doi:10.1111/j.1365-2591.2008.01521.

EDITORIAL

Professor Tom Pitt Ford a friend and colleague

As has been reported previously in the International Endodontic Journal, Tom Pitt Ford, Professor of Endodontology at Kings College London, UK died on Sunday 17, August 2008. This special issue of the International Endodontic Journal provides an opportunity for the endodontic community to celebrate the professional life of Tom and to remember his intellectual contribution to the development of the speciality through his research and other scholarly activities. Included in this issue are tributes from several colleagues and friends. Dag rtsavik has provided an overview of the contribution Tom made to research in Endodontology. Jack Rowe, his former Head of Department at Guys Dental Hospital and School, has provided an insight into the early formative years of Toms career whilst Nick Chandler has reected on his relationship with Tom, rst as an undergraduate student, then as a PhD student and nally as a friend and colleague. Finally, we have included several key articles published by Tom together with a commentary from a co-author who has reected on the background and relevance of the work that led to the publication. I thank all the contributors for their personal reections of Tom and their insight into his career. Uniquely, Tom was elected twice as President of the British Endodontic Society. Indeed, Tom was a Council member of the BES for many years and his wisdom and political insight were invaluable as the society developed to become one of the largest and most inuential specialist societies in the UK. Tom also contributed to the work of the European Society of Endodontology where he held the honorary position of Editor for many

years and was a member of its Executive Board. He also chaired the working group that developed the Quality guidelines for endodontic treatment: consensus report of the European Society of Endodontology that was published in the International Endodontic Journal initially in 1994 and then revised in 2006. This contribution to the management and direction of UK and European Endodontology will have an impact for many years and is a tting legacy of his professional career. Tom was Editor of the International Endodontic Journal from 1982 to 1991. He took over the position from Fred Harty at a relatively tender age and immediately made improvements to both the format and content. As a result of these changes, the IEJ quickly established itself as one of the most successful scientic endodontic journals in the world. During this time his meticulous attention to detail was a great advantage and his editorial rigour was a major reason why the IEJ improved its reputation and impact. Clearly, Tom was a remarkable individual and one who made a major and enduring contribution to the dental profession, to clinical practice as well as to Endodontology. His legacy must be his outstanding and world-leading research and his mentorship of young research workers who have continued to pursue careers in Endodontology and make signicant contributions to the discipline. I would like to thank Elsevier Publications for their kind permission to republish three articles that appeared originally in the Journal of Endodontics and the Journal of Prosthetic Dentistry, and Wiley-Blackwell for their permission to republish two articles that appeared originally in the International Endodontic Journal. Paul MH Dummer Editor-in-Chief

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Thomas R Pitt Ford: detail, diligence and determination

Reviewing the academic achievements of Tom Pitt Ford provides a measure of consolation to a mourning friend. As professionals, we all seek to add to the knowledge base of our discipline and to aid in its development, clinically and scientically. More often than not, we are too busy to reect on if and how we succeed in these efforts. Tom denitively was busy in his career, and if he reected on his achievements (I hope he did), he certainly did not boast of them in public. It is therefore with great pleasure, and some melancholy, that I review his scientic career. His scientic production may be divided into several main areas of interest. From the outset, one topic of particular interest to him was dental materials, particularly, endodontic materials. As we have come to realize and to use as a reference for our clinical and scientic efforts, endodontics is largely the cure, or the prevention, of apical periodontitis. Apical periodontitis is preceded by infection and necrosis of the pulp, which is caused by traumatic or infectious damage to the pulp-dentine organ. A crucial step in the prevention of pulpal and periapical infections, is the immediate damage control of exposures of the pulp; i.e. indications and procedures for pulp capping. This clinical procedure represents the link between Conservative Dentistry and Endodontics, and it was in this eld Toms scientic endeavours started. His early work compared the ability of commercial brands of calcium hydroxide-containing materials to induce or support the formation of a dentine bridge under the capping material. He demonstrated that the mere presence of Ca(OH)2 was not enough for such support; other factors of the formulations were necessary for optimum results (Pitt Ford 1980). Materials for pulp capping hardly changed for the next two decades, but with the advent and application of mineral trioxide aggregate (MTA), we can sense Toms excitement when this material that he tested so extensively, proved to give enhanced tissue responses and stimulate pulpal

repair better than the conventional materials (Mitchell et al. 1999, Nair et al. 2008), and when he could see that it was adopted and taught in dental schools throughout the UK (Pitt Ford et al. 2007). In the late 1970s, at the start of Toms scientic carrier, we may safely say that experimental, clinical and laboratory research in dentistry was still in its infancy. The eld of Endodontics was dominated by strong opinion-makers, and teaching and clinical practices were based much on expert opinion in the absence of sound clinical data. Concepts of aetiology and pathogenesis, on effects and importance of clinical procedures, and on criteria for testing of new methods and materials varied widely. Tom was among the rst to address such issues with a modern approach of generating hypotheses and testing them in discretely designed experiments where one could assess one variable at the time. Resisting uid leakage along root llings was, at that time, considered crucial for their clinical performance, both conventionally and surgically placed. Toms initial work followed this mainstream of research, and he set out to test endodontic materials for leakage and to evaluate the then novel glassionomer cements for suitability as root lling materials. He quickly realized that glassionomer cements, at least with regard to leakage resistance, were not optimal as root lling materials (Pitt Ford 1979, Pitt Ford & Roberts 1990). However, Tom pursued and extended his research into biological aspects of these materials, and made some discoveries that we should heed even today. One of them was that leakage, at least in the form of ex vivo dye leakage, was not per se related to biological tissue responses to root llings with different materials in animals (Pitt Ford 1983). He went on to study which measurable factors in the lled root canal were indeed associated with an inammatory response (translating into failure of treatment). He then made another astute and easily forgotten observation: debris in the root canal was not related to infection or to the inammatory response (Pitt Ford 1982). This was and in part still is, contrary to the opinion of many, but in

