginal
deshuction may be obscure radiographically and ihe
periapical lesion may be mistaken for a process of
endodontic origin (Fig. 15.24).
 Radiographic
examination

Fig. 15.18 (a) Questionable periapical

lesionàround
the apexof endodonticallytreatedtooth21. (b) Distal
view revealsthat the'lesion'is dueto nostrilradiolu-
cencyandnasalcartilâgerâdiopacity.

Fig.15.19 {a)Preoperative
radiographshowingcystic at tooth22.
lesion tig. 15.20 Periapical
radiolucencies
ot teeth11 and21 dueto luxation
(b)Controlradiograph
14monthsâfterresection
of rootandretrograde
root following tràuma.
mechanical
filling(amalgàm), periapicalbony
showing scararoundtheapexofthetooth.

tion is accompanied by severe pain and elevated body

In lesions of suspected combined endodontic and
periodontal origin, pulp vitality may exclude the need
for endodontic treatment, but in cases of non-vitality the
two entities are often difficult to distinzuish from each
other.
Osteornyelitis
On very rare occasions endodontic infections may
spread and involve large areas of surroulding bone ald
cause osteomyelitis (Chapter 9; Fig. 15.25). This condi-
temperature. The radiographic image is characteristic
artd shows a linear pattem of radiolucent bone, leaving
islands of normal bone, which later may become devi-
talized and trarrsform to sequestrae.
Radicular cysts
A periapical inïlammatory lesion eventually may traas-
form to a radicular cyst (Chapter 9; Fig. 15.26). A sign
indicating cystic trarsformation is a sclerotic zone bor-
dering a distinct, fairly large radiolucent area. Cysts tend
 clinicalmethodologies
to be larger than non-cystic lesions of apical periodonti-
tis (granulomas), although tlrcre is a u.ide yariation in
the size of each. Only a few non-cystic lesions grow to a
size exceeding 70nnf (22), whereas cysts will expand
continuously and finally may occupy a considerable
portion of the iaw bone. Flowever, a fum diagnosis is
often not possible, especially when lesions are relatively
srnall. Frorn a treatment point of view the differential
diagnosis is not important because both lesions are
treated similarly by conventional endodontic therapy.
Only if failing or if exudation tfuough the root caral by
Fig.15.21 Horizontal followingfrontalinjury(cour-
(arrows)
roottractures
tesyof Dr G.Bergenholtz).
cyst fluid prevents completion of endodontic therapy is
surgical treatment indicâted.
Informationf rom radiographsessential
to endodontictherapy
Producing radiographs of optimum image quality and
interpreting them correctly serves an important basis for
attaining high success rates of endodontic therapy.
Dental anatomy
PuIp caoity
On assessing a possible exposuie of the pulp in carious
teeth or the relation of the pulp to deep fillings, one has
to understand two facts about the radiographic image:
(1) The radiograph is two-dimensional arrd distances
between two points will depend on the projection
angle.
(2) The radiographic image shows a bum-out effect.
This means that a pulp cavity with curved borders and
tiny extensions of pulpal homs will not be depicted with
clearly deLineated margins. In general, the pulp cavity
has a greater extension than is usually visualized by
radiographs.
Root cotnplex
In many cases the depiction of the root complex on
a radiograph seems unsatisfactory but carmot be
improved for anatomical reasons. Figure 15.27 shows an
example of root apices of a maxillary first premolar that
Fig. 15.22 (a) Radiograph of lower right
incisorinjuredfollowinga fall in the school-
yard.lhereârenovisiblepathological changes.
(b) one yearlatera perkâdiculâr radiolucency
wâspresentandrootcanaltreatmentwasini-
tiated.observethattheaccess openingis situ-
atedtoo fâr gingivâlly,
whichprecludes access
to a lingualcanal(courtesyof Dr P Horsted-
Bindslev).
 Radiographic
examination

Fig. 15.23 (a) Periapicalradiolucency

aroundthe apicesof teeth31 and41 with
vitalpulp,diagnosedasperiapical cemental
dysplâsia.(b) later in the process,the
râdiolucency becomes filled by coalescent
radiopâcities o{ cementum(counesyol
Dr G.Bergenholtz).

Fig..|5.24 Periapicalradiolucency
aroundthe âpexof tooth16.presumably
of periodontâl
origin.

are hardly distinguishable from the surrounding bone.

Fig..|5.25osteomyelitis oftooth43ina 7,|-yeâr-old
intheapicalarea man.
Two factors determine how clearly visible and how dis-
Tooth42 hasbeenlostdueto theinfection.
A widespread,
diffusely
demar-
tinct a root structwe will be depicted in a radiograph: catedradioluceng
is seen.
(1) The rutin betuem root uolume and suftounding bone
aolume.'lhe thicker the root and the thinner the sur-
roulding bone, the better the root will present Root cattals
itself, and vice versa. Gracile roots surrourLded by Information about root anatomy, i.e. number of
thick and heavily mineralized bone rnay be cam- roots, deviations, obstructions, root canal width, etc.
ouflaged easily. (Fig. 15.2), which is essential for proper treatment plan-
(2) Root morphologyand the directinn of the centrul x+ay ning, may be obtained in two ways: by tactile explo-
beam.A flat lateral root surface depicted by x-rays ration during root canal instrumentation and by
parallel to its surface will appear with maximum imaging methods, e.g. radiography. In Beneral these two
definition compared with a rounded surface. An methods supplement each oilrcr and one carnot do
apex with a cut surface will appear more distinct without the other. Although it should be possible to
than a pointed one. identifv all root calal orifices bv direct visual examina-
 clinicalmethodologies

tion, it is essential to ernploy radiograPhic examinations
prior to initiation of ttrerapy. Radiographs may reveal
ihe number of roots and the exPected number of canals
as well as lheir courses and passages Also, any aber-
rations from the normal pattern may be disclosed'
For example, mandibular premolars and canines may
present doublings of root complexes and supemumer-
àry root carals (Fig. 15.28).Mandibular molars may also
exhibit supernumerary roots (radix paramolaris an.d raditt
entomolaris)with seParate suPernumerary root cana$
(Fig. 15.29).It should be noted that supernumerary roots
ma:y be camouflaged completely in ordinary, orthogonal
projections.
Root curoatuïes
Deviations of root aPices that are parallel to the fiLn
plane are normally clearly visualized, but deviations
ihat are perpendicular to the film plane are hardly dis-
cemlble. Therefore during endodontic treatment the
clinician should anticiPate that curvatures in such direc-
tions do occur and may pose a risk for causing a ledge
or root pedoration. If a trial file radiograph shows that
the ideal working length is not reached, and if the oper-
ator feels an obstiuction in the root canal, then a buccal
or lingual curvature may be the cause (Fig 15 30) In
such casesan angulated view may reveal the existence
of a curvature. Using the SLOB ru1e (see above), it is dlen
possible to determine if the deviation is directed in a
buccal or a lingual direction.

Root canal utidth

In order to carry out a successful endodontic treatment
the root canal must be patent all the way to the apical
region (Fig. 15.2).There may be a generalnarrowirg of
the canal, resulting in a (nearly) total obliteration, or
there may be local obstructions dùe to mineralizations'
cyst
radicular
Fig.15.26 Typical On assessing these aberrations it should be borne in

'1 (b) canine

(a)premolârprojection;
invisibility: cârefulexaminâ-
Fig.15.27 Gracileroot componenls ot tooth 4, resultingin virtuâlradiographic .proiection
of normal length.Ihestructure markedwith ân arrowin (b),resembling
a shortroot represents
two separated
reveals
tion of originâlradiogrâphs components
the furcationbetweenthe rootcomponents.
 Radiographic
examination

Fig. 15.28 ldentification

ofthe numberof root canals.In tooth 46 two
distinctcanalsareseenmesially,
tooth45 is a two-rootedvariantwith two
separate canalsandtooth44 exhibitsdiversion
ot the apicâlhall

tig, 15.30 (a) tacialview of a mandibular premolârwith an instrument

insertedshodnga'stop'5mmfromapex.lnâ clinicalsituation the operator
â moreapicallevel.(b)Amesialviewtells
mighttry to forcethe instrumentto
usthat the root hasa buccâldiversion.Efforbto forcethe instumentin a
moreapicaldirection wouldprobably resultin a linguâlperforation
olthe root
or an instrumentfracture.

The most common core material for root fillings is

gutta?ercha, and a radiopaque root canal sealer is often
added. Although these products have a virtually identi-
cal degree of radiopacity, it is somewhat below that of
Fig.15.29 A rôdixentomo/ar,s
located
linguâlly
in tooth46.lt hasobvi- metal (Fig. 15.31).
ouslynotbeenidentified
duringtheendodontic
treatment becâuse it is not In clinical practice, patients sometimes have root fill-
filled. ings with metallic cones as the core material (most often
silver). Root fillings with silver cones and gutta?ercha
are easily distinguishable due to the radiopacity of the
mind that the radiographic image of a root canal metal (Fig. 15.32).
depends on: The radiograph may also suggest the kind of post
material being used. Identification of post material is of
r The morphology of the canal.
. great significance for the assessment of whether post
Its extent in relaton to the central x-ray beam.
removal should be attempted or not in a retreatment
r The ratio between hard-tissue volume and pulp
effort. The radiopacity of post materials differs accord-
canal volume.
ing to their atomic number (Z). Posts ftom gold (Z = 79)
This means that in certain cases, even if a canal seems are highly radiopaque, whereas posts from carbon fibers
totally obliterated, a root canal may be found and (Z = 6) arc radiolucent. Posts with radiopacities in-
successfully treated. between these values are: palladium (Z = 46), zicoriurn
(Z = 40), ttanium (Z = 22) and silicium-hforced carbon
(z(51) = 14\ (Fig. 15.31).
Previousendodontictreatments
Retrograde root fillings formerly were identified
Rootfillings and post materials easily because amalgam was the most commonly used
Root fillings may show apical or lateral voids andlor be material. Toda, retrograde root fillings are often made
either short or overfilled. Root filled teeth also may with various cements (e.g. glass ionomer cements, re-
contain posts that are fabricated from various materials. inforced zinc oxide-eugenol cements, mineral trioxide).
 Clinical
methodologies

Fig. 15.31 Differentrootfillingandpostmateriâls.(a)A 5-yeâr-old metallicfusedbridgefromtooth11 to tooth22 (courtesy

porcelâin of Dr F.lsidor).(b) ln
tooth11 thereis a castedmetallicpost(possibly
gold)andthe renainingguttâ-perchâ rootfilling.In tooth22 the postis madefromcârbonfibers,whichis
radiolucent,
andthe canalappears by a gutta-perchâ
emptyexceptIor the apicalpart,whichis occupied filling(courtesy
o{ Dr P Horsted-Bindslev).

Root frflcture
Too violent handling during endodontic procedures
may cause root fracture. More often, however, root frac-
tures are seen as a late complication to endodontic treat-
ment and post placement (Chapter 12). Fractures of this
kind may be difficult to diagnose in an early sta8e, ard
tlLey may not become evident until the fragments sepa-
rate from each other and a periradicular radiolucency
has appeared (Fig. 15.35).

Peiapical extuusion of root filling material

Sealeras well as core material maybe forced through the
apical foramen in conjunction with the filling procedure
Fig.15.32Tooth 36withtwosilver
conerootfillings onegutta-
mesiallyand (Fig. 15.36a{). In many casesonly minor initial symp-
percharootfillingdistâlly.
Periâpicâl
râdiolucencies
âreseenaroundboth
toms follow, and root filling matedal may remain peri-
roots.
apically for years without causing much irritation and
may gradually disappear (Fig. 1,5.36a,b).
Flowever, complications do occur. Figure 15.36c
A retrograde filLing also may be carried out with gutta- shows a case where a root filLing has been forced into the
percha and a sealer (Chapter 20). There is a varying maxillary sinus. Another serious compLication is when
radiodensity of such materials, which makes them diffi- root filling mate al is extruded periapically in the lower
cult to identify. A composite matedal introduced by Rud molar region or directly into the mandibular canal
et al. (17) contains ytterbium trifluoride to produce (Fig. 15.36d, e). Such a complication often causes either
(semi-)radiopacity (Fig. 15.33). temporary or permanent paresthesia. The intracanali-
cular location is revealed by a horizontal extension of
root filling material along the cranial border of the canal
Treatmentcomplications (Fig. 15.36e).Rapid surgical removal of the excessmat-
Fractureof instruments erial may prevent long-term persistenceof the paresthe-
An undesirable complication to endodontic treatment is sia (9) (seeCase study 3).
the separation of an instrument in the canal. The instru- In the mandibular molar region, extrusion of root
ment is easily identified by radiography because of the filling material through the thin lingual alveolar plate
radiopacity of the metal. In root filled teeth fractured has been reported (1). Owing to the summarizing effect
inshuments are more difficult to identify due to over- in radiography, a displacement of root filling material to
projection of the gutta-percha (Fig. 15.34). the sublingual soft tissues may be mistaken for an intra-

Fig.15.33 Surgicaltreatmentof periapical
lesionon mesialanddistalrootcomponentsof tooth36:(a)preoperative
procedure
surgical of retrograde
rootcanalsealingwith composite
resincontaining
Fig.15.34 Careful examination reveâls
â brokeninstrument;n themesial themetallicpost.
rootcomponent oftooth36{)). lt maybesituated
in a non-filled
rootcanal
concealedbytherootfillingintheneighboring
canal.
bony localization. A cross-sectional occlusal projection
view will give the answer.
Iq.trogeflic root perforatiot s
Instruments used for access opening or for canal prepa-
ration may be forced through the root canal wall and
cause a perforation to the lateral surface of the root
(Fig. 15.37). Also, perforations through the subpulpal
wall may occur (for a review, seeRef. 2). In certain cases
a false root canal may be created outside the root by the
operator and, if urnoticed, a root filling may be placed
in the periodontal space or in the surrounding bone
rather than in the canal per se (seeCase study 4),
Controlsfollowing completionof root filling
The immediate radiographic control of a completed root
filling includes the same considerations as the initial
demonstration of root anatomy. In order to depict all
filled root canals without overlaps, angulated views
are essential. Many root canals in single-rooted teeth
Radiographic
examination
radiograph;(b)controlradiograph
âfter
contrastmedium;(c)healingafter1 year.(Courtesy
DrV Rud.)
oftherootfilledtooth15,probôbly
tig. 15.35 Fracture dueto forces
from
have faciolingual dimensions that are larger tlan the
mesiodistal dimension. Often a circular cross-section of
the canal is not obtained prior to root filling, with a risk
of leaving narrow extensions of the root canal buccally
and lingually ulfilled. This indeed emphasizes the
importance of angulated views. Figure 15.38ashows a
central incisor with an apparently sufficient root filLing.
An angulated protection reveals severe torsion of the
gutta-percha point (Fig. 15.38b).
Non-healing or emerging lesion
Because success cannot be guaranteed in endodontic
fteatment ajrd because clinical s''mptoms are infre-
quently present in cases of periapical pathosis, radi-
ographic control is essential. After completion of an
endodontic treatment, a clinical ald radiographic check-
up should be scheduled within a 6 12-month period. If
a tooth then is without clinical ryrnptoms and is radi
ographically without a periapical radiolucency, the treat-
ment is regarded as successfuland need not be followed
further If a lesion persists or has appeared, the patient
should be re-examined periodically until a decision
about further treatment measures is taken (Chapter 14).
Fig.15.36 (a)SunlusoI rootfillingmaterialperiapically oflooth45.Nopostoperâtive symptom'(b)Resorptionof someofthe rootfillingmaterialand nomâl
pe âpicalconditions 10 yearslater(courtesy of Dr B Horsted-Bindslev). sinut associated
{c) Rootfillingmaterialforcedinto mâxillâry with irritativemucosal
reaction(arrows).(d) Extrusion
of rootfilljngmaterialthroughâpicâlforamenanda closerelationto mândibular canal.Ihepatientsuffered fiom paresthesia
of the skinareainnervated lrom the inlerioralveolarneruelor monih' (e) Rootfillingmaterialforcedinto mandibularcanalduringendodontic treatmentof
tooth37.

(4, (b)

Fig. 15.37 târgepeiapicallesionoriginating fromunsuccessful

treatment
of mesialcanalsândperforâtion
of the distalrootby a post.
Fig.15.38 Misleading imageof rootlillingquality.(a)canineprojectionof
teeth11ând21.Varying radiopacity (+) mayindicatecurvature
in rootcanâl
or a looseflt of the rootfilling.(b)Anjncisalprojection
reveals
torsionof the
gutta-percha point{courtesy of Dr P Hsrsted-Bindslev).

Casestudy 1
Root resorption due to apical pedodontitis
A male patient felt discomfort and mild tendemess from
tooth 26 for years. Apicectomy and retrograde root fill-
ings of the buccal root components were Performed. A
€ase study 2
Differential diagnosisin periapical pathoiogy
A 32-year-old healthy man was referred for an inciden-
tal radiographic finding of a widened periodontal mem-
Radiographic
examination
control radiograph showed a well-delineated palatinal
root component with a periodontal space of normal
width (a). After a period of persisting symptoms the
tooth was extracted. An extensive resorPtion of the
palatal root component was found, indicating chronic
periodontits (b).
brane space around tooth 21. A pulp vitality test was
positive. The tooth had changed its position and, further-
more, there was a hard swelling in the apical region of
the facial alveolar bone. The findings are suggestive of a
malignant disease and biopsy revealed an osteosarcoma.
 Clinical
methodologies
Casestudy 3
Root filling material intruding the mandibular canal
A 52-year-old woman had tooth 36 root filled. The
patient soon felt pain and paresthesia developed in the
mental region of the same side. The dentist removed
the root fillins but was ulable to remove the material
Casestudy 4
Value of angulated radiographic view
A 62-year-old female presented with symptoms from
tooth 16. A radiograph was taken, which showed root
fillings in the mesiofacial, distofacial and palatinal
canals and a metallic post in the palatinal canal (a). An
apical radiolucency is seen around the mesiofacial root
component and it seems that a gutta-percha point is
extending 3mm through its apical foramen.
outside the apical foramen. A radiograph taken after
removal of the root filling (a) showed sealer and 4mm
of gutta-percha in the periapical area, in close relation to
or inside the mandibular canal.
The radiograph (b) was taken after surgical removal
of the excessmatedal and after new root filling. (Cour-
tesy of Dr Jens Kolsen Petersen.)
The angulated view below confirms the presence of
root fillings and a post in the distofacial and palatinal
canals (b). However, it is demonstrated that the gutta-
percha point, which was thought to belong to the mesio-
facial canal, is located in the furcation.
A frontal tomogram confirms the diagnosis and
shows that the gutta-percha point is intruded into
the maxillary sinus ald surrounded by a rnucosal
swelling (c).

References
1. Alantar A, Taûagano H, Lefèvre B. Extrusion of endodon-
tic filling matedal into the insertions of the mylohyoid
muscle. O/al Sr,"g. 1994;78: 646-9.
2. Alhadainy HA. Root pedorations. A review of literatufe.
Oral Sutg. 1994;78t 36W4.
3. Arrdreasen JO, Andreasen F}l. Textbookand Color Atlls
of the Tttlutuatic Injuries to fàe îeetl. CoPenlagen:
Munksgaard, 1994.
4. Bianchi SD, Roccuzzo M, Capello N, Libero A, Rendine S.
Radiological visibility of small artificial periaPical bone
lesions. Dentomaxillofac.Radiol.7997;20: 35 9.
The nean oisibility inder (MVI) { artifcial periûpictll bone
lesionswas comparedwith six bone pafi eteÆ:thicknessof
bone; thicknessof the cortex; thicknessof the spongiosa;àensity
of the spongiosa; corter/spotlgiosa :ttio; and erosion of the
cortex.The MVI uas signirtcantlytissociated@ith the erosion
of the cortexa d uith the densityof the spongiosaqnd the dia-
meterof the lesion.
5. Bjorndal L, Carlsen O, Thuesen C, Darvann T, Kreiborg
S. External aid internal macromorphology in 3D-
reconstructed maxillary molars using computedzed X-ray
microtomography. lflt. Endodoilt.]. 1991 32t 3-9.
6. CàAse O. Dental Motphology. Copen\agen: Munksgaard,
1987.
7. Forsberg J, Halse A. Radiographic simulation of
a periapical lesion compadng the paralleling and the
'1994;
bisecting-angle techniques. Int. Endodonl. I. 27:
133-8.
'lesion' Taasproduceàusing an acrylic
A sim lated peûûpicttl
sphere(diameter2.0mm) cooeredwith a ndiopaque surface
'lesion'
nateriûl. The wasplacedin closecontactTniththe apical
region of 60 extractedteethttfld in continw)tiol1of tfu apical
ûperture.The teethroererûdiogrdphedat controlledIngulations
using bisectingangle and paralleling techniques.The i oesti
gûtion clea y indicatedthat the patalleling techfliqueproTtides
the most leliableinfotmation obout the extefit of tt ptrtholo&ical
8. Green TL, Walton RE, Taylor JK Merrell P Radiographic
and histologic peiapical findings of root canal treated
teeth in cadaver. O/dl Sutg. 1997;831707-17.
9. Grôtz KA, Al-Nawas B, Aguiar EG de, Schulz A, Wagner
W. Treâtment of injudes to the infedor alveolar nerve after
endodonhc procedures. CIin. Oral Iflaest. 7998;2: 73-6.
10. Gutierez JH, Aguayo P. Apical forarninal oPenings in
hurlrnallrteeth. Oral Surg. 1995; 79: 76917.
11. Heddck RI, Dove SB, Peters DD, McDavid WD.
Radiographic determination of cânal length: direct
digital radiography versus conventional radiography
I. Endodont.1994;2o: 320-26.
12. Holtzmann DJ, Johnson WT, Southard TE, Khademi
JA, Chang PJ, Rivera EM. Storage-PhosPhor comPuted
radiography versus film radiography in the detection of
235
Radiographicexamination
pathologic pedradicular bone loss in cadaverc. Orcl Surg
7998; 86190-97.
Miyashita M, Kasahara E, Yasuda E, Yamamoto A,
Sekizawâ T. Root canal system o{ the mândibular incisor'
'1997;23:
I. Etrdotlont. 479-84.
11. Molven O, Halse A, Grung B. lncomPlete healing (scar
tissue) after pedapical surgery - tadiographic findings 8
to 12 years âfter treatme t.I. Endodont.1996;22: 264-8.
T\\ent!-t'our teeth treated b! periapicttl sttgety were obseroed
'l-yeûr
t'or 8-12 yeafi. Scartîsste healingat the contrcl did not
chûflgefor 22 teeth.
Nielsen RB, Alyassin AM, Peters DD, Carnes DL,
Lancaster J. Microcomputed tomograPhy: an advanced
system for detailed endodontic research.,f.Endodot1t1995)
21: 561. 8.
16. Plonait D, Becker J, Barthel C. Kônnen digitale Aufnah-
meverfahren enorale Rôntgenfilme bei der Diagnostik
von Entzikrdungen im Kiefer etsetzen? Dfsch. Zahnaerztl.
Z. 1997;52: 745-4.
L 7 . Rud J, Rud V, Munksgaard EC. Long-term evaluation
of retroglade root filling with dentin-bonded resin com-
posite. ]. Etldodant.1996;22:90 93.
18. Sanderinl GCH, Huiskens & van der Stelt PF, Welândel
US, Stheeman SE. lmage quality of direct digital intraofal
x-rây sensors in assessing root canal length The Radio
VisioGraphy, Visuatix/VIXA, Sens-A-Ray, and Flash
Dent systems compared with EktasPeed fi1ms. Oral Suri.
7994; 78: 125-32.
't9.
ScarfeWC, Fana CR, Fârman AG. RadiograPhic detection
of accessory/lateral calrlrals:use of RadiovisiocraPhy and
Hypaque. /. Endodont.1995;21':1'85-90.
Tammisalo T, Luostarinen T, Vzihâtalo K, Tammisalo EH
Comparison of periapicâl and detailed narrow-beam
radiography for diagnosis of periapical bone lesions.
Dentomaxillofac.Rntliol. 1993;22: 783 7
\ Ihite SC, Hollender L, Gratt BM. Comparison of xerora-
diographs and filln for detection of pedaPical lesions
l. Dent. Res.1984;63: 91.0-13.
Histological diagnosesof periapicallesiolrsot| cadaoerspeci
mens were comparedwilh radiogruphic diagnoses,scoredby ten
orul rudiologists.ln general,the obseroersàetectedabout 70ok
of the cases uith periapical d.isease,uhile simultIneousl!
considering10-15y" of the normal s tfacesto be abflol'm\l
V/hite SC, Sapp IP, Seto BG, Mantovich NJ. Absence of
radiomehic differentiation between PedaPical cysts and
granulomas. Orul Surg. 1994;781650-54.
The fidioyaphic chatucteisticsof 15 periapicalclsts aûd 40
periapicalgranulomasuere comparcd.C':lsts-trercsignit'ictttly
larger than granulomas,btt thereuas û uide potiatiotl il1size
of both types.Therewas no signilicant corrclatiollbetweenthe
densityof a lesionand its size.
Yokota ET, Miles DA, Newton CW, Brown CE. Interpre-
tation of peiapical lesions using RadioVisioGraphy.
l. Enàodont.\994;20: 490 94.
C h a p t e r1 6
Root canalinstrumentation
William P. Saunders
and ElisabethSaunders
Introduction
Root canal inshumentation involves the removal of soft
ard hard tissue, including pulp tissue, pulp stones and
denticles and micro-organisms. It is important that dis-
eased and inJected tissue is renoved as effectively as
possible without damage to the patient, either in a
general sense in relation to systemic healt[ or locally in
relation to the periapical tissues and the tooth itself.
Instrumentation also shapes the carral to accept a sor.urd
root filling effectively, thereby preventing the tooth from
becoming a reservoir for microbial infection.
The complexityof the task
lhe root canal system of the tooth is nearly always
complex, with each tooth displaying its ola.n unique
anatomy (Fig. 16.1).
Root canal curvature
Few root canals are straight, and even subtle curves
introduce complexity into the instrumentation proce-
dure. Straight root canals are found most frequently in
maxillary central incisors, but curvature can occur in the
roots of all tooth t)?es. This curvature may be in a
mesiodistal plane and is thus detected on periapical
radiographic examination. Curves in a buccolingual
plare are often not detected radiographically (Fig. 16.2).
Instruments, especially those of relatively wide cross-
sectional diameter and made from stiff metal, placed
into a curved canal tend to remain straight within the
root canal. This can lead to iatrogenic damage to the root
canal system, which may compromise the successof the
treatment. Not only the direction of the curve should be
ascertained but also the degree of curvature and where
the curvature starts on the root. A sharp curye starting
in the apical one-third (Figs 16.3-16.5)will be more dif-
ficult to manage than a gentle curve beginning in the
coronal one-third (Fig. 16.6).
236
Cross-sectional
shape
A root canal with a round cross-section is easier to
prepare than oval-shaped canals. A rotating instrument
will cut a root canal with a rolÛrd section uniformly, but
instrumentation of a root canal with an oval cross-
section inevitably precludes removal of tissue consis-
tently fuom all the root canal wall. This means that it will
not be as easy to clean an oval canal. Most often the nar-
rowest dimension of tlLe root canal lies in the mesio-
distal plane, which is the one that is detected
radiographically (FiB. 76.7) Some root canals, especially
in specific ethnic groups, have extreme cross-sectional
shapes, including the C-shaped canal. A ribbon-shaped
canal is most often encountered in the distal root of
mandibular molars (Fig. 16.8).
Numberof root canals
The number of root canals contained within the root of
a tooth forms a general pattem (Table 16.1). Of course,
anomalies do occur and vigilance is necessary in inter-
preting radiographs; if in doubt, other radiographs
should be taken at different angles mesiodistally to
allow separation of canals on the processed irnage (see
Chapter 15).
Mandibular incisors often have two root canals and
two root canals are normally found in the maxillary first
premolar The mesiobuccal root calal of the maxillary
first permanent molar often has two root canals. The
minor mesiobuccal or rnesiopalatal root canal (often
termed MB2) may be difficult to find because it is often
very nar{ow and the entrance is often covered by a lip
of dentine (Fig. 16.9). This canal may have a separate
apical foramen or may join the mesiobuccal canal as it
extends apically. The mesial root of mandibular molars
usually contains two root canals but these may not be
discrete throughout their length and the presence of
these fins and anastomoses makes instrumentation more
difficult (Fig. 16.10).
 Rootcanalinstrumentation

Fig..|6.3 Extracted leftmolarshowingsevere

maxillary of bu€cal
curvâture
rootsin apicalpartof root.These without
wouldbeveryd;fficultto instrument
Fig. .|6.1 Rootcanalmorphology molarshowingcomplex
of mandibular
anatomy. causing damage.

firstmolar(tooth26)showing
oI maxillâry
Fig.16.4 Radiograph curvature
portion
in aDical of mesiobuccal
root.

of extradedmaxillarymolârshowinga mesiodistal
Fig, 15.2 Radiograph
Thebuccalcuwatureof the palatalroot is obvious.
projection,
Root canal narrowing and obliteration
Dentine continues to be laid down throughout the life of
the tooth with a vital pulp. Pulpal resPonse to trauma
and dental caries may cause reparative dentine to be
deposited, with consequent narrowing and obliteration
of part of the root canal svstem. This increased hard-
tissue response usually begins in the coronal part of the
root canal system ând proceeds apically. It may take the
form of pulp stones that are free within the root canal
system or attached to the root canal wall. There may be
generalized accumulation of hard tissue on the wall
of the root canal, narrowing the lumen b:r the pulp
chamber of molars the hard tissue tends to form on the
roof and the chamber becomes shortened vertically Care
must be taken in these cases,when gaining access to the
 Clinical
methodologies

Fig.16.5 l\4axillâry
leftlateralincisortooth
showingdistalcuruature
of root
cânalin apicalone-third.
Thiscurveprobably palàtallyaswell,which
extends
furthercompli(ates
instrumentation.
Fig. 16.7 Maxillarycaninetooth:(left view)standardbuccolingual
radi-
ographic (rightview)mesiodistâl
proiection; radiographic
projection
showing
truesizeof rootcanal.

Apicalconfiguration
The apical extent of instrumentation is very important.
This should be at the junction of the pulpal tissue and
the periodontal tissue aJtd is located at the apical con-
shiction (Fig. 16.13).In an immature tooth there may be
no such constriction and great care must be taken to
avoid overinstrumentation. Classic work carried out by
Kuttler (17) demonstrated that the apical constriction
lies 0.5-1mm from the radiographic apex in most cases.
Howevet in elderly patients extensive amounts of sec-
ondary cementum may be laid dowry and the apical con-
striction will be situated coronally, up to approximately
3mm from the radiographic apex. In addition, the main
exit fuom the root canal is rarely positioned at the radio-
graphic apex of the root.
Fig. 16.6 Extracted mâxillaryright molarshowingcurvature
of the
mesiobuccalroot.Thiscurvebeginningabouthalfi^,/ay
downtheroot,willbe
relatively
straightforward
to instrument.
Basictechniques

root canal, to avoid damage to the floor of the pulp Accesspreparation

chamber (Fig. 16.11). In some cases the radiographic
image of the tooth may indicate complete obliteration of
the root canal. If a periradicular radiolucency is present,
however, a patent canal often will be present (Fig. 16.12).
The presence of coronal mineralization makes accessto
the root canal system much more difficult to achieve
with the very real risk of perforation. General nar-
rowing of root canals often makes them difficult to
lnstrument.
Access to the root canal system should allow its suitable
cleaning and shaping without unnecessary damage or
removal of too much coronal tooth tissue. Careful exam-
ination of an undistorted preoperative radiograph will
allow some evaluation of the shape and number of root
canals and the size of the pulp charnber. The presence of
a radiopaque metal coronal restoration will prevent this
evaluation and may complicate the initial accessprepa-
ration of the root canal system. The decision to rernove

Distal canal
first
Fig. 16.8 lhe accesscavityfor a mandibular (note ribbonshape)
m0!ar.
Fig.16.9 Theâccess cavityfor a maxillaryfirst
molâris triangularin shapewith eâchof the Dentinelip covering
mainroot canalsat a cornerof the triângle. mesiopalatalcanal
and eventually replace the coronal restoration is made
easier if the marginal fit of the restoration is judged to
be unsatisfactory or if there is obvious marginal leakage
or dental caries. The removal of a metal restoration will
allow better radiographic interPretation of the anatomy
of the coronal part of the root calal system and will
provide a better view of the access cavity by allowing
more refracted light to enter the PulP chamber.
Rootcanalinstrumentation 2t9
Mesiolingual
canal
Mesiobuccal
canar
Distobuccal
canal
The access cavity should be prepared in such a way
as to remove the entire roof of the pulp chamber and
provide straight-line access to the root canals (Clinical
procedure 16.1).Over the years a number of shapes and
positions for accesscavities have been recommended for
each tooth in the dental arch (Fig. 16.14).
Initial penetration into the pulp chamber should be
undertaken using a bur in a water-cooled high-speed
24O Clinicalmethodologies

Table16.1 Rootcanâlsin teethof mâxillaandmandible.

Maxilla

Centralinclsor '| canal

100%
Lateralincisor 1 canall00o/o
canine 1 canal100%
lst premolar 2 roots57%
Singleroot,2 canâls16%
Singleroot,2 canalt 1 forâmen120lo
3 root' 3 canals6%
2nd premolar 1 canâl530,6
2 canalt 1 foramen22%
2 canal' 'l foramen13%
2 roott2 canals 11%
3 roott 3 canals1olo
lst molar 3 roott 3 canals38%
4 cânals60%
lvesiobuccal Distaicanal
Distai canal lresiobuccal
canal:2 canals60%
canal
2 foramina20%
1 foramen80% Fig. 16.10 Theaccess cavityfor a mandibulâr
firstmolar,wherethe distal
2ndmolar 3 roots600/0 canalis obscured.
Notethe groovejoining
the mesialcanâls.
Thiswillcontain
1 mesiobuccâl canal70% pulpsofttissue.
2 mesiobu(cal cânals:1 foramen|590
2 foramina10%
2 roots25ok
'| root 100/0
Clinicalprocedure16.1

Principles
for preparation
of theaccess
cavityinclude:
Mandible
. Completeremoval of theroofof the pulpchamber to prevent
Centralincisor 1 canal70% of pulpaltissueunderoverhangs
retention of dentine.
o Extension
of theopening to include
all rootcanals.
Lateralincisor 1 canal55%
. Entrances
of therootcanals positionedat theperipheryof the
2 cênal' 2 foramina:central5% accesscavityto ensure thatinstruments canbe placedin the
laterâl150/o
rootcanalseasilywithoutunduebending andstressing.
2 canalt I foramenicentral25%
o Flaring
theopening to allowpropervisualization,especiallyif
laterâl30%
magnificationis to beused.
Canine 1 cânâl70olo
2 canâls,1 foramen20olo
2 câralt 2loraminâ10o/o
1stpremolar 1 canal,1 foramen74%
Branching canali1 foramen4% handpiece. Special burs are available to penetrate metal
2 foramina25% restorations (Fig. 16.15a).It is important to reduce vibra-
2ndpremolar 1 canâ|,I foramen97% tion and bur chatter to a minimum, especially in teeth
Branching cânâl:1 foramen12% with acute apical periodontitis. The basic outline of the
2 loramina3% cavity should be completed with these burs. Rubber
1stmolar 2 mesialcanals600/0,
1 forâmen40% dam placement may be delayed until the pulp chamber
1 distalcânal70olo has been for.urd, although the equipment should be
Distalcânôl:2canalt I foramen35% ready for quick application. The decision on whether to
2 cânâlt2 foramina10o/o
place a rubber dam before or after access to the root
2ndmolar 2 mesiâlcanals40%,1 forâmen35% canal system has been achieved depends on:
I canal25%
I distalcanal92olo o The experience of the operator.
2 canaltI foramen5olo o The completty of the root canal anatomy.
2 canalt2 foramina3% . The alignment of the tooth under treatment in rela-
Cânhavea C-shaped distalcanal tion to the adiacent teeth in the dental arch.

Directing the initial penetration of the pulp chamber
over the widest root canal is less likely to result in iatro-
genic damage to the floor of the pulp chamber. The
anatomy of the floor of the pulp chamber is such that
openings of the root canals usually can be traced by fol-
lowing the grooves in the floor. Subtle changes in color
from a yellowish roof of the pulp chamber to a grayish
floor also assist in finding root canal entrances (Fig.
1.6.1.6).
The use of ultrasonically powered instruments and
magnification has revolutionized the controlled removal
of tooth tissue when finding an opening into root canals.
These instruments are used at low power settings and
with a light touch. The tip of the instrument is cooled
with a stream of air from the 3-in-1 sydngei water cannot
be used becauseit interferes with vision. It is possible to
pick small amounts of tooth structure away in a con-
trolled manner Often, openings to root canals have been
Fig.16.11 (a)largecoronal pulpin a youngmolâr(1J).(b) Hârdtissue
âppositionin the coronalpulp has nâûowedthe lumen,especiallyin the
verticâldimension(1J). (Courtesy
of Dr P Horsted-Bindslev.)
Fig. 16.13 Drawings depicting
tionsof apicalconstrictions
surface,
variousconfigura
ând exit of canalat root
rur
Rootcanalinstrumentation 241
partially covered by mineralized tissue. This rnust be
removed with care to avoid perforation. Overhanging
margins of the roof of the pulp chamber can be removed
with a stainless steel fissure or tapered fissure bur, with
a non-cutting tip, used in a slow-speed handpiece (Fig.
16.15b).This will avoid damage to the floor of the pulp
chamber. Openings to the root canals can be investigated
with a sharp-tipped endodontic explorer and denticles
overhanging the root canal can be picked away. A long
shank or swan-necked bur in a slow-speed handpiece
that is rotating at no more than 1000rpm should be used
to find narrow root canals (Fig. 16.15b).Multiple radio-
graphs at varying angles may be required to ensure
that the relationship of the bur to the root canal is moni-
tored. These should be taken after each millimetre pro-
gression of the bur Agairy the use of magnification helps
to ensure that the bur is kept on track. Subtle changes in
color and texture of the dentine should be looked for
(Figs 16.8and 16.9).
calcifiedroot canalin an elderly
Fig. 16.12 Tooth42 showingapparently
patientbut endodontic
treatmentwâsfeâsible.
 Clinical
methodologies

iir{ #V
Upperincisor Upperpremolar U p p em
r olar

Mesial

Lower incisor Lower molar

Fig.16.14 Drawings
showingtypicalaccess
cavities upperpremolar,
to upperincisoflowerlncisor, lowerpremolar
andupperandlowermolar.

Rootcanalinstrumentation Clidden burs increase the likelihood of stripping in

fhê firr.âriôn rêoi^n
Root canal instrumentation should enlarge the root canal
system as a smooth taper ftom crown to apex, which
Zipping
includes the original canal, without causing damage to
Stainless-steel instruments placed into a curved root
or needless weakening of the tooth (41) (Fig. 16.17).
canal tend to straighten within the canal. This is because
Instruments and teclniques have been developed to
of the inherent rigidity of the metal. Flexibility of an
minimize iatrogenic damage. Of these, stdpping and
instrument depends on a number of factors, including
zipping canals are the most common.
the matedal from which it is manufactured, the cross-
sectional configuration alrd the diameter of the instru-
Stripping
ûrent. An instrument that is too stiff will cut more on the
The root canal system does not always lie in the center
convex side of the curve than the concave side, thereby
of the root, and this eccentdc placement means that
straightening the curve. This results in a phenornenon
uniform cutting of the canal wall will result in over-
termed zipping (Fig. 16.19). The resultant hour-glass
preparation of the imer wall, known as stripping. This
shape is very difficult to obturate and, if cutting is con-
is a particular problem on the distal surface of the
tinued, perforation by the tip of the instrument may
coronal part of the mesial roots of mandibular molars
occur. It is to avoid these significant problems tl.rat
(Fig. 16.18).Indiscdminate removal of tooth structure in
modem root canal instruments have been developed.
this area may cause a strip perforation. To avoid such an
occurrence, instrumentation must be carried out with
regard to the anatomy of the tooth and overenlargement
must be avoided; therefore a balance must be struck
Instruments
between removal of root canal wall to achieve a suitable
Alloys
shape and diameter to allow efficient delivery of irrig-
ant and subsequent obturation. Using hand instruments The properties of root canal instruments are linked to
in a rasping action or the injudicious use of Gates- alloy, taper, flute pattern and cross-sectional design.

Fig.16.15 (a)High-speed throughthecorcnâlrestora-
bursfor initiaI access
tion.(b) Bursusedto locateentrances to root canalsandmodi{ythe âccess
cavity.
Modern root canal instruments are constructed of either
stainless steel or nickel-titanium. Carbon steel instru-
ments are also available but these are for one use only
becausethey carmot be resterilized due to corrosion. This
is uncommonly seen after sterilization of stainless-steel
instruments and rarely occurs with nickel-titanium.
Newer alloys, including chrome-nickel steel arrd V4
steel, provide good flexibility and produce better shaped
root canal preparations than conventional instrurnents
A\.
N i ck el-tit anium (N i-Ti)
The introduction of nickel-titanium instruments has
revolutionized root canal preparation. These alloys
consist of approximately 55% nickel and 45% titanium
by weight. Ni-Ti is known as a shape memory alloy,
Rootcanalinstrumentation
Advancedconcept15.1
Austeniteis a high-temperature phaseandis a stableenergy con-
dition.Thisis the originalparentstructure with orientationas à
body-centered cube.
Martensitic transformation occurswhen an externalforce
exceeds a givenamount, causing Ihis causes
deformation, a volu-
metricchange in stresslevelsoff
in the alloy.Iherateof increase
because of progressive deformationandthisresultsin theso-called
superelasticity.
which means that it demonshates an ability to retum to
some previously defined shape or size when subjected
to an appropriate thermal procedure, approximately
125"C. The Ni-Ti instrunents have about three times the
elastic flexibility in bending and torsion compared with
stainless-steel files. In the proportions used in endodon-
tic instruments, Ni-Ti exhibits superelastic behavior that
allows a return to the original shape when urùoaded.
The alloy undergoes a stress-induced martensitic hans-
formation from a parent austenitic structure (Advanced
concept 16.1). When the stress is released the material
retums to austerlite and its original shape.
These physical properties allow instruments made
from Ni-Ti alloys io prepare severely curved root canals
without permanent deformation. Nickel-titanium files
camot be made by twisting a tapered wire, as with
many of the stairùess-steel instruments, and are thus
machined from a blank.
The major advantage of Ni-Ti is its abiÏty to retain
flexibility with increased taper. This has resulted in the
development of groups of instrurnents that have a two-
to six-fold Breater taper than the ISO standardized 02
(Fig. 16.20).Hand Ni-Ti inshuments are available, but
these instruments are also manuJactured for use in
a constant-speed, high-torque handpiece rurming at
between 150 and 350rpm.
Nickel-titarrium instruments are not immune from
fracture and this may happen without any particular
warnin& although twisting or unwinding of the flutes
may be observed. Like other root canal instruments,
Ni-Ti instruments should not be overused and should
be checked for distortion before each use (Fig. 16.21).
Titqnium-aluminum
One manuJacturer has produced an instrument that con-
sists of an alloy containing 90% titanium and 5% alu-
minum by weight. This alloy does not have superelastic
properties but is more flexible than conventional stain-
less steel. However, it has no advantages over flexible
stainless steel in terms of cutting efficiency.
 Clinical
methodologies

l\.4esiobuccal
canal

Fig.16.18 over€nthusiastic instruments

useof mechanicâl coronallyinthe
mesialrootofthemandibular
molarhasalmost inâ stripperforation
resulted
inthefurcâtion.

a greater diameter at the tip compared with the canals,

Distal canal Mesiolingual
canal and thus a cutting tip was required for penetration. The
triangular cross-sectonal tip was better in narrow canals
Fig.16.16 ]he access cavityfor â mândibulâr
first molâris rectangular
in
than those with a square cross-section. In additioru a
shapewith eachoTthe mainroot canalsat the periphery of the rectangle.
pyramidal design was better than a conical shape.
Notethe grayishfloorof the pulpchamber.
Another view was expressed that a cutting tip may
cause damage during preparation of the apical part of
the root canal. Luls in 1974 (19) suggested that the sharp
tip of instruments made at ihat time should be removed
witlr an emery board. Subsequently, Powell et al. (30,31)
demonstrated that the shape of root canal preparation
with hand instruments using modified-fipped K files
(safe-ended files) was superior to unmodified-tipped
Êil'es.Sabala et al. (35) found that inexpedenced students
maintained the original canal curvature better with
modified-tipped files compared with unmodfied instru-
ments. Many hand instruments now have a non-cutting
'16.22).
np $ig. Schafer ef al. (41) compared simulated
root canals prepared with a wide variety of hand instru-
ments, including those manu-factured from stainless
steel and Ni-Ti. The best results were obtained with flex-
ible irutruments with non-cutting tips.

lnstrumentconfiguration
Fig. .|6.17 Radiogrâph
of completed rootfillingon mandibular
first molar Root canal shaping may be carried out with hand-held
(tooth36),showinggoodshapingol root cânalwith adequate
taperand no or engine-driven instruments. These instruments now
iatrogenicdamage come in many configurations but are conventionally
grouped according to ISO (Intemational Organization
for Standardization) and ANSI (American National
Standards Institute) standards. The quality of instlu-
Tip configuration
ments, sizing, physical properties and materials used for
It was shown in the 1980s that ihe design of the tip of their manufacture come under these standards (see Core
the instrument had an effect on cutting efficiency (26, concept 16.1). The instruments can be separated further
24. In these experiments the instruments used were of into groups, depending on the shape of ihe cutting part.
 Rootcanalinstrumentation

Fig. 16.19 lhe stiff instrumenttendsto straighten

within the canâl (1), causingledgeformation(2),
zippjng(3)or perforation(4).

Fig,16.21 Nickel-titanium showingdistortion

instrument of flutes.

Fig.16.20 Variably
tâpercd
instruments inorderfromtop,02,04,
showing,
06,08,10and12tapers.

