International Endodontic Journal (1998) 31, 384±393

Apical limit of root canal instrumentation and obturation,

part 1. Literature review
D. RICUCCI
Private Practice, Cetraro (CS), Italy

Summary within the root canal (Cailleteau & Mullaney 1997), and
moreover many authors have frequently confirmed the
One of the major controversies in root canal therapy
principle of stopping instrumentation/obturation short of
concerns the apical limit of instrumentation and
the radiographic apex and some, more precisely, at the
obturation. The results of longitudinal prognostic
apical constriction.
studies, basic anatomical knowledge of the apical third
Weine (1982) stated that, in general, a point located
of the root canal, and the histological pulp reaction to
1 mm coronal to the apex is close to the area of the
caries progression demonstrated the presence of a vital
cemento-dentine junction (CDJ). He said that in the
apical pulp remnant, even in the presence of a periapical
evaluation of the exact point where the canal preparation
lesion. Finally necrosis and bacteria establish
should end, 1 mm short of the radiographic apex is
themselves in the periapical lesion. All valid prognosis
probably acceptable. Weine agreed with Kuttler's study
studies confirm the practice of staying short of the apex
(1955) which identified a smaller diameter or `apical con-
with a homogeneous obturation to obtain the highest
striction' as the point where the canal preparation should
success rate of 90±94% (when done by or under
end and where the deposition of calcified tissue is most
supervision of specialists; results in the general
desirable. In the case of a periapical radiolucency with
population had a failure rate greater than 50%). The
radiographic signs of apical resorption, the preparation
location of the apical foramen(ina) related to root canal
should be shortened by an additional 0.5 mm from the
treatment most frequently ends short of the apex, often
radiographic apex. Weine (1982) suggested instrumenta-
by several millimetres.
tion and obturation to the CDJ, which he believed was
located at the same level as the apical constriction (Figs 1
Keywords: apical limit, root canal instrumentation/
and 2). Nguyen (1985) indicated the CDJ as the limit of
obturation, tissue reactions
the preparation (Fig. 1).
Ingle (1973), based on Kuttler's study, stated that the
Introduction narrowest diameter of the apical foramen was located at
the CDJ (Figs 1 and 2), which was usually found about
The apical limit of root canal instrumentation and
0.5 mm from the external surface of the root. Limiting the
obturation is one of the major controversial issues in root
instrumentation to 0.5 mm from the radiographic
canal therapy. For decades this subject has been, and still
terminus of the root would certainly maintain the
continues to be, a topic of discussion between endodon-
minimum and ideal apical opening. The overextension of
tists. The related literature often generates confusion and
instrumentation and the displacement of toxic products
uncertainty for the practitioners who are looking for
from the root canal into the periapical tissue would be
adequate clinical solutions based on facts rather than on
avoided. This author also recommended obturation at
opinions.
0.5 mm from the radiographic apex and stated that
obturating up to the radiographic terminus of the root
Literature survey actually results in an overfilling.
Frank et al. (1988) suggested an apical stop located
Most North American and European Schools believe that
between 0.5 mm and 1 mm from the apex. The stop
instrumentation and obturation should be contained
represents the apical limit of the instrumentation and
Correspondence: Dr Domenico Ricucci MD, DDS, Piazza Calvario 7, keeps the obturation material inside the canal during con-
87022 Cetraro (CS), Italy (e-mail: ricucci@fr.antares.it). densation. With regard to the problem of accessory

