Aarti Daswani

Foreword
Sharad Kokate
Short Textbook of
Endodontics
Short Textbook of
Endodontics

Aarti Daswani  BDS

Dental Surgeon and Private Practitioner
Divine Smiles Dental Clinic
Andheri (East), Mumbai, Maharashtra, India

Foreword
Sharad Kokate

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Short Textbook of Endodontics

First Edition: 2016

ISBN  978-93-5250-121-2

Printed at
 Dedicated to
My Parents
(Mr Rupchand and Mrs Sangita Daswani)
 Foreword

It is a proud moment and a great pleasure to see one of our talented graduates writing the Short Textbook
of Endodontics.
Aarti Daswani’s strong will and passion for last several years after graduation has given a wonderful
shape to the final content of this textbook. Aarti Daswani has made an excellent attempt at making the
indispensable knowledge of Endodontics easier to understand for the students as well as clinicians. The
unique feature of this textbook is the mind-maps in each chapter, which should help in summarizing and
memorizing during examinations.
The meticulously prepared content will further help as an invaluable reference for the students as well
as clinicians. The language of the textbook is very simple and the diagrammatic representation makes it
simpler.
I am confident that the book will go a long way in clearly simplifying and developing interest amongst the readers.

Sharad Kokate
Dean, Professor of Conservative Dentistry and Endodontics
Yerala Medical Trust’s Dental College and Hospital,
Kharghar, Navi Mumbai, Maharashtra, India
Vice President
Maharashtra State Dental Council
Mumbai, Maharashtra, India
 Preface

What led me to the idea of writing Short Textbook of Endodontics is an astonishing realization that the field of Endodontics has
undergone sea changes in the last few years. Endodontic treatment has come a long way from what it was till about two decades
ago. Not only dental materials and instruments have become technically superior, but also the concepts, procedures and attitudes of
clinicians have acquired a modern outlook. Technology has made Endodontic treatment swift, convenient, easier and interesting.
In addition to incorporating the new developments in Endodontics, Short Textbook of Endodontics has been designed to
cover each and every aspect of Endodontics in a concise yet comprehensive manner. Considering the fact that time is a critical
factor in today’s competitive and busy world, there is no doubt that reading big fat textbooks to get through the examinations
is an uphill task for the students. However, remembering the information is important and this requires repeated reading and
revision. This book is expected to make reading Endodontics interesting and a fun-filled experience through the use of different
memory improvement techniques. Purpose of this book is not to serve as replacement of standard textbook but to complement
the textbook and be used solely for revision.
Thus, Short Textbook of Endodontics is a:
• Memory aid: That helps you memorize, retain and reproduce the required information of the basic texts.
• Rapid revision guide: That helps you save time and quickly revise the subject while preparing for the examinations.
Unique feature of this book is inculcating learning through “Mind-maps”, a concept introduced by Tony Buzan, popular
Psychology author and television personality. A mind-map is a diagram used to visually organize information. This diagramming
tool can be used to generate, visualize, structure and classify ideas and as an aid to studying and organizing information in a
concise yet comprehensive manner. Mind-maps used in this book act as a quick learning aid to the ever-expanding world of
Endodontics. Of course, it goes without saying that mind-maps are just meant to help the reader remember all relevant points
of a topic and should not be reproduced in the examination papers as the same may not be acceptable.
The general practitioners can use this book to train their mind to remember what next in the course of performing Endodontic
procedures. The book will serve as a foundation for sound theoretical knowledge, based on which practitioners can perform
better in a given clinical situation.
Writing this book would not have been possible without contributions from multitude of people including my college teachers,
eminent Endodontists and general dentists, computer experts and artists.
“If you cannot explain it simply, you do not understand it well enough”—Albert Einstein.
Through this book, I have made a sincere attempt to simplify the subject of Endodontics based on my understanding and
clinical experience of seven years. I hope it will be useful to the readers.
I look forward to your suggestions, contributions and comments on Short Textbook of Endodontics (First edition) for future
additions and improvements.

Aarti Daswani
 Acknowledgments

First and foremost, I would like to express my heartfelt gratitude to my Satguru and God Almighty for all their blessings,
unconditional love and wealth of knowledge they have showered on me and continue to shower on me every single day.
My sincere thanks to my parents for being a constant source of support and encouragement in all my endeavors and for all
their love and sacrifices. Special thanks to my younger sister Yogi, for introducing me to Tony Buzan’s concept of ‘Mind-maps’ and
to my elder sister Lata, for being my critic, inspiration and guide throughout the compilation of Short Textbook of Endodontics.
Special thanks to my dear friends Mamta, Samta, Jayshree, Amita and Kanika for their constant motivation and encouragement
that inspired me to move faster towards realizing my dream of being an author.
I am grateful to my assistants in clinical practice, Maya and Kalpana, for their support and cooperation during the compilation
of the book.
I would like to thank Shri Jitendar P Vij (Group Chairman), Mr Ankit Vij (Group President), Mr Tarun Duneja (Director–
Publishing), Mr KK Raman (Production Manager) and the entire team of M/s Jaypee Brothers Medical Publishers (P) Ltd, New
Delhi, India, for believing in my convictions and giving me an opportunity to write this book and allowing me to make a small
contribution to dental profession in my own way. Special thanks to Mr Ramesh Krishnamchari and Mr Sabarish Menon (Author
Coordinators), Mr Sunil Dogra (Production Executive) and Mr Mohit Bhargava (Production Coordinator), of M/s Jaypee Brothers,
for guiding me throughout the project.
My heartfelt thanks to Dr Sharad Kokate, Dean, Yerala Medical Trust’s (YMT) Dental College and Hospital, Kharghar, Navi
Mumbai, for giving me permission to use innumerable reference books from college library and for his constant support, guidance
and encouragement throughout the compilation of the book. He also very kindly agreed to write the foreword for the book.
I am truly indebted to my teacher Dr Mrunalini Vaidya, who is a great Endodontist, an excellent academician and a Professor
at YMT Dental College and Research Institute, Navi Mumbai, Maharashtra, India, for Conservative Dentistry and Endodontics.
I take this opportunity to extend my deep gratitude to her for devotion of her time and dedicated efforts in critically evaluating
each chapter and providing valuable suggestions to improve the book.
My sincere thanks to Dr Vishal Rathod for creating amazing diagrams and simplified illustrations for the book.
I am grateful to Dr Manoj Ramugade, MDS, Conservative Dentistry and Endodontics, teacher at Nair Hospital Dental
College, Mumbai, Maharashtra, India, for his valuable contribution towards the layout of the book. He also helped me with critical
evaluation of initial chapters and gave valuable suggestions to improve the contents including contribution by way of some very
good photographs and radiographs for the book.
I am thankful to my friend Dr Suvarna Kondawale for going through the chapters and providing suggestions for improvement.
Many thanks to Dr CR Suvarna for providing few photographs of Endodontic equipment and also his case photographs.
I am really grateful to Dr Ajay Bajaj for his critical evaluation and valuable suggestions as well as encouragement and support
including contribution in the form of his case radiographs for the book.
Many thanks to Dr Ashwin Jawdekar for providing useful information, case radiographs and photographs for the three
chapters namely Pediatric Endodontics, Pulp Therapies and Management of Dental Traumatic Injuries.
My heartfelt thanks to Dr Mansi Shah for contributing valuable information on Cone Beam Computed Tomography (CBCT)
scans in the chapter Diagnosis and Diagnostic Aids in Endodontics and for providing her case radiographs and CBCT scans for
the book.
xii Short Textbook of Endodontics

My deep appreciation to Dr Shivani Bhatt, a dynamic and enthusiastic dentist for contributing her case photographs and
radiographs for the book.
My humble gratitude to Dr Roheet Khatavkar, an Endodontist par excellence, who uses all the latest available equipment and
instruments in Endodontics selectively for his cases, for contributing valuable information and his case radiographs.
I am grateful to Dr Nilesh Kadam for contributing his case radiographs for the book.
I am thankful to Dr VS Mohan, Dr Mukul Dabholkar, Dr Rajesh Podar, Dr Raunak Rai, Dr Paresh Dodhiwala, Dr Samir
Khaire, Dr Rajesh Shivhare, Dr Ritesh Mahashabde, Dr Sonam Singh, Dr Mugdha Mitkar, Dr Nomal Sheth and Dr Dharna Parekh
for their contribution, help and support for the book.
I am grateful to Dr Chetan Shah for his sincere and enthusiastic support and encouragement, which helped me give a new
dimension to the book.
My special thanks to Dr Cliffton Ruddle for giving me permission to use photographs from his inventions in Endodontics.
Also special thanks to American Association of Endodontists for giving me permission to reprint the Endodontic case difficulty
forms.
Heartfelt thanks to Dr Priyanka Karande and Dentsply company for providing me with high resolution photographs of
Dentsply Endodontic products; to Mr Amit Borkar and Dr Raghu for providing me with high resolution images of the Sybron
Endo products; to Mr Guru and Micro-Mega company for providing me with high resolution images of the Micro-Mega Rotary
Endodontic system; to Re Dent Nova company and Dr Ajit Jha for valuable information and photographs of the latest self-adjusting
file system.
My sincere gratitude to Mr A Sawant for preparing the initial computerized typescripts of the entire textbook.
 Contents

1. Introduction 1
What is the Scope of Endodontics?  1;  What are the Aims and Objects of Endodontics?  2;
What are the Changes and Recent Advances that have Occurred in the Field of Endodontics?  2

2. The Dental Pulp and the Periradicular Tissues 5

What is the Dental Pulp and the Dentin-Pulp Complex?  5;  What are the Special Characteristics of
the Dental Pulp as Connective Tissue?  6;  How is the Dental Pulp Formed?  6;  What are the Histologic
Features of Dental Pulp?  8;  What is the Blood Supply of the Pulpal Tissues?  11;  What is the Nerve
Supply of Pulpal Tissues?  12;  What is the Lymph Supply of Pulpal Tissues?  12;  What are the Functions
of the Pulp?  13;  What is the Morphology and Histology of Periradicular Tissues?  14

3. Morphology and Internal Anatomy of the Root Canal System 19

What are the Anatomic Components of the Root Canal System?  19;  What are the Regressive Changes
that Occur in the Anatomy of Root Canal System?  21;  What are the Different Types of Root Canal
Systems in any Root?  21;  What is the Anatomy of the Apical Portion (Apical 1/3rd) of the Root
Canal?  25;  Which are the Anatomic Complexities that can Occur in Root Canal System?  26;  What is
Isthmus and What is its Role During Endodontic Surgical Procedure?  29;  Role of Isthmi in Endodontic
Surgical Procedure  29;  What are the Possible Developmental Anomalies and Variations in the Anatomy
of Root Canal System?  29;  What is the Morphology of the Root Canal System of the Individual Teeth?  32

4. The Pulpal Reactions to Caries and Dental Procedures 50

How is the Response of Dental Pulp Unique and Different from other Connective Tissues of
The Body?  50;  Which are the Different External Stimuli that can Affect the Dental Pulp?  50;
How does the Pulp React to Dental Caries?  50;  How does the Pulp React to Dental Procedures?  54

5. Diseases of the Pulp and the Periradicular Tissues 62

What are the Possible Causes of Diseases of Dental Pulp?  62;  How does the Pulp React to Different Direct
and Indirect Stimuli and how is the Response Unique?  66;  How do we Classify the Diseases of Dental
Pulp?  66;  What are the Different Features of the Diseases of the Dental Pulp?  67;  What are the Causes
of Diseases of the Periradicular Tissues?  71;  How do we Classify the Diseases of Periradicular Tissues?  72;
What are the Different Features of the Diseases of Periradicular Tissues of Endodontic Origin?  72;
What is the Pathogenesis of Primary Apical Periodontitis?  81

6. Endodontic Microbiology 83
What is the Basis of Focal Infection Theory and why is it Totally Rejected Today?  83;  What are the Pathways
or Portals of Entry of Microorganisms in the Pulp?  84;  What is the Microbial Flora of Root Canal?  84;
Which are the Types of Endodontic Infections?  86;  What is the Role of Microbial Virulence and Host Response
in the Pathogenesis of Disease?  88;  What are the Methods for Detection, Identification and Examination of
Microbes from a Root Canal?  89;  What is the Biofilm and What is its Significance in Endodontics?  92

7. Diagnosis and Diagnostic Aids in Endodontics 98

What is Diagnosis and how to be a Successful Diagnostician?  98;  What are the Steps to
be Followed to Arrive at a Correct Diagnosis?  98;  Step 1: Case History Taking  99;  Step 2: Clinical
Examination  104;  Radiographs  109;  Requirements of a Good Radiograph  111;  Limitations or
Drawbacks of Radiographs  111;  Radiation Safety  111;  Film Holders  115;  Cone Beam Computed
Tomography (CBCT) for Endodontics 118;  Step 3: Diagnostic Tests  118;  Special Tests  123;
Step 4: Arriving at an Accurate Endodontic Diagnosis  129
xiv Short Textbook of Endodontics

8. Rationale of Endodontic Therapy 130

Which were the Proposed Theories of Spread of Infection that Developed into the Modern Philosophy of
Endodontics?  130;  How do the Dental Biologic Tissues React to Noxious Stimuli?  131;  Why is the
Inflammatory Response in Connective Tissue of Dental Pulp Different from other Parts of Body?  131;
What are the Tissue Changes that Occur during Inflammation?  131;  What Tissue changes occur
following Inflammation?  135;  What is the Role of Immunity in Endodontics?  135;
What are the Zones of Reaction of Periradicular Tissues and Endodontic Implications?  136

9. Case Selection and Treatment Planning 139

How to Evaluate a Case for Treatment?  139;  What are the Factors to be Considered for Case Selection
for Root Canal Treatment?  141;  What are the Indications and Contraindications of Root Canal
Treatment?  143;  How to Develop an Endodontic Treatment Plan?  145;  How to Assess Difficulty
of an Endodontic Case?  146;  AAE Endodontic Case Difficulty Assessment Form and Guidelines  147

10. Principles of Endodontic Treatment 150

What are the Principles of Endodontic Treatment?  150

11. Endodontic Armamentarium: Instruments, Materials and Devices 158

What Changes have Occurred in the Endodontic Armamentarium in the Practice of Modern
Endodontics?  158;  What are the Devices used for Enhanced Vision, Illumination and Magnification?  159;
What are the Instruments, Materials and Devices used as Diagnostic Aids in Endodontics?  161;  What is
the Armamentarium for Administration of Local Anesthesia?  163;  What are the Materials used for
Isolation of Endodontic Field?  163;  What is the Armamentarium Needed for Access Cavity Preparation of
Root Canal?  163;  What are the Instruments and Devices for Determination of Working Length?  167;
What are the Materials used for Disinfection of the Root Canal?  169;  What are the Instruments and
Devices used for Root Canal Preparation?  169;  Hand-Operated Instruments  170;  Engine-Driven
Instruments  177;  Ultrasonic and Sonic Instruments  178;  Nickel-Titanium Hand and Rotary
Instruments  179;  What are the Instruments used for Obturation of Root Canals?  186;  What are the
Instruments and Devices used for Removal of Root Canal Fillings and other Obstructions in Root
Canal?  187;  What are the Materials used as Temporary Restorations?  189;  What is the Armamentarium
for Periradicular Surgery?  190;  What are the Materials used for Post-Endodontic Restoration?  190;
What is the Role of Laser Device in Endodontics?  190

12. Asepsis and Sterilization of Endodontic Instruments 192

Why is Effective Infection Control Important in Endodontics?  192;  How to Achieve Effective Infection
Control in Dental Practice?  193;  What is Sterilization and Disinfection?  195;  How to take Proper
Care of Endodontic Instruments?  196;  What are the Commonly Employed Methods of Sterilization/
Disinfection of Various Endodontic Instruments?  198

13. Endodontic Access Cavity Preparation 199

What is Endodontic Triad?  199;  What is Coronal Access Cavity Preparation of the Root Canal?  199;
What are the Objectives of Access Preparation?  200;  What are the Principles of Endodontic Access
Cavity Preparation?  200;  What are the Guidelines to be followed for an Optimum Access Cavity
Preparation?  201;  What is the Armamentarium Needed for Access Cavity Preparation?  206;
Which are the Steps of Access Cavity Preparation?  207;  What are the Specific Features of Access
Preparation of Individual Teeth and Possible Errors Related to Them?  211;  Which are the Challenging
Access Cavity Preparations and How to Deal with them?  226;  What Errors can Occur During Access
Cavity Preparation?  228

14. Cleaning and Shaping of the Root Canal System Including

Working Length Determination 231
What is Cleaning and Shaping of Root Canals?  231;  What are the Objectives of Cleaning and Shaping
of Root Canals?  232;  Which are the Important Numerical Concepts in Root Canal Preparation and how
 Contents xv

to Determine them?  233;  What are the Current Concepts and Terminology for Root Canal
Preparation?  241;  What are the Different Instrument Motions for Effective Shaping of Root Canals?  243; 
What are the Requirements before Starting Canal Preparation?  244;  Which are the Different Root
Canal Preparation Techniques?  244;  What are the Precautions to be taken during Instrumentation?  262; 
What are the Procedural Errors that can Occur during Root Canal Preparation?  263

15. Disinfection of the Root Canal System 264

What is Disinfection of the Root Canal System?  264;  How to bring about Disinfection of the Root
Canal System?  264;  Which are the Different Chemical Agents used for Disinfection of the Root Canal
System?  265;  What is a Root Canal Disinfectant and What are its Requirements?  265;  Which are
the Different Root Canal Irrigants?  265;  Different Root Canal Irrigants  267;  What is Smear Layer and
how is it Managed in Endodontics?  271;  What are Intracanal Medicaments?  273;  What are the Methods
of Activation of Irrigating Solutions in the Root Canal System?  276

16. Obturation of Root Canal System 280

What is Obturation of Root Canal?  280;  What are the Objectives of Obturation?  280;  When to do
Obturation of the Root Canal?  281;  What should be the Apical Extent of Obturation?  282;  With what
should we do Obturation?  282;  What are the Requirements for an Ideal Root Canal Filling Material?  283;
Which are the Different Core Materials that can be used for Obturation?  283;  What are Root Canal Sealers
and What are the Requirements of an Ideal Root Canal Sealer?  288;  What is the Purpose of using a Root
Canal Sealer?  288;  How is the Sealer Placed in the Root Canal?  288;  Which are the Different Root Canal
Sealers used in Obturation?  289;  Root Canal Sealers in Detail  289;  What is the Preparation for
Obturation?  293;  How to do Obturation/which are the Different Techniques of doing Obturation?  294;
How should an Ideal Obturation be?  308;  What can go Wrong in Obturation?  308;
What is the Importance of Coronal Seal and How can we Enhance it?  309

17. Drugs or Medicaments used in Endodontic Treatment 311

How to Manage Fear and Anxiety in an Endodontic Patient?  311;
Which are the Drugs or Medicaments used in Endodontics?  312;

18. Single Visit Endodontics 320

What is Single Visit Endodontics?  320;  What is the Rationale for SVE?  320;  What are the Advantages
and Disadvantages of SVE?  320;  What are the Possible Indications and Contraindications of SVE?  321;
What are the Factors to be Considered for Case Selection for Doing SVE?  321;  What has Held Back SVE?  322

19. Endodontic Emergencies and Midtreatment Flare-Ups 323

What is an Endodontic Emergency?  323;  What is Meant by the Terms ‘Hot Tooth’ and ‘ERCO’?  323;
How to Make Correct Diagnosis in Case of Endodontic Emergencies?  324;  How do we Classify
Endodontic Emergencies?  325;  Endodontic Emergencies in Detail  326;  Endodontic Emergencies before
Treatment  326;  Interappointment Endodontic Emergencies  331;  Endodontic Emergencies after Treatment  335

20. Endodontic Mishaps: Management and Prevention 336

What are Endodontic Mishaps?  336;  How do we Classify Endodontic Mishaps?  336;
Endodontic Mishaps in Detail  337

21. Restoration of Endodontically Treated Teeth 355

How are Endodontically Treated Teeth Different?  355;  What is Expected Out of Postobturation Restoration?  357;
What is Direct ‘Coronal-Radicular’ Postobturation Restoration?  357;  What are the Factors to be Considered
for a Postendodontic Restoration?  357;  What are the Ideal Requirements of a Restorative Material to be
used for Postendodontic Restoration?  358;  What are the Restorative Options for a Postendodontic
Restoration?  359;  What is Post and Core Restoration?  360;  What is “Ferrule Effect” and “Biologic Width”?  361;
What are the Indications for Using Posts?  362;  What are the Required Clinical Characteristics
of Posts?  362;  What are the Different Types of Posts?  362;  What are the Clinical Parameters for Post
xvi Short Textbook of Endodontics

Selection?  365;  What are the Required Physical Characteristics of the Core?  367;  What are the Different
Types of Core Materials?  367;  What is the Technique of Fabrication of Foundation Restoration?  369; 
What are the Causes of Failure of Post and Core Restorations?  372

22. Endodontic Failures and Nonsurgical Endodontic Management 373

What is the Outcome of Endodontic Treatment?  373;  What are the Measures to be Employed to Improve
the Rate of Success of Treated Endodontic Cases?  373;  What are the Causes of Endodontic Failures?  374; 
How do you Diagnose Post-Treatment Disease?  375;  What is the Treatment Plan for the Patient with
Post-treatment Disease?  377;  What are the Indications and Contraindications of Endodontic Retreatment?  377; 
What are the Factors to be Considered for Endodontic Retreatment?  377;  What are the Steps of
Nonsurgical Endodontic Retreatment?  377;  What is the Prognosis of Endodontic Retreatment?  381

23. Management of Discolored Teeth 382

What are the Causes of Tooth Discoloration?  382;  What are the Different Methods of Management of
Discolored Teeth?  383;  What is Bleaching of Teeth?  383;  Why Bleaching?  383;  What is the Chemistry
and Mechanism of Bleaching?  384;  Etiology of Tooth Discoloration and its Management in Detail  384; 
What are the Indications and Contraindications of Bleaching?  388;  Which are the Materials used
for Bleaching?  388;  What is the Technique for Bleaching Vital Teeth?  389;  What are the Side Effects and
Adverse Effects of Extracoronal Bleaching of Vital Teeth?  391;  What is the Technique for Bleaching
Endodontically-Treated Teeth?  392;  What are the Side Effects and Adverse Effects of Intracoronal
Bleaching of Endodontically Treated Teeth?  397;  How do we Restore Intracoronally Bleached
Endodontically Treated Tooth?  398;  What is Enamel Microabrasion?  398;  What is the Role of Veneers
and Crowns in Management of Discolored Teeth?  400

24. Management of Dental Traumatic Injuries 401

What are the Unique Aspects of Dental Trauma?  401;  What are the Consequences of a Dental Traumatic
Injury?  401;  How do we Classify Traumatized Teeth?  402;  How do we Make Diagnosis in Case of Dental
Traumatic Injuries?  403;  What are the Factors to be Considered for Treatment of Traumatized Teeth?  404; 
What are the Different Dental Traumatic Injuries and Their Management?  404;  Requirements for Success
of Vital Pulp Therapy in Case of Traumatized Teeth  405;  Pulp Therapies in Traumatized Teeth  405

25. Endodontic-Periodontal Inter-Relationships 414

How are Endodontic and Periodontal Tissues and their Diseases Inter-Related?  414; 
What are the Etiologic Factors and Contributing Factors causing Endodontic-Periodontal Diseases?  415; 
How do we Classify Endodontic-Periodontal Lesions?  416;  How to Detect Endodontic Periodontal Lesions?  417; 
What Differential Diagnosis will you Consider when you see Features of both Endodontic and
Periodontal Lesions?  418;  Which are the Different Types of Endodontic-Periodontal Lesions?  418; 
What are the Treatment Alternatives in case of Endodontic-Periodontal Lesions?  422; 
What is the Prognosis of a Tooth with both Endodontic and Periodontal Disease?  424

26. Surgical Endodontics 425

What is Endodontic or Periradicular Surgery and what are its Objectives?  425;  What are the Indications
of Periradicular Surgery?  425;  What are the Contraindications of Periradicular Surgery?  426; 
What is the Contemporary Classification of Endodontic Surgery?  427;  What are the Important
Considerations while case Selection and Treatment Planning for Periradicular Surgery?  427; 
What are the Basic Principles and Steps to be followed in Periradicular Surgery?  429

27. Pulp Therapies 439

What is Vital Pulp Therapy?  439;  What are the Objectives of Vital Pulp Therapy?  439;  What are the
Techniques and Materials used for Vital Pulp Therapy?  439;  What are the Hemostatic Agents and
Antimicrobial Materials used in Vital Pulp Therapy?  446;  What is the Criteria for Case Selection for
Vital Pulp Therapy?  446;  What is Apexification (Nonvital Pulp Therapy)?  446
 Contents xvii

28. Pediatric Endodontics 450

What is Pediatric Endodontics?  450;  What are the Objectives of Preserving Primary Teeth?  450;
What are the General Features of Endodontic Treatment of Pediatric Patients?  450;  What are the Specific
Morphologic Features of Teeth of Pediatric Patients?  450;  How to Establish a Correct Pulpal Diagnosis
in Children?  453;  What is the Important thing you must Know about the Proximal Lesions in Primary
Teeth?  455;  Which are the Different Pulp Therapies Performed in Children?  457;  Pulp Therapies for
Primary Teeth  458;  Direct Vital Pulp Therapies  459;  Nonvital Pulp Therapy for Primary Teeth  463

29. Geriatric Endodontics 468

What is Geriatric Endodontics?  468;  What is the Scope of Geriatric Endodontics?  468;  What is the Need
for Geriatric Endodontics?  468;  What are the Specific Features of General Health of Older Patients?   469;
What are the Regressive Changes that Occur in the Teeth with Increasing Age?  469;  What are the Specific
Features of Teeth of Older Patients?   469;  Which Orofacial and Dental Signs and Symptoms are Elicited by
Clinician to Derive Correct Diagnosis?  470;  What are the Different Diagnostic Tests?   470;
How to Formulate Treatment Plan after making Correct Diagnosis in Geriatric Patient?  471;
What are the Steps in Endodontic Treatment in Geriatric Patient?  471

30. Pathologic Tooth Resorption 474

What is Tooth Resorption?  474;  What is Mechanism of Tooth Resorption?  474;  What are the Etiologic
and Stimulating Factors of Tooth Resorption?  475;  Which are the Types of Tooth Resorption?  475;
Which are the Clinical and Radiographic Features of Different Types of Tooth Resorption and How to
Manage Them?  476;  What are the Differences Between External and Internal Root Resorption?  480

31. Dentinal Hypersensitivity and its Management 482

What is Dentinal Hypersensitivity?  482;  What are the Different Hypotheses put Forward to Explain
the Mechanism of Dentinal Hypersensitivity?  482;  What is the Incidence and Prevalence of Dentinal
Hypersensitivity?  484;  What are the Predisposing Factors that cause Dentinal Hypersensitivity?  484;
How to Diagnose Dentinal Hypersensitivity?  484;  How to Manage Dentinal Hypersensitivity?  484

32. Lasers in Endodontics 488

What is Laser?  488;  What are the Properties of Lasers?  488;  What are the Components of Lasers?  488;
What are the Modes of Laser Light Emission?  489;  How is the Laser Interaction with Biologic Tissues?  489;
Which are the Types of Lasers?  490;  What are the Applications of Lasers in Endodontics?  491;
What are the Advantages and Limitations of Using Lasers in Endodontics?  494

33. Endodontic Practice: Ethics and Legal Responsibilities 495

What is Dental Ethics?  495;  What are the Principles of Ethics?  495;  What is Standard of Care?  495;
What is Dental Negligence and Malpractice?  496;  What are the Legal Responsibilities of the Clinician
While Performing Endodontics?  497

34. Regenerative Endodontics 500

What is Regenerative Endodontics?  500;  What is Tissue Engineering?  501;  What are the Mechanisms
and Clinical Procedures Related to Regenerative Endodontics?   503;  What is the Triple Antibiotic Paste?  503;
What are the Advantages and Limitations of Revascularization Procedure over Apexification Procedure for
a Necrotic Immature Permanent Tooth with Open Apex?  503;  What are the Clinical Considerations
for Regenerative Endodontics?  504;  What is the Protocol for Revascularization Endodontic Therapy?  504;
What are the Clinical Measures for Assessment of Endodontic Revascularization Treatment Outcome?  505

Index 507
 1
CHAPTER
Introduction
This chapter gives an overview of the subject of Endodontics and its importance in the field of dentistry.
 You must know
• What is the Scope of Endodontics?
• What are the Aims and Objects of Endodontics?
• What are the Changes and Recent Advances that have Occurred in the Field of Endodontics?
DEFINITION
• According to Grossman, Endodontics is that branch
of dentistry that deals with the etiology, diagnosis,
prevention and treatment of diseases of the pulp and
periapical tissues compatible with good health.
• According to American Association of Endodontists,
Endodontics is that branch of dentistry that is concerned
with the morphology, physiology and pathology of
human dental pulp and periradicular tissues. Its study
and practice encompass the basic clinical sciences
including biology of the normal pulp; the etiology,
diagnosis, prevention and treatment of diseases and
injuries of the pulp; and associated periradicular
conditions.
WHAT IS THE SCOPE OF ENDODONTICS?
1. Diagnosis and management of oral/dental pain
2. Diagnosis and treatment of diseases of pulp and
periradicular tissues.
3. Pulp therapies:
i. Pulp capping—indirect pulp capping (IPC) and
direct pulp capping (DPC)
ii. Pulpotomy
iii. Apexogenesis and apexification
Pulp capping and pulpotomy comes under vital pulp
therapy (VPT)
4. The root canal treatment (RCT) or the Endodontic
treatment
5. Nonsurgical retreatment of teeth that have undergone
Endodontic failure (Re-RCT)
6. Post-obturation restoration (POR) including post and
core built-ups
7. Bleaching of teeth
8. Treatment of traumatized teeth. For example,
replantation of avulsed tooth
9. Age-specific Endodontics:
i. Pediatric Endodontics
ii. Geriatric Endodontics
10. Surgical Endodontics including apicoectomy,
hemisection, Endodontic implants, etc.)
11. Research of newer biocompatible materials and
techniques to make Endodontics more predictable.
12. Use of magnification in Endodontics such as dental
operating microscope (DOM) to enhance efficacy of
procedures (Microendodontics)
13. Use of other clinical adjuncts such as ozone therapy in
Endodontics and lasers in Endodontics.
Figure 1.1 shows a mind-map giving the scope of
Endodontics in short.
2 Short Textbook of Endodontics

Fig. 1.1  Mind-map to remember the scope of Endodontics

WHAT ARE THE AIMS AND OBJECTS OF
ENDODONTICS?
Schilder stated goals of Endodontics: “Root canal systems
must be cleaned and shaped to receive a three-dimensional
hermetic (fluid-tight seal) filling of the entire root canal
space.”
“The logical goal of Endodontic treatment is to eliminate
or substantially reduce the microbial population within the
root canal system and to prevent reinfection by a tight seal
of the root canal space.” (PNR Nair, Pathways of Pulp, 9th
edn. p.573).
The aims and objects of Endodontics can be summarized
as given in Figure 1.2.
(Remember the mnemonic: P3 R3 ESS).
WHAT ARE THE CHANGES AND RECENT
ADVANCES THAT HAVE OCCURRED IN
THE FIELD OF ENDODONTICS?
In the last 2–3 decades, lot of advances have taken place
in the art of Endodontics and science of Endodontology.
Epidemiological studies suggest that the percentage of teeth
that can be retained through contemporary Endodontic
 Introduction 3

Fig. 1.2  Aims and objects of Endodontics

therapy is rising well above 90%. Millions of teeth are being
saved and then successfully restored to their full functional
and esthetic value.
Sea changes in Endodontics: There have been major
changes in the practice of Endodontics. Although goals
to be achieved remain same but ‘How’ these goals can
be achieved efficiently, effectively and without much
discomfort to the patient in as less time as possible, has led
to a lot of research in this field. Few examples of change
in Endodontics are listed in Table 1.1. These have been
explained in detail in the respective chapters.
4 Short Textbook of Endodontics
TABLE 1.1  Endodontics—Past and Present
Changes in
Diagnostic aids
Visualization
Endodontic instruments
Instrumentation
Instrumentation technique
Working length and detection of apical
constriction (Minor apical diameter)
Irrigation of root canals
Obturation materials
Improved biocompatible materials
Surgical Endodontics
Newer devices and equipment
Other advances
BIBLIOGRAPHY
1. Cohen S, Hargreaves KM. Pathways of Pulp, 9th edn. St. Louis:
Mosby; 2006.p.573.
From past → to → present day Endodontics
• Conventional radiographs → Enhanced imaging with the help of digital radiography (2-dimensional) and
CBCT scans (3-dimensional)
• Conventional methods of testing Pulp vitality → Improved methods such as laser Doppler flowmetry (LDF),
pulse oximetry vitality scanner, etc.
Naked eye vision → Enhanced vision with magnification using loupes, dental operating microscope (DOM)
with and without illumination, Endoscope and Orascope
Made of carbon steel → Made of stainless steel (improved quality) → Made of nickel -titanium multitapered
instruments (different shapes)
Using manual (hand) instruments → Engine-driven nickel-titanium rotary instruments combined with hand
instrumentation → other newer ways of instrumentation
Conventional → Step-back → Crown-down approach
Tactile sensation → Radiographs → Electronic apex locators combined with radiographs
Use of syringe-needle → Improved delivery systems, use of ultrasonic tips, EndoVac irrigation system and
other newer irrigation systems. One of the recent advances include self-adjusting file (SAF) system, in which
cleaning, shaping, irrigation and agitation of the irrigant are achieved simultaneously
•  Core materials: Silver points → Gutta-percha → Thermoplasticized gutta-percha: Devices such as System-B,
Touch-n-heat, Obtura II etc. → Resilon (resin-based)
• Sealers: Zinc oxide eugenol sealers → Eugenol-free calcium hydroxide and other sealers → Epoxy resin-
based sealers, methacrylate resin-based sealers
• Calcium hydroxide and other repair materials → mineral trioxide aggregate (MTA)
• MTA is a root canal repair material that has made perforation repair and apexification possible even in the
presence of moisture
Conventional Endodontic surgery → Microsurgical Endodontics
Microsurgical Endodontics is a predictable option due to:
• Use of microscope (good magnification and illumination)
• Use of ultrasonic tips
• Use of MTA as retrograde filling material
• Microinstruments
•  Retreatment: Use of hedstrom files to remove old root canal fillings → Use of DOM and improved devices
and instruments for retreatment including:
–  Specialized kit for gutta-percha removal
– Devices to retrieve obstructions such as separated instruments, posts, foreign objects, etc.
For example, Brassler Endo Extractor kit and Masserann kit, Guttapercha removal rotary file systems such
as D1, D2 and D3, Postremoval system (PRS) kit, etc.
•  Introduction of lasers in Endodontics
• Use of saliva for diagnosis and DNA information through biomarkers
• Tissue engineering
• Tissue regeneration
2. Grossman L, Oliet S, Del Rio C. Endodontic Practice, 11th edn.
Varghese Publication; 1991.pp.29-58.
3. Ingle J, Bakland L, Baumgartner J. Ingle’s Endodontics 6, 6th edn.
BC Decker Inc, Hamilton; 2008.p.3.
 2
CHAPTER

The Dental Pulp and

the Periradicular Tissues

This chapter describes the anatomy, embryology, histology and the physiology of the human dental
pulp and its surrounding periradicular structures.
  You must know
• What is the Dental Pulp and the Dentin-Pulp Complex?
• What are the Special Characteristics of the Dental Pulp as Connective Tissue?
• How is the Dental Pulp Formed?
• What are the Histologic Features of the Dental Pulp?
• What is the Blood Supply of the Pulpal Tissues?
• What is the Nerve Supply of the Pulpal Tissues?
• What is the Lymph Supply of the Pulpal Tissues?
• What are the Functions of the Dental Pulp?
• What is the Morphology and Histology of the Periradicular Tissues?

WHAT IS THE DENTAL PULP AND
THE DENTIN-PULP COMPLEX?
Dental Pulp
Dental Pulp is a soft vascular connective tissue of mesen­
chymal origin occupying the pulp chamber and the  root
canals and provides dentinogenic, nutritive, sensory and
defensive functions reflecting complete tooth vitality.
A total of 52 pulp organs are usually present in human
dentition, 32 in the permanent teeth and 20 in the primary
teeth. Each pulp organ has the shape that conforms to that
of the respective tooth.
Each pulp organ is composed of:
• Coronal pulp: Located centrally in the crowns of the
teeth.
• Radicular pulp: Located in the roots of the teeth.
Coronal pulp resembles the shape of the outer surface of
the crown dentin. Coronal pulp has six surfaces: the roof
or occlusal, the mesial, the distal, the buccal, the lingual
and the floor. The protrusions of the pulp that extend into
cusps of each crown are called pulp horns. The pulp organ
constricts in the cervical region of the tooth and at this zone,
the coronal pulp joins the radicular pulp.
Radicular pulp extends from cervical region of crown
to the root apex. Radicular portion of the pulp organ
communicates with periapical connective tissues through
the apical foramen or foramina.
The anatomic components of the pulp cavity are
discussed in detail in Chapter 3: “Morphology and Internal
Anatomy of the Root Canal System”.
Dentin-Pulp Complex
The specialized cells of the dental pulp, the odontoblasts,
are arranged peripherally in direct contact with the dentin
matrix. This close relationship between odontoblasts and
dentin is referred to as the dentin-pulp complex. Dentin
and pulp are embryologically, structurally and functionally
related. Figure 2.1 shows the diagrammatic representation
of histologic section of dentin-pulp complex. The histology
of pulp is explained in detail later in this chapter.
6 Short Textbook of Endodontics
Fig. 2.1  Diagrammatic representation of histologic section of dentin-
pulp complex showing how dentin and pulp are structurally related
WHAT ARE THE SPECIAL CHARACTERISTICS OF
THE DENTAL PULP AS CONNECTIVE TISSUE?
Certain special characteristics of the pulp tissue that
distinguish it from other connective tissues of the body are:
• Dental pulp is encased within hard tissues in an
unyielding low-compliance environment that limits
its ability to increase in volume during episodes of
vasodilation and increased tissue pressure. Pulp being
incompressible, volume within pulp chamber cannot be
increased. So, during an inflammatory reaction, there is
an increase in tissue pressure instead of volume.
• Even the mature pulp resembles embryonic connective
tissue. Therefore, it is relatively rich source of stem cells.
• Pulp is supported by microcirculatory system, its largest
vascular components being arterioles and venules.
There are no true arteries or veins that enter or leave
the pulp. The pulp lacks a true collateral system and is
dependent on relatively few arterioles entering through
the foramina. Due to minimal collateral blood supply,
there is reduced capacity for repair following injury.
• After development of tooth also, the pulp retains its
ability to form dentin throughout life. As a result, vital
pulp can partially compensate for loss of enamel and
dentin caused by mechanical trauma, disease or aging.
• Sensory receptors in the pulp cannot differentiate
between heat, touch, pressure or chemicals because
pulp organs lack receptors specific to different stimuli.
As a result, the unique feature of dentin receptors is that
any of the environment stimuli always elicit pain as a
response of the tooth.
HOW IS THE DENTAL PULP FORMED?
Development of Tooth
The connective tissue cells underlying the oral ectoderm
are neural crest or ectomesenchyme in origin and these
cells induce or instruct the overlying ectoderm to start tooth
development. Tooth development begins in the anterior
portion of future maxilla and mandible and then proceeds
posteriorly.
During sixth week of embryonic life, certain areas of
basal cells of oral ectoderm proliferate to form horse-
shoe shaped structures called the primary dental laminae
associated with the maxillary and mandibular processes.
Primary dental lamina splits into vestibular and dental
lamina.
Role of Dental Lamina
• It acts as primordium for ectodermal portion of
deciduous teeth
• Distal extension of dental lamina gives rise to permanent
molars
• Lingual extension of free end of dental lamina develops
successors of deciduous teeth (Incisors, Canines and
Premolars).
The formative tissues for an entire tooth and its
supporting structures include:
• Enamel Organ (forms Enamel): It is downgrowth of
dental lamina.
• Dental Papilla (forms Dentin and Pulp): On inside
depression of enamel organ, ectomesenchymal cells
increase in number and tissue appears more dense
representing dental papilla.
• Dental Sac (forms Cementum and Periodontal ligament):
It consists of ectomesenchymal cells and fibers that
surround dental papilla and enamel organ.
Stages of tooth development: Formation of tooth is a
continuous process but for convenience and descriptive
purposes, it is divided into various morphologic stages.
The morphologic stages and the associated physiologic
processes are as follows:
Morphologic stage Physiologic processes
Dental lamina Initiation
Bud stage
Cap stage Proliferation
Bell stage (Early) Histodifferentiation
Bell stage (Advanced) Morphodifferentiation
Formation of enamel and dentin matrix Apposition
 The Dental Pulp and the Periradicular Tissues 7

Certain growth factors such as Epidermal Growth Factor (EGF) – Cervical loop: Rim of enamel organ where outer and
and others initiate tooth development
↓
inner enamel epithelia join.
Specific cells of dental lamina form Enamel organ in – Enamel knot and cord: Cells in center of enamel
response to those factors organ are densely packed and form the enamel knot.
At the points of initiation, enhanced proliferative activity Vertical extension of enamel knot into dental papillae
ensues and successively results into the different stages of is called Enamel cord.
tooth development. According to the shape of the epithelial Enamel knot serves as a transient critical signaling center
part of tooth germ, they are called as Bud, Cap and Bell that has dense population of epithelial cells without any
stages (Morphologic Stages): proliferative activity and marked by expression of multiple
• Bud stage is the initial stage of tooth development during signaling molecules. These signaling molecules are critical
which the epithelial cells of dental lamina proliferate for proper development of tooth organ.
and produce a budlike projection into adjacent ecto- • Bell stage: As the cells forming the loop continue to
mesenchyme (Fig. 2.2). proliferate, there is further invagination of the enamel
Differentiation of dental lamina organ into mesenchyme and the enamel organ assumes
↓ a bell shape (Figs 2.4 and 2.5).
Round or ovoid swellings arise from basement membrane at ten different
points corresponding to future positions of deciduous teeth-primordia of
enamel organs (the tooth buds)

Development of tooth germ is initiated and the cells

continue to proliferate faster than the adjacent cells.
Transition of the bud to the cap stage is important step
in tooth morphogenesis that involves multiple signaling
molecules within the enamel organ epithelium that
regulate the expression of various transcription factors in
the surrounding mesenchyme.
• Cap stage is reached when the cells of dental lamina
have proliferated to form a concavity with a caplike
appearance (Fig. 2.3).
It shows:
– Outer Enamel Epithelium: Formed by outer cuboidal
cells.
– Inner Enamel Epithelium: Formed by elongated cells.
– Stellate Reticulum: Branched reticular arrangement Fig. 2.3  Diagrammatic representation of cap stage
of cellular elements.

Fig. 2.2  Diagrammatic representation of bud stage Fig. 2.4  Diagrammatic representation of early bell stage
8 Short Textbook of Endodontics

Fig. 2.5  Diagrammatic representation of advanced bell stage

Fig. 2.6  Diagrammatic representation of histologic section of the

During bell stage, there is differentiation of inner pulp showing predentin and zones of pulp
enamel epithelium and enamel organ epithelial cells
into ameloblasts and differentiation of mesenchymal
cells into odontoblast and dentin production begins.
Now the dental papilla is designated as dental pulp. WHAT ARE THE HISTOLOGIC FEATURES
It is during bell stage that crown assumes its final OF DENTAL PULP?
shape (Morphodifferentiation) and the cells that make
hard tissue-ameloblasts and odontoblasts, acquire their Dental pulp can be divided into four zones from the
distinctive phenotype (Histodifferentiation). periphery to the center:
1. Odontoblastic zone
Histodifferentiation 2. Cell-free zone of Weil
3. Cell-rich zone
Undifferentiated mesenchymal cells of dental papilla
4. Pulp proper
↓ Gradually differentiate
Into stellate shaped fibroblasts
Odontoblastic Zone (Fig. 2.6)
As the crown formation continues with the deposition
of Enamel and Dentin, growth and organization of pulp • This is the peripheral zone of the pulp that separates the
vasculature occurs. During this time, unmyelinated sensory loose connective tissue of the pulp from predentin.
nerves and autonomic nerves develop into pulp tissue. • Constituents:
Myelinated nerve fibers develop and mature at a slower rate. – Cell bodies of odontoblasts
Advanced bell stage marks an important stage of – Capillaries
Morphodifferentiation in the crown, that outlines the – Nerve fibers
future Dentinoenamel junction. – Dendritic cells
The boundary between outer enamel epithelium and • Structure:
the odontoblast forms future Dentinoenamel junction. – Odontoblasts have palisading arrangement, forming
The junction of inner and outer enamel epithelium at the periphery of the pulp.
the basal margin of enamel organ represents the future – There are tight and gap junctional complexes in
Cementoenamel junction. between the odontoblast cell bodies, that connect
Apposition is deposition of matrix of hard dental them and bring about exchange of metabolites.
structures. Appositional growth of Enamel and Dentin – Odontoblasts in coronal pulp:
is characterized by regular and rhythmic deposition of - Have a crowded arrangement due to rapid
extracellular matrix with alternate periods of activity and reduction of pulp chamber due to dentin
rest at definite intervals. deposition.

- Odontoblasts are tall and columnar with the
nuclei polarized towards the center of the pulp
arranged in about 6–8 layers in the region of the
pulp horns.
• Odontoblasts in Radicular pulp:
– Odontoblasts are cuboidal in midportion of radicular
pulp
– Have less crowded arrangement in root and spread
out laterally
– Odontoblasts are squamous or flattened in the apical
portion of the pulp.
Arranged in 2–3 layers in midportion of pulp and
in a single layer in the apical pulp.
• Function: Production and deposition of dentin is the
primary function of odontoblasts.
Cell-Free Zone of Weil (Fig. 2.6)
• This is a narrow zone about 40 um in width, located
immediately subjacent to the odontoblastic zone.
• Constituents:
– Blood capillaries
– Rich network of unmyelinated nerve fibers called as
plexus of Rashkow
– Slender cytoplasmic processes of fibroblasts
– Ground substance.
• Structure: Its presence or absence depends on functional
status of pulp. It may be completely absent in young
pulps during dentinogenesis and in older pulps due to
reparative dentin formation.
It is more prominent in coronal pulp.
• Functions:
– Capillaries are involved in the nutrition of
odontoblasts especially during dentinogenesis and
periods of inflammation
– Rashkow’s plexus involved in the neural sensation
of pulp
– Ground substance involved in the metabolic
exchanges of the cells and it has the role in limiting
the spread of infection due to its consistency.
Cell-Rich Zone (Fig. 2.6)
• Cell-rich zone is located central to the cell-free zone.
• Constituents:
– Ground substance
– Fibroblasts
– Collagen fibers
– Undifferentiated mesenchymal cells
– Macrophages.
The Dental Pulp and the Periradicular Tissues 9
• Structure: Cell-rich zone is more prominent in coronal
pulp than the radicular pulp.
– Ground substance forms the matrix that surrounds
and supports the cellular and vascular elements of
pulp. It is composed of proteoglycans, glycoproteins
and water.
– Fibroblasts are present in large numbers in the cell-
rich zone especially in coronal portion. Fibroblasts
are stellate-shaped cells with ovoid nuclei and
cytoplasmic process.
– Two types of fibers are found:
i. Elastic fibers that are found in the walls of the
arterioles.
ii. Collagen fibers secreted by fibroblasts found in
the body of the pulp.
In young pulp, collagen fibers are small and occur
in diffuse pattern and in older pulp, they are found in
large bundles usually found in central region.
The apical third of mature pulp contains more
collagen fibers than the coronal third.
– Undifferentiated mesenchymal cells are stellate-
shaped with a large nucleus and little cytoplasm.
They are located around the blood vessels in the
cell-rich zone.
– Macrophages are blood monocytes that have
migrated into the pulp tissue.
• Functions:
– Ground substance acts as a barrier against the spread
of bacteria. It is a transport medium for metabolites
and cellular waste products.
– Fibroblasts bring about formation as well as
degeneration of collagen fibers. They can bring about
deposition of calcified tissue. They have the potential
for reparative dentin formation.
– Collagen fibers secreted by fibroblasts support the
body of pulp and those secreted by odontoblasts
form the dentinal matrix. Collagen fibers in the
apical third of root protect the neurovascular bundle
from injury.
– Undifferentiated mesenchymal cells can differentiate
into fibroblasts, odontoblasts, macrophages or
osteoclasts to bring about repair and regeneration.
Pulp Proper
• It forms the central mass of pulp.
• Constituents:
– Larger blood vessels
– Nerve fibers
– Fibroblasts
10 Short Textbook of Endodontics
– Undifferentiated mesenchymal cells
– Defense cells: Macrophages, lymphocytes, dendritic
cells
– Ground substance.
• Structure and Functions: Blood vessels and nerves are
embedded in the pulp matrix in the central portion of
pulp and send branches to the periphery of the pulp.
Arterioles along with myelinated and unmyelinated
sensory nerve fibers enter the pulp through the apical
foramina and venules along with lymphatics exit the pulp
through the apical foramina and lateral and accessory
foramina.
Structural Elements of the Pulp
The dental pulp contains:
• Ground substance
• Cells
• Fibers
• Blood vessels
• Nerves
• Lymph vessels.
Ground Substance
• The Dental Pulp is a connective tissue that consists of
cells and fibers, embedded in ground substance, also
called Extracellular Matrix (ECM). ECM is amorphous
and gel-like.
• Contents:
– Polyanionic polysaccharides
– Glycoproteins such as fibronectin, laminin and
tenascin
– Proteoglycan such as hyaluronic acid, dermatan
sulfate and chondroitin sulfate
– Glycoprotein and proteoglycan contain GAG chains
that bond to cell surfaces and
– Other matrix molecules
– Water content of young pulp is 90%.
• Functions:
– Forms a cushion that is capable of protecting cells
and vascular component of the tooth
– It acts as molecular sieve in which it excludes large
proteins
– Glycoprotein and proteoglycan molecules support
cells, provide tissue turgor and mediate cell
interactions
– Proteoglycans regulate dispersion of interstitial
matrix solutes, colloids and water and determine
the physical characteristics of the pulp
– It serves as means for transport of nutrients from
blood vessels to cells and transport of metabolites
from cells to blood vessels.
• In certain inflammatory lesions, degradation of ground
substance can occur through the hydrolytic enzymes of
lysosomal and bacterial origin.
Cells of the Pulp
Odontoblast
• Odontoblast is the most characteristic cell of the dentin-
pulp complex
• It is responsible for dentinogenesis both during tooth
development and even in the mature tooth
• Odontoblast is a tall columnar cell and has a cellular
process that forms dentinal tubule
• Ultrastructure of odontoblast: Shows large nucleus, four
nucleoli, well-developed Golgi complex, Golgi bodies
centrally located, mitochondria, Rough Endoplasmic
Reticulum (RER) and ribosomes distributed throughout
the cell body
• Odontoblast synthesizes type I collagen, proteoglycans,
dentin sialoprotein and phosphophoryn. Phos­
phophoryn is phosphorylated phosphoprotein that is
involved in extracellular mineralization and is found
only in dentin, not in any other mesenchymal tissue
• Odontoblast secretes acid phosphatase (a lysosomal
enzyme) and alkaline phosphatase (enzyme related to
mineralization).
Pulp Fibroblast
• Most numerous cells of pulp
• Fibroblast is a spindle-shaped cell responsible for
collagen fiber formation throughout the pulp during
the life of the tooth
• Fibroblast synthesize type I collagen, type III collagen,
proteoglycans and GAGs and maintain the matrix
proteins of the ground substance. Fibroblasts are
capable of ingesting and degrading this same matrix.
Thus the fibroblasts have dual function of synthesis and
degradation of the same cell
• Fibroblasts remain in relatively undifferentiated state,
never grow up. Undifferentiated cells are also termed
as stem cells
• Pericytes are fibroblasts found around capillaries of pulp.
Defense Cells
• Histiocytes or Macrophages: They are active in endo­
cytosis and phagocytosis and act as scavengers that

remove extravasated red blood cells, dead cells and
foreign bodies from the tissue. Few macrophages are
involved in immune reactions by processing antigen
and presenting it to the memory T cells.
• Dendritic cells: They are the accessory cells of the
immune system and are termed as antigen presenting
cells. They induce T-cell dependent immunity.
• Lymphocytes: T-lymphocytes are mainly found.
B-lymphocytes are scarce. Lymphocytes appear at
the site of injury after invasion by Neutrophils (PMN
Leukocytes)
• Mast cells: They are found in relation to blood vessels in
chronically inflamed pulps. Mast cell granules contain
heparin (anticoagulant) and histamine (inflammatory
mediator) and other chemical factors.
Undifferentiated Mesenchymal Cells
• They are the primary cells in very young pulp, but a
few undifferentiated cells remain in the pulps after
root development. Their number decreases in older
pulps.
• They are believed to be totipotent cells that can
differentiate into odontoblasts, fibroblasts or macro­
phages when need arises. Also called Reserve cells.
• These cells are found scattered throughout the central
pulp along pulp vessels in cell-rich zone.
• They appear polyhedral in shape with peripheral
processes and large oval staining nucleus.
Fibers
• The pulp consists of Type I and Type III collagen fibers
• Odontoblasts and osteoblasts synthesize Type I collagen;
Fibroblasts synthesize Type I, III, V and VII collagen
• After completion of root formation, the pulp matures
and collagen fiber bundles increase in number. Thus,
the collagen content of pulp increase with age.
WHAT IS THE BLOOD SUPPLY
OF THE PULPAL TISSUES?
Arterial Supply
• Arterial supply of the pulp is from the posterior superior
alveolar arteries and
– Infraorbital artery
– Inferior alveolar branch of internal maxillary arteries.
The Dental Pulp and the Periradicular Tissues 11
Arterioles, Venules and Capillaries and
Arteriovenous Anastomoses
• Blood from the arteries enters the tooth by way of
Arterioles having diameter of 100 µm or less and the
Venules having diameter of 200–300 µm leave the tooth
through the apical foramen.
Smaller vessels may enter the pulp via accessory or
lateral canals. But the tooth does not have a collateral
alternative blood supply.
• From the root pulp, arterioles pass to supply the coronal
pulp in a straight direction so that 90o branching patterns
develop as shown in Figure 2.7.
– They spread laterally towards the odontoblast layer
and form a capillary plexus beneath the odontoblast
layer.
– Terminal capillary networks are most important
vessels in the pulp and carry out the following
functions: Maintains pulp homeostasis by:
a. Transport of nutrients and gas to cells
b. Removal of waste products and CO2 from the cells.
• Coronal portion of the pulp has nearly twice the capillary
blood flow than the root portion being greatest in the
region of Pulp Horns.
• From the capillary networks, blood passes into post-
capillary venules and into larger venules.
These venules have thin and discontinuous muscular
coat for the movement of fluid in or out of the vessel.
• Arteriovenous anastomosis connects the arteriole
directly to a venule bypassing the capillary bed. These
are small vessels having diameter of 10 µm. They may
Fig. 2.7  Diagrammatic representation of pulpal blood supply
12 Short Textbook of Endodontics
play a role in regulation of blood flow. May be found in
coronal and radicular portions of pulp, more frequent
in radicular portion.
• ‘U’-Turn loops filled with streaming blood may be found
in the pulp vascular network that shunt blood away from
area of injury or inflammation thus preventing injury to
microcirculation.
• Changes in pulpal blood flow can be measured using
the laser Doppler flowmeter.
• Pulpal blood flow may be affected by change in posture.
Change of posture from standing to supine position
causes increase in blood flow resulting in elevated pulpal
tissue pressure sufficient to activate pulpal nocireceptors
to initiate spontaneous pulpal pain.
• The stealing theory of pulpal blood flow: Most of the
vascular resistance regulating the pulpal blood flow is
located in the venules and also outside the pulp. As a
result,
Changes in blood flow in surrounding tissues ↓
such as gingiva, alveolar bone and PDL
↓ to form sub-odontoblastic plexus within the Schwann cells from which
Causes changes in pulpal blood flow
According to Poiseuille law, “Any vasodilatation in tissues that receive
their blood supply through the side branches of the end arterioles mediated by large myelinated fibers.
feeding the pulp will, steal blood pressure from the pulp.”
Thus, vasodilatation of alveolar bone, periodontal ligament or gingiva
↓
Fall in arterial blood pressure of the Vasoactive Intestinal peptide, prostaglandins, acetyl­
arterioles feeding the pulp
• Dental pulp is called as the LOW COMPLIANCE SYSTEM
because it is encased in rigid structures namely enamel,
dentin and cementum. Due to limited ability of pulp
to expand, any vasodilatation and increased vascular
permeability occurring during inflammation cause an
increase in pulpal hydrostatic pressure and thus reduced
pulpal blood flow.
A mind-map to remember all points of blood supply
of pulpal tissues (Fig. 2.8).
WHAT IS THE NERVE SUPPLY
OF PULPAL TISSUES?
• Trigeminal ganglion supplies sensory innervation to
pulp by means of:
– Maxillary nerve and within the pulp.
– Mandibular nerve
• Within the dental pulp, two types of sensory nerve fibers:
– Myelinated A-fibers including A-β and A-d (90% are
Ad)
– Unmyelinated C-fibers: About 80% of nerve fibers
that enter the pulp are Unmyelinated. They are found
in close association with the blood vessels of the pulp
and many are sympathetic in nature.
A-fibers transmit fast pain which is sharp and piercing.
C-fibers transmit slow pain which is dull, aching pain.
• Apart from sensory fibers, sympathetic fibers from the
superior cervical ganglion appear with the blood vessels
when the vascular system is established in the dental
papilla. In adult tooth, sympathetic fibers form plexuses
around the pulpal arterioles usually.
• A network of nerves located adjacent to the cell-rich
zone formed by peripheral axons is called plexus of
Raschkow. A-delta fibers lose their myelin sheath at the
odontoblastic layer forming this plexus.
Formation: Nerve bundles along with the blood vessels pass from
radicular pulp to coronal pulp
↓
They branch into smaller bundles beneath the cell-rich zone
↓
Ramify into plexus of single-nerve axons called the plexus of Raschkow
In this plexus, A-fibers emerge from their myelin sheaths and branch further
terminal axons exit and pass between odontoblasts as free nerve endings.
• Pain sensation caused by external stimuli in the tooth is
• Certain neurotransmitters are present in the nerves of the
dental pulp such as substance P, 5-Hydroxytryptamine,
choline, norepinephrine.
• Sensory response in the pulp cannot differentiate
between heat, touch, pressure or chemicals because
pulp organs lack receptors specific to different stimuli.
As a result, the unique feature of dentin receptors is that
environmental stimuli always elicit pain as a response.
• A-delta fibers get stimulated first when Electric pulp
tester is used. C-fibers also get stimulated if intensity of
stimulus is increased.
A mind-map to remember all points of Nerve supply
of pulp is given in Figure 2.9.
WHAT IS THE LYMPH SUPPLY
OF PULPAL TISSUES?
Lymphatic vessels help to remove the interstitial fluid and
metabolic waste products and maintain the tissue pressure
Most of the lymphatics are found in the radicular pulp
whereas in coronal pulp, lymph vessels are observed
in central part. Lymphatics in peripheral pulp join to
form large collecting vessels, which further unite with
progressively larger lymphatic vessels that pass through
the root apex along with blood vessels.

Fig. 2.8  A mind-map to remember all points of blood supply of pulpal tissues
Lymph vessels draining the pulp and the periodontal
ligament of anterior teeth pass to the submental lymph
nodes and those of the posterior teeth pass to the
submandibular and deep cervical lymph nodes.
WHAT ARE THE FUNCTIONS OF THE PULP?
• Inductive: The pulp anlage interacts:
– With the oral epithelial cells leading to differentiation
of the dental lamina and enamel organ formation.
The Dental Pulp and the Periradicular Tissues 13
– With the developing enamel organ to determine the
particular type of tooth.
• Formative: The cells of the pulp organ produce the
dentin that surrounds and protects the pulp. The pulpal
odontoblasts play a role in developing the organic matrix
and calcification during dentin formation.
• Nutritive: The blood vascular system of the pulp
nourishes the surrounding avascular dentin through
odontoblasts and their processes.
14 Short Textbook of Endodontics

Fig. 2.9  Mind-map to remember nerve supply of pulp

• Sensory: Although the pulp is encased by protective WHAT IS THE MORPHOLOGY AND
layer of dentin, which in turn is covered with enamel, HISTOLOGY OF PERIRADICULAR TISSUES?
the pulp is quite sensitive to different external stimuli
such as heat, cold, pressure, chemicals and mechanical Periradicular tissues include (Fig. 2.11):
trauma. The response is always pain irrespective of the • Cementum
type of stimulus due to lack of specific receptors related • Periodontal ligament
to those stimuli. The nerves in the pulp initiate reflexes • Alveolar process
that control circulation in the pulp.
• Defensive or reparative: The dental pulp responds to Cementum
mechanical, thermal, chemical or bacterial irritation Cementum is hard, bone-like calcified tissue structure
by producing reparative dentin and mineralizing any covering the roots of the teeth.
affected dentinal tubules (Sclerosis) to wall off the pulp
from the source of irritation. In response to bacterial Types
infection, pulp elicits inflammatory and immunologic • Cellular cementum
reaction. The macrophages, lymphocytes, neutrophils, • Acellular cementum.
monocytes, plasma and mast cells of the pulp help in
the process of repair of the pulp. Cellular Cementum
A mind-map listing all points of dental pulp is given • It contains cells called cementocytes and deposited
in Figure 2.10. usually in the apical third of root.
 The Dental Pulp and the Periradicular Tissues 15

Fig. 2.10  Mind-map to remember all points of the dental pulp

16 Short Textbook of Endodontics
Fig. 2.11  Diagram showing periradicular tissues
• It is deposited at a greater rate than acellular cementum
• Thickness: 20 to 150 µm.
Acellular Cementum
• It does not contain cells and deposited in the cervical
and middle thirds of root
• Thickness is 20–50 µm at CEJ
• It contains lot of Sharpey’s fibers.
Functions
• To give form to the mature apical foramen.
Continuous deposition of cementum increases the
major diameter and deviates the apical foramen by
about  0.2 to 0.5mm from the center of the root apex.
The minor diameter is located about 0.5mm from the
cemental surface in young teeth and about 0.75mm from
the cemental surface in mature teeth.
• Cementum plays a role in repair.
Root resorptions get repaired by deposition
of cementum. Accessory and apical foramina are
sealed after root canal treatment due to deposition of
cementum.
• To form apical barrier in immature pulpless teeth
Materials used for apexification bring about
deposition of cementum or cementum-like tissue to
close the apex of immature pulpless teeth.
• Due to its avascularity, cementum can withstand the
orthodontic tooth movement forces without much
resorptive damage.
• To maintain width of PDL space by continuous
deposition of cementum.
Periodontal Ligament
The periodontal ligament is a dense, fibrous connective
tissue surrounding the roots of the teeth and occupying the
space between the cementum and the alveolar bone and
is continuous with the pulp and the gingiva. It attaches the
root to the surrounding tissues.
Two important components of periodontal ligament
are:
1. Cells
2. Fibers
Cells of PDL
Fibroblasts
• Most important cells of the periodontal ligament
• Bring about deposition as well as degradation of
collagen fibers. This constant remodelling of periapical
fibers maintains the health of the periodontal
ligament.
Osteoblasts (Bone Forming Cells)
• Bring about deposition of collagen and matrix on the
surface of the bone forming the osteoid
• Calcification of osteoid occurs to anchor Sharpey’s
fibers.
Osteoclasts (Bone-resorbing Cells)
• These are multinucleated Giant cells found in scooped
out areas of bone called Howship’s lacunae.
• They bring about resorption of bone.
The constant remodelling of bone by deposition and
resorption continuously renews the attachment of PDL
to bone.
Cementoblasts
• Bring about deposition of matrix containing collagen
fibers and ground substance called cementoid.
• Calcification of cementoid occurs to anchor the
periodontal ligament fibers in the bone.

Cementoclasts
• Under physiologic conditions, there is no resorption
of cementum. So cementoclasts are not found in the
normal periodontal ligament.
• Found in pathologic conditions.
Other Cells
• Epithelial cell rests of Malassez
• Undifferentiated mesenchymal cells
• Mast cells
• Macrophages.
Fibers of PDL
• Two types of periodontal fibers are present:
– Collagen fibers
– Oxytalan fibers
• Sharpey’s fibers are terminal fibers of the collagen
bundles that are:
– Inserted into CEMENTUM on one side
– Inserted into BONE on the other side.
• The principal fiber groups of periodontal ligament
include:
– Transseptal fibers: Traversing the alveolar crest and
connecting from cementum of one tooth to the
cementum of adjacent tooth.
– Horizontal group of fibers: Embedded into cementum
apical to the alveolar crest group running horizontally
from cementum to the alveolar bone.
– Oblique group of fibers: Embedded into cementum
apical to horizontal group running obliquely from
cementum to the alveolar crest of bone.
– Alveolar crest fibers: They arise from the alveolar crest
of the bone in a fan-like manner and attach to the
cementum.
– Apical group of fibers: These fibers are embedded into
the apical cementum and the fundus of the alveolar
socket.
– Interradicular group of fibers: Embedded into
cementum and alveolar bone in the furcation areas
of Multirooted teeth.
Oxytalan fibers are immature elastic fibers that
traverse the periodontal ligament in an axial direction.
• Functions of the periodontal ligament:
– Attachment: The fibers of the periodontal ligament
attach the tooth to the alveolar bone (socket).
– Protection: The fibers absorb the occlusal forces and
protect the tooth and the alveolar socket from the
masticatory injuries.
The Dental Pulp and the Periradicular Tissues 17
– Nutrition: The periodontal ligament provides blood
supply to the adjoining structures such as gingiva,
cementum and alveolar bone.
– Formation: The cells of the PDL help in the formation
of adjoining structures such as alveolar bone and
cementum.
Alveolar Process
It can be divided into:
• Alveolar bone proper which is a part of periradicular
tissues
• Supporting alveolar bone.
Alveolar Bone Proper
• Alveolar bone proper is the bone forming the bony
socket into which the root is housed.
• Alveolar bone proper consists of:
– Peripheral bone called bundle bone into which the
Sharpey’s fibers of the PDL are embedded.
– Central bone called lamellated bone.
• Alveolar bone proper appears radiopaque on radiographs
and is called as lamina dura.
• Alveolar bone proper consists of multiple foramina
containing blood vessels and nerve fibers that supply
the teeth, periodontal ligament and alveolar bone. So,
it is also known as the cribriform plate.
Supporting Alveolar Bone
• It is formed by diploe of cancellous bone covered by two
outer tables of cortical bone:
– Vestibular or buccal plate
– Lingual or palatal plate.
• Cancellous bone is arranged in the form of trabeculae
and there are medullary spaces in between the
trabeculae.
• Cells of the alveolar bone:
– Osteoblasts are bone-forming cells, which deposit
an organic matrix called osteoid which then gets
calcified.
– Osteocytes are the cells which get entrapped in the
organic matrix.
– Osteoclasts are bone-resorbing cells.
A mind-map to remember all points of Periradicular
tissues is given in Figure 2.12.
18 Short Textbook of Endodontics

Fig. 2.12  A mind-map to remember all points of periradicular tissues

BIBLIOGRAPHY
1. Bhaskar SN. Orban’s Oral Histology and Embryology, 11th edn. 3. Grossman L, Oliet S, Del Rio C. Endodontic Practice, 11th edn.
Mosby, 2001.pp.28-48,pp.139-79. Varghese Publication; 1991.pp.29-58.
2. Cohen S, Hargreaves KM. Pathways of Pulp, 9th edn. St.  Louis: 4. Ingle J, Bakland L, Baumgartner J. Ingle’s Endodontics 6, 6th edn.
Mosby, 2006.pp.460-513. BC Decker Inc, Hamilton; 2008.pp.118-50.
 Morphology and Internal

3
CHAPTER

Anatomy of the Root

Canal System

This chapter describes the morphology and internal anatomy of teeth and their root canal systems
  You must know
• What are the Anatomic Components of the Root Canal System?
• What are the Regressive Changes that Occur in the Anatomy of Root Canal System?
• What are the Different Types of Root Canal Systems in any Root?
• What is the Anatomy of the Apical Portion (Apical 1/3rd) of the Root Canal?
• Which are the Anatomic Complexities that can Occur in Root Canal System?
• What is Isthmus and what is its Role during Endodontic Surgical Procedure?
• What are the Possible Developmental Anomalies and Variations in the Anatomy of Root
Canal System?
• What is the Morphology of the Root Canal System of the Individual Teeth?

WHAT ARE THE ANATOMIC COMPONENTS

OF THE ROOT CANAL SYSTEM?
Central cavity within a tooth that is entirely enclosed by
dentin except at the apical foramen, into which the pulp is
housed is called as the root canal system.
Root canal system can be divided into two basic
components:
1. Pulp chamber: Coronal portion, that which is located in
anatomic crown of tooth. Also called coronal pulp.
2. Root canal: Radicular portion, that which is located in
anatomic root of tooth. Also called radicular pulp.

Components of the Pulp Chamber (Fig. 3.1)

• Roof of the pulp chamber: Portion of dentin covering the
pulp chamber occlusally or incisally is called as the roof
of the pulp chamber.
• Pulp horn: An accentuation of the roof of the pulp
chamber directly under a cusp or developmental lobe
is called as the pulp horn.
• Floor of the pulp chamber: The portion of dentin
bounding the pulp chamber near the cervix of the tooth
particularly that forming the furcation area is called as
the floor of the pulp chamber. It runs parallel to the roof
of the pulp chamber.
• Walls and angles of the pulp chamber: Walls of the
pulp chamber correspond to the respective walls of the
tooth  surface. Angles of the pulp chamber correspond
to the respective angles formed from the walls of the
pulp chamber.
20 Short Textbook of Endodontics
• Canal orifices: The openings in the floor of the pulp
chamber that lead into the root canals are called as the
canal orifices. They are not separate structures, but are
continuous with both pulp chamber and root canals.
Components of the Root Canal (Fig. 3.1)
• Principal/main root canal:
– The root canal is that portion of the pulp cavity from
the canal orifice to the apical foramen.
– For convenience, the root canal is divided into three
sections namely: coronal, middle and apical thirds.
– Usually the root canal does not extend straight along
the entire length of the root. Either a curvature or a
constriction is present before the apex is reached.
– The shape of the root canal usually conforms to the
shape of the root. If there is curvature in the root,
usually the root canal follows this curve.
– The curvature may be:
a. Gradual curvature of the entire canal.
b. Sharp curvature of canal near the apex.
c. Gradual curvature of canal with straight apical
ending.
d. Double curvature of the canal (S-shaped canal).
– Usually, the number of root canals corresponds
to the number of roots. But a root can have more
than one canal. For example, the mesial root of
Fig. 3.1  Diagram showing components of root canal system.
A: Coronal pulp; B: Radicular pulp/Principal root canal; a: Pulp horn;
b: Roof of pulp chamber; c: Canal orifice; d: Floor of pulp chamber;
e: Lateral canal; f, g, h: Portals of Exit (POE)
mandibular first molar almost always has two canals;
its distal root occasionally has two canals.
– According to Meyer, roots which are round and
cone-shaped, usually contain only one canal but
roots which are elliptical and have flat or concave
surfaces frequently have more than one canal.
• Apical foramen: A funnel-shaped opening where the
root canal exits is called as the apical foramen. Besides
there are numerous geometrical configurations and
intricacies along the length of the root canal. Apical
foramen may be located in the center of root apex or
may exit on the mesial, distal, labial or lingual surface
of the root slightly eccentrically.
• Accessory, lateral and furcation canals: Minute canals
extending in horizontal, vertical or lateral directions
from pulp to the periodontium are called as accessory
canals. Accessory canals consist of connective tissue and
vessels but they do not supply the pulp with collateral
circulation.
Accessory canals that branch to the lateral surface of
the root are called as lateral canals. These may be visible
on radiograph. Canals occurring in the bifurcation
or trifurcation of multirooted teeth are called as the
furcation canals.
Formation: Accessory canals are formed as a result
of entrapment of periodontal vessels in Hertwig’s
Epithelial Root Sheath (HERS) during calcification.
Furcation canals are formed as a result of entrapment
of periodontal vessels during the fusion of diaphragm
that becomes pulp chamber floor.
Clinical significance: Accessory, lateral and furcation
canals can serve as avenues for the passage of irritants,
primarily from the pulp to the periodontium.
• Accessory foramina: Openings of accessory and lateral
canals in root surface are called as accessory foramina.
• Apical delta: A pyramidal or pointed structure made
of multiple fine channels in the apical third of the root
through which the blood vessels and nerves pass is
called apical delta. Figure 3.2 shows the diagrammatic
representation of the apical delta.
For convenience, the root canal is divided into three
sections: coronal, middle and apical thirds as shown in
Figure 3.1.
• Portals of exit (POE): The openings from the root canal
system to the PDL space through which the micro-
organisms and the potential Endodontic breakdown
products may pass are referred to as Portals of Exit
(POE).
 Morphology and Internal Anatomy of the Root Canal System 21

Fig. 3.2  Diagrammatic representation of the apical delta

Fig. 3.3  Characteristics of root canal system in young person Fig. 3.4  Characteristics of root canal system with increasing age

WHAT ARE THE REGRESSIVE CHANGES THAT WHAT ARE THE DIFFERENT TYPES OF ROOT
OCCUR IN THE ANATOMY OF ROOT CANAL CANAL SYSTEMS IN ANY ROOT?
SYSTEM?
The canals within the root, may branch, divide and
See Figures 3.3 to 3.5. rejoin.
22 Short Textbook of Endodontics

A C

B D

Figs 3.5A to D  Diagrams showing age changes in the root canal system in order: a: Pulp horns: High pulp horns go on receding with increasing
age; b: Pulp chamber: Large and wide pulp chambers become smaller and shorter; c: Root canals: Wider root canals become narrower due
to deposition of secondary and reparative dentin; d: Apical foramen: Broad open apex of immature tooth closes and becomes narrow and
forms an apical stop; e: Pulp stones: Calcification is seen in older pulps and few pulps with chronic infection. Calcification starts in the pulp
chamber and proceeds apically

Classification of Root Canal Systems (Fig. 3.6)
The possible configurations of the root canal systems as
given by Weine include:
• Type I: Single canal extending from the pulp chamber
to the apex (1) (Fig. 3.6A)
• Type II: Two separate canals leaving the pulp chamber
and joining short of the apex, to form one canal (2-1)
(Fig. 3.6B)
• Type III: Two separate, distinct canals extending from
the pulp chamber to the apex (2) (Fig. 3.6C)
• Type IV: One canal leaving the pulp chamber and
dividing short of the apex into two separate, distinct
canals with separate apical foramina (1-2) (Fig. 3.6D)
Weine’s classification is the first clinical classification of
more than one canal system in a single root.
Later, Vertucci et al gave the classification categorizing the
root canal system into following eight types:
1. Type I: Single canal extending from the pulp chamber
to the apex (1) (Fig. 3.7)
2. Type II: Two separate canals leaving the pulp chamber and
joining short of the apex, to form one canal (2-1) (Fig.  3.8)
 Morphology and Internal Anatomy of the Root Canal System 23

A B C D
Figs 3.6A to D  Weine’s classification of root canal systems

Fig. 3.7  Type I Fig. 3.8  Type II

3. Type III: One canal leaving the pulp chamber and
dividing into two canals in the root. The two root canals
then merge to exit as one canal (1-2-1) (Fig. 3.9)
4. Type IV: Two separate, distinct canals extending from
the pulp chamber to the apex (2) (Fig. 3.10)
5. Type V: One canal leaving the pulp chamber and
dividing short of the apex into two separate, distinct
canals with separate apical foramina (1-2) (Fig. 3.11)
6. Type VI: Two separate canals leaving the pulp chamber,
and joining in the body of the root to form one canal,
which redivides short of the apex to exit as two distinct
canals (2-1-2) (Fig. 3.12).
7. Type VII: One canal leaving the pulp chamber and
dividing into  two canals and then rejoining to form one
canal in the body of the root, and then finally redivides
into two distinct canals short of the apex (1-2-1-2)
(Fig. 3.13).
8. Type VIII: Three separate, distinct canals extending from
the pulp chamber to the apex (3) (Fig. 3.14).
The only tooth that has been found with all eight possible
configurations is the maxillary 2nd premolar.
According to Vertucci’s classification:
• Types I, II, III show One canal at apex
24 Short Textbook of Endodontics

Fig. 3.9  Type III Fig. 3.12  Type VI

Fig. 3.10  Type IV Fig. 3.13  Type VII

Fig. 3.11  Type V Fig. 3.14  Type VIII

 Morphology and Internal Anatomy of the Root Canal System 25

• Types IV, V, VI, VII show Two canals at apex determine the number and location of orifices on the
• Type VIII shows Three canals at apex. pulp chamber floor which have been described in detail
in Chapter 13: Endodontic Access Cavity Preparation.
Vertucci’s Findings Those guidelines should be followed.
• Magnification and illumination aids such as dental
• Whether the canals join or remain as separate canals, is loupes and dental operating microscope are valuable
determined by the proximity of the canal orifices. aids that improve visualization and greatly reduce the
• Joining of canals: If orifices are less than 3 mm apart, chances of missing root canals or any variable anatomy.
canals usually are joined together. • Other orifice location aids such as Champagne bubble
As the distance between the orifices decreases, canals test using sodium hypochlorite and other aids have
are found to join more coronally. been described in Chapter 13: Endodontic Access Cavity
• Separation of canals: If the distance between the orifices Preparation.
is more than 3 mm, the canals tend to remain separate
through their entire length. WHAT IS THE ANATOMY OF THE APICAL
PORTION (APICAL 1/3rd) OF THE ROOT CANAL?
Some of the Practical Hints to Determine
The apical portion of the root contains three anatomic and
the Type of Canal System Clinically
histologic landmarks (Fig. 3.15):
• It is important to have knowledge of different variations I. Apical foramen or major apical diameter.
that can occur in the root canal anatomy including the II. Apical constriction or minor apical diameter.
possibility of finding additional canals than the usual III. Cementodentinal junction (CDJ).
for a given tooth.
• Pretreatment radiographs taken in two-three different Apical Foramen or Major Apical Diameter
angulations gives an idea of the internal anatomy of the
(Fig. 3.15b)
tooth and the number of root canals.
• Follow the “dentinal map” which is the road-map to the • Cohen has defined it as follows:
root canal system and preserve the pulpal floor. “Apical foramen is the circumference or rounded edge,
• Location of canal orifice on pulpal floor can indicate the like a funnel or crater, that differentiates the termination
number of canals present as follows:
– Canal located in center of the pulpal floor may
indicate that one canal is present.
– Canal orifices located less than 3 mm apart: Indicates
tendency to join/unite.
– Canal orifices located more than 3 mm apart may
indicate tendency to remain separate.
• On radiograph, sudden disappearance or narrowing of
canal (fast-break guideline): Indicates bifurcation of root
canal.
• When the first file inserted into distal canal of a
mandibular molar, points in buccal or lingual direction:
may indicate 2 distal canals are present.
• When two canals join in the root to form one canal,
lingual/palatal canal has direct access to apex.
• When one canal separates into two canals, configuration
of separated canals is in the shape of letter ‘h’, where
(given by Slowey)
– Buccal canal is straight portion of ‘h’
– Lingual canal generally is the one that splits from the
Fig. 3.15  Diagrammatic representation of anatomy of apical third
main canal at a sharp angle. of root. a: Cementum; b: Apical foramen; c: Cementodentinal
• Krasner and Rankow have given certain guidelines junction (CDJ); d: Major constriction; e: Minor constriction; f: Apical
or laws of pulp chamber anatomy to help clinicians constriction
26 Short Textbook of Endodontics
of the cemental canal from the exterior surface of the
root”.
• Generally, the apical foramen does not exit at the apex,
it may be about 0.5 – 3 mm offset from center.
• The apical foramen may not always be located in the
center of the root apex and it may be on mesial, distal,
labial or lingual surface of the root.
• In immature tooth with open apex, the apical foramen
is funnel-shaped filled with periodontal tissue which is
replaced by dentin and cementum as the root develops
so that the apical foramen becomes narrower. Root
canals can take various courses and accordingly the
apical foramen is located. Figures 3.16A to D show
different curvatures of root canals and the locations of
the apical foramina.
• Average size of apical foramen in maxillary permanent
teeth is 0.4 mm diameter and that of mandibular
permanent teeth is 0.3 mm. The apical opening may not
always be found in the center of the apex. Frequently
two or more foramina are found separated by a portion
of dentin and cementum or by cementum only.
Apical Constriction or Minor Apical Diameter
(Fig. 3.15f)
• Apical constriction is the part of the root canal with the
smallest diameter.
• Apical constriction is generally 0.5 – 1.5 mm inside the
apical foramen.
• Apical constriction is delicate and should be maintained.
Over-instrumentation violates and breaks this
constriction resulting in irritation of periapical tissues
and over-extended root canal filling may occur.
• The mean distance between the major and minor apical
diameters, i.e. between the AF and AC has been found
A B C D
Figs 3.16A to D  Various courses of the root canals and the location
of the apical foramina: (A) Curvature in the apical third of the root
canal and apical foramen distant from the root apex; (B) Curvature
in the apical third of the root canal and apical foramen near the
apex; (C)  Constriction in the root canal as the apical foramen is
approached; (D) Double curvature of the root canal and apical
foramen distant from root apex
to be 0.5 mm in young persons and 0.67 mm in older
individuals.
• The space that occurs between the major and minor
apical diameters, i.e. between the AF and AC is funnel
shaped, described as ‘hyperbolic’ shape or ‘shape of the
morning-glory’.
Cementodentinal Junction (CDJ) (Fig. 3.15c)
• It is the junction where cementum meets dentin.
• At CDJ, pulp tissue ends and periodontal tissues begin.
• CDJ is approximately 1 mm from the apical foramen.
• The CDJ is considered to be the ideal point of termination
for the preparation and obturation of the root canals.
Anatomy of Root Apex
Figure 3.15 shows diagrammatic representation of anatomy
of root apex.
A mind-map to remember all points of landmarks in
apical portion of canal is illustrated in Figure 3.17.
WHICH ARE THE ANATOMIC COMPLEXITIES
THAT CAN OCCUR IN ROOT CANAL SYSTEM?
Anatomic complexities of root canal system include:
• C-shaped canals
• Additional canals
• Fins, deltas, loops, intercanal connections, etc.
‘C’-shaped Canals (Fig. 3.18)
• Roots and their root canals with their cross-sectional
morphology C-shaped are called as C-shaped canals.
• C-shaped canal first documented in Endodontic
literature by Cooke and Cox in 1979.
• C-shaped canals result from fusion of the mesial and
distal roots on either the buccal or the lingual root
surface. Failure of fusion of the Hertwig’s epithelial root
sheath to fuse on buccal or lingual root surface forms
C-shaped roots that contain C-shaped canals.
• Occurs most commonly in mandibular second molars
but may also be seen in mandibular first molar, maxillary
first and second molars.
• C-shaped root canal system has single, ribbon-shaped
orifice that has an arc of 180 degrees or more.
• It starts at mesiolingual line angle of pulp chamber and
goes around buccal or lingual and ends at distal aspect
of pulp chamber.
• Classification of C-shaped canals:
I. Based on number of canals that leave from orifice
and reach apex (Flow chart 3.1)
 Morphology and Internal Anatomy of the Root Canal System 27

Fig. 3.17  A mind-map to remember all points of landmarks in apical portion of canal

Flow chart 3.1  Classification of C-shaped canals based on number

of canals that leave orifice and reach apex

Flow chart 3.2  Melton’s classification of C-shaped canals

Fig. 3.18  C-shaped canal in mandibular second molar

II. Classification of C-shaped canals as given by Melton

et al (based on their cross-sectional shape) (Flow
chart 3.2)
28 Short Textbook of Endodontics

Flow chart 3.3A  Fan et al’s anatomic classification of C-shaped canals

Flow chart 3.3B  Fan et al’s radiographic

classification of C-shaped canals

Fig. 3.19  Diagrammatic representation of anatomic classification of

C-shaped canals: Category I, II, III, IV, V

III. Fan et al classification of C-shaped canals: In 2004,

Fan et al modified the Melton’s classification and
gave two classifications: anatomic and radiographic
(Flow chart 3.3)
a. Anatomic classification: (Flow chart 3.3A) Figure
3.19 shows cross-section at the apical 1/3rd of
the root of mandibular second molar showing
different categories of C-shaped canals.
b. Radiographic classification: (Flow chart 3.3B)
Figure 3.20 shows Type I, Type II and Type III
C-shaped canals respectively as per radiographic Fig. 3.20  Type I, Type II, Type III of C-shaped canals
classification. (Radiographic classification)
 Morphology and Internal Anatomy of the Root Canal System
• Sometimes the C-shaped groove runs connecting two or
three orifices such as mesiobuccal and distal orifices or
mesiobuccal and distobuccal and distolingual orifices
with the mesiolingual orifice remaining separate in
mandibular first molar. These canals at the apical
portion may end into separate apical foramina or may
get merged to exit as single canal. Due to a number
of anatomic variations seen in the C-shaped canal
morphology, the cleaning, shaping and obturation of
these teeth becomes difficult.
Figures 3.21A and B show preoperative and post-
operative radiographs of mandibular second molar with
C-shaped canal.
• Presence of additional canals: There is always a possibility
of additional root canals than that are normally found,
in any tooth. If these canals are missed, it results in
incomplete debridement causing Endodontic failure.
A with appropriate root end filling material for the success of
B • Gemination: It is a developmental anomaly characterized
Figs 3.21A and B  Preoperative and postoperative radiographs of
mandi­bular second molar with C-shaped canal (Courtesy of Dr
Nilesh Kadam)
29
• Other complexities: Fins, deltas, loops, intercanal
connections, etc.
WHAT IS ISTHMUS AND WHAT IS ITS ROLE
DURING ENDODONTIC SURGICAL PROCEDURE?
When two or more canals are present in the root, a narrow
ribbon-shaped communication that occurs between the
root canals containing pulp or pulpally derived tissues is
called an isthmus (Fig. 3.22A).
Kim et al classified isthmi into 5 types that can be found:
1. Type I: An incomplete isthmus with a faint
communication between the two canals (Fig. 3.22B).
2. Type II: A complete isthmus with a definite
communication between the two canals (Fig. 3.22C).
3. Type III: A very short, complete isthmus between the
two canals (Fig. 3.22D).
4. Type IV: A complete or an incomplete isthmus that
occurs between three or more canals (Fig. 3.22E).
5. Type V: Two or three canal openings without visible
communication between the canals (Fig. 3.22F).
ROLE OF ISTHMI IN ENDODONTIC
SURGICAL PROCEDURE
• When multiple canals are present, careful inspection of
the resected root surface is to be done to locate all isthmi.
• Although the canals may be thoroughly cleaned, the
narrow isthmus area remains untouched. Thus it serves
as bacterial reservoirs.
So, all isthmi must be identified, prepared and filled
surgical procedure.
WHAT ARE THE POSSIBLE DEVELOPMENTAL
ANOMALIES AND VARIATIONS IN THE ANATOMY
OF ROOT CANAL SYSTEM?
Certain developmental anomalies cause variations in root
canal anatomy that may render the execution of Endodontic
procedures difficult or even impossible sometimes.
• Hypopitutarism: In this condition, there is retarded
eruption of teeth and open root apices may be seen.
• Hyperparathyroidism: Pulp calcification and loss of
lamina dura may be seen.
by two completely or incompletely separated crowns
that have single root and root canal caused by division
of single tooth germ by invagination (Fig. 3.23).
30 Short Textbook of Endodontics

A B C

D E F

Figs 3.22A to F  (A) Diagram showing enlarged view of ribbon-shaped communication between root canals: Isthmus;
(B) Type I; (C) Type II; (D) Type III; (E) Type IV; (F) Type V

Fig. 3.23  Diagrammatic representation of gemination Fig. 3.24  Diagrammatic representation of fusion of teeth

• Fusion: It is a developmental anomaly caused by union
of two normally separated tooth germs. The tooth
may have separate or fused root canals (Figs 3.24 and
3.25).
• Concresence : It is the fusion of teeth after root formation
is completed. Teeth are joined by cementum only (Fig.
3.26).
• Dilaceration: It is an angulation or a sharp bend or curve
in the root or crown of a formed tooth caused due to
trauma during tooth development. This curvature needs
to be recognized on preoperative radiograph to prevent
procedural errors (Fig. 3.27).
• Talon’s cusp: It is an anomalous structure that resembles
an eagle’s talon, that projects lingually from the
 Morphology and Internal Anatomy of the Root Canal System
Fig. 3.25  Intraoral periapical radiograph showing fusion of lower
central and lateral incisor teeth of both left and right sides appearing
as wide central teeth having fused pulp chambers and root canals
(Courtesy of Dr Mansi Shah, Dentoview-Advanced Dental Imaging
Center)
Fig. 3.26  Diagrammatic representation of concresence of maxillary
second and third molars
cingulum area of maxillary or mandibular permanent
incisor. There is a deep developmental groove where
the talon’s cusp blends with the sloping lingual tooth
surface that consists of a horn of pulp tissue. Exposure
of pulp horn necessitates Endodontic therapy.
• Dens invaginatus/dens in dente: It is a developmental
variation caused by invagination within the crown or
root of the lingual surface of tooth before calcification
has occurred. Permanent maxillary incisors are the teeth
more frequently involved, although may occur in other
anterior teeth as well.
31
Fig. 3.27  Diagrammatic representation of dilaceration in the apical
third of the roots of a maxillary molar
Fig. 3.28  Intraoral periapical radiograph showing dens in dente in
maxillary left central incisor (Courtesy of Dr Mansi Shah, Dentoview
Advanced Dental Imaging Center)
Figure 3.28 shows a radiograph showing dens in dente
in maxillary left central incisor.
Three types of Dens in Dente include: (Fig. 3.29)
– Type I: It is minor type, lined by enamel that occurs
within the crown and not extending beyond
Cemento enamel junction (CEJ).
– Type II: It consists of enamel lined blind sac that
invades the root and may connect with the dental pulp.
– Type III: It is the severe type which extends to the
root and opens in the apical region but without
connection with the dental pulp.
32 Short Textbook of Endodontics
Fig. 3.29  Diagrammatic representation of dens in dente
types I, II, and III
• Dens evaginatus: It appears as an accessory cusp or a
globule of enamel on occlusal surface between buccal
and lingual cusps of premolars, rarely on molars, canines
and incisors. This extra cusp may contribute to pulp
exposure with subsequent infection following occlusal
wear or fracture.
• Taurodontism: It is a dental anomaly in which the
body of tooth is enlarged at the expense of the roots.
On radiograph, the involved tooth appears rectangular
in shape rather than taper toward the roots. The pulp
chamber is extremely large and the usual constriction
at the cervical of tooth is lacking and the roots are
exceedingly short. Bifurcation/trifurcation may be
present only few millimeters above the root apex.
Figure 3.30 shows diagrammatic representation of
taurodontism in mandibular molars and Figures 3.31A
and B show the pre- and postoperative radiograph of
pulpally involved mandibular molar with taurodontism.
• Supernumerary roots: Extra roots than the usual
may be present. Teeth that usually have single root,
particularly mandibular premolars and canines,
often have two roots. Molars also may exhibit one or
more supernumerary root. Additional roots must be
recognized on preoperative radiograph to accomplish
Endodontic treatment properly.
• Dentinogenesis imperfecta (Hereditary opalescent
dentin): In type I and type II dentinogenesis Imperfecta,
there is partial or total obliteration of the pulp chamber
and root canals by continued formation of dentin.
• Dentin dysplasia: Dentin dysplasia is a hereditary
disease characterized by normal enamel but atypical
Fig. 3.30  Diagrammatic representation of taurodontism in
mandibular molars (Courtesy of Dr V.S. Mohan)
dentin formation with abnormal pulpal morphology.
Roots are malformed in both the dentitions. In Radicular
dentin dysplasia, obliterated pulp chambers are seen
in both the dentitions. In coronal dentin dysplasia,
obliterated pulp chambers in deciduous teeth and
abnormally large pulp chambers in permanent teeth
occur.
• Palatal developmental groove: It originates from palatal
surface usually the cingulum of maxillary lateral incisor
and ends apically at various levels of root.
• Additional root canals than the usual may be present.
Figures 3.32A and B show radiographs of maxillary
lateral incisor with four canals.
WHAT IS THE MORPHOLOGY OF THE ROOT
CANAL SYSTEM OF THE INDIVIDUAL TEETH?
Maxillary Central Incisor (Fig. 3.33)
• Average length of tooth: 22.5 mm
• Usual number of roots: 1
• Usual number of root canals: 1 (Lateral accessory canals
may be present)
• Root curvature: Mostly straight, but may be curved to
labial or distal.
Morphology of Root Canal System
Morphology of pulp chamber
• Pulp chamber wider mesiodistally than buccolingually
• Three pulp horns present in newly erupted central
incisor
 Morphology and Internal Anatomy of the Root Canal System
A B
Figs 3.31A and B  Taurodontism seen in a mandibular molar:
(A) Preoperative radiograph showing deep caries involving the pulp
(B) Postobturation radiograph (Courtesy of Dr Roheet Khatavkar)
A B
Figs 3.32A and B  Preoperative and postoperative radiographs
showing maxillary lateral incisor with four canals which were
located, negotiated, cleaned and shaped and obturated (Courtesy of
Dr V.S. Mohan)
• Since there is single canal usually, the division between
pulp chamber and root canal is indistinct
• Floor is oval generally.
Morphology of root canals
• Cross-section at CEJ level is generally triangular in young
teeth and oval in older teeth
• Cross-section at apical level gradually becomes round.
Figures 3.34A and B show the preoperative and
postoperative radiographs of maxillary central incisor
tooth.
33
Dotted line shows the outline for access cavity preparation
Fig. 3.33  Maxillary central incisor
A B
Figs 3.34A and B  Preoperative and postoperative radiographs of
maxillary central incisor tooth (Courtesy of Dr Roheet Khatavkar)
Possible Variation and Anomalies
• More than one main canal may be present.
• Dens invaginatus.
• Shovel shaped incisor crowns.
• Fusion, gemination.
Maxillary Lateral Incisor (Fig. 3.35)
• Average length of tooth: 21 mm
• Usual number of roots: 1
34 Short Textbook of Endodontics

Fig. 3.36  Postoperative radiograph of maxillary central and lateral

incisor teeth (Courtesy of Dr Mrunalini Vaidya)
Dotted line shows the outline for access cavity preparation
Fig. 3.35  Maxillary lateral incisor

• Usual number of root canals: 1 (about 5% cases have

been reported to have 2 canals)
(Lateral accessory canals may be present)
• Root curvature: Mostly its root gets curved to the distal,
sometimes straight.

Morphology of Root Canal System

Morphology of pulp chamber
• Pulp chamber wider mesiodistally than buccolingually
• Similar to maxillary central incisor but smaller
• Two pulp horns usually, sometimes pulp horns are
absent.

Morphology of root canals

• When cross-section is taken at CEJ level, pulp chamber
appears to be centered in the root Dotted line shows the outline for access cavity preparation
• Cross-section at CEJ level is triangular or oval or round Fig. 3.37  Maxillary canine
• Cross-section at midroot level is round
• Cross-section at apical level is also round.
Figure 3.36 shows the postoperative radiograph of
maxillary central and lateral incisor teeth. Maxillary Canine (Fig. 3.37)

Possible Variation and Anomalies
• Two roots may be present usually associated with a
developmental radicular palatal groove.
• Dens invaginatus or dens in dente.
• Fusion, gemination.
• Additional canals may be present.
• Average length of tooth: 26 mm (Longest root in dentition
of approximately 17 mm length)
• Usual number of roots: 1
• Usual number of root canals: 1 (Lateral accessory canals
may be present commonly in the apical third of the root)
• Root curvature: Mostly its root gets curved to the distal,
sometimes straight or may be curved to the labial.
 Morphology and Internal Anatomy of the Root Canal System
Morphology of Root Canal System
Morphology of pulp chamber
• No pulp horns
• Wider labiolingually than mesiodistally
Morphology of root canals
• Cross-section at CEJ level is oval shape.
• Cross-section at mid-root is oval shape.
• Cross-section at apical level shows constriction.
Figures 3.38A and B show the preoperative and
postoperative radiograph of maxillary canine.
Possible Variation and Anomalies
• Dilacerated root
• Two roots
• Dens invaginatus
• Dens evaginatus
Clinical Considerations
• Due to abscess in relation to maxillary canine, if
perforation occurs below insertion of levator muscles
of upper lip, abscess drains into buccal vestibule. If
perforation occurs above insertion of levator muscles,
drainage occurs in canine space resulting in cellulitis.
• Occasionally, thin buccal bone over canine eminence
disintegrates and fenestration occurs leading to clinical
problems such as inaccurate apex location, risk of
irrigation accident, slight permanent apical pressure
sensitivity after root canal therapy.
A B
Figs 3.38A and B  Preoperative and postoperative radiographs
of maxillary canine (Courtesy of Dr Roheet Khatavkar)
35
Maxillary First Premolar (Fig. 3.39)
• Average length of tooth: 20.6 mm
• Usual number of roots: 2
• Usual number of root canals: 2 in most cases, 1 in few
cases
• Root curvature: Buccal root—mostly gets curved to the
palatal sometimes may be straight or be palatally curved
– Palatal root—mostly straight, sometimes may get
curved to the buccal or distal
– When there is single root, it is usually straight or may
be distally or labially curved.
Morphology of Root Canal System
Morphology of pulp chamber
• Wider buccolingually than mesiodistally
• Buccal and palatal pulp horns present.
Morphology of root canals
• When cross-section is taken in the coronal third, it
appears to be kidney-shaped due to mesial concavity.
• Cross-section at mid-root level is round shape.
• Apical third generally has curved root canals.
Figures 3.40A and B show the preoperative and
postoperative radiographs of maxillary first premolar
tooth.
Figures 3.41A and B show the preoperative and
postoperative radiographs of maxillary first and second
premolars.
Dotted line shows the outline for access cavity preparation
Fig. 3.39  Maxillary first premolar
36 Short Textbook of Endodontics

A B A B
Figs 3.40A and B  Preoperative and postoperative radiographs of Figs 3.41A and B  Preoperative and postoperative radiograph
maxillary first premolar tooth (Courtesy of Dr Roheet Khatavkar) of maxillary first and second premolars (Courtesy of Dr Roheet
Khatavkar)

Possible Variation and Anomalies

• More than two roots and root canals.
• Canals may separate, may join, rejoin or divide.
• Taurodontism has been reported in few cases.

Clinical Considerations
• There is thin layer of bone separating the alveolar socket
of maxillary first premolar from maxillary sinus.
• Buccal root fenestration through the bone leading to
clinical problems such as inaccurate apex location, risk
of irrigation accident, slight permanent apical pressure
sensitivity after root canal therapy.
• Maxillary first premolar is susceptible to mesiodistal
root fracture and fracture at the base of the cusps.

Maxillary Second Premolar (Fig. 3.42)
• Average length of tooth: 21.5 mm
• Usual number of roots: 1
• Usual number of root canals: 1 in most cases, 2 in few
cases
• Root curvature: Mostly the root is distally curved,
sometimes may get curved to the buccal or to the distal.
Morphology of Root Canal System
Morphology of pulp chamber
• Wider buccolingually than mesiodistally
• Buccal and palatal pulp horns are present, buccal pulp
horn is larger.
Dotted line shows the outline for access cavity preparation
Fig. 3.42  Maxillary second premolar
Morphology of root canals: From floor of pulp chamber
to the apex the cross-section is oval. When two canals are
present, they are nearly parallel to each other since the tooth
has one root usually.
Figure 3.43 shows the postoperative radiograph of
maxillary second premolar tooth with one canal.
Figures 3.44A and B show the preoperative and
postoperative radiograph of maxillary second premolar
tooth with two canals.
 Morphology and Internal Anatomy of the Root Canal System 37

Possible Variation and Anomalies

• Rare
• Dens invaginatus
• Deep distal root concavity
• Taurodontism has been reported.

Clinical Consideration
• Maxillary second premolar is also susceptible to
fractures like the maxillary first premolar.

Maxillary First Molar (Fig. 3.45)

Fig. 3.43  Postoperative radiograph of maxillary second
premolar tooth (Courtesy of Dr Roheet Khatavkar)
A
• Average length of tooth: 20.8 mm (Largest tooth in
volume)
• Usual number of roots: 3
• Usual number of root canals
– In 80% of cases, 4 namely the MB1, MB2, DB and
palatal (Fig. 3.46B)
– In 20% of cases, 3 namely the MB, DB and palatal
(Fig. 3.46A)
Clinical studies have shown that use of magnification
in the form of loupes or dental operating microscope
(DOM) has caused increased prevalence of the
clinical detection of the MB2 canal.
A clinical study by Buhrley et al (Ingle’s Endodontics
6, p.176) showed incidence of MB2 canals as follows:
– Using DOM: 71.1%
– Using loupes: 62.5%
– Without any magnification: 17.2%
• Root curvature
– Mesiobuccal root is mostly distally curved, sometimes
it may be straight

B
Dotted line shows the outline for access cavity preparation
Figs 3.44A and B  Preoperative and postoperative radiographs of
maxillary fist premolar tooth (Courtesy of Dr Shivani Bhatt) Fig. 3.45  Maxillary first molar
38 Short Textbook of Endodontics

– Distobuccal root is mostly straight sometimes it may Figures 3.48A and B show the preoperative and
be curved to the mesial or distal postoperative radiographs of maxillary first molar with
– Palatal root is mostly curved to the buccal sometimes four canals.
it may be straight.
Possible Variation and Anomalies
Morphology of Root Canal System
• Two palatal canals have been reported (Fig. 3.49)
Morphology of pulp chamber • C-shaped canals
• Its buccolingual dimension is widest. • Taurodontism.
• Four pulp horns are present: MB, MP, DB, DP.
• Cross-section of the floor of the pulp chamber is
triangular (Molar triangle) when three canals are present
as shown in Figure 3.46A.
It is rhomboidal when four orifices are present, with
corners corresponding to each of the four orifices
as shown in Figure 3.46B.
• Mesiobuccal orifice lies under the mesiobuccal cusp,
distobuccal orifice lies distal and palatal to the MB
orifice, Palatal orifice is centered palatally. There are two
possible locations of the MB2 orifice: It may lie palatal
and mesial to the main mesiobuccal orifice or it may lie
on a line drawn from the main mesiobuccal orifice to
the palatal orifice. Use of dental operating microscope
or even loupes has resulted in increased prevalence of
A B
clinical detection of MB2 canal.
Figs 3.47A and B  Preoperative and postoperative radiographs
Morphology of root canals of maxillary first molar with three canals (Courtesy of Dr Roheet
• The palatal canal is flat and ribbon-like. Khatavkar)
• It has largest dimension and is wider mesiodistally.
• Cross-section of the distobuccal canal is oval in the
coronal two-thirds and round in the apical one-third.
• MB1 and MB2 canals are closely interconnected and
may sometimes merge into one canal.
• Mesiobuccal root has a concavity on its distal aspect.
So the root canal wall becomes thin in that area. As
result, care has to be taken not to instrument the wall
excessively because strip perforation can occur. A B
Figures 3.47A and B show the preoperative and Figs 3.48A and B  Preoperative and postoperative radiographs of
postoperative radiographs of maxillary first molar with maxillary first molar with four canals (Courtesy of Dr Shivani Bhatt)
three canals.

A B

Figs 3.46A and B  Occlusal view of maxillary first molar with three Fig. 3.49  Occlusal view of maxillary first molar with two palatal
and four canals respectively canals and two mesial canals (MB1, MB2)
 Morphology and Internal Anatomy of the Root Canal System
Clinical Consideration
• Pulp chamber of maxillary first molar lies mesial to the
oblique ridge, so access cavity is usually confined mesial
to oblique ridge in most cases.
• Soreness can occur in maxillary teeth due to sinusitis
or sinusitis can occur due to pulpal disease due to close
proximity of maxillary sinus and because of thin buccal
bony plate.
Maxillary Second Molar (Fig. 3.50)
• Average length of tooth: 20 mm
• Usual number of roots: 3
• Usual number of root canals: 3 or more, sometimes 2 or 1
• Root curvature:
– Mesiobuccal root is mostly curved to the distal
sometimes it may be straight.
– Distobuccal root is mostly straight sometimes it may
be curved to the mesial or distal.
– Palatal root is usually straight, sometimes it may be
buccally curved.
Morphology of Root Canal System
Similar to maxillary first molar with few differences such
as shorter roots, less curvature and roots closer together.
Morphology of pulp chamber
• A flat triangle or a straight line is formed by the orifices.
• The mesiobuccal canal orifice more to the buccal and
mesial as compared to the first molar.
• The palatal canal orifice lies on the most palatal aspect
of the root.
• The distobuccal orifice lies midway between the
mesiobuccal and palatal orifice.
Dotted line shows the outline for access cavity preparation
Fig. 3.50  Maxillary second molar
39
Figure 3.51 shows the occlusal view of maxillary second
molar with three canals, two canals and one canal.
Morphology of root canals
• There may be two, three or four root canals.
• When two canals are present (seen in case of fused
roots), they are generally parallel and of equal length
and diameter.
Figures 3.52A and B show the postoperative
radiographs of maxillary second molar tooth with three
and four root canals respectively.
Possible Variation and Anomalies
• Four roots; double palatal root
• Taurodontism
• Single rooted teeth with single canal (Fig. 3.51)
• C-shaped canals
• Two canal system-buccal and palatal (Fig. 3.51)
Clinical Consideration
• Maxillary second molar lies closer to maxillary sinus
than the first molar. Due to proximity of roots of
maxillary second molar to the maxillary sinus, pulpal
disease can cause sinusitis or sinusitis can cause
soreness in maxillary teeth.
Maxillary Third Molar (Fig. 3.53)
• Average length of tooth: 16.5 mm.
• Usual number of roots and root canals: Extremely
variable. 1 to 4 roots and 1 to 6 root canals, C-shaped
canals.
Morphology of Root Canal System
Morphology of maxillary third molar is unpredictable. Great
variations in shape, size, form of both pulp chamber and
root canal.
Figure 3.54 shows the postoperative radiograph of
maxillary third molar tooth.
Fig. 3.51  Occlusal view of maxillary second molar with three
canals, two canals and one canal respectively
40 Short Textbook of Endodontics

A B
Figs 3.52A and B  (A) Postoperative radiograph of maxillary second molar with three canals (Courtesy of Dr Ajay Bajaj);
(B) Postoperative radiograph of maxillary second molar with four canals (Courtesy of Dr Mrunalini Vaidya)

Clinical Consideration
• Two anatomic structures to which maxillary third
molars lie close are the maxillary sinus and maxillary
tuberosity.
• Since maxillary third molars may be significantly tipped
to distal, buccal or both, there can be great access
problem.
• Limited mouth opening can make root canal therapy
almost impossible in maxillary third molar teeth.

Dotted line shows the outline for access cavity preparation
Fig. 3.53  Maxillary third molar
Mandibular Central Incisor (Fig. 3.55)
• Average length of tooth: 20.8 mm
• Usual number of roots: 1
• Usual number of root canals: 1 or 2 canals which usually
exit into a single apical foramen
• Root curvature: Mostly it is straight, sometimes it may
be curved to the distal or labially curved.

Morphology of Root Canal System

Morphology of pulp chamber
• Wider labiolingually than mesiodistally.
• Oval-shaped which is narrow mesiodistally and long
incisogingivally.

Morphology of root canal

• Cross-section at CEJ is oval
Fig. 3.54  Postoperative radiograph of maxillary third molar with • Cross-section at mid-root is ribbon-shaped
three canals (Courtesy of Dr Shivani Bhatt) • Cross-section at apical third is round
 Morphology and Internal Anatomy of the Root Canal System 41

• When two root canals (buccal and lingual) are present,
they usually join at the apical portion. Sometimes they
exit as two separate canals (Fig. 3.56).
Figure 3.57 shows the postoperative radiograph of
mandibular central and lateral incisor teeth.
Clinical Consideration
• Second canal is found lingual to the main canal. It should
not be missed.
• Due to lingual inclination of apex of mandibuar central
incisor, surgical access may be difficult to achieve.

Possible Variation and Anomalies Mandibular Lateral Incisor (Fig. 3.58)

• Two canals with single or separate foramina • Average length of tooth: 20.8 mm
• Dens invaginatus • Usual number of roots: 1
• Fusion • Usual number of root canals: 1 or 2 canals which usually
• Gemination exit into a single apical foramen
• Root curvature: Mostly it is straight, sometimes it may
be curved to the distal or labially curved.

Morphology of Root Canal System

Almost similar to mandibular central incisors but slightly
larger dimensions. Slight distolingual angulation of incisal
edge should be considered.
See Figure 3.57 for the postoperative radiograph of
mandibular lateral incisor tooth.

Possible Variation and Anomalies

• Two canals with single or separate foramina
• Dens invaginatus
• Fusion
• Gemination.

Mandibular Canine (Fig. 3.59)

Dotted line shows the outline for access cavity preparation
• Average length of tooth: 25 mm
Fig. 3.55  Mandibular central incisor • Usual number of roots: 1, sometimes 2

Fig. 3.56  Postoperative radiograph of mandibular central incisor Fig. 3.57  Postoperative radiograph of mandibular central incisors
with two canals (Courtesy of Dr V.S. Mohan) and lateral incisor (Courtesy of Dr Ajay Bajaj)
42 Short Textbook of Endodontics

Dotted line shows the outline for access cavity preparation Dotted line shows the outline for access cavity preparation
Fig. 3.58  Mandibular lateral incisor Fig. 3.59  Mandibular canine

• Usual number of root canals: 1, sometimes 2

• Root curvature: Mostly it is straight, sometimes it may
be curved to the distal or labial.

Morphology of Root Canal System

Morphology of pulp chamber
• Similar to maxillary canine but smaller dimensions
• Single pulp horn present
• Narrow mesiodistally
• Floor is ovoid in shape.

Morphology of root canals

• Narrow mesiodistally than buccolingually
• It may have two roots and two root canals. Fig. 3.60  Postoperative radiograph of mandibular canine
Figure 3.60 shows the postoperative radiograph of (Courtesy of Dr Nilesh Kadam)
mandibular canine tooth.

Possible Variation and Anomalies

Mandibular First Premolar (Fig. 3.61): Enigma to
• Two-rooted canine with two canals has been reported Endodontist
• Dens evaginatus
• Fusion. • Average length of tooth: 21.6 mm
• Usual number of roots: 1, sometimes 2 or 3
Clinical Consideration • Usual number of root canals: 1, sometimes bifurcated
canals which join at apical third
• Buccal wall larger, lingual wall slit-like poses a challenge • Root curvature: Usually it is straight, sometimes it may
to clean and shape. be curved to the distal or buccal.
 Morphology and Internal Anatomy of the Root Canal System 43

Morphology of Root Canal System Morphology of root canals

• When single canal is present, it has oval outline
Morphology of pulp chamber • When two canals are present, they have round shape
• Wider buccolingually than mesiodistally from pulp chamber to the apical foramen. The lingual
• Two pulp horns present. Lingual pulp horn is small and canal diverges from the main canal at a sharp angle.
rounded • Sometimes may have three root canals with C-shaped
• Lingual inclination of crown makes location of lingual canal anatomy.
orifice difficult. • In some cases, a single broad root canal may bifurcate
into two separate root canals.
Figures 3.62 to 3.64 show postoperative radiographs of
mandibular first premolar.

Dotted line shows the outline for access cavity preparation

Fig. 3.61  Mandibular first premolar Fig. 3.63  Postoperative radiograph of mandibular first premolar
showing lateral canals filled too (Courtesy of Dr Shivani Bhatt)

Fig. 3.62  Postoperative radiograph of mandibular first premolar Fig. 3.64  Postoperative radiograph of mandibular first premolar
(Courtesy of Dr Nilesh Kadam) with moderate J-shaped curvature in the apical part of the root
(Dilaceration) (Courtesy of Dr Roheet Khatavkar)
44 Short Textbook of Endodontics
Possible Variation and Anomalies
• Numerous variations in root canal morphology occur in
mandibular first premolar and access to its second canal
is difficult. This is the possible reason for the highest
failure rate in mandibular first premolar of nonsurgical
root canal therapy
• Gemination
• Dens invaginatus
• Dens evaginatus
• Two roots, three roots
• Two canals in single root
• Three canals with fused roots
• Three canals in single root
• Three canals with two roots
• Three canals with three roots.
Due to numerous variations in the root canal morphology
and highest chances of failure, the mandibular first
premolar is termed as an enigma to Endodontist.
Clinical Consideration
• Due to lingual inclination of crown, access cavity may
need to be extended upto cusp tip, to gain straight
line access. Location and negotiation of lingual canal
becomes difficult.
• Due to close proximity of root apex of mandibular first
premolar to mental canal and foramen, sometimes
periapical radiolucency on radiograph must be
differenciated from periapical pathology.
Dotted line shows the outline for access cavity preparation
Fig. 3.65  Mandibular second premolar
• Surgical access of mandibular first premolar is
complicated due to proximity to mental nerve.
Mandibular Second Premolar (Fig. 3.65)
• Average length of tooth: 22.3 mm
• Usual number of roots: 1
• Usual number of root canals: 1
• Root curvature: Mostly straight, sometimes may be
curved to the distal or buccal.
Morphology of Root Canal System
Morphology of pulp chamber
• Wider buccolingually than mesiodistally
• Similar to mandibular first premolar but lingual pulp
horn may be larger.
Morphology of root canals: Oval shaped root canals.
Figure 3.66 shows the postoperative radiograph of
mandibular second premolar tooth.
Possible Variation and Anomalies
• Similar to first premolar but found less often.
Figures 3.67A and B show the preoperative and
postoperative radiographs of mandibular second premolar
with additional root and root canals.
Mandibular First Molar (Fig. 3.68)
• Average length of tooth: 21 mm
• Usual number of roots: 2, sometimes 3
• Usual number of root canals: 3 or 4 usually, sometimes
more
Fig. 3.66  Postoperative radiograph of mandibular second
premolar tooth (Courtesy of Dr Shivani Bhatt)
 Morphology and Internal Anatomy of the Root Canal System
B
Figs 3.67A and B  Preoperative and postoperative radiographs of
mandi­bular second premolar with additional root and root canals
(Courtesy of Dr Roheet Khatavkar)
• Root curvature:
– Mesial root : Mostly gets curved to the distal
sometimes straight.
– Distal root: Mostly straight, sometimes may be
curved to the distal.
Morphology of Root Canal System
Morphology of pulp chamber
• Four pulp horns are present: MB, ML, DB, DL
• Roof of pulp chamber is located in cervical third of root
and is rectangular in shape.
• Floor of pulp chamber is located in cervical third of root
and is rhomboidal in shape.
• Mesiobuccal canal orifice is located under the
mesiobuccal cusp
• Mesiolingual orifice is found just lingual to central
groove
• Distal orifice is located distal to buccal groove.
Figure 3.69 shows occlusal view of mandibular first
molar with three, four and five canals respectively.
45
Dotted line shows the outline for access cavity preparation
Fig. 3.68  Mandibular first molar
Fig. 3.69  Occlusal view of mandibular first molar with three, four
and five canals respectively
Morphology of root canals
• Cross-section of all canals is ovoid in cervical and middle
thirds and round in the apical third.
• Mesial root usually has two canals—MB and ML.
Sometimes, a third canal called middle mesial (MM)
(Figs 3.69 and 3.71) is found between the two mesial
canals. Mesial root canals are curved; MB canal having
the greatest curvature.
• Distal root may have a single canal or two canals—DB
and DL are present. Sometimes a third canal middle
distal may be present.
Figures 3.70 to 3.72 show radiographs of mandibular
first molar tooth.
46 Short Textbook of Endodontics

A A

B B
Figs 3.70A and B  Preoperative and postoperative radiographs of Figs 3.72A and B  Preoperative and postoperative radiographs of
mandibular first molar tooth (Courtesy of Dr Shivani Bhatt) mandi­bular first molar with radix entomolaris (Courtesy of Dr Nilesh
Kadam)

Possible Variation and Anomalies

• Additional canals in one or more roots

• Supernumerary roots and canals. An additional root on
the lingual aspect (radix entomolaris) has been reported.
Figures 3.72A and B show the preoperative and
postoperative radiographs of a mandibular molar with
additional lingual root (Radix entomolaris)
• Taurodontism
• C-shaped canals.

A B Clinical Consideration
Figs 3.71A and B  Preoperative and postoperative radiographs
of mandi­bular first molar with three mesial canals (Courtesy of Dr • Multiple accessory foramina are present in the furcation
Roheet Khatavkar) of mandibular molars.
 Morphology and Internal Anatomy of the Root Canal System
Dotted line shows the outline for access cavity preparation
Fig. 3.73  Mandibular second molar
• The distal surface of the mesial root and the mesial
surface of the distal root have a root concavity making
dentinal wall very thin. Instrumentation against these
walls should be minimized to prevent strip perforation.
Mandibular Second Molar (Fig. 3.73)
• Average length of tooth: 19.8 mm
• Usual number of roots: 2
• Usual number of root canals: 3, sometimes 2
• Root curvature
– Mesial root: Mostly curved to the distal, sometimes
may be straight
– Distal root: Mostly straight, sometimes may be
curved to distal or mesial or buccal
– Mesial and distal roots usually sweep distally in a
gradual curve with their apices closer together
– When there is single root, it is usually straight
sometimes may get curved to distal or lingual.
Morphology of Root Canal System
Morphology of pulp chamber
• Similar to mandibular first molar but more symmetric.
• Smaller size of pulp chamber and canal orifices as
compared to mandibular first molar.
• Two mesial orifices located closer together.
• C-shaped canals commonly occur in mandibular second
molar. Figure 3.74 shows occlusal view of mandibular
second molar with three canals, four canals, two canals
and C-shaped canals respectively.
47
Fig. 3.74  Occlusal view of mandibular second molar with three
canals, four canals, two canals and C-shaped canals
Morphology of root canals
• Cross-section is ovoid in cervical and middle third
• Cross-section is round in apical third
• Sometimes shows two canals connected by a semicircular
slit or C-shaped canal.
Figures 3.75 to 3.77 show the radiographs of mandibular
second molar tooth.
Possible Variation and Anomalies
• One to six canals. Most common configurations are two,
three and four canals
• Additional canals in one or more of roots
• Supernumerary roots
• Fused or single root
• Taurodontism.
Clinical Consideration
• Multiple accessory foramina are present in the furcation
of mandibular molars
• The distal aspect of the mesial root of mandibular second
molar and the mesial aspect of the distal root have a root
concavities where careful instrumentation needs to be
done.
Mandibular Third Molar (Fig. 3.78)
• Average length of tooth: 17.5 mm
• Usual number of roots and root canals: 2
48 Short Textbook of Endodontics

A B
A Figs 3.77A and B  Preoperative and postoperative radiographs of
mandi­bular second molar with C-shaped canal (Courtesy of Dr
Roheet Khatavkar)

B
Figs 3.75A and B  Preoperative and postoperative radiographs of
mandibular second molar tooth (Courtesy of Dr Shivani Bhatt) Dotted line shows the outline for access cavity preparation
Fig. 3.78  Mandibular third molar

• Fused, short, severely curved or malformed roots. 1–4

roots and 1–6 canals, C-shaped canals may be present.

Morphology of Root Canal System

The morphology of mandibular third molar is unpredictable.
It resembles mandibular first and second molar but with
numerous variations.
Figures 3.79A and B show the preoperative and
postoperative radiographs of mandibular third molar tooth
showing curved canals.

Clinical Considerations
Fig. 3.76  Postoperative radiograph of mandibular second molar • Anatomic structure that lies close to the roots of
with C-shaped canal (Courtesy of Dr Shivani Bhatt) mandibular third molar is mandibular canal.
 Morphology and Internal Anatomy of the Root Canal System 49

A B
Figs 3.79A and B  Preoperative and post-operative radiograph of mandibular third molar
showing curved canals (Courtesy of Dr Nilesh Kadam)

2. Grossman L, Oliet S, Del Rio C. Endodontic Practice, 11th edn.

• Accessibility may be a problem due to its location
• Isolation and moisture control is difficult.
BIBLIOGRAPHY
1. Cohen S, Hargreaves KM. Pathways of Pulp, 9th edn. St. Louis:
Mosby, 2006. pp.148-65,193-232.
Varghese Publication, 1991. pp.29-58.
3. Ingle J, Bakland L, Baumgartner J. Ingle’s Endodontics, 6th edn.
BC Decker Inc, Hamilton, 2008. pp. 151-220.
4. Jafarzadeh H, You-Nong. The C-shaped root canal configuration:
A Review, JOE. 2007;33:5.
5. Shafer W, Hine M, Levy B. A Textbook of Oral Pathology, 4th edn.
WB Saunders Company, 1993. pp.38-45.
 The Pulpal Reactions

4
CHAPTER

to Caries and Dental

Procedures

This chapter explains how the reaction of pulp to various external stimuli is unique and
describes in detail the reaction of pulp to dental caries and various dental procedures.
  You must know
• How is the Response of Dental Pulp Unique and Different from Other Connective Tissues of
the Body?
• Which are the Different External Stimuli that can Affect Dental Pulp?
• How does the Pulp React to Dental Caries?
• How does the Pulp React to Dental Procedures?
– How does the Pulp React to some of the Diagnostic Procedures?
– How does the Pulp React to Treatment Procedures?
• How does the Pulp React to Specific Dental Materials?

HOW IS THE RESPONSE OF DENTAL PULP
UNIQUE AND DIFFERENT FROM OTHER
CONNECTIVE TISSUES OF THE BODY?
Pulpal response to external stimuli is unique due to
following reasons:
• Pulp is encased within the hard tissues, in an unyielding
low-compliance environment
• Pulp has limited space to expand during inflammation
• Pulp has limited portals of entry
• Pulp is an organ of terminal and limited circulation with
no efficient collateral circulation
• Pulp is more susceptible to injury and may have
complicated regeneration due to scarcity of circulation
• Even the mature pulp resembles embryonic connective
tissue. Therefore, it is relatively rich source of stem cells.
It has the ability to form dentin throughout life
• Rich neurovascular supply within the pulp may promote
the effect of inflammation and can lead to rapid
degeneration and necrosis of pulp
• Various dental treatment procedures involve cleaning
and shaping of enamel and dentin, causing further
irritation of pulp
• Bacteria enter the pulp at a very late stage. Initially there
is invasion of bacterial products and toxins rather than
bacteria themselves
• Pulp organ lacks specific receptors for different
external stimuli, the sensory response is always pain
irrespective of the type of stimulus-heat, cold, pressure,
touch, etc.
A mind-map to remember all unique features of dental
pulp is given in Figure 4.1.
WHICH ARE THE DIFFERENT EXTERNAL STIMULI
THAT CAN AFFECT THE DENTAL PULP?
Flow chart 4.1 gives the detailed list of external noxious
stimuli that can affect the dental pulp causing its
inflammation, necrosis and dystrophy beginning with the
most frequent irritant: Micro-organisms. These have been
discussed in detail in the next chapter under the possible
causes of diseases of dental pulp.
HOW DOES THE PULP REACT TO DENTAL CARIES?
Dental caries is a polymicrobial disease affecting the dental
pulp. Bacteria are mainly responsible for causing pulpal
disease.

Fig. 4.1  Mind-map of unique features of dental pulp
Pathways of Bacterial Invasion of the Pulp
Figure 4.2 shows different pathways through which there is
invasion of bacteria and toxins into the pulp.
Initially, there is invasion of bacterial toxins and invasion
by bacteria themselves occurs at later stages of the carious
process that clinically present as carious exposure. This is
because toxins pass through enamel and dentin well ahead
of bacteria themselves.
Bacterial byproducts and toxins include:
• Acids and proteinases that dissolve and digest enamel
and dentin
• Lipopolysaccharides (LPS)
• Lipoteichoic acid (LTA).
Reaction of Pulp to Dental Caries
Pulp exhibits inflammatory reaction in response to bacteria
and their byproducts and toxins.
• To protect dental pulp against caries, three basic
reactions occur in the following sequence:
– Dentin sclerosis: Decrease in dentin permeability
– Formation of tertiary dentin
– Inflammatory and immune reactions.
The Pulpal Reactions to Caries and Dental Procedures 51
Dentin Sclerosis: Decrease in Dentin Permeability
First defense reaction to caries is dentin sclerosis.
This occurs by:
• Increased deposition of intratubular dentin.
Transforming growth factor-beta 1 (TFG-beta 1) has
been implicated to be mainly responsible for this
reparative dentinogenesis.
• Direct deposition of precipitated mineral crystals into the
narrowed dentinal tubules causing occlusion of tubules.
As a result, there is effective decrease in dentin
permeability occurring in a relatively short period of
time.
Formation of Tertiary Dentin
This occurs over a longer period of time as compared to
sclerotic dentin.
Resultant character of tertiary dentin depends on the
intensity of stimulus. Either reactionary or reparative dentin
is formed (Fig. 4.3).
• In response to mild stimulus, resident quiescent
odontoblasts are activated forming reactionary
dentin. This mostly is seen in cases where dentin
52 Short Textbook of Endodontics

Flow chart 4.1  Noxious stimuli affecting dental pulp/causes of diseases of dental pulp

Fig. 4.2  Pathways of bacterial invasion into the pulp Fig. 4.3  Diagram showing effect of caries on pulp. a: Bacterial
plaque; b: Outer carious dentin; c: Transparent inner carious dentin;
d: Reparative dentin; e: Pulp
 The Pulpal Reactions to Caries and Dental Procedures 53

demineralization has occurred beneath the noncavitated • Chronic hyperplastic pulpitis: In case of primary and
enamel lesion. immature permanent teeth, pulp exposure can result in a
• In response to aggressive stimulus, the subjacent proliferative pulpal response called chronic hyperplastic
odontoblasts die and there is disruption of odontoblast pulpitis characterized by proliferation of exuberant
layer. As a result, there is differentiation of secretory cells inflammatory pulp tissue through the exposure forming
to cause repopulation of the disrupted odontoblast layer pulp polyp.
either by • Pulp necrosis: In case of persistent inflammation,
– Organized tubular reparative dentin or tissue pressure is increased, stasis occurs resulting
– Disorganized irregular fibrodentin. in pulp necrosis. Whether partial or total necrosis of
Sclerotic and tertiary dentin formed provides a physical pulp occurs is determined by possibility of drainage.
barrier to noxious stimuli. In case of pulp open to oral fluids, drainage is possible.
So, partial necrosis is likely to occur. Apical pulp tissue
Inflammatory and Immune Reactions remains uninflammed. But if drainage is not possible,
total necrosis of pulp may occur.
Inflammation Figure 4.5 shows diagrammatic representation of
• Acute inflammation: Polymorphonuclear (PMN) sequel of dental caries, how it affects the dental pulp and
leukocytes reach the area of bacterial involvement to the periradicular area demonstrating caries in enamel
prevent the further dissemination of bacteria deeper and dentin becomes deeper and causes inflammation in
into the pulp.
In case of severe inflammatory process, symptoms
of acute reaction are manifested.
– There is accumulation of inflammatory exudates,
causing pain from pressure on nerve endings.
– As the PMN leukocytes die, there is formation of pus
which further irritates the nerve cells.
• Chronic inflammation: In case of less severe inflam­
matory process, PMN leukocytes are replaced by
lymphocytes and plasma cells. The inflammatory
reaction is confined to the surface of the pulp.
– Microorganisms may penetrate deeper causing an
acute exacerbation manifested by clinical flare-up.
– Microorganisms may cause reaction in the periapical
tissue by means of their metabolic products.
Chronic inflammation due to deep dental caries
involving the pulp appears radiolucent on intraoral Fig. 4.4  Radiograph showing mandibular first molar with extensive
periapical radiograph (IOPA) as seen in Figure 4.4. caries involving the pulp (Courtesy of Dr Chetan Shah)

A B C D E
Figs 4.5A to E  Diagrammatic representation of sequel of dental caries: (A) Caries in enamel and dentin; (B) Deep caries causing pulpitis;
(C) Widening of the periodontal ligament space; (D) Periapical granuloma or abscess; (E) Necrotic pulp and periapical abscess
54 Short Textbook of Endodontics

the pulp. There is widening of the PDL space. Persistent – Calcific metamorphosis progresses from coronal part
inflammation causes necrosis of the pulp. Less virulent of the tooth to the apical canal.
microorganisms may result in formation of chronic An alternative sequela to trauma may be idiopathic
abscess. Low grade irritation can result in the formation internal resorption.
of periapical granuloma or cyst. • Repair and regeneration: When inflammatory and
immune reactions are effective, the foreign material
Immune Reactions may be neutralized and removed, initiating repair and
• Humoral and cellular pulpal immune response occurs regeneration.
to invading microorganisms. • There is formation of reactionary (tertiary) dentin, when
• Immunoglobulins such as IgG, IgM and IgA have been no odontoblasts are killed.
found within the odontoblasts of carious dentin. • There is formation of reparative (tertiary) dentin, when
• The three antigen-presenting cell types of pulp include: odontoblasts are killed.
– Macrophages However, normally organized pulp may not reform.
– Dendritic cells Pulp polyp is considered as a chronic inflammation
– B-lymphocytes. in which injury and repair are going on at the same time.
Macrophages express type II major histocompatibility Pulp polyp contains epithelial cells from oral mucosa, large
complex (MHC) molecules on stimulation of bacteria or lymphocytes and also fibrous tissue.
cytokines. Figure 4.6 shows a photograph of pulp polyp in a primary
Dendritic cells form network around blood vessels second molar.
within the pulp and the odontoblast layer and constantly Lymphocytes represent cells of inflammation.
express MHC molecules without provocation. Fibrous tissue represents an attempt to ‘wall off’ the
B-lymphocytes secrete antibodies during specific diseased tissue, i.e. repair.
immune response and express MHC molecules. A mind-map to remember all points of reaction of pulp
Initially, antibodies accumulate in the odontoblast to dental caries (Fig. 4.7).
layer. But as the lesion progresses, they may be found in
dentinal tubules. HOW DOES THE PULP REACT TO DENTAL
• The first cells to encounter an antigen diffusing along the
PROCEDURES?
dentinal tubules are the odontoblasts. The odontoblasts
are stationary and do not directly participate in the Flow chart 4.2 shows different diagnostic and dental
activation of T-cells, but may have a role in activating treatment procedures.
dendritic cells.
• Calcification and internal resorption:
Formation of pulp stones and calcific metamorphosis
has been found to occur in response to caries in chronic
long standing cases.
Calcific metamorphosis
– A pulpal response to traumatic injury characterized
by deposition of hard tissue within the root canal
space is called calcific metamorphosis.
– Calcific metamorphosis commonly occurs in the
anterior teeth that get affected by trauma.
– A tooth with calcific metamorphosis appears darker
in hue than the adjacent teeth and has dark yellow
color due to greater thickness of dentin.
– There is reduction in size of both the coronal and
radicular pulp spaces, sometimes resulting in partial
or total obliteration of pulp canal when seen on
radiograph. PDL space is normal and lamina dura Fig. 4.6  Photograph showing pulp polyp in a primary second molar
is intact. (Courtesy of Dr CR Suvarna)
 The Pulpal Reactions to Caries and Dental Procedures 55

Fig. 4.7  Mind-map of reaction of pulp to dental caries

56 Short Textbook of Endodontics
Flow chart 4.2  Different diagnostic and dental
treatment procedures
How does the Pulp React to Some of the
Diagnostic Procedures?
Pulp Vitality Testing
Thermal tests: Both heat and cold tests if performed within
normal clinical parameters do not cause any damage to
dental pulp.
Heat Test
Heated gutta-percha or tip of heat-testing device such as
system B reaches a temperature of 200oC, just before the
smoke point and is applied to the tooth surface for 5–10
seconds.
The maximum temperature at the pulp-dentin junction
(PDJ) was recorded using a thermistor and found to be
about 39.9oC for 10 second application of heat to tooth. This
temperature does not reach the threshold at which damage
to the tissue can occur.
Thus, within normal clinical parameters (temperature
and time) heat test is relatively safe and does not cause any
pulpal damage.
Cold Test
Carbon dioxide snow has an inherent temperature of
–78oC  that may be applied to tooth surface for 5 seconds
to 5 minutes.
The maximum temperature at the pulp-dentin junction
(PDJ) was recorded using a thermistor and found to be about
9.5oC for 5-minute application. When carbon dioxide snow
was applied to the tooth for 20 minutes, the pulp suffered
damage and there was necrosis of odontoblasts.
Thus, within normal clinical parameters (temperature
and time) cold test is relatively safe and does not cause any
pulpal damage.
It has been found that value of 10 oC above body
temperature is considered as threshold to cause irreversible
damage to vital tissues. Higher temperatures and greater
time of application leads to greater damage.
How does the Pulp React to Dental
Treatment Procedures?
How does the Pulp React to Local Anesthetics?
• Vasoconstrictors, such as epinephrine, which are added
to local anesthetics to enhance its duration of action,
cause reduction in pulpal blood flow (Fig. 4.8).
• Reduction in pulpal blood flow can have a negative effect
on the health of dental pulp as it reduces the clearance of
large molecular weight toxins or waste products that may
result in irreversible pulpal pathosis. This effect is more
likely particularly if the pulp is inflamed preoperatively.
• During cavity preparation in an anesthetized tooth, the
response of pulp is suboptimal. If the pulp is already
severely inflamed, local anesthesia compromises its
ability to recover from inflammation.
• Supplemental injections (such as intraosseous, intra­
ligamentary and intrapulpal) cause more severe
reduction or even transient cessation of pulpal blood
flow. This has been concluded from animal studies.
• During Endodontic access preparation, if in spite of
nerve block and repeated supplemental injections, if
pain persists, then intrapulpal injection is indicated. It
is achieved by injecting the anesthetic into pulp tissue
under pressure. The pharmacologic action of anesthetic
solution occurs on nerve cell membrane. Mechanical
pressure of injection causes circulatory interference. If
anesthetic solution is deposited passively into the pulp
chamber, the solution will not diffuse throughout the
pulp and hence is ineffective.
How does the Pulp React to Ultrasonic Scaling
and Periodontal Procedures?
Heat is generated during ultrasonic scaling which has the
potential to cause pulpal damage if adequate cooling with
water coolant is not used (Fig. 4.9).
 The Pulpal Reactions to Caries and Dental Procedures 57

Fig. 4.8  Reaction of pulp to local anesthetics

Fig. 4.10  Reaction of pulp to ultrasonic scaling of some teeth

Fig. 4.9  Reaction of pulp to inadequate water

during periodontal procedures

There is greater amount of heat generated with heavy

load of force exerted by the ultrasonic tip against the tooth.
Thus, proper water cooling of ultrasonic scalers is a must
to control the excessive heat production and prevent any
damage to pulp.
Also, periodontal scaling and root planing may result in
removal of thin cementum that exposes the dentin to the
oral cavity resulting in dentin hypersensitivity.
Thus, periodontal disease that causes attachment loss
and exposes root surface to oral cavity as well as periodontal
treatment such as scaling and root planning can be Fig. 4.11   Factors affecting amount of heat produced during
associated with pulpal pathosis particularly if large lateral cavity and crown preparation
or accessory canals are exposed (Fig. 4.10).

Factors Affecting Amount of Heat Produced during

How does the Pulp React to Cavity
Cavity and Crown Preparation (Fig. 4.11)
and Crown Preparation?
The physical irritation of the pulp from heat, desiccation i. Length of time of contact of cutting instrument with
or vibration while performing restorative procedures may the tooth structure, if more, then can cause lots of heat
affect the pulp adversely. production. Intermittent cutting is recommended.
58 Short Textbook of Endodontics
ii. Sharpness of bur: Old blunt burs may require application
of lots of pressure for cutting.
iii. Amount of pressure exerted on bur: Light pressure is
recommended. More pressure can cause more heat
production.
iv. Revolutions per minute.
v. Nature of cutting instrument: Steel burs produce
more heat as compared to carbide burs causing more
thermal damage to the pulp. Diamond burs cause
abrasive action and pressure may need to be exerted.
Damaged or improper handpiece with poor torque
characteristics can cause pulpal damage due to
eccentric bur rotation.
vi. Cooling method: When only air is used as coolant, more
potential for pulpal damage. When water is used as
coolant, less chances of pulpal inflammation.
  If only air is used as coolant at 2,00,000 rpm, it has
been found that it takes just 11 seconds of continuous
preparation at this speed to burn the pulp.
The density of dentinal tubules at DEJ is 65,000/mm2 and
the density of dentinal tubules at the pulp is 15,000/mm2.
As the remaining dentinal thickness (RDT) decreases,
the response of pulp to restorative procedures increases.
Remaining Dentinal Thickness
• It is the thickness of dentin present between the floor of
cavity preparation and the roof of the pulp chamber.
• It is an important factor in determining the pulpal
response to various noxious stimuli.
• Dentin thickness of about 2 mm between the floor of
cavity preparation and the pulp is considered adequate
to serve as an insulating barrier against irritants.
• Permeability of dentin increases with lesser remaining
dentinal thickness (RDT). It has been found that when
RDT is about 0.75 mm, effects of bacterial invasion are
seen and when RDT is about 0.25 mm, odontoblastic
cell death is seen
Figures 4.12A and B show diagram of cavity preparation
is madibular molar with more RDT in (A), less possibility of
damage to pulp and lesser RDT in (B) where there will be
increased pulpal response.
Thus, RDT of less than 0.5 mm, can cause severe pulpal
reaction and more chance of pulp undergoing irreversible
pulpal pathosis. Dentin is a good insulator, damage to pulp
does not occur unless RDT is less than 1 mm.
In case of large and wide cavity preparation and extensive
preparation for crown, more dentinal tubules are exposed to
external microbial or chemical irritation. If adequate water
coolants are not used during such preparations, there can
be marked reduction in pulpal blood flow.
A B
Figs 4.12A and B  (A) More RDT; (B) Lesser RDT
Abbreviation: RDT, remaining dential thickness
The diameter of dentinal tubules at DEJ is 0.6–0.8 µm and
the diameter of dentinal tubules at pulp is 3 µm. Bacterial
cells have diameter of 0.5–1 µm and can migrate through
remaining dentin into pulp.
To minimize the liberation of heat during preparation:
• Use ultrahigh speeds of rotation for Enamel and
superficial dentin.
• Use efficient water cooling system.
• Use light pressure. When using high speed, instru­
mentation pressure should not be more than four ounce
and when using low speed, instrumentation pressure
should not be more than twelve ounce.
• Do intermittent cutting.
Remember that the bur-dentin interface must always be
wet.
• Finish the crown/cavity preparation using low-speed
cutting and hand instruments.
How does the Pulp React to Drying of Tooth?
Rapid, prolonged blast of air causes rapid outward flow of
dentinal fluid into patent dentinal tubules which stimulates
the nociceptors in dental pulp producing pain (Fig. 4.13).
Also, odontoblasts are aspirated into the tubules. These
displaced cells undergo autolysis and disappear within a
short-time. They are replaced by new odontoblasts from
stem cells deeper in the pulp which are capable of producing
tertiary dentin.
Some harsh chemicals such as lipid solvents-like acetone
or ether have been used in the past to clean cavity floors. But
they were found to produce strong hydrodynamic forces in
dentinal tubules causing odontoblast displacement.

Fig. 4.13  Reaction of pulp to drying of tooth
It is recommended that cavity floors be dried with cotton
pellets and short blasts of air rather than harsh chemicals.
In deep cavities, air blast can cause lots of discomfort to the
patient. Cotton pellets should be used.
Also, the tooth must be kept moist during preparation
and while drying the cavity preparation, care must be taken
just to remove extra moisture from the operative field and
not remove dentin’s natural moisture (desiccation).
How does the Pulp React to Cavity
Cleansing and Sterilization?
Certain caustic chemicals such as hydrogen peroxide,
sodium hypochlorite, calcium hydroxide, etc. were used
in the past for cavity disinfection to get rid of residual
microbial contamination of the cavity preparation. But these
chemicals may be potentially toxic to the pulp and so they
are not used these days.
When dentin is exposed, there is outward flow of
dentinal fluid, so the inward flow of any noxious agents is
minimized. As a result, the irritation from residual microbial
contamination in dentinal tubules is reduced.
How Does the Pulp React to Acid
Etching of Enamel and Dentin?
When dentin is cut, smear layer is produced containing
fragments of microscopic mineral crystals and organic
matrix. Smear layer blocks the orifices of dentinal tubules
and reduces the permeability of dentin. Etching of dentin
with phosphoric acid removes the smear layer and causes
demineralization of surface layer of collagen (Fig. 4.14).
The Pulpal Reactions to Caries and Dental Procedures 59
Fig. 4.14  Reaction of pulp to acid-etching of dentin
If the open dentinal tubules are left unsealed, the
irritants can diffuse into the pulp and may intensify and
prolong the severity of pulpal reactions.
In superficial cavities, diameter of dentinal tubules is
narrow and density of peripheral dentin is low, so etching
of dentin followed by adequate sealing with restorative resin
will not cause any detrimental effects on pulp.
In case of deep cavities or presence of exposure,
phosphoric acid etching can be detrimental.
Also, in cases where phosphoric acid etching is done
and bacteria are also present, severe pulpal inflammation
and necrosis tends to occur.
Due to such effects with total etch systems, self-etching
systems have become popular these days which eliminate
etching with phosphoric acid. They do not remove the
smear layer but this smear layer is incorporated within the
restoration. But the only drawback of self-etch system is that
it may form a relatively poor bond due to weaker acidity of
acidic primers of self-etch system than total etch system.
How does the Pulp React to Cementation
of Crown or Bridge?
When cementation of crowns, inlays or bridges is done on
vital teeth, hydraulic forces may be exerted on the pulp as
cement compresses the fluid in dentinal tubules.
• Gentle and careful cementation must be done in case
of vital teeth
• Vents are provided in the casting that allow the cement
to escape and facilitate seating.
60 Short Textbook of Endodontics

How does the Pulp React to Vital

Bleaching Techniques?
Strong oxidizing agents such as 10% carbamide peroxide
and hydrogen peroxide are used to bleach enamel of vital
teeth. These chemicals are in contact with teeth for long
duration, i.e. overnight and they may cause mild pulpitis that
usually gets reversed within 2 weeks. This occurs particularly
if dentin with open tubules or cracks is present.
The symptoms usually are reversible and can be
prevented by treating the teeth with fluorides and by doing
the necessary restorative treatment preoperatively.

Fig. 4.15  Reaction of pulp to orthodontic tooth movement

How does the Pulp React to Polishing
of Restorations?
• When glass ionomer and composite restorations are
polished, no significant increase in temperature at the
pulp-dentin interface has been found.
• But polishing of amalgam restorations, especially with
high speed, high contact pressure and no coolant can
cause increased temperatures that may be damaging.
If water coolant is not to be used, it is recommended
that speed should not exceed 4000 rpm.
It is safer to use a coolant, apply light pressure and inter­
mittent contact during polishing of amalgam restoration to
prevent any likely pulpal damage.
How does the Pulp React to Cavity
Preparation using Air Abrasion?
Air abrasion is a conservative, nonpainful cavity preparation
technique that forces aluminum oxide particles in a rapid
stream onto tooth structure and is simultaneously evacuated
from the field.
If higher pressure and small particle size is used, there
are fewer pulpal effects as compared to high-speed burs.
Air-abrasion technique can be used in case of shallow
caries and in pediatric patients.
How does the Pulp React to Orthodontic
Tooth Movement?
Orthodontic forces cause changes in pulpal blood flow
not only of teeth undergoing active movement but also of
adjacent teeth (Fig. 4.15).
Thus, the pulpal response to orthodontic forces is
hemodynamic.
Heavy forces used to reposition malaligned teeth
especially impacted canines may lead to pulp necrosis or
calcific metamorphosis.
Some of the methods used for removal of orthodontic
brackets at the completion of treatment have been found to
cause injury to pulp.
How does the Pulp React to Laser Procedures?
• Commonly used lasers in dentistry include Er:YAG,
Nd:YAG and CO2 lasers
• Er:YAG laser is used for removal of caries and cutting
dentin. Lower energy delivered through low power
settings with Er:YAG laser is found to produce favorable
results
• CO2 laser can be used for pulpotomy procedure in
primary teeth, pulpotomy procedures in permanent
teeth with immature apex and in exposed pulps due to
fracture
• Nd:YAG laser can be used for pulp and in surgery
• The pulpal responses to Nd:YAG and CO2 lasers are not
found to be favorable. They may cause charring and
significant inflammation in pulp compared to Er:YAG
laser.
How does the Pulp React to Specific
Dental Materials?
The effects of dental materials on pulp may be related to
the permeability of associated dentin which in turn may
be affected by the thickness of dentin remaining (RDT)
between the cavity preparation and the pulp.
Zinc Oxide Eugenol
Zinc oxide eugenol (ZOE) has anesthetic and antiseptic
properties. When ZOE is applied to deep cavities, it blocks
transmission of action potentials in nerve fibers and

suppresses nerve excitability in the pulp. It adapts well to
dentin and inhibits bacterial growth on cavity walls.
Zinc oxide eugenol is suitable as temporary filling but
not long-term restoration as it has been found to leak over
a period of time.
Zinc Phosphate Cement
The phosphoric acid liquid phase may be harmful to the
pulp. But studies have shown that it is relatively safe. Zinc
phosphate cement has been used as base beneath amalgam
restorations for years.
Zinc phosphate is also well-tolerated by pulp when used
as a luting agent.
Glass Ionomer Cement
When glass ionomer cement is used as liner in deep cavities
with RDT of 0.5–0.25 µm, it results in deposition of tertiary
dentin but at a slower rate than calcium hydroxide.
When glass ionomer cement is placed over exposed
healthy pulp, there is severe pulpal inflammation or necrosis
similar to that for calcium hydroxide.
When glass ionomer cement is used as luting agent in vital
teeth, for sometime after luting, there is postcementation
sensitivity which subsides over a period of time.
Silver Amalgam
Amalgam cannot be placed directly over the cavity
preparation, it has to be placed over a liner/base such as
zinc phosphate cement to protect the pulp.
During setting, amalgam shrinks, which results in micro­
leakage. But over a period of time, marginal seal improves
The Pulpal Reactions to Caries and Dental Procedures 61
as the corrosion products accumulate between restoration
and the cavity walls.
Restorative Resins
Placement of resin restoration is technique sensitive.
Improper technique can result in faulty bond to tooth
structure causing dentin hypersensitivity, recurrent disease
and pulpal inflammation or necrosis.
Etching with phosphoric acid dissolves the highly
mineralized peritubular dentin leaving free collagen fibrils
and opening dentinal tubules. The resin in the form of
bonding agent has to infiltrate the exposed collagen mesh
and seal the open dentinal tubules. If it does not do so then
there is nanoleakage.
Pulpal irritation from resin placement can be
due to irritants such as unpolymerized monomer
and polymerization shrinkage. The components of
unpolymerized monomer may leach directly into pulp
in case of deep cavities and cause chemical irritation.
Polymerization shrinkage of composites induce internal
stresses on dentin and create voids causing microleakage.
This can be minimized by incremental placement and
curing of composites and starting the restoration with
flowable resins.
BIBLIOGRAPHY
1. Cohen S, Hargreaves KM. Pathways of Pulp, 9th edn. St. Louis:
Mosby; 2006.pp.514-40.
2. Grossman L, Oliet S, Del Rio C. Endodontic Practice, 11th edn.
Varghese publication, 1991.pp.59-65.
3. Ingle, Bakland Endodontics, 5th edn. BC Decker-Elsevier; 2002.
pp.95-6.
4. Ingle J, Bakland L, Baumgartner J. Ingle’s Endodontics 6, 6th edn.
BC Decker Inc, Hamilton; 2008.pp.468-87.
 5
CHAPTER

Diseases of the Pulp and

the Periradicular Tissues

This chapter describes in detail the various diseases of the dental pulp and
the periradicular tissues and their possible causes.
  You must know
• What are the Possible Causes of Diseases of Dental Pulp?
• How does the Pulp React to Different Direct and Indirect Stimuli and how is the Response
unique?
• How do we Classify the Diseases of Dental Pulp?
• What are the Different Features of the Diseases of the Dental Pulp?
• What are the Causes of Diseases of the Periradicular Tissues?
• How do we Classify the Diseases of Periradicular Tissues?
• What are the Different Features of the Diseases of Periradicular Tissues of Endodontic Origin?
• What is the Pathogenesis of Primary Apical Periodontitis?

