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Odontogenic pain
L. Daniel

The most frequent pain in the orofacial district is certainly that of dental
origin, as consolidated by the broadest clinical experience [1].
Despite the significant progress that has been made, especially in some
countries, in terms of caries prevention through water fluoridation programs,
health education and an increase in the number of people who have access to
dental hygiene services, dental caries and other pathologies responsible for
oral and dental pain are still widespread and this is one of the major health
problems.
Dental pain is considered a great simulator due to the remarkable
polymorphism with which it is expressed, which makes it easily confused
with other algic manifestations of the orofacial region.
Dental pain can originate from nociceptive nerve endings present inside the
teeth, activated by external stimuli that affect the dentin and the pulp: the
main causal agents are the bacteria that cause caries, pulp exposure and,
consequently, the pulpitis. Or it can originate from the periodontal tissues,
especially the periodontal ligament that surrounds the apex and root of the
tooth.
Endobuccal pain can also come from the oral mucosa which covers the hard
and soft tissues of the oral cavity. Pain of mucosal origin can mostly be due
to trauma, such as occurs during tooth eruption, or it can be caused by
systemic viral diseases, such as herpes simplex, measles, immune system
dysfunction or even from neoplastic diseases.
The nerve fibers of the dental pulp, dentin, gingiva and periodontal ligament
are specialized in guaranteeing different types of sensory information; they
are necessary for the normal activity and function of the teeth, for the
maintenance of the tissues and for the response to harmful stimuli. The hot
and cold sensations felt at the level of the tooth depend on the innervation of
the dentin, while the information concerning the contact between the teeth,
the movements performed during
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chewing, phonation and mandibular reflexes depend on mechanoreceptors

and nociceptors present at the level of the periodontal ligament, and therefore
outside the tooth [2].
Neuroanatomy and Physiology show us how these receptors are positioned at
the level of the apical third of the ligament and are mostly non-encapsulated
mechanoreceptors similar to Ruffini's corpuscles. Ruffini endings are located
at the periodontal level and, interacting with the trigeminal ganglion, provide
the conscious sensation of contact between the teeth, while the midbrain
trigeminal neurons reach the periodontal receptors responsible for
unconscious proprioceptive reflexes [3,4].
In theFigure 2.1the sensory innervation of the dentin, pulp and periodontal
tissue of a mature tooth is illustrated. The innervation of the dentinal tubules
of the most coronal portion of the dental pulp is much more intense and
numerous than the less coronal and more apical portions. In fact, in the area
identified with the letter A the innervation of the tubules is equal to 40%, in
area B 4-8%, in area C 0.2-1% up to area D in which the innervation of the
dentinal tubules is equal to 0.02-0.2%. The enlargements show the pulp
fibroblasts (F) with the nerve fibers (N) which position themselves on the
odontoblasts (O) and around the odontoblastic process (or Thomas' fiber),
penetrating inside the dentinal tubules.
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Fig.2.1Sensory innervation of the dentin, pulp and periodontal tissue of a

mature tooth. F, pulp fibroblasts; N, nerve fibers; O, odontoblasts. (From:
Cattaneo L, Baratta L. Stereograms of human anatomy – The mouth. Milan:
Ciba-Geigy Edizioni; 1985; modified.)

The innervation of the periodontium is guaranteed by mechanical Ruffini

receptors connected with large and medium caliber nerve fibers, and by
nociceptors innervated by small caliber nerve fibers with rare non-
encapsulated endings.
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Furthermore, in the periodontal ligament there are acute and polymodal

nociceptive fibers of the A-δ and C types that terminate in association with
the blood vessels and within the bundles of the ligament itself [5].
The nerve fibers located outside the root react to the inflammation of the pulp
and contribute to the generation of dental pain through processes of
sensitization, growth and modification of their cytochemical component [6].
Pain is the main sensation felt inside an inflamed or injured tooth, regardless
of whether the stimulus is thermal, electrical, mechanical, bacterial, osmotic
or chemical.
Teeth are capable of producing two different qualities of pain: short-lived
focal pain and widespread pain. Widespread pain, precisely because of this
characteristic, can lead to difficulties and can be confused with other oro-
facial painful situations at the time of diagnosis. This so indefinite location of
pain may be due both to the considerable dispersion of the nerve fibers
present in the brain stem [7] and to their equally extensive peripheral
branches between different teeth, and to the nerve ramifications and
vasodynamic reflexes present between the teeth and the supporting tissues
[8]. The inflammatory state also causes significant changes in the receptor
territories of sensory and central neurons [9,10].
Until the teeth are seriously damaged by a noxious stimulus, the painful
sensation is short-lived. The sensory nerve fibers present within the tooth
terminate at the level of the coronal pulp and at the level of the coronal
dentin, in extensively branching endings which are adjacent to the
odontoblasts, but are not in contact, by means of synapses or gap junctions,
with the latter (you seeFig.2.1). Important studies on dental pain in humans
[11-13] have demonstrated that the movement of fluids within the dentin
occurs whenever a stimulus (thermal, mechanical, osmotic, etc.) causes a
rapid outflow of interstitial fluid, such as it occurs when the dentin tubules
are exposed at the level of the cervical portion of the root or in case of crown
fractures. Studies conducted on single fibers of animals have shown that the
sensation of sudden and sharp pain is correlated with the innervation of the
myelinated A-δ-type dentin, and that the short and dull pain depends on the
slow-conducting A-δ fibers and from the slightly or not at all myelinated C
fibers present in the pulp [14-16] (Tab. 2.1). In the normal tooth there are also
receptors, in a silent or latent state, which become active once
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that tissue damage has occurred and inflammation is present. A-β fibers have
properties similar to A-δ in most experimental conditions and determine a
brief sensation of "pre-pain" when the stimulus has a low intensity [17].

Tab. 2.1Correlation between nerve fiber type and pain

type

Numerical data demonstrate that nerve conduction velocity is much higher outside the tooth
than inside the pulp.
From: Ikeda H, Tokita Y, Suda H. Capsaicin-sensitive A delta fibers in cat tooth pulp. J Dent
Res 1997;76:1341-9.

The process that leads to the activation of sensory-type receptors present in

the dentin is characterized by a movement of fluids which, through
hydrodynamic mechanisms, activates the distant nerve endings of the A-δ
and A-β type present in the innermost portion of the tubules of the dentin and
near the pulp organ [13]. In the past, a sensory function was attributed to the
odontoblasts, mainly due to the sensitivity of the enamel-dentine junction and
the presumed presence of odontoblastic extensions at this level. It is now
clear that neither the odontoblastic prolongations nor the nerve endings reach
the enamel-dentin junction [18]. The sensitivity of
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Enamel-dentine junction should be caused by the transfer of extracellular

material from this site to sensory receptors in the innermost portion of the
dentin or in the periphery of the pulp. The sensory endings do not form
synapses or gap junctions with odontoblasts, but some of the larger diameter
fibers form adhesive-like junctions with the cell body of these cells,
presumably to anchor their nerve endings near the exit holes of the dentin
canaliculi. [13,19].
Damage localized at the pulpal level leads to the activation of A-δ and C
fibers, which are polymodal and chemosensitive, with a receptor mechanism
different from that present at the level of the sensory apparatus of the dentin
[20].
During aging, dentin thickness increases and pulp volume decreases;
consequently the innervation changes its position and shrinks [21,22]. This
fact suggests that dental innervation can modify the volume and cytochemical
aspects of the sensory apparatus in relation to the production of local growth
factors. Although the nerve fibers of the teeth have various functions (among
them the vasoregulation of the pulp), these, as happens in all patients
suffering from dental pain, are capable of signaling short or acute noxious
episodes through stabbing pain (for example, as the moving bur tip breaks
through the enamel-dentine junction) or through pain due to inflammation of
the pulp. Once the pulpal inflammation has taken place, complex reactions
occur resulting in changes in function, structure, cytochemistry, axonal
transport, expression of ganglion genes, and central nerve cell connections,
such that a stimulus that would not normally be detected becomes painful,
resulting in increased of the range of receptors present at the level of dental
neurons [23]. Cytochemistry and neural function change again when the
healing process proceeds to a state comparable to a state of well-being or
when the damage within the tooth and its nerve fibers becomes irreversible.
in the expression of ganglion genes and in the central connections of nerve
cells, so that a stimulus that would not normally be detected becomes painful,
with the consequent increase in the range of receptors present at the level of
dental neurons [23]. Cytochemistry and neural function change again when
the healing process proceeds to a state comparable to a state of well-being or
when the damage within the tooth and its nerve fibers becomes irreversible.
in the expression of ganglion genes and in the central connections of nerve
cells, so that a stimulus that would not normally be detected becomes painful,
with the consequent increase in the range of receptors present at the level of
dental neurons [23]. Cytochemistry and neural function change again when
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the healing process proceeds to a state comparable to a state of well-being or

when the damage within the tooth and its nerve fibers becomes irreversible.

Pain transmission
Transmission represents the process by which information
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it is transferred not only to the medulla, but also to the structures of the CNS
responsible for processing the pain sensation, i.e. the ascending transmission
system.
Nerve endings of the primary afferents, i.e. peripheral A-δ and C fibers, form
synapses according to a precise anatomical pattern within the posterior horn,
maintaining spatial localization of peripherally applied stimuli. Second-order
nociceptive neurons, with the cell body in the dorsal horn and with the axon
endings in the contralateral thalamus, are divided into two types: those that
respond to weak stimuli and that increase the response when the stimulus
becomes more intense (noxious), and those that respond to exclusively
noxious stimuli. These neurons are defined as WDR (Wide Dynamic Range)
and NS (Nociceptive-Specific) respectively [24-26].
However, some nociceptive impulses activate second-order neurons of other
types. Directly or via interneurons, they stimulate somatomotor and
sympathetic preganglionic neurons, respectively, thus generating reflex
nociceptive responses such as reflex muscle contraction or vasoconstriction.
In this case we speak of segmental responses.
Returning to the ascending transmission system, the A-δ fibers, responsible
for the transmission of "fast" or "first pain" pain, would transmit to second
neurons which, moving contralaterally to the anterolateral cord of the
medulla, would form the neo- spinothalamic (pauci-synaptic). Following a
relay at the thalamic level, it would go on to transmit at the level of the
primary cortico-sensory area. Conversely, the C fibers, with little or no
myelination, would transmit "slow" or "second pain". They would come into
contact with second neurons which, also moving to the contralateral
anterolateral cord, would form a polysynaptic pathway, the paleo-spino-
thalamic pathway. It, after a relay at the thalamic level,
A descending system of pain transmission is correlated to the ascending
system of pain transmission, an inhibitory modulation system starting from
the periaqueductal gray (PAG) and from the nucleus of the raphe magnum
(NRM) [28,29]. Endorphins, enkephalins, dynorphins and exogenous opioids
act on this system, characterized by noradrenergic and serotonergic
neurotransmission. The nerve endings of the neurons, belonging to this
endorphingic system, contact directly, at the level of the horns
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dorsal, with I and II order neurons, hyperpolarizing them and, therefore,

reducingthe intensity of the depolarization wave linked to the painful
stimulus (Fig.2.2).

Fig.2.2Scheme of transmission of pain stimulus to the CNS.

Clinical considerations
A correct diagnosis of pain localized in the tooth or in the surrounding tissues
requires knowledge of the anatomy as well as a systematic approach which
allows obtaining information and conducting an appropriate clinical,
instrumental and radiographic examination. As a general approach, the
history and description of pain are the first and perhaps the most important
information in the assessment provided by the patient. The patient should
give the dentist a detailed description of the pain when it occurred, during the
interval between the first episode
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painful and the clinic visit, and during the visit itself. Detailed information
regarding the location and distribution of pain should be obtained, as well as
the quality, intensity, frequency, periodicity and duration of pain should be
assessed. If the pain is not constant, information about the period of the day
during which the painful attack occurs, the stimuli capable of provoking this
attack and those which, on the contrary, are able to relieve the painful
symptomatology, must be obtained. In addition to a general clinical
examination of the mouth, the subject's response to all diagnostic
instrumental tests such as percussion of the tooth, application of a hot or cold
stimulus, electrical stimulation and radiographic examination must be
evaluated; exams that will be widely described later. It is also important to
compare the responses of the affected tooth with those of the contralateral
tooth.

Dentistry
It is the classic "toothache" and can originate from the pulp tissue present
inside the tooth or from the periodontal structures surrounding the root, from
the exposure of the dentin or the root surface and, to a lesser extent, from
occlusal traumatisms and causes iatrogenic. Dental pain not associated with a
well-defined pathology is called "atypical odontalgia". These conditions are
summarized inTable 2.2.

Tab. 2.2Pain of odontogenic origin

Clinical signs
Condition Etiology
and
symptoms
Pain
located,
also irradiated
to the arch
contralateral,
towards
of the temple or
Caries ear; button
(Bacterial type,
Pulpitis infection of
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the
12

dentin) intermittent,
increased by
sweet, hot,
cold stimuli
Clinical and
radiographic
signs of
caries are
evident
Easily
located,
throbbing,
long-lasting
pain,
sometimes
increased by
heat
Clinical signs:
Intracanal
Periodontitis Sensitivity to
infection
percussion,
tissue edema,
often an apical
radiolucent
lesion is
evident on
radiographic
examination
Intermittent,
brief, sharp,
stabbing pain.
Lateral
chewing and
percussion
increase the
Facial or pain,
dental trauma radiography
when chewing does not
Tooth infringement or
fracture
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of objects orfoodis useful if not

for horizontal
fractures or for
particularly
serious vertical
fractures

Poorly
localized,
intermittent,
acute pain,
resulting from
Hydrodynamic mechanical,
stimulation thermal,
Pain due to exposed dentin and caused by sometimes
cementum infringement even sweet
of the pulp- stimuli Clinical
dentin junction signs:
considerable
exposure of the
dentin or
cementum on
the root of the
tooth
Poorly
localized pain
Progressive involving the
exposure of the upper and
coronal dentin lower teeth on
resulting in both sides of
Bruxism pain rapid bacterial the mouth,
contamination dull ache
of the pulp Clinical signs:
veneer wear,
enamel loss
and exposure
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of the dentin
occlusal
Very well
localized,
intermittent,
stabbing pain,
barodontalgia
or pain
perceived
during
Procedures modifications
Acheiatrogenodentalpressural in badconducting planes; The
contact
between
different types
of metals
causes
galvanic
currents that
can stimulate
the dental pulp
Dental caries is the main etiological agent of periapical pulp disease.

Cavity
This disease is a complex pathological process which involves bacterial
infection of the organic component of the inorganic matrix of the tooth with
consequent biochemical alterations which cause the loss of the calcified
tissue protecting the pulpal tissue [30]. The cariogenic process is often slow
in enamel and the pulp tissue may have time to form secondary dentin as a
protective barrier against microbial attack. In any case, without interventions
such as antibacterial measures, diet control, fluoride applications, removal of
decayed dental tissue, followed by replacement with reconstruction material,
the course of the pathology is characterized by bacterial invasion of the
dentinal tubules and
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by inflammation of the pulp, with subsequent spread of the infection to the

periodontal ligament space and periapical tissues. Pain may or may not be felt
as these disease processes progress. Although this remains a controversial
consideration, only a modest correlation between pain characteristics and
histopathologic status of the pulp has been demonstrated [31-33]. However,
pain remains a factor capable of predicting the extent of caries in the dentin
quite effectively.

Acute pulpitis
The progression of caries and the penetration of bacteria into the dentinal
tubules cause an inflammatory process in the dental pulp which activates
chemically and physically mediated nerve stimulation (the increase in
intrapulpal pressure is the main cause of pain in acute pulpitis) [ 34].
Pain of pulpal origin is often difficult to localize and is typically radiated
towards the eye and temple for the teeth of the upper arch and towards the ear
for those of the lower arch [35] (Figs. 2.3And2.4).

Fig.2.3Decayed lower second molar in acute pulpitis.

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Fig.2.4Radiographic view and extent of caries.

The pain of pulpitis can also be felt without an apparent stimulus or be

caused (or aggravated) by different stimuli, tactile, pressure, chewing, in
contact with sweet, hot, cold foods. There does not appear to be a strong
correlation between the degree of pulpal pathology and the pain felt in
response to the stimulus [32]. When the pain is acute, it takes on a pulsating
and burning character and can also be characterized by paroxysms of
considerable intensity. The pain is most often of an intermittent nature,
lasting from a few minutes to a few hours; percussion exacerbation is not
usually associated with mild pulpitis but may occur if pulpitis is severe.
However, there is a large number of pulpits – even up to 40% according to
the various studies – which occur without pain;

Acute apical periodontitis

It is the most frequent consequence of acute untreated pulpitis. The bacterial
infection, through the apex of the root, penetrates the space of the periodontal
ligament and the alveolar bone contributing to the more generalized orofacial
inflammatory process. Pain caused by inflammation of the periodontium is
similar in quality and duration to pain of pulpal origin. Unlike the pain of
acute pulpitis, it is throbbing in nature and longer in duration. The infected
tooth is generally easier to locate
17

by the patient and the clinician. The intensity varies according to the severity
of the inflammatory process, the cellular destruction, the amount of pus
present and the extension of the infection.
When pulp necrosis is caused by gas-producing microorganisms, heat applied
to the tooth often causes a severe exacerbation of pain. The administration of
iced water determines an improvement of the painful symptoms.
A predominant feature of periapical inflammation is sensitivity to percussion
of the tooth. In addition, the patient may report feeling the affected tooth as if
it were taller, so that closing the mouth becomes painful from the anticipated
contact between the teeth.
Acute periapical inflammation can be associated with osteolysis, visible
radiographically as a periradicular radiolucent area, superimposing an acute
picture on a chronic picture, also called "phoenix abscess" (Fig.2.5).

Fig.2.5Lower second premolar with apical radiolucency; typical observation of dental

elements affected by acute pathologies superimposed on chronic conditions

In general, there is no strong correlation between radiological findings and

pain symptoms [37].
Sometimes, in some untreated patients, acute apical periodontitis is followed
by the formation of an intraoral fistulous tract which allows drainage of the
purulent material, thus causing a decrease in pain.

Post-treatment acute apical periodontitis or flare-up

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endodontic
The "flare-up" is a not rare occurrence characterized by severe pain and/or
swelling following an endodontic treatment; more recently, another term that
equally well defines the problem has been introduced in the literature:
Endodontic Interappointment Emergency (EIE) [38]. The explanation of such
a clinical picture lies in the establishment of a bacterial infection initially
supported by anaerobes and subsequently, as soon as a cavity is created
which allows oxygen to enter the endodontic space, by aerobes [39]. The
rapid increase of microorganisms is the cause of the inflammation.
There is also a second type of flare-up which is reported by the patient 10-12
hours after the endodontic treatment, complaining of pain and showing a
swelling; in the latter case the inflammatory episode would be supported by
an immune mechanism, which can be proven by demonstrating the presence
of immunoglobulins in the periapical area. Indeed, it may happen that, during
root canal instrumentation, the antigens present in the root canal are pushed
beyond the apex. In that area, the antigen-antibody complexes could be
formed which would activate the complement and could lead to acute
inflammation [40].
Flare-up-related pain is acute, short-lived, very intense pain that begins soon
after initiating treatment of an asymptomatic tooth or that persists after an
initial emergency session.
From the data of Tsesis et al. [38], the prevalence of flare-ups on
endodontically treated teeth would be 8.4%: the main causes explaining the
occurrence of flare-ups would be multiple endodontic sessions, retreatments,
periradicular pain prior to treatment, presence of lesions radiographically
evident periapicals. There is no correlation between flare-ups and gender, age
and location of the teeth.

Cracked tooth syndrome

One of the pathologies that can question the diagnostic ability of an operator
in the endodontic field is surely the cracked tooth syndrome (SDI). SDI is the
incomplete fracture of any portion of a vital tooth, characterized by
sensitivity to heat, cold and sweets associated with pain when chewing. It
turns out, most of the
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sometimes difficult to diagnose as it is not easy to highlight the fracture both

clinically and radiographically [41].
Although it is a pathology of not recent acquisition, it has had clinical
relevance only in recent years as an increase in the incidence has been noted,
probably due to a longer persistence of the molars in the oral cavity and to an
increase in masticatory parafunctions [42].
The teeth that are most affected are the lower molars in subjects aged
between 40 and 49 years; the causes capable of determining an incomplete
fracture are different and can be summarized as follows: chewing accidents,
external traumas, parafunctions and iatrogenic causes (preparation of non-
conservative carious cavities) [43].
As previously stated, the diagnosis of SDI is not easy as it is based only on
the symptoms reported by the patient (pain in heat, cold and on percussion)
which cannot be supported by any objective or radiological sign (the crack
tends to have a mesio-distal course).

Dental fracture
Teeth that have been weakened by decay, major reconstruction or root canal
therapy, and unrestored teeth that have been subjected to excessive loading
(such as occurs in bruxism or teeth grinding) are very susceptible to fractures
and breaks (Figs. 2.6And2.7).

Fig.2.6Coronal fracture on a vital tooth due to bruxism.

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Fig.2.7View of the fracture after removal of part of the coronal tissue.

In the vital tooth, pain is produced by hydrodynamic mechanisms [44] or by

inflammation of the pulp caused by the infiltration of oral fluids and
microorganisms across the fracture line, while in the non-vital tooth, pain
comes from irritation of the periodontal ligament (Figs. 2.8And2.9).

Fig.2.8Radiograph of an endodontically treated tooth with vertical fracture.

21

Fig.2.9View of the fracture line after opening a surgical flap.

The pain is intermittent, of short duration and is described as sharp and

violent. Eccentric (lateral) chewing often causes an exacerbation of pain [45].
During the examination of the oral cavity, the percussion of one or more
cuspids can reproduce the painful symptoms. The fracture fissure proper is
often difficult to detect, and x-rays are usually not helpful. Staining solutions
are available to help spot any infractions that are early stage fractures. It is
important to underline that the presence of signs and symptoms indicating a
fracture can also be detected in teeth in the normal state, therefore this sign
alone cannot be considered sufficient for the diagnosis. In an advanced stage,
when the external fracture line becomes colonized by bacteria,

Exposure of dentin and cementum

Sensitivity in healthy teeth is believed to be the result of a hydrodynamic
stimulation of the nerve extensions of the innermost portion of the exposed
dentinal tubules [44]. A sharp, intermittent pain often follows a mechanical,
thermal, or chemical (soft) stimulus. It is usually not difficult to locate the
pain of the affected tooth. Clinical examination reveals exposure of dentin or
root surface (cementum) in avital tooth, which may also show signs of
erosion or abrasion (Fig.2.10).
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Fig.2.10Lower teeth with extensive cervical erosions and considerable exposure of the
dentin.

Bruxism pain
Bruxism pain, or clenching and grinding pain, is thought to be the result of
prolonged trauma resulting in inflammation of the periodontal ligament or
pulp.
Traumatic pain is described as a generalized dull ache involving the
maxillary and mandibular teeth on one or both sides of the mouth. This
widespread oral pain often accompanies myofascial pain dysfunction and
must be differentiated from this pathological condition and from pain of
psychological origin.

Iatrogenic pain
Odontogenic pain can also be caused by an incorrect maneuver by the
odontostomatologist. Among these procedures we can mention: incorrect
dental preparations, i.e. without the use of cooling air-water spray, the
presence of galvanism (i.e. formation of an intraoral electric cell) associated
with the contiguous presence of different metals such as amalgam, gold and
silver, lack of seal between the reconstruction material and the tooth, fillings
that are too high or with pre-contacts [46,47], situations that lead to
sensitization of the pulp organ and, if not resolved in time, to possible
pulpitis. Also barodontalgia, that is the pain felt during the pressure variations
of the plane flight or in case of change of
23

altitude, may have an iatrogenic cause associated with the inclusion of liquid
or air under the filling [48,49].
These intermittent pains are described as sharp and stabbing. Pain associated
with traumatic nerve injury, as may occur in orthognathic surgery, in
orthodontics with too intense and rapid forces or in incorrect insertion of
dental implants, can present as paroxysmal characterized by electric shocks
or sudden acute pain, or it can be described as a persistent burning pain.

Atypical odontalgia
The underlying causes of atypical odontalgia are unknown. Given the lack of
an evident underlying pathology, it has been hypothesized that chronic pain
perceived at the level of the tooth or gingiva could be of neuropathic origin
[50,51] and that, perhaps, it could be maintained by a sympathetic
mechanism [52,53].
Other factors historically linked to atypical odontalgia are vascular changes
or psychological conditions such as depression and stress. The pain, or throb,
of atypical odontalgia persists for hours and is continuous, mild to moderate
to severe. Its duration varies from a few months to years. The pain can be
focal but more often it is diffuse, radiating and migratory [54]. It is frequently
exacerbated by procedures such as coronal repositioning, periodontal therapy,
or a surgical procedure. Pain may migrate to sites adjacent to the initial ones
following tooth extraction. Although epidemiological research on dental pain
is generally limited and data on atypical odontalgia are scarce, it is
recognized that this pathology has a higher frequency in females.

Septum syndrome pain

Another type of pain, not exactly of dental origin, to be included in this area
is that caused by the prolonged stagnation of food between the teeth. Initially,
a pressure sensation can be perceived with a dull pain which can later take on
a throbbing character.
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Trauma to the gingiva, as occurs during tooth eruption, or coronal fractures

with compression of the periodontium, also lead to the generation of pain.
Normally the removal of the broken portion of the tooth or of a possible
foreign body contributes to the cessation of the painful symptoms.

Postoperative pain
This type of pain is not so uncommon and usually occurs in the days
following endodontic therapy. Some studies [55] describe a pain prevalence
of 64% after root canal preparation, but less than 10% of patients show
severe pain. Pain after endodontic filling, in the first 48 hours, occurs in 40%
of patients, but less than 12% of them complain of severe pain [56].
Recent research has shown that the prevalence of postoperative pain 24 hours
after surgery is higher after treatment of vital teeth than that found in
treatments of necrotic or previously treated teeth [57].
On the other hand, the persistence of pain from 1 to 5 years after endodontic
treatment, even with complete radiographic filling of the canals, reaches
12%; the factors that constitute an element of risk are: the presence of
preoperative pain, the duration of the preoperative pain, the presence of pain
on percussion, the intake of systemic therapy with steroid drugs, the presence
of previous chronic pain in the orofacial region [58-60].
Non-odontogenic pain following endodontic therapy is also described in the
literature; it is defined as dentoalveolar pain present for 6 or more months
after endodontic treatment without obvious dental pathology. From a
systematic review and meta-analysis of 770 scientific articles it was found
that non-odontogenic pain persists in 3.4% of cases [61]. These researches
must make the clinician reflect on the possibility of not achieving complete
success of the case due to the "inexplicable" persistence of pain despite the
evident execution of a correct endodontic therapy, fully respecting the rules
of the state of the art in endodontics.
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51. Parashos P, Vickers ER. Atypical odontalgia. Aust Endod J 2000;26:121-3.
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post-obturation pain in patients undergoing root canal treatment. Int Endod J
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prospective cohort study. Int J Dent 2012;20(12):310-467.
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postpreparation pain ,in patients undergoing two-visit root canal treatment. Int Endod J
2004;37:29-37.
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28

61. Nixdorf DR, Moana-Filho EJ, Law AS, McGuire LA, Hodges JS, John MT. Frequency
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analysis. JEndod 2010;36:1494-8.

Endodontic diagnosis
M. Badino

Introduction
Pathologies of the endodontium and periapical tissues are very common, just
think that around 75% of visits required in public dental facilities in Western
countries are due to acute pathologies of the dental pulp and supporting
tissues. Pathologies of endodontic origin, if they occur, must be interpreted as
events of a medical nature for which it is necessary to pass through an initial
diagnostic phase, to understand what is the cause of the patient's symptoms.
This will serve to bring the clinical picture back to a specific pathology; once
the latter has been ascertained, the formulation of a correct treatment plan
will be the natural consequence [1].
However, the clinical situations concerning the dental elements affected by
problems relating to the endodontium, including or not the periodontal tissues
adjacent to the root apex, are not always easy to interpret, both due to the
anatomical peculiarities concerning the nervous system which carries the
algic and proprioceptive sensitivities of the teeth, and for the progression –
sometimes subtle, sometimes slow – of the diseases involving the dental pulp
[2-4].
Added to this is the impossibility, up to now, of having sufficiently specific
and sensitive diagnostic tools available; in fact, it is not possible to establish -
with a high approximation - whether a dental element affected by a pathology
affecting the pulpodentinal system has a clearly identifiable histopathological
picture and, as such, is diagnosable [5-7].
Only through a specific, duly structured path, it is possible to arrive, with a
good approximation, at the diagnosis and, consequently, at the planning of a
correct treatment plan [8].
It is therefore necessary to develop a methodology for conducting the
29

visit – for endodontic problems in particular – that is reproducible and, above

all, easy to put into practice in daily work [9].

Medical history and its clinical implications

The importance of carrying out a correct anamnesis transcends medico-legal
issues. The primary collection of a complete medical history must first allow
the patient to be framed in its entirety, to evaluate any general pathologies
that may be considered a concomitant risk factor, and then direct the patient
to the most appropriate treatment for the problem of endodontic origin
identified [10,11].
For reasons of speed and reproducibility, it will be possible to arrange for the
patient to register and fill in a questionnaire, perhaps with a minimum of
assistance from the paramedical staff, to be sealed with a signature; the
dentist, therefore, must carefully read the answers provided and ask for
clarifications on the patient's general conditions. In cases of particular chronic
infections - in which the risk of cross-infections may be high, both for
subsequent patients and for medical and paramedical personnel - such as viral
hepatitis, herpes virus infections, positivity for the HIV virus or venereal
diseases it will be good to accurately identify the state of illness in order to
put in place additional protection mechanisms for the dentist and all auxiliary
personnel,
It is also possible that, – if the above conditions lead to a particularly serious
state of disease for the patient, – the diagnosis of pulpal or periapical
pathology is followed by a treatment plan that does not include endodontic
treatment but avulsion of the dental element or the prescription of a drug
therapy.
It is not infrequent to observe patients taking medicines for chronic
pathologies; it will be advisable, also in these cases, to calibrate any
endodontic intervention taking into account this factor. In fact, if the patient
is subjected to pharmacological therapies that may interact with drugs that
may be administered after endodontic therapy, it seems necessary to make a
careful preliminary evaluation of the endodontic treatment,
30

perhaps even contacting the patient's own doctor.

General medical contraindications to endodontic

treatment
In general, there are no specific contraindications, however some preliminary
considerations must be made, related to the times and methods that some
endodontic treatments require.
There are pathological states in which – both for problems related to the acute
or chronic pathologies from which the patient is affected, and for
pharmacological problems inherent to the pathologies under therapeutic
control – a careful assessment of the opportunity must be made before
proceeding whether or not to perform endodontic treatment.

Blood dyscrasias

Coagulation defects

Haemophilia.It is erroneously thought that the haemophilic patient is a

patient that is difficult to treat in the dental field. In clinical cases of
irreversible acute pulp pain, only an endodontic treatment will solve the
problem, as this type of therapy is decidedly preferable to extraction: in fact,
it is rare that a pulpectomy or normal endodontic procedures cause copious
blood losses. The dental extraction that many haemophilic patients undergo,
which causes disinterest and fear towards them by the dental class in the early
diagnosis phase, can instead create much more serious problems due to the
difficulty in obtaining a complete coagulation process.

Alterations of coagulation from drug therapy.An analogous discourse to

what is described in the pictures related to coagulation defects can be made
for patients - increasingly numerous - in therapy with antiplatelet or
anticoagulant drugs. Usually all odontostomatological procedures can be
performed with INR values equal to or lower than 3.5 [12]. Furthermore,
endodontic therapies in the strict sense do not
31

they cause copious bleeding and, as such, can be performed without

difficulty.

Diabetes.There is no contraindication to endodontic treatment in a

pharmacologically compensated diabetic patient. However, the control of a
diabetic state can be delicate and easily altered by the stress that any dental
procedure entails; acute pain, typical of dental elements that can undergo
endodontic treatments, can become a determining factor for the relapse of the
diabetic disease. In this type of patient, premedication with paracetamol and
non-steroidal anti-inflammatory drugs provides little help, as does the
administration of anxiolytics [13].

Cardiovascular diseases.There are no contraindications to endodontic

treatment in cases of hypertension, especially if this is controlled
pharmacologically, while, in the case of previous myocardial infarction or
valvular heart disease, a specific protocol must be used depending on the type
of therapy that must be faced to cure the endodontic pathology responsible
for it [14].
The use of anesthetic solutions devoid of any vasoconstrictor reduces the
potential of the anesthetic itself, becoming practically ineffective for the
intended purpose [15]. If the painful sensation is not eliminated, the patient
may become tense and anxious and, consequently, release a much higher
amount of endogenous adrenaline than that contained in an anesthetic
solution [16-19].
The main danger to the heart patient, or anyone with damaged heart tissue, is
subacute bacterial endocarditis; it is advisable to consult the patient's
cardiologist for the possible administration of preventive antibiotic therapy
according to the prophylaxis schemes (see Chapter 11).

Respiratory diseases.The patient with respiratory system diseases should be

considered particularly at risk for endodontic procedures, since the use of the
rubber dam could be an element that aggravates the dysfunction; there are no
other phenomena if you don't show allergies to anesthetics, which are very
rare.
32

Endodontics in pregnancy.It is evident that the state of pregnancy imposes

significant restrictions for the treatment of dental pathologies; however, a
precise understanding of the real needs of the future mother is advisable.
Literature data [20-22] advise operators to concentrate treatment during the
second trimester of pregnancy and to avoid exposure to radiogenic sources
throughout the gestation period.
As far as endodontic treatments are concerned, it is clear that emergency
procedures must be implemented under the strict supervision of the attending
physician, especially when medical therapies must also be carried out.

Patients with liver disease or disorders of the digestive

or urogenital tract
The problems related to hepatic dysfunction associated with endodontic
pathologies are very limited; they can be linked to the transmission of
infectious agents (hepatitis C and B viruses) to medical or paramedical
personnel and to the lack of control of cross-infections.
There are no absolute contraindications to the treatment of these patients
except those related to the simultaneous administration of drugs, as well as
for all other categories of patients who, being already in therapy with
different medicines, should also include in their carnet other medicines
necessary to overcome the postoperative stage.
The same argument can be extended to patients with dysfunctions of the
urogenital system or other areas of the digestive system, or subjects with
previous or intercurrent peptic ulcers and individuals with malabsorption
diseases who would not adapt to the prolonged intake of anti-inflammatories
[20 ].

Diagnostic path
Recognizing and treating pain is the most challenging task for the dentist. An
understanding of all aspects of pain will be a useful basis for the diagnosis of
odontogenic pain; often, in fact, from its intensity, localization and recurrence
it will be possible to trace, even before the intraoral examination, the
pathological alterations that caused it.
33

Dental history
The dental history very often identifies the problem and accompanies, in the
first instance, the diagnostic process; it is important to listen to the patient
during the description of the symptoms, guiding him with clear and precise
questions.
It is also true that collecting the correct information is difficult, therefore it is
good to guide the patient in the description with specific questions (Table
2.3).

Tab. 2.3Specific questions for the dental history

● How long has it been since the last dental checkup?
● Did the problem arise after recent dental treatment?
● How long ago did the trouble start?
● Is the pain reported spontaneous or provoked?
● In the case of spontaneous pain, what is the frequency?
● Does the pain increase during sleep or as the patient lies down?
● In the event that the pain is caused, it is good to have the patient specify what the
triggering factors are: thermal variations such as heat or cold, the ingestion of sweet
foods or chewing
● Is the pain localized or radiated?
● Is the pain sharp, dull, throbbing, continuous or intermittent?

Finally, it will be advisable to observe how the patient indicates the painful
area or, in simpler and more fortunate cases, the tooth itself responsible for
the pain.

Clinical examination
Once an accurate anamnesis has been carried out, the clinical examination
will be carried out: it can be schematically divided into extra- and intraoral
examination. It is good practice to start from the extra-oral exam.

Extraoral exam.Externally it is advisable to evaluate whether there are

swellings in the face and whether there are facial asymmetries. A palpation
maneuver of the submandibular lymph node stations and of the neck can
evoke pain and make the perception of swelling; will not be overlooked
34

presence of skin fistulas.

Intraoral exam.The intraoral examination will obviously concern both soft

and hard tissues; in the first case, the conditions of oral hygiene, the presence
of whitish or reddish mucous lesions, swelling, redness, the presence of
fistulas or scars from previous surgical operations will be evaluated
(Fig.2.11).

Fig.2.11Purulent exudation typical of periapical lesions of endodontic origin.

In the second case, the teeth will be checked to evaluate the presence of
caries, occlusal abrasions and, in the cervical third of the teeth, the presence
of small fractures both in the enamel and in the conservative restorations, the
color alterations and, with the aid of instruments specific such as periodontal
probes, thepresence of periodontal pockets and the degree of gingival
bleeding (Fig.2.12).
35

Fig.2.12Resolution of purulent exudation after adequate endodontic treatment.

From the previous description it is perfectly understood that the clinical

examination must be carried out completely, in order not to be limited to
specific analyzes on one or more dental elements which could be misleading.

Clinical Trials
As previously described, there are no specific and sufficiently precise tests to
diagnose the state of health of the pulp of a dental element.
The objective of these tests is to judge, with sufficient approximation,
whether the pulpodentinal system of a dental element is affected by a
reversible or irreversible inflammatory process; or if the inflammatory
process, as previously described, can be solved by the organic component of
the residual healthy pulp, or if a reversibility of the inflammatory process is
possible, or if the pulp itself must be eliminated, in the case of judgment of
irreversibility of the pathology.
In cases where the disease of endodontic origin has also affected the
supporting tissues of the tooth, it will be the objective of the diagnostic
process
36

verify if it can be eradicated through the decontamination of the endodontic

space, whether it is carried out orthograde or retrograde.
The clinician is therefore able, through the use of coordinated tests, to
investigate the conditions of the pulp tissue of dental elements, where there is
the suspicion of the presence of an endodontic pathology; the interpretation
of the answers to the tests that will be described below will allow the
formulation of the diagnosis. However, this result is often conditioned by the
patient's emotional state and by concomitant factors such as the assumption
by the patient of painkillers, anxiolytics and hypnotics.
All these elements can raise the pain threshold with the result of obtaining
false answers from the patient.
In fact, there is the possibility of registering false positives or false negatives,
in particular when it is necessary to evaluate dental elements in which the
presence of several root canals - some not affected by pathological processes
and others, perhaps, already degenerated - can lead us to give interpretations
wrong.
The complexity of interpreting the results of some tests, as opposed to the
advantage represented by both the simplicity of implementation and the cost-
effectiveness of most of them, remains a strong point of the diagnostic path
that the odontostomatologist must face.
The most suitable tests for identifying pulpal or periapical pathologies of
endodontic origin will be listed below.

Anamnestic findings and preliminary diagnosis

See theTable 2.4.

Tab. 2.4Diagnostic scheme

Anamnesis
● Specific questions about:
● Site
● Pain accurately referable or confused and radiated
● Accentuation with hot or cold food or chewing
● Duration of pain symptoms (continuous or intermittent)
Clinical examination
● Objectivity
● Soft tissue
● Dental surfaces
37

Semeiological tests
●
● Thermals
● Electric
X-ray examination
Diagnosis and prognosis

Instrumental tests

Percussion examination (Fig.2.13).It is a test that is carried out by applying

a little pressure with a finger on the dental element under examination and,
subsequently, by beating it gently with the handle of a mirror. It is useful for
detecting the presence of an inflammatory state of the periodontal ligament,
but it can also give indications on the state of health of the dental pulp. In this
way it will be possible to diagnose acute apical periodontitis, a consequence
of pulp inflammation that is no longer reversible, but it is advisable to place
ligament inflammation linked to an occlusal trauma and those linked to
periodontal disease in the differential diagnosis.

Fig.2.13Percussion to highlight pain.

Palpation examination (Fig.2.14).

It is carried out by applying light digital pressure to the suspected area,
apically to the dental element, both in the vestibular and palatal or lingual
areas, in order to verify whether the patient experiences any painful
symptoms, a pathognomonic sign of an apical periodontitis or an abscess in
38

acute phase. It is essential to carry out this maneuver even when dental
mobility is detected or suspected, following a trauma (seeTab. 2.2), a dental
fracture associated with a simultaneous infringement of the alveolar bone.

Fig.2.14(to)Buccal palpation examination and (b) assessment of tooth mobility.

Exams with thermal stimulation.These are tests that are based on the ability
of the pulp to evoke pain-like sensations, depending on the state of
inflammation, if stimulated with thermal stimuli, whether hot or cold.
It is not infrequent to already have feedback from the patient in this regard:
the pain evoked by cold stimuli, often burning and not coercible in the short
term, is in fact common in the stories of patients who come to observation for
irreversible pulpal problems. The same can be said for the problems, perhaps
prognostically more serious, described when drinks or hot foods are ingested,
even if there is no consensus data in the literature [23-25].
The thermal tests are therefore confirmatory of what has already been
described by the patient and, no less important, they must always be used
with a comparative method, as the pain threshold differs from patient to
patient. Therefore, during the conduct of this test, it is always advisable to
test the sensitivity threshold on healthy contiguous teeth or homologous
contralateral teeth not affected by intercurrent or previous pathologies.

cold test (Fig.2.15).An agent is normally used, ethyl chloride stored in the
liquid state under pressure in special containers, the vaporization of which
transforms the compound into a crystalline state which can reach
temperatures between −10 °C and −25 °C. The test is carried out by placing a
small cotton ball soaked in the liquid, then placing it on the cervical
vestibular face of the dental element under examination, after drying, taking
care not to involve other
39

adjacent teeth or the periodontium. The response to the cold stimulus of a

normal pulp is positive and disappears immediately after the cessation of the
stimulus itself. The patient feels only a passing discomfort; if, on the other
hand, the pain is greater in the tooth that is supposed to be involved in the
pathology, this may be an indication of pulpal inflammation. The lack of
response could be due to a state of pulp necrosis or the presence of pulp
sclerosis with consequent atrophy of the residual pulp. An equivocal response
to this test is very common in traumatized teeth [26].

Fig.2.15Cold stimulation using a cotton ball soaked in ethyl chloride.

In cases of severe spontaneous pain, the very cold stimulus can provide the
patient with temporary relief; the patient himself, during the anamnestic
examination, reports having noticed that the intake of very cold water
relieved the acute pain. In the latter case, the diagnosis of irreversible pulpal
disease is almost certain.

heat test (Fig.2.16).This examination, positive when there are large areas of
colliquative necrosis and abscess formations inside the pulp chamber, can be
used, not systematically, as an accessory examination in dental elements in
which the response to cold has been found to be doubtful. It can also be used
- as a confirmation - when the patient reports pain symptoms associated with
the ingestion of hot foods or drinks. To practice the examination, warm gutta-
percha can be used, placing it on the buccal surface of the tooth under
examination, or a hot instrument of the "heat carrier" type can be used [27]. It
is also possible to use rubbers for gold burnishing or for polishing composites
mounted on a contra-angle, turned without the aid of water. A normal pulp
tissue responds positively and within a few seconds, once the stimulus is
removed, the response ceases. It's very important when you do this
40

type of examination, keep both anesthesia and cold water close at hand
because, in the event of a serious inflammatory state of the pulpal tissue, a
hot stimulus can trigger a very strong pain, which can be alleviated with
appropriate cooling.

Fig.2.16Warm stimulation using heated gutta-percha.

Examination with electrical stimulators.This examination is based on the

transmission of electric current to the nerve endings of the pulp; it is normally
used after other tests, in case of dubious answers or to confirm an already
supposed diagnosis.
Reliability often depends on the validity of the equipment used and the
number of false positives and negatives can be very high.
It should be remembered that this test cannot be performed in cardiac patients
with pacemakers [24,28].

Examination with execution of cavities (Cavity test) (Fig.2.17).In some

cases, after many dubious answers obtained with all the other tests or when
the teeth under examination are covered with prosthetic products, a small
cavity can be made – using a small diameter diamond bur, under water
irrigation, mounted on a handpiece contra-angle or high-speed turbine,
without having applied anesthesia – on the dental crown in the occlusal area
of the posterior teeth and palatally or lingually in the anteriors. Once the
surface has been pierced, contact with the dentin will cause initial pain in the
case of vital pulp; in the absence of pain, it will most likely be possible to
suspect an atrophic, sclerotic, calcified pulp state or even necrosis of the pulp
itself. It is a very specific examination and to be reserved for all cases in
which the other tests do not confirm the diagnostic hypothesis.
41

Fig.2.17Cavity test to be conducted only in very doubtful cases.

Examination of anesthesia.Similarly to the above mentioned, in some

circumstances, anesthesia examination may be resorted to. If a patient
complains of diffuse pain that cannot be clearly defined in one quadrant of
the mouth, often also referred to the homologous antagonist side, by carrying
out a selective anesthesia it is possible to locate the responsible tooth. It is
recommended [13] to carry out intraligamentary anesthesia at the vestibular
level of the tooth and not in the interproximal area, because in this way the
adjacent tooth can also be anesthetized and thus distort the patient's response.

Transillumination examination.It plays an accessory role, useful for

highlighting small cracks, dental fractures, interproximal caries; it is used in a
preliminary phase of the examination of the dental compartment and, with the
aid of optical fibers or powerful light sources, it is possible to appreciate the
deformities of the dental crown which may be a prelude to an involvement of
the pulpal organ.
It is normally also combined with another exam for the diagnosis of both
vertical fracture and cracked tooth: the latter is performed by making the
patient bite a wet cotton roll on the teeth under examination, thus causing a
slight divarication of the dental fragments, if present , with relative painful
sensation.

Possible evolutions of diagnostic tests

Examination by pulse oximetry (pulse oximetry).It is an experimental,

non-invasive test, which is based on tools that have long been used in
medicine to determine the oxygen saturation of peripheral tissues. The
principle of operation consists in the emission of a light beam of two
42

different wavelengths (760 nm, red light, and 850 nm, infrared light) passing
through the tooth and being picked up by a photodetector; the difference
between emitted and received light is calculated by an electronic circuit to
provide the oxygen saturation rate present within the pulpodentinal system
[29-31].
Oxyhemoglobin absorbs less red light than deoxyhemoglobin; it is the ratio
of the absorption of the two wavelengths which provides the percentage of
blood oxygenation.
A very important prerogative for the reliability of this test is the absolute
immobility between the probe emitting the light beam and the tooth; the latter
must be isolated by rubber dam and must be covered with gel at the point of
application of the tip of the probe to increase light transmission.
Since there is no dedicated system in dentistry, this examination can be
carried out by modifying the "ad hoc" probes in hospitals or similar
structures, and has its real efficacy in the diagnosis of anterior dental
elements affected by trauma.

Examination by laser-Doppler flowmetry.It is an experimental test that

allows the blood flow of the dental pulp to be measured non-invasively [32-
35].
Clinically it is implemented by directing a probe emitting a laser beam with a
wavelength of 632.8 nm towards the tooth which, upon encountering red
blood cells in movement, will be deflected, while a portion of the light will
be rejected outside the tooth and scattered in a photodetector ; the
measurement of this portion of light can be considered an index of pulpal
blood flow.
Pulp circulation assessment represents a considerable improvement over
conventional methods for ascertaining tooth vitality, considering that the
latter only detect tooth sensitivity. The great utility of the examination is
therefore immediate, especially in cases of traumatized teeth which initially
result negative to thermal and electrical tests due to the reversible damage to
the sensitive nerve fibres.
However, this recent method requires precise positioning of the probe on the
tooth surface and is impracticable on teeth with metal restorations, which
would interrupt the passage of the beam.
Laser-Doppler flowmetry, having the non-invasiveness as its main advantage,
given by the lack of pain sensations felt by the
43

patient, and the greater certainty of results, lacking the subjective component
of the patient himself, could in the future be of good help for the evaluation
of dental vitality.

Examination through TLP (Transmitted Light

Photoplethysmography).It is another experimental examination, by which
the light transmitted in photoplethysmography on vital and non-vital
permanent teeth is recorded; some studies [36] confirmed that TPL can be
used to detect the presence of pulpal blood flow and thus can be applied in
the diagnosis of pulpal vitality, but, at present, no dedicated instrument has
appeared on the market.

Radiographic examination as a diagnostic aid.The diagnosis in

endodontics cannot be separated from the radiological examination; in fact, a
careful study of the radiography assumes a role of primary importance.
However, the radiological image represents a two-dimensional picture of a
three-dimensional space and therefore it will be up to the operator to establish
the correlation between the radiogram itself and the anatomical formation
under examination. Furthermore, it should be remembered that periapical
pathological lesions that are difficult to interpret are often limited to the bone
marrow alone and are not highlighted in traditional radiographic examination
[37-41] and, furthermore, the extent and dimensions of the lesions themselves
are underestimated compared to the representation radiographic.
It is not the object of this chapter to examine in full the radiological problems
in endodontics, however some brief excursus will be useful to better explain
the diagnostic problems (Figs. 2.18-2.20).
44

Fig.2.18X-ray taken with the centering device. It highlights a monocanal endodontic

anatomy at the level of the upper premolars.

Fig.2.19Radiograph taken with a mesio-distal projection on the same teeth, which highlights
the presence of three canals in the first premolar and two canals in the second premolar.
45

Fig.2.20(to)Radiography of little value. It will hardly help to make a correct diagnosis.

Considerable distal bone loss at 33. (b) Strong hypersensitivity to both touch (brushing) and
thermal substances. Caused pain. No tooth mobility. (c) After 3 months, initial nocturnal pain
of severe intensity. Spontaneous pain. To thermal tests very painful response that persisted
for a few minutes. Endodontic treatment.

Complementary radiological examinations and possible

evolutions of diagnostic investigations
Still in the dental field, there are currently other latest generation
technological means which allow, especially in the planning of oral surgery
or implantology operations, to have the greatest amount of information on the
morphology, dimensions and quality of the bone. The advent of CT and
subsequent Dentascan programs marked a fundamental step forward in the
diagnostic investigation of bone sites, allowing precise programming of the
type of intervention and prediction of its evolution.
This important method has been the protagonist of a continuous evolution in
terms of hardware and software, which has made it possible to achieve an
important goal: obtaining data in ever shorter times.
Currently a new technology finds its point of reference in the new concept
digital volumetric tomograph dedicated to the imaging of the dento-
maxillofacial area. It is a CT system that uses cone beam technology [37].
With this radiological technique it is possible to visualize the endodontium
and the periapical tissues in a three-dimensional way.
From a careful review of the literature and from the experience of the
Authors in endodontic surgery, it has been shown that pathological lesions
limited to the
46

bone marrow alone are often not highlighted in conventional radiographic

examination and, moreover, that the size and dimensions of the lesions
themselves are decidedly wider in surgical reality than their radiographic
representation [39,40].
In the literature there are quite a few contributions in which it is possible to
deduce that the treatment of all endodontic problems is not always possible;
in fact, dealing with complex clinical pictures with long-standing lesions,
larger than 10 mm in diameter, perhaps with concomitant fistulas and
previous root canal treatments, becomes an operation whose long-term result
is the subject of many discussions on the real success of the same [38].

Pathological pictures to be diagnosed

The dental pains to be diagnosed are substantially attributable to two major
pathologies; the pathologies linked to states of pulpal inflammation judged to
be no longer reversible and the pathological pictures of the periapical tissues,
whether acute or chronic.

Pulp pathology: clinical pictures

As already partially mentioned and reported in theTable 2.2, the forms of
pulp pathology can be traced back to two broad categories: reversible pulpits
and irreversible pulpits.

Reversible pulpitis
Precisely establishing the reversibility or non-reversibility of an inflammatory
process affecting the dental pulp is a very difficult undertaking. The
dependence on many factors and cofactors that are not well quantifiable is
often disorienting and the diagnosis, by virtue of the combination of these
causes, remains veiled by areas of uncertainty.
Further elements such as the age of the patient, the site of the carious lesion,
the experience of caries of the subject, just to name a few, are then inserted
almost independently.
Therefore, the more the subject is young, has a limited experience of caries
and the anatomical location of the carious lesion is favourable, i.e. distant
from the dental pulp, the more it will be possible to estimate the
47

repair process by the residual intact pulp, once the pathogenic noxa has been
removed.
Histological data, as demonstrated by a very consolidated literature, are
almost never associated with clinical pictures and, considering that they are
not available in daily practice, they are useless for practical diagnostic
purposes.
The clinical data, mediated by what is reported above, which can lean
towards the diagnosis of reversibility of the pulp pathological process are
summarized inTable 2.5.

