Textbook of Endodontics

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 Textbook of
Endodontics
Fourth EDITION

Nisha Garg MDS

Professor
Department of Conservative Dentistry and Endodontics
Bhojia Dental College and Hospital
Baddi, Himachal Pradesh, India

Amit Garg MDS

Professor and Head
Department of Oral and Maxillofacial Surgery
Rayat and Bahra Dental College and Hospital
Mohali, Punjab, India

Foreword
Mohammad Hossein Nekoofar

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Textbook of Endodontics
First Edition: 2007
Second Edition: 2010
Third Edition: 2014
Fourth Edition: 2019
ISBN: 978-93-5270-535-1
Dedicated to

Prisha
and
Vedant
 Contributors

Akash Dupper MDS Avninder Kaur MDS

Professor Professor and Head
Department of Conservative Dentistry Department of Pediatric and Preventive
and Endodontics Dentistry
Sri Sukhmani Dental College and Bhojia Dental College and Hospital
Hospital Baddi, Himachal Pradesh, India
Mohali, Punjab, India Chapter: 36
Chapter: 4 Ibrahim H Abu Tahun DDS PhD (Endo)
Ajay Chhabra MDS Associate Professor
Principal Department of Conservative Dentistry,
Department of Conservative Dentistry School of Dentistry
and Endodontics University of Jordan
Bhojia Dental College and Hospital Amman, Jordan
Baddi, Himachal Pradesh, India Chapter: 2
Chapter: 21 Jaidev Singh Dhillon MDS
Amit Garg MDS Former Principal and Head
Professor and Head Department of Conservative Dentistry
Department of Oral and Maxillofacial and Endodontics
Surgery Gian Sagar Dental College and Hospital
Rayat and Bahra Dental College and Rajpura, Punjab, India
Hospital Chapter: 18
Mohali, Punjab, India Jaydev MDS
Chapters: 7, 8, 10, 12 Assistant Professor
Amita MDS Department of Conservative Dentistry
Professor and Endodontics
Department of Conservative Dentistry Panineeya Mahavidyalaya Institute of
and Endodontics Dental Sciences and Research Center
BRS Dental College and Hospital Hyderabad, Telangana, India
Panchkula, Haryana, India Chapter: 24
Chapter: 26 JS Mann MDS
Anil Chandra MDS Associate Professor and Head
Professor Department of Conservative Dentistry
Department of Conservative Dentistry and Endodontics
and Endodontics Government Dental College and Hospital
King George Medical College Patiala, Punjab, India
Lucknow, Uttar Pradesh, India Chapter: 19
Chapter: 15 Manav Nayar MDS
Anil Dhingra MDS Member
Professor and Head Royal College of Dental Surgeons of
Department of Conservative Dentistry Ontario
and Endodontics Consultant Endodontist
Seema Dental College and Hospital Napa Dental
Rishikesh, Uttarakhand, India Ontario, Canada
Chapter: 14 Chapter: 17
viii Textbook of Endodontics

