Endo PDF

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PRACTICE

1
IN BRIEF
● Root canal treatment is normally prescribed to treat an infection, and as with all surgical
procedures an aseptic technique is essential throughout.
● As research has shown that success is only achieved when all microorganisms are removed
from the entire root canal system, the anatomy of this system must be understood for each
tooth.
● Modern endodontic practice is concerned not with the old cliché of cleaning, shaping and
filling, but with shaping first, to open the canals wide, so that cleaning can be effectively
carried out prior to three-dimensional filling.
VERIFIABLE
CPD PAPER
Endodontics: Part 1
The modern concept of root canal treatment
P. Carrotte1 NOW AVAILABLE
AS A BDJ BOOK
Root canal treatment has changed considerably since the hollow tube theory was first postulated in 1930. Research continues
into the elaborate anatomy of root canal systems, and also into the microbial causes of endodontically related diseases. Only by
understanding these aspects in detail can the practitioner quickly and effectively shape the main root canals to facilitate
thorough cleaning of the entire system, and easy and effective filling.
ENDODONTICS
1. The modern concept of In 1965 Kakehashi, Stanley and Fitzgerald1 reduce the level of microbial contamination as
root canal treatment showed conclusively that pulpal and endodontic far as is practical, and to entomb any remaining
problems are primarily related to microbial con- microorganisms with an effective three-dimen-
2. Diagnosis and treatment
tamination of the root canal system. Since that sional seal.
planning
time endodontology has increasingly focussed The prime aim when preparing the root canal
3. Treatment of endodontic
on the ways and means of eliminating micro- has long been stated as cleaning and shaping.
emergencies
organisms from the entire root canal system. One of the prime aims of this text will be to
4. Morphology of the root The majority of patients who require root encourage the practitioner to see this in
canal system canal treatment will have been diagnosed as suf- reverse, ie shaping and cleaning. Modern
5. Basic instruments and fering from the disease of periradicular peri- instruments and techniques will be described
materials for root canal odontitis. The treatment of this disease must which rapidly open and shape the main root
treatment address the microbial contamination of the
6. Rubber dam and access entire root canal system. It must also be carried Fig. 1 The root
cavities out under aseptic conditions in order to prevent canal system of
7. Preparing the root canal further microbial ingress, in particular from saliva. this lower molar
has been stained
8. Filling the root canal The use of a rubber dam very much reflects the and the tooth
system use of a surgical drape in other invasive medical totally decalcified,
9. Calcium hydroxide, root procedures. Such a biological approach will be showing the
emphasized throughout this text. The temptation complex nature of
resorption, endo-perio the root canal
lesions to regard root canal treatment as a purely system. (Courtesy
10. Endodontic treatment for mechanical procedure, producing excellent of Professor R T
children post-operative radiographs but with little regard Walker.)
to diagnosis and prognosis, must be resisted in
11. Surgical endodontics
today’s practice.
12. Endodontic problems
Research into the morphology of the pulp has
shown the wide variety of shapes, and the occur-
1*Clinical Lecturer, Department of Adult rence of two or even three canals in a single
Dental Care, Glasgow Dental Hospital and root.2 There is a high incidence of fins which run
School, 378 Sauchiehall Street, Glasgow longitudinally within the wall of the canal and a
G2 3JZ
*Correspondence to: Peter Carrotte
network of communications between canals
Email: [email protected] lying within the same root (Fig. 1). The many
nooks and crannies within the root canal system
Refereed Paper make it impossible for any known technique,
doi:10.1038/sj.bdj.4811565
© British Dental Journal 2004; 197: either chemical or mechanical, to render it total-
181–183 ly sterile. The objective of treatment must be to
BRITISH DENTAL JOURNAL VOLUME 197 NO. 4 AUGUST 28 2004 181

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PRACTICE
a b
Fig. 2 (a) The pre-operative radiograph of tooth LR6 (46) shows a large the patient finally returned to continue treatment shows evidence of bony
radiolucent area associated with the root apex and the furcation area. Root repair with a return to a normal periodontal ligament space around the
canal treatment was commenced. (b) A radiograph 6 months later when apex and in the furcation.
canals, thus permitting the effective access of of root canals, but the experimental group were
antimicrobial irrigants to the entire root canal not obturated. They ensured that an effective,
system, including lateral canals, fins, anasta- well-sealed, coronal restoration was placed.
moses and other canal aberrations. It is imper- They found that healing occurred in every case.
ative that these instruments are not seen as Figure 2 shows a lower molar with a large peri-
providing a route to quick and speedy root radicular lesion. The root canal system was
canal treatment. To achieve success the time shaped and cleaned, and an intervisit dressing of
saved by the rapid opening of the canal system calcium hydroxide placed. The patient did not
must be spent in thorough and effective return for further treatment for 6 months, when a
antimicrobial irrigation. radiograph revealed that complete healing had
Research has also shown that when an infect- taken place.
ed root canal is accessed, the number of different Of course, this does not mean that obturation is
species of microorganisms is small, rarely above unimportant. It is essential for the reasons
single figures.3 Treatment will become far more described earlier. It does prove, however, the old
difficult and extended, and success may well be cliché that it is what is removed from the canal
compromised, if this flora is altered by the that is important, not what is put in. Similarly,
ingress of saliva. Isolation of the tooth under Ray and Trope6 found that root-treated teeth with
treatment is essential not only for medicolegal a poor obturation on radiograph but a good coro-
reasons to protect the airway, but, far more nal restoration had a better prognosis than teeth
importantly, to prevent further contamination of with a good obturation but a poor restoration.
the root canal system and to permit the use of The majority of root canal sealers are soluble
strong intracanal medicaments. and their only function is to fill the minute
Other areas of research have had the signifi- spaces between the wall of the root canal and the
cant effect of changing the approach to root filling material. Their importance, judged
endodontic treatment. The hollow tube theory by the number of products advertised in the den-
put forward by Rickert and Dixon in 19314 tal press, has been over-emphasized. Despite
postulated that tissue fluids entering the root much research, gutta-percha remains the root
canal stagnated and formed toxic breakdown filling of choice, although it is recognized that a
products which then passed out into the peri- biologically inert, insoluble and injectable paste
apical tissues. This theory, that dead spaces may be better suited for obturation of the root
within the body must be obturated, originally canal. Most of the new root canal filling tech-
formed the basis for filling root canals. How- niques are concerned with methods of heating
ever, a variety of different studies have gutta-percha, making it softer and easier to
demonstrated that, on the contrary, hollow adapt to the irregular shape of the canal wall. It
tubes are tolerated by the body. As a result must be emphasized, however, that, whatever
there are currently two indications for filling a the obturation system used, if the root canal sys-
root canal, once the canal system has been tem has not been adequately cleaned healing
shaped and cleaned. Firstly, to prevent the may not occur (Fig. 3).
entry of microorganisms to the root canal sys- Finally, lesions of endodontic origin which
tem from either the oral cavity, should the appear radiographically as areas of radiolucency
coronal restoration leak or fail, or via the around the apices or lateral aspects of the roots
bloodstream (anachoresis). Secondly, to pre- of teeth are, in the majority of cases, sterile.7,8
vent the ingress of tissue fluid which would The lesions are the result of toxins produced by
provide a culture medium for any bacteria microorganisms lying within the root canal sys-
remaining within the tooth following treatment. tem. This finding suggests that the removal of
A report by Klevant and Eggink5 is particular- microorganisms from the root canal followed by
ly relevant. They shaped and cleaned a number root filling is the first treatment of choice, and
182 BRITISH DENTAL JOURNAL VOLUME 197 NO. 4 AUGUST 28 2004

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PRACTICE
Fig. 3 A radiograph of tooth LL7

(37) showing a root canal
treatment carried out 12 months
previously, with what appears to be
an effective obturation yet no
evidence of healing of the
periradicular lesion.
that periradicular surgery, including an apicec- 1. Kakehashi S, Stanley H R, Fitzgerald R. The effects of
surgical exposures of dental pulps in germfree and
tomy with a retrograde filling, can only be sec- conventional laboratory rats. J South California Dent
ond best.9 Apicectomy with a retrograde filling Assoc 1966; 334: 449–451.
at the apex is carried out in the hope of merely 2. Burns R C, Herbranson E J. Tooth Morphology and
incarcerating microorganisms within the tooth, Cavity Preparation, Chapter 7 in Cohen S and Burns
R C, Pathways of the Pulp, St Louis 2002: Mosby.
but does not take into account the fact that 3. Molven S, Olsen I, Kerekes K. Scanning electron
approximately 50% of teeth have at least one microscopy of bacteria in endodontically treated teeth.
lateral canal. The long-term success rate of III In vivo study. J Endod 1991; 7: 226–229.
apicectomy must inevitably be lower than 4. Rickert U G, Dixon C M. The controlling of root
surgery. In Transactions of the Eighth International
orthograde root treatment. Dental Congress. Section 111a p15. Paris, 1931.
In summary, the principles of treatment of the 5. Klevant F J, Eggink C O. The effect of canal preparation
disease of periapical periodontitis are as follows. on periapical disease. Int Endod J 1983; 16: 68–75.
Shape: Produce a gradual smooth taper in the 6. Ray H A, Trope M. Periapical status of endodontically
treated teeth in relation to the technical quality of the
root canal with its widest part coronally root filling and the coronal restoration. Int Endod J
and the narrowest part at the apical 1995; 28: 12–18.
constriction, which, as discussed in 7. Grossman L I. Bacteriologic status of periapical tissue
Part 4, is normally about 1 mm short of in 150 cases of infected pulpless teeth. J Endod (Special
Issue) 1982; 8: 513–515.
the apex. 8. Siqueira J F, Lopes H P. Bacteria on the apical root
Clean: Use antimicrobial agents to remove surfaces of untreated teeth with periradicular lesions:
microorganisms and pulpal debris from a scanning electron microscopy study. Int Endod J
2001; 34: 216–220.
the entire root canal system.
9. Pitt Ford T R. Surgical treatment of apical
Fill: Obturate the canal system with an inert, periodontitis. Chapter12 in Ørstavik D and Pitt Ford
insoluble filling material. T R, Essential Endodontology. Oxford 1998: Blackwell.
One Hundred Years Ago

British Dental Journal, July 1904
Letter to the Editor
Fluorine in Food
Sir,
No doubt after our Annual General Meeting you will be dealing with fluorine. It is my conviction that fluorine
should be given to children in the natural foodstuffs such as unrefined cereals, sea foods and cod liver oil, etc.
Yesterday I saw an 11-month baby chewing and enjoying raw carrot. A short time ago I saw a girl of 16 brought
up on Hovis toast from the age of 12 months with excellent teeth.
The fluorine should be ingested at weaning time and onwards. Adding fluorine to drinking water may do a lit-
tle good but it is very doubtful if it is of permanent value. I preach the building up of the atomic structure.
C.N. Peacock
Br Dent J 1904

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PRACTICE
2
IN BRIEF
● An accurate diagnosis of the patient’s condition is essential before an appropriate treatment
plan can be formulated for that individual.
● A logical approach to clinical examination should be adopted.
● A high quality long-cone parallel radiograph is mandatory before commencing root canal
treatment, and should be carefully examined to obtain all possible information.
● Root canal treatment may not be the most appropriate therapy, and treatment plans should
take into account not only the expected prognosis but also the patient’s dental condition,
expectations and wishes.
VERIFIABLE
CPD PAPER
Endodontics: Part 2
Diagnosis and treatment planning
AS A BDJ BOOK
As with all dental treatment, a detailed treatment plan can only be drawn up when a correct and accurate diagnosis has been
made. It is essential that a full medical, dental and demographic history be obtained, together with a thorough extra-oral and
intra-oral examination. This part considers the classification of diseases of the dental pulp, together with various diagnostic
aids to help in determining which condition is present, and the appropriate therapy.
ENDODONTICS The importance of correct diagnosis and treat- practitioner should be consulted before any
1. The modern concept of ment planning must not be underestimated. endodontic treatment is commenced. This also
root canal treatment There are many causes of facial pain and the dif- applies if the patient is on medication, such as
2. Diagnosis and treatment ferential diagnosis can be both difficult and corticosteroids or an anticoagulant. An example
planning demanding. All the relevant information must be of the particulars required on a patient’s folder is
3. Treatment of endodontic collected; this includes a case history and the illustrated in Table 1.
emergencies results of both a clinical examination and diag- Antibiotic cover has been recommended for
nostic tests. The practitioner should be fully certain medical conditions, depending upon the
4. Morphology of the root
canal system
conversant with the prognosis for different complexity of the procedure and the degree of
endodontic clinical situations, discussed in bacteraemia expected, but the type of antibiotic
5. Basic instruments and
Part 12. Only at this stage can the cause of the and the dosage are under continual review and
materials for root canal
problem be determined, a diagnosis made, the dental practitioners should be aware of current
treatment
appropriate treatments discussed with the patient opinion. The latest available edition of the Dental
6. Rubber dam and access and informed or valid consent obtained. Practitioners’ Formulary1 should be consulted for
cavities the current recommended antibiotic regime.
7. Preparing the root canal CASE HISTORY However, when treating patients who may be
8. Filling the root canal The purpose of a case history is to discover considered predisposed to endocarditis, it may be
system whether the patient has any general or local con- advisable to liaise with the patient’s cardiac
9. Calcium hydroxide, root dition that might alter the normal course of
resorption, endo-perio treatment. As with all courses of treatment, a Table 1 A simple check list for a medical history
lesions comprehensive demographic, medical and previ- (Scully and Cawson2)
10. Endodontic treatment for ous dental history should be recorded. In addi- Anaemia
children tion, a description of the patient’s symptoms in
Bleeding disorders
11. Surgical endodontics his or her own words and a history of relevant
Cardiorespiratory disorders
12. Endodontic problems dental treatment should be noted.
Drug treatment and allergies
1*Clinical Lecturer, Department of Adult Medical history Endocrine disease
Dental Care, Glasgow Dental Hospital and There are no medical conditions which specifi- Fits and faints
School, 378 Sauchiehall Street, Glasgow Gastrointestinal disorders
G2 3JZ cally contra-indicate endodontic treatment, but
*Correspondence to: Peter Carrotte there are several which require special care. The Hospital admissions and attendances
Email: [email protected] most relevant conditions are allergies, bleeding Infections
Refereed Paper
tendencies, cardiac disease, immune defects or Jaundice or liver disease
doi:10.1038/sj.bdj.4811612 patients taking drugs acting on the endocrine or Kidney disease
© British Dental Journal 2004; 197: CNS system. If there is any doubt about the state Likelihood of pregnancy or pregnancy itself
231–238 of health of a patient, his/her general medical
BRITISH DENTAL JOURNAL VOLUME 197 NO. 5 SEPTEMBER 11 2004 231

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PRACTICE
Fig. 1 A facial sinus It is usually possible to decide, as a result of

associated with a questioning the patient, whether the pain is of
severe periapical
abscess on the upper pulpal, periapical or periodontal origin, or if it is
canine. non-dental in origin. As it is not possible to
diagnose the histological state of the pulp from
the clinical signs and symptoms, the terms acute
and chronic pulpitis are not appropriate. In cases
of pulpitis, the decision the operator must make
is whether the pulpal inflammation is reversible,
in which case it may be treated conservatively,
or irreversible, in which case either the pulp or
the tooth must be removed, depending upon the
patient’s wishes.
If symptoms arise spontaneously, without
stimulus, or continue for more than a few sec-
onds after a stimulus is withdrawn, the pulp may
be deemed to be irreversibly damaged. Applica-
tions of sedative dressings may relieve the pain,
specialist or general medical practitioner. Not all but the pulp will continue to die until root canal
patients with cardiac lesions require antibiotic treatment becomes necessary. This may then
prophylaxis, and such regimes are not generally prove more difficult if either the root canals
supported by the literature.2 However, if it is have become infected or if sclerosis of the root
agreed that the patient is at risk, they would nor- canal system has occurred. The correct diagno-
mally be prescribed the appropriate prophylactic sis, once made, must be adhered to with the
antibiotic regime, and should be advised to appropriate treatment.
report even a minor febrile illness which occurs In early pulpitis the patient often cannot
up to 2 months following root canal treatment. localise the pain to a particular tooth or jaw
Prior to endodontic surgery, it is useful to pre- because the pulp does not contain any proprio-
scribe aqueous chlorhexidine (2%) mouthwash. ceptive nerve endings. As the disease advances
and the periapical region becomes involved, the
Patient’s complaints tooth will become tender and the proprioceptive
Listening carefully to the patient’s description nerve endings in the periodontal ligament are
of his/her symptoms can provide invaluable stimulated.
information. It is quicker and more efficient to
ask patients specific, but not leading, ques- CLINICAL EXAMINATION
tions about their pain. Examples of the type of A clinical examination of the patient is carried
questions which may be asked are given out after the case history has been completed.
below. The temptation to start treatment on a tooth
1. How long have you had the pain? without examining the remaining dentition must
2. Do you know which tooth it is? be resisted. Problems must not be dealt with in
3. What initiates the pain? isolation and any treatment plan should take the
4. How would you describe the pain? entire mouth and the patient’s general medical
Sharp or dull condition and attitude into consideration.
Throbbing
Mild or severe Extra-oral examination
Localised or radiating The patient’s face and neck are examined and
5. How long does the pain last? any swelling, tender areas, lymphadenopathy, or
6. Does it hurt most during the day or night? extra-oral sinuses noted, as shown in Figure 1.
7. Does anything relieve the pain?
Intra-oral examination
An assessment of the patient’s general dental
Fig. 2 An assessment state is made, noting in particular the following
should be made of the
patient’s general
aspects (Fig. 2).
dental condition. • Standard of oral hygiene.
• Amount and quality of restorative work.
• Prevalence of caries.
• Missing and unopposed teeth.
• General periodontal condition.
• Presence of soft or hard swellings.
• Presence of any sinus tracts.
• Discoloured teeth.
• Tooth wear and facets.
Diagnostic tests
Most of the diagnostic tests used to assess the
state of the pulp and periapical tissues are
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PRACTICE
Fig. 3 The anatomical detail

a b obtained from a radiograph taken by
the long-cone paralleling technique
(a) is far clearer and more accurate
than when the bisecting angle
technique (b) is used.
relatively crude and unreliable. No single test, Radiography

however positive the result, is sufficient to make a In all endodontic cases, a good intra-oral paral-
firm diagnosis of reversible or irreversible pulpi- lel radiograph of the root and periapical region
tis. There is a general rule that before drilling into is mandatory. Radiography is the most reliable
a pulp chamber there should be two independent of all the diagnostic tests and provides the most
positive diagnostic tests. An example would be a valuable information. However, it must be
tooth not responding to the electric pulp tester emphasised that a poor quality radiograph not
and tender to percussion. only fails to yield diagnostic information, but
also, and more seriously, causes unnecessary
Palpation radiation of the patient. The use of film holders,
The tissues overlying the apices of any suspect recommended by the National Radiographic
teeth are palpated to locate tender areas. The site Guidelines3 and illustrated in Part 4, has two dis-
and size of any soft or hard swellings are noted tinct advantages. Firstly a true image of the
and examined for fluctuation and crepitus. tooth, its length and anatomical features, is
obtained (Fig. 3), and, secondly, subsequent
Percussion films taken with the same holder can be more
Gentle tapping with a finger both laterally and accurately compared, particularly at subsequent
vertically on a tooth is sufficient to elicit any ten- review when assessing the degree of healing of a
derness. It is not necessary to strike the tooth with periradicular lesion.
a mirror handle, as this invites a false- A radiograph may be the first indication of the
positive reaction from the patient. presence of pathology (Fig. 4). A disadvantage of
the use of radiography in diagnosis, however,
Mobility can be that the early stages of pulpitis are not
The mobility of a tooth is tested by placing a fin- normally evident on the radiograph.
ger on either side of the crown and pushing with If a sinus is present and patent, a small-sized
one finger while assessing any movement with (about #40) gutta-percha point should be
the other. Mobility may be graded as: inserted and threaded, by rolling gently
1 — slight (normal) between the fingers, as far along the sinus tract
2 — moderate as possible. If a radiograph is taken with the
3 — extensive movement in a lateral or gutta-percha point in place, it will lead to an
mesiodistal direction combined with a area of bone loss showing the cause of the
vertical displacement in the alveolus. problem (Fig. 5).
Fig. 4 A radiograph taken as part
of a periodontal assessment also
reveals a previously undiagnosed
and asymptomatic periradicular
lesion on the palatal root of tooth
UL6 (26).

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PRACTICE
between them. Most pulp testers manufactured

Fig. 5 A gutta-percha point has been
a
today are monopolar (Fig. 6).
threaded into a sinus tract adjacent to
a recently root-treated canine (a). The As well as the concerns expressed earlier
radiograph (b) reveals the source of the about pulp testing, electric pulp testers may give
infection to be the first premolar. a false-positive reading due to stimulation of
nerve fibres in the periodontium. Again, posteri-
or teeth may give misleading readings since a
combination of vital and non-vital root canal
pulps may be present. The use of gloves in the
treatment of all dental patients has produced
problems with electric pulp testing. A lip elec-
trode attachment is available which may be
used, but a far simpler method is to ask the
patient to hold on to the metal handle of the pulp
tester. The patient is asked to let go of the handle
if they feel a sensation in the tooth being tested.
The teeth to be tested are dried and isolated
b with cotton wool rolls. A conducting medium
should be used; the one most readily available is
toothpaste. Pulp testers should not be used on
patients with pacemakers because of the possi-
bility of electrical interference.
Teeth with full crowns present problems with
pulp testing. A pulp tester is available with a
special point fitting which may be placed
between the crown and the gingival margin.
There is little to commend the technique of cut-
ting a window in the crown in order to pulp test.
Thermal pulp testing

This involves applying either heat or cold to a
tooth, but neither test is particularly reliable and
may produce either false-positive or false-
negative results.
Heat
Pulp testing There are several different methods of applying
Pulp testing is often referred to as ‘vitality’ test- heat to a tooth. The tip of a gutta-percha stick
ing. In fact, a moribund pulp may still give a may be heated in a flame and applied to a tooth.
positive reaction to one of the following tests Take great note that hot gutta-percha may stick
as the nervous tissue may still function in fast to enamel, and it is essential to coat the
extreme states of disease. It is also, of course, tooth with vaseline to prevent the gutta-percha
possible in a multirooted tooth for one root sticking and causing unnecessary pain to the
canal to be diseased, but another still capable patient. Another method is to ask the patient to
of giving a vital response. Pulp testers should hold warm water in the mouth, which will act on
only be used to assess vital or non-vital pulps; all the teeth in the arch, or to isolate individual
they do not quantify disease, nor do they meas- teeth with rubber dam and apply warm water
ure health and should not be used to judge the directly to the suspected tooth. This is explored
degree of pulpal disease. Pulp testing gives no further under local anaesthesia.
indication of the state of the vascular supply
which would more accurately indicate the Cold
degree of pulp vitality. The only way pulpal Three different methods may be used to apply a
blood-flow may be measured is by using a cold stimulus to a tooth. The most effective is the
Laser-Doppler Flow Meter, not usually avail- use of a –50°C spray, which may be applied using
able in general practice! a cotton pledget (Fig. 7). Alternatively, though
Doubt has been cast on the efficacy of pulp less effectively, an ethyl chloride spray may be
testing the corresponding tooth on the other side used. Finally, ice sticks may be made by filling
of the mid-line for comparison, and it is sug- the plastic covers from a hypodermic needle with
gested that only the suspect teeth are tested. water and placing in the freezing compartment
of a refrigerator. When required for use one cover
Electronic is warmed and removed to provide the ice stick.
The electric pulp tester is an instrument which However, false readings may be obtained if the
uses gradations of electric current to excite a ice melts and flows onto the adjacent tissues.
Fig. 6 A modern electric pulp tester response from the nervous tissue within the pulp.
combined with an endodontic apex Both alternating and direct current pulp testers Local anaesthetic
locator. are available, although there is little difference In cases where the patient cannot locate the pain

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PRACTICE
and routine thermal tests have been negative, a of the perforation, followed by the provision of
reaction may be obtained by asking the patient to new posts and cores, and crowns.
sip hot water from a cup. The patient is instructed However, success in this case may depend
to hold the water first against the mandibular upon the correct planning of treatment. For
teeth on one side and then by tilting the head, to example, what provisional restorations will be
include the maxillary teeth. If a reaction occurs, used during the root canal treatment, and during
an intraligamental injection may be given to the following re-evaluation period. Temporary
anaesthetise the suspect tooth and hot water is post-crowns have been shown to be very poor at
then again applied to the area; if there is no reac- resisting microleakage.4 The provision of a tem-
tion, the pulpitic tooth has been identified. It porary over denture, enabling the total sealing
should be borne in mind that a better term for of the access cavities, would seem an appropri-
intraligamental is intra-osseous, as the local ate alternative, but if this has not been properly
anaesthetic will pass into the medullary spaces planned for, problems may arise and successful
round the tooth and may possibly also affect the treatment may be compromised.
proximal teeth.
INDICATIONS FOR ROOT CANAL TREATMENT
Wooden stick All teeth with pulpal or periapical pathology are Fig. 7 A more effective source of
If a patient complains of pain on chewing and candidates for root canal treatment. There are also cold stimulus for sensibility testing.
there is no evidence of periapical inflammation, situations where elective root canal treatment is
an incomplete fracture of the tooth may be sus- the treatment of choice.
pected. Biting on a wood stick in these cases can
elicit pain, usually on release of biting pressure. Post space
A vital tooth may have insufficient tooth sub-
Fibre-optic light stance to retain a jacket crown so the tooth may
A powerful light can be used for transilluminat- have to be root-treated and restored with a post-
ing teeth to show interproximal caries, fracture, retained crown (Fig. 9).
opacity or discoloration. To carry out the test,
the dental light should be turned off and the Overdenture
fibre-optic light placed against the tooth at the Decoronated teeth retained in the arch to pre-
gingival margin with the beam directed through serve alveolar bone and provide support or
the tooth. If the crown of the tooth is fractured, removable prostheses must be root-treated.
the light will pass through the tooth until it
strikes the stain lying in the fracture line; the Teeth with doubtful pulps
tooth beyond the fracture will appear darker. Root treatment should be considered for any
tooth with doubtful vitality if it requires an exten-
Cutting a test cavity sive restoration, particularly if it is to be a bridge
When other tests have given an indeterminate abutment. Such elective root canal treatment has
result, a test cavity may be cut in a tooth which a good prognosis as the root canals are easy to
is believed to be pulpless. In the author’s opin- access and are not infected. If the indications are
ion, this test can be unreliable as the patient may
give a positive response although the pulp is
necrotic. This is because nerve tissues can con-
tinue to conduct impulses for some time in the
absence of a blood supply.
TREATMENT PLANNING
Having taken the case history and carried out the
relevant diagnostic tests, the patient’s treatment is
then planned. The type of endodontic treatment
chosen must take into account the patient’s med-
ical condition and general dental state. The indi-
cations and contra-indications for root canal
treatment are given below and the problems of re-
root treatment discussed. The treatment of frac-
tured instruments, perforations and perio-endo
lesions are discussed in subsequent chapters.
It should be emphasised here that there is a
considerable difference between a treatment
plan and planning treatment. Figure 8 shows a
radiograph of a patient with a severe endodontic
problem. A diagnosis of failed root canal treat-
ments, periapical periodontitis (both apically
and also associated with a perforation of one
root), and failed post crowns could be made. A Fig. 8 This complicated case exhibits a number of
treatment plan for this patient may be different endodontic problems, and requires careful
orthograde re-root canal treatment, with repair treatment planning if success is to be achieved.

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PRACTICE
Fig. 9 Tooth UL1 (21) requires a sure. In some cases these teeth should be elec-
crown, but there is insufficient tively root-treated.
coronal tissue remaining. One
possible treatment plan would be
elective endodontic treatment Periodontal disease
followed by the provision of a post- In multirooted teeth there may be deep pocket-
retained core build-up and crown. ing associated with one root or the furcation.
The possibility of elective devitalisation follow-
ing the resection of a root should be considered
(see Part 9).
Pulpal sclerosis following trauma

Review periapical radiographs should be taken
of teeth which have been subject to trauma.
If progressive narrowing of the pulp space is
seen due to secondary dentine, elective root
canal treatment may be considered while the
coronal portion of the root canal is still patent.
This may occasionally apply after a pulpotomy
has been carried out. However, Andreasen6
refers to a range of studies that show a maxi-
mum of 16% of sclerosed teeth subsequently
cause problems, and the decision over root
canal treatment must be arrived at after full
ignored and the treatment deferred until the pulp consultation with the patient. If the sclerosing
becomes painful or even necrotic, access through tooth is showing the classic associated discol-
the crown or bridge will be more restricted, and oration the patient may elect for treatment, but
treatment will be significantly more difficult, with otherwise the tooth may better be left alone
a lower prognosis.5 (Fig. 10).
Risk of exposure CONTRA-INDICATIONS TO ROOT CANAL

Preparing teeth for crowning in order to align TREATMENT
them in the dental arch can risk traumatic expo- The medical conditions which require special
precautions prior to root canal treatment have
already been listed. There are, however, other
a conditions both general and local, which may
contra-indicate root canal treatment.
General
Inadequate access
A patient with restricted opening or a small
mouth may not allow sufficient access for root
canal treatment. A rough guide is that it must
be possible to place two fingers between the
mandibular and maxillary incisor teeth so that
there is good visual access to the areas to be
treated. An assessment for posterior endodon-
tic surgery may be made by retracting the
Fig. 10 A 23-year-old female patient cheek with a finger. If the operation site can
b suffered trauma to tooth UL1 (21) when be seen directly with ease, then the access is
aged 16, and is complaining about the
yellow discoloration of the tooth (a). A sufficient.
radiograph (b) reveals that the pulp
space has sclerosed. Poor oral hygiene
As a general rule root canal treatment should
not be carried out unless the patient is able to
maintain his/her mouth in a healthy state, or
can be taught and motivated to do so. Excep-
tions may be patients who are medically or
physically compromised, but any treatment
afforded should always be in the best long-term
interests of the patient.
Patient’s general medical condition

The patient’s physical or mental condition due to,
for example, a chronic debilitating disease or old
age, may preclude endodontic treatment. Similar-
ly, the patient at high risk to infective endocardi-

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PRACTICE
Fig. 11 Tooth UL1 (21) was so extensively decayed Fig. 12 The vertical root fracture can be clearly seen in
subgingivally that restoration would have proved this extracted tooth which had been fitted with a post
impossible even if endodontic treatment had been carried crown.
out.
tis, for example one who has had a previous pathological fracture of the tooth. Internal resorp-
attack, may not be considered suitable for com- tion ceases immediately the pulp is removed and,
plex endodontic therapy. provided the tooth is sufficiently strong, it may be
retained. Most forms of external resorption will
Patient’s attitude continue (see Part 9) unless the defect can be
Unless the patient is sufficiently well motivated, repaired and made supragingival, or arrested with
a simpler form of treatment is advised. calcium hydroxide therapy.
Local Bizarre anatomy

Tooth not restorable Exceptionally curved roots (Fig. 13), dilacer-
It must be possible, following root canal treat- ated teeth, and congenital palatal grooves
ment, to restore the tooth to health and function may all present considerable difficulties if
(Fig. 11). The finishing line of the restoration must root canal treatment is attempted. In addition,
be supracrestal and preferably supragingival. any unusual anatomical features related to the
An assessment of possible restorative problems roots of the teeth should be noted as these
should always be made before root canal treat- may affect prognosis.
ment is prescribed.
Re-root treatment
Insufficient periodontal support One problem which confronts the general
Provided the tooth is functional and the dental practitioner is to decide whether an
attachment apparatus healthy, or can be made inadequate root treatment requires replace-
so, root canal treatment may be carried out. ment (Fig. 14). The questions the operator
should consider are given below.
Non-strategic tooth
Fig. 13 The tooth UR4 (14) has such a
Extraction should be considered rather than bizarre root canal anatomy that
root canal treatment for unopposed and non- endodontic treatment would probably
functional teeth. be impossible.
Root fractures
Incomplete fractures of the root have a poor prog-
nosis if the fracture line communicates with the
oral cavity as it becomes infected. For this reason,
vertical fractures will often require extraction of
the tooth while horizontal root fractures have a
more favourable prognosis (Fig. 12).
Internal or external resorption

Both types of resorption may eventually lead to

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PRACTICE
Fig. 14 Tooth UL4 (24) has previously

been root treated (and obturated with
silver points) but is symptomless.
However, the tooth now requires a full
crown restoration. A decision must be
made as to whether the tooth should
be re-treated before fitting the
advanced restoration.
1 Is there any evidence that the old root filling root canal filling of a tooth with a periradicu-
has failed? lar lesion falls to about 65%.
• Symptoms from the tooth. The final decision by the operator on the treat-
• Radiolucent area is still present or has ment plan for a patient should be governed by the
increased in size. level of his/her own skill and knowledge. General
• Presence of sinus tract. dental practitioners cannot become experts in all
2 Does the crown of the tooth need restoring? fields of dentistry and should learn to be aware of
their own limitations. The treatment plan pro-
3 Is there any obvious fault with the present
posed should be one which the operator is confi-
root filling which could lead to failure?
dent he/she can carry out to a high standard.
Practitioners should be particularly aware
of the prognosis of root canal re-treatments. 1. Dental Practitioners’ Formulary 2000/2002. British
Dental Association. BMA Books, London
As a rule of thumb, taking the average of the 2. Scully C, Cawson R A. Medical problems in dentistry.
surveys reported in the endodontic literature Oxford: Butterworth-Heinemann, p74, 1998.
(see Part 12) suggests a prognosis of 90–95% 3. National Radiographic Protection Board. Guidance
for an initial root canal treatment of a tooth Notes for Dental Practitioners on the safe use of
x-ray equipment. 2001. Department of Health,
with no radiographic evidence of a periradicu- London, UK.
lar lesion. When such a lesion is present prog- 4. Fox K, Gutteridge D L. An in vitro study of coronal
nosis will fall to around 80–85%, and the microleakage in root-canal-treated teeth restored by
the post and core technique. Int Endod J 1997; 30:
longer the lesion has been present the more 361–368.
established will be the infection, treatment (ie 5. Ørstavik D. Time-course and risk analysis of the
removal of that infection from the entire root development and healing of chronic apical
canal system) will be more difficult and the periodontitis in man. Int Endod J 1996; 29: 150–155.
6. Andreasen J O, Andreasen F M. Chapter 9 in Textbook
prognosis significantly lower. The average and colour atlas of traumatic injuries to the teeth. 3rd
reported prognosis for re-treatment of a failed Ed, Denmark, Munksgard 1994.
Fifty years ago today

British Dental Journal, January 1954
Subscriptions 1954
Members are reminded that the Annual Subscription for the Association was due on January 1,
1954. If not already paid this should be sent at the earliest possible moment. The rates of subscrip-
tion for 1954 are as follows:
£ s. d.
Ordinary members 6 6 0
Service members 4 14 6
Retired members 2 12 6
Overseas members 3 13 6
Members within three years from qualifying 3 13 6
Affiliated members 2 12 6

06p299-305.qxd 24/08/2004 11:24 Page 299
PRACTICE
3
IN BRIEF
● Before any dental treatment is provided it is essential that the patient’s symptoms have been
correctly diagnosed.
● Conditions causing dental pain on first presentation may include pulpitis (reversible or
irreversible), periapical periodontitis, dental abscess, as well as cracked tooth syndrome and
other oro-facial pain disorders.
● Conditions arising during treatment may include high restorations, (probably the most
common), root or crown fractures, problems with root canal instrumentation and infection.
● Following treatment pain may be due to any of the above, or failure of the root canal treatment.
However, patients should always be cautioned to expect a certain amount of post-treatment
discomfort.
VERIFIABLE
CPD PAPER
Endodontics: Part 3
Treatment of endodontic emergencies
NOW AVAILABLE
P. Carrotte1 AS A BDJ BOOK
The swift and correct diagnosis of emergency problems is essential when providing treatment, especially in a busy dental
practice. A diagnosis must be made and appropriate treatment provided in usually just a few minutes. The sequence considered
here encompasses problems presenting before, during and after dental treatment. Various diagnostic aids are considered, and
some unusual presenting conditions discussed.
ENDODONTICS
The aim of emergency endodontic treatment is considered together with the medical history.
1. The modern concept of to relieve pain and control any inflammation or The following points are particularly relevant
root canal treatment infection that may be present. Although insuffi- and are covered more fully in Part 2.
2. Diagnosis and treatment cient time may prevent ideal treatment from 1. Where is the pain?
planning being carried out, the procedures followed 2. When was the pain first noticed?
3. Treatment of endodontic should not prejudice any final treatment plan. It 3. Description of the pain.
emergencies has been reported that nearly 90% of patients 4. Under what circumstances does the pain
4. Morphology of the root seeking emergency dental treatment have symp- occur?
canal system toms of pulpal or periapical disease.1,2 5. Does anything relieve it?
5. Basic instruments and Patients who present as endodontic emergen- 6. Any associated tenderness or swelling.
materials for root canal cies can be divided into three main groups. 7. Previous dental history:
treatment Before treatment: a) recent treatment;
6. Rubber dam and access 1. Pulpal pain b) periodontal treatment;
cavities a) Reversible pulpitis c) any history of trauma to the teeth.
7. Preparing the root canal b) Irreversible pulpitis
8. Filling the root canal 2. Acute periapical abscess Particular note should be made of any disor-
system 3. Cracked tooth syndrome ders which may affect the differential diagnosis
of dental pain, such as myofascial pain dysfunc-
9. Calcium hydroxide, root
Patients under treatment: tion syndrome (MPD), neurological disorders
resorption, endo-perio
1. Recent restorative treatment such as trigeminal neuralgia, vascular pain
lesions
2. Periodontal treatment syndromes and maxillary sinus disorders.
10. Endodontic treatment for
children
3. Exposure of the pulp
4. Fracture of the root or crown Diagnostic aids
5. Pain as a result of instrumentation • Periapical radiographs taken with a parallel-
12. Endodontic problems a) acute apical periodontitis ing technique.
b) Phoenix abscess • Electric pulp tester for testing pulpal
1*Clinical Lecturer, Department of Adult responses.
Dental Care, Glasgow Dental Hospital and Post-endodontic treatment: • Ice sticks, hot gutta-percha, cold spray and
School, 378 Sauchiehall Street, Glasgow 1. High restoration hot water for testing thermal responses.3
G2 3JZ
*Correspondence to: Peter Carrotte 2. Overfilling • Periodontal probe.
Email: [email protected] 3. Root filling
4. Root fracture Pulpal pain
Refereed Paper The histological state of the pulp cannot be
doi:10.1038/sj.bdj.4811641
© British Dental Journal 2004; 197: BEFORE TREATMENT assessed clinically.4,5 Nevertheless, the signs and
299–305 Details of the patient’s complaint should be symptoms associated with progressive pulpal

06p299-305.qxd 24/08/2004 11:25 Page 300
PRACTICE
Fig. 1 Initial Only when the inflammation has spread

radiographic throughout the pulp and has involved the peri-
assessment.
Radiographs should be odontal ligament, will the tooth become tender
checked for any to bite on. In these circumstances, the applica-
relevant information tion of heat will cause prolonged pain which
such as deep caries, may be relieved by cold. Both hot and cold can
pinned restorations,
precipitate a severe bout of pain, but as a rule
and the appearance of
the periodontal heat tends to be more significant.
ligament space. Pain from an irreversibly damaged pulp can
be spontaneous and may last from a few seconds
to several hours. A characteristic feature of an
irreversible pulpitis is when a patient is woken at
night by toothache. Even so, if untreated a
symptomatic pulpitis may become symptomless
and pulp tests may give equivocal results. In
time, total pulp necrosis may ensue, without the
development of further symptoms and the first
and periapical disease can give a reasonable indication of an irreversibly damaged pulp may
indication of the likely state of an inflamed pulp, be seen as a periapical rarefaction on a radi-
that is whether it is reversibly or irreversibly ograph, or the patient may present with an acute
damaged.6 periapical abscess.
Irritation of the pulp causes inflammation, To summarize, therefore, in reversible pulpitis:
and the level of response will depend on the • The pain is of very short duration and does
severity of the irritant. If it is mild, the inflam- not linger after the stimulus has been
matory process may resolve in a similar fashion removed.
to that of other connective tissues; a layer of • The tooth is not tender to percussion.
reparative dentine may be formed as protection • The pain may be difficult to localize.
from further injury. However, if the irritation is • The tooth may give an exaggerated response
more severe, with extensive cellular destruction, to vitality tests.
further inflammatory changes involving the rest • The radiographs present with a normal
of the pulp will take place, which could eventu- appearance, and there is no apparent
ally lead to total pulp necrosis. widening of the periodontal ligaments.
There are features of pulpitis which can make
the borderline between reversible and irreversible In irreversible pulpitis:
pulpitis difficult to determine clinically. In gener- • There is often a history of spontaneous bouts
al, if the responses to several tests are exaggerat- of pain which may last from a few seconds
ed, then an irreversible state is possible. up to several hours.
The essential feature of a reversible pulpitis is • When hot or cold fluids are applied, the pain
that pain ceases as soon as the stimulus is elicited will be prolonged. In the later stages,
removed, whether it is caused by hot or cold flu- heat will be more significant; cold may
ids, or sweet food. The teeth are not tender to relieve the pain.
percussion, except when occlusal trauma is a • Pain may radiate initially, but once the peri-
factor. Initially, one of the following treatment odontal ligament has become involved, the
may be all that is necessary: patient will be able to locate the tooth.
• Check the occlusion and remove non- • The tooth becomes tender to percussion once
working facets. inflammation has spread to the periodontal
• Place a sedative dressing in a cavity after ligament.
removal of deep caries. • A widened periodontal ligament may be
• Apply a fluoride varnish or a dentine bond- seen on the radiographs in the later stages.
ing resin to sensitive dentine and prescribe a
desensitizing toothpaste. Careful evaluation of a patient’s dental history
and of each test is important. Any one test on its
Should the symptoms persist and the level of own is an insufficient basis on which to make a
pain increase in duration and intensity, then the diagnosis. Records and radiographs should first
pulpitis is likely to be irreversible. The patient be checked for any relevant information such as
may be unable to decide which tooth is causing deep caries, pinned restorations, and the appear-
the problem, since the pain is often referred to ance of the periodontal ligament space (Fig. 1).
teeth in both the upper and lower jaw on the Vitality tests can be misleading, as various fac-
same side. In the early stages, the tooth may tors have to be taken into account. For example,
exhibit a prolonged reaction to both hot and the response in an older person may differ from
cold fluids, but is not necessarily tender to per- that in someone younger due to secondary den-
cussion. When testing for sensitivity to percus- tine deposition and other atrophic changes in
sion it is not necessary to tap the tooth with the the pulp tissue. Electric pulp testing is simply an
handle of dental instrument. Gentle finger indication of the presence of vital nerve tissue in
pressure will be more than sufficient to elicit a the root canal system only and not an indication
response, and much kinder to your patient. of the state of health of the pulp tissue.