Tab. 2.5Clinical data to establish the reversibility of the

pulp disease process
● Ache
● only provoked and never radiated
● fleeting to thermal stimuli
● Objective: carious lesion
● primary
● superficial
● Clinical trials with mild responses
● Dentine hypersensitivity

It is an intermediate clinical picture that can mimic a form of irreversible

pulpal pathology, but with a very lively symptom procession in the presence
of thermal stimuli and with a more limited objectivity. It is typical of carious
and non-carious lesions of the cervical third.
It is also not uncommon after a metal filling, after aggressive conservative
procedures or following excessive removal of the cervical root cement. This
can occur as a result of incorrect brushing maneuvers with the consequent
brief painful reaction of the pulp caused by the intratubular movement of the
dentinal fluid (hydrodynamic theory) [42].
This phenomenon can be ascribed to a very precise and defined anatomical
reason: the loss of the epithelial attachment, associated or not with a
chemical-mechanical erosion of the root cementum and part of the dentin of
the coronal cervical third, connects the pulpodentinal system with the oral
cavity. As previously described, thermal variations can generate a painful
response as the dentin fluid, for osmotic reasons, is
48

systematically drawn towards the oral cavity, as the fluid contained by the
envelope made up of enamel and root cementum, which are particularly thin
in that anatomical area, is no longer present.
There are various remedies for this paraphysiological state, all attributable to
a sealing of the patent dentinal tubules, whether performed with resinous
materials or with combined restorative-periodontal interventions.

Irreversible pulpitis
As previously described, irreversible pulpitis can sometimes have very
different clinical and histopathological pictures. In full-blown cases it is
described by the patient in very precise ways: the pain - in its most acute
forms - often occurs at night, when the patient is lying down or when the
patient assumes a sloping position, most likely due to an increase in blood
pressure of blood in the pulp chamber district.
The subjective sensations are always the most indicative: from feeling the
tooth "different" from the others to the transient symptoms related to the
ingestion of liquids or cold or hot foods, up to violent, stabbing, throbbing,
unbearable pain. However, generally, the pain is triggered by the cold and is
a pain that does not resolve when the irritating cause is removed, but
continues for a few minutes and sometimes even for hours. In some forms of
irreversible pulpitis, in the more advanced stages, cold water gives immediate
relief, having an astringent effect on the vascular flow which has remained
functional and thus reducing intrapulpal pressure; in these situations, on the
other hand, the heat exacerbates the painful sensation.
A peculiarity of the irreversibility pictures of pulpal pathology is represented
by the irradiation of pain, typically towards the chin and towards the ear in
the teeth of the lower arch and, in the elements of the upper arch, in the
direction of the auriculotemporal, zygomatic, orbital areas and to the wing of
the nose depending on the location of the affected tooth.
The radiographic examination cannot provide direct information, but detects
any presence of interproximal caries not evident on clinical examination,or
caries under old restorations near the pulp (Figs.
2.21And 2.22). The apical-periapical area usually appears intact and,
normally, the periodontal ligament space is intact; in some cases, it may
present a slight enlargement, a sign of a progression of the
49

pathology. In other radiological pictures, the condensation of the trabecular

pattern of the periradicular bone can provide an element in favor of the
diagnosis of irreversibility. This phenomenon has been repeatedly described
as “periapical sclerosis” [43].

Fig.2.21Spontaneous pain in the lower right premolar area. The radiograph showed a carious
process, interproximal, under an old amalgam restoration.

Fig.2.22Endodontic treatment, after pre-endodontic reconstruction.

An advanced acute pulpitis normally presents a periapical periodontal

involvement and the diagnosis is easier as there is also a painful
symptomatology on percussion of the dental element. This is due to the
involvement of the proprioceptors present in the periodontal ligament; the
patient himself, by precisely locating the responsible tooth, can be of great
help in the diagnosis phase.
50

Necrosis
Pulp necrosis is a sequela of one or more episodes, perhaps subacute, of
inflammation of the pulp, although it is an immediate arrest of circulation
following a traumatic lesion and the evolution of deep periodontal disease
involving the apical vascular-nervous bundle of the tooth can also be causes
determining a partial or total necrosis of the dental pulp.
The inflammatory process induced by the bacteria and the continuous
alterations of the pulp tissue determined by it lead to the formation of one or
more zones of colliquative necrosis which, if not addressed, generate a total
necrosis of the pulp tissue; the pulp hardly becomes completely necrotic
quickly, although, as already mentioned, the irritants, bacterial and non-
bacterial, can begin their destructive action - direct or mediated - on the
periapical tissues.
There are situations, for example in multi-rooted teeth, in which not all the
pulp tissue has undergone the process of necrosis and the areas of pulp still
alive can be misleading as regards the tests aimed at determining the state of
pulp involvement. The symptomatology of the tooth with necrotic pulp is
usually without notes; however, as stated above, various and subtle pains,
linked to islands of pulp tissue in which nerve endings survive, can be alarm
bells. Furthermore, it is not uncommon to hear pain associated with chewing,
deriving from the involvement of the periapical tissues by a parcelal pulp
necrosis; in fact, on palpation, we can easily highlight a slight swelling with
little mobility of the dental element,
The radiographic examination does not highlight anything striking except a
slight enlargement of the space of the periodontal ligament (Figs.
2.23And2.24).
51

Fig.2.23Slight pain on palpation apically at 26. Negative vitality tests. The radiograph
showed a slight enlargement of the periodontal ligament on the distal-buccal root.

Fig.2.24Endodontic treatment. Presence of necrotic pulp in all canals.

Periapical pathology: clinical pictures

As already mentioned, irreversible inflammatory pathologies of the pulp are
one of the causes of disease of the tooth support apparatus. We have already
talked about the close relationship between the pulp and periradicular tissue
and, therefore, it is understandable how an inflammation of the pulp can
cause inflammation at the level of the periodontal ligament; when the
necrosis involved significant parts of the dental pulp, bacteria (directly or
with their own toxins), immunological agents and products of tissue
breakdown and necrosis, from the intracoronal and intraradicular district
52

they reach the periradicular area, passing through all the existing
communication routes between the endodontium and the periodontium.
The reaction to a harmful stimulus, which passes from the root canal to the
periapical tissues, can only be of two types: an acute reaction or a chronic
type reaction. As already mentioned, due to bacterial causes, there is hardly
an ab initio ma acute reaction, but it is more frequent to see a periapical
reaction of a chronic nature, which is followed by one or more episodes of an
acute nature.
We will therefore talk about two clinically characteristic diseases, which are
chronic apical periodontitis (PAC) and acute apical periodontitis (PAA).

Chronic apical periodontitis (PAC)

The flow of bacterial toxins and their degradation products, together with the
intervention of the body's defense cells, aimed at limiting the bacterial load
and removing the bacterial and non-bacterial catabolites, determines the
formation at the apical level of a phenomenon, typical of inflammation,
called a granuloma. It is a slow process, often without obvious clinical signs,
often detected through radiographic examinations ordered for other reasons.
Being linked to processes of massive destruction of the dental pulp, it is
never associated, during its evolution, with directly determined clinical
symptoms.
A mild sensitivity during chewing can be felt by the patient, a sign that is
often insignificant but which should always be paid attention to in the
anamnesis phase.
Pulp examinations often indicate greatly diminished or even absent
sensitivity to thermal and electrical stimuli. Percussion can be positive, as can
palpation in the fornix area. It is not uncommon to evoke even marked
tenderness in the periapical areas of teeth affected by PAC; it is also frequent
to perceive a certain swelling of the areas close to the lesion.
A characteristic and characterizing sign is the presence of a fistula,
sometimes secreting serous or purulent liquid, often the result of an acute
episode that went unnoticed or managed autonomously by the patient.
A comparable picture is that found in the presence of a periapical
odontogenic cyst, whose diagnosis, as already mentioned, is impossible
except by histological route, but whose clinical behavior and therapeutic
resolution differ little from that reserved for PAC.
53

Acute apical periodontitis (PAA)

Acute inflammation localized at the level of the periapex is called PAA; in its
evolution it involves all the supporting tissues of the tooth, primarily the
periodontal ligament, to then expand into the bone marrow, evolve into the
bone cortex, affect the subperiosteal area and encroach on the alveolar
submucosa. In severe cases it can also progress to the integumentary tissues
or involve structures such as the floor of the mouth and parapharyngeal areas
up to the mediastinum (Fig.2.25, Clinical case 1).

Complications of periapical pathologies

The case of this periapical pathology corresponds to a 17-year-old girl who

complained of pain referred and localized in the fourth quadrant. The patient
reported having performed a pulpectomy and having been discharged with
therapy based on amoxicillin, with a dosage of 1 g per day. An accentuation
of the difficulty in swallowing had made her suspicious and brought her back
to the observation of the dentist.
On clinical examination, swelling of the right hemimandible, redness in the
mediastinal area and enlarged cervical lymph nodes were highlighted,
appreciable during palpation.
An in-depth radiographic study by CT revealed a serious picture of latero-
cervical and mediastinal dissemination of the septic process which, if not
treated with aggressive antibiotic therapy, could have brought very serious
consequences to the patient's health.
54

Fig.2.25(a)Lower molar with previous pulpotomy. (b) Orthopanoramic examination showing

a mild apical radiolucency in 47. (c) CT image showing an increase in volume of the face
and neck. (d) CT shows leftward deviation of the internal organs of the submandibular region
and leftward shift of the trachea. (eg) CT shows a leftward deviation of the internal organs of
the submandibular region and a leftward shift of the trachea. Furthermore, a collection of
material organized in the right submandibular region is highlighted.

From the extent of the acute inflammatory situation and from the
involvement of the tissue structures it is easy to understand how varied the
symptomatological pictures can be.
It is advisable to distinguish the various phases and to associate their clinical
and symptomatological kits.
For ease of reading we can rely on the following diagram:
● Stages of acute apical periodontitis:
55

● periodontal;
● alveolar;
● subperiosteal;
● submucosa;
● integumentary.

Periodontitis
The first tissue to be involved, in the initial stages of PAA, is, of course, the
periodontal ligament and inflammation can be caused by multiple etiological
agents. In teeth with advanced irreversible pulpal pathologies, it is easy to
distinguish the signs of a PAA, in the form of pressure pain reported by the
patient and confirmed by percussion tests that can be performed during the
odontostomatological visit. Even radiographically, a slight enlargement of the
space of the periodontal ligament, called ectasia, can be appreciated. In the
more advanced stages, in which part of the pulp can be abundantly necrotic,
the inflammatory process confined to the periodontal ligament can cause an
expansion such as to make the dental element higher and therefore
perceptible, only in the closing movement, by the patient.
The symptomatological picture, however, must be the subject of reflections
when one is faced with a tooth that responds positively to tests to certify its
vitality, or a tooth with healthy pulp; in fact, an occlusal trauma due to a
recent restoration not suited to the patient's occlusion or chronic
parafunctions can be responsible for a picture of acute periodontitis, since
this is not caused by bacteria present in the endodontium (Fig.2.26).
56

Fig.2.26Endoperium anatomical communications, after endodontic treatment.

Furthermore, it is not infrequent to observe this same picture as a

consequence of recent endodontic treatments which have led to apical over-
instrumentation, the cause of limited dissemination of bacteria or infected
dentinal residues beyond the limit of the apical foramen. Also in this case the
pain, sometimes intense when percussion of the tooth, is generated by the
accumulation of exudate between the fibers of the ligament, which are thus
stretched. In these cases, it is advisable to lighten the dental element in the
occlusal contacts and prescribe a medical therapy based on non-steroidal anti-
inflammatory drugs (see Chapter 11) to relieve the pain. Palpation in the
apical area can also evoke pain (Fig.2.27).
57

Fig.2.27Acute pain on percussion and chewing after root canal treatment at the level of the
second upper premolar; there is a slight outflow of material beyond the apex.

Alveolar phase
In cases where the pathology is of frank endodontic origin, after passing the
apical periodontal ligament, the acute process encroaches on the medulla of
the maxillary or mandibular bone. In this phase the symptomatological kit
differs little from that previously described; there may be more marked
periradicular tenderness on palpation.

Subperiosteal stage
Among the evolutionary phases of the acute pathological process, it is
undoubtedly the most painful. Sharp pain, extreme sensitivity of the tooth to
touch and very evident swelling are its salient clinical features. The pain is
throbbing and the patient may report feeling pulsations synchronous with the
heartbeat in correspondence with the tooth; furthermore, as in the previous
stages, the sensation of perceiving the elongated tooth remains. It is an easy
diagnosis, as the patient clearly indicates which tooth is responsible;
furthermore, it is painful on percussion and palpation and may also have
marked mobility. The swelling surrounding the dental element responsible
for the lesion is clinically evident, but when the swelling is greater, it will be
mandatory to check,

Submucosal stage
58

If the macroscopic clinical picture, represented by a marked swelling that can

also mildly involve the skin tissue, cannot deviate from the previous state, the
symptomatological picture can show variations, however mildly positive, as
pain is not very present in this phase. However, situations that may affect the
general state of health of the patient are not infrequent; fever, sometimes
exceeding 38 °C, is a sign of progressive worsening of the clinical picture
which must keep the attention of the odontostomatologist so that the
worsening does not lead to far more serious and undesirable consequences.

Integumentary stage
Hardly separable from the previous submucosal phase, it does not differ
much in terms of the symptomatological procession and the general clinical
picture. As in the previous case, immediate countermeasures should be taken
in order to limit the progression of the pathology of septic origin.
It is clear that in the latter two stages drug therapy is essential, as is the
association with surgical drainage in the most striking cases (periodontitis).

Recurring abscess
It is the exacerbation of a chronic inflammation (granuloma or cyst); it is also
referred to as a flared abscess or phoenix abscess. Chronic asymptomatic
lesion can occur suddenly both spontaneously and following our intervention.
In the first case, a decrease in the body's defenses allows, in the presence of
bacteria in the endodontic canal system, to interrupt that balance established
for years, with the result of an acute picture. In the second case, the abscess
develops during or after an endodontic operation in which, involuntarily, the
surgical maneuvers have pushed the infected material beyond the apex or
have not completely cleaned and shaped the root canal system, still leaving
an active bacterial load.
This picture never occurs in the presence of a fistula, which provides
spontaneous drainage to the pus that forms in the event of an exacerbation,
without pain.
Clinically, the recurrent abscess is often indistinguishable from acute apical
abscess. Radiographically there is an important difference, as a radio-
transparency image is clearly highlighted, even of considerable size; together
with the clinical data, this removes any doubts about the
59

diagnosis.

Medical treatment of PAA

The septic origin of PAAs is very clear and the treatment modality is equally
clear: the administration of broad-spectrum antibiotic therapy is almost
always decisive.
The most widely used therapeutic schemes involve the use of oral penicillins,
associated or not with synergistic agents such as clavulanic acid.
In patients allergic to penicillins, drugs of choice may be cephalosporins or
tetracyclines.
In the most critical situations, i.e. when the evolution of the septic process
has caused a very high involvement of the structures and districts close to the
oral cavity, such as the maxillary sinus and the pharyngeal space, up to
possible mediastinal involvement, the antibiotic therapy will have to be
directed intramuscularly or parenterally with more potent antibiotic drugs and
possibly targeted through bacterial culture and susceptibility testing.

Treatment of pulpal pathologies

Root canal treatment involves the eradication of the dental pulp from the
endodontium; as amply described in the chapters concerning pulpal
pathologies (seeChapter 1), this process rarely involved the pulp tissue
completely; in particular, root canals host tissues that are often free from
inflammation [44]. Removing the root pulp in the phase of non-bacterial
contamination determines, as a consequence, the ability, on the part of the
clinician, to obtain a particularly effective disinfection of the endodontium
and the walls of the root canal. This, together with the shaping and obturation
procedures of the endodontic space, provides the necessary elements to
obtain long-term success of the therapy, which various case studies have
reported to be greater than 95% of the cases treated [45,46].
Even with differences of vision and types of treatment, numerous authors
agree in stating that, in these clinical cases, the instrumentation and
contextual closure of the root canal can represent an advantage [47].

Treatment of periapical pathologies

It is evident that, once the periapical pathology of endodontic bacterial origin
has been estimated, the treatment of the root canal or of the endodontic space
60

infected - performed directly or indirectly - will not eliminate the main risk
factor that makes possible a new exacerbation of the always latent chronic
pathology. In these situations, the endodontic treatment will have to be
particularly accurate, since the elimination of the bacteria from the
endodontium will be particularly difficult. The anatomical characteristics of
the intracanal space and the organization of bacteria in biofilms strongly
adhered to the root surfaces make the shaping and disinfection maneuvers
particularly difficult; in this context, the timing of the endodontic treatment
can be of two types. The treatment can be performed in a single session or in
several sessions, interspersed with the intracanal placement of medications
such as calcium hydroxide or similar,
In this regard, quite a few studies have been carried out in support of this
theory and these have not always produced the expected result. To date,
however, the choice to carry out one or more sessions in these clinical
circumstances is the prerogative of the operator who, according to his
conscience, will autonomously decide to accelerate or delay the therapy
(Fig.2.28, Case report 2) [48-50].

Chronic periapical pathologies

61

Fig.2.28(a)Apicoperiapical lesion in a previously treated element. Slight discomfort on

vestibular palpation in the apical area. Absence of pain. The lesion was highlighted in a
follow-up radiographic examination. (b) Endodontic retreatment. Control at 15 months. A
mesiodistal view shows a different anatomy than the first radiographic image. (c)
Apicoperiapical lesion in a previously treated element. Periodontal probing distal to the distal
root. Absence of both spontaneous and provoked pain. (d) Endodontic retreatment. Checkup
at 24 months. (e) Large lesion at level 11 and 12. Negative vitality tests. Vestibular swelling
with pain on palpation. (f) Endodontic treatment of 12. Leakage of citrine fluid from 11;
dressing with calcium hydroxide for 3 months. (g) Endodontic treatment of 11. (h) Control at
24 months.

Peculiar clinical pictures

62

Cracked tooth syndrome

A fairly common situation, especially among elderly patients and among
bruxists, increasingly frequent today, which can cause difficulties in
diagnosis, is the appearance of a crack on the dental surface that reaches the
amelo-dentinal border [51,52]. It is also seen in patients with amalgam
fillings in the back teeth, premolars and molars. The symptomatological
framework that leads patients to the dentist's observation is similar to that of
pulp pathologies; thermal stimuli, especially in the cold, evoke pain which,
however, does not allow identifying the responsible tooth. Clinical
examination usually fails to detect tenderness in the cervical region, primary
and secondary caries, or radiographic signs of possible pulp involvement.
When the infraction reaches the pulpal tissue, the pain may be more
pronounced and may become persistent and spontaneous. In these cases, in
addition to the thermal symptoms present, the patient will report a sharp, very
strong pain on the cracked tooth in cases in which it evokes pressure during
chewing. The decisive clinical examination is carried out by placing a wet
cotton roll on the teeth under examination; the patient is invited to close his
mouth with caution, a lateral traction is exerted and the tooth with the
infringement will be the origin of a much more marked pain stimulus than the
other contiguous teeth. This is a very effective diagnostic technique.
A careful clinical examination of the tooth will allow the suspect element to
be identified and in it, after having removed the filling material, the presence
of a crack will be revealed, usually with a mesio-distal course. In doubtful
cases, greater evidence can be obtained with the use of a dye, usually
methylene blue; transillumination and magnifying optical systems are also of
valid help. The course and depth of the crack, associated with the symptoms,
will determine the treatment plan, which will often be that of root canal
therapy with endodontic reconstruction with cuspid coverage.
In these cases it is very important to carry out a timely diagnosis, otherwise,
in a short time, the patient will return to our observation with the fractured
tooth (Figs. 2.29And2.30) [42,53].
63

Fig.2.29Periodontal lesion with minimal distal and furcation probing. Acute pain on
chewing, mobility grade 1. Positive pulp tests. Bruxist patient.

Fig.2.30A careful clinical examination revealed a fracture of the lingual wall, starting
occlusally, 6-7 mm below the gingival margin. Surgical treatment.

Endoperiodontal lesion and endoperiodontal

interrelationships
The presence of numerous ways of communication between the endodontic
space and the surrounding supporting tissues means that a pathology of pulp
origin can lead to impairment of the periodontal tissues and vice versa. These
connections are mediated by the dentinal tubules, by lateral or accessory
canals and by the apical foramina; only on the external root surface at the
level of the enamel-cement junction there are, on average, about 15,000
tubules
64

dentinals per square millimeter, connected to pulp tissue.

Normally these tubules do not communicate with the periodontium as they
are protected by the root cementum, the thickness of which, however, in the
enamel-cement junction area is very small.
Lateral/accessory canals can affect the health of the dental pulp and
periodontium; they can be found along the entire root surface and at the
bifurcation of pluriroots.
Several studies have demonstrated its presence with greater frequency at the
level of the apical third of the root and in the bifurcations of the molars.
The apical foramen is the main route of communication between the
endodontium and the periodontium. The leakage of pathogenic material into
the periradicular tissues can determine the appearance of an inflammatory
process, with resorption of bone, cementum and even root dentin [54,55]
(Fig.2.31, you seeFig.2.26).

Fig.2.31(to)Large apicoperiapical lesion; presence of rhizolysis of the mesiobuccal root.

Absence of both spontaneous and provoked pain. Presence of a fistulous tract
65

evidenced by the gutta-percha cone during radiographic examination. (b) Gutta-percha cone
inserted into the fistulous tract. (c) Endodontic treatment. The rhizolysis of the mesiobuccal
root and the presence of a double distal canal are clearly evident; radiograph taken with a
mesio-distal projection. (d) Control at 24 months.

Here, in order to make the text related to diagnostics usable, only brief hints
are provided with some emblematic clinical situations.

Primary endodontic lesion with secondary

periodontal lesion
See theFigure 2.32.

Fig.2.32(to)Large endodontic lesion with periodontal probing both distal and at the
bifurcation. Pain on chewing and vestibular palpation. Grade 1 mobility.
(b) Root canal and periodontal treatment. Checkup at 12 months. (c) Control at 24 months.

Primary periodontal lesion

See theFigure 2.33. The therapy will be periodontal.
66

Fig.2.33Mesial and distal periodontal lesion with apical involvement. Presence of calculus
distally. Positive vitality tests. Grade 2 mobility. Pain on chewing.

Primary periodontal lesion with secondary endodontic

involvement
This is a fairly rare situation, when an endodontic lesion is established in the
presence of an important periodontal pocket following a passage of toxins
and bacteria through any lateral channels. Certain therapeutic and non-
therapeutic procedures, such as curettage, erosion and caries, can contribute
to pulp necrosis by promoting free access to the pulp in the dentinal tubules
(Figs. 2.34And2.35).
67

Fig.2.34(to)Periodontal lesion with large distal probing and at the furcation on 47. Partially
positive vitality tests. Grade 2 mobility. Pain on palpation and chewing. (b) Endodontic
treatment. The mesial canals showed some tenderness and bleeding on root canal probing. A
periodontal treatment was then performed.(c) Follow-up at 6 months. (d) Control at 24
months. Absence of periodontal probing and mobility.
68

Fig.2.35(to)Ample reabsorption at the level of the mid-apical third of the distal root of 37
due to bone inclusion of 38. Distal periodontal probing of 11 mm at 37, its partial positivity
in vitality tests. Pain with swelling in area 38. (b) Satisfactory treatment of the distal canal,
despite the severe resorption, and therefore following surgical treatment of 38. Vitality of the
mesial canals of 37. (c) Follow-up at 8 months. (d) Control at 18 months. Absence of
periodontal probing, the case is under observation.

Differential diagnosis, in many situations, is not possible; in fact, excluding

the primary periodontal lesions, all the other pictures present a coexistence of
the two pathologies, endodontic and periodontal; therefore, clinically,
endodontic therapy, when indicated, will be the primary treatment, followed
by any periodontal treatment. Hasty diagnoses often lead to consider the
pictures as if they were combined injuries; often, on the other hand, a
correctly performed endodontic treatment completely resolves the present
pathological picture.

Vertical root fracture

The diagnosis of vertical root fracture can present considerable difficulties,
since it does not manifest itself with a precise clinical picture, but with a
combination of symptoms and signs that can generate suspicion [56,57].
69

The symptomatological procession, in fact, can be that of pulp necrosis or

periodontal disease; moreover, the objectivity is strongly dependent on the
location and extension of the fracture line; in fact, it can be coronal, apical or
originate from an intermediate section of the root (Fig.2.36).

Fig.2.36(to)Clinical picture of swelling. Fistulous tract at the level of the coronal third;
vestibular probing. (b) Radiologically, apical radiolucency is noted. (c) The exploration flap
shows a complete fracture highlighted by 2% methylene blue.

The longitudinal fracture occurs only when it affects the superficial

periodontium; in that phase a periodontal pocket is formed, usually deep and
narrow, which follows the fracture line in depth. A tubular periodontal defect
probeable with a very thin dedicated probe, alongside normal periodontal
probing areas in the remaining parts of the tooth, is perhaps the most
characteristic sign of this type of clinical situation. This sign can become
pathognomonic when it occurs on both sides of the root: typical is the double
tubular vestibular and palatal defect affecting flattened roots, which we find
at the level of the premolars and molars.
Not all cases of fractures are diagnosed when the fracture line has reached the
superficial periodontium; sometimes patients may complain of a dull,
annoying pain, a transient swelling in the middle of the root and a possible
slight mobility of the dental element. The main clinical signs, in addition to
the tubular probing mentioned above, are a swelling with a fistula in the
intermediate region between the crown and the apex of the tooth. In many
cases, the pressure exerted on the tooth under examination during chewing
causes pain, which can be reproduced by having the patient squeeze a wet
cotton roll between the dental arches (Figs. 2.37-2.39).
70

Fig.2.37Swelling associated with sinus tract and deep mesial periodontal pocket.

Fig.2.38Radiological picture of a mesial pararadicular radiolucency.

71

Fig.2.39The spontaneously debonded Richmond crown allows for direct inspection of the
root and fracture line.

The radiographic examination shows a pararadicular radiolucency; only in

the most striking cases can a complete fracture of the two segments of the
root be appreciated.
In doubtful cases, before the extraction of the whole tooth and the fractured
root, it is advisable both to inspect the external surfaces of the crown and the
root, slightly moving the gingival margin or making an exploratory flap, and
to examine the internal surface of the pulp chamber after having eliminated
all restorative materials, to highlight any fracture line; in all these cases the
use of a dye as a highlighter can be useful (Fig. 2.40).

Fig. 2.40After making an exploratory flap, a fracture starting from

72

margin of "closure" of the crown.

From a literature review[58] the symptoms and signs

morefrequently encountered in
the course of vertical fractures are:
● presence of tubular periodontal pockets 78% (Fig.2.41);
● tenderness or dull ache 58%;
● periodontal abscesses 53%;
● fistulous tract 42%.

Fig.2.41Tubular type periodontal probing.

Radiological signs of widening of the periodontal space and marked

radiolucency are present in 72% of cases.
The dental elements that most frequently undergo fractures are the teeth of
the latero-posterior sectors and the premolars represent the largest group with
56% of cases, followed by molars with 28%, canines with 8% and incisors
with equal frequency; moreover, it can be seen that vertical root fractures
more frequently affect patients between the ages of 45 and 60 (Figs. 2.42-
2.44) [59].
73

Fig. 2.42Radiographic examination reveals a large lesion at the level of the distal root and at
the bifurcation. Slight swelling, partial periodontal probing and slight chewing pain.

Fig. 2.43After surgery, a fracture was highlighted with dye on the mesiobuccal root starting
coronally.
74

Fig. 2.44Fracture at the level of the distal root always starting coronally.

Another very important data is represented by the high presence of endocanal

retentions (93%) in the fractured roots; most of these dental elements present,
in fact, very large conservative restorations accompanied by endocanal
retentions. Furthermore, it is not infrequent to find these problems in dental
elements at the end abutments of complex prosthetic reconstructions.
Unfortunately, the prognosis of vertical root fractures is always poor and the
only therapy is represented by avulsion.

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2008;41(1):6-31.
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practice: a study by the Practitioners Engaged in Applied Research and Learning
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pulpitis: treatment and prognosis. JEndod 2007;33(12):1405-7.
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periodontal correlations. G It Endo 2000;3:128-3.
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etiology of vertical root fractures. G It Endo 1990;IV (3):44-7.
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teeth: a clinical survey of 36 cases. J Endodon 1993;19:87-90.
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G It Endo 1995;1:10-8.

Endodontic emergencies
M. Colla, R. Raffaelli, S. Rizzoli, A. Dorigato

Introduction
An endodontic emergency can be defined as a situation in which pain,
associated or not with swelling, is not coercible with the usual
pharmacological therapies. This clinical event is determined either by the
various stages of inflammation of the pulp concomitant with the involvement
of the periapical tissues, or by an encroachment of the intracanal septic
process into the periapical tissues.
Proper diagnosis and management of acute dental pain is one of the most
rewarding aspects of providing dental care. However, coping with endodontic
emergencies can sometimes be challenging and, in some cases, frustrating for
the clinician, since there is no clear correlation between pain intensity and the
extent of pulpal or periapical compromise. Deciding when to intervene or
postpone is the real challenge that every dentist faces in this clinical setting.
Finally, since the time required to carry out the entire therapy is almost never
sufficient, you will have to
78

put into practice a few maneuvers to implement a provisional treatment plan

that allows the patient to be discharged without any symptoms in order to
schedule the sessions necessary to complete the treatment.
As already explained above, the inflammatory events – pulpal or periapical –
can be generated by bacterial proliferations in primary or secondary carious
processes or by traumas, for the discussion of which we refer to Chapter 9 [1-
3]. Treatment will depend on the inflammatory stage of either the pulp organ
or the periapical tissues, the intensity and duration of the pain, and the extent
of any swelling [1,2].
Last but not least, once the type of endodontic emergency has been identified,
the clinician has, in any case, the responsibility of informing the patient - in
relation to his general conditions - on the type of treatment recommended, on
alternative treatments, on the risks, benefits and prognosis that the dental
element may have once definitively treated.

Types of emergencies
Many classifications have been drawn up to catalog endodontic emergencies;
here a clinical classification will be adopted, based on the symptoms that the
patient can report and on the signs that the dentist can immediately highlight.
It is clear that the term emergency cannot include all those inflammatory
states of the pulp or periapical tissues that generate transient or provoked
pain, for which reference should be made to the initial part of this chapter
[1,2].

Classification
Irreversible pulpitis not sedated by drug therapy
This stage of inflammation of the pulp is one of the painful conditions with
the greatest impact on the whole organism, being uncoercible by analgesic
pharmacological aids of average efficacy; requires immediate clinical
treatment. The main symptom is, in fact, acute and spontaneous pain, often
throbbing, radiated; it is accentuated in the supine position, especially at
night. Sometimes, exposure to temperature changes
79

generates episodes of intense and prolonged pain, sometimes cold stimuli

soothe the symptoms but certify the state of irreversibility of the pulp disease
[1-5].

Treatment.The eradication of the pulp is the only means to obtain a

resolution of the symptoms; however, this situation is not always simple and
possible, both for reasons related to time, and as regards the morphology of
the dental element affected by the pathology, and the degree of septicity of
the pulp content. The choice will depend on the time available to the operator
and essentially provides for two opportunities: pulpotomy or pulpectomy. In
any case, the pulpotomy maneuver, on the one hand, creates a space where
the inflammatory process can drain, at least partially; on the other, it
eliminates important neurosensory receptors which will make the element to
be treated less sensitive. In multi-rooted teeth, pulpotomy will be
preferable,Figs. 2.45And2.46) [1,6].

Fig. 2.45A longitudinal coronal fracture resulted in pulp pathology: top of frame, pulp
exposure during removal of carious dentin.
80

Fig. 2.46The dental pulp ready to be removed.

As in any root canal treatment, a series of operations is envisaged to ensure

analgesia and the aseptic nature of the maneuvers to be implemented.

Anesthesia.The analgesia techniques, in these cases, will be difficult to

obtain, since the decrease in pH in the inflamed areas makes it difficult for
the dissociation of the anesthetic molecules and their consequent penetration
into the nerve sheaths. The refractoriness to the anesthetic (hot tooth) can be
overcome by reinforcing the plexus and/or block anesthesia, which remain
the solutions of first choice, resorting to additional anesthesias such as the
intraligamentous, the intraosseous and the always effective intrapulpal [2] .

Preoperative drug treatment.The association of a supportive

pharmacological treatment which aims to favor the effect of the anesthetics
and reduce the patient's suffering may prove useful [1,2,7,8].
Among the painkillers, the non-steroidal anti-inflammatory drugs (NSAIDs)
based on diclofenac, ibuprofen or ketoprofen to be administered orally are
recommended. The doses vary, depending on the intensity of the pain, from
400 to 800 mg every 6-8 hours.
In cases of severe inflammatory symptoms, the prophylactic administration
of cortisone (dexamethasone or methylprednisolone) by both oral and
intramuscular routes is advisable.
81

After deep anesthesia is achieved, rubber dam is placed and a proper access
cavity is made – and it is emphasized that making a limited access cavity due
to time constraints is a serious mistake – eliminating all potential sources of
infection, such as tooth decay and defective restorations that could
recontaminate the root canal system between appointments.
As already stated at the beginning of this sub-chapter, depending on the type
of tooth and the time available, the operator will opt for pulpotomy or
pulpectomy.
In the first case, sharp curettes or a Gates-Glidden bur n. 1 or no. 2, used only
at the entrance of the canals, avoiding probing or instrumenting them so as
not to irritate the root pulp. The purpose of making a clean cut is to ensure
less bleeding. The root stumps will be haemostasised using sterile cotton
pellets soaked in anesthetic with a vasoconstrictor, exerting slight pressure.
When the bleeding has stopped, another sterile cotton pellet will be placed on
the chamber floor and the access cavity will be hermetically sealed [2,7,8].

periodontal complications.It is not infrequent, in highly septic pulp

pathological states, to observe an involvement of the periapical tissues; in
fact, the patient also reports pain on compression, a sense of "stretched tooth"
and, when the chamber is opened, there is significant bleeding from the pulp
stumps; in this case the removal of the pulp in its entirety is recommended, ie
a pulpectomy is performed. Partial pulpectomy is not recommended as it may
cause mechanical irritation of residual tissue, leading to exacerbation of
postoperative pain.
If you decide to postpone the filling of the root canal system to a later
appointment, due to lack of time or because complications arise, an
intermediate medication with a bactericidal substance is recommended. In
modern endodontics, shaping and disinfection assume greater importance
than intermediate dressings, which have long been considered essential for
eliminating bacteria within the root canal system. Until recently, formocresol
and related molecules were frequently used as medication intermediates, but
recently it has been shown that they could induce various harmful effects,
including allergies. They are also potent carcinogens and, therefore, there is
no longer any indication for
82

their use [9]. Biocompatibility and stability are essential properties for
intermediate dressings.
Calcium hydroxide is bactericidal, stable for long periods and is harmless to
the body. Induces hard tissue formation and is effective for arresting
inflammatory exudates. This is why its use is recommended if endodontic
treatment is not completed in a single appointment [9-16].
If an intermediate dressing is to be used, it is recommended to use composites
or materials as temporary filling materialsreinforced glass ionomers, which
guarantee good hermetic properties and resistance (Fig. 2.47).

Fig. 2.47(to)Critical clinical situation in a tooth with acute periapical pathology.

(b) Clinical picture after cleaning and pre-endodontic reconstruction.

In vital teeth in which the inflammation extends to the periapical tissues, an

occlusal reduction is also recommended to relieve postoperative pain [17].
To avoid fracture of the element between appointments, it is advisable to
reinforce and protect unsupported cusps [2].
The literature reminds us that there seem to be no contraindications to
endodontic treatment in a single session of teeth with acute pulpitis not
complicated by apical periodontitis and the incidence of post-operative flare-
ups does not differ from that of teeth treated in several sessions [1, 2.18].

Postoperative drug treatment.Pharmacological treatment aims to alleviate

pain and the risk of postoperative flare-ups, whether you decide to treat the
tooth in one session or in several sessions. Among the painkillers, NSAIDs to
be administered orally (diclofenac, ibuprofen or ketoprofen) are
recommended. The doses vary according to the intensity of the pain
83

(400 to 800 mg every 6 to 8 hours). In cases of very intense postoperative

pain, intramuscular injection of ketorolac tromethamine (Toradol®) can be
used. Analgesics based on acetaminophen possibly associated with opiates
are instead the drugs of choice for patients intolerant to aspirin-like drugs. In
cases of very serious inflammatory symptomatology, it is possible to resort to
premedication with cortisone. The efficacy of cortisone prophylaxis with
dexamethasone or methylprednisolone has been demonstrated in many works
and would see its maximum efficacy in the 24 hours following the
endodontic treatment, to then decrease after 48-72 hours. Both oral
administration (1-2 mg every 4-6 hours for 2-4 days) and intramuscular
administration (0.07-0.09 mg/kg every 8-12 hours for 2 days) have been
shown to be effective.
Antibiotics are not recommended [2,19,20].

Acute apical periodontitis (PAA) without soft tissue

swelling
The extension of the pulpal inflammation to the periradicular tissues makes
the affected tooth hypersensitive to chewing and pressure stimuli, as the
edema that accompanies the inflammation rapidly activates the periodontal
ligament proprioceptors.
PAA can arise as a spontaneous evolution of an irreversible pulpitis or as a
complication of an endodontic treatment. In the first case, different
histopathological pictures coexist within the pulp organ itself and the
transition from one to another is very gradual. The patient will complain of
widespread, continuous, dull, sometimes throbbing pain, spontaneous or
exacerbated by thermal stimuli, and at the same time severe pain on pressure
and chewing. This type of pulpo-periodontal symptomatology is particularly
frequent in multi-rooted teeth, in which the inflammatory pathology can
evolve with different times and severity in the two or three roots, and it is for
this reason that it is possible to identify periapical lesions in teeth that still
respond to vitality (Fig. 2.48).
84

Fig. 2.48(to)Lower molar affected by exacerbated chronic pathology. (b) Treatment after
handling the emergency. (c) Remote control.

PAA can also arise as a complication of a

treatmentendodontic. There can be various causes,
including:
● over-instrumentation; failure to respect the working length results in
continuous mechanical trauma to the periapical tissues (Fig. 2.49);
● extrusion of infected pulpal debris;
● extrusion of irritating liquids;
● overfills (Fig. 2.50).

Fig. 2.49Non-observance of the working length.

85

Fig. 2.50Radiographic aspect of acute periapical pathology in chronic process post-

endodontic treatment.

Literature shows that the incidence of PAA in retreatments is higher than in

conventional treatments. The same goes for endodontic treatments of teeth
with large periapical lesions (Fig.2.51) [1,2].
86

Fig.2.51(to)Acute evolution into chronic periapical process. (b) Palatal clinical aspect.
(c) Root canal therapy with slight cement overflow. (d) Resolution of the palatal swelling.
(e,f) Remote controls.

The symptoms of PAA as a consequence of an endodontic treatment are

mainly severe pain on contact with the opposing tooth and on percussion;
sometimes there may also be pain on palpation in the apical area.

Treatment.Emergency treatment of teeth with PAA without

87

soft tissue swelling involves the execution of plexus or block anesthesia (both
to reassure the patient and to protect the clinician in the case of multi-rooted
teeth that present vital and necrotic canals at the same time).
We will then proceed to occlusal reduction of the offending tooth to prevent
contact with the antagonist. We will then move on to the removal of all the
pulpal debris and all the canal filling material, accompanied by abundant
washings with sodium hypochlorite; finally, the apical foramen will be
probed with an 08-10 K-file to check the patency of the foramen itself and
ensure drainage of the exudate inside the canal itself.
The access cavity should be sealed tightly with a temporary filling after
placing a cotton pellet in the pulp chamber. It is important to keep the root
canal system open to allow any exudate or gas produced by residual bacteria
to flow back, which would otherwise compress the apical proprioceptors,
increasing the patient's suffering.
NSAIDs can be administered, associated in the most serious cases with
intramuscular corticosteroids, and antibiotic therapy (clarithromycin and the
combinations of amoxicillin plus clavulanic acid) is recommended for a
period of not less than 5 days.
If the patient does not show an improvement in symptoms a few hours after
emergency endodontic treatment, it will be necessary to remove the filling
and leave the tooth open with a simple cotton pellet inserted into the pulp
chamber.
Leaving a tooth open between appointments to allow for drainage or to numb
otherwise intractable pain is controversial. In fact, the literature clearly states
that this procedure can complicate the treatment and make it difficult to
resolve [1,21].

Drainage. Trepanation of the buccal bone cortex.To reduce the local

pressure of the periapical tissues, it is possible to create a drainage route for
the exudates by drilling the cortical, buccal bone. The creation of the artificial
fistula is obtained, after incision of the mucosa, by making a hole with a bone
rosette n. 4-6 adhigh speed in the cortical bone up to the spongiosa
incorrespondence
of the apex of the tooth affected by the abscess mass. To keep the tract open,
a drain is placed and the flap is sutured.
88

This technique should be limited to cases of severe pain and resistant to non-
surgical therapies [22-23].

Acute alveolar abscess (AAA) with soft tissue swelling

AAA is an acute inflammation characterized by a collection of pus localized
in the alveolar bone surrounding the apex of a tooth with necrotic pulp. The
patient complains of localized spontaneous pain, pain on percussion and
chewing, and on palpation of the apical area.
The treatment of acute alveolar abscess consists in providing a drainage to
the purulent collection, in order to relieve the patient's pain or, in any case,
the sense of tension he feels in the affected area and improve his general
conditions [24,25].

Treatment.Perform infiltration anesthesia gently starting at the periphery of

the swollen area and create drainage either through the root canal or through
the abscess incision.
Drainage through the apical foramen is obtained by creating an adequate
access cavity and, after having mechanically and chemically cleaned the root
canal system, a manual instrument is voluntarily pushed, of a size compatible
with the size of the foramen, for a few millimeters beyond the length of work,
in order to create a way out for the exudate. This manoeuvre, not to be used
during classic root canal therapy, is the only way to guarantee an effective
link between the endodontium and the periodontium, so that the latter is freed
from the rapidly expanding purulent content. We will wait for the purulent
and/or haemorrhagic material to finish spontaneously by irrigating delicately
and with great attention with a sodium hypochlorite solution,Fig. 2.52) [2.5].
89

Fig. 2.52Periapical abscess drainage.

External drainage.In the presence of a fluctuating purulent collection, after

having checked the limits of the swelling by palpation, drainage can be
obtained by making an incision with the blade of a scalpel, introducing it into
the most dependent point and slowly pushing it inside until it meets the
cortical. To perform this manoeuvre, anesthesia with a vasoconstrictor is
required to be injected into the thickness of the mucosa by introducing the
needle tangentially to the mucosa itself, so that it can be seen through the
tissues through transparency. The few drops of anesthetic must be injected
slowly, in order to see the ischemic effect (Fig. 2.53). It is advisable to keep
the incision open for at least a day or two (until the symptoms have
completely remitted); this can be achieved by attaching a small piece of
rubber dam to one edge of the incision with a suture. The patient will be
asked to rinse frequently with a hypertonic solution of water and salt to
facilitate the release of pus [2,5].

Fig. 2.53Drainage of skin abscess of endodontic origin.

Antibiotic therapy has the aim of favoring the resolution of the abscess focus
and avoiding its diffusion in the soft tissues and along the muscular planes.
Clindamycin, clarithromycin, the combinations of amoxicillin and clavulanic
acid and cephalosporins are recommended, both orally and for
90

systemic route [2,26].

The pain-relieving therapy involves the use of non-steroidal anti-inflammatory
drugs also systemically (Toradol®).

Bibliography
1. Wolcott J, Rossman LE, Hasselgren G. Orofacial dental pain emergencies: management
of endodontic emergencies. In: Cohen S, editor. Pathways of the pulp. 10th ed. Mosby
Elsevier; 2011. p. 108-48.
2. Cantatore G. Endodontic emergencies. Online notebooks. Milan: Edition of the Italian
Endodontic Society; 2004.
3. Bender IB. Pulpal pain diagnosis – a review. JEndod 2000;26:175.
4. Brannstrom M. The hydrodynamic theory of dentinal pain: sensation in preparations,
caries, and the dentinal crack syndrome. JEndod 1986;12:453.
5. Castellucci A. Pulp and periapical pathology. In: Arnaldo Castellucci, Endodontics.
Editions The Trident; 2002. p. 118-75.
6. Lee M, Winkler J, Hartwell G et al. Current trends in endodontic practice: emergency
treatments and technological armamentarium, J Endod 2009;35(1):35-9.
7. Gatewood RS, Himel VT, Dorn S. Treatment of endodontic emergency: a decade later.
JEndod 1990;16:284.
8. Hargreaves KM, Keiser K. New advances in the management of endodontic pain
emergencies. J Calif Dent Assoc 2004;32:469-73.
9. Kawashima N, Wadachi R, Suda H et al. Root canal medicaments. Int Dent J 2009
Feb;59(1):5-11.
10. Weiger R, Rosendahl R, Lost C. Influence of calcium hydroxide intracanal dressing on
prognosis of teeth with endodontically induced periapical lesion. Int Endod J
2000;33:219.
11. Chong BS, Pitt Ford TR. The role of intracanal medication in root canal treatment. Int
Endod J 1992 Mar;25(2):97-106.
12. Athanassiadis B, Abbott PV, Walsh LJ. The use of calcium hydroxide, antibiotics and
biocides as antimicrobial medicaments endodontics. Aust Dent J 2007 Mar;52(1
Suppl):64-82.
13. Zehnder M, Lehnert B, Schönenberger K, Waltimo T. Irrigants and intracanal
medicaments in endodontics. Schweiz Monatsschr Zahnmed 2003;113(7)756-63.
14. Sigueira JF jr, Guimararaes Pinto T, Rocas IN. Effects of chemomechanical
preparation with 2.5% sodium hypoclorite and intracanal medication with calcium
hydroxide on cultivable in infected root canal, J Endod 2007 Jul;33(7):800-5.
15. Lima RK, Guerreiro-Tanomaru JM, Faria-Junior NB, Tanomaru-Filho M.
Effectiveness of calcium hydroxide base intracanal medicaments against Enterococcus
faecalis. Int Endod J 2011 Nov. doi: 10.11117j.1365-2591.2011.01976
16. Menezes MM, Valera MC, Jorge AO et al. In vitro evaluation of effectiveness of
irrigants and intracanal medicaments on microorganisms within root canals. Int Endod
91

J.2004 May;37(5):311-9.
17. Rosemberg PA, Babick PJ, Schertzer L, Leung A. The effect of occlusal reduction on
pain after endodontic instrumentation. JEndod 1998;24:492.
18. Penesis VA, Fitzgerald PI, Fayad MI et al. Outcome of one-visit and two-visit
endodontic treatment of necrotic teeth with apical periodontitis: a randomized controlled
trial with one-year evaluation. JEndod 2008;34:251-7.
19. Keenan JV, Farman AG, Fedorowicz Z, Newton JT. A Cochrane Systematic Review
find no evidence to support the use of antibiotics for pain relief in irreversible pulpitis.
JEndod 2006:32(2)87-92.
20. Pickenpaugh L, Reader A, Beck M et al. Effect of prophylactic amoxicillin on
endodontic flare-up in asymptomatic necrotic teeth. JEndod 2001;27:53-6.
21. Weine FS, Healey HJ, Theiss EP. Endodontic emergency dilemma: leave teeth open or
keep it closed? Oral Surg Oral Med Oral Pathol 1975;4:531.
22. Henry BM, Fraser JG. Trephination for acute pain management. J Enodod
2003;29(2):144-6.
23. Moos HL, Bramwell JD, Roahen JO. A comparison of pulpectomy alone versus
pulpectomy with trephination for the relief of pain. JEndod 1996;22:422.
24. Natkin E. Treatment of endodontic emergencies. Dent Clin North Am;1974;18:243.
25. Morse DR, Furst ML, Belott RM et al. Infectious flare-ups and serious sequelae
following endodontic treatment: a prospective randomized trial on efficacy of antibiotic
prophilaxis in cases of asymptomatic pulpperiapical lesion. Oral Surg 1987;64:96-109.
26. Harrison JW. The appropriate use of antibiotics in dentistry: endodontic indications,
Quintessence Int 1997;28:827.

Non-odontogenic pains
A. Deregibus, R. Preti

Pain is defined by the IASP (International Association for the Study of Pain)
as “an unpleasant sensory and emotional experience associated with actual or
potential tissue damage”. Pain is always constituted by a subjective sensory
experience; therefore there are no objective means to evaluate it: pain is such
when a subject says it is pain.
It is described in terms of intensity (mild, moderate, severe), location
(affected region), quality (stringent, stinging, burning, etc.), in relation to its
duration (acute and chronic) and the moment of onset. Pain also has an
affective component (emotional response) and a cognitive component (the
person compares pain with previous experiences of pain and interprets it in
relation to the current situation) [1].
92

Price and Wade described the pain sequence as follows:

● initial stage, corresponding to the perceived intensity of the painful
sensation;
● second stage, linked to an unpleasant sensation of pain, which reflects an
immediate individual affective response to this painful sensation and to the
context in which it occurs. This sensation is often connected to the physical
perception of pain;
● third stage, which includes the phenomena related to the meaning and
implication that pain has in the life of the individual. This third stage is
characterized by negative emotions (depression, frustration, anxiety, fear,
anger) as well as individual expectations;
● a fourth and final stageit is characterized by overt painful expressions
[2].
Based on the pathogenesis, pain can be classified into four main categories
[3].
● Nociceptive: transient pain in response to a peripheral stimulus.
● Inflammatory: spontaneous pain associated with painful hypersensitivity
following tissue and inflammatory damage. Any lesion produces an
inflammatory state which leads to the release of some chemical mediators
by the injured tissue, its vessels and its nerve endings. Based on the site
involved, it is divided into: (1) superficial somatic (skin, mucous
membranes); (2) deep somatic (muscles, bones, joints); (3) visceral
(internal viscera).
● NeuropathicPain arising in the peripheral or central nervous system in the
absence of a nociceptive insult, but as a result of a functional impairment
or organic lesion of the peripheral nerve (peripheral neuropathic pain) or
afferent nerve conduction pathways in the nervous system central (central
neuropathic pain).
● Psychogenic: pain caused by an anomalous interpretation of perceptual
messages in the absence of documentable damage to the central or
peripheral nervous system.

Another important aspect consists of the different ways in which the area of
pain can extend or project towards other areas with respect to the point of
origin of the pain itself. Depending on the behavior it is divided into: (1)
widespread pain (extension of the sensation area in continuity with the area
of
93

origin); (2) projected pain (displacement of sensation due to a lesion/error in

the transmission pathway of the nociceptive impulse) and (3) referred pain
(sensation located in an area not in continuity with the area of origin of the
pain). This phenomenon is predominantly recognized in cases of non-
odontogenic dental pain. Furthermore, referred pain can occur both in
association with pain manifestations at the point of origin and in isolation. If
the pain is of muscular origin, it tends to manifest itself following a relatively
constant pattern, so it is often possible to identify the muscle involved. If the
pain is referred to more than one site, it is referred to as radiated pain [4].
The most frequent non-odontogenic pathologies which, due to the reference
modality of the pain, can be the subject of differential diagnosis for the
endodontist are described below.

Gingivitis
It is an inflammatory process, characterized by swelling, redness, heat and
bleeding of the gums, resulting from the accumulation of plaque.
Depending on the degree of inflammation, gingivitis can be acute, subacute
or chronic. Depending on its extension, it can instead be limited to one dental
element, two or more teeth or generalized.

Signs and symptoms

Bleeding, increased crevicular fluid, pain absent in chronic forms, present in
acute phases.
The evolution of the pathology leads to periodontitis with involvement of the
deep periodontium and the formation of intraosseous pockets. These lesions
are no longer reversible and therefore the damage caused lasts over time. In
the more advanced stages, tooth mobility can occur which, if left untreated,
can lead to the loss of the affected tooth [5] (Tab. 2.6).

Tab. 2.6Characteristics of non-odontogenic pathologies.

