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Cohen’s TWELFTH
EDITION
PATHWAYS
of
the
PULP
EDITORS
LOUIS H. BERMAN, DDS, FACD
Clinical Associate Professor
Department of Endodontics
School of Dentistry
University of Maryland
Baltimore, Maryland
Faculty
Albert Einstein Medical Center
Philadelphia, Pennsylvania
Private Practice
Annapolis Endodontics
Annapolis, Maryland
Diplomate, American Board of Endodontics
Web Editor
ILAN ROTSTEIN, DDS
Associate Dean of Continuing Education and Chair
Division of Endodontics, Orthodontics, and General Practice Dentistry
Herman Ostrow School of Dentistry
University of Southern California
Los Angeles, California
ELSEVIER
3251 Riverport Lane
St. Louis, Missouri 63043
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Center and the Copyright Licensing Agency, can be found at our website: www.elsevier.com/permissions.
This book and the individual contributions contained in it are protected under copyright by the Publisher
(other than as may be noted herein).
Notices
Knowledge and best practice in this field are constantly changing. As new research and experience
broaden our understanding, changes in research methods, professional practices, or medical treatment
may become necessary.
Practitioners and researchers must always rely on their own experience and knowledge in evaluating
and using any information, methods, compounds, or experiments described herein. In using such
information or methods they should be mindful of their own safety and the safety of others, including
parties for whom they have a professional responsibility.
With respect to any drug or pharmaceutical products identified, readers are advised to check the most
current information provided (i) on procedures featured or (ii) by the manufacturer of each product to
be administered, to verify the recommended dose or formula, the method and duration of administra-
tion, and contraindications. It is the responsibility of practitioners, relying on their own experience and
knowledge of their patients, to make diagnoses, to determine dosages and the best treatment for each
individual patient, and to take all appropriate safety precautions.
To the fullest extent of the law, neither the Publisher nor the authors, contributors, or editors, assume
any liability for any injury and/or damage to persons or property as a matter of products liability,
negligence or otherwise, or from any use or operation of any methods, products, instructions, or ideas
contained in the material herein.
Printed in Canada
Louis H. Berman
Dr. Berman received his dental degree from the University of Maryland School of
Dentistry and his Certificate in Endodontics from the Albert Einstein Medical Center. He
is Clinical Associate Professor of Endodontics at the University of Maryland School of
Dentistry and a Clinical Instructor and Guest Lecturer at the Albert Einstein Medical
Center. He has lectured internationally in the field of endodontics and has published in
several peer-reviewed international dental journals as well as co-authoring textbook
chapters on numerous topics in various endodontic textbooks. He is past president of
the Maryland State Association of Endodontics and is a member of the Journal of End-
odontics Scientific Advisory Board. A Diplomate of the American Board of Endodontics
and Fellow of the American College of Dentistry, Dr. Berman has been in full-time
private practice in Annapolis, Maryland since 1983.
Kenneth M. Hargreaves
Dr. Hargreaves is Professor and Chair of the Department of Endodontics at the
University of Texas Health Science Center at San Antonio. He is a Diplomate of
the American Board of Endodontics and maintains a private practice limited to
endodontics. He is an active researcher, lecturer, and teacher and serves as the
Editor-in-Chief of the Journal of Endodontics. He is principal investigator on several
nationally funded grants that combine his interests in pain, pharmacology, and
regenerative endodontics. He has received several awards, including a National In-
stitutes of Health MERIT Award for pain research, the AAE Louis I. Grossman
Award for cumulative publication of research studies, and two IADR Distinguished
Scientist Awards.
Ilan Rotstein
Dr. Rotstein is Professor and Chair of Endodontics, Orthodontics, and General Practice
Residency and Associate Dean at the Herman Ostrow School of Dentistry of the Univer-
sity of Southern California in Los Angeles. He is on the Executive Leadership Team of the
School of Dentistry and an ambassador member of the University of Southern California.
He has served in leadership roles for various dental organizations, including Chair of
the International Federation of Endodontic Associations’ Research Committee; as a
committee member of the American Association of Endodontists and European Society
of Endodontology; and as a scientific reviewer for international endodontic and dental
journals. He has also served as President of the Southern California Academy of Endo-
dontists, Israel Endodontic Society, and International Association for Dental Research—
Israel Division and as Chair of the Israel National Board of Diplomates in Endodontics.
Dr. Rotstein has published more than 150 scientific papers and research abstracts in
the dental literature as well as chapters in international endodontic textbooks, includ-
ing Pathways of the Pulp, Ingle’s Endodontics, Endodontics: Principles and Practice, Seltzer
and Bender’s Dental Pulp, and Harty’s Endodontics in Clinical Practice. He has lectured
extensively in more than 25 countries throughout 5 continents.
iii
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Dr. John Ingle
The development of every edition of Cohen’s Pathways of the Washington Study established proof of outcome for endo
Pulp, for all of its editors and contributors, is a journey into dontic treatment and remains a seminal work in the
both the future and the past of endodontics. What we as literature for our field.
clinicians know today and the care that knowledge enables New fields offer many new challenges to their pioneers,
us to provide to our patients are the result of the curiosity, and Dr. Ingle soon turned his attention to the development
dedication, and commitment of the teachers, researchers, of standardization of endodontic instruments. His work
and clinicians who have come before us. Dr. John Ingle, resulted in the metric measurements and the 0.2 taper of
who contributed to the science, practice, and teaching endodontics files that were established in 1957.
of endodontics for more than 7 decades, is one of those In 1965, Dr. Ingle brought together his experience
extraordinary pioneers. as both a clinician and an educator in the publication of
Dr. Ingle began his career as an educator at the Univer- his foundational textbook Ingle’s Endodontics. Now in its
sity of Washington in Seattle, where he taught periodon- sixth edition, Ingle’s Endodontics has provided an essential
tics. While teaching, he became interested in the new field evidence-based reference to students and clinicians for
of endodontics and, perhaps drawing on the example of more than 50 years.
his pioneer great-grandfather, Daniel Boone, he entered While Dr. Ingle’s many accomplishments are known and
a specialty program in endodontics at the University of admired, the attributes of his character are equally revered.
Michigan to explore this new discipline, earning graduate Dr. Ingle was modest about his many contributions to end-
degrees in endodontics and periodontics. odontics and was unfailingly generous in his support and
As an educator and clinician, Dr. Ingle knew the impor- encouragement of others. The compassion and empathy
tance of evidence in establishing the efficacy of endodontic that motivated his work were experienced by all those he
treatment as a new specialty. To meet this need, he evalu- touched throughout his long and exemplary career and life.
ated the results of endodontic treatment in 3000 patients It is with profound gratitude and appreciation that we
and presented his findings to the annual session of dedicate this twelfth edition of Cohen’s Pathways of the Pulp
the American Association of Endodontists in 1953. The to Dr. John Ingle, a scholar, a leader, and a gentleman.
v
Contributors
Abdulaziz A. Bakhsh, BDS, MClinDent, Nicholas Chandler, BDS (Lond), MSc (Manc),
MEndo (RCSed) PhD (Lond), LDSRCS (Eng), MRACDS (Endo),
Endodontist FDSRCPS (Glas), FDSRCS (Edin), FFDRCSI, FICD
Department of Restorative Dentistry Professor of Endodontics
Faculty of Dentistry Faculty of Dentistry
Umm Al-Qura University University of Otago
Makkah, Saudi Arabia Dunedin, New Zealand
Bettina Basrani, DDS, PhD Gary S.P. Cheung, PhD, BDS, MDS, MSc, FHKAM,
Program Director FCDSHK (Endo), SFHEA, FICD, FAMS, FRACDS,
MSc Endodontics MRACDS (Endo), FDSRCSEd
Department of Endodontics Clinical Professor
University of Toronto Division of Restorative Dental Sciences
Toronto, Canada Associate Dean of Undergraduate Education
Faculty of Dentistry
Ellen Berggreen, PhD University of Hong Kong
Professor Pokfulam, Hong Kong
Biomedicine
University of Bergen Till Dammaschke, Prof, Dr Med Dent
Head of Research Dentist and Assistant Medical Director
Vestland County Department of Periodontology and Operative Dentistry
Bergen, Norway Westphalian Wilhelms University
Münster, Germany
Louis H. Berman, DDS, FACD
Clinical Associate Professor Didier Dietschi, DMD, PhD, Privat-Docent
Department of Endodontics Senior Lecturer
School of Dentistry School of Dental Medicine
University of Maryland Department of Cardiology and Endodontics
Baltimore, Maryland University of Geneva
Faculty Geneva, Switzerland
Albert Einstein Medical Center Adjunct Professor
Philadelphia, Pennsylvania School of Dentistry
Private Practice Department of Comprehensive Care
Annapolis Endodontics Case Western Reserve University
Annapolis, Maryland Cleveland, Ohio
Diplomate, American Board of Endodontics
Anibal Diogenes, DDS, MS, PhD
George Bogen, BS, DDS Assistant Professor
Senior Lecturer Endodontics
Department of Endodontics University of Texas Health Science Center at San Antonio
School of Dentistry San Antonio, Texas
University of Queensland
Brisbane, Australia Melissa Drum, DDS, MS
Diplomate, American Board of Endodontics Professor and Advanced Endodontics Director
Endodontics
Ohio State University
Columbus, Ohio
vi
CONTRIBUTORS vii
Conor Durack, BDS NUI, MFDS RCSI, James L. Gutmann, DDS, Cert Endo, PhD, FICD,
MClinDent (Endo), MEndo RCS (Lond) FACD, FIAD, FAAHD, FDSRCSEd, Dipl ABE
Specialist Endodontist and Practice Partner Professor, Chair, and Postdoctoral Program Director
Riverpoint Specialist Dental Clinic Endodontics
Limerick, Ireland College of Dental Medicine
Nova Southeastern University
Bing Fan, DDS, PhD Davie, Florida
Professor and Chair Professor Emeritus
Endodontic Center Restorative Sciences/Endodontics
School and Hospital of Stomatology College of Dentistry
Wuhan University Texas A&M University
Wuhan City, China Dallas, Texas
Adjunct Professor Honorary Professor
Department of Endodontics Stomatology
Dental College of Georgia School of Stomatology
Augusta University Wuhan University
Augusta, Georgia Wuhan, China
The radiographic interpretation of odontogenic and non Science Topics, and Part III: Advanced Clinical Topics. The
odontogenic lesions is exactly that: an “interpretation.” twelve chapters in Part 1 focus on the core clinical con
This new twelfth edition boasts a completely new chapter cepts for dental students, while the chapters in Parts II and
entitled Lesions That Mimic Endodontic Pathosis that eluci III provide the information that advanced students and
dates and differentiates lesions that may appear as endo endodontic residents and clinicians need to know. In addi
dontic origin. This is a perfect adjunct to the chapters on tion, three additional chapters are included in the online
Diagnosis and Radiographic Interpretation. version.
The chapter on Managing Iatrogenic Events has been The new organization better reflects the chronology of
completely rewritten to include an expansive section on endodontic treatment.
injury to the inferior alveolar nerve.
Damage to the inferior alveolar nerve secondary to endo
dontic treatment is an avoidable dilemma. There is now Digital Content
specific content elaborating on the avoidance and manage
ment of these types of injuries. New features included on the companion site include:
Root resorption and root fractures can be some of the n Three chapters found exclusively online:
most difficult defects to clinically manage. The Root Resorp n Chapter 26: Bleaching Procedures
tion chapter on these subjects has been completely updated n Chapter 27: Endodontic Records and Legal Responsi
and will prove beneficial to the clinician and academician.
bilities
This edition updates all of the previous chapters to reflect n Chapter 28: Key Principles of Endodontic Practice
the changes in the literature since the last edition.