06p299-305.qxd 24/08/2004 11:26 Page 301
PRACTICE
Fig. 2 Radiographic changes range from a widening of the periodontal

ligament space (note that this upper first premolar has two separate buccal
roots)…
Once pulpal inflammation has spread to the Fig. 3 … to a large,

well-defined area
periodontal ligament, the resulting inflammato- of radiolucency.
ry exudate may cause extrusion of the tooth,
making it tender to bite on. This particular
symptom, acute apical periodontitis, may be a addition to standard techniques, supplemen-
consequence of occlusal trauma; the occlusion tary analgesia can be obtained with the fol-
must therefore always be checked. lowing:
Ideally, the treatment for irreversible pulpitis 1 Additional infiltration anaesthesia, such as
is pulp extirpation followed by cleaning and long-buccal, lingual and palatal.
preparation of the root canal system. If time does 2 Intraligamental (intra-osseous) injection.
not permit this, then removal of pulp tissue from 3 True intra-osseous injection.
the pulp chamber and from the coronal part of 4 Intrapulpal analgesia.
the root canal is often effective. Irrigation of the 5 Inhalational sedation with local analgesia.
pulp chamber using a solution of sodium
hypochlorite before carrying out any instrumen- Should these techniques give only moderate
tation is important. (Sodium hypochlorite is usu- success, it is advisable to dress the pulp to allow
ally sold as a 5% solution. This may be diluted the inflammation to subside and to postpone
with purified water BP to the operator’s prefer- pulp extirpation. A corticosteroid/antibiotic
ence.) Sodium hypochlorite solution has proved preparation with a zinc oxide/eugenol tempo-
to be one of the most effective disinfecting rary restoration will provide an effective, short-
agents used in root canal treatment,7,8 with dif- term dressing.
ferent authors recommending strengths between Continuation of pain following pulp extirpa-
0.5 and 5.0%. The pulp chamber and root canals tion may be due to one of the following causes.
are dried, and a dry sterile cotton wool pledget 1 The temporary filling is high.
placed in the pulp chamber with a temporary 2 Infected pulp tissue is present in the canal.
filling to seal the access cavity. Antiseptic 3 Some of the canal contents have been
solutions such as phenolic solutions or corticos- extruded through the apex.
teroid/ antibiotic preparations on cotton wool
4 Overinstrumentation of the apex or perfora-
pledgets have been advocated, but their effec-
tion of the canal wall.
tiveness is of doubtful value. Corticosteroid
dressings should be used sparingly as there is 5 An extra canal may be present which has not
evidence that suppression of an inflammatory been cleaned.
response by steroids allows bacteria to enter the If the problem is not found to be occlusal,
bloodstream with ease.9 This is a particularly whatever the cause the remedy is to irrigate the
undesirable effect in patients who, for example, pulp chamber and root canal system again with
have a history of rheumatic fever. Studies have sodium hypochlorite solution and perhaps gen-
shown that provided the pulp chamber and the tly instrument, then dry and redress the tooth as
root canals have been cleansed and dried, med- before.
ication of the pulp chamber and root canals is of
little practical benefit. Paper points are used to Acute periapical abscess
dry the canals and under no circumstances This condition develops from an acute periapi-
should they be left in the canal, otherwise any cal periodontitis. In the early stages, the differ-
fluid that enters the canal system will be ence between the two is not always clear. Radi-
absorbed and so provide an effective culture ographic changes range from a widening of the
medium for any residual bacteria. periodontal ligament space (Fig. 2), to a well-
Difficulty with local analgesia is a common defined area (Fig. 3). The typical symptoms of
problem with an acutely inflamed pulp. In an acute periapical abscess are a pronounced

06p299-305.qxd 24/08/2004 11:26 Page 302
PRACTICE
Fig. 4 A pronounced
swelling may be
present adjacent to the
abscessed tooth.
Fig. 5 Immediate relief is obtained as pus drains feely from an access cavity.
soft-tissue swelling (Fig. 4) and an exquisitely soft-tissue swelling should be examined to see
tender tooth. Extrusion from the socket will if it is fluctuant. Where the swelling is pointing
often cause the tooth to be mobile. Differential intra-orally, copious amounts of surface anal-
diagnosis of a suspected periapical swelling is gesia should be applied, for example ethyl chlo-
important in case the cause is a lateral peri- ride or topical lignocaine ointment. Regional
odontal abscess. The diagnosis can be made by anaesthesia may not be effective due to the
testing the vitality of the tooth. If it is vital, then presence of pus, and the administration of a
the cause may well be periodontal in origin. local analgesic solution may spread the infec-
The immediate task is to relieve pressure by tion further into the tissues.
establishing drainage, and in the majority of Incise the swelling with a Bard–Parker No. 11
cases this can be achieved by first opening up or 15 scalpel blade, or aspirate, using a wide-
the pulp chamber, as seen in Figure 5. Initially, bore needle and disposable syringe. It may be
gaining access can be difficult because the possible to aspirate the abscess via the root canal
tooth is often extremely tender. Gently grip the as well. The advantage of this technique is that
tooth and use a small, round, diamond bur in a the sample can be sent for bacteriological exam-
turbine to reduce the trauma of the operation. ination if required. It is not usually necessary to
Regional analgesia may be necessary, and insert a drain, but if it is thought necessary then
inhalation sedation can prove invaluable. If a piece of quarter-inch or half-inch selvedge
drainage is not immediate it is permissible to gauze may be used. The same criteria apply
explore the apical foramen with a very fine when extra-oral drainage is indicated, and it
(size 08 or 10) file. The foramen should not be may be possible to use the same technique of
instrumented or enlarged, and if drainage does aspiration with a wide-bore needle and dispos-
not result the procedure should not be perse- able syringe. However, if an extra-oral incision
vered. As discussed in Part 7, the use of ultra- is considered necessary, as in Figure 7, it is wise
sonically activated endodontic files may be to refer the patient to an oral surgeon for this
particularly helpful in this situation for effec- particular procedure.
tively flushing infected debris from the root
canal system. Root canal treatment
If a soft-tissue swelling is present and point- Once access and initial drainage have been
ing intra-orally, then it may be incised to estab- achieved, a rubber dam should be applied to the
lish drainage as well. The presence of a cellulitis tooth to complete the operation. Before any fur-
may result in little or no drainage. If a cellulitis is ther instrumentation is carried out, the pulp
present, medical advice should be sought before chamber should be thoroughly irrigated with a
any treatment is carried out (Fig. 6). solution of sodium hypochlorite to remove as
much superficial organic and inorganic debris
Incision to establish drainage as possible. This in itself may bring considerable
Incision to establish drainage is the only surgi- pain relief and will make subsequent instru-
cal endodontic procedure which may be under- mentation easier. Having debrided the canals to
taken when acute inflammation is present. The the best possible extent with frequent changes
principal indication is the presence of a collec- of irrigant, the canals should be dried with
tion of pus which points from a fluctuant paper points and a dry sterile cotton wool pled-
abscess in the soft tissues. Establishing drainage get placed in the pulp chamber to prevent
to help bring the infection under control is ingress of the temporary dressing. The access
essential, and should always be obtained cavity is then sealed to prevent re-infection of
through the root canal and soft tissues in prefer- the canals from the oral cavity. If complete
ence to administering antibiotics alone. The debridement was not possible the patient must

06p299-305.qxd 24/08/2004 11:28 Page 303
PRACTICE
Fig. 7 External incision

may be required, and
the patient should
preferably be referred
to a general surgeon.
follow before any further symptoms develop.

The patient may present with a whole range of
bizarre symptoms, many of which are similar to
those of irreversible pulpitis:
• Pain on chewing.
Fig. 6 A teenage patient who had a large periapical • Sensitivity to hot and cold fluids.
lesion of a lower incisor is developing a cellulitis.
• Pain which is difficult to localize.
• Pain referred along to the areas served by the
be recalled within 48 hours. At this time it will fifth cranial nerve.
usually be possible to complete instrumentation • Acute pulpal pain.
and place a calcium hydroxide dressing in the • Alveolar abscess.
canals.
The temptation to leave the tooth open to Diagnosis can be difficult and much depends
drain must be resisted at all costs.10 The micro- on the plane of the fracture line and its site on
bial flora of the canal will be changed, making the tooth. Radiographs are unlikely to reveal a
treatment more difficult and lowering the long- fracture unless it runs in a buccolingual plane.
term prognosis. Furthermore, this treatment A fibre-optic light is a useful aid as it will often
contravenes the prime objective of treatment: to reveal the position of the fracture. One diag-
disinfect the root canal. If the clinician does not nostic test is to ask the patient to bite on a piece
have sufficient time to carry out adequate treat- of folded rubber dam. Care must be exercised as
ment when opening the tooth, good clinical this test may extend the fracture line. The
practice would suggest re-appointing the patient extent of the fracture line and its site will
to the end of the treatment session when time is decide whether the tooth can be saved or not. If
available. it is a vertical fracture, involves the root canal
Antibiotics are only required when there is system and extends below the level of the alve-
systemic spread of the infection, the patient is olar crest, then the prognosis is poor and
unwell and has a raised temperature. Antibi- extraction is indicated (Fig. 8). However, if the
otics are not an alternative to appropriate fracture line is horizontal or diagonal and
cleaning and disinfection of the root canal.11 superficial to the alveolar crest, then the prog-
There is a serious tendency to over prescription nosis may be better.
of antibiotics in situations where they are not
indicated. If, however, there is a clinical reason
for their use, amoxycillin is usually the agent of
choice, prescribing 250 mg three times a day
until the infection is under control and root
canal therapy initiated. Metronidazole is a use-
ful alternative where the penicillins are contra-
indicated.
CRACKED TOOTH SYNDROME

(POSTERIOR TEETH)
Crazing of the enamel surface is a common find-
ing on teeth as a consequence of function, but
on occasion it may indicate a cracked tooth. If
the crack runs deep into dentine and is therefore Fig 8 A patient who
complained of classic
a fracture, chewing may be painful. Initially, this ‘cracked-cusp’ pain
may not be of sufficient intensity for the patient was found to have such
to seek treatment. However, once the fracture a deep subgingival cusp
line communicates with the pulp, pulpitis will fracture that the tooth
was extracted.
ensue. A quiescent period of several months may

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PRACTICE
PATIENTS UNDER TREATMENT Root or crown fractures

Following endodontic procedures, patients may Most root or crown fractures can be avoided by
sometimes experience pain no matter how care- adequately protecting the tooth during a course
fully the treatment has been given. It would be of root canal treatment. If the structure of the
prudent to warn every patient to expect a certain tooth is damaged between appointments, pain is
amount of discomfort following endodontic likely to occur as a result of salivary and bacteri-
treatment, advising them that this is caused by al contamination of the root canal. If the tooth
an inflammatory response at the tooth apex. happens to fracture in a vertical plane, the prog-
They should be advised to take over-the-counter nosis is poor and the tooth may have to be
analgesics, preferably NSAIDs. However, if the extracted (Fig. 9). In the case of multirooted
pain persists for more than two or three days, teeth, it may be possible to section the tooth and
further treatment is probably required for one of remove one of the roots.
the following reasons.
Pain as a result of instrumentation
Recent restorations The two conditions that may require emergency
Pain may be a result of: treatment during a course of root canal treat-
• High filling ment are:
• Microleakage • acute apical periodontitis;
• Micro-exposure of the pulp • Phoenix abscess.
• Thermal or mechanical injury during cavity
preparation or an inadequate lining under Acute apical periodontitis may arise as a result
metallic restorations of over instrumentation, extrusion of the canal
• Chemical irritation from lining or filling contents through the apex, leaving the tooth in
materials traumatic occlusion, or placing too much
• Electrical effect of dissimilar metals. medicament in the pulp chamber as an inter-
appointment dressing.
It is not always possible to know beforehand Irrigation of the canal with sodium hypochlorite
whether there is a pre-existing pulpal condition and careful drying with paper points is usually
when operative procedures are undertaken. Con- sufficient to alleviate the symptoms. The occlusion
sequently, a chronic pulpitis may be converted must be checked, as there is likely to be a certain
into an acute pulpitis. amount of extrusion of the tooth from its socket.
The term ‘Phoenix abscess’ relates to the sud-
Periodontal treatment den exacerbation of a previously symptomless
There is always a chance that some of the periradicular lesion. It can be one of the most
numerous lateral canals that communicate with troublesome conditions to deal with and occurs
the periodontal ligament are exposed when peri- after initial instrumentation of a tooth with a
odontal treatment is carried out. This aspect is pre-existing chronic periapical lesion (Fig. 10).
considered in the section in Part 9 on ‘perio- The reasons for this phenomenon are not fully
endo lesions’. understood, but it is thought to be due to an
alteration of the internal environment of the root
Exposure of the pulp canal space during instrumentation which acti-
If a carious exposure is suspected, then removal vates the bacterial flora. Research has shown that
of deep caries should be carried out under rubber the bacteriology of necrotic root canals is more
dam. The decision to extirpate the pulp or carry complex than was previously thought, in partic-
out either a pulp capping or partial pulpotomy ular the role played by anaerobic organisms.
procedure depends on whether the pulp has been Treatment consists of irrigation, debridement
irreversibly damaged or not (see Part 9 — calci- of the root canal and establishing drainage. In
um hydroxide). If there is insufficient time, or
any difficulty is experienced with analgesia,
temporary treatment, as recommended for irre-
versible pulpitis, may be carried out.
Fig. 9 Root or
crown fractures can
often be avoided by
protecting the
tooth during
endodontic
treatment, and
providing cuspal
coverage following
treatment. If the Fig. 10 Phoenix abscess. Endodontic treatment was
tooth fractures in commenced on this tooth with a chronic periradicular
the vertical plane lesion, which had previously been symptomless. The
the prognosis is patient returned 2 days later with extreme pain and
poor. swelling.

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PRACTICE
severe cases, it may be necessary to prescribe an Root fracture

antibiotic. The forces needed to place a satisfactory root
filling, using the lateral compaction of gutta-
POST-ENDODONTIC TREATMENT percha technique, should not be excessive; too
The following factors need to be considered much pressure increases the risk of root frac-
should pain occur following sealing of the root ture. The most common type of fracture is
canal system. usually a vertical one and the prognosis is poor.
• High restoration Extraction, or sectioning of the root in the
• Overfilling case of a multirooted tooth, is all that can be
• Underfilling recommended.
• Root fracture
1. Hasler J F, Mitchell D F. Analysis if 1628 cases of
odontalgia: A corroborative study. J Indianapolis
Once obturation of the root canal space has District Dent Soc 1963; 17: 23–25.
been completed, restoration of the rest of the 2. Drinnan D L. Differential diagnosis of orofacial pain.
tooth can be carried out. The occlusion must be Dent Clin North Am 1987; 31: 627–643.
checked for interferences, to avoid an apical 3. Mosaku A O, Watkins K E E, Grey N J A. The hot water
test: a diagnostic procedure and a case report. CPD
periodontitis, or worse, a fractured tooth. Dentistry 2000; 1: 101–103.
Root fillings that are apparently overfilled do 4. Seltzer S, Bender I B, Zionitz M. The dynamics of pulp
not as a rule cause more than mild discomfort inflammation: Correlation between diagnostic data
after completion. The most likely cause of pain and histologic findings in the pulp. Oral Surg 1963;
16: 846–871, 969–977.
following obturation of the root canal space is 5. Garfunkel A, Sela J, Ulmansky M. Dental pulp
the presence of infected material in the periapical pathosis; clinico-pathological correlations based on
region. The significance of an underfilled root 109 cases. Oral Surg 1973; 35: 110–117.
6. Dummer P H, Hicks R, Huws D. Clinical signs and
canal is whether the canal has been properly symptoms in pulp disease. Int Endod J 1980; 13:
cleaned and prepared in the first instance, and 27–35.
infected debris is still present in the canal. Post- 7. Baumgartner J C, Mader C L. A scanning electron
endodontic pain in these circumstances may well microscopic evaluation of four root canal irrigation
systems. J Endod 1987; 13: 147–157.
be due to inadequate debridement of the canal. 8. Berutti E, Marini R. A scanning electron microscopic
Removal of an overextended root filling is evaluation of the debridement capability of sodium
rarely completely successful and the options left hypochlorite at different temperatures. J Endod 1996;
are as follows: 22: 467–470.
9. Watts A, Patterson R C. The response of the
• Prescription of analgesics and, if the pain is mechanically exposed pulp to prednisolone and
more severe and infection is present, triamcinolone acetonide. Int Endod J 1988; 21: 9–16.
antibiotics. 10. Harrington GW, Natkin E. Midtreatment flare-ups.
Dent Clin North Am 1992; 36: 409–423.
• An attempt at removal of the root filling and 11. Longman L P, Preston A J, Martin M V, Wilson N H.
repreparation of the root canal. Endodontics in the adult patient: the role of antibiotics.
• Periradicular surgery and apicectomy. J Dent 2000; 28: 539–548.

British Dental Journal, August 1904
Excerpt
It seems not improbable that ultimately we may follow the lead of general surgery, and
depend less and less on antiseptics and germicides, which probably destroy the normal
balance of power among the bacteria of the mouth and thus interfere with the natural
struggle for existence among the different species. Return to natural conditions is the
keynote of preventive medicine of modern times, and that also is the trend of dental
hygiene in so far as the bonds of civilisation permit. At any rate, there is little dispute that
the thorough cleaning with the brush is of primary importance, and yet it is most ineffi-
ciently carried out. In fact, with the carelessness of children and the indifference of many
parents, it is impossible to hope for any dental millenium in regard to hygiene until it is
recognised that instruction in schools is the only way to attain it.
From the Presidential Address delivered by Mr W.H. Williamson at the BDA Annual
General Meeting at Aberdeen, August 1904
Br Dent J 1904

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PRACTICE
4
IN BRIEF
● Practitioners must be aware that the main root canals in a tooth may only provide access to
the complexities of the root canal system, which must be fully cleaned of all microorganisms.
● Research has shown that the dental anatomy learned as a dental student may now be out of
date.
● Knowledge of canal anatomy is essential in designing and executing access cavities that give
straight line access to the main root canals.
Endodontics: Part 4
Morphology of the root canal system NOW AVAILABLE
AS A BDJ BOOK
P. Carrotte1
Unless the practitioner is familiar with the morphology of the roots of all teeth, and the associated intricate root canal
anatomy, effective debridement and obturation may be impossible. Recent research has improved knowledge and
understanding of this intricate aspect of dental practice. After studying this part you should know in what percentage of each
tooth type you may expect unusual numbers of root canals and other anatomical variations.
This part may seem at first sight the most boring ROOT CANAL SYSTEM
ENDODONTICS in the book, yet it could be the most important in The pulp chamber in the coronal part of a tooth
1. The modern concept of improving clinical practice. Both undergraduate consists of a single cavity with projections
root canal treatment students and dentists on postgraduate courses (pulp horns) into the cusps of the tooth (Fig. 1).
2. Diagnosis and treatment frequently state that the reason they find root With age, there is a reduction in the size of the
planning canal treatment so difficult, and the reason sur- chamber due to the formation of secondary
3. Treatment of endodontic veys frequently report inadequate treatment dentine, which can be either physiological or
emergencies standards, is because they are working ‘blind’. pathological in origin. Reparative or tertiary
Unless a surgical microscope is available it is dentine may be formed as a response to pulpal
impossible to see down the root canal – to visual- irritation and is irregular and less uniform in
canal system
ize exactly what the instruments are doing. An structure.
understanding of the architecture of the root The entrances (orifices) to the root canals are
canal system is therefore an essential prerequisite to be found on the floor of the pulp chamber,
treatment
for successful root canal treatment (see Part 1, usually below the centre of the cusp tips. In
6. Rubber dam and access Fig. 1). As long ago as 1925, when Hess and cross-section, the canals are ovoid, having their
cavities Zurcher first published their study,1 it became greatest diameter at the orifice or just below it.
7. Preparing the root canal clear that teeth had complicated root canal sys- In longitudinal section, the canals are broader
8. Filling the root canal tems rather than the simplified canals that had bucco-lingually than in the mesiodistal plane.
system been previously described. The canals taper towards the apex, following
9. Calcium hydroxide, root Sadly their work, and many similar publica- the external outline of the root. The narrowest
resorption, endo-perio tions, have largely been overlooked and den- part of the canal is to be found at the ‘apical
lesions tists still remain obsessed with the concept of a constriction’, which then opens out as the api-
10. Endodontic treatment for ‘root canal’, a hollow tube down a root which cal foramen and exits to one side between 0.5
children has to be cleaned and shaped, eventually and 1.0 mm from the anatomical apex. Deposi-
11. Surgical endodontics appearing as a nice white line on the post-oper- tion of secondary cementum may place the api-
12. Endodontic problems ative radiograph. Undergraduate students learn cal foramen as much as 2.0 mm from the
the number of canals in each tooth by rote. anatomical apex. It must be realized, however,
However, many teeth have more than one that the concept of a ‘single’ root canal with a
canal, as described in this part. Where two ‘single’ apical foramen is mistaken. The root
canals exist within the same root, for example canal may end in a delta of small canals, and
the mesial root of a lower molar, lateral com- during root canal treatment cleaning tech-
munication (anastomosis) in the form of fins or niques should be employed to address this
1*Clinical Lecturer, Department of Adult accessory canals, occurs between them. Even clinical situation.
Dental Care, Glasgow Dental Hospital and roots with a single canal will have lateral and
School, 378 Sauchiehall Street, Glasgow accessory canals leaving the main canal. Unless LATERAL AND ACCESSORY CANALS
G2 3JZ this concept of an entire root canal system is As previously discussed, lateral canals form
Email: [email protected] clearly understood, and a method of cleaning channels of communication between the main
and shaping this system employed to address body of the root canal and the periodontal liga-
Refereed Paper these anastomoses as well as the main canals, ment space. They arise anywhere along its
doi:10.1038/sj.bdj.4811711
© British Dental Journal 2004; 197: infection will remain in the root canal system, length, at right angles to the main canal. The
379–383 and the treatment may fail. term ‘accessory’ is usually reserved for the small
BRITISH DENTAL JOURNAL VOLUME 197 NO. 7 OCTOBER 9 2004 379

07p379-383.qxd 07/09/2004 12:32 Page 380
PRACTICE
Fig. 1 The pulp

chamber in the coronal
part of the tooth
consists of a single
cavity with projections
(pulp horns) into the
cusps of the tooth.
Fig. 2 The small canals found in the apical few millimetres and forming the
apical delta are seen here filled with sealer.
canals found in the apical few millimetres and impossible to instrument and can only be
forming the apical delta (Fig. 2). Both lateral cleaned by effective irrigation with a suitable
and accessory canals develop due to a break in antimicrobial solution. Consequently, sealing
‘Hertwig’s epithelial root sheath’ or, during such canals is only moderately successful.
development, the sheath grows around existing The following descriptions of normal canal
blood vessels. Their significance lies in their rel- morphology and access cavities are illustrated in
atively high prevalence, Kasahara et al.2 finding Figure 3 (maxilliary) and Figure 4 (mandibular).
60% of central incisors with accessory canals,
and 45% with apical foramina distant from the MAXILLARY CENTRAL INCISORS
actual tooth apex. Kramer found that the diam- These teeth almost always have one canal. When
eter of some lateral canals was often wider than viewed on radiographs the canal appears to be
the apical constriction.3 Lateral canals are fairly straight and tapering, but labiopalatally
the canal will tend to curve either towards the
labial or palatal aspect at about the apical third
level. One feature to note is the slight narrowing
of the lumen at the cervical level, which immedi-
ately opens up into the main body of the canal.
The inverted-triangular shaped access cavity is
cut with its base at the cingulum to give straight
line access.
MAXILLARY LATERAL INCISOR

Similar in shape to the central incisors, but frac-
tionally shorter, the apical third tends to curve
Fig. 3 The basic pulp distally and the canal is often very fine with thin
canal shape and walls. Labiopalatally, the canal is similar to the
suggested access cavity central incisor, but there is often a narrowing of
openings in the the canal at the apical third level. The root is
maxilliary teeth.
more palatally placed, an important point when
any periradicular surgical procedures are carried
out on this tooth. The access cavity is similar to
the central incisor.
MAXILLARY CANINE
As well as being the longest tooth in the mouth,
its oval canal often seems very spacious during
instrumentation. However, there is usually a
sudden narrowing at the apical 2–3 mm; this
leads to a danger of overinstrumentation if too
large a file is used at this level. The length of this
Fig. 4 The basic pulp tooth can be difficult to determine on radi-
canal shape and ographs, as the apex tends to curve labially and
suggested access the tooth will appear to be shorter than it actual-
cavity openings in the ly is. The oval shape of the root canal is reflected
mandibular teeth.
in the shape of the access cavity.
380 BRITISH DENTAL JOURNAL VOLUME 197 NO. 7 OCTOBER 9 2004

07p379-383.qxd 07/09/2004 12:33 Page 381
PRACTICE
MAXILLARY FIRST PREMOLAR

Typically, this tooth has two roots with two
canals. In many ways this is the most difficult
tooth to treat, as it can have a complex canal
system. Variations range from one to three roots,
(Fig. 5), but there are nearly always at least two
canals present, even if they exit through a com-
mon apical foramen. The roots of these teeth are
very delicate and at the apical third they may
curve quite sharply buccally, palatally, mesially
or distally, so instrumentation needs to be car-
ried out with great care (Fig. 6). In a small per-
centage of cases the buccal root may subdivide
into two canals in the apical third, as shown in
Figure 7. An oval access cavity is cut between
the cusp tips, being wider buccopalatally than
mesiodistally.
Fig. 5 Examples of upper premolars with three roots.
MAXILLARY SECOND PREMOLAR
In 40% of cases, this tooth, which is similar in MAXILLARY SECOND MOLAR
length to the first premolar, has one root with a This tooth is similar to the first maxillary molar,
single canal. Two canals may be found in about but slightly smaller and shorter, with straighter Fig. 6 The roots of upper first
58% of cases.4 The configuration of the two roots and thinner walls. Usually there are only premolars are very delicate and may
canals may vary with two separate canals and three canals and the roots are sometimes fused. curve quite sharply buccally,
palatally, mesially or distally, so
two exits, two canals and one common exit, one The access cavity is the same as for the first instrumentation needs to be carried
canal dividing and having two exits. In one molar, modified further to accommodate the out with great care.
study,5 it was found that 59% of maxillary sec- angle of approach.
ond premolars had accessory canals. As with the
first maxillary premolar, the apical third of the MAXILLARY THIRD MOLAR
root may curve quite considerably, mainly to the The morphology of this tooth can vary consider-
distal, sometimes buccally. The access cavity is ably, ranging from a copy of the first or second
similar to the first premolar. maxillary molar to a canal system that is quite
complex. They are best explored with a wide
MAXILLARY FIRST MOLAR access cavity and direct vision of the individual
This tooth has three roots. The palatal root is canal anatomy.
the longest, with an average length of 22 mm;
the mesiobuccal and distobuccal roots are
slightly shorter, at 21 mm average length. The
percentage of mesiobuccal roots having two
canals reported in the literature has increased
steadily as research techniques have devel-
oped. In vitro studies have usually reported a
higher incidence than in vivo studies. Stropko,
reporting an extensive in vivo study,6 found
second canals in 73% of cases before the use
of an operating microscope, but 93% follow-
ing its use. The canals of the mesiobuccal root
are often very fine and difficult to negotiate;
consequently, more errors in instrumentation
occur in this tooth than in almost any other.
Anastomosis between these two canals may
take the form of narrow canals or wide fins,
both almost impossible to instrument. The
curvature of the roots can be difficult to visu-
alize from radiographs, and the second
mesiobuccal canal is nearly always superim-
posed on the primary mesiobuccal canal. The
palatal root has a tendency to curve towards
the buccal and the apparent length on a radi-
ograph will be shorter than its actual length.
The access cavity represents the shape of the
Fig. 7 Cross-sections
pulp chamber, enlarged slightly, and flared up taken at different
on to the mesiobuccal aspect of the occlusal levels in a maxillary
surface to accommodate the angle of instru- first premolar showing
ment approach when working at the back of the division of the
buccal canal.
the mouth.

07p379-383.qxd 07/09/2004 12:34 Page 382
PRACTICE
Fig. 8 Lower canines may Fig. 9 A lower second

occasionally be found with two premolar with a severe
separate roots. distal curve at the
apex.
Table 1 Average root canal configurations

MANDIBULAR CENTRAL AND LATERAL
Tooth Average Length No. of roots No. of canals INCISORS
Maxillary anteriors The morphology of these two teeth is very simi-
Central incisor 22.5 mm 1 1 lar. The central incisor has an average length of
Lateral incisor 22.0 mm 1 1 20.5 mm and the lateral is a little longer with
Canine 26.5 mm 1 1 an average length of 21 mm. Over 40% of these
Maxillary premolar
teeth have two canals, but only just over 1%
have two separate foramina. Careful reading of
First premolar 20.6 mm 2-3 1 (6.%)
the pre-operative radiograph may show a
2 (95%)
change in the radiodensity of the root canal,
3 (1%) indicating division into two separate canals,
Second premolar 21.5 mm 1-3 1 (75%) and a correctly designed access cavity will
2 (24%) facilitate checking for a second canal. This is
3 (1%) oval in shape, commencing above the cingu-
Maxillary molars lum and almost notching the lingual incisal
First molar 20.8 mm 3 4 (93%) edge.
3 (7%)
Second molar 20.0 mm 3 4 (37%) MANDIBULAR CANINE
3 (63%)
This tooth is similar to its opposite number,
although not as long. On rare occasions, two
Third molar 17.0 mm 1-3
roots may exist and this can cause difficulty
Mandibular anteriors
with instrumentation (Fig. 8). An oval access
Central incisor 20.7 mm 1 1 (58%) cavity is again indicated.
2 (42%)
Lateral incisor 20.7 mm 1-2 1 (58%) MANDIBULAR FIRST PREMOLAR
2 (42%) The canal configuration of this tooth can be
Canine 25.6 mm 1 1 (94%) quite complex. Vertucci7 has shown that the sin-
2(6%) gle canal normally found may divide into two
Mandibular premolars canals and two apical foramina in 25% of cases.
First premolar 21.6 mm 1 1 (73%) It is the way in which the second canal branches
2 (27%)
that can cause difficulty with instrumentation.
Occasionally, the canal terminates with an
Second premolar 22.3 mm 1 1 (85%)
extensive delta, making obturation of the acces-
2 (15%)
sory canals even more challenging. As in the
Mandibular molars upper premolars, the access cavity is oval
First molar 21.0 mm 2-3 3 (67%) between the cusp tips.
4 (33%)
Second molar 19.8 mm 2 2 (13%) MANDIBULAR SECOND PREMOLAR
3 (79%) This tooth is similar to the first premolar, except
4 (8%) that the incidence of a second canal is very
Third molar 18.5 mm 1-2 much lower. One study stated this to be 12%.7
Another study revealed that only 2.5% had two

07p379-383.qxd 07/09/2004 12:36 Page 383
PRACTICE
Fig. 11 The
developmental
anatomy of lower third
molars may be quite
bizarre.
MANDIBULAR THIRD MOLAR

Together with the maxillary third molar, this
tooth displays some of the most irregular
canal configurations to be found in the adult
dentition, as seen in Figure 11. However, the
mesial inclination of the tooth generally
makes access easier. The canal orifices are not
Fig. 10 Lower first molars may occasionally be found too difficult to locate, but the degree of curva-
with two separate distal roots. ture of the apical half of the root canal system
is often pronounced. Added to this, the apex is
apical foramina.8 Consequently, it is a much eas- frequently poorly developed and lies close to
ier tooth to treat compared with the mandibular the inferior alveolar canal. A large access cav-
first premolar, unless the radiograph reveals a ity allowing direct visualization of the floor of
sharp distal curve at the apex as shown in the the pulp chamber enables the canal orifices to
extracted tooth at Figure 9. be identified.
It should always be remembered that whilst
MANDIBULAR FIRST MOLAR the above descriptions are the norm, occasional-
This is often the most heavily restored tooth in ly other teeth may be encountered with unusual
the adult dentition and seems to be a frequent or even bizarre anatomy. This may only be dis-
candidate for root canal treatment. Generally covered after the treatment has failed and the
there are two roots and three canals: two canals tooth has been extracted. Clues may sometimes
in the mesial root and one large oval canal dis- be found by careful examination of the radi-
tally. According to Skidmore and Bjorndal,9 one ographs, especially with the use of magnifica-
third of these molars have four canals. Occa- tion, as described in Part 5.
sionally, three roots are to be found: usually two
distal and one mesial (Fig. 10), rarely one distal 1. Hess W, Zurcher E. The anatomy of the root canals of
and two mesial. Anastomoses occur between the teeth of the permanent dentition and the anatomy
of the root canals of the deciduous dentition and the
the canals and accessory communication with first permanent molars. London: Basle, Sons and
the furcation area is a frequent finding. The Danielson, 1925.
mesiobuccal canal tends to exhibit the greatest 2. Kasahara E,Yasuda E, Yamamoto A, Anzai M. Root
degree of curvature. The access cavity once canal systems of the maxillary central incisor. J Endod
1990; 16: 158–161.
again represents the shape of the pulp chamber, 3. Kramer I R. The vascular architecture of the human
enlarged slightly, and flared up on to the dental pulp. Arch Oral Biol 1960; 2: 177–189.
mesiobuccal aspect of the occlusal surface to 4. Bellizi R, Hartwell G. Radiographic evaluation of root
canal anatomy of in vivo endodontically treated
accommodate the angle of instrument approach maxillary premolars. J Endod 1985; 11: 37–39.
when working at the back of the mouth. 5. Vertucci F J, Seeling A, Gillis R. Root canal
morphology of the human maxillary second premolar.
MANDIBULAR SECOND MOLAR Oral Surg 1974; 38: 456-464.
6. Stropko J J. Canal morphology of maxillary molars:
This tooth is similar to the mandibular first clinical observations of canal configurations. J Endod
molar, although a little more compact. The mesial 1999; 25: 446–450.
canals tend to lie much closer together, and the 7. Zillich R, Dowson J. Root canal morphology of the
mandibular first and second premolars. Oral Surg
incidence of two canals distally is much less. This 1973; 36: 738–744.
tooth seems to be more susceptible to vertical 8. Vertucci F J. Root canal morphology of
fracture. Occasionally, the root canals may join mandibular premolars. J Am Dent Assoc 1978;
97: 47–50.
in a buccal fin giving a ‘C-shaped’ canal, which 9. Skidmore A E, Bjorndal A M. Root canal morphology
may lead all the way to the apex.10 The access of the human mandibular first molar. Oral Surg 1971;
cavity is similar to that of the first molar. 32: 778–784.
10. Melton D C, Krall K V, Fuller M W. Anatomical and
histological features of C-shaped canals in mandibular
second molars. J Endod 1991; 17: 384–388.

08p455-464.qxd 22/09/2004 10:22 Page 455
PRACTICE
5
IN BRIEF
● A basic pack of all the endodontic instruments required must be available suitably sterilised to
ensure rapid efficient treatment.
● Modern radiographic techniques facilitate swift diagnosis and treatment procedures.
● The development of endodontic instruments from reamers to greater taper nickel titanium
files is considered.
● The importance of thorough and efficient irrigation with appropriate antiseptic agents is
discussed, together with the necessary precautions.
Endodontics: Part 5 VERIFIABLE

CPD PAPER
Basic instruments and materials for
root canal treatment NOW AVAILABLE
AS A BDJ BOOK
P. Carrotte1
In this part the basic endodontic instruments necessary for effective root canal treatment are described. The properties of,
and manufacturer’s claims for, new instruments and techniques may be compared to these basic principles before they are
purchased and introduced to clinical practice. Having the correct instruments for different clinical situations may make
treatment both more efficient and more effective.
ENDODONTICS
Many dental practitioners find it difficult to this part are generic, and may be purchased
1. The modern concept of resist new gadgets, and there are an inordinate from most dental supply companies.
root canal treatment number made specifically for endodontics.
2. Diagnosis and treatment New instruments and materials are frequently INSTRUMENT PACK
planning sold with the promise of simplifying a tech- A basic pack of instruments must be available
3. Treatment of endodontic nique, shortening the time taken or even specifically for routine root canal procedures.
emergencies increasing the success rate. Unfortunately, An example is given in Figure 1. A front surface
4. Morphology of the root these promises are often not fulfilled, and the reflecting mouth mirror is preferable to prevent
canal system result may be cupboards in the practice con- the double image of the fine detail in an access
5. Basic instruments and taining unwanted endodontic armamentaria. It cavity that occurs with a conventional mirror.
materials for root canal would be impossible to cover all the instru- Endolocking tweezers allow small items to be
treatment ments and materials used in endodontics in gripped safely and passed between nurse and
6. Rubber dam and access one part, but it is hoped to mention most of the operator. A DG16 endodontic probe is required
cavities basic equipment and discuss some of the newer to detect canal orifices. The excavator is long
7. Preparing the root canal items. For continuity, some instruments will be shanked, with a small blade to allow access into
8. Filling the root canal described in the relevant parts. The majority of the pulp chamber. The pocket-measuring probe
the instruments and materials referred to in is useful, a routine CPITN probe with clearly vis-
system
lesions
children Fig. 1 An endodontic
instrument pack. From
11. Surgical endodontics left to right; front
12. Endodontic problems surface reflecting
mirror; DG16
endodontic probe;
1*Clinical Lecturer, Department of Adult Western probe; CPITN
Dental Care, Glasgow Dental Hospital and probe; endo-locking
School, 378 Sauchiehall Street, Glasgow tweezers; long shank
G2 3JZ excavator; flat plastic,
*Correspondence to: Peter Carrotte artery forceps,
Email: [email protected] endodontic syringe;
plus clean stand, file
Refereed Paper stand, measuring
doi:10.1038/sj.bdj.4811738
device, sterile cotton
© British Dental Journal 2004; 197:
455–464
wool rolls and pledgets.