Pathogene Figure
Pathology Stairs
sis 2.54
category
Gingivitis 2 b Days
94

Periodontitis 2 b Days
Trigeminal neuralgia 2 d Minutes
Arthromyopathies 1-2 b/a Months
Sinusitis 2 b Days
Otitis media 2 to Days
Canker sores 1-2 Hour
s
Herpes simplex 1-2 c Hour
s
Lockjaw 1 c Hour
s
Sialolithiasis 1 And Hour
s
Heart attack 1 b Minutes

Fig. 2.54Typical trend over time (x axis) of pain level (ordinate axis). (a) Odontogenic pain
with a very violent onset that tends to decrease over time. (b) Tension headache pain with
fluctuating pain course over time. (c) Extremely severe migraine pain, but of limited
duration. (d) Neuralgic pain, with trains of very violent accesses of pain with more or less
long intervals of remission. (e) Typical pain from endocranial expansive process with
progressive increase of pain until extremely important levels of pain are reached.
95

Trigeminal neuralgia
96

The trigeminal nerve is a mixed nerve made up of sensory fibers (main

component) and motor fibers. Sensitive fibers innervate the meninges, the
eye, the mucous membrane of the nasal cavity and that of the oral cavity, the
tongue and the teeth [6].
Trigeminal neuralgia is a neuropathic nerve disorder.

Signs and symptoms

Shooting and paroxysmal pain of a neuralgic nature, lasting from a few
seconds to a few minutes, which can affect the eyes, lips, nose, scalp,
forehead, external skin areas, teeth and internal mucous membranes of the
jaw and jaw.
The crisis is triggered by the execution of movements (talking, swallowing,
shaving) and by the stimulation of skin areas called trigger zones (wing of the
nose, upper lip).
It is usually unilateral, like pulpitis, but does not have the frequent nocturnal
recurrence of the latter.
It usually affects more women than men, after the age of 50 and more
frequently between the ages of 60 and 70.
It should be differentiated from cluster headache which is five times more
frequent in men than women and is characterized by pain behind the ear,
which lasts a few minutes and not a few seconds and is often nocturnal
compared to trigeminal neuralgia [7 ] (you seeTab. 2.6)

Arthromyopathies
It is an acute or more frequently chronic algic process which can affect the
temporomandibular joint or the intrinsic muscles of the skull (with a four
times higher frequency) or both. The origin is multifactorial with differences
between the articular component (mainly inflammatory, traumatic or due to
mandibular dislocation of dental origin) and the muscular component (mainly
linked to muscle hyperactivity).

Signs and symptoms

Signs and symptoms differ between the two components.
● Arthrogenic pain is violent, stinging, located in front of the tragus,
97

exacerbated by mandibular movements, sometimes even just by the

locution, sometimes accompanied by crashing noises or preceded (over a
period lasting even years) by popping noises; it is also accompanied by
cheek pains of an antalgic nature. Mandibular movements are limited,
especially laterality to the side contralateral to the involved joint (Fig.
2.55).
● Myogenic pain is constricting, sometimes throbbing with a tendency to
reflect on the cheek, inside the ear, in the maxillary sinus area, on the
forehead or more frequently on the teeth (generally both maxillary and
mandibular premolars and molars). The pain is accompanied by difficulty
opening the mouth and chewing hard foods, while generally the
mandibular lateral movements are symmetrical (Fig. 2.56; you seeTab. 2.6)
[8].

Fig.2.55 The patient reports pain in the joint

temporomandibular. (a) Front view. (b) Lateral view.

Fig. 2.56The patient reports widespread pain in the affected area. (to)
Front view. (b) Lateral view.
98

Sinusitis
It is an acute or chronic inflammatory process that affects the paranasal
sinuses.

Signs and symptoms

Collection of exudate in the paranasal cavities, pain caused by compression
of the nerve endings by the exudate or empyema in purulent forms. In the
maxillary forms the pain, of a neuralgic type, dull, continuous and more
violent in the morning, radiates from the suborbital region and from the
canine fossa to the teeth. Mucous and/or purulent rhinorrhea (which may be
accompanied by fever) and headache in the frontal forms.
In the chronic forms, the involvement is predominantly monosinusal [9]
(seeTab. 2.6).

Otitis media
Inflammatory process affecting the middle ear which can be catarrhal or
purulent, to be differentiated from acute arthromyopathic processes of the
temporomandibular joint.

Signs and symptoms

Sudden and violent otodynia, tinnitus, transmission hypoacusia, sometimes
vertigo [10] (seeTab. 2.6).

Mouth ulcers (recurrent aphthous stomatitis – SAR)

Canker sores are recurring ulcers. Three different clinical pictures are
distinguished:
● minor: ulcers smaller than 4 mm;
● majors: ulcers whose diameter can exceed 1 cm;
● herpetiformis: multiple small ulcers, 1-2 mm in diameter.

Signs and symptoms

Severe pain symptoms and appearance of painful and palpable lymph nodes
[11] (seeTab. 2.6).

Herpes simplex
99

Herpes simplex 1 (VHS-1) has a particular tropism for the oral mucosa and
the skin above the diaphragm. Herpetic gingivostomatitis has an incubation
period of 3-7 days.

Signs and symptoms

Multiple vesicles and erosions with a yellow background in the oral
cavity,cervical lymphadenitis, fever, irritability and loss of appetite [12]
(seeTab. 2.6).

Lockjaw
It is a spastic contracture of the jaw muscles. It is a sign and symptom of
several pathological causes.
Extra-articular causes:
● infections and inflammation near the masticatory muscles;
● temporomandibular dysfunction;
● condylar neck fractures;
● fibrosis (scars, radiation therapy, submucosal fibrosis);
● tetanus.

Intra-articular causes:
● dislocation;
● intracapsular fracture;
● arthritis;
● ankylosis [13] (cfTab. 2.6).

Sialolithiasis
Salivary calculi is a frequent pathology that most frequently affects the
submandibular gland.

Signs and symptoms

Salivary colic synchronous with food intake, enlargement of the affected
gland, possible purulent secretions due to consequent bacterial superinfection
following salivary stasis [14] (seeTab. 2.6).
100

Heart attack
Acute coronary syndrome due to obstruction of a coronary artery by an
atheromatous plaque and consequent necrosis of myocardial tissue.

Signs and symptoms

Chest pain radiating to the left arm (it can also radiate upwards, to the neck,
jaw and teeth), intense asthenia, icy sweating, nausea and vomiting due to
vagal stimulation.
The patient is characteristically anxious and agitated [15] (cfTab. 2.6).

Bibliography
1. Miles TS, Nauntofte B, Svensson P. Clinical Oral Physiology. Copenhagen:
Quintessence; 2004; 93-139.
2. Riley JL, Robinson ME, Wade JB et al. Sex Differences in Negative Emotional
Responses to Chronic Pain. JPain 2001;2:354-9.
3. Woolf CJ. Pain: Moving from Symptom Control toward Mechanism-Specific
Pharmacologic Management. Ann Intern Med 2004;140:441-51.
4. Canteens S, Simons DG. muscle pain. Understanding Its Nature, Diagnosis, and
Treatment. Philadelphia: Lippincott Williams and Wilkins; 2001.
5. Modica F. Periodontopathies. In: Modica R. Treatise on clinical dentistry. Turin:
Minerva Medica; 2004. pp. 405-31.
6. Cattaneo L. Anatomy of the central and peripheral nervous system of man. Milan:
Monduzzi Editore; 1989. pp. 259-60.
7. Modica R. Dental caries and pulpopathies. In: Modica R. Treatise on Clinical Dentistry.
Turin: Minerva Medica; 2004. pp. 127-39.
8. Palla S. Myoarthropathies of the masticatory system and orofacial pain. Milan: RC
Books Editions; 2001.
9. Rossi G. Acute and chronic sinusitis and their complications. Otorhinolaryngology
manual. Turin: Minerva Medica; 1987. pp. 65-89.
10. Rossi G. Otitis media. Otorhinolaryngology Manual. Turin: Minerva Medica; 1987. pp.
262-89.
11. Gandolfo S, Scully C, Carrozzo M. Afte (Recurrent aphthous stomatitis – SAR).
Pathology and Medicine of the oral cavity. Turin: UTET; 2002. pp. 42-4.
12. Carrozzo M, Arduino P. Infectious diseases of the oral mucosa. In: Modica R. Treatise
on clinical dentistry. Turin: Minerva Medica; 2004. pp. 338-58.
13. Gandolfo S, Scully C, Carrozzo M. Differential diagnosis for signs and symptoms.
Pathology and Medicine of the oral cavity. Turin: UTET; 2001. pp. 11-12.
14. Modica R. Odontogenic infections. In: Modica R. Treatise on Clinical Dentistry.
101

Turin: Minerva Medica; 2004. pp. 285-323.

15. Rugarli C. Ischemic heart disease. In: Textbook of systemic internal medicine. Milan:
Elsevier Masson; 1986. pp. 119-37.
102

Endodontic treatment plan

M. Badino

Caries and periodontal disease are opportunistic infections associated with

the formation of biofilms on the surfaces of the teeth.
Factors such as the specificity of the bacteria and their pathogenic power, the
patient's susceptibility to disease, local and general host resistance can
influence the clinical character of dental disorders associated with plaque.
It has been shown that treatment aimed at eliminating the infection through
accurate bacterial plaque control measures can, in the majority of cases,
restore patients' oral health.
The treatment of carious processes and periodontal disease must follow a
strategy that includes the elimination of the opportunistic infection and
prefigures the clinical outcome parameters to be achieved.
The therapies to be implemented are the result of the integration of many
operating techniques with traditional connotations, such as surgical and non-
surgical periodontology, endodontic treatment, conservative reconstructive
and possibly prosthetics.
Furthermore, we must not overlook the fact that the entity of the therapies
necessary for a particular patient and the choices of the methods to be used
are intimately linked to the ability of the patient himself to collaborate in
every phase of the therapeutic plan.
If this ability is judged insufficient, the advisability of initiating a series of
treatments should be discussed; in fact, only through a complete collaboration
on the part of the patient will it be possible to reach the end of the therapeutic
plan.
Although the fundamental stages of endodontic treatment are
represented by an initial
diagnostic phase and the subsequent phases related to cleaning-shaping and
obturation of the root canal system, only a more complete and careful initial
diagnosis on the real conditions of the dental element can help in the study of
a correct treatment plan. It is a very important step: endodontic treatment
aims to ensure the conservation and use of the dental elements in question. It
is therefore evident that only after completing the comprehensive
examination and having
103

having carefully evaluated the list of problems relating not only to endodontic
pathology, but also to periodontal disease, masticatory functions and the
positioning of the element itself in the arch, a treatment plan can be presented
to the patient.
In the diagnostic-therapeutic study phase it is important to understand
whether the patient's subjective needs can coincide with the clinical
evaluation.
Starting from the data deduced from a global clinical examination, it is
possible, on the basis of the consequent diagnosis, to establish an adequate
therapeutic programme; the task of the odontostomatologist is to define the
cost-benefit ratio before carrying out any kind of therapy which – however
simple or complicated it may appear – requires an operating time and can
lead to complications, more or less bearable by the patient. In conducting a
general examination of the patient - beyond situations of strict emergency -
the dentist will have to frame the general state of the patient, defining any
risk factors that may be identified in some systemic diseases; however it is
common opinion that there do not seem to exist absolute contraindications to
endodontic treatment.
To begin a succinct but exhaustive review, some of the factors most
implicated in contraindications to endodontic treatment can be listed: general
anatomical variables are among the most frequent. An obvious example is
represented by the lower or upper third molars, which must be examined with
great care, both for their macroscopic anatomical location in the oral cavity
and for their intrinsic anatomical peculiarity (Fig. 2.57).
104

Fig. 2.57Lower molar with non-endodontically treatable mesial caries.

In the first case, the opening of the patient's oral cavity must be very well
evaluated before each endodontic maneuver, verifying the possibility of
introducing the suitable instruments to isolate the operating field and those to
practice the specific treatment.
Limiting the root canal therapy to parts of it, or to the pulp chamber alone,
can be a transitory remedy to relieve the pain of the patient but, in non-acute
situations, avulsion must be considered the treatment of choice, since it is free
from the typical complications of incomplete root canal therapy.
The same could be said for dental elements with anomalous anatomies or
with particularly difficult previous treatments; it may be necessary to use
microscopic techniques and therefore turning to "super" specialists could
represent a solution hypothesis which, if notfeasible for various reasons,
could lead to the choice of avulsion (Fig. 2.58).
105

Fig. 2.58Lower molar with complex retreatment; (a) careful examination and the particular
intraoral location, as well as the patient's will to keep the dental element led the clinician to
keep it, after careful retreatment (b).

It is evident that a complete review of these situations can be the subject of

innumerable distinctions and it is not possible, however scrupulous one may
want to be, to be exhaustive in this regard.
In theFigure 2.59 a diagram is illustrated from which it is possible to obtain a
summary guideline on what the clinician's attitude could be in the presence of
an endodontic pathology of carious or traumatic origin.
106

Fig.2.59Outline of the treatment plan.

In Clinical Cases 3-5 (Figs. 2.60-2.62) some treatment hypotheses of clinical

realities are listed which have required multidisciplinary treatments and
which can serve as a behavioral paradigm for clinicians.

Reprocessing
107

Fig. 2.60(to)Presence of an apical-periapical lesion affecting the mesial root of 46,

associated with endocanal retention in the distal canal. Clinical examination revealed pain on
both vestibular palpation and percussion. (b) Considering the size of the endocanal screw and
the localization of the lesion (mesial), it was preferred to concentrate the efforts only on the
mesial roots, retracting them. (c) From a 6-month follow-up, good healing was ascertained at
the level of the bifurcation, although a radiolucent image remained at the apical level. There
was a decrease but not disappearance of the symptoms to percussion and chewing and this
led to a review of the treatment plan; the root canal retention was removed in the distal root
and a new retreatment of the mesial roots was performed.

Reprocessing
108

Fig. 2.61(to)On radiographic examination, the patient presented a clear apical-periapical

endodontic lesion, with involvement of the mesial root of 46 and the root of 45. Furthermore,
the disappearance of the lamina dura at the apical level of the distal root of 46 was
highlighted. After careful analysis the reprocessing of the mesial root of 46 was considered
useless, since it is very compromised in the area of the bifurcation. (b) In the first session, the
crown with relative root canal screw was removed from 45 and then the orthograde
retreatment was carried out. (c) In the second session, only the distal root of 46 was retracted
and, subsequently (d), a rhectomy of the mesial root of 46 was performed. (e,f) Follow-ups at
6 months and 14 months with the patient in provisional maintenance therapy.
109

Endoperium

Fig. 2.62(to)On dental element 46, the radiographic examination highlighted periodontal
impairment of the distal root, the presence of a 48 in a mesio-inclined position, pulpal
necrosis of 47 with an apicoperiapical lesion, estimated as such because it was negative in
diagnostic tests. The treatment plan consisted of retreatment of the mesial roots of 46,
extraction of 48 and rizectomy of the distal root of 46, followed by endodontic treatment of
47. (b) Follow-up at 16 months with good healing and solution
110

completed prosthesis (c).

Medical records
G. Del Mastro

Definition and contents

The term medical record can be understood as a support, digital or paper, on
which the information useful for the treatment of each individual patient is
recorded.
Inside it can find information of a different nature, primarily personal data,
but also anamnestic findings of a general nature as well as others relating to
the motivation that prompted the patient to present himself for observation.
It is a precious aid that is constantly updated, in which, over time, some very
useful findings are noted such as the list of therapies (often subdivided into
clinical phases), their chronological progression, the notes relating to each
single phase or session, the medical history and any changes in the patient's
general state of health, as well as the frequency of scheduled checks. This
collection of information aims to highlight the central position of the patient
and his clinical problem and has as its primary purpose the provision of
qualified services, thanks also to the meticulousness of the information
collected.
Furthermore, it allows effective dialogue with the patient and allows the
traceability of the various activities, useful for identifying which operator has
taken charge of the patient or the individual therapeutic phases. In particular,
it can be used to carry out statistical evaluations useful for accounting or
management purposes of study resources: treatment times, analysis of the
fixed and variable costs of each therapy and inventory planning. Its
importance in litigation should not be underestimated [1], a situation in which
it plays a fundamental role in demonstrating the diligence of the clinician,
often questioned due to the absence or incompleteness of the documentation
produced.
An incomplete formation of the medical record can help to give concrete
form to the presumption of a correlation between the culpable conduct of the
doctor and the adverse consequences of the treatment, if such conduct is
capable
111

to provoke them.
In order to facilitate its compilation, the folder should be organized in a
schematic way, using predefined elements as much as possible that make it
usable by all operators and auxiliary staff. As a summary for practical
purposes, the following should find a place in a medical record that is as
useful and punctual as possible:
● demographic information and personal data;
● anamnestic data of a systemic and dental nature
● diagnosis of existing pathologies and their configuration within a
treatment plan;
● preventive;
● informed consent to therapies;
● chronological update of the therapies performed and related clinical
comments;
● elements of an administrative-accounting nature.

The folder may also contain, physically or in digital form, the results of the
physical examination, x-rays, photographs or other details useful for the
continuation of the therapy, any haematological tests or the list of drugs taken
by the patient, the forms insurance or other forms of complementary
assistance (Fig. 2.63).
112

Fig. 2.63The paper container, bare in its essentiality, understood as a medical record.
113

In the form of a book, various elements can be found inside (see text). (a) Cover.
(b)The three inside pages. (continued)
114
115

Fig. 2.63- Following

It is advisable to highlight, emphasizing the size of the fonts and the colors
used, the clinical problems of indisputable interest to the operator, to allow
speeding up the operations of the various phases and exploiting the file as a
means of preventing errors [2].
In private, the use of the folder is not mandatory; it still represents a useful
tool, not to mention indispensable. It should be emphasized that, at the time it
is drafted, its conservation becomes unlimited (Min. San. circular no. 61 of
19 December 1986) and must be kept within the framework of the legislation
governing sensitive data (Legislative Decree 196 of 30 June 2003 on
Privacy). The extension of the file and its sharing are subject - among other
things - to the rules governing professional secrecy (art. 622 PC).
The file, the original version of which is by the professional who drafted it,
can and must be delivered in copies whenever the patient explicitly requests
it. It can also be issued to those who exercise parental authority over a minor,
or to a person provided with a specific proxy.

Anamnesis
In the first phase – acceptance – the data relating to the patient's personal data
and a generic reconstruction of the patient's health history must be collected,
also through the use of an anamnestic questionnaire illustrated to him by the
auxiliary staff. The form, signed and dated by the patient and continuously
updated over the years, is subsequently critically evaluated by the operator,
who will integrate it with the appropriate questions during the first visit.
The prepared form – numerous exemplifying models are reported in the
literature [3] – will first of all report the personal data, organized in such a
way as to make it easy to extrapolate them for therapeutic, documentary or
accounting purposes (Fig. 2.64).
116
117

Fig. 2.64Registration form and anamnesis (From: Guastamacchia C. Elementi di

118

ergonomics and dental professional practice. Milan: Masson; 1988; modified.)

The next section can be occupied by the dental and general anamnesis, which
will help the clinician to frame the type of problem, providing an aid to the
diagnosis and the formulation of a correct treatment plan.
«The medical history must reveal any medical and/or dental condition that
may, to some extent, condition the diagnosis on the one hand and the
treatment plan on the other; suffice it to mention, for example, the septic
situations of the paranasal sinuses or jaw bones of non-odontogenic origin or
neoplasms, chronic heart disease and all those systemic manifestations that
bring about medium or severe disability. Pharmacological treatments that can
be influenced by dental procedures, such as, for example, drugs containing
bisphosphonates, must also be given great consideration.
The existence of overt allergies to some drugs, intercurrent drug therapies
and radiation therapies must be recorded.
All factors listed above, which may be important for diagnosis and treatment
planning, should be recorded in the patient's medical record.
Finally, in the dental medical anamnesis it will be important to pay
particular attention to any painful symptoms reported by the patient,
ascertaining their nature, duration, affected area, periodicity, factors
responsible for exacerbation or attenuation." [4]
Without dwelling in particular on this topic, which has been explored in this
same chapter in the part relating to the diagnosis in endodontics, it is however
appropriate to remember that the registration form should include a
preliminary assessment of the reasons that prompted the patient to request the
visit ; in fact, observations related exclusively to the objective examination
can lead to an erroneous diagnosis, since the operator can find dental
problems that do not correspond to the pathological condition that led the
patient to be observed.
In addition to the dental history, the folder will also find a section dedicated
to the remote pathological history (APR) or Past Medical History (PMH) and
the next one (APP) or History of the Present Illness (HPI), which can be
conveniently collected on the acceptance form in one
119

medical history section [5].

Numerous systemic pathologies may affect possible therapeutic alternatives,
postoperative pain control, possible allergic events or the risk associated with
surgery, in relation to haemostasis or the need/opportunity for selective forms
of prophylaxis [6]. In this regard, it is important that the continuous training
of the dentist does not stop at the specialist component but also includes
constant updating in the general field. For example, recently [7] the
guidelines on endocarditis prophylaxis that the American College of
Cardiology/American Heart Association has been developing since 1955
have been modified.
All data available to date have been completely reviewed and the current
recommendations reflect the analysis of all the literature on the subject. A
multidisciplinary team nominated by the American Heart Association with
representatives of the American Dental Association, the Infectious Disease
Society of America and the American Academy of Pediatrics stressed that the
previous guidelines contained ambiguities and inconsistencies and were the
result more of personal opinions than of objective data.
The conclusions established that only a small number of cases of infective
endocarditis could be prevented by an antibiotic prophylaxis preceding the
dental procedures and therefore it would be reasonable only for patients with
high cardiac risk of adverse events. Thus, patients: (1) with a prosthetic heart
valve; (2) with a history of prior endocarditis;
(3) with heart valve disease following heart transplantation; (4) with serious
problems related to congenital heart disease (Tab. 2.7). In these cases,
prophylaxis is recommended for all procedures involvingmanipulation of
gingival tissue or the periapical region of the teeth (Tab. 2.8). Predictably, as
a result of this new attitude dictated by EBM, the volume of prophylaxis
performed will be drastically reduced, also because:
● you are more likely to get infective endocarditis as a result of accidental
exposure to bacteria associated with daily activities rather than dental-
induced bacteraemia;
● the risk of adverse effects associated with antibiotics outweighs the
benefit (if any) of prophylactic antibiotic therapy;
● maintaining an optimal level of oral hygiene can reduce the incidence of
bacteraemia due to daily activities and therefore seems more relevant than
antibiotic prophylaxis.
120

Tab. 2.7Prophylaxis of bacterial endocarditis for dental

procedures*
Reasonable Not recommended
Endocarditis prophylaxis is Endocarditis prophylaxis is not
reasonable for patients with the recommended for:
highest risk of adverse outcomes ● injections of anesthetic
who have to undergo dental into non-infected tissue
procedures involving gingival ● dental radiographs
tissue or the periapical region of ● placement or removal of
the teeth or involving perforation prostheses or orthodontic
of the oral mucosa. appliances
● activation of orthodontic
appliances
● placement of orthodontic
brackets
● exchange of deciduous teeth
● bleeding from lip or oral
mucosal trauma
*
This table corresponds to Table 3 of the ACC/AHA 2008 guideline update on valvular heart
disease (From: Nishimura RA, Carabello BA, Faxon DP et al. ACC/AHA 2008 guideline
update on valvular heart disease: focused update on infective endocarditis prophylaxis. J Am
Coll Cardiol 2008;52:676-85.)

Tab. 2.8Administration for dental procedures*

121

Clinical diary
In the context of modern therapy, the medical record becomes an essential
tool to all intents and purposes: a sort of chronological diary in which to
collect data relating to the treatment of individual dental elements. It
therefore has a logical rationale to list the need for a preliminary treatment for
endodontic therapy, which instruments have been used, the method of
obturation of the root canal system, the accessory but useful details such as
the working length, the possible appearance of a related symptomatology or
its recourse, any additional therapies made necessary during the work
[8] and, finally, the periodic documentation - objective and radiographic -
relating to the remote checks carried out [9], their temporal expiry, etc.
In this regard, it should be emphasized that, in endodontics, radiographic
documentation plays a fundamental role, which can be observed as an
external diagnostic kit or be the result of internal investigations of the
structure in charge of the patient.
It is clearly recommended to always repeat a radiographic examination of the
elements to be retreated referred to by other colleagues, in order to accurately
represent the situation at time zero, represented by the patient entering his
office, also and
122

especially as medical-legal documentation.

«Regarding the performed services, it is advisable to report: the use of local
anesthesia, the isolation with a rubber dam, the relevant results (for example,
the presence of cracks or iatrogenic damage), the working length of the
canals , the apical diameter to which the canals were prepared, the
preparation technique, the irrigants used, the intermediate medications and
the type of reconstruction or temporary obturation possibly applied, the
analgesic, anti-inflammatory and antibiotic drugs prescribed (where
indicated), the material of root canal filling, the endodontic cement and the
obturation technique used, the number of radiographs, any notes on the
radiographs taken, possible complications (for example, iatrogenic
accidents) and indications on the final restoration or the type of restoration
performed.[4].

Paper or file?
The advent of information technology has supplemented and sometimes
replaced paper. It has radically changed the settings and work habits by
making individual patient data archived more simply and easily transmitted
as well as shared on the network by different operators [10].
In this sense, the experience of Dr. Henry Plummer at the Mayo Clinic
proved pioneering, who more than 100 years ago developed the concept of
unit record: the idea was to convey all the information relating to a patient in
a single document that with the patient himself and was stored in a central
archive. With the digital processing of data, this archiving standard was then
improved and expanded, which made it possible to record the data of more
than 6 million patients from the year 1907 to today [11].
However, the advantages of a digital file are not limited only to the different
use of the instrument (paper or electronic medium), but computerization
allows for cross-referencing information relating to study activity, an
otherwise impossible operation. Filing in a database allows the use of data in
real time and for any need, without having to extrapolate them one by one
from the paper files. To this end, it is not enough to transform the paper
clinical file into numerical data, but a process of computerization of the study
is required, to eliminate as much as possible non-computer data: agenda for
appointments, X-rays and photographs of the patient, accounting files,
prescriptions, etc. (Fig. 2.65). This challenging
123

process makes possible a real control of all the data (clinical, accounting,
management) which constitute the only and true advantage of the use of the
computer, with an inevitable positive impact on the dentist's ability to
monitor the effects of his own clinical and extra-clinical activity [12].
124

Fig. 2.65Example of a digital medical record, an integral part of a specific software for
dental practices. The tree structure can show – superimposed – the treatment plan, the
economic estimate and the data of a single session.

The greater accessibility has brought undisputed benefits but also the need to
guarantee the certainty that the available data maintain a level of security
such as to prevent unauthorized persons from accessing so-called sensitive
data. Furthermore, it entails the requirement that what is archived, especially
for medico-legal purposes, cannot be manipulated in an illicit manner.

Informed consent
«The patient must be informed, possibly using - for explanation and
discussion - intraoral images and/or radiographs of the clinical situation, the
presumable prognosis, any alternative treatments. Information relating to the
treatment and the cost of the proposed services must be delivered to the
patient in writing. The patient is required to grant his approval to proceed by
signing a
125

copy of this information, which will be attached to the medical record and
kept according to the indications of the law.[4].
Consent is a fundamental act, the starting point for all activities
clinics.
The patient, once correctly informed, gives his assent to the therapies with a
free and voluntary act. In this way a sort of agreement is created between the
professional and the patient, who therefore becomes an active part of the
decision-making process and is no longer a simple passive subject.
In endodontics, informing may require uncommon communication skills,
taking into account the particular "invisibility" of what is being done. For
example, it is difficult to explain in words the criteria that inform correct root
canal therapy, while, on the contrary, it is easy to convey the aesthetics of a
ceramic crown. In this regard, the American Association of Endodontists
(AAE) and the Italian Endodontic Society (SIE) have developed some
educational brochures, structured in an attractive way and written with simple
terminology, which are easy to understand for patients. These have proved to
be particularly effective for underlining some passages of biology and
therapy in a synoptic way – always particularly difficult
– making them easily understandable (Figs. 2.66And2.67).

Fig. 2.66Brochure prepared by SIE to explain the endodontic treatment to the patient. (From:
Detachable insert by SIE. G It Endo 1999;13(2), central pages.)
126

Fig. 2.67AAE brochures introducing the concept of the endodontist, treatment alternatives
and endodontic surgery. (From:www.aae.org/treatmentoptions)

In order to avoid future misunderstandings, any type of didactic support -

from the intraoral camera to the step-by-step analysis of an X-ray - can,
however, be useful to allow the patient to understand what will be done in his
mouth.
Without a doubt, the adoption of an appropriate language is fundamental,
which can create the opportunity for a communication interface that is
sufficiently effective to make the patient understand even quite complex
situations, in order to guarantee correct and unfiltered information, of a
qualitative level certainly superior to what the patient could find on the Web
or through the mass media. Unfortunately these are, in fact, the primary
sources of scientific literature on which the patient relies to understand his
problems. It is easy to understand how superficially and carelessly the news
can be distorted, especially if filtered by "bar" chatter or misleading
advertising messages.
For the elaboration of a correct treatment plan it is necessary to allow the
127

patient a serene evaluation of the possible therapeutic alternatives available in

his case. Allowing him to discern between a therapeutic approach based on
surgical endodontics or the opportunity for an implant replacement is not
always easy, but it is possible by offering himself as a guide. Rational choices
can start from operational/prognostic (endodontic retreatment vs implant [13-
15]) or economic (orthograde vs surgical endodontics) evaluations, without
neglecting general health conditions, which certainly orient the clinician and
the patient towards more or less invasive. The component relating to the time
factor - linked to the availability that the patient deems useful to grant us - or
the psychological one should not be underestimated,
Obviously, this type of path involves dedicating time to these things, which
cannot be delegated and which cannot be limited to the pedestrian taking
delivery of a pre-printed form on which to have a signature affixed [16] (Fig.
2.68). It is not a waste of time but to take a few precious minutes so that a
good part of the misunderstandings that often emerge at the end of therapy
can be reduced. In this regard, what is reported by a journalist of the New
Yorker [17] is singular, who underlines how «a good rate of litigation in
healthcare is triggered by the antipathy that the patient feels towards the
professional».
128

Fig. 2.68A proposal for informed consent specific to endodontics (From: Fresa R. Informed
consent in dentistry. CG Edizioni Medico Scientifiche; 1998. p. 179-94; modified.)

Some good reasons for obtaining a truly informed consent [18] concern first
of all the attempt to realize a true "therapeutic alliance". The premise is an
exchange of ideas that supports the dentist-patient relationship and
determines the birth of a relationship of trust, in which the dentist - with his
professionalism - guides the patient in his choices, with a sharing of
responsibility for the consequences [19]. Know-how
129

it does not always mean knowing how to communicate: giving importance to

the opinion of those who listen to us and showing maximum availability, has
much more value for the patient than the perfect technical execution of the
service, the outcome of which can only be evaluated at a later time.
It is remarkable how often the operator forgets an obvious concept: the
patient chooses to undergo treatment before being able to appreciate the
operative ability of the clinician.
Secondly, especially in the private sphere, it can be extraordinarily effective
to use this moment as a legitimate marketing operation. This is an
opportunity to emphasize, without frightening the patient, some particularly
sophisticated procedures, the use of specific materials or technologies, the
operational commitment aimed at recovering a particular element even in
future projections, for an exhaustive prognostic balance. These passages,
among other things, also contribute to the operator's motivation, who can find
a stimulus in thinning out the curtain of scarce information that forms the
patient's baggage, and not seeing this task as monotonous, but exploiting it as
a moment of professional growth.

Essential regulations
The obligation that the doctor assumes towards the patient to provide
adequate information is, for the most part of the jurisprudence, ofcontractual
nature; this means that, in any dispute, it is the
dentist must demonstrate that he has provided the patient with all of them
necessary information [20]. It is
specified that the failure to request consentof the patient health treatment
constitutes an independent source Ofresponsibility
incumbent on the dentist for lesion ofright to self-
determination based on art. 13 (right of the individual to protect his physical
integrity) and in art. 32 (right of the individual to choose whether or not to
undergo medical treatment) of the Constitution. According to jurisprudence,
the information must have as its object the nature of the medical intervention,
the extension, the risks, the possible results that can be achieved, the possible
negative consequences, the possibility of obtaining the same result through
other interventions and the risks of these last; the patient must be concretely
put in «the condition to evaluate every risk and alternative (for all: T. Milano,
V civ, 29-3-2005 n. 3250). The obligation to
130

information extends to all the alternative choices, so that the patient with the
technical-scientific help of the healthcare professional can decide on one or
the other of the possible choices through a conscious assessment of the
relative risks and the corresponding advantages». (Cass. Section III 30-7-
2004 n. 14638; T. Milano 3520/2005).
Any pre-printed form must be: «a model expressed in a language that is fully
understandable by anyone who is not a technician in the sector, given that
information rendered in a way that is not fully understandable by the
interlocutor is essentially unable to fulfill its function and is equivalent to
non-information» (T. Venezia, section III civ, 10-04-2004). The model must
therefore be clearly understandable for the patient – and above all for those
who could examine it in the event of litigation! – and it shouldn't be too
generic either. Recently (T. Bari, section II, 19-10-2010 n. 3135), however it
has been specified that the information contained in a "standard" form and
signed by the patient does not constitute a suitable "informed consent" since
the information are “necessarily generic,
The correctness of the medical treatment has no relevance for the purposes of
the doctor's liability deriving from inadequate information provided to the
patient before submitting him to treatment and this on the assumption that, as
mentioned, in the absence of informed consent, the doctor's activity
constitutes an offense which must be answered [21].
The most recent jurisprudence (Cass. 02/09/2010 n. 2847) has however
specified that the doctor is liable for damage to health only if there is a
connection between the omitted information and the damage reported by the
patient [22].

Difficulty level analysis

A few years ago, and recently updated, a form was proposed for a
preliminary evaluation of the most complex endodontic cases, to be attached
to the classic medical record [23].
In this module the levels of difficulty relating to the treatment have been
schematically divided; the evaluation form facilitates the selection of cases
that can be more easily referred to a specialist in endodontics.
131

All the conditions indicated on this sheet must be considered potential risk
factors, which can complicate the treatment and negatively affect the result.
There are considerations relating to the patient in a general sense (for
example, health, degree of collaboration, mouth opening), others related to
the diagnosis and treatment phase, such as position and difficulty of
accessing the arch, root canal morphology, apical resorption or calcifications;
finally some additional considerations, such as traumahistory, complex
retreatments or assessments of an endoperium nature(Tab. 2.9).

Tab. 2.9Evaluation form of the difficulty of an

endodontic treatment.
132
133

The classification has three different levels.

1. Low Difficulty: Treatment steps are routine. The general dentist,
even with limited experience, can obtain a predictable and
satisfactory result.
2. Medium difficulty: the preoperative condition is complicated, with the
patient presenting one or more of the risk factors indicated in the
"medium" category. Achieving a positive result will be difficult and the
expertise of an experienced professional is required.
3. High difficulty: the preliminary evaluation reveals several problems of
'medium' category or at least one of a "high" level. Successful treatment
will be challenging even for a very experienced practitioner with a long
history of positive results.

The didactic utility of this type of diagnostic support is linked to its

schematic nature: in a short time it is possible to establish whether or not one
possesses the necessary skills to solve the single case under examination.

Bibliography
1. Givol N, Rosen E, Taicher S et al. Risk management in endodontics. J Endod. 2010
Jun;36(6):982-4.
2. AAVV. Patient safety and clinical risk management. The profession library – quarterly –
year X, 2007. Ministry of Health, FNOMCeO, Ipasvi. p. 81-84
3. Guastamacchia C. Elements of ergonomics and dental professional practice. Milan:
Masson; 1988. p. 233-6.
4. Malentacca A, Pasqualini D, Mollo A et al. Endodontics - Proposal for Clinical
Recommendations. Edited by the Ministerial Commission for clinical recommendations
in Endodontics. 2011. Pages 3-7
5. Cohen S, Hargreaves K. Pathways of the pulp. Ninth edition. Philadelphia: Mosby
Elsevier; 2006. p. 2-96.
6. Murray CA, Saunders WP. Root canal treatment and general health: a review of the
literature. Int Endod J. 2000 Jan;33(1):1-18
7. Bonow RO, Carabello BA, Chatterjee K et al. American College of
Cardiology/American Heart Association Task Force on Practice Guidelines. J Am Coll
Cardiol. 2008 Sep 23;52(13):e13-e17.
8. Pagavino G, Pace R. Progress in endodontics, volume I. Guidelines for diagnosis and
therapy. EEA 2001. P. 59
9. Ross C, Scheetz J, Crim G et al. Variables affecting endodontic recall. Int Endod J. 2009
Mar;42(3):214-9.
10. Guess G. Modern office design in the “information age”. Dent Clin North Am. 2004
134

Jan;48(1):309-21.
11. http://www.mayoclinic.org/emr/.2011.
12. Guastamacchia C. AIO – Ergonomics and communication in the dental office (from
general principles to digital high-tech). Turin, Saturday 2 April 2011
13. Wolcott J, Meyers J. Endodontic re-treatment or implants: a contemporary conundrum.
Compend Contin Educ Dent. 2006 Feb;27(2):104-10; quizzes 111-2
14. Christensen GJ. Implant therapy versus endodontic therapy. J Am Dent Assoc. 2006
Oct;137(10):1440-3.
15. Bobba V, Del Mastro G, Pilotti E. The choice between endodontic and implant
treatment in the light of bibliographic research. 8th Piedmontese endodontic day
organized by the SPE. Turin, 10 February 2007.
16. Bur R. Informed consent in dentistry. Rome: CG Medical Scientific Editions; 1998. p.
179-84.
17. Gladwell M. In the blink of an eye - The secret power of intuitive thinking. Milan:
Mondadori; 2006. p. 33-4.
18. Aversa M. Tagete. Archives of Legal Medicine and Dentistry. 2009;15(4).
19. Paterick TJ, Carson GV, Allen MC et al. Medical informed consent: general
considerations for physicians. Mayo Clin Proc. 2008 Mar;83(3):313-9
20. Redi G, Macchia R. AIO - Day of Legal Dentistry. 46th Congress of the Friends of
Brugg, Rimini, Saturday 17 May 2003
21. Redi G. Informed consent in civil jurisprudence. Dentistry Perspective, 10/2006, 3:17-
18
22. Redi G. Personal communication, 2011.
23. AAE extension. Endodontic case difficulty assessment form and guidelines.
2010;www.aae.org.

Endodontic radiology
E. Ambu

Introduction
The completely accidental discovery of X-rays by Wilhelm Conrad Roentgen
in December 1895, constituted a real epochal turning point for diagnostics in
the medical field: for the first time the possibility presented itself to the
clinician of "exploring" the human body from the outside without having to
resort to surgical procedures.
In the following years, the many researches in the radiodiagnostic field led to
the development, by Alessandro Vallebona, of the tomographic technique,
from which the theories that allowed Hounsfield, at the end of the seventies,
to develop computed tomography
135

(CT), thus marking another evolutionary moment for radiology, namely the
transition from two-dimensional to three-dimensional imaging.
Undoubtedly the radiographic investigation plays an essential role for the
clinical evaluation of the dental patient. Intraoral radiographs were first used
in the weeks following Roentgen's discovery of X-rays; extraoral imaging,
including cephalometric radiography, is slightly later. Hence, the introduction
of orthopantomography (OPT) in the 1960s and its widespread diffusion in
the 1970s and 1980s brought about considerable progress in dental
diagnostics, providing the clinician with a single and comprehensive image of
the dental arches and the maxillo- facial [1].
Two-dimensional radiology has further evolved and, in the last twenty years,
the analogue support, consisting of the traditional plate, has been
progressively replaced with digital supports, which have become increasingly
sophisticated with the evolution of computerized technology.
Today we have technologies based on radiovisiography (RVG) (Fig. 2.69) or
that exploit phosphor supports that allow us to obtain images directly on the
screen of our terminals in real time, with fewer environmental pollution and
storage problems.
136

Fig. 2.69Wireless RVG device.

Despite the possibilities offered to "see" the inside of the human body in a
non-invasive way, intra- and extraoral procedures, used individually or in
combination, are characterized by the same limitations intrinsic to all two-
dimensional projections. In fact, like all projective radiographic images, they
transform a series of three-dimensional anatomical structures into a two-
dimensional image. This chapter will discuss this limitation and how it has
been possible to overcome it today with the introduction of devices that allow
3D imaging in our surgeries.

X-ray formation
X-rays are electromagnetic radiations which are propagated with an
undulatory motion characterized by a very short wavelength (about 1/10,000
of the wavelength of light), a property which allows them to
137

penetrate and pass through bodies that reflect or absorb light. The formation
of X-rays takes place inside the X-ray apparatus, called Coolidge tube, a
glass container in which a vacuum has been created, containing a cathode
(negative pole) and an anode (positive pole). The cathode contains a tungsten
filament in a bowl-shaped housing, while the anode consists of a copper
structure inside which a tungsten target is housed, the surface of which is
defined as the focal spot.
This system is immersed in a medium, water or oil, suitable for dissipating
the heat that is generated during the emission of X-rays (ie 99% of the energy
used) and is contained inside a metal box, in order to reduce radiation
dispersion in all directions (Fig. 2.70).

Fig. 2.70X-ray tube scheme. (From: Ambu E. Illustrated Manual of Endodontics. Milan:
Masson; 2003.)

The system is crossed by two electric circuits: the first consists of the passage
of a current in the tungsten filament of the cathode, which produces the cloud
of electrons attracted by the anode, with a speed depending on the kilovoltage
of a second electric current existing between the two poles. The impact of the
cloud of electrons produced in the area of the cathode with the focal spot
housed in the anode produces an emission of rays, including those of interest,
which will be collimated and directed so as to provide a
138

"brush" of X-rays of the smallest possible dimensions. The speed of the

electrons, therefore the "energy" of the rays produced, depends on the
potential difference between the anode and the cathode, while the quantity of
electrons produced depends on the intensity of the current (expressed in
milliamperes, mAmps) which passes through the filament in tungsten [2].
The number of electrons produced by the tungsten filament, therefore the
number of X-rays produced, depends on the milliamperage of the current
flowing through the structure and on the duration of the passage of the
current itself (exposure time).
In modern radiological equipment, the milliamperage cannot be modified and
therefore the quantity of electrons produced can only be varied by modifying
the exposure time: the reference value is therefore the quantity of electrons
emitted during the exposure time, expressed in milliamperes per second
(mAmp/ sec). Wanting to visualize the concept, the milliamperage is
comparable to a tap: the more you open it, the more water comes out and the
amount released depends on the time this flow remains active. Doubling the
exposure time doubles the number of electrons and therefore the amount of
X-rays emitted, causing a greater darkening of the film. The milliampere is
therefore responsible for the "quantity" of the rays emitted [3].
The kilovoltage, on the other hand, is responsible for the "quality" of the X-
ray beam: low kilovoltage devices produce high-contrast images, with a
reduced gray scale and therefore less richness of detail. This occurs because
the rays produced by a 50 kV source have a lower penetration force. Going
back to the faucet example, if the “timing” (mAmp/sec) indicates the volume
of beams emitted, the kilovoltage is like a spray nozzle. A low kilovoltage is
like an open nozzle: you have little energy and little penetration (aka “short
scale”). By raising the kilovoltage, the nozzle closes, the beam becomes
"harder" and produces "long scale", ie low contrast images. It is precisely this
factor that makes it possible to highlight slight contrast variations in the
image.
The higher the kilovoltage of the device, the longer the grayscale produced is
the longer it is: a greater quantity of grays produces an image richer in detail,
because it is less contrasted. All of this obviously has its limits: too high
kilovoltages produce ineffective images due to the excessive lack of contrast.
50 kV appliances having been abandoned, today 65-kV appliances are
common
139

70 kV. In almost all the devices available today it is not possible to select the
peak kilovoltage: where this is possible, it is usually possible to choose
between an emission at 65 kV and one at 70 kV. The latter, richer in detail, is
considered more useful for radiological examinations aimed at a periodontal
diagnosis, while the 65 kV devices, providing more contrasted images, are
more useful for endodontic diagnosis.
The second aspect related to kilovoltage is the greater amount of X-rays
produced by the generator as the peak power increases. This occurs following
a non-linear relationship which can be summarized, empirically, in the need
to halve the exposure time at each 10 kV increase of the generating machine.
This aspect is linked to the need to irradiate the patient as little as possible,
according to the concept expressed by the US acronym ALARA (As Low As
Reasonably Archievable) and taken up in Law 187/2000 with the principle of
optimization and justification.
There are many factors that make it possible to decrease the radiation of the
patient. A high-frequency device, for example, provides a higher quality
beam, reducing patient radiation by 30% compared to a conventional
generator, just as the use of F-speed film reduces patient exposure by 20%.
than that of less sensitive E-speed film, itself 60% more sensitive than D-
speed film.
In conclusion, in order to obtain high-quality images with a consistent
reduction in patient irradiation, high-sensitivity films and high-frequency
generators at 65-70 kV and low milliamperage (7-10 mAmp) will have to be
used, which allow obtain an image with good contrast of bone and dental
tissues.

Image quality
A good radiological image, which allows you to obtain the maximum
possible information, must be sharp and well defined and not show gross
distortions.
The definition of the image and its sharpness depend on several factors. The
X-ray source is not of the punctiform type and the resulting beam is
consequently conical.
This means that the image of the investigated object that is formed
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on the detector, i.e. on the support, it is magnified and has more or less large
areas of penumbra. The magnification problem can be easily solved, using
the Rinn centerer (Fig. 2.71), which allows a uniform enlargement of the
image of 5%, thus preventing the risks of uneven enlargement of the image,
i.e. distortion. This means that the radiographic image of an element
measuring 20mm from anatomical apex to incisal edge will be magnified by
1mm (5%) and that various parts of the element will reflect this
magnification equally. This magnification factor should be taken into account
in the preliminary assessment of the working length on the preoperative
radiograph [4].

Fig. 2.71Rinn centering device for posterior sectors.

Furthermore, the Rinn centering device allows the film to be kept

perpendicular to the X-ray beam and parallel to the long axis of the dental
element. In the investigation of the posterior elements of the maxilla, Rinn's
centering device allows the pellicle to be moved away towards the center of
the palate, keeping it in the correct position.
The increase in the penumbra determines a lesser definition of the edges of
the element to be investigated, whose details are therefore less clear. If the
film is moved away from the object to be radiographed, or the distance
between the X-ray source and the object is reduced, there will be a
proportional increase in the penumbra (Fig. 2.72).
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Fig. 2.72Areas of shade and penumbra. (From: Ambu E. Illustrated Manual of Endodontics.
Milan: Masson; 2003.)

The 50 kV generators, having a low "peak power", have a very small "skin-
fire" distance (ie between focal spot and film) and therefore a great
penumbra, due to the proximity of the X-ray source to the object. Also, since
the power of X-rays, like that of light, decreases with the square of the
distance, one cannot compensate for the dim light created by moving the film
away from the teeth in the maxilla. To obtain an image with reduced
penumbra, using 50 kV generators, it is therefore necessary to place the film
in contact with the margin of the crown and to use the "bisector rule" which
produces highly distorted images of no clinical use (Fig. 2.73).
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Fig. 2.73Bisector technique. (From: Ambu E. Illustrated Manual of Endodontics. Milan:

Masson; 2003.)

Only in relatively recent times, with the introduction of high power

generators and high sensitivity films, has it been possible to use the parallel
beam technique (Fig. 2.74). In this case the film, placed parallel to the long
axis of the teeth and perpendicular to the direction of the X-ray beam, is
moved away towards the center of the palate so as to avoid interference from
the palatine vault. The increase in twilight, due to the distance of the target
from the object, is compensated by the distance of the source from the object.
To do this, of course, it is necessary to have an apparatus (with a long cone)
with a power sufficient to compensate for the decrease in the power of the X-
rays based on the square of the distance.
143

Fig. 2.74Parallel technique. (From: Ambu E. Illustrated Manual of Endodontics. Milan:

Masson; 2003.)

The same increase in the penumbra also depends on the origin and
collimation of the X-ray cone. The electron beam that runs from the cathode
to the anode generates X-rays when they hit an area in tungsten, the focal
spot . The smaller the area of the focal spot, the less the penumbra generated
by the X-ray beam. Furthermore, this target is inclined by 45° so as to further
collimate the cone of radiation produced, which undergoes a further reduction
by passing through a a special lead collimator, which eliminates non-coaxial
X-rays, and an aluminum filter, which eliminates soft rays which do not serve
to form the image but cause useless irradiation of the patient.

two-dimensional radiology
Two-dimensional radiology uses extraoral means of investigation (x-ray
machines) whose detectors (analog or digital) can be intra-or extraoral. The
most common intraoral detector is the traditional or digital plate: among the
extraoral ones, we recall the supports for the OPT or for the stratigraphy of
the temporomandibular joints.
In recent years, alongside the traditional analogue support based on the X-ray
plate, the use of digital supports has been developing. Yes
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these are devices that are used in the same way as traditional films but collect
the radiation after crossing the body to be investigated on sensitive plates
(memory phosphors), which are read by a special laser reader, or on sensitive
plates coupled electric charge (CCD sensors) that download data directly to
the computer via a cable. RVG systems have a better definition than
phosphor sensors, but pay for this momentary advantage with sensors of
inadequate dimensions and with the presence of the connection cable which
makes the examination more complex and less pleasant for the patient.
Conversely, systems with memory phosphors still require the use of a
"reader" and "reading" procedures, with a delay in the availability of the
video image. Once acquired, the images are visible on the computer screen
and the brightness and contrast can be modified, improving their readability;
moreover, useful measurements can be made to define the length of the
channel and the amounts of residual structure [2].
Digital systems show a number of advantages over traditional systems:
● reduction of the dose delivered to the patient;
● processing and better reading of the image;
● digital archiving;
● possibility of immediate sharing of images via local network or the Web;
● elimination of the darkroom and of the developing liquids, with a
reduction in disposal costs and impact on the ecosystem;
● immediate possibility to provide the patient with his own image archive.

Use of two-dimensional radiology in endodontics

Until a few years ago intraoral radiography was considered the gold standard
for endodontic diagnosis. However, this technique has many limitations,
which have only recently been overcome by three-dimensional radiology,
which has become usable in dental surgeries thanks to volumetric machines
based on cone beam technology.
Here we will examine the current indications for the use of two-dimensional
radiology in endodontic diagnosis and we will focus on the limits of this
technique.
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Two-dimensional radiology applied to endodontic

diagnosis and therapy
Traditionally, intraoral radiography has been the only means that has helped
the clinician in endodontic diagnosis. In fact, precisely because of the
intrinsic characteristics of this type of problem (“endo” is the suffix that
indicates the concept of interior, or “hidden”), it was necessary to make use
of tools that would allow one to “see” inside the bone and dental structures.
This type of exam is used to diagnose the presence of radiolucent lesions
related to one or more roots, to highlight the presence of caries and their
proximity to the dental pulp, to detect the presence of root pathologies, such
as resorptions and fractures. Furthermore, the intraoral radiogram provides,
albeit with obvious limitations, information on the dental and endodontic
anatomy (position of the canals, shape and number of roots) and helps the
clinician in analyzing the obstacles he will find on his way to the apex in
retreatment (posts, broken instruments, steps, type of root canal filling
material used in previous treatment, etc.).
Finally, the use of the "intraoral plate" is indispensable in some clinical
situations such as the confirmation of the working length obtained with the
electronic apex locator (Fig. 2.75) or in dissolving some clinical doubts in the
intraoperative phase (presence of "false roads", control of the direction of
penetration in case of calcifications with deep obliterations of the canal) [4].

Fig. 2.75Radiography for determining the working length.

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Limits of two-dimensional radiology

The limits of two-dimensional radiology, even if technically well performed,
are many as they are intrinsic to this system, which can only provide a two-
dimensional image of a three-dimensional structure.
This has generated problems of interpretation that make this technique very
"operator-dependent". Goldman et al. in 1972 they evaluated the agreement
between the examiners regarding the analysis of the same cases: six expert
observers were asked to evaluate the presence of lesions in 253 cases
including controls [5] and the agreement between the observers was less than
50%. Even more surprising was the fact that after eight months the test was
repeated and the agreement of the judgments with those previously expressed
was between 71 and 88% [6].
The limits of two-dimensional radiology are due to the presence of dense
anatomical structures which, by overlapping the element being investigated,
prevent the detection of correct information. The most typical case is the
presence of the shadow of the zygomatic process of the maxilla, which
sometimes makes it impossible to read not only the endodontic but also the
dental anatomy of the upper molars (Fig. 2.76).