Standardized instruments have cutting flutes 16mm tip of handinstrument.

long and for each millimeter of file ihe diameter
increases by 0.02mm, so the final cutting part of the
irstrument (known as d2; see Fig. 16.23) is 0.32mm
wider than the first part of the cutting tip Gnown as d1).
These files are thus kno$,.n as 02 tapers.
These instruments are color coded and increase in
diameter in set increments, t}te smallest diameter being
Fig.16.22 Non-cutting
0.06mm at d1 and increasing to 1.4mm (Table 16.2).The
length of the shaft of the instrument from the cutting tip
to the handle may be 21, 25 or 31mm. The longer instru-
ments are useful when treating maxillary canines, wNch
246 Clinicalmethodologies

are over 25mm long, and many molars can be treated
with the 21-mm instruments.
Reamers
Rearners (Fig. 1.6.24) are made from stairùess steel ârrd
may be square or triangular in cross-section.A tapered
wire is twisted to create sharp cutting flutes that are
present every 0.5 1mm along the length of the instuu-
ment. Although the cross-sectional shape varies among
manufacturers, the smaller sizes (nos 15-50) are usually
square and the larger sizes triangular. The angle of the
blades to the long axis of the reamer is about 10-30", so
these instruments are used in rotation where the flutes
cut into arld remove dentine from the wall of the root
canal. The use of hand, stairùess-steelISO-sized reamers
has declined in popularity because of their lack of fle-
xibility (especially in large sizes), their inability to
prepare canals with anything other than a round cross-
section and their lack of cutting efficiency compared
with other instruments.
Files
Files come in a number of configurations within the 02
taper standardization. The main generic types include:
K files, flexible K files, Hedstrôm files and S files.
K Files; manufactured in a similar manner to reamers
except that the cutting spirals produced by twisting are
much tighter. The cross-section can be triangular or
square in shape. The angle of the cutting flutes to the
long axis of the instrument is about 2$-40o and hence
they cut the wall of the root canal when used in rotation.
K Files have a greater angular deflection than reamers
and thus there is less risk of torsional fracture with tiese
instruments compared with reamers (48).
Flexible K files (Fig. 16.25); essentially similar to K files
except that the cross-sectional design is such that the
instrument is able to Ilex more than the conventional K
Table 16.2 codedsizes,diameter
at dl and colorof standardized
rnsûumentl,

d1(mm)
Coreconcept16.1
006 0.06 0range
Standardization
of cuttinginstruments
includesl 008 0.08 Grey
010 0.10 Purple
. Diameterandtaperof eachinstrument. 015 0.15 White
. Regimentedincreasein size. 020 0.20 Yellow
. A numbering systembaseduponthe diametet
of the instru- 025 0.25 Red
mentat thecuttingaspect of thetip. 030 0.30 Blue
035 0.35 Green
040 0.40 Black
045 0.45 White
050 0.50 Yellow
055 0.55 Red
060 0.60 Blue
070 0.70 Green
080 0.80 Black
090 0.90 White
100 1.00 Yellow
110 1.10 Red
120 1.20 Blue
130 1.30 Green
140 1.40 Black
Fig.16,23 Drawingshowinga file with the distances
markedd2-d3,etc.

O ", Q.,.o,,,"o'on Fig.16.24 Reamer

with 02 taper.

Fig.16.25 tlexibleK file with 02 tâper.
Fig.16.26 Hedstrôm
filewith02taper.
file. They may be triangular in cross-sectionor a more
elaborate rhomboid. In addition, they may be made from
new stairùess-steel alloys, titanium or nickel-titanium,
which are more flexible. Most of the flexible K files are
made by twisting a tapering blanl<. Sorne, however, are
machined from a tapered blank. They cut the root canal
wall if used in rotation or with a filing action. The angle
between the cutting flutes and the long axis of these
instruments varies between 23 aItd 30' at ihe tip and 45
and 50" at the end of the working part of the file. Schafer
et aI. (41) have shor,rmthat these flexible files are more
efficient than conventonal reamers and files in cutting
dentine. However, tiere is now a distinct trend in con-
temporary endodontic practice toward the use of Ni-Ti
instruments in preference to those manufactured from
stainless steel.
Hedstlôn files (Fig. L6.26): manufactured by machining
a steel tapered blark that has a round cross-section. The
machining produces a spirally tapered series of cones
with cutting edges at the base of each cone. The alrrgle
between this cutting edge and the long axis of the instru-
ment is about 60-65" artd thus is designed for a filing
motion. The instrument cuts only when being with-
drawn from the root canal, and if rotated may break
relatively easily because of the small core diameter, The
cutting efficiency of Hedstrôm files is greater than that
of K files. Hedstrôm files are used mainly for coronal
flaring of root canals and to remove fractured instru-
ments and gutta-percha in retreatment cases. Larger-
sized Hedstrôm files, being dgid, cause iatrogenic
damage within the canal, including the formation of zips
and elbows, when used in a filing motion (seebelow) (2,
4, 5).
S Files: in principle these are modified Hedstrôm files.
They are machined from a blark, have an 'sashaped
cross-section alrrd are stiffer than Hedstrôm files.
Rootcanalinstrumentation
Crosssêction
Q..o,,,".'on
Movementof hand instruments
durino
shapingof the root canal
Hand instruments may be used in a variety of ways to
enlarge and shape the root canal system. The efficiency
with which this shaping is done depends on the move-
ment applied, the inshument type used and the ma-
terial from which the instrument is made. Again, it is
important to stress that the enlargement of the root canal
must be achievedwithout iatrogenjcdamage.
Push-pull motion (Fig. 16.27)
A pushlull motion, especially when applied to
Hedstrôm files, will file dentine from the wall of the root
canal. An arnplitude of 1-2mm is recornmended but
there are inherent difficulties with this method. These
difficulties include grooving the root canal wall, udess
a conscious effort is made to move the file circumJeren-
tially, and packing of debris ahead of the tp of the
instrument, which may block the root canal. When K
files were used with a filing motiorç pronourced zips
and elbows were created (1, 10). Becauseof the possi-
bility of iatrogenic damage, rasping is not recommended
for routine root canal preparation. However, it cart be
used in retreatment cases to aid the removal of sutta-
hêr.hâ rô^r fillind<
Reaming (Fig. 16.27)
A reaming motion denotes a clockwise or anticlockwise
rotation of the instrument in the canal. It is generally
recommended to rotate the reamer a quarter-turn before
removal to prevent the instrument from binding in the
canal. Two techniques are described here.
Watch winding: a clockwise/anticlockwise rotation of
the instrument through an arc of 30-60' while advanc-
ing into the root canal. This method is less aggressive
than the ouarter-tum and pull and should be used with
 Clinicalmethodologies

lî l'fi
Fig. 16.27 Drawingshowingpush-pullmotion(left)
Push-pullmotion Reaming andreamingkight).

light apical pressure. With precurved stainless-steel

instruments (Fig. 16.28) this technique is extremely
useful for initial negotiation of root canals, especially
those that are severely cuwed or narrow. The apical part
of the very curved root canal can be prepared using this
motron.

The balancerlforce technique:devised by Roane ef al. (34)

and later endorsed by Charles and Charles (9) on the
basis of a mathematical model. Although the mechanism priorto negotiâtion
of thetipof a fineinstrument
Fig.16.28 Precurving of
as described by Roane ef nl. (34) has been challenged by witha watch-winding
therootcanal movement.
Kyomen ef al. (18), essentially the clinical result is the
same.
This technique is essentially a reaming action using straight instruments that are not precurvedi modified-
clockwise movement to insert the file and anticlockwise tipped instrurnents are recommended although
movement to remove dentine. The file is placed into the non-modified-tipped instruments have been shorvn to
root canal until it binds against the wall. The file is then produce satisfactory results (37). A tecturique of reverse
rotated through 60-90'. This creates threads within the balanced force instrumentation has been developed for
dentine. The instrument is moved anticlockwise through use with variably tapered nickel-titanium files where
120-180' with apical pressure, which crushes and breaks the flutes of the instruments are machined in an oppo-
off the dentine threads and enlarges the root canal. site thread to normal files.
A final clockwise rotation allows flutes to be loaded
with debris and removed from the root canal (38). This
Specificfeaturesof root canal instruments
techrtque has been shown to be efficient and less prone
to cause iatrogenic damage (6, 45, 36, 37, 43).It appears Culting flutes
to keep the instrument more centrally placed within the The configuration of the flutes of an instrument will
root canal and extrusion of debris apically is much affect its cutting ability. A flute with a positive rake angle
reduced compared with other hand instrumentation planes the dentine surface whereas that with a negative
techniques (3,12,25). The technique must be used with rake angle scrapes the surface (Fig. 16.29). The greater

Positive Neutral Negative
raKeangre raKeangre raKeangre
'x
T { F
\.
v
I É É
I I
Fig.16.29 Rakeangles.
I
the positive rake angle, the more aggressive the cutting
potential.
Cro ss-sectiondl conflguration of files
The cross-sectional design of an instrument affects the
number of cutting blades presented to the dentine and
the flexibility of the instrument. The most commonly
seen cross-sectional shapes are the square, triangular,
round and rhomboid (Fi,gs 16.24-16.26). More recently,
U-shaped or radial land (Fig. 16.30),and more complex
cross-sectionsbased on the radial land, have been intro-
duced. The U shape is basically triangular in shape but
the points at each apex of the triangle have been flat-
tened to give a flat planing surface. This U shape has
been modified further to produce a complex fluting
pattern in cross-section where the flute is shaped to
allow more easy removal of debris from the cutting site
but only two radial lands are present.
Rotary instruments
Not all root caral preparation is carried out using
hald instruments and there is a trend for increased use
of rotary instruments in all aspects of root canal
preParauon.
Gates-Glidden burs (Fig. 16.31) are, in effect, engine-
driven reamers. Gates-Glidden burs come in various
sizes from ISO 050 (size 1) to ISO 150 (slze 6) and are
available in 15- and 19-mm lengths. The tip of the inshu-
ment is elliptically shaped with short cutting flutes and
a non-cutting tip. The instruments are designed so that
if stressedthey will fracture at the junction of the shank
and the shaft. They are used to open root canals and flare
the coronal straight part of the root canal but because
they are relatively aggressive care must be taken to
Rootcanalinstrumentation
nickeltitaniuminstrument.
view of radial lands (R) on
Fig. 16.30 Scanningelectronmicroscope
avoid overuse coronally, which may lead to strip perfo-
ration. Gates-Glidden burs should be used at no greater
than 1500rpm to ensure adequate control. They gener-
ate considerable swarf and should be used only
when the root canal system is filled with irrigant fluid
in order to avoid canal blockage. There is a tendency,
especially at relatively high speed, for the bur to pull
itself into the root canal and cause overcutting. This may
'coke
lead to a poor final shape, often referred to as a
bottle'shape.
Peeso reamers (Fig. 16.31) differ from the Gates-
Glidden drill in having parallel-sided cutting flutes.
They are available from ISO 070 (size 1) to ISO 170 (size
6), with and without non-cutting tips. Becausethey are
less well controlled than Gates-Glidden drills, their use
tends to be restricted to post space preparation.
Gates Clidden burs and Peeso drills, although very
popular, are being superseded by Ni-Ti rotary instru-
ments specifically designed to give a bettet more
controlled shape coronally (Fig. 16.32a). Although
engine-driven rotary instruments have been available
for many years, the advent of Ni-Ti has seen exciting
developments in the use of engine-driven instruments.
Basically there are two different designs of these
instruments: a design with a cutting tip at the end of a
long, slim and flexible shank (Fig. 16.32b);and a design
resernbling conventional hand instruments but with
vadous tapers and cutting flute configurations different
from hand files (Fig. 16.32c-e). Most of these instru-
ments have a radial land design that prevents uncon-
trolled cutting into the canal wall. During rotation the
land planes the wall of the root canal and the flutes
direct the debris coronally away from the cutting
surface. A recent introduction is a Ni Ti rotary file with
 Clinical
methodologies
Fig.16.31 Photograph
of cates-Glidden
andPeeso
reamet
varying tapers along its length. This is claimed to be able
to prepare severely cuwed canals without altering the
natural shape or fracturing the instrument (Fig. 16.32f).
The most important feature of these Ni-Ti instruments
is that the taper of the instrument can be increased to
provide good shaping with consistent taper using fewer
instruments. The rotary instruments are used in contra-
angle handpieces ruming at a speed of 150 650 rpm.
Some special motors and harrdpieces are manufactured
with torque adiustment, which opens up the possibility
of preventing deformation and separation of the instru-
ments if they lock into the canal.
Despite the flexibility of Ni-Ti instruments, several
studies have reported defects and breakage following
the use of such instruments (7, 14, 32, 40, 50). Breakage
has primarily occurred during the leaning period
because certain basic rules have not been followed (see
Clinical procedure 16.2). The fractures have been
divided into torsional and flexural fractures. Torsional
fracture may be preceded by unwinding or reverse
winding, which can be detected, whereas flexural
fatigue fracture may occur without warning. It is there-
fore recommended to discard instruments after some
tirne even though defects cannot be seen (see Clinical
procedure 16.2).
Basicprinciplesof root canal
instrumentation
Step-downtechnique
The shape of the prepared root canal ideally should be
a gradually increasing taper from the apical constriction
procedure
Clinical 16.2 Operation
of
rotarvinstruments
a Secure straightlineaccess to themostcoronal portionofcanal.
. Ensure canalpatency witha smalllso-sized handfile.
. Usea constant speedduringinsertion, operationandremoval
lromcanal.
o Useverylighlpressure andprogress slowlyintocanal.
o Donotstopandrestartrotationwithintheroolcanal.
a Usesmallvertical upanddownmovemeîts witha lubricantin
the canalduringoperation. Do not workin a drycanal.Ihe
rotatingfilewill taketheirrigantwithit intothedepths oI the
canal.
a Useoperation sequences of 5-7t cleanthe instrument with
sterilegauzeandirrigatethecanalwitha copious amountof
irrigationsolution.
a Discard instruments afterusein a severely cuwedcanal.
. Discard all instruments withdeformatjons - usea magnirying
glass.
a In general, discardall instrumentsafterusein 8-10 canals
depending oncurvature, pressure
canaldiameler, ontheinstru-
mentandsizeof instrument.
to the coronal opening (42). Experience has shown that
this is most predictably attained by the use of a step-
down technique (Fig. 16.33).
With the step-down technique the coronal portion of
the canal is prepared first. The apical region is then grad-
ually approached with a range of instruments of smaller
cross-sectional area, Ieaving behind a fully cleaned and
tapered canal lumen. The working length is accurately
measured when step-down instrumentaton is within
2-3 mm of the apical constdction. In the step-back tech-
nique (Fig. 16.33), the working length is first established
(see below) and then the apical part of t}re canal is
cleaned and shaped, followed by preparation of the
coronal parts with a sequenceof larger instruments used
in gradually increasing distances from the apical region.
Step-down is now regarded as the preparation tech-
nique of choice. It was originally described as the
'crown-down pressureless technique' (22) and under-
went research scrutiny by Morgan and MontSomery
(28). The advantages of this techdque over step-back are
outlined in Core concept 16.2.
In this technique the preparation is begun with
GaterGlidden ddlls or rotary Ni-Ti instruments and
larger files in the coronal part of the root canal. Sequen-
tially smaller files are then used until the apical con-
striction is reached.The balanced force techique should
be used for hand instruments.
Most protocols for the use of Ni-Ti files in a rotating
handpiece involve a crown-down approach. Before
instrumentation is begun, it is helpftrl to increase the size

(e) K3 (f) Protaper
Fig.16.32 Nickel-titanium (a)orificeshaper;
rotaryinstrumentsr (b)Lightspeed;
ànour \. tnomoson.l
of the openings of the root canals with a rotating tapered
instrument. This provides a guide path and allows easier
entry to the root calal by all ihe other instruments. The
root canal then should be investigated for patency. A
srnall-sized hand file (08-15) with an 02 taper is pre-
curved in its apical few millimeters, coated with a small
quantity of lubricant or chelating paste (Fig. 16.34)and
placed into the root canal with a stem-winding motion.
It is advisable at this stage not to take this instrument to
the full working length. The root canal then should be
flared coronally, which will allow irrigant to be intro-
duced more effectively into the root canal. A step-down
Rootcanalinstrumentation 251
(c)Profile (e)K3;(f)Protaper
06;(d)GTRotary; (counesy
of DrP Dummer
approach then can be adopted, using progressively
smaller diameter instruments until the working length
is within approximately 2mm. The working length then
is determined and apical preparation can be completed.
The final refinement of the shape of the root calal then
can be undertaken.
Methodsto establishthe working length
The apical extent for preparation of the root canal has
been the subiect of some controversy over the last few
years. Preparation into the periradicular tissues beyond
 Clinical
methodologies
Step down Step back
Dimensionsof file decrease Dimensionso1 file increâse
Coreconcept16.2
Thestep-downtechnique
. Plovides lessriskof extrusionof pulpdebril irrigantsolution
anddentine mudbecause thereislesshydrostatic gen-
pressure
eratedin an àpicaldirection.
. Reduces the riskoTinoculationof endodontic pathogensinto
the periradiculartissues(15)because thereis a markedlen-
denqfor the majorilyof microorganisms to bein thecoronal
partof therootcanalsystem (44).
. Provides lesslikelihood
for a changeof the workinglength
measurement duringpreparation.
. Facilitatesadequate penetrationof irrigantintotherootcanal
system.
a Prevents bindingof instruments exceptin the apicalflutes,
reduces thestress placed ontheinstrument andresults
in less
riskof preparation errorssuchaszipping.
the root canal may cause an acute inflammatory reaction
with postoperative pain and delayed healing. If there is
subsequent overfilling, then there will be incomplete
regeneration of the supporting periradicular tissues.
Some authorities consider that the apical termination of
the root filling should be at the cementodentinal junc-
tion (16). However, this anatomical landmark is impos-
sible to detect radiographically. Therefore a better
position is the smallest diameter of the root canal at the
apex: the constriction or apical foramen (33). This may
be regarded as the junction between the periodontal
tissue and the pulpal tissue. Depending on the amount
of secondary cementum that has been laid down at the
apex, this position may be 0.5-3mm ftom the radio-
graphic apex (77, 73, 77). The distance tends to increase
with the age of the patient as secondary cementum is
Fig. 16.33 Drawingshowingthe pincipleof the
step-downandstep-back
techniques.
Fig.16.34 lhefileshould
becoated priorto placement
witha lubricânt in
ther00tcanal.
laid down at the anatomical apex. Tactile detection
of this constriction may be difficult clinically and impos-
sible if there has been pathological root resorption
apically.
The working length may be determined in a number
of ways but whatever method is used it must be accu-
rate, repeatable and carried out easily.
Measuring zoorking length by radiography
Radiography is the most commonly used method. An
undistorted periapical radiograph taken using a film-
holder and a paralleling technique prior to heatment
allows a good estimation of the tooth length to be made.
A precurved instrument with a silicone stop on the shaft
is placed into the root canal 1-2rlm short of the full
working length. If preflaring of the root canal has been
done prior to working length determination, then tactile
'feel' for
sensation can be used to the apical constriction,
although this takes some practice (46). ln some cases
there will be no proper tactile feedback, especially if the
apical constriction has been destroyed, if there is imma-
ture development of the root end or if the root canal is
 Rootcanalinstrumentation

narrow along most of its length. The root canal needs to Electricalôpex locâtor
be widened to a size of at least ISO 15 so that the apical
part of the instrument may be seen clearly on a radi
ograph. The working length radiograph should be taken
using a paralleling technique ard a film-holder (see
Chapter 15).
If the processed film shows the tip of the instrument
to be more than 2mm short of the radiographic apex and
there is obvious root canal apicallt then the stop should
be readjusted and a further film exposed. If the radio-
graph shows the instrument to be long, then the stop
should be adjusted accordingly and another radiograph
taken. The working length should always be recorded in
the patient's case notes together with the coronal refer-
ence point. Cusp tips are not very useful for this exer-
cise and judicious flattening will help to provide a more
positive landmark.

Measuing working length by electuical

aper locatols
Sunada (47) was the first to apply to endodontics the
principle that the electrical resistance between the peri-
odontal membrane and the oral mucosa was a constant
value of 6.5kÇ).This led to the introduction of the elec-
trical apex locator (Fig. 16.35).One side of the electrical
circuitry is connected to the root canal instrument and
the other to a lip clip that connects with the oral mucosa.
\44ren the fi1e is placed into the root canal and advanced
to the apex to make contact with the pedodontal tissues,
the electrical contact is completed and visual and
audible signals will be triggered. There are three types
of apex locators: resistance type, impedance type and
frequency-dependent type (23). Many of these locators,
particularly the frequency-dependent types, are now
so sophisticated that it is possible to obtain accurate
readings even in the presence of fluids within the canal
(Clinical procedure 16.3).
There is, however, a rather steep learning curve for the
accurate use of an apex locator.
The accuracy of contemporary electrical apex locators
is high (24), even up to 100%, with a tolerance level of
0.5mm, in teeth with an apical foramen in the long axis
of the tooth (29). However, it is still prudent to take a
periapical radiograph with the working length file in
place to confirm the position.
Paper points
A fine paper point placed into a dried canal and
extended beyond the working length will absorb tissue
fluid at the apex and, if withdrawn after just a few
seconds in positiory will allow measurement of the dry
portion of the point and provide some indication of the
working length.
Electricêl resistan<e
Fig.'16.35 Drawingshowinghowthe apexlocatorworks.
Flarepreparation
The coronal flare should be completed as soon as pos-
sible after confirmation that the root canal is patent and
can be instrumented. An Ni-Ti engine-ddven instru-
ment of suitable taper is used in the coronal 3-5mm of
the root caral. This phase of preparation will allow irri-
gant and lubricant to be introduced more efficaciously
into the root canal. Gates-Glidden drills can also be used
judiciously in a step-down fashion in the coronal
straight section of the root canal. Instruments of ISO
sizes 110, 090 and 070 (Fig. 16.36) can be used but ISO
050 is not advised because there is a tendency for these
smaller sized instruments to break too easily. The root
canal system should be flooded with irrigant when
using these instruments to avoid blockage of the root
canal with debris. Root canal preparation then can be
continued toward the apex using hand files of progres-
sively smaller size. These should be used with a bal-
anced force movement. Stainless steel (02 taper) or
variably tapered Ni-Ti hand or rotary instruments can
be used. The canal should be irrigated between each
change of instrument and a small quantity of chelating
 Clinicalmethodologies

Clinicalprocedure
16.3 Electrical
apexlocators
( 1 ) Place lipclip,dampened withwater,to provide sufficient
elec-
tricalcontact.
(2) A rootcanalinstrument attachedto the second eledrodeis
advanced untiltheaDicalloramen isreached. Contact mustbe
madebetweeninstrument and canalwall at entrance and
aDex.
(3) Movethe instrument up anddownl-2 mm;the display will
followthismovement.
(4) A reading thatis withintherootcanalbutis obviously notat
theapexmayindicate thepresence of a largelateralcanalor
a perforation.Ihe reading alsomaybefalseif theinstrument
touches a metalrestoration and.for somelocatortif exces-
sive moisture(especially sodiumhypochlorite) is present
withintheoulochamber.
(5) Contact mustbemadebetween theinstrument andtheapical Fig.16.36 (â) Rotaryinstrumêntwith increâsed
tâperfor coronalenlarge-
exitlromtherootcanal,With anopenor immature apex,this ment.(b) Gates-Glidden
bur (lSO090)for coronâlenlârgement.
canbeachieved bymakinga 5mallbutsharpcuNeat thetip
of thefile.

the proximity to the apex all influence how often patency

lubdcant picked up with each file prior to placement in
the root canal.
Apical preparation
The arrourt of preparation carried out in the apical part
of the root canal is the subject of considerable contro-
versy. Some consider that it is unnecessary to widen the
apical preparation because preflaring and patency filing
will allow the irrigant to reach and be agitated in the
apical part of the canal and therefore cleaning takes
place, Others consider it necessary to remove infected
dentine in the apical few millimeters of the root canal
(49) and thus shaping should be carried out to at least a
size ISO 30 file. Certainly the widening of the apical part
of the root canal to a reasonable size after preparation of
the coronal and middle sections allows easier olacement
oI the needle for irrigation and also of the gutta-percha
cone when cold lateral condensation is used for
obturation.
Patencyfiling
Schilder (42) and Buchanan (8) stressed the need to avoid
apical blockage by placing a small file through the apical
constriction of ttrc root canal, without enlargement. It is
purported that this file stirs the apical debris back into the
irrigation fluid, which is flushed subsequently from the
root canal. The patency file also moves clean irrigating
fluid into the apical portion of the root canal. This file
should be used frequently but factors such as the move-
ment of the file itself, tlLenarrolrmess of the root canal and
is used. The balanced force technique arrd the use of
Ni-Ti rotary instruments tend to gather debris into the
flutes of the instrument, thereby minimizing packing of
debris toward the apex. It must be appreciated also that
it is impossible to achieve patency of all the exits of the
complex anatomy of the apical delta.
Finishing the root canal preparation
The presence of clean white dentine chips on the api.cal
flutes of the master apical file, the presence of clear irri-
gating fluid and the presence of glassy smooth walls
have all been used to indicate when canal preparation is
complete. Each of these criteria is inaccurate artd there
has yet to be a reliable method devised. Certainly the
wall of the root canal should be smooth with no ledge
or interference. A spreader should be able to penetuate
to within 2mm from the apex. It should be possible to
place the master apical file to the working length with
only light apical pressure with the tip of the forefinger
It is impossible to tell how clean the root canal system is
following instrumentaton and it is of fundamental
importance, therefore, that large volumes of a suitable
irrigant are delivered to the root canal system during
this process,
ltigation
Irrigation of the root canal system is an essential and
integral part of root canal preparation. It is the iffigant
that actually does the cleaning of the system while the
instrurnentation shapes the root canal. The irrigant helps
lubrication and flushes out debris generated during
preparation. Sodium hypochlorite used in copious
 Rootcanalinstrumentation

amounts not only is antimicrobial but also dissolves

necrotic debris and is therefore more efficient than
saline, sterile water or local anesthetic solution (see
Chapter 11). Chlorhefdine also has a place as a root
canal irrigant because it is antimicrobial and possesses
substantivity, although it does not have the tissue-
dissolving propertes oI sodium hypochlorite. At least
15ml of fluid should be used to irrigate each root canal
during mechanical instrumentation.

Remoaal of the srneat layer

I{hen the root canal is instrumented, organic and
rnineralized debris becomes impacted against the wall
to form an amorphous layer lcrown as the smear layer,
This varies in thickness depending on the way the wall
has been instuumented. Debris also extends into the
dentinal tubules to form plugs of material, Various
Iactors suggest that it should be removed prior to root
filing (Fig. 16.37) (see turther Chapter 11).

Technicalaids
A number of technical aids have been introduced
in mdodonticsto help provide morc predictablc
instrumentation.

Surgicaloperating microscope
The use of the surgical operating microscope in root
canal preparation (Fig. 16.38a)is now recognized as an
invaluable tool. The ability to visualize the root canal
system in fine detail gives the opporturrity to clean and
shape more efficiently. Microscopic examination of the
floor of the pulp chamber (Fig. 16.38b) helps to identify
the openings of the root canals, especially of additional
root canals such as the mesiopalatal canal in the
mesiobuccal root of the maxilJary first molar (39). The
use of the microscope, combined with the removal of
coronal dentine with an ultrasonically powered pick,
allows both conservative and accurate removal of tooth
structure. Most operative procedures can be undertaken
at x6 to x10 magnification arld up to x16 when experi-
enced. The use of a high magnification of x26 is useful
for examination of the root canal system but it is diffi-
cult to operate at this leve1. The use of the operating
microscope requires practice and it may take several
months before fu1l proficiency is reached.
Lasers
There has been considerable research into the use
of lasers in root canal preparaton, although to date
these can be regarded orùy as experimental. Originally
Nd:YAG and COr lasers were investigated but with little
(b)
Fig,16.37 (a)smearlayeroncanalwallaftermechanical
instrumentation.
(b)Rootcanalwallin
middleonethirdafterremovalofsmear
layerwith
citric
acidandNaocl.opendentinaltubules
areclearly
seen.
improvementover conventional preparation techniques.
Research continues using other types of lasers, includ-
ing excimer lasers, with more promising results. It is
hoped that lasers may be used to clean root canal
systems alr,Idmelt dentine to close dentinal tubules artd
seal the apical delta.
Ultras onic instruments
Ultrasonic energy may be used to power K-t'?e files.
This energy is generated with either a magnetostrictive
device or a piezoelechic crystal. The former generates
considerable heat and requires a cooling unit for the
handpiece. The energy generates a sinus waveform
through the file with areas of maximum displacement
(antinode) and areas of minimal displacement (node).
The tip of the instrument is an antinode and, depending
 Clinical
methodologies
(b)
Fig. 16.38 (a) operatingmicroscope
in use.(b)Viewof openingof distâl
rootcanalof mandibular
molarasseenthroughthe microscope(xl6 orjginal
magnification).
on the power setting, produces an amplitude of up to
2mm at a frequency of 30kHz. The ultrasonic unit for
endodontic use should be designed to accept sodium
hypochlorite with no ill effects to the apparatus. The file
is used with a constant stream of irrigant. The fluid may
generate two phenomena: acoustic microstreaming and
cavitation. The former occurs most often and results in
eddy currents around the file, which develop hydrody-
namic shear stressesthat clean the wall of the root canal.
Cavitation occurs as a result of pressure changes within
the fluid. A cavity can form in the fluid and the follow-
ing pressure change results in implosiorç which can
occur with a great force sufficient to clean the surface.
Unfortunately the constraints of the instrument within a
fine root canal prevent the consistent generation of these
physical phenomena. Howevet the delivery of large
amounts of irdsant aids debddement of the root canal
system. In additiory the activity of the instrument heats
the iffigant, which, in the case of sodium hypochlorite,
will improve its effects. The use of a small file with
minimal contact to the root canal wall provides the best
conditions for the use of ultrasonics. Care must be taken
not to have the power setting too high, when the uncon-
strained tip of the instrument may fracture or cause
damage to the wall of the root calal. As mentioned pre-
viously, ultrasonically powered instruments are used
more frequently for removing coronal tooth tssue when
finding root canals, and also to aid in tïe removal of
fractured instruments and for root-end Dreparation in
surgical endodontics.
Sonic instruments
Sonically powered instruments have a frequency of
1400-1500H2. This produces a single antinode at the tip
of the instrument. On contact with the wall of the root
canal the force is directed into the long axis of the file
and cutting takes place. Special files are available for use
with these units.
Non-instrumentqtion techfliques for
root cannl preperation
An innovative technique for root canal treatment was
introduced recently (20, 21). Alher accessto the root canal
system is gained, cleaning is achieved using NaOCI irri-
gation under altemating pressure fields generated by a
vacuum pump and an electrically driven piston. Bubbles
are formed in the irrigation fluid, which, with a subse-
quent increasein pressure, implode. This createshydro-
dynamic turbulence that cleans the wall of the root
canal, including the ramifications and fins. The pressure
system operates below tssue pressure so there is little
risk of extrusion of the irrigant into the periradicular
tissues.The root canal system canbe obturated using the
same system. As yet, there is no published evidence of
the clinical effectiveness of this technique.
Proceduralerrorsduring
root canalpreparation
There are several errors that may occur during root canal
preparation.
Perforation
Perforation may occur at any time during the shaping of
the root canal system but is more prevalent during the
accessand when undertaking apical shaping, especially
in curved root canals. Sudden bleeding from the root
canal system is indicative of a perforation. Injudicious
use of large burs in the floor of the pulp chamber may
 Rootcanalinstrumentation

Secondary
dentine

Fig.16.40 zippingof mesialroot

canalofmandibular rightlirstmolar(tooth
havenot followedthe pathof the canaland the
46).the stiff instruments
aDicalDarthasnot beeninstrumented ândcleaned.

Fig.16.39 furcalperforation.
Clinical
orocedure16.4 Treatment of a
perforation
in thefloorof the pulpchamber
duringaccesspreparation
cause furcal perforator; which is difficult to repair (Fig. ln a casewith a necrotic pulp,a perforation is usuallyobvious
16.39).Even the use of ultrasonically powered picks may because thereis somebleeding.Inthevitalcase, thepulpchamber
cause this type of perforation. If there has been no loss should beirrigatedgentlywithslerilesalineor sodium hypochlorite
of furcal bone it is best to repair the perforation imme- solution,dried,andthefloorof the pulp€hamber examined care-
diately (CLinical procedure 16.4). wheretheperforation
fullyto establish siteis situated. lf possiblq
the perforation shouldbe repaired immediately. Ihe bleeding is
stopped wilh pressureusinga sle.iledampcotton-wool pledget
Ledging appliedfor severalminutes.l\4ineral trioxideaqgregate is then
mixedandplaced overlhe perforation.lt should begenllyplugged
A ledge results from repeated preparation or the inser- intothe delect.Thismaterial thencanbe covered with a resin-
tion of a relatively large inflexible instrument to a par- modilied glassjonomer to protectthesitq or a dampcotton-wool
ticular level in the root canal, which is usually at the pledget canbeplaced inthepulpchamber Thetoothisthenclosed
beginning of the curve (Figs 16.40and 16.41).The ledge with a temporary Ihe mineraltrioxideaggregate
dressing. takes
makes subsequent preparation apically very difficult or about4h to set,soshouldbe hardif thetoothis re-entered after
impossible. To attempt to bypass a ledge, a severe curve 24h.lf thereis extensivebonelossin thefurcation it maybenec-
is placed in the apical 2mm of a fine stair ess-steel essary to usea matrixto prevent the mineraltrioxideaggregate
instrument aJrldthis is passed down the root canal with Irom beingpushedinto the periradicular tissues. lvlatrices used
include collagenandcalcium sulfate.
a stem-winding motion. The use of a lubricant such as
EDTApaste is helpful. If the ledge can be bypassed then
gentle filing may remove the ledge.

(Fig. L6.42b).Unfortunately the canal is often overpre-

Fractured
instruments
pared during this procedure. If an instrument fractures
Instruments may fracture as a result of misuse or during root canal treatment, the patient must be
overuse (Fig. 16.42a). kÉtruments should be checked hformed and the case notes suitably annotated. (For
carefully to ensure that the cutting flutes are not further reading, see Chapter 19.)
damaged, arrd rotary instruments must be used at
speeds and in a malner recommended by the manufac-
hrrers. The introduction of the operating microscope and Conclusion
ultrasonically powered picks allows dentine to be
removed precisely so that in many cases fractured Root canal insbumentation is a difficult techdcal proce-
instruments may be freed and subsequently removed dure that must be urdertaken with diligence and skill.
258 clinicalmethodologies
tig. 16.41 A simulâted
curved rootcanalin a plastic
blockshows
severe
ledgingasa result
of overinstrumentation
witha rotaryinsûument,Prepara-
tionoftherootcanalapical
to thisdêmage
isdifficult.
It is important to get the root canal system as clean as
possible and with a resultant shape that makes obtura-
tion with Butta-percha relatively straightforward. This
biomechanical preparation should be done without
cawing iatrogenic damage to the tooth.
References
1. Alodeh MHA, Dumrner PMH. A compdison of the ability
of K files and Hedstrôm files to shape simulated root
canals in resin blocks. I'?t. Endodont. ]. 7989; 22:22Ç
35.
2. Alodeh MllA, Doller PM, Dunrner PMH. Shapingof
simulated root canals in resin blocks using the step-back
technique with K-files manipulated in a simple inlout
filing motion. In t. Endodont. I. 1989;22:707-11-
3. al€mari MA, Dumner PM. Canal blockage and debris
extrusion with eight ptepâration techniques. ]. Endodont.
7995; 2l: 154-8.
4. al{mari MA, Duûrmer PI!,I, Newcombe RG. Comparison
of six files to prcpare simulated root canals. 1. Int.
Endodont. I. 1992;25: 57-46.
A total of 300 simulated.root cafials of oarious angles and posi-
tions of cltflature in clear resin blocks were ptepated.by htnd
ltsitlg six fle Wes. Eachfile type was used with a linear fling
motion afld an anticun)ature stepback techflique. Oaerall,
preparation @ith Hedstritm fles u)as signirtcantlV quicker thon
ta, (b)
Fig. 16.42 (a) Fractured
file in tooth22.(b)Ihiswasremovedusingultrâ-
sonicenergy,
resulting
in overenlargement ofthe rootcânal.
uith anyotherfile, @hereas prepantiotl with Kfle6 a\d K-FIex
files took signifcantly longet Fncture and d.eformationof
,hstlufient' occurred substantiallylessoften@ithFlea-Rond
Hedstrômfles, but significantlymoreoftet with Unifiles.Loss
of working distanceoccurredqith all file Wes, bltt wûs sig-
nifcantly geater in canalspleparedwith Krtles. Unililes and
Hedstriittlfiles wererespotlsible
for signifcantly morezûeight
lossthan the othcrfiles, whereasK fles ptodrcedsignifcantly
Iessweight loss.Catals with rough ulld latiflg walls were
createilîtost often by Hedstrômrtles and Untfiles. Ooenll,
under the conditionsof this st1.td!/,
Flexofiles,FlerR fles and
Hedstraim files aryenredto besubstantiallyflnre efrectioethafl
K fles, K-FIetfles and Unifles.
5. al-Omari MA, Dummer PM, Newcombe RG, Doller R.
Compârison of six files to preparc simulated root canals.
2, Int, Endodont.L 1992:25: 67-31
6. Backmân CA, Oswald RJ,Pitts DL. A radiographic com-
parison of two root canal instrumentation techrriques./.
Endodoflt. 1992:18. 19-24.
7. Barbakow F, Lûz F. The 'Lightspeed' pleparation
technique evaluated by Swiss clinicians after attmding
continuing educatroncourses.Int. Efldodont. ].7997;30:
46-50.
8. Buchanaa LS. Management of the curved root cânal. /.
Calif.Denf.Assoc.198\ 17t1&-25.
9. Charles TJ, Charles p. Itre 'balanced force' concept of
instrurnmtation of cùrved canalsrevisited, I t. E dodont.
. L 1998t3| 766-72.
10. Cirnis GM, Boyer TJ, Pelleu GB. Effect of three file t,?es
on the apical prepamtions of moderately curved loot
car\aJs.L Endodoflt. 7988:74:M14.
11. Dummer PMH, Mccinn IH, ReesDG. The position and
topogaphy of the apical constriction and apical foramen.
lnt, Endodont.L 7984:77: 192-8.

Fairbourn DR" Mcwalter GM, Montgomery S. The
effect of four preparation techrniques on the amount of
apically extruded debis. ]. Endodont. 1987; 73:.702-3.
Green D. A stereomicroscopic study of the rcot apices of
400 maxillary ând mandibular anterior teeth. O,"d Srl9.
196V L3t 72813.
Haikel ! Serfaty & Bateman G, Senger B, Allemann C.
Dlnamic and cyclic fatigue of engine-ddven rotary
nickel-titaniûn endodontic instruments. J. Endodont.
1991 251+3H0.
Hession RW. Endodontic morphology. III Canal prepara-
ti,otl]..Oral Surg. 1977; M: 775-85.
16. lngle JI, Bakland Lli Petels DL, Buchanan LS, Mullaney
'lP.
Etldodotltic Caoit! Preparation in Endodontics (4th edn')
(Ingle JI, Bakland LK, eds) Baltimore: Lea & Febiger, 1994,
198.
1.7. Kuttler Y Microscopic inveEtigation of root apices./. Am.
Dent. Assoc. 195, 50: 544 52.
Kyomen SM, Caputo AA, \ /hite SN. C tical analysis of
the balanced force technique in endodonhcs. ]. Endodont.
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t9. Luls S. lrk Practical Endodontics.Philadelphia, PA: JB
Lippincott, 1974.
Lussi A" Nussbacher U, Grosrey J. A novel noninshu-
mented technique for cleansing the root cânal system. ,f.
Etldodoht. 1993; 19t 549-53.
The ain of this study uas to exûfiine û no -i str rfle tal tech-
nique for root canal preparotion. A deoice that u)as able to
dez.telopcontrolled caoitation ifi the root cûnûl u)tis compûreil
with afiling step-bûcktechnique using 3"/" NaOCI as an irtig-
aht. Teeth in the three test groups were prepared uith the neu
machineusing 1, 2 ot 3"/. NaOCI. The treatmenttime ran&ed
t'ron 16 to 32min in thehandgroupandJrom tÔ to 15nin in
the fiûchifie gfoups. The teeth uere then preparedfor histolog-
ical emmination. The apical one-third of curztedcanals was sig-
ùt'icantly cleanerwhen using the machineand 3% NaOCI than
with hand instrumentation.
Lussi A, Messerli L, Hotz P, Grosrey J. A new non-
instrumental technique for cleaning and filling root
cânals. Irf. Endodotlt.I. 1995;2811-6.
Maishall FJ, Pappin I. A CrorLlnDozon PressurelessPrcpata-
tiotl Root Canal EnlargementTechnique:TechniqueMan al.
Pordand, Oregon: Oregon Health SciencesUniversity, 1980.
McDonald NJ. The elechonic determination of working
length. Denf. Clini. North Am. 1992; 36: 293 307.
This is û reoie@paper that describesthe àeoelopnent anil the
adoantagesand disadaantages of the aarious typesand clinical
se of apexlocators.
McDonâld NJ, Hovland EJ. An evaluation of the apex
locator Endocater. /. Endodont. 199q 16 5-8.
McKendry DJ. Comparison ofbalanced {orces,endosonic
and step-back filing instrumentation techniques: quantifi-
cation of extruded apical debris. I. E dodotlt. 1990; 161
2+ 7.
MiserendinoLJ,MoserJB,HeuerMA, OsetekEM.Cutting
efficiency of endodontic instruments. PaIt II: Analysis of
tip design. /. Endodont.1986;12: 8-12.
27. Miserendino LJ,Moser JB,Heuer MA, OsetekEM. Cutting
efficiency of endodontic instrurnents. Part 1: A quantita-
Rootcanalinstrumentation
tive comparison of the tip ând fluted regiorrs. ]. Endodont.
1985; 11: 435-41.
Morgan LF, Montgomery S. An evaluation of the crown-
down pressurelesstecfuique.l. Endodont.1984;10:491 8.
29. Pagavino G, Pace & Baccetti T. A SEM study of in ?iz,o
accuracy of the Root ZX electronic apex locatoi. /.
Elldodottt. 1998; 24t 43841.
Powell SE, Simon JHS, Maze BB. A comparison of the
ef{ect of modified and nonmodified instrurnent tips on
apical canal configuranon. l. Endodont. 1986; 12: 293-j00.
Powell SE, Wong PD, Simon JH. A comparison of the effect
of modified and nonmodified instrument tips on apical
canal configuratron. Part 11.l. Endodont.1988; 74: 22Ç8.
Pruett JP,Clement DJ, Carnes DL. Cyclic fatigue testing of
nickel-titanium endodontic instruments,f . Endoàont.1997;
23t 77-85.
Ricucci D. Apical limit of root canal instrumentation and
obturation. Part 1. Literature review. 1'?1.Efldodont.J.1998;
31: 384 93.
Roane JB, Sabala CL, Duncanson MG Jr. The balanced
force concept for instrumentation of curved canals. .f.
Endodottt. 1985t 11: 203-11.
Sabala CL, Roane JB, Southard LZ. Instmmentation of
curved canals using a modified tipped inshument: a
'l4t
comparison study. /. Endodont. 1988; 59-44.
Saunders WP, Saurrders EM. Effect of non cutting tipped
instrurnents on the quality of root canal preparation using
a modified double-flared technique. ,f. Ërdodotlt. 1992; 181
32-.6.
37. Saunders WP, Saundeis EM. Comparison of three instru-
ments in the prepamtion of the crùved root canal using
the modified double-flared technique. l. Endodotlt. 1994;
20144OrL
38. Saunders EM, Saunders !\ry. The challenge of preparing
the curved root canal in today's root treatment cases.Derf.
UpdateL997;24.24LJ.
39. Saunders V\P, Saunders EM. Conventional endodontics
and the operating mictoscope. Dent. Clin. North Am.1997;
4l: 415J8.
't
his is a reL)icuof lhe usc of lhc opemling mi.ros opc [n non-
sllrgicûl root cakûl treat ent. Included are clinical tips to
improoeelfciency TDiththis treatfient aid.
Sattâpan B, Nervo GJ, Palamara JE, Messer HH. Defects
in rotary nickel titanium files after clinical use. ,f.
Endodont.2000;26: 161-5.
Schafer E, Tepel J, Hoppe W Properties of endodontic
hand instruments used in rotary motion. Part 2. Instru-
mentahon of curved canals.I. Endodont.7995;21,:493 7.
Schilder H. Cleâning and shaping the root canal. Derf.
Clin. North Am. 1974; 78: 269-96.
Short JA, Morgan LA, Baumgartner JC. A compadson of
canal centedng ability of four instrumentation techniques.
I. Endodont.1997;23: 503 7.
Shovelton DS. The presence and disbibution of micro-
organisms within non-vital leelh. Br. Dent. J. 1,964; 11,7:
'to1-7.
Southard DW Oswald RJ, Natkin E. Instrurnentation of
curwed molar root canals !r'ith the Roane technique. /.
Endoàokt.7987; 13: 479-89.
 clinical methodologies
Stabholz A, Rotstein I, Torabinejad M. Effect of preflaring
on tactile detection of the apical constrictiofi. I. Endodont.
1991 211924.
The frcac! of tactile detection of the apical coflstriction in
flared and nonflared rcot cafiûls. h1 the fionflared group a size
L5 ot 20 K-îile was sed.to detect the apical constiction, whilst
in the secondgroup the coronal portiotl of the rcot canal was
prcflûrcà Wior to testing the apic,tl constriction. Afet placiflg
a size 15 or 20 file in each loot canal, a radiograph zo.tstakeh,
and the distance betueen the tip of thefle and the radiographic
apex was measureil. The location of the file tip was classifed
into three categorie\: (a) within 1mm short of the radiographic
ape:t; (b) undete*ended, fiore than 1mfi short of the îadi-
ogtaphic apex; and (c) ooerextendedbeyond the radiographic
apex. l the non-flared group, 32.3"/. of the root canals were
cl.tssifiedin category a, as conparcd with 75.07" in the prcllarcd
gro p. Ooer 26% of the rcot canls in the unflaled group and
aryrorirftatelv 4"/. of the canals in the preflored group uere
included in category b. Files inserted in pteJlared rcot canals
had .t signifcafltlll lower blcideflce of ooerettension than those
placedin nonflaredcanals (217" aersus41yo). The ability to
detel1lli e the ûpical constriction by ttlctile sensation 7.0q66ig-
iifcantl! incrcased when the canals utere preflarcd (P <
0.0001).
Sunada I. New method for measuring the length of the
root canal. ,J.DenL Res.7962 41,,375 8-
Tepel J, Schafer E, Hoppe W. Properties of endodontic
hând instruments used in rotary motion. Part 3. Resis-
tânce to bending and fuact.îe.l, Endodont.7997;23:1,415.
49. Wu M-K Wesselink PR. Efficacy of three techniques in
clearring the apical portion of curved root canals. Oral
Sur&. 1991 79. 4924.
This study examined the cleaning of mesiobuccal catals
of human fiandibulat molors ruith afi atrerage cur-a)atureof
25" using step-back, ctowa down pressureless or balanced
force techniquesuith 2"/o NaOCI as an irrig.trlt. The cleaning
eficacy of these techniques was maluated lry counting the
ranaining surface debris under a stereomicroscopeuith a
calibrated eyepiece fliÛometeL The res lts indicated that
the apical pottion of the cannl was less clean than the middle
and cotonal portions regûrdless of the technique petforfied,
and that the balanced force techniq e prod ced .t cleoner
apiul poltion of the canal than did the other techniq e6
studied. They 7terc able to mlarge the apical Êtop to size 40 60
using the balanced force technique without recogllizable
tfinsport.ttion. They cotlsiàered that enlargemefit to size
25 11111fi from the opex and to size 35 3mm from the apex
may be insuficient to clean the ûpical p.trt of the root canol
system,
Yared GM, Bou Dagher FE, Machtou P Cyclic fatigue of
ProFile rotary instruments âfter clinical use, lnt. E|1àodot1t.
I . 2000; 33t 204-7 .
C h a p t e r1 7
Rootcanalfilling materials
GottfriedSchmalz

