Professor an d C h ai r ma n Department of Endodont olo gy Oregon Health & Sciences Un iversity Port land, Oregon
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Notice: The authors and publisher h ave made every effort to ensure that the pat ient care recommended herein, includi ng choice of dru gs and drug dosages, is in acco rd with the accep t ed st and ard and pra cti ce at the time of publication However, sin ce research a nd regulat ion constantly chan ge clin ical standards, the reader is urged to check the product inform at ion sheet included in the pa ckage of each drug, which includes recommended doses, warnings, and contra indications. This is particularly importan t with new or infrequently used drugs. Any tr eatment regimen, par ticularly one invo lving medication, involves inherent risk that must be weighed on a case-by-case basis againsllhe benefits anticipated. Th e reader is cau tioned that the purpose of this book is 10 inform and enUghten; the information contained herein is not intended as, and should no t be employed as, a subs t itu te for individ ual diagnosis and trea tment.
DEDICATION
The edi t ors of In glc's ENDODONTICS are proud to dedicate this edition to two of the most inspire d and beloved tea ch ers and practitioners of e ndod ontics during our generatio n: Dr. Dudley H. Glick and Dr. Alfred L. Frank. Tr u e gen tl emen, world famous, innovators. and the closest of friends. So dose, AI and Dud ley were often referred to as Al G li ck and Dudley Frank. Both practiced in Beverly Hi ll s, both with a bevy of fa mOlls patients, they could ha ve be en long time competitors. In stead, they were inseparab le - Damon and Pythias - p rofessionally, academically, and socia ll y. Their wives, Ellie Glick and Te r i j: ra n k, arc the ve r y b est of friends. Between th em t hey have e ight sons.
Both we re born, ra ised and ed u ca ted in Ohio; they served w ith h ono r and decoration in World War II and fo ll owi ng the wa r Dudl ey an d Al were both graduated in dentistry from the University of Sout h ern Cal ifornia. As predoctoral dental stud cnts th ey were infamou s for their unu s ual interest in endodo ntic s, in a sc h ool famous for it s re s tor at ive denti s tr y. Upon graduation they both star ted genera l practices in the Los Angeles area and were soo n noted for their superb restorat ive dentistry. The y joined th e endodon ti c facult y at USC and whcn wor d of their endodontic s kills s pread, referrals s tarted to pour in. After consulting a number of endodontic friends , they "took the leap," and announced the y were limiting themselves to endodont ics, among the fi rs t rea ll y fulltime endodont ists in Sou th ern Californ ia.
They were the last of the "self-trained " endodont ist s. Self trained , that is, by takin g evc r y pos tgrad uat e endodontic course and attending avai lable meetings, and v is iting profcssionally with t he nation's be st known endodontists; first on the West Coast and then nationwide.
Over the years th ey be came the e n dodont ist's endodon t ists. If we, ourselves, needed root ca nal treatment , we would t ravel cross country to h ave ei t he r Al or Dudley perform the treatment. T her e was ne ver a fee! They were proud of the trust placed in them b y other ski ll ed professionals. In fa c t , dentists , phYSicians and the clerg y were rarely cha rged in their offices. That was their stron g belie f in professional counesy. And eve r yone else paid the s'1.me fee , whelhe r you werc Cary Grant , Nancy Regan, Mae We s t or Jo e thc plumber. Except teachers who received a reduced fee.
As thcy gained in renow n , both AI and Dudle y. were inundated with requests to speak to national and foreign audiences. No one made and retain ed SO man y devoted friends around the world. Their homes in Beverly Hills be ca me a haven for the famous and s tudents alike. some times for weeks at a time as yo ung people mme to learn from thc masters.
They never ceased their d edic a ti on to teaching, at USC, at UCLA, at Lo rn a Linda, a nd at Ceda rs-Si na i Hos p ita l . Bolh Dudl ey an d AI we re ho n o r ed over and over b y socie tie s a nd uni vers ities ali ke.
T h ey became famo us loc all y, nationall y inte rna t ionally, yet remained the sa m e mode s t . ge ne rous. cons id e rat e. liter all y lovable ge ntl e m en t h ey alwa ys were. brimming wit h in tegr it y an d hone sty. This is what en d eare d th e m to th ose of us fortunate to ha ve bee n their friends an d d isciples, student s. em p loyees a nd pati e nt s. We on ly w ish t he enti re speci alty professio n had had the same opportu ni ty.
Dr. D ud ley H. Glic k
Dr. AJfre d L. Frank
PREFACE TO THE FIRST EDITION OF ENDODONTICS 1965
" PULL AND BE DAMNED
ROAD"
This book wa s begun at Sneeoosh Beach, a quie t ret reat overlooking Puget Sound and the San Juan I slands. At Snc -oosh it is possible to escape from complex civilizat ion, and conce ntrate on the job at hand-writing a n endodontic text.
H ard by Snee-oosh is an old Indian trail called PULL AND BE DAMNED ROAD. One could hardly im agine a more fitting loca t ion w h ile writing a text on the pulpless tooth than nearby P ULL AND BE DAMNED ROAD, for "Pu ll and be damned" could well be the motto o f th e dental profess ion from its inceptio n
P ULL AND BE DAtVlNED ROAD goes down to the shores of Skagit Bay, an inside passage of the gentle Pacific leading ominously to DECEPTION PASS. This delusive inlet, which so easi l y deceived the ea rl y explorers, reminds us of how our professio n has practiced self- deceptio n over the yea r s. Un fortunately, many pass in t o the "pull and be damned" decept ive ph ase of d ental practice, never to return.
Inside D ECEPTION PASS, however, lies H OPE ISLAND, our symbol of the future. H OPE we must have, cou p ted with resolve. H OPE t h at t he future of dentistry will noticeably improve HOPE that an enlightened profess ion will be gu ided by lhe concept of re tention and rehabilitation of the dental apparatus. HOPE for the rejection of "oral amputat ion."
In this new tex t we hope to inspi re dent ists to consider root canal t reatment as an integral par t o f t h eir pract ice We discuss in great de tail the operative aspects of endodontic the r apy: cavity preparation, canal debridement and filling. We leave to othe rs the detailed discuss ion of an t i-infec t ives, local anesthesia, oral microbiology,
a lthoug h t hese s ubje cts are d ea lt w ith in th is text, brief an d 10 the point. We ha ve s pent , however, and unusual amount of s pa ce and time in developing the chapte r o n DIFFERENT IAL DI AGN O SIS OF ORAL AND P ER IORAL PA IN, so ne cess ary in a rri ving at a proper d iag no s is. Di agnos is of pain is falling mo re and mo r e in the prov in ce of en dod ont ics. Prop e r dia g no s is is th e discip line lhat sepa r ates the really compe tent d en tist fr om the merely m echani ca l. So a g rea t deal of thought and t ale n t ha s go ne into d evel o p in g th e four ba ckg round chapt ers o n n or mal and pat h o· logic pulp and p er iapi ca l tis su es .
Snee-oos h Beac h is no Walden Pond, nor a rc we T horeau for that matt er. But we m ay learn fr o m Walden. "Si mplify, Si mplify!" was Thoreau 's tex t , and s implifica t ion we hav e taken to h eart. We h ave removed the " mumb o·jumb o" from en d odo nt ic treatm ent, a sign ifi can t facto r that di sco ur aged den t is ts from including e nd odo nt ics in their p rac tice.
We ha ve a tt em pte d 10 pre se nt th e subject, no t o nl y in a s implifi ed fo rm , bu t in a sys tematic m anne r leading to success, pleasure and p r ofit. We ha ve attempte d to r emove the myste r y and reta in the bas ic core of th e s ub ject. We only hope th is text su ccee d s in br inging so m e o rd er out of the pr ese nt chao s.
John I. In gle Seattle, Wash ington 1964
The Hinman had a fo r mat wherein eac h lectu rer wo uld repeat his same lecture the n ext d ay. I d idn't atte nd Dr. Me n ninger's secon d lecture but he attended min e. There he was again, seated in the front row. I was flattered beyo n d m easure. At the end of th e lecture I asked him why his su dden i n teres t in endodontics. His reply wa s st ar tl ing.
" Dr. Ingle:' he said, "I was so im pressed with your lecture, bu t 1 was also terribly e m ba rr assed. O n behalf of my profession I must apologize to you fo r my past behavior. When J think of h ow m a ny patients I have reco mm ende d th at th ey h ave t h ei r tee th extracted, I am appa ll ed at t h e destruct ion [ have caused I ha d no idea. Now 1 fi n d these teeth co u ld h ave been saved a nd their a bscesses h eale d. You have n o idea how tha nkful I a m to you, for directing me fro m my past behavior." Spoke n like a psyc hi atris t!
We've co m e a long way since those days, a time o f w hole sa le ex trac ti ons. But we face a new ch allenge to day; not who lesa le extrac t io n s but selective extractions; for the sole purpose of placing a n implan t. Once again, d entists a r e urging pat ie nt s to have t eeth extracted, ignor in g th e fac t th at a healthy root is far preferable to a mechanical implant; less costly, less painful, less ti m e con sumin g, a nd above all , more b iologicaL
Now I'm n ot say ing implants are unhea lth y or less successful. What I am ing is my concern th at many salvab le teeth are being sacrificed on the altar of insatiability. Back to pull and be damned. I'm n ot against impla n ts! As a ma tt er of fact, implant the r apy is now being taugh t in a n umber of endodont ic post doctoral programs The thesis b eing, ho wever. th at teeth tha t ca nn ot or shou ld not be save d by endodontics m ay well be ext r acted a n d rep laced b y an imp lant rather than a bridge. And wh o better to pla ce th at implant than a well-t r ained e ndodonti st who ha s just made that ju d gme nt ?
The 6 th editi on of Endodonlics is reple t e with new innovat io n s an d know ledge. Now, more th an ever, it rem'li n s the "Bible of En do d ontics" a nam e long ap pli ed b y othe rs to the prev ious e ditio ns.