Management
n Case Studies
Review Articles
New Chapter Organization n
n Review Questions
n Videos
Chapters have been reorganized and grouped into three parts:
Part I: The Core Science of Endodontics, Part II: Advanced
x
Introduction
The foundation of the specialty of endodontics is a gift from clinician, or with the augmented reality of digital microsur-
the generations of great endodontists and researchers be- gical devices? In the years to come, will we be able to truly
fore us. They guided us with the goals of treatment, the eliminate all of the canal microorganisms, biofilms, and
benefits of their advancements, and the frailties of their pulpal tissue? Will we be facilitating our canal cleaning with
deficiencies. From volumes of research, we have collectively less toxic and more directed irrigants? Once we are finally
built a virtual library of knowledge that leads us to the evi- able to totally clean and disinfect the canals to a microscopic
dence we need for mastering our clinical procedures and level, will we have an obturation material that finally satis-
benefiting our patients. As we look into our future, we fies ALL the material requirements that Dr. Louis Grossman
should be directed toward developing the necessary tools enumerated at the inception of our specialty? Will this obtu-
for maximizing our outcomes with consistency, longevity, rating material be newly regenerated vital pulp?
and, above all, patient well-being. Clearly, our endodontic future lies in out-of-the-box
Over the past several decades, we have gone from arsenic thinking, with the next generation of transformations
to sodium hypochlorite, from bird droppings to gutta- coming with collaborations not just from within the bio-
percha, from hand files to motor-driven files, from culturing logical sciences, but also in conjunction with physicists,
to one-visit appointments, from 2D to 3D radiography, and chemists, engineers, and a multitude of other great inno-
from pulp removal to pulpal regeneration. Yet still, the vative minds. The predictability of endodontics must be
clinical and academic controversies are pervasive. incontestable, not just with better technology to guide us
With patients living longer and with the inescapable toward greater success, but also to better elucidate exactly
comparison of endodontics to endosseous implants, the when endodontic treatment cannot be successful. Our fu-
demand for endodontic excellence has greatly increased. ture needs to focus on predictability and consistency, which
Surprisingly, we still base our diagnosis on a presumed and will only be achieved with disruptive technologies, rather
almost subjective pulpal status. Imagine a future in which than persisting with variations and modifications of our
endodontic diagnosis could be made more objective by current convictions. As a specialty, we have advanced by
noninvasively scanning the pulp tissue. Imagine algorithms leaps and bounds since our inception; but we are still in our
built into all digital radiography for interpreting and infancy with a brilliant future ahead of us. Since 1976,
extrapolating disease processes. CBCT has made a huge and now with 12 editions, Cohen’s Pathways of the Pulp has
impact on endodontic diagnosis, but can we enhance these always been about the art and science of endodontics, with
digital captures with a resolution that would approach an emphasis on evidenced-based direction rather than an-
microcomputed tomography, and with less radiation? Will ecdotal guidance. The dedicated contributing authors have
these 3D scans guide us not just with diagnostic objectivity, generously given their time to meticulously describe what
but also with direct treatment facilitation to guide us dur- is considered the state of the art of our specialty. We are
ing surgical and nonsurgical treatment? Truly, we are now hopeful that future editions will guide us toward enhanced
on the cusp of gaining the knowledge and technology endodontic outcomes, with the never-ending pursuit of
for accomplishing this. As for clinical visualization, will 3D endodontic excellence.
visualization and monitor-based observation change the
way we visualize and implement our procedures? Will our Louis H. Berman
procedures still be done with the fine motor skills of the Kenneth M. Hargreaves
xi
Contents
5 Case Assessment and Treatment Planning, 139 19 Management of Endodontic Emergencies, 737
PAUL A. ROSENBERG and MATTHEW MALEK FABRICIO B. TEIXEIRA and GARY S.P. CHEUNG
7 Tooth Morphology and Pulpal Access 21 The Role of Endodontics After Dental Traumatic
Cavities, 192 Injuries, 808
JAMES L. GUTMANN and BING FAN BILL KAHLER
8 Cleaning and Shaping of the Root Canal 22 Chronic Cracks and Fractures, 848
System, 236 LOUIS H. BERMAN and AVIAD TAMSE
OVE A. PETERS, CHRISTINE I. PETERS, and BETTINA BASRANI
23 Restoration of the Endodontically
9 Obturation of the Cleaned and Shaped Root Canal Treated Tooth, 870
System, 304 DIDIER DIETSCHI, SERGE BOUILLAGUET, AVISHAI SADAN,
ANITA AMINOSHARIAE, WILLIAM T. JOHNSON, JAMES C. KULILD, and KENNETH M. HARGREAVES
and FRANKLIN TAY
24 Vital Pulp Therapy, 902
10 Nonsurgical Retreatment, 343 GEORGE BOGEN, TILL DAMMASCHKE, and NICHOLAS CHANDLER
ROBERT S. RODA, BRADLEY H. GETTLEMAN, and SCOTT C. JOHNSON
25 Endo-Perio, 939
11 Periradicular Surgery, 411 GERALD N. GLICKMAN and VINCENT J. IACONO
BRADFORD R. JOHNSON, MOHAMED I. FAYAD,
and LOUIS H. BERMAN
xii
PART I
Art and Science of Diagnosis and carefully interpreting the answers. In essence, the pro-
cess of determining the existence of an oral pathosis is the
Diagnosis is the art and science of detecting and distin- culmination of the art and science of making an accurate
guishing deviations from health and the cause and nature diagnosis.
thereof.6 The purpose of a diagnosis is to determine what The process of making a diagnosis can be divided into five
problem the patient is having and why the patient is having stages:
that problem. Ultimately, this will directly relate to what
1. The patient tells the clinician the reasons for seeking
treatment, if any, will be necessary. No appropriate treat-
advice.
ment recommendation can be made until all of the whys
2. The clinician questions the patient about the symptoms
are answered. Therefore, careful data gathering as well as
and history that led to the visit.
a planned, methodical, and systematic approach to this
3. The clinician performs objective clinical tests.
investigatory process is crucial.
4. The clinician correlates the objective findings with the
Gathering objective data and obtaining subjective find-
subjective details and creates a tentative list of differential
ings are not enough to formulate an accurate clinical
diagnoses.
diagnosis. The data must be interpreted and processed to
5. The clinician formulates a definitive diagnosis.
determine what information is significant, and what infor-
mation might be questionable. The facts need to be col- This information is accumulated by means of an orga-
lected with an active dialogue between the clinician and nized and systematic approach that requires considerable
the patient, with the clinician asking the right questions clinical judgment. The clinician must be able to approach
2
1 • Diagnosis 3
the problem by crafting what questions to ask the patient and complete update of the patient’s medical history should
and how to ask these pertinent questions. Careful listening be taken if the patient has not been seen for over a year.51,52
is paramount to begin painting the picture that details the Baseline blood pressure and pulse should be recorded for
patient’s complaint. These subjective findings combined the patient at each treatment visit. Elevation in blood pres-
with the results of diagnostic tests provide the critical infor- sure or a rapid pulse rate may indicate an anxious patient
mation needed to establish the diagnosis. who may require a stress reduction protocol, or it may indi-
Neither the art nor the science is effective alone. Estab- cate that the patient has hypertension or other cardiovas-
lishing a differential diagnosis in endodontics requires a cular health problems. Referral to a physician or medical
unique blend of knowledge, skills, and the ability to inter- facility may be indicated. It is imperative that vital signs
pret and interact with a patient in real time. Questioning, be gathered at each treatment visit for any patient with
listening, testing, interpreting, and finally answering the a history of major medical problems. The temperature
ultimate question of why will lead to an accurate diagnosis of patients presenting with subjective fever or any signs or
and in turn result in a more successful treatment plan. symptoms of a dental infection should be taken.57,80,105
The clinician should evaluate a patient’s response to the
CHIEF COMPLAINT health questionnaire from two perspectives: (1) those medi-
cal conditions and current medications that will necessitate
On arrival for a dental consultation, the patient should com- altering the manner in which dental care will be provided
plete a thorough registration that includes information per- and (2) those medical conditions that may have oral mani-
taining to medical and dental history (Figs. 1.1 and 1.2). festations or mimic dental pathosis.
This should be signed and dated by the patient, as well as Patients with serious medical conditions may require
initialed by the clinician as verification that all of the sub- either a modification in the manner in which the dental
mitted information has been reviewed (see Chapter 27 for care will be delivered or a modification in the dental treat-
more information). ment plan (Box 1.1). In addition, the clinician should be
The reasons patients give for consulting with a clinician aware if the patient has any drug allergies or interactions,
are often as important as the diagnostic tests performed. allergies to dental products, an artificial joint prosthesis,
Their remarks serve as initial important clues that will help organ transplants, or is taking medications that may nega-
the clinician to formulate a correct diagnosis. Without tively interact with common local anesthetics, analgesics,
these direct and unbiased comments, objective findings sedatives, and antibiotics.80 This may seem overwhelming,
may lead to an incorrect diagnosis. The clinician may find a but it emphasizes the importance of obtaining a thorough
dental pathosis, but it may not contribute to the pathologic and accurate medical history while considering the various
condition that mediates the patient’s chief complaint. In- medical conditions and dental treatment modifications that
vestigating these complaints may indicate that the patient’s may be necessary before dental treatment is provided.
concerns are related to a medical condition or to recent Several medical conditions have oral manifestations,
dental treatment. Certain patients may even receive initial which must be carefully considered when attempting to
emergency treatment for pulpal or periapical symptoms in arrive at an accurate dental diagnosis. Many of the oral
a general hospital.93 On occasion, the chief complaint is soft-tissue changes that occur are more related to the medi-
simply that another clinician correctly or incorrectly ad- cations used to treat the medical condition rather than to
vised the patient that he or she had a dental problem, with the condition itself. More common examples of medication
the patient not necessarily having any symptoms or any side effects are stomatitis, xerostomia, petechiae, ecchymo-
objective pathosis. Therefore, the clinician must pay close ses, lichenoid mucosal lesions, and bleeding of the oral soft
attention to the actual expressed complaint, determine the tissues.80
chronology of events that led to this complaint, and ques- When developing a dental diagnosis, a clinician must
tion the patient about other pertinent issues, including also be aware that some medical conditions can have
medical and dental history. For future reference and in order clinical presentations that mimic oral pathologic
to ascertain a correct diagnosis, the patient’s chief com- lesions.13,28,32,74,80,102,107,133 For example, tuberculosis in-
plaint should be properly documented, using the patient’s volvement of the cervical and submandibular lymph nodes
own words. can lead to a misdiagnosis of lymph node enlargement
secondary to an odontogenic infection. Lymphomas can
MEDICAL HISTORY involve these same lymph nodes.80 Immunocompromised
patients and patients with uncontrolled diabetes mellitus
The clinician is responsible for taking a proper medical his- respond poorly to dental treatment and may exhibit recur-
tory from every patient who presents for treatment. Numer- ring abscesses in the oral cavity that must be differentiated
ous examples of medical history forms are available from a from abscesses of dental origin.43,76,80,83 Patients with iron
variety of sources, or clinicians may choose to customize deficiency anemia, pernicious anemia, and leukemia fre-
their own forms. After the form is completed by the patient, quently exhibit paresthesia of the oral soft tissues. This find-
or by the parent or guardian in the case of a minor, the cli- ing may complicate making a diagnosis when other dental
nician should review the responses with the patient, par- pathosis is present in the same area of the oral cavity. Sickle
ent, or guardian, and then initial the medical history form cell anemia has the complicating factor of bone pain, which
to indicate that this review has been done. The patient “of mimics odontogenic pain, and loss of trabecular bone pat-
record” should be questioned at each treatment visit to tern on radiographs, which can be confused with radio-
determine whether there have been any changes in the graphic lesions of endodontic origin. Multiple myeloma can
patient’s medical history or medications. A more thorough result in unexplained mobility of teeth. Radiation therapy
4 PART I • The Core Science of Endodontics
1. Are you experiencing any pain at this time? If not, please go to question 6. Yes No
2. If yes, can you locate the tooth that is causing the pain? Yes No
5. Please check the frequency and quality of the discomfort, and the number that most closely
reflects the intensity of your pain:
1 2 3 4 5 6 7 8 9 10 Constant Sharp
Intermittent Dull
Momentary Throbbing
Occasional
If yes, what?
If yes, what?
When eating or drinking, is your tooth sensitive to: Heat Cold Sweets
Does your tooth hurt when you bite down or chew? Yes No
Does it hurt if you press the gum tissue around this tooth? Yes No
Does a change in posture (lying down or bending over) cause your tooth to hurt? Yes No
8. Has a restoration (filling or crown) been placed on this tooth recently? Yes No
9. Prior to this appointment, has root canal therapy been initiated on this tooth? Yes No
10. Is there anything else we should know about your teeth, gums, or sinuses that would assist us in our
diagnosis?
