Contents PART ONE: THE ART OF ENDODONTICS 1 Diagnostic Procedures, 2 Stephen Cohen 2 Orofacial Dental Pain Emergencies: Endodontic Diagnosis and Management, 25 Alan H. Gluskin and William W. Y. Goon 3 Nonodontogenic Facial Pain and Endodontics: Pain Syndromes of the Jaws that Simulate Odontalgia, 51 Lewis R. Eversole 4 Case Selection and Treatment Planning, 60 Samuel (). Dorn and Arnold H. Gartner 5 Preparation for Treatment, 77 Gerald Neal Clickman 6 Armamentarium and Sterilization, 110 Robert E. Averbaeh and Donald J, Kleier 7 Tooth Morphology and Access Openings, 128 Richard C. Burns and I.. Stephen Buchanan 8 Cleaning and Shaping the Root Canal System, 179 John D. West, James B. Roane, and Albert C. Goerig 9 Obturation of the Root Canal System, 219 Nguyen Thanh Nguyen, with section by Clifford J. Ruddle 10 Records and Legal Responsibilities, 272 Edwin J. Zinman PART TWO: THE SCIENCE OF ENDODONTICS 11 Pulp Development, Structure, and Function, 296 Henry O. Trowbridge and Syngcuk Kim 12 Periapical Pathology, 337 James H. S. Simon 13 Microbiology and Immunology, 363 James D. Kettering and Mahmoud Torabinejad 14 Instruments, Materials, and Devices, 377 Leo J. Misercndino, with section by Herbert Schilder 15 Pulpal Reaction to Caries and Dental Procedures, 414 Syngcuk Kim and Henry O. Trowbridge XI Xll Contents PART THREE: RELATED CLINICAL TOPICS 16 Traumatic Injuries, 436 Stuart B. Fountain and Joe H. Camp 17 Root Resorption, 486 Martin Trope and Noah Chivian 18 Endodontic-Periodontal Relations, 513 James H. S. Simon and Leslie A. Werksman 19 Surgical Endodontics, 531 Gary B. Carr 20 The Management of Pain and Anxiety, 568 Stanley F. Malamed 21 Bleaching of Vital and Pulpless Teeth, 584 Ronald E. Goldstein, Van B. Haywood, Harald O. Heymann, David R. Steiner, and John D. West 22 Restoration of the Endodontically Treated Tooth, 604 Galen W. Wagnild and Kathy I. Mueller 23 Pediatric Endodontic Treatment, 633 Joe H. Camp 24 Geriatric Endodontics, 672 Carl W. Newton 25 Endodontic Eailures and Re-treatment, 690 Adam Stabholz, Shimon Friedman, and Aviad Tamse PART FOUR: ISSUES IN ENDODONTICS 26 Ethics in Endodontics, 730 James T. Rule and Robert M. Veatch Answers to Self-Assessment Questions, 737 Daniel B. Green, H. Robert Steiman, and Richard E. Walton PART ONE THE ART OF ENDODONTICS Chapter 1 Diagnostic Procedures Stephen Cohen THE ART AND SCIENCE OF DIAGNOSIS quired before diagnostic examination or clinical treatment is The dictionary* defines diagnosis as "the art of identifying undertaken. Some patients require antibiotic prophylaxis be a disease from its signs and symptoms." Although scientific fore clinical examination because of systemic conditions like devices can be used to gather some information, diagnosis is heart valve replacement, a history of rheumatic fever, or ad still primarily an art because it is the thoughtful interpretation vanced AIDS. Patients who daily take anticoagulant medica of the data that leads to a diagnosis. An accurate diagnosis is tions may need to have the dose reduced or dosing suspended a result of the synthesis of scientific knowledge, clinical expe if the clinician is to conduct the thorough periodontal exami rience, intuition, and common sense. nation, which is integral to a complete endodontic workup. To be a good diagnostician a clinician must learn the fun When patients report being infected with communicable dis damentals of gathering and interpreting clinical information. eases such as AIDS, hepatitis B, or tuberculosis, dentist and An inflamed or diseased pulp is a common, straightforward, staff need to be especially attentive to the use of protective and nonurgent condition. Systematic recording of a patient's barriers. In case endodontic therapy is required, the clinician presenting signs and symptoms and careful analysis of the find must know what drugs the patient is taking so that adverse drug ings from clinical tests inevitably lead to a correct diagnosis. interactions can be avoided. In such cases, consultation with There arc instances, however, when a patient presents with an (he patient's physician is recommended. Patients who present acute situation, conflicting signs and symptoms, or inconsis with mental or emotional disorders are not uncommon. Some tent responses to clinical testing. Chapter 2 explores the meth patients are aware of their disorder and inform the dentist. Oth ods for diagnosing and testing these endodontic riddles. Chap ers may have undiagnosed psychological