Fig. 2.76Shadow interference of the zygomatic process.

This limit is also evident in the reading of the anatomy of the single element,
where the disappearance of the path of the canal lumen can mean a
bifurcation of the apical third (Fig. 2.77) or the presence of a split canal in the
middle third (Fig. 2.78). One can somehow overcome this limitation by
applying the vestibular object rule,
147

thus obtaining a greater quantity of information deriving from the comparison

of a first image, obtained with an orthogonal projection, with a second
"unprojected".

Fig. 2.77Radiological disappearance of the canal lumen in the presence of an apical delta.

Fig. 2.78Radiological disappearance of the lumen of the canal in the presence of a doubling
of the middle third.

The vestibular object rule, first enunciated by Clark in 1910, establishes that,
performing a projection with an angle different from
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that of the orthogonal projection, the most vestibular object moves in the
same direction as the X-ray beam (Fig. 2.79). In this way it is possible to
distinguish the position of two canals in the same root or to identify the
correct location of an intracanal obstacle (for example, a fractured instrument
in a bicanal root). This rule also allows to recognize the anatomical position
of an occluded element, the relationship between dental apices and sensitive
structures (such as the inferior alveolar nerve) or to carry out differential
diagnoses between periapical pathologies and anatomical structures (mental
hole) or non-endodontic pathologies ( for example, a nasopalatine cyst).
Finally, Clark's rule allows to highlight the anatomy in case of canals with
large apical curvatures (Fig. 2.80).

Fig. 2.79Vestibular object rule. (From: Ambu E. Illustrated Manual of Endodontics. Milan:
Masson; 2003.)

Fig. 2.80Application of the vestibular object rule.

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The use of two-dimensional radiology shows evident limitations in the

diagnosis of radiolucent lesions. The possibility of detecting this type of
structure through a two-dimensional investigation depends in fact on various
factors. These images are taken because, being bone cavities filled with soft
tissue or liquid, they appear to be more radiotransparent than the adjacent
areas, formed by bone and therefore more radiopaque. Basically, the
radiograph describes the lesion based on the difference in bone density in
adjacent areas.
The presence of denser anatomical structures, which overlap the radiolucent
area, limits their evidence (Fig. 2.81). One of the factors that most influence
the detection of lesions is the thickness of the cortex. In this way, in some
areas, such as for example in correspondence with the apexes of the upper
incisors, the lesion will be easily detectable due to the smallness of the
cortex; in other areas, for example that of the lower molars, the lesion will be
visible only if it has promoted, by resorption, a considerable reduction in
thickness, at least 30-50% of the cortex itself [7]. In the same article, Bender
recalls how the lesion is only visible if near or inside the bone cortex, while it
may not be visible if positioned outside the bone case (where we cannot have
any bone density contrast).Figs. 2.82And2.83).

Fig. 2.81The presence of large overlapping anatomical structures can limit the detection of
the structures of our interest. (From: Ambu E et al. 3D Radiology in Dentistry. Milan:
150

Elsevier; 2013.)

Fig. 2.82Two-dimensional radiological examination of the area of clinical interest: the

periapical lesion of 2.5 is noted.

Fig. 2.83Volumetric radiological examination of the area of clinical interest: a large lesion is
noted which affects the area of the second premolar, the first molar and the maxillary sinus.

Therefore, the search for a periradicular lesion cannot be entrusted to the

mere reading of an intraoral radiogram: lesions of even 1 cm, if resident only
in the medullary component of the bone, can go completely unnoticed [8]. In
a fine review performed by Huumonen and Ørstavick [9], the Authors point
out that it is the thickness of the cortex that makes it possible to read the
lesions in some areas and not in others, where the cortex is thicker. This
concept is taken up by other authors [10] who note how injuries of
3 mm may be visible in the areas of the lower incisors and premolars,
however becoming undetectable moving distally in the molar areas.
Again Huumonen and Ørstavick state that the same root can be an obstacle to
the detection of the lesion, as often happens for the lateral
151

showing anatomically the apex facing the palate, and how the lesion may not
be identified depending on the angle of incidence of the X-ray beam (Fig.
2.84).

Fig. 2.84The root can "cover" the image of the lesion, limiting the possibility of diagnosis.
(From: Huumonen S, Ørstavik D. Radiological aspects of apical periodontitis. Endodontic
topics 2002;1:3-25; modified.)

In an attempt to give a scale of detection to the peripical lesions, the so-called

Peri Apical Index (PAI) [11] was proposed, starting from the work of
comparison between the radiological and histological data proposed by
Brynolf. The validity of this index, in any case, is limited only to areas, such
as the upper central incisors, where the thickness of the cortex is very thin.
Brynolf [12], examining the elements treated endodontically in cadavers,
found that histological signs of inflammation were present in 93% of the
samples examined and that in many cases they were not detectable with a
radiological examination.
These percentages were reviewed by Green et al. [13] who found that 26% of
the elements showing signs of inflammation of varying degrees actually did
not show any radiological evidence. Finally, in a more recent work, Barthel et
al. [14] showed that as many as 35% of the lesions present are not detected
on intraoral examination. The fact that this problem is linked to anatomical
situations and to the limits of two-dimensional radiology, and therefore is
unsolvable, is demonstrated by the work of Holtzmann et al. [15], who found
no differences between the use of traditional radiographic films and digital
devices, such as
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phosphorus. The evidence that one third of the lesions is in fact not detectable
with common intraoral radiographic examinations should lead to consider the
use of two-dimensional radiology in the diagnosis of the periapical lesion as
obsolete; in the light of all this, the absence of the radiolucent lesion on the
two-dimensional radiological examination will no longer be able to justify,
from the medico-legal point of view, the omission of the re-treatment of an
element before providing for its functional recovery, if from this omission
factors may intervene to worsen the patient's health.
Today, fortunately, devices for volumetric radiographic diagnosis are
available (Fig. 2.85), which allow to overcome the limit of two-dimensional
radiography.

Fig. 2.85A small FOV volumetric radiology device.

Volumetric radiology
Lofthag-Hansen et al. found that lesions that are not detected on intraoral
radiographs can be detected by three-dimensional radiographic examination
performed with a Cone Beam Computed Tomography (CBCT) device
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a focused "field of investigation" (Focused Field of View or small FOV in

Anglo-Saxon literature) [16]: in this work performed on 46 dental elements,
both techniques detected lesions in 32 cases, but only CBCT allowed to
identify other 10 elements affected by periapical pathology. Considering the
single roots, small FOV CBCT allowed to detect 86 lesions against only 53
highlighted by intraoral radiographs.
The scientific papers that have been interested in this aspect have been
different: Low et al. [17] found that in 34% of cases it was not possible to
find, by periapical radiography, the periapical lesion otherwise detectable by
focused CBCT. The lesions are poorly detectable in the case of the molars
(especially the second ones), if the apices are close to the maxillary sinus or
when the thickness of the bone between the lesion and the floor of the
maxillary sinus is less than 1 mm. Estrella et al. [18] compared the ability to
detect lesions using OPT, intraoral radiographs and CBCT volumes, both in
non-endodontically treated teeth and in already treated teeth. Out of 1425
elements already treated endodontically examined, the lesions were found in
17.6% of cases using an OPT, in 35.3% of cases with intraoral radiography
and in 63.3% with CBCT, while in the case of the 83 previously untreated
teeth, periapical lesions were detected in 21.7% with OPT, in 36 .1% with
intraoral and 74.7% with CBCT. In a study performed on dogs, de Paula-
Silva et al. [19] detected the periapical lesion in 71% of the roots using
intraoral radiography, 84% using CBCT and 93% with definitive histological
examination, respectively.
The Estrela group also proposed a new PAI classification, based on CBCT,
which was dubbed PAICBCT [20]; Wu et al. [21], highlighting how the
limits of two-dimensional radiology have influenced the works dedicated to
the long-term prognosis of endodontic treatments, limiting their validity,
proposed to use only the PAICBCT index for this type of evaluation.

What is CBCT?
CBCT is the emission of X-rays through a conical beam (Fig. 2.86) which
distinguishes this type of device, differentiating them from more traditional
CT devices, characterized by the "fan beam"
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(Fig. 2.87).

Fig. 2.86Scheme of action of the cone beam CT device. (From: Ambu E, et al. 3D Radiology
in Dentistry. Milan: Elsevier; 2013.)

Fig. 2.87Scheme of action of the fan beam CT device. (From: Ambu E, et al. 3D Radiology
in Dentistry. Milan: Elsevier; 2013.)

Acquisition in fan beam devices proceeds through multiple rotations of the

detectors around the patient, integral with the support bed, which translates
horizontally, allowing the acquisition of raw data which will then be
transformed into images by the processors. Cone beam devices, on the other
hand, allow the acquisition of a certain volume of data through
155

only one rotation of 360° around the part to be examined of the patient. The
portion of the body scanned will depend, in its maximum dimension, on the
surface of the detector, called field of investigation (Field of View, FOV),
which essentially identifies the dimensions of the acquired volume. Today,
for most of these systems, the acquired volume is a cylinder: in this case the
FOV corresponds to the dimensions of the rectangle obtained by sectioning
the cylinder along the axis passing through the centers of its bases. The raw
data acquired is then processed by a computer which reconstructs the
volumetric data and allows it to be viewed and processed directly on video by
the clinician. A volume is expressed as a composition of many elementary
parts, the voxels, in each of which the radiodensity is homogeneous and
constant.
Based on the size of the FOV, and therefore of the sensor, the aCBCT
technology are divided into large, medium and small FOV machines (Fig.
2.88).

Fig. 2.88Dimensions of the different FOVs.

A wide FOV machine is capable of examining areas over 20 × 18 cm, a

medium FOV area of 9 × 15 cm. In the first case, a good reconstruction of the
whole skull is obtained with a scan, in the second case the vision of both
arches, the vertebral column and part of the facial mass.
The amount of data collected is obviously enormous and therefore the
reconstruction and processing times are strongly dependent on the power
156

of the processor and the size of the FOV. To reduce the amount of data, and
therefore to make their use possible, the minimum size of the voxel becomes
progressively larger moving from a small FOV to a wide FOV machine.
Small FOV machines are able to investigate even smaller spaces (for
example, 3.8 × 5 cm). This reduced surface allows the machine to obtain very
thin "slices", even less than a tenth of a millimeter thick. One of the
fundamental advantages is that of being able to reduce the effective dose
absorbed by the patient to values comparable and in some cases even lower
than those of an overview, making it possible to satisfy the principle of
justification also in daily dental practice. Furthermore, this type of machine
makes it possible to work with a high resolution, a fundamental requirement
for giving meaning to many of the clinical investigations typical of this
branch of medicine.

Dose delivered to the patient and criteria for choosing

CBCT
The aforementioned acronym ALARA (As Low As Reasonably Archievable)
can be translated as the principle of optimization and justification, established
by Law 187/2000. The principles that will have to regulate the use of CBCT
devices at the European level are taking shape through a series of Community
[22] and national recommendations; in Italy a clarification was recently
received with Circular 124 of 29 May 2010 from the Ministry of Health
"Recommendations for the correct use of cone beam volumetric CT
equipment".
Given these principles, the smallest possible quantities of ionizing radiation
must therefore be supplied to the patient in order to obtain sufficient images
for a correct diagnosis; therefore it is necessary to understand which devices
are suitable for our daily practice.
To understand what the values of the different CBCT devices are, it is
necessary to fix the parameters relating to the radiation that each of us
undergoes for the "background" values, linked to the characteristics of the
soil and to cosmic radiation.
As can be seen from Table 2.10, published by Patel [23], the exposure, due to
cosmic radiation suffered by a passenger during a plane flight between Paris
and Tokyo is 15 microsieverts (μSv) while an OPT causes an absorption of
6 .3 μSv.
The background of natural radioactivity is the background of ionizing
radiation due to
157

natural causes and that can be detected anywhere on Earth; it is of both

terrestrial origin (due to radioactive isotopes of natural elements contained in
the earth's crust) and extraterrestrial (cosmic rays).
The world average of the equivalent dose of radioactivity absorbed by a
human being and due to the natural background is 2.4 millisieverts (mSv) per
year, or 6.57 μSv per day. This value must constitute the reference for
estimating any radioprotection risk assessments.
However, the natural background level of radioactivity varies significantly
from place to place. In Italy, for example, the average equivalent dose
assessed for the population is 3.4 mSv/year, but it varies considerably from
region to region.

Tab. 2.10Comparison of the effective dose of different

X-ray sources and as a percentage of the annual per
capita dose of "background" radiation

Absorption also varies according to the work performed: some categories,

such as
158

the crews of intercontinental flights suffer an irradiation of 9 mSv, which

rises to 20 mSv as the average annual absorption limit for a worker in a
nuclear environment. At average exposures above 100 mSv, an increase in
the onset of tumor pathologies is noted.
These data serve as a reference when one considers that the intraoral
radiogram causes an irradiation of 0.005 mSv, or 5 μSv, as detectable in
theTable 2.10.
Different CBCT devices cause different irradiations of the patient. A scan of
both jaws, performed with a medium FOV CBCT exposes the patient to an
average irradiance between 69 and 125 μSv, while a scan with small FOV
devices, in a focused area, causes an average irradiance between 9 ,8 and 31
μSv. Looking into theTable 2.11, we note how enormous irradiation values
are encountered when areas of modest extension are investigated using
medium FOV devices, reaching up to an irradiance of 534 μSv using
Planmeca Promax 3D. In terms of equivalent dose, ie in relation to the
average daily natural irradiation, performing an examination with Kodak
9000 3D is equivalent to a single day's exposure, against the equivalent 82
days of exposure with Planmeca Promax 3D.

Tab. 2.11Characteristics of commercially available

CBCT devices
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Ludlow [24] reports, as an effective dose delivered by the Kodak 9000 3D in

the anterior maxillary sector, only 5.3 μSv. In the examination of this specific
area and with the use of this device, the effective doses of a volumetric
examination and an intraoral radiography are superimposable, obviously
making it mandatory to carry out only the CBCT examination, in accordance
with the principle of "justification and optimization". In detail, given the
same irradiation to the patient, the quantity of data obtained is infinitely
greater with the volumetric examination compared to a traditional 2D
examination.
Another value to take into consideration is the size of the voxel, which
practically becomes the thickness of the "slice" with which the clinician goes
160

to investigate
161

the image of the examined area. The voxel is the elementary unit in which the
radiodensity is homogeneous and constant. Also in this case we go from very
low nominal values, such as the 76 μm of the Kodak 9000 3D or the 80 mm
of the Morita 3D Accuitomo, up to the minimum nominal values of 160 μm,
i.e. double the previous ones, again of the Planmeca Promax 3D, i.e. of the
device that shows the least favorable values in the table.
Looking at medium FOV devices, voxel sizes range from a minimum of 150
μm to a maximum of 400 μm.
If we are looking for a structure that has a diameter of 1/10 mm, i.e. 100 μm,
a device with a voxel of 160 μm will not be of any use to us, as the structure
will be masked in the elementary unit of radiodensity too large for the scope.
In practice, every millimeter of the image of the investigated element can be
examined either by dividing it into 13 "slices", therefore with a great
definition, or with 5 or even a little more than 2 "slices", with obviously
unfavorable results in the search for structures often very subtle, as occurs in
endodontic diagnosis.
In this thesis, elaborated by Bauman in 2009, the volume of an isotropic
voxel was evaluated, useful for highlighting in vivo the presence of the
mesio-palatine canal in the upper first molar [25], demonstrating an accuracy
level higher than 93% with a resolution of 0.12mm voxel, but decreasing
below 60% when the voxel resolution is 0.40mm.
As previously mentioned, small FOV devices pay for their high definition
with an increase in "noise", i.e. that disturbance that appears as a "fog" in the
peripheral parts of the image (Fig.2.89). This entails a greater difficulty in
"cleaning" the three-dimensional reconstructions (the so-called 3D
rendering), increasing the problems in the use of this type of scan in
computer-guided implantology or in the creation of stereolithographic
models.
162

Fig.2.89Sort of “clouding” of the image defined as noise.

Recently, the stitching function has been introduced in some small FOV
devices, which allows you to acquire an entire arch through the automatic
union of three volumes. In this case the minimum voxel will be 200 mm (Fig.
2.90).

Fig. 2.90Stitchingderived from the union of three volumes.

In any case, both individual volumes and entire arches acquired with stitching
163

can be "cleaned" using programs such as Osirix, available on the net (Fig.
2.91).

Fig. 2.913D reconstruction derived from a small FOV device.

Pulling the strings of these data, the choice of the device will have to be
based on some general factors, such as the irradiation of the patient or the
dimensions of the voxel, but above all the real use that will be made of this
machine in the clinic. If the activity is predominantly or exclusively aimed at
computer-guided implant-prosthesis or maxillofacial surgery, a medium FOV
device, which allows rapid use with the rendering programs used for implant-
prosthetic programming, it will certainly be the device of choice. Conversely,
if a more generic activity is carried out in the surgery, which includes oral
and periodontal surgery, "sector" implantology and endodontics, the device
of choice will certainly be a small FOV device.
Some proposals for a future regulatory framework at European level have
recently been made [22]. The 20 Basic Principles, proposed by SedentecCt
and shared by the European Academy of DentoMaxilloFacial Radiology are
extremely varied. Some of them are intended exclusively for the use of
CBCT in dentistry. Principle no. 20 (For non-
164

dental small fields of view - eg temporal bone - and all craniofacial CBCT
images - fieldsields of view larger than 8 cm × 8 cm - clinical evaluation -
radiological report should be made by a specially trained DMF Radiologist
or by a Clinical Radiologist - Medical Radiologist) proposes to exclude
Dentists, unless specialized in Radiology, from using wide FOV devices.
Conversely, the No. 19 (For dento-alveolar CBCT images of the teeth, their
supporting structures, the mandible and the maxilla up to the floor of the nose
- eg 8 × 8 cm or smaller fields of view, clinical evaluation - radiological
report - should be made by a specially trained DMF Radiologist or, where
this is impractical, an adequately trained general dental practitioner) suggests
the exclusion of Doctors, including Radiology Specialists, from the use of
devices typically dedicated to dental volumetric Radiology, allowing their
exclusive use by Dentists Specialists in Radiology or non-specialist Dentists
"after adequate preparation".
So there is no "best" CBCT in an absolute sense, but you will have to choose
a machine:
● adapted to the real needs of the professional studio;
● with the lowest possible irradiation of the patient, and therefore with the
best cost-benefit ratio in compliance with the principle of justification and
optimization;
● with the best economic cost-benefit ratio (the cost of the machine
depends on the size of the detector, therefore on the size of the FOV);
● with a good after-sales assistance service (assess the presence of
adequately trained technical personnel in the area).

Use of CBCT in endodontics

Some scientific papers have examined the use of CBCT in clinical practice
[26].
While medium FOV devices are very useful in the diagnosis and planning of
implant-prosthetic rehabilitations [27], in maxillofacial surgery and in
orthodontic diagnosis [28], the limitations already mentioned for this type of
device, in terms of definition and irradiation, make its use in endodontics
complex. The specific use of CBCT in this specialized branch has been
indicated by several authors [23,29-31].
165

From the analysis of these articles and, more generally, of the literature, it is
possible to extrapolate the indications for the use of CBCT in endodontics,
confirmed by the clinical experience of the Authors, in:
● assessment of endodontic anatomy;
● research and diagnosis of periradicular lesions;
● presurgical planning and follow-up;
● evaluation of the outcomes of traumatology of the dentoalveolar district;
● diagnosis of vertical root fractures;
● diagnosis of root resorption;
● assessment of the presence and position of intraradicular obstacles;
● differential diagnosis with lesions of non-endodontic origin.

Evaluation of endodontic anatomy

CBCT is currently used as the gold standard in in vivo epidemiological
studies detecting endodontic anatomy in different populations [32-34].
The use of CBCT devices has proved to be very useful, thanks to its high
spatial resolution, in the retrieval of root canal systems "in vitro" [35].
Blattner et al. have emphasized its utility in locating the mesio-palatal canal
in the mesial root of maxillary molars [36] and La et al. in locating the mesio-
median canal in the lower first molar [37].
We illustrate here the case of a failure to locate the mesiobuccal canal which
is immediately resolved after detecting the position of the canal by CBCT
(Fig. 2.92, Clinical case 6).

Finding a “forgotten” channel

166

Fig. 2.92(to)At the end of the treatment, the presence of another root canal system in the
mesiobuccal root of the first molar is evident. (b,c) The volumetric examination reveals the
presence of a canal in the mesiobuccal position. (d) The orifice of the mesiobuccal canal is
easily detected. (e) Clinical case terminated.

The use of CBCT is also valuable in the diagnosis and management of

elements with serious anatomical alterations such as the dens invaginatus
[38].

Search for periradicular lesions

Of the reliability of CBCT in the detection of radiolucent lesions,
167

especially if placed in comparison with the intraoral radiogram, it has already

been discussed previously. Here we only want to consider an aspect not yet
clarified by the literature, i.e. whether this type of device is able to help us in
the differential diagnosis between cysts and granulomas.
In this chapter it is recalled how Professor E. Cotti and her group have found
an effective method of differential diagnosis using ultrasound examination
[39].
Returning to CBCT, Simon et al. [40] found that this type of device, although
unable to indicate whether the lesion is a cyst or a granuloma, is still able to
define whether it is an area filled with solid material or a cavity filled with
liquid.
On the other hand, Rosenberg et al. obtained opposite results. [41], who did
not find CBCT accuracy in the differential diagnosis between these two
pathological structures, reconfirming that only surgical excision and
subsequent histological examination can resolve the diagnostic doubt.
Recently Kaya et al. [42] highlighted how it is possible to detect changes in
periapical lesion bone density before and after treatment, using the
Hounsfields Units (HUs)
See theFigs. 2.93And2.94, relating to a wound with liquid content and one
with solid content.

Fig. 2.93In the area distal to 3.6 a "liquid content" lesion is evident.
168

Fig. 2.94A "solid content" lesion is evident at the apex of 2.2.

Presurgical diagnosis and planning. Follow up

The use of CBCT in presurgical planning was proposed by Bornstein et al.
[43] who examined some parameters, in comparison between CBCT and
periapical radiographs, such as the presence of lesions, the distance of the
apices from the inferior alveolar nerve canal and the thickness of the cortical
bone and, more generally, vestibular at the superscript. This work
demonstrated the great utility of CBCT in presurgical investigations,
compared to intraoral radiographs which often fail to indicate the correct
position of the various anatomical landmarks. In another report [44], 17
accessory mental foramina were found in 150 patients examined with small
FOV CBCT. The detection of these accessory branches, often located near
the apices of the first molar or posterior to the main mental foramen,
The group of E. Berutti [45] evaluated the advantages introduced by the use
of CBCT in the vestibular approach to apical surgery of the palatal canal of
the upper first molar. In particular, the distance between the vestibular cortex
and the palatal root (9.73 mm) and the presence of a recess of the maxillary
sinus between the vestibular and palatal roots, estimated in approximately
25% of cases, were evaluated.
Similarly, the position of the palatal root apex of the maxillary first premolar
and the surgical approach to it was evaluated with the use of CBCT by
Widmer et al. [46].
Finally, Tanomaru-Filho et al. evaluated the use of CBCT in the follow-up of
endodontic surgery, noting how this tool is extremely useful both for
diagnosis and pre-surgical planning and for evaluating the
169

post-treatment repair of bone [47].

The use of CBCT makes it possible to effectively plan endodontic surgery
and to evaluate its resolution over time. In the first case presented below, the
use of CBCT in the planning of periradicular surgery is highlighted, with
particular reference to the relationship with the mental foramen (Fig. 2.95,
Clinical case 7). In the second it is possible to evaluate the relationship of the
lesion with the maxillary sinus and the possibility offered by this device to
control the retrograde seal (Fig. 2.96, Clinical case 8).

Localization and removal of broken

instruments in the extraradicular area
and in relation to the mental hole
170

Fig. 2.95(to)The diagnostic X-ray reveals, in 3.5, the presence of a perforation and two
broken instruments in an extracanal position. (b,c) The volumetric examination highlights the
proximity between the mental foramen and the apex of the fractured instrument. (d)
Radiograph at the end of the orthograde phase. The canal was treated endodontically and the
perforation closed with MTA. In the following surgical phase the mental nerve is isolated,
the instruments are removed after osteotomy performed with piezosurgery. The anatomical
structure is reconstructed with autologous bone and resorbable membrane. (e) Follow-up at
12 months shows excellent case resolution.

Pre-surgical planning, post-surgical control

171

surgery and follow-up of an endodontic surgery near the

maxillary sinus

Fig. 2.96In this case we can observe the treatment of a case of endodontic surgery. (a,b)
Presurgical planning. (c,d) Checking the retrograde seals at the end of the procedure. (e,f)
Follow-up after 12 months.

Diagnosis of root fracture and traumatology

172

dentoalveolar
The use of CBCT in the diagnosis of root fractures has been evaluated in
several works. Zou et al., in the analysis of a small group of fractured
elements, have found that the fracture is not visible in intraoral radiography if
the X-ray beam is not parallel to the plane of the fracture, while it is visible
with a volumetric examination performed with the CBCT [48]. The vertical
fracture is often evident, initially, due to the loss of alveolar bone, highlighted
by a radiolucency that follows the profile of the root (Fig. 2.97). This aspect
must lead us to look for the presence of fracture lines, evident above all in the
axial sections (Fig. 2.98).

Fig. 2.97(to)The OPT of this patient, referred for a new surgical therapy, shows the presence
of a periapical lesion and a deficient retrograde seal. (b) Volumetric examination, on the
contrary, shows the real extent of the lesion, especially in the palatal part of the alveolar
bone.
173

Fig. 2.98Examination of the axial sections clearly shows the presence of a vertical root
fracture.

CBCT is also useful in the diagnosis of horizontal root fracture, especially

where the fracture can be masked by anatomical superimpositions [49,50]
(Fig. 2.99).

Fig. 2.99(to)The patient is referred for the presence of a vestibular fistula and tenderness.
The intraoral radiography is not decisive for the diagnosis (Dr. R. Ghiretti case). (b) The
presence of a horizontal root fracture is evident on volumetric examination.

Finally, CBCT is widely used in diagnosis and clinical management

174

and in the follow-up of dentoalveolar fractures [51].

Root resorptions
Volumetric devices find great use both in the detection of different root
resorptions and in the differential diagnosis between internal, cervical [31]
and external [52] resorptions.
In Clinical Cases 9, 10 and 11, illustrated in theFigs. 2,100,2.101And2.102,
some cases of resorption diagnosed with intraoral radiography and with
focused FOV CBCT are treated.

Fig. 2.100Clinical case 9.Idiopathic cervical resorption. (a) Radiological image.

(b) Clinical image.

Fig. 2.101Clinical case 10.Internal resorption. (a) Radiological image. (b)

Clinical image.
175

Fig. 2.102Clinical case 11.External resorption. (a) Radiological image. (b)

Clinical image.

Presence and location of obstacles and intracanal

problems
Calcifications, broken instruments, steps, metal or fiber pins, perforations are
problems constantly present in the retreatment of the endodontically treated
tooth, which often create enormous difficulties especially in the
intraoperative management of the case. Although they fall within the
particularly complex cases in which, according to the joint position of the
Association of American Endodontists and the American Academy of Oral
and Maxillofacial Radiology [53], the use of CBCT for diagnosis and
treatment management is suggested , these topics are little or nothing
represented in the international literature.
On the contrary, volumetric radiology allows these problems to be solved
effectively, allowing the different problems to be correctly placed in the three
dimensions of space and thus favoring their resolution.
Clinical cases 12 and 13 show how the use of this new technology is of great
help in solving some problems, such as broken instruments (Fig. 2.103) and
perforations (Fig. 2.104).
176

Fig. 2.103Clinical case 12.Localization of a tool fragment. (a) The intraoral radiograph
reveals the presence of an instrument fragment within the root of 4.3 and suggests the
presence of two canals. (b) The volumetric examination allows to define the confluence of
the canals and the position of the broken instrument. (c) The clinical reality appears quite
evident in the three-dimensional reconstruction. (d) The 1-year follow-up shows the health of
the periradicular tissues.

Fig. 2.104Clinical case 13.Root perforation. (a) The patient complains of soreness in the
apparently well treated 2.4. (b) Volumetric examination highlights a radiolucent lesion and
confirms the presence of a perforation, suspected during retreatment. (c) The 3D
reconstruction seems to highlight the extraradicular course of the Thermafil® carrier used in
the first treatment. (d) During the surgical phase it can be observed how the clinical situation
can be superimposed on the 3D reconstruction. (e) The canals and perforation are treated
retrogradely. (f) Control volumetric examination at the end of the surgical phases, which also
included the lateral elevation of the maxillary sinus and the positioning of two implants.
177

Differential diagnosis with lesions of non-endodontic

origin
Finally, CBCT is used in the differential diagnosis between lesions of
endodontic and non-endodontic origin. CBCT is useful in the detection of
benign or malignant tumor lesions (Fig. 2.105), problems of the paranasal
sinuses or large transparent lesions, also in the maxillofacial area [54].

Fig. 2.105Three-dimensional reconstruction of a large lesion which turns out to be a

keratocyst.

In the literature it can also be seen that volumetric radiology is useful in the
differential diagnosis between lesions of endodontic origin, nasopalatine duct
cysts [55] and Stafne's lacunae [56].

Conclusions
Radiology has always accompanied the endodontist, who for decades had
intraoral radiography as the only possible tool for exploring the endodontium.
Today, although this medium maintains its absolute irreplaceability in some
phases of therapy, the possibility of overcoming the intrinsic limits linked to
two-dimensionality requires updating one's diagnostic horizon with the
introduction of three-dimensional radiology within one's clinics. The advent
of CBCT devices allows today a diagnostic approach different from the
traditional one, allowing to obtain images with a real three-dimensional
reconstruction of the clinical reality, quickly and with low irradiation of the
patient. We remind you that it is necessary to carefully evaluate the needs of
your practice
178

clinic, choosing, where possible, devices with a small or focused FOV, which
drastically reduce the radiation of the patient. This last aspect is the
fundamental one and in all our actions, including diagnostics, we must
carefully evaluate the cost-benefit ratio for the patient, in compliance with the
ALARA rule. It concludes by reporting the joint opinion of the Association
of American Endodontists and the American Academy of Oral and
Maxillofacial Radiology: «Limited field of view CBCT systems can provide
images of several teeth from approximately the same radiation dose as two
periapical radiographs, and they may provide a dose savings over multiple
traditional images in complex cases» [53].

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182

CHAPTER 3

Endodontic instruments

Dam and its accessories

(F. Cardinals)

Magnifying systems and operating microscope

(D. Pasqualini)

Nickel-titanium instruments for root canal preparation

(G. Gambarini)

Root canal shaping instruments

(A. Bonaccorso, TR Tripi)

Micro-endodontics: basics of ergonomics

(M. Rigolone)

Activation of irrigants
(R. Beccio, F. Stuffer)
183

Dam and its accessories

F. Cardinals

Introduction
The use of the dam for the isolation of the operating field was described for
the first time in 1864 by Dr. Barnum of New York; after almost 150 years
this method is not only still valid, but is now to be considered the standard of
care for orthograde endodontic treatments [1]. The execution of a correct
endodontic treatment, in fact, is inextricably linked to a suitable isolation
with a rubber dam [2-4]. According to Ingle, the isolation of the operative
field in endodontics is so important that if the operator realizes that he does
not know how to use the dam correctly, then it would be better for him to
abandon endodontics altogether and not waste time trying to learn the
delicate techniques of instrumentation and root canal obturation [5]. Only
daily use of the dam allows the clinician to understand the advantages
deriving from the use of the dam itself [6]. Lastly, we must not forget the
importance that having or not having isolated the operating field can assume
in cases of medico-legal litigation.

Advantages
The application of the rubber dam results in better and safer access to the
operating area. In fact, the soft tissues (gingiva, lips, cheeks and tongue) are
retracted and protected from the cutting action of the burs and root canal
instruments (Figs. 3.1 And3.2). The improved access results in increased
visibility of the working area and allows the operator to work in a clean and
dry field. The application of the dam protects the patient from possible
ingestion and/or inhalation of dental debris, necrotic pulp fragments, purulent
exudate, root canal instruments, burs or other operating materials, root canal
irrigants (Figs. 3.3And3.4). The dam prevents contamination of the
endodontic system by saliva, thus allowing the operator to first obtain and
then maintain an aseptic operating field. Furthermore, the operator, no longer
having to worry about possible ingestion and/or
184

inhalation of the root canal instruments, he will be able to grip them with less
force thus increasing sensitivity and delicacy during the instrumentation
phases [7]. During the tooth reconstruction phases, the dam not only protects
the patient from the possible ingestion of etching acids and resinous
monomers, but also prevents the contamination of the operating field by
organic fluids (saliva, crevicular fluid and blood) during the procedures of
adhesion, thus guaranteeing the restoration a greater adhesive strength and a
better resistance to marginal microleakage [8-12]. With the rubber dam, the
risk of transmission of infectious diseases carried by saliva and blood is
reduced, but not eliminated; it also occurs a reduction in the degree of
contamination of the dental operating environment by aerosols secondary to
the use of rotary instruments during cavity preparation. The use of the dam
results in a reduction in operating times: in fact, the patient cannot converse
or rinse his mouth as he pleases; moreover, the performance will be more
continuous by not having to replace the cotton rolls from time to time.
Therefore the operator is in the best conditions to perform the endodontic
treatment and all the advantages deriving from the isolation of the operative
field will contribute to raising the quality of the service provided to the
patient. nor rinse the mouth at will; moreover, the performance will be more
continuous by not having to replace the cotton rolls from time to time.
Therefore the operator is in the best conditions to carry out the endodontic
treatment and all the advantages deriving from the isolation of the operative
field will contribute to raising the quality of the service provided to the
patient. nor rinse the mouth at will; moreover, the performance will be more
continuous by not having to replace the cotton rolls from time to time.
Therefore the operator is in the best conditions to carry out the endodontic
treatment and all the advantages deriving from the isolation of the operative
field will contribute to raising the quality of the service provided to the
patient.
185

Fig.3.1Muscle tone in the tongue and cheeks makes it difficult to access 4.7.

Fig.3.2A properly placed dam retracts the soft tissue and facilitates access to the 4.7.
186

Fig.3.3The dam protects the patient from ingesting the purulent exudate that comes out of the
tooth.

Fig.3.4The isolation of the operative field prevents the ingestion of root canal irrigants.

Disadvantages
In the literature and scientific texts on endodontics, no author refers to the
disadvantages deriving from the correct use of the rubber dam. It is not a
question of time, since the dam leads to a reduction in operating times
[6,7,13], and it is not true that patients do not like it because only 1.5% of
them live there application of the dam as a moment of panic [14]. As far as
costs are concerned, the impact of the dam on performance is
187

laughable, while the click of the intraoperative plate is not a problem if the
appropriate techniques are adopted.

InstrumentsSh
eets of rubber
Dam sheets can be made of latex or synthetic material. Latex is a complex
emulsion composed of alkaloids, proteins, cells, enzymes, hydrocarbons and
other substances. There are also powder-free latex sheets on the market to
reduce non-allergic contact dermatitis caused by chemical additives and
powders. In subjects allergic to latex, on the other hand, it is possible to use
dams made of synthetic material. The dam is commercially available in 15
cm square pre-cut sheets (Fig.3.5) or in rolls of 6 meters 15 cm wide. The
sheets are commercially available in various thicknesses (thin, medium,
heavy, extra-heavy). In endodontics it is preferable to use a light colored
rubber dam which gives more luminosity to the operative field and allows to
see the position of the film during the intraoperative radiography.
188

Fig.3.5Some commercial products of pre-cut rubber sheets.

Dam drilling forceps

The dam punching forceps allows to make perfectly circular holes in order to
increase the resistance of the edge of the perforated sheet when it is enlarged
and distorted during the application [7]. The pliers allow you to make holes
of various diameters; generally the largest has a diameter of 2.3 mm and the
smallest 0.9 mm (Figs. 3.6 And3.7).
189

Fig.3.6Pliers for punching rubber sheets.

Fig.3.7The ferrule of the Ivory dam-drilling pliers allows you to make holes of 6 different
diameters.

Hook holder pliers

The hook holder forceps is needed to position the hook on the tooth (Figs.
3.8And3.9).
190

Fig.3.8Hook holder pliers.

Fig.3.9The forceps engages the hook to spread it and position it on the tooth.

Bows
The dam tending arch is, together with the rubber sheet and the hook, one of
the three indispensable instruments for the isolation of the operative field.
The archer's task is to keep the dam sheet taut, preventing it from collapsing
and falling into the patient's mouth. When the sheet is stretched and fixed to
the arch, the retraction of the cheeks and lips is obtained and thanks to the
arch, this situation is maintained for the entire duration of the treatment.
Different types of frames are available on the market; the metal ones are
more suitable for conservation (Fig.3.10), while the plastic ones are
radiotransparent and indicated for endodontics, not interfering with the click
of the intraoperative plate (Figs. 3.11And3.12).
191

Fig.3.10The metal arch is recommended for conservatives.

Fig.3.11The Nygard-Ostby frame is radiolucent and does not interfere with taking the
intraoperative radiograph.
192

Fig.3.12Intraoperative radiograph of the case inFig.3.11.

Hooks
The hooks are the fundamental tools to obtain the isolation of the operative
field. Many parts can be recognized in the hook: stirrup, wings, holes, etc.
(Fig.3.13). The inclination of the jaws is very important and determines the
clinical use of the hook itself. Clamps with flat jaws are indicated for teeth
with intact crowns, while those with more inclined jaws are more aggressive
at the periodontal level and are more indicated for teeth that have
compromised coronal structure (Figs. 3.14 And3.15). The hooks can then be
divided according to the presence or absence of the wings. The hook holder
pliers are engaged in the holes in the jaws. More than 50 different types of
hooks are available on the market, often also offered in the satin version and
in the one with knurled jaws. Only by knowing how they work and their
characteristics is the operator able to find the correct hook for each clinical
situation.
193

Fig.3.13Hook pattern 7 with wings.

Fig.3.14Hook 7 has horizontal jaws and is indicated for molars with intact clinical crown and
well-defined equator.

Fig.3.15The W8A hook has jaws which, due to their inclination, seek contact with the tooth
deep down at the level of the gingival sulcus.

Choosing the hook: the rule of 4

The ideal for the clinician who is preparing to isolate the operative field with
the rubber dam is to find a hook that remains stable in position during all
phases of the procedure.
194

treatment. Regardless of the dam application technique or the tooth to be

isolated, a very important phase in the operative protocol for the isolation of
the operative field is the choice of the clamp. Finding the right hook is
essential to obtain a stable operative field for the duration of the therapy. To
be applied to the tooth, the hook is spread using the hook holder forceps.
Once the area where the jaws are to be gripped is reached, the forceps are
closed delicately so as to create a progressive and non-sudden pressure on the
dental structures. The hook, in returning to its rest position, impacts the tooth
with the jaws and exerts a greater force on it the further it is from its rest
position.Fig.3.16); clearly, before proceeding to the application of the rubber
sheet, the stability of the hook must be clinically tested by exerting rocking
pressure on the arms of the hook and by exerting traction on the bracket from
the inside towards the outside of the oral cavity (Figs. 3.17And3.18). Many
types of hooks are available on the market, often also offered in the satin
version and in the one with knurled jaws. The manufacturers commercially
divide the hooks into 3 groups: for anteriors, for premolars and for molars.
This division does not represent an absolute indication of the right choice:
only the clinical examination can give the indications for directing the
clinician towards certain types of clasps rather than others. It is also for this
reason that, if the clinical situation requires it, one should not hesitate to use
anterior hooks on premolars or molars and premolar hooks on molars, as long
as the rule of 4 is respected (Figs. 3.19 And3.20).
195

Fig.3.16The clasp grips the tooth with all four contact points simultaneously and is stable.

Fig.3.17Hook stability test with rocking pressure on the hook arms.

Fig.3.18Stapes traction hook stability test.

196

Fig.3.19Anterior hook 212 applied to a maxillary second premolar.

Fig.3.20Using a premolar hook 1 provides four points of contact and hook stability on this
upper right second molar.

Auxiliary systems
This category includes those materials that can help the clinician in applying
the dam. Among these, the dental floss is certainly important, which is used
to slide the dam into the interdental spaces and/or
197

to make bindings. The lubricant helps the dam slide into the interdental
spaces and reduces the risk of sheet tearing during its application. The stamp
and/or templates help the operator to make the holes in the right position and
at the correct distance from each other. On the other hand, when the hook-
dam complex has little adaptation to the natural shape of the tooth in its
cervical portion, it is possible to resort to the use of liquid dams or foams to
prevent an exchange of liquids to and from the oral cavity.

Application techniques
The clinician often wonders what is the most appropriate moment during
endodontic therapy to mount the dam. The advantages deriving from the
isolation of the operating field [1,3,5-7] are known, therefore the sooner the
dam is mounted and the sooner it can be enjoyed. The tooth to be treated
endodontically should always be isolated before opening the pulp chamber, to
avoid contamination of the root canal system with bacteria from the oral
cavity. Once the hook has been chosen and tested and the hole has been made
in the sheet, the operator can move on to applying the dam. The dam
application techniques are essentially four and will be described below. Each
technique has its own characteristics and the preference in using one rather
than another is often the result of the personal confidence that each clinician
has with the different techniques. Regardless of the technique used, after
having isolated the tooth with dental floss, the dam is slid into the
interproximal spaces and the result will be that of having the rubber sheet that
adapts to the neck of the tooth and which is held in position by the hook
(Fig.3.21).
198

Fig.3.21What the isolated tooth looks like regardless of the technique used after sliding the
dam into the interproximal spaces with dental floss.

Bracket technique
The hook bracket is pushed out of the hole in the sheet (Fig.3.22). With one
hand the sheet is collected and with the other, after having applied the hook
holder to the hook, the hook is applied to the tooth (Figs. 3.23And3.24). After
applying the dam-stretching arch, the sheet is slid, with the finger or a small
spatula, under both jaws of the hook (Fig.3.25).

Fig.3.22Stirrup Technique: The hook stirrup is pushed out of the hole in the rubber sheet.
199

Fig.3.23Bracket technique: the operator picks up the sheet with one hand and the hook is
applied to the tooth with the other.

Fig.3.24Bracket technique: The hook is placed on the tooth.

Fig.3.25Stirrup Technique: The dam is slid under the hook arms.

200

Fin technique
In this technique the hook is applied to the sheet by engaging the flaps around
the hole (Fig.3.26). Having applied the hook holder to the hook, the hook is
positioned on the tooth (Fig.3.27). With a small spatula, the rubber is then
freed from the fins in order to make it slide around the neck of the tooth
(Fig.3.28).

Fig.3.26Wing Technique: The hook wings are engaged through the hole in the rubber sheet.

Fig.3.27Fin technique: The hook is applied to the tooth.

201

Fig.3.28Wing technique: with a small spatula, the dam is slid under the wings of the hook.

Hook technique first

In this technique, the clip is first applied to the tooth to be isolated (Fig.3.29),
then the dam is applied by first sliding the rubber around the bracket
(Fig.3.30) and then around the branches of the hook (Fig.3.31) until the
rubber dam has completely slipped around the tooth neck.

Fig.3.29First hook technique: The hook is placed on the tooth.

202

Fig.3.30Hook-first technique: the dam is slid through the hook stapes first.

Fig.3.31Hook first technique: the dam is then slipped under the hook arms.

Eraser technique first

This is a four-handed technique that requires the presence of two operators.
An operator applies the gum to the tooth by spreading the hole with his
fingers and holds it in place with both hands (Fig.3.32). The other operator
applies the hook to the tooth (Fig.3.33).
203

Fig.3.32Gum first technique: An operator applies the rubber dam to the tooth.

Fig.3.33Gum first technique: The second operator applies the hook to the tooth.

complex isolations
The execution of a correct endodontic treatment is inextricably linked to a
suitable isolation with a rubber dam [2-4]. This means that even in complex
cases such as teeth with a severely compromised clinical crown due to caries
and/or fractures, prosthetic abutments, malpositioned teeth, the clinician must
in any case carry out the isolation of the operating field in order to carry out
the endodontic treatment correctly and predictably; teeth that are difficult to
isolate are no excuse for the
204

failure to use the dam, on the contrary, the more difficult the tooth is to
isolate, the more the clinician will appreciate the advantages deriving from
the use of the dam [15]. The isolation in these situations must be carefully
planned and only the knowledge of the materials associated with an operative
rationale, a careful clinical evaluation and a suitable operative timing, will
allow the operator to obtain a perfectly isolated and stable field for the entire
duration of the treatment. In these cases, in fact, despite the fact that the dam
has been correctly applied and the clamp is stable, it is very common to have
a poor adaptation of the clamp-dam complex to the natural shape of the tooth
in its cervical portion [16,17]. It follows the lack of a perfect seal between the
rubber sheet and the tooth, with entry into the operating field of saliva and/or
blood and filtration from the operating field towards the oral cavity of the
irrigation liquids [18] and of the canal exudates. If the clasp is stable, the
presence of these gaps is not a valid indication for finding another clasp that
fits the tooth better. The gaps can be managed in clinical practice with
specific materials that make it possible to obtain a perfect seal. Among the
various materials in the past, cements for temporary fillings based on zinc
oxide eugenol have been proposed [19], cellulose-based foams and glass
ionomer cements which have the peculiarity of adhering both to unetched
enamel and to the dentin surface and to the dam [20,21]. On the market there
are currently products defined as liquid dams, fluid photopolymerizable
resins, easy to use,

prosthetic abutments
Regardless of the type of preparation (vertical or horizontal) and the type of
tooth (single-rooted or multi-rooted), the strategy that often proves successful
for these teeth is to seek contact between the hook and the tooth apically at
the finishing line where almost always begins the undercut given by the
conical shape of the root (Fig.3.34). Once the stable hook has been found, the
clinician will proceed to apply the dam with the most suitable technique; in
these cases it is common to have gaps that can be sealed with liquid dams
(Figs. 3.35And3.36).
205

Fig.3.34In the prosthetic abutments apical to the finishing line, the natural undercut of
the root begins.

Fig.3.35Hook 4 contacts the abutment apical to the finish line.

206

Fig.3.36Obtaining the seal is possible thanks to the use of the liquid dam.

Teeth prosthetic abutments of bridges

In the case of bridge abutment teeth, generally there are no problems finding
the right hook, while obviously, at least in an interproximal space, the dam
will never descend (Fig.3.37). In these cases the seal is obtained with the use
of liquid dams (Fig.3.38).

Fig.3.37Tooth 3.5 is the mesial abutment of an isolated bridge. Note the large buccal-distal
gap.
207

Fig.3.38After the application of the liquid dam, the seal from the infiltrations is obtained.

Teeth with severely compromised clinical crown due to

caries and/or fracture requiring periodontal intervention
The operator often finds himself isolating teeth that require orthograde
endodontic treatment and which, due to caries or fracture, have lost part of
their coronal structure and have the marginal periodontium covering that part
of the healthy tooth on which the clasp can be applied. In these cases it is
known that the restoration must always be performed after having re-
established the biological width with the intervention of clinical crown
lengthening, because in order to be long-lasting the adhesive restoration
requires a perfect adaptation of the dam around the neck of the tooth and a
physiological relationship with periodontal tissues [22-30]. As far as
endodontic treatment is concerned, however, the operator in these cases has
two possibilities:
The more the tooth is compromised from an endodontic point of view
(retreatments, apical lesions, etc.), the greater is the need for the clinician to
evaluate early, with root canal treatment, the real possibility of recovery of
the dental element by procrastinating, if the tooth can be recovered
endodontically, or by avoiding, if the tooth is not recoverable, the
intervention of clinical crown lengthening. The operator in these
208

situations can use hooks with jaws with a more aggressive design, which
allow you to move the gingival margin and look for a deep grip. In some
cases it may be useful to remove the marginal gingiva and highlight the part
of the tooth covered by it with the electrosurgical unit; it is clear that this
maneuver does not replace clinical crown lengthening surgery in the tooth
recovery treatment plan (Figs. 3.39And3.40). In these cases, a perfect fit of
the dam around the tooth neck is often not obtained, but this is not decisive in
this phase since with the foams or the liquid dam it is possible to control any
gaps from which the filtrations originate and thus obtain an optimal seal
(Figs. 3.41And3.42). Therefore, in the absence of indications that make it
imperative to perform the clinical crown lengthening periodontal surgery
first, it is possible to state that if the operator manages to find a stable hook,
then he will be able to perform the endodontic phase first and then the
periodontal phase. while in the absence of a stable hook and therefore in the
impossibility of performing endodontics with an isolated operating field, the
lengthening of the clinical crown will be performed first and then the
endodontic treatment.

Fig.3.39Tooth 1.2 with coronal fracture; the marginal periodontium covers the dental tissue
at the buccal level.
209

Fig. 3.40A vestibular gingivectomy is performed with the electrosurgery.

Fig.3.41Once the tooth margin has been freed from the periodontium, the hook is able to grip
the tooth.
210

Fig.3.42The seal is obtained with the use of the liquid dam.

Bibliography
1. Weathers AK. Access to success, part II. Improving your quality, speed and efficiency.
Dentistry Today 2004;23(04):90-93.
2. Glickmann G. Preparation for treatment. In: Cohen S, Burns R, editors. Pathways of the
pulp. St. Louis: CV Mosby Co Editors; 1998. pp. 80-116.
3. Cochran MA, Miller CH, Sheldrake MA. The efficacy of the rubber dam as a barrier to
the spread of microorganisms during dental treatment. J Am Dent Assoc 1989;119:141.
4. Cohen S, Schwartz SF. Endodontic complications and the law. JEndod 1987;13:191.
5. English JI. Endodontics. Piccin Publisher 1973; 2:81.
6. Wahl P. Endodontic isolation and radiology. Dentistry Today 1996;15(4):92-95.
7. Castellucci A. Endodontics. Bologna: Martina Editions; 1996; Postal Code. 9; p. 189.
8. Trowbridge HO. Model Systems for determining biological effects or microleakage.
Operative Dentistry 1987;12:164.
9. Jendresen MD. Overview of the clinical requirements for posterior composites. In:
Posterior composite resin dental restorative material. Vanherle & Smith 1985:41-43.
10. Baier RE, Glantz PO. Characterization of oral in vivo films formed on different types of
solid surfaces. Abstract 531. J Dent Res 1977;56:175.
11. Vettraino et al. Saliva affect on in vitro composite microleakage: permanent and
primary teeth. 2005 Iadr confess.
12. Murray PE, Smythg TW, About I et al. The effect of etching on bacterial microleakage
of an adhesive composite restoration. J Dent 2002 Jan;30(1):29-36.
13. Christensen GJ. Using rubber dams to boost quality, quantity of restorative services. j
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Am Dent Assoc 1994;125:81-82.

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2002;35:812-819.
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procedures and operative rationale, from the simple to the complex case. G It Endo
2009;23(2):151-166.
16. Gorni FGM, Gagliani M. Pre-endodontic reconstruction: critical analysis of a common
clinical procedure. G It Endo 2001;4:165-171.
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1993;1:30-32.
18. Weisman MI. Remedy for dental dam leakage problems. JEndod 1991;2:88-89.
19. Messing JJ, Stock CJR. Color atlas of endodontics. St. Louis: CV Mosby; 1989. pp.
121-4.
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buildups of reinforced glass ionomer cement. JEndod 1990;16(9):450-3.
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bonding of glass ionomer cement to dentin. Endod Dent Traumatol 1993;9(2):75-6.
22. Jendresen MD. Overview of the clinical requirements for posterior composites. In:
Posterior composite resin dental restorative material. Vanherle & Smith 1985:41-43.
23. Trowbridge HO. Model Systems for determining biological effects or microleakage.
Operative Dentistry 1987;12:164.
24. Reid JS, Callis PD, Patterson CJW. Rubber dams in clinical practice. Chicago:
Quintessence Public Co; 1990. pp. 5-20.
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32.