Manoj Hans MDS Rakesh Singla MDS

Professor Professor and Head
Department of Conservative Dentistry Department of Conservative Dentistry
and Endodontics and Endodontics
KD Dental College and Hospital Jan Nayak Ch Devi Lal Dental College
Mathura, Uttar Pradesh, India Sirsa, Haryana, India
Chapter: 6 Chapters: 13, 21, 29
Navjot Singh Khurana MDS Riyaz Farooq MDS
Lecturer Principal and Dean
Department of Conservative Dentistry Government Dental College and Hospital
and Endodontics Srinagar, Jammu and Kashmir, India
Government Dental College Chapter: 20
Patiala, Punjab, India
Chapter: 14
RS Kang MDS
Navkesh Singh MDS
Former Associate Professor and Head
Senior Lecturer
Department of Conservative Dentistry
Department of Conservative Dentistry
and Endodontics
and Endodontics
Government Dental College and Hospital
Bhojia Dental College and Hospital
Patiala, Punjab, India
Baddi, Himachal Pradesh, India
Chapter: 13
Chapter: 11
Ruhani Bhatia
Nisha Garg MDS
Senior Lecturer
Professor
Department of Conservative Dentistry
Department of Conservative Dentistry
and Endodontics
and Endodontics
Bhojia Dental College and Hospital
Bhojia Dental College and Hospital
Baddi, Himachal Pradesh, India
Baddi, Himachal Pradesh, India
Chapter: 28
P Karunakar MDS Sameer Makkar MDS
Professor and Head Professor and Head
Department of Conservative Dentistry Conservative Dentistry and Endodontics
and Endodontics Swami Devi Dyal Hospital and
Panineeya Mahavidyalaya Institute of Dental College
Dental Sciences and Research Center Panchkula, Haryana, India
Hyderabad, Telangana, India Chapter: 16
Chapter: 19
Poonam Bogra MDS Sanjay Jain MDS
Professor Ex-Professor and PG Guide
Department of Conservative Dentistry Consultant Periodontist
and Endodontics Pune, Maharashtra, India
DAV Dental College Chapter: 34
Yamunanagar, Haryana, India
Chapters: 5, 15, 37
Puneet Jindal MDS Sanjay Miglani MDS FISDR
Ex-Senior Resident Department of Conservative Dentistry
Post Graduate Institute of Medical and Endodontics
Education and Research Faculty of Dentistry
Chandigarh, India Jamia Millia Islamia (A Central
Chapters: 37 University)
Jamia Nagar, New Delhi, India
Chapter: 14
 Contributors ix

Savita Thakur MDS Vijay Singh Babloo MDS

Ex-Senior Lecturer Professor and Head
Department of Conservative Dentistry Department of Conservative Dentistry
and Endodontics and Endodontics
Bhojia Dental College and Hospital DAV Dental College and Hospital
Baddi, Himachal Pradesh, India Yamunanagar, Haryana, India
Chapter: 28 Chapter: 27
Sheenam Markan MDS Viresh Chopra MDS
Reader Faculty of ARD (Adult Restorative
Department of Conservative Dentistry Dentistry)
and Endodontics Department of Conservative Dentistry
Bhojia Dental College and Hospital and Endodontics
Baddi, Himachal Pradesh, India Oman Dental College
Chapter: 25 Muscat, Oman
Tom JM Dienya BDS MDSc (Endo) Chapter: 23
Chairman Yoshitsugu Terauchi DDD PhD
Department of Conservative and Lecturer
Prosthetic Dentistry Tokyo Medical and
School of Dental Sciences Dental University
University of Nairboi Japan
Nairboi, Kenya Chapter: 24
Chapter: 13
 Foreword

As dentists, especially endodontists, we are continuous students in this vast, ever-changing

field. It has been predicted by the American Clinical and Climatological Association that by
the year 2020 medical knowledge will double every 73 days. Facing this big data problem
is why the approach of this textbook is a suitable choice for a variety of readers differing in
background, knowledge and experience. By incorporating both new and latter studies in
areas, such as vital pulp therapy, bioactive ceramics, laser, microbiology, and regenerative
endodontics, this textbook acts as an efficient instructional manuscript keeping practitioners
updated in comprehensive clinical decision making.
In addition to its recognition of almost all the important advances in today’s endodontics
world, the element that also captured my attention greatly, was the utilization of illustration
and color to smoothly guide the reader through otherwise very intricate and complex material.
This brought me back to the Indian festival of colors in all its beauty. Dr Nisha Garg and Dr
Amit Garg have truly captured the soul of their roots in the books setting, whilst tastefully showcasing their collaboration
with globally admired scholars in what could only have been achieved by great minds coming together.
If given the chance, I would gladly take the steps toward translating Textbook of Endodontics to Persian, in order to
give my fellow Iranian colleagues and students the opportunity to take advantage of this comprehensive, well-compiled
piece.
I wish all the best for Dr Nisha Garg and Dr Amit Garg, as I see a clear, bright future for both of them in the forth in
coming endeavors.

