Electrosurgery Implant Risk Factors Xerostomia and Diet Fear Factor

CHAPTER 29 Endodontic Records and Legal Responsibilities e169

of the general liability policy for an “accident” rather than leakage after compaction until a permanent restoration is as a malpractice incident compensable under the profes- cemented.305 Besides an adequate coronal sealing, an adequate sional liability policy. Call the patient periodically to check apical sealer should be well adhered to the canal walls. on healing, recovery, and any follow-up plastic or other The endodontic goal is to prevent bacterial contamination surgeries. of the periradicular tissue by predictably providing adequately cleaned, shaped, and filled root canal systems. Any Fear Factor residual bacteria should be entombed in the root canal filling. U.S. Centers for Disease Control and Prevention’s National A bacteria-tight apical seal should be designed to last long Center for Health Statistics report that cost is the overriding term with sealed portals to prevent reentry of microorgan- factor preventing adults from seeking dental care. Fear is the isms, which cause reentry recontamination and lead to end- second reason for delayed dental care. Medicaid recipients odontic failure.84,298 Younger patients are more susceptible to were at five times greater risk for worse dental health than bacterial penetration inside dentin tubules and thus recur- those with private coverage. Adults on Medicaid were twice as ring infections.177 likely to have not visited a dentist in more than 5 years.319 Dental fear may result in patients delaying or avoiding Electrosurgery dental care.199 Frequent cancellations and missed appoint- Electrosurgery can cause problems if mishandled. Damage to ments are characteristically associated with fearful dental the oral cavity caused by improper use of electrosurgical patients. Although it is ordinarily a defense of contributory devices consists primarily of gingival necrosis, osteonecrosis, negligence if patients do not follow a clinician’s treatment sloughing adjacent to the surgical field, and pulpal necrosis of recommendations, the patient’s advocate may contend that the affected teeth. defendant clinician negligently failed to diagnose a fearful All equipment should be properly maintained and certified patient. Fearful patients tend to avoid dental treatment because to meet the American National Standard (ADA specification they believe it may exacerbate a prior traumatic dental experi- no. 44 on electrical safety standards). Current equipment ence. Referral to clinicians who specialize in treating fearful should be checked to see that units meet these standards and patients should be considered to facilitate comprehensive that electrical cords and other components are in good repair. dental treatment and to avoid future emergency endodontic Electrical receptacles should meet the requirements of the care because of repeatedly canceled treatment visits. National Electrical Code for circuit grounding and ground fault Dental anxiety and finances are the two most important protection. During use, the dispersive electrode plate should barriers to patients obtaining regular dental care. Fearful dental be well away from metal parts of the dental chair and the patients avoid necessary treatment, delay recalls, and are reluc- patient’s clothing, because skin contact can cause burns. Use tant to undergo painful procedures. Therefore, it is essential of plastic mirrors, saliva ejectors, and evacuator tips is strongly that such patients be identified for proper management or recommended. referral for fear-reduction therapy. A patient who experiences intense anxiety in the dental chair, together with a history of Implant Risk Factors avoiding dental care, suggests a diagnosis of dental phobia. Patient risk factors such as grinding teeth or diabetes increase Fearful dental patients fear loss of control during clinical treat- the odds of implant failure.166 Higher implant failure rates ment and require reassurance and reaffirmation that they have occur with surgeons who have less than 5 years of implant the power to halt the procedure by raising a hand or using experience.166 another appropriate gesture. After trust is gained, additional procedures may be performed. Fluoride Varnish for Caries Prevention In addition to desensitizing techniques, the use of proven In 2006, the ADA Council on Scientific Affairs published topical-anesthesia delivery systems helps to ensure a relatively evidence-based research with fluoride recommendations for painless injection of local anesthetics. Topical-anesthetic caries prevention. The ADA recommends that fluoride varnish patches and oral-anesthetic rinses may prove a valuable aid for treatments for at-risk patients should be done between two to pain management of the fearful patient. four times annually, depending on risk classification. The use of psychological questionnaires, such as the Dental If fluoride trays are used, trays are effective only when used Anxiety Scale or the Modified Dental Anxiety Scale, may help for 4 minutes. One-minute foam or gel fluoride treatments are to identify such individuals.154 These simple questionnaires are ineffective. short, quick, and easy to complete, and users are provided with One of many benefits of fluoride varnish is very little sys- cutoff scores that help the clinician identify patients who have temic exposure, which does not require daily patient compli- psychological special needs. In this way, the clinician will be ance compared to fluoride trays. Fluoride varnish containing in a position to assist the dentally anxious or dentally phobic 5% sodium fluoride with 22,600 ppm fluoride ions help patient in accessing dental health care. occlude dentin tubules and aid remineralization. Leakage Xerostomia and Diet Long-term seal of the root canal system is determined apically A common side effect of cancer treatment is diminished saliva by the sealer and coronally by the final restoration.36,134,228,293 production, which increases the risk of dental demineraliza- Root canal–filled teeth should be permanently restored without tion, caries, and candidiasis. Milk may help because it moistur- undue delay to prevent leakage contamination of the previ- izes, lubricates, and buffers acids while contributing to enamel ously obturated canal system, because varying canal shapes remineralization. Demineralization aggravated by a chronic from round to oval prevent a 100% seal.84,85,202 Bonded seals lack of saliva may result in osteoradionecrosis. Therefore, dis- covering the canal surfaces should be used to control any eased teeth should be treated prior to cancer therapy. e170 PART III Expanded Clinical Topics

DNA preserved in calcified bacteria on the teeth of ancient human skeletons has shed light on the health consequences of the evolving diet and behavior from the Stone Age to the present.3 Composition of oral bacteria changed markedly with the introduction of farming and again around 150 years ago. With the introduction of processed sugar and flour in the Industrial Revolution, the diversity in oral bacteria dramatically decreased, allowing domination by caries-causing strains. As a result, the modern mouth basically exists in a permanent disease state.

Reasonable versus Unreasonable Errors in Judgment Although a clinician is legally responsible for unreasonable errors in judgment, mistakes occasionally happen despite adherence to the standards of reasonable care. A mistake does A not prove malpractice unless the mistake is caused by a malpractice error or omission.141 For example, accessory or fourth canals on molar teeth are frequently difficult to locate and may tax the best clinicians. Failure to locate an accessory or fourth canal does not conclusively constitute an unreasonable error of judgment. Rather, this may represent a reasonable error of judgment in the performance of endodontics. Nevertheless, if the additional canal could have been diagnosed radiographically with diagnostic quality radiographs at different angles, the existence of a fourth canal should have been considered. Instrument and seal the extra canal for successful obturation.

Incorrect Tooth Treatment A reasonable, non-negligent mistake in judgment may occur because the clinician has difficulty localizing the source of endodontic pain. Vital pulps may on occasion be sacrificed in B an attempt to diagnose the pain source, but it is unreasonable and therefore inexcusable to treat the wrong tooth if it is inad- FIG. 29-29 A, Tooth #31 with three separated files, one in each canal. equately tested with pulp tests, misidentified on the referral K-files used for cleaning canals and also obturation (1996). B, No apparent slip, or if radiographs are mounted or read incorrectly. Also, radiographic changes in 1998. treating large numbers of teeth endodontically (e.g., an entire quadrant) when attempting to localize chronic pain suggests pain is probably not of pulpal origin, and other differential diagnoses should be ruled out including atypical facial pain, advising the patient of leakage potential may constitute fraudu- referred pain, or TMD pain. lent concealment (Figs. 29-29 and 29-30). Patients should be If the wrong tooth is treated because of an unreasonable informed of such mishaps for (1) referral consultation or treat- mistake in judgment, the clinician should be compassionate, ment; (2) advising the patient, who on his or her own may waive payment for all endodontic treatment, and offer to pay seek a second opinion; or (3) disclosure, so as to return if a the fee for crowning the unnecessarily treated tooth. flare-up occurs.

Post Retrieval Swallowing or Aspirating an Ultrasonic instruments will vibrate and loosen the cement Endodontic Instrument around posts.68 The clinician can avoid overheating the post Use of a rubber dam in endodontics is mandatory.14,294 Even if by proceeding slowly with a water coolant, periodically resting the endodontically treated tooth is broken down and cannot for cool down, and checking the post temperature periodically be clamped, a rubber dam, regardless of required modification, to be reasonably certain overheating is not occurring.96,130,230 should be used in all instances (see Chapter 5). Not only is Figure 29-21 demonstrates what happened when an endodon- microbial contamination reduced with the use of a rubber dam, tist negligently overheated the post during attempted removal, but the risk of a patient’s aspirating or swallowing an endodon- causing tissue necrosis, bone loss, need for augmentation pro- tic instrument is eliminated (Fig. 29-31). Accordingly, if a cedures, irreversible pulpitis in an adjacent tooth, and the loss patient swallows or aspirates a file, it is likely because of the of two teeth.252 clinician’s failure to observe the standard of care. If a swallowing or inhalation incident does occur, the clinician should do Broken Files the following: Leaving broken files behind without referring the patient to 1. Advise the patient that the clinician regrets and is sorry an endodontist for attempted microscopic retrieval and not about what occurred. CHAPTER 29 Endodontic Records and Legal Responsibilities e171

FIG. 29-31 Swallowed endodontic instrument demonstrates the wisdom of using a rubber dam.

the incident as “medical payment” for an accident and not as a malpractice claim.

B Overextensions and Overfills A common error in utilizing periapical or Panorex imaging is presuming that when only one cortical border of the IANC is visible, the sole visible border is the superior border. Instead, virtually always when only one cortical border is clearly visible, it is the inferior cortical border.206 (See Fig. 29-30, B, periapical, which may appear to show only one cortical border, and Fig. 29-30, C, a clearer CBCT image of the same area showing both cortical borders.) Misassumption of the IANC borders results in mismeasure- ment of the IANC location. Because the IANC is approximately 3 mm in diameter, misassuming the sole observable cortical canal border to be the superior border (rather than the inferior border) can result in an imprudent treatment decision to delay microsurgery if overfill occurs and belated CBCT confirms an overfill inside the IANC. In Fig. 29-30, B, the defendant endo- C dontist misdiagnosed the overfill as being superior to the IANC rather than inside the IAN canal. Resultant permanent pares-

FIG. 29-30 A, Apical radiolucent changes with draining 9-mm buccal thesia occurred from watching and waiting for sensory return abscess (August 2003). B, Endodontist retreatment (August 2003). C, Suc- rather than referring to a microsurgeon for a stat microsurgical cessful retreatment with no buccal pocket (September 2003). (Courtesy removal. James YS Ho, DMD.) A slight overextension of root canal filling with conventional obturation or sealants can occur without violating the standard of care if not in close proximity to the IANC or sinus 2. Refer the patient for immediate medical care, including radio- (see Chapters 2 and 29). Gross overfill usually indicates faulty graphic imaging, to determine if the instrument is lodged in technique. Fig. 29-32, A and B, illustrates gross overfill of the bronchus, esophagus, or stomach so that appropriate calcium hydroxide, causing permanent paresthesia. Neverthe- medical measures are taken promptly to remove it. less, so long as the overextension is not in contact with 3. Offer to pay for the patient’s out-of-pocket medical expenses vital structures such as the IANC or sinuses, permanent harm and wage loss. Some professional liability policies will cover is unlikely. An exception is paraformaldehyde-containing e172 PART III Expanded Clinical Topics

FIG. 29-32 A-B, Calcium hydroxide overfill, causing permanent paresthesia. sealants, which cause a neurotoxic chemical burn type of probably will not penetrate beyond the mature root into the injury that chemically diffuses through bone and soft tissue IANC or other vital structures without prior excessive instru- spaces. ment perforation into the IANC. If, however, postoperative pain is foreseeable as a result of Mental foramen distances can be overestimated on the pan- overextension, the patient should be advised with postopera- oramic radiograph. Panoramic radiography may show more tive written instructions of the likelihood of postoperative dis- deviation (+0.6 mm) from the perioperative measurement.110,289 comfort or paresthesia because of suspected contact of the Paraformaldehyde-containing sealants can create cytotoxic sealant material with surrounding vital structures. A note chemical destruction of the IAN if placed in close proximity should be made on the patient’s chart of the overextension to, even though not directly contacting, the underlying IAN should symptoms later manifest. The clinician should observe (see reference, Sargenti Opposition Society [SOS]).278 On the with close follow-up visits and patient phone calls that evening, other hand, conventional obturators and sealants usually the next morning, and the following 3 days to rule out post- require coming closer to contact with the IAN before resulting operative persistent numbness or dysesthesia pain resulting permanent anesthesia, paresthesia, or dysesthesia occurs from any overfill. Slight overextensions with inert conven- (Fig. 29-33). Consequently, the incidence of permanent tional endodontic sealers, such as gutta-percha with Gross- sequelae with conventional filling materials is lower than the man’s sealant, can repair themselves and produce no irreversible greater cytotoxic potential with paraformaldehyde-containing changes if done without direct contact with the sinus or IANC sealants.234 Because of the higher risks associated with or indirectly through chemical leakage and seepage beyond the paraformaldehyde-containing endodontic materials, use of N2, initial area of operation. RC2B, or similar toxic pastes is contraindicated and violates Overextending the root canal filling material risks perma- the standard of care.11 Permanent injury risk is substantially nent consequences if the underlying IAN is initially “har- less likely with traditional eugenol-containing filling materials, pooned” with files. A portal of entry into the IANC results from less toxic chemicals than paraformaldehyde, which destroys overinstrumentation penetration. Flexible gutta-percha alone and mummifies nerve tissues. When safer, less risky alternative CHAPTER 29 Endodontic Records and Legal Responsibilities e173

A B

FIG. 29-33 A-C, Overextended gutta-percha and extracted tooth with gutta-percha intact. effective therapy exists, it is unreasonable (and substandard) IAN penetration resulted. Removal of gutta-percha and seal- to elect an unsafe alternative methodology. Also, the doctrine ants that have entered the IANC should be attempted as soon of informed consent is highly relevant because it is contrary as possible (preferably no later than within the first 24 hours).254 to public policy to request a patient to assume inherently dan- The eugenol component of the sealant causes an inflammatory gerous treatment risks that are reasonably avoidable with safer reaction in a constricted space, which is best relieved by and more predictable methodologies. When the risk exceeds retrieval. If retrieval fails, a decortication microsurgical proce- the benefits, such risks are regarded as negligent and thus dure with an oral surgeon is indicated at the earliest possible should be avoided and not undertaken. time (preferably within the first 24 hours) owing not only to Any significant overextension should be considered for eugenol chemical toxicity but also eugenol reaction with gutta- immediate retreatment by attempted retrieval of overextended percha, which causes expansion and thus a mechanical com- gutta-percha and sealant.135 The clinician also has the option pression ischemic injury.219,254 of immediately referring the patient to an endodontist for retrieval before the sealant sets. Conventional filling agents Compartment Syndrome such as gutta-percha do not penetrate the cortical walls of the Inflammatory edema that compresses and compromises blood IANC unless probably preceded by prior penetration with supply to soft tissues and nerves in limited spaces with resulting overinstrumentation. This principle can apply to sinus perfora- ischemia is termed compartment syndrome.285,339 Compartment tion. If despite local anesthesia, the patient feels an electric syndromes are a group of conditions that result from increased shock during mandibular molar or premolar instrumentation, pressure within a limited anatomic space, acutely compromis- this may be a warning sign that the IAN was pierced with ing the circulation and ultimately threatening the function of endodontic files. If this occurs, the root canal should not be the tissue within that space. Compartment syndrome occurs filled; instead, periapical radiographs at different angles should from an elevation of the interstitial pressure in a closed osseo- be exposed with instruments in place to confirm whether any fascial compartment that results in microvascular compromise. e174 PART III Expanded Clinical Topics

The pathophysiology of compartment syndrome is an insult Mental Nerve Injuries to normal local tissue homeostasis that results in increased The mental nerve, as the terminal branch of the IAN, is at risk tissue pressure, decreased capillary blood flow, and local during elevation of the mandibular mucoperiosteum. Careful tissue necrosis caused by oxygen deprivation. Compartment flap design and elevation are important to avoid mental nerve syndrome is caused by localized hemorrhage or postischemic injury while working on the buccal surface of the mandible in swelling. The pathophysiology of compartment syndrome the region of the mental foramen.207 In performing incision and is a consequence of closure of small vessels. Increased com drainage in the region of the mental foramen, a diagnostically partment pressure increases the pressure on the walls of arteri- accurate radiograph is necessary to avoid incising through the oles within the compartment. Increased local pressure also course of the mental nerve.84,180 occludes small veins, resulting in venous hypertension within When carrying out periradicular surgery (PRS) in the man- the compartment. The arteriovenous gradient in the region dibule, consideration must be given to the path of the inferior of the pressurized tissue becomes insufficient for tissue dental nerve bundle in the mandibular canal, which lies in perfusion. close proximity to the root apices.277 Be aware of the position The clinician should have a high index of suspicion when- of the mental nerve exiting through the mental foramen. A ever a nerve is located inside a closed bony compartment shallow sulcus, coupled with a prominent mandibular protu- where nerve injury within the surrounding neurovascular berance, together with the lingual inclination of the roots may bundle has the potential for bleeding or swelling. Compart- make access to the root apices difficult. Approximately 40% of ment syndromes are characterized by pain beyond what should lower incisors have two root canals, which may preclude ade- be experienced from the initial injury. Also, diminished sensa- quate resection and retrograde filling of the root apex, which tion may be noted in the distribution of the nerve within a may ultimately lead to treatment failure. compartment that is being compressed, such as the IAN, which is enclosed by bone on all sides. Local Anesthesia: Septocaine Root canal followed by root resection without an adequate Septocaine and Articaine are not suitable for an inferior dental retrograde restoration will likely fail. Open drainage is no nerve block due to the potential increased risk of paresthesia longer recommended. Dissect out subapical granulation tissue and nerve damage.91 cleanly and without damage to vital structures. Caution should be taken when granulation tissues are attached to vital ana- Implant versus Endodontics tomic structures such as neurovascular bundles or sinus A natural tooth with its periodontal support, function, and linings. A potential for recontamination exists unless the root proprioception is superior to an implant-retained restoration. apex is removed. Apical resection of 3 mm will remove poten- Whenever reasonably feasible, teeth should be retained. tial problems. This resection will additionally permit inspec- Reasonable clinicians may differ in recommending extraction. A straight fissure bur design with appropriate air venting tion versus periradicular surgery depending on location is recommended rather than a conventional air rotor to prevent near vital structures and clinical conditions. Extraction of air emphysema. the diseased tooth and placement of a dental implant has Currently preferred methodology utilizes specifically a better long-term prognosis and thus should be the treatment designed ultrasonic tips inserted into a piezoelectric ultrasonic of choice is one author’s conclusion.275 Conversely, every handpiece. Amalgam is no longer recommended as a material reasonable effort should be made to retain the natural tooth for root-end filling. MTA and newer silicate trioxide materials with its periodontal support, function, and proprioception. are recommended.243 Thus, an implant-retained restoration should be considered as the last possible treatment option as concluded by other Periradicular Surgery (PRS) clinicians.24,73,310 Accessing mandibular posterior teeth can generate increased Infraocclusion of the implant restoration in teenage patients heat during removal of significant quantities of bone to gain with residual craniofacial growth occurs as the adjacent teeth apical access. Thus, copious coolants must be applied to avoid erupt. Therefore, delay implant placement until dental and risking injury to adjacent structures. Molar teeth surgical skeletal maturation occurs.309 access should avoid the facial artery as it crosses the border of Aesthetics is an important outcome for patients receiving the mandible adjacent to the first molar. implant-supported restorations. To achieve this outcome, patients require good bone volume and quality, as well as soft- Avoiding the Inferior Alveolar Nerve Canal tissue height. Following extraction, the alveolar bone resorbs When placing implants or performing apicoectomies in close vertically, as well as horizontally (buccolingually). Socket pres- proximity to the mental foramen in the bicuspid region, the ervation intervention grafting may aid in reducing the bony clinician should consider the anterior loop of the IAN.277 The dimensional changes after tooth extraction but ridge resorp- IAN ascends as it approaches the mental foramen, compared tion is not completely prevented. Intervention techniques with the IAN’s more inferior location in the molar region. The including autografts, allografts, xenografts, guided bone regen- IANC varies from buccal to lingual as it courses the length of eration (GBR) and growth factors accomplish varying degrees the mandible. Thus, CBCT imaging aids in assessing the IANC of success in maintaining the anatomic dimensions of the location for planning implant placement or apical surgery75,97 alveolus before implantation.54 (Fig.29-34, A to C138; this Los Angeles case settled for $915,000, with permanent dysesthesia). Current Use of Silver Points Figure 29-35 illustrates avoidance of the IANC to demon- Based on what has been known for more than 3 decades, use strate that IANC penetration with the implant or drill is a of silver points in lieu of gutta-percha or other conventional preventable adverse event. endodontic filling materials represents a departure from the CHAPTER 29 Endodontic Records and Legal Responsibilities e175

Cut-section Implant # 20

Gingiva (gums) Mandibular bone Mental nerve Mental foramen

Implant

FIG. 29-34 A, Illustration showing Inferior alveolar implant placed into ascending inferior alve- nerve olar nerve canal (IANC). B, Cone-beam computed tomography (CBCT) image of A Canal B implant into ascending IANC. Settlement of $915,000. C, Implant into IANC; immediate postoperative Panorex image. Same patient but with CBCT image.

Incorrect drill depth

FIG. 29-35 Medicolegal implant image.

Drill tip Bone Implant 2mm Drill tip safety zone Inferior alveolar nerve canal

Correct drill depth Incorrect drill depth Incorrect implant depth e176 PART III Expanded Clinical Topics

current standard of care.13 This is because silver points corrode The AAE Position Statement does not recommend the pro- in time, and a tight 3D apical seal is lost. Figure 29-36, A to phylactic revision of silver point obturation, unless there is C, represents gross overextension with a silver point that ulti- clear evidence of endodontic pathosis or if the silver points mately caused the loss of tooth #14 as a result of endodontic complicate proper restoration of the tooth.13 failure. N2 (Sargenti Paste) Dental literature reports that permanent paresthesias are associated with gross overfilling with paraformaldehyde sealant (N2) (Fig. 29-37).200,234 Current use of paraformaldehyde- containing endodontic sealants is not merely the result of a philosophic difference between two respectable schools of thought. Rather, the distinction is between the reasonable and prudent school of thought that advocates conservative conventional endodontics and the imprudent and radical school of paraformaldehyde providers who unreasonably risk permanent, deleterious injury with N2 overextensions. Regardless A of the small number of clinicians professing to use N2, it is cytotoxically unsafe and should be avoided. A customary negligent practice by some clinicians is no defense to safe and prudent practice, which the standard of care requires. No matter how few or how many do it wrong, this never makes it right. The AAE recommends against the use of paraformaldehyde- containing materials as they have proved to be both unsafe and ineffective. Accordingly, the use of such materials is below the standard of care for endodontic treatment.11 Four years after her settlement, a Sargenti paste overfill patient wrote about her persistent dysesthesia as follows: B

I have been in a pain cycle that is almost unbearable. I fully understand why the closest God given disease to what I suffer, trigeminal neuralgia, is nicknamed the suicide disease. There are days where that option enters my mind but I believe that suicide is a sin and will land me in an eternal life worse than what I was trying to escape.

Clinicians may be liable for fraudulent concealment, intentional misrepresentation, or co-conspiracy if they discovered that a previous clinician’s negligence is the cause of dental C disease and both the prior clinician and subsequent treater concealed the prior clinician’s negligence. For instance, if a FIG. 29-36 Gross overfill into sinus with a silver point, which ultimately gross overextension of a paraformaldehyde packing or sealant caused sinusitis and loss of tooth #14 as a result of endodontic failure. is evident radiographically and the patient reports that another

A B

FIG. 29-37 A and B, Overextensions of Sargenti paste filling the inferior alveolar nerve canal. Both cases could have been avoided if the practitioners had selected a conventional sealing material and used a technique that emphasizes length control. CHAPTER 29 Endodontic Records and Legal Responsibilities e177 clinician caused the overfill (that resulted in permanent lip and through the coronal seal between visits. Treatment of apical chin anesthesia), subsequent treating clinicians may be liable periodontitis with signs or symptoms of a beginning lesion is for fraudulent concealment if they misinform the patient that determined by the sound judgment choice of the clinician. the anesthesia will probably disappear shortly and that using Either one or two visits will comply with the endodontic stan- N2 merely reflects a philosophic difference rather than sub- dard of care.242 standard practice. Some clinicians who differ on therapies regard such differences as controversial. The difference between standard of care and substandard practice is not controversial Prevention of Orthopedic but rather an indisputable difference between right and wrong. Joint Infections For instance, quackery based on pseudoscience is not contro- Available evidence is insufficient to recommend prophylactic versial. Instead it is fraudulent practice.37,224 Likewise, if the antibiotics for dental procedures in persons with joint replace- radiographs indicate sealant is inside the IANC and the patient ment, according to the American Academy of Orthopedic Sur- complains of persistent anesthesia, the patient should not be geons (AAOS) and the American Dental Association (ADA) told to wait for return of sensation. The clinician should refer clinical practice guidelines. the patient immediately for microsurgical consultation for This new guideline, titled “Prevention of Orthopedic decortication and decompression surgery.263 Implant Infection in Patients Undergoing Dental Proce- The Federal Food, Drug, and Cosmetic Act prohibits inter- dures,” replaces the previous AAOS Information Statement, state shipment of an unapproved drug or individual compo- “Antibiotic Prophylaxis for Bacteremia in Patients with Joint nents used to compound the drug.100 On February 12, 1993, Replacement.”8,21 the FDA dental advisory panel confirmed that N2’s safety and A collaborative systematic review of the correlation between effectiveness remain unproven. N2 may not be shipped inter- dental procedures and prosthetic joint infection (PJI) found no state or distributed intrastate if any of the N2 ingredients direct evidence of a causal link. The new clinical practice were acquired interstate. Mail-order shipments of N2 from guidelines were developed using the published AAOS develop- out-of-state pharmacies in quantities greater than for single- ment process, which meets or exceeds recommended Institute patient use are considered a bulk sales order rather than a of Medicine standards for the development of systematic prescription, thus violating FDA regulations.63 A San Fran- reviews and clinical practice guidelines. cisco jury awarded punitive damages against an N2-distributing Research showed that invasive dental procedures, with or New York pharmacy for knowingly shipping N2 in violation without antibiotics, did not increase the odds of developing a of FDA regulations, done with deliberate disregard for patient prosthetic joint infection. safety.162 Clinical practice guidelines include three specific recommendations: Defective Restorations 1. Practitioners should consider changing their customary Marginal gaps greater than 50 µm lead to cement dissolution practice of prescribing prophylactic antibiotics to patients and cause 10% of crown failures within 7 years after cementa- with prosthetic joints undergoing dental procedures. This tion. Dull or worn explorers substantially increase the likeli- recommendation is based on limited evidence that dental hood of nondetection of open margins. A sharp explorer can procedures are unrelated to PJI. detect margin defects as small as a 35-µm opening.36 Accord- 2. There is no direct evidence that the use of oral topical anti- ingly, a sharp clinician should utilize a sharp explorer to detect microbials before dental procedures will prevent PJI. This open margins. Open crown margins contribute to endodontic is an inconclusive recommendation. The guidelines’ authors failure and should be avoided (see Chapter 22). were unable to recommend for or against the use of topical oral antimicrobials in patients with prosthetic joint implants Restoration Marginal Integrity or other orthopedic implants A pathologic apical lesion will resolve when the origin of infec- 3. Good oral hygiene should be maintained. This is the only tion is eradicated, the root canal system effectively sealed, and consensus recommendation in the new guideline. a satisfactory coronal restoration placed. Many clinical studies Potential adverse effect of routine prophylactic antibiotic report a high success rate for nonsurgical root canal treatment use may include increased bacterial resistance, allergic reac- (NSRCT) of greater than 90%. tions, diarrhea, and death. Immunocompromised patients may be at greater risk for PROPHYLACTIC ENDODONTIC PRACTICE implant infections. Antibiotic use might be considered in this group. Malpractice Prophylaxis Immunocompromised patients include patients with diabe- Most negligently injured patients do not sue.51 Nonetheless, tes mellitus type 1 and type 2, autoimmune diseases, post– litigation serves a prophylactic purpose because litigation fears organ transplants, chemotherapy, bone marrow transplants, make some clinicians more careful and help promote profes- HIV positive status, chronic steroid use, obesity, hemophilia, sional guidelines. For example, after the American Society of malnutrition, tobacco or alcohol use, leukemia or other Anesthesiologists adopted practice guidelines to reduce patient cancers, radiation therapy history, immunomodulated therapy, harm, deaths and professional liability premiums decreased or the elderly. dramatically.252,283 Disclosure Errors One-Visit versus Two-Visit Endodontics Should dental negligence harm a patient, then full disclosure, One visit endodontics, if done well, will allow disinfection of including accepting the clinician’s responsibility along with the canals and obturation without risk of recontamination providing an apology and explanation, results in the best e178 PART III Expanded Clinical Topics

