Ebook Textbook of endodontics (3/E): Part 2

Part 2 book “Textbook of endodontics” has contents: Obturation of root canal system, single visit endodontics, endodontic emergencies, endodontic failures and retreatment, procedural accidents, surgical endodontics, endodontic periodontal relationship, tooth resorption, pediatric endodontics,… and other contents.

19 Obturation of Root Canal System Timing of Obturation Extent of Root Canal Filling Materials used for Obturation Methods of Sealer Placement Obturation Techniques Armamentarium for Obturation Lateral Compaction Technique Variation of Lateral Compaction Technique  Chemical Alteration of Gutta-Percha          Vertical Compaction Technique  System B: Continuous Wave of Condensation Technique  Lateral/Vertical Compaction of Warm Gutta-Percha  Sectional Method of Obturation/ Chicago Technique  McSpadden Compaction/ Thermomechanical Compaction of the Gutta-Percha  Thermoplasticized Injectable GuttaPercha Obturation  Solid Core Carrier Technique  Obturation with Silver Cone  Apical Third Filling  Postobturation Instructions  Repair following Endodontic Treatment The success in endodontic treatment is based on proper diagnosis and treatment planning, knowledge of anatomy and morphology, debridement, sterilization and obturation The process of cleaning and shaping determines both the degree of disinfection and the ability to obturate the radicular space, obturation is therefore a reflection of the cleaning and shaping and an obturant (obturating material) must seal the root canal system three dimensionally so as to prevent tissue fluids from percolating in the root canal and toxic byproducts from both necrotic tissue and microorganisms regressing into the periradicular tissues (Figs 19.1 to 19.4) The obturation of the prepared space have been achieved by using a wide variety of materials selected for their intrinsic properties and handling characteristics These core materials have been classified as cements, pastes, plastics or solids Gutta-percha, in its various forms, has remained the paragon as a root canal filling material during the course of last century The development of core materials and delivery techniques has generated carrier-based gutta-percha and resin-based system These filling materials are combined with sealers to provide an adequate obturation of the root canal space that ideally prevents the emergence of endodontic disease and encourages peripheral healing when pathosis is present This process can only succeed if the sealed root canal space prevents further ingress of bacteria, entombs remaining microorganisms and prevents their survival by obstructing the nutrient supply Root canal obturation involves the three dimensional filling of the entire root canal system and is a critical step Fig 19.1 Radiograph showing three-dimensional obturation Fig 19.2 Diagrammatic representation of an obturated tooth Obturation of Root Canal System A B C D Figs 19.3A to D Endodontic treatment of mandibular right first molar (A) Preoperative radiograph showing carious 46; (B) Working length radiograph; (C) Master cone radiograph; (D) Postobturation radiograph Courtesy: Anil Dhingra A B Figs 19.4A and B 283 284 Textbook of Endodontics C D Figs 19.4C and D Figs 19.4A to D Endodontic treatment of mandibular left first molar (A) Preoperative radiograph showing carious 36; (B) Working length radiograph; (C) Master cone radiograph; (D) Postobturation radiograph Courtesy: Anil Dhingra The importance of the three dimensional obturation of the root canal system cannot be overstated, with the ability to achieve this goal primarily dependent on the quality of root canal cleaning and shaping as well as clinical skills Objectives of root canal obturation • Total debridement of the pulpal space • Development of a fluid tight seal at the apical foramen • Total obliteration of root canal Fig 19.5 Leakage in an obturated canal leading to root canal failure in endodontic therapy There are two main purposes of obturation—the elimination of all avenues of leakage from the oral cavity or the periradicular tissues into the root canal system, and sealing within the root canal system of any irritants that remain after appropriate shaping and cleaning of the canals, thereby isolating these irritants Pulpal demise, subsequent periradicular infection result from the presence of microorganisms, microbial toxins and metabolites and the products of pulp tissue degradation Failure to eliminate these etiological factors and further irritation as a result of continued contamination of the root canal system are the prime reasons for the failure of nonsurgical and surgical root canal therapy (Fig 19.5) History 1757 – Carious teeth were extracted, filled with gold/lead and replanted again 1847 – Hill’s stopping was developed 1867 – CA Bowman claimed to be the first to use gutta-percha for root canal filling 1883 – Perry claimed that he had been using a pointed gold wire wrapped with some gutta-percha ( the roots of present day core carrier technique) 1887 – SS White Company began to manufacture GP points 1914 – Lateral condensation technique was developed by Callahan 1953 – Acerbach advised filling of root canals with silver wires 1961 – Use of stainless steel files in conjunction with root canal sealer as given by Sampeck 1979 – McSpadden technique TIMING OF OBTURATION Patient Symptoms • Sensitivity on percussion—indicates inflammation of periodontal ligament space, canal should not be obturated before the inflammation has subsided • In case of irreversible pulpitis, obturation can be completed in single visit if the main source of pain, i.e pulp has been removed Obturation of Root Canal System Pulp and Periradicular Status Vital Pulp Tissue When patient exhibits a vital pulp, obturation can be completed in single visit if the main source of pain, i.e pulp has been removed It further precludes contamination as a result of leakage during the period between patient visits Necrotic Pulp Tissue • Teeth with necrotic pulp may be treated in single visit if the tooth is asymptomatic • If patient presents with sensitivity on percussion, it indicates inflammation in periodontal ligament space, canal should be obturated before the inflammation has subsided Purulent Exudates • According to Cohen, the apical points of termination should be 1 mm from the radiographic apex • Radiographically the root canal filling should have the appearance of a dense, three dimensional filling that extends as close as possible to the cementodentinal junction • The importance of length control in obturation relates to extrusion of materials One should avoid overextension overfilling and underfilling of root canal system Overfilling is the total obturation of root canal system with excess material extruding beyond apical foramen Overextension is the extrusion of filling material beyond apical foramen but the canal may not have been filled completely and apex have not been sealed (Fig 19.6) Underfilling is filling of the root canal system more than mm short of radiographic apex (Fig 19.7) • Even presence of a slight purulent exudates may indicate possibility of exacerbation If canal is sealed, pressure and subsequent tissue destruction may proceed rapidly • After complete cleaning and shaping procedure, calcium hydroxide should be placed as an antimicrobial and temporary obturant in necrotic cases that cannot be treated in one visit because investigators noted that bacteria in instrumented, unfilled canals can multiply and reach their pretreatment number in to days Negative Culture Experience has shown that filling a root canal known to be infected is risky But the reliance on negative culture has decreased now since the researchers have shown that false negative results can give inaccurate assessment on microbial flora, also the positive results not indicate the potential pathogenicity of bacteria Procedural Concerns Fig 19.6 Radiograph showing overextended obturation • Procedural concerns also indicates the time of obturation Difficult cases may require more time for preparation and can be managed more uneventfully in multiple appointments • Patients may require multiple short appointments because of medical conditions, their psychologic state of mind and fatigue EXTENT OF ROOT CANAL FILLING • The anatomic limit of the pulp space are the dentinocementum junction (DCJ) apically and the pulp chamber coronally • Canals filled to the apical dentinocementum junction are filled to the anatomic limit of the canal Beyond this point, the periodontal structure begins • Kutler (1995) described dentinocementum junction (DCJ) as minor apical diameter which ends 0.5 mm short of apical foramen in young patients and 0.67 mm short in older patients 285 Fig 19.7 Radiograph showing underfilling of 45 286 Textbook of Endodontics POINTS TO REMEMBER Features of an ideal root canal obturation • Three dimensional obturation close to CDJ • Radiographically, filling should be seen 0.5 to 0.75 mm from radiographic apex • Minimal use of a root canal sealer which is confined to root canal metal like copper, nickel which add up the corrosion of the silver points Indications Due to stiffness of silver cones, these are mainly indicated in round, tapered and narrow canals, for example maxillary first premolars or buccal roots of maxillary molars and mesial root of mandibular molars if they are straight MATERIALS USED FOR OBTURATION Contraindications An ideal root canal filling should be capable of completely preventing communication between the oral cavity and periapical tissue Root canal sealers should be biocompatible or well tolerated by the tissues in their set state, and are used in conjunction with the core filling material to establish an adequate seal Silver cones cannot conform with the shape of root canal because they lack plasticity; so their use is not indicated: • For obturation of anterior teeth, single canal premolars, or large single canals in molars • In young teeth having large ovoid canals Grossman (1982) grouped acceptable filling materials into plastics, solids, cements and pastes He also delineated 10 requirements for an ideal root canal filling material, these are as follows: Easily introduced into a root canal Seal the canal laterally as well as apically Not shrink after being inserted Impervious to moisture Bacteriostatic or at least not courage bacterial growth Radiopaque Non-staining the tooth structure Non-irritating Sterile/easily sterilized immediately before obturation 10 Easily removed from the root canal if necessary Various endodontic materials have been advocated for obturation of the radicular space A variety of core materials have been used in conjunction with a sealer/cement, the most common method of obturation involves gutta-percha as a core material The properties of an ideal obturation material were outlined by Grossman (mentioned above) Historically a variety of material have been employed A common solid material used was the silver cone, though gold, iridoplatinum, tantalum, titanium are also available Materials used