I feel most co m for t a ble as I "pass the torch" to the new editors, Leif Bakland a nd C rai g Baumgar tner. And I h ave a feeli n g the profession will come to its senses; veerin g off " Pull and Be Damned Road" and o nto the "Road Best Traveled."
John 1. In gle Decembe r 2007
PREFACE
"PULL AND BE DAMNED ROAD"
REVISITED
The orig in al sign for Pull and be Damned Road h as been pilferC'd so many times the au th orities have had to place a new sign ove r 20 feet above the ground. (Courtesy of D r. James Stephens. )
Over 40 years ago the preface to the first ed it ion of Endodontics featured "P ull And Be Damned Road." Nothing from the first ed ition left such a lasting impression as that saying. Even today, "old timers" come up to me at meetings to reminisce about t hi s preface. They may not remember the details of endodont ic cavity preparation or the chapter on pain first expressed in that edition. Those features have become an integral part of any endodontic practice. But they do remember "Pull and Be Damned Road." And for good reason .
Forty years ago it was more prevalent to ex t ract teeth than to save them by root canal therapy. A plea was made in this preface to trust endodontic treatment and to reverse this trend towar d "oral amputation." Gradually this became a fact, as endodontics spurred ahead an d full dentures declined.
And this brings to mind an incident I long have savored. I was a speaker at the Hinman Dental Meeting in Atlanta. Joining me as a headliner was Dr. Will Menninger, head of the famou s Menninger Psyc hiatric Clinic, then based in Topeka, Kan sas. Dr. Menninger and his brother Karl were unquestionably the world 's most famous psychiatr is ts. Dr. \Vill had been a brigadier general in World War II, head of aU the army's psychiatrists. In 1948 he was the first psychiatrist on the cover of TIME magazine. It was an honor for me to be on the same program with him, and I eagerly attended his first lec t ure that preceded mine.
VVhen I began my lecture, there was Dr. Mennin ger seated in the front row. I consi d ered it professional courtesy on h is part, but I did notice him taking notes.
ACKNOWLEDGEMENTS
Once again. I am particularly indebted to my wife Joyce and my son Geoffrey, who were so helpful in manuscript preparation and compu te r utilizatjon. An d s peaking of computers, I am especially indeb t ed to my computer " maven ': Lynda Ar n ett. who frequently spe nt hours "set ting me st raight and ba ili ng m e out" of tro u b le.
Bei n g isolated in a city without a sc hool of dentistry presents a prob lem in lit era t u re search Dr. Rob er t Bra vi n o f EI Cajon CA, who has a nearly com pl ete library of th e Journal of E'ldmiontlcs, was especially helpful i n providing back issues of JOE. In addition, I receive d a great deal of help from the dental schoo l library at the University of Southern Ca li fornia and C hi ef Librar ian, Professor Fr ank Ma son, as we ll a s Librarian John Gl u eckert. And at the University of Washington, in the Departm en t of D e ntal H ea lt h Sciences, Dr. Petc r Mi lgrom, cha irman , and Janessa M. Strea m Graves, Research Coordinator, were most helpful with t rends and statistics. I received si milar help from Jill Coc h ran at t h e Ame ri ca n Assoc ia tio n of Endodont is ts.
Fi naU y, I must acknowledge the advice and co un seling I rece ived fro m my dear friend th e late Dr. Dudley Glick. But mo s t of a ll , I acknowledge , with p r idc and admi ra tion , my coe dit o rs, Dr. Leif K. Bakland a nd Dr J. Cra ig Baumgartner. They have ca r ried the m ajo r load in producing this e dition of Etldodotltics, ti rele ss hour s, hund reds of e mail s, phone calls a nd faxes. 1 leave thi s text in the good hands of the se ski ll ed a nd h ig hl y knowledgeable indi viduals.
John I. Ing le
A textbook with th e sco pe and fo r mat of this, the 6th edition of It/g/e's Endodontics, would no t be possib le but for the tremendous effort by numerous individuals. Each contrib u tor to this book devoted considera bl e time to research, preparation, a nd wri tin g. To them I express m u ch gratitude for th e ir efforts, b u t also for putting up w ith my deadli n e prodding My h ope is that thi s collaborative effort make s them as proud as it ma kes me.
Editing ma nu sc r ip ts fTOm aro un d the world ( Euro p e, Asia , and the Americas) wo uld be impossible but for the expert secretarial suppo rt prov id ed by Luci D e nger and Sh annon Kokanour in the De p artment of Endo d ontics at Lorna Linda Uni ve rsity. These capable coworkers skillfu ll y completed in a timel y fas hion all the reque s ts for cha n ges, co r rections, formatting and interaction s wit h aut hor s and publi sh e r. To both Luci and Shannon -your contributions arc most appreciated. Anyone who takes on the job of editi ng a major t ext book know s that it will have an im pact on th e "day job" tha t each of us has. We re it not for an unders tanding dean , Dr. Charles Goodac re, and a cooperative departm ent facu lt y, Drs . Mahmoud Tor abinejad, Robert H a nd ysides, and David Jaramill o, th e r e would neither be the time nor the energy to complete this task. To them I say a heartfelt " Thank yo u. "
This grand text b ook is n ot the result of any single individual, a fact that is t r ue with regar d s to the editing as well as the writi n g and publishing. This was truly a team effort by 10hn I. I ngle, J. Craig Baumgartner and m e. We were in contact wi th each other, often daily, and I app recia t e so man y aspects of that interaction. John continues to teach me gra mmar and s t yle, and C raig has a way of seeing throug h problems w ith humor and clarity. l ohn and Cr aig , you ha ve t ruly enriched my life.
Producing a textbook is mor e than w riting - to reach yo u , the reade r, it n eeds to b e assemb led, printed and distr ibuted. My ap preciation for making thi s possib le goes to :
Brian Decke r, who enth u siastically sup p orted the notion of a te xtbook dedica ted to the spec ialty of endo d ontics; Tricia Bin dn e r, who served as production man · ager and who prodded wh en necessary and was alwa ys available for help and advice; and the suppo rt staff at BC Decker. Thank yo u all.
Looki n g back at the pa s t several months o f intense effort and the se tting as id e of ot her ac t ivities, it is dear to me that one pe rso n in my life made it po ssible, namel y my wife Grete. Under stand ing when pressures mount ed, re-assuring when dou b ts occur red, Grete unfailingly s upport ed my effor ts. Wi thout he r selfless par t· ners h ip, m y work could not have been comple t ed on time. From my heart, tha n k you Grete.
Leif K. Bakland
I want to acknowledge and than k my dear wife Teddi, for her loving s u pport of my acade m ic en d eavo rs. In addition, I especia ll y want to thank John Ingle for the honor of being asked to par ti ci pa te in the editing of the 6th edition of Ingl e's Endodontics Also thanks to ou r co-editor, LeifBakland, for his en thus ia stic encouragement on vi r tually a daily basis du r ing the long p rocess of editing a text of this enormi ty. An d finall y a hearty than ks to all the con t r ibutors for lh eir ex pe r tise and th e tireless effort requ ired to mak e thi s text th e very b es t it can be .
J. Craig Baumgartner
FIGURE ACKNOWLEDGEME
T Chapter 1
F igure 2:
Fi gure 15:
Figure 16:
Figure 18:
Figure 19:
Figure 20:
Figure 23
Figure 24
H gure 25 :
F igure 26 : Figure 28
Ingle JI, P DQ Endodon tics 2005, F igure 5 - 4
Ingle JI, l3 akla n d L, End o dontics 5th ed.2002, Fig 1-6
Ingle JT , Bakland L, Endodontics 5t h ed.2002, Fig 1-7
Ingle 11 , Bakland L, Endodo n tics 5t h ed.2002, Fig 1- 10
Ingle JI , Bakl a nd L, Endodo n tics 5 th ed.2002, F ig 1- 11
Ingle IT , PD Q En dodont ics 2005, Figure 7 - 38
Ingle J I, Ba k la nd L, Endodontics 5t h ed.2002, Fig 1- 15
Ingle JI, Ba ld and L, Endodontics 5th ed.2002, Fig 1- 16
I ngle II , Bakland L, Endo d on t ics 5th ed.200l, Fig 1-17
I ng lc JI, P DQ Endodo n tics 2005, Fi gure 11 - 6
T Ch a pte r II
Figure 3 : Figure 8: Figure 21:
Modified from Ingle- Bakland, Endodo n tics; 2002
Modified from Ingle- Bakland, En d o d o nt ics; 2 0 02
Modified from Ingle - Baklan d , En d odon t ics; 2002
T Ch a pt e r 22
Figure 3 : Ingle JI, PDQ Endodo n tics 2005, F igure 3-4
T Ch apter 26C
Figure 2: Figure 3: Egure 4 : Figure 5:
Ingle JI, Bakl a nd L, Endo d on t ics 5th ed.2002, p476
Ing le JI, BakJ and L, E ndo don t ics 5th ed.2002, p477
Ingle JI , Bakland L, En d odon t ics 5th ed.2002, p 479
Ing le JI, Bakland L, En d odon t ics 5th ed.2002, p 480
T C h a p te r 38
Figure 2 : Figure 3 : Figure 5: Figure 9:
Ingle JI, PDQ Endodontics 2005, Figure 11 - 3 A,B
Ingle JI, PDQ Endodo n t ics 2005, Figure 11 - 3 C
Ing le JI, PDQ Endodontics 2005, Figure 11-5
In g le JI , PDQ En dodon t ics 2005, Figure 11-8
Str u ctur e and Fu n ction of the Dentin-Pulp Co m plex
Syngc uk Kim , Ka r in J. J-I eyeraas, Sivakami R. Haug
Morphology of Teeth and Their Root Cana l Sys tem s
Blaine M. Cleghorn, Cha rl es J. Goo d acre, William H. C h ristie
Microb iology o f End odontic Disease
J Craig Baumgartner, Jose F. Siqu eira Jr , Christine M. Sedgley, An i! Kishcn .•.