WHAT ARE THE POSSIBLE CAUSES OF DISEASES
OF DENTAL PULP?
Causes of Diseases of the Dental Pulp
The various causes of diseases of the dental pulp are listed
in Flow chart 4.1 ‘Noxious stimuli affecting dental pulp/
Causes of diseases of dental pulp’, in the previous chapter.
They will be discussed in detail here.
Microbial/Bacterial Causes
• Fractured crown: Microorganisms can invade the pulp
Coronal Ingress
• Caries: Coronal caries is the most common means of
ingress for infecting bacteria and/or their toxins into
the dental pulp
– Direct microbial invasion:
- There are various portals of entry of micro­
organisms into the pulp. These have been
explained in detail in Chapter 6: Endodontic
Microbiology
- Active carious lesion is composed of an outer
infected layer and a deeper (underlying) affected
layer. The affected layer is the area which has
been demineralized by acids produced by
bacteria in the infected surface layer.
- Reaction of dental pulp to dental caries has been
explained in Chapter 4: The Pulpal Reactions to
Caries and Dental Procedures.
– Bacterial toxins before direct invasion: The pulp
becomes inflamed from irritation by preceding
bacterial toxins long before the bacteria reach the
pulp to actually infect it.
following injury to tooth (Trauma)
– Complete fracture: Accidental fracture generally does
not devitalize the pulp at that instant. But untreated
coronal fracture results in infection by oral bacteria
gaining ready access to the pulp. Most commonly
affected teeth are maxillary anterior teeth. Various
dental traumatic injuries and their management
have been discussed in detail in Chapter 24:
Management of Dental Traumatic Injuries.
– Incomplete fracture: Incomplete fracture of the crown
(infraction) causes entry of bacteria into the pulp.

Pulp infection and associated pulpal inflammation
depends on the extent of fracture (whether complete
or incomplete) extending into pulp chamber or only
through enamel. If it extends into pulp chamber,
pulpitis develops. If only through enamel, pulp is
merely hypersensitive to cold and mastication.
• Nonfracture trauma: It was found by Grossman that the
pulp canal infection can occur from trauma even without
fracture of teeth.
• Anomalous tract: Anomalous tooth development of
tooth crown and the root can be a cause of bacterial
invasion into the pulp.
– Dens invaginatus: Most commonly found in
maxillary lateral incisors. It can range from a slight
lingual pit in the cingulum area to a frank anomalous
tract apparent visually or radiographically.
- Coronal dens in dente may involve all layers of
enamel organ into the dental papilla. In such
cases, pulp may be exposed and thus opens to
bacterial invasion, inflammation and necrosis.
There may be early development of periradicular
lesions.
- In radicular dens, there is a fold in HERS into
developing tooth, producing enamel and dentin
there.
– Dens evaginatus: It has a tract to the pulp at its
point of attachment. Found usually in mandibular
premolars.
– Radicular lingual groove or palatogingival groove:
It is found primarily in maxillary lateral incisor.
The defect starts in the region of the cingulum and
proceeds apically and frequently towards the distal
portion of the tooth for various distances along the
surface of the root. Due to the nature of the groove, it
is thought that the cementum formation is disturbed
or even absent—No cementum, no attachment.
In case of long groove, palatal abscess that forms
extends to the apex.
Radicular Ingress
• Caries:
– Root caries is bacterial source of pulpal irritation
- Less frequent occurrence than coronal caries
- Cervical root caries occurs as a common sequel
to gingival recession
- Interproximal radicular caries may follow
periodontal procedures if meticulous oral
hygiene is not maintained.
• Retrogenic infection: Pulp may become infected through
apical foramen or lateral accessory canals associated
with chronic periodontal pocket.
Diseases of the Pulp and the Periradicular Tissues 63
– Periodontal pocket: It may extend to and surround
the root apex. Such retrogenic infection is less
common. Periodontal lesion causing Endodontic
lesion is explained in Chapter 25: Endodontic-
Periodontal Inter-relationships.
– Periodontal abscess: Retrogenic pulp infection
accompanying or immediately following an acute
periodontal abscess, may be sometimes the cause
of unexplained pulp necrosis.
– Hematogenic blood borne microorganisms colonizing
in the pulp: (Anachoresis) It refers to colonization or
fixation of blood-borne microorganisms in the pulp.
There is no enough evidence to explain the invasion
of pulp by bacteria through blood. Systemic transient
bacteremia may explain the unusual number of
infected pulp canals following impact injury or
fracture.
Physical
Mechanical
• Traumatic Injury to Teeth (Acute trauma)
– Traumatic injury may directly or indirectly affect the
dental pulp.
– Trauma to teeth can occur in case of accidents,
sports-related injury (Contact sports) or blow to
the tooth. Various dental traumatic injuries, their
effects on the pulp and their management have been
discussed in Chapter 24: Management of Dental
Traumatic Injuries.
- Coronal fracture: Most pulp death following
coronal fracture is due to bacterial invasion
following the accident.
- Radicular fracture: Accidental fracture of the root
disrupts the pulp vascular supply and the injured
coronal pulp can lose vitality. The apical radicular
pulp tissue may remain vital.
- Vascular stasis: In case of severe impact injury,
the tooth may lose pulp vitality immediately. The
pulp vessels get severed at the apical foramen
causing ischemic infarction. Another response of
pulp to trauma is formation of irritation dentin.
- Luxation: Extrusive luxation, lateral luxation and
intrusion result in pulp death nearly always. Pulp
recovery may occur in case of immature young
permanent tooth with wide, open apices.
- Avulsion: Pulp necrosis occurs as a consequence
of total avulsion of tooth.
• Wasting diseases of teeth/noncarious destruction/
diseases of teeth/pathologic wear from attrition,
64 Short Textbook of Endodontics
abrasion: Wasting diseases such as attrition, abrasion
cause Enamel to wear off and dentin gets exposed
resulting in open dentinal tubules. If secondary dentin
is deposited the tubules get occluded. Restorative fillings
can be done to occlude these open dentinal tubules.
In the absence of secondary dentin deposition and
restoration, the pathologic wear continues, causing
changes in pulp due to near exposure and direct
exposure of pulp can result.
• Cracked teeth: Cracked teeth may be in the form of:
– Infractions of the crown
– Actual fractures of crown and/or the root.
Tooth infractions include:
– Craze lines which involve only enamel.
– Cuspal fracture, usually diagonal fracture involving
enamel and running into dentin and may not directly
involve the pulp.
– ‘Cracked tooth syndrome’ is the term given to pain
of apparently idiopathic origin that occurs due to
incomplete fracture through the body of the tooth
involving the pulp.
Complete fractures include:
– Split tooth: Complete vertical fracture of the crown
and the root.
– Vertical root fractures: usually associated with
Endodontically treated teeth (nonvital teeth). Cracks
and fractures occur in the vital teeth due to various
causes such as: Weakening of teeth due to caries
or restorative treatment procedures, hard chewing
habits such as betel nut chewing, parafunctional
habits such as bruxism.
• Barometric changes: Changes in atmospheric pressure
can affect the dental pulp. Low atmospheric pressure at
higher altitudes over 10,000 feet may cause symptoms in
a tooth that was chronically inflamed and symptomless
at ground level. This is called barodontalgia. Generally
pain is experienced in a recently restored tooth during
low atmospheric pressure.
Classification of barodontalgia given by Rauch:
Biomechanical Causes
• Parafunctional habits such as clenching or bruxism may
cause dentinal cracks with exposed dentinal tubules
resulting in direct portal to subjacent pulp.
• Occlusal loading causing tooth deformation occurs
– Due to reduced occlusal isthmus while faciolingual
extension of cavity preparation, loss of marginal
ridges in case of mesio-occlusodistal (MOD)
preparations causing 50% reduction in cuspal
stiffness and fracture resistance.
– Polymerization shrinkage of few composite resins
can cause inward cuspal flexure and stresses on
tooth.
Dentin deformation causes flow of dentinal fluid
activating nerve endings in odontoblast layer of tooth.
Bacterial microleakage can occur through the gap at the
restoration dentin interface that gets opened repeatedly
during occlusal loading thus affecting the dental pulp.
Thermal Causes
• Heat generated during cavity and crown preparation:
Inadequate water coolant used during cavity and crown
preparation can induce changes in pulp due to generation
of heat. If only air is used as coolant at 2,00,000 rpm, it has
been found that it takes just 11 seconds of continuous
preparation at this speed to burn the pulp.
• Frictional heat from polishing: During polishing of
restorations, heat is generated.
• Conduction of heat: Temperature changes may be
conducted rapidly to the pulp when metallic fillings are
placed in deep cavities without protective cement base.
• Heat is generated from curing of resins during direct
fabrication of provisional restoration.
• Exothermic heat: Cements that set by exothermic
reaction, liberate heat on setting causing atleast
transient pulp injury.
Electrical Causes
Dissimilar metallic fillings in the mouth when come in
contact cause production of galvanic currents resulting in
injury or pathologic changes in pulp. Such fillings are no
longer done.
Iatral (Iatrogenic)
• Cavity preparation
– Heat of preparation: Heat generated during cavity
preparation can cause pulp damage if adequate
water coolant is not used.

Four basic factors in rotary instrumentation
that cause temperature rise in the pulp, given by
Swerdlow and Stanley, include:
- Force applied by operator
- Size, shape and condition of cutting tool
- Revolutions per minute (RPM)
- Duration of actual cutting time
Lower speeds produce less thermal elevation
than high speeds.
– Depth of preparation: Deeper cavity preparations
cause more extensive pulpal inflammation.
– Dehydration: Excessive drying (desiccation) of
the exposed dentin during cavity preparation can
contribute to pulp inflammation.
– Pulp horn extensions and pulp exposure: The close
proximity of the pulp to the floor of the cavity
preparation can expose the high pulp horns.
Slow speed carbide burs can be used in areas of
deep cavity preparation to avoid any traumatic
mechanical exposure of the pulp. If possible, a layer
of solid dentin (nonleathery) is allowed to remain as
pulp cover. Also, it should be noted that use of air-
water coolant is important in the areas where dentin
is thinned and the pulp approached to prevent any
pulpal damage.
– Pin insertion: Earlier the pins that were used to
support amalgam restorations or as a framework
for building up badly broken down teeth for full
coverage restorations, were found to cause pulp
inflammation and pulpal death. In some cases, pins
were inadvertently inserted directly into pulp or so
close to that they acted as severe irritant. Such pins
are no longer used with the advent of dentin bonding
agents and adhesives.
• Restoration
– Insertion: After the insertion of gold foil or silver
amalgam, severe hypersensitivity and pulpalgia
may occur related to force of insertion or expansion
of amalgam after insertion. Mild to severe
hypersensitivity is found to occur after insertion of
composite restoration, especially when total-etch
technique using phosphoric acid is used or other
causes such as over-drying of dentin, over-etching,
faulty technique, moisture contamination, etc.) The
use of self-etch bonding agents has been found to
reduce the postoperative sensitivity to a great extent.
– Fracture: Complete or incomplete fracture of
posterior teeth have been found to occur after
placement of silver amalgam or soft gold inlays or
foil. Patient may have complaint of hypersensitivity
or pulpalgia in case of undetected incomplete
Diseases of the Pulp and the Periradicular Tissues 65
fractures. Patient gets relief when the cusp of
the tooth finally fractures or the crown fractures
horizontally.
– Force of cementing: The tremendous hydraulic force
exerted during cementation of an inlay or full crown
in case of a vital tooth would drive the liquid towards
the pulp causing pain while cementing.
– Heat of polishing: Already discussed before in the
thermal causes.
• Orthodontic movement: Use of mechanical separators
for rapid separation of teeth or rapid orthodontic tooth
movement can cause changes in the pulp. Also, some
of the methods employed for removal of orthodontic
brackets after treatment have the potential to injure the
pulp.
• Periodontal curettage: During the periodontal curettage
of a lesion that entirely extends around the apex of the
root, the pulp vessels may be severed and the pulp may
get devitalized.
• Electrosurgery: Inadvertent contact with metallic
restorations during electrosurgery procedure may
severely endanger the pulp and the periodontal
structures.
• Laser burn: Higher intensity laser radiation can cause
damage to the pulp.
• Periradicular curettage: During the periradicular
curettage of an extensive bony lesion, the devitalization
of the pulps of adjacent teeth has been found to occur.
• Intubation for general anesthesia: If an inflexible
endotracheal tube is used during general anesthesia,
heavy retraction against the mandibular incisors can
cause their luxation.
Chemical Causes
• Erosion caused due to acidity: Acidity (hydrogen ion
concentration) causes erosion of enamel on labial or
facial surface of teeth that eventually gets the dental pulp
closer to irritating agents present in plaque and foods.
• Restorative materials:
– Acid etching of dentin with phosphoric acid: Acid
etchants that contain phosphoric acid used for total
etch technique of composite bonding are known
to cause irritation of the pulp especially when
prolonged dentinal etching is done opening up the
dentinal tubules which are not completely occluded
by application of bonding agent over the etched
surface.
– C h e m i ca l i r r i t at i o n o f pu l p o c c u r s f ro m
unpolymerized monomer
– Cavity liners, bases: Since the cavity liners and
bases are applied directly on dentin, they should be
66 Short Textbook of Endodontics

nontoxic, nonirritating and cause no irreversible HOW DO WE CLASSIFY THE DISEASES

changes in the pulp and must have sufficient OF DENTAL PULP?
compressive strength so that it does not collapse or I. Grossman has classified the diseases of dental pulp as:
crush down under biting pressure.
– Dentin bonding agents: If dentin is covered and
protected with dentin bonding agents in case of
Composite restorations, the problem of microleakage
is avoided and the pulp is protected.
• Disinfectants: Use of cavity disinfectants such as silver
nitrate, phenol and sodium fluoride may adversely affect
the pulp.
• Dessicants: Use of dessicants such as alcohol, ether and
others followed by air-drying with a blast of air may
cause dessication, damaging the pulp.

Idiopathic
• Aging: Regressive changes occur in the pulp tissue, such
as decrease in number and size of cells and increase in
the number of collagen fibers. There is deposition of
secondary and tertiary dentin and pulp recedes with
advancing age.
• Resorption (internal and external): Various changes
that can occur in case of pathologic tooth resorption
have been explained in Chapter 30 Pathologic Tooth
Resorption.
• Systemic diseases such as sickle cell anemia, herpes
zoster infection, etc.
In case of sickle cell anemia, microcirculation of pulp
is found to be affected resulting in pulp death.
In herpes zoster infection, it is found that the virus
may infect the pulp vasculature leading to infarction and II. Baume classified pulpal diseases based on clinical
pulp death. symptoms as follows:

HOW DOES THE PULP REACT TO DIFFERENT

DIRECT AND INDIRECT STIMULI AND HOW
IS THE RESPONSE UNIQUE?
Pulp reacts to the above listed stimuli by inflammation.
Inflammatory response of pulp is unique and differs from
other connective tissues of the body as explained in the
previous chapters.

III. Seltzer and Bender classified pulpal diseases according
to histologic findings:
WHAT ARE THE DIFFERENT FEATURES OF
THE DISEASES OF THE DENTAL PULP?
Features of Pulp Inflammation (Pulpitis)
Reversible Pulpitis
Definition:
• “Reversible pulpitis is a mild to moderate inflammatory
condition of the pulp caused by noxious stimuli in which
the pulp is capable of returning to the uninflamed state
following removal of stimuli.” (Grossman’s Endodontic
Practice, 11th edition, p.65)
Etiology: Various etiologic factors include: (c2d2e2s2t2)
• caries
• defective restorations
• exposed dentin
• excessive dehydration of dentin caused by stream of
compressed air or with alcohol or chloroform
• chemical stimulus from irritation caused by silicate or
self-cure acrylic resin
• recent dental treatment
• Decreased threshold stimulation for A-delta nerve fibers
• Maxillary sinus disease causing generalized transient
hyperemia of pulp of maxillary posterior teeth
• trauma caused from a blow or due to disturbed occlusion
or occlusal prematurity (high point)
• thermal shock due to cavity preparation without
adequate water coolant or using a dull bur or keeping the
bur in contact with the tooth for long time or excessive
heat produced during polishing of restoration.
Diseases of the Pulp and the Periradicular Tissues 67
In reversible pulpitis, peripheral A delta fiber stimulation
occurs.
Signs and symptoms:
• Chronic or asymptomatic reversible pulpitis may be
due to incipient caries and it gets resolved on removal
of caries followed by appropriate restoration.
• Acute or symptomatic reversible pulpitis may present
with:
– Sharp pain which is momentary
– Responsive to cold food or beverage and/or cold
air
– Does not occur spontaneously
– Does not continue when the etiologic factor is
removed
– Discomfort on biting on the recently placed
restoration
– Pain associated with an old restoration.
Diagnosis: It is based on signs and symptoms and clinical
diagnostic tests.
• Clinical signs and symptoms such as sharp pain which
is momentary (few seconds) that generally disappears
on removal of stimulus such as cold, sweet or sour may
point towards reversible pulpitis.
• Diagnostic test such as cold thermal test can help locate
and diagnose the involved tooth.
• Radiographs generally show normal periodontal
ligament status. Caries or deep restoration may be
evident.
Histopathologic findings:
• Disruption of odontoblast layer
• Dilated blood vessels
• Extravasated edema fluid
• Acute or chronic inflammatory cells
Treatment:
• Prevention of reversible pulpitis by:
– Prevention of caries
– Early detection of caries and restoration
– Pulp protection base under restoration for deep
cavities
– Placing well-sealed restorations, to avoid marginal
leakage
– Proper contouring of restorations.
– Adequate water coolants while cavity preparation or
while polishing metallic restorations.
• Palliative treatment includes:
– Remove the restoration and replace it with a sedative
cement such as Zinc oxide Eugenol.
68 Short Textbook of Endodontics
If pain persists or worsens, then extirpation of pulp
is advised.
– Reduce occlusal trauma if present.
Irreversible Pulpitis
Definition: “Irreversible pulpitis is a persistent inflammatory
condition of the pulp, symptomatic or asymptomatic,
in which the pain persists for several minutes to hours,
lingering even after the removal of the stimulus”. (Grossman’s
Endodontic Practice, 11th Edition, p.67)
Etiology:
• Most common cause is bacteria affecting the pulp from
caries.
• Untreated reversible pulpitis progresses to irreversible
pulpitis
• Can have any of the other physical or chemical causes.
• Thermal stimulation of A-delta nerve fibers causing
lingering pain and stimulation of unmyelinated C-fibers
causing spontaneous, dull aching pain.
Signs and symptoms:
• In case of symptomatic irreversible pulpitis:
– In early stages:
i. Intermittent or spontaneous pain.
ii. Sudden temperature changes particularly cold
stimuli elicit pain which lingers for long time
even after the stimulus is removed.
iii. Pain may be described as sharp, shooting, piercing
which may be intermittent or continuous.
iv. Pain may be localized or may get referred to
adjacent teeth or other related structures such
as temple, maxillary sinus, etc.
v. Packing of food into the open cavity.
vi. Pain with change in position or on lying down.
– In later stages (Advanced)
i. Pain may become severe described as boring,
gnawing or throbbing
ii. Intense pain on food lodgement in cavity or with
stimulus
iii. Severe pain affecting sleep that may be intolerable
and not controlled in spite of all efforts of
analgesia
iv. Pain increased with hot water or food
v. Exposed pulp may get covered with soft, leathery
decay
• In case of asymptomatic irreversible pulpitis: Deep
caries may be evident clinically or radiographically but
does not produce symptoms. If not treated, may become
symptomatic or necrosis may occur.
Diagnosis: Based on clinical findings and diagnostic tests
and radiographic examination:
• On inspection, deep cavity or secondary caries at the
margins of restoration may be seen or grayish leathery
layer over the exposed pulp and surrounding dentin may
be visible.
• Probing over this superficial layer may not be painful.
Deeper layers might elicit pain on probing.
• Thermal tests elicit pain persisting even after removal
of stimulus.
• Radiographic appearance of periradicular bone may
show minimal changes such as thickening of periodontal
ligament.
• Calcification in the form of pulp stones or calcification
in canal may be evident on radiograph.
Histopathology:
• Chronic and acute inflammatory changes in the pulp
are evident.
• Congestion of postcapillary venules
• Phagocytosis of PMN leukocytes
• Areas of microabscesses walled off by fibrous connective
tissue, where calcific masses may be seen
• Areas of necrotic tissue.
Treatment: Endodontic treatment should be performed.
Chronic Hyperplastic Pulpitis
Definition: “Chronic hyperplastic pulpitis or ‘pulp polyp’ is a
productive pulpal inflammation due to an extensive carious
exposure of a young pulp resulting from a long standing low
grade irritation” (Grossman’s Endodontic Practice, 11th
Edition, p. 70).
Etiology: Etiologic factor is slowly progressing carious
exposure of the pulp.
Pulp polyp develops when there is:
• Chronic low grade stimulus from mechanical irritation
while chewing or bacterial irritation from caries in young
pulp (Fig. 5.1 shows photograph showing pulp polyp in
permanent mandibular first molar)

• Large open cavity (Figure 5.2 shows photograph of pulp
polyp in deciduous molar with large open cavity).
Signs and symptoms:
• Usually asymptomatic
• Sometimes if food bolus gets lodged in the open cavity
causing pressure, discomfort may be felt by the patient
• May bleed profusely if gets traumatized.
Diagnosis:
• Generally occurs in teeth of children and young adults
• On inspection, fleshy, reddish pulpal mass filling most
of the pulp chamber or cavity is seen.
• Such polypoid tissue sometimes may extend beyond the
confines of the tooth causing discomfort while biting.
Fig. 5.1  Pulp polyp in permanent mandibular first molar
(Courtesy of Dr Manoj Ramugade)
Fig. 5.2  Pulp polyp in deciduous molar (Courtesy of Dr CR Suvarna)
Diseases of the Pulp and the Periradicular Tissues 69
• Pulp polyp should be distinguished from gingival polyp
– Pulp polyp is more sensitive than gingival polyp
– Raise the polyp and trace its stalk to find its origin.
Pulp polyp originates from pulp chamber
• On probing, pulp polyp bleeds profusely due to rich
network of blood vessels within it.
• While performing diagnostic tests such as thermal and
electric pulp tests, more current and more cold stimulus
may be required to elicit pulp response.
Histopathology:
• Stratified squamous epithelium covering the surface of
pulp polyp is seen.
• Chronic inflammatory changes in pulp
• Granulation tissue containing PMN neutrophils,
lymphocytes and plasma cells is evident.
Treatment:
• Periodontal curette or spoon excavator is used to
remove the hyperplastic pulpal mass completely to the
level of orifices.
• Bleeding is controlled.
• Endodontic treatment is completed.
Ulcerative/open form of chronic pulpitis: It is the chronic
inflammation of the pulp in which there is formation of
an abscess at the point of exposure due to caries and the
abscess is surrounded by the granulomatous tissue. It is
also known as pulpal granuloma.
Closed form of chronic pulpitis: It is the chronic inflammation
of the pulp that may occur due to trauma, excessive
orthodontic forces, any operative procedure or periodontal
lesion. Caries may be absent.
Internal Resorption
Definition: “Internal resorption is an idiopathic slow or
fast progressive resorptive process occurring in the dentin
of the pulp chamber or root canals of teeth”. (Grossman’s
Endodontic Practice, 11th Edition, p. 71)
Figure 5.3 shows diagrammatic representation of the
internal resorption. The etiology, clinical features, diagnosis
and different types of internal root resorption are discussed
in detail in Chapter 30 Pathologic Tooth Resorption.
Features of Pulp Degeneration
Pulp degeneration occurs in:
• Pulps of older people
• May occur in pulps of younger people due to persistent
mild irritation.
70 Short Textbook of Endodontics
• Calcific degeneration:
– Calcific material replaces the pulp tissue in case of
calcific degeneration in the form of pulp stones or
denticles.
– Calcification more commonly is seen in the pulp
chamber since calcification proceeds from crown
to root.
– Types of calcification (see flow chart at the bottom of
this page)
– Pulp stone may either be in the body of pulp or
attached to pulpal wall. Occurs as free, attached
and embedded forms as shown in histologic section
shown in Figure 5.4. True denticle is composed of
dentin that is formed from detached odontoblasts
or fragments of HERS. False denticle is formed by
Fig. 5.3  Internal resorption
deposition of concentric layers of calcified tissues
with degenerated tissue structure as nidus.
• Atrophic degeneration:
– Seen in older people’s pulps on histopathologic
examination.
– The number of collagen fibers/unit area increases
leading to fibrosis.
– The number and size of cells decreases. These cells
appear as shrunken solid particles in sea of dense
fibers.
– Pulp with atrophic degeneration is less sensitive than
normal.
• Fibrous degeneration:
– Fibrous connective tissue replaces cellular elements
of the pulp in this type of degeneration.
Fig. 5.4  Free, attached and embedded pulp stones
 Diseases of the Pulp and the Periradicular Tissues 71

– It has been found that such degenerated pulp from
the root canal has leathery fiber appearance.
Atrophic and fibrous degeneration do not have a
clinical diagnosis.
Features of Pulp Necrosis
• Definition: Pulp necrosis is defined as: “Partial or
total death of pulp following inflammation or a
traumatic injury in which pulp gets destroyed before an
inflammatory reaction takes place”.
• Etiology:
– Untreated symptomatic or asymptomatic irreversible
pulpitis progresses to necrosis.
– Trauma: Basically, injury to pulp by noxious stimuli
such as bacterial, traumatic or chemical irritation
leads to necrosis of pulp.
• Types:
i. No response to cold test
ii. No response to electric pulp test
iii. Response may be elicited to prolonged
application of heat due to remnants of pulpal
fluid or gases expanding and extending into
periapical region.
– Radiographic changes :
i. Large carious lesion may be seen.
ii. Pulp stones in pulp chamber or some evidence
of calcification in root canal may be seen.
iii. Thickening of PDL space.
• Histopathology: Pulp cavity shows necrotic pulp tissue,
cellular debris and microorganisms.
• Treatment: Endodontic treatment.
WHAT ARE THE CAUSES OF DISEASES
OF THE PERIRADICULAR TISSUES?

• Diagnosis:
– History of severe pain lasting from few minutes to
few hours, followed by cessation of pain completely.
– In some patients, there can be slow death of pulp
without any symptoms
– Tooth may become symptomatic to percussion as
the infection extends into PDL space
– Tooth may exhibit hypersensitivity to heat or
sometimes even to the warmth of oral cavity. Such
pain is often relieved by application of cold. This
helps in localization of necrotic tooth.
– Diagnostic tests such as thermal and electric pulp
tests:
72 Short Textbook of Endodontics

HOW DO WE CLASSIFY THE DISEASES OF WHAT ARE THE DIFFERENT FEATURES

PERIRADICULAR TISSUES? OF THE DISEASES OF PERIRADICULAR TISSUES
OF ENDODONTIC ORIGIN?
A. Grossman has given the following classification:
Features of Normal Periradicular Tissues
• Clinical:
– No tenderness to pressure
– No tenderness to percussion
– No tenderness to palpation of mucosa overlying the
periapical region
– No swelling
– No symptoms
• Radiographic: (Fig. 5.5)
– Intact lamina dura
– Periodontal ligament space normal and of consistent
width along the entire root
– Periradicular bone with no rarefaction or
condensation.

Features of Periradicular Diseases

Acute Apical Periodontitis/Symptomatic

Apical Periodontitis
• Definition: “Acute apical periodontitis is a painful
inflammation of the periodontium as a result of trauma,
B. WHO classification of diseases of periradicular irritation or infection through the root canal, regardless
tissues: of whether the pulp is vital or nonvital”. (Grossman’s
Endodontic Practice, 11th Edition, p.82)
Code number Category • Etiology:
KO4.4 Acute apical periodontitis i. Bacterial: As a sequelae of pulpal disease, bacteria and
KO4.5 Chronic apical periodontitis (apical their noxious products from inflamed or infected pulp
granuloma) may get diffused into periradicular area.
KO4.6 Periapical abscess with sinus
KO4.60 Periapical abscess with sinus to
maxillary antrum
KO4.61 Periapical abscess with sinus to nasal
cavity
KO4.62 Periapical abscess with sinus to oral
cavity
KO4.63 Periapical abscess with sinus to skin
KO4.7 Periapical abscess without sinus
KO4.8 Radicular cyst (apical periodontal cyst,
periapical cyst)
KO4.80 Apical and lateral cyst
KO4.81 Residual cyst
KO4.82 Inflammatory paradental cyst

C. Ingle has given the following classification: (see flow Fig. 5.5  Intraoral periapical radiograph showing normal
chart on next page) periradicular tissues
 Diseases of the Pulp and the Periradicular Tissues 73

ii. Trauma: – There may be severe soreness in the tooth.

– Occlusal trauma caused by abnormal occlusal
contacts.
– Occlusal prematurity of recently inserted restoration
– Blow to the tooth
– Wedging of foreign object in between teeth
– Trauma from rapid orthodontic tooth movement
iii. Iatrogenic:
– Improper instrumentation forcing bacteria or debris
inadvertently through the apical foramen
– Forceful irrigation with irrigants such as sodium
hypochlorite
– Forcing irritating intracanal medicaments beyond
the apex
– Root perforation
– Overinstrumentation
– Over-extension or overfilling of obturating material
extruding beyond the apex.
• Signs and symptoms:
i. Clinical:
– May be associated with slight soreness in tooth,
sometimes only when percussed.
– Tenderness to percussion is usually present.
– Tooth may be extruded, making closure quite
painful.
– Tenderness to pressure
– Mucosa overlying the root apex may not be tender.
ii. Radiographic:
– Slight widening of PDL space may be evident.
– Small area of rarefaction may be seen especially in
case of tooth undergoing Endodontic treatment.
• Diagnosis: It is based on clinical and radiographic
findings and history of a tooth under Endodontic
treatment or of trauma or of a recently placed
restoration.
• Treatment: Etiologic factor should be determined and
treatment provided accordingly.
• Possible consequences of acute apical periodontitis:
i. If the insult was of shor t duration such as
overinstrumentation through healthy periapical region,
symptoms usually subside and healing takes place.
ii. In case of continuous and persistent irritation, the path
would be:
74 Short Textbook of Endodontics
Chronic Apical Periodontitis/Asymptomatic
Apical periodontitis:
• Definition: “Asymptomatic apical periodontitis is
a long-standing periapical inflammatory lesion in
which there are minimum or no clinical symptoms but
radiographically visible periapical bone resorption.”
• Signs and symptoms:
– Clinical: None or minimal symptoms such as slight
discomfort on biting.
– Radiographic: Periapical lesion may be evident.
• Diagnosis: May be discovered on radiograph as an
incidental finding. The radiologic appearance of lesion
may be of any shape or size. There is widening of
periodontal ligament space (Fig. 5.6).
• Histopathologic findings: Histologically the radiolucent
area may be in the form of granuloma or cyst.
• Treatment: If extremely small lesion, it should be kept
under observation. In case of larger lesion suggesting
a granuloma or cyst with specific etiologic factor, Root
canal treatment with enucleation or decompression may
be required.
Persistent Apical Periodontitis
It is the term used for the apical periodontitis that persists
in the teeth even after Endodontic treatment. In spite
of all efforts of performing Endodontic treatment well,
due to complexity of root canal anatomy, instruments or
irrigants and thus the obturation material may not reach
few areas causing persistence of apical periodontitis. Also,
few extraradicular factors that may contribute to persistent
apical periodontitis, as given by Nair, include:
• Periapical biofilms
• Periapical scar tissue
• Actinomyces infection
• Cholesterol crystals
• Foreign body reaction to gutta-percha.
Fig. 5.6  Radiograph showing apical periodontitis in relation to
mandibular first molar with extensive caries involving the pulp
(Courtesy of Dr Chetan Shah)
Acute Apical Abscess/Acute Alveolar Abscess
• Definition: “An acute alveolar abscess is a localized
collection of pus in the alveolar bone at the root apex
of a tooth, following pulp necrosis, with extension
of infection through the apical foramen into the
periradicular tissues, accompanied by severe local and
sometimes general reaction.” (Grossman’s Endodontic
Practice,11th Edition, p. 78)
Figure 5.7 shows diagrammatic representation of
periapical abscess.
• Etiology:
i. Bacterial invasion from necrotic pulp tissue is the most
common cause.
ii. May be associated with history of trauma.
iii. Chemical or mechanical irritation of pulp
• Signs and symptoms:
General:
– General systemic reaction sometimes occurs
– Patient may have mild to moderate fever accompanied
by chills
– Other symptoms such as headache, malaise,
weakness
– Patient may appear pale and irritable due to loss of
sleep and absorption of septic products
Local: (S4)
– Initial signs and symptoms: Slight tenderness of tooth
which gets relieved with slight pressure on extruded
tooth pushing it back into the alveolus. Tender to
percussion.

Fig. 5.7  Periapical abscess
– Later signs and symptoms:
i. Severe spontaneous and throbbing pain due to
pressure build up in the restricted periapical
space.
ii. Swelling of overlying soft tissue The affected tooth is necrotic and does not respond
a. Begins with intraoral swelling
b. Swelling then may become extensive resulting
in cellulitis that distort patient’s appearance
c. Swelling extends to the surrounding soft
tissues:
1. In case of maxillary anterior tooth such as
canine, swelling of the upper lip occurs, it
may extend upto eyelid causing distortion
of appearance. Then, there is separation of periodontal fibers
2. In maxillary posterior teeth, huge swelling
of cheek may occur • Treatment:
3. In mandibular anterior teeth, lower lip
and chin may get swollen – Administration of antibiotics.
4. In mandibular posterior teeth, swelling of
cheek extending upto the ear may occur.
iii. Suppuration or pus breaks to form:
a. Sinus tract, that generally opens in the labial
or buccal mucosa may remain for sometime before it gradually
OR
b. Spreads to overlying soft tissues taking the
path of least resistance. This occurs due to
perforation of overlying cortical plate and
subsequently perforation of periosteum.
In maxillary teeth since the labial alveolar
plate is thinner than the palatal alveolar plate,
Diseases of the Pulp and the Periradicular Tissues 75
suppuration usually occurs through labial or
buccal mucosa except in case of maxillary
lateral incisors and palatal root of maxillary
molar in which suppuration occurs palatally
due to close proximity of their roots to the
palatal plate of the bone.
In mandibular teeth also usually labial or
buccal alveolar abscess occurs but lingual
alveolar abscess may occur in case of
mandibular molars due to the position of
their roots in alveoli.
– Radiographic findings:
i. In case if the acute alveolar abscess is an
exacerbation of a chronic lesion, a periapical
radiolucency is generally evident on the
radiograph.
ii. Radiograph may not show destruction of alveolar
bone in case of short duration acute alveolar
abscess since the lesion is confined only to the
medullary bone initially.
Although radiograph may be helpful in determining
the affected tooth showing carious involvement of pulp
or thickened PDL space, etc.
• Diagnosis: It is based on history, clinical and radiographic
examination and diagnostic tests.
to electric pulp test and thermal tests.
Location of swelling may help determining the
affected tooth.
Mobility and extrusion of tooth may be evident.
• Histopathologic findings: Infiltration of PMN leukocytes
and accumulation of inflammatory exudate cause
distension of periodontal ligament and thereby causing
extrusion of tooth.
causing mobility of tooth.
– Control the acute systemic reaction if present.
– In case of localized swelling, incision and drainage
should be established.
– Concomitantly, establishing drainage through the
root canal relieves the severe symptoms. Swelling
subsides.
– In case of hyperocclusion, relieve the tooth out of
occlusion.
– Nonsteroidal anti-inflammatory drugs can be given
to control pain.
– In the subsequent visit, thorough cleaning and
shaping of root canals is performed.
76 Short Textbook of Endodontics

Chronic Apical Abscess/Chronic Alveolar Abscess

• Definition: “Chronic alveolar abscess is a long-standing
low-grade infection of the periradicular bone. The source
of infection is in the root canal.” (Grossman, 11th edition,
p.85)
It is also called suppurative apical periodontitis as
an exudate is formed due to egress of irritants from root
canal system into periradicular area.
• Etiology:
– An acute alveolar abscess may become chronic
apical abscess
OR
– Necrosis of pulp may result in low-grade infection
extending into periradicular bone.
• Signs and symptoms:
i. Generally, a ‘sinus tract’ is detected, which is Fig. 5.8  Radiograph showing periapical radiolucency suggestive of
considered a hallmark sign of chronic alveolar abscess in relation to maxillary right lateral incisor tooth (Courtesy of
abscess. Although intraoral sinus tract is common, Dr Mansi Shah, Dentoview: Advanced dental imaging center)
sometimes it may open through skin of face.
ii. There is usually no pain or mild pain may be present.
iii. Sinus tract causes continual drainage of the
periradicular lesion into the oral cavity and it thus
prevents swelling or an acute exacerbation of the
lesion.
iv. Sometimes a large carious lesion with open cavity
may be present causing drainage by way of root
canal.
• Radiographic findings: Radiograph mostly shows
periapical radiolucency (Figure 5.8 shows a radiograph
showing periapical radiolucency in maxillary right Fig. 5.9  Gutta-percha point/cone being used to trace the source of
lateral incisor tooth). infection (Courtesy of Dr Manoj Ramugade)
• Diagnosis:
– In case of sinus tract, a gutta-percha point can be
introduced into the tract and a radiograph taken
to find the source of infection. Figure 5.9 shows
the photograph of mandibular molar where gutta-
percha point has been used to trace the source of
infection. Figure 5.10 shows the radiograph of the
same case.
– Tooth generally does not respond to the diagnostic
tests such as thermal and electric pulp vitality tests.
– Necrotic tooth may be discolored in few cases.
– Radiograph may show diffuse area of rarefaction.
• Histopathologic findings:
– With the invasion of microorganisms and their toxins
into the periradicular area, some of the periodontal
ligament fibers at the root apex are detached or lost
and the apical periodontal ligament gets destroyed
subsequently.
Fig. 5.10  Radiograph showing gutta-percha point/cone used for
– In the periradicular lesion, PMN leukocytes are found tracing the sinus tract shows that the source of infection is in the
in the center and the lymphocytes and plasma cells distal root canal of mandibular second molar (Courtesy of Dr Manoj
at the periphery. Ramugade)

• Treatment:
– Root canal treatment to eliminate infection.
– Sinus tract does not require any special treatment. It
closes and disappears once the root canal is properly
cleaned and shaped.
Acute Exacerbation of Chronic Lesion/Phoenix Abscess
Phoenix abscess is discussed in Chapter 19: ‘Endodontic
Emergencies and Mid-treatment Flare-ups’.
Periapical Granuloma
• Definition: “Periapical granuloma is a chronic, low-
grade defensive reaction of the alveolar bone occurring
as a granulomatous tissue growth continuous with
the periodontal ligament in response to continued
mild irritation caused by the diffusion of bacteria and
bacterial toxins from the root canal into the surrounding
periradicular tissues through the apical and lateral
foramina.” (Endodontic Practice, Grossman, 11th
Edition, p.89)
Figure 5.11 shows diagrammatic representation of
periapical granuloma.
• Etiology:
Fig. 5.11  Periapical granuloma
Diseases of the Pulp and the Periradicular Tissues 77
• Signs and symptoms:
– Usually asymptomatic
– If it undergoes suppuration, there may be symptoms
– Radiographic findings: Loss of continuity of lamina
dura and well-defined area of rarefaction varying
in size from few millimeters to a centimeter or even
larger at the apex of the root.
• Diagnosis:
– Usually diagnosed on routine radiographic
examination (Fig. 5.12)
– Exact diagnosis to be named as ‘Periapical
granuloma’ can be made only after microscopic
examination.
– Tooth does not respond to thermal and electric
pulp tests.
• Histopathologic findings: The alveolar bone and
periodontal ligament are replaced by granulomatous
tissue showing the following features:
– Inflammatory lesion consisting of macrophages,
lymphocytes and plasma cells in the loose connective
tissue forming the inner or central portion.
– Shows collagenous connective tissue forming the
capsule of the lesion which is continuous with the
periodontal ligament.
– Epithelial cell proliferation is a common feature.
– There are abundant capillaries and blood vessels
along with numerous fibroblasts and connective
tissue fibers.
– Clusters of epithelial cells called cell rests of Malassez
derived from Hertwig’s epithelial root sheath (HERS)
are also found.
Fig. 5.12  Radiograph showing periapical radiolucency likely to be
a periapical granuloma in relation to maxillary right central incisor
tooth (Courtesy of Dr Mansi Shah, Dentoview: Advanced dental
imaging center)
78 Short Textbook of Endodontics

• Treatment: – Radiographic findings: Loss of continuity of lamina

– Root canal treatment. dura and well-defined round, ovoid or pear-shaped
– Once the source of chronic irritation is removed, radiolucency at the apex of the tooth which is larger
there is resorption of granulomatous tissue and than the granuloma and may involve adjacent teeth
repair of the periradicular bone. (Figure 5.14).
• Diagnosis
Radicular Cyst – Generally from radiographic examination
– Diagnostic tests such as thermal and electric pulp
Also called periapical cyst (Figure 5.13 shows diagrammatic tests are negative.
representation of periapical cyst). – CBCT is recent diagnostic tool that may help to detect
• Etiology: periapical cyst easily and clearly. Figure 5.15 shows
a CBCT image of a tooth with periapical pathology
most likely to be radicular cyst.
• Histopathologic findings: An epithelium-lined cavity
containing fluid or semisolid material commonly
surrounded by dense connective tissue.
Cystic cavity is lined by stratified squamous
epithelium derived from epithelial cell rests of Malassez.

• Signs and symptoms:

– Most common site for radicular cyst is anterior
maxilla area. In case of radicular cyst related to
maxillary lateral incisor, palatal expansion is usually
seen.
– Usually the tooth with radicular cyst is discolored and
nonvital. It may show fracture or failing Endodontic
treatment. • Treatment: Root canal treatment with or without surgical
– Asymptomatic when small in size. enucleation of radicular cyst.
– When the cyst becomes larger, it may cause swelling,
increased pressure causing mobility of teeth, pain,
etc.

Fig. 5.14  Radiograph showing periapical radiolucency likely to be

a periapical cyst in relation to maxillary right central incisor tooth
(Courtesy of Dr Mansi Shah, Dentoview: Advanced dental imaging
Fig. 5.13  Periapical cyst center)
 Diseases of the Pulp and the Periradicular Tissues 79

Fig. 5.15  CBCT image showing tooth with a pathology likely to be Fig. 5.16  Radiograph showing condensing osteitis in relation
radicular cyst (Courtesy of Dr Mansi Shah, Dentoview: Advanced to mandibular second molar tooth (Courtesy of Dr Mansi Shah,
dental imaging center) Dentoview: Advanced dental imaging center)

It is generally recommended to perform root canal

treatment alone and if the lesion fails to resolve then
surgical treatment (Apicoectomy) may be indicated.

Condensing Osteitis: (Or Focal

Sclerosing Osteomyelitis)
• Definition: “Condensing osteitis is a diffuse radiopaque
lesion of the periradicular area that occurs in response
to a low-grade inflammatory stimulus from the root
canal.”
• Etiology: Chronic mild irritation from long-standing
pulpal pathosis causes stimulation of osteoblastic
activity in the alveolar bone.
• Signs and symptoms: Asymptomatic, diagnosed only on
Fig. 5.17  Radiograph showing condensing osteitis in relation to
radiographic examination. mandibular first molar tooth (Courtesy of Dr Mansi Shah, Dentoview:
• Radiographic findings: Overproduction of bone in the Advanced dental imaging center)
periapical area around the apices of teeth with long
standing pulpal pathosis. Most commonly involved
teeth are apices of mandibular premolars and molars
(Figs 5.16 and 5.17). External Root Resorption
• Diagnosis: From radiographs.
Appears as localized area of radiopacity surrounding • Definition: “External resorption is a lytic process
the affected root. It is dense area due to overproduced occurring in the cementum or cementum and dentin of
bone with reduced trabecular pattern. the roots of the teeth.” (Grossman’s Endodontic Practice,
• Histopathologic findings: Area of dense bone is seen with 11th Edition, p.98)
the trabecular borders lined with osteoblast cells. Figure 5.18 shows diagrammatic representation of
• Treatment: Root canal treatment. external root resorption.
May or may not respond to root canal treatment. • Types: External root resorption
80 Short Textbook of Endodontics
• Etiology: Not exactly known.
– Suspected causes — Inflammation of the
periradicular area caused due to:
a. Trauma
b. Injury to external root surface
c. Excessive forces caused by orthodontic treatment
d. Periapical granuloma or cyst applying pressure
on the root
e. Overinstrumentation during root canal treatment
Fig. 5.18  External root resorption
f. Impaction of adjacent tooth
g. Central jaw tumors
h. Systemic diseases
– When the cause is not evident, it is termed as
idiopathic resorption
• Signs and symptoms: Asymptomatic, diagnosed only
on radiographic examination. Only when the root is
completely resorbed, mobility of tooth may occur.
Sometimes in the same tooth, both external and
internal root resorption may occur. When external root
resorption extends into the crown, it appears as “pink
tooth”(Internal resorption)
• Radiographic findings:
– Radiographic appearance of external root resorption
is concave or ragged areas on root surface or blunting
of apex which is sometimes difficult to detect on
radiographs.
CBCT scans can show these changes caused
by external resorption quite well. Figure 5.19
shows CBCT image of tooth in which external root
resorption has caused blunting of apex of root.
– In case of replacement resorption or ankylosis:
Resorbed root with no PDL space and bone replacing
the defects is seen.
– In case of inflammatory resorption caused due
to pressure of growing granuloma, cyst or tumor,
an area of root resorption adjacent to area of
radiolucency may be seen.
All these different types of resorption have been
explained in detail in Chapter 30: Pathologic Tooth
Resorption.
Fig. 5.19  CBCT image of tooth in which external resorption
has caused blunting of apex of root (Courtesy of Dr Mansi Shah,
Dentoview: Advanced dental imaging center)

• Diagnosis: From radiographs.
– It is difficult to detect external root resorption on
radiograph especially the small areas of surface
resorption of cementum which can be detected only
histologically. Only when significant amount of root
substance is removed, it can cause enough contrast
to be detected on radiograph.
– Resorptive defect on the mesial or distal aspect of
the root may be detected on the radiograph
– Bone adjacent to root resorption also gets affected
by inflammation causing bone resorption which is
more easily detected on radiograph because bone is
not as radiodense as the root.
• Histopathologic findings:
– Small areas of cementum resorption replaced by
connective tissue or repaired by new cementum
– Large areas of resorption replaced by osseous
tissue
– “Scooped out” areas of resorption replaced by
inflammatory or neoplastic tissues.
• Differential diagnosis: Internal root resorption and
other types of Root Resorption discussed in Chapter 30:
Pathologic Tooth Resorption.
• Treatment:
– Treatment varies with etiologic factor : to the destruction of the pulpal tissue and microbial
a. When caused by extension of pulpal disease into
supporting tissues, root canal treatment will stop
the resorptive process.
b. When caused by excessive forces from
orthodontic appliances, the resorptive process
can be stopped by reducing those forces
c. When caused in case of replantation, preparation
of root canal and obturation with calcium
hydroxide may stop the resorptive process
Prognosis of external root resorption is guarded as
although the resorptive process may stop once the etiologic
factor is removed but tooth may become weak and may not
be able to sustain functional forces.
Periradicular Diseases of Nonendodontic Origin
• Periradicular diseases may originate in the remnants
of odontogenic epithelium or may be manifestations of
systemic disease such as multiple neurofibromatosis or
may occur in case of periodontal disease.
• Few examples of periradicular disease of Non-
Endodontic origin include:
a. Periapical cemental dysplasia
b. Cementoma
Diseases of the Pulp and the Periradicular Tissues 81
c. Cementoblastoma
d. Odontogenic cysts
e. Central giant cell granuloma
f. Metastatic malignant tumors or ameloblastoma
• The periradicular diseases of nonendodontic origin
may resemble the sequelae of pulpal diseases in
periradicular area clinically and radiographically. They
should be differentiated from them to avoid errors in
treatment. The main distinguishing point is that the
in case of lesions of Endodontic origin, the pulp is
irreversibly diseased or may be necrotic whereas in case
of periradicular diseases of nonendodontic origin, the
pulp is usually vital.
• In case of metastatic malignant tumors or ameloblastoma,
aggressive signs such as excessive bone loss, mobility of
teeth, loss of pulp vitality may be evident.
WHAT IS THE PATHOGENESIS OF PRIMARY
APICAL PERIODONTITIS?
• Persistent microbial infection of the root canal system
results in the inflammatory disorder of the periradicular
tissues called primary apical periodontitis.
• Apical periodontitis is the body’s defense response
infection of the root canal system which minimizes the
spread of the infection but it cannot eliminate microbes
present in the necrotic root canal as protected biofilms.
Thus, apical periodontitis is not self-healing, its
resolution requires nonsurgical or sometimes surgical
Endodontic therapy.
• The infected and necrotic root canal system consists of
microorganisms in the following forms:
– Planktonic cells suspended in fluid phase of canal,
– Sessile biofilms (discussed in detail in the next
chapter)
– Aggregates and coaggregates.
• Related Periradicular pathologies:
1. Acute apical periodontitis is an acute inflammation
of the periodontium of Endodontic origin. Distinct
focus of neutrophils is present in the lesion.
Types of acute apical periodontitis:
A. Primary or initial acute apical periodontitis: It
is the inflammation of healthy periodontium in
response to irritants and is of short duration.
B. Secondary or exacerbating apical periodontitis:
It is an acute response in an already existing
chronic periodontal lesion. It is also called
periapical flare-up, or phoenix abscess.
82 Short Textbook of Endodontics

2. Established chronic apical periodontitis is a

long standing inflammation of periodontium of
Endodontic origin. Granulomatous tissue infiltrated
with lymphocytes, plasma cells and macrophages is
seen.
3. Periapical true cyst is an apical inflammatory cyst that
consists of pathologic cavity completely enclosed in
an epithelial lining. There is no communication to
the root canal.
4. Periapical pocket cyst is an apical inflammatory cyst
that consists of a sac-like, epithelium lined cavity.
There is communication to the root canal.

Root canal therapy aims at prevention or treatment of

apical periodontitis.

BIBLIOGRAPHY
1. Cohen S, Hargreaves KM. Pathways of Pulp, 9th edn. St. Louis:
Mosby; 2006.pp.40-58, 541-79.
2. Grossman L, Oliet S, Del Rio C. Endodontic Practice, 11th edn.
Varghese publication; 1991.pp.59-101.
3. Ingle J, Bakland L, Baumgartner J. Ingle’s Endodontics, 6th edn.
BC Decker Inc, Hamilton; 2008.pp.468-487, 494-513.
4. Ingle, Bakland Endodontics, 5th edn. BC Decker, Elsevier; 2002.
pp.95-149.
 6
CHAPTER

Endodontic Microbiology

This chapter tells you about the role of microorganisms in the pathogenesis of Endodontic disease and
the techniques for identification and control of Endodontic infections.
  You must know
• What is the Basis of Focal Infection Theory and Why is it Totally Rejected Today?
• What are the Pathways or Portals of Entry of Microorganisms in the Pulp?
• What is the Microbial Flora of Root Canal?
• What are the Types of Endodontic Infections?
• What is the Role of Microbial Virulence and Host Response in the Pathogenesis of Disease?
• What are the Methods for Detection, Identification and Examination of Microbes?
• What is the Biofilm and what is its Significance in Endodontics?

WHAT IS THE BASIS OF FOCAL INFECTION
THEORY AND WHY IS IT TOTALLY
REJECTED TODAY?
Supporters of this theory believed that pulpless and
Endodontically treated teeth may leak bacteria or toxins
or both into the body, causing illnesses such as arthritis,
intestinal disorders, anemias and other diseases of the
various systems of the body.
With the expansion of this theory, millions of teeth were
needlessly extracted to cure various chronic illnesses.
Origin of Focal Infection Theory
• In 1890, WD Miller proposed that pulpal and periapical
disease was associated with the presence of bacteria.
• In 1904, Billings defined ‘focus of infection’ as
‘circumscribed area of tissue infected with pathogenic
organisms’ and described the positive correlation
between oral disease and bacterial endocarditis.
• In 1904, Rosenow, a student of Billings, described the
‘theory of focal infection’ which stated that localized
or generalized infection is caused by bacteria traveling
through the bloodstream from a distant focus of
infection.
• In 1910, William Hunter, in a lecture on role of sepsis
and antisepsis in medicine, condemned the practice
of dentistry and stated that nonvital pulps and
Endodontically treated teeth were the cause of many
chronic illnesses. This presentation inadvertently
affected the practice of root canal therapy and
unwarranted extraction of nonvital and Endodontically
treated teeth continued for approximately 20 years.
Other details of the focal infection theory are given
in Chapter 8 Rationale of Endodontic Therapy.
Rejection of Focal Infection Theory
In 1930, an editorial published in dental cosmos, rejected the
focal infection theory and called for a return of constructive
rather than destructive dental treatment rationale.
Numerous studies were conducted to cure chronic
illness, but in nearly all cases, the disease returned and
the patient now faced the additional difficulty of living
with mutilated dentitions.
Conclusion
On the basis of various clinical and scientific studies, both
medical and dental professions concluded that there is
no relationship between Endodontically treated teeth or
84 Short Textbook of Endodontics
nonvital pulps and the degenerative diseases implicated
in the theory of focal infection.
Also, many epidemiologic and biologic studies dem­
onstrated that Endodontic therapy is safe and results  in
saving the teeth without endangering systemic health.
WHAT ARE THE PATHWAYS OR PORTALS OF
ENTRY OF MICROORGANISMS IN THE PULP?
Microorganisms can enter the pulp through different
pathways as listed in Figure 6.1. (Remember the Mnemonic:
Fig. 6.1  Portals of entry of microorganisms in the pulp
DRAPE—Dentinal tubules, Restorations, Anachoresis,
Periodontal tissues, Exposure of pulp).
WHAT IS THE MICROBIAL FLORA
OF ROOT CANAL?
Colonization is the establishment of microbes in a host
when biochemical and physical conditions are adequate for
growth. Normal microbial flora is the result of permanent
colonization of microbes in a symbiotic relationship that
produces beneficial results.
 Endodontic Microbiology 85

Fig. 6.2  Diagram showing dental caries: (a) Dental caries; Fig. 6.4  Diagram showing pulp exposure due to trauma: (a) PDL
(b) Infected pulp; (c) Periapical pathology widening; (b) Traumatic exposure of pulp; (c) Angle fracture of
maxillary central incisor

A B

Figs 6.3A and B  Diagram showing exposed dentinal tubules as Fig. 6.5  Diagram showing pulp exposure during restorative
pathway to pulp: (A) Normal tooth; (B) (a) Attrition; (b) Exposed procedures. Pulp exposure in a mesially inclined mandibular molar
dentinal tubules; (c) Abrasion during tooth preparation for receiving fixed partial denture indicated
by arrow
86 Short Textbook of Endodontics

Fig. 6.6  Diagram showing pathways of pulp through periodontal Fig. 6.8  Radiograph showing recurrent caries at the margins of
tissues: (a) Lateral canal; (b) Furcation canal; (c) Periodontal pocket; restoration causing pulpal involvement and periradicular infection
(d)  Accessory canals; (e) Apical foramen in mandibular first molar (Courtesy of Dr Chetan Shah)

Flow chart 6.1  Microorganisms that may be

present in an infected root canal

Fig. 6.7  Diagram showing leakage underneath the restoration.

Marginal leakage under restoration may cause pulpal infection

Root canal flora predominantly consists of aerobic and

iii. Low oxygen tension
facultative anaerobic microorganisms. Most of them are
iv. Bacterial byproducts.
gram-positive but few gram-negative and obligate anaerobes
are also found.
• Endodontic infections are polymicrobial in nature. WHICH ARE THE TYPES OF ENDODONTIC
• The number of colony forming units (CFU) is 100 to 10 INFECTIONS?
to the power 8.
Endodontic infections can be:
• Classification of microorganisms present in an infected
I. Primary
root canal are listed in Flow charts 6.1, 6.2 and 6.3.
II. Secondary
Which bacteria will predominate is determined by: III. Persistent
i. Tissue fluid I. Primary root canal infections generally consist of
ii. Necrotic pulp tissue anaerobic gram-negative bacteria such as:

Flow chart 6.2  Different bacteria in an infected root canal
Flow chart 6.3  Classification according to Gram stain technique
– Porphyromonas endodontalis, Porphyromonas
gingivalis
– Prevotella
– Peptococci
– Peptostreptococci
– Fusobacterium
– Eubacterium
– Actinomyces.
All these species are black-pigmented and have been
associated with clinical signs and symptoms.
• Bacteroides melanogenicus, an important causative
agent can be classified into two groups:
– Saccharolytic species (Prevotella genus)
– Asaccharolytic species (Porphyromonas genus)
• Treponema denticola, a recognized periodontal
pathogen, has been found in infected root canals and
abscesses.
• Three pathogens that form red complex:
– T. denticola
– T. forsythia
– T. gingivalis
have also been found in Endodontic infections.
Endodontic Microbiology 87
II. Secondary root canal infections may be caused by
microorganisms that were not present during primary
infections but introduced during treatment between
appointments or after Endodontic treatment.
Commonly found microorganisms in case of
secondary Endodontic infections include:
– Enterococcus
– Staphylococcus
– Streptococcus
– Actinomyces
– Pseudomonas
– Candida sp.
– Propionibacterium
Improper coronal seal causing leakage has been
implicated as an important cause of post-treatment
apical periodontitis.
III. Persistent root canal infections may be caused by
bacteria present within the canal at the time of
obturation that resist filling procedures and materials
to survive even in changed environment maintaining
the periradicular inflammation. This is most important
cause of Endodontic failure.
Enterococcus faecalis is predominant microbe
in canals undergoing retreatment in cases of failed
Endodontic therapy and canals with persistent
infections. Also Streptococcus faecalis, Actinomyces sp.,
Candida sp. may be found in such cases.
Enterococcus faecalis:
E. faecalis is a gram-positive cocci and a facultative anaerobe
which is normally present in the intestine. It may be found
in the oral cavity and gingival sulcus.
E. faecalis has following unique features due to which it
can survive even in treated root canals (Fig. 6.9 mind-map):
Fig. 6.9  Mind-map to remember unique features of E. faecalis that
make it exceptional survivor in root canal
88 Short Textbook of Endodontics
• It can persist in spite of poor nutrient environment in
Endodontically treated teeth.
• It survives even in the presence of root canal irrigant such
as sodium hypochlorite and intracanal medicament
such as calcium hydroxide.
• It tends to invade and metabolize fluid within dentinal
tubules and adheres to collagen in the presence of
human serum.
• It endures prolonged periods of starvation and utilizes
tissue fluid from periodontal ligament.
• It is known to convert into a Viable But Non-Cultivable
state (VBNC)
• It can survive in adverse conditions such as low pH, high
salinity and high temperatures.
• It can acquire gene-coding antibiotic resistance
Fig. 6.10  Mind-map to remember types of Endodontic infections
in combination with natural resistance to various
antimicrobial agents.
Figure 6.10 shows a mind-map to remember all the
microbial flora of root canal and types of Endodontic
infections and Figure 6.11 summarizes all points of
microbiology of infected root canal.
WHAT IS THE ROLE OF MICROBIAL
VIRULENCE AND HOST RESPONSE IN
THE PATHOGENESIS OF DISEASE?
The ability of microorganisms to produce a disease is called
pathogenicity.
The degree of pathogenicity caused by microbes is
referred to as virulence.

The pathogenic response includes damage caused
by the host in response to the microbes. Host’s response
includes:
• Nonspecific inflammatory reaction
• Specific immunologic reaction
The pathogenic responses are associated with:
a. Microorganisms (Bacterial virulence factors given in
Figure  6.12)
b. Associated host responses (Flow chart 6.5).
Bacterial Virulence Factors
(Remember the short sentence: PLEASE Care For—
Polyamines, Lipopolysaccharides, Enzymes, Ammonia,
Short chain fatty acids, Extracellular vesicles, Capsule,
Fimbriae (Fig.  6.12).
Fig. 6.11  Mind-map to remember all points of microbiology of infected root canal
Endodontic Microbiology 89
WHAT ARE THE METHODS FOR DETECTION,
IDENTIFICATION AND EXAMINATION OF
MICROBES FROM A ROOT CANAL?
Flow chart 6.6 lists the methods for detection, identification
and examination of microbes.
Culture Methods
Technique
• Isolate the tooth with rubber dam.
• Remove the dressing from root canal of previous visit.
• Insert a sterile absorbent point into the canal and wipe
the canal to remove any intracanal medicament.
• Take a fresh, sterile absorbent point till the apex or
slightly beyond to absorb as much periapical exudates
and microorganisms from the root canal as possible.
90 Short Textbook of Endodontics
Fig. 6.12  Bacterial virulence factors
Let the absorbent point remain there for at least one
minute.
• The absorbent point is removed with the sterilized cotton
pliers and is put into the culture medium.
• The sample is sent for laboratory examination. Gram-
staining demonstrates which type of microorganisms
predominate.
• Culturing anaerobic microorganisms from samples
obtained from root canal and periapical tissue require
special equipment and temperature controlled, oxygen-
free medium.
Using an aseptic technique, sterile needle of Luer Lok
syringe is inserted into periradicular space. Aspirate is
collected in oxygen free, anaport vial and transported to
any anaerobic culturing depot for examination.
Advantages
• It allows identification of a great variety of microbial
species in a sample.
• Helps in determination of antimicrobial susceptibility
for appropriate treatment.
Disadvantages
• They have low sensitivity and specificity
• May give false-negative results

Flow chart 6.5  Host response to the microbes
• Time-consuming
• Transport of sample to the laboratory is required.
For anaerobic bacteria, sampling and transportation
will have to be done in carefully controlled anaerobic
condition.
Molecular Diagnostic Methods
These methods have been recently introduced for
precise identification of Endodontic pathogens based
on the microbial genome and there is then no need for
cultivation.
Advantages
• They have greater sensitivity and specificity
• They can detect both cultivable and uncultivable
microbial species and strains
• Less time-consuming
• There is no need for cultivation and the microbial species
can be detected directly in clinical samples.
Disadvantages
• Expensive
• Can be laborious.
1. DNA—DNA hybridization method: This method uses
DNA probes that may target whole genomic DNA or
individual genes such as 16S rDNA.
Useful for large-scale epidemiologic research as
it allows simultaneous determination of multitude of
bacterial species in single or multiple clinical samples.
Endodontic Microbiology 91
Flow chart 6.6  Methods for detection, identification and
examination of microbes
2. Polymerase chain reaction method:
– It involves in vitro replication of DNA referred to as
genetic xeroxing
– Standard PCR procedure is called Single PCR
– Variation in standard PCR: Nested PCR,
Reverse transcriptase (RT)-PCR
Multiplex PCR, Real-time PCR
– PCR has excellent detection limits
– Can be used to investigate microbial diversity in a
given environment
– PCR techonology can be used for clonal analysis of
microorganisms.
In the past, with culture sensitivity, microorganisms were
detected and specific drugs were used against them such as
PBSC/PBSN paste.
P – Penicillin (Against Gr +ve)
B – Bacitracin (Against penicillin resistant organisms)
S – Streptomycin (Against Gr –ve)
C – Caprylate sodium (Against yeast and fungi)
These drugs were in powder form carried in a vehicle to
form a paste.
Sterility of root canal or reduction in number of micro­
organisms in root canal is detemined by bacteriological
examination before obturating a canal to ensure that no
evidence of microbial growth is present.
In difficult cases that do not respond to routine
Endodontic treatment, microbiologic examination has to
be done. If culture techniques yield a negative result then
the newly introduced molecular techniques may detect
the specific microbes in Endodontic infections, that were
previously unidentified or uncultivable.
A mind-map showing methods for detection and identi­
fication and examination of microbes (Fig. 6.13).
92 Short Textbook of Endodontics

WHAT IS THE BIOFILM AND WHAT IS ITS 1. Autopoiesis (ability to self-organize)

SIGNIFICANCE IN ENDODONTICS?
Biofilm
Biofilm is a mode of microbial growth where dynamic
communities of interacting sessile cells are attached to each
other and to a solid substratum irreversibly and embedded
in a self-made matrix of extracellular polymeric substances
(EPS).
Four basic criteria that determine a microbial biofilm,
as given by Ingle, include:
2. Homeostasis (resist environmental perturbations)
3. Synergy (more effective in association than in isolation)
4. Communality (respond to environmental changes as a
unit rather than single individuals)
– Dental plaque can be considered as typical example
of a biofilm
– Bacterial cells: Planktonic—Free floating bacterial
cells in an aqueous environment
Biofilm—Sessile bacterial cells attached to a solid
surface.

Fig. 6.13  A mind-map to remember all points of methods for detection, identification and examination of microbes

The sessile microorganisms protected in biofilms are
more than 1000 times resistant to antimicrobial agents as
the same organisms in planktonic form.
The phenotype of biofilm bacteria is distinct from that
of planktonic bacteria.
Bacterial cells within the biofilm have altered phenotypic
properties that protect them from:
i. Antimicrobials
ii. Environmental stresses
iii. Bacteriophages
iv. Phagocytic amoebae
Since biofilms are resistant to both host defense
mechanisms and antibiotic therapy, they are responsible
for most chronic infections and recalcitrant infections in
human beings.
• Common biofilms found in oral cavity are protective
in nature and essential for maintenance of oral
health as they inhibit the adherence of pathogenic
microorganisms through colonization resistance.
But any environmental change favoring colonization
by pathogenic bacteria causing ecological shift and
decline in host defense mechanism due to disease will
cause harmless commensals to become opportunistic
patho­gens. Type and availability of nutrients and oxygen
tension determine the nature of bacteria associated with
a biofilm. All common oral diseases—Dental caries,
Gingivitis, Periodontitis, apical periodontitis are biofilm-
mediated diseases.
• Ultrastructure of Biofilm (Fig 6.14): Microcolonies or
cell clusters formed by surface adherent bacterial cells,
surrounded by Glycocalyx matrix made of Extracellular
Fig. 6.14  Schematic representation of ultrastructure of mature biofilm (N-Nutrients; M-Metabolic products; S-Signal molecules)
Endodontic Microbiology 93
Polymeric Substances (EPS) that anchors bacterial
cell to substrate. About 85% by volume of Biofilm
is matrix material and 15% is cells. A fresh biofilm
consists of polysaccharides, proteins, nucleic acids
and salts embedded in extracellular matrix. Matured
biofilm structure and composition varies according to
environmental conditions such as: growth conditions,
nutritional availability, etc. A viable, fully hydrated
mature biofilm appears as tower or mushroom shaped
structure adherent to the substrate. The primitive
circulatory system in the biofilm is water channels that
intersect the structure of biofilm and form connections
between microcolonies that facilitate exchange of
materials between bacterial cells and bulk fluid. This
is important in coordinating functions of biofilm
community.
• Development of Biofilm: Biofilms tend to form when
there is flow of fluid, microorganisms and a solid surface.
Figure 6.15 shows the schematic representation of stages
of biofilm formation.
Stage 1: Formation of conditioning layer: The inorganic and
organic molecules get adsorbed to the solid surface to form
conditioning layer, e.g. Saliva pellicle is the conditioning
layer on tooth during dental plaque formation.
Stage 2: Adhesion of microbial cells to the conditioning layer.
Stage 3: Bacterial growth and biofilm expansion. Micro­
colonies are formed. Two microbial interactions that occur
at cellular level include:
i. Coadhesion which is recognition between suspended
cell and cell already attached to substratum (Fig. 6.16B)
94 Short Textbook of Endodontics
Stage 1  Formation of conditioning layer
Stage 2  Planktonic bacterial cell attachment
Fig. 6.15  Stages of biofilm formation
ii. Coaggregation in which genetically distinct cells in
suspension recognize each other and clump together
(Fig. 6.16A).
The detachment of microcolonies to detach from biofilm
community can be in two forms:
i. Erosion: Continual detachment of single cells and small
portions of biofilm.
ii. Sloughing: Rapid, massive loss of biofilm.
Detachment shapes morphological characteristics of
biofilm and serves as active dispersive mechanism (Seeding
dispersal). Detached cells that have acquired resistance
traits from parent biofilm community, can be a source for
persistent infection.
Biofilm in Endodontics: When there is infection in
the root canal, its nutritional and environmental status is
altered. It becomes more anaerobic. Nutritional level is
depleted making it a tough ecological niche for surviving
microorganisms. This favors biofilm formation both
Stage 3  Bacterial growth and biofilm expansion
in primary and post-treatment Endodontic infections.
Microbes persist in anatomical complexities such as
isthmus, deltas and in apical portion of root canal system
and may also invade beyond the apical foramen.
Types of Biofilm
1. Intracanal Microbial Biofilms:
– Formed on root canal dentine of Endodontically
infected tooth
– Intracanal bacterial biofilm was documented in
detail by Nair in 1987
– Composed of loose collection and biofilm structure
of cocci, rods and filamentous bacteria
– Monolayer and/or multilayered bacterial biofilms
adhere to the dentinal wall of root canal
– Intracanal biofilm has extracellular matrix
material of bacterial origin interspersed with cell
aggregates

A the root tip adjacent to the apical foramen
B Endodontic treatment.
Figs 6.16A and B  Schematic representation of coaggregation and
co-adhesion between different bacterial cells forming biofilm
– E. faecalis can develop biofilms according to
prevailing environmental and nutrient conditions:
i. In nutrient-rich environment (aerobic and
anaerobic): E. faecalis is found to produce
typical biofilm structures with characteristic
surface aggregates of bacterial cells and water
channels. Viable bacterial cells present on
biofilm surface.
ii. In nutrient-deprived environment (aerobic
and anaerobic): Irregular growth of adherent
cell clumps. Dead bacterial cells and pockets
of viable bacterial cells found.
Formation
Stage 1: E. faecalis adhere and form microcolonies on the
root canal dentine surface.
Stage 2: Bacterial-mediated dissolution of the mineral
fraction from dentin substrate was induced.
Stage 3: Mineralization or calcification of E. faecalis biofilm
due to localised increase in calcium and phosphate ions.
Coaggregation interactions between E. faecalis
and F. nucleatum occur and contribute to Endodontic
infections.
Endodontic Microbiology 95
2. Extraradicular Microbial Biofilms:
– Also called root surface biofilms
– Formed on root (cementum) surface adjacent to root
apex of Endodontically infected teeth
– Composed of cocci, short rods and filaments, with
cocci attached to tooth substrate
– Smooth structureless biofilm containing extracellular
matrix and embedded bacterial cells found to coat
– Calcified extraradicular biofilms were found in cases
of periapical inflammation and delayed periapical
healing in spite of adequate orthograde nonsurgical
Endodontic treatment.
3. Periapical Bofilms:
– Isolated biofilms found in periapical area of
Endodontically infected teeth
– Actinomyces and P. propionicum have been found
in asymptomatic periapical lesions refractory to
– Actinomyces has yellow granular appearance (called
sulfur granules). Periapical biofilm structure is
granular containing central mass of intertwined
branching bacterial filaments held together by
extracellular matrix with peripheral radiating clubs.
– Phagocytes cannot engulf bacteria in matrix
enclosed biofilm structure.
4. Biomaterial Centered Infection (BCI):
– Bacteria adheres to an artificial biomaterial surface
to form biofilm.
– When biomaterials are present in close proximity to
the host immune system, it increases susceptibility
for BCI.
– It is a major complication associated with prosthesis
and implant-related infections. In Endodontics, it
can form on root canal obturating materials and can
be intraradicular or extraradicular depending on
whether the obturation material is within the canal
or extruded beyond apex.
– Microbes associated with BCI: Coagulase negative
Staphylococcus, S. aureus, enterococci, streptococci,
P. aeruginosa and fungi found from infected
biomaterial surfaces. E. faecalis, S. sanguinis,
S. intermedius, etc. have been isolated from biofilms
related to obturation material. Gram-positive
facultative anaerobes can colonize and form
extracellular matrix on GP points. Serum plays a role
in biofilm formation.
– Bacterial adherence to biomaterial surface is
described in following phases:
96 Short Textbook of Endodontics
Fig. 6.17  Mind-map to remember all points of Biofilm
- Phase 1: Transport of bacteria to biomaterial
surface
- Phase 2: Initial, nonspecific adhesion phase
- Phase 3: Specific, adhesion phase.
– Clinical Significance: Apical periodontitis is
essentially a biofilm-induced disese. The structure
of Biofilm and the resident microorganisms is
such that it is resistant to antimicrobial agents
such as antibiotics, disinfectants or germicides.
Endodontic treatment should focus on elimination
of microbes that colonize infected root canal
system (by means of Antisepsis) and prevent
introduction of new microorganisms in the canal
(by means of Asepsis). For the disruption of biofilm
and reduction of microbial load, combination
of mechanical instrumentation and various root
canal irrigants and disinfectants such as Sodium
hypochlorite, Chlorhexidine digluconate, MTAD,
calcium hydroxide, etc. are being used. Also other
methods such as use of Endoactivator, Ultrasonics,
Lasers, Ozone therapy, etc. are being employed to
eradicate biofilms and achieve complete root canal
disinfection. These have been discussed in detail in
Chapter 15: Disinfection of the Root Canal System.
Mind-maps to remember all points of biofilm are given
in Figures 6.17 and 6.18.
 Endodontic Microbiology 97

Fig. 6.18  Mind-map to remember types of Endodontic biofilm

2. Grossman L, Oliet S, Del Rio C. Endodontic Practice, 11th edn.

BIBLIOGRAPHY Varghese Publication; 1991.pp.234-41.
1. Cohen S, Hargreaves KM. Pathways of Pulp, 9th edn. St. Louis: 3. Ingle J, Bakland L, Baumgartner J. Ingle’s Endodontics 6, 6th edn.
Mosby; 2006.pp.541-79, 580-607. BC Decker Inc, Hamilton; 2008.pp.268-308.
 7
CHAPTER

Diagnosis and Diagnostic

Aids in Endodontics

This chapter describes a systematic and methodical approach towards making an accurate
diagnosis. It includes the various odontogenic and nonodontogenic causes of orofacial pain,
which sometimes presents a true diagnostic and therapeutic challenge to the clinician. The
chapter also explains in detail the various diagnostic aids in Endodontics.
  You must know
•  What is Diagnosis and how to be a Successful Diagnostician?
• What are the Steps to be followed to Arrive at an Accurate Diagnosis?

WHAT IS DIAGNOSIS AND HOW TO BE A Prerequisites of proper diagnosis: To be successful in

SUCCESSFUL DIAGNOSTICIAN? diagnosis, the diagnostician should have:
PATIENCE,
Diagnosis is the process of evaluating the patient’s health INTEREST,
and the resulting opinion formulated by the clinician. CURIOSITY,
“Oral diagnosis is a systematic method of identifying KNOWLEDGE,
an oral disease process on the basis of facts obtained from SENSES to be alert,
history, clinical examination and various diagnostic tests”. INTUITION
Making an accurate diagnosis is an Art and Science. EQUIPMENT (Instruments and devices) for examination
Figure 7.1 shows the requirements for making correct and diagnostic tests.
diagnosis. (Remember the above prerequisites of the diagnostician
as: An excellent diagnostician P I C K S It Early).
“Symptoms are defined as phenomena or signs of
a departure from the normal and indicative of illness.”
(Grossman’s Endodontic Practice, p.1).

WHAT ARE THE STEPS TO BE FOLLOWED TO

ARRIVE AT A CORRECT DIAGNOSIS?
Flow chart 7.1 shows a simplified chart showing steps
in diagnostic process. Diagnostic process should be
Fig. 7.1  Requirements for making correct diagnosis methodical and systematic.

Flow chart 7.1  Simplified chart showing steps to make an accurate diagnosis
Differential diagnosis: It is the technique of distinguishing
one disease from several other similar disorders by
identifying their differences.
Diagnosis by exclusion: It is the technique in which all
possible diseases under consideration are eliminated until
one remaining disease correctly explains the patient’s
symptoms.
Diagnosis and Diagnostic Aids in Endodontics 99
STEP 1: CASE HISTORY TAKING
Case history taking is an active dialogue between the
clinician and the patient. The clinician asks a set of leading
questions and carefully interprets the answers.
A written case history form can be filled in by the patient
and then verified and reviewed by the clinician.
100 Short Textbook of Endodontics

Chief Complaint • History of illness requiring hospitalization in the past

should be enquired for.
The reason for the patient seeking dental care/treatment • Any known drug allergy.
should be documented in patient’s own words. • Whether the patient is taking any Medications
With this expressed chief complaint, the clinician can (prescription medications as well as over the counter
determine the nature and order of events that lead to the medications).
patient’s complaint. The clinician may have to consult with the patient’s
physician and decide about the dental treatment
Medical History modifications that will have to be made in order to provide
the appropriate care.
• Enquire about the general health of the patient and about
the presence of any medical problems. Completion of Dental History
a preprinted comprehensive medical history form is
mandatory. It gives clinician information about presence Present Dental Illness
of any medical problems and serves as baseline record.
It needs to be updated, especially if the patient comes Open ended: Leaves patient open
for a recall check-up or other dental problems after a for discussion
long time. Questions
• Need: Information about the medical problems is Closed: Response is Yes or No
necessary as: Open-ended questions are encouraged to obtain specific
– Some medical conditions may require modification information regarding the present illness from the patient
in providing dental care. For example, in case of such as:
hypertension, Local anesthesia without adrenaline
may have to be used. In patients taking drugs such • Onset of symptoms and its intensity: When did the
as Ecosprin, it needs to be discontinued with the symptoms first started and what is the intensity of
consent of patient’s physician before performing symptoms.
any surgical procedure. Antibiotic prophylaxis is Spontaneous
indicated for patients with congenital or rheumatic – Onset
heart disease. Initiating event Trauma
– Some medical conditions may have oral manifes­ Biting on hard object
tations. For example, AIDS, diabetes mellitus. After dental visit
– Some oral soft tissue changes are related to for a restoration
medications used to treat the medical condition. – Intensity of symptoms: Whether the Mild
For example, nifedipine, an antihypertensive drug symptoms are Moderate
induces gingival hyperplasia. Severe
– It helps to determine the risks to the clinician and • Duration of symptoms: Whether the symptoms are:
staff and risk to the patient due to presence of – Momentary
particular medical condition. – Lingering
– In medically compromised patients, it helps to • Progress: Whether intensity of symptoms is increasing
determine the risk of treatment against the risk of or decreasing.
nontreatment. • Aggravating factors may be: Biting, temperature changes,
Thus, the medical history will enable the clinician etc.
to determine the need for: • Relieving factors may be: Medications, holding cold
- Medical consultation, water in mouth, etc.
- Any modification of therapy, Provocation and relief factors may help to determine
- Any premedication which diagnostic tests should be performed to establish
• The American Society of Anesthesiologists has a more objective diagnosis.
developed a system to determine the extent of risk in • Localization of area or tooth: Whether the patient can
medically complex patients. These guidelines can be point the offending tooth or the symptoms are not well-
followed. localized and radiating to which all areas.
 Diagnosis and Diagnostic Aids in Endodontics 101

Past Dental History • Progression of pain: Whether the pain has reduced,
• Information regarding the last dental visit. become worse or same (unchanged).
• Whether there has been any recent dental treatment. • Aggravating factors: Factors that precipitate or aggravate
This may help to localize a particular problem. pain help in directing objective tests.
The lack of aggravating factors indicates that the pain
Pain History is nonodontogenic.
• Relieving factors: Factors that alleviate pain.
This involves both careful listening and astute questioning. – Whether the pain is responsive to specific medication
The clinician has to determine the source of pain. – Moderate intensity pain but unresponsive to anti-
Odontogenic inflammatory drugs suggests a noninflammatory
Source of pain origin.
Nonodontogenic • Associated factors: Such as swelling, discoloration and
Well-localized numbness.
•  Location
Diffuse Orofacial Pain/Dental Pain
Superficial
Location Definition of Pain
Deep
– Easily localized superficial pain: May be Cutaneous “Pain is defined as an unpleasant sensory and emotional
or Neurogenic origin. experience associated with actual or potential tissue damage
– Deep pain, that may be localized when provoked: or described in terms of such damage.” (International
May be Musculoskeletal in origin Association of Study of Pain (IASP).
– Deep diffuse pain: May be Somatic, Visceral or By far ‘pain’ is the most important/only factor that
Musculoskeletal. provokes the individuals to seek dental care.
– Superficial and spreading pain: May be Neurogenic
rather than a Cutaneous source. Classification
• Intensity: Can be determined using Verbal Analog Scale
which means on a scale of 0–10, with 0 being no pain • Classification of dental pain:
and 10 being the worst pain, how does the patient rate
the pain.
Sudden
• Onset of pain
Gradual
This helps to determine the etiology.
Unchanging pain that has been present over a protracted
period is highly suggestive of a nonodontogenic source.
Whether the pain is – Spontaneous
– Elicited with hot/cold/chewing
• Duration of pain – Momentary
– Lingering
• Whether the pain is Continuous or Intermittent
• Nature of pain – Dull ache (May be muscular)
– Sharp shooting
– Shock like, Burning
(May be neurogenic)
– Throbbing, pulsatile
(May be vascular)
102 Short Textbook of Endodontics
• Classification of pulpal pain:
Referred Pain
“The perception of pain in one part of the body that is
distant from the actual source of pain is known as Referred
pain”.
• Pain of nonodontogenic origin can refer pain to teeth.
Also teeth may refer pain to other teeth as well as to
other anatomic areas of the head and neck.
• It is provoked by intense stimulation of pulpal C-fibers
that cause intense, slow, dull pain.
• Referred pain always radiates to Ipsilateral side of the
tooth involved.
• Rarely, anterior teeth refer pain; Posterior teeth may refer
pain to Opposite arch, to Periauricular area, or rarely to
anterior teeth.
Orofacial Pain of Nonodontogenic Origin
Rhinosinusitis and Endodontic Disease
Maxillary rhinosinusitis is the most common nonodonto­
genic cause of dental pain.
Pain may get referred from the maxillary sinus to the
maxillary dentition primarily due to the close anatomic
relationship between the floor of the maxillary sinus and
the roots of the posterior maxillary teeth.
Thus, two important conditions to be considered during
diagnosis include:
1. Referred dental pain from maxillary sinus (Figure 7.2
shows points explaining the mechanism how pain gets
referred to teeth from inflammed maxillary sinus).
2. Maxillary sinusitis of dental origin (MSDO) (Figure 7.3
shows points explaining the mechanism how dental
infection can spread to the maxillary sinus).
The distinguishing points of Rhinosinusitis and
Odontalgia due to Endodontic disease are listed in Table 7.1.
Figure 7.4 shows schematic representation of spread of
periapical infection from maxillary second premolar into
the maxillary sinus.
Fig. 7.2  Mechanism of referred dental pain from maxillary sinus
 Diagnosis and Diagnostic Aids in Endodontics 103

TABLE 7.1  Distinguishing points of rhinosinusitis and odontalgia

due to Endodontic disease
Symptoms of rhinosinusitis Symptoms of odontalgia
• Dull aching dental pain that is • Pain of pulpal origin is more
difficult to pinpoint or localize to a easily localized
single tooth
• Positional changes can cause • Positional changes generally
increased pain due to movement of do not affect pain of pulpal
mucosal fluid over sensitive sinus origin except in some cases
ostium or it can be due to raised of irreversible pulpitis
intracranial pressure from blood
flow. Throbbing or increased pain
sensation is felt on lying down or
when the head is placed lower than
the level of heart
• Fullness or pressure below eyes and • No such fullness or pressure
on external palpation of cheeks
• Often all the teeth that are • Usually only the offending
proximate to the sinus floor are tooth is tender to
tender to percussion percussion Fig. 7.3  Mechanism of spread of dental infection to maxillary sinus
• Symptoms may be severe, but there • Symptoms may vary from
is sudden and total relief if drainage mild to moderate to severe
is established and sinus pressure is depending on the cause.
alleviated Endodontic treatment
provides total relief
from severe pain due to
irreversible pulpitis
• Application of local topical • Sometimes, administration
anesthetic to maxillary sinus ostium of local anesthetic nerve
can relieve perceived dental pain block causes relief of dental
in case of referred sinus pain. pain
Anesthetic nerve blocks will not
abate pain of rhinosinusitis
• Generally the tooth in question • To detect the offending
responds within normal limits to a tooth and the etiology of
pulpal stimulus such as electric pulp dental pain, the pulp vitality
test or thermal test such as ice, when test is the key diagnostic
compared with other healthy teeth test. It helps to effectively
differentiate maxillary sinus
etiology from pain of pulpal Fig. 7.4  Schematic representation of spread of dental infection in
origin
maxillary sinus from infected maxillary second premolar. Big arrow
indicates how periapical infection from maxillary second premolar
has spread into maxillary sinus and small arrow heads indicate floor/
Periapical infection from maxillary second premolar has lining of maxillary sinus
spread into the maxillary sinus shown by big arrow. Small
arrow-heads indicate the floor/lining of maxillary sinus.
Localized mucosal thickening in the adjacent sinus • Myofascial pain is described as diffuse, constant, dull,
mucosa in response to apical periodontitis in a maxillary aching sensation, which may be misdiagnosed as pulpal
posterior tooth is referred to as periapical mucositis. It is pain.
asymptomatic and resolves following Endodontic treatment. • Masticatory muscle pain is felt when chewing. This pain
is triggered by contraction of masticatory muscles rather
Dental Pain of Myofascial Origin: than loading of PDL.
Palpation of masticatory muscles will reproduce pain
Myofascial Pain vs Pulpal Pain
whereas percussion of teeth will not.
• Myofascial pain originate from small foci of muscle • Etiology of myofascial pain: Injury or sustained
tissue termed as TRIGGER POINTS. contraction such as clenching/parafunctional habit.
104 Short Textbook of Endodontics
• Dental pain of myofascial origin may or may not be
associated with pulpal or periapical pathosis.
• Dental pain of myofascial origin can be diagnosed based
on following:
– Local anesthetic block will not resolve symptoms but
if local anesthetic is administered into trigger point,
it will resolve symptoms
– Lack of symptoms after pulp testing
– Palpation of masticatory muscles will elicit pain
– Percussion of teeth will not elicit pain.
Neurovascular Pain vs Pulpal Pain
Neurovascular pain presents mainly as headache with
accompanying toothache perceived secondary to headache.
Primary headache is of three types:
1. Migraine
2. Tension-type headache
3. Cluster headache
• Migraine presents as unilateral, pulsatile, moderate
to severely intense headache which is likely to be
aggravated with routine physical activity. Patients may
experience nausea or vomiting or photophobia.
• Tension-type headache does not mimic toothache.
• Pain of neurovascular origin presenting primarily as
toothache is more likely to be cluster headache.
Cluster headaches occur in episodes lasting for 15
minutes to 2 hours. There may be 1–8 such episodes in a day.
Presents as unilateral, excruciating orbital, supra-orbital or
temporal pain. Other symptoms may be ipsilateral nasal
congestion, rhinorrhea, lacrimation.
Elimination of pain following 10-minute inhalation of
100% oxygen is diagnostic for cluster headache.
Referred pain is felt in maxillary anterior or premolar
teeth.
Important Diagnostic Features
• Neurovascular pain occurs in episodes with complete
remission between episodes whereas pulpal pain will
be continuous or may present as discomfort between
any aggravating episodes.
• Local anesthetic administration is unpredictable.
• Administration of oxygen to rule out cluster headache
can make definitive diagnosis.
Neuropathic Pain vs Pulpal Pain
Neuropathic pain arises from abnormalities in neural
structures.
Trigeminal neuralgia: It can be diagnosed based on:
• There is intense, sharp, shooting pain on stimulation of
trigger zones and is unilateral.
• Slight pressure on trigger zones results in severe pain.
This pain usually subsides within few minutes until
triggered again.
• Trigger zones for trigeminal neuralgia may be intraoral
and may be triggered by chewing.
• Administration of local anesthetic in the area of trigger
zones may resolve the symptoms and can be misleading.
• Sharp, shooting pain in the absence of dental etiology
should alert the clinician to include trigeminal neuralgia
in differential diagnosis.
Cardiac Pain
• Cardiac pain may be referred to left side of mandible.
• Cardiac pain can be spontaneous and diffuse similar to
pulpal pain.
• Diagnostic features:
– Associated medical history pointing to cardiac
problem
– Cardiac pain will not get aggravated by local
provocation of teeth
– Administration of local anesthetic will not reduce
the pain.
Psychogenic Pain
• Patient will have complaint of toothache, yet lacks a
physical cause.
• Psychogenic toothache is very rare.
• Diagnosis of psychogenic toothache only by ruling out
all other potential diagnoses.
• Psychogenic pain may be precipitated by severe
psychologic stress. It may not follow any anatomic
distribution. Pain may be felt in multiple teeth.
A Mind-map to remember all points of case history
taking (Fig. 7.5).
STEP 2: CLINICAL EXAMINATION
General
• The clinician must observe the patient as he/she walks
into the operatory by his/her gesture and body language.
• Obtain and record the patient’s vital signs: (TPR BP)
Temperature, pulse rate, respiratory rate, blood pressure.
Temperature
• An elevated body temperature (fever) indicates total
body reaction to inflammatory disease.

Fig. 7.5  Mind-map to remember all points of case history taking
• Normal body temperature is 98.6oF. A temperature above
this but below 100oF indicates localized disease.
Localized disease can be treated:
• By removing the cause (Root canal opening and cleaning
and disinfection) and/or
• Incision and drainage (I and D).
Pulse rate: Normal pulse rate is 60–100 beats per minute.
Stress and anxiety can cause elevated pulse rate.
Respiratory rate: Normal respiratory rate is 16–18 breaths
per  minute. This rate also gets elevated due to stress and
anxiety.
Blood pressure: Normal BP is 120/80 mm Hg for persons
under 60 years of age and 130/90 mm Hg for persons over
age of 60 years.
Diagnosis and Diagnostic Aids in Endodontics 105
No dental treatment should be done if blood pressure
readings of diastolic pressure is over 100 mm Hg on that
day. Consent and consultation with the patient’s physician
needs to be done.
Sometimes, elevated blood pressure is caused only by
stress and anxiety of the moment and must be dealt with
reassurance or pretreatment sedation if required.
• Other abnormalities such as breathlessness, altered gait,
unusual body movements must be recorded.
• Cancer screening of soft tissues: Extraoral and intraoral
soft tissues must be evaluated for any kind of lump,
swelling, white spots or scaly patches or sore spots
for early detection of any precancerous or cancerous
lesion.
106 Short Textbook of Endodontics

Extraoral Examination
• Patient is examined for any signs of facial asymmetry.
Figure 7.6 shows photograph of a patient having
facial asymmetry due to extraoral swelling on left
side.
• Any localized swelling, change in color, bruises, or similar
signs of disease, trauma or previous treatment should be
looked for.
• Inspection and palpation of painful and/or enlarged
lymph nodes.
• Any opening of sinus tracts through skin of face.
• Extent and manner of jaw opening.
• Temporomandibular joint examination—any tender­
ness, clicking, irregular movement, etc.
Fig. 7.6  Facial asymmetry due to extraoral swelling on left side
Intraoral Examination (Courtesy of Dr Manoj Ramugade)
Visual and Tactile Inspection
• For careful inspection, there should be good light and
dry conditions and good mouth mirror and probe/
explorer.
• Magnification in the form of Loupes and dental
operating microscope allow the clinician to visualize
what cannot be observed with naked eye.
• Inspection of:

Fig. 7.7  Photograph showing generalized hypoplastic

maxillary teeth (Courtesy of Dr Samir Khaire)

Figure 7.7 shows photograph of a patient with
changes in color, contour and consistency of all
maxillary teeth due to hypoplasia.
The clinician should avoid “tunnel vision”–that is
examining only the area of chief complaint of the patient.

Palpation
• Manual digital palpation, i.e. palpation with fingers of
soft and hard tissues around the tooth in question should
be done.
Figure 7.8 shows photograph demonstrating manual Fig. 7.8  Photograph showing manual digital palpation in the
digital palpation in the mucobuccal fold of maxillary left mucobuccal fold of maxillary left canine (Courtesy of Mr Amar,
canine. Dr Dabholkar’s clinic)
 Diagnosis and Diagnostic Aids in Endodontics 107

Location of swelling Offending tooth

• Anterior part of Apex of maxillary lateral
palate (Figure 7.9 incisor
shows photograph of or
swelling in anterior Palatal root of maxillary
part of palate due to first premolar
spread of infection
from maxillary right
lateral incisor)
• Posterior palate Palatal root of one of the
maxillary molars
• Mucobuccal fold of Apex of root of any
maxilla fold maxillary tooth that exits
the alveolar bone on
the facial and inferior to
Fig. 7.9  Swelling in anterior part of palate due to spread of infection muscle attachment
from maxillary right lateral incisor shown by arrow • Mandibular Apex of root of any
mucobuccal fold mandibular tooth that exits
the alveolar bone on the
facial and superior to the
Presence of tenderness on palpation should be level of muscle attachment
noted. • Tonsillar and Severe infection involving
• It is recommended that the clinician should Always pharyngeal areas maxillary or mandibular
bilaterally palpate both the area in question and the molar
contralateral side.
• Palpation of lymph nodes to note any lymph node Percussion
enlargement, tenderness, mobility and consistency.
Infection from anterior teeth may cause enlarge­ • Pain to percussion indicates inflammation of the
ment of submental lymph nodes. Infection from periodontal ligament (PDL)
mandibular molar teeth involve submandibular lymph • First gently percuss digitally with gloved finger
nodes. In acute infection, involved lymph nodes are • Then percuss with the butt end of the mirror handle
usually firm, tender and palpable. In chronic infection, (Figure 7.10 demonstrates the percussion of upper right
lymph nodes may be palpable but no pain. Hard and canine with butt end of mirror handle).
fixed lymph node with stone-like consistency indicates • Always the contralateral tooth should be first tested as
malignancy. control and also other adjacent teeth that are certain to
• Palpation of temporomandibular joint (TMJ) may be respond normally
done in cases of TMJ-related problems such as clicking, • First vertical percussion is done—that is percussing
restricted movement, deviation in movement. occlusally
• Intraoral swelling should be palpated to determine if the Then lateral percussion is done—that is buccal and
swelling is: lingual aspects of teeth.
Diffuse Sometimes the patient is not able to locate the tooth
Swelling with pain. On percussion of the involved tooth and other
Localized adjacent teeth, patient may be able to localize painful
Firm tooth.
Swelling Inflammation of PDL causing tenderness on
Fluctuant percussion may be due to physical trauma, occlusal
• Location of swelling can determine the offending tooth prematurities, periodontal disease or due to extension
from which it has originated. of pulpal disease into the PDL space.
108 Short Textbook of Endodontics
Fig. 7.10  Percussion of upper right canine with butt end of mirror
handle (Courtesy of Mr Amar, Dr Dabholkar’s clinic)
Mobility and Depressibility
Mobility of teeth indicates either loss of periodontal
attachment due to trauma, parafunctional habits,
periodontal disease, root fracture or it could be extension
of infection from pulp to PDL space. Once the initiating
factors are eliminated or treated, the mobility reverses to
normal.
Lateral movement of tooth in socket is called mobility.
Vertical movement of tooth in socket is called
depressibility.
This test is performed using back ends of two mirror
handles—one on buccal aspect of tooth and one on lingual
aspect of tooth as shown in Figure 7.11.
Periodontal Examination
• Periodontal probing is an essential part of the diagnostic
process.
• Each tooth is evaluated in atleast three locations—
mesial, middle and distal aspect, on both buccal and
the lingual surfaces.
• Periodontal defects could be a sign of either an
Endodontic or a periodontal problem.
Fig. 7.11  Back ends of mirror handles to check mobility of tooth
(Courtesy of Mr Amar, Dr Dabholkar’s clinic)
• The periodontal probe is “stepped” around the long-axis
of the tooth, progressing in 1 mm increments.
Diagnostic criteria given by Harrington to determine
whether the periodontal defect is of Endodontic or
periodontal origin:
– If periodontal probe Sinks abruptly into an isolated
periodontal defect, it could be due to Vertical root
fracture.
– If periodontal probe Steps down into a periodontal
defect and a similar finding occurs on the
contralateral side of the arch, it could be due to a
generalized periodontal disease.
• Furcation defect or bone loss can occur secondary to
periodontal or pulpal disease. Furcation canals can be
a portal of exit for necrotic pulp tissue byproducts.
Clinical furcation probing and radiographic
assessment of the furcation defect is done. Grades of
furcation involvement:
Figure 7.12 shows mind-map to remember all points of
clinical examination.

Fig. 7.12  A mind-map to remember all points of clinical examination
RADIOGRAPHS
The radiograph is one of the most important diagnostic aid
in Endodontics. It is an indispensable tool of Endodontic
practice. Radiograph is referred to as the ‘Third Eye’ of the
Dentist as it permits visual examination of oral structures
that would otherwise be unseen by naked eye.
Radiographs are essential to all phases of Endodontic
therapy. There uses can be categorized as:
Diagnostic Uses
• In Endodontics, primary radiograph is IOPA view to
determine:
Diagnosis and Diagnostic Aids in Endodontics 109
– Involvement of pulp/presence of pulpal disease:
(Crown of tooth).
  Detection of CARIES and its extent in relation to
the pulp chamber. Figure 7.13 shows a radiograph
showing deep occlusal caries in maxillary first molar
approaching the pulp.
  Remaining dentinal thickness (RDT) can be
estimated through the preoperative radiograph
suggesting whether caries is approaching the pulp
or away.
– Anatomy of pulp and root and variations (Root of
tooth):
- Number of roots and root canals
- Width of canals
- Complete or incomplete root formation
- Curvatures
- Presence of pulp stones, calcification
- Presence of fused or extra roots and canals,
accessory canals, any bifurcation or trifurcation
in root canal system
- Additional root
Radix Ento/Paramolaris
110 Short Textbook of Endodontics
– To view the periradicular area:
- Integrity of lamina dura and PDL space
- Bone loss in the area of periapex
- Radiolucency in the periapical area
  Figure 7.14 shows a radiograph showing
deep caries lesion in the crown and periapical
radiolucency in relation to the mesial root of
mandibular first molar
– To view pathological conditions like:
- Fracture of roots
- Resorption -  Internal
-  External
Fig. 7.13  Radiograph showing deep occlusal caries in mandibular
first molar approaching the pulp
Fig. 7.14  Radiograph showing deep carious lesion in the crown and
periapical radiolucency in relation to mesial root of mandibular first
molar
– Normal radiolucent and radiopaque anatomic
landmarks: that lie in close proximity, which should
be distinguished from pathological lesions.
– Periodontal considerations
– A good preoperative IOPA gives an idea about the
orientation and depth of angulation of handpiece
for access opening. A grid can be used to obtain near
about exact measurements.
• Bitewing radiographs can be used as a supplemental
film to determine:
– Anatomic extent of pulp chamber
– Interproximal caries
– Recurrent caries
– Pulp stones
– Calcifications
– Depth of existing restoration
– Crestal height of bone
  It is useful when very young children are being
examined.
  Bitewing view shows the involvement of nasal
cavity, maxillary sinus, floor of mouth, etc.
  Diagnostic radiographs must be best radiographs
as possible. Two to three radiographs with 10–20°
change in horizontal angulation change can provide
lots of information which can be missed otherwise.
Therapeutic Uses
For treatment radiographs, technique is even more critical.
With rubber dam in place, visibility is reduced,
sometimes it may be difficult to expose working radiographs.
During Endodontic treatment, radiographs are useful
for:
• For determination of working length (Fig. 7.15)
• Examining the position of an instrument within the root
to localize hard-to-find and negotiate root canals
• To determine position and adaptation of master cone
• To evaluate obturation
• During root end surgery, to localize the apex and
following root end surgery, to confirm before suturing
that all tooth fragments and excess filling material have
been removed.
Prognostic Uses
• To evaluate the outcome of treatment:
– Success: Radiographic evidence of resolution of
lesion and re-establishment of normal periapical
structures.
– Failure: Persistence or emergence of radiographic
signs of disease.

Fig. 7.15  Radiograph taken with no. 15 k-files in the four root
canals of maxillary first molar tooth for estimation of working length
(Courtesy of Dr Shivani Bhatt)
• Resolution and healing of pretreatment periapical lesion
is determined. (Refer figures 8.2 A to D, that shows
portion of panoramic image in which periapical lesion/
radiolucency has resolved after Endodontic treatment)
• Any new lesion developed in the periapical area, after
the treatment can be detected (Recurrent or de novo
infection).
REQUIREMENTS OF A GOOD RADIOGRAPH
• For Endodontic purposes, radiograph should depict the
tooth in the center of the film. Center of the film contains
least amount of distortion.
• At least 3 mm of bone must be visible beyond the apex
of tooth.
• Image on film must be as anatomically correct as
possible.
• Radiograph should be accurate with no elongation or
foreshortening.
LIMITATIONS OR DRAWBACKS OF
RADIOGRAPHS
• Radiographs provide two-dimensional image of three-
dimensional object. Additional radiographs at different
angulations have to be taken to obtain the desired
information.
• Radiograph is only an adjunctive tool and can be
misleading. Radiographs alone cannot be used for
diagnosis. Radiograph alone can lead to misinterpretation
Diagnosis and Diagnostic Aids in Endodontics 111
of normality and pathosis if not coupled with proper
history and clinical examination and testing.
• Radiographic appearance of Endodontic pathosis can
sometimes be subjective.
• Lesions of medullary bone often go undetected unless
there is marked resorption or until the resorption has
eroded a portion of the cortical plate.
• There is risk of receiving small doses of ionizing radiation
if techniques and necessary precautions are not properly
executed.
• Improper technique resulting in errors, having to retake
or repeat the radiographs increasing further exposure.
• Superimposition of anatomic structures.
• Distortion due to improper chemical processing with
conventional radiography procedures.
• Various pulpal pathologies may be indistinguishable on
radiographs.
• Periradicular soft tissue lesions cannot be accurately
diagnosed by radiographs, they require histologic
verification. For example, chronic inflammatory tissue
cannot be differentiated from healed, fibrous, scar tissue.
RADIATION SAFETY
ALARA principle: As Low As Reasonably Achievable.
As per this principle, ‘No matter how small the radiation
dose, there still may be some deleterious effects’.
It is best to keep the ionizing radiation to a minimum
for protection of both the patient and the dental staff.
112 Short Textbook of Endodontics

Principles of ALARA

Clinical Aspect

• Use of protective lead aprons and thyroid collars.

• When exposing films, clinician should stand behind a
barrier or atleast 6 feet away from the patient and in an
area that lies between 90o and 135o to the beam.
• Film badges for recording exposure can be worn by all
dental personnel who might be exposed to occupational
X-radiation.
• Use of meticulous radiographic technique to reduce the
number of retakes and exposures.

Technical Aspect
• Select fast (i.e. sensitive) speed film, either Ultraspeed
(U) or E.
• Use dental units with 70 kvp or higher kilovoltage
since lower kvp causes increased patient’s skin dose.
Optimally 90 kvp should be used.
• Units operating at 70 kvp must have filtration equivalent
of 2.5 mm of aluminum to eliminate the low-energy
X-rays before patient absorbs them.
• Collimation with lead diaphragm restricts the X-ray
beam size so that it does not exceed 2.75 inches (7 cm)
at the patient’s skin surface.
• Open-ended, circular, or rectangular lead-lined
cylinders are called position-indicating devices (PIDs)
are recommended as they direct the beam to target and
collimate the X-ray beam reducing patient exposure.
PIDs should be at least 12–16 inches long. Pointed cones
should not be used as they produce increased amount
of scatter radiation.
It should be understood that digital detectors are
much more sensitive to radiation as compared to
conventional direct exposure emulsion X-ray films.
So, digital detectors require lower radiation exposure.
With digital radiography there is 50–90% reduction
in exposure as compared to conventional film-based
radiography.
Thus, digital radiography plays an important role in
radiation safety.
Conventional Radiography
• Requires use of conventional standard films and
processing chemicals.
• Requires dark room procedures for processing of
radiographs.
• Increased radiation exposure.
• Perfectly exposed and perfectly processed radiograph
is required for it to have good diagnostic quality.
Proper dark room organization, film handling and
adherence to time and temperature method of film
processing play an important role in producing good
images.
Xeroradiography
• Xeroradiograph can be exposed by conventional
X-ray machine using less than usual radiation. It
is automatically processed and delivered as a dry,
laminated permanent film in 25 seconds.
• Xeroradiography produces images of sharper clarity and
finer detail.
 Diagnosis and Diagnostic Aids in Endodontics 113

Digital Radiography Radiography (RVG)

Dr Francis Mouyen, a French Dentist, developed a prototype

digital radiographic system that he named Radiovisiography
(RVG). Since 1989, there have been seven newer generations
of RVG.
• Digital radiography uses no X-ray film and requires
no chemical processing. It uses a sensor to capture the
image created by the radiation source.
• The sensor is either directly or remotely attached to a
local computer.
• The computer interprets the signal and using a
specialized software translates the signal into a
digital image that is displayed on the monitor almost
instantly.
• The image can be enhanced, magnified/zoomed,
colored, contrast adjusted, etc. in order to visualize it
better or as a tool for patient education.
• The image is stored in the patient’s file, in a dedicated
network server and can be recalled whenever needed.

Digital imaging systems require:

• An electronic sensor or detector
• An analog-to-digital converter
• A computer
• Monitor
• Printer

Figure 7.16 shows the photograph of the monitor and

the electronic sensor for digital radiography.
Figure 7.17 shows the mandibular posterior region
radiograph taken using digital radiography.

Digital Subtraction Radiography

• This technique is based on the fact that:
‘Given radiographs taken in precisely the same position
and with the same beam geometry and exposure
parameters, images can be subtracted to show changes
over time’.
114 Short Textbook of Endodontics

Fig. 7.16  Photograph showing the monitor and the electronic sensor for digital radiography

• Images can be manipulated for the purpose of

enhancement, contrast, etc. for viewing it better. They
can also be colorized for patient education.
• Images can be duplicated any number of time without
any loss of image quality.
• Digital systems provide certain measurement tools that
can accurately measure, for example, root canal working
length.
• Multiple exposures, from various angles, both horizontal
and vertical, may be made without moving the sensor
once positioned.

Disadvantages of Digital Imaging System

• High initial cost
• Difficulty in placing the sensor as most of the solid state
Fig. 7.17  Radiograph of mandibular posterior region taken using detectors are somewhat thicker and more rigid
digital radiography (RVG)
• Potential for reduction in image quality when compared
with conventional radiography
• Mishandling can cause mechanical damage with high
• It detects changes in radiographic density over time. replacement costs for CCD and CMOS detectors.
• It can evaluate osseous healing after treatment.
• All anatomic structures that have not changed between
radiographic examinations are subtracted. So, the
changes in diagnostic information become easier to
interpret.

Advantages of Digital Radiography Over

Conventional Radiography
• Radiographic images are obtained instantly.
• Radiation exposure is reduced from 50% to 90%
compared with conventional film-based radiography.
• Elimination of radiographic film and processing
chemicals and hence elimination of errors associated
with them.
• Image enhancement, storage, retrieval and even
transmission of images to remote sites in digital format.

Paralleling Technique
• Also called long cone or right angle technique.
• Film is placed parallel to long-axis of teeth and the
central beam is directed at right angles to the film and
aligned through root apex.
• Parallel placement of film is difficult due to variations
in size and shape of oral structures (shallow palatal
vault, tori, long roots, shallow floor of mouth, etc.).
To compensate for difficult placement, film can be
positioned so that it diverges as much as 20˚ from long-
axis of tooth.
Modified Paralleling Technique
• This technique increases vertical angulation by 10˚–20˚.
• This orientation causes a small degree of foreshortening
but clear periradicular radiograph of maxillary posterior
region can be obtained.
• Also, a distal angulated radiograph 10o–20o distal shift of
cone from the distal with beam directed towards mesial,
projects the buccal roots and the zygomatic process to
the mesial, thus increasing clarity.
Bisecting Angle Technique
• Film is placed directly against the teeth without
deforming the film and the central beam is directed
perpendicular to an imaginary line that bisects the angle
between the tooth and the film.
• Generally the projected length of the tooth is same
as the actual length of the tooth in this technique but
the resultant image has the potential for distortion,
superimposition, etc.
• It is used only when modified paralleling technique
cannot be used.
FILM HOLDERS
To ensure film placement and parallelism, Film Holders
can be used. Figure 7.18 shows photograph of film holder.
Finger retention of the film is generally not recommen­
ded.
A straight hemostat is a good film holder and additionally
it aids in cone positioning as well.
Cone Angulation
Vertical Angulation
The cone is aligned so that the beam strikes the film at right
angle.
Diagnosis and Diagnostic Aids in Endodontics 115
Fig. 7.18  Photograph showing film holder
(Courtesy of Dr Ritesh Mahashabde)
If the angle of the film in relation to long-axis of teeth is
no greater than 20o and the beam is directed at right angle
to the film, no distortion occurs, although reduced definition
of few structures may occur.
But the resulting radiograph is considered adequate.
Horizontal Angulation
In Endodontic therapy, a technique to vary the horizontal
angulation of the central ray of X-ray beam can be used to
visualize the ‘third’ dimension (i.e. ‘Spatial’ or buccolingual
relation of an object). This technique has various names:
Buccal Object Rule/Cone Shift Technique/Clark’s Rule/Slob
Rule.
Application of Clark’s Rule helps:
• To locate additional canals or roots
• To distinguish between objects that have been
superimposed
• To locate foreign bodies
• To determine buccolingual position of fractures
• To locate anatomic landmarks in relation to root apex.
Clark’s rule states that:
“The most distant object from the cone (lingual) moves
towards the direction of the cone”.
It is called as SLOB rule (Fig. 7.19)
Same Lingual Opposite Buccal (SLOB rule)
The object that moves in the same direction as the cone is
located toward the ‘Lingual’. The object that moves in the
Opposite direction from the cone is located towards the
‘Buccal’.
116 Short Textbook of Endodontics
Fig. 7.19  Schematic representation of the SLOB rule: Same Lingual
Opposite Buccal (1) Mesial angulation (2) Perpendicular to tooth (3)
Distal angulation (Courtesy of Dr Vishal Rathod)
Knowing the direction from which a radiograph was
taken, mesial, straight on or distal, one can determine
‘Buccal’ and ‘Lingual’.
Clark rule also applies to changes in vertical angulation.
When the location of mandibular canal in relation to
the root apices is to be determined, radiographs should be
taken at different vertical angulations.
If the canal moves with or in the same direction as the
cone, the canal is Lingual to root apices.
If the canal moves opposite the direction of cone head,
the canal is Buccal to root apices.
Ingle’s Rule is ‘MBD’, which states that
‘Always shoot from the Mesial and the Buccal root will
be Distal.
RADIOGRAPHIC INTERPRETATION
IN ENDODONTICS
Radiograph should be carefully examined with an eye
towards diagnosis and treatment. It is worth spending
some time thoroughly reading the radiographic film and
interpreting it.
Film placement and cone angulation for individual teeth for
Endodontic purposes
Teeth Specific requirements
1. Maxillary Straight facial cone angle is preferred
anterior teeth
2. Maxillary Mesial cone angulation is preferred. The right-angle
premolars horizontal projection produces single canal image
in case of maxillary 1st premolar. By varying the
angulation by 20o (Walton projection) the two canals
are separated
3. Maxillary Mesial cone angulation is preferred. Standard right
molars angle projection of maxillary 1st molar shows
superimposition of roots with sinus floor, zygomatic
process and overlap of roots. To view the roots
clearly, horizontal angulation can be varied
• With horizontal angulation 20o to the mesial,
distobuccal root is cleared of the palatal root and
the zygomatic process is ‘moved’ to distal of 1st
molar
• With horizontal angulation 20o to the distal,
mesiobuccal root is isolated
4. Mandibular • Distal horizontal angulation is preferred
incisors • Separate canals in mandibular incisors can be
viewed by varying the horizontal angulation
5. Mandibular • Mesial horizontal angulation is preferred
canines
6. Mandibular • Mesial horizontal angulation is preferred
premolars • 20o mesial angulation will show separate canals if
present or any bifurcation of canals
7. Mandibular • Distal horizontal angulation is preferred.
molars • With standard perpendicular X-ray projection,
the mesial or distal canals are superimposed
appearing as single.
• Walton projection causes roots to open up
• 20o–30o mesial angulation separates the two
canals in each root.
Now that the four canals are seen on the
radiograph, buccal canals can be distinguished
from lingual canals by applying Ingle’s rule of ‘MBD’!
Buccal canals are towards the distal and lingual
canals are towards the mesial.
Systematic evaluation of each and every structure seen,
should be done as follows:
Crown of Tooth
Caries
• Extent of caries in relation to pulp is determined.
• Depth of proximal caries is more than what is seen on
the radiograph.
• Caries located on buccal or lingual aspect sometimes
may give the false impression of pulpal involvement.

Pulp Chamber
• Size of pulp chamber is observed.
• Abnormal pulp calcification in response to caries or
trauma may be seen.
• Calcification may be diffuse or localized.
• Sometimes, pulp chamber may appear to be obliterated.
• Small areas of resorption, invaginated enamel, dens
in dente, etc. these findings sometimes may be
overlooked.
Root
Pulp Canal/Root Canal
• Number of canals, additional roots and canals,
accessory, lateral canals should be looked for, while
interpreting the radiograph for Endodontic diagnosis
and treatment.
Two or more radiographs at different angulations can
be viewed and compared and then the findings can be
interpreted.
• Shape of the canals, curvatures should be noted.
• Degenerative localized or diffuse calcifications in the
radicular pulp.
• Pulp obliteration.
Root Fracture
Fracture of root may not be evident on radiograph but may
result in reparative processes that become recognizable in
later radiographs.
Root Resorption: External or Internal
Internal resorption causes replacement of dentin by a soft
tissue with resorbing cells. This may result in a balloon-
shaped lesion starting from the radicular pulp seen as round
or ovoid radiolucent area observed on the radiograph.
Internal pulp wall appears to be destroyed whereas
cementum and periodontium seem to be unaffected in
initial cases of internal resorption.
Periapical Area
Integrity of Lamina Dura
Determining the integrity of lamina dura has a diagnostic
value when recent radiograph can be compared with
previous one.
Also, integrity or lack of integrity of lamina dura in
relation to health of the pulp is to be determined.
Diagnosis and Diagnostic Aids in Endodontics 117
Periodontal Ligament Space
Resorption of apical lamina dura and widening of PDL space
may occur as an early or limited response to infection in
root canal system or may be due to increased tooth mobility
occurring as a result of orthodontic movement, periodontal
disease or parafunctional habits.
Alveolar Bone
• Density of bone in periapical area: Increased density of
bone in response to infection may be seen in periapical
area referred to as condensing osteitis.
• Bone loss: Around the roots should be noted.
Periapical Pathology
Periapical granuloma, cyst, abscess may be evident on the
radiograph.
Anatomic Structures
Sometimes normal anatomic structures may be misinter­
preted as pathoses. For example, mental foramen, incisive
foramen will appear as radiolucencies in the periradicular
area. They can be differentiated from pathologic conditions
by exposures at different angulations and by pulp-testing
procedures. Other anatomic radiolucencies include:
Maxillary sinus, nutrient canals, nasal fossa, submandibular
fossa, etc.
Differential Diagnosis Based on Radiographic
Findings can be Interpreted
Based on radiographic evaluation, following conditions may
be suspected or diagnosed (As given in Ingle):
• Hypercementosis: Cementum deposition around the
roots clearly seen on radiographs. It may occur in
response to pulpal inflammation without infection in
apical part of canal.
– Pulpitis would require Endodontic treatment.
– Hypercementosis persists even after Endodontic
treatment.
• Condensing apical osteitis: It represents altered bone
structure associated with chronic pulpitis and resolves
following adequate therapy.
• Idiopathic osteosclerosis: It may be closely located to
apex of a vital tooth.
– Does not require Endodontic treatment.
• Marginal periodontitis: Its radiographic features are
similar to apical periodontitis. If it is associated with
118 Short Textbook of Endodontics
necrotic and infected pulp, combined Endodontic-
periodontal treatment is recommended.
• Root fractures: It may be seen as a variant of apical
periodontitis. When pulp canal space and the fracture
slit are infected, it results in periodontitis, where the
fracture communicates with periodontal space.
In vertical root fracture (VRF), the whole length of root
may be affected, producing a diffuse halo of radiolucent
bone around the root.
• Osteomyelitis: Sequestration of bone and apparently
normal bone structures are seen between areas of bone
destruction.
• Inflammatory paradental cyst: A rare entity, occurring
exclusively in mandibular molar area.
• Lateral periodontal cyst: A developmental cyst occurring
in premolar area of mandible and sometimes in maxilla.
It may be mistaken for apical periodontitis.
• Nonodontogenic incisive canal developmental cyst:
Located centrally between maxillary incisors and may
be mistaken for apical periodontitis if projected over the
apex.
• Simple bone cyst: Traumatic bone cyst.
• Osseous/cemental dysplasia: Occurring in lower
anterior region. Teeth are vital, there are no clinical
symptoms. Radiographically can mimic chronic apical
periodontitis.
• Giant cell granuloma: Large multilocular, radiolucent
area.
• Hyperparathyroidism.
• Odontogenic keratocyst.
• Benign or malignant tumors of jaw.
A mind-map to remember all points of RADIOGRAPHS
is given in Figure 7.20.
Advanced Multiplanar Imaging: Cone Beam
Computed Tomography (CBCT) for Endodontics
It is digital advanced imaging that helps to obtain an image of
virtually any plane through a structure that greatly improves
diagnostic information of its 3-dimensional morphology. It
involves section imaging. Axial, coronal and sagittal sections
can be obtained with less patient exposure as compared to
conventional CT scans. Cone beam computed tomography
(CBCT) is a compact, faster and safer version of regular CT.
The buccolingual dimension which cannot be appreciated
on radiographs can be clearly visualized on CBCT images.
Applications of CBCT in Endodontics include:
• Localization of canals (Fig. 7.21)
• Assessment of root fractures (Figs 7.22A to C)
• Evaluate the angulation of root (Fig. 7.23) and root
resorption (Figs 7.24 and 7.25)
• Periradicular pathologies in all planes can be
evaluated. Example periapical or radicular cyst (Figs
7.26A and B).
STEP 3: DIAGNOSTIC TESTS
Goals of Diagnostic Tests
Ingle has stated 2 goals of diagnostic tests (Fig. 7.27).
Diagnostic tests are important adjunctive tools in the
decision-making process that leads to both pulpal and
periapical diagnoses. Do not rely on a single diagnostic test
result. If at least one more test gives similar findings, then
the appropriate treatment is recommended.
Various Pulp Tests
Pulp tests determine the pathological status of pulp.
Specific Pulp Tests
• Thermal tests:
– These tests identify the presence of pulp nerve
tissue that is capable of responding to a change in
temperature.
– They may provide information that suggests whether
the pulp is reversibly or irreversibly inflamed or
necrotic.
– The preferred temperature for heat test is 65.5oC
(150oF).
– It is important to isolate individual tooth with rubber
dam while performing thermal tests to prevent any
false positive results from the adjacent teeth.
– Abnormal response to thermal tests is elicited as:
- Lack of response to stimulus-Lingering or
intensified pain sensation after removal of the
stimulus
- Immediate, excruciating painful sensation as
soon as the stimulus is placed upon the tooth.
Figure 7.28 shows heat test being performed using
guttapercha stick.
 Diagnosis and Diagnostic Aids in Endodontics 119

Fig. 7.20  A mind-map to remember all points of radiographs

120 Short Textbook of Endodontics

Fig. 7.21  CBCT image showing MB2 canal in a maxillary first molar Fig. 7.23  CBCT image of a tooth with dilaceration. (Courtesy of Dr
tooth. (Courtesy of Dr Mansi Shah, Dentoview: Advanced Dental Mansi Shah, Dentoview: Advanced Dental Imaging Center)
Imaging Center)

A B C
Figs 7.22A to C  CBCT images showing horizontal root fracture of palatal root of maxillary second premolar tooth.
(Courtesy of Dr Mansi Shah, Dentoview: Advanced Dental Imaging Center)

A B
Fig. 7.24  CBCT image showing blunting of apex caused due to Figs 7.25A and B  CBCT image showing internal resorption in a
external root resorption. (Courtesy of Dr Mansi Shah, Dentoview: tooth. (Courtesy of Dr Mansi Shah, Dentoview: Advanced Dental
Advanced Dental Imaging Center) Imaging Center)
 Diagnosis and Diagnostic Aids in Endodontics 121

A B
Figs 7.26A and B  CBCT image of a radicular cyst. (Courtesy of Dr
Mansi Shah, Dentoview: Advanced Dental Imaging Center)

– False negative response to heat test (pulp vital but

Fig. 7.27  Goals of diagnostic tests
• Electric tests
no response) in cases of:
- Recent trauma cases
- Newly erupted teeth with immature apex due to
incompletely developed Rashkow’s plexus)
- Calcification present in the tooth
– False positive response to heat test (pulp nonvital
but positive response) in cases of:
- Partially necrotic tooth with some vital tissue
present
- Inadequately dried tooth may give false-vital
response
- Or when there is contact with metal restorations
causing conduction of current to periodontium.

Purpose: It is a test for assessment of pulp vitality by gauging

the ability of nerves in the pulp to respond to electric
stimulation.

Response and Test Result

Patient may feel a ‘warm’, ‘tingling’, ‘burning’ or pain
sensation. This response is due to A-Delta nociceptors
in pulp that do not transmit electric, thermal, touch or
proprioceptive sensations to CNS, but only pain.
Fig. 7.28  Photograph showing heat test being performed using A positive response indicates vitality of pulp.
heated gutta-percha stick (Courtesy of Dr CR Suvarna) No response indicates nonvital pulp or necrosis of pulp.
122 Short Textbook of Endodontics
Procedure
• Teeth to be evaluated are isolated and dried.
• A control tooth (contralateral vital tooth) should be
tested first in order to establish a baseline response and
to help the patient know what a “normal” sensation is.
• Dry contact with the tooth does not evoke a response.
The tooth should be coated with a conductive medium
to transmit current such as petroleum jelly, water-based
jelly, toothpaste or prophylactic paste.
• Optimal placement of probe tip is on the occlusal 2/3rd
of labial or buccal surfaces of teeth or the incisal edges.
• Once the probe tip is in contact with the tooth, the
patient is asked to place the finger lightly on the metal
part of the probe to complete the circuit and initiates
the delivery of electric current to the tooth.
• Patient is instructed to remove his/her finger from the
probe handle when a warm, tingling sensation is felt.
• The suspected tooth should be tested at least twice to
confirm the results.
• In case of complete coverage crown, a small metal
Endodontic instrument such as files or explorers can
be used as bridging instrument, with the tip coated with
contact medium and placed on enamel or dentin of the
tooth being evaluated. The probe tip is then placed on
the metal of the bridging instrument.
Figure 7.29 shows electric pulp test being performed
using electric pulp tester.
Limitations
• The response to electric pulp testing (EPT) does not
reflect the histological health or disease status of the
Fig. 7.29  Electric pulp test being performed using electric pulp
tester (Courtesy of Dr CR Suvarna)
pulp. It only denotes that some viable nerve fibers are
present in the pulp that are capable of responding.
• The use of electric pulp tester in a patient with cardiac
pacemaker can interfere with its function. So it is contra-
indicated in such patients.
• It may cause some anxiety in the patient knowing the
instrument passes an electric current through their
teeth.
• False-positive responses can also occur just as in thermal
tests in adjacent teeth especially those with contacting
metal fillings.
• This test is not reliable in younger teeth with immature
apices or in teeth following a traumatic injury.
• It relies on subjective response by the patient and only
measures the neurological status of pulp, not the vitality
in true sense.
Cohen has given the following accuracy rate results of pulp
tests:
Cold test → 86%
Electric test → 81%
Heat test → 71%
These usual pulp tests provide information only about
the presence or absence of nerve receptors in the pulp and
not about the pulpal blood supply.
Methods to assess pulpal circulation: Assessment of pulpal
circulation is more accurate determinant of pulp vitality as
compared to thermal tests because it uses methods that are
objective tests that help to differentiate between vital and
necrotic pulp.
Pulpal circulation can be assessed with the following
methods:
• Laser Doppler flowmetry
• Pulse oximetry
• Transmitted light-Photoplethysmography
• Infrared thermography
Laser Doppler Flowmetry and Pulse Oximetry are
explained here.
Laser Doppler Flowmetry
It is a method used to assess blood flow in microvascular
system.
Doppler principle: This technology uses a beam of infrared
(780 to 820 nm) or near infrared (632.8 nm) light, directed
into the tissue by optical fibers. As light enters tissue, it is
scattered by stationary tissue cells and moving red blood
cells.

According to the Doppler principle (Law of Light
Frequency Shift)
• The light beam will be frequency-shifted by moving red
blood cells.
• The light beam will remain unshifted as it passes through
the static tissue.
This average Doppler frequency shift will measure the
velocity at which the red blood cells are moving.
Application of Laser Doppler Flowmetry (LDF)
in Dentistry
Laser Doppler Flowmetry can be used to assess pulpal
blood flow.
The initial use of LDF was exclusively for direct soft tissue
blood flow measurements. But for dental situations, there
is interference of hard tissues like dentin and enamel.
If it is properly conducted:
• It is found to be an accurate, reliable and reproducible
method to assess pulpal blood flow and check vitality
of tooth pulp.
• It has been shown to work in primary incisors as well
• It is very useful in cases of dental trauma
• It can identify “at risk” teeth early after the trauma
• In case of avulsion, it can detect revascularization after
a few weeks and well in advance of other traditional
clinical tests.
Requirements
To ensure consistent and accurate reading,
• The Laser Doppler flowmetry (light) probe tip should
be placed on the same part of the crown. This requires
a custom-made stabilizing stent that can be made easily
out of rubber base impression material.
• Prior to placing the stent, the gingiva should be covered
with a dark dental dam or aluminum foil.
• Patient should be on similar position in the dental chair
each time while the recording is done.
Drawbacks
• Initial high set-up cost
• Accurate and consistent reading of LDF assessment
requires certain critical steps to be taken
• May not be feasible for routine dental practice.
• Cannot be used if the tooth to be tested cannot be
stabilized.
Pulse Oximetry
It is a noninvasive and objective way to record the oxygen
saturation of blood and pulse rate.
Diagnosis and Diagnostic Aids in Endodontics 123
Principle: It employs a light source probe that emits
simultaneously two light beams:
1. One transmits red light (640 nm)
2. Other transmits infrared light (940 nm)
• The light passes through the tissue of interest
• A photodetector is placed on the opposite side
of the light source to capture whatever light gets
through
• Oxygenated hemoglobin and deoxygenated
hemoglobin absorb different amounts of red and
infrared light.
The machine calculates the difference between the light
emitted and the light received to provide the pulse rate and
oxygen concentration in blood.
Application in Dentistry
Pulse oximetry has been tested and suggested to assess pulp
vitality with mixed results. Some studies have found pulse
oximetry test to have high accuracy rate while other studies
showed that it does not have predictive diagnostic value for
diagnosing pulp vitality.
The technology uses devices that are too cumbersome
and complicated, hence, not feasible for routine dental
practice.
SPECIAL TESTS
Bite Test
• When a patient presents with pain while biting and
is unable to identify which tooth is sensitive to biting
pressure, bite test may help to localize the tooth involved.
• Causes of pain while biting:
• Devices used for bite test: Cotton applicators, toothpicks,
orangewood sticks, rubber polishing wheels.
Tooth slooth is specifically designed to perform bite test.
Figure 7.30 show bite test using cotton roll. Figures 7.31
and 7.32 show tooth slooth for bite test.
124 Short Textbook of Endodontics

Procedure

• The small cupped-out area on the device is placed in

contact with the cusp to be tested.
• The patient is asked to slowly but firmly apply biting
pressure with opposing teeth to the flat surface on the
opposite side of the device until full closure is achieved.
• After a few seconds, patient is then asked to release the
pressure very quickly. Each individual cusp on a tooth
is tested in this manner.
• The clinician notes whether the pain is elicited.
– During pressure phase or
– Upon quick release of pressure
Pain upon release of biting pressure frequently indicates
fractured cusp or cracked tooth.
Fig. 7.30  Bite test using cotton roll
(Courtesy of Mr Amar, Dr Dabholkar’s clinic)
Staining and Transillumination

• A small amount of dye is coated onto the crown/root

with a small cotton pellet.
  Figures 7.33 and 7.34 show caries detector dye and
Fig. 7.31  Tooth slooth (Courtesy of Dr CR Suvarna)
staining test respectively.
• Remaining dye on the surface is washed away or
removed with a moist application of 70% isopropyl
alcohol.
If fracture or crack is present, dye remains in that crack
line and can be observed through magnifying loupes or
dental operating microscope.

Transillumination
• Applications:
– To determine the presence of a crown or root
fracture
– Detection of caries, calculus and soft tissue lesions
– Aid in determination of pulp vitality
• Devices used:
– Specifically designed fiberoptic lights
– High speed handpiece with fiberoptic activated or
Fig. 7.32  Bite test being performed with tooth slooth in place. Tooth other bright point light sources.
slooth should make contact with the cusp tips (Courtesy of Dr CR Figure 7.35 show the fiberoptic light source for
Suvarna) transillumination test as demonstrated in Figure 7.36.
 Diagnosis and Diagnostic Aids in Endodontics 125

• Procedure: The dental unit light should be turned off and

only the fiberoptic light used.

Fig. 7.34  Staining test being performed on mandibular first molar

(Courtesy of Dr CR Suvarna)

Anesthetic Test
• When other diagnostic tests have been inconclusive,
then selective anesthesia may be helpful to locate the
offending tooth or the arch and to derive the appropriate
diagnosis.
• Administration of the local anesthesia could be by
infiltration, block or intraosseous injection.
• When the patient is unable to determine which arch Fig. 7.35  The fiberoptic light source for transillumination test
(Courtesy of Dr CR Suvarna)
the pain is coming from then a periodontal ligament

Fig. 7.33  Caries detector dye (Courtesy of Dr CR Suvarna) Fig. 7.36  Demonstrating transillumination test
(Courtesy of Dr CR Suvarna)
126 Short Textbook of Endodontics
injection (Intraligamentary) can be administered
starting from the most posterior tooth in the quadrant,
one tooth at a time, until the pain is eliminated.
This is done first in the maxillary arch. If after
appropriate period of time, the pain does not get
eliminated, the technique is repeated for the mandibular
teeth.
• When a patient reports vague location of pain such as
discomfort over entire left cheek, and associated hard
and soft tissues, if a diagnostic left inferior alveolar block
remits the pain, the pathosis can be attributed within the
distribution of inferior alveolar nerve and its branches.
If the pain does not remit, and remains constant,
then cardiac pain or pain from myocardial infarct can be
suspected which might have referred to the left mandible
and mimics pain of dental or orofacial origin.
• If the patient is unable to locate an individual tooth
or arch, but the clinician feels that pain may be from
posterior maxillary quadrant, infiltration anesthetic test
may be used for each tooth starting from most posterior
tooth. If the pain remits, the source of pain is identified
but if the pain does not remit, the clinician may suspect
the pain source to be in mandibular arch and now
administer mandibular block with an assurance that
pain should abate. If the pain still remains, the clinician
can conclude that the pain is not of Endodontic origin
and do further evaluation.
Tracing of Intraoral Sinus Tract
An infection from a tooth draining through an intraoral
communication to the gingival surface is known as ‘sinus
tract’. When it becomes lined with epithelium, it is termed
as ‘fistula’.
Sinus tract facilitates drainage of infectious exudates, as
a result, a periapical infection with an associated sinus tract
is not generally painful.
Sinus tract can be a useful objective diagnostic aid to
trace the origin of infection. This test is done with a fine
Guttapercha point. The GP cone is inserted through the
opening of the sinus tract until the resistance is felt.
Then an intraoral periapical radiograph is exposed.
The radiograph is viewed to determine the path taken
by Guttapercha cone and the point of termination of
sinus tract. This helps to locate the offending tooth and
specifically the offending root (Refer to figures 5.9 and 5.10
for the photograph and radiograph respectively of tracing
of intraoral sinus tract).
Once the etiology of sinus tract is eliminated, the sinus
tract closes within a few days.
Test Cavity
• Test cavity method allows one to determine pulp vitality.
But is seldom used today.
• It is performed only when other diagnostic tests have
been inconclusive and the clinician has a high level of
suspicion that the pulp is necrotic.
• Patient is informed about the exact procedure and the
reason why it is being done.
• Patient is not anesthesized during this procedure.
• This test involves use of #1 or # 2 round bur at high speed
with proper air and water coolant for drilling in the tooth
to remove enamel and about half of the total thickness
of dentin.
If sensitivity is experienced beyond the dentino­
enamel junction, it signifies that there is some viable
tissue remaining in the pulp, not that the pulp is totally
healthy. The procedure is terminated and the tooth is
restored.
If there is absolutely no pain or sensation during
cavity preparation, until the pulp chamber is reached,
it is a good indication that the pulp is necrotic and root
canal treatment is indicated.
• Reliability of this test is questionable as:
– A tooth with calcification causing pulpal obliteration
may not give clear results
– Gangrenous or inflammed pulp can give false results.
Other Tests
• Ultraviolet light: It can be used to determine the pulp
vitality.
When exposed to UV light, the teeth with necrotic
pulps and teeth with Endodontic treatment did not
fluoresce.
When exposed to UV light, the teeth with vital pulps
fluoresce normally (The property of the objects to emit
light of higher wavelength when illuminated with
ultraviolet (UV) light is called fluorescence).
UV light can be harmful to eyes. So the patient and
the staff should wear protective eyewear (goggles).
To view the color changes in the tooth clearly, the
operating light needs to be suppressed.
• Measurement of tooth surface temperature:
– Measurement of crown surface temperature may
determine whether vital tissue or necrotic tissue fills
the pulp chamber.
– Cholesteric liquid crystals at a temperature of 30–40oC
range are used for this purpose.
– When applied to the tooth surface the crystals
undergo color changes that are compared with
adjacent or contralateral teeth.
 Diagnosis and Diagnostic Aids in Endodontics 127

PULPAL DIAGNOSIS
Simplified chart that will direct your thinking process to correct clinical diagnosis
Clinical • No spontaneous • Presence of caries, • Sometimes deep caries • Asymptomatic • Symptoms of pain
subjective symptoms exposed dentin, but asymptomatic • No response to electric (spontaneous)
and objective • Respond to pulp recent dental • Intermittent or pulp tests or to cold • No response to
findings tests treatment, defective spontaneous pain stimulation electric pulp tests or
• Symptoms/ restorations • Stimuli causing • May respond to heat cold tests
response to • Stimulation with temperature changes • Multirooted teeth: • May respond to heat
pulp tests are an irritant causes (Especially cold) elicit sometimes roots • Pain on percussion
mild that do not symptoms, but its heightened and may give confusing • Tooth may become
cause distress removal resolves prolonged episodes of symptoms, one root very hypersensitive
• Transient symptoms pain even after removal responds, other does to heat
sensation, of stimulus not
reverses in • Pain may be sharp, or • Tooth may become very
seconds dull, localized or referred hypersensitive to heat
Radiographic • No evidence of • No significant • Minimal changes in • Deep caries • Thickening of PDL
findings resorption, caries radiographic change radiographic appearance • Thickening of PDL space
or pulp exposure of periradicular bone • Pulpal involvement • Periapical radiolucent
• Calcification may • Thickening of PDL lesion
or may not be • Extensive canal
present calcification in response
to pulpal irritation
• Deep restorations, caries,
exposure may be evident
↓ ↓ ↓ ↓ ↓
Diagnosis Indicates normal Indicates reversible Indicates irreversible Partial or complete pulp Pulp necrosis with
pulp pulpitis pulpitis necrosis periapical lesion
Treatment plan No treatment • Requires palliative • Root canal treatment • Root canal treatment • Root canal treatment
treatment according
to cause
• Remove etiologic
factors
PERIAPICAL DIAGNOSIS
Clinical • Very painful • No clinical symptoms • Very painful to biting pressure, percussion • No clinical symptoms
response to • No response to pulp and palpation • No response to pulp vitality
biting pressure or vitality tests • Not respond to any pulp vitality tests tests
percussion • Tooth not sensitive to • Mobility of various degrees may be • Tooth not sensitive to
• May or may not biting pressure, but some present biting pressure but “feels
respond to pulp different sensation may • Swelling may be present in mucobuccal different” upon percussion
vitality tests be felt on percussion fold • Intermittent drainage
↓ ↓ • Febrile, lymph nodes may be tender on through an associated
palpation sinus tract
Radiographic • Widened PDL • Periradicular • Can exhibit anything from a widened PDL • Periradicular radiolucency
findings space but not radiolucency, usually space to a periradicular radiolucency present
periradicular around apical third of
radiolucency. root
↓ ↓ ↓ ↓
Diagnosis Acute periradicular/ Chronic periradicular/ Acute periradicular/apical abscess Chronic periradicular/apical
apical periodontitis apical periodontitis abscess (suppurative)
128 Short Textbook of Endodontics

Fig. 7.37  A mind-map to remember all points of diagnostic tests


– Thermistors are found to be consistent in recording
the surface temperatures of teeth with both vital and
necrotic pulps.
– Electronic thermography can determine the relative
differences in temperature in both superficial and
deep areas and it can be a useful adjunct to other
pulp diagnostic tests.
A mind map to remember all point of diagnostic
tests is given in Figure 7.37.
STEP 4: ARRIVING AT AN ACCURATE
ENDODONTIC DIAGNOSIS
After thorough questioning, examination and testing, the
various subjective, objective, clinical testing and radiographic
findings are considered for decision-making process to
arrive at an accurate diagnosis.
The clinical judgment for decision-making is influenced
by various factors such as:
• Knowledge and skills: Developed by education and
training.
• Clinical experience: With experience of various cases
over a period of time, clinician develops the judgment
to correlate various findings and come to a definite
conclusion in a short time.
• Updating information: Keeping abreast with the latest
trends in the field:
– by reading appropriate literature and
– Attending continuing education courses
Diagnosis and Diagnostic Aids in Endodontics 129
• Clinician’s attitude: Clinician must have the attitude of
considering each and every patient ‘important’ and give
his full attention and expertise in treatment.
Diagnosis
Some cases may be straight forward, where, the findings
clearly point towards the diagnosis. In few cases, a list of
differential diagnosis is made and then based on reasoning
and clinical judgment, a definitive diagnosis is derived by
exclusion.
Few cases may present a diagnostic challenge, where an
obvious dental etiology cannot be found. An existing medical
problem or a nonodontogenic cause should be  suspected
and looked for and appropriate referral be made to protect
the patient from unnecessary dental treatment.
The pulpal and periapical diagnosis is made based on the
findings and appropriate reasoning to determine whether
the case requires Endodontic treatment or not.
A simplified chart that directs your thinking towards an
accurate pulpal and periapical diagnosis to formulate the
necessary treatment plan is given on page number 127.
BIBLIOGRAPHY
1. Cohen S, Hargreaves KM. Pathways of Pulp, 9th edn. St. Louis: Mosby,
2006. pp.2-39.
2. Grossman L, Oliet S, Del Rio C. Endodontic Practice, 11th edn.
Varghese publication, 1991. pp.1-18.
3. Ingle J, Bakland L, Baumgartner J. Ingle’s Endodontics, 6th edn. BC
Decker Inc, Hamilton, 2008. pp.520-637.
 8
CHAPTER

Rationale of Endodontic
Therapy

This chapter tells you about the logic behind doing Endodontic therapy.
 You must know
• Which were the Proposed Theories of Spread of Infection that Developed into Modern
Philosophy of Endodontics?
• How do Dental Biologic Tissues React to Noxious Stimuli?
• Why is Inflammatory Response of Pulp Different from other Parts of Body?
• What Tissue Changes Occur during Inflammation?
• What Tissue Changes Occur following Inflammation?
• What is Role of Immunity in Endodontics?
• What are the Zones of Reaction of Periradicular Tissues and What are Endodontic
Implications?

WHICH WERE THE PROPOSED THEORIES OF
SPREAD OF INFECTION THAT DEVELOPED INTO
THE MODERN PHILOSOPHY OF ENDODONTICS?
Focal Infection Theory (FIT): An Obsolete
Concept Now
In 1891, WD Miller published a report, entitled as “Human
mouth as focus of infection”. He used Robert Koch’s postulates
to establish microbial etiology of infectious diseases. He
concluded that mouth was a focus of infection and that the
bacteria in mouth caused various systemic diseases.
In 1909, Dr William Hunter identified  oral sepsis as a
cause of systemic diseases. Later Billings described the
terms focus of infection and focal infection and the term
oral sepsis was replaced by focal infection.
A focus of infection is described as a confined area
that contains pathogenic microorganisms, that can occur
anywhere in the body and usually causes no clinical
manifestations.
A focal infection is a localized or generalized infection
caused by the dissemination of microorganisms or toxic
products from a focus of infection.
According to the Focal Infection Theory, the  focus of
infection is often unrecognized, while secondary infections
might occur at sites particularly susceptible to such
microbial species or toxins such as gallbladder, kidney, liver,
prostate; but most commonly oral tissues.
In 1920s, Dr Weston Price presented a research
suggesting that the bacteria entrapped in the dentinal
tubules during Endodontic treatment could leak and lead to
systemic diseases such as arthritis, diseases of kidney, heart,
nervous, gastrointestinal, endocrine and other systems.
Dr Price advocated tooth extraction over Endodontic
treatment. It resulted in era of tooth extraction both for
treatment of systemic disease and as a prophylactic measure
against future illness.
The Focal Infection Theory led to needless extraction of
millions of Endodontically treated teeth until well-designed
studies conducted during 1930s demonstrated that this
theory was not valid. Dr Price’s research techniques were
criticized as they lacked many aspects of modern scientific
research, including absence of proper control groups and
induction of excessive doses of bacteria.
In 1940, Reiman and Havens stated that the suggested
focal infection theory has not been proved. The infectious

agents involved were not known patients whose teeth or
tonsils were removed, often continue to suffer from the
original disease.
Mechanism of Focal Infection
Two generally accepted mechanisms in production of focal
infection (Shafer’s Textbook of Oral Pathology, 7th edn.
p.512):
1. Metastasis of microorganisms from an infected focus by
either hematogenous or lymphogenous spread.
2. Toxins or toxic products may be carried through the
bloodstream or lymphatic channels from a focus to a
distant site where they may result in a hypersensitive
reaction in the tissues.
Oral foci of infection: The theoretical sources of infection
that may set-up distant metastases include:
a. Teeth with infected root canals or infected periapical
lesions such as periapical granuloma, cysts or abscesses;
b. Transient bacteremia that is found to occur after tooth
extraction or after manipulation of gingiva related to
severity of periodontal disease.
HOW DO THE DENTAL BIOLOGIC TISSUES REACT
TO NOXIOUS STIMULI?
Various noxious stimuli that can affect the dental biologic
tissues (Bacterial, Physical, Chemical, etc.) and the reaction
of the dental pulp to these stimuli have been explained in
detail in Chapter 4 ‘The Pulpal Reactions to Caries and
Dental Procedures’.
Such stimuli can result in reversible or irreversible
changes in the pulp and the periradicular tissues as listed
in Flow chart 8.1.
The changes that occur in the pulp and the periradicular
tissues are mediated by a series of inflammatory and
immunological reactions in order to eliminate the irritant
and repair any damage, which will be explained in detail in
this chapter.
WHY IS THE INFLAMMATORY RESPONSE IN
CONNECTIVE TISSUE OF DENTAL PULP
DIFFERENT FROM OTHER PARTS OF BODY?
Pulpal inflammatory response is modified due to following
reasons:
• Pulp is encased within the hard tissues
• Pulp has limited space to expand during inflammation
• Pulp has limited portals of entry
Rationale of Endodontic Therapy 131
Flow chart 8.1  Reaction of dental biologic
tissues to noxious stimuli
• Pulp is an organ of terminal and limited circulation
• Pulp has no efficient collateral circulation.
WHAT ARE THE TISSUE CHANGES THAT
OCCUR DURING INFLAMMATION?
Inflammation: Basic Concepts
• Inflammation is local physiologic reaction of body to an
irritant or noxious stimulus.
• Object of Inflammation → to Remove the irritant
(R2) → to Repair damage to the
tissue
• Type of inflammation Predominant cells
– Acute and early stages PMN neutrophils
of inflammation
– Chronic inflammation Lymphocytes, plasma
cells, monocytes,
macrophages
• Cardinal symptoms of inflammation:
– Pain (dolor)
– Swelling (tumor)
– Redness (rubor)
– Heat (color)
– Disturbance of function (Functio lesea).
In an inflamed pulp, all these symptoms occur, but only
pain and disturbance of function are recognized clinically.
In case of acute inflammation of periradicular tissues, all
the cardinal symptoms may be recognized clinically.
132 Short Textbook of Endodontics
Inflammatory Cells
1. Polymorphonuclear neutrophils (PMNs):
– Present during acute or early stages of inflammation
– Function: To phagocytise bacteria and lyse fibrin and
cellular debris and engulfment of antigen-antibody
complexes and nonmicrobial material.
– PMNs are attracted to the area of inflammation by
chemotactic factors produced by bacteria or by
complement.
– They are the first cells to migrate from the vessels.
– Serum factors of complement and immunoglobulins
called opsonins bind bacteria to surface of PMNs.
– PMNs have narrow life span. They are destroyed
in the inflammatory site when pH of tissue fluids
becomes less than 6.5.
Destruction of PMNs
↓ replication as needed by immune response.
Release of proteolytic enzymes, pepsin and cathepsin
↓ – Shorter lifespan than B-cells
Tissue lysis
↓ – When activated, B-cells become larger cells
PMNs along with products of cellular lysis and debris
constitutes the pus.
2. Macrophages:
– Derived from circulating monocytes
– At the site of inflammation, in extravascular areas,
immature monocytes differentiate into macro­
phages.
– Function: They are phagocytic cells that ingest
cellular debris, microorganisms and particulate
matter. They enhance the immunologic reaction by
ingesting, processing and degrading antigen before
presenting to lymphocytes, thus causing repair.
– Macrophages secrete mediators of inflammation
such as lysosomal enzymes, complement proteins
and prostaglandins.
– Monophages are mononucleated cells that fuse with
other macrophages to produce multinucleated giant
cells.
3. Lymphocytes:
– Appear in chronic stage of inflammatory reaction.
– Two types: T-lymphocytes and B-lymphocytes, both
derived from pluripotential hemopoetic stem cells.
Stem cells carried to thymus, where they become
immunologically competent T-cells whereas B-cells
tend to become immunocompetent in the bone
marrow.
• T-lymphocytes:
– T-lymphocytes have long lifespan
– Found in paracortical areas of lymph nodes
– Responsible for cell-mediated immunity.
– T-lymphocytes stimulated by an antigen.
Sensitized lymphocyte can have following
manifestations:
i. Memory T-cells: They speed the immun­
ologic reaction in subsequent encounters
with same antigen
ii. Helper/Suppressor T-cells: Stimulate or
suppress development of effector T- or
B-cells
iii. Effector T-cells: Cell-mediated immunity
such as delayed hypersensitivity.
– Sensitized lymphocyte release chemical
mediators: Lymphokines may activate macro­
phages, polymorphonuclear leukocytes
and non-sensitized T-cells. Lymphokines
may produce interferon, that inhibits viral
• B-lymphocytes:
– Found in cortical areas of lymph nodes
called plasmablasts. Plasmablasts divide into:
i. Memory B-cells: They speed the immun­
ologic reaction in subsequent encounters
with same antigen.
ii. Plasma cells: Large, oval or round cells with
eccentric nuclei containing chromatin in
cart-wheel form.
Plasma cells produce immunoglobulins:
IgG, IgA, IgM, IgE and IgD (Remember:
GAMED) which are involved in different
defense reactions such as:
a. Neutralization of bacterial toxins by
antitoxins
b. Coating of bacteria with antibodies or
opsonization for phagocytosis
c. Lysis of bacteria by complement
activation
d. Agglutination of bacteria
e. Combining of antibody with viruses
to prevent their entry into cells.
– Responsible for humoral immunity.
4. Eosinophils, basophils, mast cells are also found in the
pulp and periradicular tissues.
– Eosinophils mainly found in allergic reactions and
parasitic reactions.
– Function : Phagocytosis of antigen-antibody
complexes and detoxification of histamine.
– Basophils and mast cells are the same with basophils
found in hemopoetic system and mast cells found in
tissue.