Mohammad Hossein Nekoofar

DDs MSc Diplomate of Iranian Board of Endodontics PhD (Cardiff UK)
Department of Endodontics
School of Dentistry
Department of Tissue Engineering and Applied Cell Sciences
School of Advanced Technologies in Medicine
Tehran University of Medical Sciences
Honorary Senior Clinical Lecturer
School of Dentistry
College of Biomedical and Life Sciences
Cardiff University, UK

Member of Editorial Board of International Endodontic Journal

Immediate Past-President of Iranian Association of Endodontists
 Preface to the fourth edition

In presenting the fourth edition of Textbook of Endodontics, we would like to express our appreciation in the kindly
manner in which the earlier editions were accepted by dental students and professionals across the country.
The scope of book is simple yet comprehensive that serves as an introductory for dental students and a refresher
source for general practitioners. This book attempts to incorporate most recent advances in endodontics while at the
same time not losing the sight of basics; therefore, making the study of endodontics easier and interesting. We could not
have achieved the current level of success without the help of students and our colleagues who always motivate us to
deliver our best.
In an attempt to improve this book further, many eminent personalities were invited to edit, write and modify the
important chapters in the form of text and photographs. We would especially thank Drs Jaidev Dhillon, Ajay Chhabra,
Anil Dhingra, Jaydev, Puneet Jindal, Navjot Singh Khurana, Viresh Chopra, Manoj Hans, and Sanjay Jain, for providing
us clinical case photographs and radiographs for better understanding of the subject.
We are indebted to Dr Poonam Bogra for writing important chapters biofilm and smear layer in endodontics for
the book. We are especially thankful to Dr Poonam Bogra for editing chapters, access cavity preparation, regenerative
endodontics, and cleaning and shaping.
We fall lack of words to thank Dr Vijay Singh Babloo for critically evaluating the chapter post-endodontic restorations,
Dr Sameer Makkar for irrigation and disinfection, Dr Karunakar for obturation, Dr Riyaz for MTA, and Dr Ibrahim
Abu Tahun for editing chapter pulp and periapical tissues. We are especially grateful to Dr Rakesh Singla for critical
evaluation and being always present throughout the duration of our project.
We are thankful to Dr Sanjay Miglani for editing the chapter internal anatomy, Dr Tom JM Dienya for endodontic
instruments, Dr Avninder Kaur for vital pulp therapy, Dr Savita Thakur for editing management of traumatic injuries,
and Dr Manav Nayar for working length determination. We are especially thankful to Dr Yoshitsugu Terauchi for sharing
his device for removal of the separarted instrument.
We are thankful to Dr RS Kang and Dr JS Mann, for their constant support, motivation and encouragement. We wish
to thank for critical evaluation and profound comments by our colleagues Drs Pranav, Shabnam, Alka and Mohit; and
postgraduates, for their ‘ready to help’ attitude and positive criticism which helped in improvement of the book.
We offer our humble gratitude and sincere thanks to Mr Vikram Bhojia (Secretary, Bhojia Trust) for providing healthy
and encouraging environment for our work.
We are grateful to companies Dentsply, Coltene Whaledent, Sybron Endo, and 3M ESPE for providing high-resolution
images of products related to endodontics.
It is hoped that all these modifications will be appreciated and render the book still more valuable basis for endodontic
practice.
We are specially thankful to our kids, Prisha and Vedant, for their understanding, patience and support throughout
this project.
We are very grateful to the whole team of M/s Jaypee Brothers Medical Publishers (P) Ltd, who helped and guided
us, especially Shri Jitendar P Vij (Group Chairman), Mr Ankit Vij (Managing Director), Mr MS Mani (Group President),
Ms Ritu Sharma (Director–Content Strategy), Ms Sunita Katla (Executive Assistant to Group Chairman and Publishing
Manager), Ms Pooja Bhandari (Production Head), Ms Samina Khan (Executive Assistant to Director–Content Strategy),
Dr Pinky Chauhan (Development Editor), Ms Seema Dogra (Cover Visualizer), Gopal Singh Kirola (Graphic Designer),
and their team members, for all their support and work on this project and make it a success. Without their cooperation,
we could not have completed this project.