outcome for the clinician and patient. Also, assurance of efforts patient cannot be seen within a reasonable time, a staff to prevent a recurrence results in greater patient satisfaction member should communicate the reason and, if appropriate, and retains trust with the disclosing clinician to sustain a con- offer to reschedule the appointment. Staff or the clinician tinuing clinician-patient relationship. Patients want to be told should telephone the patient at the end of the day after any of treatment errors, regardless of whether the error can be cor- difficult procedure or surgery to check on the patient’s status rected. One study in which there was full disclosure of negli- and remind the patient to follow postoperative instructions. gently caused therapeutic errors resulted in only one patient The clinician should record any patient complaints, symp- thereafter seeking legal advice.210 In the same study, patients toms, and noncompliance with instructions. The latter can be paradoxically acknowledged, “It is realistic to expect that used as evidence of patient contributory negligence if litiga- doctors will make errors. … Patients have a right to expect that tion occurs. their doctors will not make errors.” Nonetheless, virtually all The clinician should remember that the patient lacks the patients concluded, “Patients should be able to trust their information and expertise to evaluate quality and performance. doctors to give them the right care.” As noted earlier, apolo- Patients have their own experiences and perceptions and often getic expressions of sorrow or empathy for a patient’s injuries rely on lay information when gathering facts about dental are barred in evidence from being construed as admissions of procedures and treatment options. However, clinicians should fault in 29 states.182 Protecting the patient’s best interest expect some patients (especially those with access to the includes telling the patient when negligent errors occur. Internet) to ask technical questions and expect sophisticated responses.199,246 Future of Antibiotics and Resistance Clinical signs, symptoms, and outcomes of infection result as Rapport Building Blocks much from the host response to the microbe as from the direct Sir William Osler advised, “Listen to the patient. He is trying effects of the microbe itself. The speed with which antibiotic to tell you what’s wrong with him.” The best communicators resistance spreads is driven by microbial exposure to all anti- listen more than they speak. When they do speak, it is mostly biotics, whether appropriately prescribed or not. Even if all to clarify what the patient has said. Difficult clinician-patient appropriate antibiotic use were eliminated, antibiotic-resistant relationships create poor communications. Improved under- infections would still occur (albeit at lower frequency). Wide- standing of the patient’s complaints fosters better rapport, aids spread antibiotic resistance was recently discovered among treatment, and reduces the likelihood of litigation. bacteria found in underground caves that had been geologi- In discussing the patient’s complaints, the clinician should cally isolated from the surface of the planet for 4 million ask, “What do you think is causing the problem?” Otherwise, years.45 Resistance was found even to synthetic antibiotics that the clinician may solve the patient’s dental problem while did not exist on earth until the 20th century. To slow the spread failing to solve the patient’s perceived problem. Failing to of resistance in order to prolong the useful lives of currently clarify the patient’s expectations about diagnoses and recom- available antibiotics, careful clinicians should prevent infec- mended treatment leaves the patient with unresolved worries tions from occurring in the first place. and concerns. For instance, a patient may fear that a retained In 2009, more than 3 million kilograms of antibiotics endodontic file is carcinogenic unless this fear is allayed with were administered to human patients in the United States a careful explanation that it is not. alone. In 2010, a staggering 13 million kilograms were administered to animals, the majority to promote the growth of Unhurried Visits livestock.297 Paying full attention to the patient’s complaints, making good eye contact, and respectful addressing of the patient will gain Temporomandibular Disorders rapport, improve communication, and prevent lawsuits. The Occlusal prematurities can trigger temporomandibular disor- clinician should avoid questions that require a yes-or-no ders (TMDs) in patients with a prior TMD history, so during answer and instead ask what the patient perceives as the or following endodontic therapy for such a patient, it is essen- problem, rephrase the patient’s complaints to prevent miscom- tial that temporary and final restorations not open the bite or munication, and ask if the patient’s complaints have been significantly alter existing occlusion.194 Hyperocclusion is a summarized accurately. Summarizing clarifies understanding potential TMD trigger that can result from open bite or on a by repeating important points. The clinician should also ask contralateral side, when a terminal abutment tooth is taken out whether there are any remaining questions. Nonverbal com- of occlusion. munication is a powerful tool. The clinician should shake hands initially and comfort with an outstretched hand if pain Patient Rapport is provoked. Good patient relations are 15% dependent on the clinician’s Emotions are the dominant force behind most malpractice competency to cure and 85% dependent on the clinician’s claims. Patients who feel misled, betrayed, or abandoned ability to assure the patient that the treatment being given will become angry and may seek vindication instead of simply be done with the clinician’s best judgment and care. seeking financial compensation. Thus, the clinician should Rapport between clinician and patient reduces the likeli- maintain a tactful and courteous approach and be attentive to hood the patient will sue, despite an adverse result. The clini- the patient’s needs and complaints. In addition, the clinician cian can develop rapport by demonstrating genuine interest should always make sure that communications with the in the patient and making the patient feel valued. Patients patient are clear, even to the point of being repetitious, by feel important if they are seated in the operatory within a asking if the patient has any questions. The patient should reasonable time after arriving. The longer a patient is kept never be abandoned in the middle of a course of treatment. waiting, the more frustration and animosity build. If the Also, the clinician should always be available to provide CHAPTER 29 Endodontic Records and Legal Responsibilities e179 follow-up care. Clinicians should avoid making telephone complications, such as extended postoperative visits or retriev- diagnoses. Instead, recommend an office exam to assess treating broken instruments, should be resisted. ment needs. An overzealous receptionist who places payment pressure Good telephone communication is a matter of asking the on a dissatisfied patient, or a clinician who sues to collect a fee right questions, such as asking a patient complaining of post- from an already displeased patient, may invite a countersuit for operative swelling if there is difficulty breathing or swallowing, malpractice. Refunding fees or paying for the treatment fee of as well as the degree and location of swelling. In cases of sus- the subsequent treating clinician is usually much less expen- pected infection, clinicians should ask the patient or family sive than 1 week in court and a jury award for a patient’s pain member to call back with a temperature reading to verify the and suffering. If clinicians must sue for a fee, they should do patient is afebrile. so only if treatment is beyond reproach and records substanti- ate proper diagnosis, treatment, and informed consent options. Off-the-Cuff Diagnoses Suing for unpaid fees continues to be a proven method for One clinician misdiagnosed a patient’s party guest’s endodon- getting countersued for dental malpractice. The client who has tic problem as “sensitivity caused by gum recession” and paid fees in the past but who stops at some point is either recommended a desensitizing toothpaste. Although the con- unhappy with the dental service received or short of funds. versation took place in a social setting, a lawsuit can result Dealing with a patient’s countersuit takes time, and collection based on an inadequate diagnosis. Suggest instead a thorough of unpaid fees may prove difficult. The patient being sued may office exam with diagnostic-quality radiographs or provide a seek an attorney to scrutinize the clinician’s records for a referral. potential cross-complaint suit against the clinician who initiated the lawsuit for fee collection. Keeping Conversations Professional Some cross-complaints for dental malpractice lack merit, Making light of a minor occurrence, such as the dropping of whereas others have genuine merit. Pain, suffering, and lost an instrument, with a quip about the clinician’s “one drink too wages may provide a larger potential patient recovery amount many” at lunch may seem funny at the time. However, it may than the clinician’s fees in dispute. Whenever possible, clini- not sound so funny if the patient soberly reiterates the quip to cians should avoid suing patients for unpaid fees. Before con- a jury. sidering suing, the clinician should discuss the fee situation The clinician must not let a patient’s flattery of the clini- with the patient and consider a payment schedule, fee reduc- cian’s abilities undermine one’s best professional judgment. tion, or fee waiver. Heroic measures usually result in treatment failures, dissatis- The amount of money being awarded by juries is increasing. fied patients, and, ultimately, lawsuits for uninformed consent. In 1999, a New York City jury awarded $3.5 million against a A patient dissatisfied with prior treatment that appears clinician who had replaced three amalgams with composites. adequately performed should prompt the clinician to stop To relieve postoperative sensitivity, endodontics was performed treatment. Young clinicians are more apt to walk into traps and subsequently failed. Chronic TMD followed the extrac- involving a patient’s request for unreasonable treatment. A tion, from which the patient was likely to suffer lifetime pain. compassionate clinician who is able to communicate conscien- In Michigan, two endodontists were disciplined in 2008 for tious concern avoids many malpractice actions. Thus, when an sedation overdose after settling for $3.5 million.278 In 2008, a iatrogenic mishap occurs, it behooves the clinician to be frank Spokane, Washington, jury awarded $14.2 million for unneces- and forthright with the patient. Moreover, negligence conceal- sary temporomandibular joint (TMJ) surgery. In Figure 29-38, ment may extend the statute of limitations. Most states with a Los Angeles jury awarded $2.7 million against a periodontist discovery statutes construe discovery as the date on which the who “harpooned” the IANC with his implant. patient discovered or reasonably suspected the negligent cause of the injury, not the date of the injury itself.89,117,267,331 Further, Post Perforation belated discovery of injury from another clinician evokes a Post selection is important for minimizing the risk of perfora- feeling of betrayal in the patient and destroys rapport that tions.68 Generally, posts should not exceed one third of the would otherwise dissuade the patient from instituting litiga- mesiodistal width of a tooth, should follow the canal anatomy, tion. Beginning in July 2001, the Joint Commission on Accred- and should leave 4 to 5 mm for sealant in the opened post itation of Health Care Organizations required hospitals to space; this is described more thoroughly in Chapter 22. When provide an honest explanation to patients regarding medical a tooth is already crowned, access to the root canal entrance mishaps. These standards are designed to prevent errors and reduce medical negligence claim payouts. In 1999, the Annals of Internal Medicine concluded that “extreme honesty may be the best policy.” A full-disclosure policy in a study involving a hospital in Lexington, Kentucky, showed that this hospital was in the top 25% of claim incidence, but it was also in the bottom 25% of claim payouts ($1.3 million over 7 years). Fees Clinicians should clarify fees and payment procedures before initiating treatment. If the dental treatment becomes more extensive than originally planned, the clinician should discuss any increased charges and reasons for those charges with the patient before continuing treatment. Charging for untoward FIG. 29-38 Implant “harpooned” the inferior alveolar nerve canal. e180 PART III Expanded Clinical Topics

FIG. 29-40 Post perforation of tooth #5.

due care.228 Furcation perforations are avoided by adhering to basic principles of pulpal chamber removal such as cleaning and shaping in a coronal rather than an apical direction. Inno- vative bur designs can access the pulp chamber without risking furcation perforation by preventing cutting or ditching of the pulp chamber by use of a non–end-cutting bur.87 Bleach Injury Because of the varying shapes of the root canal system in the apical third after cleaning, shaping, and obturation, some residual bacteria may remain, which are entombed. Sodium hypochlorite is the usual disinfectant irrigant used to minimize these remaining bacteria.268 Apical or lateral extrusion occurs B when bleach is extruded past the protective apical constriction or through a root perforation. The common denominators of FIG. 29-39 Avoidable perforation. (Courtesy Stephen Cohen, MA, DDS.) bleach injuries are sudden severe pain and facial swelling.* Because of the clinician’s concern for emergency treatment and surface should be located before rubber dam placement. This the patient’s pain, further endodontic therapy is deferred and will aid in orienting the root’s long axis, which may vary from usually not completed at the same visit. However, two cases the prosthetic crown’s long axis. Figure 29-39, A and B, repre- report that compaction was completed during the same visit, sents an endodontist’s perforation of tooth #7 because of dif- despite a bleach injury.215,276 One article reports that subse- ficulty locating the entrance into the root canal apical to the quent flare-up may be related to the original bleach injury.52 pulp chamber.107 Figure 29-40 shows a general clinician’s mis- Prevention of bleach extrusion is done with bleach syringes aligned post and perforation of tooth #5. with safe, side-venting needles constantly moving to prevent Ordinarily, a careful clinician performing endodontic hydrostatic pressure buildup from bleach fluid. Sodium hypo- therapy should be able to avoid post perforations. If post per- chlorite is extruded into the periapical tissues during root foration occurs, early diagnosis and treatment are important. canal therapy if excessive pressure is placed on the irrigating Belated diagnosis and treatment substantially increase the risk syringe, resulting in an expression of sodium hypochlorite of endodontic failure. If the perforation is relatively small (i.e., beyond the apex. Subsequent pain is caused by the solution 1 mm or less) and promptly diagnosed at the time of the post diffusing into the surrounding bone and soft tissue, causing perforation, immediate treatment with intracanal sealants swelling, tissue necrosis, and paresthesia. Surgery is usually (MTA) or tricalcium silicate in the area of the perforation will contraindicated, and palliative treatment such as cold com- probably succeed. However, delayed diagnosis and treatment presses accompanied by reassurance that most symptoms will (beyond 24 to 72 hours) result in bacterial contamination in dissipate is usually adequate.186 However, if the bleach diffuses the area surrounding the perforation. Delayed perforation into vital nerve tissue of the infraorbital or inferior alveolar repair therapy can cause periodontal or endodontic lesions and nerves, permanent paresthesia and occasional dysesthesia may lateral periodontal abscesses occurring secondary to delayed result.101,214,249,336 Figures 29-41 and 29-42, A to C, represent diagnosis, which usually prognosticate a high failure risk. bleach injuries secondary to a root canal perforation. Paresthe- sia persists. Note the periapical film does not show the perfora- Perforation Prevention tion, but the Accuitomo CBCT does. Irreversible endodontic complication such as furcation perforation during pulpal chamber access is usually preventable with *References 2, 101, 186, 214, 249, 260, 268, 336. CHAPTER 29 Endodontic Records and Legal Responsibilities e181

A FIG. 29-41 Bleach injury.

Bleach Usage

Use of 35% H2O2 as a bleaching agent can be clinically adverse in the long term or after recurring bleaching treatments. Precautions include the following: ◆ Reduce hydrogen peroxide concentration ◆ Reduce the time of each application, and increase the time between applications ◆ Avoid reaction catalysts, such as lamps or lasers Post-bleaching sensitivity is mostly due to reversible pulpitis that may progress in some cases. Cores Incorrect choice of cores can contribute to failure, including fractures. Some manufacturers (e.g., 3M ESPE, St. Paul, MN, for Ketac silver) recommend against use of their core material unless at least two thirds of the tooth remains before buildup. Failure to follow the manufacturer’s directions can be considered when an expert determines whether the standard of care was met. B Resin-reinforced post-and-core systems show promise for structurally weakened incisors, but long-term longevity has not been reported. A ferrule or other counter-rotational core design is an important consideration for fracture resistance and retention,155 although it has not been proved as statistically significant for the resin-reinforced core systems.279 Absorbable Hemostatic Agents Absorbable collagen hemostatic agents should not be placed on or adjacent to peripheral nerves because of the potential for neural injuries, particularly in bony nerve canals.105,200 Also, as this material is absorbed, its chemotactic properties promote collagen formation and scarring. Compression injuries of peripheral nerves in bony canals can result from expanding scar tissue. FDA adverse incident reports list 11 patients with C severe neural defects, including paraplegia secondary to absorbable collagen products placed in the spinal canal for FIG. 29-42 A, Periapical tooth #19 showing fractured file but no perfora- hemorrhage control. Thus, the FDA warned of paralysis from tion. B, Accuitomo cone-beam computed tomography (CBCT) showing perfo- absorbable hemostatic agents.105,200 Accordingly, after hemor- ration on the lingual side above the tooth #19 furcation. Perforation not evident rhage is controlled with hemostatic agents, absorbable collagen in periapical view. Image demonstrates Accuitomo accuracy. C, Bleach extru- agents should not be left in situ or near bony neural spaces. sion through tooth #19 perforation, with resultant slough of lingual tissue. This will avoid having remaining hemostatic material cause swelling, pressure, or migration to adjacent neural tissues. The minimum amount of collagen agents necessary to achieve hemostasis should be used. e182 PART III Expanded Clinical Topics

FIG. 29-43 Tensile overload shown in elongated ductile dimple voids.

FIG. 29-44 Needle blunting of broken needle tip demonstrating striking Pneumomediastinum (Air Embolus) hard object (ramus). When performing endodontic surgery, a surgical handpiece should be used that ventilates air through the back of the during surgery. Instead, an ultrasonic device that can deliver a handpiece rather than an air turbine that directs air into open sterile irrigant during surgery should be used. Dental unit tissue spaces. Pneumomediastinum, also known as mediastinal water lines are available with tubing that can be disposed or emphysema, may result from air embolisms dissecting down the autoclaved for surgery. Some ultrasonic devices are also avail- neck facial planes from air forced into the submandibular or able with disposable tubing to maintain a sterile water coolant sublingual spaces contiguous with neck spaces.40,301 delivery system. Rotary NiTi files likely contain bioburden material that after Broken Needle sterilization may act as a foreign body. Efficiency degradation Scanning electron microscopy (SEM) with an energy- after sterilization should suggest to the prudent clinician a dispersive x-ray spectrometer attachment can analyze whether single-use philosophy.31 a broken instrument is due to excessive operator trauma or a Digital radiographic devices that contact the oral mucosa manufacturing defect. Figure 29-43 represents a combination region require a combination of barrier protective sheath and of low-cycle bending fatigue and tensile overload. Accordingly, chemical disinfection in accordance with prudent manufactur- the local anesthetic needle likely fractured because of bending ers’ directions.151 deformation as it struck the ramus. Ductile rupture in metals results from shearing along planes Medication Errors that are oriented at 45 degrees to the tensile stress. Tensile The FDA has received more than 95,000 reports of medication “necking” results from multiple slipping deformations in all errors since the year 2000. Medication errors involve the wrong the 45-degree planes to the needle axis because of significant drug, an extra or wrong dose, omission of a drug, or adminis- overload. Final rupture results from a combination of bending tering a drug by the wrong route or at an incorrect time.190 and tension. Figure 29-44 shows the needle tip bent and Medication errors are often preventable.306 Two major blunted as it hit a hard object. No manufacturing defects were sources of errors in prescribing are poor penmanship and the found. Figure 29-45, A and B, shows SEM views of the fracture. use of error-prone abbreviations. Writing “1.0 mg” can be read Figure 29-45, C, is a SEM view of the needle fracture taken at as “10 mg” if the decimal point is not clearly visible. The FDA the hub side of the fracture. These illustrations demonstrate recommends that no trailing zeros be used when denoting why longer 25-gauge needles should be used for mandibular doses expressed as whole numbers and that preceding zeros be blocks rather than shorter 30-gauge needles.207 used whenever a decimal point is needed for a dose that must Preventable causes of a broken local anesthesia needle are be administered as a fraction of a whole number (e.g., 1 mg, as follows207: 0.5 mg). Recent drug label changes can be readily accessed on ◆ Use of a 30-gauge needle for mandibular block the National Library of Medicine’s DailyMed website. ◆ Bending needle ◆ Insertion of needle to the hub Posttrauma Therapy ◆ Multiple use of the same needle The reader is referred to Chapter 20 for a full discussion of how to treat and manage patients who have sustained a trau- Sterilization matic injury. The nonsurgical use of the dental unit water supply should comply with the Environmental Protection Agency regulatory standard of less than 500 colony-forming units (CFU)/mL. Millennium Management CDC guidelines require sterile water or sterile solutions for of Endodontic Advances all surgical procedures.188 Disinfected water from handpieces Technologic advances are touted as ideal endodontics. or ultrasonic devices is no longer acceptable as a water coolant However, the standard of care is a minimal standard of CHAPTER 29 Endodontic Records and Legal Responsibilities e183

B C

FIG. 29-45 A, Needle fracture with scanning electron microscopy (SEM). B, Needle fracture, side view (SEM). C, Needle fracture at high SEM magnification. reasonably acceptable practice rather than the perfect ideal. The reasonable and prudent clinician is not required to know and use all the latest technologic advances in endodontics. On the other hand, the reasonable and prudent clinician must keep current with available advances that are generally accepted and proved by research. Microsurgical endodontics is an example of improved endodontic technology; use of magnifying loupes or similar devices may prove inadequate for apical surgery or fractured instrument retrieval compared with microscopes. Therefore, the clinician should adopt proven improvements in the endodontic field. Three- dimensional reconstruction of mandibles can be accomplished with cone-beam volumetric tomography to accurately locate the course of the IANC or mental foramen. Figure 29-46 shows an example of volumetric tomography usage for implant placement or apical surgery. If studies demonstrate significantly superior results for some alternative to surgical endodontics, the informed consent FIG. 29-46 Cone-beam computed tomography usage for implant place- standard of care may require that the patient be advised of the ment or apical surgery. alternative technique, even if it is more expensive. There may be more than one path to success. So long as the clinician uses Clinicians should evaluate the quality of peer-reviewed reasonably acceptable techniques and informs the patient of research articles for new products rather than accepting them reasonable alternatives, the standard of care is met, but clini- at face value. A case report amounts to no more than the cians should remember that today’s surgical advance may be author’s personal experience with one patient. Some authors tomorrow’s retreat. For example, temporomandibular joint report a “series” of patients if there are only two patients. A (TMJ) implants were inadequately tested technology on loading brash conclusion is to state something has occurred time and joints and proved virtually 100% disastrous.102,258 Microscopic time again if similar findings were observed with only two or apical surgery has gained general acceptance, is performed by three patients. Valid scientific principles mandate that other the majority of endodontists, and represents the current stan- competent scientists duplicating a particular research protocol dard of care.15,76,166,183 can replicate a test result. If research cannot be duplicated, e184 PART III Expanded Clinical Topics

sweeping conclusions should not be made. Comparative effec- an existing drug. A fair comparison would contrast the new tiveness studies should demonstrate not only better results drug with an older FDA-approved drug at equivalent doses. As than a placebo but also relatively better results compared the former editor for two decades of the New England Journal with similar marketed products tested under similar clinical of Medicine concluded in a 2008 JAMA article, “It is naive to conditions. assume bias is only a matter of a few isolated instances. It permeates the entire system. Physicians can no longer rely on Statistical Research the medical literature for valid and reliable information.”27 Statistical research conclusions may vary, because research pro- Prudent clinicians do not adopt every new technology. tocols may not similarly control variables of population groups Before adoption, such technology must have demonstrated studied.137,253 Discrepancies occur even within trials or among benefits with acceptable levels of risk. It must also beade- large trials. Meta-analyses of multicenter randomized con- quately tested, with sufficient numbers of test subjects, over a trolled trials aim to reduce bias by estimating the effect size significant length of time. Because manufacturers too often for outcomes and adverse effects after pooling all qualified rush their products to market, newer products may not meet research studies. This approach will not assist if the supporting this criterion. Therefore, except for breakthrough technologic randomized controlled trials are derived from confounded data changes, a clinician will not likely be judged negligent for from heterogeneous trials. Such research results represent an failure to adopt each latest device or technique. However, clini- estimate of the average difference in the responses of the tested cians must keep in mind that in the information technology treatment groups. These differences in results of different industry, 1 year is considered several generations, if not an centers from various test groups may reflect important distinc- eternity.44,123 In general, do not be the first or the last to adopt tions in the clinical conditions of enrolled research subjects. improved technology. Such distinctions may help identify subgroups of patients The standard of care usually does not mandate incorpora- harmed by the researched product, although on average, treat- tion of every new technology. However, in those states with ment has an overall benefit.153 informed consent laws that are based on what a prudent patient Because most research is currently controlled and spon- would want to know rather than what prudent clinicians sored by companies marketing a product, only favorable should do, the patient may argue that an alternative technology studies are usually submitted for publication. Literature reviews or technique used by a different clinician would have been are prone to publication bias because journal editors are more chosen had the clinician provided the patient with such infor- likely to publish favorable than unfavorable conclusions. The mation. Microscopic endodontics for broken file retrieval most important use of literature review articles is to develop and CBCT to aid apical surgeries and implant placement are research questions that ultimately must be tested using a ran- pertinent examples of what a reasonable patient would wish domized controlled trial. Studies other than randomized con- to know.75,157 trolled trials were the basis for prescribing hormone replacement therapy to millions of women to prevent cardiovascular disease. Other Clinicians’ Substandard Treatment A randomized controlled trial of this therapy was terminated Clinicians should not be overly protective of blatant examples early because increases in cardiovascular disease and breast of another clinician’s substandard dental treatment. On discov- cancer were discovered. ery of apparent negligent treatment by a previous clinician, the Before the 1980s, pharmaceutical industry grants to aca- clinician should consider investigation. Begin by obtaining demic institutions to fund studies by faculty members gave the patient’s written authorization for transfer of a copy of the investigators total responsibility to design the study, analyze previous clinician’s records, including radiographs. If negli- and interpret the data, write the papers, and decide where and gence is still suspected after reviewing the records, the clinician how to report the results. Neither the investigators nor should consider talking with the previous clinician to learn the their institutions had other financial connections to sponsor- circumstances of what occurred during the patient’s past treating companies. Drug companies now finance most clinical ment (after obtaining the patient’s written consent pursuant research on prescription drugs. There is mounting evidence to HIPAA). that research is skewed to make drugs look better and safer On discovery of a gross violation of the standard of care, a than research findings warrant.* clinician has an ethical responsibility to report the matter to Negative results are often not published. For example, a the local dental society, peer review, dental licensing board, or study of 74 clinical trials of antidepressants found that 37 of agency.18,122 If the patient was misinformed and later discovers 38 positive studies were published. Conversely, of 36 negative patently obvious negligent treatment, the subsequent clinician studies, 33 were either not published or published in a form could arguably be sued as a co-conspirator to fraudulent con- that conveyed a positive outcome.316 cealment of the prior clinician’s neglect. Published clinical research is too often biased, usually by designing the studies in ways that will almost inevitably yield Peer Review favorable results for the sponsor.216,337 For example, compara- If despite good rapport, candid disclosure, and an offer to pay tive drugs may be administered at a too-low dose so that the corrective medical or surgical bills the patient is still unsatis- sponsor’s drug looks more effective, or at a too-high dose so fied, the clinician should consider referring the patient to peer that the sponsor’s drug has relatively fewer adverse effects. Bias review. Peer-review committees award damages for out-of- also takes the form of comparing a new drug with a placebo pocket losses but not for pain and suffering or lost wages. when the relevant research question is how it compares with Consequently, even if the committee’s decision is adverse to the clinician, the damage award will probably be less than a jury’s verdict. If peer review finds for the clinician, the patient *References 27, 113, 190, 196, 269, 274, 284, 295, 316, 337. may be discouraged from proceeding further with litigation. CHAPTER 29 Endodontic Records and Legal Responsibilities e185

taining the confidentiality of patient health histories, because these histories may document AIDS, venereal disease, or other socially stigmatizing diseases. If a patient requests that the clinician not inform the staff of his or her HIV status, the clinician should refuse to treat that patient. This information is essential to staff members who may come in contact with the infection.48 An accidental needle stick with HIV-infected blood, which carries a risk of approximately 1 in 250 chances of seroconversion, may occur. Current medical protocol includes prophylactic administration of zid- ovudine (AZT), either to prevent or to slow the manifestation of AIDS from a deep, penetrating, accidental needle-stick exposure. Although a treating clinician risks devastating a dental practice by informing patients that the clinician has contracted AIDS, the legal risk of not informing patients is much greater. The health care provider may be required to advise patients of positive HIV test results under the doctrine of informed consent (i.e., advising of a known risk of harm from accidental expo- FIG. 29-47 Dental auxiliary confidentiality agreement. sure).88 Even if an uninformed patient never contracts AIDS, in those states that use a reasonable patient standard for disclosure of material risks of treatment (which could include Peer review proceedings, including the committee’s decision, accidental direct contact such as an unintended cut or needle are not admissible in court.61 Insurance carriers usually honor stick), the patient may decide to bring an action for intentional and pay a peer-review committee award, because a fair adjudi- concealment as a variant of informed consent and seek to cation of the merits has been determined; the award is usually recover emotional distress and punitive damages. Conversely, less than a jury would award. Also defense costs, including patients may be legally liable for intentionally misrepresenting attorney’s fees, are saved with peer review. their health history regarding their HIV status.51

Human Immunodeficiency Virus SUMMARY and Endodontics If the clinician performs endodontics within the standard of A clinician may not ethically refuse to treat an HIV-seropositive care as described in this chapter, there should be little concern patient solely because of such diagnosis.82 Although in the that a lawsuit for professional negligence will be successful. 1980s, no federal law had clearly extended the protection of Prophylactic measures suggested in this chapter should lessen the handicapped laws to patients with AIDS, federal congres- the likelihood of litigation by reducing, if not eliminating, sional action in 1990 extended this protection to the dental avoidable risks associated with endodontic care. office setting with the passage of the Americans with Disabili- Both the patient and the clinician benefit from risk reduc- ties Act.23 Many states already offer additional protection under tion.119 To do it wrong does not take long, but it is far better state law.59,83 for the clinician to take the extra precautionary time to do it Confidentiality for patients disclosing their HIV status is right. We are in a profession that deserves the public’s trust, important. An inadvertent disclosure to an insurance carrier or but only if that trust is earned. Clinicians deservedly earn to other third parties without any need to know may result in public trust by providing safe and excellent quality patient cancellation of the patient’s health, disability, or life insurance. care. The best prophylaxis against being sued is to make pro- This cancellation could result in a claim against the clinician tecting the patient’s best interest our paramount goal. No whose office disclosed the information without authorization. matter how many others do it wrong, this never makes it right. Therefore, employees should sign the confidentiality agree- Our ethical and legal obligation adheres to the identical ment shown in Figure 29-47. In signing this agreement, the bedrock principle, which is service to our patients first and staff may be alerted to the seriousness and importance of main- foremost.

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Key Principles of Endodontic Practice Management

ROGER P. LEVIN

CHAPTER OUTLINE Endodontic Management Systems Staff Training and Development Systems Design Scheduling Management Customer Service Vision Marketing Mission Endodontic Referral Marketing Goal Setting Leadership Target Setting The Endodontic Leader Key Production Indicators Summary

Operating a successful endodontic practice requires both Effective practice management allows endodontists to provide excellent clinical and management skills (Fig. 30-1). Endodon- optimal patient care while creating a highly productive, low- tists are extremely well trained in their clinical specialty, but stress office environment. The design and implementation of most do not receive extensive business training prior to becom- effective practice management and marketing systems enables ing a practice owner. This scenario is beginning to change as endodontists to operate their practices as successful businesses more in the dental profession recognize the value of practice with steady growth and maximum efficiency. Endodontists management skills and the role they play in an endodontist’s who can combine excellent clinical skills with strong practice ability to have a successful and rewarding career. management skills will experience greater practice success Endodontists who possess management skills are better (see Fig. 30-1). positioned to handle the demands of operating an endodontic practice—a business that can generate significant revenue. His- torically, there was a time when endodontists could enter prac- ENDODONTIC MANAGEMENT SYSTEMS tice without strong business skills and enjoy a long, prosperous Written, documented systems are the basic foundation for all career, but the business side of endodontics has become more successful operations within an endodontic practice. Step-by- complicated due to the difficult economy. step, reproducible systems enable a practice to consistently Young endodontists are leaving dental school and resi- operate and be successful as both a provider of patient care and dency with far more debt than even a decade ago. The cost of a business enterprise. Documented systems reduce unneces- purchasing or opening an endodontic practice continues to sary stress and allow endodontists to remain chair-side so they rise. In addition, endodontists face increased competition can focus on providing exceptional quality of care. As each from other doctors who perform root canal treatments. The system is established, every step in that system must be clearly success of endodontic practices can also be affected by the documented and then implemented. Many endodontists fail to development of new clinical techniques or services. For establish efficient systems in the early years of a new practice, example, some doctors believe that dental implants represent and inefficient systems can hinder the practice’s growth, a better treatment option than root canals, depending on the increasing stress for the doctor and team. difficulty of saving the infected tooth. As dental implant pro- Endodontists should begin their careers by developing and cedures become easier and more common, this trend may implementing effective practice systems. This way, when an continue to grow. endodontic practice begins to grow, the office has a solid man- To meet these and other challenges, endodontists need to agement foundation in place to handle the growth with low supplement their clinical expertise with excellent practice stress as well as to reach more challenging goals. If the practice management skills. Practice management involves the use of waits until it becomes more established, there is less time to documented systems to achieve superior business results. design effective systems, and the endodontist often becomes

e191 e192 PART III Expanded Clinical Topics

to reflect on why one endodontic practice can be somuch more financially successful than another practice in similar circumstances. Assuming a sufficient patient flow, the answer always comes down to management systems. It is not about working harder or faster, but it is about creating systems that allow Excellent Endodontic Excellent practice the practice to operate at a specific production and profitabil- clinical skills practice success management skills ity level in a low-stress environment. Key systems and principles for effective endodontic management and marketing include these: 1. Vision 2. Mission 3. Goal setting 4. Target setting 5. Key production indicators FIG. 30-1 The keys to achieving practice management success. 6. Staff training and development 7. Scheduling less motivated to do so owing to an increasingly busy office 8. Customer service and other responsibilities in life. MANAGEMENT Systems Design New endodontic practice owners have an excellent opportu- Vision nity to design systems because the office is nowhere near its The first question endodontists should answer before opening capacity. This type of foresight sets the stage for practice growth or purchasing an endodontic practice is “What kind of end- in the years to come. However, systems should be evaluated odontic practice do I want to have?” This question requires the and updated throughout an endodontist’s career. It will be endodontist to take some time and identify a vision, which is necessary to replace most major endodontic practice systems a description of where the doctor wants the practice to be in on a 5-year cycle to maintain growth and profitability. The 3 years. Whereas some vision statements may reflect a longer reason is that practices regularly outgrow their systems as a period, this shorter time frame works well for most endodon- result of changes in staff, equipment, technologies, referral tists because it is difficult to predict changes in dentistry, the relationships, and the economy. economy, and other events more than 3 years into the future. Immersed in the day-to-day pressures of running the prac- In addition, after 3 years, it is time for the doctor to review tice, evaluating systems can be difficult. Therefore, endodontic what has been accomplished and possibly establish a new practices are well advised to seek outside experts to help them vision for the practice. determine the “state of the practice.” An in-office practice To create a vision statement, the following questions should analysis should include the following: be answered: ♦ First-hand observations of the team and practice ♦ What location is most suitable for the practice? operations ♦ What size should the practice be in 3 years? ♦ Interviews with the doctor and key team members ♦ Does the doctor want to be in solo practice or multidoctor ♦ In-depth assessment of all key production indicators practice? ♦ Thorough evaluation of all practice systems, physical layout, ♦ What working days and hours will be satisfactory for the and patient flow practice? Through such careful analysis, it is possible to accurately deter- ♦ What services will the practice provide? mine the effectiveness of practice systems that are in place. ♦ Is the intent to have only one practice or to have more than Systems should be designed based on the specific charac- one location? teristics of each practice. Areas to be considered include the These are just examples of questions that can stimulate the following: design of a vision statement. ♦ Days of operation A vision statement clearly articulates where the practice is ♦ Hours of operation going. The length of a vision statement can vary between a ♦ Number of staff short, single paragraph and several paragraphs. It is probably ♦ Number of patients counterproductive to have a multipage vision statement; it will ♦ Number of true emergencies be difficult for both the endodontist and the staff to fully grasp ♦ Average daily patient flow such a lengthy and complex vision. ♦ Types of procedures offered The vision guides the long-term development and growth ♦ Number of chairs of the endo practice. Once the vision statement has been Effective management systems can make the difference created, it should be shared with the staff on a regular basis. between a successful endo practice and a highly successful Good leaders always communicate their vision to their staff. endodontic practice. Many endodontists cannot fathom how When team members understand where the practice is headed, they could see any more patients, produce any more revenue, they are empowered to help the endodontist achieve his or her or work any harder. Yet, there exist similar practices that have vision. Sharing the vision inspires commitment and participa- much higher production in the same number of days per tion in achieving the vision. The following are two examples week with the same number of staff. It is always interesting of vision statements. CHAPTER 30 Key Principles of Endodontic Practice Management e193