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this work he very elegantly demonstrated that debris in the root canal was of signicance in this regard only when infested with microorganisms. Whilst the foundation for the modern concept of the singular importance of microbial activities for the initiation, progression and persistence of apical periodontitis had been laid by the studies of Kakehashi et al. (1965), Bergenholtz (1974), Kantz & Henry (1974) and Sundqvist (1976), Toms work here coincided with and was supported by the extensive experiments by the group of Mo ller in Gothenburg (Mo ller et al. 1981, n et al. 1982), and solidied the infectious nature Dahle of the disease. More than many, he then rightly focussed on the importance of the irrigation liquids and preparations for medication of the canal as keys to improved success in endodontic treatment. Today, we see a renewed interest in the effect of instrumentation techniques on canal cleanliness and debris removal. Whilst these are important in the overall antimicrobial strategies of treatment, we may be wise to remember the conclusion from Toms paper in 1982 (Pitt Ford 1982): There was a close association between not only infection and inammation, but also infection and resorption. In contrast, there was no relationship between infection and the extent of debris in the root canal. The ability of procedures to remove debris is clearly subordinate to measures ensuring asepsis and antisepsis. Early in his career, Tom took a particular interest in materials for root-end lling. Whilst endodontic surgery and apical lling is a time-honoured procedure, it was considered until recently to give unpredictable and often poor clinical and radiographic results. The material of choice for lling up to the 1990s was amalgam, the performance of which had been improved by changes in its formulation and in its preparation. However, signicant improvement in the treatment outcome awaited the use of the surgical microscope and the introduction of new materials. Tom pursued his interest in new materials for rootend lling with animal testing. In an elegant paper from 1990, he documented that the disinfection of the main root canal is of crucial importance, and that even an adhesive material, the glassionomer cement, was unable to prevent bacterial leakage, and subsequent apical inammation, from an infected root canal when placed as a root-end lling (Pitt Ford & Roberts 1990). Working with Bunsan Chong, he assessed modications of the glassionomer cements for their suitability as root-end lling materials, but observed that the introduction of composite resins for light curing of the

glassionomer reduced rather than enhanced important physical properties (Chong et al. 1991). Around this time, he also initiated work together with Jens Andreasen in Copenhagen, and tested extensively a variety of materials for root-end lling also prior to replantation of extracted teeth (Andreasen & Pitt Ford 1994, Pitt Ford et al. 1994). These studies of Toms placed zinc-oxide-eugenolbased cements in the forefront of currently available materials for root-end lling; particularly, the resinreinforced variant known as IRM. Toms work in this eld was essential in side-lining the traditionally dominant use of amalgam; this material is now no longer recommended for this usage. Since the mid-90s, the collaboration with Mahmoud Torabinejad on MTA has been the most extensive of Toms scientic activities. If you were looking for expertise on the biological effects of endodontic materials including materials for rootend lling (a phrase promoted by Tom) in the early 90s, Tom stood out as one of the most knowledgeable and productive in this eld. So, when the MTA idea was to be tested and put into practice, it was quite natural that Tom and Mahmoud should work closely together. This collaboration would turn out to be a very productive and fruitful one. The design and renement of the composition of the MTA, together with the extensive technological, biological and clinical testing of this material have provided endodontics with a highly versatile and forgiving material to be used in a variety of situations. It is to their credit that we for the rst time in decades have seen the implementation of a product that not only eases the job and looks good, but which may also improve the clinical results of endodontic procedures. Toms experience with clinical and biological studies was particularly important for the documentation of MTA (Koh et al. 1997, Camilleri & Pitt Ford 2006, Nair et al. 2008); and he also concluded the rst truly randomized clinical trial of two materials for root-end lling: MTA and IRM. This study (Chong et al. 2003) stands out as the best documentation of apical surgery with either material so far designed and executed, and gives proof that both can provide impressively high healing rates. Being a teacher and a skilled practitioner with an inquisitive mind, Tom was also engaged in many other elds of research: he published high-quality research papers on pulpal blood ow and devices for assessment of pulpal vitality; he worked in radiology on practical issues of lm sensitivity and on the radiographic