Fig. 1.1 Dental history form that also allows the patient to record pain experience in an organized and descriptive manner.
1 • Diagnosis 5
How would you rate your health? Please circle one. Excellent Good Fair Poor
If you are under the care of a physician, please give reason(s) for treatment.
Name Address
Date
Have you ever had any trouble with prolonged bleeding after surgery? Yes No
Do you wear a pacemaker or any other kind of prosthetic device? Yes No
Are you taking any kind of medication or drugs at this time? Yes No
If yes, please give name(s) of the medicine(s) and reason(s) for taking them:
Name Reason
Have you ever had an unusual reaction to an anesthetic or drug (like penicillin)? Yes No
Is there any other information that should be known about your health?
Fig. 1.2 Succinct, comprehensive medical history form designed to provide insight into systemic conditions that could produce or affect the patient’s
symptoms, mandate alterations in treatment modality, or change the treatment plan.
6 PART I • The Core Science of Endodontics
Fig. 1.3 When taking a dental history and performing a diagnostic examination, often a premade form can facilitate complete and accurate documen-
tation. (Courtesy Dr. Ravi Koka, San Francisco, CA.)
8 PART I • The Core Science of Endodontics
Fig. 1.4 Several practice management software packages have features for charting endodontic diagnoses using user-defined drop-down menus and
areas for specific notations. Note that for legal purposes, it is desirable that all recorded documentation have the ability to be locked, or if any modifications
are made after 24 hours, the transaction should be recorded with an automated time/date stamp. This is necessary so the data cannot be fraudulently
manipulated. (Courtesy PBS Endo, Cedar Park, TX.)
1 • Diagnosis 9
Provocation or attenuation. “What produces or reduces the after the more objective testing and scientific phase of the
symptoms?” Mastication and locally applied temperature investigatory process.
changes account for the majority of initiating factors that
cause dental pain. The patient may relate that drinking Examination and Testing
something cold causes the pain or possibly that chewing or
biting is the only stimulus that “makes it hurt.” The patient EXTRAORAL EXAMINATION
might say that the pain is only reproduced on “release from
biting.” On occasion, a patient may present to the dental Basic diagnostic protocol suggests that a clinician observe
office with a cold drink in hand and state that the symptoms patients as they enter the operatory. Signs of physical limita-
can only be reduced by bathing the tooth in cold water. Non- tions may be present, as well as signs of facial asymmetry
prescription pain relievers may relieve some symptoms, that result from facial swelling. Visual and palpation exami-
whereas narcotic medication may be required to reduce nations of the face and neck are warranted to determine
others. Note that patients who are using narcotic as well as whether swelling is present. Many times a facial swelling
non-narcotic (e.g., ibuprofen) analgesics may respond dif- can be determined only by palpation when a unilateral
ferently to questions and diagnostic tests, thereby altering “lump or bump” is present. The presence of bilateral swell-
the validity of diagnostic results. Thus, it is important to ings may be a normal finding for any given patient; however,
know what drugs patients have taken in the previous 4 to it may also be a sign of a systemic disease or the conse-
6 hours. These provoking and relieving factors may help quence of a developmental event. Palpation allows the
the clinician to determine which diagnostic tests should be clinician to determine whether the swelling is localized or
performed to establish a more objective diagnosis. diffuse, firm or fluctuant. These latter findings will play a
Duration. “Do the symptoms subside shortly, or do they significant role in determining the appropriate treatment.
linger after they are provoked?” The difference between a Palpation of the cervical and submandibular lymph nodes
cold sensitivity that subsides in a few seconds and one is an integral part of the examination protocol. If the nodes
that subsides in minutes may determine whether a clinician are found to be firm and tender along with facial swelling
repairs a defective restoration or provides endodontic treat- and an elevated temperature, there is a high probability that
ment. The duration of symptoms after a stimulating event an infection is present. The disease process has moved from
should be recorded to establish how long the patient felt a localized area immediately adjacent to the offending tooth
the sensation in terms of seconds or minutes. Clinicians to a more widespread systemic involvement.
often first test control teeth (possibly including a contralat- Extraoral facial swelling of odontogenic origin typically
eral “normal” tooth) to define a “normal” response for is the result of endodontic etiology because diffuse facial
the patient; thus, “lingering” pain is apparent when com- swelling resulting from a periodontal abscess is rare. Swell-
paring the duration between the control teeth and the ings of nonodontogenic origin must always be considered
suspected tooth. in the differential diagnosis, especially if an obvious dental
With the dental history interview complete, the clinician pathosis is not found.77 This situation is discussed in subse-
has a better understanding of the patient’s chief complaint quent chapters.
and can concentrate on making an objective diagnostic A subtle visual change such as loss of definition of the
evaluation, although the subjective (and artistic) phase of nasolabial fold on one side of the nose may be the earliest
making a diagnosis is not yet complete and will continue sign of a canine space infection (Fig. 1.5). Pulpal necrosis
A B
Fig. 1.5 A, Canine space swelling of the left side of the face extending into and involving the left eye. B, Swelling of the upper lip and the loss of
definition of the nasolabial fold on the patient’s left side, which indicates an early canine space infection.
10 PART I • The Core Science of Endodontics
and periradicular disease associated with a maxillary canine be noted as swelling in the submandibular space. Further
should be suspected as the source of the problem. Extremely discussions of fascial space infections may be found in
long maxillary central incisors also may be associated with Chapter 16.
a canine space infection, but most extraoral swellings asso- Sinus tracts of odontogenic origin may also open through
ciated with the maxillary centrals express themselves as a the skin of the face (Figs. 1.9 and 1.10).2,56,64 These open-
swelling of the upper lip and base of the nose. ings in the skin will generally close once the offending
If the buccal space becomes involved, the swelling will be tooth is treated and healing occurs. A scar is more likely to
extraoral in the area of the posterior cheek (Fig. 1.6). These be visible on the skin surface in the area of the sinus tract
swellings are generally associated with infections originat- stoma than on the oral mucosal tissues (see Fig. 1.10, C
ing from the buccal root apices of the maxillary premolar and D). Many patients with extraoral sinus tracts give a
and molar teeth and the mandibular premolar (Fig. 1.7) history of being treated by general physicians, dermatolo-
and first molar teeth. The mandibular second and third gists, oncologists, or plastic surgeons with systemic or
molars also may be involved, but infections associated with topical antibiotics or surgical procedures in attempts to
these two teeth are just as likely to exit to the lingual where heal the extraoral stoma. In these particular cases, after
other spaces would be involved. For infections associated multiple treatment failures, the patients may finally be re-
with these teeth, the root apices of the maxillary teeth must ferred to a dental clinician to determine whether there is a
lie superior to the attachment of the buccinator muscle dental cause. Raising the awareness of physicians to such
to the maxilla, and the apices of the mandibular teeth must cases will aid in more accurate diagnosis and faster referral
be inferior to the buccinator muscle attachment to the to the dentist or endodontist.
mandible.77
Extraoral swelling associated with mandibular incisors INTRAORAL EXAMINATION
will generally exhibit itself in the submental (Fig. 1.8) or
submandibular space. Infections associated with any man- The intraoral examination may give the clinician insight as
dibular teeth, which exit the alveolar bone on the lingual to which intraoral areas may need a more focused evalua-
and are inferior to the mylohyoid muscle attachment, will tion. Any abnormality should be carefully examined for
either prevention or early treatment of associated patho-
sis.4,30,75,113,110,126 Swelling, localized lymphadenopathy, or
a sinus tract should provoke a more detailed assessment of
related and proximal intraoral structures.
Soft-Tissue Examination
As with any dental examination, there should be a routine
evaluation of the intraoral soft tissues. The gingiva and
mucosa should be dried with either a low-pressure air
syringe or a 2-by-2-inch gauze pad. By retracting the
tongue and cheek, all of the soft tissue should be examined
for abnormalities in color or texture. Any raised lesions or
ulcerations should be documented and, when necessary,
evaluated with a biopsy or referral.82
Intraoral Swelling
Fig. 1.6 Buccal space swelling associated with an acute periradicular Intraoral swellings should be visualized and palpated to
abscess from the mandibular left second molar.
determine whether they are diffuse or localized and whether
A B C
Fig. 1.7 A, Buccal space swelling of the left side of the patient’s face. Note the asymmetry of the left side of the face. B, Intraoral view of another patient
shows swelling present in the left posterior mucobuccal fold. C, This buccal space infection was associated with periradicular disease from the man-
dibular left first molar. Note on the radiograph the periradicular radiolucency and incomplete endodontic treatment. (B and C, Courtesy Dr. Jaydeep S.
Talim, Los Angeles, CA.)
1 • Diagnosis 11
A C
B
Fig. 1.10 A, Extraoral sinus tract opening onto the skin in the central chin area. B, Radiograph showing large radiolucency associated with the
mandibular incisors. C, A culture is obtained from the drainage of the extraoral sinus tract. D, The healed opening of the extraoral sinus tract 1 month
after root canal therapy was completed. Note the slight skin concavity in the area of the healed sinus tract.
Histologic studies have found that most sinus tracts are not
lined with epithelium throughout their entire length. One
study found that only 1 out of the 10 sinus tracts examined
were lined with epithelium, whereas the other 9 specimens
were lined with granulation tissue.55 Another study, with a
larger sample size, found that two thirds of the specimens did
not have epithelium extending beyond the level of the surface
mucosa rete ridges.12 The remaining specimens had some
epithelium that extended from the oral mucosa surface to the
periradicular lesion.12 The presence or absence of an epithe-
lial lining does not seem to prevent closure of the tract as long
as the source of the problem is properly diagnosed and ade-
quately treated and the endodontic lesion has healed. Failure
of a sinus tract to heal after treatment will necessitate further
diagnostic procedures to determine whether other sources of
infection are present or whether a misdiagnosis occurred.
Fig. 1.11 Fluctuant swelling in the anterior palate associated
with periradicular disease from the palatal root of the maxillary first In general, a periapical infection that has an associated
premolar. sinus tract is not painful, although often there is a history
of varying magnitudes of discomfort before sinus tract
1 • Diagnosis 13
clinician to the tooth involved and, more specifically, to the Once the disease state extends into the periodontal ligament
part of the root of the tooth that is the source of the patho- space, the pain may become more localized for the patient;
sis. Once the causative factors related to the formation of therefore, the affected tooth will be more identifiable with
the sinus tract are removed, the stoma and the sinus tract percussion and mastication testing.
will close within several days. Before percussing any teeth, the clinician should tell the
The stomata of intraoral sinus tracts may open in the patient what will transpire during this test. Because the
alveolar mucosa, in the attached gingiva, or through the presence of acute symptoms may create anxiety and possi-
furcation or gingival crevice. They may exit through either bly alter the patient’s response, properly preparing the pa-
the facial or the lingual tissues depending on the proximity tient will lead to more accurate results. The contralateral
of the root apices to the cortical bone. If the opening is tooth should first be tested as a control, as should several
in the gingival crevice, it is normally present as a narrow adjacent teeth that are certain to respond normally. The
defect in one or two isolated areas along the root surface. clinician should advise the patient that the sensation from
When a narrow defect is present, the differential diagnosis this tooth is normal and ask to be advised of any tenderness
must include the opening of a periradicular endodontic or pain from subsequent teeth.
lesion, a vertical root fracture, or the presence of a develop- Percussion is performed by tapping on the incisal or
mental groove on the root surface. This type of sinus tract occlusal surfaces of the teeth either with the finger or with
can be differentiated from a primary periodontal lesion a blunt instrument. The testing should initially be done
because the latter generally presents as a pocket with a gently, with light pressure being applied digitally with
broad coronal opening and more generalized alveolar bone a gloved finger tapping. If the patient cannot detect signifi-
loss around the root. Other pulp testing methods may assist cant difference between any of the teeth, the test should be
in verifying the source of infection.111,112,121 repeated using the blunt end of an instrument, like the
back end of a mirror handle (Fig. 1.15). The tooth crown is
Palpation tapped vertically and horizontally. The tooth should first be
In the course of the soft-tissue examination, the alveolar percussed occlusally, and if the patient discerns no differ-
hard tissues should also be palpated. Emphasis should be ence, the test should be repeated, percussing the buccal and
placed on detecting any soft-tissue swelling or bony expan- lingual aspects of the teeth. For any heightened responses,
sion, especially noting how it compares with and relates to the test should be repeated as necessary to determine that it
the adjacent and contralateral tissues. In addition to objec- is accurate and reproducible, and the information should be
tive findings, the clinician should question the patient about documented.
