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Endodontic
Prognosis
Clinical Guide for
Optimal Treatment
Outcome
Nadia Chugal
Louis M. Lin
Editors
123
Endodontic Prognosis
Nadia Chugal • Louis M. Lin
Editors
Endodontic Prognosis
Clinical Guide for Optimal Treatment
Outcome
Editors
Nadia Chugal Louis M. Lin
Section of Endodontics Dept of Endodontics
UCLA School of Dentistry NYU College of Dentistry
Los Angeles New York
California New York
USA USA
ISBN 978-3-319-42410-1 ISBN 978-3-319-42412-5 (eBook)

DOI 10.1007/978-3-319-42412-5
Library of Congress Control Number: 2016960548
© Springer International Publishing Switzerland 2017

This work is subject to copyright. All rights are reserved by the Publisher, whether the whole or part of
the material is concerned, specifically the rights of translation, reprinting, reuse of illustrations, recita-
tion, broadcasting, reproduction on microfilms or in any other physical way, and transmission or infor-
mation storage and retrieval, electronic adaptation, computer software, or by similar or dissimilar
methodology now known or hereafter developed.
The use of general descriptive names, registered names, trademarks, service marks, etc. in this publica-
tion does not imply, even in the absence of a specific statement, that such names are exempt from the
relevant protective laws and regulations and therefore free for general use.
The publisher, the authors and the editors are safe to assume that the advice and information in this book
are believed to be true and accurate at the date of publication. Neither the publisher nor the authors or the
editors give a warranty, express or implied, with respect to the material contained herein or for any errors
or omissions that may have been made.
Printed on acid-free paper
This Springer imprint is published by Springer Nature

The registered company is Springer International Publishing AG Switzerland
The registered company address is Gewerbestrasse 11, 6330 Cham, Switzerland
To my family, friends, and mentors for their
love, support, and encouragement.
Nadia Chugal
Foreword
It is indeed a privilege to write this foreword for an Endodontics book with progno-
sis as its main emphasis. While all practitioners aspire to achieve the highest levels
of success of treatment, the definition of this success and the factors that affect it
receive very little attention among clinicians. Complicating this matter is that, with
the exception of resolution of pain or purulent drainage, true and complete end-
odontic success is not demonstrable clinically until a long period has passed after
treatment, typically measured in years. The difficulty in establishing an effective
follow-up program for all patients, especially that they are typically asymptomatic,
has led many practitioners to rely only on surrogate measures of success like the
quality of the obturation and the resolutions of symptoms. While there are some
population-based data in the literature to support reliance on these parameters, they
clearly provide an incomplete assessment of prognosis.
As one reflects on this book’s working definition of endodontics, as the preven-
tion and/or elimination of apical periodontitis, it is reasonable to reconsider whether
this is still consistent with recent information as noted in the relevant chapters. For
example, the word “prevention” is used in a discipline in which home care is not
thought to affect the outcome of treatment. The intent likely arose from the need to
diagnose irreversible pathosis more vigilantly, in order to perform the endodontic
treatment at this stage, and avoid pathogenesis of apical periodontitis. However,
recent advances in vital pulp therapy leads one to question whether the priority is
still to remove the vital inflamed pulp at all costs to assure the goal of preventing
apical periodontitis. The growing interest in pulp and dentin regeneration, the
advent of more biocompatible reparative materials, and the presence of good out-
come studies on vital pulp therapy make one reflect more on this classic definition
of endodontic therapy.
This book also provides an excellent discussion in several chapters of the radio-
graphic detection of emergent and residual disease, as it has evolved in the last 60
years or so. Today, tools like CBCT allow us to visualize this disease earlier in the
diagnostic process, and for a longer period after treatment. Therefore, there is more
of an overlap in the pulpitis/apical periodontitis spectrum of diagnosis, and perhaps
a longer period when teeth with apical radiolucencies may be considered healing.
There are even questions as to whether teeth with long-standing small
vii
viii Foreword
radiolucencies, and no other abnormalities, should be retreated or subjected to root

end surgery. There is more realization that complete bone regeneration may not be
achievable in many of these asymptomatic cases, the way it is not achievable in
cases with marginal periodontitis.
Postoperative factors that affect the prognosis are also of particular interest. The
profession has in the last decade transitioned from relying on bench-top laboratory
studies to clinical outcome studies in making many clinical decisions that are related
to coronal leakage. The question remains as to who controls the prognosis to a
larger extent: is it the practitioner that did the endodontic therapy or the one who
restored the tooth?
Finally, this book eloquently addresses the emerging concept of personalized
endodontics, in which the prognosis may be affected by a combination of the unique
and complex microbiota that causes the disease, together with the systemic health
of the patient, as well as genetic and epigenetic variability among patients. This area
promises to provide us in future more detailed predictors for outcomes, which can
help the provider with treatment planning and help the patient with decision
making.
Ashraf F. Fouad, DDS, MS

Preface
This book distinguishes itself from endodontic textbooks because it is the first text-
book completely focused on the prognosis of endodontic treatments. Our goal for
this book was to make recent results at the forefront of endodontics accessible for
clinical practice.
The book is intended to serve as a clinical guide to help practitioners in their
clinical decision-making process and ultimately improve endodontic treatment
outcomes.
The goal of endodontic treatment is to prevent and/or eliminate apical periodon-
titis, a disease entity occurring as a result of microbiologic challenge to the pulp and
periradicular tissues. Like many other human diseases, endodontic treatment out-
comes are profoundly affected by a multitude of prognostic factors. These determi-
nants of treatment success or failure can exert their effect preoperatively,
intraoperatively, and postoperatively. Therefore, it is important for the clinician to
be familiar with the favorable predictors of outcome as well as prognostic risk fac-
tors. This knowledge is essential to effectively circumvent and manage risks in
order to achieve the desired treatment result.
We first outlined the theme of every chapter that we considered important for the
book. We then invited experts in their respective areas to write on the specific topics.
These topics include both basic and clinical sciences and cover several key aspects
of endodontic prognosis. The multidisciplinary authorship by highly respected cli-
nicians and scientists reflects the multifactorial nature of endodontic outcome.
Outcome assessment of endodontic therapy has evolved from Strindberg’s strin-
gent criteria that emphasized the absence of clinical symptoms/signs and restoration
of normal structure of the periapical tissues to newer patient-centered criteria focus-
ing on the absence of clinical symptoms/signs and survivability and functionality of
endodontically treated teeth even with the presence of small and stable periapical
lesions. However, as pulpal and periapical pathosis is a disease, a tooth with a per-
sistent inflammatory periapical lesion after treatment, regardless of its size, should
be considered as unsuccessful elimination of the disease. Therefore, complete elim-
ination of the disease still remains the ultimate goal of root canal treatment.
We hope that the readers will enjoy this book and benefit from it, as much as we
have enjoyed spending our time and energy working on it.
Nadia Chugal
Louis M. Lin
ix
Acknowledgments
We thank all contributors for their time, support, and contributions to this book.
Without their generosity and dedication, this book would not have been published.
We wish to express our deep appreciation for the many cases, radiographic images,
photographs, and histologic slides provided by our colleagues. We also thank the
editors from Springer for believing in us and for their support, understanding, and
patience.
Nadia Chugal
Louis M. Lin
xi
Contents
1 Introduction: Endodontic Prognosis and Outcome�� 1

Nadia Chugal, Louis M. Lin, and Bill Kahler
2 Microbiology and Immunology of Endodontic Infections �� 13
Luis E. Chávez de Paz and Gunnar Dahlén
3 Diagnosis of Pulpal and Periradicular Disease�� 29
Katsushi Okazaki, Matthew Malek, Nadia Chugal,
and Louis M. Lin
4 Endodontic Treatment of Mature Teeth�� 43
Louis M. Lin, Simona Loghin, and Domenico Ricucci
5 Regenerative Approaches in Endodontic Therapies
of Immature Teeth�� 65
Mo K. Kang and George Bogen
6 Endodontic Pharmacotherapeutics�� 87
Helaine De Brito-Gariepy, Thereza Cristina Botelho-Dantas,
and Jennifer Lynn Gibbs
7 Anatomy, Access, and Length Determination �� 115
Frederick Barnett
8 Instrumentation and Disinfection of Root Canals�� 131
Frederic Barnett and José F. Siqueira Jr.
9 Obturation of Root Canals�� 141
Dag Ørstavik
10 Restoration of Endodontically Treated Teeth�� 161
Nadim Z. Baba, Shane N. White, and George Bogen
11 Local, Systemic, and Genetic Considerations of Endodontic
Treatment Prognosis�� 193
Matthew Malek and Louis M. Lin
xiii
xiv Contents
12 Criteria for Outcome Assessment of Nonsurgical

