Najamul H. Ansari, MD

• Assistant Professor, Department of Internal
• Medicine, Division of Cardiology
• Rush Medical College
• Attending Physician
• Section of Adult Cardiology, John H. Stroger, Jr.
• Hospital of Cook County
• Chicago, Illinois

It is beyond the scope of this chapter to outline all of the medical conditions that need to be managed when considering endodontic microsurgery heart attack 6 minutes cheap 100 mg labetalol amex. This allows the endodontist to know how the specific tooth in question will be restored and used in the restorative plan blood pressure readings by age labetalol 100 mg purchase free shipping. The history of the specific tooth or teeth that may require endodontic treatment will give the endodontist the background to know if the tooth should be treated nonsurgically arrhythmia flowchart labetalol 100 mg order free shipping, re-treated nonsurgically arrhythmia or anxiety buy labetalol 100 mg mastercard, or treated with surgical endodontics hypertension kidney disease labetalol 100 mg order with visa. Nonsurgical endodontics has a very high success rate and usually should be the first line of treatment. If initial root canal therapy was not successful, retreatment to correct any deficiencies is indicated prior to surgical intervention, if possible. Surgical endodontic outcomes with modern techniques is as successful as nonsurgical retreatment, and in some situations is better. Some nonsurgical retreatment involves potential risk, such as removing a large post or requiring removal of additional dentin. These potential risks would make surgical endodontics a better option for these patients. Clinical considerations the presence of teeth with nonvital pulps in the surgical field may require nonsurgical endodontics to be performed before surgical endodontics on the tooth in question is completed. A thick buccal cortical plate with a prominent external oblique ridge may preclude root-end surgery on a mandibular second molar. The same may true for a palatal approach to a maxillary molar palatal root, if there is a shallow palatal vault with thick palatal bone. An extremely shallow facial vestibule can contraindicate root-end surgery, or it can at least be an indication to extend the mucoperiosteal flap in a horizontal direction. Palpation over the root eminences can reveal areas of dehiscence or concavities between roots, thus indicating where vertical incisions may be placed. Care must also be exercised to not place a vertical incision where it could intersect the mental nerve as it exits from the mental foramen. Periodontal considerations Periodontal probing depths will indicate bone level and dictate a flap design that would allow inspection of the crestal bone in some cases and would detect a periodontal pocket in other cases. Teeth with a poor periodontal prognosis should not be considered for root-end surgery. Teeth with gingival recession, furcation defects, horizontal or vertical bone loss, and endo­perio lesions can affect the decision to treat the tooth with endodontic surgery, and will determine flap design if a tooth will be treated surgically. Soft tissue considerations the width of the attached and keratinized gingiva and the periodontal tissue type also influence flap design. The presence of a sinus tract influences the reflection of the mucoperiosteal flap. Muscle attachments and frenums may dictate where vertical releasing incisions are placed. Preexisting scar tissue and exostosis call for careful reflection of the mucogingival flap. Radiographical considerations If cracks, vertical root fractures, or cervical resorptive areas are present, an intrasulcular flap may be required to view and examine these areas. The size of the periapical lesion will determine the horizontal component of the mucogingival flap. A large lesion requires a longer horizontal component to the flap as opposed to no lesion or a small periapical lesion. The placement of a vertical incision must be at least one tooth away from the extent of the periapical lesion. Prosthodontic considerations Teeth that are not restorable should not be considered for root-end surgery. The presence of crowns in the esthetic zone might lead the endodontic microsurgeon to consider a submarginal flap design or a papilla base incision. The presence of a fixed bridge can influence the location of the incision in the area of the pontic. In some cases, with enough tissue present, the incision can be placed 3 to 4 mm from the pontic so that the flap may be elevated, allowing enough tissue for suturing. In other cases, the incision can be extended to the lingual or palatal side of the pontic and reflected from beneath the pontic as part of the mucoperiosteal flap. The length and type of material of the post in teeth that have been restored with a post must be evaluated, because it can affect the ability to perform root-end preparation. Presurgical preparations Before initiating the procedure, the risks and benefits should be explained to the patient. A consent form for endodontic microsurgery should be discussed and signed by the patient. Prior to the procedure, the oral and written postoperative instructions should be given to the patient. On the day of the surgery, the patient should be given 400 to 600 mg of ibuprofen to limit the inflammatory response from the surgical procedure. The patient is then draped with sterile covers or towels, and the endodontic microsurgical team proceeds with their surgical scrub, donning surgical and personal infection-control gear. Anesthesia and hemostasis Hemostasis during surgical procedures is important to enhance visibility, instrumentation, and placement of root-end filling materials and to maximize the physical properties of the root-end filling materials. It is essential to ascertain if the patient is taking any medications that might increase bleeding or if the patient has any bleeding disorders. Liver disease, including vitamin K deficiency, and alcoholism can increase bleeding. Other platelet-altering drugs, such as clopidogrel (Plavix), alcohol, and -lactam antibiotics can effect bleeding. Drugs that alter coagulation include heparin, warfarin (Coumadin), and direct thrombin inhibitors [6, 7]. It is now thought that for relatively minor oral surgical procedures, including root-end surgery, it is better to have the patient who is on anticoagulant therapy, such as aspirin, clopidogrel, or warfarin, to continue these medications rather than risking thromboembolisms. Some patients do not consider herbal medications and other dietary supplements to be drugs, but several of these medications can cause bleeding problems. Supplements such as echinacea, gingko biloba, and fish oil can prolong bleeding time. In general, if the endodontic microsurgeon can use blocks rather than local supraperiosteal infiltrations, a wider area will be anesthetized with fewer injections. For hemostasis, lidocaine with 1:50,000 epinephrine is infiltrated in the surgical area near root apices, carefully avoiding the skeletal muscle at the depth of the mucobuccal fold. One does not want to activate the 2 -adrenergic receptors in skeletal muscle, which will lead to vasodilation and increased bleeding instead of the desired vasoconstriction. Activation of the 1 -adrenergic receptors in the alveolar mucosa and gingival tissues will lead to the desired vasoconstriction to aid in hemostasis in the surgical field. Lidocaine with 1:50,000 epinephrine has been demonstrated to be an effective means of controlling bleeding during surgical procedures in the oral cavity [19]. The delivery of anesthetic solution should be at a relatively slow rate, perhaps taking one to two minutes to support patient comfort, adequate surgical anesthesia, and effective hemostasis. A long-acting local anesthetic such as bupivacaine is useful