Short Vision Statement the vision and mission realities. Goal setting is a step-by-step In 3 years, we will be the leading endodontic practice in the methodology that leads to the achievement of the overall area. We will be known for exceptional quality of care and vision. To be effective, a goal must be outstanding customer service. We will grow by 15% per year. 1. Written Our staff is motivated and committed to continuously improv- 2. Deadline driven ing our management systems and to a lifelong learning process. 3. Measurable We strive to meet or exceed our goals in a low-stress work Goals that lack these three characteristics cannot be considered environment. goals and are much less likely to be achieved. Be sure that all Long Vision Statement of the goals are aligned with the practice’s vision and mission to achieve the desired results. In 3 years, we will be known in the community for being the most comprehensive and skilled endodontic practice in the The pace of today’s endodontic practice forces many doctors area, offering our patients an atmosphere of compassion and to focus on day-to-day operations. In doing so, they cannot see comfort. the big picture until many years have gone by. Goal setting and Our excellent management skills create an environment that regular goal reviews can help endodontists manage their is low-stress and productive. We consistently meet our produc- practice—instead of being managed by it. tion goals without creating a rushed atmosphere, and our days Far more than just a motivational concept, goal setting acts are fulfilling. as a timeline, benchmark, and directional process to achieve We provide exceptional customer service that consistently the vision and mission. A vision or mission without specific generates spontaneous, positive comments. Team members goals is merely an idea. Endodontists who set goals are much have a clear understanding of their roles and responsibilities. more likely to succeed. We have developed practice systems that foster a sense of fulfill- ment and accomplishment for all. In year 3, we will engage an associate doctor. Target Setting Targets measure whether you are accomplishing your short- term and long-term goals. Each year, endodontists need to set Mission 12 to 15 specific targets to be achieved for the next year. This Once the vision statement has been created, the next step is helps motivate the team to reach goals and drive practice the development of a mission statement. growth. Targets should be reviewed on a weekly basis. For Whereas the vision statement is about where the practice will example, if the practice is only collecting 85% of its fees, be in the future, the mission statement is focused on where the then the office needs to implement more effective financial practice is today. procedures to reach the 99% target (if that is the target that Once again, a strong leader has a clear practice mission and has been set). shares it with the team. Because of the similar services provided Sample endodontic targets to achieve include the by endodontic practices, many mission statements resemble following: one another—they talk about quality, patient care, practice ♦ Increase practice production by 15% in the next 12 months services, and customer satisfaction. It is not important to have ♦ Ensure that 98% of all nonemergency patients are scheduled a mission that differentiates one practice from another, but it at all times is essential to have a mission that reflects the doctor’s true ♦ Collect 99% of all money owed to the practice vision. Here is an example of a mission statement: ♦ Maintain a less than 1% no-show/last-minute cancellation rate Our endodontic practice is dedicated to delivering quality care to meet the endodontic needs of our patients and referring Key Production Indicators doctors. We provide exceptional clinical care and customer Without data, an endo practice cannot be well managed. service in a comfortable, relaxed environment. To obtain a clear picture of current and potential practice performance, practice goals must be monitored and measured. One way to keep the mission statement on everyone’s mind Key production indicators (KPIs) provide an accurate assess- is to display it prominently in several places throughout the ment of the practice’s most critical functions, including the office, as well as on the practice’s website. The most powerful following: reason for displaying the mission statement is to reinforce to ♦ Production the team that the mission is a living document that guides the ♦ Collections practice. An added benefit of displaying the mission statement ♦ Profit is the opportunity to let patients know that they are important ♦ Overhead to the practice. ♦ New patients The endodontist should refer to the mission statement on ♦ Accounts receivable a regular basis. Reinforcing the mission during meetings helps ♦ Number of re-treats versus initial root canal treatments staff members focus on why the practice exists and the differ- ♦ Insurance percentages ence the team is trying to make in the lives of patients. ♦ Production per hour These KPIs offer endodontists a starting point for analyzing Goal Setting their practices. Once the information has been collected, Goal setting represents one of the most important business weekly measurement and analysis are necessary. Although this activities for endodontists. It is critical to achieving success in may sound arduous, a weekly review should take only a few a doctor’s professional and personal life. Once a vision and minutes. Such frequent analyses can bring substantial benefits mission are established, annual goals are the method to make to the practice. e194 PART III Expanded Clinical Topics

Evaluating KPIs every week allows endodontists to rapidly its impact on all other major systems. If the schedule is inte- identify trends or performance deviations that may be difficult grated properly with all other endodontic management systems, to discern otherwise. With accurate practice data, endodontists the practice has the best opportunity to achieve the endodon- are then able to take appropriate actions. tist’s targets. Schedules are created to achieve specific practice production in Staff Training and Development a low-stress environment. This means that an endodontic prac- Establishing practice systems will only be effective if team tice must establish a target for annual production and design members understand their roles in making those systems the schedule accordingly. Each year, endodontic practices work. Training the endodontic team begins with the develop- should calculate the desired level of growth and create a sched- ment of job descriptions that list the skills, responsibilities, and ule that allows for that growth. The greatest challenge to accountabilities for each staff position. increasing production is scheduling inefficiencies that make it Bear in mind that the majority of staff will be hired without all but impossible for the practice to grow. previous endodontic or dental experience and must be trained The following principles are essential when designing the on the job. Training is specific to each position so that all team ideal schedule for any endo office. members can perform their duties as independently and effectively as possible. During training, it is critical that practices Schedule for Production document training policies and procedures so they can be Design the schedule to achieve a specific production target. clearly communicated to new staff and regularly reinforced Endodontic practices are typically capable of growing between with established team members. 5% and 15% annually. Less than 4% growth represents moving One frequent problem is that many staff members fail to onto a plateau. There are endodontic practices that can grow fully understand their job responsibilities and are not held by as much as 20% to 25% in a single year as optimal systems accountable for their performance. As a result, the endodontist are implemented. will continue to handle numerous responsibilities that should Scheduling is a quantitative and mathematical activity be performed by other team members. because time is quantitative and therefore measurable. The Although this type of behavior may be common in the early schedule should answer questions like these: How many root stages of an endo practice, endodontists who become effective canals will we need to perform this year? Will those numbers leaders learn how to delegate appropriate tasks to the team. allow for the production goal to be achieved? Benchmark these The goal for all endodontists should be to spend 98% of their production goals against the hours and days per week the workday involved in direct patient care or communication practice is available for patient care, and adjust the schedule with referring doctors. To reach this goal, it is recommended accordingly. that endodontists make a list of all activities they perform and which of those responsibilities can be assigned to the staff. This Set the Daily Production Target exercise will enable the endodontist to clearly identify which Setting the daily goal is a reflection of the annual production activities should be handled by the doctor only and which target. To determine the daily goal, simply take the annual should be delegated to the team. production goal and divide it by the number of days the prac- Delegation empowers the team to take ownership of their tice will operate that year. Then build the schedule around this roles in contributing to practice success. The concept involves key number. Front desk personnel should become aware that giving responsibilities to staff members so that endodontists the top practice management priority is to achieve the daily can concentrate on what they do best. Without delegation, goal. By implementing an excellent scheduling system, they endodontists often carry out numerous responsibilities that will have a far greater chance of successfully accomplishing can easily be performed by others. To spend more time in direct this task. patient care, endodontists must delegate appropriate responsibilities to specific staff members. In addition, the team should Perform Procedural Time Studies be cross-trained on systems to cover for any illnesses, vaca- Many endodontic practices are unrealistic about how much tions, or turnover. time they actually need for procedures. One common example Once all team members have achieved a high level of exper- is for root canals to simply be scheduled for one set length of tise and independence, the endodontic practice can operate at time, regardless of the level of complexity involved. Performing peak performance. Efficiency, professional satisfaction, and “procedural time studies” is recommended to determine the quality of care steadily climb to maximum levels. At this stage, exact amount of time needed for each appointment. endodontists trust their teams to effectively perform their During procedural time studies, each type of treatment per- duties with minimal oversight. Best of all, doctors can focus formed by the office should be measured approximately 10 on providing exceptional patient care without distractions and times to develop an average procedure time. Once these studies unnecessary stress. are performed and the schedule is updated, most endodontists In highly successful endodontic practices, the doctor will usually be able to increase their endodontic workload by focuses 98% of working hours strictly on patient care, inter- using time more efficiently. disciplinary treatment, and referring-doctor communication. Young endodontists should perform procedural time studies These practices will typically reach 90% to 100% of their pro- once a year for the first 5 years they are in practice. After that, duction potential. studies can be conducted at less frequent intervals (every 3 to 5 years) to evaluate whether the endodontist has become faster Scheduling or more efficient in terms of experience, technique, or the use Making changes in the area of practice management should of new technologies in the practice. Procedural time studies begin with a thorough evaluation of the schedule because of play a critical role in building an effective and accurate CHAPTER 30 Key Principles of Endodontic Practice Management e195 schedule, which directly affects the success of the endodontic emergencies, and these patients do not need to be seen practice. immediately. Scripting and training can help staff members elicit specific information from patients about Create the Ideal Day the level of discomfort (mild tenderness versus extreme The schedule should be designed to perform larger and more pain) while providing excellent customer service. complex appointments in the morning whenever possible. • If it is a true emergency, bring the patient in immediately, This can be extremely challenging owing to the number of but still evaluate the schedule to facilitate the overall emergencies endodontists see during a normal day. By schedul- process. Highly systemized endodontic practices use ing larger procedures in the morning, practices can take advan- trained staff to evaluate emergency situations as much as tage of the high energy level for both the endodontist and the possible, including preliminary assessment and x-rays. team earlier in the day. Of course, emergencies will continue • If the emergency call does not constitute a true emer- to occur, but effectively managing other appointments will gency, it is important to use effective scripting to move better position the practice to handle end-of-day emergencies. the patient into an emergency time slot that will prevent Other recommendations for creating the ideal day include the the appointment from disrupting the entire schedule. following: This approach can be used with either a referring office ♦ Handle less complex cases in the early afternoon. or a patient. ♦ Perform consults and diagnoses in the midafternoon. • If the practice notices ongoing disruptions from emer- ♦ Schedule all minor procedures, such as posttreatment evalu- gencies, it should reevaluate the emergency policy and ations, for the end of the day. scripting to create a more effective methodology. Many Basically, this means that the more difficult or larger cases endodontic practices tell every emergency patient to will occur in the morning when the doctor and team are fresh. come in immediately. The problem arises from mistaking As the day goes forward, the doctor and staff have the opportu- high-level customer service with providing immediate nity to work on less complex cases, such as second visits and treatment. It is much more effective to manage the emer- patient consultations, with all minor procedures taking place at gency patient into a time slot reserved for emergencies, the end of the day. A highly organized schedule will allow for unless the patient is experiencing an endodontic problem increased productivity and higher profitability while decreasing that necessitates immediate treatment. Staff training is stress for the endodontist and the team throughout the day. critical for effectively managing emergencies while providing quality customer service. Manage Emergencies Scheduling is the single most important system, because it No discussion of endodontic scheduling would be complete integrates with all other systems. When an effective scheduling without focusing on emergency management. Obviously, system has been established and properly implemented, the emergency procedures are a frequent occurrence in endodon- practice will immediately see an increase in productivity and tic practices. Managing emergencies well requires a com a decrease in stress. Most stress in endodontic practices is bination of referring-doctor management, setting patient based on poor scheduling methods that overwhelm the doctor expectations, and effective scheduling. The result will be a and team and lower customer service. Even though the endo- highly productive, satisfying professional environment for any dontist and team are actually working harder, profitability will endodontic practice. be lower. An efficient schedule enables the endodontic practice The first step in managing emergencies is to develop a sched- to provide a high level of care and customer service to all ule that allows some flexibility. It does not benefit the practice patients. to create a schedule that is 100% maximized without accounting for emergencies. Instead, analyze how many genuine emergen- Customer Service cies occur on an average day, and then leave time for that number Customer service today means much more than just “being of emergencies in the schedule. Many high-level endodontic nice” to patients. It is a system focused on managing the practices will schedule only 80% of their day, leaving time slots patient experience from the initial referral to treatment to for emergencies. The key is to not ignore the time slots and postoperative care. Outstanding customer service is critical to invite every emergency patient to visit the office immediately, exceeding patient expectations and building strong relation- but to manage each situation appropriately. ships with referring doctors. For example, a patient who is in mild discomfort calls at 10 The majority of endodontic patients are referred to the a.m. The practice does not have an opening until noon. If the practice by general dentists. The growth of the endodontic patient is allowed to come in immediately, the office feels a practice therefore depends on the satisfaction and confidence need to work the patient into the schedule, not only causing of referring doctors. General dentists want to know that their stress for the doctor and team but possibly forcing already- patients’ expectations, as well as their own, are being met. scheduled patients to wait longer than expected. If the practice When patients receive excellent clinical treatment and superior instead schedules the patient in an emergency time slot, there customer service, they are likely to provide positive feedback is a much greater opportunity to maintain excellent flow for when returning to their general dentist. Positive feedback from the day and create a positive customer service experience for patients reinforces the dentist’s confidence in the endodontist every patient. The main point is to provide optimal care and and leads to continuing referrals. exceptional customer service without disrupting the daily Developing a customer service system is more complex than schedule. simply telling the staff to be nice to patients and referral The keys to effective emergency management are as follows: sources. A customer service system requires that patients • Evaluate each call from a patient or referring office to consistently receive the same level of responsiveness, caring, determine the level of emergency. Many calls are not true and concern from every member of the endodontic practice. e196 PART III Expanded Clinical Topics

Consistency and quality are at the core of a practice’s customer that must be carried out in a systemized manner to achieve service system. desired results. Although the patient’s time in the endodontic practice may be limited, the endodontist must realize that the patient will Consistency be returning to the referral source and sharing his or her expe- Inconsistent referral marketing leads to inconsistent referrals. rience with the referring doctor or the clinician’s staff. The The typical pattern is that if the practice has slowed down, the patient will also share information about the experience with endodontist will attempt to increase referral marketing until family, friends, and others. Negative word-of-mouth descrip- positive results are generated. Once referrals increase, then tions about the office will obviously hurt the endodontic prac- referral marketing slows down or ceases altogether. This stop- tice’s reputation within the community. and-start approach to marketing leaves practices more suscep- Patients want to believe they are the practice’s only priority tible to the effects of difficult economic conditions, increased when they come in for their appointments. Endodontic prac- competition, and a host of other factors. A consistent referral tices with excellent customer service strive to meet this expec- marketing program is the solution to numerous challenges that tation. If a practice fails to return phone calls quickly, is face endodontic practices. running late when patients arrive, or does not seem prepared Referral marketing should be viewed as a mandatory part of for appointments, patient confidence and trust disappears, as the practice’s systems. Referral marketing has two major does the patient’s perception of quality care. components: Endodontic practices should manage expectations by 1. Establishing strong relationships with referring doctors making everything about the patient’s treatment plan value (Fig. 30-2) based. Do patients fully understand the value of their treatment 2. Designing a consistent marketing program that reaches the plans? Do they know exactly what the treatment entails, what doctor’s targeted demographic the fees are, and why the treatment must be done? Does the patient know the projected outcome? All these questions must Establishing Strong Relationships with be satisfactorily answered before treatment starts. Referring Doctors Endodontic practices have an opportunity to exceed expec- Referral marketing differs from traditional marketing because tations when the following occurs: it is relationship driven. A successful referral marketing ♦ There is complete understanding about why, how, and when program requires positive and consistent contact with referring endodontic treatment will take place doctors and offices. It is an investment in time and energy, but ♦ Patients have realistic expectations of outcomes when done correctly it can generate a steady influx of referred ♦ Patients and referring doctors receive accurate and timely patients from dentists and other doctors. Communication is information about the treatment process critical to establishing and maintaining strong relationships ♦ The practice has timely follow-up posttreatment communi- with referring dentists and their teams. Sharing information cation with patients about mutual patients throughout the treatment process creates a sense of partnership and teamwork that is essential to rela- MARKETING tionship building. To strengthen relationships with their referral base, endodontists should meet regularly (e.g., quarterly) Endodontic Referral Marketing with their referring doctors. These meetings can be formal or The business model of an endodontic practice is based on informal occasions, but they provide an opportunity to enhance receiving referrals from general dentists and other doctors. both the treatment process and the referral relationship. There will certainly be the occasional patient who selects an endodontic practice through telephone directories, Internet, Designing a Consistent Marketing Program social media, or recommendation from a friend, but the major- Building a strong relationship with referring doctors requires ity of endodontic patients will be referred by other doctors. For more than one or two conversations or meetings a year. By endodontic practices to reach their true production and profit- implementing a series of consistent, ongoing marketing strate- ability potential, an effective referral marketing program should gies that reach referring doctors, endodontists create greater be in place. There are major challenges with implementing a awareness for their practices and services while building and referral marketing program. maintaining referral relationships. Referral marketing strategies are selected from areas such as professional relationship, Expertise clinical education, social activities, and patient satisfaction. For Referral marketing is a specialized form of marketing. Endo- example, hosting a practice management seminar is a “profes- dontists are trained doctors with little to no experience or sional relationship” strategy, and attending a sporting event expertise in this type of marketing; most endodontists typically with a referring doctor is considered a “social activity” strategy. learn about referral marketing through trial and error. This An effective referral marketing program encompasses multiple process can be time consuming and costly in terms of missed strategies, resulting in stronger relationships with referring opportunities. doctors and their teams. The more referrals an endodontist receives, the greater potential for long-term growth and prac- Time tice success. It is not unusual for endodontists to work 8 hours a day highly focused on providing patient care and managing the practice, with little time to think about referral marketing. LEADERSHIP This is problematic because effective referral marketing Leaders possess many skills, qualities, and attributes that are involves not a few sporadic activities but a complete program the result of learning, experience, and self-motivation. Many CHAPTER 30 Key Principles of Endodontic Practice Management e197

Doctor A Doctor B

Referring doctors Referring doctors

Patients Patients

FIG. 30-2 The impact of referral marketing. Doctor A does not have a formal referral marketing program in place. Doctor B does have a formal referral marketing program in place. The results are dramatic. Doctor B has many more referring doctors, who refer more patients for treatment. people have great ideas or vision, but true leaders are able to Interpersonal Communication implement those ideas or carry out the steps necessary to Interpersonal skills are the foundation of leadership. Endodon- achieve predetermined goals. They have the ability to inspire tists work with a small group of people in a fairly limited space. others to do their best. The most successful endodontic prac- Good interpersonal skills are essential for a smoothly function- tices are guided by strong leaders. ing office environment. In business, there are many successful Becoming an excellent leader starts with the desire to have “tough” bosses. Even though they may be disliked, they are an outstanding practice. Most endodontists are highly moti- respected. However, being tough or inflexible is not always the vated to be excellent clinicians. Endodontic continuing educa- best strategy, especially in dentistry. Few endodontists can be tion is focused mainly on clinical topics, which is appropriate, tough leaders in a very small office environment and still expect given that doctors have an obligation to provide the best pos- to have happy team members and a successful practice. sible care to patients. This makes it even more important for The best practice leaders can motivate their staff, accom- endodontists to seek out opportunities to develop leadership, plish goals, and earn the respect of team members. Regular business management, and marketing skills. morning meetings and monthly staff meetings provide excellent opportunities to communicate with the team, increase The Endodontic Leader awareness of practice challenges and goals, and build stronger As practice owners, endodontists are automatically viewed as interpersonal relationships with team members. leaders by team members. The more leadership skills endodontists master, the better leaders they become. Though not an Decision Making exhaustive list, the following leadership skills are critical for As the CEOs of their practices, endodontists must make busi- endodontists. ness decisions. There are many people who do not progress in e198 PART III Expanded Clinical Topics business simply because they vacillate between two choices and fail to make a decision in a timely manner. No matter what the issue, excellent leaders make decisions and trust their instincts, based on analysis, education, and experience. Why? Strong leaders believe in themselves and their knowledge. Leadership They are confident that they have the ability to make decisions that are in their best interest and that of their teams. Referral Management Motivation marketing The ability to motivate is one of the most important leadership skills. By earning the trust and respect of the team, the endodontic leader is able to bring together the individuals to Customer Staff Scheduling achieve shared goals and move toward the practice vision. service training Many people are not self-motivated. Instead, some external force motivates them. In this case, the external force is the practice leader. Vision Mission Goals KPIs Pursuit of Knowledge Practice leaders are usually in constant pursuit of knowledge. FIG. 30-3 Key principles of endodontic practice management. They want to excel in the management of the endodontic practice and will read, listen, and learn as much as possible about the subject of practice management. Leaders are typically lifelong learners who do not seek knowledge sporadically but significant effect on how the team acts. The professionalism take advantage of opportunities to learn new ideas and strate- exhibited toward patients, the doctor’s attitude and interac- gies on an ongoing basis. tions with individual staff members—all of these behaviors send messages to the team. The team is looking to the endo- Teamwork dontist for guidance, and the best strategy is to serve as an An endodontic leader never works on his or her own. These effective role model. If the team is expected to show up on leaders rely on their team to help achieve practice goals. time, the endodontist cannot stroll in 15 minutes late every However, many people mistake the concept of being a leader day without causing resentment. Good leaders adhere to the with being a “ruler.” The “ruler” approach is not an effective rules others are expected to follow. one when working closely with a team whose performance is Leadership is a way of thinking and acting based on desire, tied to the ultimate success of the practice. Therefore, end- skills, training, and specific behaviors. Endodontists who are odontic leaders must remember that they are part of a group willing to develop leadership skills will inevitably build better dynamic. In fact, the practice leader is like the coach of a bas- teams with lower turnover and higher efficiency. ketball or football team. He or she creates a game plan, guides the team, and facilitates teamwork. SUMMARY Time Management Effective practice management involves management and Time is one of the leader’s most important assets. Endodontic referral marketing systems that enable an endodontic practice leaders must not only manage their own schedule but their to provide outstanding patient care while operating as a suc- team’s as well. However, good leaders do not micromanage cessful business enterprise (Fig. 30-3). The number one source their team. They educate staff members, provide guidance, set of practice stress is the lack of efficient systems. When an endo expectations, and hold the team accountable for the results. practice operates year after year without strong systems, the Successful leaders effectively and efficiently use their time, endodontist experiences increased stress and frustration. On creating positive outcomes for themselves, their teams, and the other hand, endodontists who implement documented, their practices. Good leaders also eliminate extraneous items high-performance systems enjoy greater satisfaction (and from their lives that take time away from achieving their goals. profitability) throughout their careers. Endodontics is a challenging and rewarding profession. Leading by Example With the right systems, team training, and leadership skills, The best way to earn the team’s respect is to “talk the talk and endodontists can achieve their vision and create a highly suc- walk the walk.” The way the endodontist behaves will have a cessful practice. Index

Page numbers followed by “f ” indicate figures, t“ ” indicate tables, and “b” indicate boxes.

A Access cavity preparation (Continued) Access cavity preparation (Continued) A fibers, 543-544, 543f, 543t, 548-549, 551 Micro-Openers, 146, 146f pulp chamber wall and flow inspection, AAE. See American Association of Endodontists ultrasonic unit and tips, 150, 150f 147 AAOS. See American Academy of Orthopaedic lingual surface for, 146, 146f removal of defective restorations and Surgeons magnification for, 147 caries before pulp chamber entry, A-beta fibers, 685, e1 mandibular incisors 146-147, 147f Abscess central, 183-185, 188f removal of unsupported tooth structure, acute apical, 30 lateral, 183-185, 188f 147 description of, 30, 614, 617f mandibular molars, 236f space adequacy evaluation for coronal pulpal necrosis with, 708-711 first, 193-199, 197f seal, 147 in apical periodontitis, 641-642, 642f second, 199, 200f tapering of cavity walls, 147 definition of, 641 mandibular premolars visualization of anatomy, 145 management of, 715-716 first, 155f, 185-192, 191f straight-line periapical, 642f second, 192-193, 194f in anterior teeth, 152, 153f swelling with, 710-711, 711f maxillary canines, 169, 172f-173f description of, 145, 145f Abutment teeth maxillary incisors in posterior teeth, 157, 158f endodontic disease of, 332, 332f central, 165, 167f-168f Accessory canals root-treated teeth used as, 506 lateral, 165-166, 170f apical, 414f survival rates for, 515 maxillary molars description of, 132-133, 286 Access cavity preparation first, 171f-172f, 175-177, 179f illustration of, 414f access cavity second, 177-183, 182f-183f in mandibular first molars, 133, 133f incisal wall of, 152 third, 183, 183f, 185f Acellular afibrillar cementum, 630 visual inspection of, 152-153 maxillary premolars Acetaminophen angulations that affect, 164 first, 169-173, 175f analgesic uses of, 117 anterior teeth, 151-153, 236f second, 173-175, 175f-176f, 179f nonsteroidal anti-inflammatory drugs and, coronal flaring of orifice, 152, 152f in metalloceramic crown, 159, 162, 162f 121 external outline form, 151, 151f with minimal or no clinical crown, 157-159 in pregnancy, 74 inadequate, 153f “mouse hole” effect, 156, 157f Acetylcholine, 557-558 lingual shoulder removal, 152, 152f objectives of, 145 Actinomyces, in periapical granuloma, 483f pulp chamber roof penetration and occlusal surface for, 146, 146f Activ GP, 292, 292f, 299 removal, 151-152, 151f posterior teeth, 237f Acute apical abscess, 30 restorative margin refinement and cervical dentin bulge removal, 156-157, description of, 30, 614, 617f smoothing, 153 158f pulpal necrosis with, 708-711 straight-line access determination, 152, coronal flaring of orifice, 156-157 Acute apical periodontitis, 638, e5 153f external outline form, 154, 154f-155f apical bone destruction in, 641 visual inspection of access cavity in, mandibular first premolars, 155f clinical features of, 641 152-153 pulp chamber roof penetration and description of, 638 in calcified canal teeth, 162-163, 163f-164f removal, 154, 156, 156f macrophages in, 639 cervical dentin bulge removal, 156-157, 158f restorative margin refinement and natural killer cells in, 639 challenging cases for, 157-165 smoothing, 157 outcomes of, 641-642 coronal, 335-336, 335f, 337f-338f straight-line access determination, 157, polymorphonuclear neutrophilic leukocytes in, coronal seal for, space adequacy evaluation 158f 638 for, 147 visual inspection of pulp chamber floor, Acute endodontic pathosis, 83f in crowded teeth, 163-165 157, 159f Acute inflammation, 475 errors in, 160f, 165, 166f-167f, 733f pulp chamber roof penetration and removal Adaptive immune response, 634-635, 636f, in heavily restored teeth, 159-162, 161f-162f in anterior teeth, 151-152, 151f 642-643 illumination for, 147 in posterior teeth, 154, 156, 156f Adaptive immunity, 633t, 634 inadequate pulpal irritation caused by, 585 Adaptive prior image constrained compressed in anterior teeth, 153f restorative margin refinement and sensing algorithms, 52 complications of, 362-363 smoothing A-delta fibers, 685-686, e1 instrumentation for in anterior teeth, 153 Adhesive systems, 844, e2 access cavity wall preparations for, 147 in posterior teeth, 157 Afferent neurons, 542 burs, 148-150, 148f-149f, 235f in rotated teeth, 163-165 Aging, pulp changes caused by, 566 description of, 240 steps involved in, 145-147 Air emphysema, 749-750, 749f-750f endodontic explorer, 150, 150f, 164f access cavity wall preparation, 147 Allergic reactions endodontic spoon, 150, 150f cementoenamel junction evaluation, to latex, 93-94 handpieces, 147-148 145-146, 145f to local anesthetics, 93-94 illumination, 147 lingual surface, 146, 146f sulfite-induced, 94 magnification, 147 occlusal tooth evaluation, 145-146 Allodynia, 550-551, 550t, 554, 693-694

877 878 INDEX

Allograft, 435t Anesthesia (Continued) Anterior teeth (Continued) Alloys indications for, 107 restorative margin refinement and nickel titanium, 219-222, 221f-222f mechanism of action, 107 smoothing, 153 of root canal instruments, 219-222, 222f onset of anesthesia, 108 straight-line access determination, 152, Alprazolam, for oral conscious sedation, 113 periodontal safety with, 108 153f Alternating wall contact points, 231 postoperative discomfort caused by, 108 visual inspection of access cavity in, Alveolar bone, 631 primary teeth safety with, 109 152-153 Alveolar nerve blocks pulpal safety with, 109 structurally compromised, 834 anterior middle superior, 103-104, 104f success of, 107 structurally sound, 830 inferior. See Inferior alveolar nerve block systemic effects of, 108 Antibiotics palatal–anterior superior, 103, 104f intraosseous bacterial resistance to, 718 Alveolar process, 631 alveolar mucosa injection of, 106 definition of, 718 Amalgam core, 826, 833t, 840f, 844 attached gingiva injection of, 106 description of, 119-120 Amalgam restorations, e10 bupivacaine for, 106 endodontic infections treated with, 717-719 American Academy of Oral Medicine, 71, 78 definition of, 104 overprescribing of, 119 American Academy of Orthopaedic Surgeons, 78 description of, 101 prophylactic administration of American Academy of Pediatric Dentistry, e1 discomfort associated with, 106 before periradicular surgery, 396, American Association of Endodontists duration of anesthesia with, 104, 105f, 402-404 Case Difficulty Assessment Form and 106 description of, 119 Guidelines, 707f, 708 endodontic uses of, 109-110 selection of, 718-719 description of, 73, 637 failure of, 105 systemic, 787 vertical root fracture criteria, 802 heart rate increase after, 106-107 Anticoagulants American Board of Endodontists, 637 injection pain with, 110 guidelines for, 73 American Society of Anesthesiologists injection site locations, 106 heparin, 397 Physical Status Classification system of, 71, lidocaine levels in plasma after, 107 novel oral, 397 72b for mandibular posterior teeth, 111 periradicular surgery in patients receiving, surgical risk system, 395-396 medical considerations for, 107 396-397 AMPA/kainate antagonists, 554 onset of anesthesia, 106 Antigen-presenting cells, 538-539, 634 Anachoresis, 601 perforator breakage with, 105-106 Antimicrobial nanoparticles, 265 Analgesics postoperative discomfort from, 107 Antiresorptive agent-induced osteonecrosis of flexible strategy for, 121f repeating of, 106 the jaw, 394-395 non-narcotic Stabident system for, 104, 105f Anxiety, 87 acetaminophen, 117 success with, 105 Apex locators, 237-238, 238f alternatives to, 117 X-Tip delivery system for, 104-106, 105f, Apexification contraindications for, 117 110 apical periodontitis treated with, 467 drug interactions with, 117, 117t intrapulpal, 581 bioceramic barrier, 770-773, 771f efficacy of, 116t local. See Local anesthesia/anesthetics calcium hydroxide for, 458, 770, 770f, 772f limitations of, 117 for mandibular anterior teeth, 112 dentinal wall reinforcement, 772 nonsteroidal anti-inflammatory drugs, for mandibular first molars, 99f disadvantages of, 458 114-115 for mandibular posterior teeth, 111, 113 hard tissue apical barrier, 770-773, overview of, 114-117 maxillary, 101-103, 102f 770f-772f types of, 115t for maxillary anterior teeth, 112 of immature teeth, 769-773, 770f-772f opioid for maxillary molars, 102f indications for, 458, 769 description of, 117-118, 118t for maxillary posterior teeth, 112 mineral trioxide aggregate, 462-464, 468, nonsteroidal anti-inflammatory drugs and, noncontinuous, 96 771f 121 pain satisfaction with, 110-111 Apical abscess pain management using, 719 for periapical surgery, 114 acute, 30 Anastomoses, root canal, 140 pulpal description of, 30, 614, 617f Anesthesia articaine for, 99 pulpal necrosis with, 708-711 for endodontics confirming of, 95, 95f chronic, 30, 646, 800-801 infiltrations, 109 inferior alveolar nerve block for, 96-97, Apical barrier intraligamentary, 110-111 97f calcium hydroxide for, 314 intrapulpal injection, 110-111 maxillary, 102-104 creation of, 770-773, 770f-772f local, 109-111 for pulpal necrosis teeth, 112 mineral trioxide aggregate as, 314, 314f, future directions for, 114 selective, 20 771f for incision and drainage procedures, summary of, 114 Apical constriction 113-114 Angiogenesis, in wound healing, 392-393 description of, 142, 142f, 285, 285f intraligamentary Anterior middle superior alveolar nerve block, localization of, 144 amount of solution delivered, 108 103-104, 104f root apex and, 143t anesthetic solutions for, 107 Anterior teeth. See also specific anterior teeth root canal procedure termination at, 144, avulsion after, 109 access cavity preparation in, 151-153, 238, 285, 286f back-pressure for, 107 236f Apical cysts, 647-649, 649f, 654 computer-controlled local anesthetic coronal flaring of orifice, 152, 152f Apical diameter, 238 delivery system for, 108, 108f, 110 external outline form, 151, 151f Apical foramen description of, 101 inadequate, 153f cementum extension into, 142 discomfort during, 108 lingual shoulder removal, 152, 152f description of, 142 duration of anesthesia with, 108 pulp chamber roof penetration and diameter of, 142 endodontic uses of, 110-111 removal, 151-152, 151f localization of, 144 INDEX 879