lntroduction up to days. Owing to several reasons outlined later,

combinations of cones and sealers are currently recom-
Puroose mended. Still less commonly used are thermoplastic
materials (gutta-percha preparations), which are heated
It has been well established that bacteda play the
for better adaptation to the root canal wall, or are melted,
primary role in the etiology and pathogenesis of apical
injected into the root canal in a liquid state and then
periodontitis, therefore the fully instrumented root canal
hardened by cooling. Again, these materials are nor-
has to be provided wiih a tght and longlasting obtura-
rnally recommended to be used together with a sealer
tion in order to prevent bacteda (and antigens) from
spreading from (or through) the canal system to the peri-
apical area. Thus, a root canal filling material should Limitations
prevent infection/reirLfection as a cause of inflamma-
As will be shown in this chapter, all materials recom-
tion. Together with an acceptable level of biocompati-
mended for root canal filling have advantages and dis-
bility (inert matedal) this shall provide the basis for
advantages and there is no material/method available
promoting healing of the periodontal ligament or for
so far that fulfills all requiiements, therefore clinicians
maintaining its health.
are well advised to observe carefully the new develop-
In addition to this traditional concept of the purpose
ments and the relevant scientific literature. It also should
of a root canal filLing material, recently ideas have been
be kept in mind that clinical properties of root canal
promoted that a root canal filling material also should
filling materials depend substantially upon the treat-
be able to actively stmulate regeneration of the peri-
ment technique: e.g, the amount of sealer used may
odontal connective tissue attachment apparatus, espe-
determine the tissue reactions alrd the amount of
cially after a sometimes aggressive treatment procedure
leakage for some matedals due to factors such as shrink-
or after apical pathosis. Relevant materials maybe osteo-
age during setting, the formation of pores or enhalced
conductive (serve as a scaffold for the ingrowth of pre-
solubility (40). Therefore, the selection and the use of a
cursor osteoblasts) or osteoinductive (inducing new
root canal filling material must be part of a conclusive
bone formation by differentiation of pluripotent local
treatment concept. Finally, there is no magic material by
connective tissue cells into bone-forming cells).
which the tedious work of correct diagnosis and chemo-
mechanical preparation of the root canal system can be
circumvented.
Classification
Root canal filling materials may be divided into three
Selection
t),?es:
Root canal filling materials should be selected on the
r Cones
basis of a critical evaluation of the presented evidence
o Sealers
(preferably reports in scientific journals) in relation to
o Combinations of the two.
the requirements, which will be mentioned below.
Cones are prefabricated root canal filling materials of a Sometimes, however, contradicting results are rePorted
given size and shape (taper). Sealers are pastes and for the same material. This may be due to the special cir-
cements that are mixed and hardened by a chemical cumstances of both the test method involved and the
setting reaction after a given amor.nt of time. This time preparation of the specirnens (tested freshly after mixing
varies between the vadous preparations, from minutes or in a set state). Thus, the clinician should ask for a set
261
 Clinical
methodologies

of tests preferably performed in a comparative (i.e. con- odontal ligament and the adjacent bone. In cases of
trolled) way, testing the new product against one or material extrusion beyond the apex, which is associated
more currently accepted preparations. Selection of a with elevated rates of clinical failure (63), resorption of
suitable root canal filling material is a challenge for the the material would be desirable. However, this is in con-
clinician regarding both his/her level of updated infor- tradiction to the required insolubility, therefore utmost
mation and his,/her ability for cdtical assessment of the care must be exerted to avoid overfilline.
presented inJormation.
Biologicalproperties
Requirements Biological properties are related to preventing systemic
and local tssue irritation for both the patient and the
Root canal filling materials may be considered as dental personnel and to stimulating regeneration of
implants and thus should fulfill the requirements of the apical region. The risk (frequency and severity of
such a device concerning techrical, biological and han- adverse effects) for general health impairment as a con-
dling propertes (Core concept 17.1). sequence of the use of root canal filling rnaterials is gen-
erally low. Single casesof allergic reactions of patients
and medical personnel have been reported. More
Technicalproperties
dramatic are local effects, especially in the context of
Tèchnical properties are mainly related to sealing overfilling beyond the apex and eventually into the
aspects, taking into account that the success of a root mandibular canal (seebelow).
canal filling significantly depends upon the prevention There are also some inherent contradictions between
of infection/reinfection of the apical and lateral peri- the requirements for a root canal filling matedal that
have to be weighed against each other, e.g. antibactedal
properties versus local todcity. Bacteria in the root canal
should be removed by chemomechanical debridement.
However, the complex anatomy of the root canal system
Coreconcept for an ideal
17.1 Requirements makes debridement difficult, especially in the apical
rootcanalfillingmaterial delta region. Furthermore, bacteria have been demon-
strated to invade dentinal tubules up to 1mm and thus
Technical they may not be removed totally by chemomechanical
a Noshrinkage. debridement. T?Lerefore, thorough cleaning, shaping
a No solubility
in tissuefluidt undisturbedsettingin the pres- and irrigation with disinfectants may not result in a
enceof moisture. completely sterile root canal system. Owing to the
Goodadhesion/adaptation to dentineor combining materials fact that microleakage cannot be prevented by any
(conetsealers). material/method available today, percolation followed
o Noporesandwaterabsorplion. by bacterial penetration and growth may occur Anti-
a Notoothdiscoloration. microbial activity of root canal sealers should compen-
sate for these imperfections, although this is not
Biological
supported by direct scientific evidence.
Nogeneralhealthproblemsor allergiesfor patientsanddental On the other hand, it was consistently demonstrated
personnel. that sealers with high antimicrobial activity, such as
a No irritationof localtissues. formaldehyde-releasing ZnOE (zinc oxide-eugenol), are
a Sterile, also toxic. Furthermore, sealers that release substances
o Antimicrobial - no enhancedbacterialgrowÎh.
may, at the same time, disintegrate. Therefore, anti-
o Stimulation of the periapical
healingproces:.
bactedal properties of a root canal filling material based
on the releaseof antibacterial substancesfrom the sealer
Handling
should not compromise its physical properties (such as
Radiopaque: l506876(62)requires
> 3 mmaluminum (dentine stability and sealability) or biological properties. Some
has0.6{.7) (radiopacityof dentalmaterialsis measuredas materials (e.g. epoxy resin sealers) are antirnicrobially
mmaluminum equivalent).
active only during the setting pedod, which is an inter-
settingin anadequatetime,allowing timefor obtu-
sufficient
esting approach. For a short period residual bacteria
rationandx-raycontrol.
Easyto applyandeasyto remove (e.9.for postplacementor may be killed (toxicity is accepted); in the long run, the
revision)usingsolventtheator mechanicalinstrumentation. material is not toxic, leaving time for the surrounding
tissues to heal.

Fig.17..1 Lateralandâpicalregeneration process
of an osteolytic
aftershapingandcleaning
(guttâ-percha
toxicity with an epoxyresinsealer)
Apical healing has been observed after elimination of
bacteria and a radiographically tight sealing of the root
canal system (Fig. 17.1). Actl?,e stimulation of apical
reseneration is - so far - based on the releaseof calcium
hyàroxide from the root canal filling material. However,
again it should be required that such a release of active
substances from a root canal filling material does not
interfere with the stability of the matedal and does not
increase leakage.
Handlingproperties
Handling properties shall facilitate the actual use of the
material and the conLrol of Lhe technique/heatment
result. The length of the root canal filling is of utmost
importance for the clinical successof a root canal filling
and a sufficientradioPacityis needed for x-ray control'
Setting conditions must be ad,usted to the special situa-
tion of the root canal filling techniques and relevant
Rootcanalfillingmaterials
the rootcanalandfillingwith conesanda sealerof temporary
requirements may be different for regular root canal fill-
ings (slow setting allowing for condensation and even-
tual conection after x-ray control) and retrograde fillings
(fast setting for better moisture control during the
oPeratlonr.
The ideal root canal filling material has not been
developed yet. Compromises have to be made between
the different requirements in relation to the sPecial
clinical situation. New formulations, however, shouldbe
checked critically against this list of requirements (Core
concept17.1).
Biocompatibility
An acceptable level of biocompatibility is an essential
requirement for a suitable root canal filling material'
According to ËU regulations (Medical Device Directive
9g/42 EEC) valid within the EU and in Switzerland,
 v

264 Clinicalmelhodologies

çil
'.î?,"i
i"à1,'^i:
lentine "-""': l,:":'
"i :", :?";:ï
f;. ,..".1:'ji
ReOrder606.15.208

Fig.17.2 TheCEsignonthepackage shows thatthemateria haspassed

a r skassessmentprocedure;
notethenumber thatidentifies thesuperulsing
body('NotifiedBody').
Fig.17.3 Cyrotoxicity testwitha polyketone rootcânasealer: zoneol
decoLorization aroufd thetesrspecimen (eft)indcates moderare toxicity;the
lcelancl, Liechtenstein anrl, Nonray, rooL canal filling partial lossof dye(neutral red)fromthecells (right) indicates nroderate cell
damage.
materialshave to successfullvpass a clinical risk:rssess
ment plocerlure before they arc allorved to be marketecl.
The CE sign on the package (Fig. 17.2)shows that the 10993or ISO 7405) (57).Normalll,, i,/ i'/tfo cvtotoxiciq'
material is in conformity with the essential leqllirements i ( s t . d r ep e r f , ' r m p r l i r ' t L r . i ' r Ë , . l i i ' e r e,nell l c u l t r . r ' r l' e
- .è1.
of this directive: namelv safetri efficacy and quality. pelioclontal licanent fibrobltrsts or osteoblasts) fbr
'clir.ricalrisk assess- mcasuring local toxic e'ffccrs(Fig. 17.3).Cytotoxicit)' is
Although for this process thc tcrm
mcnt'is being used, it shoulcl be noted that a neh'root regardedas a measLlreof the basicr]laterialpropeltv to
canal filling material does not necessarily have to pass damage cells ancl thus cause inflammation (56). Fur
any clinical testing if the manufacturcr assumes fiom thermorc, c)-totoxicity m;iy impair the local defense bv
(e.g. 'lristoric'cl;rta causingdamage to essentialcells of the lmmune svstcrl1
preclinical and other dat;i so-called
from similar/ iclentical materials Lhat are on the market (11). A possible influencc of a mâterial on the gcnetic
alreadv ancl/or have been tested in tlre past) that the informatioil âpparatlrs of cclls is teste.l in genotoxic-
material is both safe and effective. The c-lcrlListshould ity/mutation assiiys,e.g. using cclls or bacteria.Anti-
therefore ask the rnanufactnter for clinical data (see microbial propefties, being of special interest lor' l'oot
belou,), becausc hc/she is finally responsiblefor the canal filling rnaLclials,can be tested irt i,lfto, exposing
selection of the material in the sjngle patient situation diffcrcnt bactelial strains to the nâterials and nrt'asur-
and ihc patient relies on his/her independcr'rt cxpertise ing the gro!vLITpattern.Rele!ant bactcriacomplise thosc
(57).The timespanfor rvhich a root can.rlfilling matelial prcsent in the oral environment, especiallvir'r infecteLl
shal1be il sltr (ve;rrs)should bc rcÉlectedin the times- loot canals (mainlv Cram-negatir-e antrerobic rotis).
pan of clinical tcsts. Thcrc are so far no official r'egul;i- Ilecentlv thele has bccn increasing intcrcst ir1 ye:tst
ti()ns concerl-ringrccolnmended periocls ior a clinical tcst (nrainly Cordirln a/ùrcnrrs) infection in cases of apical
in root canal lilling matcrials.In anâloUyto filling mat- periodontitis.
crials,a time of 1 vear for excludingcatastrophicfailures The clinical relevanceof thesc ,r .'lt,.otest nethods is
antl a timespan of 3 5 )'ears for Lhefinal testing may be limitcd, becausethey do rlot take the complcx clinical
aclvisable. Productsrvithout a CE mark must not bc used situation of Lhe apical region of a looth into accor-lnt.
in those countries \\'lrcrc Lhc aforementioned EU Dircc- D.rt:r from slrch tests provide basic informaiiolr or1 the
tiye ir1effective. material and can be used to cxPlain certaiuclinical Icac-
Root canal iillirrg nlalerials come into close anrl pto- tions, e.g. in relation lo e\trtlsion of rool canal m.rterial
longeclcontactwitl.rliving tissuesof patients (e.g.bonc, o\'er the apex. Thcy ale L-rvthemseh es r-roLsufficient t(r
conncctivctissue,the sinus rrarillarris,the N. alvcolalis shor'r'the biocompaiibilitv of a matcrial (56).
inferior) and of dental personnel (e.g. skin of hands). /]r .1.,0bioconlpatibllitYtest metl.rodsare mainll'y.er-
Possibleadverse reacLionsarc of svstemic toxic, aller- formed on laboriitoryanimals.Reler,anttestsin{oh'e the
genic (imnrunological)or krcaltoxic natrire.Accordingly, implantatiù1 of ;r matelial into Lhc subcLltane()us/
a large numbel of different tesL mcthoels have been mnsclc Lissùesof rats, micc or rabbits (Fig. 17.1).These
dcsjgnecito test the tliffe|ent aspectsof the bjocompati- testsare Drainlydesignedto tcst lhc local toric potential.
bilit)' of root canal filJing materials.Relevantrnethods Of special interest are entloclouticusa5ictests (e.9. in
har'c been included in intcmati()nal stanclards (ISO dogs anc-lmonkevs), in lr'lich thc nraterial is applit'cl as
 Rootcanaltillingmaterials

Coreconcept
17.2 Factors
influencing
leakage
(1) RootcûAalarultonyaltd prcporation.oval and keyhole-
shaped profiles
oftherootcanals andunsuitable cleaning
and
shaping impede thecorrect application oftherootcanalfilling
maïeflat.
\2J Access caoit!.Bacleriamaypenetrate anobturated rootcanal
withina fewdays/weeks if theaccess cavityis notsufficiently
sealed (coronal leakage).
13) Smeat lûler. Remoual usingcitricacid(10-50%)or EDTA
(ethylened jaminetetraacetic acid) (17%) may influence
leakage, althoughresultsareunequivocal. Theeffectdepends
apparently uponthesealer used.
14) Hemostasis/dryness of the rootcanal.Ihewallof the root
Fig.17.4 llssuereaction14 daysaftersubcutaneous (rat)of
implantation canalmust becleananddryfora tightadapration ofthesealer
a set polyketone root canalsealerfilled into a Teflontube:accumulation to thewall.
of inflammâtorycells(mainlypolymorphonuclear neutrophilic
granulo(ytes) (5) Rootcanalfilling material. STabilily,
adhesion to dentine
and
at the contactarea(*) with the test materialindicates moderatetoxicity; lackof pores.
no lissuereadion at the contactarea with the Teflontube.tm = test (6) Sealetthichness and obt rûLiontechnique.Ihick laye$ol
tf = Teflontube(negative
materiâ1, controlandmaterialcarrier). rootcanalsealers (e.9.a ZnOEsealeror a calcium hydroxide
sealer)showed moreleakage thana thinone(40),whichmay
bedueto thefactthatmostsealers contain poresor dissolve
fasterin thicklayers.
A thinlayerof rootcanalsealeristhere-
used later with the patient, i.e. for filling root canals. foregenerally recommended.
With such an approach special issues such as apical
repair (e.g. new cement formation) or the fonnation of
hard tissue after treatment of teeth with oDen apices
(root-endclosure)can be studied, becausethis requires Howevet they are unsatisfactory because they do not
the interaction of different specialized cell types that so allow fo{ histological evaluation ald a substantial
far camot be simulated ]n in ztitro tests or in implanta- amount of calcium must be lost (>30%) before it can be
tion studies. Although endodontic usage tests are closer detected in standard x-rays. This demonshates that the
to the clinical situataoîlhaî in ïitlo tests, again they have biocompatibility of a new material cannot be evaluated
disadvantages, e.g. results of endodontic usage tests by one test alone, but a set of tests is necessaryto cover
depend strongly on the treatment method and there are the different aspects of biocompatibility.
indications that these tests do not provide a sensitive
discrimination among endodontic materials of widely
different chemical composition (50). Leakage/sealing
The allergic potential of dental materials is tested pre-
clinically maidy on guinea pigs, which provides a rough It is generally believed that the main cause for failure of
estimate. Patients who show cLinical symptoms of an endodontic treatment is the lack of seal of the root canal
allergic reaction toward a dental material may be sub- filling (apical and coronal leakage), facilitating bacterial
iected to special allergy tests, which apply a series of growth. Many studies (about 25% of the current
materials on the skin (e.9. patch test). Positive patch test endodontic Literature)âre devoted to leakage and seala-
results together with corresponding clinical symptoms bility. Leakage mairùy occurs between the root canal
(e.g. swelling, redness, itching) are indicative of a filling and the root canal wall, although there are some
material-related allergy. For allergy testing and for reports showing leakage between sealer (ZnOE or glass
avoiding relevalt allergenic products in the sensitized ionomer cement) and gutta?ercha and throughout the
patient, the composition of the material to be used must sealer. Leakage is influenced by the root canal filling
be known. matedal itself and by a number of other factors (Core
None of the test models described so far for assessins coîcept 17.2).
the biological properlies of root canal fillirg materiali Results reported in the literature on leakage depend
can be said to be identical to the clinical situation under greatly upon the test methods used. Test methods most
which the material is used, therefore clinical trials are often used are performed in ztitro and include dye
essential.These clinical trials (including x-rays) are con- penetration, additionally with pressure, centrifugation
ducted with the prime target organ, the human tooth. or vacuum. Other authors used bactedal penetration or
 Clinical
methodologies
fluid transport (73). The clinical relevance of these ln
ulflo studies is questionable and contradictory results
have been reported for the same material using differ-
ent methods (6), therefore these tests are - at most valid
in a comparative manner whereby a new matedal is
compared with a clinically established one. In alao usage
tests (e.g. on experimental animals) reveal more relevant
results but are more difficult to perform and more
uncontrollable variables (e.g. application technique) are
included. Agairç a set of different test methods is neces-
sary to evaluate the leakage properties of a new root
canal filling material. Leakage data reported in the liter-
ature for root canal filling materials therefore should be
regarded with caution because, as with data for other
properties (e.g. biological), they are only mosaic stones
that need other properties to determine the clinical use-
fulness of the new material.
Gutta-perchacones
Cutta-percha is the most common cone material used for
root canal fillùrg. Silver was used ilr the past but has
been abandoned because of the mediocre sealing quali-
ties, even when used together with sealers,and because
of high corrosion leading to tooth discoloration and local
tissue reactions (Fig. 17.5).Titanium cones are available
and have good biocompatibility, but they show low
radiopacity and poor adaptation to the root canal wall
tn casesof a non-circular cross-sectionof the shaped root
canal. This requires a comparatively high amount of
sealer and therefore aggravates the seal of the filling. In
nauow and curved canals, where the application of
(b)
Fig.17.5 (a)Discolofation
ofa rootafterrootcanalfi/lingwitha silvercone.
(b)Renoved
silverroneshowing signsot sevÊreco4osion.
gutta-percha points is difficult, these cones rnay be
considered.
Gutta-percha cones are the mateial of choice for
filling the major part of the canal volume. The clinician
should carefully select materials with exact dimensions
and a composition that is not tissue irritating. Gutta-
percha cones (even standardized ones) do not as such fit
optimal to the shaped root canal and therefore must be
compacted and used together with sealers; the less
sealer necessary,the better.
Composition
Gutta-percha is a natr-rral product that consists of
the purified coagulated exudate of mazer wood trees
(lsonandrapercha) fuom the Malay archipelago or from
South America. It is a high-molecular-weight polymer
based on the isoprene monomer. Two forms of gutta-
percha are relevant for dental products: the o- and the
p-form. The B-form is used in most gutta-percha cones
(less bdttle than the c,form) but the s-form is used
for injectable products because of its better tlow
charactedstics.
The composition of gutta-percha cones (Thble 12.1)
varies considerably between different manufacturers.
This and the fact that gutta-percha is a natural product
(with varying molecular weight) may be the reasons for
different properties being reported for different brands.
Formerly, cadmium (Cd)-based dyes were aclded to
provide a yellow color, which should facilitate removal
(if necessary; e.g. for revision). Modern gutta-percha
preparations use other colorants and do not contain any
intentionolly added Cd compounds (zinc oxide may
contair low levels of Cd impurities). Some gutta percha
preparations contain calcium hydroxide or chlorhexi-
dine, with the aim of enlancing their antibacterial activ-
rty (temporary root canal dressing) and stimulating
apical healing. Clinical experience is limited so far
Cutta-percha cones are supplied by the rnanufacturers
in different sizes (length, diameter, taper; Table 12.2).
Standardized cones frequently are used and the idea of
having a cone that coryespondsclosely to the shape and
the dimensions of the prepared root canal is striking.
Tâble17.1 Typical
composition
of gutta-percha
cones.
Components Composition{o/o)
Zincoxide
[4etalsulfates(radiopâcity) 11
Gutta-percha 2Q
Additiveslikecolophony (rosin,mainlycomposed
of 3
diterpene resin),pigments
or tracemetals

Fig,1?,6 Scanning
electronmicroscopepictureof thetip oTâ gufta-percha
root(analfile;notethe discrepancies
conêândthe conesponding in shape.
of gutta-percha
Table17.2 Dimensions cones.
Typeof cone size
Standardized
cones corresponds in diameter andtaper(2%)to root
canalshapinginsfiumentaccordinq to 1506877.
Ihe size5of the guttâ-perchâ conesrangeïrom
15010to 150140(Fig.17.8)
Accessory
cones targertàper,descriptive size,maybe usedfor
lateralcompaction
tapercones Coneswith a 4% or 6% (andup to 12%)taperused
Greâter
togetherwilh specialengine-driven root canâl
shapinginstruments (seeChâptêr16)
compactioncones Tapercorresponds to the taperof finger-spreaders
However, there are discrepancies between the shapes of
the cones and the shaping instmments (Fig. 17.6), and
the actual dimensions of the gutta-percha cones show
considerable variation. Therefore, it is advisable to check
the dimensions of each cone by a suitable gauge Prior to
use (Fig. 17.7). Some manufacturers offer gutta-percha
cones with a color coding according to the ISO system
for the different sizes (ISO 10-ISO 140) (Fig. 17.8)and/or
with a millimeter scale to control the length of insertion.
Cones with a 47o or 6% (arld up to 127o)taper are offered
in sizes using the ISO nurrLbering system (i.e. 10-140);
however not orùy the taper but also the (apical) diame-
ters may be different from the standardized cones.
Depending on the shaping system, the taper of Sutta-
percha cones may be constant over the 16 mm length of
the cone or it may be limited to the apical part of the
cone.
RootcanalTillingmaterials
Fig.l7.7 (a)Gâuge cone.
thesizeoftheactualguttâ-percha
forcontrolling
(b)Theactuâl
coneistoothin,because outofthegauge.
it reaches
Gutta-percha may be used per se (i.e. cold) in combi
nation with a sealer. Owing to the thermoPlastic prop-
erties, gutta-percha may be used also in a heated state,
which allows closer adaptation to the canal walls (Fig.
17.9). The products consist of a plastic core (carrier)
coated by o-phase gutta-percha for improved flow char-
actedstics and to reduce shrinkage after cooLing. Gutta-
percha also may be liquefied at a temperature of 70"C
(Ultrafil) or 1,60/200"C (Obtura II) and injected directly
into the root canal.
Technicalproperties/leakage
Gutta-percha cones are flexible (elastic) at room tem-
perature, become plastic at about 60'C and are volume-
constant under mouth conditions. Heating leads to
expansion (and cooling to contraction), a fact that reduces
the sealing quality of warm or liquid gutta-percha appli-
cation (when used without a sealer). Gutta-Percha is
soluble in organic solvents such as eucal)?tus oil.
Gûla-percha per se does not adhere to the canal walls,
regardless of the obturation technique applied, resulting
in marked leakage. Therefore, gutta-Percha (used cold
and heated) is generally recommended to be used
together with a sealer For an optimal seal the sealer
layer generally should be as thin as possible, therefore
the skill of the operator plays an imPortant Part in the
success of the treahlent by corectly comPacting gutta-
percha, whereas it is apparently of minor imPortance
which method of compaction is applied.
Biologicalproperties
No systemic-toxic reactions toward gutta-percha have
been reported in the literature. Concerning the Cd
 Clinicalmethodologies

Notes
1. The diametersare expressedin hundredths
of millimetêrs.ISO-tablegivesthe values
of d1, dz and d3 for each size,
2. The têper of standardized cones is
0.02 mm per 1 mm length, therefore Fig. 17.8 Schemefor the dimensions of a
d" = d. + 0.32 mm. standardized
gutta'percha
coneâccordingto lS0
3. In detàil X, the exactshapeof the tip rs 6877;4 x 100= sizedesignation
of gutta'perchâ
left to the manufêcturer cone(lS010-lS0140).

Fig,17.9 ovenlor warminggutta-percha cones(b).

cones{a)andthe corresponding

content of 'o1der' gutta-percha (produced up to the
1980s; information from manufacturers), no systemic
reaction is to be expected owing to the small masses
involved and the low solubility. Allergic reactons
towards gutta-percha are extremely rare, One case was
reported of a suspected allergic reaction duing a root
caaEl treatment with a patient who was sensitized to
natural latex. No latex gloves were wom during treat-
ment, but pain, swelling of lips and diffuse urticaria
developed after treatment. After 4 weeks the gutta-
percha cone was removed and the sFnptoms abated.
The allergy was attributed by the authors to the fact that
pure gutta-percha and natural latex are fabricated from
natural substances derived from trees of the same botan-
ical family (10). No further cases have been reported.
Cones made from s)'ïrthetic gutta-percha are available.
ln several cell culture studies, gutta-percha proved to
be non-cytotoic or orùy a little cytotoxic, depending on
the product (Fig. 17.10).Generally, gutta-percha is well
tolerated by animal tissues (e.9. rat and mice connective
tissue), inducing the formation of a collagenous capsule
with nolalrnost no inflamnation (Fig. 17.11).Interesi-
ingly, it was found that in oitro and. in uiro some guitta-
percha preparations were more toxic than others (22 55).
After subcutaneous implantation of large particles in
guinea pigs only mild reactions occurred, whereas small
gutta-percha particles (50-100pm) caused an accumula-
tion of macrophages and giant cells (typical of a foreign
body reaction), which may impair apical healing (64).
This shows that gutta-percha is by no means a homoge-
neous group of materials, and that the tissue reaction
also depends upon the particle size.
The elevated temperatures involved in the application
of i-Ljectable tquefied gutta-percha or of heat-mediated
condensation/compaction techrriques haye been the
motive for several investisations into the involved risk
 Rootcanalfillingmaterials

measurements
Tâble17.3 Temperature gutta-perchâ
forliquefied
Toxicityscore 'l h setting time
I
I 24 h sêtting time Technique lntracânal Toothsurtace
Ê No mixing temperature Iempera re
('c) rise('C)

Ultrâfil 70
obturall Max.6l Mâx.8.9
Warmverticalcondensation 45-80 3-1
Ihermomechanical 55-100 14-35
compactt0n

which reflects the cooling process during aPplication

(70\.
However, the main target tissue (the Periodontal liga-
ment) is separated from the heated Sutta-Percha by
dentine, whiclu owing to its low thermal conductivity,
AH 26 Diaket znoÉ/Form Gutta- Gutta acts as a thermal isolator. Its effectiveness depends on
perchaI perchâ2
the dentine thickness, therefore temperature measure-
Test materiâl ments at the surface of the root are clinically more rel-
evant. It is generally accepted that a temPerature rise of
Fig.17.10 Cytotoxicityof differentrootcanalflllingmaterialsihuman.ells
wereexposedto eluatesof the materiâlsandthe effectuponcellgrowthwas approximately 10'C above normal body temperature is
highscores
measured; indicatestrong Forsealers,
cytotoxicity. effects
offreshly critical if maintained over l mirt over 5min more con-
mixedmaterialsand set mâterialswere meâsured; for gutta-perchâ,two sistent bone darnage will occur (20). AgairL the highest
brândsweretested.ZnoÉ/Form = formaldehyde-contâining ZnoEsealer(55) temperatures were measured on the root surface with
the thermomechanical comPaction technique, with dif-
ferences depending on the rotational speed of the com-
pacting instrument. After stopPing comPaction/ heat is
dissipated in 1$-30s for a less than 10'C elevation (53).
The reaction of the target tissues (periodontal liga-
ment) after injection of heated gutta-percha into the root
canals of a dog showed no evidence of inflammation. In
the case of overfilling, an acute inJlammatory reaction
was observed briefly after insertion and a chronic/
foreign body reaction was found in long-term experi-
ments (41). The classical warm vertical condensation or
the warm lateral condensation did not cause any heat-
related periodontal damage in monkeys and miniature
pigs at the coronal, middle or apical segments of the
root. Contrary to these data, thermomechanlcal com-
paction of gutta?ercha with a sealer caused tissue
damage (seeKey literature 17.1).
Fig.17.11 Issue reaction7 daysafterintramuscular of gufta
implantatjon
br conclusion, for melted injectable gutta-Percha, no
percha:
no inflammatory at the contâctâreawith the
cellscanbe observed
test materiâl (*), which indicatesgood biocompatibility. tm = test tissue damage is expected due to rapid cooling during
tf = Teflontube(negative
material, controlandmaterialcafiier). application and isolation of the dentine layer If this
layer is not present, e.g. after overfilling, a tissue reac-
tion may occul No such risks exist for the classicalwarm
condensation technique, with the use of heated instru-
for adverse clinical effects. Intracanal temperatures have ments or with the prewarming of Sutta-Percha cones
been measured, the highest being for the thermo- The use of sealers further reduces temPerature rises.
mechanical condensation technique (see ChaPter 18) However, with the therrnomechanical compaction tech-
(Table 17.3). Interestingly, for liquefied Sutta-Percha nique most elevated temperatures on the root surfaces
(Obtura II), which is heated to more than 160'C, the were recorded, as well as tissue damage with cementum
intracanal temperature shows a maxirnum of only 61"C, resorption and ankvlosis.
 Clinicalmethodologies
Keyliterature
17.1
Saunders {54)studiedhistologically
theefTect
of thermomechanical
compaction (10,000
revolutionsperminute) of gutta-percha witha
calcium hydroxide sealeruponthecementum of ferretteeth.Twenty
daysafterrootfilling,20%oTtheexperimental teethshowed signs
oI surface resorption
of cementum inthecentral sectionoflhe root
withnosignsol inflammation. After40 dayg28%showed resorp-
tion and,of these,22% exhibited ankylosis
of alveolar boneto
cemenlum. Controlswith lateralcondensation showedno resorp-
tionor ankylosis.Theauthors conclude thatheatgeneration bythis
method issufficjentto
stimulatesurface resorDtionandankvlosis in
thelongerterm.
Antimicrobi al prop erties
It y/as reported that gutta-percha revealed some anti-
microbial properties, the active substance being ZnO
from which zinc ions (Zn'*) are mobilized by hydrolysis.
Other authors found some brands of gutta-percha active
against anaerobically cultivated isolates from root
canals. The occurrence and the size of the detected zones
varied with the bacteda used for testins and the brand
of the gutta-percha cone (69).
Handlingproperties
Gutta-percha cones are usually supplied by the manu-
facturer in a non-stedle way. Storage in comrnonly used
disinfectants may have a negative influence on the
mechanical properties of the cones and should be
avoided, udess evidence is presented that the cones are
not damaged. Rather, an effective surface disinfection
(e.9. with 5.25% NaOCI) imnediately pdor to use is
advisable; the cones afterwards should be rinsed in 70%
alcohol to prevent NaOCI crystals forming on the gutta-
percha cone. Recentlt gutta-percha cones that are 'free
of living germs' (declaraton of the manufacturer) have
been marketed (Fig. 77.12). Gutta-percha cones should
be stored cool and dark in order to prevent enhanced
hardening and brittleness due to further crystallization
and/or oxidation. A technical problem with the use of
heated gutta?ercha is the higher frequency of extrusion
of root canal sealer
Gutta-percha can be removed mechanically owing
to its comparatively soft consistency, for example, by
conventional hand file or by rotary instruments (see
Chapter 19). Chloroform is not recommended due to
its possible carcinogenicity. Gutta-percha preparations
using a plastic carrier can be removed using organic
solvents, e.g. eucalyptus oil. The carrier can be bypassed
by endodontic instruments. The radiopacity of gutta-
Fig. 17,12 Guttâ-percha
conesdelivered jn an aqueous
('germ-free')
solution
of ethânol
andhexetidine.
percha was measured to be between 6.14 and 8.8mm Al
(62) and this is considered to be sufficient.
Sealers
Sealersare used to fill voids and minor discrepancies of
fit between the gutta-percha cones and the root canal
wall. Without a cone, leakage increases significantly,
probably owing to the fact that sealers may shrhk
dudng setting, pores may develop and the solubility of
the sealers is enhanced when used in thick layers; the
net effect is volume dependent, which is the main reason
for using no more sealer than is absolutely necessary.
Therefore, the use of sealers without any cone, as was
recommended in the past, is today obsolete. AI ISO
standard for dental root canal sealing materials (ISO
6876) is being pubLished and it describes mainly techni-
cal and radiopacity requirements for such materials.
Sealers comprise a heterogeneous group of materials
with different compositions (Core concept 17.3).Sealers
commonly used will be discussed in more detail in the
following paragraphs. In former times, gutta-percha dis-
solved in chloroform was commonly used as a sealer.
However, sealing qualities are regarded as being poor
owing to shrinkage toward the center of the material
mass after chloroform evaporation. Furthermore, the use
of chloroform is discouraged because of its inherent
health problems (e.g. carcinogenicity).
Composite resins/dentine bonding agents were tested
as root canal sealersin a few studies. They are reported
to achieve a good seal, with penetration of the resin into
the dentinal tubules, although there are apparently dif-
ficulties in applying the matedal to the apical one-third
of the canal (42). Removal of the set resin is difficult and
thus problemsoccur when a re-entry is needed.
 Rootcanalfillinomaterials 271

Recently, calciurl phosphate cements (CPCs) have for promoting cementum-like hard-tissue deposition
been described as root canal sealers. They consist of (76.
tetracalcium phosphate and either dicalcium phosphate Silicone as a basis for root canal sealers was intro-
dihydrate or arùrydrous dicalcium phosphaie mixed duced in 1984. The fust product was based on a con-
with a 1M solution of sodium phosphate dibasic hep- densation polymerizing silicone ('C-SiLicone') and, after
tahydrate. Reports on the sealing properties are still subcutaneous implantation in rats, this material was ini-
unequivocal, apparently being dependent upon the tially mildly irritating and in the long run virtually non-
actual formulation. Biological reactions are favorable: toxic (28). In comparison with calcium hydroxide and
after implantation no or only mild inflamrnatory reac- ZnOE sealers it proved to be the material that was the
tions occuffed. After correct application and even after least tissue irritating. Recently, a root canal sealer with
deliberately overfilling root canals, the CPC caused no an additional poll'rnerizing siÏcone ('A-Silicone') be-
or only minimal alterations. There was even a potential came available (Fig. 17.13).A-Silicones, used as impres-
sion materials, are known to be rnore dimensionally
stable than C-Silicones, which release ethanol during
polymerization. In different in vitro studies this sealer
was used together with the thermoplastic technique
and the lateral condensation technique and Proved to
Coreconcept17.3 Classificationof root provide, in most cases, better sealing properties than
canalsealers calcium hydroxide- or epoxy-based sealers (18). A-
Silicones (as impression material) tested non-toxic both
sealers usedarebasedon:
commonly in ritro and after implantation into experimental animals
(ZnoE)
. zincoxideandeugenol (58). Yet, so far, no reports are available on the long-term
. Polyketone clinical behavior of silicone root canal sealers.
o Epoxyresin
o Glassionomercement
. calciumhydroxide. Zinc oxide-eugenolsealers
underjnvestigation/recently
sealers arebasedon:
marketed Zinc oxide-eugenol (ZnOE) sealers have been used for
many years and ample clinical experience exists with
o composite bonding
resins/dentine agents
phosphate these materials. FIowever, sealing ability and biological
a Calcium cements
. silicones. properties are, in general, inferior cornpared with other

Fig. 17.13 (a) Cellculturetoxicityteston t929 mousefibroblastsof an A-silicone'root cânâlsealer.Jhecellsâre growingbeneaththe filter (circulargrey
âreâ).A positive (5%
control phenol), prepared
the freshly sealerandthe setsealer are placedon top of the filter in threedifferent
rings.
{b)Ihe cellsbeneath
freshandsetmaterialarenot damaged, whereasall cellsbeneaththe controlâredead.(Courtesy of DI D Orstavik.) RS= rootsealer.
 Clinical
methodologies
root canal sealers. Because of its tendency for disinte-
gration it is still recommended as root canal filling
material for deciduous teeth. However, it has not been
shown that disintegration of the material occurs parallel
to tooth resorption. Formaldehyde-releasing ZnOE root
canal sealers should not be used anymore because of
their inherent toxicity potential. The European Saciety of
Endodontology discourages the use of these materials
(23).
Composition
These sealers comprise a fairly large group of different
preparations. Additionally to the standard composition
oI ZnOE sealers (Grossrnan sealer, Table 17.4) some
preparations further contain thymol or thymol iodide
for increasing the antimicrobial effects. Also, hydroxya-
patite or calcium hydroxide has been added for improv-
ing apical healing. In some sealers eugenol is partially
or totally replaced by oil of cloves, Peru balsam or
eucalyptol. Oil of cloves is a natural product that con-
tains 60-80% eugenol. The ZnOE sealers may contain
colophony (a rosin, mainly diterpene resin acids) to give
body, to impart adhesivenessto the sealer and to reduce
the solubility/disintegration of the sealer
Modified ZnOE preparations are composed of: 60%
zinc oxide, 34% alumina and 67onatural resin (powder);
or 62.5"/" ortho-ethoxy benzoic acid and 37.5% eugenol
(liquid). Another frequently used cement contains 807"
ZnO and 20% PMMA (polymethylmethacrylate) in the
powder, and the liquid is eugenol. These materials are
preferably used for temporary fillings of the access
cavity and for root-end fillings. Some ZnOE-based
sealers contain paraformaldehyde (e.g. 77" oI the
powder), with the claim of long-term disinfection by the
release of formaldehyde.
The ZnOE preparations harden in a humid environ-
ment by forming a ZnOE chelate compound. The mix
sets within 24h but the speed can be regulated by the
addition of resins, calciurn phosphates or zinc acetate.
The setting reaction is reversible, releasing eugenol ar-rd
zinc ions under hydrolytic conditions.
Table17.4 Typical composition
of a ZnoEsealer.
Liquid
Zincoxjde(42%) Eugenol
resin(27%)
Staybelite (4-allyl-2-methoxyphenol)
(15olo)
Bismuthsubcâùonate
Bâdum sulfate(15%)
Sodiumborate,anhydrous{1%)
TechnicaI p ro p ertie sI leakage
Several studies showed apical leakage around ZnOE
sealers that increased with storage time (measured up
to 2 years), in thick layers more than in thin layers
(40). Sealing properties of ZnOE sealers were inJerior in
comparison to other sealers (epoxy resin or calcium
hydroxide sealers)butbetter than those of glass ionomer
cements. Adhesion of ZnOE sealers to gutta-percha
cones is sufficienl. Also, coronal leakage was greater
Ior a ZnOE sealer (when used with a lateral condensa-
tion technique) than for a calcium hydroxide sealer,
probably due to the relatively high solubiliÇ of the
ZnOE sealer (5). Acid end-products of Grarn-negative
bacteda penetrated a seemingly well-obturated canal
within 12 weeks. These acid end-products are able to
induce inflammation, e.g. by stimulation of interleukin-
1p (a protein that belongs to the group of cytokines and
plays an essential role in immune/ù1flaûrmatory reac-
tions) secretion of cells (15). Modified ZnOE cements
appear to have better sealing qualities (see root-end
filling).
A ZnOE preparation releasing formaldehyde partially
dissolved in contact with vital pulp tissue, and particles
of the sealer were dislocated at varying distances from
the contact site up to the periapical ligament (36).
Removal of the smear Iayer (17"k EDTA) improved
(coronal) sealing and in EDTA-pretreated canals differ-
ent ZnOE sealers showed homogeneous penetration
into the root dentine tubules, up to 600pm deep.
From these data it can be concluded that the sealing
properties of ZnOE sealersin general are somewhat inJe-
rior to most other available materials. Removal of the
smear layer improves the seal.
Biological properties
Eugenol, a phenol derivative, has attracted prime inter-
est from a biological point of view. Systemic toxicity was
evaluated to be low and eugenol is an accepted nutfi-
tion additive. However, eugenol is a known contact
allergen, as well as colophony and Peru balsam. Eugenol
and its derivatives are used in fragrances, and allergies
toward fragrances may be related to eugenol. Cases of
allergic reactions toward ZnOE-containing temporary
filling materials have been reported (33), but apparently
not for root canal sealers. ln some cases, dental per-
sonnel reported contact dermatitis toward eugenol-
containing materials (38). Fornaldehyde, which is
releasedfrom certain ZnOE sealers,is a known allergen.
A female patient, a few hours after the application of
a high formaldehyde-containing root canal paste,
reported urticaria of the lower jaw that rapidly cleared
with oral corticosteroids. In the skin test, the patient
reacted positive toward the formaldehyde-containing
liquid of the root canal paste (19).
 Rootcanalfillingmaterials 2 7 3

(a)

Fig.17.14 An emptypolytr.rbe (a),a tubefi ledwitha ZnoEseaer (b)anda tube

fl ed with a formaldehyde-releasing ZnOEsealer (c)weretransferred,lmmedatey
afterobturatlng, to tissuecutureflasks containingculturesof humanorâlf broblasts.
Toxicitywasevaluated after5, 10and15days. showsthe resultsafter
Theillustratlon
15dàys.In (a),thecontfogroup, thefibroblastsproliferate
closely
upto thetesttube
(right).
In (b)a narrowlnhibitlon zonepersists adjacentto a Zn0Econtaining tube.
In (c),wherethetubecontained a lorma!dehyde-releasing no vitalcellgare
sealeç
seen(3).(Courtesy of DrP Horsted Bindslev.)

Eugenol is cytotoxic and the same has been sl'tow'nfre-
quently for ZnOE with clifferent cell culture systems,
especially after mixing but also in a scL state. Even
higher cytotoxicity u'as observed $'ith formaldchyde-
containing ZnOE sealers, rn'hich rvcrc classified as
highly / extremcly cytotoxic (Fig. 17.14)(3) and reveal
strong cytotoxic effects (Fig. 17.10)cven afler ser,eralelu-
tions of the hardenecl specimens (27). A ZnOE sealer
without paraformaidehydc tested nonmutagenic.
Mutagenicity of formaldehyde, u'ith paraformaldehyde
being one of its sor-rrccs,l-rasbeen demor1strated.
Some componei'rrs of ZnOE sealers have neurotoxic
effects. Er-rgenolinhibjLcd nerve conductance it1ritrc rn
experiments rvith diffelent nerve tissues. Furthermore,
eugenol has both local and general anesthetic effects.
Taking into consideration the concentrations involved, il
possible neurotoxic effect of eugenol mav be reversiblc
in t,i-oo(12). On the contrary, formaldchyde irreversibly
suppresscd nerve conduction in concentlations tl1atmay
be reachcd in patierlts with form;rldehyde-containing
rooL canal sealers oiving to the high solubility of
formaldeJ.rydein lr'ater (12). The concentration in root
canal sealers and in formocresol pastes is much highcr
(2-19'X,) than that neededfor irt i'lfro destr"rctionof nerve
and rmrscle excitabilit),. Accordinglr', a ZnOE sealer in
direct contact with the ner\re caused colnplete btlt
rcvcrsible ir-rhibition of the nelve conductance, u4rereas
formaldehycle-containing root canal sealers completely
;rncl irreversibly inhibited the nerle conductance (13).
The resulLs u'ith the forrnaldclrvde-containing; seaLcrs
suggestpcrmanent clamageof thc nen'e l,?./.,0.
ln addition to the obsen'ed allergic reactions, ZnC)E
root canal sealers may inflr-rencethe immlrne s)'stcm.
hr .)ifro iN'estigations (11) shorved both stir.rltllatol,v
(low concentrations) and inhibitorv (higher conccntra-
tions) effecLsof extracts of ZnOE sealers on immune-
competent cells, rvith arld without formalclehyde. The
stimulatorv effect may indicâte that these materials
evoke or accentuate arr inflarnmatorv reaction in the
apical region in uir,,.t(11).After intramuscular iniections
of a mixtule of pulp tissue r,vith a formaldehvcle
releasing loot canal filling materi.rl, a marked immune
rcsponse (iymphocyte proliferâtion ancl elevated anti
body titers) r,as obselved with thjs rraterial (3).
A ZnOE sealer consistently has sltolvn an initial
inflarnmatory effect on the periapical tissues after obtr.l-
ration of ferret root canals, r'r.hereasonly three out of ten
showecl inflammation âfter root filling u'iLh a calcium
hyclroxide fomulation (3-1). A paraformaldeh,vcle-
containing ZnOE sealer producecl cxLensive inflaDrma-
tion ancl tissue necrosis aftei intlamuscular jmPlant.rtion
(Fig. 17.15) ancl n'hen used in root c.rnals of clogs'
tcctlr. Such a sealersignificantlv impaireclapical tissue
repair'. Scvere reactions occuLtcd after overfilling (35,
Kev Literature17.2).When rrsedas a Iooi canàl sealelin
human teeth, a fonnaldehyde-releasing ZnOE sealer'
274 Clinical
methodologies

Fig.17.15 Tissue reaction7 daysafterintrâmuscular implantation

of a fomaldehyde releasing ZnOEsealetextended areaof inflàmmatory cellsandnecrotic
tissu€at the contactareawith the testmaterial(*) indicates
strongtoxicityfor the materialaftermixjng(a)andafter7 daysof setting(b).tm = testmâterial,
tf = Teflontube(negativeconlrolandmaterialcarrier).