Magnifying systems and operating microscope

D. Pasqualini

Introduction
212

Magnifying optical systems were introduced in dentistry as early as the end

of the 1800s to overcome the ergonomic difficulties, of accommodative effort
and reduction of the visual field, resulting from the operator approaching the
patient to increase the perceived size of the operating field. At the same time,
the progress of surgery in the search for less invasiveness [1] has introduced
new concepts applicable to all medical specialties, including dentistry.
Endodontics is certainly the dental specialty that has most enjoyed the
advantages deriving from the use of magnification systems, significantly
contributing to their improvement [2-4].
The most commonly used magnification systems are as follows.
● Galilean optical systems: converging lenses mounted on visors or goggles
with a power of 2-4.5× and functioning similar to simple microscopes
(Fig.3.43).
● Prismatic optical systems: goggle or helmet mounted with a power of 4-
8× (Fig.3.44).
● Diopter systems: magnifying systems consisting of a single lens corrected
to different diopters. They are relatively cheaper, but are not very useful in
clinical practice due to the low magnification and the need to get close to
the object to appreciate the magnifying effect.
● Operating microscope(Fig.3.45).

Fig.3.43Galilean optical system. It consists of two or more lenses: a group of positive-

powered lenses (objective) and one with negative-powered lenses (eyepiece). Thanks to this
simple structure, the weight and the dimensions for the operator are reduced. (Courtesy of
Carl Zeiss SpA.)
213

Fig.3.44Prismatic optical system. It consists of two or more lenses with positive dioptric
power intercalated with roof prisms for straightening the image. It can achieve higher
magnifications while maintaining a large field of view. The disadvantage of this system may
be the larger footprint. (Courtesy of Carl Zeiss SpA.)

Fig.3.45Modern operating microscope. (Courtesy of Carl Zeiss SpA.)

There are Galilean or prismatic magnifying systems with external mount

(Flip-up loupes) (Fig.3.46) or set inside the support lenses (TTL loupes,
Through The Lens loupes), (Fig. 3.47). The Flip-up system can be less
expensive because it is adjustable and not custom built. Furthermore, it can
be mounted on correct lenses according to the needs of the operator. On the
other hand, it has a greater heaviness and a smaller field of vision due to a
greater distance between the eyes and the eyepieces. In
214

lastly, prismatic optical systems can be mounted on helmet support systems

(Fig. 3.48). Traditional or LED light sources are available as accessories
(Fig.3.49) adaptable to the magnification support system [5]. These optical
aids of magnification do not allow the magnification to be varied and the
operator, in order to have the operating field in focus, can occasionally
assume inappropriate postures [6]. For what concerns the notions of
ergonomics of use of magnification systems, the reader is referred to the
paragraph Endodontic ergonomics. The fundamental adjustments include the
identification of the correct individual interpupillary distance and of the
visual axis, as well as the distance and habitual working posture of the
operator (see below,Tab. 3.4). The visual axis must coincide with the optical
axis of the lens in order for them to be securedsimultaneously the correct
postures of the head and back [7] (Fig.3.50).

Fig.3.46Flip up loupes. (Courtesy of Orascoptic Simit Dental Srl.)

Fig. 3.47TTL loupes, Through The Lens loupes. (Courtesy of Orascoptic Simit Dental Srl.)
215

Fig. 3.48Prismatic magnifying system on helmet support. (Courtesy of Carl Zeiss SpA.)

Fig.3.49Prismatic magnifying system with external frame (Flip-up loupe) and illumination
system with LED light. (Courtesy of Carl Zeiss SpA.)

Tab. 3.4Adjustment of the operating microscope

Adjustment Preoperative Intraoperative
sforeplay adjustments adjustments
Distanceinterpupillary Positioning of Choice
and variation
operator andpatient of the magnification

It is adjustable by movingiSi position the patientinGenerally binocular tube

microscopesa base to the type ofinterventionoperators to use
when the visual fieldsnot from make.The dental operator ensure they are founded in
aunique must to hervoltaun magnification around
fieldoperative position asplus 16-20×. The circular
magnifications. The valuevariesusual it is comfortablepossible
minors (3-8×) are
between 52 and 76 mm (average65
used for the mm). It matchesat Positioningof
the
the placement
bodyoptical
216
interaxial distance when
viewed under the
operating microscope that
does not require
convergence effort
Dioptric correction
The eyepieces allow for
diopter adjustment
(generally negative up to
−5D for farsighted and
farsighted and positive up
to +5D for nearsighted).
After having focused the
image on the monitor (the
video camera cannot have
dioptric defects), the object
in focus is observed under
the microscope with one
eye by lowering the diopter
correction from
+5D until you see
the sharp object. To
be repeated three
times
Parafocusing
This is the condition in
which the image remains
sharp at varying
magnifications. The
magnification changer is
set to the highest value and
the object is brought into
focus.
Then you check if the
focus remains with
decreasing magnification.
If you lose focus, the
operation must be
repeated from the
beginning
The optical body of the
microscope is roughly
positioned so as to center
the light beam on the
operating field. It is
essential that the operator
is seated comfortably: he
forms the center around
which the position of the
patient and that of the
microscope must be
adapted
Centering of the
operative field
The operating field as a
whole is generally viewed
with a low magnification
value. In this preoperative
phase, only the most
balanced position of the
optical body is sought in
relation to the posture
assumed autonomously by
the operator
Focus
It is advisable to
maintain a distance of
about 22 mm between
the eye and the
binocular tubes in order
to distinguish a single
circular operating field
(exit pupil). The
operative field is in
focus when it coincides
with the anterior focal
plane of the objective.
To find the fire you can
raise or
microscope
preliminary.
Higher magnifications (10-
18×) correspond to ever
smaller depth of field and
ever smaller field of view.
By decreasing the
magnification and closing
the diaphragm, a greater
depth of field is
guaranteed, necessary if
anatomical details on
different planes have to be
viewed at the same time
Diaphragm adjustment
Opening the
diaphragm means:
• increase the
numerical aperture
• increase brightness. This
also reduces the contrast
which in itself increases
the perception of three-
dimensionality
• reduce depth of field
• increase optical
aberrations due to fringe
rays and reduce image
sharpness
If you close the aperture
too much, the resolution
of the details decreases.
With magnifications over
10×, the use of the
217

lower the chair orthe diaphragm it is useless because optical body,or yes they only use the parts to operate
mechanical or electrical focus

Fig.3.50Correspondence between the visual axis of the observer and the optical axis of the
magnifying system. (Courtesy of Carl Zeiss SpA.)

In theTable 3.1the main advantages and disadvantages of the magnification

systems mentioned in this paragraph are summarized.

Tab.3.1 Outline of the advantages and disadvantages of

systems
Ofmagnification
Advantages Disadvantages of
of the magnifying glasses
microscope
Forced posture of
the spine
Physiological posture
Posture Cumbersome
of the spine
equipment, difficulty
in movement
Often monocular
Binocular vision vision (director
eye)
218

Magnifications Fixed magnifications e

219

Vision major and variable reduced (2-

8x)
Accommodatio
Less visual effort
n effort
Extensive
documentation
No documentation is
Documentation possibilities Real
possible
documentation of
the operating field
Advantages of Disadvantag
magnifying glasses es of the
microscope
Standardized job
positions (learning
Easy to use
period)

Need for
Greater range of intraoperative
Ease of use movement for the repositioning of
operator the microscope
and the patient
Greater control of
Reduced
the surrounding
mobility of the
environment
operator
Purchase cost Reduced High
Ideal for working on Ideal for working on
extended operating small operating fields
fields without the with the need to check
need to check critical critical details
details
Directions
Ductility for
interventions with the Not suitable for
need for frequent working on large
changes of position operating fields

(From: Montagna F, Dal Pont F. Working with the operating microscope in dentistry. Editions
220

Acme; 2004.)

Outcome of endodontic treatment with the use of

magnifications
In orthograde endodontics, the effectiveness of the operating microscope has
been demonstrated in identifying the root canal openings, both in the case of
extensive calcifications and in finding the mesio-palatine canal in maxillary
molars [8-11]. Baldassari-Cruz et al. reported a recovery rate of the mesio-
palatine canal of 51% without the aid of any type of magnification and of
63% with the operating microscope [12]. According to other Authors, the
operating microscope would increase this percentage up to 82% [13]. Buhrley
et al. demonstrated an in vivo frequency of the mesio-palatal canal of 17%
without any magnification, 63% with loupes and 71% with the operating
microscope [14].
An increase in the detection rate of the median accessory canal in mandibular
molars has also been demonstrated: from 16% to 20% in mandibular second
molars and from 11% to 16% in mandibular first molars with the use of the
microscope [15].
However, the number of randomized clinical trials evaluating the impact of
the use of certain magnification systems on the prognosis of endodontic
treatment is relatively small [16]. Beyond the current lack of indisputable
scientific solidity, the identification of some anatomical peculiarities can lead
to greater accuracy in clinical procedures [17-18].
In surgical endodontics, Setzer et al. demonstrated a 1-year success rate of
88.09% of surgical endodontics performed with modern techniques but
without the aid of magnification or only with magnifying glasses (CRS,
Contemporary Root-end Surgery) against 93.52 % of the same clinical
procedure performed with the use of the operating microscope (EMS,
Endodontic Microsurgery) [19-21].
Surgical micro-endodontics which makes use of the operating microscope
and ultrasonic instruments is now considered a highly predictable therapeutic
alternative [22-23] with a 1-year success rate of about 93%, approaching 95-
97%. of the orthograde treatment [24-25]. In theTable 3.2 and inFigure 3.51
the main advantages deriving from the use of magnification systems in
endodontics are represented
221

orthograde and surgical [26-27].

Tab. 3.2Advantages of the microscope in endodontics

With operating
Traditional
microscope
Treatments
urgical −
Apicectomy
Top identification Often difficult He specifies
Wide (>10
Osteotomy Reduced (<5 mm)
mm)
Visibility of the root
Inaccurate He specifies
surface
Wide (45-
Bevel angle Reduced (<10°)
65°)
Identificationo Often
He specifies
f the isthmus impossible
Retrograde cavity
Approximate He specifies
preparation
Retrograde obturation Inaccurate He specifies
Suture 3.0, 4.0 5.0-7.0
Suture removal
1 week 2-3 days
Treatmentor
thograde
Often difficult He specifies
Increased
Less risk of
Identification of risk of
perforation
canal orifices in case perforation
of extensive Greater
calcifications sacrifice of Less sacrifice of
tooth tooth substance
substance
222

Frequent (the
Locating the mesio-
percentage of
palatine canal in the Infrequent
presence is estimated
upper molars
at 93% of cases)
Less
conservative
technique More conservative
Removal of root (wider access technique (direct
canal fractured pins preparations action on the foreign
and instruments that weaken body with saving of
the cervical dental tissue)
portion of the
root)
Repair of forcal or
root perforations Approximate He specifies

Identification of
root Inaccurate He specifies
microfractures
223

Fig.3.51(to)Preoperative digital radiographic image with fistulography of the element

1.6. Evidence of chronic apical periodontitis affecting the mesiobuccal root despite previous
good quality endodontic treatment. (b) Intraoperative image (12.5×) after apical resection
and methylene blue staining. Presence of the MB2 channel not identified during the
orthograde treatment. (c) Intraoperative image (12.5×) of the retrograde cavity filling,
including canals MB1, MB2 and the isthmus joining them. (d) Follow-up postoperative
radiographic image at 1 year. The healing process with formation of the lamina dura is
evident.

Principles of optics
The three-dimensional perception of the working field is essential during
clinical practice. Stereoscopic vision is characterized by the perception of the
relief of an object as a result of binocular vision. It is based on the fusion, in a
single three-dimensional image, of two different images of the same object
which are distinguished separately by the two eyes. For this reason the
operating stereo microscope is equipped with twoparallel optical paths
leading from a single objective lens (Fig.3.52), so that each eye can see only
one of the two images
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of the stereoscopic pair, as normally occurs in natural vision [6]. The

expedient of using a single objective decreases the stereoscopic effect in a
scarcely appreciable way, increasing instead the working distance available
for inserting the hands and surgical instruments into the operating field.
Furthermore, in this way, the accommodation is infinite, since the fusion of
the images has already occurred directly in the single lens [28]. For this
reason, the operator's visual fatigue is reduced. However, to better understand
the characteristics and methods of use of magnifying systems, it is necessary
to know the basic notions of optics and the correct terminology.

Fig.3.52The operating stereomicroscope is equipped with a pair of parallel optical paths

which depart from a single objective lens in order to make stereoscopic vision of the
observed object possible.

Shallow depth of field

Depth of field is the measure of the distance between the two planes, the
farthest and the closest, that a lens can focus at the same time (Fig.3.53).
● Increase:
● if the numerical aperture of the objective decreases (it indicates the
width of the cone of light entering through the objective);
● if the operating distance increases, i.e. the distance between the optical
center and
225

the image (the optical center is intended as the center of the lens, i.e. the
point through which the light rays pass without undergoing any
deviation);
● if the iris diaphragm of the operating microscope is closed (this
precaution reduces the angular opening of the objective and therefore
the dimensions of the cone of incoming light. Consequently, the image
is less bright, but more contrasted).
● Decreases: if the magnifications increase.

Fig.3.53Shallow depth of field. (Courtesy of Carl Zeiss SpA; modified.)

Operating distance
The operating distance is understood as the distance between the optical
center and the observed object (Fig.3.54). In a magnifying system, the optical
center is the center of the lens, i.e. the point through which light rays pass
without undergoing any deviation. As the operating distance decreases, the
angle of view corresponding to the projection of the observed object
increases.
226

Fig.3.54Operating distance. (Courtesy of Carl Zeiss SpA; modified.)

Magnification
Magnification is the property of increasing the image of the imaged object: it
is described as the ratio between the size of the image and the size of the real
object (Fig.3.55).
● If it increases, there will be: a decrease in the depth of field, a reduction in
the field of view and a decrease in the defining power of the image (ie the
ability to provide clear and defined images).
● It decreases if the focal length of the lens increases (the focus is the point
in space from which light rays originate or, after passing through the lens,
towards which they converge; its distance from the lens is the focal length.
It is important as determines the working distance. In clinical practice this
distance varies around 20-40 cm).
227

Fig.3.55Magnification. (Courtesy of Carl Zeiss SpA; modified.)

Depth of field decreases as magnification increases:

● 2× magnification: approximate depth of field 12.5 cm;
● 3.25× magnification: approximate depth of field 6 cm;
● 4.5× magnification: approximate depth of field 2.5 cm.

Field of view measurement varies with magnification and working distance.

Prismatic magnifying systems boast greater image definition even at the
limits of the field of view compared to Galilean systems.

Resolving power
The resolving power is defined as the minimum distance at which two points
of the observed object are separately discernible (Fig.3.56).
228

Fig.3.56Resolving power. (Courtesy of Carl Zeiss SpA; modified.)

It increases if the numerical aperture of the objective increases, with the same
magnification.

Operating microscope
In 1953, in Amsterdam, the first binocular operating microscope for
commercial use was put on the market: Zeiss OpMi 1 (Zeiss Operating
Microscope number 1 − Carl Zeiss Meditec). The model was characterized
by high stability, coaxial illumination and a magnification changer without
the need to change the focal distance and, therefore, greater ease of use. Only
in 1978 Apotheker and Jako had the idea of introducing this new equipment
in the dental field and collaborated in the development of the first dental
operating microscope which was then marketed a few years later, in 1981, by
Chayes-Virginia Inc. under the name of Dentiscope. However, we had to wait
until 1992, with the American Carr, to see a convinced promotion of the
operating microscope in endodontics, in contrast to the skepticism still
present. In 1995, the American Association of Endodontists (AAE) formally
recommended to the Commission on Dental Accreditation that microscope
instruction be introduced into the endodontic residency program. This request
was accepted in 1996 and the compulsory teaching came into force in
January 1997, starting the diffusion of the use of the operating microscope in
endodontics [29]. The use of the operating microscope among active
members of the AAE between 1999 and 2007 grew from 52% to 90% and its
distribution seems This request was accepted in 1996 and the compulsory
teaching came into force in January 1997, starting the diffusion of the use of
the operating microscope in endodontics [29]. The use of the operating
229

microscope among active members of the AAE between 1999 and 2007 grew
from 52% to 90% and its distribution seems This request was accepted in
1996 and the compulsory teaching came into force in January 1997, starting
the diffusion of the use of the operating microscope in endodontics [29]. The
use of the operating microscope among active members of the AAE between
1999 and 2007 grew from 52% to 90% and its distribution seems
230

decrease as the operator's age increases, underlining an increasing use among

the younger operators and those close to completing the specialist training
course [30].

Anatomy of the operating microscope

The operating stereomicroscope is a microscope characterized by two
eyepieces which guarantee stereoscopic vision and by some components
which make it possible to use it in the microsurgical and dental fields [31]. It
consists of some mechanical parts, such as the stand and the arm, and some
optical parts represented by the objective, the eyepiece, the optical paths and
the binocular tubes, the diaphragm, the magnification changer and the
illumination system [ 6].

Optical body
The term optical body refers to the entire body of the operating microscope
supported by the articulated arm (Fig.3.57). It houses the objective, the
magnification adjuster, the diaphragm, the optical splitter and the integrated
documentation systems.

Fig.3.57Optical body.
231

Objective
The lens is the closest optical component to the object (Fig.3.58). It is a
system of lenses that create the first magnified image of the operating field.
This image, called intermediate image, is projected onto the lower focal plane
of the eyepiece, a component placed inside the optical body which has the
function of seeing it and further magnifying it. Currently manufactured lenses
are infinitely corrected; this means that the intermediate image is focused not
in a fixed area, but at infinity. In this way it is not necessary for the optical
path to have a fixed length (generally 160-170 cm) and various
interchangeable accessories can therefore be added without fearing optical
aberrations.

Fig.3.58Objective. (Courtesy of Carl Zeiss SpA; modified.)

The following parameters depend on the characteristics of the lens.

● focal length: it is understood as the distance between the center of the lens
and the operating field and is inversely proportional to the power of
magnification. It generally corresponds to about 200-400 mm
(interchangeable lenses are currently available with focal lengths ranging
between 91 and 390 mm) and affects the working distance. In fact, the
working distance is the space between the outer surface of the lens and the
operating field. The objectives used in surgical microscopy are defined as
ULMO (Ultra Low Magnification Objective) since they are made up of
apochromatic lens systems with magnification values
232

equal to or less than 0.5× and a numerical aperture equal to or less than
0.025. These objectives are essential to obtain a correct focal length and an
adequate working distance to leave enough space for the operator's hands
and tools (about 20-30 cm). For these reasons, lenses are also referred to as
SLWD (Super Long Working Length).
● Magnifying power: this parameter is inversely proportional to the focal
length. Therefore, these objectives provide an even smaller image of the
operative field (0.5-0.34×).
● Shallow depth of field: is intended as the focus range. In other words, the
sharp depth of field visible to the observer. This parameter is inversely
proportional to the power of magnification and, therefore, modern
operating microscopes ensure a good depth of field, in the order of a few
centimetres.
● Field of view diameter: it is a parameter inversely proportional to the
power of magnification and directly proportional to the focal length; for
these devices it is therefore quite broad.
● Perceived brightness of the image: it is directly proportional to the
diameter of the individual optical paths as a wider beam of light is allowed
to enter.
The wording corresponding to the power of magnification (for example 0.5×)
and the numerical aperture (for example 0.025) may be written on the lens
frame.
The lens focus can be adjusted manually by moving the optical body for
macrometric adjustments and, depending on the model, manually using a ring
or electrically thanks to a push-button focal shifter.
When the focal distance of the optics can be adjusted using an electric push-
button mechanism, neither the microscope nor the object need to be moved to
focus.
Fixed focal length lens.Some models are equipped with a systemwith
interchangeable lenses, each with a fixed focal length (Fig.3.59).
233

Fig.3.59Fixed focal length lens. In the example, a lens with a fixed focal length of 250mm
was taken. In this case, the observed object is in focus only at a corresponding operating
distance. In other cases, however, the object will be out of focus. Some of these lenses mount
an aid that allows minimal variations in focus at a fixed focal distance for fine focusing on
the object. (Courtesy of Carl Zeiss SpA; modified.)

Varioscope technology (Vario Objective Technology).This innovative

technology allows rapid change of the focal length of the lens system of the
surgical microscope via a motorized push-button control (Fig. 3.60). In this
way it is possible to focus easily on the observed object while varying the
operating distance. Within a given range, at any operating distance, it is
possible to focus on the object without the need to change the objective lens
or reposition the microscope body. This is possible thanks to the presence of
two different groups of lenses installed inside the optical body. each
234

group, formed by five different lenses, is arranged in a variable way along the
optical axis allowing a rapid variation of the focal length of the lens. This
system increases operator comfort by decreasing operating times.
Furthermore, operating microscopes with Varioscope lenses allow you to
appreciate a greater depth of field of the observed object compared to devices
with fixed focal length objectives.

Fig. 3.60Varioscope technology (Vario Objective Technology). (Courtesy of Carl Zeiss SpA;
modified.)

SpeedFocus system.Operating microscopes equipped with a Varioscope

system can use an autofocus mechanism, similar to modern digital cameras,
which allows the observed image to be focused automatically via a simple
push button command at any working distance within a range of approx. 200-
400mm.

Magnification changer
235

The magnification changer is a mechanism assembled in the central part of

the optical body, just above the objective, with the function ofincrease or
decrease the magnification with which the object is observed (Fig.3.61). It
can be mainly of two types.
● Mechanical: the variation of magnification is implemented through a
revolver device operated thanks to a knob placed on the optical body
which has the function of exchanging some lenses with a different
magnification power. There are usually five magnification values (0.4×,
0.6×, 1×, 1.6×, 2.5×).
● Electric: the variation of magnification takes place continuously thanks to
an electrically operated device which varies the distance between the same
lenses without changing the objective with a constant operating distance
(0.4-2.4×). The presence of more lenses can dim the brightness slightly.

Fig.3.61Magnification changer. (Courtesy of Carl Zeiss SpA; modified.)

236

Diaphragm
The most common is the iris diaphragm. It is an opaque screen with a central
hole which, just like the iris, can be closed to modulate the width of the light
cone and the quantity of light rays directed towards the eyepiece (Fig.3.62). It
has the function of eliminating the marginal rays and therefore:
● increases the depth of field keeping the image sharp even if the working
distance is changed by a few millimetres;
● reduces glare from excessive light and increases the contrast of the object
image.

Fig.3.62Diaphragm. (Courtesy of Carl Zeiss SpA; modified.)

Binocular tubes
This term describes the two side-by-side monoculars on which the eyepieces
are mounted (Fig.3.63). They are part of the optical paths and have the
function of sending the observer two different distinct images in order to
guarantee stereoscopic vision. The operator can adjust the interpupillary
distance (from 55 mm to 75 mm) and their inclination up to over 180°. Some
models are equipped with fixed inclination binoculars: straight parallel to the
microscope axis or inclined at 45° without the possibility of adjustment.
Undoubtedly the binocular tubes with adjustable inclination facilitate clinical
activity and improve work ergonomics as they allow the visual angle of
access to the operating field to be varied, increasing the possibility of
reaching each area in direct vision without fatigue.
237

Fig.3.63Binocular tubes. (Courtesy of Carl Zeiss SpA; modified.)

In modern operating microscopes, the optical paths are usually spaced 22 mm

apart. This ensures a good stereoscopic effect as well as greater penetration of
the visual ray into narrow openings, such as root canals. In fact, if the
distance between the two optical paths were greater, the visual ray would
have greater difficulty in accessing such small anatomical structures, albeit
with a better stereoscopic effect.

eyepieces
The eyepieces are mounted on top of the binocular tubes and have
thefunction to magnify the intermediate image projected by the lens
(Fig.3.64). In this way, a virtual, straight and vertical image is sent to the
viewer magnified. In dentistry, eyepieces with magnifications around 10-
12.5× are mostly used.
238

Fig.3.64eyepieces. (Courtesy of Carl Zeiss SpA.)

Eyepieces with magnifications of 10× boast a 40% larger field of view than
those of 12.5× which, on the other hand, obviously show a higher additional
magnification.
To calculate the total magnification value in microscopes with a fixed focal
distance, the following formula can be applied:

Magnification = [Tube Focal Distance/Main Lens Focal Distance] x

Magnification Level x Eyepiece Magnification

For a surgical microscope equipped with a 12.5× magnification eyepiece, the

total magnification value is:

[170/250] x 2.5 x 12.5 = 21.25

The number of magnifications, the field index and the dimensions of the
operating field are indicated on the frames. The eyepieces also allow diopter
adjustment (typically from −5 to +5) to allow the operator to correct any
visual defects and therefore work without glasses.
Finally, there are micrometric eyepieces equipped with a graduated scale to
make it possible to measure the dimensions of the observed object.

Lighting
239

One of the main features and a major selling point of the microscope is the
coaxial illumination (Figs. 3.65 And3.66). A light source placed laterally to
the optical paths projects the light onto a prism which deflects it parallel to
the axis of the optical body. Condensers can be inserted along this path that
collect the light and concentrate it into a cone that uniformly illuminates the
operating field. At this point, the operating field itself reflects the light that
falls on it and projects it vertically through the objective so that it is
perceived by the observer through the eyepieces (vertical incidence
illumination).

Fig.3.65Lighting. (Courtesy of Carl Zeiss SpA; modified.)

Fig.3.66Scheme of operating microscope with optical paths, illumination system and manual
magnification changer with revolver mechanism. (Courtesy of
240

Carl Zeiss SpA; modified.)

The light sources can consist of tungsten incandescent bulbs, quartz-iodine

halogen lamps, xenon ARC lamps and LED lamps. Incandescent filament
lamps are the most widespread since low voltage ones (6-12 V with 15-100
W) are light sources of a point area with good intensity and duration over
time. However, their intensity can be discontinuous over time due to the
evaporation of the tungsten with which the filament is built and due to
ageing. Halogen lamps have a low cost and a long life, even if the light they
produce is cold and yellowish and can alter the perception of details if not
corrected by specific filters which raise the color temperature to the solar
equivalent.
Each of these systems also includes a fan to dissipate the heat produced by
the bulbs and a rheostat which allows the light intensity to be varied. The
light directed onto the operating field can come directly from the optical
system (warm light supported by thermal filters which dissipate the heat
away from the operating field) or it can be conveyed through optical fibers
(cold light).
Furthermore, some filters applicable to the light beam are available: the
orange filter to prevent premature polymerization of the composite resins and
the green filter to facilitate the recognition of very fine vascular structures by
increasing the visible contrast of heavily perfused tissues.

Arm and stand

The stand, the arm and all the balancing and stabilizing devices of the
microscope's optical body are perhaps the most important element in
choosing the ideal apparatus (Fig. 3.67). In most cases, in fact, the ease and
precision of use of the entire system depend on these elements, and it is
precisely here that the challenge is played out between the expectations of the
buyers and the possibilities of technical realization of the manufacturers.
The stand can be:
241

● On the floor, according to the houses, the width of the support base varies.
It is the most requested conformation and also the one with the largest
second-hand market;
● Wall, recommended in some logistical situations in which it is preferable
to keep the overall dimensions of the equipment contained, eliminating the
floor stand, and if there is the possibility of starting the articulated arm
from a stabilization plate fixed to the wall;
● to the ceiling, constitutes the solution with the smallest footprint. This,
however, to the detriment of ease of installation and, as for the wall-
mounted one, of the lack of portability in other operating rooms.

Fig. 3.67Arm and stand. (Courtesy of Carl Zeiss SpA; modified.)

Balancing systems can be:

● with mechanical clutches;
● with perforated discs locking in certain positions;
● with magnetic blocks.

The mechanical balancing system uses frictions that are gently adjusted so as
to allow shifting and rotation and orientation movements, with the possibility
of blocking the optical body in certain positions. Lately, some manufacturers
offer the magnetic block system. By simply pressing a button on the direction
handles, the operator can unlock the microscope and position it appropriately.
When you then release the button, the magnetic blocks immediately stabilize
the microscope. Some models have
242

fully motorized movements.

Accessories
Currently, thanks to the introduction of infinity corrected objectives, it is
possible to insert interchangeable accessories by varying the length of the
tube without the risk of inserting aberrations (Fig.3.68). This attitude of
modern microscopes is called modularity. To allow simultaneous vision by
several operators, co-vision for the assistant can be adapted, i.e. a binocular
system that connects to the same optical system. Alternatively, optical
splitters (beam splitters) can be installed for cameras or cameras; one
installation obviously does not exclude the other. This brings the undoubted
advantage of being able to document the interventions, thus also facilitating
communication between doctor and patient.

Fig.3.68Accessories. Configuration of an Endodontic operating unit, Dental School,

University of Turin.

Video and photographic documentation with the

operating microscope
The video recording of the operation offers the advantage of keeping the
images both for educational purposes and for any medico-legal problems;
moreover, it allows effective communication between doctor and patient. The
real-time projection of the images allows the visualization of
243

various phases of the operation by the entire surgical team in order to

improve collaboration and work ergonomics, thus reducing operating times
[6].
As regards the video and photographic documentation, numerous accessories
are available with which to equip the operating microscope.
● Optical splitter: it is the optical component which has the function of
splitting the image on the lateral outputs in order to allow both co-vision
and photographic and video documentation (Figs. 3.69And3.70).
● Photo adapter: it is necessary to connect reflex, 35 mm film or digital
cameras, both with universal T 2 connection (Fig.3.71).
● Video adapter: it is a device for connecting a camera with a universal C-
mount mount. Different focal lengths can be chosen according to the
camera chosen, in order to take images with the same magnification and
the same field observable by the microscope eyepieces (Fig.3.72).
● Integrated video camera, available on some models, also in the Full HD
version, immediately ready for use after switching on the microscope.

Fig.3.69Optical splitter.
244

Fig. 3.70Co-vision system for the assistant.

Fig.3.71Photo adapter. (Courtesy of Carl Zeiss SpA; modified.)

Fig.3.72Digital video camera connected via adapter.

In most systems, the camera or camcorder is connected to the optical path via
a balanced splitter that plugs in
245

before the binocular tube. This avoids the obvious drawbacks of attaching the
camera directly to one of the eyepieces, such as loss of balance and the need
to stop surgery to collect images. On the other hand, there is the problem of
the magnification discrepancy between the video or photo image and the
image transmitted to the observer through the binocular tubes. To overcome
this problem, the manufacturers supply additional supplementary lenses.
However, currently it is possible to get very good quality still images directly
from the video file using editing software. During filming, it is therefore
important to remember that the operator's binocular field of view is wider
than the video field. The operator must therefore always remain well centered
on the object, which could still be clearly visible through the binocular, even
if at the margins of the visual field, but leave the video field, compromising
the documentation. Another trick to obtain optimal video documentation,
especially in surgery or when you intend to visualize entire sectors of the oral
cavity at low magnifications, is to rotate the video camera connected to the
microscope, so that the plane of the video images is parallel to an ideal
horizontal plane. (Fig.3.73). In this way, viewing the finished video is
certainly more comfortable (try to imagine the unpleasant sensation of
watching a film in which the scene appears inclined with respect to an ideal
horizontal plane of perception).

Fig.3.73Image plane: the image captured by the documentation system represents the
operator's view of the operating field (a) which sometimes does not coincide with the ideal
horizontal plane. It is sufficient to rotate the camera position to obtain a video image parallel
to the ideal axis, certainly more pleasant to view (b).

Finally, it is important to remember that the captured image cannot have the
same
246

stereoscopic characteristics enjoyed by the observer through the two

binoculars (Tab. 3.3). However, the recent advent of 3D cinematic
technologies has also stimulated the evolution of medical imaging in the
same direction.

Tab. 3.3Problems in using the operating microscope and possible causes

Affirmation Possible causes
Operating distance
Glasses wearer
Image is out of focus
Shallow depth of field
Dirty lens
Lighting
The image has little contrast
Dirty lens
Two images Interocular distance
Dark edges Tilt angle
Shadows Eye-to-eye distance

Operating microscope settings

The steps to correctly adjust the operating microscope are summarized
inTable 3.4.

Thanks
We thank Dr. Mario Alovisi for his valuable contribution to the drafting of
this chapter; Dr. Donatella Cavicchioli (Product Manager Henry Schein) and
Massimiliano Sicignano (Product Manager Zeiss) for support and
collaboration.

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19. Setzer FC, Kohli MR, Shah SB, Karabucak B, Kim S. Outcome of endodontic surgery:
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a meta-analysis of the literature. Part 2: Comparison of endodontic microsurgical

techniques with and without the use of higher magnification. JEndod 2012;38(1):1-10.
20. Taschieri S, Del Fabbro M, Testori T et al. Use of a surgical microscope and
endoscope to maximize the success of periradicular surgery. Pract Proced Aesthet Dent
2006;18(3):193-8.
21. Kim S, Kratchman S. Modern endodontic surgery concepts and practice: a review.
JEndod 2006;32(7):601-23.
22. Kim SG, Solomon C. Cost-effectiveness of endodontic molar retreatment compared
with fixed partial dentures and single-tooth implant alternatives. JEndod
2011;37(3):321-5.
23. Setzer FC, Shah SB, Kohli MR, Karabucak B, Kim S. Outcome of endodontic surgery: a
meta-analysis of the literature. Part 1: Comparison of traditional root-end surgery and
endodontic microsurgery. JEndod 2010;36(11):1757-65.
24. Tsesis I, Faivishevsky V, Kfir A, Rosen E. Outcome of surgical endodontic treatment
performed by a modern technique: a meta-analysis of literature. JEndod
2009;35(11):1505-11.
25. Iqbal MK, Kratchman SI, Guess GM, Karabucak B, Kim S. Microscopic periradicular
surgery: perioperative predictors for postoperative clinical outcomes and quality of life
assessment. J Endod. 2007 Mar;33(3):239-44.
26. Tsesis I, Rosen E, Schwartz-Arad D, Fuss Z. Retrospective evaluation of surgical
endodontic treatment: traditional versus modern technique. J Endod. 2006
May;32(5):412-6.
27. von Arx T. Frequency and type of canal isthmuses in first molars detected by
endoscopic inspection during periradicular surgery. Int Endod J 2005;38(3):160-8.
28. Paliaga GP The vices of refraction. 4th ed. Turin: Minerva Medica; 2008. p. 1-28.
29. Selden HS. The dental-operating microscope and its slow acceptance. JEndod
2002;28(3):206-7.
30. Kersten DD, Mines P, Sweet M. Use of the microscope in endodontics: results of a
questionnaire. JEndod 2008;34(7):804-7.
31. Michaelides PL. Use of the operating microscope in dentistry. J Calif Dent Assoc
1996;24(6):45-50.

Nickel-titanium instruments for root canal preparation

G.Gambarini

Introduction
In the last few years nickel-titanium (Ni-Ti) has established itself in
endodontics as the greatest innovation in the field of instrumentation of the
system of
249

root canals, especially through the use of rotary files. The success of this
technique compared to methods involving the use of traditional manual tools
is mainly due to the mechanical characteristics of the alloy, superior to those
offered by steel, but also to the innovations brought about by the production
processes in the design of the tools, in particular as regards dimensions and
taper [1-4].
In order to create these instruments it was necessary, in the early 1990s, to
design and build special computerized equipment (Fig.3.74) able to work the
Ni-Ti wire in order to give it increasingly complex and performing designs
compared to traditional K files, reamers and hedstroem. Through these
innovative equipment it was possible to create sections and coils with
complex morphologies and to introduce the concept of increased taper,
different from the traditional ISO .02. Only by exploiting the superelasticity
of Ni-Ti has it been possible to create instruments of larger dimensions
(reaching files with taper from .04 to .12), i.e. capable of maintaining
characteristics of flexibility and resistance suitable for rotating
instrumentation of curved canals [4 -8].

Fig.3.74Equipment used for the production of endodontic instruments in Ni-Ti.

The advantage of having instruments with increased conicity and continuous

rotation, which ensures superior cutting efficiency and optimal use of the
superelasticity of the alloy, consists in being able to prepare the root canal in
shorter times and through simpler procedures, with less number of
instruments [9,10]. The other innovation, inherent in the need to use
sophisticated computer equipment in the process
250

production by turning (or carving), concerns precisely the possibility of

varying the design of the instrument, in terms of both the cross section and
the course and orientation of the coils [11,12]. This innovation has
contributed to the introduction of technologically more advanced instruments,
remarkably performing in terms of cutting capacity and able to withstand
higher physical stresses so as to reduce the risk of fracture during continuous
rotation within the curvatures of the root canal (Fig.3.75). This problem, i.e.
the resistance to flexural and torsional stresses, actually remains the major
limitation of their use. The continuous rotation within accentuated curves
involves stresses far greater than those deriving from manual use, which,
despite the favorable properties of the Ni-Ti alloy, can lead to intraoperative
fractures with a higher frequency than in the past with the manual use of steel
files [13,14].

Fig.3.75Sections and profiles of some rotary endodontic instruments in Ni-Ti.

In fact, although Ni-Ti is an alloy with unique mechanical properties, the

instruments used in the rotating preparation of the endodontium are subjected
to stresses of particular intensity which correspond to the same number of
high structural stresses (fatigue of the alloy) which could evolve into
intraoperative fracture of the instrument and therefore, from a clinical point
of view, translate into an iatrogenic error [15,16]. In recent years, therefore,
all the evolutions relating to the design of the instruments and their
techniques of use have been motivated precisely by the attempt to improve
their mechanical characteristics and make them even more reliable and safe,
particularly in the more complex anatomies, in which the the solicitations
251

mechanics they undergo. In spite of this, however, it must be said that the
introduction of Ni-Ti in endodontics has led to undisputed advantages, which
can essentially be summarized in three points [8,17,18].
● Speeding up of operating procedures: the traditional methods based on
the manual use of steel tools involved the use of a large number of files.
The particular cutting efficiency of the Ni-Ti instruments and the use of
increased tapers have made it possible to significantly reduce the number
of instruments required for a truncated conical shaping of the canal and
therefore to spend less time in achieving these objectives.
● Simplification of operating procedures: the technique of use is simpler
and more immediate than the traditional ones, precisely by virtue of the
extreme flexibility of the Ni-Ti alloy and the use of continuous rotation.
This point, together with the reduction of the number of instruments
necessary to shape the canal, and of the relative recapitulations, results in a
reduction of iatrogenic errors (false roads, steps and transport of the canal).
Furthermore, there is a qualitative increase due to greater respect for the
original trajectories of the canals while ensuring a valid shaping of the
endodontic space. The instrumentation is also simplified because there is
no need to pre-curve the hand files in the more complex canals. In essence,
fewer steps mean, in theory, fewer chances of errors.
● Predictability and efficacy of treatment: the increase in the taper of the
Ni-Ti instruments allows to reach more suitable transverse diameters of the
preparation. Larger preparation diameters improve the instrument's ability
to mechanically remove contaminants and, at the same time, increase the
area on which the irrigating solutions are able to exert their chemical
action, also favoring their diffusion up to the apical region. In fact, the
apical penetration of the irrigants is increased by a good flaring of the
canals, just as the root canal obturation procedures are simplified and made
more predictable if the canal is correctly shaped, maintaining the apical
constriction.

Properties of the nickel-titanium alloy

Ni-Ti alloys were developed for industrial uses in the early 1960s by the
American Buehler who highlighted their peculiar characteristics
252

such as shape memory (SME, Shape Memory Effect) and superelasticity (SE,
Superelastic Effect). In particular, the properties of these alloys, since then
called Nitinol by the naval laboratories of the US Navy [19], derive from a
reversible phase transformation in the solid state between the austenitic and
martensitic structure, known as thermoelastic martensitic transformation
(Fig.3.76). This transformation allows to recover high deformations and can
be activated mechanically (SIM, Stress Induced Martensite) or by
temperature variations (TIM, Thermally Induced Martensite). The former is
more useful for endodontic purposes, and will be described below; the second
is suitable in orthodontics and medicine, and consists in the ability of some
metal artifacts to return to an initial shape if subjected to an appropriate heat
treatment [20,21].
253

Fig.3.76Austenitic-martensitic phase transformation.

However, it must be emphasized that the Ni-Ti alloy is a binary intermetallic

and equiatomic compound whose mechanical characteristics make it different
from any other alloy (for example steel or titanium) previously used for the
production of instruments in the endodontic field. The main feature that
makes this alloy so suitable for use in endodontics is represented by its
superelasticity (Fig.3.77). This term indicates the aptitude of the alloy to
undergo large reversible deformations in the elastic range by virtue of a
constant load, not as a consequence of a plane sliding phenomenon (typical of
traditional
254

metals), but through a change in the crystalline structure (phase change).

Fig.3.77Superelasticity: stress-strain curve.

In the Ni-Ti alloy there are three phases (Fig.3.78):

● austenitic, with a body-centered cubic lattice structure, particularly
stable;
● martensitic, with a compact hexagonal lattice, more ductile but also more
unstable;
● intermediate, called R or rhomboidal phase, is the transition phase
between the previous two, with a different crystallographic configuration
(trigonal) and with a different orientation of the crystals. Within this phase
there are various intermediate forms which, in the finished product and/or
during the production processes (following heat treatments), are nowadays
attributed the possibility of improving the properties of the alloy for
endodontic use.
255

Fig.3.78Crystallographic phases of the Ni-Ti alloy.

The Ni-Ti alloy at rest at room temperature is in the austenitic phase and in
the intermediate R phase, but if subjected to mechanical stresses, such as for
example rotation in a root canal with consequent torsional stresses, it
modifies its phase crystalline. Initially there is a crystallographic variation of
the R phase in one of its intermediate forms and subsequently the actual
phase transformation occurs with the formation of martensite or SIM (Stress
Induced Martensite); this represents the most elastic form in which the alloy
can deform significantly (7-8%). When the stress ceases, there is a
reconversion into the more stable and resistant austenitic phase. However, it
is also true that in the martensitic phase the alloy is much weaker and can
therefore fracture under lower loads (even 10 times lower) than those
required for the alloy in the austenitic phase [22,23]. As far as Ni-Ti
endodontic instrumentation is concerned, this phenomenon is then
accentuated by the presence of points of least resistance of the structure
deriving from the manufacturing processes themselves.
A fundamental requirement for the stress martensitic transformation to take
place correctly is that the stress is constant. This requirement, in theory, is
satisfied through the use of a handpiece that rotates the instruments with a
suitable and pre-established speed and torque, thus administering constant
energy. In reality, however, the applied effort is not always constant because
what determines inside the channel
256

the extent of the stress is the canal configuration itself, i.e. the complexity of
the endodontic anatomy and the frictions which, as a function of this, are
generated in the process of cutting and removing the debris. It follows that,
ideally, Ni-Ti rotary instruments should work in the superelastic range in
order to function at their best in terms of efficacy and safety, but often these
limits are exceeded with fatigue accumulation and increased risk of fracture
[24,25 ].

Ideal characteristics of endodontic instruments

While Ni-Ti was introduced in endodontics in 1988, with the first hand
instruments tested by Walia et al. [26], rotary Ni-Ti files were developed in
1993-1994 by J. McSpadden and Ben Johnson and in subsequent years have
been adopted worldwide by a large number of endodontists [27]. The
transition from manual to rotary use is justified by the fact that rotary
instruments, if used through special motors with precise speed control (and
possibly also torque), make the most of the superelasticity of the alloy, i.e. a
large deformation in the elastic range, keeping the applied stress almost
constant. This results in easier instrumentation due to the greater flexibility of
the Ni-Ti alloy in curved canals, but also to the increased cutting capacity
resulting from continuous rotation. The average speed should be at least 250-
300 rpm (or even higher according to different systematics and the individual
preferences of the operators). The greater efficacy and speeding up of the
procedures adds the advantage of an adequately centered preparation of the
canal by virtue of the lower elastic return, with a reduced tendency to
deformation of the canal anatomy [28].
One of the major advantages of Ni-Ti rotary instrumentation is the ability to
profitably use instruments with increased tapers. In fact, before the advent of
the Ni-Ti alloy, instruments for endodontic preparation were normally used
manually and made of steel with a standard taper of .02, according to the
standardization according to ISO (3630-1): more precisely, they increased by
diameter of 0.02 mm for each millimeter, proceeding from the tip to the end
of the active part, 16 mm long [29]. The clinical use of these instruments
involved, if one wanted to obtain adequate preparation tapers, the gradual use
of the instruments,
257

that is, taken to different lengths within the canal, to create a clinically valid
taper. All of this required a certain clinical skill on the part of the operator,
but above all long times and a large number of instruments, starting from the
assumption that preparations with standard taper (.02) are insufficient to
ensure valid shaping for cleansing and root canal filling. With the advent of
the Ni-Ti alloy, more flexible and more resistant to mechanical stress, it has
been possible to design and use instruments with increased conicity capable
of shaping even curved canals without excessive risks of iatrogenic errors,
linked to the rigidity of these files and to the speed of rotation with the
dynamic stresses it entails [30-32].
These tools immediately established themselves for a number of advantages.
In particular, the use of increased tapers (.04, .06, .08 and .12) allows to:
1. early elimination of coronal interference;
2. convey a greater quantity of irrigant in the apical site, thus enhancing
chemical cleansing;
3. reduce the number of instruments required for root canal shaping;
4. easily obtain a uniform and predictable taper;
5. improve the cutting efficiency of the instruments, reducing the contact
area between the instrument and the root canal wall, thus increasing the
force applied per unit area;
6. simplify the three-dimensional obturation techniques through an intimate
adaptation of the thermoplastic material to the canal walls, with reduction
of the risk of extrusion beyond the apex [33,34].
Despite these advantages, it must unfortunately be noted that the properties of
Ni-Ti, to date, do not allow for maintaining ideal flexibility in the tapers and
in the larger sizes, above all if used at the level of particularly complex
curvatures. Various modifications have therefore been proposed over the
years, both in terms of design (orientation and course of the coils, reduction
of the contact points of the coils-canal walls) and in terms of instrument
dimensions (for example, introducing variable tapers or reducing the size of
the working part ) to try to increase flexibility and simplify the
instrumentation of curved canals, reducing the possibility of iatrogenic errors
such as the transport of the apex and the most apical portion of the curvatures
(the one after the initiation of the curvature), which involve the risk of
leaving part of the canal underinstrumented and/or full of potentially infected
tissue debris [35,36]. The current trend, however, in order to obtain
258

greater flexibility and resistance to fatigue in larger size instruments, is to

improve the characteristics of the alloy by increasing its mechanical qualities.

Advantages and limitations of nickel-titanium rotary

instrumentation and anatomical variables
Rotating instrumentation with Ni-Ti instruments is considerably influenced
by root canal anatomy since, if particularly complex, it is capable of
transmitting considerable mechanical stress to the instruments, such as to
make the shaping phase difficult or dangerous and expose to greater risk of
iatrogenic errors and fractures. With the advent of Ni-Ti, anatomy is
increasingly a key factor, which must be carefully evaluated even before
starting the root canal treatment itself, precisely to avoid those morphological
conditions that could result in excessive stress for the instruments rotating.
Unfortunately, this morphological evaluation is very complex as radiographic
diagnostic tools allow an exclusively two-dimensional evaluation of the
canals (Fig.3.79). The correct interpretation of the anatomical difficulties is
therefore largely entrusted to subjective findings, deriving from the
sensitivity of the operator in the probing phases of root canal patency using
manual instruments, and to the ability to interpret them for a "mental"
reconstruction of the three-dimensionality of the system. Empirically, canals
can be divided into easy, medium or difficult, on the basis of the initial
probability respectively with files of 20 or greater caliber, with files of 10 or
15, or with files of smaller calibre; to these observations must then be added
the ability to "feel" constrictions, "hidden" curvatures, factors which further
influence the progression of the rotary instruments inside the canal [37-39].
In recent years, however, several researchers have attempted to evaluate how
much root canal anatomy affects the clinical performance of instruments,
using more objective data. Several analyzes have been performed which
correlate the intensity of stress accumulated by rotary Ni-Ti files to the radius
of curvature and angle of curvature of the canal [27,33,34]. In particular, it
has been observed that the greater the bending radius, the lower the stresses
will be and the greater the angle, the greater the stresses will be. So especially
sharp and sharp turns will be Several analyzes have been performed which
relate the intensity of stress accumulated by rotary Ni-Ti files to the radius of
curvature and angle of curvature of the canal [27,33,34]. In particular, it has
been observed that the greater the bending radius, the lower the stresses will
be and the greater the angle, the greater the stresses will be. So especially
259

sharp and sharp turns will be Several analyzes have been performed which
relate the intensity of stress accumulated by rotary Ni-Ti files to the radius of
curvature and angle of curvature of the canal [27,33,34]. In particular, it has
been observed that the greater the bending radius, the lower the stresses will
be and the greater the angle, the greater the stresses will be. So especially
sharp and sharp turns will be
260

by far the most dangerous for Ni-Ti instruments as at this level the fatigue
stress is decidedly high. Once again, it must be emphasized that the mere
mesial or distal orientation of these curves makes them radiographically
appreciable; when, on the other hand, this orientation is vestibular or lingual,
or when there are confluences of the canals in this direction (for example in
the mesial root of the lower molars), these anatomical complexities are rarely
diagnosed by the operators, running the risk that inadequate rotary
instruments are used to support high stresses. The same can be said for the
initial diameters of the channels. The more the canal is narrow or calcified,
the more the mechanical work that the instrument must perform inside it
increases in order to progress apically and, consequently, the mechanical
stresses to which it is exposed. The initial probing provides useful
information, even if narrowings and calcifications can sometimes be present
in an unpredictable way along the course of the canals.
Another variable to consider is the length of the canal beyond the curvature.
In fact, after bending, the instrument does not work exclusively in torsion, but
continuous tensile and compressive stresses (flexural stresses) must be added
to this stress, which determine a considerable accumulation of fatigue. These
stresses will be greater the longer the portion of the channel located apical to
the curvature is, since a larger portion of the blades is excessively stressed
with a considerable accumulation of fatigue. Therefore, with the same
diameter and radius of curvature, the curves located at a more coronal level
are those that cause greater mechanical stress for the instruments.Fig. 3.80).
Obviously the stresses accumulated by the instruments increase significantly
if used through a double curvature, another occurrence that is particularly
risky for the rotating Ni-Ti instruments (Fig.3.81).
261

Fig.3.79Hidden curvatures (only visible in 3D).

Fig. 3.80Difference between linear access (a), with elimination of coronal interferences and
canal rectification in the coronal third, and non-linear access (b).

Fig.3.81Instrumentation with continuous rotation.

262

As far as the radius and angle of curvature are concerned, it must also be said
that sudden curvatures can be encountered whenever there are canal
confluences, particularly frequent especially at the level of the mesial roots of
lower and upper molars, but also in the presence of oval roots , which often
contain two channels. In the case of canal confluences, if both canals are
instrumented up to the apex, one of the two will present a curvature close to
90° at the confluence level, which exposes the instruments to the risk of
fracture. In reality, if the situation is diagnosed in advance, the problem does
not arise, as it is sufficient to instrument one canal up to the apex and the
other up to the confluence [37].
Another factor to pay particular attention to is the inclination of the
instrument when introduced at the root canal entrance level. If one succeeds
in being sufficiently straight when introducing the instrument, the only
stresses transmitted to it will be those deriving from the contact with the
canal walls, therefore in relation to the anatomy of the endodontic space.
When, on the other hand, for reasons of space (related, for example, to a
limited ability to open the mouth on the part of the patient), it is not possible
to have an ideal inclination of the instrument at the entrance to the canal, it
will undergo further curvature and it will thus be subjected to additional
stresses to those deriving from the normal anatomy of the root canal system
[38].
Further reflection must be made on the relationship between the mass of the
instrument and the anatomy of the endodontic system. In straight canals
where there are exclusively torsional stresses, instruments of larger
dimensions and taper, i.e. with greater mass, work better. In curved canals,
where flexural stresses also come into play, the instruments that work best are
instead the thinner ones, with less mass and therefore more flexible, which
resist more to cyclic fatigue. It is therefore necessary to pay attention to the
use of instruments of excessive dimensions because they are too rigid and
therefore more exposed to fractures in the presence of important curvatures
[27,38].