any areas that feel unusually sensitive during this palpation Although this test does not disclose the condition of the
part of the examination. pulp, it indicates the presence of a periradicular inflamma-
A palpation test is performed by applying firm digital pres- tion. An abnormal positive response indicates inflamma-
sure to the mucosa covering the roots and apices. The index tion of the periodontal ligament that may be of either
finger is used to press the mucosa against the underlying pulpal or periodontal origin. The sensitivity of the proprio-
cortical bone. This will detect the presence of periradicular ceptive fibers in an inflamed periodontal ligament will help
abnormalities or specific areas that produce painful response identify the location of the pain. This test should be done
to digital pressure. A positive response to palpation may indi- gently, especially in highly sensitive teeth. It should be
cate an active periradicular inflammatory process. However, repeated several times and compared with control teeth.
this test does not indicate whether the inflammatory process
is of endodontic or periodontal origin. Mobility
Like percussion testing, an increase in tooth mobility is not
Percussion an indication of pulp vitality. It is merely an indication of a
Referring back to the patient’s chief complaint may indi-
cate the importance of percussion testing for this particular
case. If the patient is experiencing acute sensitivity or pain
on mastication, this response can typically be duplicated by
individually percussing the teeth, which often isolates the
symptoms to a particular tooth. Pain to percussion does not
indicate that the tooth is vital or nonvital but is rather an
indication of inflammation in the periodontal ligament (i.e.,
symptomatic apical periodontitis). This inflammation may
be secondary to physical trauma, occlusal prematurities,
periodontal disease, or the extension of pulpal disease into
the periodontal ligament space. The indication of where the
pain originates is interpreted by the mesencephalic nucleus,
receiving its information from proprioceptive nerve recep-
tors. Although subject to debate, the general consensus is
that there are relatively few proprioceptors in the dental
pulp; however, they are prevalent in the periodontal liga-
ment spaces.24 This is why it may be difficult for the patient
to discriminate the location of dental pain in the earlier Fig. 1.15 Percussion testing of a tooth, using the back end of a mirror
handle.
stages of pathosis, when only the C fibers are stimulated.
1 • Diagnosis 15
compromised periodontal attachment apparatus. This com- the tooth, progressing in 1-mm increments. Periodontal
promise could be the result of acute or chronic physical bone loss that is wide, as determined by a wide span of deep
trauma, occlusal trauma, parafunctional habits, periodon- periodontal probing, is generally considered to be of peri-
tal disease, root fractures, rapid orthodontic movement, or odontal origin and is typically more generalized in other
the extension of pulpal disease, specifically an infection, into areas of the mouth. However, isolated areas of vertical bone
the periodontal ligament space. Tooth mobility is directly loss may be of an endodontic origin, specifically from a non-
proportional to the integrity of the attachment apparatus or vital tooth whose infection has extended from the periapex
to the extent of inflammation in the periodontal ligament. to the gingival sulcus. Again, proper pulp testing is impera-
Often the mobility reverses to normal after the initiating tive, not just for the determination of a diagnosis but also
factors are repaired or eliminated. Because determining for the development of an accurate prognosis assessment.
mobility by simple finger pressure can be visually subjective, For example, a periodontal pocket of endodontic origin may
the back ends of two mirror handles should be used, one on resolve after endodontic treatment, but if the tooth was
the buccal aspect and one on the lingual aspect of the tooth originally vital with an associated deep periodontal pocket,
(Fig. 1.16). Pressure is applied in a facial-lingual direction as endodontic treatment will not improve the periodontal con-
well as in a vertical direction and the tooth mobility is scored dition. In addition, as discussed in Chapter 22, a vertical
(Box 1.2). Any mobility that exceeds 11 should be consid- root fracture may often cause a localized narrow periodon-
ered abnormal. However, the teeth should be evaluated on tal pocket that extends deep down the root surface. Charac-
the basis of how mobile they are relative to the adjacent and teristically, the adjacent periodontium is usually within
contralateral teeth. normal limits.
Furcation bone loss can be secondary to periodontal or
Periodontal Examination pulpal disease. The amount of furcation bone loss, as
Periodontal probing is an important part of any intraoral observed both clinically and radiographically, should be
diagnosis. The measurement of periodontal pocket depth documented (Box 1.3). Results of pulp tests (described
is an indication of the depth of the gingival sulcus, which later) will aid in diagnosis.
corresponds to the distance between the height of the free
gingival margin and the height of the attachment appara- PULP TESTS
tus below. Using a calibrated periodontal probe, the clini-
cian should record the periodontal pocket depths on the Pulp test (pulp sensibility test) is a diagnostic procedure to
mesial, middle, and distal aspects of both the buccal and determine pulp status. It can be performed with electrical,
lingual sides of the tooth, noting the depths in millimeters. mechanical, or thermal stimuli, or by the assessment of the
The periodontal probe is “stepped” around the long axis of blood supply to the tooth.6 It involves attempting to make
a determination of the responsiveness of pulpal sensory
neurons.62,63 It aims to obtain a subjective response from
the patient (i.e., to determine whether the pulpal nerves
are functional), or the tests may involve a more objective
approach using devices that detect the integrity of the
pulpal vasculature. Unfortunately, the quantitative evalua-
tion of the status of pulp tissue can only be determined
histologically, as it has been shown that there is not neces-
sarily a good correlation between the objective clinical signs
and symptoms and the pulpal histology.122,123
Thermal
Various methods and materials have been used to test the
pulp’s response to thermal stimuli. The baseline or normal
response to either cold or hot is a patient’s report that a
sensation is felt but disappears immediately upon removal
of the thermal stimulus. Abnormal responses include a lack
of response to the stimulus, a lingering or intensification of
a painful sensation after the stimulus is removed, or an
immediate, excruciatingly painful sensation as soon as the
Fig. 1.16 Mobility testing of a tooth, using the back ends of two mirror
handles.
stimulus is placed on the tooth.
Cold testing is the primary pulp testing method used by cotton roll so the frozen CO2 will not come into contact with
many clinicians today. It is especially useful for patients pre- these structures. Because of the extremely cold tempera-
senting with porcelain jacket crowns or porcelain-fused-to- ture of the frozen CO2 (269°F to 2119°F; 256°C to
metal crowns where no natural tooth surface (or much 298°C), burns of the soft tissues can occur. It has been
metal) is accessible. If a clinician chooses to perform this test demonstrated on extracted teeth that frozen CO2 applica-
with sticks of ice, then the use of a rubber dam is recom- tion has resulted in a significantly greater intrapulpal tem-
mended, because melting ice will run onto adjacent teeth perature decrease than either skin refrigerant or ice.11 Also,
and gingiva, yielding potentially false-positive responses. it appears that the application of CO2 to teeth does not
Frozen carbon dioxide (CO2), also known as dry ice or result in any irreversible damage to the pulp tissues or
carbon dioxide snow, or CO2 stick, has been found to be reli- cause any significant enamel crazing.61,104
able in eliciting a positive response if vital pulp tissue is The most popular method of performing cold testing is
present in the tooth.46,98,99 One study found that vital teeth with a refrigerant spray. It is readily available, easy to use,
would respond to both frozen CO2 and skin refrigerant, with and provides test results that are reproducible, reliable, and
skin refrigerant producing a slightly quicker response.66 equivalent to that of frozen CO2.46,66,96,141 One of the cur-
Frozen carbon dioxide has also been found to be effective in rent products contains 1,1,1,2-tetrafluoroethane, which
evaluating the pulpal response in teeth with full coverage has zero ozone depletion potential and is environmentally
crowns for which other tests such as electric pulp testing is safe. It has a temperature of 226.2°C.66 The spray is most
not possible.11 For testing purposes, a solid stick of CO2 is effective for testing purposes when it is applied to the tooth
prepared by delivering CO2 gas into a specially designed on a large #2 cotton pellet (Fig. 1.18). In one study,65 a
plastic cylinder (Fig. 1.17). The resulting CO2 stick is significantly lower intrapulpal temperature was achieved
applied to the facial surface of either the natural tooth when a #2 cotton pellet was dipped or sprayed with the re-
structure or crown. Several teeth can be tested with a single frigerant compared with the result when a small #4 cotton
CO2 stick. The teeth should be isolated and the oral soft pellet or cotton applicator was used. The sprayed cotton
tissues should be protected with a 2-by-2-inch gauze or pellet should be applied to the midfacial area of the tooth
or crown. As with any other pulp testing method, adjacent
or contralateral “normal” teeth should also be tested to
establish a baseline response. It appears that frozen CO2 and
refrigerant spray are superior to other cold testing methods
and equivalent or superior to the electric pulp tester for as-
sessing pulp vitality.11,46 However, one study found that
periodontal attachment loss and gingival recession may
influence the reported pain response with cold stimuli.116
To be most reliable, cold testing should be used in con-
junction with an electric pulp tester (described later in this
chapter) so that the results from one test will verify the
findings of the other test. If a mature, nontraumatized
tooth does not respond to both cold testing and electric pulp
testing, then the pulp can be considered necrotic.23,98,141
However, a multirooted tooth, with at least one root con-
taining vital pulp tissue, may respond to a cold test and
electric pulp test even if one or more of the roots contain
necrotic pulp tissue.98
Another thermal testing method involves the use of heat.
A Heat testing is most useful when a patient’s chief complaint
is intense dental pain on contact with any hot liquid or
food. When a patient is unable to identify which tooth is
sensitive, a heat test is appropriate. Starting with the most
posterior tooth in that area of the mouth, each tooth is in-
dividually isolated with a dental dam. An irrigating syringe
is filled with a liquid (most commonly plain water) that has
a temperature similar to that which would cause the pain-
ful sensation. The liquid is then expressed from the syringe
onto the isolated tooth to determine whether the response
is normal or abnormal. The clinician moves forward in the
quadrant, isolating each individual tooth until the offend-
ing tooth is located. That tooth will exhibit an immediate,
intense painful response to the heat. With heat testing, a
B C
delayed response may occur, so waiting 10 seconds between
Fig. 1.17 A, Carbon dioxide tank with apparatus attached to form each heat test will allow sufficient time for the onset of
solid CO2 stick/pencil. B, CO2 gas being transformed into a solid stick/ symptoms. This method can also be used to apply cold
pencil. C, CO2 stick/pencil extruded from end of a plastic carrier and water to the entire crown for cases in which cold is the
ready for use.
precipitating stimulus.
1 • Diagnosis 17
B C
Fig. 1.18 A, Refrigerant spray container. B, A large cotton pellet made of a cotton roll, or a ready-made size #2 (large) cotton pellet, can be used to
apply the refrigerant spray to the tooth surface. The small #4 cotton pellet does not provide as much surface area as the #2 cotton pellet, and therefore
should not be used to deliver the refrigerant to the tooth surface. C, A large cotton pellet sprayed with the refrigerant and ready to be applied to the
tooth surface. (A, Courtesy Coltène/Whaledent, Cuyahoga Falls, OH.)