384 q 1998 Blackwell Science Ltd


Fig. 1 CDJ is located at different levels on opposite sides of the root
canal wall, and does not coincide with the apical contriction.
canals, these authors stated that too much importance
has been given to these canals, as if they were crucial
elements in obtaining success or failure. In fact their
importance is relatively little if the main canal is properly
prepared and filled. Their obturation happens by chance
and does not have clinical significance.
Guldener (1985) suggested choosing a working length
which corresponds to the tooth length less 0.5 mm for
cases with a necrotic pulp. In cases of vital pulp
extirpation, he recommended an additional reduction of
0.5 mm, 1 mm short of the tooth length. Taylor (1988)
pointed out a narrower spot at the apical level called
`Minor Diameter' which he believed to correspond histolo-
gically to the CDJ (Figs 1 and 2).
Langeland (1957, 1967, 1987, 1995), however,
advocated termination of instrumentation and obturation
at the apical constriction (Fig. 2). He demonstrated histo-
logically that the pulp in the apical portion of the root
canal, in the lateral canals and in the apical ramifications
remains vital and often uninflamed, even in the presence
of a radiolucency (Langeland et al. 1976, Lin et al. 1984).
Finally, despite necrosis and bacteria establishing
themselves in the periapical lesion (Oguntebi et al. 1982,
Pascon et al. 1987), the instrumentation and obturation
should remain at the apical constriction.
Langeland stated that the most frustrating clinical
aspect is that no exact distance from the radiographic
apex could be given, because the distance from the radio-
q 1998 Blackwell Science Ltd, International Endodontic Journal, 31, 384±393
RTC instrumentation and obturation 385
Fig. 2 The choice of the apical constriction as limit of the procedure
appears reasonable regardless of the type of tissue contacted by the
instrument (dentine, cementum or CDJ).
graphic apex to the apical constriction varies widely from
root to root. Histologically, he demonstrated that the CDJ
± being highly irregular (e.g. 3 mm higher on one wall
than on the opposite wall) ± did not at all coincide with
the apical constriction (Fig. 1). Consequently, he refused
to accept any distances from the radiographic apex as an
accurate indicator for the termination of the endodontic
debridement and obturation. Contrary statements in the
literature, although calculated from large numbers of
measurements, are based on averages and oversimplifica-
tions which cannot give accurate clinical direction. This is
a situation where the use of averages adds to the
confusion rather than giving a solution to the problem.
Furthermore the CDJ is a histopathological structure
which cannot be found clinically and thus cannot be in-
strumented or obturated. Langeland's firm clinical advice
is: `Carefully study a high quality radiograph in a viewing
device blocking out all extraneous light, have the
knowledge of the variations of root canal anatomy
foremost in your mind, use your tactile sense to locate the
apical constriction, observe if blood or other tissue fluids
appear on the instrument tip, or anywhere on a paper
cone, indicating that you are in the periapical tissue. This
is an inaccurate art, based on precise science. Finally, put
it all together using common sense: instrumentation
beyond the foraminal constriction causes an unnecessary
enlargement of the pulpal wound, contaminants from the
386 D. Ricucci

