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PDQ* SERIES
ACKERMANN

PDQ PHYSIOLOGY
BAKER, MURRAY

PDQ BIOCHEMISTRY
CORMACK

PDQ HISTOLOGY
JOHNSON

PDQ PHARMACOLOGY, 2/e

KERN

PDQ HEMATOLOGY
McKIBBON

PDQ EVIDENCE-BASED PRINCIPLES AND PRACTICE

NORMAN, STREINER

PDQ STATISTICS, 2/e

STREINER, NORMAN

PDQ EPIDEMIOLOGY, 2/e

SCIUBBA

PDQ ORAL DISEASE

*PDQ (Pretty Darned Quick)

PDQ ENDODONTICS
JOHN I. INGLE, DDS, MSD
Lecturer, Department of Endodontics School of Dentistry Loma Linda University Loma Linda, CA Formerly Dean and Professor of Endodontics and Periodontics University of Southern California Los Angeles, CA Formerly Professor of Endodontics and Periodontics University of Washington Seattle, WA Diplomate, American Board of Endodontics Diplomate, American Board of Periodontology

2005 BC Decker Inc Hamilton London

EXIT

BC Decker Inc P.O. Box 620, L.C.D. 1 Hamilton, Ontario L8N 3K7 Tel: 905-522-7017; 1-800-568-7281 Fax: 905-522-7839; 1-888-311-4987 E-mail: info@bcdecker.com www.bcdecker.com 2005 BC Decker Inc All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted, in any form or by any means, electronic, mechanical, photocopying, recording, or otherwise, without prior written permission from the publisher. 05 06 07 08 / WPC / 9 8 7 6 5 4 3 2 1 ISBN 1-55009-273-1 Printed in the United States of America Sales and Distribution
United States BC Decker Inc P.O. Box 785 Lewiston, NY 14092-0785 Tel: 905-522-7017; 800-568-7281 Fax: 905-522-7839; 888-311-4987 E-mail: info@bcdecker.com www.bcdecker.com Canada BC Decker Inc 20 Hughson Street South P.O. Box 620, LCD 1 Hamilton, Ontario L8N 3K7 Tel: 905-522-7017; 800-568-7281 Fax: 905-522-7839; 888-311-4987 E-mail: info@bcdecker.com www.bcdecker.com Foreign Rights John Scott & Company International Publishers Agency P.O. Box 878 Kimberton, PA 19442 Tel: 610-827-1640 Fax: 610-827-1671 E-mail: jsco@voicenet.com Japan Igaku-Shoin Ltd. Foreign Publications Department 3-24-17 Hongo Bunkyo-ku, Tokyo, Japan 1138719 Tel: 3 3817 5680 Fax: 3 3815 6776 E-mail: fd@igaku-shoin.co.jp UK, Europe, Scandinavia, Middle East Elsevier Science Customer Service Department Foots Cray High Street Sidcup, Kent DA14 5HP, UK Tel: 44 (0) 208 308 5760 Fax: 44 (0) 181 308 5702 E-mail: cservice@harcourt.com Singapore, Malaysia,Thailand, Philippines, Indonesia, Vietnam, Pacific Rim, Korea Elsevier Science Asia 583 Orchard Road #09/01, Forum Singapore 238884 Tel: 65-737-3593 Fax: 65-753-2145 Australia, New Zealand Elsevier Science Australia Customer Service Department STM Division Locked Bag 16 St. Peters, New South Wales, 2044 Australia Tel: 61 02 9517-8999 Fax: 61 02 9517-2249 E-mail: stmp@harcourt.com.au www.harcourt.com.au Mexico and Central America ETM SA de CV Calle de Tula 59 Colonia Condesa 06140 Mexico DF, Mexico Tel: 52-5-5553-6657 Fax: 52-5-5211-8468 E-mail: editoresdetextosmex@prodigy.net. mx Brazil Tecmedd Av. Maurlio Biagi, 2850 City Ribeiro Preto SP CEP: 14021-000 Tel: 0800 992236 Fax: (16) 3993-9000 E-mail: tecmedd@tecmedd.com.br India, Bangladesh, Pakistan, Sri Lanka Elsevier Health Sciences Division Customer Service Department 17A/1, Main Ring Road Lajpat Nagar IV New Delhi 110024, India Tel: 91 11 2644 7160-64 Fax: 91 11 2644 7156 E-mail: esindia@vsnl.net

Notice: The authors and publisher have made every effort to ensure that the patient care recommended herein, including choice of drugs and drug dosages, is in accordance with the accepted standard and practice at the time of publication. However, since research and regulation constantly change clinical standards, the reader is urged to check the product information sheet included in the package of each drug, which includes recommended doses, warnings, and contraindications. This is particularly important with new or infrequently used drugs. Any treatment regimen, particularly one involving medication, involves inherent risk that must be weighed on a case-by-case basis against the benefits anticipated. The reader is cautioned that the purpose of this book is to inform and enlighten; the information contained herein is not intended as, and should not be employed as, a substitute for individual diagnosis and treatment.