Apical foramen (Continued) Apical periodontitis (Continued) Apical periodontitis (Continued) in maxillary anterior teeth, 142-143 chronic factors that affect, 654-655 odontoblasts, 533 asymptomatic, 632-633 growth factors in, 653, 653t size of, 143t bacteria in, 624 periapical, 652-654 Apical granuloma, 642-646 cysts associated with, 647-649, 648f Apical pressure, 156 Apical infection, 632 inflammatory mediators in, 647 Apical pulpitis, 637-638 Apical inflammation, 632 nerve fibers in, 646f Apical root resorption, 237 Apical lesion, 327f clinical features of, 641 Apical surgery Apical papilla clinical findings, 635 nonsurgical retreatment versus, 334 anatomy of, 449-450, 450f cone beam computed tomography diagnosis periapical healing following, 482t, 519t-520t, stem cells of, 449-451, 450f, 460 of, 328-329 521f Apical pathosis, 211f definition of, 599 posttreatment disease after, 334f Apical periodontitis development of, 637-638 in silver point cases, 361, 363f abscess in, 641-642, 642f diabetes mellitus and, 650-652 Apical tissue, 29 acute diagnosis of, 635-636 Apicomarginal defect, 426-428 apical bone destruction in, 641 endogenous factors, 631 Apoptosis, 634 clinical features of, 641 etiology of, 631-632 Arachidonic acid metabolism, 640 description of, 638 exogenous factors, 631 Archaea, 619 macrophages in, 639 genetic risk factors for, 651-652 Argyrophilic collagen fibers, 537 natural killer cells in, 639 healing of, 85, 283 Articadent. See Articaine, with 1 : 100,000 outcomes of, 641-642 histologic findings, 635-636 epinephrine polymorphonuclear neutrophilic leukocytes histopathology of, 636-637, 641, 645-646 Articaine in, 638 illustration of, 603f with 1 : 100,000 epinephrine, for inferior apexification for, 467 as infectious disease, 599-600 alveolar nerve block, 97-98 asymptomatic inflammatory mediators in, 639-641, 640t, for endodontics, 109 bacteria in, 645-646, 647f 645 insurance carrier warning about, 98 bone resorption in, 645 intraradicular infection as cause of, 614f, supplemental infiltrations of, 101, 104 cells involved in, 643-645, 647 622-623 As low as reasonably achievable principle, 52, characteristics of, 642 lesion associated with, 614 62, 329 chronic focal sclerosing osteomyelitis microbial causation of, 614-615 Asians associated with, 650 microbiologic issues for, 82 mandibular second molar root configurations clinical features of, 646 microorganisms that cause, 600 in, 137, 140f condensing osteitis associated with, 650 multifactorial nature of, 604 maxillary first premolars in, 169 cyst formation with, 646-649, 654 nonsurgical therapy for, 389 Aspergillosis, maxillary sinus, 741f description of, 30, 331f, 642-646 outcomes of, 641-642, 649 Aspirin epithelial cell rests of Malassez in, 644, pathogenesis of, 633-635 analgesic use of, 719 645f adaptive/specific immune response, description of, 73 external root resorption in, 645 634-635, 636f, 642-643 discontinuation of, before periradicular fibroblasts in, 644-645 innate immune response in, 633-634, surgery, 397 histopathology of, 645-646 633t opioid analgesics and, 121-122 inflammatory mediators in, 645, 647 neurogenic inflammation, 635, 636f Asymptomatic apical periodontitis lymphocytes in, 643 periradicular surgery for, 389, 394-395 bacteria in, 645-646, 647f macrophages in, 643 periradicular tissue responses, 631 bone resorption in, 645 osteoclasts in, 643-644 persistent cells involved in, 643-645, 647 outcomes of, 646, 649 genetic risk factors for, 651-652 characteristics of, 642 periapical bone destruction in, 643 systemic disease risk factors for, 652 chronic focal sclerosing osteomyelitis radicular cysts with, 646-649, 649f, pocket cyst in, 646-649, 648f associated with, 650 654 posttreatment, 329, 380-381, 620f clinical features of, 646 reactive bone formation with, 650 prevalence of, 631 condensing osteitis associated with, 650 bacteria in, 600, 602-603, 622-623 prevention of, 477 cyst formation with, 646-649, 654 as biofilm-related disease, 609-610 primary intraradicular infection as cause of, description of, 30, 331f, 642-646 caries as cause of, 631-632 614f epithelial cell rests of Malassez in, 644, 645f cells involved in pulpal infection as cause of, 631-632 external root resorption in, 645 dendritic, 643 after pulpal necrosis, 637-638 fibroblasts in, 644-645 endothelial cells, 638 radiographs of, 361f, 636 histopathology of, 645-646 epithelial cell rests of Malassez, 644, risk factors for, 651-652 inflammatory mediators in, 645, 647 645f symptomatic lymphocytes in, 643 fibroblasts, 644-645 cells involved in, 638-639 macrophages in, 643 lymphocytes, 643, 645 description of, 19, 614-615, 637-642 osteoclasts in, 643-644 macrophages, 639, 643, 645 herpesvirus in, 619 outcomes of, 646, 649 mast cells, 638 histopathology of, 641 periapical bone destruction in, 643 natural killer cells, 639 inflammatory mediators in, 633t, 639-641 radicular cysts with, 646-649, 649f, 654 osteoclasts, 643-644 trephination for, 708-709 reactive bone formation with, 650 platelets, 639 systemic diseases associated with, 650-652 Asymptomatic irreversible pulpitis, 28-29 polymorphonuclear neutrophilic leukocytes, wound healing of symptomatic irreversible pulpitis versus, 109 638-639 cytokines in, 653, 653t Asymptomatic vital teeth, pulp anesthesia cemental changes in, 645 description of, 652-653 determinations in, 95, 95f cholesterol crystals in, 645 diabetes mellitus effects on, 654-655 ATD Automatic Crown & Bridge Remover, 336 880 INDEX

Atypical facial pain, 694-695 Biofilms (Continued) Burs (Continued) Atypical odontalgia, 44, 690, 694-695 microcolonies in, 608 fissure carbide, 148, 148f Austenite, 219-221, 222f in root canal system, 631 Gates-Glidden, 152, 156-157, 225f, 235, Autogenous bone graft, 435t Biologic debridement, 654 236f Autonomic nervous system, 687 Biopsy, in periradicular surgery, 411-412 Mueller, 149, 149f Avulsed teeth BioPure MTAD, 258-259, 258f root canal system cleaning and shaping consequences of, 784-785 BioRaCe instrument, 231 using, 224 description of, 759 Bisphosphonates root-end surface preparation in periradicular emergency management of, 785 indications for, 394 surgery using, 416 pulpal necrosis caused by, 785 medication-related osteonecrosis of the jaw round carbide, 148, 148f replantation of, 785 caused by, 76, 655 round diamond, 148, 149f root preparation in, 786-787 osteonecrosis of the jaw caused by, 394 transmetal, 148-149, 149f socket preparation in, 787 wound healing affected by, 394-395 types of, 148-150, 148f-149f treatment of, 785 Bite test, 19-20, 20f Biting force, 829 C B Bleeding, after periradicular surgery, 437 C fibers, 30, 543f, 546, 548-549, 551, B cells, in adaptive immunity, 635 Blood clots 686-689 Bacteremia, periradicular surgery and, 396 formation of, 392 C+ files, for gutta-percha removal, 348-349, Bacteria. See also Microorganisms Nygaard-Ostby’s work with, 448 349f antibiotic-resistant, 718 prevention of, 767. See also Anticoagulants Calamus flow obturation delivery system, 309f, in apical periodontitis, 600, 602-603, Blood pressure 310 622-623 elevated, 73 Calcific metamorphosis, 566, 566f asymptomatic, 645-646, 647f measurement of, 5 Calcifications chronic, 624 Bone pulpal, 372f, 564-566, 564f-566f biofilms, 602, 603f, 604, 606f burs for removal of, 411 root canal in caries, 601 glucocorticoids effect on, 395 access cavity preparation in, 162-163, in chronic apical periodontitis, 624 heating effects on, 411 163f-164f in dentinal tubules, 591-592, 600-601 homeostasis of, 395 cone-beam computed tomography of, host defense mechanisms against, 603-604 loss of, vertical root fracture-associated, 49-50 intraradicular infection caused by, 614, 800f-801f removal of calcified material, 163 615f-617f regeneration of, 653-654 Calcifying odontogenic cysts, 647-649 multidrug-resistant, 718 resorption of Calciobiotic root canal sealer, 292 nutrient sources for, 617-618 in asymptomatic apical periodontitis, 645 Calcitonin gene-related peptide, 544f-545f, 547, during obturation, 620 inflammation-induced, 633 552f, 577, 632, 653t phagocytosis of, 647f nonsteroidal anti-inflammatory drugs effect Calcium hydroxide in radicular cysts, 649f on, 395 antibacterial use of, 788 root canal infection caused by, 616-617 osteoclasts as cause of, 643, 644f apexification using, 458, 770, 770f, 772f structure of, 603-604, 604f Bone formation apical barrier use of, 314 Bacterial endocarditis lamellar, 393-394 application of, 261f description of, 73 phases of, 393 benefits of, 260 periradicular surgery in patients with, 396 woven, 393 characteristics of, 260, e2 Balanced force technique, for canal Bone grafts, 435t chlorhexidine with, 256 enlargement/preparation, 243, 243f, 737 Bone marrow stem cells, 449 clinical protocol for, 260 Barbed broaches, 224, 224f Bone morphogenetic proteins, e2 direct pulp capping using, e2 Batt tips, 214, 218f Bone morphogenic proteins, 434 disadvantages of, 766 B-cell antigen receptors, 634 Bone sialoprotein, 452-453 Enterococcus faecalis resistance to, 622 Behavioral disorders, 78 Bone wax, for hemostasis, 413 illustration of, 770f Bioactive glass, 262 Bradykinin, 551, 640 inflammatory response caused by, 587f Bioactive protein graft, 435t Brasseler Endo Extractor Kit, 362f as intracanal medicant, 708 BioAggregate, e3 Brasseler extractors, 369 intracanal use of, 459-460 Biocalex 6.9, 356-358, 358f Breast cancer, 73 limitations of, 260-261 Bioceramics. See also Mineral trioxide aggregate Breastfeeding obturation uses of, 292, 314 pulp capping uses of, 766 concerns for, 75 partial pulpotomy, 766f as root-end filling materials, 422 drugs used during, 74b pH of, 765-766, 781f Biodentine, e3 Buccal space, 712f-714f, 713 pulpal irritation caused by, 586 Biofilms infection of, 9-10, 9f-10f in pulpal necrosis, 285, 765-766 antimicrobial resistance of, 608-609 swelling of, 9f-10f reparative bridge formation using, e4f apical periodontitis associated with, 609-610 Buccal vestibular space, 712f-714f, 713 sodium hypochlorite and, 679 bacterial interactions with, 607-608, 607f Buccinator muscle, 713 studies of, 459-460 community lifestyle of, 608 Bupivacaine uses of, 260 definition of, 607 intraosseous anesthesia using, 106 vital pulp therapy use of, 765-766, 765f, e5 description of, 602, 604 local anesthesia using, 98, 98f Calcium silicate cements, e1, e6-e10 extracellular polymeric substances in, Burs Calcium silicate sealers, for obturation, 607-608 access cavity preparation using, 148-150, 294-295, 295t-296t extraradicular, 609, 624 148f-149f Calcium sodium phosphosilicate bioactive glass, illustration of, 603f, 606f bone removal using, 411 579 infections and, 609 diamond, 148, 148f-149f, 235 Calcium sulfate, 770-771 intraradicular, 609 Extendo, 149, 149f for hemostasis, 413 INDEX 881

Camphorated paramonochlorophenol, 255 CDJ. See Cementodentinal junction Chief complaint, 699 Canal transportation, 267-268 CEJ. See Cementoenamel junction diagnostic use of, 2-5 Cancellier extractors, 369, 369f Cell homing, 455-456, 456f investigating of, 2-5 Candida albicans, 622 Cellulitis Children Canine space, 715 description of, 710 crown fractures in, e14f infection of, 9, 9f management of, 715-716 pulpal exposure in, e16f swelling of, 9f Cement(s) Chlorhexidine Ca(OH)2. See Calcium hydroxide calcium silicate, e1, e6-e10 allergic reactions to, 256 Capillary plexuses, 392 glass ionomer antibacterial efficacy of, 255 Capsaicin, 547 luting, 827 before periradicular surgery, 402-404 Carbamide peroxide, for vital bleaching, pulpal responses to, 586-587 calcium hydroxide with, 256 590-591 as root-end filling material, 420 cytotoxicity of, 254-255 Carbocaine, 97 luting, 827-828 as decalcifying agent, 256-257 with Neo-Cobefrin, 97 polycarboxylate, 827 dentin bonding and, 256 Carbon dioxide, for cold testing of pulp, 16, resin-based, 827-828 as endodontic irrigant, 255 16f resin-modified glass ionomer, 826, e5-e7 history of, 254 Carbonated anesthetic solutions, 100 self-adhesive, 828 indications for, 404 Cardiac pain, 697 tricalcium silicate, 294 as intracanal medicine, 255 Cardiovascular disease, 72-73 zinc phosphate, 827 mode of action, 254 Cardiovascular system, 93 Cementation, of post, 337-339 molecular structure of, 254, 254f Caries Cementoblasts, in hard-tissue healing, 394 sodium hypochlorite and, 256f apical periodontitis caused by, 631-632 Cementodentinal junction substantivity of, 254 bacteria in, 601, e1 description of, 142 Chloroform, for gutta-percha removal, 347-348, deep evaluation of, 145-146, 145f 348f, 742-743 in mandibular first molars, e8f Cementoenamel junction Chondroitin sulfate, 541 in mandibular second molars, e13f anatomy of, 667 Chronic apical abscess, 30, 646 occlusal, e8f location of, 145 Chronic apical periodontitis radiographs of, 730f, e5f, e16f Cementogenesis, 394 asymptomatic, 632-633 dendritic cell accumulation caused by, Cementoma, 22f bacteria in, 624 575-576, 576f Cementum cysts associated with, 647-649, 648f dentin layers of, e6 acellular afibrillar, 630 inflammatory mediators in, 647 dyes for detecting, e6 apical foramen extension of, 142 nerve fibers in, 646f humoral immune response to, 576 definition of, 630 Chronic continuous dentoalveolar pain disorder, inflammatory response to, 575, 575f formation of, 478f 44 lasers for prevention, diagnosis, and growth factors in, 630, 653 Chronic focal sclerosing osteomyelitis, 650 treatment of, 588-590, 589f resorption of, 643-644 Chronic inflammation, 475 proliferative response to, 577f in root resorption, 653 Chronic pain, 700-702 pulpal exposure caused by Central nervous system, 686-687 Chronic renal failure, 77 description of, 578 Central neuropathy, 696 Citanest Forte, 97 direct pulp capping for, 587-588 Central sensitization, 553-555, 687, 688b, Citanest Plain, 97 disinfectants effect on, 588 695 Citric acid hemostatic agents effect on, 588 Centrality, 145 root-end surface modification using, 416 illustration of, 578f, 603f Ceramic graft, 435t smear layer removal using, 288-289, 416 pulpal reactions to, 573-576, e2-e6 Ceramic onlays and overlays, 822, 830t Clinical decision making radiation therapy and, 652 Cervical dentin for periradicular surgery, 389-390 remaining dentin thickness after progression bulges of, 156-157, 158f shared approach to, 389-390 of, 584 root canal cleaning and shaping objectives Clot formation, 392 removal of, e9 for, 211 Cluster headaches, 692 removal of, before access cavity preparation, Cervical fasciitis, 716 CO2 lasers, 588 146-147, 147f Cervical lymph nodes Coaggregation, 619 Sjögren syndrome and, 652 palpation of, 9 Codeine, 118, 122 Carrier-based gutta-percha, 311-313 tuberculosis involvement of, 5-6 Cold testing, of pulp, 16, 16f-17f, 547 Case Difficulty Assessment Form and Guidelines, Cervical pulpotomy, 768 Collagen 707f, 708 Cervical spaces, 715 in dentin, 452-453 Case selection Cervicofacial subcutaneous emphysema, odontoblast synthesis of, 535 description of, 71 748-750, 749f-750f procollagen, 541-542 factors that affect, 86-88 C-factor, 821-822, 830-833 in pulpal interstitium, 540 Cast core, 826-827 c-fos, 553 as scaffold, 455 Cast gold post and core, 844-846 Charged coupled device synthesis of, 541-542 Cast posts, 337, 826-827, 833t description of, 33-34, 61 in wound healing, 392-393 Caufield silver point retrievers, 359-360, 360f external inflammatory resorption diagnosed Collagen fibers, in pulp, 541-542, 542f Cautery, in periradicular surgery, 414 using, 666 Collagen fibrils, 537 Cavernous sinus thrombosis, 715 Chemokines Collagen-based hemostasis products, 412, Cavit, 315 cells that produce, 575 413f CBCT. See Cone beam computed tomography description of, 638, 641 Colloid osmotic pressure, 558 CD4+ T cells, 77, 634 Chemomechanical debridement, 666, 679 Colony-stimulating factor, 653t CD8+ T cells, 634-635 Chemotherapy, wound healing affected by, Communities, of microorganisms, 606-607 CD14, 450-451 75-76 Complement cascade, 640-641 882 INDEX

Complementary metal oxide semiconductor, Cone beam computed tomography (Continued) Cost-effectiveness of treatment procedures, 33-34, 34f periradicular surgery applications of 474 Complicated crown fractures, 763-765, computed tomography versus, 400-402 COX-1, 114, 395, 551 763f-764f description of, 400-402, 479 COX-2, 114, 395, 551 Composite resin core, 826, 833t, 842f-843f mandibular canal identification, 398 COX-2 inhibitors Composite resins maxillary sinus identification, 399 description of, 115 polymerization of, shrinkage during, 584 mechanism of action, 400-401 prothrombotic adverse effects of, 115-117 as root-end filling material, 420-421 scan times, 401-402 wound healing affected by, 395 Computed radiography, 34-35 posttreatment disease applications of, COX-inhibiting nitric oxide donators, 122 Computed tomography 328-329, 402 Crack(s) cone beam volumetric, 36-37 presurgical visualization using, 55-60, 55f-59f craze lines, 25 cone-beam computed tomography versus, principles of, 23, 23f-24f, 37-42 cusps, 794-795 400-402 radiation source for, 24, 24f definition of, 793-794 history of, 36-37 risks associated with, 402 diagnostic challenges for, 793 micro-, 37 root canal imaging using, 46, 49f, 130-131, emergency management of, 719-720 multidetector, 37 283 optical coherence tomography of, 25 Computer-controlled local anesthetics delivery root fracture diagnosis using, 51-52, 329, 389 propagation of, 796-797 system root perforations detected using, 50-51, 681 split tooth/roots, 26 description of, 100 spatial resolution requirements, 42, 43f staining and transillumination to detect, 20, for intraligamentary anesthesia, 108, 108f, traumatic dental injury evaluations, 760-761, 21f, 719-720, 794, 796f 110 763f types of, 25-26 Concentricity, 145 treatment planning uses of, 681 unobserved trauma as cause of, 793 Concussion, 777 two-dimensional radiographs and, 24, 25f Cracked tooth Condensing osteitis, 650 vertical root fracture diagnosis using, 45, 46f, clinical manifestations of, 795-798 Cone beam computed tomography 389, 808-809 definition of, 795 American Association of Endodontists/ voxel sizes, 38-39, 42 diagnosis of, 795-798 American Academy of Oral and voxels, 38-39, 38f-40f etiology of, 798 Maxillofacial Radiology position wound healing assessments, 58-60 masticatory forces as cause of, 798 statement on, 63-66 Cone beam volumetric computed tomography, treatment planning for, 798 anatomic landmarks on, 55f-58f 36-37 Cracked tooth syndrome, 26, 719-720 apical periodontitis diagnosis using, 328-329 Connective tissue, 540 Craze lines, 25 classification of, 400-401 Conscious sedation Crowded teeth, access cavity preparation in, computed tomography versus, 400-402 nitrous oxide for, 113 163-165 dental anomalies diagnosed using, 45-46 oral, with triazolam and alprazolam, 113 Crown description of, 33, 37 for periradicular surgery, 402-404 design of, 812-815 diagnostic uses of, 23-24, 24f, 37, 38f, CONSORT, 709 electric pulp testing in patients with, 18 328-329, 401f Consultation letter, 71, 72f fatigue failure of, 823-824 differential diagnosis uses of, 43-44, 44f Contrast resolution, 35 full, 822-827 endodontic treatment applications of Core length of, 238 complications amalgam, 826, 833t, 840f, 844 minimal or no clinical crown, access cavity calcified canals, 49-50 cast, 826-827 preparation in patients with, 157-159 dentoalveolar trauma, 51-52, 52f-53f cast gold, 844-846, 845f preparation for external root resorption, 52-55, 54f characteristics of, 825-826 dentinal tubule exposure during, 584-585, fractured instruments, 48-49, 51f clinical procedures for, 838-844, 840f-843f 585f internal root resorption, 52-55, 54f composite resin, 826, 833t, 842f-843f description of, 846 materials extending beyond root canal, glass ionomer, 826 provisional, 846 46-48, 50f materials used in, 825-826 recurrent caries under, 161f perforations, 50-51 Coronal access cavity preparation, 335-336, removal of, instruments for, 336, 337f failure of treatment, 44-45, 45f 335f, 337f-338f Crown fractures outcome assessments, 402 Coronal binding, 240 in children, e14f external cervical resorption evaluations, Coronal leakage description of, 759 670f-671f, 672 coronal orifice seal for, 315-316 pulpal necrosis secondary to, 764, 764f external inflammatory resorption evaluations, description of, 159 vital pulp therapy for 666 treatment failure caused by, 281 pulp capping, 766-767 field of view, 39-42, 41f Coronal orifice seal, 315-316 requirements for, 765-766, 765f full, 400-401 Coronal preflaring, 235-236, 236f-237f Crown infraction, 763 future of, 60 Coronal pulp Crown-down technique, for canal enlargement/ hardware for, 23f calcification of, 564, 564f preparation, 241-243, 267 imaging software, 39 inflammation of, e7 Crown-root fractures, 759, 773-774 implant site assessments using, 60 odontoblast layer of, 533 Crown-to-root angulation, 159 inferior alveolar nerve injury, 748 Coronal restorations, 505 CS 9300 3D Extraoral Imaging System, 39-40, internal root resorption evaluations, 677 Coronal root fractures, 774, 776f 42f Intersocietal Accreditation Commission for, Coronally located sinus tracts, 801f, 803-805 C-terminal cross-linking telopeptide of type 1 62 Corticosteroids collagen, 395 limited, 400-401 description of, 118-119 C-terminal telopeptide of type 1 collagen chain mechanism of action, 37, 400-401 endodontic pain managed with, 119 test, 77 outcomes assessment using, 56-60 intracranial administration of, 118 Curettage, in periradicular surgery, 411-412 patient characteristics, 40-42 systemic administration of, 119 Cuspal flexure, 593 INDEX 883

Cusps Dental implants (Continued) Dentin sclerosis cracked, 794-795 site assessments for, using cone beam definition of, 574 fractured, 794-795, 797f computed tomography, 60 description of, 566, 593, 600-601, 819 Cvek pulpotomy, 767, 768f, e1-e2 survival rates for, 85-86 illustration of, 574f CXCL12, 575 after tooth extraction, 332 Dentin sialoprotein, 451-453 CXCL14, 575 treatment planning and, 85-86 Dentinal bridge, 587f Cyclic fatigue, 726 Dental injection needle, for root canal Dentinal fluid, 593 Cyclooxygenase, 395 obstruction removal, 365-366, 368f Dentinal pain, 549 CYP2D6, 122 Dental injury, traumatic. See Traumatic dental Dentinal tubules Cysts injury A-delta fibers in, 685-686 formation of, 326 Dental operating microscope, 131, 132f anatomy of, 548, 600-601 periapical Dental pain, 5-6 bacterial infiltration through, 591-592, incidence of, 326 Dental pulp stem cells, 449, 450f, 451, 457 600-601 pocket, 326 Dental resorption, 660 cocci bacteria in, 607f true, 326 Dental trauma. See Traumatic dental injury Enterococcus faecalis in, 622, 622f types of, 326 Dentin exposure of posttreatment disease caused by, 326, age-related changes of, 566 in crown fracture, 763 327f carious, e6 during crown preparation, 584-585, types of, 326 cervical 585f Cytokines bulges of, 156-157, 158f fluid movement through, 28, 28f, 548f biomineralization induced by, e2 root canal cleaning and shaping objectives hypersensitivity and, 579, 580f description of, 551, e1 for, 211 infections of, 604, 607f in osteoclast progenitor cell differentiation, collagen fibers in, 452-453 irrigant penetration in, 257f 643 composition of, 452-453 odontoblast displacement into, 549, 549f in pulpal inflammation, 560 cracks in, 593 Dentinogenesis in wound healing, 392, 653, 653t in endodontically treated teeth, 819 odontoblasts in, 535 Cytolysin, 634-635 fibrodentin, 574-575, 575f reparative, 574 Cytolytic T lymphocytes, 634-635 hypersensitivity of tertiary, 573-574 Cytotoxic T cells, 634-635 dentinal fluid blockage as cause of, 593 Dentin-pulp complex. See Pulp-dentin complex description of, 549-550, 579, 580f Dentoalveolar ankylosis, 778 D lasers for, 590 Dentoenamel junction, 536 Danger zones, 241, 268 periodontal scaling as cause of, 592 DENTSPLY, 734 Deafferentation, 553 root planing as cause of, 592 Dermatan sulfate, 541 Debridement, 654, 666 intertubular, 819 Desiccation, 583, 586 Deep caries lasers as protective measure for, 590 Detergents, irrigants and, 258 in mandibular first molars, e8f nonvital, 819 Dexamethasone, for endodontic pain, 119 in mandibular second molars, e13f in nonvital teeth, 819 DGGE. See Denaturing gradient gel occlusal, e8f peritubular, 585, 585f, 819 electrophoresis radiographs of, 730f, e5f, e16f permeability of Diabetes mellitus Deep pain, 699 demineralization effects on, 289 apical periodontitis and, 650-652 Denaturing gradient gel electrophoresis, 611 dentin sclerosis, 574 hyperglycemia associated with, 652 Dendritic cells description of, 600-601 oral infection risks, 74 in asymptomatic apical periodontitis, 643 illustration of, 601f pathophysiology of, 74 in dental pulp, 662 pulpal irritation affected by, 585 prevalence of, 73-74 description of, 538-539, 538f-539f, variability in, 586 tooth survival after root canal treatment 575-576, 634 primary, 560-561 affected by, 509-512 mononuclear, 662 probing of, 549 treatment planning affected by, 73-74 Dens invaginatus, 45-46, 48f, 166 radicular, 811, 811f wound healing affected by, 654-655 Dental anxiety, 87 reactionary, 561, 574-575, 574f DIAGNOdent, 588-589 Dental artery, 556 remaining thickness of, 584, 763, 812 Diagnosis Dental follicle stem cells, 449, 450f reparative, 132, 133f, 549-550, 560-561, chief complaint, 2-5 Dental history 561f-563f, 563, 575f, e2-e3 data gathering for, 2 definition of, 6 resin-based luting cement adhesion to, definition of, 2 form for, 3f, 7f 828 examination for. See Examination history of present dental problem, 6 resorption of, 643-644 imaging for. See Imaging interview portion of, 6-9 secondary, 560-563, 566 referred pain effects on, 30 questioning areas of, 6-9 sensitivity of, 547-550 stages of, 2 SOAP format for, 6 tertiary Diaket, 420 software for, 6, 8f description of, 560-562 Dialysis Dental implants formation of, 574-575 drugs affected by, 77 osseointegrated, 593 transparent, 819 treatment planning affected by, 77 periradicular lesions effect on success of, ultimate tensile strength of, 819 Diamond burs, 148, 148f-149f, 235, 235f 594 undermineralized, 585 DICOM. See Digital Imaging and prosthetic, treatment planning affected by, vital, 819 Communications in Medicine 77-78 Dentin bonding, 256 Differential diagnosis, 2 pulpal reactions to placement and function of, Dentin chips, 314 Difluorodichloromethane, 759, 759f, 788 593-594 Dentin matrix, growth factors in, 453t Digital Imaging and Communications in single-tooth, 85-86 Dentin phosphoprotein, 452-453 Medicine, 36, 60-61 884 INDEX

Digital radiography Effective dose, 401-402 Endodontic infections (Continued) advantages of, 60-61 Efferent neurons, 542 persistent/secondary description of, 22-23, 23f Eggler Post Remover, 341, 344f bacteria at root obturation stage, 620 diagnostic uses of, 22-23, 23f, 36-37 EGPR-L/R/U/D hand instruments, 743 definition of, 619 direct, 35-36 EIR. See External inflammatory resorption treatment failure and, 619-620 file formats for, 36 El DownPak device, 308, 308f primary, 618-619 healing evaluations using, 36 Elastic fibers, 541 pulp vitality in, 82-83 image perception, 60 Elastin fibers, 541 pulpal exposure as cause of, 601 viewing environment for, 60 Electric motors, for rotary instruments, 233 pulpal necrosis caused by, 602 working length determination using, 36, 37f Electric pulp testing types of, 612 Digital subtraction radiography, 43-44 description of, 547 Endodontic lesions Dihydroxyphenylalanine, 558 pulp anesthesia determinations using, 95, 95f cone beam computed tomography of, 43-44 1,25-Dihydroxyvitamin D3, 454 pulp vitality tests using, 16-19, 18b, 18f, 92, differential diagnosis of, 43-44 Diphenhydramine, 100 578 Endodontic pain Direct composite restorations, 821-822, responses to, 468 dexamethasone for, 119 835f-836f Electronic speckle-pattern interferometry, 823 management of, 120 Direct digital radiography, 35-36 Electronic standards, 36 Endodontic spoon, 150, 150f Direct pulp capping Electropolishing, 221-222 Endodontic surgery bonding agents for, e2 Electrosurgery, 414 goal of, 467 calcium hydroxide for, e2 Elements obturation unit, 311 guided tissue regeneration and, 426-435 cariogenic bacteria survival after, e7 Embryonic stem cells, 448-449 healing after, 84-85 definition of, e1 Emergencies indications for, 83, 84f hemostatic agents for, 588 abscess, 715-716 outcomes of, 85 of mandibular molars, e6f analgesics for, 719 referral for, 87 mineral trioxide aggregate for, 587-588, e7, cellulitis, 715-716 traditional root-end surgery versus, 85 e8f, e13f classification of, 706 Endodontic treatment outcomes of, 483, 488t-490t cracked teeth, 719-720 extraoral time less than 60 minutes, 787-788 partial pulpotomy versus, e2 fascial space infections as, 711-715, failure of, 44-45, 45f Discoloration, tooth, 821, 821f 712f-714f goal of, 599 Disinfectants, 588 flare-ups, 719 traumatic dental injury, 787-788 Disinfection, in root canal system cleaning and incision for drainage of, 716 Endodontically treated teeth shaping irreversible pulpitis, 707-708 aesthetic changes in, 821 antimicrobial nanoparticles for, 265 leaving teeth open, 716-717, 717f-718f Candida albicans in, 622 description of, 373-374 reversible pulpitis, 707 dentin structure in, 819 of immature tooth, 770 symptomatic teeth with previous endodontic discoloration of, 821, 821f intracanal medications for treatment, 716 Enterococcus faecalis in, 620-622, 621f-622f bioactive glass, 262 types of, 706 features of, 818-821 calcium hydroxide. See Calcium hydroxide in vital pulp, 707-711 fracture resistance of, 819-821 chlorhexidine. See Chlorhexidine Enamel microbiota in, 620-622, 621f-623f formaldehyde, 261 cracks in, 602-603 periodontal evaluation of, 829 halogens, 261 penetration of, 154 provisional crowns for, 846 lubricants, 262 Endo Bender pliers, 372-373, 374f restorations for phenolic preparations, 261 Endo Extractor kit, 366-367, 368f adhesive systems, 844 steroids, 261-262 EndoActivator, 263, 263f aesthetic evaluation and requirements, triple-antibiotic paste, 262 Endocal 10, 358f 829-830 irrigants. See Irrigants Endocarditis biomechanical evaluation, 829 irrigation. See Irrigation bacterial clinical procedures, 834-846, 835f-843f, manually activated techniques for, 263 description of, 73 845f photoactivation, 265 periradicular surgery in patients with, 396 direct composite, 821-822, 835f-836f superoxidized water for, 265 infective, 73 endocrown, 822, 830t, 839f syringe delivery for, 262 Endocrown, 822, 830t, 839f ferrule, 822-823 Displacement trauma, e5 Endodontic explorer, 150, 150f, 164f foundation, 822-823 Distobuccal angle, 175 Endodontic infections full crowns, 822-827 Doping, 34-35 acute apical abscesses as, 614, 617f indirect, 822 Double-flare technique, for canal enlargement/ antibiotics for, 717-719 luting cements used with, 827-828 preparation, 243 apical periodontitis. See Apical periodontitis onlays and overlays, 822, 830t, 838f Drugs culture analyses of, 610 partial, 844 in pregnancy, 74, 74b description of, 599 periodontal evaluation, 829 vasoconstrictor interactions, 94t extraradicular, 650 post and core, 824-827, 838-844, Dyract, 421 intraradicular, 612 840f-843f Dystrophic calcification, 565 microorganisms that cause pretreatment evaluation, 828-830, 829f, Archaea, 619 830t E ecology of, 616-619 provisional crowns, 846 Easy Pneumatic Crown and Bridge Remover, fungi, 619, 622 resin composite, 821-822 336 geographic influence on, 615-616 in structurally compromised anterior teeth, Ecosystem, 606-607, 616-619 viruses, 619 834 ECR. See External cervical resorption molecular biology methods for studying of, in structurally compromised posterior teeth, EDTA. See Ethylenediamine tetraacetic acid 610, 611f 834 INDEX 885