canal will interfere with the wound healing and

medicaments and/or materials will cause tissue
destruction, inflammation, and a foreign body reaction in
the periapical tissue' (Langeland 1996).
Regardless of a vital or necrotic pulp, however, he
suggests termination of the obturation at the apical con-
striction, that is short of the apex, radiographic or
anatomic, which will result in the smallest possible wound
and optimal healing. This decision is based on anatomical
and histological material.
Pecchioni (1983) stated that during instrumentation it is
better not to go nearer than 0.5±1 mm from the radio-
graphic apex. Even regarding the distance where the
obturation should end, he affirmed that it must, in any
event, end at 0.5 mm from the radiographic apex. However
he continued: `. . . while it is very serious and damaging to
go beyond this limit with instrumentation, it is less serious
to slightly overfill the apex, since the common sealers are
generally tolerated and easily resorbable'. Thus: `. . . we feel
comfortable saying that in necrotic cases an overfill does not
represent a contra-indication. In fact, while treating vital
teeth alteration of the apical pulp stump must be avoided, in
necrotic cases leaving necrotic or infected debris, or an Fig. 3 An instrument inserted at the radiographic apex is already
empty space in the last part of the root canal must be beyond the root canal limits, in the adjacent periodontal ligament.
avoided'. Langeland (1974, 1995), by contrast, stated that
all endodontic sealers are irritant and resorbable. The above
authors seem to agree that instrumentation and subsequent section(s) distinguish(es) between facts and fiction, and
canal obturation should be confined to the root canal space, only the section(s) that go(es) through the foramen(ina) is
coronal to and at some varying distance from the radio- (are) valid for this evaluation'. His sections demonstrated
graphic apex. that none of the above methods or chemicals dissolved all
By contrast, other authors have advocated penetration the debris. Langeland (1995) also stated: `The root canal
of the foramen to or beyond the radiographic apex. anatomy and histology were more important in obtaining
Schilder (1967, 1976) declared his aim was to debride full debridement than any cleaning device'.
and to fill to the apex and to fill lateral canals and apical Schilder opposed limitation of preparation at the CDJ or
ramifications. He admitted that his procedure in most at the apical constriction, because he considered these as
cases involved instrumentation beyond the root canal variables. Thus, it is too approximate to apply a mathema-
limit, inside the adjacent periodontal ligament (Fig. 3). He tical or statistical formula (0.5, 1 or 2 mm). Shifting from
stated (Schilder 1976) that a 3±5% NaOCL solution earlier clinical orientation, which was to stop at the radio-
completely removes necrotic organic debris from the root graphic apex, Schilder (1987) later requested that canal
canal system. Some of his followers (Scianamblo 1989) instrumentation and obturation should stop at the canal
maintained that root canals and ramifications can be terminus.
effectively cleaned during cleaning and shaping if these In summary (Table 1), most authors suggest instrumen-
systems are properly irrigated with sodium hypochlorite. tation and obturation short of the radiographic apex,
After debris is removed with correct irrigation it is possible whereas Schilder goes beyond (Fig. 3). Those finishing
to fill those spaces easily, if appropriate obturation within the canal have different rationales. Some suggest
techniques are used. Langeland et al. (1985), however, the CDJ as the ideal limit (Ingle 1973, Weine 1982,
have demonstrated that canals are not necessarily cleaned Nguyen 1985, Taylor 1988) (Fig. 1); others (Ingle 1973,
totally regardless of hand or machine debridement, and Weine 1982, Taylor 1988) the zone of maximum con-
regardless of chemical irrigation with a concentration of striction or `apical constriction', erroneously considered to
solution of biological acceptability (Guldener et al. 1995). coincide with the CDJ (Figs 1 and 2); others (Langeland
Langeland (1996) firmly states: `Only the histologic 1957, 1967, 1987, 1995) the apical constriction,

q 1998 Blackwell Science Ltd, International Endodontic Journal, 31, 384±393

 RTC instrumentation and obturation 387

regardless of the combinations of tissues present on the
opposite root canal wall (dentine, cementum or CDJ);
finally some others (Pecchioni 1983, Frank et al. 1988)
use average measurements (0.5±1 mm) from the radio-
graphic apex.
Different opinions also exist regarding the treatment in
the case of a necrotic pulp compared with a vital pulp
(Table 1). Most recently Buchanan (1996), disregarding
many scientific and clinical investigations (EngstroÈm et al.
1964, EngstroÈm & Lundberg 1965, SjoÈgren et al. 1997),
made the statement that all cases, regardless of bacterial
status, could be treated the same, in one visit. He
suggested success rates were the same.
In cases with nectrotic pulps and apical resorption,
Weine (1982) suggested shortening the working length,
whereas Guldener (1985) suggested increasing it. An
apical overfilling in necrotic cases has also been suggested
(Pecchioni 1983). In addition different opinions have been
voiced about the problem of biological damage caused by
overinstrumentation and overfilling. Finally, opinions
become contradictory when it comes to the treatment of
lateral canals and apical ramifications (Table 1; Fig. 4).
These controversies in the literature are unfortunate,
especially because most of the suggested therapeutic
procedures are based on philosophical considerations and,
even worse, on different author's personal opinions rather
than on scientific evidence. Langeland (1987, 1995)
stated that endodontic therapy is to a high degree
influenced by devices sales brochures and opinions rather
than by scientific investigations.
This paper aims to clarify the problems described on
the basis of strict scientific criteria. These will include
(i) statistical/longitudinal studies, (ii) anatomical
evidence, and (iii) histopathological/microbiological
evidence.
Statistical/longitudinal studies
Since 1956 many statistical studies on the results of
endodontic treatment have been published. From these
studies a correlation between clinical variables and
success rate can be made. One of the most investigated
aspects is success rate related to the radiographic level of
the endodontic obturation.