for root canal filling • Silver cones • Gutta-percha • Custom cones • Resilon • Root canal sealers Gutta-percha (Fig 19.8) Gutta-percha was initially used as a restorative material and later developed into an indispensable endodontic filling material Gutta-percha was earlier used as splints for holding fractured joints, to control hemorrhage in extracted sockets, in various skin diseases such as psoriasis, eczema and in manufacturing of golf balls Gutta-percha is derived from two words: “GETAH” – meaning gum “PERTJA” - name of the tree Historical background 1843 – Sir Jose d Almeida first introduced gutta-percha to Royal Society of England In Dentistry – Edwin Truman introduced gutta-percha as temporary filling material 1847 – Hill introduced Hill’s stopping (a mixture of bleached guttapercha and carbonate of lime and quartz) 1867 – Bowman first used gutta-percha as root canal filling material 1883 – Perry packed gold wire wrapped with gutta-percha in root canals 1887 – SS White Company started the commercial manufacture of gutta-percha points 1893 – Rollins used gutta-percha with pure oxide of mercury in root canals 1914 – Callahan did softening and dissolution of gutta-percha with use of rosins and then used for obturation of the canals 1959 – Ingle and Levine proposed standardization of root canal instruments and filling materials Silver Cones • Jasper (1941) introduced silver cones which he claimed produced the same success rate as gutta-percha and were easier to use • Rigidity provided by the silver cones made them easy to place and permitted length control • They were mainly used for teeth with fine, tortuous, curved canals which make the use of gutta-percha difficult • But now-a-days their use has been declined, because of corrosion caused by them Silver cones contain traces of Fig 19.8 Gutta-percha cones Obturation of Root Canal System 287 Sources Gutta-percha is a dried coagulated extract which is derived from Brazilian trees (Palaquium) These trees belong to Sapotaceae family In India, these are found in Assam and Western Ghats Chemistry Its molecular structure is close to natural rubber, which is also a cis-isomer of polyisoprene Chemical Structure Fig 19.9 Brittle gutta-percha point breaks on bending In crude form, the composition of gutta-percha is Gutta – 75 – 82% Alban – 14 – 16% Fluavil – 04 – 06% Also contains tannins, salts and saccharine Composition of commercially available gutta-percha (Given by Friedman et al) • Matrix (Organic) Gutta-percha • Filler (Inorganic) Zinc oxide • Radiopacifiers (Inorganic) sulfates Heavy metal • Plasticizers (Organic) Waxes or resins 20% 66% 11% 3% In other words • Organic content – Gutta-percha + Waxes = 23% • Inorganic content – ZnO + Metal sulfates = 77% Chemically pure gutta-percha exists in two different crystalline forms, i.e a and b which differ in molecular repeat distance and single bond form Natural gutta-percha coming directly from the tree is in a—form while the most commercial available product is in b—form POINTS TO REMEMBER Different forms of gutta-percha Alpha form • Pliable and tacky at 56°–64° • Available in form of bars or pellets • Used in thermoplasticized obturation technique Beta form • Rigid and solid at 42°–44° • Used for manufacturing gutta-percha points and sticks Amorphous form Exists in molten stage Phases of gutta-percha These phases are interconvertible • a - runny, tacky and sticky (lower viscosity) • b - solid, compactable and elongatable (higher viscosity) • g - unstable form • On heating, gutta-percha expands which accounts for increased volume of material which can be compacted into the root canal • Gutta-percha shrinks as it returns to normal temperature So, vertical pressure should be applied in all warm guttapercha technique to compensate for volume change when cooling occurs (Schilder et al) • Aging of gutta-percha causes brittleness because of the oxidation process (Fig 19.9) Storage under artificial light also speeds up their deterioration • Brittle gutta-percha can be rejuvenated by a technique described by Sorien and Oliet In this, gutta-percha is immersed in hot water (55°C) for one or two seconds and then immediately immersed in cold water for few seconds • Gutta-percha cannot be heat sterilized For disinfection of gutta-percha points, they should be immersed in 5.25 percent NaOCl for one minute (Fig 19.10) • After this, gutta-percha should be rinsed in hydrogen peroxide or ethyl alcohol to remove crystallized NaOCl before obturation, as these crystallized particles impair the obturation • Gutta-percha should always be used with sealer and cement to seal root canal space as gutta-percha lacks adhering qualities • Gutta-percha is soluble in certain solvents like chloroform, eucalyptus oil, etc This property can be used to plasticize gutta-percha by treating it with the solvent for better filling in the canal But it has shown that gutta-percha shrinks (12%) when solidifies • Gutta-percha also shows some tissue irritation which is due to high content of zinc oxide Current Available Forms of Gutta-percha • Gutta-percha points (Figs 19.2 and 19.11): Standard cones are of same size and shape as that of ISO endodontic instruments 288 Textbook of Endodontics Fig 19.10 Sterilization of gutta-percha by immersing in 5.25% sodium hypochlorite for one minute Fig 19.12 Auxiliary points Fig 19.13 Greater taper points Fig 19.11 Gutta-percha points • Auxiliary points: Non-standardized cones; perceive form of root canal (Fig 19.12) • Greater taper gutta-percha points: Available in 4 percent, 6 percent, 8 percent and 10 percent taper (Fig 19.13) • Gutta-percha pellets/bars: They are used in thermoplasticized gutta-percha obturation, e.g obtura system • Precoated core carrier gutta-percha: In these stainless steel, titanium or plastic carriers are precoated with alpha-phase gutta-percha for use in canal, e.g thermafil (Fig 19.14) • Syringe systems: They use low viscosity gutta-percha, e.g Success-fil and alpha seal • Gutta flow: In this gutta-percha powder is incorporated into resin based sealer Fig 19.14 Thermafil gutta-percha • Gutta-percha sealers like chloropercha and eucopercha: In these, gutta-percha is dissolved in chloroform/ eucalyptol to be used in the canal • Medicated gutta-percha: Calcium hydroxide, iodoform or chlorhexidine diacetate containing gutta-percha points Obturation of Root Canal System 289 Fig 19.16 Calcium hydroxide containing gutta-percha Fig 19.15 Radiograph showing radiopaque gutta-percha Advantages of gutta-percha • Compatibility: Adaptation to canal walls • Inertness: Makes it non-reactive material • Dimensionally stable • Tissue tolerance • Radiopacity: Easily recognizable on radiograph (Fig 19.15) • Plasticity: Becomes plastic when heated • Dissolve in some solvents like chloroform, eucalyptus oil, etc This property makes it more versatile as canal filling material Disadvantages of gutta-percha • Lack of rigidity: Bending of gutta-percha is seen when lateral pressure is applied So, difficult to use in smaller canals • Easily displaced by pressure • Lacks adhesive quality Medicated Gutta-percha • Calcium hydroxide containing gutta-percha (Fig 19.16): These are made by combing 58 percent of calcium hydroxide in matrix of 42 percent gutta-percha They are available in ISO size of 15 to 140 Action of calcium hydroxide is activated by moisture in canal Advantages of calcium hydroxide points • Ease of insertion and removal • Minimal or no residue left • Firm for easy insertion Disadvantages • Short lived action • Radiolucent • Lack of sustained release • Calcium hydroxide plus points – Along with calcium hydroxide and gutta-percha, they contain tenside which reduces the surface tension – Due to presence of water soluble components tenside and sodium chloride, they are three times more reactive then calcium hydroxide points – They have superior pH and increases wettability of canal surface with increased antibacterial property – They have sustained alkaline pH for one week • Iodoform containing gutta-percha – Iodoform containing gutta-percha remains inert till it comes in contact with the tissue fluids – On coming in contact with tissue fluids, free iodine is released which is antibacterial in nature • Chlorhexidine diacetate containing gutta-percha – In this, gutta-percha matrix embedded in percent chlorhexidine diacetate – This material is used as an intracanal medicament Resilon (Fig 19.17) • A resin-based obturation system, epiphany (Pentron Clinical Technologies, Wallingford, CT) and Real Seal (Sybron Endo) have been introduced as an alternative to gutta-percha • The system resembles gutta-percha and can be placed using lateral compaction, warm vertical compaction or thermoplastic injection • It consists of a resin core material (Resilon) composed of polyester, difunctional methacrylate, bioactive glass and radiopaque fillers and a resin sealer • Resilon is a nontoxic, nonmutagenic, and biocompatible • The core material is available in conventional and standardized cones and pellets for use in the Obtura II • The Resilon core bonds to the resin sealer, which attaches to the etched root surface forming a “monoblock” This results in a gutta-percha sealer interface and a tooth – sealer interface This bonding of resilon appears to provide a better coronal seal and may strengthen the root • Resilon core material shrinks only 0.5 percent and is physically bonded to the sealer by polymerization When it sets, no gaps are seen due to no shrinkage The detailed description regarding the use of this system has been discussed in “obturation techniques” section 290 Textbook of Endodontics Fig 19.18 Custom cone made according to shape of canal Root Canal Sealers Fig 19.17 Real seal obturation system Custom Cones (Fig 19.18) • When the apical foramen is open or canal is large, a custom cone may need to be developed • This allows the adaptation of the cone to the canal walls, reduces the potential for extrusion of the core material, may improve the seal • The technique involves selection of a master cone and fitting the cone to mm short of the prepared length with frictional resistance • The cone is removed and the tip is softened in chloroform, eucalyptol or halothane for 1 to 2 seconds • Only the outer superficial portion of the cone is softened The central core of the canal should remain semirigid • The cone is then placed into the canal and gently tamped to the length The process can be repeated until an adequate impression of the canal is obtained at the prepared length • Radiograph is obtained to verify the proper fit and position • An alternate method to solvents is softening with heat It can be accomplished by heating several large guttapercha cones and rolling the mass between two glass slabs until an appropriate size is obtained • Purpose of sealing root canals is to prevent periapical exudates from diffusing into the unfilled part of the canal, to avoid reentry and colonization of bacteria and to check residual bacteria from reaching the periapical tissues Therefore to accomplish a fluid tight seal, a root canal