Nisha Garg
Amit Garg
 Preface to the first edition

The amount of literature available in dentistry today is vast. Endodontics being no exception. However, during both our
graduation as well as postgraduation, we always felt the need for a book which would help us to revise and update our
knowledge. When we were doing undergraduation, there were no Indian authored books on endodontics. We were thus
motivated to frame a specialized, precise, concise, easy to read and remember yet, up-to-date Textbook of Endodontics.
The line diagrams are in an expressive interpretation of endodontic procedures, which are worked upon and simplified
to render them more comprehensive and comparable with real photographs. These illustrations (around 1,200) are easy
to remember and reproduce during examinations.
Emphasis is laid upon the language which is simple, understandable and exclusively designed for undergraduates,
postgraduates, general practitioners and teachers in the field.
It took us more than three years to accomplish the arduous task of writing this book. This thrust for knowledge led us
to link everywhere, where we could Medline journals, books and more.
Nevertheless, a never-ending approach and internal craving of mind and soul finally resulted in publication of the
book. God perhaps gave us some ability and showered his light on us, guiding us for this task.
Till the last week before the publication of the book, we were frantically looking for loopholes, missing information
and any important updates we might have missed out. To the best of our knowledge, we did everything we could. But for
knowledge, one life is not enough. The sky is the limit.
We await the response of this first edition, which would improve us in the next editions to come.

Nisha Garg
Amit Garg
 Contents

1. Introduction 1 Diseases of Periradicular Tissue of Nonendodontic

Origin 49
Scope of Endodontics 1
History of Endodontics 1
Contemporary Endodontics 3 4. Endodontic Microbiology 51
Portals of Entry for Microorganisms 51
2. Pulp and Periradicular Tissue 5 Classification of Microorganisms 52
Microbial Virulence and Pathogenicity 52
Development of Dental Pulp 6
Factors Influencing the Growth and Colonization
Histology of Dental Pulp 7
of Microorganisms 54
Systemic Factors Affecting Pulp 10
Microbial Ecosystem of the Root Canal 54
Supportive Elements 10
Types of Endodontic Infections 55
Innervation of Pulp 12
Identification of the Bacteria 56
Anatomy of Dental Pulp 14
How to Combat Microbes in the Endodontic
Functions of Pulp 16
Therapy? 58
Age Changes in the Pulp 17
Pulpal Calcifications/Pulp Stones/Denticles 17
Periradicular Tissue 18 5. Biofilm and Smear Layer in
Endodontics 61
3. Pathologies of Pulp and Periapex 21 Biofilm in Endodontics 61
Etiology of Pulpal Diseases 22 Definition 61
Progression of Pulpal Pathologies 23 Characteristics of Biofilm 61
Diagnosis of Pulpal Pathology 25 Stages of Biofilm Formation 62
Classification of Pulpal Pathologies 25 Types of Endodontic Biofilm 62
Barodontalgia/Aerodontalgia 25 Ultrastructure of Biofilm 63
Reversible Pulpitis/Hyperemia/Hyperactive Microbes in Endodontic Biofilms 64
Pulpalgia 26 Methods to Eradicate Biofilms 64
Irreversible Pulpitis 27 Smear Layer in Endodontics 65
Chronic Hyperplastic Pulpitis 29
Internal Resorption/Pink Tooth of Mummery 30 6. Rationale of Endodontic
Pulp Degeneration 31
Pulp Necrosis 34
Treatment 69
Pathologies of Periradicular Tissues 35 Theories of Spread of Infection 69
Classification of Periradicular Pathologies 37 Culprit of Endodontic Pathology 69
Symptomatic Apical Periodontitis (Acute Apical Inflammation 70
Periodontitis) 38 Nonspecific Mediators of Periradicular Lesions 72
Acute Apical Abscess 39 Antibodies (Specific Mediators of Immune
Phoenix Abscess/Recrudescent Abscess/Acute Reactions) 74
Exacerbation of Asymptomatic Apical Role of Immunity in Endodontics 74
Periodontitis 41 Endodontic Implications (Pathogenesis of Apical
Asymptomatic Apical Periodontits/Chronic Apical Periodontitis as Explained by Fish) 75
Periodontitis 41 Kronfeld’s Mountain Pass Theory (1939) 76
Chronic Alveolar Abscess 42 Rationale of Endodontic Therapy 77
Periapical Granuloma 43
Radicular Cyst/Cystic Apical Periodontitis 44 7. Diagnostic Procedures 79
Condensing Osteitis 47
Case History 79
External Root Resorption 47
Pulp Vitality Tests 84
Persistent Apical Periodontitis 48
xviii Textbook of Endodontics

