The Editors

Lars Bjørndal, PhD, is Associate Professor in the Section of Cariology and Endodontics, Department of Odontology, Faculty of Health and Medical Sciences at the University of Copenhagen in Copenhagen, Denmark.

Lise-Lotte Kirkevang, PhD, is Associate Professor in the Department of Dentistry and Oral Health at Aarhus University in Aarhus, Denmark and Professor of Endodontics, at the Institute of Clinical Dentistry, Faculty of Dentistry, University of Oslo in Oslo, Norway.

John Whitworth, PhD, is Professor of Endodontology/Consultant in Restorative Dentistry in the School of Dental Sciences at Newcastle University/Newcastle Hospitals NHS Foundation Trust in Newcastle, UK.

List of contributors xiii Foreword xvii Preface xix About the companion website xxi 1 Introduction to endodontology 1
John Whitworth, Lise-Lotte Kirkevang, and Lars Bjørndal Endodontology 1 The objective of endodontic treatment 2 Clinical problems and solutions 2 The diagnostic dilemma 6 The outcome dilemma 6 The tools of treatment 6 References 7 Part 1 The Vital Pulp 2 The dentin-pulp complex: structure, functions, threats, and response to external injury 11Lars Bjørndal and Alastair J. Sloan Introduction 11 The odontoblast and the dentin-pulp complex 11 The dental pulp 17 Immune responses in the dentin-pulp complex 22 Responses of the healthy dentin-pulp complex to nondestructive stimuli 25 The dentin-pulp complex and responses to external injuries 25 Summary 29 References 29 3 Dentinal and pulpal pain 33Inge Fristad and Matti N¿arhi Introduction 33 Classification of nerve fibers 33 Morphology of intradental sensory innervation 33 Function of intradental sensory nerves 36 Sensitivity of dentin: hydrodynamic mechanism in pulpal A-fiber activation 38 Responses of intradental nerves to tissue injury and inflammation 40 Local control of pulpal nociceptor activation 44 Dentin hypersensitivity 44 Pain symptoms and pulpal diagnosis 45 References 46 4 Clinical pulp diagnosis and decision-making 49
Kerstin Petersson and Claes Reit Introduction 49 Evaluation of diagnostic information 49 Diagnostic accuracy 50 Diagnostic strategy 51 Clinical manifestations of pulpal and periapical inflammation 51 Collecting diagnostic information 52 Diagnostic methodology: assessment of pulp vitality 53 Diagnostic methodology: evaluation of reported pain 55 Diagnostic methodology: provocation/inhibition of pain 56 Diagnostic methodology: evaluation of tooth discolorations 58 Diagnostic classification 58 References 59 5 Caries pathology and management in deep stages of lesion formation 61Lars Bjørndal Enamel lesions without clinical cavitation 63 Progressive stages of enamel-dentin lesions without surface cavitation and exposure of dentin to the oral environment 65 Cavitation of the dentin lesion 67 Concluding remarks on the natural history of dental caries 72 Strategies for the management of deep caries 72 Detailed treatment protocol for deep caries management 74 References 76 6 Treatment of vital pulp conditions 79
Lars Bjørndal, Helena Fransson, and St¿ephane Simon Introduction 79 Indications and treatment concepts for preserving vital pulp functions 80 Protocols for treatments aiming to preserve the vitality of the exposed pulp 81 Factors of importance in preserving vital pulp functions 87 Capping materials and healing patterns 89 Tissue-biomaterial interaction and pulp healing 91 Pulp-preserving treatments - a controversial treatment? 92 Indications and treatment concepts for treating the irreversibly inflamed vital pulp (pulpectomy) 93 Postoperative considerations 96 Choosing between pulp-preserving vital pulp therapies and pulpectomy 96 Concluding remarks on the avoidance of pulpectomy by vital pulp therapies 97 Revitalization and/or regenerative endodontic procedures 97 References 98 Part 2 The Infected Necrotic Pulp and Apical Periodontitis 7 Apical periodontitis 103Zvi Metzger, Anda Kfir, and Itzhak Abramovitz Introduction 103 The nature of apical periodontitis 103 Interactions with the infecting microbiota 107 Treatment and healing of periapical lesions 114 Persistence of periapical lesions 115 Clinical manifestations and diagnostic terminology 117 References 119 8 Microbiology of the inflamed and necrotic pulp 123Luis E. Ch¿avez de Paz Introduction 123 Historical background 123 Clinical evidence 124 Infections in root-filled teeth with persistent apical periodontitis 126 Microbial pathogenesis of apical periodontitis 128 Association of signs and symptoms with specific bacteria 129 Biological evidence 131 Extraradicular biofilms 133 Ecological determinants for microbial growth in root canals 134 Microbial interactions in biofilms 134 Microbial resistance to antimicrobials 136 Antibiofilm strategies 137 Concluding remarks 138 References 138 9 Clinical diagnosis of pulp necrosis and apical periodontitis 143Dag Ørstavik Introduction 143 Clinical features of pulp necrosis and root canal infections 144 Radiographic features of apical periodontitis 147 A strategy for the formulation of a periapical diagnosis 153 Diagnostic challenges during treatment 153 Special cases of endodontic infections 154 An integrated approach to endodontic diagnosis 162 References 165 Part 3 Endodontic Treatment Procedures 10 Endodontic emergencies 171Peter Jonasson, Maria Pigg, and Lars Bjørndal