A B
C D
Fig. 1.23 Sometimes there is no clear indication of why a tooth is symptomatic. This radiograph shows a mandibular second molar with a moderately
deep restoration (A); the pulp tests nonvital. Without any transillumination, a fracture cannot be detected (B). However, by placing a high-intensity
light source on the tooth surface, a root fracture can be observed on the buccal surface (C) and the distal-lingual surface (D).
and testing, the radiograph alone can lead to a misinterpre- For standard two-dimensional radiography, clinicians
tation of normality and pathosis (Fig. 1.24). Because treat- basically project x-radiation through an object and cap-
ment planning will ultimately be based on the diagnosis, the ture the image on a recording medium, either x-ray film or
potential for inappropriate treatment may frequently exist a digital sensor. Much like casting a shadow from a light
if the radiograph alone is used for making final diagnosis. source, the image appearance may vary greatly depending
The clinician should not subject the patient to unnecessary on how the radiographic source is directed. Thus, the
multiple radiation exposures; two pretreatment images from three-dimensional interpretation of the resulting two-
different angulations are often sufficient. However, under dimensional image requires not only knowledge of nor-
extenuating circumstances—especially when the diagnosis mality and pathosis but also advanced knowledge of how
is difficult—additional exposures may be necessary to deter- the radiograph was exposed. By virtue of “casting a
mine the presence of multiple roots, multiple canals, resorp- shadow,” the anatomic features that are closest to the film
tive defects, caries, restoration defects, root fractures, and the (or sensor) will move the least when there is a change in
extent of root maturation and apical development. the horizontal or vertical angulation of the radiation
The radiographic appearance of endodontic pathosis can source (Fig. 1.25). This may be helpful in determining the
sometimes be highly subjective. In a study by Goldman and existence of additional roots, the location of pathosis, and
colleagues, there was only 50% agreement among inter- the unmasking of anatomic structures. Changes in the
preters for the radiographic presence of pathosis.49 When horizontal or vertical angulation may help elucidate valu-
the cases were reevaluated several months later, the same able anatomic and pathologic information; it also has the
evaluators agreed with their own original diagnosis less potential to hide important information. An incorrect ver-
than 85% of the time.50 This further emphasizes the neces- tical angulation may cause the buccal roots of a maxillary
sity for additional objective diagnostic tests, as well as the molar to be masked by the zygomatic arch. An incorrect
importance of obtaining and comparing older radiographs horizontal angulation may cause roots to overlap with
of the same area of the patient. the roots of adjacent teeth, or it may incorrectly create
22 PART I • The Core Science of Endodontics
Radiation
source Film or
A sensor
Radiation
source
Change
vertical Film or
B angulation sensor
Fig. 1.25 Radiographic images are only two-dimensional, and often it
is difficult to discriminate the relative location of overlapping objects.
A, When the source of radiation is directly perpendicular to overlap-
ping objects, the image is captured without much separation of the
Fig. 1.24 Radiograph showing what appears to be a mandibular lat- objects. However, when the radiation source is at an angle to offset the
eral incisor associated with periapical lesion of a nonvital tooth. Al- overlapping objects, the image is captured with the objects being
though pulp necrosis can be suspected, the tooth tested vital. In this viewed as separated. B, The object that is closest to the film (or sensor)
case, the appearance of apical bone loss is secondary to a cementoma. will move the least, with the object closest to the radiation source ap-
pearing farthest away.
the appearance of a one-rooted tooth, when two roots are is correlated with the relationship of the periapex of the
actually present. tooth and its juxtaposition to the cortical-cancellous bone
In general, when endodontic pathosis appears radio- junction. The apices of most anterior and premolar teeth
graphically, it appears as a radiolucency in the area of the are located close to the cortical-cancellous bone junction.
periapex. The pathosis may present merely as a widening or Therefore, periapical pathosis from these teeth is exhibited
break in the lamina dura—the most consistent radiographic sooner on the radiograph. By comparison, the distal roots
finding when a tooth is nonvital67—or it may present as a of mandibular first molars and both roots of mandibular
radiolucent area at the apex of the root or in the alveolar second molars are generally positioned more centrally
bone adjacent to the exit of a lateral or furcation accessory within the cancellous bone, as are maxillary molars, espe-
canal. On occasion no radiographic change can be seen at cially the palatal roots. Periapical lesions from these roots
all, even in the presence of a disease process in the alveolar must expand more before they reach the cortical-cancellous
bone. This is mainly due to the fact that the disease process bone junction and are recognized as radiographic pathosis.
did not reach the cortical plate of the bone. For these reasons, it is important not to exclude the possibil-
Two-dimensional dental radiography has two basic ity of pulpal pathosis in situations in which there are no ra-
shortcomings: the lack of early detection of pathosis in the diographic changes.
cancellous bone, because of the density of the cortical Many factors can influence the quality of the radio-
plates, and the influence of the superimposition of ana- graphic interpretation, including the ability of the person
tomic structures. Variability in the radiographic expression exposing the radiograph, the quality of the radiographic
of an osseous pathosis has much to do with the relative film, the quality of the exposure source, the quality of the
location of the root of the tooth and how it is oriented with film processing, and the skill with which the film is viewed.
respect to the cortical and cancellous bone. Radiographic Controlling all of these variables can be a difficult challenge
changes from bone loss will not be detected if the loss is only but is paramount for obtaining an accurate radiographic
in cancellous bone.16 However, the radiographic evidence interpretation.
of pathosis will be observed once this bone loss extends
to the junction of the cortical and cancellous bone. In addi- Digital Radiography
tion, certain teeth are more prone to exhibit radiographic Digital radiography has been available since the late 1980s
changes than others, depending on their anatomic loca- and has recently been refined and popularized with better
tion.17 The radiographic appearance of endodontic pathosis hardware and a more user-friendly interface. It has the
1 • Diagnosis 23
ability to capture, view, magnify, enhance, and store radio- The diagnostic quality of this technology has been shown
graphic images in an easily reproducible format that does to be comparable to conventional film-based radiogra-
not degrade over time. Significant advantages of digital phy.39,73,97 The interpretation of a digital radiograph can
radiographs over conventional radiographs include lower be subjective, similar to that of the conventional film.134
radiation doses, instant viewing, convenient manipula- Factors that appear to have the most impact on the inter-
tion, efficient transmission of an image via the Internet, pretation of the image are the years of experience of the
simple duplication, and easy archiving. examiner and familiarity of the operator with the given
Digital radiography uses no x-ray film and requires no digital system.134
chemical processing. Instead, a sensor is used to capture
the image created by the radiation source. This sensor is Cone-Beam Computerized Tomography
either directly or wirelessly attached to a local computer, Limitations in conventional two-dimensional radiography
which interprets this signal and, using specialized soft- promulgated a need for three-dimensional imaging, known
ware, translates the signal into a two-dimensional digital as cone-beam computerized tomography (CBCT) (also known
image that can be displayed, enhanced, and analyzed. The as cone-beam volumetric tomography [CBVT]) or as cone-beam
image is stored in the patient’s file, typically in a dedicated volumetric imaging [CBVI]. Although a form of this technol-
network server, and can be recalled as needed. Further ogy has existed since the early 1980s,106 specific devices for
information about digital radiography may be found in dental use first appeared almost two decades later.90 Most
Chapter 2. of these machines are similar to a dental panoramic radio-
The viewing of a digital radiographic image on a high- graphic device, whereby the patient stands or sits as a
resolution monitor allows for rapid and easy interpretation cone-shaped radiographic beam is directed to the target
for both the clinician and the patient. The image appears area with a reciprocating capturing sensor on the opposite
almost instantly, with no potential for image distortion side (Fig. 1.27). The resulting information is digitally recon-
from improper chemical processing. The clinician can structed and interpreted to create an interface whereby
magnify different areas on the radiograph and then digi- the clinician can three-dimensionally interpret “slices” of
tally enhance the image in order to better visualize certain the patient’s tissues in a multitude of planes (Figs. 1.28
anatomic structures; in some cases, the image can even and 1.29).37,33 The survey of the scans can be interpreted
be colorized, which is a useful tool for patient education immediately after the scan. Various software applications
(Fig. 1.26). have been used to enable the images to be sent to other
In the past, x-ray film has had a slightly better resolution clinicians. This is accomplished either in printed format or
than most digital radiography images, at about 16 line with portable and transferable software that can be used
pairs per millimeter (lp/mm).87 However, current sensors interactively by another clinician.
offer resolutions beyond that of conventional film. Under In general, many dental applications only require a
the best of circumstances, the human eye can see only limited field of vision, confining the study to the maxilla
about 10 lp/mm, which is the lowest resolution for most and mandible. However, many devices have the ability to
dental digital radiography systems. Digital sensors are
much more sensitive to radiation than conventional x-ray
film and thus require 50% to 90% less radiation in order to
acquire an image, an important feature for generating
greater patient acceptance of dental radiographs.
80 mm
Voxel size
0.16 mm
0.08 mm
0.08 mm
0.16 mm
0.16 mm 0.08 mm
Fig. 1.29 Cone-beam volumetric tomography has the advantage of
being able to detect pathosis in the bone or associated with the teeth Fig. 1.30 The radiation source in cone-beam volumetric tomography is
without the obstruction of anatomic structures. The planes of vision conical. The receiving sensor captures the image as “voxels,” or three-
may be axial, sagittal, or coronal. (Courtesy J. Morita USA, Irvine, CA.) dimensional pixels of information, allowing digital interpretation.
provide a full field of vision for viewing more regional struc- and providing for a more accurate interpretation of ana-
tures. Clinicians should thoroughly understand the ethical tomic structures and pathologic conditions. The develop-
and medical-legal ramifications of doing scans with full ment of limited field of vision devices has also contributed
fields of view. Incidental nondental findings have been seen to decreasing the radiation and cost of these machines,
from these scans, such as intracranial aneurysms, which, making them more practical for endodontic use.41
when undetected, could be life threatening.91 Compared with two-dimensional radiographs, CBCT can
The radiation source of CBCT is different from that of clearly visualize the interior of the cancellous bone without
conventional two-dimensional dental imaging in that the the superimposition of the cortical bone. Studies show that
radiation beam created is conical in shape. Also, conven- CBCT is much more predictable and efficient in demonstrat-
tional digital dental radiography is captured and inter- ing anatomic landmarks, bone density, bone loss, periapical
preted as pixels, a series of dots that collectively produces lesions, root fractures, root perforations, and root resorpti
an image of the scanned structure. For CBCT, the image is ons.1,21,26,27,38,47,71,78,81,85,92,94,128,131,142
instead captured as a series of three-dimensional pixels, The superimposition of anatomic structures can also
known as voxels. Combining these voxels gives a three- mask the interpretation of alveolar defects. Specifically, the
dimensional image that can be “sliced” into various planes, maxillary sinus, zygoma, incisive canal and foramen, nasal
allowing for specific evaluations without a necropsy bone, orbit, mandibular oblique ridge, mental foramen,
(Fig. 1.30). One of the advantages of using a device that mandibular mentalis, sublingual salivary glands, tori, and
has a limited field of vision is that the voxel size can be less the overlap of adjacent roots may either obscure bone loss
than half that of a device using a full field of vision, or mimic bone loss, making an accurate interpretation of
thereby increasing the resolution of the resulting image conventional radiography sometimes difficult or impossible.
1 • Diagnosis 25
Several studies have demonstrated the advantages of CBCT line may directly alter the prognosis assessment for a given
in the differential diagnosis of such structures from patho- tooth and should be examined before treatment decision
logic conditions.21,29,71,137 making. Certain types of cracks may be as innocent as a
CBCT should not be seen as a replacement for conven- superficial enamel craze line, or they may be as prominent
tional dental radiography, but rather as a diagnostic ad- as a fractured cusp. The crack may progress into the root
junct. The advantage of conventional dental radiography is system to involve the pulp, or it may split the entire tooth
that it can visualize most of the structures in one image. into two separate segments. The crack may be oblique, ex-
CBCT can show great detail in many planes of vision but tending cervically, such that once the coronal segment is
can also leave out important details if the “slice” is not in removed the tooth may or may not be restorable. Any of
the area of existing pathosis (Fig. 1.31). There is a promis- these situations may present with mild, moderate, or severe
ing future for the use of CBCT for endodontic diagnosis and symptoms or possibly no symptoms at all.
treatment. It has already proven invaluable in the detection
of dental and nondental pathoses (Fig. 1.32). For a further Crack Types
review of CBCT and radiography, see Chapter 2. There have been many suggestions in the literature of how
to classify cracks in teeth. By defining the type of crack
Magnetic Resonance Imaging present, an assessment of the prognosis may be determined
Magnetic resonance imaging (MRI) has also been suggested and treatment alternatives can be planned. Unfortunately,
for dental diagnosis. It may offer simultaneous three- it is often extremely difficult to determine how extensive a
dimensional hard- and soft-tissue imaging of teeth without crack is until the tooth is extracted.
ionizing radiation.58 The use of MRI in endodontics is still Cracks in teeth can be divided into three basic categories:
limited. n Craze lines
n Fractures (also referred to as cracks)
CRACKS AND FRACTURES n Split tooth/roots
The wide variety of types of cracks and fractures in teeth Craze lines are merely cracks in the enamel that do not
and their associated signs and symptoms often make their extend into the dentin and either occur naturally or develop
diagnosis difficult. The extensiveness of the crack or fracture after trauma. They are more prevalent in adult teeth and
B
Fig. 1.31 A, This standard two-dimensional radiographic image reveals recurrent caries under the mesial margin of the maxillary first molar. However,
the patient localized pain to mastication on the maxillary second molar. B, Cone-beam volumetric tomography revealed an apical radiolucency associ-
ated with the maxillary second molar. The bone loss was obscured on the two-dimensional radiograph by the maxillary sinus, zygoma, and cortical
bone.