– Both basophils and mast cells contain granules
and when stimulated, by injury they degranulate
and release chemical mediators such as histamine
(vasodilator) and heparin (anticoagulant). They can
initiate inflammatory allergic responses.
Inflammatory Mediators
The main biologic function of inflammatory mediators is to
cause vasodilatation and increased vascular permeability
and recruit inflammatory cells, mainly neutrophilic
leukocytes and macrophages from blood circulation to
the site of tissue injury. The inflammatory reactions are
mediated by chemical substances produced by certain cells
or present in plasma.
Nonspecific Inflammatory Mediators
I. Cell derived mediators:
1. Vasoactive amines such as histamine, serotonin
(5-Hydroxytryptamine)
2. Lysosomal enzymes
3. Neuropeptides
4. Cytokines
5. Nitric oxide
6. Eicosanoids.
II. Plasma derived mediators
1. Complement system
2. Kinin system
3. Coagulation and fibrinolytic system.
Specific Inflammatory Mediators: Antibodies
I. Cell derived mediators:
1. Vasoactive amines such as Histamine, Serotonin
(5-Hydroxytryptamine): Histamine is released by mast
cell degranulation in response to variety of stimuli
such as physical injury, immune reactions involving
binding of antibody to mast cell, etc. Histamine
causes dilatation of arterioles and increased vascular
permeability of venules. Serotonin is present in platelets
and enterochromaffin cells. Its release is stimulated
when platelets aggregate after contact with collagen,
thrombin, antigen-antibody complexes. It causes
increased vascular permeability.
2. Lysosomal enzymes: Collagenase can mediate tissue
injury by degrading collagen and other tissue proteins.
Kallikerin released from the lysosomes promotes the
generation of bradykinin. Lysosomal enzymes cause
increase in vascular permeability and play a role in
activation of the complement system.
Rationale of Endodontic Therapy 133
3. Neuropeptides: Neuropeptides such as Substance P,
Calcitonin-gene related peptide (CGRP) are potent
vasodilators. Increased production and release of
neuropeptides plays an important role in initiating and
propagating the inflammation of the pulp.
4. Cytokines: They are polypeptides produced by many cell
types that play a role in modulating the function of other
cell types. These include Interleukin-1, Interleukin-8 and
tumor necrosis factor (TNF). IL-1 and TNF are produced
by activated macrophages. They induce the synthesis
and surface expression of the endothelial adhesion
molecules and bring about enhanced leukocyte
adhesion to endothelial walls. IL-1 has been found
mainly in periapical pathology and IL-8 is associated
with acute apical periodontitis. TNF is associated with
chronic apical lesions and root canal exudates. IL-1
and IL-8 are proinflammatory cytokines and TNF is a
chemotactic cytokine.
5. Nitric oxide: Nitric oxide in macrophages act as free
radicals, which are cytotoxic to certain microbes and
tumor cells. It increases vascular permeability and
causes inactivation of anti-proteases.
6. Eicosanoids such as prostaglandins or leukotrienes
are released through the cyclooxygenase pathway and
lipooxygenase pathway in response to injury to cells,
which are involved in inflammatory process.
II. Plasma derived mediators:
1. Complement system: It consists of 20 component
proteins and their cleavage products found in greatest
concentration in plasma. Components of complement
system such as C3a, C3b, C5a, C5b, C5-C9 are products
of the complement cascade, which can be activated by
two pathways: The classic pathway and the alternate
pathway. The classic pathway is initiated by activation of
C1 by multimolecular aggregates of IgG or IgM antibody
complexed with specific antigen and the alternate
pathway is activated by microbial cell components
(lipopolysaccharide, teichoic acid) and plasmin. C3a
and C5a causes vasodilation and increases the vascular
permeability and C5a is a powerful chemotactic agent
for neutrophils, monocytes, eosinophils and basophils
and causes increased adhesion of leukocytes to
endothelium.
2. Hageman factor activated Kinin and Coagulation system:
Kallikrien converts kininogen into bradykinin, which in
turn converts plasminogen into plasmin. Kinins cause
increased vascular permeability, vasodilation and
smooth muscle contraction.
Coagulation/Clotting system and fibrinolytic
system: Its two components: Fibrinopeptides which
134 Short Textbook of Endodontics
increase vascular permeability and are chemotactic for
leukocytes and thrombin which increases leukocyte
adhesion and fibroblast proliferation.
Vascular Changes
1. Vasodilatation: Induced by histamine, prostaglandins,
nitric oxide.
2. Increased vascular permeability: Vasoactive amines, C3a,
C5a, Bradykinin, Leukotrienes, Platelet activation factor
play a role in it. It causes increase in concentration of
red cells in small vessels. Increase in viscosity of blood
causes slower flow of blood.
3. Leukocyte accumulation and migration.
Tissue changes that occur in dental biologic tissues
during inflammation are summarized in Flow chart 8.2.
Correlation between Clinical and Histologic Findings
Clinical diagnosis of inflammatory pulpal or periapical
disease is mainly based on clinical signs and/or symptoms,
Flow chart 8.2  Changes in dental biologic tissues during inflammation
duration of disease, pulp tests, percussion, palpation
and radiographic findings whereas histologic diagnosis
is a morphologic and biologic description of cells and
extracellular matrix of diseased tissues.
Clinical diagnosis represents provisional diagnosis based
on signs, symptoms and testing results whereas histologic
diagnosis is a definitive diagnosis of diseased tissue.
There is no good correlation between clinical symtoms
and histopathologic findings of pulpitis and apical
periodontitis. For example, a pulp tissue with acute pulpal
abscess at cellular level may be clinically completely
asymptomatic. Also, many teeth with apical periodontitis
histologically are clinically asymptomatic.
Correlation between Radiographic
and Histologic Findings
Radiography detects pathologic changes at tissue level,
not cellular levels. Even by using very sensitive imaging
systems such as cone beam computed tomography (CBCT),

ultrasound and other technologies, it is impossible to
detect the presence of inflammatory changes in pulp and
periradicular tissues.
Sometimes the tooth with inflammation of periradicular
tissues observed histologically might have normal
radiographic features. This is because the lesions localized
in the cancellous bone may not be visible radiographically
unless they involve cortical bone. In addition, radiographic
findings may not be able to predict asymptomatic apical
periodontitis (granuloma) from asymptomatic apical
periodontitis with cyst formation (radicular cyst). There is
poor correlation between radiographic and histopathologic
findings of inflammation or disease of periradicular tissues.
WHAT TISSUE CHANGES OCCUR
FOLLOWING INFLAMMATION?
Tissue changes that occur following inflammation are
summarized in Flow chart 8.3.
Same substance can act as stimulant and irritant. For
example: Calcium hydroxide. In the center of inflammatory
area, strong irritant causes degeneration/destruction. At the
periphery, mild irritant causes proliferation.
Flow chart 8.3  Changes in dental biologic tissues following inflammation
Rationale of Endodontic Therapy 135
WHAT IS THE ROLE OF IMMUNITY IN
ENDODONTICS?
Two types of immune responses are involved when there is
infection or inflammation in the pulp and the periradicular
tissues: innate immunity and adaptive immunity.
The immune cells present in human periradicular
lesions include lymphocytes, macrophages, plasma cells,
neutrophils and natural killer cells (NK).
1. Nonspecific innate immune response: The primary
nonspecific innate immune defense mechanism in
response to apical periodontitis is phagocytosis of
microbes by specialized phagocytes such as PMNs
and macrophages. Inflammation of tissue causes
recruitment of PMNs from the blood circulation into
periradicular tissue. Activated PMNs cause an abrupt
increase in oxygen consumption (respiratory burst),
resulting in release of oxygen radicals that destroy
microbes. Phagocytosed microbes or foreign particles
are exposed to a very toxic environment that contains
specific and azurophilic granules and oxygen radicals
and are eventually degraded.
136 Short Textbook of Endodontics

2. Adaptive/Specific immune response: The specificity of Fish’s Zones of Reaction: ICIS

adaptive immune response is regulated at genetic level Zones of Infection, Contamination, Irritation, Stimulation.
in B and T lymphocytes through a complex process that
leads to generation of molecules, which are specific Implications
receptors on T-cells and B-cells. These molecules
recognize and bind to foreign or self-antigens. • Root canal is a seat of infection.
The T-cell antigen receptors on T-cells interact with • Microorganisms in root canal are rarely motile and will
antigens that are presented by MHC molecules along not move into periradicular tissues by themselves.
with accessory molecules.
The B-cell antigen receptors, also called as immuno­
globulins interact with antigens directly. They may be
secreted in the blood circulation or in the tissues as
antibodies.

WHAT ARE THE ZONES OF REACTION

OF PERIRADICULAR TISSUES AND
ENDODONTIC IMPLICATIONS?
Fish performed an experiment to study the reaction of the
periradicular tissues to noxious products of tissue necrosis,
bacterial products and antigenic agents from root canal.
In the experiment, he established an experiment foci of
infection in the guinea pigs by drilling openings in the jaw
bone and packing it with wool fibers saturated with a broth
culture of microorganisms.
He described four zones of reaction surrounding foci of
infection as shown in Figure 8.1. Fig. 8.1  Diagram showing the four zones of reaction: (a) Infected/
Table 8.1 gives the details of each of the zones of Necrosed pulp; (b) Zone of infection; (c) Zone of contamination;
reaction. (d) Zone of irritation; (e) Zone of stimulation as described by Fish

TABLE 8.1  Zones of reaction

Zone of infection Zone of contamination Zone of irritation Zone of stimulation

PMN leukocytes Round cell Macrophages and osteoclasts Fibroblasts and osteoblasts
infiltration and lymphocytes

Microorganisms are found Around central zone, cellular Small round cells, normal bone cells and Toxins are too diluted and mild
destruction caused by toxins osteoclasts could just survive enough to act as stimulant
discharged from central zone is
seen

Infection is present in the
center of the lesion. Thus,
root canal is seat of infection
In this area, bone cells die due
to toxins, undergo autolysis. So,
lacunae appear empty
Toxins become diluted Collagen fibers are laid down
by fibroblasts which act as wall of
defense around zone of irritation.
It also acts as scaffolding, on which
the osteoblasts built new bone in
an irregular fashion

When microorganisms Macrophages digest collagen and A granuloma may be found or if

multiply or produce osteoclasts attack bone tissue, as a result epithelial rests of malassez are
byproducts, they reach of which a GAP is opened up in the bone stimulated, a cyst will form
periradicular area around center of lesion, which is then
filled with PMN leukocytes. Histologically,
activity preparatory to repair is seen
 Rationale of Endodontic Therapy 137

A B

C D
Figs 8.2A to D  Enlarged view of the lower left side of panoramic radiograph (OPG); (A) Preoperative view showing large area of
rarefaction in relation to mandibular canine and mandibular second premolar; (B) Postoperative view after doing Endodontic treatment
in mandibular second premolar and Endodontic retreatment in mandibular canine; (C) One-year follow-up view shows resolution of
radiolucency to a great extent; (D) Two-year follow-up view shows further improvement and return of periradicular tissues to the normal
(Courtesy of Dr Ajay Bajaj)

Flow chart 8.4  Fate of microorganisms in periradicular area

However, microorganisms may multiply sufficiently
to grow out of root canal or the metabolic or toxic
products of microorganisms may be diffused to
periradicular area.
• In the periradicular area: (Flow chart 8.4)
• At the periphery of destroyed area, granuloma or cyst
forms as shown in Flow chart 8.5.
• When root canal therapy is done, the reservoir of
microorganisms and their toxic products is eliminated,
followed by obturation of root canal system to produce
a three-dimensional hermetic seal, the destroyed
periapical bone will undergo repair.
Fish’s theory is the basis for successful Endodontic
treatment.
138 Short Textbook of Endodontics
Flow chart 8.5  Lesion formed as per stimulant
Rationale of Endodontic Therapy
• Effective elimination of the reservoir of microorganisms
and their toxins from the root canal system by means
of:
– Unobstructed straight-line access to the apical part
of the root canals.
– Thorough instrumentation of root canals combined
with irrigation (cleaning and shaping).
• Well cleaned and well-shaped root canal is obturated to
produce a three-dimensional hermetic seal which:
– Prevents entry of microorganisms or fluids from
root canal to periapical area or vice-versa (apical
leakage).
– Seal the remaining irritants in canal, i.e. entombment
of residual bacteria.
• The Endodontically treated tooth is protected by quality
coronal restoration to prevent bacterial contamination.
(coronal leakage).
Access cavity preparation and optimum cleaning
and shaping of root canals eliminates the reservoir of
bacteria or noxious products. Obturation of the well-
cleaned and well-shaped root canal system followed
by good post-Endodontic coronal restoration seals the
tooth against leakage from oral fluids and bacterial
contamination. As a result, the destroyed periapical
bone undergoes repair and the area of rarefaction
that was seen radiographically gradually resolves and
disappears.
Figures 8.2A to D show portions of the panoramic
radiographs taken preoperatively, post-treatment, and
follow-up after one and two years of a case in which
Endodontic treatment has been successful and has
resulted in the repair of periapical bone. The huge area of
rarefaction that is seen in preoperative view has resolved
and almost disappeared in the follow-up radiographs
taken after one and two years respectively.
BIBLIOGRAPHY
1. AAE Fact Sheet on Focal Infection Theory.
2. Grossman L, Oliet S, Del Rio C. Endodontic Practice, 11th edn.
Varghese publication; 1991.pp.116-25.
3. Hargreaves KM, Cohen S. Pathways of Pulp, 10th edn. Mosby
Elsevier, St Louis, MO; 2011.pp.532-5.
4. Indramohan J, Karthika B, Mohiddin G. Myth of Endodontics in
oral focal infection. Indian Journal of Multidisciplinary Dentistry.
2011;2(1):380-2.
5. Rajendran R, Sivopathasundharam B, Shafer’s Textbook of Oral
Pathology, 7th edn, Elsevier Publication; 2012.p.512.
 9
CHAPTER

Case Selection and

Treatment Planning

This chapter describes thorough evaluation of a patient who has come for dental treatment. It will help
you to make a decision whether to do or not to do root canal treatment in a particular case and guides
you to formulate an effective Endodontic treatment plan to carry out the procedure.
  You must know
• How to Evaluate a Case for Treatment?
• What are the Factors to be Considered for Case Selection for Root Canal Treatment?
• What are the Indications and Contraindications of Root Canal Treatment?
• How to Develop an Endodontic Treatment Plan?
• How to Assess Difficulty of an Endodontic Case?

HOW TO EVALUATE A CASE FOR TREATMENT?
Each case must be evaluated thoroughly before
commencement of treatment.
Proper evaluation of the patient for treatment includes:
• Evaluation of medical condition of patient
• Psychological evaluation
• Dental evaluation.
Evaluation of Medical Condition of Patient
Most of the medical conditions do not contraindicate
Endodontic treatment. There are few systemic conditions
that can influence the course of treatment and will require
specific modifications. So, it is necessary to evaluate the
medical condition of the patient before we plan to do root
canal treatment (RCT).
Physical status classification for patients given by
American Society of Anesthesiologists (ASA):
ASA I: Normal, healthy patient.
No dental management alterations required.
ASA II: A patient with mild systemic disease that does not
interfere with daily activity or who has significant
health risk factor such as smoking, obesity, etc.
May or may not need dental management
alterations.
For example, stage I or II hypertension, type II
diabetes, allergy, well-controlled asthma.
ASA III: A patient with moderate to severe systemic disease
that is not incapacitating but may alter daily
activities, may have significant drug concerns, may
require special patient care.
Would generally require dental management
altera­tions.
For example, stage III hypertension, type
I diabetes, unstable angina pectoris, recent
myocardial infarction, poorly controlled congestive
heart failure, AIDS, COPD, hemophilia.
ASA IV: A patient with severe systemic disease that is constant
threat to life; definitely requires dental management
alterations; best treated in special facility.
For example, kidney failure, liver failure,
advanced AIDS.
The ASA classification is a useful guide for preoperative
assessment of relative risk involved in treating a patient.
If the patient has a systemic disease, under certain
circum­stances, consultation with the patient’s physician
may be necessary.
140 Short Textbook of Endodontics
Certain medical conditions that may influence Endodontic
treatment planning [Remember ABCDE CAP]:
Medical condition Precautions to be taken and
treatment modifications
1. Allergy: • If patient gives history of known
allergy to a particular agent such as
certain drugs, LA, latex gloves, etc.
avoid using those agents that the
patient is allergic to.
• Always keep an emergency kit
available in case of an unknown
allergy.
While designing an emergency
drug kit, following drugs should be
included as minimum: (As per ADA
Council on Scientific Affairs, 2002):
1. Epinephrine 1:1000 (Injectable)
2. Histamine blocker (Injectable)
3. Oxygen with positive pressure
administration capability
4. Nitroglycerin (Sublingual tablet
or aerosol spray)
5. Bronchodilator (Asthma inhaler)
6. Sugar
7. Aspirin
2. Bleeding • Consultation with the patient’s
  disorders: physician
• Evaluate patient’s recent blood test
report for bleeding time, clotting
time
• Use of antibiotic prophylaxis may be
required.
3. Cardiovascular • Consultation with the patient’s
  diseases: physician
• Such patients are vulnerable
to emotional stress. Reassurance
and effective pain control is very
important to manage the stress.
• Patient with a history of myocardial
infarction within past 6 months
should not have elective dental care.
• Use of vasoconstrictor (Adrenaline)
in the local anesthetic should be
considered. Sometimes plain LA, i.e
LA without adrenaline may have to
be used.
• Patients with congenital heart
disease and valve defects must be
given prophylactic antibiotics prior
to Endodontic treatment to prevent
bacterial endocarditis.
• Pat i e nt s o n m e d i c at i o n s f o r
hyper­­tension should also have their
blood pressure measured prior to
treatment.
4. Diabetes: • Consultation with patient’s physician
may be required.
• Evaluate blood glucose levels.
• Before dental appointment, patient
is asked to have his/her regular dose
of insulin and normal meals.
• Antibiotics may have to be prescribed
in certain cases.
• Patients with controlled diabetes and
without any medical complications
can receive the Endodontic treatment
without any treatment modification.
But a modified treatment plan is
indicated for diabetic patients with
medical complications.
5. End-stage renal • Endodontic treatment may have to
  disease: be provided in a hospital setting
to restore oral health and prevent
infection.
6. Cancer: • Patients who are on chemotherapy
or radiation therapy to head and
neck may have impaired healing
response.
• Consultation with patient’s physician.
• Whether to do extraction or Endo­
dontic treatment for preradiation
patients should be determined.
• Perform treatment only if urgent care
is needed.
• Such patients may have symptoms
like mucositis, trismus, xerostomia,
which will require some local
treatment for relief of symptoms.
7. AIDS • Adherence to universal pre­cautions
• Determine CD4 count
• Medical consultation
• Antibiotic prophylaxis.
8. Pregnancy: • Second trimester only seems to be
safe period to provide routine dental
care.
• As far as possible no drug should
be administered during pregnancy,
especially during first trimester. If
need for drug administration arises,
consultation with patient’s physician
is a must.
• There is concern for the use of radio­
graphs in pregnant females. Use of

safety aids such as protective lead
apron with thyroid collar is a must.
• Care needs to be taken about the
com­fortable position of the patient
during treatment, if any kind of
emergency procedure needs to be
performed.
Psychological Evaluation
• Patient’s psychological status is considered during
treatment.
• Most of the patients are found to have anxiety if they have
to undergo Endodontic treatment. The anxiety reduction
protocol includes reassurance to patient and explaining
the entire procedure to the patient. Also, the patients
need to be informed what they can expect during the
treatment.
• Behavioral intervention for the anxious patient reduces
the anxiety and increases the level of cooperation from
the patient during treatment.
Dental Evaluation
Thorough clinical and radiographic evaluation of the tooth
needs to be done to determine the following:
(Remember the sentence: Lets Start Root Canal
Procedure After Making Proper Diagnosis Previously)
• Location of tooth: Most posterior tooth in the arch or
tilted  posterior teeth may present access and visibility
problems. Ability to isolate the tooth is an important
consideration.
• Strategic value of tooth.
• Restorability of tooth.
• Complications from previous treatment : Such as
perforations, canal blockages, ledges, nonretrievable
posts, etc.
• Periodontal status of tooth.
• Accessibility to apical foramen through the root canal.
• Morphology of tooth: Root canal shape, presence
of any curvatures, calcifications or resorptions, etc.
which may be revealed on radiographs. But remember
that radiographs do not always demonstrate canal
complexities.
• Proximity to anatomic structures: Proximity of root
apices to anatomic structures such as mental foramen,
mandibular canal and maxillary sinus should be
considered.
• Difficulty anticipated during treatment: Evaluating
various factors that may complicate the proposed
Endodontic therapy of the involved tooth.
• Prognosis of the case.
Case Selection and Treatment Planning 141
WHAT ARE THE FACTORS TO BE
CONSIDERED FOR CASE SELECTION
FOR ROOT CANAL TREATMENT?
Factors to be Considered for Case-selection
for Root Canal Treatment
Systemic/General Factors
These include age and health considerations.
Endodontic treatment is possible for all age groups. It
can be done in deciduous teeth and young permanent teeth
with open apices (Pediatric Endodontics) and also in older
people above 65 years of age (Geriatric Endodontics). Thus,
age is not a determinant in Endodontic therapy.
General health of the patient must be evaluated prior to
performing root canal treatment. In case of certain medical
conditions, treatment may require some modifications.
Local Factors
• Consideration regarding the strategic importance of
tooth: The clinician needs to determine whether the
involved tooth is needed or important. Consider whether
it has the opposing (antagonist) tooth or not.
• Consideration regarding the status of the oral condition:
The involved tooth may be associated with other
dental problems such as rampant caries, periodontal
lesions, orthodontic malalignment, root resorption,
history of trauma, etc. Treatment of such tooth will
require a combined team work of various dental
specialists.
• Consideration of the prognosis of Endodontic therapy:
– Teeth with pre-existing apical radiolucency are found
to have a lower success rate than the teeth without
such lesions. Apical periodontitis is considered to be
the main prognostic factor in initial treatment cases.
– Clinician’s skills: Quality of instrumentation,
obturation and final restoration play an important
role in the ultimate outcome of Endodontic
treatment.
• Restorative considerations: When the tooth is badly
damaged and very little amount of sound crown
structure is remaining, it may not be satisfactorily
restored. Surgical crown lengthening procedure (CLP)
may have to be considered when crown height is
compromised or there is subosseous root caries. A tooth
which is Endodontically treatable but nonrestorable may
represent a potential restorative complication in a large
prosthesis.
• Periodontal considerations: If the tooth is severely
involved periodontally, it may be soon lost for
142 Short Textbook of Endodontics
this  reason. So, in spite of probability of a favorable
Endodontic prognosis, a tooth with poor periodontal
support will have to be sacrificed.
• Esthetic considerations: As an alternative to orthodontic
treatment in case of malaligned anterior teeth such
as proclined teeth, intentional Endodontic treatment
can be done and the teeth prepared to correct the
inclination to receive full coverage esthetic crowns
(Smile Designing).
• Surgical considerations: Cases where re-treatment is
being considered, one must determine whether non-
surgical or combined means for re-treatment would be
appropriate.
• Anatomic considerations: Extra roots and canals which
are sometimes not revealed on radiographs will pose
anatomic challenge before the clinician. Anatomic
variations with respect to position of tooth, shape of
roots and canals, presence of curvatures, calcifications,
etc. should be considered during case selection.
• Other factors:
– Ability to isolate the tooth is an important
consideration.
Fig. 9.1  Mind-map showing local factors for Endodontic case selection
– Accessibility of tooth: Endodontic treatment in
the third molars may be difficult due to poor
accessibility.
Limited mouth opening, trismus can make
accessibility of posterior teeth difficult or even
impossible.
– Retreatment cases, particularly those presenting with
procedural mishaps such as ledges, perforations,
etc. will pose a mechanical challenge before the
clinician.
– Level of anticipated difficulty in a particular case
has to be determined beforehand and the need for
referral to a specialist has to be considered if the case
seems to be beyond the clinician’s ability.
Figure 9.1 shows the mind-map to remember all
the local factors to be considered for Endodontic case
selection.
Grossman gave the four main factors that determine the
decision to do or not to do root canal treatment: (Grossman’s
Endodontic Practice, 11th edn. p.126)
1. Accessibility of the apical foramen through the root canal
2. Restorability of the involved tooth

3. Strategic value of the involved tooth
4. General resistance of the patient.
All these have been explained previously in this
chapter.
WHAT ARE THE INDICATIONS
AND CONTRAINDICATIONS OF
ROOT CANAL TREATMENT?
Indications
1. Irreversible pulpitis: – Acute
– Chronic
2. Acute apical periodontitis
3. Pulp necrosis: Necrosis of pulp may cause discoloration
of tooth (Figures 9.2A and B show photograph of
discolored nonvital teeth due to trauma)
4. Chronic apical periodontitis
5. Nonvital tooth with periapical cyst
A
B
Figs 9.2A and B  Discolored nonvital teeth
(Courtesy of Dr Manoj Ramugade)
Case Selection and Treatment Planning 143
6. Chronic hyperplastic pulpitis (Pulp polyp) (Figure 9.3
shows photograph of mandibular first molar with pulp
polyp)
7. Internal resorption (Pink teeth) (Figures 9.4A and B show
photograph of teeth with internal resorption that have
turned pink colored)
8. Pulp exposure from severe attrition of tooth (Figure 9.5
shows photograph of multiple teeth requiring root canal
treatment due to pulp exposures from severe attrition)
9. Intentional root canal treatment for restorative or
prosthetic procedures
10. Roots with good periodontal support, over which over
denture can be constructed.
11. In case of Combined Endodontic-Periodontal lesions,
in which tooth is salvageable, Endodontic treatment is
done prior to Periodontal treatment.
Contraindications
1. Nonrestorable tooth, i.e. a tooth with insufficient sound
tooth structure remaining (or nonrestorable root surface
caries).
Figure 9.6 shows photograph of badly broken down
teeth due to caries that cannot be restored.
Figure 9.7 shows radiograph showing insufficient
sound tooth structure remaining of maxillary first
premolar tooth that seems to be nonrestorable.
2. Vertical root fracture (VRF).
3. Extensive and untreatable internal or external root
resorption.
4. Caries involving floor of pulp chamber.
5. Extensive periodontal disease around the tooth causing
grade III mobility of tooth.
Fig. 9.3  Mandibular first molar with pulp polyp
(Courtesy of Dr Manoj Ramugade)
144 Short Textbook of Endodontics

Fig. 9.6  Nonrestorable teeth (Courtesy of Dr Manoj Ramugade)

B Fig. 9.7  Radiograph showing insufficient sound tooth structure

Figs 9.4A and B  Pink teeth (Courtesy of Dr Manoj Ramugade) remaining-nonrestorable tooth (Courtesy of Dr Sharad Kokate)

Fig. 9.5  Multiple teeth requiring root canal treatment due to pulp Fig. 9.8  Radiograph showing extensive periodontal
exposures from severe attrition (Courtesy of Dr Manoj Ramugade) involvement in mandibular teeth

Figure 9.8 shows radiograph of mandibular teeth
with extensive periodontal involvement.
6. Extensive destruction of periapical tissues involving
more than one-third the length of the tooth.
7. Teeth with complex anatomy where proper instrumen­
tation will not be possible
8. Endodontic failure cases with complications of previous
treatment such as untreatable perforations, large non-
retrievable posts, canal transportations, ledges, etc.
9. Poor accessibility of tooth due to limited mouth
opening which may be due to trauma, scar from surgical
procedure, oral submucous fibrosis (OSMF), systemic
conditions, etc. or inaccessible position of tooth in the
arch.
10. Nonstrategic tooth. For example, third molars whose
antagonist is missing and other all teeth are present for
proper function.
HOW TO DEVELOP AN ENDODONTIC
TREATMENT PLAN?
After arriving at a definitive diagnosis, treatment is planned.
In a general treatment plan to maintain oral health of
the patient, Endodontic treatment is included in the phase
II or surgical phase of treatment. But few cases may require
an emergency root canal opening (ERCO) as a preliminary
treatment for pain management.
In case of emergency, to relieve pain:
1. For single-rooted tooth: Remove entire pulp tissue from
the canal when possible
2. For multirooted tooth:
a. Pulpotomy—if less time
b. If some time permits, then removal of pulp tissue
from largest (biggest) canal, after pulpotomy.
Once the clinician has done a detailed evaluation of the
case and made a definitive diagnosis and has now decided
to perform Endodontic treatment, various factors need to
be considered to plan, how to go about carrying out the
procedure.
While formulating an Endodontic treatment plan:
(A) Determine the vitality of tooth:
• Vital Tooth
– Patient presents with severe pain in an acute vital
case. Pain is due to:
- Increased intrapulpal pressure
- Inflammatory mediators such as prostaglandins.
Case Selection and Treatment Planning 145
– Local anesthesia must be administered.
– Simply debriding the pulp chamber, i.e. performing
pulpotomy is a highly predictable method of
providing pain relief in emergency cases.
– If time permits, complete Endodontic treatment for
vital teeth can be performed in the same visit (single
visit Endodontics). If not, then clinician must stop at
pulpotomy, restore the tooth with a temporary filling
and schedule the next appointment for the patient.
– Once the canal is entered, the clinician must
remove all pulp tissue from it as it has been found
that partial  instrumentation (i.e. leaving tissue
remnants in the canal) may result in increased
postoperative pain.
• Nonvital Tooth
– Can present in 3 ways:
1. In a chronic nonvital case, tooth would be
absolutely painless.
2. Such a tooth, sometimes may suddenly become
acutely painful due to decreased host defense
mechanism and increase in virulence of bacteria.
3. Sometimes, it may be associated with a fluctuant
swelling.
– Nonvital tooth is a microbiologic challenge. Clinician
needs to reduce the bacterial load in the root canal
system by opening the tooth and debriding it.
– Usually there is involvement of periradicular
tissues. Clinician needs to promote decompression
of periradicular tissues by instrumentation and
irrigation of the canal.
– If fluctuant swelling is present, incision and drainage
should be performed along with instrumentation.
– Single visit Endodontics is not recommended in
nonvital teeth because complete eradication of
infection from nonvital tooth may not be possible
in a single visit due to increased microbial load.
– There is role of intracanal medicament such as
calcium hydroxide in these cases for antimicrobial
effect in between visits.
(B) Determine whether it is only an Endodontic lesion or
there is periodontal involvement also:
– Clinician needs to classify the case as primary
Endodontic or periodontal, secondary involvement
or true combined disease.
Once the case is clearly classified, appropriate
therapy as needed can be provided.
146 Short Textbook of Endodontics
Fig. 9.9  A mind-map to remember all points of Endodontic treatment plan
(C) Consider role of Endodontic surgery:
– Periradicular surgery can sometimes be considered
as primary treatment modality. For example, in a
case of completely calcified canal.
– Often periradicular surgery is considered for
retreatment of an Endodontic failure case.
(D) Treatment plan for retreatment case must consider the
following:
– Determination of:
i. Cause of failure
ii. Strategic value of tooth
iii. Accessibility for re-entry
iv. Any obvious procedural problems
v. Factors affecting prognosis of tooth
vi. Patient’s willingness to undergo re-treatment.
– Nonsurgical retreatment sometimes may have to be
combined with surgical Endodontics.
– Referral to specialist may be required.
Figure 9.9 shows a mind-map to remember all points of
Endodontic treatment plan.
HOW TO ASSESS DIFFICULTY OF AN
ENDODONTIC CASE?
The American Association of Endodontists has designed
the Endodontic case difficulty assessment form to assess
the level of difficulty of a particular case that helps in
case selection and in decision making of referral of case
to an Endodontist. These forms are given on the following
pages, which have been reprinted with permission from
the American Association of Endodontists.
BIBLIOGRAPHY
1. ADA Council on Scientific affairs, “Office Emergencies and
Emergency kits”, report in Journal of American Dental Association,
2002;133(3):364-5.
2. Cohen S, Hargreaves KM. Pathways of Pulp, 9th edn. St. Louis,
Mosby, 2006.pp.80-95.
3. Grossman L, Oliet S, Del Rio C. Endodontic Practice, 11th edn.
Varghese Publication, 1991.pp.126-31.
4. www.aae.org
 Case Selection and Treatment Planning 147

PATIENT INFORMATION DISPOSITION

Name_____________________________________________________ Treat in Office: Yes ☐ No ☐
Address___________________________________________________ Refer Patient to:
City/State/Zip_____________________________________________ ____________________________________________________
Phone____________________________________________________ Date: _______________________________________________

Guidelines for Using the AAE Endodontic Case Difficulty Assessment Form
The AAE designed the Endodontic Case Difficulty Assessment Form for use in endodontic curricula. The Assessment Form makes case
selection more efficient, more consistent and easier to document. Dentists may also choose to use the Assessment Form to help with
referral decision making and record keeping.
Conditions listed in this form should be considered potential risk factors that may complicate treatment and adversely affect the
outcome. Levels of difficulty are sets of conditions that may not be controllable by the dentist. Risk factors can influence the ability to
provide care at a consistently predictable level and impact the appropriate provision of care and quality assurance.
The Assessment Form enables a practitioner to assign a level of difficulty to a particular case.

LEVELS OF DIFFICULTY
MINIMAL DIFFICULTY Preoperative condition indicates routine complexity (uncomplicated). These types of cases would exhibit
only those factors listed in the MINIMAL DIFFICULTY category. Achieving a predictable treatment
outcome should be attainable by a competent practitioner with limited experience.
MODERATE DIFFICULTY Preoperative condition is complicated, exhibiting one or more patient or treatment factors listed in the
MODERATE DIFFICULTY category. Achieving a predictable treatment outcome will be challenging for
a competent, experienced practitioner.
HIGH DIFFICULTY Preoperative condition is exceptionally complicated, exhibiting several factors listed in the MODERATE
DIFFICULTY category or at least one in the HIGH DIFFICULTY category. Achieving a predictable
treatment outcome will be challenging for even the most experienced practitioner with an extensive
history of favorable outcomes.
Review your assessment of each case to determine the level of difficulty. If the level of difficulty exceeds your experience and comfort,
you might consider referral to an endodontist.

The contribution of the Canadian Academy of Endodontics and others to the development of this form is gratefully acknowledged.
The AAE Endodontic Case Difficulty Assessment Form is designed to aid the practitioner in determining appropriate case disposition. The American
Association of Endodontists neither expressly nor implicitly warrants any positive results associated with the use of this form. This form may be
reproduced but may not be amended or altered in any way.
© American Association of Endodontists, 211 E. Chicago Ave., Suite 1100, Chicago, IL 60611-2691; Phone: 800/872-3636 or 312/266-7255;
Fax: 866/451-9020 or 312/266-9867;
E-mail: info@aae.org; Web site: www.aae.org
(Reprinted with permission from the American Association of Endodontists)
148 Short Textbook of Endodontics

AAE Endodontic Case Difficulty Assessment Form

Criteria and subcriteria Minimal difficulty Moderate difficulty High difficulty
A. PATIENT CONSIDERATIONS
Medical History ☐ No medical problem (ASA Class 1*) ☐ One or more medical problems (ASA Class 2*) ☐ Complex medical history/serious illness/
disability (ASA Classes 3-5*)
Anesthesia ☐ No history of anesthesia problems ☐ Vasoconstrictor intolerance ☐ Difficulty achieving anesthesia
Patient Disposition ☐ Cooperative and compliant ☐ Anxious but cooperative ☐ Uncooperative
Ability to Open Mouth ☐ No limitation ☐ Slight limitation in opening ☐ Significant limitation in opening
Gag Reflex ☐ None ☐ Gags occasionally with radiographs/treatment ☐ Extreme gag reflex which has compromised
past dental care
Emergency Condition ☐ Minimum pain or swelling ☐ Moderate pain or swelling ☐ Severe pain or swelling
B. DIAGNOSTIC AND TREATMENT CONSIDERATIONS
Diagnosis ☐ Signs and symptoms consistent with ☐ Extensive differential diagnosis of usual signs ☐ Confusing and complex signs and symptoms:
recognized pulpal and periapical and symptoms required difficult diagnosis
conditions ☐ History of chronic oral/facial pain
Radiographic Difficulties ☐ Minimal difficulty obtaining/ ☐ Moderate difficulty obtaining/interpreting ☐ Extreme difficulty obtaining/interpreting
interpreting radiographs radiographs obtaining/interpreting radiographs (e.g., superimposed anatomical
radiographs (e.g., high floor of mouth, narrow structures)
or low palatal vault, presence of tori)
Position in the Arch ☐ Anterior/premolar ☐ 1st molar ☐ 2nd or 3rd molar
☐ Slight inclination (<10°) ☐ Moderate inclination (10-30°) ☐ Extreme inclination (>30°)
☐ Slight rotation (<10°) ☐ Moderate rotation (10-30°) ☐ Extreme rotation (>30°)
Tooth Isolation ☐ Routine rubber dam placement ☐ Simple pretreatment modification required for ☐ Extensive pretreatment modification required
rubber dam isolation for rubber dam isolation
Crown Morphologic ☐ Normal original crown morphology ☐ Full coverage restoration ☐ Restoration does not reflect original anatomy/
☐ Porcelain restoration alignment
☐ Bridge abutment ☐ Significant deviation from normal tooth/root
☐ Moderate deviation from normal tooth/root form (e.g., fusion, dens in dente)
form (e.g., taurodontism, microden)
☐ Teeth with extensive coronal destruction
Canal and Root ☐ Slight or no curvature (<10°) ☐ Moderate curvature (10-30°) ☐ Extreme curvature (>30°) or S-shaped curve
Morphology ☐ Closed apex (<1 mm in diameter) ☐ Crown axis differs moderately from root axis. ☐ Mandibular premolar or anterior with 2 roots
Apical opening 1-1.5 mm in diameter ☐ Maxillary premolar with 3 roots
☐ Canal divides in the middle or apical third
☐ Very long tooth (>25 mm)
☐ Open apex (>1.5 mm in diameter)
Radiographic ☐ Canal(s) visible and not reduced in ☐ Canal(s) and chamber visible but reduced in size ☐ Indistinct canal path
Appearance of Canal(S) size Pulp stones ☐ Canal(s) not visible
Resorption ☐ No resorption evident ☐ Minimal apical resorption ☐ Extensive apical resorption
☐ Internal resorption
☐ External resorption
C. ADDITIONAL CONSIDERATIONS
Trauma History ☐ Uncomplicated crown fracture of ☐ Complicated crown fracture of mature teeth ☐ Complicated crown fracture of immature teeth
mature or immature teeth ☐ Subluxation ☐ Horizontal root fracture
☐ Alveolar fracture
☐ Intrusive, extrusive or lateral luxation
☐ Avulsion
Endodontic Treatment ☐ No previous treatment ☐ Previous access without complications ☐ Previous access with complications (e.g.,
History perforation, non-negotiated canal, ledge,
separated instrument)
☐ Previous surgical or nonsurgical endodontic
treatment completed
Periodontal-Endodontic ☐ None or mild periodontal disease ☐ Concurrent moderate periodontal disease ☐ Concurrent severe periodontal disease
Condition ☐ Cracked teeth with periodontal complications
☐ Combined endodontic/periodontic lesion
☐ Root amputation prior to endodontic
treatment
*American Society of Anesthesiologists (ASA) Classification System
Class 1: No systemic illness. Patient healthy.
Class 2: Patient with mild degree of systemic illness, but without functional restrictions, e.g. well-controlled hypertension.
Class 3: Patient with severe degree of systemic illness which limits activities, but does not immobilize the patient.
Class 4: Patient with severe systemic illness that immobilizes and is sometimes life threatening.
Class 5: Patient will not survive more than 24 hours whether or not surgical intervention takes place.
(Reprinted with permission from the American Association of Endodontists) www.asahq.org/clinical/physicalstatus.htm
 Case Selection and Treatment Planning 149

Use of Endodontic Case Difficulty Assessment Form

In order to make the Case Difficulty Assessment Form a more objective exercise, it is recommended that a point score be
assigned to each item within each difficulty category. This point system is offered for educational purposes only and is
not recommended for clinical practice.
Those items listed in the Minimal Difficulty category are assigned a point value of 1.
Those items listed in the Moderate Difficulty category are assigned a point value of 2.
Those items listed in the High Difficulty category are assigned a point value of 5.
The following score ranges are recommended in making the decision whether to treat or refer:
• Less than 20 points: Dental student may treat—level of faculty supervision should be tailored to the student’s level of
experience.
• 20 – 40 points: An experienced and skilled dental student may treat with very close supervision by an endodontist, or
the case referred to a graduate student or endodontist.
• Above 40 points: The case should not be treated by a predoctoral dental student. The patient should be referred to a
graduate student or endodontist.
The assignment of an objective “point score” will hopefully assist the dental student in critically evaluating the difficulty
associated with treating each patient, assist him/her in making a treatment decision that will be in the patient’s best
interests, as well as enhance the student’s educational experience.

© 2005, American Association of Endodontists, 211 E. Chicago Ave., Suite 1100, Chicago, IL 60611
Phone: 800/872-3636 (North America) or 312/266-7255; Fax: 866/451-9020 (North America) or 312/266-9867
E-mail: info@aae.org; Web site: www.aae.org
(Reprinted with permission from the American Association of Endodontists)
 10
CHAPTER

Principles of Endodontic
Treatment

This chapter explains about the basic principles to be followed for Endodontic treatment which are
similar to any routine surgery with few differences associated with the anatomy of the root canal system.
  You must know
• What are the Principles of Endodontic Treatment?

WHAT ARE THE PRINCIPLES OF
ENDODONTIC TREATMENT?
Grossman has given the following nine principles of
Endodontic treatment as given in Figure 10.1.
Let us remember these nine principles with the help of
following sentence:
I T I S IMPORTANT TO DO CLEAN DENTISTRY
Isolation, Trauma avoidance, Immobilization, Sterili­
zation, Irritation avoidance, Trephination, Debridement,
Chemoprophylaxis, Drainage.

Principle 1: Isolation
The tooth under Endodontic treatment should be isolated to
maintain a safe and aseptic operative technique. Isolation
of tooth can be achieved using cotton rolls and rubber dam.
Use of rubber dam is mandatory during nonsurgical
Endodontic therapy. Figure 10.2 shows schematic
representation of teeth being isolated using rubber dam
and ready for Endodontic procedure.

Rationale
The rubber dam should be used in Endodontics for the
following reasons.
• Patient protection: From possible aspiration or
swallowing of tooth debris, restorative materials,
Endodontic instruments (files), medicaments, irrigating
solutions, etc.
• Dry, clean operating field: Prevents contamination of
root canal system from saliva, blood and other tissue
fluids.
• Retraction: Adjacent soft tissues (tongue, lips, cheek) are
Fig. 10.1  Principles of Endodontic treatment as given by Grossman retracted and protected.

Fig. 10.2  Schematic representation of teeth being isolated and
ready for Endodontic procedure
• Visibility: Rubber dam provides a dry field and reduces
mirror fogging, thus improving visibility.
• Increased efficiency: Better visibility increases efficiency
of operator. Also, since the rubber dam minimizes
patient conversation during treatment and frequent
rinsing by the patient, there is increased efficiency due
to bacteria free field.
• Standard of care: Use of rubber dam for Endodontic
treatment is considered as the standard of care.
Routine placement of rubber dam eliminates the risk of
accidental swallowing or aspiration of instruments and
medicaments, etc. thus the clinician is protected from
litigation.
Figures 10.10 and 10.12 show photographs of
Rubber dam isolation of tooth undergoing Endodontic
treatment.
– In certain instances such as severe tipping of teeth or
orientation difficulties due to restoration, the coronal
access to root canals needs to be made prior to rubber
dam placement.
Components of Rubber Dam System (Fig. 10.3)
Principles of Endodontic Treatment 151
Fig. 10.3  Rubber dam kit containing rubber dam sheets, rubber
dam frame, rubber damp clamp or retainers, rubber dam punch and
rubber dam forceps (Courtesy of Dentsply)
Rubber Dam Sheet/Material
• Available in variety of thicknesses:
– Thin
– Medium
– Heavy
– Extra heavy
– Special heavy
Medium weight thickness is recommended for
Endodontic purposes as it gets tightly adapted to cervical
area of tooth and does not tear easily. It retracts soft tissues
better than the thin type and is easier to place than the
heavier types.
Thin material needs to be used on mandibular anterior
teeth and partially erupted posterior teeth. Figure 10.4
shows photograph of rubber dam sheet.
• 2 sizes: 5 × 5 inches (127 × 127 mm)
6 × 6 inches (152 × 152 mm)
Figure 10.5 shows photograph of commercially
available packets containing 6 × 6 inches rubber dam
sheets.
• Available in variety of colors: Light yellow, blue, green,
gray
• 2 sides of sheets: One side is dull, other side is shiny
Dull side of rubber dam should be towards the operator.
Two types of rubber dam material:
1. Latex rubber dam
2. Nonlatex: Nitrile or nonlatex rubber dam (for
patients with allergy to latex).
152 Short Textbook of Endodontics

Fig. 10.4  Rubber dam sheet Fig. 10.6  Rubber dam frame
(Courtesy of Mr Amar, Dr Dabholkar’s Clinic) (Courtesy of Mr Amar, Dr Dabholkar’s Clinic)

Fig. 10.5  Commercially available packed rubber dam sheets Fig. 10.7  Rubber dam clamps
(Courtesy of Mr Amar, Dr Dabholkar’s Clinic) (Courtesy of Dr Shivani Bhatt)

Rubber Dam Frame Rubber Dam Clamp or Retainer

• To retract and stabilize the rubber dam • To anchor the rubber dam to the tooth requiring
• Two materials of frames – Metal (Nygaard Ostby frame) Endodontic treatment
– Plastic (Young’s frame) • It also helps in soft tissue retraction
• For Endodontic purposes, plastic frames are • Two types:
recommended as they are radiolucent and do not cause
obstruction of important areas on radiographs.
Figure 10.6 shows photograph of plastic rubber dam
frame.
• U-shaped Young’s rubber dam frame made of plastic is
commonly used.
• Foldable plastic frame is also available which need not – For Endodontic purpose, wings allow rapid and
be disengaged while taking radiograph. efficient placement of dam.

Figure 10.7 shows photograph of the rubber dam
clamps.
– Wings cause buccal-lingual deflection of dam from
isolated tooth, allowing increased access.
– Disadvantage: Wings may sometimes interfere in
radiographic interpretation.
• Parts of clamp: A bow and two jaws.
• Available in 2 sizes: Small and large.
Rubber Dam Punch
• To punch sharp, clean holes on rubber dam sheet
according to the tooth to be isolated. Figure 10.8 shows
photograph of rubber dam punch.
• If the punch is not centered correctly, a ‘nick’ or jagged
cut margin is produced resulting in poor seal.
Rubber Dam Forceps
• To hold and carry the retainer during placement and
removal.
Figure 10.9 shows photograph of rubber dam forcep.
• Ash-style or ivory-style forceps is used
• Ash-style forceps beaks provides a fulcrum point for
posterior or anterior rotation of clamp
• Ivory-style forceps provides projections from engaging
beaks that allow the clinician to exert gingivally directed
force necessary to direct the clamp beyond the bulk of
contour and into proximal undercuts.
Adjuncts to Rubber Dam Placement
• Plastic or cement instrument:
– To ‘tuck’ the edges of rubber dam into gingival sulcus
to achieve a fluid tight seal.
Fig. 10.8  Rubber dam punch
(Courtesy of Mr Amar, Dr Dabholkar’s Clinic)
Principles of Endodontic Treatment 153
– To shed the rubber dam off the wings of the clamp
after the clamp is positioned.
• Dental floss.
– To check contacts prior to rubber dam application.
– To pass the rubber dam material through the
contacts after placement.
• Wedgets stabilizing cord: Small strips of cord wedged into
interproximal space, help to stabilize the interproximal
area of rubber dam.
• Orabase, rubber base adhesive, cavit, periodontal pack:
To control seepage of fluids at the interface of the tooth
and the rubber dam material.
Recently, disposable, single use, preframed rubber
dams have been introduced. For example, Instadam and
HandiDam for quick application of rubber dam without
the use of conventional frame.
Methods of Rubber Dam Placement
Patient is asked to rinse for 30 seconds with an antibacterial
agent such as 0.12% chlorhexidine gluconate, to reduce the
number of microorganisms in mouth prior to rubber dam
placement.
• Single motion technique: Most efficient dam application
technique for Endodontics.
It is named so, as the dam, clamp and the frame are
taken to the tooth to be isolated in a single motion.
– Position the bow of the selected clamp through the
hole made in rubber dam sheet.
– Place the rubber dam over the wings of the clamp.
– The forceps stretch the clamp to maintain the
position of the clamp in the dam.
Fig. 10.9  Rubber dam forcep
(Courtesy of Mr Amar, Dr Dabholkar’s Clinic)
154 Short Textbook of Endodontics

– Then the rubber dam is attached to the plastic frame, c. The stretched interproximal dam is cut with scissors
thus allowing for the placement of the dam, clamp and dam is removed.
and frame in one motion. d. Inspect and ensure that no interproximal dam has
– Once the clamp is secured on the tooth, a plastic been left in between teeth.
instrument is used to tease the dam under the wings
of the clamp. Problems Encountered in Rubber Dam Placement
– Use dental floss to pass the dam through contacts.
• Double motion technique. • Leakage – Due to error in placement, seepage can
– Punch appropriate size hole on the dam material. occur.
– Then the rubber dam is loosely attached to the four – In patients with excessive salivation, saliva
corners of the frame. may seep even through well-placed rubber
– The selected clamp is placed over the bulk of contour dam.
of the tooth to be isolated. Solution – Meticulous placement of rubber dam.
– The rubber dam is stretched over the clamp. – Premedication with anticholinergic drug to
– Then it is stretched onto all prongs of the frame. reduce saliva.
– Use dental floss to pass the dam through the contacts.
Figure 10.11 shows diagrammatic representation
of rubber dam placement.
• Split dam technique: To isolate anterior teeth without
using rubber dam clamp. It can also be used for tooth
with insufficient structure.
Figure 10.10 shows photograph showing rubber
dam in place for Endodontic treatment in mandibular
first molar and Figure 10.12 shows access opening of
maxillary central incisor with rubber dam in place.

Rubber Dam Removal.

i. In case of rubber dam applied to isolate single tooth,
remove the clamp with the forceps and remove the
rubber dam.
ii. In case of multiple teeth applications
Fig. 10.11  An ivory no. 3 clamp has been trial-fitted to the
a. Remove the clamp. mandibular first molar. After trying, the clamp is removed and placed
b. Place finger under the dam in the vestibule and on the rubber dam (Single motion technique) or the rubber dam is
stretch the dam to the facial, away from the teeth. stretched over the clamp (Double motion technique)

Fig. 10.10  Rubber dam in place for Endodontic treatment in Fig. 10.12  Access opening in maxillary central incisor with rubber
mandibular first molar (Courtesy of Dr Manoj Ramugade) dam in place (Courtesy of Dr Manoj Ramugade)

• Insufficient tooth structure: There is problem during
placement of clamp.
Solution – Use clamps with prongs inclined apically.
– Consider restorative procedures to build-up
the tooth so that the retainer can be placed
properly.
– Canal projection technique: Allows pre­
Endodontic build-up of broken down
coronal and radicular structure while
preserving individualized access to canal.
Pre-Endodontic build-up: It may be
necessary in some cases to supply a missing
wall with amalgam or composite or an
orthodontic band may be cemented over the
remaining natural crown before Endodontic
treatment is begun to prevent the rubber-
dam clamp from slipping off the tooth and
to facilitate proper placement of retainer.
• Partially erupted, broken tooth or tooth prepared for
crown: Cause inadequate clamp placement.
Solution: Customize the rubber dam retainer by
modifying the jaws to adapt to a particular tooth.
• Tooth with extreme mobility or multiple adjacent teeth
requiring treatment: Clamp the posterior tooth normally,
whereas a second clamp is reversed on the most anterior
tooth.
Or
Clamp the posterior tooth normally, whereas anterior
portion of dam is retained without a clamp.
Situations where use of rubber dam is contraindicated:
• Asthamatic patients
• Patients with allergy to latex, nonlatex material will have
to be used.
• Mouthbreathers
Principle 2: Sterilization
This principle is discussed in detail in Chapter 12.
Principle 3: Debridement
• The infected root canal must be cleaned of debris by
thorough biomechanical preparation (cleaning and
shaping) and chemical means by use of root canal
irrigants and disinfectants.
• Combination of instrumentation and irrigation help to
remove all necrotic material and debris from the root canal
resulting in complete debridement and cleansing of root
canal.
• Presence of dead tissue in the canal prevents disinfection
and repair.
Principles of Endodontic Treatment 155
• Grossman’s statement: “It is not so much what you put
into a root canal, but what you take out that counts.”
Although for successful Endodontic treatment, both are
important.
Principle 4: Drainage
In case of gross infection and swelling, drainage is
established through the root canal or incision or both.
Drainage through the root canal is preferable as it
allows pus, necrotic tissue, toxic products and gas to
escape. But in case if access is difficult, or tooth is very
tender and access cavity cannot be prepared and a soft
fluctuant swelling present, then incision and drainage is
treatment of choice.
Drainage through the incision is made from the most
dependent part of the swelling near the root apex.
In case of a hard swelling, it is converted into soft, fluctuant
swelling by warm rinses and then the incision is made.
In case of swelling, patient should be instructed not
to apply heat to outside of face, as it can cause sinus tract
(fistula) leaving a scar.
In case of a large swelling, after the incision is made, a
drain is inserted to keep the wound open.
Principle 5: Chemoprophylaxis
Patients with history of rheumatic fever or congenital heart
disease require prophylactic antibiotics to prevent bacterial
Endocarditis.
Two gram of phenoxymethyl penicillin 1 hour before
treatment and then 1 g six hours postoperatively.
In case of allergy to penicillin, erythromycin is given.
Dose is 1 g 1 hour before treatment and 500 mg 6 hours
postoperatively.
Principle 6: Immobilization
The affected tooth can be immobilized by relieving occlusal
stress or contact with the opposing tooth.
Slightly relieving occlusion in an Endodontic case,
lessens the possibility of traumatizing the periodontal
ligament. Another philosophy is only to disocclude in lateral
excursive movement.
Figures 10.13 and 10.14 show relieved occlusal cusps
of mandibular molar during the first appointment of
Endodontic treatment.
Principle 7: Avoidance of Trauma
• Gentle handling of soft tissues
• Prevent overinstrumentation
156 Short Textbook of Endodontics

Fig. 10.13  Reduction of occlusal contacts to relieve the tooth of Fig. 10.14  Access preparation and relieved occlusal contact
occlusion during the first appointment of Endodontic treatment of mandibular molar during first appointment of Endodontic
(Courtesy of Dr Manoj Ramugade) treatment, to reduce the possibility of pain by traumatizing PDL
(Courtesy of Dr Manoj Ramugade)

Fig. 10.15  A mind-map to remember the principles of Endodontic treatment

 Principles of Endodontic Treatment 157

• Determine accurate working length and follow it during Principle 9: Irritation by Chemicals Avoidance
instrumentation to confine all the instruments within
the root canal to minimize trauma to periapical tissues. Irrigating solutions such as sodium hypochlorite or
hydrogen peroxide, if forced through the apical foramen
Principle 8: Trephination can cause considerable pain and edema.
All such irritating drugs should be confined to the root
• Trephination means creating a surgical passage in the canal itself and should not be forced through the apical
region of root apex using a bur or a special drill to provide foramen.
a channel for the escape of pus and blood. This is done Figure 10.15 shows mind-map to remember all points
to relieve the pressure of accumulated fluid or gas in the of the principles of Endodontic treatment.
jaw bone.
• Indications: BIBLIOGRAPHY
– Acute alveolar abscess
– Teeth with large areas of rarefaction 1. Cohen S, Hargreaves KM. Pathways of Pulp, 9th edn. St. Louis:
Mosby, 2006.pp.120-7,
– Overfilled canal with lot of pain and discomfort 2. Grossman L, Oliet S, Del Rio C. Endodontic Practice, 11th edn.
– Postoperative pain following obturation. Varghese Publication, 1991.pp.132-44.
• Not generally recommended as it itself causes surgical 3. Ingle J, Bakland L, Baumgartner J. Ingle’s Endodontics, 6th edn.
trauma. BC Decker Inc, Hamilton, 2008.pp.791-9,
 Endodontic
Armamentarium:

11
CHAPTER

Instruments, Materials
and Devices

This chapter classifies the Endodontic Armamentarium according to their use in various Endodontic
procedures. Some of them have only been listed, their detailed description is given in the respective
chapters along with the procedures and techniques in which they are used.
  You must know
• What Changes have Occurred in the Endodontic Armamentarium in the Practice of Modern
Endodontics?
• What are the Devices used for Enhanced Vision, lllumination and Magnification?
• What are the Instruments, Materials and Devices used as Diagnostic Aids in Endodontics?
• What is the Armamentarium for Administration of Local Anesthesia?
• What are the Materials used for Isolation of Endodontic Field?
• What is the Armamentarium Needed for Access Cavity Preparation?
• What are the Instruments and Devices for Determination of Working Length?
• What are the Materials used for Disinfection of Root Canal?
• What are the Instruments and Devices for Root Canal Preparation (Endodontic Instruments)?
• What are the Instruments used for Obturation of Root Canal System?
• What are the Instruments and Devices for Removal of Root Canal Obstructions and Fillings?
• What are the Materials used as Temporary Restorations?
• What are the Materials used for Post-Endodontic Restoration?
• What is the Armamentarium for Periradicular Surgery?
• What is the Role of Laser Device in Endodontics?

WHAT CHANGES HAVE OCCURRED IN THE
ENDODONTIC ARMAMENTARIUM IN THE
PRACTICE OF MODERN ENDODONTICS?
In last 2–3 decades, following changes have occurred in the
Endodontic armamentarium:
• Enhanced vision with magnification devices such
as surgical operating microscope/dental operating
microscope.
• Improvements in diagnostic aids: For example,
– Enhanced imaging with digital radiography (RVG)
– Laser Doppler flowmeter and other newer devices
to precisely detect pulp vitality
– Advanced 3D imaging—Cone beam computed
tomography (CBCT) scans.
• Electronic apex locators to precisely determine the
working length and the apical termination position
(apical constriction) of root canal preparation and filling.
• Improved instruments for effective coronal and radicular
access cavity preparation.
• Nickel-titanium Endodontic instruments for refined
cleaning and shaping of canals.
• Thermoplasticized and newer obturation systems for
denser and three-dimensional obturation with gutta-
percha.
• Improved and simplified post systems and core build-up
materials for badly broken down teeth.
• Microsurgical instruments for periradicular surgery.
• Retreatment devices for removal of old obturations and
obstructions.
 Endodontic Armamentarium: Instruments, Materials and Devices
• Ultrasonic devices for enhanced irrigation and many
other irrigation devices and methods.
• Introduction of lasers in Endodontics.
Newer armamentarium have made Endodontic
treatment predictable, quicker and simpler too!
WHAT ARE THE DEVICES USED FOR ENHANCED
VISION, ILLUMINATION AND MAGNIFICATION?
Earlier, the root canal system could be viewed only on the
radiographs and that also gave a two-dimensional image
of the three-dimensional biological system. But with the
advent of optical magnification instruments such as loupes,
microscope, endoscope and orascope, the root canal system
can actually be viewed in a magnified form, thereby allowing
the clinician to perform the Endodontic procedures with
great precision and ease.
Dental Loupes
• Also called as surgical telescopes.
• Dental loupes are currently the most common
magnification aid used in dentistry.
• Dental loupes consist of convergent lenses attached to
the regular glasses of the spectacles. Figure 11.1 shows
photograph of Loupes.
• Single lens loupes have fixed focal length and working
distance.
• Loupes used in dentistry generally consist of multi-
lens optic system called as Galilean optical system that
provides better magnification and improved working
distance.
Fig. 11.1  Photograph showing loupes
(Courtesy of Dr CR Suvarna)
159
• Properties of telescopic loupes:
– Magnification : L oupes are available with
magnification of 2X, 2.5X, 4X, 6X, etc.
2.5X is considered to be ideal magnification with
telescopic loupes, as higher magnification causes
problems such as change in depth of field with the
change in operator’s position, and problems related
to working distance. Also, more illumination is
required with increase in magnification in loupes.
– Working distance: Distance from dentist’s eye to the
field of treatment is the working distance.
2.5X magnification allows comfortable working
distance thus improved posture of the operator while
working.
– Depth of field: It is the distance between the nearest
and the farthest objects appearing in a sharp focus.
Dental loupes provide good depth of field.
– Field of view: It is the total area visible through optical
magnification.
Dental loupes provides an acceptable field of view
required to perform regular procedures.
– Illumination: Some of the loupes are manufactured
with the attached light sources to improve
illumination.
• Advantages:
– Improved vision due to magnification
– Improves body posture during working preventing
the possible neck and back strain
– Good optical properties
– Acceptable weight
• Disadvantages:
– Does not satisfy the magnification need for Endodontic
treatment which may be from somewhere around 3X
to 30X. If more than 2.5X magnification is used with
loupes, problems occur related to depth of field and
working distance
– Weight on the face and head of the operator while
working which may be quite uncomfortable.
– Optical performance not acceptable for Endodontic
purposes.
– Some clinicians may take time to get used to it.
Dental Operating Microscope/
Surgical Operating Microscope
• The use and benefits of an operating microscope
for conventional Endodontics was first reported by
Baumann.
• Dental operating microscope (DOM) or surgical
operating microscope (SOM) also uses the Galilean lens
system.
160 Short Textbook of Endodontics
• It is an invaluable optical magnification instrument.
• With the advent of DOM, performing Endodontic
therapy is no longer a blind procedure that was earlier
based on tactile sensation and presumptions.
• Components of DOM and its uses:
The components of DOM include the following:
– Eye piece
– Binocular field glasses
– Magnification changer
– Objective lens
– Fiberoptic light source
Figure 11.2 shows schematic view of dental operating
microscope and Figure 11.3 shows the photograph of the
head portion of the dental operating microscope.
- In DOM, the eyepiece connected to the binocular
field glasses allows adequate focal length, the
magnification changer adds to the flexibility
of DOM and the objective lens increases the
magnification.
- The magnification of DOM is determined by :
a. The magnification power of the eyepiece: The
eyepiece has -5 to +5 diopter settings which
are used to adjust for accommodation (ability
to focus the lens of eyes).
b. The focal length of the binoculars: The distance
between the binocular tubes is adjusted to set
the interpupillary distance. With increased
focal length, the magnification is more but
the field of view becomes less.
c. The magnification changer factor: Magnifica­
tion changers are located within the head
Fig. 11.2  Dental operating microscope
of microscope and are available as 3- to
5-step manual changers or power zoom
changers. Manual step changers contain
lenses mounted on a turret. Power zoom
changers is series that move back and forth
on a focusing ring giving wide range of
magnification factors.
d. The focal length of the objective lens: Objective
lenses with focal length ranging from 100
to 400 mm are available. The focal length
of objective lens determines the operating
distance between the objective lens and the
surgical field.
- DOM satisfies the magnification need of
Endodontic treatment. DOM can provide magni­
fication ranging from  3X to 27X. The required
magnification can be adjusted.
• Illumination
– The light source for DOM is 100 watt xenon (white)/
halogen bulb (yellow)
– The intensity of light is controlled by rheostat,
then light reflected to a series of prisms (through
condensing lens) and then to surgical field (through
objective lens)
– The light reaches the surgical field and is reflected
back to the eyes as two separate beams of light
(through the objective lens through magnification
changer lenses through binoculars) causing a
stereoscopic effect allowing clinician to see depth
of field.
• Documentation using DOM
– Good quality slides and videos can be obtained if
the quality of the magnification and illumination
systems within the microscope is good.
– Beam splitter provides illumination for photographic
and video documentation and is attached to the
camera through an adaptor.
• Accessories: Include
– Auxillary monocular or binoculars that can be added
and used by dental assistant.
– LCD screen, which receives its signal from video
camera, etc.
• Mounting of DOM:
– The head portion of microscope should be firmly
attached to a rigid surface in order to reduce its
oscillating movement,
– The head portion of DOM is supported by a counter-
balanced arm which in turn is attached to a floor, wall
or ceiling for its free movement and for easy access
to oral cavity.
 Endodontic Armamentarium: Instruments, Materials and Devices
• Instruments used for Micro-Endodontics:
– While using DOM for viewing Endodontic treatment
field, a standard dental mirror or micromirror is used
to overcome the angulation difficulties of certain
tooth positions in the mouth. Mirror placed slightly
away from the tooth at an angle of 45 degrees to the
microscope for better view.
– Microinstruments for locating canals
– Endodontic files called micro-openers
– Other microinstruments.
• Advantages:
– Enhanced vision of treatment field due to enhanced
illumination and magnification.
– Dentin can be removed with great precision.
– Increased ability to locate and negotiate canals.
– DOM is a valuable aid for removing separated
instruments, for diagnosis of microfractures and for
repairing root perforations.
– DOM is a very useful tool for case documentation.
– In Surgical Endodontic treatment, DOM is very
effective as it causes enhanced view of surgical
treatment field and need to take fewer radiographs.
– With DOM, the Endodontic management of failed
cases has become easier and more predictable.
• Disadvantages:
– Cost
– Difficulties encountered while using it related
to convenience, position, angulation, etc. till the
clinician gets trained and experienced.
– Increased treatment time.
Other advanced magnification devices: Endoscope and
orascope (Fiberoptic Endoscope)
Fig. 11.3  Photograph of head portion of dental operating
microscope (Courtesy of Seiler)
161
WHAT ARE THE INSTRUMENTS, MATERIALS
AND DEVICES USED AS DIAGNOSTIC
AIDS IN ENDODONTICS?
Endodontic Armamentarium required for diagnosis and
various diagnostic procedures include:
• Instruments for clinical examination:
– Mouth mirror
– Standard dental explorer
– Periodontal probe
– DG-16 Endodontic explorer.
Figure 11.4 shows schematic representation of DG-16
Endodontic explorer.
• Radiography: Discussed in detail in Chapter 7 Diagnosis
and Diagnostic Aids in Endodontics.
• Instruments and materials for diagnostic tests:
– Materials used for thermal tests: (Thermometric
evaluation)
Agents for heat test:
- Warm water bath
- Heated ball burnisher
- Heated gutta-percha stick
- Rotating burlew rubber wheel
- System B
Agents for cold test:
- Sticks of ice
- Frozen CO2 or dry  ice (–78oC)
- Endo ice (1,1,1,2-Tetrafluoroethane):
- Ethyl chloride
- Cold water bath.
Thermal tests are explained in detail in Chapter
7 Diagnosis and Diagnostic Aids in Endodontics.
• Device for electric pulp test: Electrometric/Electric pulp
tester
Electric pulp tester (EPT):
– It is used to evaluate the responding nerve endings.
When an electric current is passed through the tooth,
patient feels the sensation as a result of direct nerve
stimulation.
– Various types of EPT are commercially available.
Some newer units have electric pulp testing and
Electronic apex locator combined in one unit.
– Electric pulp testing is based on Ohm’s law: E = R
× I (where E—Electromotive force, R—Resistance,
I—Current flowing through resistance.) Enamel and
dentin constitute high resistance in electric circuit
Fig. 11.4  Schematic representation of DG-16
Endodontic explorer
162 Short Textbook of Endodontics

through the tooth. The pulp testers operate at high Figure 11.7 shows photograph of commercially
potential difference but a very low current (mA). available caries detector dye.
– Earlier, electric pulp testing devices were not well- • Devices for transillumination test: Fiberoptic light is used
calibrated and had such a design that sometimes as light source, which can be specifically designed for
applied higher current directly to the tooth causing transillumination test.
great discomfort. Figures 11.8A and B shows photograph of fiberoptic
– Newer electric pulp tester (EPT) devices use battery light source for transillumination test.
or AC power in which the speed of delivery of current Handpiece with fiberoptic activated or other bright
can be adjusted. point light source can also be used for transillumination.
Figure 11.5 shows schematic representation of
electric pulp tester. Transillumination test has been explained in Chapter 7:
The electric pulp test has been described in Chapter Diagnosis and Diagnostic Aids in Endodontics.
7: Diagnosis and Diagnostic Aids in Endodontics.
• Device for testing pulp vitality: Laser Doppler flowmeter
and pulse oximeter assess pulpal blood flow to
determine the pulp vitality. (Explained in Chapter 7:
Diagnosis and Diagnostic Aids in Endodontics)
• Devices used for bite test:
– Cotton rolls
– Wooden end of cotton tip applicator
– Rubber polishing wheel
– Tooth slooth: Tooth slooth is specifically designed for
performing bite test. Figure 11.6 shows photograph
of tooth slooth.
It has the design that allows the biting force to be
applied  selectively to one cusp at a time so that the
specific areas can be determined for the diagnosis
of incomplete crown fracture. Bite test is described
in Chapter 7: Diagnosis and Diagnostic Aids in
Endodontics.
• Stains used for caries detection and for diagnosis of Fig. 11.7  Commercially available caries detector dye
cracks or fracture: (Courtesy of Mr Amar, Dr Dabholkar’s clinic)
– Acid red in 1% propylene glycol
– Methylene blue dye
– India ink

Fig. 11.5  Electric pulp tester

A

B
Fig. 11.6  Tooth slooth (Courtesy of Dr CR Suvarna) Figs 11.8A and B  Fiberoptic light source for transillumination test
(Courtesy of Dr CR Suvarna)
 Endodontic Armamentarium: Instruments, Materials and Devices 163

WHAT IS THE ARMAMENTARIUM FOR Handpieces

ADMINISTRATION OF LOCAL ANESTHESIA?
• Topical local anesthetic agent
• Lignocaine hydrochloride 2% with and without
Adrenaline
• Disposable syringes and needles
• Cartridges
• Special pressure syringe for intrapulpal anesthesia.
(These have been discussed in Chapter 17: Drugs or
Medicaments used in Endodontic Treatment)
WHAT ARE THE MATERIALS USED FOR
ISOLATION OF ENDODONTIC FIELD?
Use of rubber dam is considered to be mandatory for non-
surgical Endodontic therapy.
Rubber dam armamentarium has been discussed in
detail in Chapter 10 ‘Principles of Endodontic Treatment’.
WHAT IS THE ARMAMENTARIUM NEEDED
FOR ACCESS CAVITY PREPARATION OF ROOT
CANAL?
Magnification and Illumination
• Use of magnification and an appropriate light source is
needed for adequate access cavity preparation.
• The preferred means of magnification and illumination
is dental operating microscope (DOM). If not, then
surgical loupes with an auxiliary light source should be
used at least.
• High speed handpiece: For initial penetration.
• Slow speed handpiece: For deeper penetration and in
case of calcified and receded pulp chambers.
• Low-speed contra-angle handpiece.
Burs (Figs 11.9A and B)
• For removal of caries, initial penetration and deroofing
the pulp chamber:
– Round carbide burs (Medium sizes such as #2, #4).
– In case if the teeth requiring access preparations have
restorations such as porcelain fused to metal crown,
then Round diamond burs need to be used.
– In case if the tooth has receded pulp chamber and
calcified orifices, Extended shank round burs will
have to be used that move the head of handpiece
away from tooth, thus improving visibility. For
example, LN Bur (Dentsply) or Ultrasonics can be
used.
– Tapered fissure burs with rounded cutting end:
Advantage is that same can be used for axial wall
extension of access cavity preparation. But should be
carefully used, especially by inexperienced clinicians
as their cutting ends can gouge the pulp floor and
axial walls.
– Transmetal burs (for penetration through metal)
• For extension of axial walls:
– Safe-ended diamond and tungsten carbide burs.
These burs have the tip or end which is noncutting
and sides are cutting. For example, Endo access bur,
Endo Z bur, safe nonend cutting bur.

A B
Figs 11.9A and B  Access preparation bur kit showing round bur, transmetal bur, long shank round burs, safe-ended bur and X-gates
(Courtesy of Dentsply)
164 Short Textbook of Endodontics
B
Figs 11.10A and B  Safe-ended carbide bur:
(A) Endo access bur; (B) Endo Z bur (Courtesy of Dentsply)
Figures 11.10A and B shows photograph of safe-
ended carbide bur.
These burs are used for final refinement extending
from enamel to pulpal floor orienting the bur along the
axial walls without causing gouging. So, they are safer
choice for axial wall extensions.
• For occlusal reduction: Fissure carbide and diamond burs
also can be used to reduce or level off the cusp tips and
incisal edges for two reasons:
– Disocclusion of tooth in case of inflammation.
– Flat cusp tips and incisal edges can be used as
reproducible reference points during working length
determination.
• For enlarging the orifices and preflaring of coronal
portion of root canal: Root canal orifices have to be
blended into the axial walls in order to gain straight-line
access (SLA) so that the subsequent instruments used
for cleaning and shaping can enter the root canal easily
and effortlessly. This can be done using Gates Glidden
drills.
Gates Glidden Drills
These are engine driven reamers used in Endodontics.
• Instrument design:
– Gates Glidden (GG) drill has
- A long, thin shaft
- A flame-shaped head with a safe tip.
  Shaft is designed in such a way that the
weakest part of the shaft is at the neck, which
Fig. 11.11  Gates Glidden 1 to 6
is the narrowest diameter lying adjacent to the
handpiece. If the drill binds during use and the
instrument separates, the separation occurs at
the neck and the separated part can be removed
from the canal easily.
  Flame-shaped head cuts laterally and it has a
safe tip to guard against perforations.
– The GG drills are available in various lengths such
as 28 mm, 32 mm, etc.
– The GG drills are available in a set of 6 instruments
with a diameter ranging from 0.5 mm to 1.5 mm. The
specific drill size can be identified by the number of
rings on the shank.
Figure 11.11 shows photograph of Gates Glidden
drills 1–6.
GG 1: 0.5 mm diameter (ISO size # 50) with one ring on
shank
GG 2: 0.7 mm diameter (ISO size # 70) with two rings
on shank
GG 3: 0.9 mm diameter (ISO size # 90) with three rings
on shank
GG 4: 1.1 mm diameter (ISO size # 110) with four rings
on shank
GG 5: 1.3 mm diameter (ISO size # 130) with five rings
on shank
GG 6: 1.5 mm diameter (ISO size # 150) with six rings
on shank.
An instrument called X gates (GG X) drill has been
manufactured which has features of GG1 to GG4. It has
no ring on the shank. It has better cutting efficiency.
 Endodontic Armamentarium: Instruments, Materials and Devices 165

progressing shorter than the preceding one with larger

Fig. 11.12  X Gates (GGX)
Figure 11.12 shows diagrammatic representation of
X-gates (GGX).
• USES: GG drills are used for:
– Pre-enlargement of coronal areas of root canal.
– To remove dentin overhangs such as lingual shoulder
in anterior teeth and the cervical dentin bulge in
posterior teeth during access preparation in order
to achieve straight line access (SLA) to the canals.
– To clean and shape the cervical 1/3rd of the root
canals using the step-back and step-down (crown-
down) techniques.
– GG drills open and flare the root canal orifices that
facilitates better cleaning by allowing more amount
of irrigants to penetrate into the root canal system
and better shaping procedures by establishing
smooth glide path from the access cavity into the
root canal system.
Cutting Action
The GG drills are side-cutting instruments that cut dentin
during an outstroke movement as they are withdrawn from
the canal.
The optimum speed at which the GG drills can be used
safely is about 800 rpm (750–1500 rpm).
While using GG drills, they should be directed away
from the external root concavities in anterior teeth and the
furcation area in posterior teeth to prevent mishaps such
as perforations. In posterior teeth, using GG drill in the
direction of the name of the canal directs it away from the
furcation.
size drills in sequence.
Advantages
• Safe to use
• Inexpensive
• No fear of separation in the canal as in case if it does
separate, it occurs at the neck so that the separated part
can be easily removed from the canal
• Useful for initial opening of root canal orifices and also
for deeper penetration in both straight and curved canals
• Causes pre-enlargement of coronal part of canal making
the subsequent cleaning and shaping procedures easier.
Disadvantages
Improper use can cause:
• Strip perforations of canals:
– Such as using it at a high speed
– Applying excessive pressure while using
– Inserting it in incorrect direction.
• Fracture of short cutting heads: Due to high torsional
loads or due to cyclic fatigue when GG drills are used
in the areas of curvature of the canals, the short cutting
heads may fracture.
• Coke bottle preparation: Overzealous use of GG drills
causes  the so-called “coke-bottle” shape of canal, as
shown in Figure 11.13.

Manner of Use
The GG drills are used with air motors or preferably with
electric gear reduction handpieces.
They should be inserted in the correct direction and
used passively without any pressure. They should be used
only in straight portion of canal.
Their use should follow the sequence of their sizes.
• In step-down technique, starting with larger size drill
that can be introduced into the orifice and progressing
deeper into the coronal 1/3rd of root canal with smaller
size drills.
• In step-back technique, starting with smaller size drill Fig. 11.13  Overzealous use of Gates Glidden causing
into the coronal 1/3rd of root canal and withdrawn and coke bottle effect
166 Short Textbook of Endodontics
Fig. 11.14  A mind-map to remember Gates Glidden drills
A mind-map to remember all points of Gates Glidden
drills is given in Figure 11.14.
Hand Instruments for Access Preparation
• Mouth mirror
• Probe
• Explorer
• DG-16 Endodontic explorer: It is used for location of root
canal orifices and to determine the angulation of the
canals. The two ends of Endodontic explorer are sharp
and angled in two different directions from the long axis
of instrument.
• Endodontic spoon excavator or Endodontic spoon is
slightly different from regular dental spoons in that
they have a much longer offset from the long axis of the
instrument for better reach inside the constricted pulp
chambers.
This is used to:
– Scoop out carious dentin
– To excise coronal pulp tissue.
Figures 11.15A and B shows diagrammatic representation
of DG-16 Endodontic explorer and Endodontic spoon
excavator respectively.
Endodontic spoon excavators are designed in such a
way that they are offset from the long axis of the instrument.
 Endodontic Armamentarium: Instruments, Materials and Devices
B
Figs 11.15A to B  Diagrammatic representation of DG-16
Endodontic explorer (A) and Endodontic spoon excavator (B)
This design facilitates access to the constricted pulp
chambers so that the entire pulp tissue can be removed.
Ultrasonic Unit and Various Ultrasonic Tips
During access cavity preparation, ultrasonic tips can be
useful for exploring the root canal orifices by troughing and
deepening the developmental grooves to remove the tissue
with minimal collateral tooth structure removal.
Figure 11.16 shows Endodontic ultrasonic tips.
Ultrasonics for Endodontic use has been described in detail,
later in this chapter.
WHAT ARE THE INSTRUMENTS
AND DEVICES FOR DETERMINATION
OF WORKING LENGTH?
• Millimeter ruler or Endo block for measurement of
instrument length
• Radiographs
• Smaller size, i.e. #8, #10, #15 number K-files with rubber
stops
• Electronic apex locators
• Paper points.
Currently, it is believed that the use of radiographs
in combination with the apex locators can accurately
determine the working length. Details of working length
determination using the above are given in Chapter 14
Cleaning and Shaping of Root Canal System Including
Working Length Determination.
Electronic Apex Locator
Electronic apex locator is an electrical device which helps
to estimate the working length.
It indicates the position of apical constriction by means
of some “sound”, or “movement of a dial on the display
screen”.
167
Fig. 11.16  Start X ultrasonic tips 1—Access cavity walls, 2—MB2
canal scouting, 3—calcified canal scouting and fiber postremoval,
4—Metal postremoval, 5—finishing pulp chamber floor.
(Courtesy of Dentsply)
Generations of Apex Locator
• First generation apex locators: Also called resistance
apex locator and are based on direct current.
– Principle: Based on the principle that the resistance
offered by periodontal ligament and oral mucous
membrane is the same.
– With the file advancing in the canal, when the
conductive periodontal ligament is reached, the
resistance decreases until the circuit is complete.
– The first generation apex locators are no longer used.
• Second generation apex locators:
– Principle: Based on impedance of single-frequency,
that measure opposition to the flow of alternating
current. The property of impedance includes both
resistance and capacitance.
– These apex locators gave more information than the
first generation apex locators.
The first and second generation apex locators
were found to be sensitive to the contents of the
canal including the irrigating solutions used during
treatment. So they require the canals to be dry to give
accurate readings.
• Third generation apex locators:
– Principle: Based on impedance of multiple
frequencies.
– There is difference in impedance in different parts of
the root canal, being least in the coronal part of the
canal and greatest at the cementodentinal junction.
168 Short Textbook of Endodontics

– It was found that electrolytes did not have significant

effect on the accuracy of the unit.
– Commercially available third generation apex
locators include: Root ZX which emits the current at
the frequency of 8 and 0.4 KHz and the Endex device
which emits the current at the frequency of 1 and 5
KHz.
• Fourth generation apex locators:
– These apex locators are the latest ones that use
multiple frequencies and they overcome the
disadvantages of the previous generation apex
locators.
– Principle: It measures the individual components
of impedance, i.e. resistance and capacitance
independently and compares the information to a
database to determine the correct working length.
– Less chances of error as different combinations of the
properties provide the same reading of impedance.
– Since multiple frequencies are used, the electrolytes
or canal contents do not have any effect on the
accuracy of the unit.
– Commercially available fourth generation apex
locators include APA apex finder and Elements
diagnostic unit.
Fig. 11.17  Apex locator with its components: 1—Lip clip; 2—File
The third and fourth generation apex locators are based on clip; 3—Display screen; 4—Cord connecting the above components
the fact that:
There is difference in impedance between the high and • Crown-down preparation of canal: It has been found that
low frequencies at different portions of root canal. preflaring of the coronal portion of the root canals and
• Coronal portion of the canal shows the least difference removal of dentin obstructions from within the coronal
between frequencies. access cavity increases the accuracy of the apex locator.
• Deeper portions of the canal show more difference • Type and size of file used: The type of file, whether
between frequencies. stainless steel or nickel-titanium and the size of file,
• Cementodentinal junction of the canal shows the smaller or larger does not affect the accuracy of the apex
greatest difference between frequencies. locator.
• Metallic restorations: It has been found that if the
Components of an Electronic Apex Locator file used with the apex locator contacts the metallic
restoration or the fluid in contact with the metallic
• Lip clip restoration then the apex locator gives false readings.
• File clip
• Instrument with the display screen Apex Locator and Cardiac Pacemaker
• A cord connecting the above three parts.
Figure 11.17 shows the photograph of commercially Electronic apex locators should not be used in patients
available apex locator and components. with cardiac pacemakers. It requires consultation with the
patient’s cardiologist regarding their use in such patients.
Factors Determining the Accuracy of Apex Locators
Advantages and disadvantages of electronic apex locator
• Dry and wet conditions of canal: Earlier generation apex have been explained in Chapter 14 Cleaning and Shaping
locators gave accurate readings only in dry canals. Newer of the Root Canal System Including Working Length
generation apex locators are found to give accurate Determination.
readings in both dry and wet conditions including the A mind-map to remember all points of apex locators is
presence of pulp tissue, irrigating solutions and blood. given in Figure 11.18.
 Endodontic Armamentarium: Instruments, Materials and Devices 169

Fig. 11.18  A mind-map to remember electronic apex locators

WHAT ARE THE MATERIALS USED FOR WHAT ARE THE INSTRUMENTS AND
DISINFECTION OF THE ROOT CANAL? DEVICES USED FOR ROOT CANAL
PREPARATION?
Chemical agents for disinfection of root canal include:
• Root canal irrigants
• Decalcifying materials Classification of Endodontic Instruments
• Intracanal medicaments.
These have been discussed in detail in Chapter 15 • Grossman has classified the Endodontic instruments
Disinfection of the Root Canal System. according to their function.
170 Short Textbook of Endodontics

• According to manner of use, Endodontic instruments

can be classified as follows. This nomenclature follows
the recommendations of the International Organization
for Standardization (ISO)

• Cohen has classified Endodontic instruments for root

canal preparation into three groups:

HAND-OPERATED INSTRUMENTS

ISO Standardization for Root Canal Instruments

Ingle and Levine gave few specifications for the

standardization of root canal instruments which have been
revised and also new specifications have been added with
the introduction of newer instruments.
• Classification given by ISO-FDI (Federation Dentaire
• Numbering of instruments : Ingle and Levine
International) according to method of use:
recommended that the instruments shall be numbered
from 10 to 100, the numbers to advance by 5 units to size
60, then by 10 units to size 100.
Later smaller numbers such as sizes 6 and 8 and
larger numbers to the size 140 also became available.
Thus, the standardization is that the instruments are
numbered from 6 to 140, the numbers include #6, #8, then
from #10 to #60 sizes, numbers advance by 5 units and
then from sizes #60 to #140, numbers advance by 10 units.
• Diameter of instrument tip: The number of the instrument
is representative of the diameter of instrument in
hundredths of a millimeter at the tip.
For example: No. 6 is 6/100, i.e. 0.06 mm at the tip
No. 10 is 10/100, i.e. 0.1 mm at the tip, etc.
• The working blade: The working blade begins at the tip,
which is an imaginary measuring point designated as
Do (or D1) which projects the taper of the instrument at
the tip and extends to a length of 16 mm terminating at
point D16 (or D2) which represents the diameter at the
 Endodontic Armamentarium: Instruments, Materials and Devices 171

end of the working part of instrument. Thus, the working • Color coding of instrument: Instrument handles have
part of instrument must be at least 16 mm long. A new been color coded to recognize them easily. Specific color
diameter measurement point D3 was added, according is given to the numeric diameter at Do.
to ADA specification no. 28, D3 is the diameter point
Color code Instrument number Diameter at Do (mm)
3 mm from the tip of the cutting end of the instrument.
Figure 11.19 shows diagrammatic representation of Pink #6 0.06
root canal instrument standardization. Gray #8 0.08
Purple # 10 0.10
• Taper of instrument: As per ISO standardization, there
White # 15 0.15
was a constant increase in taper of 0.02 mm (2%) per Yellow # 20 0.20
millimeter for every instrument regardless of size. Red # 25 0.25
Nowadays, instruments with greater taper such as Blue # 30 0.30
0.04, 0.06, 0.08, 0.10 and 0.12 have become popular. It Green # 35 0.35
Black # 40 0.40
means that with every millimeter increase in the length
White # 45 0.45
of the cutting blade, the width (taper) of instrument Yellow # 50 0.50
increases by 0.04, 0.06, 0.08 of a millimeter rather Red # 55 0.55
than the ISO standard of 0.02 mm/mm. These new Blue # 60 0.60
instruments with the increased taper allow for the Green # 70 0.70
Black # 80 0.80
greater coronal flaring than the 0.02 instruments.
White # 90 0.90
Some manufacturers have even made half sizes in the Yellow # 100 1.00
0.02 flare such as 2.5, 17.5, 22.5, 27.5, 32.5, 37.5. These Red # 110 1.10
have been made for shaping extremely fine canals. Blue # 120 1.20
• Working diameter of instrument: It is the product of the Green # 130 1.30
Black # 140 1.40
taper and the length of the tip, i.e.
The working diameter of an instrument = taper × length
of tip • Material of instrument : Earlier instruments were
= 0.02 × 16 manufactured using carbon steel which were susceptible
= 0.32 mm greater than the diameter at Do. to corrosion usually on contact with sodium hypochlorite
For example, No. 20 file will have working diameter of: solution and were more likely to fracture when strained
= 0.02 + 0.32 (deformed).
= 0.52 mm Now, instruments are universally made of stainless
• Tip angle of instrument: The tip angle of an instrument steel and nickel-titanium.
is about 75 ± 15o • Manufacture of instrument: Smaller size finer instru­
• Length of instrument: Instruments are available in ments may break if they bind in the root canal. So, they
standard lengths of 21 mm, 25 mm, 28 mm and 31 mm. are manufactured from square blanks to make them
Short instruments are helpful in 2nd and 3rd molars and resistant to torque fractures. Triangular blanks are used
when patients cannot open the mouth wide and longer for larger instruments to improve their cutting efficiency.
instruments are often required for canines. Shorter Besides the ISO standards, the instruments and filling
length instrument such as 19 mm have also become materials have been numbered as per the standards
available now. given by American National Standards Institute (ANSI)
as follows:
ANSI number Instrument

No. 58 Hedstroem file

No. 63 Rasps and barbed broaches
No. 71 Spreaders and condensers
No. 95 Root canal enlargers
No. 57 Filling materials
No. 73 Absorbent points
No. 78 Obturating points

A mind-map to remember all points of IS O

Fig. 11.19  ISO standardization of root canal instrument standardization is given in Figure 11.20.
172 Short Textbook of Endodontics

Fig. 11.20  A mind-map to remember the ISO standardization

Hand Instruments for Root Canal

Preparation in Detail
Broaches and Rasps
• Broaches:
– Broaches are of two types—Smooth broach and
Barbed broach
– Smooth broach does not have barbs and was used
earlier as pathfinder. Now flexible files are available
for this and smooth broaches are no longer used.
– Barbed broaches are short-handled instruments with
barbs.
– ISO Specification No. 63 sets the standards for barbed
broaches.
Figure 11.21 shows photograph of barbed broaches.
– Barbed broaches have taper of about 0.007 to 0.01
– Broaches are available in different sizes, from extra Fig. 11.21  Barbed broaches
fine to extra coarse. (Courtesy of Mr Amar, Dr Dabholkar’s clinic)
 Endodontic Armamentarium: Instruments, Materials and Devices
– Manufacture: Round wire is notched to form
sharp barbs bent at an angle from the long axis to
manufacture these instruments.
– Uses:
- For extirpation of vital pulp
- For removal of loose debris from necrotic canals
- For removal of paper points or cotton pellets from
the canals K-type instruments include:
- For enlarging the canals when used in conjunction
with sonic or reciprocating handpieces.
– Manner of use: A barbed broach should be inserted
in the canal only after it has been enlarged to a size
no. 25 file/reamer. It is inserted in the canal till the
length where it first binds, then rotated to engage the
pulp tissue or debris until it meets resistance against
the canal walls and then gently withdrawn without
twisting.
Increased pressure during use may embed the
barbs onto the canal walls and increased pressure
during its withdrawal from the canal may cause
its separation in the canal and it may be almost
impossible to remove the separated barbed broach
from the canal.
• Rasps:
– Rasps are similar to barbed broaches with some
differences related to taper and barb height.
– Rasps have greater taper (about 0.015–0.02) and
smaller barbs as compared to Broaches.
– Rasps are also used for extirpation of pulp tissue from
the root canal.
Distinguishing features between broaches and rasps
given in Table 11.1.
Fig. 11.22  File stand with instruments arranged in sequence. (Courtesy of Dentsply)
173
Figure 11.22 shows a file stand with Endodontic
instruments arranged in sequence.
K-Type Instruments
These are named so because they were first designed and
manufactured by KERR company.
• K-Reamers
• K-Files
• K-Flex files
• Reamers: Reamers are k-type instruments.
– “Reamers are Endodontic instruments that are used
to cut and enlarge the canals by reaming or rotational
drilling motion, which means penetration, rotation
and retraction”. That means it cuts by inserting in the
canal, twisting clockwise one-quarter to half turn and
then withdrawing.
– Stainless steel wire is ground along its long axis into
tapered triangular cross-section (3-sided), i.e. A
triangular metal blank is twisted along its long axis
to produce a K-reamer (Fig. 11.23).
TABLE 11.1  Distinguishing features of broach and rasp
Broach Rasp
• Has larger and fine thickness •  Has smaller and blunt barbs
barbs
•  Lesser taper (0.007–0.01) • Greater taper (0.015–0.02)
• Barbs present up to half of its • Barbs are present only up to
core diameter, that makes it a 1/3rd of its core
weaker instrument
174 Short Textbook of Endodontics
– Cutting action occurs during retraction/withdrawal
– Reamers have ½ to 1 cutting blade (flute) per mm of
working end
– Reaming is the only method that produces a round,
tapered preparation in straight root canals, where the
reamers are rotated one-half turn. In a slightly curved
canal, reamer is rotated only one-quarter turn as
more stress may lead to its separation (breakage)
– Uses:
- Cutting and machining root dentin
- Penetrating and enlarging root canals for
bringing about shaping or preparation of Root
canals.
• K-files
– Files are Endodontic instruments that are used to
enlarge the canals by rasping motion, which means
“reciprocal insertion and withdrawal motion”.
– Stainless steel wire is ground along its long axis into
tapered square cross-section (4-sided), i.e. A square
metal blank is twisted along its long axis to produce
a K-file (Fig. 11.24).
– Cutting action of K-file: The tighter spiral of
file establishes a cutting angle, called rake,that
achieves its primary action on withdrawal. It can be
used in:
- Filing (Rasping) motion or push-pull motion:
Instrument is placed in the canal till the desired
length, pressure is exerted against the canal wall
and while maintaining pressure the instrument
is withdrawn without turning. The file need not
contact all the root canal walls simultaneously,
it can be used by filing circumferentially around
the walls.
Fig. 11.23  Triangular cross-section of reamer
Fig. 11.24  Square cross-section of K-file
- Reaming (drilling) motion: Similar to reamer:
penetration, rotation and retraction.
– K-files have 1 ½–2 ½ cutting blades (flutes) per mm
of working end.
– Uses of K-files:
- Cutting and machining root dentin
- Penetrating and enlarging root canals for bring-
ing about shaping or preparation of Root canals.
– Few other points about K-files:
- Smaller size K-files such as #6 and #8 files do not
remove any significant amount of dentin except
in severely calcified canals. They are mainly used
to establish patency.
- Significant wear and loss of efficiency occurs
with the repeated use of files. It is recommended
that the smaller size files be discarded after
one or two uses because initially a point crack
develops with its use resulting in metal fatigue in
the fragile instrument which causes its distortion
and breakage with further use.
- Files are generally used in clockwise motion. If
they are rotated in counter clockwise direction,
they are more prone to fracture.
- Copious irrigation should be done in between
using Endodontic files to prevent packing of
debris in the root canal and files should be
lubricated while using in the canal.
- After every use, the flutes of the files should be
carefully inspected for any distortion or cracks.
Distorted files must be discarded otherwise they
may break in the root canal.
Figure 11.25 shows photograph of reamer No. 30 and
K-file No. 30.
K-Reamer
K-file
Fig. 11.25  Photograph showing K-reamer and K-file No. 30
(Courtesy of Dentsply)
 Endodontic Armamentarium: Instruments, Materials and Devices 175

TABLE 11.2  Distinguishing features between K-files and K-reamers

Distinguishing points K-files K-reamers
Manufacture Stainless steel wire is ground along its long axis Stainless steel wire is ground along its long axis
into tapered square cross-section (4-sided), i.e. A into tapered triangular cross-section (3-sided), i.e. A
square metal blank is twisted along its long axis to triangular metal blank is twisted along its long axis to
produce a K-file produce a K-reamer
Number of flutes twisted into blade More number of flutes per length unit Less number of flutes per length unit
(1 ½ to 2 ½ cutting blades (flutes) per mm of (½ to 1 cutting blade (flute) per mm of working end.)
working end.)
Nature of flutes Tighter flutes (1.93–0.88 mm) Looser flutes (0.80–0.28 mm)
Design feature Due to square blank, these instruments can resist Triangular blanks are used for larger instruments
fracture more effectively than those made from
triangular blanks
So, square blanks are used for manufacturing
smaller, fragile instruments
Cutting efficiency Less efficient than reamers Triangular blanked instruments can cut approximately
2.5 times more efficiently than square-blanked
instruments. But they have been found to loose
sharpness more rapidly than square ones of same size
Motion of use • Basically rasping motion, i.e. push and pull motion • Reaming motion, i.e. penetration, rotation and
Penetration and retraction motion for retraction
circumferential filing of canals Rotation within the canal should be only one-quarter
• Can also be used in reaming motion, i.e. to one-half turn
penetration, rotation and retraction
Apical transportation Chances of transportation are more with a filing Chances of transportation are less with a reaming
motion motion
Apical preparation shape Usually ovoid Usually round

Reamers and K-files, both cause compression-and-

release destruction of the root dentin surrounding the canal
for enlarging the canals.
Although used for same purpose, there are few differences
between K-reamers and K-files. These distinguishing
features are given in Table 11.2.

Fig. 11.26  Rhomboidal shaped blank of K-flex file

K-flex Files
• Manufacture: Stainless steel wire is ground along its long
axis into rhomboidal or diamond shaped cross-section,
i.e. Rhomboidal or diamond-shaped metal blanks are
twisted along the long axis to produce K-flex file.
• Design:
– Rhomboidal shape of blanks having (Fig. 11.26):
- Acute angles: Cause increased sharpness and
improved cutting efficiency
- Obtuse angles: Provide more area for removal of
debris
– K-flex files have alternate high and low flutes. This
design further increases its efficiency in removing
debris.
• Advantages:
– Increased flexibility
– Increased sharpness
– Increased cutting efficiency
– K-files have decreased contact with the canal walls
thus providing space to facilitate irrigation that
reduces the chance of packing debris in the canal.
• Flexo files: It is similar to K-flex file but it has triangular
cross-section for better flexibility and resistance to
fracture and has modified noncutting tip.
• Flex R-file/Roane file:
– It is made up of nickel-titanium.
– It is made by removing the sharp cutting edges from
the tip of the instrument (noncutting tip)
– It has a triangular cross-section that makes it flexible
to be used in curved canals.
– The noncutting tip design reduces procedural errors
such as ledge formation, canal transportation, etc.
when used with balanced force technique.
176 Short Textbook of Endodontics
H-Type Instruments
H-type instruments have a design that facilitates cutting
during pulling stroke. Example of H-type instrument is
Hedstrom file.
• Manufacture: Hedstrom files are manufactured by
cutting spiral flutes from a round stainless steel wire.
Hedstrom configuration resembles cones or a wooden
screw (Christmas-tree pattern). Its flutes appear as
successive triangles set one on another.
Figure 11.27 shows single helix teardrop configuration
of Hedstrom file.
Figure 11.28 shows photograph of Hedstrom file
No. 30.
• Design:
– H-type instruments have a more positive rake angle
that increases its cutting efficiency.
– The blade of these instruments has a cutting rather
than scraping angle.
• Motion of use:
– H-files cut the canal wall when they are rotated
clockwise within the canal and pulled.
– They are relatively ineffective when pushed or
rotated counterclockwise.
– Rotational working movements like that of reamers
should be avoided with H-files because of the
possibility of fracture.
• Cutting efficiency: H-type instruments have higher
cutting efficiency than K-type instruments.
• Instrument fracture:
– H-type instruments are fragile and tend to fracture
easily.
– When a Hedstrom file is bent, there are points
of greater stress concentration that can cause
propagation of cracks and fatigue failure.
Fig. 11.27  Tear-drop cross-section of Hedstrom file
Fig. 11.28  Hedstrom file No. 30
– Improper use of Hedstrom file can cause the
instrument to get screwed or locked in the dentin
within the canal, which may be impossible to be
retrieved. So, the Hedstrom files should not be used
in torquing action.
• Caution: Considerable thinning of radicular wall even
strip perforations can occur with overzealous use of
Hedstrom files.
• Uses:
– Can bring about enlargement or negotiation of small
constricted canals and blocked canals.
– Can be used to remove gutta-percha fillings from the
root canal
– Adequate filing strokes can be given with Hedstrom
files to remove the overhangs from the canal.
• Design modification: “S” file, Unifile and Safety Hedstrom
file.
– “S” file has double-helix configuration, rather than
the single helix teardrop cross-section of Hedstrom
file as seen in Figure 11.29. It is stiffer than the
Hedstrom file and has good cutting efficiency.
– Unfiles:
- A modification of Hedstrom file.
- Manufactured from round stainless steel wire by
grinding superficial grooves in order to produce
flutes with a double-helix design.
- Less fragile and hence less subject to fracture as
compared to Hedstrom files
- But they are less efficient.
– Safety Hedstrom file has noncutting side to prevent
ledge formation in curved canals. The noncutting
side is directed to the side of the canal where cutting
is not required.
Table 11.3 gives the distinguishing features between
K-files and H-files.
C+ Files
• These are special files made for difficult and calcified
canals as they have better buckling resistance than
K-files.
• Made of stainless steel and have square cross-section.
Fig. 11.29  Double-helix configuration of “S” file
 Endodontic Armamentarium: Instruments, Materials and Devices 177

TABLE 11.3  Distinguishing features between K-files and H-files

– It activates a stainless steel barbed broach or reamer
K-type instruments (K-files) H-type instruments (H-files) in root canal through a 90 degrees reciprocating arc.
• Have square cross-section • Have round cross-section – Disadvantages of this handpiece: Packs dentinal
• Lesser cutting efficiency • More cutting efficiency when debris in the canal, takes longer time and creates
when compared to H-files compared to K-files ledges and may over-enlarge the apical foramen.
• Rake angle is less positive and • Rake angle is more positive and It is found to be less effective as compared to hand
blade has scraping angle blade has cutting angle
• Less sharp edges • More sharp edges instrumentation for preparing root canals.
• Less fragile compared to • More fragile and tends to fracture • The Racer contra-angle handpiece makes use of a
H-file easily standard file and oscillates the file in the root canal.
• Motion of use: Rasping • Motion of use: Slight clockwise Due to contra-angle design, the instrument length can
motion or reaming motion rotation (about quarter turn) and
retraction be adjusted till the working length. But there are more
chances of clogging of canal and pushing of debris into
the periapical area.
• M4 safety handpiece:
– It has 30 degrees reciprocating motion.
– It has a unique chuck that locks regular hand files in
place by their handles.
– The safety Hedstrom instrument (Kerr company) can
be used with this handpiece.
• The vertical stroke handpiece:
– Introduced by Levy
– It is either electrically-driven or air-driven
Fig. 11.30  Photograph of C+ file – It delivers a vertical stroke ranging from 0.3 to 1 mm.
(Courtesy of Dentsply)
– The more freely the instrument moves in the canal,
longer would be the vertical stroke.
• Available in sizes of No. 8, 10 and 15 and of lengths 18, – This handpiece also has a quarter-turn reciprocating
21 and 25 mm. motion along with the vertical strokes.
Figure 11.30 shows the photograph of C+ file. • Electric handpieces: Many newer electrical handpieces
have been developed to be used with or without motors.
ENGINE-DRIVEN INSTRUMENTS In these handpieces, speed and torque can be set. These
have been explained later in this chapter along with the
• Engine-driven instruments are used with contra-angle nickel-titanium instruments.
handpiece. Different types of handpieces have been
designed for use. Engine-driven Rotary Instruments
• Engine-driven handpieces have been developed for
opening of root canals and less preferred for preparation Most widely used engine-driven rotary instruments
of root canals. include the Gates Glidden drills and the Peeso reamers. A
• Before using the engine-driven instruments, hand modification of Gates Glidden drill, called Flexogates has
instruments should be used to gain access to apical been developed, made of nickel-titanium.
foramen. • Gates Glidden drills: Discussed earlier in this chapter
• Flexogates:
Engine-driven Handpieces – Flexogates is the modification of Gates Glidden drill.
– It is made up of nickel-titanium.
• Reciprocating or quarter turn handpiece: – It is more flexible and can be used for curved canals.
– Giromatic handpiece is a commonly used flat plane – It is rotated in the handpiece through 360 degrees.
reciprocating handpiece – It has a safety design with noncutting tip and its
– It is mounted with latch type instruments that weakest part at the neck (about 16 mm from tip), so
undergo quarter-turn motion at the rate of 3000 it can be easily retrieved if fractured.
times/minute • Peeso reamers:
– Broaches, K-type and H-type instruments can be – Instrument design: Peeso reamers have long, sharp
mounted. flutes on a thick shaft and with a safe tip.
178 Short Textbook of Endodontics
– Available as 28 mm and 32 mm long instruments.
– Peeso reamers are usually available in a set of 6
instruments Peeso 1 to 6, identified by the number
of rings on the shank.
– Peeso reamers are available in tip diameters ranging
from 0.7 to 1.7 mm.
The tip diameter of Peeso 1 is 0.7 mm, peeso 2 is
0.9 mm, Peeso 3 is 1.1 mm, Peeso 4 is 1.3 mm, Peeso
5 is 1.5 mm and that of Peeso 6 is 1.7 mm.
Figure 11.31 shows photograph of peeso drills 1 to 6.
– Cutting action: Peeso reamers have lateral cutting
action.
– Use: Mainly used for postspace preparation in the
coronal portion of the root canal.
– Caution: Peeso reamers should be used in a slow
speed and in correct angulation to prevent lateral
perforations or excessive removal of radicular
dentin.
ULTRASONIC AND SONIC INSTRUMENTS
Ultrasonic Devices for Endodontic Use
• Principle: Sound is used as energy source at 20–25 KHz
for the three-dimensional activation of an Endodontic
file (K-file) resulting in three-dimensional activation of
the file in the surrounding medium.
• Mechanism: Two physical actions occur during
ultrasonic oscillation namely: cavitation, acoustic
streaming.
– Bubbles are formed by the free ultrasonic vibration
of Endodontic file within the fluid of the canal during
negative pressure oscillation and these unstable
Fig. 11.31  Photograph showing Peeso drills-1 to 6
(Courtesy of Mr Amar, Dr Mukul Dabholkar’s clinic)
bubbles implode with a great force during positive
pressure phase of oscillation. This process is called
cavitation. Earlier it was thought that the main
debriding action of the ultrasonics was by cavitation.
Now it is believed that debridement is caused due
to the other physical phenomenon called ‘Acoustic
streaming’.
– Circular fluid movement called Eddy flow occurs
around the Endodontic instruments due to acoustic
streaming, which is the main mechanism involved in
bringing about the cleaning effect of the irrigant in
the pulp space. It depends on the free displacement
amplitude of the file.
• Use: Effective for irrigating the root canal systems for
root canal cleaning. When ultrasonic oscillation is used
in conjunction with sodium hypochlorite irrigation, it
brings about effective root canal disinfection.
• Requirements: Free vibration of file within the canal is
required for optimum cleansing action with ultrasonic
oscillation.
So, it is recommended that:
For optimum cleansing action with ultrasonic
oscillations:
– Canals should be enlarged and prepared, i.e. bio­
mechanical preparation of the canals should be
completed.
– Use a smaller size Endodontic file, such as of size No.
15, that has minimal contact to the walls of the root
canal.
– Files should be loose in the canal.
– Ultrasonic oscillation with an Endodontic file
combined with sodium hypochlorite irrigation
brings about effective cleaning and disinfection of
root canals.
• Types: Ultrasonic devices of 2 types can be used:
1. Piezoelectrical.
2. Magnetostrictive.
Piezoelectrical unit generates less heat, does not
require cooling system and transfers more energy
to the file as compared to the magnetostrictive unit
and hence are more preferred devices.
Figures 11.32A and B show photograph of
ultrasonic device and ultrasonic tips respectively for
Endodontic use.
Sonic Devices for Endodontic Use
Sonics (6 KHz, 8K Hz and 10 KHz) can be used for root canal
preparation and disinfection.
Example is MM1500 Sonic handpiece that can be used
for cleaning, shaping and disinfecting the canal system.
 Endodontic Armamentarium: Instruments, Materials and Devices 179

A B
Figs 11.32A and B  Ultrasonic device and ultrasonic tips for Endodontic use. (A) Ultrasonic unit for Endo purpose; (B) Ultrasonic tips
(Courtesy of Sybron Endo)

This has been explained in detail in Chapter 14 Cleaning
and Shaping of the Root Canal System Including Working
Length Determination and Chapter 15 Disinfection of the
Root Canal System.
• Mechanism: Sonically powered files oscillate up and
down in a longitudinal oscillation motion to bring about
preparation of root canals.
• Uses:
– Remove pulp remnants and necrotic debris from
root canals.
– Rasp and remove dentin during preparation of root
canals.
• Requirements: Sonic instruments should be loose and
free to oscillate within the root canal. So, canals should
be enlarged to the working length and apical part of root
canal prepared using conventional files after which the
sonic files are used.
• Sonic length: The Sonic instruments, with 1.5–2 mm safe
tips, begin their rasping action 1.5–2 mm from the apical
stop. This is called ‘Sonic length’.
• Examples:
– Rispi sonic files
– Shaper sonic files • Nitinol alloys contain 55% nickel and 45% titanium
– Trio Sonic files
of which shaper sonic files are found to be more
effective for widening the canals than Rispi Sonic
files. But Rispi Sonic files are less aggressive than
shaper Sonic files.
A mind-map to remember all points of Sonics
and Ultrasonics in Endodontics is given in Figure
11.33.
Uses of Ultrasonics and Sonics in Endodontics
(Endosonics)
• Removes isthmus tissue between canal
• Helps in location of orifices
• Smoothens the axial walls and floor of the pulp chamber
during access cavity preparation finishing
• Removes pulp stones smoothly and safely from pulp
chamber without scoring
• Opens calcified canals
• Brings about effective irrigation when used along with
sodium hypochlorite and results in cleaner root canals
• It can be used for obturation of root canal (Ultrasonic-
plasticized gutta-percha obturation technique)
• Used during retreatment to remove gutta-percha, to
remove cement around posts that aids in post removal
• It can be used to help retrieve separated files
• It can be used for MTA placement in the canals.
NICKEL-TITANIUM HAND AND ROTARY
INSTRUMENTS
by weight. (Ni—Nickel, Ti—Titanium, NOL—Naval
Ordnance Laboratory).
• Property of Super elasticity: It is the property of nickel-
titanium alloy that allows it to return to its original
shape following significant deformation. This property
of nickel-titanium makes Endodontic files more flexible,
better able to conform to curvatures of canal, resist
fracture and wear less than stainless steel instruments.
180 Short Textbook of Endodontics

Fig. 11.33  A mind-map to remember sonics and ultrasonics in Endodontics

Figure 11.34 lists the other properties of nickel-

titanium instruments.
Root canal preparation with Ni-Ti rotary files is very
effective, rapid and safe procedure. But it demands that the
clinician understands the:
• Root canal anatomy
• Principles of use of the selected rotary system.
The length, width and the curvature of the root canal
needs to be evaluated to decide the strategy for preparation
of the root canal.
Components of a rotary file:
• Flute of file: It is the groove in the working surface of file
used to collect soft tissue and dentin chips removed from
Fig. 11.34  Mind-map of properties of nickel-titanium instruments canal wall.
 Endodontic Armamentarium: Instruments, Materials and Devices 181

• Land: The surface formed in between flutes that projects Comparative Properties of Stainless Steel
axially from the central axis. and Nickel-titanium Instruments
• Cutting/Leading edge: The surface where the flute and
land intersect that has the greatest diameter and follows See Table 11.4.
the groove as it rotates is called the cutting edge or blade
of file. Phases of Nickel-titanium Alloys
• Helix angle: It is the angle formed by the cutting edge
with the long axis of the file as shown in Figure 11.35. It
augers debris collected in the flute from the root canal.
• Rake angle: It is the angle formed by the cutting edge
with the radius of the file when the file is sectioned
perpendicular to its long axis. If this angle is obtuse, it
is called positive or cutting and if it is acute, it is said to
be negative or scraping.
• Pitch of file: It is the distance between a point on the
cutting edge and the corresponding point on the
adjacent cutting edge as shown in Figure 11.35.
When the instrument is designed in such a way
that there is balance between the helical angle and Phase Transformation
pitch of file, there is better cutting action and debris is
effectively removed from the canal. Also the instrument • On heating, Martensite → R-phase → Austenite
is prevented from inadvertently screwing in the canal. This is called forward transformation.
Nickel-titanium instruments are superior to stainless • On cooling, Austenite → R-phase → Martensite
steel instruments for Endodontic use. This is called reverse transformation.
The comparative properties of stainless steel and nickel- • During Endodontic use:
titanium instruments are given in Table 11.4. – External stresses cause transformation of Austenitic
crystalline phase to martensitic crystalline phase.
Martensitic crystalline phase can accommodate
stresses without resulting in proportional strain.
– When the stress is released, reverse transformation
to austenitic crystalline phase occurs and the
instrument recovers its original shape in the process.

Fig. 11.35  Components of a rotary Endodontic file: Manufacture

helical angle and pitch
TABLE 11.4  Distin-guishing features between stainless steel and
nickel-titanium instruments
Stainless steel instruments
• Cannot be used for manufacture
of rotary files as: They tend to
develop fatal fatigue and fracture
after fewer flexural cycles (540°
revolutions)
• High torque
• Rigid
• No phase transitions
• High modulus of elasticity
• Do not show super elasticity and
shape memory
• Show signs of fatigue/distortion/
deformation before fracture
• Less wear resistant
Nickel-titanium instruments
• Widely used for manufacture of
rotary files: They can withstand
several flexural cycles and
may fracture after 2½ full
revolutions (900° revolutions)
• Low torque
• Flexible
• Phase transitions
• Low modulus of elasticity
• Super elasticity and shape
memory
• Do not show any signs of
fatigue before fracture
• More wear resistant
Nowadays, nickel-titanium instruments are precision
ground into different designs (K-style, Hedstrom, U files,
etc) and made in different sizes and tapers for hand use
(manual) or mechanical rotation (Rotary). In addition,
Ni-Ti spreaders and pluggers are also available.
Precautions to be Taken While Using
Nickel-titanium Instruments
See Table 11.5.
Recommended Motions of use for Ni-Ti
Rotary Instruments
• Research studies have shown that Ni-Ti instruments
should be used with rotational or reaming motion and
182 Short Textbook of Endodontics

TABLE 11.5  Precautions to be taken while using nickel-titanium instruments

“Dos” “Don’t’s”

• Carefully evaluate root anatomy as well as extent and position of canal
curvatures from radiographs
• Prepare adequate access cavity with straight-line access, prior to using
nickel-titanium (Ni-Ti) files
• Enlarge and flare the orifices and the coronal 1/3rd of canal adequately
before you use Ni-Ti files
• Use hand files to negotiate the canal and create a glide path with smaller
K-files such as 10, 15, and possibly 20, before using Ni-Ti rotary files. Thus,
Ni-Ti rotary files should be introduced in the root canal only after glide
path has been established
• Discard these files after single use ideally
• Measure each file length
• Frequently inspect the instruments for any bend or signs of fatigue
• Advance nickel-titanium increments passively in the canal
• While using Ni-Ti files, as soon as resistance is encountered, stop
immediately and before you continue, increase coronal taper and prepare
the canal till the working length with smaller size K-files
• Lubricate the Ni-Ti files with chelating agent during instrumentation
• Irrigation with sodium hypochlorite after use of each file
• Recapitulate with smaller stainless steel K-files to ensure patency till length
in between use of rotary Ni-Ti files
• A pecking, up and down motion with rotary Ni-Ti files is recommended to
prevent screwing in of file and to distribute stresses away from the point
of maximum flexure of the instrument
• Do not force the file
• Do not overuse the files
• Do not use Ni-Ti files to bypass the ledges
• Do not change the direction of the instrument suddenly by jerky or
jabbing move­ments
• Do not apply additional pressure if the easily progressing instrument in
canal, feels as if it hits bottom
• The Ni-Ti rotary file should not remain in the canal for more than 2 to 5
seconds
• Do not cause ‘taper lock’ or ‘frictional fit’ of the rotary file within the canal.
(When entire length of the file blade is to cut a smaller size canal, the
frictional fit of instrument engages root dentin and causes instrument
to lock. Rotating the file counter-clockwise will remove it from the canal.)
• Do not work in a dry canal
• Do not advance larger increment of rotary file into the canal since it may
act as a drill and will increase stress on metal
• Do not cut with the entire length of the blade

that they are quite effective in shaping the root canal #15 and #20 before introducing the Ni-Ti rotary file in
systems. the root canal
• Ni-Ti files with the design of radial lands can be used as • Use gentle/light touch and low speed (rpm)
reamers in 360 degrees motion as opposed to traditional • Crown-Down sequence should be followed
reamers with more acute angles. In this, there is a • Replace rotary instruments frequently.
new design of rotary file, in which an identical hand
instrument is available. Also, a converter handle is Separation of Nickel-titanium Instruments
available that allows the operator to use the rotary file
as a hand instrument. Cohen classified instrument separation of nickel-titanium
• Ni-Ti instruments are more efficient and safer when used rotary files into:
passively.
• Two instrument motions which are recommended
include:
1. Gentle pecking motion: Up and down movements
2. Lateral brushing motion: Mainly recommended for
Protaper shaping files.
According to the American Association of Endodontists
(AAE), the “Golden Rules” for Ni-Ti Rotary Preparation
include:
• Case difficulty should be assessed
Cyclic Fatigue
• Adequate access must be prepared
• Preparation with hand files up to size No. 20 prior to • When an instrument rotates in a curvature
use of rotary files, which means glide path must be – It gets compressed on inner side of curve,
established with pathfinder files or smaller K-files #10, – It gets stretched on outer side of curve.
 Endodontic Armamentarium: Instruments, Materials and Devices
With every 180 degrees rotation, instrument
flexes and stretches again and again. This results
in cyclic fatigue and can cause fracture of the
instrument.
• Canal curvature and number of rotations determine
separation of Ni-Ti files.
Rotary Ni-Ti files with larger tapers and sizes tend to
fatigue even with fewer rotations.
In curved canals, if instrument is worked with high
torque, cyclic fatigue occurs.
Cyclic fatigue occurs in lateral direction or axial
direction.
• When the instrument is bound and released during
instrumentation into irregularities of canals, cyclic
fatigue occurs.
• Rigid and larger files are susceptible to cyclic fatigue.
(Such files can withstand torsional load)
A file with greater taper and larger diameter is
vulnerable to fatigue failure.
Torsional Fracture
• Nickel-titanium files are low-torque instruments which
are quite efficient and safe when used passively. When
the torque limit is exceeded, torsional fracture occurs.
• Torsional load is transferred into the file through friction
against the canal wall that weakens the rotary file causing
subsequent fracture.
• With the apical movement of the rotary file, torque
increases due to increased contact area between the file
and canal wall. So, careful passive use of the rotary file
as the file advances in the apical portion of the canal, is
important.
• Torque control motors are available now in which the
torque values are set for the rotary instrument.
• When there is increased surface area of contact of Ni-Ti
files with the walls of the canal, large portion of these
tapered instruments get engaged and locked into root
dentin. This is referred to as taper lock, which generally
occurs when shape of tapered root canal which is
being prepared becomes similar to the instrument in
use. As a result instrument gets locked in canal and its
tip fractures. Such taper lock can also occur in canal
irregularities such as where canals, merge or divide.
• Fine and flexible files are vulnerable to torsional load.
Lower rotational speeds up to 250 rpm can reduce
file fractures.
Single time use if possible is ideal and can remarkably
reduce the fracture of rotary instruments.
183
Fig. 11.36  Taper lock of nickel-titanium rotary instrument in the
root canal
Other aspects of instrument separation have been
discussed in detail in Chapter 20, Endodontic Mishaps:
Management and Prevention.
Figure 11.36 shows diagrammatic representation of
taper-lock of Ni-Ti rotary instrument in root canal.
Advantages of Ni-Ti Instruments
• Reduced incidence of clinical problems such as:
– Ledge formation
– Apical zipping
– Stripping or lateral perforations
– Canal transportation.
• Creates a smooth, tapered canal.
• Causes cleaning and shaping in short period of time.
Saves clinical time.
• Has increased flexibility to negotiate canal curvatures.
• Irrigants such as sodium hypochlorite do not cause
corrosion or affect the efficacy of Ni-Ti rotary files.
• Provides excellent cleaning and shaping if used properly.
Disadvantages of Ni-Ti Instruments
• Fatigue resistance reduces significantly after use,
especially larger files are found to fail sooner after they
have been used. Hence, the need to discard these files
frequently.
• Also, increase in angle of canal curvature with reduced
radius may cause the file to fail sooner.
• Increased chances of instrument separation in the
canals.
• When Ni-Ti rotary files are used with higher rpm,
there are more chances of instrument separation and
distortion.
184 Short Textbook of Endodontics

• Tends to cause apical extrusion of debris.

• Canals that abruptly curve or merge cannot be easily
prepared using Ni-Ti rotary files.

Motors and Devices for Nickel-titanium

Rotary Instruments

Fig. 11.37  Motor for rotary instrumentation

(Courtesy of Dentsply)

• Electric motors specifically designed to power the rotary

nickel-titanium instruments in canal preparation are
available.
• Newer electric handpieces are available in which there
is: speed and torque control
The speed and torque are set for a certain instrument
and the handpiece will ‘stall’ and reverse if the torque
limit is exceeded.
• Electric motors with gear reduction ensure a constant
rpm level. So, they are more suitable for rotary Ni-Ti
system. Example of such an Endo motor is the X-Smart Fig. 11.38  Anthogyr reduction gear handpiece
motor (Dentsply), which operates on battery or electric
power. Supplied with 16:1 contra-angle. It has a display
screen which shows the speed and torque. It also has
an auto reverse mode for safety and nine adjustable is a cordless, battery-operated, Endodontic slow-speed
program selections. handpiece with in-built apex locator. It has three
Figure 11.37 shows photograph of X-Smart Endo automatic functions:
motor. 1. It automatically starts when file enters the canal and
• Various contra-angle torque control reduction stops when file is removed
handpieces are available, which are very good for 2. If too much pressure is applied, automatically
beginners and inexperienced clinicians, which can be handpiece stops and reverses rotation
used with the regular micromotors and airmotors of 3. When the file touches the apical stop (As determined
dental chair. An example of such handpiece is Anthogyr by apex locator), the handpiece automatically stops.
handpiece, which is a contra-angle handpiece that is Currently, electric motors with torque presets are
applicable to all standard nickel-titanium file systems. recommended. They reduce the incidence of instrument
It allows easy adjustment of the torque by sliding up and fracture particularly if the torque settings are low and
down. There are markings 1, 2, 3, 4 to denote Torque accurate.
values: 0.7, 1.4, 3.2 and 4.5 N.cm respectively. It has
microhead which offers maximum visibility and access Various Available Nickel-titanium Rotary
in the molar areas. Figure 11.38 shows photograph of
Instrument Systems
the Anthogyr Endo hanpiece.
• New development is electric handpiece with in-built Many Ni-Ti instrument systems are being developed and
apex locator. Example is Tri-Auto ZX (J. Morita) which available in the market with different designs.
 Endodontic Armamentarium: Instruments, Materials and Devices
Two main factors that impact the shaping potential of
Ni-Ti rotary instruments include: Cross-sectional design
and tip configuration. All the currently available Ni-Ti
rotary systems have noncutting tips. Some rotary systems
have radial land areas while some systems have nonlanded
design.
• Presence of radial lands make the preparation slower
but safer. Examples of rotary systems which are radial-
landed include: Profile system, Quantec and K3.
• Rotary files with nonlanded areas cut rapidly but can
lead to preparation errors. Examples of rotary systems
which are nonlanded include: Protaper, RaCe.
Few of the currently available Ni-Ti rotary systems with
their specific design features are given below. The technique
and strategy of use of few of them are discussed in detail in
Chapter 14: Cleaning and Shaping of the Root Canal System
Including Working Length Determination.
Greater Taper (GT)
• Cross-sectional design: Three U-shaped grooves, radial
lands: Present, rake angle: Neutral
• Tip configuration: Noncutting
• Taper: Fixed taper 2, 4, 6, 8, 10 and 12%
• Recommended speed: 150–300 rpm
• Other features: Available in ISO tip sizes of 20, 30 and 40,
having a maximum diameter of 1.50 mm. It has variable
pitch.
Profile
• Cross-sectional design: Three U-shaped grooves, radial
lands—present, rake angle—Negative rake angle
• Tip configuration: Noncutting
• Taper: Fixed taper 2%, 4%, 6%
• Recommended speed: 150–300 rpm
• Other features: Earlier was available as series of 29
instruments, in which each file increased by 29% instead
of 0.05 in between sizes. Has 20 degrees helical angle.
Light Speed Instruments
• Cross-sectional design: Three U-shaped grooves, radial
lands—present, rake angle—neutral
• Tip configuration: Noncutting
• Taper: Specific instrument sequence will produce
tapered shape
• Recommended speed: 750–2000 rpm
• Other features: Light speed instruments are slender
instruments with thin parallel shaft. Its noncutting tip
with unique, short, flame-shaped working end similar
in configuration to the Gates Glidden drill.
185
Quantec File System
• Cross-sectional design: S-shaped design with double
helical flutes, radial lands—present, rake angle—positive
rake angle
• Tip configuration: Both cutting and noncutting tips are
available
• Taper: Fixed taper 2%, 3%, 4%, 5%,6%,8%,10%,12%. Uses
Graduated taper technique.
• Recommended speed: 300–350 rpm
• Other features: S-shaped design minimizes its contact
with the canal, thus reducing the torque. 0.02 tapered
files are available in sizes of #15 to #60.
Protaper
• Cross-sectional design: Convex triangular cross-section,
sharp cutting edges, radial lands—no radial lands, rake
angle—positive.
• Tip configuration: Noncutting.
• Taper: Progressive taper. Variable taper along the length
of cutting blades improves flexibility, cutting efficiency
and safety.
• Recommended speed: 250–350 rpm.
• Other features: Has changing helical angle and pitch
over cutting blades that prevents instrument from
screwing into the canal. Available as 3 shaping files: SX,
S1, S2 and 3 finishing files: F1, F2, F3. Explained in detail
in Chapter 14: Cleaning and Shaping of the Root Canal
System Including Working Length Determination.
Hero 642
• Cross-sectional design: Trihelical Hedstrom design,
radial lands—no radial lands, rake angle—positive rake
angle
• Tip configuration: Noncutting
• Taper: Fixed taper 2%, 4%, 6%
• Recommended speed: 300–600 rpm
• Other features: Available in sizes of #20 to #45. The
trihelical, sharp blades are followed by recessive lands
that do not extend axially to the circumference, which
is designed to reduce stress.
K3 Rotary System
• Cross-sectional design: Three asymmetric flutes, radial
lands—present, rake angle—positive rake angle
• Tip configuration: Noncutting
• Taper: Fixed taper 2%, 4%, 6%
• Recommended speed: 200–300 rpm
186 Short Textbook of Endodontics
• Other features: It is similar in concept to Quantec file
system. Due to its cross-sectional geometry, these are
among the most resistant to fracture. It has variable pitch
and variable core diameter.
Reamer with Alternating Cutting Edges (RaCe)
• Cross-sectional design: Triangular cross-section, few
files have square cross-section. Radial lands—no radial
lands, Rake angle—positive
• Tip configuration: Noncutting
• Taper: Fixed taper 2%, 4%, 6%, 8%, 10%
• Recommended speed: 300–600 rpm
• Other features: It incorporates alternating nonspiralled
and spiralled segments along its working length. This
design minimizes torsion of engagement and that
resulting from screwing-in forces.
Flex Master
• Cross-sectional design: Convex triangular shape, sharp
cutting edges, radial lands—no radial lands, Rake
angle—positive
• Tip configuration: Noncutting
• Taper: Fixed taper 2%, 4%, 6%. Intro file has taper of 11%
• Recommended speed: 150–300 rpm
• Other features: It has individual helical angle for each
instrument size. This reduces the screwing-in forces.
Newer Systems
Revo S system, WaveOne single-file reciprocating system,
Reciproc system, Protaper Next system and the latest
self-adjusting file system have been explained in detail in
Chapter 14: ‘Cleaning and Shaping of the Root Canal System
Including Working Length Determination’, along with their
techniques of use.
WHAT ARE THE INSTRUMENTS USED FOR
OBTURATION OF ROOT CANALS?
For Compaction of Gutta-percha
The two most commonly used hand instruments during
compactions of gutta-percha during obturation include:
• Spreaders
• Pluggers.
Spreaders
• A spreader is a tapered, pointed instrument used in
the lateral compaction obturation with gutta-percha
to displace gutta-percha laterally to create space for
additional accessory gutta-percha cones.
• Spreaders are available as:
– Hand-held instruments
– Finger-held instruments
Finger-held spreaders are preferred because in case
of hand-held spreaders the tip of the working end is
offset from the long axis of the handle which can cause
strong lateral wedging forces on the working end if the
instrument is not used carefully. Also, the hand-held
spreaders do not have standardized size and shape.
Figure 11.39 shows photograph of the finger spreader
of size #30 and Figure 11.40 shows photograph of hand-
held spreader.
• Spreaders are available in the sizes of 15–45 and are color
coded as per the ISO standardization.
Nonstandardized spreaders with larger taper are also
available.
• Spreaders are made of stainless steel. Nowadays nickel
titanium finger-held spreaders are also available that
can reach more apically in the canal and useful for
penetration in the curved canals due to their flexibility
and other properties.
Pluggers
• Plugger is an instrument with blunt end used in vertical
compaction obturation of gutta-percha.
• Pluggers are available as:
– Hand-held instruments
– Finger-held instruments
Finger-held instruments are preferred because
the working tip of the hand-held instrument is offset
Fig. 11.39  Finger-held spreader for obturation
(Courtesy of Dentsply)
Fig. 11.40  Hand-held spreader for obturation
(Courtesy of Dentsply)
 Endodontic Armamentarium: Instruments, Materials and Devices
from the long axis of the handle which can cause
strong lateral wedging forces on the working end
if the instrument is not used carefully. Also, finger-
held instruments provide better tactile sensitivity
than the hand-held instruments. Figure 11.41 shows
photograph of finger-held plugger and Figure 11.42
shows photograph of hand-held plugger.
• Finger pluggers are available in the sizes of 15–140 and
are color-coded as per the ISO standardization. Hand
plugger does not have standardized size, shape and
color.
• Pluggers have larger diameter than spreaders and have
a blunt end.
• Uses of pluggers:
– Vertical and lateral compaction of warm gutta-
percha during obturation.
– To carry small sections of gutta-percha into the canal
during sectional method of obturation.
– To pack materials such as calcium hydroxide and
Mineral Trioxide Aggregate (MTA) into the canals.
Besides spreaders and pluggers, certain heat carriers are
available which transfer heat in the root canal for the apical
and lateral displacement of gutta-percha.
Commercially available heat carriers include Endotec,
Touch ‘N Heat and System B devices.
These heat carriers and many other obturation systems
have been explained in detail in the Chapter 16: Obturation
of Root Canal System.
Fig. 11.41  Finger plugger for obturation
(Courtesy of Dentsply)
Fig. 11.42  Hand-held plugger for obturation
(Courtesy of Dentsply)
187
For Delivery of Sealers in the Root Canal
Sealers can be coated on the walls of root canal using:
• Instrument called Lentulo spiral
• Bispiral
• File or reamer
• The master cone itself
• Paper points or
• Ultrasonic tips.
Lentulo Spiral
• Lentulo spiral is used in a slow-speed contra-angle
handpiece to deliver the sealer cement into the root
canal, i.e. for the application of sealer cement to the root
canal walls during obturation.
Figure 11.43 shows photograph of a lentulo spiral.
• While using lentulo spiral it is important that it is started
and stopped outside the root canal otherwise it may cut
into the wall of root canal and even break.
• The spiral should be large to drive the paste forward so
that the material gets squeezed between the spiral and
the root canal walls.
• Other uses of lentulo spiral: It can also be used to place
dressings in the root canal such as calcium hydroxide.
Lentulo spiral and bispirals have been explained in
Chapter 16: Obturation of Root Canal System.
WHAT ARE THE INSTRUMENTS
AND DEVICES USED FOR REMOVAL
OF ROOT CANAL FILLINGS AND OTHER
OBSTRUCTIONS IN ROOT CANAL?
Removal of Gutta-percha
Gutta-percha from the root canal can be removed
progressively by dividing the root canal into:
• Coronal 1/3rd
• Middle 1/3rd
• Apical 1/3rd.
Fig. 11.43  Photograph showing lentulo spiral
(Courtesy of Dentsply)
188 Short Textbook of Endodontics
Various techniques for removal of gutta-percha are as follows:
Rotary Files
• Currently, rotary instrumentation is the most efficient
method for removal of gutta-percha.
• Rotary files should be used at low speed (900–1200 rpm)
and with caution to prevent file separation.
• There is commercially available Endo-Retreatment Kit
containing rotary files—D1 D2 D3 in this order having
one, two and three rings respectively on their shaft. D1
D2 and D3 are used at the speed of 500 to 700 rpm. Figure
11.44 shows the photograph of these rotary files.
– D1 has cutting surface blade of 16 mm, 11 mm
handle, one white ring and a taper of 9%.
– D2 has cutting surface blade of 18 mm, 11 mm
handle, two white rings and a taper of 8%.
– D3 has cutting surface blade of 22 mm, 11 mm
handle, three white rings and a taper of 7%.
– D1, D2 and D3 are used in coronal, middle and apical
thirds of the root canal, respectively.
Besides this system, there are few other new systems
with rotary files for removal of old obturation in case of
retreatment.
Fig. 11.44  Photograph showing the rotary Endodontic re-treatment
files—D1, D2, D3 in this order used for removal of GP root canal
filling (Courtesy of Dentsply)
Power-driven Drills
Such as Gates Glidden drills and Peeso reamers effectively
remove gutta-percha from the coronal and straight portion
of the root canal.
Ultrasonic Instruments
Piezoelectric ultrasonic tips can be used to rapidly remove
gutta-percha from the root canals by producing heat that
thermosoftens the gutta-percha.
Heated Pluggers
• Heated plugger can be used to sear off the gutta-percha
from the coronal portions of the root canal.
• Another technique involves placing and plunging
a heated instrument into the gutta-percha and
immediately withdrawing it and then quickly inserting
size #35, #40 or #45 Hedstrom file and gently screwing it
into the thermosoftened gutta-percha so that it solidifies
on the flutes of Hedstrom file and entire or most of the
gutta-percha filling comes out with the file.
In cases where gutta-percha extends beyond the
apical foramen, the above technique can safely remove
over-extended gutta-percha.
• Specific electric heat carriers also can be used to thermo-
soften and remove increments of gutta-percha from the
root canal.
Chemicals
Gutta-percha solvents include chloroform and xylol.
• These solvents chemically soften the gutta-percha that
can be removed by sequential instrumentation with
K-files or H-files.
• Irrigation with chloroform is combined with watch-
winding motion use of files that creates space for use of
larger files.
• Softened gutta-percha comes on the cutting flutes of
files as they are withdrawn.
 Endodontic Armamentarium: Instruments, Materials and Devices 189

• The solvent filled canals can be dried using paper points
and this is called wicking action which helps to remove
the residual sealer and gutta-percha from the root
canals.
Other details of gutta-percha removal techniques are
explained in detail in Chapter 22: Endodontic Failures and
Nonsurgical Endodontic Management.
Removal of Silver Points
In an old root canal treated case filled with silver point,
lateral retention of silver point in the canal might have
been reduced due to chronic leakage and corrosion of silver
points and if the butt end of silver point is easily accessible in
the pulp chamber, then silver point removal is accomplished
quite easily.
• But most of the times, the butt end of silver point is
embedded in the cement, composite or amalgam core.
So, the initial access is made with round burs with
extended shanks to carefully remove the core material
without inadvertently shortening the silver points.
• Then ultrasonic instruments can be used to carefully
“brush-cut” the core material to expose the silver point
which can be then grasped using a suitable grasping
instrument such as Steiglitz pliers.
• Ultrasonic energy can also be used when silver point lies
below the orifice to disintegrate the interface within the
canal and enhance the removal of silver point.
Removal of Obstructions from Root Canal
such as Separated Instruments
Various microtube removal techniques have been currently
introduced to aid in the removal of the obstruction from
the root canal.
The Masserann kit, instrument removal system (IRS),
endoextractor system (EES) are few commercially available
kits that can be used for removal of obstructions such as
separated instruments from the root canal.
cement has sufficient strength to withstand the masticatory
forces.
Temporary cements include:
Cavit
• It is a premixed material for use as temporary cement.
• Composition: Zinc oxide, calcium sulfate, glycol,
polyvinyl acetate, polyvinyl chloride, triethanolamine.
• Cavit cement sets as it absorbs fluid.
• For adequate seal, it should have depth of at least
3.5 mm.
Intermediate Restorative Material (IRM)
• It is a polymer resin-reinforced zinc oxide cement
• Available as powder and liquid in mixing capsules
• Its compressive strength is double that of Cavit.
It has been found to cause extensive marginal leakage.
TERM
• It is light cured filled composite resin which can be used
as temporary restoration.
• Composition: Urethane Dimethacrylate (UDMA) poly­
mers, inorganic radiopaque filler, pigments, initiators.
• Adequate seal can be achieved with it even at the
thickness of 1 to 3 mm.
Figure 11.45 shows photograph of a commercially
available temporary restorative cement.

WHAT ARE THE MATERIALS USED AS

TEMPORARY RESTORATIONS?
In case of multivisit Endodontic therapy, temporary
restorations or cements have to be placed in the access
cavity or pulp chamber to achieve a satisfactory coronal
seal in order to prevent contamination from the bacteria
and fluids from the oral cavity. Fig. 11.45  Commercially available ready mixed temporary filling
It is recommended that these cements be placed in the material which sets when it comes in contact with patient’s saliva
thickness of 4–5 mm for an effective coronal seal and that the (Courtesy of Ammdent)
190 Short Textbook of Endodontics

WHAT IS THE ARMAMENTARIUM FOR WHAT ARE THE MATERIALS USED FOR POST-
PERIRADICULAR SURGERY? ENDODONTIC RESTORATION?

For details refer to Chapter 26 Surgical Endodontics. Instruments for Postspace Preparation
• BP blade no. 15 or microsurgical scalpel
• Periosteal elevator • Peeso drills can be used for postspace preparation
• Microexplorer, endoexplorer • Various postspace preparation drills are available with
• Microtissue forceps the preformed post systems.
• Miniature handpieces Flow charts 11.1 and 11.2 list the materials used for post-
• Straight handpiece with different burs Endodontic restoration. They have been discussed in detail
• Sterile saline in Chapter 21 Restoration of Endodontically Treated Teeth.
• Sterile cotton, cotton pliers
• Surgical forceps WHAT IS THE ROLE OF LASER
• Curettes
DEVICE IN ENDODONTICS?
• Root-end filling materials:
– Amalgam Different types of lasers used in dentistry:
– Mineral trioxide aggregate (MTA) • Er:YAG laser
– Composite resin system (Retroplast) – Effective for drilling and cutting enamel and dentin.
– Intermediate restorative material (IRM) • CO2 laser
– Super-EBA – Quite effective in soft tissues of oral cavity. But not
– Glass ionomer cements suitable for drilling and cutting enamel and dentin.
– Resin cements such as Diaket
• Micromirrors
• Microcondensers or microburnishers and pluggers of Flow chart 11.2  Classification of core materials for restoration of
Endodontically treated teeth
different sizes
• Needle holder, suturing needle, suturing material
• Hemostatic agents:
↓ ↓
Collagen-based Noncollagen based
–  Collacote –  Bone wax
–  Collastat –  Ferric sulfate
–  Gelfoam
–  Thrombin

Flow chart 11.1  Classification of post systems for restoration of Endodontically treated teeth
 Endodontic Armamentarium: Instruments, Materials and Devices
• Nd:YAG laser
– Effective on dark pigmented tissue.
• Argon laser
– Effective on pigmented or highly vascular tissues.
Applications of lasers in Endodontics:
– Laser Doppler flowmetry developed to assess pulpal
blood flow to determine vitality of pulp.
– Lasers may be used for pulp capping and pulpotomy
procedures.
– Lasers have been tried in the cleaning and shaping
procedures and also in obturation.
– Nd:YAG and Er:YAG lasers may be used for removal
of old root canal filling materials during Endodontic
retreatment.
191
– Lasers may be used for root-end preparation during
periradicular surgery.
Lasers have been explained in detail in Chapter 32
Lasers in Endodontics.
BIBLIOGRAPHY
1. Cohen S, Hargreaves KM. Pathways of Pulp, 9th edn. St. Louis:
Mosby; 2006.pp.233-81.
2. Grossman L, Oliet S, Del Rio C. Endodontic Practice, 11th edn.
Varghese Publication; 1991.pp.190-6, 210-6.
3. Ingle J, Bakland L, Baumgartner J. Ingle’s Endodontics 6, 6th edn.
BC Decker Inc, Hamilton; 2008.pp.800-76.
4. Ingle, Bakland Endodontics, 5th edn. BC Decker-Elsevier; 2002.
pp.473-98.
5. “Rotary Instrumentation: An Endodontic Perspective,”
Colleagues for Excellence, Winter 2008, American Association
of Endodontists.
 12
CHAPTER

Asepsis and Sterilization of

Endodontic Instruments

This chapter explains the importance of infection control and the various methods to achieve effective
infection control in dental practice. It describes the ways to take proper care and about sterilization of
various Endodontic instruments.
  You must know
• Why is Effective Infection Control Important in Endodontics?
• How to Achieve Effective Infection Control in Dental Practice?
• What is Sterilization and Disinfection?
• How to Take Proper Care of Endodontic Instruments?
• What are the Commonly Employed Methods of Sterilization/Disinfection of Various
Endodontic Instruments?

WHY IS EFFECTIVE INFECTION CONTROL

IMPORTANT IN ENDODONTICS? (FIG. 12.1)

Asepsis is the state of being free from disease-causing micro-

organisms or preventing contact with microorganisms. It
is necessary to avoid contamination by microorganisms
during Endodontic therapy as postoperative infection can
be caused by break in sterile technique. Aseptic techniques
in Endodontics such as use of sterilized instruments,
disinfecting solutions, use of procedural barriers such as
rubber dam, etc. is very important to prevent infection.
Fig. 12.1  Goal of infection control
infectious microorganisms from the blood and saliva of
patients.
For example, influenza, hepatitis B, C, D, upper
respiratory disease, herpes, AIDS, etc.
So, effective infection control procedures must be used
to protect the dental team from contracting infections while
delivering dental procedures.

Protection of Dental Health Care Personnel
All dental health care personnel (including both those that
are directly involved and those that are indirectly involved
in patient care) are at risk for exposure to a wide variety of
Protection of Patients
Infection should not get transmitted from one patient to
other patient due to use of same infected instruments
without sterilizing them.
The dental team should never be responsible for
introducing infection in patients due to lack of adopting
appropriate infection control methods.

Sterile instruments and proper techniques should be
used to avoid contamination by microorganisms during
Endodontic therapy in order to prevent postoperative
infection.
Transmission of infection can occur in 2 ways: (Cross-
infection)
HOW TO ACHIEVE EFFECTIVE INFECTION
CONTROL IN DENTAL PRACTICE?
Occupational Safety and Health Administration (OSHA),
American Dental Association (ADA), Center for Disease
Control (CDC) and other Governmental and Non-
Governmental agencies give recommendations for infection
control.
These guidelines must be followed by the dental team.
Considerations for Dental Operatory
• Operatory surfaces such as over-head light handles,
X-ray unit heads, dental chair switches and any other
surface likely to become contaminated with potentially
infectious material should be covered or disinfected.
Protective coverings can be in the form of clear plastic
wrap, special plastic sleeves, etc. These covers should
be changed between patients.
• Endodontic microscopes: Handles and controls
of microscope should be covered with barriers.
Microscope manufacturer’s guidelines should be used
for disinfection of microscope.
• Sensors of digital radiography are covered with single-
use plastic sleeves for each patient.
• Dental unit water lines should be periodically flushed.
This can be done with water or a 1:10 dilution of 5.25%
sodium hypochlorite to reduce biofilm formation.
Biofilm is sticky water line with bacteria, that can
travel upstream in dental unit water lines due to slow
movement of water.
Flushing water lines for 20–30 seconds between
patients is recommended to avoid transmission of
microbes from one patient to the next.
• Waste management: Sharps are included in regulated
medical waste category and should be discarded in a
rigid container with ‘biohazard’ label. Sharps include
Asepsis and Sterilization of Endodontic Instruments 193
needles, scalpel blades, Endodontic instruments and
other items that can cause injury to skin. Gauze or cotton
rolls soaked in blood or saliva are also regulated medical
waste and should be appropriately disposed.
• It is recommended that there should be separate areas
in the operatory for the cleaning/sorting/packaging of
contaminated instruments for sterilization.
• Aerosols generated during dental procedures can
spread throughout the room, so all surfaces need to be
disinfected. Doors, drawer pulls should also be covered
with barriers or disinfected routinely.
• High-volume evacuation can greatly reduce the number
of bacteria in dental aerosols and should be used when
using high-speed handpiece or ultrasonics.
Considerations for Dental Personnel
• Vaccination: All dental health care personnel should be
vaccinated against infectious diseases such as hepatitis
B, influenza, etc.
• Protective attire and barrier techniques:
– Protective clothing such as gowns, aprons, lab coats,
clinic jackets, either disposable or reusable must be
worn. Endodontic surgery will require long sleeved
uniforms.
Contaminated laundry should not be taken home
for wash to avoid transmission of infection to family
members.
– Protective eyeglasses with solid side shields are
required when splashes or sprays of infectious
materials are anticipated.
– Use of disposable latex or vinyl gloves and masks.
Gloves should be replaced after each patient
contact.
Commonly available masks protect the wearer
only partially. Small droplets containing bacteria
can pass through them. If the mask becomes wet, it
should be changed immediately.
Sterile gloves to be worn for surgical procedures.
Examination gloves may be contaminated and may
harbor microbes. Since gloves do not give total
protection, chlorhexidine disinfectant hand wash
can be used due to its property of substantivity, it
bonds to skin and maintains antibacterial action for
longer time as compared to other scrubs.
Polyethylene gloves can be worn over treatment
gloves to prevent contamination of objects, such as
drawers, light handles or patient charts.
Figure 12.2 shows photograph of disposable
examination gloves, mask and protective eye glasses.
194 Short Textbook of Endodontics
Fig. 12.2  Disposable examination gloves, mask and protective eye
glasses (Courtesy of Mr Amar, Dr Dabholkar’s clinic)
Fig. 12.3  A mind-map to remember all points of infection control in dental practice
Considerations Related to the Patient
• Patient’s clothing should be protected from splatter and
caustic materials with plastic coverings.
• Reducing bacteria within oral cavity before treatment
by use of appropriate mouthwash such as 0.12%
chlorhexidine gluconate.
• Use of rubber dam as a protective barrier is mandatory
for nonsurgical root canal treatment.
• Patient screening: A thorough medical history must
be  taken and updated at each visit to include specific
questions regarding hepatitis, AIDS, current illnesses,
weight loss, etc.
Figure 12.3 shows mind-map to remember all points of
infection control in dental practice.

WHAT IS STERILIZATION AND DISINFECTION?
Sterilization is the process of destroying all life forms,
including spores, from an article or surface.
Disinfection is the process of destroying most life forms,
especially pathogens, but does not include killing spores.
1. Autoclave: (Moist heat/Pressurized steam)
– Commonly used method
– Cycle: 250oF temperature (121oC)
15 psi pressure
15–20 minutes
– Flash sterilization 273oF (134oC)
at higher 30 psi pressure
temperatures: 10 minutes
Autoclaves are available as:
– Top loading
– Front loading
Figures 12.4A and B show photograph showing
commercially available front loading autoclave.
2. Chemiclave:
– It utilizes a solution of 72% ethanol and 0.23%
formaldehyde in place of water in its autoclave.
– It is not suitable for liquids
– Temperature of 270oF (132oC) at 20 psi pressure for
20 minutes.
– It avoids instrument corrosion.
A B
Figs 12.4A and B  Photograph showing commercially available front loading autoclave (Courtesy of Mr Amar, Dr Mukul Dabholkar’s clinic)
Asepsis and Sterilization of Endodontic Instruments 195
3. Dry heat:
– It utilizes still air in an oven or forced air.
– It avoids instrument corrosion.
Based on this principle, there are two sterilizers:
i. Hot salt sterilizer
ii. Glass bead sterilizer.
Hot salt sterilizer: It is an efficient and compact apparatus
for sterilization of Endodontic instruments.
• Components: It consists essentially of a metal cup in
which table salt is kept at the temperature of between
425oF and 475oF (218.3oC–246.1oC)
Table salt contains:
– Sodium silicoaluminate 1% and
– Magnesium carbonate/sodium carbonate
A thermometer is kept inserted in the salt at all times.
• Uses:
– Broaches, files and reamers are sterilized by
immersion for 5 seconds.
– Absorbent points and cotton pellets can be sterilized
by immersion for 10 seconds.
• Advantages:
– Table salt is readily available
– Eliminates the risk of clogging the root canal. Thus,
the hot salt sterilizer has superseded the molten-
metal sterilizer and glass bead sterilizer.
• Disadvantages:
– Ineffective in killing spores
– Dry heat has poor penetration capability.
196 Short Textbook of Endodontics

Glass bead sterilizer: It is an efficient and compact apparatus

for sterilization of Endodontic instruments.
• Components: It consists of glass beads of less than 1 mm
diameter in a metal cup.
Large beads cannot transfer heat effectively to
Endodontic instruments due to large air spaces
between the beads that reduce the efficiency of
sterilizer.
Figures 12.5A and B show photograph of commer-
cially available glass bead sterilizer.
• Temperature: 425–475oF (218–246oC)
• Uses:
– Broaches, files and reamers are sterilized by
immersion for 5 seconds.
– Absorbent points and cotton pellets for 10 seconds.