Endodontically treated teeth (Continued) Eucalyptol, for gutta-percha removal, 347-348, External root resorption (Continued) in structurally sound anterior teeth, 830 348f radiographic features of, 783, 783f-784f tooth preparation for, 838 Eugenol, 827 treatment of, 779 veneer, 830t, 837f Examination Extracellular matrix tooth stiffness of, 819-821 bite test, 19-20 connective tissue in, 540 vertical root fractures in, 800, 809-810 extraoral, 9-11, 9f-12f glycoproteins of, 540 Endodontics intraoral. See Intraoral examination of periodontal ligament, 630-631 anesthesia for periodontal, 15 Extracellular polymeric substance, 607 infiltrations, 109 pulp testing. See Pulp testing Extraction-replantation, 381, 382f intraligamentary, 110-111 Explorer Extractor System, 360, 362f intrapulpal injection, 110-111 endodontic, 150, 150f, 164f Extraoral examination, 9-11, 9f-12f local, 109-111 operative, 150f Extraradicular biofilms, 609 anxiety effects on, 87 Extendo bur, 149, 149f Extraradicular endodontic infection, 650 case selection for, 86-88 External cervical resorption Extraradicular infections description of, 30 clinical features of, 667-668, 668f-669f description of, 612, 622-624 factors that affect, 86-88 cone beam computed tomography of, development of, 623-624, 624f goal of, 467 670f-671f, 672 intraradicular infection and, 624 scheduling considerations, 88 definition of, 667 posttreatment disease caused by, 326 Endo-Eze file system, 232 etiology of, 667 Endogenous opioid peptides, 554 histologic appearance of, 667, 668f F EndoHandles, 146, 146f internal root resorption versus, 677, Facial pain, 684 EndoSequence Root Repair Manual, 422 678f-679f Facial root fractures, 775f EndoSequence rotary instrument, 231 management of, 672-675 Facial swelling Endosolv-E, 351f, 356 nonsurgical treatment of, 675 buccal space, 9-10, 9f-10f Endosolv-R, 356 pathogenesis of, 667 canine space, 9, 9f Endotec II device, 308, 308f predisposing factors for, 667 examination of, 9-11, 9f-12f Endothelial adhesion molecules, 640t radiographic features of, 668-672, 668f-673f odontogenic causes of, 9 Endothelial cells traumatic dental injury as cause of, 667 submental space, 10, 10f in apical periodontitis, 638 treatment of, 672-675 Factitious pain, 696-697 in wound healing, 392-393 External inflammatory resorption Famotidine, 117 EndoTwinn instrument, 308 apical, 663f-664f Fascial spaces End-stage renal disease, 77 clinical features of, 665 anatomy of, 712, 712f-714f Engine-driven instruments, for gutta-percha cone beam computed tomography of, 666 infections of, 711-715, 712f-714f removal, 350 diagnosis of, 662, 784 Fatigue failure, 823-824 Enterococcus faecalis etiology of, 665 Fatigue root fracture, 798 calcium hydroxide resistance of, 622 follow-up of, 666 Ferric sulfate, for hemostasis, 413 in dentinal tubules, 622, 622f histologic appearance of, 665 Ferrule, 822-823 description of, 388, 499-504, 739, e3 illustration of, 663f-664f Fetal hypoxia, 74-75 in endodontically treated teeth, 620-622, imaging of, 665-666 Fiber posts, 825, 834 621f-622f luxation as cause of, 662, 664-665 Fiber-reinforced composite post, 341-343 in root canals, 632 management of, 666 Fibroblast(s) sodium hypochlorite for, 253 pathogenesis of, 665 in asymptomatic apical periodontitis, Epidermal growth factor, 653t pink spots associated with, 784, 784f 644-645 Epinephrine prevalence of, 662 in cell-rich zone, 537 in cardiovascular disease patients, prognosis for, 666 description of, 537-538 72-73 progression of, 665 in wound healing, 392 cardiovascular effects of, 93 radiographic features of, 662, 665-666, 783, Fibroblast growth factor, 653t hemostatic uses of, 413-414 784f Fibrodentin, 563, 574-575, 575f Epinephrine pellets, 413-414 subepithelial, 784 Fibrogenesis, 393 Epiphany Obturation System, 351f surface resorption versus, 665 Fibronectin, 540 Epithelial cell rests of Malassez treatment of, 662, 666 Field of view, of cone beam computed in asymptomatic apical periodontitis, 644, External root resorption tomography, 39-42, 41f 645f, 647 apical neurovascular supply damage as cause File(s) description of, 326, 631 of, 779-781, 779f-782f Endo-Eze, 232 Epithelial cells, 392 in asymptomatic apical periodontitis, 645 flute of, 216, 218f Epithelial stem cells, 449 cervical. See External cervical resorption GT, 229 Epoxy resin sealers, 292, 293f cone beam computed tomography of, 52-55, GTX, 229 Epstein-Barr virus, 619 54f history of, 223 Er:YAG laser, 588-589, 590f description of, 777-778 ISO-normed, 218 Ethylenediamine tetraacetic acid diagnosis of, 783-784, 783f-784f K-, 164f, 213-214, 223 biocompatibility of, 289 external root surface injury as cause of, LightSpeed, 227, 244-245, 246f description of, 234, 257 778-779 nickel-titanium, 240 endodontic applications of, 257-258 general histologic features of, 660-662 nickel-titanium rotary, 214-216, 218f-219f history of, 257 inflammatory type of. See External patency, 236-237 mode of action, 257 inflammatory resorption pitch angle of, 216-217 root-end surface modification using, 416 luxation injury as cause of, 778-781 Profile Vortex, 231 smear layer removal using, 289, 416 pulpal space infection as cause of, 779-781, RaCe, 231 sodium hypochlorite and, 258 780f retrieval kit for, 729-731, 732f 886 INDEX

File(s) (Continued) Furcation defects Guided tissue regeneration self-adjusting, 226, 228f, 232, 245 case example of, 428f case examples of, 427f-433f separated, 365, 367f-368f, 726-727, causes of, 15 membranes used in, 433f-434f, 434, 435t 728f-729f cleaning of, 377 in periradicular surgery, 426-435, 427f-433f stainless steel, 223, 224f, 237f, 246-247 recording of, 15b GuttaCore, 312, 355-356 ultrasonically activated, 356, 357f repair of, 377 GuttaFlow, 294 Finger spreaders, 302f-303f, 303-304 GuttaFlow2, 294 Fissure carbide burs, 148, 148f G Gutta-percha Fistula, 12 G protein-coupled receptors, 92 advantages of, 347 Fixed partial dentures Gap junctions, 533-534 α form of, 298, 311 fabrication of, abutment teeth affected by, Gates-Glidden burs, 152, 156-157, 225f, 235, carrier-based, 311-313 332f 236f disadvantages of, 297 after tooth extraction, 332 description of, 152, 156-157, 225f, 235, glass ionomer-based endodontic sealer used Flare-ups, 719 236f with, 349 Flexible probes, 802-803, 806f silver point removal using, 360 heat application to, 347 FlexMaster, 230-231 Gates-Glidden drills heated, for pulp testing, 17 Flexural fracture, of instruments, 266 description of, 225, 225f lateral compaction of, 304 Flute of file, 216, 218f gutta-percha removal using, 347 warm, 308-309, 308f Forceps, for crown removal, 336, 337f radicular access using, 365 modified, 355 Foreign bodies Gelfoam, 413 nickel-titanium files for removal of, 742 in open teeth, 717, 718f Genetic polymorphisms, 651-652 obturation use of, 297-299, 298f-299f, 304, periapical infection caused by, 632 GentleWave system, 264-265, 264f 355, 681 Foreign body reaction Geristore, 376-377, 377f, 421 overextended, removal of, 349, 349f, 742 definition of, 643 Gingiva examination, 11 removal of, during nonsurgical retreatment, posttreatment disease caused by, 326 Gingival-derived mesenchymal stem cells, 449 347-351, 347f-351f, 742, 745f Formaldehyde, 261 Glass ionomer(s) Resilon and, comparison between, 300 Formocresol core, 826 rotary systems for removal of, 349-350, 350f dentin tensile strength affected by, 819 obturation use of, 292, 292f-293f solvents used to remove, 347-349, 348f description of, 261 resin-modified, 826 thermoplastic injection techniques for, Formocresol pulpotomy, e2 as sealers, 292, 292f-293f 309-311, 309f-310f Foundation restorations Glass ionomer cements warm lateral compaction of, 308-309, cast post and core as, 826-827, 830 luting, 827 308f direct, 824-826 pulpal responses to, 586-587 warm vertical compaction of, 304, 305f-306f general considerations for, 822-823 as root-end filling material, 420 Gutta-percha cones, 298, 298f-299f indirect, 826-827 Glass ionomer-based endodontic sealer Gutta-percha points, 299, 299f luting cements as. See Luting cements description of, 504-505 GyroTip, 341-343, 345f under full crowns, 844-846, 845f gutta-percha and, 349 FracFinder, 19-20 Glial cell line-derived neurotrophic factor, 552 H Fracture(s) Glial cells, 554 Halo radiolucency, 802, 804f, 805-806 crown. See Crown fractures Glide path, 243 Halogens, 261 crown-root, 759, 773-774 Glucocorticoids, 395 Halothane, for gutta-percha removal, 347-348, definition of, 793-794 Glycoproteins, 540 348f diagnostic challenges for, 793 Glycosaminoglycans, 541 Handpieces magnification to detect, 797-798 Gonon Post Removing System, 340, 342f for access cavity preparation, 147-148 mechanics of, 793-794 Granulation tissue, in wound healing, 392-393 heat exhaustion from, 411, 411f pulpal necrosis induced by, 797f Granulocyte-macrophage colony-stimulating Hank’s Balanced Salt Solution, 785 root. See Root fractures factor, 575-576 Hard tissue symptoms of, 25 Granuloma apical barrier, 770-773, 770f-772f transillumination for detection of, 20, 21f definition of, 642-643 healing of, 393-394 treatment of, 25 periapical, 642-646 HBPT, 258-259 unobserved trauma as cause of, 793 Granulomatous inflammation, 642-643 Headaches, 691-692 vertical root. See Vertical root fractures Granzymes, 634-635 Healing, wound. See Wound healing Fractured cusps, 794-795, 797f Greater palatine foramen, 399f Heart failure, acute, 73 Full coverage restorations, 85 Greater Taper nickel-titanium hand files, Heart valves, artificial, 73 Full crowns 372-373, 374f Heat for endodontically treated teeth, Growth factors bone damage caused by, 411 822-827 in cementum, 630, 653 damage caused by, 370-371 foundation restoration underneath, 844-846, in dentin matrix, 453t generation of 845f in odontoblast-like cell differentiation, 454t by ultrasonic instruments, 346, 346f, Full pulpotomy, 494t, 767-768 regenerative endodontics use of, 452-455, 370-371 Full-thickness flap, in periradicular surgery, 453t-454t for nonsurgical retreatment, 370-371 410f sequestration of, 453 pulp testing using, 16-17, 17f Functional retention, 479 in wound healing, 653, 653t Heavily restored teeth, access cavity preparation Fungal cells, 604, 605f Growth hormone, 453 in, 159-162, 161f-162f Fungi, 619, 622 GT file, 229, 372-373 Hedström files Furanocoumarins, 555-556 GT obturators, 311-312, 311f description of, 221f, 223-224, 349, 349f Furcal perforations, 378f GTR. See Guided tissue regeneration for loosening of separated instruments in Furcation canals, 133, 133f GTX file, 229 canal, 365 INDEX 887

Hedström files (Continued) Iatrogenic events (Continued) Immediate obturation, 314-315, 315f separated, 726-727 nonsurgical causes of, 746-747, 746f-747f Immune response silver point removal using, 360, 360f paresthesia caused by, 747-748 adaptive, 634-635, 636f, 642-643 Helical angle, 216, 219f prevention of, 747 innate, 633-634, 633t, e1 Hemostasis prognosis for, 748 specific, 634-635, 636f agents for, e9 sealer cement effects on, 745-746 Immunity bone wax for, 413 surgical causes of, 747-748, 748f adaptive, 633t, 634, 636f, 642-643 calcium sulfate for, 413 third molar extractions as cause of, 746 innate, 633t, 636f collagen-based materials for, 412, 413f instrument separation Immunoglobulins, 634 epinephrine pellets for, 413-414 causes of, 725-726 Implants, dental ferric sulfate for, 413 chemical removal, 726 osseointegrated, 593 Gelfoam for, 413 description of, 724-725 periradicular lesions effect on success of, in periradicular surgery, 412-414, 437 files, 365, 367f-368f, 726-727, 728f 594 sodium hypochlorite for, e7, e21f, e23f-e24f improper use as cause of, 725-726 prosthetic, treatment planning affected by, Surgicel for, 412-413 management of, 726-727 77-78 Heparin in mandibular molars, 726 pulpal reactions to placement and function of, low-molecular-weight, 397 prognosis for, 733 593-594 periradicular surgery in patients receiving, radiograph of, 725f-726f single-tooth, 85-86 397 removal techniques, 727-733, 728f-732f site assessments for, using cone beam Hermann, B. W., 447 surgical approaches for management of, computed tomography, 60 Hermetic seal, 283 731-733 survival rates for, 85-86 HERO 642, 230 ultrasonic instruments for removal after, after tooth extraction, 332 Hero Shaper, 230 727 treatment planning and, 85-86 Herpes zoster, 693-694, 694f ledge formation Incisal bevel, 152f Herpesvirus, 619 bypassing of, 734-737, 735f-737f Incision and drainage procedures Hertwig’s epithelial root sheath, 132-133, causes of, 733, 734b for abscesses, 716 199-201, 631, 653 complications of, 737 anesthesia for, 113-114 Hess, Walter H., 213, 216f description of, 733 Incisive nerve block, 99 Heterotopic pain, 688b, 690, 700 hand instruments for bypassing/removal of, Indirect pulp capping Heterotopic symptom, 684 734, 735f boundary point for, e2 High-resolution magnetic resonance imaging, incidence of, 733 case selection for, e2 48 management of, 733-734 definition of, e2 Histamine, 638 prevention of, 737 indications for, e2 History of present dental problem, 6 prognosis for, 737 outcomes of, 480-482, 485f, 486t, 491f HIV. See Human immunodeficiency virus rotary instruments for bypassing of, 737 stepwise excavation, 480 Hodgkin disease, 73 ultrasonic tips for removal of, 736-737, Induced pluripotent stem cells, 448-449 Höehl cell layer, e1 737f-740f Infections Holism, 607 nonsurgical perforations, 737-739 apical, 632 Hormones, in hard-tissue healing, 394 root canal filling material radicular extrusion buccal space, 9-10, 9f-10f Horner syndrome, 700-702 description of, 739 canine space, 9, 9f HotShot delivery systems, 311 illustration of, 743f dentinal tubules, 604, 607f Howship lacunae, 660-662, 661f, 665 management of, 742-745 endodontic. See Endodontic infections H-type instruments, 223-224, 224f obturation as cause of, 740, 742-744 extraradicular Human cytomegalovirus, 619 tissue damage caused by, 744-745 description of, 612, 622-624 Human immunodeficiency virus, 619 sinus perforation, 745 development of, 623-624, 624f CD4+ cell count in, 77 sodium hypochlorite, 722-724, 723f-724f intraradicular infection and, 624 oral manifestations of, 77 tips for reducing, 722 posttreatment disease caused by, 326 Hyaluronan, 541 Ibuprofen, 436, 719 fascial space, 711-715, 712f-714f Hyaluronic acid, 541 I-CAT, 38f host–parasite conflict in, 632-633 Hyaluronidase, 99 Illumination, periapical healing affected by, 497 innate immune response to, 633-634, 633t Hydrogels, as scaffolds, 455 Images intraradicular Hydrophilic resins, e5-e6 characteristics and processing of, 35-36 apical periodontitis caused by, 614f, Hyperalgesia, 550-551, 550t, 554 postprocessing of, 35-36 622-623 secondary, 687, 690-691 Imaging bacteria that cause, 614, 615f-617f Hyperglycemia, 652 cone beam computed tomography. See Cone definition of, 612 Hyperplastic pulpitis, 576, 577f beam computed tomography extraradicular infection and, 624 Hypersensitivity, dentin, 549-550, 579, 580f conventional radiographs. See Radiographs microbial composition and diversity of, digital radiography, 22-23, 23f 614, 614f I magnetic resonance imaging, 24 primary, 614-619 Iatrogenic events three-dimensional, 36-37, 38f persistent, 612 cervicofacial subcutaneous emphysema, Immature teeth primary, 612 748-750, 749f-750f apexification of, 769-773, 770f-772f pulpal space, 779-780, 780f definition of, 722 apical closure, e1 secondary, 612 inferior alveolar nerve injury periradicular periodontitis in, 773f Infective endocarditis, 73 causes of, 745-748, 745b, 746f-748f pulp necrosis in, 314-315 Inferior alveolar nerve, 46-48 complications of, 748, 749f pulpectomy contraindications in, e5 Inferior alveolar nerve block cone-beam computed tomography of, 748 revascularization of, 780f bupivacaine for, 92-93, 98, 98f description of, 745-746 root canal treatment in, 764 duration of action, 97 888 INDEX

Inferior alveolar nerve block (Continued) Inflammation (Continued) Instruments (Continued) enhancement methods for, 101, 101f-102f neurogenic, 635, 636f Masserann technique for removal of, 367, epinephrine concentrations in percussion testing for, 14-15 726-727 2% lidocaine with 1 : 100,000 epinephrine, periapical, 632 nickel-titanium instruments, 727-728 96 pulpal. See Pulpal inflammation operating microscope used in removal of, 4% prilocaine with 1 : 200,000 of pulpal interstitium, 541 369, 369f epinephrine, 97 vascular permeability in, 560 prevention of, 363 articaine with 1 : 100,000 epinephrine, Inflammatory periapical progenitor cells, 449 prognosis for, 364-365, 733 97-98 Inflammatory response radiograph of, 725f-726f increasing of, 99 to calcium hydroxide, 587f removal techniques for, 365-370, failure of to caries, 575, 575f 365f-367f, 727-733, 728f-732f definition of, 96 mediators of, 639-641, 640t S.I.R. System for retrieval of, 370 factors involved in, 100-101 Inflammatory root resorption, 780f, 788 surgical approaches for management of, inaccurate injection as cause of, 100 Informed consent, for periradicular surgery, 402 731-733 mylohyoid nerve block, 100, 100f Infraorbital nerve block, 103 ultrasonic instruments for removal of, 365, needle bevel as cause of, 100-101 Infraorbital space, 712f-714f, 715 366f, 727 needle deflection as cause of, 100 Innate immune response, 633-634, 633t taper of, 217, 220f theories on, 101 Innate immunity, 633t tip design of, 214-216, 218f Gow-Gates technique for, 99 Instrument Removal System, 369-370, 370f Intentional replantation, 381, 436, 436f injection sites for, 99 Instruments Intercellular adhesion molecules, 638-639 intraligamentary anesthesia with, 101 apical pressure during use of, 362 Interferon-τ, 641 intraosseous anesthesia with, 101 for crown removal, 336, 337f Interleukin-1, 641, 651 lidocaine for cutting angle of, 216 Interleukin-8, 652 2%, with 1 : 100,000 epinephrine, 96, 101 cutting edge of, 216 Interleukin-12, 641 buffered, 98-99 discarding of, 362 Internal ankylosis, 566, 566f mannitol and, 99 engine-driven, 225-235, 226t, 228f-229f Internal root resorption of mandibular anterior teeth, 112 fracture of characteristics of, 781 mannitol for, 99 cone beam computed tomography of, chemicomechanical debridement of root canal noncontinuous anesthesia, 96 48-49, 51f for, 679 onset of action, 88, 96-97 cyclic fatigue as cause of, 726 clinical features of, 677 preemptive nonsteroidal anti-inflammatory description of, 226, 227f, 266-267, 363 clinical manifestations of, 782 drugs, 113 incidence of, 48-49 cone beam computed tomography of, 52-55, pulpal anesthesia onset using, 96-97, 97f torsional fatigue as cause of, 726 54f, 677 ropivacaine for, 98 hand, separation of, 361-362 definition of, 675 solutions for helical angle of, 216, 219f description of, 778 2% lidocaine with 1 : 100,000 epinephrine, improper use of, 362 diagnosis of, 677, 784 96, 101 irrigants and, 253 early, 674f 2% mepivacaine with 1 : 20,000 ISO-normed, 217-219, 220f etiology of, 675, 781-782 levonordefrin, 97, 103 nickel-titanium, 214-216, 218f-219f, 221 external cervical resorption versus, 677, 3% mepivacaine, 97 for obturation 678f-679f 4% prilocaine, 97 continuous wave compaction technique, histologic appearance of, 674f, 675-677, 4% prilocaine with 1 : 200,000 305-306, 307f 676f, 782, 782f epinephrine, 97 warm vertical compaction technique, 304, historical description of, 660 articaine with 1 : 100,000 epinephrine, 305f management of, 677, 679, 681 97-98 periradicular surgery, 405, 405f-407f of maxillary lateral incisor, 676f hyaluronidase added to, 99 post removal using, 339-341 obturation for, 681 increasing the volume of, 99 rake angle of, 216, 219f odontoblasts in, 675-676 success of, 96 reciprocal motions with, 726 pathogenesis of, 675, 676f success of, methods of increasing, 99 root canal system cleaning and shaping. pulp tissue in, 675, 676f in symptomatic irreversible pulpitis, 109 See Root canal system cleaning and radiographic features of, 671, 676f, 677, Inferior alveolar nerve injury shaping, instruments for 680f, 781f-783f, 782 causes of, 745-748, 745b, 746f-748f rotary, 226-235, 226t, 228f-229f in root fractures, 776f complications of, 748, 749f separated root perforations associated with, 681 cone-beam computed tomography of, 748 causes of, 361-363, 364f, 725-726 subepithelial, 784 description of, 745-746 chemical removal, 726 tissue destruction caused by, 681 nonsurgical causes of, 746-747, 746f-747f dental injection needle for removal of, treatment of, 782-783 paresthesia caused by, 747-748 365-366, 368f in vital pulp, 784 prevention of, 747 description of, 724-725 International Association of Dental Traumatology, prognosis for, 748 Endo Extractor kit for removal of, 366-367, 760 sealer cement effects on, 745-746 368f, 729-731 International Headache Society, 691 surgical causes of, 747-748, 748f files, 365, 367f-368f, 726-727, 728f International Standards Organization norms, third molar extractions as cause of, 437, 746 Hedstrom files for removal of, 365, 367f 217-219, 220f Inflammation illustration of, 366f Intersocietal Accreditation Commission, acute, 475 improper use as cause of, 362, 725-726 62 apical, 632 Instrument Removal System for removal of, Interstitial fluid, 558 chronic, 475 369-370, 370f Interstitium, pulpal, 540-541, 540f coronal pulp, e7 management of, 726-727 Intertubular dentin, 819 mediators of, 551, 554-555, 647 in mandibular molars, 726 Interview, 6-9 INDEX 889

Intracanal medicaments Intrasulcular incision, for periradicular surgery Irrigants (Continued) calcium hydroxide, 459-460 access, 409, 409f HBPT, 258-259 triple antibiotic paste, 459-460, 459f Intrusive luxation, 777 instrumentation with, 253 Intracoronal restorations, 798, 838 Invasive cervical resorption, 54f, 667 iodine potassium iodide, 260-261 Intraligamentary anesthesia Iodine potassium iodide, 260-261 optimal properties of, 250-251, 251b amount of solution delivered, 108 Irreversible pulpitis QMiX, 259-260 anesthetic solutions for, 107 anesthesia in smear layer effects on action of, 288 avulsion after, 109 preemptive nonsteroidal anti-inflammatory sodium hypochlorite back-pressure for, 107 drugs, 113 allergic reactions to, 252 computer-controlled local anesthetic delivery in symptomatic patients, 111 calcium hydroxide and, 679 system for, 108, 108f, 110 asymptomatic “champagne bubble” test, 131, 163 description of, 101 definition of, 707 chemicomechanical debridement of root discomfort during, 108 description of, 28-29 canal using, 679 duration of anesthesia with, 108 in mandibular posterior teeth, 113 chlorhexidine and, 256f endodontic uses of, 110-111 opioid receptors and, 578-579 complications of, 722-724, 723f-724f indications for, 107 symptomatic irreversible pulpitis versus, concentrations of, 253 mechanism of action, 107 109 description of, 770, 818-819 onset of anesthesia, 108 corticosteroids for, 119 ethylenediamine tetra-acetic acid and, periodontal safety with, 108 definition of, 28-29 258 postoperative discomfort caused by, 108 diagnosis of, 707, e5 extrusion of, 723-724, 723f primary teeth safety with, 109 emergency management of, 707-708 heating of syringes for, 252-253, pulpal safety with, 109 maxillary molar infiltration in, 109 253f success of, 107 pain reduction in, 112-113 hemostasis using, e7, e21f, e23f-e24f systemic effects of, 108 pulpotomy for, 112 history of, 251 Intraoral examination radiographic findings, 75f hypersensitivity to, 252 mobility, 15, 15b, 15f reversible pulpitis and hypochlorous acid formation, 251-252 palpation, 13 differential diagnosis of, e5 iatrogenic events caused by, 722-724, percussion, 14f, 15, 19 sodium hypochlorite for differentiation of, 723f-724f periodontium, 15 e5 mode of action, 251-252, 252f sinus tracts, 12-13, 14f single-visit endodontic treatment for, 709 neutralization reaction, 251 soft tissue, 11 sodium hypochlorite for diagnosis of, e5 pH of, 252 swelling, 11, 12f-13f symptomatic pulp tissue dissolution capacity of, Intraoral radiographs, 20-22, 22f anesthesia in, 111 253 Intraosseous anesthesia asymptomatic irreversible pulpitis versus, pulpitis diagnosis using, e5 alveolar mucosa injection of, 106 109 root canal retreatment success affected by, attached gingiva injection of, 106 definition of, 707 498-499 bupivacaine for, 106 description of, 28-29 saponification reaction, 251 definition of, 104 inferior alveolar nerve block in, 109 temperature effects on, 252-253, description of, 101 management of, 708 252f-253f discomfort associated with, 106 in mandibular posterior teeth, 113 time course of, 253 duration of anesthesia with, 104, 105f, 106 Irrigants toxicity of, 253-254, 254f endodontic uses of, 109-110 benefits of, 251b syringe delivery of, 262 failure of, 105 biologic function of, 249 Tetraclean, 258-259 heart rate increase after, 106-107 BioPure MTAD, 258-259, 258f Irrigation, of root canal injection pain with, 110 chlorhexidine efficiency of, 249, 250f injection site locations, 106 allergic reactions to, 256 GentleWave system, 264-265, 264f lidocaine levels in plasma after, 107 antibacterial efficacy of, 255 hydrodynamics of, 249-250, 250f-251f for mandibular posterior teeth, 111 before periradicular surgery, 402-404 irrigants for. See Irrigants medical considerations for, 107 calcium hydroxide with, 256 laser-activated, 264f, 265 onset of anesthesia, 106 cytotoxicity of, 254-255 manually activated, 263 perforator breakage with, 105-106 as decalcifying agent, 256-257 needles used in postoperative discomfort from, 107 dentin bonding and, 256 diameter and bevel of, 249-250, repeating of, 106 as endodontic irrigant, 255 251f Stabident system for, 104, 105f history of, 254 illustration of, 251f success with, 105 indications for, 404 types of, 262 X-Tip delivery system for, 104-106, 105f, as intracanal medicine, 255 negative apical pressure for, 264, 264f 110 mode of action, 254 objectives of, 249 Intrapulpal injection, for endodontic anesthesia, molecular structure of, 254, 254f passive ultrasonic, 263-264 110-111, 581 sodium hypochlorite and, 256f protocol for, 269 Intraradicular biofilms, 609 substantivity of, 254 root canal shape effects on, 250f Intraradicular infection dentinal tubule penetration of, 257f Safety-Irrigator for, 264, 264f apical periodontitis caused by, 614f, 622-623 detergents added to, 258 sonically activated, 263, 263f bacteria that cause, 614, 615f-617f ethylenediamine tetraacetic acid Irrigation pressure, 249-250 definition of, 612 description of, 234, 257 Ischemic heart disease, vasoconstrictors in extraradicular infection and, 624 endodontic applications of, 257-258 patients with, 72-73 microbial composition and diversity of, 614, history of, 257 ISO norms, 217-219, 220f 614f mode of action, 257 Isolation techniques, 497 primary, 614-619 sodium hypochlorite and, 258 Isthmuses, 141, 141f 890 INDEX

