Problems in Endodontics: Etiology, Diagnosis and Treatment

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Michael Hlsmann, Edgar Schfer (Editors)

Clemens Bargholz, Claudia Barthel (Associate editors)

Problems in
Endodontics
Etiology, Diagnosis and Treatment
With contributions from:
Michael Arnold
Thomas Attin
Clemens Bargholz
Claudia Barthel
Hans-Willi Herrmann
Dirk Hr
Michael Hlsmann
Tina Rdig
Edgar Schfer

London, Berlin, Chicago, Tokyo, Barcelona, Beijing, Istanbul, Milan,


Moscow, Mumbai, Paris, Prague, So Paulo und Warsaw

Contents

1 Diagnosis 1
Edgar Schfer

2 Problems in preserving pulp vitality 33


Edgar Schfer and Claudia Barthel

3 Problems in treatment planning 45


Michael Hlsmann, Edgar Schfer and Clemens Bargholz

4 Health-related problems 65
Edgar Schfer

5 Preoperative restoration and placement of


rubber dam 97
Clemens Bargholz

6 Problems in dental anesthesia 115


Claudia Barthel, Michael Hlsmann and Edgar Schfer

7 Problems in the treatment of endodontic


emergencies 127
Michael Hlsmann and Edgar Schfer

8 Problems in gaining access to the root canal


system 145
Michael Hlsmann and Claudia Barthel

9 Visualization 173
Michael Arnold

10 Problems in determining endodontic working


length 191
Dirk Hr, Tina Rdig and Michael Hlsmann

Contents

11 Problems in root canal preparation 209


Michael Hlsmann and Edgar Schfer

12 Problems in disinfection of the root


canal system 253
Michael Hlsmann and Tina Rdig

13 Problems of root canal obturation 293


Hans-Willi Herrmann and Michael Hlsmann

14 Problems in the assessment of healing,


success and failure 335
Michael Hlsmann, Edgar Schfer and Claudia Barthel

15 Vertical tooth and root fractures 353


Clemens Bargholz

16 Periodontalendodontal lesions 371


Michael Hlsmann and Edgar Schfer

17 Perforations 385
Clemens Bargholz

18 Instrument fractures 401


Michael Hlsmann

19 Resorption 421
Michael Hlsmann and Edgar Schfer

20 Retreatment 435
Clemens Bargholz, Michael Hlsmann and Edgar Schfer

21 Incomplete root formation 463


Edgar Schfer

22 Aspiration and swallowing accidents 479


Edgar Schfer

23 Endodontic treatment of teeth with


anatomical malformations 485
Michael Hlsmann and Edgar Schfer

VI

Contents

24 Problems in bleaching of endodontically


treated teeth 515
Thomas Attin

Index 531

VII

Contributors

Michael Arnold, BDS (Stomatology)


Knigstrasse 9
D-01097 Dresden
Germany

Dr. Dirk Hr
Oberlinxweilerstrasse 19
D-66606 Niederlinxweiler
Germany

Prof. Thomas Attin


Department of Preventive Dentistry, Periodontology
and Cariology
Zurich University
Plattenstrasse 11
CH-8028 Zurich
Switzerland

Prof. Michael Hlsmann


Department of Operative Dentistry, Preventive
Dentistry and Periodontology
Georg-August-Universitt Gttingen
Robert-Koch-Strasse 40
D-37075 Gttingen
Germany

Dr. Clemens Bargholz


Mittelweg 141
D-20148 Hamburg
Germany

Dr. Tina Rdig


Department of Operative Dentistry, Preventive Dentistry and Periodontology
Georg-August-Universitt Gttingen
Robert-Koch-Strasse 40
D-37075 Gttingen
Germany

Prof. Claudia Barthel


Department of Operative Dentistry
Heinrich-Heine-Universitt Dsseldorf
Moorenstrasse 5
D-40225 Dsseldorf
Germany
Dr. Hans-Willi Herrmann
Zahnarztpraxis Im Dienheimer Hof
Mannheimer Strasse 6
D-55545 Bad Kreuznach,
Germany