Table 1 Recommended limit of instrumentation and obturation

Authors Ideal limit Practical limit Modifications in `necrotic Materials beyond the Lateral canals and apical
cases' foramen ramifications

Weine (1982) CDJ (apical 1 mm from the Additional 0.5 mm Ð Rarely cause failure
constriction) apex shorter (1.5 mm total
from the apex

Nguyen (1985) CDJ Ð Ð Ð Ð

Ingle (1983) CDJ (apical 0.5 mm from the Ð Ð Ð

constriction) apex

Frank et al. (1988) Ð 0.5±1 mm (apical Ð Ð Their obturation casual and

stop) not clinically relevant

Guldener (1985) Ð 1 mm from the 0.5 mm longer (0.5 mm Ð Ð

apex from the apex)

Taylor (1988) Apical Ð Ð Ð Ð

constriction
(minor diameter)

Pecchioni (1983) Ð 0.5±1 mm from Overfilling accepted Slight overfilling not Ð

the apex relevant

Seltzer et al. (1968, Ð Instrumentation Ð Not accepted Ð

1969) and obturation
`short'

Langeland (1967) Apical Apical constriction No difference in limit of Not intended Not intended material in
constriction procedure lateral canals

Schilder (1967, Ð Radiographic No difference in limit of Not relevant Obturation desired

1976, 1987) terminus of the procedure
canal

q 1998 Blackwell Science Ltd, International Endodontic Journal, 31, 384±393

388 D. Ricucci
Fig. 4 The decision to limit the procedure inside the canal near the
constriction does not interfere with the tissue contained in the apical
ramifications.
In a clinical follow-up study on 775 endodontically
treated roots, reviewed up to 10 years after treatment,
Strindberg (1956) suggested a model for clinical/radiologi-
cal prognosis studies, and concluded that the highest
success rate in endodontics was obtained when the
obturation terminated 1 mm short of the radiographic
apex. This study has been used as a guide in a number of
subsequent prognosis studies (Mayer & Ketterl 1958,
Ketterl 1965, Molven 1976, Kerekes & Tronstad 1979,
Kerekes et al. 1980).
In a study on 1007 endodontically treated teeth, 1770
canals, Swartz et al. (1983) evaluated several variables and
came to the conclusion, among others, that `. . . overfilled
canals were four times more likely to fail than canals filled
short of the radiographical apex'. Marin (1989) conducted a
retrospective analysis on the clinical radiological results of a
sample of 1200 roots treated over a period of 5 years. The
purpose was to determine whether a significant statistical
relationship existed between the level of the root canal filling
and the success rate. He concluded that `. . ..cases with
fillings at 0.5 and 1 mm from the radiological apex appear to
have a significantly superior clinical prognosis. In cases
where the filling reaches or goes beyond the radiological
apex, there is a considerable decrease in the number of
complete repairs and a consequent increase in incomplete
repairs and failures'.
The importance of staying inside the root canal with
the obturation and avoiding extruding material into the
periapical tissues in order to obtain a higher success rate
has also been stressed more recently (SjoÈgren et al. 1990,
Smith et al. 1993, Friedman et al. 1995, SjoÈgren 1996).
SjoÈgren et al. (1990) found that in roots with necrotic
pulps and periapical lesions the best prognosis was
obtained when the filling reached within 2 mm of the
apex (94%). By contrast, in cases with excess root filling
the success rate decreased to 76%; in cases of excess root
filling during retreatment of previously filled roots the
success rate decreased to 50%.
Smith et al. (1993) had a 86.95% success rate when the
position of the root filling was within 2 mm of the radio-
graphic apex. In cases with `long' obturation the success
rate was reduced to 75%. Friedman et al. (1995) found that
in the presence of extruded sealer the success rate was
56.7% against 81.9% in the absence of extrusion.
Contrary to the studies undertaken by endodontic
specialists which reported success rates of 91±94%, epide-
miological studies of large population groups showed
uncertain and failure rates of about 50% of endodontic
procedures performed by generalists (Jokinen et al. 1978,
OÈdesjoÈ et al. 1990, Buckley & SpaÊngberg 1995, Weiger et al.
1997). OÈdesjoÈ et al. (1990) found that 24.5% of the endo-
dontically treated roots demonstrated periapical lesions.
Buckley & SpaÊngberg (1995) found 31.3% of root-filled
teeth with periapical lesions, and 42.9% of overfills had
periapical disease. In a recent study on an urban German
population Weiger et al. (1997) found that 61% of root
canal-filled teeth showed radiographic signs of periapical
pathosis. When evaluating the technical standard, only
14% of the endodontic treatments were considered as
adequate. These studies agreed that inadequate canal
obturation and overfilling were strongly associated with the
presence of periapical disease. It is clear that all studies
confirm the practice of staying short of the apex with a
proper obturation to obtain the highest success rate.
On the other hand, authors who advocate obturation
beyond the apical constriction do not have comparative
data, which include the necessary number of cases of the
various categories and length of observation periods, to
support this treatment.
Anatomical evidence
The anatomical complexity of the root canal system has
been well known since the beginning of this century.
q 1998 Blackwell Science Ltd, International Endodontic Journal, 31, 384±393