Endodontic Treatment�� 211
Nadia Chugal, Sanjay M. Mallya, and Bill Kahler
13 From Tooth Retention Through Root Canal Treatment
to Extraction and Replacement�� 229
Shane N. White and Mahmoud Torabinejad
Index�� 239
Introduction: Endodontic Prognosis
and Outcome 1
Nadia Chugal, Louis M. Lin, and Bill Kahler
Many authors display a propensity to reduce complex problems

such as success and failure to terms so simple that a casual
reader with little effort can expand a narrow grasp of the
subject into a broad convenient misunderstanding
Dudley Glick, DDS
Excerpt from a lecture
Year unknown
Abstract
Prognosis and outcome are two terms routinely used in medicine and dentistry to
predict and assess the treatment of disease. Prognosis is a practitioner’s assess-
ment about how a patient will recover from an illness or injury. It is a forecast of
the probable course of recovery for any particular disease considering the assess-
ment of the case. Outcome is the end result of the treatment and a consequence
of treatment decisions made by the practitioner. In endodontics, there are prog-
nostic factors which are universal to all cases as well as variables unique to a
specific case, all of which can affect endodontic treatment outcomes. Prognostic
factors can be grouped into preoperative, intraoperative, and postoperative. They
influence endodontic treatment outcomes indirectly through control and elimina-
tion of infection. Importantly, an understanding of prognostic factors helps prac-
titioners as well as patients decide the appropriate treatment procedures and is
especially important for higher-risk conditions such as teeth with a periapical
N. Chugal (*)
Section of Endodontics, UCLA School of Dentistry, Los Angeles, CA, USA
e-mail: nchugal@dentistry.ucla.edu
L.M. Lin
Department of Endodontics, New York University College of Dentistry, New York, NY, USA
e-mail: lml7@nyu.edu
B. Kahler
School of Dentistry, University of Queensland, Brisbane, QLD, Australia
e-mail: wyattkahler@bigpond.com
© Springer International Publishing Switzerland 2017 1

N. Chugal, L.M. Lin (eds.), Endodontic Prognosis,
DOI 10.1007/978-3-319-42412-5_1
2 N. Chugal et al.
lesion, calcified canals, resorption, and others. This applies to immature or

mature teeth for consideration for nonsurgical or surgical management. Although
many prognostic factors are not under the control of the practitioners, they can
nevertheless be managed by a practitioner’s thorough evaluation of the present-
ing condition, risk assessment inherent in each individual case, and application
of biologically based therapies alongside with technical competency. Treatment
outcome is usually assessed using clinical and radiographic examination and has
evolved from Strindberg’s stringent criteria to patient-centered criteria.
Practitioners have to be familiar with the prognostic factors to inform patients of
the appropriate treatment modalities and to achieve the optimal treatment
outcome.
1.1 Introduction
The terms prognosis and outcome are routinely applied in medicine and dentistry.
They are used to predict and evaluate the result of disease treatment. Prognosis is
a forecast about probable course and outcome of a disease and chances of recovery
[1]. Applied to endodontics, it is a prediction of the outcome of resolution of apical
periodontitis. This forecast of the outcome is summarized by the practitioner for
the patients and serves to inform them how they will recover from an illness or
injury [1]. It synthesizes the prospect of recovery as anticipated from the usual
course of disease, or in the case of endodontics, the risk assessment of variables
that may influence the treatment outcome [1]. Outcome, on the other hand, is a
measure of the success of the treatment, as a result of an activity or a process, and
is a consequence of the decisions made during the course of treatment. Applied to
endodontics, outcome is the end result that follows as a consequence of endodontic
treatment [1].
There are a number of well-researched studies that elucidated prognostic factors
that exert significant effect on endodontic outcome. In turn, this information can be
used to prognosticate the course of disease resolution and predict the end result of
the proposed treatment.
Practitioners can systematically evaluate prognostic factors to guide their
patients in the decision-making process and ultimately propose the best treatment
options to achieve an optimal outcome. In accordance with evidence-based den-
tistry principles, the patients are also members of the treatment planning team and
have the right to know the prognosis and expected outcome before commencement
of treatment. Given this information, patients can evaluate their treatment options
and make an informed decision about the need or preference for their treatment
choices [2].
Optimal dental treatment planning requires an accurate assessment of the
outcome of the proposed endodontic treatment. This assessment, however, is
dependent on a correct understanding of variables affecting the outcome and
must be done with both high validity and reliability [3]. When such assessment
1 Introduction: Endodontic Prognosis and Outcome 3
is made, it is possible to offer the patient a wide range of appropriate endodontic

treatment options.
1.2 Multifactorial Nature of Endodontic Outcome
The multifactorial nature of endodontic outcome has been demonstrated in numer-

ous studies that have addressed a wide range of factors with the potential to impact
on endodontic treatment outcome. Outcome studies and recent systematic reviews
identified biologic- and treatment-associated variables as well as restorative factors
that are the most predictive of treatment outcome for contemporary conventional
endodontic therapy [4–9]. These studies applied advanced statistical methods to
determine the magnitude of risk the identified variables exert on outcome [3, 10].
Therefore, prognostic factors, which can affect the outcome of endodontic thera-
pies, are multiple and intertwined in complex relationships. An overview of these
interconnected variables and their possible relationships is illustrated (Fig. 1.1).
Some prognostic factors, such as the presence and extent of periapical lesion
(Fig. 1.2); the complexity of the root canal system, especially in cases with apical
periodontitis (Fig. 1.3); obliterated canal(s) due to hyper-mineralization (Figs. 1.4
and 1.5); pathologic or idiopathic root resorption (Fig. 1.6); and infection-induced
apical root resorption (Fig. 1.7), are not under the control of treatment providers.
However, most conditions can be managed by practitioners through a systematic
evaluation and risk assessment followed by application of sound biologic treatment
Fig. 1.1 Possible relationships between prognostic factors affecting the outcome of endodontic
treatment
4 N. Chugal et al.
a b c
a b c
Fig. 1.2 (a) Occlusal radiograph showing large periradicular cyst-like lesion that extended to the
floor of the nasal sinuses and along the mesial surface of the canine and the distal border of the
implant in the central incisor site. (b) Occlusal radiograph showing the completed root filling.
Some extrusion of sealer is evident. (c) Occlusal radiograph showing complete osseous repair
consistent with favorable healing outcome.
Lower frame (a) Cone-beam imaging showing extent of lesion surrounding the lateral incisor.
(b) Cone-beam imaging showing extent of lesion surrounding the implant. (c) Cone-beam imaging
showing lesion involving the distal aspect of the implant and the roots of the lateral incisor, canine,
and first premolar tooth (Images reproduced from Kahler B. Healing of a cyst-like lesion involving
an implant with nonsurgical management. Journal of Endodontics 2015;41:749–752)
a b c d e f
Fig. 1.3 (a) Preoperative radiograph of tooth #10 exhibiting complex tooth anatomy. Large peri-
apical radiolucency is approximately 10 mm in diameter. (b) Completion of root canal treatment.
Final radiograph after obturation shows the extent of periapical bone destruction. (c) A 15 month
follow up radiograph prior to commencing orthodontic treatment shows significant reduction in
size of periapical radiolucency. (d) A two year post endodontic treatment and one year in orthodon-
tic treatment. The residual radiolucency that remains may be indicative of healing with scar forma-
tion. (e) A four year follow up after endodontic treatment and six months after completion of
orthodontic treatment, the treatment exhibits successful outcome. (f) An eighteen year follow up
shows normal periradicular structures (Images courtesy of Dr. Nadia Chugal)
a b c
Fig. 1.4 (a) Radiograph of tooth #8 showing large periapical lucency and no canal is evident.
(b) The tooth is root filled though the root filling is not centered in the root which has the potential to
affect outcome. (c) At 18 month review the PA lucency is reduced in size and the tooth is asymptom-
atic. This case is an example of a ‘functional outcome’ as the strict Strindberg criterion has not yet
been met. However further healing with time is still possible (Images courtesy of Dr. Bill Kahler)
principles and technical expertise in order to achieve an optimal treatment outcome.

Often, a complex-presenting condition of the tooth comprises multiple risk factors
(Fig. 1.8).
Importantly, an understanding of these high-impact factors assists practitioner’s
decision-making process about the appropriate treatment procedures. In addition, it
also has practical implications related to treatment execution and preparation of
armamentariums necessary to treat these preexisting conditions. For example,
protocols may be different for immature vs. mature teeth, teeth with or without a
periapical lesion, and for both nonsurgical and surgical management.
For clarity of analysis and comprehension, they can be grouped into three major
categories: preoperative, intraoperative, and postoperative.
1.3 Preoperative Factors
An accurate assessment of the pulpal and periapical diagnosis is essential for an

