Chapter 1

MODERN ENDODONTIC THERAPY

John I. Ingle, Leif K. Bakland, Edward E. Beveridge,
Dudley H. Glick, and Anthony E. Hoskinson

“Because I’ll have you know, Sancho, that a mouth without teeth
is like a mill without its stone, and you must value a tooth more
than a diamond.”
– Miguel de Cervantes, Don Quixote

The newspaper headline read, “Ancient Root Canal

Filling Found.” Datelined Jerusalem, the article went on
to state that “a green tooth containing the oldest known
root canal filling was discovered in the skull of a
Nabatean warrior who was buried in a mass grave
2,200 years ago.”
Joseph Zias, curator of the State of Israel
Department of Antiquities, later reported on this his-
toric archeologic finding in the Journal of the American
Dental Association.1 The tooth in question—a maxil-
lary right lateral incisor—dated from the Hellenistic
period (200 BC). Radiographic examination of the
ancient skull “disclosed a 2.5 mm bronze wire that had
been implanted in the root canal—the earliest known
archeologic example of a tooth filled with a metal
object” (Figure 1-1). Professor Zias went on to explain
the probable reason for the primitive “endodontics”:
“The accepted cause of tooth disease in the
Mediterranean—a worm burrowing inside the tooth—
Figure 1-1 Oldest known root canal filling. Radiograph of skele-
may give a clue as to why this tooth was filled with a tal remains showing maxillary incisor with bronze wire implanted
metal wire. It is possible that the wire was implanted in the root canal of a Nabatean warrior buried in the Negev desert
into the tooth canal to close the passage and prevent 2,200 years ago (200 BC). Reproduced with permission from Dr.
‘toothworms’ from burrowing into the tooth and caus- Joseph Zias, State of Israel Department of Antiquities, and J Am
ing further dental pain.” The first mention of the Dent Assoc 1987;114:665.
“toothworm” theory is found in the Anastasia Papyrus
of the thirteenth century BC.1
Somewhat earlier in China, the ancient Chinese sub- thought to be an invasion of “worms” into teeth, the
scribed to the “toothworm” theory of dental caries as Chinese language character for “caries” was composed
well. According to Tsai-Fang, “The oracle bone inscrip- of a worm on top of a tooth2 (Figure 1-2).
tion, excavated from the ruins of the Ying Dynasty Fifteen hundred years later, by the year 200 AD, the
(fourteenth century BC), clearly shows a character Chinese were using arsenicals to treat pulpitis, preced-
meaning ‘caries.’”2 Since the cause of tooth decay was ing Spooner, who was the first to do so in Europe, by
2 Endodontics

advent of local anesthetics, and the acceptance of anti-

sepsis as a part of endodontic therapy. In 1891, for
example, Otto Walkhoff introduced camphorated
monoclorophenol (CMCP) as an intracanal medica-
ment. It was this same Dr. Walkhoff who took the first
dental radiograph in 1895.3
Beginning about 1912, dentistry in general and
A B endodontics in particular were set back by the wide
Figure 1-2 A, A piece of “oracle bone” inscribed with Chinese acceptance of the theory of focal infection. Wholesale
character meaning “caries” (fourteenth century BC). B, Chinese extraction of both vital and pulpless teeth took place.
characters for “worm” and “tooth” combined to form the word
The professions were not to recover their senses until
“caries.” Reproduced with permission from Dr. Tsai-fang Tsao,
Faculty of Stomatology, Peking Medical College; Int Endodont J well after World War II.
1984;17:163; and L.F. Zhens. Diseases of the mouth and teeth. 4th The final 50-year period, 1926 to 1976, saw improve-
ed. Beijing (PRC): People’s Health Publishing House; 1957. p. 2–5. ments in radiographs, anesthetics, and procedures as
well as the introduction of new methods and agents.
Calcium hydroxide made its appearance, as did ethyl-
1,600 years.2 The Chinese also used amalgam to fill cav- enediaminetetraacetic acid (EDTA) for chelation.
ities in the teeth as early as 659 AD.2 Many root canal medications appeared, and arsenic
This ancient history, preceding dentistry in North finally disappeared from the dental pharmacopeia. This
America and even Europe by thousands of years, was a same period saw the publication of the first major text
harbinger of things to come. devoted to endodontics, Dr. Grossman’s Root Canal
Jumping ahead to more modern times, Dr. Louis I. Therapy, as well as the introduction of standardized
Grossman (Figure 1-3), dean of endodontists in instruments and cavity preparation.5–7 The period also
America, if not the world, pointed out that, by 1750, witnessed the rise and decline of the silver root canal
“Pierre Fauchard, the noted French dentist
(1678-1761), had dispelled the ‘toothworm’ legend and
was recommending the removal of diseased pulps as
well.”3 Dr. Grossman also chronicled the historical
events impacting on root canal therapy since the
American Revolution.4
In his usual orderly manner, Dr. Grossman divided
the 200 years between 1776 and 1976 into four 50-year
periods.4 During the first period, 1776 to 1826, he
noted that treatment was crude—abscessed teeth were
treated with leeches or toasted fig poultices, and pulps
were cauterized with red-hot wires. Nevertheless, it was
during this same period that root canals were being
filled from apex to crown with gold foil.
The second half-century, 1826 to 1876, was marked
by the founding of the first dental journal and the first
dental school, the introduction of general anesthesia,
rubber dam, gutta-percha root canal points, and the
barbed broach, as well as three- and four-sided taper-
ing broaches for cleaning and enlarging root canals,
intracanal antiseptics, and oxyphosphate of zinc
cement. At the same time, however, pulps were still
being removed by driving wooden pegs into the canal,
and crowns of the teeth were also being “snipped” off at
the gingival level to cure toothache. Arsenicals were still
Figure 1-3 The late Louis I. Grossman, DDS, Dr. med. dent., dean
being used to devitalize pulps. of American endodontists. His substantial contributions over more
The third half-century, 1876 to 1926, was highlight- than half of the twentieth century enormously improved the prac-
ed by the discovery and development of the x-ray, the tice, science, and standing of endodontics.