Factors influencing the clinical performance of rotary

nickel-titanium instruments

Drawing
263

The design plays a fundamental role because it characterizes the different

instruments offered by the various manufacturers and, above all, their clinical
performance. Over the years, the design characteristics of the instruments that
have been gradually proposed have largely changed, so much so that today
we can speak of at least three generations of instruments [26,34,40,41]. The
first generation is characterized by the presence of radial planes and a central
part (the core or residual soul) of reduced diameter for greater flexibility of
the instruments with increased taper, which have been developed hand in
hand with the introduction of rotary instrumentation in Ni-Ti. The limit of
these tools (represented above all by Profiles and GTs) lies in their low
aggressiveness, due to the presence of radial planes and neutral cutting
angles, made mandatory by a technology that is still "inexperienced" in
solving the problems related to continuous rotation in curved canals and,
therefore, aimed mostly at finding a centering of the instruments inside the
canals and to minimize the risk of screwing. For these reasons, also the tip in
the first generation instruments was generally pilot, non-cutting, even if there
were exceptions (such as the Quantec, with radial planes and positive cutting
angles) in which it was possible to choose between a cutting tip , active, very
effective but more risky (steps, false roads, etc.), than a non-active one. made
mandatory by a still "inexperienced" technology in solving the problems
associated with continuous rotation in curved canals and, therefore, mostly
aimed at finding a centering of the instruments inside the canals and
minimizing the risk of screwing. For these reasons, also the tip in the first
generation instruments was generally pilot, non-cutting, even if there were
exceptions (such as the Quantec, with radial planes and positive cutting
angles) in which it was possible to choose between a cutting tip , active, very
effective but more risky (steps, false roads, etc.), than a non-active one. made
mandatory by a still "inexperienced" technology in solving the problems
associated with continuous rotation in curved canals and, therefore, mostly
aimed at finding a centering of the instruments inside the canals and
minimizing the risk of screwing. For these reasons, also the tip in the first
generation instruments was generally pilot, non-cutting, even if there were
exceptions (such as the Quantec, with radial planes and positive cutting
angles) in which the possibility of choosing between a cutting tip , active,
very effective but more risky (steps, false roads, etc.), than a non-active one.
Nowadays it is known that less efficient instruments require greater stresses
to exert their cutting action and this increases the risk of intraoperative
fractures, since the limit of clinical use is closer to that of their mechanical
264

resistance. Furthermore, there is an increased risk of taper-lock, ie blocking

of the instrument inside the canal due to engagement of its more coronal
parts, deriving from a lower cutting capacity. In fact, it should be emphasized
that the effectiveness of the tools largely depends on the cutting angles,
which can be positive, neutral or negative. A moderately positive angle
shows maximum cutting efficiency, while an excessively active angle can
cause fracture.
Over the years, having become aware of the possibility of controlling the
rotating instrumentation with adequate torque and speed values, by exerting a
minimum pressure, greater attention has been paid to the cutting capacity, for
which
265

A series of tools have been proposed, which can be defined as second

generation with negative blades and cutting angles (Race) or positive blades
and cutting angles (Hero). In these instruments, in general, in order to be able
to support the blades and avoid the stretching of the coils (that is, to increase
the torsional resistance), the residual soul, that is the central part of the
instrument (core), has been increased, even if this has made the instruments
more rigid, increasing the risk of iatrogenic errors in the apical portion of
canals with complex curves.
To overcome these stiffness problems, some manufacturers have tried to
reduce the engagement of the coils during rotating instrumentation, a source
of high mechanical stresses, using various expedients such as the alternation
of the coils (Race) or the reduction of the working part of the tools
(HeroShaper). Furthermore, the use of these tools to avoid the risks
associated with the use of tools that are too rigid at the apex has often been
associated with techniques that aim to obtain final preparation tapers lower
than .06, even if considered by various operators to be insufficient to carry
out root canal obturation with techniques that include the use of
thermoplasticized gutta-percha and/or to guarantee an optimal truncated-taper
for root canal cleansing.
More recently, other tools have been proposed with different properties, but
generally characterized by a very efficient cut, which can be defined as third
generation tools. These are characterized by innovative design solutions,
aimed at improving the effectiveness and safety of rotary instrumentation,
maintaining a simplified approach to preparation, providing for the use of a
limited number (generally 5-6) of Ni-Ti instruments . These tools include the
K3, with a relatively large residual core, with a complex design (radial planes
with a variable design of the same to reduce torsional friction, associated with
an improved cutting capacity due to a positive cutting angle,
Other third generation instruments are the Protaper, extremely efficient in
cutting but with a large residual core, which together with the decidedly
increased tapers, tends to give a certain rigidity, especially in larger
instruments with the risk of root canal transport; to overcome this
phenomenon, the concept of non-uniform taper of the instrument has been
introduced:
266

that is, the instrument is more conical in the apical portions and less in the
more coronal ones. Equally innovative, and different from the previous ones,
is the Mtwo tool, characterized by the presence of only two cutting blades
and a reduced residual core. It is an instrument with a good cutting capacity,
so instrumentation is easy, even if the tips, which are rather thin compared to
the tapers, involve the risk of intracanal fractures linked to the difference
between stresses and resistance, in the event of differences between
transverse diameters particularly marked apical and coronal.
In general, the current trend is to optimize the cutting efficiency, which
appears to be important for two factors: less formation of smear layer and less
tendency to fracture "due to engagement", since even the wider (coronal)
parts of the instruments are less likely to get stuck inside the canals.
Furthermore, in some cases, to increase flexibility and decrease the
engagement of the working portions, modifications have been made to the
design of the coils in the longitudinal direction, enlarging it and varying its
angle, also in an attempt to reduce the tendency to screw.
A further advantage of these designs derives from a better cleaning of the
endodontic space, in particular through the reduction of the dentinal layer
produced. All root canal instruments, in fact, produce dentinal sludge by
depositing it on the walls and pushing it inside the dentinal tubules. We have
already mentioned how this phenomenon is even more significant in
techniques involving the use of rotary tools, especially if not very sharp, and
the fact that the radial lands, with the plane action, seem to increase this
effect [42- 45]. As regards the pressure required to advance the instrument,
this varies according to the cutting capacity of the file, but in general one
should be very "light", avoiding forcing the instruments at the tip, because a
blockage of the same generally involves high torsional stresses and risk of
breakage. Conversely, optimal penetration into the canal must be ensured.
First generation instruments (unlike what was recommended by the
companies at the time) require moderate pressure to be able to advance in the
canal. The second generation ones can actually be used without exerting any
pressure, while the third generation ones will almost have to be "held" to
prevent them from "self-screwing" as soon as they are inserted [46].
In conclusion of this brief examination, which does not intend to be
exhaustive regarding all the designs and tools proposed over the years, but
only intends to provide a brief description of the evolution of file design in
the
267

time and its influence on the mechanical performances, it can be asserted that
each variation of the design has its advantages and disadvantages. Therefore,
it can be stated that in reality today there is no ideal design, but different
ways to achieve the goal: a correct preparation of the endodontic lumen
acting in terms of efficacy, safety and simplicity.

Operating systematics
There are many techniques for root canal preparation with rotating Ni-Ti
instruments. The most frequently used is the crown-down or corono-apical
technique; the term implies an operative sequence which first foresees the
preparation of the coronal part of the canal, then of the middle one and lastly
of the apical one (Fig.3.82). This is associated with the sequential use of
instruments of large size and taper, followed by those with smaller diameter
and taper as one approaches the apex. The rationale for this method is that the
larger diameter instrument prepares the canal to receive the more flexible and
fatigue-resistant instruments of smaller diameter. Furthermore, theoretically
the instruments for apical preparation, since the canal is already flared,
should work only with the final part, i.e. without engaging the entire working
part, thus reducing the stresses deriving from the taper-lock (coronal
engagement).

Fig.3.82Crown-down technique.

Crown down techniques generally involve the use of instruments without

developing any apical pressure; therefore, when apical progression of the
instrument becomes impossible, it is removed from the canal and moved on
to the next. Obviously it is not very simple to evaluate how much a tool
268

must or can go deep, so this technique is subject to individual variations

according to the pressure that the operator puts on the instrument inside the
canal. There will therefore be greater or lesser stresses depending on the
greater or lesser engagement of the instrument.
Crown down instrumentation can be differentiated by taper or diameters. This
means that you can pass from a larger tool to a smaller one both by varying
the taper, i.e. going from a higher to a lower taper, and by changing the
diameters by going from a larger to a smaller diameter. Furthermore, it is
possible to act on the dimensions of the tool by varying the diameter and
taper at the same time. This is the mechanically more convenient method
because it involves a greater apical progression of the instrument [47,48].
Obviously mixed or hybrid techniques can be used which provide for an
initial preflaring (manual or rotary, bringing the instruments to the apex)
before crown down instrumentation in Ni-Ti, or techniques in which the
crown down technique is used for the coronal and middle portion of the canal
and a step back technique for the apical portion. A method rather used with
the rotary crown down preparation techniques is that which provides for an
initial pre-enlargement of the canal with manual instruments, to obtain that
the tip of the rotating Ni-Ti instruments is always free afterwards, and that the
instrument is less stressed torsionally. In principle, if rotary instruments with
a diameter of 25 at the tip are to be used, according to users of manual
preflaring, the canal (apex included) must initially be prepared up to at least a
diameter of 25. This obviously requires some skill and requires time and
precision so as not to create steps, caps or transport in the most complex
cases,
As regards the other preparation techniques with rotating Ni-Ti instruments,
there is also the possibility, although much less used in clinical practice, of
performing the preparation with a step back technique, achieved through
serial instrumentation with instruments of increasing caliber working at an
increasing distance from the apex. This technique, in vogue with manual
instrumentation through .02 tapered files, is superseded by the use of
increased tapered files, even if it can find a rationale in very curved and long
canals to try to avoid the use of larger tapers, i.e. less flexible and resistant to
fatigue. It follows
269

however the need for a greater number of operating steps to recreate a correct
final taper.
Similar but faster is the technique that involves the use of instruments with
tapering and increasing diameters directly at the apex, assuming the
simultaneous preparation of different parts of the canal regardless of the
presence of curvatures; this technique has been proposed with the use of
MTtwo instruments and, theoretically, requires flexible and resistant
instruments due to the greater risk of iatrogenic errors and fractures compared
to a crown down approach. Finally, McSpadden's technique called zone
technique deserves to be mentioned, which mainly aims to limit the
mechanical stresses accumulated by the instruments during the shaping phase
by enlarging the portion just coronal to the curvature with larger and more
rigid instruments, to then use instruments thinner and more flexible to
prepare the post-curvature portion.
Alongside these techniques there are others which, generally starting from
preparations with a crown down approach, involve a wider preparation of the
apical region (deep shaping) using instruments with increased conicity and
larger diameter (even greater than 40). The theoretical presupposition of these
techniques arises from anatomical observations of apices often much larger
than the diameter 25, perhaps the most commonly sought today for fine
preparation, on the basis of Schilder's dictates. This expedient is made in
order to increase the contact surface between the canal walls and the rotating
instrumentation, with an increase in the cleansing power. If this involves
undoubted advantages in terms of cleansing, it should however be
emphasized that complications may arise in the case of accentuated
curvatures, having to use large tools at this level. Recently, in fact, various
manufacturers have proposed instruments for apical preparation, designed
according to these concepts, to implement the normal preparation techniques.
Another complication that can arise when adopting large apical preparation
diameters is the possible greater risk of material leakage during the obturation
phase.
270

Endodontic motors
A fundamental prerequisite for rotating instrumentation is the use of motors
that allow continuous rotation (Fig. 3.83). In fact, to be able to conveniently
exploit the superelastic properties of the alloy, i.e. to be able to induce the
austenite-martensite (SIM) transformation, a certain stress must be provided
and possibly kept constant. This cannot be verified clinically with manual
use, but only with assisted rotation, through motors that are able to control
the rotation speed, according to the indications of the various manufacturers.
In fact, for a good use of Ni-Ti instruments, a low speed is required
(generally, a minimum of 250-300 rpm) but above all constant maintenance
of the speed. Equally important is that the motor used for Ni-Ti instruments
has an electronic control that differentiates speed from torque (i.e. the force
developed during rotation), feature present in more recently built engines. In
older motors, on the other hand, there is no such disjunction between speed
and torque, so that as the former decreases, the latter also decreases
[38,52,53].

Fig. 3.83Endodontic motors.

Torque control was designed as a safety system to minimize the risk of

intraoperative fractures. Rotating Ni-Ti instruments give maximum efficiency
in the superelastic range, between the mechanical values of initial martensitic
stress and those of final martensitic stress, beyond which the instrument
easily fractures. Unfortunately, this ideal area of use is contracted and
difficult to determine, also because it varies with the clinical use of the
instrument due to the accumulation of fatigue. Furthermore, depending on the
anatomical complexities, it may not be
271

adequate to obtain an efficient cutting action from the instruments, which

depends on the design of the instrument and above all on the characteristics
of the dentin and on the dimensions and morphology of the canal. Ideally, the
manufacturers should indicate, depending on the size, section and taper of
each individual instrument, the right torque or torque range that guarantees
maximum cutting efficiency with the minimum risk of fracture (Fig.3.84).
Unfortunately there is little commercial interest in the subject, due both to the
difficulty of determining these parameters and to the liability deriving from
improper indications on the part of the manufacturers. However, it should be
emphasized that the right compromise between efficacy and safety is not a
simple determination, especially where the anatomical variables are very
complex and different, as it is difficult to identify a torque value for each
given instrument that is suitable for all clinical cases. It follows that the pre-
set values represent only general indications and that it is generally the single
operator who, in the search for the right torque values, must modify these
settings, based on empirical criteria deriving from his own clinical experience
and not from scientific data. All this has meant that torque control is now
seen not as a real resource, but as a possibility that needs to be verified and
validated. This parameter is therefore entrusted to individual preferences and
choices that can be more or less correct and acceptable, with the hope that in
the future designs will be created or operating sequences specially designed
on the basis of concepts deriving from validated scientific experiences.
272

Fig.3.84Torque for the feed (thanks to FKG for the data).

Method of clinical use

Much has been written on the design of rotary instruments, less on the
operative sequences and even less on how to use the instruments clinically, ie
on which movements to implement inside the root canal. In general, we limit
ourselves to generic suggestions such as "never force the tip of the tools",
"use the same pressure that you would do when writing on a sheet with a
pencil" etc., which, although theoretically correct, provide only summary
indications that each operator interprets and realizes in a subjective way. In
reality, the force for apical progression of the instrument should be provided
by the endodontic motor (with adequate speed and torque) and the operator
should limit himself to "passive" use, even if there is often a tendency to
"push" the instrument apically tool to facilitate the instrumentation, especially
for those less effective side and/or tip cutting files. McSpadden, in an attempt
to standardize these procedures and improve progression without risking
forcing the instruments at the tip, recommends always using the same
pressure that allows the rotary instrument to advance in the first millimeter.
This indication must be taken as a rule when one wishes to "push" the
instrument apically, ie limiting the engagement to only 1 mm at a time; the
same way it can be This indication must be taken as a rule when one wishes
to "push" the instrument apically, ie limiting the engagement to only 1 mm at
273

a time; the same way it can be This indication must be taken as a rule when
one wishes to "push" the instrument apically, ie limiting the engagement to
only 1 mm at a time; the same way it can be
274

applied in cases where back-and-forth techniques are used within the canal,
thus limiting any apical progression movement to a maximum of 1 mm
[54,55].
However, it should be noted that generally all this refers to the use of rotary
files as reamer, i.e. during the progression towards the apex of the instrument.
During this phase, the file is highly stressed and engaged in cutting,
progressing and removing debris, with high mechanical stress both at the tip
and for the remaining working portion. These stresses translate into the
accumulation of fatigue and expose to the risk of fracture, a condition which
also occurs due to the possibility of screwing the instrument inside the canal
and locking the instrument at the tip or by taper-lock. For these reasons it is
suggested, once the working length has been reached (understood as the
progression of the instrument without forcing it), to interrupt the
instrumentation, thus limiting it to a few seconds and avoiding useless risks.
Actually, all this is correct if we consider only the work of the incoming files,
as reamer, but it is not so if we consider the possibility of using them also as
rotating hedstroems, i.e. making them work also in the output. In this case the
secret lies in preventing the tool from working while it is stuck at the tip or
with too much engagement of the blades. In this regard, it is sufficient to
withdraw the tip 1-2 mm in the coronal direction and make the instrument
work in rotation, leaning it against the walls according to all those methods
(circumferential reaming, anti-curvature method, etc.) that are usually used
with hedstroem manuals. The advantage is that the tool, thus working
outward, uses only a few turns for cutting with respect to the entire working
part; the result is minimal fatigue, therefore a coronal enlargement can be
performed for several seconds "at no cost", i.e. without weakening the
instrument. This has been well demonstrated in the rectilinear and more
coronal portions of the canals.
If these routine movements are used, each instrument will prepare the canal
with taper and diameters greater than its nominal size, with a great practical
advantage: in simpler canals, the number of files can be reduced because each
instrument enlarges more , in the more complex ones the apex can be
instrumented with greater safety and effectiveness as a greater coronal
enlargement has been obtained. These expedients go beyond the type of
instrument and sequence used, as these instrumentation techniques have been
proposed exclusively in order to simplify and speed up the procedures, using
the instruments
275

routine rotary working both in and out of the canal [56-58]. A further
possibility is to resort to alternating rotation which, although less effective in
terms of cutting efficiency, allows the mechanical stresses to be significantly
reduced, by alternating engagement and disengagement of the blades. Over
the years, various solutions have been proposed by some authors in this
sense. Different angles of rotation and counter-rotation have been introduced,
also with the intention of reducing the number of instruments in the
sequences. To date, however, the method is still little known, even if
theoretically it follows principles of certain interest, so there are no studies or
clinical experiences in this regard, with the exception of those of a single
Canadian author. Based on these premises, however, Reciprocating
instruments (WaveOne and Reciproc) have been proposed in the last year
which use particular movements with cutting angles greater than those of
disengagement and which would allow, at least in many cases, to prepare the
canal with a single instrument. However, there is still no literature on the
subject that highlights the strengths and weaknesses of these methods.

New production processes

Despite the undeniable advantages of the Ni-Ti alloy, rotary instrumentation
still encounters problems related mostly to the increased risk of intraoperative
fracture and the relative rigidity of instruments with increased tapers
(Fig.3.85). It has been seen previously that numerous attempts have been
made over the years to improve the characteristics of the instruments by
varying their design, dimensions and operating sequences, while no further
significant innovations in the properties of the Ni-Ti alloy have ever been
proposed. Only recently has there been a certain interest from manufacturers
in using new alloys and production processes different from the common
turning used up to now. These processes aim not to weaken the tools during
the manufacturing phase and make use of particular heat treatments on the
alloy and innovative production methods capable of maintaining and
increasing the mechanical properties of the tools. In particular, heat
treatments have been used to improve the flexibility and resistance of the
files, as in the case of M-wire technology and Endowave files, which have
recently been commercially available. In general, these innovations appear to
be promising, even if they make the production process more complex and
more difficult to standardize: in
276

In particular, it does not seem easy to obtain alloys with constant properties,
given their considerable sensitivity (with consequent variability) to these
treatments. An innovative Ni-Ti production process has recently been
proposed which implies a peculiar initial treatment of the alloy made possible
by an in-depth knowledge of the characteristics relating to the phases present
in Ni-Ti: the Twisted Files (TF) technology.

Fig.3.85Fatigue fracture of a Ni-Ti endodontic instrument.

This is considered by some scholars to be perhaps the most important

technological innovation since the introduction of the Ni-Ti alloy in
endodontics. For the first time, in fact, operators have at their disposal new
rotary instruments which differ not only in their design (Fig.3.86), but above
all for the characteristics of the alloy, deriving from a cutting-edge
production technology. In fact, Sybron Endo (Orange, USA) has developed
an original manufacturing process by torsion of Ni-Ti rotary instruments,
until now considered impossible, as the superelastic Ni-Ti alloy tends to
return to its original shape if subjected to twist (Fig.3.87). The
aforementioned torsion manufacturing process is instead possible as it makes
use of innovative heat treatments and patented finishing processes, which
allow for control of the phases and characteristics of the alloy, used both for
production and to improve the final properties of the alloy. More precisely,
the austenitic Ni-Ti wire is subjected to a patented thermal cycle of heating
and cooling with temperatures and times suitable for modifying the
crystalline phase (R-phase) so as to make it non-superelastic.
277

In this way, root canal instruments can be produced from the wire by twisting
without using turning or carving processes (grinding). After shaping the
instruments, they must be subjected to a thermal cycle again to return to the
superelastic austenitic crystalline phase, the characteristics of which are
necessary for endodontic use. Finally, the instrument is subjected to a final
finishing (deoxidation), which is not very aggressive, which maintains the
hardness and integrity of the crystals without losing the edge of the blades.
The result is a finish which, although anti-aesthetic, is decidedly
advantageous from the point of view of clinical performance.

Fig.3.86Twisted Files tools.

Fig.3.87Twisted Files tools.

The differences compared to the traditional production processes for turning

or carving are many (Fig.3.88), as the latter inevitably lead to greater damage
to the internal and external structure of the instruments, with the formation of
defects and micro-cracks (Fig.3.89), trigger points and facilitated propagation
of fractures. These aspects represent factors of weakening of the mechanical
resistance of the instruments even for stresses lower than the breaking load
(loci Minoris Resistenzae), this
278

explains the possibility of unexpected and sudden fractures during clinical

use. These surface defects can be partially minimized by carrying out
sophisticated finishing treatments, such as electropolishing, which, however,
only affect the external surface of the instrument and, therefore, do not
completely solve the problem, with the disadvantage of reducing the
effectiveness of the cut.

Fig.3.88Realization by notching of the common rotary instruments in Ni-Ti.

Fig.3.89Microcracks (a) and surface defects (b,c) from notches on Ni-Ti instruments.

In theory, with the TF technology the mechanical resistance of the

instruments is greater in relation to the advantages deriving from the thermal
control of the phases, through the variation of the properties of the different
crystallographic forms, but also in relation to the maintenance of the integrity
of the crystalline structure deriving from the torsion and finishing processes,
as demonstrated by comparative cyclic fatigue studies performed on new
tools [35,36,59]. The result is then a greater ease and simplicity of use, as the
improvement of the resistance, flexibility and cutting characteristics allows to
simplify and speed up the operating techniques to the maximum, proposing
basic sequences with the smallest number of instruments ever proposed. With
only three
279

instruments (or even less in the simplest cases) it is possible to prepare almost
all of the canals, even the most complex ones. The innovative technology
required a wide range of studies and experimental verifications, partly
already present in the international literature, partly still under construction,
also due to possible future developments of the production process, which is
now taking its first steps and lends itself to a series of evolutions. It can
therefore be said that the TF technology, due to its unique characteristics and
the innovative mechanical properties of the alloy, perhaps opens a new era in
rotating Ni-Ti instrumentation, laying the foundations for an approach to
mechanical preparation with levels of , simplicity and safety of use up to now
unthinkable.

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Root canal shaping instruments

A. Bonaccorso, TR Tripi
283

Introduction
The term shaping refers to the crucial phase of root canal instrumentation.
The shaping has the objectives of widening the canal volume, eliminating the
pulp and bacterial components, allowing the detergents to act effectively and
the filling material to fill the entire endodontic space [1]. A non-
instrumentation technique has been proposed by Lussi [2], however the
preparation with manual or mechanical instruments capable of widening and
effectively removing the dentin is the most commonly accepted, reproducible
and most used by schools of endodontics [3].
In the past, various materials and techniques were used to shape the canals,
from ultrasound devices (Rispi, Giromatic), to steel alloy, both using manual
instruments (K-file, Headstrom, Reamer) and rotary instruments (Gates burs,
Largo etc.), up to the nickel-titanium alloy 55-45 (Ni-Ti).
The composition of the first Ni-Ti alloys for endodontic use required the
presence of 50% nickel atoms and 50% titanium atoms (1:1 ratio),
corresponding to 55% nickel mass and 45% titanium [4]. For this reason they
have been marked with the initials Ni-Ti 55-45.
The Ni-Ti alloy differs from steel for its shape memory and for its
superelasticity (or rather pseudoelasticity), even if in endodontics the first
characteristic is not exploited. The pseudoelasticity is particularly useful as it
gives the alloy the ability to flex in rotation, allowing it to adapt to the
anatomy of the canal and to maintain centering even in the presence of
accentuated curvatures. The introduction of Ni-Ti rotary files (SRN) for root
canal preparation has brought a number of advantages for the operator
compared to the use of steel hand files [5]. SRNs can be used in mechanical
rotation, without producing the typical negative effects of steel hand
instruments such as stripping, perforations, and anatomical defects of the
apical area [6]. Compared to steel hand instruments, with the use of SRNs it
is easier to maintain the working length (LL), there is greater respect for the
original anatomy, the degree of alteration at the apical level is lower, there is
less leakage of debris beyond the apex, the preparations are rounder and more
centered in the canal, especially in curved ones [7]. These advantages are
evident in inexperienced operators, with a shorter technique learning curve
[8].
Ni-Ti alloy 55-45 has been further improved in terms of strength
284

to bending and torsion by means of surface electropolishing techniques [9],

heat treatments [10] and chemical composition [11]. Different alloys in
chemical composition are used today such as M-wire (Vortex, Wave one,
Maillefer), R-Phase (Twist file, Sybron Endo) and CM-wire (Hyflex,
Coltene).
The unpredictability of SRN separation still remains a hotly debated topic in
endodontics, although the fracture of an instrument within the canal does not
necessarily lead to a poor prognosis [12]. Some SRNs can continue to twist
up to three times after becoming locked in the canal without fracturing, but
unfortunately this occurs with reaction times of less than 1 second,
preventing the operator from withdrawing the instrument and avoiding
separation [13]. Furthermore, SRN fracture can occur without any warning
even in new instruments, while the fracture of steel hand instruments is
usually preceded by excessive engagement of the instrument, acting as an
alarm to avoid further forcing the instrument and preventing its fracture [14].
The removal of the SRN fragment can be easy or complex depending on the
type of instrument, the position with respect to the curvature and the entrance
of the canal, the experience and the instruments in possession of the operator
[15]. The blockage caused by the fragment can complicate the
chemomechanical preparation process of the apical area for the obstacle and
make disinfection impossible [16]. Attempting to remove the fragment, even
with the operating microscope, ultrasound and special removal tips and kits,
can lead to excessive loss of dentin, weakening of the root up to cases of
perforation [ 17].

Fracture incidence
SRN fracture has complex and multifactorial causes. Although SRNs fracture
is perceived to be more frequent than steel hand instruments, the frequency
depends on many variables: anatomy, angle and radius of curvature, type of
instrument, instrumentation technique, number of uses, experience and skills
of the operator, speed and torque used, use of specific devices to work with
constant torque and speed [18]. These variables underlie the reported
differences in fracture rates across studies [19].
The literature review reveals that the incidence of tool fracture
285

manual endodontics (mainly steel) is about 1.6%, with a range between 0.7
and 7.4% [5]. The mean fracture rate of SRNs is around 1.0% with a range of
0.4 to 3.7% (Tab. 3.5) [20]. From the data present in the literature, no
differences emerge in terms of fracture percentage between SRN and steel
hand tools.

Tab. 3.5Comparison between Ni-Ti alloy and steel

Property Ni-Ti Stainless steel
Springback 8% 0.8%
Biocompatibility Excellent Sufficient
Elastic module approx. 48 gPa 193 gPa
Torsional capacity Excellent Limited
Density 6.45 g/cm3 8.03 g/cm3
Magneticity No Yes
Resistance to approx. 1.240
approx. 760MPa
tensile stresses MegaPascals
Thermal 6.6 to 11.0×10-6
17.3 x 10-6cm/cm/°C
expansion cm/cm/°C
coefficient
80 to 100 micro-
Resistivity 72 micro-ohms*cm
ohms*cm
(From: Mcspadden, 1995; modified.)

Studies carried out with remote controls on all types of teeth have
demonstrated the presence of fractured SRNs, with 2.4% of cases on
ProTaper instruments [21]. Sattapan et al. [22] report a frequency of 21% out
of 378 Quantecs used over a 6-month period by an endodontic specialist. A
study of 7,159 rotary Ni-Ti instruments reported a frequency of 5% [23].
Alapati's study reports a rate of 5.1 out of 822 SRNs used [24]. Lower
percentages are found by Arens et al. reporting a fracture incidence of 0.9%
on 786 single-use ProFile instruments in varying degrees of difficulty [25]. A
recent study of ProTaper Universal used for up to 3 molars, 10 premolars or
30 anterior teeth revealed an incidence of 2.6% by number of teeth and 1.1%
286

compared to the number of channels [26].

It can be concluded that there are no significant differences between steel and
Ni-Ti in terms of fracture and that the percentage of fracture depends on the
number of uses, the type of tool and the use made by the operator.

Fracture mechanism
During the shaping phase, endodontic instruments are subjected to different
forces, including bending, torsion, traction and apical pressure [27]. Forces
can be divided into simple (flexion, torsion and vertical) and compound
(flexion-torsion). A bending type stress occurs when the system of external
forces is reduced to a torque lying in a plane containing the longitudinal axis,
called the stress plane; an element is subjected to torsion when the resultant
of the external forces is a torque acting in a plane perpendicular to the axis of
the element itself. The twisting moment or torque of an instrument can be
defined as the resistance that opposes the instrument when it hits the canal
walls during its rotation; this force is measured in g/cm or in N/mm. Flexion-
torsion is due to the simultaneous action of a bending moment and a twisting
moment and occurs when the body has a rotation with respect to its
longitudinal axis, which is associated with the application of a load along one
of the two axes of symmetry of the geometric section. When rotating within
the canal, the endodontic instrument is subjected to compound-type stresses
due to both rotating bending and torque [13]. It is no coincidence that the
greatest number of fractures occurs where the flexion-torsional stresses are
high, such as in the molars (94.3%) compared to the premolars (4.3%) and in
the anteriors (1.4%) ; the mesial roots of the mandibular molars (85.3%) and
those of the maxillary (61.5%) are the sites in which the greatest separations
occur [26].
Compared to the Ni-Ti alloy, steel has a higher modulus of resistance to
torsional forces (Ni-Ti 1.1 N/cm; steel 2.5 N/cm), higher hardness and
density, but also a much higher modulus of elasticity: Ni-Ti alloy 30 gPa;
steel 200 gPa [6,9]. This translates clinically into the ability of the SRNs to
follow the curvatures of the rotating canals without the "straightening" typical
of steel instruments, but also in the lower resistance to torsional forces and to
the accumulation of cyclic fatigue within the alloy [13 ].
287

The elastic strength of SRNs is their ability to withstand stress without

breaking. This capacity is a function of the intermolecular cohesion (strength
of its bonds) and depends on the internal structure of the alloy and on the
defects or weak points present in the material both inside and on the surface
[28].
The tools, when stressed by static or dynamic forces, do not just resist or
break, but dynamically go through the following phases [29]:
● reversible or elastic deformation, as a result of which the tool can return to
its initial shape, if the stress is removed; therefore the deformation did not
exceed the elastic limit of the alloy;
● irreversible or plastic deformation, as a result of which the tool can no
longer return to its initial shape even if the stress is removed; in this case
the permanent deformation is caused by a force that has exceeded the
elastic limit of the alloy; the deformability of a material is the ability to
undergo permanent deformation without fracturing;
● fracture, in this case the force acting on the body exceeded its ability to
withstand deformation.
Sattapan et al. [22] distinguish two types of fracture: torsion (with
deformation) and flexion fatigue (without deformation).

Torsion fracture
The torsion fracture occurs due to a pair of forces acting along the axis of the
instrument opposing each other and orthogonal to the axis itself. Typically,
this type of fracture occurs with unwinding of the instrument coils [13].
Under the scanning electron microscope, gross plastic deformation is always
found in the coils adjacent to the fracture site (Fig.3.90) and typical irregular
craters are noted in the periphery with a fibrous appearance in the center
(Fig.3.91) [30].
288

Fig.3.90Fracture, alteration of the coils.

Fig.3.91Fracture.

In Ni-Ti rotary tools, torsional stress is the result of several components [13]:
shear forces that create a dentin chip within the canal walls and that are
proportional to the cutting angles present in the instrument section ( for
example, they are shallow in ProFiles − they have no cut angle − and higher
in RaCe or ProTaper); screwing forces which are a function of the number of
coils present in the instrument and their inclination (more coils means a
greater tendency of the instrument to screw, different inclined planes of the
coils less tendency to screw); abrasion forces, due to the contact between the
surface of the file and the canal walls, which can be decreased by using a
lubricating agent such as liquid EDTA;
289

Torsion fracture occurs when one part of the rotating instrument (often the
tip) rotates at a different speed or becomes stuck relative to another part (the
area near the shaft) which continues to rotate [20]. This phenomenon known
as taper-lock occurs more frequently with tools that have a lower mass and
are damaged more at the tip. In torsional fractures, most tool breaks are 1 to 6
mm from the tip with the highest frequency in the last 3 mm of the tip [23].
Instruments with smaller tip diameters are more likely to experience torsion
fractures and more frequently show signs of deformation in the coils [31].
Torque in SRNs depends on:
● rotation speed: as the speed increases, the torque values decrease;
however, as the rotation increases, the phenomena of cyclic fatigue
increase;
● section of the tool: SRN sections with cutting angles (e.g. ProTaper)
produce less torque than instruments with smoothing surfaces (e.g.
ProFile). Sections with larger volumes and surfaces resist torsional stress
better than those with smaller surfaces;
● presence of lubricant: the in vitro study by Boessler et al. demonstrates
that the presence of aqueous lubricants (hypochlorite or H2O) is more
advantageous in terms of torque than dry working conditions. The presence
of
chelators both in gel and in aqueous solution determines lower values of
torque versus hypochlorite [32];
● instrument surface: reduced working surface (8-10 mm compared to the
traditional 16 mm) produce a lower torque effect;
● inclination of the blades of the tool: instruments with different cutting
planes produce lower torque values;
● number of uses: Torque resistance values decrease with increasing
number of canals [33].

Cyclic fatigue fracture

Flexion rotation within a root canal curvature of endodontic instruments
results in a cyclic fatigue process [34]. Fatigue fracture is a type of separation
that occurs in fluctuating structures subjected to dynamic stress. SRNs with
larger tip diameters are
290

more susceptible to cyclic fatigue separations and should be reused with

caution [35]. In these circumstances it is possible that the fracture occurs due
to considerably lower stress levels than those corresponding to a static type of
load or force [36]. The term fatigue is used because this type of fracture
usually occurs after a long period of repeated stress or strain cycles. Fatigue
is the leading cause of fracture in metals. Furthermore, it is insidious and
catastrophic, and occurs subtly and without warning [37]. Fatigue fracture is
similar to brittle fracture: the process begins with crack formation and
propagation and normally the fracture surface is perpendicular to the
direction of the applied tensile stress.
1. Crack formation: a small crack forms on some points of high
concentration of stress.
2. Crack propagation: they increase in relation to each cycle of stress.
3. Final fracture: Occurs quickly after crack progress reaches a critical point
(Fig.3.92).

Fig.3.92Instrument fracture.

The cracks associated with fatigue fracture always start on the surface of a
material, at the points where the stresses are most concentrated (Fig.3.93).
Crack sites include shallow, sharp, blunt scratches, flaws, and various other
imperfections [39]. Furthermore, the same cyclic stresses can create
microscopic discontinuities on the surface as a consequence of the
fluctuations [40].
291

Fig.3.93Crack on tool.

Cyclic fatigue in endodontic instruments is influenced by a number of factors

described below.

Tool diameter.In a curved canal, the ability of an instrument to resist fatigue

varies inversely with the square of its diameter [13]. The smaller the diameter
of the file, the longer it can rotate within a curved canal without exhibiting
signs of cyclic fatigue. For example, a #20.02 diameter file is 50% more
likely to resist than a #25 diameter file. Conversely, in a perfectly straight
canal, an instrument with a larger diameter at the tip resists better [13].
Unfortunately, there are no perfectly straight canals in the tooth roots.

Tool taper.With the same tip diameter, the smaller the taper, the longer the
tool survives [9]. For example, in the Quantec series (Sybron Endo, Orange),
which has intermediate tapers (.03-.05) as its peculiarity, it is possible to
highlight a different reaction to fatigue, with the same diameter in bends
(bending radius of 5 mm ) [6]. The survival time of tools with a #25 tip
diameter is 130 seconds for the .02 taper, 83 seconds for the .03 taper, 60
seconds for the .04, 51 seconds for the .05 and 23 seconds for the .06 [ 13];
this means that, on equal terms
292

anatomical conditions (angle and radius of curvature), a 25.06 can be used

only for two molars while the 25.02 can be used five times more, i.e. for ten
cases of molars.

Instrument section.With the same tip diameter and taper, it is of significant

importance and this is demonstrated, for example, by the comparative study
carried out on ProFile, Hero and Quantec. With a 5 mm radius and .04 taper,
the Quantec performs better in terms of survival time, while the ProFile
performs better than the Quantec and the Hero in 6% taper and a less
accentuated (10 mm) [13].

Number of rotations.The fatigue of a file increases as the number of

rotations within the channels increases. If you insert the file ten times within
a canal with a rotation of 150 revolutions per minute, you will have a total of
1,500 rotations of the file. If the tool is rotated at 300 rpm for ten insertions
there will be a total of 3,000 rotations. It is evident that reducing the speed of
use extends the useful life of the instrument. The study by Zelada et al.
demonstrates that there is a statistically demonstrable difference in instrument
separations between the speed of 150 and that of 350 rpm in canals with a
radius of curvature of 5 mm [41]. In vitro research also demonstrates how the
ProFile .04 have greater resistance when rotated at a low number of
revolutions. The fracture rate depends more on the number of canals than on
the number of contoured teeth [26]. Studies by Yared et al., of ProFile .04
and .06 to prepare 225 mesial roots of mandibular molars with as few as five
canals per file, did not report any instrument fractures [42]. A work by
Alapati et al. [43] finds an incidence of 5.1% of 822 SRNs used in a specialist
endodontic clinic.

Instrument movement within the canal.The absence of movement causes

greater stress on the instruments, probably because the same points of the
surface are always strained. Short movements, of 1-3 mm of amplitude,
instead allow a greater resistance to fatigue compared to the absence of
movement [6].
293

Rotation type.Alternating rotation at different angles in one direction

relative to the other, instead of continuous, increases fatigue strength
approximately six-fold on ProTaper F2 [44].

Instrument surface.The electropolishing treatment improves resistance to

cyclic fatigue, corrosion and the ability to work in the presence of
hypochlorite (Fig.3.94) [45].

Fig.3.94Electropolishing.

Number of uses.Influences the fracture rate of the instrument [25]. A study

including 7,159 rotary Ni-Ti files used by 14 endodontists reported a
frequency of 5% [24]. The study by Arens et al. [25] reports a fracture
incidence of 0.9% on 786 rotary instruments used only once in cases with
varying degrees of difficulty by a single operator.

Degree of curvature, diameter and length of the channels.They

significantly influence the fracture frequency, so after use in particularly
curved, narrow, calcified and long canals it is better to discard the
instruments, especially if with a taper greater than .04 [46]. The majority of
cyclic fatigue fractures of SRNs occur in the apical third where there is the
greatest degree of curvature [46].

Method of disinfection and sterilization.Hypochlorite can produce

294

microcracks on the surface of the Ni-Ti instruments and cause

electrocorrosion phenomena if used as a disinfectant for cleaning the
instruments, although it does not alter the cutting capacity, it does not reduce
the torsional and flexural strength [47]; sterilization in autoclaving, although
it produces a greater oxidation of the surface and a consequent formation of
oxides which can reduce the shear capacity, does not appear to influence the
resistance to torsion and bending of the SRNs.

Prevent fractures
To counteract the onset of torsion fractures you can:
● create a glide path up to the working length with a hand file size #15 or
better 20; this will reduce the possibility of a toe taper-lock effect;
● use an electric motor with speed and torque control and slavishly follow
the setting provided for each different instrument;
● advance the instrument in the canal 1 mm at a time, slowly and gradually;
if the instrument does not advance more than 1 mm in the canal, change
the instrument and use one possibly thinner in taper or size;
● adopt a tooling sequence that contains different tapers (to reduce the
contact areas) and different tip diameters, so as to reduce or distribute
torsional stress across all the tools in the sequence; do not skip steps within
the sequence;
● lubricate the canal with irrigating solutions, preferably with chelators, in
order to reduce the friction of the instrument on the canal walls and
therefore the torque;
● do not lower the instrumentation speed too much (never below 150 rpm)
because the torque value is increased.

To counteract and prevent fatigue fracture you can:

● obtain straight-line access to the apical part of the canal, thus reducing the
stress on the instrument and lengthening the radius of curvature;
● avoid using files with greater than .04% taper (stiffer) for canals with
medium or narrow radii of curvature;
● use only .02 tapered (more flexible) files if shaping canals with steep
curvatures;
● limit contact of SRNs with hypochlorite to reduce potential effects
295

of electrocorrosion; do not disinfect by immersion in hypochlorite;

● avoid using the autoreverse mode of the micromotors to reduce the risk of
torsional fatigue; use a back and forth movement to distribute the stresses
over the entire surface of the instrument;
● tool inspection is a method that does not guarantee the reusability of
tools. The detection of distortions in the pitch of the instruments is a sign
of a previous excessive torsional stress which discourages their use.

Nickel-titanium instruments
All companies offer sequences and instruments to reduce the incidence of
fractures, but the ideal system of Ni-Ti instruments does not yet exist. The
ideal sequence should have the following requirements:
● be simple, ergonomic, with fast working times, easy to use and easy to
learn, at relatively affordable costs;
● maintain the original anatomy, preserving the maximum possible root
structure, avoiding iatrogenic errors such as stripping, perforations, leakage
of debris beyond the apex;
● maintain the position and diameter of the foramen;
● create channels wide enough to accommodate adequate quantities of
irrigating solutions;
● determine predictable and reproducible shapes;
● do not have intracanal separations of the instrument;
● allow you to prepare from the simplest canals (wider and with slight
curvature) to difficult canals (narrow, curved and long). The diameters of
the preparations can vary from #20 in the narrowest and most curved
canals of the molars to #60 in cases of palatine roots of maxillary molars:
the ideal system should provide for the majority of these diameters;
● respect the biological parameters of preparation;
● have a compatible obturation system.

Ni-Ti endodontic instruments can be classified into various generations based

on their design characteristics and their appearance on the market.
296

First generation tools

Profile(Maillefer, Switzerland), designed by Dr. Ben Johnson, have .02, .04
and .06 tapers and diameters from #15 to 40, have a working part of 16 mm,
triple helix U cross section, presence of radial land between the grooves,
therefore they do not have cutting angles but flattening surfaces similar to a
plane, non-active tip with elimination of the transition angle (Fig.3.95). For
the elimination of coronal interference the Orifice Shapers combined with the
Profiles are used at 300-500 rpm.

Fig.3.95Profile.

Lightspeed, designed by Dr. Steeve Senia, with a non-cutting pilot tip,

similar to Gates drills but more flexible thanks to the Ni-Ti alloy. The
working part of the tool is extended only 0.25-1.75 mm, U cross section,
fixed taper .02 and diameters from #20 to 70 (Figs. 3.96And3.97). They are
used at 800 rpm.

Fig.3.96LightSpeed (SybronEndo, USA).

297

Fig.3.97Section of RaCe (FKG, Switzerland).

Quantic(Sybron Endo, USA), instruments designed by Dr. John McSpadden,

have a fixed diameter at the tip #25 and taper .02, .03, .04, .05, .06. They
have a slightly positive cutting angle, presence of two large radial lands,
active tip in the LX version (to favor greater progression in narrow, curved
and calcified canals) and non-cutting, rounded in the SC version (for wider
canals) (Fig.3.98).

Fig.3.98Quantec (discontinued).

GT Rotary(Maillefer, Switzerland), designed by Dr. Stephen Buchanan,

feature three diameters #20, 30 and 40 (for difficult, medium and easy canals
respectively) and taper .04, .06, .08 and .10. Peculiar is the reduction of the
surface
298

working, which from the traditional 16 mm decreases according to the taper:

13 mm in the .06 taper, 10 mm in the .08, 8 mm in the .10 and 6 mm in
the .12. GTs have a typical U-shaped cross section, similar to ProFiles,
rounded, non-machining tip, with more sloped face surfaces than ProFiles
(Fig.3.99).

Fig.3.99GT Rotary.

Hero 642(MicroMega, France): these are instruments with .02, .04 and .06
tapers and tip diameters from #20 to #40. The symmetrical section with three
cutting edges, the non-cutting point and the constant thread pitch is similar to
that of the new Revo-S (see Third Generation Tools).
All first generation instruments, with the exception of the Lightspeeds, have
instruments called Flares or Shapers for widening the coronal third and/or for
eliminating coronal interferences. These tools, called as the case may be,
Orifice shapers (ProFile), Flare (Quantec) or Accessory Files (GT Rotary) are
not very flexible, with a reduced working surface, and diameters ranging
from #25 up to #80. McSpadden criticized the use of Ni-Ti instruments with
such high tapers, given that it is not possible to appreciate the flexibility of
the shape memory alloy, evident instead only in the diameters (#15-20.25)
and in the smaller tapers (.02) [13]. All first generation tools, except the
Lightspeed (800rpm), should be used at speeds of 300-500rpm.

Second generation tools

RaCe(Reamers with Alternating Cutting Edge), produced by FKG (La chau
de Fonds, Switzerland), have a triangular section with three cutting angles, a
non-active tip, without release surfaces. RaCe #15, 20 and 25 only
.02 have a more robust, square section. To limit the effect
299

determined by the three active angles, the cutting surfaces of the instrument
alternate with non-working surfaces in order to make the debris flow out of
the canal (Fig. 3.100). The RaCe have a surface electropolishing treatment
(electropolishing) which reduces the surface defects (microcrack) caused by
the mechanical working of the Ni-Ti alloy from which microfractures can
occur. The electropolishing treatment improves resistance to cyclic fatigue,
corrosion and the ability to work in the presence of hypochlorite. The RaCe
have different diameters (from #15 to 40) and different tapers (from .02 to
0.12) of the instruments dedicated to the preparation of the coronal third and
the elimination of interferences (Pre-RaCe) both in Ni-Ti and in steel and a
typical daisy from which to remove each petal after each use.

Fig. 3.100RaCe.

Mtwo, conceived by prof. Vinio Malignino and marketed by Sweden &

Martina (Italy), have a helical section with two cutting edges, sharp blades
almost parallel to the long axis of the instrument, non-active point (Fig.
3.101). To reduce the screwing effect, the blades of the instrument are
elongated with a reduced number of turns per unit of length. The set of
instruments, available in lengths of 21, 25 and 31 mm, consists of four basic
instruments (#10.04, #15.05, #20.06, #25.06) plus three finishing instruments
(#30.05, #35.04 and #40.04). A #25 Mtwo with a .07 taper is also present to
allow for the obturation of the canals with the System B technique. The files
are used in a simultaneous sequence, where the first file is brought to
working length and subsequent files gradually shape the channel by
increasing both the taper and the diameter at the tip.
300

Fig. 3.101Mtwo (Sweden & Martina, Italy).

Third generation tools

ProTaper(Maillefer, Switzerland), the six instruments in the series have a
triangular section with three convex cutting angles and possess a unique
feature which distinguishes them from all other Ni-Ti instruments: a taper no
longer with constant increase from tip to shank of the tool, but variable and
progressive with larger tapers near the tip and smaller tapers near the shank
(Fig. 3.102). The series consists of the left auxiliary file of only 19 mm for
flaring the coronal third, two Shaper S1 and S2 for shaping the canal up to
the working length and three finishing instruments of the apical third (F1, F2
and F3) with increasing diameter (#20, 25 and 30). Auxiliary files F4 and F5
with diameters #40 and 50 respectively are used for apical finishing of canals
with larger diameters.

Fig. 3.102ProTaper (Maillefer, Switzerland).

K3, produced by Sybron Endo (Orange USA), are asymmetrical instruments

built in three tapers (.02, .04 and .06), tip caliber ranging from #15 to # 60,
have an acute and positive cutting angle, tip not active, variable coil angle,
asymmetrical triple helix section with two cutting surfaces,
301

wider and with a large relief to reduce friction, and a third large radial section
(radial land) stabilizing to allow the instrument to work centered in the canal
(Fig. 3.103). To complete the series there are also Orifice Openers for the
elimination of coronal interferences, with a taper of
.08 and .0.10 and a point gauge of #25, with an 8mm working surface.

Fig. 3.103K3 (SybronEndo, USA).

Revo-S, heirs to the Hero 642, have an asymmetrical section with the three
blades arranged so as to have three different radii with respect to the center of
the channel. In this way, along the canal walls when one blade works, the
others are free and do not touch the canal walls (Fig. 3.104). This type of
section, by reducing the mass of metal present in the center (core) of the
instrument, allows for greater flexibility compared to the corresponding
instruments with a symmetrical section. The set of tools involves the use of
only three tools all with a #25 tip diameter and with a 4 or 6% taper, but with
different coil spacing. The sequence includes root canal probing with
stainless steel hand files, electronic LL determination and radiographic
confirmation, use of the Endo Flare for root canal orifice preparation, manual
preflaring with #10 to 20, the SC1 tool 21 mm long, #25 and 6% taper, with
coils spaced averaged up to 3-4 mm from the LL. This is followed by the use
of the SC2 tool #25 4% taper with tighter coils brought to the LL. In the end,
use the SU tool, #25 and 6% taper and coils far apart. Once the apical
diameter has been measured, #30, 35 or 40 diameter Revo-S Apicals are used
for apical preparation with a 6% taper in the last 5 mm and 0 in the remaining
13 mm of the working portion.
302

Fig. 3.104Revo-S (MicroMega, France).

endowave, distributed by J. Morita (Kyoto, Japan), have a defined

continuous wave design with alternating straight and oblique cutting edges,
electropolishing treatment identical to the RaCe (they are produced in
Switzerland by FKG) to reduce the presence of surface defects and
consequently improve resistance to cyclic fatigue, passive non-working tip,
triangular cross section in .04, .06 and .08 tapers and square in .02 tapers
(Fig. 3.105). The sequence includes the use of file #35.08 to eliminate
coronal interference, a mechanical glide path phase with instruments #10.02,
15.02 and 20.02 up to the apex, a canal shaping phase with files #25.06 and
20.06 brought up to the LL depending on the apical diameter.

Fig. 3.105Endowave (Morita, Japan).

Twisted file, literally tool created for winding, produced by

303

SybronEndo (Orange USA), has an innovative manufacturing process (see

Instruments for endodontic access) that eliminates the typical micromilling
cracks as well as a surface process called Deox which is supposed to seal
surface imperfections and increase the cut of the instrument. They have a
triangular section, a small handle of 11 mm, are made up of a handle-blade
monobloc, coils with variable pitch, non-working tip (Fig. 3.106). In addition
to #25 tools with a .04 taper,
.06, .08, .010 and .012 are present in the series on #30.06, #40.04 and #50.04.
Twisted files can be used at 450-500 rpm with crown-down technique or
single file technique.

Fig. 3.106Twisted Flex (SybronEndo, USA).

4S sequence(Komet, Germany), includes six instruments coated with

titanium nitride which improves the surface hardness of the Ni-Ti alloy and
which increases its wear resistance, with two sections alternating in the
sequence (rhombic and double S), non active or transitional, with a minimum
dimensional increase between the various instruments in the series, namely:
#15.03, #15.04, #20.04, #20.05, #20.06, #25.06. The sequence is completed
with flare instruments to eliminate coronal interference (#45.010 taper) and
FAF or Complementary Sizes which in sizes #30.02, #35.02, #40.04, #50.04
and #60.04 allow to prepare the apical area in all situations clinics (Fig.
3.107).
304

Fig. 3.1074S Komet (Komet, Germany).

Glide path tools

S-Apex, FKG(La chau de Fonds, Switzerland), starting from the assumption
that the majority of SRN fractures occur in the apical third of the canal, the
S(Safe)-Apex are created with a dual purpose: in the initial phase of shaping,
to widen the apical area up to a diameter greater than #20 before using SRNs
of larger tapers and diameters; at the end of the shaping, to shape the apical
part of the canal up to a diameter #35 or 40 without risking weakening the
tooth structure with more rigid instruments of greater tapering (Fig. 3.108).
Used for safe preparation of the last few millimeters of the canal, they protect
the SRNs from fracture and allow the SRNs to better maintain curvatures
(unpublished data). The S-Apex have the peculiarity of having a reverse taper
with a diameter in D1 greater than in D16 and a pre-established fracture point
near the handle; they can also be removed from canals if they fracture as
occurs with Gates burs. They exist in six diameters from #15 to #40 and have
an active portion of 16mm in length. They have a safety tip to avoid the
formation of steps and false paths and must be rotated at 600-800 rpm.
305

Fig. 3.108S-Apex (FKG, Switzerland).