Non-M icrob ial Endodonti c Disease
r.N. R. Nair
Inflammation and Immunolog ic al Responses
Ashraf F. Fouad, George T.-J. Huang
Mec h anisms of O d o nto ge ni c an d No n -Odontoge ni c Pain
Jen nifer L. Gib b s, Kenneth M. H argreaves
No n -O dontogenic Too thach e and Ch ronic Head a nd Neck Pain
Bernadette Jaege r, Marcela Rom ero Reyes
Pulpal Pathosis
G . R. Ho lland, Ste ph e n B. Dav is .
Periapical Lesions of Endodon t ic Origin
Zv i Metzge r, It zhak Ab ramovi t z
14 Diagnosis of Endodontic Di se ase
A End o d ontic Exam in a tion
Robe r t A Handysides, Davi d E. Ja r a millo, John I. Ingle
B D ia gn o s t ic Tes t in g
James C. Kulild
C La ser Dop pl er F10wmetry
Asgeir Sigu rdsso n
A Endodont ic Ra di o gr;:;. ph y
Richard E. Walton.
B Dig i tal1mag in g for Endo d ont ics
Allan G. Farman, Ramya Ramamurthy, Lars G. H ollender
C Ultrasonic Ima g in g
Elisabetta Cotti . .
Ra diographic Interpretati on Dag 0rstavik, Tore Arne Lar h eim
Rhino s inu s it is and Endodo n tic Di sease
Roderick W. Tatary n .. ... . .
Endodonti c-Pe riodontal Int e rrel ations hip s
IIan Rotstein, James H. S. Simo n
Toot h In frac tions
Leif K. Bakland ..
Vertica l Root Fracture s o f Endodont ically Treat ed Teeth
Av iad Tamse
Trea t ment of Endodont ic
Pharmacologic Ma na geme nt of Endodon tic Pain
Kenneth M. Har greaves, AJ Reader, John M. N uss t ein, 1.Gordon Marsha
Anxiety and Fear in the Endodontic Pati en t
Stanley
The Medica ll y C omp lex Endodontic Patient
Bradford R. Johnson, Den a J. Fi sche r, Joel B Epstein
Dr u g Intera ct io n s a n d Labo r a tor y Tests
Paul D. Eleazer
WiUiam
Intro d uc tion of N ickel-Titanium Allo y to Endodontics
William A Brantley
C In st rumen t s for Cleaning and Shapi ng
Timothy A. Svec
D Electron ic Apex Locator
Adam Lloyd, John r. Ingle
E Lasers in Endodo n t i
Adam Stabholz, Joshua Moshonov, Sharonit Sahar -Hel
James K. Bahcall Preparation of Corona l and Radicular Spaces
Ove A. Peters, Ravi S. Koka
lrrigants and lntracanal
Gerald N. Gli ckman, Gary R.
Jaim e L. Lozada, Alejandro Kleinman
Jean -P aul Rocca.
CONTRIBUTORS
Itzhak Abramovitz, DMD
Depar t me n t of En do d onti cs
Hadassah School o f Dental Me di cine
H e br ew University
Jerusa lem, Israel
Jens Ove Andreasen, DDS. Odont. Dr.
Associate Professor
Department of Ora l a n d Maxill ofacial Surge r y
Un iversity H ospital
Copen hag e n , Denmark
Nadim Z. Baba, DMD, MSD
Associate Professor
D epa rtment of Res torat ive Denti str y Lorn a Li n da Universi ty
Lorna Li n da, C alifornia
James K. Bahcall, DMD, MS
Associate Professor a nd Cha irm a n
Depar tment of Surgical Sc ie n ces a nd
Director of the Postgraduate Pro gram in Endodont ics
Marquette U ni versity Sc hoo l of Dentistry
Milwa u kee, Wisconsin
Leif K. Bakland, DDS
Professor and Chair
Department of En dodonti cs
Sc h ool o f D e nti stry
Lorna Linda Univers ity
Lorna Linda, Ca lifornia
J. Craig Baumgartner, MS, DDS, PhD
Professor and Chairman
Department of Endodontolo gy
Oregon H eal th & Sc ie n ces U ni ve rsity
Portland, Oregon
Fred W. Benenati, 0 DS, MEd
Cl ini cal Professor Em e ritu s Depar t me n t o f Endodonti cs
U ni ve r s it y of Oklah o m a College of Dent istr y Okla h o m a City, Okla h oma
George Bogen, DDS
Pr ivate Practice in E n dodontics
Los An geles, Cal ifornia
William A. Brantley, MS, PhD
P rofesso r an d Director of Graduate Program in Dental Ma teria ls Sc ien ce
Colle ge of D en t is tr y
The Oh io State U n ive rs ity
Co l umb u s, Ohio
L. Stephen Buchanan, DDS, FlCD, FACD
P ri va te Pra c tic e Limit e d t o Endod ont ics and Impl an t Su rgery
Sa nta Ba rb ara, Ca lifornia
Ass ist ant Clin ical Professor
Uni ve r sity of Sout h ern Californ ia and UC LA Sc ho ol of Dentis try
Los Angeles, California
Nicholas P. Chandler, BDS, MSc, PhD, LDSRCS(Eng), FDSRCPS(Glas), FDSRCS(Ed), FFDRCSI
Associate Professor
D epartmen t of Oral Rehab ilitat ion
School o f D entis t ry
Univer sity of Ot a go
Dunedin, New Zealand
William H. Christie, DMD, MS, FRCD (C)
Professor, Divi sion H ead
Endodontol ogy
U ni ve r sity of Manitoba
Winnipeg, Manitoba, Cana da
Blaine M. Cleghorn, DMD, MSc
Associa te Professor
Director, Clinical Affairs
Da lhous ie Univ ersity Halifax, Nova Scotia, Canada
Elisabetta Cotti, DDS, MS
Professor and Chair
Department of Conse r vative De n tist r y and Endodontics
Univers ity of Caglia r i Cagliar i, Ital y
Stephen B. Davis, DDS
Director, Endodontic Residency P rogram
Ve t er an Affairs Long Beach H ealthcare System
Long Beach, Californ ia
Paul D . Eleazer, DDS, MS
Chair, Professor
Department of Endodontics a nd Pulp Bi ology
University of Alabam a at Birmin gha m Birmin gham, Alabama
Joel B. Epstein, DMD, MSD, FRCD(C)
Professor and H ead
Department of Oral Med icine and Diagnostic Sciences College of D e nti stry
Uni ve rsity of Illinois at Chicago Chicago, Illinoi s
Allan G. Farman, BDS, LDSRCS, PhD, EdS, MBA,DSc
Professor of Radiology an d Ima g ing Science
Departme n t of Su rgi cal and H ospital D e nti stry
The Univ ersity of Louisville
School of Dentistry
Lou isv ill e, Kentucky
Dena J. Fischer, DDS, MSD, MS
Ass istant Pr ofesso r Department of Oral Medicine College of Dentist r y
Univer s ity of Ulinois at Chicago Chicago, Illinoi s
Ashraf F. Fouad, BDS, DDS, MS
Assoc ia t e P rofesso r and Chairman Department of Endodo nt ics, Prosthodo nti cs and Operative Dentis t ry
Baltimore College of Dentistry
U ni vers ity of Marylan d Baltimo r e, Maryland
Shimon Friedman, DMD
Professor, Head, Di sc ipl in e of Endodo n tics Director, MSc Endodontics Program Faculty of Dent istry University of Toronto Toronto, Ontario, Canada
Jennifer L. Gibbs, DDS, PhD
Endodonti c Reside nt I Post Do ctoral Fellow
Univer sity of Cal ifornia at San Francisco San Franci sco, California
Gerald N Glickman, DDS, MS, MBA, JD
Pr ofesso r and Chair
Departm ent of Endodontic s Director of Grad uat e Endodontics
Texas A & M H ealth Science Ce nter Ba ylor College o f Dentistr y Dallas, Texas
Alan H. Gluskin, DDS
Professor and Chair
Depar tm ent of Endodontics
Arthur A. Dugo n i School of Dent istry Univ ers ity of the Pacific Sa n Francisco, Cal ifornia
Charles J. Goodacre, DDS, MSD
Dean and Pr ofesso r o f Prosthodont ics
Departm ent of Restorative Dentistry
Lorna Lind a Unive rsity Sc hool of Dentist r y Lorna Linda, Cal ifornia
James L. Gutmann , DDS, PhD (he), FlCD, FACD,FADI
Honorary Professor Wu h an Un ivers ity
Wu h an, China
Markus Haapasalo, Dr Odont (PhD)
Professo r, Head of D iv ision of Endo d ontics
Ac ti ng Hea d of th e D epartment of Oral Bi ological and Me d ica l Sciences
Faculty of Dent istr y Uni ve rsity of Br iti s h Co lumb ia Vanco u ver, Bri t ish Col u mb ia, Cana da
Robert A. Handysides, DDS
Assistant Professor
Departmen t of Endodontics
School o f Dentis tr y 1 0ma Lind a Uni vers ity Lo m a Li n da, C aliforni a
Kenneth M. Hargreaves, DDS, PhD
Professor and Chair
Department of Endodontics
President's Council Endowed Chair in Researc h Uni ve rs ity of lexas at Sa n Antonio San Antonio, Texas
Gary R. Hartwell, DDS, MS
Professor and C h air
Depar tm e n t of End odontic s Uni ve r s ity of Medicine and Dentistry of New Jersey New Je rsey De n ial Sch ool Newark, New Je r sey
Sivakami R. Haug, BDS, Dr. Odont
Post doctorate, Department o f Biomedicine
Sec ti on fo r Physiology, Facult y o f Medici n e
Un iversit y of Bergen Be r gen , Norway
Karin J. Heyeraas, Dr. Odont
Professor of Physio logy Department of Biomedic in e
Sec tio n for Phys io logy, Faculty of Med icine University of Bergen Bergen, Norway
Michael M Hoen, DDS
Associate Professor
Depar tm e nt o f Endodonti cs
Directo r o f Graduate Endo dontics
U ni ve rsity of De t roit
Mercy School of Dent is t r y
Detroit, Michigan
G. R. Holland, BSC (Hons), BDS (Hons), PhD
Pr ofesso r
Departme n t of Car iol ogy, Resto r a ti ve Scie n ces a nd Endodont ics
Schoo l of Dentistry
P rofessor
De partm e nt of Ce ll and D evelopment Bio logy
Faculty of Medicine
Uni versi t y of Michi ga n
Ann Arb or, Michiga n
Lars G. Hollender, DDS, PhD
Professo r Emeritus
Depa rtm e n t of Oral Me di cine
Schoo l of Dentistry
Unive rs ity of Washington
Seattle, Washing ton
George T. - j. Huang, DDS, MSD, DSe
Associate Professor
Depar t ment of Endodo n tics
Ba ltimore Co ll ege of De ntist r y
Uni ve rs it y of Mary land
Balt imore, Mary land
John I. Ingle, DDS, MSD
Lect ur er
Lo m a Lin d a Unive r sit y
Sc hool o f De nti st ry
Lom a Lind a, Cali fo rnia
Bernadette Jaeger, DDS
Associa te Professor of Oral Med ici n e a n d Orofacial
Pai n
Un iversi t y of Southe rn Ca lifo rni a
School of Den ti stry
Los Angeles, Califo rni a
David E. Jaramillo, DDS
Ass ist ant Pr ofesso r
Department of Endodon t ics