understanding of the major biological factors as this diagnosis reflects a change in
the disease process and the extent of the infection into the periapical tissues [4, 6,
11, 12]. The literature is unequivocal that preoperative presence vs. absence of peri-
radicular osteolysis is one major indicator of postoperative healing or failure [4, 10,
13, 14]. Consequently, teeth with a preoperative periapical lesion have a poorer
outcome than teeth without a periapical lesion after nonsurgical root canal treatment
[4, 7, 10, 14]. In addition, larger bone lesions show a significantly lower frequency
of complete regeneration of the periapical bone than smaller lesions (4, 103).
Therefore, when a periapical lesion is present, the smaller the lesion, the more
favorable is the treatment prognosis [4, 10]. However, successful resolution of large
6 N. Chugal et al.
a c d
Fig. 1.5 (a) Radiograph of tooth #9 with a history of trauma. The root tip is blunted consistent
with apical resorption. The canal appears to have undergone complete obliteration in the coronal
half of the root. The canal in the apical half of the root is of an irregular shape and not centered in
the root. (b) CBCT imaging revealed an irregular resorptive lesion in the apical half of the root.
Therefore more complex imaging was advantageous as interpretation of conventional periapical
radiography was suggestive of canal patency. Furthermore the extensive periapical radiolucency is
revealed with erosion of the buccal and palatal cortical bone plates. After consultation with the
patient it was decided that optimal treatment option was surgical management due to the prognos-
tic considerations of calcified canal, resorptive defect in the apical third of the root and the exten-
sive periapical radiolucency. (c) A radiograph taken after the surgical revision and placement of a
MTA retrofill. (d) A radiograph at a 2 year review showing an intact lamina dura and periodontal
ligament space around the root. The periapical radiolucency is consistent with a periapical scar
and is a common observation following surgery when both cortical plates have been eroded
(Images courtesy of Dr. Bill Kahler)
periapical radiolucencies is often achieved (Figs. 1.2 and 1.3), although the risk of
future surgical treatment remains.
Teeth with a preoperative periapical lesion usually have a long-standing root canal
infection compared to teeth without a periapical lesion. Therefore, these teeth have a
well-established biofilm in the canal [15]. In addition, bacteria may also establish
infection in some periapical lesions, resulting in an extraradicular infection [16].
a c
Fig. 1.6 (a) Preoperative periapical radiograph of symptomatic first maxillary molar where crown
was placed one month earlier. (b) CBCT images revealed a Heithersay Grade III invasive cervical
lesion highly suggestive of pulpal involvement. (c) Radiograph showing completed root filling and
resorptive lesion filled with mineral trioxide aggregate (Images courtesy of Dr. Bill Kahler)
a b c d e
Fig. 1.7 (a) Pre-treatment periapical radiograph showing periapical radiolucency around the
mesial root of the mandibular first molar (white arrow). Note external resorption of the mesial root
apex. (b–e) Sequential periapical radiographs over twenty four months follow up after completion
of endodontic treatment show an increase in the radiodensity of the periapical bone, although a
minimal area of rarefaction remains. Further resolution of the radiolucency with time is expected
and at this stage can be considered as healing and a functional outcome as the tooth is asymptom-
atic (Images courtesy of Dr. Nadia Chugal)
8 N. Chugal et al.
a b c d
Fig. 1.8 (a) Preoperative periapical and (b) bitewing radiographs shows large periapical radiolu-
cencies associated with mesial and distal root apices, missed and untreated canals, fractured instru-
ment and near perforation of pulpal floor. (c) Completion of root canal treatment. (d) Nine months
follow up radiograph shows significant reduction in size of periapical lesion. Further healing with
time is likely. Patient remained asymptomatic and the tooth was functional (Images courtesy of
Dr. Nadia Chugal)
Consequently, it would be more difficult to eliminate bacteria in the root canal system
in teeth with than without a periapical lesion, thus affecting treatment outcome.
Medical conditions such as diabetes is one of the constitutive preoperative fac-
tors, negatively affecting the success of endodontic treatment of teeth with apical
periodontitis [17, 18]. This is in addition to the major effect of the presence and
magnitude of the infection of root canal system and structural condition of the tooth
in question. The existence of these factors is usually not under the control of the
practitioner.
1.4 Intraoperative Factors
Practitioners through systematic and thorough preoperative evaluation and a well-

executed clinical protocol can manage most intraoperative factors, such as level of
instrumentation, quality of root canal obturation, and procedural mishaps. Over-
instrumentation could introduce necrotic tissue and bacteria in the root canal into
the periapical tissues [19, 20]. Under-instrumentation could leave bacteria in the
apical few millimeters of the root canal [21].
The level of instrumentation of root canals is important for elimination of infec-
tion and may not be the same for roots with a normal periapex or with apical peri-
odontitis [22]. For teeth with apical periodontitis, it has been shown that one
millimeter loss of working length is associated with 14% and 12% decrease in
favorable outcome, respectively [10, 23].
In terms of underfilling, it should be distinguished between complete instrumenta-
tion and underfilling and incomplete instrumentation and underfilling. The former has
a better outcome than the latter because of elimination of intra-canal bacteria.
Inadequate root canal obturation with voids may allow coronal leakage of oral bacte-
ria to reach the periapical tissues [24, 25]. A separated instrument or root perforation
may prevent complete chemomechanical debridement of the canal system apical to
the separated instrument or perforation, thus preventing effective elimination of bac-
teria in the root canal system and compromising the treatment outcome [26].
1.5 Postoperative Factors
Postoperative factors, such as timely placement and quality of coronal restoration of

endodontically treated teeth, are under the control of the dentist and the patient. The
importance of an adequate coronal restoration of endodontically treated teeth in
relation to the success of root canal treatment has been demonstrated in many stud-
ies [27–30]. For the best outcome, endodontically treated teeth should have both an
adequate root canal treatment and adequate coronal restoration [30]. A permanent
coronal restoration is critical for prevention of reinfection and further damage to the
structural integrity of the tooth [3, 9, 27, 28, 31].
1.6 Effect of Root Canal Infection on Treatment Outcome
Maximizing successful outcomes for endodontic treatment rests on the elimination

of microorganisms from the infected root canals [6, 11–14] and without bacterial
inoculation of the periapical tissue [19, 20]. It must be emphasized that of all prog-
nostic factors, the reduction and/or elimination of root canal infection is the key to
the successful endodontic treatment outcome [32]. The effect of residual infection
on treatment results was demonstrated in human and animal studies. A clinical
study of the human teeth with apical periodontitis showed that negative bacterio-
logic cultures before root filling resulted in 94% success rate of root canal therapy.
In contrast, if bacteriologic cultures were positive, the success rate was reduced to
68% [13, 14]. An animal model study on monkeys showed that 79% of treated root
canals had non-healed periapical lesions when bacteria remained after endodontic
treatment, compared to 28% where no bacteria were found [33]. It was also reported
that it is the presence of bacteria in the canal and not underfilling or overfilling that
is the primary cause of persistent apical periodontitis of endodontically treated teeth
[12]. Periapical lesions could heal even without placement of a root canal filling, if
the root canal infection was effectively controlled and coronal leakage was pre-
vented [34, 35]. Sometimes, even endodontically well-treated teeth could fail [36].
Therefore, prognostic factors have a profound effect on the control of root canal
infection and subsequent treatment outcome.
1.7 Outcomes in Endodontic Therapy
Outcome is the consequence or the result of the treatment of disease, which is pro-
foundly influenced by a multitude of prognostic factors. Outcome of endodontic
therapy is usually assessed using radiographic and clinical examination.
Radiographic examination is to detect the presence or absence of a periapical lesion
and clinical examination for the presence or absence of symptoms/signs. Both con-
ventional periapical radiography and cone beam computed tomography have been
employed for radiographic examination in endodontics [37, 38]. Outcome assess-
ment of endodontic therapy has evolved from Strindberg’s stringent criteria
10 N. Chugal et al.
emphasizing the absence of clinical symptoms/signs and restoration of normal

structure of the periapical tissues [4] to the patient-centered criteria focusing on
absence of clinical symptoms/signs and survivability and functionality of endodon-
tically treated teeth even with the presence of small and stable periapical lesions
[39, 40]. However, the patient should be fully informed of the difference between
disease and survival or function of a tooth. As pulpal and periapical pathosis is con-
sidered a disease, then a tooth with persistent inflammatory periapical lesion after
treatment, regardless of its size, should be considered as unsuccessful elimination of
the disease. Therefore, complete elimination of disease still remains the ultimate
goal of root canal treatment.
There is a wide range in reported success rates of endodontic therapy [4–6]. This
can be attributed to variations in criteria for outcome measures, proportion of teeth
of a given type in a study, length of follow-up period, distribution of preoperative
diagnoses, interoperator and inter-evaluator variability, and endodontic treatment-
associated factors [4, 5, 41–43]. These variations make it difficult to make a valid
comparison between the findings of different studies.
Most prognostic factors in endodontic therapy can be managed by practitioners
through careful evaluation of the risk factors and execution of appropriate treatment
planning. Practitioners should always perform at the best standard of care to achieve
the best treatment outcome [44]. It is paramount that both the patient and practitio-
ner have a full understanding of the prognostic factors and the risks to subsequent
outcome before commencement of root canal treatment.
Conclusion
To augment understanding and effective management of prognostic factors asso-
ciated with optimal outcome of endodontic treatment, individual chapters of this
book are dedicated to key facets of endodontic therapy. These include the range of
essential topics, from accurate diagnosis of pulpal-periapical status to pathobiol-
ogy of pulpal-periapical tissues. The appropriate treatment plan for the various
stages of pulpal-periapical disease and meticulous treatment procedures to elimi-
nate root canal infection and prevent reinfection are presented. At the end, the
outcome assessment of the treatment and post-treatment sequelae is presented.
Acknowledgments We thank Dr. Sanjay Mallya and Brian Lozano for assistance with prepara-
tion of the illustrations.
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38. Ørstavik D, Kerekes K, Eriksen HM. The periapical index: a scoring system for radiographic
assessment of apical periodontitis. Endod Dent Traumatol. 1986;2:20–34.
39. Friedman S. Prognosis of initial endodontic therapy. Endod Top. 2002;2:59–88.
40. Friedman S, Mor C. The success of endodontic therapy – healing and functionality. CDAJ.
2004;32:493–503.
41. Kerekes K, Tronstad L. Long-term results of endodontic treatment performed with a standard-
ized technique. J Endod. 1979;5:83–90.
42. Goldman M, Pearson AH, Darzenta N. Reliability of radiographic interpretation. Oral Surg
Oral Med Oral Pathol. 1974;38:287–93.
43. Reit C, Hollender L. Radiographic evaluation of endodontic therapy and the influence of
observer variation. Scand J Dent Res. 1983;91:205–12.
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endodontics.aspx
Microbiology and Immunology
of Endodontic Infections 2
Luis E. Chávez de Paz and Gunnar Dahlén
Abstract
Endodontic infections are complex diseases associated with apical tissue inflam-
mation that is determined by microbial, immunological, and environmental fac-
tors. During the past years, the integration of research tools, including molecular
techniques for identification, sophisticated in vitro modeling, and human micro-
biome analysis, has provided additional insight in the understanding of endodon-
tic infections. Recent studies suggest that the basis for infections associated to
root canals of teeth is polymicrobial in nature and includes the emergence of
microbial colonization in form of biofilms. Biofilms deep seated in areas that are
difficult to reach by mechanical treatment will enhance microbial virulence, anti-
biotic resistance, colonization potential, and resistance. Furthermore, with the
advent of the human oral microbiome project, insights on the differences among
oral microfloras in different individuals appear to have an important role in pro-
gressing endodontic infections. This chapter discusses the current data regarding
the role that microbial biofilms play in endodontic infections, as well as its place
in the current knowledge of endodontic microbiology. The complex relations
between the root canal microflora and the inflammatory response in apical peri-
odontitis are also highlighted in this chapter, as well as their implications in
regard to the diagnosis and clinical management of endodontic infections.
L.E. Chávez de Paz, DDS, MS, PhD (*)