J Lidocaine Local anesthesia/anesthetics (Continued) Jaw 2%, with 1 : 100,000 epinephrine, 96, 101, perforator breakage with, 105-106 metastases to, 75, 75f 111 postoperative discomfort from, 107 osteonecrosis of buffered, 98-99 repeating of, 106 medication-related, 76-77, 76b infiltrations of, 99 Stabident system for, 104, 105f radiation therapy as cause of, 655 meperidine added to, 100 success with, 105 JS Post Extractor, 341 Light-curing luting cements, 827-828 X-Tip delivery system for, 104-106, 105f, J-shaped radiolucency, 802, 804f, 805-806 LightSpeed file, 227, 244-245, 246f, 266 110 Lingual shoulder latex allergies, 93-94 K in anterior teeth, 152, 152f lidocaine K3, 229-230 in maxillary canine, 169 inferior alveolar nerve block use of, 96, K-files in maxillary central incisors, 165 98-99 for coronal preflaring, 235 removal of, 152, 152f infiltrations of, 99 description of, 164f, 213-214, 223 Lip lacerations, 787 meperidine added to, 100 pitch of, 216-217 Lipopolysaccharides long-acting, 98, 120-121, 408 for root canal enlargement, 246 calcium hydroxide effects on, 260 mandibular, 101, 101f-102f stainless steel, 223, 224f description of, 454 maxillary, 101-103, 102f KY Pliers, for crown removal, 336, 337f nerve fibers stimulated by, 632 mechanism of action, 91-92 odontoblast exposure to, 576f methemoglobinemia caused by, 93 L Toll-like receptor 2 expression affected by, nerve blocks for Lamellar bone, 393-394 575 anterior middle superior alveolar, 103-104, Lamina limitans, 535-536 vascular endothelial growth factor affected by, 104f Largo Bur, 341-343 560 incisive, 99 Laser(s) as virulence factor, 604 inferior alveolar. See Inferior alveolar nerve caries prevention, diagnosis, and treatment Lipoteichoic acid, 633 block using, 588-590, 589f Local anesthesia/anesthetics infraorbital, 103 CO2, 588 adverse effects of, 93-94 palatal–anterior superior alveolar, 103, dentin hypersensitivity treated with, 590 allergic reactions to, 93-94 104f Er:YAG, 588-589, 590f antagonism of, 96 posterior superior alveolar, 103 GaA1As, 590 articaine, 97-99 second division, 103 Nd:YAG, 588-589, 589f buffered lidocaine for, 98-99 pain origin determination using, 701f pulpal reactions to, 588-590 bupivacaine for, 98, 98f in patients with previous difficulty with pulpotomy applications of, 589-590 carbonated anesthetic solutions, 100 anesthesia, 95 types of, 588 cardiovascular reactions to, 93 peripheral nerve paresthesias caused by, wavelengths of, 588f computer-controlled delivery system for, 100 93 Laser Doppler flowmetry, for pulpal blood flow confirming of, 95, 95f periradicular surgery using, 405-408 assessments, 19, 759-760, 760f description of, 388 phentolamine mesylate for reversal of, Laser-activated irrigation, 264f, 265 diphenhydramine for, 100 96 Lateral compaction obturation, 302-304, for endodontics, 109-111 in pregnancy, 74b, 94 302f-303f failure to achieve, 96 pulpal, 95, 95f Lateral pharyngeal space, 715 G protein-coupled receptor regulation of, 92 pulpal reactions to, 579-581, 580f-581f Latex allergies, 93-94 Gow-Gates technique, 99 reversal of action, 96 Le Fort I osteotomy, 592 incisive nerve block for, 99 ropivacaine for, 98 Leaving teeth open, 716-717, 717f-718f inferior alveolar nerve block for. See Inferior routes of administration, 95 Ledermix, 118, 261-262, 586, 779 alveolar nerve block “rule of 25” for, 93 Ledges infiltrations, 104 systemic diseases or conditions that affect, bypassing of, 734-737, 735f-737f 0.5% bupivacaine with epinephrine, 103 94-95 causes of, 733, 734b 3% mepivacaine, 102, 102f systemic effects of, 93 complications of, 737 4% prilocaine, 102-103 topical anesthetics with, 96 description of, 268, 371, 733 articaine, 104 types of, 92-93, 92t hand instruments for bypassing/removal of, lidocaine, 99, 104 vasoconstrictors 734, 735f injection sites for, 99 contraindications for, 94 incidence of, 733 intraosseous description of, 72-73 management of, 733-734 alveolar mucosa injection of, 106 drug interactions with, 94t prevention of, 737 attached gingiva injection of, 106 pulpal blood flow affected by, 579-581, prognosis for, 737 bupivacaine for, 106 580f rotary instruments for bypassing of, 737 definition of, 104 pulpal health affected by, 579-581 ultrasonic tips for removal of, 736-737, description of, 101 sulfites included in, 94 737f-740f discomfort associated with, 106 Vazirani-Akinosi technique for, 99 Lentulo spiral duration of anesthesia with, 104, 105f, Localized hemostasis, in periradicular surgery, calcium hydroxide application using, 770, 106 412-414, 437 770f endodontic uses of, 109-110 Locus ceruleus, 686-687 for sealer placement in obturation, 296, failure of, 105 Long-acting local anesthetics, 98, 120-121, 297f heart rate increase after, 106-107 408 Levonordefrin injection site locations, 106 Low-molecular-weight heparin, 397 2% mepivacaine with 1 : 20,000 lidocaine levels in plasma after, 107 Lubricants, 262 levonordefrin, for inferior alveolar nerve medical considerations for, 107 Ludwig’s angina, 716 block, 97, 103 onset of anesthesia, 106 Luting cements, 827-828 INDEX 891

Luxation injuries Mandibular first molars (Continued) Mandibular posterior teeth apical neurovascular supply damage caused calcification age for, 195f anesthesia for, 111, 113 by, 779-781, 779f-782f caries in, e2f-e3f with asymptomatic irreversible pulpitis, 113 biologic consequences of, 777-784 computed tomography of, 196f molars. See Mandibular molars definition of, 777 deep caries in, e8f premolars. See Mandibular first premolars; description of, 759 distal root of, 195.e2t Mandibular second premolars external inflammatory resorption secondary eruption time for, 195f with symptomatic irreversible pulpitis, 113 to, 662, 664-665 external cervical resorption in, 672f-673f Mandibular premolars incidence of, 777 furcation canal in, 133f crown of, 154f intrusive, 777 lateral canal in, 287f first. See Mandibular first premolars lateral, 777 mesial root of, 605f, 664f, 195.e1t root canal configuration in, 141f osseous replacement for, 778, 778f-779f morphology of, 135t root canal morphology in, 141f pulpal canal obliteration caused by, 779, pulp chamber floor in, 136f second. See Mandibular second premolars 779f radix entomolaris of, 198-199, 198f Mandibular second molars pulpal necrosis caused by, 779 root canal configurations in, 139t, 196f-198f, access cavity preparation for, 199, 200f pulpal space infection caused by, 779-781, 204f apical canal configuration of, 199.e1t 780f Mandibular first premolars apical resorption of, 663f radiograph of, 760f access cavity preparation of, 155f, 185-192, in Asians, 137, 140f radiographs of, 762, 763f 191f buccal space swelling associated with, 9-10, subluxation, 777 apical canal configurations for, 190.e1t 9f treatment of, 777 calcification age for, 191f computed tomography of, 200f types of, 777 computed tomography of, 191f deep caries in, e13f LY293558, 554 eruption time for, 191f eruption time for, 199f Lymphatic vessel endothelium receptor-1, 558, extra root of, 133-136, 136f external cervical resorption in, 672f-673f 559f medial mesial canal in, 195 foramina in, 204f Lymphocytes, 539, 540f, 645 morphology of, 135t morphology of, 135t Lymphomas, 5-6 root canal configurations in, 139t, 185-199, in Native Americans, 137, 140f 191f-192f pulp chamber of, 199 M Mandibular implants, neuritic complications of, pulp floors in, 205 Macrophages 694 root canal configurations in antigen-presenting, 538-539 Mandibular incisors C-shaped, 201, 204f in apical periodontitis, 639, 643, 645 central description of, 139t, 199, 200f-201f, 204f description of, 538, 538f access cavity preparation for, 183-185, Mandibular second premolars foreign antigens phagocytosis by, 634 188f access cavity preparation for, 192-193, 194f micrograph of, 538f apical canal configurations for, 185.e1t apical canal configurations for, 193.e1t in wound healing, 392 calcification age for, 185f computed tomography of, 193f Magnetic resonance imaging, 24, 48 computed tomography of, 186f morphology of, 135t Magnetic resonance neurography, 48 eruption time for, 185f root canal configurations in, 139t, 192-193, Magnification, periapical healing affected by, morphology of, 135t 192f-194f 497 root canal configurations in, 139t, Mandibular teeth, 135t. See also specific teeth Major histocompatibility antigen, 538, 539f 183-185, 188f Mandibular third molars Malignancy lateral access cavity preparation for, 199, 201f-203f jaw metastases of, 75, 75f access cavity preparation for, 183-185, apical canal configuration for, 199.e2t treatment planning affected by, 75-76, 75f 188f buccal space swelling associated with, 9-10, 9f Malingering, 696-697 apical canal configurations for, 185.e1t calcification age for, 201f Mandibular anterior teeth calcification age for, 185f computed tomography of, 202f anesthesia for, 112 computed tomography of, 187f eruption time for, 201f canines. See Mandibular canines eruption time for, 185f root canal configuration in incisors. See Mandibular incisors morphology of, 135t C-shaped, 199, 203f root canal configurations in, 139t root canal configurations in, 139t, description of, 199, 201f-203f Mandibular artery, 747 183-185, 188f Mannitol and lidocaine, in inferior alveolar nerve Mandibular body, 712 morphology of, 135t block, 99 Mandibular buccal vestibule, 712, 712f-714f periradicular surgery on, 400 Manually activated irrigation, 263 Mandibular canines root canal configurations in, 139t Marginal periodontitis, 631 access cavity preparation in, 185, 190f Mandibular molars Martensite, 219-221, 222f apical canal configurations for, 185.e1t direct pulp capping of, e6f Masserann technique, for separated instrument calcification age for, 188f first. See Mandibular first molars removal, 367, 726-727 computed tomography of, 189f furcation openings in, 133 Mast cells, 539, 638 eruption time for, 188f infections of, 11 Masticatory muscles, 690 morphology of, 135t instrument separation in, 726 Matrix metalloproteinases, 578, 828 root canal configurations in, 139t, 185, mesial roots of, 285, 287f, 812f Maxillary anesthesia, 101-103, 102f 188f-190f root canal in Maxillary anterior teeth Mandibular first molars calcification of, 163f anesthesia for, 112 access cavity preparation for, 193-199, 197f configurations of, 139t apical foramen in, 142-143 accessory canals in, 133, 133f C-shaped, 201, 204f canines. See Maxillary canines accessory foramina in, 195 root canal treatment of, 210f incisors. See Maxillary incisors anesthesia of, 99f second. See Mandibular second molars labiolingual diameter of, 142-143 apical canal configuration for, 195.e1t third. See Mandibular third molars root apex in, 142-143 892 INDEX

Maxillary arch, 180f Maxillary incisors (Continued) Medical conditions Maxillary canines palatal radicular groove in, 166, 171f dental care modification for, 5, 5b access cavity preparation for, 169, 173f periradicular disease of, 389f oral manifestations of, 5-6 apical canal configurations for, 169.e1t root canal configurations in, 139t, Medical consultation letter, 71, 72f calcification age for, 171f 165-166, 169f, 171f Medical history, 5-6 computed tomography of, 172f morphology of, 134t blood pressure measurement, 5 eruption time for, 171f root canal configurations in, 139t form for, 4f, 5 morphology of, 134t Maxillary molars medical conditions, 5, 5b root canal configurations in, 139t, 169, 171f anesthesia of, 102f Medicaments, 499, 741, 766. See also Maxillary first molars first. See Maxillary first molars Intracanal medicaments access cavity preparation for, 171f-172f, infections of, 11 Medicated sealers, 295-296, 297f 175-177, 179f palatal roots of, periradicular surgery Medication-related osteonecrosis of the jaw, apical canal configuration for, considerations for, 399 76-77, 76b, 394 177.e1t-177.e3t root canal configurations in, 139t, 248 Medullary dorsal horn, 553-554 buccal roots of, 179f second. See Maxillary second molars Melanocortin-1 receptor gene, 87 calcification age for, 177f third. See Maxillary third molar Memory cells, 634 computed tomography of, 178f Maxillary posterior teeth Memory T cells, 538 distobuccal root of, 177.e2t anesthesia for, 112 Menstrual cycle, 94-95 eruption time for, 177f molars. See Maxillary molars Mental foramen external inflammatory resorption of, 663f premolars. See Maxillary first premolars; anatomy of, 747-748 mesiobuccal root of, 178f, 415f Maxillary second premolars periradicular surgery localization of, 398, mesiopalatal root of, 177, 177.e3t Maxillary premolars. See Maxillary first 398f morphology of, 134t premolars; Maxillary second premolars Mental space, 712, 712f-714f palatal root of, 180f, 177.e1t Maxillary second molars Meperidine, 100 periradicular disease of, 390f access cavity preparation for, 177-183, Mepivacaine (3%) preemptive nonsteroidal anti-inflammatory 182f-183f for inferior alveolar nerve block, 97 drugs, 113 apical canal configurations for, 182.e1t for mandibular posterior teeth anesthesia, pulp chamber of, 175 calcification age for, 180f 111 root canal configurations for, 175-177, computed tomography of, 181f Mesenchymal stem cells 177f-180f distobuccal root of, 182.e1t description of, 448-449, 450f Maxillary first premolars eruption time for, 180f gingival-derived, 449 access cavity preparation for, 169-173, 175f heavily restored, access cavity preparation in, markers of, 450-451, 451f apical canal configurations for, 171.e1t 161f multipotent, 630-631 in Asians, 169 mesiobuccal root of, 177-182, 606f, 182.e1t odontoblast differentiation from, 451-452, bonded root-end filling in, 419f morphology of, 134t 454, 454t calcification age for, 173f orifices in, 182f in perivascular tissue, 392 computed tomography of, 174f palatal root of, 183f, 606f, 182.e2t in root canal space, 450-451, 452f eruption time for, 173f pulp chamber of, 182-183 undifferentiated, 562 morphology of, 134t root canal configurations in, 139t, 177-183, Mesiobuccal angle, 175 pulp chamber of, 169-171 180f-183f, 182.e1t-182.e2t Mesiopalatal canal orifice, 175 root canal configurations of, 169-171, 173f, Maxillary second premolars Messing gun-type syringe, 407f 175f access cavity preparation for, 173-175, Metal carrier, 352-353, 352f-353f Maxillary incisors 175f-176f, 179f Metal restorations, 149 central apical canal configurations for, 173.e1t Metalloceramic crown, access cavity preparation access cavity preparation for, 165, computed tomography of, 176f through, 159, 162, 162f 167f-168f, 175f morphology of, 134t MetaSEAL, 293-294 apical canal configurations in, 165.e1t root canal configurations in, 139t, 173-175, Methacrylate resin sealers calcification age for, 167f 176f-177f characteristics of, 292-294 computed tomography of, 168f Maxillary sinus obturation use of, 292-294 eruption time for, 167f aspergillosis of, 741f Methemoglobinemia, 93 lingual shoulder of, 165 cone-beam computed tomography Methylchloroform, 347-348 morphology of, 134t identification of, 399 Microbiota. See also Microorganisms periradicular disease associated with, 9 perforation of, 745 definition of, 612 root canal configurations in, 139t, 165, periradicular surgery concerns regarding, diversity of, 612-614, 613f 169f 399, 437 in endodontically treated teeth, 620-622, root fracture in, 46f Maxillary sinusitis, 5-6 621f-623f trauma to, 51, 52f Maxillary teeth. See also specific teeth identification of, 610-612, 610b, 612t lateral morphology of, 134t in oral cavity, 612-613 access cavity preparation, 165-166, 170f root canal configurations in, 139t Microcomputed tomography, 37 accessory foramina in, 171f Maxillary third molar Microcondensers, 406f anomalies of, 166, 171f access cavity preparation for, 183, 183f, Microcracks, 810-812, 811f-812f apical canal configurations for, 166.e1t 185f Microfilaments, 535 calcification age for, 169f apical canal configurations for, 183.e1t Micromirror, 406f computed tomography of, 170f calcification age for, 183f Micro-Openers, 146, 146f dens invaginatus of, 166 eruption time for, 183f Microorganisms. See also Bacteria eruption time for, 169f root canal configurations in, 183, 183f-185f anachoresis of, 601 internal root resorption of, 676f McSpadden Compactor, 313 apical periodontitis caused by, 600 morphology of, 134t Mechanical allodynia, 551 communities of, 606-607 INDEX 893

Microorganisms (Continued) Mobility Nerve growth factor, 538, 552 culture of, 610, 610b recording of, 15b Neural modulating agents, for dentin identification of, 610-612, 610b, 612t testing of, 15, 15b, 15f hypersensitivity, 579 intraradicular, posttreatment disease caused Modified glass ionomer core, 826 Neuralgia, 692-693 by, 325-326 Molar triangle, 175 Neuritis, 693-694, 694f molecular methods for studying of, 611b, Molars Neurogenic inflammation, 635, 636f 612, 613f mandibular. See Mandibular molars Neurokinin A, 547 pathogenicity of, 602-604 maxillary. See Maxillary molars Neuroma, 693 persistent periradicular disease caused by, Monoclonal antibodies, 536-537 Neuropathic pain, 688b, 692-696 388-389 Monsel’s solution, 413 Neuropathy, 694-696 populations of, 606-607 Morphogens, 453-455 Neuropeptides posttreatment disease caused by, 388 Mounce extractor, 369, 369f description of, 547, 635, 641 root canal penetration of, during root canal “Mouse hole” effect, 156, 157f pulpal immune response modulated by, 577 treatment, 602 MRONJ. See Medication-related osteonecrosis of Y, 542, 543f, 578-579 root canal system cleaning of, 209-210 the jaw Neurovascular pain, 691-692 spatial distribution of, 604-606 Msx1, 453 Neutrophil extracellular traps, 634 studies of, 611-612 Msx2, 453 Neutrophils, polymorphonuclear, 392 virulence factors, 602-604 MTA Fillapex, 295 Niche, 607 MicroRNAs, 579 MTA-Angelus, e3 Nickel-titanium instruments Microseal system, 681 MTwo, 231-232 coronal preflaring using, 235, 237f Microsurgical scalpel, 405f Mucobuccal fold, 11, 13f deformation of, 223f Microtubules, 535 Mucoperiosteal flap, 675 design of, 228f Midface swelling, 715 Mucous cell metaplasia, 647-649 files, 240 Midroot perforations, 374-375, 379f-380f Mueller bur, 149, 149f fracture of, 227f, 235b, 724-725 Migraine headaches, 691-692 Multidetector computed tomography, 37 Greater Taper hand files, 372-373 Miller, Willougby Dayton, 599-600 Multinucleated osteoclasts, 779-780, 780f gutta-percha removal using, 349-350, 350f, Mineral trioxide aggregate Multiple myeloma, 5-6 742 apexification using, 462-464, 468, 771f Multiple-visit treatment, 79-82 root canal curvatures maintained using, 737 as apical barrier, 314, 314f Multipotent mesenchymal stem cells, 630-631 rotary, 214-216, 218f-219f, 226, 233f, 266, biocompatibility of, e2 Multipotent stem cells, 448-449 811f characteristics of, 421, e2 Musculoskeletal pain, 699 separated, 727-728 color of, 766 M-Wire, 222 success rates with, 497 components of, e3 Mylohyoid nerve block, 100, 100f Nickel-titanium spreaders, 812, 815f description of, e1, e6 Myofascial pain, 690-691 Nitinol, 219-220 disadvantages of, 376-377 Myofibroblast, 392 Nitrous oxide, for conscious sedation, 113 hard-tissue formation caused by, 563 MZ100, 822 Nitrous oxide–oxygen, in pregnancy, 74 history of, e2 NK1 antagonists, 554 inflammatory cascade, e2 N NMDA receptor, 554 MTA-Angelus, e3 N-2, 295-296 Nociceptive pain, 688b pulp capping using, 483, 587-588, 766, e7, N-acetyl-p-benzoquinone imine, 117-118 Nociceptors e10-e16 Nanoparticles, antimicrobial, 265 inflammatory mediators on, 550t direct, 587-588, 766, e7, e8f, Nasal mucosal pain, 691 sensitization of, 550 e13f Nasolabial fold, 9, 9f transmission of information, 546f one-step, e10-e11 National Council for Radiation Protection, 35, 35b Nociceptors, pulpal, 689 two-visit, e10-e16, e26f Native Americans, mandibular second molar root Nogenol, 292 pulpal repair promotion by, e4 configurations in, 137, 140f Noncontinuous anesthesia, 96 pulpotomy with, e7, e14f, e16f Natural killer cells, 639 Non-narcotic analgesics reparative bridge formation using, e4f Nd:YAG laser, 588-589, 589f acetaminophen, 117 root perforations repaired using, 26-27, 147, gutta-percha removal using, 351 alternatives to, 117 376-378, 377f, 681 Negative apical pressure, 264, 264f contraindications for, 117 as root-end filling material, 421-422 Negative rake angle, 216, 219f drug interactions with, 117, 117t sealers using, 294 Negative-pressure irrigation, 264, 264f efficacy of, 116t for sealing root perforations, 26-27, 147 Neovascularization, 644-645 limitations of, 117 signaling molecules, e2 Nerve blocks nonsteroidal anti-inflammatory drugs, vital pulp therapy using anterior middle superior alveolar, 103-104, 114-115 biocompatibility of, e2 104f overview of, 114-117 characteristics of, e2 incisive, 99 types of, 115t components of, e3 inferior alveolar. See Inferior alveolar nerve Nonodontogenic lesions, 83 contralateral tooth development, e10 block Nonodontogenic toothache. See also Pain description of, e1, e6 infraorbital, 103 cardiac pain as cause of, 697 direct pulp capping with, e7, e8f, e13f mylohyoid, 100, 100f case studies of, 702-703, 702f, 702t-703t history of, e2 second division, 103 craniofacial structures that cause, 697-698 inflammatory cascade, e2 Nerve fibers, 543t description of, 684 MTA-Angelus, e3 in chronic apical periodontitis, 646f examination for, 700-703 pulpotomy with, e7, e14f, e16f intradental, plasticity of, 552-553 frequency of, 698 radiographs of, e27f pulpal indicators of, 703 signaling molecules, e2 description of, 545-546, 545f intracranial structures as cause of, 697 Minocycline, 788f neuropeptides in, 547 musculoskeletal pain as cause of, 690-692 894 INDEX

Nonodontogenic toothache (Continued) Nonsurgical retreatment (Continued) Obturation (Continued) myofascial pain as cause of, 690-691 root canal blockage, 373, 374f historical perspectives on, 283-284 neuralgia as cause of, 692-693 root canal impediments, 371-373 immediate, 314-315, 315f neuritis as cause of, 693-694, 694f root perforation repair, 374-378, 375f-379f inadequate, 282f neuroanatomy of, 684-687 root-filling material removal, 346-361, incomplete, failures caused by, 280 A-beta fibers, 685 347f-355f, 357f-361f internal root resorption treated with, 681 A-delta fibers, 685-686 separated instrument removal, 361-370 in large root canal systems, 301, 302f autonomic nervous system, 687 causes of, 361-363 lateral compaction method of, 302-304, C fibers, 686-687 silver point removal, 358-361, 358f-363f 302f-303f central nervous system, 686-687 solid core obturators, 351-356, 352f-355f length of, 285-287, 285f-286f neural structures, 685-687 surgical retreatment and, 333 paraformaldehyde-containing materials for, peripheral nervous system, 685-686 treatment planning for, 331-334, 331f-335f 289, 290f primary afferent neurons, 685-686 Nonsurgical root canal treatment pastes for, 314, 356-358, 357f second-order neurons, 687 outcomes evaluation preparation for, 287-289, 288f-290f neuroma as cause of, 693 periapical healing after, 495-509 in pulpal necrosis, 284-285 neuropathic pain as cause of, 692-696 quality of life, 515, 517t radiographic assessment of, 284 neuropathy as cause of, 694-696 tooth survival, 509-515, 514f, 516f resin-bonded, 351 neurovascular pain as cause of, 691-692 quality of life effects of, 515, 517t after root canal cleaning and shaping, 285 patient examination for, 700-703 Nonvital teeth sealers used in red flags for, 703 aesthetic changes in, 821 biocompatibility of, 290-291 salivary gland pain as cause of, 691 anterior, 830, 831f-832f calcium hydroxide, 292, 314 sinus pain as cause of, 691 compositional changes in, 818-819 calcium silicate, 294-295, 295t-296t somatic pain as cause of, 690-692 dentin structure in, 819 extrusion of, 291, 291f sources of, 690-700 discoloration of, 821, 821f glass ionomer, 292, 292f-293f Nonspecific innate immune response, 634 fracture resistance of, 819-821 ideal properties of, 290b Nonsteroidal anti-inflammatory drugs moisture content changes in, 818 lentulo spiral for placement of, 296, 297f acetaminophen and, 121 posterior, 831f-832f medicated, 295-296, 297f COX-inhibiting nitric oxide donators and, 122 tooth stiffness of, 819-821 noneugenol, 292 cyclooxygenase inhibition by, 395 Novel oral anticoagulants, 397 paraformaldehyde-containing, 295-296 description of, 114-115 Nucleus raphe magnus, 686-687 periradicular extrusion of, 291, 291f drug interactions with, 117, 117t placement of, 296, 297f opioid analgesics and, 121 O radiopacity of, 290 periradicular surgery use of, 402-404, 436 Obtura II, 681 resin, 292-294. See also Resin sealers postoperative pain managed with, 436 Obtura III, 309-310, 309f silicone, 294, 294f preemptive uses of, 113, 120 Obturation tricalcium silicate, 294, 295t-296t pretreatment uses of, 120 adequate, 282f zinc oxide–eugenol, 291-292, 292t swelling reduction using, 719 apical barriers for, 314 smear layer removal before, 288, 289f, 311 wound healing affected by, 395 apical portion of fill, 290 solid core obturators, 351-356, 352f-355f Nonsurgical perforations, 737-739 bacteria during, 620 solvent techniques for, 314 Nonsurgical retreatment continuous wave compaction technique of, thermomechanical compaction technique for, access cavity preparation for, 335-336, 335f, 305-308, 307f-308f 313 337f-338f core materials used in, 296-301, 812 thermoplastic injection techniques for, apical area access, 346-361, 347f-355f, Active GP, 299 309-311, 309f-310f 357f-361f custom cones as, 300-301, 301f-302f timing of, 284-285 apical periodontitis managed with, 389 extrusion of, beyond radicular foramen, in vital pulp tissue, 284 apical surgery versus, 334 742-745, 743f warm lateral compaction technique of, armamentarium for, 325f gutta-percha. See Obturation, gutta-percha 308-309, 308f considerations for, 334 for warm vertical compaction method of, coronal access cavity preparation for, ideal, 289-290, 297b 304-305, 305f-307f 335-336, 335f, 337f-338f in large root canal systems, 301, 302f Occlusal caries, e8f finishing of, 373-374, 375f Resilon, 299-300, 300f, 351, 351f Occlusal cavities, 830-833 gutta-percha removal, 347-351, 347f-351f, silver cones, 296-297, 298f Occlusal forces, 829 355 coronal microleakage after, 315-316 Occlusal loading, tooth deformation during, 593 healing rates of, 334, 380 coronal orifice seal after, 315-316 Occlusal teeth evaluation, in access cavity heat generation during, 370-371 GuttaCore for, 355 preparation, 145-146 irrigant effects on, 498-499 gutta-percha for Occlusal trauma, 328 metal carrier removal, 352-353, 352f-353f carrier-based, 311-313 Occlusal wear facets, 328 outcome measures for, 477-479 description of, 284, 297-299, 298f-299f, Occlusion-related pain, 706 outcome of, 515-517, 518f, 521f 304, 681 Ochsenhein-Luebke flap, 410f, 424-425 overview of, 324 illustration of, 315f Odontoblast(s) paste, 356-358, 357f lateral compaction of, 304 alkaline phosphatase secretion by, 535 periapical healing after, 517, 518f, 521f overextension of, 742 cell body of, 535 persistent periradicular pathosis after, 404f removal of, 742, 745f cementoblasts versus, 535 plastic carrier removal, 353-354, 354f solvent techniques, 314 characteristics of, 535, e1 post removal in, 337-346, 338f-345f thermoplastic injection techniques for, chemokine secretion by, 575 posttreatment disease. See Posttreatment 309-311, 309f-310f collagen synthesis by, 535 disease vertical compaction of, 312 dentin sialoprotein expression by, 451 prognosis of, 380-381, 380f-382f warm vertical compaction of, 304, 305f-306f in dentinogenesis, 535 INDEX 895

Odontoblast(s) (Continued) Osteoclasts (Continued) Pain (Continued) description of, 451 bone resorption caused by, 643, 644f intensity of, 699 destruction of, 562-563 definition of, 660 local anesthetics used to localize, 701f differentiation of, 575-576 in hard-tissue wound healing, 393 management of, 706-707 displacement of, 549, 549f multinucleated, 779-780, 780f flexible analgesic strategy for, 121-122, illustration of, 534f ruffled border of, 660, 661f 121f inactive, 535 Osteomyelitis, chronic focal sclerosing, 650 long-acting local anesthetics for, 98, in inflammatory response to caries, 576, 577f Osteonecrosis of the jaw 120-121 in internal root resorption, 675-676 medication-related, 76-77, 76b nonsteroidal anti-inflammatory drugs for, mesenchymal stem cell differentiation into, radiation therapy as cause of, 655 436 451-452, 454, 454t Osteopontin, 575-576 after periradicular surgery, 437 morphologic characteristics of, 535 Osteoprotegerin, 662 pretreatment for, 120 neuropeptides on, 535, 536f Outcome measures strategies for, 120-122 nucleus of, 535 nonsurgical retreatment procedures, 477-479 muscular, 700 osteoblasts versus, 535 nonsurgical root canal treatment procedures, musculoskeletal, 690-692, 699 predentin-dentin matrix secreted by, e1 477-479 myofascial, 690-691 progenitors of, e1 periapical surgery, 479-480, 481f-483f nasal mucosal, 691 in reparative dentin formation, e1 for regenerative endodontic procedures, neuroanatomy of, 684-687 resting, 535 467-468 A-beta fibers, 685 secretory function of, 537 surrogate, 475 A-delta fibers, 685-686 structure of, 537 types of, 475 autonomic nervous system, 687 Toll-like receptor expression, 575 vital pulp therapy procedures, 476-477, 476t C fibers, 686-687 ultrastructural features of, 535, 536f vitality responses as, 468 central nervous system, 686-687 Odontoblast layer, of pulp, 532-534, 533f-534f, Outcomes evaluation neural structures, 685-687 577f cone beam computed tomography for, 56-60 peripheral nervous system, 685-686 Odontoblast process, 535-537, 575-576, 590f context for, 474-475 primary afferent neurons, 685-686 Odontoblast-like cells direct pulp capping, 483, 488t-490t second-order neurons, 687 growth factors in differentiation of, 454t effectiveness of procedures determined using, neuropathic, 44, 688b, 692-696 regenerative capacity of, 585-586 475 neurophysiology of, 687 Odontoclasts, 643-644, 660-662, 661f factors that affect, 475-476 neurovascular, 691-692 Odontogenic keratocysts, 647-649 full pulpotomy, 494t nociceptive, 688b Odontogenic pain indirect pulp capping, 480-482, 485f, 486t, occlusion-related, 706 history-taking for, 698-700, 698f 491f onset of, 699 pulp-dentin complex as source of, 687-689 nonsurgical retreatment, 515-517, 518f, origins of, determination of, 700, 701f Odontogenic toothache 521f patient examination for, 700-703 description of, 687-689 nonsurgical root canal treatment peripheral sensitization in, 687, 688b, 695 sources of, 687-690 periapical healing after, 495-509 periradicular, 690 One-step pulp capping, e10-e11 quality of life, 515, 517t after periradicular surgery, 437 Onlays, 822, 838f tooth survival after, 509-515, 514f, 516f persistent dentoalveolar pain disorder, Operating microscope, in separated instrument periodontal incisional wound healing, 522 695-696, 695f, 696b removal, 369, 369f pooling data, 475-476 progression of, 699 Operative explorer, 150f prognostication value of, 476 psychogenic, 697 Opioid analgesics pulpotomy, 483-484 pulpal, 689 applications of, 117-118, 118t purpose of, 475-476 pulpitis-related, 551-552 nonsteroidal anti-inflammatory drugs and, surgical retreatment, 517-522 quality of, 699, 699t 121 Overhangs, 240 reduction of, in irreversible pulpitis, Opioid receptors, in pulp, 578-579 Overlays, 822, 830t, 838f 112-113 Opportunistic pathogens, 602 Oxygen consumption, 539 referred, 30, 684, 688f, 699 Optical coherence tomography, for enamel crack salivary gland, 691 detection, 25 P sinus, 691 Oral Health Impact Profile, 479, 515, 517t Pain. See also Nonodontogenic toothache somatic, 690-692 Oral Radiographic Differential Diagnosis, 75 aggravating factors of, 699 subjective nature of, 542 Orofacial pain. See Pain alleviating factors for, 699 superficial, 699 Orthodontic extrusion, 834 analgesics for, 719 temporal aspects of, 699 Orthodontics associated factors, 700 types of, 687, 688b pulpal blood flow affected by, 592 cardiac, 697 voltage-gated sodium channels and, 92t pulpal reactions to, 592 central sensitization in, 553-555, 688b, 695 Pain history, 698-699, 698f Orthognathic surgery, 592 chronic, 700-702 Pain modulation, 555f Osseous defects, 802 deep, 699 Pain perception Osseous replacement, for luxation injuries, 778, definition of, 688b detection and, 546-547 778f-779f, 785 description of, 684 mechanism of, 546 Osteoblasts descriptors of, 699, 699t medullary dorsal horn in, 553-554 collagen secretion by, 393-394 detection of, 546-547 processing step of, 553-555 in hard-tissue wound healing, 393-394 facial, 684 schematic diagram of, 555f Osteoclasts gender differences in, 94-95 thalamus to cortex pathway, 555-556 actin cytoskeleton of, 660 heterotopic, 688b, 690, 700 Painless pulpitis, 578 in asymptomatic apical periodontitis, 643-644 history-taking, 698-700, 698f Palatal–anterior superior alveolar nerve block, bone loss caused by, 633 induction of, 641 103, 104f 896 INDEX