Sc ho ol of Dentistry
Lorna Linda Univers ity
Lorn a Lin da, Califo rn ia
Bradford R. Johnson, DDS, MHPE
Asso ci ate Pr ofesso r and Di rector of Postdoctoral En d odo nt ics
D ep art m e nt of Endodontics
Sch ool of Den ti stry
Un iversi t y o f Ill in oi s a t Chicago
C h icago. Illinois
James David Johnson. DDS. MS
Chai r and Cli nica l Ass o ciate Pro fesso r
Prog r am Direc tor, Adva nced Educa t ion
Program in En dodontics
Depa rt ment of Endodontics
Schoo l of Den t istry
University of Washing ton
Sea ttl e, Washington
Wm. Ben Johnson) DDS
Assoc iate Clinical P rofesso r
Nova Southeaste rn Uni vers it y Ft. Lauderdale. Florida
Louis iana St a te University
New Orlea n s. Lou isiana
Ba ylor Colle ge of Dentistry
Dalla s. Texas
Syngcuk Kim, DDS, MPh, PhD
Louis 1. Grossman Professor an d C h a ir
Department of Endodontics
School of Dental Medicine
Un ive rsity of Pennsylvania
Ph il ad el phi a, Pe nn sylvan ia
Ani! Kishen, BDS, MDS, PhD
Assistan t Professor
Department of Res t orative Dentistry
Na t ional Uni ve r sity of Singapore
Singapore, Republic of Singapore
Alejandro Kleinman, DDS
Ass o ciate Professor
Res t o rati ve Depa rtm ent
Coo rdinato r. In t ernship Prog ram in Impl an t De n t ist r y
Sc h ool o f Dentistry
Lorna Linda University
Lorna Linda. Ca li fo rnia
Ravi S. Koka, DDS, MS
Assista n t Professor
Arth ur A. D ugo n i Sc h ool of Dentistry
U ni ve r sity of the Pacific
Sa n Francisco. Ca liforn ia
James c. Kulild, DDS, MS
Profe ss or a nd Director
Advanced Specialty Education Pro gr a m in En d odontics
UM KC Sc hoo l of Dentist r y
Ka n sas C it y. Missouri
Tore Arne Larheim, DDS, PhD
Professor
Institute of C lini cal Dent istr y
Faculty of Dent istry
Unive r s ity of Oslo
Oslo, Nor way
Martin D. Levin, DMD
Adju n ct Ass istan t Profess or , Postgradua t e Endodontic s
College of Dental Medici n e
No va South eastern University
Fort Lauderdal e. Florida
Yiming Li, DDS, MSD, PhD
Pro fessor an d Director
Ce nt e r fo r Dental Researc h
School of Den t istry
Lorna Linda University
Lorna Linda. Califo rnia
Louis M. Lin, BDS, DMD, PhD
Pro fesso r and D irector
Advanced Ed ucation Pro g r am in End odontics
Colle ge of Dent ist ry
New York Unive r sity
New Yo rk , New Yo rk
Contributors
Adam Lloyd, BDS, MS
As s istant Professor
Depa r tm e nt of Endodonti cs
No va South eas tern Un ivers ity
For t Laud e rd a le, Fl ori da
Jaime L. Lozada, DDS
Professor and Dir ec tor
Graduate Progra m in Imp lant Dentistry
Sc ho o l of De nti str y Loma Linda Univer si ty Lorna Linda , C. lifornia
Stanley F. Malamed, DDS
Pro fessor of Anest hes ia & Medicine
Schoo l of Denti s try
Un ivers ity of South e rn C alifornia
Los Angel es. C aliforni a
T. Gordon Marshall, DMD
Ass oci ate Professor
Depa rtment of Endodonto logy
OH SU Sc hoo l of Dent ist r y
Portland Oregon
Zvi Metzger, DMD
Direc t or of Research La bor ator ies
The Gold sc hl eger Schoo l of Dental Med ici n e
Tel-Aviv Univers ity
Tel-Aviv, Isra el
T. Todd Milledge, DDS
Clinical Associate Professor of Pedia t ric Den t istr y
School of Dent is t ry
Lorna Li nd a Un ive r sit y Lorna Lind a. Cali fornia
Joshua Moshonov, DMD
Cli n ical Asso ciat e Professo r, Act in g C hair
Department of Endodontics
H adassah Sc hool of De nt a l Medi cin e
Heb rew Unive rs it y
Je r u sal e m , Is r a el
P.N.R. Nair, BVSe, DVM, PhD (he)
Senior Scie nti st
Ins t itute o f Oral Bi ology
Cen t re of Denta l & O r al Med icine
Univer s ity of Z urich
Z uri c h . Sw it 7.e rl and
lobo M. Nusstein, DDS, MS
Associate Pro fesso r
Sec tion Head of End o d on ti cs
Dir ec tor Gra dua te Endodont ic Clini c
Co ll ege of De nti st r y
The Ohio Sta te Unive rs ity
Co l umbu s, O hi o
Dag 0rstavik, Cand Odont, Dr Odont
Professo r and H ead
Departm e nt of Endodonti cs
I nstitute of Cl ini ca l De nt istry
Faculty of Den ti stry
U ni ve rs ity of Oslo
O s lo. No r wa y
Christine 1. Peters, Dr Med Dent
Assis tant Professo r
De partm e nt of Endodontics
Arthur A. Dugoni Sc hoo l of De nti stry
Uni ve rs it y of t he Pacific
Sa n Franci sco, C aliforni a
Ove A. Peters, DMD, MS, PhD
Profe ssor of Endod o n t ics
Arthur A. Dugoni Sc hoo l of De nti stry
Uni ve rsi t y of th e Pac ifi c
San Franci sco, Ca liforni a
Wei Qian, DMD, PhD
Re searc h Assoc iat e
Departm e nt of Oral Biological and Medica l Sciences
Fa c ul ty of Dentis tr y
University of Br iti s h Col umbi a
Va n couver, British Col umbi a
Ramya Ramamurthy, BDS, MS
Fourth Year I nternat ional D DS Studen t
University of California
Sa n Francisco, Californi a
Al Reader, DDS, MS
Professor and Program Director of Endodontics
College o f Dentis t ry
T he Ohio State University Columbus, Oh io
Jean-Paul Rocca, DDS, PhD
Professor and Hea d
Clinica l Research Unit
Dental Faculty
Unive rsity of Nice
N ice, France
Marcela Romero Reyes, DDS, PhD
Lecturer, Section of Orofacial Pai n and Medicine
University of California at Los An geles
School of Dent ist ry
Post Docto r al Fellow
Department of Neurology
Headache Research and Treatment Program
University of Cali fornia a t Los Angeles School of Medicine
Los Angeles, California
Paul A. Rosenberg, DDS
P rofessor and Chair, Igna t ius N. Sally Quartaro
Department of Endodontics
College o f Dentistry
New York Un ive rsity
New York, New York
Han Rotstein, DDS
Chair, Surgical Therapeutic and Bioengineering Sciences
Associate Dean , Co n tinuing Oral Health Professional Education
University of Southern California School of Dentistry
Los Angeles, California
Clifford J. Ruddle, DDS, FACD, FlCD
Assista n t P rofesso r of Endodon t ics
Schoo l of Dentistry
Lorna Linda University
Lorna Li nda, California
Associate Clinical Professor
Schoo l of Dentistry
Un ive r sity of California Los Angeles al1d
Un ive rsity o f California San Fr anc isco
Sharonit Sahar-Helft, DMD
Clinica l Instructor
Departme n t of Endodontics
Hebrew University
H adassah Sc hool of Denial Medicine
Je r usalem, Israe l
William G. Schindler, DDS, MS
Clinica l Professor
Department of Endodontics
University of Texas Health Science Cen ter
San An tonio, Texas
Christine M. Sedgley, BDS, MDSc, MDS, FRACDS, PhD
Assistant Professor
Cariology, Restorative Sc iences & Endodontics
School of Dent is t ry
University of Michigan
Ann Arb or, Michigan
Bruce H. Seidberg, DDS, MScD , JD, DABE, FCLM, FACD, FAAHD, FPFA
Ch ief of De n tist r y
Crouse Hospital
Senior Attending Endodontist
SI. Jos e ph 's Hospital
Syracuse, New Yo r k
E Steve Senia
Former Director, Postdocto r al Endodontics
Un iversity of Texas at San Antonio
Sa n An tonio, Texas
Asgeir Sigurdsson, Cand Odont, MS
Ad junct Assoc iate Professor
Department of En d odontics
University of Nort h Carolina
School of Dentistry
Chapel Hill, North Carolina
James H S. Simon, DDS
Director
Advanced Educa t ion Pr ogram in Endodontics and Wayne G . and Ma r garet L. Bemis Endowed Professor of Endodontics
School of Dentistry
University of Southern California Los Angeles, California
Jose F. Siqueira Jr, DDS, MSc, PhD
Chai rm an and Professor
Department of En d odontics
Estacio de Sa Universit y Rio de Janeiro, RJ, Brazil
Harold C. Slavkin, BS, DOS
Dea n and G. Donald and Mar ian James Montgomery Professor of Dentistry
School of Dentistry
Un iversity of Southern California Los An geles, California
Ad am Stabholz, OMO
Dean and Chairman
Department of Endodontics
Hadassah Schoo l of Dental Medicine
Hebrew Uni ve r s ity Jerusalem, Israel
Timothy A Svec, DDS, MS
Associate Professor a nd D irector
Advanced Educatio n Program in End o d on t ics
Un iversi t y of Texas Dental Branch
H ouston, Texas
Aviad Tamse, DMD
Professor and Chair
Director of Graduate Endodontic Program
Department of Endodontology
Goldch lager School of Dental Medicine
Tel-Aviv Un iversity
Tel -Aviv, Israel
Roderick W. Tataryn, MS
Private Practice, En d odontics
Spokane, Washington
Mahmoud Torabinejad, OMO, MOS, PhD
Professor of Endodontics, Director of the Advanced Education Program in Endodontics
School of Dentistry
Lorna Lind a University Lorna Linda, California
Martin Trope, 0 MO
Professor and Chai r Depa rt ment of Endodontics
School of Dentistry
University of Nor t h Carol ina Chapel Hill, Nor th Carolina
Richard E. Walton , OMO, M S Professor of Endodontics
Co ll ege of Dentistry
Uni versity of Iowa Iowa City, Iowa
Ralan Oai Ming Wong, DDS, MS
Associate Professor Department of Endodontics
Arthur A. Dugoni School of Dentistry
University of the Pacific San Francisco, Cali fo rnia
T THE DISCIPLINE OF ENDODONTICS
C H A PTER 1
MODERN ENDODONTI C THERAPY: PAST,
PRESENT AND FUTURE
J OHN I. I NGLE, H AROLD C . SLAVKIN
Bem use l' ll have you know, Sancho, that a mouth without teeth is like a mill without its stone aIld you must value a tooth more than a diamond.