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detection of periapical lesions; on dental students performance of endodontic procedures; and more. It was his activity in endodontic lling materials that initiated my collaboration with him: in 1988, he visited NIOM, the Scandinavian Institute of Dental Materials, where I also worked at the time. At that particular time, the concept of endodontics as either the prevention or cure of apical periodontitis was being developed. Later, when the idea to present this concept in a comprehensive text was pursued, it was my good fortune to benet from the superb qualities of Tom as an experienced writer and co-editor of the ensuing text, Essential Endodontology: Prevention and Treatment of Apical Periodontitis, now in its second edition (rstavik & Pitt Ford 2008). The book would not have happened without him applying his best qualities: attention to detail, diligence and determination to get the work done. Tom had then nished a 10-year period as editor of the International Endodontic Journal. During that period, the journal had become truly international, with contributions from many of the foremost scientists in Endodontology as well as in related elds. His ability to attract authors from other, established, sciencebased disciplines and to integrate their work with the traditionally technical discipline of endodontics was one of the prerequisites for the general acceptance of Endodontology as a topic with a scientic base and with proponents and practitioners that have academic training and evidence-based procedures. As if this were not enough, he has edited the later versions of Hartys Endodontics in Clinical Practice (Pitt Ford 2004) as well as publishing his own textbook together with Heather Pitt Ford and John Rhodes: Endodontics: problem-solving in clinical practice (Pitt Ford et al. 2002). He carried his work to the European scene as an active member of the European Society of Endodontology. In 1993, the British Endodontic Society hosted the sixth ESE biennial congress in London, with Tom as a major driving force together with the President, Anthony Hoskinson. He chaired the committee for endodontic education within the ESE, and thus had a major impact on the policy document which has been an important source of reference for the endodontic curriculum in dental schools in Europe and world wide. The books also supplemented Toms long-standing commitment to the advancement of Endodontology as a discipline and a speciality. His pioneering work in setting up the comprehensive graduate programme at Guys and St Thomas together with the Institute of Dental Surgery was essential for the eventual

recognition of Endodontics as a specialty in the UK. The UK specialty and the programme are now references for the work seeking recognition of Endodontics as a European specialty (ESE 1998). The academic activities of Tom Pitt Ford have been important for the development and recognition of Endodontology as a clinical and scientic discipline over the past 30 years. His efforts have contributed signicantly to important scientic issues, particularly in relation to endodontic materials and their application. He has raised the standard for scientic writing and communication in the eld; and he has been instrumental in the development of Endodontology as a specialty in the UK as well as in Europe. We hope that he himself did see and feel the effects of his work as his career developed, and that he felt the recognition by his peers and students that he richly deserved.

References
Andreasen JO, Pitt Ford TR (1994) A radiographic study of the effect of various retrograde llings on periapical healing after replantation. Endodontics and Dental Traumatology 10, 27681. Bergenholtz G (1974) Micro-organisms from necrotic pulp of traumatized teeth. Odontologisk Revy 25, 34758. Camilleri J, Pitt Ford TR (2006) Mineral trioxide aggregate: a review of the constituents and biological properties of the material. International Endodontic Journal 39, 74754. Chong BS, Pitt Ford TR, Watson TF (1991) The adaptation and sealing ability of light-cured glass ionomer retrograde root llings. International Endodontic Journal 24, 22332. Chong BS, Pitt Ford TR, Hudson MB (2003) A prospective clinical study of Mineral Trioxide Aggregate and IRM when used as root-end lling materials in endodontic surgery. International Endodontic Journal 36, 5206. n G, Fabricius L, Heyden G, Holm SE, Mo Dahle ller AJ (1982) Apical periodontitis induced by selected bacterial strains in root canals of immunized and nonimmunized monkeys. Scandinavian Journal of Dental Research 90, 20716. European Society for Endodontology (1998) Guidelines for specialty training in Endodontology. International Endodontic Journal 31, 6772. Kakehashi S, Stanley HR, Fitzgerald RJ (1965) The effects of surgical exposures of dental pulps in germ-free and conventional laboratory rats. Oral Surgery, Oral Medicine, Oral Pathology 20, 3409. Kantz WE, Henry CA (1974) Isolation and classication of anaerobic bacteria from intact pulp chambers of non-vital teeth in man. Archives of Oral Biology 19, 916. Koh ET, Torabinejad M, Pitt Ford TR, Brady K, McDonald F (1997) Mineral trioxide aggregate stimulates a biological

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response in human osteoblasts. Journal of Biomedical Materials Research 37, 4329. Mitchell PJ, Pitt Ford TR, Torabinejad M, McDonald F (1999) Osteoblast biocompatibility of mineral trioxide aggregate. Biomaterials 20, 16773. n G, Ohman AE, Heyden G (1981) Mo ller AJ, Fabricius L, Dahle Inuence on periapical tissues of indigenous oral bacteria and necrotic pulp tissue in monkeys. Scandinavian Journal of Dental Research 89, 47584. Nair PN, Duncan HF, Pitt Ford TR, Luder HU (2008) Histological, ultrastructural and quantitative investigations on the response of healthy human pulps to experimental capping with mineral trioxide aggregate: a randomized controlled trial. International Endodontic Journal 41, 12850. rstavik D, Pitt Ford TR (eds) (2008) Essential Endodontology: Prevention and Treatment of Apical Periodontitis. Oxford: Blackwell Munksgaard. Pitt Ford TR (1979) The leakage of root llings using glass ionomer cement and other materials. British Dental Journal 146, 2738. Pitt Ford TR (1980) Pulpal response to MPC for capping exposures. Oral Surgery, Oral Medicine, Oral Pathology 50, 818.