This volume, PDQ Endodontics, is the offspring of the major text Endodontics. My children are my offspring. And it is with a great deal of pride and pleasure that I dedicate this volume to them: JOHN GEOFFREY INGLE SCHUYLER NEAL INGLE LESLIE JOYCE INGLE MOXLEY

Contents

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Contents
PREFACE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . VIII ACKNOWLEDGMENTS . . . . . . . . . . . . . . . . . . . . . . . . . XIII 1. EXAMINATION, DIAGNOSIS, . . . . . . . . . . . . . . . . . . . . . 1 AND TREATMENT 2. ENDODONTIC TREATMENT PROCEDURES . . . . . . . . . 41 3. ACCESS TO THE ROOT CANAL SYSTEM: . . . . . . . . . . 58 PREPARATION FOR TREATMENT 4. ACCESS TO THE ROOT CANAL SYSTEM: . . . . . . . . . . 71 CORONAL CAVITY PREPARATION 5. ROOT CANAL PREPARATION . . . . . . . . . . . . . . . . . . . . 111 6. OBTURATION OF THE RADICULAR SPACE . . . . . . . . 142 7. ENDODONTIC SURGERY . . . . . . . . . . . . . . . . . . . . . . . . 167 8. ENDODONTIC MISHAPS. . . . . . . . . . . . . . . . . . . . . . . . 215 9. MANAGEMENT OF ENDODONTIC . . . . . . . . . . . . . . . 235 EMERGENCIES 10. RESTORATION OF ENDODONTICALLY . . . . . . . . . . . 261 TREATED TEETH 11. DISCOLORATION AND BLEACHING . . . . . . . . . . . . . . 279 INDEX . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 292

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Preface
Endodontics is that branch of dentistry centered on the dental pulp and periradicular tissues. The scope of endodontics deals with the diagnosis and treatment of pulp and periradicular pathology and the prevention of pulp disease; of oral pains of pulpal and/or periradicular origin as well as extraoral referred pain; vital pulp capping or pulpotomy; pulp extirpation and cleaning and shaping of the root canal, its disinfection, and its obturation; surgical removal and biopsy of pathologic periapical tissue; root end resection and reverse obturation of the canals, as well as hemisection and full root resection of pathologic roots; endodontic and osseointegrated implants; management of traumatic injuries to the teeth and implantation of avulsed teeth; internal and external bleaching of discolored teeth; retreatment of previously treated teeth; and post and core placement involving the root canal space. An endodontist is a dentist with 2 or more years of advanced training in endodontics who has received a certificate or advanced degree from an accredited program. Those who meet these qualifications have the privilege of appearing before the American Board of Endodontics; if they pass, they become diplomates of the ABE. Note to the reader: If you are seeking additional information over and above the contents of this book, please refer to the full text Endodontics by J.I. Ingle and L.K. Bakland, published by BC Decker, Hamilton, ON, 2003; 974 pages. To contact BC Decker, phone 1-800/568-7281, fax 1-905/522-7839, or e-mail info@bcdecker.com, or visit their Web site at www.bcdecker.com.

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The fifth edition of Endodontics.

Endodontology deals with diseases of the pulp and periradicular tissues as well as the study of their anatomy, physiology, and pathology.

PDQ ENDODONTICS

Root canal treatment is well illustrated by this treatment of two pulpless teeth that serve well as bridge abutments. Courtesy of N. Hertl.

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A, previous page, Two central incisors were fractured through the pulp and the lateral incisor was totally luxated as a result of a bicycle accident. B, above, The lateral incisor was treated in hand and replanted, and the injuries began to heal. C, left, Radiograph illustrates the root canal treatment to the central incisors and the replanted root of the lateral incisor. D, below, Final restoration with three porcelain jacket crowns.

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A, Left Advanced cellulites related to an infected maxillary lateral incisor. B, Right Eight days following incision, drainage, and antibiotic therapy. Courtesy of B. Wolfson.

Left, Discolored central incisor, years after trauma. Right, Incisor 1 week later, following internal bleaching with 30% hydrogen peroxide.

Acknowledgments

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Acknowledgments
My cup runneth over. Psalm XXIII I have been so blessed! Blessed first of all with loving parents who provided me a fine education. And then with a loving and extraordinary family. I have also been blessed with wonderful teachers, brilliant students, and marvelous associates and fellow faculty members, who have led me on a pathway I never dreamed of. And through it all, I have been backed up by talented and dedicated nurses, assistants, secretaries, technicians, and publishers. How fortunate I have been! In my course through life, I have been associated with a number of unusual universities, each one depositing special skills and knowledge. I am deeply indebted to them all: Washington State University, Northwestern University, University of Michigan, University of Washington, University of Southern California, Howard and Georgetown Universities, UCLA, and finally, Loma Linda University. My stint at the Institute of Medicine, National Academy of Sciences, was a humbling experience. I suddenly learned what I didnt know. And now to this text. The backup at Loma Linda University has been outstanding. Drs. Leif Bakland and Mahmoud Torabinejad were eager to help. The very versatile, talented, and enormously patient, Richard Tinker, director of Loma Lindas Educational Support Services, was untiring in his efforts to make perfect every illustration and photo. How fortunate I am, at my age, to be a member of such a distinguished faculty. Thanks to my computer guru and maven, Scott Arnett, I was able to suffer through many failures, viruses, worms, and my own inadequacies. And I must thank my wife, Joyce, for her exceptional computer typing skills, far outclassing my hunt and peck abilities.

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Id be remiss if I failed to thank those countless associates who, as contributing authors, were so generous with their time and knowledge to make the text Endodontics the success it has been. I have borrowed unsparingly from their writings and research in producing this condensed version. Finally, I must acknowledge those at BC Decker, Publisher, who worked so diligently on editing, indexing, publishing, and marketing this text. They include Brian Decker, Paula Mucci, Susan Ball, and Petrice Custance. John I. Ingle, DDS, MSD San Diego, CA, 2005

The Loma Linda Three Musketeers: Left to right, Leif Bakland, John Ingle, Mahmoud Torabinejad at the 2004 meeting of the American Association of Endodontists. Dr. Torabinejad was president of the AAE in 20032004, Dr. Ingle was president of the AAE in 19661967, and Dr. Bakland was president of the American Board of Endodontics in 19921993.