Recent Advances in Pulp Vitality Testing 87 13. Endodontic Instruments 146

Role of Radiographs in Endodontics 90
Standardization of Instruments given by
Digital Radiography 95
Ingle and Levine 146
Cone-beam Computed Tomography 96
Classification of Endodontic Instruments 148
Group I Hand-operated Instruments 148
8. Differential Diagnosis of Files 149
Orofacial Pain 101 Group II Low Speed Instruments with
Latch-Type Design 153
Diagnosis 101
Group III Engine-Driven Instruments 155
Orofacial Pain 102
Generations of NiTi Rotary Files 159
Sources of Odontogenic Pain 102
First Generation NiTi Rotary Files 159
Pulpal Pain 102
Second Generation 161
Periodontal Pain 103
Third Generation Files 164
Sources of Nonodontogenic Pain 104
Fourth Generation Reciprocating Instruments 165
Fifth Generation Instruments 167
9. Case Selection and Treatment ScoutRace Files 168
Planning 111 Group IV Sonics and Ultrasonics in
Endodontics 168
Indications of Endodontic Treatment 111
Sonic Handpiece 168
Contraindications of Endodontic Therapy 112
Instrument Deformation and Breakage 170
Treatment Planning 113
Instruments Used for Filling Root Canals 172
Factors Affecting Treatment Planning 114
Medical Conditions Influencing Endodontic
Treatment Planning 114 14. Internal Anatomy 175
Pulp Cavity 175
Root Canal Classification 178
10. Asepsis in Endodontics 116 Methods of Determining Pulp Anatomy 179
Rationale for Infection Control 116 Variations in the Internal Anatomy of Teeth 181
Cross Infection 116 Factors Affecting Internal Anatomy 190
Objective of Infection Control 117 Individual Tooth Anatomy 190
Universal Precautions 117
Classification of Instruments 119 15. Access Cavity Preparation 201
Instrument Processing Procedures/ Instruments for Access Cavity Preparation 202
Decontamination Cycle 120 Guidelines for Access Cavity Preparation 204
Disinfection 125 Laws of Access Cavity Preparation for
Antiseptics 126 Locating Canal Orifices 205
Infection Control Checklist 127 Access Cavity of Anterior Teeth 206
Waste Disposal 127 Access Cavity Preparation for Premolars 208
Access Cavity Preparation for Maxillary Molars 210
11. Isolation of Teeth 130 Access Cavity Preparation for Mandibular
Molars 212
Isolation with Rubber Dam 130
Clinical Management of Difficult Cases
Recent Modifications in the Designs of
for Access Opening 214
Rubber Dam 136
Minimal Invasive Endodontics/Recent Trends
Placement of Rubber Dam 137
in Endodontic Access Preparation 216
Management of Difficult Cases 138