point. A more sensible attitude toward endodontic sur-
gery developed.
During this period, the American Association of
Endodontists (AAE) was formed, followed by the
American Board of Endodontics. Continuing education
in endodontics widely disseminated information, skills,
and techniques to an eager profession. The prevention
of pulp disease began to play a more important role in
dental practice. In part because of fluoridation, there
was a decline in dental caries. Research into the causes
and biology of dental trauma led to improved awareness
and treatment of dental injuries. Antibiotics greatly
improved the profession’s ability to control infection,
while new anesthetics and injection techniques
increased control over pain. The high-speed air rotor
handpiece added to patient comfort and the speed and
ease of operation, as did prepackaged sterilized supplies.
The mandatory use of masks, gloves, and better steriliz-
ing methods rapidly emerged with the spread of human
immunodeficiency virus/acquired immune deficiency
syndrome (HIV/AIDS) and hepatitis. The widespread
use of auxiliaries expanded dental services.
It is now more than two decades since Grossman’s
historic report, a period in which new instruments and
techniques for cleaning and shaping as well as filling
root canals have been introduced. Some of them are
still in the development stage. All in all, the new decade,
if not the new millennium, should prove exciting and
profitable for the profession and patients alike.
RECENT ATTITUDES TOWARD DENTISTRY AND
ENDODONTIC THERAPY
Increasingly, the term “root canal” has become fashion-
able and generally known. In conversation, people
proudly proclaim that they have had a “root canal.” The
stigma of fear and pain is fast disappearing.
Another impressive factor in the acceptance of
endodontics is television. Countless advertisements
emphasize a beautiful smile—not just toothpaste
advertisements, but commercials in every field, from
Buicks to beer. At the same time, the constant barrage
of denture adhesive and cleanser advertisements pro-
duces a chilling effect. The public sees the problems
that develop from the loss of teeth. Obvious missing
teeth are anathema.
There is no question that the public’s acceptance of
endodontic treatment is on the rise. In 1969, for exam-
ple, the American Dental Association (ADA) estimated
that 6 million root canal fillings were done each year.
By 1990, their estimate had risen to 13,870,000. One
might add that the ADA also estimated that another
690,000 “endodontic surgeries and root amputations”
Modern Endodontic Therapy 3
were done in l990.8 By the year 2000, it was estimated
that 30 million teeth were root-filled annually.9
This upward trend was also documented by the
Public Affairs Committee of the AAE. Reporting on
surveys of the general public made by the Opinion
Research Institute in 1984 and 1986, the Committee
noted that 28% of 1,000 telephone respondents report-
ed that they had had root canal therapy by 1986, an
increase of 5% over 23% in 1984.10 Also, in 1986, 62%
said they would choose root canal therapy over extrac-
tion, an increase of 10% over 52% in 1984. More than
half the respondents (53%) believed that an endodon-
tically treated tooth would last a lifetime.10
On the other hand, the perceptions of younger peo-
ple (under 25 years) in this survey were disappointing
in that 70% described root canal therapy as “painful”
and 58% thought it would be less expensive to extract
the tooth and place a bridge.10 Clearly, the profession
has a mission in educating this age group to reverse
their image of endodontics and the value of a treated
pulpless tooth.
A rate of use of endodontic services similar to the
rate in the United States (28%) was also reported from
Norway, where 27% of an older age group (66 to 75
years) had had root canal therapy, as had 12% of a
younger age group (26 to 35 years). Incidentally, 100%
of the root-filled teeth in the younger group were still
present 10 to 17 years later, a remarkable achievement.11
The growth in endodontic services is also reflected
in the sale of endodontic equipment, supplies, and
instruments. In 1984, endodontics was a $20 million
market, growing at a rate of 4% a year.12 By 1997, 13
years later, the endodontic market, through dental
dealer retail stores alone, was $72 million, up from
$65.6 million in 1996, a growth of nearly 10%. One
must add to these sales another 10% to account for
mail-order/telephone sales, a grand total in 1997 of
nearly $80 million. Worldwide sales are probably dou-
ble this figure!13
There is no question that the greatest share of
endodontic procedures is carried out by America’s gener-
al practitioners. On the other hand, the specialty of
endodontics is growing as well. In 1986, for example, only
5% of those patients who had root canal therapy were
treated by a specialist.10 By 1990, this percentage had
grown to 28.5%.8 In 1989, there were 2,500 endodontic
specialists in the United States.9 By 2,000, the figure was
around 3,300 endodontists,14 and these endodontists
were completing 39% of all of the root canal therapy and
endodontic surgery in the United States.8
In spite of these encouraging figures for the imme-
diate future of endodontics, one has to question what
4 Endodontics
the distant future will bring. The rate of dental caries is
declining precipitously.
In two separate reports, the US National Institute of
Dental Research (NIDR) proudly announced in 1988
that half of all children in the United States aged 5 to 17
years had no decay in their permanent teeth. None!15 In
contrast, in the early 1970s, only 28% of the permanent
teeth of American children were caries free. By 1980, this
figure had risen to 36.6%, and by 1986–1987, 49.9%
were caries free. Furthermore, there was a 50% improve-
ment in 17 year olds, a most encouraging sign for den-
tists, who were once faced with repairing the ravaged
mouths of adolescents in the 1950s through the 1970s.
The national decayed-missing-filled surfaces (DMFS)
rate had dropped to 3.1 for all US schoolchildren and,
even more importantly, “82 percent of the DMF surfaces
are filled, about 13% decayed and 4% are missing.”15
A comparable radiographic survey in 1980 on 1,059
US Air Force basic trainees 18 to 20 years old found
that 10% had “no restorations, no decay and no miss-
ing teeth.” Moreover, another 10% had at least one root
canal filling.16 A comparison between these 1980
recruits and Navy recruits in 1956 proved that missing
teeth per recruit had dropped from 2.4 to 0.75 in 24
years, a reduction of 31%.16
As far as older adults are concerned, the NIDR
reported a remarkable decline in edentulism as well,
particularly in the middle-aged, a group in which “total
tooth loss has been practically eliminated.”17 The elder-
ly (age 65 and older), however, “are still in serious trou-
ble,” root caries and periodontal disease being the pri-
mary offenders.17
All of these encouraging figures suggest greater pre-
ventive measures and higher use of dental services by
the public. Part of the improvement can be credited to a
healthier economy and lifestyle, part to the national
water supply and dentifrice fluoridation programs, part
to the dental profession’s efforts, and part to dental
insurance. Bailit et al. have shown that third-party pay-
ment has increased dental use and improved oral
health.18 By 1995, the ADA estimated that 63% of all US
citizens were covered by a private insurance program
and another 5.3% by public assistance. A remaining
31.4% were not covered by any insurance program.19
In providing these burgeoning services, the dental
profession has fared well financially. Over the past 30
years, the net income of dentists has more than dou-
bled in constant 1967 dollars.20 Moreover, between
1986 and 1995, the net income of dentists rose 30.7%,
from $102,953 to $134,590.19
Dental expenditures by the public have increased as
well, from $3.4 billion in 1967 to $10 billion in 1977, to
$25.3 billion in 1987 and $47.5 billion in 1996.21 In
1996, the average person spent $172.70 for dental serv-
ices, up from $108 (adjusted to 1996 dollars) in 1967.
This amounts to a 60% increase in outlay for dental
care in 30 years.21
After all of this expenditure and care, one is hard-
pressed to explain why 15.1 million workdays are lost
annually because of dental pain.22
ENDODONTIC CASE PRESENTATION
All of these improvements notwithstanding, many
patients still must be convinced that root canal therapy
is an intelligent, practical solution to an age-old prob-
lem—the loss of teeth. The “case for endodontic treat-
ment” must be presented to the patient in a straight-
forward manner. The patient with the correct “oral
image” will be anxious to proceed with therapy.
“Is this tooth worth saving, doctor?” This sentiment
is voiced more often than not by the patient who has
been informed that his or her tooth will require
endodontic therapy. Superficially, this appears to be a
simple question that requires a direct, uncomplicated
answer. It should not be interpreted as hostile or as a
challenge to the treatment recommendations present-
ed for the retention of the tooth. Psychologically, how-
ever, this initial question is a prelude to a Pandora’s
box of additional queries that disclose doubts, fears,
apprehensions, and economic considerations: for
example, “Is it painful?” “Will this tooth have to be
extracted later?” “How long will this tooth last?” “Is it
a dead tooth?” “Will it turn black?” and “How much
will it cost?”
Following the first question, the dentist should
anticipate such a series of questions. These may be
avoided, however, by including the answers to antici-
pated questions in the presentation. In turn, the dentist
will gain a decided psychological advantage. By this
apparent insight into his or her problems, the patient is
assured that the dentist is cognizant of the very ques-
tions the patient was about to raise or possibly was too
reticent to ask. Most of the patient’s fear and doubts
can be allayed by giving a concise answer to each ques-
tion. The dentist should be able to explain procedures
intelligently as ideas are exchanged with the patient.
To do this, one must be endodontically oriented.
That is, one must believe in the value of endodontic
therapy. By believing in such treatment, one cannot
help but influence the patient favorably. The dentist
will soon gain the confidence of the patient who real-
izes that professional recommendations emanate
from an honest desire to preserve the mouth’s func-
tional efficiency.23
 Modern Endodontic Therapy 5