in postoperative pain control by providing anesthesia to the surgical area for 4 to 9 hours [20]. Patient positioning and microscope alignment Patient positioning is extremely important in endodontic microsurgery. Because the surgeon is required to retract tissues with one hand and use the dominant hand for instrumentation, direct vision through the microscope is necessary, as the microsurgeon does not have a free hand with which to hold a mirror. The exceptions to this rule are surgeries performed on palatal roots, where the palatal flap can be sutured to the other side of the mouth to reflect it, or surgeries on lingual surfaces of mandibular teeth for procedures to repair resorptive defects. One that simplifies patient positioning, microscope alignment, and surgeon position has been developed by Dr. The patient must be positioned in the dental chair so that the long axis of the tooth undergoing the surgical procedure is parallel to the floor. This allows direct vision through the microscope and also places the long axis of the tooth parallel to the floor. The microscope should be aligned so that it is parallel to the long axis of the tooth upon which the procedure is being performed. To prevent neck strain, the patient should be positioned completely on their side, rather than simply turning their neck. This facilitates looking directly down on the tooth at a right angle to the long axis of the tooth. The microscope may be tilted slightly, or the patient may tilt their head up or down once the resection has been completed, so that the resected root end face may be inspected. This inspection will confirm the completion of the resection and identify the location of canals and isthmus, which may be enhanced with methylene blue dye. With the correct positioning and alignment of the patient, the microscope, and the surgeon, the surgery can be more accurately carried out using the increased magnification and illumination provided by the surgical operating microscope. Other patient-positioning schemes and microscope alignments have been proposed by Rubinstein [22], by Merino [1], and by Kim [2]. This will ensure that the resection cuts are at 90 degrees to the long axis of the tooth. The diagram on the left demonstrates a parallel alignment where the microscope axis is parallel to the long axis of the tooth, which leads to a resection of 90 degrees to the long axis of the tooth. The diagram on the right demonstrates an angled alignment where the microscope axis does not match the long axis of the tooth, which can result in an angled resection. For root-end preparation, the microscope can be angled to view the resected root end. The surgeon is not aligned in the long axis of the tooth in some of these positions. Memory foam may be customized and fitted to the dental chair to make it more comfortable for the patient, especially when the patient must lie completely on their side during the surgical procedure. Mucogingival flap designs and soft tissue management the selection of the most favorable mucoperiosteal flap design affects access during surgery and healing outcomes. The choice of flap design should be based on many factors to ensure maximum access and visibility of the surgical site, favorable hard and soft tissue response, minimal gingival recession, and good healing with little or no morbidity. The mucogingival flap designs used in endodontic microsurgery include the envelope flap, the intrasulcular flaps (triangular and rectangular), the submarginal flap (Ochsenbein­Luebke), the palatal flap, and the papilla base flap. The semilunar flap has many disadvantages and minimal advantages or indications in endodontic microsurgery. Some of the disadvantages include limited access and disruption of blood supply to unflapped tissues, which can result in delayed healing and scarring. The difference in the triangular and rectangular flap design is that the rectangular flap has two vertical releasing incisions, whereas the triangular flap has only one. The horizontal incision for the triangular and the rectangular intrasulcular mucogingival flaps is made in the gingival sulcus and extends to the crestal bone, cutting through the gingival attachment and the periodontal Envelope flap the envelope flap is an intrasulcular incision without a vertical releasing incision. It may be used for repair of cervical defects such as resorption repairs, submarginal caries removal, or other corrective surgery in the cervical areas of teeth or crestal bone areas. The vertical incision should be parallel to the supraperiosteal blood vessels, which run in a vertical direction from superior to inferior parallel to the long axis of the tooth roots [3]. Creating an incision with this in mind greatly reduces the number of vessels that will be severed, thus providing better blood supply to the reflected flap. The vertical incisions should be over sound bone, avoiding periapical lesions and frenum or muscle attachments [24]. Ideally, the vertical incision should be in the concavities between the bony eminences covering the roots. This follows a plastic surgery principle that states incisions should be placed in shadows or creases to help hide the incision line when the incision is healed. The vertical incision should start at the line angle of the tooth at the marginal gingiva and should meet the marginal gingiva at a 90-degree angle. This gives the vertical incision a shape similar to a hockey stick, with the blade portion of the hockey stick extending at right angles from the marginal gingiva to the longer vertical portion of the incision, which could be viewed as the handle of the hockey stick. It is critical that this portion of the vertical incision be at right angles to the marginal gingiva to prevent a pointed tip to the flap, which will be difficult to reapproximate and suture and can result in healing with a double papilla. Also, when the incision meets the marginal gingiva in the apical third of the papilla, it reduces the distance for blood profusion to the rest of the papilla. The vertical portion of the incision can be slightly beveled toward the flap and not extend into the mucobuccal fold. For ostectomy, curettage, and resection, the microscope can be at a 90-degree angle to the long axis of the root. Intrasulcular flaps provide a good view of crestal bone, periodontal defects, and vertical root fractures, if present. It is relatively easier to reapproximate the triangular and rectangular flaps, and they are easier to suture. The disadvantages of the intrasulcular flaps are the amount of gingival recession and possible alteration of the gingival papilla. Submarginal flap the submarginal flap, or the Ochsenbein­Luebke flap, is a flap design used primarily in the anterior maxilla, particularly where there are full crowns in the area [27]. It is reported to cause less recession around crowns, thus preventing the unesthetic exposure of crown margins. The flap consists of two vertical releasing incisions and a horizontal incision, which is in the attached keratinized gingiva. It is extremely important to perform periodontal probing in the area where the flap will be prepared to ensure that there is at least 3 mm of attached keratinized gingiva apical to the probing depths. One method of doing this is with a pocket marking instrument that has one beak inserted into the sulcus and the other beak at a right angle to the tip. When they are closed together, a bleeding point will mark the depth of the sulcus [21]. The arrow indicates a vessel passing into the papillary layer to form a capillary plexus next to epithelium. Both vertical releasing incisions should be in the concavities between the bony eminences over teeth and meet the marginal gingiva at right angles at the junction of the middle and apical third of the interdental papilla.