(Fi9.77.1,6). Clinical symptoms are inconclusive: most

Keyliterature
17.2 patients repod intermittent pain and tenderness of the
cheek. Other patients have no clinical syrnptoms and
Honget a/.(35)performed experiments ontheincisorsoI monkeys.
Theydeliberately (thussimulating aspergillosis may be detected incidentally at an x-ray
overfilled
therootcanals a worst-
casesituation) withtwo ZnOE sealersonereleasing for-maldehyde examination (7).
and,theothernot.Iïe tissuereaction wasevaluated histologically.
Theformaldehyde-releasing Zn0Esealercaused severeperiapical Antimicrobial prcperties:These could be demonshated
inflammation evenafter6 months; the formaldehyde-free sealer even 7 days after mixing on a variety of micro-
evoked milderalterations.Underthesameexperimental conditions organisms, including Enterococcus/aecaûs suspensions
a calcium phosphate sealer(experimental produced
material) only and anaerobic bacteda. This effect was st{onger than the
minimal tissuereactionsandevennewbonewasTormed. Based on effect produced with calcium hydroxide products but
theirresultstheauthors recommend materialsthatalteroeriaoical less than alr effect from ar epoxy resin sealer (Fig. 17.17).
tissuesas littleas possible,to preventsevereandchronic tissue Apparently, eugenol is the main antimicrobial agent.
reactionsafterinadvertently overfilling
therootcanal.
Urstavik (48),in an experimental model of contaminated
dentinal tubules, has shown that a ZnOE sealer in the
pulp chamber disinfected the dental tubules to a depth
of 250pm (Fig. 17.18). Formaldehyde-releasing ZnOE
evoked a strong inflammatory reaction of the contacting sealers show extensive antimicrobial properties (Fig.
pulp tissue 6 months after placement, and in correspon- 77.77).
ding animal experiments particles from this sealer were
scattered in the adjacent tissue and surrounded by Handling propefiies
foreign body cells (multinuclear giant cells, macro- Zinc oxide-eugenol-based sealers are easy to handle.
phages) (36). From these data it can be concluded They can be mixed to a smooth paste, which allows
that ZnOE sealers have a moderate local toxicity that enough time for obturation and control (x-ray) before
is strongly enhanced by the addition of paraformalde- setting. Removal can be performed with organic
hyde. There are repods indicating favourable clinical solvents. The radiopacity of different ZnOE sealers
results using sealers containing formaldehyde. was 5.1,Ç7.97mm Al (62) and thus can be regarded as
Howevel as mentioned, clinical outcome depends on sufficient.
many variables and is by itself no proof of acceptable
biological properties.
Zinc oxide{ugenol sealers with paraformaldehyde
Polyketonesealer
were reported to induce aspergillosis of the sinus The polyketone sealer has good mechanical and sealing
maxillaris if the material is overfilled into the sinus. A properties and no effects on general health are to be
t)?ical x-ray shows a homogeneously clouded antrum expected. On the other hand, the relatively short period
with one or more round-to-oval radiodense objects for setting may be a problem, especially when compli-
 Rootcanalfillingmaterials 275

Fig. l7.16 X-râyoIâ maxillarysinuswith suspected fromân overfilled

aspergillosis rootcanalinthe rightsinusrround
to ovalradiodense objectrin the right
sinusindicateaspergillosis;
the responsible (a)andthe tissuewasremoved
toothwasextracted frcmthe sinus(b).(Counesy of Dr Hârle.)

Inhibitionzone (mm) Depth of disinfection(pm)

I strep.faec 1000
E P aerug
æ slaph. aur
E Saliva/fresh
mat 800
I Salivê/set
mat

600

400

200

0
AH 26 Diaket ZnOE/Form ZnOE- Chlor- AH 26 ZnOEICH ZnOE/Form ZqOE- CH-
Sealer hexidine Sealer Seâler
Tertmâterial Testmaterial

properties:
Fig.17.17 Antimicrobial of growthinhibition
distance zonefor properties:
Fig. 17.18 Antimicrobial depthof dentineât which bacteria
several
rootcanalsealers
anddifferent
baderial
strains.
Largezones indicate (Enterccoccus
faecalis) znoE/Form
werekilledby the root canalsealers; =
extensive properties;
antimicrobial ZnoE/torm= formaldehyde'containing ZnoE sealer;ZnoE/CH= calcium hydroxide-
fonnaldehyde-containing
ZnoEsealer(47). ZnoEsealer(48).
containing

cated compaction techniques are used and teeth with of a polyketone

Table17.5 composition sealer.
more than one root canal are to be treated. However, this
may be advantageous in a root-end filling situation. The Liquid
material is orùy moderately toxic and apparently does
Zincoxide(97%) Propionylacetophenone(76%)
not actively stirnulate the healing of apical tissues.
Bismuth (3%)
phosphate Copolymersof vinyls(23.3%)
Dichlorophen
{0.5"/o)
Composition jne (0.20lo)
Triethanolam
There has been one commonly used polyketone-based
root canal sealer on the market since 1952 (Table 17.5).
During setting, a chelate between tlLe ketone and zinc is
formed.
 Clinical
methodologies
Technical prop efiies I leakqge
The polyketone-based sealer proved to have acceptable
techdcal properties (sufficient strength, low shrinkage
and good adhesion to dentine). Leakage studies showed
that this material had lower microleakage scores than
the other tested sealers (ZnOE sealers and a glass
lOnOmeI Cemenlr.
Biological properties
There are no reports available indicating any sys-
temic-toxic effect or allergic reactions. Cell culture
expedments for local toxic effects consistently showed
cytotoxic reactions that were less pronounced than those
reported with paraformaldehyde-containing ZnOE
sealers and that decreasedafter setting (Fig. 17.10).The
material was shown to be non-mutagenic in a commorùy
used bacterial mutation test (59). The sealer showed
partial inlribition of nerve conductance in aitro, which
was partially reversible (13).
When mixed to sealer consistency, the polyketone
sealer was shown to cause chronic inflammation after
intraosseous implantation and in subcutaneous tissue.
The reactions resolved totally or pafially with increas-
ing postoperative observation periods. A thicker con-
sistency showed better biocompatibility wift bone. A
mild hJlammatory reaction occurred when used (and
ovedilled) in rat molars (46).It was resorbed slowly with
a tendency toward fibrous encapsulation. In a com-
parative study the polyketone sealer showed marked
antibacterial properties (4). Antimicrobial actiyity was
dependent upon the bactedal strain used for testing
(Fig- 77.1,7)and was generally less distinct than with
epoxy sealers.
Handling propefties
The sealer hardens rather rapidly (approximately
6min is stipulated by the manufacturer), which may
create a problem with complex lateral condensation
methods and when more than one canal needs to be
filled. The short setting time, however, is an advantage
when the sealer is used for a root-end filling. Radiopac-
ity is sufficient (4.4mm Al). The sealer is very difficult to
remove and thus must be used together with gutta-
percha cones.
Epoxyresinsealers
Epoxy resin sealershave comparatively good mechani-
cal and sealing properties. No effects on general health
are expected and allergic reactions are apparently rare.
Antimicrobial propeties are good, especially in a freshly
mixed state. Cytoioxicity is moderate to low (set state).
Mutagenicity is mainly observed shortly after mixing
and no unacceptable risk is expected for the patient.
Table17.6 Composition
o{ epoxysealer.
tiquid
Bismuth(lll) oxide(60%) (BADcE)
Bisphenol-A-diglycidylether
Hexamethylene (25%)
tetraamine
(10%)
Silver
dioxide(5olo)
Titanium
product
Fora follow-up adamantaneamine,
^/,/Vadibenzoyf5-oxânonâne'diamine
1.g-TCD-diamineis usedasa catalvst
For dental personnel, a 'No Touch Technique' is
recommended.
Composition (Table 17.6)
The original preparation (4H26), although still on the
market in some countries, has been replaced by a follow-
up product (AHPlus, Topseal).
Because the silver in AH26 may lead to tooth dis-
coloration due to the formation of black silver sulfides,
preparations are available without silver, and bismuth
oxide is added for radiopacity. A newly developed
preparation (AHPlus) is also based on an epoxy resin
(BADGE) but contains a different catalyst.
The setting reaction of AH26 lasts about 1-2 days (at
body temperature) and is a poll.merization process
during which formaldehyde is released, but the con-
centration is more than 300-fold less than that of a
forrnaldehyde-releasing ZnOE formulation (66). The
AHPlus is set after about th. There are indications that
AHPlus does not release formaldehyde.
Technic al prop erties I le ak age
The epoxy-based sealer showed good mechar-ricalprop-
erties as well as excellent adhesion/adaptation
to dentine. After initial volumetric expansion, the sealer
showed some shdnl<agewhen tested at longer intervals.
In general, in uitro and la olrrostudies with the material
showed better sealing properties than with any other
sealer tested, although it was far from perfect because
an increasing storage time (up to 2 years) decreasesthe
sealing quality (40). The use of third-generation dentine
bonding agents improved significantly the seal of AH26
to destine via lateral condensation (rM). However, there
is very little experiencewith this combination, especially
concerning the tissue reaction toward potentially
(cyto)toxic dentine bonding agents. Studies on the
sealing properties of AHPlus compared with AH26
show inconsistent results. If the smear layer is removed
from t]le root canal walls, AH26 is able to flow into the
orifices of the dentinal tubuli (Fig. 17.19),which is the
reason for the comparatively good adhesion of AH26 to
 RootcanalTillingmaterials

Fig.17.19 (à)scanning elêctronmicrograph of root canâldentineaftersmearlayerremovalwith citricacid.(b)AH26usedasa sealeron a smear-layer-free

the sealerentersthe dentinaltubuli.(Courtesy
dentinesurface: of DrA, Petschelt.)

dentine. Alcohol residues in the canal rnay impair adhe-

sion of AFIPlus [o the canal walls.

Biological ptoperties
Epoxy resins are biologically active molecules but no
rE)orts are available in the literature on systemic-toxic
reactions caused by epory-based sealers. One case of
allergic reaction ioward AH26 was reported after root
canal filling, characterized by erythema of ihe face and
the neck and a positive skin test (Fig. 17.20) (37). Posl-
tive reactions to A1126 have also been obsered in the
guinea pig mâximization test (32).
The cytotodcity of AH26 is related to the setting reac-
tion: freshly mixed, the material is cytotoxic, but after
setting it is not toxic or only slightly toxic (Fig. 17.10) Fig,17,20 Allergicreâction towardan epoxyresinsealer,A coupleof hours
(55). Cyiotoxicity wâs related to the initial release of followingrootfillingof tooth46thepâtientdeveloped swellinganderythema
formaldehyde during setting. In uitro AH26 showed of the rightsideof the faceand neck.Redness ol the oral mucosaaround
some inhibition of the nerve conductance, which was tooth46 wasexperienced and the tooth becamelenderto percussion.Ihe
partially reversible (13). symptoms subsided aftera coupleoI dâys.Therootfillingwasremoved and
the canals were lâter obturatedwithout complications using guttâ-
In both in oitro aîd in aioo experjrr:ter:.+aAH26 was
perchapointsând ZnoEcement.Beforeobturationa strongpositivepatch
mutagenic (21, 30,49), especially in a freshly mixed state (BISEIVA),
test reactionto bisphenol-A-ethyldimetacrylate bisphenol-A"
(59, 61). The cause for the mutagenic reaction may be glycidyldimetacrylate (BISGMA) and epoxyacrylate was demonstrated, lhe
formaldehyde formed during the setting reaction or the pâtientrecalledthat almostsimilarsymptoms hadarilen6 monthspreviously
epoxy monomer (BADGE). The AlIPlus (which also con- whenanothertoothwasrootfilled.However, the previousreactlonswerenot
tains BADGE) was also shown to be mutagenic, but only asserious. (Courtesy ol Dr P.Horsted-Bindslev)
irnmediately after mixing (60). In contast to studies
with AH26, an almost ten-fold higher amount of AHPlus
is needed to elicit similar mutagenic effects and no muta-
'No
genicity was observed 24h after mixing (a3, 60). The with the unpolymerized material. Therefore, a
mutagenicity data are difficult to interpret. After expo- Touch Technique' is recommended.
sure to an enzyme mix containing esterases, BADGE is After subcutaneous, intramuscular or intraosseous
further hydrolyzed to a compound that is no longer implantation into different small laboratory animals, the
mutagenic (59). Because the set material in most studies epoxy sealers proved to be toxic initially but the reaction
was non-mutagenic, we conclude that it carl be used in resolved partially or even totally with prolonged post-
the patient situation but care should be taken for the operative obseration periods (Fig. 17.21). As was
dental personnel, who may come into ftequent contact observed with cytotoxiciw, the toxic reactlollin aioo was
 Clinical
methodologies
Fig. 17.21 Tissuereaction7 daysafterintrâmuscular jmplantation ofAH26:ân accumulatjon of inflammâtory cells(mâinlypolymorphonuclear
granulocfes) the testmaterialandthe tissue(*) indicates
ât the contactareabefl,leen
€ontactwith the setmaterialshowsno inflammatory cells(*) andis therefore
virtuallynon-toxic
materialcarrier).
related to the setting reaction; immediately after mixin&
implanted samples caused a severe reactiolL but after
7 days of setting before implantation no toxic reaction
occurred. In rat molars after overfilling an inllammatory
reaction was observed. Overfilled AH26 was solubilized
and phagocytized.
Antimicrobi,clproperties:These have been demonstrated
consistently for AH26 (Flg. 77.77). As was shown with
the local toxicity, the antimicrobial effect decreased with
increasing setting time. Compared with ZnOE, calcium
hydroxide and glass ionomer cement sealers on the
model of infected root dentine AH26 showed the
strongest antimicrobial effect (Fig. 17.18) (31), probably
due to the initial release of formaldehvde (66).
Handling properties
Epoxy-based sealers have been used for more than 40
years worldwide and their handling properties are
usually considered to be good. Radiopacity is sufficient
(6.66mm Al). However, the materials set to a hard mass
that, in a clinically relevant time, is virtually non-soluble
even for organic solvents. Therefore, this matedal must
be used together with gutta-percha cones.
Glassionomercement(GlC)sealer
The main problems of the glass ionomer cement (GIC)
sealer are related to leakage, which again may be due to
moisture sensitivity during setting. The formation of
pores may be another problem. On the other hand, these
materials offer the possibility to strengthen the root
due to chemical binding to dentine, therefore further
test results and/or material improvements should be
monitored.
neutrophilic
moderâte toxicityof the materialdirectlyattermixing{â);the tissuein
(b).tm = testmaterial,
tf =Teflontube(negative controland
Composition
More than 10 years ago a GIC (Ketac-Endo) was intro-
duced as a root canal sealer.This material basically con-
tains ground silicates (calcium-sodium-fluor-phosphor
silicate) in the powder and polyacrylic acid, malenic acid
or tartaric acid in the liquid. The setting reaction, which
is sensitive to both moisture and desiccation, starts as
dissolution of the particle surfaces followed by an
acid-base reaction by which the metal ions from the
powder (first calcium and later aluminum) 'replace' the
protons of the carboxylate groups and form a non-
soluble matrix into which the remnants of the particles
are embedded.
Technic al prop efties I le akage
The good adaptation and chemical adhesion to the
dentine provided the rationale for using GICs as root
canal sealers.In contrast to all other sealers,a single cone
technique was described with the idea of strengthening
the root canal with a thick layer of CIC. Gutta-percha
was recommended only for better re-entry. The GICs
have shown good mechanical properties in other appli-
cations but the presence of pores reduces the sealing
quality considerably.
h aitro leakage sf,rdies revealed contradicting results:
some authors conclude that, in general, Ketac-Endo
showed greater dye penetration than other sealers such
as ZnOE and 4H26, and that there was no significant
difference between the lateral condensation and the
single cone technique for Ketac-Endo. On the other
hand, no difference in apical dye penetration between
Ketac-Endo and AH26 was reported and an even better
seal was formed when used as a thin layer (74). These
differences may be due to problems of the test method
(the GIC sealer seems to absorb the dye) or to the sensi-

tivity of the setting process of GICS with respect to mois-
ture. No bacterial penetration was observed after 60
days when Ketac-Endo was used with a one-cone tech-
nique. As was observed with other sealers, leakage
increased with increasing storage time (2-year observa-
tion period) (40).
Biological properties
Glass ionomer cements have been used for more than 25
years in different applications in dentistry, but there are
no reports available in the corresponding literature
about systemic-toxic or allergic reactions. Cell culture
experiments with GICS consistently show some cyto-
toxicity of the freshly mixed material. After setting, no
or only minirnal cytotoxicity occurred. Flowevet for
optimal setting the correct water balance is necessary:
either too much or too little moistuie leads to iruufficient
setting combined with enhanced solubility and cyto-
toxicity. This may be a problem in a root canal with an
open apex and with the sealer in direct contact with the
living tissue. After subcutaneous implantation in rats a
mild inflammation was observed after 5 days with the
GIC, which turther diminished with time (120 days),
compared with a ZnOE sealer that produced a stronger
inflammation even after 120 days (39). A GIC root canal
sealer was non-mutagenic in a conmonly used bacterial
test system (21).
Antimicrobial properties:The antimicrobial properties of
a GIC sealer compared with other sealers(ZnOE sealers,
calcium hydroxide sealer) on anaerobic bacteria were
somewhere between the ZnOE sealers (strong activity)
and the calcium hydroxide preparations (weak activity)
(1). On bovine dentine models with infected root
dentine, the GIC showed the lowest activity in com-
parison with a ZnOE sealer,a calcium hydroxide sealer
and an epoxy sealer (31).Antimicrobial activities of GICs
may be due to the initially low pH and the fluoride
release.
Handling propetties
Basically, handling of these materials seems uncompli-
cated. Howevet the working time in the mouth is
limited to 7min. This may cause some problems if the
material is used with the lateral condensation technique
on teeth with several root canals. It should also be kept
in mind that the mixed rnaterial should not be stored
much longer than Tmin outside the capsule, becausethe
water evaporates and the paste tends to thicken. The
mixed material can be kept inside the capsule for about
40min. The radiopacity of the materials is sufficient. The
material carmot be removed from the canal under clini-
cal conditions once it has set and thus must be used with
ù,trâ-nêr.hâ.ônêe
Rootcanalfillingmaterials
components
Table17,7 l\4ain of a câlcium
hydroxide
sealer.
Basepasle paste
Câtalyst
Calcium hydroxide{32%) (36%)
Disalicylâtes
(18%)
Colophony (32%) Bismuth carbonate
(15%)
Silicondioxide(8%) Silicon
dioxide
calciumoxide{6010) Colophony (5%)
Zincoxide(60lo) phosphate
Tricâlcium (5%)
others(16%) Others(21%)
Calciumhydroxide(CH)sealers
Calcium hydroxide sealers have inJerior technical
properties compared with polyketone or epoxy resin
preparations. Leakage studies show inconsistent results,
with a tendency for less sealing quality compared with
other sealers. From a biological point of view, calcium
hydroxide sealers are very favorable materials and they
exhibit - at least in a freshly mixed state - considerable
antimicrobial activity. Furthermore, they belong to the
few materials that apparently stimulate apical heaLing
and hard-tissue formation (root-end closure). Fudher
research with these materials should be monitored
carefully.
Composition
These sealers were introduced in an attempt to stimulate
periapical healing with bone repair through the release
of calcium hydroxide (lable 17.7). The setting reaction
is based on the salicylate compounds. One ZnOE
sealer contains calcium hydroxide as an addition to the
powder. This material, however, should be considered
more as a ZnOE sealer because most effects (e.g.
cytotoxicity) are related to this group of sealers. Some
authors recommend the use of calcium oxide, which
after contact with fluids is partially transformed into
calcium hydroxide. It is reported to have the same prop-
erties as calcium hydroxide but with the potential of
better intratubular penetration and rernoval of unmin-
eralized extracellular matrix.
Calcium hydroxide sealersreleaseOH- and Ca' ions.
The amount varies between different brands, but the
cLinical significance of this difference is not known.
Releaseof these ions is markedly higher when suspen-
sions are used. Calcium hydroxide sealers evoked an
increase of pH when placed in distilled water (48h after
setting) of 9.14 and 8.6; under the same condi.tions,pure
calcium hydroxide paste increased the pH to 12.5.V{hen
calcium hydroxide sealersare used together with lateral
condensation of gutta-percha, the outer dentine surface
does not become alkaline, in contrast to the use of
calcium hvdroxide suspensions. The authors conclude
 Clinical
methodologies
that after setting of calcium hydroxide sealers no OH
ions are available anymore for diffusion through dentine
(22).
Technicalproperties/leakage
Mechanical properties of calcium hydroxide sealers
are inferior compared with polyketone-, epoxy- or GIC-
based sealers. The desired release of OH ions may be
associated with degradation of the sealer, enhancing
leakage. Degradation of salicylate-based materials is
known from their application as pulp capping agents.
Studies clearly indicate significant volumetric expan-
sion, disintegration and high solubility of a calcium
hydroxide sealer following long-term observations.
Apparently, some calcium hydroxide sealersdissolve at
a relatively high rate, especially when used in a thick
layer (75). The bond to dentine is weak (71).
Sorne in aitro studies showing less leakage for a
calcium hydroxide sealer than for an epoxy sealer and a
ZnOE sealer could not be confirmed in aiao. In aitro
leakage studies with the comrnonly used dye methylene
blue are problematic because calcium hydroxide decol-
odzes methylene blue. Coronal leakage for bacteria after
up to 90 days of exposure proved to be less for a calcium
hydroxide sealer than for a ZnOE sealer,when used with
the lateral condensation technique (14). After 2 years of
storage, leakage of a calcium hydroxide sealer increased
(40). The removal of the smear layer has no effect
on coronal leakage of a calcium hydroxide sealer
when applied together with the lateral condensation
technique.
Biologicalproperties
There are no reports available in the literature about
systemic-toxic or allergic effects on calcium hydroxide
sealers.Their cytotoxicity was generally low (compared
with other commonly used sealers) when tested in
different cell culture systems (27). ln a more complex
cell culture system capable of demonstrating both cyto-
toxicity and the influence on immunocompetent cells, a
calcium hydroxide sealer was nearly irmocuous (11).A
salicylate-based calcium hydroxide sealer was non-
mutagenic in an ia Ll|tro bactelial test system (21).
However, both a calcium hydroxide sealer and a calcium
hydroxide-containing ZnOE sealer indu ced.in aitro a last
and complete inhibition of nerve conductance when in
direct contact with the nerve. After 30 min of contact, the
nerve conduction was irreversibly blocked by both
materials (9).
After implantation in rats and guinea pigs, calcium
hydroxide sealers initially caused a severe reaction that
diminished after several months and was finally lower
than with a ZnOE sealer. In root canals of ferrets (34),
all teeth with the ZnOË matedal showed an inflamma-
tory reaction at their apices, whereas only three out of
ten showed this effect with the calcium hydroxide-
formulation. Furthermore, a calcium hydroxide sealer
evoked the most extensive apical hard-tissue formation;
a pure calcium hydroxide preparation induced less hard
tissue and gutta-percha had the least effect (65).
Antimicrobial properties:for calcium hydroxide sealers
these properties have been shown in several in oitro
experiments, and the activity may even increase with
time due to partial disintegration of the sealer The
mechanism of this antimicrobial activity was related to
the high pH; the buffer capacity ofbody fluid will reduce
the effect with time. However, it was also consistently
demonstrated that ZnOE sealers exhibited a stronger
antimicrobial effect than calcium hydroxide products
regardless of the micro-organisms tested (1). In accor-
dance with these studies, the calcium hydroxide sealer
did not disinfect the dentinal tubules infected with Ërfe-
rococcusfaecalis after 4h (Fig. 17.18) (48). This is in line
with the obserwation that Enterococci, which are fre-
quently isolated from persistent root canal infections,
were found ta be resistant to calcium hvdroxide.
Root-end closure
A 'root-end closure' is the induction of calcified tissue
formation to obturate the dental apical forameni it
was first reported in 1960. In several experiments with
monkeys, osteocementum/cementoid substancesat arld
around the open root apices were developed after the
application of a calcium hydroxide suspension for 3
and 6 months. Clinical successrates are in the range of
7 4-1,00"k (Fig. 77.22).
The mechanism of inducing hard-tissue formation by
calcium hydroxide preparations is not yet elucidated. It
is apparently related to the high pH and the released
calcium ions from the material, which promote a state
of alkalinity of the adjacent tissues - a condition that
arrests root resorption arld favors repair, due to an inhi-
bition of osteoclastic activities. It has been postulated
further that Ca/ actson the processof cell diflàrentiatjon
and on macrophage activation and that acids produced
by osteoclasts are neutralized and calcium phosphate
complexes are formed. It was suggested that activation
of ATP, which accelerates bone and dentine mineraliza-
tion, and the induction of TGF-p (transforming growth
factor p), which represents a group of signaling mol-
ecules,play a central role in biomineralization. A further
factor is the profound antimicrobial activity of calcium
hydroxide sealers (68).

Fig. 17.22 Root-end closureofâ lowerpremolaraftertreatment
with a calciumhydroxide
filling(lowerrightimage)an epoxysealerwith gutta-percha
wasused.(Courtesy of Dr B.Ihonemann.)
Handling properties
Handling properties of calcium hydroxide sealers are
adequate; the radiopacity is regarded as sufficient. The
material can be removed with common rotary instru-
ments from the root canal.
Materialsfor retrogradefillings
(root-endf illings)and replantation
These materials are used to create an apical seal and
to permit regeneraton of the periodontal ligament
apparatus. Contrary to conventional root canal filling
therapt these materials are used in a surgical environ-
ment characterized by early moisture access and a bony
defect.
A number of different materials have been used for
root-end fillings, such as gutta-percha, composite resins,
glass ionomers, amalgams, modified ZnOE cements artd
a polyketone sealer. Potentially applicable are mineral
tdoxide aggregates (MTAs) and calcium phosphate
cements. Preformed titanium irùays in combination with
Rootcanallillingmaterials
for 6 months(lowerleftimage).Forthefinalrootcanal
suspension
standard ultrasonic preparation were recommended
(cemented with a modified ZnOE cement), as well as
ceramic inserts. Amalgam used to be very popular, but
the potential to release metalLic components into the
surrounding tissue has made amalgam a controversial
material in this context.
The classical material for root-end filling - amalgam -
has been gradually abandoned. Modified ZnOE
cements, a polyketone sealer (thick consistency) used
with or without metallic/ceramic inserts or a light-cured
GIC were successfrily used instead. However, reports
on cementum deposition are unequivocal. A resin com-
posite has shown promising results in the hands of a
single group and MIAs apparently have the potential to
stimulate further apical healing and thus may - after
firrther clinical experience is gained - replace other
materials for this purpose.
Comoosition
Modified ZnOE cements have been described above
(see ZnOE sealers). A composite resin recommend-
 clinicalmethodologies
ed for retrofills was based on bisphenol-A-
glycidytdimetacrylate,/triethyleneglycoldimetacrylate
(BISGMA/TEGDMA, 1:1), containing silver or (more
recently) ytterbium trifluoride for radiopacity. It is used
together with a dentine bonding system (52). Mineral
trioxide aggregates comprise a mixture of tricalcium
silicate, tricalcium aluminate, tricalcium oxide and sili-
cate oxide. Hydration of the powder results in a colloidal
gel that solidifies to a hard structure in less than 4h.
Technicalproperties/leakage
The good mechanical properties of amalgams were
the reason for their widespread use in the Past. Data
reported on the marginal seal of amalgams are, however,
controversial. A polyketone sealer and a GIC sealer
were reported to produce a better seal that various
amalgams. Good sealing ability of a light-cured GIC was
reported, probably due to the fast setting and little mois-
ture sensitivity. Modified ZnOE cements have also been
shown to produce a good seal, as well as a composite
resin. Mineral trioxide aggregate produced a better seal
than amalgam, being the most effective root-end-filling
material against bactedal penetration in comPadson
with amalgam and two modiJied ZnOE sealers (25).
Biologicalproperties
The group of materials used for root-end filling is rather
heterogeneous. Especially for composite resins a]ld
amalgams, much literature is available on real or
claimed systemic-toxic effects. The same is true for
allergies. The reader is referred to corresPonding text
books. However, in general, there is no contraindication
for the use of any of the mentioned materials due to
systemic toxic or allergenic effects. In the single patient
situatiory materials must not be used that contain a sub-
stance to which the patient is sensitized.
Cell culture experiments for local toxic effects show
consistently that all setting materials used for root-end
filling are cytotoxic initially after rnixing. In the set state,
cytotoxicity decreasesto different levels characteristic of
each material. Mineral tdoxide aggregate, a fairly new
root-end filling matedal, is less cytotoxic than amalgam,
Z\OE or epoxy sealers (51). Implantation studies are
available for all root-end filling materials, because they
are used for other applications (e.9. filling technique). In
parallel with cell culture experiments, the local toxic
reaction decreaseswith increased aging of the material.
The same is basically true for antimicrobial properties.
For details, see the paragraphs on the sPecific matedals
above.
Of special clinical relevance are usage tests. Poor
sealing properties, rneasured in animal exPerimentation
17.3
Keyliterature
In a studyin dogsby Harrison et ai. (29),rootcanals wereobtu-
ratedwilh a znOE material(lRM) or amalgam and then the root
endswerereseded.orthograde fillingswith gutta-percha/ZnoE
sealerwereusedascontrols. Thetestmaterials evoked no inhibi-
tion of osseous woundhealingand cementum was presentin
contactwith all materialsafter a 45-dayobservation period
However, chongeta/.(16)modified thislestmethod: afteranificial
infectionof roolcanals ôeforetherootresection andapplication of
theroot-end filling,amalgam in experiments upto 8 weekscaused
persistentinflammation in the apicalarea.Betterresultswere
observed with a ZnOEmaterial anda liqht-cured GlC.lt wascon-
cluded thatthepoorsealing properties of amalgam werethemain
clin-
reasons forthenegative testresultandthatina corresponding
icalsituationa Zn0E or
material a light-curedGIC isrecommended.
(Key literature 77.3), are in line with the poor clinical
long-term prognosis of amalgam root-end fillings, as
was reported by sorne authors (26).
A polyketone sealer with and without tricalciurn
phosphate (TCP) showed in dogs after 60 days a pre-
osteoid/cementoid-like matdx in direct and intimate
approximation to the root-end filling material (72). A
dentine-bonded resin composite (Gluma-Retroplast)
used in monkeys for root-end fillings without intention-
ally infected canals evoked cementum coverage, indi-
cating optimal tissue tolerance. However, if the root
canal was infected, less favorable results were observed
The resin material hardly entered the apical cavity and
thus provided orùy a superficial seal (2).
Root-end fillings with MTA in monkey and dog teeth
showed cementum coverage over the filling, whereas
amalgam produced inJlamrnation and no cementum
layer on the material. Mineral trioxide aSSregatestimu-
lates cytokine release from bone cells with the potential
of actively promoting hard-tissue formation (67).
Clinical data indicated inferior clinical successrates
when amalgam was used compared with other mated-
als (26).Further disadvantages are the Potential of stain-
ing of the mucosa, scattering of Particles dudng
Dlacement and corrosion. For modified ZnOE cements,
good clinical results are reported over a Pedod of uP to
14 years (17). For comPosite resins orùy a few clinical
studies are published, but a clinical successrate of about
907" was reported recentlY (52).
Handlingproperties
Owing to the special surgical environrnent mentioned
above, good handling properties are imPortant. \ /hereas
ZnOE (and amalgam) harden in a moist environment,

conventional GIC is susceptible to moisture and desic-
cation. Light-cured products may have certain advan-
tages in this respect because of fast setting. It had been
reported also that it is not easy to apply dentine bonding
agents arrd a resin devoid of voids into a rather small
apical cavity. Root-end filLing materials should have
a radiopacity greater than that of root canal filLing
materials.
Mandibularnerveinjuries
These injuries after root canal filling therapy occur
rather seldom in daily practice but they are dramatic in
each single case. At least four different pathogenic
mechanisms have been proposed:
a Instrurnentation beyond the apex and mechanical
sever;mce.
o Combined effect of regional analgesia and mechani-
cal nerve damage.
o Degeneration of the nerve due to the mechanical
compression caused by filling the materials in the
nerve canal.
o Toxicity/neurotoxicity of the root canal filling
material.
Irreversible sensory nerve damage may involve ftequent
paresthesia, which constitutes altered sensation of pai&
touch or temperature. Symptoms are the sensation of
warmth, cold, burning, aching, prickling, tingling, pins
and needles, numbness, itching and formication (feels as
iJ ants are crawling on the skin) (45). In the endodontic
literature most cases have resulted from overfill of
paraformaldehyde-containing sealers in the vicinity of
the inferior alveolar nerves. Long-term paresthesia of up
to 13 years has been described. A survey of the literature
in the year 1988 (12) has shown that more than 40 cases
of root canal cements associatedwith paresthesia of the
inferior alveolar nerve have been reported in the past
two decades. Most of these patients have been treated
with materials that contain (para)formaldehyde. The
reaction of ZnOE sealers with the addition of form-
aldehyde was irreversible unless surgical treatment was
performed. This is in line with data from fu oitro exper
iments on different nerve tissues described above, which
have shown alrrirreversible effect on nerye conductance
from formaldehyde-releasing root canal sealers. Thus,
there are indications that the material and especially the
release of formaldehyde may play a major role in these
injuries (12).
There are also case reports on paresthesia after
overfill of AH26, which was attributed to the short-
term release of formaldehyde during setting. A 4-
Rootcanalfillingmaterials 283
month paresthesia was reported to be eugenol-
induced. Another case caused by ZnOE was reversible.
Six cases of paresthesia after overfill of Sutta-Percha/
chloropercha were reported and the s''rnPtoms resolved
after a maximum of 3 months (45)
Single cases were reported for other root canal filling
matedals,/techîiques. Melted gutta-percha (thermo-
mechanical compaction used with a CH-based sealer)
was extruded into the maldibular canal causing severe
nerve injury with persistent local paresthesia(numbness
'pins and needles' in the lip
and intermittent bouts of
and chin). A few days later the area of Paresthesia was
replaced by anesthesia.After surgical removal from the
periapical area and from the nerve canal, anesthesiawas
replaced by paresthesia. The authors assume that the
reason for this adverse reaction was the elevated tem-
perature by which the gutta-percha was extruded out of
the root canal (24).
It can be concluded that with most of the cuffently
used root canal filling matedals detrimental effects on
local nerve tissues were observed when the root canals
were dramatically overfilled and the local nerve fibers
were involved. However, most cases are described in
connection with formaldehyde-releasing sealers with
long lasting,/irreversible damage to the nerve tissues.
The clinician should be aware of this situation and be
familiar with preventive measures when choosing the
root canal filling material. These are:
. Appropriatetreatmenttechni4ue'. to reduce the risk that
the filling material is displaced beyond the apex and
into the vicinity of the nerve.
. Appropriate ffiaterial selection.use root canal filling
materials with the least possible (neuro)toxic effects.
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Heil J, Reifferscheid G, Waldmann P, Leyhausen G,
Geurtsen W Genotoxicity of dental materials. Mutat. Res.
L996; 368: 787-94.
Heling I, Chandler NP. The antirnicrobial effect within
dentinal tubules of four root canal sealets. l. End.odont.
1996; 22: 257-9.
Hensten-Pettersen A, Orstavik D, Wennberg A. Allergenic
potential of root canal sealers. Ëndodont. Dmt. Traunatol.
1985; 1: 61-5.
Hensten-Pette$en A, Jacobsen N. Perceived side effects of
biomaterials in prosthetic dentistry. ,f. P/osthet. Dent. 1997;
65: 138-44.
Holland GR. A histological comparison of periapical
inJlamrnatory aid neural responses to two endodontic
sealers in the fe et. Arch. OtaI Biol. 1994; 39: 539-44.
Hong YC, Wâng If, Hong CY, Brown WE, Chow LC. The
periapical tissue reactions to a calcium phosphate cement
in the teeth of monkeys. ]. Biomed. Matet. Res. 1991;25:
485-98.
Harsted P, Harsen JC, Langelând K. Studies on N2
cement in marl and monl<ey - cement lead content, lead
blood level, and histologic findings. /. Endodont. 1.982;8.
341-50.
37. Horcted P, Sôholm B. Overfôlsomhed overfor rodfyld-
ningsmatedalet AH26. Tandlaegebladet 1976; 80]. 19*-
7.
Kânerva L, Estlander T, Jolanki R. Dental nurse's occupa-
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39. Kolokuris I, Beltes P, Econornides N, Vlemmas I. Experi-
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22t 3958.
Kontâkiotis EG, Wu MK Wesselink PR. Effect of sealer
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f-r
,11. Langeland K, Liao K, Costa N, Pascon EA. Ef{icacy of
Obtula and Ultlafil loot filling devices. ,1.Ëndoclortf.1987;
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Leyhausen G, Heil J, Reifferscheid G, Waldmann I
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44. Mannocci F, Ferrari M. Apicâ1 seal of roots obtr-uàted$'ith
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C h a p t e r1 B
Rootfilling techniques
PauI Wesselink

Introduction both spaceand nutritional elements for growth (Chapter

Filling the instrumented root canal is the final step in
the fulfiLment of an endodontic treatment. Regardless of
whether the treatment was undertaken to remove a vital
pulp (pulpectomy), a necrotic and/or infected pulp (root
canal therapy) or a previous root canal filling (retreat-
ment), the prime objective of the root filling is to prevent
microbial organisms from entering, growing and multi-
plying in the empty space that resulted from the instru-
mentation procedure (Fig. 18.1).Root filLing also serwes
as a wound dressing against which healthy periapical
tissue can be laid down.
Specificobjectives
Atter a pulpectomy a wouncl surface remains lhat will
not heal with epithelium as it does with wounds in other
body sites. Such a wound is therefore vulnerable to
infection. Wound ir.rfection may be induced inadver-
tently in conjunction with the treatment procedure, e.g.
from improper rubber dam isolation or by bringing
chips of carious dentine to the apical region of the root
canal. It may also follow leakage of bactedal organisms
from the oral environment after completion of the filling
where it incompletely sealsthe canal space.The latter is
known as coronal leakage (seeChapter 13). Therefore, a
hermetic and permanent seal of the wound surface is
essential to allow proper healing after pulpectomy and
to prevent bacterial organisrns from later accessing the
periapical tissue if, for any reason, the coronal restora-
tion breaks down. Core concept 18.1 summarizes the
overall fulctions of root fillings.
In tlrc treatment of a tooth with arr infected, non-
vital pulp (i.e. root canal therapy), instrumentation and
irrigation with a disinfecting solution will not always
eLiminatethe microbial organisms. If such a root canal is
left unfilled or improperly filled, residual organisms
may continue to grow and multiply (Chapter 11). It
needs to be recognized that microbial organisms require
8), therefore in root canal therapy the root filling has two
additional objectives:
(1) To prevent nutritional elements from accessingthe
pulpal space along any entrance to the root canal
space, including apical foramina, accessorycanals
and the oral accesscavity.
(2) To eliminate space for further growth of micro-
organisms that may have survived the biomechan-
ical preparation.
Most often it is sufficient to block the Portal of exit to the
periapical tissue. However, lateral or accessory canals
may also allow egress of bactedal elements to the peri-
odontium, therefore it is essential that the entire length
of the instrumented canal becomes completely filled.
This means that all portals of exit to the periodontal
tissue should be sealed and it is ftom this asPectthat the
quality of root fillings in general is assessed(seebelow).
Selectinga root canalfilling material
A variety of factors determine the choice of a root canal
filling material. Although a primary requirement is to
allow a complete fill of the instrumented root canal(s),it
should also be biologically compatible because it will
often be in direct contact with vital tissue. In other
words, except for a variety of technical and physical
demands, a root filling material should also satisfy the
requirements that are requested fuom implant matedals
(Chapter 17).
The most critical technical and physical requirernents
of a root filling matedal are:
. AbîIity to adapt to the shapeof the calcl. After cleaning
and shaping, root canals may still harbor various
irregularities that can allow space for bacterial
growth. It has been shown that in many situations it
is impossible to createa round and smooth root canal
without removing so much of the irmer root canal
wall that the root structure is weakened. Therefore,

246
 Rootfillingtechniques

Coreconcept18.1

Theoverallfundion of a roottillingisto occupy root

theinstrumented \2) To hold backany surviving bacteriain dentinaltubulesand
canalspaceto allowproperhealingof the periapical tissue.
specili- uninstrumentedpartsoTtherootcanalspace.
callyit attemptsl (3) ToDrevent ol baderial
release elementsintheotherdiredion,i.e.
fromtherootcanalto theapicalenvironment (apicalleakage).
(1) Io preventleakage organismg
oI baderial bacterialelements
and (4) Toprevent leakage fromtheperiapical
factors
of nutritional tissue
nutritional
elements to therootcanal
fromtheoralenvironment to lhe canalsDace.
(coronalleakage).

Stopscoronal leakage
Entombssurvivingbacteriê
stops influx of periapicaltissue
fluid
and releaseof bâcterialelements

because it may cause both cytotoxic and neurotoxic

initation (22 34, 4). It may also produce a foreign
body reaction (34). Furthermore, clinical outcome
studies indicate that extrusion and overextension of
root filling material negatively influence the healing
of the periapical tissue (10, 30).
Safety. The material and the technique used for
its application should be safe for the Patient. The
demand for biocompatibility has already been stated
(see also Chapter 17), but the technique should not
pose risks for root fracture, require overzealous
instrumentation or cause damage to the periodontal
ligament by, for example, detdmental temperature
increasesor exhusion of male al.
Insoluble.Becarse of the risk for coronal leakage and
Fig,18,1 Radiogrâphdepicts rootfillingol a mesiobuccal
anoptimal root the fact that root filling material may be exposed to
havebeenfilledwithintheconfines
of anuooermolarwherelwo canals of percolation of tissue fluid at the aPical foramery it is
theroot.(Courtesy
of DrGunnarBergenholtz.) important that it is not affected by moisture. There-
fore, after setting, a root filLing material should be
to provide a tight seal, a root canal filling material insoluble in both saliva and tissue fluid.
should be able to fill these irregularities. Remoaable.A root filling may not be performed per-
. Length control. A root canal filling material should fectly at the first attempt or may ttlIn out to be defec-
allow a tecblique that keeps the entire material tive at a follow-up. The outcome of a treatment may
within the canal space. Extrusion of material to also be such Lhdtone can suspectonSoing rool.cdnal
the periapical tissue compartment is r.rndesirable infection. In these instances, retreatment and refill-
288 Clinical
methodologies

Gutta-percha

Softened core
I
Singlecone Laterâl solvent Heat
compaction
I
t l
Vâriousmodes
Fig.18.2 outlineof techniques withgutta,percha.
to fill rootcanals

ing of the root canal may be necessary (Chapter 19).

Therefore the material used should be removable by
simple means without involving the risk of damag-
ing the root shucture or the periapical tissue.
. Radiopaque.In order to judge whether the root canal
has been sufficiently filled, a most important require-
ment is that the root filling is discernible in a radio-
graph, i.e. it should be radiopaque.

Hardly any root filling matedal tested so far has been

able to satisfy all these demands, yet a formulation
based on gutta-percha as one of the pdncipal ingredi-
ents has stood the test of time and has been widely used
since the end of the 19th century. It is still the matedal
of choice in most countries. By pressure or by softening
with heat or organic solvent, gutta-percha is suitable for
application in inshumented root car-ralsusing a variety
of techniques. Combined with a sealing agent, the ma-
terial can be adapted to the shape of root canals and
serve as a reasonably insoluble and non-porous core of
filling. At the same time, it is fairly easy to remove if nec-
essary.Gutta-percha formulations also satisfy biological
demands (Chapter 17) ald, becauseof the universal use
of gutta-percha-basedformulations in endodontics, only
techniques that are based on this material will be con-
sidered in the present chapter

Fig.18.3 outlineof the lateralcompaction technique.Mâsterconefit (a),

Root filling techniquesfor gutta-percha
There are various methods for delivering and packing
gutta-percha in root calals and they can be divided into
solid core and softened core techniques (Fig. 18.2).Solid
core techniques imply that ulsoftened gutta-percha
cones are fitted to the instrumented canal(s) (Fig. 18.3a)
and cemented to the canal walls with a root canal sealer.
Tectmiques exist whereby either a single cone or multi-
ple cones are placed in the root canal space (Fig. 18.4).
In softened core techniques gutta-percha is plasticized
either prior to or after insertion in the root canal by
lateralcompaction wjthspreaderfollowingadditjonofoneaccessorycone(b),
continued (c)andfurtheradditionof accessory
lateralcompactjon cones(d).
Rootfillingiscompletewhenit is notpossible
to plâceânotheraccessorycone
furtherthan2mm intothe root canal(e).ln (e)the transveBe red lineindi-
cateswherethe cross-sectionalviewto the rightis tâken.
solvent or heat. Also, these techniques often make use of
a sealing a8ent to supplement the filling.
Gutta-perchacones
For solid core techniques, gutta-percha cones of differ-
ent lengths, sizes and shapes may be employed. In

Master cone Cement
Accessory
Masterconê
! Cemênt
(al
Fig. '18.4 {a) Sketchshowinga cross-sectional
cut throughâ root canalfilledwjth a masterconeand multipleâccessory cones.{b)Thecross-sectional
showsa truefillingwherethe sealer(blackmaterial)
unitesthe conesandfillsout spacelaterallyto the root cânâlwâll.
general, cones are round and have a tapered form so
they gradually increase in size from the tip. So-called
'stardardized'
cones were designed to match the size
and taper of the root canal instruments used to shape the
canal at its apical end. ln early days these cones had a
rather small taper of 27", corresponding to the ISO stan-
dard root canal instruments (seeChapter 16). Nowadays
there are cones standardized to fit canals prepared with
differently tapered instruments. Hence, th"r" u.. aon",
with 4% and 6% tapers (see Chapter 17). Also available
are 'conventional' cones, which are not standardized
and classified as fine, medium and larqe.
Root canal sealers
Unsoftened gutta-percha does not adhere to dentine
and softened gutta-percha may shrink after cooling as a
result of being heated or from evaporation of the solvent
used, thus leaving gaps between the material artd the
root dentine (47). NaturaUy such defects may allow
either coronal or apical leakage, or both, to cause or
maintain apical periodontitis. It is, therefore, considered
necessary to use a cement or sealer that forms a tight
connection between the gutta-percha arrd the root
dentine. In general, it is believed that this layer should
be as thin as possible because,upon setting, sealersmay
shrink and dissolve in a moist environment (7, 18).
Roottillingtechniques
cut
The above-mentioned consideration has led to the
development of gutta-percha techniques that aim to
create a filling consisting of a well-adapted mass of
gutta-percha wiih a thin layer of root canal sealer
between the gutta-percha and the root dentine. In this
respect, consideration is similar to that with cast restora-
tions, where well-fitting margins are created to leave as
little cement as possible between the metal and the tooth
structure.
As a general trait, but to a varying extent, root canal
sealers in the initial setting phase are cytotoxic arrd
bacteriotoxic and thereafter most sealers become sub-
stantially less bioactive (27, 41). Thus, as little contact
as possible with the apical pulp tissue or periapical
tissue is desirable and, in particular, overfilling of sealer
material should be avoided. Several reasons for this
view can be claimed:
(1) Except for being initially cytotoxic, all root canal
sealersmay potentially elicit allergic reactions (13),
although animal and clinical observations indicate
that sensitization via the root canal occurs rarely, It
is occasionally reported (19, 11).
(2) Root canal cements in contact with nerve tissue, e.g.
when inadvertently extruded into the mandibular
canal, may causeanesthesiaand long-lasting pares-
thesia as well as painful events (4, 25, 36).
 clinicalmethodologies

cone should fit tightly to the apical Portion of the root clinically to be an improvement over the single-cone
canal. technique (15, 32).