or emotional prob ter 3 discusses the ostensible toothache of nonodontogenic or lems; abnormal or highly inappropriate behavior may suggest igin. the presence of illness. In these cases, too, medical consulta tion before the diagnostic examination would be in the best Medical History interests of patient, doctor, and staff. A brief summary of these Even though there are virtually no systemic contraindica consultations with treating physicians and an outline of their tions to endodontic therapy (except uncontrolled diabetes or a suggestions should be recorded and dated in the patient record. very recent myocardial infarction), a recent and succinct, com Dental History prehensive preprinted medical history is mandatory (see box on p. 3). It is only with such a history that the clinician can After completing the medical history the clinician should de determine whether medical consultation or premedication is re- velop the dental history. The purpose of a dental history is to create a record of the chief complaint, the signs and symp toms the patient reports, when the problem began, and what Unless otherwise indicated, the illustrations in this chapter were prepared by the patient can discern that improves or worsens the condition. Dr. Albert Goerig. *Wehster's ilurd Imem.ahona! Dicuonaiy. Springfield. Mass. 1976. Merriam- The most efficacious way for the clinician to gather this im Webster Inc. portant information is to ask the patient pertinent questions re- garding the chief complaint, and to listen carefully and sensi establish the location, nature, quality, and urgency of the prob tively to the patient's responses. For example, the doctor might lem and encourage the patient to volunteer additional infor begin by simply asking the patient. "Could you tell me about mation that completes the verbal picture of the problem. The your problem?" To determine the chief complaint, this ques clinician may be able to formulate a tentative diagnosis while tion should be followed by a series of other questions, such as taking a dental history. The examination and testing that fol "When did you first notice this?" (inception). Affecting fac low often corroborate the tentative diagnosis. It is then merely tors that improve or worsen the condition should also be de a matter of identifying the problem tooth/1'7 termined. "Docs heat, cold, biting, or chewing cause pain?" In the gathering of a dental history, common sense must pre (provoking factors). "Does anything hot or cold relieve the vail. The questions outlined here, along with other questions pain?" (attenuatingfactors). "How often does this pain occur?" described in Chapter 2, should be asked if the diagnosis is elu (frequency). "When you have pain, is it mild, moderate, or sive. If the clinician can see a grossly decayed tooth while sit severe?" (intensity). The answers to these questions provide ting and talking with the patient and if the patient points to the information the dentist needs to develop a brief narrative that tooth, the dental history should be brief because of the description of the problem. obvious nature of the problem. Furthermore, if the patient is The majority of patients present with evident problems of suffering from severe distress, with acute symptoms (Chapter pain or swelling, so most questions should focus on these ar 2), the dental history should be brief so the clinician can re eas. For example, "Could you point to the tooth that hurts or lieve the pain as soon as possible. the area that you think is swelling?" (location). "When cold {or heat) causes pain, docs it last for a moment or for several Pain seconds or longer?" (duration). "Do you have any pain when Because dental pain frequently is the result of a diseased you lie down or bend over?" (postural). "Does the pain ever pulp, it is one of the most common symptoms a dentist is re occur without provocation?" (stimulated or spontaneous). quired to diagnose.14" The source of the pain is usually made "What kind of pain do you get? Sharp? Dull? Stabbing? evident by dental history, inspection, examination, and test Throbbing?" (quality). Questions like these help the clinician ing. However, because pain has psychobiologic components— 4 The art of endodontics physical, emotional, and tolerance—identifying the source is patient's eyes should be observed for the pupillary dilation or at times quite difficult. Furthermore, because of psychological constriction that may indicate systemic