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The preparation of the dentin through these chemical agents may prevent shrinkage of the resin filling away from the dentin wall and aid in sealing the roots with the Resilon material blood pressure chart print discount labetalol 100 mg without a prescription. The self-etching primers are further reduced from a two-bottle system to a single-bottle system arteria radial buy labetalol paypal. In the single-bottle self-etching primer hypertension in pregnancy buy labetalol 100 mg with visa, the functional acidic monomers blood pressure medication in pregnancy cheap labetalol 100 mg on-line, solvents hypertension 101 purchase labetalol online now, water that is necessary for ionization of the acidic monomers, and self-cured catalysts are incorporated into one component in the single bottle. The premise behind the material is the formation of a monoblock, that is, the primer forms a hybrid layer with dentin, which bonds to sealer and then bonds to the Resilon core. The ability of Resilon to bond to methacrylate-based root canal sealers has been questioned. Unpolymerized resin was found to be available between the core material and the resin sealer. This led to the conclusion that the amount of dimethacrylate in the thermoplastic composite might not be optimum for chemical coupling. Hence, although the sealer had low viscosity, keeping all the above factors in mind, the sealing ability of thin films inside the canal remained questionable [48, 49]. Resilon/Epiphany sealer was then introduced again as RealSeal by adding a thinning solvent ethoxylated bisphenol-A-dimethacrylate to adjust the viscosity but did not include photoactivation. Dentin adhesive primers are now incorporated into the resin-based sealer/composite to render them self-adhesive to dentin substrates. The combination of an etchant, a primer, and a sealer into an all-in-one self-etching, self-adhesive sealer is advantageous in that it reduces the application time as well as errors that might occur during each bonding step. Therefore, in theory, the bonding mechanism of self-adhesive sealers is similar to self-adhesive resin materials. These materials are relatively new, and detailed information and research is limited. It is recommended for use exclusively with cold-compaction or single-cone techniques. The sealer is claimed to bond to both the Resilon core and radicular dentin via hybrid layers in both substrates, leading to a monoblock unit. It may be used with Resilon cones or pellets by using cold lateral or warm vertical techniques or with RealSeal 1, a carrier-based Resilon obturator system [58]. This combines adhesive bonding technology with a carrier product and provides benefits of an efficient obturation technique combined with optimal leakage resistance (explained later). Problems associated with resin-based sealers Bonding within a deep and narrow root canal is a challenge due to the complex geometry of the root canal. The resin penetrates into the dentinal tubules, Chapter 5: Root canal filling 121 whereas the filler particles remain at the interface. Proper and uniform application of the adhesive and primer is critical, but it is difficult to achieve this in the apical third of the canal. Polymerization shrinkage is inherent to methacrylate resin­based sealers, which tend to produce debonding at the resin­dentin interface. Modern root canal filling core materials Gutta-percha Since its introduction in 1914 by Callahan, gutta-percha is the standard material of choice as a solid core-filling material for root canal filling (Box 5. It is a trans-isomer of polyisoprene and exists in two crystalline forms (alpha and beta) with differing properties. The use of alpha phase gutta-percha has increased as thermoplastic techniques have become more popular. Gutta-percha cones consist of approximately 20% gutta-percha, 65% zinc oxide, 10% radiopacifiers, and 5% plasticizers. Alpha phase gutta-percha is brittle at room temperature and is runny, tacky, and sticky (low viscosity), whereas beta phase gutta-percha is stable and flexible at room temperature and is solid and compactible (high viscosity). Although gutta-percha has many desirable properties, such as chemical stability, biocompatibility, nonporosity, radiopacity, and the ability to be manipulated and removed, it does not always bond to the internal tooth structure, resulting in the absence of a hermetic seal [59] (Box 5. Many attempts have been made to resolve the problem through variations in obturation techniques such as vertical and lateral condensation, the use of reverse-fill or touch and heat systems. The disadvantages of gutta-percha in endodontic therapy have led to the development of a new material known as the Resilon/Epiphany (R/E) system. Resilon (Pentron Clinical Technologies) Resilon is a core obturation material alternative to guttapercha and requires a sealer to complete obturation of the canal system. Resilon, a synthetic resin-based polycaprolactone polymer, is used with Ephiphany, (Pentron Clinical Technologies), a resin sealer, in an attempt to form an adhesive bond at the interface of the synthetic polymer-based core material, the canal wall, and the sealer. These have gutta-percha­like handling properties and the ability to bond to the sealer, which in turn bonds to dentin within the root canal. This eliminates the probability of microleakage between the core material­sealer interface and the sealer­dentin interface. In 2003, Resilon Research introduced Resilon obturating points and Epiphany sealer into the commercial market. The system consists of Epiphany primer, Epiphany sealer, and Resilon core material (Box 5. Based on polymers of polyester, Resilon Material contains bioactive glass and radiopaque fillers. It is a high-performance industrial polyurethane adapted for endodontic use and resembles gutta-percha in color, texture, radiopacity, and handling properties. It consists of a resin core material, available in conventional/standardized cones or pellets, and a resin sealer. It is obturated with RealSeal sealer, formerly known as Epiphany, which incorporates self-etching primers. The manufacturer claims that this system creates a monoblock effect with the canal wall. Such a monoblock eliminates the gaps associated with the core material and sealer, resists shrinkage, and strengthens the root [60­62]. Because the Resilon/Epiphany root filling material is a composite resin-based system, it does not have a deleterious effect on the subsequent resin-bonding procedures often used for coronal restorations. Any obturation technique may be used with the Resilon system, although it works effectively with vertical and lateral condensation techniques. The Resilon points melt at a lower temperature than gutta-percha: about 70 C to 80 C. Research on apical seal of Resilon-based systems has shown that irrespective of the technique used for obturation-lateral condensation or vertical compaction using thermoplasticized materials-the Resilon-based systems have shown less apical leakage as compared to gutta-percha points used with various sealer combinations or gutta-percha thermoplasticized systems. A bond is formed when the resin sealer contacts the resin-coated gutta-percha cone. Resilon is also available as a terminus on a fiber obturator that allows one to obturate the canal and place a fiber post simultaneously with a methacrylate sealer. Another example is coating Coated cones Coated gutta-percha is also available to inhibit leakage between the solid core and sealer. Currently, Chapter 5: Root canal filling 123 gutta-percha cones with glass ionomer. Lateral condensation and warm vertical condensation of gutta-percha are techniques that have stood the test of time. Newer methods include the use of injectable, thermoplasticized gutta-percha systems; carriers coated with an alpha-phase gutta-percha; cold, flowable obturation materials that combine Obturation with gutta-percha