Textbook of Endodontology

Lars Bjørndal, Lise-Lotte Kirkevang, John Whitworth, Lars Bjørndal, Lise-Lotte Kirkevang, John Whitworth

• Publisher: Wiley-Blackwell
• Year: 2018
• ISBN:
  9781119057369
• Edition: 3
• Topic: Medizin
• Subtopic: Zahnmedizin

The third edition of Textbook of Endodontology provides lucid scholarship and clear discussion of endodontic principles and treatment to dental students and dental practitioners searching for current information on endodontic theories and techniques.

• Completely revised and updated new edition
• Featuressix new chapters
• Provides pedagogical features to promote understanding
• Includes clinical case studies to put the information in the clinical context
• Illustrated in full color throughout with clinical images and detailed diagrams
• Offers interactive multiple-choice questions on a companion website

Chapter 1
Introduction to endodontology

John Whitworth, Lise-Lotte Kirkevang, and Lars Bjørndal

Endodontology

The word “endodontology” derives from the Greek language and can be translated as “the knowledge of what is inside the tooth.” Thus, endodontology concerns all structures and processes within the tooth, with particular reference to the dental pulp and the space it occupies. But what about “knowledge”? What does it actually mean to “know” things? Most people would probably say that knowledge has something to do with truth and being able to provide reasons for things. It is often believed that dental and medical knowledge is simply scientific knowledge – truth that is supported by scientific research to provide reasons for disease processes and justification for clinical actions. But as practicing dentists, scientific knowledge is not always sufficient, and although it is important to know about the anatomy of the pulp space and the fatigue failure of engine-driven endodontic files, we must also develop sound judgment and the ability to make correct clinical decisions, often in the face of uncertainty. The knowledge required by dental practitioners is therefore complex and multidimensional and can be considered within Aristotle's domains of “episteme,” “techne,” and “phronesis” [1].

Episteme

Episteme is the word for theoretical, scientifically supported knowledge, the opposite being doxa, which refers to common beliefs or opinions that may not be so grounded in “hard” evidence. The body of epistemic knowledge in endodontology is enormous, spanning from fundamental pulp biology to the clinical risk factors associated with root canal treatment failure. The knowledge generated by science, however, is often less certain than we would wish, and subject to the weakness of study design, the bias of conflicting interests, and a lack of obvious translation to the realities of “wet-fingered” dentistry. Nevertheless, efforts are made to present scientific knowledge in a balanced way through lectures, articles, and textbooks, so from a student's point of view, learning requires ample time for reading and opportunities for discussion and reflection. This book, in large part, is composed of epistemic knowledge.

Techne

A substantial element of learning endodontology must be characterized as techne, or “knowing how,” which embraces elements of practical skill, craft, and artistry. It is not always possible to explain every detail of how we perform technical acts, such as negotiating a challenging root canal with delicate tactile sense or riding a bicycle around a corner without falling off. In this way, it is not sufficient to teach students how to shape a root canal solely by asking them to read a book or attend a lecture. Their knowledge must be supplemented with practical experiences, both observing and doing, and by discussion and personal reflection to understand the challenges they encounter, develop cognitive and practical strategies to overcome them, and to help them do better next time.

It is not possible to learn all about the procedures in endodontology by studying a textbook. Observing a good clinical instructor, watching other dentists at work, performing the procedures oneself, and reflecting on what has been learnt are all important. The preclinical simulation laboratory provides an essential environment in which to embed new factual knowledge and translate it into practical reality.

Phronesis

According to Aristotle, phronesis is the ability to think about practical matters and then acquire the ability to act in the “right” way in any given circumstance. The practice of clinical dentistry demands that wisdom is exercised, “to do the right thing at the right moment,” acting in the best interest of the patient, even if it is difficult or costly for the dentist to do so. Examples might include the use of rubber dam to control asepsis in all endodontic procedures, or being honest with patients and seeking a practical solution when when things have gone wrong. Again, this cannot be fully developed by reading a book; the essence of phronesis must be learnt from practice.