08p455-464.qxd 22/09/2004 10:24 Page 456
PRACTICE
Fig. 3 A patient wearing safety glasses, a waterproof

protective bib and a rubber dam.
Fig. 2 A selection of file holders.
Fig. 4 The rubber dam RUBBER DAM

equipment; clamps, Rubber dam is essential in root canal treatment
dental floss, forceps, for three reasons:
sheet, punch, frame
and napkin. • To provide an operating field free from oral
contamination.
• To prevent the patient swallowing or inhal-
ing root canal instruments or medicaments.
• To give good visual access by retracting the
lips and tongue.
A basic kit for rubber dam equipment is
shown in Figure 4. Details of this equipment,
and of the techniques for the application of rub-
ber dam, are given in the next part.
ible gradations is ideal. A furcation probe is
useful to check for the presence of furcation RADIOGRAPHIC EQUIPMENT
involvement. Other items usually included are a Long-cone parallel radiography is a requirement
flat plastic, sterile cotton wool rolls, sterile cot- for endodontics,1 because it gives an undistorted
ton wool pledgets, artery forceps to grip a peri- view of the teeth and surrounding structures and
apical radiograph and a metal ruler, or other is repeatable, thus allowing more accurate assess-
measuring device that may be sterilized. A ment of periapical healing. The bisecting angle
clean-stand or other device such as the endo- technique should no longer be employed. It is fur-
ring is required to hold the endodontic instru- ther recommended that rectangular collimation
ments. Paper points are also required, and the
simplest method of storage and use is to pur- a
chase presterilized packs with five points in
each pack.
These instruments should be sterile when
treatment commences, and every possible effort
must be made to avoid contamination. Few
practices will have an autoclave sufficiently
large to take a metal tray with a lid that may
contain an entire set of sterile instruments. If an
open tray system is used, as illustrated in Figure
1, it is useful to have all endodontic instruments
in sterilized containers, such as the clean stand
or endodontic ring shown in Figure 2. This b
allows the instruments to be easily controlled,
and accessed by both the operator and assistant
during treatment.
PATIENT PROTECTION
Glasses are needed to protect the patient’s eyes.
Figure 3 also shows a waterproof bib being
Fig. 5 A film holder for taking worn, as the patient’s clothes must be protected
parallel radiographs, incorporating a against accidental spillage of sodium hypochlo- Fig. 6 a) A manual radiographic processing unit being
cage device to fit over the rubber rite, a frequent source of patient complaint or used and b) containing rapid developing and fixing
dam clamp. chemicals.
even litigation.

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PRACTICE
a b
Fig. 7 An automatic radiographic processor, with a Fig. 8 An illustration of the

simple device to bypass the drying cycle. computer screen produced by digital
radiography, enabling immediate
viewing and manipulation of the
be fitted on all new radiographic equipment, and image The sensor plate or ‘film’ may
retro-fitted to existing equipment as soon as pos- file. These root canal preparation instruments be either loose, resembling a
sible. There are many beam-aiming devices avail- have been manufactured to a size and type conventional periapical radiographic
film, which must be inserted into the
able to hold the x-ray film parallel to the tooth. advised by the International Standards Organi-
machine for processing, or linked by
Figure 5 shows an example of a popular holder, sation (ISO). The specifications recommended cable to the processor as in b).
with a special cage attachment to fit over a rubber are complex and differ according to the type of
dam clamp. instrument. For most standardized instruments
A quick, reliable method of viewing radi- the number refers to its diameter at the tip in
ographic images is essential for endodontics. one-hundredths of a millimetre; a number 10,
Considerable time can be lost if such a system is for example, means that it has a tip diameter of
not available, especially on those occasions when 0.10 mm. Colour coding originally denoted the
the exposed film does not show the required size, but now represents a sequence of sizes. All
detail. Practitioners using conventional radiogra- these instruments have a standard 2% taper over
phy may wish to purchase an x-ray film processor their working length.
with rapid developing and fixing solutions, capa- Recent changes in both metallurgy and
ble of producing a radiograph for viewing in endodontic concepts have led to the introduc-
under a minute; an example is shown in Figure 6. tion of a range of new instruments which do not
However, a modern automatic processor (Fig. 7) conform to these specifications. These are
may be adjusted to deliver wet films in under two described individually later and in Part 7. These
minutes. Films from both types of processor instruments have been widely adopted, and
should be carefully dried after viewing for accu- appear to give consistently better results in root
rate storage in the patient’s records. canal treatment. However, the conventional 2%
A modern alternative involves the use of digi- taper instruments are essential for the initial
tal radiography. A sensor plate, appropriately exploration of most root canals, for difficult
sterilized and sealed, is used in place of the con- procedures such as bypassing separated instru-
ventional film. The sensor may be either directly ments, and for the apical preparation of some
linked to the computer, or resemble a conven- difficult canals.
tional periapical film packet. The resultant Conventional ‘standardized’ instruments are
image is digitally processed and projected upon made of steel, which may wear quickly in den-
the computer screen in a matter of seconds. The tine, and small size files may be regarded as dis-
quality of the image can be manipulated to posable. Although some hand files are now
enable greater clarity when reading the picture. available in a nickel–titanium alloy, which is Fig. 9 A radiographic viewer
For purposes of record keeping, the image may more resistant to wear than ordinary steel, the designed to eliminate extraneous
be either dated, labelled and stored in the central increased cost and inability to pre-curve has not light and magnify the image.
database, or a hard copy printed for the patient’s led to their widespread use. The majority of these
records. An example of such a system, and the modern files are manufactured with a modified
images produced, is shown in Figure 8. non-aggressive tip to prevent iatrogenic damage
The pre-operative radiograph contains much to the canal system, and improve performance of
information to assist the operator, which may the instrument. Figure 10 shows the different
not be seen if the film is carelessly viewed. An x- appearance of the principal types of these
ray viewer and some form of magnification are instruments.
needed to examine periapical films, and it is very
helpful if glare from the light around the radi- K-type file
ograph can be excluded (Fig. 9). These instruments were originally made from a Fig. 10 Conventional hand
square or triangular blank, machine twisted to instruments; top – reamer with red
DEVELOPMENT OF HAND INSTRUMENTS form a tight spiral. The angle of the blades or stop; middle - Hedstroem file with
For many years the standard cutting instruments flutes is consequently near a right-angle to the black stop; bottom - K-flex file with
yellow stop.
have been the reamer, K-type file and Hedstroem shank, so that either a reaming or a filing action

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PRACTICE
Fig. 13 An EDTA paste which will usually be picked up on

each instrument before use.
Fig. 11 A pack of hand files of Fig. 12 A low-speed, high-torque motor required for use
greater taper, 12% taper (blue), with nickel-titanium rotary instruments.
10% (red), 8% (yellow) and 6%
(white).
may be used. The K-type file has been subject to Reamer
continuous development. The K-flex file is made The reamer is constructed from a square or trian-
from a rhomboid or diamond shaped blank. The gular blank, machine twisted into a spiral but
acute angle of this shape provides the instru- with fewer cutting flutes than a file. The reamer
ment with two sharp blades and the narrower will only cut dentine when it is rotated in the
diameter allows greater flexibility in the shaft canal; the mode of action described for its use is
than a conventional K-file. The manufacturers a quarter to a half turn to cut dentine, and with-
claim that more debris is collected between the drawal to remove the debris. The stiffness of an
blades and therefore removed from the canal instrument increases with each larger size, so
than with a standard K-file. The Flex-o-file that larger reamers in curved canals will tend to
employs a more flexible type of steel. It does not cut a wider channel near the apical end of the
fracture easily and is so flexible that it is possible root canal (apical zipping). Considerable damage
to tie a knot in the shank of the smaller sizes. may be caused to a root canal by the incorrect
The latest developments in file design have use of a reamer, and their routine use is no
seen a move away from the ISO standard 2% longer recommended.
taper to files with increasing tapers of up to 12%,
made in a nickel-titanium alloy. Although most Power-assisted instruments
of these new developments are used with an Handpieces providing a mechanical movement
electric motor, hand files of greater taper are to the root canal cutting instrument have been
available. These are illustrated in Figure 11. available since 1964. Their function was prima-
Their use is described in Part 7. rily a reciprocating action through 90° and/or a
Although most K-type files were originally vertical movement, according to the design and
used with an ‘in-out’ circumferential filing tech- make. Because steel files do not have the flexi-
nique, the ‘balanced-force’ technique, described bility necessary for rotary movements in a
in Part 7, is now considered the manipulation curved canal without damaging the canal con-
method of choice. figuration, these instruments were never really
acceptable in endodontic practice.
Hedstroem file A totally new concept in canal preparation
The Hedstroem file is machined from a round came with the development of sonic and ultra-
tapered blank. A spiral groove is cut into the sonically activated endodontic handpieces.
shank, producing a sharp blade. Only a true fil- Much research took place into the mode of action
ing action should be used with this instrument and effectiveness of these machines. It was gen-
because of the angle of the blade. There is a erally agreed that while the sonic machines were
strong possibility of fracture if a reaming action more effective at hard tissue removal, the ultra-
is used and the blades are engaged in the den- sonic machines were more effective in irrigation.
tine. The Hedstroem file is useful for removing The piezo-electric machines were found to be
gutta-percha root fillings. more effective than the magnetostrictive. The
latter also generated more heat, and irrigation
Other hand files with effective quantities of sodium hypochlorite
Different types of hand file have been introduced was found to be difficult.
from time to time with varied structure and cut- The ultrasonic action causes acoustic micro-
ting action. The Unifile and Helifile were modifi- streaming of the irrigant, intensive circular fluid
cations of the Hedstroem design. The Mani Flare movement carried right to the tip of the instru-
file is made from a triangular blank, and features ment, found to be very effective at canal
a greater taper than conventional 2% files. It is debridement. This effect is reduced, however,
essential when considering the use of new file when the file is constrained by the canal wall.
designs that the operator understands the basic The main use of these instruments today is in
principles of canal preparation, and compares irrigation and debridement, using a freely oscil-
and contrasts the properties with the file manipulating file in a sodium hypochlorite filled canal,
lation technique currently being used. after thorough mechanical canal shaping.2

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PRACTICE
However, the development of nickel-titanium canal treatment. The practitioner must have
alloy for endodontic instruments has allowed appropriate risk assessment procedures in place
the concept of an engine driven endodontic when such materials are incorporated into their
instrument to be fully explored. The total flexi- clinical practice.
bility of this alloy, and the use of radial lands on Chlorhexidine solution 0.2% has a similar
the cutting flutes to keep the instrument centred antibacterial action, but will not dissolve the
in the canal, permit controlled cutting of the organic debris found in parts of the canal system
dentine walls. Most major manufacturers have inaccessible to hand instrumentation, such as
developed a nickel-titanium rotary system. lateral canals, fins and apical deltas. However,
Lightspeed, Profiles, GT Rotary files, FlexMaster, the substantivity associated with this irrigant
Quantec system, Hero, K3, Protaper, and no means that it will adhere to dentine, thereby
doubt more will appear before this book is even exhibiting a prolonged antibacterial activity.
published. It would not be possible to describe Although chlorhexidine may not be quite as Fig. 14 Some of the burs specifically
each of these fully, but the basic concepts are effective as sodium hypochlorite, its use should manufactured for endodontic
presented here, with a general description of not be dismissed. treatment; a safe-tipped access bur;
a long-shanked round bur; a swan-
their use being given in Part 7. Researchers are constantly seeking improved
necked bur; a Gates-Glidden bur.
The systems will generally conform to one of methods of cleaning root canals; reports have
three patterns. appeared recently relating to the use of electro-
• The system may have a standard ISO tip size activated water as an irrigant,4 and the use of
sequence, with the instruments being manu- high frequency electric current.5 These and oth-
factured with an increased taper, usually ers may prove interesting developments in root
either 4% or 6%. canal preparation and irrigation.
• The system may be presented with a single EDTA paste (Ethylenediamine tetra-acetic
tip size, but with the sequence of file sizes acid) is a chelating agent which softens the den-
having an increased taper of up to 12%. In tine of the canal walls and greatly facilitates
order to accommodate this taper in a narrow canal preparation (Fig 13). EDTA solution may
root canal, the diameter of the instrument is be used as an irrigant at the end of the canal
usually limited to 1 mm, giving quite a short preparation phase to assist removal of the smear
functional blade in the greater tapers. layer prior to placement of an intervisit dressing,
• Both of these new developments may be or obturation.
combined into one system.
Burs
A low-speed, controlled-torque motor is nec- Several types of bur may be required for root
essary when using these instruments, as illus- canal treatment. Some of these are described
trated in Figure 12. below, and shown in Figure 14.
Irrigation and lubrication materials Cutting an access cavity

It is generally accepted in endodontic practice It is generally accepted that high speed burs
that sodium hypochlorite is the most suitable should be used to gain access and shape the cav-
solution for irrigation of the root canal system. ity. A diamond or tungsten carbide tapered fis-
Normal household bleach is approximately 5.5% sure bur is used for initial penetration of the roof
sodium hypochlorite solution, and this may be of the pulp chamber. A tapered safe-ended dia-
diluted with purified water up to five times to the mond or tungsten carbide bur is then used to
operator’s preference. Research has shown that remove the roof of the pulp chamber without
the antibacterial effect is the same for a 0.5% damaging the floor.
and a 5.0% solution.3 However, the greater the
dilution the less effective is the solution at dis- Location of canal
solving organic debris in the root canal system. Burs should only be used as a last resort to locate
Great vigilance is essential when using sodi- a sclerosed canal because of the danger of perfo-
um hypochlorite, and practitioners must be ration. Small round burs are used; the standard
aware of the risks and dangers involved in its length is usually too short but longer shank burs
use. Irrigation under pressure may force the are available. Specially designed ultrasonic tips
solution through the apical foramen into the may also be used to remove secondary dentine,
periradicular tissues, which may result in a assist in the identification of canal orifices and
rapid, painful and serious inflammatory in shaping the canal orifice during preparation.
response. The patient will be extremely dis- The use of ultrasonic tips has become more
tressed, and little can be done to relieve the situ- widespread with the introduction of a wider
ation which may take several days to resolve. range of fittings to different piezo-electronic
Cases have also been reported where excess machines. Figure 15 shows the diamond coated
pressure on the syringe has resulted in the nee- CPR® tips, designed for troughing and chasing
dle coming loose and hypochlorite spraying sclerosed canals, and the BUC® tips, with vari-
over the patient, operator and assistant. Protec- able grades of diamond grit for refining access
tive goggles are essential for the patient and all cavity walls and line angles, removing obstruc-
staff. Clothing should also be protected. The tions and cutting around posts. As with all
defence societies have received claims from irate instruments and materials, the manufacturer’s
patients for damaged clothing following root instructions and guidance should be carefully

08p455-464.qxd 22/09/2004 10:28 Page 460
PRACTICE
Fig. 15 (a) CPR® ultrasonic tips, now

available to fit different piezo- a b
electronic machines. (b) Also shown
are KiS tips for periradicular surgery.
followed or these delicate diamond tips may be ria, viruses, fungi and prions may contaminate
damaged. It is generally wise to use them with a instruments and research has shown that some
low power setting, and to ensure that they are in of these may not be destroyed by any method of
contact with dentine before activating the piezo- sterilization.7 Figure 18 illustrates this dramati-
electric unit. cally. Concern has been raised over the steriliza-
tion of other items of dental equipment as well.8
Canal preparation Under the Medical Devices Directive, the man-
The use of rotary cutting instruments in a stan- ufacturer of any dental instrument has an obli-
dard handpiece is condemned because of the gation to inform the end-user (ie the dentist)
danger of fracture of the instrument or perfora- how their product should be decontaminated. It
tion of the root canal. The exception to this rule is essential that this guidance is followed. What-
is the Gates–Glidden bur, which has a safe- ever may be written in this and other texts may
ended tip. In addition, the site of fracture, if it be superseded at any time. Dentists should
does occur, is almost always near the hub so the therefore ensure that they are familiar with and
fractured piece is easily removed. In the past this conform to the manufacturer’s instructions. At
bur has been recommended for initial flaring of present, some endodontic instruments are
the coronal portion of the canal. This may now marked with the symbol shown in Figure 19
be carried out in a more controlled manner with indicating that they are single use instruments.
a nickel-titanium orifice shaper. The Gates– It is assumed that all manufacturers will shortly
Glidden bur may also be used to make post space follow this Medical Devices Directive.
and to remove gutta-percha from the canal. It may, however, be necessary to sterilize
Gates–Glidden burs are manufactured in six instruments for further treatment of the same
sizes; their use is described in Part 7. patient on a subsequent occasion when cross-
infection control would not be a problem. After
Measurement of working length use, instruments must be cleaned as soon as pos-
Fig. 16 An electronic apex locator.
There are two established methods of assessing sible to remove debris which harbours and pro-
the working length of a root canal: one by radi- tects microorganisms. Cleaning is carried out by
ography and the other with the use of an elec- scrubbing in warm water and detergent, although
tronic device apex locator (Fig. 16). Both meth- the debris may be first removed from most root
Fig. 17 A device for ods will be described in Part 7. canal instruments by stabbing them into a
setting instruments Once the working length has been confirmed, sponge. The best method of cleaning is to place
at the correct
the individual preparation instruments must be the instruments into an ultrasonic bath. The cavi-
working length
accurately marked to length accordingly. There tational effects of ultrasonics will dislodge debris
are many different gadgets available for transfer from places which are inaccessible to normal
of the working length; the author prefers the cleaning. When the instruments are clean they
device shown in Figure 17. There are also differ- must be sterilized in an autoclave. Microorgan-
ent stops for the instrument, the most popular isms are destroyed at lower temperatures and in a
being rubber or silicone stops. These should shorter period in moist heat as all biological reac-
always be placed at right angles to the shank of tions are catalysed in water. The disadvantages of
the instrument. Ideally the stops should be either autoclaving are that metal instruments tend to
notched, or pear shaped, so that in curved canals corrode and sharp instruments are dulled.
the notch or point of the pear may be directed
towards the curve placed in the instrument. Barbed broach
This instrument has sharp rasps pointing
Sterilization towards the handle. They may be used to
Any instrument which is placed in the root canal remove the contents of the root canal before
should be sterile, for two reasons. Firstly, to commencing shaping procedures. A vital pulp
prevent the introduction to the root canal sys- may be extirpated when carrying out elective
tem of extraneous microorganisms, which may endodontic procedures, or when treating a tooth
severely compromise treatment, for example with an irreversible pulpitis, by introducing the
pseudomonas.6 Secondly, if instruments and barbed broach deep in the canal, twisting it a
devices were to be used on different patients, to quarter to a half turn, and withdrawing, as
prevent cross-infection between patients. Bacte- shown in Figure 20.

08p455-464.qxd 22/09/2004 10:29 Page 461
PRACTICE
a b c
Fig. 18 Illustrations from the work on decontamination of endodontic instruments by Dr Andrew Smith, Glasgow: a) photomicrograph (x16) of an unused
endodontic file; b) photomicrograph (x16) of a used instrument after sterilization; c) SEM (x500) of the file shown in illustration b.
Spiral root canal fillers is zinc oxide (up to 75%), with the remainder
Spiral root canal fillers are seldom used in mod- comprising various resins, waxes and metallic
ern endodontics. Their main use is for the inser- sulphates to the specific manufacturer’s formula.
tion of calcium hydroxide into the root canal.
When a spiral filler is required, the blade type is Sealers/cements
preferred by the author, as this is the least likely Root canal sealers play an important role in the
to fracture. It is essential to ensure that the size obturation of the prepared root canal system, as
selected fits loosely and passively to the required described in Part 8. Although many proprietary
depth before the instrument is rotated in the root products are available (Fig. 23), they may gener-
canal (Fig. 21). ally be divided into three groups, according to
their main constituents: eugenol, non-eugenol
Fig. 19 The symbol indicating
ROOT CANAL FILLING MATERIALS and medicated. instruments intended for single use
Gutta-percha only.
Gutta-percha is the most commonly used mate- Eugenol
rial for the obturation of the prepared root canal The eugenol-containing group may be divided
system. Standardized gutta-percha points corre- into sealers based on the Rickert’s formula
spond to the ISO sizing system with a 2% taper. (1931) and those based on Grossman’s (1958)
Various other shapes are now available to com- (Table 1). The essential difference between the
plement the recently introduced increased taper two groups is that Rickert’s contains precipitat-
filing systems (Fig 22). Gutta-percha is the dried ed silver and Grossman’s has a barium or bis-
resin of the Taban tree, and exists in two forms. muth salt as the radiopacifier. The disadvantage
Alpha phase is the natural form, but when heat- of Rickert’s sealer is that the silver will stain
ed and cooled the beta-phase results. This latter dentine a dark grey. One of the most widely
is normally used for root canal filling points. used sealers in this group is Tubliseal, a two- Fig. 20 During root canal treatment
Gutta-percha points in fact contain only paste system and, consequently, simple to mix; of a tooth diagnosed as having an
about 20% gutta-percha. The major component it does not contain silver. Tubliseal EWT irreversible pulpitis, the vital pulp has
(extended working time) is preferred. been extirpated on a barbed broach.
Non-eugenol sealers
Some sealers are manufactured with a calcium
hydroxide base instead of zinc oxide/eugenol,
Fig. 22 Some of the different gutta-percha points:

Fig. 21 Spiral fillers may fracture if the size is not standarized; greater taper; 04 and 06 taper; feather
verified passively before rotating in the canal. tipped.

08p455-464.qxd 22/09/2004 10:30 Page 462
PRACTICE
Fig. 23 A selection of
Table 1 Grossman’s sealer
root canal sealers.
Powder
Zinc Oxide 42.0%
Staybelite resin 27.0%
Bismuth subcarbonate 15.0%
Barium sulfate 15.0%
Sodium borate (anhydrous) 1.0%
Liquid
Eugenol 100%
for example Sealapex. This is promoted as having Mineral trioxide aggregate

a therapeutic effect, although there has been lit- Mineral trioxide aggregate (Fig. 25) is a com-
tle reported on this in the endodontic literature. pound consisting of mineral oxides, (tricalcium
It has been shown, however, that the calcium silicate, tricalcium oxide, silicate oxide and
hydroxide is prone to leakage,9 which may result traces of other mineral oxides), developed first
in unwanted voids in the seal. by Mahmoud Torabinejad and co-workers at
Other sealers are manufactured that contain a Loma Linda University.10 Although originally
wide variety of chemicals. AH+ is an epoxy resin developed as a root-end filling material during
base with a bisphenoldiglycidyl ether liquid. It periradicular surgery, researchers across the
has a long working time and seals well to den- world have reported positive results when the
tine. The original AH26 initially caused a severe material is used for the repair of perforations, as
inflammatory response, which subsided after a pulp capping agent, and to induce apical clo-
some weeks, but AH+ is far more biocompatible. sure of immature roots. The superb sealing abili-
Diaket is a polyketone and is presented as a fine ty, marginal adaptation and biological compati-
powder and thick viscous liquid. The setting bility of the material appear to make this
time is 8 minutes on the mixing pad and some- material the sealant of choice for any communi-
what quicker in the root canal. A glass ionomer cation between the root canal system and the
cement, Ketac-Endo, is available, which has a external surface of the tooth. The material is
relatively low toxicity. continually being refined, and the latest product
A more recent addition to this group is has some oxides removed to produce a white,
Roekoseal, a silicone polymer. Although initial rather than grey, powder. MTA is a difficult
experience of this material is favourable, there material to manipulate, having the consistency
Fig. 24 A medicolegal case where a has been little published on several of these of wet sand. Methods of placement are described
formaldehyde containing root canal recent materials, and the prudent clinician may in Part 11.
sealer has been extruded into the
inferior dental canal, causing
wish to await the results of extended clinical
paraesthesia of the lip. trials before adopting these into their practice. Root canal filling instruments
Spreaders
Medicated Cold lateral compaction using gutta-percha
The current thinking is that provided the prin- requires either long-handled or finger spreaders
ciples of root canal preparation and filling are (Fig. 26). These have a long, tapered shank with
observed, there is no justification for the use of a sharp point. The instrument is used to compact
therapeutic sealers. The active ingredient in the gutta-percha laterally against the walls of the
majority of medicated sealers is paraformalde- root canal and provide a space for the insertion
hyde, which is usually accompanied by a corti- of further gutta-percha points. There are several
costeroid. Figure 24 shows a medicolegal case sizes available, and these are selected according
where excess medicated sealer entered the infe- to the canal size and the size of the gutta-percha
rior dental canal, causing permanent nerve point. The choice of long-handled spreaders or
damage with paraesthesia of the lip and soft finger spreaders depends on personal preference.
tissues. The advantage of finger spreaders is that less
force can be used, and this reduces the risk of
root fracture.
Heat carriers
The application of heat to the gutta-percha fill-
ing permits improved lateral and vertical
compaction of the softened material. Ordinary
hand and finger spreaders are not designed for
this purpose, but the instruments illustrated in
Figure 27 may be used. They are of various
sizes, and have both a pointed tip for lateral
Fig. 25 Mineral Trioxide Aggregate spreading, and a flat tip for vertical compaction.
is commercially available as Pro- The instrument shown in Figure 28 is a Sys-
Root.
tem B, for the controlled and precise application

08p455-464.qxd 22/09/2004 10:32 Page 463
PRACTICE
of heat to the gutta-percha filling. Figure 29 Fig. 26 Cold lateral

shows an Obtura machine, used to deliver heated compaction may be
carried out with either
gutta-percha directly to the root canal. The use finger spreaders or
of these and other similar machines is described long-handled
in Part 8. spreaders.
Magnification
When asked why endodontics is a difficult
subject, undergraduate and postgraduate stu-
dents alike frequently reply that it is because
they cannot see what they are doing. There is
no doubt that magnification of the pulp cham-
ber greatly assists in finding and accessing
narrow canal orifices, and many practitioners
Fig. 27 Machtou heat
now routinely use loupes, as seen in Figure 30. carrier/pluggers for
This one purchase has made huge improve- warm lateral and
ments in the quality and ease of endodontic vertical compaction.
treatment for many practitioners. Indeed,
the improved vision gained from the use of
loupes improves all aspects of general dental
practice, not just endodontics. The patient in
the illustration is merely undergoing a routine
examination.
However, specialist practitioners, and some
generalists, are moving to the use of surgical
microscopes, as seen in Figure 31 where it is
being used by a relatively new member of staff
in training, who was seeking, and found, a
sclerosed canal in an upper incisor.
Fig. 28 The System B heat source for controlled warm Fig. 29 The Obtura 11 system for injecting heat-
gutta-percha techniques. softened gutta-percha into the root canal.
Fig. 30 The use of Fig. 31 A surgical

magnifying loupes is microscope may be
increasing in essential for some of
restorative dentistry. today’s intricate
endodontic procedures.

08p455-464.qxd 22/09/2004 10:32 Page 464
PRACTICE
1. National Radiographic Protection Board. Guidance in-vitro study. J Dent Res 1999; 78: 117.
Notes for Dental Practitioners on the safe use of x-ray 6. Ranta K, Haapasalo M, Ranta H. Monoinfection of root
equipment. 2001 Department of Health, London, UK. canals with Pseudomonas aeruginosa. Endod Dent
2. Cameron J A. The synergistic relationship between Traumatol 1988; 4: 269–272.
ultrasound and sodium hypochlorite: a scanning 7. Smith A J, Dickson M, Aitken J, Bagg J. Contaminated
electron microscope evaluation. J Endod 1987; dental instruments. Journal of Hospital Infection 2002
13: 541–545. (in press).
3. Byström A, Sundqvist G. Bacteriological evaluation of 8. Lowe A H, Bagg J, Burke F J T, MacKenzie D, McHugh
the effect of 0.5% sodium hypochlorite in endodontic S. A study of blood contamination of Siqveland
therapy. Oral Surgery, Oral Medicine, Oral Pathology matrix bands. BDJ 2002; 192: 43–45.
1983; 55: 307–312. 9. Tronstad L, Barnett F, Flax M. Solubility and
4. Solovyeva A M, Dummer P M. Cleaning effectiveness biocompatibility of calcium hydroxide-containing
of root canal irrigation with electrochemically root canal sealers. Endod Dent Traumatol 1988;
activated anolyte and catholyte solutions: a pilot 4: 152–159.
study. Int Endod J 2000: 33: 494–504. 10. Torabinejad M, Hong C U, McDonald F, Pitt Ford T R.
5. Haffner C, Benz C, Folwaczny A, Mech A, Hickel R. Physical and chemical properties of a new root-end
High frequency current in endodontic therapy; an filling material. J Endod 1995; 21:349–353.
Fifty years ago today

British Dental Journal, 21 September 1954
Letter to the Editor
Sir,
Is there a connexion between the sucking of peppermints, and the extremely rapid type of
caries sometimes seen in adult patients? I am convinced that there is, having observed it for
some years in regular patients, hitherto fairly free from caries, and entirely free from cervical
caries, who, wishing to give up smoking, have taken to eating peppermint sweets — especially
one particular brand. The resultant cervical caries, even in a few months, can be alarming. Just
as quickly, by stopping the use of peppermint, the mouth seems to resume its original caries
immunity, although the consumption of other forms of confectionery is not limited. If these
observations of mine are correct, peppermint would seem to be an unfortunate choice of
flavouring for a toothpaste!
R. Dunstan
Br Dent J 1954

09p527-534.qxd 27/10/2004 09:23 Page 527
PRACTICE
6
IN BRIEF
● Rubber dam is essential for effective isolation of the root canal and operating field from salivary
bacteria, as well as protection of the airway.
● Only a very small number of rubber dam clamps are required for the efficient application of
rubber dam, which must be supported by a well-trained dental nurse.
● Success in modern endodontic treatment may be dependent upon a well-designed access
cavity to permit straight-line access to all the main root canals.
VERIFIABLE
Endodontics: Part 6 CPD PAPER
Rubber dam and access cavities

P. Carrotte1
NOW AVAILABLE
AS A BDJ BOOK
Rubber dam is easy to apply once the basic components and principles are understood. An efficient and well-trained dental
nurse will greatly facilitate the application procedure. Although preparation of the access cavity may be commenced before
rubber dam is applied to enable anatomical landmarks to be followed, the rubber dam should be placed as soon as possible
with adequate protection against contamination of the access. The access cavity reflects the shape of the pulp chamber,
modified by the angle of instrument approach.
ENDODONTICS RUBBER DAM inhaled, a medicolegal allegation of negligence

1. The modern concept of The use of a rubber dam is almost mandatory in may be impossible to defend, even if the patient
root canal treatment modern endodontic practice for three reasons. had appeared to accept the risk. A practitioner
2. Diagnosis and treatment Firstly, it provides an aseptic operating field, should never do anything to a patient which he
planning isolating the tooth from oral and salivary con- or she knows to be wrong, and a patient may not
3. Treatment of endodontic tamination. It cannot be stressed enough that sign away their rights in law.
emergencies contamination of the root canal with saliva With a little practice, an understanding of the
4. Morphology of the root introduces new microorganisms to the root basic principles, a well organised surgery and a
canal system canal which may prolong treatment and reduce well-trained dental nurse, a single tooth can be
prognosis. isolated in only a few seconds.
Secondly, rubber dam facilitates the use of the
treatment strong medicaments necessary to clean the root
canal system.
6. Rubber dam and access
Finally, it protects the patient from the inhala-
cavities
tion or ingestion of endodontic instruments, as
7. Preparing the root canal shown in Figure 1.
8. Filling the root canal Practitioners may also be advised to develop
system their rubber dam skills for another reason.
9. Calcium hydroxide, root Research has shown1 that rubber dam used dur-
resorption, endo-perio ing routine conservation procedures reduces
lesions aerosol contamination and cross-infection by up
10. Endodontic treatment for to 98.5%.
children Research has also shown that patients do not
11. Surgical endodontics dislike the use of rubber dam,2 and the author
12. Endodontic problems has never had a single patient request its
removal once the reasons for its use have been
1*Clinical Lecturer, Department of Adult explained. It may be particularly helpful to
Dental Care, Glasgow Dental Hospital and explain to the patient that the rubber dam is nec-
School, 378 Sauchiehall Street, Glasgow essary to isolate the operating area in exactly the
G2 3JZ same way as a surgical drape is essential for sim-
Email: [email protected] ilar invasive medical procedures, where bacterial
contamination may have a profound effect on
Refereed Paper the outcome. Indeed, refusal to accept a rubber
doi:10.1038/sj.bdj.4811799 Fig. 1 An endodontic instrument has been inhaled due to
© British Dental Journal 2004; 197: dam may preclude the prescription of endodon-
tic therapy. If an endodontic instrument is a lack of airway protection.
527–534
BRITISH DENTAL JOURNAL VOLUME 197 NO. 9 NOVEMBER 13 2004 527

09p527-534.qxd 27/10/2004 09:25 Page 528
PRACTICE
Fig. 2 A modern single Fig. 3 For multiple

table rubber dam punch. isolation, the position of
the holes to be punched
may be marked by
holding the rubber dam
against the teeth.
Rubber dam sheets defect in the cut may cause the dam to split
Most manufacturers supply rubber dam in three when stretched out. The new rubber dam punch-
thicknesses or grades, for different applications. es are single table (Fig. 2) and should always cut
Depending upon the manufacturer, these will be a clean hole. If they do not, they should be
designated either light, medium and heavy, or returned to the supplier.
medium, heavy and extra-heavy. The thinnest of
the three is more prone to splitting, and the heav- Rubber dam stamp
iest more difficult to manipulate, which means This is another piece of equipment now largely
that the most widely used is the middle grade. The superseded. For single tooth isolation, a hole
sheets are presented in a variety of colours, some punched 2 cm diagonally from the middle of the
being impregnated with peppermint and other sheet gives universal dam. The hole is simply
scents to disguise the smell of the rubber. The feel orientated to the quadrant under treatment. For
of rubber against the skin may be countered by multiple isolation, it is preferable to hold the
simply placing a gauze underneath the dam. dam against the teeth to be isolated, and mark
A pack of latex free dam is also necessary for the centre of each tooth with a pen, as shown in
patients with latex allergies. This material Figure 3. The holes will then be punched in
appears slightly stiff at first but stretching the accordance with the patient’s dentition and not
sheet a few times makes it easier to handle. with an arbitrary stamp.
Rubber dam punch Rubber dam forceps

Much of the equipment for rubber dam has been The rubber dam forceps are used to carry the
rationally modified. The revolving plate on the clamp to the tooth. The most frequently reported
old punch was rarely used, as a single size hole problem with rubber dam is that when the clamp
will really fit all teeth. When the table was has been expanded and placed on the tooth, the
moved it frequently led to eccentric wear of the forceps are stuck in the clamp and cannot be
pin, which then did not cut a clean hole. The removed! This is because the grooves in the tips
of the forceps are too deep. These should be
Fig. 4 The tips of the rubber dam modified with a stone or sandpaper disc so that
forceps on the right have been they just engage the clamp, but slide off easily.
modified for ease of use. Most forceps have a second groove slightly dis-
tant from the tip, which may be used to remove
the rubber dam clamp without re-engaging the
holes (Figs 4 and 5). There are several designs of
forceps, and they may be employed with either
an over-hand or under-hand grip — experimen-
tation will reveal the most comfortable.
a b
Second groove
First groove
Fig. 5 a) The second groove for removal of the rubber

dam clamp, as shown in b).
528 BRITISH DENTAL JOURNAL VOLUME 197 NO. 9 NOVEMBER 13 2004

09p527-534.qxd 27/10/2004 09:26 Page 529
PRACTICE
a b
Fig. 6 Universal molar and premolar clamps,

demonstrated on a phantom head. a) A wingless molar
clamp (W8a). b) A winged premolar clamp (1)
Rubber dam clamps It is an active clamp, and fits every molar tooth,
There is a vast range of shapes and sizes of rub- even when these are quite broken down. The
ber dam clamps, supposedly to suit every possi- author would suggest therefore that all the other
ble tooth and situation. In fact, this merely caus- designs merely confuse the issue, and until the
es confusion, as an ill-fitting clamp may be quite operator is very experienced only this clamp is
unsatisfactory, and dislodge during treatment. used for all molar teeth. Likewise, the size 1 fits
When properly fitted, a clamp should have four- virtually all premolars (Fig. 6). If passive clamps
point contact with the tooth. If not, it will either are preferred size 0 or 00 are suitable for premo-
rock back and forward or dislodge completely. lars, although they will not be as retentive.
Clamps are described as being either ‘active’, Rather than place aggressive clamps on anterior
where the jaws slope downwards and positively teeth, it is usually kinder to use interproximal
slide into cervical undercuts, or ‘passive’ when wedges, either pieces of rubber dam or a com-
they tend to remain where placed. They may also mercial product such as ‘Wedgets’ (Fig. 7). It is
be either winged or wingless, depending upon often easier to isolate several anterior teeth, giv-
the chosen method of application. ing a clear operating field.
The size 8A clamp is described by the manu- Occasionally, a clamp may be dropped in the
facturers as a ‘universal retentive molar clamp’. patient’s mouth, or may fracture across the bow
as seen in Figure 8, during application. All rub-
ber dam clamps should be protected with a
length of dental floss, about 50 cm, threaded
through the holes on either side. It is not neces-
sary for this to be wrapped around the clamp as
was described in some early restorative text-
books. Indeed this should not be done since,
once the clamp is in place above the rubber dam
sheet and technically outside the mouth, the
floss should be cut and withdrawn. If not it may
act as a wick, drawing saliva into the operating
field, or taking medicaments down into the
mouth. Small voids around the dam may be
Fig. 7 Wedgets may be used in place of clamps for sealed with a caulking agent such as Oraseal or
anterior teeth. Cavit (Fig. 9).
a b
Fig. 8 Rubber dam clamps should always be protected

with a length of dental floss in case they either fracture, Fig. 9 a) A caulking agent which may be used to seal voids around the rubber dam that may allow
as shown here, or are dropped in an unprotected mouth. salivary contamination, as shown in b).

09p527-534.qxd 27/10/2004 09:27 Page 530
PRACTICE
a b
Fig. 11 The winged technique. The hole in the rubber sheet has been stretched over the wings of the
Fig. 10 The rubber dam frame may be easier to clamp a), which is then fitted to the tooth b). The rubber is pushed off the wings, and the seal verified.
place beneath the rubber sheet.
The rubber dam frame Winged technique

The old Ash frame, with its ‘butterfly’ retainers, The appropriate winged clamp (8A for molars, 1
has largely been replaced by plastic or metal for premolars) is selected and flossed. The rubber
frames with sharp points or pins. It should be dam is punched and aligned with the quadrant to
noted that the majority of these retentive points be treated. The clamp is held in the forceps and
slope backwards, and the frames are designed to retained with the ratchet. The hole in the rubber
be placed under the rubber dam (Fig. 10). It is stretched across the wings of the clamp, posi-
seems to be much easier to place the frame tioning the bow of the clamp towards the back of
beneath the dam and simply stretch the sheet the arch. All this may be done by the dental nurse
over the points than the other way round. In while the dentist is otherwise occupied, perhaps
addition, the tension in the sheet can be better administering the local anaesthetic. The nurse
controlled, particularly relevant when working then holds the top of the sheet to improve vision
in a situation where the clamp may be less for the operator, who simply places the clamp
retentive than normal. onto the tooth to be treated (Fig. 11). A flat plastic
For comfort, most patients appreciate a small instrument is then used to push the rubber off the
piece of gauze placed between the rubber and wings, and the frame and gauze are applied. The
their skin, and some practitioners place a prop floss may then be removed and the seal verified
(an old McKesson anaesthetic type) between the or adjusted as necessary.
teeth on the non-working side to relieve the
patient’s muscle tension. Wingless technique
The appropriate wingless clamp (W8A for
APPLICATION TECHNIQUES molars, W1 for premolars) is selected and
A well-trained dental nurse and a well organised flossed. The rubber dam is punched and aligned
surgery, are essential for efficient application of with the quadrant to be treated. The clamp, held
the rubber dam. If a tray is prepared with ready in the forceps and retained with the ratchet, is
punched sheets, and sterilised clamps already placed securely on the tooth. One advantage of
flossed, application can be performed in a matter this method is that the opportunity now exists to
of seconds. verify the fit of the clamp before proceeding
There are three standard methods of applica- (Fig. 12). The rubber dam is now held in both
tion, described and illustrated here. hands, and the index fingers used to stretch out
the punched hole, which is slipped over the bow
a b
Fig. 12 The wingless technique. a) The flossed clamp has been placed on the tooth, and b) the rubber is stretched
over the bow and pulled forward around the clamp.