Several obturation techniques are available for root canal treatment (Table 5. Obturation with gutta-percha Technique Lateral condensation Explanation A master cone corresponding to the final instrumentation size and length of the canal is coated with sealer, inserted into the canal, laterally compacted with spreaders, and filled with additional accessory cones. A master cone corresponding to the final instrumentation size and length of the canal is fitted, coated with sealer, heated, and compacted vertically with pluggers. Continuous wave is essentially a variation of warm vertical compaction (downpacking) of core material and sealer in the apical portion of the root canal using commercially available heating devices and then backfilling the remaining portion of the root canal with thermoplasticized core material using injection devices. Warm lateral A master cone corresponding to the final instrumentation size of the canal is coated with sealer, inserted into the canal, heated with a warm spreader, laterally compacted with spreaders, and filled with additional accessory cones. Injection techniques A preheated, thermoplasticized, injectable core material is injected directly into the root canal. Cold, flowable matrix that is triturated and consists of guttapercha added to a resin sealer. The technique involves injecting the material into the canal and placing a single master cone. Thermomechanical A cone coated with sealer is placed in the root canal and engaged with a rotary instrument that frictionally warms, plasticizes, and compacts it into the root canal. Carrier-Based Carrier-Based Thermoplasticized: Warm gutta-percha, on a plastic carrier, is delivered directly into the canal as a root canal filling Carrier-Based Sectional: A sized and fitted section of gutta-percha with sealer is inserted into the apical 4 mm of the root canal. The remaining portion of the root canal is filled with injectable, thermoplasticized gutta-percha using an injection gun. Downpak (Hu-Freidy) An alternative to cold lateral compaction is ultrasonics and, more recently, a combination of vibration and heat using the DownPak Obturation Device. Lateral condensation can be employed by alternating heat after the placement of each accessory gutta-percha cone; heat can be transferred to the canal to soften the cones for better condensation and homogeneity of both the sealer and the gutta-percha. The Downpak, introduced in 2007, is cordlessand has a multifunctional endodontic heating and vibrating spreader device; it can be used for both vertical and lateral obturation. It uses a combination of controlled heat application and sonic vibrations to plasticize the gutta-percha. While the temperature can be graduated and controlled in intensity during the procedure, it also allows the vibrations to be turned off when required. This allows Downpak to be used with different materials like gutta-percha, Resilon and hybrid resin filling materials having variable softening temperatures, making it a versatile system. The heat-carrying tips are designed in nickel­titanium and Ultrasoft stainless steel for use in tapered root canals. The technique involves adapting a master cone in the same manner as with lateral compaction. The system is activated and heated in the temperature cum vibration mode for 2 seconds and subsequently inserted till it reaches the predetermined binding point. This is followed by the insertion of accessory cones, and the procedure is repeated till the spreader can insert for no more than 2. Chapter 5: Root canal filling 125 the combined use of heat and vibration by this system has been proven to provide denser, more compact fillings than heat alone. The system is no longer under Hu-Freidy and is now directed under Nikinc Dental with the name Root Buddy. Harvard Martin, this is a batterypowered, heat-controlled spreader/plugger used for warm lateral compaction of gutta-percha. It combines the simplicity and accurate length control of the lateral compaction technique with the clinical advantages of warm vertical compaction to attain superior obturations where the gutta-percha is made to coalesce and fuse into a dense, homogeneous mass with better adaptability to the root canal [63]. The instrument consists of a cordless battery-operated handpiece with a heat depressor button for a precise temperature control and with a quick-change top that is used to deliver heat and to thermo-soften the gutta-percha using a specially designed and shaped instrument tip. Once the master cone is placed, the Endotec tip is fitted and canal length is marked to 2 to 4 mm short of the apex. The tip is then heat activated outside the canal for 3 to 4 seconds and inserted to the marked length in a circumferential rotation manner for 5 to 8 seconds and removed cold while laterally spreading on withdrawal. Herbert Schilder and provides an excellent source of heat for searing off excess gutta-percha during any obturation technique. It has the added advantages of adjustable heat intensity and System B Heat Source (Sybron Endo) System B is a new generation of portable obturation devices. This cordless obturation system permits fill and pack units for use with any warm vertical technique. System B uses a continuous wave compaction technique, which is a variation of warm vertical compaction. The gutta-percha cones mimic the tapered preparation, permitting application of greater hydraulic force during compaction. After fitting the master cone, a plugger is sized to fit within 5 to 7 mm of the canal length. Compaction is done by placing the cold plugger against the gutta-percha in the canal orifice. The plugger is moved rapidly (for 1 to 2 seconds) to within 3 mm of the binding point. The heat is inactivated while firm pressure is being maintained on the plugger for 5 to 10 seconds. In ovoid canals when the canal configuration may prevent the generation of hydraulic forces, an accessory cone can be placed alongside the master cone before compaction. Filling the remaining space left by the plugger can be accomplished with a thermoplastic-injection technique or by fitting an accessory cone into the space with sealer, heating it, and compacting it with short applications of heat and vertical pressure [67]. This allows control of the viscosity of the gutta-percha through a control on the chamber temperature. A hybrid filling technique is recommended by filling the canal to approximately 4 to 5 mm from the apex, using the lateral compaction technique before 126 Current therapy in endodontics gradually filling the coronal portion with thermoplasticized gutta-percha [68]. The needle backs out of the canal as it is filled, and pluggers may be then used to compact the gutta-percha. Calamus 3D Obturation system (Dentsply, Tulsa Dental Speciality) this system uses a method of warm vertical condensation for filling the root canal. Ever since Schilder introduced the vertical condensation technique more than 40 years ago there have been various advancements in the warm gutta-percha methods, and these advancements help in filling the accessory canals. This quest has led to the development of the Calamus 3D obturation system, which progressively and continuously carries more of the gutta-percha along the master cone, starting from the coronal portion of the canal to the apical foramen. The Calamus Pack handpiece is the heat source that, in conjunction with an appropriately sized Electric Heat Plugger, is used to thermosoften and condense gutta-percha during the downpacking phase of obturation. The Calamus Flow handpiece is used with a guttapercha cartridge and integrated cannula to dispense warm gutta-percha into the preparation during the backpacking phase of obturation. The Calamus Dual 3D Obturation System provides a bending tool that may be used to place a smooth curvature on the cannula. The choice of gutta-percha cannula depends on the desired consistency and whether or not the gutta-percha will be condensed.