M igu el d e Cerv ant es, Don Quix o te
"Through shifting times there passed- those little bands of struggling beings who someday wOIl/d be men. They mrvived through plasticity, - through a growing capa city /0 recognize, in changing limes, that today is different than yesterday, and tomorrow from today. Many-most without doubt - were conservative crealures These died by dry, unanticipated stream beds, or numbed all d froze in unanticipated storms. Those, quite obviously, were IIot your ancestors. It was the others-tile witty, sensitive, the flexible. the ones who could recognize a changing environment- these were the ones to assemble a new and most remarkable genetic package : Ourselves."
Robe r t Ardrey , The Te rri torial I mperat ive
Ch a nge
It was Benjam in Franklin (n o t Mark Twain) who sai d , " T he o n ly two certa inties in life a re death an d taxes ." C hange has been th e one co nstan t of hi story T h e challe n ge is n ot to avoi d change, bu t t o manage it. But ch ange ca n be " for be tt er o r for wo rse."
Fortunately, or un fo rt u nately, we have exper ienc ed both in endodontics. T he disappo in t m en t in ro ot ca nal fill ing materials suc h as silver points, n umerous in t racanal d isinfectants, a nd several sea lers is an example o f t h e fa il ures we ha ve endu red. T he move fr o m film to dig ita l ra d iographs, more profound local anesthetics,
stan d ardi za tion o f end odon t ic in strum ent s, an d new in str ume nt all o ys wit h novel geometr ic d esigns are o nly a few of th e adva n ces over th e years T he re are now ma n y exc it in g devel o pmen ts to im p rove th e q u ality an d th e ou tp ut of our en deavors; some of t h em will be "win ne rs" and some will be losers Ti m e an d experim entation will determine which is wh ich .
In C hapter 2, Dr James Gut mann presen ts an h isto rical chro ni cl e of en d od ontics, so t h ere is no need to repe at it here. Bu t it might be interes t ing (as well as ed u catio na l) t o fo llow through on two ear ly changes in end odontics tha t still affect us to d ay-no me n cla t ure an d instrument design an d sta nda rd ization.
NOM ENC LAT URE
Duri n g Wo rld War II , Dr. Balin t Or ba n was as ked by th e fede ral governme nt to solve the p ro blem of hig h alt it ud e too t hac h e b eing suffere d by a number of Army Air Cor ps P ilots . Th is expe ri en ce rene wed h is in terest in pul p path ol o gy Dr. O rb an, a fa mous physician , p syc hi a trist, d en ti st, pe r io d o n t is t , a ut h o r an d a su perb hist o pa tholo gist , was then as ked to m o d ern ize en dodon tic n o menclatu re, which he di d. l
He firs t ta ckle d t he pulpal cond it io ns an d d efined the vario us stages of p ulp it is, wisely bas in g a classification on th e sym pto ms o f pulpalg ia fac in g an y de n tist diagno sin g pain ful to oth ache . He m atche d t hese symptoms wit h what he knew was h appen ing pa t hologically in the p ulp. T hey ranged fro m reversible incipient pul palgia, throug h irreversible adva nced p u lpalg ia wit h its excruciat ing pa i n, to the painless necrosis o f the pul p. " Reversible" p u lps ca n be saved, but most really pa inful p u lps are inflame d a nd/ or in fec ted beyo nd re d empt ion
Before this time we spoke of " hyper emia of the p ulp " wi th no proof that hyperem ia occ u rred. It was not unt il 1965 that Beveridge and Brown 2 followed by Van Hasse l3 demonstrated changes in tntrapulpal pressures that we re related to a number of clinical variables, including inflammation.
Orban also changed the nomenclature for periapical disease , basing it on his class i fication of periodontitis for periodontal disease. " Inflammat io n of the per iodontium anywhere is periodontitis" he would say. " It 's apica l periodontitis at the apex of the tooth - ju s t as it is marginal periodontitis at the alveolar crest " .4 Before Orban, we spoke of pyorrhea and trenc h mouth or Vincent's disease.
So changes in nomenclature, informed by critical observation, he lped to form a backgroun d for an avalanc h e o f research efforts placed en dodon tics on a much mor e scientific footing .
INSTRUM ENT DE SIGN AND STANDARDIZATION
Unt il 1957, most e ndodon tic instrumen ts came i n 6 s izes - I through 6. T here we re Jiles t hat were to be used in a push - p u ll rasping mo t ion and reamers t h at were to be used in a rotary motion There was no s tandard i7.ation within a size or bet ween sizes, o r among manufacturers. The de s ign of m ost files and reamers was based on the original design developed by Kerr Co. in 1904, morc than a half century before ( Figure 1) . Hence, t h e de s ignat ion K files and K reamers . The only variation wa s the Swe d ish H ed st rom fil e shaped like a wood screw. And of co u rse, there was also the ubiquitous b roach that came in small , medium, and large s izes. Change was calle d for!
In 1957, a plea wen t out to the p rofession and th e manufacturers to sta ndardi ze endodontic ins t rum ents 5 It was answered by a $vnss company, and a stud y was undertake n to develop a standa rd that a1l manufacturers would adhere to a nd that would be accept.ed by the profession.
In 1958, a p ropos al was i ntroduced to stan d ardize lh e taper of instruments as wel! as t he length. i n addition, based on the me tr ic system, a formula fo r a graduated increment in size from one instrumen t to the next was deve!oped. 6 ,7 The new numbe r in g system aUowed for numbers from 10 to 100 based on the tip diameter, # 10 for a tip size of 0.1 mm t o # 100 for a tip size of 1.0 mm. The cutting blades we re to exte nd up the shaft for 16 mm and the advance in taper was to be a ga in of 0.3 mm, which figured out to be an increase of 0.0 187 5 mm/mm ( Figu re 2 ) . T h is figure soon became clumsy for manufacturing and was ch ange d to 0 02 mm / mm. H ence these new standar d iz ed i nstrumcnts came to be known as 0.02 instruments.
At first, most companies werc unwiHing to junk a ll their overage machines that produced ins trum ents, while one Sw iss company that backed the ch ange began to capture t h e market. When the newly designed instruments were designated as the " Int erna ti ona l Standard " b y the Intern ational Standards Organi7.a tion , all the companies, worldwide, chan ge d their manufacture to the new st an d ard t h at remains t he st andard tOO ay. s
For a nu mber of years there was not m uch movement in ins t rument design. An d th en it b lossomed! Today there is a ple thora of design changes as well as
Magnified Many times. Note the triple cutting edge
Figure 1 The origin al Kerr reamer, ca. 1904 (titled a broach at that ti me). is the origin of today"s K style ins truments _ Reproduced with permission from Ke rr Dental Manu facturing Co 1904 catalog.
Figure 2 Original recommendation for standardized instrume nts_ The number of the instrument is determined by the diameter size at 01 in hundredths of millimeters. Diameter 2 (02) is uniformly 0 32 mm greater than 01. a gain of 0.G2 mm/1 mm of cunin g blades_
Kerr Broach
size changes. The standard .02 taper instrument has now been joined b y .04, .06, .08, even up to .12 mmJmm tapers. Th e original K sty le in strum en ts have been joined b y a col o n y of other d esig n s; a few proved impractical and have di sappeare d from the mark e t. Ca rbon s t ee l gave way to st a inl ess stee l that is now bein g challe n ged b y nickeVtitanium , wit h probabl y more to come.
" Fin ger-powe red " in st rum e nts , altho ugh they still have their place, a rc slo w ly being ove rtak e n by electric - powered ro tary in strum e nt s. According to an anon ymo us industry representative. in 1996 les s than 1 million nickel - titanium (N iTi) rotary instruments we re so ld in the U nit e d Sta tes. co mpared to 20 million stain less st ee l in strum e nt s. In 8 yea rs. by 2004, sales of NiTi rotary fil es had jumped from 1 million to 1 1.4 mill io n , and by 200 6 10 13 .4 m illion . At t h e same t ime, 2004 and 2006, sa les of stai n le ss instrumen ts reac he d a plateau of 23 5 and 24 m ill ion , re sp ec tively. With these Iwo e xample s of c han ge that ha s taken pla ce in en d odon t ics, it is obvious tha t there wi ll b e more in t h e futu re.