Single cone Softenedgutta-perchatechniques

The single-cone technique consists of matching a cone to
the prepared canal. For this technique a tyPe ol PrePa-
ratiôn (Chapter 16) is advocated so that the size of the
cone and ihe shape of the preparation are closely
matched. When a Sutta-Percha cone fits the aPical
portion of the canal snugly, it is cemented in place with
a root canal cement.
Although the technique is simple, it has several dis-
advantagés and cannot be considered as one that seals
canals completely. After preparatiorl root canals are
seldom round tfuoughout their length, excePt Possibly
for the apical 2 or 3mm. Therefore, the single-cone tech-
nique, ai best, only seals this portion ln aitrc research
hai shown that the single-cone techrrique Permitted sig-
nificantly more dye Penetration than other techniques
(1, 3) (see also Advanced concept 18.1).
In an attempt to overcome the deficiencies of the cold
lateral compaction technique, heat and solvents have
been appliâd to render gutta-percha Plastic Gutta-
perchais then compdctedto createa homo8eneousroot
ianal filling of greaier density tfuoughout the canal than
solid-coretechniquescan Provide
In recent years several modes of utilizing heat have
been developed to soften Eutta-Percha'ln principle' heat
softening can be carried out inside the root canal or
outside: the latter in the form of injecting preheated
s.utta-perchaand lhe former by applying heat after
inserrion of unco{tened cones These techniques will
now be described in some detail.
Techniques employing heat inside the canal

Warm lateral compaction:this technique evolved as a

Lateral compaction compromise between lateral compaction of cold gutta-
ln lateral comPaction techniques additional secondary percha und the vertical comPaction of warm gutta-
laterally around the oercha (see below). The teclùique is similar to lateral
-masterare inserted and compacted
points
cone to reduce the thickness of the sealer layer compaction of cold gutta-Percha but here a heated
this technique, after cementing
(Figs 18.3 and 18.4). ln spreader is initially advanced into the mass of Sutta-
ihe-naster cone in position, specially designed spread- pl"rcha cor-r.s placed in the canal (Fig 18 5) Following
- instruments- are placed
ers long, tapered, Pointed its removal a cold spreader is inserted, and the space
possible and the master
in the canal as far apically as thus obtained is filled up with accessory cones The
cone is laterally comPacted against the wall Next, the process is repeated until the canal is completely filled'
spreader is removed and the first auxillary point forced briginally, ii was advised to insert a heated spreader
fully to place. The canal is filled in this way until it is not aftei every accessoly cone. ln Practice, usually after
oossible to pluce another accessorycone further than 2-
àmm into the root canal. Excess gutta-percha is then
removed with a heated instrument at the canal orifice
and. final comPaction is completed by vertical Pressure
with a plugger or condensor - an instrument with a flat
aDical
- tip.
The aàvantage of the lateral comPaction technique
in comParison with the single-cone technique is that it
reduces the amount of sealer left in the canal Because
the relation between the but end of the cones and the ref-
erencepoint of the preParation can be monitored dudng
the filling procedure, the length control of the filling is
quite goàd and usually no filling material is extruded
É"yo.rà th" fo.u-en. The seal in comparison with other
techniques is good (44).
The àisadvântage of the lateral compaction method is
thdt the root filting does not çonsistoI a homogeneous
mass of material but rather of a large number of indi-
vidual points tightly Pressed together and joined by-a
frictionil grip of cementing substance (Fig 18 4b) Jn
spite of this criticism the technique has been used tor
of gutta-percha
Fiq.18.5 Demonstration with hot instrument'
compâction
Âurru u"ur" with considerable success and appeared
 Clinicalmethodologies

(3) Although sealer material may be dissolved and

resorbed by vjfal tissue over time, components of of differentsealers
coreconcept18.2 Properties
sealer material may be found in the periapical
sealers
zinc oxide-€ugenol-based
tissue malry years after filling, where it causes
ongoing phagocytic reactions (23, 30). Root filLing a Reasonableseal
material also rnay be found in several peripheral . in fluids
Dissolve
organs (9). o Long-lastingcytotoxicity
. sensibilization
Currently used root canal sealers may be divided into
four groups: sealers
Resin-based
a Goodseal
r Zinc oxide-eugenol based. . Initialcytoxicity
o Resin based. . onceset,biocompatible
r Dentine-adhesivematerials. . Allergenic
r Materials to which medicaments have been added.
sealers
Gutta-per€ha-based
The benefits, uses and problerns of each are discussed
below ald summarized in Core concept 18.2.For a more o Moderate seal
detailed description of these materials, the reader is . Initialcytotoxicity
. shrinkage
referred to Chapter 17.
a Plasticizegutta-percha

Zinc oxide-eugenol-b ssed sealer sealers

Dentine-adhesive
Once zinc oxide-eugenol matedals set, they form a weak a Goodseal
porous product and are decomposed in tssue fluids (43, . Selveryquickly
40, 23). Nevertheless, these materials are regarded to be o Goodbiocompatibility
clinically satisfactory (26). Practically all zinc oxide'- to remove
o Difficult
eugenol sealers are cytotoxic and the response may be
more long lasting compared with most other sealers sealers
Formaldehyde-containing
(22 30). Potential for sensitization exists (13, 11). Zinc based
. Zincoxide-eugenol
oxide-eugenol cements are comrnercially available as o Severelonglastingc!'totoxicity
Hermetic, Tubliseal, Procosol and Kerr pulp canal o Sensibilization
sealers, and form the basis of many medicament-
containing sealers. sealers
Calcium-hydroxide-containing
o Release hydroxide,
calcium whichmayresultin disintegration
o no calciumhydroxide
onceset and integrityis maintained,
Resin-b aseil sealers
leaches outandnoeffectcanbeexpected
Well-known resin-based materials are AH26 and
. effect
Initialantibaderial
AHPlus (De Trey Dentsply) and Diaket (EsPe). Both . overtime
Riskof dissolution
AH26 and AHPlus consist of an expoxy resin. They are
thin fluid matedals that set slowly in 34h (23, 7). The
long setting time may sometimes be an advantage
because it gives sufficient time to coûect deficiencies
in the root canal filling that were noticed at the Post-
operative radiographic check. Diaket is a mixture of D entin e- a dh esia e m at er i al s
vinylpollrnerizates that sets in about 7min, which Adhesive cements have been tested as a root canal filling
makes it less suitable in techniques that require some material in an attempt to imProve the sealing quality of
waiting tirne (23). sealers. Cyanoacrylate, calcium phosphate, polycar-
These resin-based sealers elicit an initial severe boxylate and glass ionomer cements have all been used.
inflamnatory reaction that subsides after some weeks Of these, only glass ionomer cements have been widely
and thereafter seems well tolerated by the periapical marketed (Ketac-Endo, Endion). Although in aitro aîd
tissues (26, 24. The sealerAH26 has been shown to have in long-term studies favorable results were obtained, the
both a stlong allergenic and a mutagenic Potential (13, rnaterials have never gained great PoPularity, probably
24). The cLinical implications of these findings, however, becausethey set too quickly (4min) (18).Although quite
are unclear but contact allergy to this matedal has been biocompatible, glass ionomers are difficult to remove for
reported (14). retreatment.
 Rootfillingtechniques

Mateials to which medicaments haoe been added
These materials may be divided into two groups:
(1) Materials based on the inclusion of strong disin-
fectants and/or antiphlogistic agents to suppress
possible postoperative pain.
(2) Materials based on calcium hydroxide.
In the first group the added disinfectant is
paraformaldehyde and the anti-inflammatory compo-
nent is often a corticostedod. Examples of brands in this
category of sealers are EndornetÀasone, N2, Spad and
Rocanal. If deposited in the periapical tissue, these
filling materials may give rise to severe inflammatory
reactions and thus do not satisfy the requirement for
biocompatibility (29, 22)- Paralormaldehyde also causes
allergic reactions (8).
Calcium hydroxide is known to stimulate the {orma-
tion of hard tissue at the foramen and therefore has been
incorporated as an active component in several root
canal sealers. The most popular commercial calcium-
hydroxide-based cements are calciobiotic root canal
sealer (CRCS, a zinc oxide-eugenol-based sealer),
Sealapex (a polymeric resin-based sealer) and Apexit
(a colophonium-based salicylate resin).
ln aitro leakage studies have shown their sealing
ability to be similar to the zinc oxide-eugenol cements
or, in the long run, slightly less favorable (18). The latter
observation supports the concem that during long-term
exposure to tissue fluid calciurn hydroxide may leach
out of the cement, which may result in a loss of root
filling integrity (48, 38).
Rootfilling techniquesemploying
gutta-perchaand sealer
These can be divided into solid core and softened core
techrriques (Core concept 18.3).
Solidcoretechnioues
\ /hether a single-cone or multiple-cone technique
(lateral compaction; Fig. 18.2), tÀe most important step
in solid core methods is to select and fit a cone (point)
of gutta-percha to the apical &-4mrn of the canal. This
cone is often refeued to as the mastercone,Cones come
in various tapered shapes and it is critical that the fitting
procedure is given considerable attentiory because the

Coreconcept18.3 Rootfilling techniques

Solidcoretechniques gutta'percha
lniection-nolded
Singlecone . Quicktechnique
. simpre : l::lHil#:i:periodontium
. Quick
. coodlengthcontrol 'lhernome(haniaal
. Round preparation
standard required conpaction

Laterct
compaction t Quicktechnique
a Poorlengthcontrol
. Goodlengthcontrol o Heatmaydamage periodontium
o Notonecompact massof gutta-percha . lnsrrument
fracture
risk
o Time-consuming
technique
. Supposed
riskof rootTracture
corecarrier
Softenedcorete(hniques . Quicktechnique
Wam lateralcompaction t seâlerextrusion
*""'"
. r\4oderate
renslh
contror : 3i,i:;iîi:*i"iïïl::1,'"J,.'."'"
' Time-consuming
technique . withposts,
In combination inconvenient
technique
. Heatmaydamageperiodontium

Warn veftical(.onpaction chlorofom-rcsin

. Poorlengthcontrol . Quicktechnique
o Seâler
extrusion . healthhazard
Potential ondentalpersonnel
effects overlongtime
. Heatmaydamage periodontium use
 clinicalmethodologies

cone should fit tightly to the apical Portion of the root clinically to be an improvement over the single-cone
canal. technique (15, 32).

Single cone Softenedgutta-perchatechniques

The single-cone technique consists of matching a cone to
the prepared canal. For this technique a tyPe ol PrePa-
ratiôn (Chapter 16) is advocated so that the size of the
cone and ihe shape of the preparation are closely
matched. When a Sutta-Percha cone fits the aPical
portion of the canal snugly, it is cemented in place with
a root canal cement.
Although the technique is simple, it has several dis-
advantagés and cannot be considered as one that seals
canals completely. After preparatiorl root canals are
seldom round tfuoughout their length, excePt Possibly
for the apical 2 or 3mm. Therefore, the single-cone tech-
nique, ai best, only seals this portion ln aitrc research
hai shown that the single-cone techrrique Permitted sig-
nificantly more dye Penetration than other techniques
(1, 3) (see also Advanced concept 18.1).
In an attempt to overcome the deficiencies of the cold
lateral compaction technique, heat and solvents have
been appliâd to render gutta-percha Plastic Gutta-
perchais then compdctedto createa homo8eneousroot
ianal filling of greaier density tfuoughout the canal than
solid-coretechniquescan Provide
In recent years several modes of utilizing heat have
been developed to soften Eutta-Percha'ln principle' heat
softening can be carried out inside the root canal or
outside: the latter in the form of injecting preheated
s.utta-perchaand lhe former by applying heat after
inserrion of unco{tened cones These techniques will
now be described in some detail.
Techniques employing heat inside the canal

Warm lateral compaction:this technique evolved as a

Lateral compaction compromise between lateral compaction of cold gutta-
ln lateral comPaction techniques additional secondary percha und the vertical comPaction of warm gutta-
laterally around the oercha (see below). The teclùique is similar to lateral
-masterare inserted and compacted
points
cone to reduce the thickness of the sealer layer compaction of cold gutta-Percha but here a heated
this technique, after cementing
(Figs 18.3 and 18.4). ln spreader is initially advanced into the mass of Sutta-
ihe-naster cone in position, specially designed spread- pl"rcha cor-r.s placed in the canal (Fig 18 5) Following
- instruments- are placed
ers long, tapered, Pointed its removal a cold spreader is inserted, and the space
possible and the master
in the canal as far apically as thus obtained is filled up with accessory cones The
cone is laterally comPacted against the wall Next, the process is repeated until the canal is completely filled'
spreader is removed and the first auxillary point forced briginally, ii was advised to insert a heated spreader
fully to place. The canal is filled in this way until it is not aftei every accessoly cone. ln Practice, usually after
oossible to pluce another accessorycone further than 2-
àmm into the root canal. Excess gutta-percha is then
removed with a heated instrument at the canal orifice
and. final comPaction is completed by vertical Pressure
with a plugger or condensor - an instrument with a flat
aDical
- tip.
The aàvantage of the lateral comPaction technique
in comParison with the single-cone technique is that it
reduces the amount of sealer left in the canal Because
the relation between the but end of the cones and the ref-
erencepoint of the preParation can be monitored dudng
the filling procedure, the length control of the filling is
quite goàd and usually no filling material is extruded
É"yo.rà th" fo.u-en. The seal in comparison with other
techniques is good (44).
The àisadvântage of the lateral compaction method is
thdt the root filting does not çonsistoI a homogeneous
mass of material but rather of a large number of indi-
vidual points tightly Pressed together and joined by-a
frictionil grip of cementing substance (Fig 18 4b) Jn
spite of this criticism the technique has been used tor
of gutta-percha
Fiq.18.5 Demonstration with hot instrument'
compâction
Âurru u"ur" with considerable success and appeared
 Rootfillingtechniques

Advancedconcept18.1 Leakagetests

Randomized, controlled,
clinicalstudiesthat compare the efficacyof daysdoesnotreallygivean indicationaboutthedifferencein quality
variousrool fillingmaterialsand lechniques as to theirabilityto olthese Onlycomplete
fillings. voidsfromcrown to apexcanbedetected.
promotea successful outcomeof endodoniic therapyare lacking.
Therelorqto selectlhematerialandmethod, resultsof,n vltroleakage Rubber
testsareoftenclaimed. Although havinglimitedclinicalvalueperJe, stopper
togetherwith biocompatibilitytesting(Chapter 17)theycontribute
informationoI importancefor thechoice.A common denomjnator for
thesemethods. whicharedescribed below.isthatextracted teethare
employed that havebeeninstrumented andfilledwiththe materials
andtechnioues to betested.

Dyepenetration
Afterfilling,eitherthecoronalportionor the roottip is exposed to a
dyethatwill penetrate anyvoidsin andaroundtherootlilling.After
thedyeexposure, eithertransverse or longitudinalsections of theroots +
arecut at differentlevels, or the teetharedemineralized andmade
clearbychemicals. Thelengthof dyepenetration alongtherootIilling FluidtransDort
is a measure of leakage aroundthefilling.
An advantage oI thistechnique is thatit is a relatively
simpleand Atbothends, tubesfilledwilhwaterareattached,Atone endthewater
inexpensive way to acquirepreliminary evaluation oI the sealing is applied underpressure, At theotherend,a fineglasscapillary tube
qualityof a rootlilling.A disadvantage is that it doesnot provide isattached thatcontains a smallairbubble to measurethefluidtrans-
a quantitative evaluation because it givesno information about port,if any,asindicated by movement Themethod
of theair bubble.
thevolumeof leakage andthesizeoI thevoid.Entrapped air in the is a simpleand inexpensive model.lt givesquantitalive dataand
voids,furthermore, mayhinderpenetration of dyeintothevoid,giving allowstheleakage pattern to befollowed overtime,because thespec-
an underestimation oI ils length(46).Ako, the methodleadsto imenis not destroyed duringthe evaluation process(45).Thedisad-
destruction of the specimens studied, makinqan evaluation of the vantage isthatit onlydetects voidsthatrunfromcrownto apex,with
samerootfillinqat several timeperiods impossible. 5omefillingmaf dead-end tractor cul-de-sac voidsnotbeingdeteqted.
erialsmaydiscolor the dye,resulting in an underestimation of the
. Connectedwith
reaKage.
a microsyringe
. Aarpressure
MicrobialDenetration (1.2 atm)
A coronal andanapicalreservoir areattached to thetoothcontaining bath (20'C)
therootfilling.Thecoronal reservoir
isfilledwitha baderial suspension
andtheapicalcontainer is givenculturemedium. lf baderiaor micro- 1. Unfilled root
organisms passalongtheroollilling,itwillreach theapical reservoir
and
resultin growthturbidity of themedium (37,46).An advantage ofthis
technique isthatbacterial leakageis measured, whichmayseemmore
relevant thansmalldyeparticle
biologically leakage.The disadvantage
isthatin ordertoprevent contamination thissystem requires consider-
ableattention,lt js notquantitativebecause evenonebacterium will
ingroMh.Whether
result a bacteriumpasses along a fjllingin10or20

every three to four accessory cones the gutta-percha
mass is heated and the compaction is continued. There
are devices in which the spreader is heated electrically
in a few seconds and thereafter quickly cools down
'n
again (e.g. Touch Heat, ElE/Analytic).
The advantage of warm lateral compaction is that it
leads to a homogeneous mass that, in aitro, pernlTted
significantly less leakage than cold lateral compaction
(17). A distinct disadvantage is that t}le softening of the
gutta-percha may lead to overextension of root filling
material.
Warm aertical compaction: tlr.e objective is to obLiterate the
canal with a filling material softened by heat and packed
with sufficient vertical pressure to force it to flow into
the root canal system, including accessory and lateral
canals. A non-standardized master cone is selected and
adjusted so that it is loose in the coronal and the middle
 clinicalmethodologies
third, fits to the apical terminus of the preparation and
is snug in its apical extent. The canal is lightly coated
with sealer The cone is plasticized with a hot instru-
ment. Next, the soft gutta-percha is compacted with a
cold plugger in an apical and lateral direction.
Recently, a new instrument, System B Heat Source,
was introduced to simplify the down-pack of gutta-
percha. This technique has been described as the contit
uous waoetechnique(21). The advantage of this system is
that the tip of the instrument acts as a heat carrier and
cold plugger at the same time. The tip of the plugger of
this inshument maintains a temperature of 200'C
throughout the down-pack procedure, permitting a
smooth continuous progression of the plugger to a
depth just shy of the apical terminus. The coronal
portion of the canal is back-filled with small segments
of warmed gutta-percha, injectable gutta-percha or an
additional cone is compacted with the System B.
The advantage of the warm vertical compaction tech-
nique is that it results in a well-adapted homogeneous
mass of gutta-percha to the canal wall that requires a
minimum of sealer The disadvantage is that the tech-
nique almost consistently leads to extrusion of filling
material.
Techniques employing heat outside the c.tnel
Injection technique.'gutta-percha is thermoplastically
molded and ejected out of a needle into the canal. For
this technique there are two versions. The Obtura system
(Fig. 18.6a) uses a pressure syringe in which the gutta-
percha is warmed to 200"C and expressedinto the canal
through a needle as fine as 25 gauge (0.5mm diameter).
The gutta-percha leaves the needle at approximately
70"c.
Pluggers are prefitted to ensure that they match the
middle portion of the canal while not contacting the
dentine wall. A little root canal cement is wiped along
Fig.18.6 Twocommonly to providethermoplasticized
useddevices gutta-perchâ
for injection:
the canal wall and gutta-percha is passively injected into
the root canal. In 5-10s the softened gutta-percha will
fill the apical segment and begin to lift the needle out of
the root. Dudng this lifting by the softened, flowing
mass, the middle and the coronal portions of the canal
are continuously filled until the needle reaches the calal
odfice. Compactlon of the material follows to adapt the
gutta-percha to the canal walls.
Becauseof concern over the high temperature gener-
ated, a thermoplasticized low-temperature (70'C) gutta-
percha was developed along with a slightly different
delivery system, Hygienic Ulfafil (Fig. 18.6b),where the
canule with gutta-percha is heated in a specially
designed heating device. The injection technique is used
as the sole techîique to fiIl the canal but is also fre-
quently applied for the so-called back-pack phase of
vedical compaction once the apical fill has been prop-
erly compacted.
Advantages of the injection technique are sirnilar to
those of warm vertical compaction. It also appears to be
very useful inwide canals with an apical stop (Fig. 18.7a)
and in casesof internal resorption (Fig. 18.7b).
The disadvantage is that here it may be even more
difficult to control the level of the root filling, with a
possible under- or overfill ensuing. Shrinkage of the
gutta-percha during cooling may result in voids, which
may make it necessary to use continuous compaction
with pluggers during cooling. For this reason a
segmental filling technique where small portions
are injected and compacted with pluggers has been
advocated.
Thermomechanical compaction:gutta-percha is plasticized
by frictional heat and inserted by means of a compactor
that forces the matedal apically. The compactor is an
engine operated instrument resembling a Hedstrôrn file,
but with the blades directed toward the bluntiipped
end, and operates on the principle of the reverse tuming
(b)the Hygienic
(â)the obturasystem; Ultrafilsystem.

incisor(b)
Fig.18.7 {â)çilledrcotcânaloftrâumatized
Internalresorption.
Fig.18.8 Proliles (top)andâ Hedstrôm
ol a compactor file(bottom).
screw (Fig. 18.8).The technique with which this method
gives best results is different from the original one
suggested, where only one cone slightly larger than the
master apical file and a compactor of the same size as
the master apical file was used. To improve the reliabil-
ity of the technique, thermomechanical compaction has
been used following lateral cornpaction of the apical part
of the canal, resulting in a reduction of dye penetration
in oitro (35).
The advantage is that it is a very fast technique
leading to a compact mass of gutta-percha that, in wide
canals, resulted in less leakage thaJt lateral compaction
(16). The disadvantage is that the technique requires a
lot of practice to get consistent results. In inexperienced
hands, instrument fracture, extensive exfusion or
poorly compacted filLings may occur If the instrument
is used by accident, when rotating clockwise it may
perforate the foramen and fracture, leaving part of
the instrument in the DeriaDex.
Rootfillingtechniques
Core carrier technique:a metal or resin core coated with
gutta-percha is used (Thermafil, Soft core) (Fig. 18.9).
After root canal preparaton t}re correct size of the cone
is selected and heated in a special oven for 45s. After
heating, the cone is pushed with pressure into the canal
that is coated with sealer Next, the coronal part is
removed fuom the core that remains in the canal and the
gutta-percha is then compacted in the canal orifice with
a hand plugger.
The advantage of the technique is that, once the cone
is properly heated in the oven, with this system the canal
can be well obturated in all its dimensions within a short
time. So far, this system has been evaluated orùy in aitro
and it seems reasonable to assume that at least in straight
canals the techrrique is about as good as lateral com-
paction of gutta-percha (2).
The disadvantage of the system is that, especially in
curved canals, there is the risk of the gutta-percha being
stripped off and apically only the metal or resin core
being cemented (12). In almost all studies it appeared
that, just as with most of the other warm gutta-percha
techniques, sealer is extruded beyond the apical
foramen (2).
Warm gutta-percha techniques - concluding
remqrks
Although it is known that dentine is a Bood insulator,
concern exists as to whether the high temperatures that
may develop in the canal during the application of
warm gutta-percha and heating devices are transferred
to the outer surface of the root to cause damage to the
periodontal ligameît. In aitro the temperature rise at the
root surface may be as high as 15-30'C (21), Ieading to
 Clinicalmethodologies
Fig.18.9 Theprinciple (a)uncoated
for the corecârriertechnique:
andgutta-percha
materialin the middle.
periodontal tissue injury. In experimental animals root
resorpton and ankylosis have been observed with these
techniques (31).
The warm gutta-percha techniques have much to
commend t}tem and undoubtedly the resultant root
filling appears to be homogeneous and, from radio-
graphs, seems to fill the root canal space well. Yet there
is no evidence to show that these techniques result in
higher cLinical success than for instance cold lateral com-
paction. So Êa\ in aitro studies have not answered the
question as to which of these techniques results in the
least leakage (44).
Tbchniques enpl oying solztent
Chloroform-resin technique: based on softening the master
gutta?ercha cone in chloroform for a few seconds prior
to insertion. The master cone then should be cut approxi-
mately 2ûIm short of the working length and is moved
to length by a slight pumping movement. As a sealing
agent in the canal, 6oÂresin in chloroform is used. This
technique is not commonly practised, pdmarily owing
to the alleged risk for shrinkage of the root filling after
evaporation of the softening agent and the potential
carcinogenecity of chloroforrn (Chapter 17).
Proceduresprior to root canalfilling
Smearlayer removal
The instmmented dentine surface of the root canal
interior is covered with a debris layer that sticks to its
underlying structure and consists of (pre)dentine, pulpal
remnants and, in previously infected root canals, micro-
bial elements. By its presence it may jeopardize a proper
seal of the root canal space.
coatedcores;(b) a cross-sectional
cut of tlvo filledcanalswith the core
Studies indicate that removal of the smear layer
reduces leakage of fluid and bacterial elements along the
root filling. Thus, it is not unreasonable to see the smear
layer as a weak link, which should be removed to allow
better adherence of the root filling to the root canal wall
(33). To remove the smear layer, irrigation with EDTA
(15%) followed by a sodium hypochlorite flush seemsto
be effective (33).
Dryingcanal
It is critical that, prior to root filling, tlrc canal is corn-
pletely evacuated of irrigation solution to allow good
adaptation of the filling material. This is accomplished
easiest by aspiration with a syringe, followed by drying
with one or two paper points to the full working length.
It may be necessary to measure up the paper points so
that they are not extruded into the apical tissue, where
they may cause bleeding or where fragments may be left
to cause a foreign body reaction. The last point should
not show signs of fluid present after its removal (28). It
is important to note that if tips continue to be wet by
bleeding or exudation, root filling should be postponed
and the canal dressed temporarily (see Chapter 11). To
eliminate moisture 90% alcohol is often used but the
efficacy of this extra procedure has been questioned
@2\.
Sealer olacement
Because a thin layer of sealer between the gutta-percha
and canal wall is preferred, it seems desirable to coat the
complete canal wall with sealer prior to applying the
core material. Generally, it is recommended that a file be
used that is one size smaller than the last instrument
used for enlargement and set iust short of the working
 Root'fillingtechniques 297

length. A small amount is gathered on the blades of the
'twirling' the
instrument, which is carried up by rapidly
handle counter-clockwise. The procedure is repeated
until the canal appears to be coated liberally with
'buttered' in cement and
cement. The point itself is
slowly passed into the root canal, allowing time for the
cement to flow back in a coronal direction.
root filling quality
Assessing
After the root filling procedure the quality of the fill
should be checked radiographically with regard to the
extent the inshumented canal was filled. An acceptable
fiIl should reach the working length, as indicated by the
trial file, and cornpletely fill the canal sPace over its
entire length (Core concept 18.4). Proper assessmentis
often difficult in an orthogonal view, therefore all angu-
lated view is often essential (Fig. 18.1), not least to be
able to observe the quality of fills in two- and multi-
rooted teeth. If the root filling does not filI the canal
properly, i.e. if there is a short fill or if the fill displays
obvious voids, the filling should be adiusted (see Core
concept 18.4). Oftery comPlete removal and reinsertion
of a new filling is the best strategy in such casesrather
than adjustmentby comPaction.An overextended filling
norrnally cannot be corrected owing to the diffuse
spreading of sealer material.

of root filling quality

core concept18.4 Assessment

(1) optimaloutcome tromthe radi- (3) Obvious

of lootfillingafterpulpectomy. to theloolcanalwalls(retreatment
lateralspaces case)
ographit canbeseenthatthelengthof thefillingisto anappro-
priateworkinglenglh(a)andit appears fill the canal
to densely
space in its entirety(b).

(4) Overextended rootfillingonboththemesial anddistalcanalsbut

(2) Tooshorta fill of an uppercanine(retreatment
case). it appearsto fill out the canalspaceproperly.
No retreatmenl
becauseof thelimjtedpotential to removetheexcesslootfilling
material.
 Clinical
methodologies
Fillingof the pulp chamberand
coronâlrestoration
Because of the potential presence of accessory canals
near the floor of the pulp chamber of multi-rooted teeth
and the fact that exposure of the root canal filling to
saliva and bacteria seriously detedorates the quality of
the seal, application of a well-sealing, colored dentine-
adhering cement is recommended (20, 37, S).In the case
of retueatment to be able to locate the canal asain this
material should have a color distinct from dentine but
not to the extent that it discolors the crown of the tooth.
Considering the negative effect of the oral fluids on
the quality of the root canal filling, it is not surprising
that the quality of the coronal restoration may also influ-
ence the outcome of endodontic treatment, particularly
if the root canal is not perfectly sealed. It is recom-
mended that a good coronal restoration be placed im-
mediately after root canal filling. Therefore, the root
filling rnaterial should be removed at or just apical from
the canal orifice, and in single-root teeth just apical to
the cernento-enamel junctiory because all root canal
cements stain dentine to cause tooth discoloration (39).
In cases where a cast restoration is indicated, a core
material is placed. This procedure is deleted if a post and
core are indicated shortly after filling the canal. In that
case/ space for a post may be created right after filling
the root canal, leaving at least H mm of gutta-percha in
lhe canàl (6).
Conclusions
and recommendations
Insufficient research has been carried out to determine
which technique under certain given conditions (root
canal anatomy, apical constdctio4 preparation shape) is
the most appropdate (44). However, there are indica-
tions that the risk for leakage of bacteria and bactedal
elements is larger when the single-cone technique is
used than with the use of other techniques (1, 3). There-
fore, the clinician is advised to make him or herself con-
fident with one or two of the techniques described. It
needs to be recognized that no root filling technique can
make up for an irnproper root canal preparation.
References
1. Beatty RG. The effect of standard or setial preparation on
single cone obturatiorÊ. Int. Endodont.]. 1.987;20:276-8L.
2. Becker TA, Dormelly JC. Thermafil obturation: a literature
revie /. Get?.Dent.7997;45: 46 50.
3. Beer VR" G:ingler R Beer M. In-vitro Untersuchungen
unterscheidlicher Wurzelkanalfiilltechniken und -materi-
alien. Zahh-. Mund-. Kiefetheilk. 1986; 74: 800-806.
Brodin B Roed A" Aars H, Urstavik D. Neurotoxic
effect of root filling matelj.als. l. Dent. Res.1982;67:1020-
Chailertvânitkul R Saunders WP, Sâunders EM, el al. An
evaluation of microbial coronal leakage in the restored
pulp chamber of root canal treated multirooted teeth. Irt.
Êndotlont. l. 1997; 3O: 318-22.
De Cleen MJH. The relationship between the root canal
filling and post space prcparation. Int. Endodont.]. 1993;
26: 53-8.
7. De Gee AJ, Wu M-K, Wesselink PR. Sealing properties of
Ketac-Endo glass ionomer cement and AH26 root canal
sealers.ht. Endodont.J. 199Q 27:23944.
Fehr B, Huwyler T, Wùtrich B. Formaldehyd- und
Paraformaldehyd-allergie. Schweiz. Monatsscht. Zahnmed.
1992; 702: 94-6.
9. Feiglin B, Reade PC. The distribution of (rt)leucine and
35SRlabeled microsphercs ftom rat incisot root canals.
Ctrcl. Surg. 1979;47. 277-81.
10. Friedman S- Treatment outcome ând prognosis of
endodontic therapy. In Essenti1lEndodolltology(Orctavlk
D, Pitt Ford TR" eds). Oxlord: Blackwell Science, 1998;
367-97.
Grade AC. Eugenol in Wurzelkânalzementen als môgliche
Ursache ftir eine Urtikaria. Endodontie 7995; 2: 12L-5.
Gutmam JL, Saunders \À?, Saunders EP, ef l?1.An assess-
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Matedal adaptâtion arld sealability. Irt. Endodont. I. 1993;
26:179-f.3.
Hensten-Pettersen A, @rstavik D, Wenaberg A. Alleigenic
potential of root canal sealeÉ. Enilodont.Dent, Traumatol.
1985, 1: 61-5.
L4. Horsted R Saholm B. Overfslsomled overfor todfyllrLings
materialet 4H26. Tandlaegebladet7976; 80|.194Â.
Kerekes K Tronstad L. Long-term rcsults of endodontic
treatment performed with a standardized techrrique. /.
Endodont. 1979; 5t 83-90.
't6.
Kersten HW Fransman R, Thoden van Velzen SK. Ther-
momechanical compaction II. A comparison with lateral
condensafion in curyed canals. Int. Endodont. ]. 1986;191
13440.
L7. Kersten lIW. Evâluation of thrce thermoplasticized gutta-
percha filling techniques using a leakage model in vitro.
lnt. Endodotlt.I. 7988;211353 60.
Kontakiotis EG, Wu M-K, Wesselint PR. Effect of sealer
thickness on long-term sealing ability: a 2-year follou/-up
sttldy. Int. Endodont.I. 1997;30: 307-12.
19. Longwill DG, Marshall FJ, Creamer RH. Reactivity of
human lymphocytes to pulp arrtigens./. Ëndodont.1982;8:
2712.
Madison S, Wilcox LR. An evaluation of coronal
microleakage in endodontically treated teeth. Part III. In
vivo study. /. Endodont. 7988; 1,4t 455 L
Mccullagh JJ,Setchell DJ, Gulabivala K, ef ll1.A compâri-
son of the infrared thermographic analysis of temperatuie
dse on the root surface dudng the continuous wave of
condensation. Int. Endodont.I. 2OOq33l.326-32.
Negm MM. Biologic evaluation of SPAD IL A clinical
compadson of Tlaitement SPAD with the conventional

root canal filling technique. Oral. Surg. 1987; 63: 487-
93.
Orstavik D. Weight loss of endodontic sealers, cements
and pastes in water Sctutd.]. Dent. Res.1983;9'lt 316-19.
Zrstavik D, Hongslo JK. Mutagenicity of endodontic
sealers.Biomaterials1985;6: 1,29l2.
Orstavik D, Brodin P, Aas E. Paraesthesia following
endodontic beatment: suNey of the literature and repoÉ
of a câse. Ir?f. Endodont.I. 19a3;16: 167-72.
OÉtâvik D, Kerekes K, Edksen HM. Clinicâl performance
of three endodontic sealers- Endoclont.Dent. Traumatol.
1987;3: L78 86.
27. Orstavik D, Miôr lA. Histopathology and X-ray micro-
analysis o{ the subcutâneous tissue response to endodon-
Lic(edlers./. L,ldodotrt.lqg& l4: l3-23.
28. Petschelt A. Das Trocknen des Wurzelkanals. Dts.h.
Zah iitztl. Z. 7990; 45: 222 6.
29. Pitt Ford TR. Tissue reactions to two root canal sealels
containing formaldehyde. Oral. Surg. 1985; 60: 6674.
Ricucci D, Langeland K. Apical limit of root canal instru-
mentation and obturation. Part 7I. Lnt. Endodont.l. 1998;
3 1 : 3 9 44 0 9 .
Saunders EM. In vivo findings associated with heat gen-
eration during thermo-mechanical compaction of gutta
percha. Part II. Histological response to tempeiature
elevation on the external surface of the root. I11t.Etldodoht.
l. 199ù 23t 25844.
Seltzer S, Bender IB, Turkenkopf S. Factors affechng suc-
cessful repair after root canal therapy. _1.Ant. De11t.Assoc.
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Sen BH, Tùrkiin M, Wesselir < PR. The smear layer: a phe-
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141 8.
Sjôgren U, Sundqvist G, NaiI PR. Tissue reaction to
gutta-percha particles of various sizes when implanted
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3L3,2L.
Tagger M, Tamse A, Katz A, ef al. Evaluation of the apical
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bining lateral condensation and thermatic compaction.
I. Endodont.1984; 1O:299-303.
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Teeuwen R. Schâdigung des NeNus alveolaris inferior
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"1999;
8: 323-j6.
37. Torabinejad M, Ung B, Kettedng JD. In vitro bacterial
penetration of coronally unsealed endodontically treated
Teelh.I. Endodollt.1990;1,6:566 9.
Tronstad L, Bamett F, Flax M. Solubility and biocom-
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'1212314.
Von Fraurrhofer JA, Branstettei J. The Physical ProPetties
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8: 126 30.
Weiss EI, Shallav M, Fuss Z. Assessment of antibactedal
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'1995;
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1973; 52: 25340.
Wu M-K, Wesselink PR. Endodontic leakage studies
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Wu M-K, De Gee AJ, Wesselink PR, Moorer WR Fluid
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C h a p t e r1 9
Non-surgical retreatment
PierreMachtou and ClaesReit
Introduction
Endodontic treatment is not always successfuland peri-
radicular ùtflamrnatory lesions might persist or develop
postoperatively. Such 'failures' are most often caused by
micro-organisms that have either survived the conven-
tional treatment procedures or invaded the root canal
system at later stages via coronal leakage. In order to
combat the infection, the root canal has to be renesoti-
ated using eilher ar orthograde (non-surgicalrelieat-
ment) or a retrograde (surgical retreatment) route of
entry It is the aim of the present chapter to review
specifically the non-surgical retreatment procedures.
In terms of objectives there are no differences between
the primary treatment of the infected root canal system
and a retreatment, i.e. micro-organisms should be elim-
inated and the space hermetically sealed with a bio-
compatible filling material. However, retreatment cases
often are technically complicated and require high skills
by the dentist. Becauseendodontically heated teeth are
frequently prosthodontically restored, canals regularly
have to be re-entered through crowns. The canals might
be obstructed by posts, insoluble filling matedals or sep-
arated instruments. Furthermore, during the previous
treatment a variety of procedural errors such as canal
blockage, Iedging, apical transportation and root perfo-
ration may have occurred.
Indications
Clinical outcome studies have failed to show any sys-
tematic difference between a surgical ald non-surgical
approach to retreatment (1, 17). Consequently the selec-
tion of retreatment procedures primarily has to be based
on case-specificfactors such as the tech:rical qualify of
the root filling and the personal valuation of iisks and
monetary costs.
The typical indication for non-surgical retreatment
is a case classified as a 'failure' in which the canals are
poorly sealed.As soon as it is possible to improve on the
300
quality of the previous instrumentation and obturation,
the non-surgical approach should be considered as the
primary choice. However, an orthograde route may be
contraindicated subjectively if the patient regards the
costs or risks of the procedures to be unacceptably high.
The monetary costs will increase if crowns, bridges and
posts have to be removed and later replaced. In certain
situations accessopenings through the crowns of abut-
ment teeth and removal of posts might increasethe risk
of bridges loosening and roots fracturing.
Non-surgical retreatment might be indicated also for
preventive reasons. In conjunction with the placement
of new crowns or posts, the root filling seal inevitably
will be challenged by oral micro-organisms. A poor fill
might not resist such provocation and thus allow micro-
organisms to invade the root canal, therefore the replace-
ment of defective root fillings always should be
considered when new prosthodontic restorations are to
be conducted.
Core concept box 19.1 summarizes the cdtical steps
in non-surgical retreatment, and these are discussed in
more detail below
Accessto the root canal
Because defect restorations might allow oral micro-
organisms to invade the root canal system, amalgam
and composite fillings frequently have to be removed
completely prior to retreatment. Sometimes crowns and
bridges have to be disassembled. Dismantling enables
the clinician to assessthe actual axis of the tooth and
the remaining coronal structure, excavate recurrent or
hidden caries and look for cracks, missed or additional
canals. The decision to retain a restoration may be taken
only when the latter is well fitting and fulfills esthetic,
functional and periodontal requirements, and if the
accesspreparation will not seriously damage it. In the
case of an accesscavity via a metallic restoration, care
should be taken to make the occlusal outline wide
enough at the start to allow for controlled manipulation
 retreatment
Non-surgical

Coreconcept stepsin non-surgical

19.1 Critical Advancedconcept19,1 Alternativecrown
retreatment removal
techniques

. Accessto therootcanal (1) TheMetaliftCrownRemoval System isrecommended to gently

- access openingthroughcrowns remove individualcrowns be(ause the procedure is simple and
- removal oTcrowns, bridge5posts. highlyefficient withminimaldamage to theprosthetic crown
a Accessto theapicalarea (a tiny holeis createdon the occlusal surface) and tooth
- removal of rootfillingmaterial structure.A self-tapping instrument threadsthe metâlon
- removal of separated instruments. the occlusal surface, pushes againstthe dentinqbreaksthe
o Reshaping therootcanal. cementlayerand resultsin a loosening and liftingof the
. Antimicrobialtreatment. restoration.
(2) TheCoronaflex forceps maybeusedwhenmaintenance ofthe
crown integrity is mandatory Ïhe forceps are placed at the
margins of thecrown. Thenthecorona{lex handpiece is posi-
tionedagainst fie Iorceps archto ensure anaxialpulling direc-
procedure
Clinical 19.1 Crownremoval tion,andseveral impulses aredelivered to lift off thecrown
technique (3) To removepermanently or temporarily cemented bridqes
withoutanydamagqlhe parachute technique shouldalways
(t) Witha transmetal
bur,a slotis madeonthebuccalaspect of be usedin conjunction with air-driven pneumatac crown
thecrownto reachthetoothstructurq startingat thegingival removers suchastheKavoCoronaflex or the EasyPneumatic
marginandstopping in the middleof theocclusal surface CrownandBridge Removerfrom Dentco.Ihe technique allows
(2) Anultrasonic
insertisthenworked to disaggregate thecement theremoval of bridges in anaxialpullingdiredion. ÏTe para-
bondandhelptheplacement to forceapartthe
of anelevator chutetechnique usesmetallicwiresplacedthroughtwo or
crownandthendislodge it. Ihe procedureis safe,expedient moreembrasures of thebridgein orderto createloopsacting
the crowncanbe relinedto be reusedas a
and,if needed, asa restfor a metalrod.Viaa curvedinsert,the pneumatic
temporaryone.Forbridgettheabutments areseparated and handpiece delivers a lotoI energy in anaxialpullingdirection
removed.
individually thatbreaks thecement bond.