Preiswerk (1903) stated that he was the first to describe
the presence of an anastomosing canal system. Subse-
quently Hess (1917) undertook a further study of the
anatomical complexity of the root canal system. Kuttler
(1955) made an impressive number of measurements on
the apical part of the canal.
What is most important is the topography of the apical
foramen(ina) related to root canal treatment. Very seldom
does a root canal end at the radiographic apex. Much
more frequently the foramen ends at a location short of
the apex. This was reconfirmed in a recent study by
Gutierrez & Aguayo (1995), who examined 140 extracted
permanent teeth with a scanning electron microscope. All
the root canals were found to deviate from the long axis
of their roots. The number of foramina ranged from 1 to
6. The openings always ended short of the apices by
0.20±3.80 mm.
This represents a problem for the endodontist, because
this phenomenon is recognizable on the radiograph only
when the foramen ends on the mesial or distal aspect of
the root. When the foramen ends on the buccal or lingual
aspect it is not possible to recognize it radiographically.
Thus, overinstrumentation of the root canal must be a
common and unnoticed occurrence, unless the operator is
diligently examining the tip of the instrument for blood.
Cases of endodontic failure where the canal appeared to
be filled short of the apex radiographically were in fact
obturated beyond the foramen. Apicectomies and
successive histological sections demonstrated that the
obturation material protruded into the periodontal
ligament from a foramen ending several millimetres short
of the apex on the buccal aspect (Ricucci et al. 1991).
Frequently the main canal in the apical third divides
into several branches, each ending on the external root
surface with a distinct foramen. Lateral canals can also be
present at any level along the root, and it is evident that
the tip of a file cannot suddenly make a 908 turn to
instrument these spaces. From all these considerations it
may be concluded that the best place to end the
preparation procedure is at the apical constriction which
is usually located at a distance between 1 and 2 mm from
the radiographic apex, keeping in mind that in particular
cases the foramen could be found several millimetres short
of the apex (Ricucci et al. 1990, 1991, Gutierrez &
Aguayo 1995). However, apart from those exceptions
where the experience and expertise of the operator will
allow recognition of anatomical variations, instrumenting
at an average distance of between 1 and 2 mm from the
apex will prevent overinstrumentation, leaving the pulp
tissue contained in the apical part of the canal and the ra-
mifications undisturbed.
q 1998 Blackwell Science Ltd, International Endodontic Journal, 31, 384±393
RTC instrumentation and obturation 389
Langeland (1996), based on anatomical/histopathologi-
cal studies, refused to settle for any particular length from
the apex. The radiographic apex ± with all its radiographic
inaccuracies ± is the `constant' against which the ever-
changing distance from the anatomical apical constriction
must be measured. This has to be inaccurate, as
confirmed by Gutierrez & Aguayo (1995).
Histopathological/microbiological evidence
The first scientific basis for modern clinical endodontology
was established by Davis (1922). This author, on the basis
of Hess's study (1917), was the first to suggest that
careful treatment of the apical tissue was a requirement
for success in endodontics. His conclusion was not based
on histological observation, but since then many histologi-
cal studies ± based on biopsies of the apex with the
surrounding periapical tissues or on extractions of teeth
performed at varying periods of time following the
endodontic treatment ± have confirmed his observation.
All these studies agreed that, in vital pulp treatment,
partial pulpectomy was preferred to total pulp removal.
The first histological studies on pulp wound healing
were made by Hatton et al. (1928) and by Blayney
(1929) but the series were too small and data about
diagnosis, procedures, observation periods and results
were insufficient.
Subsequently Nygaard-O / stby (1939, 1944) performed
clinical/histopathological studies on 20 human teeth. On
some of them pulpectomy was performed; in the others a
partial pulpectomy was performed using a blunted
HedstroÈm file. The distance from the apex was checked
radiographically. Observation periods ranged from one
month to several years. Despite limitations in the number
of cases and a number of uncontrolled variables such as
diagnosis, medicaments and filling materials, Nygaard-
/ stby stated: `To leave the apical and foraminal part of
O
the pulp tissue and to retain its vitality will play a decisive
role for the success in the treatment of the vital pulp'.
Also: `In cases where the pulp is vital before treatment, no
matter whether the diagnosis be clinically intact pulp,
acute or chronic pulpitis, partial extirpation seems to give
the most favourable prognosis. By appropriate treatment,
in the majority of cases, the vitality of the residual pulp
may be conserved, the result being a normal apical
periodontal ligament and fibrous connective tissue in the
apical portion of the root canal'.
Laws (1962), after carrying out partial pulpectomy and
irrigation with saline solution in 8 intact teeth, performed
canal obturation using calcium hydroxide mixed with
