Essential Endodontology

Prevention and Treatment of Apical Periodontitis

Dag Orstavik

• Publisher: Wiley-Blackwell
• Year: 2019
• Print ISBN: 9781119271956
• eBook ISBN: 9781119271994
• Edition: 3
• Topic: Medicine
• Subtopic: Dentistry

The authoritative reference that continues to present a systematic analysis of the scientific basis of endodontology

The third edition of Essential Endodontology: Prevention and Treatment of Apical Periodontitis has been revised and updated to include the most recent developments in the field, maintaining its position as the major scientific treatise of apical periodontitis. Making an often-complex subject more digestible, the book explores the scientific basis of endodontology, adopting a systematic analysis of the available clinical and laboratory evidence.

Promoting apical periodontitis as a disease entity, the comprehensive third edition focuses on its biology and clinical features, enabling the reader to have a better understanding of its diagnosis, prevention and treatment. In addition to thorough updates and full colour illustrations throughout, a new chapter on regenerative endodontics has been added to this edition.

• Written with a focus on the scientific basis of endodontology
• Includes a new chapter on regenerative endodontics
• Presents the most current information and major developments in this fast-moving field
• Provides helpful learning outcomes in each chapter
• Contains full colour illustrations, enriching the text
• Features contributions from a noted panel of international experts, including new contributors from across the globe

Regarded as a vital companion to the pursuit of excellence in postgraduate and specialist education, Essential Endodontology is an indispensable and accessible resource for practicing endodontists, postgraduate students of endodontology and those seeking professional certification in endodontology.

1
Apical Periodontitis: Microbial Infection and Host Responses

Dag Ørstavik

1.1 Introduction

Endodontology includes pulp and periapical biology and pathology. As a clinical discipline, however, endodontics mainly deals with treatment of the root canal and the placement of a root filling, or treatment by surgical endodontics. The technical procedures associated with treatment focus on the particular problems of asepsis and disinfection of the pulp canal system. Treatment measures to preserve pulp vitality are a shared responsibility with conservative dentistry, and include specific techniques in dental traumatology. Recent research has shown the importance of asepsis and disinfection procedures also for treatment of pulps exposed by caries or trauma, extending classical endodontic treatment principles to the management of deep caries (see Chapter 9).

For vital teeth requiring partial or full pulp removal, the initial diagnoses and the difficulties associated with treatment may be related to the state of the pulp, but the purpose of treatment is no longer the preservation of the pulp but the prevention and/or elimination of infection in the root canal system. The ultimate biological aim of this treatment is to prevent apical periodontitis. For teeth with infected/necrotic pulpal with an established apical disease process, the biological aim is to cure apical periodontitis. Of the endodontic diseases, apical periodontitis is therefore prominent as it is a primary indication for root canal treatment and because it is by far the most common sequel when treatment is inadequate or fails (Figure 1.1). Even the measures taken to preserve pulp vitality may be viewed as ultimately preventing root canal infection and the development of apical periodontitis.

The importance of microbes in the initiation, development and persistence of apical periodontitis has been thoroughly documented (see Chapter 4). The emphasis in this book is on the infectious etiology of apical periodontitis and on the aseptic and antiseptic principles applied during treatment. Furthermore, new research findings have impact on aspects of diagnosis, treatment, prognosis and evaluation of outcome in endodontics. It is therefore important to use the acquired knowledge to build treatment principles logically, and to show how all these fundamental aspects can be applied in clinical practice.

1.2 Terminology

Both pulp and pulp‐periodontal diseases have been subject to many classification systems with variable terminology. Periodontitis caused by infection of the pulp canal system has been termed apical periodontitis, apical granuloma/cyst, periapical osteitis and periradicular periodontitis, among other terms. Sub‐classifications have been acute/chronic, exacerbating/Phoenix abscess and symptomatic/asymptomatic, among others [18]. The two most accepted classification schemes are presented in Table 1.1. These are quite similar, but symptomatic teeth according to the AAE classification may include more cases than teeth with acute apical periodontitis according to the ICD. The latter term is for cases presenting with subjective needs for immediate treatment, while symptomatic teeth may include teeth that only slightly affect the patients and that are diagnosed by chairside testing (see Chapter 7). The term “chronic” is useful for prognostication and follow‐up studies: symptomatic or not, it implies the presence of a radiolucent lesion, which is a major predictor for treatment success [24]. The term “symptomatic” confirms that there are objective signs verifying the diagnosis.

Figure 1.1 Pulp extirpation (a) prevents and root canal disinfection (b) cures apical periodontitis. Both need a root filling of the entire pulpal space.

Table 1.1 Classification of apical periodontitis [18].

AAE	ICD‐10
Symptomatic apical periodontitis SAP^1	K04.4 Acute apical periodontitis of pulpal origin^2
Asymptomatic apical periodontitis AAP	K04.5 Chronic apical periodontitis
Chronic apical abscess	K04.6 Periapical abscess with sinus^3
Acute apical abscess	K04.7 Periapical abscess without sinus
Condensing osteitis^4
Radicular cyst	K04.8 Radicular cyst

¹ presents with a broad range of symptoms

² presents with strong pain

³ further subdivided in relation to sinus tract location on surfaces

⁴ may be seen as a variant of AAP or Chronic apical periodontitis

Apical periodontitis includes dental abscess, granuloma and radicular cyst as manifestations of the same basic disease. The balance between the virulence and extent of infection on the one hand and the body's response on the other, determines whether the condition is symptomatic/acute versus asymptomatic/chronic. The historical emphasis on the differential diagnosis of a cyst versus a granuloma has been abandoned. This is due to the fact that radiographs, even from CBCT, are not very sensitive in discriminating between cysts and granulomas [6]; they share the same etiology and basic disease processes (Chapters 3 and 4); and their treatment and prognosis are also similar (Chapters 11 and 12). However, so‐called true cysts separated from the root canal infection that initiated them may show impaired healing [27] and require surgical removal, but there are no means for diagnosing such cases without scrupulous histological investigation of surgical biopsies [32].

Terminology should not be considered a straitjacket for authors or clinicians. Therefore, variants of the terms and references to other diagnostic schemes, in this book and other te...

Table of contents

• Cover
• Table of Contents
• Foreword
• List of Contributors
• About the Companion Website
• 1 Apical Periodontitis
• 2 Dentin‐Pulp and Periodontal Anatomy and Physiology
• 3 Etiology and Pathogenesis of Pulpitis and Apical Periodontitis
• 4 Microbiology of Apical Periodontitis
• 5 Epidemiology, Treatment Outcome, and Risk Factors for Apical Periodontitis
• 6 Radiology of Apical Periodontitis
• 7 Clinical Manifestations and Diagnosis
• 8 Biological Basis for Endodontic Repair and Regeneration
• 9 Prevention
• 10 Vital Pulp Extirpation
• 11 Endodontic Treatment of Apical Periodontitis
• 12 Surgical Endodontics
• Index
• End User License Agreement