Pitt Ford TR (1982) The effects on the periapical tissues of bacterial contamination of the lled root canal. International Endodontic Journal 15, 1622. Pitt Ford TR (1983) Relation between seal of root llings and tissue response. Oral Surgery, Oral Medicine, Oral Pathology 55, 2914. Pitt Ford TR (ed.) (2004) Hartys Endodontics in Clinical Practice, 5th edn. Edinburgh: Wright. Pitt Ford TR, Roberts GJ (1990) Tissue response to glass ionomer retrograde root llings. International Endodontic Journal 23, 2338. Pitt Ford TR, Andreasen JO, Dorn SO, Kariyawasam SP (1994) Effect of IRM root end llings on healing after replantation. Journal of Endodontics 20, 3815. Pitt Ford TR, Rhodes JR, Pitt Ford H (2002) Endodontics: Problem-Solving in Clinical Practice. London: Martin Dunitz. Pitt Ford TR, Mannocci F, Woolford M (2007) Survey on the teaching and use of mineral trioxide aggregate in UK dental schools. European Journal of Dental Education 11, 1559. Sundqvist G (1976) Bacteriological studies of necrotic dental University Odontological Dissertations No. 7. pulps. Umea , Sweden: University of Umea . Umea

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A tribute from Professor AHR (Jack) Rowe, former Dean of Guys Dental School and Head of the Department of Conservative Dentistry

Thomas Russell Pitt Ford, the son of a Guys dentist, entered the Dental School at Guys Hospital in 1967. I would have met him at the end of the Preclinical Course in Operative Dentistry in 1969 when his group started to treat patients in the Conservation Department. I was approached by an anxious lady in the Records Department asking if it was in order to give this new student a large number of patients. I requested the name of the individual and it was Tom Pitt Ford. As I had not had any complaints from the staff I assured her that it was OK. At that time the students had to complete certain targets of work in three and a half years before taking Finals. In just a year, Tom had nearly completed them and before qualication he already had considerable clinical experience. Tom passed the LDS RCS in October and the BDS London in 1971 with honours in Prosthetic Dentistry. He went on to take the FDS RCPS in Glasgow in 1975 and was awarded a PhD in London in 1980 for his study of the in vivo biological response to various root canal sealers. He obtained the FDS RCS Edinburgh in 2000 and the FDS RCS England in 2005. After obtaining the BDS exam he worked part time in General Practice with his father and then I was pleased to have him as a part-time lecturer in the Conservation Department at Guys. He undertook the routine supervision of students work and was a very reliable member of staff. He was made a full time Lecturer in 1981 and a Senior Lecturer in 1982. He conducted introductory courses in the Phantom Head Department with small groups and then supervised their work in the clinics and until 1990s he regularly carried out chair-side teaching of Conservative Dentistry at all levels. Tom had three or four sessions a week devoted to research and decided to investigate in detail the biological effects of various commercial materials on the dental pulp and apical tissues. He asked me to supervise his work for a PhD. This task was simple as he reported to me on a regular basis what he had been doing and the results of his work, and all I could do was to commend him for the work he had carried out. He

completed the experiments and thesis in good time and was awarded the PhD. Another of Toms roles between 1986 and 1997 was as Postgraduate Dental Tutor and he organised many courses for House Ofcers and General Practitioners, and courses for the Primary FDS. He took all these activities in his stride and was never ustered. Tom and I discussed the need for an MSc programme in Endodontics. He planned the course, which was approved by the University of London. This was the rst postgraduate degree in Endodontics in the UK. Tom organised the programme of lectures and seminars and supervised the clinical treatment and the research projects of the students. The rst programme started in October 1988 and he subsequently supervised a total of 35 students for the Masters Degree and 7 PhD students. Tom was made a Reader in Endodontics in 1995 and appointed as Professor of Endodontology in 1998 the rst person in Britain to hold this title. In 1998, Guys Dental School, the Dental School at Kings College Hospital and St. Thomas merged with Kings College London to form the Dental Institute of Kings College. Tom was very involved in developing the new curriculum and later amended the curriculum as required by the GDC. In 1997 he was appointed Vice Dean of the Dental Institute and in 2002 was appointed as Director of Education in the Institute. This position carried the responsibility for ensuring the effective delivery of the undergraduate and postgraduate taught degree programmes. Tom was presented with the Alumnus Distinguished Service Award in March 2008. In addition to these leadership and management roles, Tom continued to act as an examiner for undergraduate and postgraduate degrees both in London and other Universities. As you have read in the tribute by Dag rstavik, much of Toms research was devoted to studying the biocompatibility of various materials used in Operative Dentistry, as well as pulp capping agents, materials used in root canals, and those in contact with periapical tissues. Later work was concerned with the effect of bacterial contamination. He also investigated

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the use of Laser Doppler owmetry following traumatic injuries to determine the vitality of the pulp in anterior teeth in children. Further work was carried out on the biological response to surgical root-end procedures. Of particular note was the use of a new material, a mineral trioxide aggregate (MTA), which gave excellent results conrmed in a clinical outcome study. The material is now available commercially. Toms research was supported by many grants from a variety of sources and in total exceeded 245,000. He published 116 papers in refereed scientic journals and 11 papers in other journals. He wrote a number of text books including The Restoration of Teeth, which was also published in Polish and Indonesian. He was co-author, with Dag rstavik, of Essential Endodontology, now in its second edition. In addition, he revised Hartys Endodontics in Clinical Practice 4th and 5th editions and coauthored Endodontics Problem solving in Clinical Practice and Local Anaesthesia in Dentistry.

Tom had an extremely busy life but rarely looked stressed and even had time to treat patients himself. He was also a competent electrician, an expert plumber, builder and decorator. He was also a keen gardener. Tom leaves his wife Heather, a daughter and two sons to whom we extend our deep sympathy.