To answer patients’ questions, the ADA produced an

inexpensive pamphlet entitled “Your Teeth Can be
Saved…by Endodontic.”24 The AAE also publishes a
number of pamphlets25 for patients: the “Your Guide
To”* series: “Endodontic Treatment, Cracked Teeth,
Endodontic Retreatment, and Endodontic Surgery.”*
Dr. Joel Burns has beautifully illustrated a booklet enti-
tled Why Root Canal Therapy?26 Although this
approach is a little impersonal, it is a tangible reference,
particularly when the patient returns home and tries to
explain to an interested spouse what endodontic thera-
py involves. A
Based on previous experiences in the office, the aver-
age patient has sufficient confidence in the dentist’s
ability to help. He or she is ready to accept the profes-
sional knowledge and advice offered but likes to have
some part in evaluating the reasonableness of treat-
ment. The professional person and the staff must spend
the time and thought necessary to understand the
patient’s initial resistance, which is often based on false
assumptions and beliefs in matters dealing with pulp-
less teeth. However, once the patient is secure in the
thought that this is the correct treatment, most of the
fears and apprehensions related to unfamiliarity with
endodontic therapy will be dissipated. B
A dental appointment is still associated with fear in
Figure 1-4 A, Rash occurred in this terrified patient, who was
the minds of many people27–29 (Figure 1-4). The mere merely sitting in the dental chair. B, The patient’s apprehension was
thought of treating the “nerve” of a tooth implies pain. allayed by sympathetic management, allowing successful comple-
Patients require reassurance, supported by all available tion of endodontic therapy in a four-canal molar. (Courtesy of Dr.
psychological and therapeutic methods of relaxation Norbert Hertl.)
and pain control. The patient must be reassured that
endodontic therapy need not be painful and usually
requires no more than a local anesthetic.
All too often, we hear negative remarks about root cedure designed to retain a tooth safely and comfort-
canal therapy: “Trying to do anything positive in ably. The tooth, when properly treated and restored,
Tacoma is akin to getting a root canal without can be retained as long as any other tooth. It is not a
Novocain.” Or “Whew! What you just heard was a col- “dead tooth” as long as the roots of the tooth are
lective sigh of relief following 7 months of agonizing embedded in healthy surrounding tissues. Although
root canal”—remarks made following President teeth do not turn “black” following root canal therapy,
Clinton’s “confession” on television. In contrast to these a slight change in color owing to reduced translucency
commonly heard excoriations, LeClaire et al. reported may occur. Discoloration associated with pulp necrosis
that 43.9% of endodontic patients reported a decrease and leakage around restorations can be managed suc-
in fearfulness after having root canal therapy. cessfully (see Chapter 16). Most often, retention of the
Furthermore, 96.3% said that “they would have root tooth and bleaching, veneering, or crowning (Figure 1-
canal therapy again to save a tooth.”29 5) are preferable to extraction and replacement with a
It should be explained to the concerned patient that prosthetic appliance.10
root canal therapy is a specialized form of dental pro- There is little doubt that economic considerations
play an important role (and for some a supreme role)
in the final decision. Some patients “think financially,”
*Available from the American Association of Endodontists and even though they are able to afford treatment, they
Information Services, 211 East Chicago Ave., Suite 1100, Chicago, allow financial considerations to govern decisions that
IL 60611-2691. should logically be made on a physiologic basis only. It
6 Endodontics
is necessary to point out to these people the financial
advantage of retaining a tooth by endodontic therapy
rather than by extraction and prosthetic replacement.
The properly informed patient is quick to recognize
that the fee for a bridge is more than that for root canal
therapy and proper restoration.10 In addition, it should
be mentioned in all honesty that any vital tooth pre-
pared for a crown could become a possible candidate
for future endodontic therapy. Also, the patient who
says “Pull it out”’ should be informed of the problems
that arise if a space is left unfilled (ie, tilting, reduced
masticatory efficiency, future periodontal problems,
and cosmetic effects).
Another commonly heard statement by the patient
is, “It’s only a back tooth, anyway,” or “If it were a front
tooth I would save it, but no one sees it in back.” This
patient thinks cosmetically. The disadvantages of the
loss of any tooth, let alone a posterior one so essential
for mastication, must be explained.
A retained around roots, and there will not be the usual
B integral part of restorative and prosthetic treatment.
Figure 1-5 Fractured premolar restored by endodontics and
post-and-core crown. A, Tooth immediately following fracture. B,
Restoration and periradicular healing at 3-year recall. Note the
spectacular fill of arborization (arrows) at the apex. (Courtesy of
Dr. Clifford J. Ruddle.)
Fortunately, today’s patient is becoming more
sophisticated, too “tooth conscious” to permit indis-
criminate extraction without asking whether there is an
alternative. Extraction contributes to a crippling aber-
ration from the normal dentition. There is no doubt
that a normally functioning, endodontically treated,
and well-restored tooth is vastly superior to the best
prosthetic or implant replacement.
INDICATIONS
The indications for endodontic therapy are legion.
Every tooth, from central incisor to third molar, is a
potential candidate for treatment. Far too often, the
expedient measure of extracting a pulpless tooth is a
short-sighted attempt at solving a dental problem.
Endodontic therapy, on the other hand, extends to the
dentist and the patient the opportunity to save teeth.
The concept of retaining every possible tooth, and
even the healthy roots of periodontally involved teeth,
is based on the even distribution of the forces of masti-
cation. The final success of any extensive restorative
procedure depends on the root-surface area attached
through the periodontal ligaments to the alveolar bone.
Like the proverbial horseshoe nail, root-filled teeth may
often be the salvation of an otherwise hopeless case.
To carry this concept one step further, recognized
today is the importance of retaining even endodonti-
cally treated roots, over which may be constructed a
full denture, the so-called overdenture.30 On some
occasions, attachments may be added to these roots to
provide additional retention for the denture above. At
other times, the treated roots are merely left in place on
the assumption that the alveolar process will be
ridge resorption so commonly seen under full or even
partial dentures.
Most dentists would agree that the retained and
restored individual tooth is better than a bridge replace-
ment and that a bridge is better than a removable par-
tial denture, which, in turn, is superior to a full denture.
Although recent success with dental implants is impres-
sive, the long-term outcome is not known, and, func-
tionally, the patient’s own tooth is superior. Treatment
in every case should adhere to the standards set by the
dentist for himself or herself and his or her family.
Modern dentistry incorporates endodontics as an
Most any tooth with pulpal involvement, provided that
it has adequate periodontal support, can be a candidate
for root canal treatment. Severely broken down teeth,
and potential and actual abutment teeth, can be candi-
dates for the tooth-saving procedures of endodontics.
 Modern Endodontic Therapy 7

