Essential Endodontology: Prevention and Treatment of Apical Periodontitis

Foreword ix

List of Contributors xi

About the Companion Website xiii

1 Apical Periodontitis: Microbial Infection and Host Responses 1
Dag Orstavik

1.1 Introduction 1

1.2 Terminology 1

1.3 Pulp Infection and Periapical Inflammation 3

1.4 Biological and Clinical Significance of Apical Periodontitis 4

1.5 Concluding Remarks 7

References 8

2 Dentin-Pulp and Periodontal Anatomy and Physiology 11
Leo Tjaderhane and Susanna Paju

2.1 Introduction 11

2.2 Dentin 11

2.3 Pulp Tissue and its Homeostasis 22

2.4 Pulp Inflammation 27

2.5 Pulp Nociception and Hypersensitivity 32

2.6 Age-related Changes in Dentin-pulp Complex 34

2.7 The Periodontium 39

2.8 The Periodontal Ligament (PDL) 39

2.9 Cementum 44

2.10 Alveolar Bone 46

References 49

3 Etiology and Pathogenesis of Pulpitis and Apical Periodontitis 59
Ashraf F. Fouad and Asma A. Khan

3.1 Introduction 59

3.2 Etiology of Pulpitis and Apical Periodontitis 60

3.3 Inflammation Versus Infection of the Pulp and Periapical Tissues 61

3.4 The Dental Pulp 62

3.5 The Periapical Tissues 70

3.6 Concluding Remarks 79

References 80

4 Microbiology of Apical Periodontitis 91
José F. Siqueira Jr and Isabela N. Rôças

4.1 Introduction 91

4.2 Microbial Causation of Apical Periodontitis 91

4.3 Endodontic Biofilms and the Community-as-Pathogen Concept 95

4.4 Mechanisms of Bacterial Pathogenicity 102

4.5 Microbial Ecology and the Root Canal Ecosystem 105

4.6 Types of Endodontic Infections 110

4.7 Identification of Endodontic Bacteria 111

4.8 Endodontic Biofilm Community Profiles 115

4.9 Microbiota in the Apical Root Canal 116

4.10 Symptomatic Infections 117

4.11 Persistent/ Secondary Endodontic Infections 120

4.12 Extraradicular Infections 123

4.13 Other Microorganisms in Endodontic Infections 125

References 127

5 Epidemiology, Treatment Outcome, and Risk Factors for Apical Periodontitis 143
Lise-Lotte Kirkevang and Michael Vaeth

5.1 Introduction 143

5.2 General Aspects of Epidemiology 144

5.3 Elements of an Epidemiologic Study 155

5.4 Evaluation of Epidemiologic Data 157

5.5 Factors and Conditions Associated with Treatment Outcome 160

References 169

6 Radiology of Apical Periodontitis 179
Shanon Patel and Conor Durack

6.1 Introduction 179

6.2 Normal Apical Periodontium 180

6.3 Radiographic Appearance of Apical Periodontitis 190

6.4 Healing Characteristics 194

6.5 Conventional Radiography for Assessment of Apical Periodontitis 195

6.6 Advanced Radiographic Techniques for Endodontic Diagnosis 195

6.7 Differential Diagnosis 197

6.8 CBCT for Assessment of AP 202

6.9 Concluding Remarks 204

References 204

7 Clinical Manifestations and Diagnosis 211
Asgeir Sigurdsson

7.1 Introduction 211

7.2 Pulpal Diagnostic Terms 212

7.3 Symptomatology of Pulpal Disease 213

7.4 Clinical Findings 216

7.5 Diagnostic Testing 217

7.6 Formulation of a Pulpal Diagnosis 223

7.7 Periapical Diagnosis 225

7.8 Symptomatology of Periapical Disease 226

7.9 Formulation of a Periapical Diagnosis 230

7.10 Future of Pulpal and Periapical Diagnosis 231

References 231

8 Biological Basis for Endodontic Repair and Regeneration 237
Kerstin M. Galler

8.1 Principles of Regeneration and Repair 237

8.2 Vital Pulp Therapy 238

8.3 Cell Types Involved in Pulp Healing 239

8.4 The Role of Inflammation 242

8.5 Signaling Molecules in Dentine 243

8.6 Tissue Engineering Approaches to Dental Pulp Regeneration 245

References 248

9 Prevention: Treatment of the Exposed Dentine Pulp Complex 253
Lars Bjorndal

9.1 Diagnostic Challenges of Deep Caries and Traumatic Pulp Exposure 253

9.2 Discerning Pulpal Diagnosis 254

9.3 The Pulp Biology Associated with Pulp Capping 257

9.4 Criteria for Assessing Success of Vital Pulp Therapies 259

9.5 Indirect Pulp Capping and Stepwise Excavation 259

9.6 Pulp Capping of the Uninflamed Pulp (Class I) 261

9.7 Pulp Capping of the Cariously Involved Pulp (Class II) 261

9.8 Partial Pulpotomy 261

9.9 Pulpotomy 262

9.10 Treatment Details for Pulp-preserving Techniques 263

9.11 The Available Evidence for Relative Merit of Treatment Procedures for Vital Pulps 264

9.12 Future Perspectives of More Advanced Biological Approaches 270

References 270

10 Vital Pulp Extirpation 275
John Whitworth

10.1 Introduction 275

10.2 Pulpectomy – Definition and Rationale 275

10.3 The Challenge of Effective Local Anesthesia 277

10.4 Principles of Effective Pulpectomy 278

10.5 Canal Shaping 283

10.6 Canal Irrigation and Medication 294

10.7 Preserving the Aseptic Environment: Root Canal Filling and Coronal Restoration 299

10.8 Concluding Remarks 304

References 304

11 Endodontic Treatment of Apical Periodontitis 313
Dag Orstavik

11.1 Introduction 313

11.2 Anatomic Location of the Microbes 314

11.3 Bacteriological Status During Treatment 316

11.4 Infection Control During Treatment 318

11.5 Root Filling Phase 323

11.6 Clinical Issues During Diagnosis and Treatment of Primary Apical Periodontitis 326

11.7 Treatment of Persistent or Recurrent Apical Periodontitis 327

11.8 Treatment of Immature Permanent Teeth with Apical Periodontitis 328

11.9 Monitoring Healing, Prognostication 329

11.10 Concluding Remarks 330

References 331

12 Surgical Endodontics 345
Frank C. Setzer and Bekir Karabucak

12.1 Introduction, Including History 345

12.2 Surgical Endodontic Procedures 346

12.3 Indications 346

12.4 Contraindications 348

12.5 General Preparations for Surgery 348

12.6 Anesthesia 349

12.7 Surgical Anatomy 351

12.8 Clinical Steps in Root-end Surgery 354

12.9 Perforation Repair 363

12.10 Replantation 363

12.11 Root Amputation, Hemisection 364

12.12 Guided Tissue Regeneration 366

12.13 Retreatment of Failed Surgical Cases 367

12.14 Modes of Healing 368

12.15 Outcome of Surgical Endodontics 368

References 372

Index 387