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FIFTH EDITION
Endodontics
PRINCIPLES AND PRACTICE
Mahmoud Torabinejad, DMD, MSD, PhD
Professor and Program Director
Department of Endodontics
School of Dentistry
Loma Linda University
Loma Linda, California
Richard E. Walton, DMD, MS
Professor Emeritus
Department of Endodontics
The University of Iowa
College of Dentistry
Iowa City, Iowa
Ashraf F. Fouad, BDS, DDS, MS
Department of Endodontics
Prosthodontics and Operative Dentistry
School of Dentistry
University of Maryland
Baltimore, Maryland
3251 Riverport Lane
St. Louis, Missouri 63043
ENDODONTICS: PRINCIPLES AND PRACTICE ISBN: 978-1-4557-5410-6
Copyright © 2015 by Saunders, an imprint of Elsevier Inc.
No part of this publication may be reproduced or transmitted in any form or by any means, electronic or
mechanical, including photocopying, recording, or any information storage and retrieval system, without
permission in writing from the publisher. Details on how to seek permission, further information about the
Publisher’s permissions policies and our arrangements with organizations such as the Copyright Clearance
Center and the Copyright Licensing Agency, can be found at our website: www.elsevier.com/permissions.
This book and the individual contributions contained in it are protected under copyright by the Publisher
(other than as may be noted herein).
Notices
Knowledge and best practice in this field are constantly changing. As new research and experience
broaden our understanding, changes in research methods, professional practices, or medical treatment may
become necessary.
Practitioners and researchers must always rely on their own experience and knowledge in evaluating
and using any information, methods, compounds, or experiments described herein. In using such
information or methods they should be mindful of their own safety and the safety of others, including
parties for whom they have a professional responsibility.
With respect to any drug or pharmaceutical products identified, readers are advised to check the most
current information provided (i) on procedures featured or (ii) by the manufacturer of each product to be
administered, to verify the recommended dose or formula, the method and duration of administration, and
contraindications. It is the responsibility of practitioners, relying on their own experience and knowledge
of their patients, to make diagnoses, to determine dosages and the best treatment for each individual
patient, and to take all appropriate safety precautions.
To the fullest extent of the law, neither the Publisher nor the authors, contributors, or editors, assume
any liability for any injury and/or damage to persons or property as a matter of products liability,
negligence or otherwise, or from any use or operation of any methods, products, instructions, or ideas
contained in the material herein.
Previous editions copyrighted 1989, 1996, 2002, 2009
ISBN: 978-1-4557-5410-6
Executive Content Strategist: Kathy Falk
Senior Content Development Specialist: Brian Loehr
Publishing Services Manager: Julie Eddy
Senior Project Manager: Richard Barber
Design Direction: Karen Pauls
Printed in China
Last digit is the print number: 9 8 7 6 5 4 3 2 1
Contributors
George Bogen, DDS Van T. Himel, DDS
Lecturer Professor, Chair
Department of Endodontics Department of Endodontics
Loma Linda University Louisiana State University
Loma Linda, California New Orleans, Louisiana
University of California
Los Angeles, California Graham Rex Holland, BDS, PhD
Professor
Nestor Cohenca, DDS Department of Cariology
Tenured Professor Restorative Sciences and Endodontics
Endodontics and Pediatric Dentistry School of Dentistry
School of Dentistry University of Michigan
University of Washington Ann Arbor, Michigan
Seattle, Washington
Bradford R. Johnson, DDS, MHPE
Paul D. Eleazer, DDS Associate Professor, Director of Postdoctoral Endodontics
Professor, Chair, Program Director Department of Endodontics
Department of Endodontics University of Illinois at Chicago
University of Alabama at Birmingham Chicago, Illinois
Birmingham, Alabama
James D. Johnson, DDS, MS
Ashraf F. Fouad, BDS, DDS, MS Chair, Advanced Program Director
Department of Endodontics Department of Endodontics
Prosthodontics and Operative Dentistry School of Dentistry
School of Dentistry University of Washington
University of Maryland Seattle, Washington
Baltimore, Maryland
William T. Johnson, DDS, MS
Charles J. Goodacre, DDS Richard D. Walton Professor and Chair
Professor Department of Endodontics
Restorative Dentistry College of Dentistry
School of Dentistry The University of Iowa
Loma Linda University Iowa City, Iowa
Loma Linda, California
Bruce C. Justman, DDS