PRESE NT STANDING OF ENDODONTICS
Speakin g of c h a n ge, what has bee n the impact on en d odo nti cs from th e pre se nt ru sh towa rd implant s? At a time when successfu l outcome In en dodonti cs ha s vastly improved, when the stigma of painful root canal therapy is disappearing. when tre a tment tim e h as been shortene d , a nd whe n e ndodontic fee s compare so favorably to implant and pro s thetic fees, one wonde rs why t hi s move toward implants. Conve rsation s amon g e ndodonti st s often include comments about situation s in which pat ie nts have been advised by general d entis t s or specia li sts, in for ex ample, periodontics, that a tooth an endodontist might conside r sui t ab le fo r treat m cnt should instead be rep lace d with an imp lan t
T his ha s becom e a di s turbing t rend and t he specialty of e n d odonti cs fa ces a c ha ll e ng e to educate b o t h co ll eagues in d e nti s t r y and patien t s about t h e demon s trat e d benefi t s in main ta inin g the natura l te e t h. In C hapt e r 4, Dr. Mahmoud T orabinejad addresses this contr ove r sy th a t hi gh light s the import ance of in vo lve m e nt by the endodo ntic c ommunit y. Suc h invo lveme nt a lso includes incorporating the area of imp lant d e nti s t ry into th e scope of practice for e ndodonti sts. In C hapt e r 33, Drs. Jaim e Lozada and Alejandro KJeinman d escr ib e the procedures involved i n replacing a tooth that cannot be retained (e .g .• du e t o a ve rti ca l root fracture ); many en dodonti st s are beg innin g to in co rp o rat e implant dentistry
in their practices. What then is the pre sent st anding of endodontics? With the profession? With the public? Let u s loo k at some int e rest ing facts.
DEFINITIO N OF E NDODONTICS
First, we had better define en dod o nti cs-w hat is endodontology or what enc o m pa sses the practice of endodontics? The best d efinit io n may be modified from th e definition by the Ame ri can Associatio n of Endodon ti s ts. 9
" Endod ontics is that branch of dentistry that is conce rned with the m orp holo gy, phy s iology and pat hology of th e h uman dental pulp and periradicular ti ss ue s . Its stud y and pra c tice encompass the ba sic clin ica l scie nces including biology of the normal pulp; th e e t iolog y, diag nosis, prevention and treatment of dis cases and injuries o f th e pu lp; and assoc iat e d peri radicular conditions
Th e scope of e nd odon tics inclu d es, but is not limit ed to , the d iffe rentia l di agn o s is and the treatment of oral pain of pulpal or pe r irad ic ular origin; vi tal pulp therapy . suc h as pulp capping and pulpotomy; nonsurgical treatment of root cana l systems w ith or w ithout periradicular patho sis of pulpal o ri g in and th e obt ur a tion of these root canal systems; se lective surgica l removal of pathologica l tissues resulting from pulpa l pathosis; repair procedures related to s uch s u rgical removal of pathological ti ssues; intentional replantation and rep lantation of avulsed teeth; s urgical removal of tooth s tructure, such as roo t-end resection and root -e nd filling; hemisect io n , bicu spidization and root resec ti o n ; en dodonti c implant s; bleaching of di sco lo red dentin and ena mel; retreatment of t eelh previously trea ted endodontic a lly; and treatment pro ce dures relate d to coronal res toratio n s b y means ofrost and/or cores invo lvi n g t he ro ot can al space.
The endodontic sp (.'C ia list is responsib le for the advan ceme nt of endo donti c knowledge throug h research; th e tran smi ss ion of information conce rning the mo st recent advan ces in biologically accepta ble procedures and materials; and the education of th e public as to the importance of endodonti cs in keeping the dentition in a physiologically fun ctional stat e for the maintenance o f oral and systemic health. "
To this one might add: the di ag no s is of extraora[ referred pain; th e management of traumatic injuries to the t eeth; the biopsy of pathological tissue, and the growing recognition o f pathological condi t ions
between the maxillary posterior teeth and the maxillary sin us.
RE CENT ATTIT UDE S TO WAR D DE NTISTR Y AND ENDODONTI C THER APY
Increasingly, the term "root canal" has become fashionable and generally known. In conversation, people proudl y proclaim that the y have had a " root cana l. " The stigma ta of fear and pain are fast disappearing. Another impressive facto r in the acceptance of endod o nti cs is telev i sion. Countless advertisements empha s ize a b eautiful smi le-not ju st toothpaste adve r t isements, but commercials in every field, from Bui cks to beer. At the same time, th e constant barrage of denture adhesives and cleanse r advertisem ents produces a chilling effec t The public sees the problems that d eve lop from the loss of t eeth. Obvious missing teeth are anathema.
There is no question that the public's acceptance of endodontic treatment is on the rise. In 1969, for ex a mple, t he American Dental Association ( ADA ) estimate d that 6 million teeth were treated endo do ntically eac h year. By 1990, the ADA reported 20, 754,000 endodontic procedu res, or 2.1 % of all dental procedures. By 1999 , they reported th at total endodontic acti vity had increased to 21,932,800 proce d ures, but now accounte d for only 1. 7% o f the total d ental procedures t hat num bered I billion 250,000 procedures. IO,1 1
This upward trend was also d ocumented b y the Public Affairs Committee of the AAE. Reporting on the surveys of the genera l public made by the Opinion Research In st itu te in 1984 and 1986, the Com mitt ee noted th at 28% of 1,000 telephone respondents reported that they had h ad root canal therapy by 1986, an increase of 5% points over th e 23% reported in 1984 . 12 Als o, in 1986,62% said that they would choose root ca nal therapy over extraction, an increase of 10% points o ver the 52% in \984. More than half the respondents ( 53% ) believed that an endodontically treated tooth would last a lifetime. 12
Twenty years later, in 2006, the AAE was reporting s im ilar positive figures. 13 On the other hand, 63% of the respondents d esc rib ed root can al therapy as " painful. " It turned o ut , however, that the respondents who had had root canal therap y we re 6 times more likel y to describe the procedure as "painless" than th e cohort wh o had never had roOI canal t reatment Y In othe r words, patients have been shown to ant icipate more pain than they will actually experience dur in g endodon t ic treatment. 14 Clearly, the profession has a mi ssio n to con tinu e educat in g the public
to reverse its image of en dodont ics and promote the value of an endodontically treated tooth.
Th e rate of the use o f en dodontic serv ices s imi lar to the rate in the Unit ed Stat es ( 28 % ) was reported from Nonvay also, where 27 % of an older age group (66-75 years ) had had root canal therapy , as had 12 % of a younger age group (26-35 years ) Inci d entally, 100 % of the root - fille d teeth in the younger g roup we re still present 10-1 7 years later, a remarkable achievement. 15
T he growth in endodontic services is also re fl ec ted in the sales of endodon ti c equipments, s up p l ies, and instruments. In 1984, according to an anonymous industry representative, endodontics was a $20 million market , growing at a rate of 4% pe r year. 16 By 1997, 13 years later, the endodontic mar ket, through dental dealer re tail stores alone, was $72 million, up from $65.6 million in 1996, a growth of ne arly 10%. One must add to these sa les another 10% to account for mail order/tele phon e sales, a grand total of nearly $80 million in 199 7. Worldwide sa les were probably dou b le this figure! 17 I n the year 2005, it was revealed that total en dod ontic sales exceeded $200 million in th e USA alon e and $400 million worldwide.
Future of Endodontics as a Speciality
Every 4 years the Am erican Dental Associatio n Survey Center p ubli shes a review of all aspects of de n tistry including a report entitle d " T h e Economics of En dodontics " In this report, th e Survey Center covers endodontic services an d utilization, growth of the s pecialty, location of endodontists, ch ara cte r is t ics o f endodontists , finances, refe rral s, and " A Look at t he Future ." Th e latest report was published in 2003 covering the years through 1999 with a few references in the years 2000 an d 2001. 10 Portions of the report were pu bli shed in the Journal of Endodontics in 2006. 11
T he report paints a rat h e r pleasant picture of the present but vo ice s some concerns about the distant future. Some co nc erns had not developed by 1999, such as the impact implants wou ld have on th e practice of endo d ontics. The report a lso predicted that th e pop ul ation of the United States would not reach 300 million unt il 2010 wh en in re al ity this fig u re was reached in October of 2006 On the who le, howeve r, their concerns for the future bear review and attention.