26 PART I • The Core Science of Endodontics
A C
D E
Fig. 1.33 Poorly fitting intracoronal restorations can place stresses within the tooth that can cause a vertical root fracture. A, This radiograph of a
mandibular second premolar (with a gold inlay) reveals extensive periapical and periradicular bone loss, especially on the distal aspect. B, The tooth
pulp tested nonvital, and there was an associated 12-mm-deep, narrow, isolated periodontal pocket on the buccal aspect of the tooth. After the tooth
was extracted, the distal aspect was examined. C, On magnification (316) the distal aspect of the root revealed an oblique vertical root fracture. Simi-
larly, the placement of an ill-fitting post may exert intraradicular stresses on a root that can cause a fracture to occur vertically. D, This radiograph
depicts a symmetrical space between the obturation and the canal wall, suggesting a vertical root fracture. E, After the tooth is extracted, the root
fracture can be easily observed.
these vertical root fractures may be difficult, they often be able to make a prediction as to the eventual potential of
go unrecognized. Therefore, diagnosing the existence and healing, and convey this information to the patient. A more
extent of a vertical root fracture is imperative before any detailed discussion on vertical root fractures is described in
restorative or endodontic treatment is done, as it can Chapter 22.
dramatically affect the overall success of treatment.
A patient who consents to endodontic treatment must be PERFORATIONS
informed if the tooth has a questionable prognosis. The cli-
nician must be able to interpret the subjective and objective Root perforations are clinical complications that may
findings that suggest a vertical root fracture or split tooth, lead to treatment failure. When root perforation occurs,
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all joyously interested? Why, vice! He’d begin the vice rampage now,
instead of waiting till the business meeting after lunch.
He pounded on the table, and demanded, “Most of you have
been in Zenith longer than myself. I admit ignorance. It is true that I
have unearthed many dreadful, dreadful cases of secret sin. But you
gentlemen, who know the town so much better—— Am I right? Are
Conditions as dreadful as I think, or do I exaggerate?”
All of them lighted up and, suddenly looking on Elmer as a really
nice man after all, they began happily to tell of their woeful
discoveries. . . . The blood-chilling incident of the father who found in
the handbag of his sixteen-year-old daughter improper pictures. The
suspicion that at a dinner of war veterans at the Leroy House there
had danced a young lady who wore no garments save slippers and a
hat.
“I know all about that dinner—I got the details from a man in my
church—I’ll tell you about it if you feel you ought to know,” said Dr.
Gomer.
They looked as though they decidedly felt that they ought to
know. He went into details, very, and at the end Dr. Jessup gulped,
“Oh, that Leroy House is absolutely a den of iniquity! It ought to be
pulled!”
“It certainly ought to! I don’t think I’m cruel,” shouted Dr. Zahn, the
Lutheran, “but if I had my way, I’d burn the proprietor of that joint at
the stake!”
All of them had incidents of shocking obscenity all over the place
—all of them except Father Smeesby, who sat back and smiled, the
Episcopal Dr. Tate, who sat back and looked bored, and Mr. Tillish,
the healer, who sat back and looked chilly. In fact it seemed as
though, despite the efforts of themselves and the thousands of other
inspired and highly trained Christian ministers who had worked over
it ever since its foundation, the city of Zenith was another Sodom.
But the alarmed apostles did not appear to be so worried as they
said they were. They listened with almost benign attention while Dr.
Zahn, in his German accent, told of alarming crushes between the
society girls whom he knew so well from dining once a year with his
richest parishioner.
They were all, indeed, absorbed in vice to a degree gratifying to
Elmer.
But at the time for doing something about it, for passing
resolutions and appointing sub-committees and outlining programs,
they drew back.
“Can’t we all get together—pool our efforts?” pleaded Elmer.
“Whatever our creedal differences, surely we stand alike in
worshiping the same God and advocating the same code of morals.
I’d like to see this Committee as a permanent organization, and
finally, when the time is ripe—— Think how it would jolt the town! All
of us getting ourselves appointed special police or deputy sheriffs,
and personally marching down on these abominations, arresting the
blood-guilty wretches, and putting them where they can do no harm!
Maybe leading our church-members in the crusade! Think of it!”
They did think of it, and they were alarmed.
Father Smeesby spoke. “My church, gentlemen, probably has a
more rigid theology than yours, but I don’t think we’re quite so
alarmed by discovering the fact, which seems to astonish you, that
sinners often sin. The Catholic Church may be harder to believe, but
it’s easier to live with.”
“My organization,” said Mr. Tillish, “could not think of joining in a
wild witch-hunt, any more than we could in indiscriminate charity. For
both the poverty-laden and the vicious—” He made a little whistling
between his beautiful but false teeth, and went on with frigid
benignancy. “For all such, the truth is clearly stated in ‘Science and
Health’ and made public in all our meetings—the truth that both vice
and poverty, like sickness, are unreal, are errors, to be got rid of by
understanding that God is All-in-all; that disease, death, evil, sin
deny good, omnipotent God, life. Well! If these so-called sufferers do
not care to take the truth when it is freely offered them, is that our
fault? I understand your sympathy with the unfortunate, but you are
not going to put out ignorance by fire.”
“Golly, let me crawl too,” chuckled Rabbi Amos. “If you want to
get a vice-crusading rabbi, get one of these smart-aleck young
liberals from the Cincinnati school—and they’ll mostly have too much
sympathy with the sinners to help you either! Anyway, my
congregation is so horribly respectable that if their rabbi did anything
but sit in his study and look learned, they’d kick him out.”
“And I,” said Dr. Willis Fortune Tate, of St. Colomb’s Episcopal, “if
you will permit me to say so, can regard such a project as our acting
like policemen and dealing with these malefactors in person as
nothing short of vulgar, as well as useless. I understand your high
ideals, Dr. Gantry—”
“Mr. Gantry.”
“—Mr. Gantry, and I honor you for them, and respect your energy,
but I beg you to consider how the press and the ordinary laity, with
their incurably common and untrained minds, would misunderstand.”
“I’m afraid I must agree with Dr. Tate,” said the Congregational
Dr. G. Prosper Edwards, in the manner of the Pilgrim’s Monument
agreeing with Westminster Abbey.
And as for the others, they said they really must “take time and
think it over,” and they all got away as hastily and cordially as they
could.
Elmer walked with his friend and pillar, Mr. T. J. Rigg, toward the
dentist’s office in which even an ordained minister of God would
shortly take on strangely normal writhings and gurglings.
“They’re a fine bunch of scared prophets, a noble lot of apostolic
ice-cream cones!” protested Mr. Rigg. “Hard luck, Brother Elmer! I’m
sorry. It really is good stuff, this vice-crusading. Oh, I don’t suppose it
makes the slightest difference in the amount of vice—and I don’t
know that it ought to make any. Got to give fellows that haven’t our
advantages some chance to let off steam. But it does get the church
a lot of attention. I’m mighty proud of the way we’re building up
Wellspring Church again. Kind of a hobby with me. But makes me
indignant, these spiritual cold-storage eggs not supporting you!”
But as he looked up he saw that Elmer was grinning.
“I’m not worried, T. J. Fact, I’m tickled to death. First place, I’ve
scared ’em off the subject of vice. Before they get back to preaching
about it, I’ll have the whole subject absolutely patented for our
church. And now they won’t have the nerve to imitate me if I do this
personal crusading stunt. Third, I can preach against ’em! And I will!
You watch me! Oh, not mention any names—no come-back—but tell
’em how I pleaded with a gang of preachers to take practical
methods to end immorality, and they were all scared!”
“Fine!” said the benevolent trustee. “We’ll let ’em know that
Wellspring is the one church that’s really following the gospel.”
“We sure will! Now listen, T. J.: if you trustees will stand for the
expense, I want to get a couple of good private detectives or
something, and have ’em dig up a lot of real addresses of places that
are vicious—there must be some of ’em—and get some evidence.
Then I’ll jump on the police for not having pinched these places. I’ll
say they’re so wide open that the police must know of ’em. And
probably that’s true, too. Man! A sensation! Run our disclosures
every Sunday evening for a month! Make the chief of police try to
answer us in the press!”
“Good stuff! Well, I know a fellow—he was a government man,
prohibition agent, and got fired for boozing and blackmail. He’s not
exactly a double-crosser, lot straighter than most prohibition agents,
but still I think he could slip us some real addresses. I’ll have him see
you.”
IV
When from his pulpit the Reverend Elmer Gantry announced that
the authorities of Zenith were “deliberately conniving in protected
vice,” and that he could give the addresses and ownerships of
sixteen brothels, eleven blind tigers, and two agencies for selling
cocaine and heroin, along with an obscene private burlesque show
so dreadful that he could only hint at the nature of its program, when
he attacked the chief of police and promised to give more detailed
complaints next Sunday, then the town exploded.
There were front-page newspaper stories, yelping replies by the
mayor and chief of police, re-replies from Elmer, interviews with
everybody, and a full-page account of white slavery in Chicago. In
clubs and offices, in church societies and the back-rooms of “soft-
drink stands,” there was a blizzard of talk. Elmer had to be protected
against hundreds of callers, telephoners, letter writers. His assistant,
Sidney Webster, and Miss Bundle, the secretary, could not keep the
mob from him, and he hid out in T. J. Rigg’s house, accessible to no
one, except to newspaper reporters who for any Christian and
brotherly reason might care to see him.
For the second Sunday evening of his jeremiad, the church was
full half an hour before opening-time, standing-room was taken even
to the back of the lobby, hundreds clamored at the closed doors.
He gave the exact addresses of eight dives, told what dreadful
drinkings of corn whisky went on there, and reported the number of
policemen, in uniform, who had been in the more attractive of these
resorts during the past week.
Despite all the police could do to help their friends close up for a
time, it was necessary for them to arrest ten or fifteen of the
hundred-odd criminals whom Elmer named. But the chief of police
triumphed by announcing that it was impossible to find any of the
others.
“All right,” Elmer murmured to the chief, in the gentleness of a
boxed newspaper interview in bold-face type, “if you’ll make me a
temporary lieutenant of police and give me a squad, I’ll find and
close five dives in one evening—any evening save Sunday.”
“I’ll do it—and you can make your raids tomorrow,” said the chief,
in the official dignity of headlines.
Mr. Rigg was a little alarmed.
“Think you’re going too far, Elmer,” he said. “If you really
antagonize any of the big wholesale bootleggers, they’ll get us
financially, and if you hit any of the tough ones, they’re likely to bump
you off. Darn’ dangerous.”
“I know. I’m just going to pick out some of the smaller fellows that
make their own booze and haven’t got any police protection except
slipping five or ten to the cop on the beat. The newspapers will make
’em out regular homicidal gangsters, to get a good story, and we’ll
have the credit without being foolish and taking risks.”
V
At least a thousand people were trying to get near the Central
Police Station on the evening when a dozen armed policemen
marched down the steps of the station-house and stood at attention,
looking up at the door, awaiting their leader.
He came out, the great Reverend Mr. Gantry, and stood posing
on the steps, while the policemen saluted, the crowd cheered or
sneered, and the press cameras went off in a fury of flashlight
powder. He wore the gilt-encircled cap of a police lieutenant, with a
lugubrious frock coat and black trousers, and under his arm he
carried a Bible.
Two patrol wagons clanged away, and all the women in the
crowd, except certain professional ladies, who were grievously
profane, gasped their admiration of this modern Savonarola.
He had promised the mob at least one real house of prostitution.
