Textbook of Endodontology

The Editors Lars Bjrndal, PhD, is Associate Professor in the Section of Cariology and Endodontics, Department of Odontology, Faculty of Health and Medical Sciences at the University of Copenhagen in Copenhagen, Denmark. Lise-Lotte Kirkevang, PhD, is Associate Professor in the Department of Dentistry and Oral Health at Aarhus University in Aarhus, Denmark and Professor of Endodontics, at the Institute of Clinical Dentistry, Faculty of Dentistry, University of Oslo in Oslo, Norway. John Whitworth, PhD, is Professor of Endodontology/Consultant in Restorative Dentistry in the School of Dental Sciences at Newcastle University/Newcastle Hospitals NHS Foundation Trust in Newcastle, UK.

List of contributors xiii Foreword xvii Preface xix About the companion website xxi 1 Introduction to endodontology 1 John Whitworth, Lise-Lotte Kirkevang, and Lars Bjrndal Endodontology 1 The objective of endodontic treatment 2 Clinical problems and solutions 2 The diagnostic dilemma 6 The outcome dilemma 6 The tools of treatment 6 References 7 Part 1 The Vital Pulp 2 The dentinpulp complex: structure, functions, threats, and response to external injury 11 Lars Bjrndal and Alastair J. Sloan Introduction 11 The odontoblast and the dentinpulp complex 11 The dental pulp 17 Immune responses in the dentinpulp complex 22 Responses of the healthy dentinpulp complex to nondestructive stimuli 25 The dentinpulp complex and responses to external injuries 25 Summary 29 References 29 3 Dentinal and pulpal pain 33 Inge Fristad and Matti Narhi Introduction 33 Classification of nerve fibers 33 Morphology of intradental sensory innervation 33 Function of intradental sensory nerves 36 Sensitivity of dentin: hydrodynamic mechanism in pulpal A-fiber activation 38 Responses of intradental nerves to tissue injury and inflammation 40 Local control of pulpal nociceptor activation 44 Dentin hypersensitivity 44 Pain symptoms and pulpal diagnosis 45 References 46 4 Clinical pulp diagnosis and decision-making 49 Kerstin Petersson and Claes Reit Introduction 49 Evaluation of diagnostic information 49 Diagnostic accuracy 50 Diagnostic strategy 51 Clinical manifestations of pulpal and periapical inflammation 51 Collecting diagnostic information 52 Diagnostic methodology: assessment of pulp vitality 53 Diagnostic methodology: evaluation of reported pain 55 Diagnostic methodology: provocation/inhibition of pain 56 Diagnostic methodology: evaluation of tooth discolorations 58 Diagnostic classification 58 References 59 5 Caries pathology and management in deep stages of lesion formation 61 Lars Bjrndal Enamel lesions without clinical cavitation 63 Progressive stages of enameldentin lesions without surface cavitation and exposure of dentin to the oral environment 65 Cavitation of the dentin lesion 67 Concluding remarks on the natural history of dental caries 72 Strategies for the management of deep caries 72 Detailed treatment protocol for deep caries management 74 References 76 6 Treatment of vital pulp conditions 79 Lars Bjrndal, Helena Fransson, and Stephane Simon Introduction 79 Indications and treatment concepts for preserving vital pulp functions 80 Protocols for treatments aiming to preserve the vitality of the exposed pulp 81 Factors of importance in preserving vital pulp functions 87 Capping materials and healing patterns 89 Tissuebiomaterial interaction and pulp healing 91 Pulp-preserving treatments a controversial treatment? 92 Indications and treatment concepts for treating the irreversibly inflamed vital pulp (pulpectomy) 93 Postoperative considerations 96 Choosing between pulp-preserving vital pulp therapies and pulpectomy 96 Concluding remarks on the avoidance of pulpectomy by vital pulp therapies 97 Revitalization and/or regenerative endodontic procedures 97 References 98 Part 2 The Infected Necrotic Pulp and Apical Periodontitis 7 Apical periodontitis 103 Zvi Metzger, Anda Kfir, and Itzhak Abramovitz Introduction 103 The nature of apical periodontitis 103 Interactions with the infecting microbiota 107 Treatment and healing of periapical lesions 114 Persistence of periapical lesions 115 Clinical manifestations and diagnostic terminology 117 References 119 8 Microbiology of the inflamed and necrotic pulp 123 Luis E. Chavez de Paz Introduction 123 Historical background 123 Clinical evidence 124 Infections in root-filled teeth with persistent apical periodontitis 126 Microbial pathogenesis of apical periodontitis 128 Association of signs and sympt