propylene glycol. Pulpectomies were made 2 mm from the
390 D. Ricucci
radiographic apex. Histological checks were made 19±126
days later. He classified 7 out of the 8 treatments as
successful.
Nyborg & Tullin (1965) reported histological results
after pulpectomy in 17 teeth with previous vital pulps. In
15 of these a pulpectomy was performed, with the wound
surface between 1.5 and 6 mm from the radiological apex.
Although a number of uncontrolled variables were
present, they recorded histological success in 10 out of
the 15 cases.
EngstroÈm & SpaÊngberg (1967) performed partial pul-
pectomies in 12 contralateral tooth pairs. Half the canals
were obturated with calcium hydroxide mixed with saline,
the other half with chloropercha and gutta-percha,
according to the Nygaard-O / stby technique. The teeth
were extracted after observation periods of 4 to 29 weeks.
They classified 12 of the 23 partial pulpectomies as
successful and 4 as more or less successful. They
concluded that optimal results `would appear to be
obtained' with a residual apical pulp 1±2 mm long.
Seltzer et al. (1968) performed a study on 27 noncarious
human teeth and on 24 noncarious teeth of monkeys. After
pulp extirpation the root canals of 12 human and 12
monkey teeth were instrumented 2±10 mm short of the
apices. In 15 human teeth and in 12 monkey teeth, the root
canals were instrumented several millimetres beyond the
apices. After time intervals ranging from immediately to
360 days the root apices and surrounding bone of human
teeth were block resected. The animals were killed 1 week to
6 months following the procedure. It was found that tissue
reactions following instrumentation short of the apex were
milder than those reactions which followed instrumentation
beyond the apex.
In a subsequent study Seltzer et al. (1969) performed
pulp extirpations and root canal instrumentation short of
the apices on 34 human anterior teeth and on 32 roots of
16 teeth of monkeys. The root canals were then filled
short of the apices of 24 human teeth and 22 roots of 11
monkey teeth. Root canal fillings were purposely forced
beyond the apices of 9 human teeth and 10 roots of 5
animal teeth. Observations were made of the periapical
tissue reactions after time intervals ranging from 6 to 270
days in the human groups and 14 to 270 days in the
animal series. They concluded that, in cases of vital pulp
extirpation, optimum results, in terms of tissue repair,
were obtained when root canals were instrumented and
filled short of the apices of the teeth. They emphasized
that when obturation materials are forced into the
periapical tissues `. . . they cause the inflammatory
response to persist. The foreign materials act as
continuing irritants. Over-all the best results are obtained
when the apical pulp stump retains its vitality and no
foreign material is impinged on the pulp or periapical
tissues'.
Substantial agreement exists among many researchers
that partial pulpectomy is preferable to total pulpectomy
in vital pulp treatment. The same agreement is not
registered in the treatment of `necrotic cases'. A very
strict distinction between the vital pulp condition and
necrotic pulp condition has always been made by
clinicians. It seems a very common cliche that, when a
pulp appears clinically necrotic (i.e. it does not respond to
sensitivity tests), it is generally considered to be necrotic
in its entirety, including the apical pulp and the tissue
contained in lateral canals and in apical ramifications.
This is a basic conceptual error on which, subsequently,
inappropriate therapeutic options have been based.
In fact progression of the pulp necrosis as the result of
caries is a slow process. The invasion of bacteria into
necrotic pulp tissue occurs in irregular `pockets', deeper in
some areas, adjacent to vital pulp tissue on the same level
as the orifice. This process has been described in detail by
Langeland (1957, 1967, 1976, 1981, 1987, 1995).
The progression of pulp degeneration
Although stages are commonly used to describe the
progress of disease, biologically and pathologically there
are no stages. The development and progression of disease
is continuous, although the rate may vary. For
endodontic treatment purposes, the only distinction which
has to be made is whether or not necrosis and bacterial
colonization have reached beyond the coronal orifice of
one canal. The importance of this distinction is that when
there is bacterial colonization bacteria have the ability to
enter the dentinal tubules of the root canal. This will
require more than one visit and intermediate Ca(OH)2
treatment, as has been demonstrated by BystroÈm et al.
(1985) and SjoÈgren et al. (1997).
Proceeding beyond the initial pulp reactions to the
carious process, the time when a pulpitis becomes irrever-
sible, is significant. This occurs when bacteria penetrate
the dentinal tubules of the irritation dentine and a minor
area of necrosis is established in the adjacent pulp. The
entire process more often than not happens in the total
absence of pain (Langeland et al. 1976).
All past attempts to correlate clinical findings with
complicated histopathological classifications of pulp
disease have met with failure (Anderson et al. 1981).
Thus, in carious teeth the precise moment, if there is any
such thing, that bacteria enter the pulp tissue adjacent to
carious dentine, thereby determining the transition from
q 1998 Blackwell Science Ltd, International Endodontic Journal, 31, 384±393