On e changing relationship arising is be tween the specialty and general practitioners. For instance, the ratio between general dent ists and endodo ll tists is drop pin g; in 198 2, there were 50.3 possible referring general d enti s t s to each e ndodontist. But b y 2002, the
rat io was down to 34.5 and falling (F igure 3) . Although general dentists perform about 75% of all endodo nti c procedures, they still refer 25% to endodontistsi whether this will change is open to speculation . T h e numb er of endodontists has grown at a faster rate than any othe r d ental specialty. Between 1982 and 2002 "the number of professionally active endo d ontists had increased by 85%," In contrast, " [gJeneral practitioners grew at a rate of 33% from 198 2 to 2002.,,10,11 In 1989, there were 2,500 endodontic specialis ts in the United States. It! By the year 2003, the number had risen to 4258 practicing endodon ti sts. 19 Between 1982 and 2003, t he number of endodontists grew 107.9%, faster than any other specialty, well exceeding the rate of the growth of general practi-
l ioners ( 38.4% ) 20 By Novembe r of 2006, according to th e AAE, t he specialty h ad grown to 4,859 endodontist members (perso nal communication, AAE ) . There is no question that the greates t share of endo dont ic procedures is carried out by America ' s gene r al practi t ioners ( Table 1) On the o t her hand, the special t y of endodontics is growing as well. For examp le , only 5% of those patients who had had root canal therapy in 1986 were treated by a specia li s\. 12 By 1999, however, endodont i sts were providing 4.4 million procedures, which was 20.3% of the 21.9 million tota l endodontic procedures provided by all dentists, endodontis t s included (see Table 1) .1 0 In 1999, there were over 1 billion dental services rendered. Only 1.7% of Ihese procedures were endodontic. It is interesting to note, however, that while
Source: American DenIal Association Survey Center. 199) and 1999 Surveys of DenIal Services Rendered
Figure 3 Ra ti o of
Table 1 Distribution of Endodontic Procedures by Specialty, 1990 and 1999
General Practitioners
< 2 % of the total services were endodontic, 15 % of the total dental expenditures in 1999 went for endodontic treatmen t at a cost of 8 2 billion dollars. lo
On a per capita basis, 6 % of the total populat ion r eceived endodontic services in 1999. On the other hand, 9 % of a ll denta l patients received some form of endodontic treatment. In this same vein, general pract it ioners performed 16.5 million root canal p ro cedures in 1999 compared to 4.5 million b y endodontic specialists (see Table O. Howeve r , endodont ists performed 24.7 procedures a week compared to only 1.9 b y gen-
eral practitioners ( Figure 4 ) Th e average numbe r of endodontic procedures in 1999 b y a general practitioner ( 94.6 ) versus each endo d ontic speciali st (1 263.3 ) is st riking ( Figu r e 5 ) .10
It is intere sting to note the differences in the type of pro c edures performed b y specialists ver sus ge n eral denti sts . Endodontists performed 6 1.9% of the molar root canal treatment s and general practitioners did 29.6 % of the molars-less than half. The remainder was probably done b y oral surgeons. By the same token, general dentists did 20.1 % of the anterior root canal procedures
General Practitioners
Figur e 4 Tota l ro ot ca nal tre at ments per we ek pe r dentis t. 1999, So urce: Americ an Den
Re nde red.
Figure 5 Root canal lrea tm
per dentist ,
Source: Amer ican Oenta l Association Survey Center, 1990 and 1999
Surveys of Dental Servi ces Ren dered and 9 8% of the pulp cappings, whereas the specialists tr eated only ha lf as many anterior teeth and performed onl y 0.4 % of the pulp cappings (Table 2).10,)[ Molar endodontics fairly well defines the difference in en dodontic treatme nt performed between gene ral dent ists and endodontists.
Ano t her consideration by the ADA su r vey group concerned amalgam versus resin restorations be in g placed, particularly in the posterior teeth. Th ey poin ted
out the age old record of ama lgams protecting the pulp over long periods of time. In the year 2000, the jury was still out on the life span of posterior resins, so they were speculating on how failing resins in the future would impact the amount o f en dodo ntics to be done. They pointed out that amalgam restorations had declined from 100 million t o 80 m illio n between 1990 and 1999, a 20% decline, whereas resin restorati ons increased from 4 7.7 million i n 1990 to 85.8 million in 1999, an 80% increase ( Figure 6 ). 10
Failing resins impacting an increase in endodontics may not be predictable at th is t im e, whereas the age of patients in the future is predictable . Mo st root canal treatment is performed for pat ients between the ages of 25 and 64, particularly molar end odontics , done mostly by endodontists (Figure 7) U n fortunately, projected future change in the US population shows a severe drop off in t he very age g roups most prone to endod onti c th erapy (F igure 8 ) . So this population sh ift may reduce the numb er of patients seeking endodontic services; at the same lime the number of referring general denti sts is decreasing . IO,1 1 It is possible that the aging population « 64 ) will provide an increasing pool of patients needing endodontic services
The present good news is that in the years 1997- 1998, endo donti st s enjoyed an average net income of $230,000, second onl y to oral surgeons, a surprising figure considering average gross
Amalgam, Amalgam, Amalgam, Amalgam, Resi n Resin one s urface two surfaces three fou r plus restoretion , restoration, surfaces surfeces anterior posterio r
Figur e 6 Number of amal gams and resi ns 1990 (blue) and 1999 (red) Source: American Den tal Associ ation, Su rvey Ce nter 1990 and 1999 Survoys of Dental Servi ces Rendered.
Figure 7 Root canal treatments by age Source: American Den ta l Association, Survey Center. 1999 Survey of Dental Services Rendered.
Figure 8 Projected change in the US population from 2000 to 20211. Source: American Dental Association, Survey Center.
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marrying Jeanette Lucas was wise, and that his sacrifice of an income will be made up to him without much loss of time.”
“How contemptible!” cried Cis. “As though there were need of looking beyond Jeanette herself for a reason for wanting to marry her! If Mr. Randolph had that sort of worldly prudence he need not have come into the Church at all! Why are human beings so mean?”
“Because they are human, my dear. People must belittle fine actions when they are small people; big deeds are most annoying to small minds; they take them as personal affronts,” returned Miss Braithwaite placidly. “It really does not matter about the chatter of parrakeets. If you are so partizan of Paul Randolph why did you seem to hesitate just now in approving the marriage?”
“I always hoped Jeanette would marry Mr. Lancaster, you know,” said Cis promptly. “But neither of them ever showed symptoms, so I don’t suppose it’s Mr. Randolph’s fault.”
“Not in the least!” Miss Braithwaite laughed. “I sometimes think it may be another girl’s fault, though. I suspect Anselm of other wishes.”
“How exciting!” cried Cis. “Aren’t you going to tell me? He seems so splendid, so interested in affairs, it’s hard to imagine him thinking of marrying.”
Miss Braithwaite laughed again, but she held up her hands in horror.
“Now heaven forfend!” she cried. “Cis, are you transforming poor Anselm into the hero of the early Victorian novel? Solitary, superior, remote, a demi-god, with the human, half wishy-washy, artificial? Because it’s distinctly unfair of you, if you are! He is thoroughly a human being, but he has made his humanity what God meant a man to be. To my mind he’s forceful, strong and quick in feeling; a vital man. He’s precisely the man to think of marriage, and not to think of it coolly, but to bring to it a great love, such as would honor any woman and make her happy.”
Cis stirred uneasily; she could not have said why she felt uncomfortable, ill-at-ease.
“I don’t think anything of him that you would not want me to think, Miss Braithwaite,” she said. “I don’t know him as you do, of course, but I admire him almost as much. If only you could have seen him with those boys! And Tom said in the station everybody stared at him.”
“Boys? Station?” echoed Miss Braithwaite. “Tell me.”
And Cis told her the story, to which she listened without comment.
The next day Cis spent happily picking up the dropped threads of her Beaconhite existence. She went to Mr. Lucas’ office and received a welcome beyond her expectation.
“Ah, my dear!” Mr. Lucas cried. “Now I shall have you back as soon as I can open the way for you! You were a good secretary; I miss you. But you were also a good confessor of the Faith! Amazing, but it was you who first brought home to me unescapably what I’d been suspecting all along; that there really was something unaccountable on natural grounds in the Old Church. I’m going to be a Catholic at Pentecost, my dear Cicely!”
“Yes, I know; Jeanette told me. I’m so thankful! And I could cry when you say I was the one who set you on!” Cis exclaimed.
“Nothing to cry over! We don’t cry Te Deums, and that’s your theme,” Mr. Lucas smiled at her. “When will you return to the office? As soon as I provide the space?”
“I think so, Mr. Lucas. Miss Braithwaite would rather I’d stay at home all the time, but I’m afraid that’s a risk for a red-haired girl; they’re not crickets on hearths! Miss Braithwaite promises me all that I can do, though. We’ll see. May I have a few days in which to adjust?” Cis asked. “Now I’m going on to find Father Morley.”
The Jesuit was at home; he received Cis with his cordial, yet appraising look that took an inventory of her days since he had last seen her. He seemed satisfied with what he saw; his eyes softened
and smiled approvingly. He recognized in Cicely’s face a new expression of self-reliance, purpose; peace that was not incompatible with the eager, wistful, unsatisfied look which her face also wore.
“Ready for the next thing,” he told himself, “and it’s not far ahead of her.”
But aloud he said: “I am glad, exceedingly glad that you have come back to us, Cicely. Miss Braithwaite is thankful; she is deeply attached to you. You wrote me of that remarkable sequel to your fidelity to God’s law. Do you care to tell me more about it?”
“I want to tell you all about it, Father,” Cis answered. “I might have married Rodney without wrong-doing, but—Father, I couldn’t! Isn’t that strange? I didn’t want to. I’m not a fickle person, but I didn’t want to. He told me that I had been right as to his still being married. He felt that there was no divorce when he knelt by his dying wife. It’s all strange, isn’t it?”
“That isn’t,” said Father Morley. “It is strange, that you were the one who saved that poor creature from suicide to die like a Christian, but it is not strange that her husband recognized the indissoluble link between them. You will find it always true that the supernatural law does no violence to the natural law, but, on the contrary, confirms it, while elevating it beyond nature. To my mind that is one of the proofs of the Church. Heretics have gone contrary to natural laws in all sorts of ways. The Church repeatedly proves that the hand of the Creator is also the hand that founded her. She has sanctified, ennobled, supernaturalized, not contradicted man’s natural instincts and desires. Well, well! You’re not demanding her proofs! Why do I set poor little you up as an heretical tenpin to be bowled over? What is your next step, or do you not know it yet, Cicely Adair?”
“No, Father,” replied Cis wistfully. “I don’t know a step; not the next one, nor any beyond that. Do you think I might be a nun? A Sister of Charity would be more in my line; active, you know. Is that what I’m made for?”
Father Morley looked at her gravely, yet with a quizzical twinkle in his eye, as if he were enjoying with himself a pleasant secret.
“No, my child, I do not think that is your vocation,” he said. “I think that you are meant to be a real helpmeet to a fine man; to do good in the world, bear witness to the value of Catholic Faith and standards, and train up your sons and daughters to carry on that noble inheritance, while they rise up and call you blessed. Perhaps one day to see your son raise his hands before the altar, holding in them the Host, and to kneel, thanking God with tears, that you upheld those hands for that miracle.”