09p527-534.qxd 27/10/2004 09:28 Page 531
PRACTICE
Fig. 13 The rubber first method.

The operator is holding the sheet
over the tooth whilst the assistant
places the clamp to secure it in
place.
a b c
Fig. 14 a) The rubber dam is lying on the tooth b) stretching the rubber away from the tooth c) using a flat plastic instrument to tuck the
surface and may allow leakage. It should be and drying the mucosa with a stream of cold air, rubber into the crevice.
everted into the gingival crevice by before
of the clamp and pulled forward and down onto Everting the margins
the tooth. Again, the nurse may hold the top of If the rubber dam is lying on the tooth surface it
the sheet to improve vision for the operator. The may allow leakage of saliva, a problem particu-
frame and gauze are applied, the floss removed larly when the dam has been applied during
and the seal verified or adjusted as necessary. adhesive restorative procedures, but also with
endodontics. The margin should be everted into
Rubber first the gingival crevice as shown in Figure 14. The
The third method taught in some centres involves operator stretches the rubber away from the
the dental nurse to a greater extent. The dentist tooth whilst the assistant directs a stream of
stretches out the rubber and places the hole over cold air from the triple syringe onto the
the tooth in question, holding it down on each mucosa. With the use of a flat plastic instru-
side with light finger pressure. At the same time ment the margin of the rubber dam may be
the dental nurse picks up the flossed clamp in the tucked into the gingival crevice, providing a
forceps and places it over the tooth, retaining the tight seal.
dam in place (Fig. 13). Once again, the frame and Alternatively, some operators apply floss liga-
gauze are applied, the floss removed and the seal tures, as shown in Figure 15, using a flat plastic
verified or adjusted as necessary.
Fig. 15 Alternatively, floss ligatures
may be used to hold the rubber dam
Anterior teeth in the gingival crevice. Ligatures will
As stated previously, in a relatively intact arch it be applied to each tooth under
is easier to isolate several anterior teeth. Dental treatment.
floss should be used first to verify that the con-
tacts are clear and that the rubber dam will pass
through. The rubber sheet is held against the
teeth and the centre point marked of those teeth
to be isolated. Holes are punched at these points,
and the rubber dam is then applied to the teeth.
Taking a leading edge of rubber through the
contact — ‘knifing through’ — makes application
relatively simple, or dental floss may be used to
draw the rubber through a difficult contact.
Once in place the selected wedges are applied.

09p527-534.qxd 27/10/2004 09:29 Page 532
PRACTICE
a b
Fig. 16 a) A slot has been cut in the rubber dam to enable this root to be isolated. b) However, it is essential that
a caulking material is applied to prevent salivary contamination.
to push the floss above the cingulum, and tying a Split dam
knot securely on the labial aspect of the tooth. Occasionally, a broken down tooth may be iso-
lated using a slit cut between the holes made for
DIFFICULT SITUATIONS the two adjacent teeth, as shown in Figure 16. It
There are a few situations where the application is essential that the caulking material illustrated
of rubber dam may present difficulties, although in Figure 9 is applied to prevent leakage and
the cautious clinician may consider whether root contamination.
canal treatment is then either appropriate, or
may be severely compromised. Finally, if an operator decides to proceed with
root canal treatment without the use of rubber
The broken down tooth dam, each hand file must be protected with
The broken down tooth may be tackled in a vari- either floss tied around the handle or an appro-
ety of ways. Many molar teeth with large defi- priate safety device. The excess saliva must be
ciencies may have rubber dam applied, provid- controlled with cotton wool rolls and aspiration,
ing the right clamp is used; the author and great care must be taken with medicaments.
recommends a W8a (see Fig. 2). With an appro- It would be advisable to inform the patient of the
priate length of floss as described earlier, the risks involved, and the reduced prognosis for the
clamp is placed directly on to the tooth, so that treatment if salivary contamination of the root
there is a four-point contact between the jaws of canal occurs.
clamp and the root. Once in position, the clamp
is checked for stability by pressing on the bow. If ACCESS
firm, the rubber dam may be stretched over the Access cavity preparation
clamp using the wingless technique described. There is an old cliché that ‘Access is Success’.
It is also feasible to build up the tooth before Unlike other aspects of dentistry, root canal
commencing root canal treatment using glass treatment is carried out with little visual guid-
ionomer (for example, Vitremer). Alternatively, ance; therefore, the difficulties that are likely to
an orthodontic band may be cemented around be encountered need to be considered. An
the tooth. On occasion, a clamp may be fitted on assessment of the following features can be
to a broken down tooth, but only if the gingival made after visual examination of the tooth, and
tissue encroaching on to the margin is first study of a pre-operative periapical radiograph
removed with electrosurgery or a surgical blade. taken with a paralleling technique:
As part of the restorative treatment, periodontal • The external morphology of the tooth.
crown lengthening, or orthodontic extrusion, may • The architecture of the tooth’s root canal
be indicated. These procedures should be carried system.
out prior to commencing the root canal treatment. • The number of canals present.
• The length, direction and degree of curvature
Bridges of each canal.
Bridges do not present a problem with the appli- • Any branching or division of the main canals.
cation of rubber dam. A suitable winged clamp is • The relationship of the canal orifice(s) to the
fitted onto the abutment tooth and the dam pulp chamber and to the external surface of
stretched over the clamp. If there are any small the tooth.
gaps, these can be sealed with a caulking material • The presence and location of any lateral
such as Oraseal or Cavit. canals.
When root treating teeth acting as bridge • The position and size of the pulp chamber
abutments a careful check should always be and its distance from the occlusal surface.
made that the bridge is not loose. If a bridge has • Any related pathology.
become debonded it must be removed. This
should be carried out before any attempt is made Before commencement of root canal treat-
to root-treat one of the abutment teeth. ment, the tooth must be prepared as follows:

09p527-534.qxd 27/10/2004 09:30 Page 533
PRACTICE
Fig. 17 This diagram illustrates the importance

of straight line access and correctly designed
access cavities. If root canal treatment were to
be carried out through a Class III cavity, as
shown on the left, the file would be deflected
and the canal would be transported. However, if
the access cavity is cut incorrectly in the palatal
surface, not giving straight line access, the
same deflection and damage will occur.
• All caries and any defective restorations removed. However, if the tooth is already com-
should be removed and made good. The promised and will require some form of cuspal
tooth should be protected against fracture coverage restoration, an onlay or a crown, then
during treatment. it may be practical to reduce the cusp height,
• The tooth should be capable of isolation. particularly mesiobuccally in molars, to enable
• The periodontal status should be sound, or better visualisation of the pulp chamber. If
capable of resolution. access to the back of the mouth is difficult, it is
It may be prudent to commence access cavity again reasonable to consider reducing the mar-
preparation before isolating the tooth with rub- ginal ridge of the tooth concerned to achieve
ber dam in order that the anatomical landmarks, this (Fig. 18), or perhaps gain access through the
tooth inclination and other helpful features are mesiobuccal wall. Unless the root treatment is
not lost. It is, of course, crucial that the root successful, any further restoration to the tooth
canal does not become contaminated during will be put at risk.
either access preparation or canal instrumenta- Before beginning the access cavity prepara-
tion, and the tooth should be isolated in an tion, it is wise to check the depth of the prepara-
aseptic field as soon as possible. tion by aligning the bur and handpiece against
If there is a danger of fracture of the coronal the radiograph, in order to note the position and
tooth structure, the cuspal height should be depth of the roof of the pulp chamber in relation
reduced to prevent this. If the loss of coronal tis- to the length of the bur in the handpiece
sue is extensive, there may be a need to provi- (Fig. 19). Particular note should be made of the
sionally restore the tooth with a temporary position of the largest pulp horn.
crown, copper ring or an orthodontic band. It is, The stages of access cavity preparation may be
however, not always necessary to restore the summarised as follows:
tooth before carrying out endodontic proce- 1. The initial entry is made with a tungsten car-
dures. Provided the tooth will anchor a rubber bide or diamond bur in a turbine handpiece
dam, the canals can be isolated from the oral and the outline form completed as required.
cavity and a temporary seal can be placed over The bur is advanced towards the pulp horns
the canals, this will be sufficient. until the roof of the pulp chamber is just
The objectives of access cavity preparation are penetrated. (Note particularly that in a molar
to: tooth the bur approaches the tooth from the
• Remove the entire roof of the pulp chamber mesial and from the buccal. Thus the access
so that the pulp chamber can be debrided.
• Enable the root canals to be located and Fig. 18 Reducing the
mesial marginal ridge
instrumented by providing direct straight may be necessary to
line access to the apical third of the root permit clear
canals, as illustrated in Figure 6.17. Note visualisation of the
that the initial access cavity may have to be pulp chamber.
modified during treatment to achieve this.
• Enable a temporary seal to be placed securely
in order to withstand any displacing forces.
• Conserve as much sound tooth tissue as pos-
sible and as is consistent with treatment
objectives.
The subsequent restoration of the tooth should

always be considered first. If the tooth is not
heavily restored then only the amount of coro-
nal tissue sufficient for the successful comple-
tion of the root canal treatment should be

09p527-534.qxd 27/10/2004 09:30 Page 534
PRACTICE
Fig. 19 The pre-operative Fig. 20 These

radiograph should be examined a diagrams illustrate
carefully for suitable landmarks how, in a molar
before commencing the access tooth, the bur
cavity. Here, the depth of approaches the
penetration of the bur is being pulp chamber from
estimated. the mesial (a) and
from the buccal
(b). When the roof
DISTAL MESIAL of the pulp
chamber has been
penetrated, a
safe-tipped bur (c)
should be used to
remove the roof of
the pulp chamber
and shape the
walls without
b damaging the floor
and canal orifices.
cavity is cut in the mesiobuccal segment of
the occlusal surface.)
2. At this point, the rubber dam should be
applied if it is not already in place.
3. The removal of the entire roof of the pulp BUCCAL PALATAL
chamber, and the tapering of the walls, is now
carried out with a safe-tipped endodontic
access bur, as described in Part 5. (Stages 1 and
3 are illustrated in the diagrams in Fig. 20.)
4. The walls of the pulp chamber may now be
gently flared out towards the occlusal surface.
The end result should be a gentle funnel- c
shape, with the larger diameter at the
occlusal surface. The safe tip of the bur will
be felt passively following the contours of
the floor of the pulp chamber.
5. Any remaining pulp tissue and debris is
cleared with an excavator from the floor of
the pulp chamber and the canal orifices. BUCCAL PALATAL
6. The access cavity should be flushed with a

solution of sodium hypochlorite to remove
any residual debris.
7. The canal orifices may be located with a DG
16 endodontic probe. Any alteration to the
access cavity outline form may now be 9. An access cavity must be seen as dynamic,
undertaken to ensure a direct line of with modifications being made as treatment
approach to the canal orifices. Any sclerotic progresses to permit the straightest possible
or secondary dentine surrounding the canal access of instruments.
orifices may be removed with a CT4 tip in a 10. It can only be repeated that access is success.
piezo-electronic ultrasonic machine. If the access cavity is not large enough to
8. Once the canal orifices have been identified, permit easy and thorough shaping and
the preparation of the coronal part of the cleaning of the entire root canal system, the
root canals should be commenced. Depend- root canal treatment may be compromised
ing upon the operator’s preferred technique, and the tooth lost.
either Gates–Glidden burs or nickel-titanium
orifice shapers, should be employed. Copious
1. Marshall K. Dental workspace contamination and the
irrigation is necessary, together with the use role of rubber dam. CPD Dentistry 2001; 2: 48-50.
of a canal lubricant containing EDTA. These 2. Gergely E J. Rubber dam acceptance. BDJ 1989; 167:
techniques are described in Part 7. 249-252.

10p603-613.qxd 01/11/2004 12:06 Page 603
PRACTICE
7
IN BRIEF
● Modern techniques for preparing the root canal involve a crown-down approach to more
efficiently remove infected debris and to improve access for irrigants.
● The balanced-force technique, with a 60° clockwise turn followed by a balanced anti-clockwise
cutting motion, is accepted as the most efficient method of file manipulation, (except that
when using Hand GT files the motions are reversed).
● Copious irrigation with an appropriate antiseptic material is essential to clean the root canal
system following shaping of the main canals.
● The smear layer should be removed with an EDTA solution before placing an intervisit
dressing, or carrying out obturation.
VERIFIABLE
CPD PAPER
Endodontics: Part 7
Preparing the root canal NOW AVAILABLE
AS A BDJ BOOK
P. Carrotte1
Research into root canal preparation has led to significant changes in instrumentation techniques. Hand files should be
manipulated by the balanced-force technique. Recent designs of endodontic instruments have variable tapers giving
improved shaping ability. Nickel-titanium rotary instruments will rapidly and safely open the main root canals creating deep
space to permit full permeation of irrigant solutions. Practitioners considering changing their endodontic technique are
advised to attend hands-on practical courses to gain competence before using these in clinical practice.
ENDODONTICS Success in endodontic treatment depends almost must be used which can be flushed through this
1. The modern concept of completely on how well the root canal is shaped system, will destroy the microorganisms and
root canal treatment and cleaned. This part will cover the principles of preferably dissolve organic debris at the same
2. Diagnosis and treatment root canal preparation, irrigation, root length time. Thus the current concept of root canal
planning determination, intracanal medication, and tem- preparation is not cleaning and shaping, but
3. Treatment of endodontic porary fillings. shaping and cleaning. The main root canals
emergencies There have been more developments in recent should be rapidly and efficiently shaped with
years in this aspect of endodontic practice than instruments to permit thorough and extended
any other. New instruments have been devel- cleaning of the entire pulpal system with the
canal system
oped, employing different metals and different irrigant solution.
engineering philosophies. There has been a sig- Once shaped and cleaned, the root canal sys-
nificant move away from the ISO standard 2% tem is obturated to prevent further ingress of
treatment
taper instrumentation. microorganisms, both apically and coronally,
6. Rubber dam and access Two root canal preparation techniques using and to entomb any remaining microorganisms
cavities hand instruments will be described in detail, as to prevent their proliferation. Currently, the root
7. Preparing the root canal these are the standard techniques currently canal filling material of choice is gutta-percha,
8. Filling the root canal taught in most dental schools, and are consid- which requires a gradual, even, funnel-shaped
system ered to be the most efficient and suitable for preparation with the widest part coronally and
9. Calcium hydroxide, root clinical dental practice. Details are also given of the narrowest part at the apical constriction,
resorption, endo-perio the use of engine-driven rotary instruments. normally approximately 1.0 mm short of the
lesions root apex (Fig. 1). Wide, relatively straight
10. Endodontic treatment for PRINCIPLES AND RECENT DEVELOPMENTS OF canals are simple to prepare, but fine, curved
children ROOT CANAL PREPARATION canals can present considerable difficulties. In
11. Surgical endodontics The principles of root canal preparation are to the past, a number of techniques have been
12. Endodontic problems remove all organic debris and microorganisms described, all of which have been designed to
from the root canal system, and to shape the produce a tapered preparation.
1*Clinical Lecturer, Department of Adult walls of the root canal to facilitate that cleaning
Dental Care, Glasgow Dental Hospital and and the subsequent obturation of the entire root DEVELOPMENT OF PREPARATION TECHNIQUES
School, 378 Sauchiehall Street, Glasgow canal space. However, a tooth root rarely con- In order to fully understand the current tech-
G2 3JZ tains a single simple root canal. Accessory niques for canal preparation, it would be benefi-
Email: [email protected] canals, lateral canals, fins, anastomoses between cial to look briefly at previous methods, and the
canals, and an apical delta all contribute to the associated problems which led to further develop-
Refereed Paper root canal system, as shown in Part 1. The ment. Interestingly, in 1933 a paper was published
doi:10.1038/sj.bdj.4811823
© British Dental Journal 2004; 197: majority of these anatomical features are not in the dental literature recommending the use of
603–613 accessible to instrumentation. An irrigant solution maggots to consume and remove the necrotic

10p603-613.qxd 26/10/2004 14:55 Page 604
PRACTICE
Fig. 1 The shape of larger instrument is then inserted 1.0 mm less

the prepared root into the canal so that a taper is formed. In
canal should be a
gradual, even taper,
between placing each larger instrument, the
with the widest part master apical file is inserted to the working
coronally and the length to clear any debris collecting in the
narrowest part apical part of the canal; this is referred to as
1.0 mm from the recapitulation.
root apex.
The stepback technique helped to overcome
the procedural errors of the standardised tech-
nique in slight to moderately curved canals, but
in the more severely curved root canals prob-
lems still exist. There are three ways in which
some of the problems of the curved root canal
may be overcome, by using:
• A special filing technique.
• A file with a modified non-cutting tip.
• More flexible instruments.
Stepdown technique
This method, although not the term stepdown,
was first suggested by Schilder in 1974, and the
technique was described in detail by Goerig
et al.2 It has been followed by other, similar
techniques such as the double flared3 and the
crown-down pressureless.4 The principle of
these techniques is that the coronal aspect of the
root canal is widened and cleaned before the
apical part (Fig. 3). The obvious advantages of
these methods over the stepback are as follows.
(a) (b) (c) (d) (e) • It permits straighter access to the apical
region of the root canal.
Fig. 2 Procedural errors in the preparation of curved canals. a) Dentine debris and pulp remnants • It eliminates dentinal interferences found in
packed into the apical part of the canal resulting in loss of working length. This may be avoided by the coronal two-thirds of the canal, allow-
recapitulation with fine files and copious irrigation. b) Ledging due either to not precurving the
ing apical instrumentation to be accom-
instrument, or forcing it into the canal. c) Apical zip caused by rotating the file excessively.
d) Perforation due either to persistent filing with too large an instrument, or continual zipping. Note plished quickly and efficiently.
the narrower part of the canal in c) and d) is termed an elbow. This makes obturation of the root • The bulk of the pulp tissue debris and micro-
canal very difficult in the widened apical area. e) Strip perforation caused by overpreparing and organisms are removed before apical instru-
straightening the curved canal. mentation is commenced, which greatly
reduces the risk of extruding material through
tissue in the root canal, replacing them every the apical foramen and causing periapical
3 days. It soon became apparent that more objec- inflammation. This should reduce the inci-
tive and controllable techniques were required! dence of after-pain following preparation of
the root canal.
The standardised system • The enlargement of the coronal portion first
This technique was used for many years and has several benefits. It allows better penetra-
required each instrument, file or reamer, to be tion of the irrigating solution to the entire
placed to the full working length. The canal was root canal system and forms a reservoir of
enlarged until clean white dentine shavings irrigant which is more readily replenished in
were seen on the apical few millimetres of the the canal system. It also reduces the risk of
instrument. The filing was continued for a fur- compacting debris apically which may block
ther two or three sizes, to complete the prepara- the canal.
tion. This method was satisfactory in straight
canals, but was quite unsuitable for curved The stepdown technique is now the most
canals. As the instrument sizes increase, they widely used technique for canal preparation,
become less flexible and led to iatrogenic errors and will be described later in this part.
in curved root canals. Common problems
encountered were ledging, zipping, elbow for- INSTRUMENT MANIPULATION
mation, perforation and loss of working length In addition to the method of approach to the
owing to compaction of dentine debris (Fig. 2). root canal, there have been numerous tech-
niques for the manipulation of endodontic
The stepback technique shaping instruments.
The stepback technique was devised to over-
come the problem of the curved root canal and Watchwinding and circumferential filing
has been described by Mullaney.1 The apical Watchwinding, or a continuous back and forth
region is first enlarged using files to a final mas- rotation with slight apical pressure, rapidly
ter apical file size 25 or 30; each successively advances a fine file down a root canal. Each

10p603-613.qxd 26/10/2004 14:55 Page 605
PRACTICE
Fig. 3 The root canal in this tooth

contains necrotic infected debris.
The objective in endodontics is to
remove the debris without
extruding any through the apical
foramen. It makes good sense to
use a technique which cleans the
coronal part first and then the
apical portion.
slight turn engages the flutes of the file in the now rotated through 360° in an anticlockwise
canal wall and removes dentine. Only fine files direction. The first 60° of this turn cuts off the
should be advanced to the apex in this way as dentine engaged in the flutes of the file, and the
there is a danger of compacting pulpal debris remainder of the movement picks up this den-
ahead of the file. If such a blockage occurs it can tine in the flutes of the file prior to the next
be extremely difficult to remove. cycle. The amount of apical pressure required to
Once the file has reached the desired length, a rotate the file anticlockwise is just sufficient to
push-pull filing action was used, moving the file prevent it from winding out of the canal. Watch-
circumferentially around the canal walls. When ing the rubber stop in relation to the tooth assists
using K-type files an attempt was made to file on in keeping the file steady with no in or out
the outstroke only, again to reduce the apical movement.
compaction of debris. Hedstroem files were more If the file is engaged too far into dentine with
efficient for circumferential filing, although the first clockwise movement, ie if the turn is
these should not be used when watchwinding. greater than 60°, excessive force is applied to the
Research into canal preparation found two file during the cutting phase, and the file may
distinct problems with circumferential filing. fracture. The balanced force cycle of movement
The first was a tendency to preferentially file should be made no more than three times before
the inside wall of a curved canal. The technique the file is withdrawn to be cleaned, ideally by
of anticurvature filing was put forward by pressing it into a sterile sponge. The root canal
Abou-Rass et al.5 Anticurvature filing involves system should be irrigated copiously before the
filing predominantly away from the inner curve file is reintroduced. Using this method, curved
of a root to reduce the risk of a strip perforation. canals may be prepared to the full working
The mesiobuccal roots of maxillary molars and length without producing apical transportation.
the mesial roots of mandibular molars are the
teeth most frequently at risk. The method is used Ultrasonic technique
only in canals with a moderate-to-severe curve. Ultrasound has been used to activate specially
The second finding was that once the file designed endodontic files. Ultrasound consists
engaged in the coronal part of the root canal, the of acoustic waves which have a frequency high-
apical flutes tended not to cut dentine but er than can be perceived by a human ear. The
remain passive. The majority of the filing acoustic energy is transmitted to the root canal
occurred coronally, which tended to leave instrument, which oscillates at 20–40,000 cycles
underprepared canals which were not fully per second, depending on which unit is used.
cleaned. The superior cleaning effect is achieved by
acoustic streaming of the irrigant and not, as
The balanced force technique originally thought, by cavitation.7 Irrigation
The balanced force technique, first described by with sodium hypochlorite is necessary,8 although
Roane et al.,6 is now the most widely taught some of the ultrasonic units are not designed to
technique for manipulating handfiles. It is par- accept sodium hypochlorite through the system
ticularly good when negotiating the curved root and, if water is used, they will be less efficient in
canal. The technique requires flexible files with their cleansing effect. Even when units designed
non-cutting tips. The file is inserted into the to take sodium hypochlorite are used, daily
canal until slight resistance is felt and then maintenance must be carried out to prevent
rotated 60° clockwise to engage the flutes into damage, particularly to metals, because the
the dentine. If a greater movement is made, irrigant is corrosive.
iatrogenic problems can quickly arise. Using The irrigant passes down the shank of the
light apical finger pressure to hold the file at instrument and into the root canal, producing a
exactly the same depth in the canal, the file is continuous and most efficient system. Acoustic

10p603-613.qxd 26/10/2004 14:56 Page 606
PRACTICE
Fig. 5 One modern system of nickel-titanium rotary

instruments — the System GT.
Fig. 4 A diagram of a nickel-titanium rotary file showing

the concept of radial lands.
streaming is produced by the rapid file oscilla-

tions in the irrigant within the root canal. With
more recent developments, ultrasonic machines
are now largely used for their efficient irrigation
properties rather than for canal shaping.
Automated devices
There have been many automated handpieces on
the market over the years which claim to make
the preparation of root canals quicker and more
efficient. Although different designs and
mechanical actions have been tried, they have
all suffered from the inherent difficulties
referred to earlier, caused by rotating or twisting
conventional stainless steel instruments, such as
zipping, perforation, canal transportation and
broken instruments.
Nickel-titanium
However, the development of nickel-titanium
alloys has revolutionised automated root canal Fig. 6 A ‘state-of-the-art’ endodontic motor, being a
preparation. The remarkable ability of these rechargeable slow-speed, high-torque handpiece
encompassing an apex locator and associated facilities.
alloys to alter their crystalline state gives instru-
ments manufactured from nickel-titanium pro-
found flexibility. Mechanised instruments can manufacturer, and more frequently if an instru-
withstand the distortions caused by repeated ment has been used to negotiate difficult curved
rotation in curved canals without causing canals. The files should also be removed from
preparation errors. Most of these instruments the canal and cleaned frequently. Although
have design features such as radial lands (Fig. 4) debris is moved coronally it tends to compact in
to keep the instrument centred in the canal, and the file flutes, and if these become occluded the
a non-cutting tip to guide the instrument down instrument will fracture. The separated part will
the canal. New designs are constantly appearing, engage in the root canal and may prove
(Fig. 5) and the clinician should ensure that con- extremely difficult to remove.
siderable experience with whichever system is
chosen has been obtained on extracted teeth, IRRIGATION
before the instruments are introduced into clinical Sodium hypochlorite
patient treatment. The importance of effective irrigation in root
A controlled high-torque, low-speed motor is canal preparation cannot be overemphasised. A
required for efficient use of the instruments. maxim in endodontics states that it is what you
Most manufacturers of endodontic instruments take out of a root canal that is important, not
produce such a motor, and their complexity may what you put in. Sodium hypochlorite is consid-
vary from that illustrated in Part 5, Figure 12, to ered the most effective irrigant, as it is bacterici-
that shown here in Figure 6. It must be empha- dal, dissolves organic debris and is only a mild
sized that these nickel-titanium instruments do irritant. It must be clearly understood that almost
have a limited life, and will fracture in time after any irrigant solution will cause an inflammatory
a large number of rotations. Slow (150–250 rpm) reaction in the periapical tissues if it is expressed
rotation does not impede their efficiency but under pressure.9 Great care must be taken to
extends their life. However, it is recommended follow the irrigation regime described below.
that the instruments should be discarded after a There is considerable debate about the recom-
certain number of cases as described by the mended or optimum concentration of sodium

10p603-613.qxd 26/10/2004 14:57 Page 607
PRACTICE
hypochlorite. Ordinary domestic bleach, such as LUBRICATION

that purchased from any supermarket, has Proprietory pastes containing EDTA are avail-
approximately 5% available chlorine. This may able, in combination with various agents, which
be used neat, or may be diluted with purified greatly help instrumentation by chelating and
water BP up to 5 times. Greater dilutions do not softening the dentine. If a small portion is dis-
affect the antibacterial properties, but diminish pensed near to the file storage system, a little
the tissue dissolution property. Diluted solutions may be picked up on the tip of each new file as it
must therefore remain in the root canal for is selected (Fig. 8).
longer. Warming the irrigant makes it even more
effective.10 There are other commercially avail- DETERMINATION OF ROOT CANAL LENGTH
able sodium hypochlorite products, but it must The exact apical termination of the root canal
be emphasised that there should be no other preparation has always been a subject of con-
additives, particularly sodium chloride. tention. The pedantic answer is that the root
During preparation, the root canal should be canal should be prepared to that point where the
kept wet, with copious irrigation used after ‘inside’ of the tooth becomes the ‘outside’. Some
each instrument. The irrigant in the canal is authors suggest this is the apical constriction,
only replaced to the depth of insertion of the some the cemento-dentinal junction, some sug-
needle. The needle must remain loose in the gest that the apical foramen should be enlarged,
canal while the irrigant is being injected, to some suggest that the preparation be taken to an
prevent the solution being expelled under pres- arbitrary point 1 mm from the radiographic
sure into the periapical tissues. To obtain total apex. As described in Part 4, the apical anatomy
replacement of irrigant solution in the root may be complex, and the term apical delta may Fig. 7 EDTA solution for final
flushing of the canal system.
canal, the smallest needle available (30-gauge) be more appropriate. This author considers that
should be placed at the apical foramen. Obvi- the preparation should be taken as close as pos-
ously, this is a most hazardous procedure and it sible to the cemento-dentinal junction, and that
is suggested that the irrigation needle is only wherever possible the foramen of the major
inserted to a maximum depth of 2.0 mm short canal should be kept patent. (This technique is
of the working length. A file may then be described later.) The other minor canals forming
worked in the apical 2.0 mm, to stir and with- the apical delta will only be cleaned by antibac-
draw the dentine debris further into the canal, terial irrigation flushing through the entire canal
so that it can be flushed away. There are several system.
differently designed irrigation needle tips, but An estimate of the root length is made from
in the author’s opinion these are of little impor- the pre-operative radiograph taken with a paral-
tance compared with the diameter of the nee- lel technique. However, confirmation of the
dle. Whatever the tip design, unless the needle actual working length is not carried out until the
can penetrate loosely to the correct depth in the coronal preparation of the canal has been com-
root canal, irrigation, however copious, will pleted, as this may straighten a curved canal
not remove dentinal debris. which would change a measurement that had
been taken too early. Most operators now con-
Chlorhexidine firm the actual working length when the crown-
As referred to in Part 5, some practitioners have down preparation has progressed to within 3 or
concerns about the use of sodium hypochlorite 4 mm of the estimated working length. There are
and prefer to use a solution of chlorhexidine. three accepted methods for this determination.
Whilst this has a similar antibacterial spectrum,
it does not have the ability to dissolve organic Working length radiograph
debris and may not clean the entire root canal A file is placed carefully in the canal until it is
system as effectively. However, chlorhexidine within approximately 2.0 mm of the overall
does exhibit substantivity (adherence to den- length. Before insertion the file should be pre-
tine) and there is some evidence to suggest that curved to the shape of the canal and gently
it may be a more appropriate irrigant for manoeuvred into position, if necessary using a
retreatment of failed orthograde cases where watchwinding technique and slight apical pres-
sodium hypochlorite was the original irrigant. sure. For accurate reading of the radiograph a
size 15 file is usually necessary. A silicone stop
Ethylene-diamene tetracetic acid (EDTA)
solution
Endodontic instrumentation creates a smear
layer on the root canal walls, particularly when
using nickel-titanium rotary instruments. This
smear layer occludes the dentinal tubules, and
may protect microorganisms from the effects of
the sodium hypochlorite irrigation. Flushing the
canal with EDTA solution (Fig. 7) periodically
during instrumentation removes the smear layer,
and enables more effective cleansing. The final Fig. 8 EDTA paste should be placed
irrigation should always be with sodium near the files and picked up on each
instrument before use.
hypochlorite.

10p603-613.qxd 26/10/2004 14:59 Page 608
PRACTICE
` Fig. 9 The
buccal object
rule. When the
x-ray cone is
moved to the
mesial and
directed
distally, the
buccal canal
will appear the
most distal on
the radiograph.
on the instrument shank is positioned against a dry the canal before use as they work in the pres-
reference point on the tooth, and both the length ence of electrolytes. There is a distinct learning
and the reference point should be noted in the curve with their use, but it is usually apparent
records. When taking diagnostic radiographs, whether or not the measurement is in accor-
use should be made of the ‘buccal object rule’, dance with the original radiographic estimated
where there are two or more canals present in working length. Errors may occur if there is a
the root (Figs 9 and 10). A second way of achiev- large coronal restoration or metallic crown
ing the same result is to place a Hedstroem file in causing a short circuit; if there is an open apex
one canal and a K-file in the other, as the differ- with a large periradicular lesion, or if there is a
ence between the two is clear on the radiograph. perforation. These are usually apparent and
The working length is calculated by measuring further measures should be taken.
directly on the radiograph from the tip of the In use, a file is inserted into the root canal and
instrument to 1.0 mm short of the radiographic an electrical contact is made with the shank of the
apex. It is only possible to estimate this arbitrary instrument. The device has a second electrode,
position using this technique. which is placed in contact with the patient’s oral
mucosa. A digital display or audible signal shows
Electronic apex locators when the tip of the instrument reaches the apical
Electronic apex locators (seen in Part 5, Fig. 15) foramen. There is no doubt that modern apex
may be used as an alternative to a working- locators can be even more accurate in length
length radiograph, assuming that a pre-opera- determination than a radiograph.11,12
tive film has been examined to obtain an esti-
mated figure. These machines are capable of Tactile sensation
accurate measurement, and will give the loca- An experienced clinician, armed with an accu-
tion of the apical foramen. Apex locators are rate pre-operative parallel radiograph, can often
essential when a patient elects to have a mini- feel the apical constriction with a fine instru-
mum number of further radiographs taken. ment. If tactile sensation is in accord with the
Many practitioners now use them routinely, par- estimated length, further confirmation may not
ticularly when the outline of the canal on the be necessary.
pre-operative film is indistinct or the canal
curves towards or away from the radiograph PREPARATION OF THE ROOT CANAL
beam. Modern apex locators work using differ- Two techniques will be presented in detail, one
ent frequencies, determining the ratio between using conventional hand instrumentation and
the different electric potentials proportional to one using nickel-titanium hand Files of Greater
each impedance. There is no longer any need to Taper. The stepdown technique has been modi-
fied slightly from the original description by
Goerig.2 The use of nickel-titanium rotary
instruments is presented in general terms only.
As discussed earlier, there is a rapid development
of these instruments, and the instructions and
guidance of the manufacturers of the specific
instruments chosen by the clinician should
always be adhered to. It is strongly recommend-
ed that appropriate hands-on training is under-
taken, practising the technique on a large num-
Fig. 10 The diagnostic ber of extracted teeth before taking the new
radiograph was taken procedures to a patient.
from the mesial with
the x-ray cone
pointing distally. The STEPDOWN TECHNIQUE WITH
buccal canal is CONVENTIONAL 2% TAPER INSTRUMENTS
therefore the distal A pre-operative radiograph is taken, rubber dam
one on the radiograph.
placed and an access cavity prepared. The canal

10p603-613.qxd 26/10/2004 14:59 Page 609
PRACTICE
preparation is divided into two parts: i) coronal Fig. 11 A Gates-Glidden bur which
a fractured during use in the root
preparation, which permits radicular access for
canal, showing the normal point of
ii) apical instrumentation. separation, permitting removal with
Steiglitz forceps. However, b) shows
Coronal preparation or radicular access that this is not always the case.
First, the pulp chamber is copiously irrigated with
sodium hypochlorite. Gates–Glidden burs are
next introduced into the canal, directed apically
and laterally away from the furcation. The larger
sizes are introduced first, working sequentially
further down the canal with smaller sizes. Some b
canals will accept a size 6 bur, but normally a size
4 would be used first, followed by a size 3. Each
bur will penetrate 2–3 mm further than the pre-
vious one. EDTA paste should be used with each
bur, and the canal should be irrigated between
each entry. Eventually, in a relatively straight
canal, the No. 2 bur is inserted 10–12 mm into
the canal from the occlusal reference point. In a
curved canal the pre-operative radiograph
should be checked for the maximum straight line
penetration of the bur.
Gates–Glidden burs should be rotated with
constant medium drill speed from the time they
enter the canal until removed. Gates-Glidden
burs must not be taken into a curve, or they will
almost certainly fracture. If the shank of a bur size 60, the tip dipped into a canal lubricant, and
does break, it usually does so near the handpiece the instrument worked slightly further into the
head and may be retrieved easily from the tooth, canal. Sequentially smaller files are selected
as seen in Figure 11. However, if the head does until the canal is prepared to 3–4 mm short of
become separated from the shank within the the estimated working length. Now the actual
canal, removal may be extremely difficult.13 working length must be confirmed by one of the
The bur may be flexed against the canal wall methods described earlier, radiograph or apex
slightly on withdrawal to ensure that the natural locator. Once the working length has been con-
shape of the canal is maintained. Thus a round firmed, the apical preparation can be completed.
canal will remain round, but an oval canal will In narrow or sclerosed canals the operator may
be prepared to a smooth oval funnel. A wide oval prefer to take a small 08, 10 and 15 files to work-
or ‘figure-of-eight’ shape may need preparing at ing length before commencing any canal prepa-
both extremities to produce a wide flare. Instru- ration. The prepared canal then acts as guidance
mentation with the stepdown technique in the for the larger sizes. This procedure is illustrated
radicular access is accomplished using only light diagrammatically in Figure 12.
pressure directed apically and away from the
furcation, or perforation may result. Stepback technique
An alternative to Gates–Glidden burs is the Following the preparation of the coronal part of
use of standard flexible K-type files with safe the root canal, the apical preparation may also
tips, used with the balanced force technique. Fol- be carried out using the stepback technique.
lowing initial widening of the mouth of the Starting with the size 15 file at the working
canal only with a Gates–Glidden bur, the largest
hand file which will enter the canal is selected
and worked apically, using EDTA paste as a
lubricant. Once penetration proves difficult the 1 Gates-Glidden #4
file should not be forced further, or fracture may irrigate
2 Gates-Glidden #3
result. The next size smaller file is selected, and irrigate
sequentially smaller files used until the coronal 3 Gates-Glidden #2

irrigate
preparation is complete. 4 K-flex type file #60
irrigate
Apical preparation 5 K-flex type file #55

irrigate
The coronal flaring already carried out makes 6 K-flex type file #45
irrigate
access to the apical portion of the root easier, as 7 K-flex type file #40
there are no dentinal obstructions and access is irrigate
When 3mm from estimated
more direct. Thus, once the coronal preparation working length verify actual
working length with x-ray or
is complete, flexible K-type files with safe tips apex locator.
8 K-flex type file #35

may be used sequentially with the balanced irrigate Fig. 12 A diagrammatic illustration
force technique previously described. A size 9 K-flex type file #30
irrigate with EDTA
of the sequence of instruments in a
appropriate to the particular canal and the final irrigate & dry conventional 2% taper hand file
canal preparation.
size Gates–Glidden drill is selected, perhaps a

10p603-613.qxd 26/10/2004 15:00 Page 610
PRACTICE
Fig. 13 An illustration of the steps size is inserted 1.0 mm less than the previous
involved in the preparation of a size until the radicular access preparation is
simulated root canal with Hand Files
of Greater Taper. reached. In between each larger file selection the
master apical file is inserted to full working
length (recapitulation) and irrigation is used to
remove all the debris.
STEPDOWN TECHNIQUE WITH HAND FILES OF