PathFile(Maillefer, Switzerland), are instruments designed to perform a

mechanical pre-enlargement before shaping the canal with more tapered
instruments such as ProTaper or similar instruments. They can be 21, 25 and
31 mm in length, have a working surface of 16 mm, with a rounded tip,
square section design, tip diameters of #0.13, 0.16 and 0.19 mm respectively,
and a .02% taper. They must be used in increasing sequence, at a speed of
300 rpm, with a high torque of about 5.5 N/cm and with a slight back and
forth movement (Fig. 3.109).

Fig. 3.109PathFile.

Scout FKG files(La chau de Fonds, Switzerland), are #10 tip size
instruments with .02, .04 and .06 tapers for preparing canals prior to using the
rotary instruments selected for shaping.

Disposable instruments with reciprocating movement o

single file technique
This category includes the Reciproc-file and the Wave one, both built with
the innovative M-wire alloy, and the Saf file. The first two instruments are
the evolution of an idea published in the International Endodontic Journal by
Dr. Ghassan Yared (Ontario, Canada) who presented a clinical case made
with a single instrument, a ProTaper F2 (Maillefer, Switzerland), rotated in
alternating rotation. This type of movement, already studied in
306

passed by other authors, reduces excessive engagement of the instrument and

prevents its blockage inside the canal. In addition, single use avoids
sterilization, improves ergonomics and prevents cyclic fatigue fractures.
Reciprocating rotation increases the resistance to cyclic fatigue up to six
times [43]. However, reuse is not recommended.

Wave one(Maillefer, Switzerland), comes in three sizes: #21.06 (constant

taper), #25.08 and #40.08 (variable taper) in lengths of 21, 25 and 31 mm.
The course of the blades and the section are those of the ProTaper. It must be
used on a special micromotor which provides for a specific alternating
movement (Fig. 3.110).

Fig. 3.110Wave one (Maillefer, Switzerland).

reciprocal-file(Dentsply), comes in three lengths (21, 25 and 31 mm) and in

three sizes #25.08, #40.05 and #50.04, a handle of only 11 mm, non-cutting
point, with the section and pitch similar to the file Mtwo (see previous
paragraph), from the tip to the shank of the instrument the three dimensions
do not increase constantly but reach respectively the measure of 1.05, 1.10
and 1.17 mm (Fig. 3.111). It requires a special micromotor to control the
reciprocating movement which is characterized by a clockwise rotation angle
followed by one in the opposite direction but with a smaller amplitude,
specifically designed for Reciproc-files.
307

Fig. 3.111Reciproc (VDW, Germany).

Saf fileis a hollow Ni-Ti instrument (Fig. 3.112), compressible, completely

different from the previous ones. It is a tool that has the characteristic of
shaping and cleansing the canal at the same time. It exists in lengths of 21, 25
and 31 mm in length and in two diameter sizes, 1.5 and 2 mm, which can be
used after carrying a size 20 and 30 hand K-file respectively. The tool does
not rotate in traditional way but works connected to a vibrating handpiece
(500 vibrations per minute) under constant passive irrigation (from 1 to 10
mL per minute).

Fig. 3.112Saf (Self Adjusting File, ReDent Nova Ltd., Israel).

308

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311

Micro-endodontics: basics of ergonomics

M. Rigolone

Introduction
Ergonomics (or human factor science), as defined by the IEA (International
Ergonomics Association) in San Diego in 2000, is the discipline that deals
with the design of products, environments and services that respond to user
needs in order to to improve human safety, health, comfort, well-being and
performance. It is an interdisciplinary science that concerns engineering,
anatomy, biology, physiology, psychology, biomechanics, sociology, the
work environment, etc.: it integrates the concepts and knowledge that each
discipline can put available individually.
The objective of ergonomics consists in the application of theories,
principles, data and methods with the ultimate aim of optimizing human well-
being and the overall performance of the man-machine-work system, i.e. it is
the science that deals with the study of the interaction between individuals
and technologies, making it possible to improve the quality of living
conditions, in all work and non-occupational activities [1,2].
The term ergonomics derives from the Greek words érgon (work) and ńomos
(rule, law) and was used for the first time by Wojciech Jastrze bowski in a
Polish journal in 1857 [2,3], then taken up again in 1949 by the psychologist
KFH Murrell , who wanted to give the term a new multidisciplinary design
approach which had the aim of protecting the safety and well-being of people
in the workplace [4]. This concept was substantially based on the idea that
the central element from which to start the design process of more or less
complex machines must necessarily be man (concept of adaptation of the
machine to man). This new conception of ergonomics was essentially based
on the desire to increase the efficiency of human activity while minimizing
the costs deriving from inefficiency and physical incapacity,
One of the principles on which ergonomics is based is the simplification of
work
312

(work simplification) to improve the efficiency of any operating system,

through an accurate observation and analysis of times and movements [6].
The dental field cannot be an exception and must submit to ergonomic rules,
in order to optimize the man-machine-work environment system, to allow the
reduction of physical and cognitive stress and thus prevent related
occupational diseases, i.e. allowing operators to express their professionalism
in the most comfortable and least disabling way over time and increasing
productivity in both a quantitative and qualitative sense [7].
Comes et al. indicate, as already done in the 60-70s by authors such as
Kilpatrick, Schon and Kimmel, Gall, the ways to economize movements and
simplify work in dental medicine [2,8].
Ergonomics therefore seeks to identify the most important parameters to
eliminate negative factors and make each action to be performed in the
workplace easier and more natural.
These negative factors can be found both in the machine, with which the
individual is in contact (for example the poor readability or too high reading
speed required by the instruments), and in the environment, where noise,
vibrations, heat, light, colours, smells can distract, annoy, ruin the sense
organs and, finally, decrease the intellectual capacities of the operator. This
discipline also studies the optimal levels, tolerability and wear and tear of
human organs and systems over time, in order to establish the criteria on the
basis of which to adapt, as far as possible, machines and the working or non-
working environment.
Once all these parameters have been obtained and evaluated, it will be
necessary to take into consideration the movements that the limbs can
perform and among these to evaluate which ones are the most natural, i.e.
those that produce the maximum performance with the minimum effort and,
if more than one limb is used in an action , which ones are more compatible
with the action itself.
The fundamental parameters that should be considered in ergonomic planning
in the dental workplace are mainly:
● individual capabilities;
● psychophysical limits;
● factors that can generate errors;
● working team;
313

● management.
Ultimately, these foundations should ensure that the final result is achieved in
an analogous and similar way by different operators, who have equal
experience and equivalent times and methods employed. However, it must be
pointed out that when working in the healthcare field, all these concepts must
be integrated with other variables which, at times, can modify the result
itself: the difficulty of the clinical case, the therapeutic possibilities and the
operational potential, linked to the single operator, to the working team, the
technology used, the patient's conditions.
To obtain a satisfactory result in the construction of an optimal ergonomic
project, it is necessary, albeit didactically, to divide the concepts of general
ergonomics into three essential principles, as reported by some authors [6,9]:
● concept of operating procedure;
● principle of economy of movements;
● elementary or standard movements.

Operating procedure
An operating procedure is defined as any task performed by a single operator
or by a work team. In the field of dentistry, any service that is provided to the
patient is considered such, i.e. a conservative, endodontic, surgical treatment,
etc.
Each operating procedure can be simple or complex, but in any case it can be
broken down into three basic phases:
● preparation;
● execution;
● tidy up.

Only the second stage, i.e. the execution phase, can be defined as productive,
while the other two phases are substantially dispersive and only add costs to
the service provided and do not determine an increase in value of the same
[10,11].
The analysis of the operating procedure can be carried out in a simple way,
evaluating four essential parameters [6]:
● removable steps,the evaluation must be carried out without compromising
the quality of the result, the quality of the work of the operators
314

and/or security;
● substeps that can be simplified,to reduce production times and costs and
increase the effectiveness of operational movements, as well as increase
the degree of safety;
● equipment and/or instrumentation,which can be added or combined, to
increase the value of the result, to improve the working capacity of the
operator and/or the team as a whole, to reduce production times and costs,
as well as to increase safety;
● changes to the layout of the plan and/or work environment,in order to
improve efficiency, eliminate interference and/or improve security.
As can be seen, the common denominator of all these parameters is safety, a
fundamental concept that permeates the entire ergonomics discipline, taken
up and codified by Legislative Decree no. 626, introduced in 1994 to regulate
safety in the workplace. Currently the Legislative Decree n. 626/94 was
completely transfused into the so-called Consolidated Law on Work Safety
(Legislative Decree 81/2008), which was in turn subsequently integrated by
Legislative Decree no. 106 of 3 August 2009 containing supplementary and
corrective provisions (Official Gazette no. 180 of 5 August 2009 – Ordinary
Supplement no. 142). The rules contained in the so-called corrective decree
entered into force on 20 August 2009.

Movement economy
Movement economy is defined as the least expensive way in terms of space-
time to carry out one or more elementary movements [12].
To make an operating procedure more effective, it is therefore necessary to
evaluate some basic concepts, among which we can include:
● the elimination of useless movements, reducing their number to the
minimum possible;
● the execution of elementary movements in a short time;
● the execution of elementary movements with limited spatial extensions;
● the realization of movements in the most rectilinear way possible;
● coordination of movements with both hands;
● the optimal organization of the work field in order to avoid movement
arrests and/or uncertainties (everything within easy reach);
● the optimization of the workplace in order to make it more
315

comfortable (by position, posture, disposition, team work);

● ambient and operating field lighting suitable for the work to be performed
and to avoid eye fatigue and/or incorrect postures;
● the limitation of movements of the head and the glasses
minimumindispensable, especially in
the working team.
These concepts have been studied to speed up the performance to be provided
to the patient, thanks to the reduction of operating times and superfluous
spaces, as well as to reduce the stress of the operators and give greater
fluidity to the operating procedure as a whole.

Elementary or standard movements

Elementary movements are defined as all the simplest actions which, taken as
a whole, make up an operating procedure.
Reference is generally made to the Work-factor method [13], which is the
most complete and precise procedure for studying working times.
The elementary movements according to the Work-factor system are
essentially eight and are reported inFigure 3.113.
316

Fig. 3.113Elementary movements. (From: Guastamacchia, 1990; modified.)

It is easy to understand how the elementary movements are very different

depending on the instrumentation used, its spatial location, the materials
used, etc.

Work-related damages
Dentistry is a profession in which clinical performance takes place in
317

a rather narrow area: the mouth. This statement, albeit trivial, explains how
the movements that must be performed by the operators have very specific
characteristics, in terms of forces to be exercised, minimal distances to travel,
repetitive movements to be carried out, precision to be applied.
Therefore, the various clinical situations presented to the operator can cause
various types of stress which sometimes take on physical, sometimes even
mental contours. These stresses are recognized as the origin of a series of
work-related pathologies, now well known to operators in the sector [14,15].
All these occupational issues should be known and taught right from the
university training period, where the student begins to become aware of the
incorrect behaviors in posture and/or in the ergonomic approach that dental
work entails, with the awareness that all this can determine, in the future
career, notable physical and mental inconveniences.
Scientific evidence shows that in carrying out clinical activities, starting from
the academic period, malpositions or bad habits are acquired which will be
consolidated and worsened over the entire duration of the working life.
All the risks associated with the dental profession can be summarized inTable
3.6 and inFigure 3.114.

Tab. 3.6Risks related to the dental profession

318
319

Fig. 3.114Incidence of the main occupational pathologies in dental operators. (From: Comes
et al., 2008.)

Musculoskeletal disorders
Dental operators, whether they are dentists, hygienists or dental office
assistants, must assume, during clinical manoeuvres, often forced static
postures, or forced positions. Said operators work assuming postures that
expose them to long-lasting static muscle loads that can cause
musculoskeletal disorders and, ultimately, trigger the "pain" symptom.
In order to underline the importance that musculoskeletal disorders (MSDs)
linked to work in the dental field can assume, it is enough to think not only of
the suffering they can cause to professionals in the sector, but also of the cost
paid to society through lost productivity, as well as increased use of medical
and social services [16]. A Spanish study has shown that out of a sample of
74 dental operators, 15% were absent from work due to musculoskeletal
problems, while 12% had to resort to non-steroidal anti-inflammatory drugs
(NSAIDs) [17].
According to some studies carried out in different countries, the cost to
society related to the development of DMS could be estimated at around 2-
14% of GDP [18,19].
ThereTable 3.7 expresses, through an examination of the literature, the
importance that MSDs can assume towards the operators of the
320

sector.

Tab. 3.7Musculoskeletal disorders seen in dental

professionals (%)

Prolonged efforts on the muscles of the neck, back and shoulders have been
frequently reported by operators in the dental sector as responsible for work-
related pain and consequent abstention from work [20-22].
Therefore, the identification of postural inadequacies by dental workers is
important, so that this can be of help in the prevention and/or reduction of the
physical consequences during the dental operation over time [23,24].
Examples of the most commonly reported musculoskeletal pathologies are
back pain, neck pain, neck pain and shoulder tendonitis. Musculoskeletal
pain, in particular that located in the back, has been extensively investigated
at a scientific level and identified by occupational medicine as a significant
problem for operators in the
321

the dental sector, considering how everything can be traced back to incorrect
and mostly static postures, the maintenance of forced positions for a long
time, the use of extremely precise movements of the hand and wrist, the lack
of ergonomic planning of the surrounding environment, the incorrect
arrangement of equipment and materials in space etc. [14,15,20,25-38].
However, most of the studies carried out consider only some of these risk
factors as simultaneous causes [39,40], thus constituting a confounding
factor, which makes it difficult to evaluate the real impact that specific risk
factors may individually have on health of the working subjects.
Some researches have ascertained how MSDs in dentistry have assumed a
substantial contribution in determining absences from work due to illness,
reduced productivity, as well as abandonment of the dental profession, with
consequent huge economic losses [14,16,41].
MSDs are often caused by excessive (overuse) or inadequate (misuse) use of
articular or muscular portions, continuous stress and/or trauma affecting both
hard and soft tissues, in particular muscles, tendons, ligaments, cartilage,
joints and blood vessels, resulting in pain affecting various body regions
[178]. Other Authors attribute the greatest MSD risk to work positions
[20,46-48]. Particular attention must be paid to the incorrect positions
assumed by the operator and/or the patient [28,43,49], especially in situations
deriving from the continuous attempts that the dental operator makes to seek
work with a direct view of the operating field (Fig. 3.115) [43,49,50].
322

Fig. 3.115Incorrect positions mostly found in dentistry.

Furthermore, considerable difficulties derive from rotations and flexions of

the cervical portion of the spine, from flexion at the level of the elbow and
from rather energetic gripping movements made with the hand [51].
Neuropathy in the hand has been reported following the use of high-
frequency vibration equipment [52-55]; however, the causal mechanisms
have not yet been well understood and, moreover, it remains to be clarified
whether it is the vibration itself or the repetitive use of such tools that entails
the real risk of injury [45].
Recent reviews of the literature show that the prevalence of AMD in dental
operators is comprised in a variable range between 54 and 93% [45,55-59].
Female dentists generally report more severe symptoms and report more
frequent pain and headaches (Fig. 3.116) [60].
323

Fig. 3.116Comparison of headache symptoms in dentists interviewed by gender (n = 355).

(From: Marshall et al., 1997.)

It is now known that unfavourable, or rather incorrect and often

uncomfortable working positions can generate high static loads prolonged
over time which develop in different parts of the body due to an increase in
muscle tension and, ultimately, can create discomfort musculoskeletal or
fatigue of some areas, such as the neck, shoulders and back [16,20,44-
46,48,50,54,55,61-68].
A curious fact is the finding of a higher prevalence of MSDs in these districts
in younger and less experienced operators, compared to older colleagues [69].
A possible explanation could derive from the ability that expert operators
have developed in using effective strategies to adjust their posture and related
work techniques, in order to minimize pain or to be able to live with said
symptoms for a longer time ( compensation situation) [14]. Another reliable
hypothesis could be found in the withdrawal from the profession of older
operators with musculoskeletal problems and their consequent exclusion
from statistical analyzes [50].
The time factor also seems to be an important variable in the development of
DMS; in fact, longitudinal studies have revealed that in dentistry the risk is
greater the longer the period of work is, compared to other professions [50].
Furthermore, it can be demonstrated that working for a long time without
breaks and/or with insufficient breaks during the working day correlates with
the development of MSD [16,27,60,62,66].
According to the guidelines cited by Hurutunian, professionals who perform
324

repetitive movements should schedule at least 6 minutes of rest for each

working hour [17].
Furthermore, a Swedish study demonstrates how the development of MSDs
can be more predictable based on the number of hourly services and the
accumulation of weekly hours performed, given that this can be modified in a
pejorative sense if the work is performed by a "single" operator (to be
understood without assistance) [177].
Among the causes responsible for the development of MSDs is psychosocial
stress [33,44,70,71], while other studies relate emotional problems
(emotional symptoms) and work-related and/or non-occupational stress with
the consequent increase of pain symptoms [44,71-78].
It is now known that the relationship between the patient and the dental team
is physically and psychologically demanding. Time constraints and
unexpected procedural problems often add stress to the clinical environment.
Therefore, the persistence and aggravation of musculoskeletal symptoms
could be connected to a series of physical factors (for example, repetitive
movements, incorrect posture, joint fixity, incorrect positions), but also to
mental stress which, ultimately, could aggravate the pre-existing pain,
making it worse during the execution of the procedures, until triggering a
redundant effect, in a pejorative sense, within the musculoskeletal stress-pain
system [77].
Westgaard demonstrated how stress of various origins can cause muscle
contraction and consequent pain, especially in the trapezius muscle [79].

Postural biomechanics and DMS

In the literature it has been highlighted how dental operators are often
exposed to high muscle tensions which are concentrated in a particular way
in the trapezius muscle, in a bilateral sense, due to the bending of the head
forwards, for a prolonged time [80].
In an observational study, conducted in the USA, the operative time was
evaluated in which dentists and hygienists kept both the trunk and the
cervical portion in flexion with curvatures varying between 30° and 60°
(Figs. 3.117 And3.118). TheFigures 3.119And3.120make it clear that, about
86% of the time, these professionals were subjected to considerable tension
[20]. All
325

this is in agreement with what is already present in the literature and could
explain the degree of pain in the spine, reported by the subjects interviewed
[22,81,82].

Fig. 3.117Trunk inclination.

Fig. 3.118Inclination of the cervical portion. Grade 0 is considered when the neck is in line
with the trunk.
326

Fig. 3.119Percentage of work time in which dentists and hygienists exhibit varying degrees
of trunk flexion. (From: Marklin and Cherney, 2005.)

Fig. 3.120Percentage of working time in which dentists and hygienists exhibit various
degrees of flexion of the cervical portion. Grade 0 is considered when the neck is in line with
the trunk. (From: Marklin and Cherney, 2005.)

However, there are no significant findings correlating the degree of curvature

of the cervical spine and the intensity of perceived pain
327

[83].
TheFigures 3.121 And3.122, on the other hand, quantify the operative time in
which the shoulders, right and left, respectively, are maintained at a certain
degree of abduction; that is, it has been demonstrated that the left shoulder
remains raised and/or abducted for more than 50% of the performance in
dentists and 45% in hygienists, while, as regards the right shoulder, only 25%
and 34%, respectively, in the observation period.

Fig. 3.121Percentage of time dentists and hygienists work with the right shoulder at different
angles of elevation (in degrees). Grade 0 is considered when the arm is placed at the side of
the trunk. (From: Marklin and Cherney, 2005.)
328

Fig. 3.122Percentage of time dentists and hygienists worked with the left shoulder at
different angles of elevation (in degrees). Grade 0 is considered when the arm is placed at the
side of the trunk. (From: Marklin and Cherney, 2005.)

The difference in the angle of abduction between the right and left shoulders
seems to be due to the concept of dominance of the hand in the operators
interviewed. In fact, for right-handed people, the typical working position
involves the left shoulder being raised and the right shoulder being lowered,
in order to keep the right arm closer to the trunk. A considerable muscle-joint
mechanical disadvantage is thus produced, which translates into a greater
demand for muscle forces to statically maintain said positions and consequent
development of high loads and compressions on the joint structures.
Ultimately, this decompensation can lead to the so-called shoulder rotator
cuff syndrome, as well as muscle pain, even of a certain importance, located
in the shoulders and various portions of the neck and back.
As previously seen, to carry out the various clinical services, operators in the
sector must necessarily assume forced static postures and maintain them for a
rather prolonged period (PSP, Prolunged Static Postures). In this way, muscle
imbalances, joint hypomobility, nerve compression, degeneration and
herniation of the intervertebral discs, ischemia of muscle tissues, or rather
329

situations that can result in tissue necrosis with hypofunctionality of some

musculoskeletal districts [16,31,38,84,85]. ThereFigure 3.123reports the
pathogenesis of PSP that can evolve through the pain symptom and lead to
MSD [38].

Fig. 3.123Pathogenic progression from prolonged static posture to musculoskeletal disorders

[38].

For example, due to PSP, dentists tend to lose the flexibility of the neck
muscles responsible for the inclination of the neck.
330

head in the opposite direction to that normally taken during the entire
working day [86].
Frequent breaks, short stretching sessions and inversions of posture between
one work session and another can prevent work-related problems, helping to
better face daily clinical activity [16,38,87]. In fact, all this leads to an active
recovery of the muscular and neurological structure with an increase in blood
flow and with a consequent greater supply of nutrients and removal of
harmful catabolites, as well as a better restoration of damaged structures and
reduction in the formation of muscle contractures. In this way, in fact, it
converges towards the maintenance of normal joint motility, an improvement
in muscular and neurological performance, or rather an active form of
prevention against work accidents is constituted. ThereFigure 3.124shows
some stretching exercises that can be performed in the studio, during breaks
during the working day.
331

Fig. 3.124Stretching exercises during breaks in operational activity. These exercises are
intended for right-handed operators. For left-handed people they must be evaluated in order
to adapt them to their posture and make them more effective. (From: Valachi, 2003; Sarkar,
2012; modified.)

In order to better understand the extent of the posture-ergonomics problem

and the development of ergonomic lesions in the dental field, it is necessary
to resort to physics and biomechanical engineering, which explain how in a
balanced system (neutral or balanced system) it is possible develop a
rotational force, or torque (force couple), when
332

said system is placed in a condition of decompensation (unbalanced system)

(Fig. 3.125).

Fig. 3.125Representation of a balanced physical system.

According to a study published online [88], the human head weighs on

average between 4.5 and 5 kg, making up about 8% of the total weight of the
entire human organism (4, 98 kg in women, 6.35 in men).
In the literature it is reported how the weight of the human head increases due
to the forward movement; that is, for each inch (1 in = 2.54 cm) of
advancement of the head there will be an increase equal to approximately 10
pounds (1lb = 453.59 g). All of this results in an increase in the strength
needed for the muscles to workcervical spine can support the head in an
unbalanced spatial position (Fig. 3.126) [89].
333

Fig. 3.126Head weight. Due to the force of gravity, the muscles of the cervical portion of the
column are subjected to constant tension to support the weight of the head, in order to
prevent it from falling on the sternum. For every inch (1 in = 2.54 cm) of forward movement,
the weight of the head, which rests on the neck muscles, increases by about 10 lb (1lb = 0.45
kg) [89].

Assumed, consider the human body in a neutral position similar to an

experimental system consisting of a bowling ball inserted on a series of bars
connected with single degree of freedom hinges (Fig. 3.127).
334

Fig. 3.127Balanced system applied. The operator sitting in rest position. Next you can see
the experimental system made up of bars connected by hinges with a single degree of
freedom, to the end of which a bowling ball has been fixed to simulate the weight of the
operator's head.

Now tilt the head forward, on the sagittal plane, at an angle of 45° and keep it
for 10 minutes, making the fulcrum at the level of the transition area between
the cervical spine and the thoracic spine (shoulder height). In this way a
torque equal to 8.89 Nm is developed (Fig. 3.128a), i.e. the neck muscles
require a force equivalent to that required by the biceps muscle to be able to
lift a dumbbell weighing approximately 9 kg 92 times (Fig. 3.128b).
335

Fig. 3.128(to)45° unbalanced system. The operator is seated in the working position with an
inclination of the head-neck system equal to 45° with the fulcrum at shoulder height. By
formulating the force (F) and the distance (d) between the fulcrum and the point of
application of the force itself, we obtain the torque (Ω) to which the cervical muscles are
subjected to counterbalance the hypothetical fall of the head forward. (b) System unbalanced
at 45°. The effort made by the cervical muscles to keep the head at a 45° inclination for about
10 minutes is equivalent to the force developed by the biceps during the curl-dumbbell
exercise, performed with a 20 lb (9.07 kg) dumbbell repeated 92 times . (From: [88];
modified.)

If, on the other hand, the trunk is inclined forward by 30°, with respect to the
vertical, on the sagittal plane, making the fulcrum at the level of the hips, and
maintaining this position for 10 minutes, an effort will be developed at the
level of the lumbar muscles equal to 25 .24Nm (Fig. 3.129a), equivalent to an
exercise of lifting a dumbbell of about 9 kg repeated 266 times (Fig. 3.129b).
336

Fig. 3.129(to)30° unbalanced system. The operator is seated in the working position with a
trunk inclination of 30° with the fulcrum at the height of the femoral joint. By formulating
the force (F) and the distance (D) between the fulcrum and the point of application of the
force itself, we obtain the torque (Ω) to which the lumbar muscles are subjected to
counterbalance the hypothetical fall of the trunk forward. (b) System unbalanced at 30°. The
effort made by the lumbar muscles to keep the trunk at a 30° inclination for about 10 minutes
is equivalent to the force developed during the execution of the curl-barbell with a 100 lb
(45.36 kg) barbell repeated 53 times (From: [88]; modified.).

All this makes it clear how it is necessary to make ergonomic changes in the
operating environment, in order to be able to remedy the incongruous
working session podurature that can often extend over time.

Ideal posture
Attention and awareness of MSDs in the dental profession have increased
significantly in recent years. A large amount of studies on ergonomics and
new technologies that can be integrated into the modern dental practice have
been developed in the last decades. It must be considered that technological
innovations and continuous posturological modifications aim to give the
dentist, and other operators in the sector, greater comfort and better health
(work in a seated position, modification of the patient's position, 4-handed
work) [ 90]. In dentistry it has been possible to witness a further upheaval in
the ways in which to deal with daily operations with the advent of new
concepts
337

postural, such as for example the one defined as proprioceptive position (Pp)
[91,92].
The idea of a posture that could have a proprioceptive derivation was
developed by Dr. Daryl R. Beach who, at first, defined it as performance
logic [92,93]. The primary objective of this concept is to provide dental staff
with good posture that can ensure optimal balance control while performing
their duties in the chair, so as to minimize the musculoskeletal discomforts
that may arise. . This posturological idea sees as basic the figure of the dentist
sitting erect, with both hands at heart level, able to easily reach all the
necessary equipment and materials (ergonomics of movements), while the
patient is necessarily placed in a position horizontal (Figs. 3,130-3.132). The
operator is therefore in a favorable position, in full comfort and is encouraged
to maintain this posture with maximum balance and comfort.

Fig. 3.130Dentist in working position. According to the concept of the proprioceptive

position, the operator is seated on a stable armchair with his feet flat on the floor, so as to
form a tripod on which to base his postural balance. The arms are parallel to the axis of the
trunk and close to it, while the hands are kept at heart level. The patient is in an almost
horizontal position. (From: [93]; edited.)
338

Fig. 3.131Ergonomics of movements. Single operator at workstation positioned correctly

from a postural point of view (balanced, poised and in comfort), able to easily reach all
necessary equipment and materials. (a) Top view. (b) 3D perspective view.

Fig. 3.132Ergonomics of movements. Dental Team in workstation in correct position from a

postural point (subjects balanced, balanced and in comfort). All operators are able to easily
reach the necessary equipment and materials. (a) Top view. (b) 3D perspective view.

In other words, the Pp concept includes a reasoning system that dentists are
called to implement in determining the working position they feel is the most
comfortable and in modifying it, based on awareness of the environment and
working conditions. It remains obvious that all this can be extended to other
operators in the dental sector, such as hygienists and practice assistants.
This principle allows dental workers to implement a whole series of strategies
to help them seek and maintain the best and ergonomically most effective
posture, through an optimal and
339

meticulous control of balance, which must develop throughout the duration of

the work session [91,92,94,95].
It should be noted that the musculoskeletal pathologies of dental operators are
not caused only by incorrect behavior and/or posture, but above all by
permanence in static positions for a prolonged time [16]. All this can lead,
over time, to musculoskeletal, tendon and joint alterations, which can often
combine and/or cause, in turn, neurological pathologies and visceral disorders
of various kinds. Therefore, as we have seen, there is no ideal or best posture,
but only worse postures [6].
In fact, the so-called rigid fixity can ultimately lead to joint problems and
MSDs, particularly affecting the spine [30,96].
Dental operators must therefore seek the most balanced and comfortable
position possible, in order to optimize the various operating procedures,
trying not to become fossilized in the assiduous search for what, erroneously,
is considered the ideal posture to maintain throughout the clinical activity .
Once the operator is comfortably seated, the patient's oral cavity induces all
the postural adjustments and modifications that develop during the entire
duration of the appointment, in order to allow the maintenance of a balanced
position to be able to work more accurately and more efficiently [93].
Therefore, the ideal posture is nothing more than the position that the
operator reaches through his own proprioceptive perception, which he
implements both consciously and completely involuntarily [97].
Posturology applied to the dental sector is certainly a subject that many
researchers have taken into consideration and analyzed in a rather in-depth
way [16,50,66,86].
It has been observed that dentists prefer to work in a seated position with
percentages ranging between 78 and 100% of the time dedicated to patient
care (Fig. 3.133) [20,27,66,93].
340

Fig. 3.133Percentage of time dentists adopt the sitting position. Comparison between various
authors.

However, it has been ascertained and demonstrated that dentists who work
only in a seated position are more subject to severe low back pain than those
who alternate sitting with orthostatic work [16,65]. Regarding the working
position in relation to the patient's mouth (clock-related working position)
(Fig. 3.134), it is reported in the literature that 67.9% of dentists use a
position between 10 and
12 [98], with a preference for the position at 10 o'clock (80%), while a
minority work at 9 o'clock (10%) or at 11 o'clock (10%) [93].
341

Fig. 3.134Clock-related working position. The patient's mouth is taken as the point of origin
(center) of a circle and the working positions of the dentist and other team members are
described according to a clock face; consequently at 12 o'clock corresponds a dental operator
sitting behind the patient's head.

Finsen et al., in their Danish study [27], found that approximately 50% of
dentists use the 10 o'clock position as the most common, followed by the 11
o'clock and finally the 9 o'clock position. Rundcrantz et al. instead they found
that the 9 o'clock position is the most frequently adopted in the treatment of a
patient [66].
Contrary to what has been reported so far, all the dentists who have used the
Pp concept have worked in the 12 o'clock position for most of the time: the
probable reason is to be found in the guidelines that are found at the basis of
the concept itself [93] .
Another interesting aspect, which can be combined with the use of correct
positions and postures from a proprioceptive, balance and comfort point of
view, is that deriving from the concept of dynamic position, decidedly
advantageous from an ergonomic point of view, as reported from numerous
studies [27,84,99].
This principle consists in the continuous modification of the posture during
the course of a working session, maintaining it in a correct and balanced area.
All this means rather frequently shifting the load from one muscle group to
another, with the ultimate aim of preventing the susceptibility of the dental
worker to develop musculoskeletal lesions in a given body sector
[27,84,99,100].
The results of these studies look quite encouraging and should
342

be increased and updated in the light of new technologies introduced in the

dental field, such as the use of magnifiers (loupes) or better yet the operating
microscope.
For example, it is possible to consider a common error among operators in
the dental sector that of placing the operating field (the patient's oral cavity)
in a too high position, i.e. maintaining a decidedly reduced
eye-operator/mouth-patient working distance. This necessarily causes
excessive lifting of the shoulders and arms, resulting in prolonged static
tension of the neck and shoulder muscles with the development, over time, of
pain and MSDs.
The use of magnifying systems, on the other hand, allows operators to
maintain an adequate working distance associated with a more relaxed
posture, i.e. positioning the operating field (the patient's mouth)
approximately at the height of the operator's elbows, the forearms are
approximately parallel to the floor (or at an angle of about 15-20° with
respect to the horizontal plane), the arms placed vertically andclose to the
bust and consequently shoulders and neck in a neutral position (Fig. 3.135)
[101].

Fig. 3.135Dental team in operating position with operating microscope. The use of
magnifying systems, on the other hand, allows operators to maintain an adequate working
distance associated with a more relaxed posture.

From theFigure 3.135Furthermore, it is possible to consider how the use of

magnifying systems imposes a rather obligatory posture on the dental worker,
which does not allow any type of torsion in the planes of space of the various
body portions, which would otherwise cause muscle imbalances and/or tissue
damage and structural, resulting in low back pain of various
343

degree [102,103].
It is important to underline how operators in this sector must become aware
of the problems exposed so far and learn to integrate the various strategies
necessary to obtain a more ergonomically acceptable type of work in order to
maintain a state of health, in order to increase productivity, provide safety on
the work and prevent MSDs for a longer and more comfortable career [101].

Ergonomics in microscopic dentistry

The introduction of magnifications in dentistry (Surgery or DentalOperating
microscopes, magnifying glasses or dental loupes and helmets) (Fig. 3.136)
has significantly improved the visualization of the field procedure, postural
habits and, ultimately, the productivity of dental operators [104].
344

Fig. 3.136Operating microscope (a) and magnifying glasses (b).

The operating microscope has been introduced in the medical field since the
1950s, when it was introduced in otorhinolaryngology and ophthalmology
[105,106]. Around 1960 he entered neurosurgery, where his greatest
expansion took place, which was followed by various medical-surgical
disciplines, including urology, andrology and general surgery, limited to the
reattachment of limbs and extremities amputated in accidents [81,107-113].
In the 1980s and 1990s, the operating microscope was also introduced in the
dental field, thanks to Apotheker, who modified the Medical Operating
Microscope for mainly endodontic use [105,114]. In 1995, the AAE
(American Association of Endodontists) formally recommended to the
Commission on Dental Accreditation the introduction of training in the use of
the operating microscope for the new Accreditation Standard for Advanced
Specialty Education Programs in Endodontics. Since January 1997, all post-
graduate courses for endodontists to be held in the USA require specific skills
in the use of the operating microscope and must necessarily include adequate
training [106]. In subsequent years,
However, it finds a leading role in orthograde endodontics, portrait dentistry,
surgical endodontics, periodontology, periodontal plastic surgery [120-
124,126-138].
In a 2007 study of 2,340 AAE members, it was observed that the use of the
operating microscope increased from 52% in 1997 [139] to about 90% in
2007 (Fig. 3.137) [140].
345

Fig. 3.137Increase in the use of the operating microscope in the period 1999-2007. (From:
Kersten et al., 2008; Mines et al., 1999.)

To understand how important the ergonomic aspect of working with

magnifications is, first of all we must evaluate the average time dedicated to
the use of the microscope in the various endodontic procedures (Fig. 3.138).
It is evident how, for non-surgical procedures, 27% of the participants in the
survey indicated that they only used the operating microscope for 25% of the
procedure. However, another 25% of those interviewed stated that they use
the loupe for the entire duration of the performance. As far as surgical
therapies are concerned, however, it is evident that 24% of the respondents to
the questionnaire use microscopy for 75% of a surgical intervention and 21%
for the totality of the treatment [140].
346

Fig. 3.138Extremely variable percentage of use of the operating microscope during the
operative phases in both orthograde (non-surgical) and surgical endodontics. For example,
during an orthograde procedure, one in four dentists said they only used the operating
microscope 25% of the entire procedure, while only a quarter of survey participants said they
used the microscope the entire time. of the intervention. (Kersten et al., 2008.)

It is therefore important to evaluate how, from an ergonomic point of view, it

emerges that the forward movement of the head should not exceed 20-25°
during operation, as postures with higher degree neck flexion have been
associated, by various Authors, to situations generating pain and MSD
[84,104,141].
Branson, in an observational study conducted on students of the Dental
School of the University of Missouri-Kansas City, highlighted the adoption
of more ergonomically correct postures when the subjects used magnifying
devices, rather than those assumed during work with normal protective
glasses [63]. . A similar result was also achieved by Maillet et al. in a study
of dental hygiene students at Dalhousie University [142].
Well-adjusted magnifiers, therefore, can modify both the posture and the
position of the operators during the procedures, with consequent ergonomic
improvement of the working modality of each member of the team [143].
347

The ++ are the magnifying devices most frequently used by dentists today.
They offer a 2- to 5-fold image increase.
From a study carried out in 2003 it is interesting to note how ergonomics and
the improvement of posture were the main drivers to encourage the purchase
of these magnifying devices, but only for 21% of dental operators. However,
of those who said they had not purchased any magnification, approximately
50% incorrectly claimed that they had better vision with the naked eye [144].
It is obvious that the correct design of the device, the correct assembly of the
lenses and above all their optical qualities must be considered as essential
requirements to optimize the influence of magnifiers on vision and posture, in
order to avoid the risk of future eye problems [145].
According to Sunell [146], in order to adopt a magnification system and/or
lean towards a specific typology, some considerations should be made:
● establish the ideal posture with which the operator must work;
● choose the appropriate degree of magnification for the operation to be
performed;
● evaluate the dimensions of the operative field;
● consider the need and degree of illumination of the area to be observed;
● determine the optimal working distance;
● opt for any need for documentation
(camera,video camera etc.);
● decide the best structure of the operating team:
● individual or team work;
● number of assistants;
● off-screen assistants;
● use of the co-observer;
● posture of the operators;
● position of the operators in relation to the field of intervention.

One of the most important parameters to evaluate, according to the

ergonomic point of view, is certainly the working distance, the determination
of which must be particularly accurate.
In order to better understand its importance, it is first of all necessary to know
its precise definition and the detection method: it can be considered as the
distance between the front of the eye of the
348

clinician and the patient's central incisor (Fig. 3.139).

Fig. 3.139Naked eye working distance. It is calculated as the distance between the operator's
eye and the patient's upper central incisor.

Due to anthropometric differences, taller individuals generally require a

greater working distance than shorter operators [147].
According to Valachi, the working distance can be between approximately
355.6 mm (14 inches) and 508 mm (20 inches): distances that are too short
can lead to excessive curvature of the spine and anomalous postures from an
ergonomic point of view, while excessive distances they can cause excessive
stretching of limbs and musculoskeletal structures [148].
Therefore it can be asserted that an incorrect assessment of the working
distance can cause postural disturbances and consequent MSDs, which,
ultimately, translate into symptoms and pains of various entities, up to the
achievement of a reduction or an abstention from the activity clinic
[14,16,20-22,41].
The introduction of the operating microscope changed the definition of the
operating distance, describing it as the space between the objective lens and
the field to be observed. It is nothing more than the focal distance of the lens
of the magnifying system (Fig. 3.140).
349

Fig. 3.140Working distance with operating microscope. It is calculated as the distance

between the operating field to be observed and the objective lens of the magnifying system.

Kersten has highlighted how operators of shorter stature make use of the
operating microscope more frequently than their taller colleagues [140].
A Japanese study related the height of the operator and his posture when a
loupe is used, in order to maintain an ergonomically comfortable and
practical posture (Fig. 3.141;Tab. 3.8And3.9) [147].

Fig. 3.141Posture of the operator under the operating microscope. Lines and glides are shown
350

angles used to evaluate the position of the operator based on his height: the axis of the
binoculars (A) in relation to the floor surface (reference plane) and relative angle of
inclination (α), the axis of the body of the microscope (B) which forms an angle (β) with the
reference plane (D), the normal to the mirror surface (C), which forms an angle (μ) with the
reference D. The picture shows the observation of the maxilla − see C-axis direction (mirror)
(From: [147]; modified).

Tab. 3.8Tilting the operating microscope and mirror for

viewing the maxilla*
Tilt of the Operating Inclinationo
binoculars (α) microscope tilt f the mirror
(β) (μ)

Group S 183.1 ± 4.6 93.8 ± 2.8 37.8 ± 3.8

(1,550mm)
Group N 172.0 ± 5.5 94.2 ± 3.1 40.8 ± 2.3
(1,680mm)
Group T 169.0 ± 5.0 91.3 ± 4.7 37.6 ± 2.7
(1,810mm)
*The angles were measured using the floor plane as a reference in a counterclockwise
direction. The objective lens used on the operating microscope is 250 mm [147].

Tab. 3.9Inclination of the operating microscope and

mirror for observation of the lower jaw*
Tilt of the Operating Mirror angle
binoculars (α) microscope tilt (μ)
(β)
Group S 182.6 ± 3.9 91.1 ± 4.7 121.7 ± 3.3
(1,550mm)
Group N 169.3 ± 5.9 87.3 ± 2.6 117.2 ± 5.3
(1,680mm)
Group T 165.0 ± 6.2 81.1 ± 4.0 115.3 ± 5.0
(1,810mm)
351

*The angles were measured using the floor plane as a reference in a counterclockwise
direction. The objective lens used on the operating microscope is 250 mm [147].

Nowadays microscopes are available that have a so-called variable focal

system, which allows to eliminate the problem of the objective lens and the
working distance associated with it. All this means that, in order to vary the
focus according to the working distance, it is not necessary to change the
objective lens, but the above system allows to vary the parameters of the
optical system inside the microscope-body without varying the distance
microscope-operating field.
Other aspects must be considered when deciding to use magnifying systems
and in particular the operating microscope [135,136,139,149], namely:
● an adequate learning curve;
● the use of indirect vision in orthograde endodontics;
● the use of direct vision in surgical endodontics;
● the position of the operator in relation to the operative field.

A good learning curve can be fundamental and necessary, especially at the

first approach to enlargements; furthermore, some eye fatigue may be felt
especially in the initial periods [139,147].
The learning curve must include periods of adaptation to work with
magnifications and, in particular, the attendance of both preclinical and
clinical training courses, in order to learn both the technical characteristics of
the chosen magnification system and the work potential that derive from it. It
is also advisable to have the support of qualified tutors to improve the
operational skills and postures adopted during the various phases of the
intervention.
In fact, it can be difficult to autonomously evaluate the problems associated
with microscopic working techniques, such as physical problems (eye
fatigue, muscle fatigue), difficulty in illuminating the operating field (with
loss of ergonomic position, considerable effort on the ocular muscles of the
'accommodation), disorders related to the continuous search for a direct
vision and the assumption of incorrect positions (which can cause twisting
and tension of body portions and
352

fatigue affecting various musculoskeletal districts, as well as AMD) and,

finally, the ever-increasing need for higher-grade magnification in the pursuit
of more accurate precision.
Kersten evaluated the significant limitations found in the use of
operating microscope, including the positioning difficulties highlighted by
the32% of respondents. The results of this study are reported in theTable
3.10and in the relativefigure 3.142[140].

Fig. 3.142Significant limitations on the use of the operating microscope. (From: Kersten et
al., 2008; modified.)

Tab. 3.10Significant limitations on the use of the

operating microscope
Positioning difficulty 32
Long-term musculoskeletal disorders 17
Increase in operational times 16
Perception of a narrow operative field 18
Maintenance issues <1
Initial cost na
Design and installation issues na
(From: Kersten et al., 2008; modified.)
353

Achieving a level of comfort associated with maximum productivity can be

time-consuming and frustrating, especially in microscopic dentistry [150].
As regards the type of observation of the operating field, it must not be
forgotten that in endodontics the use of mirrors (indirect vision) is
fundamental and practically inevitable, especially for non-surgical
treatments.
In fact, the use of the mirror allows to obtain numerous advantages, including
the ability to examine the floor of the pulp chamber, the possibility of
locating the root canal orifices [140,151-155], the identification of any
lesions (perforations, fractures and cracks dentinal, stripping, steps) [156]
and/or intrapulpal or intracanal obstructions (stones and calcifications,
fractured instruments); it is also very useful for being able to observe and
facilitate instrument maneuvers within the root canal system (identification
and approach to calcified canals) [157] or for positioning materials inside the
endodontium (for example MTA) [ 140,158], as well as to reflect light and
illuminate the interior of the root canal system itself.
Therefore, considering that the use of indirect vision (with the aid of the
mirror) in microscopic endodontics is fundamental both from an ergonomic
and a functional-operative point of view [66], the orientation of the mirror
could prove to be a critical factor for the success in using techniques with
magnification (Fig. 3.143; you seeFig. 3.141 AndTab. 3.8 And3.9)
[147].
354

Fig. 3.143Operator's posture under the 3D operating microscope. The lines and angles used
to evaluate the position of the operator: the axis of the binoculars (A, green) in relation to the
reference plane (floor surface: D, violet) and its angle of inclination (α), l the axis of the
microscope body (B, red) forming an angle (β) with the reference plane (D, violet); the
normal to the mirror surface (C, light blue), which forms an angle (μ) with the reference. The
image shows the observation of the mandible (see direction of the mirror axis: the circle
indicates the direction of vision). The whole can be compared with theFig. 3.141.

The operating microscope offers a stereoscopic, three-dimensional and highly

magnified view of the operating field, associating everything with direct and
optimal lighting and, at the same time, allows the operator to maintain a
comfortable working position, even when using the indirect vision with the
mirror angled correctly [147].
Therefore, in order for the clinician to make the most of the advantages that
indirect vision can offer, an adequate period of training is necessary for the
correct use of the mirror during micro-endodontic techniques.
The microscope, therefore, compared to other magnifying systems, allows
greater visibility, better lighting and higher degree precision [159], also
allowing the operator to maintain a correct posture
355

neutral, without excessive and unergonomic flexure of the cervical spine

[101], provided that the microscope has been correctly adjusted and that the
workstation has been well designed.
Returning to Carter's work, it is easy to demonstrate how the use of the
microscope is more favorable from an ergonomic point of view [88]. The
inclination of the neck, in fact, can vary between 0° and a maximum of 5°,
therefore the head will be positioned in line with the rachis and therefore the
weight-force will be supported more favorably and without excessive efforts
on the back. neck, shoulder and back musclesFig. 3.144). This results in
better ergonomics and an increase in the quality of working life of the dentist
and his team.

Fig. 3.144Posture of the dentist in different operative attitudes. On the basis of the
magnifying system used, it can be observed how the torque (Ω) generated by the weight-
force of the head tilted forward varies: from this it is also easy to derive the degree of tension
developed by the muscles responsible for maintaining the posture and, based on the time, the
state of musculoskeletal stress (as per the biomechanical theory covered in the text).

So that the second operator (assistant) can also benefit from the ergonomic
advantages deriving from micro-dental operations, the microscope can be
equipped with a co-observer, which further improves the working potential
and the harmony of the dental team.
356

It is important to consider how all the ergonomic and posturological

advantages can be maintained throughout the entire operating session, since it
is possible to change the position of the patient's head or, even, by making the
patient rotate on the dental unit chair, so that these are placed on one side. In
this way, a better viewing angle will be obtained without continuously
changing the position of the microscope and, at the same time, the patient
will be in a comfortable position for the entire duration of the operation,
without any stress on the neck and back muscles.
With regard to the correct design of the operating station, it is interesting to
consider the importance that the chair used by dentists, assistants and
hygienists who work in a seated position can assume. Naturally this device
must adapt to the operator's body, so that it is supported throughout the
operating time, ie maintained in a neutral and balanced position. The modern
stools are also the work of careful planning which must comply with the rules
dictated by ergonomics and posturological science. In fact, there are many
technical characteristics that must be carefully evaluated by the dentist before
being able to proceed with a weighted purchase: the height of the piston, the
shape and depth of the seat, the presence and type of armrests,
Below we will briefly analyze the backrest, whose primary function is to
maintain the lumbar lordosis in an optimal position while sitting. All this is
possible as the contact between the operator's back and the convex portion of
the backrest defined as lumbar support is maintained [160,161]. In the
absence of this convexity, there would be a relaxation and a "sinking" of the
bust downwards, with consequent flattening of the lumbar curve and
excessive stress and weakening of the ilio-lumbar ligament and other dorsal
structures. This chain of events would determine, over time, the onset of
variously configured lesions [161-164], such as MSD, swelling and
protrusion of the intervertebral disc (disc herniation) [165]. Therefore, from
using the lumbar support,
357

benefits including the reduction of pressure on the lumbar discs, a decrease in

episodes of low back pain and sciatica, a limitation of the positioning and
forward movement of the head and the consequent decrease in the degree of
activity of the back muscles [100,166-168].
Another interesting option from an ergonomic point of view are the armrests
of the operator chair (Fig. 3.145). Studies have shown that the use of these
supports can be part of the prevention of neck, shoulder and low back pain
[100,169-171], especially if used for bilateral support, as demonstrated by
Rundcrantz et al. [66,86].

Fig. 3.145Operator chair with armrests.

It has been shown that the support for the forearm and the elbow determines a
reduction of the muscular activity of the cervical portion of the spine, in
particular of the superior portion of the trapezius, of the rhomboid and of the
spinal erector muscles of the thoracic and cervical spine (Figs. 3.146
And3.147) [101,169,172]. Biomechanically, the benefit deriving from the use
of this aid is to be found in the support given to the arm's weight-force
[173] and to the upper part of the trunk which they otherwise should
besupported and counterbalanced by the muscles of the back and neck (Fig.
3.148), with onset of AMD, myalgias of various degrees involving the
muscles
358

of the upper back, as well as degenerative pathologies [173].

Fig. 3.146Back muscles in 3D.

359

Fig. 3.147Muscles of the deep layer of the neck – Suboccipital group.

Fig. 3.148Armrests: support the weight-force given by the arm and upper trunk, resulting in
a decrease in tension in the back and neck muscles, with prevention of overload and stress on
the musculoskeletal segments of the spine
360

cervical and consequent reduction of the onset of MSDs, myalgias and degenerative
pathologies.

On the market there are different types of armrests: fixed, mobile, swivel,
telescopic. They should be widely adjustable in order to allow the user to
customize his sitting and comfort, thus configuring a more correct and neutral
posture possible [173,174,175], especially when working in microscopy.
A correct adjustment of the supports is essential in the prevention of MSDs of
the neck and shoulder; for example, incorrect vertical adjustment (too high)
can worsen neck pain and can even cause neck stiffness and generate pain in
the thoracic portion of the back [173]; positioning the armrests too far
forward can cause trunk flexion, compromising the operator's balance and
posture. It is easy to understand how essential it is to adopt these arm support
devices in microscopic practice. In fact, for the operator, it translates into the
possibility of working in the absence of muscle fatigue (complete comfort,
absence of hypertonicity and muscle stress) and of making micrometric
movements of the hand and wrist (fine movements without tremors,the use of
the operating microscope and the small operating field
impose.
In conclusion, it is possible to state that the use of the operating microscope
must not revolutionize the basic principles of dental ergonomics, but must
allow a better quality of working life for the dentist and his team, who can
thus acquire better visual access and a facilitation in clinical operations,
compared to those who do not yet use this type of technology [150].

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Activation of irrigants
R. Beccio, F. Stuffer

At the beginning of this chapter, the guidelines of the Italian Society of

Endodontics are mentioned:

«Endodontic therapy of permanent teeth involves treatment

370

mechanic of the root canal system in order to eliminate periradicular and

pulpal pathologies, favoring the healing and repair of the periradicular
tissues. Cleaning and shaping of the root canal system is followed by
filling with a solid or semi-solid, non-absorbable root canal filling
material» [1]
It can be seen that in these guidelines the cleansing phase is mentioned first;
according to the authors it is not only for a reason to construct the sentence,
but precisely because of the great importance it has.
Although technology and research in the endodontic field have made
available new extremely effective tools for shaping the root canal, one of the
fundamental objectives during the preparation of the endodontium certainly
remains that of minimizing the production of debris and dentinal mud [ 2].
Today it is believed that this principle is partly disregarded and that the
evolution has pushed towards the development of ever more performing
instruments from the point of view of the reduction of usage times and the
simplification of the operating sequence, reaching as far as the single
instrument, without considering instead the aspect concerning the production
of dentinal mud by these instruments. We have therefore witnessed the
flourishing of a specific instrument set designed for the removal of debris,
In addition to the smear layer, there is also the problem of biofilm: currently
no experimental systems have been produced that are able to demonstrate
which is the most effective way to destroy the bacterial biofilm, or which is
the most suitable irrigant activation system to eliminate it [4].
Having established how extremely important it is to optimize the action of
irrigants, the means by which it is possible to increase their action will be
described below.
The purpose of this chapter is therefore to illustrate the various methods that
the clinician can use to cleanse the root canal system.