“Father!” cried Cicely, and was silent, tears on her cheeks. “If I might! I’d like that most of all,” she murmured after an instant.
Anselm Lancaster came that evening to see Cis; he announced that his call was wholly for her. Cis saw him come into the library with amazement that his presence so changed it. There was about him a buoyant happiness; charm went out from him, and purposeful assertion, which was far from conceit, sat on his every movement.
“Miss Miriam, Cicely Adair has never seen my house. I was offended last year that you never showed it to her, as much as you drove about, but I hid my wrath. Now I’m out for revenge! I’m going to show it to her myself, and not invite you! Cicely, I’ll be here at half past two to-morrow afternoon. Please be ready to drive with me, out to my house—it’s a shame you’ve not been shown it!—and also wherever the fancy takes us to go. This selfish and unfriendly Miss Miriam shall sit here and languish, eating her heart out till we return!”
“Is it a matter so serious as a heart-consuming?” asked Miss Braithwaite.
She caught and returned the flash of a look which Anselm darted at her.
“I’ll not pretend a virtue I lack; I hope so!” he said.
Cis was ready when he came for her; he helped her into his car, and she cried out, almost reproachfully:
“A new car! Why are men always changing cars? What did you do with that nice one, the roadster?”
“Turned it in; I don’t need two. I thought when Paul and Jeanette were married, and you were here, we’d need the five passenger; we can take Miss Braithwaite, too. But please don’t speak of that nice one; as if it weren’t thisnice one! Let me tell you I’m proud of this car!” Anselm said as he shoved out the brake and started.
“Of course you are! They always are! Boys of new knives; men of new cars! They are much alike, aren’t they?” said Cis.
“Knives and cars? Oh, I don’t know; I could always distinguish the differences,” Anselm remarked.
“Boys and men! I never thought you would be stupid!” Cis said severely.
“I’ll prove to you I’m not, if you’ll wait a bit!” Anselm’s remark sounded like a continuation of the nonsense they were happily talking, but his look silenced Cis, and set her nervously wondering why it made her nervous.
The Lancaster house was far finer than Cis had expected to find it. She had known all along that Anselm Lancaster had wealth; he used it generously, and it must have been considerable for him to accomplish with it all that he did. But ocular proof is another thing from hearsay. Here was a house of great dignity, standing in the midst of considerable land, approached by an avenue of old trees. Its solid doors, opening, revealed a stately hall; in the rooms opening from the hall Cis found old furniture, beautiful and stately. Pictures which even her untrained eye instantly knew for good ones, hung on the walls; bronzes, a tall clock, all sorts of beauty which was evidently the slow accumulation by many people with taste and means to gratify it, filled the house.
“How beautiful!” cried Cis. “Why, Mr. Lancaster, it’s what the novels call a mansion! It’s as fine as Miss Braithwaite’s house!”
“They are contemporaries. Her great-grandfather and mine, and each generation since, have been friends. This house was built when hers was. My people were not Catholics, till my grandmother married a Lancaster and brought this house to him; she became a Catholic after she had married him. My father married a saintly woman; it is two generations—I the third—since the Lancaster house became a Catholic home. Now I try to make it a home for converts who are put to too hard a test at first; a temporary home, of course. I’m more than glad that you like my house, Cicely!”
Anselm spoke in a curious muffled voice, and Cis smiled up at him, disturbed, at a loss to account for it, and for the disturbance which she recognized in him. “How could I not like it?” she said.
“Will you come to see my dear mother’s sitting room?” Anselm asked, going toward the stairs. “It is up one flight. It is like a chapel to me; I’ve often wanted to make it into one, but there are necessary sleeping rooms over it; I can’t use it for a chapel. It is the room in which I was happiest as a child, though I was always happy. It is the room where I learned to love books and all beauty, and where my soul was born through the soul of that lovely creature who gave me physical life.”
Cis followed him, wondering, deeply moved. This was not the Anselm Lancaster she knew, yet it was not the contradiction of him; rather it was his efflorescence. He led her into a small, light room, facing toward the sunset, which was not yet, nor for hours, due. Evidently the room had not been changed since it had been used by the mother whom he had so dearly loved. Books, a work-basket, were on the table; a low armchair, considerably worn, stood beside the table. Anselm gently put Cis into it, and stood before her.
“My mother’s chair, dear Cicely,” he said. “I like to see you there. How you would have loved each other! Cis, dear, lovely, glowing
Cicely, don’t you know what I’ve brought you here to tell you? Don’t you know? Haven’t you guessed?”
Slowly Cis shook her head, looking at him intently, as if she were groping her way, her mind rejecting the one explanation of his words that it could present to her.
“Why, I love you, Cis! That’s what it is. That’s easy to guess, easier to understand!” cried Anselm.
“No, no, no! It’s impossible to understand!” cried Cis.
“You’re going to marry me, dearest; you’re going to be here in my mother’s place, always. Can’t you love me? I love you so much!” Anselm pleaded.
“I never once thought of it; never once!” Cis cried.
“You don’t have to think of it; just do it!” Anselm said boyishly.
“I think you are the best, the finest—” began Cis, but he interrupted her with an impatient exclamation.
“Good heavens, Cis, stop! That’s nothing to tell me, nor to feel! Love me; don’t admire me!”
“Isn’t it? I think I couldn’t love anyone I didn’t admire,” said Cis, trying to find her puzzled way. “I loved someone; you know that. I was crazy to see him; it made my breath short when he came; I— One doesn’t love again, does she? But I know now that I couldn’t love him last winter because I didn’t admire him.”
“Cis, dear,” began Anselm, sitting on the edge of the table as if he meant to argue it out, “I think we don’t love again in that same first way; it’s the dream of youth. I had it, too, but I was only a lad of seventeen when I fell madly in love. You were older than I when it happened to you but you were not much older, and you were no more experienced, and experience is what counts in these things. There is a glamor over everything that is part of that time of life, and we have our first love hard. But, dear, it’s not in the same class with our later, mature love. Do you imagine I felt for that little fluffy
girl of twenty whom I loved when I was seventeen, anything like what I feel for you? Nor was that first love of yours, which you so bravely conquered for God’s sake, the love you’ll feel for your husband, who will be one with you in all things of soul and body. Cis, honestly—though it may sound conceited—I am sure you love me. Will you be sure of it? Father Morley, Miss Braithwaite, Jeanette, hope for it.”
“Oh! Do they all know?” gasped Cis.
“That I love you? Surely. Blind little Cis not to have known it yourself! But now that you do know it—”
“I couldn’t so much as think of marrying you!” Cis hastily interrupted him. “Why, I’d be—what would I be? One of the people brought into a country to serve it, then deserting its flag—a traitor! That’s it! Miss Braithwaite imported me to live with her, be almost a daughter to her. Much good I’d do her if I—”
“Now, Cicely, can’t you trust Miss Miriam to me?” Anselm interrupted in his turn. “Do you suppose we haven’t discussed my hopes? Haven’t I just told you that she wanted them fulfilled? Good mothers do not want to mortgage their daughters’ lives; they want them to find their own places and happily fill them. Miss Braithwaite shall not lose you if I win you, dear one! She is most anxious for this marriage, Cis. ‘Cis must come to me, Anselm; then you shall woo her at your best. She shall be in her home, the home that holds you part of it, and I hope that will incline her to harken to you. But if not, then at least she is still in her own home; the dear child will be made secure however she decides.’ That is what she said to me, Cicely beloved, before I went away to try to bring you back. Marry me, then there will be another besides ourselves happy; Miss Miriam the third rejoicing.”
“I don’t see how you can possibly mean that you want to marry me!” said Cis slowly abandoning Miss Braithwaite’s cause. “Don’t you think you mean someone else?”
“I distinctly think that I mean no one else!” cried Anselm. “Do I strike you as positively feeble-minded? There’s no difficulty in telling you from all others. I can tell you apart literally, quite apart from all others created! And I’m not grave and settled down; I’m only thirtyeight, darling! Are you thinking of me as solemn, serious, almost elderly? No, no; I’m not! I’m your lover, Cis, and he loves you more than he can tell you. Will you come here, Cis, desire of my heart? Will you help me in the beautiful schemes we’ve discussed? Take my mother’s place, but fill only your own place, my wife’s place, my helpmeet’s place—and more; a thousand times more!”
“You are meant to be a real helpmeet to a fine man.” Cis heard Father Morley’s voice again saying these words to her. He had known when he said it that Anselm meant to ask her to marry him; he wanted her to marry Anselm, though Anselm was a great man, while she was only red-haired Cicely Adair!
It came upon her with an irresistible rush of conviction that she did love Anselm, that she had been loving him and had not known it. For how could she ever have thought of his loving her? Yet this was why all other things, Nan, her old home, Rodney Moore seemed insufficient to her; this was why she had been restless, longing, unsatisfied. What a life it was that opened out before her in this house, the wife of this man, his helpmeet, his beloved!
Distrust of herself, the magnitude of the joy stretching out before her drove her into the true woman’s dalliance with yielding to this unforeseen bliss.
She must hold off for a little while the glorious submergence of herself out of which she knew would arise the truer, greater self which would forevermore be Cicely.
“Take me home,” Cis said rising. “I cannot answer yet.”
Obediently Anselm followed her toward the door, but he looked bitterly disappointed. Cis halted, wavering, on the threshold, as her heart smote her for this look. This was Anselm’s mother’s room, the
sanctuary of his childhood, the shrine of a tender love. It would be sweet to make him happy here; he had brought her hither for this.
She was a generous Cicely, albeit a frightened one. She turned fully and faced Anselm.
“I think I do. Love you, I mean. I’ll come,” she said. He caught her, reverently, gratefully, yet most lovingly in his arms and kissed her flaming hair, her white brow, her closed eyes, and at last, with the bridegroom’s kiss, he kissed her sweet lips.
The great cable which had held her fast, had also drawn Cis safe into port.