sealer is needed • Sealer performs several functions during the obturation of a root canal system with gutta-percha; it lubricates and aids the seating of the master gutta-percha cone, acts as a binding agent between the gutta-percha and the canal wall and fills anatomical spaces where the primary filling material fails to reach • Root canal sealer, although used only as adjunctive materials in the obturation of root canal systems, have been shown to influence the outcome of root canal treatment • The adequate combination of sealing ability and biocompatibility of root canal sealer is important for a favorable prognosis of the root canal treatment • Studies have shown that most commercially available sealers can irritate the periapical tissues Initially some type of cytotoxic reaction may even be partially beneficial with respect to eventual periapical healing So, for a root canal filling material, this toxicity should be minimal and clinically acceptable at the time of obturation At a later time period, the material should become as inert as possible • There are a variety of sealers that have been used with different physical and biological properties The clinician must be careful to evaluate all characteristics of a sealer before selecting Requirements of an Ideal Root Canal Sealer Grossman listed following requirements and characteristics of a good root canal sealer: Obturation of Root Canal System • It should be tacky when mixed so as to provide good adhesion between it and the canal wall when set Only polycarboxylates, glass ionomers and resin sealers satisfy the requirement of good adhesion to dentin • It should create hermetic seal • It should be radiopaque so that it can be visualized in the radiograph Radiopacity, is provided by salts of heavy metals such as silver, barium and bismuth • The particles of powder should be very fine so that they can be mixed easily with the liquid • It should not shrink upon setting All of the sealers shrink slightly on setting, and gutta-percha also shrinks when returning from a warmed or plasticized state • It should not stain tooth structure Grossman’s cement, zinc oxide-eugenol, endomethasone, and N2 induce a moderate orange-red stain, Diaket and Tubli-Seal cause a mild pink discoloration, AH-26 gives a distinct color shift towards gray, Riebler’s paste cause a severe dark red stain Diaket causes the least discoloration Leaving any sealers or staining cements in the tooth crown should be avoided • It should be bacteriostatic or atleast not encourage bacterial growth All root canal sealers exert antimicrobial activity to a varying degree and those containing paraformaldehyde to a greater degree initially • It should set slowly The working and setting times of sealers are dependent on the constituent components, their particle size, temperature and relative humidity There is no standard working time for sealers, but it must be long enough to allow placement and adjustment of root filling if necessary • It should be insoluble in tissue fluids • It should be tolerant, nonirritating to periradicular tissue • It should be soluble in a common solvent if it is necessary to remove the root canal fitting The following were added to Grossman’s basic requirements: • It should not provoke an immune response in periradicular tissue • It should be neither mutagenic nor carcinogenic 291 Functions of Root Canal Sealers Root canal sealers are used in conjunction with filling materials for the following purposes: • Antimicrobial agent: All the popularly used sealers contain some antibacterial agent, and so a germicidal quality is excreted in the period of time immediately after its placement • Sealers are needed to fill in the discrepancies between the filling material and the dentin walls (Fig 19.19) • Binding agent: Sealers act as binding agent between the filling material and the dentin walls • As lubricant: When used with semisolid materials, sealer act as a lubricant • Radiopacity: All sealers display some degree of radiopacity; thus they can be detected on a radiograph This property can disclose the presence of auxiliary canals, resorptive areas, root fractures, and the shape of apical foramen • Certain techniques dictate the use of particular sealer: The choropercha technique, for instance, uses the material as sealer as well as a solvent for the master cone It allows the shape of normal gutta-percha cone to be altered according to shape of the prepared canal POINTS TO REMEMBER Functions of root canal sealers • As antimicrobial agent • Fill the discrepancies between the materials and dentin walls • As binding agent • As lubricant • Give radiopacity • As obturating material Classification There are numerous classifications of root canal sealers Classifications according to various authors are discussed below POINTS TO REMEMBER Requirements of an ideal root canal sealer • Should be tacky when mixed to provide good adhesion between it and the canal wall when set • Should create hermetic seal • Should be radiopaque • Powder particles size should be very fine, for easy mixing with liquid • Should not shrink upon setting • Should not stain tooth structure • Should be bacteriostatic • Should set slowly • Should be insoluble in tissue fluids • Should be non-irritating to periradicular tissue • Should be soluble in a common solvent • Should not provide immune response in periradicular tissue • Should not be mutagenic or carcinogenic Fig 19.19 Sealer fills the space between gutta-percha points 588  Textbook of Endodontics • • • • influence of cells of Hertwig’s epithelial root sheath, which are quite resistant to destruction, even in the presence of inflammation The newly formed odontoblasts can lay down atubular dentin at the apical end, causing apexogenesis as well as on lateral aspects of dentinal walls of the root canal, reinforcing and strengthening the root Continued root development due to multipotent dental pulp stem cells, which are present in permanent teeth and might be present in abundance in immature teeth These cells from the apical end might be seeded onto the existing dentinal walls and might differentiate into odontoblasts and deposit tertiary or atubular dentin Stem cells in the periodontal ligament can proliferate, grow into the apical end and within the root canal, and deposit hard tissue both at the apical end and on the lateral root walls Root development could be attributed to stem cells from the apical papilla or the bone marrow Instrumentation beyond the confines of the root canal to induce bleeding can also transplant mesenchymal cells from the bone into the canal lumen These cells have excellent proliferative capacity Transplantation studies have shown that human stem cells from bone marrow can form bone or dentin in vivo Blood clot itself being a rich source of growth factors could play important role in regeneration These include platelet– derived growth factor, vascular factor, and tissue growth factor and could stimulate differentiation, growth and maturation of fibroblasts, odontoblasts, cementoblasts, etc from the immature undifferentiated mesenchymal cells in the newly formed tissue matrix ADVANTAGES OF REVASCULARIZATION PROCEDURE • Short treatment time • The approach is technically simple and can be completed using currently available instruments and medicaments without expensive biotechnology • The regeneration of tissue in root canal systems by a patient’s own blood cells avoids the possibility of immune rejection and pathogen transmission from replacing the pulp with a tissue engineered construct • Cost effective • Obturation of canal not required • Continued root development and strengthening LIMITATIONS OF REVASCULARIZATION PROCEDURE • The case reports of a blood clot having the capacity to regenerate pulp tissue are exciting, but caution is required, because the source of the regenerated tissue has not been identified Generally, tissue engineering does not rely on blood clot formation, because the concentration and composition of cells trapped in the fibrin clot is unpredictable This is a critical limitation to a blood clot revascularization approach because tissue engineering is founded on the delivery of effective concentrations and compositions of cells to restore function It is very possible that variations in cell concentration and composition, particularly in older patients (where circulating stem cell concentrations may be lower) may lead to variations in treatment outcome • Enlargement of the apical foramen is necessary to promote vascularizaton and to maintain initial cell viability via nutrient diffusion Related to this point, cells must have an available supply of oxygen; therefore, it is likely that cells in the coronal portion of the root canal system either would not survive or would survive under hypoxic conditions before angiogenesis Interestingly, endothelial cells release soluble factors under hypoxic conditions that promote cell survival and angiogenesis, whereas other cell types demonstrate similar responses to low oxygen availability • Crown discoloration, development of resistant bacterial strains and allergic reactions to intracanal medications Access opening may be sealed with dentin bonding agents and flowable composite to avoid contact of triantibiotic paste with dentin • Canal may get calcified compromising esthetics and not allowing post placement It is accepted that in luxated or avulsed teeth with open apices and apical periodontitis, revascularization is a possibility The explanation for this positive outcome is that although the pulp is devitalized after avulsion, it will stay free of bacteria for some time If, in this time, the new vital tissue fills the canal space, the ingress of bacteria will be stopped Thus, the disinfection relies solely on irrigants and intracanal medications and formation of a blood clot in the canal after disinfection This blood clot acts as a matrix for the growth of new tissue into the pulp space An interesting question is the origin of the new pulp tissue Based on the fact that the root continued to grow and that the walls of the root appeared to thicken in a conventional manner, it is likely that the tissue is in fact pulp with functioning odontoblasts Therefore, even though a large apical lesion is present, it is probable that some vital pulp tissue and Hertwig’s epithelial root sheath remained When the canal is disinfected and the inflammatory conditions reversed, these tissues can proliferate However, the predictability of this procedure and the type of tissue that develops in these cases are still to be studied The benefit is so great compared with leaving a root with a thin and fracturesusceptible wall that, in our opinion, it is worth attempting If no root development can be seen within months, the more traditional apexification procedures can then be started Tissue Engineering  589 We have entered an exciting era where the diverse fields of stem cell biology tissue engineering, nano technology, and material science have converged synergistically to characterize and manipulate