One of the greatest services rendered by the profes-
sion is the retention of the first permanent molar
(Figure 1-6). In contrast, the long-range consequences
of breaking the continuity of either arch are also well
known (Figure 1-7). Root canal therapy often provides
the only opportunity for saving first molars with pulp
involvement.
In addition to saving molars for children, saving
posterior teeth for adults is also highly desirable.
Retaining a root-filled terminal molar, for example,
means saving two teeth—the molar’s opposite tooth as
well (Figure 1-8, A). Moreover, root canal treatment
may save an abutment tooth of an existing fixed pros-
thesis. The gain is doubled if the salvaged abutment is
also the terminal posterior tooth in the arch and has a
viable opponent (Figure 1-8, B).
Another candidate for endodontic therapy is the ado-
lescent who arrives in the office with a grossly damaged
dentition and is faced with multiple extractions and den-
tures (Figure 1-9). Many of these children are mortified
by their appearance. It is gratifying to see the blossoming
personality when an esthetic improvement has been
achieved. The end result in these cases would not be pos-
sible without root canal therapy (Figure 1-10).
Intentional Endodontics
Occasionally, intentional endodontics of teeth with
perfectly vital pulps may be necessary. Examples of sit-
uations requiring intentional endodontics include
hypererupted teeth or drifted teeth that must be
reduced so drastically that the pulp is certain to be
involved.31 On other occasions, a pulp is intentionally
removed and the canal filled so that a post and core
may be placed for increased crown retention. In these
cases, the endodontic treatment may be completed
before tooth reduction is started.
Over and above these quite obvious indications for
intentional endodontics, it has been recommended that
pulpectomy and root canal filling be done for vital
teeth badly discolored by tetracycline ingestion.

A B

C
Figure 1-6 A, Pulpless first molar following failure of pulpotomy. Note two periradicular lesions and complete loss of intraradicular bone.
Draining sinus tract opposite furca is also present. B, Completion of endodontic therapy without surgery. C, Two-year recall radiograph.
Complete healing was evident in 6 months. New carious lesions (arrows) now involve each interproximal surface.
8 Endodontics

Figure 1-7 Extrusion, recession (arrow) tip-

ping, malocclusion, rotation, and gingival
cemental caries are only a few of the
long-range consequences following early
extraction of a permanent first molar.

Following root canal therapy, internal bleaching may

be carried out.32

Considerations Prior to Endodontic Therapy

Although it is true that root canal treatment can be
performed on virtually any tooth in the mouth, there
are some important considerations that must be evalu-
ated prior to recommending root canal treatment.
Some of these were delineated by Beveridge (personal
communication, June 1971):

1. Is the tooth needed or important? Does it have an

opponent? Could it some day serve as an abutment A
for prosthesis?
2. Is the tooth salvageable, or is it so badly destroyed
that it cannot be restored?
3. Is the entire dentition so completely broken down
that it would be virtually impossible to restore?
4. Is the tooth serving esthetically, or would the patient
be better served by its extraction and a more cos-
metic replacement?
5. Is the tooth so severely involved periodontally that it
would be lost soon for this reason?
6. Is the practitioner capable of performing the needed
endodontic procedures?
B
In regard to the last point, today in the United States
Figure 1-8 A, Terminal molar retained by endodontic therapy
and many other countries, endodontic specialists are
saves opposing molar as well. (Courtesy of Dr. L. Stephen
available to whom patients may be referred. A decision Buchanan.) B, Fixed partial denture possible only because abut-
to refer is preferable before a mishap, such as perfora- ment teeth are retained by root canal therapy. (Courtesy of Dr.
tion of the root canal, occurs. If a mishap does occur Norbert Hertl.)
 Modern Endodontic Therapy 9

A B
Figure 1-9 A, Caries-decimated dentition in a 14-year-old girl. Personality problems had developed in this youngster related to her feeling
embarrassed about her appearance. B, Provisional restoration following endodontic therapy has restored the cosmetic appearance and con-
fidence so necessary for the adolescent.

during treatment, the patient must be given the option
of seeing a specialist before the decision to extract the
tooth is made.
The well-trained dentist should have no fear of the
pulpally involved tooth. If a carious exposure is noted
during cavity preparation, the patient is informed of
the problem and the recommended treatment, and, if
consented to, the endodontic therapy is started while
the tooth is anesthetized. The prepared dentist can
begin pulpectomy immediately, using sterile instru-
ments packaged and stored for just such an emergency.
Age and Health as Considerations
Age need not be a determinant in endodontic therapy.
Simple and complex dental procedures are routinely
performed on deciduous teeth in young children and

A B

Figure 1-10 A, Obvious pulp involvement of incisors shown in Figure 1-9. B, Root canal treatment of these incisors makes possible dowel
restoration followed by cosmetic provisional plastic crowns.
10 Endodontics
on permanent teeth in patients well into their nineties.
The same holds true for endodontic procedures. It
should be noted, however, that complete removal of the
pulp in young immature teeth should be avoided if
possible. Procedures for pulp preservation are more
desirable and are fully discussed in chapter 15.
Health consideration must be evaluated for
endodontics as it would for any other dental procedure.
Most often, root canal therapy will be preferable to
extraction. In severe cases of heart disease, diabetes, or
radiation necrosis,33 for example, root canal treatment
is far less traumatic than extraction. Even for terminal
cases of cancer, leukemia, or AIDS, endodontics is pre-
ferred over extraction. Pregnancy, particularly in the
second trimester, is usually a safe time for treatment. In
all of these situations, however, endodontic surgery is
likely to be as traumatic as extraction.
A B
Figure 1-11 A, Mandibular molar with furcal bone loss (arrow)
owing to endodontic infection and no periodontal disease. B, Root
canal treatment completed without any periodontal intervention.
C, One-year control shows recovery of furcal lesion by endodontic
treatment alone.
Status of the Oral Condition
Pulpally involved teeth may simultaneously have peri-
odontal lesions and be associated with other dental
problems such as rampant decay, orthodontic
malalignment, root resorption, and/or a history of
traumatic injuries. Often the treatment of such teeth
requires a team effort of dental specialists along with
the patient’s general dentist.
The presence of periodontal lesions must be evaluat-
ed with respect to the correct diagnosis: Is the lesion of
periodontal or endodontic origin, or is it a combined sit-
uation? The answer to that question will determine the
treatment approach and the outcome; generally, lesions
of endodontic origin will respond satisfactorily to
endodontic treatment alone34 (Figure 1-11), whereas
those of periodontal origin will not be affected simply by
endodontic procedures (Figure 1-12). Combined
C
 Modern Endodontic Therapy 11

A B

C D
Figure 1-12 A, Retraction of surgical flap reveals the extent of periodontal lesion completely involving buccal roots of second molar abut-
ment of full-arch periodontal prosthesis. Root canal therapy of a healthy, palatal root is completed before surgery. B, Total amputation of
buccal roots reveals extent of cavernous periodontal lesion. C, Extensive bone loss, seen in A and B, is apparent in a radiograph taken at the
time of treatment (the root outline was retouched for clarity). D, Osseous repair, 1 year following buccal root amputation. A solidly sup-
ported palatal root serves as an adequate terminal abutment for a full-arch prosthesis. Endodontic therapy was completed in 1959 and has
remained successful. (Courtesy of Dr. Dudley H. Glick.)