19.1). The latter techniques are too aggressive and dan-

gerous for the tooth structure. They are unpleasant and
painful for the patient and a crown or tooth fracture may
often ensue.

of the endodontic instruments without interfering or
scraping the cavity walls. Metal chips may be shaved off
the walls and forced into the canal to create iffeversible
blockage, especially in mandibular teeth. Owing to their
own wei8ht, the shavings will not stay in susPension in
the inigating solution.
Removingcrownsand bridges
Disassembling implies the use of a transmetal bur (CIin-
ical procedure 19.1) to cut off the crorrr.n while preserv-
ing at best the ulderlying tooth structure, instead of
'tapping off' techniques with crown-removers in
using
order to break the luting cement (Advanced concept
Removingcoresand posts
Composite and analgam cores are easily removed with
a high-speed handpiece bur. l^rhen a post is Present, care
must be taken not to damage the Protruding head in the
pulp chamber. In the case of a composite core, the dif-
ference in color between the metallic Post alrrd the filling
material acts as a guide and makes the procedure easy.
Amalgam cores should be drilled in a concentric fashion,
starting from the outline of the cavity and moving closer
and closer to the post. In both cases, with good illumi-
nation and magnification alrr ultrasonic tip placed in a
piezoelectric ultrasonic rmit is well suited to remove
iesidual pieces of restorative material around the Post
and on the pulp chamber floor.
To remove a cast post and core in one piece from a
single-rooted supporting tooth, the'Parachute' technique
works well. First the metalLic core has to be Pierced right
through with a trarsmetal bur. A metallic wire is then
passed through the hole and tied with a knot to create a
 Clinical
methodologies
Fig 19'1 Radiogrâphs
showing{â)screwpostt(b)castposts,(c)Parapostand(d) cârbon-fiber
loop, acting as a rest for the Coronaflex or the Pneumatic
Crown Remover (seeAdvanced concept 19.1).
Depending upon the number of posts present, cast
cores should be separated into two or more pieces with
transmetal burs to isolate each post. Utmost care is
needed when reaching the pulp chamber floor, especially
in the case of a very hard core such as those fabricated of
NiCr. kr many instances, the huge amount of vibration
delivered during the drilling of the core, coupled with the
use of ultrasonics, is sufficient to loosen the post.
\Ahen considering post removal it is essential to make
a careful assessment of the root anatomy and the bT)e,
length and width of the post (Fig. \9.1). Screwposts or
threaded posts usually should be unscrewed after suffi-
cient ultrasonic vibration with a piezoelectric unit. A
10-min session of ultrasonics is considered to be the
minimum amount of tirne needed to expect efficacv.
Passiueconicalor parallel postsalong vvith cast posisare
good indications for using a post removal system. Either
the Gonon (Chige, USA) or its refined clone the Ruddle
Post Removal System (Analytic Endodontics) may be
used. Both devices are safe, efficient and predictable.
Their use is similar and based on the principle of a
post(distalcanalin firstmolât.
corkscrew: one force is applied on the tooth structure,
providing the fulcrum, while the pulling force is placed
on the post (21).
When a post is broken deep inside the canal, the
Masserann kit (Micro Mega, France) should be the pre-
ferred post-removal device becauseit is more conserva-
tive for the root structure. Alternately, the post may be
troughed with one of the suborifice ultrasonic tips in a
dry operating field. While grooving around the post, the
ulhasonic energy will vibrate the post and loosen it. Pro-
viding coaxial light arrd magnification, the advent of the
surgical microscope (7) has made these procedtues easier
and allows them to be conducted in a controlled marner.
After post removal, some residual luting cement may
have been left in the canal beyond the apical tip of the
post. This can be removed easily with the use of a sub-
orifice tip or an ultrasonic file.
Accessto the apicalarea
Before attempting to reach the apical portion of the
canal, the obturating material that obstructs the space

has to be removed. ln order to avoid the risk of defini-
tive canal blockage or pushing and extruding debris into
the periapical tissues,a pronounced crown-down instru-
mentation procedure should be used. As a complicating
factor, root canal instruments might have fractured and
been left in the canal; in a retreatment situation they
have to be removed or at least passed.
Removingg utta-percha
Gutta-percha is quite easy to remove but aJrlorganic
solvent is often a necessary adjunct, especially in the
case of densely filled or curved canals. Chloroform is
the best solvent for gutta-percha but great concem exists
as to its potential carcinogenicity and mutagenicity.
Howevet McDonald and Vire (22) reported that there
were no negative health effects to the dentist or assis-
tant and air vapor levels were well below mandated
maximum levels when chloroform was used in common
endodontic treatment procedures. The report concluded
that with careful and controlled use chloroform can be a
useful adjunct in the practice of dentistry. Several alter-
natives to chloroform have been suggested, such as
eucalyptol, methyl chloroform, halothane and rectified
white turpentine, but all solvents are toxic and, when-
ever possible, retreatment should be carried out without
using solvents (2).
When gutta-percha-filled canals demonstrate some
degree of taper, a rotary nickel-titanium instrument is
used at 1200rpm. This will generate sufficient heat to
soften the gutta-percha, which is evacuated in a coronal
direction owing to the flute design of the instrument (5).
When a canal is small and curved it is safer to use
chloroform to avoid creating a ledge or a perforation.
The coronal portion of gutta-percha is removed with
either a hot heat carrier or plugger or by using an appro-
priate sized Gates-Glidden drill or an orifice shaper (or
similar) at 1200rpm. Using a glass syringe, two or three
drops of chloroform are introduced into the newly
created reservoir inside the root canal. The softened
gutta-percha then can be removed with Hedstrôm files
in an apical direction.
The 'wicking technique'- flushing the canal with
solvent followed by drying it with paper points - helps
to remove any residual gutta-percha and sealer and
gives the irrigation solution access to the canal walls
during subsequent cleaning and shaping procedures
(28). (SeeAdvanced concept 19.2.)
Removalof sealers,cementsand pastes
It is critical that any residual sealer is eliminated from
the canal walls becausebacteria may be harbored in the
interface (39). Moreover, successful removal will allow
Non-surgical
retreatment
Advancedconcept19.2 Removing
Thermafil
plasticcarriers
TheThermalil obturators wereintroduced about10yearsago.First
withmetallic carrierttheywere latermodified andplastic
marketed
replaced the metal.Currently, the obturatorsare with a
available
specialgrooved plastic carrier
designed to makeretreatment easier.
Plasticcarriers are easilyremoved initiallyusingfirst a 0.04
tapered rolaryfileplaced atthegroove location androtated at 1200
pressure. heatmellsthegutta-percha,
frictional
rpm with light The
whichallowsthe instrument to advance apically. Whenresistance
to progression is felt,switchto a 0.06tapered rotaryfileandwork
it at 300rpm.owingto thegreater taper,the instrument will bind
between theplastic andthedentine
carrier andexertanextracting
force.As a lastresort, anH-fileusedin conjunction withchloroform
will engage thesoftened plastic andlift it out{14).0ncethe
carrier
thewicking lechnique mustbeusedto eliminate
carrieris removed,
anyresidual gutta-percha beforereinstrumentation.
irrigation of the contaminated walls during the canal
reinstrumentation (10). This steP in the retreatment Pro-
cedure is difficult and is often overlooked.
In paste-filled teeth, generally some paste is present in
the pulp chamber. During the accesscavity preparation,
the clinicianhas to clean out the pulP chamber floor with
an ultrasonic tip and the amount of time taken indicates
the type of paste that has been used. Most of the time it
is a zinc oxide- eugenol paste that is removed easily. To
dissolve the paste inside the root canals, a solvent must
be used (Clinical procedure 19.2). Tetrachloroethylene
(Endosolv E, Septodont, France) is recommended but
xylene, orange solvent, eucalyptol or eugenol are also
efficient. A zinc oxide eugenol paste that is easily dis-
solved with these solvents is N2.
For several pastes (epoxy resins, bakelites, glass
ionomers, zinc phosphates) no efficient solvents are
available (8). Currently, the best method is to use a
piezoelectric ultrasonic unit with either an ultrasonic tiP
or an easy-to-fit file system. If the procedure can be mon-
itored permanently under the surgical microscoPe,it can
be more predictable. Of course, only straight Parts of
root canals can be managed in this way, but fodunately
the densest portion of the paste is usually the coronal
one and the apical podion is often not set.
Removingsilvercones
Silver cones were introduced in endodontics by Jasper
(15) 70 years ago to simplify the obturation of curved
and narrow canals. Their widespread use has led to
numerous endodontic failures. Often canals with silver
cones are underprepared and, with a defective seal,
 Clinicalmethodologies

procedure
Clinical 19.2 Removing
soluble procedure
Clinical 19.3 Removing
silvercones
pastes
(1) Thefour-wall access cavityis floodedwiththesolvent andan
explorerfirmlyprobesthe canalorificebringsthe solventin
contadwith the pasteandstartsthe lirst penetration.
l2) Selecta 21-mmHedstrôm file whosesizeis adapted to the
canalwidth.lheH-filehasa sharptip andaggressive tlutes
on pulling,sothefillingmaterial canbe removed laterally
as
the instrument penetrates into the paste.Thematerialis
removed ina coronal-apical diredion,usingsmallerfiles asthe
apicalportionof thecanalis reached. lrrigatecopiously with
Naoclto flushout debrisandrenewthesolvent.
(3) It mustbeanticipated thata ledgeis present at theterminus
of the previousobturation. Therefore,if an obstruction or
blockage is fell the penetration shouldbe stopped, a radi-
ograph takenandspecific measures implemented (seelater).

coronal and apical leakage will bring about metallic cor-

rosion. Today, silver cones are considered outdated but
are stll in use.
Various techniques have been described to retrieve
silver cones (20) (Ciinical procedure 19.3), but their
removal depends mainly on two factors: being able to
grab them; and the canal morphology, i.e. whether it is
possible to bypass them with a K-file (33)..

Removingbroken instruments
It is not uncommonto find broken instrumentsleft
inside the root canal system. An instrument usually frac-
tures when an overaggressive manipulaton has tightly ( 1 ) A preoperative radiograph givesinformation aboutlengthand
locked its tip in the root dentine. One should realize that fittingof the conqandwhether thecoronalheadis protrud-
the broken instrument itself is not a direct cause of treat- ingintothepulpchamber. lf thereis a crown,a second radi-
ment failure but rather an indirect one, because it may ographmustbetakenaftercrownremoval,
have prevented cleanin& shaping and filling of the (2) lhe restorative materialis carefully elimjnatedfromthe pulp
apical portion of the root canal. Therefore, the thera- chamber with an ultrasonictip,beingcarefulnotto damage
peutic goal is either to retrieve the fractured instrument thelragilesilverconeend.Atthisstage, noattemptshould be
or to bypass lt in order to get access to the rmcleaned madeto pulloutthecongunless it isveryloose,
(3) Floodtheaccess cavitywithEndosolv Eandtryto bypass the
portion of the canal (Core concept 19.2 and Clinical pro-
conewitha no.08or 10 K-Tile to dissolve andbreakuDthe
cedures 19.4 and 19.5). this pathway
sealeraroundthe cone.Thenenlârge to allow
New teclmological advances such as surgical micro- theplacement of a no.15 K-file.
scopes, powerful piezo-electric ultuasonic uîits and (4) worka no.15or largerultrasonic tilealongside theconewith
refined ultrasonic instruments have significantly a shortamplitude andin-and-out movements undercopious
increased the possibilities to retrieve separated instru- waterirrigation to floatoutthecone,lf unsuccesful, then:
ments. As a rule, any broken instrument even partially (s) Graspthe coronalendof the conewith a modifiedSteiglitz
located in the straight portion of tlrc canal that can forceptwhosebeak havebeenmadethinner, andusethe
be visualized in tlrc microscope should be removed. toothstrudure asa fulcrum to Dulloutthecone.lf resistance
However, if the fragment is close to the forarnen or pro- isfelt,indirect isapplied
ultrasonics onthebeaks ofthepliers
trudes beyond it, surgical endodontics is indicated. closeto thecone,to helpdislodge it.
 retreatment
Non-surgical

Coreconcept strategies
19.2 Clinical in canals instruments
withfractured
(1) Tryto remove
thefragment.

(2) lf removal theinstrument

attemptto bypass
is notsuccessful, andincorporate rootfilling.
it in thesubsequent

u'l 'q

lf theinstrument andsealthespace.
cleanthecanalupto thefragment
cannotbebypassed, thecasefor a periodof timebefore
observe
apicalsurgery
is conducted.

lnstrumentationof the root canal
Reshapingthe root canaI
Reshaping the root canal system may be done by hand
or by rotary instrumentation. In any case, the crown-
down and patency concepts should be used to allow
passive apical progression of the endodontic instru-
ments working in a progressively deeper intracanal
reservoir of sodium hypochlorite. The constant use of
the patency file will move the irrigating solution into the
restricted apical area to clean it. The apical preparation
is done last, keeping in mind that a sufficiently deep
shape should be produced to enable copious renewal of
irrigation during final flushing and to pack the canal
three-dimensionally. If NiTi rotary instrumentation is
elected, a smooth path guide to the canal terminus must
be obtained beforehand for safe shaping of the root
carral.
One should be aware that the requested reshaPing of
an already instrumented canal might create an overen-
largement of the root canal space (40), therefore the
danger zones of the root anatorny should have been
assessed thoroughly before startù1g the retreatment.
Avoiding canal deviation dudng reinstrumentation
should be a permanent concern (27).
Apicalobstructions
When canals have been underfilled, obstructive calcifi-
cations might be found in the apical unfilled portion.
After coronal pre-enlargement and relocation of the
 clinicalmethodologies

procedure
Clinical 19.4 Removingstainless-steel €linicalprocedure
19.6 Bypassing
a ledge
instruments
(1) lf thefragment canbebypassed, usethetechnique described
for tloatingoutsilvercones. It unsuccessful,do notinsistand
proceed to cleaning andshaping, often,thefragment is elim-
inatedduringtheseproceduret butif notit will beentombed
in thellling material,
(2) lf the instrument cannolbebypassed, geta straightradicular
access to it. Ihis is doneusinga sequence of K-lilesfrom
no. l0 to no,35, followedby an ascending sequence of
Gates-Glidden drillsfromno.I to no.5, payingattention not
to damagethe root structure, In curvedcanaltthis step
provides a relocation of thecanalorifice.
(3) At thisstagethe instrument canbe seenin the microscope,
Depending uponthedepthof it5location in the canal,select
an appropriate ultrasonic suborifice tip to makea tren(h
aroundit, Undervisioncontrolandwith a permanent light
streamof airgivenbytheStropko syringqrotatethetip anti-
clockwise against thecoronal endof thefragment to vibrate
it, unwindit andthenlift it out.

( t ) tloodthe canalwith RCPrepor a similarproductsuchas

procedure
Clinical 19.5 Removing
fractured File-Eze(Ultradent,UsA)or Glyde(Dentsply-Maillefer).
rotaryNiTiinstruments \2) Select a no.10SSK-file,placea sharpl-mmcurvature at the
tip andorientthedirectionalstoptowardtheIiletip.
Nickel-titanium alloysare brittlgso usingultrasonics maybreak (3) Insertthe lle in the canalwith the tip directed towardthe
theinstrument. Radicularaccess is gainedasdescribed earlier,
and canatcuryaure.
a stagingplatformis created to gainbetterlateralaccess around (4) Pickgentlywithveryshortstroketsearching for a catch.Ihis
the fragment(28).fhis is donewith a no. 1 or 2 modified procedure will movethe irrigantandhelpto disintegrate the
Gates-Glidden drill,whoseworkingheadhasbeensectioned with dentinemud.lf unsuccessful,rebend theTjletipandrepeatthe
a bur at the maximumcross-sectional diameter.lhen a 1.8-cc sameprocedure whileslightlyreorienting
thetip.
syringe with a bluntneedleslightlylargerthanthe instrument is (5) Whena catchis lelt, slightlywigglethe file backandforth
seleded. Afterthe canalhasbeendriedwith purealcoholandthe whilemaintaining a lightapicalpressure.
Stropko,1ccof Core-Paste (Den-l\4at)is loadedin thesyringe and (6) Whentheblockis bypassed, movethetilein anup-and-down
a smallexcess of materialis extruded lromthe needle. Theneedle motionto smooth theledge.After obtaininga goodglidepath,
is removed fromthesyringe andwipedclean.Iheloadedneedle is copiousirrigationwithsodium hypochlorite
should replacethe
placed overthefraduredinstrument andthematerial isallowed to lubricatino
oel.
setfor 5min,Theinstrument is removed with a counter-clockwise
twist.

canal orifice with Gates-Glidden drills, the coronal

portion of the canal is copiously rinsed with sodium
h)?ocNorite and then thorougNy dried with paper
points and the Stropko sy'ringe. At this stage, and if pos-
sible, the intracanal anatomy should be inspected care-
fully under the mic{oscope to get hformation about the
obstruction. Thery a small-size precurved K-file in asso-
ciation with a lubdcating gel is worked with a slight
pecking motion to try to find a caich. As long as a catch
is felt at the tip of the K-fiIe, apical progression should
be continued arrd checked periodically with a radio-
graph until the canal terminus is reached.
Ledges
Often a ledge has been formed at the end of the previ
ous obturation of the canal. Most of the time a ledge is
the result of an inadequate angle of access to the root
canal and goes hand in hald with canal blockage. Pre-
flaring the coronal portion of the canal with K-files and
relocating tlre canal orifice with Gates-Glidden drills are
preliminary steps to bypassing a ledge (Clinical proce-
dure 19.6) and recovering patency.
If the ledge is located in the apical portion of the canal,
the fitting of the gutta-percha cone may be frustrating
and repeatedlv unsuccessful. Once the canal has been

Fig19,2 Location
of additional molar(seepage236).
canal(MB2) in upper
negotiated with a no. 20 SS K-file, select a 0.06 GT hand
frle. Prebend the tip of the instrument to get a permanent
deformation. ksert the tip file beyond the ledge and
move the GT file to length with the balanced force tech-
nique. Repeat the procedure with a 0.08 GT file. Owing
to the greater taper of these files, the ledge is quickly
srnoothed and a perfect deep shape is obtained.
Missedcanals
Sometimes missed canals can be seen overtly in well-
angulated radiographs but often they must just be sus-
pected, e.g. when a tooth is reacting to thermal stimuli
or is sore after an apparently adequate treatment (36).
After the main canals have been completely cleaned
and shaped, the pulp chamber floor should be examined
thoroughly. At this stage in the heatment this area is well
cleaned by the irrigating solution. A careful inspection
of the floor anatomy is made under high magnification
and with good illumination. ShÏts in dentine color and
anatomic grooves may lead to the orifice of an additional
canal (Fig. 19.2).An ultrasonic tip might be used on the
pulpal floor to uncover hidden orifices and calcified
canals.
Perforationrepair
Furcal or root perforations might happen during root
canal therapy, post spacepreparation or as a result of the
extension of an internal resorptive defect. According to
Ruddle (28), the four dimensions of a perforation that
have to be analysed are its lepel,location,size ar.d t}]Letime
that has elapsed since its occurrence.
At a coronal level the inflammatory process that
evolves as a response to the perforation might commu-
nicate with the gingival pocket and establish a peri-
odontal defect. It is therefore favorable to seal the
perforation site at an early stage before any major bone
resorption has taken place. A wide perforation will be
Non-surgical
retrealment
procedure
Clinical repair:
19.7 Perforation
the internalmatrixtechnique
(1) Aftercleaning the
the perforation wallswith 0.5%NaOCl,
usingan apexlocatorand
workinglengthis established
several paperpoints.The wetportionofthepaper
consistently
pointindicates thelevelof theperforation.
(2) Smallpieces oI collacote arecutandsequentiallypacked with
a prelittedplugger throughthe perforationsiteandintothe
bonylesionuniila solidbalrielis established at the border-
lineof therootdefect.
(3) Theperforation rinsed
siteis copiously with2.5%Naocland
thendried.Finally, the defectis coveredwith a restorative
material suchasSuper EBA,a glassionomeror a composite.
more difficult to seal than a small one. The sites are
mostly ellipiical because an instrument usually Perfo-
rates the canal wall at an oblique angle. Non-surgical
repair is less affected by the location of the Perforation
than a surgical approach to treatment, which can be
impossible in certain areas of the root.
Through the years numerous techniques and mated-
als to repair perforations have been described. In this
chapter two techniques are described (see Clinical pro-
cedures 19.7 and 19.8): the one-visit internal matrix
technique using absorbable bovine collagen (Collacote,
Calcitek, USA) (18); and the two-visit technique using
mineral tdoxide aggregate (MTA, Pro Root DentsPly-
MailleferX3T).
Antimicrobialtreatment
Microbiotaof the root filled tooth
Compared with the microbiota of non-treated PulPs,
little is known about the flora associatedwith failed root
 clinicalmethodologies

procedure
Clinical 19.8 Perforation
repair: Clinical
orocedure 19.9 Standardized
the MTAtechnioue antimicrobial
retreatmentstrategy
tirst visit (1) Remove smearlayerwilh citricacidor EDTA.
(2) till the root canalwith 5% iodinepotassium iodideor
(1) After cleaningthe perforation site with 0,5% Naocl,rhe
Churchill's
solutionlor 10-'l5min.
Churchill's
solution consists
workinglengthis established usingan apexlocatorand
paperpoints.The of iodine(16.59),potassium iodide(3.59),distilled
warer(20
several consistentlywetportionofthepaper
pointsindicales g) and90%ethanol (609).
thelevelof theDerforation.
(2) TheMTAis mixedwithdistilled (3) Prepare a mixof calcium pasteandtheiodinecom-
hydroxide
waterto a thickcement con-
poundused.Fillupthecanalbymeans of a Lentulo spiral.
sislency, to theperforation
carried defectwitha lvlessinggun
(4) Nlakea re€allappointment l-2 weekslater.Repeat steps(1)
andgentlypacked with a plugger,
lt is thensmoothed anda
and(2)andobturate thecanal.
wetcottonpelletis placed againstthel\4TA because themat-
erialneedsmoisture to set.Theaccess cavityis temporarily
IilledwithCavitandthepatientis dismissed.

Secondvisit:48h later
It must be observed that sampling of root filled canals
(1) AfterremovaloftheCavitandthecottonpelle!theIVITAhard- is fraught with difficulties. Initially it has to be preceded
nessis probedwitha sharpexplorer.
lf foundto be hard: by removal of the sealing matedal. This physical activity
(2) fhe definitive
obturation
is madewith the samerestorative might influence the anaerobes more negatively because
materialsasusedwiththematrixtechnique,
they are generally more mlrlerable. Yet, the composition
of the described flora is as would be expected, i.e. more
robust and treatment-resistant micro-organisms may
remain after completed root canal therapy. The intra-
Coreconcept 19.3 Features
of the microbiota canal antmicrobial treatment acts as a selection Droce-
of the 'failed'rool canal dure, favoring a certain $pe of microbiota either
resistant to applied antimicrobial measures or able to
. Fewstrains(l or 2) survive in such a restrained nutritional habitat.
a Gram-positive predominate
micro-organisms
r Dominance of facultatives
overanaerobes
o E faecalr's
frequently found
Antimicrobialretreatmentstrategies
When treating the non-vital pulp, calcium hydroxide
often is recommended as the routine interappoint-
canal treatments. In carals where maior portions have ment dressing. Few organisms will survive when
been left umegotiated, it is reasonabie tà assume that directly exposed to calcium hydroxide, but several
the flora are similar to those of the necrotic pulp (34). factors may impair its antirnicrobial potency in the root
Consequently, in such cases t}re procedures recom- canal. Complex anatomy will make it difficult to pack
mended for primary treatment should be applied also in satisfactorily the whole canal system with paste (31).
retreatment. However, when canals have been instru- Also, calcium hydroxide lacks the potential to reach
mented in their main parts a strikingly different com- microbes colonizing the dentinal tubules (25). Further-
position of the recovered microflora has been found (9, more, some species such as enterococci (6, 29) and yeasts
23,24, 26,34). (38) may resist high pH levels and thus show low sen-
Instead of polymicrobial rnicrobiota, often only one or sitivity to calcium hydroxide. Therefore, in a retreatment
two stlains are detected in failed cases. The micro- situation other medicaments are likely to have greater
organisms are predominantly Gram-positive with a potential.
sLight dominance of facultative over obligate anaerobes A standûrdized relreatment strategy (Clirical procedure
(Core concept 79.3). Enterococcus faecalisis rarely found 19.9) must include measures to combat a potential E.
in primary samples of the necrotic pulp but has been faecalis inlection, It has been observed that enterococci
recovered frequently in obturated canals. Among are sensitive to iodine compounds. Safavi et al. (29)
culture?ositive teeth, E. faecalis was found in 24'k by infected dentinal tubules of human teeth with E. faecium
Engstrôm (9), in 47Lby Molander et aI. (23) and n77% and treated the canals with 2% iodine potassium iodide
by Peciuliene ef al. (26).Aitention also has been attracted {lPI). A lO-min period of medicameni-dentinecontact
to such species as actinomyces (72, 32,35), candida (30, was sufficient to prevent growth. The presence of a
38) and enteric rods (11,16, 79\. smear layer on the canal walls may delay the intratubule

Advancedconcept strategy
19.3 lndividualized
sampling
basedon microbiological
Themicrobiological situationwill varybetween casesandas an
'individual'
alternativeto thestandardized retreatment strategy an
monitoring mightbe tried.sucha strategymustbe basedon a
microbiological diagnosis.Afterremoval of the rootfilling(preler
ablywithoutthe useof chloroJorm) the canalis explored andan
'initial'sample is obtained.When interpretingthetestresults, cases
areassigned to oneof fourcategories:
(1) 'Specific micro-organisms'.the testresultsshowthepresence
of enterococci, enlericrodt adinomyces or candida. speciïic
retreatment strategies
areneeded.
(2) 'Typi(al residualflora'.No'specific'
micro-organisms ateiso-
lated,butthefloraarewhatotherwise mighlbeexpeded to
Dersistin rootcanals.
(3) Atypicalmicroflora'. Micro-organisms not expectedin a
'typical'retrealment casee.g.a largenumber of species and
bacterial cellswith a mixtureof anaerobes andfacultatives.
Sucha testresultindicates leakage dueto loosening bridge-
workor a verticalrootfradure,for example.
(4) Nomicro-organisms detected, Thecause of failureis probably
non-microbial. Consider surgicalretreatment.
antibacterial activity of a medicament (25), therefore in
a clinical situation the application of IPI should be pre-
ceded by a smear-layer-rernoval procedure. Owing to its
vapodzation, IPI has a long-distance bactericidal effect.
However, its duration in the root canal has been shown
to be very short (9, 24) and therefore should not be left
as an interappointment dressing. Instead, IPI in a mix
with calcium hydroxide paste has been proposed (23).
There are several reasons (microbial and non-
microbial) why an endodontic treatment fails and a
standardized retreatment protocol will not consider
these various reasons. As an alternative, indiaidualized
monitoring ol rcteatment casesmight be designed based
on intracanal microbiological sampling (Advanced
concept 19.3).
Preventiveretreatment
Intracanal micro-organisms have been recovered in root
hTled teeth TVithoutapical periodontitis (9, 23) . However,
the lack of a visible periapical radiolucency does not
necessarily imply the absence of periapical pathosis.
Attention must be paid io the possibility of periapical
healing, although microbes survive in the root canal.
Consequently, when a canal is retreated on a Preventive
indication, the case should be regarded as Potentially
infected. Also, patency filing through the foramen
should be avoided. As long as there is no pathway to the
retreatment
Non'surgical
pedapex, a periapical tissue resPonsewill not develop
If an avenue is opened up, nuhitional suPPly will
increase and an inllammatory reaction may be induced.
Supportive clinical data have been presented showing
that the development of periapical radiolucencies
after rctreatment is significantly associated with over-
instrumentaton and overfilling of the root canal (3).
Bergenholtz et aI. (4) diagnosed postoperative PedaPical
radiolucencies in 3% of cases where the root fillings
ended short of the apex, and in 18% when calals were
overfilled.
Prognosis
Data on the outcome of non-surgical retreatment are
most often available as part of general endodontic
follow-up studies (for a review, see Ref. 13). RePorted
successrates in these investigations vary between 567o
and 88%. The issue has been addressed specifically
only by a few authors. After 2 years of observation,
Bergenhohz et aI. (3) found, in a prospective study, com-
plete resolution of apical radiolucencies in 48% of 234
retreated roots. Decreased size of the radiolucency was
observed in a further 30%. After a follow-up period of 5
years, Sundqvist ef al. (34) reported complete healing in
74"k of 54 retreated teeth. In this study microbiological
sarnples were obtained at the time of root filling and
'positive' casesdid heaLingtake place
only in two of six
(33%). Three of the 'failed' canals did contain E. faecalis
and in one canal A. israelii was detected. The samples
'negative' in 44 casesand 35 of these showed radio-
were
graphic signs of healing (80%).
Based on the available data, the prognosis of retreat-
ment seems not to be as good as that of initial treatment.
However, three out of four cases retreated non-
surgically might be expected to heal. When retreatment
is conducted for preventive reasons, and Procedures are
kept within the canal, failures might be anticiPated in
very few cases.
References
1. Allen RK, Newton CW Brown CE. A statistical aralysis of
surgical and non surgicâl rcbeatment cases.-J.Efidodoflf.
"15:
7989; 261-6.
2. Barbosa SV Burkhard DH, SPangberg LSV Cytotoxic
effects of gutta-percha solvenrs.]. Endodont 1994;20: Â.
3. Bergenholtz G, Lekholm U, Milthon R, Heden G, Odesjô
B, Engstrôm B. Reheatment of endodontic fillings. Scad
I. Dent. Res.1979;87. 217 23.
4. Bergenholtz G, Lekholm U, Milthon R, Engstrôm B. Influ-
ence of apical ovednsttumentation and overfilling on
re-treated root canals.l. Endodollt.7979;5: 310-14.
3r0 Clinicalmethodologies
Bramante CM, Betti LV Efficacy of Quantec rotary instru-
ments for gutta-percha removal. Irt. Endotlont.1.2000;33:
Bystrôm A, Claesson R, Sundqvist G. The antibacterial
effect of camphorated paramonochlorophenol, camphor-
ated phenol and calcium hydroxide in the treatment of
infected root canals. Endodont. Dent.'11a ru o1. 1985;1:
170-5.
7. Carr GB. Microscopes in endodontics. /. Calif. Dent. Assoc.
199L 2Ot 55 61,.
Cohen AG. The efficiency of different solvents used in
the retreatment of paste-filled root canals. Mastet Thesis,
Boston University, 1986.
9. Engstrôm B. The significance of enterococci in root canal
treatment. Odontol. Re.,V1,964;1,5:87-706.
Fdedman S. Treatment outcome and prognosis of
endodontic therapy. In EssentialEndodontology(@tstavik
D, Pitt-Ford T, eds). London: Blackwell Science.
Haapasalo M, Ranta H, Ranta K. Fâcultative Gram-
negative enteric rods in persistent periapical inlectior-rs.
Actd Odontol. Scand.1,983;41,:19-22.
Happonen R-P Pedapical actinomycosis: a follow-up
study of 16 surgically treated cases.Elldodont.Dent. Trau-
'1986;
ru ol. 2t 205-9.
Hepworth MJ, Friedman S. Treatment outcome of surgi-
cal and nonsurgical management of endodontic failures.
I. Can. Dent. Assoc.1997 63l.364 71.
1.4. Ibarrola JL, Knowles KI, Ludlow MO. Rekievability of
Thermafil plastic cores using organic solveîTs.]. Endodont.
1993; 19: 417-19.
Jasper EA. Root canal therâpy in modern dentisfry. D?rt.
Cosmos1933; 75. 823-9 .
Kaufman A, Henig EF The microbiologic approach in
endodontics. Otûl Sur&. 1976; 42t 870-1,6.
17. Kvist T, Reit C. Results of endodontic retreatmenl a ran-
domized clinical study comparing surgical and nonsurgi-
cal procedures. .l. Endodont.1,999;25:.874-17.
Lemon RR. Non surgical repair of peiforation defects.
Internal matdx concept. Derf. Cltt. N. A111.199L 36:
439-57.
19. Lrltle JA. Klebsiella pneumoniae rn endodontic therapy. O/al
Sutg. 1975;40:278 81.
Lovdahl PE, Gutmanrl JL. Problems in nonsurgical rooi
canal rebeatment. 7n ProblemSoh)ingin kldodontics (2rrd
edn) (Gutmann JL, Dumsha TC, Lovdahl PE, Hovland EJ,
eds). St Louis: Mosby-Year Book, 1992.
2't. Machtou P, Cohen A, Sarfati P Post removal pdor to
retreatment. /. Endodont.798, 1,5.5524.
McDonald MN, Vire DE. CNoroform in the endodontic
operaLory./. Fndodonl.laq2: l& 301 3.
Molander A, Reit C, Dahlén C, Kvist T. Microbiologicâl
status of rcot filled teeth with apical pedodontitis. Irr.
Endodont.J. L998;31,:1, 7.
Mô[er ÀJR. Microbiological examination of root canals
and periapical tissues of hunan teet}:r. Odontol. Tidskr.
796O 74.
Zrstavik D, Haapasalo M. Disinfection by endodontic irri-
gants and dressings of experimentally infected dentinal
nlbrJles.Endodont.Dent. Trûun1atol.1990;6t 142-9.
Peciuliene V Reynaud AH, Balciuniene I, Haapasalo M.
Isolation of yeasts and enteric bacteria in ioot filled teeth
with chronic apical periodontitis. -hrt.Ërzdodonf. l.2OO1,;34:
429-34.
27. Peters O, Barbakow F Apical transportation rcvisited or
'Where did the file go?' h1t. Endodont. 1999;
l. 32: 131-7.
Ruddle CJ. Nonsurgical endodontic retreatment. /. Calrf
Dent. Assoc.1997;25:769 99.
29. Safavi E, Spângberg L, Langeland K. Root canal de11tinal
tubule disinfection. ,l. Endodont.1990;16 207 1,0.
30. Se BH, Piskin B, Demirci D. Observaton o{ bacteriâ and
fungi in infected root canals and dentinal tubules by SEM.
Endodont.Dent. Traunûtol. 799, 1116-9.
31. Sigurdsson A, Stancill R, Madison S. Intracanal placement
of Ca(OH).: a comparison of techniques.,f.Et1dodol1t. 1992;
'18:
367J0.
Sjôgren U, Happonen R-l Kahnberg K-E, Sundqvist C.
Survival of Arachnia propionicain periapical tissue. lri.
Endodont.J. 1988;2'l: 277-82.
Stabholtz A, Fdedman S, Tamse A. Endodontic failurcs
a]1d re-btleatment. In Pathu)aysof the Pulp (6th edrr) (Cohen
S, Bums RC, eds). St Louis: Mosby Company, 1994.
Sundqvist G, Figdor D, Persson S. Microbiologic findings
of teeth 'ith failed endodontic treatment and the outcome
of conservative re-treatment. Orul Surg.1998; 85: 86-93.
Sundqvist G, Reuterving C-O. Isolation of Actinomllces
israelii from periapicâl lesion. /. End.odont.1980;6t 602-4.
Tidwell E, Witherspoon DE, Gutmann JL, Vreeland DL,
Sweet PM. Thermal sensitivity of endodontically treated
teeIh.lnl. Lndodont.J. lqqqj 32 138 4c.
37. Torabinejad M, Chivian N. Clinical applications of
Mineral TrioxideAggrcEate. ]. Etldodoi'tt.1,999;25: 197-205.
Waltimo TMT, Sirén EK, Orstavik D, Haapasalo MPP Sus-
ceptibility of oral Cardid,i speciesto calcium hydroxide in
vitto. Int. Endodont.l. 1999;32: 94 8.
39. Wilcox LR, Krell KV Madison S, Rittman B. Endodontic
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'l3t
453 1.
Wilcox LR, Swift ML. Endodontic ietrcâtment in small
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Chapter20
Surgicalretreatment
PeterVelaart
lntroduction
Micro-organisms Iodging in root filled canals may cause
endodontic heatment failures. In order to eradicate
the microbes in such cases,the root canal system has to
be renegotiated and retreated. If the canals are poorly
filled and fairly easy to access,an orthograde route of
re-entry generally is recommended (Chapter 19).
However, in many cases non-surgical retreatment may
not be feasible from technical as well as financial
aspects. Furthermore, failures rnight be caused by
factors located outside the root canal, such as micro-
organisms colonizing the periapical tissues, cysts and
foreign-body reactions (Chapter 9). In such cases a
surgical approach to retreatment may be considered
(Fig.20.1).
Although extensively debated over the years, there
is little evidence to suggest that cysts are unable to heal
following conventional endodontic therapy. But Nair
(45) has drawn attention to the fact that some radicular
cyst cavities do not have a direct connection with the
root canal space. These so-called true radicular cysts
are thought to be autonomous processesand are there-
fore not likely to respond to conventional therapy. From
a clinical point of view, however, there are no means
by which the existence of such a pathological condition
can be determined. Consequently, all radiolucent lesions
associated with non-vital pulps, whether cyst or not,
should be seen as treatable by conventional means
and be subjected to surgery only if healing cannot be
attained. In surgical endodontic retreatment the pro-
cedural objectives are to expose the root tip and the
periapical tissues by means of raising a mucoperiostal
flap and, if necessary,cutting through the cortical bone.
The treatment aims to combat a potential intracanal
infection (usually the root tip is cut and the apical part
of the canal is inshumented and sealed). Core concept
20.1 summadzes the typical indications for surgical
retreatment.
Generaloutlineof
the procedure (Coreconcept20.2)
Following local anesthesia (step 1) a mucoperiostal flap
is raised (step 2). If the periapical tissue responsehas not
perforated the cortical bone plate, bone has to be
removed (step 3) to provide accessto the root tiP. The
soft-tissue lesion is then curetted (step 4) and the root tiP
is cut (step 5). Usually a root end preparation is made
(step 6) and a filling (retrofill) is placed (step 7). The sur-
gical procedure is finished with meticulous cleaning of
the would area and repositioning and suturing of the
flap (step 8).
Locala nesthesia
Proper pain control is required to perform the surgical
procedure and to achieve optimal Postsurgical comfort.
Two kinds of medicarnents are used: anesthetics and
analgesics.
Choice of anesthetic &gent
Anesthetic agents are most effective in a non-ionized
form within a pH range near 7.4. In this state the drug
can easily penetrate the nerve mernbranes and displace
the calcium ions at the membrane recePtor sites. The
sodium channels are then blocked ald upon nerve
stimulation the membrane will remain in a polarized
state. In acutely irLflamed tissue the pH is lowered. In
such an environment the anesthetic may remain in
ionized form. The result can be lesser penehation of the
drug, leading to inadequate anesthesia.This is one pos-
sible explanation as to the deficient pain control some-
times experienced when operating on acutely inflamed
tissue. Endodontic surgeries should therefore notbe Per-
formed in such instances, if possible. There are several
anesthetics suitable for surgical pain control. Because
allergic reactions to anesthetic drugs occur mainly to
ester-based agents (such as procaine) (24), anesthetics
311
 Clinical
methodologies
Fig.20.1 Clinicâl photograph showing access to theroottipsof a lower achieved only if the anesthetic has reached the tissue.
second molarin anendodontic surgical procedure, whereretrograde
mentâtion androotfillingwerecarried out.(Couriesy of DrG.Bergenholtz.) thetic must be administered also to the surgical
based on amide groups are preferred. Good and pro-
found anesthesia can generally be obtained with Arti-
cain, Lidocain and Bupivacain.
Vasoconstictors
A vasoconstrictor is added to local anestheticsto reduce
the blood flow at the iniection site. This serves two
rmporranr PurPoses:
(1) To retain the agent longer in the tissue, thereby
extending the time for the anesthetic effect.
(2) To eniance hemostasis.
The reduced blood llow will also decreaseabsorption of
the anesthelicand minimi,/e syslemic toxic effeits.
The most widely used vasoconstrictor is epinephrine.
This sympathomimetic agent causesvasoconstdction by
stimulating specific membrane-bound receptors on the
vascular smooth-muscle cells. The pharmacological
action of epinephrine depends largely on the t'?e of
receptors present in the tissue. There are two types of
adrenergic receptors: alpha vasoconstrictive and beta
vasodilating receptors. Similar to mucosal and gingival
tissues, alpha-adrenergic receptors predominate in the
apical periodontium. Thus, upon its penehation to these
tissue sites, the effect of epinephrine will be contraction
of blood vessels.In skeletal muscles, on the other hand.
vessels are controlled by beta-adrenergic vasodilating
receptors (41). This means that injection of epinephrine
to muscle tissue will result in increased blood flow and
cause the opposite of the desired hemostatic effect (5).
For this reason,the anesthetic should be administered to
mucosal tissue only and close to the bone in the area in
focus for the operation.
Concentrations of vasoconstrictor amons anesthetic
s o l u t i o n s v a r y b e t \ a e e n1 : 5 0 0 0 0 a n d 1 r 2 0 0 0 0 0 T
higher the concentration, the better the hemostatic effect.
Mostwidely used is the concentration 1 : 100000-200000.
Although this concentration is adequate for non-surgical
needs (31), it will not produce sufficient hemostasis for
surgical procedures. For this purpose, at least 1 :80000
qr rather 1:50000 is recomrnended. It has been found
that the use of 1:50000 epinephrine results in good
visualization of the surgical site, reduced surgery time
and decreased postoperative bleedings and blood loss
(5). High concentrations of epinephrine may cause an
undesirable increased heart rate, cardiac contractility
and peripheral vascular resistance. These systemic
effects can be reduced by using several measures (see
Core concept 20.3).
It should be realized that sufficient hemostasis can be
instru- Therefore, on inferior alveolar nerve blocks the anes-
site to
obtain adequate hemostasis, even though blood flow
peripheral to such nerve blocks becomes reduced (29).
Flapraising
The successof any surgical procedure depends largely
upon the extent to which adequate access can be
obtained. Endodontic surgery first requires exposure of
the bone overlaying the tip of the root(s) and then the
root end(s) per se (Fiç.20.1). To accessthe bone, a full-
thickness flap must be raised. This means a soft-tissue
flap, which consists of gingival and mucosal tissue as
well as pedosteum. To mobilize the flap various modes
of incision can be selected,including horizontal incisions
(sulcular and submarginal) and vertical releasing
incisions.
It is critical that incisions and flap elevations are
carded out in a manner such that soft-tissue healing by
primary intention is facilitated. This is secured by:
. Complete and sharp incision of the tissues.
o Avoiding severing of the tissues during flap
elevation.
. Preventing drying of the tissue remnants on the root
surface during the procedure (seefurther below).
Flap designs
Triangularflap: a horizontal incision extending one tooth
distally and one tooth mesially to the involved area,
combined with only one vertical releasing incision (Fig.
20.2), forrns the triangular flap. The main advaltage of
this flap design is easy repositioning and minimal dis-
ruption of the vascular supply to the flap. It is indicated
for correction of rnarginally located processes such as
perforations, cervical root resorptions or resections of
very short roots. If it turns out that the access is too
. he limited, the tdangular flap can be converted easily to a
rectangular flap by placing an additional releasing inci-
 retreatment 3 13
Surgical

Coreconcept
20.1 Typical
indications
for surgical
retreatment
. A filefragmentthatcouldnotberemoved blocktherootcanal. a Grosslvoverinstrumented
and overfilledcanal.
Thetop{ightradiograph wastakenimmediatelypostoperatively
andthe bottomradiograph (Radi-
afterI yearshowshealing.
ographs courtesy
of DrI Kvist.)

Failedtreatment
in spiteof adequate rootfillingresults
in intra-
canaltreatment.
Persistenceof a Tistula.

o Apicalrootcanalsblocked
by ledge.

sion at the distal end of the horizontal incision (see and gentle surgical technique with proper wound man-
below). agement minimizes such esthetic disadvantages.

Rectangular flap: the rectangular flap is formed by a
horizontal incision with two vedical releasing incisions
(Fig. 20.3) and is the most frequently used flap in
endodontic surgery. The rectangular flap will give excel-
lent surgical access to the apical area in any region. In
esthetcally critical areas with prosthetic restorations
involving submarginally placed crown margins, a post-
operative sequel can result in recessiory leading to expo-
sure of the crown margins. Using a proper atraumatic
Submarginalflap according to Ochsenbein-Luebke: the sub-
marginal flap is formed by a scalloped horizontal sub-
marginal incision with two vertical releasing incisions
(Fig. 20.4). The submarginal flap is only to be used when
there is a broad attached gingiva and when the expected
apical lesion or surgical bony accesswill not involve the
incision rnargins. This flap design has the advantage of
presewing the marginal gingiva and does not expose tlrc
marginal crestal bone.
 Clinical
methodologies
Coreconcept20.2 Criticalstepsin surgicalretreatment
(l) Localanesthesia (2) Raising
a flap
(5) Rootendresection (6) Rootendpreparation
Except for the risk of massive loss of marginal tissue
due to a possible insufficient blood supply to the urre-
flected gingival tissue (see above), the risk of scardng is
another disadvartage of this flap design. This is because
the flap tends to shrink during surgery resulting in
tension on the flap d uring and aïter suturing.
Incisions
Sulcular incision: the scalpel size has to be small enough
to allow free movement of the blade within the sulcus
and to avoid cutting into the gingiva (Figs 20.5 and 20.6).
The scalpel should be kept in constant contact with the
tooth. Even so, the incision will sever sulcular epithe-
lium and fibers of the gingival attachment, leaving
epithelium and connective tissue at the root surface
(Fig. 20.6). These tissue reûrnants are delicate and easily
injured, which can result in impaired healing (17), and
should not be allowed to dry out because they facilitate
epithelial and gingival reattachment. Interproximally
the tissue should be dissected in the middle of the
papilla, to preserve its buccal and lingual aspects (Fig.
20.n.
Submarginal incision: l}:r:esubmarginal incision to raise
an Ochsenbein-Luebke flap is performed within the
attached gingiva and should be at a level where the
(3) Boneremoval (4) SoTt-tissue
lesioncurettage
(7) Retrofill (8) Suturing
incision cuts well into the crestal bone (39). The cutting
action is a continuous firm stroke with the blade, which
separates the tissue all the way to the bone. For easy and
precise repositioning of the flap, the incision should not
be in a straight line, but scalloped and extending slighily
into the interproximal direction. Thus, the contour of the
incision should reflect the contour of the marginal
gingiva (Fig. 20.8c). The submarginal incision should be
at a level that is 2mm apical to the base of the sulcus (33)
in order not to risk subsequent necrosis and recession of
the unreflected marginal portion. To size up the width
of the attached gingiva, the pocket probing depth has to
be determined (Fig. 20.8a). The width of the attached
gingiva is then calculated on the basis of the distance
from the base of the sulcus ro l}:.e linea gi andiformis
(Fig. 20.8b).
In general, healing after this mode of incision is
favorable because there is sufficient blood supply from
vessels exiting at the crestal bone level and from
anastomosing vessels deriving from the papilla.
\44rere there are deep pockets, this type of incision is
contraindicated and a marginal incision should be per-
formed instead. The incision also should not be used
when there is danger of having the incision over the
bony defect, which increases the risk of postoperative
infection. Therefore, the selecton of this t!.'pe of incision
 Surgical
retreatment 315

Fig.20.2 (â)Triangular flaprequiresa sulcular

anci-
sion,usuallywith mesialplacement of the vertical
releasing
incision.
{b) Flâpreflected.

Fig,20.3 (â)Rectangular flapinvolves tlvo releasing

incisions
combined with a marginalsulcularincasion.
the releasing incisionsare placedat leâstone tooth
âwayfromthe toothto be operated on,exceptjn the
areaof the mentalforamen, whichshouldnot DesuD-
jectedto verticalincisions.
{b) tlap reflected.

LJ-
zontalincision
G00e0
Fig 20.4 An ochsenbein Luebke
withintheâttâched
flap is raisedby placinga scalloped
gingiva, reflecting
hori-
thegingivalandmucosal
tissues(39).tor verticâlincisiontthe sâmerulesapplyasfor the rectangular
flaps.

Coreconcept
20.3 Iniection
technique
Fig20.5 Sulculârincision
using
a microscalpel
blade.
Notetheblade enter-
Toreduce painandcardiovascular
effectsuponinjecting
an anes, ingintothegingivaltissue
owingto a smallrootdiâmeter
inthecervical
area
theticsolution
containing
epinephrine: of theroot.

(l) Aspirateto preventintravascular

administration.
(2) Injectat a slowpace.Speedshouldnot exceed 1-2ml per requires thorough treatment planning. The main advan-
minute. tage is that the original level of the epithelial attachment
(3) Anesthetizefirstwith halfthedoseof thesolutionat a con- can be maintained, which is not always the case with
centrationof1:100000 epinephrine.
Wait3 5minuntil initial the sulcular incision. This is an important esthetic
vasoconstriction
andthenuse1t50000epinephrine. consideration especially with full crowns, where healing
(4) Usea pulseoxymeter to monitorpulserate. after a sulcular incision can result in gingival recession
to such aJIextent that the crown margins become visible.