4. Cold chemicals: A

• Recommended only for those items that cannot be heat
sterilized.
• They usually require extended soak times.
HOW TO TAKE PROPER CARE OF
ENDODONTIC INSTRUMENTS?
Effective care for Endodontic instruments involves:
• Preparation of instruments for sterilization
• Sterilization proper
• Effective storage of instruments.
B
Figs 12.5A and B  Glass bead sterilizers. (A) As seen from front; (B) As
seen from above. Note the different timings required for sterilization
of various instruments are mentioned on the lid (Courtesy of Dr
Nishant Singh)
Preparation of Instruments for Sterilization
Handling, cleaning and packaging of contaminated
instruments are frequent sources of injury and possible
infection.
Reusable instruments that become contaminated after
use are immediately taken to a dedicated area for removal
of gross debris by scrubbing or by use of ultrasonic
cleaner. Clean, dry instruments can then be subjected to
sterilization process.
 Asepsis and Sterilization of Endodontic Instruments 197

If immediate cleaning of instruments is not possible Effective Storage

then they should be placed in a disinfectant bath to prevent
blood, saliva or tissue debris from drying on the surface Sterile instruments covered with sterile wrapping should
of instruments because dried material is more difficult to be properly stored in closed cabinets and can be removed
remove. and reused when needed. If the wrapping gets exposed to
For scrubbing of instruments, heavy puncture-resistant fluids or is not intact, then it should be considered to be
gloves should be worn and long handled brushes should be contaminated and resterilization is indicated before use.
used to minimize the risk of percutaneous injury. Figure 12.7 shows photograph showing Endo box for
Use of ultrasonic cleaner is more effective and preferable effective storage of Endodontic files.
than hand scrubbing. The ultrasonic bath should be covered
with a lid to reduce aerosols and should contain a germicide
solution, which must be discarded and replaced daily.
Figure 12.6 shows photograph of a ultrasonic cleaner.
After scrubbing/ultrasonic cleaning, instruments are
rinsed under running tap water.
These instruments are dried and then wrapped/
packaged for the sterilization process.

Care of Instruments

Fig. 12.6  Photograph of ultrasonic cleaner

Sterilization Proper
Clean, dry instruments can now be made sterile by
appropriate methods of sterilization.
According to CDC guidelines about sterilizers, instru­
ments should be dried before removing from the sterilizer
as wet wraps may tear easily or may allow microbes to reach
the sterile contents. In addition, cooling will avoid thermal Fig. 12.7  Photograph showing Endo box for keeping files
injury to the personnel. (Courtesy of Dr Mahashabde, Dr Rajesh Shivhare’s clinic)
198 Short Textbook of Endodontics
WHAT ARE THE COMMONLY EMPLOYED
METHODS OF STERILIZATION/DISINFECTION OF
VARIOUS ENDODONTIC INSTRUMENTS?
Instrument/material Method of sterilization/
disinfection
1. Rubber dam After the rubber dam has
been applied it should be
thoroughly swabbed with
2% benzalkonium chloride
in 50% isopropyl alcohol.
  Rubber dam clamp and
frame can be sterilized
using dry heat, ethylene
oxide or autoclave
2. Burs Autoclave
3. Broaches, Autoclave, or
files, Glass bead sterilizer or
reamers Hot salt sterilizer
for 5 seconds
4. Dappen dishes Swab with tincture of
thimerosal followed by
alcohol.
5. Glass slab Swab the surface with
tincture of thimerosal
6. Absorbent points and Glass bead sterilizer or hot
cotton pellets salt sterilizer for 10 seconds
7. Gutta-percha cones 1-minute exposure to
1% sodium hypochlorite
or 5-minute exposure to
0.5% sodium hypochlorite
or gutta-percha cone
Instrument/material Method of sterilization/
disinfection
freshly removed from the
manufacturer’s box is
immersed in 5.2% sodium
hypochlorite for 1 minute,
then rinse the cone with
ethyl alcohol and dry it
between two layers of
sterile gauze
8. Cement spatula Flame it 3–4 times by
passing it through bunsen
flame
9. Silver cones Slowly passing them back
and forth 3–4 times through
bunsen flame
10. Diagnostic instruments Autoclave
mouth mirrors, probes,
explorers, tweezers
11. Long-handle Dipping the working end
instruments tips of in alcohol, passing through
cotton pliers, scissor the flame 2–3 times
blades
12. Local anesthetic Presterilized with ethylene
Cartridges, needles oxide and are disposable
BIBLIOGRAPHY
1. Cohen S, Hargreaves KM. Pathways of Pulp, 9th edn. St. Louis:
Mosby; 2006.pp.98-101,136-47.
2. Grossman L, Oliet S, Del Rio C. Endodontic Practice, 11th edn.
Varghese publication. 1991.pp.136-41.
 13
CHAPTER

Endodontic Access
Cavity Preparation

This chapter discusses in detail the first step of Endodontic treatment, i.e. access cavity preparation
of root canal and explains how Endodontic success greatly depends on a good access.
  You must know
• What is Endodontic Triad?
• What is Coronal Access Cavity Preparation of the Root Canal?
• What are the Objectives of Access Preparation?
• What are the Principles of Endodontic Access Cavity Preparation?
• What are the Guidelines to be Followed for an Optimum Access Cavity Preparation?
• What is the Armamentarium Needed for Access Cavity Preparation?
• Which are the Steps of Access Cavity Preparation?
• What are the Specific Features of Access Preparation of Individual Teeth and Possible Errors
Related to Them?
• Which are the Challenging Access Cavity Preparations and How to Deal with them?
• What Errors can Occur During Access Cavity Preparation?

WHAT IS ENDODONTIC TRIAD? • Coronal Access cavity preparation (This chapter)

The Endodontic treatment (Root canal treatment) can be
accomplished in three main phases commonly referred to
as the ‘Endodontic triad’, which includes:
• Cleaning and Shaping of the Root Canal, i.e.
Biomechanical Preparation of Root Canal (Chapter 14)
• Irrigation and Disinfection of the Root Canal System
(Chapter 15)
• Obturation of the Root Canal System (Chapter 16).

WHAT IS CORONAL ACCESS CAVITY

We shall study each of these phases in detail in the
following chapters:
PREPARATION OF THE ROOT CANAL?
After establishing an accurate diagnosis and proper case
selection, the first phase of Endodontic treatment directly
applied to the tooth is “access cavity preparation”, also
referred to as “Endodontic entry”.
Undoubtedly, a good beginning is essential to
achieve a good end result. Thus, a well-designed access
cavity preparation is a must to achieve a good Endodontic
result.
200 Short Textbook of Endodontics
Definition
“The preparation extending from the occlusal table to the
canal orifices that facilitates smooth, unobstructed, straight-
line path to the canal system and ultimately to the apex is
called coronal access cavity preparation of the root canal”.
A well-designed access preparation will allow:
• Thorough cleaning and shaping
• Complete irrigation and disinfection
• Quality obturation.
WHAT ARE THE OBJECTIVES OF ACCESS
PREPARATION?
The objectives of access preparation are given in Figure
13.1.
It is important to understand that:
• Access cavity preparation should be
– Wide enough:
- To facilitate visibility and ease of handling
instruments in highly complex root canal system
- To locate all root canal orifices and smoothly
negotiate all root canals
– Conservative enough:
- Preserving sound tooth structure to improve
tooth’s fracture resistance
- To increase its structural integrity and long-term
prognosis.
Unnecessary tooth structure removal should be avoided.
• Access cavity preparation is specific and unique for each
tooth and each patient. Standard protocol is followed for
making initial entry but extension of access preparation
varies for individual tooth considering various factors as
given in Figure 13.2.
Fig. 13.1  Objectives of access preparation
WHAT ARE THE PRINCIPLES OF ENDODONTIC
ACCESS CAVITY PREPARATION?
Principles of Access Cavity Preparation
• Outline form: “Outline form is that form of the area of the
tooth surface to be included within the finished margins
of the Endodontic access cavity preparation.”
– The outline form of the access preparation is dictated
by the internal anatomy of the tooth. The preparation
is extended from inside to outside.
– The access cavity design is primarily dependent on
the anatomic position of the orifices.
– Size and shape of the pulp chamber also determines
the outline form.
– The access preparation should be such that the
pulpal roof including all overlying dentin is removed.
– It resembles the inlay cavity preparation with the
walls diverging occlusally.
– Factors to be considered for access cavity design are
given in Figure 13.2.
Besides these factors, whenever required, the access
preparation needs to be extended to eliminate any other
restrictive interference in the straight line path to the
apical portion of the canals.
Shamrock Preparation
In case of extremely curved canals, the access preparation
needs to be extended at the expense of coronal tooth
structure so that the instrument can be accommodated
unrestrained in the canal and there is straight line access
to the apical foramen. Such a modified outline form of the
access preparation is called as Shamrock preparation. It has
been demonstrated in Figure 13.3.
Fig. 13.2  Factors affecting extension of access preparation

A B
Figs 13.3A and B  (A) Dentinal shelf obstructing the straight-line
access, dotted line shows the required extension; (B) Shamrock
preparation that provides straight-line access (SLA) to the apex
Access preparation needs to be extended at the expense
of coronal tooth structure shown by dotted line in Figure
13.3A for unrestrained access of instrument—Shamrock
preparation (Fig. 13.3B)
• Convenience form: “Convenience form is that form
of the access cavity preparation that allows adequate
observation and unobstructed access of Endodontic
instruments into the canal orifices and ultimately to the
apical foramen.”
– The overhanging roof of the pulp chamber needs to
be removed so that the orifices can be easily located
and visualized.
– The walls of access preparation should be made
smooth and occlusally diverging so that the
instrument can freely slide down the orifices into
the canals.
– Root curvatures and the angle at which the canal
leaves the pulp chamber should be considered and
the access preparation modified accordingly.
Mouse-hole Effect
Orifices should be located at the corners of the preparation
and entirely on the pulpal floor and not into axial walls.
If the orifice extends into axial walls it will appear as tiny
“mouse-hole” and indicates that the access cavity is under-
extended. In that case, the lateral wall of the cavity should
be extended so as to remove the overlying dentin from the
Endodontic Access Cavity Preparation 201
A B
Figs 13.4A and B  (A) Mouse-hole effect; (B) Correcting the mouse
hole effect and optimum extension of access preparation
orifice. This will eliminate the mouse-hole and the orifice
will now be entirely on the pulpal floor.
Figure 13.4A shows under extended access preparation
with mouse hole effect.
Figure 13.4B shows correcting the mouse hole effect and
optimum extension of access preparation.
WHAT ARE THE GUIDELINES TO BE FOLLOWED
FOR AN OPTIMUM ACCESS CAVITY
PREPARATION?
• Guidelines: Let us consider the 10 guidelines given in
Cohen’s Pathways of Pulp, 9th Edition, as Golden rules for
the completion of an optimum access preparation and
remember them with the help of following sentence:
Very Easy Preparation Requires Root Canal Details
to be Learnt and Implemented Throughly, i.e. Visualize,
Evaluate, Prepare, Remove, Remove, Create, Delay,
Locate, Inspect, Taper.
Visualization of the Likely Internal Anatomy
Figure 13.5 shows the mind-map that gives details of
visualization of the likely internal anatomy.
Figure 13.6 shows the diagrammatic representation
of how the depth of pulp chamber can be estimated by
keeping the handpiece with the bur alongside a preoperative
radiograph.
202 Short Textbook of Endodontics
Fig. 13.5  Mind-map showing details of visualization
of the likely internal anatomy
Fig. 13.6  Estimation of depth of pulp chamber by keeping the
handpiece with the bur alongside a preoperative radiograph
Evaluation of the Cementoenamel
Junction and Occlusal Anatomies
One cannot rely completely on occlusal anatomy to prepare
the access cavity as the crown might have been destroyed by
caries or reconstructed with restorative materials, thus there
can be a change in the morphology of the tooth.
According to studies by Krasner and Rankow, cemento-
enamel junction (CEJ) is the most important landmark for
determining the location of pulp chambers and root canal
orifices.
They found that anatomy of pulp chamber floor is
specific and consistent and they have given the following
guidelines or laws of pulp chamber anatomy to help
Fig. 13.7  First law of symmetry
clinicians determine the number and location of orifices
on the pulp chamber floor:
• Law of Centrality: The pulp chamber floor is always
located in the center of the tooth at the level of the CEJ
• Law of Concentricity: The pulp chamber walls are always
concentric to the external surface of the tooth at the
level of the CEJ, which means, the external root surface
anatomy reflects the internal pulp chamber anatomy.
• Law of the CEJ : At the level of the CEJ, the distance from
the external surface of the clinical crown to the wall of the
pulp chamber is the same throughout the circumference
of the tooth. The CEJ is the most consistent, reproducible
landmark for locating the position of the pulp chamber.
• First law of symmetry: Canal orifices are equidistant from
a line drawn in mesiodistal direction through the pulp
chamber floor. Exception is maxillary molars.
Figure 13.7 shows schematic representation of the
first law of symmetry.
• Second law of symmetry: Canal orifices lie on a line
perpendicular to a line drawn in a mesiodistal direction
across the center of pulp chamber floor. Exception
is maxillary molars. Figure 13.8 shows the schematic
representation of the second law of symmetry.
• Law of color change: The color of the pulp chamber floor
is always darker than the walls.
• First law of orifice location: Orifices of root canals are
always located at the junction of walls and floor.
• Second law of orifice location: Orifices of root canals are
located at the angles in the floor-wall junction.
• Third law of orifice location: Orifices of root canals are
always located at the terminus of roots’ developmental
fusion lines.
Preparation of the Access Cavity Through Lingual
and Occlusal Surfaces
Access cavity is prepared through the lingual surface in
anterior teeth and the occlusal surface in posterior teeth.
(Fig. 13.9).
 Endodontic Access Cavity Preparation 203

Fig. 13.8  Second law of symmetry

Fig. 13.10  Mind-map of details of removal of caries

and defective restorations

Fig. 13.9  Mind-map to remember the starting point (surface) for

access cavity preparation

Incisal approach in case of mandibular anterior teeth

improves access to the lingual canal and allows for complete
canal debridement.
Fig. 13.11  Mind-map of details of removal
of unsupported tooth structure
Removal of all Defective Restorations and Caries
Before Entry into Pulp Chamber
sometimes on buccal and lingual surface in addition to
Figure 13.10 shows the mind-map explaining why all the the mesial and distal surface especially in case of curved
caries and defective restorations should be removed before canals. Also, it involves selective removal of outer canal tooth
entry into pulp chamber. structure in order to protect the furcal surface.
Figure 13.12 gives the mind-map showing details of SLA.
Removal of Unsupported Tooth Structure
Delay of Dental Dam Placement Until Difficult
Figure 13.11 shows mind-map of details of removal of
Canals have been Located and Confirmed
unsupported tooth structure.
Figure 13.13 shows mind-map showing until when the
Creation of Access Cavity Walls that do not Restrict dental dam placement to be delayed.
Straight or Direct-line Passage of Instruments to
the Apical Foramen or Initial Canal Curvature—
Straight-line Access
“Straight-line access (SLA) describes a preparation that
provides a straight or outwardly flared, unimpeded path
from the occlusal surface to the apex.” (Ingle’s Endodontics Micro-openers are excellent instruments for locating
6, pp.878-879) SLA allows Endodontic instrument (file) to canal orifices when a dental dam has not been placed.
reach the apex with minimal deflection. In order to obtain Micro-openers have –  #0.04 and #0.06 tapered tips
SLA, coronal tooth structure removal may be needed –  Offset handles
204 Short Textbook of Endodontics

Fig. 13.14  Mind-map explaining location,

flaring and exploring root canal orifices

Fig. 13.12  Mind-map giving details of creating access

cavity walls to get straight-line access

Fig. 13.15  DG-16 Endodontic explorer for locating the canals

Fig. 13.13  Mind-map to show delaying dental dam placement

These flexible, stainless steel hand instruments provide

enhanced visualization of the pulp chamber.

Location, Flaring and Exploration of

all Root Canal Orifices
Figure 13.14 shows mind-map that explains details of this.
Figure 13.15 shows diagrammatic representation of DG-
16 Endodontic explorer. Fig. 13.16  GG drills no. 1 to 6 used for flaring of canal orifices
Figure 13.16 shows photograph of GG drills no. 1 to 6 (Courtesy of Mr Amar, Dr Dabholkar’s clinic)
used for flaring of root canal orifices.
Figure 13.17 shows photograph of K-files no. 6, 8, 10
used for exploring the canals. ( Remember PGPu Pink, Gray, Tapering of Cavity Walls and Evaluation
Purple)
of Space Adequacy for a Coronal Seal
Figure 13.18 shows photograph of commercially
available EDTA gel for lubrication. A properly prepared access cavity has Tapering/Diverging
Walls that is widest at the occlusal surface.
Inspection of Pulp Chamber Using Magnification It is recommended to place a temporary filling material
of at least 3.5 mm depth to provide an adequate coronal seal
and Adequate Illumination
in between appointment so as to reduce the risk of bacterial
Figure 13.19 shows mind-map giving details of this. contamination.

Fig. 13.17  K-files 6, 8, 10 (Courtesy of Dr Shivani Bhatt)
Fig. 13.18  EDTA gel (Glyde) for lubrication (Viscous chelator)
(Courtesy of Dentsply)
Temporary filling:
• The access cavity should be sealed with a temporary
filling material between visits in case of multivisit
approach so as to prevent the contamination of the root
canal system by saliva with its bacterial flora and food
particles and to prevent any intracanal medicament
from leaking.
• Requirements of an ideal temporary filling material:
– It should seal the cavity peripherally and be
impervious to bacteria and the oral fluids
– It should set in few minutes after insertion into the
cavity.
– It should withstand the mastication forces.
– It should be easy to manipulate
– It should be easy to remove.
• The most commonly used temporary filling material is
zinc oxide eugenol cement which provides a good seal.
But it lacks the strength to withstand the masticatory
forces and is slow-setting and its deformation while
setting may contaminate the root canal system. 0.5 to
Endodontic Access Cavity Preparation 205
Fig. 13.19  Mind-map giving details of inspection of pulp chamber
Fig. 13.20  Temporary filling
1% zinc acetate is added to accelerate the setting time
of zinc oxide eugenol and prevent its distortion. For
greater surface hardness, polymer-reinforced zinc oxide
eugenol called intermediate restorative material (IRM)
can be used.
• Zinc-oxide polyvinyl preparation, commercially available
as Cavit, can also be used as a temporary filling material.
It is a hydrophilic compound that sets in the presence of
moisture. Its use in vital teeth should be avoided as it may
dessicate dentin causing sensitivity in the teeth.
• To prevent leakage, the thickness of temporary filling
material should be about 3–4 mm.
• A dual filling (double seal) is advisable which consists
of a medicated cotton pellet sealed in the pulp chamber
by an inner seal of temporary stopping and an outer seal
of zinc oxide eugenol, IRM or Cavit. Figure 13.20 shows
the diagrammatic representation of a temporary filling.
The single seal uses a medicated cotton pellet in pulp
chamber covered by dry cotton pellet and sealed with
zinc oxide eugenol, IRM or Cavit.
206 Short Textbook of Endodontics

WHAT IS THE ARMAMENTARIUM NEEDED
FOR ACCESS CAVITY PREPARATION?
• Magnification using dental operating microscope
(DOM) or surgical loupes (2.5X, 4X) can be really helpful.
Figure 13.21 shows schematic representation of the
dental operating microscope (DOM).
Figure 13.22 shows schematic representation of a
magnifying loupe. (The dental operating microscope
(DOM) and the magnifying loupes have been described
in detail in Chapter 11: Endodontic Armamentarium:
Instruments, Materials and Devices).
• Handpieces:
– High speed handpiece: For initial penetration
– Slow speed handpiece: For deeper penetration and
in case of calcified and receded pulp chamber.
• Burs: (Fig. 13.23):
– For removal of caries, initial penetration and
deroofing the pulp chamber
- Round carbide burs (Medium sizes such as # 2,
# 4).
- Round diamond burs (for access through
porcelain)
- Long shank round burs
- Transmetal burs for penetration through metal
- Tapered fissure carbide bur or a diamond bur
with rounded cutting end
– For axial wall extensions
- Safe-ended diamond and tungsten carbide
burs (tip/end is noncutting, sides are cutting),
for example, endo access bur, endo Z bur (Figs
13.24A and B), safe nonend cutting bur
These can be used for final refinement extending
from enamel to the pulp floor orienting the axial
walls without causing gouging.

Fig. 13.23  Access preparation bur kit showing round bur, transmetal
bur, long shank round burs, safe-ended Endo Z bur and X-gates
(Courtesy of Dentsply)

Fig. 13.21  Dental operating microscope (DOM)

Fig. 13.22  Magnifying loupe Figs 13.24A and B  (A) Endo access bur; (B) Endo Z bur
(Courtesy of Dentsply)
 Endodontic Access Cavity Preparation 207

– For enlarging the orifices and flaring of coronal WHICH ARE THE STEPS OF ACCESS
portion of the root canal and blending of the orifices CAVITY PREPARATION?
into the axial walls in order to gain straight-line
access (SLA), Gates Glidden burs can be used. Gates The general sequence of steps to be followed for access
Glidden drills/burs cut laterally in a selective manner cavity preparation are as follows:
so that excess removal of furcal dentin is avoided. Step 1: Removal of caries and existing restorations if any:
See Figure 13.16 for Gates Glidden drills -1 to 6 Penetration of enamel through lingual surface in
GG burs 1 to 6 and GG X: case of anterior teeth and through occlusal surface
GG 1 (ISO size # 50) in case of posterior teeth using the appropriate size
GG 2 (ISO size # 70) round bur, the size smaller than the size of the pulp
GG 3 (ISO size # 90) chamber of the tooth.
GG 4 (ISO size # 110) Figure 13.28 shows the diagram of initial entry
GG 5 (ISO size # 130) made through lingual surface in anterior tooth
GG 6 (ISO size # 150) perpendicular to the long axis of tooth.
GG X (Features of GG 1 to GG 4)
Figure 13.25 shows schematic representation of X
gates that has combined features of GG 1 to GG 4. It has
no ring on its shank. Figure 13.23 shows photograph of
X gates.
• Hand instruments:
– DG-16 Endodontic explorer: To locate root canal
orifices and to determine canal angulation
– Endodontic spoon excavator: To scoop out carious
dentin and to remove coronal pulp
Figure 13.26 shows diagrammatic representation
of DG 16 Endodontic explorer and Endodontic spoon
excavator.
• Ultrasonic unit and various ultrasonic tips: Can be useful
for exploring the root canal orifices by troughing and
deepening the developmental grooves to remove the
tissues with minimal collateral tooth structure removal. Fig. 13.27  Commercially available Endodontic ultrasonic tips—
Figure 13.27 shows commercially available Start X (Courtesy of Dentsply)
Endodontic ultrasonic tips.

Fig. 13.25  Schematic representation of X Gates. GG X has

combined features of GG 1 to GG 4. It has no ring on its shank

Fig. 13.26  DG-16 Endodontic explorer and Fig. 13.28  Initial entry through the lingual surface in anterior teeth
Endodontic spoon excavator with the round bur perpendicular to the long axis of tooth
208 Short Textbook of Endodontics

In case of access through the crown, use of round the pulp remnants, dentinal mud and debris in
diamond bur for access through porcelain and suspension.
transmetal bur for access through metal.   Figure 13.30 shows the withdrawal movement to
It is recommended to use a new sharp bur and deroof the pulp chamber.
cut the dentin in a light brushing motion to reduce   In case of necrotic pulp, the pulp chamber be filled
the heat produced. with 5.25% warm sodium hypochlorite.
Step 2: Penetration of roof of pulp chamber: Keeping the bur Step 4: Axial wall extension: Is done at this step in order to
parallel to the long axis of the root all the time in case achieve a good convenience form. Tapered fissure
of anterior teeth and premolars as shown in Figure carbide or diamond bur with rounded end or safe-
13.29A. In case of molars, the penetration angle is ended diamond or carbide burs are used to funnel
towards the largest canal as shown in Figure 13.29B. the corners of the access cavity directly into the
  A sudden sinking of the bur or “drop in” effect orifices and to plane the axial walls and slightly flare
is felt as soon as the roof of the pulp chamber is them towards the occlusal.
penetrated. But in case if the pulp chamber is deep or   Figure 13.31 shows diagram demonstrating axial
calcified, such a feeling of drop may not be felt. So, it wall extension in maxillary molar.
is important to evaluate the preoperative radiograph
and measure the distance between the cusp tip and
the roof of the pulp chamber. The penetration should
be carefully limited to this distance.
Step 3: Complete removal of roof of the pulp chamber: Once
the pulp chamber roof has been penetrated, stop
pushing the bur, now withdrawal movement has to
be carried out in order to deroof the pulp chamber
completely. Brush cut against the roof as if lifting the
bur against the edge of the roof till the entire roof
is removed. This allows the internal pulp anatomy
to dictate the external outline form of the access
opening.
  Ruddle recommends that in case of bleeding
vital pulp, at this step, the pulp chamber be filled
with viscous chelator such as EDTA to bring about Fig. 13.30  Deroofing the pulp chamber using round bur in
emulsification of vital pulp tissue and to hold withdrawal movement from inside of the pulp chamber to the outside

A B
Figs 13.29A and B  (A) After penetration of enamel the bur is held Fig. 13.31  Axial wall extension in maxillary molar
along the long axis of the tooth till the pulp chamber is reached; (B) In
case of molars, the penetration angle is towards the largest canal

  Access preparation should have occlusally
divergent smooth axial walls resembling inlay cavity
preparation in order to remove all the obstructions
hindering the straight-line access to the canals.
Also smooth and diverging walls enhance vision by
improving the refraction of light.
Step 5: Identification of all root canal orifices: After complete
deroofing of the pulp chamber, an Endodontic
explorer (DG-16) can be used to locate the root canal
orifices if there is adequate radicular space. As the tip
of the Endodontic explorer is placed into the orifice,
the portion of the shaft is checked for clearance from
the axial walls. It may also give an idea about the
angle at which the canal leaves the pulp chamber. If
there is inadequate radicular space to allow the entry
of Endodontic explorer, then a small-sized hand file
can be gently inserted into the coronal portion of
the canal to determine the entry angle of the canal
relative to the long axis of tooth.
  In posterior teeth, the extension of the outline form
of access cavity should be such that the orifices are
located at the corners of the preparation and entirely
on the pulp floor and should not extend into an
axial wall. If the orifice extends into an axial wall,
it indicates that the access cavity is underextended
and it creates a mouse-hole effect that impedes the
straight-line access (SLA).
  Knowledge of the anatomic location of the
orifices and the possibility of finding additional
canals should be kept in mind while identification
of orifices.
  In case of calcified root canal, orifice location may
cause difficulty. For such cases:
Orifice location aids:
• Carefully read multiple pretreatment radiographs
(atleast three preoperative radiographs)
• Use of sharp explorer to examine the pulp
chamber floor. Multiple canal orifices can
be explored effectively using an Endodontic
explorer
• Ultrasonic tips can be helpful for troughing the
grooves and relocating the orifices.
• Color: Walls of pulp chamber are white or light
yellow in color. Floor of the pulp chamber and the
grooves connecting the orifices are dark brown
or gray in color.
• “Champagne Bubble” Test (Fig. 13.32): Sodium
hypochlorite (NaOCl) is allowed to remain in the
pulp chamber for some time. Tiny bubbles may
appear in the solution. This indicates the position
of root canal orifice.
Endodontic Access Cavity Preparation 209
Fig. 13.32  Champagne bubble test
• 17% EDTA and 95% Ethanol can be applied
sequentially for effective cleaning and drying of
the floor of the pulp chamber. This makes it easier
to visualize the orifices.
Step 6: Removal of internal impediments to straight-line
access or restrictive shelf of dentin, i.e. lingual
shoulder and cervical dentin bulge.
• In case of anterior teeth, a lingual shelf of dentin
exists called as lingual shoulder from cingulum
of the tooth to a point about 2 mm apical to the
orifice.
  Removal of lingual shoulder aids in straight-
line access (SLA).
  Lingual shoulder can be removed using
tapered safety tip diamond or carbide bur or
with Gates Glidden burs. During rotation, the
GG bur must be leaned gently, against the lingual
shoulder and withdrawn as shown in Figure
13.33.
• In case of posterior teeth, shelves of dentin that
frequently overhang the canal orifices are called
as cervical dentin bulges.
  Removal of cervical bulge aids in straight line
access (SLA)
  Cervical dentin bulges can be removed using
tapered safety tip diamond or carbide bur or with
Gates Glidden burs. GG burs are used by gently
leaning towards the dentin bulge in sweeping
upward motion with lateral pressure away from
the furcation to remove the overhanging shelf.
  Sometimes secondary dentin may be overlying
the orifices and obscures it. Long shank round
bur can be used to remove it.
210 Short Textbook of Endodontics
Fig. 13.33  Removal of lingual shoulder
  If a small file such # 10 K-file is inserted into
the canal through the orifice, it is important to
obtain uniform contact of file within the access
cavity. If the file is being deflected or held up
by any restricting or restraining dentin in the
access cavity or in the coronal portion of the root
canal, then it should be removed to cut a “relief
channel” through which the file can contact the
dentin evenly along its length without undue
strain. This can be done by using thin needle
diamond bur or safety tip diamond bur to relieve
that area of access cavity wall and by using
smaller GG burs to relieve the restraining dentin
in the coronal portion of the canal.
Step 7: Preflaring the orifice, coronal relocation and removal
of triangles of dentin: All of these processes can be
accomplished using GG drills.
• Preflaring the orifice:
– Root canal orifices should be flared and made
contiguous with the walls of the access cavity
preparation.
– For adequate cleaning and shaping, the
orifices can generally be enlarged to a
diameter of 0.9 to 1.1 mm without causing
undue loss of root strength.
– The procedure of orifice flaring is also referred
to as “facing-off” the orifices.
– A larger size GG drill such as no. 3 or no. 4
which passively fits into the orifice is selected.
– Notice the GG drill/canal orifice pivot point
and move the head of the hand piece in an
orbital arc above this pivot point. The belly of
the GG drill enlarges the orifice and facilitates
the entry of smaller size GG drill, i.e. no.
2 or no. 3 to be used in gentle “pecking”
motion or “brushing” action. This is to
enlarge the coronal one-third of the canal by
removing the dentin on the outstroke. Then
sequentially no. 2 and no. 1 GG drills can be
used in the straight portion of the canal. No.
4 GG drill is used to the depth such that only
its flame shaped bud is below the orifice.
– Orifices can also be flared using rotary nickel-
titanium orifice openers to be used at slow
speed and low torque.
• Coronal relocation:
– The purpose of the coronal relocation is to
center the radicular preparation within the
circumferential dimension of the root, so as
to prevent the thinning of the root that may
predispose it to radicular fracture or strip
perforations.
– In case of multirooted teeth, the coronal
portion of the canal has to be intentionally
relocated away from the furcal danger.
– Also in teeth with external root concavities,
the radicular preparation has to be directed
towards the greater bulk of the dentin away
from these concavities.
– This is accomplished by using the GG drill in
an orbital arc above the GG drill/canal orifice
pivot point in the direction of the name of the
canal as shown in Figure 13.34.
• Removal of internal triangles of dentin:
– In some roots, an internal triangle of dentin
may hinder the straight line access of the
Endodontic instrument to the apical portion
of the canal.
  Figure 13.34B shows the diagrammatic
representation of internal triangle of dentin
hindering the straight line access.
– Use of GG drills removes the internal triangle
of dentin (Fig. 13.34C).
Step 8: Determination of straight-line access (SLA): A small
Endodontic file such #10 K-file, when inserted in the
root canal orifice should have unimpeded access to
the apical foramen or first point of canal curvature
to facilitate proper cleaning and shaping, as shown
in Figure 13.34D.
  It should have uniform even contact with the walls
and smooth glide path.
  Gently insert the file and withdraw it and feel if
there is canal binding or deflection. If the handle of
small sized file is off the long axis of tooth, it suggests
that there may be an internal triangle of dentin that
needs to be removed to achieve SLA.

A B
Figs 13.34A to D  Removal of internal triangle of dentin. (A) Mandibular molar in which access preparation is to be done; (B) Diagrammatic
representation of internal triangle of dentin hindering the straight line access; (C) Gates Glidden drill is used to remove the internal triangle
of dentin; (D) Straight-line access to the apical foramen after removal of internal triangle of dentin
• When there is SLA: There is better tactile
sensation to feel the root canal anatomy and to
feel how the file performs in root canal system.
This allows all the areas of canal to be cleaned
and shaped effectively.
• When there is no SLA: Procedural errors such
as—ledge, transportation, zipping, instrument
separation, etc. can occur.
Step 9: Careful evaluation of the prepared access cavity:
Under good illumination and magnification using
dental operating microscope (DOM) and magnifying
loupes, the access cavity should be inspected
carefully.
  Additional canals may be located, that should then
be cleaned and shaped.
  After preparing the access cavity, when you view
it using a mouth mirror, without moving the mouth
mirror if all orifices can be visualized, then the access
cavity is said to be adequately prepared. If you have
to move the mirror to view the orifices individually,
then it means that the access cavity is underprepared
and you need to extend it further.
Step 10: Refinement and smoothing the cavosurface margins:
The access cavity preparation should have smooth,
diverging axial walls that allow smooth sliding down
of the instruments into the preflared orifices.
  After using GG drills, a surgical length tapered
diamond can be used to refine the access cavity.
Endodontic Access Cavity Preparation 211
C D
  Also, if the cavosurface margins are rough
and irregular, coronal leakage occurs through
temporary or permanent restoration. Refinement
and smoothing of cavosurface margins helps
improve the coronal seal.
  Figure 13.35 shows a mind-map to remember steps
of access preparation.
WHAT ARE THE SPECIFIC FEATURES OF ACCESS
PREPARATION OF INDIVIDUAL TEETH AND
POSSIBLE ERRORS RELATED TO THEM?
Maxillary Anterior Teeth
Steps of Endodontic access cavity preparation for maxillary
anterior teeth are shown in Figures 13.36A to E.
Maxillary Central Incisor
• External access outline form: Rounded triangle with
incisal aspect forming the base of the triangle and the
mesial and distal external walls converging towards
the cingulum as shown in Figure 13.37. The internal
walls must funnel towards the root canal orifice. Since
the palatal surface is functional, a butt joint should be
formed between the incisal internal wall and the lingual
surface of the tooth to allow for the bulk of restoration.
212 Short Textbook of Endodontics

Fig. 13.35  A mind-map to remember steps of access preparation

 Endodontic Access Cavity Preparation 213

A B C D E
Figs 13.36A to E  Access cavity preparation for maxillary anterior teeth. (A) Maxillary anterior tooth in which access is to be made; (B) Initial
entry made through the lingual surface with the round bur perpendicular to the long axis of tooth; (C) After penetration of enamel the bur
held along the long axis of the tooth till the pulp chamber is reached; (D) Complete removal of the roof of pulp chamber using round bur
working from inside to outside in withdrawal movement; (E) Removal of lingual shoulder using Gates Glidden

outside in withdrawal movement following internal

Fig. 13.37  Access cavity outline form of maxillary central incisor
(Palatal surface), (D, Distal; M, Mesial)
• Stepwise procedure:
Step 1: Initial entry is through the center of lingual surface
of crown using a #2 or #4 round bur to penetrate
through enamel and slightly into dentin (approx. 1
mm) at an angle perpendicular to the lingual surface
Step 2: Penetration of pulp chamber roof: With same round
or tapered fissure bur, angle of bur is changed from
perpendicular to the lingual surface to parallel to the
long axis of the root until the roof of pulp chamber
is penetrated.
  A “drop-in” effect is felt when this occurs.
Step 3: Complete roof removal: Overhanging enamel and
dentin of lingual roof of pulp chamber, including
pulp horns are removed by working from inside to
anatomy using a round bur.
  In case of pulpal hemorrhage that impairs
visibility, coronal pulp should be amputated at
orifice level with an Endodontic spoon or round
bur and the chamber is filled with a viscous chelator
EDTA followed by copious irrigation with sodium
hypochlorite.
Step 4: Axial wall extension: A tapered fissure or safe-ended
bur is used in withdrawal movement to extend the
access preparation for convenience form precisely
in labiolingual and mesiodistal dimensions and to
achieve straight-line access to the apex. Complete
roof removal is confirmed using an Endodontic
explorer. No “catches” or obstruction should be
encountered as explorer tip is withdrawn from the
pulp chamber along mesial, distal and facial walls.
Step 5: Identification of all canal orifices: After deroofing
the pulp chamber, locate the canal orifices using an
Endodontic explorer.
  Keep in mind the probability of finding additional
canals in the tooth and the most likely anatomic
location of these canals.
Step 6 and 7: Lingual shoulder removal and orifice and
coronal flaring: Lingual shoulder is lingual shelf of
dentin that extends from cingulum to a point about 2
mm apical to the orifice. Its removal aids in straight-
line access to the apex. It is removed using tapered
safety tip diamond or carbide bur or with Gates
Glidden burs. During rotation, the GG bur is leaned
against lingual shoulder and withdrawn.
214 Short Textbook of Endodontics
  The orifice should be flared using small to large
GG burs. These burs are used in circumference filling
motion, flaring each wall of canal in sequence.
Step 8: D etermination of straight-line access: Insert into
the canal the largest file that fits passively to the
apical foramen or the point of 1st canal curvature
to evaluate the straight-line access.
  The file is inserted gently and withdrawn. If the file
binds or deflects, the adequacy of lingual shoulder
removal is re-evaluated.
Step 9 and 10: Refinement and smoothing of restorative
margins and careful evaluation of access preparation
  The cavosurface margins should be refined and
smoothened in order to place and finish the final
restoration with precision that is necessary to
minimize coronal leakage.
  Using appropriate magnification devices, the
completed access preparation is evaluated. It should
be smooth, funnel-shaped and continuous with the
radicular portion of pulp cavity. Also it must provide
straight-line access to the apical third of root canal.
• Variations: The access cavity preparation is
designed to be more oval shaped in outline in
mature teeth due to receded pulp horns.
• Possible errors:
– Too far gingival extension of access
preparation
– Failure to remove the lingual shoulder
– Gouging due to improper alignment of bur
– Perforations
– Inadequate incisal extension causing failure
to remove the tissue from the pulp horns
that causes discoloration of the tooth after
treatment.
Fig. 13.38  Access cavity outline form of maxillary
lateral incisor (palatal surface), (D, Distal; M, Mesial)
Maxillary Lateral Incisor
• External access outline form
– Rounded triangle as shown in Figure 13.38.
– Sometimes it is oval shaped when mesial and distal
pulp horns are not prominent.
– Shape of a slender triangle when the pulp horns are
prominent.
• Stepwise procedure: Same as for the maxillary central
incisor.
• Variations: Crown can have lot of variations or
anatomic anomalies such as gemination, fusion with a
supernumerary tooth, dens invaginatus, etc.
• Possible errors:
– Failure to remove lingual shoulder
– Gouging due to improper inclination of bur
– Perforations
• Important considerations:
– An important anatomic feature of this tooth that
should be considered is that most of the times,
the root typically curves to the distal although
sometimes it may be straight.
– This tooth is known to have many anomalies that
may cause difficulty in treatment.
Maxillary Canine
• External access outline form: Oval or slot shaped due to
absence of mesial and distal pulp horns. Figure 13.39
shows the external access outline form of a maxillary
canine.
• Stepwise procedure: Technique is same for the maxillary
central and lateral incisors. Since this tooth is heavily
involved in excursive movements and occlusal function,
Fig. 13.39  Access cavity outline form of maxillary
canine (palatal surface), (D, Distal; M, Mesial)
 Endodontic Access Cavity Preparation 215

a butt joint relation is required between the incisal
wall and the lingual surface of the crown for adequate
thickness of restorative material.
• Variations: Usually has single canal but in some cases
two canals have been reported.
• Possible errors:
– Gouging due to improper inclination of bur
– Failure to remove the lingual shoulder
– Perforations.
Maxillary Premolar Teeth
Steps of Endodontic access cavity preparation for maxillary
premolar teeth are shown in Figures 13.40A to F.
Maxillary First Premolar
• External access outline form: Oval or slot shaped that
runs in buccolingual direction with buccal extension

A B C

D E F

Figs 13.40A to F  Access cavity preparation for maxillary premolar teeth. Endodontic preparation in maxillary premolar. (A) Initial entry
made parallel to the long axis of tooth through occlusal surface in the central groove of maxillary premolar using a round or small tapered
fissure bur in an accelerated speed contra-angle handpiece; (B) No. 2 or No. 4 round bur is used to penetrate into the pulp chamber; (C) An
Endodontic explorer used to locate the canal orifices; (D) Deroofing the pulp chamber using round bur working from inside the pulp chamber
to outside; (E) Buccolingual extension and finishing of cavity walls using tapered fissure bur; (F) Final preparation should allow straight-line
access of Endodontic instrument to the apex
216 Short Textbook of Endodontics
A B
Figs 13.41A and B  Access cavity outline form of maxillary first
premolar (occlusal view) with three and two canals respectively.
(B, Buccal; D, Distal; M, Mesial; L, Lingual)
about two-third up the buccal cusp incline and palatal
extension about half up the palatal cusp incline as shown
in Figures 13.41A and B.
• Stepwise procedure:
Step 1: Removal of caries and old restorations and establishing
initial outline form: Caries and restorations should
be removed to achieve initial outline form. For an
intact tooth, an access starting location is on the
central groove between the cusp tips.
Initial entry is made using a #2 round carbide bur to
penetrate the enamel in the center of the occlusal
surface between the buccal and lingual cusps.
Step 2: Penetration of pulp chamber roof: Using the same #2
round carbide bur or tapered fissure bur, held along
the long axis of tooth, penetrate through the dentin
into pulp chamber.
  A “drop” into the chamber is felt when the
chamber is large.
  Avoid underextended, shallow access opening that
will expose only the pulp horn tips, mistaken for root
canal orificies.
Step 3: Complete roof removal: A round bur, a tapered fissure
bur or a safety tip diamond or carbide bur is used
to remove the roof of pulp chamber completely,
including all pulp horns.
Step 4: Axial wall extension: Walls of access cavity are made
smooth and sloped slightly towards occlusal surface
using a tapered fissure bur or a safe-ended bur.
Step 5: Identification of root canal orifices: Dentinal map
(anatomic dark lines on pulpal floor) should be
examined to identify the orifices.
Usually the orifice of buccal canal lies beneath the
buccal cusp and orifice of palatal canal lies beneath
the palatal cusp.
Internally the access cavity should have all orifices
positioned entirely on pulpal floor and should not
extend in to axial wall otherwise there will be a
mouse-hole effect, which indicates under-extension
that will impede straight line access. In such cases,
access preparation must be further extended such
that the orifices are repositioned on to pulpal floor
without interference from axial walls.
Step 6 and 7: Removal of cervical dentin bulges and orifice
and coronal flaring: Cervical bulges are shelves of
dentin that frequently overhang orifices restricting
straight line access.
These bulges can be removed with safety tip diamond
or carbide burs or Gates Glidden burs. These
instruments are gently leaned towards the dentin
bulge to remove the overhanging shelf.
The orifice and constricted coronal portions of
the canal can be then flared with GG burs used in
sweeping upward motion with lateral pressure away
from the furcation in the direction of the name of the
canal
Step 8: Determination of straight-line access: An exploring
file such as #10 K-file is inserted in the canal. It must
have unimpeded access to the apical foramen or to
the first point of canal curvature for proper cleaning
and shaping.
Step 9 and 10: Careful evaluation of access preparation and
refinement and smoothing of restorative margins:
This is done to reduce the potential for coronal
leakage.
• Variations: Sometimes three canals may be
present two on the buccal side and one palatal.
The third canal is the mesiobuccal canal.
• Possible errors:
– Perforation due to misalignment of bur at the
mesiocervical indentation.
– Vertical underextension exposing only the
pulp horns.
• Important considerations: Mesial concavity is
present in the root so the preparation should not
be overextended in that direction as it can result
in strip perforation.
Maxillary Second Premolar
• External access outline form: Oval shape with wider
buccolingual extension when one or two canals are
present and triangular when three canals are present.
Figure 13.42 shows the access outline form of
maxillary second premolar with single canal (occlusal
view).
• Stepwise procedure: The technique is similar to maxillary
first premolar. Most of the times a single canal is present
and the buccolingual extension of the access preparation
is less simply corresponding to the buccal and palatal
pulp horns.
 Endodontic Access Cavity Preparation 217

widely spaced and are nearly parallel to each other.

Fig. 13.42  Access cavity outline form of maxillary second premolar
with single canal (occlusal view), (B, Buccal; D, Distal; M, Mesial;
L, Lingual)
There is slightly greater buccolingual extension to permit
the straight-line access to both the canals.
• Possible errors:
– Perforation due to misalignment of bur at the
mesiocervical indentation
– Vertical underextension exposing only the pulp
horns
– Gouging resulting as a result of search for orifices in
case of receded pulp chamber.
• Important considerations: This tooth has close proximity
to the maxillary sinus. Large periradicular abscess
related to this tooth may drain into the sinus.

When two canals are present, the access preparation Maxillary Molar Teeth
is identical to maxillary first premolar with the difference Steps of Endodontic access cavity preparation of maxillary
that only single root is present and the canals are not molar teeth are shown in Figures 13.43A to G.

A B C

D E F G

Figs 13.43A to G  Access cavity preparation for maxillary molars. (A) Buccal view of maxillary molar in which access cavity is to be
prepared; (B) Proximal view of same tooth; (C) Initial entry through occlusal surface using round bur in the exact center of mesial pit;
(D) Endodontic explorer is used to locate the canal orifices; (E) Deroofing the pulp chamber using round bur in withdrawal movements from
inside of pulp chamber to outside; (F) Final finishing and funnelling of cavity walls; (G) Final preparation should allow unobstructed access
to all the orifices
218 Short Textbook of Endodontics
A B C to occlusal table towards the largest canal (palatal)
Figs 13.44A to C  Access cavity outline form of maxillary first
molar with three, four and five canals respectively (occlusal view),
(B, Buccal; D, Distal; M, Mesial; L, Lingual)
Maxillary First Molar
• External access outline form: When three canals are
present, it is triangular with round corners as shown in
Figure 13.44A.
Extensions are towards mesiobuccal cusp tip,
marginal ridge and oblique ridge.
When four canals are present, it is rhomboidal
with mesiobuccal angle forming an acute angle and
distobuccal angle forming an obtuse angle, palatal
angles being right angles as shown in Figure 13.44B.
Mesially the access cavity does not extend into the
mesial marginal ridge. Distally it should not encroach
onto the oblique ridge. Buccally it should be parallel to
the line connecting MB1 and DB canal orifices.
Location of orifices: The main mesiobuccal canal orifice
(MB 1) is located within the acute angle of the pulp
chamber lying mesial and buccal to the distobuccal
orifice.
The distobuccal canal orifice (DB) is located within
the obtuse angle of the pulp chamber.
The palatal canal orifice is centered palatally.
A line drawn connecting these orifices forms a
triangle called as molar triangle.
The fourth canal which is almost always present but
commonly missed due to a ledge of dentin covering
its orifice, is the second mesiobuccal canal (MB2). Its
location varies:
– It may lie mesial to the main MB1 canal orifice
– It may be present mesial to the main MB1 canal
orifice on a line joining the MB1 and palatal canal
orifices.
• Stepwise procedure:
Step 1: Removal of caries and old restorations and establishing
initial outline form: Remove caries and restorations
to achieve initial outline form.
  Initial entry is made using a #4 round carbide bur
to penetrate the enamel with the bur held in the
central fossa.
  Mesial and distal boundary limitations should be
determined for access preparation. Mesial boundary
is a line connecting the mesial cusp tips and the distal
boundary is the oblique ridge.
Step 2: Penetration of pulp chamber roof: Using the same bur,
the angle of penetration is changed from perpendicular
because the pulp chamber space usually is largest just
occlusal to the orifice of this canal.
  A “drop” effect will be felt.
Step 3: Complete roof removal: Complete removal of roof of
pulp chamber including all pulp horns using a round
bur, a tapered fissure bur, or a safety tip diamond or
carbide bur.
Step 4: Axial wall extension: Tapered fissure carbide or
diamond bur with rounded end or safe-ended
diamond or carbide burs are used to funnel the
corners of the access cavity directly into the orifices
and to plane the axial walls and slightly flare them
towards the occlusal to remove all the obstructions
in the smooth, straight-line access to the canals.
Step 5: Identification of all canal orifices: The anatomic dark
lines in the pulpal floor (Dentinal map) should be
examined with an Endodontic explorer to identify
the orifices.
  One should routinely search for a fourth orifice
and canal that may be present in the mesiobuccal
root (MB2).
Step 6 and 7: Removal of cervical dentin bulge and orifice and
coronal flaring: Cervical dentin bulges are shelves of
dentin that may overhang the orifices restricting the
straight-line access to apex and causing accentuation
of existing canal curvatures. They are removed with
safety tip diamond or carbide burs or Gates Glidden
burs.
  Orifice and the constricted coronal portion of the
canal can be flared with Gates Glidden burs, used in
sweeping upward motion with lateral pressure away
from furcation in the direction of the name of the
canal.
  Sometimes an internal triangle of dentin may hinder
the straight-line access of the Endodontic instrument
to the apical portion of the canal. Gates Glidden burs
are used to remove these internal triangles.
Step 8: Determination of straight–line access:
Step 9 and 10: Evaluation of access preparation and
refinement and smoothing of restorative margins:
• Variations: Mild to severe curvatures are seen in
the roots especially the mesiobuccal root. Two or
three canals in any root are possible especially in
the mesiobuccal root.

  Figures 13.45A and B show clinical photo­
graphs of access cavity preparation of maxillary
first molar with four canals in two cases.
• Possible errors:
– Underextended preparation merely exposing the
pulp horns mistaken for root canal orifices.
– Gouging in an attempt to search for orifices in a tooth
with receded pulp chamber.
– Furcal perforation due to failure to recognize the
depth of pulp chamber.
– Lateral perforation due to improper bur angulation.
– Failure to recognize the canal curvatures causing
further procedural errors such as ledging, perforation.
Maxillary Second Molar
• External access outline form: When two canals are
present, it is oval shaped extending buccolingually.
When three canals are present, it is rounded triangle
which is more obtuse due to position of distobuccal
orifice being quite closer to a line connecting the
mesiobuccal and palatal orifices as shown in Figure
13.46.
When four canals are present, it is rhomboid shaped.
• Stepwise procedure: Similar to maxillary first molar with
some differences such as all orifices are located more
closer mesially than in first molar.
A B
Figs 13.45A and B  Clinical photographs of access cavity preparation
of maxillary first molar with four canals. Case A (Courtesy of Dr
Roheet Khatavkar), Case B (Courtesy of Dr Shivani Bhatt)
Fig. 13.46  Access cavity outline form of maxillary second molar with
three, two and one canal respectively (occlusal view), (B, Buccal; D,
Distal; M, Mesial; L, Lingual)
Endodontic Access Cavity Preparation 219
• Variations: Additional root canals such as second palatal
canal or second canal in mesiobuccal root have been
reported.
– Possible errors:
- Under extended preparation merely exposing the
pulp horns mistaken for root canal orifices.
- Gouging in an attempt to search for orifices in a
tooth with receded pulp chamber.
- Furcal perforation due to failure to recognize the
depth of pulp chamber.
- Lateral perforation due to improper bur
angulation.
- Failure to recognize the canal curvatures causing
further procedural errors such as ledging,
perforation.
Maxillary Third Molar
Root canal anatomy of this tooth is unpredictable and lot
of variations are possible. Access cavity preparation will
vary as per the number of roots and root canals and other
anatomic variations. About one to four roots and one to six
canals are possible. Most of the times the roots are fused to
form a single large root.
Figure 13.47 shows the access cavity preparation in
maxillary third molar with three canals.
Mandibular Anterior Teeth
Steps of Endodontic access cavity preparation of mandibular
anterior teeth are shown in Figures 13.48A to E, Figures
13.48F and G show errors in access preparation of
mandibular anterior teeth. Figure 13.48H shows correct
external access preparation.
Mandibular Central Incisor
• External access outline form: Triangular or oval
shaped, which is longer incisogingivally and narrower
mesiodistally as shown in Figure 13.49.
Fig. 13.47  Access cavity preparation of maxillary third molar with
three canals, (B, Buccal; D, Distal; M, Mesial; L, Lingual)
220 Short Textbook of Endodontics

A B C D

E F G H

Figs 13.48A to H  Access cavity preparation for mandibular anterior teeth (A) Initial entry made through lingual surface in the exact center
using a tapered fissure bur in accelerated speed contra-angle handpiece perpendicular to long axis of tooth; (B) Round bur No. 2 to penetrate
into pulp chamber; (C) Round bur used to deroof the pulp chamber working from inside the pulp chamber to outside; (D) Removal of lingual
shoulder and finishing the cavity walls; (E) Final preparation should allow unobstructed straight-line access of Endodontic instrument to the
apex; (F) Inadequate access opening can let the pulp tissue remnants to remain the coronal part of the tooth leading to discoloration later;
(G) Failure to remove the lingual shoulder will lead to missed lingual canal causing Endodontic failure; (H) Correct extension after removal of
lingual shoulder causing straight-line access of Endodontic instrument in both the canals

• Stepwise procedure: Technique is similar to that of
maxillary central incisor.
The initial entry point is just above the cingulum
with the bur held perpendicular to the entry point.
Remove the lingual shoulder completely as this tooth
often has two canals that are buccolingually oriented
and the lingual canal most often gets missed. About
40% of mandibular incisors have two canals—buccal
and lingual.
It is not necessary to have butt joint junctions
between the internal walls and the lingual surface
because lingual surface of the tooth is not involved in
occlusal function.

A B
Figs 13.49A and B  Access cavity outline form of mandibular central
incisor with one canal and mandibular lateral incisor with two
canals, (D, Distal; M, Mesial)
• Possible errors:
– Extension too far gingivally.
– Failure to remove the lingual shoulder that mostly
causes missed lingual canal. Figure 13.50 shows the access outline form of
– Gouging due to improper bur angulation and failure
to recognize the linguoaxial or mesioaxial angulation
of tooth.
– Inadequate incisal extension causing failure
to completely remove the pulp debris causing
discoloration of tooth after treatment as shown in
Figure 13.48F.
Mandibular Lateral Incisor
• External access outline form: Triangular or oval
shaped which is longer incisogingivally and narrower
mesiodistally.
Figure 13.49B shows the access outline form of
mandi­bular lateral incisor with two canals from incisal
view.
• Stepwise procedure: Same as mandibular central incisor
• Possible errors:
– Extension too far gingivally.
– Failure to remove the lingual shoulder that mostly
causes missed lingual canal.
– Gouging due to improper bur angulation and failure
to recognize the linguoaxial or mesioaxial angulation
of tooth.
– Inadequate incisal extension causing failure
to comple­t ely remove the pulp debris causing
discoloration of tooth after treatment.
Mandibular Canine
• External access outline form: Oval or slot-shaped narrow
mesiodistally and wider buccolingually. Its incisal
extension is towards the incisal edge and gingival
extension penetrates the cingulum. Mandibular canine
has almost straight mesial edge, its distal surface is
Endodontic Access Cavity Preparation 221
Fig. 13.50  Access cavity outline form of mandibular canine (incisal
view) with one and two canals, (B, Buccal; D, Distal; M, Mesial;
L, Lingual)
larger and its cusp tip is inclined lingually, so the access
preparation lies more to the mesial of the midpoint
mesiodistally.
mandibular canine (incisal view).
• Stepwise procedure: Technique is similar to Maxillary
canine. The lingual shoulder must be removed to gain
access to the lingual wall of the root canal or to the
entrance of a second canal. Buccal wall is larger and the
lingual wall is slit-like. As a result, cleaning and shaping
may be difficult.
Like the mandibular incisors, butt joint junctions are
not necessary.
• Possible errors:
– Extension too far gingivally
– Failure to remove the lingual shoulder that mostly
causes missed lingual canal
– Gouging due to improper bur angulation and failure
to recognize the linguoaxial or mesioaxial angulation
of tooth.
– Inadequate incisal extension causing failure
to completely remove the pulp debris causing
discoloration of tooth after treatment.
Mandibular Premolar Teeth
Steps of Endodontic access cavity preparation of mandibular
premolar teeth are shown in Figures 13.51A to E.
Mandibular First Premolar
• External access outline form: Oval shaped as shown in
Figure 13.52.
• Stepwise procedure: The procedure is the same as for
the maxillary premolars. But some specific points for
mandibular first premolar are:
– Usually the initial entry is made at the upper third
of lingual incline of the facial cusp with #2 round
222 Short Textbook of Endodontics

A B C D E

Figs 13.51A to E  Access cavity preparation of mandibular premolars: (A) Initial entry through occlusal surface in the central groove of
mandibular premolar; (B) Round bur used to penetrate into the pulp chamber; (C) Endodontic explorer used to locate canal orifice; (D) After
deroofing of pulp chamber, tapered fissure bur used for buccolingual extension and finishing of cavity walls; (E) Final preparation should
allow straight line access of Endodontic instrument to the apex

– Because of lingual inclination of the crown, buccal

Fig. 13.52  Access cavity outline form of mandibular first premolar
with one and two canals respectively (occlusal view), (B, Buccal;
D, Distal; M, Mesial; L, Lingual)
carbide bur centered mesiodistally and directed
along the long axis of root. This helps to compensate
for the tilt and to prevent perforations.
– When two canals are present, they tend to be round
from the pulp chamber to their foramen. Sometimes
a single broad root canal may bifurcate into two
separate root canals.
– Direct access to buccal canal usually is possible,
whereas lingual canal may be very difficult to find
due to following reasons: The lingual canal tends
to diverge from the main canal at a sharp angle and
the crown has lingual inclination that directs files
buccally, making location of lingual canal orifice
more difficult. To counter this, lingual wall of the
access cavity needs to be extended farther lingually,
this makes lingual canal easier to locate.
extension can nearly approach the tip of buccal cusp
to achieve straight-line access.
– Mesiodistally the access preparation is centered
between the cusp tips.
• Possible errors: Perforation due to improper bur
angulation or due to failure to recognize the lingual
inclination of the crown
– Inadequate extension causing further preparation
errors
– Apical perforation due to overinstrumentation or
due to failure to recognize the buccal or lingual apical
curvature.
• Important considerations: Due to lingual inclination
of the crown, the access cavity needs to be extended
lingually so that the lingual canal is easier to locate
and negotiate. Also the buccal extension should be
approaching the buccal cusp tip to achieve straight-line
access.
Mandibular Second Premolar
• External access outline form: Oval shaped as shown in
Figure 13.53.
• Stepwise procedure: Similar to mandibular first premolar,
with few specific variations:
– Crown has less lingual inclination, so less extension
up the buccal cusp incline is required for straight-line
access.
 Endodontic Access Cavity Preparation 223

Fig. 13.53  Access cavity outline form of mandibular second
premolar (occlusal view), (B, Buccal; D, Distal; M, Mesial; L, Lingual)
– Lingual half of the tooth is more fully developed, so
lingually access preparation may extend halfway up
the lingual cusp incline.
• Possible errors:
– Perforation due to improper bur angulation or due
to failure to recognize the tilt of premolar
– Inadequate extension causing further preparation
errors
– Apical perforation due to overinstrumentation or
due to failure to recognize the buccal or lingual apical
curvature.
Mandibular Molar Teeth
Steps of Endodontic access cavity preparation of mandibular
molar teeth are shown in Figures 13.54A to G.

A B C D

E F G

Figs 13.54A to G  Access cavity preparation of mandibular molars. (A) Buccal view of mandibular molar in which access is to be prepared;
(B) Proximal view of same tooth; (C) Initial entry made using round bur through the occlusal surface in the exact center of the mesial pit;
(D) Endodontic explorer is used to locate the canal orifices; (E) Round bur is used from inside to outside of the pulp chamber for deroofing
of the pulp chamber; (F) Final finishing and funnelling of access cavity walls; (G) Final access preparation should allow unobstructed access
to the canal orifices
224 Short Textbook of Endodontics
Fig. 13.55  Access cavity outline form of mandibular first molar with
three, four and five canals respectively (occlusal view). (B, Buccal;
D, Distal; M, Mesial; L, Lingual)
Mandibular First Molar
• External access outline form: Trapezoid or triangular
shaped with rounded corners and rectangular if two
distal canals are present.
Figure 13.55 shows the external access outline form
of mandibular first molar with three, four and five canals
respectively (occlusal view).
Mesially the access preparation should not invade
the marginal ridge. Distally it should be extended so
as to have adequate access to the distal canals. Buccal
and lingual wall are formed by the lines connecting the
respective two orifices
• Stepwise procedure:
Step 1: Removal of caries and old restorations and establishing
initial outline form: Remove caries and restoration
to achieve initial outline form. Initial entry is made
using #4 round carbide bur to penetrate the enamel
in the central fossa perpendicularly. The starting
location for molar access cavity preparation is
determined by establishing mesial and distal
boundary limits.
Step 2: Penetration of pulp chamber roof: Using the same bur,
angle of penetration is changed from perpendicular
to occlusal table towards the largest canal (distal)
because the pulp chamber space usually is largest
just occlusal to the orifice of this canal. A “drop”
effect will be felt.
Step 3: Complete roof removal: Complete roof removal
including the pulp horns using a round bur, tapered
fissure bur, or a safety tip diamond or carbide bur.
Step 4: Axial wall extension: Tapered fissure carbide or
diamond bur with rounded end or safe-ended
diamond or carbide burs are used to funnel the
corners of the access cavity directly into the orifices
and to plane the axial walls and slightly flare them
towards the occlusal to remove all the obstructions
in the smooth, straight line access to the canals.
Step 5: Identification of all canal orifices: The anatomic dark
lines in the pulpal floor (Dentinal map) should be
examined with an Endodontic explorer to identify
the orifices. Usually all canal orifices are located in
the mesial two-thirds of crown. Mesial canal orifices
are connected by developmental groove and are
well-separated within pulp chamber. Mesiobuccal
orifice is under the mesiobuccal cusp. Sometimes
the mesiobuccal cusp tip has to be encroached on
to achieve straight-line access. Mesiolingual orifice
is found just lingual to the central groove. In case of
single distal canal, the orifice is oval buccolingually
and the opening generally is located distal to the
buccal groove that can be explored from mesial side.
Step 6 and 7: Removal of cervical dentin bulge and orifice
and coronal flaring and removal of internal triangles
of dentin.
Step 8: Determination of straight-line access.
Step 9 and 10: Final evaluation of access preparation and
refinement and smoothing of restorative margins.
Figure 13.56 shows the clinical photograph of
completed access cavity preparation in mandibular
molar seen under magnification.
• Variations: In between mesiobuccal and
mesiolingual canals, a middle mesial canal may
be present as seen in Figure 13.57.
• Possible errors:
– Gouging in an attempt to search for orifices
in a tooth with receded pulp chamber
– Furcal perforation due to failure to recognize
the depth of pulp chamber
– Lateral perforation due to improper bur
angulation
– Missed second distal canal
– Ledge formation due to underextended
access preparation
– Failure to recognize the curvature in the canal
causing further procedural errors such as
ledging or perforation.
• Important considerations: The mesial and the
lingual inclination of the crown should be
considered during access preparation on this
tooth to prevent unnecessary gouging.
  A concavity is present on distal surface of
mesial root and on mesial surface of distal root.
So careful instrumentation should be done to
avoid strip perforation.
Mandibular Second Molar
• External access outline form: When three canals are
present, triangular form or slightly rhomboid shaped.
 Endodontic Access Cavity Preparation 225

Fig. 13.56  Clinical photograph of access cavity preparation in Fig. 13.57  Clinical photograph of access opening in mandibular first
mandibular molar with four canals seen under microscope (Courtesy molar with three canals (Additional middle mesial canal) (Courtesy
of Dr Roheet Khatavkar) of Dr Shivani Bhatt)

When two canals are present, rectangular shaped

opening which is wider mesiodistally.
When only one canal is present, oval shaped in the
center of occlusal surface.
• Stepwise procedure: Similar to mandibular first molar
with the variations due to smaller size. Due to bucco-
axial inclination of the tooth, sometimes large portion of
mesiobuccal cusp may have to be reduced to clean and
shape the mesiobuccal canal. The two mesial orifices
are located closer together.
• Variations: Mandibular second molars have roots and
canals usually close together and may have single or
fused roots. One to six canals are possible. Sometimes
a file placed in mesiobuccal canal may appear to be in
the distal canal when these two canals are connected
by a semicircular slit in case of a C-shaped canal (Fig.
Fig. 13.58  Clinical photograph of access opening done in
13.58). mandibular second molar with C-shaped canal (Courtesy of Dr
Figures 13.59A to D show the outline form of Roheet Khatavkar)
mandibular second molar with 3, 4, 2 canals respectively
and C-shaped canal (occlusal view).
C-shaped canals have been described in detail in – Ledge formation due to underextended access
Chapter 3: Morphology and Internal Anatomy of the preparation
Root Canal System. – Failure to recognize the curvature in the canal
• Possible errors: causing further procedural errors such as ledging
– Gouging in an attempt to search for orifices in a tooth or perforation
with receded pulp chamber • Important considerations: Distal aspect of mesial
– Furcal perforation due to failure to recognize the root and mesial aspect of distal root have concavities.
depth of pulp chamber So careful instrumentation should be done to avoid
– Lateral perforation due to improper bur angulation strip perforation. The roots have close proximity
– Missed second distal canal to the mandibular canal. So appropriate working
226 Short Textbook of Endodontics
A B
Fig. 13.60  Access cavity preparation in mandibular third molar
• Safe approach to face the challenge:
C D
Figs 13.59A to D  Mandibular second molar with (A) 3 canals;
(B) 4  canals; (C) 2 canals; (D) C-shaped canal, (B, Buccal; D, Distal;
M, Mesial; L, Lingual)
length determination should be done to avoid
overinstrumentation.
Mandibular Third Molar
It may have unpredictable anatomy. Lot of variations
are possible. May have severely curved roots. Access
preparation varies according to the number of roots and root
canals and other anatomic variations. Figure 13.60 shows
the access cavity preparation in a mandibular third molar
tooth with three canals.
WHICH ARE THE CHALLENGING ACCESS CAVITY
PREPARATIONS AND HOW TO DEAL WITH
THEM?
Teeth with Calcifications in Pulp Chamber
and Root Canals
• Challenge: Identification of calcified root canal orifices
and then negotiation of calcified canals is a challenge.
• Possible errors:
– Improper attempt to locate canals can lead to
perforations of root wall or of the furcation.
– Overzealous attempt to locate canals can cause
excavation of large amount of sound dentin resulting
in weakening of tooth structure (Figs 13.61A to C)
with three canals, (B, Buccal; D, Distal; M, Mesial; L, Lingual)
– Knowing beforehand that calcification exists, to be
prepared to deal with it, is important. Careful reading
of preoperative radiograph will reveal calcification
of pulp chamber and radicular canal spaces.
– One must know that calcification progresses from
the coronal part to the apex of the root. There may be
severe coronal calcifications but the canals become
less calcified as they approach the apex. So, complete
cleaning, shaping and obturation of these canals
upto the apical terminus needs to be achieved.
– Use of adequate illumination (For example,
transillumination with fiber-optic light) and
magnification (For example, dental operating
microscope or loupes) is very helpful diagnostic aids
in such cases.
– Careful examination of color differences can help
in searching the calcified orifices. Floor of pulp
chamber is darker in color than the walls of the
pulp chamber. Developmental grooves connecting
orifices are lighter in color than the floor of pulp
chamber.
– Exact knowledge of the anatomic location of root
canal orifices and possible variations and knowing
the fact that canal orifices are located at the end
points of developmental grooves and at the angles
formed by the pulp chamber walls and floor.
– Other diagnostic aids for location of calcified root
canal orifices:
- Use of sharp Endodontic explorer
- Use of ultrasonic tips
- Sodium hypochlorite champagne bubble test
- Sequential application of 17% EDTA and 95%
ethanol
– Patency of the canal can be determined using smaller
Endodontic files such as #6, #8 K-files coated with
chelating agent such as EDTA
 Endodontic Access Cavity Preparation 227

A B C
Figs 13.61A to C  (A) Radiograph showing calcified canal in maxillary left central incisor tooth, in which overzealous attempt to locate
canal has removed large amount of sound dentin; (B) With the use of dental operating microscope (DOM) and adequate light, the root
canal was located and negotiated, cleaned and shaped and obturation completed; (C) Access cavity opening sealed with a restoration
(Courtesy of Dr Roheet Khatavkar)

– Patience and slow, careful removal of dentin is the

key for uncovering calcified canals.

Teeth with Curved Canals

• Challenge: Following the anatomic curvature and
its complete cleaning, shaping and obturation is the
challenge.
• Possible errors:
– Failure to follow the curvature, can result in
procedural errors such as:
- Ledge formation
- Apical transportation and zipping
- Root perforations
- Incomplete cleaning and shaping
• Safe approach to face the challenge:
Fig. 13.62  Postoperative radiographs of two cases of maxillary first
– Recognition of canal curvature from preoperative premolar with S-shaped/Bayonet-shaped canals (Courtesy of Dr
radiographs. Roheet Khatavkar)
Figure 13.62 shows postoperative radiographs of
two cases of maxillary first premolar with curved/S-
shaped/Bayonet shaped canals.
– Sometimes the root may not seem to be curved on Teeth with Unusual and Complex Anatomy
radiograph, but there may be sharp angle between of Roots and Root Canals
the pulp chamber and the canal, which should be
carefully evaluated from radiographs. In such cases, • Challenge: Complete cleaning and shaping and
to obtain SLA, significant reduction of orifice walls obturation of such complex root canal system is a
may be required. challenge.
– Precurving the Endodontic files • Possible errors: Failure to negotiate through such
– Adequate extension of access cavity preparation to complex root canals can cause
allow for straight-line access (SLA) to curved canals – Inadequate cleaning and shaping
– Careful use of rotary files in curved canals. – Inadequate or ineffective obturation
228 Short Textbook of Endodontics
• Safe approach to face the challenge:
– Careful reading of preoperative radiographs to
recognize such complexities
– Careful negotiation and instrumentation of such root
canals keeping in mind the complex anatomy.
Teeth with Minimal Coronal Tooth Structure
• Challenge: To conserve as much sound tooth structure
as possible to protect it from fracture.
– Crown to root relation may not be identified due to
inadequate coronal tooth structure.
• Possible errors: Coronal or root perforation may occur
as a result of loss of significant coronal anatomy.
• Safe approach to face the challenge:
– Careful study of preoperative radiographs to study
the root angulation
– Careful probing of the cervical crown anatomy with
an explorer
– Palpate the root eminences
– Start access before placing rubber dam in such
cases
– If the canal is not located till a greater depth, then
instead of attempting to search the orifices, take
radiographs at various angles before proceeding.
Crowded Teeth
• Challenge: To obtain straight-line access while
conservation of tooth structure and without compro­
mising esthetics is the challenge.
• Possible errors:
– Inadequate access leading to inadequate cleaning
and shaping, missed canals, etc.
– Failure to achieve straight-line access (SLA) causing
further procedural errors
• Safe approach to face the challenge:
– Such cases may require an alternative approach of
access preparation
– Sometimes buccal access preparation will have to
be made to achieve SLA.
Rotated Teeth
• Challenge: To visualize the anatomic crown-to-root
relationship before making access preparation in order
to correctly angulate the bur with respect to the long axis
of root is the challenge.
• Possible errors:
– Perforations during access preparation
– Missed canals
– Excessive gouging of coronal or radicular tooth
structure in search of orifice of canal in a wrong
direction.
• Safe approach to face the challenge:
– Determine the anatomic relationship of the crown
to root by taking angled diagnostic periapical
radiographs
– Visualize and determine if there are any likely
variations that have to be made during access cavity
preparation.
Access Through Full Veneer Crowns
• Challenge: If the full veneer crown has to be retained,
making access cavity preparation through it is a
challenge.
• Possible errors:
– If you are conservative during access cavity
preparation, preparation may be underextended
causing various procedural errors.
– Failure to recognize crown to root angulation may
result in perforation.
– Leakage or recurrent caries may be left unattended
to resulting in failures later.
• Safe approach to face the challenge:
– When you prepare access through the full veneer
crown, do it with caution.
– Check the root prominence.
– Identify the long axis of the tooth.
– Carefully evaluate preoperative radiographs to find if
the full veneer crown has been altered. For example,
rotated tooth may have the full veneer crown that is
in the correct position and not in rotated position.
– Also, evaluate from preoperative radiograph, the
mesial/distal or axial inclination of the involved
tooth and its parallelism to the adjacent teeth.
– Check for the orientation of adjacent teeth clinically.
– Dental operating microscope (D OM) and
transillumination of CEJ can be a valuable aid.
– When some doubt exists that the underlying tooth
may be rotated, drill through the center of the full
veneer crown for a safe access.
Table 13.1 shows the summary of the challenging
access preparations.
WHAT ERRORS CAN OCCUR DURING ACCESS
CAVITY PREPARATION?
Errors may occur in access cavity preparation if:
• There is clinician’s lack of understanding of the internal
or external morphology of tooth or
 Endodontic Access Cavity Preparation 229

TABLE 13.1  Summary of the challenging access preparations

Challenging access Possible errors Safety measures

preparations
• Teeth with • Perforations • Preoperative recognition
calcifications in • Weakening of of calcification from
pulp chamber tooth structure radiographs
and root • Knowledge about
canals progress of calcification
• Adequate illumination
and magnification
• Evaluating color
differences
• Knowledge of anatomic
location of root canal
orifices
• Diagnostic aids to locate
orifices
• Smaller Endodontic files
• Chelating agent
• Patience and caution
• Teeth with • Ledge formation • Recognition
curved canals • Apical • Optimal reduction of
transportation orifice walls for SLA
and zipping • Precurving of files
Fig. 13.63  A mind-map to remember errors
• Root perforations • Use more flexible files
• Incomplete • Careful use of rotary files
in access cavity preparation
cleaning and
shaping
• Teeth with • Inadequate • Recognition
unusual complex cleaning and • Careful negotiation and • The clinician does not follow access guidelines.
anatomy of roots shaping instrumentation keeping
and canals • Ineffective in mind the complex
obturation anatomy
• Teeth with • Perforations • Evaluation of root
minimal coronal angulation by palpation
tooth structure and using radiographs
• Start access preparation
before placing rubber
dam
• Radiographs at different
angulations Poor Access Cavity Design
• Crowded teeth • Inadequate access • Alternate approach of
• Failure to achieve access preparation • Inadequate extension: Inadequate mesial or distal
SLA causing • Buccal access extension may leave the orifices uncovered.
procedural errors preparation may be
required
Failure to remove the pulpal roof completely is called
vertical underextension.
• Rotated teeth • Perforations • Radiographs at different
• Missed canals angulations
• Inadequate opening: Inadequate access opening results
• Excessive gouging • Variations/alterations in inadequate instru­mentation and obturation and it can
of tooth structure in the usual access also cause various procedural problems like:
preparation – Coronal discoloration when pulp horns are not
• Access through • Under extended • Caution debrided.
full veneer preparation • Careful evaluation of – Instrument breakage (separation)
crowns • Perforations preoperative radiograph
unrecognized • DOM and – Ledging of canal
• Leakage or transillumination – Apical transportation.
recurrent caries • Stay in center of tooth • Overextension: Gross overextension of access cavity
when in doubt preparation will weaken the coronal tooth structure and
230 Short Textbook of Endodontics
hence compromise the final restoration and longevity
of the treated tooth.
• Overzealous tooth removal: Gouging
Improper bur angulation and failure to recognize
the inclination of tooth can result in overzealous tooth
removal. This results in weakening and mutilation of
tooth structure predisposing it to fracture.
These have been discussed in detail in Chapter 20
Endodontic Mishaps: Management and Prevention.
Perforations
Results in communication between root canal system and
the periodontal tissues.
(Discussed in detail in Chapter 20 Endodontic Mishaps:
Management and Prevention).
Figure 13.63 shows a mind-map to remember the errors
in access cavity preparation.
BIBLIOGRAPHY
1. Cohen S, Hargreaves KM. Pathways of Pulp, 9th edn. St. Louis:
Mosby. 2006.pp.165-228.
2. Grossman L, Oliet S, Del Rio C. Endodontic Practice, 11th edn.
Varghese publication. 1991.pp.151-77, 79.
3. Ingle J, Bakland L, Baumgartner J, Ingle’s Endodontics, 6th edn.
BC Decker Inc, Hamilton. 2008.pp.877-918.
4. Ingle, Bakland, Endodontics, 5th edn. Plates 3 to 27, BC Decker-
Elsevier. 2002.
 Cleaning and Shaping of
the Root Canal System

14
CHAPTER

Including Working Length

Determination

This chapter describes the objectives and the various concepts and strategies for effective root canal
preparation and discusses in detail the root canal preparation techniques.
  You must know
• What is Cleaning and Shaping of Root Canals?
• What are the Objectives of Cleaning and Shaping of Root Canals?
• Which are the Important Numerical Concepts in Root Canal Preparation and how to
Determine Them?
• What are the Current Concepts and Terminology for Root Canal Preparation?
• Which are the Different Instrument Motions for Effective Shaping of Root Canals?
• What are the Requirements before Starting Canal Preparation?
• Which are the Different Canal Preparation Techniques?
• What are the Precautions to be taken during Instrumentation?
• What are the Procedural Errors that can Occur during Root Canal Preparation?

WHAT IS CLEANING AND SHAPING ‘Cleaning’ and ‘Shaping’ Concepts

OF ROOT CANALS?
Definition of Biomechanical Preparation
“Obtaining straight-line access to the apical foramen and
enlarging and disinfecting the root canals by chemo-
mechanical means without causing injury to the periapical
tissues is called biomechanical preparation of root canals”.
Earlier the term biomechanical preparation was
commonly used. However, now the terms ‘radicular
preparation’ and cleaning and shaping of root canals,’
are commonly used. ‘Cleaning’ and ‘Shaping’ are two
interdependent steps of root canal treatment procedure
performed in order to obtain complete disinfection of
root canal system and to obtain a continuously tapering
funnel from coronal access to apex in order to facilitate
3-dimensional obturation of root canals.
Effective ‘Shaping’ is the mechanical instrumentation of the
root canal with hand and rotary instruments to remove vital
and necrotic pulp tissue and eradicate microbes from the
accessible parts of the root canal and to shape the canals
in such a way that directs and facilitates optimal irrigation,
debridement and placement of local medicaments followed
by 3-dimensional obturation of the root canal system.
Shaping is specific for each root.
Effective ‘Cleaning’ refers to the use of chemicals
to eradicate microorganisms, dissolve necrotic tissue
and remove necrotic dentin and debris created from
instrumentation by means of antimicrobial irrigating
solutions, detergents and decalcifying materials and then
placement of intracanal medicaments to render the root
canal system free of microbes.
232 Short Textbook of Endodontics

Without irrigation, mechanical instrumentation
becomes ineffective rapidly due to accumulation of
debris. Without enlarging and shaping, the irrigating
solutions cannot reach all parts of the root canal system.
Shaping removes restrictive dentin thereby improving
the effectiveness and the control of canal preparation and
allows irrigation solution to completely penetrate the root
canal system. Thus, shaping facilitates cleaning and cleaning
facilitates shaping.
Also only well-shaped canals can be filled in three
dimensions. Thus, shaping facilitates 3-D obturation.
Various instrumentation and shaping techniques will
be discussed in this chapter. Various chemical agents used
for effective cleaning will be discussed in the next chapter
(Chapter 15).
WHAT ARE THE OBJECTIVES OF CLEANING AND
SHAPING OF ROOT CANALS?
Biologic objectives are to:
• Remove pulp tissue remnants and infected dentin from
the root canal system.
• Remove bacteria and their endotoxins and all potential
irritants from the entire canal system.
• Confine all instrumentation procedures within the root
canal space.
• Avoid pushing contaminated debris beyond the apical
foramina.
• Create sufficient space within the canal for irrigation
and intracanal medicaments (Remember biologic
objectives-CCARR).
• Prepare a sound apical dentin matrix at the cemento-
dentinal junction (CDJ) for apical seal.
• Design the preparation such that the cross-sectional
diameter becomes narrower at every point apically.
• Avoid preparation errors such as zipping, perforations,
etc.
Clinical objectives:
• To remove restrictive dentin in order to
– Improve effectiveness and control of canal
preparation,
– Allow irrigation solution to completely penetrate the
root canal system (Shaping facilitates cleaning).
• To remove the accumulated debris created by mechanical
instrumentation by means of root canal irrigation for
effective shaping (Cleaning facilitates shaping).
• To develop a logical cavity preparation specific for the
anatomy.
• To allow for three-dimensional filling of well-shaped and
cleaned root canals (Cleaning and shaping facilitates
three-dimensional obturation of the root canal system).
Figure 14.1 shows the mind-map to remember all
objectives of cleaning and shaping.

Mechanical objectives:
(Remember these mechanical objectives with the help of
following sentence: Kindly Prepare Design Mechanically
with Anatomy Maintained and Less Disturbed.)
• Develop a smooth continuously tapering funnel-shaped
preparation in all three-dimensions such that the cross-
sectional diameter of the canal narrows towards the
foramen.
• Maintain the original root canal anatomy by fully
incorporating all walls of canals into prepared shape
such that the preparation flows with the shape of the
original canal.
• Maintain the original position of apical foramen.
• Keep the apical opening as small as practically possible.
• Leave as much radicular dentin as possible to prevent
weakening of root structure. Fig. 14.1  Mind-map of objectives of cleaning and shaping
 Cleaning and Shaping of the Root Canal System Including Working Length Determination 233

WHICH ARE THE IMPORTANT NUMERICAL

CONCEPTS IN ROOT CANAL PREPARATION
AND HOW TO DETERMINE THEM?

Endodontic treatment involves preparation of the coronal

and radicular spaces (Earlier called Biomechanical
preparation, now termed as Cleaning and Shaping of the
root canal system).
Coronal access cavity preparation has been described
in detail in the previous chapter (Chapter 13 Endodontic
Access Cavity Preparation).
Radicular preparation or root canal preparation is
discussed in detail in this chapter. Fig. 14.2  Significance of determining working length (WL)
The important concepts in root canal preparation are as
follows:

Working Length
Canal length is the distance from a coronal reference point
to the apical exit of the root canal.
Anatomic apex of the root is the tip or end of the root
which is morphologically determined.
Radiographic apex of the root is the tip or end of the root
which is determined on the radiograph.
The radiographic apex may be different from the
anatomic apex due to variations in the morphology of the
root and factors related to the radiographic technique. A B

Figs 14.3A and B  Representation of how the position of apical

Definition of Working Length
According to Glossary of Endodontic terms: “Working length
is defined as the distance from a coronal reference point to
the point at which the canal preparation and obturation
should terminate”.
Significance
Figure 14.2 gives the importance of working length
determination.
Apical Limit of Working Length
• Theoretically, the apical extent for termination of root
canal preparation and obturation is the cemento-dentinal
foramen changes the working length: (a) Tooth length; (b) Working
length
junction (CDJ), which is a histological entity and cannot
be accurately determined clinically.
• Clinically, the desired apical extent considered is the
apical constriction, which does not always coincide with
the CDJ. Apical constriction is located about 0.5–1 mm
short of the radiographic apex. Apical constriction is the
portion of the root canal with narrowest diameter, also
referred to as minor apical diameter.
Figures 14.3A and B show how the position of apical
foramen changes the working length.
234 Short Textbook of Endodontics
Method for Determination of Working Length
• The process of determination of the current working
length (WL) is called Endometrics.
• Requirements for the ideal method of accurate working
length determination: Ingle 6th edition has given
following requirements:
– The method should allow location of apical
constriction rapidly (Quick)
– The method should provide accurate readings in all
conditions of pulp and in the presence of all canal
contents
– The method should provide easy measurement
– The method should allow for confirmation and
periodic monitoring of working length
– The method should be comfortable to both the
patient and the clinician
– The method should cause minimal radiation to
patient
– The method should be easy to use even in specific
condition of patient such as severe gag reflex, limited
opening of mouth and pregnancy
– The method should be economical.
Since no single method satisfies all requirements,
combination of several methods should be used for accurate
working length determination.
• Various methods for working length determination:
1. Digital tactile sense
2. Evaluation of patient’s response to a file introduced
into the canal (Apical periodontal sensitivity)
3. Evaluation of paper point placed in the canal
4. Use of mathematical formula (Grossman’s method)
5. Use of radiographs
Different radiographic methods:
a. Grossman’s method
b. Ingle’s method
c. Weine’s method
d. Kuttler’s method
e. Radiographic grid
f. Endometric probe
g. Direct digital radiography
h. Xeroradiography
i. Subtraction radiography
6. Use of electronic apex locators.
Currently, the widely used method for working length
determination is the combination of use of electronic apex
locators and the radiographs.
Digital Tactile Sense
Resistance is felt as the file approaches the apical 2–3 mm,
which can be detected by tactile sense by an experienced
clinician especially when the coronal portion has been
adequately enlarged.
This method requires that the canal is preflared prior to
determining the working length.
The tactile method can be used as a supplementary
method with other methods for working length
determination but cannot be used alone because it has
high chances of giving inaccurate measurements in case
of excessively constricted and curved canals. It is also an
inaccurate method in root canals with an immature apex.
Evaluation of Patient’s Response to a File Introduced in
the Canal (Apical Periodontal Sensitivity)
This is not a method for working length determination per se,
but a file introduced beyond the apical constriction causes
painful response, which gives an indication that the WL
would be approximately lesser than this length to which the
file was introduced. This, however, can be misleading when
a file is advanced in a canal with inflamed tissue may cause
pain even when instrument tip is short of apical constriction.
Evaluation of Paper Point Placed in the Canal
In this method, the blunt end of the paper point is gently
inserted in the canal to the extent it can penetrate after
profound anesthesia. The moisture or blood on the apical
portion of the paper point gives an estimation of WL.
This method is also a supplementary method to aid in
working length determination.
It is useful in canals with immature root apex and in
cases of apical resorption or perforation where the moisture
or blood determines the amount of overextension.
Use of Mathematical Formula
• Grossman’s formula
KLI × ALT
Correct Length of Tooth (CLT) = __________________
ALI
Where, KLI = Known length of instrument or the pre­
measured length
ALT = Approximate length of tooth from
radiograph
ALI = Approximate length of instrument from
radiograph
In this method, a premeasured file is placed in the canal
and a radiograph is taken and then using the above formula,
the working length is determined.
Methods requiring formula for working length
determination have been abandoned. Bramante and
 Cleaning and Shaping of the Root Canal System Including Working Length Determination 235

Fig. 14.5  Endoblock from side

(Courtesy of Dentsply)
A B
Figs 14.4A and B  Weak unsupported enamel is ground to obtain a
flat, stable reference plane

Berbert found great variability in formulaic determination

of working length, with only a small percentage of successful
measurements.

Use of Radiographs
Requirements
• For determination of working length, the radiographs
taken should be of good quality and undistorted.
• Reference points: The anatomical landmark on tooth used
as coronal reference point should be reproducible. So,
the cusps which are weakened by caries or restoration
may have to be reduced to a flat surface as shown in
Figures 14.4A and B in order to have a stable reference
plane and thus preventing the possibility of loss of A B
reference point due to fracture of weak enamel or cusps
in between appointments. Figs 14.6A and B  Instrument stop should be placed perpendicular
• Exploring instrument: In this method, an appropriate to the reference plane: (A) Incorrect placement of instrument stop;
(B) Correct placement of instrument stop
size K-file with an instrument stop is used as exploring
instrument to determine the working length.
Smaller fine instruments such as #8 and #10 K-files when
used as exploring instruments may be quite loose in Figure 14.5 shows the photograph of an Endoblock.
the canals and may cause errors in WL and also their • Instrument stops should be properly placed on the shaft
tips are sometimes not clearly visible on radiographs. of the exploring instrument such that it lies perpendicular
So, an instrument size which is not very small but can to the shaft as shown in Figure 14.6B. Instrument stops
negotiate the entire length of root canal should be used made of different materials such as metal, plastic and
as exploring instrument such as no.15 K-file. silicone rubber are available. Teardrop-shaped silicone
• A scale or an Endodontic millimeter ruler such as a rubber stops help in the orientation of instrument into
calibrated “Endoblock’ is used to adjust the instrument canal curvatures and they need to be removed from the
stop. instrument during sterilization.
236 Short Textbook of Endodontics

Fig. 14.7  Measurement of approximate tooth length Fig. 14.8  Deducting 1 mm and determining
from a preoperative radiograph tentative working length

Steps Involved in this Method

Step 1: From a preoperative diagnostic radiograph, the
length of the tooth from the occlusal surface to
the root apex is measured as shown in Figure 14.7.
Then, 1 mm is deducted from this length as ‘safety
allowance’ for possible radiographic distortion
as shown in Figure 14.8. This is tentative working
length.
Step 2: An appropriate sized K-file is inserted into the root
canal with a slight wiggling motion so that it can
bypass any obstruction or debris and be placed till
the tentative working length. Shaft of K-file should
have properly placed instrument stop at the level of
coronal reference points.
Step 3: Take a radiograph.
Step 4: Determine the difference between the end of the
instrument and the end of the root.
Step 5: If necessary, the measured length is adjusted such
that the instrument tip lies about 0.5 mm from the
radiographic apex as shown in Figures 14.9A and B.
Step 6: If apical resorption is evident on radiograph, then A B
Weine has recommended that the working length Figs 14.9A and B  Here, the measured length adjusted so that
be kept about 1.5–2 mm short of the radiographic instrument tip lies about 0.5 mm from radiographic apex
apex.

Different Radiographic Methods b. Ingle’s method of working length determination:

Makes use of a preoperative radiograph of tooth to be
a. Grossman’s method: Using the mathematical formula treated. The length of the tooth is determined from this
described above. radiograph and an instrument adjusted to 1 mm lesser
 Cleaning and Shaping of the Root Canal System Including Working Length Determination 237

than this length is placed in the canal and a radiograph Direct digital radiography (RadioVisuo Graphy and
is taken to determine the working length. Phosphor Imaging System), Xeroradiography and
c. Weine’s method: It makes use of radiographs for working Subtraction radiography are the advanced radiographic
length determination and Weine has recommended the methods for determining the working length, with
following apical termination points: digital radiography being quite common and widely
– If no bone or root resorption—1 mm from apex used these days. These methods have been described
– If only bone resorption—1.5 mm from apex in detail in Chapter 7 Diagnosis and Diagnostic Aids in
– If both bone and root resorption—2 mm from apex Endodontics.
d. Kuttler’s method: According to studies done by Kuttler,
the root canal preparation should terminate at apical Use of Electronic Apex Locators
constriction, i.e. minor diameter.
The average distance between the major and minor Radiographs enable us to arbitarily work around the apical
diameter: constriction. To overcome this limitation, an electronic
– Young patients—0.524 mm device called apex locator was introduced that helps to
– Older patients—0.659 mm accurately determine the position of apical constriction
Step-wise procedure: or the Cemento-Dentinal Junction (CDJ) and not the
i. Locate major and minor diameter on the pre- radiographic apex (The term apex locator is a misnomer).
operative radiograph. Apex locators are electrical devices that determine the
ii. Estimate length of the roots from preoperative working length and give the measurement by means of
radiograph using a millimeter scale. some ‘sound’ or ‘movement of a dial’ or ‘indicator’ when
iii. Estimate width of root canal on the preoperative the correct position is reached.
radiograph using #10 or #15 K-file for narrow canal, Figure 14.10 shows the photograph of commercially
#20 or #25 K-file for average width and #30 or #35 available apex locator.
K-file for wide canals.
iv. Insert the selected K-file in the root canal to the Principle: Apex locator compares the electrical resistance
estimated canal length and take a radiograph. of periodontal membrane with that of gingiva surrounding
v. On radiograph: the tooth, both of which should be similar.
- If file appears too long or short by more than Difference in impedance is found between high and low
1 mm from the minor diameter, then readjust frequencies at various sites in the root canal.
the instrument accordingly and take another Difference between two frequencies is less in coronal
radiograph to confirm. portion of canal.
- If file appears reaching the major diameter,
subtract 0.5 mm from that length in young
patients and subtract 0.67 mm in case of older
patients.
vi. Advantages of this method: It is quite accurate
with minimal errors and has resulted in many
successful cases.
vii. Disadvantages of this method: It is complicated
method and requires excellent quality radio­
graphs.
e. Radiographic grid: This method involves superimposing
a millimeter grid on the radiograph, making it simpler to
estimate the working length with no need for calculation.
But if the radiograph is bent, it may not give the correct
length.
f. Endometric probe: This method uses the graduations
on diagnostic file which are visible on the radiograph.
Endometric probe is etched at millimeter increment. The
disadvantage of this method is that the smallest size of Fig. 14.10  Commercially available apex locator
file used is number 25. (Courtesy of Dentsply)
238 Short Textbook of Endodontics
Difference between two frequencies increases in deeper
portion of canal.
Difference between two frequencies is highest at
Cemento-Dentinal Junction (CDJ).
Generations of apex locator: These have been discussed
in detail in Chapter 11: Endodontic Armamentarium:
Instruments, Materials and Devices.
Components of apex locator: Discussed in Chapter 11.
Factors determining accuracy of apex locators: Discussed
in Chapter 11.
Method: Generally a no. 15 K-file is used in the root canal
held on the file clip to estimate the length since it gives
apex locator readings efficiently and its tip well seen on the
radiograph taken to confirm the position of the file within
a root canal. Smaller files like no. 6, 8, 10 may not be well-
appreciated on radiograph and may be loosely fitting in
the root canal.
Advantages
• It precisely locates the position of apical constriction.
(Accuracy up to 90% or more).
• Reduction of radiation exposure by eliminating the need
for multiple radiographs. One radiograph may be taken
to confirm the readings given by apex locator.
• Eliminates errors associated with radiographic image
distortion.
• Easy and quick method.
• It is useful in verifying perforations, bifurcations of root
and any obstructions.
• It is very useful in maxillary molar teeth, where radio­
graphs may be difficult to read accurately due to
radiopaque structures such as malar process and floor
of maxillary sinus.
• Useful in patients with gag reflex and in children who
cannot tolerate placement of X-ray film and also a
valuable tool in case of pregnant patients in whom the
radiation exposure should be avoided.
Disadvantages
• Some of the earlier generation apex locators do not give
accurate readings in presence of canal contents.
• Erroneous readings are obtained in case where current
flows into marginal gingiva or into metal restorations.
• Inaccurate readings in case of low battery, blockage of
canal and in too wet or too dry canal.
• There can be difficulty in estimation of length in cases
with wide open apex such as immature teeth.
• Cannot be used in patients with cardiac pacemakers.
This problem has been overcome in newer generation
apex locators.
A mind-map to remember all points of working length
is given in Figure 14.11.
Working Width/Apical Width/Apical Preparation
One of the objectives of radicular preparation is to keep the
apical opening as small as practically possible.
Whether the apical width should be kept narrow or wide
is a matter of debate with advantages and disadvantages of
either of them. The aim is to reduce the intracanal microbial
load as much as possible by preparing the apical canal
areas so as to facilitate optimal irrigation and antimicrobial
activity.
‘Apical width’ or ‘Working width’ is the term used for
the size of the preparation to which the apical portion of
the canal should be enlarged—Apical preparation.
Apical scouting is the process of determining the
anatomy and cross-sectional diameter of the apical 1/3rd
of the root canal, based on which the final size to which the
preparation should be enlarged, is estimated.
Ruddle has suggested passing a series of K-files to
working length to gauge the apical width.
Grossman had recommended to enlarge a root canal
to three sizes more than the first instrument that binds
in the root canal or to enlarge it till all infected dentin is
removed and clean, white dentinal shavings appear on
flutes of the working instrument blade. However, these
recommendations are no longer considered optimum for
determining the apical width.
Factors to be considered to determine apical width: Size of
preparation of the apical portion varies from case to case
and can be determined by considering following factors as
given in Figure 14.12.
Advantages and Disadvantages
• Wider apical preparation:
– Advantages:
- Ensures that all of the infected dentin has been
removed.
- Provides access to irrigating solutions and allows
placement of intracanal medicaments in the
apical portion to reduce the microbial load.
– Disadvantages:
- There is risk of errors in an attempt to make the
apical preparation wider such as:
■ Apical perforation
■ Apical transportation
■ Overinstrumentation
■ Extrusion of irrigants and medicaments peri­
apically
■ Overextension of obturating material
 Cleaning and Shaping of the Root Canal System Including Working Length Determination 239

Fig. 14.11  A mind-map to remember all points of working length determination

- Not suitable for thermoplastic techniques of ■ Less chances of overextension of obturating

obturation in which there are more chances of
overextension of obturation with wider apex.
– Narrower apical preparation:
- Advantages:
■ Minimal risk of preparation errors such
as apical transportation, perforation, over
instru­mentation
■ Reduced risk of extrusion of irrigants and
medicaments periapically
material
■ Suitable for thermoplastic techniques of
obturation.
- Disadvantages:
■ Irrigants may not have access to the
complexities of the apical third
■ Intracanal medicaments may not be properly
placed. So, there may be compromised disin­
fection during interappointment period
240 Short Textbook of Endodontics

■ May not remove all infected dentin

■ It is not considered ideal for lateral compaction
obturation.
A mind-map to remember all points of working width
is given in Figure 14.13.

Taper
Taper of the preparation is brought about by the taper of the
instruments used for shaping of the root canal.
Earlier, stainless steel hand instruments that were used
had a constant taper of 2% (0.02) throughout the length
Fig. 14.12  Mind-map showing factors determining
apical width of root canal
of the instrument as per the ISO standards. Currently,
instruments with greater tapers such as 4%, 6%, 8%, 10%,
12% have also become available made of Nickel-titanium.

Fig. 14.13  A mind-map to remember all points of working width

 Cleaning and Shaping of the Root Canal System Including Working Length Determination
It has been found that preparations with larger tapers
and smaller apical width preparation can adequately
disinfect the root canal.
WHAT ARE THE CURRENT CONCEPTS
AND TERMINOLOGY FOR ROOT CANAL
PREPARATION?
Few Concepts and Terminology
Apical Control Zone
It is the area located in the apical third of the root canal
system that demonstrates an exaggerated taper from the
clinician defined apical constriction.
Need for greater rate of taper of apical control zone (ACZ):
• To provide resistance against condensation pressures
of obturation.
• To provide resistance/retention form to prevent
extrusion of filling material.
Apical Control Zone can be created by different
techniques depending on Operator’s preference.
Coronal Scouting
Initial process of determining the coronal and cross-
sectional diameter of coronal 2/3rds of root canal. Fine
instrument sizes such as #8, #10, #15 in conjunction with a
viscous chelator is used to explore, discover and secure the
canal path in its coronal two-thirds. This is coronal scouting.
These smaller files are called scouting files that are used
initially in the canal before any radicular preparation is
done. Scouting files are used to:
• Determine the anatomy and cross-sectional diameter
of root canal.
• Confirm the presence or absence of straight-line access
to the canal. When the handle of the file is off the long-
axis of the canal it suggests lack of straight-line access
as shown in Figure 14.14A.
Figure 14.14B shows straight-line access of file in canal.
Apical Scouting
Process of determining the anatomy and cross-section
diameter of apical 1/3rd of root canal. Fine instrument
sizes such as #8, #10, #15 can be used for apical scouting in
conjunction with a viscous chelator to explore, discover and
secure the canal path in its apical one-third.
Apical scouting helps in determining the final size to
which the preparation should be enlarged.
241
A B
Figs 14.14A and B  (A) Handle of file of the long-axis;
(B) Straight-line access of file in canal
Apical Gauging
Process of determining the most apical cross-sectional
diameter of the canal where a hand or rotary Endodontic
instrument fits snugly at the terminus and resists any further
apical travel. Thus, it confirms whether a uniform taper has
been achieved in the apical one-third of the canal.
It is recommended that the apical one-third of canal is
prepared so as to have a deep shape with 8–10% taper.
Apical gauging is usually done at the end of root canal
preparation to determine the master apical file, i.e. the file
used for final preparation of the canal based on which an
appropriate corresponding master cone can be selected for
obturation.
After finishing the apical preparation, insert no. 20
K-file till length and tap on its handle (do not rotate). Check
whether it is snug or loose. This is apical gauging.
Use of Endo gauge: It has holes of different diameters into
which the gutta-percha cone is placed to confirm the exact
diameter to which the apical preparation of the canal has
been done.
Figure 14.15 shows the photograph of the Endodontic
gauge.
Apical Tuning
Apical tuning is the process to confirm that the diameter
of the master apical file (MAF) represents the true size of
the foramen.
242 Short Textbook of Endodontics

Fig. 14.15  Endodontic gauge (Courtesy of Dentsply)

Fig. 14.16  Apical tuning: Uniform backout of successively larger

instruments at the interval of 0.5 mm

This is done by recapitulating using a series of

successively larger instruments in sequence until those
instruments uniformily back out of the canal. The interval
of back out should not be more than 0.5 mm.
Figure 14.16 shows apical tuning: Recapitulating with
series of successively larger instruments no. 20, 25, 30, 35,
40, 50 and 60 diameter with 0.5 mm interval of backout.

Patency File
Patency file is a small K-file (such as size #10) which is
passively just pushed through the apical foramen to the
radiographic terminus without causing its enlargement as
shown in Figure 14.17.
The concept of using patency file is controversial.
• Points in favor of using patency file:
– Patency file cleans the apical foramen
Fig. 14.17  Patency filing with no. 10 K-file
– It prevents packing of debris in the apical portion of
the canal
– It helps to maintain working length by removal of
accumulated dentinal debris and shavings produced Apical Clearing
as a result of instrumentation
– It does not cause any apical enlargement. Process of removal of loose debris from the apical extent
• Points against using patency file: of the root canal by using two to four successively larger
– It might push contaminated debris periapically instruments than the initial apical file at the working length.
through the apical foramen. After final irrigation and drying, the last instrument is
– It may mechanically injure the periapical tissues. once again worked in the canal called as master apical file
– It may inoculate microorganisms periapically. for the purpose of apical clearing.
 Cleaning and Shaping of the Root Canal System Including Working Length Determination
Fig. 14.18  Push-pull motion
WHAT ARE THE DIFFERENT INSTRUMENT
MOTIONS FOR EFFECTIVE SHAPING
OF ROOT CANALS?
Filing Motion (Fig. 14.18)
• Filing motion is penetration and withdrawal, where the
primary cutting action occurs on withdrawal.
Also called as push-pull motion or rasping motion.
• The instrument is to be placed into the canal till
appropriate length and pressure is exerted against the
wall of the canal. While maintaining pressure, the file is
withdrawn from the canal.
• The filing motion is carried out circumferentially to file
all walls of the canal.
• K-files are commonly used in filing motion. Hedstrom
files bring about very effective filing motion.
• Chances of apical transportation are more with filing
motion.
Reaming Motion (Fig. 14.19)
• Reaming motion is penetration, rotation and retraction,
cutting action occurs on retraction.
• The instrument is inserted in the canal till appropriate
length and twisted clockwise one-quarter to one-half
turn so that the instrument blades are engaged into the
dentin and then the instrument is withdrawn.
243
Fig. 14.19  Reaming motion: Penetration, rotation and retraction
• Reaming motion involving one-half turn before
withdrawal can be used for preparing straight canals
and that involving one-quarter turn before withdrawal
can be used for slightly curved canals.
• Reaming produces round, tapered preparation.
• Reamers are used in reaming motion. Files can also be
used in reaming motion.
• Chances of apical transportation are less with reaming
motion.
Watch-winding Motion
• It is back and forth oscillation motion of instrument as
it is advanced without applying any apical pressure.
• This motion involves a quarter turn rotation using
smaller size files such as #8 or #10.
• It is most desirable during the initial phases of root canal
preparation before coronal flaring is done.
• The instrument is inserted to explore the canal with this
motion.
• There are less chances of preparation errors with this
motion.
Rotary Motion
• Continuous rotary movement with Nickel-Titanium
rotary files is now the most commonly used motion for
root canal preparation.
244 Short Textbook of Endodontics

• These instruments have reduced the potential

preparation errors.

Balanced Force Technique Instrument Motion

Balanced force hand instrumentation involves:
• Insertion of instrument and advancing it in the canal in
one-quarter turn clockwise rotation of less than 90o with
slight or no apical pressure (Fig. 14.20A).
• Second movement involves applying sufficient apical
pressure to the instrument and rotating the instrument
in half to three quarter turn counterclockwise rotation of
120o (Fig. 14.20B).
• Third movement is to gently remove the instrument from
the canal in clockwise rotation (Fig. 14.20C).
These movements are carried out as the instrument is
A B C
advanced towards the apex till the working length.
Figs 14.20A to C  Balanced force technique instrument motion
WHAT ARE THE REQUIREMENTS BEFORE
STARTING CANAL PREPARATION?
WHICH ARE THE DIFFERENT ROOT CANAL
• An optimal coronal access preparation is a must before PREPARATION TECHNIQUES?
initiating the canal preparation.
• There should be unobstructed straight-line access to the I.
orifices of the canals.
• The cusps or the incisal edges, which are going to be used
as reference planes for working length determination
should be flattened to get a stable reference point which
is reproducible.
• All the instruments that will be required for shaping
of root canals must be sterilized and kept ready in an
organized manner, i.e. in order of their sequence of use
which saves time. The chronology of these techniques is as follows:
• Before initiating the canal instrumentation, the A. Apical to coronal approach:
preoperative radiograph should be carefully studied – Standardized technique by Ingle in 1967
to know beforehand the canal anatomy or curvature – Step-back technique by Mullaney in 1979
or  any other irregularity that may be encountered B. Coronal to apical approach:
during instrumentation to prevent any preparation – Crown-down technique by Marshall in 1980
mishaps. – Step-down technique by Goerig in 1982
• For safe use of nickel-titanium rotary instruments – Balanced force technique by Roane in 1985
in the canal without undue stress, most important II. Root canal preparation techniques:
requirements are: – Hand instrumentation
– Adequate coronal enlargement – Rotary instrumentation techniques
– Establishment of straight line access (SLA) to the – Ultrasonic and Sonic root canal instrumentation
canals. techniques
– Establishment of glide path with pathfinders or – Laser-assisted root canal preparation techniques
smaller K-files # 8, # 10, # 15 and even # 20. – Noninstrumentation technique (NIT)
 Cleaning and Shaping of the Root Canal System Including Working Length Determination
Apical to Coronal Approach
Conventional/Standardized Technique of Root Canal
Preparation (Ingle)
The conventional technique considers two guidelines for
instrumentation:
• Root canal should be enlarged to atleast three sizes
beyond the size of first instrument that binds in the
canal.
• Root canal should be enlarged till all infected dentin
from the canal is removed and white clean, dentinal
shavings appear on the blade of the instrument.
This is no longer followed as it was found that:
• Enlarging the canal to three subsequent sizes was
insufficient in some cases, while in few cases it was found
to be more than adequate. The degree of enlargement
depends on the width and configuration of a particular
root canal.
• Color of dentinal shavings is not a reliable parameter
and it is also not an indication of the presence of
infected dentin.
Step-back Method of Root Canal Preparation
(Mullaney et al)
The step-back method is the traditional canal preparation
strategy which was in use for many years.
• Other names: Telescopic technique, Flare method, serial
root canal preparation.
• Principle: Stepwise reduction of working length with
increasing instrument sizes.
The working length is reduced incrementally in 0.5 mm
or 1 mm steps to create flared shapes having 0.10 or 0.05
taper respectively while using larger and stiffer instruments.
• Step-wise procedure:
A. For straight canals: Performed in following phases:
- Locating apical constriction and cleaning of
apical foramen (Phase I instrumentation):
■ Explore the canal with a fine instrument such
as size #8, #10 in watch-winding motion and
carry out gross debridement of the root canal.
■ Determine the working length.
■ Irrigation with 5.25% sodium hypo­chlorite.
■ Insert smaller sized file lubricated with a
chelating agent and with instrument stop
positioned to the correct working length in
the canal.
■ File is engaged against dentinal wall and
lateral pressure is exerted while maintaining
the pressure, the file is withdrawn from the
canal. Watch winding motion can be carried
out with the file before it is withdrawn.
245
Fig. 14.21A  Circumferential filing
The procedure is repeated while carrying
out circumferential filing around the entire
perimeter of the canal for all the walls of the
canal as demonstrated in Figure 14.21A.
■ It is necessary to irrigate the canal with sodium
hypochlorite between each instrument use.
Irrigation is done using a side-vented needle
as demonstrated in Figure 14.22.
This phase cleans the apical foramen. Now
the preparation of the apical 1/3rd of the
canal is started.
- Preparation of apical 1/3rd of canal (Phase II):
■ Instrument stops are positioned about
0.5–1  mm short of the established working
length.
■ Lubricated files are used in increasing
sequence and the procedure of circumferential
filing is repeated for this new working length.
Figure 14.21B shows circumferential filing in apical third
of canal.
■ Recapitulation: Previous smaller instrument
is used till full depth periodically to prevent
apical blocking with debris.
- Preparation of body of canal:
■ Instrument stops are positioned at 0.5–1 mm
lesser length than the length the previous
instrument was used in a step-wise manner
and larger files are used in the canal in
sequence.
■ Circumferential filing is carried out until
the file makes unforced contact with the
246 Short Textbook of Endodontics
Fig. 14.21B  Circumferential filing in apical third. Irrigation
between each instrument use is a must
walls of the canal with irrigation in between
instrumentation and recapitulation with
smaller instruments periodically.
Purpose of recapitulation:
i. Prevent blocking with dentinal debris
ii. Permit insertion of larger instruments to
the working length
iii. Smoothen the walls of the canal
■ The last file that was used for apical
preparation called the master apical file is
reinserted to the working length to maintain
the patency of the apical segment.
■ Body of the canal is instrumented with three
or four larger files in sequence with periodic
recapitulation in between and copious
irrigation with sodium hypochlorite after
each instrument use.
Figure 14.23 demonstrates the preparation of
apical third and body of canal.
- Preparation of coronal portion of canal (Phase
II A):
■ Gates Glidden (GG) drills or Hedstrom files,
one or two sizes larger than the previous
instruments used in canal can be carefully
used to flare the coronal portion of root canal
as shown in Figure 14.24.
- Refining phase of preparation (Phase II B):
■ It involves use of master apical file to
smoothen all the walls and get a continuous
Fig. 14.22  Irrigation is done using a side-vented needle
taper from the apical constriction to the
cervical canal orifice as shown in Figure
14.25.
The step-back method aims at providing the final
preparation as an exact replica of the original canal
configuration, shape and taper, but only of larger size.
• An example illustrating the step-back technique for
instrumentation:
A straight root canal with working length determined as
20 mm.
Working length (WL) adjusted to: Size of file
•  20 mm # 10, # 15, # 20, # 25
• 19 mm (WL minus 1 mm) Use of # 20 for recapitulation
(i.e. 1 mm short of apical foramen) # 30, # 35, # 40
• 18 mm (WL minus 2 mm) Use of # 30 for recapitulation
(i.e. 2 mm short of apical foramen # 45, # 50, # 55
Use of # 50 for recapitulation
B. Curved root canals and other anatomic variations
causing difficulty
– Modifications for root canals with gentle curvature:
- The instrument blade should be precurved as
per the curvature and a directional silicone
instrument stop should be positioned such that it
indicates the direction in which the file has been
curved.
- Smaller K-files used in apical portion of root
canal are flexible and can be precurved easily
 Cleaning and Shaping of the Root Canal System Including Working Length Determination 247

Fig. 14.23  Serial root canal preparation of apical third and body of canal

Fig. 14.24  Gates Glidden (GG) drill for coronal flaring Fig. 14.25  Master apical file used for refining phase of preparation

but for larger inflexible files a diamond file or
sandpaper disc is used to dull the flutes of the
outer portion of the curve in apical segment of
instrument to prevent preparation errors such
as apical transportation. This is demonstrated
in Figure 14.26.
• Modifications for narrow root canals:
– Since even the smaller files tend to bind in narrow
canals, they should not be forced in the canal.
– Smaller file is used till whatever length it penetrates
without forcing and then the canal is irrigated with
sodium hypochlorite.
– Instrument tip of a smaller file is modified by cutting
about 1 mm from the end and smoothening it with a
diamond file thus making a smaller file to act as an
intermediate sized file as demonstrated in Figure
14.27.
– Narrow canals should be enlarged to atleast size #25
or #30 K-files.
• Modifications for double-curved or s-shaped canals:
– After cleaning the apical foramen area, the curvature
in the middle third of the root canal is carefully
eliminated by filing with Hedstrom file to straighten
the inner portion of the curve.
248 Short Textbook of Endodontics
Fig. 14.26  Schematic representation of modification of flutes
of K-file. The outer portion of curve dulled with diamond file to
prevent transportation of foramen in curved root canals (Courtesy of
Dr Vishal Rathod)
– After eliminating the middle third curve, only the
apical curve is left to be instrumented.
Advantages of Step-back Technique
• Less chances of periapical trauma.
• Develops an apical matrix or stop preventing over­
instrumentation and overfilling of root canal.
• Also, greater pressure can be exerted during lateral
compaction of gutta-percha facilitating filling of lateral
canals.
• Provides greater flare in the canal to provide dense
obturation with gutta-percha.
• Allows for removal of more debris.
Disadvantages of Step-back Technique
• Full length may not be reached due to coronal binding
caused by overhangs or obstructions in the coronal
portions of root canal. As the canal is less tapered than
instrument, the instrument binds somewhere coronally.
• Narrow coronal portions of canal will prevent adequate
passage of irrigating solutions to the apical portions of
canal.
• Due to limited irrigating solution, debris gets
accumulated causing blockage.
• Due to insufficiently enlarged coronal portion of canal,
clinician has insufficient tactile control.
• When a precurved negotiating file is inserted through
coronally tight canal, the instrument gets straightened
Fig. 14.27  Modification of instrument to clean
and shape narrow root canals
thus preventing proper instrumentation of the apical
portion of canal.
A mind-map to remember all points of step-back
technique is given in Figure 14.28.
Coronal to Apical Approach
Crown-down Technique of Root Canal Preparation
(Marshall and Pappin)
This is the most popular strategy for root canal preparation
in present-day Endodontics. It can be performed using both
hand and rotary instrumentation.
• Other names: Pressure less technique, Step-down
technique.
• Rationale:
– Pressureless coronal to apical movement minimizes
or eliminates the extrusion of necrotic debris beyond
the apical foramen.
– Eliminates the coronal binding of instruments for
controlled apical cleaning and shaping.
• Step-wise procedure:
– After access cavity preparation with unobstructed
access to the root canal orifices, the access cavity is
filled with a root canal irrigant (NaOCl).
– Pre-flaring of the canal orifices with Gates Glidden
drills in sequence. Orifice shapers of various Ni-Ti
rotary systems such as profile orifice shapers can be
used for pre-enlargement.
– Establishing patency with smaller K-file such as no.
10 K-file.
 Cleaning and Shaping of the Root Canal System Including Working Length Determination 249

Fig. 14.28  A mind-map to remember the step-back technique

– Then a larger instrument is passively inserted into the

canal till the depth it can advance without binding
as shown in Figure 14.29A.
– The next instrument one size smaller than the
previous instrument is used to progress deeper in
the canal. The third instrument follows and this
process is continued till the tentative working length
as shown in Figure 14.29B.
– It is recommended that the files be lubricated with
a chelating agent while using in the canal.
- Copious irrigation with sodium hypochlorite in
between use of instruments.
- Recapitulation with smaller sized instruments to A B C D
prevent blockage of debris.
Figs 14.29A to D  Steps of crown-down technique of root canal
– Irrigate, recapitulate and reirrigate after every two preparation: (A) After coronal pre-flaring, larger instrument passively
to three instruments. inserted into canal till the depth it can advance without binding;
– Determination of exact working length only after (B)  Instrument one size smaller than previous instrument used to
adequate coronal enlargement. Figure 14.29C shows progress deeper into the canal; (C) Adequate coronal enlargement;
adequate coronal enlargement of canal. (D) Exact working length determined after coronal enlargement
250 Short Textbook of Endodontics

– Preparation of apical third of the root canal till the
working length as shown in Figure 14.29D.
– The final step in crown-down technique is the apical
finishing involving apical gauging and apical tuning.
• Advantages of crown-down technique:
– It provides straighter, unimpeded access to the apical
region of the canal by removing the coronal inter­
ferences.
– It allows deeper penetration of irrigants.
– It removes bulk of pulpal tissue and microorganisms
and their products from the coronal portions of
the canal. As a result it minimizes or eliminates
the extrusion of necrotic debris beyond the apical
foramen.
– It eliminates the constraint of the apical enlarging
instruments.
– Flaring of the coronal 2/3rds of canal improves
clinician’s tactile control of instrument preventing
the preparation errors such as zipping.
• Disadvantages of crown-down technique: This technique
is relatively free of disadvantages when carefully
performed to confine the instruments within the root
canal space.
Over-enthusiastic use of rotary files or GG drills should
be avoided as it can lead to preparation errors such as
perforations or can weaken the root structure predisposing
it to fractures.
Step Down Technique of Root
Canal Preparation (Goerig)
• Other names: Coronal two-thirds pre-enlargement
technique or reverse flaring technique.
• Technique:
i. After access Cavity preparation, hand instruments
such as K or H files are used in the root canal till the
length at which they bind in the canal.
ii. Use of GG drills to flare the coronal third of the root
canal.
iii. Determination of working length for the tooth and
creating an apical stop with no. 25 instrument.
iv. Remaining canal is shaped in step-down approach,
using a descending file sequence and progressing
about 1 mm per consecutive instrument apically.
v. Recapitulate with no. 25 instrument.
The current trend is to use a crown-down approach for root
canal preparation involving enlargement of coronal portions
of canal followed by preparation of apical portions of canal.
Thus, it involves dividing the radicular preparation into
coronal, middle and apical one-third as shown in Figure
14.30.
Step 1: Pre-enlargement/Coronal 2/3rds Preparation
• Instruments used: Sequential use of Gates Glidden (GG)
drills or various systems orifice shapers such as profile
orifice shaper, etc. are used for coronal flaring. “Face off”
the orifices with an appropriate size of Gates Glidden
drill to create smooth glide path to facilitate placement
of subsequent instruments.
• Coronal scouting and shaping: Smaller K-files such as
no.10 and then no. 15 are used for coronal scouting (i.e.
inserting the file to a predetermined length estimated
from a preoperative radiograph) to confirm the straight
line access and to establish a glide path.
• Benefits:
– It allows for smooth, unobstructed path of the instru­
ment into the canal.
– Gives better tactile control while using small
precurved negotiating files in the apical portions of
the canal.
– It provides access for large amount of irrigating
solution to reach the apical portion of canal and into
various irregularities of canal.

Modified Crown-down/Step-down Technique of

Root Canal Preparation (Ruddle)
There have been number of modifications of the step-down Fig. 14.30  Radicular preparation divided into coronal,
technique. One of the modifications is by Ruddle as follows: middle and apical one-third
 Cleaning and Shaping of the Root Canal System Including Working Length Determination
– It facilitates removal of accumulated dentinal mud.
– Since a bulk of pulp tissue and bacteria and
their products have been removed by coronal
enlargement, there are less chances of inadvertently
inoculating them periapically.
– It helps in easier location of the apical foramen.
After the coronal scouting, the coronal two-thirds of the
canal is shaped (Coronal Shaping).
Step 2: Scout to Terminus and Apical 1/3rd Preparation
Apical scouting is the process of determining the anatomy
and cross-sectional diameter of apical 1/3rd of root canal.
Fine instruments such as size #8, #10, #15 can be used for
apical scouting.
It helps in determining the final size to which the
preparation should be enlarged and also helps determine
whether hand or rotary instruments should be used to finish
the apical one-third preparation.
This step involves:
• Negotiating the apical one-third of canal
• Establishing patency
• Determining the exact working length
• Establishing and confirming smooth glide path to the
apical terminus.
Fig. 14.31  Mind-map of crown-down technique
251
• Determining the working width, i.e. apical width to
which the canal can be enlarged.
• Shaping of the apical one-third of the canal (Apical
shaping).
Step 3: Apical Finishing—Apical Gauging and Tuning
This is the final step that completes the root canal
preparation.
It confirms whether uniform taper has been obtained
in the apical 1/3rd.
It involves:
• Apical gauging: Process of determining the most apical
cross-sectional diameter of the canal where a hand or
rotary Endodontic instrument fits snugly at the terminus
and resists any further apical travel.
This is done usually at the end of root canal
preparation to determine the master apical file used
for final preparation of the canal based on which an
appropriate corresponding master cone can be selected
for obturation.
• Apical tuning: Process of recapitulation by using a series
of successively larger instruments in sequence until
those instruments uniformly back out of the canal.
A mind-map to remember all points of crown-down
technique is given in Figure 14.31.
252 Short Textbook of Endodontics

TABLE 14.1  Step-back technique versus Crown-down technique

Sr. Step-back Technique Sr Crown-down Technique

No No.
1. Also called telescopic or serial root canal preparation 1. Also called pressure-less or step-down technique
2. Was used earlier. Now rarely used 2. Most popular strategy in present-day Endodontics
3. Uses hand instruments 3. Uses both rotary along with hand instruments
4. Involves apical preparation first followed by coronal preparation 4. Involves enlargement of coronal portions of canal first followed by
of canal apical portions of canal
5. Beginning with smallest file close to apex and moving back from 5. Beginning with larger file to remove coronal debris first and moving
that point while increasing file size to smaller files as the files move closer to apex
6. Causes coronal binding of instruments due to obstruction in 6. Since the obstruction in coronal portions of root canal are removed,
coronal portions of root canal. As a result, full length may not be eliminates coronal binding of instruments for controlled apical
reached cleaning and shaping
7. Narrow coronal portion prevents adequate passage of irrigating 7. Allows deeper penetration of irrigating solutions
solutions to apical portions of canal
8. Debris accumulation which may get extruded beyond apical 8. Deeper penetration of irrigants facilitates removal of debris and
foramen eliminates its extrusion beyond apical foramen
9. Obstructions in coronal portions of canal prevents straight, 9. Provides straighter, unimpeded access to the apical region of the
unimpeded access to the apical region of canal canal by removing coronal interferences
10. Due to insufficiently enlarged coronal portion of canal, clinician 10. Coronal 2/3rds flaring improves clinician’s tactile control preventing
has insufficient tactile control preparation errors such as zipping

Step-back technique v/s Crown-down Technique - Third movement is to gently remove the
instrument from the canal in clockwise rotation
See Table 14.1. as shown in Figure 14.32C.

Balanced Force Technique of Canal Preparation

Introduced by Roane et al. using a series of rotational move­
ments with ‘Flex-R files’, which is a new type of K-file.
• Principle: Makes use of hand instruments to be
positioned in the canal in a clockwise rotation followed
by shaping the canal in a counterclockwise rotation.
• Step-wise procedure:
– Flaring of the coronal and middle thirds of the
canal with GG drills in sequence so that most of the
contamination from the canal is removed and there
is passive movement of hand instruments into the
apical third of the canal.
– Balanced force hand instrumentation involves (Figs
14.32A to C):
- Insertion of instrument and advancing it in the
canal in one-quarter turn clockwise rotation of
less than 90o with slight or no apical pressure as
shown in Figure 14.32A. A B C
- Second movement involves applying sufficient/
Figs 14.32A to C  Balanced force technique of canal preparation:
slight apical pressure to the instrument and (A) Insertion of Flex-R file into the root canal and turning it in
rotating the instrument in half to three quarter clockwise direction (<90°); (B) With slight apical pressure, rotating
turn counter-clockwise rotation of 120o or more the file 120° anticlockwise; (C) Release the pressure and remove the
as shown in Figure 14.32B. instrument (file)
 Cleaning and Shaping of the Root Canal System Including Working Length Determination
These movements are carried out as the instrument
is advanced towards the apex till the working length.
– Copious irrigation with sodium hypochlorite in
between use of instruments is recommended to
prevent packing of debris.
– The force applied during the balanced force
technique should be minimal with light working
loads to reduce the amount of tooth structure
removed.
– Balanced force technique can be used with any of the
K-files or other tapered Ni-Ti hand instruments but
can provide maximum advantage when used with
Flex-R files which prevents preparation errors such
as transportation due to its specific design.
Flex-R file has tip design free of transitional angles
which are inherent in standard K-files.
– The apical preparation is completed by gradually
reducing the working length by 0.5–1 mm in a step-
back manner using increasing sizes of instruments
in sequence under copious irrigation with sodium
hypochlorite.
Fig. 14.33  A mind-map to remember the balanced force technique
253
• Advantages:
– Less chances of canal transportation.
– Creates excellent shapes due to canal centering
ability provided by the technique.
– Minimal chances of extrusion of contaminated
debris beyond the apical foramen.
• Disadvantages: Can lead to preparation errors if not
performed carefully.
A mind-map to remember all points of balanced force
technique is given in Figure 14.33.
Hybrid Technique of Canal Preparation
Basic techniques described above can be combined into a
hybrid technique to take advantage of each technique and
eliminating or minimizing the drawbacks of individual
technique. Generally, coronal pre-enlargement is followed
by different sequences for apical preparation. Which
systems are to be combined is based on root canal anatomy
and with a goal of adequate preparation.
254 Short Textbook of Endodontics

Others III. Root Canal Preparation Techniques

Anticurvature Filing
In case of curved canals, this concept of anticurvature filing
reduces the excessive removal of dentin from thinner root
sections and preventing the potential perforations.
This method of filing was advocated for mesial roots of
mandibular molars which have:
• Less dentin on furcation side referred to as danger
zone
• More dentin on mesial side referred to as safety zone.
Anticurvature filing in these roots prevented the risk of
perforation.
Double flare: This technique combines:
• Crown-down enlargement with sequential use of K-files
in descending order
• Apical enlargement
• Stepping-back in 1 mm increments with sequential use
of K-files in ascending order.
Copious irrigation with sodium hypochlorite in between
instrument use and recapitulation with master apical
file is recommended.
1.  Hand instrumentation
Various hand instrumentation motions and techniques
have already been described above.
Hand Instrumentation v/s Rotary Instrumentation
Distinguishing features between hand and rotary
instrumentation are given in Table 14.2.
2.  Root canal preparation using rotary instrumentation:
• Different rotary systems made of Nickel-Titanium
have been introduced for easy, quick and effective
instrumentation of canals relatively free of preparation
errors.
• Principle of rotary instrumentation: Creating smoothly
tapered canals by following the basic crown-down
approach to avoid overloading of rotary instruments
with frictional forces as they contact the canal walls.
Various features are incorporated in the instrument
design of different Nickel-Titanium rotary systems
produced by different manufacturers to get uniform,
smooth ‘Taper’ in the canals. Manufacturers’ guidelines

TABLE 14.2  Hand instrumentation versus rotary instrumentation

Sr. Hand Instrumentation Sr Rotary Instrumentation
No No.
1. Endodontic hand instruments were earlier made of carbon- 1. Rotary instruments are made of Nickel-Titanium (Ni-Ti)
steel, then stainless steel and then with Nickel-Titanium (Ni-Ti).
Stainless steel and Ni-Ti hand instruments are widely used
2. There is standardized technique for using hand instruments 2. Rotary instruments are used in step-down approach with light
(ISO standardization) pressure
3. Different instrument motions:—push-pull, watch-winding, 3. Gentle reaming or rotary motion
reaming, etc.
4. Can be autoclaved and used many times. Smaller number #6, 8, 4. Single-use is recommended
10, single-use; but larger instruments can be used more number
of times
5. Smaller K-files can be used for apical scouting to create glide path 5. Coronal enlargement and creation of glide path is important to allow
rotary file to work without undue stress. Ni-Ti rotary files cannot
create the glide path but can follow that made by hand instrument
6. Can be used to bypass leges 6. Cannot be used to bypass leges
7. Deformation of files generally can be seen on the instrument 7. Due to excellent shape memory of Ni-Ti files, sometimes deformation
under magnification will not be observed and instrument will fracture without warning
8. Rigid instruments 8. Flexible, elasticity, shape memory
9. Do not require passive instrumentation technique 9. Require passive technique always
10. Less chances of instrument separation if carefully used and rules 10. More tendency to separate in root canals if improperly used due to
followed such as: frictional resistance and torisional load. Gel-based lubricants should
– Using instruments in sequence always be used in conjunction with rotary Ni-Ti files or fill access
– Lubricants and NaOCl cavity with NaOCl before insertion of file
– Precurving in case of curved canals
 Cleaning and Shaping of the Root Canal System Including Working Length Determination
need to be strictly followed while working with
instruments of different systems.
It is important to understand that no canal can be
completely prepared using rotary instrumentation
alone. Hand instrumentation generally is required prior,
during and sometimes after rotary instrumentation to
complete the preparation.
Exploring the canal and achieving a glide path into
the canals is always done with smaller size K-files #6, #8,
#10, etc.
• Classification of Nickel-Titanium rotary instruments
systems: Based on design, Cohen classified Nickel-
Titanium rotary instruments as follows:
Group I: Light Speed Instruments System
• About the instruments: Consists of set of 25 instruments
in sizes #20 to #100 including half sizes such as #22.5,
#27.5.
These instruments are designed to have long, thin
noncutting shaft with 0.25–2 mm anterior cutting part.
They are to be used at working speed of 1500–2000
rpm with minimal torque.
• About the technique:
– Coronal pre-enlargement
– Using smaller stainless steel hand instruments such
as #8, #10, #15 K-files
– Determination of working length
– Apical gauging is done with light speed instruments
of increasing sizes until the instrument is found
to bind in canal just before reaching full working
length using a handpiece. This instrument is called
as FLSB (First Light Speed instrument to Bind before
reaching working length)
– Master Apical Rotary (MAR) size is the last instrument
used for apical preparation which may require 12 or
more pecking motions to advance from the point of
first binding to the working length
255
– Then the middle 1/3rd of the canal is instrumented
– Finally, the MAR file has to be used again for
recapitulation to the working length.
Group II: Instruments
Example is the Profile system.
Profile System
• About the instruments:
– Profile instruments have greater taper as compared
to hand instruments
– Cross-section of profile Endodontic files shows
central parallel core with three equally shaped
U-shaped grooves along with radial lands as shown
in Figure 14.34.
– These instruments have negative rake angle which
makes them to cut dentin in planning motion
– Have tapers of 0.02, 0.04 and 0.06 (2%, 4%, 6%)
– Consists of series of 29 instruments with constant
proportion of increasing diameters (29%) which
were nonstandardized diameters. Later Profile series
was introduced with modified tips with standardized
diameters.
Figure 14.35 shows photograph of profiles for rotary
use.
• About the technique:
– Coronal pre-enlargement
– Estimation of tentative working length from pre-
operative radiograph
– Establish glide path with K-files up to size #15 or #20
– Use profile orifice shapers in coronal portion of root
canal in descending order, i.e. #4, #3, #2, #1
– Canal preparation with profile instruments of taper/
size: 0.06/30, 0.06/25, 0.04/30, 0.04/25 and so on
Fig. 14.34  Cross-section of Profile Endodontic files
256 Short Textbook of Endodontics

Fig. 14.36  Cross-section of protaper Endodontic files

Fig. 14.35  Profiles for rotary use

– Determine the exact working length using apex

locator combined with radiograph
– Then use profiles till working length for apical
preparation such as 0.04/25, 0.04/30, taper and size
respectively
– Then 0.06/20 profile is used short of working length
for final flaring and smooth tapered preparation by
merging coronal and apical preparations.

Group III: Instruments

Example is Protaper Universal system, named so, as it
has progressively tapered design that improves flexibility,
cutting efficiency and safety of these files.
• About the instruments: Rotary Protaper files are consi­
dered good for narrow constricted canals (posterior
teeth) while for wide canals (anterior teeth), hand
protaper files may be used.
Protaper Endodontic files have triangular cross-section
Fig. 14.37  Protaper files for hand use: Sx, S1, S2, F1, F2, F3
as shown in Figure 14.36.
(Courtesy of Denstply)
Consists of set of 6 instruments:
– 3 shaping files: SX, S1, S2
– 3 finishing files: F1, F2, F3
These instruments are coded by colored rings
on handles: S1 (purple), S2 (white), F1 (yellow), F2 (red),
F3 (blue).
They are side cutting instruments with fine, fragile tips.
Figure 14.37 shows photograph of protaper files for
hand use. Figure 14.38 shows photograph of protaper files
for rotary use.
• About the technique:
– Straight-line access to canals
– Estimation of approximate working length from Fig. 14.38  Rotary Protaper Universal files — S1, S2, F1
radiographs (Courtesy of Dentsply)
 Cleaning and Shaping of the Root Canal System Including Working Length Determination 257

– Initial glide path with #10, #15 K-files short of
approximate WL
– Gates Glidden drills may be used for enlargement of
orifices
– Establish a smooth glide path before protaper rotary
instruments are inserted into the canal
– Use SX shaping file for enlargement of coronal third
of canal, especially in shorter teeth
– Prepare the coronal third of the canal by inserting
shaping file S1 passively in the canal, not more than
two-thirds of estimated canal length
– Irrigate with sodium hypochlorite and recapitulate
– Use shaping file S2 to the estimated canal length
– Irrigate and recapitulate
– Establish accurate working length using apex locator
and radiographs
– Shape with S1 shaping file till working length
– Shape with S2 shaping file till working length
– Then use finishing file F1 till working length
– Carry out apical gauging with stainless steel K-files.
Then finishing files F2 and F3 may be used if
necessary as per the apical widening required.
• Newer Nickel-Titanium rotary instruments systems:
Here few more Ni-Ti rotary instrument systems will be
discussed which have been recently developed and are
being used by many clinicians. These include:
1. Protaper Next System
2. Revo S System
3. Wave One System
4. Reciproc Rotary File System
– Recommended speed for use: 300 rpm
– Torque: 4–5.2 Ncm
– Motion of use: Brushing motion away from external
root concavities to facilitate file progression
– The Protaper Next sequence is the same always
irrespective of length, diameter or curvature of root
canal.
Figure 14.39 shows photograph of the Pathfiles and Protaper
Next system rotary files namely X1, X2, X3, X4 and X5.
• About the technique
– Pre-enlargement and straight line access to canals
– Establish glide path using small-sized hand files
determining the Working Length(WL)
– Path files can be used to establish a glide path
– Use X1 (17/04) file one or two times along glide path
in presence of NaOCl until WL is reached
– Irrigate, recapitulate and re-irrigate
– Use X2 (25/06) similar way as X1, until WL is reached
– Irrigate, recapitulate and re-irrigate
– Apical gauging: Use #25 k-file. If it is snug at length,
then that finishes the instrumentation
– If size #25 k-file is loose at length, then continue
shaping with X3 (30/07) and if necessary with
X4 (40/06), and X5 (50/06) gauging after each
instrument with 30, 40 and 50 hand files respectively.

1. Protaper Next system

• About the instruments
– Protaper Next is the advanced version of the widely
used Protaper Universal system
– It has variable/progressive tapers (Similar to
Protaper Universal)
– It has an innovative M-wire technology
– It has a unique offset mass of rotation
– It consists of set of 5 files namely:
a. X1 with size of 17/04 with yellow ring for
identification
b. X2 with size of 25/06 with red ring for identifi­
cation
c. X3 with size of 30/07 with blue ring for
identification
d. X4 with size 40/07 with double black rings for
identification
e. X5 with size 50/07 with double yellow rings for Fig. 14.39  Pathfiles and Protaper Next system rotary files: X1, X2,
identification. X3, X4 and X5
258 Short Textbook of Endodontics
Both protaper universal and protaper next files have
variable taper unlike the constant-tapered ISO files. Both
share the same shaper file SX. The reduced tip and taper
of protaper next allows for a more conservative apical
preparation than that of protaper universal. Greater
efficiency is achieved with Protaper Next rotary files and
need to use fewer files than Protaper Universal system.
2. Revo S system
• About the instruments:
– The Revo S system consists of a set of three
instruments namely:
i. Shaper and Cleaner 1 (SC1) that has 6% taper
and has a black stopper and #25 diameter.
ii. Shaper and Cleaner 2 (SC2) that has 4% taper
and has a gray stopper and #25 diameter.
iii. Shaper Universal (SU) that has 6% taper and has
black stopper and #25 diameter.
– These instruments have asymmetrical cross-section
that provides more flexibility and less stress on the
instrument.
– Speed required for Revo S rotary files is 250–400 rpm
– Torque needed: 0.8–1.2 Ncm.
Figure 14.40 shows photograph of the Revo S rotary files.
• About the technique
– Coronal pre-enlargement using GG drills or orifice
shaper such as Endoflare (Fig. 14.41)
– Establish glide path with #10 K-file or G files
– Use SC1 in free progressive movement without
pressure. Only one stroke up to first resistance level.
– Irrigate with NaOCl and recapitulate
– Estimate the accurate working length
– Use SC 2 in three wave technique without pressure
till the working length
Fig. 14.40  Revo S rotary files (Courtesy of Micro Mega products)
– Irrigate and recapitulate
– Reshape whole length of canal in free progressive
stroke without pressure using SU. Circumferential
filing is recommended with SU.
3. Wave One Single-file Reciprocating system
• About the instruments
– It is a single-file system to shape the root canal
completely from start to finish recommended for
single-use
– Single file does the work that is traditionally
performed by three or more rotary Ni-Ti files
– The Wave One Single-file reciprocating system
consists of three files available in lengths of 21, 25
and 31 mm namely:
a. Wave One small file (yellow) used in fine canals
with tip size of ISO 21 with continuous taper of
6%
b. Wave One primary file (red) used in majority of
canals with tip size of ISO 25 with apical taper of
8% which reduces towards the coronal end
c. Wave One large file (black) used in large canals
with tip size of ISO 40 with an apical taper of 8%
which reduces towards the coronal end.
– Cross-section of Wave One files is convex triangular
that improves the flexibility of the instrument
– Wave one rotary files can only be used with the Wave
One Endodontic motor with its reverse reciprocating
function
– Selection of single file is based on:
a. If 10 K-file resistant to movement, use Wave One
small file
b. If 10 K-file moves to length easily, use Wave One
primary file
Fig. 14.41  Endoflare (Courtesy of Micro Mega products)
 Cleaning and Shaping of the Root Canal System Including Working Length Determination
c. If 20 K-file or larger goes to length, use Wave One
large file.
Figure 14.42 shows the photograph of the Wave One small,
primary and large files.
• About the technique
– Coronal pre-enlargement and straight-line access.
Glide path can be established using the path files
– Use hand K-file into the canal in watch-winding
motion to length or resistance
– Use Wave One file approximately two-thirds of canal
length
– Irrigation with sodium hypochlorite and recapitu­
lation
– Confirm the working length
– Use Wave One file to length.
4. RECIPROC Rotary file system
– It is also a single-file system to prepare the root canal
completely from start to finish recommended for
single-use
– It is made of M-wire Ni-Ti. So, it has higher flexibility
and greater resistance to cyclic fatigue
– Reciproc instrument alternates between clockwise
and counterclockwise rotation
– Reciproc instruments are available as R25, R40 and
R50 in 3 sizes 21 mm, 25 mm and 31 mm
– Reciproc files are used with Reciproc motors, which
have precise angles of reciprocation. So, the risk of
instrument fracture is minimum
– Since the rotation in cutting direction is more than
the reverse rotation, the instrument advances
towards the apex
Fig. 14.42  Wave one: small (yellow), primary (red) and large
(black) files (Courtesy of Dentsply)
259
– Due to reciprocating movement:
a. Stress on the instrument is relieved, which
reduces the risk of cyclic fatigue caused by
tension and compression
b. Instrument remains centered in the canal
c. It allows root canals to be prepared with one
single instrument
– Usually there is no need to use hand files
– If the reciprocating instrument binds in the canal, it
does not fracture because it will not rotate past the
specific angle of fracture. As a result, creation of glide
path to minimize instrument binding is not required
for the Reciproc instruments.
Recent system: Self-Adjusting File (SAF) system in which
cleaning, shaping, irrigation and agitation of the irrigant are
achieved simultaneously.
• About the SAF instruments:
– It is also a single file system
– The Self-Adjusting File is a hollow, compressible
Ni-Ti file which adapts itself to the root canal’s 3D
anatomy
– SAF is available in two diameters: 1.5 mm and
2.0  mm
– The SAF 1.5 mm is available in 3 standard lengths
– 21 mm (active part: 16 mm), 25 mm (active part:
18 mm) and 31 mm (active part: 21 mm). The SAF
2  mm is available in two lengths—21 mm and
25  mm (Fig. 14.43B)
– The initial size of the SAF 1.5 mm is equal to ISO #150,
but its lattice-like structure can compress down to
0.2 mm when inserted into the canal, which is equal
to ISO #20. The compression is important to assure
that the SAF’s attempt to expand applies light lateral
pressure inside the root canal. The final apical size
follows the original root canal morphology and is
expected to be 2–3 ISO sizes larger than the initial
apical size
– The SAF 1.5 mm is compatible with canals with initial
apical size of ISO 20–30. SAF 2 mm for wider canals
with initial apical size of ISO 35–60 in maxillary
incisors and canines, in younger patients and in
cases of retreatment
– While removing dentin, SAF gradually expands to
enable the preparation of the root canal as achieved
by sequentially increasing the size of hand-operated
or motorized file
– The SAF is not a rotary instrument. Its main mode
of operation is vertical vibration at 5,000 rpm, at an
amplitude of 0.4 mm, combined with a slow rotation
(~80 rpm)
260 Short Textbook of Endodontics
– The SAFs abrasive surface, its compressibility and
adaptability, the application of light lateral pressure
on the canal walls due to its compression—all
together circumferentially remove a thin layer of
dentin in a “sandpaper effect”
– The continuous scrubbing motion of the SAF
is applied for 4 minutes, and combined with
simultaneous irrigation, of sodium hypochlorite
or any other irrigation fluid. The recommended
irrigation rate is 4 mL/min, and it is continuously
carried through the lumen of the SAF in a no-
pressure mode, suspending the created debris
and washing it away. The 5,000 vibrations per
minute help to continuously refresh the sodium
hypochlorite, as well as create sonic agitation of the
sodium hypochlorite irrigation, to achieve a high
level of disinfection
B
Figs 14.43A to B  (A) Parts of SAF; (B) 1.5 mm and 2 mm SAF of different lengths (Courtesy of ReDentNOVA)
– SAF prevents canal transportation. File separation
is prevented. Improved preservation of root canal
walls
– Parts of SAF (Fig. 14.43A):
a. Compressible working end
b. Shaft
c. Rubber stopper
d. Irrigator barb-connects to a tube delivering
irrigant. Made of medical grade polypropylene.
e. Shank-Shank connects to the handpiece by
means of friction grip. Made of medical grade
polypropylene.
• About the technique with SAF:
i. Access cavity preparation done. Orifices are funneled.
ii. Path is established up to no. 20 K-file
iii. Single instrument SAF used
iv. Simultaneous irrigating while working with SAF.
 Cleaning and Shaping of the Root Canal System Including Working Length Determination
3. Root canal preparation using Ultrasonics and Sonics
Ultrasonic canal instrumentation
– Ultrasonics in Endodontics use sound as an energy
source (at 20–25 kHz) and activates an Endodontic
file.
– Mechanism:
- Cavitation: The bubbles formed from action
of file become unstable, collapse and cause
an implosion. During oscillation of file, the
continuous flow of irrigant solutions from the
handpiece along the file causes cavitation or
implosion.
- Acoustic streaming: It is a process by which a
vibrating Endodontic file generates a stream of
liquid to produce eddies and flows of oscillation.
It has been found to be useful in reducing the
smear layer and loosening aggregates of bacteria,
thus it is excellent for root canal cleaning.
Earlier it was thought that mechanism is cavitation.
But now it has been found that Ultrasonics exerts its
effects via acoustic streaming.
– Technique: The root canal is enlarged using hand
instruments to atleast size #20. Then the ultrasonic
handpiece uses #15 K-file for canal shaping. The file
is activated for about one minute.
The ultrasonic devices for Endodontic use
(Endosonics) allow for delivery of irrigant such
as NaOCl and the vibrating K-file causes canal
preparation.
– The ultrasonic vibration produces heat which warms
up the sodium hypochlorite irrigant, increasing the
effectiveness of sodium hypochlorite. Thus, there is
synergistic relationship between the ultrasound and
sodium hypochlorite.
– Ultrasonics produce cleaner canals but there is
little support for use of ultrasonics in preparation
of root canals. So, now-a-days ultrasonically
activated instruments are used for final root canal
debridement rather than canal preparation.
– The disadvantages include more chances of canal
transportation with the use of ultrasonics and the
ultrasonic insert may fracture in the canal causing
iatrogenic problem.
Sonic Canal instrumentation
– Sonic Endodontic handpiece attach to the regular
airline with an adjustable ring on the handpiece to
adjust the air pressure to give an oscillatory range of
1.5–3 kHz
– The oscillatory motion of Sonic file in the canal is
a longitudinal motion, up and down, which is an
261
efficient form of vibration for preparation of root
canals.
– Like the ultrasonic instrumentation, there is
currently little support for the use of Sonic vibration
to prepare root canals, the only exception being the
orthograde canal preparation during Endodontic
surgery.
– Sonic and ultrasonic active irrigation: A stream
of solution is continuously delivered from the
ultrasonic or sonic unit.
– Sonic and ultrasonic passive irrigation: Irrigant
deposited in the canal is activated. Passive irrigation
after removing the smear layer, using #15 K-file in the
presence of 5.25% NaOCl, has been found to produce
cleaner canals as compared to hand instrumentation
alone.
The use of sonics and ultrasonics for cleaning and
disinfection of the canal has been further explained
in next chapter (Chapter 15: Disinfection of the Root
Canal System).
4. Laser-assisted root canal preparation technique
– Laser light travels straight. So, specific light-emitting
probes have been developed in order to direct the
laser energy into curved root canals.
– Er:YAG laser has been found to be effective and faster
than step-back technique with K-files.
– Erbium:YAG laser has been found to be effective in
debris removal.
– Er, Cr:YSGG (erbium, chromium: Yettruim scan­
dium gallium garnet) is recently introduced
laser specifically for Endodontic therapy. The
waterlase-hydrokinetic hard and soft tissue laser
device effectively cleans the root canal walls
and prepares it for obturation. Water energizes
the YSGG laser photons. So, no thermal side-
effects. Other advantages of this technique include
minimal patient discomfort and less postoperative
complications such as inflammation, swelling and
pain and also good antibacterial action.
– Disadvantages of using Lasers:
- Access into severely curved roots not possible
- High cost of equipment
- Operator and patient safety.
– Safety precautions while using lasers include: safety
glasses specific for each wavelength, warning signs
and high-volume evacuation near the treated area.
5. Noninstrumentation technique (NIT)
– NIT involves removing canal contents and accom-
plishing disinfection without the use of file.
262 Short Textbook of Endodontics
– This system consists of a pump, hose, a special valve
and a connector that is cemented into the access
cavity and cleaning action provided by oscillations
of irrigation solution such as 1–3% NaOCl at reduced
pressure.
– In this technique, the canal is not mechanically-
shaped or enlarged at all.
– Mechanism: Cavitation loosens the debris and NaOCl
dissolves viable and necrotic tissue components
which are then removed by suction.
– This technique is still under research and not
commercially available.
WHAT ARE THE PRECAUTIONS TO BE TAKEN
DURING INSTRUMENTATION?
Precautions During Instrumentation
Do’s
• Use only controlled finger pressure in manipulating an
instrument in the root canal.
• Instrument should be coaxed and not forced.
• The specific anatomy of each case should be carefully
reviewed prior to instrumentation.
• Establish apical patency before starting biomechanical
preparation of root canal.
• Keep all working instruments within the confines of root
canal to avoid procedural accidents.
• Check the instruments to see whether flutes of blade are
uniformly spaced and are not deformed. This should be
done after each use.
• Accurate working length should be established and
controlled throughout instrumentation.
Fig. 14.44  Instrument blade is held between layers of gauze with
some digital pressure and is turned counterclockwise (Courtesy of
Dr Vishal Rathod)
• Instrumentation should always be done in a wet canal.
Use of irrigating solution such as sodium hypochlorite
is recommended in between instrument use.
• Instrument stops should be positioned well while using
instruments to prevent their being forced through apical
foramen.
• Establish glide path with K-files prior to rotary instru­
mentation.
• Instruments should be used in sequence of sizes and
increase the file size only after current working file fits
loosely into the canal without binding.
• Recapitulation should be done to loosen debris by
returning to working length with smaller files.
• Precurve the files for instrumentation in curved canals.
• Instruments should be carefully used in apical third of
canal to prevent trauma to the periapical tissues.
• Smooth gentle reaming or rotary motion of Nickel-
Titanium instrument is recommended.
• Flutes of hand instruments should be cleaned of debris
to prevent canal blockage.
Figure 14.44 shows how the instrument blade is cleaned
by holding between layers of gauze with some digital
pressure and is turned counterclockwise.
Dont’s
• Do not force the instrument if it binds in the root canal.
Force invites breakage.
• Do not use instruments with deformed flutes. Discard
them.
• Do not do instrumentation without lubrication.
Instruments lubricated with EDTA should be used
combined with copious irrigation with sodium
hypochlorite.
Fig. 14.45  Taper lock of Nickel-Titanium rotary
instrument in the root canal
 Cleaning and Shaping of the Root Canal System Including Working Length Determination
• Do not force debris or infected material beyond the
root apex or traumatize the periapical tissues. Careful
instrumentation in delicate apical third is a must.
• Do not use larger instruments out of sequence or short
of working length.
• Do not overuse the files.
• Do not cause sudden changes in direction of Ni-Ti
instrument by jerky movement.
• Do not use Ni-Ti instruments to bypass ledges.
• Do not cut with entire length of blade of Ni-Ti instrument
as this frictional fit can cause instrument lock in the
canal (taper lock).
Figure 14.45 shows diagrammatic representation of
taper lock of Nickel-Titanium rotary instrument in the root
canal.
WHAT ARE THE PROCEDURAL ERRORS
THAT CAN OCCUR DURING ROOT CANAL
PREPARATION?
• Overinstrumentation and overpreparation
• Instrument separation
263
• Blockage of canal
• Ledge formation
• Apical transportation and zipping
• Elliptication
• Apical perforations
• Stripping or lateral perforations.
These have been discussed in detail in Chapter 20:
Endodontic Mishaps: Management and Prevention.
BIBLIOGRAPHY
1. Cohen S, Hargreaves KM. Pathways of Pulp, 9th edn. St. Louis:
Mosby, 2006.pp.290-348.
2. Grossman L, Oliet S, Del Rio C. Endodontic Practice, 11th edn.
Varghese Publication, 1991.pp.179-216.
3. Ingle J, Bakland L, Baumgartner J. Ingle’s Endodontics 6, 6th edn.
BC Decker Inc, Hamilton, 2008.pp.919-73.
4. Ingle, Bakland, Endodontics, 5th edn. BC Decker, 2002.pp.525-35.
 15
CHAPTER

Disinfection of the
Root Canal System
This chapter describes the various methods for disinfection of the root canal system and discusses in
detail the various chemical agents used for root canal disinfection. It also explains about the smear
layer and its management in Endodontics.
  You must know
• What is Disinfection of the Root Canal System?
• How to bring about Disinfection of the Root Canal System?
• Which are the Different Chemical Agents used for Disinfection of the Root Canal System?
• What is a Root Canal Disinfectant and What are its Requirements?
• What is Smear Layer and How is it Managed in Endodontics?
• What are Intracanal Medicaments?
• What are the Methods of Activation of Irrigating Solutions in the Root Canal System?