Department of Endodontics, Karolinska Institute, Stockholm, Sweden
e-mail: luis.chavez.de.paz@ki.se
G. Dahlén, DDS, PhD
Department of Oral Microbiology and Immunology, Institute of Odontology, Sahlgrenska
Academy, University of Gothenburg, Box 450, Göteborg, SE 40530, Sweden
© Springer International Publishing Switzerland 2017 13

N. Chugal, L.M. Lin (eds.), Endodontic Prognosis,
DOI 10.1007/978-3-319-42412-5_2
14 L.E. Chávez de Paz and G. Dahlén
2.1 The Oral and Root Canal Environments
2.1.1 The Oral Ecosystem
The oral ecosystem comprises a group of sites including the tongue, mucosa, gingi-
val sulcus, and tooth surfaces, each of which possesses unique ecological character-
istics that foster the growth of different kinds of microorganisms. The general
characteristics of the oral ecosystem include a constant temperature; the presence of
various soft and hard tissue surfaces to adhere, colonize, and grow; and a variable
supply of soluble nutrients. Specific collections of oral bacteria, also known as oral
plaque, are associated to different sites in the oral ecosystem [1,2].
2.1.2 Microbial Colonization of Tooth Surfaces
The tooth surface is an ideal site for microbial colonization, as it comprises plenty
of moisture, air, and the intervallic input of nutrients during food intake [3,4]. The
microbial plaque associated to the tooth surfaces is divided into supragingival and
subgingival, in reference to its location from the gingival margin. The microbial
composition and differences of these two types of dental plaque are principally con-
nected to ecological changes, pH, and nutritional factors. While the nutritional
sources for supragingival plaque include dietary components, saliva, and gingival
crevicular fluid, the subgingival plaque depends predominately on host-derived
components of crevicular fluid, which has a composition similar to serum [5].
2.1.3 Oral Health and Disease
Health of the different structures in the oral cavity is dependent on the interplay
between bacteria and their microenvironments, including the participation of immu-
nological factors such as antigens, both humoral and cellular. This ecological bal-
ance affecting oral health is of great complexity as it can also be influenced by
external factors such as nutrition, habits, and the social lifestyle of each individual.
Marsh in 2003 proposed the ecological plaque hypothesis to clarify the changes
in oral ecology that lead to the development of common oral diseases such as caries
or periodontal disease. Caries and periodontitis occur as consequence of imbalances
in the resident microflora resulting from enrichment within the microbial commu-
nity of selected microorganisms that are associated with disease [6,7]. Excessive
consumption of dietary fermentable carbohydrates will favor the overgrowth of
highly fermentative aciduric organisms, e.g., Streptococcus mutans and Lactobacillus
species. The acidified microenvironment produced by these organisms promotes the
demineralization of the hydroxyapatite matrix of enamel, thus increasing the risk of
dental caries. In the case of periodontal disease, lack of oral hygiene causes accu-
mulation of dental biofilm in the subgingival sulcus, thus inducing a chronic inflam-
matory condition. This inflammatory process will concomitantly lead to a change of
the subgingival flora favoring the increase of anaerobic proteolytic Gram-negative
2 Microbiology and Immunology of Endodontic Infections 15
bacteria and ultimately result in the destruction of the connective tissues and bone
that supports the teeth [8].
2.1.4 The Root Canal Ecosystem
Unlike other sites in the oral ecosystem, the root canals of teeth are naturally sterile com-
partments that contain healthy dental pulp tissue. Dental pulp is a highly vascularized and
innervated connective tissue that extends to the apex of the tooth. Dental pulp also con-
tains an efficient immune system that reacts in response to microbial invasion [9–11].
Once bacteria have invaded the root canal space, they encounter with a highly
controlled environment primarily affected by the presence of active inflammatory
mediators. After the pulpal inflammatory barrier is defeated, a variety of environmen-
tal changes in root canals act as selective factors limiting the growth of one species
relative to others [10]. The main selective factors that influence bacterial colonization
and growth in root canals are pH, oxygen (redox potential), and nutrient availability.
Following root canal treatment, other selective factors become involved, in particular
during treatment and the short-/long-term effects of the antibacterial medicaments
applied. Hence, microbial survival in root canal environments, especially after root
canal treatment, is based on the capacity of organisms to adapt to the existing condi-
tions [12]. Microbial adaptation to environmental challenges is facilitated by survival,
in many cases in a dormant stage, and growth in biofilms.
2.2 Root Canal Infections
2.2.1 Pathways of Microbial Entry
The integrity of the hard tissue barriers that protect the pulp may be breached by a
number of reasons. The most common microbial challenge of the pulp derives from
deep carious lesions. Other routes of entry include trauma, fracture, and cracks as well
as following unprotected iatrogenic exposure in mechanic dental procedures. The root
canal space may be also exposed in teeth with severe periodontal disease. In the later
cases, bacteria may gain access through accessory lateral and furcal canals and lastly
through the apical foramen. Root resorption, root caries, and breaches in the cemen-
tum may also lead to bacterial invasion into the pulpal space [13,14].
2.2.2 Pulp Inflammatory Reaction
The pulp tissue reacts with inflammation already when the caries lesion and the
bacteria reach the dentin. The bacteria and their metabolic products, such as acids,
enter the dentin tubuli and have a direct communication with the pulp. At this stage
the pulp executes a rapid inflammatory response that neutralizes the invasive agents
and repairs the damaged tissue. However, depending on the damage caused by the
offensive stimulus, e.g., an extensive caries lesion, the inflammatory response
executed by the pulp may intensify reaching up to destructive levels. The stage
when the inflammatory response exceeds the limit from a reversible to an irrevers-
ible state is unknown. However, irreversibility is marked by the accumulation of
mediators that ultimately lead to necrosis. These alterations in the pulp tissues may
result in severe pain that could last for several days [15–17].
2.2.3 Primary Invaders
Typically, the microorganisms that are responsible for the initial inflammatory
response of the vital pulp tissue are associated to the carious dentin. The flora is
predominantly Gram-positive saccharolytic species, foremost Lactobacillus spp.
and Streptococcus spp (Streptococcus mutans, Streptococcus sanguinis,
Streptococcus oralis, Streptococcus mitis, Streptococcus salivarius), but also
Actinomyces, Propionibacterium, Corynebacterium, and Bifidobacterium spp. are
commonly present. They are acid producers (acidogenic) and acid tolerant (acidu-
ric). These microorganisms will acquire their nutrients from the saliva through the
carious lesion as well as from the exudate of the pulp.
2.2.4 Progression of the Infection
During and after necrosis of the pulp, a critical invasion of the pulp chamber and
the canals will occur, with microbial invaders establishing in the necrotic mass or
attached to inner dentin walls in the form of biofilms. Bacteria that progress with
the invasive mass have an armamentarium of immunoevasive strategies, including
the secretion of exoproducts, antibiotic-resistance proteins, and phenotypic
changes, which renders them virtually invulnerable from the remaining immune
response (Fig. 2.1). The physical and immunological protection provided by the
biofilm structures they form is probably key in their long-term survival. After a
while, an inflammatory lesion in the periapical tissues known as apical periodon-
titis will develop.
2.2.5 The Endodontic Pathogen
Endodontic pathogens are defined as any organism capable of inducing the tissue
destruction in apical periodontitis [18]. Currently, however, there is no substantial
evidence indicating that certain microorganisms of the microbial flora in root canal
infections are more virulent than others. Thus, it is very hard to differentiate between
simple bystanders (commensals) and those that are actively participating in the infec-
tion (true pathogens). The majority of endodontic-microbiology studies refer to the
endodontic pathogen as the bacterium isolated from a symptom-associated root canal
that grows in the laboratory in a specific media. By this approach, the most frequently
recovered species have assumed the role of endodontic pathogen [12].
2 Microbiology and Immunology of Endodontic Infections 17
Production of specific proteases that are The bacterial cell surface is modulated to avoid
produced as modulators or toxins recognition: lipid A of LPS, carbohydrates in
capsules, outer membrane proteins and by
expressing adhesins & invasins
Inhibition of phagocytosis by multiple-cell Immune cells/phagocytes are directly subverted

clustering or killed by superantigens, avoidance of
phagolysosomal fusion, blockage of
inflammatory pathways or replication within
immune cells
Interference with TLRs ligands to decrease Blockage of antimicrobial small molecules by

recognition, to dampen inflammation and to secretion of proteases, alteration of cell surface
inhibit downstream inflammation signaling to avoid peptide insertion, usage of pumps to
transport peptides and directly sense small
molecules to trigger defence mechanisms
Blockage of acquired immunity by IgA Modulation of apoptosis/autophagy by direct