Introduction 171 General diagnostic considerations and emergency principles 171 The etiology and pathogenesis behind emergency scenarios 171 Non-endodontic tooth pain - conditions of differential diagnostic interest 181 Management of patients with acute dental pain 182 References 183 11 Controlling the environment - the aseptic working field 185Merete Markvart and Pia Titterud Sunde Background 185 Preparing teeth for rubber dam isolation and the development of an aseptic working field 186 Rubber dam isolation 187 Application of the rubber dam 189 Disinfection of the working field 189 Aseptic working procedures 190 References 192 12 Access and canal negotiation: the first key procedural steps for successful endodontic treatment 195Ove A. Peters and Ana Arias Introduction 195 Principles of tooth development and tooth anatomy 195 Individual analysis of the tooth, preoperative radiographs, and additional CBCT scans in complex cases 196 Rubber dam isolation 196 Access cavity preparation 197 Canal negotiation 202 References 203 13 Root canal instrumentation 205Lars Bergmans and Paul Lambrechts Introduction 205 Principles of root canal instrumentation 205 Root canal system anatomy 206 Anatomical variations in teeth 211 Procedural steps 213 Endodontic instruments 217 Instrumentation techniques 221 Limitations of root canal instrumentation 223 Preventing procedural mishaps 225 References 228 14 Irrigation and disinfection 231Markus Haapasalo and Ya Shen Introduction 231 Eradication of microorganisms from the root canal system 231 Microbial reduction by instrumentation 232 Root canal irrigation 232 The apical root canal - a special challenge for irrigation 236 Activation of irrigant flow 237 Use of lasers in irrigation 238 Wide-spectrum sound energy for cleaning the root canal system 239 Intracanal medicaments 240 Concluding remarks 241 References 241 15 Root canal filling 247 15.1 Root canal filling materials 248
Gottfried Schmalz and Birger Thonemann Introduction 248 Requirements 249 Evaluation of specific materials 253 References 272 15.2 Root canal filling techniques 277Amir-Taymour Moinzadeh and Hagay Shemesh Introduction 277 Clinical objectives and in vitro investigations 277 The root canal filling-dentin interface 277 Root canal filling techniques 281 Concluding remarks 289 References 289 Part 4 The Endodontically Treated Tooth 16 The root canal-treated tooth in prosthodontic reconstruction 295
Kishor Gulabivala and Yuan-Ling Ng Introduction 295 Fracture predilection of root-treated teeth 295 Occlusal loading 298 Root canal-treated teeth as abutments 299 Distribution of remaining tooth structure and restorability 299 Principles of restoration of root-treated teeth 300 Timing of restoration after endodontic treatment 301 Approach to restoration of anterior teeth 302 Characteristics of posts 303 Preparation of the post space 307 Approach to restoration of posterior teeth 308 Core materials 310 Modes of restoration failure in root canal-treated teeth 310 Conclusions 311 References 312 17 Clinical epidemiology: measuring endodontic disease and treatment outcome 315
Lise-Lotte Kirkevang Introduction 315 Defining a "successful" outcome 315 Study designs commonly used in endodontic research 317 Treatment outcome and risk factors 319 Concluding remarks 323 References 323 18 Endodontic retreatment - the decision-making process 327
Frank Setzer and Bekir Karabucak Introduction 327 Why might the initial treatment be unsuccessful? 327 When may further intervention be considered? 329 Decision-making - the dentist's perspective 330 Decision-making - the patient's perspective 338 References 339 19 Nonsurgical retreatment 343
Thomas Kvist and Luc van der Sluis Introduction 343 Indications 343 Instrumentation of the root canal 350 Prognosis 357 Summary 357 References 358 20 Surgical endodontics 361Lise-Lotte Kirkevang, Vibe Rud, and Thomas Kvist Introduction 361 General outline of the procedure 361 Local anesthesia 363 Flap design, incision, and raising the flap - general considerations 363 Access to the root tip 368 Root-end resection 369 Curettage of the soft-tissue lesion 369 Management of bleeding 370 Root-end preparation 371 Root-end filling 372 Repositioning and suturing of the flap 373 Postoperative measures 374 Follow-up after surgery 375 References 376 Part 5 Additional Considerations 21 Local anesthetic considerations 381Nigel Foot and John Whitworth Introduction 381 Fundamentals of local anesthetic action 381 Common local anesthetic agents in endodontics 382 Standard methods of local anesthesia for endodontics 383 Failure to secure anesthesia 385 Why may teeth be difficult to anesthetize? 386 Measures to preempt or overcome challenging local anesthesia 387 Supplementary injections 388 Sedation 390 Complications of local anesthesia 391 References 392 22 Complex orofacial pain conditions 393
Lene Baad-Hansen and Peter Svensson Introduction 393 Overview of pain mechanisms 393 Diagnostic process 395 Complex orofacial pain conditions 397 Painful posttraumatic trigeminal neuropathy 397 Persistent idiopathic facial pain 398 Atypical odontalgia/persistent dentoalveolar pain 399 Trigeminal neuralgia 399 Trigeminal autonomic cephalalgias 401 Migraine/neurovascular orofacial pain 401 Temporomandibular disorder pain - referred pain 401 Summary 402...