WHAT IS DISINFECTION OF THE
ROOT CANAL SYSTEM?
Different microbes such as bacteria, yeasts and possibly
viruses, can infect the pulp. The microbial load is considered
minimal so long as the pulp is vital. But, with proceeding
infection, pulp necrosis occurs and the entire root canal
system becomes invaded by microorganisms leading to
apical periodontitis.
The microorganisms present in the root canal can invade
the periapical tissue, not only giving rise to pain but they
destroy the periodontium including bone.
The microorganisms have to be eliminated from the root
canal system to re-establish periradicular health.
“Disinfection is a process whereby microorganisms are
destroyed.”
“Eradication of microorganisms from the root canal
system and neutralization of any antigens that may be
left in the canal after destruction of microbes, is known as
disinfection of root canal”.
Destroying 100% of the infective flora from the root canal
system and the periradicular area is a challenge because of
its anatomic complexity.
Certain areas of canal walls, particularly in the apical
third and in ribbon-shaped and oval canals, cannot be
cleaned mechanically, meaning that the residual bacteria
and other microbes exist in these untouched areas that
could survive.
Since, the goal of Endodontic treatment is prevention
or treatment of apical periodontitis by elimination of
microorganisms from the root canal system, it can be said
that disinfection of root canal is an important cornerstone
for successful Endodontic treatment because it reaches the
microorganisms in dentinal tubules and in crevices, fins and
ramifications of the root canal system.
HOW TO BRING ABOUT DISINFECTION
OF THE ROOT CANAL SYSTEM?
Disinfection of root canal system is brought about by
effective “Cleaning” and “Shaping” procedures.
Effective shaping:  Mechanical instrumentation of the
root canal with hand and rotary instruments to remove
vital and necrotic pulp tissue and eradicate microbes
from the accessible parts of root canal and shape the
canals in such a way that directs and facilitates optimal
irrigation, debridement and placement of local medicaments.

Effective cleaning: Use of chemicals to eradicate micro-
organisms, dissolve necrotic tissue, remove necrotic
dentin and debris created from instrumentation by
means of antimicrobial irrigating solutions, detergents
and decalcifying materials and then placement of intra-
canal medicaments to render the root canal system free of
microbes.
Without irrigation, mechanical instrumentation
becomes ineffective rapidly due to accumulation of debris.
Without enlarging and shaping, the irrigating solutions
cannot reach all parts of the root canal system.
Thus, shaping facilitates cleaning and cleaning facilitates
shaping.
“Cleaning” and “Shaping” are not two different steps
of root canal procedure but are interdependent and are
carried out together for complete disinfection of the root
canal system.
The various chemical agents used for effective cleaning
will be discussed in this chapter. Various shaping procedures
have been discussed in the previous chapter (Chapter
14).
WHICH ARE THE DIFFERENT CHEMICAL
AGENTS USED FOR DISINFECTION OF
THE ROOT CANAL SYSTEM?
Disinfection of the Root Canal System 265
WHAT IS A ROOT CANAL DISINFECTANT
AND WHAT ARE ITS REQUIREMENTS?
“A disinfectant is a chemical agent capable of destroying
pathogenic microorganisms”.
“Root canal disinfectant is a chemical agent that brings
about eradication of microorganisms from the root canal
system”.
Requirements of a Root Canal Disinfectant
A root canal disinfectant:
• Should: (a2s2)
– Have prolonged antimicrobial effect (bactericide,
germicide, fungicide)
– Have low surface tension to produce good cleaning
effect
– Be active in presence of blood, serum, etc.
– Be stable in solution for prolonged duration
• Should not: (I3s)
– Irritate the periapical tissues
– Interfere with healing and repair of periapical tissues
– Induce cell-mediated immune response
– Not stain the tooth.
WHICH ARE THE DIFFERENT ROOT
CANAL IRRIGANTS?
Root canal irrigants are used for the purpose of:
• Removal of pulp tissue remnants
• Antimicrobial action
• Reducing friction during instrumentation, i.e. lubrication
• Debridement or lavage of debris from root canal
(Mnemonic tall).
An optimal irrigant should have the following properties:
• Should be nontoxic and nonirritating to the periapical
tissues and should not induce an allergic response.
• Should be an effective disinfectant.
• Should retain its effectiveness within the root canal
system when it comes in contact with dentin or dentin
powder and should not have any chemical interactions
with other irrigants used.
• Should be able to distinguish between necrotic and vital
host tissue.
• Should have low surface tension for good cleaning
action.
(Mnemonic: needs)
Root canal irrigants are effective when they are flooded
into shaped canals and given ample time to work in the root
266 Short Textbook of Endodontics
canal. Files used in conjunction with the root canal irrigants
carry the irrigants deeper in the canal by surface tension.
On withdrawal of file, irrigant flows in the space occupied
by the file.
Important factors to be considered for irrigation include:
Irritation potential of irrigants: Solutions that are toxic for
bacterial cells may be toxic for human cells also. So care
must be taken to avoid extrusion of irrigants into periapical
regions.
Volume of irrigant: Volume of irrigant can affect cleanliness
of root canal. It has been found that sodium hypochlorite
and EDTA administered in larger volumes produced
significantly cleaner root canal surfaces than smaller
volumes.
Effective shaping: Root canals that have not been
instrumented are too narrow to be reached effectively by
disinfectants even when very fine irrigation needles are
used. So, effective cleaning with optimum instrumentation
should be done. Also, intermittent agitation of canal with
a small instrument prevents accumulation of debris in the
apical end of the root canal.
Choice of irrigating needle and manner of use: Larger gauge
needle (27–30) with wider diameter allow irrigant to be
flushed and replenished more quickly, but may not allow
cleaning of apical and narrower areas of root canal system.
Excess pressure or wedging of needles into root canals
during irrigation should be avoided to prevent extrusion
of irrigant into periapical tissues. The needle is bent to an
obtuse angle closer to the hub of the syringe to allow for
easier access and entry into the root canal orifice.
In modern systems, the irrigation solution is delivered
with a fine caliber needle passively in the canal, in large
volume and debris is aspirated with a good suction device.
Designs of needles: Needles are available in various
configurations for the delivery of irrigants.
The various types of irrigating needles according to
design include:
A. Blunt-ended side venting needle: It is recommended
for safe delivery of irrigants into the canal preventing
extrusion into the periapical area (Fig. 15.1A)
Another example of this type is the ProRinse Endodontic
irrigation system which uses a small-bore irrigating
needle having a closed blunt end and is side-vented. It
has the lumen of 2 mm from the tip creating turbulence
along and beyond the probe so that forceful periapical
injection of irrigant is prevented.
B. Notched tip Monojet Endodontic needle (27 gauge)
(Fig.  15.1B)
C. Bevelled needles (Fig. 15.1C)
D. Open ended blunt needles
E. Maxi-Probe
F. Perforated needle- Example is Endovage (Goldman and
others)
A perforated irrigating needle delivers the irrigant 360
degrees in the root canal. It is found that large volumes
of irrigant solution physically removes more material
when delivered using perforated irrigation needle.
Disadvantage of perforated needle is that it is delicate
and may lose its shape when bent.
Figure 15.1 shows diagrammatic representation of
different types of irrigating needles.
Stropko irrigator: It is a new device that can be used as an
adjunct in few procedures of Endodontics.
• It combines the delivery and recovery of irrigant in one
probe as it consists of needle that delivers the solution
and an aspirator held in the same sheath that retrieves
the delivered irrigant.
• The Stropko irrigator places the perfect amount of air and
water pressure into the field. Its small, luer lock tips do
not impede visibility during irrigation or drying and are
excellent for use under microscope. It fits most triplex
air/water syringes (3-way syringe of dental chair).
• It is a valuable tool to rinse and dry precisely for
improved vision during every procedure. It can clean
and dry root-end preparations when performing micro-
surgical procedures. Also, it can air-dry the canal system
with a light touch of air prior to obturation for improved
seal.
Figures 15.2A and B shows the Stropko irrigatorirrigation
tips and adapter.
A B C
Figs 15.1A to C  Different types of irrigating needles: (A) Side-vented
  needle; (B) Monojet Endodontic needle; (C) Needle with a bevel
 Disinfection of the Root Canal System 267

A B
Figs 15.2A and B  (A) Blue irrigation tips; (B) Adapter of the Stropko irrigator
  (Courtesy of Sybron Endo)

DIFFERENT ROOT CANAL IRRIGANTS

Sodium Hypochlorite (5.25%)

• It is most commonly used irrigating solution.

• Mechanism of action: Sodium hypochlorite is a reducing
agent, containing about 5% of available chlorine. In
water, sodium hypochlorite ionizes to produce sodium
and hypochlorite ions.
In H2O, NaOCl → Na+ + OCl–
and establishes equilibrium with hypochlorous acid
(HOCl).
This hypochlorous acid brings about bacterial
inactivation by disrupting oxidative phosphorylation
and DNA synthesis.
NaOCl causes destruction of bacteria in 2 phases:
Fig. 15.3  Commercially available sodium hypochlorite for irrigation
– First its penetration into bacterial cell occurs (Courtesy of Mr Amar, Dr Dabholkar’s clinic)
– Secondly combination with protoplasm takes place
• Concentration: Sodium hypochlorite is available in
concentrations ranging from 0.5% (Dakin’s solution) to Antimicrobial Action
7%.
Clinically useful concentrations are 0.5–5.25%. Sodium hypochlorite is effective against most of the
A concentration of 5.25%, sodium hypochlorite is Endodontic microorganisms, including those that are
highly toxic, so it is diluted in 1:1 or 1:3 ratios with water to difficult to eradicate from root canals, such as, Enterococcus,
produce 2.5% or 1% solution which are suitable for clinical Actinomyces and Candida.
Endodontic use. Sodium hypochlorite can kill bacteria rapidly even at
Lower concentrations of NaOCl (0.5 or 1%) dissolve only low concentrations.
necrotic tissue. G ra m - n e g a t i v e a n a e ro b i c b a c t e r i a s u c h a s
Higher concentrations of NaOCl dissolve both vital and Porphyromonas gingivalis, Porphyromonas endodontalis
necrotic tissue. and prevotella intermedia isolated from apical periodontitis
Figure 15.3 shows photograph of commercially available are also highly susceptible to sodium hypochlorite (0.5–5%
sodium hypochlorite for irrigation. conc.).
268 Short Textbook of Endodontics
Advantages
• It has excellent antimicrobial properties
• It is a powerful solvent of necrotic pulp tissue and
organic debris
• It acts as a lubricant, antiseptic and bleach.
• It has strong proteolytic effect
• It is readily available, inexpensive
Disadvantages
• Cannot remove smear layer.
• It does not have effect on inorganic material
• Unpleasant taste
• Due to its inability to remove dentin and smear layer, its
use has to be combined with demineralizing agents for
effective cleaning of inaccessible areas such as lateral
canals.
• Can have chemical interactions with other irrigants
used. It has been found that sodium hypochlorite can
become ineffective if it comes in contact with EDTA or
chlorhexidine gluconate 2%).
• Toxicity: Extrusion of high concentration of sodium
hypochlorite can cause serious damage to periapical
tissues.
• Solution has to be replenished frequently due to free
chlorine, to constantly renew fluid in root canal during
instrumentation.
How to Increase Efficacy of Sodium Hypochlorite?
1. NaOCl solutions can be heated to temperatures ranging
from 45oC to 60oC using syringe warmer or ultrasonic
devices. Using heated sodium hypochlorite potentiates
the antimicrobial and tissue dissolving effects of NaOCl.
2. Use NaOCl along with ultrasonic energy (Agitation)
3. Contact time: Antimicrobial efficacy of NaOCl is directly
related to its contact time in the canal.
4. Volume of irrigant: NaOCl administered in large volumes
produces significantly cleaner root canal surfaces than
the smaller volume.
5. Concentration of NaOCl: Higher concentrations of
NaOCl (5.25%) has more antimicrobial efficacy than
lesser concentrations (2.5% and 0.5%)
Figure 15.4 summarizes the factors affecting the efficacy
of NaOCl.
Sodium Hypochlorite Accidents
Accidental injection or extrusion of sodium hypochlorite
during irrigation into periradicular tissues can cause
Fig. 15.4  Factors affecting the efficacy of NaOCl
effects of toxicity such as excruciating pain, bleeding
from periapical tissue, swelling, abscess, osteonecrosis,
paresthesia, etc. Pain may subside within 2–3 days.
Swelling may increase for first day and then gradually
decrease.
Precautions to be Taken for Safe Irrigation
with Sodium Hypochlorite
• Bend the irrigating needle so that it can easily penetrate
deeper portions of canal without binding and mark the
working length on needle with this bend or a rubber
stop to prevent extrusion of sodium hypochlorite into
periapical area.
• Irrigating needle should remain loose in the canal to
allow back flow of fluid and should not bind.
• Continuously move the irrigating needle up and down.
• Careful use of patency files that should not extend farther
than the periodontal ligament.
• Deliver irrigating solution passively without exerting
pressure while injecting.
• Administer irrigant dropwise slowly and gently and not
in a rapid projectile motion.
• Always hold a sterile gauze sponge around the tooth
to be irrigated to prevent spilling of excess solution in
mouth and it also helps monitor the debris removal from
root canal. It has been demonstrated in Figure 20.20 in
Chapter 20: Endodontic Mishaps: Management and
Prevention.
A mind-map to remember all points of sodium
hypochlorite is given in Figure 15.5.
 Disinfection of the Root Canal System 269

Fig. 15.5  Mind-map on sodium hypochlorite

Hydrogen Peroxide (H2O2) (3%)

H2O2 can be used for cleaning the pulp chamber from blood
and pulp tissue remnants. H2O2 has antimicrobial activity
against bacteria, viruses, yeasts and bacterial spores.
Figure 15.6 shows photograph of commercially available
hydrogen peroxide.
In the past, hydrogen peroxide was used as an irrigant
in conjunction with sodium hypochlorite.
It was thought that if alternate irrigation is done with 3%
hydrogen peroxide and 5.2% sodium hypochlorite, it can
cause following beneficial action:
• Effervescent action of hydrogen peroxide that can push
the debris out of the root canal through the least resistant Fig. 15.6  Commercially available hydrogen peroxide for irrigation
orifice into the pulp chamber. (Courtesy of Mr Amar, Dr Dabholkar’s clinic)
270 Short Textbook of Endodontics
• The solvent action of sodium hypochlorite for dissolution
of organic debris.
• The disinfecting and bleaching action of both solutions.
Alternate irrigation with hydrogen peroxide and sodium
hypochlorite was done in the past.
But, now, this combination is no longer used due to the
following reasons:
i. It has been found that combination of hydrogen peroxide
with sodium hypochlorite, tends to reduce the tissue
solvent property of sodium hypochlorite.
ii. No additional cleaning effect was found with this
combination.
iii. The oxygen-free radicals that are released have the
potential to reduce the bonding of resin to dentin.
Chlorhexidine Digluconate (2%)
Chlorhexidine digluconate can be used in Endodontics as
an irrigating solution and as an intracanal medicament.
Figure 15.7 shows the photograph of commercially
available chlorhexidine digluconate.
Mechanism of Action
Chlorhexidine Digluconate (CHX) has a cationic molecular
component which attaches to negatively charged cell
membrane areas resulting in cell lysis.
The CHX penetrates the cell wall and attacks the bacterial
cytoplasmic membrane or the yeast inner membrane. CHX
can cause coagulation of intracellular components in high
concentrations.
When CHX is applied to dentin, it binds to hydroxyapatite,
producing a lasting reservoir of chlorhexidine, that remains
Fig. 15.7  Commercially available chlorhexidine digluconate for
Endodontic use (Courtesy of Dr Chetan Shah)
even after the completion of treatment. This property is
called substantivity meaning long-term continued effect
that may reduce the effect of postoperative coronal leakage.
Antimicrobial Action
The CHX has an excellent antimicrobial activity.
• It is effective against gram-positive and gram-negative
bacteria and yeasts.
• But ineffective against mycobacteria and bacteria spores.
• Two percent solution of CHX is highly effective against
Enterococcus faecalis.
It has been found that higher concentrations of NaOCl
such 5.25% can kill E. faecalis in 30 seconds but lower
concentrations of NaOCl may take longer, i.e. about 5–30
minutes for killing E. faecalis whereas 2% CHX can kill
E.  faecalis in 30 seconds or even less.
Advantages
• Excellent antimicrobial activity
• Relatively nontoxic
• Substantivity property
• Does not have bad odor.
Disadvantages
• Does not have tissue dissolving property
• Its activity is dependent on the pH and its effectiveness
reduces in presence of organic matter
• Ineffective against mycobacteria and bacterial spores.
So, it cannot be used for disinfection of gutta-percha
cones.
• The CHX cannot remove the biofilm, that may remain
within the canal and continue to express its antigenic
potential thus affecting the seal of root canal filling.
• The CHX has cytotoxic effect when it comes in direct
contact with human cells.
Use of NaOCl followed by CHX for
Achieving Benefits of Both
As CHX lacks the tissue dissolving property of NaOCl, it may
be used in the following sequence:
1. NaOCl → 2. Saline wash → 3. CHX
Greater percentage of microbe reduction may be found
when both are used in the above sequence than achieved
with either used alone.
But it is important to note that if NaOCl and CHX are
combined (mixed), a brownish-orange precipitate is formed
(parachloroaniline), which is difficult to remove from the

root canal walls. So, saline wash should be used in between
both of them. The brownish-orange color may be due to iron
impurities in hypochlorite. This mixture should not be used
for irrigation of root canal system.
Quaternary Ammonium Compounds
These are detergents that were used for irrigation in the past.
They have low surface tension and can remove lipid pulp
breakdown products thus aiding in pulp space cleaning.
Quarternary ammonium compound such as Cetrimide
may be added to EDTA in EDTAC to provide some
antimicrobial effect.
Quarternary ammonium compounds are no longer used
as irrigants due to their toxicity.
Antibiotic Containing Irrigating
Solutions such as MTAD
MTAD is a recently introduced root canal irrigant which is
a Mixture of a Tetracycline isomer, citric Acid and a surface
active Detergent.
Actions
• The MTAD removes smear layer after NaOCl irrigation
• Antimicrobial activity.
Since it combines the smear layer removal activity with
antimicrobial effect, it may be ‘gentler’ with dentin than
EDTA.
Experimentally, MTAD is found to be effective against
E. faecalis.
Detergents
Detergents remove the fatty tissue residues which are the
byproducts of tissue necrosis.
These include quaternary ammonium compounds that
were used in the past but are no longer used due to their
toxicity.
Detergents also include iodophors such as wescodyne
and Iodopax, which are organic iodine products effective
at low concentrations (0.05%).
Detergents may be mixed with calcium hydroxide for
irrigation.
EDTA Solution (17%)
Seventeen percent EDTA solution is considered as irrigation
solution to chelate and remove the inorganic portions of
smear layers. 17% EDTA is discussed in detail later.
Disinfection of the Root Canal System 271
WHAT IS SMEAR LAYER AND HOW IS IT
MANAGED IN ENDODONTICS?
Whenever the wall of a root canal is instrumented, whether
by hand or rotating instruments, the parts of dentinal wall
touched by an instrument, gets covered by a surface layer
called smear layer.
Smear layer consists of dentin shavings, cell debris
and pulp remnants. Thus it consists of both organic and
inorganic components and can have thickness of 1–5 µm.
It has two separate layers:
1. Loose superficial deposit
2. An attached stratum that extend into the dentinal
tubules forming occluding plugs.
Removal of Smear Layer: A Controversial Issue
Studies have been carried out and different clinicians have
given their opinion regarding whether the smear layer
should be removed or left behind.
Recent evidence indicates that it is beneficial to remove
the smear layer before obturation.
Reasons in Favor of Smear Layer Removal
• Smear layer may interfere with the action of irrigants
and disinfection.
• Smear layer may interfere with adhesion and penetration
of root canal sealers into the dentinal tubules during
obturation.
• Organic substrate in smear layer may serve as nutrition
source for the growth of bacteria.
• Smear layer may increase microleakage after root canal
obturation.
• Smear layer removal enhances disinfection of deeper
layers of dentin and of root canal walls.
• With the removal of smear layer, root canal filling
materials adapt well to canal walls, improved seal is
achieved and there is reduced microleakage in root canal
filled teeth.
Reason Against Smear Layer Removal
• Smear layer can serve as a beneficial barrier, that
prevents microorganisms from entering the dentinal
tubules in between appointments.
• Some studies showed that smear layer did not have
significant effect on apical leakage.
• Smear layer removal can permit microbial colonization
of dentinal tubules at a significantly higher rate when
compared with leaving it in place.
272 Short Textbook of Endodontics
Management of Smear Layer in Endodontics
After completion of cleaning and shaping, smear layer is
removed by the following methods:
• Irrigating the canal with 5.25% NaOCl to remove
the organic component, followed by 1-minute rinse
with 17% disodium EDTA to remove the inorganic
compounds.
• Fifty percent citric acid can also be used to remove the
inorganic portions of smear layer.
• A new method of removing smear layer is by using MTAD
(Mixture of tetracycline isomer, an acid and a detergent).
Lower concentration NaOCl can be used as an intracanal
irrigant to remove the organic components. Then the
final rinse with MTAD to remove the inorganic portion
can have a good antimicrobial effect.
• Sonic and ultrasonic passive irrigation with 5.25% NaOCl
after hand instrumentation has been tried but is not
found effective in removing smear layer.
• CO2 laser and Er:YAG laser have been found to be quite
effective in removal of smear layer.
Figure 15.8 shows mind-map to remember all points of
smear layer.
Fig. 15.8  Mind-map to remember all points of smear layer
Decalcifying Materials Used for
Smear Layer Management
1. EDTA:
– Ethylenediaminetetraacetic acid (EDTA) is a
chelating agent that was introduced into Endodontic
practice by Nygaard-Ostby for the purpose of
treatment of calcified narrow root canals.
– Structure and composition: EDTA consists of four
acetic acid groups attached to Ethylenediamine.
- Formula:
Disodium salt of EDTA 17 g
Distilled water 100 mL
5N sodium hydroxide 9.25 mL
- Additives:
i. EDTA + Urea peroxide (RC prep)
ii. EDTA + Cetavlon → EDTAC
(Cetavlon is added for its disinfecting
properties)
iii. EDTA + quaternary ammonium compound for
slight detergent effect in addition to chelating
effect.

– Mechanism of action: EDTA forms a calcium chelate
with calcium ion of dentin. The dentin becomes
friable and easier to instrument.
By removing the dentinal debris from root canal walls
that are produced during preparation.
↓ be replaced through frequent irrigation to have a
EDTA opens dentinal tubules continuous effect.
↓ – Some form of EDTA used during cleaning and
Allows better penetration of disinfectants
Thus EDTA indirectly exerts an antimicrobial effect by
facilitating cleaning and removal of infected tissue and by
enhancing antimicrobial effect of locally used disinfecting
agents in deeper layers of dentin.
A chelating agent holds the debris in suspension and
causes lubrication and emulsification.
• Available as:
– Liquid of concentration 15–17%: This is called as
aqueous chelator. 17% liquid buffered solution is
commonly used. Its photograph shown in Figure
15.9.
– Gel: This is called as viscous chelator. Discussed in
Chapter 13 “Endodontic Access Cavity Preparation”.
• Actions:
– EDTA can help to open very narrow (hair-fine) root
canals.
– EDTA can decalcify to a depth of approximately
50  µm if used liberally. 4. Carbamide peroxide and salvizol were tried but not
– EDTA opens dentinal tubules.
– Seventeen percent EDTA combined with 5.25%
NaOCl used alternately can effectively remove the
smear layer. One minute rinse of 17% EDTA is used
Fig. 15.9  Commercially available 17% liquid EDTA for removal of
smear layer (Courtesy of Mr Amar, Dr Dabholkar’s clinic)
Disinfection of the Root Canal System 273
for finishing the preparation as it removes the smear
layer and provides a cleaner surface against which
obturation materials are adapted.
– Decalcifying process of 17% EDTA is self-limiting
since the chelator gets used up. So, EDTA needs to
shaping of root canals can help achieve canal
patency, enlargement, floatation of dentinal debris
and pulp remnants and with additives, debridement
and disinfection. Thus it prevents the canal from
getting blocked.
A mind-map to remember all poins of EDTA is
given in Figure 15.10.
2. Citric acid: Can be used for irrigation of root canal and
for removal of smear layer.
Fifty percent concentration of citric acid is effective.
Citric acid can remove only the inorganic portion of
smear layer, so complete removal of smear layer requires
irrigation with 5.25% NaOCl before or after citric acid
irrigation.
Citric acid demineralizes intertubular dentin making the
tubular openings larger than that caused by use of EDTA.
Citric acid has weak antimicrobial activity.
3. MTAD: Explained already.
found reliable in removing smear layer.
WHAT ARE INTRACANAL MEDICAMENTS?
“Antimicrobial medicaments that are placed in the root
canal, in case of multiappointment Endodontic treatment
of a tooth, especially the one with the necrotic pulp, in
which the biomechanic instrumentation and irrigation with
antimicrobial solution may not completely eradicate micro-
organisms and further disinfection may be necessary, are
called intracanal disinfectants or intracanal medicaments
used as intracanal dressing”. They are also referred to as
Inter-appointment Medicaments.
Frequency of medication: Disinfectant dressing should
be renewed in a week and not longer than 2 weeks as
dressings tend to get diluted by periapical exudates and
are decomposed by interaction with the microorganisms.
Calcium Hydroxide
• Calcium hydroxide was introduced in dentistry by
Hermann in 1920.
• Most widely used intracanal medicament.
274 Short Textbook of Endodontics
Fig. 15.10  Mind-map to remember all points of EDTA
• Calcium hydroxide is available in:
i. Paste form: Generally used as a paste of calcium
hydroxide in a water base.
Calcium hydroxide as a single paste or combined
with iodoform is available (Fig. 15.12).
ii. Powder form: Calcium hydroxide powder can be
mixed with saline or anesthetic solution and used
as intracanal medicament by coating on the walls
of root canal using paper points, spreaders or
lentulospirals.
iii. Calcium hydroxide points: Calcium hydroxide
incorporated sterile absorbent points are also
available to deliver calcium hydroxide into the root
canal, especially in the apical region.
Water is used as vehicle for calcium hydroxide paste
because calcium hydroxide needs water to dissolve. It is
available as nonsetting form which can be conveniently
dispensed in pulp space and removed for redressing or for
obturation.
According to the vehicle used for calcium hydroxide, it
is available as following types:
– Aqueous/water based in which vehicles are water-
soluble substances such as water, saline, anesthetic
solution, carboxymethylcellulose, etc. Sterile water
and saline are most commonly used carriers.
– Viscous vehicles such as glycerine, polyethyleneglycol,
propylene glycol. They are also water-soluble that
release calcium and hydroxyl ions more slowly and
for longer periods. These may remain in canals for
several months, so number of appointments to
change dressings are reduced.
– Oil-based which are non water-soluble. Oil-based
vehicles such as olive oil, silicone oil, etc. They are
difficult to remove from canals and leave a residue
on canal wall, so they are not recommended.
• Mechanism of action of calcium hydroxide as an
intracanal medicament:
Calcium hydroxide has a slow action as an antiseptic, so
it requires prolonged exposure.
It has high pH and leaching action on necrotic pulp
tissue.
It causes damage to microbial cytoplasm and disrupts
cell membrane, suppresses the enzymatic activity and
causes inhibition of DNA replication by splitting it.
Apart from killing bacteria, calcium hydroxide has one
beneficial function:

Calcium hydroxide neutralizes the biologic activity of
bacterial lipopolysaccharide, thus reducing its effect.
As a result:
– The necrotic tissue becomes more susceptible to the
solubilizing action of sodium hypochlorite in the
next appointment. • Advantages of calcium hydroxide:
– Continued stimulation of inflammatory response
caused by dead cell wall material, remaining even
after the bacteria are killed, is prevented. Thus it  acts
as a physical barrier for the ingress of bacteria.
• Indications of calcium hydroxide as an intracanal
medicament:
i. Calcium hydroxide is quite effective in case of
weeping canals. In case of a tooth with large
periapical lesion undergoing Endodontic treatment,
a constant clear or reddish exudation occurs.
Root canals in which such exudates are found are
called weeping canals. Tooth often is asymptomatic
and bacterial culture report is negative. Antibiotics
are not useful in such cases. Calcium hydroxide plays
an excellent role in such cases.
ii. Calcium hydroxide is found to be an effective
intracanal medicament in cases of pulp necrosis and
apical periodontitis.
iii. It is used in pulp therapies: indirect and direct pulp
capping and pulpotomy cases.
iv. Apexification
v. Resorption cases
vi. In root canal sealers.
• Application of calcium hydroxide in the canal: Calcium
hydroxide mixed with sterile water or saline making a
mixture that is thick enough to carry as many calcium
hydroxide particles as possible, is placed in the canal
Fig. 15.11  Commercially available calcium hydroxide
(Courtesy of Mr Amar, Dr Dabholkar’s clinic)
Disinfection of the Root Canal System 275
with  a lentulospiral homogeneously upto the working
length.
• Calcium hydroxide combined with 0.12% chlorhexidine
solution may be applied as an intracanal medicament
[Ca(OH)2 – CHX 0.12% mixture].
– It stimulates periapical healing.
– It inhibits root resorption.
• Disadvantages of calcium hydroxide:
– It is found to be ineffective against E. faecalis, that
is often associated with persistent Endodontic
infections
– It may be sometimes difficult to remove from the
root canal walls
– It decreases the setting time of zinc oxide eugenol
cements
– Its action as an antiseptic is slow and short-lasting.
Figures 15.11 and 15.12 shows photograph of
commercially available calcium hydroxide.
Chlorhexidine Digluconate (CHX)
• The CHX in a gel form or as a mixture with calcium
hydroxide can be used as an intracanal medicament in
between appointments.
• Studies have shown that Ca(OH)2 – CHX mixture is more
effective against E. faecalis than pure Ca(OH)2.
• While some studies have shown that pure Ca(OH)2, or
2% CHX gel and combination of both, can give equally
good results.
• The CHX can be an effective intracanal medicament
due to its substantivity property and long-lasting
antimicrobial effect.
Fig. 15.12  Commercially available calcium hydroxide
with iodoform (Courtesy of Ammdent)
276 Short Textbook of Endodontics
Antibiotic Containing Intracanal Medicaments
Generally, locally used antibiotics have bacteriostatic
action, which may not be effective in necrotic teeth.
Such medicaments have been thought of, for infection
control in Endodontics, but not found to be effective.
Phenol and Phenol Derivatives
• Mechanism of action: Phenol is a protoplasm poison that
causes necrosis of soft tissue.
Paramonochlorophenol
• Derivatives of phenol Thymol
Cresol
phenol derivatives are stronger antiseptics and toxins
than phenol.
• Concentration: Optimal antibacterial effect is found to
be at 1–2%.
For dental use, concentration of 30% that has been used
was found to have quite low antimicrobial effect and is
of short duration.
Phenol and phenol derivatives are highly toxic to
mammalian cells and their antimicrobial effectiveness
does not balance their potential toxicity.
Phenol and phenol derivatives are no longer used as
intracanal medicaments.
• Camphorated parachlorophenol (CMCP): Camphoration
results in less toxic phenolic compound. This is due to
slow release of toxins to the surrounding tissues.
Camphor serves as vehicle and a diluent, thus reducing
the irritating effect of pure parachlorophenol.
CMCP was widely used in the past. It used to be applied
into the pulp chamber to act as devitalizing agent soaked
with a moist cotton pellet covered with temporary
cement such as zinc oxide eugenol.
But now CMCP is no longer used.
Formaldehyde
• Formaldehyde has been used extensively as an intra-
canal medicament in the form of formocresol.
• Due to its toxic and tissue destructive effect and
mutagenic and carcinogenic potential, formaldehyde
is no longer used as an intracanal medicament.
• Formocresol is a combination of formalin and cresol in
proportion of 1:2 or 1:1.
• Mechanism of action: Formaldehyde combines with
albumin to form an insoluble, indecomposable
substance.
Halogens
Disinfectant action of halogens has been found to be
inversely proportional to their atomic weight.
• Chlorine:
– Chlorine has lowest atomic weight and greatest
disinfectant action
– Chlorine may be used as an intracanal dressing in
the form of Chloramine T.
• Iodine:
– Iodine potassium iodide (IKI) is effective against
a wide spectrum of microorganisms found in root
canals including resistant microorganisms like
E.  faecalis.
– Mechanism of action: Iodine acts as oxidizing agent
by reacting with free sulfhydryl groups of bacterial
enzymes.
– The IKI is an effective disinfectant against infected
dentin but iodine may have possible allergic
reactions in some patients, that limits its use.
Bioactive Glass
Use of bioactive glass as an intracanal medicament is under
research.
Resilon, a new root canal filling material contains
bioactive glass.
Superoxidized Water
• Saline is electrolyzed to form superoxide water.
• This solution has an antibacterial effect.
• But its effectiveness reduces by contact with albumin.
• It is nontoxic to tissues.
Its use as an intracanal medicament is still under
research.
WHAT ARE THE METHODS OF ACTIVATION
OF IRRIGATING SOLUTIONS IN THE ROOT
CANAL SYSTEM?
Archimedes screw effect: Rotating instruments used along
with the irrigant causes significant reduction of bacterial
load and also transports the debris in an apicocoronal
direction thus removing the debris that could block the
canal.
There have been ongoing advances in the field of root
canal disinfection. Few of them will be described here in
short.

Flow chart 15.1  Different methods of activation of irrigants in root
canal system
The various physical and mechanical methods of
activation of irrigants in the root canal system have been
tried including: (Flow chart 15.1).
Hand/Manual
• Well-fitting gutta-percha cone
• K-files
May be moved with the hand in up and down motion
(agitation) in the canal in which the irrigating solution
such as NaOCl has been delivered.
Mechanical
i. Intracanal brushes: Example of intracanal brushes is
Endodontic microbrushes shown in Figure 15.13. Rotary
tapered microbrushes may be used with various irrigants
to optimally finish a root canal preparation following
shaping procedures.
– Endodontic microbrushes have bristles that can
be attached to a flexible plastic core material and
the brushes activated using a rotary handpiece at
about 300 rpm to optimally finish the root canal
preparation.
– These microbrushes have a tapered shape and
helical bristle pattern that enhances cleaning as
bristles deform into irregularities of the preparation
and helps to remove the debris out of the canal in a
coronal direction.
ii. Sonics (6 KHz, 8K Hz and 10 KHz) can be used for root
canal disinfection.
a. Example is MM1500 Sonic handpiece that can be
used for cleaning, shaping and disinfecting the canal
system.
Disinfection of the Root Canal System 277
Fig. 15.13  Endodontic microbrushes
(Courtesy of Clifford J Ruddle, Advanced Endodontics®)
– It is an air-driven handpiece that can be adapted
to the air-line couplings of dental units (two,
three or four-hole connectors)
– The air pressure in the handpiece transmits sonic
waves along Endodontic instruments having an
adjustable frequency range of zero to 1500 Hz.
– The water from the dental unit is channelled
through the spout directly below the instrument
cradle on the MM1500 handpiece, causing
continuous irrigation of the canal system.
– The Rispisonic (coronal two-thirds) and
Shapersonic (apical and coronal thirds)
instruments are used with the MM1500 sonic
handpiece for debriding the canals.
– The water from the dental unit to the handpiece
is turned off and then used for cavitating
the irrigating solution into the canal. An
irrigating solution such as sodium hypochlorite,
chlorhexidine 2% or aqueous EDTA is introduced
in the canal and then a sonic irrigating file is
passively inserted in the canal to cavitate the
irrigating solution by 3–5 mm vertical motion for
1–2 minutes per irrigating solution.
Figure 15.14 shows the photograph of MM 1500
sonic handpiece.
b. Another example is a new device called the Endo
Activator system.
– The EndoActivator system consists of a cordless
and battery-operated handpiece with contra-
angled design for easy access to posterior teeth
and the EndoActivator® Tips that are 22 mm in
278 Short Textbook of Endodontics
Fig. 15.14  MM1500 Sonic handpiece
(Courtesy of Micro Mega)
length and are available in three sizes: small
(yellow 15/02), medium (red 25/04), and large
(blue 35/04).
– The EndoActivator® System brings about the
debridement and disruption of the smear layer
and biofilm.
Figure 15.15 shows the photograph of the
Endoactivator system.
iii. Ultrasonics
– Ultrasonic energy (30–40 KHz) can be combined with
irrigant for disinfection.
– Ultrasonic energy is found to be more effective in
removing artificially created debris.
– Many studies have shown that ultrasonics, together
with an irrigant, contributed to better cleaning
of the root canal system than irrigation and hand
instrumentation alone. Physical mechanisms
of cavitation and acoustic streaming of irrigant
contribute to the biological chemical activity for
maximum effectiveness.
– Ultrasonics help irrigants penetrate into the complex
canal systems, which are not easily reached by
normal irrigation.
– Many commercially available specialized ultrasonic
tips for Endodontic use are available. For example,
Irrisafe tips (Satellac).
iv. Lasers
– Role of lasers in eradicating the root canal microbes
has been studied.
– Nd:YAG and Diode lasers have been used for
disinfection of the root canal system.
– CO2 laser microprobe attached to special handpiece
can also be used for disinfection of root canal.
Fig. 15.15  EndoActivator system
(Courtesy of Dr Clifford J Ruddle, Advanced Endodontics®)
– Lasers such as Er: YAG and Er.Cr.:YSGG have been
found to facilitate removal of smear layer.
– It has been found that the antibacterial effect
of lasers in root canal was inferior to NaOCl
irrigation.
– Effect of laser is dependent on the applied output
power and is specific for different bacteria.
– Gutknecht et al reported excellent antibacterial
efficiency against E. faecalis using holmium:yttrium-
aluminium-garnet (Ho:YAG) laser.
v. Ozonated water irrigation
– This has been tried as an irrigant and few studies
show that it is effective antimicrobial agent against
bacteria, fungi, protozoa and viruses.
Ozone in aqueous or gaseous phases has a strong
oxidizing power and it shows rapid antimicrobial
effects.
– It is relatively safe and nonmutagenic.
– Mechanism:
a. Ozone destroys cell walls and cytoplasmic
membranes of bacteria and fungi
b. Permeability increases which leads to ingress of
ozone causing microbial death.
Figure 15.16 shows commercially available ozone device
for Endodontics.
Negative Pressure Irrigation,
e.g. EndoVac Irrigation System
EndoVac irrigation system is a true apical negative pressure
system that draws fluid apically by way of evacuation.
Irrigation solutions are sucked away from the apical
foramen, virtually eliminating the risk of irrigation.

Fig. 15.16  Commercially available ozone machine
(Courtesy of Mr JP Mishra, Sanjeevani ozone products)
Figure 15.17 shows photograph of the EndoVac irrigation
system.
BIBLIOGRAPHY
1. Cohen S, Hargreaves KM. Pathways of Pulp (9th edn.), St. Louis:
Mosby; 2006.pp.258-62 and pp.339-48.
2. Grossman L, Oliet S, Del Rio C. Endodontic Practice (11th edn.).
Varghese publication; 1991.pp.228-33.
Disinfection of the Root Canal System 279
Fig. 15.17  EndoVac irrigation system
(Courtesy of Sybron Endo)
3. Hegde MN. Textbook of Endodontics (1st edn.), Emmess Medical
Publishers; 2009.pp.227-47.
4. http://www.endoruddle.com/inventions.html.
5. Ingle J, Bakland L, Baumgartner J. Ingle’s Endodontics 6 (6th edn.)
BC Decker Inc, Hamilton; 2008.pp.992-1011.
6. Mohammadi Z, Dummer PMH. Review-‘Properties and
applications of calcium hydroxide in Endodontics and dental
traumatology,’ International Endodontic Journal; 2011.pp.697-
730.
 16
CHAPTER

Obturation of
Root Canal System

This chapter discusses in detail the various aspects of obturation including the different materials
and techniques used for obturation of the root canals.
  You must know
• What is Obturation of Root Canal?
• What are the Objectives of Obturation?
• When to do Obturation of the Root Canal?
• What should be the Apical Extent of Obturation?
• With what should we do Obturation?
• What are the Requirements for an Ideal Root Canal Filling Material?
• Which are the different Core Materials that can be used for Obturation?
• What are Root Canal Sealers and what are the Requirements of an Ideal Root Canal Sealer?
• What is the Purpose of using a Root Canal Sealer?
• How is the Sealer Placed in the Root Canal?
• Which are the different Root Canal Sealers used in Obturation?
• Root Canal Sealer in detail
• What is the Preparation for Obturation?
• How to do Obturation? Which are the different Obturation Techniques?
• How should an Ideal Obturation be?
• What can go Wrong in Obturation?
• What is the Importance of Coronal Seal and how can we Enhance it?

WHAT IS OBTURATION OF ROOT CANAL? • 3-Dimensional Seal apically (from periapical

impermeable/ tissue fluids)
Obturation of the root canal system is placing of an inert fluid-tight Seal coronally (from oral cavity
filling in the space previously occupied by pulp tissue in (Hermetic) microflora)
order to eliminate all portals of entry between the root canal seal: Seal laterally (from remaining
and the periodontium by achieving a three-dimensional Obturation irritants in canal and from
impermeable seal, so as to prevent reinfection of the root should: periodontal tissues) ...to achieve a
canal system by way of circulation (Anachoresis) or through 3-dimensional impermeable seal.
break in the integrity of the crown of the tooth. • To prevent leakage: Coronal leakage
Obturation should eliminate: Apical leakage
WHAT ARE THE OBJECTIVES OF OBTURATION? • To prevent reinfection: All portals of exit (POE) should be
sealed to prevent any exchange of contaminants such as
Objectives: As given in Figure 16.1, include: tissue fluids, micro-organisms or breakdown products
 Obturation of Root Canal System 281

Factors Determining Timing of Obturation

Figure 16.2 shows the mind-map to remember the factors
that determine timing of obturation.

Fig. 16.1  Mind-map of objectives of obturation
between the root canal system and the periodontium as
well as the oral cavity.
Current Concepts Related to
Obturation of Root Canal
• “Hermetic seal”: The term ‘hermetic’ seal of root canal
described by Grossman is considered inaccurate now.
The dictionary meaning of this term:
‘hermetic’ = sealed against escape or entry of ‘air’ or
made airtight by fusion or sealing.
But in the obturation of root canals, the main concern
is not related to ‘air’, the concern is about ‘fluid’ leakage
and bacterial leakage either apically or coronally.
So, the accurate term to use would be ‘impermeable’
seal, ‘fluid-tight’ seal or ‘fluid impervious’ seal and not
‘hermetic’ seal.
• Coronal seal: Establishing and maintaining “coronal
seal” is essential for the success of root canal treatment
and for the long-term prognosis of an Endodontically
treated tooth.
A good post-Endodontic restoration with a
permanent restorative material (definitive restoration)
must be placed as soon as possible after obturation to
reduce the chances of coronal microleakage.
Studies have shown that coronal seal can be
enhanced by sealing the orifices with special adhesives
and bonded restorations (Intraorifice barriers). The
floor of the pulp chamber can be covered with a lining
of bonded material or dual cure resin-modified glass
ionomer cement.
Such a coronal-radicular restoration and other
considerations and methods for the restoration of an
Endodontically treated teeth are described in detail
in Chapter 21 (Restoration of Endodontically Treated
Teeth).
Related to Procedure
• When the root canals have been optimally enlarged and
thoroughly cleaned and shaped to the appropriate size
and to the correct working length, the canals can be
considered ready for obturation.
• In case of asymptomatic teeth with vital pulp and
not much of procedural difficulty, obturation can be
completed in the same visit of access opening and
preparation of canals [(Single Visit Endodontics (SVEs)].
Related to Patient
• The tooth should be asymptomatic, i.e. no pain, no
swelling or signs/symptoms of infection in relation to
the involved tooth.
• Patient’s general health condition should be considered.
Few medical conditions may require multiple short
appointments for completion of treatment whereas
some physically compromised or aged patients may not
be able to come on multiple visits.
Related to Tooth
When the root canals have been optimally cleaned and
shaped.
• The prepared canal should be ‘dry’, with no exudation
or weeping of fluids into the radicular space
• There should be no foul odor from the canal

WHEN TO DO OBTURATION OF THE ROOT

CANAL?
“The root canal is ready to be filled when the canal is cleaned
and shaped to an optimum size and dryness”. (Ingle’s
Endodontics, 5th edn. p.574). Fig. 16.2  Mind-map of factors determining timing of obturation
282 Short Textbook of Endodontics
• Negative microbial culture with no infection
• Asymptomatic tooth
• In case of multiappointment treatment procedure, if
the temporary filling (provisional coronal restoration)
that was placed over the prepared root canals has
broken or is leaking, then the canals may be considered
recontaminated. In such cases, adequate irrigation and
disinfection should be performed to make it sterile
before obturation.
WHAT SHOULD BE THE APICAL EXTENT OF
OBTURATION?
• According to earlier studies, the apical limit of obturation
was considered to be at the Cemento-Dentinal Junction
(CDJ).
It may not be clinically possible to determine
whether this apical point of termination of obturation
has been achieved because:
– CDJ is a histologic landmark
– Location of CDJ has been found to be irregular within
the canal
– CDJ does not coincide with the narrowest portion of
the canal or the apical constriction.
Studies by Kuttler have shown that CDJ is on an
average 0.5–0.7 mm away from the external surface
of the apical foramen.
One conclusion that can be derived is that the
apical extent of obturation is always short of apex and
not flush with it and canals filled to the radiographic
apex are actually overextended.
• Kuttler described the anatomy of the apical portion of
the root and gave the following terms:
– Major diameter: Greater diameter of the apical
foramen which is next to the
periodontal ligament.
– Minor diameter: Which coincides with the
CDJ. Minor diameter of apical
constriction lies 0.5–0.7 mm
short of the external surface of
apical foramen.
– Apical constriction: Narrowest portion of the canal
marking the end of root canal.
Thus,
- Anatomic apex is where the root ends,
Apical constriction is where the root canal ends.
- Distance between apical foramen and apical
constriction is about 0.5–0.7 mm. This distance
increases with age due to cementum deposition.
Ideal apical termination of root canal preparation
and obturation should be at the apical
A B
Figs 16.3A and B  (A) Apical extent of obturation about 1 mm short
of apex in a tooth without periapical radiolucency; (B) Apical extent of
obturation about 1 to 2 mm short of apex in a tooth with apical root
and bone resorption due to periapical pathosis
constriction, which lies about 0.5–1 mm from
the apex as shown in Figure 16.3A.
• Apical limit of obturation is also determined by
pathology such as root resorption and apical bone
resorption that can result in loss of apical constriction.
It has been found that better results are obtained
in nonvital cases, when filled at or within 2 mm of
radiographic apex. Necrotic teeth with periapical
pathosis should have the apical termination of obturation
even shorter than the apical constriction, i.e. about 1–2
mm short of the apex as shown in Figure 16.3B.
• To confine the preparation and obturation in the root
canal system is necessary to prevent extrusion of root
canal filling. Overextended and overfilled canals have
been found to have greater failure rate and decreased
prognosis for complete regeneration.
WITH WHAT SHOULD WE DO OBTURATION?
Materials used for Obturation
Core materials in conjunction with root canal sealers are
used for obturation.
Core materials Root canal sealers
•  Solid core materials: •  Zinc oxide containing sealers
  – Silver cones: Which were widely • Calcium hydroxide containing
used in past. sealers
No longer used now. •  Resin sealers
  – Resilon: Recently introduced •  Glass ionomer-based sealers
Resin-based obturation system. •  Medicated sealers
• Semisolid core materials: •  Silicone-based sealers
Gutta-percha: Most commonly •  Solvent-based sealers
used. •  Urethane methacrylate sealers
•  Paste materials:
  –  Zinc oxide containing pastes
  –  Paraformaldehyde pastes

Classification of Root Canal Filling Materials
WHAT ARE THE REQUIREMENTS FOR AN IDEAL
ROOT CANAL FILLING MATERIAL?
Grossman suggested the following requirements for an ideal
root canal filling material: material which satisfies most of the criteria for an ideal root
• It should be sterile, or easily and quickly sterilized imme­
diately before insertion.
• It should be easily manipulated, provide ample working
time and should be easily introduced into the root canal.
• It should seal the canal laterally as well as apically.
• It should be impervious to moisture, unaffected by tissue
fluids and nonporous.
• It should be bactericidal or atleast inhibit bacterial
growth.
• It should not shrink after being inserted.
• It should not stain the tooth structure.
• It should not irritate the periapical tissues.
• It should be radiopaque and easily discernible on
radiographs.
• It should be easily removable from the canal if necessary.
Gutta-percha (GP), as root canal filling material has been
in Endodontics, since 1867 and is still the most widely used
material to obturate root canals. It meets most of the above
criteria. (Friends, you can remember the above 10 points of
requirements of an ideal root canal filling material, simply
by imagining the sequence in which you use a GP point to
obturate:
Obturation of Root Canal System 283
• You will first sterilize gutta-percha cone using sodium
hypochlorite {point (1)}
• Then you will introduce it in the canal {point (2)}
• When GP is inserted, you expect, it should {points
(3),(4)(5)} and it should not {points (6),(7),(8)}
• Then, you would like to check if the root canal (RC)
filling was done properly, so you will take a radiograph
to confirm {point (9)}
• In case of error, you would like to remove it {point (10)}
and re-do it).
WHICH ARE THE DIFFERENT CORE MATERIALS
THAT CAN BE USED FOR OBTURATION?
• Gutta-percha: Most commonly used core material.
• Metal cores: These have been used in the past.
– Silver cones
– Sectioned silver cones
– Stainless steel (Instrument blade)
– Amalgam (used as retrograde filling material)
• Resilon: Resin-based root canal filling material.
• Paste filling materials.
Gutta-percha
Gutta-percha is the most commonly used root canal filling
canal filling material.
• Introduced by Bowman in 1867.
• Composition:
Gutta-percha 18–22% (Matrix)
Zinc oxide 59–79% (Filler)
Heavy metal salts 1–17% (Radiopacifier)
Wax or resin 1–4% (Plasticizer)
Erythrosine (Coloring agent)
• Properties:
– It can be easily sterilized prior to insertion.
– It is impervious to moisture.
– It does not encourage bacterial growth. It is not an
effective microbicide but has slight antibacterial
activity due to zinc oxide content.
– It does not shrink after insertion unless it is
plasticized with a solvent or heat.
– It is nonstaining.
– It is probably the least toxic and least irritating to the
periapical tissues of all root canal filling materials.
– It is radiopaque.
– It can be removed with specialized instruments from
the canal if necessary.
284 Short Textbook of Endodontics

– It has the property of plasticity or flow when heated
or exposed to solvents, which is made use of for
obturation.
– Heated thermal conductivity through gutta-
percha occurs over the length of 4–5 mm. Vertical
compaction and adaptation of thermosoftened
gutta-percha are also effective over the range of 4–5
mm.
Although gutta-percha has good biocompatibility,
studies have been done to evaluate the tissue toxicity exerted
by gutta-percha in case of an overfill or overextension of
gutta-percha into the periapical area. It was found that the
intensity of inflammatory response was determined by the
size of gutta-percha particles.
Larger gutta-percha particles caused Less inflammation
around them and appeared well encapsulated, whereas
with smaller gutta-percha particles a more intense localized
response was seen.
It was also found that sealer was the most toxic portion
of the sealer-gutta-percha obturation.
• Limitations:
– Gutta-percha lacks rigidity. Smaller size gutta-percha
bends easily under lateral pressure.
– Gutta-percha is difficult to introduce into a narrow
canal.
– Gutta-percha lacks adherent properties. So, it cannot
be used as the sole filling material to seal the root
canal space.
– Gutta-percha cannot seal the canal apically or
laterally unless combined with a sealer.
– Gutta-percha has limited shelf life. It becomes brittle
with age, probably through oxidation.
– Warmed Gutta-percha shrinks as it returns to body
temperature. So, it was recommended by Schilder
that vertical pressure should be applied in case of
warm gutta-percha techniques to compensate for
volume changes that occur as cooling takes place.
• Forms of gutta-percha:
• When heated, the material changes to α-phase and
becomes tacky and pliable. It can be made to flow under
pressure.
• The unheated phase is the β-phase when the material is
a solid mass and compactable. It is purified, commercial
form which is used to manufacture Endodontic GP
points.
• Temperatures for phase transitions of gutta-percha:
– Transition from β-phase to α-phase occurs at 115oF
(46oC), i.e. about 3–8oC above the body temperature
is sufficient to mold gutta-percha.
– An amorphous phase develops at 130 o –140 o F
(54o–60oC)
– Gutta-percha crystallizes to α-phase when cooled
very slowly
– Gutta-percha returns to β-phase with normal
cooling.
Mechanical properties of both α- and β-phase are
same, but when α-phase gutta-percha is heated
and cooled, there is less shrinkage. α-phase is
more dimensionally stable for thermoplasticized
techniques.
• Commercially available gutta-percha cones:
– Gutta-percha cones are available as:

Raw gutta-percha from the tree undergoes a rigorous

process involving purification, dissolving of resins, and
denaturing of proteins and gets converted into commercial
gutta-percha.
Gutta-percha is the transisomer of polyisoprene and the
two crystalline forms α and β undergo phase transition with
the change in temperature:

Sterilization
Gutta-percha can be disinfected by immersion into 5.25%
sodium hypochlorite for 1 minute to kill bacteria and spores
on gutta-percha. But, by doing so, sodium hypochlorite
crystals get accumulated on the gutta-percha surface, that
may impair the obturation seal. So, NaOCl crystals are
removed by rinsing it in 96% Ethyl alcohol, 70% isopropyl
alcohol or distilled water or clinical spirit. Another
alternative is to use 0.5% sodium hypochlorite solution for
rapid decontamination of gutta-percha as this concentration
does not cause any alteration in the topography or elasticity
of GP points.
Rejuvenation
Sorin and Oliet described the aging process of gutta-percha.
They introduced a technique to rejuvenate the aged brittle
gutta-percha cones by momentary immersing it in hot tap
water (above 55oC) until the grasping forceps indents the
softened gutta-percha followed by immediate quenching
in cold tap water (less than 20oC) for several seconds.
Gutta-percha Sticks
These are different from gutta-percha points. They are not
used for obturation.
Their applications include:
• To check vitality of tooth by heat test
• As temporary restoration
• Can be used as slow separators.
A
B C
Figs 16.4A and B  Conventional standardized color-coded gutta-
percha points: (A) Gutta-percha points no. 15–40; (B) Gutta-percha
points no. 45–80 (Courtesy of Dentsply)
Obturation of Root Canal System 285
New Formulation of Gutta-percha with Additives
• Gutta-percha + iodoform called medicated gutta-percha
(MGP) for inhibiting microbial growth. Contraindicated
in patients with history of allergy to iodine.
• Gutta-percha + calcium hydroxide, which permits
simple placement of medicament within the canal space
between appointments. This point is removed from the
canal once calcium hydroxide has leached out. Such
points have been found to improve apical sealing quality
of root canal filling.
• Gutta-percha + chlorhexidine, that cause slow release of
chlorhexidine for antibacterial effect.
• Gutta-percha + tetracycline, for antibacterial effect.
Gutta-percha for Newer Obturation Systems
• T h e r m o pl a st i c i z e d gu tt a -p e rc h a : The new er
thermoplasticized obturation systems use gutta-
percha pellets that are inserted into a delivery system
gun and heated to 150o–200oC prior to delivery into
the canal system. 20, 23 or 25 gauge needles can then
be used to deliver the warmed and softened gutta-
percha. Intermittent vertical compaction of injected
thermosoftened gutta-percha is carried out every
3–5  mm so as to prevent shrinkage and loss of volume.
• Carrier-based gutta-percha: Obturators such as thermafil
obturators, GT obturator, simplifil, successfil make use
of metal or plastic carriers which are coated with alpha-
phase gutta-percha.
B
Figs 16.5A to C  Standardized Protaper gutta-percha points-F1, F2
and F3 for obturation: (A) F1 gutta-percha point; (B) F2 gutta-percha
point; (C) F3 gutta-percha point (Courtesy of Dentsply)
286 Short Textbook of Endodontics
A mind-map to remember all points of gutta-percha
is given in Figure 16.6.
Metal-core Obturation
• Silver cones: These are solid core filling materials that
were used in the past for obturation of root canals.
Current use of silver points for obturation is considered
to be below the standard of care.
– Introduced by Jasper in 1933.
– Pure silver was moulded into conical shape to form
silver points, having the same diameter and taper
as files and reamers used in the preparation of the
canal.
Fig. 16.6  A mind-map to remember all points of gutta-percha
– Advantages:
- Easier to insert into fine, tortuous canals.
- Rigidity: Silver cones are stiffer than gutta-
percha.
- Length control is also easy.
– Disadvantages
- Lack of plasticity: So, they cannot seal the canal
laterally and apically.
- Cannot adequately fill the root canal space and
cannot be compacted into the spaces or voids
within the root canal system.
- Silver cones have round shape but the enlarged
canal is not round, so the space that remains
between silver point and canal walls gets filled

Fig. 16.7  Silver points (Courtesy of Mr Amar, Dr Dabholkar’s clinic)
with sealer cement which over a period of time
causes leakage.
- Corrosion of silver points and formation of
corrosion products due to leakage.
  Figure 16.7 shows the photograph of silver
cones used for obturation.
• Stainless-steel file method of obturation: In the past,
stainless steel files were, at times, used for obturation of
narrow, calcified root canals. Due to their rigidity, they
could be easily inserted in the root canal.
• Silver amalgam: Has been widely used as a retrograde
filling material in apically resected root during
periradicular surgery.
Resilon (Resin-based Obturation System)
• Resilon is resin core material to be used in conjunction
with resin sealer. It follows the concepts of adhesive
dentistry.
• Composition: Polyester, difunctional Methacrylate
Resin, bioactive glass, radiopaque fillers
(Bismuth oxychloride and barium sulfate)
• Resilon is available as:
– Conventional and standardized cones,
– Pellets for use in Obtura II
• Use of Resilon as root canal filling material requires
steps such as using self-etch primer, bonding and then
application of resin sealer and resilon points. Lateral
condensation, vertical condensation or thermoplastic
injection techniques can be used for obturation with
resilon.
• After polymerization, the core and the sealer becomes
one unit mass, i.e. Resilon core bonds to resin sealer
Obturation of Root Canal System 287
which bonds to the etched root surface forming a
‘Monoblock’ providing a good seal.
• Since resilon is resin-based, it is compatible with most
of the current restorative techniques in which posts and
cores are placed with resin-bonding agents.
• Long-term results with the use of this material are still
awaited.
• An example of the resilon-based obturation system is
the Real Seal system (Sybron Endo). Figure 16.8 shows
the photograph of the same. It uses a kit containing
resilon points (autofit points) of different tapers, self-
etch sealer, thinning resin and a primer. It has similar
handling characteristics that of gutta-percha and is
found to provide good seal against coronal and apical
leakage.
Paste Filling Materials
• Zinc oxide: Zinc oxide is the major component in these
paste materials but due to solubility of zinc oxide, not
an effective core filling material. Zinc oxide exerts
antibacterial effect. Useful as root canal filling material
in deciduous teeth.
• Mineral trioxide aggregate (MTA): It can be used as
a paste filling material for obturation of root canals,
especially when other core filling materials cannot be
satisfactorily used. Used as root-end filling material in
Root-end Endodontic Surgery.
– Composition: Tricalcium silicate, tricalcium
aluminate, tricalcium oxide,
silicate oxide
– Available as: White powder, gray powder
Gray MTA has more FeO than white
MTA.
Fig. 16.8  Resin-based obturation system
(Courtesy of Sybron Endo)
288 Short Textbook of Endodontics
– Advantages:
- Excellent sealing ability
- Biocompatibility
- Good marginal adaptation
– Disadvantages:
- Difficult handling characteristics
- Extended setting time
– The thickness of MTA placed, when used as root end
filling material or as an apical barrier or perforation
repair material is important.
3–4 mm thickness should be good enough.
– MTA requires presence of moisture for setting as it
is hydrophilic material and takes about 4–6 hours to
set.
Moisture from periradicular tissues may provide
adequate moisture for MTA to set or a moist cotton
pellet is placed in between appointments when MTA
is used as a perforation repair material, as an apical
barrier or as an intraorifice barrier.
– When MTA is placed, there is gradual dissolution
of MTA and there is nucleation and growth of
hydroxyapatite crystals filling the space between
MTA and dentinal wall and a mechanical SEAL is
achieved. But as the reaction proceeds, a chemical
bond is formed between MTA and dentin.
WHAT ARE ROOT CANAL SEALERS AND WHAT
ARE THE REQUIREMENTS OF AN IDEAL ROOT
CANAL SEALER?
Definition
“Root canal sealers are the cements that are used to seal the
space between the dentinal wall and the obturating core
interface and also to fill the voids and the irregularities of
the root canal system such as lateral and accessory canals.”
Requirements of an Ideal Root Canal Sealer
Grossman outlined the following requirements of an ideal
root canal sealer: (To remember these requirements:
Friends, in other words we are looking for a best sealer
that will help us to achieve an ideal root canal filling. So,
we can remember the requirements of an ‘ideal’ sealer by
remembering the word BES6T2)
• B → The sealer should be Bacteriostatic, or atleast
should not encourage bacterial growth.
• E → Easy to mix. It should be in the form of a fine powder
so that it can be mixed easily with liquid. It should be
easy to introduce in the canals.
• S → Establish an excellent hermetic Seal.
• S → Should be slow setting, to ensure sufficient working
time.
• S → No shrinkage on setting (dimensionally stable).
• S → No staining of tooth structure.
• S → Should be seen on radiograph (Radiopaque)
 Should be soluble in a common
solvent if it is necessary to remove
• S → Solubility the root canal filling
Should not be soluble in tissue fluids
• T → Should exhibit tackiness when mixed to provide
good adhesion between it and the canal wall, when set.
• T → Should be tissue tolerant, that is, it should be non-
irritating to periradicular tissues.
Ingle has added the following to Grossman’s basic
requirements:
– It should not provoke an immune response in
periradicular tissue.
– It should be neither mutagenic nor cariogenic.
WHAT IS THE PURPOSE OF USING A ROOT
CANAL SEALER?
Purpose: Root canal sealer serves as (Fig. 16.9):
• Binding agent: To bind or cement a well-fitted master
cone into the root canal
• Filler: To fill the irregularities of root canal, lateral and
accessory canals and discrepancies or voids between
the core material and canal walls
• Lubricant: To facilitate seating of the master cone into
the canal.
The American Association of Endodontists’ Guide to
clinical Endodontics outlines contemporary Endodontic
treatment. It has made the following statement regarding
obturation. “Root canal sealers are used in conjunction
with a biologically acceptable semisolid or solid obturating
material to establish an adequate seal of the root canal
system.”
HOW IS THE SEALER PLACED
IN THE ROOT CANAL?
Preparation for obturation involves removal of smear layer
(Smear layer and methods for removal of smear layer have
been discussed in Chapter 15).
Fig. 16.9  Mind-map to remember purpose of root canal sealer

Sealer penetration into the dentinal tubules is enhanced
by removal of smear layer.
Sealer penetration of dentinal tubules is affected by the
method of obturation. Thermoplastic techniques produce
deeper sealer penetration.
The root canal walls can be coated with the sealer using:
• Master cone: The core material which is going to serve
as master cone can be used to coat the canal walls with
the sealer cement.
• Paper points: Appropriate size paper point can be used
to coat the canal walls with sealer cement.
• Files or reamers: Appropriate size file or reamer can be
used to coat the canal walls with sealer cement.
• Lentulospiral: Lentulospiral is used with a slow-speed
contra-angle handpiece in anticlockwise direction
to deliver the sealer into the canal. While using
lentulospiral, it is important that it is started or stopped
outside the root canal otherwise it may cut into the canal
wall and might break. Figure 16.10 shows photograph of
a Lentulospiral.
• Bidirectional spiral: Bidirectional spiral cement carrier
coats the canal walls and prevents excess cement from
exiting apically.
– Mechanism: Its coronal grooved spirals travel in
an apical direction and carry the sealer cement
apically. Its apical reverse spirals flow the cement in
a coronal direction simultaneously, thus preventing
the periapical extrusion of the sealer. Also, the two
independent flows of cement collide in the area
where the grooved spirals change direction. At this
Fig. 16.10  Lentulospiral
(Courtesy of Dentsply)
Obturation of Root Canal System 289
point of collision, the cement flow is forced to travel
laterally. This creates forces to fill the lateral canals
and any other invaginations that may exist.
• Ultrasonics: Ultrasonics can be used to place the sealer
in the root canal. It has been found that ultrasonic
placement of sealer is superior to manual techniques.
WHICH ARE THE DIFFERENT ROOT CANAL
SEALERS USED IN OBTURATION?
• Different root canal sealers include:
– Zinc oxide containing sealers
– Calcium hydroxide containing sealers
– Resin sealers
– Glass ionomer-based sealers
– Medicated sealers
– Silicone-based sealers
– Solvent-based sealers
– Urethane methacrylate sealers
• Sealers can be classified as (as per ANSI standard no.
57):
ROOT CANAL SEALERS IN DETAIL
Zinc Oxide-containing Sealers
These have been the most widely used root canal sealers.
They have an extended working time. They set faster in
the tooth than on the glass slab because of increased body
temperature and humidity.
Greatest advantage of ZOE sealers is that Zinc Oxide
and Eugenol form Zinc Eugenate that is known to block
prostaglandins (pain mediators). Hence, reduced post-
obturation pain and discomfort.
290 Short Textbook of Endodontics
There are different formulations of this sealer, which
have zinc oxide as the primary component such as:
Grossman’s Sealer
Grossman developed the original formula of Zinc Oxide
containing sealer, which satisfied most of the ideal
requirements of an ideal root canal sealer. It is available as
Roth’s sealer.
• Composition:
Powder Liquid
(ZB2S2) – Eugenol
– Zinc oxide 42 parts
– Staybelite resin 27 parts
– Bismuth subcarbonate 15 parts
– Barium sulfate 15 parts
– Sodium borate, anhydrous 1 part
• Setting time: Hardens in 2 hours at 37oC and 100%
relative humidity. It sets in root canal within 10–30
minutes.
• Manipulation: ZOE sealer powder and liquid are slowly
mixed on a sterile glass slab with a sterile spatula to a
proper consistency of a smooth, creamy mix. When the
flat blade of the spatula is lifted up, the cement should
“string out” for about an inch before breaking or the
cement should cling to the inverted spatula blade for
10–15 seconds before dropping from spatula. This is
the test given by Grossman to check for the proper
consistency of the sealer cement.
• Insertion: After drying the root canals, a smooth broach,
reamer or file or Lentulospiral is used to carry small
amounts of cement into the canal and the canal is coated
in lateral or rotary motion gently without forcing any
sealer into periapical tissues.
• Advantages:
– Antibacterial
– Resorbs if extruded into periapical tissues
– Plasticity
– Good sealing potential
– Slow setting
– Nonstaining
• Disadvantages: Not compatible with resin containing
core materials or resin containing luting cements
for posts. Zinc eugenate gets decomposed by water
through a continuous loss of the eugenol. This makes
ZOE a weak, unstable material. So, it cannot be used
for retrofillings placed apically through a surgical
approach.
Pulp Canal Sealer (Kerr)
It is also a Zinc oxide and eugenol based sealer. It has been
used widely as a sealer for the warm gutta-percha, vertical
condensation method.
• Setting time: 1–2 hours
• Advantages:
– Good flow and variable viscosity
– Fast setting as compared to other sealers
– Nonresorbable
– Extended working time
– Blocks pain due to zinc eugenate
• Disadvantages: Not compatible with resin containing
core materials or resin containing luting cements for
posts.
Rickert’s Sealer
• Composition:
Powder Liquid
Zinc oxide Oil of clove,
Precipitated silver Canada balsam
White resin
Thymol iodide
• Advantages:
– Germicidal
– Excellent lubricating and adhesive qualities.
• Disadvantages: Staining of tooth structure from the silver
if it is not completely removed from the coronal tooth
structure.
Tubli-seal
Tubli-SealTM is a Zinc oxide eugenol root canal sealer. Figure
16.11 shows the photograph of the same.
Available as 2 paste system developed as an alternative
to silver containing Rickert’s sealer.
It is light in color, nondarkening and radiopaque.
• Composition:
Base paste Catalyst paste
Zinc oxide Eugenol
Barium sulfate Thymol iodide
Mineral oil Resin
Corn starch
Lecithin
• Advantages: Easy to mix, excellent lubrication, does not
stain the tooth structure.
• Disadvantages: Rapid setting time. It sets rapidly
specially in presence of moisture.

Wach’s Cement
• Composition:
Powder Liquid
Zinc oxide Oil of cloves
Bismuth subnitrate Canada balsam
Bismuth subiodide Eucalyptol
Magnesium oxide Beechwood creosote
Calcium phosphate
• Advantages:
– Smooth consistency
– Canada balsam makes the sealer tacky
– Germicidal
– Adequate setting time
– Low tissue irritation: Hence, desirable when there is
possibility of overextension.
• Disadvantages:
– Odor of the liquid (like that of an old-time dental
office)
– Limited lubricating properties.
Nogenol
It is noneugenol sealer to overcome the irritating effects of
eugenol.
• Composition: Two paste system.
Base paste Catalyst paste
Zinc oxide Hydrogenated rosin
Barium sulfate Methyl abietate
Bismuth oxychloride Lauric acid
Vegetable oil Chlorothymol
Salicylic acid
Fig. 16.11  Tubli-Seal root canal sealer (Courtesy of Sybron Endo)
Obturation of Root Canal System 291
• Can be in the form of powder-liquid in which the liquid
contains eucalyptus or pimenta leaf oil.
• Removing eugenol from nogenol exerts the sought-after
effect of reducing toxicity.
Calcium Hydroxide Containing Sealers
These were developed to exert therapeutic activity such as
antimicrobial action, osteogenic cementogenic potential,
etc. But, the drawback of these sealers is that solubility is
required for the release of calcium hydroxide and sustained
activity, which is not a desirable property for a root canal
sealer.
Some of the commercially available calcium hydroxide
containing sealers include:
Sealapex
Sealapex® is the original noneugenol, calcium hydroxide
polymeric root canal sealer that promotes rapid healing
and hard tissue formation (Fig. 16.12).
Its a noneugenol sealer available as 2-paste system.
In 100% humidity, it takes up to 3 weeks to reach a final
set, whereas in dry atmosphere, it never sets.
It is the only sealer that expands while setting.
The fluid sorption characteristics of Sealapex are due to
its porosity, which allows marked ingress of water.
• Composition:
Base paste Catalyst paste
Zinc oxide Barium sulfate
Calcium hydroxide Titanium dioxide
Butyl benzene Isobutyl salicylate
Fig. 16.12  Sealapex root canal sealer (Courtesy of Sybron Endo)
292 Short Textbook of Endodontics

Sulfonamide Available as two paste system. Base is Biphenol A-epoxy

Zinc stearate and catalyst is hexamethylene-tetramine. It also contains
• Advantage: 60% Bismuth oxide for radiographic contrast. It sets slowly
– Can encourage apical closure by cementum in 24–36 hours.
deposition • Advantages:
– Good sealing ability. – Strong adhesive property
• Disadvantage: Induces chronic inflammatory reaction – Setting is not affected by moisture
in the PDL if it is overextended. – Low solubility
– Increased radiopacity
Calcibiotic Root Canal Sealer (CRCS) • Disadvantages:
– Toxicity due to formaldehyde release.
It is ZOE/eucalyptol sealer with calcium hydroxide as one – Staining
of the components, added for its so called osteogenic effect. – Extended setting time (24 hours).
• Composition:
Base paste Catalyst paste AH PLUS
Zinc oxide Barium sulfate
Calcium hydroxide Titanium dioxide It is a modified formulation of AH-26 in which formaldehyde
Butyl benzene is not released. It is also available as paste-paste system. It
Sulfonamide has working time of 4 hours and a setting time of 8 hours. It
Zinc stearate has half the film thickness and half the solubility of regular
• Advantages: AH-26 and can be removed from the canal if necessary.
– Slow setting sealer. May require about 3 days to fully • Advantages:
set. – Strong adhesive property. It shows highest bond
– Good sealing ability. strength to dentin of all the sealers.
• Disadvantages: – Low toxicity and well-tolerated by periapical tissues
– Calcium hydroxide is not readily released, so limited – Antibacterial activity
cementum and bone formation – Low solubility
– Periapical reaction if extruded. – Increased radiopacity
– Slight shrinkage
Resin Sealers • Disadvantages: Relatively expensive.
• Available as 2 paste system as shown in Figure 16.13.
Contain epoxy resin for strong adhesive properties. • Working time: 4 hours
• Setting time: 8 hours.
Diaket
• Contains polyvinyl chloride in polymer form mixed with
zinc oxide and bismuth phosphate.
• Sets by chelation. Resin reinforced chelate is formed
between zinc oxide and diaketone. It is a very tacky
material and it contracts slightly while setting, which is
subsequently negated by water uptake.
• Advantages:
– Good sealing due to bond to dentin
– High resistance to absorption
– Exhibits tackiness.

AH-26
It is a slow setting epoxy resin that releases formaldehyde
on setting, the highest amount being released in the
freshly mixed sealer and amount goes down after 48 hours. Fig. 16.13  Resin-based sealer-AH plus (Courtesy of Dentsply)

Epiphany Sealer
A resin-based sealer to be used in conjunction with a resin-
based core material.
• Composition: Epiphany contains urethane dimeth­
acrylate, BisGMA and other resins along with calcium
hydroxide, barium sulfate, peroxide photoinhibitors,
etc.
– It is a dual-cure composite resin sealer that self-cures
in 25 minutes.
– Prior to using this sealer, priming and bonding has
to be done.
– Sodium hypochlorite can affect the bond strength
of primer, so after sodium hypochlorite irrigation,
rinsing with EDTA and sterile water is required.
– After completing obturation using epiphany, the
coronal surface may be light-cured for about 40
seconds for creating coronal seal.
Real Seal Sealer
Another example of a resin-based sealer (self-etch) is the
Real Seal sealer (Sybron Endo). Figure 16.14 shows its
photograph.
Glass Ionomer Sealers
• Has dentin bonding property.
• Disadvantages: If retreatment is required, its removal is
very difficult.
• A commercially available Endodontic Glass Ionomer
sealer is Ketac-Endo (3M/ESPE).
Medicated Sealers
• Medicated canal sealer containing iodoform for
antibacterial purpose to be used with medicated gutta-
percha.
Fig. 16.14  Commercially available resin-based self-etch root canal
sealer (Courtesy of Sybron Endo)
Obturation of Root Canal System 293
• Certain antimicrobial medicaments can be physically
mixed with ZOE-based sealer’s powder components.
• N2 sealer: Containing 6.5% paraformaldehyde, lead and
mercury. Unacceptable as sealer due to toxic effects on
periradicular tissues.
• Sealers such as endomethasone, paraformaldehyde
containing Reibler’s paste, SPAD, etc. are no longer used
in present day Endodontics due to high toxicity, risk to
patients and legal issues.
Silicone-based Sealers
To provide adhesion, moisture resistant seal and stability, a
few commercially available sealers have been manufactured
such as Lee Endo-fill, Roekoseal, etc.
Solvent-based Sealers
Gutta-percha particles dissolved in chloroform to produce
chloropercha, can be used as sealer with gutta-percha points
for obturation.
Problem with it is shrinkage creating voids and leakage.
Urethane Methacrylate Sealers
Such as EndoRez, EZ Fill and MetaSeal have also been
marketed to improve the sealing ability and bond strength
to dentin.
Dentin Bonding Agents
Such as Scotchbond, Gluma have been tried as root canal
sealers. There was dramatic improvement in the quality
of sealing root canals using dentin-bonding agents. But
the problems associated with these sealers would be, first
the preparation of dentin has to be done to remove all
the smear layer, especially from apical third of the canal.
Second obstacle is radiopacity. If radiopaque metal salts
are added to the adhesive, it might affect polymerization. All
of the bonding agents are technique-sensitive. They do not
polymerize in the presence of moisture. Delivery system is
also the problem for its placement in the canal. Also, their
removal from canal is very difficult in case of a failure.
A mind-map to remember all points of root canal sealers
is given in Figure 16.15.
WHAT IS THE PREPARATION FOR OBTURATION?
It has been found that most of the currently accepted
methods of chemomechanical preparation are inadequate
in producing a debris-free canal. In addition to pulp
294 Short Textbook of Endodontics

Fig. 16.15  A mind-map to remember all points of root canal sealers

tissue, debris and bacteria, “Smear layer” which is present HOW TO DO OBTURATION/WHICH ARE
obstructs the dentinal tubules. Smear layer created THE DIFFERENT TECHNIQUES OF DOING
by instrumentation (inorganic) and due to chemical
OBTURATION?
composition of dentin (organic) may interfere with the
adaptation of filling materials to the canal wall. If all the Obturation Technique Using Silver Points
dentinal tubules are opened up by removing the smear layer, • Silver cones had been used for obturation in the past.
it will provide a better seal by allowing the sealer or filling • Method:
material to penetrate the dentin. – Dry the canal.
17% ethylene diamine tetra-acetic acid (EDTA) can be – Select a silver cone of the same size as last file used
used to remove the smear layer before the obturation. to shape the canal (Master Apical File) and cut off its

butt end to give it proper length. Sterilize and insert
in the canal.
– Take radiograph to confirm the length.
– Coat the canal walls with sealer.
– Carry the cone into the canal with sterile cotton pliers
or stieglitz forceps until it fits snugly.
– Clean the pulp chamber and fill it with temporary
cement.
Figure 16.16 shows radiograph showing obturation
with silver points.
The use of Silver points for obturation is now
considered to be below the standard of care.
Other Obturation Techniques
Currently, most root canals are being filled with gutta-
percha and sealers. The use of gutta-percha for obturation
of canals is due to its property of ‘flow’ or ‘plasticity’. When
force is applied to gutta-percha, it becomes compacted and
it tends to flow away from a force directed at its mass.
There are different methods for obturation using gutta-
percha which can be classified based on:
• Direction of compaction: Lateral or vertical compaction
• Temperature of gutta-percha: Cold or warm (plasticized).
Two basic procedures of obturation are:
1. Lateral compaction of cold gutta-percha
2. Vertical compaction of warmed gutta-percha. Other
methods are variations of warmed gutta-percha.
For each of the above techniques, you must know the
principle, the stepwise method to perform the technique,
advantages and disadvantages.
Fig. 16.16  Obturation with silver points
Obturation of Root Canal System 295
Classification of different obturation methods (Ingle’s
Endodontics, 5th edn., p.598) is given in the Flow chart 16.1
and they are explained in detail as follows:
Solid Core Gutta-percha with Sealants
Cold Gutta-percha Points
Lateral Compaction of Gutta-percha
It is the most commonly used technique of obturation and
has long been the standard against which other methods of
obturation have been judged.
Principle: This technique involves first placing a sealer lining
in the canal, followed by a measured primary gutta-percha
cone, that in turn is compacted laterally by a plugger-like
tapering spreader used with vertical pressure in order to
make room for additional accessory cones. The final mass of
gutta-percha points is severed at the canal’s coronal orifice
using a hot instrument and final vertical compaction is done
with a large plugger.
Lateral and vertical apical pressure compacts the gutta-
percha and makes it flow into the root canals.
Criteria for lateral compaction technique: (in canal
preparation and instrument selection)
Lateral condensation compaction is the obturation
technique of choice if the following criteria are fulfilled:
• The final canal shape should be continuous taper
• In the apical area, it should be parallel, matching the
taper of the spreader/plugger
• The spreader must reach within 1–2 mm of working
length
• An apical stop must be created, to resist apically directed
condensation
• The gutta-percha cones used as accessory cones must
be smaller in diameter than the spreader/plugger.
Preparation for lateral compaction technique—It includes:
• Size determination of the spreader: A spreader of size of
apical instrument size or one size larger, that fits within
1–2 mm of the working length and that matches the taper
of the preparation is selected. A rubber stop is placed
on the shaft of the spreader to mark true working length
minus 1 mm.
• Size determination of primary point and accessory points:
Gutta-percha points have been standardized in size,
shape and are color-coded to match the standardized
instrument sizes and color. The primary point/master
cone should be selected to match the size of the last
296 Short Textbook of Endodontics
Flow chart 16.1  Classification of different obturation methods
instrument used at the apex. It should be tested in place
and confirmed radiographically.
Sterilization of gutta-percha using 5.25% NaOCl.
Methods to determine the proper fit of the master cone
include:
– Visual test: The gutta-percha point is measured and
grasped with cotton pliers at a position within 1mm
of the prepared length of the root canal. The point is
then grasped 1mm back and again pushed apically.
If point can be pushed beyond the working length
(apex), then a larger size cone is used or the same
cone is cut from its tip. The point is retried in the
canal until it goes to the correct position by trial and
error.
– Tactile test: It determines whether the point tightly
fits the canal. If the apical 3–4 mm of the canal have
been prepared with near parallel walls, some degree
of force is required to seat the point, and once in
position, a pulling force is required to dislodge it.
This is known as“Tug-back.” If the point fits loosely
in the canal, next larger size point should be tried or
the point can be cut from its tip and retried in canal
until it fits the canal correctly by trial and error.
– Patient’s response: Patients who are not anesthesized
during the treatment of a nonvital pulp or during
the second appointment of vital pulp, may feel pain
when gutta-percha penetrates the apical foramen.
Pain could also occur if pulp remnants are still
present in the root canal and it is of much greater
intensity than the pain from periapical tissue.
Granulation tissue does not produce any pain.
– Radiographic test : After the visual and tactile
tests, the position of the master cone is finally
checked with the radiograph. On the radiograph,
the point extending to within 1mm from the tip of
the preparation should be seen. The master cone
radiograph (as shown in Figure 16.17) helps to
evaluate whether the working length of the tooth was
correct, whether instrumentation followed the curve
of the canal and whether any perforation occurred.
If the primary point appears to be overextended,
then it should be shortened from the fine end and
then returned to the correct position. If the primary
point appears to be underextended, then a smaller
size gutta-percha point is selected or a new file
of the same number is selected and the canal is
reinstrumented to full working length until the file
is loose in the canal and the point is reseated and
radiograph taken again.
- Drying the canal: To dry the canal, an absorbent
paper point is placed in the canal to absorb
moisture or blood that might accumulate.
- Mixing and placement of sealer: A sterile slab and
spatula is used in case of powder-liquid system to
 Obturation of Root Canal System 297

dispense 1–2 drops of liquid and mix the cement

according to manufacturer’s instructions. The
cement should have creamy consistency and
should string out atleast an inch, when the
spatula is lifted from the mix. Sealer is placed in
the canal by the following ways:
■ Gutta-percha point is used to pump the sealer
into the canal;
■ Using a file or a reamer;
■ Using rotary or spiral paste fillers, (turned
with fingers or slow handpiece;
■ Recent method: Use of an ultrasonic file, run
without fluid coolant.

Step-wise Method
• The largest file used in the canal at the working length Fig. 16.17  Master cones placed in the canals of mandibular second
or the last file that was used to shape the apical part of molar tooth (Courtesy of Dr Shivani Bhatt)
the root canal is called as the Master Apical File (MAF).
First step is to select a standardized gutta-percha
cone as per the master apical file. This cone will be called
as the primary cone or master cone.
An alternative is to use a conventional cone of
appropriate taper and to adapt it by cutting small
increments from the tip.
• Insert the master cone into the root canal to the
established working length. It should fit snugly and
should resist removal (“tug-back”).
• Take a radiograph to determine the apical and lateral fit
of the primary cone. Figure 16.17 shows radiograph of
mandibular second molar with primary cone in each of
the canals.
On the radiograph:
– If the primary cone extends beyond the working
length and protrudes through the apical foramen,
then select a larger cone and adapt it in the canal or Fig. 16.18  Paper points which are caliberated, color-coded and of
the size and shape of the ISO standardized instrument (Courtesy of
cut off the tip so that the reinserted primary cone fits Dentsply)
snugly, has “tug back” and seals apically.
– If the initial fit of the primary cone fails to go to
the prepared length or appears 2–3 mm short of master cone. Figures 16.21A to F demonstrates the
the apex, then select a smaller cone and adapt it or following steps.
reprepare the canal to the corrected length, and then • Apical half of the primary cone is coated/buttered with
adapt the primary cone, and confirm its placement the sealer cement and the cone is carefully replaced in
radiographically. the canal.
• After the appropriate primary cone is selected and • Select an appropriate size spreader that can be placed
adapted, remove it from the canal and disinfect it by within 1–2 mm of the working length and insert it along
placing it in sodium hypochlorite for 1 minute followed side the primary cone applying gentle pressure laterally
by rinsing it with alcohol or wiping it with cotton swab and apically.
dabbed in clinical spirit. Figure 16.19 shows the photograph of finger-held
Irrigate the canal and dry it with paper points. Figure spreader no. 30 and figure 16.20 shows the photograph
16.18 shows photograph of the paper points. of hand-held spreader.
• Coat the walls of the canal with a thin layer of sealer It has been found that deep spreader penetration
cement using a lentulospiral, reamer, file or end of the minimizes apical leakage and percolation.
298 Short Textbook of Endodontics
Fig. 16.19  No. 30 Finger spreader (Courtesy of Dentsply)
Fig. 16.20  Hand-held spreader (Courtesy of Dentsply)
A B C percha is more, larger spreader needs to be used.
D E F
Figs 16.21A to F  Steps of lateral compaction obturation: (A) Master
cone selection with sealer in the canal; (B) Spreader; (C) Accessory
cone placed; (D) Spreader; (F) Master cone with accessory gutta-
percha; (F) Completed obturation
• Now, disengage the spreader from the cone by rotating it
back and forth between the fingertips as it is withdrawn
or while using a long handled hand spreader, by rotating
the handle in an arc.
Once disengaged, the spreader can be removed
without disturbing the seated gutta-percha.
• Place an accessory cone in the space vacated by
the instrument. This should be done as soon as the
instrument is removed from the canal.
The process is repeated until the entire canal gets
filled and the spreader no longer penetrates the coronal
one-third of the canal.
• Then sear off excess gutta-percha from the chamber.
A heated plugger can be used to vertically compact
the gutta-percha at the orifice or approximately 1 mm
below the orifice in posterior teeth and till the CEJ in the
anterior teeth.
Figure 16.22 shows radiograph of completed obturation.
Clinically Relevant Points
• The amount of force used for gutta-percha compaction
is determined by:
– The apical fit of the primary cone and
– By the distance the gutta-percha has to flow to seal
the root canal apically and laterally.
Only slight gentle pressure should be applied
because:
- Gutta-percha is not compressible, and
- Force of about 1.5 kg or more has the potential
to cause root fracture.
• The size of the spreader to be selected is determined by:
– Width of the prepared canal
– The lateral FIT of the primary cone. If the space
between the canal wall and the butt end of the gutta-
A spreader that fits within 1–2 mm of the working
length is selected and when this spreader is inserted
in the canal alongside the master cone, it should be
within 2 mm of the working length.
Fig. 16.22  Postobturation radiograph of the same case of mandibular
second molar tooth. Here lateral compaction obturation was done
(Courtesy of Dr Shivani Bhatt)

• It has been found that:
– Finger spreaders provide better tactile sensation and
have lesser potential to induce fractures in the root
as compared to the hand-held spreader.
Figures 16.18 and 16.19 show the photographs
of the finger spreader and hand-held spreader
respectively.
– Nickel-Titanium spreaders provide reduced stress
due to increased flexibility and provide deeper
penetration as compared to stainless steel spreaders
in curved canals.
• Deeper spreader penetration minimizes apical leakage
and percolation.
• Standardized GP cones have lesser taper than
conventional GP cones. So, when it is used as master
cone, it permits deeper spreader penetration.
Advantages
• Widely used method for obturation that can be used in
most clinical situations.
• Provides for length control during compaction.
Disadvantages
• This technique does not produce a homogeneous mass.
• It may not produce a dense filling. There is possibility of
voids between the filling and canal wall and within the
filling.
• It may not fill the canal irregularities well, when
compared with warm vertical compaction.
• There is potential for vertical root fracture if excessive
forces (of more than 2.5–3 kg) are applied.
Variations of Lateral Compaction
• Curved canals: Roots may have mesial or distal curvature,
which is visible on radiograph or buccal or lingual
curvature which is not visible on radiograph. Some teeth
have severely curved, dilacerated or bayonet canals. In
case of lateral compaction of primary gutta-percha point
(master cone) in a curved canal, more vertical force will
have to be exerted against it as the spreader will tend to
catch into gutta-percha point, forcing it apically. In such
cases, more flexible spreaders such as Nickel-Titanium
spreaders are preferred to reach within apical 1 mm and
distribute the forces evenly in curved canals. Warmed
or thermoplasticized gutta-percha techniques may be
preferred in curved canals.
• Immature canals and apices: Blunderbuss apex of
an immature tooth makes obturation complicated.
Apexification is the technique of choice that creates an
apical stop, before carrying out obturation. Apexification
is explained in detail in Chapter 27 Pulp Therapies. If
apexification fails or is inappropriate, then other special
Obturation of Root Canal System 299
methods can be used such as Tailor made gutta-percha
roll (explained later). Warm gutta-percha techniques are
more suitable for filling immature canals and apices.
• Tubular canals: Tubular canals have large apical opening
with nonconstrictive terminus. It may be best filled
with a coarse primary gutta-percha cone, that has been
blunted by cutting off the tip or a tailor-made point
can be used. Warm gutta-percha techniques may be
preferred.
• Tailor-made gutta-percha roll: In case of immature canal
with blunderbuss apex or tubular canal, the largest
gutta-percha point may be still loose in the canal. So,
a tailor-made gutta-percha roll is preferred by heating
a number of large gutta-percha cones and combining
them, butt to tip, until a roll has been developed much
the size and shape of the canal. After preparing the roll, it
must be chilled with a spray of ethyl chloride or ice water
to stiffen the gutta-percha before fitting into the canal.
Chemically Plasticized Cold Gutta-percha
This technique is a modification of lateral compaction
obturation that uses a solvent to soften the primary gutta-
percha point to ensure that it will better conform to the
aberrations in apical canal anatomy.
Solvents such as chloroform, eucalyptol and xylol
plasticize the gutta-percha and this plastic mass can be
forced into the canals.
Gutta-percha plasticized using chloroform is called
chloropercha.
Gutta-percha softened in warm oil of eucalyptus is called
eucapercha.
It is not practically possible to use this technique for
obturation as the solvent evaporates over a period of time
causing shrinkage and voids in obturation.
Usually, only the tip of the gutta-percha point is dipped
in the solvent and that too just for one second as two to three
dips will cause serious leakage.
Sealers such as Calcibiotic Root Canal Sealer and Wach’s
sealer contain the solvent-oil of eucalyptol and Canada
balsam respectively.
Canal-warmed Gutta-percha
Warm Vertical Compaction Technique
Also called as Schilder technique.
• Principle: Makes use of vertical force combined with the
applied heat in order to drive the gutta-percha apically
and laterally.
This technique was introduced by Schilder with
an objective of achieving 3-dimensional filling of the
radicular space. He recommended obturation with
300 Short Textbook of Endodontics
maximum amount of gutta-percha and minimum
amount of sealer to fill all the portals of exit.
Obturation with this technique requires that:
– The canal is prepared with a continuously tapering
funnel
– The apical foramen should be as small as possible.
• Step-wise method:
– Fit the primary gutta-percha cone larger than the size
of prepared canal preferably a conventional cone,
short of the working length such that it has resistance
to displacement. The master cone has to be cut back
about 0.5–1 mm from the canal terminus.
Or else, select a nonstandardized cone of gutta-
percha such as medium or fine-medium GP point
since it has greater taper and moreover its rate of
taper matches the rate of taper of the prepared canal.
Take a radiograph to confirm it.
– Remove the cone and disinfect and dry it and keep
it aside.
– Prefit the three pluggers (widest, middle and
narrowest) into the canal preparation at different
depths and record the desired lengths of the desired
plugger depth.
For example, Widest plugger to a depth of about 8–10
mm, middle to a depth of 13–15 mm and narrowest
to within 3–4 mm of apical terminus.
– Dry the canal with paper points and coat the canal
walls with the sealer.
– Replace the master cone in the canal.
– Then use heated spreader or plugger to remove the
portions of gutta-percha and to soften the remaining
material in the canal as shown in Figure 16.24A.
  Heat source such as Touch’N heat device provides
a controlled temperature and can be used to
apply heat instead of heated spreader or plugger.
It is an electronic device specially developed for
warm gutta-percha technique. Figure 16.23 shows
photograph of the Touch ‘N heat device.
– A room-temperature widest vertical plugger is
then used to vertically compact the plasticized
material apically in firm short strokes as shown in
Figure 16.24B.
  Heat carrier or alternate application of plugger-
middle sized and narrowest one, is done until the
plasticized gutta-percha seals the accessory canals
laterally and the apical portion in 3-dimensions
over a range of 3–5 mm. This is referred to as wave
of condensation as shown in Figures 16.24C to E.
Figures 16.26A to D show the photographs
of different pluggers used for Warm Vertical
obturation).
Fig. 16.23  Touch ‘N Heat device (Courtesy of Sybron Endo)
– Backfilling (Back-pack) of canal: After the apical
compaction (apical down-pack) is complete, a
segment of gutta-percha is placed in the canal and
heat is applied as shown in Figures 16.24F and G.
The process is repeated for the remaining coronal
portion of the canal and the canal is backfilled or
backpacked as shown in Figures 16.24H to J. An
alternative method of backpacking is by injecting
plasticized gutta-percha from Obtura II syringe
(discussed later).
In either case, plasticized gutta-percha must be
compacted with vertical pluggers to ensure its flow
against canal walls to minimize shrinkage.
Figure 16.25 shows the post-obturation
radiograph of a mandibular molar tooth in which
warm vertical compaction obturation was done.
• Advantages:
– This technique can fill the canal irregularities and the
accessory canals better than the lateral compaction
technique. Thus, it brings about 3-dimensional
obturation
– Quite effective for severely curved canals
– Simple and effective
– Enhanced hydraulics
– In case if there is need to remove the gutta-percha
for any reason, this technique is reversible.
• Disadvantages:
– Less control of length than lateral compaction
technique
– Compaction forces cause risk of vertical root fracture
– There is possibility of extrusion of root canal filling
material into the periradicular tissues (Fig. 16.25).
– Overfill or overextension is more likely to occur with
this technique.
 Obturation of Root Canal System 301

A B C D E

F G H I J

Figs 16.24A to J  (A) Heated plugger used to remove gutta-percha from above the coronal portion of master cone gutta-percha; (B) Room
temperature plugger used to vertically compact the plasticized material apically; (C to E) Alternate application of plugger and condenser until
plasticized gutta-percha seals the accessory canals; (F and G) Backfilling of canal: After apical compaction,segment of gutta-percha placed in
the canal and heat applied laterally; (H to J) Backfilling of the remaining coronal portion of the canal

– The pluggers used in this technique are rigid which #0.12 tapered pluggers (as shown in Figure 16.27) having a
cannot penetrate to the required depth, especially in diameter of 0.5 mm and an electric heat carrier, System B
case of curved canals and ribbon-shaped canals. unit. The System B unit is a new heat source that monitors
the temperature at the tip of the heat-carrier pluggers and
Continuous Wave Compaction Technique delivers a precise amount of heat for an indefinite time.
(System B Compaction) Figure 16.28 shows the photograph of the Buchanan hand
Buchanan introduced a variation of Warm Vertical pluggers.
Compaction technique called as the Continuous Wave
Compaction technique, which is faster and more accurate. Tapered pluggers GP cones
# 0.06 is used to approximate Fine conventional GP cone
Principle # 0.08 is used to approximate Fine-medium GP cone
Makes use of cones that are manufactured to mimic the
# 0.10 is used to approximate Medium GP cone
tapered preparation that is achieved with the use of Nickel-
# 0.12 is used to approximate Medium-large GP cone
Titanium rotary instrument by using #0.06, #0.08, #0.10 and
302 Short Textbook of Endodontics
Fig. 16.25  Postobturation radiograph of a case in which
obturation was done by warm vertical compaction technique
(Courtesy of Dr Roheet Khatavkar)
Figs 16.26A to D  Different types of pluggers: (A) Finger plugger;
(B) Hand-held plugger; (C) Schilder plugger anterior; (D) Schilder
plugger posterior (Courtesy of Dentsply)
These pluggers are consistent with Greater Taper
instruments.
Step-wise Method
• Insert the appropriate master cone in the canal and
along with that a corresponding tapered plugger is
prefitted to fit within 5–7 mm of the canal length. (Figure
16.29 shows the photograph of Autofit gutta-percha
Fig. 16.27  Buchanan heat pluggers in sequence: 0.12 Medium large,
0.10 Medium, 0.08 Fine Medium, 0.06 Fine, 0.04 Extrafine (Courtesy
of Sybron Endo)
Fig. 16.28  Buchanan hand pluggers in sequence: Size #0, #1 and #2.
(Courtesy of Sybron Endo)
points consistent with the size of the Greater Taper
instruments).
• Set the system B unit to 200oC in touch mode. Figure
16.30 shows photograph of the System B cordless unit.
• Activate the appropriate size plugger to remove the
excess coronal material.
• Room temperature plugger of appropriate size is
used to compact the gutta-percha in the canal while

Fig. 16.29  Greater taper autofit points (Courtesy of Sybron Endo)
Fig. 16.30  System B cordless unit (Courtesy of Sybron Endo)
Fig. 16.31  Elements obturation unit (Courtesy of Sybron Endo)
Obturation of Root Canal System 303
applying firm pressure along with heat by activating
the device.
• Move the plugger rapidly for 1–2 seconds to within
3  mm of the point of plugger binding.
• Inactivate the heat but maintain firm pressure on plugger
for 5–10 seconds.
• Allow gutta-percha mass to cool and then apply heat for
one second to separate the plugger and remove it.
• The remaining coronal portion of the canal be back
filled using thermoplastic injection technique or other
method.
• Recent advancement: Elements Obturation Unit (Fig.
16.31)
The Elements Obturation Unit combines System B
technology with a motor-driven extruder handpiece to
make obturation efficient, predictable, and accurate.
Advantages
• Provides good apical seal
• Can effectively fill lateral and accessory canals
• Saves time, quick procedure (15–20 seconds)
• Postspace can be created easily.
Disadvantages
• Chances of extrusion of obturation beyond the apex
• Additional equipment may be required to backfill the
coronal portion of the canal.
Sectional Method of Compaction
It is an earliest modification of the vertical compaction
method described by Webster as root canal filling with
gutta-percha, using points heated and well-packed in with
hot instruments.
• Principle: Makes use of 3–5 mm segments of gutta-
percha cone to fill root canal in sections as gutta-percha
can hold heat over a distance of 3–5 mm.
• Step-wise method:
– A gutta-percha cone that is approximately the size
of the prepared canal is cut into sections each about
3–4 mm long as shown in Figure 16.32A.
– Coat the canal walls with the sealer cement.
– A plugger that can be inserted in the canal to within
3–4 mm of the apex is heated and a section of gutta-
percha is mounted on the heated plugger.
– This heated plugger with a mounted section of
gutta-percha is carried into the canal to a previously
measured depth and slight vertical pressure is
applied as shown in Figure 16.32B.
Figure 16.32C shows the inserted section of gutta-
percha in the canal.
– Carefully disengage the plugger to prevent dislodging
of the inserted section of gutta-percha.
304 Short Textbook of Endodontics
– Take a radiograph to check the position and fit of the
condensed section of gutta-percha.
– Take another section of gutta-percha 3–4 mm long
dipped in eucalyptol and warm it over a flame and
add it to the previous section in the canal and apply
vertical pressure.
– The process is repeated to fill the entire canal as
shown in Figure 16.32D.
If post and core restoration is to be done, only the first
or apical section of gutta-percha is sufficient to obturate
the canal in which the remaining canal is used for post-
placement.
• Recent development: Instead of laboriously adding
sections of gutta-percha, backfilling may be done
with thermoplasticized gutta-percha using the Obtura
II gutta-percha system, in which the canals can be
backfilled, up to 10 mm in a single increment.
• Advantages: This technique seals the canal apically and
laterally.
• Disadvantages:
– Time-consuming technique
– Sections of gutta-percha may be difficult to retrieve
if the canal is overfilled.
– Condensing sections of gutta-percha into a
homogenous mass may be difficult. As a result, voids
may occur in between the sections.
A B
Figs 16.32A to D  Sectional method of compaction: (A) A gutta-percha cone of approximate size of prepared canal placed in canal and apical
section of length 3–4 mm is cut; (B) Heated plugger with mounted section of gutta-percha is inserted in the canal to within 3–4 mm of the
apex; (C) Inserted section of gutta-percha in apical portion of canal; (D) Entire canal filled
Warm Lateral/Vertical Compaction Technique (Hybrid
Technique)
Hybrid technique combines lateral compaction technique
+ thermoplasticized GP technique.
Begins with lateral compaction to achieve a good apical
seal. After placing master cone and several accessory cones,
use a hot plugger to sear off the GP points at the length of
4–5 mm from the apex.
Then, light vertical compaction is applied to restore the
integrity of the apical plug of gutta-percha.
Remaining canal is then back-filled with the
thermoplasticized gutta-percha injection.
Endotec Device II
Considering the ease and speed of lateral compaction
technique and superior density achieved using vertical
compaction of warm gutta-percha, Martin developed
Endotec II device that incorporates the qualities of both
techniques.
Endotec II device brings about warm lateral compaction
of gutta-percha into the prepared canals in the form of a
solid homogeneous mass.
Various tapers and tip diameters of Endotec II tips are:
Tapers/Tip diameters
# 0.02/30
# 0.05/30
C D

# 0.02/40
# 0.04/40
# 0.04/70
# 0.06/70
# 0.06/100
Step-wise Method
• Adapt a master cone to the working length with a good
tug-back.
• Select an appropriate size Endotec II tip. Motion of use
of Endotec II- plugger/spreader—vertical pressure with
sweeping lateral pressure.
• Activate the device and insert the tip beside the master
cone to within 2–4 mm of apex.
• Rotate the tip for 5–8 seconds.
• Place an unheated spreader in the channel created to
ensure adaptation and place accessory cone in the space
created.
• In this way, lateral compaction is done with the heated
plugger to provide space for additional gutta-percha and
the vertical compaction done with the cooled plugger to
condense the heat-softened gutta-percha. The process
is repeated until the canal gets filled.
• Finally, a cold hand plugger is used to firmly condense
the fused gutta-percha bolus.
Advantages
• Provides length control
• Produces fusion of gutta-percha into solid homogeneous
mass
• Less stress during obturation
• No heat-related damage.
Thermomechanical Compaction
This technique was given by McSpadden.
Principle
Makes use of McSpadden compactor, an instrument
similar to a reverse hedstrom file, that fits into a latch-type
handpiece and is rotated at up to 20,000 rpm, generating
heat by friction. This heat decreases viscosity of gutta-
percha, softens it and makes it flow.
Step-wise Method
• Adapt a master cone short of the working length and
take a radiograph.
• Dry the canal and coat the walls with the sealer.
• An appropriate size McSpadden compactor is selected
and inserted alongside the gutta-percha cone about 3–4
mm from the apical extent of preparation.
Obturation of Root Canal System 305
• It is fit into a latch-type handpiece and spun in the canal
at the speed of 8,000–10,000 rpm. It heats the gutta-
percha by friction.
• As the compactor is withdrawn from the canal, the
pliable mass of gutta-percha is compacted apically and
laterally.
Advantages
• It can fill the irregularities of the canal.
• It is simple and quick technique.
Disadvantages
• Possibility of extrusion of material periapically.
• Cannot be used in curved canals.
• Heat generation.
• Compactor blades may gouge the canal walls or break
in the canal.
• Set filling may shrink.
Modifications of McSpadden Compactor:
• Modified hedstrom-type instruments such as Gutta-
condensor, Zipperer and Engine plugger which more
closely resembles an inverted K-file.
– The Microseal system: It is a modification of the
original McSpadden Compactor, which is gentler
and slow-speed model made of Nickel Titanium,
which because of flexibility can be used in curved
canals. It is used in conjunction with the alpha-phase
like gutta-percha or even with regular gutta-percha
points. It has controlled speed of 1000–4000 rpm.
– McSpadden developed a technique for open apex
cases in which a low-heat gutta-percha bolus is
deposited at the apex with a large condenser and
then allowed to cool and harden to form an apical
plug against which the remaining canal is obturated.
• Hybrid technique: After the initial lateral compaction
is complete, the Guttacondensor and Zipperer Engine
plugger are used for ‘back-filling’ the canal. In the
hybrid technique, a regular primary point is placed
with a sealer, spread it aside with a finger spreader and
followed by an accessory cone. The Engine plugger size
of 45 or 50, 4–5 mm is placed in the canal and rotated
at 15,000 rpm. After one second, it is advanced into the
canal until resistance is met and backed out while still
rotating. Within 2–3 seconds, the canal is completely
filled. Advantages of this technique include: quicker
to complete than lateral condensation, reduced risk of
fracture to slender roots and less chances of overfilling.
• Thermomechanical solid-core gutta-percha obturation:
J.S. Quick-fill is the example, which consists of titanium
306 Short Textbook of Endodontics
core devices of ISO size 15–60. They resemble the latch-
type Endodontic drills and are coated with alpha-phase
gutta-percha. After placing in the prepared root canal
with the sealer, it is spun in the canal using a regular low-
speed, latch-type handpiece. Frictional heat generated
plasticizes and compacts the gutta-percha by the design
of the Quick-fill core. After compaction, compactor
may be removed while it is spinning or left in place and
separated in the coronal cavity with an inverted cone bur.
• Ultrasonic plasticized gutta-percha technique: Moreno
described that the ultrasonic instrument can be used to
plasticize gutta-percha. He used the friction of ultrasonics
plus hand or finger pluggers for condensation. It was
found that the heat generated by this technique is safe
and effective. However, it is not commonly used.
Thermoplasticized Gutta-percha
Thermoplasticized Injectable Gutta-percha Techniques
• Principle: This technique involves application of heat
to gutta-percha outside the tooth to soften it and this
softened gutta-percha is then injected into the canal.
– Examples of thermoplastic injection techniques:
Obtura II System and Ultrafil 3D system are
examples.
Step-wise Method
• Dry the canal and coat the canal walls with sealer
cement. Sealer fills the microscopic interface between
the dentin and gutta-percha as well as acts as lubricant.
It also compensates for shrinkage as the gutta-percha
cools.
• Pre-heat the gutta-percha in the gun and position the
needle in the canal such that it reaches within 3–5 mm
of apical preparation.
• Squeeze the trigger of the gun and then gradually and
passively inject gutta-percha.
• As the apical portion of the canal is filled, the needle
backs out of the canal.
• Unheated plugger dipped in alcohol is used to compact
gutta-percha. Continue compaction until gutta-percha
cools and solidifies.
Advantages
• Provides good adaptation to canal walls.
• Quick, saves time.
Disadvantages
• Lack of length control: Both overextension and
underextension have been found to occur.
• In narrow preparation, it may be difficult to reach deep
in the canal.
• Special care needs to be taken while introducing the
needle into the canal as it is hot and should not touch
patient’s oral tissues.
Inject-R Fill backfilling technique: It uses a miniature-
sized metal tube containing conventional gutta-percha
and plunger and allows for delivery of a single backfill
injection of gutta-percha once the apical segment of the
canal has been obturated. The apical segment of the canal
can be obturated using any of the techniques such as
lateral compaction, traditional warm vertical compaction
or System B.
Solid Core Carrier-based Gutta-percha Technique
Principle
Makes use of certain carriers coated with gutta-percha and a
heating device. These obturators are designed to correspond
to the ISO standardized file sizes and to Nickel-Titanium
GT files (GT obturators) and Protaper files (Protaper
obturators), etc. Appropriate carrier is selected with the
help of size verifiers. The carrier should fit passively at the
working length. Carrier-based GP systems include:
• Thermafil
• Successfil
Thermafil
• It has a solid core
• Original thermafil obturators had a metal core coated
with gutta-percha (α-phase).
Currently available thermafil obturators have a
plastic core coated with alpha phase gutta-percha as
shown in Figure 16.33.
• Stepwise Method:
– Dry the canals.
– Coat sealer on canal walls.

– Mark the carrier at correct working length and place
it in the heating device (Thermafil oven) to heat it to
appropriate temperature for 10 seconds.
– Retrieve it and rapidly insert it into the canal.
– Take a radiograph to confirm the position of the
carrier.
– Allow gutta-percha to cool for 2–4 minutes. Then
resect the carrier, few millimeters above the canal
orifice using round or inverted cone bur.
– Compact the coronal gutta-percha vertically.
• Advantages:
– Facilitates flow of gutta-percha apically and into
lateral and accessory canals.
– Very less amount of sealer is needed.
• Disadvantages:
– Possibility of extrusion of material beyond the apex.
– It is difficult to prepare the postspace as the plastic
core retains in the canal.
Successfil
• Successfil obturators have either titanium carriers or
radiopaque plastic carriers.
• It is used in conjunction with Ultrafil 3D system.
• After placing the carrier in the canal to the correct
working length, gutta-percha around the carrier is
compacted with plugger.
• Then the carrier is resected few millimeters above the
canal orifice with a bur.
Apical-Third Filling
Lightspeed Simplifill
• Used in canals prepared with Lightspeed instruments.
• Uses a stainless steel carrier to place and compact 5 mm
of gutta-percha into the apical portion of a canal.
Fig. 16.33  Thermafil obturator
Obturation of Root Canal System 307
• The Apical GP Plug has same ISO size as the Lightspeed
“Master Apical Rotary” (MAR).
• The canal is coated with a sealer and the Apical GP Plug
carrier is inserted into the canal.
• Once placed, the carrier is removed, leaving behind an
apical plug of gutta-percha.
• The remaining portion of the canal is back-filled either
by using a Simplifil syringe or other method such as
Obtura II.
• Advantages:
– It helps to conserve dentin due to Light-Speed
instrumentation technique (less flaring).
– It eliminates additional internal forces as it does not
use any additional spreader or plugger to compact
the apical plug.
– No carrier is left in the canal.
Dentin-chip
• This new technique is being studied that will provide a
biological seal rather than mechanochemical seal and
will stimulate osteogenesis or cementogenesis as well.
• After root canal preparation, when the dentin is no
longer contaminated, a Gates Glidden drill or Hedstrom
file is used to produce dentin powder in the central
portion of the canal.
• A premeasured file one size larger than the last apical
enlarging instrument is used to pack the dentinal chips
at the apex. About, 1–2 mm of dentinal chips should
block the apical foramen.
• The resistance to perforation is tested using no. 15 or 20
file to check the completeness of density of the apical
plug.
• The final gutta-percha is then compacted against that
apical plug.
• Advantages: It prevents overfilling and leads to quicker
healing, minimal inflammation and apical cementum
deposition.
Calcium Hydroxide
• Calcium hydroxide has been widely used to bring about
apexification in case of immature teeth with open apex.
In canals with closed apex also if calcium hydroxide is
used, cementification occurs.
• Calcium hydroxide can be placed as an apical plug in
either dry or moist state.
• It acts as a stimulant to cemental growth. It also acts as
a barrier to extrusion of well-compacted gutta-percha
obturation.
308 Short Textbook of Endodontics
Injection or ‘Spiral’ Obturation
Techniques that use injecting or pumping or spiralling
the obturation material in place have been found to be
inadequate due to shrinkage from heated to cooled state,
failure to compact or eliminate the voids and chances of
overfilling.
Calcium Phosphate Cement Obturation
• Harbert suggested that tricalcium phosphate can be
used as an apical plug, like the calcium hydroxide and
dentin shavings. Recently, calcium phosphate has been
suggested as total root canal filling material.
• A simple mixture of calcium phosphates-one acidic
(Dicalcium phosphate) and one basic (Tricalcium
phosphate), that sets to become a hardened mass-
hydroxyapatite has been developed. The final set,
calcium phosphate cement (CPC), consists of crystalline
material and its porosity is in direct ratio to the amount
of solvent used.
• It is radiopaque.
• It is insoluble in saliva and blood.
• It is soluble in strong acids in case if it needs to be
removed.
• The use of calcium phosphate as an obturation material
is still under research and it may be thought to be a
replacement of calcium hydroxide for apexification.
• Since hydroxyapatite is a naturally occurring product
and bone grows into and eventually replaces extruded
material, this material is biologically acceptable.
But it is still under clinical trial and not being used.
Mineral Trioxide Aggregate (MTA) has been found to be
an excellent root end filling material.
HOW SHOULD AN IDEAL OBTURATION BE?
Criteria for radiographic evaluation of obturation include:
• Length of root canal filling: Canal should appear filled
from the level of canal orifice to about 0.5–1 mm short
of the radiographic apex.
• Taper: Obturated root canal should reflect the original
canal shape.
• Width: Obturation should be equal in width to the width
of the surrounding root dentin.
• Rule of thirds: Root canals shaped and obturated
proportionate to the root diameter.
• Density: Obturation should appear dense on radiograph.
There should be no voids in the obturation.
• Removal of sealer: In anterior teeth, sealer should be
removed to the facial cemento-enamel junction (CEJ)
and to the canal orifice in posterior teeth.
• Provisional restoration: Adequate provisional restoration
should be placed over the orifices of the obturated
canals.
• Density of apical portion of fill: Apical portion of the canal
should appear radiodense without any gaps or voids
filled with both—master cone as well as sealer and not
radiodensity just due to sealer.
WHAT CAN GO WRONG IN OBTURATION?
Previous procedural errors such as ledge formation, canal
blockage, improper instrumentation, etc. during cleaning
and shaping of root canal can cause poor obturation, as a
result of which there is persistent bacterial infection in the
root canal causing Endodontic failure.
Poor Obturation
• Underfilling indicates voids or spaces occurring within
the obturation or laterally between the root canal filling
and the root canal walls.
• Underextension indicates that the obturation has not
extended till the apex.
Figures 16.34A to C show few examples of underfilled
and underextended obturation.
• “Overfilling” is total obturation of the root canal space
with excess material extruding beyond the apical
foramen (Ingle’s Endodontics, p.1054).
It indicates that the canal has been densely obturated
and along with that there is extension of the root canal
filling material beyond the apex. Usually, overfilled
canals cause more postoperative discomfort than do
those filled to the Cemento-Dentinal Junction (CDJ).
• ‘Sealer puff’:
– This is not an error in obturation.
– Surplus sealer extruded through the apical portal
of exit (POE) is referred to as sealer puff. Purposely
overfilling to produce a periradicular ‘puff ’ has
been advocated primarily by the proponents of the
softened gutta-percha technique.
– The ‘puff ’ or ‘button’ is designed in order to
compensate for shrinkage of filling by pulling down
tightly against the apex.

– This is generally acceptable and may be well-
tolerated in the periradicular tissues in case of
biocompatible sealers and various studies and
research shows that it does not affect the osseous
repair and healing.
– In fact it is believed that the apical puff is an indicator
that the gutta-percha has been densely packed into
the apical preparation and that all of the aberrations,
as well as lateral and accessory canals of the root
canal system have been cleansed and filled. Figure
16.35 shows the postoperative radiograph of a
mandibular molar showing “sealer puff”.
• Overextension indicates that the obturating material
has extended and has got extruded beyond the apical
foramen but with the caveat that the canal has not been
adequately filled and the apex has not been sealed.
Thus, overextension may be associated with underfilled
canal, i.e. the canal may not have been adequately filled
within its confines.
Leakage
• Poor apical seal causes apical leakage, that is leakage
between root canal and periapical tissues.
• Poor coronal seal causes coronal leakage, that is leakage
from the oral cavity into the root canal.
Leakage adversely affects healing and repair and is the
main cause of Endodontic failures.
WHAT IS THE IMPORTANCE OF CORONAL SEAL
AND HOW CAN WE ENHANCE IT?
• If obturated canals are not protected with coronal
restoration over the orifices, leakage occurs in short
period of time. Magura et al. have found that obturated
canals exposed to oral cavity for more than 3 months
are considered to be contaminated and retreatment is
recommended for such cases.
A B
Figs 16.34A to C  Few examples of underextended obturation
Obturation of Root Canal System 309
It is recommended that the postobturation coronal
restoration such as bonded core built-up material
be placed as soon as possible after obturation and
preferably at the obturation appointment itself to
prevent any coronal leakage.
• It has been found that microleakage can occur through
well-obturated canals if proper seal has not been
achieved with an appropriate coronal restoration. Thus,
coronal seal plays an important role in maintaining the
apically sealed environment.
Preventing coronal microleakage has significant
impact on long-term success of Endodontic therapy.
The importance of coronal seal by means of an
appropriate coronal restoration placed over the canal
obturation is to prevent microleakage and subsequent
reinfection of the root canal system and the periapical
area for a successful Endodontic treatment.
• Microleakage has been found to occur even with the
permanent coronal restorations such as amalgam or
Fig. 16.35  Postobturation radiograph of a mandibular molar
showing sealer ‘puff’. (Courtesy of Dr Roheet Khatavkar)
C
310 Short Textbook of Endodontics

composite along with crown placed over the Endodontic

access cavities. So, it is necessary to enhance the coronal
seal.
In case of multivisit Endodontic therapy, the access
cavity or the pulp space must be closed with a temporary
cement or an interim restoration to provide coronal seal
in order to prevent contaminants such as bacteria, tissue
fluids and food particles from oral cavity into the pulp
space.
• Properties of interim restoration/temporary cement:
– Should provide satisfactory coronal seal by
preventing marginal leakage
– Should be insoluble in oral fluids
– Should have enough strength to withstand
masticatory forces
– Should have antibacterial properties Fig. 16.36  Commercially available temporary filling material for
• Thickness of temporary cement: 4–5 mm. provisional seal in between appointments, it is noneugenol calcium
• If temporary restoration is required for more than hydroxide-based cement and has been found to provide good
one week, stronger/harder cement should be used or coronal seal (Courtesy of Mr Amar, Dr Dabholkar’s clinic)
soft cement should be covered with glass ionomer or
composite resin.
• Examples: IRM
Cavit It has been found that coronal microleakage is
Term prevented with placement of 1–2 mm of intracoronal
Coltosol barrier.
Figure 16.36 shows photograph of commercially Various materials that can be used for this purpose
available temporary filling material–COLTOSOL. include:
These have been discussed in Chapter 11: Endodontic • Flowable light cured composite resin
Armamentarium: Instruments, Materials and Devices. • Mineral trioxide aggregate (MTA)
• Resin modified glass ionomer liner
Methods to Enhance the Coronal Seal • Dentin bonding agent
• Cements such as Cavit, IRM, Super EBA.
Placement of an appropriate intraorifice barrier between
the orifices of obturated canals and the permanent coronal
BIBLIOGRAPHY
restoration can enhance the coronal seal and prevent the
penetration of micro-organisms into the obturated root 1. Cohen S, Hargreaves KM. Pathways of Pulp, 9th edn. St. Louis:
canal system. Mosby; 2006.pp.358-91.
• Intraorifice barriers: “Materials placed 1–2 mm into the 2. Grossman L, Oliet S, Del Rio C. Endodontic Practice, 11th edn.
orifice of the canals or on the pulpal floor to serve as a Varghese Publication; 1991.pp.242-68.
3. Ingle, Bakland Endodontics, 5th edn. BC Decker-Elsevier. 2002.
barrier against the penetration of micro-organisms into pp.571-656.
the obturated root canal system, thereby enhancing the 4. Ingle J, Bakland L, Baumgartner J. Ingle’s Endodontics, 6th edn.
coronal seal are called as intraorifice barriers.” BC Decker Inc, Hamilton; 2008.pp.1019-43, 1053-79.
 Drugs or Medicaments

17
CHAPTER

used in Endodontic
Treatment

This chapter explains how Root canal treatment can be made comfortable, pain-free and successful
for the patient by appropriate management of patient’s fear, anxiety, pain and elimination of infection,
when present. It gives an overview of various drugs used in Endodontics.
  You must know
• How to Manage Fear and Anxiety in an Endodontic Patient?
• Which are the Drugs or medicaments used in Endodontics?

HOW TO MANAGE FEAR AND ANXIETY Examples of iatrosedative techniques include hypnosis,
IN AN ENDODONTIC PATIENT? audioanalgesia, biofeedback, etc.

Frequently in Endodontic practice, clinician comes

across  patients who have some kind of anxiety and fear
related to undergoing root canal treatment as given in
Figure 17.1.
Clinician must recognize patient’s dental fear for
following reasons:
• Unrecognized fear and stress can result in a medical
emergency situation such as syncope, hyperventilation,
bronchospasm, etc. on the dental chair, due to
catecholamine release into cardiovascular system.
• It prevents the cooperation from the patient.
• It acts as a barrier for the clinician to the delivery of
quality dental care.
• Ignoring fear will complicate Endodontic treatment
unnecessarily.
• Fear lowers the pain reaction threshold.
Once the clinician recognizes patient’s fears, appropriate
measures can be taken to manage it prior to and during the Most of the times, certain behavior approaches followed
root canal treatment procedure. by the clinician can effectively manage patient’s anxiety and
fear. Such an approach includes:
Iatrosedation • Explaining each step of root canal treatment procedure
before beginning it.
Dr Friedman formulated a term called ‘Iatrosedation’, • Inform the patient about the possible discomfort and
meaning relaxation of a patient by doctor’s behavior. how it can be managed.
312 Short Textbook of Endodontics

  →  Nonbenzodiazepines: Zolpidem
Zaleplon
To be taken – The night prior to the planned appoint­
ment to ensure restful night’s sleep
– I n the morning, 1 hour prior to the
scheduled dental visit.
• Parenteral routes:
– Intravenous sedation → IV conscious sedation
with benzodiazepines
such as Midazolam
and/or Diazepam
– Intramuscular sedation → Not safe and controll­
able, so generally not
recommended for use
in dentistry
Fig. 17.1  Different kinds of fear that an Endodontic – Intranasal sedation → Not as controllable
patient may have as IV route, not
recommended for use
• Making local anesthetic injections comfortable and in dentistry.
atraumatic by
– Application of topical anesthetic at the site of
WHICH ARE THE DRUGS OR MEDICAMENTS
injection to avoid even the pain from the needle
prick. USED IN ENDODONTICS?
– Slow administration of local anesthetic solution.

Pharmacosedation
In few cases, behavioral intervention may not be effective
and pharmacologic management of anxiety needs to be
carried out.
This includes use of sedatives and tranquillizers that
can calm the patient without producing sleep, but may
cause drowsiness to some extent. They act by depressing
the central nervous system (CNS) and decreasing cortical
excitability decreasing the patient’s awareness and
distracting their minds from the dental procedure.
Minimal, moderate or deep sedation can be achieved For Management of Anxiety
as per the need with the help of drugs used for conscious
sedation. Inhalation, oral and parenteral routes such as Antianxiety drugs such as sedatives (discussed already).
intramuscular, intravenous and intranasal are the routes
of administration of CNS-depressant drugs. Inhalation and
For Effective Pain Control
oral routes are commonly used.
Local Anesthetics
Drugs Used for Sedation
Root canal treatment will not be possible without achieving
• Inhalation sedation  →  Uses N2O-O2 combination effective pain control. Effective local anesthesia helps
• Oral sedation  →  Benzodiazepines: Alprazolam achieve profound pain control.
Diazepam
Lorazepam Local anesthetic technique should be made “painless” and
Midazolam comfortable for the patient by:
Flurazepam • Use of topical anesthetics at the injection site.
 Drugs or Medicaments used in Endodontic Treatment 313

2 % lidocaine with 1:1,00,000 epinephrine is the most

commonly used local anesthetic agent.
• Routes of administration of local anesthesia:

Primary injection Supplemental injection

techniques techniques

Mandibular anesthesia: • Intrapulpal anesthesia

• Inferior alveolar nerve • Intraligamentary
block (IANB) anesthesia
• Alternate injection • Intraosseous
techniques: anesthesia
–  Infiltration
–  Incisive nerve block
Fig. 17.2  Local anesthetic armamentarium –  Gow-Gates and Vazirani-
(Courtesy of Mr Amar, Dr Dabholkar’s clinic)    Akinosi technique
Maxillary anesthesia:
• Infiltration
Figure 17.2 shows photograph of commercially • Alternative injection techniques:
available topical anesthetic spray (LIGNOX) and other local – Posterior superior alveolar nerve block (PSANB)
anesthetic armamentarium. – Infraorbital nerve block
• Slow administration of anesthetic (Slow injection is – Palatal-anterior superior alveolar nerve block
less painful and has higher anesthesia success rate as (P-ASA)
compared to rapid injection). – Anterior middle superior alveolar (AMSA) nerve
• Classification of local anesthetics: block
– Second division nerve block

Mandibular Anesthesia
For the mandibular anterior teeth, infiltration technique of
anesthesia can be quite effective. A combination of labial
and lingual infiltration is to be administered.
For the mandibular posterior teeth, inferior alveolar
nerve block has to be administered. But it is not always
successful due to various factors such as inaccurate
positioning of needle, improper technique, accessory
path of innervation, tooth with preoperative pain and
inflammation, needle deflection, cross innervation, etc.
• Onset: Onset of pulpal anesthesia with infiltration occurs
in 5–7 minutes and with inferior alveolar nerve block
occurs in 10–15 minutes in most cases.
• Duration: Effect of anesthesia lasts for approximately
1–2½ hours with 2% lidocaine with 1:1,00,000
epinephrine.
When IANB is not successful, alternate or supplemental
injection techniques are indicated.

Alternative Techniques
Such as Gow-Gates and Vazirani-Akinosi do not replace
the conventional inferior alveolar nerve block but may be
314 Short Textbook of Endodontics
indicated in certain selected cases. For example, Vazirani-
Akinosi block for limited mandibular opening, incisive nerve
block for premolar teeth.
Supplemental Techniques
After an inferior alveolar nerve block, when profound lip
numbness has developed but patient still experiences
pain upon Endodontic access, supplemental injection
techniques are indicated rather than repeating the IANB
which are follows:
• Intraligamentary injection:
– Traditional or pressure syringe can be used with 25,
27 or 30 gauge needle.
– Injection under strong back pressure to force the
solution into marrow spaces is the most important
factor for anesthetic success with intraligamentary
injection.
– About 0.2 mL of solution can be delivered with each
mesial and distal injection. Figure 17.3 demonstrates
the intraligamentary injection. There is immediate
onset of anesthesia and if still not adequate,
reinjection is indicated.
– The drawback of this technique is moderate to
severe pain during injection especially in teeth with
irreversible pulpitis as compared to normal teeth
and possibility of postoperative pain that may last
for 14–72 hours after injection.
– Recent technology for intraligamentary supplemental
injection makes use of computer-assisted local
Fig. 17.3  Intraligamentary injection
anesthetic delivery system such as Wand or
CompuDent®.
• Intraosseous injection:
– It delivers the local anesthetic solution directly
into the cancellous bone adjacent to the tooth to
be anesthesized. Figure 17.4 demonstrates the
intraosseous injection.
– Commercially available intraosseous systems
include:
- The stabident system
- The X-tip system
- The intra-flow system
– Drawback is moderate to severe pain during
perfo­ration and deposition of solution especially
in teeth with irreversible pulpitis as compared to
asymptomatic teeth.
– Site of injection is distal to the tooth to be anesthetized
except for maxillary and mandibular second molars,
where the site of injection is mesial to the tooth.
Perforation is made in attached gingival or alveolar
mucosa where the cortical bone is thinner and allows
injection at a site equidistant between adjacent root
structures.
– Onset of anesthesia with intraosseous injection is
almost immediate.
– Transient tachycardia has been reported to occur for
3–4 minutes after intraosseous injection.
– There is possibility of moderate pain on
a postoperative day but less as compared to
intraligamentary injection.
Fig. 17.4  Intraosseous injection

– There can be swelling or exudate for few weeks after
injection.
• Intrapulpal injection:
– In case of mandibular posterior teeth, in spite
of inferior alveolar nerve block and repeated
supplemental intraosseous injections, if pain persists
during Endodontic access, the intrapulpal injection
is indicated. Figure 17.5 demonstrates intrapulpal
injection.
– Onset of anesthesia is immediate and the technique
does not require any special syringe or needles.
Duration of action is less (about 15–20 minutes)
– But the major drawback is moderate to severe
pain during injection as the needle placement and
injection are directly into a vital and very sensitive
pulp.
– It produces profound anesthesia if it is given under
backpressure.
– If the anesthetic solution is deposited passively
into the pulp chamber, the solution will not diffuse
throughout the pulp and hence is ineffective.
Maxillary Anesthesia
Clinically, it is easier to achieve maxillary anesthesia than
mandibular anesthesia.
Fig. 17.5  Intrapulpal injection
Drugs or Medicaments used in Endodontic Treatment 315
Most commonly used primary injection technique for
maxillary teeth anesthesia is infiltration with 1.8 mL of 2%
lidocaine with 1:1,00,000 epinephrine.
Onset of anesthesia occurs in 5–7 minutes and duration
of action is approximately 20–30 minutes for anterior teeth
and 30–45 minutes for posterior teeth.
It has been found that increasing the volume of 2%
lidocaine with 1:1,00,000 epinephrine to 3.6 mL can increase
the duration of pulpal anesthesia.
• Alternative maxillary injection techniques:
– Posterior superior alveolar (PSA) nerve block: To
anesthetize some first molars and all second and
third molars.
– Infraorbital nerve block: To anesthetize first and
second premolars and the lip, but not the central or
lateral incisors.
– Second division nerve block: (High tuberosity
approach): To anesthetize the pulps of molar teeth
and about 50% of the second premolars.
– Palatal-anterior superior alveolar (ASA) nerve
block: To anesthetize maxillary incisors and canines
bilaterally. Anesthetic solution is deposited into the
incisive canal.
– Anterior middle superior alveolar (AMSA) nerve
block: To anesthetize maxillary central and lateral
incisors, canine and first and second premolars.
Anesthetic solution is deposited palatally at a point
that bisects the premolars and lies halfway between the
midpalatine raphe and the crest of free gingival margin.
Evaluation of Anesthesia
To confirm whether anesthesia has acted, following
methods are used:
• Questioning the patient:
– Does the area feel numb?
– Do you feel any kind of heaviness or tingling?
• Using a sharp explorer for soft-tissue testing. There will
be no mucosal response if anesthesia has acted.
The pulpal anesthesia of the tooth under treatment is
evaluated:
– By application of cold refrigerant (cold test) or
– By using an electric pulp tester.
If profound anesthesia is not achieved after an
initial injection, then supplemental injection is
indicated.
316 Short Textbook of Endodontics
Analgesics
Non-narcotic Analgesics
Nonsteroidal anti-inflammatory drugs: Produce analgesic
and anti-inflammatory effect. Acetaminophen:
• Mechanism: Inhibition of cyclooxygenase (COX)
• Classification:
• Ibuprofen is considered the prototype of contemporary
NSAIDS. It can inhibit both COX 1 and COX 2 enzymes,
so it can be termed as “mixed COX” inhibitor, more so,
that of COX 1 enzyme.
• Blockade of COX 1 can have gastrointestinal adverse
effects such as ulcers. Blockade of COX 2 can have
cardiovascular adverse effects such as thrombotic
events.
• NSAIDs are very effective in managing pain of
inflammatory origin.
• Adverse effects:
– Ceiling effect that limits the maximal level of
analgesia
– GIT side effects
– CNS side effects (Dizziness, headache)
• Contraindications: NSAIDs are contraindicated in
patients with ulcers and aspirin hypersensitivity.
• Drug interaction
NSAIDs interact with number of drugs such as:
– Anticoagulants
– ACE inhibitors
– b-blockers
– Cyclosporine
– Digoxin
• Dosage: Ibuprofen 200 mg, 400 mg, 600 mg.
400 mg and 600 mg doses of ibuprofen produce
greater levels of analgesia.
NSAIDs can be considered as a primary class of
analgesics for treating acute inflammatory pain due to
surgical or nonsurgical procedures.
• Research has found that: Since NSAIDs reduce the levels
of prostaglandins in inflamed tissue, they can increase
the effectiveness of local anesthetics if given 1 hour prior
to anesthetic administration.
Further research is needed on this finding.
• Useful for mild to moderate pain.
• Lesser side effects than aspirin and other NSAIDs.
Acetaminophen can be used in patients for whom
NSAIDs are contraindicated.
• Mechanism of action is unknown.
• Acetaminophen and opioid combination drugs
(Acetamino­p hen 600–650 mg/codeine 60 mg) are
alternative for patients unable to take NSAIDs.
Opioid Analgesics
• They are potent analgesics effective for moderate to
severe pain.
• Mechanism of action: Opioids activate mu receptors that
are located at important sites in brain
↓
Inhibition of transmission of nociceptive signals from
trigeminal nucleus to higher brain centers.
• Opioids are not anti-inflammatory.
• Adverse effects: Nausea, dizziness, drowsiness,
constipation, respiratory depression, tolerance and
dependence with chronic use.
• Due to numerous side effects, opioids are usually
used in combination with other analgesics to manage
Endodontic pain. Opioid analgesics are used in
combination with acetaminophen, aspirin or ibuprofen.
Corticosteroids
• Not routinely used.
• Mechanism : Glucocorticoids reduce the acute
inflammatory response

– by inhibiting the formation of arachidonic acid, and
– by suppressing vas odilatation, migration
of polymorphonuclear (PMN) leukocytes and
phagocytosis
↓ – Appropriate Endodontic procedure along with
Thus, they block the cyclooxygenase (COX) and lipo-
oxygenase (LOX) pathways
↓ Systemically administered antibiotics cannot
Blocking synthesis of prostaglandins and leukotrienes
↓ mechanical debridement of the infected root canal
Pain control
• Steroids have been used in the past as:
– Pulp capping agent
– Intracanal medicament alone or in combination with
antibiotics/antihistaminics
– Systemic administration to decrease pain and
inflam­mation in Endodontic patients
• Steroids have been found to be more effective in pain
from pulpal necrosis with associated radiolucency
compared to pain from irreversible pulpitis because
necrosis with periapical radiolucency has a more
complex chronic inflammatory process.
• Dosage: 6–8 mg of dexamethasone or 40 mg of methyl-
prednisolone can be given by an intraoral IM injection
or an intraosseous injection for the adult patient for
significant post-treatment pain relief.
For Prevention or Elimination of Infection
Antibiotics
Not all Endodontic cases require antibiotics.
• Conditions that require adjunctive antibiotics:
1. a. Cases with show signs of systemic involvement
such as fever, malaise, lymphadenopathy,
trismus, etc.
  Acute alveolar abscess is the condition which
may show such systemic involvement and
will need antibiotic treatment in addition to
debridement of root canal and drainage of any
accumulated purulence.
b. Progressive infections—increased swelling,
cellulitis, osteomyelitis.
c. Persistent infections
2. Prophylactic antibiotics are prescribed in medically
compromised patients to prevent infection.
3. Surgical Endodontics
• Conditions that do not require adjunctive Endodontics:
Most of the infections of Endodontic origin, such
as symptomatic irreversible pulpitis or apical
periodontitis, necrotic teeth with radiolucency or a
Drugs or Medicaments used in Endodontic Treatment 317
draining sinus tract or localized fluctuant swellings,
etc. can be effectively managed without the use
of antibiotics. They can be effectively managed by
analgesics and combination of
– Use of intracanal medicament in few cases and
– Occlusal reduction (Bite relief )
substitute timely Endodontic treatment. Chemo­
system and incision and drainage if there is swelling,
usually begins the healing process in case of a normal
healthy patient. Incision and drainage provides pathway
for removal of inflammatory mediators and helps
prevent further spread of cellulitis.
• Use of antibiotics in Endodontics is controversial in
certain cases due to various reasons such as:
– Overprescribing of antibiotics, in cases where not
indicated can result in bacterial resistance and
patient sensitization.
– Sometimes, severe pain may be from a vital tooth
where bacteria are not a causative factor, where
antibiotics are not needed.
Antibiotics commonly used in dentistry
• Penicillins:
– Effective against both facultative and anaerobic
micro­o rganisms associated with polymicrobial
Endodontic infections.
– Mechanism of action: Inhibition of cell wall synthesis
during multiplication of microorganisms. Exerts
bactericidal action.
– 1g of penicillin VK can be orally administered
followed by 500 mg every 4–6 hours.
– Amoxicillin 1 g—as a loading dose can be very
effective to treat infections followed by 500 mg every
8 hours.
• Clavulanate:
– It causes competitive inhibition of beta-lactamase.
– Clavulanate + amoxicillin (Augmentin) combination
is very useful in Endodontic infections. This
combination is effective in immunocompromised
patients also.
• Erythromycin and other macrolides:
– Mainly used in patients allergic to penicillin
– Not effective against anaerobes associated with
Endodontic infections
– Clarithromycin and azithromycin are other
macrolides with some advantages over erythromycin.
– Dosage: Clarithomycin 250–500 mg every 12 hours
for 6–10 days
318 Short Textbook of Endodontics

Fig. 17.6  A mind-map to remember the drugs used in Endodontics


Azithromycin loading dose: 500 mg followed by
250 mg daily.
– These antimicrobials can block the metabolism of
anticoagulant drugs like warfarin causing serious
bleeding in patients undergoing anticoagulation
therapy.
• Clindamycin:
– Effective against both facultative and strict anaerobic
bacteria associated with Endodontic infections
– Dose is 600 mg loading dose followed by 300 mg
every 6 hours.
• Metronidazole:
– Effective against anaerobic bacteria.
– Can be combined with penicillin to treat severe or
persistent Endodontic infections.
– Patients taking metronidazole should not consume
alcohol during therapy and atleast 3 days afterward
to prevent disulfiram type of reaction.
• Cephalosporins:Usually not indicated for treating
Endodontic infections.
• Doxycycline: May be occasionally prescribed when the
above antibiotics are contraindicated.
• Ciprofloxacin : May be indicated in persistent
infections.
Drugs or Medicaments used in Endodontic Treatment 319
Prophylactic antibiotics are recommended for both non-
surgical and surgical Endodontic procedures in patients
with cardiac conditions who are at risk of developing
bacterial endocarditis.
Intracanal Irrigants and Disinfectants
Such as sodium hypochloride, EDTA, chlorhexidine, etc. are
the agents used during root canal treatment for debridement
and cleansing of infected root canal of all necrotic debris
and for removal of smear layer.
Discussed in detail in Chapter 15: Disinfection of the
Root Canal System.
A mind-map to remember the drugs used in Endodontics
is given in Figure 17.6.
BIBLIOGRAPHY
1. Cohen S, Hargreaves KM. Pathways of Pulp, 9th edn. St. Louis:
Mosby; 2006. pp.597-9, pp.668-90, pp.691-723.
2. Grossman L, Oliet S, Del Rio C. Endodontic Practice, 11th edn.
Varghese publication; 1991.pp.1-18.
3. Ingle J, Bakland L, Baumgartner J. Ingle’s Endodontics, 6th edn.
BC Decker Inc, Hamilton; 2008.pp.690-709.
 18
CHAPTER

Single Visit Endodontics

This chapter tells you about the concept of single visit Endodontics (SVE), which has become quite
popular these days and guides you to the proper case selection for the same.
  You must know
• What is Single Visit Endodontics?
• What is the Rationale for SVE?
• What are the Advantages and Disadvantages of SVE?
• What are the Possible Indications and Contraindications of SVE?
• What are the Factors to be Considered for Case Selection for Doing SVE?
• What has Held Back SVE?

WHAT IS SINGLE VISIT ENDODONTICS? WHAT ARE THE ADVANTAGES AND

DISADVANTAGES OF SVE?
Single visit Endodontics (SVE) means one-appointment
root canal therapy. Advantages
It involves access opening, cleaning, shaping and
disinfection of a root canal system followed by obturation For dentist: 3 Es For patient: 3 Cs
of the root canal at the same appointment. • Efficiency: Immediate familiarity • Comfort: No repeated local
This is not a new concept. It has been reported in with particular patient’s root anesthetic injections, no
canal anatomy, canal shape additional appointment visits
literature over 100 years back. But, there is still ongoing
and contour facilitates effective
controversy among clinicians regarding the merits of a obturation
single-visit or multivisit approach to Endodontic treatment. •  Errors reduced: • Complete treatment in the same
  – Errors in working length due visit: Root canal therapy is
to loss of reference point as a completed in one appointment
WHAT IS THE RATIONALE FOR SVE? result of fracture or occlusal thus eliminating leakage and
• Removal of the normal or inflamed pulp tissue and grinding in case of flare-ups bacterial contamination that
during multiple visits, are could result in mid-treatment
performing cleaning, shaping and obturation of the root reduced flare-ups
canal under aseptic conditions in the same appointment   – Risk of bacterial leakage
should result in successful outcome because of absence beyond temporary coronal
of bacterial contamination. seal in between appointments
eliminated
• Obturation of the well cleaned and shaped root canal
in the same visit completely eliminates the risk of • Economics: Use of lesser • Cost: Reduced cost of treatment
materials and lesser clinical time due to lesser number of visits
microbial contamination as a result of leakage beyond compared to multiple visits of
a temporary coronal seal during the period between same patient, gives economic
patient visits. benefit

Disadvantages
Remember F2D2
Fatigue Flare-up Disinfectant Difficult
• Fatigue:
– Clinician fatigue with extended one-appointment
operating time.
– Patient fatigue: Keeping mouth open for long
duration.
• Flare-ups: If flare-up happens to occur, access is difficult
to the apical canal. It is easier to establish drainage in a
tooth which is not obturated.
• Disinfectant: No opportunity to place an intracanal
medicament such as calcium hydroxide which serves
as a good disinfectant and facilitates healing in case of
multivisit regimen.
• Difficult cases: Difficult Endodontic cases such as the
ones with curved, calcified, very fine or multiple canals
may not be effectively treated in a single visit.
WHAT ARE THE POSSIBLE INDICATIONS AND
CONTRAINDICATIONS OF SVE?
Indications
Remember the sentence:
Patients Requiring Single Visit Endodontic Treatment
Physically Restorative Sedation Vital Esthetic Tract
compromised reason Systemic concern
problem
• Uncomplicated Vital teeth (Most important indication)
• Nonvital teeth with sinus Tract
• Elective/Prophylactic Root Canal Treatment for
Restorative reasons (Intentional RCT)
• Physically compromised patients who cannot come on
multiple visits
• Patients with Systemic problems who require antibiotic
prophylaxis before every visit
• Patients who require Sedation during every visit
• Traumatized anterior teeth where Esthetics is a concern
Contraindications
Single visit Endodontics cannot be performed in:
(Remember P2A2RTS)
• Acute apical Periodontitis with severe pain on
percussion
• Acute Alveolar abscess
• Retreatment cases
• Nonvital teeth with Periapical radiolucencies
Single Visit Endodontics 321
• Anatomic anomalies such as calcified or fine tortuous
canals
• Patients with TMJ disorders who are unable to keep their
mouth open for long duration
• Symptomatic/Painful nonvital teeth and no sinus tract
for drainage.
Thus
• Whenever possible, single visit Endodontic treatment
is desirable for vital teeth for several reasons, including
less post-treatment pain.
• When patient presents with acute symptoms due to pulp
necrosis and acute periradicular abscess, obturation is
delayed until the patient is asymptomatic.
• Difficult cases may require more time for treatment. So,
multiple appointments may be needed to manage those
more uneventfully.
WHAT ARE THE FACTORS TO BE CONSIDERED
FOR CASE SELECTION FOR DOING SVE?
Factors to be considered for case selection for doing SVE
include:
1. Clinician’s skills and speed: Clinician should have the
ability to perform all the steps of root canal treatment
in single visit, in short duration of time without
compromising the quality of treatment.
2. Positive patient acceptance and cooperation: Patient’s
cooperation is needed if all steps of root canal treatment
have to be effectively completed in single visit. In
patients with TMJ problems, limited mouth opening,
gaggers, SVE should be avoided.
3. Difficulty of case: Number of roots, anatomic inter­
ferences like curved, calcified or fine canals should be
considered. Complicated cases may require multiple
visits.
4. Anatomic variations: Additional canals can be present
in the teeth than the usual number. Clinician should
always look for those and not rush to obturate the usual
canals. Teeth with anatomic aberrations are not suitable
for SVE.
5. Status of pulp: Vital or nonvital.
SVE is indicated in uncomplicated vital teeth because
of less chances of flare-ups as compared to nonvital
teeth.
6. Accessibility: Good accessibility and visibility will be
helpful to complete all steps of root canal treatment in
single visit.
7. Time available to complete a case: Sufficient time should
be available with both, the clinician and the patient for
SVE.
322 Short Textbook of Endodontics
Fig. 18.1  Mind-map to remember all factors to be considered for SVE case selection
8. Clinical symptoms: SVE cannot be done in case of acute
symptoms such as severe pain, tenderness, swelling,
continuous hemorrhage or exudation.
9. Periapical pathology: Teeth with acute alveolar abscess
or a chronic apical lesion visible on radiograph should
not be treated in single visit. Multiple appointments with
an intracanal medicament may be needed in such cases.
Figure 18.1 shows a mind-map to remember all
factors to be considered for SVE case selection.
Single visit Endodontics can be a beneficial treatment
modality provided there is:
• Accurate diagnosis
• Careful case selection
• Adherence to standard Endodontic principles
• Clinician’s skill in technique.
WHAT HAS HELD BACK SVE?
The fear of postoperative pain and the fear of failure of
SVE are the reasons why few clinicians prefer multivisit
approach over SVE. Also, lack of adequate time to do SVE
and lack of skills and speed may hold back the clinicians
from doing SVE.
There is still ongoing controversy about SVE regarding
postoperative pain, flare-ups and healing rate after SVE as
compared to multivisit approach.
BIBLIOGRAPHY
1. Grossman L, Oliet S, Del Rio C. Endodontic Practice, 11th edn.
Varghese Publication; 1991.pp.349-50.
2. Ingle J, Bakland L, Baumgartner J. Ingle’s Endodontics 6, 6th edn.
BC Decker Inc, Hamilton; 2008.pp.21-25.
 19
CHAPTER

Endodontic Emergencies
and Midtreatment Flare-ups
This chapter describes in detail the various emergency conditions that may be encountered in
Endodontic practice, so that the clinician can identify them and provide prompt treatment because
prognosis of an emergency procedure depends on:
– Clinician’s ability to do correct diagnosis
– Clinician’s ability to deliver optimal emergency treatment.
  You must know
• What is an Endodontic Emergency?
• What is Meant by the Terms ‘Hot Tooth’ and ‘ERCO’?
• How to make Correct Diagnosis in Case of Endodontic Emergencies?
• How do we Classify Endodontic Emergencies?
• Endodontic Emergencies in Detail
• Endodontic Emergencies before Treatment
• Interappointment Endodontic Emergencies
• Endodontic Emergencies after Treatment

WHAT IS AN ENDODONTIC EMERGENCY?
As the name suggests, Endodontic Emergency is the
occurrence of severe pain or swelling or discomfort
of sudden onset associated with pathosis in pulp and
periradicular tissues (Endodontic) or traumatic injuries,
which should be addressed immediately (Emergency) to
give relief to the patient.
Endodontic Emergency can be defined as the condition
associated with severe pain and/or swelling caused by
pathosis in the pulp or periapical tissues or traumatic
injuries, requiring an unscheduled visit for immediate
diagnosis and treatment.
It has been found that one-third of all dental emergencies
are Endodontic with ‘pain’ as the major symptom in most
of them.
An Endodontic emergency can be an unscheduled
intrusion when the clinician is involved in his routine
practice. As the clinician sees the patient’s discomfort and
apprehension, he may feel tempted to rush through the
diagnosis and provide prompt treatment. However, in no
circumstances, the urgency of the situation precludes a
thorough clinical evaluation of the patient. Reassurance of
the patient is the first step in management of an Endodontic
emergency to control patient anxiety. The clinician must
accurately diagnose the origin of pain or other symptoms,
as quickly as possible and then attempt to provide speedy
and effective relief of symptoms.
After all, for a clinician, effective pain relief builds up
good dental practice and also gives lot of job satisfaction.
WHAT IS MEANT BY THE TERMS
‘HOT TOOTH’ AND ‘ERCO’?
• ‘Hot tooth’ is the term used for the painful tooth and
initial therapy for hot tooth refers to the treatment that
needs to be done to give relief from pain during an
emergency visit.
• The ERCO means emergency root canal opening, that
is initiation of Endodontic treatment immediately to
carry out pulpotomy or pulpectomy and even root canal
preparation in few cases.
Cases requiring an emergency root canal opening
(ERCO):
• Emergency-type pain from an odontogenic origin often
comes-on quickly, i.e. Spontaneous.
(Seldom, something that has been present for several
months).
324 Short Textbook of Endodontics
• A true Endodontic emergency awakens the patient from
sleep. the most important aspect of diagnosis in case of
The patient can be disoriented from lack of sleep or
ingestion of analgesics.
• Pain of odontogenic origin is usually acute in onset and
severe.
Irreversible inflammation of pulp or infection of pulp
that has affected the periapical area
↓ that is referred indicates pulp is the likely source of
Acute periapical periodontitis or abscess
↓ and is well-localized indicates periapical pathology).
Acute pain
• When inflammation spreads to the periodontal ligament
and surrounding osseous structures
↓ – Objective examination: It includes careful extraoral
Pain intensifies and localizes.
Due to higher innervations of proprioceptors in the PDL,
pain is easier to localize.
Often, potent analgesics are not adequate to control
Endodontic pain which can awaken the person from sleep.
Odontogenic pain is eliminated with Endodontic treatment
(root canal treatment) or tooth extraction.
HOW TO MAKE CORRECT DIAGNOSIS IN
CASE OF ENDODONTIC EMERGENCIES?
• Differentiation of ‘emergency’ and ‘urgency’: A true
‘Emergency’ is a condition that requires an unscheduled
visit with diagnosis and treatment. The visit cannot
be rescheduled due to severity of the problem. A true
emergency disrupts patient’s activities, sleep or quality
of life and has rarely been severe for more than few hours
to 1–2 days. Analgesics usually do not relieve the pain
of true emergency. A rule of true emergency is that one
tooth is the offender, which is the source of pain.
‘Urgency’ indicates a less severe problem. So the visit
can be scheduled as per the convenience of the patient
and the dentist.
• System of diagnosis: In the presence of severe pain,
patient may provide information and responses that are
exaggerated and inaccurate. Such patients tend to be
apprehensive and may be confused. Before any treatment
is given, it is important to make correct diagnosis in
order to avoid giving wrong treatment which will further
complicate the problem. So a systematic approach should
be followed which includes obtaining medical and dental
history and careful clinical and radiographic examination
and use of other diagnostic aids.
– Medical history: Presence of any medical problem
and any medications that the patient is taking should
be recorded.
– Dental history: Patient’s last dental visit or any recent
dental treatment should be recorded.
– Subjective examination: Careful questioning is
Endodontic emergencies. Questions relate to onset
of pain, location, intensity, duration, character,
aggravating and relieving factors, etc. Careful
questioning usually provides important information
about the source of pain, whether it is pulpal or
periradicular (Pain elicited by thermal stimuli or pain
pain; pain that occurs on tooth contact or while biting
Subjective examination helps to arrive at a tentative
diagnosis, objective examination and radiographic
findings are used for confirmation.
and intraoral examination of oral soft and hard
tissues. Note the presence of deep carious lesion in
the tooth, any related swelling, defective restorations,
fractures, etc.
- Pulp vitality tests: Thermal tests for reaction to
heat and cold and electric pulp test indicate
the pulp status. To identify the offending tooth,
repeat the tests with the stimulus that patient
reports subjectively. For example, cold test will
reproduce the pain of same type and magnitude
as related by the patient.
- Periradicular tests include palpation over the
apex, digital pressure or light percussion of the
teeth with butt end of mirror handle and selective
biting on an object such as cotton swab or tooth
slooth. Percussion is an important test as it
determines whether inflammation has extended
to the periapical tissues.
- Periodontal examination: Probing helps to
differentiate Endodontic from periodontal disease.
A periodontal abscess can simulate acute apical
abscess. But the important differentiating point
is that the pulp is usually vital in case of localized
periodontal abscess whereas acute apical abscess
is related to an unresponsive (necrotic) pulp.
– Radiographic examination: Although, radiographs
are quite useful in deciding on correct emergency
treatment when minimal time is available to gain
pain relief, but the tendency to rely too much on
radiographs may lead to unfortunate consequences.
Intraoral periapical radiographs and bitewing
radiographs may detect presence of interproximal
and recurrent caries, pulpal exposure, presence
or absence of periapical lesion, thickening of
periodontal ligament, etc.