GREATER TAPER
The stepdown technique may be modified with
the use of this range of files described by
Buchanan in 1996.14 The balanced force tech-
nique is used as described previously, except that
these instruments are used in the opposite rota-
tion to conventional files. It was considered that
the crucial part of the balanced force technique is
the cutting cycle. Right-handed clinicians (repre-
senting some 90% of the work-force) can make
this movement more easily in a clockwise direc-
length, and progressing to sizes 20 and 25, an tion than anticlockwise. Thus the initial move-
apical stop is made. Copious irrigation and reca- ment to engage the dentine with these files only
pitulation with fine files will prevent build-up of is a 60° turn anticlockwise, and the balanced
canal debris. The master apical file will usually force cutting motion is 360° clockwise.
be no greater than 25 or 30. The apical portion of Following access to and irrigation of the pulp
the canal is now tapered by stepping back. A file chamber the canal must first be gently explored
one size larger than the master apical file is to length with conventional 2% taper hand files.
worked with balanced force to 1.0 mm short of A gentle watchwinding technique is used with
the working length. Each successively larger file size 08, 10 and 15 files. The tip of the Greater
Taper File then acts as a pathfinder rather than
Table 1 Root canal preparation using GT hand files as a preparation file.
Aceess and coronal preparation Using EDTA lubrication paste, the largest file
• Access — Remove roof of pulp chamber and locate canal orifices with the use of safe ended access
with a blue handle and a taper of 12%, is used
Bur and DG16. Ensure straight line access to the canal orifice. first to gain coronal access. When resistance
• Irrigate pulp chamber with sodium hypochlorite is met the instrument is not forced further
• Estimate working length from pre-operative radiograph. apically, but the red handled 10% taper file is
• Using a gentle watchwinding technique, and EDTA chelating agent/lubricant (File Eze/Glyde),
used to penetrate further. The yellow handled
advance a #08, #10, #15 and #20 K-type file to about 3 mm short of the estimated working length. 8% taper and white handled 6% taper follow
• If desired, with irrigation with NaOCI and with the use of the lubricant, open up the canal orifice in sequence, until the canal is prepared to
using Orifice Shaper 4 & 3 crown down for approximately 3 or 4 mm. Orifice Shapers should be working length.
rotated at 250 rpm and used with a light pecking motion, keeping the instrument rotating within The technique is varied according to the clini-
the canal at all times (Gates-Glidden drills can also be used for this procedure). cal situation. In a wide, straight canal, only a sin-
Mid-canal preparation gle 12% taper file may be required. In a narrow,
• Continue irrigation with NaOCI and the use of lubricant. Insert the #12 (BLUE) GT hand file within curved canal, the clinician may only use the
the canal and using a reverse balanced force action (60° turn anticlockwise followed by clockwise smaller files, alternating them repeatedly to
180° turn with apical pressure — the ‘balanced force’) progress the file until resistance is felt and no create space for further apical penetration. Before
further advancement of the file is possible. Do not use excessive force, and remove and clean the attempting to instrument narrow, curved canals
file after every three cycles.
it is again always advisable to use conventional
• In the same manner insert the #10 (RED) GT hand file, repeating the procedure to penetrate further
down the canal 2% taper instruments from size 08 through to
size 20. The tip of the Greater Taper file then acts
• Either repeat the process with the #08 (YELLOW) hand file, or if approximately 3 mm from the
estimated working length, proceed to: as a pathfinder, dentine removal occurring at the
side of the instrument, not the tip.
Apical preparation Once a smooth-tapered canal has been pre-
• Establish working length using electronic apex locator or with a diagnostic radiograph. pared, the clinician may consider it necessary in
• Negotiate canal to full working length advancing #15 and #20 K-type files with watchwinding or some cases to enlarge the apical constriction
balanced force motion.
slightly with conventional hand files.
Apical shaping The technique is summarised in Table 1, and
• Check canal patency using #15 K-type file with copious irrigation of NaOCI and use the #08 shown in Figure 13.
(YELLOW) GT hand file looking for resistance.
• Check canal patency before introducing the #06 (WHITE) GT hand file, this file should progress to NICKEL-TITANIUM ROTARY TECHNIQUE
full working length. The development and design of these instru-
• Apical gauging can be checked or further enlarged with the use of K-type files. ments has been referred to earlier, and should be
• Continue irrigation with NaOCI for a total preparation time of 30 minutes, followed by final rinse of referred to in conjunction with this description
EDTA solution. of technique. Each manufacturer of these instru-
The above procedural protocol may have to be adapted taking into account the apical constriction, ments produces a protocol for use for their own
working length, apical curvature and general canal anatomy.
specific product. As it would not be appropriate
`
to describe any single manufacturer’s technique

10p603-613.qxd 26/10/2004 15:01 Page 611
PRACTICE
here, the description which follows must there- have been selected, as in Fig. 5, then a 10%
fore be generic. The basic concepts are the same taper file will be used until resistance is felt,
whatever the instrument chosen. The technique moving to an 8%, 6% and 4% until any of
for use is crown-down, with copious irrigation. these reaches working length, depending upon
Indeed, these instruments conform totally to the the canal size. Alternatively, if a single taper,
stated objectives in modern root canal therapy, variable tip system has been selected, the
shaping the canal rapidly and efficiently so that largest tip size will be used first, reducing sizes
thorough cleaning of the root canal system can as the canal is negotiated until, once again,
be carried out with appropriate irrigants. The one instrument reaches working length.)
files must be used in a slow-speed, controlled
torque motor, or they are prone to fracture. FURTHER READING
It must be stressed that the techniques described
Coronal preparation or radicular access are generic, and that hands-on practice is essen-
Nickel-titanium instruments cannot easily be tial, following the specific manufacturer’s proto-
precurved, and require straight line access to the col until competence is achieved. The various
root canal orifice. The use of ultrasonic tips to instruments and techniques are described, com-
refine the access cavity has already been pared and contrasted, in numerous publications,
described. Nickel-titanium ‘orifice shapers’ have for example.15–18 The prudent clinician would
replaced Gates-Glidden drills, and may be used be advised to refer to the endodontic literature
sequentially from the largest to the smallest before embarking on new purchases and clinical
sizes. These remain centred in the canal and will practice. A useful series of clinical articles was
flare the canal walls to approximately halfway presented by Buchanan.19
down the canal. Their use may be restricted in
narrow or curved canals. They are used with a PATENCY FILING
very light apical pressure, often described as the Research has shown that most canal preparation
‘pencil-lead’ pressure, ie that which would break techniques lead to the extrusion of debris
the lead when using a propelling pencil. Each through the apical foramen. This is removed by
instrument should be used for no more than the normal body defence systems, although a
5–10 seconds at a time before removing from the certain amount of inflammation will result.
canal, cleaning, irrigating and adding lubricant. Concern has been expressed by some authorities
that such debris may remain in the apical con-
Apical preparation striction, and may contribute to failure, particu-
Once the coronal preparation is completed, the larly if it harbours microorganisms.20 The tech-
canal should be explored to full working length nique of patency filing involves passively
using fine hand files and the balanced force tech- inserting a small file, size 08 or 10, 2 mm beyond
nique. The working length should be confirmed, the established working length. No attempt is
and the canal enlarged to a size 15 or 20. If this is made to instrument the foramen, merely to keep
not done, the rotary instrument will have to cut it open or patent by deliberately extruding the
at its tip, rather than along its length, which may debris into the periradicular tissues.
lead to jamming and fracture. Each time a file is The literature on patency filing is at present
removed from a canal after use the position of quite equivocal. No research workers have been
the dentine debris in the flutes should be inspect- able to show either a decrease or an increase in
ed. The instruments should cut along their entire post-operative symptoms or case prognosis. The
length. If debris is only seen at the tip, the instru- technique remains subjective and subject to the
ment may be excessively stressed, which may operator’s personal philosophy.
lead to fracture. The apical part of the canal may
now be prepared with sequentially smaller INTRACANAL MEDICATION
instruments, stepping down the canal with each Calcium hydroxide
smaller size. It may be necessary to return to a There is almost universal agreement that when
larger size during preparation (recapitulation) to an intervisit dressing is required, calcium
create more space for the smaller instruments. hydroxide is the material of choice, and this is
discussed in Part 9. There is far less agreement as
Summary of technique to whether such dressings are indicated. Single-
• Motor set at slow speed recommended for visit endodontics — the shaping, cleaning and
instrument, usually 150–250 rpm. obturation of the root canals in one appointment
• Use each instrument for only 5–10 seconds. — remains controversial. Most endodontists
• Light apical pressure, using either a gentle would agree that when the tooth under treat-
‘planing’ pressure, or a slight ‘pecking’ ment is not infected, for example when perform-
motion depending upon the instrument ing elective endodontics or treating large expo-
design. sures of vital pulps, completing treatment in a
• Use EDTA lubricant with each instrument. single visit is advisable. However, Sjögren et al.
• Copious irrigation with sodium hypochlorite showed a significant increase in prognosis when
between instruments. infected root canals were dressed with calcium
• Step down in sequence from the largest to the hydroxide for one week before obturation.21
smallest. (NB This will depend upon which Gutmann has suggested that this effect was only
system is being used. If variable taper files apparent because their research employed 1%

10p603-613.qxd 26/10/2004 15:01 Page 612
PRACTICE
Fig. 14 A fine tipped plastic canula on a pledget of cotton wool and sealed into the
may be used to deliver medicaments pulp chamber between appointments. The
deep into the root canal. Its size may
author prefers to mix the paste with a calcium
be compared to the standard
28-gauge irrigating needle. hydroxide preparation, adding a little sterile
water or local anaesthetic to make the mixture
slightly more fluid. The canals may then be com-
pletely filled with this mixture prior to placing a
temporary coronal seal.
Of course, no intracanal medicament yet
exists that will sterilise the root canal, and the
importance of biomechanical preparation cannot
be stressed too strongly.
TEMPORARY RESTORATIVE MATERIALS

sodium hypochlorite, whereas the use of a full If endodontic treatment cannot be completed in
strength solution would preclude the need for one visit, it is essential that a temporary restora-
such a dressing.22 The wise practitioner would tive material is used as an inter-appointment
consider which approach best suits his or her dressing that will not permit access to bacteria
style of practice. or oral fluids. Even when the root canal treat-
Calcium hydroxide is applied with a spiral ment has been completed, a well-sealed tempo-
paste filler (noting the caution given at Part 5, rary restoration is necessary prior to the place-
Fig. 20), or a fine-tipped syringe may be used as ment of a permanent restoration. The material
seen in Figure 14. Care should always be taken should prevent contamination of the root canal
not to extrude the material beyond the apical system and must be sufficiently strong to with-
constriction. If this happens, inflammation may stand the forces of mastication.
result which could take several days to subside. Two different temporary materials are recom-
Calcium hydroxide containing points are avail- mended. Of the many proprietary materials,
able from which it is postulated that ions will dis- Cavit has been shown to provide the best seal.23
sociate into the fluid in the root canal, and which Cavit provides a good seal, is simple to apply
may be better controlled in apical length. How- and quick to set. On the other hand, it lacks
ever, research supporting this has not yet been strength and will not stand up to masticatory
reported in the endodontic literature. forces. It should be confined to single surface
A recent addition to the range of intracanal fillings for periods not exceeding a week. How-
dressing available is the mixture Vitapex, shown ever, the shape of an endodontic access cavity is
at Figure 15. As well as calcium hydroxide, the not retentive, and all such materials will either
material contains iodoform. It may be indicated leak or be lost entirely in time. Any ingress of
for deep-seated infections of the root canal, such microorganisms may reinfect a prepared canal,
as the upper canine, shown in Part 2, Figure 1, and the time saved by using a rapid technique
which had resulted in an extra-oral sinus may be severely lost if such leakage occurs. Thus
beneath the patient’s eye. This closed and the the use of a glass-ionomer cement should be
tooth healed following one week’s dressing. considered. It is adhesive, antibacterial, stands
Extreme care is needed to ensure that this vis- up well to forces of mastication and is more
cous dressing has been fully removed from the stable than other materials.
canal walls before obturation. It is a useful routine, with an inter-appoint-
ment dressing, to place a sterile pledget of cot-
Steroids ton wool in the pulp chamber, followed by a
Steroids are readily obtainable in the form of tri- layer of gutta-percha. The temporary restora-
amcinalone (Ledermix paste). The use of the tive material is then placed over the gutta-
paste for dressing an inflamed vital pulp prior to percha (Fig. 16). At the next visit, a high-speed
commencing root canal therapy is discussed in bur may be used to remove the temporary
Part 3. Some authorities recommend the use of restoration without any danger of filling mate-
the paste as an intervisit medicament paste rial lodging in the canal entrances or blocking
when severe periradicular inflammation is pres- the canals. The gutta-percha provides a base for
ent. It is suggested that it may be wiped on the the restorative material and prevents the bur
canal wall using a file or paper point which is becoming caught in the cotton wool when the
then withdrawn; a small amount is then placed temporary filling is removed.
Fig. 15 Vitapex
intracanal dressing.

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PRACTICE
Fig. 16 A layer of gutta-percha temporary filling

material has been placed to protect the root canals
before the restorative material is applied. The inset
shows how this may be removed and prevents fragments
of the temporary filling entering the root canal.
1. Mullaney T P. Instrumentation of finely curved canals. instruments. CPD Dentistry 2000; 1: 87–92.
Dent Clin North Am 1979; 23: 575–592. 14. Buchanan L S. The art of endodontics: Files of greater
2. Goerig A C, Michelich R J, Schult H H. Instrumentation taper. Dentistry Today 1996; 42: 44–49.
of root canals in molars using the stepdown technique. 15. Kavanagh D, Lumley P J. An in vitro evaluation of
J Endod 1982; 8: 550–554. canal preparation using Profile .04 and .06 taper
3. Fava L R. The double flared technique: an alternative instruments. Endod Dent Traumatol 1998; 14: 16–20.
for biomechanical preparation. J Endod 1983; 9: 76–80. 16. Hulsmann M, Schade M, Schafers F. A comparative
4. Morgan L F, Montgomery S. An evaluation of the study of root canal preparation with HERO 642 and
crown-down pressureless technique. J Endod 1984; Quantec SC rotary Ni-Ti instruments. Int Endod J
10: 491–498. 2001; 34: 538–546.
5. Abou-Rass M, Frank A, Glick D. The anticurvature 17. Barbakow F, Lutz F. The Lightspeed preparation technique
filing method to prepare the curved root canal. J Am evaluated by Swiss clinicians after attending continuing
Dent Assoc 1980; 101: 792–794. education courses. Int Endod J 1997; 30: 46–50.
6. Roane J B, Sabala C L, Duncanson M G. The ‘balanced 18. Bryant S T, Thompson S A, Al-Omari M A,
force’ concept for instrumentation of curved canals. Dummer P M H. Shaping ability of Profile rotary
J Endod 1985; 11: 203–211. nickel-titanium instruments with ISO sized tips in
7. Ahmad M, Pitt Ford T, Crum L. Ultrasonic debridement simulated root canals. Int Endod J 1998; 31: (part 1)
of root canals: an insight into the mechanisms 275–281, (part 2) 282–289.
involved. J Endod 1987; 13: 93–101. 19. Buchanan L S. The standardised taper root canal
8. Griffiths B, Stock C. The efficiency of irrigants in preparation. Parts 1–6. Int Endod J. Part 1 2000; 33:
removing root canal debris when used with an 516–529; Part 2 2001; 34: 63–71; Part 3 2001; 34:
ultrasonic preparation technique. Int Endod J 1986; 149–156; Part 4 2001; 34: 157–164; Part 5 2001; 34:
19: 277–284. 244–249; Part 6 2001; 34: 250–259;
9. Sabala C L, Powell S E. Sodium hypochlorite injection 20. Ruddle C J. in Cohen S and Burns R C, Pathways of the
into periapical tissues. J Endod 1989; 15: 490–492 Pulp Eighth Edition, Page 276–277. St Louis: Mosby,
10. Berutti E, Marini R, A scanning electron microscope 2002.
evaluation of the debridement capability of sodium 21. Sjögren U, Figdor D, Persson S, Sundqvist G. Influence
hypochlorite at different temperatures. J Endod 1996; of infection at the time of root filling on the outcome
22: 467–470. or endodontic treatment of teeth with apical
11. Pagavino G, Pace R, Baccetti T. A SEM study of in vivo periodontitis. Int Endod J 1997; 30: 297–306.
accuracy of the Root ZX electronic apex locator. 22. Guttman J L. Presentation to The British Endodontic
J Endod 1998; 24: 438–441. Society Spring Scientific Meeting, October 2000,
12. McDonald N J. The electronic determination of Chester, UK.
working length. Dent Clin North Am 1992; 36: 23. Anderson R W, Powell B J, Pashley D H. Microleakage
293–307. of three temporary endodontic restorations. J Endod
13. Lumley P J. Management of silver points and fractured 1988; 14: 497–501.

British Dental Journal November 1904
Miscellanea
A Caution
A correspondent at Kettering warns those of his vicinity against an obvious begging impos-
tor who called upon him personating a practitioner at Wrexham. We learn from the letter
that he has been inconvenienced by enquiries from others who have been victimised and is
willing to prosecute if the man can be detained.
Br Dent J 1904

11p667-672.qxd 22/11/2004 15:14 Page 667
PRACTICE
8
IN BRIEF
● No matter how well the obturation of the root canals is performed, success will be dependant
upon the initial cleaning and debridement of the entire root canal system.
● Cold lateral compaction of a master gutta percha point and accessory points remains the
norm against which other obturation methods are assessed.
● The gold standard of obturation is the warm vertical compaction of gutta percha with a
heated plugger.
● Research suggests that the coronal seal, achieved with a layer of glass ionomer cement on
the floor of the pulp chamber, may be more important than the apical seal.
VERIFIABLE
CPD PAPER
Endodontics: Part 8
Filling the root canal system NOW AVAILABLE
AS A BDJ BOOK
P. Carrotte1
The purpose of the obturation phase of a root filling is two-fold; to prevent microorganisms from re-entering the root canal
system, and to isolate any microorganisms that may remain within the tooth from nutrients in tissue fluids. The seal at the apical
end of the root canal is achieved by a well-fitting gutta-percha master point, and accessory points, although heated techniques
may result in a better seal. The seal at the coronal end is achieved by the application of a layer of resin-modified glass ionomer
cement as accessory canals may lead from the floor of the pulp chamber to the furcation area. It must always be remembered
that success will only be achieved if the root canal system has been as thoroughly debrided as possible of infected material.
In modern endodontic treatment the emphasis is • Radiopaque

ENDODONTICS placed far more on cleaning and preparing the • Easily removed from the canal if necessary.
1. The modern concept of root canal system than on filling it. This does not
root canal treatment mean that root canal obturation is less important, To these properties may also be added, inca-
2. Diagnosis and treatment but that the success of endodontic treatment pable of staining tooth or gingival tissues and
planning depends on meticulous root canal preparation. easily manipulated with ample working time.
3. Treatment of endodontic The purpose of a root canal filling, as illustrat- Gutta-percha has a number of these desirable
emergencies ed in Figure 1, is to seal the root canal system to properties. It is semisolid and can be compressed
4. Morphology of the root prevent: and packed to fill the irregular shapes of a root
canal system • Microorganisms from entering and reinfect- canal using lateral or vertical compaction tech-
5. Basic instruments and ing the root canal system; niques. It is non-irritant and dimensionally stable.
materials for root canal • Tissue fluids from percolating back into the It will become plastic when heated or when used
treatment root canal system and providing a culture with solvents (xylol, chloroform, eucalyptus oil).
medium for any residual bacteria.1 It is radiopaque and inert, and can be removed
from the canal when required for post preparation.
cavities
In the past, attention has been focussed on the
7. Preparing the root canal
importance of obtaining an hermetic apical seal.
8. Filling the root canal However, research has indicated that as well as
system sealing the root canal system apically, it is equal-
9. Calcium hydroxide, root ly important to ensure that the coronal access to
resorption, endo-perio the canal itself has a fluid-tight seal, to prevent
lesions infection from the oral cavity.2 Although numer-
10. Endodontic treatment for ous materials have been used to fill root canals,
children the most universally accepted is gutta-percha.
12. Endodontic problems PROPERTIES OF ROOT CANAL FILLING
MATERIALS1
1*Clinical Lecturer, Department of Adult Ideally, a root canal filling should be:
Dental Care, Glasgow Dental Hospital and • Biocompatible
School, 378 Sauchiehall Street, Glasgow
G2 3JZ
• Dimensionally stable
*Correspondence to: Peter Carrotte • Capable of sealing the canal laterally and
Email: [email protected] apically, conforming with the various shapes
and contours of the individual canal
Refereed Paper
doi:10.1038/sj.bdj.4811855 • Unaffected by tissue fluids and insoluble
© British Dental Journal 2004; 197: • Bacteriostatic Fig. 1 A radiograph of a well-obturated upper molar.
667–672
BRITISH DENTAL JOURNAL VOLUME 197 NO. 11 DECEMBER 11 2004 667

11p667-672.qxd 09/11/2004 14:07 Page 668
PRACTICE
Fig. 2 These teeth with resorptive

defects may be impossible to
obturate with conventional
methods.
Its disadvantages are few. It is distorted by Nevertheless, the cold lateral compaction of
pressure and, consequently, can be forced gutta-percha is still the most widely taught, and
through the apical foramen if too much pressure the technique against which most others are
is used, and it is not rigid and so can be difficult compared. However, as there is a demand for
to use in smaller sizes. Also, a sealer is necessary saving teeth with complex pathology and root
to fill in the spaces around the filling material. canal morphology (Fig. 2), it is sometimes easier
Root canal scalers were considered in Part 5. to combine the merits of various techniques in a
Gutta-percha points are manufactured in var- hybrid form to simplify the filling procedure.
ious forms. Standardised points match the ISO Studies have shown that these are satisfactory,
sizes, and have a 2% taper. Accessory points although not always as easy as lateral com-
have fine tips and variable taper to facilitate and paction to carry out.5,6
improve lateral compaction. Greater taper Before a root-filling is inserted, it is essential
points are available in 4% and 6% taper to that the canals are dry. Any serous exudate from
match modern preparation techniques. Feather- the periapical tissues indicates the presence of
tipped points permit individual and specific inflammation. Calcium hydroxide may be used
cone fitting to the prepared root canal. as a root canal dressing until the next visit
(calcium hydroxide BP mixed with purified
REMOVAL OF SMEAR LAYER water or local anaesthetic solution to a thick
A smear layer is created by the action of metal- paste — see Part 9).
lic instruments on dentine, especially rotary
instruments. It is composed of dentine filings, LATERAL COMPACTION OF GUTTA-PERCHA
pulpal tissue remnants and may also contain The objective is to fill the canal with gutta-percha
microbial elements. It may occlude dentine points (cones) by compacting them laterally
tubules thus harbouring bacteria, and may con- against the sides of the canal walls. The tech-
tain a bacterial plaque on the canal walls. It has nique requires selection of a master point, usu-
been shown that gutta-percha penetrates the ally one size larger than the master apical file,
dentine tubules when the smear layer has been which should seat about 0.5 mm short of the
removed.3 working length (Fig. 3a). If the point is loose at
It is therefore suggested that the root canal working length, then either 1 mm should be cut
should be irrigated with an EDTA solution to from the tip and the point refitted to the canal,
remove the smear layer, followed by a final irri- or a larger size point selected. It should be noted
gation with sodium hypochlorite, prior to drying that gutta-percha points can not be as accurately
and obturating the canal. machined as metallic instruments. There may be
variance in the size stated, and if a matched
FILLING TECHNIQUES point does not fit a prepared canal it may be
The studious reader will have noted the use of worth either trying another point from the
the word ‘compaction’ rather than ‘condensa- packet, or fitting the point in a measuring/sizing
tion’. In 1998, the American Endodontic Associ- gauge, as illustrated in Figure 4.
ation recognised that this was a more appropri- Once the master point is fitted to length and
ate term for the techniques used in obturation, demonstrates a slight resistance to withdrawal
and the term has been adopted in this text.4 (tug-back), accessory points are then inserted
Several techniques have been developed for alongside the master point and compacted lat-
placing gutta-percha into the root canal system. erally with a spreader until the canal is sealed
668 BRITISH DENTAL JOURNAL VOLUME 197 NO. 11 DECEMBER 11 2004

11p667-672.qxd 09/11/2004 14:08 Page 669
PRACTICE
a b c
Fig. 3 a) In cold lateral compaction, the master point should exhibit ‘tug-back’ slightly short of the working lengths. (Paper points have been placed to protect
the other canals.) b) A finger spreader inserted alongside the master point, is left in place for 30 seconds. c) The spiral of successive accessory points in an
effective obturation.
(Fig. 3b). The most simple system of accessory using an in-out movement, before seating
points designates these from A, the finest, the point home into the canal at full work-
through B and C to D, the largest, shown in ing length.
Figure 5. As each point is used the prepared, 4. A fine finger spreader is selected and the rub-
flared, canal is becoming progressively wider, ber stop set to working length. Place the
and the accessory points may therefore be used spreader alongside the master point and com-
sequentially from small to large. The resultant pact using firm apical finger pressure only.
filling appears above the access cavity as a spi- Leave the spreader in situ for 30 seconds. This
ral, with each point extruded slightly further is important as continuous pressure from the
out of the canal (Fig. 3c). spreader is required to deform the gutta-per-
There are two main types of spreading instru- cha point against the canal walls and to over-
ments for compacting gutta-percha: long- come its elasticity.
handled spreaders and finger spreaders. The 5. Select an accessory point with locking
main advantage of a finger spreader is that it is tweezers and dip its tip into sealer. Do not
not possible to exert the high lateral pressure leave the points in sealer while working
that might occur with long-handled spreaders. (Fig. 6) as a reaction may occur between the
The chance of a root fracture is reduced and it is zinc oxide in the points (up to 80%) and the
therefore a suitable instrument for beginners. eugenol in the sealer, softening the points
and making insertion difficult.
PROCEDURE 6. This stage is best carried out using two
1. The canal should be irrigated, cleaned and hands. Assuming the operator is right hand-
dried. ed, the tweezers holding the accessory point
2. A master point is selected and fitted to the are aligned above the tooth in the right hand,
canal as described above. It should be marked while the left hand rotates the spreader a few
at working length, or grasped securely in times through an arc of 30–40° and with-
endodontic locking tweezers. draws it.
3. The master point is coated with sealer and 7. Immediately place the accessory point
used to paste the canal walls with the sealer, alongside the master point. Any delay will
Fig. 4 An endodontic gauge for

accurately sizing gutta-percha
points.
Fig. 6 Gutta-percha points should NOT be presented to

Fig. 5 Finger spreaders sized A to D with matching the operator by the surgery assistant with the tips dipped
accessory points. in sealer.

11p667-672.qxd 09/11/2004 14:09 Page 670
PRACTICE
a b
Fig. 7 The excess gutta-percha has been removed with a hot instrument, and the coronal filling has been compacted
into the root canal orifice a), prior to the placement of a glass ionomer coronal seal b).
allow the master point to relax and space It is important that the instruments are only
will be lost. Reinsert the spreader and laterally gently warmed. If the spreader is too hot it will
compact both points. melt the gutta-percha, which will adhere to the
8. Repeat the sequence using gradually larger instrument and be withdrawn from the canal.
spreaders and gutta-percha points until the
canal is filled. SINGLE GUTTA-PERCHA POINT AND SEALER
9. Remove excess gutta-percha from the canal With the tendency to preparation techniques of
orifice with a heated plugger, and firmly greater taper, gutta-percha points of matching
compact the remaining gutta-percha to seal taper may be used. These fit the prepared canal so
the coronal access to the canal (Fig. 7). well that some operators are using a single gutta-
10. If post-space preparation is required it may percha point and sealer. The only advantage of
be carried out at this stage. this technique is its simplicity. The disadvantage is
11. If not, a layer of resin-modified glass- that the majority of sealers are soluble. As the
ionomer cement should be applied over the canal will not be fully filled in three dimensions,
gutta-percha and the floor of the access tissue fluids may leach out the sealer over time.
cavity, completing the coronal seal. This technique cannot therefore be recommended.
12. A periapical radiograph should be taken on However, in difficult anatomical cases it may be
completion, using a long-cone parallel tech- necessary to create a custom-fitted cone.
nique. This is primarily for subsequent mon- A slightly large cone is selected and the apical part
itoring of healing by sequential radiographs, softened, either by solvents such as chloroform,
taken if possible in the same film-holder sys- rectified turpentine or oil of eucalyptus, or by
tem to ensure reproducible and comparable immersion in hot water. The softened cone is fitted
exposures. to working length with gentle pressure. The cone is
carefully marked for orientation, and the process
LATERAL COMPACTION OF WARM repeated until a satisfactory fit is obtained. The
GUTTA-PERCHA cone should then be cleaned of all solvents, and the
A simple modification to the cold lateral com- canal obturated using sealer in the usual way.
paction technique is to apply heat to the gutta- As with all single-cone techniques, if the
percha. The softened material is easier to compact excess sealer resorbs in the apical tissue fluids,
and will result in a denser root filling. However, microleakage may allow the ingress of tissue flu-
finger spreaders will not retain heat sufficiently ids, and failure of the stated criteria of obtura-
for this procedure, and specially designed heat tion. Really, an attempt should always be made to
carriers should be used. The instruments illustrat- improve the fit of a single cone with warm or
ed in Figure 8 have a sharp tip for lateral cold lateral compaction of accessory points.
compaction, and a blunt plugger tip for limited
vertical compaction of the softened gutta-percha. THERMATIC COMPACTION OF GUTTA-PERCHA
Electrically heated spreaders are also available. In 1979, McSpadden devised a handpiece-
a b
Fig. 8 Machtou heat carriers/ Fig. 9 a) Maillefer Gutta Condensors, with b) showing
pluggers for warm compaction. the apically directed thread structure.

11p667-672.qxd 09/11/2004 14:10 Page 671
PRACTICE
a b
Fig. 10 An example of a Thermafil device a), a heated

gutta-percha carrier, with an oven necessary for accurate
c softening b). The U-shaped cross-section of the plastic
carrier is shown in c).
driven compactor, which is effectively an invert- meantime the rubber stop on the selected device
ed Hedstroem file.7 Although no longer made, is set to working length, and the device placed in
other similar devices, such as the gutta conden- a special oven to soften the gutta-percha. When
sor (Fig. 9), are available. The frictional heat from ready, the device should be swiftly and smoothly
the compactor plasticises the gutta-percha and inserted to working length, and held in place for
the blades drive the softened material into the a few seconds. Using a high-speed bur the excess
root canal under pressure. The main problem carrier may be sectioned and removed from the
found was lack of control over the apical portion canal orifice, and a plugger used to compact the
of the gutta-percha, which may be extruded gutta-percha in this area. A layer of resin-modi-
through the apex in its softened state. To over- fied glass ionomer completes the obturation.
come this problem, the technique was modified Some carriers are manufactured with a
by Tagger, who recommended laterally condens- U-shaped cross-section to facilitate removal with
ing a master point and two or three accessory a drill should retreatment be necessary. However,
points, and then using the condensor to plasticise although it may be possible to drill out the carrier,
the gutta-percha in the coronal part of the canal.8 this technique may not be appropriate if a post
The laterally compacted material in the apical and core may be indicated in the future.
half effectively prevents any apical extrusion.
The technique is particularly useful for the VERTICAL COMPACTION OF WARM
rapid and effective obturation of the coronal part GUTTA-PERCHA
of a root canal after placement of an accurate Heated gutta-percha has been shown to flow
apical seal. extremely well into all canal irregularities. It is
particularly useful in situations such as internal
HEATED GUTTA-PERCHA CARRIERS resorption, C-shaped canals, and those with fins
Several manufacturers now supply these or webs. As referred to earlier, when the smear
devices, illustrated in Figure 10. Alpha-phase layer is removed the gutta-percha has been
gutta-percha is attached to a rigid carrier, in a shown to penetrate dentine tubules.3 This tech-
variation of the technique originally described nique is now considered the gold standard for
by Johnson in 1978.9 Most carriers are now endodontic obturation. The principle of vertical
plastic. The excess material is removed, and the compaction of increments of warm gutta-percha
carrier remains in the canal as a central core. was first described by Schilder in 1967.11
The softened gutta-percha flows well in to canal Although delivering excellent results, the method
aberrations, fins, etc., giving very good three- was difficult to master and time-consuming.
dimensional obturation.10 Success depends, as The state of the art at present is the method
with all techniques, upon thorough canal clean- first described by Buchanan employing the
ing and shaping. The carriers have a 4% taper, System-B heat source (Fig. 11), which delivers a
and an underprepared canal will be difficult if precise heat to the tip of the plugger.12 A non-
not impossible to obturate to working length standardised (4%, 6% or feathered tip) gutta-
with these devices. A range of sizes is presented, percha cone is carefully fitted to the canal.
and most systems employ a method of ensuring Using a selected plugger, a continuous wave of
the fit of the device before obturation is com- heat is applied to soften and downpack a cone,
menced. This may either be a blank carrier with resulting in very well-compacted obturation of
no gutta-percha attached, or preferably a file of the apical portion of the canal. The remainder of
the same dimensions as the carrier. The apical the canal may be obturated by further incre-
preparation may then be refined to ensure an ments, or by another method. Briefly, the
accurate fit of the device. technique is as follows.
The canal should be cleaned and dried, and a 1. Fit a gutta-percha cone and mark it at work- Fig. 11 The System-B heat source.
very fine coating of sealer applied to the canal ing length. When the ring on the handpiece is
orifice only. Excess sealer may be extruded under 2. Select one of the System-B pluggers that pressed as shown the tip of the
hydraulic pressure through the apical foramen, plugger is immediately heated to the
binds in the canal 5–7 mm short of the work-
temperature selected.
with resultant pain and inflammation. In the ing length. Set a rubber stop at this level, and

11p667-672.qxd 09/11/2004 14:10 Page 672
PRACTICE
Fig. 12 Heated alpha- ` obturation of a root canal, apical control can be

phase gutta-percha being difficult. The machine has become accepted for
extruded from the silver two specific procedures.
needle of the Obtura II
machine.
CORONAL BACK-FILLING
The previously described System-B achieves an
excellent and controlled obturation of the apical
5–7 mm of the root canal. At this point the canal
is quite wide, and can accept the tip of the Obtu-
ra’s needle. A film of sealer is applied to the
select a conventional plugger to fit at this
canal wall. The machine is heated to 200°C. A
length as well.
small amount of the warm gutta-percha should
3. Dry the canal with paper points.
be extruded to warm the needle and discarded.
4. Apply a thin layer of sealer to the apical
The needle is then quickly introduced to the
third of the selected cone, and insert it to
canal. If this part of the protocol is not followed,
working length.
a void may result between the two parts of the
5. Set the temperature of the System-B at
filling. The trigger is activated and thermoplasti-
200°C, with full power. Heat is applied to the
cised gutta-percha extruded into the canal, gen-
plugger via the finger-tip microswitch, and
tly pushing the needle out. Once the canal is
the part of the cone extruding from the canal
filled conventional pluggers may be used to
orifice is seared off.
compact the gutta-percha, which is finally
6. The tip of the plugger is placed in the centre
sealed with glass ionomer as usual.
of the gutta-percha cone, heat applied, and
the plugger is carefully pushed down the
OPEN APICES
canal in one slow, even movement to the
The open apex, particularly in paediatric
depth marked. This should take about 3 sec-
endodontics, can present a problem if it is too
onds. The heat is turned off, and the plugger
wide to permit the creation of a custom-fitted
held in place for a further 10 seconds.
cone. A method of using the Obtura-II has been
7. With a brief burst of heat to separate the
described whereby an increment of gutta-percha
plugger from the gutta-percha, the plugger is
is applied to the canal close to the apex, and
removed from the canal. It is usually found
gently compacted with pluggers. A rapid-devel-
to bring with it the coronal portion of the
oping radiograph is exposed to verify the posi-
gutta-percha as well.
tion of the apical seal, and further compaction
8. The apical part may now be further compacted
carried out if required. Once the apical seal is
with conventional hand pluggers.
intact the remainder of the canal may be filled
9. The coronal part of the canal may now be
with the Obtura-II in the normal way.
obturated with either injectable gutta-
percha, described later, or further use of the 1. European Society of Endodontology. Consensus report
System-B as follows. for the European Society of Endodontology on quality
10. A small length of gutta-percha, about 7 mm, guidelines for endodontic treatment. Int Endod J 1994;
27: 115–124.
is cut from a further accessory point, coated 2. Saunders W P, Saunders E M. Coronal leakage as a
with sealer and inserted into the canal. cause of failure in root canal therapy: a review. Endod
11. With the heat source turned down to 100°C, Dent Traumatol 1994; 10: 105–108.
3. Gutmann J L. Adaptation of injected thermoplasticised
otherwise this gutta-percha will not stay in gutta percha in the absence of the dentinal smear layer.
the canal, a short burst of heat is applied, the Int Endod J 1993; 26: 87–92.
gutta-percha compacted, and the plugger 4. American Association of Endodontists. Glossary,
removed as before. Hand pluggers may be contemporary terminology for endodontics, edition 6.
Chicago: American Association of Endodontists, 1998.
used to further compact this and any 5 Gee J Y. A comparison of five methods of root canal
subsequent increments required. obturation by dye penetration. Aust Dent J 1987;
12. A layer of resin-modified glass-ionomer 32: 279–284.
6. Haas S B, Campbell A D, Hicks M L, Pelleu G B.
cement is applied over the obturation, and a A comparison of four root canal filling techniques.
post-operative radiograph is exposed as J Endod 1989; 15: 596–601.
normal. 7. McSpadden J T. Presentation to the meeting of the
American Association of Endodontists, Atlanta,
Georgia, USA 1979.
INJECTABLE GUTTA-PERCHA 8. Tagger M, Tanse A, Katz A, Korzen B H. Evaluation of
the apical seal produced by a hybrid root canal filling
Devices for injecting softened gutta-percha have method, combining lateral condensation and thermal
been available for some time, but in the past have compaction. J Endod 1984; 10: 299–303.
suffered from techniques which led to difficulty 9. Johnson W B. A new gutta-percha technique. J Endod
1978; 4: 184–188.
in accurate apical placement. The latest of these, 10. Gutman J L, Saunders W P, Saunders E M, Nguyen L.
the Obtura-II, has recently gained acceptance by An assessment of the plastic thermal obturation
endodontists. The machine resembles a glue-gun. technique. II Material adaptation and sealability.
Pellets of alpha-phase gutta-percha are softened Int Endod J 1993; 26: 179–183.
11. Schilder H. Filling root canals in three dimensions.
at about 200°C in the handpiece, and extruded Dent Clin North Am 1967; 11: 723–744.
through a heated silver needle (Fig. 11). A wide, 12. Buchanan L S. The continuous wave of obturation
well-prepared canal is a prerequisite. Although technique: ‘centred’ condensation of warm
gutta percha in 12 seconds. Dent Today 1996;
the manufacturers describe a procedure for total 15: 60–87.