disease, premedication, conditioning, including fear, the intensity of pain perception or fear. Additionally, the patient's skin should be observed for may not be proportional to the stimulus. When patients present any lesion(s) and, if there is more than one, whether the le with a complaint of pain that is subsequently determined to be sions appear at random or follow a neural pathway. of odontogenic origin, the vast majority of these cases reflect After a careful external visual examination the clinician conditions of irreversible pulpitis, with or without partial ne should, with the aid of a mouth mirror and the blunt-ended crosis.19'23 handle of another instrument, begin an oral examination to Patients may report the pain as sharp, dull, continuous, in look for abnormalities of both hard and soft tissues. With a termittent, mild, severe, etc. Because the neural portion of the head lamp and good magnification the lips, cheek pouch, pulp contains only pain fibers, if the inflammatory state is lim tongue, palate, and throat should be briefly examined (Fig. ited to the pulp tissue it may be difficult for the patient to lo 1-1, B). Because it is easier to observe abnormalities when tis calize the pain. However, once the inflammatory process ex sues are dry, the liberal use of 2x2 inch gauze, cotton rolls, tends beyond the apical foramen and begins to involve the peri and a saliva ejector is strongly recommended (Fig. 1-1, C). odontal ligament, which contains proprioceptive fibers, the pa During the visual phase of the examination the clinician should tient should be able to localize the source of the pain. A also be checking both the patient's oral hygiene and the integ percussion test at this time to corroborate the patient's percep rity of the dentition. Poor oral hygiene and/or numerous miss tion of the source will be quite helpful. ing teeth may indicate that the patient has minimal interest in At times pain is referred to other areas within, and even be maintaining a healthy dentition. yond, the mouth. Most commonly it is manifested in other Visual inspection of the teeth begins with drying the quad teeth in the same or the opposing quadrant. It almost never rant under examination and looking for caries, toothbrush abra crosses the midline of the head. However, referred pain is not sion (Fig. 1-1, D) (cervical lesions occasionally are over necessarily limited to other teeth. It may, for example, be ipsi- looked), darkened teeth (Fig. 1-1, £), observable swelling laterally referred to the preauricular area, or down the neck, (Fig. 1-1, F), fractured or cracked crowns (Fig. 1-1, G), and or up to the temporal area. In these instances the source of defective restorations. cxtraorally referred pain almost invariably is a posterior tooth. The clinician should observe the color and translucency of Ostensible toothache of nonodontogenic origin (i.e., resulting the teeth. Are the teeth intact or is there evidence of abrasion, from neurologic, cardiac, vascular, malignant, or sinus dis attrition, cervical erosion, or developmental defects in the eases) is described in Chapter 3. crowns? Patients may report that their dental pain is exacerbated by A high index of suspicion must prevail during examination lying down or bending over. This occurs because of the in for numerous types of soft-tissue lesions.8,20 This also means crease in blood pressure to the head, which increases the pres looking for unusual changes in the color or contour of the soft sure on the confined pulp. tissues. For example, the clinician should look carefully for The dentist should be alert for patients who manifest emo lesions of odontogenic origin such as sinus tracts (fistulas) tional disorders as dental pain. If no organic cause can be dis (Fig. 1-2, A) or localized redness or swelling involving the at covered for what appears as dental pain, the patient should be tachment apparatus. The presence of a sinus tract may indi referred for medical consultation. Patients with atypical facial cate that periapical suppuration has resulted from a pulp that pain of functional rather than organic cause may begin their has undergone complete necrosis in at least one root. The sup long journey through the many specialties of the health sci purative lesion has burrowed its way from the cancellous bone ences in the dentist's office. through the cortical plate and finally to the mucosal surface. If the dentist can determine the onset, duration, frequency, All sinus tracts should be traced