HOW DO WE CLASSIFY ENDODONTIC EMERGENCIES?
Classification of Endodontic Emergencies
(According to P Carrotte)
Endodontic Emergencies and Midtreatment Flare-ups 325
Weine’s Classification of the Conditions Requiring
Endodontic Emergency Treatment
Pretreatment
• Pulp and periradicular conditions:
– Acute pulpitis
– Acute pulpitis with apical periodontitis
– Pulp necrosis
– Acute periapical abscess
• Dental traumatic injuries:
– Crown fracture without pulp exposure
– Crown fracture with vital pulp exposure
– Crown fracture with necrotic pulp exposure
– Horizontal root fracture
– Avulsed teeth.
Intratreatment
• Apical periodontitis secondary to treatment
• Incomplete removal of pulp tissue
• Recrudescence of chronic apical periodontitis
• Recurrent periapical abscess.
Classification of Endodontic Emergencies
(By Walton and Torabinejad)
326 Short Textbook of Endodontics
Grossman’s Classification of Endodontic
Emergencies
• Acute reversible pulpitis
• Acute irreversible pulpitis
• Acute alveolar abscess
• Emergencies during treatment related to trauma caused
to periapical tissues due to over-instrumentation,
extrusion of irrigants or chemicals beyond apex, over-
filling.
• Traumatic injury causing crown fracture, root fracture,
avulsion.
ENDODONTIC EMERGENCIES IN DETAIL
We will discuss the Endodontic emergencies under the
following categories:
• Pretreatment Endodontic emergencies:
– Related to pathosis of pulp and periradicular tissues
- Acute irreversible pulpitis
- Acute pulpitis with acute apical periodontitis
- Gangrenous necrosis of pulp
- Acute alveolar abscess
– Related to traumatic injuries:
- Crown or root fracture
- Tooth avulsion
• Interappointment emergencies:
– Hyperocclusion
– Pain related to incomplete removal of pulp
– Recrudescence of a chronic apical periodontitis
– Midtreatment flare-ups
– Irrigant-related mishaps—Sodium hypochlorite
accidents
– Tissue emphysema
• Postobturation emergencies:
– Overinstrumentation and overfilling
– Hyperocclusion/high restoration
– Crown or root fracture
– Underfilling.
ENDODONTIC EMERGENCIES BEFORE
TREATMENT
Related to Pathosis of Pulp and
Periradicular Tissues
Acute Irreversible Pulpitis
Signs and Symptoms
• Patient presents with spontaneous pain and exaggerated
response to hot or cold that lingers even after the
stimulus is removed.
• Severe pain that may even affect sleep.
• There may be pain in the tooth on change of position of
head.
• Involved tooth may have extensive restoration or deep
caries.
Causes
• Presence of mediators of inflammation that lower the
threshold of stimulation of intrapulpal nerve fibers
• Dental pulp develops allodynia and hyperalgesia
• Thermal stimulation of A-delta nerve fibers causes
lingering pain, stimulation of unmyelinated C-fibers
causes spontaneous, dull aching pain
• Inflammatory process has progressed and has resulted
in irreversible pulpitis.
Diagnosis
Made by visual and tactile inspection, diagnostic tests:
thermal, electric pulp tests, radiographic examination.
The findings that pain coming from a vital pulp in a
tooth without tenderness to percussion establishes that
inflammation has not involved the periapical tissues.
Radiographically, there is no change from normal in the
periapical tissues. However, radiograph may show some
cause of pulp inflammation such as deep caries, extensive
restoration, etc.
Management
• A tooth with irreversible pulpitis presents as a true
emergency and emergency root canal opening
(ERCO) needs to be carried out to alleviate patient’s
pain. Complete removal of pulp and total cleaning
and shaping of the root canal system is the treatment
of choice for emergency irreversible pulpitis, if time
permits.
But if there are time constraints, then pulpotomy
(total pulp tissue removal) from pulp chamber and
partial pulpectomy from at least the largest root canal
in case of molars (palatal or distal), should be done. This
can also provide pain relief. Root canal treatment can be
completed in the next appointment.
• Relieving occlusion is not indicated in these cases
without periapical involvement.
• Since the irreversibly infamed pulp is still vital and
immunocompetent, with the ability to resist bacterial
infection, antibiotics are not indicated in these cases.
Irreversible Pulpitis with Acute Apical Periodontitis
Signs and Symptoms
• Discomfort to biting or chewing
• Tooth is tender to percussion
 Endodontic Emergencies and Midtreatment Flare-ups 327

• Both pulpal and periapical symptoms as the pulpal
inflammation has spread to periradicular tissues
• Pain is increased by heat (hot stimulus) and relieved by
cold (cold stimulus). In few cases, patient may arrive
in the clinic applying ice to the affected area or sipping
a glass of ice water, saying that cold reduces pain and
removal of cold causes return of symptoms.
• In few cases, there may be sensitivity to both heat and
cold.
Causes
• Inflammation of PDL due to:
– Extension of pulpal pathosis
– Occlusal trauma
– Tissue damage
• Pressure on the tooth gets transmitted to the fluid which
pushes on nerve endings of PDL resulting in pain
• Pressure build up in the PDL may cause elevation of
tooth out of its socket so the pain occurs when tooth
comes in contact with the opposing tooth.
Diagnosis
Pain on percussion is an important diagnostic test.
Inspection, radiographic examination and other diagnostic
tests such as thermal or electric pulp vitality tests confirm
the diagnosis.
Widening of PDL space may be seen on radiograph.
• In between visits, the canals can be medicated with
calcium hydroxide to prevent bacterial regrowth.
• Relieving occlusion reduces postoperative pain in teeth
that exhibited pulp vitality, sensitivity to percussion and
preoperative pain.
• Antibiotics are not needed. Analgesics may be prescribed
to be taken as and when required to relieve pain.
Gangrenous Necrosis of the Pulp
Pulp necrosis is partial or total death of pulp following
inflammation or a traumatic injury in which pulp gets
destroyed before an inflammatory reaction takes place. As a
result, an ischemic infarction can develop which may cause
a dry-gangenous necrotic pulp.
Causes
• Untreated symptomatic or asymptomatic irreversible
pulpitis progresses to necrosis.
• Trauma.
Basically, injury to pulp by noxious stimuli such as
bacterial, traumatic or chemical irritation can lead to
necrosis of pulp.
Types

Management
• Complete extirpation of pulp and thorough cleaning
and shaping of root canals is preferred, if sufficient time
permits. In nonmolar teeth, this is usually possible. But
in case of molar teeth, if time does not permit complete
pulpectomy, then partial pulpectomy from the largest
canal is done.
• Achieving adequate anesthesia is sometimes a problem
in case of acute pulpitis with acute apical periodontitis
due to severe inflammation. More dosage of anesthetic
may be needed. In cases of severely inflamed pulp,
patient may still feel the sensitivity to access preparation,
even after good signs of paresthesia have been obtained.
Patient needs to be reassured and explained that severe
inflammation is preventing the anesthetic to attain full
effectiveness and requested to endure the discomfort Diagnosis
for few more minutes until the anesthetic can be directly • In some patients, there can be slow death of pulp
administered into the inflamed pulp tissue (Intrapulpal without any symptoms. Pulp necrosis rarely causes a
anesthesia under pressure), after which usually no true emergency.
further pain will be experienced. • In few cases, there may be a history of severe pain lasting
• In acute pulpitis with acute apical periodontitis, since from few minutes to few hours, followed by cessation of
the inflamed tissue is present in the apical portion of the pain completely.
root canal, performing only pulpotomy will not provide • Tooth is not sensitive to percussion or may become
relief of pain. mildly sensitive as the infection extends into PDL space.
328 Short Textbook of Endodontics
• Tooth may exhibit hypersensitivity to heat or sometimes
even to the warmth of oral cavity. Such pain is often
relieved by application of cold. This helps in localization
of necrotic tooth.
• Diagnostic tests such as thermal and electric pulp tests:
– No response to cold test
– No response to electric pulp test
– Response may be elicited to prolonged application
of heat due to remnants of pulpal fluid or gases
expanding and extending into periapical region. – It can be exacerbation of chronic periapical lesion.
• Radiographic changes:
– Large carious lesion may be seen.
– Thickening of PDL space or presence of periapical
lesion.
Treatment
• The treatment for pulp necrosis is thorough canal
debridement
• No anesthetic is necessary in most cases.
• Access cavity is prepared, sufficient enlargement of
the canal and heavy irrigation (thorough cleaning and
shaping) is done to remove necrotic pulp tissue.
Acute Alveolar Abscess
Acute alveolar abscess is localized collection of pus in the
alveolar bone at the root apex of a tooth following pulp
necrosis with the extension of the infection through the
apical foramen into the periapical tissue.
Clinical Features
• There may be swelling in the oral mucosa of the involved
tooth.
• The affected tooth may be tender to touch and
percussion and may also be slightly mobile.
• There would be discomfort due to swelling but
generalized pain may be absent.
• In some patients, pain is present before swelling occurs
as the toxic products build up pressure. But once the
bone is perforated, the exudates expand to the soft
tissues and pain may be relieved or lessened.
• Severe local reaction may be associated with general
reaction due to systemic involvement with signs such
as:
– Elevated temperature
– Malaise
– Nausea
– Dizziness
– Symptoms related to continuous pain and lack of
sleep.
Causes
• It indicates breakdown of body’s immune system that
failed to confine the microbes in the root canal system
and resulted in passage of large numbers of bacteria past
the apex causing periapical abscess
• Local collection of purulent exudates
• Such an acute episode may result from:
– Irreversible pulpitis that progressed to pulp necrosis
and extended to periapical tissues
This condition is referred to as Phoenix abscess.
– It may be caused by a combined Endodontic-
Periodontal lesion.
Diagnosis
Diagnosis is based on clinical findings. Radiographic
evidence of bone destruction may or may not be seen as
fluids rapidly spread away from tooth. In case if it occurs as
an acute exacerbation of chronic lesion, periapical lesion
may be seen.
Management
• Administration of local anesthetic may not be needed
since the pulp is necrotic. In fact, local anesthesia is
contraindicated in acutely inflamed tissue with infection
due to:
– Acidic pH
– Chances of dissemination of virulent micro-
organisms.
But to reduce the pain of acute alveolar abscess,
conduction anesthesia (such as inferior alveolar
nerve block in mandible or infraorbital nerve block
in maxilla) can be administered so long as the route
of injection is distant from inflamed area.
• Diagnostic test such as ‘test cavity’ is of value in these
cases as:
– It tests for any remaining vital pulp tissue in the
tooth
– It initiates emergency therapy quickly as the pulp
chamber can be penetrated quickly and painlessly
without any delay.
• Pain may occur during access cavity preparation due to
tooth movement resulting from vibration of rotating bur.
So, the tooth should be stabilized by bracing the tooth
with finger pressure.
• Once the roof of pulp chamber is removed, in many
cases, drainage will occur immediately, with a bloody
and/or purulent exudates discharging through the
access opening.
• Debride the pulp chamber and irrigate profusely.
 Endodontic Emergencies and Midtreatment Flare-ups 329

• Then carry out debridement and cleaning and
shaping of the root canals after correct working length
determination to confine the instruments in the root
canal.
• Antibiotics may be prescribed if indicated. Usually if the
patient is febrile and minimal drainage has occurred,
an antibiotic should be prescribed. But when sufficient
drainage has been established and patient is afebrile,
no antibiotic coverage is needed.
• Analgesics may be taken as and when required.
• The tooth should be slightly disoccluded if it is extruded
from its socket.
completion of apexogenesis. At the intervals of 3 to 6
months, radiographs are taken to evaluate the degree
of apical development.
– In case if the pulp is found to be nonvital and
apical closure has not occurred, then apexification
procedure needs to be done after cessation of acute
symptoms.
• Root fracture: May present as an Endodontic emergency.
Classification

Related to Traumatic Injuries

Sometimes, patients with traumatic injuries to the teeth will
present as a dental emergency which will require immediate
management. Traumatic injuries and their management
has been explained in detail in Chapter 24: Management
of Dental Traumatic Injuries. Emergency Endodontic
treatment may be required as a result of traumatic injury Signs and Symptoms
such as a crown fracture, root fracture, luxation or tooth • Spontaneous dull pain or pain on mastication
avulsion. • Tooth mobility may be present
Emergency treatment in case of traumatic injuries, may • There can be presence of sinus tracts, osseous defects
be complicated due to presence of local edema, bleeding or periodontal type abscesses.
or other consequences of the accident. Also, it is difficult Typical signs of vertical root fracture:
to evaluate the pulpal status using the diagnostic aids as in • Alveolar bone loss buccal to the affected root (J-shaped
most impact injuries, a temporary paresthesia of the nerves bone loss)
to the pulp occurs due to trauma. • Deep osseous defect and a sinus tract located near the
cervical area of the tooth.
Fractured Crown or Root
Cause
• Crown fracture without pulp exposure:
Vertical root fracture (VRF) is commonly associated with
– If only a small portion of Enamel is chipped off,
Endodontically treated teeth.
smoothen the jagged edge (Enameloplasty) to
prevent irritation to the tongue and the lips.
– If a fragment of crown shears off but the pulp is not
exposed: Put a sedative cement dressing and cement
a stainless steel band in place.
– The fractured tooth should be checked with
radiographs and the pulp tests before any extensive
permanent restoration is placed.
• Crown fracture with pulp exposure:
– If a fragment of crown shears off and the pulp is
exposed: A stainless steel band is cemented in place
and Endodontic treatment is performed.
– Before initiating the Endodontic treatment, it is
important to determine the presence or absence of
apical closure using radiograph.
– If the apical closure has not occurred, then pulpotomy
is performed to keep apical pulp tissue unimpeded for
330 Short Textbook of Endodontics
Diagnosis
Diagnosis of root fracture can be challenging.
• Based on clinical signs and radiographic findings.
• An exploratory surgical procedure may be necessary
to visualize the vertical root fracture that can show the
characteristic features:
– Deep osseous defect
– Cervically located sinus tract
– Typical bone loss upon exploratory surgery.
• Radiographically, a ‘hair like’ fracture line may be seen
or there may be evidence of separation of root fragments
seen as a large radiolucency surrounding the bone
between the roots.
Figures 19.1 and 19.2 show radiographs showing
horizontal and vertical root fracture respectively.
Management
For horizontally fractured root:
With vital pulp With nonvital pulp
– Stabilize the – Stabilize the tooth by
tooth by ligation ligation and root canal treatment
– Better prognosis – Prognosis is not as good
for root repair as that of vital pulp
Prognosis in case of horizontally fractured root also
depends on location and direction of fracture:
– If horizontal fracture lies above alveolar crest, it has
excellent prognosis.
– If horizontal fracture lies at mid root level, at or below
the crest of alveolar bone, it has guarded to poor
prognosis
• Vertically fractured root has hopeless prognosis, so
extraction is advised.
Fig. 19.1  Radiograph showing horizontal fracture in Endodontically
treated maxillary right central incisor (Courtesy of Dr Samir Khaire)
Tooth Avulsion
In case of patient who gets an avulsed tooth to the
dentist, the conditions at the emergency visit will have an
important effect on the steps to be taken at subsequent
visits.
The replacement of tooth that has been removed from
the alveolar socket either intentionally or by trauma, is called
Replantation.
Most important parameter that influences emergency
treatment of an avulsed tooth is the duration of time, it has
been out of the socket. The longer the luxated tooth is out of
its socket, the less likely it will remain in a healthy, functional
state after replantation. The sooner the replantation, better
will be the prognosis. Optimally, the extraoral time for an
avulsed tooth should not exceed 30 minutes.
Management
• Replant, ligate and stabilize the tooth in its socket
• Disocclude it
• Take radiograph to verify the position of the tooth in its
socket and to examine if there is any root or alveolar
bone fracture
• Endodontic treatment can be done for it at a later date.
If unable to replant the tooth immediately then it should
be placed in a physiologic storage medium to allow for
an extended extraoral time such as Hank’s Balanced Salt
Solution, milk, saliva, physiologic saline.
Stabilization is required to retain the replanted tooth in
desired relationship until a new periodontal attachment is
initiated using a splint. According to Andreasen, splint can
be removed one week after replantation.
Fig. 19.2  Radiograph showing vertical crown-root fracture involving
enamel, dentin and pulp and extending to the root (Courtesy of Dr
Chetan Shah)

INTERAPPOINTMENT ENDODONTIC
EMERGENCIES
Hyperocclusion
If the temporary filling that was placed after the first visit is
high, i.e. in hyperocclusion, patient will continue to feel the
discomfort and pain till it is relieved.
As the patient reports to the clinic and hyperocclusion
is found to be the cause of pain, the occlusion should be
adjusted. In cases with periapical lesion, further relief
of occlusion to keep the tooth out of contact has been
advocated to eliminate any intra-appointment pain.
In the next visit, the root canal treatment procedure can
be completed. If working length had been determined prior
to relief of occlusion it should be taken again due to change
that occurs as a result of reduction of reference points, i.e.
occlusal cusps.
Pain Related to Incomplete Removal of Pulp Tissue
If during the initial appointment for Endodontic therapy,
pulpotomy or partial pulpectomy was performed, the
patient may experience pain due to incomplete removal
of inflamed pulp tissue. Anesthesia is administered and
thorough cleaning and shaping of root canals is done.
Recrudescence of a Chronic Apical Periodontitis
(Phoenix Abscess)
Most teeth with necrotic pulps and apical lesions which are
asymptomatic, referred to as chronic apical periodontitis,
may become acute after the first Endodontic appointment.
This condition is called as recrudescence or acute
exacerbation of chronic abscess or a phoenix (rebirth)
abscess.
This may occur due to change in the environment
within the root canal. Multiple strains that were harboured
in a particular lesion, few strains may be severely reduced
and few strains may be relatively unaffected. Due to fewer
organisms with which to compete, a virulent strain may then
begin rapid multiplication.
The symptoms of Recrudescence are similar to acute
periapical abscess: mobility, tenderness to percussion and
swelling. Same emergency management as for acute abscess
needs to be done.
Flare-ups in Between Appointments
(Midtreatment Flare-up)
The American Association of Endodontics has defined
Endodontic flare-ups as, “an acute exacerbation of an
Endodontic Emergencies and Midtreatment Flare-ups 331
asymptomatic pulp or periapical pathosis after the initiation
or continuation of root canal treatment”.
Signs and Symptoms
There can be moderate to severe pain with or without
swelling that occurs soon after the effect of anesthesia wears
off following patient’s dental appointment or later.
Causes
Patient-related factors or operator-related factors: Generally
the cause is any kind of mechanical, chemical and/or
microbial injury to the pulp or periapical tissues that is
induced or gets exacerbated during Endodontic treatment.
Microbial induced injury is the major cause of
Endodontic flare-up.
• Patient-related factors:
– Fear and anxiety: High levels of fear and anxiety
concerning the Endodontic procedure causes
the patient to perceive the slightest pressure and
discomfort as ‘pain’.
– Tooth type: More common in mandibular teeth than
maxillary teeth. Mandibular premolars followed by
mandibular incisors have been found to have highest
incidence of flare-ups after cleaning and shaping.
– Age, gender, history of allergy: It has been found that
flare-ups occur commonly in women more than 40
years and in patients with history of allergies.
– Vital v/s necrotic pulp: Necrotic teeth show greater
incidence of flare-ups than the vital teeth.
– Teeth with preoperative apical periodontitis are
associated with increased incidence of midtreatment
flare up.
– History of preoperative pain: These are associated
with increased incidence of flare-ups.
– Retreatment cases: These are usually associated with
a persistent or secondary root canal infection caused
by therapy-resistant microorganisms that may be
more difficult to eradicate in comparison to primary
Endodontic infections.
Retreatment cases have shown significantly higher
incidence of flare-ups than conventional cases.
– Decrease in host-resistance or increased microbial
virulence may allow a previously asymptomatic
tooth to become symptomatic.
• Operator-related factors:
– Overinstrumentation: Errors in working length
determination or failure to follow it, can result in
instrumentation beyond the confines of the root
canal system in the periapical area resulting in
332 Short Textbook of Endodontics

postoperative pain and inflammatory response
due to forcing of infected debris into the periapical
tissues.
– Incomplete debridement:
- If only pulpotomy or partial pulpectomy has
been performed, patient may experience pain
in between appointments due to remaining
inflamed pulp tissue.
- It has also been found that due to incomplete
instrumentation, there is imbalance within
the microbial flora that may allow previously
inhibited virulent species to overgrow resulting in
exacerbation of the lesion. Also, environmental
changes that are induced by incomplete
debridement also have the potential to activate
the virulence genes.
– Overfilling and overextension:
- Overextension of sealer (and its cytotoxic
components), and/or gutta-percha into the
periapical area can cause tissue damage and
inflammation that can result in increased
pain and percussion sensitivity especially
immediately after obturation and may last for
few more days.
– Acute apical periodontitis:
- When obturation is done in a tooth with
significant acute apical periodontitis, there is
more possibility of increased postoperative
pain. So, it is advisable to postpone obturation to
next visit in cases that present with acute apical
periodontitis till the tooth becomes comfortable.
- There is change in the environment of the
root canal due to the Endodontic procedures
that favors the growth of some pathogens in
incompletely instrumented canals predisposing
to flare-ups.
- Due to bacterial interaction and changes in
oxidation-reduction potential, microorganisms
tend to become more virulent and induce higher
concentrations of inflammatory molecules and
cytokines from damaged periapical tissues
causing flare-up. It is found that asymptomatic
infected teeth with periapical pathosis or
asymptomatic retreatment cases, suddenly
develop a flare-up after initiation or continuation
of root canal treatment.
- Preoperative symptomatic teeth already have
pathogens associated with pain or acute
periapical abscess in the root canals. Such
cases are predisposed to flare-ups if incomplete
debridement is done or if there is extrusion of
the infected debris into the periapical area.
Thus,

• Microbial factors associated with flare-ups:

– Microorganisms have been found to be the major
causative agents of flare-ups.
– Microbes act as irritants and induce nonspecific
innate or specific adaptive immune host responses.
– Impaired host resistance and increased microbial
virulence: The response of the host to microbial
challenge depends on virulence factors, number
of pathogens and also the innate and adaptive
immunity of the host. If the immunity of the host
can overcome the microbial challenge, the micro-
organisms will be eliminated. But if it cannot
overcome the microbial challenge, inflammatory Management
response as a result of innate or adaptive immunity Appropriate treatment will depend on the cause. The
occurs. clinician must determine whether flare-up is:
– Mechanism: The microbes in infected root canal are – Primarily iatrogenic in nature (due to overinstrumen­
affected by nutrient supply, bacterial interaction and tation, overfilling, overextension or incomplete
oxidation-reduction potential. debridement, etc.) or

– Microbiologically based (such as in infected necrotic
cases.)
• In case of swelling, drainage needs to be established:
Drainage can be achieved by soft tissue incision and re-
opening the access cavity that may allow purulent and
hemorrhagic exudates to be discharged and reduce the
periapical pressure to cause relief of pain.
Along with establishing drainage, the canals can be
accessed, instrumented and thoroughly irrigated and
then give dressing (seal with temporary filling).
Prescribe antibiotics and anti-inflammatory drugs.
• In case of pain without any associated swelling,
– First establish profound local anesthesia.
– Reopen the access cavity.
– Check for any canals that were missed in previous
appointment that contain inflammatory pulp tissue
and treat it.
– Reconfirm the established working lengths of the
canals.
– Achieve patency to the apical foramen.
– Perform thorough debridement with copious
irrigation and complete the canal cleaning and
shaping procedures.
In case of excruciating pain in the tooth with no
associated swelling, where drainage cannot be achieved,
surgical perforation of the alveolar cortical plate over the
apex of the root called as ‘Trephination’, may be performed
to release the exudates that is causing pain.
• In case of history of acute apical periodontitis: A tooth with
history of acute apical periodontitis, in which occlusal
reduction was not done, that could be the probable
cause of postoperative pain. Occlusal reduction should
be done in such cases to relieve the pain that reduces
the mechanical stimulation of sensitized nociceptors
relieving the pain.
• If flare-up resulted due to overinstrumentation: Relief of
pain is achieved by giving analgesics.
In case of flare-up related to underinstrumentation:
Further instrumentation to the correctly measured
length as well as analgesics can provide pain relief.
• Intracanal medicament: Use of intracanal medicaments
such as calcium hydroxide between visits can reduce the
bacterial count.
Diagnosis
This involves finding the cause of pain and associated
swelling if present.
• Any associated periodontal etiology that was left
undiagnosed in the previous visit, should be looked for.
Endodontic Emergencies and Midtreatment Flare-ups 333
• Look for the adjacent or opposing teeth other than
the  tooth undergoing Endodontic treatment for
any pulpal or periapical pathology causing pain and
swelling.
• Rule out nonodontogenic causes of pain in the area
of tooth undergoing Endodontic treatment by paying
attention to the vague symptoms felt by the patient.
• Review the treatment performed in the previous
appointment and try to find out the exact cause of
Endodontic flare-up.
Prevention
Endodontic flare-ups can be prevented by:
• Elimination of patient’s anxiety and fear concerning
Endodontic procedures by adopting various anxiety
reduction measures discussed in Chapter 17: Drugs or
Medicaments used in Endodontic Treatment.
• Careful and appropriate treatment:
– Accurate determination of working length
– Avoid inadvertent overinstrumentation
– Once you start instrumentation, complete
the cleaning and shaping of the canals in that
appointment itself in order to avoid inflamed pulp
tissue to remain in the canals.
• Relieve occlusion: Especially in cases with acute
apical periodontitis present preoperatively. Relieving
occlusion is found to be a predictable method to prevent
postoperative pain and relief of pain due to acute apical
periodontitis.
• Anti-inflammatory and analgesic drugs: Such as NSAIDs
and acetaminophen given preoperatively have been
found to be effective to reduce postoperative pain.
In cases where there is predictable possibility of flare-
up, patient can be asked to take these drugs immediately
after treatment before the effect of local anesthetic
wears off rather than taking medications after the onset
of pain.
• Use of long-acting local anesthetics: Can provide
analgesia for prolonged period beyond the usual
duration of anesthesia.
Thus they are valuable in providing analgesia during the
immediate postoperative period.
A mind map to remember midtreatment flare-ups is
given is Figure 19.3.
Irrigant-related Mishaps
Sodium hypochlorite accidents can present as Endodontic
emergency. It has been discussed in the next chapter.
334 Short Textbook of Endodontics

Fig. 19.3  A mind-map to remember midtreatment flare-ups

Tissue Emphysema Cause

Tissue emphysema is the collection of gas or air in the body • Air may get entrapped in tissues during periapical
tissues or spaces. surgery if air from air rotor is directed towards the
exposed soft tissues.
Signs and Symptoms • If blast of air through three-way syringe of dental chair
is directed towards open root canals to dry them.
• Rapid swelling that develops in seconds or minutes • As a result of complication of fracture involving facial
• Erythema or redness skeleton.
• “Crepitus” or cracking sound on palpation of affected
tissues, is the pathognomonic sign of tissue emphysema. Differential Diagnosis
• Migration of air into neck region can cause respiratory • Anaphylaxis
difficulty and its progression to the mediastinum can be • Internal hemorrhage
fatal. • Angioedema

Management
• Mostly uneventful as air is gradually absorbed from the
tissues
• Antibiotics can be given to prevent the risk of spread of
infection of involved tissues.
• In case if the condition seems to worsen due to spread
of infection or respiratory obstruction, then immediate
medical attention and hospitalization may be needed.
Prevention
• Avoid using air rotor for surgical procedures
• Avoid the blast of air directed towards the access
openings from three-way syringe of dental chair
ENDODONTIC EMERGENCIES
AFTER TREATMENT
True postobturation emergencies are infrequent. Most of
the times, postobturation pain or some discomfort tend to
occur for first 24 hours or 1–2 days after obturation. It has
been found that there are more chances of postoperative
discomfort when pain was present preoperatively.
The factors that may result in postobturation pain
include:
• Overinstrumentation and overfilling: Overinstrumen­
tation that violates the apical constriction, may result in
an overextended filling. This causes postoperative pain
to the patient. Such pain may subside over a period of
time.
For emergency management of such cases, reassure
the patient. Prescribe analgesics and keep the tooth
under observation.
Endodontic Emergencies and Midtreatment Flare-ups 335
If postobturation pain persists for longer period of
time, then the cause of pain should be investigated. It
may be due to other causes such as:
– Root fracture, or
– Endodontic failure
Persistent symptoms for a longer period may be
considered as Endodontic failure and retreatment may
be indicated.
• Hyperocclusion: After root canal treatment is completed,
the temporary filling or permanent restorative filling
that is done, if it is high in occlusion, it may result in
discomfort or pain while biting. Occlusion should be
adjusted immediately.
• Crown/root fracture: After root canal treatment, the tooth
needs to be protected with a full coverage restoration
as soon as possible otherwise it may fracture under
masticatory load especially if considerable amount
of tooth structure had to be sacrificed due to carious
involvement, while performing Endodontic treatment.
Most cases of root fracture require extraction of the
tooth.
• Underfilling of root canals: Underfilling may cause pain
due to inadequate debridement of the root canals.
BIBLIOGRAPHY
1. Cohen S, Hargreaves KM. Pathways of Pulp, 9th edn. St. Louis:
Mosby; 2006. pp.23-37, 46-55.
2. Franklin S Weine. Endodontic therapy, 6th edn. Mosby-Affliate
of Elsevier, St Louis, Missouri; 2004.pp.72-101.
3. Grossman L, Oliet S, Del Rio C. Endodontic Practice, 11th edn.
Varghese publication; 1991.pp.19-28.
4. Ingle J, Bakland L, Baumgartner J. Ingle’s Endodontics 6, 6th edn.
BC Decker Inc, Hamilton; 2008.pp.700-8.
5. Mithra Hegde’s Textbook of Endodontics, 1st edn. Emmess
Medical publishers; 2009.pp.297.
6. Torabinejad M, Walton RE. Endodontics-Principles and Practice,
4th edn. Saunders-an imprint of Elsevier; 2009.pp.148-60.
 Endodontic Mishaps:

20
CHAPTER

Management and
Prevention

This chapter discusses in detail the various aspects of Endodontic mishaps to guide the clinician to be
careful in performing all Endodontic procedures for a safe and prudent Endodontic practice.
  You must know
• What are Endodontic Mishaps?
• How do we Classify Endodontic Mishaps?
• Endodontic Mishaps in Detail

WHAT ARE ENDODONTIC MISHAPS?

Failure to adhere to the basic principles of root canal

treatment procedure can predispose to various
complications and unwanted situations during treatment
that may lead to Endodontic failure or affect the prognosis
of Endodontic therapy. Such accidents during the procedure
are referred to as Endodontic mishaps. They can also be
called iatrogenic procedural errors or procedural accidents.
Endodontic mishaps can occur during any stage of
Endodontic treatment procedure. Some may be termed as
unfortunate accidents whereas some are a result of dental
negligence. It is important to inform the patient when such
an accidental or negligent error occurs regardless of whether
the error can be corrected in order to prevent a dentolegal Fig. 20.1  Mind-map of what you must know
of each Endodontic mishap
consequence.
Detailed knowledge of the various aspects of Endodontic
mishaps is essential for a safe and prudent Endodontic The best way to handle Endodontic mishaps is to prevent
practice. them from occurring. Prevention is better than cure!!!
About each of the Endodontic mishaps, clinician
must understand: etiology, recognition, consequences, HOW DO WE CLASSIFY ENDODONTIC MISHAPS?
management and prevention. Figure 20.1 shows the
mind-map of what you must know about each Endodontic Classification of Endodontic mishaps is given in
mishap. Flow chart 20.1.

Flow chart 20.1  Classification of Endodontic mishaps
ENDODONTIC MISHAPS IN DETAIL
Errors Related to Improper Diagnosis
Access Opening in a Wrong Tooth
Clinician may make an unreasonable mistake by making
access opening in a wrong tooth, often the tooth adjacent
to the involved tooth. This may occur due to:
• Improper rubber dam placement
• Tooth recorded incorrectly on the referral slip
(Miscommunication of a referral).
• Inaccurate or incomplete review of records, especially
radiographs.
• Radiographs mounted incorrectly
• Lack of concentration.
To avoid such error, clinician must do complete review of
records and correlate clinically and be sure of the involved
tooth requiring treatment. If rubber dam has been placed
by the dentist or staff, steps should be taken to minimize
the risk of isolating the wrong tooth.
Improper Diagnosis Leading to
Unnecessary Endodontic Treatment
• Incorrect diagnosis due to wrong judgement may occur
when clinician finds difficulty localizing the source of
Endodontic pain leading to unnecessary Endodontic
treatment.
• Vital pulps may be sacrificed sometimes in an attempt
to diagnose the source of pain.
Endodontic Mishaps: Management and Prevention 337
To prevent such errors, it is important to make correct
diagnosis through sound knowledge and by using various
diagnostic aids and be sure of the involved tooth requiring
Endodontic treatment.
Errors and Mishaps Related to
Access Cavity Preparation
Errors may occur in access cavity preparation if:
• There is clinician’s lack of understanding of the internal
or external morphology of tooth, or
• The clinician does not follow the access guidelines.
Poor Access Cavity Design
• Inadequate extension: Inadequate mesial or distal
extension may leave the orifices uncovered.
Failure to remove the pulpal roof completely is called
vertical underextension.
• Inadequate opening: Inadequate access opening results
in inadequate instrumentation and obturation and it can
also cause various procedural problems like:
– Coronal discoloration when pulp horns are not
debrided
– Instrument breakage (separation)
– Ledging of canal as demonstrated in Figure 20.2.
– Apical transportation.
• Overextension: Gross overextension of access cavity
preparation will weaken the coronal tooth structure and
338 Short Textbook of Endodontics
hence compromise the final restoration and longevity
of the treated tooth as demonstrated in Figures 20.3A
and B.
• Overzealous tooth removal: Gouging—Improper bur
angulation and failure to recognize the inclination of
Fig. 20.2  Inadequate access opening in maxillary molar causing
ledge formation. Proper extension of the outline form and internal
preparation to the mesial would have avoided this error
A B
Figs 20.3A and B  Overextension of access cavity preparation can
weaken the coronal tooth structure shown by arrows (A) that reduces
the longevity of Endodontically treated tooth and can cause fracture
of the tooth under occlusal forces (B)
tooth can result in overzealous tooth removal referred
to as gouging. This results in weakening and mutilation
of tooth structure predisposing it to fractures.
Perforations
According to American Association of Endodontists,
“Perforation can be defined as the mechanical or
pathological communication between the root canal system
and the external tooth surface.”
Perforations result in communication between the
root canal system and the periodontal tissues, which can
significantly affect the long-term prognosis of a tooth.
Furcation perforation is considered to be the worst
possible outcome in root canal treatment. Figure 20.4 shows
diagrammatic representation of furcation perforation.
Etiology:
• Improper bur angulation
• Failure to recognize inclination of tooth
• Difficulty in accessibility to the tooth due to its location
• Failure to determine the distance between the occlusal
surface and furcation, can result in furcal perforation
• During search for canal orifices
Perforation during access cavity preparation may involve:
• Labial or palatal surface
• Mesial or distal surface
• Furcation of tooth.
Fig. 20.4  Iatrogenic procedural error: Perforation of the furcation
during access cavity preparation
 Endodontic Mishaps: Management and Prevention 339

Types of perforations:
i. Subgingival perforations occur during the access cavity
preparation and the search for canal orifices.
ii. Midroot perforations occur mainly during postspace
preparation or during aggressive cleaning and shaping
the midroot area of the canal.
iii. Apical perforations occurs during instrumentation.
Using large inflexible file in curved canals violates the
apical constriction

Consequences: Untreated perforation has the potential for

secondary periodontal infection.
Perforations weaken the tooth structure.
Coronal one-third perforations threaten the sulcular
attachment and since there is direct communication with
oral flora, it can present as a treatment challenge. Fig. 20.5  Commercially available MTA
(Courtesy of Dr Ritesh Mahashabde at Dr Rajesh Shivhare’s Clinic)
Recognition: When perforation is above the periodontal
attachment, an artificial opening or ‘hole’ in the tooth would
be created that is visible. • Super EBA
• Glass ionomers
When perforation below the periodontal attachment occurs: The MTA is material of choice for perforation repair.
• Sudden appearance of bleeding is the hallmark sign Figure 20.5 shows photograph of commercially available
• There will be pain experienced by the patient as the MTA.
instrument touches the periodontal tissue
• Exposing a radiograph after placing an Endodontic Procedure:
instrument in the opening will help identify the Step 1: Achieve hemostasis and isolate the perforation site:
perforation • Application of pressure with cotton pellet in case of a
• Microscope, paper points, apex locator can be helpful in visible perforation.
recognizing the level, location and extent of perforation. • Placing calcium hydroxide in the root canal for 4–5
minutes and then calcium hydroxide is flushed from
Management: Immediate repair of perforation as soon as it the field using NaOCl.
occurs and is recognized is very important for the tooth to • Use of hemostatics such as collagen, calcium sulfate,
have favorable prognosis. etc.
• Use of a barrier material to produce a dry field and to
An ideal perforation repair material should be: act as matrix which can be:
• Nontoxic
• Antimicrobial
• Capable of providing an adequate seal
• Nonabsorbable
• Easy to handle
• Radiopaque
• Capable of promoting osteogenesis and cementogenesis
• Should be stable and act as a matrix against which the
obturation and restoration can be condensed.

Perforation repair materials:

• Calcium hydroxide
• Mineral trioxide aggregate (MTA).
• Cavit Step 2: Disinfection of perforation site: If the perforation
• Amalgam has just occurred and is clean and hemostasis has been
340 Short Textbook of Endodontics
achieved, repair with the appropriate material is carried
out immediately.
If the perforation is long-standing, the site is first
disinfected and may be prepared with ultrasonic instruments
before receiving the appropriate restorative material.
Step 3: Maintain the patency of canal: The barriers and the
restorative materials used can inadvertently cause canal
blockage during perforation repair procedure, so a paper
point or gutta-percha point or a collagen plug can be placed
in the canal apical to the defect to maintain the patency of
the canal.
Perforation repair: When esthetics is a concern, a calcium
sulfate barrier, in conjunction with composites, glass
ionomers or white MTA can be used.
When esthetics is not an issue, super EBA, amalgam or
MTA can be used.
It should be understood that MTA is material of choice
for perforation repair only when there is no sulcular
communication.
Step 4: Completing the treatment: Wait for the perforation
repair material to set hard. MTA takes about 4–6 hours.
The tooth can then be cleaned, shaped and obturated.
Factors Affecting Prognosis for Healing of Perforation
• Location of perforation in relation to gingival sulcus: If
the perforation site is located near gingival sulcus, there
is potential for periodontal inflammation and loss of
epithelial attachment causing pocket formation, thus
affecting the prognosis.
Perforation located away from gingival sulcus and
healthy periodontium has fair prognosis for healing.
• Size of perforation: Smaller defect has better prognosis
due to ease of attaining proper marginal adaptation,
and well-condensed uncontaminated seal and smaller
contact surface area of restorative material with
periodontium.
• Time elapsed between inception of perforation and seal:
Immediate repair provides favorable prognosis than
delayed repair as further loss of attachment and pocket
formation is prevented.
• Perforation repair material used.
• Clinician’s skills.
Prevention of Perforation
• Understand the external and internal morphology of
tooth.
• Pay careful attention to the three-dimensional spatial
orientation of the tooth by means of:
– Three clear preoperative radiographs: 2 IOPAs and
1 bite wing
– Palpation and periodontal probing of root surfaces
to assess the long-axis of tooth root especially during
access preparation through prosthetic crowns.
• The access cavity preparation bur can be placed on
a preoperative radiograph (IOPA) to estimate the
distance between occlusal surface and furcation and
the approximate depth of pulp chamber.
• Use safe, nonend cutting Endo access burs once
deroofing of pulp chamber has been accomplished.
A mind-map to remember all points of perforations
is given in Figure 20.6.
Errors in Cleaning and Shaping
Incomplete Debridement
Inadequate cleaning and shaping can result in pulp tissue,
debris and bacteria to remain in the root canal system
causing reinfection and thus Endodontic failure. Figure
20.7 shows diagrammatic representation of incomplete
debridement in apical third of the root canal.
• Etiology:
– Anatomic difficulties: Curvatures, calcifications.
– Errors in working length determination or failure
to follow the exact working length (Loss of working
length during instrumentation) due to improper
instrument stops, variation in reference points,
carelessness, etc.
– Missed canals: Failure to locate canals and carry out
their cleaning and shaping will result in pulp tissue
and microorganisms to remain in these canals.
– Inadequate irrigation.
– Due to procedural errors such as ledges and
blockages that prevent complete cleaning and
shaping.
• Prevention
– Pay careful attention to the anatomy of the root canal
system. Take appropriate steps to safely clean and
shape curved canals.
– Combination of methods to determine the correct
working length. Use of apex locators along with
radiographs and use of paper points to determine
the working length.
Confine and use all instruments to the correct
working length by using proper instrument stops and
sound reproducible reference points. Directional
instrument stops should be used and direction of
stop must be constantly observed.

Fig. 20.6  A mind-map to remember perforations
– When using radiographs to verify the instrument
position, consistent radiographic angles should be
maintained.
– Locate and explore all root canals carefully to avoid
missing canals and leaving them untreated.
– Adequate use of irrigants to dissolve pulp tissue and
debris.
– Avoid procedural errors like ledges by following
principles of biomechanical preparation.
Endodontic Mishaps: Management and Prevention 341
Overinstrumentation and Overpreparation
• Etiology and consequence: Error in working length
determination or not following the correct length during
instrumentation and enlarging the canal beyond the
length can violate the delicate apical constriction and
will result in an open apex with the risk of trauma to
periapical tissues, lack of adequate apical seal, risk of
overfilling and postoperative pain and discomfort to the
342 Short Textbook of Endodontics
Fig. 20.7  Incomplete debridement of canal. Apical 1/3rd of canal
left uninstrumented leading to persistence of microorganisms and
debris in RC system
patient. Figure 20.8 shows diagrammatic representation
of overinstrumented canal.
• Recognition: When paper point is inserted in the canal,
hemorrhage is evident at the tip of the paper point.
Loss of tactile resistance of the apical stop.
• Management:
– Nonsurgical: Use of calcium hydroxide or MTA to
create an apical barrier can be tried.
If not possible, then careful obturation of the root
canal to prevent extrusion of filling beyond the apex.
– Surgical: Apicoectomy and retrograde filling
procedure.
• Prevention:
– Confine all instruments within the root canal system
by strictly following the correct working length using
sound reference points and stable instrument stops.
– Confirm the position of apical constriction using
apex locators, paper points and radiographs in order
to avoid violating it.
– When using radiographs to verify the instrument
position, consistent radiographic angles should be
maintained.
Overpreparation refers to excessive removal of root
structure during cleaning and shaping procedure. This
can occur if larger diameter files are used in fine, tortuous
canals. Overpreparation can predispose to stripping or
lateral perforation and weakening of root structure with the
risk of fracture during obturation procedures or later under
masticatory stress.
Fig. 20.8  Overinstrumentation of canal. Over­instrumentation can
cause trauma to periapical tissue, transport of bacteria and debris
into periapical area, lack of adequate apical seal, risk of overfilling
and postendodontic infection
Separated Instruments
Fracture or breakage of instrument in the root canal system
blocking the access to the apical canal terminus is called
instrument separation.
It could be separated stainless steel or Ni-Ti file, a
sectioned silver point, lentulospiral paste fillers, a Peeso or
Gates Glidden drill, a portion of carrier-based obturation,
or any other instrument obstructing the root canal.
Figure 20.9 shows diagrammatic representation of separated
instrument in the apical third of root canal.
• Etiology:
– Improper use:
- Applying too much apical pressure during
instrumentation, especially when using rotary
Ni-Ti files causes increased frictional binding
against the canal walls, overstressing the metal,
resulting in separation.
- Instrumentation in a dry canal causing increased
frictional stresses on an instrument.
- Applying excessive or unnecessary force to the
instrument when there is interference from
access cavity walls due to inadequate access
cavity preparation, there is increased chance of
separation.
- Due to inadequately enlarged preparations,
file has to negotiate more number and severity
of curvatures causing increased stress on
instrument leading to separation.

Fig. 20.9  Separated instrument in the apical
third of root canal
- Dentin shavings and debris incorporated in the
flutes of instrument causes greater frictional
forces and results in separation.
– Overuse: When the instrument has been excessively
used resulting in bending or crimping, use of such
an instrument in the canal leads to its separation.
Such bending may not be evident on nickel-
titanium instruments and they may break without
any warning. Cutting efficiency of Ni-Ti instruments
is reduced by 50% after initial use. Risk of breakage
of Ni-Ti hand and rotary files increases if they are
re-used.
– Manufacturing defect: Defective instrument tips are
more likely to separate during use.
– Anatomy of tooth: Abrupt curvatures or anatomic
ledges, prevents free passage of instrument in the
canal. Clinician may tend to force it and this may
result in file separation.
Figure 20.10 shows the radiograph of Endodontically
treated mandibular second molar with a separated
instrument in the mesial canal.
• Management:
– If instrument separation occurs, first take a
radiograph to confirm separation and to find its
location, size of broken fragment, and whether
removal is possible or not.
– Inform the patient about the accident and preserve
the remaining segment of instrument in a coin
envelope in the patient’s record for medicolegal
purpose.
Endodontic Mishaps: Management and Prevention 343
Fig. 20.10  Radiograph of Endodontically treated mandibular
second molar with a separated instrument in the mesial canal
– The surgical operating microscope increases
visibility by the use of magnification and light
and is a necessary tool for retrieval of separated
instruments.
– Separated instrument removal techniques vary
accord­ing to the location of the instrument in the
canal.
- Removal techniques for separated instrument in
coronal portions of canal:
■ If the instrument is clinically visible in the
coronal access and is loosely fitting in the
canal and can be grasped with an instrument,
a hemostat or Stieglitz pliers can be used to
hold the instrument and extract it out through
access cavity preparation. Sometimes, a slight
counter clockwise action will be required to
unscrew the flutes.
- Removal techniques for separated instrument in
deeper portions of canal:
■ If the instrument is not clinically visible but
appears to be in coronal portions of the canal
on radiograph, first step is to flare the canal
wall along side the instrument to provide
space for subsequent treatment. This can
be done by using hand files, small to large,
coronal to obstruction or with Gates Glidden
drills used in a ‘brushing action’ to create
a uniform tapered shape and maximize
visibility. GG1 and GG2 can be used to the
depth of head of the separated instrument in
344 Short Textbook of Endodontics
the straight portions of the canal. At this stage,
if the separated instrument becomes loose in
the canal, it can be held with a hemostat and
extracted.
■ If the instrument is tightly binding in the
deeper portion of the canal achieve straight-
line coronal radicular access with GG drills
to create a circumferential staging platform
to facilitate ultrasonic use.
When an ultrasonic tip is placed on the
staging platform between the exposed end
of the file and the canal wall and is vibrated
around the obstruction, the separated
instrument is unscrewed and loosened and
jumps out of the canal.
■ But if the separated instrument cannot
be loosened with ultrasonic energy, the
separated fragment can be grabbed and
retrieved using various techniques and
devices such as a microtube system or use of
an end-cutting trephine bur to remove tooth
structure around the separated instrument
Fig. 20.11  Factors for separated instrument removal
and then use an extraction device to retrieve
it.
■ Some of the available extraction devices and
kits for separated instrument removal are:
the Endo Extractor, the Masserann kit and
the Extractor system.
– If the separated instrument lies apical to the canal
curvature and orthograde removal is not possible
and there is persistent disease and separated
instrument cannot be bypassed safely, then apical
surgery or extraction may be necessary.
– If the separation occurred during later stages of
preparation and the preoperative pulp was vital and
noninfected, bypass the instrument and incorporate
it into obturation.
Also, if removal of separated instrument requires
excessive enlargement of canal or has the risk for an
additional iatrogenic mishap such as perforation, then do
not attempt removal, incorporate it into obturation. Observe
the case closely and if symptoms persist, consider apical
surgery or extraction. Figure 20.11 gives the factors affecting
removal of separated instrument.

Prevention
To prevent separation of hand instruments:
• Examine new instruments under magnification to look
for any manufacturing defect such as distorted flutes
or defective tips. Discard the instruments with such
manufacturing defects.
• Careful examination of instruments for deformation
before use and replacement of used instruments with
new ones.
• Smaller size instruments such as #6, #8, #10 k-files are
easily deformed and should be examined after each use
and discarded if distorted.
• Larger size instruments such as #25 and above may be
used number of times if they do not show effects of stress
under magnification.
• Always use the instruments in sequence
• Copious irrigation of root canals
• The instrument can be coated with chelating agent such
as EDTA gel before inserting in the root canal.
• Precurving the instruments in case of curved canals.
• Instruments are subjected to stress and deform more
while preparing difficult canals such as narrow canals,
severely curved canals and S-shaped canals. So,
instruments used for such canals should be discarded
after use.
• Do not force the instruments in the canal.
• Remove the dentinal shavings and debris from the flutes
of the instruments by cleaning them periodically during
instrumentation process.
To prevent separation of rotary instruments:
• Carefully monitor the rotary instrument before use.
Discard the instruments if they show flaws such as shiny
areas, corrosion, bending or crimping.
• Ideally the nickel-titanium rotary instruments should
be discarded after single tooth use.
• Access cavity should be adequately prepared and flared.
• Nickel-titanium rotary instruments should be introduced
in root canals only after the canals have been negotiated
by smaller hand instruments such as number 8, 10, 15
k-files or path files and glide path has been established.
• Do not force the instruments in the canal.
• Never use the instruments in the dry canal. Continual
lubrication of canal with irrigating solutions or
lubricants.
• Follow the rule of irrigation, recapitulation (with smaller
hand instrument such as number 15 k-file) and re-
irrigation in between use of the rotary files.
• Clean the instrument before reinserting into the canal to
remove the debris that is collected between the flutes of
Endodontic Mishaps: Management and Prevention 345
the instrument during use. If the debris is not removed,
it increases the frictional torque between the instrument
and the canal wall, that may lead to its separation in the
root canal.
• Follow the recommended speed and torque for
particular rotary instrument, as per the system and the
portion of root canal where it is used, i.e. coronal two-
thirds or apical one-third, given by the manufacture.
A mind-map to remember all points of instrument
separation is given in Figure 20.12.
Canal Blockage
• Etiology:
– Dentinal debris accumulated due to inadequate
irrigation or lack of recapitulation as shown in Figure
20.13A.
– Blockage caused by separated instrument as shown
in Figure 20.13B.
– Blockage due to old filling materials in cases of re-
treatment.
• Consequences: Blockage prevents access to apical
constriction as the instrument may not reach up to the
established working length, resulting in inadequate
cleaning, shaping and obliteration of the canal if the
obstruction is not removed or by passed.
• Management:
– Irrigate the canal with sodium hypochlorite.
– Lubricate small-sized file with EDTA and try to gently
slide the file to length.
– Do not force or give excessive rotation to instrument
as it may cause instrument separation.
– If the blocked canal cannot be negotiated, and the
tooth is asymptomatic and no lesion of Endodontic
origin is present, the preparation may be finished
to the level of obstruction and obturated. If clinical
symptoms are present, then root canal should
be efficiently treated and obturated and the case
closely followed up for the need of apical surgery or
extraction.
• Prevention:
– Do not instrument in a dry canal. Copious irrigation
with sodium hypochlorite and lubrication of each
instrument with EDTA should be done.
– Do not force the instrument in the canal.
– Recapitulation during instrumentation to maintain
patency of canal.
– Removal of caries, unsupported tooth structure and
restoration and obtaining adequate access cavity
preparation prior to instrumentation.
346 Short Textbook of Endodontics

Fig. 20.12  A mind-map to remember instrument separation

Ledge Formation constriction in an otherwise patent canal as shown in

Figure 20.14.
Ledge is an internal transportation of canal that usually • Other causes of ledge formation:
results due to over-enlarging a curved canal or working – Careless instrumentation
short of full canal length that prevents access to the apical – Use of large instruments out of sequence

A B
Figs 20.13A and B  Iatrogenic procedural error: Canal blockage
leading to improper cleaning and shaping of root canal due to: (A)
Dentinal mud; (B) Separated instrument
– Insertion of instruments short of working length
– Use of straight or inflexible instrument in a curved
root canal
– Poorly designed access cavity that prevents straight
line access to apical third of root canal.
• Recognition of ledge:
– Instrument does not reach the estimated working
length
– On tactile sensation, the instrument does not bind
at the apex but feels loose.
• Management: Ledge typically occurs on the outer wall
of the canal curvature.
– Choose the shortest file to reach working length
lubricated with EDTA and gently slide the file to
length.
– If above is not possible, pre-enlarge the canal above
the stopping point to facilitate moving it to length.
– If obstruction is encountered, use precurved file in
an apically directed, gentle pecking motion.
– Use small-sized instrument lubricated with EDTA
with very short amplitude, light pecking strokes in
order to negotiate the canal terminus.
– When the instrument tip is apical to a ledge, it is
moved in short push-pull motion to reduce the
ledge and to confirm the presence or absence of any
residual internal canal irregularities.
– After the ledge is bypassed, establish patency of the
canal with a #10 K-file. Enlarge up to #20 K-file and
then Ni-Ti instruments can be used to complete the
root canal preparation.
• Prevention:
– Be careful in instrumentation
– Use instruments in correct sequence
Endodontic Mishaps: Management and Prevention 347
Fig. 20.14  Ledge formation in root canal
– Determine correct working length and use
instruments till that length
– Precurve the instruments for use in curved canals
– Adequate access cavity preparation and straight line
access to the apical third of the canals.
Missed Canals
• If the clinician fails to detect a canal, it may be left
untreated and can act as reservoir of tissue debris,
bacteria and other irritants and subsequently result in
Endodontic failure.
• Common sites of missed canals: Several teeth with
predisposition for extra canal, which might be missed,
such as:
– Maxillary premolars may have three canals
– Maxillary first molars usually have four canals
– Mandibular incisors usually have extra canal
– Mandibular premolars often have complex root
anatomy
– Mandibular molars may have extra mesial and/or
distal canal.
• Clinician must use all possible armamentarium to locate
and treat the entire root canal system.
Diagnostic aids for location of root canal orifices include:
– Careful examination of multiple pretreatment
radiographs taken at different angles
– Use of sharp explorer, DG 16 Endodontic explorer to
examine the pulp chamber floor
348 Short Textbook of Endodontics
– Use of ultrasonic tips to detect and explore the
troughing grooves
– Staining the pulp chamber floor with 1% methylene
blue dye
– Visualize the canal bleeding points
– “Champagne bubble” test: When sodium hypochlorite
is allowed to remain in the pulp chamber tiny
bubbles appear in the solution, indicating the
position of orifice. This test is especially useful in
locating calcified root canal orifice (Fig. 13.32).
– If 17% EDTA and 95% ethanol is used sequentially,
it facilitates effective cleaning and drying of pulp
chamber floor for enhanced visual examination.
– Use of magnification aids such as dental operating
microscope, magnifying loupes improves the
clinician’s ability to locate and negotiate canals.
The possibility of location of MB2 canal in
maxillary 1st molar has been found to be: 40% with
naked eye, 60–70% with magnifying loupes, 80–90%
with dental operating microscope
– Distinguishing the color difference of the dentin of
the pulp chamber floor and walls.
– Adequately flared access cavity with diverging walls
increases the visibility for easy location of the root
canal orifices.
Prevention:
i. Good radiographs with proper angulation
ii. Good illumination and magnification
Fig. 20.15  Internal transportation of canal:
a—Elbow; b—Apical zipping
iii. Adequate access cavity preparation
iv. Sound knowledge about the possible anatomic
variations in the root canal system
v. Clinician must always look for an additional canal in
every tooth being treated.
Apical Transportation and Zipping
“Apical canal transportation is moving the position of the
canal’s physiologic terminus to a new iatrogenic location
on the external root surface”.
Internal transportation of canal is called ledge.
“Apical zipping or tearing is transposition of canal in the
apical portion of the canal caused by using progressively
larger and stiffer files to working length”. Commonly seen in
curved canals. It is shown in Figure 20.15. Here instrument
remains within the confines of the root canal, but results in
internal transportation of the canal.
Due to apical transportation, there is reversed apical
shape referred to as elbow preparation, which cannot
provide the resistance form to condense gutta-percha
resulting in vertically overextended but internally underfilled
obturation as shown in Figure 20.16. Here instrument goes
outside the confines of the root canal and results in external
transportation of the canal.
The potential for canal transportation is determined by
cutting ability of file and rigidity of file.
It is important to understand that canal transportation
cannot occur as long as the file is engaged 360 degrees.
Fig. 20.16  External transportation: a—Elbow; b—Apical zipping
 Endodontic Mishaps: Management and Prevention 349

A file which is overused begins to cut on one side resulting
in transportation.
• Filing the lateral wall of the canals with lateral pressure
results in elliptication.
• Cause of elliptication: When less flexible curved
instrument is used in a curved canal it may overcut the
outer surface of curved canal and produces elliptic shape
of apical preparation.
• Elliptical preparation is difficult to obturate.

Apical Perforations
Use of large inflexible files in curved canals can violate the
apical constriction breaking the apical seal referred to as
apical perforation as shown in Figures 20.17 and 20.18.

• Management
– In case of type I canal transportation, attempt should
be made to create a positive apical canal architecture
if sufficient residual dentin can be maintained and
the preparation above the foramen can be corrected
without root weakening or lateral strip perforation.
– In case of type II canal transportation, an attempt
to create a positive apical canal architecture would
increase the risk of root weakening and perforation.
So, the management technique for type II apical
canal transportation is with the use of MTA, Fig. 20.17  Apical perforation
which creates a barrier from the periapical space.
It also helps to control bleeding and provides a
matrix against which the obturation can be safely
condensed without the risk of overextension.
The MTA is the material of choice in these cases
as it induces cementogenesis and is not affected by
presence of slight moisture. It sets hard within 4–6
hours with slight expansion.
– In case of type III apical canal transportation, barrier
technique is not feasible. Corrective apical surgery is
indicated. If it cannot be treated surgically, extraction
is the only alternative.
• Prevention:
– Precurve the files in case of curved canals.
– Avoid using larger and stiffer files to working length
especially in fine curved canals
– Use flexible files.

Elliptication
• Elliptication means cone-shaped preparation with the
middle third of the canal forming the apex or “elbow”
and the cementum surface forming the base of the cone
known as the “zip”
Fig. 20.18  Failure to precurve the apical end of instrument in a
curved canal and excessive apical pressure during instrumentation
caused perforation in the apical portion of the canal
350 Short Textbook of Endodontics
• Etiology:
– Improper shaping procedures
– Attempts to negotiate canal blockages and ledges
can result in perforations in the apical one-third of
root
– Pushing the larger files beyond the working length.
• Consequences: Due to lack of apical matrix, the
obturation material will get grossly overextended if the
apical perforation is not repaired.
Also, without the repair of apical perforation, it is
impossible to achieve a good apical seal to prevent
against further infection.
• Recognition:
– When the paper point is inserted in the canal, the tip
turns red due to bleeding from periapical area.
– If a radiograph is taken with an instrument placed
in the canal, it is found to go beyond the confines of
the root canal system.
– Pain and/or discomfort felt by the patient, when
instrumentation is done beyond the apex.
• Management:
– Nonsurgical:
- MTA is the material of choice for repairing apical
perforations
- Specialized instruments are used to place
MTA in the apical third of root at the site of the
perforation
- A ‘holding file’ is placed in the canal to maintain
its patency
- Radiograph is taken to confirm the position of
MTA
- A moist cotton pellet is placed in the pulp
chamber and closed with temporary filling
- In the next appointment, the holding file is
removed and if MTA apical seal has been
accomplished well, master cone is adapted and
obturation is done.
– Surgical: Few cases with apical perforation may not
show healing with nonsurgical management and will
require apical surgery or extraction.
Stripping or Lateral Perforations
Overinstrumentation with large stiff files in thin curved roots
can result in stripping or lateral perforations on the inside
or concave wall of a curved canal.
• Recognition: Bleeding is the hallmark sign detected on
a paper point inserted in the canal, it turns red.
• Management:
– Nonsurgical: If possible, arrest bleeding and obtain
a dry field, finish the root canal preparation prior to
initiating perforation repair procedure.
Access to midroot perforation is quite difficult
due to limited visibility.
Materials like calcium hydroxide or MTA can
be used to seal the perforation area. In the next
appointment the seal is confirmed and obturation
done.
– Surgical: Some cases may require surgery for repair
of strip perforation.
• Prevention:
– Precurve the instruments in case of curved canals
– Do not use large stiff files in thin curved canals
– Do not do overinstrumentation
– Sometimes files are modified for curved canals by
removing flutes of files at certain areas for safe instru­
mentation in the curvature.
Accidents Related to Irrigation
Sodium Hypochlorite Accidents
Sodium hypochlorite is routinely used for irrigation
during Endodontic treatment. An event in which sodium
hypochlorite is expressed in the periapical area causing
severe discomfort to the patient, is called as sodium
hypochlorite accident.
• Etiology:
– Forceful injection of large volume of sodium hypo­
chlorite with an irrigating needle wedged in the root
canal
– Irrigating solutions are more likely to get expressed
in the periapical area in cases of apical resorption,
immature apex or large apical foramen.
• Recognition:
– Patient may present with severe pain
– Swelling may be associated
– Bleeding and discharge of exudates from root canal
– There may be accompanying symptoms such as
edema, ecchymosis, tissue necrosis, paresthesia
– Signs of secondary infection may also occur
• Management: Reassure the patient
– A regional block can be administered for relief of
severe pain
– Root canals can be flushed with sterile water and
allow drainage to occur
– Antibiotics and analgesics can be prescribed
– Corticosteroids may be prescribed to reduce inflam­
mation
– Patient should be advised to use cold compresses
intermittently for few hours on that day. Next day,
warm water rinses or compresses may be used
– Patient may be referred to a specialist if need be.

• Prevention:
– Irrigating needle should not bind against the root
canal walls.
– Deliver the irrigating solution passively without
exerting any pressure while injecting
– Bend the irrigating needle so that it can easily
penetrate deeper portions of the canal without
binding
– Administer the irrigant dropwise slowly and gently
and not in a rapid projectile motion
– Side-vented needles can be used for irrigation as
shown in Figure 20.19.
– Always hold a sterile gauze sponge around the tooth
to be irrigated to prevent spilling of excess solution in
mouth and it also helps monitor the debris removal
from root canal as shown in Figure 20.20.
Obturation Mishaps
Damage to Neurovascular Structures
Overfill or extrusion of obturation materials due to over
instrumentation or open apex may result in their pathway
to important neurovascular structures that are in close
proximity such as the maxillary sinus, inferior alveolar
nerve and can cause serious injury. This is seen in teeth
being treated that are in close proximity to anatomically
important structures such as maxillary sinus and inferior
alveolar canal.
Fig. 20.19  Side-vented irrigating needle that is fitting loose in root
canal, not binding, is used to deliver the irrigating solution passively
Endodontic Mishaps: Management and Prevention 351
Injury to neurovascular anatomy may result in
paresthesia, neural injury or compartment syndrome.
Increased pressure from inflammatory edema with
resulting ischemia within a limited anatomic space such
as inferior alveolar canal can compromise circulation
and threaten function of tissue within that space. This
is called compartment syndrome. Patient presents with
severe pain and there may be diminished sensation in the
distribution of the nerve within the compartment that is
being compressed.
• Management: Some of the inferior alveolar nerve
injuries may resolve spontaneously within a 6 month
period.
Some cases may require surgical intervention to
remove the overfill.
• Prevention:
– Careful radiographic examination to determine the
risk involved due to close proximity to important
anatomic structures such as: Maxillary sinus, mental
foramen, inferior alveolar nerve.
– Use safe obturation materials. Use of N2 or para­
formaldehyde pastes for obturation that were used
in past, is considered below the standard of care
and should be avoided because they can cause
irreversible sensory nerve damage.
– Accurate working length determination and
confining the instruments within the root canal
system to prevent overinstrumentation.
Fig. 20.20  Sterile gauze sponge held around the tooth to be
irrigated to prevent spilling of excess solution in mouth
352 Short Textbook of Endodontics

– When there is extreme proximity to the neurovascular Leakage

anatomic structure, use of clean dentin plug or
material barrier at the apical terminus may be
considered.
Poor Obturation
Poor obturation is usually a result of previous procedural
errors such as ledge formation, canal blockage, improper
instrumentation of root canal, etc. Due to poor obturation,
there is persistent bacterial infection in the root canal
causing Endodontic failure.
Leakage between root canal and periapical tissue adversely
affects healing and repair. Leakage can be:
• Apical
• Coronal.
Apical seal is achieved by proper instrumentation and
3-dimensional obturation till the apex.
Figure 20.24 shows diagrammatic representation of
improper apical seal that has caused apical microleakage.
Coronal seal is enhanced by sealing the orifices after
obturation with special adhesives and bonded restorations.

An underextended filling means filling that has not

reached the apex. Figure 20.21 shows diagrammatic
representation of underextended root canal filling.
An underfilling means spaces remaining laterally
between the canal walls and the root canal filling and spaces
within the filling called voids.
Figure 20.22 shown diagrammatic representation of
underfilled root canal.
An over extended filling means filling that has extended
beyond the apex. Figure 20.23 shows diagrammatic Fig. 20.22  Underfilled obturation. The white colored area indicates
represen­tation of an overextended root canal filling. voids or space left between the obturation and canal wall

Fig. 20.21  Underextended obturation Fig. 20.23  Overextended obturation


Fig. 20.24  Improper apical seal caused apical microleakage
Fig. 20.25  Improper coronal seal caused coronal microleakage
Figure 20.25 shows diagrammatic representation of
improper coronal seal that has caused coronal microleakage.
Post Related Mishaps
Perforations
Misdirection of post space preparation drills can result in
iatrogenic perforations of middle one-third of roots.
Endodontic Mishaps: Management and Prevention 353
Fig. 20.26  Excessive removal of radicular dentin caused
weakening of root predisposing it to fractures
Bleeding is the hall-mark sign.
Perforation site needs to be sealed. This can be done
non­surgically or surgically.
Various materials have been used for nonsurgical repair
of perforation site such as calcium hydroxide, MTA, glass
ionomer, amalgam, etc.
Weakening of Root Caused by Excessive Removal of
Radicular Dentin during Postspace Preparation
Use of excessively large postdrill for postspace preparation
or larger number peeso drills or Gates Glidden drills in
smaller canals can cause excessive removal of radicular
dentin. This causes weakening of root structure predisposing
it to fractures under stress.
Figure 20.26 demonstrates how excessive removal of
radicular dentin for placing a large post causes weakening
of root predisposing it to fractures.
Mishaps Related to Post Placement
Internal wedging forces occur from large rigid posts or
from use of threaded posts engaging the radicular dentin
that can lead to self-destructive process of cracking and
root fractures.
354 Short Textbook of Endodontics
Miscellaneous
Instrument Aspiration
Accidental swallowing or aspiration of an Endodontic
instrument can occur due to failure to use rubber dam.
Patient is referred immediately to seek medical care,
including radiographic imaging to determine the location
of instrument whether in bronchus or stomach. Appropriate
measures need to be taken to promptly remove it.
• Prevention:
– Use of rubber dam
– Use of floss that can be tied to Endodontic
instruments while in use that helps in easy retrieval
of the instrument if it slips from operator’s hand and
falls into mouth.
Air Emphysema
Compressed air introduced into periapical tissues during
invasive root canal therapy can do great harm. Air can
dissect along fascial planes to produce emphysema causing
impingement on critical anatomic structures and can be
life-threatening.
Compressed air should never be used to dry a root canal
that is open to periapical tissues.
Vertical Root Fractures
Various iatrogenic procedures can predispose to vertical
root fractures. Vertical/Longitudinal root fracture originates
from root apex and propagates to coronal part.
• Etiology: Vertical root fracture (VRF) is commonly
associated with Endodontically treated teeth.
• Recognition: Based on clinical signs and radiographic
findings. An exploratory surgical procedure may be
necessary to visualize the vertical root fracture (VRF)
that can show the characteristic features (Typical signs
of VRF)
– Deep osseous defect
– Cervically located sinus tract
– Alveolar bone loss buccal to the affected root
(J-shaped bone loss)
• Management: VRF has hopeless prognosis, so extraction
is advised.
• Prevention:
– Root canals should be cleaned, shaped and prepared
optimally.
– Excessive removal of radicular dentin during
cleaning and shaping of root canal should be
avoided.
– Generating stresses on the root during lateral
condensation obturation should be avoided. Flexible
Ni-Ti spreaders can be used for lateral condensation
obturation.
– Posts should be carefully selected for restoration of
Endodontically treated teeth. Active threaded posts
should be avoided.
– Nonrigid posts such as fiber posts are preferred over
metal posts due to their modulus of elasticity nearly
similar to dentin. As a result there is reduction of
transfer of forces through the post to the root, thus
protecting the root from fracture (Fiber posts prevent
root split).
Thermal Injury
There is potential for injurious heat transfer to dentin and
bone from the use of different devices such as ultrasonics,
lasers, thermoplasticized obturation systems. There is also
frictional heat generation with the use of engine-driven
drills such as Peeso reamers and postspace preparation
drills.
Care should be taken not to continue ultrasonic vibration
over prolonged time period to prevent injurious heat
transfer.
Safe postremoval techniques to avoid thermal damage
to adjacent periodontal tissues.
Be cautious with heat-generating devices.
BIBLIOGRAPHY
1. Cohen S, Hargreaves KM. Pathways of Pulp, 9th edn. St. Louis:
Mosby; 2006.pp.944-1005, 24-32.
2. Ingle J, Bakland L, Baumgartner J. Ingle’s Endodontics, 6th edn.
BC Decker Inc, Hamilton; 2008.pp.1088-147.
 Restoration of

21
CHAPTER

Endodontically
Treated Teeth

This chapter discusses in detail the various principles involved in the restoration of an Endodontically
treated tooth and describes the restorative materials and clinical procedures for the same.
  You must know
• How are Endodontically Treated Teeth Different?
• What is Expected out of Postobturation Restoration?
• What is Direct ‘Coronal-radicular’ Postobturation Restoration?
• What are the Factors to be Considered for a Postendodontic Restoration?
• What are the Ideal Requirements of a Restorative Material to be used for Postendodontic
Restoration?
• What are the Restorative Options for a Postendodontic Restoration?
• What is Post and Core Restoration?
• What is “Ferrule Effect” and “Biologic Width”?
• What are the Indications for Using Posts?
• What are the Required Clinical Characteristics of Posts?
• What are the Different Types of Posts?
• What are the Clinical Parameters for Post Selection?
• What are the Required Physical Characteristics of the Core?
• What are the Different Types of Core Materials?
• What is the Technique of Fabrication of Foundation Restoration?
• What are the Causes of Failure of Post and Core Restorations?

HOW ARE ENDODONTICALLY • Translucency of tooth is reduced: As a result of loss of

TREATED TEETH DIFFERENT?
Certain structural changes occur in the Endodontically
treated teeth that make them:
• More susceptible to fracture:
– Due to the volume changes and physical changes
that occur in Endodontically treated teeth.
– Weakening caused due to loss of tooth structure is
the main cause.
• Tooth’s function under load gets affected: When
significantly less amount of natural tooth structure
remains, then there are chances of tooth fracture, even
under normal functional forces.
moisture from the dentin, and other physical changes,
the natural translucency of the tooth gets affected.
• Loss of proprioception occurs:
– Root canal treated tooth undergoes changes in the
mechanoreceptive properties.
– There is increase in load perception threshold of
nonvital teeth. As a result, they can take-up twice
the load than vital teeth before actually recognizing
its application. Patient may bite on something hard
without even realizing its hardness and eventually
there is fracture of tooth.
Figure 21.1 shows mind-map of the above
characteristics of Endodontically treated teeth.
356 Short Textbook of Endodontics

Fig. 21.1  Characteristics of Endodontically treated teeth Fig. 21.2  Effect of volume changes on Endodontically treated tooth

Structural Changes that Occur in

Endodontically Treated Teeth

Volume Changes
Due to diminished volume, the Endodontically treated tooth
is weakened (Fig. 21.2).
• There is loss of tooth structure due to caries. Figure 21.3
is a radiograph showing considerable amount of carious
destruction of maxillary second molar tooth.
• Dental procedure causes further loss of tooth structure
– Removal of tooth structure in mesio-occlusodistal
(MOD) preparation may reduce the stiffness by 60%
due to loss of marginal ridge integrity
– Increased depth of cavity renders the cusps more
susceptible to flexure Fig. 21.3  Radiograph showing considerable amount of carious
– Increased width of occlusal isthmus causes further destruction of maxillary second molar (Courtesy of Dr Chetan Shah)
decrease in stiffness
– The structural integrity provided by coronal dentin is
destroyed due to Endodontic access to pulp chamber
causing greater flexion under function load.

Physical Changes
• There are changes in collagen cross-linking.
• There is loss of moisture causing dehydration of dentin.
• The commonly used root canal irrigants and disinfectants
such as sodium hypochlorite (NaOCl), ethylenediamine
tetra-acetic acid (EDTA) and calcium hydroxide interact Fig. 21.4  Effect of physical changes on Endodontically treated tooth
with root dentin.
NaOCl affects the organic substrate causing extensive
fragmentation of collagen (proteolytic action) and Esthetic Changes
EDTA affects the mineral content causing depletion of
calcium and also affect noncollagenous proteins (NCPs) • Pulpal hemorrhage due to trauma or pulp necrosis
resulting in erosion and softening of dentin. causes discoloration of a nonvital tooth.
• Due to altered physical properties of Endodontically • Biochemical alteration of dentin modifies the refraction
treated tooth, there is reduction in its strength and of light causing changed appearance of Endodontically
toughness (Fig. 21.4). treated teeth.

Fig. 21.5  Effect of esthetic changes on Endodontically treated tooth
• Faulty Endodontic technique such as pulp horns not
included in access preparation (underextended access
cavity) or a retained root canal filling in the coronal tooth
structure can cause discoloration of Endodontically
treated teeth.
Figure 21.5 shows the mind-map of the above causes of
change in esthetic appearance of Endodontically treated
tooth.
WHAT IS EXPECTED OUT OF
POSTOBTURATION RESTORATION?
A definitive coronal restoration of an Endodontically treated
tooth is required to provide optimal:
SELF (Mneumonic “SELF”
Remember it as: Restoration of Endodontically
treated tooth should be self-sufficient)
• Coronal Seal
• Esthetics
• Clinical Longevity
• Function.
A Good Postobturation Restoration Must
• Protect the delicate root canal filling from microleakage
of organisms into the root canal system from the oral
cavity by ensuring optimal coronal seal. This improves
the long-term success of Endodontic treatment.
• Restore and/or enhance esthetics.
• Encompass the stress-bearing areas such as the occlusal
cusps in posterior teeth to increase the clinical longevity
of the Endodontically treated teeth.
• Provide occlusal load bearing and restore the tooth to
its full functional value.
Restoration of Endodontically Treated Teeth 357
WHAT IS DIRECT ‘CORONAL-RADICULAR’
POSTOBTURATION RESTORATION?
A direct coronal-radicular restoration for an Endodontically
treated tooth consists of a core that replaces the coronal
tooth structure and extends about 2–3 mm into the coronal
portion of root canals (Cohen’s Pathways of Pulp, 9th edn.).
In this, part of gutta-percha from the canals is removed
by atleast 2 mm and the orifices are then sealed with one of
the following materials:
• Bonded composite resin, especially with flowable
composites.
• Bonded core built-up material.
• Glass ionomer cement (dual cure).
• Mineral trioxide aggregate (MTA) provides good seal
and has antibacterial action also. But it is not favored
as it sets so hard that it may make retreatment difficult
in case it is required due to Endodontic failure.
Sealing the orifices will reduce the chances of leakage in
the canal and, thus, reduce the chances of Endodontic failure.
This is usually done in case of posterior teeth that have
large pulp chambers and multiple canals for retention.
Coronal-radicular restoration is generally indicated
when not much of coronal tooth structure is lost and no
reinforcement with posts is required.
WHAT ARE THE FACTORS TO BE CONSIDERED
FOR A POSTENDODONTIC RESTORATION?
The factors to be considered for a post-Endodontic
restoration are given in Figure 21.6.
A mneumonic to remember these factors is ROPES.
Fig. 21.6  Factors to be considered for a
post-Endodontic restoration
358 Short Textbook of Endodontics
Amount of Remaining Tooth Structure
• This is the most important factor to be considered for
the choice of restoration.
• Longevity of the tooth is affected when there is extensive
loss of sound tooth structure.
• Sound teeth with more than half the tooth structure
intact, may be restored only with coronal restorations,
without the need for posts.
• When the amount of remaining tooth structure is less,
post and core and crown will have to be considered.
• In case of extensively damaged tooth structure,
additional procedure such as periodontal crown
lengthening procedure (CLP) or Orthodontic extrusion
needs to be considered, to expose additional root
structure to allow for a biologic restoration.
Position of Tooth in the Arch and
the Subjected Occlusal Forces
Posterior teeth are constantly under ↓↓
compression load ↑↑
Anterior teeth are under shearing and →←
tensile force Shear
• Intact, nonvital anterior teeth can be restored with
coronal restorations without the need for posts and/or
crowns.
• Nonvital anterior teeth that are extensively damaged
require restoration with a crown, supported and retained
by post and core.
• Posterior teeth are always subjected to occlusal forces
and require cuspal protection against tooth fracture.
• Post and core restoration should be done in posterior
teeth with extensive loss of coronal tooth structure,
followed by a crown.
• Occlusal load increases with parafunctional habits
such as bruxism and such teeth with wear, cracks and
heavy function, need stronger restorative components
to protect against fracture.
• If the position of anterior teeth in the arch is such that
there is deep vertical overlap of maxillary anterior teeth
to mandibular anterior teeth, then the maxillary anterior
teeth are subjected to:
– Horizontal protrusive forces
– Lateral forces.
When such teeth with heavy function lose extensive
amount of tooth structure, then stronger restorative
components have to be used to resist flexion.
Restorative Considerations
• If the Endodontically treated tooth has to serve as
abutment for a fixed bridge, it will be subjected to greater
transverse load than single crowns.
• If the opposing dentition consists of removable partial
denture, then the Endodontically treated tooth will be
subjected to comparatively lesser load.
Such restorative considerations have to be kept
in mind while choosing the optimal post-Endodontic
restoration.
Esthetic Considerations
Restoration for Endodontically treated teeth in the esthetic
zone of the mouth, require special considerations to restore
the natural appearance, such as:
• Management of discolored anterior teeth by means of
bleaching and other methods (discussed in Chapter 23
“Management of Discolored Teeth”).
• Careful selection of esthetic restorative materials such
as tooth colored posts, cores, luting cement and crowns.
• Careful handling of gingiva.
WHAT ARE THE IDEAL REQUIREMENTS OF A
RESTORATIVE MATERIAL TO BE USED FOR
POSTENDODONTIC RESTORATION?
The requirements of a restorative material to be used for
post-Endodontic restoration include:
• It should be biocompatible
• It should provide a good seal of the coronal access cavity
against leakage
• It should be dimensionally stable
• It should possess high compressive strength to provide
protection against fracture
• It should be tooth-colored (esthetic), especially if
it is to be used in anterior teeth with minimal loss
of coronal tooth structure that will not need a full
coverage crown
• It should have a contrasting color to tooth for better
distinction in posterior teeth
• It should be easy to manipulate and should have short
setting time
• It should have ability to bond to the tooth
• It should be nonstaining
• It should be radiopaque.
 Restoration of Endodontically Treated Teeth 359

WHAT ARE THE RESTORATIVE OPTIONS FOR A Structurally Compromised Posterior Tooth
POSTENDODONTIC RESTORATION?
• Posterior tooth requires cuspal protection by means of
Structurally Sound Anterior Tooth onlay restoration, endocrown or a full coverage crown.
Endocrowns combine the post in the canal, the core and
• Anterior teeth need Endodontic treatment most of the the crown in one component. Onlays and Endocrowns
times due to trauma causing loss of vitality or sometimes allow for conservation of remaining tooth structure.
due to caries. Overlays incorporate cusps by covering the missing
• When there is minimal structural damage, restorative tissue.
treatment is limited to sealing the access cavity with • Onlays, overlays and endocrowns are fabricated in
Direct Composite restoration. laboratory from ceramics or hybrid resin composites.
• If discoloration is present, nonvital bleaching procedure Ceramics are a material of choice for indirect restorations.
is done, explained in detail in Chapter 23: Management • When significant amount of tooth structure is lost, post is
of Discolored Teeth. In case of untreatable discoloration needed to increase retention and stabilize and reinforce
with bleaching procedure or relapsing one, conservative the restoration. When the remaining tooth structure is
restorative treatment such as direct or indirect veneers adequate: Remaining walls of height of 3–4 mm from
is done. pulp chamber floor and thickness of 1.5–2 mm, then
post is not needed.
Nonvital Posterior Tooth with Minimal
Loss of Tooth Structure Simple Calculation to Determine Type of
Post-Endodontic Restoration
• Occlusal cavity or mesio-occlusal or disto-occlusal cavity
can be restored with either direct- or indirect-adhesive Anterior Teeth
intracoronal restoration. But the residual walls should
be thick enough (proximal ridges and buccolingual walls →
• Structurally intact + Access Restore the access
more than 1.5 mm thickness) tooth preparation opening with
• Depending on the functional and occlusal environment, composite resin
conservative restorative options should be considered. • Proximal cavity on + Access → Esthetically restore the
For example, in the presence of bruxism or steep one side (mesial or preparation proximal cavity and
occlusal anatomy, full coverage restoration (crown) is distal) seal the access opening
with composite resin
mandatory.
• Proximal cavity on + Access → Restore the proximal
both sides (Mesial preparation cavities and protect
Structurally Compromised Anterior Tooth and Distal) the tooth with a full
coverage crown
• Anterior tooth with significant loss of tooth structure Or
needs protection with a full coverage restoration Esthetic post and core
(crown), supported and retained by a core and possibly restoration followed by
post also. “Post and core” is explained in detail later in full coverage crown
this chapter. • Proximal cavity on + Labial + → Esthetic post and core
one or both sides Access restoration followed by
• When more than half of the coronal structure is lost
(Mesial/distal) and/or a full coverage crown
or when the remaining walls are extremely thin (less preparation
than 1  mm), a post is needed to increase retention and
stabilize and reinforce the foundation.
• Nonmetal esthetic posts such as ceramic or resin- Posterior Teeth
reinforced need to be done. Adhesion is the preferred Cuspal coverage is needed for all posterior teeth to prevent
mode of post cementation. fracture.
360 Short Textbook of Endodontics

• When all the axial walls of the → Coronal restoration 3. More than 2/3rds coronal structure lost, reduced wall
cavity are intact and have thickness followed by onlay height – Composite core + metal post or Amalgam core
greater than 1 mm restoration or full + metal post
coverage crown
Tooth preparation guidelines: Maintain all residual
• When there is one proximal cavity → Strong coronal restoration structures > 1 mm thickness (after core prep).
(Mesio-occlusal or Disto-occlusal) followed by full coverage
or two proximal cavities (MOD) but crown 4. More than ¾ coronal structure lost – Cast gold post and
the remaining three axial walls or core (+/- porcelain)
two axial walls are intact and have Tooth preparation guidelines: Maintain all residual
thickness greater than 1 mm structures > 1 mm thickness (after core prep) Internal
• When there are two proximal → Post and core restoration walls divergent.
cavities (MOD) and one labial/ followed by full coverage
lingual cavity and only one axial crown
wall remaining intact WHAT IS POST AND CORE RESTORATION?
• When both proximal axial walls → Post and core restoration
(Mesial and distal) and both labial followed by full coverage Post and core restoration is a foundation restoration that
and lingual axial walls have been crown supports the coronal restoration (full coverage crown) in an
destroyed and its a decoronated extensively damaged Endodontically treated tooth.
tooth with no axial walls remaining

Definition of ‘Post’ as given in Cohen’s
Pathways of Pulp (9th Edn.)
Clinical Protocols for Restoring Nonvital Teeth
“Post is a restorative dental material placed in the root of a
with Partial Restorations (Most likely Procedures)
structurally damaged tooth in which additional retention is
(Cohen’s Pathways of Pulp, 10th Edn.) needed for the core and coronal restoration”.
The post is either bonded or cemented into the root of
1. Minimal tissue loss—Composite restoration the tooth and part of the post extends coronally to anchor
2. Limited tissue loss in anterior tooth with minimal to the core.
moderate discoloration only—Veneer
Tooth preparation guideline: > 1 mm buccal reduction, Definition of ‘Core’ as given in Cohen’s
lingual enamel present.
Pathways of Pulp (9th Edn.)
3. Thin remaining walls—Overlay (Composite/Ceramics)
Tooth preparation guideline: Minimum 2 mm occlusal “Core is a restorative material placed in the coronal area of
reduction. the tooth that replaces carious, fractured or missing coronal
4. Loss of occlusal anatomy—Endocrown (Composite/ structure and retains the final restoration”.
Ceramics) The core is anchored to the tooth either by its extension
Tooth preparation guideline: Minimum 2 mm occlusal into the coronal aspect of the root canal or by means of an
reduction, extension into pulpal chamber. Endodontic post.
Post and core are fabricated of different materials. So,
Clinical Protocols for Restoring Nonvital Teeth the bond between the tooth, post and core is mechanical
retention by means of luting or bonding agents.
with Full Prosthetic Restorations (As given in
The post and the core, along with the luting or bonding
Cohen’s Pathways of Pulp, 10th Edn.) agents to retain them, together form the foundation
restoration.
1. Reduced walls but > ½ Crown height—Composite core The specific design of the foundation restoration varies
Tooth preparation guidelines: Maintain all residual with the relative clinical need for each of the individual
structures > 1 mm thickness (after core prep). components.
2. More than ½ coronal structure lost, reduced wall height The tooth, the post, the core, the bonding or luting
- Composite core + Ceramic post or Composite core + agents and the coronal restoration together form a monobloc
in vitro fiber post (unified whole). Appropriate selection of each of the
Tooth preparation guidelines: Maintain all residual components is essential for the clinical success of the fully
structures > 1 mm thickness (after core prep). restored tooth.

Basic Components of the Fully Restored Tooth
The basic components of the fully restored tooth include:
• Remaining coronal and radicular tooth structure
(Fig. 21.7d).
• Restorative material in the root: post (Fig. 21.7c).
• Restorative material in the pulp chamber and the
coronal area replacing the missing tooth structure: core
(Fig. 21.7b).
• Restoration to protect the tooth and to restore the
function and esthetics: Coronal restoration/crown
(Fig. 21.7a).
• Adhesive component to join each of the above
components: Bonding or luting agents.
The residual root and its attachment mechanism
(supporting periodontium) must be preserved by Endodontic
therapy followed by appropriate restorative treatment.
WHAT IS “FERRULE EFFECT” AND
“BIOLOGIC WIDTH”?
Ferrule Effect
“The ferrule is a band of metal that encircles the tooth and
greatly increases its resistance to fracture”.
Ferrule is a protective ring which encircles the tooth.
Restoration encirclement of tooth with a ferrule will protect
Fig. 21.7  a—Final coronal restoration (Crown); b—The core; c—The
post; d—Remaining tooth structure; e—Apical seal preserved with
3–5 mm of gutta-percha
Restoration of Endodontically Treated Teeth 361
Endodontically treated tooth against fracture by bringing
about proper transmission of forces.
Figure 21.8 a shows the diagrammatic representation of
ferrule.
• The ferrule must:
– Be atleast 1.5–2 mm in height
– Have parallel axial walls
– Completely encircle the tooth (360o)
– End on sound tooth structure and not on the
restoration
– Not invade the attachment apparatus.
• Functions of ferrule:
– Dissipates the force that concentrates at the
narrowest circumference of tooth
– Resists lateral forces from posts and leverage from
crown in function
– Increases resistance and retention of the restoration
– Reduces the incidence of fracture in a nonvital tooth
by reinforcing the tooth at its external surface.
• Whenever there is loss of coronal tooth structure till the
level of gingival margin and an effective ferrule cannot
be given, then there is chance of fracture of tooth or early
failure of restoration.
In such cases, it is recommended to expose tooth
surface by surgical crown lengthening procedure (CLP) or
by Orthodontic extrusion to prepare the ferrule.
Biologic Width
“The dimension of the junctional epithelial and connective
tissue attachment to the root above the alveolar crest is called
biologic width”.
Figure 21.8b shows the diagrammatic representation of
biologic width.
In order to preserve the biologic width, the margin of
the crown preparation should be about 2.5–3 mm away
from the alveolar crest.
Violation of biologic width during crown preparation
↓
Unexpected and uncontrolled bone loss around the tooth.
Ferrule Effect and Biologic Width: Implication
Ferrule of 1.5–2 mm above the margin of crown preparation
(Ferrule effect).
The margin of crown preparation about 2.5–3 mm above
the alveolar crest (Biologic width).
Thus, Ferrule effect + Biologic width = 4–5 mm of
minimum tooth structure should be remaining above the
alveolar crest for a successful restoration.
362 Short Textbook of Endodontics
Fig. 21.8  a—Ferrule effect; b—Biologic width
WHAT ARE THE INDICATIONS FOR
USING POSTS?
Indications
1. Extensive loss of coronal tooth structure where
subsequent core built-up cannot be easily retained by
the existing walls of the tooth.
2. When more than 50% of coronal tooth substance is lost
or less than 2/3rds of sound tooth structure remains and
the displacement forces will dislodge the restoration.
3. When adjacent surface axial walls of the tooth are lost.
For example, buccal and distal axial wall or buccal and
mesial axial wall in case of a molar.
4. When no axial wall of the coronal part of the tooth
remains, i.e. decoronated tooth.
Few Facts About ‘Posts’ to
Eliminate Misconceptions
• Posts do not strengthen the tooth or prevent fracture
(Strength of the tooth is related directly to the bulk of
remaining dentin and the surrounding alveolar bone).
• Posts may actually weaken the tooth, as the central core
of dentin is removed and root is made hollow for post
space preparation.
• All Endodontically treated teeth do not need posts
(Extensive loss of coronal tooth structure is indication).
• Post is mainly used to retain the core by the existing tooth
structure, i.e. to anchor the post-core complex within
radicular portion.
WHAT ARE THE REQUIRED CLINICAL
CHARACTERISTICS OF POSTS?
An ‘Ideal’ post should have combination of RFSS →
Resilience
Flexibility
Strength
Stiffness
+
Esthetics (when it has to be used for anterior teeth).
Required Clinical Characteristics
1. Posts should provide maximal retention within the root
2. Posts should provide maximal retention of the core and
the crown
3. Posts should provide protection of root from fracture
4. Posts should provide protection of apical seal from
bacterial contamination caused by coronal leakage
5. Posts should be easy to remove (retrievability)
6. Posts should provide light transmission and pleasing
esthetics, when indicated
7. Posts should be biocompatible
8. Posts should be radiopaque
9. Posts should have fatigue resistance
10. Posts should have high strength.
WHAT ARE THE DIFFERENT TYPES OF POSTS?
Classification of Post Systems
• According to the material of which posts are made:
 Restoration of Endodontically Treated Teeth 363

• According to the method of their fabrication: Post Systems in Detail

Rigid Posts
Esthetic: Zirconia posts:
• Zirconia post is an all-ceramic post, composed of
zirconium oxide (ZrO2)
• Advantages: Esthetic
– Extremely radiopaque
– High flexural strength
– High fracture toughness
– Excellent resistance to corrosion
• According to mode of use: – Very rigid (stiffest of all rigid posts)
• Disadvantages:
– Brittle
– Cannot be cut or removed from the canal if
Endodontic retreatment has to be done
– Have poor resin bonding. Failure at cement/post
interface can occur due to poor bond strength of the
resin composite cement to zirconia posts
– If zirconia posts fracture, since they are not
retrievable from the roots, they will render the roots
unrestorable.
• Zirconia posts are available with a smooth surface
configuration with no grooves or serrations or roughness.

Active posts are no longer used. Nonesthetic

• These include metallic posts composed of crown
• According to their shapes: and bridge alloys, stainless steel or titanium-titanium
alloy.
Figure 21.9 shows photograph of commercially available
preformed metal posts of different sizes.

• According to their design:

Fig. 21.9  Commercially available preformed metal posts in a box

(Courtesy of Mr Amar, Dr Dabholkar’s clinic)
364 Short Textbook of Endodontics
Figure 21.10 shows photograph of preformed metal posts
along with their corresponding postspace preparation drills.
• Advantages:
– Rigid: Made of stiffer materials which do not fracture
or bend easily
– Radiopaque
– Dissipate functional forces along the length of root
and the periodontal structures. This is an important
consideration when there is minimal remaining
tooth structure for crown margins.
– Cervical stiffening is provided that protects the crown
margins and resists leakage.
• Disadvantages:
– Failure of metal posts can cause root fracture
(Induces root split)
– Stainless steel posts contain nickel, an allergen, that
can leach out through dentinal tubules into the tissue
– Corrosion of stainless steel posts
– Nonesthetic.
Nonrigid Posts
They are composed of glass, quartz or carbon fibers
embedded in a resin matrix.
These are fiber-reinforced resin-based composite posts
which are used with bonded resin-based composite core
built-ups.
In modern dentistry, these nonrigid posts have become
quite popular.
Fig. 21.10  Preformed metal posts along with their corresponding
postspace preparation drills (Courtesy of Dr Chetan Shah)
Studies have shown that nonrigid posts tend to exhibit
fewer catastrophic irreversible root fracture.
Data indicates that nonrigid fiber posts are acceptable
alternatives to metallic posts and can be used clinically
wherever metal posts have been used.
Advantages of Nonrigid Posts
• Designed to have physical properties similar to dentin
Modulus of elasticity of dentin: 18 GPa
Modulus of elasticiy of fiberposts: 17–25 GPa.
The primary benefit of lower modulus of elasticity is
protection of root from fracture (fiber posts prevent root
split) through reduction of transfer of forces through the
post to the root.
• Fiber-posts are resilient posts that flex with the tooth
under function, thus reducing the transfer of force to
the root and reducing the risk of root fracture.
• They are easily retrievable if Endodontic retreatment
has to be done.
• Light transmitting posts and bonded composite provide
increased fracture resistance by reinforcing weakened
roots.
• Fiber posts do not cause any stress concentration.
• Fiber posts are safer.
In case of failure of fiber posts, fracture of post occurs,
which can be removed and replaced, rather than fracture
of the root.
• No corrosion.
• Good esthetics with quartz and glass fiber-reinforced
posts.
• High tensile strength.
• High fatigue strength.
• Glass fiber posts can transmit curing light to internal area
of root. So, dual-cure adhesive cements can be used.
• Fiber posts are adhesively bonded in the root and
composite fiber post with composite resin core. All this
gives good bond between individual components of
monoblock.
Disadvantages of Nonrigid Posts
• Little to moderate radiopacity may be difficult to
visualize on radiographs.
• In case of structurally compromised teeth, there is lack
of cervical stiffness from dentin. Excessive post flexion
in such teeth may be detrimental to marginal seal.
• Primary mode of failure of nonrigid posts is decementation
of post from root.

Types of Nonrigid Posts
1. Glass fiber-reinforced epoxy resin posts: Composed of
Glass or silica fibers. Glass fibers can be made of different
types of glasses such as high-strength, electrical glass,
or quartz fibers.
Glass fibers in the matrix increase the strength of
the post. Glass fiber-reinforced posts have high fatigue
strength, high tensile strength and modulus of elasticity
closer to dentin.
Contact of glass fiber reinforced posts with oral fluids
reduces their flexural strength.
Figure 21.11 shows photograph of commercially
available packet of glass fiber posts.
2. Polyethylene fiber-reinforced posts: Composed of
ultrahigh molecular weight polyethylene woven fiber
ribbon.
This polyethylene woven fiber ribbon is coated with a
dentin bonding agent and packed into the canal, where
it is then light polymerized in position.
These posts protect the remaining tooth structure.
This is because for these posts, the root canals are not
enlarged, the undercuts present in the root canal are not
removed and 1.5–2 mm crown ferrule is formed.
3. Carbon fiber-reinforced epoxy resin posts: Composed of
unidirectional carbon fibers parallel to the long-axis of
the post in an epoxy resin matrix.
These posts have high fatigue strength, high tensile
strength and modulus of elasticity similar to dentin.
Fig. 21.11  Commercially available pack of
glass fiber posts (Courtesy of Dr Chetan Shah)
Restoration of Endodontically Treated Teeth 365
Available as smooth or serrated posts.
Contact of these posts with oral fluids reduces their
flexural strength.
When the tooth is structurally compromised, the
carbon fiber reinforced post may flex under functional
load causing micromovement of the entire core.
WHAT ARE THE CLINICAL PARAMETERS
FOR POST SELECTION?
While selection of post or while preparation of post space
or while using post, one key guiding principle that should
be kept in mind is preservation/conservation of remaining
tooth structure.
Traditionally, the metal (rigid) posts have been widely
used. Earlier, the choice of whether rigid or nonrigid posts
should be used, was based on two considerations:
1. The amount of remaining tooth structure.
2. The anticipated forces in each clinical circumstance.
Amount of Remaining Tooth Structure
Based on this, a simple rule that was followed is:
• Teeth with more than 50% of tooth structure remaining:
Post not needed
• Teeth with 25–50% of tooth structure remaining: Use
nonrigid post
• Teeth with less than 3–4 mm of vertical height or when
less than 25% of tooth structure is remaining: Use rigid
post.
But, now-a-days, use of Rigid posts has declined because
of its potential to cause root fracture. In almost all clinical
situations requiring posts, one of the nonrigid posts is
preferred.
Anticipated Forces in a Given
Clinical Circumstance
• Occlusal forces are transmitted through the core and the
post and ultimately distributed along the length of the
root.
The more, the posts, cements and restorative
materials will behave like dentin, the less, the force will
be concentrated between the component and the root
during function.
Types of post Stress concentration
•  Stainless steel Increased stress concentration
•  Titanium Less stress concentration
•  Fiber posts No stress concentration
• The posts and their associated core/crown complex tend
to undergo repeated lateral forces during function.
366 Short Textbook of Endodontics
• Biting and parafunctional habits such as clenching or
Bruxism transmit nonaxial shear, tensile and compressive
forces to a post in the root.
In case of structurally weak teeth, force concentration
in the root can predispose the root to fracture.
With very little amount of tooth structure remaining,
and minimal or no crown ferrule to resist force, more force
will get transferred to the post. Post flexure of nonrigid posts
under occlusal loads may result in micromovement of the
core that causes disruption of the cement seal and leakage
or may result in loss of the core and the crown.
Clinical Parameters for Post Space
Preparation and Post Selection
Apical Seal
It has been found that atleast 5 mm of gutta-percha is
required for an adequate apical seal. If less than this is left
behind, there are high chances of leakage.
The integrity of apical seal is proportional to the amount
of Endodontic filling material. Original full length root canal
fillings have a superior seal compared with 3, 4, 5 or 7 mm
of apical gutta-percha.
Post Space
The residual dentin of the root canal should undergo
minimal alteration to accept the post. Preparation of post
space should not enlarge the root canal at the expense of
dentin.
At least 1 mm of tooth structure must remain
circumferentially around the post to prevent perforation
and provide fracture resistance.
Root Selection for Post Placement in Multirooted Teeth
• Premolars: Posts are placed in
– Palatal root of maxillary premolar
– Straightest root of mandibular premolar.
It is found that in case of maxillary premolars, if
1–2  mm of preparation is done in the buccal root, it
serves as an antirotational lock.
• Molars: Posts are placed in
– Palatal roots of maxillary molars
– Distal roots of mandibular molars.
In distal roots of mandibular molars, the post space
drills larger than size #3 GG drill should not be used.
Root Anatomy
• Root concavities should be considered.
Maxillary first premolars have deep mesial concavities.
Maxillary first molars have deep concavities on the furcal
surface.
• Root curvatures should be considered.
Generally, root curvatures occur in the apical 5 mm
of the root. Therefore, when 5 mm of gutta-percha is
retained apically, the curved portions of the root are
usually avoided. In case of greater curvature, limit the
post length so as to preserve dentin, thereby preventing
root fracture or perforation.
• Root canal shape: Maxillary premolars and mesial roots
of mandibular molars have elliptical or ribbon shaped
canals and post space preparation should be avoided in
those.
Post Size/Length and Post Diameter
• Post length:
– Post should be long enough to satisfy clinical
requirements while maintaining the root integrity
and the apical seal.
– Recommendations for post length:
- Post length equal to or greater than the
crown length (incisocervical/occlusocervical
dimension) of the tooth is recommended.
- Generally, apical seal dictates the post length.
Retaining atleast 5 mm of apical gutta-percha
and extending the post to the gutta-percha.
- In case of teeth with long roots, post of
approximately 3/4th the length of the root, while
maintaining the apical seal, can be considered.
- Alveolar bone height also influences the post
length.
Occlusal forces generate the least risk to the
remaining tooth structure when post extends
atleast 4 mm apical to the alveolar crest.
- In case of molars, the post should not extend
more than 7 mm apical to the root canal orifice.
– Studies show that:
- When post length is equal or greater than the
length of the crown, the success rate has been
found to be 95–100%.

- When post length is shorter, then the success
rate has been found to be the same as for the
restoration without the post in such teeth.
– Problems with very long posts:
– Problems with very short posts:
- Causes transfer of forces to unsupported root,
extending above the alveolus. This can result in
root fracture.
- Short posts are less retentive. Loosening of post
causing restoration failure can occur.
• Post diameter:
– Diameter of the post should be the minimum
dimension to withstand functional loading.
– Recommendations for post diameter:
- Preserve radicular dentin. The post space
preparation drills should be related in size to root
dimensions to avoid excessive post diameters
that can lead to root perforation.
- Permit tooth to resist fracture. At least 1 mm of
tooth structure must remain circumferentially
around the post.
- Post diameters should not exceed one-third of
root diameter in any location. Safe diameters for
post space preparation drills are:
i. 0.6–0.7 mm for smaller teeth such as
mandibular incisors.
ii. 1–1.2 mm for larger diameter roots such as
maxillary central incisors.
A mind-map to remember clinical parameters for
postspace preparation and post selection is given in
Figure 21.12.
WHAT ARE THE REQUIRED PHYSICAL
CHARACTERISTICS OF THE CORE?
(Remember the alphabetic formula: ABCDE ST)
• The core material should have an Ability to bond to
both—the tooth and the post
• Biocompatibility
Restoration of Endodontically Treated Teeth 367
• High Compressive strength, Contrasting Color to tooth
for better distinction in posterior teeth
• Dimensional stability
• Ease of manipulation, Esthetics (for anterior core built-
up)
• Short Setting time.
WHAT ARE THE DIFFERENT TYPES
OF CORE MATERIALS?
Metallic Core Materials
• Amalgam core
– Advantages:
- High compressive and tensile strength
- High modulus of elasticity
- Easy manipulation and short setting time
- Highly retentive when used as coronal-radicular
restorations or with preformed metal post in
posterior teeth
- Improved seal with bonded amalgam procedures
at tooth-alloy junction
– Disadvantages:
- Corrosive
- Discoloration of gingiva or remaining dentin
- Safety and environment issues.
• Cast core:
– Advantages:
- Cast core is an integral extension of post
- Does not depend on mechanical means of
retention
- So, no chances of dislodgement of core and
crown from post and root, even when the amount
of tooth structure remaining is minimal
- Noble metals used in cast core are noncorrosive.
– Disadvantages:
- Increased incidence of root fracture, since
valuable tooth structure is removed to create
path of withdrawal
- Procedure requires several appointments and
laboratory involvement. So it is expensive.
- Fracture of metal can occur at the postcore
interface resulting in restoration failure.
368 Short Textbook of Endodontics

Fig. 21.12  A mind-map to remember the clinical parameters for post space preparation and post selection

Nonmetallic Cores - For adequate retention, the dentin bonding

agents must be compatible with composite core
• Composite resin core materials. For example, self-cure composite resin
– Advantages: (Almost fulfils ABCDEST) will be incompatible with light-cured adhesive.
- Adhesive bonding to tooth structure and many - Zinc oxide eugenol used as root canal sealer or
posts. as a temporary restoration, inhibits the setting of
- Biocompatible composite resins.
- Compressive strength is high - Bond strength of composite resin core to dentin
- Dimensional stability requires complete setting of resin materials.
- Ease of manipulation Figure 21.13 shows photograph of commercially
- Rapid Set (Short setting time) available composite core built-up material.
- Opaque (for nonesthetic areas) and translucent • Glass ionomer core
(for esthetic, anterior zones) and various colored – Advantages:
formulations are available (Color Contrast). - Anticariogenic due to fluoride release
– Disadvantages: - Forms chemical bond with tooth
- Microleakage
 Restoration of Endodontically Treated Teeth 369

Step 1: Post Space Preparation

• Post space is prepared by removal of gutta-percha from

the root canal using hot instrument (Thermal method)
or rotary instruments such as gates glidden drills, Peeso
drills or specially designed post space preparation drills
(Mechanical method) without disturbing the apical seal.
• At least 5 mm of apical gutta-percha should be left
behind for a good apical seal.
• Conservation of root dentin should be the goal of post
space preparation. Little or no dentin should be removed
from the root, i.e. Postspace preparation should not
enlarge the root canal at the expense of dentin.
• Desired post length, the bone height and the root
morphology are the factors to be considered while post
Fig. 21.13  Commercially available core built-up material space preparation.
(Courtesy of Mr Amar, Dr Dabholkar’s clinic)

Step 2: Post and Core Restoration

– Disadvantages:
- Low strength
- Low fracture toughness
- Low retention when preformed posts are used
- Solubility and sensitivity to moisture
- Insufficient strength to be used as core for the
tooth to serve as abutment for bridge.
• Resin-modified glass ionomer core: (Composite resin +
glass ionomer)
– Advantages:
- Moderate strength
- Satisfactory core material for moderate size built- Using Preformed Post Followed By Core Built-up
ups
- Anticariogenic • Commonly used technique nowadays.
- Higher bond strength • This system makes use of appropriate post space
- Minimal microleakage. preparation drills to prepare the post space of desired
– Disadvantages: length measured from a fixed coronal landmark till the
- Hygroscopic expansion may result in fracture of point in the root canal up to which the gutta-percha is
ceramic crowns to be removed retaining atleast 5 mm of gutta-percha
- Solubility between glass ionomer and composite apically and depending on other factors as shown in
resin. Figures 21.14A to E.
• After the post space is prepared, the post corresponding
WHAT IS THE TECHNIQUE OF FABRICATION OF to the drill is placed in the prepared space to check the
length and fit.
FOUNDATION RESTORATION?
• The extra length of the post is cut using air-rotor
Clinical procedure involves: handpiece with a water coolant.
• Step 1: Post space preparation • The post is then bonded or cemented in place as shown
• Step 2: Post and core restoration. in Figure 21.14F.
370 Short Textbook of Endodontics

A B C D E

F G H I
Figs 21.14A to I  Steps involved in restoring an endodontically treated tooth using preformed-post technique: (A) An Endodontically treated
tooth with very little sound coronal tooth structure, indicated for post and core restoration; (B) Gates Glidden drill no. 1 is used to remove
the gutta-percha from the coronal third of the root; (C) Alternatively a Peeso drill can also be used for removal of gutta-percha to the desired
length so as to preserve about 3–5 mm of gutta-percha for the apical seal; (D) The post space preparation drill is used to remove the gutta-
percha to the required length; (E) This is a special drill to create a positive stop for post head/hub increasing the retention of post; (F) Post
bonded or cemented in place; (G) Core built-up; (H) Preparation of tooth to receive full coverage coronal restoration; (I) A completely restored
Endodontically treated tooth

• Core material is then placed around the post into the
remaining pulp chamber and is built-up to form the
coronal area as shown in Figure 21.14G.
• The tooth is then prepared to receive a full coverage
restoration as shown in Figure 21.14H.
• Figure 21.14I shows a completely restored Endodontically
treated tooth.
Cast Post and Core
• Direct technique:
– This involves intraoral fabrication of a castable post
and core pattern on the prepared tooth.
– Prefabricated plastic postpattern is seated in the
post space and autopolymerizing acrylic resin can
 Restoration of Endodontically Treated Teeth 371

be used to reline the post pattern to fit the post

space.
– Using the same resin, the core is made over the post
pattern and is contoured intraorally to the desired
form.
– After removing the finished pattern from the tooth,
it is sent to the laboratory for casting.
– In the next appointment, cast post and core is seated
in the post space; any obstructions if present are
corrected and then the cast post and core is passively
cemented.
• Indirect technique:
– This technique involves making a final impression of
the prepared tooth and post space and sending it to
the laboratory for die preparation and subsequent
fabrication of cast post and core.
– For making impression of the prepared post space,
impression material needs to be reinforced with
plastic pin or metal wire to achieve an undistorted
impression. Safety pin can also be used for reinforcing
impression material.
– Also, various plastic impression posts are available
in the market which make the procedure easy. In
this, the clinician has to select the desired diameter
of plastic post, use the corresponding drill to prepare
the post space at appropriate length. Place the
plastic post. Then light body rubber base impression
material is injected into the canal. When it sets,
remove and send it to laboratory.
– In the next appointment, cast post and core is seated
in the post space; any obstructions if present are
corrected and then the cast post and core is passively
cemented.
Harmful hydraulic pressures can be generated
inside the root that can crack the root if the cast
post and core is rapidly seated or seated with heavy
pressure or if excessive cement is used.
Cast post and core is not commonly used now-
a-days.

Coronal Coverage
• After the fabrication of the foundation restoration,
the final step in Endodontic reconstruction is coronal
coverage.
• The rule is to give a coronal coverage restoration for
most Endodontically treated posterior teeth and all
structurally damaged anterior or posterior teeth. Fig. 21.15  Causes of failure of post and core restorations
372 Short Textbook of Endodontics

Purpose of coronal coverage:

• To distribute functional forces
• To protect the tooth against fracture
• To re-establish function
• To isolate the dentin and Endodontic filling from
microleakage.

WHAT ARE THE CAUSES OF FAILURE

OF POST AND CORE RESTORATIONS?
Causes of Failure of Post and
Core Restorations (Fig. 21.15)

Causes of failure: Fracture of root,

(F7) Fracture, bending or distortion of post,
Fatigue failure,
Fit of post affected, i.e. loosening of post
or loss of retention of post
Ferrule of adequate amount missing,
Flexion,
Forces.
It has been found that loss of retention and tooth fracture
are the two most common causes of post and core failure.
Why Roots Fracture?
Fatigue failure: Structures subjected to low but repeated
forces (cyclic loading), may appear to fracture suddenly
for no apparent reason. This phenomenon is called fatigue
failure, which is a progressive failure that proceeds by
initiation and propagation of cracks. Since the teeth are
constantly subjected to fluctuating cycles of loading and
unloading during mastication, fatigue failure of dentin,
posts, cores, crown margins or adhesive components is
likely to occur resulting in tooth/root fracture. Moreover,
if the tooth has minimal tooth structure remaining, fatigue
can cause Endodontic posts to bend permanently or break,
Fig. 21.16  Forces (a) exerted on a weak
root from a rigid post resulting in root fracture (b)
or it can cause a fiber-matrix complex to disintegrate.
Fatigue failure of nonvital tooth restored with a rigid post
is likely to cause complete fracture of the root as the rigid
post has higher modulus than the root dentin, the stress
concentration occurs adjacent to the bottom of the post
resulting in root fracture originating at the apex of a rigid
post.
Figure 21.16 shows diagrammatic representation of rigid
post exerting forces on a weak root resulting in root fracture.
BIBLIOGRAPHY
1. Cohen S, Hargreaves KM. Pathways of Pulp, 9th edn. St. Louis:
Mosby; 2006. pp. 786-818.
2. Hargreaves KM, Cohen S. Pathways of Pulp, 10th edn. Mosby
Elsevier, St Louis, MO; 2011. pp. 777-804.
3. Ingle J, Bakland L, Baumgartner J. Ingle’s Endodontics, 6th edn.
BC Decker Inc, Hamilton; 2008. pp. 1431-64.
 Endodontic Failures and

22
CHAPTER

Nonsurgical Endodontic
Management

This chapter tells you about the causes of post-treatment Endodontic disease and explains in detail
how nonsurgical Endodontic retreatment can result in healing and thus saving the involved tooth.
  You must know
• What is the Outcome of Endodontic Treatment?
• What are the Measures to be Employed to improve the Rate of Success of Treated
Endodontic Cases?
• What are the Causes of Endodontic Failures?
• How do you Diagnose Post-treatment Disease?
• What is the Treatment Plan for the Patient with Post-treatment Disease?
• What are the Indications and Contraindications of Endodontic Retreatment?
• What are the Factors to be Considered for Endodontic Retreatment?
• What are the Steps for Nonsurgical Endodontic Retreatment?
• What is the Prognosis of Endodontic Retreatment?

WHAT IS THE OUTCOME OF ‘Success depends on:

ENDODONTIC TREATMENT?
Goal of Endodontic Treatment
Broadly, it can be said that the Endodontic therapy is
directed towards a specific goal: ‘To prevent or cure
periradicular periodontitis’ (Apical periodontitis).
The outcome of Endodontic treatment—success or
failure is explained in Flow chart 22.1.
WHAT ARE THE MEASURES TO BE EMPLOYED TO
IMPROVE THE RATE OF SUCCESS OF TREATED
ENDODONTIC CASES?
Molven and Halse have said:
– Elimination of root canal infection present when
treatment starts
– Prevention of both contamination during treatment,
and prevention of reinfection later.
So, success rates reflect the standard of the cleaning,
shaping and filling of root canals’.
To ensure nearly 100% success rate, Ingle has
recommended to follow ten rules which can be considered
as the ten commandments of Endodontics.
Let us remember the ten commandments of Endodontics
given by Ingle with the following true statement:
Careful Application of Root Canal Laws and Principles
Can Cause Successful Treatment (C = Case selection,
A  =  Apical density, R = Restore, C = Cavity preparation,
L  =  Length, P = Practice, C = Curved, C = Cone, S =
Surgery, T = Treatment)
• Use great care in Case selection. Choose proper cases
for Endodontic treatment and reject those that will
obviously fail.
374 Short Textbook of Endodontics
Flow chart 22.1  Outcome of Endodontic treatment
• Use greater care in Treatment. Do not hurry, maintain an
organized approach. Be certain of instrument position
and procedure before progressing.
• Establish adequate Cavity preparation. Access cavity can
be improved by modifications of coronal preparation.
Radicular preparation can be improved by thorough
canal cleaning and shaping.
• Determine the exact Length of tooth to the foramen
and be certain to operate only to the apical stop, about
0.5–1 mm from the external orifice of the foramen.
• Always use Curved, sharp instruments in curved canals,
and especially remember to clean and reshape the
curved stainless steel instrument each time it is used.
• Use great care in fitting the primary filling point/Master
Cone.
The apical portion of the canal must be obliterated.
Ensure total obturation of the entire root canal. Always use
root canal sealer cement.
• Use Periradicular Surgery only in those cases for which
surgery is definitely indicated.
• Always check the Apical density of the completed root
canal filling of the patient undergoing periradicular
surgical treatment, and this should be done by using a
sharp right-angled explorer.
• Properly Restore each treated pulpless tooth to prevent
coronal fracture and microleakage.
• Practice Endodontic techniques on extracted teeth
mounted in acrylic blocks to improve your skills to carry
out the procedures well in the patient’s mouth.
WHAT ARE THE CAUSES OF
ENDODONTIC FAILURES?
Microbial
Microbial infection persisting in the apical portion of the
root canal system is the major cause of Endodontic failure.
Intraradicular infection is the essential cause of primary
apical periodontitis and major cause of post-treatment apical
periodontitis.
Microorganisms may be left behind in the apical portion
of the complex root canal system due to improper root canal
treatment procedures.
Microorganisms may be found as biofilm located
within small canals, lateral or accessory canals or in the
space between root fillings and canal wall of incomplete
obturated canal.
Nonmicrobial
True cysts, cholesterol crystals, foreign bodies in periapical
area are the nonmicrobial causes of Endodontic failure.
Healing by scar tissue formation may be misdiagnosed
as radiographic sign of Endodontic failure.
Flora Associated with Root Canal Treated Teeth
• Bacteria, yeasts, fungi, mixed anaerobic microbiota,
viruses, may be found.
• Gram +ve cocci, rods and filaments may be the bacteria
found.
• Mostly species belonging to genera Actinomyces,
Enterococcus and Propionibacterium.
• Enterococcus faecalis is commonly isolated from failing
root canal treated teeth and it is known to be especially
 Endodontic Failures and Nonsurgical Endodontic Management 375

difficult to eliminate with standard instrumentation and Other Classification

irrigation.
– It can tolerate pH up to 11.5
– It can survive prolonged starvation
– It is resistant to most of the intracanal medicaments
– It can grow as microinfection in treated canals
without any synergistic support from other bacteria.
Actinomyces israelli and P. propionicum may establish
themselves extraradicularly even after treatment. The extra­
radicular microbial infection may be the cause of failed
Endodontic treatment.
It has been found that bacteria may not be completely
eliminated after thorough cleaning, shaping and disinfection.
This “critical amount” of bacteria that persists can sustain
periradicular inflammation.
Overaggressive instrument action can cause extrusion
of bacteria through the apex into the periapical tissue and These have been explained in detail in Flow chart 22.2.
can serve as a continuing irritant.
An obturated canal may be recontaminated from
coronal leakage. Gutta-percha root canal fillings do not HOW DO YOU DIAGNOSE
resist salivary contamination. Bacteria can penetrate from POST-TREATMENT DISEASE?
crown to periapex alongside poorly obturated canals.
Quality of coronal seal determines the long-term prognosis 1. Thorough review of patient’s health history
of treatment. 2. Clinical examination: Visual, extraoral, intraoral and
periodontal evaluation
– Signs of inflammation
Grossman Classification – Tenderness to percussion
– Presence of sinus tract
– Infection
3. Radiographic assessment : Multiple angulated
radiographs, Bitewing radiographs.
In cases of previous Endodontic therapy, radiographs
can help evaluate caries, defective restorations,
periodontal health, quality of obturation, periradicular
pathosis, perforations, fractures, resorption and canal
Stabholz et al. and Friedman Classification anatomy.
Figures 22.1 and 22.2 are radiographs showing
periapical radiolucency in root-canal treated teeth
indicating recurrent infection.
4. Periradicular tests: Percussion, palpation and bite test.
5. Pulp vitality tests: When there is vital tissue remaining
in the canals of a previously treated tooth due to missed
canal or improperly cleaned canal, patients may
complain of sensitivity to heat or cold. Pulp vitality tests
can help to assess this situation.
376 Short Textbook of Endodontics

Flow chart 22.2  Classification of causes of Endodontic failure

Fig. 22.1  Radiograph showing recurrent periapical infection in root Fig. 22.2  Recurrent periapical infection in poorly shaped and filled
canal treated mandibular premolar due to unusual anatomy canals and mesial canal blocked with separated instrument
 Endodontic Failures and Nonsurgical Endodontic Management
WHAT IS THE TREATMENT PLAN FOR THE
PATIENT WITH POST-TREATMENT DISEASE?
Post-treatment apical periodontitis should be diagnosed
and its cause should be detected.
Treatment options for a case of Endodontic failure:
Option 1: Wait and watch when etiology of the condition
remains unknown.
Option 2: Extraction of tooth: It may be a desirable option in
certain cases. Recent advances in prosthetic reconstruction
and dental Implantology have made it possible.
Option 3: Nonsurgical retreatment—Preferred choice as it is
less traumatic, less invasive, preserves the tooth.
Option 4: Surgical retreatment—Periradicular curettage,
apical root resection, root amputation, intentional
replantation are various surgical treatment options.
The choice of which option to undertake, is determined
by:
• Knowledge and experience of clinician
• Patient considerations.
WHAT ARE THE INDICATIONS AND
CONTRAINDICATIONS OF ENDODONTIC
RETREATMENT?
Indications
• Endodontically treated teeth presenting with symptoms
such as tenderness to percussion, swelling, fistula, or
signs of infection.
• Endodontically treated asymptomatic tooth with
improperly done treatment such as inadequate filling
viewed radio­graphically. Patient should be informed.
Retreatment may be postponed but must be done before
prosthetic treatment for that tooth.
• Generally, periapical radiolucencies that have not
healed or decreased in size or have increased in size in
a period of 4 years evidenced by follow-up radiographs
should be considered for retreatment.
• Root canal fillings which have been exposed to oral
environment for long period of time due to lack of
coronal seal by means of permanent coronal restoration
can be considered infected and retreatment may have to
be done.
Contraindications
As such, there is no absolute contraindication of Endodontic
treatment or retreatment. But teeth with the following
conditions if indicated for retreatment may have poor
prognosis:
• Untreatable root resorption
• Terminal periodontal disease
377
• Vertical root fracture
• Untreatable root perforations
• If the tooth with root canal failure is not important
strategically such as diseased maxillary 2nd molars with
no opposing tooth or having developed class I or class
III occlusion or articulating with another tooth.
• Tooth that is hopelessly nonrestorable such as extensive
caries or coronal fracture approaching or entering the
furcation or biologic width.
• Unfavorable root anatomy
• Procedural complications such as nonretrievable
separated instrument, irreparable perforation, ledge,
etc.
Operating the tooth with dental operating microscope
(DOM) and Surgical Endodontics is better choice than
extraction of tooth in most of the above cases.
WHAT ARE THE FACTORS TO BE CONSIDERED
FOR ENDODONTIC RETREATMENT?
The factors to be considered for Endodontic retreatment are
given in the form of mind-map in Figure 22.3.
WHAT ARE THE STEPS OF NONSURGICAL
ENDODONTIC RETREATMENT?
• Access cavity preparation (coronal radicular access):
– Retreatment access is challenging and differs from
that of primary treatment.
– Goal: To establish straight-line access to apical area
of root canal system while conserving as much tooth
structure as possible.
• Recleaning and reshaping:
– Correct length of canal is established.
– Reinstrumentation and reshaping using the crown-
down technique.
378 Short Textbook of Endodontics
Fig. 22.3  A mind-map to remember all factors to be considered for retreatment
– Canal gets slightly over-enlarged in an attempt to
remove all the residue of previous treatment such
as sealer and filling material from canal walls as
bacteria can hide behind the sealer.
– Since primary treatment fails mostly due to infection,
one has to be extra careful with asepsis and extra
vigorous with antimicrobial treatment.
– Liberal use of sodium hypochlorite is recommended.
Also other intracanal irrigants like 2% chlorhexidine,
final rinse with 17% EDTA to remove the smear layer.
– Intracanal medicament like calcium hydroxide may
be helpful as an interappointment medicament.
• Obturation: Using any of the routinely followed methods.
• Post-Endodontic restoration: Coronal restoration as soon
as possible to develop good coronal seal followed by full
coverage restoration.
Detailed Explanation of Access Preparation
• Gaining access through the restoration (Crown or Bridge)
– For access through metal, carbide fissure burs are
used
– For access through porcelain fused to metal (PFM)
crowns:
- Round diamond bur to cut through porcelain
- Transmetal bur for metal substructure
– Copious water coolant spray and use of diamond
burs are recommended during access through
porcelain to minimize occurrence of micro-
fractures
– Advantages:
- Restoration is maintained in its place, so esthetics
will be minimally changed
- Facilitates rubber dam placement; so isolation
is easier
- Occlusion is preserved
- Cost and time involved in replacement of
restoration is saved.
– Disadvantages:
- Reduced visibility and accessibility
- More chances of errors during procedure
- Some findings such as extent of caries, vertical
fracture of tooth or a hidden canal may be
missed.
It is generally recommended to remove the existing
restoration so that the morphology of tooth is better viewed,
radiographic information of coronal part of tooth is obtained
and accessibility is improved.
• Coronal disassembly: Retreatment access is called
coronal disassembly as it mostly requires removal of full
coverage restoration or a restoration supported by post
and core, etc.
If there is defect or caries associated with the existing
restoration or if the treatment plan calls for a new crown,
the old crown is removed and replaced later.
Different devices have been manufactured for
conser­vative removal of crown without damaging the
internal tooth structure. Sometimes reuse of these
restorations is possible.
 Endodontic Failures and Nonsurgical Endodontic Management 379

But, most of the times, the restorations need to be

sacrificed.
• Regaining access to apical area.

Removal of Posts
Techniques

Removal by reducing retention Removal by pulling the post

from its preparation

Step 1: Expose the post by removal of If post cannot be removed by

adjacent restorative materials. reducing its retention, then
Step 2: Small to medium sized post can be pulled out using
ultrasonic tip is inserted at the one of the post removal kits
interface between the post and the such as:
tooth and then it is constantly moved
around the circumference of the post •  The Thomas screw post
to disrupt the cement along the post removal kit for removal of Fig. 22.4  Post removal system (PRS) KIT (Courtesy of Dr Clifford J
and canal wall interface. active or screw posts Ruddle, Advanced Endodontics)
This decreases the post retention and • The Ruddle post removal
facilitates its removal. system for removal of parallel
Thus, judicious use of the ultrasonic or tapered passive posts
instrument in conjunction with a • JS post extractor post. The post removal extracting plier is then mounted
solvent can loosen the post and • Post puller or Eggler post onto the tubular tap and the jaws of the plier opened by
remover
post may actually spin out of the turning the screw knob clockwise (CW). As the jaws open,
preparation.
the tooth is visually inspected to assure, it is cushioned and
protected. Increasing pressure will be noted when turning
the screw knob, and ultimately this action will serve to
Ruddle Post Removal System
remove virtually any post.
• The post removal system (PRS) kit is a device intended Tooth-colored posts fabricated from ceramic, zirconium
to be used when the removal of posts with ultrasonics or fiber-reinforced posts are difficult to remove.
is unsuccessful. Ceramic and zirconium posts are usually impossible to
• The PRS kit can mechanically engage any obstruction retrieve as they are more fragile than metal posts.
whose cross-sectional diameter is 0.60 mm or greater.
• The PRS kit contains an extracting plier, a transmetal
bur, five trephines of varying internal diameters, five
corresponding tubular taps whose internal diameters
range from 0.60–1.60 mm, a torque bar, tube spacers,
and a selection of rubber bumpers of varying diameters
to properly cushion and protect the tooth during the
loads generated by extracting forces. Figure 22.4 shows
the photograph of Ruddle post system. Removal of Root Canal Filling

Technique Silver Point Removal

The largest trephine that will not go over the head of the
exposed post is selected. The PRS’s latch-type trephines
should rotate at approximately 15,000 rpm in a clockwise
(CW) direction in a slow speed, high torque handpiece
and, with lubricants, are utilized to machine down a
2–3  mm length of the most coronal aspect of the post. An
appropriately sized rubber bumper(s) is inserted onto the
selected tubular tap. The tap is manually turned counter-
clockwise (CCW) to form threads and actively engage the
Step 1: Carefully remove the core material in which the silver
point might be embedded.
Step 2: Flood the access preparation with a solvent such as
chloroform in order to soften or dissolve the cement.
Step 3: Grasp the exposed end of the silver point with a
Stieglitz pliers or other appropriate forceps and pull it out
with a gentle force.
Ultrasonics can be employed to facilitate removal of
silver points.
380 Short Textbook of Endodontics

Caufield Silver point retrievers are available in cases

where there is not much of silver point exposed in the
chamber.
Also, Hedstrom files can be used to remove silver point.
Two to three Hedstrom files are negotiated as far apically as
possible in two or three areas around the silver point. The
files are then twisted together and pulled out through the
access.
Trephine burs may also be used. End-cutting trephine
bur is used to remove tooth structure around the point and
then an extraction device such as Endo Extractor, Masserann
kit, etc. can be used to remove the point.

Gutta-percha Removal Techniques

Fig. 22.5  Photograph showing the rotary Endodontic retreatment
files–D1, D2, D3 in this order used for removal of GP root canal filling.
(Courtesy of Dentsply)

Rotary Endodontic instruments can be used to remove

Gutta-percha and sealer while thermoplasticizing the root
filling mass using frictional heat to remove it.
Combination of solvents along with Hedstrom file and
rotary files can be used for safe removal of old Gutta-percha
from root canals.
Solid core canal obturation systems such as Thermafil,
Dens-Fil and the GT® obturator that use a plastic or metal
carrier within the mass of Gutta-percha are very difficult to
remove from the canal. It is removed by initial use of heat
application to carrier that can soften the Gutta-percha
surrounding it. Then this carrier is grasped with a forcep.

Pastes and Cement Removal

Gutta-percha from coronal 1/3rd of canal is removed

using gates glidden drills or Peeso drills.
Rotary file systems such as Profile canal finder GPX,
Heroshaper R Endo Kit are available to remove entire length
Gutta-percha from the canal.
Figure 22.5 shows photograph of commercially available
rotary files of Endo-Retreatment Kit—D1 D2 D3 in this order
having one, two and three rings respectively on their shaft.
D1 D2 and D3 are used at the speed of 500 to 700 rpm. D1 has
cutting surface blade of 16 mm, 11 mm handle, one white
ring and a taper of 9%. D2 has cutting surface blade of 18 mm,
11 mm handle, two white rings and a taper of 8%. D3 has
cutting surface blade of 22 mm, 11 mm handle, three white
rings and a taper of 7%. D1, D2 and D3 are used in coronal,
middle and apical thirds of the root canal, respectively.
They are used in this order to remove Gutta-percha from
the canal.
 Endodontic Failures and Nonsurgical Endodontic Management 381

Removal of Canal Obstructions Such as

Separated Instruments
• Removal depends on location of instrument.
– If clinically visible in the coronal access, it can be
grasped with a hemostat or Stieglitz pliers and pulled
out.
– If the instrument is present in the middle 1/3rd of
canal, retrieval should be attempted or bypass it.
Hand instruments like reamers and files can be
used to bypass the separated instrument by inserting
alongside the separated instrument to soften its
cementation and thus facilitating its removal.
Copious irrigation with Sodium hypochlorite
(NaOCl), Hydrogen peroxide (H2O2)may float the
object coronally through the effervescence created.
– If the instrument lies in the apical 1/3rd of canal, it Fig. 22.6  File removal system (Courtesy of Dr Clifford J Ruddle,
is left behind or the case is surgically treated. Advanced Endodontics®)
The decision to retrieve the broken instrument
is based on evaluation as to how much tooth
structure will have to be removed to gain access to red and yellow instruments can be placed progressively
the instrument. deeper into smaller, more narrow canals.
– In order to remove separated root canal instruments, • Each complete instrument is comprised of a color
straight-line coronal-radicular access has to be coordinated microtube and screw wedge. First
created with the use of modified Gates-Glidden trephination is carried out using Ultrasonics, then
drills. GG drills are modified by sectioning with a position the microtube and it is used to engage and
bur at their maximum cross-sectional diameter to remove the obstruction.
create a circumferential staging platform to facilitate
ultrasonic use. The vibration caused by ultrasonics WHAT IS THE PROGNOSIS OF
placed on the platform between exposed end of file
ENDODONTIC RETREATMENT?
and the canal wall helps in removal of that broken
file. • In absence of prior apical periodontitis, the percentage of
There are many techniques and devices now available to healed cases after both initial treatment and nonsurgical
facilitate removal of separated instrument. Many kits have retreatment has been found to be about 92–98%.
been introduced such as the Endo extractor, the Masserann • In presence of prior apical periodontitis, the percentage
kit, the Extractor system and the Instrument Removal System of healed cases has been found to be 74–86% regardless
and the Separated Instrument Retrieval system (SIR). of whether initial treatment or nonsurgical retreatment
One of the Ruddle’s inventions: File removal system is was performed.
described here. Figure 22.6 shows the photograph of the A tooth that has persistent apical periodontitis may
file removal system. remain in asymptomatic function for an extended period,
• In cases, where ultrasonic trephining procedures are this state is referred to as functional retention of tooth.
limited or prove ineffective, the File Removal System
(FRS) may be utilized to mechanically engage and BIBLIOGRAPHY
potentially remove intracanal obstructions, such as
1. Cohen S, Hargreaves KM. Pathways of Pulp, 9th edn. St. Louis:
silver points, carrier-based obturators or broken file
Mosby, 2006.pp.944-1005.
segments. 2. http://www.endoruddle.com/inventions.html
• The instrument with the black handle is used to work 3. Ingle J, Bakland L, Baumgartner J. Ingle’s Endodontics 6, 6th edn.
in the coronal one-third of larger canals, whereas the BC Decker Inc, Hamilton, 2008.pp.1088-217.
 23
CHAPTER

Management of
Discolored Teeth

This chapter describes about tooth discoloration and explains in detail about ‘bleaching’, as a treatment
modality for whitening of vital and Endodontically treated teeth.
  You must know
• What are the Causes of Tooth Discoloration?
• What are the Different Methods of Management of Discolored Teeth?
• What is Bleaching of Teeth?
• Why Bleaching?
• What is the Chemistry and Mechanism of Bleaching?
• Etiology of Tooth Discoloration and its Management in Detail
• What are the Indications and Contraindications of Bleaching?
• Which are the Materials Used for Bleaching?
• What is the Technique for Bleaching Vital Teeth?
• What are the Side Effects and Adverse Effects of Extracoronal Bleaching of Vital Teeth?
• What is the Technique for Bleaching Endodontically-Treated Teeth?
• What are the Side Effects and Adverse Effects of Intracoronal Bleaching of Endodontically
Treated Teeth?
• How do we Restore Intracoronally Bleached Endodontically Treated Tooth?
• What is Enamel Microabrasion?
• What is the Role of Veneers and Crowns in Management of Discolored Teeth?

INTRODUCTION • Thickness and color of the underlying dentin

Color is an important characteristic of teeth.
• The normal color of primary teeth is bluish white.
• The normal color of permanent teeth is grayish yellow,
grayish white or yellowish white.
The color of the teeth is due to:
• Translucency and thickness of enamel
• Color of the pulp.
WHAT ARE THE CAUSES OF TOOTH DISCOLORATION?
Any change in the hue, color or translucency of a tooth is
referred to as tooth discoloration.
Etiology of tooth discoloration can be classified in
following 2 ways:
 Management of Discolored Teeth 383

Out of all the causes listed in the given two classifications,

decomposition of pulp tissue is the most common cause of
tooth discoloration particularly when the pulp is necrotic.
Several months after necrosis of the pulp or treatment of
tooth, discoloration is noticed due to slow formation of color
producing compounds.
Traumatic injury is the next common cause of tooth
discoloration. Due to trauma, there is rupture of blood
vessels in the pulp and diffusion of blood into dentinal
tubules. Immediately after accident, such a tooth may have
a dark pinkish hue and some days later it may turn pinkish
brown.
The etiology of tooth discoloration along with its
management is described in detail later in this chapter.

WHAT ARE THE DIFFERENT METHODS OF

MANAGEMENT OF DISCOLORED TEETH?
Depending on the extent of discoloration and other factors,
different methods of management of discolored teeth
include:
• Teeth bleaching
• Enamel microabrasion
• Restorative options:
– Composite veneers/restoration
– Ceramic veneers/laminates
– Crowns.

WHAT IS BLEACHING OF TEETH?

Bleaching of teeth is a treatment modality which makes
use of an oxidizing agent that is capable of bringing about
the alteration in the light-absorbing and/or light-reflecting
nature of a material structure, thereby increasing its
perception of whiteness.
Hence, bleaching of teeth is also referred to as teeth
whitening.

WHY BLEACHING?
• Yellowish looking teeth can be whitened by means of
bleaching.
Discoloration of teeth can occur due to various
endogenous or exogenous causes as listed above in the
Etiology of tooth discoloration.
• Discolored teeth can be whitened by means of bleaching.
Thus, the goal of bleaching procedure is to restore tooth
esthetics by restoring the normal color of the tooth.
384 Short Textbook of Endodontics

WHAT IS THE CHEMISTRY AND MECHANISM

OF BLEACHING?
Redox reaction: The bleaching process involves oxidation
of the bleaching agent. The oxidation-reduction reaction
that takes place in the bleaching process is called the redox
reaction.

ETIOLOGY OF TOOTH DISCOLORATION

AND ITS MANAGEMENT IN DETAIL
Patient-related Causes

Extrinsic Stains
Stains from foods, beverages, tobacco products and
chemicals from mouth rinses, toothpowders, etc. are all of Fig. 23.1  Photograph showing generalized discoloration of teeth
local origin and can be removed by scaling and polishing. due to tetracycline (Courtesy of Dr CR Suvarna)

Intrinsic Stains According to severity, tetracycline discoloration

can be classified as:
• Pre-eruptive causes: Several systemic conditions may • First degree: Light yellow, light brown or light gray
result in discoloration of teeth. uniform discoloration throughout the crown. No
a. Diseases: Several systemic conditions may result in banding.
discoloration of teeth. • Second degree: More intense discoloration. No
banding.
Systemic condition Tooth discoloration
• Third degree: Very intense discoloration;
•  Alkaptonuria • Dark brown pigmentation of
horizontal color banding seen; cervical region
primary teeth
of teeth is mostly affected.
•  Thalassemia, sickel cell anemia • Blue, brown or green
discoloration
Tetracycline discoloration usually occurs bilaterally
affecting multiple teeth in both arches.
•  Erythroblastosis fetalis • Results in lysis of erythrocytes
and hemosiderin gets
Severity of stains depends on time and duration
incorporated in the forming of drug administration, type of tetracycline and
dentin. Green, brown or bluish dosage.
stain Role of bleaching in case of tetracycline-stained teeth:
•  Porphyria • Reddish or brownish • Mild to certain moderate cases (First and second
discoloration of deciduous and degree). Repeated external bleaching for an
permanent teeth
extended period. They may respond well to three
•  Amelogenesis imperfecta (AI) •  Yellow or brown discoloration or four bleaching sessions.
•  Dentinogenesis imperfecta (DI) • Brownish violet, yellowish or • Severe cases (Third degree)—May not be
gray discoloration
amenable to bleaching. Restorative means will
be required.
Stains due to the conditions such as amelogenesis c. Fluorosis: Excessive exposure to fluoride during
imperfecta (AI), dentinogenesis imperfecta (DI) tooth formation can result in dental fluorosis or
are usually not possible to eliminate by bleaching mottled enamel.
as they originate from developmental defects of Such teeth are not discolored on eruption, but their
enamel and dentin. Correction by restorative means porous surface attracts extrinsic stains.
is preferred. Intermittent white spots, chalky or opaque areas,
b. Medications: Ingestion of certain drugs during tooth yellow or brown discoloration is seen. Severe cases
formation may cause severe discoloration in both present as surface pitting of enamel.
enamel and dentin. Role of bleaching: External bleaching may be effective
Figure 23.1 shows generalized discoloration of for mild-to-moderate dental fluorosis. Restorative
teeth due to tetracycline. procedure for severe dental fluorosis.
 Management of Discolored Teeth 385

• Posteruptive causes
a. Pulp necrosis: Most common cause of tooth
discoloration.

Several months after death of the pulp or treatment of
tooth, discoloration is noticed due to slow formation
of color producing compounds. Figures 23.2A to  C
show the photographs of discolored upper right A
central incisor due to trauma causing pulp necrosis.
Photographs are taken in three different positions.
Role of bleaching: Intracoronal bleaching is effective
in these cases.
b. Intrapulpal hemorrhage:

If pulp recovers, discoloration may be reversed. B
If pulp becomes necrotic, discoloration persists
and becomes severe with time. Figure 23.3 shows
photograph of discolored maxillary central incisor
tooth.
Role of bleaching: Intracoronal bleaching is effective
in these cases.
c. Aging: Due to aging, there is decrease in thickness of
enamel due to wasting diseases of teeth — attrition,
abrasion, erosion. On the other hand, there is
increase in the thickness of dentin and changes
in optical properties of tooth due to deposition of
secondary and reparative dentin. So, the yellow color
of dentin becomes more apparent in older teeth as
shown in Figure 23.4.
Extrinsic stains are removed by scaling and
polishing and then extracoronal bleaching can be
done to restore white color of the teeth. C
d. Calcific metamorphosis: Deposition of hard tissue Figs 23.2A to C  Photograph showing discolored upper right central
within the root canal space in response to trauma is incisor due to trauma causing pulp necrosis. Photograph taken in
called calcific metamorphosis. three different positions (Courtesy of Dr CR Suvarna)
386 Short Textbook of Endodontics
Fig. 23.3  Photograph showing discolored maxillary right central
incisor (Courtesy of Dr CR Suvarna)
Fig. 23.4  Photograph showing yellowish discoloration of teeth due
to wasting diseases (Courtesy of Dr CR Suvarna)
Such teeth appear yellowish or yellowish-brown.
To correct such discoloration, root canal treatment
should be done first and it is followed by intracoronal
bleaching.
Dentist-related Causes
Related to Coronal Restorations
• Metallic restorations: Such as silver amalgam restorations
degrade over time and corrosion products can cause
Fig. 23.5  Photograph showing discoloration of first premolar due to
old silver amalgam restoration (Courtesy of Dr CR Suvarna)
A B
Figs 23.6A and B  Photograph showing discolored composite
restorations: (A) Maxillary lateral incisor; (B) Mandibular first molar
(Courtesy of Dr CR Suvarna)
tooth discoloration. Figure 23.5 shows blackish
discoloration of first premolar tooth due to old silver
amalgam restoration
Role of bleaching: Such a discoloration is difficult to
bleach.
Replacing amalgam restoration with tooth colored
restoration can sometimes solve the problem.
• Composite resin restorations: These restorations become
discolored over a period of time. Microleakage around
the restoration can discolor the underlying dentin.
Figures 23.6A and B show discolored composite
restoration.
Replacing old composite restoration with a new, well-
sealed composite restoration can solve the problem.

Related to Endodontic Treatment
• Remnants of pulp tissue: Inadequate access cavity
preparation which has not included the pulp horns,
especially in anterior teeth, result in discoloration
of Endodontically treated tooth due to pulp tissue
remnants that are left behind.
Intracoronal bleaching is effective in such cases.
• Intracanal medicaments: Such as phenols or iodoform-
based medicaments sometimes may cause their
penetration into surrounding dentin. Oxidation occurs
resulting in discoloration.
Intracoronal bleaching may be effective.
Fig. 23.7  A mind-map to remember all points of etiology of tooth discoloration
Management of Discolored Teeth 387
• Obturating materials: If the obturating material
and sealer remnants remain in the pulp chamber of
Endodontically treated tooth, discoloration can occur.
To correct such a discoloration, the remnants
of obturating material are first removed and the
intracoronal bleaching is done.
To prevent this kind of discoloration, the obturating
materials and sealer remnants must be removed just
below the level of the gingival margin before the final
restoration is done.
A mind-map to remember etiology of tooth
discoloration is given in Figure 23.7.
388 Short Textbook of Endodontics

WHAT ARE THE INDICATIONS AND • Superoxol is a 30% solution of hydrogen peroxide by
CONTRAINDICATIONS OF BLEACHING? weight and 100% by volume in pure distilled water. It
decomposes readily in an open container, so it has to
be stored in sealed refrigerated containers.
• Hydrogen peroxide in high concentrations has ischemic
effect on skin and mucous membrane. So, these materials
should be carefully handled to avoid their contact with
tissues during handling and bleaching treatment. Figure
23.8 shows photograph of commercially available 35%
hydrogen peroxide for bleaching.