Robert Handysides, DDS Clinical Associate Professor
Associate Dean for Academic Affairs Department of Endodontics
School of Dentistry College of Dentistry
Loma Linda University The University of Iowa
Loma Linda, California Iowa City, Iowa
Eric J. Herbranson, DDS, MS Bekir Karabucak, DMD, MS
Lecturer Associate Professor, Graduate Program Director
Department of Endodontics Department of Endodontics
School of Dentistry School of Dental Medicine
Loma Linda University University of Pennsylvania
Loma Linda, California Philadelphia, Pennsylvania
Practitioner
San Leandro, California
v
ENDODONTICS
James C. Kulild, DDS, MS Ilan Rotstein, DDS
Professor Emeritus Professor, Chair
Department of Endodontics Department of Endodontics, Oral and Maxillofacial Surgery
University of Missouri and Orthodontics
School of Dentistry Ostrow School of Dentistry
Kansas City, Missouri University of Southern California
Los Angeles, California
Harold H. Messer, BDSc, MDSc, PhD
Professor Emeritus Mohammad A. Sabeti, DDS, MA
Restorative Dentistry Assistant Professor
School of Dental Medicine Department of Endodontics
University of Melbourne School of Dentistry
Melbourne, Victoria, Australia Loma Linda University
Loma Linda, California
W. Craig Noblett, DDS
Assistant Clinical Professor Kent A. Sabey, DDS
Division of Endodontics Program Director
Department of Preventive and Restorative Dental Sciences Advanced Education in Endodontics
San Francisco School of Dentistry Department of Endodontics
University of California Louisiana State University
San Francisco, California School of Dentistry
Private Practice New Orleans, Louisiana
Berkeley, California
Shahrokh Shabahang, DDS, MS, PhD
John M. Nusstein, DDS, MS Associate Professor
Associate Professor, Chair Department of Endodontics
Department of Endodontics School of Dentistry
College of Dentistry Loma Linda University
The Ohio State University Loma Linda, California
Columbus, Ohio
José F. Siqueira, Jr., DDS, MSc, PhD
Ove A. Peters, DMD, MS, PhD Professor, Chair
Professor, Co-Chair Department of Endodontics and Molecular Microbiology
Department of Endodontics Laboratory
University of the Pacific Faculty of Dentistry
Arthur A. Dugoni School of Dentistry Estácio de Sá University
San Francisco, California Rio de Janeiro, Brazil
Al Reader, DDS, MS Anthony J. Smith, BSc, PhD
Professor, Program Director Professor
Department of Endodontics Oral Biology
College of Dentistry School of Dentistry
The Ohio State University University of Birmingham
Columbus, Ohio Birmingham, Great Britain
Eric M. Rivera, DDS, MS Mahmoud Torabinejad, DMD, MSD, PhD
Associate Professor, Chair, and Graduate Program Director Professor and Program Director
Department of Endodontics Department of Endodontics
School of Dentistry School of Dentistry
University of North Carolina Loma Linda University
Chapel Hill, North Carolina Loma Linda, California
Paul A. Rosenberg, DDS Richard E. Walton, DMD, MS
Professor, Director of Advanced Education Program Professor Emeritus
Department of Endodontics Department of Endodontics
New York University The University of Iowa
College of Dentistry College of Dentistry
New York, New York Iowa City, Iowa
vi
CONTrIbuTOrS
Shane N. White, BDentSc, MS, MA, PhD Anne E. Williamson, DDS, MS
Professor Associate Professor, Director, Advanced Education in
School of Dentistry Endodontics
University of California Department of Endodontics
Los Angeles, California College of Dentistry
The University of Iowa
Lisa R. Wilcox, DDS, MS Iowa City, Iowa
Adjunct Associate Professor
Department of Endodontics
College of Dentistry
The University of Iowa
Iowa City, Iowa
vii
Preface
The primary objective of dentists has always been to relieve of microorganisms, and the prevention of recontamination
dental pain and prevent tooth loss. Despite this effort, many after treatment. This new edition of Endodontics: Principles
teeth develop caries, suffer traumatic injury, or are impacted and Practice has been systematically organized to simulate
by other diseases and disorders, often requiring endodontic the order of procedures performed in a clinical setting. It
care. Endodontics is a discipline of dentistry that deals with contains information regarding normal structures, etiology of
the morphology, physiology, and pathology of the human disease, diagnosis and treatment planning, local anesthesia,
dental pulp and periapical tissues, as well as the prevention emergency treatment, root canal instruments, access prepara-
and treatment of diseases and injuries related to these tissues. tions, cleaning and shaping, obturation, and temporization. In
Its scope is wide and includes diagnosis and treatment of pain addition, it covers etiology, prevention, and treatment of acci-