VIII

Prof. Edgar Schfer


Department of Operative Dentistry
University of Mnster
Waldeyerstrasse 30
D-48149 Mnster
Germany

Preface
Endodontics is enjoyable!
It seems that this view is shared by many of our colleagues despite the difficult conditions that sometimes prevail in everyday practice leading to a sort of endodontics euphoria over the past few years. As ever, when procedures are not only
fascinating and absorbing, but also have good prognoses, even under ordinary practice conditions (provided that basic treatment principles are upheld), there is a tendency to go deeper and deeper into the subject and risk treating increasingly more
complex and difficult cases. We often see a quick extraction being replaced by an
attempt to preserve even severely compromised teeth with endodontic or surgical
endodontic procedures. Retreatments now make up the majority of procedures carried out by endodontic specialists, whereas perforation repair and the removal of fractured instruments have become part of everyday practice routine for many dentists.
Our aim in this book is to offer support in overcoming problems, to ensure that the
enjoyment and fascination of endodontics are not lost, even in cases that cannot be
described as routine.
We contribute clinically relevant information to a few of the key problem areas
in endodontics, starting with the often neglected subjects such as diagnosis, preservation of tooth vitality and the treatment of pain, and also including preventive aspects
and practical problem-solving tips. We felt that a root canal cookbook or an
endodontic DIY manual would not be helpful, so we have made an effort to include
key findings and data from the scientific literature. Of course, the reader must be
aware that these are subject to constant change, and that some of the older information will need to be interpreted with some caution. However, old is not necessarily bad (and vice versa).
Of course, this book has a worthy model in Problem Solving in Endodontics (Gutmann, Dumsha and Lovdahl, Mosby, 2005), now in its fourth edition, which, in many
ways, reflects the American treatment philosophy. Nevertheless, this compendium still
offers a huge variety of material, knowledge, advice and food for thought, as well as
many practical tips and tricks. Our book, in its original language, represented an effort
to create a similar work for German speakers, to be regularly updated, constantly
improved and enriched by future advice and by case reports from everyday dental
practice.
At this point, therefore, we would like to thank not only all our many co-authors
but also, in particular, all our colleagues, whether based at practices or universities,
for their informative case histories.
Of course this book will not encompass every situation. So many of the clinical
findings and problems have such a variety of different solutions that they cannot all
be collected into one book. In addition, unfortunately, many practical procedures
are difficult to describe on the page; sitting in on clinical demonstrations, attending
practical courses and taking part in classic training and continuing professional

IX

Preface
development still remain essential and irreplaceable learning media for such situations. We would therefore be very pleased to hear from interested colleagues and
to receive as much as possible in the way of advice, clinical tips and even additional case reports for the next edition, which we hope to produce in due course.
This book is merely a gateway into this subject and is far from complete. Important omissions are dental traumatology, the endodontic treatment of primary teeth
and (micro)surgical endodontics. We hope these will find a place in future editions.
Prof. Dr. Michael Hlsmann, Gttingen, Germany
Prof. Dr. Edgar Schfer, Mnster, Germany

8 Problems in gaining access to the root canal system

Fig. 8-11 The radiograph suggested calcification of the root canal systems, which were no
longer visible in the film. Nevertheless, clinical
assessment revealed two root canal systems.

Fig. 8-12 Both of the remaining root canals are


visible now that the tooth has been extracted.

Fig. 8-13 Clinical view of the tooth.

Nature of the problem


Calcifications completely or partially block and obscure the access into the root canal
systems and can hamper preparation, disinfection and obturation. Searching for calcified root canal systems carries an increased risk of perforation.
Radiographs alone can never be used as a basis for determining whether
complete calcification has taken place; these teeth always require clinical
verification (Figs 8-11 to 8-13). Pulp testing ceases to have any diagnostic
value once the calcification has reached an advanced stage.