It should be noted that the last point is the most important because it will absorb the liquid from the most distant areas of the apical region hypertension 6 year old labetalol 100 mg amex. This provides the clinician with important information for the diagnosis of infection indicated by growth/no growth ocular hypertension buy labetalol in india, and for treatment decision by the number and type of microorganisms present blood pressure 40 over 0 purchase 100 mg labetalol free shipping. Liquid media are primarily recommended because they most often allow fastidious and/or dormant bacterial cells to grow heart attack 21 year old female 100 mg labetalol order otc. For practical purposes blood pressure chart europe 100 mg labetalol sale, media such as thioglycolate, trypticase broth, or brain heart infusion broth could be used. The liquid media also have the advantage that no extra equipment is necessary for the anaerobic incubation if the tubes are flushed with oxygen-free gas. If the tubes are prepared under anaerobic conditions, the sample is inoculated in the bottom layer of the tube, and the tubes are capped tightly (rubber stopper), the medium itself will ascertain anaerobic conditions even for the most oxygen-sensitive bacterial species. An important factor for the growth of a sample with few bacterial cells, sometimes in a "bad" condition, is to allow them sufficient incubation time. In the Laboratory of Oral Microbiology at University of Gothenburg, we give a preliminary reply to the dentist after 5­6 days on growth/no growth and then continue the incubation for 14 days. If growth appears after the preliminary reply has been delivered, the dentist is informed by a phone call. Specification to genus or species level is based on Gram stain, selective media, and simple biochemical tests. In practice, a detailed specification to species level on all present bacteria is not necessary as this will have little impact on the diagnosis and the choice of treatment procedure. The final reply after 14 days also includes the finding recovered from the solid media including semiquantification. If so, this will increase the false positive rate using molecular biology methods and decrease their sensitivity. For the more easily cultured species such as facultatives, theoretically only one viable cell is needed for growth in the liquid medium or to form a colony on the agar plate. In that sense, the sensitivity of the culture analysis should be regarded as high. However, it should be noted that in samples with a high number of bacterial cells, such as in primary infected and untreated teeth, bacteria in low numbers will not be detected because of dilution or overgrowth of predominant species. The sensitivity of the complete procedure including both sampling and analyses is complex and cannot be fully evaluated. A sample showing no growth (negative sample) indicates that the root canal is free from microorganisms and the treatment goal is achieved. To avoid false negatives, an adequate and representative sample must be taken, which might be somewhat demanding. All possible precautions should be taken for transportation and culture to give viable and cultured bacteria the best chance to grow. Still, there is the problem with uncultivable or difficult to culture microbial cells that give an unknown number of false negatives. Future studies should focus on whether remaining uncultivable microorganisms are of significance for failing outcomes of the endodontic treatment. False negative samples are especially difficult to avoid when taking samples at revision of a previously root-filled tooth. Even if the gutta-percha or sealer is removed mechanically, the remaining bacteria can hide in peripheral parts of the root canal system and may be in a stressed situation, which does not allow them to grow instantly in the laboratory. The stress induces production of stress proteins, which are released into the biofilm matrix. Another possibility is to leave the canal free from dressings between appointments. These bacteria cannot be reached by sampling through the root canal but only by surgical access to the root tip (see Chapter 6). This can only be performed in specific nonhealing cases, and is generally not a recommended procedure in the general dental practice. Specificity in endodontic sampling is high because the number of false positives can be significantly reduced and controlled. A false positive test means that the samples show growth by contaminating microorganisms of various kinds. The most common reason is probably an inadequately sterilized operative field or leakage despite rubber dam application. It was recommended by M¨ ller (1966) to take a separate samo ple from the operative field as a control of the antiseptic technique used. Bacteria present in the saliva and plaque may appear in the operative field samples and if they occur concomitantly in the root canal sample, a contamination can be suspected. Culture-Based Analysis of Endodontic Infections 61 canal treatment being initiated, a leakage to the oral cavity is likely because of remaining fillings, crown, and bridges, fractures, or inadequate temporary fillings. Presence of micrococci, coagulase-negative staphylococci, spore-forming bacteria. It should be noted, however, that enteric rods and Staphylococcus aureus, sometimes although rarely, can in the root canal infection usually as monoinfections. The use of intracanal medicaments between appointments improves the chances of bacterial elimination, but does not guarantee it (see Chapter 13). If the bacterial sample shows a low number of persisting bacteria, additional antiseptic procedures and interappointment dressings should be considered. If a high number of bacteria of polymicrobial and anaerobic nature still are present, a leakage (through rubber dam, fractures, remaining fillings, and crowns) should be suspected. An untreated root canal with a necrotic pulp and an apical lesion, with or without symptoms, is always infected. We know that in most of these cases the microflora is polymicrobial, predominantly anaerobic, and treatment procedure using mechanical debridement and antiseptic irrigation is the first choice. In an acute infection with general symptoms and risk of spreading, the administration of systemic antibiotics must be done instantly and based on the infection, usually anaerobic, and sensitive for penicillins and/or metronidazole. There is generally little clinical benefit of a microbiologic sample in primary endodontic infections. In refractory acute infections, a microbiologic diagnosis can be performed in order to disclose infections with more virulent microorganisms such as S. Anaerobes are usually very sensitive for most antiseptics used for irrigation and as interappointment dressings, and no specific considerations are necessary. It should be remembered that irrigation is usually of short duration and the effect is limited compared to an interappointment dressing that can extend its effect over days. A very important basis for the antiseptic effect is that as much organic materials (necrotic pulp material and microorganisms) as possible should be removed. Calcium hydroxide paste has become useful as an interappointment dressing because of its ability to fill up the root canal lumen and prevent the remaining bacteria from growing. However, calcium hydroxide has a rather weak (bacteriostatic) antimicrobial effect and many bacteria may survive, especially Gram-positive facultative species. If such bacteria remain in the root canal, other antiseptics such as iodine or chlorhexidine should be considered. There is no antibiotic that is efficient for all types of microorganisms occurring in the infected root canal and local antibiotics in the canal are therefore not recommended at this point. In primary acute infections with pus formation, antibiotics may be used systemically in order to prevent spreading of the infection. As the main character of this infection is polymicrobial, predominantly anaerobic, penicillin or 