12. Pharmacology in Endodontics 140 16. Irrigation and Intracanal

Pain Control 140 Medicaments 221
Intrapulpal Injection 141 Ideal Requirements for an Irrigant 221
Analgesics 141 Functions of Irrigants 222
Infection Control 143 Factors that Modify Activity of Irrigating
Solutions 222
 Contents xix
Commonly Used Irrigating Solutions 223 Methods of Sealer Placement 291
Normal Saline 223 Obturation Techniques 291
Sodium Hypochlorite 223 Armamentarium for Obturation 292
Hydrogen Peroxide 225 Lateral Compaction Technique 292
Urea 226 Warm Vertical Compaction Technique 297
Urea Peroxide 226 Temperature Control 299
Chlorhexidine 226 Sectional Method of Obturation/Chicago
Chelating Agents 227 Technique 301
Ultrasonic Irrigation 229 McSpadden Compaction/Thermomechanical
Newer Irrigating Solutions 231 Compaction of the Gutta-percha 301
Herbal Irrigants 232 Thermoplasticized Injectable Gutta-percha
Method of Irrigation 233 Obturation 302
Intracanal Medicaments 235 Solid Core Carrier Technique 303
Classification of Intracanal Medicaments 237 Obturation with Silver Cone 305
Characteristics of Intracanal Medicaments 237 Apical Third Filling 305
Placement of Intracanal Medicament 241 Postobturation Instructions 308
Repair Following Endodontic Treatment 308
17. Working Length Determination 243
Significance of Working Length 245 20. Single Visit Endodontics 311
Working Width 245 Advantages of Single Visit Endodontics 311
Different Methods of Working Length Disadvantages of Single Visit Endodontics 311
Determination 246 Criteria of Case Selection 311
Radiographic Method of Working Length Contraindications of Single Visit Endodontics 312
Determination 246
Nonradiographic Methods of Working Length 21. Mid-treatment Flare-ups
Determination 250
in Endodontics 314
18. Cleaning and Shaping of Root Canal Etiology 314
Mechanisms for Flare-ups 316
System 256 Clinical Conditions Related to Flare-up 318
Objectives of Biomechanical Preparation 257 Management of Flare-ups 319
Different Movements of Instruments 258
Basic Principles of Canal Instrumentation 260 22. Endodontic Emergencies 323
Techniques of Root Canal Preparation 261
Step-back Technique/Telescopic Canal Preparation/ Definition and Classification 323
Serial Root Canal Preparation 262 Diagnosis of Endodontic Emergencies 323
Crown-down/Step-down Technique 264 Pretreatment Endodontic Emergencies 324
Hybrid Technique of Canal Preparation (Step Down/ Intratreatment Emergencies 328
Step Back) 267 Postendodontic Emergencies 330
Canal Preparation Using Ultrasonic
Instruments 268 23. Endodontic Failures and
Canal Preparation Using Sonic Instruments 269 Retreatment 332
Laser-assisted Root Canal Therapy 269
Evaluation Criteria of Canal Preparation 269 Evaluation of Success of Endodontic
Management of Difficult Cases 270 Treatment 332
Case Selection for Endodontic Retreatment 337
Steps of Retreatment 337
19. Obturation of Root
Canal System 277 24. Procedural Accidents 347
Why to Obturate? 277 Inadequately Cleaned and Shaped Root Canal
Timing of Obturation 277 System 347
Extent of Root Canal Filling 278 Instrument Separation 353
Materials Used for Obturation 279
xx Textbook of Endodontics

Deviation from Normal Canal Anatomy 357 Primary Periodontal Lesions with Secondary
Inadequate Canal Preparation 359 Endodontic Involvement 401
Perforation 361 Independent Endodontic and Periodontal Lesions
Obturation Related 367 which do not Communicate 402
Vertical Root Fracture 368 True Combined Endo–Perio Lesions 403
Instrument Aspiration 369
27. Restoration of Endodontically
25. Surgical Endodontics 371 Treated Teeth 406
Definition 371 Importance of Coronal Restoration 406
Rationale 371 Factors Making Endodontically Treated Teeth
Objectives 371 Different from Vital Teeth 406
Indications 372 Restorative Treatment Planning for Endodontically
Contraindications 372 Treated Teeth 408
Classification 372 Components of the Restored Tooth 410
Presurgical Considerations 373 Classification of Posts 411
Incision and Drainage 373 Factors to be Considered while Planning
Periradicular Surgery 374 Post and Core 418
Flap Designs and Incisions 375 Preparation of the Canal Space and the Tooth 422
Full Mucoperiosteal Flaps 376 Core 422
Limited Mucoperiosteal Flaps 377 Custom-made Post 426
Flap Design Consideration in Palatal Surgery 378 Core Fabrication 426
Flap Reflection and Retraction 378 Investing and Casting 426
Hard Tissue Management 379 Evaluation 427
Principles of Surgical Access to Root Structure 379 Cementation 427
Periradicular Curettage 379
Root-end Resection (Apicoectomy,
Apicectomy) 380 28. Management of Traumatic
Root-end Preparation 381 Injuries 428
Retrograde Filling 384 Classification of Dentofacial Injuries 428
Reapproximation of the Soft Tissue 386 History and Examination of Traumatic Injuries 430
Replantation 386 Crown Infraction 432
Transplantation 387 Uncomplicated Crown Fracture 433
Hemisection/Root Resection/Root Amputation 387 Complicated Crown Fracture 435
Bicuspidization/Bisection 389 Crown Root Fracture 439
Endodontic Implants 389 Root Fracture 441
Postsurgical Care 390 Luxation Injuries 447
Suturing 390 Assessment of Traumatic Injuries 457
Postsurgical Complications 390 Prevention of Traumatic Injuries 458