Palate Periapical diseases Periodontal ligament anterior, swelling of, 11, 12f classification of, 27-30, 637 cells of posterior, swelling of, 13f inflammatory, 635 apoptosis of, 388 Palpation after root canal treatment, 477-478, 478f description of, 630-631 of cervical lymph nodes, 9 Periapical granuloma, 642-646 collagen fibers of, 630-631 in intraoral examination, 13 actinomyces in, 483f contusion injuries to, 665 of submandibular lymph nodes, 9 Periapical healing definition of, 630-631 Parachloroaniline, 255 after apical surgery, 482t, 519t-520t, 521f extracellular matrix of, 630-631 Parafunctional habits, 592-593, 829 description of, 479, 482t, 484f inflammation of, 14-15 Parallax radiographs, of internal root resorption, factors that affect, 495-509 mechanoreceptors of, 690 677 acute exacerbation during treatment, 505 stem cells of, 449-450, 450f Paranasal sinus aspergillosis, 741 apical preparation, 497-498 substance P in, 577 Parapharyngeal space, 712f-714f, 715 bacteria presence, 499-504, 500t-503t Periodontal pocket depth, 15 Paresthesia illumination, 497 Periodontal probing, 15 endodontic-related, 740-741 irrigants, 498-499 Periodontal scaling, 592 peripheral nerve, 93 isolation, 497 Periodontitis after periradicular surgery, 437 magnification, 497 advanced, with periradicular inflammation, PARRs. See Pathogen-associated recognition mechanical preparation, 497-498 426-428 receptors medicaments, 499 apical. See Apical periodontitis Partial pulpotomy number of treatment visits, 505 definition of, 29 calcium hydroxide, 766f patient-related, 495-497 marginal, 631 crown fractures treated with, 767, root canal bacterial culture, 499, periradicular, 773f 768f-769f 500t-503t pulpal inflammation caused by, 591-592 Cvek, 767, 768f root filling, 504-505 Periodontium, intraligamentary anesthesia definition of, e2 summary of, 506-509, 506f-509f injection effects on, 108 direct pulp capping versus, e2 treatment-related, 497-505 Periorbital space, 712f-714f, 715 follow-up after, 767, 769f after nonsurgical retreatment, 517, 518f, Periosteal derived stem cells, 449, 450f outcomes evaluation of, 483-484, 491f, 521f Peripheral inflammatory root resorption, 667 492t restorations effect on, 515 Peripheral nerve paresthesias, 93 pulp capping versus, 766-767 Periapical health Peripheral nervous system, 685-686 root development after, 769f after periapical surgery, 517-522, 521f Peripheral neuropathy, 696 technique for, 767, 768f after root-end filling, 517-522, 521f Peripheral sensitization, 550, 550b, 550t, 687, traumatic pulp exposures treated with, 767, Periapical index, 479 688b, 695 768f-769f Periapical infection Periradicular abscess, 9f Partial restorations, 844 description of, 632 Periradicular cholesterol cysts, 388-389 Passive ultrasonic irrigation, 263-264 foreign bodies as cause of, 632 Periradicular disease Paste with sinus tract, 13 of maxillary first molar, 390f nonsurgical retreatment using, 356-358, Periapical inflammation, 632 of maxillary lateral incisor, 389f 357f Periapical lesions Periradicular inflammation overextended, 357f nonendodontic, 650 advanced periodontitis with, 426-428 Patency file, 236-237 periapical healing affected by, 496-497 description of, 603-604 Pathogen-associated recognition receptors, 575, therapy-resistant, 481f Periradicular lesions 632-633 three-dimensional radiographic appearance implant success affected by, 594 Patient of, 44 radiograph of, 738f-740f, 744f evaluation of, 71 Periapical osteolytic lesions, 649 Periradicular pain, 690 registration of, 2 Periapical radiolucencies, 282-283 Periradicular pathosis Pattern-recognition receptors, 575, 632-633 Periapical status, 479, 480t etiology of, 281, 388, 414 Peeso drills, 225, 341-343 Periapical surgery after nonsurgical retreatment, 404f Penicillin V, 787 anesthesia for, 114 Periradicular periodontitis, 773f Percussion testing, 14f, 15, 19 healing after, 479, 482t, 484f Periradicular surgery Perforations outcome measures for, 479-480, 481f-483f access for cone-beam computed tomography of, periapical health after, 517-522, 521f flap designs, 409, 409f-410f 50-51 quality of life effects of, 522 full-thickness flap, 410f definition of, 50-51 success criteria for, 482t, 484f-485f hard-tissue, 411 furcal, 378f tooth survival after, 522 horizontal incision for, 409, 409f maxillary sinus, 745 Periapical wound healing, 653, 653t intrasulcular incisions, 409 nonsurgical, 737-739 Peri-implantitis, 332f principles used in, 408 post, 375f-376f Periodontal crown lengthening surgery, 834 soft tissue, 408 during post removal, 346 Periodontal disease submarginal flap, 410f root canal system cleaning and shaping as deep pockets associated with, 802 tissue reflection, 409-411, 410f cause of, 268, 268f illustration of, 602f tissue retraction, 411 Perforin, 634-635 pulp vitality in, 82-83 triangular flaps, 409f Periapical abscess, 642f pulpal necrosis caused by, 601 vertical incision for, 408-409, 408f-410f Periapical cysts systemic health conditions caused by, 58-60 anatomic considerations for, 397-400, incidence of, 326 terminal, 333 398f-400f pocket, 326 Periodontal evaluation, 829 anterior maxilla and mandible, 399-400, true, 326 Periodontal examination, 15 400f types of, 326 Periodontal incisional wound healing, 522 mandibular canal, 398 INDEX 897

Periradicular surgery (Continued) Periradicular surgery (Continued) Periradicular surgery (Continued) mental foramen, 398, 398f objectives of, 414 cementogenesis in, 394 posterior mandible, 397-398, 398f operatory setup for, 405 clot formation in, 392 posterior maxilla, 399, 399f pain after, 437 collagen in, 392-393 in anterior maxilla and mandible, 399-400, palatal roots of maxillary molars, 399 cyclooxygenase-2 inhibitors effect on, 395 400f paresthesia after, 437 endothelial cells in, 392-393 antibiotic prophylaxis before, 396, 402-404 patient preparation for, 402-404 epithelium in, 393 in anticoagulation, 396-397 persistent periradicular disease treated with, factors that affect, 390 apical periodontitis treated with, 389 388-389 fibroblasts in, 392 aspirin discontinuation before, 397 in posterior mandible, 397-398, 398f glucocorticoids effect on, 395 bacteremia associated with, 396 in posterior maxilla, 399, 399f granulation tissue formation in, 392 in bacterial endocarditis patients, 396 postoperative care and instructions, 426f, hard-tissue, 393-394 biopsy in, 411-412 436-437 hormones involved in, 394 bleeding after, 437 premedication before, 402-404 inflammatory phase of, 391-392 bleeding concerns during, 397 in prosthetic joint patients, 396 macrophages in, 392 bone in rationale for, 389 maturation phase of, 393 healing of, 393-394 regeneration as goal of, 390-391 nonsteroidal anti-inflammatory drugs effect heating effects on, 411 ridge preservation in, 435 on, 395 removal of, 411 root end osteoblasts in, 393-394 cautery in, 414 anatomy of, 414 osteogenesis in, 393-394 chlorhexidine use before, 402-404 angle of resection, 415, 415f polymorphonuclear neutrophils in, 392 clinical decision making for, 389-390 burs for, 416 proliferative phase of, 392-393 complications of, 437, 437f cavity preparation. See Periradicular soft-tissue, 391-393 cone-beam computed tomography in surgery, root-end cavity preparation systemic disease effects on, 389 computed tomography versus, 400-402 conditioning of, 416 systemic medications that affect, 394-395 description of, 400-402 filling materials for. See Periradicular Periradicular tissue mandibular canal identification using, 398 surgery, root-end filling materials anatomy of, 630 maxillary sinus identification using, 399 goals for, 416 injury response of, 631 mechanism of action, 400-401 management of, 414-416 sodium hypochlorite effects on, 254f scan times with, 401-402 perpendicular resection of, 415f Peritubular dentin, 585, 585f conscious sedation for, 402-404 resection of, 414-415, 414f-415f Permanent restoration curettage in, 411-412 surface preparation of, 416 traumatic dental injury and, 789 electrosurgery in, 414 surface topography of, 416 vital pulp therapy and, e10-e11 flap designs used in, 409, 409f-410f root-end cavity preparation, 417-419 Persistent dentoalveolar pain disorder, 695-696, goals of, 408, 414 errors in, 417f 695f, 696b guided tissue regeneration in, 426-435, illustration of, 417f Persistent idiopathic facial pain, 44 427f-433f root fracture concerns, 417-418, 417f Persistent infection, 612 hard tissue in ultrasonic, 417-418, 417f Phagocytes, 639, 647f access considerations, 411 root-end filling materials Phagosomes, 639 healing of, 393-394 bioceramics, 422 Phantom tooth pain, 553, 690, 694-695 removal of, 411 bonded, 418-419, 419f Phenol, 261 hemostasis during, 412-414, 437 composite resins, 420-421 Phenolic preparations, 261 incisions used in Diaket, 420 Phentolamine mesylate, 96 horizontal, 409, 409f Dyract, 421 Phospholipase A2, 640 intrasulcular, 409, 409f Geristore, 421 Phosphoryn, 535 submarginal, 410f glass ionomer cements, 420 Photoacoustic streaming, of irrigants, 265 vertical-releasing, 408-409, 408f-409f ideal characteristics of, 419 Photoactivation disinfection, 265 indications for, 388-390, 391f mineral trioxide aggregate, 421-422 Photostimulable phosphor plates, 33-35 informed consent for, 402 overview of, 422 Picture archiving and communication systems, instruments used in, 405, 405f-407f resin-ionomer hybrids, 420-421 33 intentional replantation, 436, 436f zinc oxide–eugenol cement, 419-420 Pink spot, 784, 784f local anesthesia for, 405-408 success rates for, 390 Pit and fissure sealants, 588 localized hemostasis during, 412-414, 437 surgical site closure Pits and fissures, 588 in mandible flaps for, 424-425 Plastic carriers, 353-354, 354f anterior, 399-400, 400f sutures for, 425-426 Platelet aggregation, 551 posterior, 397-398, 398f technique for, 422-426, 426f Platelet endothelial cell adhesion molecule, 638 on mandibular incisors, 400 sutures for, 425-426, 436 Platelet-derived growth factor, 653t in maxilla tissue in Platelet-rich plasma, 455 anterior, 399-400, 400f reflection of, 409-411, 410f Platelets, 639 posterior, 399, 399f retraction of, 411 Plexus of Raschkow, 544-545, 544f maxillary sinus in transient bacteremia associated with, 396 Pluripotent stem cells, 448-449 cone-beam computed tomography vertical-releasing incisions for, 408-409, PMNs. See Polymorphonuclear neutrophils identification of, 399 408f-410f Pocket cysts, 326, 646-649, 648f exposure of, 437 wound healing Pockets in medically complex patients, 395-397 angiogenesis in, 392-393 probes for probing of, 802-803, 806f mental foramen identification, 398, 398f biologic principles of, 390-391 in vertical root fractures, 802-803, 805f-806f nonsteroidal anti-inflammatory drugs and, bisphosphonates effect on, 394-395 Polocaine, 97 402-404, 436 cementoblasts in, 394 Polycarboxylate cements, 827 898 INDEX

Polyglactic acid membrane, 435t Posterior superior alveolar nerve block, 103 Prilocaine Polyglycolic acid, 455 Posterior teeth. See also specific posterior teeth with 1 : 200,000 epinephrine, 97 Polylactic acid membrane, 435t nonvital, restorations for, 830-833, 4%, for inferior alveolar nerve block, 97 Polylactic-coglycolic acid, 455 831f-832f Primary afferent neurons, 685-686 Poly-L-lactic acid, 455 partial restorations in, 844 Primary dentin, 560-561 Polymodal receptors, 548-549 structurally compromised, 834 Primary pathogens, 602 Polymorphonuclear leukocytes Posttreatment disease Probes, 802-803, 806f in apical periodontitis, 638-639 apical periodontitis, 329, 331f, 380-381, Probing defect, 802 description of, 118 620f Procollagen, 541-542 Polymorphonuclear neutrophils after apical surgery, 334f Profile GT obturators, 311-312, 311f description of, 634 clinical decision making for, 326 ProFile instruments, 226, 228-229, 229f, 266 in wound healing, 392 clinical presentation of, 326f Profile Vortex File, 231 Polytetrafluoroethylene membrane, 435t comparative testing of, 331 Prognostication Pooling data, 475-476 cone-beam computed tomography of, definition of, 476 Porcelain fused to metal restorations, 336 328-329, 402 outcomes evaluation use for, 476 Positive rake angle, 216, 219f cysts as cause of, 326, 327f Projection neurons, 686-687 Post diagnosis of, 326-331, 328f Pro-Post drills, 312 active, 337, 338f etiology of, 324-326, 325f-326f Proprioceptors, e1 broken, 339f extraction-replantation for, 381, 382f ProRoot MTA, 314f, 739 cast, 337, 826-827, 833t extraradicular infection as cause of, 326 Prostacyclin, 551 cast gold, 844-846, 845f foreign body reaction as cause of, 326 Prostaglandins cementation of, 337-339 incidence of, 324 bone homeostasis regulation by, 395 ceramic, 341-343 intraradicular microorganisms as cause of, E, 395 characteristics of, 823 325-326 F, 395 clinical applications of, 337 missed canals as cause of, 373-374, 375f as inflammatory mediators, 551 clinical procedures for, 838-844, 840f-843f overextended filling materials as cause of, Prosthetic implants, 77-78 custom cast, 337 388 Prosthetic joints, 396 excessive flexing of, 823 premolar with, 328f ProTaper Universal, 230, 244 fiber, 825, 834 pulp vitality testing, 331 ProTaper Universal obturators, 311-312 fiber-reinforced composite, 341-343 radiographic assessment of, 328, 330f, 364f ProTaper Universal retreatment files, 350 fractured, 340f treatment of Proteoglycans, 541 materials used in fabricating, 337, 338f endodontic procedures, 333 Proton pump inhibitors, 117 passive, 337, 338f options for, 331-334 Provisional crowns, 846 perforation, 375f-376f planning for, 331-334, 331f-335f PRRs. See Pattern-recognition receptors placement of, 841 tooth extraction for, 332, 332f Pseudopocket, 646 prefabricated, 337, 824-825 Potassium nitrate, for dentin hypersensitivity, Psychiatric disorders, 78 removal of 579, 580f Psychogenic pain, 697 complications of, 345-346, 346f Practice management software, 6, 8f Psychogenic toothache, 696-697 exposure of post during, 339 Precementum, 662, 665 Psychosocial evaluation, 78 instruments used in, 339-341 Predentin, 537, 537f, 782 Pterygomandibular space, 712f-714f, 713-715 location considerations, 339 Prefabricated posts, 337, 825 Pulp in nonsurgical retreatment, 337-346, Pregnancy α-adrenergic receptors in, 557 338f-345f. acetaminophen use in, 74 age-related changes in, 566, e1 perforation during, 346 drugs used during, 74, 74b amputation of, e1. See also Pulpotomy post separation during, 346 local anesthetics in, 94 anatomy of, 451, e2 retention reduction technique, 340 treatment planning affected by, 74-75, arterioles of, 556, 556f techniques for, 339-343, 339f-345f. 74b biological irritation of, 583-584 ultrasonic instrument for, 340, 340f Premedication, before periradicular surgery, calcific metamorphosis of, 566, 566f resilience of, 823 402-404 calcifications of, 372f, 564-566, 564f-566f retention of, 824-825, 827 Premiere, 802-803, 806f capillary blood flow in, 556, 557f rigid, 833-834 Premolars carious exposure of, 578, 578f shapes of, 337, 338f mandibular cell-poor zone of, 534 stainless steel, 338f crown of, 154f cell-rich zone of, 534-535, e1 in structurally compromised teeth, 833-834 first. See Mandibular first premolars central core of, e1 threaded, 825 root canal configuration in, 141f chemical irritation of, 583-584 tooth survival affected by, 515 root canal morphology in, 141f collagen fibers in, 541-542, 542f tooth weakening caused by, 345-346 second. See Mandibular second collagen in, 541, 542f tooth-colored, 341-343 premolars configurations of, 130 vented, 337, 338f maxillary first. See Maxillary first premolars connective tissue of, 540-542 zirconium maxillary second. See Maxillary second coronal composition of, 825 premolars calcification of, 564, 564f removal of, 341-343 Pressoreceptors, e1 inflammation of, e7 Post Puller, 341, 344f Pretracheal space, 715 odontoblast layer of, 533 Post space, 828-829 Pretrigeminal neuralgia, 693 defenses of, against caries, 573-576 Posterior mandible, periradicular surgery in, Prevertebral space, 715 degeneration of, inflammatory processes as 397-398, 398f Previous endodontic treatment, symptomatic cause of, 162 Posterior maxilla, periradicular surgery in, 399, teeth with, 716 dendritic cells in, 662 399f Prevotella spp., 718 disease of, clinical classification of, 27-30 INDEX 899

Pulp (Continued) Pulp capping (Continued) Pulpal blood flow (Continued) elastic fibers of, 541 mineral trioxide aggregate for, 587-588, 766, resting, 557 elastin fibers in, 541 e7, e10-e16 vasoconstrictors effect on, 579-581, 580f extirpation of, 47f one-step, e10-e11 Pulpal canal obliteration, 779, 779f fibrosis of, 564f partial pulpotomy versus, 766-767 Pulpal cells fibrotic, 372f repair process after, e1 calcification effects on, 566 fluid drainage from, 558-559 two-visit, e10-e16, e26f connective tissue replacement of, 563, 564f ground substance of, 540-541 Pulp chamber dendritic cells, 538-539, 538f-539f, healing potential of, 560 anatomy of, 132, 136f 575-576 heat-related injury to, 582-583, 582f-583f calcification of fibroblasts, 537-538 hyaluronan of, 541 access cavity preparation in, 162-163, lymphocyte, 539, 540f hyperalgesic, 551-552 163f-164f macrophages, 538, 538f immune response of, 577 illustration of, 163f mast cell, 539 innervation of, 542-546, 542f-543f, 543t, floor of odontoblast process, 535-537, 575-576 687-689 description of, 145-147 odontoblasts. See Odontoblast(s) interstitium of, 540-541, 540f types of, 203f, 205 Pulpal exposure intraligamentary anesthesia injection effects visual inspection of, 157, 159f caries as cause of on, 109 pulp stones in, 565f description of, 578 metabolism of, 539-540 roof of, 151, 151f direct pulp capping for, 587-588 morphologic zones of, 532-535, 533f-534f walls of, 147 disinfectants effect on, 588 muscarinic receptors in, 557-558 Pulp horns hemostatic agents effect on, 588 neuroimmune interactions in, 552 anatomy of, 132 illustration of, 578f, 603f nociceptors of, 689 blood vessels in, 557f in children, e16f normal, 28 intratubular nerve endings in, 545 endodontic infections caused by, 601 odontoblast layer of, 532-534, 533f-534f, Pulp proper, 535 Pulpal inflammation 577f Pulp regeneration in apical root canal, 637f opioid receptors in, 578-579 animal models of, 457 caries as cause of, 575, 575f pathosis of, 281 potential for, 453, 457, 457f clinical symptoms and, 578-579 proteoglycans in, 541 Pulp stones, 564-565, 565f description of, 559-560 radicular Pulp testing illustration of, 603f age-related changes of, 566 carbon dioxide for, 16, 16f irreversible, 578 calcification of, 564, 564f cold testing, 16, 16f-17f, 547 mediators of, 578 nerve bundles through, 544-545, 544f electric, 16-19, 18b, 18f, 92, 547, 578 periodontitis as cause of, 591-592 odontoblast layer of, 533, 534f heat methods for, 16-17, 17f preoperative, 581-582 regenerative potential of, 453, 457, 457f importance of, 15 reparative dentin associated with, 562 repair of, 560-564, 561f-564f lack of response to, 578 vital pulp therapy in, 765 restorative materials effect on, 586-587, laser Doppler flowmetry for, 19 Pulpal irritation 587f in posttreatment disease, 331 access cavity preparation as cause of, 585 revitalization of, 772-773 for pulpal necrosis, 29 biological causes of, 583-584 sensory system of, 542 pulse oximeter for, 19, 19f calcium hydroxide as cause of, 586 stem cells of, 449, 450f, 451, 457 refrigerant spray for, 16, 17f chemicals as cause of, 583-584 structural proteins in, 541 sensitivity of, 18-19 dentin permeability and, 585 substance P in, 577 test cavity method for, 20 description of, 582-585 transcapillary fluid exchange, 558-559 thermal methods of, 15-19, 16f, 759 indirect factors that cause, 587 vascular supply of, 556-560, 556f-558f Pulp vitality restorative materials as cause of, 586 zones of, 532-535, 533f-534f, e1 endodontic prognosis and, 78 Pulpal necrosis. See also Intraradicular infection Pulp capping obturation timing based on, 284 acute apical abscess with, 708-711 crown fracture treated with, 766-767 reestablishment of, 780 anesthetizing symptomatic teeth with, 112 definition of, 766 testing of. See also Pulp testing apical periodontitis after, 637-638 direct description of, 17-18, 331, 784 asymptomatic teeth with bonding agents for, e2 Pulpal anesthesia anesthetizing of, 112 calcium hydroxide for, e2 articaine for, 99 after avulsion injury, 785 cariogenic bacteria survival after, e7 confirming of, 95, 95f bacterial contamination in, 284 definition of, e1 inferior alveolar nerve block for, 96-97, burn lesion with, 583f hemostatic agents for, 588 97f Calcium hydroxide as cause of, 285, 765-766 of mandibular molars, e6f maxillary, 102-104 canine space infection as cause of, 9 mineral trioxide aggregate for, 587-588, Pulpal blood flow crown fracture as cause of, 764, 764f e7, e8f, e13f age-related decreases in, 585-586 definition of, 29 outcomes of, 483, 488t-490t anatomy of, 556f-557f, 557 diagnosis of, 578 partial pulpotomy versus, e2 electrical stimulation effects on, 557 endodontic infections caused by, 602 indications for, 766-767 humoral control of, 558 fracture-induced, 797f indirect laser Doppler flowmetry assessments of, 19, illustration of, 603f boundary point for, e2 759-760, 760f in immature teeth, 314-315 case selection for, e2 Le Fort I osteotomy effects on, 592 luxation injuries as cause of, 779 definition of, e2 local control of, 558 obturation in, 284-285 indications for, e2 orthodontic forces effect on, 592 periodontal disease as cause of, 601 outcomes of, 480-482, 485f, 486t, 491f postural effects on, 560 previously initiated therapy category of, 29 stepwise excavation, 480 regulation of, 557-558, 558f previously therapy category of, 29 900 INDEX

Pulpal necrosis (Continued) Pulpotomy Radiographs pulp testing for, 29 calcific bridge formation after, 477f cone-beam computerized tomography and, pulpal inflammation as cause of, 560 cervical, 768 24, 25f revitalization of, 772-773 definition of, e1-e2 deep caries, e5f, e16f risks for, 447-448 formocresol, e2 digital root fractures as cause of, 777 full advantages of, 33 root resorption and, 286f definition of, 767-768 description of, 22-23, 23f, 33 in sickle cell anemia, 652 follow-up, 767-768 file formats for, 36 symptomatic teeth with, anesthetizing of, 112 indications for, 767 external cervical resorption on, 668-672, Pulpal nerve fibers outcomes evaluation of, 494t 668f-673f description of, 545-546, 545f technique for, 767 external inflammatory resorption on, neuropeptides in, 547 indications for, e2 665-666 Pulpal pain, 689 intrapulpal anesthesia for, 581 external root resorption on, 783, 783f-784f Pulpal reactions irreversible pulpitis treated with, 112 image characteristics and processing, 35-36 age of patient effects on, 585-586 laser, 589-590 internal root resorption on, 671, 676f, 677, to caries, 573-576, e2-e6 mineral trioxide aggregate for, e7, e14f, 680f, 782, 782f-783f to glass ionomer materials, 586-587 e16f intraoral, 20-22, 22f to implant placement and function, 593-594 outcomes evaluation of, 483-484, 491f, luxation injuries, 760f, 762, 763f to laser procedures, 588-590 492t posttreatment disease diagnosis using, 328, to local anesthetics, 579-581, 580f-581f partial 330f neurogenic mediators involved in, 576-578 calcium hydroxide, 766f principles of, 21 to orthodontics, 592 crown fractures treated with, 767, root fractures, 774, 774f-775f to orthognathic surgery, 592 768f-769f root resorption, 330f, 760-762, 761f-762f to parafunctional habits, 592-593 Cvek, 767, 768f shortcomings of, 22 to periodontal procedures, 591-592 definition of, e2 traumatic dental injury evaluations, 760-762, to restorative materials, 586-587, 587f follow-up after, 767, 769f 761f-763f to restorative procedures outcomes evaluation of, 483-484, 491f, vertical root fractures, 800f, 802, 802f, 804f, age of patient, 585-586 492t 806, 807f-808f dentin permeability effects, 585 pulp capping versus, 766-767 Radiography desiccation, 583, 586 root development after, 769f computed, 34-35 heat, 582-583 technique for, 767, 768f digital modalities for, 33 odontoblastic layer, 585 traumatic pulp exposures treated with, direct digital, 35 overview of, 581 767, 768f-769f modalities for, 33-35 physical irritation, 582-584 pulpectomy after, 769f radiation dose during, 35, 35b preoperative pulpal inflammation, 581-582 Pulse oximeter, for pulp vitality assessments, Radix entomolaris, 198-199, 198f, 731f proximity of procedures to dental pulp and 19, 19f Rake angle, 216, 219f surface area of dentin exposed, RANKL, 643, 662 584-585 Q Ratio measurement method, 237-238 to vital bleaching procedures, 590-591 QMiX, 259-260 RC-Prep, 262 Pulpal space Quality of life Reactionary dentin, 561, 574-575, 574f configurations of, 137 nonsurgical root canal treatment effects on, RealSeal SE, 294 infection of, 779-781, 780f 515, 517t Reamers, 223, 225 morphology of, 131 periapical surgery effects on, 522 Reciproc, 232 Pulp-dentin complex Rectified turpentine, for gutta-percha removal, definition of, e1 R 347-348, 348f description of, 532, 600 RaCe file, 231 Reductionism, 607 nerve fibers in, 545, 545f Racellets, 413, 423f Referred pain, 30, 684, 688f, 699 odontoblasts in, 451 Radiation absorbed dose, 401-402 Refrigerant spray odontogenic pain caused by, 687-689 Radiation dose, 35, 35b cold testing of pulp using, 16, 17f regeneration of, 458 Radiation therapy pulpal anesthesia testing using, 95f Pulpectomy caries caused by, 652 Regenerative endodontic procedures definition of, 769 osteonecrosis of the jaw caused by, 655 case studies of, 458-459, 461f-463f in immature teeth, e5 wound healing affected by, 75-76 clinical studies on, 460 indications for, 769 Radicular cysts definition of, 448 in mature tooth, 764-765 asymptomatic apical periodontitis and, goal of, 467 after pulpotomy, 769f 646-649, 649f, 654 intracanal medicaments used with, 459-460, Pulpitis bacteria in, 649f 459f, 462-464 apical, 637-638 Radicular dentin outcome measures for, 467-468 definition of, 28 description of, 811, 811f overview of, 460-464 hyperplastic, 576, 577f luting cement adhesion to, 828 research on, 468-469 irreversible. See Irreversible pulpitis root canal cleaning and shaping objectives revascularization protocol, 464-467, 466f pain associated with, 551-552 for, 211 root development after, 468 painless, 578 Radicular pulp root length after, 460-462, 461f-464f, 468 reversible, 28 age-related changes of, 566 root wall thickening after, 460-462, case study of, 703 calcification of, 564, 564f 461f-464f, 468 causes of, 707 nerve bundles through, 544-545, 544f success rates for, 467 description of, 28 odontoblast layer of, 533, 534f summary of, 468-469 vasoactive neuropeptides, e1 Radicular space, 282 terminology associated with, 458 INDEX 901

Regenerative endodontic procedures (Continued) Restorations (Continued) Root canal(s) (Continued) treatment procedures, 464-467, 466f, 467b partial, 844 bacteria in triple antibiotic paste, 459-460, 459f periapical healing and, 515 after chemomechanical procedures, 620 Regenerative endodontics/dentistry periodontal evaluation before, 829 ecosystem of, 616-619, 618f clinical studies on, 458-468 permanent, 789, e10-e11 nutrient sources for, 617-618 contemporary, 448 physical irritation caused by, 582-584 nutritional interactions, 618-619, 618f delivery system, 455-456 pretreatment evaluation, 828-830, 829f, blockage of, 268-269, 371, 372f, 374f goal of, 447 830t calcification of growth factors, 452-455, 453t-454t principles for, 830 access cavity preparation in, 162-163, history of, 447 removal of, 146-147, 147f, 159, 162f 163f-164f morphogens, 453-455 in structurally compromised anterior teeth, cone-beam computed tomography of, 49-50 overview of, 447-448 834 removal of calcified material, 163 preclinical studies on, 448-458 in structurally compromised posterior teeth, cone beam computed tomography of, principles of, 448 834 130-131 procedures. See Regenerative endodontic in structurally sound anterior teeth, 830 configuration of, 136f-138f procedures temporary, 789, 846 apical considerations, 142-144 research on, 458, 468-469 tooth position evaluations, 829 clinical determination of, 140-144 scaffolds, 455 tooth preparation for, 838 coronal considerations, 140, 140f stem cells in, 448-452 treatment strategy for, 830, 831f-832f C-shaped, 137f, 140f, 199-205, summary of, 468-469 veneer, 830t, 837f 203f-204f translational studies, 456-457, 457f Restorative materials, pulpal reactions to, midroot considerations, 140-141, 141f Remaining dentin thickness, 584, 763 586-587, 587f S-shaped, 132 Removable partial dentures, 332 Retractors, 406f supplemental, 138f Reparative bridge formation, e2-e3, e4f Retreatment coronal anatomy of, 140, 140f Reparative dentin, 132, 133f, 549-550, case examples of, 79, 80f-81f C-shaped 560-561, 561f-563f, 563, 575f, e2-e3 considerations before, 79 access cavity preparation in teeth with, Reparative dentinogenesis, 574 illustration of, 79f 199-205, 203f-204f Replantation, of avulsed teeth, 785 plan for, 79, 80f-81f illustration of, 137f, 140f Resilon, 299-300, 300f, 351, 351f plastic carriers used in, 312 curvature of, 132 Resin cements prognosis for, 79 dental operating microscope view of, 131, placement of, pulpal irritation during, 584 Retropharyngeal space, 712f-714f, 715 132f self-adhesive, 293 Retroplast, 420-421 diameter of self-etching, 293 Retrovisceral space, 715 description of, 143, 144t Resin composites, 821-822 Revascularization protocol, 464-467, 466f irrigation affected by, 249 Resin sealers Reversible pulpitis embryology of, 132 epoxy, 292, 293f case study of, 703 empty, 806, 807f methacrylate, 292-294 causes of, 707 furcation, 133, 133f obturation uses of, 292-294, 293f description of, 28 impediments of, 371-373 Resin-based luting cements, 827-828 diagnosis of, e5 irrigation of. See Irrigation Resin-modified glass ionomer cements, 826, irreversible pulpitis and isthmuses, 141, 141f e5-e7 differential diagnosis of, e5 ledged, 372f Resorbable membranes, 434, 435t sodium hypochlorite for differentiation of, materials extending beyond, 46-48, 50f Restorations e5 midroot anatomy of, 140-141, 141f access cavity preparation in, 159-162, sodium hypochlorite for diagnosis of, e5 missed, 373-374, 375f 161f-162f vital pulp therapy for, e2. See also Vital pulp multiple, 87f adhesive systems, 844 therapy obstructions of aesthetic evaluation and requirements, Richwil Crown & Bridge Remover, 336, 338f dental injection needle for removal of, 829-830 Ridge preservation, in periradicular surgery, 365-366, 368f amalgam, e10 435 ultrasonic instruments for removal of, 365, biomechanical evaluation for, 829 RinsEndo system, 264 366f clinical procedures for, 834-846, 835f-843f, Root obturation of. See Obturation 845f apical third of, 143-144, 144f, 144t orifices of clinical protocols for, 830t, 833t curved, 87f coronal flaring of, 152, 152f, 156-157 coronal leakage of, 159 post placement and selection affected by, identification of, 140, 140f, 145-146, 156, crowns, 822-827, 846 823 157f defective, removal before access cavity preparation of, 786-787 instrumentation for, 147, 149 preparation, 146-147, 147f, 159 radiographic evaluation of, 21 “mouse hole” effect, 156, 157f direct composite, 821-822, 835f-836f Root apex rotary nickel-titanium openers for, 152 endocrown, 822, 830t, 839f apical constriction and, 143t straight-line access determination, 152, full crowns, 822-827 illustration of, 142f-143f 153f guidelines for, 830 Root canal(s) overfilling of, 46 heat produced by, 582-583, 582f-583f accessory, 132-133 pathways of, 136-137 indirect, 822 anastomoses, 140 sealers for. See Sealers intracoronal, 798, 838 anatomy of, 132-144 transportation, 267-268 in nonvital posterior teeth with minimal/ apical part Root canal infection reduced tissue loss, 830-833 anatomy of, 142 bacteria that cause, 616-617 occlusal force evaluations, 829 disinfection of, 240 primary, 632 onlays and overlays, 822, 830t, 838f pulpal inflammation in, 637f routes of, 600-602 902 INDEX