signaling cascades regulating tissue and organ regeneration The field of tissue engineering is certainly the one in which there are more questions than answers From the conceptual standpoint, there is little doubt that the best material to replace tooth structure is tooth structure QUESTIONS Define tissue engineering What are strategies of stem cell technology What are bioactive molecules in restorative dentistry Write short notes on: • Regenerative endodontics • Pulp revascularization BIBLIOGRAPHY Baum BJ, Mooney DJ The impact of tissue engineering on dentistry JADA 2000;131:309-18 Freitas RA Jr Nanodentistry JADA 2000;131:1559-65 Hochman R Neurotransmitter modulator (TENS) for control of dental operative pain JADA 1988;116:208-12 West JL, Halas NJ Applications of nanotechnology to biotechnology Curr Opin biotechnol 2000;11(2):215-7 Index Page numbers followed by f refer to figure and t refer to table, respectively A Abrasion cavities 337f Access cavity preparation 199f Access refining 200f Accessory canal 17f, 414 Acid etchants 488 Acidulated sodium fluoride 536 Acoustic streaming 154f Acute alveolar abscess 46 apical abscess 39 etiology 39, 40 management of 41 symptoms 40 apical periodontitis 39, 98, 340 etiology 39 management of 39f, 340f signs 39 symptoms 39 treatment 39, 98 dental infections 82 irreversible pulpitis 338 management 338 periapical abscess 98, 338 treatment 98 periapical inflammation 326 reversible pulpitis 338 management 338 Adhesive cementation See Fiber posts Aerodontalgia See Barodontalgia After endodontic treatment 447f AH plus 296 root canal sealer 296f Ah-26 and Ah plus, difference between 297 Air blast on dentin, effect of 532f Airborne contamination 566 Alcohols low level disinfectant 118 types of 119 Aldehydes 234 Alveolar nerve block 136, 136f Amalgam 402, 487 advantages of 403 disadvantages of 403 on pulp 487 Amelogenesis imperfecta 493, 493f Amoxycillin 142 Ampicillin 142 Anachoresis 52, 66 Anaerobic bacteria culture method 58 Analgesics in endodontic emergencies 344 Anatomic classification See Fan’s classification Anatomy of teeth, variation in 174f Anesthesia testing 84 Anesthetizing maxillary teeth, techniques for 136, 138 Ankylosis with direct union of bone and tooth 476f Anterior teeth cavity of 201 to misdirection of bur 349f Antianxiety benzodiazepines 132 Antibacterial nanoparticles 64 Antibiotic classification of 142 commonly used 142 prophylaxis 143 Antimicrobial agents action of 142 efficiency of 142 Antiseptic 119 alcohols 119 Anxiety control 131 Apex locator advantages of 241 combination of 244f disadvantages of 241 uses of 241 Apexification 462, 548, 586 calcium hydroxide 586 materials for 549 trioxide aggregate 586 MTA 462f objectives of 548 rationale of 548 Apexit 298 Apexum 274 working of 274f Apical abscess formation 39 curve 177, 178f extrusion of infected debris 328 foramen 414f locations of 179 gauging 261 of root canal 261f negative pressure irrigation system 225 periodontitis, pathogenesis of 71 preparation GT files 268f of canal 261f root anatomy 170 perforation 378 resorption 518f seal, disturbance of 448f third filling 318 Apico-coronal preparation 253f Appetite root canal sealer 295 Aqueous quarternary ammonium compounds 120 Argon laser 499 Armamentarium for obturation 302, 303f periradicular surgery 389 Arterial supply of teeth 12 Asepsis in endodontics 109 Atrophic changes of pulp with age 34f Attrition of teeth 558f Atypical odontalgia 101 Autoclave for moist heat sterilization 115f disadvantages of 116 types of 115 Autoclaving, advantages of 116 Auxiliary points 288f Average tooth length 180, 183, 185 Avulsed tooth, management options for 476 Avulsion of tooth 474f B Back filling of canal 311f Bacteria culture 57, 58 culture medium, types of 58 method advantages of 58 disadvantages of 58 technique 58 Bacteria Gram’s stain 57 interrelationships 55 molecular diagnostic methods 59 Balanced force technique 250f, 263 advantages of 263 modification of 263 Barbed broach 147f Barodontalgia 27 Bars See Gutta-percha pellets Battery operated pulp tester 84f Bay cyst 44f Bayonet-shaped canal 178, 178, 280f Beam profile and spot geometry 563 592  Textbook of Endodontics Benzyl penicillin 142 Beta-lactam antibiotics 142 Bicuspidization 405 Biofilm formation of 61 stages of 61f in endodontics 61 Biomechanical preparation, objectives of 247 Bisecting angle technique 88f Bisection See Bicuspidization Bite test 85 Bleach of nonvital teeth, walking 502 Bleaching 496 agents 497, 497f application of 501f carbamide peroxide 497 hydrogen peroxide 497 on effects on enamel 505 on materials, effect of 506 on tooth 505 carcinogenicity 506 cementum 505 cervical resorption 505 dentin 505 enamel 505 genotoxicity 506 hypersensitivity 505 mucosal irritation 506 pulp 505 restorative materials 506 toxicity 506 sodium perborate 497 Bleaching contraindications for 496 defective and leaky restoration 497 dentin hypersensitivity 496 extensively restored teeth 497 mechanism of 496, 496f of nonvital teeth 502 poor case selection 496 technique 497 inside 504 outside 504 teeth with hypoplastic marks and cracks 497 trays 498f with night guard 499f Blood borne bacteria, attraction of 52 Blunderbuss canal 306 Bone loss 420 tissue, age changes in 555 Brittle gutta-percha point breaks on bending 287f Broaches and rasps broach 147 Broad-spectrum penicillins 142 Brushing technique, types of 165f Bull like teeth 174 Bur for cutting, types of 395 C Calcibiotic root canal sealer 298 Calcific metamorphosis 19 Calcified canals 208 management of 277 preparation of 277 Calcium hydroxide 63, 216, 229, 230, 234, 289, 320, 486, 539, 585 containing gutta-percha 289, 289f in canals, use of 59 in weeping canal cases, use of 231 indications of 230 over pulp 543f points advantages of 289 disadvantages of 289 pulpotomy 543 cervical 543 partial pulpotomy 543 sealers 297 Calcium oxalate dihydrate crystals 535 Camphorated parachlorophenol and penicillin 486 phenol 234 Camphorphenol 229f Canal blockage 366 prevention 366 treatment 366 cleaning, anatomic problems in 275 complete obturation of 309f configuration of molars 80f premolar 80f diameter 213 Gates-Glidden drill, enlargement of 256f incomplete debridement of 329f instrumentation 251 management of 19 orifice 169, 169f, 366f access to 559 preparation 226 evaluation criteria of 274 inadequate 375 overinstrumentation, inadequate 375 overpreparation, inadequate 376 sonic instruments 273 ultrasonic instruments 272 underpreparation, inadequate 376 space and tooth, preparation of 447 Carbon fiber posts 436 steel advantage 146 disadvantage 146 Cardiac toothache 100 Carious exposure of first molar resulting in pulpitis 30f periapical lesion 103f pulp 4f necrosis 103f Carious second molar with c-shaped canals 280f Carious tooth to protect pulp 481f Cast metal post and core 437f Cast post and core system 433f Cavitation in ultrasonics 273f Cavity liner and varnishes 486 Ceiling mounted 570f Cell derived mediators 68, 69f cytokines 69 eicosanoids 68 lysosomal enzymes 69 neuropeptides 68 platelet activating factor 70 prostaglandins 70 vasoactive amines 70 free zone of weil in tooth resorption 508 rich zone therapy 583 type of Cementation 452 Cementoclasts 508 Cementodentinal junction 17f, 170f Cementum age changes in 555f anatomy of 4f Center of lingual surface 201f Cephalosporins 143 Cervical canal perforation 377 enamel projections 414 pulpotomy 461 root resorption 522 theories of 522 Chairside infection control 121 Chelating agents 218, 218f Chemical alteration of gutta-percha 306 burns See also Dental negligence thermal irritants on pulp, effect of 486 vapor sterilization 117 Chemiclave 117 Chemotactic cytokines 69 Chicago technique, sectional method of 313 Chloramines-t 232 Chlordiazepoxide 132 Chlorhexidine 120, 217, 218, 234 advantages of 218 digluconate 63 disadvantages of 218 gluconate 231 stain 496 uses of 218 Chloride compounds 120 Chlorine 231, 234 Chloroform 295 Chloropercha 295 methods, modified 295 Chronic alveolar abscess 46, 47f apical abscess 47 periodontitis 98 pulpitis 30 closed form of 30 diagnosis 31 etiology 31 symptoms 31 treatment 31 types 30 Index  593 Ciprofloxacin 143 Citric acid 220 Cleaned and shaped canal 308f root canal system, representation of 246f tapered preparation 310f Clinical periapical test palpation 37 percussion 37 pulp vitality 37 Closed chamber bleaching 505 technique, indications of 505 Cluster headache 100 CO2 laser 499 Cold gutta-percha compaction technique 317 Color coding of endodontic instruments 147, 147f Color of pulpal floor 207 Common canal configuration 171 Common malpractice errors endodontics 575 Commonly irrigating solutions 213 Commonly local anesthesia 390f Communication of root canal system and periodontium 247f Complete access cavity preparation 201f endodontic treatment with root canal obturation 6f obturation thermafil 317f Complete pulpotomy See also Calcium hydroxide pulpotomy cervical Complicated crown fracture 459 Composite resins 404 Concrescence 175f Concussion 472f Cone-shift technique 89f Confirm fit of cone 311f Congenital porphyria 493 Connective tissue change 555 Contributing factors for flare-ups 327 Control of corrosion by lubrication 113 Conventional bleaching light 499 Conventional hot air oven 116 Coolant, use of 395 Copiously irrigate canal 233f Core 450 amalgam 450 cast 450 composite resins 450 advantages 450 disadvantages 450 fabrication 452 materials, evaluation of 451 Coronal apical preparation 253f portion of gutta-percha 357 restoration 428 seal 321 third perforations, management of 381 to apical approach advantages of 258 technique 258 to apical preparation, disadvantages of 258 Cortical trephination 387f Corticosteroid-antibiotic combinations 232 Course of supraperiosteal vessels parallel to long axis of teeth 391 Cracked teeth classification of 525 treatment of 527 Cracked tooth syndrome 337 differential diagnosis of 527 Cracks in teeth, types of 337f Crestal extracanal invasive resorption 523f Criteria for successful pulpotomy 542 Crown down hand instrumentation techniques, types of 264 method for canal preparation 165f preparation, technique of 259 pressureless technique 259 technique for curved canals 277f Crown down technique 259f fracture 458 uncomplicated 458 infraction 457 placed, complete endodontic treatment with 249f placement 6f root fracture 464f in nature 464f tooth system bends 434 with poor retentive shape teeth 129 C-shaped canals 178, 178f, 191 anatomy 279f management of 279 C-shaped root canals, classification of 191 Culprit of endodontic pathology 65 Curved canal 306f management of 275 Custom cast metal post 435 cone made to shape of canal 290f Cyclic nucleotides, changes in 329 Cyst formation in periapical area 44f Cystic apical periodontitis 44 D Dakin’s solution 214 Dark brown discoloration caused by fluorosis 494f Dead tooth after root canal therapy Debridement of pulp tissue, inadequate 327f Debridement, inadequate 341f Deep carious lesion infecting pulp 52f Deep pulpotomy 461 Defense cells 10 Defense of pulp, part in 10f Delivery systems for irrigation 224 