VI
There were two amiable young females who, tired of working in a
rather nasty bread factory and of being unremuneratively seduced by
the large, pale, puffy bakers on Sunday afternoons, had found it
easier and much jollier to set up a small flat in a street near Elmer’s
church. They were fond of reading the magazines and dancing to the
phonograph and of going to church—usually Elmer’s church. If their
relations to their gentlemen friends were more comforting than a
preacher could expect, after his experience of the sacred and chilly
state of matrimony, they entertained only a few of these friends,
often they darned their socks, and almost always they praised
Elmer’s oratory.
One of the girls, this evening, was discoursing with a man who
was later proved in court not to be her husband; the other was in the
kitchen, making a birthday-cake for her niece and humming
“Onward, Christian Soldiers.” She was dazed by a rumbling, a
clanging, a shouting in the street below, then mob-sounds on the
stairs. She fluttered into the living-room, to see their pretty imitation
mahogany door smashed in with a rifle butt.
Into the room crowded a dozen grinning policemen, followed, to
her modest shame, by her adored family prophet, the Reverend
Gantry. But it was not the cheerful, laughing Mr. Gantry that she
knew. He held out his arm in a horrible gesture of holiness, and
bawled, “Scarlet woman! Thy sins be upon thy head! No longer are
you going to get away with leading poor unfortunate young men into
the sink and cesspool of iniquity! Sergeant! Draw your revolver!
These women are known to be up to every trick!”
“All right, sure, loot!” giggled the brick-faced police sergeant.
“Oh, rats! This girl looks as dangerous as a goldfish, Gantry,”
remarked Bill Kingdom, of the Advocate-Times . . . he who was two
hours later to do an epic of the heroism of the Great Crusader.
“Let’s see what the other girl’s up to,” snickered one of the
policemen.
They all laughed very much as they looked into the bedroom,
where a half-dressed girl and a man shrank by the window, their
faces sick with shame.
It was with her—ignoring Bill Kingdom’s mutters of “Oh, drop it!
Pick on somebody your size!”—that Elmer the vice-slayer became
really Biblical.
Only the insistence of Bill Kingdom kept Lieutenant Gantry from
making his men load the erring one into the patrol wagon in her
chemise.
Then Elmer led them to a secret den where, it was securely
reported, men were ruining their bodies and souls by guzzling the
devil’s brew of alcohol.
VII
Mr. Oscar Hochlauf had been a saloon-keeper in the days before
prohibition, but when prohibition came, he was a saloon-keeper. A
very sound, old-fashioned, drowsy, agreeable resort was Oscar’s
Place; none of the grander public houses had more artistic soap
scrawls on the mirror behind the bar; none had spicier pickled
herring.
Tonight there were three men before the bar: Emil Fischer, the
carpenter, who had a mustache like an ear-muff; his son Ben, whom
Emil was training to drink wholesome beer instead of the whisky and
gin which America was forcing on the people; and old Daddy
Sorenson, the Swedish tailor.
They were discussing jazz.
“I came to America for liberty—I think Ben’s son will go back to
Germany for liberty,” said Emil. “When I was a young man here, four
of us used to play every Saturday evening—Bach we played, and
Brahms—Gott weiss we played terrible, but we liked it, and we never
made others listen. Now, wherever you go, this jazz, like a St.
Vitus’s. Jazz iss to music what this Reverend Gantry you read about
is to an old-time Prediger. I guess maybe he was never born, that
Gantry fellow—he was blowed out of a saxophone.”
“Aw, this country’s all right, Pa,” said Ben.
“Sure, dot’s right,” said Oscar Hochlauf contentedly, while he
sliced the foam off a glass of beer. “The Americans, like when I knew
dem first, when dere was Bill Nye and Eugene Field, dey used to
laugh. Now dey get solemn. When dey start laughing again, dey roar
dere heads off at fellows like Gantry and most all dese preachers dat
try to tell everybody how dey got to live. And if the people laugh—
oof!—God help the preachers!”
“Vell, that’s how it is. Say, did I tell you, Oscar,” said the Swedish
tailor, “my grandson Villiam, he got a scholarship in the university!”
“That’s fine!” they all agreed, slapping Daddy Sorenson on the
back . . . as a dozen policemen, followed by a large and gloomy
gentleman armed with a Bible, burst in through the front and back
doors, and the gloomy gentleman, pointing at the astounded Oscar,
bellowed, “Arrest that man and hold all these other fellows!”
To Oscar then, and to an audience increasing ten a second:
“I’ve got you! You’re the kind that teaches young boys to drink—
it’s you that start them on the road to every hellish vice, to gambling
and murder, with your hellish beverages, with your draught of the
devil himself!”
Arrested for the first time in his life, bewildered, broken, feebly
leaning on the arms of two policemen, Oscar Hochlauf straightened
at this, and screamed:
“Dot’s a damned lie! Always when you let me, I handle
Eitelbaum’s beer, the finest in the state, and since den I make my
own beer. It is good! It is honest! ‘Hellish beverage!’ Dot you should
judge of beer—dot a pig should judge poetry! Your Christ dot made
vine, he vould like my beer!”
Elmer jumped forward with his great fist doubled. Only the
sudden grip of the police sergeant kept him from striking down the
blasphemer. He shrieked, “Take that foul-mouthed bum to the
wagon! I’ll see he gets the limit!”
And Bill Kingdom murmured to himself, “Gallant preacher single-
handed faces saloon full of desperate gun-men and rebukes them
for taking the name of the Lord in vain. Oh, I’ll get a swell story. . . .
Then I think I’ll commit suicide.”
VIII
The attendant crowd and the policemen had whispered that, from
the careful way in which he followed instead of leading, it might be
judged that the Reverend Lieutenant Gantry was afraid of the sinister
criminals whom he was attacking. And it is true that Elmer had no
large fancy for revolver duels. But he had not lost his delight in
conflict; he was physically no coward; and they were all edified to
see this when the raiders dashed into the resort of Nick Spoletti.
Nick, who conducted a bar in a basement, had been a
prizefighter; he was cool and quick. He heard the crusaders coming
and shouted to his customers, “Beat it! Side door! I’ll hold ’em back!”
He met the first of the policemen at the bottom of the steps, and
dropped him with the crack of a bottle over his head. The next
tripped over the body, and the others halted, peering, looking
embarrassed, drawing revolvers. But Elmer smelled battle. He forgot
holiness. He dropped his Bible, thrust aside two policemen, and
swung on Nick from the bottom step. Nick slashed at his head, but
with a boxer’s jerk of the neck Elmer slid away from the punch, and
knocked out Nick with a deliberately murderous left.
“Golly, the parson’s got an awful wallop!” grunted the sergeant,
and Bill Kingdom sighed, “Not so bad!” and Elmer knew that he had
won . . . that he would be the hero of Zenith . . . that he was now the
Sir Lancelot as well as the William Jennings Bryan of the Methodist
Church.
IX
After two more raids he was delivered at his home by patrol
wagon, and left with not entirely sardonic cheers by the policemen.
Cleo rushed to meet him, crying, “Oh, you’re safe! Oh, my dear,
you’re hurt!”
His cheek was slightly bleeding.
In a passion of admiration for himself so hot that it extended even
to her, he clasped her, kissed her wetly, and roared, “It’s nothing! Oh,
it went great! We raided five places—arrested twenty-seven
criminals—took them in every sort of horrible debauchery—things I
never dreamed could exist!”
“You poor dear!”
There was not enough audience, with merely Cleo, and the maid
peering from the back of the hall.
“Let’s go and tell the kids. Maybe they’ll be proud of their dad!” he
interrupted her.
“Dear, they’re asleep—”
“Oh! I see! Sleep is more important to ’em than to know their
father is a man who isn’t afraid to back up his gospel with his very
life!”
“Oh, I didn’t mean—I meant—Yes, of course, you’re right. It’ll be
a wonderful example and inspiration. But let me put some stickum
plaster on your cheek first.”
By the time she had washed the cut, and bound it and fussed
over it, he had forgotten the children and their need of an heroic
exemplar, as she had expected, and he sat on the edge of the bath-
tub telling her that he was an entire Trojan army. She was so
worshipful that he became almost amorous, until it seemed to him
from her anxious patting of his arm that she was trying to make him
so. It angered him—that she, so unappealing, should have the
egotism to try to attract a man like himself. He went off to his own
room, wishing that Lulu were here to rejoice in his splendor, the
beginning of his fame as the up-to-date John Wesley.
CHAPTER XXVII
I
elmer, in court, got convictions of sixteen out of the twenty-
seven fiends whom he had arrested, with an extra six months for
Oscar Hochlauf for resisting arrest and the use of abusive and
profane language. The judge praised him; the mayor forgave him;
the chief of police shook his hand and invited him to use a police
squad at any time; and some of the younger reporters did not cover
their mouths with their hands.
Vice was ended in Zenith. It was thirty days before any of the gay
ladies were really back at work—though the gentlemanly jailers at
the workhouse did let some of them out for an occasional night.
Every Sunday evening now people were turned from the door of
Elmer’s church. If they did not always have a sermon about vice, at
least they enjoyed the saxophone solos, and singing “There’ll be a
Hot Time in the Old Town Tonight.” And once they were entertained
by a professional juggler who wore (it was Elmer’s own idea) a
placard proclaiming that he stood for “God’s Word” and who showed
how easy it was to pick up weights symbolically labeled “Sin” and
“Sorrow” and “Ignorance” and “Papistry.”
The trustees were discussing the erection of a new and much
larger church, a project for which Elmer himself had begun to
prepare a year before, by reminding the trustees how many new
apartment-houses were replacing the run-down residences in Old
Town.
The trustees raised his salary to five thousand, and they
increased the budget for institutional work. Elmer did not institute so
many clubs for students of chiropractic and the art of motion-picture
acting as did Dr. Otto Hickenlooper of Central Methodist, but there
was scarcely an hour from nine in the morning till ten at night when
some circle was not trying to do good to somebody . . . and even
after ten there were often Elmer and Lulu Bains Naylor, conferring on
cooking classes.
Elmer had seen the danger of his crusading publicity and his
Lively Sunday Evenings—the danger of being considered a clown
instead of a great moral leader.
“I’ve got to figure out some way so’s I keep dignified and yet keep
folks interested,” he meditated. “The thing is sort of to have other
people do the monkey-business, but me, I got to be up-stage and not
smile as much as I’ve been doing. And just when the poor chumps
think my Sunday evening is nothing but a vaudeville show, I’ll
suddenly soak ’em with a regular old-time hell-fire and damnation
sermon, or be poetic and that stuff.”
It worked, reasonably. Though many of his rival preachers in
Zenith went on calling him “clown” and “charlatan” and
“sensationalist,” no one could fail to appreciate his lofty soul and his
weighty scholarship, once they had seen him stand in agonized
silent prayer, then level his long forefinger and intone:
“You have laughed now. You have sung. You have been merry.
But what came ye forth into the wilderness for to see? Merely
laughter? I want you to stop a moment now and think just how long it
is since you have realized that any night death may demand your
souls, and that then, laughter or no laughter, unless you have found
the peace of God, unless you have accepted Christ Jesus as your
savior, you may with no chance of last-minute repentance be hurled
into horrible and shrieking and appalling eternal torture!”
Elmer had become so distinguished that the Rotary Club elected
him to membership with zeal.
The Rotary Club was an assemblage of accountants, tailors,
osteopaths, university-presidents, carpet-manufacturers, advertising
men, millinery-dealers, ice-dealers, piano salesmen, laundrymen,
and like leaders of public thought, who met weekly for the purposes
of lunching together, listening to addresses by visiting actors and by
lobbyists against the recognition of Russia, beholding vaudeville
teams in eccentric dances, and indulging in passionate rhapsodies
about Service and Business Ethics. They asserted that their one
desire in their several callings was not to make money but only to
serve and benefit a thing called the Public. They were as earnest
about this as was the Reverend Elmer Gantry about vice.
He was extraordinarily at home among the Rotarians; equally
happy in being a good fellow with such good fellows as these and in
making short speeches to the effect that “Jesus Christ would be a
Rotarian if he lived today—Lincoln would be a Rotarian today—
William McKinley would be a Rotarian today. All these men preached
the principles of Rotary: one for all and all for one; helpfulness
towards one’s community, and respect for God.”