Concepts of endodontology

It can be concluded that endodontology encompasses not only theoretical thinking but also the practical skills of a craftsperson and the practical thinking needed for clinical and moral judgment. The serious student of endodontology must investigate all three aspects, and although this textbook will contain many pointers to the development of technical skills and clinical judgment, there are understandable limits to what can be achieved without hands-on experience combined with diligent reflection.

The objective of endodontic treatment

The consequences of inflammatory lesions in the dental pulp and periapical tissues have tormented humankind for thousands of years (Fig. 1.1) and historically, the main task of endodontic treatment was to cure toothache caused by inflammation in the pulp (pulpitis) and the periapical tissues (apical periodontitis). For a long time, this was achieved by cauterizing pulp tissues with hot wires, applying toxic chemicals such as arsenic or formaldehyde, or by incising soft tissues to drain pus; all extremely painful in the era before local anesthetic.

Fig. 1.1 A medieval skull found in Denmark showing teeth with serious attrition. In the mandibular left first molar the pulp chamber is exposed and the alveolar bone is resorbed around the root apices, indicating that this person had been suffering from periapical inflammation caused by an infected, necrotic dental pulp.

Although the relief of pain is still a primary goal of endodontic treatment, much of the pulpal and periapical disease that we encounter is painless, and the emphasis should be on managing the cause of disease, invariably microbial infection, and promoting conditions that are compatible with the healing and repair of tissues. This means that all steps of the endodontic procedures described in this book, ranging from caries management and vital pulp therapies to surgical retreatment and the final coronal restoration, should be guided by efforts to eliminate and exclude microorganisms from the pulp space, the periapical tissues, and, by extension, from other parts of the body. With meticulous infection control, the treatments described should allow predictable tissue healing and the preservation of functional teeth in the large majority of cases.

Clinical problems and solutions

Core concepts 1.1 and 1.2 provide a summary of common pulpal and periapical conditions and the treatment procedures to manage them.

The vital pulp

Under normal physiological conditions, the dental pulp is sterile and well protected from injury by hard tissues and an intact periodontium. But when the integrity of these tissue barriers is breached for any reason, microorganisms and the substances they produce may enter the pulp and adversely affect its health. The most common microbial challenge is from dental caries. Even at an early stage of caries progression, the immunocompetent pulp is aware, because substances from the cariogenic biofilm may reach the dental pulp and its odontoblast cells along patent dentinal tubules. Like any connective tissue, the pulp responds with innate and adaptive immunity, which has an important role in neutralizing and eliminating the noxious agents. Inflammation within the pulp can be seen as a two-edged sword, with the early stages providing a “necessary” defensive response, contributing to hard-tissue deposition and to the repair of damaged soft tissues. Thus, the pulp may react in a manner that allows it to sustain the irritation and remain in a functional state. Yet when caries has actively progressed to the vicinity of the pulp, the response may take a destructive course leading to tissue necrosis followed by large-scale microbial invasion. These processes may or may not be painful. In an ideal world, it would be possible to control all risk factors for caries, but caries remains highly prevalent, and if damage is to be limited, practitioners should recognize and treat precavitated carious lesions without operative intervention, and approach the operative treatment of lesions that have progressed more extensively in a way that will avoid direct pulp exposure to the mouth (Fig. 1.2a). Even in the case of frank pulp exposure after traumatic injury or during operative dentistry, especially in the young, it may be pos...

Table of contents

• Cover
• Title Page
• Copyright
• List of contributors
• Foreword
• Preface
• About the companion website
• Chapter 1 Introduction to endodontology
• Part 1 The Vital Pulp
• Part 2 The Infected Necrotic Pulp and Apical Periodontitis
• Part 3 Endodontic Treatment Procedures
• Part 4 The Endodontically Treated Tooth
• Part 5 Additional Considerations
• Index
• End User License Agreement