4. Some studies have shown that if there is absence of viable bacteria prior to filling, the prognosis of root canal treatment (Sj¨ gren et al. Saliva contamination Primary samples Careless handling in clinic or in laboratory Primary samples and abscesses (+) ­ ­ ++ + + + ++ ++ ++ +++ + ++ ++ ++ ++ ++ (+) + + ++ ++ ++ + ­ ++ ­ +++ + + + + ­ +++ ­ ++ +++ ­ ­ Primary samples and abscesses Culture-Based Analysis of Endodontic Infections 63 Table 4. Spirochetes Fungi (yeasts) Candida spp Frequency Pathogen d ++ ++ ++ + +++ ++ ++ ++ Resistance to treatment e ­ + + ­ Risk of contamination ­ ­ ­ ­ Main appearance Primary samples and abscesses Primary samples and abscesses Microscopy Seldom found in culture analysis Through leakage, persistence after treatment, and careless handling in clinic or in laboratory + + + ++ a the microorganisms are grouped as species, genus or other groups according to its clinical relevance. Bacteria invading the dentine cause inflammation in the pulp tissue that in time leads to necrosis. If the pulp loses its vitality prior to becoming infected (by trauma and physical and chemical injuries), the bacteria are attracted to the necrotic tissue through the dentine tubules, fractures, and other routes and subsequently grow and infect the root canal. As long as the pulp is vital, there is a host response mechanism in function that prevents the bacteria from invading deeper into the pulp tissues. There is no infection in the strict sense, but bacteria are present in the carious dentine adjacent to the exposed pulp (Bergenholtz 1977, 1981). Bacteria that could be isolated here are predominantly species that are associated with the caries process. Conclusively, vital pulps including those exposed to caries and those exposed by trauma may accidentally have bacteria on the surface, but usually in low numbers and without penetration into the vital pulp tissues. Younger teeth with open apices often withstand injuries better than older ones where the apical foramen is narrow. Necrosis is the terminal end of the inflammatory process which, when it becomes large enough, causes the tissue to collapse as a result of the heavy bacterial load. The invading bacteria seem to go through some selection mechanism by the route of infection and through the ecologic pressure in the root canal system. We should therefore not expect the numbers of participating species in the closed root canal to be as rich and diverse as those root canals that have been left open to the oral cavity. The bacterial growth is caused by an anaerobic, proteolytic bacterial metabolism in the root canal system and necrotic protein containing pulp. Lack of carbohydrates and especially sugars disfavor saccharolytic bacterial species and the low oxygen level does not give the facultatives any advantage over the strict anaerobes. The local and systemic host defense systems in the root canal are destroyed, and cannot act until the infection front line reaches the vital tissues in the apical region. This is the environment in which the root canal flora of teeth with necrotic pulps develops (Table 4. An inflammatory reaction is formed in the periapical tissues (apical periodontitis), which can be either acute or chronic (symptomatic or asymptomatic). At this stage, the body has one main goal and that is to prevent the infection from spreading. A fibrotic capsule can be formed in order to build a barrier more difficult for the bacteria to penetrate; however, at the cost of a total destruction of the tissues within the barrier. This is a common situation in the clinic because patients usually have Culture-Based Analysis of Endodontic Infections 65 Table 4. Total number of isolated strains Number of teeth 29 8 ­ ­ 59 12 ­ 28 ­ ­ 25 10 48 15 ­ ­ 40 10 23 4 ­ ­ 168 50 17 12 ­ ­ 78 32 21 11 ­ ­ 112 23 19 4 ­ ­ 118 17 Species >10% in bold. Conclusively, anaerobes, predominantly Gram-negatives rods, are most commonly present; however, the specificity is low. The importance of anaerobes in acute infection has been confirmed in numerous experimental animal studies (for review see Dahl´ n 2002). In one e study, eight bacterial species isolated from the same infected root canal in a monkey were inoculated into 12 experimentally devitalized teeth of monkeys in the same proportions (Fabricius et al. The eight strains were originally isolated from a monkey tooth (original infection), pure cultured in the laboratory and inoculated in equal numbers experimentally in 12 monkey teeth. The eight strains were also inoculated into steel net wound chambers implanted in the back of rabbits and the dynamics were followed for >30 days (Dahl´ n et al. However, it was necessary to include facultative anaerobes in the bacterial collection in order to let the anaerobes survive the initial phase of the infection, supposedly by reducing the redox potential by consuming available oxygen. This appearance has been confirmed in numerous other experimental animal studies using subcutaneous injections (for review see Dahl´ n 2002). It seems that the specificity in these anaerobic infections is low and numerous combinations of normally low virulent oral bacterial species have the capacity to induce an acute infection in the root canal and periapical tissues. The character of anaerobic infections, in general, is that they develop when the local and general defense is hampered (Finegold 1977). The concomitant outgrowth of bactee ria through apical foramen into the external periapical tissues cannot be prevented because the bacteria are in an active growing phase, sometimes even stimulated by host factors such as blood components and serum. The fate of the periapical acute infection or abscess is probably much dependent on the communication through the apical foramen (Sundqvist 1992b). If that communication is wide, for example, as in younger teeth, this will probably favor the bacteria because of a better nutrient supply and the infection route may be more dramatic. Even if the root canal infection is polymicrobial and unspecific, it does not mean that specific features do not exist. Some bacterial species are more common in these infections than others and some bacteria produce unique virulence factors (capsule, leukotoxins, complement resistance, and immunoglobulin degrading enzymes), which make them more adapted to survive and grow in the lesion than others and to invade the tissues and actively participate in the pathologic destruction (Table 4. It is important to emphasize that this reaction is general for all acute infections of the body. A fibrotic barrier may be formed and encapsulate the infection process into an abscess. This reaction is time dependent and it is sometimes too late to prevent bacteria and bacterial products from spreading through the tissues. Such bacteria will be cleared by the lymphatic drainage and the Culture-Based Analysis of Endodontic Infections 69 local lymph nodes which become swollen and painful. This is a stage when systemic antibiotic treatment is indicated with the purpose of inhibiting bacterial multiplication and growth and spread of the infection. In the spreading periapical abscess (if no antibiotics are given), the bacteria may still grow, leading to an expansion of the abscess through the tissues. The nature of this expansion follows the route of the least resistance and in most cases ends up with drainage into the oral cavity through either the periodontal pocket or through the mucosal membrane. The latter condition is called a sinus tract and is frequently seen in the clinic. Fortunately, less frequently the infection is spread to other compartments of the head and neck region, where serious complications can follow (see Chapter 10). The sinus tract is usually the termination of the acute phase of the infection, the symptoms decline, and the whole process becomes chronic. However, as long as the primary root canal infection is not subjected to intervention, the bacteria still remain in the tooth and maintain the process and the sinus tract can remain for a long period.