proteases and antigen presentation inhibition, activation of death signaling
pathways and alteration of apoptotic
signaling pathways
Production of antigenics: surface structures, pili, Complement system is inhibitied by degrading

outer membrane proteins, LPS (hyper-variable proteases, capsules and long chain LPS
from specie to specie)
Inhibition of cytokines interferon/chemokines by

blocking inflammatory pathways, activation of
alternate pathways and secretion of degrading
proteases
Fig. 2.1 Immunoevasive strategies of bacteria
2.2.6 Polymicrobial Nature of Root Canal Infections
Based on results from traditional culture techniques, root canal infections are pro-
voked by only few pathogens. For example, the predominance of proteolytic black-
pigmented anaerobic organisms in cultures from infected root canals associated
with acute symptoms and the occurrence of monocultures of E. faecalis in persistent
root canal infections have suggested that these organisms are primary agents in such
cases. However, comprehensive analyses of the root canal microbiome by using
high-throughput molecular techniques have revealed that the root canals are a reser-
voir of previously unrecognized but clinically relevant organisms [19].
The polymicrobial nature of root canal infections was also confirmed by a number
of studies using in vivo animal models [20]. In a study with monkeys, different combi-
nations of bacteria were experimentally inoculated in root canals, and periapical lesions
were induced. The teeth were treated endodontically and followed up radiographically
and histologically for 2–2.5 years. In the root canals with bacteria present when the
root filling was removed, 30 of the 31 canals had persisting periapical lesions.
Importantly, more of these non-healed lesions were associated with various combina-
tions of bacterial strains, i.e., mixed infections, than single strains. Additional experi-
ments using an “eight-strain collection” of species, derived from one infected root
canal that were reinoculated in equal proportions into other monkey teeth, revealed a
more potent capacity for tissue destruction than inoculations with pure cultures [20].
2.3 The Biofilm Lifestyle
The biofilm mode of growth is the preferred lifestyle of bacteria in natural and arti-
ficial settings. When bacteria in a liquid phase are in the presence of available sur-
faces, such as dentinal walls in the root canal of teeth, they have the affinity to
adhere and form biofilms. Biofilm communities are structured and heterogeneous,
matrix-encased bacterial communities where bacteria adapt their phenotype into
highly resistant toward stress, host immunological defenses, and antibiotics [21,22].
2.3.1 How Bacteria Build Biofilms
There are several steps bacteria undertake to build a biofilm. First, a free-floating
cell (planktonic) approaches a surface that has been pre-coated with proteins (con-
stituting receptors) and deposits from the environment. The bacterial cell then
establishes a transient association with the surface by means of Brownian motion,
convective transport, and/or expression of structural elements such as fimbriae and
flagella [23,24]. Within short, this cell-surface association becomes stable and starts
the formation of a microcolony, either by co-adhesion with other biofilm cells or by
active reproductive traits. The colony/biofilm formation is further favored by
mechanical forces in areas with narrow compartments and no streaming (flow) sys-
tem such as the apical labyrinth. Of importance during this phase is the expression
of extracellular polymers (EPS) such as polysaccharides, proteins, nucleic acids,
and phospholipids [25], which will build up the backbone of the biofilm, the matrix.
Lastly, the microcolonies mature into a three-dimensional structure encased in the
extracellular matrix. Occasionally, the biofilm-associated bacteria detach from the
biofilm matrix. These steps in biofilm formation are shown in Fig. 2.2.
2.3.2 Biofilms Formed in Root Canals
Microorganisms in root canals have been found to colonize by adhering to dentin

walls in all the extension of the root canals, such as the inner walls of complex apex
anatomies and accessory canals [26,27]. In 2004, Svensater and Bergenholtz pro-
posed a hypothesis for biofilm formation in root canals. Root canal biofilm forma-
tion is initiated directly after the first invasion of the pulp chamber by oral organisms
following pulp tissue inflammatory breakdown. The inflammatory lesion frontage
will then move successively toward the apex providing the fluid vehicle for the
invading organisms so these can multiply and continue attaching to the root canal
walls. This hypothesis has been confirmed by light microscopy observations, where
Another random document with
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capable of producing so much sound. I have never observed this
habit upon a dull or cloudy day.”
Mr Nuttall having presented me with the nest of this species
attached to the twig to which the bird had fastened it, my amiable
friend Miss Martin has figured it for me, as well as the plant, about
which these lovely creatures are represented. The nest, which
measures two inches and a quarter in height, and an inch and three
quarters in breadth, at the upper part, is composed externally of
mosses, lichens, and a few feathers, with slender fibrous roots
interwoven, and lined with fine cottony seed-down.
Trochilus rufus, Gmel. Syst. Nat. vol. i. p. 497.

Trochilus collaris, Lath. Ind. Ornith. vol. i. p. 318.
Trochilus (Selasphorus) Rufus, Swainson.
Cinnamon or Nootka Humming Bird, Richards. and Swains. Fauna Bor.-
Amer. vol. ii. p. 324.
Adult Male. Plate CCCLXXIX. Figs. 1, 2.

Bill long, straight, subulate, somewhat depressed at the base, acute;
upper mandible with the dorsal line straight, the ridge narrow at the
base, broad and convex toward the end, the sides convex, the edges
overlapping, the tip acuminate; lower mandible with the angle very
long and extremely narrow, the dorsal line straight, the edges erect,
the tip acuminate. Nostrils basal, linear.
Head of ordinary size, oblong; neck short; body slender. Feet very
small; tarsus very short, feathered more than half-way down, toes
small; the lateral equal, the middle toe not much longer, the hind toe
a little shorter than the lateral, anterior toes united at the base; claws
rather long, arched, compressed, laterally grooved, very acute.
Plumage soft and blended; feathers on the throat, fore part and sides
of the neck oblong-obovate, with the filaments towards the end
thickened and flattened, with metallic gloss, those on the sides of the
neck elongated and erectile. Wings rather short, extremely narrow,
falcate, pointed; the primaries rapidly graduated, the second being
longest, but only slightly longer than the first; these two quills taper to
a point; the rest are broader, and gradually become less pointed; the
secondaries are extremely short, and only five in number. Tail rather
long, broad, graduated, the lateral feathers four and a half twelfths of
an inch shorter than the central; the latter are extremely broad,
measuring four and a half twelfths across, and the rest gradually
diminish to the lateral, which are very narrow; all obtusely pointed.
Bill brownish-black; toes brown, claws dusky. The general colour of
the upper parts is bright cinnamon or reddish-orange; the head
bronzed green, the wings dusky, the coverts glossed with green, the
primaries with purplish; each of the tail-feathers has a narrow
longitudinal lanceolate median streak toward the end. The loral
space, a narrow band over the eye, another beneath it, and the
auriculars are reddish-orange; the scale-like feathers of the throat
and sides of the neck are splendent fire-red, purplish-red, yellowish-
red, greenish-yellow or yellowish-green, according to the light in
which they are viewed; behind them, on the lower part of the neck, is
a broad band of reddish-white; the rest of the lower parts are like the
upper, the abdomen inclining to white.
1/2
Length to end of tail 3 7/12 inches; bill along the ridge 7 /12, along
the edge of lower mandible 9 1/4/12; wing from flexure 1 7 1/4/12; tail
1 3 1/2/12; tarsus 1 1/2/12; hind toe 1 1/2/12, its claw 1 1/4/12; middle toe
2 1/4/ , its claw 1
1/2
/12.
12
Adult Female. Plate CCCLXXIX. Fig. 3.

The Female has the bill and feet coloured as in the male. The upper
parts are gold-green, the head inclining to brown; the wings as in the
male; the tail-feathers reddish-orange at the base, brownish-black
toward the end, the tip white. The lower parts are white, tinged with
rufous, of which colour, especially, are the sides; the throat marked
with roundish spots of metallic greenish-red.
Length to end of tail 3 7 1/2/12 inches; bill along the ridge 8 3/4/12; wing
from flexure 1 10/12; tail 1 1 1/2/12.
The above descriptions are from two individuals shot by Dr

Townsend on the “Columbia River, 30th May 1835.” A “young male,
Columbia River, 29th May 1835,” resembles the female as above
described, differing only in having the metallic spots on the throat
larger. A “young female, Columbia River, June 10th 1835,” differs
from the adult only in wanting the metallic spots on the throat, which
is spotted with greenish-brown.
Cleome heptaphylla.
The beautiful plant represented in the plate belongs to Tetradynamia

Siliquosa of the Linnæan arrangement, and to the genus Cleome,
characterized by having three nectariferous glandules at each corner
of the calyx, the lower excepted; all the petals ascending; the
germen stipitate; the siliqua unilocular, two-valved. The species, C.
heptaphylla, is distinguished by its septenate leaves, of which the
leaflets are lanceolate, acuminate, and of a deep green colour. It
grows in South Carolina and Georgia.
TENGMALM’S OWL.
Strix Tengmalmi, Gmel.

PLATE CCCLXXX. Male and Female.
I procured a fine male of this species at Bangor, in Maine, on the

Penobscot River, in the beginning of September 1832; but am
unacquainted with its habits, never having seen another individual
alive. Dr Townsend informs me that he found it first on the Malade
River Mountains, where it was so tame and unsuspicious, that Mr
Nuttall was enabled to approach within a few feet of it, as it sat
upon the bushes. Dr Richardson gives the following notice
respecting it in the Fauna Boreali-Americana:—“When it accidentally
wanders abroad in the day, it is so much dazzled by the light of the
sun as to become stupid, and it may then be easily caught by the
hand. Its cry in the night is a single melancholy note, repeated at
intervals of a minute or two. Mr Hutchins informs us that it builds a
nest of grass half-way up a pine tree, and lays two white eggs in the
month of May. It feeds on mice and beetles. I cannot state the extent
of its range, but believe that it inhabits all the woody country from
Great Slave Lake to the United States. On the banks of the
Saskatchewan it is so common that its voice is heard almost every
night by the traveller, wherever he selects his bivouac.”
Strix Tengmalmi, Gmel. Syst. Nat. vol. i. p. 291.—Lath. Ind. Ornith. vol. i. p.
65.
Strix Tengmalmi, Tengmalm’s Owl, Swains. and Richards. Fauna Bor.-
Adult Male. Plate CCCLXXX. Fig. 1.