Denaturation of protein 216 Dens evaginatus 176, 177f in dente 175 invaginatus See also Dens in dente invaginatus classification of 177f types of 175 Dental calculus 23f equipment, sterilization of 120 floss 126 health care worker 109 to patient 109 hypersensitivity, treatment of 568 material, disinfection of 120 migraine 101 negligence 575 fracture of needle in situ 575 related to local anesthesia 575 syncope 575 thermal 576 office to community 109 pain 96 of periodontal origin 97 of pulpal origin 96 plaque 23f procedures 495 pulp 13 anatomy of 15 development of histology of stem cells 582 radiology, history of 87 resins and adhesives 536 Dentin age changes in 554, 555f anatomy of 4f chip filling 320 chips 366f apically, compaction of 320f of Gates-Glidden drills 320f disease of 493 dysplasia 175 formation of 17 from stem cells of pulp 586f hypercalcification 495 hypersensitivity 337, 337f incidence and distribution of 532 management of 534 products for 534f theories of 531f sclerosis 481 sensitivity hydrodynamic theory 531 mechanism of 531 neural theory 531 odontoblastic transduction theory 531 theories of 531 shavings apical third 212f sterilizing agents 486 tubules blocked with smear layer 219f Dentinal map 173 tubules 415 exposure of 533f opening of 219f pattern of 415f 594  Textbook of Endodontics Dentinoblasts decrease 34 Dentinocementum junction 285 Dentinoclasts 508 Dentinogenesis imperfecta 175, 494 Dentofacial injuries classification of 454 Ellis and Davey’s classifications 455 Ingle’s classification 455 Designs of rubber dam, modifications in 126 Detect root resorption, methods to 510 Determining pulp anatomy, methods of 172 Devitalization of tooth 104 Diabetes mellitus 107 Diamond coated ultrasonic tips 154f instruments, rules for 485 Diazepam 132 Dichlorodifluoromethane 82 Different forms of EDTA 219 Digital dental radiology 91 methods of 92 Digital subtraction 91 Dilacerated root 175f, 324f Direct pulp capping 541, 542, 542f Discoloration, classification of 492 Discolored appearance of teeth to caries 495f Discolored teeth, management of 492 Disinfection 118 methods of 118 Dissolved gutta-percha using files, removal of 357f DNA-DNA hybridization method 59 advantages of 59 disadvantages of 59 Double flare technique 262 modified 262 Down syndrome 174 Draining root canal 58 Dry canal 58 absorbent paper points 233f Dry heat sterilization 116 advantages of 116 disadvantages of 117 Dry ice See Frozen carbon dioxide Dual wavelength spectrophotometry 86 DWLS, advantages of 86 Dycal 542f E E faecalis 63 EDTA, uses of 219 Elbow formed in curved canal 374f Elective endodontics 103 Electric endo motor with speed and torque control handpiece 163f pulp tester 83, 84f disadvantages of 84 Electronic apex locators classification of 241 components of 241 Electronic dental anesthesia 141 advantages of 141 disadvantages of 141 Emergency endodontic treatment 337 Enamel age changes in 555f disease of 493 formation, developmental defects in 493 pearl and projections 415f Endoactivator system 64 Endodontic 1, advantages of 89 age of discovery, history of biofilm, types of 61 biomaterial centered infection 62 dark age, history of emergency 104, 335 exposure of pulp 342 fracture of tooth 342 hypochlorite accident 342 intratreatment 341 periodontal treatment 342 postobturation emergencies 343 recently placed restoration 342 tissue emphysema 342 extra-radicular infections 57 microbial biofilms 62 failure 347f and retreatment 345 causes of 346 flare-up causative factors 326 chemical injury 326 definitive treatment 333 effect of chemical mediators 329 etiology 326 microbial factors 328 microbial induced injury 327 presents lot of anxiety 326f preventive management 331 hand instrument 146f handpiece 244, 244f history of 1, 2t implants 409, 411f implications 71 in geriatric patients 555 infections, types of 56 inflammation, types of 66 innovation era, history of instruments 145 classification of 145, 146 intracanal microbial biofilm 61 intra-radicular infections 56 microbiology 51 microbiota in primary infections 62 microsurgical cases, classification of 388, 388f mishaps 364 periapical microbial biofilms 62 periodontal communication in endodontic failure 351f definition 413 lesions 417 classification of 417 diagnosis of 419 problems 417 relationship 413 periodontic lesion in mandibular right first molar 424f persistent intra-radicular infections 56 prescience, history of primary intra-radicular infections 56 renaissance, history of retreatment 351 in mandibular left first molar 358f in maxillary left central incisor 352f role of radiographs in 87 scope of secondary intra-radicular infections 56 signs of inflammation 66 surgery 560 periradicular 389 therapy 3, 103 contraindications of 104 rationale of 73 tissue changes inflammation 66 treatment 345 of mandibular left first molar 284f right first molar 283f of premolars 80f planning 106 prognosis of 352, 560 rationale of 65 zone of contamination 72 infection 71 irritation 72 stimulation 72 Endodontically treated teeth 428, 429 Endodontist Endodontology, scope of 3f Endoflas 294 Endomethasone 299 Endo-microscope 207f, 570f floor type 570f Endoscope 572, 572f Endosonic files 153f tips 273f uses of 154 Endovac 225 system, complete 226f Engaging dentin with quarter clockwise turn 263f Engine driven preparation with NiTi instruments 267 Enterococcus faecalis 49 Envelope flap 392 Enzymes 55 Eosinophil 67f Epiphany advantages of 301 disadvantage of 301 Eradicate biofilms, methods to 63 Erosion of cementum 533f Erythroblastosis fetalis 493 Erythromycin 143 Establish access to root canal system 353 Ethics in endodontics 574 Index  595 principles of 574 Ethyl chloride, use of 82 Ethylene oxide sterilization 117 Eugenol 234 on tissue concentrations 228f uses of 228 Excess material, removal of 402f Excessive removal of radicular dentin 429f Exposure of pulp by caries 482f Extension of access cavity 207 Extensive loss of coronal tissue teeth 129 Extent of caries 90f External inflammatory root resorption 517, 518f External resorption 513f External root resorption 49, 49f, 516 of maxillary central incisor 50f treatment 517 surface resorption 516, 517f Extirpation of pulp chamber 339f Extra root 175 in first molar 90f Extracanal invasive resorption 522f Extracanal invasive resorption See Cervical root resorption Extracanals, presence of 175 Extracoronal bleaching See Closed chamber bleaching Extraoral discoloration See Extraoral ecchymosis Extraoral ecchymosis 412 sinus 48f Extrinsic stains, classification of 493 Extrusive luxation 473f treatment of 473f F Factors affecting pulpal survival 460 influencing growth and colonization of microorganisms 55 inhibiting tooth resorption 510 anti-invasion factors 510 intermediate cementum 510 intrinsic factors 510 presence of osteoprotegerin 510 remnant of epithelial root sheath 510 regulating tooth resorption 509 Failure of reimplantation, causes of 405 Fan’s classification 192 Fan’s radiographic classification 192f Fatty acids 55 Features of acute apical abscess 40 lesions of nonodontogenic origin 50 migraine 100 Ferrule effect 446, 446f preparation of 449f functions of 432, 446 requirements of 446 Fiber optic endoscope 173 posts 443 Fiberfill 297 obturator 319 Fibers of periodontal ligament 20f File bypass technique 368 File introduced in canal 243f Files and reamers, difference between 149 Files placed in glass bead sterilizer 118f Filling, combination of 249 Filling chamber with irrigant solution 260f Filling root canal finger pluggers 167 spreader 166 hand plugger 167 spreader 166 lentulo spirals 167 Finger plugger 167f spreader 166f Fish's zones 71f Fit of gutta-percha cone 308f Flap design for Ochsenbein-Luebke flap 393f in palatal surgery 393 principles for 391 for palatal surgery 394f functions of 391 reflection and retraction 394 repositioning of 404 retraction 394 Flare-ups to necrotic pulp 331 management of 331 Flexible files, use of 276 Flexo file 151f Flexogates 156 advantages of 156 Flexural fracture 164 Fluoride compounds 536 dentifrices 535 iontophoresis 536 Fluorosis of teeth 493f Flutes of file, modification of 374f Focal infection mechanism of 65 theory related to 65 Focal length of binoculars 571 objective lens 571 Focused and defocused laser beam 563f Forced air type See Rapid heat transfer Formocresol 229f, 234 composition of 229 pulpotomy 544 Forms of gutta-percha 287 Fourth generation apex locator 244 Fracture fragment reattachment 466f reaching pulp 525f splitting tooth 525f tooth, treatment plan for 530 Frank’s classification of cervical root resorption 522 Free eugenol 403 Freon See Dichlorodifluoromethane Frozen carbon dioxide 82 Full mucoperiosteal flaps 391, 394 G Gain entry to pulp chamber with round bur 199f Gates-Glidden bur 155 drill 155f for coronal flaring, use of 156f in canal, use of 156f uses of 156 for preflaring, use of 260f Gauge of irrigating needle 213 Gene delivery 584 therapy 584, 584f Genetic xeroxing method 59 Geriatric endodontics 554 patient 556f Giant cells 509f Gingival recession 533 Gingival sulcus See Periodontal ligament Giromatic 152 Glass bead sterilizer 118, 118f advantages of 118 disadvantage of 118 Glass fiber post 439 Glass ionomer cement 450, 487 sealer 299 Gluma desensitizing solution 536f Glutaraldehyde 119 Glycocalyx matrix 62 Golden medium file 152 Good quality radiographs 207 Gradual curve in root canal 177f Gram stain technique 53 Gram-negative anaerobes 328 Granulocytes 67 Gravity convection 116 Greater palatine nerve block 137, 137f Greater taper file 158 gutta-percha points 288 points 288f technique See Profile GT technique Grossly carious 447f Grossman’s classification 145 sealer 293 GT files See Greater taper files Gutta flow 317 Gutta-percha 286 advantages of 289 cones 286f disadvantages of 289 from root canal, removal of 448f H-file, removal of 359f pellets 288 596  Textbook of Endodontics plugger compaction of 314f vertical compaction of 167f, 310f points 288f removal 356 H Halogens 231, 234 Hand hygiene 111 indications for 112 pluggers 167f spreader 166f Handi dam 127f Handling protocols for rotary instruments, types of 165f Hand-operated instruments 146 broaches 147 carbon steel 146 manufacturing of hand 146 nickel titanium 146 rasps 147 stainless steel 146 Handwash technique 112 Hank’s balanced solution 476 Hard setting cements 359 Hard tissue applications 566 management 395 Healing after endodontic treatment 105 of root fracture 470 by interproximal bone 471f with calcified tissue 471f with calcium hydroxide 540 line of demarcation 540 zone of coagulation necrosis 540 obliteration 540 Heat from electrosurgery 490 Heated gutta-percha stick 83 on tooth for heat test 83f Heated plugger to compact gutta-percha 310f Hedstroem file 151f, 355 Heithersay’s classification 522 Hemisection in mandibular right first molar 406f High frequency apex locator See Third generation apex locator Home bleaching technique 497 advantages of 499 disadvantages of 499 Home bleaching, indications for 498 prognosis for 497 side effects of 498 Hot burnisher to vitality of tooth 83f Hot instrument like reamer