lesions—those that develop as a result of both pulpal
infection and periodontal disease—respond to a com-
bined treatment approach in which endodontic interven-
tion precedes, or is done simultaneously with, periodon-
tal treatment35 (Figure 1-13). Even teeth with apparently
hopeless root support can be saved by endodontic treat-
ment and root amputation (Figure 1-14).
Today, many pulpless teeth, once condemned to
extraction, are saved by root canal therapy: teeth with
large periradicular lesions or apical cysts36–39 (Figure 1-
15), teeth with perforations or internal or external
resorption (Figure 1-16), teeth badly broken down by
caries or horizontal fracture (Figure 1-17), pulpless
teeth with tortuous or apparently obstructed canals or
broken instruments within,40 teeth with flaring open
apices (Figure 1-18), teeth that are hopelessly discol-
ored (Figure 1-19), and even teeth that are wholly or
partially luxated.
All of these conditions can usually be overcome by
endodontic, orthodontic, periodontic, or surgical pro-
cedures. In some cases, the prognosis may be somewhat
guarded. But in the majority of cases, the patient and
dentist are pleased with the outcome, especially if the
final result is an arch fully restored.
12 Endodontics

A B

Figure 1-13 A, Maxillary premolar with both periodontal bone

loss (open arrow) and an apical lesion (small closed arrows) from
pulpal infection. B, Root canal treatment was done along with peri-
odontal pocket maintenance. C, One-year control shows apical
bony response to the endodontic procedure; the periodontal condi-
tion is unchanged.

Figure 1-14 Amputation of periodontally involved distobuccal

root allows retention of well-restored maxillary first molar. Root
canal therapy of two remaining roots is necessary. Buccal-lingual
narrowing of the occlusal table reduces the forces of mastication on
these roots. The vulva-like soft tissue defect should be corrected
with gingivoplasty.
 Modern Endodontic Therapy 13

Figure 1-15 Classic apical cyst (left) apparent in pretreatment radiograph. Total repair of cystic cavity in 6-month recall film is sig-
naled by complete lamina dura that has developed periradicularly. Biopsy confirmed the initial diagnosis of an apical cyst.

A B

C D
Figure 1-16 A, Extensive defect by internal-external resorp-
tion is demonstrated by an explorer in a 67-year-old man.
B, Retraction of the rectangular flap reveals a pathologic defect
involving over half the tooth. Under no circumstances should
root canal therapy be attempted from this lateral approach.
C, Silver point root canal filling cemented to place before
restoration of resorptive defect. D, Restoration of area of
resorption with zinc-free amalgam. Case is completed by sutur-
ing flap into position. E, Five-year postoperative photograph
(patient, age 72) reveals gingival repair and toleration of sub-
gingival amalgam filling.
E
14 Endodontics

Figure 1-17 Four maxillary incisors with coronal fractures into B

pulp. Radiograph is necessary to determine whether root fracture
has occurred and the stage of root development and apical closure. Figure 1-19 A, Intense discoloration of a pulpless maxillary cen-
Immediate pulpectomy and root canal filling are indicated for all tral incisor. B, Successful bleaching with Superoxol (30% H2O2).
four incisors. The incisor has been restored to its normal color.

Figure 1-18 Left, Flaring apex of incompletely

formed root follows pulpal death caused by
impact injury at early age. Right, Obturation of
the “blunderbuss” canal is accomplished by
retrofilling from surgical approach. Reproduced
with permission from Ingle JI. Dent Digest
1956;62:410.

