Problems in Endodontics: Etiology, Diagnosis and Treatment
Problems in Endodontics: Etiology, Diagnosis and Treatment
Problems in Endodontics: Etiology, Diagnosis and Treatment
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
Contents
1 Diagnosis 1
Edgar Schfer
4 Health-related problems 65
Edgar Schfer
9 Visualization 173
Michael Arnold
Contents
17 Perforations 385
Clemens Bargholz
19 Resorption 421
Michael Hlsmann and Edgar Schfer
20 Retreatment 435
Clemens Bargholz, Michael Hlsmann and Edgar Schfer
VI
Contents
Index 531
VII
Contributors
Dr. Dirk Hr
Oberlinxweilerstrasse 19
D-66606 Niederlinxweiler
Germany
VIII
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
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.
151
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
150
Fig. 15-25 A fine fracture line (arrow) is revealed when the marginal
gingiva is retracted.
Fig. 15-27 View of the cavity after obturation of the distal root canal.
366
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