Root canal system Root canal system cleaning and shaping Root canal treatment (Continued) components of, 132-133, 132f (Continued) nonsurgical cone beam computed tomography of, 46, 49f GT file, 229 outcome measures for, 477-479 sealing of, 280-283 GTX file, 229 periapical wound healing after, 652-654 Root canal system cleaning and shaping HERO 642, 230 periapical disease after, 477-478, 478f access cavity preparation. See Access cavity Hero Shaper, 230 periapical healing after, 282-283 preparation H-type, 223-224, 224f periapical healing after, factors that affect, bacteria after, 281 irrigation needles, 214f 495-509 biologic objective of, 211-212, 214f ISO norms for, 217-219, 220f acute exacerbation during treatment, 505 canal enlargement/preparation K3, 229-230 apical preparation, 497-498 apical preparations, 238-240, 239t K-type, 223 bacteria presence, 499-504, 500t-503t balanced force technique for, 243, 243f, LightSpeed file, 227, 266 illumination, 497 737 longitudinal design of, 216-217, 219f irrigants, 498-499 crown-down technique, 241-243, 267 low-speed engine-driven, 224-225 isolation, 497 danger zones in, 241 manually operated, 223-224 magnification, 497 hybrid techniques for, 245-248, 246b, motion of, 234 mechanical preparation, 497-498 246f-249f motors, 233-235, 233f medicaments, 499 LightSpeed technique for, 244-245, 246f MTwo, 231-232 number of treatment visits, 505 nickel-titanium instrumentation techniques, Peeso drills, 225 patient-related, 495-497 244-248 ProFile, 228-229, 229f root canal bacterial culture, 499, rationale for, 238-241 Profile Vortex File, 231 500t-503t rotary instrumentation for, 241, 243, 244f ProTaper Universal, 230 root filling, 504-505 self-adjusting file for, 245 RaCe file, 231 root filling material and technique, standardized technique for, 241, 242f reamers, 223, 225 504-505 step-back technique, 241, 242f, 737 Reciproc, 232 summary of, 506-509, 506f-509f step-down technique, 241 rotary, 226-235, 226t, 228f-229f treatment-related, 497-505 strategies for, 241 rotational speed of, 234 periapical radiolucency and, 78 vertical root fracture risks, 811 SAF, 228f restorative factors that affect, 505-509 case studies of, 269-270, 269f-270f self-adjusting file, 232 success rates for, 324 cervical dentin goals, 211 taper of, 217 tooth survival after, factors that affect clinical issues with, 212-213, 215f tip design of, 214-216, 218f description of, 509-515 coronal preflaring, 235-236, 236f-237f Twisted File, 231 diabetes mellitus, 509-512 criteria for evaluating, 265-269 WaveOne, 232 patient factors, 509-512 disinfection mechanical objective of, 210-211, 213f preoperative conditions of teeth, 513-515 antimicrobial nanoparticles for, 265 microorganisms, 209-210 restorative factors, 515 description of, 373-374 noninstrumentation technique for, 212, summary of, 515, 516f intracanal medications for 215f tooth morphologic type and location, bioactive glass, 262 objectives of, 209-212, 210b 512-513 calcium hydroxide. See Calcium obturation after, 285. See also Obturation treatment factors, 515 hydroxide patency file for, 236-237 Root development chlorhexidine. See Chlorhexidine principles of, 209-213 after partial pulpotomy, 769f formaldehyde, 261 problems during after regenerative endodontic procedures, halogens, 261 blockage, 268-269 468 lubricants, 262 canal transportation, 267-268 Root end phenolic preparations, 261 instrument fracture, 226, 227f, anatomy of, 414 steroids, 261-262 266-267 angle of resection, 415, 415f triple-antibiotic paste, 262 perforation, 268, 268f apexification. See Apexification irrigants. See Irrigants protocol for, 269 burs for, 416 irrigation. See Irrigation radicular dentin goals, 211 cavity preparation. See Periradicular surgery, manually activated techniques for, 263 smear layer removal after, 288-289, 289f root-end cavity preparation photoactivation, 265 surface irregularities created during, 221 conditioning of, 416 superoxidized water for, 265 technical objective of, 212 filling materials for. See Periradicular surgery, syringe delivery for, 262 well-shaped canals from, 265-266 root-end filling materials final apical enlargement, 248 working length determination, 237-238, 238f, goals for, 416 fluid dispersion in, 211-212, 214f 248 management of, 414-416 instruments for Root canal treatment perpendicular resection of, 415f alloys used in, 219-222, 222f access cavity preparation for. See Access resection of, 414-415, 414f-415f barbed broaches, 224, 224f cavity preparation surface preparation of, 416 breakage of, 234b bacteria effects on success of, 499-504, surface topography of, 416 characteristics of, 213-222 500t-503t Root filling cross-sectional design of, 216-217, 219f chemomechanical debridement, 666 apical extent of, 504-505 design elements of, 213-222 culture test, 478 office visit for, 789 Endo-Eze, 232 description of, 209 quality of, 505 EndoSequence, 231 diagnostic outcome of, 282-283 soft technique for, 772f engine-driven, 225-235, 226t, 228f-229f hermetic seal as goal of, 283 Root filling materials FlexMaster, 230-231 illustration of, 212f aesthetic appearance of teeth affected by, fracture of, 226, 227f, 266-267 of mandibular molars, 210f 821 Gates-Glidden drills, 225, 225f microbial penetration during, 602 heat used to soften, 370 INDEX 903

Root filling materials (Continued) Root wall thickening, after regenerative Sealers (Continued) neuritis caused by, 694 endodontic procedures, 460-462, noneugenol, 292 overextended, 388 461f-464f, 468 paraformaldehyde-containing, 295-296 removal of, 346-361, 347f-355f, 357f-361f Root-end filling penetration depth of, 288 treatment outcomes affected by, 504-505 periapical health after, 517-522, 521f periradicular extrusion of, 291, 291f Root fractures placement of, 407f placement of, 296, 297f apical, 774-777 tooth survival after, 522 radiopacity of, 290 causes of, 823-824 Root-end filling materials resin clinical presentation of, 774 bioceramics, 422 epoxy, 292, 293f complications of, 774-777 bonded, 418-419, 419f methacrylate, 292-294 cone beam computed tomography diagnosis composite resins, 420-421 obturation uses of, 292-294, 293f of, 51-52, 329 Diaket, 420 silicone, 294, 294f coronal, 774, 776f Dyract, 421 smear layer effects on action of, 288 definition of, 774 Geristore, 421 tricalcium silicate, 294, 295t-296t description of, 759 glass ionomer cements, 420 zinc oxide–eugenol diagnosis of, 51-52, 329, 391f, 774, 775f ideal characteristics of, 419 formula for, 292t exploratory surgery to diagnose, 391f mineral trioxide aggregate, 421-422 obturation uses of, 291-292, 292t facial, 775f overextension of, 742 Sealing, of root perforations, 26-27 fatigue, 798, 823-824 overview of, 422 Second division nerve block, 103 follow-up for, 777 radicular extrusion of Secondary dentin, 560-563, 566 healing of, 52, 774, 776f description of, 739 Secondary hyperalgesia, 687, 690-691 horizontal (transverse), 762, 763f, 774, illustration of, 743f Second-order neurons, 686-687 776f management of, 742-745 Sedation, conscious internal root resorption in, 776f obturation as cause of, 740, 742-744 nitrous oxide for, 113 intra-alveolar, 52 tissue damage caused by, 744-745 oral, with triazolam and alprazolam, 113 midroot, 774-777, 800 resin-ionomer hybrids, 420-421 for periradicular surgery, 402-404 prognosis for, 777 zinc oxide–eugenol cement, 419-420 Selective anesthesia, 20 pulpal necrosis caused by, 777 Ropivacaine, 98 Self-adhesive cements, 828 radiographs of, 774, 774f-775f Rotary instruments Self-adjusting file, 226, 228f, 232, 245 treatment of, 774 description of, 226-235, 226t, 228f-229f Self-curing luting cements, 827-828 ultrasonic root-end preparation as cause of, fracture of, 266-267 Self-etching adhesive systems, 844, e10 417-418 gutta-percha removal using, 349-350, 350f, Self-etching formulations, 583-584 vertical. See Vertical root fractures 355 Sensitization Root lesions, apical, 161f nickel-titanium, 214-216, 218f-219f, 226, central, 553-555, 687, 688b, 695 Root perforations, 26-27 233f, 266, 811f peripheral, 550, 550b, 550t, 687, 688b, in apical portion of canal, 378 stress on, 364f 695 cervical, 374-375 Rotary nickel-titanium orifice openers, 152 Sensory fibers, 543t, 635, 641 cone-beam computed tomography of, 50-51, Rotated teeth, access cavity preparation in, Separated instruments 681 163-165 causes of, 361-363, 364f, 725-726 coronal-radicular access to, 377 Roto-Pro bur, 340, 341f chemical removal, 726 in deep portion of canal, 377 Round carbide burs, 148, 148f, 411 dental injection needle for removal of, definition of, 26 Round diamond burs, 148, 149f 365-366, 368f furcal, 378f Roydent Extractor System, 367-369, 369f description of, 724-725 materials used to repair, 376, 376f-377f Rubber dam, periapical healing affected by, 497 Endo Extractor kit for removal of, 366-367, midroot, 374-375, 379f-380f Ruddle Post Removal System, 341, 344f 368f, 729-731 mineral trioxide aggregate for, 26-27, 147, Ruffled border, of osteoclasts, 660, 661f files, 365, 367f-368f, 726-727, 728f 376-378, 377f, 681 Hedstrom files for removal of, 365, 367f repair of, 374-378, 375f-379f S illustration of, 366f sealing of, 26-27 Saccharolytic bacterial species, 618 improper use as cause of, 362, 725-726 treatment of, 26-27 SAF instrument, 228f Instrument Removal System for removal of, Root planing, 592 Safety-Irrigator, 264, 264f 369-370, 370f Root resorption Salivary gland pain, 691 management of, 726-727 causes of, 54 Salivary gland stem cells, 449, 450f in mandibular molars, 726 cementum involvement in, 653 Sargenti paste, 694 Masserann technique for removal of, 367, cone beam computed tomography of, 52-55, Scaffolds, 455 726-727 54f Scheduling of appointments, 88 nickel-titanium instruments, 727-728 definition of, 660 Schwann cells, 545f, 575-576 operating microscope used in removal of, external. See External root resorption Scotchbond Multi-Purpose Plus, 766 369, 369f histologic features of, 660-662, 661f Sealers prevention of, 363 inflammatory, 780f calcium hydroxide, 292 prognosis for, 364-365, 733 initiating factors of, 660 calcium silicate, 294-295, 295t-296t radiograph of, 725f-726f internal. See Internal root resorption epoxy resin, 292, 293f removal techniques for, 365-370, 365f-367f, odontoclasts in, 660-662, 661f extrusion of, 291, 291f 727-733, 728f-732f osteoclasts in, 660 glass ionomer, 292, 292f-293f S.I.R. System for retrieval of, 370 pulpal necrosis and, 286f ideal properties of, 290b surgical approaches for management of, radiographs of, 330f, 760-762, 761f-762f, lentulo spiral for placement of, 296, 297f 731-733 781f medicated, 295-296, 297f ultrasonic instruments for removal of, 365, types of, 660 methacrylate resin, 292-294 366f, 727 904 INDEX

Septocaine. See Articaine, with 1 : 100,000 Sodium hypochlorite (Continued) Stoma epinephrine hypersensitivity to, 252 definition of, 12 Serotonin, 392 hypochlorous acid formation, 251-252 sinus tract, 12-13 Sialoproteins iatrogenic events caused by, 722-724, Straight-line access cavity preparation, 145, bone, 452-453 723f-724f 145f dentin, 451-453 mode of action, 251-252, 252f Strain measurement, 813f Sickle cell anemia, 5-6, 652 neutralization reaction, 251 Stromal derived factor 1, 457 Sievert, 401-402 pH of, 252 Stropko syringe, 422f Silicone sealers, 294, 294f pulp tissue dissolution capacity of, 253 Subcutaneous emphysema, cervicofacial, Silver cones, 296-297, 298f pulpitis diagnosis using, e5 748-750, 749f-750f Silver points root canal retreatment success affected by, Subepithelial external root resorption, 667 apical point of, 361, 363f 498-499 Sublingual space, 712-713, 712f-714f corrosion of, 358-359, 358f saponification reaction, 251 Subluxation, 777 disadvantages of, 358-359 temperature effects on, 252-253, 252f-253f Submandibular lymph nodes Gates-Glidden burs for removal of, 360 time course of, 253 palpation of, 9 Hedstrom files for removal of, 360, 360f toxicity of, 253-254, 254f tuberculosis involvement of, 5-6 persistent disease with, 358-359, 358f-359f Soft tissue Submandibular space, 712f-714f, 713 removal of, 358-361, 358f-363f healing of, 391-393 Submarginal flap, 410f, 424-425 separated, 363f intraoral, examination of, 11 Submasseteric space, 712f-714f, 713 trephine burs for removal of, 360 Software, dental history using, 6, 8f Submental space SimpliFill, 313, 313f Solid core carriers, 355, 355f description of, 712, 712f-714f Single amino-acid polymorphisms, 651 Solvents, for gutta-percha removal, 347-349, swelling of, 10, 10f Single nucleotide polymorphisms, 651 348f Subnucleus caudalis, 686 Single-visit treatment Somatic pain, 690-692 Subnucleus caudalis neurons, 553-554 description of, 79-82 Sonically activated irrigation, 263, 263f Subnucleus interpolaris neurons, 553-554 for irreversible pulpitis, 709 Source of the pain, 684 Subnucleus oralis neurons, 553-554 Sinus pain, 691, 700 Space-occupying lesions, 697 Substance P, 577, 635, 653t Sinus palpation, 700 Spatial resolution, 35, 42, 43f SuccessFil, 313, 313f Sinus tracts Spirochetes, 604, 605f Sulfite-induced reactions, 94 coronally located, 801f, 803-805 Splinting, 787, 787f Super-EBA, 419-420 definition of, 12 Split tooth Superficial pain, 699 extraoral, 10-11, 11f-12f definition of, 796-797 Superior cervical ganglion, 542 intraoral, 12-13, 14f description of, 796 Superoxidized water, 265 localization of, 13, 14f diagonally, 798, 799f Supraosseous extracanal invasive resorption, periapical infection with, 13 Split tooth/roots, 26 667 periapical radiograph of, 401f Spoon, endodontic, 150, 150f Surface irregularities, from root canal system stoma of, 12-13 Spot desmosomes, 533-534 cleaning and shaping, 221 S.I.R. System, 370 Staining, for crack detection, 20 Surgery Site of the pain, 684 Stainless steel carriers, 352, 352f American Society of Anesthesiologists risk 16S rRNA, 611 Stainless steel files, 223, 224f, 237f, system for, 395-396 Sjögren syndrome, 652 246-247 periradicular. See Periradicular surgery Small integrin-binding, ligand N-linked Stainless steel hand spreader, 812 Surgical debridement, 654 glycoproteins, 452-453 Stainless steel post, 338f Surgical retreatment Smear layer Staphylococcus aureus, 643 nonsurgical retreatment and, 333 bacterial adhesion affected by, 288 Steiglitz forceps, 352-353, 352f, 359f outcome of, 517-522 contamination of, 288 Stem cells periapical wound healing after, 654 irrigants affected by, 288 apical papilla, 449-451, 450f, 460 Surgicel, 412-413 removal of bone marrow, 449 Sutures before obturation, 288, 289f, 311 definition of, 448-449, 537 for periradicular surgery, 425-426, 436 citric acid for, 288-289, 416 dental follicle, 449, 450f removal of, 436 ethylenediamine tetraacetic acid for, 289 dental pulp, 449, 450f resorbable, 425-426 root-end conditioning for, 416 embryonic, 448-449 Swelling tetracycline for, 416 epithelial, 449 with acute periradicular abscess, 710 Sodium hypochlorite gingival-derived mesenchymal, 449 extraoral, 9f-12f allergic reactions to, 252 from human exfoliated deciduous teeth, 449 intraoral, 11, 12f-13f calcium hydroxide and, 679 mesenchymal. See Mesenchymal stem cells midface, 715 “champagne bubble” test, 131, 163 multipotent, 448-449 mucobuccal fold, 11, 13f chemicomechanical debridement of root canal periodontal ligament, 449-450, 450f Switch recombination, 635 using, 679 periosteal derived, 449, 450f Sympathetically maintained pain, 696 chlorhexidine and, 256f pluripotent, 448-449 Symptomatic apical periodontitis, 29 complications of, 722-724, 723f-724f populations of, 449 Symptomatic irreversible pulpitis concentrations of, 253 regenerative endodontics use of, 448-452 anesthesia in, 111 description of, 770 salivary gland, 449, 450f asymptomatic irreversible pulpitis versus, 109 ethylenediamine tetra-acetic acid and, 258 Step-back technique, for canal enlargement/ description of, 28-29 extrusion of, 723-724, 723f preparation, 241, 242f, 737 inferior alveolar nerve block in, 109 heating of syringes for, 252-253, 253f Sterilox, 265 in mandibular posterior teeth, 113 hemostasis using, e7, e21f, e23f-e24f Steroids, for root canal disinfection, 261-262 Symptomatic vital teeth, pulp anesthesia history of, 251 Stieglitz Pliers, 365 determinations in, 95 INDEX 905

Syndrome, 26 Tooth avulsion (Continued) Traumatic dental injury (Continued) Synthetic graft, 435t emergency management of, 785 luxation injuries Systemic diseases, 650-652 pulpal necrosis caused by, 785 apical neurovascular supply damage Systemic medications, wound healing affected replantation of, 785 caused by, 779-781, 779f-782f by, 394-395 root preparation in, 786-787 biologic consequences of, 777-784 socket preparation in, 787 definition of, 777 T treatment of, 785 description of, 759 Taper, 217, 220f, 268f Tooth discoloration, 821, 821f incidence of, 777 Taper lock, 267 Tooth extraction intrusive, 777 T-cell antigen receptors, 634 indications for, 333 lateral, 777 Teeth. See also specific maxillary and posttreatment disease treated with, 332, osseous replacement for, 778, mandibular teeth; specific tooth entries 332f 778f-779f abutment. See Abutment teeth vertical root fractures treated with, 815 pulpal canal obliteration caused by, 779, anatomy of, 690 Tooth germ progenitor cells, 449 779f anterior. See Anterior teeth Tooth pain, acute maxillary sinusitis versus, 5-6. pulpal necrosis caused by, 779 avulsed. See Avulsed teeth See also Toothache pulpal space infection caused by, crack. See Crack(s); Cracked tooth syndrome Tooth Slooth, 19-20, 20f, 794, 795f 779-781, 780f endodontically treated. See Endodontically Tooth stiffness, 819-821 radiographs of, 762, 763f treated teeth Toothache subluxation, 777 leaving open, 716-717, 717f-718f nonodontogenic. See Nonodontogenic treatment of, 777 nonrestorable, 333, 333f toothache types of, 777 posterior. See Posterior teeth odontogenic periodontal ligament contusion injuries sympathetic innervation of, 542 description of, 687-689 secondary to, 665 Telopeptide of the procollagen molecule, sources of, 687-690 permanent restoration, 789 541-542 organic source of, 697-698 prevalence of, 51 Temporal space, 712f-714f, 713 psychogenic, 696-697 pulpal blood flow assessments, 759-760, Temporary restoration, 789, 846 referred, 697-698 760f Tension-type headaches, 691-692 Topical anesthetics, 96 radiographic examination of, 760-762, Terminal periodontal disease, 333 Torsional fatigue, 726 761f-763f Terminal restriction fragment length Torsional fracture, of instruments, 266 replantation for, 785, 787 polymorphism, 611 Touch ’n Heat, 347, 347f root fractures Tertiary dentin Transcription factors, 453 apical, 774-777 description of, 560-562 Transforming growth factor-α, 653t clinical presentation of, 774 formation of, 574-575 Transforming growth factor-ß, 574, 653t complications of, 774-777 Tertiary dentinogenesis, 573-574 Transient receptor potential, 535 coronal, 774, 776f Test cavity method, for pulp vitality Transient receptor potential vanilloid-1 agonists, definition of, 774 assessments, 20 114 description of, 759 Tetraclean, 258-259 Transillumination diagnosis of, 774, 775f Tetracycline crack detection using, 20, 21f, 794, facial, 775f root-end surface modification using, 416 796f follow-up for, 777 smear layer removal using, 416 light source for, 796f healing of, 774, 776f Tetrodotoxin, 91, 552-553 Transmetal bur, 335-336 horizontal (transverse), 762, 763f, 774, TH0 cells, 634 Transmetal burs, 148-149, 149f 776f TH1 cells, 634 Transparent dentin, 819 midroot, 774-777 TH2 cells, 634 Traumatic dental injury prognosis for, 777 Thermafil, 311, 311f-312f, 355f adjunctive therapy for, 787 pulpal necrosis caused by, 777 Thermal allodynia, 551 aspects of, 758-759 radiographs of, 774, 774f-775f Thermal pulp testing, 15-19, 16f, 759 avulsed teeth treatment of, 774 Thomas Screw Post Removal Kit, 340, 343f consequences of, 784-785 root preparation, 786-787 Threaded posts, 825 description of, 759 soft tissue management in, 787 Three-dimensional imaging, 36-37, 38f, 62 emergency management of, 785 splinting of, 787, 787f Thromboxane A2, 551 pulpal necrosis caused by, 785 temporary restoration, 789 Tissue engineering replantation of, 785 types of, 759 advancements in, 447 treatment of, 785 vital pulp therapy for cell homing, 455-456, 456f cone beam computed tomography of, 51-52, full pulpotomy, 767-768 scaffolds, 455 52f-53f, 760-761, 763f partial pulpotomy, 767, 768f-769f Tissue reflection, in periradicular surgery, crown fractures pulp capping, 766-767 409-411, 410f complicated, 763-765, 763f-764f pulpectomy, 769 Titanium trauma splint, 787, 787f description of, 759 requirements for, 765-766, 765f TLR4/CD14, 633 treatment of, 763-765 Traumatic neuroma, 693 Toll-like receptors, 575, 632-633, 638-639, uncomplicated, 763 Treatment e1 crown infraction, 763 endodontic. See Endodontic treatment Tomography crown-root fractures, 759, 773-774 multiple-visit, 79-82 computed. See Computed tomography description of, 758 prognosis of, 78-82 definition of, 36-37 endodontic treatment, 787-788 referral considerations, 79 Tooth avulsion external cervical resorption secondary to, root canal. See Root canal treatment consequences of, 784-785 667 single-visit, 79-82 description of, 759 follow-up after, 759-760 Treatment failure. See Posttreatment disease 906 INDEX

Treatment planning U Vertical root fractures (Continued) biologic considerations used in, 82 Ultimate tensile strength, 819 patient history-taking, 799-800 description of, 71 Ultrafil 3D, 310, 310f periradicular radiolucency associated with, health status considerations, 86 Ultrasonic instruments 806, 808f interdisciplinary complications of, 346, 346f pockets associated with, 802-803, 805f-806f dental implants, 85-86 drawbacks of, 727 predisposing factors, 809-815, 810f-815f endodontic therapy, 85-86 heat generated by, 346, 346f, 370-371, 418 prevention of, 815 periodontal considerations, 82-83 post removal using, 340, 340f radiographs of, 800f, 802, 802f, 804f, prosthodontic considerations, 85 root canal obstructions removed using, 365, 805-806, 807f-808f restorative considerations, 85 366f, 371 root cross section in, 809-810 surgical considerations, 83-85 root-end cavity preparation using, 417-418, tooth extraction for, 815 medical conditions and findings that affect 417f treatment failure caused by, 389 behavioral disorders, 78 separated instruments removed using, 365, treatment planning for, 815 cardiovascular disease, 72-73 366f, 727 types of, 800f diabetes mellitus, 73-74 Ultrasonic tips warm vertical compaction as cause of, 304f, dialysis, 77 design of, 418, 418f 305 end-stage renal disease, 77 ledge removal using, 736-737, 737f-740f Vertical-releasing incisions malignancy, 75-76, 75f small diameter, 736 periradicular surgery access using, 408-409, pregnancy, 74-75, 74b Ultrasonic unit and tips, 150, 150f, 232f 408f-410f prosthetic implants, 77-78 Ultrasonically activated files, 356, 357f Virulence, 602 psychiatric disorders, 78 Uncomplicated crown fractures, 763 Virulence factors, 602-604 medical consultation letter, 71, 72f Universal Post Remover, 341 Viruses, 619 quality of life considerations, 86 Unmyelinated axons, 544 Vital bleaching risk assessments, 72 carbamide peroxide for, 590-591 treatment plan, 78 V pulpal reactions to, 590-591 Trephination, for pulpal necrosis with acute van Leeuwenhoek, Antony, 599-600 Vital pulp apical abscess, 708-709 Vascular cell adhesion molecules, 638 anatomy of, e2 Trephine burs, for silver points removal, 360 Vascular endothelial growth factor, 455-456, cells of, e1 T-RFLP. See Terminal restriction fragment length 644-645, 653t emergencies in, 707-711 polymorphism Vascular endothelial growth factor receptor 3, obturation in, 284 Triangular flaps, 409f 558 Vital pulp therapy Triazolam, for oral conscious sedation, 113 Vasoactive intestinal polypeptide, 542, 558, bacteria-tight seal in, 765 Tricalcium silicate, 294, 295t-296t, e3 578-579, 635 direct pulp capping. See Direct pulp capping Trichloracetic acid, 674-675 Vasoactive neuropeptides, e1 dressing used in, 765-766, 765f Triclosan, 259 Vasoconstrictors indications for, e5-e6 Tricresol formalin, 261 antihypertensive medications and, 73 materials for Triethylene glycol dimethacrylate, e2 in cardiovascular disease patients, 72-73 calcium hydroxide, 765-766, 765f, e5 Trigeminal autonomic cephalalgias, 691-692 local anesthesia uses of, 72-73, 94t, calcium silicate cements, e1, e6-e10 Trigeminal ganglion, 685 579-581 description of, e5 Trigeminal nerve, 686f, 746 pulpal blood flow affected by, 579-581, 580f hydrophilic resins, e5-e6 Trigeminal neuralgia, 692-693, 702-703 pulpal health affected by, 579-581 mineral trioxide aggregate. See Vital pulp Trigeminal nucleus, 686, 689f Vazirani-Akinosi technique, 99 therapy, mineral trioxide aggregate Trigeminal system V(D)J gene, 635 resin-modified glass ionomer cements, allodynia, 550-551, 550t Veneer, 830t, 837f e5-e6 deafferentation, 553 Vertical root fractures medicaments for, 766 dentin sensitivity, 547-550 apical, 809f mineral trioxide aggregate hyperalgesia, 550-551, 550t bone defect associated with, 803f, 809f biocompatibility of, e2 inflammatory mediators, 551 bone loss associated with, 800f-801f characteristics of, e2 innervation, 542-546 bone resorption associated with, 809 components of, e3 neuropeptides, 547 clinical manifestations of, 800-809, contralateral tooth development, e10 pain perception, 546-547 801f-803f description of, e1, e6 peripheral sensitization, 550, 550b, 550t complete, 794f direct pulp capping with, e7, e8f, e13f tissue injury, 553 cone-beam computed tomography of, 45, history of, e2 Trigger points, 690-691, 700 46f, 389, 808-809 inflammatory cascade, e2 Trigger zones, for trigeminal neuralgia, definition of, 798-799 MTA-Angelus, e3 692-693 description of, 26, 27f-28f, 335f pulpotomy with, e7, e14f, e16f Triple-antibiotic paste, 262, 459, 459f, 773 diagnosis of, 799-809 radiographs of, e27f Triptans, 692 diagonal, 799f signaling molecules, e2 Trismegistus, Hermes, 281 early diagnosis of, 802 in noninflamed pulp, 765 Tropocollagen, 541 in endodontically treated teeth, 800, 809-810 objective of, e1, e10 True cysts, 646-647, 649f, 654 etiology of, 809-815, 810f-815f outcome measures for, 476-477, 476t Tuberculosis, 5-6 exploratory surgery of, 809 partial pulpotomy. See Partial pulpotomy Tumor necrosis factor-α, 551 illustration of, 147f, 333f, 425f permanent restoration, e10-e11 Twisted File, 231 J-shaped radiolucency associated with, 802, postoperative follow-up and recall, e11 Two-visit pulp capping, e10-e16, e26f 804f, 805-806 prognostic factors for, 495 Type I collagen, 541 long-standing, 804f pulpotomy. See Pulpotomy Type II collagen, 541 misdiagnosis of, 802 purpose of, e1 Type III collagen, 541 occlusal factors associated with, 810 reparative bridge formation, e2-e3, e4f INDEX 907

Vital pulp therapy (Continued) Wound healing Wound healing (Continued) requirements for, 765-766, 765f angiogenesis in, 392-393 proliferative phase of, 392-393 techniques for biologic principles of, 390-391 radiation therapy effects on, 75-76 caries removal, e9 bisphosphonates effect on, 394-395 root fractures, 774, 776f diagnosis, e7-e9 cementoblasts in, 394 soft-tissue, 391-393 hemostatic agents, e9 cementogenesis in, 394 after surgical endodontic therapy, treatment considerations, e9-e10 chemotherapy effects on, 75-76 654 techniques used in, 476-477 clot formation in, 392 systemic disease effects on, 389 Vital teeth collagen in, 392-393 systemic medications that affect, asymptomatic, pulp anesthesia determinations cone beam computed tomography 394-395 in, 95, 95f assessment of, 58-60 Woven bone, 393 obturation timing in, 284 cyclooxygenase-2 inhibitors effect on, partially, anesthetic success in, 110 395 X symptomatic, pulp anesthesia determinations cytokines in, 653, 653t Xenograft, 435t in, 95 description of, 652-653 Xylene, for gutta-percha removal, 347-348, Vitronectin, 643 diabetes mellitus effects on, 654-655 348f Voltage-gated sodium channels digital radiography evaluation of, 36 description of, 91 endothelial cells in, 392-393 Y inflammation-related changes in distribution epithelium in, 393 Yeast cells, 605f of, 552-553 factors that affect, 390, 654-655 pain and, 92t fibroblasts in, 392 Z subtypes of, 92t glucocorticoids effect on, 395 Zinc oxide eugenol, 587, e24f subunits of, 92 granulation tissue formation in, 392 Zinc oxide–eugenol cement Voxel sizes, 38-39, 42 growth factors in, 653, 653t intermediate restorative material, Voxels, 38-39, 38f-40f, 329 hard-tissue, 393-394 419 hormones involved in, 394 as root-end filling material, 419-420 W inflammatory phase of, 391-392 Super-EBA, 419-420 Warfarin, 396-397 macrophages in, 392 Zinc oxide–eugenol sealers Warm vertical compaction obturation method, maturation phase of, 393 formula for, 292t 304-305, 306f-307f nonsteroidal anti-inflammatory drugs effect obturation uses of, 291-292, 292t WaveOne, 232 on, 395 Zinc phosphate cements, 827 Whitlockite crystals, 574, 574f after nonsurgical root canal therapy, 653, Zirconia Working length determination 653t burs for, 149 description of, 237-238, 238f osteoblasts in, 393-394 characteristics of, 149 digital radiographs for, 36, 37f osteogenesis in, 393-394 Zirconium posts Wound periapical, 652-654, 653t composition of, 825 decontamination of, polymorphonuclear periodontal incisional, 522 removal of, 341-343 neutrophils role in, 392 polymorphonuclear neutrophils in, Zorcaine. See Articaine, with 1 : 100,000 maturation of, 393 392 epinephrine This page intentionally left blank