of pulpal and/or periapical origin, vital pulp therapy, regenera- dental procedural errors, as well as treatment of inadequate
tive endodontic procedures, nonsurgical root canal treatment, root canal–treated teeth using nonsurgical and surgical
retreatment of unsuccessful treatment, internal bleaching, and approaches. A chapter is dedicated to the endodontic out-
endodontic surgery. Ultimately, the primary goal in endodon- comes that provide guidelines regarding the assessment of
tics is to preserve the natural dentition. Root canal treatment outcomes of these procedures. In this edition we’ve included
is a well-tested procedure that has provided pain relief and information on pulp and periapical stem cells, regenerative
has restored function and esthetics to patients. Millions of endodontic procedures, novel analyses of endodontic micro-
patients expect preservation of their natural dentition; if root flora, the use of cone beam CT in endodontics, the interaction
canal treatment is necessary, they should be aware that the of general dentists and endodontists, and systemic consider-
procedure is safe and has a high success rate if properly ations in endodontics. Furthermore, a chapter discusses single
performed. tooth implant.
As with other dental specialties, the practice of endodontics The other distinctive features of the new edition are
requires two inseparable components: art and science. The (1) updated relevant and recent references, (2) information
art consists of executing technical procedures during root regarding new scientific and technological advances in the
canal treatment. The science includes the basic and clinical field of endodontics, (3) information regarding single tooth
sciences related to biological and pathological conditions that implant, and (4) a revised contents with new authors. The
guide the art of endodontics through the principles and appendix provides colorized illustrations that depict the size,
methods of evidence-based treatment. Evidence-based treat- shape, and location of the pulp space within each tooth. There
ment integrates the best clinical evidence with the practitio- is also a website with video clips for selected procedures and
ner’s clinical expertise and the patient’s treatment needs and an interactive version of the self-assessment questions. These
preferences. A principal objective of our textbook is to incor- features provide the reader with a textbook that is concise,
porate evidence-based information when available and when current, and easy to follow in an interactive manner.
appropriate. This textbook is not intended to include all background
Because there are not enough endodontists to manage the information on the art and science of endodontics. At the same
endodontic needs of the public, general dentists must assist time, it is not designed to be a “cookbook” or a preclinical
endodontists to preserve natural dentition. Their responsibility laboratory technique manual. We have tried to provide the
is to diagnose pulpal and periapical diseases and to perform reader with the basic information to perform root canal treat-
noncomplicated root canal treatments. In fact, most of the ment and to give the reader background knowledge in related
endodontic procedures are performed by generalists. Our text- areas. This textbook should be used as a building block for
book, written specifically for dental students and general den- understanding the etiology and treatment of teeth with pulpal
tists, contains the information necessary for those who would and periapical diseases; then the reader can expand her or his
like to incorporate endodontics in their practice. This includes endodontic experiences with more challenging cases. Provid-
diagnosis and treatment planning as well as management of ing the best quality of care is the guiding light for treatment
pulpal and periapical diseases. In addition, the general dentist planning and performing appropriate treatment.
must be able to determine the case complexity and whether We thank the contributing authors for sharing their materi-
she or he can perform the necessary treatment or if referral is als and experiences with our readers and with us. Their con-
the better option. tributions improve the quality of life for millions of patients.
Although many advances have been made in endodontics We also express our appreciation to the editorial staff of
in the past decade, the main objectives of root canal therapy Elsevier, whose collaboration and dedication made this
viii continue to be the removal of diseased tissue, the elimination project possible and Mohammad Torabinejad for editing and