12p735-743.qxd 19/11/2004 11:40 Page 735
PRACTICE
9
IN BRIEF
● Calcium hydroxide is used in both the preservation of the vital pulp and the disinfection of
the prepared root canal system.
● To achieve success in direct pulp capping a strict aseptic regime must be followed.
● Various forms of root resorption, their aetiology and treatment, are considered.
● The Simon, Glick and Frank classification of endodontic/periodontic lesions is presented and
discussed.
Endodontics: Part 9 VERIFIABLE

Calcium hydroxide, root resorption,
CPD PAPER
endo-perio lesions NOW AVAILABLE

P. Carrotte1
AS A BDJ BOOK
For more than 70 years calcium hydroxide has played a major role in endodontic therapy, although many of its functions are
now being taken over by the recently introduced material MTA. Calcium hydroxide may be used to preserve the vital pulp if
infection and bleeding are controlled; to repair root fractures, perforations, open apices and root resorptions. Endo-perio
lesions are complex and the correct diagnosis is essential if treatment is to be successful. However, root canal treatment will
always be the first phase in treating such lesions.
CALCIUM HYDROXIDE toblasts and connective tissue cells and may be

ENDODONTICS Calcium hydroxide was originally introduced to termed osteodentine. The barrier, which is
1. The modern concept of the field of endodontics by Herman1 in 1930 as composed of osteodentine, is not always com-
root canal treatment a pulp-capping agent, but its uses today are plete and is porous.
2. Diagnosis and treatment widespread in endodontic therapy. It is the most In external resorption, the cementum layer is
planning commonly used dressing for treatment of the lost from a portion of the root surface, which
3. Treatment of endodontic vital pulp. It also plays a major role as an inter- allows communication through the dentinal
emergencies visit dressing in the disinfection of the root tubules between the root canal and the peri-
canal system. odontal tissues. It has been shown that the dis-
canal system association coefficient of calcium hydroxide of
Mode of action 0.17 permits a slow, controlled release of both
A calcified barrier may be induced when calci- calcium and hydroxyl ions which can diffuse
um hydroxide is used as a pulp-capping agent through dentinal tubules. Tronstad et al. demon-
treatment
or placed in the root canal in contact with strated that untreated teeth with pulpal necrosis
healthy pulpal or periodontal tissue. Because had a pH of 6.0 to 7.4 in the pulp dentine and
cavitities
of the high pH of the material, up to 12.5, a periodontal ligament, whereas, after calcium
7. Preparing the root canal superficial layer of necrosis occurs in the pulp hydroxide had been placed in the canals, the
8. Filling the root canal to a depth of up to 2 mm. Beyond this layer teeth showed a pH range in the peripheral
system only a mild inflammatory response is seen, and dentine of 7.4 to 9.6.3
9. Calcium hydroxide, root providing the operating field was kept free of Tronstad et al. suggest that calcium hydroxide
resorption, endo-perio bacteria when the material was placed, a hard may have other actions; these include, for exam-
lesions tissue barrier may be formed. However, the cal- ple, arresting inflammatory root resorption and
10. Endodontic treatment for cium ions that form the barrier are derived stimulation of healing.3 It also has a bactericidal
children entirely from the bloodstream and not from the effect and will denature proteins found in the
11. Surgical endodontics calcium hydroxide.2 The hydroxyl group is root canal, thereby making them less toxic.
12. Endodontic problems considered to be the most important compo- Finally, calcium ions are an integral part of the
nent of calcium hydroxide as it provides an immunological reaction and may activate the
1*Clinical Lecturer, Department of Adult alkaline environment which encourages repair calcium-dependent adenosine triphosphatase
Dental Care, Glasgow Dental Hospital and and active calcification. The alkaline pH reaction associated with hard tissue formation.
School, 378 Sauchiehall Street, Glasgow induced not only neutralises lactic acid from
G2 3JZ the osteoclasts, thus preventing a dissolution Presentation
Email: [email protected] of the mineral components of dentine, but Calcium hydroxide can be applied as a hard set-
could also activate alkaline phosphatases ting cement, as a paste or as a powder/liquid
Refereed Paper which play an important role in hard tissue mixture, depending on the treatment. Various
doi:10.1038/sj.bdj.4811897
© British Dental Journal 2004; 197: formation. The calcified material which is pro- proprietary brands are available, (Fig. 1),
735–743 duced appears to be the product of both odon- although ordinary calcium hydroxide powder BP

12p735-743.qxd 19/11/2004 11:40 Page 736
PRACTICE
may be purchased from a chemist and mixed as these are less prone to fracture. The paste of
with purified water. Because of the antibacterial choice is spread evenly on the shank. The spiral
effect of calcium hydroxide, it is not necessary filler is inserted into the canal and ‘wiped’
to add a germicide. The advantages of using cal- around the walls to reduce air bubble formation.
cium hydroxide in this form are that variable Using a standard handpiece with low rpm, the
consistencies may be mixed and a pH of about root canal is filled with paste. Several applica-
12 is achieved, which is higher than that of tions may be required. A large paper point may
proprietary brands. be used to condense the material into the canal,
Root canal sealers containing calcium hydrox- and this will also absorb excess moisture.
ide are available, and are discussed in Part 5. A pledget of cotton wool is pressed into the pulp
chamber so that the paste is condensed further
Clinical uses and techniques and the access cavity sealed.
The clinical situations where calcium hydroxide
may be used in endodontics are discussed below Powder—liquid
Fig. 1 One of various proprietary
and the techniques described. The method of The powder and liquid are mixed on a glass slab
brands of calcium hydroxide application of calcium hydroxide to tissue is with a spatula to form a thick paste. Although
available important if the maximum benefit is to be sterile water may be used, local anaesthetic
gained. When performing pulp capping, pulpo- solution is more readily available in the surgery.
tomy or treatment to an open apex in a pulpless The material may be applied using a spiral root
tooth, the exposed tissue should be cleaned canal filler as described earlier, however some
thoroughly, any haemorrhage arrested by irri- practitioners prefer to use the small plastic tube
gation with sterile saline and the use of sterile with a long fine point illustrated in Part 7,
cotton wool pledgets. The calcium hydroxide Figure 14. The mixed material is loaded into the
should be placed gently directly on to the tissue, tube and extruded directly deep in the canal.
with no debris or blood intervening.4 A calcium A large paper point may again be used to con-
hydroxide cement may be applied to protect the dense the material further, and absorb excess
pulp in a deep cavity as discussed later. water making the procedure easier and the fill-
ing more dense (Fig. 3). A firmer paste may be
Routine canal medication made by adding powder to a proprietary brand
The indications for intervisit dressing of the root of calcium hydroxide paste.
canal with calcium hydroxide have been con- Of utmost importance in endodontics is the
sidered in Part 7. There are two methods of temporary coronal seal which prevents leakage
inserting calcium hydroxide paste into the root and (re)contamination of the canal system.
canal, the object being to fill the root canal Intermediate restorative material (IRM), or
completely with calcium hydroxide so that it is glass-ionomer cement are useful for periods of
in contact with healthy tissue. Care should be over 7–10 days; for shorter periods, zinc oxide,
taken to prevent the extrusion of paste into the Cavit or other proprietary material may be used,
periapical tissues, although if this does occur as described in Part 5.
healing will not be seriously affected.
Radiographic appearance
Proprietary brands A root canal filled with calcium hydroxide
The root canal system is first prepared and then should appear on a radiograph as if it were com-
dried. A spiral root canal filler is selected and pletely sclerosed, as in Figure 4. The material is
passively tried in the canal. It must be a loose fit prone to dissolution, which would appear on a
in the canal over its entire length, or fracture radiograph as voids in the canal. In the past, the
may occur, as seen in Figure 2. The working addition of more radiopaque agents such as bar-
length of the canal should be marked on the ium sulphate has been recommended. As these
shank with either marking paste or a rubber materials may be resorbed more slowly than the
stop. The author prefers the blade type of filler calcium hydroxide a false picture may be given,
and this practice has largely been discontinued.
Indirect pulp capping

The treatment of the deep carious lesion which
has not yet involved the pulp has for some time
been the subject of intense debate. Some
researchers recommend the use of a calcium
hydroxide lining to stimulate odontoblasts and
increase dentine formation.4,5 Other workers
have claimed that this does not occur.6,7 Some
workers still recommend that infected carious
dentine is removed but a layer of softened sterile
Fig. 2 Spiral root
fillers are prone to
dentine may be left over the intact vital pulp.8
fracture if their passive Most endodontic texts, (for example, see Refer-
fit in the root canal has ences 9 and 10) recommend that all softened
not been verified dentine should be removed and the pulp dealt
before use with accordingly.

12p735-743.qxd 19/11/2004 11:41 Page 737
PRACTICE
Fig. 4 A radiograph showing root canal system filled with

Fig. 3 A paper point may be used to condense the calcium hydroxide, which has the same radio-density as
calcium hydroxide in the canal and remove excess the dentine. Any part of the canal not filled with the
moisture paste appears as a void
There is still controversy, however, over the sterile cotton pledgets. Persistent bleeding indi-
correct treatment of a deep, caries free, cavity, cates an inflamed pulp, which may not respond to
lying close to the pulp. As alluded to in Part 1, the treatment. After placing the calcium hydroxide,
essential treatment is to ensure that there can be the area must be sealed against bacterial ingress,
no bacterial contamination of the pulp via the preferably with a glass-ionomer lining.
exposed dentine tubules.11 This may be achieved
by either a lining of glass-ionomer cement, or the Partial pulpotomy
use of an acid-etched dentine bonding system. Although the technique of pulpotomy is indicated
Some workers have recommended washing the for immature teeth with open apices, as described
cavity with sodium hypochlorite to further disin- in Part 10, it cannot be recommended routinely in
fect the dentine surface, and this seems an emi- mature teeth. However, the technique of partial
nently sensible suggestion. Until further research pulpotomy (a procedure between pulp capping
provides conclusive evidence for or against, how- and pulpotomy) was introduced by Cvek and has
ever, the use of an indirect pulp cap of calcium been shown to be very successful in the treatment
hydroxide is recommended in these situations. of traumatically exposed pulps.12,13 The exposed
The calcium hydroxide cement provides a bacteri- pulp and surrounding dentine is removed under
cidal effect on any remaining bacteria and may rubber dam isolation with a high-speed diamond
encourage the formation of secondary dentine drill and copious irrigation using sterile saline, to
and of a dentine bridge. It is certainly no longer a depth of about 2 mm. Haemostasis is achieved
considered necessary to reopen the cavity at a and the wound dressed with a non-setting calci-
later date to confirm healing. um hydroxide paste, either powder and sterile
saline or a proprietory paste. The cavity is sealed
Direct pulp capping with a suitable lining, such as resin-modified
The aim of direct pulp capping is to protect the glass-ionomer cement, and restored convention-
vital pulp which has been exposed during cavity ally. The tooth should be carefully monitored.
preparation, either through caries or trauma. The
most important consideration in obtaining suc- Mineral trioxide aggregate
cess is that the pulp tissue remains uncontami- Although the majority of practitioners will use
nated. In deep cavities, when an exposure may be calcium hydroxide routinely and effectively for
anticipated, all caries should be removed before pulp capping and various repairs to the root,
approaching the pulpal aspect of the cavity floor. Mineral trioxide aggregate (MTA) is increasingly
If an exposure of the pulp occurs in a carious used in specialist and some general practices. The
field the chances of successful pulp capping are material is described briefly in Part 5, and the
severely compromised. A rubber dam should be application discussed in Part 11. Early research as
applied as soon as pulp capping is proposed. The a root-end filling material showed unparalleled
pulp should be symptom-free and uninfected, results, and workers have since reported similar
and the exposure should be small. Before com- success in other endodontic procedures, with no
mencing large restorations in suspicious teeth it resulting inflammation, and deposition of
may be prudent to test the vitality of the tooth cementum over the restorative material.14–16
with an electronic pulp tester, and also to expose MTA can be used in place of hard-setting calcium
a radiograph to ensure that there is no evidence hydroxide in all these pulp-capping procedures.
of pulpal or periapical pathology. The radiograph
may in fact be more valuable, as misleading Root-end induction (apexification)
results may occur when using an electric pulp The cases in which partial or total closure of an
tester on compromised multirooted teeth. open apex can be achieved are:
If the above criteria have been met and pulp 1. vital radicular pulp in an immature tooth
capping is indicated, the cavity should be cleaned pulpotomy (see Part 10);
thoroughly, ideally with sodium hypochlorite 2. pulpless immature tooth with or without a
solution, and pulpal haemorrhage arrested with periapical radiolucent area.

12p735-743.qxd 19/11/2004 11:43 Page 738
PRACTICE
Fig. 5 A calcific barrier is evident Second visit — 2 to 4 weeks later, remove the cal-
following calcium hydroxide cium hydroxide dressing with hand instruments
therapy in a case with an open apex
and copious irrigation. Care should be taken not
to disturb the periapical tissue. The root canal is
dried and refilled with calcium hydroxide.
Third visit — 6 months later, a periapical radi-
ograph is taken and root filled if closure is com-
plete. This may be checked by removing the cal-
cium hydroxide and tapping with a paper point
against the barrier. Repeat the calcium hydroxide
dressing if necessary.
Fourth visit — After a further 6 months another
periapical radiograph is taken, and the tooth
root-filled if closure is complete. If the barrier is
still incomplete the calcium hydroxide dressing
is repeated.
Fifth visit — This should take place 3 to 6 months
later. The majority of root closures will have
been completed by this time (Fig. 5).
Once again, however, reference must be made

to the increasing use of MTA for root-end
closure and other such endodontic
procedures.17
The success of closure is not related to the age Horizontal fractures

of the patient. It is not possible to determine Horizontal fractures of the root may be treated,
whether there would be continued root growth provided the fracture lies within the alveolar
to form a normal root apex or merely the forma- bone and does not communicate with the oral
tion of a calcific barrier across the apical end of cavity. The blood supply may have been inter-
the root. The mode of healing would probably be rupted at the fracture site only, so that the apical
related to the severity and duration of the peri- fragment remains vital. In these cases, the coro-
apical inflammation and the consequent nal portion of the root can be treated as an open
survival of elements of Hertwig’s sheath. apex. Cvek states that healing with a calcific bar-
Inducing apical closure may take anything rier can be achieved using calcium hydroxide.15
from 6 to 18 months or occasionally longer. It is
necessary to change the calcium hydroxide dur- Iatrogenic perforations
ing treatment; the suggested procedure is given Iatrogenic perforations are caused by an instru-
below: ment breaching the apex or wall of the root
First visit — Thoroughly clean and prepare the canal; probably the most common occurrence is
root canal. Fill with calcium hydroxide. during the preparation of a post space (Fig. 6).
Partial or complete closure by hard tissue may be
induced with calcium hydroxide, provided the
perforation is not too large, lies within the cre-
stal bone and does not communicate with the
oral cavity. Treatment should begin as soon as
possible, adopting the same procedure as for
root-end induction. Closure of perforations
using calcium hydroxide takes considerably
longer than root-end induction in most cases.
An alternative technique, if the perforation can
be visualised with the use of a surgical micro-
scope, would be direct repair with mineral
trioxide aggregate.
If foreign bodies in the form of root-filling
materials, cements or separated instruments
have been extruded into the tissues, healing with
calcium hydroxide is unlikely to occur and a
surgical approach is recommended (Part 11).
ROOT RESORPTION
Fig. 6 The mesial wall of the root Several different types of resorption are recog-
canal at tooth UL1 (21) has been nised: some are isolated to one tooth and slow
perforated during post space spreading, others are rapid, aggressive and may
preparation, causing a lateral involve several teeth. Resorption is initiated
periodontitis
either from within the pulp, giving rise to

12p735-743.qxd 19/11/2004 11:44 Page 739
PRACTICE
Fig. 7 a) Typical view of internal

a b resorption, showing a smooth,
rounded widening of the root canal.
b) A warm gutta-percha technique
will obturate the defect fully
internal resorption, or from outside the tooth, enlarged pulp is visible through the crown. The
where it is termed external resorption. typical radiographic appearance is of a smooth
The aetiology of resorption has been described and rounded widening of the walls of the root
by Tronstad who also presented a new classifica- canal. If untreated, the lesion is progressive and
tion.18 In Tronstad’s view, the permanent teeth will eventually perforate the wall of the root,
are not normally resorbed, the mineralised tis- when the pulp will become non-vital (Fig. 7a).
sues are protected by predentine and odonto- The destruction of dentine may be so severe that
blasts in the root canal and by precementum and the tooth fractures.
cementoblasts on the root surface. If the preden- The treatment for non-perforated internal
tine or precementum becomes mineralised, or, in resorption is to extirpate the pulp and prepare
the case of the precementum, is mechanically and obturate the root canal. An inter-appoint-
damaged or scraped off, multinucleated cells ment dressing of calcium hydroxide may be used
colonise the mineralised or denuded surfaces and a warm gutta-percha filling technique helps
and resorption ensues. Tronstad refers to this to obturate the defect (Fig. 7b). The main prob-
type of resorption as inflammatory, which may lem is the removal of the entire pulpal contents
be transient or progressive. Transient inflamma- from the area of resorption while keeping the
tory resorption will repair with the formation of access to a minimum. Hand instrumentation
a cementum-like tissue, unless there is continu- using copious amounts of sodium hypochlorite
ous stimulation. Transient root resorption will is recommended. The ultrasonic technique of
occur in traumatised teeth or teeth that have root canal preparation may provide a cleaner
undergone periodontal treatment or orthodon- canal as the acoustic streaming effect removes
tics. Progressive resorption may occur in the canal debris from areas inaccessible to the file.
presence of infection, certain systemic diseases, The prognosis for these teeth is good and the
mechanical irritation of tissue or increased resorption should not recur.
pressure in tissue. The treatment of internal resorption that has
perforated is more difficult, as the defect must be
Internal resorption sealed. When the perforation is inaccessible to a
The aetiology of internal resorption is thought to surgical approach, an intracanal seal may be
be the result of a chronic pulpitis. Tronstad achieved with a warm gutta-percha technique.
believes that there must be a presence of necrotic Alternatively, the root canal and resorbed area
tissue in order for internal resorption to become may be obturated using mineral trioxide aggre-
progressive.18 In most cases, the condition is gate. Before the final root filling is placed, a
pain-free and so tends to be diagnosed during calcium hydroxide dressing is recommended.
routine radiographic examination. Chronic pul-
pitis may follow trauma, caries or iatrogenic pro- External resorption
cedures such as tooth preparation, or the cause There are many causes of external resorption,
may be unknown. Internal resorption occurs both general and local.19 An alteration of the deli-
infrequently, but may appear in any tooth; the cate balance between osteoblastic and osteoclastic
tooth may be restored or caries-free. The defect action in the periodontal ligament will produce
may be located anywhere within the root canal either a build-up of cementum on the root surface
system. When it occurs within the pulp chamber, (hypercementosis) or its removal together with
it has been referred to as ‘pink spot’ because the dentine, which is external resorption.

12p735-743.qxd 19/11/2004 11:45 Page 740
PRACTICE
Fig. 8 a) Inflammatory resorption

following periodontal treatment of a a b
tooth with a necrotic pulp. b) Root
canal treatment has been carried
out, and the lesion repaired by a
surgical approach
Resorption may be preceded by an increase in Replacement resorption

blood supply to an area adjacent to the root sur- Replacement resorption is a direct result of trau-
face. The inflammatory process may be due to ma and has been described in detail by
infection or tissue damage in the periodontal Andreasen.21 A high incidence of replacement
ligament, or, alternatively post-traumatic hyper- resorption follows replantation and luxation,
plastic gingivitis and cases of epulis. It has been particularly if there was delay in replacing the
suggested that osteoclasts are derived from tooth or there was an accompanying fracture of
blood-borne monocytes. Inflammation increases the alveolus. The condition has also been referred
the permeability of the associated capillary ves- to as ankylosis, because there is gradual resorp-
sels, allowing the release of monocytes which tion of the root, accompanied by the simultane-
then migrate towards the injured bone and/or ous replacement by bony trabeculae. Radi-
root surface. Other causes of resorption include ographically, the periodontal ligament space will
pressure, chemical, systemic diseases and be absent, the bone merging imperceptibly with
endocrine disturbances. the dentine.
Six different types of external resorption have Once started, this condition is usually irre-
been recognised and recorded in the literature. versible, leading ultimately to the replacement
of the entire root. Calcium hydroxide treatment
Surface resorption is unlikely to help in the treatment of this type of
Surface resorption is a common pathological resorption.
finding.20 The condition is self-limiting and
undergoes spontaneous repair. The root surface Pressure resorption
shows both superficial resorption lacunae and Pressure on a tooth can eventually cause resorp-
repair with new cementum. The osteoclastic tion provided there is a layer of connective tissue
activity is a response to localised injury to the between the two surfaces. Pressure can be caused
periodontal ligament or cementum. Surface by erupting or impacted teeth, orthodontic
resorption is rarely evident on the radiograph. movement, trauma from occlusion, or pathologi-
cal tissue such as a cyst or neoplasm. Resorption
Inflammatory resorption due to orthodontic treatment is relatively com-
Inflammatory resorption is thought to be caused mon. One report of a 5–10-year follow-up after
by infected pulp tissue. The areas affected will be completion of orthodontic treatment found an
around the main apical foramina and lateral incidence of 28.8% of affected incisors.22
canal openings. The cementum, dentine and adja- It may be assumed that the pressure exerted
cent periodontal tissues are involved, and a radi- evokes a release of monocyte cells and the sub-
olucent area is visible radiographically. In the sequent formation of osteoclasts. If the cause of
case illustrated in Figure 8 the root canal was the pressure is removed, the resorption will be
sclerosed following trauma at an early age. Root arrested.
planing during periodontal treatment which
removed the cementum layer appeared to be the Systemic resorption
initiating factor for inflammatory resorption This may occur in a number of systemic diseases
around a lateral canal. The root canal was and endocrine disturbances: hyperparathy-
identified and root canal treatment carried out, roidism, Paget’s disease, calcinosis, Gaucher’s
followed by external surgical repair of the lesion. disease and Turner’s syndrome. In addition,

12p735-743.qxd 19/11/2004 11:46 Page 741
PRACTICE
resorption may occur in patients following Fig. 9 A severe endo-perio lesion

radiation therapy. that may require root resection
Idiopathic resorption
There are many reports of cases in which, despite
investigation, no possible local or general cause
has been found. The resorption may be confined
to one tooth, or several may be involved. The rate
of resorption varies from slow, taking place over
years, to quick and aggressive, involving large
amounts of tissue destruction over a few months.
The site and shape of the resorption defect
also varies. Two different types of idiopathic
resorption have been described.
Apical resorption is usually slow and may
arrest spontaneously; one or several teeth may
be affected, with a gradual shortening of the
root, while the root apex remains rounded. Cer-
vical external resorption takes place in the cervi-
cal area of the tooth. The defect may form either
a wide, shallow crater or, conversely, a burrow- The controversy concerning the effect of peri-
ing type of resorption. This latter type has been odontal disease on the pulp ranges between
described variously as peripheral cervical resorp- those who believe that pulpitis or pulp necrosis
tion, burrowing resorption, pseudo pink spot, or both can occur as a result of periodontal
resorption extra camerale and extracanal invasive. inflammation, to those who state categorically
There is a small defect on the external surface that pulpal changes are independent of the status
of the tooth; the resorption then burrows deep of the periodontium. In the author’s opinion,
into the dentine with extensive tunnel-shaped Belk and Gutmann present the most rational
ramifications. It does not, as a rule, affect the view, which is that periodontal disease may
dentine and predentine in the immediate vicinity damage pulp tissue via accessory or lateral
of the pulp. This type of resorption is easily mis- canals, but total pulpal disintegration will not
taken for internal resorption. Cervical resorption occur unless all the main apical foramina are
may be caused by chronic inflammation of the involved by bacterial plaque (Fig. 9).25
periodontal ligament or by trauma. Both types of The problem that faces the clinician treating
cervical resorption are best treated by surgical perio-endo lesions is to assess the extent of the dis-
exposure of the resorption lacunae and removal ease and to decide whether the tooth or the peri-
of the granulation tissue. The resorptive defect is odontium is the primary cause. Only by carrying
then shaped to receive a restoration. out a careful examination can the operator judge
the prognosis and plan the treatment.26 There are
THE PERIO-ENDO LESION several ways in which perio-endo lesions can be
The differential diagnosis of perio-endo lesions classified; the one given below is a slight modifica-
has become increasingly important as the tion of the Simon, Glick and Frank classification.27
demand for complicated restorative work has
grown. Neither periodontic nor endodontic Classification of perio-endo lesions
treatment can be considered in isolation as clini- Class 1. Primary endodontic lesion draining through
cally they are closely related and this must influ- the periodontal ligament
ence the diagnosis and treatment. The influence Class l lesions present as an isolated periodontal
of infected and necrotic pulp on the periapical pocket or swelling beside the tooth. The patient
tissues is well known, but there remains much rarely complains of pain, although there will
controversy over the effect that periodontal often be a history of an acute episode. The cause
disease could have on a vital pulp. of the pocket is a necrotic pulp draining through
Examination of the anatomy of the tooth shows the periodontal ligament. The furcation area of
that there are many paths to be taken by bacteria both premolar and molar teeth may be involved.
and their toxic products between the pulp and the Diagnostically, one should suspect a pulpally
periodontal ligament. Apart from the main apical induced lesion when the crestal bone levels on
foramina, lateral canals exist in approximately both the mesial and distal aspects appear normal
50% of teeth, and may be found in the furcation and only the furcation shows a radiolucent area.
region of permanent molars.23 Seltzer et al.
observed inter-radicular periodontal changes in Class 2. Primary endodontic lesion with secondary
dogs and monkeys after inducing pulpotomies periodontal involvement
and concluded that noxious material passed If left untreated, the primary lesion may become
through dentinal tubules in the floor of the pulp secondarily involved with periodontal break-
chamber.24 In addition to dentinal tubules, down. A probe may encounter plaque or calculus
microfractures are often present in teeth, allowing in the pocket. The lesion will resolve partially
the passage of microorganisms. Clinically, it is with root canal treatment but complete repair
common to see cervical sensitivity. will involve periodontal therapy.

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PRACTICE
Class 3. Primary periodontal lesions the timing of the root treatment. Ideally, the
Class 3 lesions are caused by periodontal disease tooth should be root filled prior to surgery,
gradually spreading along the root surface. The except for the root to be resected. The pulp is
pulp, although compromised, may remain vital. extirpated from the root to be removed, the
However, in time there will be degenerative canal widened in the coronal 2—3 mm and
changes. The tooth may become mobile as the restored with a permanent material. This means
attachment apparatus and surrounding bone are a retrograde filling will not have to be placed at
destroyed, leaving deep periodontal pocketing. the time of surgery — a procedure which is diffi-
Perodontal disease will usually be seen else- cult to perform owing to poor access and blood
where in the mouth unless there are local predis- contamination of the filling and the likelihood
posing factors such as a severely defective of the restorative material falling into the socket.
restoration or proximal groove.
1. Hermann B W. Dentinobleration der Wurzelkanale
Class 4. Primary periodontal lesions with secondary nach der Behandlung mit Kalcium. Zahnarzt
endodontic involvement Rundschau 1930; 39: 888.
2. Sciaky I, Pisanti S. Localisation of calcium placed over
A Class 3 lesion progresses to a Class 4 lesion amputated pulps in dogs’ teeth. J Dent Res 1960; 39:
with the involvement of the main apical forami- 1128–1132.
na or possibly a large lateral canal. It is some- 3. Tronstad L, Andreason J O, Hasselgren G, Kristerson L,
Riis I. PH changes in dental tissues after root canal
times difficult to decide whether the lesion is
filling with calcium hydroxide. J Endod 1981;
primarily endodontic with secondary periodon- 7: 17–21.
tal involvement (Class 2), or primarily peri- 4. Hasselgren G, Tronstad L. Enzyme activity in the pulp
odontal with secondary endodontic involve- following preparation of cavities and insertion of
medicaments in cavities in monkeys. Acta Odontol
ment (Class 4), particularly in the late stages. If Scand 1978; 35: 289–295.
there is any doubt, the necrotic pulp should be 5. Tronstad L, Mjør I A. Pulp reactions to calcium
removed; any improvement in the periodontal hydroxide containing materials Oral Surgery, Oral
Medicine, Oral Pathology 1972; 33: 961–965
disease suggests that the classification was in 6. Bergenholtz G, Reit C. Reactions of the dental pulp to
fact of a Class 2 lesion. microbial provocation of calcium hydroxide treated
dentine. Scand J Dent Res 1980; 88: 187–192.
Root removal and root canal treatment 7. Warfvinge J, Rozell B, Hedström K G. Effect of calcium
hydroxide treated dentine on pulpal responses.
To prevent further destruction of the periodon- Int Endod J 1987; 20: 183–193.
tium in multirooted teeth, in may be necessary 8. Kidd E A M, Banerjee A. What is Absence of Caries. In
to remove one or occasionally two roots. As this Albrektsson TO, Bratthall D, Glantz P-O J and Lindhe
JT, Tissue Preservation in Caries Treatment. London:
treatment will involve root canal therapy and Quintessence Books, 2001.
periodontal surgery, the operator must consider 9. Kim S, Trowbridge H, Suda H. Chapter 15 in Cohen S
the more obvious course of treatment, which is and Burns R C, Pathways of the Pulp Eighth Edition.
St Louis: Mosby, 2002.
to extract the tooth and provide some form of
10. Hasselgren G. Chapter 9 in Ørstavik D and Pitt Ford T
fixed prosthesis. As a guide, the following fac- R. Essential Endodontology Oxford: Blackwell Science,
tors should be considered before root resection: 1998.
11. Kakehashi S, Stanley H R, Fitzgerald R J. The effects of
1 Functional tooth. The tooth should be a surgical exposures of dental pulps in germ-free and
functional member of the dentition. conventional laboratory rats. Oral Surgery, Oral
2 Root filling. It should be possible to provide Medicine, Oral Pathology 1965; 20: 340–349.
12. Cvek M. A clinical report on partial pulpotomy and
root canal treatment which has a good prog- capping with calcium hydroxide in permanent incisors
nosis. In other words, the root canals must be with complicated crown fracture. J Endod 1978;
fully negotiable. 4: 232–237.
3 Anatomy. The roots should be separate with 13. Fuks A B, Chosack A, Klein H, Eidelman E. Partial
pulpotomy as a treatment alternative for exposed pulps
some inter-radicular bone so that the in crown-fractured permanent incisors. Endod Dent
removal of one root will not damage the Traumatol 1987; 3: 10–102.
remaining root(s). Access to the tooth must 14. Torabinejad M, Hong C U, Lee S J, Monsef M, Pitt Ford
T R. Investigation of mineral trioxide aggregate for
be sufficient to allow the correct angulation root-end filling in dogs. J Endod 1995; 21: 603–608.
of the handpiece to remove the root. A small 15. Schwartz R S, Mauger M, Clement D J, Walker W A.
mouth may contra-indicate the procedure. Mineral trioxide aggregate: a new material for
endodontics. J Am Dent Assoc 1999; 130: 967–975.
4 Restorable. Sufficient tooth structure must 16. Witherspoon D E, Ham K. One-visit apexification:
remain to allow the tooth to be restored. The technique for inducing root end barrier formation in
finishing line of the restoration must be apical closures. Practical Proceedings in Aesthetic
envisaged to ensure that it will be cleansable Dentistry 2001; 13: 455–460.
17. Cvek M. Treatment of non-vital permanent incisors
by the patient. with calcium hydroxide IV. Periodontal healing and
5 Patient suitability. The patient must be a closure of the root canal in the coronal fragment of
suitable candidate for the lengthy operative teeth with intra-alveolar fracture and vital apical
fragment. A follow-up. Odont Revy 1974; 25: 239–246.
procedures and be able to maintain a high 18. Tronstad L. Root resorption — aetiology, terminology
standard of oral cleanliness around the and clinical manifestations. Endod Dent Traumatol
sectioned tooth. 1988; 4: 241–252.
19. Newman W G. Possible etiologic factors in external
A tooth that requires a root to be resected will root resorption. Am J Orthod 1975; 67: 522–539.
20. Henry J L, Weinmann J P. The pattern of resorption and
need root canal treatment. The surgery must be repair of human cementum. J Am Dent Assoc 1951;
planned with care, particularly with respect to 42: 270–290.

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PRACTICE
21. Andreasen J O. Textbook and Colour Atlas of Traumatic experimental animals. J Periodontol 1967; 38: 124–129.
Injuries of the Teeth. Denmark: Munksgaard, 1993. 25. Belk C E, Gutmann J L. Perspectives, controversies and
22. Cwyk F, Scat-Pierre F Tronstad L. Endodontic directives on pulpal-periodontal relationships. J Can
implications of orthodontic tooth movement. J Dent Dent Assoc 1990; 56: 1013–1017.
Res 1984; 63: Abstract 1039. 26. Solomon C, Chalfin H, Kellert M, Weseley P. The
23. Gutmann J L. Prevalence, location and frequency of endodontic-periodontal lesion: a rational approach to
accessory canals in the furcation region of permanent treatment. J Am Dent Assoc 1995; 126: 473–479.
molars. J Periodontol 1978; 49: 21–26. 27. Simon J H, Glick D H, Frank A L. The relationship of
24. Seltzer S, Bender I B, Nazimor M, Sinai I. Pulpitis- endodontic-periodontic lesions. J Periodontol 1972;
induced inter-radicular periodontal changes in 43: 202–208.

British Dental Journal, 15 September 1904
From a discussion of a paper read by Dr H.E. Knight to the North
Midland Branch of the BDA in June 1904
Mr. Robbins wished to emphasise one point. For twenty-five years he had been trying
to find out why there should be such a dread of dentists; the fear being out of all pro-
portion to the pain given. He had arrived at the conclusion that this was caused by
wrong handling in early life. Therefore he was pleased that Dr. Knight recommended
that a child should go to a dentist before it had learned fear. If given a child early
enough, and a free hand to act squarely with that child, never taking it by surprise,
that child should never be afraid of him as a dentist. If it were not afraid of him in
childhood, it would not be in after life.
Br Dent J 1904

Endo_Chapter_10.qxd 10/12/2004 14:00 Page 9
IN BRIEF
PRACTICE




Root canal treatment in children should only be prescribed after careful consideration of the
patient, the existing dentition, and developing teeth.
Isolation with rubber dam is just as important as with the permanent dentition.
Paediatric endodontic treatment may be more directed towards pulpotomy rather than
pulpectomy.
All practitioners should be familiar with current guidelines on the treatment of the avulsed
tooth.
10
VERIFIABLE
CPD PAPER
Endodontic treatment for children
AS A BDJ BOOK
Root canal treatment for children has particular difficulties and considerations. It must be planned in light of the remaining
teeth, and the need for balancing or compensating extraction borne in mind. Diagnosis may be difficult, as may prolonged
treatment under local anaesthesia and rubber dam. Vital pulpotomy techniques with formocresol and/or calcium hydroxide
must be carefully executed in line with the UK National Guidelines. The treatment of the avulsed tooth has been the subject of
much research, and practitioners should ensure that they are up-to-date with current treatment modalities.
Although the basic aims of endodontic therapy (Fig. 2) rather than periapical in site due to the
ENDODONTICS in children are the same as those in adults, ie the presence of accessory canals in the thin floor of
1. The modern concept of removal of infection and chronic inflammation the pulp chamber.
root canal treatment and thus the relief of associated pain, there are As well as the problems associated with the
2. Diagnosis and treatment particular difficulties and considerations. The primary dentition, endodontic treatment of
planning pulpal tissue of primary teeth may become permanent teeth in children may also present
3. Treatment of endodontic involved far earlier in the advancing carious difficulties due to the incomplete root develop-
emergencies lesion than in permanent teeth. Exposure may ment and associated open apices.
4. Morphology of the root also occur far more frequently during cavity
canal system preparation due to the enamel and dentine being BALANCED EXTRACTIONS
thinner than in the permanent tooth, and the Primary teeth with pulpal exposure or pathology
pulp chamber, with its extended pulp horns, must always be treated, either by root canal treat-
treatment
being relatively larger, as can be seen in the ment or by extraction. The maintenance of arch
extracted tooth at Figure 1. Primary molar root length is important for good masticatory
canals are irregular and ribbon-like in shape. function and the future eruption of the
cavities
Periradicular lesions associated with infected permanent dentition with optimal development
7. Preparing the root canal primary molars are usually inter-radicular of the occlusion. Whilst it is preferable to
8. Filling the root canal
system
lesions
10. Endodontic treatment
for children
1*Clinical Lecturer, Department of Adult
Dental Care, Glasgow Dental Hospital and
G2 3JZ
Email: [email protected]
Refereed Paper
doi:10.1038/sj.bdj.4811946 Fig. 1 An extracted deciduous molar showing the Fig. 2 A radiograph of a grossly carious lower second
© British Dental Journal 2005; 198: 9–15 relatively large pulp chamber and root canals. primary molar showing interadicular bone loss.
BRITISH DENTAL JOURNAL VOLUME 198 NO. 1 JANUARY 8 2005 9

PRACTICE
Fig. 3 A dental
panoramic tomograph
taken as part of the
assessment for
extraction of deciduous
molars, reveals the
absence of permanent
lower second premolars.
Fig. 4 Enamel hypoplasia of an upper permanent incisor

following infection of the primary predecessor.
conserve a tooth rather than carry out an extrac- such as those with congenital heart disease, or
tion, if this does become necessary, balanced patients who are immunocompromised. The atti-
extractions should always be kept in mind. A tude of the parent to treatment and the child’s
balanced extraction is the removal of a tooth ability to cooperate during the more lengthy
from the opposite side of the same arch. A com- procedures require careful evaluation. The over-
pensating extraction, removing a tooth from the all dental health of the child, with particular ref-
opposing arch to the enforced extraction is more erence to the caries experience, must be taken
difficult to justify.1 Balanced extractions are into account when making a treatment plan. In a
rarely justified for primary incisors. The loss of a poorly cared for dentition requiring multiple
primary canine, however, may have a significant treatments, the complex conservation of one
effect on the arch and balanced extractions tooth in the presence of a number of comparable
should always be considered. When a primary teeth of doubtful prognosis is poor paediatric
molar has to be extracted it may be preferable to dentistry and should be avoided. In addition,
prevent drifting with a space maintainer than root canal treatment should be avoided in gross-
carry out balanced extractions. ly decayed teeth which may be unrestorable
Extractions should be avoided wherever pos- even after pulp therapy; in teeth where caries has
sible in certain groups of children; ie those with penetrated the floor of the pulp chamber; in
bleeding disorders, or medical conditions such teeth with advanced root resorption, or those
as diabetes where general anaesthesia is contra- close to exfoliation.
indicated. Primary teeth should also be retained An additional problem is the close relation-
where a radiograph reveals the lack of a perma- ship of the roots of the primary teeth to the
nent successor, as in Figure 3, where the patient developing permanent successor. During exfoli-
may find pulp therapy less stressful than extrac- ation, the roots of the former resorb, necessitat-
tion, and in an already crowded dentition where ing the use of a resorbable paste in endodontic
tooth loss would lead to even further crowding treatment. It is also important to remember that
of the permanent teeth. trauma to, or infection of, a primary tooth, may
result in damage to the permanent tooth. This
ENDODONTIC TREATMENT OF PRIMARY may vary from enamel hypomineralisation and
TEETH hypoplasia to, more rarely, the delayed or
Endodontic treatment may be indicated far earli- arrested development of the tooth germ (Fig. 4).
er when treating the primary dentition than in
permanent teeth. Obviously, treatment is indicat- Diagnosis
ed when a patient presents with a pulpal necrosis, The reaction of pulp tissue in primary teeth to
or symptoms of pulpitis. However, the distinction deep caries differs from that seen in the perma-
of reversible or irreversible pulpitis applied to the nent dentition and is characterised by the rapid
permanent teeth is not so relevant in the primary spread of inflammatory changes throughout the
teeth; any sign or symptom of pulpitis indicates coronal portion of the tooth. These pathological
the need for pulp therapy. Current research and changes become irreversible and, if left untreat-
practice also suggests that pulp therapy will be ed, will involve the radicular tissue. There may
necessary when a radiograph shows a carious be few, if any, clinical symptoms in the early
lesion extending more than halfway through the stages to indicate the extent of tissue damage.
dentine, or where the carious process has led to Pain may only occur after involvement of the
the loss of the marginal ridge. periradicular tissues in the spread of infection.
However, there are important assessments to Children are often unable to give accurate
be made as to the patient’s suitability for details of their symptoms, and the responses to
endodontic treatment. The general health of the clinical tests may be unreliable. Difficulties are
patient should be checked to ensure that there frequently experienced in ascertaining the
are no contra-indications to endodontic therapy, condition of the pulp from clinical findings.
10 BRITISH DENTAL JOURNAL VOLUME 198 NO. 1 JANUARY 8 2005