Verticnl inc|sions: one or two vertical incisions are

needed in an endodontic surgical procedure to allow
316 Clinicalmethodologies

sufficient exposure of the bone. The incision should
extend apically enough to prevent tension on the flap
during retraction. When cutting in the apical area the
blade often does not reach the bone owine to the thick-
ness of the mucosa, therefore a second stroke has to be
taken to separate completely the tissue through the
Perrosteum.
The vertical releasing incision is placed usually one
tooth laterally to the tooth to be operated on (Fig. 20.3).
An exception to this rule is the lower premolar region,
where a vertical cut can interfere with the nerve bundles
exiting from the mental foramen and cause temporary
or permanent paresthesia.In such casesthe vertical inci-
sion is placed one tooth mesial to the mental foramen.
In any case, it is important to determine radiographi-

Fig 20.6 l\4arginalincisionleâvessmâllamountsof gingivalconnective Fig. 20.7 Dissection of the buccâlpâpillawith a microscalpel.
Notecom-
tissueând epitheliumon the toothsurface,
whichshouldbe keptmoistand pletesepârâtion fromthe lingualportionof the papillaandthe preseruâtion
at the preoperative
vitalfor reattachment âttâchment
level. of the tissuein all its dimensions.

Fig 20.8 (a)l\4easuringthe pocketprobingdepthis necessary for calculation

of thewidthof the attachedgingivain a submarginal
incisionprocedure.(b)lhe
probeis heldon the buccâlsurfa€eof the gingivato visualize
the baseof the probingdepth.the attached gingivarepresents
the distânce
lrom the tip of the
probeto the lineâgirlandiformis
(aflows).(c)Thelinerepresents the localionfor a submaroinalincision.

Fig.20.9 Coûectverticâlincisionpreserving
the bodyof the papilla.
Fig.20.10 Raising
a flapfromthereleasing
incision
witha distal-coronal-
directed
motion,
underminingtheperiosteum.
cally the position ol the tordmen pïioï fo surgery if if is
going to be exposed by the flap.
The placement of the vertical incision should be such
that the integdty of the papilla is maintained. Figure 20.9
illustrates the correct paramediar releasing incision to
be used. Incisions midcrown and incisions that split the
papilla should be avoided because they may lead to
necrosis of a Iarge portion of the tissue and recessions.
FIap eleoation and retraction
AIter the incisiory lifting the tissue from the urlderlying
bone should raise the flap. In the process, the pedosteum
should not be perforated or tom. To optimize the healing
conditions, maintenance of an intact periosteum is
essential because it will protect the surgical cavity from
being in direct contact with the mucosal tissue, which
otherwise can enter the cavity and prevent complete
bone fill.
Flap elevation should begin ftom the releasing inci-
sion in an undermining action (Fig. 20.10).The elevating
instrument then should be directed toward the marginal
ridge. If the periostenm cannot be separated completely
from the crestal bone, the flap can be freed by dissecting
the unseparated tissue remnants with a scalpel.
retreatment
Surgical 317
Fig.20.11 CutoI a smallgrooveintheboneatthebaseot theflapseNes
âsâ restfortheperiosteal givingtheassistant
elevator, a safeposition
forit
sothatit willnotslipândpossibly
crushthetissues.
Once the flap has been rehacted, a small groove
should be prepared in the bone with a small round bur.
This groove serves as a rest for the retractor, to prevent
crushing of the flap during the surgery fig. 20.11).
Bone removal
Once the flap has been retracted and held in place, bone
usually needs to be removed to uncover the soft-tissue
lesion and the apical area of the tooth. A sufficient
amount of bone tissue must be eliminated to gain proper
access.
It is important that the osseous tissue is managed with
caution to prevent postoperative pain and to enhance
healing. Heat generation is damaging and should be
monitored by using rotating burs under light shaving
motions while irrigating with copious amounts of sterile
saline (14). Supplementary saline irrigation must be
used when cutting deep to uncover, for example, palatal
or lingual roots. Excessive pressure during drilLing
should be avoided at all times. The bone drill, in addi-
tioo should be sharp and clean (6). Diamond burs are
inefficient and should not be used (38).
Curettageof the soft-tissuelesion
Becausethe soft-tissue lesion most often represents an
hflammatory response to a root canal infection and/or
to extruded root filling material, removal of this tissue
is not essentialpei"sebut it needs to be taken out for tech-
nical reasons to allow visibility and accessibility to the
root tip for the management of the root canal system
 Clinical
methodologies

that, even though numbness is achieved soon after the

Advancedconcept 20.1 lmportance
of complete injection, sufficient vasoconstriction takes several
removalof the soft-tissue
lesion minutes to develop.

overtheyearsit hasbeendebated extensively whether or notthe

Prcper operction technique:proper handling of the soft
removal ofthesoft-tissue lesionisa critical stepinthesurgical pro-
tissue minirnizes bleeding. Remember that most vessels
cedure.lt hasbeenheldthatthe lesionrepresents a pathological
process andtherefore shouldberemoved in its enlirety.
Giventhe run parallel to the long axis of the teeth, therefore the
fâctthatthesoft-tissue lesionactually is a hosttissueresponse to releasing incisiory for example, should be placed along
irritants
associated withthetooth,mostoftento a rootcanalinfec- the long axis of the root to limit the number of blood
tion,complete curettage shouldnotbenecessary Infact in a study vessels that may be severed. Furthermore, gentle and
comparing complete andincomplete removal of periradiculartissues atraumatic elevation of the full-thickness flap prevents
duringsurgery nodifference in clinical
outcome wasfoundinterms pedoration and tearing of the pedosteum. This measure
ofperiradicularhealing at clini€alfollow-up (37).ltistherefore likely retains the microvasculature within the body of the flap
thatanyinflamed tissueleft behindwill be incorporated intothe and thus further reduces the risk of bleeding.
newgranulation tissue thatwillformaspartofthehealing process.
Evenleavingsomeepithelial remnants shouldnotjeopardize the
Suctioning: suctioning controls localized bleedings.
healingprocess. lt hasbeenproposed thatas longasthe irritants
of therootcanalsystem areeliminated, thehostt defense mecha- In ured vessels will normally constrict at the first stage
nismswilldeslroy andeliminate proliferated epithelialcells(56).An of the hemostatic cascade,eventually to be blocked by a
exception to thisviewisthecasewherebacteria arelocated within fibrin clot. Thus, bleeding ceasesspontaneously with time.
the lesionper se, e.g. AdinonJaet (Chapter9). Thesemicro-
organisms appear in nestsandcanbeobserved macroscopically as ObstrLlctionby mechanicnlmeats: slig}l.thnmmeringof tlrLe
yellowgranules.Thut lesions ofthisnaturemaybesustained bythe bone with a dull object can mechanically obstruct local-
organisms per5eandshouldbecuretted carefully. Curettage of the ized hemorrhage from a vessel in the bone. By this
soft-tissuelesiondimjnishes bleeding. Also,fromthisperspective it measure, the bony space for the vessel is occluded. The
is essentialloremove asmuchofthesoft-tissue Drocessto enhance procedure is most effective on bleedings from the corti-
themanagement oTtherootendfor preparation andfilling.
cal bone, whereas in loose cancellous bone the effect is
less predictable.
Loading the bottom of the bone cavity with a material
that mechanically obstructs the openings of the cancel-
(Advanced concept 20.1),Therefore, curettage to remove lous bone is useful. Two options are available',bonewax
the soft-tissue lesion has to be performed. This task is and calcium su\te. Bor.e wax has been used for this
greatly facilitated by the use of sharp curettes, because purpose for many years (54). It has no effect on the clot-
fibrous tissue in the pedphery of the lesion often is dif- ting and essentially has only a blocking effect. Note that
ficult to detach. bone wax causes foreign body reaction if left in the
Sometimes the lesion consists of a radicular cyst. By cavity after svgery (27), therefore it has to be curetted
careful dissection the cyst capsule can be released from out completely.
the adjacent bone and rernoved in its entirety. If the Calcium sulfate in sterile water to a thick mix (48)
blood supply of the adjacent tooth (teeth) or other vital should be inserted by pressing the matedal against the
structures, such as neurovascular bundles, is endan- cavity walls with a wet cotton pellet. The matedal sets
gered, complete removal of the soft-tissue lesion should within minutes. Calcium sulfate is used extensively in
n^l h .++ôm^+ôÀ general surgery becauseit is biocompatible (23), resorbs
completely and is reported to be osteoinductive (9).
M anagement of b I eedings
Hemostasis during endodontic surgery is essential to Electrocoagulation:electrocoagulation for hemorrhage
ensure the successful management of the root end. control should use bipolar units. The monopolar units
Hemorrhage control is not only required for visibiLity frequently used in dental practice for exposing prepara-
and assessmentof the root structure but is also neces- tion margins before impression are too traumatic owing
sary to allow insertion and setting of the retrograde root to the massive heat that these units generate. Bipolar
filling material in the absenceof moisture. units where the electric current flows only between the
Several means, described below, can be undertaken to two electrodes (usually the branches of ihe pliers) are
control bleedings. much less damaging to the collateral tissues. When
monopolar was compared with bipolar electrosurgery
Properlocalanesthesrn;hemorrhage reduction is achieved significantly more damage and elevation in lateral tissue
by local anesthesiausing a sufficient concentration of the temperature was observed (34). For a bipolar coagula-
vasoconstrictor (see above). It should be recognized tion the vessel needs to be grabbed to be effective,

otherwise this method is ineffective. Frequently the
cut vessels contract and calnot be touched. In such
instances,other hemostatic measures should be applied.
Chemicals:small pieces of gauze fitting the bone cavity
and saturated with vasoconstrictive agent, e.g. epineph-
rlne, effectively control hemorrhage. The systemic effects
are usually insignificant owing to the immediate vaso-
constriction that is promoted (30). However, the amoult
of epinephrine given in conjunction with the local anes-
thetic should be assessedand if the maximum dose is
reached then other means of hemorrhage control should
be considered.
Ferric sulfatein a concentration of 207o,also known as
Monsel's solution, reacts with blood proteins to form a
plug that occludes the capillary orifices. The pH is low
and the chemical is clearly toxic, which will therefore
severely delay healing and in some casescause abscess
formation if left after surgery (36). The dark stain often
formed represents agglutinated blood on the bone
surface and has to be curetted thoroughly and removed
by saline rinses. The bone surface maybe freshened with
a round drill to remove any remaining coagulated mat-
erial. Jeansonneet al. (28) reported that healing is normal
with only a mild foreign-body reaction provided that the
surgical wound is thoroughly cleansed prior to wound
closure.
Resorbableagents: collagen-basedhemostatic materials
applied directly to the bleeding area under pressure
result in hemostasis within a few minutes. Theù poten-
tial use in periapical surgery has been demonstrated by
Haasch ef aI. (1.6\.If left in the osseous defects there is
minimal interference with the wound healing process
and the foreign-body reaction is minimal (10).
Surgicel is a substance for hemorrhage confol pre-
pared by the oxidation of oxycellulose. Initially it serves
as a barrier and then transforms to a sticky mass that
will act as an artificial coagulum. The material should be
removed from the surgical site after completion of the
operation becauseit can causeforeign-body reaction and
impair osseous regeneration (27).
Gelfoam consists of gelatin-based sponges, which
promote the disintegration of platelets and cause subse-
quent release of thromboplastine. This in turn stimulates
the formation of thrombin in the sponge spaces (30). ff
gelfoam is left in situ, it will slow down healing initially
(4) but after a few months there are no negative effects
(47).
Root end resection
Following completion of the surgical accessto the root
end area, the tip of the root(s) normally has to be cut off
at around 2-3mm (15). This procedure is known under
Surgical
retreatment 319
forrootendresection.
Fig.20.12 Principle Excessive penetra-
bevelallows
tionof bacterial
elementsthrough dentinal
tubules to theresection
surface
(*).ldealangulation
issquareto thelongaxisof theroot(bottom).
different terms, of which apicectomy or apicoectomy are
the most common. The rationales for this measure are:
(1) To provide convenient accessto the root canal(s)for
the apical instrumentation (seebelow).
(2) To remove any bacterial organisms lodged in acces-
sory and main canals of al apex delta and/or on
the surface of the root tip.
The angle of the cut surface should be as square as pos-
sible to the long axis of the root to reduce the number of
exposed dentinal tubules (Fig. 20.12). Dentinal tubules
may serve as pathways for the release of bacterial ele-
ments from the infected root canal, especially if the root
end filling is short (13). However, occasionally a slight
bevel is needed to allow proper accessand visual obser-
vation of the resected tip (Advanced concept 20.2). Buc-
cally inclined roots do not need a bevel, whereas roots
inclined in the opposite direction and roots under a thick
bone plate need bevelling. When there is a post in the
tooth, the resection should not be performed to the base
ofitbecause the seal of the luting cement maybe broken.
Following resection, the cut surface should be
inspected for the presence of apical ramifications,
isthmus formation and possible fracture lines. The
inspection needs to be carried out with the use of magni-
fication and if necessarywith micromirrors (Fig. 20.13).
Root end preparation
The root canal of the resectedroot tip needs to be cleaned
and shaped to accommodate a retrograde root filling
according to the same rationales as for conventional
root canal therapy (Clinical procedure 20.1). Thus, the
primary objective of this measure is to exclude the (oot
320 Clinical
methodologies

Fig.20.14 Diamond-coâted
ultrasonic
tip.

Fig,20.13 lVicromirror ândprepârâtion.

viewfollowingrootendresection Clinicalprocedure20.1 Retrograde
hand
file preparation
A procedure wherethecomplete shaped
rootcanalis debrided, and
filledlromtheapicalendwasoriginally proposedbyNygaard-ostby
(46)andlaterclinically
rriedandevaluated byReitandHirsch(50).
Advancedconcept 20.2 Bevelingof the
Following a smallresectionof theroottip,thecanalis cleaned
and
root end
enlarged with Hedstrôm filesheldin a hemostat.Thecanalis irri-
garedwith0.5%sodium hypochloriteandsealed withcoldlaterally
Gilheanyet ai.(13)havedemonstrated thalthereis rtootherbasis
condensed gutta-percha.
or injectable
forbeveling therootendinendodontic surgery thanto achievecon-
venientaccess to the rootcanalsystem. In fact,an acutebevelin
combination with an inadequate rootendpreparation andfilling
carriestheriskforpenetrationof bacteria I elements alongthedenti-
nal tubulesor the rootendfilling,or both,to the resected root
surface.
/n vitro,theseinvestigatorsevaluated, bythehydrauliccon- Advanced
concept
20.3 lsthmuses
du€tance method, the degreeof apicalleakage as a functionof
variousdepths of retrograde
fillingsanddifferent cuttingangles (0, lhe anatomic complexityof therootcanalsystem hasbeenknown
30and45"to thelongaxisof theroot).Findings werea significant for years(20),bul it wasnot untilrecentlythatthe importanceol
increaseoI leakage with increased angulation and significantly isthmuses intheendodontic surgeryofcertainteethwasrecognized
decreased leakage with increasing depthof the retrograde filling, (7).HsuandKim(25)studied theresectedsurfaces
of different
teeth
suggesting thatboththepermeability oftheresected apicaldentine in thehumandentition andobserved thatin general
thechance of
andthe lengthof the retrograde fillingaresignificant factorsfor isthmus formation is higherwhenmoreof therootis resected.With
whether or nottheorocedure will succeed. theaidof proper magniTication, isthmus
bothanatomicalstructures,
andramifications canbedetected andeffectively
treated bytheuse
of ultrasonicinstrumentation (seeFig.20,15),

canal as a source of microbial exposure of t}re organism.

The cleaning procedure can be carried out with properly
angled ultrasonic root end tips (Fig. 20.14) arrd with
hand-held root canal files or both. Preparation with a
small round bur in a micro-handpiece was used for
years. Often cavities that are too large and root canals
that are insufficiently cleaned resulted ftom this tech-
nique. Also, the cavity frequently became extended to
the palatal side of the root ajrd in certain cases even per-
forations occurred. In small and fine roots and very
frequently in fused roots, forming an isthmus between
them (see Fig. 20.15),this techrique is quite unsuitable
becausethe diameter of the smallestbur size may exceed
the width of the root (Advanced concept 20.3).
ln recent years the use of ultrasonic devices has led
to a significant improvement of the apical instrumenta-

Fig.20.15 (a)Thetip of a resected upperpremolar gutta-percha
displâys
line(afiowheads)- an isthmus-barelyvisiblein 25x magnification.
thê firstsurgical
treatment.(b)Ihe cleanedretrograde
preparation
tion in endodontic surgery Richman (51) in 1957 used
ultrasonically powered chisels to remove bone and to
resect teeth. The more recent development of retro-tiPs
in combination with the use of the surgical microscoPe
has not only offset many of the drawbacks from the
preparation with rotary instruments but also made it
possible to predict the sulgical treatments of virtually all
teeth.
The ultrasonic energy puts the tip into vibration,
which will remove both hard- and soft-tissue elements
in the root canal, including root filling material. A light
touch has to be applied, because tlrc vibration wave is
only effective when the tp is not pressed to the surface
during its operation. The methodology offers the fol-
lowing advantages:
(1) An ultrasonic tip is smaller and more deLicate than
a round bur in a micro-handpiece.
(2) About 3-4mm of vertcal space in the root can be
instrumented.
(3) Preparation can be performed at the long axis of
the tooth afrrd thus can follow the uue path of it,
thereby avoiding perforations.
Studies have shown that ultrasonic preparation is suPe-
dor to conventional preparation with a round bur. The
ultrasonic preparation will result in clearer, more paral-
lel and deeper preparations (62). The drawback of ultra-
sonics is the reported risk of microcracks and fractures
(1, 35). The use of ultrasonically energized file tips has
reduced the fracture risk, Powering the files requires
much lower energy than for the stiffer root-end tps.
retreatment
Surgical
in the buccalandpalatâlcânals. areahaveâ line
Ihe fusedrootsin the connêcting
Failureto diagnoseandtreatthisanatomical ledto pêrsistence
structure of symptomsafter
with the isthmusareato befilled.
Files furthermore are resilient when tilted during the
preparatioru which mûrimizes ihe wedging forces. An
additional advantage of the use of prebend files,
commonly used for orthograde inshumentation, is the
improved cleaning/shaping and extended PreParation
turther up the canal (61).
Retrofill
The goal of the retrograde filling is to seal the prepared
cavity to prevent leakage of tissue fluid to the remain-
der of the root canal space and the exchange of bacterial
elements that may result ftom such leakage. The signifi-
cance of the retrograde root filling for a successful
outcome has been demonstrated in numerous clinical
follow-up studies (12), therefore an important feature of
a retrograde root filling is to hermetically seal the root
canal space. Furthermore, because the surface of the
filling can be quite large, e.g. following cleaning of
isthmuses, the material should not vanish by disinte-
gration in tissue fluids over time. Other important
requirements are biological comPatibility and that the
matedal interferes only minimally with the wound
healing process.
Ideally a retrograde root filling should allow new
formation of cementum on its surface into which peri-
odontal ligament fibers can insert. Such a tissue resPonse
should ensure minimal dissolution of the material over
time and thus enhance l-helon8-term prognosis.
Various retrograde filling materials have been
employed over the years. Amalgam has enjoyed great
 Clinical
methodologies

acceptance (12) but is cuuently losing popularity

because:
(1) Its sealing ability is questionable (26).
(2) It is difficult to handle during the surgical pro-
cedure and amalgam remnants may be left behind
in the sur8ical cavity.
(3) It corrodes, which can lead to disintegration and
release of metal ions into the surrounding tissues
@2\.
(4) Discoloration and tattoos of the gingiva or mucosa
may ensue in visible areas, causing non-esthetic
disfigurations.
(5) It contains mercury, which is why amalgam is
banned for clinical use in several countries.
The most salient problem with amalgam as a retrograde
filling material is the poor clinical outcome obtained in
several clinical follow-up studies with this material (11, 8). Fig.20.16 (â) Retrograde fillingwith resincompositeof an upperincisor
Alternatives to amalgam are glass ionomer cements, that hadextensiveapicalrootresoFtion.Healing wasuneventful exceptthat
resin composites in combination with dentine bonding off fromthe root.(b)Complete
the crownlaterfrâctured bonefill at about19
(26, 52) and mineral trioxide aggregate (57). Glass monthsof follow-up.(Courtesy of Dr G.Bergenholtz.)
ionomers and composites seal the cavity quite well but
are technique and moisture sensitive (49).
b). If properly managed, the healing potential is excel-
Excellent experimental (3) and clinical (8) results have
been obtained with zinc oxide-eugenol (ZOE)-based
lent(53).
cements. The handling of these retrograde filling mat-
erials is good but their biolo#cal compatibility should Flapclosureand suturing
be questioned. Releaseof eugenol causestoxic reactions
Repositioning of the soft tissue to its original position,
and will prevent the development of a biological seal at
with t}re wound edges closely approximated by careful
the root end. The toxicity of eugenol depends on the
suturing, is normally sufficient for rapid heaLing.
amount of free eugenol in the cement (18). It can be
Although the techniques for suturing can be variable, in
reduced if the cement is mixed to a very dry consistency,
endodontic surgery usually single sutures are applied to
leaving little lree eugenol in the mix, which also
hold the flap in place during the initial heaLing phase.
improves its handling. The ZOE-based cements set
The sutures are placed in each protmal space and at the
rapidly when exposed to moisture after condensation.
vertical releasing incisions.
The beveled root surface can be polished in a few
Atraumatic needles should be used. Select sutures in
minutes, and any excess filling material can be removed
sizes 6/0 and smaller Although fine, the needle should
ftom the root end surface.
still be rigid and have a 3/8 circle with sharp pointed
Another retrogaade filling material with clinical
triangular cross-section. The needle length can be a
potential is an MTA (mineral trioxide aggregate) (57-60).
problem in papilla closure, because small suture sizes
The hydrophilic powder is mixed with water to a
have rather shod needles. The needle leneth for a com-
creamy consistency,which sets to a hard mass. It seals
Fortableinterproximal suture should be ai ledst l2 mm.
well, it is reasonably biocompatible and, owing to its
The suture material should be non-resorbable because
hydrophilic properties, is probably the best material to
the irritation is considerably less than with a resorbable
use when moisture control is precarious. However, the
suture material. They should have a smooth coating or
material is difficult to handle becauseof its consistency.
be monofilamentous in sizes 7/0 and smaller. If wourd
Several authors (55, 13) have pointed out the potential
healing is uneventful, sutures can usually be removed
pathway for leakage ofbacterial elements at the resected
within 3 days, at which time an epithelial lining has
root end along the dentinal tubules. Sealing the entire
developed.
beveled surface with dentine bonding was therefore pro-
The wound healing process after an endodontic sur-
posed and introduced by Rud ef al. (52). The method
gical procedure consists of:
includes preparing a slight concavity at the root end and
applying a bonding agent, which is followed by the . Clotting and inflammation.
application of a chemically cured composite (Fig. 20.16a, o Epithelial healing.

o Connective tissue healing.
. Maturation and remodeling of the soft and hard
tissues.
These stages are not distinctly separated from each
other They overlap considerably aJrldtake place almost
simultaneously. Becausethe original incision disrupted
blood vessels,hemostasis has to take place first. Vascu-
lar and tissue injury release humoral and cellular
rnediators that cause a rather complex event of clot for-
mation. The clot connects the wound edges and forms a
pathway for the migration of inflarnmatory and repair-
ing cells. If hemostasis is not complete, blood continues
to flow into the wound site and a hematoma may
develop. This will delay healing considerably and the
coagulum must firstbe resorbed before connective tissue
healing can proceed (21). Applying pressure with soft
gauze to the flap for about smin after repositioning and
suturing can reduce clot and hematoma formation and
thereby enhance the healing process.
Under optimal conditions the maturation and re-
modeling phase of both soft and hard tissue may begin
within 5-7 days after surgery The first step is the for-
mation of an epithelial barrier to protect the underlying
connective tissue from irdtants of the oral cavity. Sutures
can be removed as soon as the epithelial lining has
formed, which usually is within 3 days.
Pain control after surgery
The use of an atraumatic operation technique will not
only reduce the amount of swelling and enhance the
healing processbut also lessenpostoperative discomJort
and pain. ln addition to the application of a cold com-
press to the surgical site to reduce swelling, analgesics
with swelling-reducing properties should be prescribed
and a dose taken pdor to the cessation of the anesthetic
effect. Different drugs have various degrees of analgesic
tig.20.17 Successfuloutcome ofan endodontic procedure
surgery
operâtively;
{c) 1-yearfollow-upradiogrâph
with complete
bonefill in the previous
Surgical
retreatment
a]ld anti-inflammatory effect. Pain perception is elevated
in the presence of prostaglandins and an analgesic that
slows down the synthesis of prostaglandins will reduce
the excitabiliiy of the pain receptors to normal levels at
the same time as providing pain relief. Inhibition of
prostaglandin slnthesis will also produce an antipNo-
gistic effect.
Bone healing
It should be understood that complete bone healing only
takes place if the etiology for the inflamrnatory lesion
that led to the surgical procedure is eliminated. If not,
arr inflammatory lesion will persist that may present
itself as a persistent radiolucent bone lesion or recurring
swelLilrtg or fistulous tract,or both.
In proper healing, the missing structures, bone and
cementum will regenerate and within months to a year
show up as complete fill of bone in the previous surgi-
cal cavity (Fig. 20.17\.
In the presence of a defect extending from the buccal
to the oral side, bony refill might not take place owing
to invasion of cells, derived from mucogingival connec-
tive tissue. In such casesprotective membranes may be
used. lncomplete bony healing results in scar tissue for-
mation (43), which is not considered as a failure (Fig.
20.18).
Prognosis
Information on the outcome of surgical retreatment is
abundant. Reported success rates vary between 30%
and 90%. Varying inclusion cdteria, length of follow-up
periods, criteria for evaluation and observer variation
render generalized conclusions difficult. Howevet there
seems to be no systematic outcome difference between
ofan uppersecondpremolar:(a)preoperative
radiograph;{b)râdiogrâph post-
immediately
surgerydefect.(Courtesy
of DrTomasKvist.)
 Clinical
methodologies

Coreconcept of postsurgical
20.4 Scheduling
follow-ups
healing
a 3-5 dayrto checksoft'tissue andremove sutures.
. 6 nontht-lyear to checkextentof bonefill or clinicalsigns
inlection.
of Dersistinq

Core concept 20.4 summadzes the scheduling of Post-

surgical follow-ups.
Among factors that might influence the healing
results, the quaLity of the root filling seal seems to be the
most important. Several authors have emphasized that
the presence of an initial good quality root filLing is
essential (22, 40, 44). The choice of root-end-filling mat-
erial is subjected to controversy and scientific investiga-
tions have not singled out one specific matedal as being
suPerror.
Fig20.18 Demonstration of a typical scârtissuerepair
imagesuggesting 'late failures' after
Attention has been called to
afterendodontic Notethebonefill andperiodontal
surgery ligament space
(coùrtesy apical surgery. fua1* et al. (11) found that among 104
at thetip of theresected
lateralincisor. of DrJohan
Warfuinge.)
investigated healed cases 44 were classified 10 years
later as failures. Similar relapses of periapical lesions
a surgical and a non-surgical approach to reheatment (2, have been reported by Kvist and Reit (32). These find-
1,9, 32), and as a rough guide three cases out of four ings indicate that healed casesshould be included in a
might be expected to heal. recall program.

Casestudy tial amounts of gold and dentine will have to be

Surgery as a primary choice of endodontic treatment
Often endodontic treatment has to be conducted
throuqh crowns. When canals are hard to find, substan-
removed, jeopardizing the retention of the Prosthodon-
tic construction. In some situations the risks for such
complications may be judged to be too high and a
primary surgical approach to endodontic treatment may
therefore be caried out.
In this case an acute apical periodontitis was diag-
nosed in the left central upper incisor. The Patient
received a full bridge in the upperjaw about 2 years pre-
viously. Before the bridge was placed, the incisor was
fractured close to the gingival margin but the pulp was
found to be vital and had kept its inte8rity. A cast post
was fabricated arrd retained with parapulpal pins. In the
new situation the risk for the post to loosen was iudged
to be high if the gold mass was penetrated in order to
reach the pulp space.Instead, a flap was raised and the
root canal cleaned with handfiles in a hemostat in a ret-
rograde direction. The canal was sealed with injectable
gutta-percha.

,---,- (Images courtesy of Dr C. Reit.)


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at a 45" a gle. Half of the apic.tl araities were PreParedwith t111
approp ate sized A r allov tip. The othet half uere Weparcd
Toithan inpertedcofiebur in û sloro-speed hûtldpiece.The teeth
uere extracted,sectionedlongitudinallyand obserpedin a scan-
ning electronnicroscope.The ultrosoniccat itiesproducedmorc
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than thosepftpared by burs.
lndex

^ b D ' r \ r r r r o t uR ( ou ccr" lr-àln nr:ROt n' .F oo'rJlir8-hrJ l'- li

l d 8 - n ù b . h r n b o l d r r c r r " r ' l o r n . . ' o no v \ e _ p d e ' u r b P r s i n J ' n f F l ' l g x ^ ' d r n r lJbh'

A fibèrs v. nerve libers

mtomy sc. dertâl anatomy
anesthesiaand anèsthciics
126,132,133-4,13Erl0
periapicat,1:15, àdveFe reâ.tions kr, 60, 62
RCT,769,170,172
145,146
systehi. complications, i.iection teclrnlqùè, 315
submù.osâI,138,139,169,170,172
subpeû)steà1,138,139,172 psvchôlogical fa.tôrs, 60, 62
âbutmenttôoth,177 82
RCT, 163
apicâlperiodontitis,130,140 surgicalretrcâhnent,311 12,318,319
dentin+pllp complex rcsPonsèsto, 39_40 vaso.onstricbrs,31,312,318,319
necrotic pù1p ûicrobiolog),, :112-13 ântibacte.ial a.tivity, rcot cànal filling mate.ials,
ftdj.iraphy, 224,226 262
dd lital pulp theraPies,66,6l càlciumhydroxide 1656,280,308
cne.gen y,86,87
painJulpllpitis, 86 glass ionomer .êûents, 279
' partialpllpotomy, 72 3,87
pxlp câppin8,72 3, 87 polyketon€sealÊrs,276
retreâtmenl,308 9
pùlpotomy,68,69,72 3,86, 87 zinc oxid€ugenol, 274,2r5
x.firdrry.rs spp.,115,120-21,132,208,309,318 disintectanis
s.e4lsoôntisePti.s;
actinomy.osis, periâpi.!], 132
affe.tivcfâcto$, Fâin,58,59,60,61,62,63 indicarions for !se, :L7t
^H26,276 8,283,294
rrroph1.1a.ti.tsc, 150 52
Miisd pæsenringcells{APCS),26,27
ântibiotics,150,151
sc.dlsodisinlectùls
psychologicalm àgeûenl,62 anxièt, and pain,5E,58,61,62,63
&ot .ànâl fillin8 mterials, 262,264,265 apexlocators,èldtdcal, 253,254,254
guttà-pc.cha cones,268
sealcrc,2713,277,290 apicàlleakage.192-3,194,1954,2o1,272,320
âpicalpe.n Dntitis,:130 -43
prcsthodonti.rdonsrructio4 186 boneresorption,133,134,135,:1389,233
;ôo1 canàl instr! mentation, 242 5, 247, 218-9, 25O bone s.lerosis, 222,224
flàreprcpdatiot,2-H claonic(periâPical grâNloûr), 133
reshaping, 305 diagnostic classificàtion,16, :17
rctrieving tiroken istrments, 306 micro{rEùisms, I I 5
step do$'n teclûique, 25È51 ràdiographi, 233
æh-eatmentdecisions,206
corèbtild-ups, 184,301 .ôndensjnEosteitis,140
rcot dd fillnl& 281,282,3212 diàgnosric clàssificatior! 16, I 7
single tooth rc.ônstructior! 187,188 eDidemiolost14041
ùà.horesis,i:13,113-14 eitheliâl pi;liferatiôn, 135,136,137
dâlgesjcs,u1, 323 €tiob6y, 130-32
327
324 ndex
apicôlperiodontitis(cont'd)
tailedcndodonti.tleahnst, I30, 1.10+11,
170/200 201,
2A+9
necFlic pulp ûi.ro olgdisms,1i3 14,126
locàtion,114-15,116,118,132
ostèomyelitis,140
pathogeni. potential, 124, I 32
Irenapical abscesses,:l:15,126,138
spe.iesspecincsimploms,125 6
lissueresponse,l3tl 35
virùle.ce facto$, 124 5
ô5teonyeliiis,133,140
periâpicalabs.esses, 115,126,132,133-1,
:t38 40
àJtèrpulpotomt 102
râdi.ûlar cysts, i33, 135--8,141,208
radiôgraphy, 222
RCT,756,1578, 16r, 165,170,200,201,2A44
rct.eahnentdecisions,204 9
nrgicâl tleahndt, 324
tissùe respoNes, 132-10
api.â1 zippin& 163,U0, 242,245
àpi.e.kny (apicocctomy), 319
RCT,158,159,160,r94
aspergillosis,274 275
autonomy, pàtidts', 205 6
B-.el]s,âpicâ1periodontitis,134
denlincp!]p compler 26
bàctedâ!c? micro-o.ganism!
bi.tèùl endocarditis seeinfe.tile êndocaditis
bàctèdâ] leakage,265-6
api.at, t92 3, 194,\954,2Ol, 272,320
.affi1, 1934, 2Q1, 202,272
dentin+pllp .ômplex responses,37S, 39
dye pdetration test, 293
nùid traosporttest,293
ûidobial penelrâtiontest,293
prosthodonticrecônshuction, 181-2,195,202
tuot end fi1brg, 321-2
sea].rs,265,27Q,272,276,2784, 281)
bio.ompâtibility, rool filling mâteriâls, 263 5
biolognàlàgents,vital pùlp iherapies,Z 103,104
black-pigûoted bacteria Opb) seeParyhlTotu as spp.j
breedin& mmagement ot 312, 318-19,323
blood clots, vital pulp therapies, 74, 92, 94, 97
dentine pub complex, 2(r,28
intemittent ù.ilation, 30-31
mediâtiônby neres,2ç5,2E, 29,31,44 5,50,51
non desttuctive siimuli, 28, 29
sûgi.al rer@âhndt,312,31E-19,323
vasoconsfi.tors,3:1,312,318,319
bl@d samples,14G7, 148
dentjnepulp compler 25 5, 29
n(rotic pulp microbiolog, r13
bonema..oa' traNplat pâtidts, 151
bone morphogcnctic protein ûoleft]es, 1ll3
bonercmova],314,317
àpi.âl pêriodontitis,133,134,135,138-9,233
s(ondary hyperpàrâth),tuidism, 142
ând primary surge{., 324
buccalobjectrulc,220
Bu.kley'sformoùesol(FC),95,96,102
âccÊss
prepa.auon,239-40,241,243,256J , 301
plosthodônticrÊcorNt.uction, 161,186,187
root en l prcpùâtiory 320,321
C-fiberc n. nerve fibers
cal.iLonin genùrclated peptide (CGRI'), 24, 28
pulpd innammâlion/32,,!5?50
.al.ium hydroxide, 9l-5, 27È81, 290
6 active seahrg compondt, 291
dtiba.terial effæls,94,165,166,280,308
ù1tiûicrcbialret eatmenl,308
interâppoinhnènt RCT d.essing, I 65-7, 308
int€nâl rcot resôrytion, 92, 102
leâkâge,280,291
pdpôtomy, 92,94 5,96, 100,101,102
stepwiseexcavàtion,989, :100,105
PulPcâPPins,75-7,95
Partial,75 z 94 5, r00
priûârv tÊetl!92,94 5,96, I00,101,102
root end closure,280
calcium phosphâtecemerts, 7Z 271
..h.d ch€mothÊrapvpâlienrs, 151
Candit1tspp.,I20,121
.apping *e pulp capping
cùbon fiber bâsedposts,186,229,230
.ùdia. conditiotu, inJe.iivê endocaditis, 148-50,167
api.âl pedodontitis, 130,140
dcntine pulp .omplex rèsponsèskr, 32 7
arrested lesions,32, 3.1
ClassII molccule expresslng.e]ls, 34
dèep lesions,34 5, 36
dentinal s.lerosis, 32, 33 4 36
mnrcralizâtion, 33
periâpi.âl tissue, 37
pûlp polyp, 37
repâràtive dentine, 3f5
restorâtivè prôcedures,29
nùrsingbotdc,121
 lndex 329

pafial pulpotom,v, 99 .orti.ostcroids,95,97,101-2

preoperative diàgnosis, 93, 9,r .rà.ked+ooih syndrone, 112-13,114
pù1p capping, 99
dentinepltp cômplex rcsponses,39
pllpôtomy, 99-100,106 vital pulp therâpies,66, 67, E6
repàrative denirne 92 f c,lsd da.ked+ooths]mdrôûe
step$'ise cxcarôtion, 98 9, 105 cro*'n doM pressurelesstè.hnirye, 250,305
loot-illcd loolh, 193
strangartationtheory, 36 à..essrnroù9h,2389, 24J,300 301,324
vità1pulp expon,re,s, 6 coronal lèàkâ8e,I 9}6, 201,202,272
diaEnosticclâssiJi.ation, 16-17 ând primary sur8ery 324
ne.roti. pulp microbiolog)t112,:l:l3F14 s. ds. pFsthôdonti. rcconsl.uctiôû restorative Procedures
pnmâry teeih r. ar.,c cultural lactors, pàin, 60-61
ùdàpies, 66, 67, 70, 73, 74, 8Ç7 .@ftage, soft tissuelesions,314,3I719
cast restorâtions sre rcslorative pro.èdæs
câvit) prepârâtionsre æstorativèPro.edtes
CE sign,root lilling rmteriâb,261 o. pedapicàl cemenlal .tvrplâsià, 143
celhlitis, 139 p.xkèt, 137,208
cemots, 270 7E,289 9:l râdi.ulà! 115,133,13H, 141,208
biolo8icalprôperties,262,2z S ràdiographt 225 6, 2.28
câl.iuû phosphate,271 su.glcalretleatrent, 311,3:18

.ore bûild-ups, 18,È5 tr!e, 115,:L3Z:141,

206,311
mndibular nene inju.y, 283
apicalpdiodontitis, 133,135
pulpotomies,8Z 95,97,100,101 chrcni. inJectio{ I 53
ràdiograpfit 229 30 cvtot.rxicity se. toxi.ity
RCT,167,194,195,196
dêâdpulp s.. n{rctic pulp
root end filLin&281 2,322 de.iduous tecû se. priûly teeth
vc ,lso zinc oridæqenol d{ision st aleSies,12,203 9, 300

corcbdld ps,:184 apicâlperiodontilis,135

responsekr stiûuli, 26, 27, 34, 35
single tooth reconstmctiô$, 188,1E9
chemical disinfectiory RCT, 1634, 194,254 5 isttûuses, 320,321
.heûoiherapy patients, :151 radiôgrâphy, 226-9
chlorhexidjne164,194,255 .oot .ânâl insirumentation, 236 8, 23742
dentâl mteiials, 94 4
gutta pe.cha in, 270,296 .orebulld-lps, 182 3, 18f5
fo. gutta pèr.hà removal, 303 ddtine-pulp complex responses,37, 38, 39
cholest€d, râdi.ulù .ysts, 137-8
Chur.hill's solution, 308 primry teèù, 94-Z 98, 100 103,106
Chss ll molecules,26, 27,34,35 pxlp .âppin& 75 Z 95
clinicâI decision anôl]sis, 204
.obalt<hromium basedalloys,186 Pdriâ], 75-z 94 5, 100
cognitive factors,Pain, 5H0 primary lætb 94 7,98,100-103,106
cold sensitivity seethermàl stimulation; thèrmàl tests ràdiographt 229 30
collagen-basedhèmosiàtic matcrials, 319 rcot cml særoot.ânàl filling matÊrials
complement systeû, 135 slngle toofi .ecostrùctioi, 187,188,189
compositèssccresin .omposiles stepwise ex.avâtior, 100
computerized microtomog.aphy, 2:16 tempordy fillings, 87
condesing osteitis, 140 toxicity s. toxi.ity
conditionin& iûpact on pair! 60 dentalplaque,115,116,ll8, 12
.ones, rcol canâ1filting, 261, 26ç70, 288 9, 29L 4 denthal fluid, 21, 28
continuoùs wâ\'e technique, gutta percha down-packin8, 294 A-fiber activatio4 47-9
control, senæ of, panl 59 hydrôdynmjc mechaism, 47-9
prct€.iivc role 29 30
dentinalsclerosis, 32,33 4,36
materials,182 3, 18ç5 dentinâltublles, 21,22
bàctedal leakage,38, 19ç5
blockin& 53
t],pès, 182 4 denlinal fluid prote.tive a.tioa 29 30
.ore .driel techniqle, root liJlû9, 291,295,296 næroticpûlp nicro-organisûs,113_15
330 lndex

ddiinàl tubules (côût'd) diagnostjcclassificaiion,16-17

nerve terminàls, 44, 45
odontoblâst àspiratiôû, 29 côNcqucnces, 1l-12
management varialion,202-3
rcsponses to stimuli, 21,23,24 diagnostic dilemmâs, Z 9, 54, 63
A fiber activatioi, 47-9 diagnosti. i.formariôn
denline hypelscnsitiviq., 52 3
h).drcdyMmicnechâ. ism,47-9,50 ndiography,16,21 6
ddtine, n{hdicâ] pùpèrties, 179,180 vjtll pllp ùcGpjcs, 70-71,92-4
denline adhesive materials, 290
vitàl pllp thèrâpiÊs,77 diagnosiic strat€g)t 11-12

dentine bridg€, use of tem, T

r. nlsohard tissue repair nicro-organismldenfitjcanon,119 20
dentine .hips, pulpe.toûy, 8f5, 86 pùlp vilallLy,14 16
denlnrehypcFcnsitiviE,52 3 diâgnosticclassification,16,17
dentine pulp compler,21,22 Pain quali\, variation, 4Z 54, 63
bàsâl fmctions, 21 € ROCùalysis, 10 12
bàsâ1mainteMnce, 26, 28
blood flow, 26, 28

intermitteût iritaiion, 30 31
nervemcdiated,2f5, 28,29,31,44 5,50,5l diglralradioE.âphy,215 16
norl destrùcti\estimuli, 28,29 diÈ.t pxlp câpping ùe pulp capping

dentinâ]fluid, 21,28,29-30 gutta pe..ha cones,270

RCT, :1634, :19!1,
255
immme systemcells,26,27,31
bà.tèriâl lèakage,38 distràction te.lniques, pàh .ontol, 58 9
DNA te.lniques, mi.rc-orgànism identifl.âtion, 119 20
hfl .màtion s?. inflanùution drcssings se dental raterials

dye pe11efàtion
test,bà.tdiàl leàlàge,293
b l . . l f o w ' o _ ù I' 2 . 1 2 ô 2 q , , | | .,.0Ê
èle.ûi.al apex locakrÉ, 253,254,254
infirmmato.y cell migration,32 electiicâl tests,pulp litàLitt :15
' morphologr 43-{, 50,51-2 pâin q@lity, 4Z 54, 63
odonkrblasls,22,44,49,50 èlècttu.ôagrlàtior! 318 t9
responsesto stimuli, 2E,32,35-6,39,40,49 52 electrcphysiologicàl studies, pub nerve â.tivitt 46, 52,
53
se. dlsopâin bânsmisstun cnergency Proceoæs
odontoblâsts, 22 3, 29 RCT,I69-70
pain sccpain mmagment, pàin trâtuhission vitâ1px1p,67,85 8
rèspônses to stimùli s.. denli.Fp!lp complexrespoNes mdo.àrditis, infe.tive, :146,147 52, 167
tubulcsrccdenthàl tubules
vasftttd supplt 25 6, 29 periâpi.âlàbs.esses,
r38
s?. alsoblôod i]ow ,bd,e
dentinepllp .omplêx.esponses RCT,161,171-2
à..idental bâuma, 39 !10 endodontic infe.tions *e inJe.tion(s)

destru.tiYestlmuli,31 40,49 52
intermittcnt irritation, 28 3:l
non'dcstructivestiûuli.28 31,49
prepâratio.trama, 29,30 31,37
restorative procedures,29, 30-31, 37-9
slstôine.lùritàtion"2lÊ31
dènthe sensitivitlt .17-9,50, 52
bone morphogeneti. prôtein motecùles,103
role of odôntôblâsts,22 3
historyot ,È5, 1ll, 112,152 3
Entetco..us Jdecdlb,120, 121, 126,308 9
envû)mental tâcb.s, pain, 60 61
epùephrinè,3:12, 315,319
epistemic knowledgè, 3
epith€Liàl.ells, api.àl pedodontitis, 135,136,137,208
cpoxy resn setuerss.. fesm .em€n$

deprcssion,impà.t on pairr 58
descfiptivc prcje.ts, d{ision mâking, 203 ethylenediaminetetraacetic acid (ED'fA),164,187
diagnosiicaccuract9-10 ELbû.teriln1spp., 120,121, 723,724,125,126
 lndex

eugdol s.dzirc oride-ugenol

exp€cted uûliq. theory (EUT), 203 4
Itsabactûiwt spp.,12o,l2l, \23, \25, 132,117
fàiled .ndodonlic treahmdt
apicalleâkage,:192 3, 194,195J, 201,320 Cates-Clid.len trurs, 249
apicalperiodontitis,130,140-41,170,200 201,201t9 fl â.e prepâràtion, 253-r
co.onal]eâkage,193J, 201,202 prosL\odonticr{onstrucûrn, 181,186,187
fâctors irù]uen.ing, 199-202 stepdown technique,25051