It was a rule of this organization, which was merry and full of
greetings in between inspirational addresses, that every one should,
at lunch, be called by his first name. They shouted at the Reverend
Mr. Gantry as “Elmer” or “Elm,” while he called his haberdasher “Ike”
and beamed on his shoe-seller as “Rudy.” A few years before, this
intimacy might have led him into indiscretions, into speaking vulgarly,
or even desiring a drink. But he had learned his rôle of dignity now,
and though he observed, “Dandy day, Shorty!” he was quick to follow
it up unhesitatingly with an orotund “I trust that you have been able
to enjoy the beauty of the vernal foliage in the country this week.” So
Shorty and his pals went up and down informing the citizenry that
Reverend Gantry was a “good scout, a prince of a good fellow, but a
mighty deep thinker, and a real honest-to-God orator.”
When Elmer informed T. J. Rigg of the joys of Rotary, the lawyer
scratched his chin and suggested, “Fine. But look here, Brother
Elmer. There’s one thing you’re neglecting: the really big boys with
the long pockets. Got to know ’em. Not many of ’em Methodists—
they go out for Episcopalianism or Presbyterianism or
Congregationalism or Christian Science, or stay out of the church
altogether. But that’s no reason why we can’t turn their money
Methodist. You wouldn’t find but mighty few of these Rotarians in the
Tonawanda Country Club—into which I bought my way by
blackmailing, you might say, a wheat speculator.”
“But—but—why, T. J., those Rotarians—why there’s fellows in
there like Ira Runyon, the managing editor of the Advocate, and Win
Grant, the realtor—”
“Yeh, but the owner of the Advocate, and the banker that’s letting
Win Grant run on till he bankrupts, and the corporation counsel that
keeps ’em all out of jail, you don’t find those malefactors going to no
lunch club and yipping about Service! You find ’em sitting at small
tables at the old Union Club, and laughing themselves sick about
Service. And for golf, they go to Tonawanda. I couldn’t get you into
the Union Club. They wouldn’t have any preacher that talks about
vice—the kind of preacher that belongs to the Union talks about the
new model Cadillac and how hard it is to get genuwine Eye-talian
vermouth. But the Tonawanda—— They might let you in. For
respectability. To prove that they couldn’t have the gin they’ve got in
their lockers in their lockers.”
It was done, though it took six months and a deal of secret
politics conducted by T. J. Rigg.
Wellspring Church, including the pastor of Wellspring, bloomed
with pride that Elmer had been so elevated socially as to be allowed
to play golf with bankers.
Only he couldn’t play golf.
From April to July, while he never appeared on the links with
other players, Elmer took lessons from the Tonawanda professional,
three mornings a week, driving out in the smart new Buick which he
had bought and almost paid for.
The professional was a traditionally small and gnarled and sandy
Scotchman, from Indiana, and he was so traditionally rude that
Elmer put on meekness.
“Put back your divots! D’you think this is a church?” snapped the
professional.
“Damn it, I always forget, Scotty,” whined Elmer. “Guess it must
be hard on you to have to train these preachers.”
“Preachers is nothing to me, and millionaires is nothing to me, but
gawf grounds is a lot,” grunted Scotty. (He was a zealous
Presbyterian and to be picturesquely rude to Christian customers
was as hard for him as it was to keep up the Scotch accent which he
had learned from a real Liverpool Irishman.)
Elmer was strong, he was placid when he was out-of-doors, and
his eye was quick. When he first appeared publicly at Tonawanda, in
a foursome with T. J. Rigg and two most respectable doctors, he and
his game were watched and commended. When he dressed in the
locker-room and did not appear to note the square bottle in use ten
feet away, he was accepted as a man of the world.
William Dollinger Styles, member of the Tonawanda house
committee, president of the fabulous W. D. Styles Wholesale
Hardware Company—the man who had introduced the Bite Edge Ax
through all the land from Louisville to Detroit, and introduced white
knickers to the Tonawanda Club—this baron, this bishop, of business
actually introduced himself to Elmer and made him welcome.
“Glad to see you here, dominie. Played much golf?”
“No, I’ve only taken it up recently, but you bet I’m going to be a
real fan from now on.”
“That’s fine. Tell you how I feel about it, Reverend. We fellows
that have to stick to our desks and make decisions that guide the
common people, you religiously and me commercially, it’s a good
thing for us, and through us for them, to go out and get next to
Nature, and put ourselves in shape to tackle our complicated
problems (as I said recently in an after-dinner speech at the
Chamber of Commerce banquet) and keep a good sane outlook so’s
we won’t be swept away by every breeze of fickle and changing
public opinion and so inevitably—”
In fact, said Mr. William Dollinger Styles, he liked golf.
Elmer tenderly agreed with “Yes, that’s certainly a fact; certainly
is a fact. Be a good thing for a whole lot of preachers if they got out
and exercised more instead of always reading.”
“Yes, I wish you’d tell my dominie that—not that I go to church
such a whole lot, but I’m church treasurer and take kind of an
interest—Dorchester Congregational—Reverend Shallard.”
“Oh! Frank Shallard! Why, I knew him in theological seminary!
Fine, straight, intelligent fellow, Frank.”
“Well, yes, but I don’t like the way he’s always carrying on and
almost coming right out and defending a lot of these crooked labor
unions. That’s why I don’t hardly ever hear his sermons, but I can’t
get the deacons to see it. And as I say, be better for him if he got
outdoors more. Well, glad to met you, Reverend. You must join one
of our foursomes some day—if you can stand a little cussing,
maybe!”
“Well, I’ll try to, sir! Been mighty fine to have met you!”
“H’m!” reflected Elmer. “So Frank, the belly-aching highbrow, has
got as rich a man as Styles in his fold, and Styles doesn’t like him.
Wonder if Styles could turn Methodist—wonder if he could be
pinched off Frank? I’ll ask Rigg.”
But the charm of the place, the day, the implied social position,
was such that Elmer turned from these purely religious broodings to
more esthetic thoughts.
Rigg had driven home. Elmer sat by himself on the huge porch of
the Tonawanda Club, a long gray countryhouse on a hill sloping to
the Appleseed River, with tawny fields of barley among orchards on
the bank beyond. The golf-course was scattered with men in Harris
tweeds, girls in short skirts which fluttered about their legs. A man in
white flannels drove up in a Rolls-Royce roadster—the only one in
Zenith as yet—and Elmer felt ennobled by belonging to the same
club with a Rolls-Royce. On the lawn before the porch, men with
English-officer mustaches and pretty women in pale frocks were
taking tea at tables under striped garden-umbrellas.
Elmer knew none of them actually, but a few by sight.
“Golly, I’ll be right in with all these swells some day! Must work it
careful, and be snooty, and not try to pick ’em up too quick.”
A group of weighty-looking men of fifty, near him, were
conversing on the arts and public policy. As he listened, Elmer
decided, “Yep, Rigg was right. Those are fine fellows at the Rotary
Club; fine, high-class, educated gentlemen, and certainly raking in
the money; mighty cute in business but upholding the highest ideals.
But they haven’t got the class of these really Big Boys.”
Entranced, he gave heed to the magnates—a bond broker, a
mine-owner, a lawyer, a millionaire lumberman:
“Yes, sir, what the country at large doesn’t understand is that the
stabilization of sterling has a good effect on our trade with Britain—”
“I told them that far from refusing to recognize the rights of labor, I
had myself come up from the ranks, to some extent, and I was doing
all in my power to benefit them, but I certainly did refuse to listen to
the caterwauling of a lot of hired agitators from the so-called unions,
and that if they didn’t like the way I did things—”
“Yes, it opened at 73½, but knowing what had happened to
Saracen Common—”
“Yes, sir, you can depend on a Pierce-Arrow, you certainly can—”
Elmer drew a youthful, passionate, shuddering breath at being so
nearly in communion with the powers that governed Zenith and
thought for Zenith, that governed America and thought for it. He
longed to stay, but he had the task, unworthy of his powers of social
decoration, of preparing a short clever talk on missions among the
Digger Indians.
As he drove home he rejoiced, “Some day I’ll be able to put it
over with the best of ’em socially. When I get to be a bishop, believe
me I’m not going to hang around jawing about Sunday School
methods! I’ll be entertaining the bon ton, senators and
everybody. . . . Cleo would look fine at a big dinner, with the right
dress. . . . If she wasn’t so darn’ priggish. Oh, maybe she’ll die
before then. . . . I think I’ll marry an Episcopalian. . . . I wonder if I
could get an Episcopal bishopric if I switched to that nightshirt
crowd? More class. No; Methodist bigger church; and don’t guess
the Episcopalopians would stand any good red-blooded sermons on
vice and all that.”
II
The Gilfeather Chautauqua Corporation, which conducts week-
long Chautauquas in small towns, had not been interested when
Elmer had hinted, three years ago, that he had a Message to the
Youth of America, one worth at least a hundred a week, and that he
would be glad to go right out to the Youth and deliver it. But when
Elmer’s demolition of all vice in Zenith had made him celebrated, and
even gained him a paragraph or two as the Crusading Parson, in
New York and Chicago, the Gilfeather Corporation had a new
appreciation. They came to him, besieged him, offered him two
hundred a week and headlines in the posters, for a three-months
tour.
But Elmer did not want to ask the trustees for a three-months
leave. He had a notion of a summer in Europe a year or two from
now. That extended study of European culture, first hand, would be
just the finishing polish to enable him to hold any pulpit in the
country.
He did, however, fill in during late August and early September as
substitute for a Gilfeather headliner—the renowned J. Thurston
Wallett, M. D., D. O., D. N., who had delighted thousands with his
witty and instructive lecture, “Diet or Die, Nature or Nix,” until he had
unfortunately been taken ill at Powassie, Iowa, from eating too many
green cantaloupes.
Elmer had planned to spend August with his family in Northern
Michigan—planned it most uncomfortably, for while it was
conceivable to endure Cleo in the city, with his work, his clubs, and
Lulu, a month with no relief from her solemn drooping face and cry-
baby voice would be trying even to a Professional Good Man.
He explained to her that duty called, and departed with speed,
stopping only long enough to get several books of inspirational
essays from the public library for aid in preparing his Chautauqua
lecture.
He was delighted with his coming adventure—money, fame in
new quarters, crowds for whom he would not have to think up fresh
personal experiences. And he might find a woman friend who would
understand him and give to his own solid genius that lighter touch of
the feminine. He was, he admitted, almost as tired of Lulu as of Cleo.
He pictured a Chautauqua lady pianist or soprano or ventriloquist or
soloist on the musical saw—he pictured a surprised, thrilled meeting
in the amber light under the canvas roof—recognition between
kindred fine and lonely souls—
And he found it of course.
III
Elmer’s metaphysical lecture, entitled “Whoa Up, Youth!” with its
counsel about abstinence, chastity, industry, and honesty, its
heaven-vaulting poetic passage about Love (the only bow on life’s
dark cloud, the morning and the evening star), and its anecdote of
his fight to save a college-mate named Jim from drink and atheism,
became one of the classics among Chautauqua masterpieces.
And Elmer better than any one else among the Talent (except
perhaps the gentleman who played national anthems on water
glasses, a Lettish gentleman innocent of English) sidestepped on the
question of the K. K. K.
The new Ku Klux Klan, an organization of the fathers, younger
brothers, and employees of the men who had succeeded and
became Rotarians, had just become a political difficulty. Many of the
most worthy Methodist and Baptist clergymen supported it and were
supported by it; and personally Elmer admired its principle—to keep
all foreigners, Jews, Catholics, and negroes in their place, which was
no place at all, and let the country be led by native Protestants, like
Elmer Gantry.
But he perceived that in the cities there were prominent people,
nice people, rich people, even among the Methodists and Baptists,
who felt that a man could be a Jew and still an American citizen. It
seemed to him more truly American, also a lot safer, to avoid the
problem. So everywhere he took a message of reconciliation to the
effect:
“Regarding religious, political, and social organizations, I defend
the right of every man in our free America to organize with his
fellows when and as he pleases, for any purpose he pleases, but I
also defend the right of any other free American citizen to demand
that such an organization shall not dictate his mode of thought or, so
long as it be moral, his mode of conduct.”
That pleased both the K. K. K. and the opponents of the K. K. K.,
and everybody admired Elmer’s powers of thought.
He came with a boom and a flash to the town of Blackfoot Creek,
Indiana, and there the local committee permitted the Methodist
minister, one Andrew Pengilly, to entertain his renowned brother
priest.