Bill short, very deep, strong; upper mandible with its dorsal line
curved from the base, its ridge convex, as are the sides, the edges
sharp and incurved anteriorly, the tip very acute, and at its extremity
nearly perpendicular; the cere short, and bare on its upper part; the
lower mandible has the angle broad and short, the dorsal line slightly
convex, the edges inflected, towards the end incurved, with a notch
on each side close to the abruptly-rounded tip. Nostrils broadly
elliptical, oblique, in the fore part of the cere, which bulges
considerably behind them.
The head is extremely large, roundish, when viewed from above
somewhat triangular; the eyes large. The conch of the ear very large,
of an elliptical form, extending from the base of the lower jaw to near
the top of the head, being an inch and a quarter in length, with an
anterior semicircular operculum stretching along its whole length,
and an elevated margin behind. The neck is very short and thin; the
body very slender; but both appear very full on account of the vast
mass of plumage. The feet are rather short, and strong; the tarsi and
toes covered with very soft downy feathers, the extremities of the
latter with two scutella. The claws are slender, tapering to a fine
point, compressed, and curved.
The facial disk is complete, as is the ruff. The plumage is full, very
soft, and blended; the feathers broadly oblong and rounded. The
wings are rather long, very broad, much rounded; the third primary
longest, the fourth almost equal, the second four-twelfths of an inch
shorter, the first equal to the seventh; the barbs of the outer web of
the first, of half the second, and the terminal part of the third, free
and recurved. Tail of moderate length, arched, slightly rounded, of
twelve broad, rounded feathers.
Bill greyish-brown, yellowish-white at the end; claws yellowish-
brown, their tips dusky. The general colour of the upper parts is
greyish-brown tinged with olive. The feathers of the head have an
elliptical central white spot; those of the neck are similarly marked
with larger white spots, of which some are disposed so as to form a
semicircular band; the scapulars have two or four large round spots
near the end, and some of the dorsal feathers and wing-coverts have
single spots on the outer web. All the quills have marginal white
spots on both webs, arranged in transverse series, there being six
on the outer web of the third quill. On the tail are five series of
transversely elongated narrow white spots. The disk is yellowish-
white, anteriorly black; the ruff yellowish-white, mottled with dusky.
The throat is brown, the chin white. The general colour of the lower
parts is yellowish-white, longitudinally streaked with brown, some of
the feathers of the sides have two white spots near the end; the
tarsal and digital feathers greyish-yellow, with faint transverse bars of
brown.
Length to end of tail 11 inches; wing from flexure 6 10/12; bill along
the ridge 1; tarsus 11/12; hind toe 5/12, its claw 5/12; middle toe 9/12, its
claw 8/12.
Adult Female. Plate CCCLXXX. Fig. 2.

The Female resembles the male, but is considerably larger.
SNOW GOOSE.
Anser hyperboreus, Bonap.

PLATE CCCLXXXI. Adult Male and Young Female.
The geographical range of the Snow Goose is very extensive. It has

been observed in numerous flocks, travelling northward, by the
members of the recent overland expeditions. On the other hand, I
have found it in the Texas, and it is very abundant on the Columbia
River, together with Hutchins’s Goose. In the latter part of autumn,
and during winter, I have met with it in every part of the United States
that I have visited.
While residing at Henderson on the Ohio, I never failed to watch the
arrival of this and other species in the ponds of the neighbourhood,
and generally found the young Snow Geese to make their
appearance in the beginning of October, and the adult or white birds
about a fortnight later. In like manner, when migrating northward,
although the young and the adult birds set out at the same time, they
travel in separate flocks, and, according to Captain Sir George
Back, continue to do so even when proceeding to the higher
northern latitudes of our continent. It is not less curious that, during
the whole of the winter, these Geese remain equally divided, even if
found in the same localities; and although young and old are often
seen to repose on the same sand-bar, the flocks keep at as great a
distance as possible.
The Snow Goose in the grey state of its plumage is very abundant in
winter, about the mouths of the Mississippi, as well as on all the
muddy and grassy shores of the bays and inlets of the Gulf of
Mexico, as far as the Texas, and probably still farther to the south-
west. During the rainy season, it betakes itself to the large prairies of
Attacapas and Oppellousas, and there young and adult procure their
food together, along with several species of Ducks, Herons, and
Cranes, feeding, like the latter, on the roots of plants, and nibbling
the grasses sideways, in the manner of the Common Tame Goose.
In Louisiana I have not unfrequently seen the adult birds feeding in
wheat fields, when they pluck up the plants entire.
When the young Snow Geese first arrive in Kentucky, about
Henderson for instance, they are unsuspicious, and therefore easily
procured. In a half-dry half-wet pond, running across a large tract of
land, on the other side of the river, in the State of Indiana, and which
was once my property, I was in the habit of shooting six or seven of
a-day. This, however, rendered the rest so wild, that the cunning of
any “Red Skin” might have been exercised without success upon
them; and I was sorry to find that they had the power of
communicating their sense of danger to the other flocks which
arrived. On varying my operations however, and persevering for
some time, I found that even the wildest of them now and then
suffered; for having taken it into my head to catch them in large
traps, I tried this method, and several were procured before the rest
had learned to seize the tempting bait in a judicious manner.
The Snow Goose affords good eating when young and fat; but the
old Ganders are tough and stringy. Those that are procured along
the sea-shores, as they feed on shell-fish, fry and marine plants,
have a rank taste, which, however suited to the palate of the epicure,
I never could relish.
The flight of this species is strong and steady, and its migrations over
the United States are performed at a considerable elevation, by
regular flappings of the wings, and a disposition into lines similar to
that of other Geese. It walks well, and with rather elevated steps; but
on land its appearance is not so graceful as that of our common
Canada Goose. Whilst with us they are much more silent than any
other of our species, rarely emitting any cries unless when pursued
on being wounded. They swim buoyantly, and, when pressed, with
speed. When attacked by the White-headed Eagle, or any other
rapacious bird, they dive well for a short space. At the least
appearance of danger, when they are on land, they at once come
close together, shake their heads and necks, move off in a contrary
direction, very soon take to wing, and fly to a considerable distance,
but often return after a time.
I am unable to inform you at what age the Snow Goose attains its
pure white plumage, as I have found that a judgment formed from
individuals kept in confinement is not to be depended upon. In one
instance at least, a friend of mine who had kept a bird of this species
four years, wrote to me that he was despairing of ever seeing it
become pure white. Two years after, he sent me much the same
message; but, at the commencement of next spring, the Goose was
a Snow Goose, and the change had taken place in less than a
month.
Dr Richardson informs us that, this species “breeds in the barren
grounds of Arctic America, in great numbers. The eggs of a
yellowish-white colour, and regularly ovate form, are a little larger
than those of the Eider Duck, their length being three inches, and
their greatest breadth two. The young fly in August, and by the
middle of September all have departed to the southward. The Snow
Goose feeds on rushes, insects, and in autumn on berries,
particularly those of the Empetrum nigrum. When well fed it is a very
excellent bird, far superior to the Canada Goose in juiciness and
flavour. It is said that the young do not attain the full plumage before
their fourth year, and until that period they appear to keep in
separate flocks. They are numerous at Albany Fort in the southern
part of Hudson’s Bay, where the old birds are rarely seen; and, on
the other hand, the old birds in their migrations visit York Factory in
great abundance, but are seldom accompanied by the young. The
Snow Geese make their appearance in spring a few days later than
the Canada Geese, and pass in large flocks both through the interior
and on the coast.”
The young birds of this species begin to acquire their whiteness
about the head and neck after the first year, but the upper parts
remain of a dark bluish colour until the bird suddenly becomes white
all over; at least, this is the case with such as are kept in captivity.
Although it is allied to the White-fronted or Laughing Goose, Anser
albifrons, I was surprised to find that Wilson had confounded the
two species together, and been of opinion that the Bean Goose also
was the same bird in an imperfect state of plumage. That excellent
ornithologist tells us that “this species, called on the sea-coast, the
Red Goose, arrives in the river Delaware, from the north, early in
November, sometimes in considerable flocks, and is extremely noisy,
their notes being shriller and more squeaking than those of the
Canada, or common Wild Goose. On their first arrival, they make but
a short stay, proceeding, as the depth of winter approaches, farther
south; but from the middle of February, until the breaking up of the
ice in March, they are frequently numerous along both shores of the
Delaware, about and below Reedy Island, particularly near Old Duck
Creek, in the State of Delaware. They feed on roots of the reeds
there, which they tear up like hogs.”
This species is rare both in Massachusetts and South Carolina,
although it passes over both these States in considerable numbers,
and in the latter some have been known to alight among the
common domestic Geese, and to have remained several days with
them. My friend Dr Bachman, of Charleston, South Carolina, kept a
male Snow Goose several years along with his tame Geese. He had
received it from a friend while it was in its grey plumage, and the
following spring it became white. It had been procured in the autumn,
and proved to be a male. In a few days it became very gentle, and
for several years it mated with a common Goose; but the eggs
produced by the latter never hatched. The Snow Goose was in the
habit of daily frequenting a mill-pond in the vicinity, and returning
regularly at night along with the rest; but in the beginning of each
spring it occasioned much trouble. It then continually raised its head
and wings, and attempted to fly off; but finding this impossible, it
seemed anxious to perform its long journey on foot, and it was
several times overtaken and brought back, after it had proceeded
more than a mile, having crossed fences and plantations in a direct
course northward. This propensity cost it its life: it had proceeded as
far as the banks of the Cooper River, when it was shot by a person
who supposed it to be a wild bird.
In the latter part of the autumn of 1832, whilst I was walking with my
wife, in the neighbourhood of Boston in Massachusetts, I observed
on the road a young Snow Goose in a beautiful state of plumage,
and after making some inquiries, found its owner, who was a
gardener. He would not part with it for any price offered. Some
weeks after, a friend called one morning, and told me that this
gardener had sent his Snow Goose to town, and that it would be sold
by auction that day. I desired my friend to attend the sale, which he
did; and before a few hours had elapsed, the bird was in my
possession, having been obtained for 75 cents! We kept this Goose
several months in a small yard at the house where we boarded,
along with the young of the Sand-hill Crane, Grus Americana. It was
fed on leaves and thin stalks of cabbage, bread, and other vegetable
substances. When the spring approached, it exhibited great
restlessness, seeming anxious to remove northward, as was the
case with Dr Bachman’s bird. Although the gardener had kept it four
years, it was not white, but had the lower part of the neck and the
greater portion of the back, of a dark bluish tint, as represented in
the plate. It died before we left Boston, to the great regret of my
family, as I had anticipated the pleasure of presenting it alive to my
honoured and noble friend the Earl of Derby.
There can be little doubt that this species breeds in its grey plumage,
when it is generally known by the name of Blue-winged Goose, as is
the case with the young of Grus Americana, formerly considered as
a distinct species, and named Grus Canadensis.
Anas hyperborea, Gmel. Syst. Nat. vol. i. p. 504.—Lath. Ind. Orn. vol. ii. p.
837.
Snow Goose, Anas hyperborea, Wils. Amer. Ornith. vol. viii. p. 76, pl. 68,
fig. 3, Male, and p. 89, pl. 69, fig. 5, Young.
Anser hyperboreus, Ch. Bonaparte, Synopsis of Birds of United States, p.
376.
Anser hyperboreus, Snow Goose, Richards. and Swains. Fauna Bor.-
Snow Goose, Nuttall, Manual, vol. ii. p. 344.
Adult Male. Plate CCCLXXXI. Fig. 1.