Carbamide peroxide:
• Carbamide peroxide is in the form of crystallized powder
that contains 35% hydrogen peroxide.
• It is called urea hydrogen peroxide and yields urea and
hydrogen peroxide on decomposition.
• Carbamide peroxide in the concentration of 10–30%
is used for at-home bleaching, 10% being the most
common.
• Carbamide peroxide in the concentration of 35% may
be used for in-office bleaching.
Carbopol: Some bleaching preparations contain a water
soluble polyacrylic acid polymer called carbopol.
Carbopol is added as a thickening agent.
Carbopol prolongs the release of active peroxide.
Thus, it improves the shelf life of the bleaching
preparation.
WHICH ARE THE MATERIALS USED FOR
Sodium perborate:
BLEACHING?
• Sodium perborate is available as a white powder
Bleaching is based on peroxide compounds as the active containing about 95% perborate, corresponding to 9.9%
agent. It acts as an oxidizing agent and there is formation of the available oxygen.
of free radicals and reactive oxygen molecules that attack
the long chained dark colored molecules and split them
into smaller, less colored and more diffusible molecules.
For extracoronal bleaching: Hydrogen peroxide, carbamide
peroxide are used.
For intracoronal bleaching: Sodium perborate and superoxol
are used.

Hydrogen peroxide:
• Hydrogen peroxide is a strong oxidizing agent, which
may be applied directly or be produced in a chemical
reaction from carbamide peroxide or sodium perborate.
Decomposition of carbamide peroxide and sodium
perborate releases hydrogen peroxide in an aqueous
medium.
• It is used in both in-office and at-home bleaching
materials. In-office bleaching materials have 25–38%
concentration of H2O2. At home, bleaching materials Fig. 23.8  Commercially available 35% hydrogen peroxide for
have 3–7.5% concentration of H2O2. bleaching (Courtesy of Mr Amar, Dr Dabholkar’s clinic)

• It is stable when dry but when exposed to acid, warm air
or water, sodium perborate decomposes to form sodium
metaborate, hydrogen peroxide, and nascent oxygen.
• Depending on oxygen content, sodium perborate is
available as monohydrate, trihydrate and tetrahydrate.
The oxygen content determines the bleaching efficacy.
• Sodium perborate is safer for use as compared to
hydrogen peroxide for bleaching. It may be mixed with
superoxol (30% H2O2 by weight) to form a paste that
decomposes into sodium metaborate, water and oxygen.
• Sodium perborate is the material of choice for
intracoronal bleaching, in which it is sealed into the
pulp chamber where it oxidizes and discolors the stain
slowly over a period of time, the technique commonly
referred to as walking bleach technique.
WHAT IS THE TECHNIQUE FOR BLEACHING
VITAL TEETH?
Extracoronal bleaching is done for vital teeth.
Fig. 23.9  Indications of extracoronal bleaching of vital teeth
Management of Discolored Teeth 389
• Indications: Figure 23.9 gives the indications for
extracoronal bleaching of teeth.
• Types: Extracoronal bleaching for vital teeth can be
carried out:
– By clinician in the dental clinic; in-office extracoronal
bleaching/chair-side bleaching/power bleaching
– By patient at home, under the guidance and
supervision by dentist ; at-home extracoronal
bleaching.
I. Technique for in-office extracoronal bleaching of vital
teeth:
– Bleaching materials:
- 25–38% H 2 O 2 (35% H 2 O 2 commonly used)
available in gel form is used.
- Carbamide peroxide gel (10%, 15%, 20%, 35%)
– Mode of bleaching:
- Bleaching gel applied alone, or
- Bleaching gel in combination with light source
390 Short Textbook of Endodontics

- Earlier, heat, electric current and other chemicals it tends to absorb extrinsic stains faster from
were applied with bleaching gel to enhance its foods, beverages, etc. So, polishing of teeth after
bleaching efficacy. They are rarely used now. in-office bleaching is an essential step.
Light used:
Regular curing light for resin composites II. Technique for at-home extracoronal bleaching of vital
• Light-emitting diodes (LED) teeth:
• Laser light (e.g. Argon, CO2): Less popular – Bleaching materials: Hydrogen peroxide and
• Specialized light for bleaching carbamide peroxide are used as active ingredients
– Clinical procedure: for professional at-home bleaching procedure.
- First step is to record the pretreatment color of Concentration is 3–7.5% H2O2 or 10–22% carbamide
teeth (shade) using a camera (Photograph). This peroxide.
provides an excellent baseline data. – Mode of bleaching: Custom tray is manufactured for
- Diagnostic testing: Clinical and radiographic the patient. Bleaching gel is to be loaded in the tray
examination of all teeth for any possible caries, and patient wears the tray for several hours in night
defective restorations, periapical or pathologic for few days. Figure 23.10 shows photograph of soft
condition which should be treated prior to vinyl custom tray fabricated for bleaching.
bleaching. Professional bleaching strip is also available for at-
- Cleaning: Thorough scaling and prophylaxis is a home bleaching. Figure 23.11 shows photograph of
must. prefabricated bleaching trays with loaded bleaching
Prophy-jet prophylaxis will free the teeth to be material.
bleached of all surface stains and plaque. – Procedure:
- Isolation: Isolating the teeth to be bleached and - Scaling and polishing of teeth and any other
protection of gingiva and other soft tissues of the restorative treatment required by the patient is
mouth using a rubber dam, waxed dental floss, performed first.
reflective resin barrier, orabase, etc. - Upper and lower arch impressions are made.
- Protection of patient and dental team:
Surgical rubber gloves and safety glasses for the
dental staff.
Heavy plastic wrap for patient’s hands and
clothes. Safety glasses for the patient.
- Bleaching proper:
■ Rinse and remove excess varnish, jelly or
orabase from enamel of the teeth to be
bleached with pumice and water
■ Etch each tooth facially and lingually for
20  seconds with 37% phosphoric acid
■ Rinse for 30 seconds and dry the teeth
■ Apply bleaching agent: Superoxol or 35%
hydrogen peroxide with a piece of cotton
gauze, adhesive strips, paint-on or trays
■ Careful handling of bleaching material and
high vacuum suction is used
■ Position the bleaching light with an adjusted
rheostat setting. Bleaching temperature
recommended for vital teeth is 115˚C.
- After bleaching procedure, remove gauze and
flush teeth with copious amounts of warm water
Fig. 23.10  Soft vinyl custom tray fabricated over the patient’s model.
before carefully removing floss and rubber dam. Blue marked areas are to incorporate reservoirs in tray for loading
- Polish the teeth with polishing wheels. Since bleaching material (Spacer) (Courtesy of Dr Mahashabde, Rajesh
the enamel is demineralized during bleaching Shivhare’s clinic)

Fig. 23.11  Prefabricated bleaching trays with loaded bleaching
material is also available commercially (Courtesy of Dr Mahashabde,
Dr Rajesh Shivhare’s clinic)
- Models are sent to the laboratory for manufacture
of custom-made trays. More attention is paid
to the tray design. Trays are constructed with
periphery barely shy of gingival line (approx.
1/4–1/3 mm). Scalloping around the interdental
papilla is to be provided in the tray.
- Trays are made of soft vinyl tray material.
Reservoirs are incorporated in the trays using
block-out or adhesive strips as shown in Figure
23.10.
- Bleaching material is dispensed to patients in
unit dose syringes, assuring dentist supervision.
- Clinician gives instructions to the patient
regarding how to carefully insert, handle and
store the tray and about the special precautions
to be taken.
- As per the type of bleaching material and its
application technique, the clinician must follow
manufacturer’s instructions to give advice to the
patient for at-home bleaching.
WHAT ARE THE SIDE EFFECTS AND ADVERSE
EFFECTS OF EXTRACORONAL BLEACHING OF
VITAL TEETH?
Bleaching of vital teeth is a relatively safe procedure, if
carefully done and all precautions taken and instructions
Management of Discolored Teeth 391
followed. In spite of all these, adverse effects can occur
depending on the individual’s response to bleaching
treatment, such as:
Postbleach Sensitivity of Teeth
Mild to moderate sensitivity of teeth can occur lasting for 2–3
days. Higher incidence of sensitivity has been found after
in-office bleaching in which H2O2 was used in combination
with heat.
Management: Postbleach sensitivity can be managed by:
• Topical fluoride application such as 0.5% fluoride ion
gel
• Desensitizing toothpastes containing 3% potassium
nitrate.
Precautions:
• Do not perform bleaching on teeth with caries, exposed
dentin or teeth with reduced enamel and dentin
thickness and close proximity to pulp.
• Defective restorations must be replaced prior to
bleaching.
• If sensitivity is noticed, shorter bleaching periods are
recommended for such patient.
Effects on Enamel
• Decrease in enamel surface microhardness.
• Increased porosity and slight erosion of enamel may be
seen. Postbleach application of fluoride to the surface
of enamel may be useful.
Gingival Irritation
Mild-to-moderate gingival irritation may occur for 2–3 days
after bleaching. Tissue burn can occur.
Causes:
• Ill-fitting bleaching tray
• Increased concentration of hydrogen peroxide
• Contact of bleaching gel to the gingiva
• Leaky gingival barrier protection.
Management: In case of tissue burn, rinse the tissue surface
thoroughly with water. Topical anesthetic may be applied.
Precautions:
• Use of protective creams such as vaseline, orabase, cocoa
butter
• Well-made bleaching tray
• Proper gingival barrier protection.
392 Short Textbook of Endodontics
Effect on Restorations
• Silver amalgam restorations : During and after
extracoronal bleaching, release of mercury has been
reported from the restorations. Avoid extracoronal
bleaching for teeth with extensive amalgam restorations.
• Composite resin restorations: Bleaching may not have
effect on the color of the restoration. Increase in
microleakage has been found. Some roughening of the
surface of the restoration has been reported.
A mind-map to remember side effects/adverse effects of
extracoronal bleaching of vital teeth is given in Figure 23.12.
WHAT IS THE TECHNIQUE FOR BLEACHING
ENDODONTICALLY-TREATED TEETH?
• Intracoronal bleaching is generally done for
Endodontically treated teeth.
Fig. 23.12  A mind-map to remember all points of side effects/adverse effects of extracoronal bleaching of vital teeth
• Methods:
– Walking bleach technique
– Thermocatalytic technique (Heat)
– Use of ultraviolet photo-oxidation (Light)
• Bleaching agents:
– Superoxol: 30% solution of hydrogen peroxide by
weight and 100% by volume in pure distilled water
– Sodium perborate: White crystalline odorless
compound which has an oxidizing effect due to its
hydrogen peroxide component
– 35% hydrogen peroxide
– 5–7% sodium hypochlorite.
Walking Bleach Technique
Sodium perborate is mixed into a paste with superoxol.
This paste decomposes into sodium metaborate, water and

oxygen. When sealed into the pulp chamber, it begins to
oxidize and discolor the stain slowly and gradually over a
period of time. This procedure is referred to as walking bleach.
It basically refers to the bleaching action occurring
between patients’ visits.
• Step-by-step clinical procedure:
– Assessment of quality of Endodontic treatment: The
Endodontically treated tooth should be evaluated
radiographically to assess the quality of obturation,
and for any signs of periapical pathosis. Endodontic
failure cases will have to be retreated prior to
bleaching.
– If postobturation coronal restoration is defective,
then replace it.
– Record the pretreatment color of the tooth (shade)
using a camera (photograph) to provide the baseline
data.
– Polish the enamel surface with a prophylaxis paste
to remove any gross surface debris or discolorations.
– Apply protective cream such as vaseline, orabase to
the gingival tissues around the tooth to be bleached.
– Isolate the tooth using rubber dam that fits tightly at
the cervical margin of the tooth to be bleached.
– Re-establish the access cavity: Lingual opening of
sufficient size is made in case of anterior teeth.
Remove:
- All restorative materials from the access cavity.
- Any gutta-percha root canal filling extending into
the pulp chamber
Refine the access, exposing the dentin.
– Examine the pulp chamber and see to it that the pulp
horns and other areas containing the pulp tissue are
clean.
– Remove the gutta-percha root canal filling up to the
level of crest of alveolar bone, that is up to a depth of
2–3 mm apical to the cervical line in order to confine
the bleaching agents to the crown of the tooth as
shown in Figures 23.13A.
– Seal the orifice of the root canal with a sufficiently
thick layer of atleast 2 mm of a protective white cement
barrier, such as zinc phosphate, polycarboxylate
cement or glass ionomer cement coronally to the
level of CEJ to cover the Endodontic obturation as
shown in Figure 23.13B.
– Apply 25% solution of citric acid or 30% solution
of orthophosphoric acid to the dentinal surface
of the pulp chamber. The acid can be removed by
flushing with sodium hypochlorite or water. Air dry
the tooth. Now, it has been found that acid etching
is not desirable as use of such chemicals can cause
irritation to periodontal ligament.
Management of Discolored Teeth 393
A B C
Figs 23.13A to C  (A) Diagram showing the level to which gutta-
percha needs be removed below the cervical line, i.e. at the level
of alveolar crest shown by dotted line; (B) Diagram showing 2 mm
cement barrier; (C) Diagram showing bleaching agent placed in
cavity and the cavity sealed with an intermediate restorative material
– Prepare the walking bleach paste by mixing sodium
perborate powder with superoxol to a thick paste in
a clean dappen dish to have consistency of wet sand.
– With a plastic instrument, pack the paste into pulp
chamber.
– Place a cotton pellet over the bleaching paste to
remove any excess liquid and to compress and push
the paste into all areas of the pulp chamber.
– Seal the access cavity with IRM (Intermediate
restorative material) or any thick well-sealed
temporary filling of thickness about 3 mm to ensure
a good seal as shown in Figure 23.13C.
Hold the restoration with digital pressure for few seconds
to a minute after it is placed, otherwise it tends to come out
due to the pressure caused by the bleaching agent due to its
chemical reaction.
Figures 23.14A to J show photographs of a clinical case
where bleaching was done for management of discolored
maxillary right central incisor and mandibular left central
incisor. Both the teeth were Endodontically treated. Internal
bleaching was done for both. Mandibular left central incisor
responded well while maxillary right central incisor was
taking a little time especially the proximal area. In-office
external bleach was also done followed by home bleach to
achieve a good result.
Walking Bleach Result
Significant lightening is attained about 24 hours after
treatment.
Evaluate the patient one week later and if necessary,
repeat the procedure several times.
394 Short Textbook of Endodontics

Fig. 23.14A  Discolored maxillary right central incisor and mandibular left central incisor—Labial view (Courtesy of Dr CR Suvarna)

Fig. 23.14B  Discolored maxillary right central incisor—Labial and palatal view (Courtesy of Dr CR Suvarna)

Fig. 23.14C  Discolored mandibular left central incisor—Labial and lingual view (Courtesy of Dr CR Suvarna)
 Management of Discolored Teeth 395

Fig. 23.14D  Postobturation radiographs of maxillary right and mandibular left incisor teeth respectively (Courtesy of Dr CR Suvarna)

Fig. 23.14E  Coronal seal achieved with glass ionomer cement after placement of bleaching material (Courtesy of Dr CR Suvarna)

Fig. 23.14F  Results of intracoronal bleaching of maxillary right central incisor and mandibular
left central incisor (Courtesy of Dr CR Suvarna)
396 Short Textbook of Endodontics

Fig. 23.14G  Extracoronal bleaching of maxillary and mandibular anterior teeth (Courtesy of Dr CR Suvarna)

Fig. 23.14H  Result of intracoronal followed by extracoronal bleaching (labial view) (Courtesy of Dr CR Suvarna)

Fig. 23.14I  Coronal seal achieved with composite restoration in both teeth (Courtesy of Dr CR Suvarna)
 Management of Discolored Teeth 397

Fig. 23.14J  Preoperative and postoperative (Courtesy of Dr CR Suvarna)

About 2–3 treatments, performed a week apart, should
suffice. If not, then reassess the case for correct diagnosis
of etiology of discoloration.
Walking bleach is the method of choice for bleaching
Endodontically treated teeth because:
• It is easy to perform
• Consumes less chairside time
• More comfortable to patient
• Requires no special equipment
• Safe technique.
Thermocatalytic Bleaching
• This technique involves placing superoxol matted cotton
pellets into the pulp chamber. The solution is activated
by heat application either by electric heating devices or
specially designed lamps.
• Intermittent 5–6 minutes exposures of the tooth with
heat and in-between cooling breaks, is done.
• Care must be taken to protect the teeth and surrounding
tissues from overheating. Protective creams such as
vaseline, orabase, cocoa butter can be applied to the
soft tissues during treatment to avoid heat damage.
• Application of high concentration of H2O2 in combination
with heat can cause irritation to the cementum and
periodontal ligament of the tooth being bleached
causing external cervical root resorption.
• Clinical result with this technique does not appear to
differ. So, the thermocatalytic approach is not used
routinely.
Use of Ultraviolet Photo-oxidation
• This technique involves placing superoxol matted cotton
pellet into the pulp chamber followed by 2-minute
exposure to ultraviolet light.
• Bleaching result does not differ.
• Not carried out routinely.
WHAT ARE THE SIDE EFFECTS AND ADVERSE
EFFECTS OF INTRACORONAL BLEACHING OF
ENDODONTICALLY TREATED TEETH?
External Cervical Root Resorption
High concentration oxidizing agent (30–35% H2O2)
may diffuse through exposed dentinal tubules
and cementum defects
↓
Necrosis of cementum
↓
Inflammation of periodontal ligament
↓
Root resorption
Prevention: Effective isolation of tooth with rubber dam,
interproximal wedges and ligatures.
Management: Use of calcium hydroxide dressing for a week,
in the access cavity prepared.
398 Short Textbook of Endodontics
Gingival Irritation and Tissue Burns
If superoxol comes in contact with the gingival tissue, it can
cause chemical burns and sloughing of gingiva.
Prevention:
• Protective creams such as vaseline, orabase, cocoa butter
to be applied to the soft tissues around the tooth to be
bleached.
• Use gingival barrier. Most of the commercially available
bleaching kits contain a gingival barrier which is light-
cured, so that the bleaching material does not leak
through to reach gingiva. For example, Pola office.
Reduction in Bonding Strength of Composite
Resin Restorations
After bleaching, if residual H 2O2 remains in the tooth
structure, the oxygen tends to:
• Inhibit resin polymerization
• There is decrease in bonding strength of resin composites
to enamel and dentin.
• There is increase in resin porosity.
Prevention: Residual H2O2 should be totally eliminated prior
to composite resin placement, which means composite
restoration placement should be delayed for 7–10 days.
Postbleaching Inflammation of
Periodontal Ligament
Improper barrier over the coronal extent of root canal filling
causes:
Leakage of bleaching agents through the space between
gutta-percha filling and root canal walls
↓ photographs
Leakage products reaching the periodontal ligament via
dentinal tubules, root apex, lateral and accessory canals
↓ 36% hydrochloric acid solution with equal volume
Inflammation of PDL
This can further lead to root resorption.
Prevention: Adequate cement barrier of thickness of atleast
2 mm over the coronal extent of root canal filling.
The ideal barrier is the one that protects the dentinal
tubules and conforms to the external epithelial attachment.
A mind-map to remember all points of side effects/
adverse effects of intracoronal bleaching of teeth is given
in Figure 23.15.
HOW DO WE RESTORE INTRACORONALLY
BLEACHED ENDODONTICALLY TREATED TOOTH?
• Any residual H2O2 from bleaching in the tooth structure
adversely affects the bond strength of composites with
enamel and dentin.
Therefore, it is recommended that one should wait
for at least 7 days after bleaching, prior to restoring the
tooth with composite restorations.
• It is recommended that a white cement be placed
beneath the composite restoration that helps in
distinguishing between composite and tooth structure
during rebleaching.
• Permanent coronal seal with composite resin restoration
after bleaching is to be done otherwise rediscoloration
of tooth would occur, if there is leaking restoration.
A mind-map to remember all points of bleaching is
given in Figure 23.16.
WHAT IS ENAMEL MICROABRASION?
• Enamel microabrasion involves decalcification and
removal of a thin layer of stained enamel.
• Enamel microabrasion technique is also called
“Controlled hydrochloric acid-pumice abrasion”
technique.
• This technique is mainly useful for fluorosis and also for
other extrinsic discolorations such as brown, orange or
yellow enamel spots and streaks, regardless of etiology
provided the stain is limited to a thin layer of tooth
surface (about 0.5 mm)
• Enamel abrasion procedure can be used independently
or prior to bleaching in certain cases.
• Step-wise procedure:
– Record the shade of the teeth. Take pretreatment
– Protect the gingiva and carefully isolate the teeth
with an inverted rubber dam and ligatures
– 18% hydrochloric acid solution is prepared by mixing
of distilled water and adding fine flour of pumice
to form a thick paste and is applied to enamel
surface using a piece of wooden tongue blade or
crushed orangewood stick. The paste is worked into
the enamel surface exerting firm pressure with a
scrubbing motion for 5 seconds.
– Then the enamel surface is rinsed with water for
10 seconds.
– A mixture of sodium bicarbonate with water forming
a thick paste is applied on the enamel surface for acid
neutralization.
 Management of Discolored Teeth 399

Fig. 23.15  A mind-map to remember all points of side effects/adverse effects of intracoronal bleaching of teeth

Fig. 23.16  A mind-map to remember all points of bleaching

400 Short Textbook of Endodontics
– Remove the rubber dam and use fine prophylactic
paste to smoothen the abraded enamel surface.
• Safety precautions:
– Excessive decalcification may occur. But, careful and
judicious application of 18% hydrochloric acid does
not usually remove significant amount of enamel.
– Chemical burns of soft tissues can be prevented by
using protective barriers.
WHAT IS THE ROLE OF VENEERS AND CROWNS
IN MANAGEMENT OF DISCOLORED TEETH?
Use of Composite Restoration/veneer for
Discolored Teeth
• If composite is to be used for discolored teeth, an
important consideration is masking of dentin shade not
only at the facial surface but also at the cervical margins
and incisal edges.
• The tooth should be prepared to allow a uniform
thickness of composite to create a polychromatic
appearance in the final result.
• If there is severe discoloration, the depth of preparation
should allow an additional thin layer of opaque
composite to mask the dark dentin.
• The incisal edges may need to be covered with
composites in few cases extending on the palatal surface.
Use of Ceramic Veneer/Laminates
for Discolored Teeth
• Ceramic laminates can be used in case of discolored
teeth. If the discoloration is mild to moderate, the tooth
preparation can be minimal from 0.3 mm cervically to
0.5 mm at the incisal edge. For severe discoloration, the
preparation has to be deeper than this.
• When more opaque ceramic is added in the veneer, it
masks the undesirable tooth color but that limits the
display of vitality.
• A more translucent ceramic allows more light
transmission and reflection internally, making the
restoration more vital.
Full Coverage Metal-ceramic or All-ceramic
Crowns for Discolored Teeth
• In case of severely discolored tooth or Endodontically
treated disclored tooth with considerable loss of tooth
structure, metal-ceramic or all-ceramic restorations are
indicated. Now-a-days, all-ceramic restorations (metal-
free), that make use of Zirconia or Lithium disilicate have
become quite popular and are being widely used to give
pleasing esthetics, simulating natural appearance.
• Intra-coronal bleaching of Endodontically treated
discolored tooth followed by all-ceramic restoration
gives favorable result.
BIBLIOGRAPHY
1. Grossman L, Oliet S, Del Rio C. Endodontic Practice, 11th edn.
Varghese Publication, 1991.pp.271-7.
2. Ingle J, Bakland L, Baumgartner J. Ingle’s Endodontics, 6th edn.
BC Decker Inc, Hamilton, 2008.pp.1383-96.
3. Patil R. Esthetic Dentistry: An Artist’s Science. 1st edn. PR
Publications, 2002.pp.105-7, 129.
4. Torabinejad M, Walton RE. Endodontics: Principles and Practice,
4th edn. Saunders, an imprint of Elsevier, 2009.pp.402-3.
 24
CHAPTER

Management of Dental
Traumatic Injuries

This chapter explains the various dental traumatic injuries with their consequences and discusses the
various treatment modalities for their management including the considerations at the emergency visit.
 You must know
• What are the Unique Aspects of Dental Trauma?
• What are the Consequences of a Dental Traumatic Injury?
• How do we Classify Traumatized Teeth?
• How do we Make Diagnosis in Case of Dental Traumatic Injuries?
• What are the Factors to be Considered for Treatment of Traumatized Teeth?
• What are the Different Dental Traumatic Injuries and their Management?
• Requirements for Success of Vital Pulp Therapy in Case of Traumatized Teeth

WHAT ARE THE UNIQUE ASPECTS OF DENTAL WHAT ARE THE CONSEQUENCES OF A DENTAL
TRAUMA? TRAUMATIC INJURY?
402 Short Textbook of Endodontics

HOW DO WE CLASSIFY TRAUMATIZED TEETH? Class II: Extensive fracture of crown involving enamel
and considerable amount of dentin but no pulp
• WHO classification has given following code numbers: exposure. Figure 24.2 shows photograph of fracture
873.60 Enamel fracture of maxillary left central incisor involving enamel and
873.61 Crown fracture involving enamel and dentin dentin.
without pulp exposure Class III: Extensive fracture of crown, involving enamel
873.62 Crown fracture with pulp exposure and considerable amount of dentin with pulp exposure.
873.63 Root fracture Figure 24.3 shows photograph of fracture of both
873.64 Crown-root fracture maxillary central incisors involving enamel, dentin and
873.66 Luxation pulp.
873.67 Intrusion or extrusion Class IV: Traumatized tooth becomes nonvital with
873.68 Avulsion or without loss of crown structure. Figure 24.4 shows
873.69 Other injuries, such as soft tissue laceration photograph of traumatized discolored maxillary right
• Andreasen’s modification of WHO classification: central incisor tooth without loss of crown structure.
873.64 Uncomplicated crown-root fracture without Class V: Tooth lost due to trauma.
pulp exposure
873.64 Complicated crown-root fractures with pulp
exposure
873.66 Concussion
873.66 Subluxation
873.66 Lateral luxation
• International association of Dental Traumatology
uses classification based on WHO and modified by JO
Andreasen and FM Andreasen, which is as follows:
Soft tissues
N873.69 Lacerations
N902.0 Contusion
N910.0 Abrasions
Tooth fractures
N873.60 Enamel fracture
N873.61 Crown fracture involving enamel and dentin
Fig. 24.1  Fractured incisal edges of both central incisors due to
without pulp exposure
trauma (Courtesy of Dr Manoj Ramugade)
N873.62 Crown fracture with pulp exposure
N873.63 Root fracture
873.64 Crown-root fracture
Luxation injuries
873.66 Tooth concussion
873.66 Subluxation
873.66 Extrusive luxation
873.66 Lateral luxation
873.67 Intrusive luxation
873.68 Avulsion
Facial skeletal injuries
802.20 Fracture of alveolar process of mandible
802.40 Fracture of alveolar process of maxilla
802.21 Fracture of body of mandible
802.41 Fracture of body of maxilla
• Ellis and Davey’s classification:
Class I: Simple fracture of crown involving enamel only.
Figure 24.1 shows photograph of fractured incisal edges Fig. 24.2  Trauma to maxillary left central incisor involving enamel
of both central incisors due to trauma. and dentin (Courtesy of Dr CR Suvarna)

Fig. 24.3  Trauma to maxillary central incisors involving enamel,
dentin and pulp (Courtesy of Dr CR Suvarna)
Class VI: Root fracture with or without loss of crown
structure
Class VII: Displacement of tooth without crown or root
fracture
Class VIII: Fracture of crown en mass
Class IX: Fracture of deciduous teeth.
HOW DO WE MAKE DIAGNOSIS IN CASE OF
DENTAL TRAUMATIC INJURIES?
Correct diagnosis is based on:
• History taking: Details of the traumatic event and the
relevant medical history.
• Clinical examination:
– Extraoral: Evaluate facial hard and soft tissues for
laceration, bone fracture, etc.
– TMJ and occlusion: Careful examination of temporo­
mandibular joint should be done. Occlusion should
be checked. Abnormalities in occlusion can indicate
alveolar bone or jaw fracture
– Intraoral:
- Soft tissues: Evaluate oral soft tissues—Lips,
tongue, cheek, floor of mouth, etc. for lacerations
and other injuries.
- Teeth and supporting tissues: Visual examination,
tactile inspection and palpation, percussion and
mobility testing.
• Diagnostic tests: Pulpal tests
– Thermal and electric pulp tests:
- May give false negative readings. This is because
due to traumatic injury, the conduction capability
of the nerve endings or sensory receptors may get
Management of Dental Traumatic Injuries 403
Fig. 24.4  Discolored nonvital right maxillary central incisor due to
trauma without any loss of crown structure and trauma to the left
side central incisor involving enamel and dentin (Courtesy of Dr CR
Suvarna)
deranged and may inhibit the nerve impulse
from an electric or thermal stimulus.
- A positive response at the initial examination
may get converted to a negative response at a
subsequent visit indicating degeneration of pulp
or a negative response initially may get converted
to a positive response indicating healthy pulp.
- To have a baseline data, these tests are performed
at the initial examination and then they are
repeated at 3 weeks, at 3, 6 and 12 months and
at yearly intervals following the accident.
- Electric pulp tests do not give predictable
results in young teeth but may be useful in
elderly patients or in traumatized teeth that are
undergoing premature sclerosis.
– Laser Doppler flowmetry:
Laser Doppler flowmetry (LDF) is a valuable
diagnostic test in assessing vitality in traumatized
teeth. It helps identify ‘at risk’ teeth early after trauma.
LDF detects blood flow more consistently and earlier
in traumatized teeth than the standard tests.
• Radiographic examination:
– Standard radiographs: Panoramic view (OPG), Intra-
Oral Periapical Radiograph (IOPA)
– Many angled radiographs have to be taken for correct
diagnosis.
– The International Association of Dental Traumatology
recommends three angulations for radiographs of
traumatized teeth, including:
i. Occlusal view
ii. Lateral view (from mesial or distal aspect of
tooth)
404 Short Textbook of Endodontics

iii. Horizontal angle of 90 degrees with central beam – Lateral luxation

through the tooth. – Extrusive and intrusive luxation
– Radiographs can be useful to detect: • Tooth avulsion.
- Any embedded foreign objects
- Bone fractures Crown Fractures
- Root fractures
- Subgingival crown fractures
- Root or bone resorption
– But, hairline fractures or fractures that run in a mesio­
distal direction may not be evident on radiographs.
• Clinical photographs: Photographs are taken to serve
as record for monitoring the patient and progress of the
treatment and also for documenting the injuries for legal
purposes.

WHAT ARE THE FACTORS TO BE CONSIDERED • Uncomplicated fractures of crown and their manage­
ment:
FOR TREATMENT OF TRAUMATIZED TEETH?
– The uncomplicated crown fractures may involve only
Figure 24.5 gives the factors to be considered for treatment enamel or enamel and dentin, but there is no pulp
of traumatized teeth in the form of a mind-map. exposure. It is not usually associated with pain or
any symptoms.
WHAT ARE THE DIFFERENT DENTAL TRAUMATIC – If fracture involves only enamel, then selective
grinding of incisal edges in order to remove sharp
INJURIES AND THEIR MANAGEMENT?
edges is done. (Enameloplasty).
We shall discuss the following dental traumatic injuries and – Fractures involving only enamel can be very well
their management: treated using composite restorations.
• Crown fractures – If fracture involves enamel and dentin, it can also be
• Crown-root fractures treated using composite restorations. A protective
• Root fractures liner may be needed if the fracture has occurred at
• Luxation injuries deeper level approaching the pulp.
– Concussion – If the fractured fragment is available, it can be re-
– Subluxation attached by etching and bonding technique.

Fig. 24.5  A mind-map to remember all points of factors determining treatment of traumatized teeth

– Carry out follow-up tests after a week, a month,
3  months, 6 months and a year to check the changes
in the condition of the pulp
- Normal response of pulp at following visits:
Indicates that pulp has recovered
- Abnormal response of pulp at follow-up visits:
Indicates unfavorable prognosis of pulp or pulp
necrosis and need for Endodontic treatment.
• Management of complicated fractures of crown:
When the fracture involves enamel, dentin and pulp, it
is called complicated fracture of the crown.
– Treatment options for complicated crown fractures
include:
– Choice of treatment depends on following factors:
(Remember the sentence): Decide To Repair Pulp
(Development, Time, Restorative treatment plan,
Periodontal injury) (Fig. 24.6).
REQUIREMENTS FOR SUCCESS
OF VITAL PULP THERAPY IN CASE
OF TRAUMATIZED TEETH
• Noninflamed pulp and less time elapsed:
– Vital pulp therapy (VPT) of noninflamed pulp has
high success rate.
– Within first 24 hours of injury, pulp inflammation
may be only superficial and if vital pulp therapy is
carried out during this time, it can have favorable
results.
– With increasing time between injury and therapy,
pulp removal must be extended apically to ensure
that noninflamed pulp has been reached.
Management of Dental Traumatic Injuries 405
• Bacteria-tight seal:
– Bacterial contamination during healing phase can
cause failure of VPT.
– If exposed pulp is effectively sealed against bacterial
leakage, healing of pulp occurs with a hard-tissue
barrier.
• Pulp dressing:
– Calcium hydroxide is commonly used in dressing for
vital pulp therapy that disinfects the superficial pulp
with its antibacterial effect and causes liquefaction
necrosis of superficial layers of inflamed pulp
forming a hard tissue barrier.
– Only disadvantage of calcium hydroxide is that it
does not seal fractured surface, as a result of which
additional material must be used to have bacterial
seal.
– Mineral trioxide aggregate (MTA) has been tried as
pulp capping agent with good results.
Pulp Therapies in Traumatized Teeth
Various pulp therapies have been discussed in detail in
Chapter 27: Pulp Therapies and Chapter 28: Pediatric
Endodontics. Here they will be explained in short, in relation
to traumatic injury.
Vital Pulp Therapy
• Pulp capping for traumatized teeth:
– In few traumatic exposures, a superficial pulp cap in
the form of a dressing such as calcium hydroxide can
be placed directly onto pulp exposure. This is called
direct pulp capping.
Figures 24.7A to C shows diagrammatic represen­
tation of direct pulp capping using calcium hydroxide
for a traumatized tooth and calcific bridge formed
after a few weeks of treatment.
– Success rate: 80%
– Disadvantages:
- Soon after traumatic exposure, superficial
inflam­mation of pulp occurs. With pulp capping,
inflamed rather than healthy pulp is treated. So,
potential for success is lowered.
- Due to limited depth of cavity, it is difficult to
achieve a bacteria-tight coronal seal.
Due to these difficulties, pulp capping is less com-
monly used treatment modality for traumatized teeth.
• Partial pulpotomy/Cvek pulpotomy:
– It involves removal of the superficial inflamed pulp
tissue.
406 Short Textbook of Endodontics

Fig. 24.6  A mind-map to remember all points of factors determining choice of treatment of complication fractured crown

– Technique: Steps include:

- Isolation : Rubber dam placement after
administration of anesthesia
- Cavity preparation : 1–2 mm deep cavity
preparation with diamond bur at high speed with
copious water coolant.
- Hemostasis: Pulp is amputated to the level
where only mild to moderate hemorrhage is
seen. Sterile  saline or anesthetic solution used
to rinse the area.
- Placement of calcium hydroxide: The pulpal cavity
and exposed dentinal tubules covered with hard-
setting calcium hydroxide.
A B C - Bacteria-tight seal: Glass ionomer cement is filled
in the prepared cavity for a bacteria-tight seal.
Figs 24.7A to C  Direct pulp capping in traumatized tooth: - Restoration: Etching and bonding for composite
(A) a: Denotes pulp exposure due to trauma resin restoration.
(B) a: Direct pulp capping with calcium hydroxide – Advantages:
b: Tooth restored with semipermanent restoration - Superficial inflamed pulp tissue is removed. So,
(C) Few weeks later more chances of success.
a: Calcific bridge formation - Space is provided for a material such as glass
b: Calcium hydroxide ionomer to provide a bacteria-tight seal to allow
c: Glass ionomer cement base pulpal healing.
d: Permanent restoration (Composite built-up) – Success rate: It is 94–96%.

• Full pulpotomy:
– When it is predicted that pulp is inflamed to deeper
levels of coronal pulp, the entire coronal pulp to the
level of root canal orifices is removed. This is called
full pulpotomy.
– Indications:
- Traumatic exposure after 72 hours
- Carious pulp exposures
This is the treatment modality in the immature
teeth with incompletely formed root apices. But, it
is contra­indicated in mature teeth.
– Technique: Steps include:
- Rubber dam placement after administration of
local anesthesia
- Removal of coronal pulp to the level of the root
canal orifices
- Calcium hydroxide is placed over the floor of pulp
chamber and glass ionomer placed to achieve a
bacteria-tight seal
- Coronal restoration
Fig. 24.8  A mind-map to remember all points of vital pulp therapy for traumatized teeth
Management of Dental Traumatic Injuries 407
- After the roots are formed completely, pulpectomy
can be done and root canal treatment completed
as usual.
– Success rate: It is 75% (prognosis poorer than partial
pulpotomy due to arbitrary site of pulp amputation.
There may be inflamed pulp sometimes extending
past the root canal orifices. This may result in
treatment of an inflamed rather than noninflamed
pulp. Thus reducing the success rate).
A mind-map to remember all points of vital pulp therapy
for traumatized teeth is given in Figure 24.8.
Nonvital Pulp Therapy
Pulpectomy
• Mature tooth:
Pulpectomy involves removal of the entire pulp
to the  level of apical foramen. In case of a mature
tooth with root apices closed, this is completed like
the routine Endodontic treatment involving access
408 Short Textbook of Endodontics
preparation, thorough cleaning and shaping followed
by obturation.
• Immature tooth:
– Apexification:
In case of immature teeth with open apices, and
thin dentinal walls, apexification procedure needs
to be carried out to form a hard-tissue apical barrier
against which an effective root canal filling can be
done and to reinforce the weakened root against
fracture both during and after apexification. Other
details of Apexification are given in Chapter 27 “Pulp
Therapies”.
– Technique: Steps include:
- Access cavity preparation: Determination of
provisional working length with the help of
a preoperative radiograph and confirmed
radiographically by placing the first Endodontic
instrument.
- Since the dentinal walls are thin, preparation of
canal is performed very lightly and with copious
irrigation using 0.5% sodium hypochlorite.
- Canal is dried with paper points and calcium
hydroxide intracanal dressing may be placed for
about 1 week for disinfection of the canal. After
1  week, the further treatment can be carried out.
A B
Figs 24.9A to D  (A) Immature pulpally involved maxillary right central incisor with rubber dam in place; (B) Apical plug of MTA;
(C) Obturation completed with thermoplasticized gutta-percha; (D) Follow-up radiograph after 6 months (Courtesy of Dr Roheet Khatavkar)
• Traditional method: A mix of pure calcium hydroxide
powder with sterile saline (or anesthetic solution) or
ready mixed commercially available calcium hydroxide
is packed against the apical soft tissue using a plugger.
Then the remaining canal is back filled with calcium
hydroxide to the level of root canal orifices. Access cavity
is filled with a well-sealed temporary filling.
Radiograph is taken to ensure the entire canal has
been filled.
Patient is recalled at 3-months intervals and
radiograph is taken to evaluate the formation of hard
tissue apical barrier. It may take about 3–18 months for
the barrier to form. If in between appointments, calcium
hydroxide wash out is seen, it is replaced as before.
After the hard tissue barrier is evident on radiograph
and tactile sensation with an Endodontic instrument,
the calcium hydroxide is washed out of the canal with
sodium hypochlorite. The canal is then filled against the
apical stop but with careful softened filling technique
without application of excessive lateral forces during
filling. Care must be taken to ensure that the root canal
filling is completed to the level of hard tissue barrier and
not forced beyond it.
• MTA Barrier: After the disinfection of the canal,
calcium sulfate is pushed through the apex to form a
resorbable extraradicular barrier against which MTA
can be packed. MTA is mixed with sterile water and
placed into the apical 3–4 mm of the canal. Radiograph
is taken to confirm its placement. A wet cotton pellet
has to be placed against MTA plug and left for about
6 hours for MTA to set and then the entire canal can
C D
 Management of Dental Traumatic Injuries 409

Fig. 24.10  A mind-map to remember all points of nonvital pulp therapy for traumatized teeth

be obturated. Alternatively, the obturation can be
done at the same appointment considering that the
tissue fluids of open apex will provide moisture for
MTA to set.
Figures 24.9A to D shows the radiographs of maxillary
right central incisor tooth in which apexification has
been done using MTA.
A mind-map to remember nonvital pulp therapy for
traumatized teeth is given in Figure 24.10.
• If the tooth can be maintained periodontally and can
allow for a well sealed coronal restoration, then the tooth
is treated as crown fracture.
Root Fractures
Root fractures involve the cementum, dentin and pulp.
• According to the level of fracture, root fractures can be
classified as:

Crown Root Fracture

• Presents a periodontal challenge
• For crown-root fractures, periodontal treatment is done
first to allow for a good margin for restoration.
410 Short Textbook of Endodontics

• According to the direction of fracture, root fractures can • Consequences of treatment: At follow-up visits, it may be
be classified as: found that:

Coronal Root Fractures

• In case of fracture at the level of or coronal to crest of
alveolar bone, prognosis is poor. The coronal segment
needs to be extracted if the fractured segments cannot
be reattached. Then the remaining root segment can
be orthodontically extruded for the restoration to be
fabricated.
• In case of fractures below the level of crest of alveolar Luxation Injuries
bone, reattachment of segments and adequate splinting
will allow for favorable healing. Luxation injuries cause damage to the attachment apparatus
(periodontal ligament and cemental layer).
Mid-root and Apical-root Fractures • Types of luxation injuries: Given on next page.
• What happens after luxation injuries?
• Necrosis may occur in the coronal segment with the
apical segment remaining vital or there may be necrosis
of both the coronal and the apical segments.
• If periapical lesion is seen in the apical segment, the
coronal root segment should be Endodontically treated
and the use of MTA or calcium hydroxide to form a hard-
tissue apical barrier can be considered in case of a wide
apical canal lumen.
• In case of mid-root fractures, removal of the apical • Management of luxation injuries:
segment may compromise the remaining attachment Concussion and subluxation:
and the crown-to-root ratio. So, careful assessment – Generally do not have any pulp consequences. Such
needs to be done. teeth should be kept under observation and pulp
• In case of apical 1/3rd fractures, if necrosis has occurred tests performed at each follow-up visit.
in the apical segment, this necrotic apical segment can – Pulp test findings:
be surgically removed, if the remaining root can provide i. Repetitive finding of positive response can be
adequate periodontal support. considered to be a sign of healthy pulp.
• Follow-up visits after splinting at 3 months, 6 months ii. Transition from positive to negative response
and 12 months are carried out to evaluate the prognosis can be an indication that pulp is undergoing
of the tooth. degeneration.

iii. Transition from negative to positive response
may occur if circulation is restored.
iv. Persistence of negative response can be
considered to be a sign of irreversibly damaged
pulp and Endodontic treatment is indicated.
– Immobilize the injured teeth using a splint.
– Relieve the occlusion by selective grinding of cusps
of opposing teeth.
Lateral luxation and extrusive luxation:
– If displacement of tooth (Luxation) occurs without
fracture:
a. Immediate management: Reposition the tooth
as soon after the accident as possible and
place a functional splint. Anesthesia needs to
be administered and then reposition the tooth
with minimal force by moving it coronally (out
of buccal bone plate) and then apically (into its
original position).
Splint can be removed in 2 weeks.
b. Late: Orthodontic treatment.
– Evaluate the width of apical constriction at the time
of repositioning.
- If width is 1 mm or more: It is considered that
revascularization will occur.
No treatment, but tooth kept under observation.
- If width is less than 1 mm: Root canal treatment
should be initiated immediately.
Intrusive luxation: Most severe traumatic injury.
– Immature tooth: May re-erupt and revasculari­zation
may occur. Observe for 4–6 weeks. If re-eruption
stops before normal occlusion is attained, then
orthodontic treatment is started to prevent ankylosis.
– Mature tooth: Pulp necrosis generally occurs.
Endodontic treatment is indicated. Severe
injury to PDL can lead to complications such as
Management of Dental Traumatic Injuries 411
replacement resorption and further dentoalveolar
ankylosis. Objective of treatment is to prevent such
complications. Severely intruded tooth may require
surgical access to attach orthodontic appliances for
extrusion of tooth.
– Primary tooth: If it gets intruded, it usually re-erupts
but may deviate the path of the permanent tooth bud.
So, immediate treatment may be needed.
Tooth Avulsion
Also called total luxation or exarticulation. It is the complete
displacement of the tooth out of the socket.
Tooth avulsion is treated by replantation, which refers
to replacement of tooth in its socket, with the object of
attaining reattachment when the tooth has been completely
avulsed from its socket.
• Management of an avulsed tooth: Management of an
avulsed tooth considers the following factors:
Ideally, an avulsed tooth must be replanted as soon as
possible and should be functionally splinted.
• Management of an avulsed tooth with extraoral dry time
of less than 60 minutes and with a closed apex:
– Rinse the root with water or saline
– Replant the root in the socket gently
– On second visit (after 7–10 days) consider Endodontic
treatment.
412 Short Textbook of Endodontics
– Obturation can be done immediately if clinical and
radiographic examinations do not indicate pathosis
– But if signs of resorption are present, long-term
calcium hydroxide therapy can be given until an
intact lamina dura can be traced
– After obturation of root canals, tooth should receive a
permanent restoration as soon as possible to obtain
a good coronal seal
– Follow-up visits at 3 months, 6 months and
12  months.
• Management of an avulsed tooth with extraoral dry time
of less than 60 minutes and with an open apex:
– It is recommended to soak the avulsed tooth in
doxycycline or cover it with minocycline for about
5 minutes and then rinse off the debris gently.
– Replant the tooth in the socket gently
– In case of an avulsed tooth with open apex, the
revascularization of the pulp and continued root
development are expected.
– But if signs of infection appear, then apexification
procedure followed by Endodontic treatment is
indicated and performed in the second visit which
is after 7–10 days.
• Management of an avulsed tooth with extraoral dry time
of more than 60 minutes and with a closed apex:
– It is recommended that all the remaining periodontal
ligament cells be removed from the root in order to
make it resistant to resorption and slow down the
ankylosis, on replantation.
This is done by:
– Soak the avulsed tooth in etching acid for 5 minutes
– Then soak it in 2% stannous fluoride for 5 minutes
– Replant the tooth in the socket gently
– Extraoral Endodontic treatment may be performed
in the avulsed tooth before replanting it, under
absolutely aseptic conditions
But, this step has not been found to have any
advantage.
– After 7–10 days, Endodontic treatment and other
considerations similar to teeth with extraoral time
less than 60 minutes.
• Management of an avulsed tooth with extraoral dry time
of more than 60 minutes in a tooth with open apex: Due
to potential complications involved with replantation
of such teeth, whether to replant such teeth or not is
controversial.
If decision is made to replant it, it is recommended
that Endodontic treatment be performed extraorally and
seal the blunderbuss apex and then replant it.
If Endodontic treatment is not possible at the
emergency visit and the avulsed immature tooth has
been replanted, then the apexification procedure is
initiated in the second visit.
Adjunctive therapy: It involves:
– Administration of antibiotics:
- At the time of replantation and before Endodontic
treatment
- Tetracycline affects the motility of osteoclast and
reduces the effectiveness of collagenase
- Penicillin V can also be beneficial
– Chlorhexidine rinses for 7–10 days to control the
bacterial content of the sulcus
– Administration of analgesics if required.
Physiologic storage media for avulsed tooth if
immediate replantation is not possible: If the avulsed
tooth cannot be replanted immediately, the tooth
should be placed in physiologic storage solution in
order to have an extended extraoral time to minimize
resorption complications after replantation.
Examples of such physiologic storage media in order
of preference are:
– Hank’s balanced salt solution (HBSS): It is a pH
preserving fluid that can keep the periodontal
ligament cells viable for 24 hours.
– Milk
– Saliva
– Physiologic saline
– Water.
Water is least desirable storage medium because the
hypotonic environment of water may cause rapid cell
lysis and hence there may be increased inflammation
on replantation.
Outcome of replantation:
– If extraoral dry time is less than 15–20 minutes,
periodontal healing is expected to occur. The
PDL cells maintain their viability and repair after
replantation with minimal destructive inflammation.
– If extraoral dry time has been more and excessive
drying has occurred before replantation, the damaged
periodontal ligament cells elicit a severe inflammatory
response, large area of root surface gets affected
that has to be repaired by new tissue. Replantation
 Management of Dental Traumatic Injuries 413

TABLE 24.1  Management of dental traumatic injuries (Courtesy of Dr Ashwin Jawdekar)

Injury Management
Enamel fracture Enameloplasty, fragment reattachment, composite
Enamel and dentin fracture Fragment reattachment, composite, pulp protection
Pulp exposure Pulp capping, pulpotomy, apexification, RCT, composite, crown
Nonvital tooth RCT, composite, crown
Lost (Avulsion) - Replantation and splinting for 2–3 weeks;
OR
- Replacement of missing tooth: RPD/FPD; implant
Root fracture Coronal third—Orthodontic extrusion or crown lengthening, core-build, crown; extraction (poor prognosis)
Middle third—Splinting for 3 months, RCT
Apical third—Splinting for 1 month, RCT (good prognosis)
Displacement without fracture Lateral luxation, extrusion: Immediate—repositioning; late—orthodontic movement
Intrusion—observe for re-eruption 4–6 weeks, orthodontic treatment
If nonvital, RCT
En masse crown fracture Extraction; orthodontic extrusion or crown lengthening, core-build, crown (poor prognosis)
Traumatic injuries to primary teeth Avulsion—no replantation as ankylosis may develop
Intrusion—usually re-erupt; may deviate path of permanent tooth bud
Root fractures—coronal and middle third- extraction
Crown en masse fracture—extraction
Displacement—immediate-repositioning, late- extraction
Splint for less period (2 weeks)

resorption may occur which is frequently followed BIBLIOGRAPHY

by ankylosis (osseous replacement or replacement
resorption). The pathologic resorption associated with
avulsed tooth has been explained in detail in Chapter
30 “Pathologic Tooth Resorption”.
Table 24.1 gives the summary of the management
of the dental traumatic injuries.
1. Cohen S, Hargreaves KM. Pathways of Pulp. 9th edn. St. Louis:
Mosby, 2006.pp.610-46.
2. Grossman L, Oliet S, Del Rio C. Endodontic Practice, 11th edn.
Varghese publication, 1991.pp.278-88, 329-33.
3. Ingle J, Bakland L, Baumgartner J. Ingle’s Endodontics, 6th edn.
BC Decker Inc, Hamilton, 2008.pp.1330-53.
 25
CHAPTER

Endodontic-Periodontal
Inter-relationships

This chapter deals with various aspects of Endodontic-Periodontal inter-relationships, the differential
diagnosis of the disease process and the appropriate treatment modality for the same.
  You must know
• How are Endodontic and Periodontal Tissues and their Diseases Inter-Related?
• What are the Etiologic Factors and Contributing Factors causing Endodontic-Periodontal
Diseases?
• How do we Classify Endodontic-Periodontal Lesions?
• How to Detect Endodontic Periodontal Lesions?
• What Differential Diagnosis will you Consider when you see Features of Both Endodontic
and Periodontal Lesions?
• Which are the Different Types of Endodontic-Periodontal Lesions?
• What are the Treatment Alternatives in case of Endodontic-Periodontal Lesions?
• What is the Prognosis of a Tooth with both Endodontic and Periodontal Disease?

HOW ARE ENDODONTIC AND PERIODONTAL
TISSUES AND THEIR DISEASES INTER-RELATED?
The tooth, its pulp and its supporting structures together
constitute a ‘biologic unit’. The pulp and the periodontium
evolved from the same mesenchymal tissue during the
formative stage. Except for enamel, which is an ectodermal
derivative, all the other dental structures are formed by
neural crest cells that later condense in developing maxilla
and mandible as dental papilla and dental follicle. The
dental papilla gives rise to the dental pulp and the dental
follicle gives rise to the periodontal structures.
Thus, the pulp and the periodontium are embryologically
and structurally related.
Intercommunication between Pulp and
Periodontal Tissues
There are intimate anatomic and vascular connections
between the pulp and periodontium through various
pathways as given here.
Pathways of communication between pulp and periodontium:
A. Physiologic modes of communication:
1. Apical foramen
2. Lateral canals, accessory canals and furcation canals
3. Exposed dentinal tubules: When cementum and
enamel do not meet at CEJ, dentinal tubules remain
exposed acting as pathway of communication
between the pulp and the periodontium.
B. Pathologic modes of communication:
1. Exposed dentinal tubules in areas devoid of
cementum due to:
a. Developmental defects such as palatogingival
groove, cervical enamel projections
b. Root caries
2. Idiopathic root resorption
3. Pathologic root perforations
4. Vertical root fractures (VRF)
5. Trauma
C. Iatrogenic:
1. Exposed dentinal tubules following periodontal
therapy such as root planning

2. Accidental perforations during Endodontic treatment
3. Surgical procedures.
Inter-relationship between Diseases of the Pulp
and the Periodontium
• Endodontic lesions can cause periodontal lesions
Inflammatory products from diseased pulp, necrotic
debris, bacterial by products and toxins
Through apical foramen and lateral and accessory canals
↓ lesions.
Inflammation in periodontium involving PDL only or
tooth socket and surrounding bone
Toxic irritants of periodontal tissue destruction migrate
towards gingival margin: Retrograde periodontitis.
• Periodontal lesions can cause Endodontic lesions
One of the main goals of Endodontics is to cure apical
periodontitis. Thus, Endodontics may be thought of as
periapical Periodontics.
WHAT ARE THE ETIOLOGIC FACTORS
AND CONTRIBUTING FACTORS CAUSING
ENDODONTIC-PERIODONTAL DISEASES?
Etiological Factors
• Bacteria: Root canal flora consists of proteolytic
bacteria and anaerobic microbiota. Spirochetes are
associated with both periodontal (subgingival plaque)
and Endodontic diseases (root canals). The spirochetes
Treponema denticola and Treponema maltophilum
have been isolated from root canals. Porphyromonas
gingivalis, Bacteroides forsythus, Prevotella intermedia,
etc. are few periodontal pathogenic bacteria.
• Fungi: Fungi mainly Candida albicans is found both in
Endodontic and periodontal lesions. Fungi may enter
the root canals from oral cavity due to poor asepsis
Endodontic-Periodontal Inter-relationships 415
during root canal treatment procedures. Fungi are found
in subgingival plaque.
• Viruses: Viruses have also been found associated with
both Endodontic and Periodontal diseases. Herpes
Simplex virus has been isolated from the gingival
crevicular fluid and gingival biopsies of the periodontal
lesions. Pulpal and associated periapical disease
containing human cytomegalovirus and Epstein Barr
virus have been found in few clinical studies. Herpes
simplex virus has not been detected in periapical
(The microbiology of root canals has been discussed
in detail in Chapter 6 Endodontic Microbiology).
Contributing Factors
• Inadequate Endodontic treatment: Poor Endodontic
treatment results in treatment failure contributing to
Endodontic-periodontal disease.
• Traumatic injuries of teeth may involve the pulp
and even the surrounding periodontal attachment
apparatus. Traumatic injuries and their management
has been discussed in detail in Chapter 24.
• Coronal leakage: Coronal leakage has been found to be
one of the major causes of Endodontic treatment failure.
Endodontically treated teeth may get contaminated by
microorganisms due to defective restorations or delay in
placement of coronal restoration. An adequate coronal
restoration is essential to prevent coronal leakage.
• Root Perforations: May be pathologic caused due to
extensive carious lesion, resorption, etc. or may be
iatrogenic (Operator error during post preparation or
access preparation or root canal instrumentation.) It can
lead to periodontal lesions. Sealing of the perforation
as early as possible and infection control is important
for good prognosis. Mineral trioxide aggregate (MTA) is
widely used perforation repair material.
• Developmental malformations: Radicular invaginations
found in central fossa of maxillary central and lateral
incisors crossing cingulum and continuing till the root
can lead to untreatable periodontal condition when its
epithelial attachment is breached, resulting in infrabony
pocket formation. This condition may get associated
with Endodontic disease.
(Remember the sentence: Contributing To Endo-Perio
Disease: Coronal Traumatic Endodontic Perforations
Developmental).
Figure 25.1 is the mind-map listing the etiologic and
contributing factors for Endodontic-periodontal disease.
416 Short Textbook of Endodontics

Fig. 25.1  Mind-map of etiologic and contributing factors causing Endodontic periodontal diseases

HOW DO WE CLASSIFY ENDODONTIC- determines the type of therapy required and probable
PERIODONTAL LESIONS? prognosis of the case.

Due to close relationship between Endodontics and

Periodontics, various classifications of Endodontic-
periodontal lesions have been suggested in order to divide
the type of cases that may require combined (Endodontic-
periodontal) or single therapy.
• Classification given by Simon et al:

• Classification given by Oliet and Pollock: Oliet and

• Classification given by Weine: Weine classified the Pollock classified the Endodontic-periodontal lesions
Endodontic-periodontal lesions based on etiology which based on the required treatment procedure as follows:

HOW TO DETECT ENDODONTIC
PERIODONTAL LESIONS?
Pulpal and periodontal diseases have common clinical
symptoms such as tenderness to percussion and swelling
and may mimic each other clinically and radiographically.
Correct diagnosis of the etiology of the disease process,
whether Endodontic, periodontal, or combined will
determine the treatment and long-term prognosis of the
case.
Close relationship between pulpal and periodontal
disease is reasonably established based on:
Case history taking
• Chief complaint of the patient
• Medical history review
Clinical examination and diagnostic tests
• Visual examination and palpation to assess the signs
and symptoms
Endodontic-Periodontal Inter-relationships 417
• Presence of swelling: A swelling related to the dental
pulp commonly found in the mucobuccal fold. Swelling
related to the periodontal problem occurs on the
attached gingiva.
• Percussion:
– Tenderness to percussion in coronoapical direction
usually indicates pulpal pathology
– Tenderness to percussion in lateral direction usually
indicates periodontal pathology.
• Pain: Usually sharp/severe/acute onset pain is related to
pulpal pathology and chronic, dull discomfort is related
to periodontal pathology.
• Distribution: Periodontitis is usually generalized and
pulpal pathology usually localized, affecting single tooth.
• Etiological factors: Periodontal problem is usually
associated with local irritating factors such as plaque
and calculus and caries or trauma is associated with the
pulpal problem.
• Pulp tests: Tooth which is pulpally involved may have
nonvital pulp and tooth which has only periodontal
involvement is vital.
418 Short Textbook of Endodontics

• Tracing sinus tract or fistula, if present. Mostly related radiographic and histopathological findings. These should
to a pulpal problem. be considered for differential diagnosis.
• Pocket probing: Pocket relates to a periodontal problem A very simplified table to explain these similarities and
if the tooth is vital. But in case of pocket associated with differences which is as follows: (Cohen’s ‘The Pathways of
a nonvital tooth, there is possibility of an Endodontic Pulp’– 9th Edition’, p. 657).
problem. Long and narrow pocket related to a single
isolated tooth is suggestive of Endodontic problem. Endodontic disease Periodontal disease
Pockets with wide entrance are suggestive of periodontal •  Clinical findings:
problem.   –  Etiology Infection of pulp Infection in
• Probing of furcation defect, if any. Usually related to periodontium
periodontal disease.   –  Vitality of tooth Nonvital Mostly vital
• Tooth mobility-determination. Mobility involving   –  Any restoration Deep or extensive Not related
multiple teeth other than the involved tooth, is more   – Local irritating Not related Primary cause
related to Periodontal problem. factors:
Plaque, calculus
Radiographic examination   –  Inflammation Acute, sometimes chronic Chronic
• Extent of caries or restorations.   – Periodontal Single, narrow Multiple, wide
• Status of any Endodontic treatment done in the tooth pockets coronally
• Condition of periradicular tissues: Thickness of PDL,   –  pH value Often acidic Usually alkaline
changes in alveolar bone such as bone loss
  –  Trauma Primary or secondary Contributing factor
• Root resorption
  – Micro- Few Complex
• Wide periapical radiolucency may be suggestive of
organisms
pulpal problem. Crestal bone loss, horizontal or vertical
•  Radiographic findings:
bone loss is suggestive of periodontal problem.
• Gutta-percha point inserted in the sinus tract and   –  Pattern Localized Generalized
radiograph taken, helps to identify the source of   –  Bone loss Wider apically Wider coronally
infection.   –  Periapical Radiolucency Not often related
  – Vertical bone Absent Present
WHAT DIFFERENTIAL DIAGNOSIS WILL YOU loss
CONSIDER WHEN YOU SEE FEATURES OF BOTH •  Histopathological findings:
ENDODONTIC AND PERIODONTAL LESIONS?   – Junctional No apical migration Apical migration
epithelium
Clinical signs and symptoms and radiographic evaluation   – Granulation Apical (minimal) Coronal (larger)
help the clinician to rule out different diseases: tissue
It may be:   –  Gingiva Normal Some recession
• Primary Endodontic or Periodontal lesion with
•  Treatment Root canal treatment Periodontal treatment
secondary involvement resulting in a combined lesion.
• Vertical root fractures: Difficult to diagnose as it may not
be detectable by clinical inspection and radiographic
WHICH ARE THE DIFFERENT TYPES OF
examination unless the root fragments have separated.
Exploratory surgical exposure of the root for direct visual
ENDODONTIC-PERIODONTAL LESIONS?
examination can give definitive diagnosis. Primary Endodontic Lesions
• Developmental grooves: Such as palatogingival grooves
found in maxillary central and lateral incisors should be • Deep caries, extensive restorations or traumatic injury
looked for as it might have caused the defect. Localized associated with pulpal involvement may lead to
Periodontal destruction occurs due to such grooves. Pulp Endodontic pathology. The inflammatory components
of such teeth may become secondarily involved. may pass through the apical foramen or lateral/
There are certain similarities and differences in the accessory canals and produce mild inflammation at the
pulpal and Periodontal diseases in terms of clinical, apex or near the opening of the lateral/accessory canals.

• A deep solitary pocket in the absence of true Periodontal
disease is indicative of lesion of Endodontic origin as
shown in Figure 25.2.
• This pocket is a sinus tract from pulpal origin that opens
along  PDL area through lateral accessory canals and
apical foramen.
• There is no increase in probing depth around the tooth
except in the area of sinus tract.
• Also, a sulcular pocket of Endodontic origin is typically
very narrow compared to pocket of Periodontal origin.
• Figure 25.2 shows diagrammatic representation of
mandibular molar showing deep carious lesion with
infected/necrotic pulp. This lesion has primarily an
Endodontic etiology. It shows the various pathways for
the spread of infection that include:
– from apex to gingival sulcus
– from apex to furcation area
– from lateral canals to gingival sulcus
– from lateral canals to furcation area
• Diagnosis: The origin of the lesion can be traced by
inserting gutta-percha cone into the sinus tract and
taking radiographs. Also, based on findings such as
minimal amount of plaque or calculus present, necrotic
pulp of the involved tooth.
Fig. 25.2  Mandibular molar with deep carious lesion. Various
pathways for the spread of infection denoted by arrows. a. from
apex to gingival sulcus; b. from apex to furcation area; c. from lateral
canals to gingival sulcus; d. from lateral canals to furcation area
Endodontic-Periodontal Inter-relationships 419
• Treatment: Root canal treatment. Primary Endodontic
lesions usually heal following root canal treatment.
The sinus tract extending into the gingival sulcus or
furcation area quickly heals by itself following root canal
treatment.
• Prognosis: Excellent prognosis. The periapical lesion
usually resolves if proper Endodontic therapy is done.
Primary Endodontic Lesions with Secondary Periodontal
Involvement
• When lesion of Endodontic origin is not treated
↓
Pathosis continues to progress causing break-down of
surrounding hard and soft tissues.
Figure 25.3 shows diagrammatic representation of an
Endodontically involved mandibular molar tooth. There
is spread of infection through apical foramen and deep
solitary pocket is formed.
• Root perforation during root canal treatment also causes
secondary Periodontal involvement.
• Root fractures also mimic the appearance of primary
Endodontic lesions with secondary Periodontal
involvement. Frequently occurs on Endodontically
treated teeth with large post.
Fig. 25.3  a. Spread of infection from an Endodontically involved
tooth through the apical foramen; b. Deep solitary periodontal
pocket formation
420 Short Textbook of Endodontics

• Diagnosis • Mobility of teeth may be seen but in most cases, teeth

– Necrotic root canal and plaque or calculus respond positively to pulp testing.
accumulation demonstrated by probing and • Treatment: Oral prophylaxis including scaling and
radiographs. polishing of teeth and root planning. Periodontal flap
– May be associated with pain, swelling, purulent surgery may be needed in some cases. Root amputation
exudates, pocket formation and tooth mobility. may be required in advanced cases.
– In cases of root fractures, local deepening of • Prognosis for such teeth depends upon the stage of
Periodontal pocket and more acute Periodontal Periodontal disease.
abscess symptoms can be found. Figure 25.4 shows radiograph of maxillary molar with
– Deep solitary periodontal pocket present. Periodontal lesion.
• Treatment
– Requires both Endodontic and Periodontal Primary Periodontal Lesions with Secondary Endodontic
treatment. Involvement
– With Endodontic treatment alone, only part of the
lesion will heal.
– First Endodontic therapy followed by Periodontal
therapy is done.
– In case of vertical root fracture, extraction of the
tooth.
• Prognosis
– Good prognosis.
– Only in case of vertical root fracture, prognosis of
tooth is poor and needs extraction.

Primary Periodontal Lesions

• Periodontal disease begins in gingival sulcus, migrates
to apex as the deposits of plaque and calculus cause
breakdown of surrounding alveolar bone and soft
tissues.
• Accumulation of plaque and calculus and presence of
wider pockets.
Figure 25.5 shows diagrammatic representation of
mandibular molar with primarily Periodontal involvement.
Infection can spread from Periodontal pocket through apical
foramen to the pulp as denoted by arrows.

Fig. 25.4  Radiograph showing Periodontal Fig. 25.5  The tooth has no carious lesion and reveals a vital pulp.
lesion in maxillary molar There is primarily Periodontal involvement. a. Periodontal pocket;
b.  Infection can spread to the pulp through the apical foramen
 Endodontic-Periodontal Inter-relationships 421

This can happen when treatment procedures like scaling, • Treatment : Both Endodontic and Periodontal
curettage or surgical flap procedures open the dentinal treatment.
tubules and lateral canals to the oral environment. This After a definitive diagnosis is established, Root
results in pulp inflammation and necrosis. canal treatment and/or required Periodontal therapy is
• Signs and symptoms of pulpal disease as well as considered in the treatment plan. Generally Endodontic
Periodontal disease become evident. treatment should precede Periodontal therapy.
• Treatment of lesions that are primary Periodontal and • Prognosis depends on the amount of Periodontal
secondary Endodontic involvement: destruction. Prognosis is guarded in single-rooted teeth.
– Endodontic treatment
– Periodontal procedures such as Scaling and root
planning
– Periodontal flap surgery may be required in few
cases.
– In certain conditions like localized Periodontal
defect associated with Endodontically untreatable
tooth or iatrogenic errors causing Endoperio lesions,
certain treatment alternatives need to be considered
such as Root resection/amputation or guided tissue
generation (GTR), discussed later in this chapter.

True Combined Lesions

• Pulpal and Periodontal disease may occur independently
or concomitantly in and around the same tooth.
• True combined lesions occur when Endodontic disease
progressing coronally joins with an infected Periodontal
pocket progressing apically as shown and explained in
Figure 25.6. The Endodontic and Periodontal lesions
which were once separate, now communicate.
• Diagnosis: Necrotic pulp or failing Endodontic
treatment, plaque, calculus and periodontitis may be Fig. 25.6  a. Caries involving the pulp; b. Spread of infection from
Periodontium into the pulp through the lateral canal; c. Periodontal
present in teeth with combined lesions. pocket; d. Spread of infection from the infected pulp to the
Figures 25.7A and B show radiographs of mandibular periodontium through the apical foramen resulting in combined
molars with combined Endodontic-Periodontal lesion. lesion

A B
Figs 25.7A and B  Radiographs of mandibular first molar with both—severe Periodontal lesion and Endodontic involvement
422 Short Textbook of Endodontics
Concomitant Pulpal and Periodontal Lesion
• Lesions that may commonly be seen clinically and reflect
presence of two separate and distinct entities are named,
concomitant Pulpal and Periodontal lesion.
• Both may have different causative factors.
• There is no clinical evidence that either disease state has
influenced the other.
• Both separate lesions have coincidently attacked the
same tooth.
• Both the disease processes must be treated concomitantly
with the removal of individual etiologic factors.
• It should be determined whether periodontal condition
is treatable. There is no point performing Endodontic
therapy in teeth with hopeless periodontal lesions.
• Endodontic therapy is performed first followed by
Periodontal therapy.
• The healing of periapical lesion is not affected by the
periodontal therapy to follow.
Weine’s classification of Endodontic-Periodontal problems:
Weine has suggested a classification of Endodontic-
Periodontal problems, that is clinically oriented and helps
in determining accurately the correct method of therapy
required. The types of Endodontic Periodontal problems
according to Weine’s classification are summarized in
Table 25.1.
WHAT ARE THE TREATMENT ALTERNATIVES IN
CASE OF ENDODONTIC-PERIODONTAL LESIONS?
Primary treatment of different Endodontic-periodontal
lesions has been explained previously with the different
types of Endodontic-periodontal lesions.
Treatment alternatives in case of Endodontic-periodontal
lesions include the following:
Respective Techniques
Root Resection
“Radisectomy or root resection is the removal of root with
accompanying odontoplasty”. This can be done before but
preferably after Endodontic treatment.
“Hemisection refers to sectioning of the crown of a
molar tooth with either the removal of half of the crown and
its supporting root structure or retention of both halves to
function as two premolars”.
• Indications of root resection:
– Root fracture
– Root perforations
– Root destroyed by extensive caries
– Extensive loss of bone around one root due to
dehiscence, fenestration, external root resorption
– Impaired Endodontic treatment of a particular root
– Severe periodontitis involving only one root
– Untreatable furcation involvement.
• Contraindication: When loss of bone involves more than
one root and the remaining root would have inadequate
support.
In such cases, extraction of such a tooth is
recommended. Occlusal function can be restored by
considering implants with hybrid prostheses.
• Case selection: Root resection is a technique-sensitive
procedure that requires careful diagnostic process
for selection of case that would be best treated with
resection technique.
• Accompanying odontoplasty:
– Crown: Proper reshaping of occlusal table and resto­
ration of the clinical crown is to be done.
– Root: Root surface must be recontoured to remove
the root stump.
• Prognosis: Long-term prognosis for vital root resection
has been found to be poor. Whenever possible, root
canal treatment should be done before root resection.
If not possible, then it should be performed as soon as
possible after vital root amputation.
Regenerative Technique
Guided tissue regeneration (GTR) barrier membranes can be
used in case of large periradicular lesions to promote bone
healing after Endodontic surgery. Bone replacement grafts
using guided tissue and bone regeneration techniques re-
establish the biologic structures that were lost during the
disease process.
 Endodontic-Periodontal Inter-relationships 423

TABLE 25.1  Types of Endodontic-periodontal problems according to Weine’s classification

Class I
1. Predominant • Endodontic (Pulp
lesion inflammation and/or
necrosis)
• Simulates periodontal
disease clinically and
radiographically
2. Etiology Endodontic (pulpal disease) Both Endodontic (pulpal and
Tooth may have deep periapical) and Periodontal
caries, large restoration disease
approaching the pulp,
pulp capping, pulpotomy,
considerable dimunition of
pulp space
3. Diagnosis It is based on finding that
patient has minimal or no
periodontal disease in other
areas of mouth
4. Treatment Endodontic therapy only
5. Prognosis Heals rapidly. Excellent
prognosis. Clinical
symptoms disappear
after initial root canal
debridement. Deep
pocket of 8–10 mm
reduces to about 2 mm
after first appointment
of Endodontic treatment.
Bone damage gets repaired
and remineralized seen on
radiograph within one year
Class II
• Both Endodontic and
Periodontal disease
concomitantly
• Pulpal disease may be
coincidental to Periodontal
lesion or may be due to degree retain the tooth
of Periodontal damage
It is based on finding that
periodontal problems are
present elsewhere in mouth and
that a pulpal pathosis is also
present
Both Endodontic and Periodontal Here treatment is aimed at Requires periodontal therapy
therapy
Prognosis for periapical
portion is superior to that of
Periodontal portion. If periapical
lesion healed after Endodontic
treatment, less chance of
recurrence. Periodontal lesion
may recur if periodontal
maintenance not followed
Class III Class IV
• Severe Periodontal disease •  Periodontal disease
• Has no pulpal problem. • Simulates clinically and
Needs Endodontic therapy radiographically pulpal or periapical
and root amputation to gain disease and appears to indicate
periodontal healing and need for Endodontic treatment
but actually requires Periodontal
therapy only
Periodontal disease. Pulp may Periodontal disease
be normal or may have some
degree of pulpal inflammation
Periodontal disease present, Due to loss of bone and soft tissue
no pulp damage in the support due to periodontal disease,
involved tooth. Possibility of affected teeth may become sensitive
retaining the tooth and good to changes in temperature which
periodontal result by means might be misdiagnosed as irreversible
of Endodontic treatment plus pulpitis. Tenderness to percussion and
root amputation mobility and swelling. Exudate may
be expressed from crevice on probing
in case of periodontal abscess
gaining healing of periodontal-
only problem. Endodontic
therapy and guided tissue
regeneration (GTR) or root
amputation (indicated in case
of severe periodontal defect
around one root of multirooted
tooth, other roots have healthy
support)
Here use of Endodontic Prognosis is poor unless periodontal
procedure produces healing treatment is done
of periodontal disease and no
further periodontal therapy
may be required in the area of
amputation of involved root

Other Treatment Alternative: Forced • Indications:

Eruption/Orthodontic Extrusion – Fractured teeth
– Teeth with extensive caries
In cases where surgical crown lengthening cannot be – Teeth with internal or external root resorption
performed or will not give the desired result, orthodontic – Teeth with lateral perforation
extrusion can be a better alternative. – Teeth in which surgical crown lengthening will
It is very infrequently used technique. produce poor prosthesis.
It serves to preserve the natural root system and related • Prognosis is usually poor in case of single-rooted
periodontal architecture. teeth.
424 Short Textbook of Endodontics
Disease process
• Primary Endodontic disease
Necrotic tooth with or without sinus tract
• Primary Periodontal disease
• Primary Endodontic disease with secondary Periodontal
involvement
• Primary Periodontal disease with secondary Endodontic
involvement or true combined lesions
Prognosis may be better in molar teeth if all the roots
have not suffered loss of supporting tissues. Root resection
can be considered as treatment alternative.
WHAT IS THE PROGNOSIS OF A TOOTH
WITH BOTH ENDODONTIC AND
PERIODONTAL DISEASE?
Long-term prognosis will be determined by correct
diagnosis of the etiology of disease process whether
Endodontic, Periodontal or combined. The prognosis of
Prognosis
Excellent prognosis if appropriate Root Canal Treatment is done.
Excellent, good to poor prognosis depending on severity of Periodontal disease,
patient’s tissue response and oral maintenance.
Good to poor prognosis. Endodontic treatment to be done first, treatment results to
be evaluated in 2–3 months and only then Periodontal therapy considered.
Guarded prognosis. It depends mainly on severity of Periodontal disease and
success of Periodontal therapy.
the tooth as per the type of Endodontic-Periodontal lesion
is given in the above table.
BIBLIOGRAPHY
1. Cohen S, Hargreaves KM. Pathways of Pulp, 9th edn. St. Louis:
Mosby; 2006.pp.650-65.
2. Franklin S Weine. Endodontic therapy, 6th edn. Mosby-Affliate
of Elsevier, St Louis, Missouri; 2004.pp.452-80.
3. Grossman L, Oliet S, Del Rio C. Endodontic Practice, 11th edn.
Varghese publication; 1991.pp.313-27.
4. Ingle J, Bakland L, Baumgartner J. Ingle’s Endodontics 6, 6th edn.
BC Decker Inc, Hamilton; 2008.pp.638-56.
 26
CHAPTER

Surgical Endodontics

This chapter discusses in detail the various aspects of periradicular surgery including the basic principles
and step-by-step procedure for performing the surgery.
 You must know
• What is Endodontic or Periradicular Surgery and what are its Objectives?
• What are the Indications of Periradicular Surgery?
• What are the Contraindications of Periradicular Surgery?
• What is the Contemporary Classification of Endodontic Surgery?
• What are the Important Considerations While Case Selection and Treatment Planning for
Periradicular Surgery?
• What are the basic Principles and Steps to be followed in Periradicular Surgery?

WHAT IS ENDODONTIC OR PERIRADICULAR WHAT ARE THE INDICATIONS OF

SURGERY AND WHAT ARE ITS OBJECTIVES?
A surgical procedure that allows visualization and
manipulation in the periradicular area in order to eliminate
pathosis and to place a biocompatible seal by means
of retrograde filling through the surgical site is called
Endodontic or periradicular surgery.
Objectives of Periradicular Surgery
• To gain adequate access to periradicular area
• To remove pathological tissue
• To visualize and evaluate the root and root canal system
• To place root-end filling in order to achieve a
biocompatible apical seal of the root canal
• To promote regeneration of periodontium.
PERIRADICULAR SURGERY?
Grossman gave the following list of indications for
periradicular surgery:
• When direct access to the apical third of the canal is
prevented either due to anatomic conditions such as
calcifications, curvatures, bifurcations, etc. or due to
iatrogenic errors such as ledging, or blockage from
separated instrument, old fillings, posts, etc.
• In case of pathologic or iatrogenic apical perforation
that cannot be sealed properly by orthograde filling of
the canal
• In case of lesions that require diagnostic biopsy
• In case of “blunderbuss” canals that do not respond to
apexification and cannot be adequately sealed with an
orthograde filling.
426 Short Textbook of Endodontics

• When the apical constricture of the root canal has been WHAT ARE THE CONTRAINDICATIONS OF
destroyed by uncontrolled instrumentation resulting in PERIRADICULAR SURGERY?
apical foramen that cannot be adequately sealed with
orthograde filling.
• For the removal of the foreign body such as extruded
filling, cement, instrument from the periradicular
area that has resulted in the origin or extension of
periradicular disease,
• In case of exacerbation of disease during nonsurgical
treatment or in case of persistent and unexplainable
pain following completion of nonsurgical treatment.
• When there is excessively large and intruding
periapical lesion that may require marsupialization
and decompression procedures for treatment.
• In case of a horizontally fractured root tip associated
with a periradicular disease.
• Failure to heal in spite of good nonsurgical Endodontic
treatment.
(Friends, we can remember the above indications by
using a simple alphabetic formula:
a2b2cde2f2
Where a = access, a = apical, b = biopsy, b = blunderbuss,
c = constricture, d = disease, e = exacerbation, e =
excessive, f = fracture, f = failure)
But, with the recent advances in the field of
Endodontics in terms of improved visualization with
microscope, increased knowledge and improved
materials has made primary nonsurgical treatment
and nonsurgical retreatment more predictable with
increased rate of success. As a result, today there are
specific indications for periradicular surgery.
Ingle has given the following specific indications for
periradiclar surgery:
– When nonsurgical retreatment has failed, that
implies that nonsurgical treatment had been
employed atleast twice.
– When the initial or primary nonsurgical treatment
provided has failed and retreatment is not possible
or practical to achieve a better result.
– When a biopsy is necessary.

WHAT IS THE CONTEMPORARY CLASSIFICATION
OF ENDODONTIC SURGERY?
• The contemporary classification of Endodontic surgery:
(Ingle’s Endodontics, p.1234)
• Richard Rubenstein and Kim gave the following
classification of Endodontic microsurgical cases:
WHAT ARE THE IMPORTANT CONSIDERATIONS
WHILE CASE SELECTION AND TREATMENT
PLANNING FOR PERIRADICULAR SURGERY?
Important considerations while case selection and
treatment planning for periradicular surgery include:
Surgical Endodontics 427
Preoperative Evaluation of Patient
Thorough evaluation of patient’s medical history and specific
assessment of patient’s cardiovascular status and any kind
of tolerance to local anesthetics containing adrenaline, is
essential.
Enquiry about drug history including any known allergy
to any medications and about the use of any nonprescription
medications that can have interaction with local anesthetics
or can inhibit coagulation, is also essential.
Anatomic Considerations
Important anatomic structures that may be encountered
during Endodontic surgery and the anatomy of the
individual root and root canal system should be considered.
Considerations in Anterior Maxilla
• Floor of nose and bony anterior nasal spine in case of
extremely long roots of maxillary incisors or a large
periradicular lesion that may erode considerable
amount of bone.
• Amount of lingual inclination of the root of maxillary
lateral incisor.
• Maxillary canine has long root and if it is combined with
a shallow vestibule in a particular patient, then it can
complicate access to the apical area.
Considerations in Posterior Maxilla
• Maxillary sinus:
– Proximity of root apices to the maxillary sinus should
be considered:
- Apex of buccal root of maxillary 1st premolar
is quite away from the floor of maxillary sinus
approximately 7.05 mm.
- Apices of maxillary 2nd premolar, and that of
mesiobuccal and distobuccal roots of maxillary
1st molar are found to be approximately 2.8 mm
from the floor of maxillary sinus.
- Mesiobuccal root of maxillary second molar is
found to be closest to the floor of maxillary sinus,
approximately 0.83 mm.
  Periradicular pathosis may cause pathologic
resorption of bone around the apices decreasing
this distance further.
428 Short Textbook of Endodontics
– Clinician must be prepared for the management and
precautions to be taken when the maxillary sinus
gets exposed during Endodontic surgery in case of
a large periradicular lesion. Sinus opening should
be temporarily occluded with appropriate material
and prevent the inadvertent displacement of infected
root fragments and debris into the sinus.
• Palatal roots: Surgical access to the palatal roots of
maxillary molars may be difficult. They can be accessed
by palatal or buccal (transantral) approach.
• Greater palatine foramen: Generally located about
1 cm from the margin of palatal gingiva in between
the maxillary second and third molars. This anatomic
structure is usually not encountered as very few apical
surgical procedures are performed on the palatal roots
of maxillary 2nd or 3rd molars.
• Anterior palatine artery: Emerges from greater palatine
foramen distal to maxillary 2nd molar. Its position
should be carefully considered to avoid severing
it during incision. But in case if it gets severed, it
should be locally clamped and pressure applied for
hemostasis.
Fig. 26.1  A mind-map to remember all points of anatomic considerations for periradicular surgery
Considerations in Anterior Mandible
• Roots of mandibular incisors are lingually inclined.
• Vestibule is shallow in the region of mandibular incisors.
• Roots of adjacent teeth are quite close to each other.
Considerations in Posterior Mandible
• Position of mental foramen: It may be located between
the apex of mandibular first premolar and the mesial
root of the mandibular first molar.
• Relationship of the root apices to the mandibular canal.
• Neurovascular bundle within the mandibular canal that
exits through the mental foramen.
• Depth of vestibule in mandibular posterior teeth.
• Distal root of mandibular second molar is located
quite away from buccal cortical plate, meaning that
mandibular second molar has quite thick overlying
buccal bone and more buccal location of mandibular
canal, all these factors cause difficulty in access to the
roots of mandibular second molar.
A mind-map to remember all points of anatomic
considerations for periradicular surgery is given in
Figure 26.1.

WHAT ARE THE BASIC PRINCIPLES AND
STEPS TO BE FOLLOWED IN
PERIRADICULAR SURGERY?
• Preoperative: Patient preparation for surgery
– Informed consent
– Premedication
– Endodontic surgical armamentarium
• Endodontic surgical phase:
Step 1: Local anesthesia
Step 2: Soft tissue surgical access:
– Incision
– Flap design
– Flap retraction
Step 3: Hard tissue surgical access—Removal of cortical
bone for periapical access
Step 4: Periradicular curettage and biopsy
Step 5: Management of hemorrhage from the surgical
site
Step 6: Management of root end:
– Root end resection
– Root end conditioning
– Root end cavity preparation
Step 7: Retrograde filling of root
Step 8: Closure of surgical site
• Postoperative care:
– Possible postoperative sequelae
– Postsurgical instructions.
Preoperative Phase: Patient Preparation for
Surgery
Informed Consent
• Patient should be informed about the benefits and also
the risks involved in the proposed surgical procedure.
• Patient should also be explained about the various
treatment alternatives other than Endodontic surgery.
• Patient should read, understand and sign a written
consent form that includes the possibility of different
serious complications during surgery.
For example, paresthesia following mandibular
posterior surgery, damage to neurovascular bundle or
Exposure of maxillary sinus, etc.
• Patient should be explained that most of the commonly
occurring complications related to surgery are self-
limiting and are readily manageable such as swelling,
bruising, bleeding and sometimes infections.
Surgical Endodontics 429
Premedication
• Preoperative administration of an NSAID, such
as Ibuprofen 400 mg is recommended to reduce
postoperative pain.
• It is recommended that a long-acting local anesthetic be
used for pain control for a longer period.
• Administration of prophylactic antibiotics depends
on general health of patient. It is necessary in case
of immunocompromised patients, diabetic patients,
patients with cardiac problems, etc.
• Chlorhexidine gluconate oral rinses (0.12%) are recom­
mended.
– To be started one day prior to surgery
– To be used immediately before surgery
– To be continued for 4–5 days following surgery.
Chlorhexidine causes reduction in number of
surface microorganisms in the surgical field and
following surgery it creates a favorable environment
for wound healing.
• It is recommended that sedative-hypnotic drugs such
as one of the benzodiazepines be given a single dose
at bed time the evening before the surgery and second
dose just before the start of the procedure to make the
patient relaxed during surgery.
Endodontic Surgical Armamentarium
• Increased visibility of surgical site with the help of mag­
nifi­cation and illumination using dental operating
microscope, endoscope or orascope.
• Newly introduced microsurgical instruments such
as ultrasonic tips used for root end preparation
(Microsonics) and micromirrors used for root-end
inspection, are very useful for increased visibility of
surgical site.
• Basic Endodontic surgical instrument tray containing
– Bard parker handle with a no. 15 blade or a micro-
surgical scalpel (Also no. 11 and no. 12 blade)
– Periosteal elevator
– Micro-tissue forceps
– Microexplorer, Endoexplorer
– Straight handpiece and different burs
– Sterile saline
– Sterile cotton, cotton pliers
– Surgical forceps
– Curette
430 Short Textbook of Endodontics
– Root-end filling material
– Micro-mirrors
– Microcondensers or micro burnishers and pluggers
of different sizes
– Needle holder, suturing needle and suture material.
Endodontic Surgical Phase
Step 1: Administration of Local Anesthesia
• Long-acting local anesthetic is recommended to be
administered to reduce postoperative pain.
• Objectives of local anesthesia administration are:
– Localized hemostasis during and after surgery for a
clear, surgical field and reduced patient morbidity
following surgery.
– Profound and prolonged anesthesia for control of
pain and anxiety.
• Site and technique of injection:
– For maxillary teeth:
- Infiltration anesthesia in buccal alveolar mucosa
at surgical site and then extended 2–3 teeth on
either side and a palatal injection. This helps
achieve both anesthesia and hemostasis.
- A supplemental block injection may be required
for maxillary posterior teeth.
- Palatal approach to anterior middle superior
nerve may be required for maxillary anterior
teeth.
– For mandibular teeth:
- Inferior alveolar nerve block will provide
anesthesia
- Additional injection in the soft tissue in the
immediate area of surgery for hemostasis.
  Always ensure that profound adequate
anesthesia has been achieved prior to starting
the procedure.
Step 2: Soft Tissue Surgical Access
Good surgical access is required for proper visibility of
the surgical site and for performing the required surgical
procedure meticulously and depends on:
• Correct location and adequate extent of incisions
• Appropriate flap design
• Proper reflection of flap.
Incisions
Give clean, atraumatic incision using scalpel blade no.
11 and 15 starting with a horizontal incision (with no. 11)
followed by vertical releasing incision (with no. 15).
• Vertical incision: Vertical releasing incision is desirable
since it:
– Severs fewer vessels, thus less hemorrhage
– Since blood supply to the tissue coronal to incision is
preserved, there is prevention of localized ischemia
and tissue sloughing
– Enhanced healing: Severely angled vertical incision
should be avoided.
Certain principles should be kept in mind while
placing vertical incisions:
- Make ver tical incision parallel to the
supraperiosteal vessels in the attached gingiva
and submucosa.
- Place incisions over solid healthy bone.
- Place incisions superior to bony eminence and
not over the radicular eminence.
- Incision should not be made across major muscle
attachment and frenal attachment.
- Do not dissect the dental papilla, either include
or exclude it.
  Vertical incisions are placed vertically between
adjacent teeth over interdental bone.
• Horizontal incision:
– The vertical incision intersects the horizontal
incision and ends in the intrasulcular area at mesial
or distal angle of tooth.
– Horizontal incision should be adequately extended
to include atleast one or two teeth lateral to the tooth
being treated.
– Horizontal incision may be the form of an
intrasulcular incision that includes the interdental
papilla so that the entire papilla is completely
mobilized.
– It can be an intrasulcular incision that excludes the
interdental papilla. In this, the incision starts at the
base of papilla and is then directed to the crestal
bone. It is called papillary based incision.
– Horizontal incision can be made in the attached
gingiva retaining about 2 mm of attached gingiva.
– Papillary-based horizontal incision is desirable in
esthetic anterior regions since it prevents papillary
recession and surgical cleft or double papilla.
Flap Design
Principles of flap design
• Base of the flap should always be wider than the free end
of the flap so that adequate circulation is maintained in
the flap.
• Always use firm, continuous strokes while making
incisions. Short, intermittent strokes result in ragged
margins.
 Surgical Endodontics 431

• There should be continuous curvatures between the   Generally used in cases when no underlying
hori­zontal and vertical incisions. Sharp angles may tear. periodontal problems are present.
• When sinus tract is present, it should be included in the   It is also called submarginal curved flap.
flap.   It is not recommended for periradicular
• Releasing incisions should not be over bony eminences surgery due to its disadvantages such as poor
but between them, as their overlying tissue is thin and surgical access, poor wound healing, etc.
it may get stretched and tear when sutured. – It can be submarginal scalloped rectangular
• Whenever possible, the sutured flap margins must rest flap: Luebke-Ochsenbein flap is formed by
on solid cortical bone plate. two vertical incisions connected by a scalloped
Periradicular surgical flaps can be of 2 types: submarginal horizontal incision in the attached
1. Full mucoperiosteal flap: Involves an intrasulcular gingiva as shown in Figure 26.7.
horizontal incision in which the marginal and   This flap gives the advantage of both-vertical
interdental (papillary) gingival tissues are reflected flap and semilunar flap. Can be used in case of
as the part of the flap. It is also called as papillary maxillary teeth where there is adequate amount
based flap. of attached gingiva.
– It can be triangular flap formed by horizontal
intrasulcular incision and one vertical releasing Flap Reflection and Flap Retraction
incision as shown in Figure 26.2. Single In this step, soft tissues such as gingiva, mucosa and
vertical releasing incision causes limited surgical periosteum are separated from the surface of the alveolar
access. bone using a periosteal elevator.
– It can be rectangular flap formed by horizontal,
intrasulcular incision and two vertical releasing
incisions as shown in Figure 26.3. This provides
good surgical access and may be indicated
in case of mandibular anterior teeth or when
multiple teeth are involved. There is difficulty
in  reapproximation of flap margins with this
design.
– It can be trapezoidal flap, which is similar to
rectangular flap but an obtuse angle is formed
where the vertical incision intersects the
horizontal and intrasulcular incision as shown in
Figure 26.4. There is possibility of severing vital
structures and increased bleeding with this flap Fig. 26.2  Triangular flap design
design. So, it is contraindicated in periradicular
surgery.
– It can be horizontal or envelope flap created by
horizontal and intrasulcular incisions but there is
no vertical releasing incision as shown in Figure
26.5. It provides limited access. It may be used in
case of cervical defects, hemisections, etc.
2. Limited mucoperiosteal flaps: These flaps have a
submarginal, i.e. subsulcular horizontal incision. It
does not include marginal or interdental tissues.
– It can be semilunar flap formed by giving a curved
incision in the attached gingiva and the alveolar
mucosa as shown in Figure 26.6. Its horizontal
component rests on alveolar bone structure
about 3 mm apical to gingival crest and ends in
attached gingiva. Fig. 26.3  Rectangular flap design
432 Short Textbook of Endodontics
Fig. 26.4  Trapezoidal flap design
Fig. 26.5  Horizontal or envelope flap design
Fig. 26.6  Semilunar flap design
Certain principles to be followed during this step include:
• While reflection and elevation of flap, microvasculature
should be maintained in the body of the tissue flap. This
controls hemorrhage during surgery.
• Appropriate instrument stabilized with adequate
finger support. Stabilization during reflection of flap is
necessary to prevent inadvertent slipping of instrument
that may cause damage.
• It is important that the retractors rest on solid cortical
bone.
Fig. 26.7  Submarginal scalloped rectangular flap design
• Damage to marginal gingiva and the delicate supra-
crestal root attached fibers should be prevented during
tissue reflection as it can cause loss of their viability
which results in alteration in the soft tissue attachment
levels.
• Soft tissues should be handled gently, but firmly to avoid
any tearing, puncturing or crushing of tissues during flap
reflection and retraction.
• Reflected tissue should be kept hydrated by irrigation
with sterile saline.
Flap reflection: Begins in the vertical incision, few
millimeters apical to the junction of horizontal and vertical
incisions in a horizontal direction to elevate the periosteum
and its superficial tissues from the cortical plate.
Then the elevator is directed coronally to separate the
marginal and interdental gingiva from the underlying bone
undermining the attached gingiva.
It has been found that elevation of flap approximately
0.7–0.8 cm apical to estimated apex would allow adequate
access to perform the surgical procedure.
Flap retraction: After the tissue is reflected, elevation of soft
tissues is done in an apical direction to provide adequate
surgical access for bone removal and subsequent root end
procedures. Flap retraction involves holding the reflected
soft tissues in position using appropriate size tissue retractors
for good access to radicular and periradicular structures.
Step 3: Hard Tissue Surgical Access
This step involves surgical access made through the cortical
bone to allow visualization of the root ends.
In case of an extensive periradicular lesion, buccal or
labial cortical plate may be lost and fenestration may be
present with no bone overlying the root whereas in some
cases with minimal or no periradicular lesion large amount

of cortical and cancellous bone may have to be removed to
gain access to the root end which can be difficult as exact
location of bony window needs to be determined to prevent
unnecessary removal of bone. Use of a radiopaque marker
can serve as a guidance to determine the position of root
apex.
• Principles that should be followed during hard tissue
surgical access include:
– Preservation of healthy bone as much as possible.
– Controlling the heat generated during the process.
• Hard tissue surgical access is achieved using a round bur
in a high speed handpiece with adequate water coolant.
– It is important that high speed handpiece that is used
should exhaust air from the base rather than the
cutting end in order to avoid the risk of air embolism.
– Round bur is used to remove bone as it readily allows
access of coolant to the cutting surface so that there
is minimal inflammation and favorable wound
healing. Bone covering the root should be slowly
and carefully removed using the round bur in gentle
brush stroke action working in an apical direction
until the root end is identified.
– Use of adequate coolant is essential to control the
heat generated during bone cutting and to clear
off the debris accumulated on the cutting flutes of
instruments.
• Technique involves creating a window by preparing 3
openings in the bone, two of the openings through the
cortical plate adjacent to mesial and distal sides of root
near its apical third and third opening slightly beyond
the apex. After completing initial access, extension of
window can be done using hand instruments such as
chisels as they are less likely to gouge the root.
• Next step is to distinguish the root apex from the
surrounding bone by following ways:
– Radiograph can be taken to serve as the “road map”
– Color: Root structure appears more yellowish as
compared to bone.
– On probing, there is no bleeding from root.
– Texture: Bone has granular and porous texture. Root
has smooth and hard texture.
– Staining dye can be used to identify the periodontal
ligament surrounding the root.
Step 4: Periradicular Curettage and Biopsy
It is recommended that prior to periradicular curettage,
local anesthetic containing a vasoconstrictor be injected
Surgical Endodontics 433
into the soft tissue mass to prevent any possible discomfort
during the process of debridement and for the purpose of
hemostasis.
• Periradicular curettage is done to:
– To remove pathologic tissue associated with root
apex such as cyst, granuloma, etc.
– To remove any foreign material that had got extruded
in the periapical area.
– To provide visibility and accessibility to facilitate
root-end procedures.
• Biopsy is done for the histopathologic assessment of the
pathologic soft tissue removed.
• Technique
– Place an appropriate size curette between the
soft tissue mass and the lateral wall of the bony
crypt.
– Then apply pressure against the bone as the curette
is inserted between the soft tissue mass and bone
around lateral margins of lesion.
– The soft tissue mass, if possible, can be removed from
the bony crypt in one piece to facilitate periradicular
curettage.
– The curette detaches the soft tissue mass from the
walls of the crypt, then a pair of tissue forceps can be
used to grasp the soft tissue mass and immediately
it is put in a bottle containing 10% buffered formalin
solution and submitted for biopsy.
– The curette is then used in scraping motion to
remove the remaining soft lesion if any from the
medial wall of the osseous defect.
Step 5: Management of Hemorrhage from
the Surgical Site
• Hemorrhage occurs during curettage and following root
end resection which can obstruct vision and prevent
careful evaluation of the root end and the further root
end procedures.
• Hemostasis can be achieved by:
– Presurgical local anesthetics and vasoconstrictors
– Use of local hemostatic agents in the surgical site.
• Local hemostatic agents control hemorrhage from small
blood vessels and capillaries by forming an occlusive
clot, either by exerting a physical tamponade action
or by enhancing the clotting mechanism.
• Sponges or cotton pellets soaked in a vasoconstrictor
such as racemic mixture of epinephrine hydrochloride
can be used as a local hemostatic agent.
434 Short Textbook of Endodontics
• Local hemostatic agents can be classified as:
• Angle of root-end resection:
Step 6: Root End Management
This step includes:
• Root end resection and inspection of the resected root
end
• Conditioning of the root end
• Preparing root end cavity to receive a filling.
Root End Resection
It involves resection of the apical 3 mm of the root apex so
as to eliminate most of the apical ramifications and lateral
canals that usually contain the irritant that contributes to
periradicular disease. Thus it removes the etiologic agent
of the disease.
• Indications:
– To eliminate anatomic variation.
– To eliminate defects due to resorption.
– In case of iatrogenic errors such as ledges,
perforations, canal obstructions and separated
instruments in the apical 1/3rd of the root.
– In order to visualize the seal created by the
orthograde root canal filling material.
– In case of persistent periradicular disease.
– Endodontic failure cases with irretrievable posts or
obturating materials.
• Objectives:
– To remove the bacterial irritants, which are the most
common etiologic agents of periradicular disease.
– To remove the diseased periradicular tissue.
– To prevent recontamination of periradicular tissues.
– To allow remodelling of bone over the tooth structure
by reducing apically fenestrated root apex below the
level of surrounding cortical bone.
• Extent of root end resection: Varies from case to case.
Adequate access and visualization should be achieved.
Factors determining extent of root end resection
include:
– Shape of the root
– Number and location of canals within the root
– Extent of periradicular lesion
– Root end filling material must be surrounded by
sound dentin
– Location of perforation, ledges, separated
instruments
– Associated periodontal factors
– Level of crestal bone
– Anatomic structures such as mental foramen or
mandibular canal.
– Concept of beveling of root end as shown in Figure
26.8, which was described in the past, no longer
stands true because it has been found that beveling
of root end opens the dentinal tubules on resected
root surface that may communicate with the root
canal space resulting in apical leakage.
- Earlier beveling was done to improve visibility.
But with advent of DOM and microsurgical
instruments, beveling of root end is not required.
– Most appropriate angle of resection would be
perpendicular (90˚) to the long axis of the root as
shown in Figure 26.9.
- Rationale for perpendicular root end resection:
■ Most likely to include all apical ramifications
■ It is convenient
■ It causes even distribution of stress forces
exerted in apical region
■ Increasing the angle of root end resection
causes decreased number of exposed
dentinal tubules thus reducing chances of
apical leakage.
Fig. 26.8  Beveling of root end

Fig. 26.9  Angle of resection should be perpendicular
(90°) to the long axis of the root
Root End Conditioning
• Resected root should be made smooth with a round
bur in slow-speed contra-angle handpiece or the newly
introduced miniature surgical handpiece, so that the
surface cracks and anatomic variations are detected
better.
• Chemical treatment of the root end is called root condi­
tioning. Its purpose is to remove smear layer and to
produce a conducive surface that allows for periodontal
cell colonization without affecting the vitality of the
adjacent periodontium.
Root end conditioning can be done with solutions such
as citric acid, tetracycline and EDTA, with citric acid being
the most effective and commonly used agent.
EDTA should not be used when MTA is going to be used
as the root end filling material.
Root end cavity preparation: A cavity is prepared to receive
the filling. It is recommended that Class I cavity be prepared
with a depth of about 3 mm and along the long axis of the
tooth.
Cavity preparation can be accomplished using micro­
handpiece with a rotating bur or ultrasonics.
Root end cavity preparation using Ultrasonics:
For root-end cavity preparation, specially designed
ultrasonic tips are available.
• Step-wise procedure:
– Examination of the site using magnification and
staining
Surgical Endodontics 435
– Outline the cavity design by a sharp point of a CT-S
ultrasonic tip, without irrigation
– Deepen the prepared cavity design using
appropriately sized and angled ultrasonic tip with
irrigation.
– Thoroughly irrigate the cavity with sterile saline.
– Dry the cavity and examine under magnification.
• Advantages of ultrasonics for root end cavity preparation:
Ultrasonic root-end preparation has several advantages
over the micro-handpiece method.
– Less bone is removed and it produced conservative
preparation
– Decreased risk of root end perforation
- No need for root-end beveling
- More parallel walls for better retention
– Less smear layer.
• Disadvantages: Risk of root fractures from ultrasonic
vibration.
For bonded root end fillings, modified root end
preparation includes a shallow, scalloped preparation of
entire root surface about 1 mm at the deepest concavity.
Root end cavity preparation for bonded root-end fillings
(composites) requires a shallow, scalloped preparation of
the entire root surface using a round or oval bur with a depth
of atleast 1 mm at the deepest concavity.
An ultrasonic preparation into the root canal system may
not be necessary.
Step 7: Retrograde Filling
Root end filling is done between the root canal space and
the periradicular tissues.
• Properties of an ideal root end filling material:
– Should not be affected by moisture during setting
– Should be biocompatible
– Should be able to induce cementogenesis over the
root end filling material and regeneration of PDL
complex.
– Should be dimensionally stable
– Should be easy to handle
– Should be insoluble in tissue fluids
– Should be seen on radiograph (radiopaque)
– Should produce a seal, preventing leakage
– Should be nonstaining
(Remember the alphabetic formula: ABCDEF S3)
• Various root end filling materials:
1. Amalgam: Amalgam is most commonly used root
end filling material. Amalgam is well-tolerated
by periapical and periodontal tissues. It is readily
available and easy to manipulate. However, amalgam
436 Short Textbook of Endodontics
used as a retrograde filling is not an ideal apical
sealant. It is dimensionally unstable and may stain
overlying soft tissues.
2. Zinc oxide eugenol cements: Zinc oxide powder and
eugenol liquid mixed into a paste is compacted
into a cavity preparation. Unmodified ZOE cements
are weak, are soluble and have long setting time.
Additions have been made to the basic ZOE
mixture in order to increase the strength and
radiopacity and to decrease the solubility of the final
material. Intermediate restorative material (IRM)
and super-EBA are commercially available ZOE
materials.
i. Intermediate restorative material (IRM):
■ Available as powder-liquid system
■ Powder contains:
– 75% zinc oxide
– 20% polymethacrylate
■ Liquid contains:
– 99% eugenol
– 1% acetic acid
■ Advantages:
– Easy to place, has clay-like consistency
on mixing powder and liquid
– Well-tolerated by periradicular tissues
– Seals well.
■ Disadvantages: No dental hard tissue
regeneration potential.
ii. Super-EBA:
■ This is also zinc oxide-eugenol based cement
■ Fast set and regular set are two forms
■ It also does not have cementum regeneration
potential.
3. Mineral trioxide aggregate: Mineral trioxide aggregate
(MTA) has been found to satisfy most of the criteria
for a root end filling material.
• Physical characteristics of MTA:
– Available as fine, gray and white colored
powders. Figure 26.10 shows photograph of
commercially available packet of MTA.
– It is mixed with saline or local anesthetic
solution on a sterile glass slab
– With the addition of more powder to liquid,
the mix becomes too dry and crumbly
– With addition of more liquid, it becomes too
wet and runny, difficult to handle
– Setting time of MTA is 2½ to 3 hours
– Has pH of 10 initially and 12.5 about three
hours after mixing.
Fig. 26.10  Commercially available MTA
• Consistency of mix for root end filling is recom­
mended to be firm, free of excess moisture.
– It should not be too dry and crumbly
– It should not be too wet and runny
• MTA mix can be placed on the root end
preparation using:
– Small spoon excavator
– Small amalgam-type carrier
– Commercially available MAP system.
• Drawbacks of MTA:
– Difficult to handle (poor handling charac­
teristics)
– Long setting time (2½–3 hours).
4. Composite resin system (Retroplast).
■ It is a two-paste, dual cure, dentin bonding
composite resin system used in conjunction with
a Gluma-based dentin bonding agent.
■ Working time of nearly 2 minutes.
■ Found to promote regeneration of periodontium
with a cementum layer over the root end filling.
■ Requirements: While using composite resin as
root end filling material:
– There should be dry field
– Optimum hemostasis.
5. Others: Glass ionomer cement, resin cements such
as DIAKET have also been tried as root end filling
material but with limited results.
Appropriate root-end filling is placed in the
prepared cavity on the root surface.
 Surgical Endodontics 437

Fig. 26.11  Endodontic surgery—postoperative sequelae

438 Short Textbook of Endodontics
Step 8: Closure of Surgical Site
• It is necessary to do careful visual and radiographic
inspection of the surgical site before attempting closure
of wound.
• Evaluate radiographically:
– To check for any root-end fragments present in
surgical site
– To check for any excess root-end filling material
– To check the quality of seal achieved with the root
end filling material.
• If indicated, barriers such as resorbable or nonresorbable
(Resorbable preferred for Endodontic surgery)
membranes may be placed for the purpose of bringing
about guided tissue regeneration (GTR) and guided bone
regeneration (GBR).
• The elevated mucoperiosteal flap is then gently
repositioned back to its original position.
• For approximation of incised tissues and to stabilize
the reflected tissue during the initial phase of wound
healing, sutures are placed using the appropriate
technique.
• Silk has been the commonly used suture material
but since silk tends to support bacterial growth,
patient should be advised to rinse with chlorhexidine
mouthwash during the postoperative period.
• Suture materials with Teflon coating, or synthetic
monofilament suture material or gortex sutures
have desirable properties for wound closure after
periradicular surgery.
Postoperative Phase
Possible Postoperative Sequelae
These have been mentioned in Figure 26.11. Endodontic
Surgery-Post-operative Sequelae (mnemonic to remember
is: S2 H2 I3P3E).
Postsurgical Instructions
• Postoperative pain can be managed well with NSAIDs
such as Ibuprofen.
• Patient is advised to do intermittent ice application
(about 20–30 min each hour) in order to reduce pain
and swelling.
• Softer or semisolid room-temperature diet is
recommended for 24 hours postsurgery.
• Patient is advised to maintain the wound flushed and
clean after meals.
• Smoking is to be strictly avoided.
• Patient is recalled for removal of sutures about 2–4 days
following surgery. This is current concept so that all
potential irritants from the incision area are removed
as soon as possible.
Earlier, it was recommended to wait for seven days
after surgery before suture removal.
• Patient is informed that minor oozing from surgical
site causing pink tinge in saliva can be expected but
if excessive bleeding occurs or if there is any event of
emergency, then the patient should call up and inform
the dentist immediately.
BIBLIOGRAPHY
1. Cohen S, Hargreaves KM. Pathways of Pulp, 9th Edn. St. Louis:
Mosby, 2006.pp.724-71.
2. Grossman L, Oliet S, Del Rio C. Endodontic Practice, 11th Edn.
Varghese publication, 1991.pp.289-311.
3. Ingle J, Bakland L, Baumgartner J. Ingle’s Endodontics, 6th Edn.
BC Decker Inc, Hamilton, 2008.pp.1233-86.Aximi, utempor eptati
conet abores entotatia voluptaesti siminci offici cus.
 27
CHAPTER

Pulp Therapies

This chapter describes the various vital pulp therapy techniques—current concepts and materials used
and also describes apexification.
  You must know
• What is Vital Pulp Therapy?
• What are the Objectives of Vital Pulp Therapy?
• What are the Techniques and Materials used for Vital Pulp Therapy?
• What are the Hemostatic Agents and Antimicrobial Materials used in Vital Pulp Therapy?
• What is the Criteria for Case Selection for Vital Pulp Therapy?
• What is Apexification (Nonvital Pulp Therapy)?

WHAT IS VITAL PULP THERAPY? WHAT ARE THE OBJECTIVES OF

VITAL PULP THERAPY?
When the pulp tissue is affected directly or indirectly by
caries, trauma or restorative procedures, the treatment Figure 27.1 gives the objectives of vital pulp therapy
carried out in order to preserve and maintain the pulp (VPT).
vitality is called vital pulp therapy.
Preserving the vitality of the pulp is crucial to the tooth’s WHAT ARE THE TECHNIQUES AND MATERIALS
long-term survival and function of tooth as during life of
USED FOR VITAL PULP THERAPY?
the tooth, the healthy pulp produces reparative, secondary
and peritubular dentin in response to various biologic and
pathologic stimuli.
Vital pulp therapy is the treatment consideration mostly
in case of pulpally involved immature permanent teeth,
where the preservation of radicular pulp tissue induces
apexogenesis in teeth with open apices in order to retain
the tooth as a functional unit. In pulpally involved tooth,
this theory is based on the fact that pulp tissue has innate
capacity for repair in absence of microbial contamination.
In the last decade, lot of advances have occurred in the
field of vital pulp therapy in terms of improved materials and Indirect Pulp Capping
techniques and expanded knowledge of pulp microbiology • Definition: Indirect pulp capping is defined as “a
and caries progression. A new bioactive substance, mineral procedure in which a material is placed on a thin
trioxide aggregate (MTA), has been found to potentiate partition of remaining carious dentin that, if removed,
the ability of dental pulp to heal, thereby retaining and might expose the pulp in immature permanent teeth”.
maintaining its natural evolutionary function and purpose. (Ingle’s Endodontics, p.1312)
440 Short Textbook of Endodontics
Fig. 27.1  Objectives of vital pulp therapy
• Objectives:
– The interim or final restoration should seal completely
the involved dentin from the oral environment
– Vitality of tooth should be preserved
– Absence of post-treatment signs or symptoms such
as sensitivity, pain or swelling.
– No radiographic evidence of internal or external root
resorption or other pathologic changes.
– Immature teeth with open apex should show
continued root development and apexogenesis.
• Indications:
– Teeth with deep caries but free from symptoms of
painful pulpitis
– No spontaneous pain
– No tenderness to percussion
– No abnormal mobility
– No radiographic evidence of radicular disease
– No internal or external root resorption detectable
radiographically.
• Contraindications:
– Teeth with deep caries with signs and symptoms of
painful pulpitis
– History of spontaneous pain
– Tenderness to percussion
– Abnormal mobility
– Radiographic evidence of interradicular bone loss.
• Materials used:
– Calcium hydroxide
– Zinc oxide eugenol
• Rationale of indirect pulp capping: Rationale is
based on the finding that when there exists a zone
of demineralized affected dentin between the outer
infected dentin and the pulp, infected dentin is removed
and the affected dentin that is left behind remineralizes
and the odontoblast form reactionary dentin, so that
pulp exposure is avoided. Few viable bacteria that
remain in the deeper layers of dentin are inactivated
when cavity is sealed properly and pulp exposure
prevented. Thus vitality of pulp is preserved.
• Mechanism:
• Indirect pulp capping is not a predictable treatment
option for permanent teeth due to following reasons:
– Difficulty in determining at what depth, caries
excavation should be halted.
– As remineralization occurs, carious dentin becomes
dry and loses volume that results in voids under the
restorative material.
– The dormant lesion may get rapidly reactivated in
case of restoration failure.
• Technique:
First visit
After profound anesthesia and isolation with rubber
dam,
Step 1: Large round bur #6 or #8 is used to excavate caries
under adequate water cooling. Careful judicious use
of spoon excavator can be made for caries excavation
as its use in deep carious lesions may remove large
segment of carious dentin.
 Pulp Therapies 441

Step 2: C aries indicator dye is applied. Stained outer • Objectives:

infected layers of dentin is removed. Unstained inner
transparent layer is left intact.
Step 3: All caries except that just overlying the pulp is
removed and the remaining carious dentin (affected)
is covered with zinc oxide eugenol or calcium
hydroxide.
Step 4: Tooth is sealed with hard setting ZOE or alternatively
amalgam or acid etched bonded composite is
placed to seal the tooth. Although use of permanent
restoration at this stage is controversial.
Second visit
After about 6–8 weeks, tooth is reentered to confirm sec-
ondary or reactionary dentin formation and to excavate
the remaining carious dentin without pulp exposure.
Figures 27.2A to C are the diagrams showing steps of
indirect pulp capping in mandibular first molar.
Direct Pulp Capping
• Definition: Direct pulp capping is defined as, “treatment
of an exposed vital pulp by sealing the pulpal wound
with a dental material placed directly on a mechanical
or traumatic exposure to facilitate the formation of
reparative dentin and maintenance of the vital pulp”.
(Ingle’s Endodontics, p.1312)
– Vitality of tooth should be maintained
– Absence of post-treatment clinical signs or symptoms
of sensitivity, pain or swelling.
– Pulp healing and formation of reparative dentin
should occur.
– No radiographic evidence of internal or external
root resorption, periapical radiolucency, abnormal
calcification or other pathologic changes.
– Immature teeth with open apex should show
continued root development and apexogenesis.
• Indications:
– Pinpoint (less than 0.5 mm in diameter) mechanical
exposures surrounded by sound dentin produced as
a result of caries removal during cavity preparation
or due to trauma or during tooth preparation.
– In teeth which are free from signs and symptoms of
pulpitis.
– Minimal or no bleeding from exposure site.
– Exposure that has occurred in a clean, uncon­ta­
minated field.
• Contraindications:
– Large pulp exposures
– Caries present surrounding the exposure site
– Teeth with history of spontaneous pain

A B C
Figs 27.2A to C  Steps of indirect pulp capping: (A) Mandibular first molar showing deep occlusal and proximal caries approaching the
pulp; (B) All caries is excavated except that is just overlying the pulp and is covered with calcium hydroxide sub-base and the tooth is sealed
externally with hard-setting zinc oxide eugenol or amalgam may be placed as an interim restoration. a: Zinc oxide eugenol; b:  Calcium
hydroxide sub-base; c: Affected dentin; d: Pulp horn; (C) After about 6–8 weeks the tooth is re-entered. Deposition of reactionary dentin is
found beneath the caries that allows eradication of remaining caries without causing pulp exposure. Cavity preparation is completed and a
fresh layer of calcium hydroxide is placed as sub-base, which is covered with zinc oxide eugenol or zinc phosphate base and a permanent
restoration is placed. a: Permanent restoration; b: Pulp protecting base; c: Calcium hydroxide sub-base; d: Calcium hydroxide reacted affected
dentin; e: Calcification seen overlying the pulp horn
442 Short Textbook of Endodontics
– Excessive bleeding indicating hyperemia or pulpal
inflammation
– Long standing pulp exposure that might have
contami­nated with oral microorganisms.
• Rationale of direct pulp capping: The remaining dental
pulp with reversible pulpitis is selectively induced to
produce a reparative barrier that protects the tissue from
microbial challenges with the intention to postpone
the more aggressive therapies, that could eventually
lower the long-term prognosis for tooth retention and
function.
“Teeth undergoing orthograde root canal therapy and
placement of posts and cores, followed by full coverage
restorations, show lower long-term survival rates than
teeth with vital pulps.” (Ingle’s Endodontics, p. 1313)
• Materials used:
– Ideal requirements of a pulp capping material:
- Adhere to dentin and overlying restorative
material
- Bactericidal or at least Bacteriostatic
- Caries prevention: Should prevent secondary
caries by releasing fluoride
- Dentin formation: Should stimulate reparative
dentin formation
- Easy to manipulate
- Forces: Should be capable of resisting forces
during restoration placement and under
masticatory load
- Should provide a tight Seal against bacteria
- Should be Seen on radiographs (Radiopaque)
(Remember the ideal requirements using
Alphabetic formula ABCDEF S2).
– Pulp capping materials:
Calcium Hydroxide Compounds
• Calcium hydroxide has been widely used as a pulp
capping agent since many years with variable treatment
outcomes.
• Have high alkaline pH that causes irritation of pulp tissue
stimulating pulpal defense and repair
• It is a relatively weak cement that may not be able to
withstand forces
• Associated with primary tooth resorption
• Can degrade and dissolve beneath restorations
• Tunnel defects: Calcium hydroxide fails to provide a long-
term seal against microleakage due to tunnel defects
under the formed dentin bridge
• Calcium hydroxide is available as:
– Two pastes (Base and catalyst)
- Dycal
- Life
- Care
– Light cured system
• Properties:
– Mechanical: Low compressive strength
Low tensile strength
Low elastic modulus limit
– Thermal: Calcium hydroxide provides some thermal
insulation if it is placed in sufficiently thick layers.
But usually it serves only as a sub-base and needs to
be covered with a overlying base to provide thermal
protection.
– Solubility of Ca(OH)2 in water is high
– Biological:
- Pulpal Repair: Alkaline pH (9.2–11.7) that causes
irritation of pulp tissue stimulating pulpal
defense and repair
- Secondary/Reparative dentin formation: Pulpal
defense reaction and protein lysing effect results
in reparative dentin formation.
It has been found that due to tunnel defects in dentinal
bridge associated with Ca(OH) 2, microorganisms can
penetrate pulpal tissue and cause subsequent pulpal
irritation. This is usually associated with pulpal calcification
and canal obliteration.
Figures 27.3A to C are the diagrams showing steps
involved in direct pulp capping using calcium hydroxide.
A B C
Figs 27.3A to C  Steps of direct pulp capping: (A) Mandibular molar
showing deep occlusal and proximal caries; (B) Caries excavation
caused mechanical exposure of mesial pulp horn; (C) Calcium
hydroxide placed as pulp capping agent, covered with pulp protective
base and permanent restoration is done

Zinc Oxide
• Has obtundant effect on pulp
• Can provide protection against chemical insults
• Weak cement
• Does not have desirable properties of a pulp capping
agent.
Adhesive Resins and Resin-modified Glass Ionomers
• Their use as pulp capping agent is controversial. Some
studies have shown favorable results with it. While other
studies are associated with unfavorable reactions and
lack of calcific bridge formation.
• They have not been found to produce predictive pulpal
healing, reparative dentin formation and elimination of
microorganisms.
Mineral Trioxide Aggregate (MTA)
• Introduced in Endodontics by Lee et al in early 1990s
• Composition: Dicalcium silicate, tetracalcium alumino
ferrite, calcium sulfate dehydrate, bismuth oxide
• Available as:
– White MTA powder (for esthetic reasons)
– Gray MTA powder: Gray formulation has been found
to give better results than white powder.
• Desirable properties of MTA making it suitable as pulp
capping agent:
– MTA is hygroscopic and sets in the presence of
moisture, so even if there is contact with tissue fluids
or blood, it does not affect its properties
– Good marginal adaptation
– Forms a reactionary layer at the dentin interface
resembling hydroxyapatite in structure
– High alkaline pH of 12.5, which is sustained, with
slow release of calcium, arrests any further microbial
growth of residual microorganisms that may be
left after caries excavation. Also, slow release of
calcium ions allows material to stimulate growth
factors from the dental pulp and promote signalling
molecules such as interleukin, TGF-Beta for hard
tissue formation.
– Due to small particle size, it produces gap-free
interface. As a result, microleakage and bacterial
ingression is prevented.
– MTA has high compressive strength and surface
texture of set cement is favorable to withstand
stresses and provide strong bonding with adhesive
restorations.
– MTA fulfils most of the ideal requirements of a pulp
capping material.
Pulp Therapies 443
• Clinical procedure with MTA: (Two-visit procedure) Refer
Figures 27.4A to F for steps of direct pulp capping using
MTA.
First Visit
After profound anesthesia and isolation of tooth with
rubber dam,
Step 1: Caries removal under magnification. Caries detector
dye is applied for 10 seconds and then tooth is
washed and dried. Slow speed round carbide burs
and spoon excavator used to excavate the stained
carious dentin. Then again apply caries detector and
check and excavate till no stain or only light stain
evident.
Step 2: During caries removal, if pulp exposure occurs,
achieving hemostasis at exposure site by placing
cotton pellet moistened with 3–6% sodium
hypochlorite for 20–60 seconds. Again staining and
careful removal of remaining caries around exposure
site till no staining visible. After caries excavation,
if still there is bleeding from the exposure site
then cotton pellet moistened with 3–6% NaOCl is
placed directly on exposure site for 1–10 minutes.
If even after 10 minutes, hemostasis cannot be
achieved, then diagnosis of irreversible pulpitis is
made and pulpotomy or pulpectomy procedure
recommended.
Step 3: MTA is mixed to consistency of wet sand and gently
patted down with moist cotton pellet over the
exposure site as well as on the surrounding dentin
of pulpal roof or axial wall in the thickness of atleast
1.5 mm.
Step 4: Place a moist cotton pellet over MTA and let it remain
there and place interim restoration over it.
Second Visit
Schedule after 5–10 days.
Ask patient for symptoms. Perform pulp vitality testing.
Isolate the tooth, remove the interim material and cotton
pellet. Confirm that MTA has set. Then, permanently
restore the tooth with bonded composite. Occlusion is
adjusted and patient is recalled at 6 weeks and subjective
symptoms evaluated and radiograph taken. Subsequent
follow-up after 6 and 12 months.
One-visit Procedure with MTA
After profound anesthesia and isolation of tooth with rubber
dam,
Step 1: Caries is excavated under constant water cooling and
magnification.
Step 2: Hemostasis at the exposure site is achieved using
cotton pellet moistened in 2.6–5% NaOCl.
Step 3: Prepare Proroot MTA and apply on exposure site and
use cotton pellet to remove excess moisture.
444 Short Textbook of Endodontics

A B C

D E F

Figs 27.4A to F  Steps of two-visit direct pulp capping using MTA in a young permanent tooth. First visit: (A) Deep caries in permanent molar
tooth excavated, small (pin-point) exposure of pulp causing bleeding; (B) Cotton pellet moistened with 3–6% NaOCl is placed directly on
exposure site for 1–10 minutes; (C) MTA mixed to consistency of wet sand of about 1.5 mm thickness is gently patted down with moist cotton
pellet over the exposure site as well as on the surrounding dentin of pulpal roof or axial wall; (D) A moist cotton pellet is placed over MTA and
covered with an interim restoration. Second visit: (E) Interim restoration and cotton pellet removed and a probe is used to confirm that MTA
has set; (F) The tooth is permanently restored with composite restoration

Step 4: Place a lining of light cured GIC liner over MTA. • Rationale:
Step 5: Place bonded composite restoration in the same visit. Surgical excision of coronal pulp
Patient is recalled and checked after 3–6 months. ↓
Inflamed and infected area is removed
Pulpotomy
↓
• Definition: Pulpotomy is defined as “the surgical Leaving behind vital, uninfected pulpal tissue
removal of the coronal portion of a vital pulp as a means
in the root canal
of preserving the vitality of the remaining radicular
↓
portion” (Ingle’s Endodontics, p. 1312).
• Objectives: Remaining pulp may undergo repair while completing
– Preservation of vitality of radicular pulp apexogenesis (Root end development and calcification)
– Relief of pain in patients with acute pulpalgia in young permanent immature tooth.
– To promote apexogenesis in immature permanent (Also, removal of inflamed portion relieves pulpalgia.)
tooth ↓
 Pulp Therapies 445

Medicament placed over the pulp stump induces necrosis,

beyond which undifferentiated mesenchymal cells
or fibroblasts in cell-rich zone differentiate into
odontoblast
↓
Odontoblast produce reparative dentin
↓
“Bridge” forms to cover and protect the pulp

• Indications: Pulpotomy is indicated in pulpally involved

immature young permanent tooth.
Teeth with healthy, hyperemic or slightly inflamed pulps
such as:
– Traumatic exposure: Young permanent anterior
tooth with wide open apex that is fractured during
sports or accident
– Carious exposure: Posterior tooth with wide open
apices that has small, asymptomatic carious
exposure.
• Contraindications:
– Abnormal sensitivity to heat and cold
– Chronic pulpagia
– Irreversible pulpitis
– Necrosis of pulp
– Calcification in pulp chamber
– Extension of pulpal disease into periapical tissues
causing periradicular disease
– Tenderness of tooth to palpation or percussion
• Types of pulpotomy: Based on the amount of pulp tissue
removed: Partial pulpotomy and complete pulpotomy.
Fig. 27.5  Partial pulpotomy in a permanent
maxillary central incisor tooth
Complete/ Cervical Pulpotomy
• Similar to partial pulpotomy, just that in cervical
pulpotomy, entire coronal pulp to the level of the root
orifices is excised.
• The coronal pulp is completely removed and the suitable
material is placed over the canal orifices.
• In case of mature permanent teeth, pulpotomy is used
as the means of relieving pain during an emergency
appointment of severe pain due to irreversible pulpitis.
Pulpectomy and completion of root canal treatment
procedure can be done in the subsequent appointment.

Partial Pulpotomy Based on the mode of action of medicament used:

Type Materials
Also called as Cvek pulpotomy
Devitalization Formocresol
• Definition: Partial pulpotomy is defined as “the surgical Electrocoagulation
removal of a small portion of vital pulp as means of Regeneration Ca(OH)2
preserving the remaining coronal and radicular pulp”. Enriched collagen
(Ingle’s Endodontics, p.1313) Hard setting Ca(OH)2
• It is similar to direct pulp capping with only difference Freeze dried bone
Demineralized dentin
that some inflamed pulp tissue is removed BMP
• It is indicated in carious or traumatic exposures when OP
the pulp is vital and only 1–2 mm of coronal pulp tissue MTA
is inflamed. Preservation ZOE
• Only about 2–3 mm of superficial inflamed pulp is Gluteraldehyde
Ferric sulfate
excised and a biocompatible material such as calcium Laser
hydroxide is placed over it.
• Glass ionomer lining can be put and the tooth is restored
with permanent restoration such as composite resin. Formocresol Pulpotomy
Figure 27.5 shows diagrammatic representation of It is usually done in case of pulpally involved primary teeth
partial pulpotomy. in which there is inflammation only in the coronal pulp or
446 Short Textbook of Endodontics
mechanical exposure cases. Coronal pulp up to the root
canal orifices is extirpated, bleeding is controlled by pressure
and then a cotton pledget moistened with formocresol is
applied for about five minutes which is covered with zinc
oxide eugenol cement base and then restored with amalgam
or glass ionomer restoration. Formocresol causes necrosis
and fixation of tissue and is a potent antibacterial substance.
Steps involved in formocresol pulpotomy procedure in
a deciduous molar are demonstrated and explained in
Chapter 28 Pediatric Endodontics.
Calcium Hydroxide Pulpotomy
Calcium hydroxide has been widely used in vital pulp
therapy in permanent tooth due to its has antibacterial
property and ability to form hard tissue barrier. It has an
alkaline pH of 11. Coronal pulp is amputed to the level of
root canal orifices, hemorrhage is controlled and calcium
hydroxide mixed with water or commercially available
paste containing calcium hydroxide in combination with
other medicaments is applied on the amputed pulp which
is covered with zinc oxide eugenol cement and then sealed
with a permanent restoration. Necrosis occurs under the
placed calcium hydroxide, beyond which a reparative
dentinal bridge is formed. A radiograph is taken for future
comparison to check the calcific bridge formation after
three months. A tooth treated with calcium hydroxide
pulpotomy may develop internal resorption or calcification
of the root canal which also should be monitored on
subsequent radiographs and Endodontic therapy should
be performed as soon as apexogenesis is completed and is
evident radiographically.
Mineral Trioxide Aggregate Pulpotomy
Pulpotomy can be an effective procedure in deciduous teeth
and young permanent teeth when MTA is used due to its
desirable properties mentioned before, such as alkaline pH
(10.2–12.5), antibacterial agent, pulp underneath has less
inflammation. It forms a dentinal bridge that is thicker and
continuous unlike calcium hydroxide. MTA mix contains
calcium oxide which comes in contact with moisture to
form calcium hydroxide and induces the hard calcific bridge
through the same mechanism as calcium hydroxide.
WHAT ARE THE HEMOSTATIC AGENTS AND
ANTIMICROBIAL MATERIALS USED IN VITAL
PULP THERAPY?
Direct pressure at the exposure site with cotton pellet
moistened in sterile water or saline may be sometimes
adequate to achieve hemostasis. Various hemostatic and
antimicrobial agents include:
• Ferric sulfate disinfectant (Consepsis-Ultradent
product)
• Epinephrine
• Hydrogen peroxide
• Sodium hypochlorite (NaOCl): It is safe and most
practical method to achieve hemostasis in vital pulp
therapy. Besides excellent hemostasis, it removes
most of the dentinal chips as well as the biofilm and
thus brings about disinfection of the cavity interface.
It also removes the damaged cells from mechanical or
traumatic exposure.
• MTAD (Mixture of Tetracycline isomer doxycycline,
citric Acid and Detergent): MTAD has been tried and
favourable results achieved.
WHAT IS THE CRITERIA FOR CASE SELECTION
FOR VITAL PULP THERAPY?
• Age of patient: In case of young patients with initial caries
on first molars causing reversible pulpitis, direct pulp
capping can be done. Favorable prognosis for vital pulp
therapy diminishes with increasing age of the patient.
• Rate of decay: In case of patient with rampant caries,
pulpotomy will be preferred over pulp capping as patient
may have recurrent caries.
• Remaining tooth structure: If there is advanced caries
and severe coronal breakdown that may need full
coverage restoration, pulpotomy rather than direct pulp
capping is recommended.
• History of restorative treatment: In case of mature
permanent teeth, teeth with no previous history of
restorative treatment, direct pulp capping can be done.
• Pulp hemorrhage: Visualize the pulp and assess the
hemorrhage. If bleeding can be controlled with 3–6%
NaOCl applied with cotton pellet on exposed pulp
for about 1–10 minutes, then direct pulp capping can
be done. But if bleeding cannot be controlled, then
diagnosis of irreversible pulpitis is made and pulpotomy
or pulpectomy may have to be done.
• Irreversible pulpitis in immature permanent tooth: In
young permanent teeth with open apices, pulpectomy
is done and MTA is used as a root end plug to promote
root end closure.
WHAT IS APEXIFICATION (NONVITAL PULP
THERAPY)?
Apexification
• Definition: “Apexification is a method to induce
development of the root apex of an immature, pulpless

tooth by formation of osteocementum or other bone-like
tissue” (Grossman’s Endodontic Practice, 11th Edition,
p. 110).
According to American Association of Endodontists,
“Apexification is a method to induce a calcific barrier
in a root with an open apex or the continued apical
development of an incomplete root in tooth with necrotic
pulp.” Apexification procedure involves debridement of
canal, short of the apex, without disturbing apical tissues
and placement of a biocompatible material to stimulate
hard tissue formation.
Open apex of an immature permanent tooth is also
called ‘blunderbuss apex’.
Apexogenesis is the physiologic process of root
development whereas apexification is induced root end
development using a biocompatible material.
• Objective:
– Induce closure of the open apical third of the root
canal
– Formation of an apical barrier, creating an apical
stop, against which obturation can be achieved.
– Preserve and stimulate Hertwig’s epithelial root
sheath (HERS), to induce root end development by
natural root lengthening process.
• Rationale:
– Any viable and undamaged apical pulp tissue present
in the root canal along with the odontoblastic layer
associated with the pulp tissue is preserved
↓ - A radiograph is taken to confirm the correct
Cleaning and shaping/disinfection of the root canal
2 mm short of the radiographic apex to remove micro-
organisms and toxic products without causing any
harm to the viable pulp tissue and HERS
↓ reinforced zinc oxide eugenol cement.
Matrix formation and subsequent calcification guided
by viable HERS, creating an apical stop, against
which  dense obturation can be achieved. (Refer
Figure 27.6A)
– If necrotic pulp and destroyed HERS,
↓ irrigation with sterile water or normal saline to
Disinfection of root canal 2 mm short of root apex
↓ is recalled every 3 months till radiographic
Biocompatible material used as chemical stimulant
to induce differentiation of cementoblast or
undifferentiated fibroblasts of periapical tissue and
periodontal ligament
↓ canal with gutta-percha is done.
A hard substance forming a calcific bridge at or short
of apex, creating an apical stop, against which dense
obturation can be achieved. (Refer Figure 27.6B)
Pulp Therapies 447
Histologically, the hard substance formed may have
configuration either of bone, dentin, osteodentin or
cementum
• Materials used: Calcium hydroxide, mineral trioxide aggre­
gate (MTA), Radiopaque calcium hydroxide paste in a
methylcellulose base, calcium hydroxide in combination
with Camphorated paramonochlorophenol, zinc oxide
paste, etc.
• Technique:
– Using calcium hydroxide:
- Anesthesia may or may not be needed. Isolation
of tooth with rubber dam. Access preparation
and coronal pulp extirpation
- Preoperative radiograph used to determine
apparent length of the tooth and instrumentation
done 2 mm short of the apex to remove necrotic
pulpal tissue and prepare the root canal for
calcium hydroxide dressing.
- Root canal is dried with blunt absorbent points
- Calcium hydroxide is mixed with sterile water
or anesthetic solution to a thick consistency
and carried to the pulp chamber using
amalgam carrier with plastic tips and then
thick, large finger plugger is used to force the
dry calcium hydroxide paste into the root canal.
Alternatively, rotating lentulospiral can be used
to deliver the calcium hydroxide paste into the
root canal.
placement of the medicament. Care should be
taken to avoid pushing it beyond the apex.
- Temporary coronal seal: A dry cotton pellet
is placed over the material and sealed with
- Recall: Patient is recalled after 3 months and
radiograph is taken to check if calcific barrier is
formed at or near apex. If it is not formed, then
old calcium hydroxide dressing from the root
canal is removed using large files and copious
prevent irritation to periapical tissues. Patient
evidence of an apical barrier is seen that denotes
apexification. It has been found that this process
takes about 3 months to 21 months.
- Once the apical stop is created, obturation of the
  Figure 27.7 shows the diagrammatic
representation of apexification procedure using
calcium hydroxide.
448 Short Textbook of Endodontics
A B
Figs 27.6A and B  Successful outcome of apexification. (A) Root end
development; (B) Calcific bridge is formed
Fig. 27.7  Apexification using calcium hydroxide
– Using mineral trioxide aggregate: MTA is considered
material of choice for apexification because it is
found to create permanent apical plug at the outset
of treatment.
- Anesthesia may or may not be needed. Isolation
of tooth with rubber dam. Access preparation
and coronal pulp extripation
- Preoperative radiograph used to determine
apparent length of the tooth and instrumentation
and irrigation done 2 mm short of the apex to
remove necrotic pulpal tissue and to prepare the
root canal.
- Root canal is dried with blunt absorbent points
A B C
D E
Figs 27.8A to E  Apexification procedure using MTA. (A) a: Necrosed
pulp, b: Open apex (blunderbuss); (B) Instrumentation done 2 mm
short of apex; (C) Apical plug of MTA and a moist cotton pellet is
placed in pulp chamber and sealed with a temporary cement. ‘a’
shows MTA apical plug; (D) Apical barrier formed is checked using
an Endodontic instrument such as plugger or spreader after 48 hours
against which obturation is achieved; (E) Outcome after 3–6 months:
a: Calcified bridge, b: Obturation of canal using gutta-percha, c:
Permanent restoration
- Mineral trioxide aggregate (MTA) is mixed with
distilled water as per manufacturer’s instructions
and placed as an apical plug in the apical 3–4 mm
using a special plugger or amalgam carrier.
- Radiograph is taken to verify the placement
- MTA sets under moisture. So, a moist cotton
pellet is placed in the pulp chamber and access
is sealed using reinforced zinc oxide eugenol
cement.
 Pulp Therapies 449

- Recall: Patient is recalled every 3 months to check

the apical barrier formation radiographically.
Figures 27.8A to E shows diagrammatic
representation of apexification using MTA.
Figures 27.9A and B show radiograph of pulpally
involved immature permanent maxillary central incisor
tooth in which MTA was used for apexification and
obturation completed with gutta-percha.
Also, one more case of immature pulpally involved
maxillary right central incisor, in which apexification was
done is explained in Chapter 24: Management of Dental
Traumatic Injuries (Figs 24.9A to D).

A B
BIBLIOGRAPHY
Figs 27.9A and B  (A) Radiograph showing immature pulpally
involved permanent maxillary right central incisor; (B) The case was
completed with an apical plug of MTA for apexification and gutta-
percha root canal filling in the same tooth (Courtesy of Dr Chetan
Shah)
- After two days, hardening of MTA is checked
gently and obturation with gutta-percha is done.
1. Cohen S, Hargreaves KM. Pathways of Pulp, 9th edn. St. Louis:
Mosby, 2006.pp.834-82.
2. Grossman L, Oliet S, Del Rio C. Endodontic Practice, 11th edn.
Varghese publication, 1991.pp.102-15.
3. Ingle J, Bakland L, Baumgartner J. Ingle’s Endodontics, 6th edn.
BC Decker Inc, Hamilton, 2008.pp.1310-29.
4. Reference Manual, V 36/No 6, 14/15, AAPD, ‘Guideline on Pulp
Therapy for Primary and Immature Permanent Teeth’.
 28
CHAPTER

Pediatric Endodontics

This chapter explains the specific features of the Pediatric patients that may require special
considerations during Endodontic treatment and describes the various pulp therapies that can be
performed in Pediatric patients.
  You must know
• What is Pediatric Endodontics?
• What are the Objectives of Preserving Primary Teeth?
• What are the General Features of Endodontic Treatment of Pediatric Patients?
• What are the Specific Morphologic Features of Teeth of Pediatric Patients?
• How to Establish a Correct Pulpal Diagnosis in Children?
• What is the Important thing you must know about the Proximal Lesions in Primary Teeth?
• Which are the Different Pulp Therapies Performed in Children?
• Pulp Therapies for Primary Teeth

WHAT IS PEDIATRIC ENDODONTICS?
Endodontic treatment performed in children for the
preservation of primary and young permanent teeth with
pulp involvement to prevent premature loss of primary
teeth and to facilitate completion of development of young
permanent teeth to render them functional for many years,
is called Pediatric Endodontics.
• Primary teeth have complex root canal anatomy.
• During Endodontic treatment of primary teeth, there is
danger of injury to permanent tooth bud.
• There can be special problems associated with the
natural resorption of primary tooth roots.
WHAT ARE THE SPECIFIC MORPHOLOGIC
FEATURES OF TEETH OF PEDIATRIC PATIENTS?

WHAT ARE THE OBJECTIVES OF PRESERVING We shall discuss these features by classifying them in the
following way:
PRIMARY TEETH?
Objectives of preserving primary teeth include (Fig. 28.1).

WHAT ARE THE GENERAL FEATURES OF

ENDODONTIC TREATMENT OF PEDIATRIC
PATIENTS?
• During treatment of pediatric patients, aspects of
child psychology and behavior management have to
be considered which can be time-consuming and
sometimes challenging too. Fig. 28.1  Objectives of preserving primary teeth
 Pediatric Endodontics 451

– Crown: Important consideration is relatively larger

pulp chambers and high pulp horns as compared to
adult teeth.
– Root: Apical root development may be incomplete
causing presence of blunderbuss canals.
If pulp necrosis occurs prior to complete dentin
deposition there would be thin roots which are more
prone to fracture.
– An immature nonvital young permanent tooth will
• Specific morphologic features of primary teeth have poor crown to root ratio.
(Fig.  28.2A): In case of a pulpally involved young permanent
– Crown: tooth, efforts are directed towards stimulation of
- Enamel: Enamel is thinner and more consistent reparative dentin to retain the tooth as functional
in thickness when compared to permanent teeth. unit. Additional procedures such as apexification
- Dentin: The thickness of dentin between the may be necessary for maintaining pulpless immature
enamel and the pulp chamber is less and does permanent tooth.
not provide much protection to large pulp.
• Specific features of primary root canal anatomy of
- Pulp chamber:
individual teeth:
Larger pulp chamber in relation to overall size
– Maxillary primary incisors (Fig. 28.3):
of tooth crown and in comparison to permanent
- Single round root canal resembling the shape of
teeth.
the root.
Pulp horns, especially mesial pulp horns are
- Permanent tooth bud lies lingual and apical to
higher in primary molars as compared to
primary tooth, so resorption is initiated on the
permanent molars.
lingual surface in apical third of roots.
- Wider mesiodistal dimension of crowns in
– Mandibular primary incisors (Fig. 28.4):
comparison with their crown length than crowns
- Single root canal flattened on mesial and distal
of permanent teeth.
surfaces
- Marked constriction at the dentinoenamel
- Occasionally, two canals may be present
junction (DEJ) as compared to permanent teeth.
- Lateral or accessory canals may be present.
- Narrower occlusal surface in the faciolingual
- Permanent tooth bud lies lingual and apical to
direction due to converging facial and lingual
primary tooth. So resorption is initiated on the
surfaces occlusally of primary molars.
lingual surface in apical third of roots.
– Root:
- Flaring (diverging) root of primary molars from
the cervix and more at the apex.
- Longer and more slender roots of primary molars
as compared to permanent molars.
- Narrower and longer roots as compared to crown
length and width. So, root-to-crown length of
primary teeth is greater than that of permanent
teeth.
- Root length completion occurs in shorter period
of time than the permanent teeth due to shorter
length of primary roots.
- Resorption of roots begins soon after root
length completion and there is deposition of
additional dentin within the root canal system
that significantly changes the number, size and
shape of the root canals within the primary tooth. A B
• Specific morphologic features of young permanent Figs 28.2A and B  Shows the diagrammatic representation of
teeth (Fig. 28.2B): primary (A) and young permanent tooth (B)
452 Short Textbook of Endodontics
– Maxillary and mandibular primary canines (Fig.
– Maxillary first primary molar (Fig. 28.6):
Fig. 28.3  Maxillary primary incisor
– Maxillary second primary molar (Fig. 28.7):
Fig. 28.4  Mandibular primary incisor
– Mandibular first primary molar (Fig. 28.8):
– Mandibular second primary molar (Fig. 28.9):
Fig. 28.5  Maxillary and mandibular primary canine
28.5):
- Single rounded root canal corresponding to
exterior root shape.
- Triangular shape of root canal with the base
towards the facial surface.
- Bifurcation of canal or lateral canals generally
not present.
- Permanent tooth bud lies lingual and apical to
primary tooth, so resorption is initiated on the
lingual surface in apical third of roots
- Two to four canals are present that correspond
to exterior root form with much variation.
- Palatal root is usually round and longer than the
facial roots.
- In about 75% of maxillary first primary molar,
there is bifurcation of mesiofacial roots into two
canals.
- The isthmus connecting separate canals is
narrow and islands of dentin exist between the
canals with many connecting branches.
- Mesial canal tends to show variations
- Accessory canals, lateral canals and apical
ramifications of pulp may be present.
- Two to five canals are present that correspond to
exterior root form.
- Mesiofacial root usually bifurcates or it may
contain two distinct canals.
- Fused palatal and distofacial roots may have a
common canal or a narrow isthmus connecting
separate canals may be present with island
of dentin between canals with connecting
branches.
- Usually 3 canals are present corresponding to
external root anatomy but may have two or four
canals.
- Approximately, 75% of mesial roots have two
canals and 25% of distal roots contain more than
one canal.
- Accessory canals, lateral canals and apical
ramifications of pulp may be present.
- Resorption begins on inner surface of roots next
to interradicular septum causing variations in
root canal anatomy
- Usually three canals are present. But, two to five
canals may be present.
- Mesial root tends to show variations.
 Pediatric Endodontics 453

Fig. 28.6  Maxillary first primary molar Fig. 28.9  Mandibular second primary molar

- Accessory canals, lateral canals and apical

ramifications of pulp may be present.
- Resorption begins on inner surface of roots next
to interradicular septum causing variations in
root canal anatomy.

HOW TO ESTABLISH A CORRECT PULPAL

DIAGNOSIS IN CHILDREN?
History Taking
• A thorough medical history to evaluate child’s general
condition is important.
In a child with systemic disease, Endodontic therapy may
be contraindicated or may require different approach.
• Pain history:
Fig. 28.7  Maxillary second primary molar In case of pediatric patients, history of pain given by
child or his parents sometimes, may not be relied on
completely.
But, still few direct questions related to pain such as
onset, duration, intensity, nature of pain, etc. can be
very useful indications of the status of the pulp.