26. Endodontic Periodontal Lesions 392 29. Pulpal Response to Caries

Pathways of Communication between Pulp and and Dental Procedure 460
Periodontium 393
Impact of Pulpal Diseases on the Periodontium 395 Response of Pulp to Dental Caries 460
Impact of Periodontal Disease on Pulpal Tissue 396 Response of Pulp to Tooth Preparation 462
Etiology of Endodontic–Periodontal Lesions 396 Response of Pulp to Local Anesthetics 463
Classification of Endodontic–Periodontal Dentin Sterilizing Agents 464
Lesions 396 Response of Pulp to Restorative Materials 464
Diagnosis of Endodontic–Periodontal Lesions 397 Effects of Pin Insertion 465
Primary Endodontic Lesions 399 Impression Material 465
Primary Endodontic Lesion with Secondary Effects of Radiations on Pulp 465
Periodontal Involvement 400 Effect of Heat from Electrosurgery 466
Primary Periodontal Lesions 400 Effect of Lasers on Pulp 466
Defense Mechanism of Pulp 466
 Contents xxi
Prevention of Pulpal Damage Due to Emission Modes of Laser 520
Operative Procedure 467 Laser Interaction with Biological Tissues 520
How Does Pulp Recover? 467 Laser Safety in Dental Practice 521
Laser Safety 521
30. Management of Discolored Applications of Lasers 522

Teeth 468
35. Bioceramics in Endodontics 525
Classification of Discoloration 468
Etiology 469 Classification 525
Bleaching 472 Rationale of Using Bioceramics 525
Bleaching Agents 473 Bioceramics Available in Endodontics 526
Bleaching Techniques 474 Portland Cement 526
Home Bleaching Technique 474 Mineral Trioxide Aggregate 526
In-Office Bleaching 475 Biodentine 530
Bleaching of Nonvital Teeth 478 Bioceramic-based Root Canal Sealers 531
Effects of Bleaching Agents on Tooth and its
Supporting Structures 481 36. Vital Pulp Therapy 533
Vital Pulp Therapy 533
31. Root Resorption 483 Pulp Capping 534
Definition 483 Apexogenesis 539
Classification of Resorption 483 Pulpotomy 539
Protective Mechanism Against Resorption 484 Apexification (Root-end Closure) 543
Cells Involved in Root Resorption 485 Revascularization 546
Mechanism of Root Resorption 485 Coronal Restoration 547
Diagnosis of Resorption 486
Internal Resorption 486 37. Regenerative Endodontics 549
External Root Resorption 492 Definition of Tissue Engineering 549
Cervical Root Resorption (Extracanal Invasive Strategies of Stem Cell Technology 549
Resorption) 497 Triad of Tissue Engineering 550
Regenerative Endodontics Procedures 551
32. Crack Tooth Syndrome and Vertical
Root Fracture 500 38. Magnification 556
Definition 500 Loupes 556
Classification 501 Surgical Operating Microscope 557
Vertical Root Fracture 505 Endoscope 562
Orascope 562
33. Geriatric Endodontics 509
Age Changes in the Teeth 509 39. Ethics in Endodontics 563
Endodontic Challenges in Geriatric Patients 510 Nature of Ethics 563
Diagnosis and Treatment Plan 511 Principles of Ethics 563
Root Canal Ethics 563
34. Lasers in Endodontics 515 Informed Consent 564
Dental Negligence 564
History 515 Malpractice and the Standard of Care 566
Classification of Laser 516 Abandonment 566
Principles of Laser Beam 516 Malpractice Cases 567
Laser Physics 517
Type of Lasers 519
Index 569
 Chapter

1 Introduction

Chapter Outline
‰‰ Scope of Endodontics ‰‰ Contemporary Endodontics
‰‰ History of Endodontics