References
rstavik D, Pitt Ford TR (eds) (2008) Essential Endodontology: Prevention and Treatment of Apical Periodontitis. 2nd edn. Oxford, UK: Blackwell Munksgaard. Pitt Ford TR (ed) (2004) Hartys Endodontics in Clinical Practice. 5th edn. Edinburgh, UK: Wright. Pitt Ford TR, Rhodes JS, Pitt Ford HE (eds) (2002) Endodontics: Problem-Solving in Clinical Practice. London, UK: Martin Dunitz. Robinson PD, Pitt Ford TR, McDonald F (eds) (2000) Local Anaesthesia in Dentistry. Edinburgh, UK: Wright.

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A tribute from Dr Nick Chandler, former student at Guys Dental School, now in Dunedin, New Zealand

I rst encountered Tom in September 1976 when allocated to his Preclinical Class at Guys Hospital; he was to teach us the rudiments of Operative Dentistry. We were told that some of us would shine like 60 Watt bulbs, and some like 100 Watt bulbs. Tooth morphology was taught with coloured waxes; I showed him my wax premolar 14 times before he passed it; the group was counting, and we soon realized that amongst our teachers this man was never particularly easy to please. We found out later when carving large amalgam restorations that he had been right to push us hard. Tom was intensely practical. Our undergraduate group was invited to a building near Watford which he had turned into a surgery for his part-time work. He had done all the cabinetry, the plumbing, the electrics, all those things we would now ask a specialist installer to do, by himself. Not long after that Tom the builder was in action again, this time on major renovations to a house at Elephant and Castle in London; further evidence of his energy, practical mind and attention to detail. If someone could do the job themselves, then they were encouraged to do so. My most stressful Pitt Ford memory is of being the photographer at his wedding to Heather in Loughborough Parish Church. No professional was engaged, and I had never taken wedding photographs before. Tom seemed happy with the result; luckily he never saw the batteries falling out of the ashgun and rolling away under several pews during the service, with his guests scrabbling on the oor to pick them up and pass them back. Time was never wasted. On trains, a laptop appeared and papers were written or textbooks edited. During his visit to New Zealand, he was observed studying the nutritional information on a bag of apples. When asked, he declared this to be more interesting than our local newspaper!! Here, I discovered his knowledge of ne wines and classical music, and noted how he continued working when most people that far from home would have been out of sight and on vacation. With his smart suits and immaculate shirts (pure cotton of course) one might think that Tom kept a

classic Bentley somewhere in the Consultants car park. The truth was that his preferred mode of transport was a Bickerton folding bicycle, which somehow found a place parked in ready-to-ride form in his tiny ofce on the 27th oor of the Guys Tower. Here, with only elbow room, coffee was brewed (fresh of course) or tea served in china cups. Under a metre away on the shelf were the jaws of various species in plastic pots being demineralized. The importance of research to him was everywhere around. Perhaps any unusual tastes in our beverages was spilt EDTA?

Tom at Queenstown, New Zealand 1997.

Tom took the ultimate risk by having several PhD students carry out their research and write their theses overseas through the University of Londons External Programme. The same care and attention to detail spanned thousands of kilometres; an e-mail pointing out that I had hit the space bar twice between two words says it all. As a supervisor and in many other roles he invented his own brand and level of academic rigour. Nothing was missed, and if something was promised on a certain day and time, then it certainly happened. I have a Christmas card signed Ruthless, sent when a particular deadline was to be met during what I imagined were the holidays.

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Despite his incredible busyness, Tom was very generous with his time and shared the good and bad things with those around him; he had phenomenal patience when the going got tough. He will be greatly

missed, but he lives on in those who came in contact with him; most will be shining several Watts brighter than before as a direct result of his company and his mentorship.

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Commentary by Majinah Ahmad Ahmad M, Pitt Ford TR, Crum LA, Walton AJ (1988) Ultrasonic debridement of root canals: acoustic cavitation and its relevance. Journal of Endodontics 14, 48693

When I was asked to write about my collaborative work with Tom Pitt Ford, I considered it to be an overwhelming responsibility. This tribute can be a personal look at a life, a dening statement about the person whom I have known, worked and cherished. Being his rst postgraduate student, I was as eager as he was to see a successful outcome of the research project. Despite his numerous responsibilities, Tom gave his time, enthusiasm and showed great keenness during many illuminating discussions we had from 1984 until 1988. In the 1980s, considerable emphasis was placed on canal debridement on the notion that a clean canal greatly contributed and enhanced the high success rate of root canal treatment. In view of this, several cleaning devices were introduced into the market; one such instrument that gained much acceptance employed ow-through irrigation in combination with ultrasonics. In 1982, a concept known as cavitation was introduced into Endodontics by H. Martin and W. Cunningham. Cavitation is dened as implosion of vapour-lled cavities in the irrigation liquid due to changes in pressure when the ultrasonic le vibrated. Claims were made that the physical phenomena of cavitation could be generated by the ultrasonic instrument when used to clean the root canals that could contribute to very clean canals. Unfortunately, these claims had not been substantiated by independent scientic evidence and testing. In 1984, when Tom Pitt Ford suggested that these claims should be investigated, I considered it to be a daunting task: a good knowledge of basic physical principles was needed. But through close collaboration with two physical scientists, namely, L.A. Crum and A.J. Walton, some light was thrown into the cavitation phenomenon presumed to be generated by this ultrasonic instrument. Using sensitive image intensier equipment, the phenomena of cavitation was investi-