Longstanding pulp infections with chronic apical lesions can exacerbate with the same symptomatic apical periodontitis or acute apical abscess blood pressure 9260 100 mg labetalol purchase fast delivery. Apart from distinguishing such conditions from marginal periodontal inflammation arteria 3d medieval village 100 mg labetalol order otc, and in particular a periodontal abscess heart attack remix labetalol 100 mg buy on line, they are seldom difficult to diagnose arrhythmia dance purchase labetalol. Asymptomatic apical periodontitis is blood pressure chart low bp buy labetalol 100 mg cheap, on the other hand, dependent on radiographic signs for diagnosis. In its early stages and during healing, this may be very difficult, whereas a well-established, asymptomatic periapical lesion is a simple condition to identify on radiographs (Ørstavik and Pitt Ford 2008). In teleologic terms, an infected root canal of a tooth is probably perceived by the body as a risk zone for invasion by (life-threatening) microbes. A defense region is then established in which the tissue architecture is changed to prepare for the containment of invading microorganisms (Ørstavik and Larheim 2008). Bone is gradually replaced by granulomatous tissue with vascular and cellular components mobilized for host defense. If such a tooth does not respond to sensitivity testing, a diagnosis of pulpal infection and apical periodontitis is certain, and treatment options instantly available. On the other hand, there may be total pulp necrosis and no infection or associated inflammation at the apex, such as when the pulp is devitalized by traumatic injury (Sundqvist 1976). The chronic development of apical periodontitis may be totally without symptoms, in which case the term asymptomatic apical periodontitis is appropriate. However, symptoms may occur at any stage during the process, ranging from barely perceptible tenderness to the acute symptoms described earlier. In summary, chronic asympomatic apical periodontitis needs radiography for detection; symptomatic and acute phases are diagnosed by clinical symptoms and signs. This is a confounding factor for assessments of the relative importance of these conditions in the overall incidence and prevalence of orofacial pain. Pulpitis may be very painful and lead to loss of quality of life (Constante et al. It is unfortunate that pulpal pain is pooled with other tooth-related pain and often with the whole specter of orofacial pain conditions in surveys and screening studies. This may be debilitating to the patient and lead to absence from work and involvement of costly health services. While it is known that emergency dental services are in great demand in most countries, in urban as well as rural areas, there is scant information on the actual incidence and prevalence of acute pulpal and apical periodontal disease. Therefore, one can only speculate that there is still, even in communities with well-developed dental services, a significant impact on the general well-being by acute pulpal and periodontal conditions (Sindet-Pedersen et al. It seems that psychologic factors influence the incidence and severity of orofacial pain including pulpal and periapical pain (Aggarwal et al. Therefore it is especially important for susceptible individuals to have conditions that cause acute dental pain treated quickly and efficiently. A frequently overlooked situation is the association of pulpal and apical disease with tooth loss in the elderly and in highly restored dentitions (Dikbas et al. Whereas marginal periodontal disease is generally accepted as a significant cause of tooth loss, pulpal and apical diseases are important causes for extraction (Eckerbom et al. The tooth with pulpitis is obviously in danger of becoming infected and developing apical periodontitis. Correct and prompt treatment of the acute situation is therefore important, not only to curb the pain and to re-establish a functional tooth, but also to reduce or eliminate the risk for the insidious spreading of the infection and the emergence of a periapical lesion. It has been known for a very long time that the prognosis for treatment of apical periodontitis is much poorer than expected treatment outcome after vital pulpectomy (see Chapter 15). Early detection and root canal treatment of teeth at definitive risk of developing root canal infection are therefore essential. On the other hand, acute dental pain must be expected to be short-lived in most cases as it is treated by medication or intervention. As a disease entity in epidemiologic studies, the incidence of endodontic disease is best assessed with a longitudinal study design, which picks up the peaks of pain that would not be found in a cross-sectional study. Dental pain and pulpal infections may be viewed also in this context; age groups, ethnic groups, socioeconomic groups may experience the diseases differently (Constante et al. The fact that dental pain conditions adversely affects the quality of life is no surprise (Shueb et al. Nevertheless, given that irreversible pulpal inflammation is associated with severe and/or lingering pain, it seems reasonable to conclude that reports listing dental caries as a source of acute or severe pain in effect have pulpal inflammation as the source of pain. The few targeted epidemiologic data that do exist point to a limited, but significant, occurrence of acute pain of Diagnosis, Epidemiology, and Global Impact of Endodontic Infections 17 pulpal origin (Sindet-Pedersen et al. The incidence and prevalence of symptomatic pulpitis and apical periodontitis are obviously important for the targeting of dental services, and form important background knowledge for the design of dental curricula and for public health measures. Comparative studies may be lacking, but it seems reasonable to assume that as the general dental health varies widely among populations within and across countries, so will the incidence and severity of pulpal and periapical pain. The insidious nature and frequently pain-free course of this disease makes it evasive to detection outside of the dental treatment situation. The fact that asymptomatic apical periodontitis relies on radiography for detection poses limitations on the possibilities for screenings and population surveys. Moreover, when radiographic data have been made available for analysis, lack of standardization in scoring makes comparisons across studies difficult. The radiographic technique may also influence the ability to detect with certainty the occurrence of asymptomatic apical periodontitis. For population surveys, panoramic radiography provides information at far lower radiation dosage than full-mouth periapical examinations, but the possibilities of detection of apical lesions may be diminished. Only when there is an overt radiolucency associated with the root tip and a concomitant finding of a necrotic pulp, are the signs pathognomonic (Ørstavik and Larheim 2008). While it is possible to make assumptions from different studies with similar descriptions of the criteria used for detection of asymptomatic apical periodontitis, the lack of standardization makes it impossible to draw conclusions with any certainty. The periapical condition is scored by comparison with a series of reference radiographs of teeth with known histology. On the basis of numerous institutional studies on the outcome of endodontic treatment, the notion that endodontic treatment was predictable and generally successful was accepted (Strindberg 1956; Grossman et al. In a series of studies, Eriksen and coworkers (Eriksen and Bjertness 1991; Eriksen et al. A primary aim was to reassess the association of the quality of the root filling as seen on the radiograph with the periapical status of the teeth. Similar to what had been documented in the institutional follow-up studies, there was a clear association between poor rootfilling quality and the presence of apical periodontitis, emphasizing the need for focus on high-quality technical performance during the endodontic procedures. However, there was also an unexpectedly high prevalence of apical periodontitis in most populations and age groups. This was a source of concern and had to be considered in oral health assessments in general. Moreover, the finding that pulpal and periapical diseases were major reasons for extractions in adults, surpassing marginal periodontitis around the fifth decade of life, emphasized the impact of periapical health for retention of the dentition into old age (Eriksen 1991; Eriksen