Endodontics is the branch of dentistry which deals with ‰‰ Vital pulp therapy like pulp capping, pulpotomy, apexo-
diseases of dental pulp and periradicular tissues. En is a genesis, and apexification
Greek word for “inside” and odont is Greek word for “tooth.” ‰‰ Nonsurgical treatment of root canal system
Endodontics is the branch of dentistry which deals with ‰‰ Surgical removal of periapical pathology of pulpal origin
morphology, physiology, and pathology of human pulp and ‰‰ Bleaching of discolored teeth
periradicular tissues. ‰‰ Retreatment of endodontic failure cases
Study of endodontics involves basic knowledge of pulp ‰‰ Restorations of endodotically treated teeth with coronal
biology, etiology, diagnosis, treatment, and prevention of restoration and post and core
the diseases and injuries of the pulp and associated per- ‰‰ Intentional replantation
iradicular tissues (Fig. 1.1). ‰‰ Replantation of avulsed tooth
‰‰ Hemisection, bicuspidization and root resection
Scope of Endodontics ‰‰ Endodontic implants
‰‰ Diagnosis and differential diagnosis of orofacial pain of
pulpal and periradicular origin
History of Endodontics (Table 1.1)
Endodontics has been practiced as early as 2nd or 3rd
century BC. The history of endodontics begins in 17th cen-
tury, and since then, many advances, developments, and
research work has been done continuously.
Advances in endodontics have been made continuously,
especially after Pierre Fauchard (1678–1761) (founder of
modern dentistry) described the pulp very precisely in his
textbook “Le Chirurgien Dentiste.”
Later in 1725, Lazare Riviere introduced the use of clove
oil as sedative, and in 1746, Pierre Fauchard demonstrated
the removal of pulp tissue. Dr. Grossman, the pioneer of
endodontics, divided the evolution of endodontics in four
eras from 1776 to 1976, each consisting of 50 years.

Prescience 1776–1826
Age of discovery 1826–1876
Dark age 1876–1926
The renaissance 1926–1976
Fig. 1.1 Model of teeth showing pulp along with endodontic
Innovation era 1977–till date
lesions of the teeth.
2 Textbook of Endodontics

Table 1.1: History of endodontics

1725 Lazare Riviere Introduced clove oil for sedative property
1728 Pierre Fauchard First described the pulp tissue
1746 Pierre Fauchard Described removal of pulp tissue
1820 Leonard Koecker Cauterized exposed pulp with heated instrument and protected it with
lead foil
1836 S Spooner Suggested arsenic trioxide for pulp devitalization
1838 Edwin Maynard Introduced first root canal instrument
1847 Edwin Truman Introduced gutta-percha as a filling material
1864 SC Barnum Prepared a thin rubber leaf to isolate the tooth during filling
1867 Bowman Used gutta-percha cones for filling of root canals
1867 Magitot Use of electric current for testing pulp vitality
1890 Gramm Introduced gold plated copper points for filling
1891 Otto Walkhoff introduced camphorated chlorophenol as a medication
1895 Roentgen Introduced formocresol
1914 Callahan Introduction of lateral compaction technique
1918 Cluster Use of electrical current for determination of working length
1920 BW Hermann Introduced calcium hydroxide
1936 Walker Sodium hypochlorite
1942 Suzuki Presented scientific study on apex locator
1944 Johnson Introduced profile instrument system
1957 Nygaard-Ostby Introduced EDTA
1958 Ingle and Levine Gave standardizations and guidelines for endodontic instruments
1961 Sparser Walking bleach technique
1962 Sunada Calculated electrical resistance between periodontium and oral mucous
membrane
1971 Weichman-Johnson Use of lasers
1979 Mullaney et al. Use of step-back technique
1979 McSpadden McSpadden technique (thermomechanical compaction)
1980 Marshall and Pappin Introduction of crown-down technique
1985–1986 Roane, Sabala, and Powell Introduction of balanced force technique
1988 Munro Introduced first commercial bleaching product
1989 Haywood and Heymann Nightguard vital bleaching
1993 Torabinejad Introduced MTA
2004 Pentron clinical laboratory Introduced Resilon

Abbreviations: EDTA: ethylenediaminetetra acetic acid; MTA: mineral trioxide aggregate.