gated via light detection. The results of the experiment showed that although cavitation could be produced by the ultrasonic instrument in vitro, it could only be generated when the le was freely vibrated in the root canal at a displacement amplitude that was clinically unrealistic. At such an amplitude opportunity for breakage was high. Furthermore, we discovered that the anatomical constraints posed by the narrow and curved canals in vivo would dampen the displacement amplitude required for cavitation inception. It was interesting to note that in large straight canals when the displacement amplitude of the le was not dampened, cavitation could be produced; however, this phenomenon generated the formation of pits sparsely distributed at the apical end of the canal but failed to remove smear layer. This study therefore dispelled the popular view that cavitation would always occur during actual clinical procedures. When cavitation occurred, it contributed little to the cleaning of the root canal so critical in clinical practice, although in general, canals prepared by ultrasonic instruments were found to be generally cleaner possibly via different mechanisms such as acoustic streaming. The results of our studies generated further curiosity as to the mechanisms involved in ultrasonic debridement and formed a basis of further experiments cited in papers subsequently published by the authors and others. With the guidance of Tom Pitt Ford, a new body of knowledge was thus presented to the eld of Endodontics. Tom Pitt Ford was a person of few words and was kind at heart. He had an enthusiastic spirit, was a likeable person with a good disposition. Throughout my collaboration with Tom, I found him to be an excellent professional teacher and a dedicated researcher with a clear enquiring mind. Without doubt, his curiosity and thirst for knowledge had provided a great contribution to the science of Endodontics.

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Commentary by Francesco Mannocci and Tim Watson Mannocci F, Bertelli E, Sherriff M, Watson TF, Pitt Ford TR (2002) Three-year clinical comparison of survival of endodontically treated teeth restored with either full cast coverage or direct composite restoration. Journal of Prosthetic Dentistry 88, 297301

This paper published more than 6 years ago was, to our knowledge, the rst randomised controlled clinical trial produced on the survival of endodontically treated teeth. It was also the rst clinical trial in which the ability of adhesive techniques to restore posterior teeth without crown coverage was tested. The clinical success rate of endodontically treated premolars with Class II carious cavities, restored either with carbon bre post/composite cores or with carbon bre post/composite cores and crown coverage, was compared. At 3 years no difference was found between the two groups. This work raised considerable interest and was quoted in virtually every paper dealing with the subject in the following years. It was also reviewed twice in evidence-based journals (Basrani & Matthews 2004, Bolla et al. 2007). At present, randomised controlled clinical trials of endodontically treated teeth are scarce. In a recent systematic review of the literature, Bolla et al. (2007) attempted to assess the effectiveness of different post and core systems for the restoration of endodontically treated teeth by including studies with randomised or quasirandomised clinical trials (RCTs) to compare failures of endodontically treated teeth with different types of posts. They only found one more randomised prospective clinical trial on the subject, again by Mannocci et al. (2005). More randomised controlled trials appeared after the publication of this review (Ferrari et al. 2007, Cagidiaco et al. 2008). All of these studies have a design that is clearly inspired by our study of 2002, in which Tom Pitt Ford had a huge input. A massive effort was put into the planning of this trial in order to control as many variables as possible;

only teeth without previous endodontic treatment, with Class II carious lesions and preserved cusp structure were included. The selected teeth needed to be in occlusal function after restoration and were not used as abutments for xed or removable partial dentures. Teeth selected did not display loss of periodontal attachment exceeding 40%. For the evaluation of the presence of gingival inammation, the gingival index score was used. Subjects were excluded from the study if the gingiva bled spontaneously (gingival index score 3). All subjects received oral hygiene instruction from a dental hygienist. Subjects had to be healthy and willing to return at regular intervals for evaluation. It is fair to say that this study remains the best controlled amongst all the others that later appeared on the same subject. Tom Pitt Ford, in his stubborn inimitable way, gave an extraordinary contribution to the design of the trial; he was the one that insisted on a prospective trial, with only one operator carrying out all the procedures. Tom had a strong biological and scientic background and always did his best to construct rigorous testing procedures for new materials and techniques; but this did not stop him from loving innovations. In this respect this study was no exception, Tom appreciated the potential advantages provided by new adhesive techniques and had a lucid vision of the progress that could be made with their use.

References
Basrani B, Matthews D (2004) Survival rates similar with full cast crowns and direct composite restorations. Evidencebased Dentistry 5, 45.

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Bolla M, Muller-Bolla M, Borg C, Lupi-Pegurier L, Laplanche O, Leforestier E (2007) Root canal posts for the restoration of root lled teeth. Cochrane Database of Systematic Reviews 1, CD004623. Cagidiaco MC, Garc a-Godoy F, Vichi A, Grandini S, Goracci C, Ferrari M (2008) Placement of ber prefabricated or custom-made posts affects the 3-year survival of endodontically treated premolars. American Journal of Dentistry 21, 17984.

Ferrari M, Cagidiaco MC, Grandini S, De Sanctis M, Goracci C (2007) Postplacement affects survival of endodontically treated premolars. Journal of Dental Research 86, 729 34. Mannocci F, Qualtrough AJ, Worthington HV, Watson TF, Pitt Ford TR (2005) Randomized clinical comparison of endodontically treated teeth restored with amalgam or with ber posts and resin composite: ve year results. Operative Dentistry 30, 915.