Bill about the length of the head, much higher than broad at the
base, somewhat conical, compressed, rounded at the tip. Upper
mandible with the dorsal line sloping, the ridge broad and flattened at
the base, narrowed towards the unguis, which is roundish and very
convex, the edges beset with compressed, hard teeth-like lamellæ,
their outline ascending and slightly arched; lower mandible
ascending, nearly straight, the angle long and of moderate length,
the dorsal line beyond it convex, the sides erect, and beset with
lamellæ; similar to those of the upper, but more numerous, the
unguis obovate and very convex. Nasal groove oblong, parallel to
the ridge, filled by the soft membrane of the bill; nostrils medial,
lateral, longitudinal, narrow-elliptical, open, pervious.
Head of moderate size, oblong, compressed. Neck rather long and
slender. Body full, slightly depressed. Feet rather short, strong,
placed about the centre of the body; legs bare a little above the joint;
tarsus rather short, strong, a little compressed, covered all round
with hexagonal, reticulated scales, which are smaller behind; hind
toe very small, with a narrow membrane; third toe longest, fourth
considerably shorter, but longer than the second; all the toes
reticulated above at the base, but with narrow transverse scutella
towards the end; the three anterior connected by a reticulated
membrane, the outer having a thick margin, the inner with the margin
extended into a two-lobed web. Claws small, arched, rather
compressed, obtuse, that of the middle toe bent obliquely outwards,
and depressed, with a curved edge.
Plumage close, full, compact above, blended beneath, as well as on
the head and neck, on the latter of which it is disposed in longitudinal
bands, separated by narrow grooves; the feathers of the lateral parts
small and narrow, of the back ovato-oblong, and abruptly rounded, of
the lower parts curved and oblong. Wings rather long, broad;
primaries strong, incurved, broad, towards the end tapering, the
second longest, but only a quarter of an inch longer than the first,
which scarcely exceeds the third; the first and second sinuate on the
inner web, the second and third on the outer. Secondaries long, very
broad, rounded, the inner curved outwards. Tail very short, rounded,
of sixteen broad rounded feathers.
Bill carmine-red, the unguis of both mandibles white, their edges
black. Iris light brown. Feet dull lake, claws brownish-black. The
general colour of the plumage is pure white; the fore part of the head
tinged with yellowish-red; the primaries brownish-grey, towards the
end blackish-brown, their shafts white unless toward the end.
Length to end of tail 31 3/4 inches, to end of claws 33 1/2, to end of
wings 31 3/4, to carpus 14; extent of wings 62; wing from flexure
19 1/2; tail 6 1/4; bill along the ridge 2 5/8, along the edge of lower
mandible 3 1/4; bare part of tibia 3/4; tarsus 3 5/8; hind toe 1/2, its claw
4 1/2/ ; middle toe 3, its claw 4/12. Weight 6 3/4 lb.
12
Young Female, in first winter. Plate CCCLXXXI. Fig. 2.

The colours of the young bird, in its first plumage, are unknown; but
in its second plumage, in autumn and winter, it presents the
appearance exhibited in the plate. The bill is pale flesh-colour, its
edges black, and the unguis bluish-white; the feet flesh-colour, the
claws dusky. The head and upper part of the neck are white, tinged
above with grey, the lower part of the neck all round, the fore part of
the back, the scapulars, the fore part of the breast, and the sides,
blackish-grey; paler beneath. The hind part of the back and the
upper tail-coverts, are ash-grey; as are the wing-coverts; but the
secondary coverts are greyish-black in the middle; and all the quills
are of that colour, the secondaries margined with greyish-white; the
tail-feathers dusky-grey, broadly margined with greyish-white. The
dark colour of the fore part of the breast gradually fades into greyish-
white, which is the colour of the other inferior parts, excepting the
axillar feathers, and some of the lower wing-coverts, which are white.
Length of an individual in this plumage, kept four years, to end of tail
26 inches, to end of claws 25; extent of wings 55; bill along the ridge
2 1/4, from frontal angle 2 1/2; tarsus 2 7 1/2/12; hind toe 6/12, its claw
4 1/2/12; middle toe 2 1/4, its claw 4/12. Weight 2 lb. 13 oz. The bird
very poor.
In an adult male preserved in spirits, the roof of the mouth is
moderately concave, with five series of strong conical papillæ
directed backwards. The posterior aperture of the nares is linear,
margined with two series of extremely slender papillæ. The marginal
lamellæ of the upper mandible are 25, of the lower about 45. The
tongue is 2 inches 5 twelfths long, nearly cylindrical, with strong
pointed papillæ at the base, and on each side a series of flattened,
sharp lamellæ, directed backwards, together with very numerous
bristle-like filaments. It is fleshy, has a soft prominent pad at the base
above, and towards the end has a median groove, the point rounded
thin, and horny. The œsophagus; which is 17 inches long, has a
diameter of 9 twelfths at the upper part, and at the lower part of the
neck is dilated to 1 inch. The proventricular glands are cylindrical,
simple, and arranged in a belt nearly 1 inch in breadth. The other
parts were removed.
The reddish tint on the head affords no indication of the age of the
bird, some individuals of all ages having that part pure white, while
others have it rusty. The same remark applies to our two Swans.
SHARP-TAILED GROUS.
Tetrao Phasianellus, Linn.

PLATE CCCLXXXII. Male and Female.
This is another species of our birds with the habits of which I am

entirely unacquainted. Dr Richardson’s account of it is as follows:
—“The northern limits of the range of the Sharp-tailed Grous is Great
Slave Lake, in the sixty-first parallel; and its most southern recorded
station is in latitude 41°, on the Missouri. It abounds on the outskirts
of the Saskatchewan plains, and is found throughout the woody
districts of the Fur Countries, haunting open glades or low thickets
on the borders of lakes, particularly in the neighbourhood of the
trading paths, where the forests have been partially cleared. In
winter it perches generally on trees, in summer is much on the
ground; in both seasons assembling in coveys of from ten to sixteen.
Early in spring, a family of these birds select a level spot, whereon
they meet every morning, and run round in a circle of fifteen or
twenty feet in diameter, so that the grass is worn quite bare. When
any one approaches the circle, the birds squat close to the ground,
but in a short time stretch out their necks to survey the intruder; and,
if they are not scared by a nearer advance, soon resume their
circular course, some running to the right, others to the left, meeting
and crossing each other. These “Partridge dances” last for a month
or more, or until the hens begin to hatch. When the Sharp-tailed
Grous are put up, they rise with the usual whirring noise, and alight
again at the distance of a few hundred yards, either on the ground,
or on the upper branches of a tree. Before the cock quits his perch,
he utters repeatedly the cry of cuck, cuck, cuck. In winter they roost
in the snow like the Willow Grous, and they can make their way
through the loose wreaths with ease. They feed on the buds and
sprouts of the Betula glandulosa, of various willows, and of the
aspen and larch; and in autumn on berries. Mr Hutchins says that
the hen lays thirteen white eggs with coloured spots early in June;
the nest being placed on the ground and formed of grass, lined with
feathers.”
Dr Townsend informs me that while crossing the north branch of the
Platte (Lorimie’s Fork), he found this species breeding, and that as
an article of food it proved to be a very well-flavoured and plump
bird, considerably superior to any of the other larger species that
occur in the United States.
Tetrao Phasianellus, Linn. Syst. Nat. vol. i. p. 273.—Lath. Ind. Ornith. vol.
ii. p. 635.—Ch. Bonaparte, Synopsis of Birds of United States, p. 127.
Tetrao Phasianellus, Sharp-tailed Grous, Ch. Bonaparte, Amer. Ornith.
vol. iii. p. 37, pl. 19.
Tetrao (centrocercus) Phasianellus, Swains. Sharp-tailed Grous,
Richards. and Swains. Fauna Bor.-Amer. vol. ii. p. 361.
Sharp-tailed Grous, Nuttall, Manual, vol. i. p. 669.
Adult Male. Plate CCCLXXXII. Fig. 1.