Clinical Examination
• Careful inspection and palpation of oral soft and hard
tissues.
Figure 28.10 shows multiple carious deciduous teeth
in a child. (Nursing bottle caries)
Figure 28.11 shows photograph of trauma to
permanent anterior teeth in a child.
• Intraoral sinus opening and draining sinus tracts are
quite common in children due to early involvement of
Fig. 28.8  Mandibular first primary molar pulp.
454 Short Textbook of Endodontics
Fig. 28.10  Nursing bottle caries involving all maxillary teeth and
mandibular posterior teeth in a child (Courtesy of Dr Samir Khaire)
Fig. 28.11  Trauma to permanent anterior teeth in a child
(Courtesy of Dr CR Suvarna)
• Percussion test may not be very reliable because it
depends on subjective response by the child.
• Mobility test also may not be very reliable because of the
aspect of normal physiologic mobility of primary teeth
associated with natural resorption of roots.
Pulpal Diagnostic Tests
Thermal tests and electric pulp test are generally unreliable
in children due to some aspects of pulpal anatomy of
primary teeth and due to other problems in children related
to apprehension and management.
Most of the times, an accurate pulpal diagnosis is
established only after direct evaluation of pulp tissue. One
has to check for:
• Size of exposure: It may be pinpoint or massive carious
expo­sure associated with varying degrees of pulpal
inflammation.
• Amount of hemorrhage: Tooth with extensive
inflammation may bleed profusely when pulp
amputation is done. There is persistence of bleeding
for long, even after pressure with cotton pellet is applied
for hemostasis.
• Pulp polyp: Chronic inflammation of pulp in the form
of pulp polyp may be seen.
Radiographic Examination
Intraoral periapical (IOPA) and bitewing radiographs of the
affected area has to be taken.
On the radiograph:
• Extension of caries can be seen.
Figure 28.12 is radiograph showing pulpally involved
immature tooth with open apex.
• Physiologic root resorption of primary teeth may be
apparent.
• Developing permanent tooth buds are seen
• Calcified masses may be seen in pulp chamber in
response to irritation to pulp
• Radiolucency may be apparent in the bifurcation
or trifurcation of roots rather than at the apex due
to presence of accessory canals on pulpal floor or
communication from necrotic pulp to furcation through
altered dental tissue in area of furcation. Figure 28.13 is
radiograph showing radiolucency in the furcation and
around the roots of an over-retained deciduous molar.
• Pathologic root resorption and bone resorption may be
present due to extensive inflammation in the tooth.
• Internal root resorption due to pulpal pathosis may be
seen.
• Follow-up of treatment: Radiographs of treated teeth are
taken during the follow-up visits to evaluate the outcome
of treatment. Figure 28.14 shows few examples of post-
treatment and follow-up radiographs.
A panoramic view is also very valuable radiograph
in Pedodontics as it shows in one view all the deciduous
teeth along with the permanent tooth buds so that proper
treatment can be planned. Figure 28.15 shows a panoramic
image of a patient.
After proper history taking and thorough clinical and
radiographic examination, or sometimes after direct

Fig. 28.12  Radiograph showing pulpally involved
immature tooth with open apex (Courtesy of Dr Chetan Shah)
Fig. 28.13  Over-retained deciduous molar
(Courtesy of Dr Chetan Shah)
evaluation of pulp tissue, pulpal diagnosis can be made
such as:
– Reversible pulpitis
– Irreversible pulpitis
– Pulp necrosis
• Important considerations for deciding treatment
– Affected tooth: Time of exfoliation with respect to
dental age of patient.
– Restorability of crown
– Presence or absence of permanent successor
– Extent of infection: Whether the infection is severe
enough that has the potential to affect permanent
tooth bud or that cannot be treated with Endodontic
therapy and will need extraction.
Pediatric Endodontics 455
Fig. 28.14  Few examples of post-treatment and follow-up
radiographs (Courtesy of Dr Ashwin Jawdekar)
Fig. 28.15  Panoramic image (commonly referred to as
orthopantogram) (Courtesy of Dr Ashwin Jawdekar)
A mind-map to remember pulpal diagnosis in
children is given in Figure 28.16.
WHAT IS THE IMPORTANT THING YOU MUST
KNOW ABOUT THE PROXIMAL LESIONS IN
PRIMARY TEETH?
Proximal lesions in primary teeth are quite deceptive. One
must consider appropriate pulp therapy in the event of:
• Lesions extending subgingivally
• Lesions with marginal ridge breakdown
• Lesions with the involvement of more than 50% of tooth
substance from the outer margin towards pulp as evident
on radiograph.
Proximal lesions without gingival seat are difficult to
restore and endanger pulp exposure.
456 Short Textbook of Endodontics
Fig. 28.16  A mind-map to remember pulpal diagnosis in children
Dentin of primary teeth has wider tubules. As a result
there is rapid progress of caries. There is possibility of
invasion of bacteria and their toxins much before frank
carious exposure.
Moreover apart from stainless steel crown, it may
not be possible to seal the margins adequately. Thus a
conservative approach in management of pulpal lesions
may not help. Therefore, pulp therapies such as indirect
pulp capping or pulpotomy needs to be considered for all
deep proximal lesions.
Another factor that needs to be considered is the
dental age of the patient. If the dental age is more, then a
conservative approach is preferred. If dental age is lesser,
then more definitive pulp therapies such as pulpotomy or
pulpectomy needs to be done.
It is needless to state that proximal lesions will need
adequate coronal seal and stainless steel restoration would
be the restoration of choice in most instances.
Figures 28.17A to C show the photographs and corres­
ponding radiographs of proximal lesions in various primary
teeth.
 Pediatric Endodontics 457

C
Figs 28.17A to C  Proximal lesions in primary teeth. (A) Maxillary posterior region;
(B) Mandibular posterior region; (C) Maxillary anterior region

WHICH ARE THE DIFFERENT PULP THERAPIES apices. The latter have been discussed in Chapter 27:
PERFORMED IN CHILDREN? Pulp Therapies and in Chapter 24: Management of Dental
In children, pulp therapies may be performed in primary Traumatic Injuries. Here we will discuss about the pulp
teeth or in young permanent teeth generally with open therapies for primary teeth.
458 Short Textbook of Endodontics

Indirect Pulp Capping

Done in case of deep carious lesion approximating the pulp,
where it is anticipated that pulp would be exposed when
caries is excavated. This should be done only when there
are no signs or symptoms of irreversible pulpitis.
• Indications: Deep carious lesion in a primary tooth with
no signs of pulp degeneration.
• Contraindications:
– Signs or symptoms of irreversible pulpitis
– Radiographic lesion such as internal or external
resorption or furcation radiolucency
• Objectives:
– The restorative material seals the involved dentin
from the oral environment.
– Vitality of the tooth preserved
– No post-treatment clinical signs or symptoms such
as sensitivity, pain or swelling.
– No radiographic evidence of pathologic external or
internal root resorption or any pathologic change.
– No harm to the succedaneous tooth.
• Technique:
– Anesthesia and rubber dam isolation.
– Excavation of caries using a round bur except that
directly overlying the pulp. Spoon excavator can be
used for excavation in deep cavities, but should be
used judiciously if indirect pulp capping is planned,
as it might remove large segment of caries causing
direct exposure of pulp.
– A biocompatible material such as calcium hydroxide
PULP THERAPIES FOR PRIMARY TEETH or zinc oxide eugenol is placed over remaining
carious dentin to stimulate healing and repair.
Protective Liner If calcium hydroxide is used, then it should be
It is a thinly-applied liquid which is placed on the pulpal covered with glass ionomer or reinforced zinc oxide/
surface of a deep cavity preparation covering the exposed eugenol material is placed over it to provide a seal
dentinal tubules, to act as protective barrier between the against microleakage as calcium hydroxide has high
restorative material and the dental pulp. Examples of solubility, poor seal and low compressive strength.
protective liner include: Calcium hydroxide, dentin bonding – The tooth is then restored with hard-setting,
agent, glass ionomer cement. reinforced ZOE or amalgam or acid-etched bonded
• Indications: composite to seal it against microleakage
In a tooth with normal pulp, after excavation of all the – The tooth re-entered after a period of approximately
caries, a protective liner may be placed in the deep areas 6 weeks and removal of remaining caries is done.
of the preparation in order to: This remaining caries generally appears dehydrated,
– Minimize injury to the pulp and promote pulp tissue slightly hard consistency and light brown color.
healing According to current literature, there is no
– Reduce postoperative sensitivity. conclusive evidence that it is necessary to reenter the
• Objectives: tooth to remove residual caries so long as the tooth
Liner is placed in deep area of the cavity preparation: remains sealed from bacterial contamination and
– To promote pulp tissue healing, shows good prognosis for caries arrest and reparative
– To promote formation of tertiary dentin dentin formation to protect the pulp.
– To preserve pulp vitality – The re-entered tooth is then permanently restored.
– To minimize bacterial microleakage. (with Glass ionomer or amalgam restoration)

Direct Vital Pulp Therapies
Direct Pulp Capping
Done in case of traumatic or mechanical pulp exposures.
• Indications: Pin-point sized mechanical or traumatic
pulp exposure, when the pulp is vital and no signs or
symptoms of irreversible pulpitis. Direct pulp capping
of a carious pulp exposure in a primary tooth should not
be done.
• Contraindications:
– Carious pulp exposure
– Large exposures
– Profuse bleeding from exposure site indicating
extensive inflammation
• Material used: Calcium hydroxide is the pulp capping
agent of choice. MTA can also be used.
• Objectives:
– Vitality of the tooth preserved
– No post-treatment clinical signs or symptoms such
as sensitivity, pain or swelling.
– Healing of pulp and reparative dentin formation
should occur.
– No radiographic evidence of pathologic external or
internal root resorption or any pathologic change.
– No harm to the succedaneous tooth.
• Technique:
– Anesthesia and rubber dam isolation
– Excavation of caries with bur or spoon excavator,
if it causes mechanical or traumatic pulp exposure
which is pin-point sized and no bleeding or minimal
bleeding occurs, then pressure with cotton pellet is
applied to control bleeding.
– Calcium hydroxide is placed over the exposed pulp.
It is covered with glass ionomer or reinforced zinc
oxide/eugenol material as base and the tooth is
permanently restored with amalgam or composite
restoration.
It is recommended that direct pulp capping be
performed in older children in cases in which the
teeth will exfoliate within 1 or 2 years.
Pulpotomy in Primary Teeth
Amputation of the coronal pulp leaving behind vital
radicular pulp is done in cases of carious pulp exposures
or large traumatic exposures, in which the inflammation is
confined to the coronal pulp.
• Indications: Carious pulp exposure in primary teeth
or inflammation of pulp confined only to the coronal
portion of tooth.
Pediatric Endodontics 459
• Contraindications:
– Pathologic root resorption or radiolucency seen on
radiograph
– Profuse bleeding that persists for long after coronal
pulp amputation
– In a tooth that is about to exfoliate
– In a tooth with draining abscess.
• Objectives:
– Radicular pulp asymptomatic with no adverse signs
or symptoms such as sensitivity, pain or swelling
– No postoperative radiographic evidence of
pathologic external root resorption
– Self-limiting and stable internal root resorption
which should be monitored.
– No harm to succedaneous tooth.
• Materials used: Calcium hydroxide has been used but
has less long-term success.
– Formocresol
– Ferric sulfate
– Glutaraldehyde
– MTA, more recent material used for pulpotomy has
high success rate and is now preferred pulpotomy
agent.
– Electrosurgery used for pulpotomy also has shown
good results.
• Pulpotomy agents used and technique for pulpotomy:
1. Formocresol pulpotomy
- One-fifth concentration formocresol can be used
for pulpotomy which is prepared as follows:
■ 3 parts of glycerin + 1 part of distilled water
(to prepare diluent)
■ One part formocresol + 4 parts of diluent
- Formocresol causes tissue fixation.
- Technique: Figures 28.18A to G show the steps of
formocresol pulpotomy
■ Anesthesia and rubber dam isolation.
■ Removal of caries. Figure 28.18A shows
mandibular first primary molar with deep
caries involving the pulp. Figure 28.18B
shows excavation of caries using a round bur.
■ Removal of entire roof of pulp chamber with
a high speed bur with adequate water coolant
(Fig. 28.18C).
■ Removal of entire coronal pulp with a long
shank round bur or spoon excavator to the
level of orifices. (Fig. 28.18D)
■ Control of hemorrhage with moist cotton
pellet pressure placed over the opening of
the root canals.
■ Then a cotton pellet dipped in the diluted
formocresol is placed in direct contact with
460 Short Textbook of Endodontics

A C

B D

Figs 28.18A to D  Steps of pulpotomy in primary teeth. (A) Caries involving coronal pulp in a mandibular first primary molar; (B) Excavation of
caries using a round bur; (C) Removal of the roof of the pulp chamber; (D) Amputation of coronal pulp to the level of orifices using a spoon
excavator

the pulp stumps. This cotton is left in contact
with the pulp stumps for 5 minutes (Fig.
28.18E).
■ A base of ZOE may be placed over stumps
■ The tooth is restored permanently (Fig.
28.18F).
Restoration can be composite resin in
anterior teeth and glass ionomer or amalgam
or composite restoration followed by stainless
steel crown for primary molars (Fig. 28.18G).
- Safety: There are concerns about the systemic
distribution of formocresol and its likely
carcinogenic potential and regarding its safe
use in dentistry.
2. Glutaraldehyde pulpotomy: 2–4% aqueous
glutaraldehyde can be used for pulpotomy instead
of formocresol.
- Advantages of glutaraldehyde over formocresol:
■ Less cytotoxic than formocresol
■ It has less systemic distribution after appli­
cation and does not diffuse out of the apex of
the tooth. There is limited tissue binding and
remainder of glutaraldehyde gets excreted in
urine or exhaled as carbon dioxide.
 Pediatric Endodontics 461

E G

Figs 28.18E to G  Steps of pulpotomy in primary teeth. (E) Cotton

pellet dipped in formocresol is placed over pulp stumps for
5 minutes; (F) A base of zinc oxide eugenol is given and covered with
a permanent restoration such as glass ionomer or silver amalgam;
F (G) The tooth is protected with stainless steel crown

■ With glutaraldehyde, there is rapid fixation
of the underlying pulpal tissue and the
remaining radicular pulp maintains vitality
and is free of inflammation.
– Technique: Similar to formocresol pulpotomy
– Disadvantages:
- Not as successful as formocresol pulpotomy
- Limited shelf life.
3. Ferric sulfate pulpotomy: Ferric sulfate can also be
used to replace formocresol for pulpotomy and has
been shown to give reasonably good clinical and
radiographic results.
4. MTA pulpotomy: Formocresol can be replaced with
mineral trioxide aggregate for pulpotomy in primary
teeth with good results.
462 Short Textbook of Endodontics

A B

C D

E (i) E (ii)
Figs 28.19A to E  Steps of pulpotomy. (A) Mandibular second primary molar is isolated using rubber dam after adequate anesthesia;
(B) Caries is excavated completely; (C) Deroofing the pulp chamber; (D) Coronal pulp is removed and hemostasis is achieved; (E) Pulpotomy
agent is placed and the tooth is restored with a temporary cement: (i) Photograph showing good temporary seal achieved after pulpotomy:
(ii) Postoperative radiograph of the same case in which pulpotomy was performed for mandibular second primary molar and pulpectomy was
performed for mandibular first primary molar (Courtesy of Dr Ashwin Jawdekar)
 Pediatric Endodontics 463

But, the disadvantages include high cost of the

material and it may cause pulp canal obliteration.

Summary of Pulpotomy Procedure

• Case selection
• Asepsis
• Hemostasis
• Coronal seal
Figures 28.19A to E are the case photographs demon­
strating the technique of pulpotomy in mandibular second
primary molar.

Nonvital Pulp Therapy for Primary Teeth

Pulpectomy
A
It involves extirpation of pulp from both coronal and
radicular spaces, cleaning and shaping of canals and
obturation with a resorbable root filling material.
• Indications:
– Irreversible pulpitis
– Necrotic pulp
• Contraindications:
– Tooth close to exfoliation having moderate to
excessive mobility
– Nonrestorable tooth with only carious root piece
or stump remaining. In such cases, extraction of
primary tooth followed by space maintainer would
be preferred.
• Objectives:
– Following pulpectomy treatment, radiographic
radiolucency suggestive of infectious process should
resolve in six months.
– Pretreatment clinical signs and symptoms should
resolve in few weeks.
– Optimum root canal filling evidenced on radiograph B
with no gross overextension or underfilling
Figs 28.20A and B  Steps of pulpectomy in primary teeth. (A) Mandi­
– Treatment should permit physiologic resorption of bular first primary molar with extensive caries involving the pulp;
primary tooth and filling material to allow for normal (B) Excavation of caries and access cavity preparation
eruption of succedaneous tooth
– No pathologic resorption or furcation/apical
radiolucency
• Technique: Figures 28.20A to F show the steps of – Access cavity preparation is done by connecting all
pulpectomy in a primary molar tooth: the pulp horns.
– Anesthesia and rubber dam isolation. Access preparation is made through the lingual
– Removal of caries. Figure 28.20A shows deep caries surface for the anterior primary teeth and through
in mandibular primary molar involving the pulp. the occlusal surface for the primary molar teeth.
Figure 28.20B shows excavation of caries and access – Removal of roof of pulp chamber followed by entire
cavity preparation. coronal pulp to the level of orifices.
464 Short Textbook of Endodontics
C D
Figs 28.20C and D  (C) Extirpation of pulp and cleaning and shaping of root canals: Circumferential filing with K-files in sequence to a
predetermined length estimated from a preoperative radiograph; (D) After thorough debridement, the canals are filled with zinc oxide
eugenol (Obturation)
– Flaring of access preparation walls for easy insertion
of files and to achieve straight line access to the apical
portion of the canals.
– From preoperative radiograph, determine the
approximate length of roots and then measure the
Endodontic instruments such as K-files about 1 mm
short of the apex.
– Barbed broach or the smaller files can be inserted
in the canals to this length for pulp extirpation (Fig.
28.20C).
– Copious irrigation with sodium hypochlorite 3% or
sterile saline should be done.
– Cleaning and shaping: Circumferential filing with
2–3 K-files or H-files in sequence of size to the length,
should be done. Excessive enlargement of canals
may cause unnecessary damage to tooth such as
perforation and hence should be avoided. Stainless
steel or nickel-titanium (Ni-Ti) instruments can be
used. Ni-Ti instruments are recommended due to
their flexibility. Both hand and rotary instruments
can be used. If stainless steel instruments are used,
the instruments need to be gently curved to help
negotiate the canals.
  The objective of cleaning and shaping in primary
teeth is to remove the pulp tissue and debris from
the canals and make space for a resorbable root
filling material.
– Irrigation of canals and then dry the canals with
sterile paper points.
– Then, obturation of canals with a suitable obturation
material (Fig. 28.20D).
• Ideal requirements of obturation material for primary
teeth:
– Biocompatible
– Antiseptic
– Resorbable—at par with tooth
– Good handling
– Economical
– Radiopaque
• Materials used for obturation of root canals of primary
teeth (Table 28.1):
– Zinc oxide eugenol: Zinc oxide eugenol is
biocompatible, antiseptic and has good handling
properties. It is economical and is a time-tested
material. It has been used as an obturation material
for primary teeth since many years. The limitation
of ZOE is that it resorbs very slowly. Its resorption is
not par with resorption of roots of primary teeth.
– C a l c i u m h y d r o x i d e : C a l c i u m h y d r o x i d e
is biocompatible and has excellent antiseptic
properties. But its antiseptic action is short-lived.
Within few days, its pH becomes neutral and
becomes ineffective. It rapidly resorbs from the root
canal. Although, it is a good material to be used for
 Pediatric Endodontics 465

TABLE 28.1  Materials used in pulpectomy of primary teeth

Requirements ZOE Ca(OH)2 Vitapex Endoflas

Biocompatible Y Y Y Y
Antiseptic Y/N Y/N Y Y
Resorbable—at Y/N N Y/N Y/N
par with tooth
Good handling Y Y/N Y Y
Economical Y Y N Y/N

TABLE 28.2  Selection of obturation material for primary teeth

Teeth
Pulp status
Incisors Canines and molars
Abscessed/nonvital Ca(OH)2 + Iodoform Ca(OH)2 +Iodoform
E (Nonsetting) (hard setting)
or
ZOE after 1 week inter-
appointment dressing
using Ca(OH)2
Nonabscessed/vital Ca(OH)2 + Iodoform ZOE or Ca(OH)2 +
(Nonsetting) Iodoform (nonsetting
or hard setting)

good primary root canal filling material and has

F • Calcium hydroxide and iodoform mixture-hard setting,
Figs 28.20E and F  (E) After obturation with zinc oxide eugenol,
permanent restoration such as glass ionomer or silver amalgam is
placed in the pulp chamber space; (F) The tooth is protected with a
full coverage restoration-stainless steel crown
following desirable properties:
- Easy to apply
- Resorbs slightly faster than roots of primary teeth
- Has no toxic effects on permanent successor
- It is radiopaque.
This combination is being widely used now-a-
days for obturation of primary teeth. It is available
as preloaded syringes with thin intracanal tips,
which makes its delivery in the canal very easy.
commercially available as Endoflas, is also a good
material for obturation of primary teeth. It undergoes
faster resorption as compared to ZOE and is hard-
setting. It is also available as preloaded syringes for easy
delivery in the root canals.

Clinical implications: (Table 28.2 Selection of obturation

intracanal dressing (medicament), its not suitable
to be used as obturation material for primary teeth.
To resist its rapid resorption and to make use of its
antiseptic properties, it has been combined with
other medicaments such as iodoform.
– Calcium hydroxide and iodoform mixture—non-
setting, commercially available as Vitapex, is a very
material for primary teeth )
• In case of primary incisors, it is always preferred to
use a nonsetting calcium hydroxide and iodoform
combination so that their roots resorb in time and
there is no delay in its shedding. Over-retained primary
incisors can deflect the path of eruption of permanent
incisors and can cause cross-bite.
466 Short Textbook of Endodontics

• In case of primary canines and molars with necrotic pulp
and abscess, if nonsetting obturation material is used,
there is high possibility that it will get resorbed easily.
So, a hardsetting material is preferred such as calcium
hydroxide with iodoform-hard setting (Endoflas).
Alternatively, in such cases, calcium hydroxide dressing
can be given for one week and then ZOE can be used as
obturation material when the canals are dry.
• In case of primary canines and molars which had a
vital pulp, any of the obturation material: ZOE, calcium
hydroxide and iodoform combination—nonsetting or
hard-setting, can be used.
• Obturation techniques in primary teeth:
– Incremental: The canals can be coated with the paste
of unreinforced ZOE using paper points, k-files or
spreader incrementally.
– Pressure syringe: Commercially available filling
devices are available such as Navitip, Vitapex syringe,
etc
– Syringe with needle
– Wet cotton: The pulp chamber is filled with the
obturating material such as ZOE and a wet cotton
pellet is pressed over it few times so that it flows into
the canals.
– Lentulospiral: Endodontic hard instruments such
as files or rotary lentulospiral fillers can be used.
Important thing to note in case of filling using
lentulospiral fillers is that it should be inserted
and removed from the canal while in rotation. The
rotation should not be started or stopped when in
the canal for its effective use otherwise the ZOE gets
removed with the lentulospiral filler.

A B
Figs 28.21A and B  Stainless steel crowns placed on Endodontically treated deciduous and permanent molars
(Courtesy of Dr Ashwin Jawdekar)

A B C
Figs 28.22A to C  Radiographs of a pulpally involved primary molar in which pulpectomy was performed. (A) Preoperative radiograph;
(B) Intraoperative radiograph with K-files inserted in the canals for determination of working length; (C) Postoperative radiograph

- Radiograph can then be taken to confirm if the
canals have been adequately filled.
- After obturation with zinc oxide eugenol,
permanent restoration such as glass ionomer or
silver amalgam is placed in the pulp chamber
space (Fig. 28.20E)
- Tooth should be restored with stainless steel
crown (Figs 28.20F and 28.21A and B)
- In case if the succedaneous permanent tooth
is missing and the retained primary tooth is
pulpally involved, the canals can be filled with
gutta-percha after pulpectomy.
Pediatric Endodontics 467
Figures 28.22A to C show the radiographs of primary
mandibular second molar tooth (Pre-intra- and post-
operative views).
BIBLIOGRAPHY
1. Cohen S, Hargreaves KM. Pathways of Pulp, 9th edn. St. Louis:
Mosby, 2006.pp.822-74.
2. Dr Ashwin Jawdekar, Little Smiles Child Care Pvt. Ltd.,
Presentations and Notes.
3. Ingle J, Bakland L, Baumgartner J. Ingle’s Endodontics, 6th edn.
BC Decker Inc, Hamilton, 2008.pp.1400-25.
4. Reference Manual, V 36/No 6, 14/15, AAPD. Guideline on Pulp
Therapy for Primary and Immature Permanent Teeth.
 29
CHAPTER

Geriatric Endodontics

This chapter describes the Endodontic treatment for the geriatric patients and explains the specific
features of the older patients that may require special considerations.
  You must know
• What is Geriatric Endodontics?
• What is the Scope of Geriatric Endodontics?
• What is the Need for Geriatric Endodontics?
• What are the Specific Features of General Health of Older Patients?
• What are the Regressive Changes that occur in the Teeth with Increasing Age?
• What are the Specific Features of Teeth of Older Patients?
• Which Orofacial and Dental Signs and Symptoms are Elicited by Clinician to Derive Correct
Diagnosis?
• What are the Different Diagnostic Tests?
• How to Formulate Treatment Plan after making Correct Diagnosis in Geriatric Patient?
• What are the Steps in Endodontic Treatment in Geriatric Patient?

WHAT IS GERIATRIC ENDODONTICS? WHAT IS THE SCOPE OF GERIATRIC

Dental clinics of North America (1989) defined Geriatric
Dentistry as the provision of dental care for adult persons
with one or more chronic debilitating, physical or mental
illness with associated medication and psychosocial
problems.
Endodontic treatment for the older adults, such as
for patients over the age of 65 years, is called geriatric
Endodontics.
Geriatric dentistry is emerging as a specialized branch
of dentistry and The National Institute of Aging has stated
that all dental professionals should receive education and
training for the management of elderly patients, as a part
of basic professional education.
ENDODONTICS?
Geriatric Endodontics deals with following as given in
Figure 29.1.
WHAT IS THE NEED FOR GERIATRIC
ENDODONTICS?
Need for Geriatric Endodontics
• With the improvement in standard of living and
availability of advanced medical care, the percentage
of aged persons in the society has increased.
• Quality of life of older patients can be significantly
improved by saving teeth through Endodontic treatment.

Fig. 29.1  Scope of geriatric Endodontics
This can have a great value in improving the overall
dental, physical and mental health.
• Root canal treatment, if possible, is definitely a
favorable alternative to the trauma of extraction and the
subsequent cost of replacement.
• Since, the primary function of teeth is mastication, loss
of teeth can lead to detrimental changes in food intake
habits resulting in reduction in general health of the
patient.
• For some patients, social issues can be a reason to save
natural anterior teeth.
Endodontic treatment is certainly less traumatic in
the extremes of age or health, than is extraction. Due to
increased awareness of benefits of saving teeth, many older
patients now seek Endodontia rather than extraction.
WHAT ARE THE SPECIFIC FEATURES OF
GENERAL HEALTH OF OLDER PATIENTS?
• With increasing age, the biological functions of body
are compromised. There may be reduced blood supply,
brittle bones and weak host resistance.
• Age-related changes in cardiovascular system,
respiratory system and central nervous system may
result in drug therapy needs.
Geriatric Endodontics 469
• Decline in renal and liver function that may alter the
behavior and interaction of drugs in the body.
• Certain complex conditions and medical problems
might make a patient functionally dependent.
• Symptoms of certain undiagnosed illness may be present.
• Visual and auditory deficits can make communication
difficult.
WHAT ARE THE REGRESSIVE CHANGES THAT
OCCUR IN THE TEETH WITH INCREASING AGE?
Regressive Changes in the Teeth
• Enamel:
– Decrease in the permeability of enamel
– Wasting diseases causing loss of enamel (attrition,
abrasion and erosion)
– Enamel becomes slightly brittle with age.
• Dentin:
– Decrease in permeability of dentin
– Secondary and reparative dentin deposition
– Deposition of peritubular dentin and gradual
obliteration of dentinal tubules
– Dentin sclerosis
• Pulp:
– More fibers, less cells
– Reduced pulp volume
– Small geriatric canals
– Decreased blood supply to tooth
– Calcification in pulp chamber and root canals.
– Calcification process associated with aging appears
clinically to be more of linear type than that which
occurs in younger tooth in response to caries or
trauma.
– Constant deposition of cementum throughout
life increases the length of the canal from actual
anatomic foramen to cementodentinal junction
• Root:
– Conditions like hypercementosis
– Apical root resorption may be present.
Figures 29.2A and B show comparison between root
canal system of young permanent tooth with that of
a geriatric tooth.
WHAT ARE THE SPECIFIC FEATURES OF
TEETH OF OLDER PATIENTS?
Specific features of teeth in elderly are described in Table
29.1.
470 Short Textbook of Endodontics

WHICH OROFACIAL AND DENTAL SIGNS AND

SYMPTOMS ARE ELICITED BY CLINICIAN TO
DERIVE CORRECT DIAGNOSIS?
Subjective symptoms Objective signs
• Clinician can ask specific • Clinician should do the following
questions and allow examination and elicit specific signs:
patient to express his A. Thorough extraoral examination: Check
symptoms: for any facial asymmetry or distension
A. Patient’s chief complaint. indicating swelling
B. About pain: B.  Thorough intraoral examination:
– Nature of pain – Examination of area of chief
– Severity complaint.
– Relationship to – Rule out predisposing factors to oral
A B stimulus or irritant cancers which may initially manifest
Figs 29.2A and B  Diagram showing comparison between an adult – Aggravating and as prodromal signs or symptoms
tooth root canal system with that of a geriatric patient: (A) Root canal relieving factors – Decreased salivation (xerostomia)
Any specific symptom due to certain medications resulting
system in a young adult tooth; (B) Root canal system in a geriatric
that patient would like to in dental caries and oral fungal
patient. a—Pulp horns: High pulp horns go on receding with
speak about infections
increasing age, b—Pulp chamber: Large and wide pulp chambers
– Gingival recession causing
become smaller and shorter, c—Root canals become thin, d—
hypersensitivity of exposed dentin
Cementum deposition causes thin narrow apical foramen, e—Pulp
and cementum.
stone
– Periodontal examination.
– Failed restorations, marginal leakage
– If sinus tract is present, gutta-percha
can be used to trace its origin
TABLE 29.1  Specific features of teeth in elderly
Clinical features Related to symptoms Related to healing
and repair WHAT ARE THE DIFFERENT DIAGNOSTIC TESTS?
• Radicular caries • Pain associated • Pulp healing is
(Root decay) with vital pulps (i.e. reduced • Inspection
• Gingival recession Referred pain, pain • Age-related • Slow and gentle percussion and palpation
• Periodontal caused by heat, changes in • Transillumination and staining to detect cracks in case
problems cold, sweets) seems connective
• Poor oral hygiene to be reduced with tissue and bone
of presence of symptoms
• Wasting diseases of age resulting in • Pulp testing: It detects the response of pulp to stimuli
teeth: • Severity seems to delayed repair and irritants. The response to stimuli may be weaker
– Attrition diminish over time of periapical than young pulps due to fewer nerve branches and
– Abrasion, etc. • Heat sensitivity tissues
• Sinus tracts may occur as the
mineralization in older pulps.
• Missing teeth and only symptom due
tilted teeth can to reduced pulp
cause compensating volume
bite which • Necrosis may
may result into occur quickly after
temporomandibular microbial invasion,
joint (TMJ) again with reduced
dysfunction or loss symptoms
of vertical dimension • High conduction
• Cracks or craze lines nerve endings in
on teeth may be dentin are reduced
present or absent, and
• Interproximal root dentinal tubules
caries are calcified; so
• Figures 29.3 and patient may not feel
29.4 show the intra- pain until actual
oral clinical features pulp exposure has
in a geriatric patient occurred
 Geriatric Endodontics 471

• Radiographs: In geriatric patients:

– It may be difficult to place the film, especially if tori
are present or if patient is unable to hold the film.
Film holders can be helpful.
– Exposure time will have to be increased to get proper
diagnostic contrast if exostoses and dense bone is
present.
– Early bone changes can be detected effectively by
digital radiography as compared to conventional
radiography.
– Evaluate the radiograph for the following:
- Receding pulp horns
- Depth of pulp chamber
- Presence of pulp stones
- Proximal and root caries and restorations
Fig. 29.3  Geriatric patient showing abrasion and erosion - Calcification between observable pulp chamber
and root canal in case of deep restorations
- Number of roots
- Root canals — number, size, shape and curvature
- Midroot disappearance of a detectable canal may
indicate bifurcation.

HOW TO FORMULATE TREATMENT PLAN AFTER

MAKING CORRECT DIAGNOSIS IN GERIATRIC
PATIENT?
Based on patient’s history, clinical examination and
interpretation of various diagnostic tests, determine:
• Vitality of tooth: Vital/nonvital
• Presence or absence of periapical pathologic conditions
and determine whether root canal treatment is
indicated.

Once you plan to do RCT, then:

• Consultation with patient’s relatives, obtain informed
Fig. 29.4  Geriatric patient showing attrition, abrasion, consent from patient and obtain valid consent from
gingival recession and craze lines
patient’s physician in case of any medical problem
• Then schedule the appointment as per patient’s
convenience
• Decide whether single-visit or multiple visit approach
In elderly patients, it becomes difficult to perform would be suitable
and interpret results of electric and thermal pulp testing • Consider patient’s comfort, chair position, jaw fatigue
due to and choice of anesthetic.
– Extensive restorations
– Pulp recession WHAT ARE THE STEPS IN ENDODONTIC
– Excessive calcifications
TREATMENT IN GERIATRIC PATIENT?
• Test Cavity:
– Less useful due to reduced dentin innervation • Pretreatment
– Should be used only when other tests have failed to • Access cavity preparation
give correct diagnosis. • Cleaning and shaping/biomechanical preparation
472 Short Textbook of Endodontics
• Obturation
• Post-Endodontic restoration
• Repair after endodontic treatment
Pretreatment
• Administration of appropriate local anesthetic (LA)
• Isolation with rubber dam
Access Cavity Preparation
• The most difficult step in Endodontic treatment of older
patients is adequate access and identification of root
canal orifices. This may be due to thin, small geriatric
canals, which may be calcified most of the times that
makes location and penetration of canal orifice quite
difficult and time-consuming.
• Remove caries and existing restorations if any, under
suitable magnification in the form of loupes or
microscopes.
• Location and initial penetration of the canal orifice with
DG-16 explorer.
Canal negotiation with #8 k-file with gentle apical
pressure and prelubricated with a chelating agent.
• If risk of deviation from long axis exists such as in heavily
restored tooth or calcified canals, surgical access may be
preferred.
• Errors:
– Canals may be overlooked. Careful location of
orifices is important.
– Perforation: Pain, bleeding, disorientation of probing
instrument may indicate perforation.
Cleaning and Shaping (Biomechanical
Preparation)
• Reparative dentin deposition and calcification makes
penetration of canals difficult
• Due to constant deposition of cementum throughout
life, length of canal from actual anatomic foramen to
CDJ increases, but actual CDJ width remains constant
with age.
• Usually crown-down technique is followed: Flaring of
coronal 1/3rd of canal to provide a reservoir of irrigating
solution and reduce the stress on metal instruments.
• Thorough copious irrigation with sodium hypochlorite
to remove debris that block access.
• Instruments with no rake angle are beneficial.
• Canal preparation should terminate at CDJ (narrowest
constriction of canal): 0.5 to 2.5 mm from radiographic
apex.
• Difficulties encountered in cleaning and shaping in root
canals of geriatric patients:
– Reduced tactile sense in identifying constriction due
to calcification
– In cases with hypercementosis, there is difficulty in
penetration of the canal in the apical third
– Achieving and maintaining patency are difficult
– Reduced periapical sensitivity causes reduced
response of patient that otherwise indicates
penetration of apical foramen.
Obturation of Root Canal System
• For older patients, excessive pressure during obturation
can result in root fracture. So, the obturation techniques
that do not require unusually large mid-root tapers and
do not generate pressure in this area are selected.
• Obturation using a thermoplasticized material such as
resilon, can significantly reduce coronal leakage that
can result from root caries after Endodontic treatment
and also it increases resistance to root fracture.
• Permanent restorative procedures should be scheduled
as soon as possible to prevent coronal leakage.
Post-Endodontic Restoration
• Root fracture is common in older adults when posts with
much taper is used.
• Post fracture or failure may occur when small diameter
parallel post is used.
• In older patients, factors determining type of restoration
include root caries, cervical erosion, gingival recession,
bone loss and lesser number of teeth remaining.
• In case of older patients, often multiple teeth are missing.
So there may be insufficient vertical and horizontal
space when opposing or adjacent teeth are missing.
Repair after Endodontic Treatment
• Repair may be delayed due to age-related changes such
as:
– Increase in atherosclerotic changes of blood vessels
– Viscosity of connective tissue is altered
– Decrease in rate of bone formation and normal
resorption
– Greater porosity of bone
– Decreased mineralization of formed bone
• In case of vital pulps with normal periapical tissue: Good
prognosis of Endodontic therapy and periapical tissue
can be maintained normal by confining preparation and
filling procedures to canal space.
 Geriatric Endodontics 473

• In case of infected nonvital pulps with periapical Considerations for Endodontic Surgery
pathologic abnormalities: Repair is determined by
Medical Local
ability of host tissue to respond.
Thorough evaluation of Medical • Presence of fenestrated or dehisced
history is done. Some special roots and exostoses
Endodontic Surgery in Geriatric Patients considerations may be needed: • Thickness of overlying soft and
• Prophylactic antibiotic bony tissue.
Endodontic surgery may be considered in geriatric patients premedication • Relationship of anatomic
if the case is definitive indication for surgery, but may • Sedation structures such as sinus, floor
• Hospitalization of nose, neurovascular bundle
require medical consultation. • More detailed evaluation with surrounding structures may
change when teeth are lost.
Need for Endodontic Surgery • If root end surgery is to be
Surgical access may be preferred in case of anatomic performed, consider whether
the root that will be left is long
complications of RC system such as small or completely enough and thick enough for
calcified canal, non-negotiable root curvatures, extensive tooth to remain functional and
apical root resorption or pulp stones. stable after surgery.
Perforation during access, losing length during
instru­m entation, ledging and instrument separation
are iatrogenic treatment complications associated with BIBLIOGRAPHY
treatment of calcified canals. Hence, surgical Endodontics 1. Cohen S, Hargreaves KM. Pathways of Pulp, 9th edn. St. Louis:
may be considered. Mosby, 2006.pp.883-915.
 30
CHAPTER

Pathologic Tooth
Resorption

This chapter explains in detail about tooth resorption and its different types.
  You must know
• What is Tooth Resorption?
• What is Mechanism of Tooth Resorption?
• What are the Etiologic and Stimulating Factors of Tooth Resorption?
• Which are the Types of Tooth Resorption?
• Which are the Clinical and Radiographic Features of Different Types of Tooth Resorption and
How to Manage them?
• What are the Differences between External and Internal Root Resorption?

WHAT IS TOOTH RESORPTION? primary predecessor can cause nonphysiologic root

According to American Association of Endodontists (1984).
Resorption is defined as, “A condition associated with
either a physiologic or a pathologic process that results in
loss of substance from a tissue such as dentin, cementum
or alveolar bone.”
Bone undergoes apposition and resorption as a part of
continual remodelling process.
In case of teeth:
• Roots of primary teeth undergo resorption during
exfoliation. This resorption is considered physiologic.
Sometimes, pathologic resorption may occur.
• Roots of permanent teeth do not undergo resorption
normally. Intact cementoblast and odontoblast cell
layers that are present in the tooth normally, provide
immunity to permanent teeth against resorption
(Homeostasis Phenomenon of Pulp and Periodontal
Ligament) Physical and chemical insults to these layers
causes loss of protection and can lead to Resorption. This
resorption of roots of permanent teeth is considered
pathologic.
If the permanent tooth germ lies in an ectopic
position, then the process of physiologic resorption of
resorption of adjacent permanent tooth.
WHAT IS MECHANISM OF TOOTH RESORPTION?
Cells involved in tooth resorption:
• Osteoclast: Osteoclast are giant cells that play an
important role in the following:
– Tooth eruption:
- Osteoclast plays a role in physiologic resorption
of primary teeth
- During development of permanent successor
and the eruption process, coronal part of the
follicle induces a rim of osteoclast, which is
involved in the resorption of roots of primary
predecessor and adjacent bone.
- Chronic periapical inflammation from pulp
necrosis in primary teeth accelerates its shedding.
– Alveolar bone growth and maintenance:
- Continuous bone remodelling (osteoblastic and
osteoclastic activity) occurs throughout life. Lack
of equilibrium in activity of these two cells causes
osteoporosis or osteosclerosis.
- In case of replacement resorption (ankylosis),
tooth becomes a part of general bone remodelling
 Pathologic Tooth Resorption 475

system and continuous replacement of root with Mechanism of Root Resorption

bone takes place. After an osteoclast is formed, it resorbs hard tissues such as
– Repair after injury: cementum, dentin, enamel or bone.
- Osteoclast has a role in revascularization process
Mechanism of hard tissue destruction by osteoclasts
in bone and teeth.
involves:
- This occurs in case of luxation injuries and root
• Dissolution of inorganic material (hydroxyapatite) by
fracture with displacement of teeth.
acids by the action of polarized proton pump produced
- This is termed as transient apical breakdown,
by ruffled border of the clast cells and enzyme carbonic
transient marginal breakdown, transient
anhydrase II and acid phosphatase.
ankylosis or transient internal surface resorption
• Breakdown of organic matrix containing type I
depending on location of the process.
collagen by enzymes such as collagenase and cysteine
– Defense cell against microbial invasion:
proteinase.
- Microbial invasion occurs in cervical area of tooth
due to plaque accumulation and periodontal
pocket formation and in apical area of tooth due WHAT ARE THE ETIOLOGIC AND STIMULATING
to bacterial accumulation in the root canal. FACTORS OF TOOTH RESORPTION?
- In both the cases, bacteria and inflammatory Tooth resorption may occur due to the following causes or
cells release a series of osteoclast-promoting situations such as:
signals that stimulate osteoclast generation and • Pulpal infection
accelerate osteoclast activities. • Periapical infection
• Periodontal infection
Methods to control osteoclastic activity: Certain medicaments
• Reimplantation cases
have been tried to inactivate the osteoclast activators,
• Excessive mechanical or occlusal forces during
which are the triggers of root resorption. Ledermix
orthodontic treatment
(Tetracycline+Triamcinolone) topically applied in the root
• Pressure caused by impacted tooth
canal can reduce the extent of osteoclastic attack on the root.
• Pressure caused by tumors and cysts
Another alternative way is to change the dentin environment
• Idiopathic.
from a neutral pH to a basic pH, that may interfere with the
Osteoclast’s mineral dissolution.
• Odontoclasts and cementoclasts: These are the resorptive WHICH ARE THE TYPES OF TOOTH
cells that are involved in the tooth resorption. RESORPTION?
• Monocytes and macrophages: They are inflammatory Classification of root resorption:
cells which are phagocytic in function. • According to etiology:
476 Short Textbook of Endodontics
• According to Andreasen and Bakland (Ingle’s Endodontics):
• According to Levin and Trope:
WHICH ARE THE CLINICAL AND RADIOGRAPHIC
FEATURES OF DIFFERENT TYPES OF TOOTH
RESORPTION AND HOW TO MANAGE THEM?
External Root Resorption
Definition: “External resorption is a lytic process occurring
in cementum or cementum and dentin of the roots of the
teeth.” (Grossman’s Endodontic Practice, 11th edn, Pg. 98).
It is resorption that occurs on the external or lateral
surface of the root.
Injury may be only to the external root surface with
no inflammation in root canal. But, sometimes injury to
external root surface is associated with an inflammatory
stimulus in root canal. In such cases, there are chances of
pulp necrosis causing pulp space infection.
Types of External Root Resorption
1. External surface resorption (repair-related resorption):
It represents the healing response to chronic and/or
acute injury in the PDL that affects the cells adjacent to
the root surface.
Fig. 30.1  External root resorption
Figure 30.1 shows diagrammatic representation of
External root resorption.
• Etiology and pathogenesis:
– Acute repair-related resorption may occur in case of:
- Dental traumatic injuries: Luxation injuries
(Concussion, subluxation and lateral luxation)
and following Intrusion
- Replantation of avulsed teeth.
- Root fracture: Here it may be found adjacent to
the fracture line.
– Chronic injury: Associated with orthodontic
treatment, traumatic occlusion, pressure from cysts
or tumors and ectopically erupted teeth.
When the trauma and/or pressure is discontinued,
spontaneous healing tends to occur. This is a typical
feature of repair-related resorption. The injured
tissue is removed by osteoclast and macrophages
in about 2–4 weeks, following which repair occurs
by progenitor cells from adjacent PDL.
• Clinical features: No significant signs or symptoms.

• Types:
– Transient surface resorption: In this resorption,
tooth has vital healthy pulp that has recovered from
traumatic event. New cementum is deposited and
resorbed area is restored to normal surface contour.
– Progressive surface resorption: It progresses to a
more destructive resorption, either inflammatory
resorption or replacement resorption.
• Radiographic features: Repair-related resorption have
very limited size. So, they may not be recognized
radiographically. After about 2–4 weeks, localized
widening of the PDL space occurs. Slight cavitations
may be seen on the lateral root surface or at the apex.
As a result, roots appear shorter in size.
• Treatment: It is a self-limiting process and does not
require any treatment. On elimination of trauma and/
or pressure, 100% repair usually occurs.
2. External infection-related resorption (inflammatory root
resorption): It represents a combined injury to the pulp
and the PDL, where bacteria located in dentinal tubules
and pulp space trigger osteoclastic activity on the root
surface.
• Etiology and pathogenesis: Exclusively related to acute
trauma, commonly seen after intrusion or replantation
of avulsed teeth.
Bacterial toxins present in dentinal tubules and/
or infected root canal can be diffused to the PDL via
the exposed dentinal tubules, which continues the
osteoclastic process and associated inflammation in the
PDL, leading to resorption of adjacent alveolar bone.
Resorption process involves the root dentin and the
root canal gets exposed. If bacteria are eliminated from
the dentinal tubules and the root canal by Endodontic
therapy, resorption process will arrest.
• Types:
– Cervical: External inflammatory root resorption that
occurs on the area of root surface just below the
attachment apparatus.
– Apical: External inflammatory root resorption that is
confined to the apex because of sufficient pressure
to overcome the resistance of the cemental layer to
resorption.
• Clinical features: This type of resorption is rapidly
progressing and may result in total resorption of roots
in few months. Patient usually gives history of trauma.
There is increased mobility in the involved tooth and
has dull percussion tone. The tooth may be extruded.
Inflammation of periodontal tissues is seen.
• Radiographic features: After 2–4 weeks of injury, it
appears as progressive cavitations involving the root
Pathologic Tooth Resorption 477
and adjacent alveolar bone. A bowl like radiolucency is
seen with ragged irregular areas on the root surface.
• Treatment : Immediate Endodontic treatment to
control or remove osteoclast-promoting factors. In
case of mature teeth, prophylactic extirpation of pulp
in replanted avulsed teeth. Use of sodium hypochlorite
and calcium hydroxide is recommended during cleaning
and shaping. Obturation of the root canal is done after
2–3 weeks. In case of immature teeth, apexification
procedure needs to be performed.
3. External trauma-related replacement resorption
(ankylosis): It represents a sequel to injury in PDL
including cell layer next to cementum.
• Etiology: Acute trauma. For example: Severe luxations
such as lateral luxations, intrusion or replantation of
avulsed teeth. In moderate sized injuries, an initial
transient ankylosis develops. (Later areas of resorption
get replaced with new cementum and PDL). In extensive
injuries, progressive ankylosis occurs (tooth becomes a
part of bone remodelling system)
• Clinical features: A tooth with ankylosis-related root
resorption appears firm in its socket, with high metallic
sound on percussion. Infraocclusion, incomplete
alveolar process development in case of young patient.
• Radiographic features: Moth-eaten appearance with
irregular border, absence of periodontal ligament and
lamina dura.
• Treatment:
– Decoronation treatment: In children and adolescents,
removal of crown of the tooth and leave behind
root portion allowing continued vertical growth of
alveolus.
– Breaking of ankylosis sites (luxation of tooth)
4. External spontaneous ankylotic resorption
• Etiology and pathogenesis: Not known. But may be
related to the instability of the RANK-RANKL-OPG
system. The ankylosis-related resorption causes
infraposition of involved tooth in young individuals and
gradual substitution of root by bone.
• Clinical features: In primary dentition, mandibular
second primary molar is commonly involved tooth.
Ankylosis causes infraposition of tooth and tilting of
neighboring teeth. In permanent dentition, first and
second permanent molars are commonly involved teeth.
Ankylosis causes gradual infraposition of tooth and high
and metallic percussion tone.
• Radiographic features: Ankylosis begins in interdental
area and then gradually spreads to remaining part of
the root in case of primary molars. In case of permanent
478 Short Textbook of Endodontics

molars, replacement resorption starts in intraradicular • Coronal portion of tooth may be necrotic.
area and gradually spread to remaining part of the root. • Pulp in the apical portion that includes the internal
• Treatment: Endodontic treatment should not be done as it resorptive defect may be vital.
aggravates the aggressive nature of ankylosis process. In • After a period of active resorption, tooth may become
case of primary dentition, decoronation treatment in early nonvital.
stages. If it is diagnosed late (during adolescence) then it
should be rebuild to prevent supraeruption of antagonistic • Diagnosis
tooth. In permanent dentition, if diagnosed early, – ‘Pink spot’ appearance of crown in later stages of
extraction of involved tooth. If diagnosed later, then rebuild resorption when integrity of crown is compromised.
the tooth to prevent supraeruption of the antagonist tooth. – Later stages may be associated with perforations.
– On radiographic examination:
Internal Root Resorption - Round or ovoid uniform radiolucent enlargement
“Internal resorption is an idiopathic slow or fast progressive of the pulp canal may be seen Figure 30.4 shows
resorptive process occurring in the dentin of the pulp
chamber or root canals of teeth”.
• It represents progressive pulp healing.
• It begins centrally within the tooth, initiated by
inflammation of the pulp.
• It is less common than external root resorption in
permanent teeth
• An oval-shaped enlargement of root canal space is seen
in internal root resorption.
• The multinucleated giant cells adjacent to granulation
tissue in the pulp cause the resorption of internal aspect
of the root.
Figure 30.2 shows diagrammatic representation of
internal root resorption.

• Etiology: Not exactly known (Idiopathic)

– Trauma has been found to be an initiating factor.
– Iatrogenic: Extreme heat produced during cutting Fig. 30.2  Internal root resorption
dentin without an adequate water coolant, partial
removal of pulp, pulp capping or pulpotomy using
calcium hydroxide.
– Caries.

Clinical Features
• Usually asymptomatic. Pain may be a symptom if
perforation of crown occurs.
Thus, two types of internal root resorption:
1. Nonperforating (asymptomatic)
2. Perforating (painful)
• Maxillary anterior tooth is found to be commonly
affected.
• Reddish area showing through the resorbed area of
the crown representing the granulation tissue is the
pathognomonic sign of internal resorption (Figure 30.3
shows reddish-pink discoloration in maxillary right
central incisor suggestive of internal resorption. Also Fig. 30.3  Internal resorption in maxillary right central incisor (pink
referred to as “pink tooth”). tooth) (Courtesy of Dr Manoj Ramugade)

Fig. 30.4  Radiograph showing internal resorption in maxillary left
central incisor tooth which has perforated the root (perforating
internal resorption)
an intraoral periapical radiograph showing
internal resorption (perforating type) in maxillary
left central incisor tooth.
- Resorption begins in the root canal so some
part of root canal space may show radiolucent
resorptive defect.
- Distorted outline of root canal.
- At a very late stage, changes in the surrounding
bone may be evident.
- CBCT is a recent diagnostic technique which
gives 3-dimensional image unlike radiographs
which are 2-dimensional. Any pathology present
in the tooth buccolingually cannot be seen on
radiographs but can be seen in CBCT images.
Figure 30.5 shows CBCT image of a tooth
with internal resorption which can be clearly
appreciated in the center of the crown.
Types of Internal Root Resorption
1. Internal surface resorption:
– Etiology and pathogenesis: Usually found in areas
where revascularization occurs, such as:
- Fracture lines of root fractures and in apical part
of root canal and
- Luxated tooth, apical part of root canal
undergoing revascularization.
It involves osteoclastic activity and formation of
granulation tissue.
– Radiographic features: Temporary widening of root
canal is seen.
Pathologic Tooth Resorption 479
Fig. 30.5  CBCT scan image of a tooth with internal resorption. Note
the oval-shaped enlargement of root canal space (Courtesy of Dr
Mansi Shah, Dentoview-Advanced dental imaging center)
– Treatment: No treatment required. Only periodic
observation.
2. Internal-infection related resorption/internal
inflammatory resorption: It represents resorbing
granulation tissue interposed between healthy and
diseased pulp tissue.
– Etiology and pathogenesis: Necrotic infected pulp
tissue or pulp tissue with chronic inflammation
is present coronal to resorption site in the pulp.
Expansion of the resorption process eventually leads
to fracture of the root.
– Types: Internal inflammatory resorption is of two
types:
– Radiographic features: Round or ovoid radio-
lucency in the central portion of the tooth with
smooth, well-defined margins. Lesion appears close
to the root canal even if angulation of radiograph
changes.
– Treatment: Endodontic treatment to stop internal
resorptive process by extirpation of pulp and delayed
obturation after repair of defect with calcium
hydroxide paste.
480 Short Textbook of Endodontics
3. Internal replacement resorption (metaplastic resorp­
tion):
– Etiology and pathogenesis: Related to trauma
mainly. Other causes include: extreme heat to tooth,
pulpotomy procedures, etc.
Damaged pulp tissue is replaced as a part of
healing process with an in growth of new tissue
which includes bone-derived cells. Root is gradually
replaced by bone. The postnatal pulp stem cells
which are present in the apical part of root canal are
the source for the metaplastic hard tissue formed in
replacement resorption as reparative response to
restorative result.
– Clinical features: Most of the times asymptomatic.
If ankylosis occurs, tooth will gradually develop
infraocclusion.
– Radiographic features: Radiographically, it appears
as a dissecting resorptive area in the center of root
canal. Root canal space may appear engorged with
radiopaque material suggestive of hard tissue.
– Treatment: Endodontic treatment, although it may
have poor prognosis due to lack of root maturity.
Cervical Invasive Resorption
It is a type of inflammatory root resorption occurring
immediately below the epithelial attachment of tooth
(which may be exactly at the apical margin or apical to the
cervical margin).
• Etiology and pathogenesis: The cause is related to a defect
in the cementoblast layer (PDL defect) in its RANK-
RANKL-OPG system.
May be related to:
– Orthodontic treatment
– Acute trauma
– Cervical restoration
– Bleaching of nonvital teeth
– Periodontal treatment
– Bruxism.
The initial cervical resorption gradually spreads and
may progress in apical and coronal direction eventually
leading to fracture of the tooth.
• Types: Heithersay has classified cervical root resorption
into following four types:
Class I: A small invasive resorptive defect near cervical
area with shallow penetration into dentin.
Class II: Well-defined resorptive defect close to coronal
pulp chamber, with little or no involvement of radicular
dentin.
Class III: Deep resorptive defect involving coronal pulp
and also coronal third of the root.
Class IV: Resorptive defect extending beyond the coronal
third of the root.
• Clinical features: Initially, the cervical invasive resorption
is asymptomatic. Long-standing cervical resorption
causes loss of tooth structure replaced by granulation
tissue, which undermines the enamel. So, a “pink spot”
next to the cervical margin is seen in expansive lesions. It
should be differentiated from the pink tooth appearance
of internal resorption, by radiographic examination.
• Radiographic features: Appears as cervical bowl-shaped
lesion that progresses in coronal and apical directions.
In initial phases, the root canal is not involved. As the
resorption progresses, the root canal gets involved.
• Treatment: Raise a surgical flap, remove granulation
tissue and place a dentin-bonded restoration. If
pulp canal gets involved then Endodontic treatment.
After Endodontic treatment, the resorbed area may
be repaired from an internal or external approach.
Intentional replantation and root amputation are the
other treatment options in such cases.
Figure 30.6 gives the mind-map to remember the
different types of pathologic tooth resorption.
WHAT ARE THE DIFFERENCES BETWEEN
EXTERNAL AND INTERNAL ROOT RESORPTION?
Distinguishing features of internal and external root
resorption:
External resorption Internal resorption
This defect moves away from This defect appears close to
the canal as the angulation of the canal even if angulation of
radiograph changes radiograph changes
Ragged or scooped out area on Here well-demarcated
the side of the root enlargement of the root canal.
Walls of root canal appear to
balloon out
Outline of root canal appears Outline of root canal is distorted
normal, defect is seen as “running
through” radiolucent defect
Resorption of bone along with Radiolucency is confined to root.
that of root. So, radiolucency in Rarely bone may be involved if
both root and bone is seen root perforation occurs
Variations in density of Uniform density of radiolucency
radiolucency
No pink spot Pink spot (Pink tooth of
mummery) is a possible sign; if
present is pathognomic of internal
root resorption
Its distribution is not symmetrical Its distribution over the root is
and can occur on any root surface symmetrical but may be eccentric
 Pathologic Tooth Resorption 481

Fig. 30.6  Mind-map to remember the different types of pathologic tooth resorption

BIBLIOGRAPHY
1. Cohen S, Hargreaves KM. Pathways of Pulp, 9th edn. St. Louis:
Mosby, 2006.pp.630-9.
2. Ingle J, Bakland L, Baumgartner J. Ingle’s Endodontics, 6th edn.
BC Decker Inc, Hamilton, 2008.pp.1358-80.
3. Zvi Fuss, Igor Tsesis, Shaul Lin. “Root Resorption-Diagnosis,
Classification and Treatment Choices based on Stimulation
Factors”, Dental Traumatology. Blackwell Munksgaard.
2003;19:175-82.
 31
CHAPTER

Dentinal Hypersensitivity
and its Management

This chapter explains in detail about dentinal hypersensitivity with respect to its etiology, diagnosis
and different treatment modalities for its management.
 You must know
• What is Dentinal Hypersensitivity?
• What are the Different Hypotheses put Forward to Explain the Mechanism of Dentinal
Hypersensitivity?
• What is the Incidence and Prevalence of Dentinal Hypersensitivity?
• What are the Predisposing Factors that cause Dentinal Hypersensitivity?
• How to Diagnose Dentinal Hypersensitivity?
• How to Manage Dentinal Hypersensitivity?

WHAT IS DENTINAL HYPERSENSITIVITY? WHAT ARE THE DIFFERENT HYPOTHESES PUT

Dentinal Hypersensitivity is a sharp, quickly reversible
pain in exposed dentin of a tooth that has no other form of
dental pathosis, in response to thermal, evaporative, tactile,
mechanical, osmotic or chemical stimuli.
Dentin is normally covered by Enamel in crown and
by cementum in the root. Loss of Enamel or Cementum
due to various causes, which have been discussed later
in this chapter, results in exposure of dentin to the oral
environment. This exposed dentin may become more
sensitive to external stimuli than the normal, immediately
after exposure. But within a few weeks, sensitivity may
diminish or subside due to gradual occlusion of dentinal
tubules by mineral deposits with aging or chronic irritation.
Reparative dentin deposition over the pulpal ends of
exposed tubules also reduces sensitivity. However, some
hypersensitive dentin may not spontaneously desensitize.
Hypersensitive tooth: A tooth is termed ‘hypersensitive’,
when it is sensitive to changes in temperature, usually cold.
Such pain/sensitivity lasts for few seconds. Common causes
that may lead to hypersensitivity include:
• Exposed dentin due to abrasion, attrition, erosion, etc.
• Leakage under restorations
• Tooth or cavity preparation without adequate water
coolant.
FORWARD TO EXPLAIN THE MECHANISM OF
DENTINAL HYPERSENSITIVITY?
Different theories have been proposed to explain the
mechanism underlying Dentin Hypersensitivity such as
(Fig. 31.1):
• Neural theory (Presence of nerves in dentin)
• Transduction theory
• Hydrodynamic theory.
Of which, the hydrodynamic theory is the most accepted
theory for exposed dentin sensitivity.
Neural Theory or Direct Innervation Theory
• Earlier it was thought that free nerve endings are present
in the entire length of dentinal tubules. Stimuli directly
activate the nerve endings causing hypersensitivity.
• Nerve fibers were shown to be present in the innermost
part of dentinal tubules in circumpulpal dentin.
• This hypothesis is not accepted now.
• Tooth is usually very sensitive at the Dentino Enamel
Junction (DEJ). But the hypothesis that nerve endings
are present at the DentinoEnamel Junction has not been
corroborated.

Transduction Theory
• According to this theory, odontoblast is the primary
structure excited by the stimulus and the impulse is
transmitted to the nerve endings in the inner dentin.
• This is not a popular theory as it has been found that
outer part of dentinal tubule contains only dentinal fluid
and not cells (odontoblasts). Odontoblastic process is
present in the inner portion of dentinal tubules.
• Also, there are no neurotransmitter vesicles in the
odontoblastic process to facilitate the synapse.
Hydrodynamic Theory
• According to this theory, when the exposed dentin of a
tooth is subjected to external stimuli such as heat, cold,
air blasts, probing with tip of an explorer, it causes rapid
displacement of fluid in the dentinal tubules producing
pain. This is called “hydrodynamic mechanism of dentin
sensitivity.”
• The fluid displacement may be inward or outward
and it stimulates the pain mechanism in the dentinal
tubules by mechanical disturbance of the nerves
closely associated with the odontoblast and its
process. Mechanical displacement of dentinal fluid
affects the nerve endings. Thus nerve endings act as
mechanoreceptors. The movement of intratubular fluid
influencing mechanoreceptors has been called as the
Hydrodynamic theory of Dentin sensitivity.
• According to studies done by Brannstrom, the rapid
movement of dentinal fluid causes pain in response to
osmotic, chemical, mechanical or thermal stimuli.
– According to studies done by Matthews, et al:
Dentinal Hypersensitivity and its Management 483
– External stimuli produce movement of dentinal fluid
causing stimulation of A-delta nociceptive nerve
fibers located on pulpal side of the dentinal tubules,
producing dental pain.
– Outward flow of fluid is found to produce stronger
nerve response than the inward movement.
– On thermal stimulation, there is rapid movement of
fluid into dentinal tubules which causes activation of
sensory nerve terminal in the underlying pulp. Heat
causes the dentinal fluid flow towards the pulp as
heat expands the dentinal fluid faster than it expands
the dentin. Cold causes fluid to contract more rapidly
than dentin causing dentinal fluid to flow outwards.
– Dentinal tubule acts like a capillary tube having
an exceedingly small diameter. Dehydration/
Dessication of dentin caused by blast of air or
absorbent paper cause capillary forces that produce
rapid outward movement of fluid in the tubule.
Brannstrom found that dessication (excessive drying)
of dentin can theoretically cause outward flow of dentinal
fluid at the rate of 2–3 mm/sec.
Fig. 31.1  Hypotheses or theories to explain mechanism of dentinal
hypersensitivity: On the left, is the direct innervation theory (Stimuli
directly affect the nerve endings in the tubules), in the center is the
hydrodynamic theory (Stimuli cause inward or outward movement
of fluid in the tubule which causes movement of odontoblast and its
process), and on the right side is the transduction theory (Membrane
of odontoblast process conducts and impulse to nerve endings in
tubules). a: Dentin, b: Predentin, c: Odontoblastic process, d: Odonto­
blast on the right side is the transduction theory (Membrane of
odontoblast process conducts an impulse to nerve endings in tubules)
484 Short Textbook of Endodontics
WHAT IS THE INCIDENCE AND PREVALENCE OF
DENTINAL HYPERSENSITIVITY?
Incidence and prevalence of Dentinal Hypersensitivity:
• More common in females than males.
• In cervical region of incisors and premolars, often on
the side opposite the dominant hand.
• Toothbrush abrasion being the most common cause.
• Occurs mostly in third to fourth decades of life.
• Decline in prevalence of hypersensitivity in older
patients due to decrease in dentinal tubule permeability.
• More with cold stimuli (90%) than other stimuli such as
chemical (Candy) or mechanical (toothbrushing).
• Commonly involved areas: Cervical areas of teeth
are commonly affected by Dentinal Hypersensitivity.
Facial root surfaces in canines, premolars and molars
are particularly affected, especially in the areas of
periodontal attachment loss due to their susceptibility to
toothbrush abrasion often on opposite side of dominant
hand.
WHAT ARE THE PREDISPOSING FACTORS THAT
CAUSE DENTINAL HYPERSENSITIVITY?
• Movement of fluid in the dentinal tubules is the basic
event in the arousal of pain.
• Dentin may be hypersensitive due to
– Lack of protection by Cementum or Enamel
– Loss of smear layer
– Hydrodynamic movement of fluids in dentinal
tubules.
• Pain is amplified when dentinal tubules are open to oral
cavity.
• Patent dentinal tubules are usually present in areas of
hypersensitivity and may result in increased irritation
and localized reversible inflammation of the pulp at
the sites involved. When the patent dentinal tubules are
exposed, ‘A’ fibers innervating the dentinal tubules or
located in pulp adjacent to dentinal tubules get activated
by stimuli such as blast of air from air/water syringe,
scratching the dentin with explorer tip, rapid cooling,
or presence of hypertonic solution (sweets).
• Thus, Dentinal hypersensitivity may be caused by:
– Inflammatory changes in the pulp or
– Mechanical changes in the patency of dentinal
tubules.
Dentinal hypersensitivity may be related to:
• Excessive abrasion caused due to vigorous tooth
brushing (Mechanical-Abrasion)
• Erosion from dietary or gastric acids (Chemical- Erosion)
• Occlusal stresses
• Periodontal patients with gingival recession and
exposed root surfaces: Periodontal disease causes
recession of gingiva. Gingival recession exposes
cementum to the oral environment. The thin layer of
cementum is lost by toothbrushing or flossing or using
tooth picks and dentin gets exposed which may respond
to stimuli.
• May be increased following Scaling and Root
planning.
• Dehydration/Dessication of dentinal surface by airblast.
• Acid etching of exposed dentin to remove the smear
layer opens the tubule orifices and makes dentin more
responsive to stimuli such as air blasts and probing.
HOW TO DIAGNOSE DENTINAL
HYPERSENSITIVITY?
Diagnosis of dentinal hypersensitivity is based on eliciting:
• Type of stimuli
• Duration of pain
• Location
• Absence of pulpal symptoms
• Absence of radiographic changes.
Dentin Sensitivity is not a problem in intact teeth. It is
possible to activate neurons with high intensity stimulus
during cold testing (vitality test for pulp) with ethyl chloride
spray. It represents normal dentinal sensitivity. When the
tooth feels more sensitive than the normal, it is called
Dentinal Hypersensitivity.
Pain is evoked by cold stimuli, mechanical stimuli
(probing with an explorer tip), and hypertonic stimuli
(sweets). Pain is short, sharp pain in response to
stimuli  arising from exposed dentin. Pain is of mild to
moderate intensity and patient usually is able to localize
the tooth.
Symptoms of dentinal hypersensitivity are reversible.
HOW TO MANAGE DENTINAL
HYPERSENSITIVITY?
Newly exposed dentin may be very sensitive. However,
within a few weeks, sensitivity subsides due to:
• Gradual occlusion of the tubules by mineral deposits,
thus reducing the hydrodynamic forces.
• Deposition of reparative dentin over the pulpal ends of
the exposed tubules.
• Formation of smear layer from tooth brushing or
dentinal sclerosis.

Thus in few cases, Dentinal Hypersensitivity resolves
without treatment. In other cases that do not spontaneously
desensitize, need treatment.
Management of Dentinal Hypersensitivity
• Identify the cause or the predisposing condition causing
dentinal hypersensitivity.
– If the exposed dentin is due to vigorous tooth
brushing habit, patient should be educated regarding
the right brushing technique, use of soft toothbrush,
etc.
– If dentin is exposed due to erosion by gastric acids,
then its medical treatment is advised to prevent
further erosion of enamel. Dietary counselling may
help in these cases. It has been found that there is
greater loss of dentin when brushing is performed
immediately after exposure of tooth surface to
dietary acids from citrus fruits. Patients should be
informed and cautioned regarding this.
– If traumatic occlusion is the cause, then it should be
corrected.
– If periodontal condition causing gingival recession
and exposed root surfaces is the problem, then
periodontal therapy along with the treatment of
dentinal hypersensitivity.
– If recent Scaling and root planning (Periodontal
therapy) has resulted in hypersensitivity, patient
should be reassured that it will resolve in few days
without any treatment or some therapeutic agent
may be used for its treatment.
– If hypersensitivity is related to recently done
Composite restoration in which acid-etching was
done (total-etch technique), patient should be
reassured that mild postoperative sensitivity will
gradually subside, but clinician should also check
for occlusal high points in the restoration and other
causes of postoperative sensitivity with composites
(such as over-drying of dentin, over-etching, faulty
technique, moisture contamination, etc.) In few
cases, removal of the restoration and re-doing it with
correct technique and using Self-etch technique will
solve the problem.
• Prescribing home-use desensitizing dentrifices and
mouthwashes: Use of Desensitizing dentrifices and
mouthwashes by the patient for few weeks to months
can provide relief from dentinal hypersensitivity. This
is specially in cases of Generalized attrition or multiple
teeth with mild abrasion.
Desensitizing dentrifices and mouthwashes may
contain the following agents.
Dentinal Hypersensitivity and its Management 485
– 5% potassium nitrate: Potassium reduces the
neuronal activity, thus decreasing the dentinal
hypersensitivity. Studies have shown that the
potassium containing dentrifices reduce the
hypersensitivity to cold by about 60%.
– 10% strontium chloride: Strontium chloride acts by
blocking the dentinal tubules. Studies have found
it to be effective by 50–70% in reducing dentinal
hypersensitivity.
– Fluoride in the form of Sodium Monofluoro-
phosphates has also been found to be quite effective
in the management of dentinal hypersensitivity.
• Following treatment modalities can be used in the
management of dentinal hypersensitivity.
– Burnishing of the exposed root surface to form smear
layer using an orange wood stick or toothpick. This
occludes the open dentinal tubules to some extent
and reduces dentinal hypersensitivity.
– Application of desensitizing agents:
- Desensitizing agents that form insoluble
precipitates within the dentinal tubules—Certain
soluble salts react with ions in tooth structure and
form crystals on the surface of dentin. Examples
of such agents include: Oxalate compounds.
Oxalate ion reacts with calcium ions in dentin
fluid causing precipitation of calcium oxalate
in the dentinal tubule. This causes decrease
in functional diameter, thereby limiting fluid
movement. Potassium ion can reduce nerve
activity. Commercially available potassium
oxalate solutions to treat sensitive dentin can be
used.
- Desensitizing agents that occlude the dentinal
tubules with precipitated plasma proteins in dentinal
fluid. For example, Hydroxyethyl methacrylate
(HEMA) with or without Glutaraldehyde.
Various therapeutic agents for dentinal hyper­
sensitivity can also be classified as:
a. Neural-modulating agents: E.g. Potassium nitrate.
b. Tubule-blocking agents: E.g. Strontium chloride,
oxalates.
– Application of dentin bonding agents: Dentin
bonding agents and dentin adhesives reduce
sensitivity by forming resin tags and a hybrid layer.
For example, Primer of the original Gluma adhesive
system (an aqueous solution of 5% Glutaraldehyde,
35% HEMA) marketed as GLUMA desensitizer. It
reduces sensitivity by protein denaturation process
with concomitant changes in dentin permeability. It
has been found to be quite effective in management
of dentinal hypersensitivity.
 486
Short Textbook of Endodontics

Fig. 31.2  Mind-map to remember all points of dential hypersensitivity


TABLE 31.1  Management of dental hypersensitivity
1. Identify the cause or predisposing condition and take measures to
correct it.
2. Home-use dentrifices and mouthwashes:
•  5% potassium nitrate
•  10% strontium chloride
•  Fluoride sodium monophosphate
3. Treatment modalities:
•  Burnishing of exposed root surface
•  Application of desensitizing agents:
  – That form insoluble precipitates within dentinal tubules
(oxalate compounds)
  – That occlude dentinal tubules with precipitated plasma proteins
in dentinal fluid (HEMA with or without glutaraldehyde)
  Therapeutic agents:
  – Neural-modulating agents, e.g. potassium nitrate
  – Tubule-blocking agents, e.g. Strontium chloride, oxalates
•  Application of dentin bonding agents: Gluma (5% glutaraldehyde
35% HEMA)
•  Composite resin restorations
•  Lasers:
  – Low-output: GaAlAs
  – High-output: Nd:YAG
– Composite resin restoration: Cervical abrasion or
erosion (Class V cavity) can be treated by restoring
with composite resin restoration. Newer self-etch
systems are preferred. The open dentinal tubules are
thus sealed preventing pain producing stimuli from
reaching the pulp.
– Us e of las ers in manag ement of dentinal
hypersensitivity: Lasers such as Nd:YAG, CO2 lasers
and others have been tried in the treatment of
dentinal hypersensitivity. Low-output lasers such
as GaAlAs have been found effective in mild to
moderate cases of dentinal hypersensitivity. They
are thought to cause a transient reduction in action
potential mediated by pulpal C fibers but not
A-delta fibers. High-output lasers such as Nd:YAG
have been found to cause superficial occlusion
of dentinal tubules in addition to action potential
blockage within the pulp. However, the clinical trials
Dentinal Hypersensitivity and its Management 487
TABLE 31.2  Management of dentinal hypersensitivity (According
to Hargreaves and Seltzer, Seltzer and Bender’s Dental Pulp, 2002
edn.)
Interventions that reduce dentinal Interventions that reduce the activity of
permeability and block dentinal dentinal neurons
fluid flow
Application of materials such as: Application of:
1.  GLUMA dentin bond 1.  Potassium containing dentrifices
2.  Oxalate salts 2.  10% strontium chloride
3.  Isobutyl cyanoacrylate 3.  Fluoride containing medicaments
4. Fluoride-releasing resins or 4.  Guanethidine 1% solution
varnishes
5.  CO2 lasers
6. Coronally positioned
mucogingival flaps
conducted and current available evidence does not
support the use of lasers for treatment of dentinal
hypersensitivity. So, other more conservative and
economical treatment modalities are recommended.
Management of Dentinal Hypersensitivity has been
summarized in Table 31.1.
Therapies for management of dentinal hypersensitivity
can also be classified as shown in Table 31.2 (According to
Seltzer and Bender).
A mind-map to remember all points of dental
hypersensitivity is given in Figure 31.2.
BIBLIOGRAPHY
1. Bhaskar SN. Orban’s Oral histology and embryology, 11th edn.
Mosby; 2001.p.123.
2. Cohen S, Hargreaves KM. Pathways of Pulp, 9th edn. St. Louis:
Mosby; 2006.pp.35, 49-50, 487-90, 520-521, 531.
3. Hargreaves KM, Goodis HE. Seltzer and Bender’s Dental Pulp,
Quintessence Books; 2002.pp.205-11.
4. Ingle J, Bakland L, Baumgartner J. Ingle’s Endodontics 6, 6th edn.
BC Decker Inc, Hamilton; 2008.pp.386-7.
5. Theodore MR, Herald OH, Edward JS. Sturdevant’s Art and Science
of Operative Dentistry, 5th edn. Elsevier, Mosby; 2006.pp.268-9.
 32
CHAPTER

Lasers in Endodontics

This chapter describes a few aspects of Laser Physics and explains the clinical applications of lasers
in Endodontics.
  You must know
• What is Laser?
• What are the Properties of Lasers?
• What are the Components of Lasers?
• What are the Modes of Laser Light Emission?
• How is the Laser Interaction with Biologic Tissues?
• Which are the Type of Lasers?
• What are the Applications of Lasers in Endodontics?
• What are the Advantages and Limitations of using Lasers in Endodontics?

WHAT IS LASER? Application of Laser light results in modification or

Laser is an acronym for “Light Amplification by Stimulated
Emission of Radiation”. The light beam consists of packets of
energy known as photons such as produced by light sources.
The actual physical process that takes place within laser
device is amplification by stimulated emission of radiation.
The radiation that is used for generating laser light is non-
ionizing and does not produce the effects of X-radiation.
In 1960, the ruby laser was developed by Maiman. Lasers
were introduced in the field of Endodontics by Weichman
in 1971.
Applications of lasers in Dentistry (approved by Food and
Drug Administration) include:
• Removal of diseased gingival tissues and other soft tissue
applications
• Dental caries removal
• As an aid in placing tooth-colored restorations
• As an adjunct in Endodontic procedures such as
Pulpotomy.
Laser is among one of the alternative methods used in
Endodontics.
removal of tissue.
WHAT ARE THE PROPERTIES OF LASERS?
Dental lasers operate in infrared, visible or ultraviolet range
of electromagnetic spectrum.
Three unique properties of lasers include:
1. Monochromatic wavelength: Laser light is all the same
color (single wavelength).
2. Collimation: The light waves of laser light are parallel
to each other. They do not diverge or have very low
divergence.
3. Coherence: Waves of light (photons) are all in one phase.
WHAT ARE THE COMPONENTS OF LASERS?
Figure 32.1 shows the schematic representation of laser
showing its components.
• Laser medium:
– The construction of a light source based on
stimulated emission of radiation needs an active
 Lasers in Endodontics 489

Fig. 32.1  Schematic representation of laser components

medium such as gas, liquid or a solid material and

Fig. 32.2  Modes of laser light emission:
is contained in glass or ceramic tube (Laser media A : Continuous wave mode
described later in this chapter). B : Gated wave mode
– The medium that produces the beam identifies the C : Pulsed wave mode
laser and distinguishes one laser from the other.
• Optical cavity:
– It is required to provide amplification in the laser and
to select the photons that are travelling in desired
direction.
– A mirror can be added to each end of the laser
medium on the laser optical cavity so that the
population of photons can be directed back and
forth through the medium stimulating the emission
of radiation from multiple excited electrons. Some
of the produced photons can pass through one of
the mirrors and the resulting light can be used as
surgical beam.
• Pumping system:
– It imparts energy to atoms or molecules of laser
medium
– Energy in the form of electric current or a flash lamp
is applied to the medium.

WHAT ARE THE MODES OF LASER LIGHT

EMISSION?
Modes of Laser light emission:
Laser energy is emitted in different ways with different
types of Lasers. These modes of laser emission are shown
in Figure 32.2.
1. Continuous wave mode: For example, in Diode laser,
energy is emitted in a Continuous Wave Mode.
2. Gated Mode: It is the mechanical interruption of energy
emission allowing for better control of thermal emission
called as Gated mode.
3. Pulsed mode: The Pulse duration and interval is in
millisecond or microsecond. For example, the Nd:YAG
and Erbium lasers emit laser energy in pulsed mode.
Each pulse has a beginning time, increase and end time
referred to as Gaussian progression. Between pulses,
Fig. 32.3  Laser interactions with biologic tissues
tissue has time to cool called thermal relaxation time
for better control of thermal effects.
HOW IS THE LASER INTERACTION WITH
BIOLOGIC TISSUES?
• Types of laser interactions when light hits the target
tissue—Light can be reflected, absorbed, scattered or
transmitted through the tissue as shown in Figure 32.3.
– Reflection: It is the phenomenon of a beam of laser
light hitting a target and reflecting back due to lack of
affinity. It is therefore mandatory to wear protective
eye wear to prevent accidental damage to eyes.
490 Short Textbook of Endodontics
– Absorption: It is the phenomenon of laser energy
incident on tissue being absorbed due to affinity
thereby exerting its biological effects.
– Diffusion: It is the phenomenon of incident light
penetrating to a depth in a nonuniform manner
with respect to the point of interaction so that the
biologic effects are created at a distance from the
surface. When the light is scattered, it travels in
different directions and energy is absorbed over a
greater surface area. This produces less intense and
less precise thermal effect.
– Transmission: It is the phenomenon by which laser
beam passes through the tissue without any affinity
and exerting no effect.
The interaction occurs between the laser light and
the tissue if there is optical affinity between them.
(Absorption and Diffusion) The lesser the optical
affinity, the more the laser light will be reflected or
transmitted.
• The effect of laser interaction with tissue depends on:
– Laser wavelength
– Energy level
– Mode of application
– Tissue characteristics
– Degree of laser energy absorbed or scattered by the
tissue.
• The biological effects of lasers which can be utilized for
their applications in dentistry are:
– Photothermal effects: The radiant light is absorbed
into heat energy which produces the tissue effect.
These effects destroy the cell wall. It has been found
that the Gram-negative bacteria are more easily
destroyed with less energy and radiation than the
Gram-positive bacteria.
– Photomechanical effects (including Photoacoustic
effects)
– Photochemical effects.
In Endodontics, the Photothermal and Photo-
mechanical effects result from interaction of different
wavelengths on target tissues.
WHICH ARE THE TYPES OF LASERS?
Classification of lasers according to their location on the
electromagnetic spectrum of light:
Different wavelengths of the electromagnetic spectrum
include:
• Ultraviolet range (140–400 nm)
• Visible light (400–700 nm)
• Infrared range (700 nm)
Lasers
• Visible and invisible:
For example, Argon Laser emits visible light (488 or 514 nm)
The excimer laser emits invisible light at various
wavelengths—ArF 193 nm, KrF 248 nm and XeCl—308 nm
• Near, medium and far infrared laser:
– Near infrared laser—803–1304 nm. For example,
Nd:YAG (1064 nm) which has the depth of penetration
in soft tissues up to 5 mm. It delivers laser energy
through an optical fiber. Diode laser (810–1064 nm)
which has depth of penetration in soft tissues up to
3 mm. Near infrared lasers are not absorbed by hard
dentinal tissues. They have no ablative effect on
dentinal surfaces.
– Medium infrared laser—2780–2940 nm. For example,
Erbium, Chromium YSGG (Er, Cr:YSGG; 2780 nm
laser) and Erbium:YAG (2940 nm). They are used
with flexible, fine tips. They are absorbed by the water
content of dentinal tissues. They have superficial
ablative and decontaminating effect on dentinal
surfaces of the root canal walls.
– Far infrared laser—For example, CO2 (10,600 nm)
Classification of lasers according to penetration power
of beam:
• Hard lasers: They have increased penetration power.
Examples include: Nd:YAG laser, Argon laser
• Soft lasers: They have decreased penetration power.
Examples include: Diode laser, He-Ne laser.
Classification of lasers according to medium that
produces the beam
• Gas lasers: Examples are Argon lasers, CO2 lasers
• Liquid lasers: Examples are Dye lasers
• Solid state lasers: Example is Nd:YAG laser
• Semiconductor lasers: Example is Gallium laser
Types of Lasers in Detail
The particular properties of each type of laser and the
specific target tissue determine which type of laser to be
used for various procedures. Different types of lasers may
have different effects on the same tissue. Also, same laser
can have different effects on different tissues.
• CO2 Laser (10.6 microns)
– It is highly absorbed by all biological soft and hard
tissues.
– It is the most effective laser in tissues with high water
content. It can be used for soft tissue procedures such
as soft tissue surgery, Gingivectomy, Frenectomy,
etc.

– It has high thermal absorption. So, they are not
suitable for drilling or cutting enamel and dentin as
damage to dental pulp may occur.
• Er:YAG laser (2.94 microns)
– It is most efficient for drilling and cutting enamel
and dentin.
– Its energy is well-absorbed by water and
hydroxyapatite.
• Nd:YAG laser (1.06 microns)
– Nd:YAG photons are transmitted through tissues by
water.
– They interact well with dark pigmented tissue.
– Nd:YAG laser is effective for disinfection of the root
canal and soft tissue procedures.
– It can be used to treat dentinal hypersensitivity.
• Argon lasers (488 or 514 nm)
– It has two wavelengths—Blue and Green. Blue
wavelength (488 nm) is used mainly for curing of
Composite Restorations, Green wavelength (514
nm) is mainly used for soft tissue procedures and
coagulation.
– They are more effective on pigmented or highly
vascular tissues
– Delivered through fiberoptic.
• Excimer lasers
- They function by breaking molecular bonds and
reducing the tissue to its anatomic constituents
before dissipating the energy as heat.
Nd:YAG, Argon and Excimer lasers can be delivered
through fiberoptic that provides greater accessibility to
different areas and structures in oral cavity.
WHAT ARE THE APPLICATIONS OF LASERS IN
ENDODONTICS?
• Pulpal diagnosis
– Laser Doppler Flowmetry (LDF) is used to assess
blood flow in microvascular system.
– It can be used to measure blood flow in the dental
pulp.
– Nd:YAG laser is applied for thermal testing (heat
test)
Laser Doppler Flowmetry has been explained in
Chapter 7, Diagnosis and Diagnostic aids in Endodontics.
• Dentinal hypersensitivity:
– Lasers used for dentinal hypersensitivity are low
output lasers such as He-Ne and GaAlAs lasers
and middle output lasers such as Nd:YAG and CO2
lasers.
– CO2 lasers seal the open dentinal tubules as well as
reduce the permeability of dentinal tubules.
Lasers in Endodontics 491
• Pulp capping
– Nd:YAG, CO2, Argon and Er:YAG lasers can be used
for pulp capping procedures.
• Pulpotomy
– FDA has approved the diode laser as an adjunct for
removal of pulp tissue in pulpotomy procedure.
– Nd:YAG and Argon lasers can be used.
• Root canal preparation (Shaping)
– Lasers can be used to remove dental pulp and
organic debris from the root canal.
– Lasers modify the dentinal walls by inducing melting
and resolidification cycles that cause enlargement of
the root canal walls.
• Disinfection of root canals
– The potential bactericidal effect of laser irradiation
can be effectively utilized in cleaning and disinfection
of the root canal system following biomechanical
instrumentation.
– For disinfection of the root canals, laser energy can be
used directly or in combination with a photosensitive
chemical, which is activated by low energy laser light
to kill the microorganisms (Photodynamic therapy)
that aid in distributing the disinfecting solutions
more effectively in the root canal system (Photon-
Induced-Photoacoustic-Streaming (PIPS).
– Pulsed low energy laser emanates propagation of
acoustic waves
– Studies have shown that Nd:YAG, Argon, Er, Cr:YAG
and Er:YAG laser irradiation has the ability to remove
debris and smear layer from the root canal walls
following biomechanical instrumentation.
– Emitted energy is delivered into the root canal system
by
a. A thin optical fiber (Nd:YAG, KTP-Nd:YAG,
Er:YSGG, argon and diode)
b. A hollow tube (CO2 and Er:YAG)
– The delivery of laser through a flexible optical fiber
of 200 microns for canal decontamination has shown
positive results.
– The properties of laser light may allow a bactericidal
effect beyond 1 mm of dentin.
– Limitations of intracanal use of lasers
a. Laser energy is emitted from the tip of optical
fiber or the laser guide and is directed vertically
along the root canal but may not be directed
laterally to the root canal walls. Thus, laser will
not be able to uniformly cover the entire root
canal surface.
b. There is potential for thermal damage to the
periapical tissues.
492 Short Textbook of Endodontics
c. There is possibility of transmission of laser
irradiation beyond the apical foramen in the
periapical tissues which may be hazardous in
case of teeth which are in close proximity to the
mental foramen or mandibular nerve.
d. Laser light may not be able to eradicate
Endodontic biofilms even on direct laser
exposure.
– A new Endodontic tip called side-firing spiral tip
has been developed to be used with Er:YAG laser,
in which delivery of laser is through a hollow tube
which allows lateral emission of radiation (side-
firing). It is designed to fit the shape and volume
of the root canals prepared using Nickel Titanium
Fig. 32.4A  Mind-map of Lasers in Endodontics
rotary instrumentation. This tip is sealed from its far
end, so that there is no transmission of irradiation to
and through the apical foramen.
– Lasers can be combined with the commonly used
irrigants such as 5.25% sodium hypochlorite, 17%
EDTA and 10% citric acid for effective cleaning of the
root canal system. The action of chelating substances
facilitates the penetration of lasers into the dentinal
walls up to 1 mm depth and is found to have stronger
decontaminating effect than the chemical agents
used alone. Laser-activated irrigation has been found
to be very effective in removing debris and smear
layer from root canals as compared to the traditional
techniques and ultrasonics.

• Obturation of root canals
– Two uses thought of with lasers for obturation of root
canals include:
a. To use laser irradiation as a heat source for
softening gutta-percha for use as obturating
material
b. To condition the dentinal walls before placing an
obturating bonding material.
– Laser-assisted root canal filling procedure that was
first performed involved using Argon 488 nm laser
that was used to polymerize a resin that was placed
in the main root canal.
Fig. 32.4B  Mind-map of “Laser application in Endodontics”
Lasers in Endodontics 493
– It was demonstrated by Kimura et al that Nd:YAG
laser was useful for reduction of apical leakage.
• Endodontic retreatment
– Laser irradiation can be used to remove foreign
material from the root canal system, which may
otherwise be difficult to remove by conventional
methods.
– Studies have shown that Nd:YAG laser irradiation is
an effective technique for removal of root canal filling
materials and has advantages over conventional
methods. Er:YAG laser can also be used for the same
purpose.
494 Short Textbook of Endodontics
• Apicectomy
– The dentin of the apically resected roots is more
permeable to fluids than the dentin of nonresected
roots.
– FDA has approved the diode laser for apicectomy.
– Advantages of using lasers for periapical surgery are
improved hemostasis and concurrent visualization
of the operative field.
– When Er:YAG laser is used in a low output power in
apical surgery, smooth and clean resected surfaces
devoid of charring were observed.
– Laser converts the apical dentin and cementum
structure into a uniformly glazed area which does
not allow egress of microorganisms through dentinal
tubules and other openings in the apex of the tooth.
• Bleaching of teeth
– Argon laser is used for bleaching of teeth by chemical
oxidation process.
– CO2 laser is used to enhance the bleaching effect
caused by Argon laser.
WHAT ARE THE ADVANTAGES AND LIMITATIONS
OF USING LASERS IN ENDODONTICS?
Advantages
• There is no need of anesthesia
• There is no noise in contrast to the noisy dental drills
• Less bleeding
• Less chances of infection
• Results in faster healing.
Limitations
• Root canals are rarely straight. They are usually curved
at least in two dimensions. Manual Endodontic
instruments (files) can be curved to follow the curvature
of the root canal. But Lasers travel in straight path. So,
laser probes need to be fabricated that cause laser light
to emerge laterally, uniformly interacting with the root
canal walls.
• Root canal preparation using lasers has not been proved
to be more effective than the mechanical shaping
procedures.
• There are hazards related to rise in temperature caused
by interaction of laser with the tissue. The increased
temperature can char the root canal space causing
damage to the tooth and its surrounding hard and
soft tissues. The bone surrounding the tooth may be
irreversibly injured resulting in ankylosis.
• The melting and solidification cycles while root canal
preparation using lasers have not shown to have any
positive effect on the clinical outcome.
Figure 32.4A gives the mind-map to remember all
points of Lasers in Endodontics, and Figure 32.4B gives
the mind-map of Laser applications in Endodontics.
BIBLIOGRAPHY
1. AAE Position Statement on Use of Lasers in Dentistry. American
Association of Endodontists. 2012.
2. Cohen S, Hargreaves KM. Pathways of Pulp, 9th edn. St. Louis:
Mosby, 2006.pp.20, 279-80, 529-31, 612-3, 852.
3. Ingle J, Bakland L, Baumgartner J. Ingle’s Endodontics 6, 6th edn.
BC Decker Inc, Hamilton, 2008.pp.857-66.
4. Kimura Y, Wilder-Smith P, Matsumoto K. ‘Lasers in Endodontics-A
Review’, International Endodontic Journal. 2000;33:173-85.
5. Olivi G, Crippa R, Iaria G, Kaitsas V, DiVito E, Benedicenti S. “Laser
in Endodontics-Part I”, Roots 1. 2011.pp.06-9.
 33
CHAPTER

Endodontic Practice: Ethics

and Legal Responsibilities

This chapter outlines the ethics in dentistry and explains the legal responsibilities of the clinician to
practice Endodontics with optimum standard of care.
  You must know
• What is Dental Ethics?
• What are the Principles of Ethics?
• What is Standard of Care?
• What is Dental Negligence and Malpractice?
• What are the Legal Responsibilities of the Clinician while Performing Endodontics?

WHAT IS DENTAL ETHICS? A prudent clinician is reasonably careful while

The word “Ethics” is derived from Greek word ‘Ethos’
meaning custom or character.
Ethics is nothing but philosophy of human conduct.
Dental ethics is a moral concept which encompasses
rules and standards that govern the dentist to perform his
duties with the expected standard of care.
Ingle’s Endodontics 6th edition gives the full form of the
word ‘ETHICS’, which can be explained as:
E = Expertise
Clinician must provide full attention and expertise
in treating each and every patient.
T = Truthful
Clinician must be truthful in all the communications
made with the patient regarding diagnosis, treatment,
prognosis, etc.
H = Honesty
Clinician is expected to be honest in all dealings.
I = Integrity
Clinician must exhibit reliability so that patients can
trust him/her completely.
C = Compassion
Clinician must show concern towards each and every
patient.
S = Sagacity
treating each patient.
Dentists are guided by the codes of ethics provided by the
governing body such as the American Dental Association
(ADA), Indian Dental Association (IDA), Dental Council of
India (DCI), etc.
WHAT ARE THE PRINCIPLES OF ETHICS?
• Recommend the therapy, which is best for the patient
• Minimize the potential harm to the patient
• Avoid placing a patient at an unreasonable risk of harm.
The principles of ethics are listed in Figure 33.1.
WHAT IS STANDARD OF CARE?
Definition: As given in Ingle’s Endodontics 6th edition.
Standard of care is defined as “that reasonable care
and diligence ordinarily exercised by similar members of
the profession in similar cases in like conditions given due
regard for the state of the art.”
For good Endodontic practice, the clinician should
be reasonably careful and must possess and exercise
reasonable degree of skill and knowledge.
Clinicians must strive to do their best and practice
Endodontics at the highest level.
496 Short Textbook of Endodontics
Fig. 33.1  Principles of ethics
It is the prudent clinician who sets the standard of care.
Endodontists, as specialists, set a higher standard of skill,
knowledge and care as compared to general practitioner
while practicing Endodontics. Thus, Endodontists set the
standard for routine Endodontics. So if the standard cannot
be met the general practitioner should refer the patient to
an Endodontist rather than performing procedures that are
beyond his training or competency to avoid performing
treatment that is below the specialist’s standard of care.
WHAT IS DENTAL NEGLIGENCE
AND MALPRACTICE?
Violation of standard of care by a provider that results in
harm to the patient is called dental negligence.
Professional negligence arising out of the doctor-patient
relationship is termed as malpractice.
In simple words, negligence is nothing but carelessness
or inattentiveness and malpractice is the layman term given
to professional negligence.
‘Pathways of Pulp’ — Stephen Cohen’s 9th edition has
given two reasons for dental negligence to occur:
1. When the clinician does not possess a reasonable degree
of education and training to act prudently or
2. Despite reasonable schooling, training and continuing
education, the clinician acts with unreasonable
carelessness or imprudently fails to act as a reasonably
careful clinician should act.
Incidents of Negligence and Malpractice in
Endodontic Practice (Malpractice Cases)
Slips of Drill
• It can cause injury to oral soft tissues such as tongue, lip
or cheek
– Clinician needs to inform the patient. Then provide
treatment for the injured soft tissues and if need
be,  patient has to be referred to an oral surgeon
and the dentist bears the expenditure. After healing
of the injured tissues, the dentist can continue with
the root canal treatment.
Incorrect Tooth Treatment
• It can occur due to failure in localizing the source
of Endodontic pain. Sometimes a vital tooth will be
sacrificed due to wrong judgment and diagnosis.
– Clinician needs to be compassionate towards the
patient and he may compensate for the error by not
taking payment for the treatment performed.
Swallowing or Aspiration of an Endodontic Instrument
• This can occur due to failure to use rubber dam
– Clinician must inform the patient.
Refer the patient for medical care to find the position
of the instrument and take appropriate measures.
Broken/Separated Instruments (Files)
• Files can break in the root canal because of overzealous
or improper use or sometimes due to defective
manufacture of the file.
• Instrument separation is the problem that occurs usually
with Ni-Ti instruments due to fatigue, if it is used for
more than 1 to 2 times. Instrument binds and separates
inadvertently.
• Instrument separation can be considered as an
unfortunate mishap and not negligence or malpractice
– Patient should be informed about the mishap. The
unbroken end of the file should be saved in a coin
envelope and placed in patient’s treatment record.
Patient should be referred to an Endodontist for
microscopic retrieval of the separated file or at least

patient should be informed that the file is going to
be left behind in the root canal and the treatment
completed. There is potential for leakage to occur
but it has been found that most of the times teeth
with separated files may remain asymptomatic and
functional for many years.
Perforations
• Iatrogenic perforation can occur during entry to canal
system due to improper bur angulation or due to
overzealous use of Endodontic instruments resulting
in stripping or perforation of canal wall or during post
space preparation.
• Complication of perforation is the potential for
secondary periodontal involvement resulting in loss of
tooth, if untreatable. So immediate repair of perforation
is to be carried out to close the communication between
root canal system and periodontal tissues, for the tooth
to have a favorable prognosis.
– Patient should be informed about the mishap. Assure
the patient that the clinician is going to use newer
materials (such as MTA) that can predictably seal the
defect in the same appointment and will follow-up
the case closely.
Use of Silver Points for Obturation
• Current use of silver points for obturation is considered
to be below standard of care.
Use of Paraformaldehyde-based Root Canal Sealers
• Overextension of such sealers can result in permanent
paresthesia. Use of such a material is unsafe and should
be avoided.
– If the clinician has used this kind of sealer and
overextension occurs, patient should be informed
and patient be referred to an Endodontist for
retrieval of the overextended sealer before it sets.
Overextensions
• Faulty technique can cause overextension of root canal
filling material that results due to over instrumentation,
breaking the apical seal.
• Permanent harm is unlikely if there is slight over
extension. But if gross over extension occurs contacting
the vital structures such as inferior alveolar nerve or
sinus it can cause permanent consequences.
• Slight to moderate overextensions often repair
themselves, so patient need not be informed, only a note
Endodontic Practice: Ethics and Legal Responsibilities 497
made on patient’s record about it and patient should be
closely observed with follow-up visits to rule out severe
postoperative pain or development of any pathology like
cyst around the overextended material.
Use of Screw Posts
Current use of active posts such as screw posts is considered
to be unreasonable due to the potential risk of root fracture
if the screw is turned more. Instead, passive posts serve as
better alternative.
Endodontic Treatment Failure
There is inherent risk of Endodontic failure (about 5–10%)
in spite of adequate Endodontic care.
But most of the times, Endodontic failure is the result
of contributing negligent factors such as inadequate
isolation of tooth, procedural mishaps such as perforations,
transported canals, over instrumentation, overextension,
underextension or leaking coronal restorations resulting
in reinfection of root canal, etc.
• Patient should be informed about non-negligent failure
of treatment and risk of complications that can result in
failure, before the treatment is initiated so as to avoid
patient disappointment later.
Besides the above mentioned incidents, various other
procedural mishaps can occur during treatment, which are
discussed in Chapter 20: Endodontic Mishaps–Management
and Prevention. Some may be termed as unfortunate
accidents whereas some are a result of dental negligence.
Most important is to inform the patient when such an
accidental or negligent error occurs regardless of whether
the error can be corrected.
WHAT ARE THE LEGAL RESPONSIBILITIES
OF THE CLINICIAN WHILE PERFORMING
ENDODONTICS?
Figure 33.2 gives the list of legal responsibilities of clinician.
Good Record Keeping
Clinician must document each and every patient’s details
and maintain Endodontic therapy record.
• Endodontic therapy record must contain:
– Patient’s detailed case history including personal
information, chief complaint, medical and dental
history
– Various findings of clinical examination
– Good quality radiographs
498 Short Textbook of Endodontics
Fig. 33.2  Legal responsibilities of clinician
– Details of referral to other specialists
– Diagnosis
– Proposed treatment plan and informed consent
– Treatment provided: Emergency or elective treatment
given along with the date of visit, any problems
encountered or any complications that occurred
during treatment.
– Drug prescriptions
– Any missed appointments and stated reasons for the
same
– Prognosis
– Findings of follow-up visits
– Payment details.
• Nowadays with increased use of computers in dental
clinic, electronic records are being maintained.
Clinician must have back up files for all patient records
and confidentiality of patient information must be
maintained by various means of protection.
• Endodontics includes use of several radiographs —
pretreatment, intratreatment, post-treatment and follow
up radiographs. Radiographs that lack diagnostic quality
should be retaken and all the radiographs should be
retained.
• Records should be complete, accurate and well
maintained.
• Records can serve as means of communication among
healthcare professionals whenever required.
• Valid information in the Endodontic therapy records can
serve as an evidence to protect the clinician, confirming
that accurate diagnosis and proper treatment were
provided, in case of a dental malpractice claim against
the clinician.
Informed Consent
Before the Endodontic treatment is performed, patient must
be informed about the benefits, risks, treatment plan and
alternatives to Endodontic treatment. Informed consent
form should be signed by the patient indicating that patient
has understood all aspects of treatment and accepts the
recommended treatment. Also, any subsequent changes in
the proposed treatment should be discussed with the patient
and an entry made in the consent form to be signed by the
patient indicating continued acceptance by the patient.
Referral to Specialists
For a competent ethical practice, the clinician must know
his limitations. The general practitioner should refer the
case to an Endodontist if it is complicated or has a moderate
to high difficulty level and will require procedures that are
beyond the general practitioner’s training or competency.
Before performing Endodontic treatment that the
referring clinician has recommended, the Endodontist must
undertake an independent diagnostic and radiographic
examination of the treatment area and the proposed
treatment plan and any associated medical and dental
history rather than relying solely on the referring clinician.
Continuing Education
A clinician is legally obligated to be updated about the
current knowledge and recent technological advances
in the field of Endodontics. So, the clinician must attend
continuing education courses to update his knowledge and
clinical skills.
Accepting Research-based Endodontic Advances
Many new dental products and techniques are being
constantly introduced to improve the quality and success of
Endodontic therapy. A reasonable clinician should review
the Endodontic advances and adopt a particular product or
technique only if it is well-accepted and proved by research.
Clinician must accept the research based facts, which
might require:
• Giving up those materials and techniques in Endodontics
which had been in use for years but research has now

Fig. 33.3  Mind-map to remember the legal responsibilities of clinician
proved them to be inappropriate or inadequate for
root canal therapy. For example, giving up step back
technique for root canal instrumentation (cleaning and
shaping/biochemical preparation), use of silver points
for obturation.
• Adopting newer materials and techniques in Endodontics
which have proved to be beneficial in root canal therapy.
For example, adopting crown-down approach for root
canal cleaning and shaping, also use of Nickel-Titanium
instruments, etc.
Endodontic Practice: Ethics and Legal Responsibilities 499
Figure 33.3 gives the mind-map to remember the legal
responsibilities of clinician.
BIBLIOGRAPHY
1. Cohen S, Hargreaves KM. Pathways of Pulp, 9th edn. St. Louis:
Mosby. 2006.pp.400-52.
2. Ingle J, Bakland L, Baumgartner J. Ingle’s Endodontics, 6th edn.
BC Decker Inc, Hamilton. 2008.pp.86-103.
 34
CHAPTER

Regenerative Endodontics

This chapter gives an overview of the upcoming field of Dentistry called Regenerative therapy in relation
to Endodontics, that can bring about regeneration of functional pulp tissue and regain vitality in a
necrotic immature young permanent tooth and also describes the different terminology related to
Regenerative Endodontics.
  You must know
• What is Regenerative Endodontics?
• What is Tissue Engineering?
• What are the Mechanisms and Clinical Procedures Related to Regenerative Endodontics?
• What is the Triple Antibiotic Paste?
• What are the Advantages and Limitations of Revascularization Procedure Over Apexification
Procedure for a Necrotic Immature Permanent Tooth with Open Apex?
• What are the Clinical Considerations for Regenerative Endodontics?
• What is the Protocol for Revascularization Endodontic Therapy?
• What are the Clinical Measures for Assessment of Endodontic Revascularization Treatment
Outcome?

INTRODUCTION • Use of Fibroblast Growth Factor 2 (FGF-2) for periodontal

Regenerative Dentistry is an evolving field of dental care.
The goal of Regenerative Dentistry is to induce biologic
replacement of dental tissues and their supporting
structures.
In the last few decades, there have been lot of
advancements in biologic therapies that apply growth
and differentiation factors which hasten or induce natural
biologic regeneration.
Scope and application of Regenerative Dental Procedures
has advanced to include:
• Guided Tissue Regeneration (GTR)
• Guided Bone Regeneration (GBR)
• Application of platelet-rich plasma for bone augmen­
tation.
• Emdogain for regeneration of periodontal tissues
• Recombinant human Bone Morphogenic Protein
(rhBMP).
tissue regeneration.
The potential of these therapies for dental practice is
being envisioned to include Endodontics. For example:
• Pulp, Dentin and Enamel can be regenerated using
scaffold material and stem cells.
• Tooth crowns can be regenerated using the primordium
of embryonic oral epithelium and adult bone marrow
stem cells.
• Stem cells isolated from extracted third molars can be
used to regenerate tooth roots and periodontal ligaments.
WHAT IS REGENERATIVE ENDODONTICS?
Definition
“ Regenerative Endodontics has been defined as biologically
based procedures designed to replace damaged structures
such as dentin, root structures, and cells of the pulp-dentin
complex.” (Cohen’s Pathways of Pulp, 10th edn. p. 602).
 Regenerative Endodontics 501

• From a biologic perspective, goal of Endodontics is to

prevent or treat apical periodontitis. This goal can be
accomplished by either:
– Maintaining pulpal health in cases of pulpal
inflammation or
– Regenerating healthy pulp tissue in cases of pulpal
necrosis.
The objective is to regenerate a functional and healthy
pulp-dentin complex.
• In case of immature (incompletely developed) young
permanent tooth with open apex, when pulp necrosis Fig. 34.1  Tissue engineering triad
occurs, its management is challenging due to
– Wide blunderbuss apex with lack of apical stop.
– Risk of extrusion of irritants into the periapical area. • Stem cells
– Thin dentin walls that are difficult to debride and are • Growth factors
prone to subsequent cervical fracture. • Scaffolds.
– If extraction of the tooth is done, then restoration is
a problem as implants are contraindicated in young Stem Cells
patients with growing craniofacial skeleton. Stem cells are relatively undifferentiated cells capable of
In such challenging cases, regenerative Endo­ self-renewal/expansion by continuously dividing many
dontic therapy is an alternative treatment option times.
that aims at regenerating functional pulp tissue that
brings about completion of root development and Types of Stem Cells
restoration of function. • Stem cells can be classified as:

WHAT IS TISSUE ENGINEERING?

According to American Association of Endodontists, “Tissue
Engineering is an interdisciplinary field that integrates
the principles of biology and engineering to develop
biological substitutes that replace or regenerate human
cells, tissues or organs in order to restore or establish normal
function.”
Regenerative Endodontics is rapidly advancing field
based on the principles of Regenerative Medicine and Tissue • Stem cells can differentiate into specialized cell types.
Engineering, which utilizes three key elements, referred to Based on their range of differentiation (Potency), stem
as ‘Tissue engineering triad’ (Fig. 34.1), including: cells can be classified as:
502 Short Textbook of Endodontics
• Based on the source of stem cells, they can be classified
as:
– The sourcing of embryonic stem cells is unsuitable
for clinical development due to legal and ethical and
medical (tissue rejection) issues. So, the researchers
are now focusing attention on developing stem cell
therapies using postnatal stem cells. The postnatal
stem cells are derived from patient themselves or
their close relatives.
– Using stem cells to regenerate entire tooth may not
be practically possible as it takes very long time
(many years) even for natural development of teeth.
But, within a patient’s existing permanent tooth, a
functional pulp-dentin complex may be regenerated
so that it can carry out the natural functions
including formation of replacement dentin, tissue
immunity and neural sensation.
– Many postnatal mesenchymal stem cells that can
differentiate into odontoblast-like cells have been
isolated including:
– Stem cells can be identified and isolated from mixed
cell population using various techniques such as
staining cells with specific antibody markers and
flowcytometry, immunohistochemical staining, etc.
Growth Factors/Morphogens
• Growth factors are proteins that bind to cell receptors
and act as signals to induce proliferation and/or
differentiation of cells.
• Growth factors trigger the differentiation of selected
mesenchymal stem cells into odontoblast-like cells.
• Growth factors found in dentin and platelets have been
utilized in the Regenerative Endodontic Procedures.
• It has been found that application of dexamethasone
combined with Vitamin D3 increases the differentiation
of human dental pulp cells into odontoblast-like cells.
Other examples of the growth factors include:
– Bone Morphogenetic Protein (BMP) derived from
bone matrix which brings about differentiation of
osteoblasts and bone mineralization. It is used to
induce stem cells to synthesize and secrete mineral
matrix
– Fibroblast Growth Factor (FGF) can promote
proliferation of many cells. So, it is used to increase
the stem cell numbers.
– Platelet Derived Growth Factor (PDGF) is obtained
from platelets and endothelial cells. It promotes
proliferation of connective tissue cells. It can also
be used to increase stem cell numbers.
Scaffolds
• Scaffolds organize the cells into correct spatial
position and regulate proliferation, differentiation and
vascularization.
• Appropriate scaffold might bind and localize the cells
selectively.
• Scaffolds contain growth factors and undergoes
biodegradation over time.
• Blood clot, dentin and Platelet Rich Plasma have been
utilized as scaffolds in few Regenerative Endodontic
Procedures.
• Classification of scaffolds:

Beneficial properties of PRP (Platelet Rich Plasma)
include:
• Autologous
• Easy to prepare in dental setting
• Forms 3-dimentional fibrin matrix.
WHAT ARE THE MECHANISMS AND CLINICAL
PROCEDURES RELATED TO REGENERATIVE
ENDODONTICS?
Terminology
• Apexification: “Apexification is defined as a method to
induce a calcified barrier in a root with an open apex or
the continued apical development of an incompletely
formed root in teeth with necrotic pulp tissue.” (Pathways
of Pulp, 10th edn.p.608)
• Apexogenesis: “Apexogenesis is defined as vital pulp
therapy procedure performed to encourage continued
physiologic development and formation of the root end.”
(Pathways of Pulp, 10th edn.p.608)
• Maturogenesis: Maturogenesis is the term used to
describe the outcome of revascularization procedure
indicating that a stage is set for physiologic root
development. (Pathways of Pulp, 10th edn.p.608)
• Revascularization: “Revascularization is defined as the
restoration of vascularity to a tissue or organ.” (Pathways
of Pulp, 10th edn.p.608)
Endodontic Revascularization Treatment aims at
regaining the vitality and vascularity of pulp tissue in
a necrotic root canal of an immature permanent tooth
with open apex.
• Guided Tissue Regeneration (GTR): It is induced or
guided regeneration of the tissues.
The biologic tissue that fills up the pulp space after the
Regenerative Endodontic Procedures (REPs) may be
dental pulp or pulp-like tissue.
The desired outcome of Regenerative Endodontic
Procedures (REPs) is regeneration of pulp-dentin
complex.
Till date, most of the studies published, can be best
described as “Revascularization” procedures, that
attempt to regenerate biologic tissues (that may not
necessarily replicate the pulp-dentin complex) and bring
about revascularization within the root canal space.
WHAT IS THE TRIPLE ANTIBIOTIC PASTE?
• The Triple Antibiotic Paste is the mixture of Ciprofloxacin/
Metronidazole/Minocycline (CMM) in the ratio of 1:1:1.
Hoshino and Colleagues greatly contributed to the
Regenerative Endodontics 503
development of this paste and this paste was originally
used by Banchs and Trope.
• It is the medicament used to disinfect the root canal
space. It can be used as an adjunct to the revasculari­
zation procedure for necrotic pulp space of immature
permanent tooth with open apex as it creates a
favorable environment for ingrowth of vasculature and
regenerative cells by reducing or eradicating bacteria
from the root canal space.
• Research studies show that this antibiotic combination
has high efficacy in eradicating the bacteria from
infected dentin of root canals.
• The disadvantage of using this paste is that: There is
potential for Minocycline staining of the crown. This
can be minimized by restricting the drug below CEJ.
If such staining occurs, then walking bleach method
using sodium perborate can be used to manage
discoloration.
• This combination is less commonly used in Dentistry.
So it needs additional review. Calcium hydroxide or
Formocresol are used instead of the triple antibiotic
paste sometimes.
• Also, this paste is not approved by the US Food and Drug
Administration.
WHAT ARE THE ADVANTAGES AND LIMITATIONS
OF REVASCULARIZATION PROCEDURE OVER
APEXIFICATION PROCEDURE FOR A NECROTIC
IMMATURE PERMANENT TOOTH WITH OPEN
APEX?
Advantages
With revascularization procedure, there is increased
likelihood of:
}
• Increased root length
Completion of root
• Increased root development
wall thickness
• Increased or maintained root strength.
Traditional apexification procedure using calcium
hydroxide has been found to affect mechanical
properties of root dentin reducing the root strength,
making it prone to fracture. Also, for apexification
using calcium hydroxide, multiple appointments are
needed for its reapplication and time taken to form
calcified bridge is about 3–24 months. However, with
the advent of Mineral Trioxide Aggregate (MTA), these
limitations of calcium hydroxide apexification have
been overcome as it is found to form a cementum-like
hard bridge in relatively shorter duration of time and
504 Short Textbook of Endodontics
also requires fewer patient appointments. However,
with both of these apexification procedures, root
development is not fostered and tooth remains prone
to subsequent cervical root fractures.
Limitations
• Although Revascularization procedure causes increased
root thickness in midroot and apical root, but not in
cervical area, making the tooth prone to fracture in that
area.
• Regenerative Endodontic Procedures are limited to
immature teeth as open apex is a ready source of stem
cells. However, its long-term goal should be to treat
mature permanent teeth as well.
• There is ongoing research and trials for the various
Regenerative Endodontic Procedures (REPs). But till
date, no randomized controlled clinical trials have
been published to evaluate the various Regenerative
Endodontic Procedures (REPs) and their potential
adverse events. Also, in case of Regenerative Endodontic
therapy in humans, histological evaluation of the
treatment outcome is not possible.
• Case studies show that with Calcium hydroxide and MTA
apexification, success rates have been as high as 95%.
For Regenerative procedures, there is ongoing research
still going on.
WHAT ARE THE CLINICAL CONSIDERATIONS
FOR REGENERATIVE ENDODONTICS?
• Age: Young patient.
Younger patients have greater healing capacity or stem
cell regenerative potential.
• Permanent tooth with immature apex. The large
diameter of the immature (open) apex may have rich
source of mesenchymal Stem Cells of the Apical Papilla
(SCAP).
• Diagnosis of pulp necrosis in such incompletely formed/
immature permanent tooth with open apex.
• Minimal or lack of instrumentation of dentinal walls.
Since the dentinal walls are not instrumented, smear
layer is not generated that could otherwise occlude the
dentinal walls or tubules.
• Use of an intracanal medicament.
Usually the Triple antibiotic paste is left in root canal
space for few days or weeks.
• Creation of a blood clot in the canal that might serve as
a protein scaffold and induces 3-dimensional ingrowth
of tissue.
Figure 34.2 lists these considerations in the form of a
mind-map.
Fig. 34.2  Clinical considerations for Regenerative Endodontics
WHAT IS THE PROTOCOL FOR
REVASCULARIZATION ENDODONTIC THERAPY?
Revascularization Protocol
Case Selection
Young patient with incompletely developed permanent
tooth with open apex that gives negative response to pulp
responsiveness testing.
Informed Consent
Inform patient and guardian about:
• The number of appointments-2 or more and the
potential benefits of the treatment.
• Adverse effects that may result from the procedure-
Minocycline staining of crown.
• There may be lack of response to treatment
• Alternative treatment options: MTA apexification, no
treatment or extraction.
• Possible post-treatment symptoms.
Procedure
First appointment
• Profound anesthesia
• Isolation with rubber dam
• Access cavity preparation
• A small k-file such as no. 10 or 15 is used to scout the
root canal system and determination of working length
using radiograph or paper point method.
• Copious irrigation of root canal system using 20
mL of 3–5% NaOCl followed by 20 mL of 0.12–2%
Chlorhexidine with saline wash in between the two to
prevent the formation of brownish-orange precipitate.
Irrigation should be done using side-vented irrigating
needle slowly and carefully so as to avoid or minimize
the irrigants passing through the open apex.

A B
Figs 34.3A to C  Schematic representation of pulp regeneration: (A) Immature nonvital permanent tooth with necrotic pulp, SCAP: Stem
cells from apical papilla; (B) Following antimicrobial medicament, in the second appointment, the canal is over-instrumented to cause
bleeding upto cervical level. Over the blood clot, colla plug and MTA seal and coronal seal with composite restoration; (C) Pulp regeneration
is expected that causes completion of root formation
• The root canal system is dried using sterile paper points.
• Delivery of antimicrobial medicament such as triple
antibiotic paste or calcium hydroxide into the root canal
space.
• The tooth is sealed with a temporary cement (e.g. Cavit).
Second Appointment (Figs 34.3A to C)
Scheduled after 3–4 weeks
• Patient is assessed for resolution of signs and symptoms,
such as pain, swelling, sinus tract, etc. that may have
been present during the first appointment.
• If the resolution of signs and symptoms has not occurred,
the antimicrobial treatment is repeated and patient
recalled after few weeks.
• If resolution of signs and symptoms has occurred, then
patient is anesthesized using 3% Mepivacaine.
(Local anesthetic containing vasoconstrictor is not
used as in this appointment revascularization-induced
bleeding is to be evoked. 3% Mepivacaine facilitates the
ability to trigger bleeding into the root canal system.)
• Rubber dam isolation of tooth and re-establishment of
coronal access.
• Copious, but slow and careful irrigation with 20 mL
NaOCl along with gentle agitation with small k-file to
remove the antimicrobial medicament.
• Root canal system is dried using sterile paper points.
• A small k-file is placed few mm beyond the apical
foramen to slightly lacerate the apical tissue causing
bleeding up to 3 mm from the CEJ.
• Insert a small piece of colla-plug into the root canal
system to serve as resorbable matrix and to restrict MTA
positioning (Fig. 34.3B)
• Place MTA in the thickness of 3 mm (Fig. 34.3B)
• Achieve good coronal seal using a permanent restoration
(Fig. 34.3B).
Regenerative Endodontics 505
C
Patient is recalled after 12–18 months for follow-up.
Successful outcome is that pulp regeneration occurs in
the canal that causes completion of root formation with
increase in root length and wall thickness (Fig. 34.3C).
WHAT ARE THE CLINICAL MEASURES
FOR ASSESSMENT OF ENDODONTIC
REVASCULARIZATION TREATMENT OUTCOME?
Assessment of Endodontic Revascularization treatment
outcome:
• Clinical
– Lack of signs and symptoms
– Clinical evidence of functioning vital tissue in the
root canal.
– Pulp testing methods such as heat, cold, electrical,
laser Doppler flowmetry suggestive of asymptomatic
tooth that does not require retreatment.
• Radiographic
– Radiographic appearance of increased root wall
thickness that could be due to ingrowth of cementum,
bone, or a dentin-like material.
– Healing of periradicular tissues and progression of
root development.
– Increase in root length.
BIBLIOGRAPHY
1. Colleagues for Excellence newsletter Regenerative Endodontics
www.aae.org/colleagues, Spring 2013.
2. Hargreaves KM, Law AS. Regenerative Endodontics. Chapter 16.
Pathways of the Pulp, 10th edn. Hargreaves KM, Cohen S, Mosby
Elsevier, St Louis, MO. 2011.pp.602‐19.
3. Peter E Murray, Franklin Garcia-Godoy, Kenneth M. Hargreaves,
‘Regenerative Endodontics: A Review of Current Status and a Call
for Action’, JOE. 2007;33:4.
4. Rudolf Jaenisch, Richard Young, ‘Stem cells, the Molecular
Circuitry of Pluripotency and Nuclear Reprogramming’, “Cell”
Press. 2008;132(4):667-82.
 Index

Page numbers followed by f refer to figure and t refer to table.

A B pulpotomy 446
with iodoform 275f
Acellular cementum 16 Bacterial virulence factors 89, 90f Calcium phosphate cement obturation
Actinomyces israelii 375 Bacteria-tight seal 406 308
Air emphysema 354 Bacteroides forsythus 415 Camphorated parachlorophenol 276
Alara, principles of 112 Bacteroides melanogenicus 87 Canal blockage 345
Alkaptonuria 384 Barbed broaches 172f Canal obstructions, removal of 381
Allergy 140 Barodontalgia 64 Canal orifices 20, 20f, 213
Alveolar abscess classification of 64 flaring of 204f
acute 74, 328 Bayonet-shaped canals 227f Canal preparation 244
chronic 76 Bioactive glass 276 balanced force technique of 252
Alveolar bone Biomaterial centered infection 95 hybrid technique of 253
proper 17 Bite test 123, 124 Canal system, type of 25
supporting 17 using cotton roll 124f Candida 267
Amalgam 435 Bleaching Candida albicans 415
restoration 458 chemistry of 384 Carbamide peroxide 388
Amelogenesis imperfecta 384 contraindications of 388 Carbide bur, safe-ended 164f
Anesthesia, evaluation of 315 material 391f Carbon fiber-reinforced epoxy resin posts
Antibiotic paste 503 points of 399f 365
Anticurvature filing 254 role of 386 Cardiac pacemaker 168
Anxiety, management of 312 Bleaching of vital teeth 390 Caries and defective restorations, removal
Apexification 446, 503 extracoronal 389f of 203f
calcium hydroxide 448f technique for 389 Caries causing pulpitis 53f
Apexogenesis 503 Bone cyst 118 Caries detector dye 125f, 162f
Apical abscess Bone forming cells 16 Caries
acute 74 Bone morphogenetic protein 502 in dentin 53f
chronic 76 Bone-resorbing cells 16 in enamel 53f
Apical canal transportation, type III 349 Bur 163 Carious dentin
Apical perforation 349f long shank round 163f inner 52f
Apical periodontitis 74 round 163f outer 52f
acute 72 safe-ended 163f Cavity design, poor access 229, 337
chronic 74, 331 sharpness of 58 Cavity preparation 200, 406
Apical third of root transmetal 163f challenging access 226
anatomy of 25f steps of 207
canal, instrument in 343f C Cavity walls 167f, 203, 204
Apical-root fracture 410 Cells of alveolar bone 17
Apical-third filling 307 Calcibiotic root canal sealer 292 Cells of pulp 10
Arterioles 11 Calcium hydroxide 273, 274, 275f, 307, Cellular cementum 14
Arteriovenous anastomoses 11 406, 441, 442, 447, 464 Cemental dysplasia 118
Asymptomatic irreversible pulpitis 68 compounds 442 Cementoblasts 16
Axial wall extension 213, 218 containing sealers 291 Cementodentinal junction 8, 26, 237,
in maxillary molar 208f in canal, application of 275 282
Azithromycin 319 points 274 Cementoenamel junction 202
508 Short Textbook of Endodontics

Cementum 14 D Dental traumatic injuries 401, 403, 404

and periodontal ligament 6 management of 401, 404, 413t
types 14 Debridement of canal, incomplete 342f Dental treatment procedures 56
Central nervous system 312 Deciduous molar 455f Dential hypersensitivity 486f
Cephalosporins 319 Defense cells 10 Dentin 483f
Ceramic veneer, use of 400 Dendritic cells 11, 54 acid etching of 65
Cervical invasive resorption 480 Dens evaginatus 32 bonding agents 66, 293, 485
Champagne bubble test 209f Dens in dente 31 dysplasia 32
Chlorhexidine digluconate 270, 275 in maxillary left central incisor 31f fracture 413
for endodontic use 270f Dens invaginatus 31 reparative 52f
Chloropercha 299 Dental biologic tissues sclerosis 51
Chronic abscess or phoenix (rebirth) 331 changes during inflammation 134 sensitivity 483
Ciprofloxacin 319 Dental caries 85f Dentinal hypersensitivity 482, 484, 491
Clindamycin 319 sequel of 53f causes of 484
Cohen’s pathways of pulp 360 Dental ethics 495 management of 482, 485, 487, 487t
Compartment syndrome 351 Dental health care personnel 192 Dentinal tubules 84, 85f
Complete roof removal 218 Dental history 100 to pulp 85f
Complete/cervical pulpotomy 445 past 101 Dentin-chip 307
Composite resin core 368 Dental hypersensitivity, management of Dentino enamel junction 482
Composite resin restorations 386, 392, 487 487t Dentinogenesis imperfecta 384
bonding strength of 398 Dental illness 100 Dentin-pulp complex 5
Composite resin system (retroplast) 436 Dental infection to maxillary sinus 103f Dentistry, antibiotics in 317
Composite restoration Dental lamina Derivatives of phenol 276
discolored 386f primary 6 Diamond bur 164
in both teeth 396f role of 6 Digital tactile sense 234
use of 400 Dental lasers 488 Direct pulp capping 405, 441, 459
Core built-up material 369f Dental loupes 159 in traumatized tooth 406f
Core materials 282, 283 Dental negligence and malpractice 496 Direct vital pulp therapies 459
for restoration of endodontically Dental operating microscope 159, 163, Distal angulation 116f
treated teeth, classification of 206f Distal root canal of mandibular second
190 head portion of 161f molar, infection in 76f
types of 367 Dental operatory 193 Distobuccal canal orifice 218
Core restoration 360 Dental pain 101 Doxycycline 319
Coronal disassembly 378 from maxillary sinus 102f
Coronal leakage 415 of myofascial origin 103 E
Coronal pulp 19, 20f Dental papilla (forms dentin and pulp) 6
Coronal root fractures 410 Dental personnel 193 Electric pulp tester 122f, 162f
Coronal seal, methods to enhance 310 Dental practice, infection control in 193, Electronic apex locator 167
Crown fracture 404 194f Elements obturation unit 303f
complication of 406f Dental pulp 5, 6, 8, 15f, 50 Elliptication, causes of 349
treatment of 406f causes of 52, 62 Ellis and Davey’s classification 402
Crown or root, fractured 329 cell-free zone of Weil 9 En masse crown fracture 413
cause 329 cell-rich zone 9 Enamel 413, 451
classification 329 classify diseases of 66 bur 208f
signs 329 connective tissue of 131 cord 7
symptoms 329 diseases of 52, 62, 67 effects on 391
Crown-down technique 251f formed 6 epithelium
Crown-root fracture 330f odontoblastic zone 8 inner 7
C-shaped canals 26 unique features of 51f outer 7
classification of 27f, 28, 28f Dental sac 6 fracture 413
Cytokines 133 Dental trauma 401 organ (forms enamel) 6

Endo access bur 206f
Endoactivator system 278f
Endodontic 92
access cavity preparation 199, 200
advances, research-based 498
armamentarium 158
biofilm 94
types of 97f
cases 373
diagnosis aids in 98, 161
diagnosis, accurate 129
disease 102, 103t, 418, 424
drugs used in 318f
emergencies 323-325, 331
after treatment 335
before treatment 326
classification of 325
midtreatment 323
treatment, Weine’s classification
of conditions 325
explorer 167f
failure 373
causes of 374, 376
classification of 376
gauge 242f
infections 86, 87
control in 192
types of 88f
instruments 158, 196
asepsis and sterilization of 192
aspiration of 496
classification of 169
disinfection of 198
interpretation in 116
lesions 415, 418
primary 418
management, nonsurgical 373
materials 158
microbiology 83
microbrushes 277f
mishaps 336, 336f, 337
classification of 337
classify 336
management 336
prevention 336
past and present 4t
periodontal diseases 416f
practice, malpractice in 496
preparation in maxillary premolar
215
retreatment 377, 381, 493
steps of nonsurgical 377
scope of 1, 2f
sonics and ultrasonics in 180f
spoon excavator 167f, 207f
surgery 425, 473
classification of 427
in geriatric patients 473
postoperative sequelae 437f
role of 146
surgical 425
armamentarium 429
phase 430
procedure 29
role of isthmi in 29
therapy 130, 138
treatment 140, 150, 150f, 156f, 337,
373, 374, 387, 469, 472
drugs used in 311, 312
failure 497
in geriatric patient 471
inadequate 415
of pediatric patients 450
plan 145, 146f
revascularization 505
success of 357
triad 199
use of
sonic devices for 178
sonics in (endosonics) 179
ultrasonics (endosonics) 179
Endodontically treated mandibular
second molar 343f
Endodontically treated teeth 355, 356,
356f
changes on 357f
physical changes on 356f
post systems for 190
restoration of 190, 355
Endodontic-periodontal diseases 415
Endodontic-periodontal lesion 422
classify 416
types of 418, 424
Endodontic-periodontal problems
Weine’s classification of 422
types of 423t
Endodontist, enigma to 42
Endoflare 258f
Endometrics 234
Endovac irrigation system 279f
Index 509
Engine-driven handpieces 177
Engine-driven instruments 177
Enterococcus faecalis 87, 278, 374
Epiphany sealer 293
Erythroblastosis fetalis 384
Extracellular polymeric substances 92
Extracoronal bleaching 396f
of vital teeth 391, 392f
Extraoral examination 106
F
Ferric sulfate pulpotomy 461
Ferrule effect and biologic width 361,
362f
Fiberoptic endoscope 161
Fiberoptic light for transillumination test
125f, 162f
Fibers 11
Fibroblast growth factor 502
Finger plugger for obturation 187f
Finger-held spreader for obturation 186f
Fissure carbide bur 164
Flap design, triangular 431f
Flap reflection 431, 432
Focal infection 83
mechanism of 131
theory 83, 130
origin of 83
Focal sclerosing osteomyelitis 79
Formaldehyde 276
Formocresol pulpotomy 445
Foundation restoration 371
Fungi 415
G
Galilean optical system 159
Gates-Glidden drills 164, 166f, 177
Genera actinomyces 374
Geriatric dentistry 468
Geriatric endodontics 468
scope of 468, 469f
Geriatric patient
abrasion 471f
attrition 471f
erosion 471f
Giant cell granuloma 118
Gingival irritation 391, 398
Gingival recession 471f
510 Short Textbook of Endodontics
Gingival sulcus 340
Glass bead sterilizers 196f
Glass fiber posts 365f
Glass fiber-reinforced epoxy resin posts
365
Glass ionomer 458, 461f
cement 61, 458
core 368
sealers 293
Glutaraldehyde pulpotomy 460
Glutaraldehyde, advantages of 460
Gram stain technique, classification to 87
Gram-negative anaerobic bacteria 267
Grossman’s classification 375
of endodontic emergencies 326
Grossman’s sealer 290
Gutta-percha 283
canal-warmed 299
carrier-based 285
chemically plasticized cold 299
compaction of 186
cone 419
for newer obturation systems 285
lateral compaction of 295
removal of 187
removal techniques 380
sterilization of 296
stick 285
heated 121f
technique
solid core carrier-based 306
thermoplasticized injectable 306
thermoplasticized 285, 306
with additives 285
with sealants, solid core 295
H L
Halogens 276
Hand-operated instruments 170
Hank’s balanced salt solution 412
Hard tissue surgical access 432
Healing of perforation 340
Hemorrhage from surgical site,
management of 433
Hemostasis 406
Hertwig’s epithelial root sheath 77
Holmium:yttrium-aluminium-garnet
laser 278
Hydrochloric acid-pumice abrasion 398
Hydrogen peroxide 269, 388 Lingual shoulder, removal of 210f, 213
for bleaching 388f, 389 Liquid EDTA for removal of smear layer
for irrigation 269f 273f
Hyperplastic pulpitis, chronic 53, 68 Local anesthesia, armamentarium for
Hypoplastic maxillary teeth 106f 163
Luxation injuries 410
I management of 410
Lymphocytes 11
Immunity in endodontics, role of 135 Lysosomal enzymes 133
Infection, elimination of 317
Infection, prevention of 317 M
Inflammatory cells 132
Inflammatory paradental cyst 118 Magnifying loupe 206f
Ingle’s endodontics 476 Mandibular anesthesia 313
Intracanal brushes 277 Mandibular anterior teeth 219, 396f
Intracanal medicaments 273 Mandibular canine 41, 42f, 221
antibiotic containing 276 Mandibular central incisor 40, 41f, 219
Intracanal microbial biofilms 94 with two canals 41f
Intracoronal bleaching 385, 387, 388, 392 and lateral incisor 41f
of endodontically treated teeth, side Mandibular first molar 44, 45f, 125f, 224,
effects of 397 224f, 386f, 441f
of maxillary right central incisor 395f deep occlusal 441f
of teeth, side effects of 399f mesial root of 110f
Intraligamentary injection 314, 314f periradicular infection in 86f
Intraoral examination 106 proximal caries approaching pulp 441f
Intraosseous injection 314, 314f pulp, deep occlusal caries in 110f
Intrapulpal hemorrhage 385 tooth
Intrapulpal injection 315f osteitis in relation to 79f
Irreversible pulpitis 68 postoperative 46f
in immature permanent tooth 446 preoperative 46f
with acute apical periodontitis 326 with canals 225f
causes 327 with endodontic 421f
signs 326 with extensive caries pulp 53f, 74f
symptoms 326 with five canals 45f
Irrigant-related mishaps 333 with four canals 45f
with pulp polyp 143f
with radix entomolaris
postoperative 46f
Laser Doppler flowmetry 122, 403 preoperative 46f
in dentistry 123 with severe periodontal lesion 421
Laser light emission 489 with three canals 45f
Laser-assisted root canal preparation with three mesial canals
technique 261 postoperative 46f
Lasers preoperative 46f
classification of 490 Mandibular first premolar 42, 43f, 221
in endodontics 488, 491-493 with one and two canals 222f
advantages of 494 Mandibular first primary molar 452, 453f
properties of 488 Mandibular lateral incisor 41, 42f, 221
types of 490 Mandibular left central incisor 394f
Lingual opposite buccal 116f discolored 394f
 Index 511

Mandibular molar Maxillary anterior region 457f Maxillary right lateral incisor
cavity preparation in 225f Maxillary anterior teeth 211, 213f, 478 infection from 107f
taurodontism in 32f cavity preparation for 213f tooth, abscess in relation to 76f
teeth 223 Maxillary canine 34, 34f, 214 Maxillary second and third molars,
with deep carious lesion 419f cavity form of 214f concresence of 31f
Mandibular posterior teeth, in child 454f postoperative 35f Maxillary second molar 39, 39f, 219
Mandibular premolar preoperative 35f carious destruction of 356f
cavity preparation of 222f Maxillary central incisor 32, 33f, 211 cavity form of 219f
teeth 221 cavity form of 213f with canal 39f
Mandibular primary incisors 451, 452f tooth with four canals 40f
Mandibular second molar 47, 47f, 224 postoperative 33f with three canals 39f, 40
C-shaped canal in 27f preoperative 33f with two canals 39f
tooth with rubber dam 154f Maxillary second premolar 36, 36f, 216
osteitis in relation to 79f Maxillary first and second premolars cavity form of 217f
postoperative 48f postoperative 36f tooth 37f
with C-shaped canal 47f, 48f, 225f preoperative 36f Maxillary second primary molar 452, 453f
postoperative 48f Maxillary first molar 37, 37f, 218 Maxillary sinus 427
preoperative 48f cavity form of 218f Maxillary teeth
with four canals 47f cavity preparation of 219f extracoronal bleaching of 396f
with three canals 47f tooth, MB2 canal in 120f in child 454f
with two canals 47f with four canals 38f Maxillary third molar 39, 40f, 219
Mandibular second premolar 44, 44f, 222 postoperative 38f cavity preparation of 219f
cavity form of 223f preoperative 38f with three canals 40f
tooth 44f with three canals 38f Medicated sealers 293
with root and root canals postoperative 38f Melton’s classification of C-shaped
postoperative 45f preoperative 38f canals 27
preoperative 45f with two palatal canals 38f Memory t-cells 132
Mandibular second primary molar 452, Maxillary first premolar 35, 35f, 215 Mesenchymal cells 11
453f, 462f cavity form of 216f Mesial and distal boundary 218
Mandibular teeth, periodontal tooth Mesial angulation 116f
involvement in 144f postoperative 36f Mesial canal 225f
Mandibular third molar 47, 48f, 226 preoperative 37f Mesiobuccal canal, second 218
cavity preparation in 226f with S-shaped, cases of 227f Metal-core obturation 286
curved canals Maxillary first primary molar 452, 453f Metallic core materials 367
postoperative 49f Maxillary lateral incisor 33, 34f, 214, Metronidazole 319
preoperative 49f 386f Micro-endodontics, instruments for 161
Mast cells 11 cavity form of 214f Mid-root fractures 410
Materials Maxillary molar 217f Midtreatment flare-ups 334f
bleaching 388 cavity preparation for 217f Mineral trioxide aggregate 357, 436, 439,
disinfection of root canal 169 teeth 217 443, 448
isolation of endodontic field 163 Maxillary posterior region 457f pulpotomy 446
obturation 282 Maxillary premolar teeth 215 Mishaps related to post placement 353
postendodontic restoration 190 cavity preparation for 215 Monocytes and macrophages 475
vital pulp therapy, techniques and Maxillary primary incisors 451, 452f Motor for rotary instrumentation 184f
439 Maxillary rhinosinusitis 102 Mouse-hole effect 201f
Maturogenesis 503 Maxillary right central incisor MTA pulpotomy 461
Maxilla, posterior 427 discolored 386f, 394f Mucoperiosteal flap 431
Maxillary and mandibular primary fracture in endodontically treated Multi-lens optic system 159
canine 452, 452f 330f Multirooted teeth, post placement in 366
Maxillary anesthesia 315 internal resorption in 478f Myofascial pain vs pulpal pain 103
512 Short Textbook of Endodontics
N signs 470
Necrosed pulp 136f
Necrotic immature permanent tooth 503
Necrotic pulp 53f
Necrotic root canal 420
Neuropathic pain vs pulpal pain 104
Neuropeptides 133
Neurovascular pain vs pulpal pain 104
Neurovascular structures, damage to 351
Nickel-titanium 299
advantages of 183
alloys, phases of 181
disadvantages of 183
instruments 182, 182t
hand and rotary 179
properties of 180f
rotary instrument
devices for 184
in root canal 183f, 262f
systems 184, 257
Nitric oxide 133
Noncollagenous proteins 356
Nonmetallic cores 368
Nonnarcotic analgesics 316
Nonrestorable teeth 144f
Nonrigid posts
advantages of 364
disadvantages of 364
types of 365
Nonvital pulp therapy 407, 446
for primary teeth 463
for traumatized teeth 409f
Nonvital teeth 145, 413
with full prosthetic restorations 360
with partial restorations 360
Normal periradicular tissues 72f
Noxious stimuli affecting dental pulp 52
O Periradicular disease 72
Obturation techniques 295
Obturation, preparation for 293
Occlusal anatomies 202
Odontalgia, symptoms of 103
Odontoblast 10
Odontoblastic process 483f
Odontoclasts and cementoclasts 475
Opioid analgesics 316
Oral foci of infection 131
Orofacial and dental
symptoms 470
Orofacial pain 101
of nonodontogenic origin 102
Orthodontic extrusion 423
Osteoblasts 16
Osteoclasts 16
Osteogenic effect 292
Osteomyelitis 118
Ozonated water irrigation 278
P Polymerase chain reaction method 91
Pain control 312
Palatal roots 428
Palatine artery, anterior 428
Palatine foramen 428
Partial pulpotomy 445
in permanent maxillary central
incisor tooth 445f
Paste filling materials 287
Pediatric endodontics 450
Periapical abscess 53f, 75f
Periapical cyst 78, 78f
Periapical granuloma 53f, 77, 77f
in maxillary right central incisor
tooth 77f
Periapical infection 376f
in root canal treated mandibular
premolar 376f
Periodontal disease 417, 418, 424
Periodontal examination 324
Periodontal fibers, types of 17
Periodontal lesion 415, 418
in maxillary molar 420f
primary 420
Periodontal ligament 16, 53f
Periodontal pocket 421f
Periradicular curettage and biopsy 433
extension of 426
of nonendodontic origin 81
Periradicular surgery 425, 426
armamentarium for 190
treatment planning for 427
Periradicular tissues 5, 14, 16f, 18, 418
causes of 71
classify diseases of 72
diseases of 71
normal 72
of endodontic origin, diseases of 72
Permanent anterior teeth in child, trauma
to 454f
Phenol and phenol derivatives 276
Phoenix abscess 331
Plasma derived mediators 133
Platelet derived growth factor 502
Plugger
finger 302f
hand-held 302f
types of 302f
Polyethylene fiber-reinforced posts 365
Polymorphonuclear neutrophils 132
Porphyria 384
Porphyromonas endodontalis 267
Porphyromonas gingivalis 267, 415
Post and core restorations 372
Post related mishaps 353
Post removal system 379f
Postbleach sensitivity of teeth 391
Postbleaching inflammation of
periodontal ligament 398
Postendodontic restoration 357, 357f,
358, 359, 472
type of 359
Posteruptive causes 385
Postobturation restoration 357
Potassium nitrate 485
Predentin 483f
Prevotella intermedia 415
Primary apical periodontitis,
pathogenesis of 81
Primary permanent tooth 451f
Primary teeth 450, 450f
material for 465t
materials in pulpectomy of 465t
obturation material for 464
obturation techniques in 466
proximal lesions in 455, 457f
traumatic injuries to 413
Propionibacterium 87
Protaper endodontic files 256f
Pseudomonas 87
Pulp
arterial supply of 11
bacterial invasion into 52f
caries involving 421f
extirpation of 464f
functions of 13
gangrenous necrosis of 327
causes 327
 Index 513

diagnosis 327 Pulp regeneration 505f Pulpal tissues

treatment 328 Pulp stones 70f blood supply of 11, 13f
types 327 Pulp tests 118 lymph supply of 12
infected 85f Pulp therapies 1, 439 Pulpectomy 463
microorganisms in 84, 84f for primary teeth 458 in primary teeth, steps of 463f
nerve supply of 14f in traumatized teeth 405 Pulpitis, acute irreversible
tissues 12 performed in children 457 causes 326
structural elements of 10 Pulp tissue, pain related to incomplete diagnosis 326
zones of 8f removal of 331 management 326
Pulp and periodontal tissues, Pulp to acid etching signs 326
intercommunication between of dentin 59 symptoms 326
414 reaction of 59f Pulpitis, symptomatic irreversible 68
Pulp and periodontium, inter- of enamel 59 Pulpotomy 491
relationship between diseases Pulp to cavity in primary teeth 459
of 415 and crown preparation 57 steps of 462f
Pulp and periradicular tissues cleansing and sterilization 59 types of 445
diseases of 62 preparation using air abrasion 60 Pulse oximetry 123
pathosis of 326 Pulp to dental Push-pull motion 243f
Pulp canal 117 caries 50
sealer 290 reaction of 51, 55f Q
Pulp capping 442, 491 procedures 54
indirect 439, 440, 458 treatment 56 Quaternary ammonium compounds 271
materials 442 Pulp to drying of tooth 58
steps of reaction of 59f R
direct 442f Pulp to laser procedures 60
indirect 441f Pulp to local anesthetics 56 Radicular cyst 78
Pulp chamber 451 reaction of 57f Radicular pulp 19, 20f
components of 19 Pulp to orthodontic tooth movement 60 Redox reaction 384
floor of 19, 20f reaction of 60f Regenerative dentistry 500
inspection of 204, 205f Pulp to periodontal procedures 56 Regenerative endodontic 500, 503, 504,
morphology of 32 Pulp to periodontium, infection from 504f
roof of 19, 20f, 218 infected 421f procedures 504
Pulp degeneration 69 Pulp to polishing of restorations 60 Resin sealers 292
Pulp dressing 405 Pulp to specific dental materials 60 Resin-based obturation system 287, 287f
Pulp exposure 413 Pulp to ultrasonic scaling of teeth, Resin-based sealer-AH plus 292f
crown fracture with 329 reaction of 57f Resin-based self-etch root canal sealer
crown fracture without 329 Pulp to vital bleaching techniques 60 293f
in mesially inclined mandibular Pulp vitality testing 56 Resin-modified glass ionomer core 369
molar 85f Pulpal blood supply 11f Restoration 406
to trauma 85f Pulpal diagnosis 455, 491 effect on 392
Pulp fibroblast 10 in children 453, 456f post and core
Pulp hemorrhage 446 Pulpal diagnostic tests 454 causes of 371f, 372
Pulp horns 5, 19, 20f Pulpal disease 417 failure of 371f, 372
Pulp inflammation (pulpitis) 67 signs of 421 Restorative material 189, 436
Pulp necrosis 53, 71 symptoms of 421 Restorative resins 61
Pulp necrosis, types of 71 Pulpal infection, cause of 86f Restorative treatment 446
Pulp polyp in Pulpal pain, classification of 102 Rhinosinusitis, symptoms of 103
deciduous molar 69f Pulpal reaction Rickert’s sealer 290
permanent mandibular first molar 69f to caries 50 Root 117
primary second molar 54f to dental procedures 50 Root anatomy 366
514 Short Textbook of Endodontics

Root and root canal system 425 Root canal system 19 Rotary instrumentation 254
Root apex, anatomy of 26 activation of irrigants in 277f Roth’s sealer 290
Root canal 31f, 87f, 117, 351f anatomic complexities in 26 Rubber dam
anatomy of apical portion of 25 anatomic components of 19 clamps 152f
apical width of 240f anatomy of 21, 29 forceps 153, 153f
bacteria in infected 87 classification of 22 frame 152, 152f
biomechanical preparation of 231 components of 20f in endodontic treatment in
cavity preparation of 163, 199 disinfection of 264, 265, 491 mandibular first molar 154f
cleaning and shaping of 231, 232 in geriatric patient 470f material 151
components of 20 in root, types of 21 placement 153
delivery of sealers in 187 in young adult tooth 470f punch 153, 153f
effective shaping of 243 internal anatomy of 19 sheet 151, 152f
infected 86 morphology of 32, 34, 35 components of 151
instruments of 186 obturation of 280, 472
ledge formation in 347f of individual teeth 32 S
microbes from 89 solutions in 276
microbial flora of 84 Weine’s classification of 23f Schilder technique 299
microbiology of infected 89f with increasing age 21f Sealapex root canal sealer 291f
obturation of 186, 280, 281, 493 Root canal treatment 1, 139, 141, 419 Sealer placed in root canal 288
shaping of 464f Root end cavity preparation 435 Sickel cell anemia 384
underfilling of 335 advantages of 435 Silicone-based sealers 293
Root canal anatomy of individual teeth, Root end Silver amalgam 61, 461
primary 451 beveling of 434f restorations 392
Root canal disinfectant 265 conditioning 435 Silver point 287f
Root canal filling material 283 development 448f obturation with 295f, 497
classification of 283 management 434 removal of 189, 379
Root canal infections 87 resection 434 Smear layer 272f
Root canal instruments 170, 171f Root fracture 117, 118, 329, 354, 372, 409, in endodontics, management
Root canal irrigants 248, 265, 267 413 of 272
Root canal of primary teeth 464 crown 409 removal of 271
Root canal opening 145, 323 of palatal root of maxillary second Sodium hypochlorite 267, 268, 269f, 356,
Root canal orifices 209 premolar tooth 120f 381, 446
exploration of all 204 Root perforations 415 accidents 268, 350
flaring and exploring 204f Root resection 422 efficacy of 268
Root canal preparation 233, 263, 491 Root resorption 117 for irrigation 267f
crown-down technique of 248, 250 classification of 475 Sodium perborate 388
devices for 169 differences between external and Sound tooth structure remaining-
hand instruments for 172 internal 480 nonrestorable tooth 144f
instruments for 169 external 79, 80f, 117, 476, 476f Stainless steel and nickel-titanium
of apical third and body of canal 247f cervical 397 instruments 181t
rotary instrumentation 254 internal 117, 478, 478f properties of 181
sonics 261 mechanism of 475 Stem cells 501
step down technique of 250 types of types of 501
step-back method of 245 external 476 Step-back technique v/s crown-down
steps of crown-down technique of 249 internal 479 technique 252, 252t
techniques of 244, 245, 254 Root-end resection, angle of 434 Streptococcus faecalis 87
terminology for 241 Roots and root canals, anatomy of 227 Strontium chloride 485
ultrasonics 261 Roots of maxillary molar, apical third of Stropko irrigator 266
Root canal sealers 282, 288, 288f, 289 31f Sulfur granules 95
in obturation 289 Rotary endodontic file, components of Supernumerary roots 32
paraformaldehyde-based 497 181f Superoxidized water 276

T Teeth with curved canals 227
Teeth
accessibility of 142
anterior 359
bleaching of 383, 494
classify traumatized 402
cracked 64
crowded 228
crown of 109, 116
development of 6
discolored nonvital 143f
hypersensitive 482
injury to 62
internal resorption in 120f
laminates for discolored 400
management of 412
discolored 382, 383, 400
mobility of 108f
normal 85f
opening in wrong 337
perpendicular to 116f
pink 144f, 478
posterior 359
preparation of individual 211
regressive changes in 469
root of 109
permanent 474
primary 474
rotated 228
structurally sound anterior 359
traumatic injury to (acute
trauma) 63
treatment of traumatized 404, 404f
veneer for discolored 400
vitality of 471
Teeth, in elderly 469, 470t
Teeth, in pediatric patients 450
Teeth to tetracycline, discoloration of
384f
Teeth to wasting diseases, yellowish
discoloration of 386f
Teeth with calcifications
in pulp chamber 226
in root canals 226
Teeth with minimal coronal tooth
structure 228
Temporary filling 205f
Temporary restorations 189
Test cavity 126
Tetracycline isomer, mixture of 272
Thalassemia 384
Thermafil obturator 307f
Thermocatalytic bleaching 397
Tissue emphysema 334
cause 334
management 335
prevention 335
signs 334
symptoms 334
Tissue engineering 501
triad 501f
Tissue regeneration 503
Tooth
with dilaceration 120f
with internal resorption 479f
with pathology to radicular cyst 79f
Tooth avulsion 330, 411
management 330
Tooth crown of caries 116
Tooth development, stages of 6
Tooth discoloration 384
causes of 382
etiology of 387f
management 384
Tooth in arch, position of 358
Tooth infractions 64
Tooth length, measurement of 236f
Tooth pulp chamber, crown of 117
Tooth removal, overzealous 338
Tooth resorption 474, 475
pathologic 474
types of 475, 476
pathologic 481f
Tooth slooth 124f, 162
contact with cusp tips 124f
Tooth structure 446
amount of remaining 358, 365
removal of unsupported 203, 203f
Index 515
Tooth treatment, incorrect 496
Transillumination test 125f
Trapezoidal flap design 432f
Treponema denticola 87, 415
Treponema maltophilum 415
Tubli-seal root canal sealer 291f
U
Ultrasonic cleaner 197f
Ultrasonic instrument 178
Ultraviolet photo-oxidation 397
Underextended obturation 352f
Underfilled obturation 352f
Urethane methacrylate sealers 293
V
Vasoactive amines 133
Vertucci’s classification 23
Viscous chelator 273
Vital pulp therapy 405, 439, 440f, 446
for traumatized teeth 407f
Vital pulps with normal periapical tissue
472
W
Wach’s cement 291
Walking bleach
result 393
technique 392
Weeping canals 275
Y
Young permanent teeth 451, 451f
Z
Zinc oxide 443
eugenol 60, 441, 461f, 464
Zinc oxide-containing sealers 289
Zinc phosphate cement 61
Zones of reaction 136t