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Commentary by Mahmoud Torabinejad Torabinejad M, Pitt Ford TR, McKendry DJ, Abedi HR, Miller DA, Kariyawasam SP (1997) Histologic assessment of Mineral Trioxide Aggregate as a root-end lling in monkeys. Journal of Endodontics 23, 2258

Thorough cleaning and proper shaping of root canals and sealing them carefully usually results in clinical and radiographic success of a high percentage of teeth requiring root canal treatment. Following careful evaluation of the aetiology, the preferred treatment of failing root lling cases is nonsurgical retreatment. Complexity of root canal systems, inadequate instrumentation and presence of physical barriers make it difcult to achieve ideal goals for nonsurgical retreatment. When nonsurgical efforts fail, surgical endodontic therapy becomes the rst alternative treatment to save the natural dentition. Because most endodontic failures occur as a result of egress of irritants from root canals into the periapical tissues, a root-end lling material is used to provide an apical seal. In addition to its ability to seal, an ideal root end lling material must be biocompatible with periapical tissues and promote regeneration of these tissues that have been altered as a result of pulpal and periapical pathosis. Numerous materials have been suggested as root-end lling materials. Despite its many disadvantages, amalgam has been the most commonly used root-end lling material, and any new lling material is usually compared with it. Most of these materials have been tested in restorative dentistry under circumstances that are different than present in periapical tissues. The materials used to seal the rootend cavities are in constant contact with moisture and bear little or no pressure. When I came up with the idea of using Mineral Trioxide Aggregate (MTA) (which provides good seal under moist conditions) I contacted Dr Tom Pitt Ford and discussed experiments to test its efcacy. Previous studies in this area lacked a systematic approach to the use of in vitro and in vivo tests. He helped me develop a set of laboratory, biological and animal studies before the use of MTA in humans. We

published a series of experiments together regarding MTA as a root-end lling material. The article that he and I like the most in that series is entitled Histologic assessment of Mineral Trioxide Aggregate as a root-end lling in monkeys and was published in the Journal of Endodontics. This experiment was the nal test to examine the suitability of a new root-end lling material. After demonstrating that MTA had similar or better properties compared with the commonly used root-end lling materials in in vitro tests, we performed a usage test in dogs. The use of MTA as a root-end lling material caused regeneration of new cementum over this material. This was a unique phenomenon that had not been reported to occur when other root-end lling materials had been investigated. To conrm this phenomenon and prove that the use of MTA as a root-end lling material results in complete regeneration of periapical tissues we used MTA or amalgam as root-end lling materials in six nonhuman primates and followed a clinical protocol for endodontic surgery in humans. After 5 months, the periapical tissues were evaluated histologically in a blind manner. We found no periapical inammation in ve out of six root-ends lled with MTA. In addition, we found ve of the six root ends lled with MTA had a complete layer of cementum over the resected root-ends and root-end lling material. In some specimens bre insertion into the new cementum covering MTA mimicked Sharpeys bres. In contrast, all root-end cavities lled with amalgam showed periapical inammation, and lack of cementum formation over this material. Dr Pitt Ford was so excited about these ndings that he knowingly called me at 3:00 in the morning when he looked at the histological slides for the rst time. The ndings from this study showed that complete regeneration of periapical tissues is possible when MTA is

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used as a root-end lling material. In contrast, the use of amalgam as a root-end lling material should be discontinued because it does not allow regeneration of the periapical structure. The stark differences between histological ndings in root-ends lled with MTA or amalgam in this study paved the way for the nal phase of evaluation of this material in humans. Today,

MTA is the material of choice for those who are looking for a material that seals well, is biocompatible and promotes regeneration of periapical tissues. Thanks to the insight and contributions of Tom Pitt Ford who helped us to examine this material systematically and use it as an aid to preserve the natural dentition.

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Commentary by Bun San Chong Chong BS, Pitt Ford TR, Hudson MB (2003) A prospective clinical study of Mineral Trioxide Aggregate and IRM when used as root-end lling materials in endodontic surgery. International Endodontic Journal 36, 5206

The whole is greater than the sum of the parts The above is the title of an editorial by Tom Pitt Ford published in this journal in 1983 (Pitt Ford 1983) with the purpose of informing readers of important changes to the journal. Tom alluded to the fact that the success of the journal was very much a team effort. Fittingly, and as exemplied by this study, it also applies to the dynamic and synergistic teamwork needed to ensure the successful execution of any research venture. Mineral Trioxide Aggregate (MTA) was developed as a new root-end lling material at Loma Linda University, California, USA. Tom was there at the outset of the MTA story. He was the supervisor of Mahmoud Torabinejads 1995 PhD thesis Investigation of Mineral Trioxide Aggregate for root-end lling. MTA was extensively investigated in the laboratory and in animals. Unlike a number of dental materials that are not moisture-tolerant, MTA actually requires moisture to set. MTA was shown to have good sealing ability and hard tissue repair was observed directly on the surface of the material, a unique property not seen with other root-end lling materials. As a result, MTA was actively promoted for root-end lling during surgery. By then, a commercially available formulation had also come on the market. Yet, there was no clinical study on the performance of MTA as a root-end lling material. As a seasoned researcher, Tom had a healthy scepticism of anything that had not been subjected to thorough scientic evaluation. Therefore, he set about planning, designing and securing funding for this, the rst randomized prospective clinical study on the use of MTA as a root-end lling material. The primary aim of this study was to compare the success rate of MTA with IRM (Intermediate Restorative Material). A secondary objective was to investigate if radiological signs of healing were completed more quickly with MTA.