or file 359f Hybrid technique of canal preparation 262 Hydrodynamic theory 532f A-d nerve fiber 532f dentin 532f odontoblast 532f odontoblastic process 532f Hydrogen peroxide 216, 216f Hydron 295 Hydroxyethylidene bisphosphonate 220 Hyperactive pulpalgia 27 Hyperemia 27 Hyperplastic form of chronic pulpitis 31f pulpitis 31f Hypochlorous acid 214 Hypodermic needle, use of 356f I Iatrogenic 415 causes 39 Iatrosedation 132 Ideal irrigant solution 212 Ideal root canal sealer, requirements of 290 Identification of bacteria 57 Immature canal 306 Immune reactions, specific mediators of 71 Immunity acquired 71 in endodontics, role of 71 innate 71 types of 71 Impact of periodontal disease on pulpal tissue 417 pulpal diseases on periodontium 416 Implant, materials for 409 Improperly obturated molar 350f Indirect pulp capping 540 Individual tooth anatomy 180 Infected root canal, microbiology of 57 Infection control 120, 141 post-treatment period 121 pretreatment period 120 rationale for 109 Infection of pulp to alveolar abscess 60f Infectious sequelae of pulpitis 25f Inferior alveolar nerve block 138, 138f Inflammation under caries 481 Inflammatory cells 67, 67f eosinophils 67 epithelial cells 68 lymphocytes 68 macrophages 67 neutrophils 67 osteoclasts 68 Inflammatory resorption 475f response to periapical lesion 69f root resorption 517f Influence of nutritional factors 55 oxygen 55 Informed consent 575 Ingle’s classification of pulpoperiapical pathosis 38 standardization, modifications from 147 Initial apical rotary in canal, use of 269f Injectable syringe for carrying sealer 301f Injury from slips of drill 577 Innervation of pulp 13 In-office bleaching 499 advantages of 500 disadvantages of 500 indications of 500 Insertion of deep restoration causing pulp inflammation 27f Instrument aspiration 385 classification of 112 for access cavity preparation 198 preparation 198f for filling root canals 166 processing procedure 113 separation 368 sterilization, classification of 112 Inter-appointment flare-ups 330 Interleukin-I beta in human periapical lesion 87 Intermediate restorative material 403 Internal anatomy 169 and external resorption, features of 512 inflammatory resorption 511 resorption 32, 178, 179f, 510, 513f diagnosis 32 etiology 32 in maxillary left central insior 513f of tooth 32f causing perforation of root 32f symptoms 32 treatment 32 types of 511 with root perforation results in pain 511f root resorption, management of 513 Intracanal medicament 227, 233f, 234 aldehydes 229 calcium hydroxide 229 formocresol 229 paraformaldehyde 229 essential oils 227 eugenol 227 functions of 227 in multi-visit root canal treatment 332 indications of 227 limitations of 234 phenolic compounds 228 cresatin 229 parachlorophenol 228 phenol 228 Intracoronal bleaching 502 complications of 503 contraindications of 503 indications of 503 Intraligamentary injection 336f Intraosseous extracanal invasive resorption 523f Intrapulpal injection 139, 139f, 336f Intrinsic stains 493 hematological disorders 493 pre-eruptive causes 493 Intrusive luxation 474, 474f treatment 474 Iodides 231 Iodine 63, 234 Index  597 Iodophor compounds 120 Irreversible pulpitis 28 definition 28 diagnosis 28 etiology 28 symptoms 28 treatment 29 Irrigant age of 213 functions of 212 solution, choice of 213 Irrigating syringe to remove debris 212f Irrigation and intracanal medicaments 211 helps in loosening of debris 212f method of 223 Irritants on pulp 483f Irritation dentin, formation of 22f Isolate microbes, methods to 62 Isthmus 171 complete 171f incomplete 171f J Johnston-Callahan method 295 K K3 rotary file system 161, 270 Kerr root canal sealer 292 Ketac-Endo sealer 300f K-file series step down technique 264 K-files 148 Kinin system 70 Klinefelter syndrome 174 Kronfeld’s mountain pass theory 72, 72f K-type instrument See Reamer Kuttler’s method 239 L L casei 63 Laser argon lasers, type of 564 assisted bleaching technique 505 root canal therapy 274 carbon dioxide, type of 564 classification of 562 Doppler flowmetry 85 advantages of 86 disadvantages of 86 in dentistry, types of 566f in endodontics 561 use of 566 interaction with biological tissues 564 neodymium, type of 564 on pulp 490 physics 562, 562f safety in dental practice 565 type of 564 Lateral and extrusive luxation, treatment of 472 and vertical compaction of gutta-percha 302f canal 17f, 414 pathological exposure of 415 compaction technique 302, 305 advantages of 302 disadvantages of 302 luxation 473f resulting in injury to periodontium 473f treatment of 473f Laws of access cavity preparation 201 Leakage in obturated canal leading to root canal failure 284f Ledge in curved canal, formation of 275f Lentulo spiral 167f Lentulospiral for carrying sealer 301f Leukotrienes 69, 70 Levels of root canals 400f Lifting of mucoperiosteum 394f Light sources for in-office bleach 499 Limited mucoperiosteal flaps 392 Liner and varnish to protect pulp, use of 486f Liner under amalgam restoration, use of 488f Lingual groove 175 opposite buccal 88 Lipopolysaccharides 54 Local adaptation syndrome 328 Local anesthesia 134 and hemostasis 389 commonly materials for 389f recent advances in 140 Local anesthetic agents, classification of 134 low pH, action of 135f normal pH, action of 135f Local factors causing endodontic failures 346 Location of canal orifice 278 Long buccal nerve block 138, 139f Longitudinal tooth fractures, classifications of 524 Loss of cementum 415 enamel 337f Loupes 569 for endodontics 569f in endodontics 570f Low frequency apex locator 242 Low temperature steam 118 Lubricant or petroleum jelly 126 Luting See Glass ionomer cement Luxation injuries 471 Lymph nodes, examination of 78f Lymphatic drainage of teeth 12 vessels 11 Lymphocytes 10, 68f M Macrophage 68f Magnification 207, 569 changers 571 Malpositioned teeth 129 Malpractice cases 577 Mandibular anesthesia techniques 138 canine 187, 187f, 203 pulp chamber 187 root canal 187 central incisor 186, 186f average tooth length 186 pulp chamber 186 root canal 186 first molar 188, 189f, 206 average tooth length 188 pulp chamber 188 root canal 189 with four canals 206f with two distal roots 177f first premolar 187, 187f, 204 average tooth length 187 pulp chamber 187 root canal 187 incisor 203 cavity of 203f lateral incisor 186, 187f average tooth length 186 pulp chamber 186 root canal 186 molars cavity preparation for 205 preparation of 206f nerve block 138 second molar 190, 190f, 206 average tooth length 190 pulp chamber 190 root canal 190 second premolar 188, 188f, 204 average tooth length 188 pulp chamber 188 root canal 188 third molar 190 average tooth length 190 pulp chamber and root canals 190 Manual step down technique, modified 264 Masserann kit 371 Mast cells 10 Master gutta-percha cone 310f Matrix placement technique, disadvantages of 381 Maxillary and mandibular teeth 207f anterior teeth, anesthesia for 390f artery, branches of 11 canine 182, 182f, 203 average tooth length 182 cavity of 203f pulp chamber 182, 183 root canal 182, 183 central incisor 203 first molar 183, 184f, 205 premolar 182, 182f, 204 incisor cavity of 203f tooth, open apex of 179f lateral incisor 181, 203 pulp chamber 181 root canal 181 598  Textbook of Endodontics molars, cavity preparation for 204 nerve block 137 posterior area, anesthesia of 390f second molar 185, 186f, 205 premolar 183, 183f, 204 third molar 186 Measurement of surface temperature of tooth 86 Mechanical nerve trauma 101 Mechanism of action of calcium hydroxide 539, 540 Medicated gutta-percha 288, 289 sealers 299 Melton’s classification 191 of C canals 191f Mental disorders 101 nerve block 139, 139f Messing gun for MTA placement 403f Metal posts 443 Metallic stains 496 Metapex sealer 297f Metaplastic resorption See Root canal replacement resorption Metronidazole 143 Microabrasion 502 Microbes in endodontic biofilms 62 Microbial ecosystem of root canal 55 flora 53 virulence and pathogenicity 54 Microcolonies 62 Microleakage, routes of 487 Microorganisms classification of 53 in infected root canal 56f types of 54f Microtubes of instrument removal system 371f Mid root perforation 378 Midazolam 132 Midtreatment flare-ups, cause of 326f Migraine 100 Mineral trioxide aggregate 321, 321f, 403 Missed canal 367 prevention of 368 significance of 368 Missing root See Extra root Mitochondria Mobility of tooth by palpating with fingers 79f Modern endodontics Modifying cutting edges of instrument 277f Moist heat sterilization 115 Moisture control, advantages of 122 Molar triangle, patterns of 205f Molars curved canals 324f Molecular methods, advantages of 59 Monoblock concept, types of 301f Monojet endodontic needle 224, 225f Morphogens molecule 582 Mouse hole effect 204 Mouth guard, functions of 479 MTA advantages of 404 disadvantages of 404 for repair of perforation, use of 382f Müller burs 198, 198f Munce discovery burs 198 Myofascial toothache 99 N Narcotic analgesics 132 Narrow apex advantages of 237 disadvantages of 237 Nasopalatine nerve block 137f Natural tooth 525f Necrotic pulp 98 Needle with bevel 224, 225f notched tip 224f Nerve anesthetized 139 density different areas of tooth 14f ending causing pain 533f fibers of pulp 14f supply of teeth 14, 14f Neuritis, treatment of 101 Neuropathic pain 100 neuralgia 100 neuritis 101 Neurovascular headache signs of 100 symptoms of 100 Neurovascular toothache 99 Neutrophil 67f New nomenclature of bacteroides species 55 Newer irrigating solutions 221 Nickel titanium advantages 146 disadvantages 146 rotary instruments 164 Night guard bleaching 497 NiTi alloys, advantages of 157 files, disadvantages of 157 rotary instruments 157 Nogenol 295 Nonadhesive cementation See Metal posts Noneugenol calcium hydroxide 298 Nonhealing abscess of poorly obturated canal 345f Nonhealing of periapical lesion of untreated canal 57f Nonodontogenic pain, sources of 99 referred pain 99 Nonopioid drugs 133 aspirin 133 classification 133 diclofenac sodium 134 ibuprofen 133 nimesulides 134 piroxicam 134 Nonpainful pulpoperiapical pathosis 38 Nonperforating resorption, management of 513 Nonrestorable teeth 104 Nonrotary endodontic instruments 152 engine driven 152 Nonspecific mediators of periradicular lesions 68 Nonstrategic teeth 105 Nonthermocatalytic bleaching 500 Normal anatomical landmarks of tooth 492f body of tooth 492f cervical margin 492f incisal edge 492f translucency of enamel 492f Normal canal anatomy canal transportation 375 deviation from 373 lateral wall perforation 374 zipping 373 Normal root apex 518f Normal saline 213, 213f causes 213 Normal tooth anatomy with protective layers of pulp 52f Noxious agents between endodontic and periodontal tissue 413f Nygaard-Ostby 295 O Objective of infection control 110 Oblique fracture 525f Obtain straight line access 269f Obtura II and ultrafil II, difference between 315 Obturated canals 5f, 66f tooth 282f Obturation materials for 286 negative culture, timing of 285 of curved roots 306f of molar 280f of root canal system 5f, 282 procedural concerns, timing of 285 sectional method of 313 techniques 301 timing of 284, 285 with silver cone 318 