with a gutta-percha cone (Fig. and quality of the pain and the factors that alter its perception, 1-2, JS to E) to locate their source, because occasionally the and if the dentist can reproduce or relieve the pain by clinical source can be remote.13 testing, then surely the pain is of odontogenic origin. The pa All observable data indicating an abnormality should be re tient will usually gain immeasurable psychological benefit if corded on the treatment chart while the information is still fresh the clinician provides caring and sincere reassurance that, once in the clinician's mind. If a tooth is suspected of requiring en the source is discovered, appropriate treatment will be pro dodontic treatment, it should be assessed in terms of its re- vided immediately to stop the pain. storability after endodontic treatment, its strategic importance, and its periodontal prognosis. EXAMINATION AND TESTING The inspection phase of the extraoral and intraoral clinical Palpation examination should be performed in a systematic manner. A When periapical inflammation has developed as an exten consistent step-by-step approach, always following the same sion of pulpal necrosis, the inflammatory process may burrow procedure, helps the clinician develop good working habits and its way through the facial cortical bone and begin to affect the minimizes the possibility of inadvertently overlooking any part overlying mucopcriosteum. Before incipient swelling becomes of the examination or testing. The extraoral visual examina clinically evident, it may be discerned by both the clinician tion should begin while the clinician is taking the patient's den and the patient using gentle palpation with the index finger tal history. (Fig. 1-3, A). The index finger is rolled while it presses the Talking with the patient provides an opportunity to observe mucosa against the underlying bone. If the mucoperiostcum is the patient's facial features. The clinician should look for fa inflamed, this rolling motion wiil reveal the existence and de cial asymmetry (Fig. 1-1, A) or distensions that might indi gree of sensitivity caused by the periapical inflammation. cate swelling of odontogenic origin or a systemic ailment. The To improve tactile skill and learn the full extent of normal Diagnostic procedures 5 FIG. 1-1 A, Swelling around the right mandible can be readily observed by the clinician while preparing the dental history. B, The Designs for Vision fiberoptic headlamp along with 2'/2 to 3'/2 x magnification allows the clinician to examine the soft tissues and teeth without any shadows. C, A thorough tissue examination is facilitated by drying with cotton rolls, 2 X 2 inch gauze, and a saliva ejector. The initial examination of the teeth and surrounding tissues is conducted with the patient's mouth partly open. With good illumination and mag nification, as shown in Fig. 1-1 B, changes in color, contour, or texture can be determined by a careful visual examination. D, Class V caries lesion, or abrasion, not always detectable radiographically, can be observed. E, Tooth discolored following a traumatic incident. Al though the tooth appears necrotic, vitality tests should still be conducted because the pulp could remain vital, F, Intraoral swelling from periapical disease usually appears around the mucobuccal fold; however, the entire mouth must be thoroughly examined because swelling from periapical disease may occur in unusual locations (e.g., the palate). G, With careful visual examination the clinician may observe crown fractures that may not appear in radio graphs. 6 The art of endodontics FIG. 1-2 A, Sinus tract (fistula). B, When a sinus tract is detected, it should always be traced with a gutta-percha cone to its source. In this case, the sinus tract appeared between the first and second premolars. C, The source of the sinus tract was the lateral incisor, as the gutta percha probe indicates. D, Gutta-percha cone used to trace a sinus tract discovered on the palate. E, An occlusal jaw radiograph revealed that the sinus tract crossed the midline. The source was a cuspid. F, After numerous unsuccessful dermatologic treatments, this patient consulted a dentist. G, The dentist discovered the source. range to be expected, the clinician is urged to perform palpa If a mandibular tooth is abscessed, it is prudent also to pal tion testing routinely. pate the submandibular area bimanually to determine whether Other techniques involving extraoral bidigital or bimanual