ONE-APPOINTMENT THERAPY
Single-appointment root canal therapy has become a
common practice. When questioned, however, most
dentists reply that they reserve one-appointment treat-
ment for vital pulp and immediate periradicular surgery
cases. In 1982, only 12.8% of dentists queried thought
that necrotic teeth would be successfully treated in one
appointment.41 Endodontists have been treating
patients in one-appointment visits for some time. At one
time, 86% of the directors of postgraduate endodontic
programs, when surveyed, reported that nonsurgical
one-visit treatment was part of their program.42
What are the advantages and disadvantages of sin-
gle-visit endodontics?
Advantages:
1. Immediate familiarity with the internal anatomy,
canal shape, and contour facilitates obturation
2. No risk of bacterial leakage beyond a temporary
coronal seal between appointments
3. Reduction of clinic time
4. Patient convenience—no additional appointment
5. Less cost
Perceived Disadvantages:
1. No easy access to the apical canal if there is a flare-up
2. Clinician fatigue with extended one-appointment
operating time
3. Patient fatigue and discomfort with extended oper-
ating time
4. No opportunity to place an intracanal disinfectant
(other than allowing NaOCl to disinfect during
treatment)
What has held back one-appointment endodontics?
The major consideration has been concern about post-
operative pain and failure.
Postoperative Pain
The fear that patients will probably develop postopera-
tive pain and that the canal has been irretrievably
sealed has probably been the greatest deterrent to sin-
gle-visit therapy. Yet the literature shows no real differ-
ence in pain experienced by patients treated with mul-
tiple appointments.41–57 In spite of this evidence, how-
ever, 40% of the endodontic course directors surveyed
were of the opinion that necrotic cases treated in one
visit have more flare-ups.41 Galberry did not find this
to be true in Louisiana,49 nor did Nakamuta and
Nagasawa in Japan, who had only a 7.5% pain inci-
dence after treating 106 infected cases in single
Modern Endodontic Therapy 15
appointments.50 Moreover, the symptoms the patients
experienced were mild and needed no drugs or emer-
gency treatment.
Oliet reported that only 3% of his sample of 264
patients receiving single-appointment treatment had
severe pain, compared with 2.4% of the 123 patients
treated in two visits.48 Wolch’s records of over 2,000
cases treated at a single appointment showed that less
than 1% of patients indicated any severe reaction.44
Pekruhn reported no statistically significant difference
between his two groups.47 Mulhern et al. reported no
significant difference in the incidence of pain between
30 single-rooted teeth with necrotic pulps treated in one
appointment and 30 similar teeth treated in three
appointments.51 At the University of Oklahoma, how-
ever, Roane and his associates found a “two to one high-
er frequency of pain following treatment completed in
multiple visits when compared to those completed in
one visit.”52 More recent reports from Brazil and Fava
from the Netherlands found no difference in the inci-
dence of pain between one- and two-visit cases,53–56 and
Trope reported no flare-ups in one-appointment cases
with no apical lesions.57 Re-treatment of failed cases
with apical periodontitis made the difference, however.
These cases suffered a 13.6% flare-up rate.57 One might
expect pain from any case, as reported by Harrison et al.
from Baylor University.58 Of 229 patients treated twice,
55.5% had no interappointment pain, 28.8% had slight
pain, and 15.7% had moderate to severe pain. Eleazer
and Eleazer compared the flare-up rate between one
and two appointments in treating necrotic canal
molars. In the two-visit cohort, there was a 16% flare-up
rate, whereas in the one-visit group, there was only a
3% flare-up experience, which proved to be signifi-
cant.59 In 1996, Ørstavik et al. also reported fewer flare-
ups following single-appointment therapy.60
In light of these studies, pain does not appear to be
a valid reason to avoid single-appointment root canal
therapy.
Success versus Failure
If pain is not a deterrent, how about fear of failure?
Pekruhn has published a definitive evaluation of sin-
gle-visit endodontics.61 From the clinics of the
Arabian-American Oil Company, he reported a 1-year
recall of 925 root-filled teeth of 1,140 possible cases.
His failure rate was 5.2%, very comparable to many
multiple-visit studies. Pekruhn was surprised to learn
that his rate of failure was higher (15.3%) in teeth with
periradicular lesions that had had no prior access
opening. If this type of case had been previously
opened, the incidence of failure dropped to 6.5%. The
16 Endodontics
highest failure rate (16.6%) was in endodontic re-treat-
ment cases. Symptomatic cases were twice as likely to
fail as were asymptomatic cases (10.6% versus 5.0%).
A Japanese study followed one-visit cases for as long
as 40 months and reported an 86% success rate.50 Oliet
again found no statistical significance between his two
groups.48 The majority of the postgraduate directors of
endodontics felt that the chance of successful healing
was equal for either type of therapy.42 The original
investigators in this field, Fox et al.,43 Wolch,44
Soltanoff,45 and Ether et al.,46 were convinced that sin-
gle-visit root canal therapy could be just as successful as
multiple-visit therapy. None, however, treated the
acutely infected or abscess case with a single visit.
In more recent times, and in marked contrast to
these positive reports, Sjögren and his associates in
Sweden sounded a word of caution.62 At a single
appointment, they cleaned and obturated 55 single-
rooted teeth with apical periodontitis. All of the teeth
were initially infected. After cleaning and irrigating
with sodium hypochlorite and just before obturation,
they cultured the canals. Using advanced anaerobic
bacteriologic techniques, they found that 22 (40%) of
the 55 canals tested positive and the other 33 (60%)
tested negative.
Periapical healing was then followed for 5 years.
Complete periapical healing occurred in 94% of the 33
cases that yielded negative cultures! But in those 22
cases in which the canals tested positive prior to root
canal filling, “the success rate of healing had fallen to
just 68%,” a statistically significant difference.62 In
other words, if a canal is still infected before filling at a
single dental appointment, there may be a 26% greater
chance of failure than if the canal is free of bacteria.
Their conclusions emphasized the importance of elim-
inating bacteria from the canal system before obtura-
tion and that this objective could not be achieved reli-
ably without an effective intracanal medicament. This
is one limited study, but it was done carefully and pro-
vides the recent evidence correlating the presence of
bacteria to longer-term outcomes.
Ørstavik et al. faced up to this problem and studied
23 teeth with apical periodontitis, all but one infected
initially. At the end of each sitting, apical dentin samples
were cultured anaerobically. No chemical irrigants were
used during cleaning and shaping, and at the end of the
first appointment, 14 of the 23 canals were still infect-
ed.63 At an earlier time, Ingle and Zeldow, using aerobic
culturing, found much the same.64,65 Ørstavik et al.
then sealed calcium hydroxide in the canal. In 1 week, at
the start of the second appointment, only one root canal
had sufficient numbers of bacteria “for quantifica-
tion”—the calcium hydroxide was that effective! They
also found “a tendency for teeth causing symptoms to
harbour more bacteria than symptomless teeth.”63
In a follow-up study, Trope et al. treated teeth with
apical periodontitis, with and without calcium hydrox-
ide, in one or two visits. They reached a number of con-
clusions: (1) “[C]alcium hydroxide disinfection after
chemomechanical cleaning will result in negative cul-
tures in most cases”; (2) “[I]nstrumentation and irriga-
tion alone decrease the number of bacteria in the canal
1000-fold, however the canals cannot be rendered free of
bacteria by this method alone”; and (3) “[T]he addition-
al disinfecting action of calcium hydroxide before obtu-
ration resulted in a 10% increase in healing rates. This
difference should be considered clinically important.”66
In another 52-week comparative study in North
Carolina, of the “periapical healing of infected roots [in
dogs] obturated in one step or with prior calcium
hydroxide disinfection,” the researchers concluded that
“Ca(OH)2 disinfection before obturation of infected
root canals results in significantly less periapical
inflammation than obturation alone.”67
One has to ask, therefore, wouldn’t it be better to
extend one more appointment, properly medicate the
canal between appointments, and improve the
patient’s chances of filling a bacteria-free canal?
Unfortunately, there is a widely held but anecdotal
opinion that current chemomechanical cleaning tech-
niques are superior, predictably removing the entire
bacterial flora. If this is so, single-visit treatment of
necrotic pulp cases would definitely be indicated.
However, the research has yet to be published to cor-
roborate these opinions. Until then, it may be more
prudent to use an intracanal medicament such as cal-
cium hydroxide, within a multiple-visit regimen, for
cases in which a mature bacterial flora is present with-
in the canal system prior to treatment. Although sin-
gle appointments would be very appropriate in cases
with vital pulps, on the other hand, for teeth with
necrotic pulps and periapical periodontitis, and for
failed cases requiring retreatment, there may be a risk
of lower success rates in the long term. To date, the
evidence for recommending either one- or multiple-
visit endodontics is not consistent. The prudent prac-
titioner needs to make decisions carefully as new evi-
dence becomes available.
Wolch said it best: “In the treatment of any disease,
a cure can only be effected if the cause is removed.
Since endodontic diseases originate from an infected or
affected pulp, it is axiomatic that the root canal must be
thoroughly and carefully debrided and obturated”
(personal communication, 1983).
 Modern Endodontic Therapy 17

“ENDODONTICS AND THE LAW”68 similar circumstances.”68 “Any departure”’ is rather

If today’s patients are becoming more sophisticated
about their dental wants, they are also becoming more
sophisticated about their legal rights. As Milgrom and
Ingle have noted, the dentist can no longer consider
himself immune to malpractice litigation by hiding
behind a doctrine of “local community standards.”69
Local community standards today are those stan-
dards set by the specialists in the community, in this
case the board-certified endodontists, not the general
practitioner. More and more often, specialists are will-
ing to testify in court, supporting patients who, in their
view, have been treated below the standard of care.
Along with authors who have alluded to the sub-
ject,70–72 the AAE has issued guidelines that could well
establish a national standard of care. Titled
“Appropriateness of Care and Quality Assurance
Guidelines,” it is now in its third edition and may be
obtained from the AAE.73
Cohen and Schwartz have pointed out that a merito-
rious claim by a patient is “any departure from the min-
imum quality of endodontic care that reasonably pru-
dent practitioners would perform under the same or
broad and includes failure to properly diagnose; failure
to perform comprehensive diagnostic tests; failure to
properly document and record all findings and treat-
ment; treatment of the wrong tooth; use of para-
formaldehyde/steroid pastes such as N2, RC2B,
Endomethazone, and SPAD; root perforations; failure to
receive informed consent; failure of yet-to-be-approved
endodontic implants; failure because of instruments
broken in the canal; and failure to use a rubber dam.74
From this list, “failure to use a rubber dam” is uncon-
scionable and may result in the most disastrous conse-
quences, namely the swallowing or inhalation of an
endodontic instrument (Figure 1-20).
Instrument breakage or, as it is euphemistically
referred to, “instrument separation” is a “disquieting
event.” One must ask, “Did the file break because of
overzealous use... or was it defectively manufac-
tured?”74 The unbroken end of the file should be saved
in a coin envelope and placed in the patient’s treatment
record. If defective manufacturing can be proved, lia-
bility shifts to the manufacturer. In either event, the
patient must be promptly informed.74