Ochsenbein-Luebke flap 393, 393f Odontoblastic layer Odontoblasts 9f Odontogenic pain, sources of 96, 97 referred pain 99 Open dentinal tubules 51 Opening burs 198, 198f Opioid drugs classification 132 codeine 132 dextropropoxyphene 133 morphine 132 tramadol 133 Oral foci of infection 65 mucosa, age changes in 554 pain, common features of 336 Orascope 572 Index  599 Organic tissue, presence of 213 Orofacial history of pain 95 pain 95, 96 differential diagnosis of 95 Orthodontic extrusion of apical segment 470f intruded tooth 474f root 467f Osseous tissue response to heat 395 Osteoclasts 508 Oval-shaped access cavity of premolars 204f Over enlargement of canal space 448f Overfilling of root canals 384 Overinstrumentation 341f Oxidation-reduction potential in root canal, change in 329f Oxygenating canal 59 Ozonated water 63 advantages of 221 irrigation 221 Ozone water 63 P Packaging of instruments for autoclaving 115 dry heat 116 Pad system 222f Pain control in endodontics 132 on percussion indicates inflamed periodontium 37f produced by different stimuli 532f Painful pulpoperiapical pathosis 38 Palatogingival groove 414, 415f Paralleling technique 88f advantages of 88 disadvantages of 88 Parathyroid hormones 509 Partial obliteration of dentinal tubules 535 Partial pulpotomy 461, 543f Partsch incision 392 Passive step back technique 257 advantages of 258 technique of 257 PBSC paste 231 PCR method advantages of 59 disadvantages of 59 Pediatric endodontics 538 Peel-pouches for packing instruments 114f Peeso reamers, disadvantages of 157 Penetrate pulp chamber with round bur 547f Penicillin G See Benzyl penicillin Penicillin V 142 Penicillinase resistant penicillins 142 Penicillins 142 Perforating internal resorption, management of 516 Perforation caused during access cavity preparation 377f endodontic therapy 415 in apical third of root canal, management of 382 in mid root level, management of 381 of molar 349f of root 415 to misdirection of drill 448f Periapex pathologies 36 Periapical abscess 40f management of 41f resulting from tooth decay 339f Periapical extrusion of debris 327f gutta-percha 448f Periapical granuloma 42, 44 apex of nonvital tooth 42f prognosis 42 treatment 42 Periapical lesion 80f to carious exposure 5f Periapical tissue pressure, changes in 328 Pericoronitis 98 treatment 98 Periodontal abscess 98, 419f treatment 98 connective tissue, age changes in 555 disease 23f causing pulpal inflammation 23f evaluation 78 health of tooth 387 lesions causing inflammation of pulp 52f ligament 52 injection 137, 138f integrity of 457f stem cells 582 pain 98 sensitivity test 240 Periodontium 35f by intrusive luxation, damage to 474f of avulsed tooth 475f Peripheral neuritis 101 Periradicular diseases 36 bacterial 36 periapical tests 37 trauma 36 Periradicular pathologies 35 classification of 38 diagnosis of 37 Grossman’s classification 38 WHO classification 38 Periradicular tissue 19, 20f alveolar bone 21 cells 21 intercellular matrix 21 cementum 19 types 20 of nonendodontic origin, diseases of 49 periodontal ligament 20 blood vessels 21 cells 20 fibers 20 functions 21 nerve fibers 21 Permanent restoration of tooth 541f Persistent apical periodontitis 49 Personal protection equipment 110 Phantom tooth pain 101 Pharmacology in endodontics 131 Phases of gutta-percha 287 Phenol 234, 486 Phenoxymethyl penicillin See Penicillin V Phoenix abscess 41, 42 Phosphor imaging system 93 Photoactivated disinfection 64 Pin insertion 488 Pink tooth 49 Place master apical file in canal 233f Place zinc oxide eugenol dressing 545f Placement of bleaching mixture into pulp chamber 504f Plasma dental probe 63 derived mediators 70 complement system 70 fibrinolytic system 70 kinin system 70 Plethysmography 87 Plexus of Raschkow 13 Plugger 166f removal of 312f Pocket cyst 44f Polyacrylic acid 220 Polyamines 55 Polycarboxylate cement 445f Polymerase chain reaction method 59 Polymorphonuclear leukocytes 10 Poorly obturated root canals 81f Portals of entry for microorganisms 51 Positive pressure vs apical negative pressure 225 Post and core components of 433f systems 451 Post designs, types of 435f, 445f Post removal system 354 Postemergency treatment 477 Postendodontic restoration, complete endodontic therapy with 428f Posterosuperior alveolar nerve block 137 Postobturation emergencies, management of 343 flare-ups 331 instructions 321 Postoperative swelling 411 management 411 postoperative bleeding 411 Posture on pulpal flow 11 Post-using ultrasonics, removal of 155f Potassium ferrocyanide 535 nitrate dentifrices 535 Power of eyepiece 571 Precoated core carrier gutta-percha 288 Precurving of file 276f Prefabricated post and core 439f Premolars, cavity of 203f preparation for 203 Preparation of canal middle-third 261f Prepare access cavity and locate canal orifices 254f 600  Textbook of Endodontics Prepared canal 275f Presence of carious tooth 419f Pretreatment endodontic emergencies 336 Primary cone for obturation 315f endodontic lesion 418f, 420, 422, 422f with secondary periodontal involvement 418f, 421 periodontal lesion 418f with secondary endodontic involvement 418f, 422 teeth, anatomy of 538 Procosol nonstaining cement 293 radiopaque-silver cement 293 Profile and protaper GT, difference between 158 Profile GT technique 264 Progenitor cells 581 Progenitor cells See Stem cells Progression chart of cracked teeth 525f Propex II apex locator 244f Prorinse probes 224 Prostaglandins 69 Protaper file 158, 159f, 265 advantages of 267 Protaper for rotary instrumentation 266 Protective barrier over gutta-percha 504f Protein delivery 584, 584f Psychogenic toothache 101 Pulp age changes in 18, 554, 555f anatomy of 4f anterior tooth 15f primary teeth 538f and periapex, pathologies of 22 and periodontium, communication between 413, 414, 414f and periradicular status 285 necrotic pulp tissue 285 purulent exudates 285 vital pulp tissue 285 tissue capping 460 agents 539 and pulpotomy 460 cavity 15f, 16f, 169, 481f isthmus 171 classification 171 of posterior tooth 15f of teeth 169 variation in 178 shape of 176 chamber 15, 169, 180, 183, 185 and root canals 169f, 186 shape of 201 to allow drainage, opening of 333f circulation of 13f condition of 456 contents of core defense of tooth, function of 17 degeneration 34 atrophic and fibrosis 34 destructive reaction, defense mechanism of 491 development, variations in 174 extirpation broach 149f technique of 148 fibroblasts, histology of 10f formation of dentin, function of 17 healthy reparative reaction, defense mechanism of 490 horns 169 in first molar, exposure of 23f infection from tooth decay 52f innervation of tooth, function of 17 morphologic, age changes in 18 necrosis 32 diagnosis 33 etiology 33 symptoms 33 treatment 34 nutrition of dentin, function of 17 oximetry 86 advantages of 86 pathologies introduction 22 physiologic changes, age changes in 18 reparative dentin formation, defense mechanism of 490 revascularization 586 in immature teeth 587 in replanted teeth 587 smear layer, defense mechanism of 490 space, variations of 174 stone, classification of 18 stones and calcifications 178, 178f tests, types of 82 therapy 538 tissue, incomplete removal of 330, 330f to dental caries 481 to local anesthetics 485 to microbial invasion 24f to restorative materials 486 to tooth preparation 482 to various irritants 24f treatment procedures 540 tubular sclerosis, defense mechanism of 490 unhealthy reparative reaction, defense mechanism of 490 vitality heat test 83 testing recent advances in 85 uses of 82 tests 82, 85, 420, 557 thermal cold test 82 test 82 Pulpal and periodontal disease, differential diagnosis between 427 Baume’s classification 26 blood flow, regulation of 11, 13f supply 11 damage to operative procedure, prevention of 491 disease 23, 23f, 420 granuloma 30 Grossman’s clinical classification 26 inflammation, cause 24f Ingle’s classification 26 injury, prevention of 488 irritants 480 pain 97 dentinal sensitivity 97 diagnosis 97 treatment 97 irreversible pulpitis 97 treatment 97 necrotic pulp 98 treatment 98 neurophysiology of 96f reversible pulpitis 97 treatment 97 pathologies 24 classification of 26 diagnostic aids for 25 reaction to microbial irritation 24 response to caries and dental procedure 480 inflammation 11 Seltzer and Bender’s classification 26 Pulp-dentin complex 7, 7f Pulpectomy for primary teeth 545 Pulpodentinal complex to mild and severe injury 489f Pulpotomy 542 materials for 545 objectives of 542 rationale of 542 Pyramid of endodontic treatment 196f Q Quantec apical preparation 265 file system 160 files, cross-section of 160f instrument technique 265 Quantity of irrigant used 213 Quaternary ammonium compounds 232 R Race files 161 advantages of 162 Radiations on pulp 489 Radicular cyst 45f Radicular cyst See Cystic apical periodontitis Radiopaque gutta-percha 289f Rapid heat transfer 116 Real seal obturation system 290f Real world endo sequence file 162, 270 system, advantages of 270 Reamer 148, 149f Reaming and filling, combination of 250 combination of 249 Reapproximation of soft tissue 404 Index  601 Recession of gingiva 533f Recrudescent abscess 41 Rectangular flap 392 Recurrent periapical abscess 331 Reduction in size of pulp volume 18f Refining burs 198, 198f Reflection of flap 392f Remaining dentin thickness 484 Remaining infective tissue 350f Remove all carious lesion 547f Remove silver point 356f Repair endodontic treatment 322 Replacement resorption resulting in ankylosis 521f Replantation 404 technique 404 Reserve cells 10 Residual tooth structure 432 Resilon 300f core material 300 Resin cement 445f Resin-based sealers 295 Resorption of tooth 24f Restoration See Extent of caries Restorations, inadequate 104 Restorative materials 402f, 495 requirements 431 resins 488 treatment planning for endodontically treated teeth 430 Restored tooth, components of 432 Retreatment coronal disassembly, steps of 352 Retrograde filling 402 periodontitis 417f pulpitis 417 Reverse balanced force preparation 264 Reversible and irreversible pulpitis, differential diagnosis of 30 Reversible pulpitis 27 definition 27 diagnosis 27 etiology 27 histopathology 27 symptoms 27 treatment 27 Rickert’s formula 292 Roeko seal 299 Roof pulp chamber 200f Root anatomy 529 apical constriction 170 delta 170 foramen 170 cementodentinal junction 170 apex, anatomy of 236f apical delta, anatomy of 170f canal 15, 170, 180, 184, 186 after coronal dissembly 353f anatomy of anterior teeth 170f, 173f, 197f mandibular molars 172f maxillary central incisor 180f maxillary lateral incisor 181f maxillary premolars and molars 173f posterior tooth 170f chemicals and dye penetration in 173f cleaning and shaping of 339f disinfectants 234 ethics 574 failure 53f defective obturation in 347f to separated instrument 347f filling, extent of 285 fillings of maxillary anterior teeth 81f incompletely filled 383 microorganisms 56f obturation 282 results in endodontic failure 347f of mandibular second premolar 315f of molar, anatomy of 197f orifices of maxillary first molar 205f perforation 377 preparation 247 biologic objectives of 248 