Ëdio8râphy, 229 32, 234

gender fa.tors, pair! 6:L
dccisionmaking,203 9, 29, 300 glàssjonomercenênts(GICS),27t, 274 9
faclo.s influencùg, :199 p.osthodonticre.oNtructjon,185
Fanatement variations,202 3 R C T ,r 9 5 , 1 9 6
non sùrgical,Z 206 9, 300 309
sùt9i,caI,7, 1,71,,
172,206 9, 31,1,-21 root eù.I filling,281,282,322
falsenègâtive(FN) dingnoscs,9l0 glularaldèhlde(CA),95,9aÈ7,101 2
diâgnosti. stràiegy, 12
periâpi.à]ndiogrâphs,16 gold stàndard,diagnosti.tests,l0
fnlse-positive (IP) diagnoses,10 f r l u l o n. . f - ; u - .. rr.J' t.nooô ri'i. 'r.nl
diagnostic shâtègy, :12
perl!picôl radioE.aphs,16 in.hloroform, 270,296
feâr ard panr,58,60,62,63 c o n e s , 2 6760 , 2 8 89 , 2 9 1 - 6
ieric suuâte,95,97,319 mmdibulàr n€re injurt 283
radtugrâphy, 230,2-12,234
files,245,246,2467,249 5A
apical ôLrstlu.tions, 306 (x,tjilling tedniqucs, 288 9, 291 {
bypàsshgledges,30G7
flârepreparation,253 ,r
pàste removal, 304 primiry tcc$, 9,r s,96, r01, 106
pat€.ncyfilin& 254,305 pûlp côppin&75 7, 95
root end pÈpàrâtion, 320,321 pulpe.krmv 83,84
seàlerplà.emcnt,29G7
sonicpo$'ered,256 pârlial,75 Z 94 5
stgp dôwn te.l'nique, 250-51,252 pùnàry tæth, 9+5, qt, 106
ând thdmomechmical compaction, 294 5 v. alsd.alcium t,ydrcxidè
ulhasôni. poa'ered, 55-6 ieart, iûfe.iive ddocardltis, \46, 147 52,167
lilLing màteriàls s.. root c.nal filling matèiâb heatbâsedtedniques,u)t filling, 26E9,268,291,
292 4
flàps,mucopcriosial,312 17,322 3
flûid træpo.! test,bacte.iâllèâkage,293 bonercmoval,3u
fo.al infcctjontheory 4 5, 149,152 3 dentifepulp .oûplex, 29,30n1, 37
fo.a1 sclerosing osteômyelitis, 140 inflamatory medi.tors,51
follow-up studjcs,199 heât sensitivity vc thermal stiûulation; dre.mal tests
TJedslrômfile, 242 295,304,32Û
ûddibllar nervejnluries,283 hemosisis,surgcrlt312,318 19,323
seôlerscontai.int, 262 2724,243, 290,297 hollow+ubc theo.y, 192
ton ity, 80,88,98,102,262,2724 283 hormonalfacûs, ddtine pulp complex,223
vitàl pulp thcrapies, 80, 88, 98 hydrod)namic mechmism, pain, .rit, 47 9,50
secrlso {ormocresol hydroxyapâlite materials, T
Hygiclic Ult|aJilsystem,294
hyperpa.athyroidism, 142
primary teethpulpôtomy,9516,97,98,100 102,103,106 hypersensitivè ddtine, 52-3
hypertoni. solutions, pain indùction, 48
29
dèntù1+pulp .onplex respotuses, hypnosis,pai. management, 62

Édiogràphy, 230,2i1
root canalinstrùmentatio4249,256 7, 295,304,305,306, âpi.ôl pc{odontitis,130,140
313
necroticpulp microbiology,u2 13,114 perforations,130,18051,1E6,2Q1),256 7
prosthodonticreconst.u.tiôi,177, 77A,179-80,181,Ing radiography,231,232
$diagtaphy, 224,226,230,231 stf\P, 242, 215
and !ita1 plrip thèrâpies, 66 t.eâhnent, 252 307,307-8
painful pulpiiis, 86 periapical heàling, 201 2
 332 Index
ialrogenic i.jury (cont'd)
prepâ.ation trallm
dentinepllp responæs,29, 30-31, 37
ne.retic pulp mimbiology, U3
pdtial putporomt 22, 87
plosthodonti. æcotutruciiory :t81
putp câpph& 72, 87
root cùai shâping, 241 2
s.c d/ro poforations dbd"e
ndiogJaphy, 230,231,231
vitd plilp therapies,66,6Z70,22,87
.
aPi.â] Peliodônrtis, 133-5
to forhocresol, 98
necroric pLilp hicrGôrgânism, tzrt 5
.
rhmme ryslm cells
apical penodontitis, 133 4, 13S
chronic infætion, 153
dèntin*Frlp compler 26,2t 31
bâcterial lealage, 38
caries,34 35, 36
zin oxidHusenol sealers,273
immmo.ôm promiæd pâtienrs, :t51,167
in isioN, sxr€ica], 314-17
diibioric prophytaxis, :lS0-52
ùtibiotic therap, i71
apicat pedodonrids, 130 3F
osteomyelitis, 140
làdiculd cysts, r3F-{
rebeatrnent d{isions, 205,206
lùal infe.rion thèo.y, +5, trl9, 152 3
history of mdodonrology, rt 5
retstâtic, 145 53
necrotir pùlp with diffGe swetin& 120
necrofl. pulp mcro-orgânisms, 6
ecology,121 2
lisrory,111-12
rocatior!114-15,1t5-18
pâthogoic porential, 12!t 5
roôt cml entry, 112-14
spe.ies{peitic s}îptoms, 125-6
viftlence facrors,:t2!t 5, 12S
râdio$aphic diâgnosis, 222-6
RCr, 156,157,236
retrêatment decision, 205,206
rubberdâh, 7, 80 81,194
systèmic complicâtions, 145 53, 767,I7l
vital pulp, H
pulp cppin& 74
pulpectomy, 60-81, 8Z 88
infetive êndocarditis, 144 147 52, 167
âccidàrtal trâuma, 40
âfter pulp cappin& 74, 75
ba.terialleakage,37 €, 39
ce[t]itis, 139
dinical signs, lZ 13
prihary teêth, 93 4
5.ea/sdparn symptoms ùdoto
.lùtinal h'?e.æNitivity, 53
calcium hydroxide, 94, 102
.orticosrerôids, 97
inflùhatory cell migrârion, 31, 32, 32
local mediators, 52, 54
necroh.pulp ûicF,oigânisms,111 12,126
âna.horesis, 114
aPi.alPdbdontitis, 130,131,132-5
root .anal otiy, 112-13,114
spæjessp{i{ic symproms, :rÆ
virulen e faclors, 124 5
nerve liber lo.ation, 46
neûo8enic, 45, 50-51
neuropeptide rcle, 32, 45, 50, 51
osteomyelitis, lrl0
pain æspoNes, 44 46, 49 52, 53, 54
pajn syhptoms, 12, 54
thermâlsensitivity,48,4950,68,70 71
vital puip therapies,66, 68,70-71,94
pnmùy teeth,92 4 9Z 102,I 04
ra.liolai cysts, 136 7
ra.liogrâphi. signs, 71
RCT,156
.etieâthent de.isioN, 205
rcot 6lled reerh,205
infractiôns scecrâcks
injeclion-ûolded g1lfta-perha, 291,294
int aligâhentary 79, 80
inbâosseoG, 79, 80
localanesthesia,3l5
injries sccaccidental trâha; ia ogenic injuy
tEtrmdtalior! root cdâl sccroot.anal ifftrmenrâtiôn
bone removal, 3u
bidge æmova],301
.rown mova1, 301
trâctûe ol, 2,19-50,257,295
ra.tiography, 230,231
retiieval, 304,305,306,313
gutta-pù.ha removal, 303
paste rêmoval, 303,304
pfusthodonticre.ônsructiorr 181,184 iEZ
rôot canârmstrumenration, 2394I, 242+7, 294 F, 30i}7
root encl prêparatior! 320,321
suturjng, 322
dentinÈpulp compler 29,30 31,37
rcôt pertorations,181,242,245,2567,307
zlppin9, 242,245
IntcLfà matri\ rcùnque. pÈrrùLàrion Èpàir,30?
urc(adicuràr pÈriodonhhs, 102
intraligamenrary injection, 29, 80
intraosæoG injection, 79, 80
intuâPulPalnjectior! 80
io.line potàssilmiodide (Ikl), r6F,308-9
jægùlâr æonddy ddtin€ s.. reparative dentinè
RCT,159,t634, \71, 255, 7
 Lndex 133

irritàtion dentine seerepùah\-e dèntine culdvâtion,117 19,14G7

dentin+PulP comPlex rcsPonsès
a..identaltrâum4 39,40
K files,2.rGZ 255,306 cades,32,33,34,35,36

klos'1edge, foms of, &-1 dentinal sclerosis,32, 33

inJlammatôry .e11mi8râtion, 3l , 32
rcslo.atiYetlterials,37 t, 39
restorâtivc P.oced@s, 37 €
lâsers,root cànalinstrumèitation,255 dislnfNtion, 163 4, 194,255
lâteràl .ompaction te.lniques, $ôt filling, 288,291,292-l @ dlsoàntisepticsdÛdr
leakage,bactèriàl ss. bacte.ial leàkâgc endodonticlare ups, 171
Iearned behâviors, pain, 60 fâiled RCTS,307 9
Ledemir, 95,97, 101-2 rocâlinJectionthèory,4-5, 149,152-3
Iedging, 2s7, 258,3A6J, 313 identificationmèthods,l 19 20
lentulo spirâ],166,187 lèàkâges.! bacteriâl lcakâgè
leukemi. pâtients,151
necrcticpulp cololizatior! 6,111 26
âdversereactionstô, 60,62
induction, hypnosis, 62 ecology,l2l-4
injectiontecf nique,315 history 111,112
locatior!11,Ê15,115-18,132
psvchologicâl faclors, 60, 62 pâthogclicpotential,1235, 132
pulpectoût 79-E0 RCT,larS9
surgicâlretreatment, 311 12,318,319 role in disèase,111-12
and vaso.oNtriclorc,31,312,31E,319 rôot c.nal dtry, 112-14,130
hxation injries, 39,224 sp€ciesspê.iJicsigns,1256
\mphâti.s, dcnlnÉ pulp complex, 26 study mêthods,11620

rc aho âpical pe.iodontitis ,b.!e

àpical pe.iodontitis, 134,135
chrcni. infeciions, 153
ddiine-pulp complex, 26, 2r, 34, 3s
major l$to.ômPàtibility coûplex (MHC), 26
233
malldibuld .dal, root filling in, EE,230,232,234,
mâxillârysins, root filling in,230,232
mechani.al lnstrumentation s.t root cmâl iNtruFentation
mecfllni.âl tests, pulp litàliry 14-15
à.cesstf rough Èstorations, 23v9, 243, 3AQ3o2,324
prosthodortic re.onstrùcttun, :186
radiography, 229,23rl
inf€.tions,145 53
merastatic
metætàtictumors,224
mi.rccomputed tomography, 2:16
nncroleâkagesc. bâ.ieriâl leakagè
ântâgonism, 123 -4
mtibiolic prophyhns, l5È52
dtiseptics, 156,158
re dlsddislîJecdo! ,?1.?
apicalperiodontitis,113 14,17a,1272,1216
osteomyeiitis, :140
periapi.al abscesses,138
tissueresponse,130 35
bacteremias, 145 52
bâcterialleakagesee,,ri, .rty
.âl.ium hyd.ôxide,94,165,166,280, 308
dentinÈpulp .omplex ftsPônses,32, 33, 34, 35, 36
necrôti.p!lp, 112,113 14
vital pllp therapies, 73, 74
non surgical etreahneni, 307 9
plihogfli. potcntial,12|5, 132
.oot.ànal colonizàtioù121 3
rôot.anôl rctÉâhne.l, 6, 7, 208,307 9, 311,318
root canal beâtrnell, 6, 149,168_9
àpicalleahge, 192-3,r94, 195-6,20r
.oro.al leâ!âge,193 5,201,202
disinfection,163-1,194,255
emergènies,170 7t
endodônticflareups, 171
fâi]êd,307-9,311
ish-lmentatiôn, 160 61,236
inte.appointmenl drèssing, 164 7
nrigùtion, 163 -4,25,Êi
objectiaês,156-8, 286
rooi filhrg, 6, 16.1,26:1,2E6
propeties of matèriàls for, 262
pulpe.toûy, E3,88
RCT,158,160-61,r6f5, 167,286
fc dlsomtibaciedàt àctivity, root canal fiiling malerials
sahpling, 117,146 7, 148,167,348,309
smèd lâyer,194 5, 265,296,3089
softnissuelesioncurctlage,318
slrgicâl retreùtment,3:11,318
systcmi.coûplications,:14553,167
vilal pulp,5
e n h yi n t o , 1 1 2 , 1 1 3 , 1 1 4
partial pulpotomy, 73, 74, 75
pulp .àppin& 73, 74, 75
puheciomy,78 9, 80-E1,84 5,87,8E
pulpotony, 73, 74 75, 94
seddlro dentin+pulP comPlexrcsPonsês4ro.c
334 lndex

microbial pènet âtion test, 293 hydrcdvnami. mæ]ranjsm, 46, 47 9

nicro orgmisms,117-18 odontôblâstfmctioù, 49

root canâl treâroent, 7,2-54 5 prlptis, 47, 54
mi.eral tioxide aggregates(MTAS) receptile fields, 46 7, 52
pe.foration repair, 2sZ 307 warning si$àls, 49

tuôt end lillin€, 281,282,322 nerve growlh lactor (NCl), 32

refle injuriès, âtter RCT,283
aftÊrpllp capping,7aÈ7
d€ntitul slerosis, 33 4 ddtine pùlp compiex, 2rt-5
and rcot.ânai access, 238,240 blood floù, .ôntro1,245,28, 29,31,44 5,50,5t
root od .losure, 280
iniammàtôr) .êll nig.âtio., 32
apicalperiôdontitis,134 morphology,43 6, s0,51 2
chronic infectiôns, 153 odontoblasts,22, 44 49, 50
.ldtine pulp .omplèx, 31 pain lraNmission sc ù./de
Motuel's soluiion, 319 Èsponsesto stimû]i,28,32,354,39, 40,49-52
moô4 impacton pain,58
ribe$ se. nèNe fibe6
pain lransmission" 24,28,43 54
an.l ùesthêsia, 79
mucoperiostal flâps, 312 17, 32-3 dentine h)?ersensitivitr 52 3
multimodal mûorv bed tonography 216 dentinescnsitiviry47 9,50, 52
lmctional chûges,51 2, 53
hydrodynanicmdhdish, 46,47 9,50
glæs ionomer .emerts, 279 hJlâmmation,4952,53
polykekrne sealeis,276 lô.a1control,52,54
moryholo8icâlc|angcs,50,51 2,53
nervêteûninallocation,45 6,53
accidentâl bauma, 39, 40 PulPitis, 4z 52, s4
apical periodontitis, 13È43 rissueinjury 49 52
mi.robiologt 113 14,115,1212,12ç6,130 35, 138, neurogeni. vasodilation, 2rÊ5, 28, 29, 31, 44 5, 50, 5l
1,10 neu.opeptides, 24,28,32,!t5,50,51
âssessment 13,14 16 nêumtoxicitv, zjnc oxidæugdol, 273
cdies, sbangLilation ùeôrt 36
côloniznrg micrcorgânisms, 6, 111-26 âpi.al peiodontitis, 133.1,13t 132 138
.ompositjon,120 dentinÈpulp complex, 31, 32, 34, 3s, 38
e.ôlogy,121+ ni.kel titdi m instrumcnls,2434,243,247,24950
histor, 111,112 flæ prepârâtbn, 253 !r
locâtior!tt4 15,11F-1E, 132 removing frâ.turêd, 306
pathogenicpotential,123 5, 132 root cml reshâping,30s
RC'I,168-9 step down tcclrnique, 250 5:l
role in diæase,111 12 nit.ic onde (NO),28,35
.oot canàlob, 112 14,130 nôn s r8icalretrcatment? Z 206 9,300 309
spè.ies specjfic signs, 125 6 àntiri.tubial, 307 9
study rèthods, 116-20 apical àreâ âc.ess,302 4, 305
api.al obsha.tions, 3!5 {
diagnosti. clâssification,16, :17 decision stâtègies, 20G9, 300
diffuse swèllin8, 170
locaLizedswèlLing,170,171 ledges,306-7
pdmary teeth, sigtu ot 94
Ëdlographic diâgnosis of sequelâe,221 6 objectives,206,300
rcsto.âlionprcced@s .aùsing,37 pèrloration repair 307,307-8
strmgulation theory 36
symptom h€e, 52, 54 Prognosis, 30t 324
fleàrûent sccroot canàl treâhnenl root cùâl âccess, 300 302
negativepredictivÊvalue (NPV),10 root.màl inshlmÊntation,305-7
root canâl reshâping,30s
nonvital pulp sc ne.rotic pùlp
classficatiory 43, 44 normative (pæs.riptive) projects, 203-9
pain trmsmissior! 43
dentine h)?ersensitivity, 53
dàrtine sensiti\.ity, 47 9, 52
tmctional prcperties, 46 7, 52, 54 mnagenent decjsioN, 202 3

Ochsenbeh Luebkefl ap, 313-1,r,315
odontoblast âspirâtion, 29
inrcNâtiôn, 21-2, 44, 45
pâin trànsmissio!, 49, s0
pdtial pulpoiomy,76,77
pimary 22 3
pulp capping, 76, 77
respons.s to stimùli, 21 3
prepâration trauma, 29
pèriâpi..l cemental dysplâsi,a,t43, 224,227
radiôgràphy, 224
one-àppointment endodôtti.s, 164-5
organtransplantpatiènts,151
orthograde apprcach, retreàtment s.c non sù9Làl
osteitis,co.densin&140
osteoclasts, boneresorption,133
ôsteôgenicsarcomas,224,233
osteomyclitis, 133,:140
focàl sclcrosing,140
ràdiography, 225,227
out.omesof treahnent
evaluaiion,162 199,200,297
faciors infl uencing, 199-202
manaSemot vdiâtioN, 202-3
non sugical retreatment, 309,324
prevàlocc of faiiu.es, 202
retrÊatmùt dè.isioN, 20f, 300
Éh:eahndt prognosis, 309,323 4
sûgical retreatnent, 323 4
diagnosti. infumâtioû Z 12, 13 14, 534, 57, 63
vital pxlp ùdàpi€s, 70-71, 94
mamgèments.. pam manaSemeût
pulp cappin8,78
RCT,t7t 2
surgical ret.eahnent, 323
psychologi.àl fa.tors jn, 57 63
affÊ.tive,58,59,60,61,62,63
anxiety,58,59,61,62,63
.ôgiitive, 5È60
enviromcntal, 60 6:L
expætatlons,59
fear,58, 60,62,63
managcmenr approachès,61 3
predi.tion, 59 50
sh€ss,58, 59, 60, 63
and pulpâl inflammalion,46, 4u,49 52,53,51
Prima{' teetb 94
vitâl pulp therapies, 66, 68, 94
iransmissions.epâin trànsmission
ùswarnhg signâI,49
lndex 335
pain managèment,57
dentinè hypersensitivity, 53
rândibulâr .anal p.obleû, 88, 23'l
paintul pllpiijs, E5 7
psy.hologicalapproà.hes,61{
pulpcctomy,79 80,87-{
RC'f, 163,169 72
sùgi.àl rctreatment,3ll 12,323
as treahnert objective, 5
pain thrèshold,sZ 59
pain tolerdce, 58, 59, 60
pain hânsmission, 2t 28, 43g
cêntrâl neNous s)-steû! 53
dentine hype.sensitiviq, 52-3
hy.kodynâmic mechànism,46, 47 9, 50
ànd inflammatioa 49-52, 53
nen'e fibes, 2,1,43
dèntine lrypersensitivity, 53
dentine sensitil-ity, 47 9, 52
fû.tioûl propertiès,467, 52,5!l
hydrodynânic ûechmism, .lar,47 9
pûlpitis, 47, 5!l
rdeptive Iields,!167, 52
nen'e termnrat lo.aiiot, 45-6, 53
nociccplo. acti!âtior! 52, 54
odontoblasts in, 49,50
pllpitis,47, 52,54
tisùe iûùy responses,49 52
ûandibù1d nerveinj!ries, 283
sealers.ontajnir& 273-4,283,291
tuxi.iry 88, 273-1, 283
vital pùlp therâpies,88
pâstes,rcnoval, 303,304
Fât€ncyfiling, 254,305
prtjents' values,d€cisionm!ù9, 12,205lt, 209
PcesoredèÉ, 181,1E6,249
P.ptnstrplocarus spp., 120,121, 723,124,125,126,\32
apicâlpeiodontitis, I 30
periâpical heahrg, 20:L2
prosthodonti.re.onstrucLion,180 81,186
radiogrâpht 231,232
snip,212,245
treahnènl257,3023073
peiapicâ] âLrs.esscss.eabEcesses,
pcrjapical
periapi.âl à.tinomycosis, 132
pedapi.alccrnentaldy+tâsia, 113,224,227
âftd accidental trâumà, 39
apicalpedodontiiisfc aPicâ]Pedodontitis
16,17
ciôssification,
clinicaisigN, 12,13
pain e!àluation, 13 lrl
radiogrâphic,16,221 6
necroticpllp m icro o.8misms,111-l2,126
]ô.âtioù 115,116,118,132,125
species*pecific slnptoms, 1256
virulencefactoÉ,124-5,125
 336 lndex

per aprcaLpeiodon ritiss( àpi.at periodontiris

periodôntallitûent injecrioû,79;s0 px rpokrm),92,93,94_Z98,99 103,106
| . o d { , . . . r l e - o r , . . . r J,:^ . d l , t \2 . _ 5 2 RCT,99,100
pcriodvntins, 102,lr0 srepwÉecx.àvÂtion,93,98 9, 100,105
ap'càlsccàpicâlperio.to.riiis
pesonal yalues,rreàtm.ntde.isn)ns,12,205 6, 209 ]+otio,tibactùiuû I'topiati.lut, 121, 132,117. 2rt8
prostiglandirs, 323
p(Flhetic johts, l 5i, 152
Plàque,115,?ltj, lt8, :t22 re.onshuction,177 90
pock€t$6is, 132 208 trostnodonLic
polyketone seâlers,27.16 ba.terialleâkagè,lBtL2, 195,202
root end filling,281,282

Potphyrcîun! spp.,12o,t2l, 124 6, 132,153 m a t e d â l s , 1 832, 1 E 4s

posfi€ p.cdictie value (pp9, 10 removâ1,301 2
rcte'ltior1, 178 9
bâctcriall.!krge, :t8l-2, 195,202
ferftle desiElr,1E9 90
tràctùæs,I79, 185,186
perforâtioN, 16È81,I 86
màterials, I 86, 229,23i)
preparanonteclùiques,186 7
ùd pnmàry surgery 32!l bacterialleàkag.,18i-2, 195,202
rà.liogrâphr 229,2j0 tra.tqres,179,185,186
nrateriats,186,229,2J0
pr€paràhonrechniq&s,1E6 7
slstem,l82 3, 185 enoval,301-2
potâssuû iodide (Kt), 165,t9t 308-9
pra.ticallnowledgc, 3 4 svstems,182-3,t85
p(pàrâ1ion Pri n.iples, til9
Ita\is Concept,decjsions,203,204 p.epàrationrectniqùes,186_7
ùd prmâry surgery, 324
.rcnhnÈputp responses,29, 30-31, 37 reDtc.tiôn,181 2,202
necrohc plrlp microbioloE], :113 retention loss, 177-9
prosthodonticÉconsrru.tion,181 singletooth,187 9
pulp câppùg/pâr1iàtpul porom, 72,sz s b e n g t h , 7 7 E , 1 71&
7 9 t, 8 o ,1 S 4 , 1 8 6
rôot.ànal shapjng,2.112 sqpeFt.uchrr. fracrure!,179
toothJ.âctûes,17Z178,t79-80,l8l, tE9
s.?rrsope*orahons
p.es.rptive (nomaûve) prcjecrs, 20}.9 t'tutt16 ,tl\aris, t93
p.cssrre .llânges, pain, 14 ps,r.hological fâctoF,pain,57_ri3
preverltive rctr€àhncnt 309 pûp amprtahons.. prlpotomy
Prc.atellû spp., 720,12I, 12+ 6, 122,1jt , IS3
pnmary,dcntine,useof term,23 .lr{f tuith pàrtiât pulpotoû}, 6Z A, 71 5

Èrtrù.6on,100,103 .iinicâl pro.edxr., 73 -1

ûolâr morphologr,92,93 controveNies, 71 2
necrôhcp!lP, sigls of, 94 .rressùgs, 67 E, 75 7

preûatlue erfoliarjoll,I 03 ta.toN in ùoosi11g,69, 70, n, 73, 75

Irllp inflaûmation,92 -l p.sloperatile rccalt, 78
ulal pxlp therapGs,92 106 sunivât fa.rors, Z2 5, 76
lvound healin&75 7
b1o1o3i.al âPpioâches,
:103,I04 drect in pimarv tecih, 9t 99, I 01
conbâindicâiions,103
'rressmgs, 67 8,75 7, 95,99,101
dir.!t pu\r.àpp,n-,.5'rq. 101
'1rcssifgs..48 too-lLlt, 1!6
prûârv teeth, 9t 99, 101
prlp câi iry, radioSrùphl, 226
folow-up prùciples, 101
prlp {entine comple. _. d.ihrc r,!lp coùDler
Jùttrè csea.ch, 104
p'rrF inlrnrn.,rnn n. n nrtnmibô; -
nrdir(r pulp .apping,99 PurPneûes sc nenes
pulp ùblii.ràtren afterputpotuml 102 t0l
rntldmàtiol 92 -,1
intemalroot resorptiôn,92,101 2
pxlp vftaLity re virâl prtp
pa|tiâl pullrotor), 93,9]-5, 99, too, 10:t
preopemnrèâssessnent, 92 4
prlpe.tdnt 99,100
c assilicaiiôn,
16 t7
 lndex 337

clinicâlsigns,12,13 treatmdt conhol, 231 2, 297

pàin el-aluatiort 13-14, 70 71,94 treatûenl 4âluation, 199
lrâiî symptoN, 1Z 53 1,52 63 limtations, 221,222,æ3
i'itâlili as:essment,13, 14-\6, 17,70J1, 92 4 managemelt vdiatLon, 203
obsèrer variation, 10
s.. rlso dentine-pulp conPlex; pulPitist vitàl PulP pârâlle1ingteclDlqùe, 216,218,219
posts, 229,230
pulpectomt 69,78 s5 pûlpal inflmMtion" 71, 94
RCT,167-8
apicalÊgion, 82 3, 84,85 retreatmentdecisiotu, 204 2A5'2A6,2A7, 229
as+tic technique, 8ù E1 ROC dâlysis, 10, 11
.linical prc.edæ, 79J3, 87-8 SLOBûle, 220,22E
tses,2\5,216 17,222
dèntine chips, 84-5, 86 vital lj!]p tltrâpies, 78, 101_2
worËins-le.sù;216,218-19,220,252-3
endodonti. flare-ups, 87-8 reactiônâry ddtine, 23
factors ù1.hoosing, 68, 69, 70, 71, 78
failed, retreatment, 6-7 prosthndôntic rec,NfuchÔn 1El 186
nid treatment êmergert), 87-E môt cùal nstrumcntitio[ 24b U- 247-a
receiver ope.ating .haracteristjc (ROC) cù.vè, 10-r '
for paintul pulpitis, 87 rêconstructio4 prosthodontic, 177-90
posçtreatment emergd.)t 87 8
primary tèeth, 99, 100
re-enby Procedure,87-{ and bacteriâlleakage,38
root canâlspace,813, 85,88
root filin& 83, 84, 85, 88, 286,297 pÊparatiôntauma, 37
working length, 83
woùd healing âfter, 83 5 D u l p i lk s p o n s ef o . à r i e ' , l a 5
;eci ndartiodontôblùsts, 23 24
chrôdc partial,93,94 tmsdentinal tÈàtment, 103
chionic t.rtâ],93,94 leplantation,matèrialsfot 281-3
clinicalsigN,9H
resincÊments, 271,27G8,290
diàgnosti. clàssificatior! 16 17 biological proPefties,262,277 8
pain response, 49 50,52,s3 ûndibuld nen'e iniuies, 283
pajù slmptoms, 53 -4 prosthodontic reconstruction,185,187
vaiability, 52, 54, 57 râdiography, 229 30
paiùtul, emergen Y treatmênt, 85-7 RCT, 195,196
pritury tceth, 93, 94
md pulpal ùflammatiù! 93 rcain modified glNS ionomer sczglassronomer æmd6

corÊbtild'ups, 182-3,184,301
for paiitul pulpitù, 87 plIP caPPing/ Partial PulPotomy,77
radiogrâpny,æ0,23?
- tuot end filling,281 2, 322
prnnâr!- teeth, 93, 9'{-5, 99, :100,101
; r ù o u l pc à D P r n ô
a7, s 6 9 , 7 0 , 1 1 E8 7
pnrry te.tt' ôi,qi q4 7 98,'rc 103 r0o singlètooth rè.onstructio.,1E7,188

radi.llâr cysts,115,133,:135E,14:1,208 €sins, fiber reiLfor.ed, 186

râdiography,225-6,228 restorative plocêdures
sûgjca1 rêheatrnent, 311,3l E dentine sensitivity, 48 9
râdiog.apht 215-i4 ddiine-pulp complèx resPotues,29, 30 31, 37 9
advantages, 221, 222 màterials usèd fe dèntal materials
ôngxlâtedviews,219-21,231,232,23!l ne.rotic pllp ûictubiology, 11J
bise.ting m6le tecnniqùe, 216,218 and root fillin8, 29E
buccalobjecirùle,220 md ljtâl pulp rhenpies, 66
diâgnostic,16,21-6 FaùrJulPUlPiti",86
film-holding devices,21E,219 p uLp.àËpnrg, l.àttià] PrnP"tumy72
tull mouth suNeYS,220 21 scr rlso orosthôdontic re.onstru.tion
iûâging techdques,215 16 rehntun ioss, tuoçfil1ed teeth, :1779
ùlformatiôû lrom
dental mtomy, 26 9, 216,237-9 antimicrobial, 307_9
dè.ision nâking, 20!9, 229,300
Prcvious treatments,229 30
treâhnent conPlications, 230-31,232 f a.tors influencing, 199-2!9
338

cùrvatur.,236,2J7 8
management vadations,2023 isihmuscs,320, J21
non{urgi.àl, Z 206 9, 300-309 nâro$'ing, 23ru, 241
nunrbcEof cùàls, 236,.23!È41
oblite.alion,237Js,2ll
sûii.a|7,171, lr-2,206 9,311 21 .orônal leakase,I 9.1
retogra.le approach,retrèahnenls.. surgi.àl retrcâtmenL
r.irogra.l€(rooLc.d) fiIing,28:L 3,321-2 cmergen.ies,l70,171
.oot rnatoû), 211,227 9, 236 E,237-42,32ù,321 insirumcÀ1s,239 -4:L,2.12
5|,294 5,305-7
root carul lillnrg mÀterials,261 E3 àllovs,242 5
aftcrpuhecton)r E3,E.1,85,87{ cltling flûtes,244,2.189
trlocomtùribility, 2635
bntogicalr.quirenents,262 3 flârep,eparation,253-4
rncturesoi, 249 50,257,29s,30t 305,306,313
closuæ bctwed appohhlenrs, 16G7 iahoEeni.injurr, 242,2.15
cones,26r, 266 70,288 9 rnovÊmenldxrjng shaping,2.17
gûttâ perchâcofcs,266 70,288 9 r€aûèrs,246,246,247-8
handlingr€glrirmcnts,262,263 rotnDt 2.1950, 250
inler.rpponrtment, 1.59,160,l6f6
lealcgc,26a 6, 27A,272,276,27W, 2a0,293 sland.rfdizà1ion,246 7, 246
tip conliEufation, 21-4,245
in mrndiLrlrlùcânal,88,230,2J2,234,
283 ùltrasoni.,2556

l€dging,252 258,306-7
râdiograph]., 229-31,234,288
RCT,159,160,l6+6, 171,194,195,196 tor ûon suryicalretr.nlm€.nt,
305 7
ràdtugraph]t229 31,23il pàten.! lilin8,25t 305
pL..forations, 25aÈ7,107
rcquir€.iFoperties,262 3,286 8 pro.cduràlerôrs, 25aÈ7
scalcrs,261,
262,270 El,2E9 9r
)eakage,265,27A,272,276,27W, 2a0 .outinc procedûes,158,159,160i3
rnandibul.rrn.r!e injrùies,283 shaping,24l 2, 24--t 2.]7 9, 250 53
medl.ànent.ontàining,291 soni. inst1ûneits,256
teclùicâ]aids,255-6
rc dlsù.alciun hydronde, resin.cmcnts;zinr tFàlilent ontcomes,200-202
o\i.l+e genol u trùsoni. itutments, 255 6
roor câna]nncû orsân,sms
sele.tion,261 2, 2EG8 ùpi.nl perio.lontitis,I 3È35
tcchni.àlreqnircrnents,
262,286 7
rcot Gnal lilLingtechniqùcss.. root filhE, techniqu€s clnur. I oorefls rz5

aplcalpcriodontitis,130 35 e n t . ! ,l l 2 1 4 , 1 3 0
osteotnyelitis,l:10 lo.àtio4 11.115,116,11i 132
rù.ti.ul.ù cvsts,135-6 root.ùùl n€âhnent,6, 149,168 9
t{cl 156,236 api.al leakâEÊ,192-3, 194,1956,201
s.. r/s! root canârf!àtment .oronnl le.rkàgè,193 5,201,202
systcmi..om icâtidF, l:15 53,:l7:l disinfc.tion,163.1,194,25!15
s.. dlsoroot.ânàl mic.o-ortùisms; vital pùLp e'nergcfclcs,1707r
endodofti. l'lareûps,171
rool canalimtrmentation, 216 59 t a i l e d , 3 0 79 , 3 1 1
baslctechniqûes,238 .13 inshflmentit on, 160 61,236
accÊss preparation,23842, 2.1J5, 2:6,300 30:L ùrterappointrnent drcsshg,164 7
àpical preparation, 2i4 irigafion, 163-4,254 5
flarepreparâtion,2a34 objectives,156 8,286
irrigntion,2s45 spccÈs-spe.ili.signs,126
pat€ncyfili.g,254 virulencela.tors, 12.Ê5,125
prepùationcomplctlon,254 5 root.!nâl sealers*. s€alers
root canal*slÉpin&2.11-2,211 5,217 9,2a]-a3 urt canalsp.r.e,pulpe.tôm!,81 3,85,88
smearlaler 255,255 rcot c.nal ireatmcnt(RCT),ar,15ar72
step-down,2s053 a.cessopcning,158,i59, 160
Norl<inglength,252 l a.h'ancedciscs,168
tornplexitvof .nnàI,23aÈ8 âpicâlzipplng,163,170,242,2il5
àpicâlconligurâtion,238,2:11 nseptictechniqùe,158,759,160,194
.ross sectidralshape,236,2Jd 9 blo.khg .anâtpale.cv 161

chenicatdisin{ection,16il'1, 19'1,25'l5
dressiùgsrr root.anil lillùg nirerials
effectsol microbnnà,16E')
emcr8en.yprocedûcs,169 70
endodonti.lare ups, 161,171 2
cvaluàtioncnteria,167
àpi.âl leakàgc,192 3, I 9!1,:19\ 6, 2AL 320
coroûl lcakage,193 5, 20I, 202
operâLivefactoF, 200 202
radioEràphy,229 32,234
rÊtrèàtmcnt secretreatment
btera;pointment drcssing,159,16A,1614
inlerâppojnrnèntrcskrrâtion,159,160,larar7
inigàtion, 159,163'1,171,25L{
mè.hinical inslrurnentatio
non-instum.ntâtnû tcchnqrÈs,246
o\;r.xlÊnsiof oI aFi.dLnranen, 161
pain aftci,u0,:l7l-2
Dainorior to,169 7:L
FÈopcràn\c iss.ç\menr rl âD-.
primàry teeth,99, 100
rool lilling nc (xrt filling
rolLtine.àscs,15!-68
smearlilîr, 164,19f5,255,255,265'296
symPtomati. Icsion ûÙ.E€ment, I 69 72
syst€ni. .omPli.ùtions,149,167
\vorkinglength,16:1,16:1, 252 3
rcot.aùal *idth, radiogfaPh),228 9
(nn.omplÊx, ràdio8raPf]t22ar7, 228
root c!11'ahùes,228, 229,23ar,237 I
root cnd closures,2Ell
.oot end fillinEs,2813,321 2
rool end pr.pa.ation,314,319-21
root €n.l rcsectiolr,3l4,3:19,324),
320
rcot fillcd teeth,6 7, 177
âpicall.ùkase,192_3,19'1,1954201'272 32O
c;ro.al ieàk;se, 193 6, 201,2112, 272
prostho.lonti.rc.onshuction,1z 90
radn)grâpht229 32,23'1
rclrcatm..l sc. retrcâtntnt
conhoisfoll{)*in& 231 2,297
dr'ring canalPljo. to,2!16
àpicallÊakùgc,192 3,191,1954,201 277,32O
.aronal leakage,1931;,20:1,202,272
fa.tors i.fluen.in8, 200 201
radiogrâphy,229 32,23'1
retreatments.t f eùeàûc.L
mandibulârcânài,EE,230,2J2,23'1, 283
matedils sc/ rool canalfillinB mdtcrials
inùa\illarl sinus,230,2;2
ôbicclives,156,l5r, 286,287
peri.ipi.alextrusn)n,230 ll, 2.12
lndex 339
preliols tÈâtmcnlr,229 30
pr).Èdlres Prior n),296 7
puLpectomy, 83,84,85,8E,286
;adioq.aphy,216,229-32,234,288
retrosraàeiloot end),2813, 321 2
root canàlttcahnent,159
antisepti.s,156,1i8
160-ii1,163,200 201
instrunlent.rtion.
obi€.ti!cs,156,157,286
ort-.Ppoùltmcr1tetdodonti.s,1a!, 165
pernraûentiitihg, 167
retrcâtmenl s?r retrcairnert
ùot cn.l (rtrogrâde),281 3, 321 2
seilcr p]à.emÊnt,296 7
smearlàycr reûoial, 296
.oronal rÊstoration âftcf,298
filli.g mdteriâlQle.tio[ 261-2,286 ir
fearbàscd,268 9, 28d,291,2926
tàtcfalc.rmpaction,288,291,292 3
pro.edurcsprior 1o,296 7
pùtp ùamb4 298
quality nssessmcnt, 297
snr'aleconÊ,:E8,291,292
solaen.dcore.268 9, 28E,2u9,291' 2924
soLidcore,2E8 9,291 2
solicnLtrased,288,296
root perfo ations.. P€riorarons
lpical periodontitis,133,J.r'1
vital pulp ther.Pies,92, 101 2
ûtùr\- itutrlnrents,249 50,250
a.cessprcpaûtion,239,2!:1,,43,256,301
naÈ prcparàtio.,252lt
prcstfodonticre.oûstructiot,181,186,187
tuot cânalrsnâPing,305
320,321
root end PrcParâtion,
dentin.-puLpaomPlèx,29,30 31,37
ru.rt terforàtions,:lEl
rlr'ber;t;ms, 7, 8, 80 81,194,240
ruLers,calibràt.d,219
ltushton'shYâlnleLiodies,137
S 6les,247
sà..omas,l.dio$àPlrlt 221,233
radtugr.phy,223-4
scalers,261,262,270til, 289 91
.ûtimicùbiil retreitm€nt,308 9
laakaÈc,26a,270,272,276,27u 9, 2n4
rnàndlbulù f eNe iniuries,283
ûcdicamcntcont!inù9, 291
root lilling le.bniques,2918
s.. r/so .àlciuû hl-dr)xdc) .esin ccments)zù'
s.condarï dentnrc, se of lenn, 23
Fulpil exposu.e,E7
scdativ.d.essings,
340 ndex

lLaprâisnrg,3l2-17
.ientine, ,17 9, 50, 52
.liagnostictests,10,16
pulp, 14 16 indications,3l l, 313
sili.ones, as sealers,271 l o . a la n e s t | e s i 3
a l,l 1 2 , 3 1 4 , 3 1 9

pnjl .ontrol âfter, 323

root cùàl f hrg, 266 pain contol dudng,3tt 12,314
sùg1e.one tech.ique,root flling, 288,297, 292 posloperativcrccall,324

SLOB.ule,220,228 radicula- .ysls,311

tuol end prepâration,314,31921
ântiûi.robiâl .eLrealmcnt,308 9 roôt end resÊction,
314,319,;20, 320
interàppôintmenL drcssing,16.1 roôt én.l tetrogmde)filling, 314,321 2
leakàge,r9fs, 265,272,296
prosùodonticæco.str!.tion, 1E7 s.!stemi. conplications,149,151
rcmo\'àI,255,255,26t 272,296 vaso.onstdctors, 312,318,319
socialfacto$, pàin, 60 6:L womd heàlù19p$cess,322 3
sodium hypo.hloritè(NaOCl),164,2a+5, 2a6,27t) S!rgicel,319
sottened.orc tcchiirlues,root ÊInr8, 268-9,288,289,291, SysLenr B H.rl Source,294
292 6
sotd coretccfniques,rôot Iilln18,288 9, 291 2
api.al pÊrnrdonlitis,
I34, 135
fiuing màteriâlremovâ],303,304 deniin+pulp complex, 26, 27, 3l , 34
root filLing tè.Luiqùes, 288,296
sonic instruments, 256
spccjficiry,diàgnostictests,l0 temperàturesensitivitysrctnermrl stimulation;theûràl

proslhodonti.r€.orlstuction,186 tcrtiary dentire s.. reparative dentùe

rcot caf al insitumerlrs, 242 3, 216,217,219,306 tcsts, diagnosti. s.. diàÊinôrtictests
Stmdâ.d Gâmble,206,207 leLrsc|lorociht'lcne, 303
Themlil otrtù.âLors, rcnroval,303
blood sômpLing,148 thcrmal i4rry seeheat injuv
.orônal leâlâge,193
inf..ti!e èndocârditis,1,17,
14E .llàgnôstic s.. themal tests
step down te.lniqre, tuot .ânal instfumentàtioû 250 53 pain responses,49 50
slcp$'iseex.â!âfiôn,prnnary 1ceth,93,98 9, :100,105 hydrcdlnâmic nêNe activation,48
strangulàtion theor), 36 inflmnàtôry lesnùs, 49 50, 68, 70-71
inl]ùrmâtôry mediâto.s, 5:L
âniibiolicprophr-làxis,
:15:L
nerve tib.r actlvation, 47
blm.t sanrPiing,148
iiJe.tive endo.ârditis,l,1Z 148,l5l tôoth rclatedpain,l4
RC'f, 194 tlrcrmomechàni.al corpâctior! rool fillin& 291,294-5
stess,inpad on pain, iE,59,60,63
strip pcrloràtions,242,245
submucosalabscess€s,]JE, 139,169,17Q,172 prosthodonticre.otutrlrtion, :LE6
subpenosLâl abscesses,:169,:U0, 172 .adiograph).,229
s bstanccR 24,28,32,45,50 li laniu n-aluminrm iNtnûents, 243
lomograph!, nicrocomputed,216

æ primâry choi.e, 32,1 ûnh loss,dentinepulf complexresponse,29

ietreàtmentscesùrgicalr€teahndt
slrEicâl rctreàtment,Z 171,172,2069,3II21
antibbtic p.ophylà\is,:15:l
blccdjng,312,318-19,l2l
formâldchydes, 80, 88, 98, :1A2,262,2721, 2A],
b o n er c m o l a l , 3 1 4 , 3 1 7 EIL'Larâld
ch) dc, 96 7, 102
rooi canalfillhg ûâterials,262,264 5
criticalsteps,311,
314 Eltb-tcrcha cones,267 E,269
.uretta8e,314,3l7-lq seale6,271 , 2721, 276,277 8,279,2AO,283,29A
de.isiônstEtegies,20rj9, 300 root end Ê11in8s,282
test ûetho.ls, 264 5
traÉdentinal treatndt, 103 '
prim;ry tætlr q3 94-5 44 100 101
-with
sceaisostePwise ex.âvatim
PulP.âPPing,67 8,70,71-{
trdspiant patimts, 151 pdrarY teeth, 92 :106
haû;ra sed;ccidental t1ôûa; iâtrogdic inlury
ireâtment out omes seeoutcohes ol treahndi p;rtial pulpotomy,93,945,99, 100,10:I
tricalctum phosptÉte, 77 pulp æsssmênt 92 4 ^,
bioxide asiregàies sdcminerâl tdoide aggregates vc Y- rr
PrrP.aPprng
.ulDêctomt 99, :lLro
t1re cysts,115,132 :141,208,311 ;,Ëobmi e2,93,e4 z e8,9e-103,106
true nesative (TN) outcomes,lu ;te;wise ;x.avatioù e3,9Èe, 100,10s
truè-positive (TP) outcomes,10 pub ;ss$sment befoÉ, 70-n, 92 rl
periapical.tentâl dysplasia, 143,224,227 '
;ith ;àrh;l prdPotomy,b bT 8 69 70 71 8 87
iadioglaPhy, 22a, 233
Dtimry teeih, 95, 99, 101
o;Dectomv
' 6 7, 68 70,71,78-45,874
ultrasonic ishuments, 241,255 { p-rinary iæù, e9, 100
pdte Eûoval, 303
pulpotomY, 68, 69,70
;oôt end PrePâration, 320,321

q2 a4 7 e8 9q 101 106
vnsculù çuppl' s.ebloud floa bluod çuPPlv i.ima.y reetl. 93
\a"ocoÈtrrct.rs, 11,312,l18, l1o h arm lateràl compàctidn' rnd nllûg 291 2c2J
wâsodilàtion, neutusenc, 21-5, 28, 29, 31, 44-5, 50' 51 -àrm , erticâlco;Pàchon loot tills8 291 2'13-4
verh.al comPactiôn,roÔt filliû1,29a' 2934 worlong length, 252 3
assèssment,13,1ç16 iadiogapÉc t .tu,que zto 2l8-1e 220 252 3
l]âin quâLitYlarjatioi" 47,54, 63 RCT,161,163,252 3
;reope(alive,70 71,92 a woûd .L€ssingss.. dentâl matsials
{
;ri;ry têèth, 92 4
bâiteriâlentry,112,113,114
X{âys 5.eradiogiaPhY
infl amation secinJlamanon xdo;adiosraPf ic imaging, 216
local anesthelics,31
perforations, 257
yests, :U7, 120,121,126,308
irepdation trarlM, 37
therâpies se. bero@ zi.c oxide+ugeno1, 2n, 271-4, 290
vilal prip theraPies,6GE9 bjolosjcalPsperties 2r'2
bidôgica1 agents nmdituljr nàwe 4uLies zsl
Drimary teeth, 103, 104 pulpotomies,87,95,97,100,101
;ulp.appins, z radioFràPhl, 229 30
"h;o;ûs.-ôs 7i. 73,75,78 RCT,162 194
.linicâl scenaios, 66
dressings, 75-7,83,84,87,88,9+8, 100 103'106
sot end fillin8, 2E1,282,322
emdgencies, 67, 85 8 \oxi,.j!', 262,1724 2a3,290
ddodonhc flde_ups, E7 8 zinc phôsplÉte cetent, 187
objêctives,66,97€
zippini, !63, 770,242' 245
p'ainful PulPitis, 85 7
,illJll[Lt[[l[[l|]