A B
Figure 1-20 Two examples of swallowed endodontic instruments because the rubber dam was not used. A, Radiograph taken 15 minutes
after an endodontic broach (arrow) was swallowed. Reproduced with permission from Heling B, Heling I. Oral Surg 1977;43:464. B,
Abdominal radiograph showing a broach in the duodenum (arrow). The broach was surgically removed 1 month later. Reproduced with
permission from Goultschin J, Heling B. Oral Surg 1971;32:621.
18 Endodontics
A major standard of care controversy has also erupt-
ed over the issue of overfilling or overextending the
root canal filling versus filling “short.” One would be
hard-pressed in court to defend gross overfilling, some-
times even to the point of filling the mandibular canal
(Figure 1-21). On the other hand, a “puff ” of cement
from the apical constriction has become acceptable.
Filling just short of the radiographic apex, at the api-
cal constriction, 0.5 to 1.0 mm, is backed by a host of
positive reports. By the same token, an inadequate root
canal filling is hardly defensible as rising to the stan-
dard of care, even though the filling might appear to
extend to the apex.
Grossly underfilled canals, 3.0 to 6.0 mm short, are
also hard to defend, particularly if an associated peri-
radicular lesion is radiographically apparent. One must
realize, however, that some root canals are so thor-
oughly calcified (obliterated) that penetration to the
apex is virtually impossible.
Facing this problem, Swedish scientists analyzed 70
cases of “obliterated” canals over a recall period of 2 to
12 years.75 The overall success rate for the partially
filled canals was 89%. If in the initial radiograph there
was an intact periradicular contour, the success rate
was an amazing 97.9%. If a preoperative periradicular
radiolucency was present, however, the success rate
dropped to a disappointing 62.5%.75
In the incompletely filled failure cases, it was theo-
rized that canals were present but so narrow that they
could not be negotiated by the smallest instruments,
Figure 1-21 Massive overextension of RC2B into the inferior alve-
olar canal. The patient suffered permanent paresthesia. A lawsuit
was settled out of court against the dentist and in favor of the 26-
year-old female secretary in Pennsylvania. (Courtesy of Edwin J.
Zinman, DDS, JD.)
but were still large enough for the passage of bacteria
and their toxins.75 Buchanan has shown that with care
and persistence, many so-called obliterated canals can
be negotiated (personal communication, 1989).
In the light of the low success rate (62.5%) of
unfilled “obliterated” canals with apical radiolucencies,
the dentist must seriously consider a surgical approach
and retrofillings. This would be well within the stan-
dard of care if done expertly.
Paresthesia is another patient complaint following
endodontic treatment. Lip numbness (“the injection
didn’t wear off ”)76 is usually caused by gross overfill-
ing, nearly always when root canal sealers or cements
impinge on the inferior alveolar nerve. This is particu-
larly true when neurotoxic filling materials are used
(eg, N2, RC2B, Endomethazone, SPAD).
Ørstavik et al. surveyed the literature for reported
cases of paresthesia related to endodontic treat-
ment.76 They found 24 published cases; 86% of
patients were female, and usually a paste-type filling
had been used. Although 5 cases “healed in four
months to two years, 14 showed no indication of the
paraesthesia healing...from 3 months up to 18 years.”
The remaining cases were resolved by surgical
removal of the offending material. Ørstavik et al.
reported the twenty-fifth case, paresthesia following
overfilling with Endomethazone. The condition still
persisted 3 years later and “the possibility of regener-
ation of the nerve must be considered negligible.”76
Others have reported the same or similar causes of
nerve damage and paresthesia.77–80
In California, endodontics became number one in
terms of the frequency of malpractice claims filed.68
Nationally, “endodontic claims are the second most fre-
quent producer of claims and dollar losses with oral
surgery being number one.”72 There is obviously “an
increase in the number of malpractice claims involving
endodontics, primarily against general dentists.”73
Many of these tragedies, for dentist and patient alike,
could have been avoided had the patient been referred
to a dentist more skilled in endodontics. “When in
doubt, refer it out.”74
Just such a tragic case—a failure to timely or prop-
erly refer a patient—involved five dentists enmeshed in
a recent malpractice suit: one general dentist, three
endodontists, and a prosthodontist. None of the four
specialists was board certified, although all were educa-
tionally qualified. The patient was first seen by the gen-
eral dentist, who took full-mouth radiographs, did an
oral examination, and established a treatment plan that
said nothing about an unusual bony lesion in the left
mandible. The patient was not satisfied with the gener-

alist, asked for her radiographs, and transferred to a
prosthodontist, who also used the original films for his
examination. He established that a number of crowns
and a bridge should be done and that he would start on
tooth #19, which had had root canal therapy that failed.
So, quite properly, he referred the patient to an
endodontist, who, for some unexplained reason, re-
treated only two of the three canals. Up to this time, all
three dentists had failed to notice the unusual bone tra-
beculation and apparent lesion that extended from the
mesial of #19 and around the roots of #20 and #21 to
the distal of #22, nor had they noted the buccal swelling
in the region! If they had done so, they should have
referred the patient to an oral surgeon, a competent
radiologist, or an oral pathologist.
The prosthodontist continued treatment, and, final-
ly, when the patient complained, noted the swelling in
the vestibule opposite the radiographic lesion. So he
sent her back to the endodontist, who was not in his
office, so his associate saw her. The associate stated that
the patient had an abscess and that root canal therapy
would have to be done on both teeth, #20 and #21. She
was very displeased with this second endodontist and
so went to a third, who stated that she had an abscess
and proceeded to do root canal therapy on tooth #21,
right in the middle of the lesion, which, by this time,
had grown almost to the midline. The patient was very
concerned about the swelling, but the endodontist
assured her that it was an abscess that was about to “fis-
tulate,” even though there were no other signs of
inflammation—no redness, no pain, no loss of func-
tion—only swelling. He did not suggest that she be
referred to an oral surgeon, nor did he aspirate the buc-
cal swelling for exudate. He stated that they should
“watch and wait” to see if the root canal therapy
improved the situation. When it did not and the buccal
swelling increased, the patient finally went to an oral
surgeon. The case was diagnosed as an ameloblastoma,
and the mandible had to be amputated from first molar
to first molar. The case against the five dentists was set-
tled out of court for nearly one million dollars.
This case is a sad example of dentists so eager to treat
the patient that they did not thoroughly examine the
evidence that was present, ignored the signs and symp-
toms, and neglected to refer the patient to someone
better trained or more competent.
REFERRALS
Just when should an endodontic patient be referred?
Dietz has listed four general categories in which refer-
ral should be considered81:
Modern Endodontic Therapy 19
1. The complex case involving multiple, dilacerated,
obstructed, or curved canals; malpositioned and
malformed teeth; and complex root morphology. To
this one might add unusual radiographic lesions
that do not appear to be “standard” periradicular
lesions.
2. Emergencies in which a patient needs immediate
treatment for toothaches, broken crowns, clinical
exposures, infection, or traumatically injured teeth.
3. Medically compromised patients with cardiovascu-
lar conditions, diabetes, and blood disorders.
4. Mentally compromised patients, those with a true
mental disorder and those who have problems with
dentistry.
Then there is “the dentist who is too busy to perform
the procedures...”81
To this list, Harman has added, “If the general den-
tist believes that a good and proper diagnosis goes
beyond his or her abilities, then the dentist should refer
the patient.”82 Nash has estimated that 85 to 90% of all
endodontic referrals come from other dentists.83 The
remainder are self-referrals, walk-ins, and patient or
physician referrals.
The endodontist would much rather receive the
patient at the beginning of treatment than become a
“retreat-odontist,” retrieving his fellow dentist’s “chest-
nuts from the fire.”
INFORMED CONSENT
Weichman has pointed out the importance of the doc-
trine of informed consent, as well as other steps that
must be taken by the dentist to maintain good patient
relations.84 According to the doctrine of informed con-
sent, a dentist must (1) describe the proposed treat-
ment so that it is fully understood by the patient, (2)
explain all of the risks attendant to such treatment, and
(3) discuss alternative procedures or treatments that
might apply to the patient’s particular problem.85 To
this should be added (4) the risks associated with doing
nothing!
The courts have decided that a patient can give a valid
or an informed consent for treatment only after receiv-
ing all of this information. If a dentist does not obtain an
informed consent, he or she is guilty of professional neg-
ligence and is liable for any injury resulting from so-
called unauthorized treatment. One way of handling this
is to list the options in the patient’s chart and have the
patient sign. “Inform before you perform.”68
Weichman points out that, at a minimum, the dentist
must tell the patient what he or she intends to accom-
plish and what any follow-up treatment, such as final
20 Endodontics