reversible to irreversible pulpitis, cannot be recorded by
any clinical means (Lin et al. 1984).
Even if necrosis has involved an entire pulp horn,
departing from the centre of the breakdown, the
surrounding pulp tissue along the vessels shows a
decrease in the severity of the inflammatory reactions in
an apical direction. In the remaining pulp tissue in the
chamber there is a typical response of neutrophilic
leucocytes next to the bacterial colonization, then a
chronic inflammatory response tapering off in severity and
density apically. The entire root pulp could still remain
totally free of inflammatory cells at this level of
development. The only pathological condition could be
dystrophic calcifications centrally in the root pulp and on
the canal wall, as demonstrated by Langeland (1987).
The next clinically discernible condition is when most of
the coronal pulp tissue is involved in the necrosis. Except
for expansion in volume of the pulpal disintegration, the
important principal difference is the presence of a radio-
graphically visible periapical lesion in the presence of a
vital root pulp. Not only is the root pulp vital, but for a
long time it is only partially inflamed. Calcifications, free
in the pulp or attached to the canal wall, and resorption
remain as the only evidence of pathology in the root pulp
(Langeland 1987).
The final recognizable stage in caries-related pulpal
destruction is when bacteria enter the root canal and
necrosis is established. During this time the clinically
important difference is that bacteria could move into the
tubules of the adjacent root canal wall. This condition
may occur in the total absence of pain, similar to the
earlier advances. Vital pulp tissue with nerves and vessels
remains in the most apical part of the main canal even in
the presence of a large periapical lesion (Langeland 1987).
This has been confirmed by taking pulp biopsies by simple
extirpation of the pulp in cases where there was a
periapical radiolucency (Lin et al. 1984). In these cases
histological observation showed that acute inflammatory
cells were present in the most coronal part, chronic in-
flammatory cells in the adjacent area, and finally in the
apical area there was vital and, in most cases,
noninflamed tissue. This cellular interrelationship is
maintained as necrosis in general moves in an apical
direction, but the necrosis and bacterial colonization are
also confined to the root canal in clinically advanced
cases, even in the presence of periapical inflammation.
This is an issue which does not seem to be easily accepted
by practitioners: the coexistance of a periapical lesion with
remaining vital root pulp tissue.
The explanation of this biological phenomenon is that
the accumulated disintegration products of the coronal
q 1998 Blackwell Science Ltd, International Endodontic Journal, 31, 384±393
RTC instrumentation and obturation 391
pulp, bacterial disintegration products and their toxins,
not whole bacteria, are transferred through veins of the
pulp to the periapical tissue. Thus, in a cross-section at
right angles to the long axis of the root canal there is not
generalized necrosis, but necrosis in one area, inflamma-
tion in an adjacent area, no inflammation in another
adjacent area, and calcifications in a last area, diffusely
intermixed. Support for this statement may be found in
the studies by Barnes & Langeland (1966) where
circulating antibodies were demonstrated as a result of
placing antigens, bovine serum albumin, human gamma
globulin or sheep erythrocytes, into the pulp chamber of
monkeys, and by Walton & Langeland (1978) where
particles of Kerr sealer were demonstrated in regional
lymph nodes after introduction which was confined to the
root canal of monkey teeth.
The reason for apical pulp tissue remaining vital for a
long time is mainly the substantial blood supply coming
from a large number of ramifications particularly concen-