and Bjertness 1991; Eckerbom et al. These studies have later been supplemented by several others from many countries and, with few exceptions, the results are quite disheartening in different countries and populations, regardless of the degree and perceived quality of the dental services offered. Blue line, teeth without apical periodontitis; red line, teeth with apical periodontitis. A minimum of false positives (healthy apical periodontium scored as diseased; blue cases in red sector) is acceptable at the expense of some false negatives (diseased teeth registered as healthy; red cases in blue sector). The steps are represented by radiographs that have histologic verification from an extensive study on human cadavers (Brynolf 1967). This makes possible a visual reference scale that reduces the risk of personal bias otherwise associated with subjective radiographic assessments. Also, the system is used after extensive and standardized calibration of the observers, which facilitates comparisons of different studies and pooling of data. A general principle in epidemiology is to avoid scoring a healthy condition wrongly as disease. In this way, some cases of asymptomatic chronic apical periodontitis will go undetected, but only a minimal number of healthy teeth will be scored as diseased. Irrespective of the radiographic method of detection, it is apparent that radiographic assessments of apical periodontitis on the whole will underestimate its true incidence or prevalence (Brynolf 1967). Even with all these provisos, it may still be prudent to review and compare results from different areas and cohorts, as long as the shortcomings of the radiographic methods are kept in mind. Apical periodontitis occurs with a prevalence of 30­80% in different populations, generally increasing in older age groups (Chen et al. It is tempting to speculate that populations with low prevalence have had teeth with apical periodontitis extracted: indeed, for the Portuguese population studied by Marques et al. The association is strongest for teeth that are diagnosed with apical periodontitis at the start of treatment, and far less dominant when the root filling is placed in teeth with no lesion prior to treatment (Sj¨ gren et al. In the latter situao tion, typically less than 10% of treated cases develop apical periodontitis; contrarily, teeth treated for primary apical periodontitis show persistence of lesions in 20­25% of cases in institutional studies. In all likelihood, there is a poorer outcome for both preoperative diagnoses in practice compared to the institutional setting. By inference, when epidemiologic surveys indicate that 30­40% of root-filled teeth have apical periodontitis, it seems fair to assume that less than 50% of teeth with apical periodontitis are cured in the average treatment setting in practice. This should not be placed in a context to advocate more radical treatment or prophylaxis of apical periodontitis. The preservation of teeth by endodontic procedures is, after all, a clinically very successful and predictable procedure. The sequels to extractions and various prosthetic procedures, as alternative treatments, are numerous and often of greater consequence. However, these epidemiologic findings clearly point to a need for improvements in the quality of endodontic care. Cost, functional needs, and aesthetics are considerations in deciding optimal therapy for a tooth with endodontic infection. Complete elimination of infection is assured if the tooth is extracted and, if functional or aesthetic needs do not mandate retention of the tooth or its replacement, this may be a preferred modality. However, if a functional tooth or its replacement is necessary, other sequels to treatment must be balanced in the equation. This will inevitably involve preparation and trauma to neighboring teeth and, unless they are in need of crown therapy irrespective of the tooth under consideration, this weighs heavily against its replacement in a fixed bridge 2. Furthermore, all teeth with restorations, and bridge abutment teeth especially, are susceptible to secondary caries and subsequent endodontic problems (Goodacre et al. The placement of an implant is often promoted as an alternative to endodontic treatment, and enthusiasm for implants have led some to suggest that indications for endodontic treatment should be more limited than has traditionally been held. Because of the differences in functional measures of performance, it is difficult to compare the suitability of the two approaches. By measuring tooth or implant retention and adding repair and replacement into a compound measure of success, some studies have been performed comparing implants with endodontic treatment (Doyle et al. Furthermore, bacterial colonization around implants leading to peri-implantitis is a rather common occurrence, introducing a new infection also in this alternative to endodontic treatment. Extensive follow-up studies of endodontically treated teeth have demonstrated remarkably high retention rates. It seems prudent to maintain a skeptical attitude to alternatives that rely on extraction of functioning teeth even if they need endodontic treatment. The microbial communities vary within an affected tooth, among affected teeth in the same mouth, among different subjects, and over geographic regions. The primary tissue responses are directed at eliminating the tooth as the physical source of this type of infection. When effective, these responses reestablish an intact mucocutaneous barrier which protects from new microbial attacks. When the initial responses (pulpitis and apical periodontitis) fail to contain and eliminate the infection, subsequent events depends largely on the microbial composition of the infection and on the general resistance of the patient. The microorganisms associated with endodontic infections in most cases will have little pathogenicity and low virulence. However, commonly found microorganisms like enterococci, Candida albicans, Burkholderia cepacia (Li et al. On rare occasions, life-threatening infections of endodontic origin can occur (Allareddy et al. Necrotizing fasciitis is an example of a major complication of endodontic infections (Leyva et al. These cases underscore the need for and add to the local indications for prompt and effective treatment of pulpitis and apical periodontitis. On the one hand, this affects the decision whether to provide antibiotic coverage prior to surgery in patients at risk of infective endocarditis or infection of implants. On the other hand, the possible association of pulp and periapical infections with the risk of developing cardiovascular disease has a major impact on the rationale and case selection for endodontic treatment, and especially on prophylactic efforts to prevent pulpal infection in the first place. Marginal periodontitis seems to have a definitive, albeit limited, association with cardiovascular disease, and data are emerging indicating that this may be the case also for apical periodontitis (Caplan et al. Periapical lesions are virtually all apical periodontitis, and apical periodontitis is caused by microbial infection of the root canal system. Imminent or established infections of the pulp and periapical tissues need to be contained or eliminated. Early and appropriate endodontic intervention is necessary in such cases, with emphasis on proper case selection and skilled technical performance of treatment. The provision of high-quality endodontic care at all levels of dental service to the individual patient as well as to populations is therefore crucial for optimum Diagnosis, Epidemiology, and Global Impact of Endodontic Infections 21 long-term oral health. The goals for these services are several: to prevent pulpal infection by effective caries prevention, by protection against dental trauma, and by appropriate dentin treatment under restorations; to limit pulpal pain as a source of discomfort and loss of work; and to eliminate dental infection and prevent its recurrence by root filling and surgical endodontic procedures. Prognosis is clearly better for root fillings following vital pulp extirpation than for root fillings after treatment of established apical periodontitis. Early intervention in established pulpitis is therefore conducive to preventing pain, spread of infection, and tooth loss. However, this principle of case selection for treatment is often in conflict with the concept of the need to preserve the pulp itself.

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