Root canal irrigation devices

371

Manuals
● Needles and syringes.
● Endodontic brushes.
● Manual stirring with rows or cones of gutta-percha.

Mechanical and physical

● Heat.
● Ultrasound.
● Subsounds.
● Pressure differential systems.

Needles and syringes

Needles and syringes are certainly the first devices used by every specialist to
cleanse the endodontic space. However, in the light of current knowledge, the
action of the syringe alone and of the flow of liquid that can be obtained does
not allow optimal cleansing.
The syringe must be able to guarantee an adequate liquid content, from 5 cc
upwards, in order to renew the content of the irrigating solution conveyed
inside the endodontium at each washing. In any case, not only the quantity of
liquid contained in the syringe is a determining factor in obtaining the
complete replacement of the liquid between one operating phase and another.
Although all the syringes on the market dedicated to this use prove to be
substantially adequate, particular attention must be paid to verifying that the
syringe is equipped with a luer-lock or secure-lock type screw connection
(Figs. 3,149 And3,150) instead of a pressure connection, in order to avoid
unexpected detachments of the needle with spreading of the irrigating
solutions. This is not a serious complication, but certainly annoying if some
splashes hit the patient's face and in particular on the eyes or on the clothes.
In this circumstance, in fact, the clinician is required to compensate the
patient.
372

Fig. 3.149Syringe with luer connection. (From: Ilic'. Products&Procedures Manual

Catalogue.)

Fig. 3.150Type of needles suitable for root canal irrigation. (From: Ilic'.
Products&Procedures Manual Catalogue.)

Much more important however is the shape of the needle, which can be
substantially of two types: with a flat opening or with a side opening (Figs.
3.151And3,152).

Fig 3.151Side exit needle to prevent expulsion of irrigant beyond the canal boundary. (From:
Ilic'. Products&Procedures Manual Catalogue.)
373

Fig. 3.152Needle with side exit and blunt tip. (From: Ilic'. Products&Procedures Manual
Catalogue.)

It is clear and intuitive how an opening placed on the side reduces the
probability of involuntarily injecting part of the irrigating solution outside the
apex; this for reasons related to the rheology of the liquid which emerges
from an opening placed next to rather than perpendicular to the tip of the
needle.
Surely the caliber and the material from which the needle is made are also
determining factors in ensuring deep irrigation.
Therefore, if you wanted to get to the last apical 3 mm, you would need a 30
gauge needle if the preparation ends at a 20 diameter; otherwise even a larger
size needle could go down to that depth.
However, it is essential that the needle is not engaged and that excessive
pressure is not exerted to avoid injecting irrigants into the periapical tissues.
Before irrigating, remember to disengage the tip of the needle from the walls
of the canal since even needles with lateral openings can produce pressures
which induce the leakage of liquid into the periapice (Fig. 3.153). A correct
washing technique foresees that, after having introduced the needle by
inserting it in the most apical portion, its tip is disengaged and then
proceeded with delicate back and forth movements (Fig. 3.154) [5].
374

Fig. 3.153The needle tip is engaged against the canal walls.

Fig. 3.154The tip of the needle is free from the canal walls.

We must therefore acquire the concept according to which the irrigant must
be conveyed to the site with a means and then activated later. Therefore,
according to this principle, one should never try to cleanse by applying
pressure or trying to forcefully inject the liquid.
The consequences can in fact be quite heavy for the patient and certainly
impressive to see [6].
In particular, in the apical third it is not possible to think of obtaining a
complete removal of debris and dentine smear with only the
375

washing, but activation of the solutions will be required to increase their

effectiveness.

Endodontic brushes
Endodontic brushes, offered in various forms, both manual and to be
mounted on a micromotor, have the defect of always requiring an apical
diameter of the preparation of at least 30-35 ISO or greater if one wishes to
reach the apex. In the opinion of the Authors they have a certain utility in the
reconstructive phase, but little in the cleaning phase during endodontic
treatment (Fig. 3.155).

Fig. 3.155Nano brush. (From: Ilic'. Products&Procedures Manual Catalogue.)

Manual activation with rows or cones of gutta-percha

It is simply a matter of reaching the working length with small instruments so
that the solution can also reach the apex. According to some authors, with
this technique it is not possible to obtain a good diffusion of the liquids due to
the formation of air bubbles which would prevent the penetration of the
irrigants. According to other authors it would be
376

on the other hand, it is possible to bring liquids to a depth with only manual
activation [7,8].
However, manual activation is a method that is within everyone's reach and
does not require any particular tools; on the other hand, however, it is
necessary to insist for some time, alternating the irrigating solutions, to
obtain good results.
The procedure is simple and consists in the repeated and delicate
introduction, up to the working length, of rows or cones of gutta-percha, after
having adequately filled the access cavity with the irrigating solutions. It is
important to remember that the displacing action of the liquids and their
consequent activation are due to the fact that the cone or the instrument takes
the place of the liquid that will have to move by penetrating into the recesses
or leaving the coronal portion. The liquid will then occupy the volume of the
cone once it is removed. It therefore becomes essential to have a pre-
treatment that makes the pulp chamber a reservoir full of irrigant which can
thus fill the root canal system every time the cone or the instrument is
extracted.
If we relied on the contents of the root canal system alone, very little fluid
could be activated after the first insertion. Clearly the same considerations
also apply to other activation systems using ultrasound and subsound.

Heat
Heat is a mode of activation of irrigating solutions which assumes particular
importance in the case of sodium hypochlorite.
One of the first authors to propose the use of heated hypochlorite was
Ruddle; in Italy the first studies on his action were conducted by prof. Beruti
[9]. However, the heating of the solution, as proposed by Ruddle, has
drawbacks in that the solution rapidly degrades, partly losing its bactericidal
capacity; therefore, it is considered more appropriate that the heating of the
solution takes place in a closed system such as the one illustrated in the figure
(Fig. 3.156).
377

Fig. 3.156Heater for root canal irrigants. (From: Ilic'. Products&Procedures Manual
Catalogue.)

Alternatively, the same result can be obtained by heating the closed syringes
in a bain-marie.
Even in this case, however, the heat can deteriorate the solution; therefore,
after heating it, it can no longer be used, but must be discarded if you want to
keep its original characteristics.
The recommended temperature is 50° and the solution must be renewed at
least every 3 minutes, otherwise the effects of the heat can be nullified due to
the rapid cooling due to the small quantities of liquid.
It is also possible to heat the solution with the means used for the hot
compaction of gutta-percha (system B), but its use is not recommended as the
heat produced is too high and, on the other hand, difficult to control.

Ultrasound
Another widely used modality to activate the irrigating solutions is
constituted by the ultrasonic sources. Today this technique is well codified
and takes the name of PUI (Passive Ultrasonic Irrigation) [10].
The technique provides that the instrument does not come into contact with
the canal walls as it happens in the preparation technique with ultrasound UI.
In this way the shaking movement of the tool is
378

more accentuated and produces a greater activation of the irrigating solutions

in which it is immersed.
The action of the ultrasounds is carried out through waves of agitation which
propagate in the liquids, which produce a phenomenon called acoustic
streaming. The latter consists of a concatenation of sound waves which
agitate the irrigating solution and produce a direct effect against the bacteria
causing the rupture of their cell membrane. Furthermore, the agitation of the
liquid which violently hits the canal walls produces a disintegration of the
biofilm adhered to them and a removal of the dentinal layer.
The only problem is the type of movement that the instruments generate, in
fact they move by vibrating in precise points called nodes and antinodes.
Therefore, it is understandable that in very curved canals it becomes almost
impossible to work passively with metal tips. If due care is not taken, the
result may be a cleaner root canal system but with an altered morphology.
Therefore, the main limitation of this irrigant activation system is due to the
stiffness of the tips used. In the opinion of the Authors, even the smooth ESI
tips in nickel-titanium can prove to be aggressive and in any case are not free
from fracture problems. Furthermore, they cannot be used pre-curved and
therefore in many curved canals their effect is less due to the contact with the
walls which reduces the amplitude of the instrument's agitations.
If the industry paid more attention to the development of non-metallic tips,
ultrasound would probably prove to be one of the best systems for activating
solutions at present.
The main companies that produce ultrasound sources have their tips and offer
the most suitable settings; therefore it is considered unnecessary to dwell here
on the various frequencies of use.
However, it is important to remember that these tips must never be activated
empty, but always immersed in a liquid. This serves to contrast the oscillation
that occurs at the tip of the instrument, which, without a means that limits its
amplitude, could lead to a fracture of the apical part of the instrument.
Furthermore, ultrasound also generates heat, which in this case must be
considered positively.
For all the reasons mentioned above, ultrasonic instruments should never be
brought closer than 3 mm from the root apex in order to
379

avoid the possibility of creating steps, of witnessing fractures of the

instrument or of causing a leakage of liquid from the periapice with certainly
not very dramatic consequences, but certainly uncomfortable for the patient.

Subsounds
The principle is the same as for ultrasounds; only the frequency and type of
oscillations vary. In this case there is a node at the instrument connection and
an antinode at the vertex. Therefore, the instrument oscillates in a different
way, always producing a good agitation of the solutions.
The best known tools are the RISPI Endoactivator.
recently, a sonic tip has been introduced by the Komet
SF 65. This sonic tip, similarly to the RISPI, uses the instruments to be
mounted on the sonic handpieces by means of a special chuck. Although less
aggressive, their limitation is, in the opinion of the Authors, that of being
made of metal: they can therefore be used comfortably only in the case of
straight canals, while their effect will certainly be less in curved canals. The
Endoactivator system has the great advantage of having been designed with
plastic material tips that can be pre-curved and ensure good cleansing
efficacy. On the other hand, a disadvantage of this system is the impossibility
of autoclaving the handpiece.
The Vibringe syringe also belongs to the group of subsonic instruments: it is
a syringe equipped with a microprocessor which supplies energy by
activating the solution and also promoting a certain vibration of the needle.

Endoactivator system
This system consists of a handpiece and some tips of polymeric material with
different diameters and tapers (Figs. 3,157And3,158). The system produces a
sonic activation of the root canal irrigants, triggering a strong hydrodynamic
phenomenon. The sonic engine can work at three different speeds: 10,000,
6,000 and 2,000 cycles per minute. To obtain better cleaning of the root canal
system it is recommended to use the Endoactivator [11] at the highest
frequency. The sonic engine works with the help of an alkaline or lithium
battery and is therefore wireless. The ultrasonic tips are yellow in color,
380

red and blue, which correspond to the file sizes 20/02, 25/04 and 30/06. Their
length is 22 mm and there are three rings at the working length of 18, 19 and
20 mm respectively. By method of use, once the instrumentation of the canal
is completed, a tip will be chosen that reaches up to 2 mm from the apex
without engaging, which will then be used with a continuous back and forth
movement. The tips are made of a non-cutting polymeric material so that
during use there is no risk of creating steps or false paths. Furthermore, it
should be remembered that they are disposable like the protective sheath of
the handpiece. The vibrations of the sonic tip produce intracanal waves
which, breaking on the endodontic walls, create a system of bubbles. Later
these bubbles can expand and then become unstable until they implode. Each
implosion favors the formation of microwaves which penetrate vigorously
inside the bacterial microfilms, destroying them and reducing the bacterial
load still present on the root canal surfaces [12,13]. The activation of the
intracanal fluid must take place at the end of the instrumentation and for a
minimum time of 60 seconds. Assisted irrigation can be used with sodium
hypochlorite, but can also be used with other irrigants. Better cleansing will
certainly favor a more effective three-dimensional filling, increasing the
success rate of the treatment. Each implosion favors the formation of
microwaves which penetrate vigorously inside the bacterial microfilms,
destroying them and reducing the bacterial load still present on the root canal
surfaces [12,13]. The activation of the intracanal fluid must take place at the
end of the instrumentation and for a minimum time of 60 seconds. Assisted
irrigation can be used with sodium hypochlorite, but can also be used with
other irrigants. Better cleansing will certainly favor a more effective three-
dimensional filling, increasing the success rate of the treatment. Each
implosion favors the formation of microwaves which penetrate vigorously
inside the bacterial microfilms, destroying them and reducing the bacterial
load still present on the root canal surfaces [12,13]. The activation of the
intracanal fluid must take place at the end of the instrumentation and for a
minimum time of 60 seconds. Assisted irrigation can be used with sodium
hypochlorite, but can also be used with other irrigants. Better cleansing will
certainly favor a more effective three-dimensional filling, increasing the
success rate of the treatment. but also with other irrigants. Better cleansing
will certainly favor a more effective three-dimensional filling, increasing the
success rate of the treatment. but also with other irrigants. Better cleansing
will certainly favor a more effective three-dimensional filling, increasing the
success rate of the treatment.
381

Fig. 3.157Endoactivator handpiece. (Courtesy of Simit Dental Srl)

Fig. 3.158Endoactivator tip range. (Courtesy of Simit Dental Srl)

382

pressure gradient
EndoVac system
A root canal cleaning and disinfection system that exploits the pressure
difference has recently been introduced [14-16]. With this system it is
possible to deliver large quantities of hypochlorite or another root canal
irrigant along the entire length of the canal. The negative apical pressure
created with the EndoVac system greatly reduces, if not completely, the
probability of accidental leakage beyond the apex of the irrigating agent,
preventing known and unpleasant consequences for the patient [17]. The key
component of the EndoVac system is represented by a steel micro-cannula
with an external diameter of 0.32 mm, at the end of which a rubber seal has
been placed with a guide function. Arranged radially at a distance of 0.2-0.7
mm, there are 12 micro-holes each of 0, 10 mm in diameter with the function
of attracting irrigants up to the last 0.2 mm from the apex and preventing
obstruction of the cannula lumen. Unlike other negative pressure systems, the
EndoVac works with a true apical negative pressure which results in a
suction effect of the irrigating fluid. This causes a turbulent flow from the
apex back towards the pulp chamber with the consequent leakage of particles
of organic and inorganic material. In fact, as known, when hypochlorite
comes into contact with the organic substances of the pulp, some gaseous
micro-bubbles are created, mostly composed of ammonia and carbon dioxide.
In the canal, this gaseous mixture tends to concentrate in the apical region
forming a vapor plug. Both endodontic instruments and ultrasound systems
are unable to dissolve the gas plug. The negative pressure generated by the
EndoVac system is instead effective in removing the microbubbles allowing
the arrival of new active irrigant [18].
The EndoVac system consists of three parts: the master delivery tip (MDT),
the macrocannula and the microcannula (Fig. 3.159). The MDT is the main
tool of the system: it releases sodium hypochlorite into the pulp chamber
through a small metal tube connected to the irrigant syringe, while
simultaneously aspirating the liquid present in the chamber through a rubber
tube with a larger diameter than the metal one connected to the high-speed
suction of the dental unit. In order to avoid incorrect use of the MDT, it is
necessary to remember some operating advice: the cavity
383

access must always be closed on all walls except the occlusal one and have at
least a depth of 6 mm; the irrigant flow must always be directed towards an
axial wall of the chamber and, finally, the MDT must never be positioned less
than 5 mm from a root canal entrance. The macro cannula is made of
transparent propylene and is mounted on a titanium holder. It is mainly used
in conjunction with MDT to remove debris present in the middle third and
coronal third. It must be used with a back and forth movement from top to
bottom and vice versa without ever being engaged in the canal. The
microcannula, already described above, acts in the apical third always
connected to the MDT. Also for the microcannula a movement equal to that
of the macrocannula must be used, but this must take place in the last 2 mm
of the canal. The back and forth movements with the irrigants last about 30
seconds and are followed by a passive phase of 60 seconds. Certainly, to
obtain the best results it is advisable to perform at least three microcycles: the
first with 5-6% sodium hypochlorite, followed by a second with 15-17%
ETDA and the third again with 5-6% sodium hypochlorite. 6%.

Fig. 3.159Elements of the EndoVac system. (a) Clinical use. (b) Cannula inserted into the
suction system. (c) Detail of the needle. (Courtesy of Simit Dental Srl)
384

Bibliography
1. SIE, Italian Endodontic Society; AIE, Italian Academy of Endodontics. Endodontic
guidelines 8.2.2. p.4; 2009.
2. Schilder H. Cleaning and shaping the root canal. Dent Clin N Am 1974;18:269.
3. Ahlquist M, Henningsson O, Hultenby K, Ohlin J. The effectiveness of manual and
rotary techniques in the cleaning of root canals: a scanning electron microscopy study.
Int Endod J 2001;34(7):533.
4. Costerton JW, Stewart PS, Greenberg EP. Bacterial biofilms: a common cause of
persistent infections. Science 1999 May 21;284(5418):1318-22.
5. Boutsioukis C, Lambrianidis T, Verbaagen B et al. The effect of needle-insertion depth
on the irrigant flow in the root canal: evaluation using an unsteady computational fluid
dynamics model. JEndod 2010;36(10):1664-8.
6. Mehra P, Clancy C, Wu J. Formation of a facial hematoma during endodontic therapy. J
Am Dent Assoc Jan 2000;131:67-71.
7. Spencer HR, Ike V, Brennan PA. Review: the use of sodium hypochlorite in
endodontics − potential complications and their management. Br Dent J 2007;202:555-9.
8. Caron G, Nham K, Bronnec F, Machtou P. Effectiveness of different final irrigant
activation protocols on smear layer removal in curved canals. JEndod 2010;36(8):1361-
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9. Paragliola R, Franco V, Fabiani C et al. Final rinse optimization: influence of different
agitation protocols. J.Endod 2010;36:282-5.
10. Berutti E, Marini R. A scanning electron microscopic evaluation of the debridement
capability of sodium hypochlorite at different temperatures. J Endod 1996
Sep;22(9):467-70.
11. van der Sluis LVM, Versluis M, Wu MK, Wesselink PR. Passive ultrasonic irrigation of
the root canal: a review of the literature. Int Endod J 2007;40:415-26.
12. Ruddle C. Hydrodynamic disinfection Tsunami Endodontics. Dentistry Today
2007;26(5):112-7.
13. Ahmad M, Pitt Ford TR, Crum LA. Ultrasonic debridement of root canals: acoustic
streaming and its possible role. JEndod 1987;13(10):490-9.
14. Ahmad M et al. Ultrasonic debridement of root canals: acoustic cavitation and its
relevance. Endo 1988;14(10):486-93.
15. Schoeffel JG. The EndoVac method of endodontic irrigation. Dentistry Today
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16. Schoeffel JG. The EndoVac method of endodontic irrigation Part 2 – Efficacy.
Dentistry Today 2008;27(1):82-7.
17. Schoeffel JG. The EndoVac method of endodontic irrigation Part 3 – System
component and their interaction. Dentistry Today 2008;27(8):106-11.
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Am Dent Assoc 2000;131:67-71.
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irrigation technique with intracanal aspiration. Int Endod J 2006;39:93-9.

386

CHAPTER 4

Primary root canal treatment

Pretreatment
(MT Sberna)

Dental morphology and access to the endodontic space

(D. Castro, M. Giovarruscio)
Shaping
(M. Martignoni, M. Lendini)

Filling
(M. Venturi, U. Uccioli)
387

Pretreatment
MT Sberna

Indications and purposes of pre-treatment

Before starting endodontic treatment, the operator must know the useful steps
for valid planning that can contribute to the success of the result.
Apart from emergencies, it is clear that before any treatment it will be useful
and recommended to review:
● medical history;
● diagnosis and treatment plan;
● informed consent;
● case study (anamnesis, x-rays, additional tests to confirm the
previous diagnosis).
However, it has been shown that there are other needs as well
of thepre-treatment, equally
important and not to be underestimated:
● dental care;
● infection control;
● premedication;
● anxiety and pain management.

Dental care
Adequate oral hygiene is necessary and can be planned in time if emergency
endodontic interventions are not foreseen. Before treatment, an oral rinse
with 2% chlorhexidine gluconate is recommended, to obtain a reduction in
the bacterial load.

Infection control
It is advisable to reduce the risk of exposure to infections for all staff and for
the patient, by implementing some simple procedures [1,2].
Certainly the greatest risks can be run in the presence of infections
388

important (such as those from HIV, HBV, TB) and it must be said that often
the disease is not declared at the time of compiling the anamnesis. For this
reason, for prevention purposes, it is necessary to adopt the appropriate safety
measures for each patient, considering them potentially infected.
The ADA (American Dental Association) has compiled the so-called
universal precautions, which have also been taken up in Italy as legal
provisions (Legislative Decree 626/94). This decree calculated the biological
risk as well as the use of personal protective equipment (PPE) with the aim of
guaranteeing, thanks to standard manoeuvres, the control of cross-infections
and the health of the patient, the operator and all the staff. Among these we
mention that:
● hands, wrists and arms should also be washed between patients after
removing gloves;
● gloves must be disposable and their integrity must be checked;
● masks and eye protection devices and a headgear must be worn;
● rubber dam should be applied;
● needles must be stored in the appropriate containers;
● suction must be carried out with appropriate power and capacity (the
air-water spray spreads in the environment and lasts for about 24
hours);
● the operating surfaces must be disinfected and suitably covered;
● sterile or disposable instruments must be used.

PremedicationAntib
iotic prophylaxis
The purpose of prophylactic antibiotic therapy is to prevent, and not to cure, a
possible exacerbation of a pre-existing systemic disease, due to the passage of
bacteria through the bleed. Root canal therapy rarely, if it does not generate
or find bleeding, can be the cause of bacteraemia.
The application of antibiotic prophylaxis in dentistry is necessary in function
of some diseases such as, for example, bacterial endocarditis, or for subjects
with immunodeficit (AIDS, decompensated diabetes, treatment with
immunodepressants, antiblastic treatments, organ transplants, shunts
389

cardiac).
Often prophylaxis is prescribed before any surgery, such as extractions or
implants, with the aim of avoiding local postoperative complications, even if
this has no scientific support [3,4].
On the other hand, there are some studies that show that extractions have a
lower incidence on the onset of bacteremia than the daily brushing maneuver
[5].
However, patients who fall into the high-risk category are particularly
concerned (AHA recommendations, American Heart Association, 2007), as
antibiotic prophylaxis is not considered for low-risk patients.
Conversely, this study demonstrated that there is no indication for antibiotic
prophylaxis in some dental procedures such as root canal therapy.
The aim of antibiotic prophylaxis is to achieve high concentrations of
antibiotic at the time of surgery. The administration must take place before
surgery in a variable time depending on the antibiotic used, in order to obtain
a coverage that remains for at least 20 minutes after the end of the operation.
In conclusion, the AHA recommends prophylaxis in endodontics (in addition
to surgery and for the execution of intraligamentary anesthesia) in case there
are factors predisposing to endocarditis such as valve prostheses, just to name
one example [6].

Prophylaxis with NSAIDs

This type of prophylaxis is useful for reducing postoperative pain. Ibuprofen
400 mg 30 minutes before treatment (1000 mg of paracetamol in case of
negative indication for NSAIDs).

Preoperative hyperalgesia
In cases where, for various reasons, it is not possible to intervene on the
patient with emergency therapy, such as pulpotomy or drainage of an
abscess, and the patient experiences pain, drug therapy can be used. This can
be used with a methodology, so to speak, modulated, as it is variable
according to the needs.
● Mild pain: 200 to 400 mg of ibuprofen (brufen) or acetaminophen
(efferalgan).
390

● Moderate pain: 400 mg ibuprofen + codeine (500 mg paracetamol

+ 30 mg of codeine).
● Strong pain: NSAIDs + oxycodone (10 mg oxycodone + 325 mg
paracetamol).

This therapeutic scheme is indicative and must be adapted to the patient. It is

clear that the elective therapy is certainly emergency surgery, although the
use of drugs can avoid numerous discomforts, also making the patient much
more relaxed at the time of endodontic treatment, thanks to these associations
that reduce the central nociceptive response as well as peripheral.

Anxiety and pain management

Before starting the treatment, the operator must be able to recognize the fear
that the intervention could cause in an apprehensive patient, in order to
prevent possible unwanted and dangerous reactions [7-10].
Anxiety can be of two types: manifested or masked; it is possible to
recognize masked anxiety through:
● contact with the patient, who has cold or/and sweaty hands;
● the visual examination, which takes place by observing the patient who
assumes a tense and stiffened posture on the chair, clings to the armrest;
the so-called white knuckle syndrome can also be observed, when the
patient squeezes a handkerchief or other forcefully.

Corah and Gale [9,10] have included some questions on the matter in the
anamnestic folder, for example:
● Have you ever had a negative or traumatic experience at a dental
clinic?
● Do you feel tense about having to start treatment?

How to manage anxiety

In theFigure 4.1 the pain and anxiety control scheme used in dentistry is
illustrated.
391

Fig.4.1Spectrum of pain and anxiety control in dentistry. (From: Malamed SF. Sedation: a
guide to patient management. 4th ed. St Louis: Mosby; 2001; modified.)

Iatrosedation
Anxiety is manageable through iatrosedation which occurs through:
● hypnosis;
● acupuncture;
● the relaxed relationship between dentist and patient, i.e. the chair side
manner, a concept introduced by N. Friedman and which indicates the
relaxation of the patient obtained thanks to the behavior of the dentist.

Pharmacosedation
The goals of pharmacosedation are as follows:
● patients must be aware, cooperative;
● protective reflexes must remain intact and active;
● vital signs must be stable and with normal values;
● the pain threshold must be elevated;
● amnesia must be present.

Oral sedation
Indications:
● previous day anxiety: sedative 1 hour before bedtime;
● anxiety on the day of the session: sedative 1 hour before treatment.
392

Advantages:
● universally accepted;
● increased security.

Disadvantages:
● sedation 1 hour before treatment;
● slow onset of effect;
● maximum effect about 60 minutes later;
● inability to achieve adequate levels of sedation;
● long duration of action (3-4 hours);
● inability to modulate the effect;
● state of impairment that requires the accompaniment of the patient.

Oral sedative drugs:

● benzodiazepines;
● hydrochlorate;
● hydroxyzine.

Intramuscular sedation
Although seldom used in dentistry, intramuscular sedation can still be
considered a valuable supportive mechanism.
Advantages:
● quick effect;
● increased security.

Disadvantages:
● maximum effect in less than 30 minutes;
● long duration of action (3-4 hours);
● inability to manage a buildable effect;
● state of impairment that requires the accompaniment of the patient.

Drugs used for intramuscular sedation:

● water-soluble benzodiazepines.

Inhaled sedation
393

Inhalation sedation is the technique most commonly used by dentists and is

performed by inhaling nitrous oxide and oxygen.Advantages:
● quick effect (from 20 seconds to 3-5 minutes);
● possibility to calibrate the effect;
● possibility to increase or decrease the level of sedation;
● rapid recovery of the patient (3-5 minutes);
● patients do not need chaperones.

Disadvantages:
● equipment costs;
● experience required by the operator;
● possibility of complications from excessive drug administration (loss of
peripheral nerve sensitivity). Since it is a conscious sedation and since
nitrous oxide is among the drugs that depress the CNS with release of
inhibition brakes by patients of the opposite sex to the operator, it is
advisable to carry out the treatment in the presence of an assistant.

Intravenous sedation
Advantages:
● quick effect (9-30 seconds);
● possibility to calibrate the effect;
● possibility to increase or decrease the level of sedation;
● possibility of canceling the effect with the introduction of other drugs;
● patients do not need chaperones.

Disadvantages:
● the presence of an anesthetist is required;
● inability to have modulable effects;
● potential complications;
● patients need chaperones.

Sedation drugs:
● benzodiazepines in combination with opiates.

Anesthesia
394

The choice of the anesthetic technique [11,12] is dictated by some needs.

● Obtain anesthesia of the tooth to be treated: choosing an appropriate
technique avoids additional injections and therefore excessive
administration of anesthetic.
● Achieve soft tissue anesthesia: Dam hook placement should be done
without causing discomfort to the patient.
● Obtaining the right degree of anesthesia: that is, it must cover
the time necessary for the operation.

Preparation
Before carrying out the anesthesia, some steps are recommended, which serve
to make the moment of the injection less painful and traumatic.
● Communicating that it is necessary to inject is often experienced by the
patient in a traumatic way, sometimes more than any other phase of the
intervention. A simple, calm and exhaustive explanation helps to obtain a
"vocal" anesthesia which will lead to its success without causing either
organic or psychological stress.
● Placing the patient in the supine position is advantageous, especially if the
choice of the surgical technique is directed towards a regional block. In
fact, this position causes greater blood flow to the head, reducing the risk
of dizziness, blurred vision and syncope.
● A stable position of the operator allows for a greater number of firm
support points that cannot be influenced by the movement of the patient.
● The preparation of the syringe will be carried out by loading the syringe
with the tube-vial and screwing the needle through the internal thread of
the connector (needles from 23 to 30 G are used in dentistry). In theFigure
4.2a conversion scheme between gauge and millimeters is illustrated. The
gauge, or internal diameter, is therefore inversely proportional to the
lumen of the needle.
● Plan the treatment sequence, evaluate the need for a pre-endodontic
reconstruction, the position of the element to be treated, the degree of
opening of the mouth by the patient, the choice of anesthesia technique.
395

Fig.4.2Comparative scheme between gauge and millimeters.

Side effects
● Paresthesia.
● Facial nerve paralysis.
● Trismus: spasm of the masticatory muscles with limitation of mouth
opening due to trauma of the infratemporal vessels and muscles mostly
associated with anesthesia of the inferior alveolar nerve trunk (IANB):
● causes: haemorrhages, direct needle injury, excessive volume of
anesthetic deposited in the tissues;
● treatment: rinses with saline solution, analgesics and muscle relaxants,
administer antibiotics if the symptoms persist for a prolonged time (over
48 hours) due to a possible infectious cause.
● Soft tissue injuries.
● Hematoma.
● Edema.
● Tissue ulceration during injection, resulting in pain, burning, post-
anesthesia lesions.
396

Technique
It must be remembered that it is always not recommended to carry out
anesthesia in the inflamed area. Brown [13] demonstrated that inflammation
tends to lower the response threshold of the nerve and thus inhibits the action
of the anesthetic.
The choice of the technique to use is dictated in these cases by the injection
site, which must be far from the inflamed area; according to Malamed [12,13]
the regional nerve block is the most effective technique for pain control.

Anesthesia of the upper jaw

Supraperiosteal injection (local infiltration, plexus
anesthesia)
It is the most commonly used technique to obtain anesthesia of the upper
teeth. It can also be used for the teeth of the mandibular arch, where however
it is often ineffective due to the greater density of the cortical bone which
limits the possibility of penetration of the drug.
The anesthetic acts in the area served by the terminal branches of the nerve
plexus and diffuses through the periosteum and maxillary bone, to act on the
bundle entering the tooth through the apex.
Indications:it is useful for inducing anesthesia in one or two dental elements.
Anesthetized anatomical areas:upper quadrants, mandibular incisors,
buccal periosteum, connective tissue and mucous membranes.
Advantages:rapid and effective anesthesia, atraumatic and easy to
perform.Disadvantages: ineffective in the presence of infection at the
level of the
teethmandibles (dense cortical bone).
Needle insertion area:the anesthetic must be diffused into the soft tissue in
the area of the arch above the apex, keeping the needle semi-parallel to the
long axis of the tooth.
Action time:2-3 minutes.
Aug:short, 25-27 G.
Dose:0.6-2 mL of anesthetic.
Alternatives:it is not advisable to perform numerous infiltrations to obtain
anesthesia of larger areas, as this would infuse a
397

excessive amount of drug. Conversely, it is preferable to perform alternative

anesthesia, such as periodontal ligament, intraosseous and regional block.
Complications:pain from inserting the needle too deeply or from too many
infiltrations.
Bence [14] developed the supraperiosteal anesthesia technique, associating it
with a subperiosteal anesthesia to be performed in two stages:
1. first time, supraperiosteal anesthesia: introduce the needle into the area at
the level of the mucogingival junction line remaining above the
periosteum and slowly inject a small amount of anesthetic;
2. second stage, subperiosteal anesthesia: the needle is reintroduced into
the already anesthetized area, the bone is reached and the rest of the
anesthetic is injected very slowly. Therefore the anesthetic diffuses
below the periosteum, which acts as a barrier to diffusion, thus
facilitating the penetration of the drug into the bone.

The supraperiosteal injection must be performed after aspiration (positive

aspiration <1%) and rather slowly, to avoid swelling of the tissues.
In the case of a high thickness of the bone cortex or in the event of a
markedly palatinized position of the root apices, the anesthetic may not be
able to spread in the area of interest, thus resulting in ineffectiveness. This
eventuality occurs more frequently at the level of the upper premolars and
molars or in the presence of buccal roots too far below the zygomatic bone,
making it difficult to reach the apex area. Therefore, in this case it is
advisable to associate a palatal infiltration near the apex of the corresponding
root, limiting oneself to performing a supraperiosteal anesthesia. Since this
maneuver is very painful, it is advisable to pre-anesthetize the region with a
surface anesthetic and just inject a small dose of drug (0.5 mL).
This is the technique to be used for the treatment of deciduous elements of
the lower arch. Prospective randomized double-blind studies have
demonstrated that, compared to IANB, vestibular infiltration of mandibular
molars provides an anesthetic effect with an earlier onset. Furthermore, the
association of the IANB with the mandibular vestibular infiltration is more
effective.
In conclusion, the vestibular infiltration technique with articaine 4% can
398

be a valid alternative in the case of mandibular first molars since, compared

to the IANB, it has a faster onset and a very similar efficacy rate.
Furthermore, mandibular buccal infiltration with 4% articaine has been
shown to be more effective with epinephrine than 2% lidocaine with
epinephrine. Both bestowals were associated with mild discomfort.
IANB injection supplemented with buccal articaine infiltration proved to be
more effective than simple IANB in the case of the mandibular teeth. On the
other hand, buccal infiltration with articaine was also found to be more
comfortable for patients than IANB [15-17].

Maxillary nerve (V2)

The maxillary nerve block can be performed either extraorally or orally.
In endodontics, regional maxillary block techniques are rarely used, since
they are mostly used in maxillofacial or plastic surgery where extensive
anesthesia is required above all to the bone and adjacent soft tissues.
Furthermore, to obtain a dental anesthesia it is always necessary to resort in
addition to infiltration techniques.
The degree of complications that these techniques involve must be taken into
account, such as the risk of vascular lesions (maxillary artery, pterygoid
venous plexus, infraorbital and suborbital arteries, internal maxillary artery),
the risk of serious infections (the area is tributary of the cavernous sinus) and
the risk of needle fractures.
Nevertheless, oral blockade techniques will be briefly described.

Posterior superior alveolar nerve (PSA) block or

tuberosity block, zygomatic block
In theFigure 4.3 the area that is anesthetized after the execution of this block
is highlighted.
399

Fig.4.3Anesthetized area after PSA anesthesia. (From: Malamed SF. Manual of local
anesthesia. 5th ed. Milan: Elsevier Masson; 2006.)

Indications:treatments of one or more molars or in case of impossibility to

perform this anesthesia.
Anatomical area of choice:upper molars, soft tissue and adjacent
bone.Landmarks:fornix, maxillary tuberosity, zygomatic process of the
maxilla.
Needle insertion area:in the fornix, above the second molar, advance into
the soft tissue in a single movement upwards, at an angle of 45° to the
occlusal plane, inwards, towards the midline at an angle of 45° with respect
to the occlusal plane, and posteriorly, at an angle of 45° with respect to the
longitudinal axis of the upper second molar. There is no resistance; in case of
contact with the bone, withdraw the needle without extracting it and position
the syringe closest to the occlusal plane. Advance with a 16 mm penetration
and aspirate in two planes by rotating the syringe and re-aspirating. Slowly
deposit the anesthetic and aspirate in one plane only.
Action time:3-5 minutes.
Aug:short, 25-27 G.
Dose:0.9-1.8 mL of anesthetic.
Aspiration:positive 3.1%.
Advantages:atraumatic, high success rate (>95%) and reduced volume of
anesthetic required, with a consequent reduction in the number of infiltrations
necessary to obtain an anesthetic effect of the same magnitude.
400

Disadvantages:haematomas, absence of bone anatomical references,

necessary palatal infiltration if an effect on the palatal soft tissues is desired,
but also a vestibular infiltration in the case of the upper first molar whose
mesial root is served by the superior median alveolar nerve (insertion of the
at the level of the fornix above the second premolar).
Alternatives:supraperiosteal anesthesia, maxillary block.
Complications:if the needle is inserted too far posteriorly, there is the
possibility of injuring the pterygoid venous plexus causing a hematoma that
develops within minutes.

Anterior superior alveolar nerve block (ASA)

This technique is little known even if it represents a safe method with a high
percentage of success. It can be used if you want to avoid supraperiosteal
anesthesia, which requires more anesthetic. Sometimes it is erroneously
associated with infraorbital nerve block, which does not induce anesthesia of
the dental pulp or soft tissues.
Anesthetized or elective anatomical areas:upper central incisor to
ipsilateral canine and premolar including soft tissue, lower eyelid, upper lip,
nose from injection side.
Indications:treatments from incisor to canine if, due to infections,
supraperiosteal infiltrations are contraindicated.
Advantages:simple and moderately safe technique.
Disadvantages:despite its relative simplicity, this maneuver is not
considered safe by the dentist who fears damaging the patient's eye. In order
to obtain anesthesia of the palatal tissues (hook of the dam), it is still
necessary to associate a palatal infiltration.
Technique:locate the infraorbital foramen which can be seen as a concavity
(its compression causes slight pain), insert the needle at the level of the fornix
above the first premolar until contact with the bone is perceived (upper edge
of the infraorbital foramen). The depth of penetration varies according to the
type of patient: in an average adult it can be about 16 mm. Keep needle and
syringe parallel to long axis of tooth, aspirate and then inject slowly.
Aug:long, 25-27G.
Dose:0.9-1.5mL.
401

Considerations:contact of the needle with the roof of the foramen avoids

encroachment into the orbit. In case of excessive insertion, withdraw the
needle without withdrawing it, palpate the foramen and reinsert. Do not inject
until contact with bone has been achieved.

Palatal anesthesia
In endodontics there is rarely the need to induce anesthesia in large palatal
areas, since it is generally preferred to opt for infiltrations which are
sufficiently useful for the purpose. Furthermore, these palatal anesthesia
techniques are very painful and it is necessary to try to relieve the pain using
maneuvers that are as atraumatic as possible.
Technique:surface anesthesia (cooling), pressure on the area (with a finger,
although it is preferable to use an object that compresses in a smaller area,
such as a cotton swab or gauze wrapped around the handle of the mirror).
Identify the needle insertion site, which is highlighted as the area made
temporarily ischemic by compression, and inject the solution very slowly
while maintaining the compression.
Aug:short, 27G.
Keyword:slow infusion of the anesthetic.

Greater palatine nerve block

Indications:surgical or periodontal treatments or extensive reconstructions.
Anatomical areas of choice:hard and soft tissues of the palate from the
retromolar region to the mesial region of the first premolar.
Advantages:good anesthesia is obtained for a large area with a single
puncture.
Disadvantages:traumatic maneuver.
Aspiration:positive <2%.
Aug:long, 27G.
Dose:0.45 mL of anesthetic.
Technique:supine patient, accentuated mouth opening. Apply light
compression at the joint between the upper alveolar process and the hard
palate, in correspondence with the upper first molar, and travel the palate
posteriorly. Reach the greater palatine foramen, which is usually located
distal to the second molar (the cotton swab falls into the concavity). Apply
pressure about 1-2 mm anterior to the
402

hole and place the syringe from the opposite side, approaching it at right
angles. Then insert the needle tip releasing small amounts of anesthetic and
continue injecting while placing the syringe on the ipsilateral lower teeth.
Advance to touch the palatine bone to a penetration depth of approximately
10 mm. Aspirate and inject the rest of the anesthetic solution.
Success rate:95%.

Nasal palatine nerve block (incisor nerve block)

Indications:restorative or surgical or periodontal treatments.
Anatomical area of choice:soft and hard tissues of the anterior palate mesial
to the right first premolar up to the mesial area of the left first premolar.
Technique:insert the needle on the palatal surface, lateral to the incisive
papilla behind the upper central incisors and along the midline, after
compressing the part. Insert the needle about 5-6 mm.
Aug:long, 27G.
Dose:0.45 mL of anesthetic.

Maxillary nerve block

Very rarely it is necessary to resort to a maxillary nerve block or second
division block.
Area:entire maxillary nerve, all ipsilateral teeth, soft tissue and bone
corresponding to the upper lip, lower cheek and eyelid, and wing of the nose.
Aug:long, 27G.
Dose:1.8 mL of anesthetic.
Intraoral approach technique:for jaw block:
● Deep tuberosity: Insertion of the needle in the same position is used for
PSA block with a greater depth, ie about 30 mm, compared to 16 mm
required for PSA anesthesia.
● major palatine canal: the canal is entered which is located palatally
between the third and second molars, at the junction between the alveolar
process and the palatine bone.
403

AMS extension
Technique of Friedman and Hochman [16,17] performed using the Wand
syringe, even if a traditional syringe can still be used. It allows to obtain the
anesthesia of the desired area with a single injection.Area:maxillary anterior
teeth up to the maxillary premolar with soft tissue and both palatal and buccal
bone. It does not determine a block of facial expressions.
Technique:the injection point is between the two premolars and the palatal
midline. With the computer-guided technique, administration is simple; if the
traditional syringe is used, the procedure recommended for the palatal must
be followed.
Aug:short, 27G.
Dose:1.35 mL of anesthetic.

Mandibular nerve
Inferior alveolar nerve block (IANB)
In theFigure 4.4the area that is anesthetized after performing the IANB is
highlighted [18-21].

Fig.4.4Area anesthetized by IANB. (From: Malamed SF. Manual of local anesthesia. 5th ed.
Milan: Elsevier Masson; 2006.)

The IANB technique is used to anesthetize all the dental elements of the
ipsilateral arch; i.e. an entire lower quadrant up to the midline, including
buccal soft tissue and bone anterior to the foramen
404

liar. To obtain anesthesia of the mucoperiosteal structures, anesthesia of the

buccinator nerve is associated, inserting the needle into the buccal fornix
distal and buccal to the last molar in the arch, especially in anticipation of
surgery.
Indications:treatments on multiple lower teeth, treatments on the lingual
mucosa and on the vestibular mucosa anterior to the mental foramen.
Anesthetized anatomical areas:lower premolars and molars. In the case of
incisors and canines, an insufficient anesthetic effect may occur, for which it
is necessary to resort to vestibular infiltrations.
Advantages:large area of anesthesia.
Disadvantages:as far as the third molar is concerned, this technique may be
sufficient to carry out the extractions, but it is instead insufficient to proceed
with an endodontic treatment. Furthermore, it is often ineffective in the
presence of infections. In this case, blockade of the incisive nerve and the
mental nerve can be used. In fact, numerous prospective randomized and
double-blind studies have demonstrated the ineffectiveness of the IANB in
the presence of irreversible pulpitis, even if it is associated with local
infiltration. It may happen that the anesthetic effect of the mesial root of the
first molar is not obtained (the cause is attributable to the presence of some
collateral branches from the mylohyoid nerve, which often presents
variability regarding its path). This drawback can be overcome by inserting
the needle against the lingual wall of the mandible, at the level of the apex of
the lower second molar. The lack of anesthetic effect is often due to errors in
the execution, in fact this is the technique with the highest percentage of
clinical failure (15-20%).
Aspiration:positive from 10 to 15%, the highest among intraoral anesthesia
techniques.
Technique:first of all, the cavity of the coronoid must be recognized and
palpated with the thumb or forefinger, exerting a slight pressure. At this
point, an imaginary line must be identified between the fingertip and the
pterygomandibular raphe: this line is parallel and runs about 8-10 mm above
the occlusal plane. The syringe is then placed on the contralateral corner of
the mouth. The injection point is located at the insertion between this
aforementioned imaginary line and a vertical line represented by the
pterygomandibular raphe at the point where it curves towards the maxilla, i.e.
the posterior limit of the ramus of the mandible (the distal end of the raphe).
The needle must be inserted until the bone is felt. Penetration with a long
needle should be approx
405

25 mm (two thirds of the needle length). Aspirate and, if the aspiration is

negative, start injecting slowly (about 1.5 mL). The needle is withdrawn
without withdrawing it, aspirated again and a quantity of approximately 0.1
mL of drug is again slowly injected to anesthetize the lingual nerve. It is
crucial to perceive the contact of the needle tip with the bone, in fact:
● if there is no contact, the needle is positioned too medially and must
be retracted approximately 1 mm and repositioned over the lower
molars;
● in case of immediate contact with the bone, the needle is positioned
laterally to the mandibular ramus, so it is necessary to withdraw it
slightly, about 1 mm, and rotate the syringe towards the contralateral
canines.
Aug:long, 27 or 25 G.
Dose:1.5 mL of anesthetic.
Alternatives:mental nerve block to achieve anesthesia of the buccal soft tissue
anterior to the first molar:
● Gow-Gates blockade;
● Vazirani-Akinosi blockade;
● intraosseous anesthesia;
● intraseptal block.
Causes of failure:the most frequent causes of failure of this technique are
generally linked to incorrect execution; in fact it is crucial to perceive the
contact of the tip of the needle with the bone.
This technique is often insufficient at the level of the incisors. This is due to
an innervation of the area of interest also by some branches of the
contralateral trunk; therefore it is advisable to add an infiltration in the fornix
in correspondence with the tooth, even if anesthesia of the periodontal
ligament (PDL) is more effective in this sector.
Complications:muscle pain following exhausted mouth movements; infusion
of the anesthetic into a blood vessel in the absence of aspiration before
infusion; mandibular nerve paresthesia; encroachment into the parotid lodge
with consequent transient paralysis of the facial nerve.

Vestibular nerve block

The vestibular nerve is a branch of the anterior branch of the mandibular nerve
(V3) also known as the buccinator nerve.
Area:buccal mucosa and periosteum at the level of the lower molars.
406

Indications:since the area of the buccal mucosa and periosteum at the level
of the lower molars is excluded even after performing an IANB, this
technique can be used when it is necessary to intervene, for example on the
buccal mucosa or in case of difficult positioning of the dam hook .
Advantages:simple technique with high success rates.
Disadvantages:it can be painful if you insert the needle too deeply.Needle
insertion area:buccal fornix of the most distal tooth of the arch.
Aug:long, 25-
27G.Aspiration:positive
0.7%.Alternatives:
● infiltration;
● Gow-Gates blockade;
● Vazirani-Akinosi blockade;
● PDL anesthesia;
● intraosseous anesthesia.

Mandibular block using the Gow-Gates technique. Third

division nerve block, V3 block
In the Figure4.5 the area that is anesthetized is highlighted
Afterthe execution of the Gow-Gates technique
(GGMNB).

Fig.4.5Area anesthetized using Gow-Gates. (From: Malamed SF. Manual of local anesthesia.
5th ed. Milan: Elsevier Masson; 2006.)
407

This technique [22-26], described by Gow-Gates in 1973, solves the

problems related to the high failure rate of the IANB (15-20%). In fact, with
a single injection it allows to obtain the mandibular block (V3) with a success
rate of about 97%.
Target nerve:
● lower alveolar;
● mentoring;
● incisive;
● lingual;
● mylohyoid;
● auriculotemporal;
● vestibular.
Anesthetized anatomical area:same area as the IANB. Molars, premolars,
canines, lower incisors.
Indications:the same as for the IANB, in the event that the lower alveolar
block is ineffective.
Contraindications: infections, patients unable to
makeadequate mouth opening and children.
Advantages:
● high success rate (>95%);
● minimal positive aspiration (2%);
● low risk of complications;
● does not require additional injections.
Disadvantages:effect time of about 5 minutes, therefore longer than with the
IANB (3-5 minutes). Learning curve required.
Needle insertion area:in the mucosa of the lateral aspect of the anterior
surface of the condyle below the insertion of the lateral pterygoid muscle,
distal to the upper second molar.
Technique:arrange the patient in such a way that he is supine or semi-supine,
with the maximum extension of the head and the maximum opening of the
mouth. Important for learning purposes are the reference points:
● extraoral: triangular incision or lower limit of the tragus, corner of the
mouth;
● intraoral: mesiolingual cusp of the upper second molar, insertion site
distal to the upper second molar.
● Syringe barrel positioned at the corner of the contralateral mouth.
Insert the needle slowly with the tip directed under the cusp
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mesiolingual of the upper second molar. Then align the barrel of the
syringe at the top of the injection, parallel to the angle between the tragus
and the labial fissure (usually over the premolars). At this point advance
the needle until it comes into contact with the bone (neck of the condyle),
maintaining an insertion height of approximately 10-25 mm (these
measurements may change, as they depend on anatomical variations). The
penetration depth is approximately 25mm. As in the IANB procedure, if
there is no contact with the bone, the needle must be withdrawn without
withdrawing and directed more distally. Do not inject if you do not come
into contact with the condyle. After this phase, withdraw the needle 1 cm,
aspirate and, in case of negative aspiration, inject slowly, in case of
positive aspiration, withdraw the needle and introduce it more superiorly.
Finally, it is advisable to ask the patient to keep his mouth open for about 2
minutes after the injection, to allow for complete diffusion of the drug.
This way there is a lower risk of taking the artery.
Aug:long, 25G.
Dose:1.8-3.0 mL of anesthetic.
Alternatives:all mandibular local anesthesia techniques can be alternatives to
GGMNB, but after an adequate learning curve the success achieved is such
that no other interventions are required.
Complications:rarely hematoma at the injection site.
Mandibular GGMNB may increase the success rate in patients with
irreversible pulpitis compared to traditional IANB.

Mandibular block with closed mouth technique or

Vazirani-Akinosi technique
In theFigure 4.6the needle insertion area for Vazirani-Akinosi block is shown
[27,28].
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Fig.4.6Needle insertion area for Vazirani-Akinosi block. (From: Malamed SF. Manual of
local anesthesia. 5th ed. Milan: Elsevier Masson; 2006.)

In the event of limited opening of the mouth, due to causes such as trismus or
trauma, this technique, causing both sensory and motor blockage, allows the
patient to open his mouth and therefore undergo endodontic treatment.
Indications:limited openness, unable to run IANB or GGMNB.Anesthetized
anatomical area:the same area as the IANB and the GGMNB.Needle
insertion area:maxillary buccal fornix at the mucogingival junction of the
most posterior maxillary tooth. It advances into the soft tissues of the face
lingually to the mandibular ramus, adjacent to the maxillary tuberosity. The
needle must be kept parallel to the mandibular ramus and the barrel of the
syringe in turn parallel to the superior occlusal plane. In case of trismus, the
patient feels the improvement immediately after the injection.
Advantages:useful in the presence of a bifid inferior alveolar nerve.
Disadvantages:the absence of contact with the bone, so that even the depth of
penetration can only be subjective.
Aug:long, 25G.
Dose:1.8 mL of anesthetic.
Failure:it is related to insufficient depth of penetration of the needle or to the
insertion point being too low.
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Complications:hematoma, trismus, transient facial nerve paralysis (due to

excessive insertion and encroachment into the parotid lodge).
Alternatives:the only alternative is the extraoral mandibular nerve block
[26].

Mental nerve block

The mental nerve is one of the terminal branches of the inferior
alveolar.Indications:this technique is generally used for treatments on the
soft tissues of the vestibular area (biopsies, sutures).
Anesthetized anatomical area:buccal soft tissue anterior to the
foramen.Needle insertion area:locate the fovea over the foramen, usually
near the apex of the second premolar. The compression of this area produces a
slight pain useful for its exact location. Further view the preoperative
radiograph for a more precise location of the foramen itself, then traction the
lower lip and soft tissues to make the injection less traumatic. Orient the
needle towards the bone and insert it close to the mental foramen. Inject to a
depth of approximately 5-6 mm, aspirate and inject slowly. It is usually
advisable to exert a slight pressure of 1 or 2 mm to facilitate the penetration of
the anesthetic into the mental foramen.
Aug:short, 25-27 G.
Dose:0.6 mL of anesthetic.
Advantages:high success rate and easy to learn.
Disadvantages:hematoma formation in the injection area.
Aspiration:positive 5.7%.

Incisor nerve block

The continuation of the mental nerve is the terminal branch of the inferior
alveolar. In general, anesthesia of this area can be obtained with the IANB,
however it can be useful in lower anterior teeth when an IANB is not desired
[29].
Indications:treatments that include the lower teeth from canine to canine,
thus avoiding performing a bilateral IANB which would be too
uncomfortable for the patient.
Anatomical area of choice:premolar, canines, lower incisors, buccal mucosa
anterior to the mental canal.