restoration, might entail; the dentist must list other ways
of treating the condition, as well as their advantages and
disadvantages, such as extraction versus root canal ther-
apy, and, above all, must discuss possible complica-
tions—what might go wrong or the fact that the treat-
ment could lose its effectiveness after a few months.84
In spite of this detailed recitation, just informing the
patient is not enough, as a famous court decision has
made quite clear: “The test for determining whether a
potential peril must be divulged to the patient is its
materiality to the patient’s decision.” For the patient to
give informed consent, he or she must understand what
the dentist is stating. In other words, technical terms
are to be avoided. For example, use “numbness” rather
than “paresthesia.” Also, the explanation must be in the
language the patient understands (eg, Spanish rather
than English). It should be pointed out that in some
states, “guaranteeing” the outcome of professional serv-
ices is against the law.
Another type of informed consent is parental con-
sent. A minor should never be treated without the writ-
ten consent of a parent. Again, “age of consent” varies
by state. One may also encounter the “emancipated
minor,” who may give consent. The definition of
“emancipated minor” also varies by state.
Weichman goes on to list the other aspect of prac-
ticing defensive dentistry, maintaining good patient
relations. He recommends showing concern for the
patient’s welfare by (1) establishing good anesthesia,
(2) anticipating problems such as unavoidable pain
and forewarning the patient, (3) telephoning patients
after treatment to inquire about their comfort, (4)
placing high priority on emergencies, (5) consulting
with other professionals to provide the best possible
care for each patient, and (6) providing competent
“coverage” in the event that the dentist is unavailable.84
Selbst has added another caveat. He shows “data sug-
gesting an increased incidence of complications associ-
ated with retreatment cases, particularly the retreat-
ment of paste fills.” He recommends that special care be
taken to advise the re-treatment patient of this
increased jeopardy.85
on opening the chamber, as well as the results of all
testing before treatment; any possible complications
foreseen or encountered, such as curved roots, obliter-
ated canals, postoperative problems, and associated
periodontal problems; a list of allergies and illnesses;
any prescription written or medications given, includ-
ing anesthetics injected; and full disclosure of any pro-
cedural accidents occurring during treatment, such as
broken instruments or fractured roots.84
Hourigan emphasized that, at the very least, records
should show the following:
• Diagnosis (Dx)
• Treatment (Tx) (eg, “carpules”—what, how many)
• Medications (Rx) (what, how much; write out)
• Follow-up (Fx)
• Complications (Cx) (broken instruments, perfora-
tions, patient’s reaction to anesthetic, etc)86
When records are filled out, abbreviations may be
used, but the dentist must know what they stand for. If
someone other than the dentist writes on the patient’s
record, the writer must initial the writing. An office
record of initials and the names they stand for should
be kept for possible future use.
The AAE has suggested an informed consent form
that will cover most situations (Figure 1-22). However,
the Association has stated that “a written consent form
cannot be used as a substitute for the doctor’s discus-
sion with each individual patient.”87

Patient Records
The importance of maintaining good patient records,
not just financial ones, is also emphasized by
Weichman.84 These records should consist, at a mini-
mum, of good, well-processed radiographs; a health
history signed by the patient; the patient’s complaints,
from “chief complaint” to any variance at subsequent Figure 1-22 Informed consent form for endodontic procedures
appointments; any objective findings made during recommended by the American Association of Endodontists (may
treatment, such as the state of the pulp’s vitality found be copied and enlarged).

Others have written extensively about informed con-
sent.88–92 Bailey and Curley have both noted that
informed consent was an outgrowth of assault and bat-
tery law—the unauthorized “offensive touching without
consent.”88,89 In 1960, Kansas was the first state to for-
malize informed consent applied to dentists. The practi-
tioner must bear in mind that informed consent is the
“rule of law rather than just a standard of practice.”89
Bailey has pointed out the wide variance among
states in applying or interpreting the law. In Alaska and
Washington state, for example, informed consent is not
mandatory in severe emergencies.88
The Council on Insurance of the ADA made note of
the fact that the issue of informed consent will be tried
in court as a civil action and that guilt will be based on
the “preponderance of evidence,” which is easier to
prove than “beyond a reasonable doubt,” used in crim-
inal cases.90
Paladino et al. have warned of the indefensibility of
using the Sargenti endodontic technique (N2 or
RC2B), informed consent or no informed consent: “A
general dentist who performs a Sargenti root canal is
going to have as an expert witness testifying against
him virtually every endodontist in town.”91 Further,
“any patient who comes to [a lawyer] with a Sargenti
treated tooth has a prima facie case of negligence”
against the dentist. “There is no way that... a dentist can
justify performing that procedure.”91
Weichman has stated that the statute of limitations
does not begin until the patient discovers (or should
have discovered) such problems as a broken instrument
or a poorly filled canal.84 He also points out the futility
of adding to or changing records at a later date, noting
the dishonesty of the procedure and the dentist’s cul-
pability when proved a fraud in court.
A serious problem in patient management that has
developed in this age of specialization revolves around
responsibility. Who among the many professionals car-
ing for the patient shall assume responsibility? “Who
should be captain of the ship?” asked Beveridge. “Let it
become a mutual objective that no patient shall move
from one practitioner to another without someone in
command. Every patient deserves to have a clearly
understood, readily identified, ‘captain of his dental
ship,’” he stated. Ideally, the dentist most responsible
should be the general practitioner who has referred the
patient to the endodontist, periodontist, or oral sur-
geon. His office should be the “clearinghouse” for cen-
tral records and coordination of treatment. Howard
has also emphasized the importance of the general den-
tist being the “captain of the ship.”92
Modern Endodontic Therapy 21
It would be easy to become discouraged about pro-
viding medical and dental care after reviewing the num-
ber of malpractice suits in recent decades. The fact of the
matter is that heightened patient awareness of their
rights, and the standard of care to be expected, forces the
health care provider to be prudent and careful in caring
for patients and makes the patient take more responsi-
bility for his or her medical and dental health.
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