any submandibular lymph nodes have been affected by exten palpation (e.g., palpating lymph nodes or the floor of the sion of the disease process (Fig. 1-3, B). mouth) arc described in complete detail by Rose and Kaye.18 Finally, the cervical lymph nodes should be palpated bidig- Occasionally a patient is able to point to a particular facial itally to discern any swollen or firm lymph nodes. area that felt tender when shaving or applying makeup. The The use Of extraoral and intraoral palpation helps the clini clinician can follow up by palpating in the mucofacial fold, cian determine the furthest extent of the disease processes. which may help pinpoint the source of the tenderness. If a site that feels tender to palpation is discovered, its location and ex Percussion tent should be recorded as well as whether or not the area is The percussion test may reveal whether there is any inflam soft or firm. This provides important information on the pos mation around the periodontal ligament. The clinician should sible need for an incision and drainage. remember that the percussion test does not. give any indication Diagnostic procedures 7 of the health or integrity of the pulp tissues; it indicates only whether there is inflammation around the periodontal ligament. Before the test, the patient should be instructed that making a small audible sound or raising a hand is the best way to let the clinician know when a tooth feels tender, different, or painful with percussion. Before tapping on the teeth with the handle of a mouth mir ror, the clinician is advised to use the index finger to percuss teeth in the quadrant being examined (Fig. 1-4, A). Digital per cussion is much less painful than percussion with a mouth mir ror handle. The teeth should be tapped in a random fashion (i.e., out of sequence) so the patient cannot anticipate when "the tooth" will be percussed. If the patient cannot discern a difference in sensation with digital percussion, the handle of a mouth mirror should be used to tap on the occlusal, facial, and lingual surfaces of the teeth (Fig. 1-4, B). Using the most appropriate force for percussing is one of the skills that the clinician will develop as part of the art of endodontic diagno sis. Percussing the teeth too strongly may cause unnecessary pain and anxiety for the patient. The clinician should use the chief complaint and dental history as a guide in deciding how strongly to percuss the teeth. The force of percussion need be only great enough for the patient to discern a difference be tween a sound tooth and a tooth with an inflamed periodontal ligament. The proprioceptive fibers in an inflamed periodontal FIG. 1-3 Palpation. A, Bilateral intraoral digital palpation aids ligament, when percussed, help the patient and the clinician the clinician in detecting comparative changes in contour or locate the source of the pain. Tapping on each cusp can, on consistency of the soft tissue and underlying bone. A "mushy" occasion, reveal the presence of a crown fracture. feeling detected during palpation around the mucolabial fold A positive response to percussion, indicating an inflamed may be the first clinical evidence of incipient swelling. B, Bi periodontal ligament, can be caused by a variety of factors manual extraoral palpation to tactilely search for the extent of (e.g., teeth undergoing rapid orthodontic movement, a recent lymph node involvement when there is a mandibular dental in high restoration, a lateral periodontal abscess, and, of course, fection. The clinician should palpate the submandibular nodes partial or total necrosis of the pulp). However, the absence of (as shown here), the angle of the mandible, and the cervical a response to percussion is quite possible when there is chronic chain of nodes. periapical inflammation. Mobility Using the index fingers, or preferably the blunt handles of two metal instruments, the clinician applies alternating lateral forces in a facial-lingual direction to observe the degree of mo- FIG. 1-4 Percussion test to determine whether there is any apical periodontitis. If the patient has reported pain during mastication, the percussion test should be conducted very gently. A, First only the index finger should be used. The teeth should be percussed from a facial as well as an incisal direction. B, If the patient reports no tenderness when the teeth are per cussed with the finger, a more definitive, sharper percussion can be conducted with the han dle of the mouth mirror.