Indications for endodontic treatment of teeth with


actual or suspected calcification
Periapical lesions of endodontic origin are always manifestations of a disease that
develops from the presence of microorganisms in the root canal system (or, in rare
cases, in the periapical region).10 Healing can take place only if these bacteria are
removed as completely as possible. Therefore, root canal treatment is strongly indicated in a tooth with a partially (or apparently) calcified root canal system and apical periodontitis. However, if all attempts still fail to result in complete exposure and
instrumentation of the root canal system, the clinician should consider root resection, hemisection or extraction.

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8 Problems in gaining access to the root canal system

Fig. 8-9 Histological view of free pulp stones in the


pulp chamber (HE stain, magnification: 16).

Fig. 8-10 Pulp stones may also be found in the pulp


tissue in the root canals.

Calcification
Definition
Initially, calcification is a process involving the reduction in size of the intradental cavities as a result of hard-tissue formation by the cells of the vital pulp; it ends in complete
calcification as a result of dentin deposition inside the tooth.

Background
Hard-structure depositions of a physiological nature (secondary dentin formation) lead
to slow and uniform constriction and narrowing of the pulp chamber. This process accelerates if the odontoblasts are stimulated by progressive caries. The pulp tissue reacts to
this stimulus by the precipitate deposition of irregular tertiary dentin, with the aim of
forming a barrier against the advancing caries. Chronic irritation caused by exposed
dentin also leads to the formation of tertiary dentin, which results in a constriction in
the cervical region of the tooth in many cases.4 Moreover, calcifications are a common
consequence of dental and occlusal trauma, certain types of maxillary surgery (e.g. Le
Fort I osteotomy) and also certain kinds of orthodontic treatment.
Calcifications of varying extent develop in teeth that have been subjected
to luxation trauma.5 Pulpal necrosis occurs with some major delay in 20%
of teeth with radiologically detectable calcifications.6 Calcifications have
been observed in 2.3% of patients following Le Fort I operations;7,8 according to other
studies, the incidence may be as high as 30%. Further causes that have been
described include surgery-related changes in perfusion and in combined surgical and
orthodontic treatment. Calcifications in the pulp chamber have also been observed
following orthodontic treatment.9

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15 Vertical tooth and root fractures

Fig. 15-25 A fine fracture line (arrow) is revealed when the marginal
gingiva is retracted.

Fig. 15-26 Corresponding radiograph.

Fig. 15-27 View of the cavity after obturation of the distal root canal.

Fig. 15-28 Course of the fracture


lines (mesial section).

Fig. 15-30 Situation following


hemisection and removal of the
mesial root.

Fig. 15-31 Corresponding radiograph.

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Fig. 15-29 Course of the


fracture lines (lingual
view).

15 Vertical tooth and root fractures


Fig. 15-32 During an extensive
implant procedure, a vertical root
fracture in tooth 23 was surgically
exposed to enable short-term
preservation of the tooth; a cavity
was prepared and sealed with
mineral trioxide aggregate (MTA).

Fig. 15-33 Extraction 2 months


later revealed that the fracture has
run through the MTA and into the
apical third of the root. (Source:
Dr. Albers, Norderstedt, Germany).

Fig. 15-34 An incomplete transverse fracture of the tooth is visible following removal of the inlay.

Fig. 15-35 An attempt was made to stabilize the tooth with an adhesive restoration.

Case report
A 59-year-old woman presented with symptoms in tooth 38, which had
been restored with a gold inlay with reasonable margins. The tooth
reacted negatively to the cold test and a radiograph showed apical periodontitis. Removal of the inlay revealed an incomplete transverse fracture (infraction) of the tooth running through the roof of the pulp chamber (Fig. 15-34). The crown of the tooth was stabilized with an adhesive
restoration, which bonded the fragments together (Fig. 15-35), followed
by root canal treatment (Fig. 15-36). Six months later, the tooth was restored with
a partial porcelain crown bonded with adhesive (Fig. 15-37). The patient presented again with symptoms 2 years later. The clinical examination and a radiograph
showed that the fracture had extended into the root, making extraction unavoidable (Figs 15-38 and 15-39).

367

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