PRACTICE
Fig, 5 A deciduous molar with a deep

carious lesion has been isolated prior
to commencing endodontic therapy.
Radiographs, which are essential prior to the Direct pulp capping

commencement of treatment, may give little This treatment is only recommended when a
information of early pathological changes. small traumatic exposure occurs, during cavity
preparation of a vital non-infected pulp.2 A cal-
Before commencing treatment cium hydroxide dressing is placed directly over
The majority of the following restorative proce- the pulp, followed by a lining and restoration,
dures will require adequate local anaesthesia. and the whole technique is carried out using
In accordance with the biological principles local anaesthesia and with adequate isolation
established throughout this text, adequate isola- from salivary contamination. It has been sug-
tion will also be necessary to prevent salivary gested that the high cellular content of primary
contamination. A rubber dam should be placed, pulp tissue may be responsible for the failure of
and isolation completed with cotton wool rolls direct pulp capping in primary teeth.3 Undiffer-
and saliva ejector as seen in Figure 5. entiated mesenchymal cells may differentiate
into osteoclastic cells in response to either the
Indirect pulp capping caries or direct pulp capping which leads to inter-
The aim of this treatment is to maintain the nal resorption. It is also suggested that exposures
vitality of the pulp in a deep carious lesion, on axial walls have a poor prognosis as the pulp
when there is no direct pulpal involvement. All coronal to the exposure may be deprived of its
the carious dentine must be removed, and a thin blood supply and undergo necrosis.
layer of sound, non-carious dentine must
remain. A lining of setting calcium hydroxide Vital pulpotomy techniques
is placed, which stimulates the formation of These techniques involve the removal of
secondary dentine. The tooth is restored over inflamed coronal pulp tissue and the application
the dressing with a permanent restorative of a dressing to the radicular pulp in an attempt
material. to either promote healing of, or fix, the upper
It has been suggested that other medicaments portions, and to preserve the vitality of the apical
may be used for indirect pulp caps, for example tissue. Because of the difficulties involved in
antibiotic pastes and anti-inflammatory drugs, diagnosing the condition of the pulp tissue histo-
but although some success has been reported, logically before the commencement of treatment,
pulp necrosis and abscess formation often result careful assessment must be made at each stage of
without symptoms. As with the permanent den- the procedure. Whenever the haemorrhage from
tition, research is presently focussing on the use the radicular pulp stumps is profuse and uncon-
of adhesive materials and bonding agents for trolled, the assumption is made that the inflam-
indirect pulp capping. The long-term results of matory process has extended into the radicular
these long-term clinical trials are awaited. tissue, and the therapy modified accordingly.
It should be noted that one technique for indi- There are three pulpotomy techniques.
rect pulp capping, which was described in the
past, is no longer recommended. This was where Vital formocresol pulpotomy
deep caries was carefully excavated, avoiding The treatment is carried out using local anaesthe-
pulpal exposure, and the deeper layers of soft- sia and adequate isolation. Following cavity
ened dentine dressed with a calcium hydroxide- preparation in the normal manner, the deep caries
containing cement and a long-term temporary is removed and the coronal pulp chamber opened,
dressing. After a period of 6–8 weeks the tooth, such that there is no overhanging dentine inhibit-
which should have been symptomless, was ing the complete removal of the pulp tissue. The
reopened, and the arrested carious lesion exam- coronal tissue is removed using a large excavator
ined. The success of this treatment was found to or sterile rosehead bur. If a high-speed diamond
be less predictable and symptoms frequently bur is used it should be cooled with sterile water
developed. It is now recommended that all caries or saline. Sterile cotton wool is applied to the
be removed, and if a pulpal exposure is found radicular pulp tissue to achieve haemostasis. A
then either a direct pulp cap or a form of pulpo- small pledget of cotton wool is dipped in a 1:5
tomy is used. dilution of Buckley’s formocresol (Table 1) and

PRACTICE
Fig. 6 Stainless steel

crowns make ideal
restorations for
compromised
deciduous molars.
Table 1 Buckley’s formocresol Table 2 Paraformaldehyde devitalising paste

Tricresol 35% Paraformaldehyde 1.00 g
Formaldehyde 19% Carbowax 1500 1.30 g
Glycerol 15% Lignocaine 0.06 g
Water 31% Propylene glycol 0.5 ml
Carmine 10 mg
squeezed to remove excess liquid. It is placed over Devitalisation pulpotomy

the radicular pulp stump for 5 minutes in order to This is a two-stage procedure, used when local
fix the inflamed tissue and bacteria and thus anaesthesia cannot be obtained to permit extir-
allow healing of the unaffected pulp. If the haem- pation of the pulp, or when haemorrhage is
orrhage has completely stopped, a layer of zinc uncontrolled before or following the application
oxide–eugenol or glass-ionomer cement is of formocresol. This technique mummifies and
applied, and the tooth restored, preferably with a fixes the coronal pulp tissue, whilst the major
preformed stainless steel crown to prevent subse- part of the radicular pulp remains vital, but it
quent fracture of the weakened tooth (Fig. 6). carries a lower success rate.6
Other materials have been considered as an If the tooth is not anaesthetised, cavity prepa-
alternative to formocresol.4 Concerns about the ration is carried out as far as possible and access
safety of formocresol led to investigations of is gained to the pulpal exposure. A small amount
pulpotomies employing a 2% glutaraldehyde of paraformaldehyde devitalising paste (Table 2)
solution as an alternative dressing, but research on a pledget of cotton wool is applied to the
has shown a lower clinical success rate than with exposed pulp tissue. Formaldehyde vapour liber-
formocresol. Concern about hypersensitivity to ated from the dressing permeates through the
and handling of glutaraldehyde have largely led pulpal space, producing fixation of the tissues. A
to its abandonment as a treatment alternative. soft layer of zinc oxide–eugenol temporary
Recent work by Waterhouse et al. has shown dressing is then placed, without applying pres-
that very favourable results have been achieved sure, to seal the medicament in position. The
with calcium hydroxide when it has been child and parent must be warned of possible dis-
applied in carefully controlled circumstances.5 comfort, for which analgesics are recommended.
Following haemostasis, calcium hydroxide pow- After one to two weeks the tooth is checked for
der was delivered to the pulp chamber using a signs and symptoms. The devitalised coronal
small, sterile, endodontic amalgam carrier. The pulp may now be removed, without the need for
powder is condensed over the pulp stumps with local anaesthesia. A hard setting layer of zinc
an amalgam condensor and small pledgets of oxide–eugenol, which may be mixed with
cotton wool. Failure of this technique is formocresol, is then placed over the radicular
explained by the presence of an extra-pulpal stumps and the tooth restored. If some vital tissue
clot separating the calcium hydroxide from the remains in the coronal pulp chamber, a further
pulpal tissue and thus impairing healing.3 dressing of paraformaldehyde paste is required.
Both the calcium content and alkaline proper-
ties of the dressing are important to achieve Non-vital pulpotomy
healing. An initial layer of necrotic tissue devel- This technique has been advocated where there is
ops, which becomes associated with an inflam- irreversible change in the radicular pulp, or where
matory reaction. Subsequently, a matrix forms the pulp is completely non-vital, but where
and mineralises to become a hard tissue barrier pulpectomy and root canal treatment is consid-
of dentine-like material. ered impractical. The little clinical evidence

PRACTICE
available suggests a limited prognosis of approxi-

mately 50%. At the first visit the necrotic pulp Table 3 Beechwood creosote
contents are removed as before, and, using small 0-Methoxy phenol (Guaicol) 47%
excavators, as much as possible of the radicular P-Methoxy phenol 26%
tissue. Beechwood creosote solution (Table 3) on a 2-Methoxy, 4 methyl phenol (Cresol) 13%
cotton pledget is sealed into the cavity with a zinc M-Methoxy phenol 7%
oxide–eugenol dressing. Other 7%
One to two weeks later the tooth is checked for
signs and symptoms. If there is evidence of
infection (sinus, pain, swelling or mobility) a
further beechwood creosote dressing should be root. Inflammatory follicular cysts9 may devel-
placed. If, however, symptoms have resolved, the op, which necessitate the removal of the primary
tooth may be restored as with the previous tooth and marsupialisation of the cyst to allow
pulpotomy techniques. the permanent tooth to erupt.
Pulpectomy PERMANENT DENTITION

Pulpectomy is indicated where the pulp is either Immature permanent incisors
non-vital or irreversibly inflamed. Although the Although one in five children will suffer trauma
technique is often considered difficult because to their developing permanent incisors, only
of the complexity of the root canals in primary about 6% of these will subsequently become
molars, clinical studies have shown a reasonable non-vital and require endodontic treatment. The
prognosis.7 The cavity preparation and removal correct initial diagnosis of such traumatised
of the necrotic coronal pulp is carried out as pre- teeth, based on signs and symptoms, radi-
viously described. If the radicular pulp is necrot- ographic examination and sensibility testing, is
ic, a two-stage procedure is required, but if it is therefore very important. Laser Doppler flowme-
found to be irreversibly inflamed a one-stage try has shown that traumatised immature teeth
technique may be undertaken. with open apices may have a vital pulp even in
the absence of a response to conventional sensi-
One-stage technique bility testing. If there is any uncertainty about
The root canals are identified and instrumented to the vitality of the pulp, root canal treatment
the working length estimated from a pre-operative should be deferred and the tooth kept under
radiograph. After drying the canals with paper regular review.
points, formocresol is applied for up to 5 minutes. If, however, endodontic treatment of an
The root canals are then filled with a thin mix of immature permanent tooth with an open apex is
zinc oxide–eugenol, using a rotary paste filler, and indicated, a root-end closure technique is neces-
the restoration of the tooth is completed. sary to form a calcific barrier against which the
obturation may eventually be compacted with-
Two-stage technique out extruding material into the periradicular
Here the root canals are again cleaned, shaped tissues (Fig. 7).
and irrigated to remove all necrotic debris. A The tooth should be isolated with rubber dam,
pledget of cotton wool moistened with either and the pulp chamber accessed. Local anaesthe-
formocresol or beechwood creosote is sealed in sia is usually given as some vital tissue may still
the pulp chamber with a rigid zinc oxide– be encountered during pulp extirpation. In
eugenol dressing for one week. At the subsequent severe cases an intracanal steroid dressing, such
visit the tooth should be symptom-free, firm, as Ledermix, may be required for one week.
without a discharging sinus. (If not, a second Canal preparation is carried out with files to
application of beechwood creosote is required.) If approximately 1–2 mm short of the working
the tooth is found to be symptomless, a dressing length, estimated from the pre-operative radi-
of zinc oxide–eugenol, with or without the addi- ograph and confirmed during treatment. Copi-
tion of formocresol, is packed into the base of the ous irrigation with a sodium hypochlorite solu-
chamber and the tooth finally restored. tion is necessary to remove all necrotic debris.
The preceding techniques are reviewed in the The root canal should be dried with paper points,
UK National Guidelines.8 and then filled to the apex with calcium hydrox-
ide paste, compressed with large paper points
Review and/or cotton pledgets. The access cavity should
Following any form of endodontic treatment, be sealed with a long-term temporary dressing,
regular clinical and radiographic reviews must such as glass-ionomer cement.
be made of the tooth involved and its successor. After one month, the dressing is carefully
If rarefaction of the bone in the furcation area is removed with copious irrigation, and the dried
seen, further pulpectomy may be possible, but canal refilled with calcium hydroxide paste.
extraction is probably indicated. Radiographs After a further three to six months the tooth is
should also be checked for evidence of internal opened again and a large paper point used at
resorption, which may occur in limited areas in working length to feel for a calcific barrier. The
formocresol pulpotomies, but may be more paper point is gently inserted into the clean, dry
extensive following the use of calcium hydrox- canal. At the estimated working length either the
ide. It may progress to cause perforation of the point will remain dry, tap against a hard barrier,

PRACTICE
Fig. 7 a) An immature tooth with a

non-vital pulp has been filled with a b
calcium hydroxide b).
with no sensation to the patient indicating clo- achieved by adequate isolation. Caries should be
sure, or will press against soft granulation tissue excavated and the tooth treated in accordance
which the patient will feel. The average time with conventional protocols. If a small exposure
taken for closure is 6 months. of a vital tooth occurs, either accidentally during
If no barrier is detected, the calcium hydroxide cavity preparation or because of caries, and the
is replaced. If the open apex is found to be surrounding tissue is healthy, a direct pulp cap
completely closed, the canal may be obturated with calcium hydroxide cement may be applied.
with gutta-percha and sealer. Closure of an open A lining of glass-ionomer cement is then placed
apex may be anticipated in over 90% of cases to seal the dentine tubules prior to the definitive
treated by this technique, with a 4-year progno- restoration. If amalgam is used, a dentine bond-
sis of 85%.10 Obturation may then be completed ing system should be considered to ensure
by one of several methods. Conventional cold complete sealing of the restoration.
lateral compaction may be used, perhaps invert- If the exposure is large and the vitality of the
ing a large gutta-percha point to obtain a good radicular pulp is to be maintained to allow for
apical tug-back. A custom gutta-percha point root development, a pulpotomy may be carried
may be made by rolling several GP points out. Following the opening of the coronal pulp
together after softening in solvent or gentle chamber and the removal of the pulp tissue, the
heat, and repeated fitting to the canal, carefully area is irrigated and dried. Haemostasis of the
marking the orientation at insertion. However, radicular pulp should be observed prior to the
injectable thermo-plasticised gutta-percha may application of calcium hydroxide cement or
be the most suitable obturation medium. paste, and the provision of a permanent restora-
tion. A calcific barrier should develop adjacent
First permanent molar to the dressing, and root development continue
The first permanent molar may, soon after erup- in the presence of healthy pulp tissue.
tion, show extensive caries, sometimes associat- If the pulp of a young, permanent molar is
ed with hypoplasia. Consideration must be given found to be non-vital, endodontic treatment
to the age of the patient and the dental develop- should be undertaken only after careful assess-
ment, the occlusion and possible need for ortho- ment of the developing occlusion, the condition
dontic treatment, as well as the long-term of the comparable teeth, the patient’s ability to
restorative prognosis of the tooth and the cooperate and the long-term prognosis of the
patient’s ability to tolerate involved treatment tooth. If pulpal necrosis occurs prior to the com-
over a long period. Where necessary, planned plete development of the apex, the objective of
extractions should be considered. The primary treatment, as described earlier, is to encourage
aim of conservation is to ensure that root growth further deposition of calcified tissue in the apical
continues with completion of apical formation, region. Thorough preparation of the root canals
so that definitive endodontic treatment, if is carried out, avoiding damage to the apical tis-
required, may be carried out at a later stage. sues and cells of Hertwig’s root sheath. Calcium
The vitality of the tooth must be assessed and hydroxide is then applied as previously
radiographs should be available, showing the described. Definitive endodontic treatment is
extent of carious involvement and the state of carried out when an apical barrier has formed
the periapical tissues. It is essential that a local and the tooth is then permanently restored. If
anaesthetic is administered and salivary control symptoms arise in fully developed, young,

PRACTICE
permanent teeth, conventional orthograde root- with a glass-ionomer restoration for at least
filling with gutta-percha and sealer is indicated. 6 months prior to verification of an apical barrier
and obturation as described earlier.
Avulsed permanent teeth Replanted teeth should be regularly reviewed
In the emergency management of an avulsed for at least 2–3 years, checking for inflammatory
permanent tooth, time is of the essence. The resorption, replacement resorption, ankylosis,
long-term prognosis begins to deteriorate after infra-occlusion and discoloration. The adjacent
only 15 minutes.11 Most cases initially present teeth should also be reviewed. Resorption may
with a telephone call. Where possible, re- commence within weeks of the injury.
implantation should be immediate, following Finally, it should be realised that there are some
rinsing if necessary in either milk (preferably) or situations where replantation is not appropriate.
tap water. The tooth should be held in place by For example:
biting gently on a soft cloth until splinting is • If the patient has other serious injuries,
possible by the dentist. If the person attending which should be given priority.
the accident is not prepared to re-implant the • If the patient has an at-risk medical history.
tooth, it should be stored in milk, normal saline • Where the extra-oral time is very prolonged,
or saliva (in the buccal sulcus) during the journey the prognosis is very poor, particularly in
to the dental surgery. teeth with short roots and wide apices.
Avoiding unnecessary delay, and keeping the • Primary teeth should not be replanted due to
tooth in the transport solution to prevent drying the possibility of damage to the permanent
of the periodontal fibres, a thorough medical, replacement.
dental and accident history should be taken and
recorded. Local anaesthesia may be necessary to
permit manipulation of the alveolar bone, and to Figures 1, 2, 3, 5, 6 and 7 have been reproduced by kind
permission of Dr M-T Hosey, Children’s Department,
enable gentle syringing of the socket with saline Glasgow University.
to remove any blood clot. The tooth, handled Figure 4 is reproduced by kind permission of Professor R R
only by the crown, should be carefully inserted Welbury.
into the socket. Root canal treatment should NOT
be commenced before re-implantation. 1. BSPD and IAPD. UK national guidelines in paediatric
dentistry. Int J Paediatr Dent 2002; 12: 151–153.
A non-rigid splint should be applied for 7–10 2. Kopel H M. Considerations for the direct pulp capping
days, using acid-etched resin with a soft arch procedure in primary teeth: A review of the literature.
wire. The patient should be advised to avoid bit- Paediatr Dent 1992; 59: 141–149.
ing on the splinted tooth, take a soft diet, and 3. Gould A, Johnstone S, Smith P. Pulp Therapy
techniques for the deciduous dentition. (Compact
maintain good oral hygiene with careful brush- Disk) London: King’s College, 1999.
ing and a chlorhexidine mouth-rinse. Systemic 4. Waterhouse P J. Formocresol and alternative primary
antibiotics may be indicated for medically com- molar pulpotomy medicaments: a review. Endod Dent
Traumatol 1991; 11: 157–162.
promised patients. The patient’s tetanus status 5. Waterhouse P J, Nunn J H, Whitworth J M. An
must be checked and a booster given by a med- investigation of the relative efficacy of Buckley’s
ical practitioner if necessary. A review appoint- Formocresol and Calcium Hydroxide in primary
ment should be made in two days to verify the molar vital pulp therapy. Br Dent J 2000; 188: 32–36.
6. Coll J A, Sadrian R. Predicting pulpotomy success
splint, and modify it if necessary. and its relationship to exfoliation and succedanesus
In very young patients where the tooth has a dentition. Paediatr Dent 1996; 18: 57–63.
wide-open apex and was out of the mouth for 7. Barr E S, Flaitz C M, Hicks M J. A retrospective
radiographic evaluation of primary molar
only a short period there is a possibility of re- pulpectomies. Paediatr Dent 2000; 13: 4–9.
vascularisation of the pulp. The tooth should be 8. Llewelyn D R. UK national guidelines in paediatric
kept under almost weekly review, and if any dentistry. Int J Paediatr Dent 2000; 10: 248–252.
9. Shaw W, Smith D M, Hill F J. Inflammatory follicular
clinical signs of non-vitality develop, such as cysts. J Dent Child 1980; 47: 97–101.
tenderness, discoloration, swelling or sinus for- 10. Mackie I C, Worthington H V, Hill F J. A follow up
mation, endodontic treatment should be com- study of incisor teeth which have been treated by
menced immediately. Endodontic treatment apical closure and root filling. Br Dent J 1993; 175:
99–101.
should be commenced on all other avulsed teeth 11. Andersson L, Bodin I. Avulsed human teeth replanted
whilst the splint is in place. A long-term calcium within 15 minutes — a long term clinical follow-up
hydroxide dressing should be sealed in place study. Endod Dent Traumatol 1990; 6: 37–42.

2p71-79.QXD 10/01/2005 11:30 Page 71
IN BRIEF
PRACTICE




A surgical approach to a failed root canal treatment should only be considered when an
orthograde approach is not possible.
The reason for failure should be carefully diagnosed before surgery is prescribed.
Modern periradicular surgery involves the use of an operating microscope, microsurgical
instruments, and appropriate retrograde sealing materials
All surgical treatment should be followed-up, and encompassed in audit procedures.
11
VERIFIABLE
CPD PAPER
Surgical endodontics
NOW AVAILABLE
AS A BDJ BOOK
Root canal treatment usually fails because infection remains within the root canal. An orthograde attempt at re-treatment
should always be considered first. However, when surgery is indicated, modern microtechniques coupled with surgical
magnification will lead to a better prognosis. Careful management of the hard and soft tissues is essential, specially designed
ultrasonic tips should be used for root end preparation which should ideally be sealed with MTA. All cases should be followed
up until healing is seen, or failure accepted, and should form a part of clinical audit.
Although conventional orthograde root canal points and subsequently suffered surgery when
ENDODONTICS therapy must always be the preferred method of the problem did not resolve. The correct treat-
1. The modern concept of treating the diseased pulp, there are occasions ment should have been a repeat of the orthograde
root canal treatment when a surgical approach may be necessary. If treatment to remove the infection from within
2. Diagnosis and treatment orthograde treatment has failed to resolve the the root canal space that was causing the failure.
planning situation, the clinician should make every effort Figure 2 shows totally inadequate endodontic
3. Treatment of endodontic to ascertain why this has happened. A surgical treatment. The case requires total dismantling
emergencies approach is only indicated when it is agreed that and thorough orthograde retreatment.
4. Morphology of the root orthograde retreatment is either not possible or There have been considerable developments in
canal system will not solve the problem. periradicular surgery, both in technique and
5. Basic instruments and The two cases shown in Figures 1 and 2, both materials, in recent years.1–6 Specialist practition-
materials for root canal of which were referred for periradicular surgery, ers routinely use surgical microscopes in conjunc-
treatment illustrate this point well. Figure 1 shows a radi- tion with specially designed microsurgical instru-
6. Rubber dam and access ograph of a lower molar that was causing symp- ments and retrograde filling materials. A
cavities toms, having first been obturated with silver description of these techniques is included in this
chapter, and general practitioners are encouraged
7. Preparing the root canal
to compare this with their current practice, and
8. Filling the root canal adopt as many of these new procedures as
system
lesions
children
Dental Care, Glasgow Dental Hospital and
G2 3JZ
Fig. 1 This tooth has been obturated with silver points,
Refereed Paper and subsequently received periradicular surgery. The Fig. 2 This case requires complete dismantling and
doi:10.1038/sj.bdj.4811970 correct treatment should have been orthograde orthograde retreatments. Periradicular surgery is unlikely
© British Dental Journal 2005; 198: 71–79 retreatment and conventional obturation to be successful

2p71-79.QXD 10/01/2005 11:31 Page 72
PRACTICE
Fig. 3 The only way

that this extruded
filling material may
be removed is by a
surgical approach
Fig. 4 It would almost certainly be impossible to carry out

orthograde root canal treatment on this tooth
Fig. 5 The pulpal space in this tooth has Root-end resection (apicectomy)
been obliterated following trauma. The term apicectomy refers to a stage of the
Orthograde access proved impossible
operation only. The principal objective is to seal
the canal system at the apical foramen from the
periradicular tissues. To do this it is necessary
to resect the apical part of the root to gain
access to the root canal, hence the term. Root-
end resection must be an adjunct measure to
orthograde root treatment for two reasons.
Firstly, there is very little chance of being able
to seal all the lateral communications between
the canal and the periodontal ligament with a
retrograde root-filling technique. Secondly, the
area of root-filling material exposed will be
greater and the long-term success affected,
because all root-filling materials are, to some
extent, irritant to the tissues.
Indications for root-end resection

Improvements in root canal treatment tech-
niques have lessened the need for apical
surgery. Cases which at first seem obvious
candidates for endodontic surgery may respond
to conventional treatment provided careful
thought is given to the aetiology. Once the
decision has been made to carry out
possible. Alternatively, if these new techniques surgery, consideration must be given to the
are not employed, greater consideration chances of success (see Part 12). Access and
should be given to referral for specialist surgical control of the operating environment are
treatment. essential, otherwise the end result will be
counterproductive.
INDICATIONS FOR SURGICAL INTERVENTION
Although endodontic surgery is carried out Retreatment of a failed root filling
primarily in cases of failed orthograde treatment, Surgery may be considered if a root filling fails
there are other indications. Surgery may and retreatment cannot be effected by orthograde
be necessary to establish drainage, (considered means. There are a number of reasons why a root
in Part 3); to biopsy a lesion; to repair any filling might fail, but generally this is due to
defects or perforations in the tooth root; to resect inadequate cleansing and filling of the root canal.
a multi-rooted tooth where, for technical reasons, Some root fillings can prove very difficult to
one of the roots cannot be successfully treated. remove, for example hard setting pastes.
Occasionally there may be an anatomical reason
Biopsy of a periapical lesion for the failure, such as an unfilled apical
The one specific indication for endodontic delta. Attempts at retreatment by a conventional
surgery is uncertainty about the nature of the orthograde route may be unsuccessful because
apical lesion. The lesion should be excised in its the original canal cannot be negotiated. Periradic-
entirety and sent for evaluation. ular surgery and root-end filling is therefore

2p71-79.QXD 10/01/2005 11:32 Page 73
PRACTICE
Fig. 7 Orthograde attempts have

failed to obturate this tooth with an
open apex
Fig. 6 This fractured instrument in the apical third of the

root canal proved impossible to remove
justified to ensure that the apical foramen has

been sealed.
Root-filling material which has been extruded
through the apical foramen may be a contribu-
tory cause of failure, since it could be an indica-
tion that the apical seal is deficient; necrotic
material may be present at the apex and between
the interface of the root filling and the canal
wall; the root-filling material itself may be
highly irritant (Fig. 3). • Existing post in the root canal unfavourable
for dismantling (Fig. 8).
PROCEDURAL DIFFICULTIES • Lateral or accessory canal (Fig. 9).
During conventional orthograde root canal
treatment, problems may arise as a result of one Unusual root canal configurations
of the following: Instrumentation of canals in roots which exhibit
• Unusual root canal configurations (Fig. 4). bizarre morphology or severe dilaceration may
• Extensive secondary dentine deposition prove impossible. Similarly, where there is an
(Fig. 5). apical delta, thorough cleansing, shaping and
• Fractured instruments within the root canal obturation of the canal may prove impossible
(Fig. 6). and surgery will be required to complement the
• Open apex (Fig. 7). orthograde approach.
Fig. 9 These lower incisors have been treated but

Fig. 8 It was agreed that any attempt to remove the large symptoms have persisted at tooth 41 (LR1). The
post and core in tooth 21 (UL1) to permit orthograde radiograph shows that the periodontitis is centred on the
retreatment may result in a root fracture. The patient portal of exit from a lateral canal, which still must
elected for a surgical approach contain infected debris

2p71-79.QXD 10/01/2005 11:33 Page 74
PRACTICE
Fig. 10 If this tooth is Existing post in the root canal

to be retained with this Periradicular surgery may be indicated for
post perforation, teeth with symptomatic periapical lesions
surgical repair will be
required
which have satisfactory post crowns in place,
provided the root filling in the main body of
the canal is satisfactory. However, it has to be
remembered that success depends on the canal
system being completely sealed. If there is any
doubt about this, it is better to remove the
crown and post and carry out orthograde root
treatment, avoid surgery, and thus provide a
sound foundation for any subsequent restora-
tion. Dismantling of post crowns is, however,
not always straightforward. An assessment
must be made of the length and shape of the
post, the strength of the remaining root struc-
ture and, if possible, the cement used. Injudi-
cious force during post removal may lead to
root fracture and the loss of the tooth. The situ-
Extensive secondary dentine deposition ation should be discussed in detail with the
The ageing process results in the deposition of patient in order that informed consent to the
secondary dentine, with a consequent reduction chosen procedure is obtained.8
in size of the pulp chamber and the root canal.
Even more profound sclerosis may result in a Lateral or accessory canal
tooth which has been subjected to trauma. An Modern endodontic techniques should enable the
asymptomatic irreversible pulpitis may result, root canal to be shaped adequately to permit
bringing about sclerosis of the root canal sys- flushing of sodium hypochlorite irrigation
tem. The canals may then be almost completely throughout the entire root canal system.
obliterated and it may prove impossible to iden- Unfortunately, infected debris may occasionally
tify the canals with even the smallest instru- persist in lateral or accessory canals. Whilst
ments. Under these circumstances, continued orthograde retreatment may be attempted, a
searching deep in the root may result in exces- surgical approach may be the only solution, par-
sive damage, weakening of the root, or even per- ticularly if these canals form part of the apical
foration. Periradicular surgery is then the only delta which may be eliminated by adequate
alternative to extraction. surgical resection.
Fractured instruments within the root canal SURGICAL REPAIR OF ROOTS

Instruments which have fractured in a root canal Surgery may be necessary to repair defects in a
do not necessarily result in failure of the root root surface due to either iatrogenic or patho-
treatment. They should be removed if possible, logical causes. The two main indications are as
but if this is impossible, then an attempt should follows.
be made to seal the rest of the canal with the
instrument in place. Surgery is only necessary if Perforations
the tooth develops symptoms, or radiographic Where possible, an orthograde approach should
review shows a failure of healing. The incident first be used to seal the perforation, ideally using
should, of course, be recorded in the records, and mineral trioxide aggregate (MTA). If this is not
the patient informed. practical, the canal must be thoroughly cleaned
and filled with calcium hydroxide paste to dry it
Open apex out and to allow the tissues time to heal. The pre-
Teeth that have been injured before root develop- pared canal space should then be obturated
ment is complete should be treated conventionally using conventional root canal filling techniques.
in the first instance. If the pulp is vital, then the Perforations caused by instrumentation errors
coronal pulp is removed and the remaining vital can usually be treated by an orthograde
radicular pulp is covered with calcium hydroxide approach as the access is generally good. How-
to allow continued root development; this is ever, if clinical symptoms persist or there is bone
termed ‘apexogenesis’. If the pulp is irreversibly resorption, or in the case of a large perforation
inflamed, then the radicular pulp is removed and as shown in Figure 10, a surgical approach will
the canal filled with calcium hydroxide to be necessary.
encourage root formation and closure of the
apex; this is termed ‘apexification’.7 Internal and external root resorption
However, should the treatment fail, then api- Internal resorption should always be treated by
cal surgery may be necessary, to provide an api- an orthograde route first. If the resorptive process
cal seal after completion of the orthograde root has perforated through to the periodontal liga-
filling. Care must be exercised when carrying ment, then surgery may be necessary to repair the
out this operation as the root structure is often root and provide an effective seal. Certain types of
very delicate. external root resorption in the early stages can be

2p71-79.QXD 10/01/2005 11:33 Page 75
PRACTICE
dealt with by surgery, provided access can be be exposed at the apex as a consequence of the
gained to the area (see root resorption). operation. If a sinus is present in the soft tissues,
the sinus tract should be visualised by taking a
Root amputation and hemisection radiograph with a gutta-percha point threaded
Periradicular surgery on a posterior tooth is a into the tract, as shown in Part 2, Figure 5.
more difficult procedure to carry out than on an Good visual access is extremely important,
anterior tooth. For this reason, the relatively sim- and the anatomy of the area must be thoroughly
pler techniques of root amputation or hemisec- understood. The position of any major structures
tion may be considered. The changes in endodon- such as neurovascular bundles and the maxil-
tic and periodontal treatment techniques in recent lary sinus must be noted. A buccal or labial
years have greatly improved the prognosis for approach is always preferred, as a palatal
this form of treatment. The principal indications approach is difficult and should only be under-
are endodontic, restorative or periodontal. Root taken in exceptional circumstances by experi-
amputation is an operation where one entire root enced practitioners.
of a multirooted tooth is removed, leaving the One of the key factors influencing the success
crown intact. Hemisection is the division of a or failure or periradicular surgery is the experi-
tooth, usually in a buccolingual plane. Normally, ence and expertise of the operator. Considera-
one half of the tooth is removed, but both sections tion should always be given to referral to an
may be retained if there is disease in the furcation appropriate specialist, especially in difficult
area only. However, the restorative problems this cases. A letter of referral should include a full
type of treatment poses are considerable and for clinical and medical history, and all relevant
this reason the prognosis is generally poor. Pre- radiographs. Both the referring dentist and the
operative assessment of both the periodontal and specialist providing treatment have a responsi-
restorative aspects is crucial if these methods of bility to obtain informed consent to the
treatment are contemplated. procedure.
MEDICAL AND DENTAL CONSIDERATIONS PERIRADICULAR SURGERY TECHNIQUE

Although there are few absolute contra-indica- The steps for carrying out this procedure are:
tions to endodontic surgery, a well-documented 1. Pre-operative care.
medical history is essential (see Part 2). In gen- 2. Anaesthesia and haemostasis.
eral, heart disease, diabetes, blood dyscrasias, 3. Soft-tissue management.
debilitating illnesses and steroid therapy may 4. Hard-tissue management.
contra-indicate surgery and special measures 5. Curettage of area.
are necessary if surgery is contemplated. Con- 6. Resection of root.
sideration must also be given to psychological 7. Retrograde cavity preparation.
factors. As a rule, local analgesia is preferable, 8. Retrograde filling.
but patients who are particularly apprehensive 9. Replacement of flap and suturing.
may wish to have any surgery carried out under 10. Post-operative care.
sedation. The choice of anaesthetic may also be
governed by the nature of the operation, the site Pre-operative care
of the tooth and ease of access. A history of Although prophylactic antibiotic therapy is not
rheumatic fever is not a contra-indication for usually required for routine periradicular sur-
endodontic surgery, provided appropriate gery, systemic antibiotics may be required for
antibiotic cover is given. If there is any doubt any flare-ups prior to surgery. Chlorhexidine
about a patient’s fitness to undergo any surgical mouthwashes may also be beneficial, and these,
endodontic procedure, then the patient’s physi- together with systemic non-steroidal anti-
cian should always be consulted. inflammatory drugs, should be considered from
The first considerations are whether the tooth the day prior to surgery.9
is worth saving and how important it is in the
overall treatment plan. The general state of the Anaesthesia and haemostasis
mouth should be considered, both hard and soft Wherever possible, local anaesthesia is the
tissues. The quality of restorative work in the method of choice, although anxious patients
tooth concerned should be particularly noted, who cannot be controlled with tranquillizers
and an assessment must also be made of the may also require intravenous sedation. The
effects of any proposed surgery on the periodon- local anaesthesia injection also provides
tal condition. The presence of any detectable haemostasis, essential for good endodontic
dehiscence or bony fenestration will influence surgery. Following topical anaesthetic applica-
the design and extent of the flap. tion, an anaesthetic solution with at least
A periapical radiograph should provide all the 1:80,000 adrenaline is injected slowly into sev-
information required for assessment of the eral sites surrounding the surgical field. Local
tooth, although it may be necessary to expose anaesthetic solutions containing Octapressin do
more than one film, from different angles. At not give adequate haemostasis and should be
least 3 mm of the periradicular tissues should be avoided if possible.
clearly visible. Assessment should be made of In the mandible, block injections should be
the root shape, taking into account any unusual given, in addition to infiltration of the tissues in
curvature and the number of foramina that may the operating area. In the maxilla, the palate

2p71-79.QXD 10/01/2005 11:35 Page 76
PRACTICE
Fig. 11 The outline for the incision to raise a) a full muco-

periosteal flap, b) a semilunar flap (not recommended), a
and c) the Luebke-Oschenbein flap
c
b
must be well infiltrated to anaesthetise the Full mucoperiosteal flap

greater palatine nerve. The incisive papilla and This design of flap provides the best possible
canal must also receive sufficient anaesthetic access to all surgical sites, and can be either a
solution to block the long sphenopalatine nerve. rectangular flap with mesial and distal vertical
The local anaesthetic should be applied at least relieving incisions, or triangular with just one.
10 minutes prior to surgery, to allow profound The former usually provides better access to the
anaesthesia and maximum haemostasis. root apex in the anterior part of the mouth,
though when operating on posterior teeth the
Soft-tissue management distal relieving incision is not usually neces-
The design of the surgical flap should permit an sary, and may prove difficult to suture in the
unobstructed view of the operating area and limited space available. The vertical relieving
permit easy access for instrumentation. The incisions are made firmly down the line angle
following points need to be considered: of the teeth into the gingival crevice, taking in
1. The blood supply to the flap and adjacent the papilla. The horizontal incision is made
tissues must be sufficient to prevent tissue along the gingival crevice. The flap is then
necrosis when it is repositioned. carefully reflected with a periosteal elevator
2. The edges of the flap should lie over sound lifting the periosteum with it from the bone.
bone and not cross any void; otherwise (Fig. 11a).
breakdown may occur and defective healing
will result. Semilunar flap
3. Relieving incisions should be vertical, and This flap, where an incision was made in a semi-
should not cross any bony eminence, for circle from near the apex of the adjacent tooth,
example the canine eminence, as healing onto the attached gingival, and finishing near
will be poor, particularly if there is a dehis- the apex of the tooth on the other side, is men-
cence or fenestration present. tioned purely for historical purposes, and is no
4. The incision must be clean, so that the flap longer recommended. Its main disadvantage is
can be reflected without any tearing of the the scarring which invariably accompanies this
margins. design. However, problems also frequently
5. The flap should always be full thickness and occurred if the margins of the bony cavity
extend to the gingival sulcus. The periodon- extended across the incision line because the
tal tissues should be healthy, as healing will lesion proved to be much larger than was origi-
be affected by any overt disease. nally apparent (Fig. 11b).
There are several designs of flaps, and, whilst Luebke–Oschenbein flap

the choice may depend upon the size of the The Luebke-Oschenbein flap was designed to
lesion, the periodontal status and the state of the overcome some of the disadvantages of the
coronal tooth structure, it usually depends upon semilunar flap. A vertical incision is made down
the operator’s preference the distal aspect of the adjacent tooth to a point

2p71-79.QXD 10/01/2005 11:36 Page 77
PRACTICE
about 4.0 mm short of the gingival margin. The Fig. 12 The sterile instruments
horizontal incision is scalloped following the necessary for periradicular surgery
should be laid out as shown before
contour of the gingival margin through the surgery commences. These include
attached gingivae to the distal aspect of the tooth micromirrors and other specialist
on the other side. The incision must always be instruments for performing such
extended to the other side of the fraenum and the surgery using a surgical operating
microscope
distal aspect of the adjacent maxillary central or
lateral incisor to avoid a vertical incision next to
the fraenum (Fig. 11c).
The flap affords an excellent view of the oper-
ating area. However, it still has the disadvantage
that the margins of the bony cavity might extend
across the incision line, as can happen with the
semilunar flap. It is essential to check if there is
any periodontal pocketing, as breakdown will Pathological material removed should be sent
then be inevitable. The aim of this flap design is for histopathological examination with full
to preserve the integrity of the gingival margins if clinical details.
there are crowns on the teeth. Scarring may again
be a problem with this type of flap. Armamentarium
Whatever design is used, the raised flap should For all surgical procedures, instruments should
be protected from damage during the operation, be set out, preferably in the order in which they
and should not be allowed to become desiccated. will be used. A typical layout is shown in Fig. 12,
and includes the modern microsurgical instru-
Hard-tissue management ments. Magnification, with either optical loupes
If the lesion has perforated the cortical plate, then or a surgical microscope, is preferable.
location is a fairly simple matter. However, if this
is not the case, then measurement of the tooth Resection of the root
from the radiograph taken with a long-cone par- The aim of resection is to present the surface of
alleling technique must be made. Initially, a large the root so that the apical limit of the canal can
size round bur, cooled by copious water or sterile be visually examined and to provide access for
saline, may be used to provide small, shallow retrograde cavity preparation. Approximately
exploratory holes to locate the site of the apex 3 mm of root is removed which will include
and the lesion. This must be done very carefully, almost all lateral canals.10 It is not necessary to
to avoid damaging the root surfaces of the teeth resect the apex to the base of the bony cavity. If
in the immediate area. Alternatively, a round bur, too much root is removed, then a greater cross-
again carefully cooled, may be used to locate the section of the canal will be revealed, exposing a
apex by paring away the cortical bone over the larger area of filling material to the tissues, and
apex. The bone is shaved away with a very light thus reducing the chances of successful healing.
motion to reduce the heat generated and improve The amount of available root length has to be
visibility. Sufficient bone should be removed considered for any future post crown construc-
using the bur and curettes until good visual tion. There is also an inherent disadvantage as
access to the root end is obtained. the crown—root ratio is reduced, which may
affect the adaptive response of the periodontal
Periradicular curettage ligament to excessive occlusal forces.
The object of this procedure is to remove any A straight fissure bur is used with copious water
soft-tissue lesion with curettes from around the spray at right angles to the long axis of the tooth.
root apex. It may not be possible to remove all the Older textbooks may describe bevelling of the cut
soft tissue until the root end has been resected. root surface at approximately 45° to the long axis
Periradicular curettage used to be a routine of the tooth. This is no longer recommended as
operation carried out by many practitioners this form of resection may result in both incom-
after completion of a root canal filling. The plete removal of the apical delta, and unnecessary
rationale for this is no longer accepted, because enlargement of the exposed root canal.11 Magnifi-
if the root filling has been carried out success- cation is strongly recommended for this proce-
fully and the canal system has been sealed, then dure, both for accuracy in visualising the true
healing of the lesion will take place without angulation of the long axis, and also for detailed
surgical intervention. inspection of the cut root surface and root canal.
When undertaking periradicular surgery, as
much as possible of the periapical lesion should Retrograde cavity preparation
be removed. However, the soft tissues in a Root-end preparation should ideally be performed
periapical lesion are essentially reparative and with a piezo-electric ultrasonic handpiece. If this
defensive in nature and if other anatomical is not available then a small, round bur should be
structures are liable to be damaged some tissue used in a miniature-headed handpiece, to prepare
may be left. This is fortunate as, technically, it is a single surface cavity to include the entire root
difficult to remove every trace of the lesion, canal. Care must be taken to ensure that the canal
especially if it is firmly attached to the wall of the is penetrated sufficiently far for an effective seal
bone cavity. to be placed. Inaccuracy may result in a cavity