Bill short, strong, as broad as high; upper mandible with the dorsal
line arcuato-declinate, the ridge narrow at the base on account of the
great extent of the nasal sinus, which is feathered, the sides convex
toward the end, the edges overlapping and thin, the tip declinate and
blunt, but thin-edged; lower mandible with the angle of moderate
length and width, the dorsal line ascending and convex, the edges
sharp and inclinate, the tip obtuse.
Head rather small, oblong; neck of moderate length; body full. Feet
rather short, stout; tarsus roundish, feathered, bare and reticulated
behind. Toes of moderate size, with numerous scutella above, but
covered over at the base by the hair-like feathers which grow from
the sides and the intervening basal membranes, laterally pectinate
with long slender projecting flattened scales; first toe small, second a
little longer than fourth, third much longer. Claws slender, arched,
moderately compressed, rather obtuse; that of the third toe with the
inner edge dilated.
Plumage dense, soft, rather compact, the feathers in general broadly
ovate; those on the head and upper part of the neck short, but some
on the upper and hind part of the former elongated and forming a
slight crest. There is a papillate coloured membrane over the eye, as
in the other species; and on each side of the neck is a large bare
space, concealed by the plumage, which I have no doubt is inflated,
as in Tetrao Cupido and T. Urophasianus, during the love season.
Wings rather short, concave, much rounded; the primaries stiff and
very narrow, so as to leave large intervals when the wing is
extended; the third quill longest, the fourth next, the second shorter
than the fifth, the sixth longer than the first. Tail short, much
graduated, of sixteen feathers, of which the lateral are three inches
shorter than the central; all the feathers are more or less concave,
excepting the two middle worn along the inner edge, obliquely and
abruptly terminated, the two middle projecting an inch beyond the
next.
Bill dusky above, brown beneath; iris light hazel; superciliary
membrane vermilion; toes brownish-grey, claws brownish-black. The
upper parts are variegated with light red or brownish-orange,
brownish-black and white; the black occupying the central part of the
feathers, the light red forming angular processes from the margin,
generally dotted with black, and a lighter bar near the end; the white
being in terminal, triangular, or guttiform spots on the scapulars and
wing-coverts. The alula, primary coverts, secondary coverts, and
quills are greyish-brown, the coverts spotted and tipped with white;
the primaries with white spots on the outer web, the inner tipped with
white, as are all the secondaries, of which the outer have two bars of
white spots, and the inner are coloured like the back. The tail is
white, at the base variegated, and the two middle feathers like the
back. Loral space, and a line behind the eye, white; a dusky streak
beneath the eye, succeeded by a light coloured one. The throat is
reddish-white, with some dusky spots; the fore part and sides of the
neck barred with dusky and reddish-white: on the lower part of the
neck and fore part of the breast, the dusky bars become first curved,
and then arrow-shaped, and so continue narrowing on the hind part
of the breast, and part of the sides, of which the upper portion is
barred; the abdomen, lower tail-coverts, axillar feathers, and most of
the lower wing-coverts, white. The hair-like feathers of the tarsi are
light brownish-grey, faintly barred with greyish-white.
Length to end of tail 17 1/2 inches, to end of wings 14, to end of
claws 17; extent of wings 23; wing from flexure 8 1/4, tail 4 1/2; bill
along the ridge 10 1/2/12, along the edge of lower mandible 1 1 1/2/12;
1/2 1/2
tarsus 1 7 /12; hind toe 6/12, its claw 6/12; middle toe 1 7 /12, its
claw 7/12.
Adult Female. Plate CCCLXXXII. Fig. 2.

The Female is considerably smaller, but is coloured like the male,
the tints being duller.
LONG-EARED OWL.
Strix otus, Linn.

PLATE CCCLXXXIII. Male.
This Owl is much more abundant in our Middle and Eastern Atlantic
Districts than in the Southern or Western parts. My friend Dr
Bachman has never observed it in South Carolina; nor have I met
with it in Louisiana, or any where on the Mississippi below the
junction of the Ohio. It is not very rare in the upper parts of Indiana,
Illinois, Ohio, and Kentucky, wherever the country is well wooded. In
the Barrens of Kentucky its predilection for woods is rendered
apparent by its not being found elsewhere than in the “Groves;” and
it would seem that it very rarely extends its search for food beyond
the skirts of those delightful retreats. In Pennsylvania, and elsewhere
to the eastward, I have found it most numerous on or near the banks
of our numerous clear mountain streams, where, during the day, it is
not uncommon to see it perched on the top of a low bush or fir. At
such times it stands with the body erect, but the tarsi bent and
resting on a branch, as is the manner of almost all our Owls. The
head then seems the largest part, the body being much more
slender than it is usually represented. Now and then it raises itself
and stands with its legs and neck extended, as if the better to mark
the approach of an intruder. Its eyes, which were closed when it was
first observed, are opened on the least noise, and it seems to squint
at you in a most grotesque manner, although it is not difficult to

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Many authors display a propensity to reduce complex problems

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lesion, calcified canals, resorption, and others. This applies to immature or

is made, it is possible to offer the patient a wide range of appropriate endodontic

1.2 Multifactorial Nature of Endodontic Outcome

The multifactorial nature of endodontic outcome has been demonstrated in numer-

principles and technical expertise in order to achieve an optimal treatment outcome.

1.3 Preoperative Factors

An accurate assessment of the pulpal and periapical diagnosis is essential for an

1.4 Intraoperative Factors

Practitioners through systematic and thorough preoperative evaluation and a well-­

1.5 Postoperative Factors

Postoperative factors, such as timely placement and quality of coronal restoration of

1.6 Effect of Root Canal Infection on Treatment Outcome

Maximizing successful outcomes for endodontic treatment rests on the elimination

1.7 Outcomes in Endodontic Therapy

emphasizing the absence of clinical symptoms/signs and restoration of normal

L.E. Chávez de Paz, DDS, MS, PhD (*)

© Springer International Publishing Switzerland 2017 13

2.1 The Oral and Root Canal Environments

2.1.1 The Oral Ecosystem

2.1.2 Microbial Colonization of Tooth Surfaces

2.1.3 Oral Health and Disease

2.1.4 The Root Canal Ecosystem

2.2 Root Canal Infections

2.2.1 Pathways of Microbial Entry

2.2.2 Pulp Inflammatory Reaction

2.2.3 Primary Invaders

2.2.4 Progression of the Infection

2.2.5 The Endodontic Pathogen

Inhibition of phagocytosis by multiple-cell Immune cells/phagocytes are directly subverted

Interference with TLRs ligands to decrease Blockage of antimicrobial small molecules by

Blockage of acquired immunity by IgA Modulation of apoptosis/autophagy by direct

Production of antigenics: surface structures, pili, Complement system is inhibitied by degrading

Inhibition of cytokines interferon/chemokines by

Fig. 2.1 Immunoevasive strategies of bacteria

2.2.6 Polymicrobial Nature of Root Canal Infections

2.3 The Biofilm Lifestyle

2.3.1 How Bacteria Build Biofilms

2.3.2 Biofilms Formed in Root Canals

Microorganisms in root canals have been found to colonize by adhering to dentin

Trochilus rufus, Gmel. Syst. Nat. vol. i. p. 497.

Adult Male. Plate CCCLXXIX. Figs. 1, 2.

Adult Female. Plate CCCLXXIX. Fig. 3.

1 Introduction: Endodontic Prognosis and Outcome�� 1

12 Criteria for Outcome Assessment of Nonsurgical

1.2 Multifactorial Nature of Endodontic Outcome

1.3 Preoperative Factors

1.4 Intraoperative Factors

Practitioners through systematic and thorough preoperative evaluation and a well-

1.5 Postoperative Factors

1.6 Effect of Root Canal Infection on Treatment Outcome

1.7 Outcomes in Endodontic Therapy

2.1 The Oral and Root Canal Environments

2.1.1 The Oral Ecosystem

2.1.2 Microbial Colonization of Tooth Surfaces

2.1.3 Oral Health and Disease

2.1.4 The Root Canal Ecosystem

2.2 Root Canal Infections

2.2.1 Pathways of Microbial Entry

2.2.2 Pulp Inflammatory Reaction

2.2.3 Primary Invaders

2.2.4 Progression of the Infection

2.2.5 The Endodontic Pathogen

2.2.6 Polymicrobial Nature of Root Canal Infections

2.3 The Biofilm Lifestyle

2.3.1 How Bacteria Build Biofilms

2.3.2 Biofilms Formed in Root Canals