trated in the apical area. The antiquated strangulation
theory, based on the belief that there is one artery
entering the foramen and two veins leaving and that
these are compressed and strangulated, denying escape of
fluids from the pulpal space, is erroneous. There are
numerous vessels going in and out of numerous foramina.
A logical clinical consequence of these observations
would be to stop instrumentation at the apical constric-
tion, that is short of the radiographic apex, even in the
presence of a periapical lesion. It is apposite to leave the
tissue contained in the foraminal area undisturbed.
For whatever reason, despite the resistance of the apical
pulp portion to disintegration, in time all pulp tissue will
be affected by necrosis, finally including the apical tissue
and ramifications. Bacteria will establish themselves in the
periapical lesion as far as the necrosis occurs (Oguntebi et
al. 1982, Pascon et al. 1987, Lin et al. 1996). Even in this
extreme situation, the most appropriate area to which to
limit the endodontic operation is still the apical constric-
tion, that is an area located inside the root canal.
The formation of the lesion in the periapical bone occurs
under immunopathological mechanisms, as described by
Wang & Stashenko (1991). When these factors, including
toxic and resorptive factors, are eliminated from the canal
space a periapical lesion will heal.
The involvement of lateral canals
It has already been stated that it is incorrectly presumed
that when a pulp appears to be `clinically necrotic' it is
considered entirely necrotic, including the pulp tissue in
the lateral canals and apical ramifications. Langeland
392 D. Ricucci
(1967, 1987) demonstrated that the histological
condition of the tissue contained in lateral canals reflects
the condition of the pulp in the main canal, from which
they emerge: when a lateral canal is present in an area
where healthy pulp tissue is present in the main canal,
healthy pulp tissue will be found throughout the lateral
canal; when a lateral canal is present in an area where
there is an inflammation in the main canal, there will be
an inflammation in the adjacent area of the lateral canal;
and when a lateral canal is present in an area where
there is necrosis in the main canal, there will be necrotic
tissue in the adjacent part of the lateral canal. This will be
followed by a transition zone of necrosis/neutrophilic
leucocytes, and then vital and inflamed tissue connected
to a periodontal lesion. In other words, during disintegra-
tion of the main canal pulp the tissue in the lateral canals
and in the apical ramifications remains vital as far as the
tissue in the main canal, but is partially necrotic when
necrosis reaches the level of the pulpal entrance of lateral
canals and apical ramifications. The inflammatory
reaction of the tissue contained in the lateral canal will
become weaker closer to the periodontal ligament.
Circulation from the periodontal ligament is mainly
responsible for the maintenance of this tissue vitality.
The explanation for lateral lesion formation in the
presence of an inflamed but vital pulp tissue is the same
as for periapical lesion formation. The accumulated disin-
tegration products of the coronal pulp, bacterial disinte-
gration products and their toxins are transferred through
functioning veins and diffuse into the periodontal tissue.
The subsequent evolution of this situation will depend on
time; necrosis may finally reach the periodontal ligament.
Practical consequences resulting from these observa-
tions are the following: it is impossible to instrument
lateral canals and apical ramifications. Material which
radiographically appears in the lateral canals was forced
into the tissue. When lateral canals appear `filled', it is
evidence that a sufficient amount of sealer has been
pushed into them to make them appear radiodense.
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