techniques of 252 procedure 4, 36 replacement resorption 511 sealers 290 functions of 291 space using Gates-Glidden drills, preparation of 448f system 260f access to 196f complete cleaning and shaping of 332f complicated with fins 211f coronal restoration 353f for drainage, opening of 339f incomplete debridement of 347 shaped 5f, 246, 364 therapy treatment 271f by laser, steps of 567 treatment of mandibular first molar 189f second molar with C-shaped canal 193f, 194f second premolar with two roots 188f third molar 191f type I to IV 171f with complete sealing of pulp chamber 249f caries 557f caused misdirection of handpiece, perforation of 401f end cavity preparation 400 end filling materials 402 end preparation 400 end resection 398 indications of 397 fracture 467, 467f cervical third 467f classification 468 in premolar 457f level of 468 oblique in nature 467f prevention of 385, 530 root canal therapy 416 treatment of 468, 470f in mandibular molar 176f macrodontia, variation in size of 179 microdontia, variation in size of 179 resections contraindications for 405 indications for 405 variation in size of 179 Rotary endodontics, history of 157 instruments characteristics 157 properties of 157 nickel titanium system 157 stainless steel instruments 155 Rough endoplasmic reticulum Rubber dam 128f accessories 123 advantages of 122 application before bleaching 501f application of 129t clamps 124, 124f clamps basis of jaw design 124 material used 124 clamps placement of rubber dam 127 clamps rubber dam accessories 126 napkin 126 punch 126 template 126 clamps, classification of 124 disadvantages of 122 equipment 123 forceps 125, 125f frame 125, 125f isolation with 122 napkin 127f placement, methods of 127 punch 126f removal of 130 sheet 123, 124f template 126f Ruddle’s solution 173, 221 S Safety Hedstroem file 152f Salivary glands age changes in 555 palpation of 76 Salvizol 220 Save-a-tooth 476 Scaffold with stem cells 583f Schilder’s technique of obturation 309 Sclerosed canals 209 Scourge of digital hyperkeratosis 145 Seal apex 298 root canal sealer 298f Second generation apex locator 242 advantages 243 602  Textbook of Endodontics disadvantages 243 Secondary caries under restoration 29f Sedative dressing 339f Semilunar flap 392, 393f Sensor for RVG 92f Sequel of caries 482f pulpal inflammation 25, 36f Serial root canal preparation See Telescopic canal preparation Shaping, anatomic problems in 275 Sickle cell anemia 493 Sickle-shaped canals 178 Signaling molecule 582 Silicone-based root canal sealers 299 Silver cones 286 nitrate 486, 535 point microsurgical forcep, removal of 355f point removal 355 Simplifill obturator 318, 319f Single visit endodontics 323 advantages of 323 contraindications of 325 disadvantages of 323 indications of 324 Sinus or nasal mucosal toothache 101 tract 47f Size of pulp cavity 18f Slight tooth injury small restoration 482f Slob rule advantages of 89 disadvantages of 89 Smaller Gates-Glidden to prepare mid root area 256f Smooth finish line and remove all undercuts 449f Sodium caprylate 231 hypochlorite 63, 214, 214f, 216, 231 efficacy of 214 solution 215 extrusion of 215f use of 216 silicofluoride 536 Soft tissue applications 566 palpation of 77f Softened gutta-percha placed in canal 309f Solid core carrier technique 315 Solvents to dissolve gutta-percha 357f Sonic and ultrasonics in endodontics 153 handpiece 153 instruments advantages of 153 disadvantages 153 Sotokowa’s classification of instrument 157 damage 157f Splinting of teeth 469f Spray of ethyl chloride 82 Spread of infection routes of 109 theories of 65 Spread of pulpal inflammation to tissues 25f Spreader and plugger tips 166f Spreader match taper of canal 304f S-shaped/bayonet-shaped canals, management of 280 Stainless steel advantage 146 disadvantages 146 Standard of care set by endodontics 577 Staphylococcus 62 Steam heat sterilization See Moist heat sterilization Stem cells 579, 580 allogenic 581 autologous cells 581 engineering of biomimetic material 584 from human exfoliated deciduous teeth 582 isogenic 581 isolation of 582 markers 582 syngeneic 581 technology 579, 583 types of 581 unique characteristics of 581 xenogenic 581 Step back technique advantages of 257 disadvantages of 257 Steps of in-office bleaching 501f Storage media for avulsed tooth 476 Straight and curved root canal 16f Streptococcus intermedius 63 Strontium chloride 536 dentifrices 534 Stropko irrigator, needle designs 224 Subluxation 472f injury to periodontium 472f Submandibular gland, bimanual palpation of 77f Submarginal flaps 394 scalloped rectangular flap 393 Success-Fil carrier based cone 318f obturation system 317f Sulfonamides 232 Super ethoxybenzoic acid 403 liquid 403 powder 403 Suppurative apical periodontitis 46 Supraosseous extracanal invasive resorption 523f Supraperiosteal technique of local anesthesia 136f Surface resorption 475f Surface tension of irrigant 213 Surgical access to root structure, principles of 395 endodontic 386 treatment 73 length burs 198 operating microscope 207f, 570 tips for ultrasonic instruments 401f Suture, principles of 411 Swelling of gingiva indicate endo-perio lesion 419f Symptoms of different forms of pulpitis 36 T Talon’s cusp 174 Tapered canal preparation 254f Tapered fissure burs 200f Tapered preparation of root canal system 303f Taurodontism 175f Techniques of biomechanical preparation 253f Teeth abrasion of 555f after bleaching, discolored 500f age changes in 554 canal anatomy 173f cementum, age changes in 554 dentin, age changes in 554 enamel, age changes in 554 from immature tooth bud 585f from tooth bud cells 584 in multiple pulp exposure 555f isolation of 122 macroscopic, age changes in 554 radiographic features of 87f resulting from tooth wear, discoloration of 496f treated endodontically variations in internal anatomy of 174 with porcelain crowns 129 Telescopic canal preparation 253 Temperature of irrigant 213 Temporomandibular joint examination of 77f, 456f palpation of 76 Test cavity 84 Tetraclean 63 Tetracycline 143 and minocycline 494 staining, classification of 494 stains 495f Tetragonal zirconium polycrystals 439 Therma cut bur 315f Thermafil cones 315f gutta-percha 288f obturator 316f selection of 316f therma cut bur 317f Thermal effects of laser irradiation 565 Thermaprep oven 316f Thermaseal 296 Thermocatalytic technique of bleaching for nonvital teeth 502 vital teeth 501f vital tooth bleaching 499 Thermomechanical compaction of guttapercha 313f Index  603 Thermoplasticized injectable gutta-percha obturation 313 Thermoplasticizing technique of guttapercha 314 Third generation apex locator 243 advantages 244 disadvantages 244 Three-dimensional obturation of root canal system 247f Tic douloureux 100 Tilted and angulated crowns 208 Tissue cultures, types of 58 effects of laser irradiation 564 engineering 579 response to bone removal 395 irritation 329f Tooth after endodontic therapy 467f anatomic position of 431 bell stage, development of 8f bleaching, maintenance after 498 blunt handle of mouth mirror, percussion of 77f bud stage, development of 8f cap stage, development of 8f cleaned and shaped 5f complete restoration of 6f, 548f decay causing damage to pulp 4f pulp exposure 254f pulpal inflammation 23f pulpitis 29f decay resulting in pulpal necrosis 33f discoloration of 33 enamel, anatomy of 4f gloved finger, percussion of 76f hypersensitivity 531 management of 534 in dental arch 446 infraction 524 synonyms of 525 resorption 507 classification of 507 clast cells 508 mechanism of 509 monocytes and macrophages 508 odonoclasts 508 systemic factors 509 slooth 85f structure amount of 430 preparation of 449f preservation of 446 to caries, weakening of 429f tissue engineering 583f with infected pulp and abscess formation 4f with large restoration 525f Topseal sealer 293f Torque control handpiece 164f Torsional fracture 163 Tracking sinus or fistula 420 Transcutaneous electrical nerve stimulation 141 Transforming growth factors 69 Transillumination with fiberoptic light 86 Transmeatal bur for dooming head of posthead, use of 354f Transudate and exudate, differences between 28 Trapezoidal flap 392, 392f Traumatic injuries assessment of 477 examination of 455 management of 454 prevention of 478 Traumatic injury 341 Treatment after endodontic treatment Triad of tissue engineering 579, 581f Triangular cross-section of protaper 159f race files 161 Triazolam 132 Triple flex file 151 True combined endo-perio lesion 426, 426f lesion 418f Tubular canals 305 Tugback with master gutta-percha cone 303f Tungsten halogen curing light 499 U Ultrasonic activation of irrigating solution 215f sodium hypochlorite 215 canal preparation advantages of 273 disadvantages of 273 cleaner 113f instrument to remove fractured instrument, use of 371f irrigation 220, 221, 221f plasticizing of gutta-percha 314 root-end preparation 401 tips for endodontic treatment 209f vibration for paste removal, use of 361f Ultrasonically activated irrigation 63 Ultrasonics helps in better cleaning of canal, use of 515f Uncontrolled diabetes mellitus 387 Underfilled canals 383f Undifferentiated mesenchymal cells See Reserve cells Universal precautions 110 Unsupported tooth structure, removal of 449f Untreatable tooth resorption 105 Urea 216 peroxide 217 disadvantages 217 uses 217 V Varnish to protect pulp 487f walls of preparation, use of 488f Vazirani-Akinosi closed mouth technique 139 Venous drainage of teeth 12 Vertical compaction technique 309 fracture of crown 343 root fracture 343, 343f, 384, 385f, 415, 529 signs 529 symptoms 529 treatment of 530 stroke handpiece 153 tooth fracture 105 Vertucci’s classification of root canal anatomy 172f Virulence 51 Virulent factors 54 Visualization endogram 173 Vitality tests 31 W Wach’s sealer 293 Wall-mounted endomicroscope 570f Wand system of local anesthesia 140 Watch winding and pull motion 251, 251f motion 251f Water coolant, requisites of 485 Wave one file 162f system 271, 272f technique of 271 Wave one paper points and gutta-percha points 272f system 162f Wear of teeth, physiological 554f Wide apex advantages of 237 disadvantages of 237 Widening root canal 237 X Xenon plasma arc light 499 Y Yellowish discoloration of teeth 496f Yttrium aluminum-garnet lasers 564 Z Zinc chloride 535 oxide eugenol 486 cements 294, 403 advantages of 294 disadvantages of 294 sealers 292 phosphate 487 cement 445f on pulp 487 polycarboxylate cement 487, 487f Zincoxide eugenol 228f Zones of pulp 8, 8f ... (Fig 19.49) 306 A Textbook of Endodontics B Figs 19.47A and B (A) Carious 12 with tubular canal; (B) Radiograph showing obturation of 12 A B Figs 19.50A and B (A) Carious 22 with blunderbass... It monitors temperature at the tip Fig 19.68 Back filling of the canal Fig 19.69 Selection of plugger according to shape and size of the canal Fig 19.70 Confirm fit of the cone 3 12 Textbook of Endodontics Fig 19.71 Filling... Sweet oil of almond 80% 20 % Grossman’s Sealer Composition Powder: Zinc oxide Precipitated silver Oleo resins Thymol iodide 34–41 .2% 25 –30.0% 30–16% 11– 12% Liquid: Oil of clove Canada balsam 78–80% 20 22 %