2p71-79.QXD 10/01/2005 11:37 Page 78
PRACTICE
Fig. 13 Ultrasonic KiS®

tips for root-end cavity
preparation
that is both too large and too shallow. The clini- However, especially when microsurgery is
cian practising without the aid of magnification being employed with appropriate magnifica-
must be aware of these difficulties, and the conse- tion, mineral trioxide aggregate (MTA) (Fig. 14)
quent reduction in prognosis of the surgery. is recommended.5 It is the least toxic, the most
It is now recommended therefore that the ret- biocompatible, hydrophilic and gives the best
rograde cavity is prepared with specially seal. The root end should be dried with paper
designed ultrasonic tips used in a piezo-electric points or a fine air syringe, and the material
handpiece. These were first introduced in the may be placed in small increments using a
early 1990s and the KiS® tips are illustrated in carrier such as the one illustrated in Figure 16a.
Figure 13.12 Used with a gentle planing motion Alternatively, the MTA may be condensed into a
along the canal configuration, at a low power tube shape using the device illustrated in Figure
setting, a depth of 3 mm may be prepared quick- 16b, when it may be carried to the
ly and cleanly. The cavity should be examined operation site on a probe. Once placed and
carefully before proceeding to restoration. compacted into the cavity, a damp cotton wool
pledget may be used to compress the material
Retrograde filling and remove excess. Note carefully that the
Before the retrograde filling is inserted, dental surgery assistant must ensure that all
haemostasis must be achieved. Dry epinephrine- instruments, especially the carriers, are thor-
impregnated cotton wool balls may be placed into oughly cleaned of every trace of MTA immedi-
the bony cavity, and will also provide a barrier to ately following surgery, or they may become
prevent accidental loss of excess filling material clogged and rendere useless.
around the root. Bone wax or ribbon gauze may Whichever material is selected for the restora-
also be used to isolate the root tip. If gauze is used, tion, it should be thoroughly compacted into the
it may be wetted with local anaesthetic solution cavity with a small plugger to ensure a dense fill,
or saline once it is in place, then dabbed dry with and burnished with a ball-ended instrument to a
a cotton wool pledget. Any excess filling material smooth finish. The bony cavity should be care-
is more easily retained by the damp gauze. fully debrided to ensure that all materials and
A biologically compatible material should be debris are removed.
used, and amalgam is no longer recommended. A
reinforced zinc oxide–eugenol cement such as Replacement of flap and suturing
IRM (modified by the addition of 20% poly- Once the retrograde filling has been completed,
methacrylate) or Super EBA (modified with the the packing around the root removed and final
addition of ethoxybenzoic acid) is recommended. debridement carried out, the flap may be sutured
Reinforced glass-ionomer cements or composite into place. Where possible, synthetic monofila-
resin may be used, although these materials are ment sutures should be used as these do not cause
more technique sensitive. wicking of bacteria into the surgical site and lead
a b
Fig. 14 The commercial presentation Fig. 15 a) The Dovgan applicator for MTA, available with either a straight or flexible tip. b) A block for compacting
of mineral trioxide aggregate and manipulating mixed MTA

2p71-79.QXD 10/01/2005 11:38 Page 79
PRACTICE
a b
Fig. 16 This tooth has been subject to repeated surgical Fig. 17 The radiograph shown at: a) was exposed immediately post-surgery and b) The radiograph
procedures, without success taken 1 year later, as part of surgical audit, shows complete healing
to better healing than when silk sutures are used. recent papers have reported treatment using the
Resorbable sutures are not recommended. modern techniques described here to have
The vertical relieving incisions should be success rates as high as 92%.15
repaired with interrupted sutures. The gingival Should failure occur, the cause must be
margin should be carefully repositioned and established before further intervention. Repeat
sutured with sling sutures. Commencing at a surgery has a low success rate, as can be seen in
buccal papilla, the suture is taken through the Figure 16. All surgical treatment should, of
embrasure, around the tooth and back through course, be encompassed within audit and clini-
the adjacent embrasure to enter the next papilla. cal governance, both for the patient and the
The suture is then taken back round the tooth to clinician (Fig. 17).
the original site and the knot tied over the buccal
papilla. The sutures may be removed after 1 Kim S. Principles of endodontic surgery. Dent Clin
North Am 1997; 41: 481–497.
48 hours, and certainly no more than 3–4 days,
2 Peters L, Wesselink P. Soft tissue management in
when the periodontal fibres will have reattached. endodontic surgery. Dent Clin North Am 1997; 41:
Sutures left longer than this may actually delay 513–528.
healing by wicking. 3 Chindia M L, Valderhaug J. Periodontal status
following trapezoidal and semilunar flaps in
apicectomy. East African Med J 1995; 72: 564–567.
POST-OPERATIVE CARE 4 Morgan L A, Marshall J G. A scanning electron
Immediately following suturing, the tissues microscopic study of in vivo ultrasonic root-end
should be firmly compressed with a damp gauze preparations. J Endod 1999; 25: 567–570.
5 Torabinejad M, Pitt Ford T R, Abedi H R,
for 5 minutes. Post-operative swelling can be Kariyawasam S P, Tang H M. Tissue reaction to
reduced by the continued application of cold implanted root-end filling materials in the tibia and
compresses (crushed ice cubes placed in a plastic mandible of guinea pigs. J Endod 1998; 24: 468–471.
bag surrounded by a clean soft cloth) for up to 6 Kim S. Endodontic Microsurgery. Chapter 19 in Cohen S,
Burns R C, Pathways of the Pulp. St Louis: Mosby 2002.
6 hours. Post-operative pain may be controlled 7 Webber R T. Apexogenesis versus apexification. Dent
by the administration of a long-acting local Clin North Am 1984; 28: 669–697.
anaesthetic at the end of the surgery, and by the 8 Layton S, Korsen J. Informed consent in oral and
maxillofacial surgery: a study of the value of written
prescription of non-steroidal anti-inflammatory warnings. Br J Oral Maxillofac Surg 1994; 32: 34–36.
drugs (NSAIDs). Chlorhexidine mouthwash 9 Martin M V, Nind D. Use of chlorhexidine gluconate for
should be used to keep the surgical site clean pre-operative disinfection of apicectomy sites. Br Dent J
until the sutures are removed. The prescription 1987; 162: 459–461.
10 Hsu Y Y, Kim S. The resected root surface. The issue of
of antibiotics is only necessary if required by the canal isthmuses. Dent Clin North Am 1997; 41: 529–540.
patient’s medical history. 11 Gilheany P A, Figdor D, Tyas M J. Apical dentin
permeability and microleakage associated with root end
resection and retrograde filling. J Endod 1994; 20: 22–26.
SURGICAL OUTCOMES 12 Carr G. Common errors in periradicular surgery. Endod
A radiograph should be exposed either immedi- Rep 1993; 8: 12–16.
ately following treatment or when the sutures 13 Jansson L, Sandstedt P, Laftman A C, Skogland A.
are removed for comparison with future films to Relationship between apical and marginal healing in
periradicular surgery. Oral Surg, Oral Med, Oral Path,
assess healing. Ideally, cementum and periodon- Oral Rad, Endod 1997; 83: 596–601.
tal ligament should regenerate over the resected 14 Rud J, Andreasen J O, Jensen J E. Radiographic criteria
root apex, although in many cases repair occurs for the assessment of healing after endodontic surgery.
by the formation of a fibrous scar. It is reported Int J Oral Surg 1972; 1: 195–214.
15 Maddalone M, Gagliani M. Periapical endodontic
that success rates may vary between 30% and surgery: a 3-year follow-up study. Int Endod J 2003;
80%.13,14 It should be noted, however, that 36: 193–198.

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PRACTICE
IN BRIEF

 Most problems in root canal treatment could have been avoided with care and attention to
treatment principles. Careful examination of the pre-operative radiograph is essential.
It is possible to remove most fractured instruments, posts and failed root filings if the correct
aids are to hand, and magnification is available.
It is essential that practitioners know the prognosis for different endodontic procedures, both
from the endodontic literature and their own clinical experience.
12
VERIFIABLE
CPD PAPER
Endodontic problems
NOW AVAILABLE
AS A BDJ BOOK
If modern clinical techniques were carefully followed, many common endodontic problems would never occur. Incorrectly
designed access cavities may make root canals both difficult to identify and to instrument. Careful study of the pre-operative
radiograph is essential. Various aids are available to remove fractured instruments and failed root fillings, but the problem
must first be correctly diagnosed. As more patients seek cosmetic procedures, the practitioner should be familiar with the
‘walking bleach’ procedure, again after careful diagnosis of the cause of the discolouration. The practitioner should also be
fully aware of the prognosis for this and other endodontic procedures.
Endodontics is a skill requiring the use of deli- surgical endodontics may be done by retracting
cate instruments in confined spaces. Inevitably, the lip at the corner of the mouth with a finger;
ENDODONTICS problems will occur, but many of these are the surgical area should be directly visible.
1. The modern concept of avoidable providing the operator exercises care The general guidelines for access cavities have
root canal treatment and patience. A few tips on how to overcome already been discussed in Part 6. However, there
2. Diagnosis and treatment some of these problems will be given in this part. are occasions when these should be adapted to
planning Should the reader require a more wide-ranging suit a particular case. Inadequate access will lead
3. Treatment of endodontic and detailed account, specialist endodontic text- to poor treatment and, unless the endodontic
emergencies books on this subject may be referred to.1 treatment is successful, further restoration of the
4. Morphology of the root tooth is irrelevant.
canal system ACCESS Before cutting the access cavity, the extent
It is important to have good visual access and suf- and type of final restoration should be borne in
ficient space to allow direct line access into the mind. If an anterior tooth will require a crown
treatment
apical third of the root canal. A useful way of following the root treatment, the access cavity
assessing a patient for molar endodontics is that could be cut on the labial surface (Fig. 1). In pos-
the operator should be able to place two fingers terior teeth it may be advantageous to reduce the
cavities
between the maxillary and mandibular incisors. If walls, if either they are already weakened or
7. Preparing the root canal this is not possible owing to a small mouth or lim- there is a crown or root fracture.
8. Filling the root canal ited opening, then it may be unwise to commence
system root canal therapy. Assessing access for posterior LOCATING AND NEGOTIATING FINE CANALS
resorption, endo-perio b
a
lesions
children
1*Clinical Lecturer, Department of Adult Dental

Care, Glasgow Dental Hospital and School, 378
Sauchiehall Street, Glasgow G2 3JZ
Fig. 1 Unconventional access cavities may be used in some situations. a) A resin-retained bridge had been fitted to
Refereed Paper replace UL1 (21) lost through trauma. When a periapical lesion developed related to UR1 (11), an access cavity was cut
doi:10.1038/sj.bdj.4812037 through the incisal edge. b) The last standing teeth are to be cut down for overdenture abutment.
© British Dental Journal 2005; 198: 127–133
BRITISH DENTAL JOURNAL VOLUME 198 NO. 3 FEBRUARY 12 2005 127

3p127-133.qxd 19/01/2005 13:31 Page 128
ENDODONTICS
Fig. 3 The operator was unable to

locate the access to the mesiobuccal
canal. A small, round bur was used to
explore the area, and an orifice was
found. Unfortunately a radiograph
revealed that a perforation into the
furcation had been created. As the
pulp chamber was clean and well
isolated, the perforation was
repaired with resin-modified glass-
ionomer cement and the tooth
remained symptomless.
Many root canals, particularly in the elderly produced by the bur. The associated risks of per-
Fig. 2 A radiograph of tooth UL1 patient, are difficult to locate. The pulp chambers foration do mean that this really is a ‘last resort’,
(21), which suffered trauma 5 years
previously, showing no apparent sign may be sclerosed or contain large pulp stones as shown in Figure 3.
of a root canal system. and the root canals may be so fine that even Once the entrance has been located, the next
when located they are difficult to negotiate. step is to negotiate the canal using a fine instru-
Dentine deposition occurs as a response to ment. A curve is placed at the tip of an 06 or 08
any moderate injury to the pulp, in particular hand file. It is useful to dip the tip of the instru-
luxation injuries. Initially, the pulp chamber ment into a lubricant such as Hibiscrub. The
reduces in size, followed by a gradual narrow- instrument is gradually advanced into the canal
ing of the root canals. The incidence of pulpal using a small, contrarotating, ‘watchwinding’
necrosis following canal obliteration is not high movement to advance the file. Force should not
and so does not warrant intervention by elective be used. The curve in the instrument tip will
root canal treatment.2 seek the path of least resistance and allow the
Radiographs of teeth showing apparent total instrument to penetrate further into the canal.
canal obliteration are deceptive (Fig. 2). Cvek et al. A push—pull filing motion may then be used to
report a study in which attempts were made to free coronal obstructions in the canal. The file is
locate and negotiate root canals which were not removed, copious irrigation used and the proce-
visible on the pre-operative radiographs.3 In 54 dure repeated until the canal is negotiated to the
incisors with periapical lesions, the root canal working length. If an electronic apex locator is
was located and treated in all but one of them. not being used it will be necessary to enlarge the
These narrow canals may take time to locate. canal with successively larger fine instruments
The pre-operative radiograph contains useful up to a size 15 before confirming the working
information: the size, curvature and position of length, as an 06 file may not be seen accurately
the root canal(s) in relation to the pulp chamber on a diagnostic radiograph.
may be noted. A meticulous search must be EDTA paste (ethylenediamine tetra-acetic acid)
made of the floor of the pulp chamber with is not recommended for the initial negotiation of
either an endodontic (DG16) probe or an 08 or the canal, as it is a chelating agent. The walls of
10 file. The floor of the pulp chamber is darker the dentine will be softened, which means a false
than the walls and the canal entrances are situ- canal could be cut. EDTA paste is, however,
ated, in posterior teeth, at each corner. Fibre- extremely useful when preparing the canal walls
optic light, transilluminating the tooth, and once the full length has been negotiated.
magnification using either binocular loupes or
an operating microscope as discussed in Part 4 LEDGED OR BLOCKED CANALS
are also of assistance. Incorrect technique in preparation can lead to
If the canal cannot be located, an ultrasonic either obstruction of the root canal with pulpal
tip as described in Part 5 may be used to break debris, compacted dentine and other debris, or
down secondary dentine from the floor of the the formation of a ledge in the wall of the canal.
pulp chamber around the anticipated canal In the case of a ledged canal (Fig. 4), a curve
opening. As a final resort it will be necessary to should be placed near the tip of a fine hand
drill using a small, round bur in a slow running instrument, the canal irrigated with sodium
standard handpiece. A bur hole, approximately hypochlorite, and the instrument inserted into
2 mm in depth, is then drilled at the expected the canal. The notch in the rubber stop should
site of the canal along the main axis of the root. be aligned with the curve so that the instrument
A radiograph is taken with the bur in situ and tip may be directed away from the ledge and
the direction of the bur corrected if further gradually advanced with small contrarotating
drilling is necessary. This can be a frustrating movements. Once the instrument is beyond the
exercise and numerous fine files will be ledge a short push–pull filing motion is used to
damaged as the tips curve in the round shape reduce the ledge in the curve before removing
128 BRITISH DENTAL JOURNAL VOLUME 198 NO. 3 FEBRUARY 12 2005

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ENDODONTIC PROBLEMS
the file. A lubricant such as EDTA paste is useful Fig. 4 A diagram of a canal with a
ledge in the outer curve, showing
to help remove the ledge. This is not a difficult how the tip of a pre-curved file may
procedure once the ledge has been bypassed. enter the ledge. If the file is rotated
A canal that has been blocked with pulpal or through 180° the curved tip will
dentine debris may well be impossible to negoti- follow the original canal.
ate. Copious irrigation, the use of EDTA paste
and a very fine instrument may be tried. The
danger is of either packing the debris harder into
the canal or creating a false canal.
RE-ROOT TREATMENT
A root filling may have to be removed and the
tooth retreated for a variety of reasons. The
patient may be experiencing symptoms, a peri-
apical radiolucency may be increasing in size, or
the coronal restoration may require replacing in a
tooth where the root filling is inadequate. What-
ever the reason, the first step is to identify the type
of filling material that has been used (Fig. 5) and
to assess the difficulty of the procedure. The
method used to remove the previous root filling
will depend on the type of material used.
Paste
A soft root-filling material may be removed easily may prove impossible. One method proposed for
with Hedstroem files and copious irrigation. this situation involves first creating a gap
between the material and the wall of the canal
Cement with a canal probe. A Hedstroem file may then
Some cements set hard and have apparently no be carefully ‘screwed’ into the space. A second
solvent and, as a result, are almost impossible to and, if possible, third file are similarly inserted
remove. The first stage in attempting to remove into the mass of the gutta-percha. The handles of
a cement is to flood the canal entrance with the files are grasped, and a steady withdrawal
chloroform or xylene and use an endodontic force exerted to remove the gutta-percha
probe and then Hedstroem files. If this fails, the point(s). Hedstroem files are needed to grip and
coronal 2–3 mm can be removed with a small pull back the gutta-percha.
rosehead bur followed by files. Alternatively,
ultrasonics may be used to break down the Metal points
cement and flush out the debris. It may, howev- The method of removing silver or titanium
er, prove impossible to negotiate a canal filled points is dictated by their position within the
with a hard setting cement. root canal. Silver points are easier to remove if
there has been leakage of tissue fluids into the
Gutta-percha canal and corrosion has occurred.
Gutta-percha is simple to remove. Gates–Glidden The simplest situation is when the coronal end
burs may be used first to gain access to the root of the point protrudes far enough into the pulp
canal. The burs both cut away gutta-percha, and chamber so that it may be grasped by either
soften it by the frictional heat of rotation. There Steiglitz forceps (Fig. 6), narrow-beaked artery
are various solvents for gutta-percha, which may forceps or fine pliers.
be dispensed into a Dappens dish and picked up If the point lies in the root canal below the
on the tip of each instrument. Chloroform, pulp chamber but in a straight part of the canal,
halothane and xylene may be available in the sur- attempts should be made to bypass and either
gery, or oil of eucalyptus and oil of turpentine are remove the point or incorporate it into the root
both effective. Once access has been made it is filling. A size 08 or 10 file or reamer is used, and
usually possible to remove the remainder of the the tip is coated with EDTA paste. If the point
gutta-percha with conventional filing techniques. can be bypassed, it can frequently be removed
Alternatively, nickel-titanium rotary instru-
ments are very efficient for softening and remov-
ing gutta-percha from canals that will accommo-
date them. Initial exploration with hand files is
necessary to create room for the cutting flutes of
the instruments. They should not be used to path-
find. The piezo-electric ultrasonic machines are
Fig. 5 This tooth has been root filled
also useful as their heat generation aids removal of using both silver points and gutta-
softened gutta-percha. Specially designed tips are percha. The operator must be able to
available for this procedure. distinguish between various root-
If the original gutta-percha filling has been filling materials by their
radiographic appearance.
extended beyond the apical foramen, removal

3p127-133.qxd 19/01/2005 13:32 Page 130
ENDODONTICS
Fig. 7 Files should be visually inspected for damage to Fig. 8 A Masserann kit for removal of fractured
the flutes every time they are removed from the tooth for instruments and posts.
cleaning.
with Hedstroem files or by using an ultrasonic 4. When using the balanced force technique,
technique. CPR® Ultrasonic tips (described in limit rotations to 60° as described by
Part 5) are ideal for accessing and dislodging Roane et al. and never rotate an instrument
points and broken instruments. more than one quarter turn in a clockwise
Alternatively, two fine devices are available to direction.4
assist in removal of such impediments. The Can- The techniques used for removal of a frac-
cellier kit contains four fine hollow tubes which tured instrument are similar to those described
may fit over a loosened point in the canal previously for metal points. In addition, the
enabling its withdrawal. The Meitrac Endo Masserann was specifically designed to extract
Safety System involves the use of a mini- metal fragments from root canals. The Masser-
trephine to free the tip of the fractured point. ann kit (Fig. 8) consists of a number of trepans
Fig. 6 Steiglitz forceps have long
This may then be gripped using two ‘locking’ with a range of diameters from 1.1 mm to
narrow beaks, and are useful for
grasping broken instruments in the tubes and withdrawn. 2.4 mm. The trepans are hollow tubes designed
pulp chamber. Unless an operating microscope is used, it is to cut a trough around the metal fragment (Fig.
seldom possible to remove a point which is 9). Note that the trepans are designed to be used
lodged in the apical third of a curved root canal. with an anticlockwise rotation. This will assist
Attempts should be made either to bypass the with the removal of any threaded materials
fragment and incorporate it into the root filling, which will have a conventional thread. The
or condense gutta-percha vertically up to the operator should be particularly aware of this as
obstruction, with a view to apical surgery should a potential problem if attempting to remove a
signs of failure occur. fractured Hand File of Greater Taper, which
have a reverse thread.
FRACTURED INSTRUMENTS The trough usually has to be cut along at least
The time required to remove or bypass a frac- half the length of the fragment before it is suffi-
tured instrument from the root canal far out- ciently loosened to allow its extraction. It is rec-
weighs the simple precautions that should be ommended that the trepan is operated by hand,
taken routinely to prevent such an occurrence. using the special handle provided, and not
The simple rules which will prevent instrument placed in a handpiece. A feeler gauge from the
fracture are as follows. kit is used to judge the size of the trepan
1. Each time an endodontic instrument is picked required. EDTA paste will help to lubricate and
up it should be visually checked for any dam- soften the dentine. The kit also contains a
age or deformation of the twisted flutes (Fig. Masserann extractor, which is placed over the
7). The assistance of a well-trained dental end of the loosened fragment so that it may be
nurse can be invaluable. Damaged instru- gripped and removed. If the fragment is too
ments should be discarded immediately. large for the extractor, then a size smaller trepan
2. Never force an instrument in the canal. may be forced over the end of the fragment,
3. Do not miss out sizes. Although appearing which is then gripped firmly enough to allow its
small, moving from a size 10 to a size 15 file withdrawal from the canal. However, the opera-
involves an increase in tip diameter of 50%.
It is preferable to repeat the use of the smaller a
file than apply excess force to the next size.
b
Fig. 9 The tip of the Masserann
trepan showing the cutting flutes,
designed to cut in an anticlockwise Fig. 10 Post extractors for dismantling post-crowns:
direction. a) the Ruddle, and b) the Eggler systems.

3p127-133.qxd 19/01/2005 13:33 Page 131
ENDODONTIC PROBLEMS
screw tightened onto the core; the feet are then

lowered on to the shoulders of the preparation
by turning the end knob. Several more turns will
ease the post out of the post hole.
With the Ruddle system, a trephine is used to
produce a parallel side in the post, which is then
grasped in a matching sized thread cutting tap to
a maximum depth of 3 mm. The post removal
pliers are placed over a rubber cushion, and gen-
tly tightened. If removal is difficult, further
ultrasonic energy may be applied. As with all
such instruments, there is a danger of root frac-
ture, and expertise should be gained in a techni-
Fig. 11 A fractured post successfully removed with the cal laboratory before attempting these tech-
Masseran kit. niques in a clinical situation.
A fractured post lying within the root canal
tor must weigh the benefits of this procedure may either be drilled out using a high-speed
against the damage to the trepan. handpiece, which is a hazardous procedure, or
A fractured instrument remaining in a canal removed with a Masserann kit as described ear-
does not mean that the attempt at root treatment lier. Figure 11 shows the initial radiograph of
will fail. It has been demonstrated that, provided the fractured post, and the item successfully
the remainder of the root canal is filled conven- removed with the Masseran kit.
tionally, the success rate is not significantly
affected.5,6 VERTICAL ROOT FRACTURE
Although infrequent, this problem may be diffi-
POSTS cult to diagnose. The patient may present with
A post may have to be removed because either mild symptoms, or it may appear that the root
the tooth requires (re)root filling or the post has canal treatment has not been successful. Cases
fractured. The procedure presents problems as have been reported where the first indication of
there is a danger of fracturing or perforating the a vertical root fracture has been when a muco-
root of the tooth. Threaded posts which have periosteal flap has been raised to carry out peri-
fractured can be removed by cutting a groove in radicular surgery on an apparently persistent
the post end and unscrewing. It is possible to lesion. Figure 12 in Part 2 shows a tooth with
extract a smooth-sided post and core using a such a fracture which had to be extracted.
post extractor (Fig. 10). The diagnosis can, however, be suspected
A piezo-electric ultrasonic system, used with when a radiograph shows bone loss extending
special tips, should first be used at the appropriate all around a root or a tooth, as in Figure 12. The
power setting. Moving the tips around the base of vertical defect has led to bacterial contamina-
the post at moderate power will remove cement tion of the entire tooth surface.
around the post. A different tip may then be used
to apply maximum vibratory energy to the post in THE DISCOLORED ROOT-FILLED TOOTH
an attempt to vibrate the post loose directly. Bleaching and tooth-whitening procedures are
With the Eggler system, the core must first be rapidly becoming a part of every dentist’s
shaped so that its sides are parallel and capable practice. The routine use of such materials in
of being gripped. The mesial and distal shoulders restorative dentistry is outside the scope of this
of the crown preparation must be cut to the same text, and the subject is comprehensively cov-
height so there is no torsional force. The post ered in other books.7,8 However, teeth which
extractor is then placed over the post and the have been root filled may darken for various
Fig. 12 A radiograph of a molar

with a vertical root fracture,
showing the pathognomonic
appearance of periodontitis
surrounding the entire root.

3p127-133.qxd 19/01/2005 13:33 Page 132
ENDODONTICS
Fig. 13 Internal bleaching has been

used to lighten this root canal
treated central incisor. Figure
courtesy of Dr M Elkhazindar,
Glasgow Dental Hospital.
5. Clean out all endodontic materials from the

Table 1 Overview of success in endodontic treatment (From Friedman12)
pulp chamber, to a depth of 2 mm into the
Treatment procedure Weighted average success of Weighted average success of root canal.
reports in approximately the reports in approximately the past 6. Seal the root filling with a layer of glass-
past 50 years 10 years
ionomer cement of the lightest shade.
Endodontic treatment of 34 studies 6 studies 7. Soak a cotton pledget in 30% hydrogen
teeth without periapical Range from 100% to 67% Range from 100% to 88% peroxide and place in the access cavity.
periodontitis Weighted average 91% Weighted average 93%
8. Apply a heated instrument to the pledget,
and repeat the process several times. (Note
Endodontic treatment of 38 studies 8 studies that in a recent comprehensive review of this
teeth with periapical Range from 96% to 38% Range from 94% to 46%
periodontitis Weighted average 76% Weighted average 77% procedure Attin et al. suggest that the use of
30% hydrogen peroxide and the application
of heat may both contribute to the initiation
Endodontic treatment of 6 studies since 1987
teeth with periapical Range from 86% to 69% of cervical resorption.10)
periodontitis using calcium Weighted average 79% 9. Place a mixture of sodium perborate and 3%
hydroxide intervisit dressing hydrogen peroxide in the pulp chamber, and
seal it in place with a non-eugenol tempo-
Orthograde endodontic 9 studies 3 studies rary cement. This constitutes the ‘walking-
retreatment in teeth with Range from 88% to 48% Range from 74% to 56% bleach’ phase of the procedure.
periapical periodontitis Weighted average 70% Weighted average 62% 10. Review the patient after one week, and
measure the change in colour.
Periradicular surgery in 29 studies 11 studies 11. The procedure may require repeating several
teeth with periapical Range from 95% to 30% Range from 81% to 30% times.
periodontitis Weighted average 59% Weighted average 63%
12. The access cavity should be restored com-
pletely with the lightest paediatric shade of
composite resin.
reasons, and may benefit from internal bleach-
ing using the technique known as ‘walking PROGNOSIS IN ENDODONTICS
bleach’. An illustration of the potential can be All endodontic procedures should be reviewed
seen in Figure 13. as part of audit and clinical governance. An
It is essential wherever possible to identify assessment of the degree of healing or otherwise
the cause of the discoloration. Some of those must be made, and unsatisfactory results may
specifically due to endodontics may be:9 require either further monitoring or retreatment.
• Internal haemorrhage within the dentine However, it should be noted that Ørstavik
following trauma; reported that over 75% of apical periodontitis
• Seepage of toxins from the infected pulpal lesions developing after endodontic treatment
contents; can be observed radiographically after one
• Staining from medicaments, cements, etc., year.11 It may be considered therefore that if
particularly those containing silver; healing is evident after one year, further radi-
• The optical effects of dehydration. ographic monitoring is not indicated.
One method of monitoring would be to
Briefly, the normally recommended technique is employ the Periapical Index (PAI) described by
as follows: Ørstavik at al.12 Standard radiographic views
1. Clean and polish all the teeth thoroughly to are presented of five apical conditions, and the
remove any extrinsic stain. operator compares their own result with these
2. Match the existing shade of the tooth with a standards. A score of 1 indicates normal periapi-
ceramic shade guide (if possible with an cal appearance; 2 indicates slight disorganiza-
intra-oral photograph of the tooth and tab). tion of the bone texture; 3 loss of bone and
3. Isolate the tooth with rubber dam, sealing unusual bone pattern; 4 shows classic periapical
the margins carefully around the teeth with a periodontitis; and 5 is similar, but with obvious
caulking agent. wider spread.
4. Remove the restoration from the access cavity, Many studies have been reported on the suc-
ensuring that all aspects are clean. cess of endodontic treatment, many assessing

3p127-133.qxd 19/01/2005 13:34 Page 133
ENDODONTIC PROBLEMS
the result against the PAI. Friedman reports a 5. Crump M C, Natkin E. Relationship of broken root
canal instruments to endodontic case prognosis: a
comprehensive review of these studies, and the clinical investigation. J Am Dent Assoc 1970; 80:
weighted averages are summarized in Table 1.13 1341–1347.
Particular note should be made of the signifi- 6. Lumley P J. Management of silver points and fractured
instruments. CPD Dentistry 2000; 1: 87–92.
cantly reduced weighted average prognosis 7. Greenwall L. Bleaching techniques in restorative
when treating teeth presenting with an estab- dentistry. London: Martin Dunitz, 2001.
lished area of periapical periodontitis seen on 8. Sheets C G, Paquette, J M, Wright R S. Chapter 21 in
radiographic examination. These figures should Cohen S & Burns R C. Pathways of the Pulp, Eighth Ed.
St Louis: Mosby, 2002.
be studied by the clinician, and an estimate of 9. Nathoo S A. The chemistry and mechanisms of
the likely prognosis should form part of the pro- extrinsic and intrinsic discoloration. J Am Dent Assoc
cedure of obtaining informed or valid consent. 1997; 128: 6S–10S.
10. Attin T, Paqué F, Ajam F, Lennon Á. Review of
1. Guttman, J L, Dumsha T C, Lovdahl P E, Hovland E J. the current status of tooth whitening with the
Problem Solving in Endodontics. 3rd Ed. St Louis: walking bleach technique. Int End J 2003; 36:
Mosby, 1997. 313–329.
2. Andreasen J O, Andreasen F M. Chapter 9 in Textbook 11. Ørstavik D. Time-course and risk analyses of the
and colour atlas of traumatic injuries to the teeth. 3rd development and healing of chronic apical
Ed. Denmark: Munksgard, 1994. periodontitis in man. Int Endod J 1996; 29: 150–155
3. Cvek M, Granath L-E, Lundberg M. Failures and healing 12. Ørstavik D, Kerekes K and Eriksen H M. The periapical
in endodontically treated non-vital anterior teeth with index: A scoring system for radiographic assessment of
post-traumatically reduced pulpal lumen. Acta Odont periapical periodontitis. Endod Dent Traumatol 18; 2:
Scand 1982; 40: 223–228. 20–34.
4. Roane J B, Sabala C L, Duncanson M G. The balanced 13. Friedman S. Treatment outcome and prognosis of
force concept for instrumentation of curved canals. endodontic therapy. In Ørstavik D, Pitt Ford T R, Essential
J Endod 1985; 11: 203–211 Endodontology. Oxford: Blackwell Science, 1998.

04p179.qxd 29/07/2004 17:27 Page 179
PRACTICE
IN BRIEF
● An overview of the new 12-part BDJ series on Endodontics.
Endodontics — a series overview

P. Carrotte1
Stock and Nehammer's BDJ textbook Endodontics in Practice was first published in
ENDODONTICS 1985, and almost immediately became a standard text for both undergraduate students
1. The modern concept of and general practitioners. In the first sentence of the first chapter the authors observed
root canal treatment ‘during the last three decades research in the field of endodontics has modified the
2. Diagnosis and treatment approach to treatment’, and that observation was retained in the extensively revised
planning second edition, published in 1990.
3. Treatment of endodontic With an inordinate amount of research of an increasingly high standard taking
emergencies place, the changes in the field of endodontics during the last decade have been even
4. Morphology of the root greater, and a third edition was required to keep practitioners up to date with current
canal system thinking and practice. Sadly, because of their research and other commitments, Chris
Stock and Carl Nehammer did not have the time to devote to such a task, and I am
therefore honoured and delighted to have edited this edition of their text and converted
it to the new BDJ Clinical Guide format.
treatment
In some aspects of the subject there has been little change, whilst the developments
in others have been immense. I may be criticised for retaining some historical material
activities
which could seem outdated to the modern practitioner using the latest canal
7. Preparing the root canal preparation techniques. However, few dental schools have the resources necessary to
8. Filling the root canal introduce many of the recent developments, and undergraduate students still learn
system conventional techniques. It is important that they understand how these have
9. Calcium hydroxide, root developed, and it is essential, as with most things in life, that they develop basic skills
resorption, endo-perio before advanced ones!
lesions The subject is covered in 12 parts. The first part emphasises the modern concept of
10. Endodontic treatment for endodontics, surprisingly founded upon research published almost forty years ago.
children Root canal treatment must be seen as essentially the treatment of a disease process.
11. Surgical endodontics The procedures must both remove all infection from the root canal system, and
12. Endodontic problems prevent contamination by other pathogenic organisms. Failure to achieve either of
these aspects may compromise success and lead to eventual failure. Parts 2 and 3
consider the importance of diagnosis in treatment planning, and how emergency
events may be quickly diagnosed and treated. Part 4 shows how research into root
canal morphology continues, knowledge of which is essential for effective shaping
and cleaning.
Parts 5 to 9 cover the technical procedures, but the wise reader will realise that
there is no ‘best way' to clean, shape and obturate a tooth. Various manufacturers make
claims that their own product is the latest and best. The emphasis in the series is the
understanding of the objectives of treatment. The actual technical procedures must be
secondary to this. Dentists are clinicians, not technicians, and should use whichever
procedure works best in their own hands to resolve the diagnosed disease process.
‘Step-back and apical stops’ may be old-fashioned, one brand of rotary instruments
may have been around longer than another, but if the technique works for you then
why change it?
Dental Care, Glasgow Dental Hospital and As in Stock and Nehammer's original text, the final three parts of the series
School, 378 Sauchiehall Street, Glasgow consider some wider aspects of endodontic treatment. These subjects are not considered
G2 3JZ in great detail, but hopefully direct readers to deeper study of the subjects concerned in
texts dedicated to that specific aspect.
However, it is hoped that readers will consider this is a practical series written for
Refereed Paper the practice of endodontics. The research which underpins this practice is discussed
doi:10.1038/sj.bdj.4811582 where necessary, but the prime aim of the series is to guide practitioners through their
© British Dental Journal 2004; 197:
179 everyday treatment of teeth with endodontic problems.

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04p181-183.

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BRITISH DENTAL JOURNAL VOLUME 197 NO. 4 AUGUST 28 2004 181

182 BRITISH DENTAL JOURNAL VOLUME 197 NO. 4 AUGUST 28 2004

Fig. 3 A radiograph of tooth LL7

One Hundred Years Ago

BRITISH DENTAL JOURNAL VOLUME 197 NO. 4 AUGUST 28 2004 183

BRITISH DENTAL JOURNAL VOLUME 197 NO. 5 SEPTEMBER 11 2004 231

Fig. 1 A facial sinus It is usually possible to decide, as a result of

232 BRITISH DENTAL JOURNAL VOLUME 197 NO. 5 SEPTEMBER 11 2004

Fig. 3 The anatomical detail

relatively crude and unreliable. No single test, Radiography

BRITISH DENTAL JOURNAL VOLUME 197 NO. 5 SEPTEMBER 11 2004 233

between them. Most pulp testers manufactured

Thermal pulp testing

234 BRITISH DENTAL JOURNAL VOLUME 197 NO. 5 SEPTEMBER 11 2004

BRITISH DENTAL JOURNAL VOLUME 197 NO. 5 SEPTEMBER 11 2004 235

Pulpal sclerosis following trauma

Risk of exposure CONTRA-INDICATIONS TO ROOT CANAL

Patient’s general medical condition

236 BRITISH DENTAL JOURNAL VOLUME 197 NO. 5 SEPTEMBER 11 2004

Local Bizarre anatomy

Internal or external resorption

BRITISH DENTAL JOURNAL VOLUME 197 NO. 5 SEPTEMBER 11 2004 237

Fig. 14 Tooth UL4 (24) has previously

Fifty years ago today

BRITISH DENTAL JOURNAL VOLUME 197 NO. 5 SEPTEMBER 11 2004 238

BRITISH DENTAL JOURNAL VOLUME 197 NO. 6 SEPTEMBER 25 2004 299

Fig. 1 Initial Only when the inflammation has spread

300 BRITISH DENTAL JOURNAL VOLUME 197 NO. 6 SEPTEMBER 25 2004

Fig. 2 Radiographic changes range from a widening of the periodontal

Once pulpal inflammation has spread to the Fig. 3 … to a large,

BRITISH DENTAL JOURNAL VOLUME 197 NO. 6 SEPTEMBER 25 2004 301

302 BRITISH DENTAL JOURNAL VOLUME 197 NO. 6 SEPTEMBER 25 2004

Fig. 7 External incision

follow before any further symptoms develop.

CRACKED TOOTH SYNDROME

BRITISH DENTAL JOURNAL VOLUME 197 NO. 6 SEPTEMBER 25 2004 303

PATIENTS UNDER TREATMENT Root or crown fractures

304 BRITISH DENTAL JOURNAL VOLUME 197 NO. 6 SEPTEMBER 25 2004

severe cases, it may be necessary to prescribe an Root fracture

One Hundred Years Ago

BRITISH DENTAL JOURNAL VOLUME 197 NO. 6 SEPTEMBER 25 2004 305

BRITISH DENTAL JOURNAL VOLUME 197 NO. 7 OCTOBER 9 2004 379

Fig. 1 The pulp

MAXILLARY LATERAL INCISOR

380 BRITISH DENTAL JOURNAL VOLUME 197 NO. 7 OCTOBER 9 2004

MAXILLARY FIRST PREMOLAR

BRITISH DENTAL JOURNAL VOLUME 197 NO. 7 OCTOBER 9 2004 381

Fig. 8 Lower canines may Fig. 9 A lower second

Table 1 Average root canal configurations

382 BRITISH DENTAL JOURNAL VOLUME 197 NO. 7 OCTOBER 9 2004

MANDIBULAR THIRD MOLAR

BRITISH DENTAL JOURNAL VOLUME 197 NO. 7 OCTOBER 9 2004 383

Endodontics: Part 5 VERIFIABLE

BRITISH DENTAL JOURNAL VOLUME 197 NO. 8 OCTOBER 23 2004 455

Fig. 3 A patient wearing safety glasses, a waterproof

Fig. 4 The rubber dam RUBBER DAM

456 BRITISH DENTAL JOURNAL VOLUME 197 NO. 8 OCTOBER 23 2004