The study demanded diligence, perseverance and meticulous attention to detail, all the hallmarks of Toms character. The study consisted of many stages: preoperative and suitability assessment, preparatory treatment, the surgical procedure itself, suture review, postoperative assessment and recall to determine treatment outcome. There were more than 10 forms to complete for each patient. Not unexpected, we experienced problems during this study, most of which will be familiar to veterans of clinical research. One of the difculties encountered was the failure of patients to return for reviews and the complex reasons were analysed. The features of note with this study include the strict entry requirements and stringent, established criteria for assessing treatment outcome. Surgery was carried out by endodontic specialists rather than general dental practitioners or junior hospital staff. In addition, IRM instead of amalgam was used as the control, as it was considered unacceptable and unethical because there are clear disadvantages with amalgam. The study commenced before the publication of the CONSORT guidelines on the reporting of clinical trials. Nevertheless, a breakdown of the ow of patients through the study, an essential and key element of CONSORT was included in this paper. The results of this study showed that the use of MTA as a root-end lling material led to a high success rate, although it was not signicantly better than using IRM. The radiological signs of healing were more advanced with MTA than IRM at both time periods. The impact of this study was to conrm that careful case selection, the employment of modern surgical techniques and instruments, combined with newer root-end lling materials lead to a very favourable treatment outcome. This and additional studies on other potential root-end lling materials played a signi-

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cant role in improving the outcome of periradicular surgery and conning to history the use of amalgam for root-end lling. Meta-analysis and literature reviews often conclude that there is a lack of good randomized controlled trials and more are needed. This routinely repeated mantra may be interpreted as insufcient enlightenment and appreciation of the challenges in designing, performing and securing funding for randomized controlled trials.

It is an honour and a privilege to have been a leading member of Toms team of clinical academics and one of his long-standing research collaborators. Toms legacy lives on.

Reference
Pitt Ford TR (1983) Editorial: The whole is greater than the sum of the parts. International Endodontic Journal 16, 1.

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Commentary by Ram Nair Nair PNR, Duncan HF, Pitt Ford TR, Luder HU (2008) Histological, ultrastructural and quantitative investigations on the response of healthy human pulps to experimental capping with Mineral Trioxide Aggregate: a randomized controlled trial. International Endodontic Journal 41, 12850

A friend and learned colleague remembered An e-mail from Dr Heather Pitt Ford to me on Monday, 18 August 2008, carried the grave message that in the early hours on the previous day, Tom passed away peacefully in his sleep, at home. Professor Thomas (Tom) Pitt Ford was yet to reach the age of 59 in November 2008. The message shocked me although I knew that Tom had not been very well for quite sometime and had been under medical care. He recovered, at least so I thought, because he presided over the PG seminar that I gave to his students just 2 months before and enthusiastically engaged in the discussions that followed! It was also just 2 months earlier, in February 2008 that our collaborative research, reprinted here, found fruition in the International Endodontic Journal. Tom and I were partners in the Mineral Trioxide Aggregate (MTA) research project initiated between me (Institute of Oral Biology, University of Zurich, Switzerland) and him (The Dental Institute, Kings College London, UK), sometime in 2002. We knew that the success of the project depended on the convergence of high clinical skill and expertise on modern histomorphological processing and evaluation of the tooth material. Tom had extensive knowledge of MTA, as he was involved in the development of the material. Because of the heavy administrative load that he carried, it was obvious to Tom and me that we needed an able clinician to do the day-to-day clinical aspects of the project. During the course of the preliminaries of the project, Tom reached the choice in Dr Hal Duncan, as the suitable clinical partner for the project. This was the context in which Tom Pitt Ford, Hal Duncan and me worked together on the MTA project, thereby combining our resources and expertise. The study was extensive yet comprehensive and was published in the February 2008 issue of the International

Endodontic Journal with selected illustrations from the paper appearing on the title page. The paper has been well received by the endodontic community, as we could judge from the numerous requests for PDFs and also enthusiastic reference to it in Endodontic conferences. Tom has been a tall gure in the world of Endodontology. He has contributed much to the development of Endodontology in Britain, Europe and the World at large at various capacities as clinician, teacher, researcher, author, editor, administrator and organizer. Toms major legacy will probably be his extensive publications in the form of original research papers, reviews and books, which he wrote and edited. As a contributing author to Essential Endodontology it was a pleasure for me to have worked with Tom as my editor. His departure at the prime age of 58 leaves a vacuum in the world of Endodontology. I have known Tom since 1989 when we met for the rst time in Amsterdam at the ESE conference. As the then editor of the International Endodontic Journal, he expressed appreciation for the well illustrated and written paper that I published shortly before in the Journal of Endodontics. True to his character, Tom was reserved, soft-spoken and low-key in conversation. His serious demeanour masked the underlying sensitive and gentle person. Our casual acquaintance in Amsterdam eventually grew into various academic interactions, mutual respect, book-projects, collaborative research and friendship. Personally, I found Tom a modest, very gentle, honest, knowledgeable and trustworthy colleague with a great sense of subtle British humour. My wife Ruth and I feel very fortunate to have come to know Tom and his equally professional and gently supportive wife Heather.

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