Ebook Textbook of endodontology (3/E): Part 1

Textbook of Endodontology



Textbook of Endodontology
Third Edition
Edited by
Lars Bjørndal
Associate Professor, Section of Cariology and Endodontics
Department of Odontology, Faculty of Health and Medical Sciences
University of Copenhagen, Copenhagen, Denmark

Lise-Lotte Kirkevang
Associate Professor, Department of Dentistry and Oral Health
Aarhus University, Aarhus, Denmark
Professor of Endodontics, Institute of Clinical Dentistry, Faculty of Dentistry
University of Oslo, Oslo, Norway

John Whitworth
Professor of Endodontology/Consultant in Restorative Dentistry
School of Dental Sciences, Newcastle University/Newcastle Hospitals NHS Foundation Trust
Newcastle, UK


This edition first published 2018 © 2018 John Wiley & Sons Ltd
Edition History
Blackwell Munksgaard (1e, 2003); Blackwell Publishing Ltd (2e, 2010)
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authors of the editorial material in this work has been asserted in accordance with law.
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Library of Congress Cataloging-in-Publication Data
Names: Bjørndal, Lars, 1963- editor. | Kirkevang, Lise-Lotte, 1970- editor. |

Whitworth, John M., editor.
Title: Textbook of endodontology / edited by Lars Bjørndal, Lise-Lotte Kirkevang,
John Whitworth.
Other titles: Textbook of endodontology (Bergenholtz)
Description: Third edition. | Hoboken, NJ : Wiley, 2018. | Preceded by
Textbook of endodontology / edited by Gunnar Bergenholtz, Preben
Hørsted-Bindslev, Claes Reit. 2nd ed. 2010. | Includes bibliographical
references and index. |
Identifiers: LCCN 2018000530 (print) | LCCN 2018001339 (ebook) |
ISBN 9781119057321 (pdf) | ISBN 9781119057369 (epub) | ISBN 9781119057314 (hardback)
Subjects: | MESH: Dental Pulp Diseases–therapy | Periapical Diseases–therapy
Classification: LCC RK351 (ebook) | LCC RK351 (print) | NLM WU 230 | DDC 617.6/342–dc23
LC record available at />Cover images: © Lars Bjørndal
Cover design by Wiley
Set in 9.5/12pt PalatinoLTStd by Aptara Inc., New Delhi, India
10 9 8 7 6 5 4 3 2 1


Contents
List of contributors
Foreword
Preface
About the companion website
1

Introduction to endodontology
John Whitworth, Lise-Lotte Kirkevang, and Lars Bjørndal

1

Endodontology
The objective of endodontic treatment
Clinical problems and solutions
The diagnostic dilemma
The outcome dilemma
The tools of treatment
References

1
2
2
6
6
6
7

Part 1
2

The Vital Pulp

The dentin–pulp complex: structure, functions, threats, and response to external injury
Lars Bjørndal and Alastair J. Sloan
Introduction
The odontoblast and the dentin–pulp complex
The dental pulp
Immune responses in the dentin–pulp complex
Responses of the healthy dentin–pulp complex to nondestructive stimuli
The dentin–pulp complex and responses to external injuries
Summary

References

3

Dentinal and pulpal pain
Inge Fristad and Matti N¨arhi
Introduction
Classification of nerve fibers
Morphology of intradental sensory innervation
Function of intradental sensory nerves
Sensitivity of dentin: hydrodynamic mechanism in pulpal A-fiber activation
Responses of intradental nerves to tissue injury and inflammation
Local control of pulpal nociceptor activation
Dentin hypersensitivity
Pain symptoms and pulpal diagnosis
References

4

xiii
xvii
xix
xxi

Clinical pulp diagnosis and decision-making
Kerstin Petersson and Claes Reit
Introduction
Evaluation of diagnostic information

11

11
11
17
22
25
25
29
29
33
33
33
33
36
38
40
44
44
45
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49

v


vi

Contents

Diagnostic accuracy
Diagnostic strategy
Clinical manifestations of pulpal and periapical inflammation
Collecting diagnostic information
Diagnostic methodology: assessment of pulp vitality
Diagnostic methodology: evaluation of reported pain
Diagnostic methodology: provocation/inhibition of pain
Diagnostic methodology: evaluation of tooth discolorations
Diagnostic classification
References
5

Caries pathology and management in deep stages of lesion formation
Lars Bjørndal
Enamel lesions without clinical cavitation
Progressive stages of enamel–dentin lesions without surface cavitation and exposure of dentin
to the oral environment
Cavitation of the dentin lesion
Concluding remarks on the natural history of dental caries
Strategies for the management of deep caries
Detailed treatment protocol for deep caries management
References

6

Treatment of vital pulp conditions
Lars Bjørndal, Helena Fransson, and St´ephane Simon
Introduction
Indications and treatment concepts for preserving vital pulp functions
Protocols for treatments aiming to preserve the vitality of the exposed pulp

Factors of importance in preserving vital pulp functions
Capping materials and healing patterns
Tissue–biomaterial interaction and pulp healing
Pulp-preserving treatments – a controversial treatment?
Indications and treatment concepts for treating the irreversibly inflamed vital pulp
(pulpectomy)
Postoperative considerations
Choosing between pulp-preserving vital pulp therapies and pulpectomy
Concluding remarks on the avoidance of pulpectomy by vital pulp therapies
Revitalization and/or regenerative endodontic procedures
References

Part 2
7

50
51
51
52
53
55
56
58
58
59
61
63
65
67
72

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79
79
80
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87
89
91
92
93
96
96
97
97
98

The Infected Necrotic Pulp and Apical Periodontitis

Apical periodontitis
Zvi Metzger, Anda Kfir, and Itzhak Abramovitz
Introduction
The nature of apical periodontitis
Interactions with the infecting microbiota
Treatment and healing of periapical lesions
Persistence of periapical lesions
Clinical manifestations and diagnostic terminology
References

103
103
103
107
114
115
117
119


Contents

8

Microbiology of the inflamed and necrotic pulp
Luis E. Ch´avez de Paz
Introduction
Historical background
Clinical evidence
Infections in root-filled teeth with persistent apical periodontitis
Microbial pathogenesis of apical periodontitis
Association of signs and symptoms with specific bacteria
Biological evidence
Extraradicular biofilms
Ecological determinants for microbial growth in root canals
Microbial interactions in biofilms
Microbial resistance to antimicrobials
Antibiofilm strategies
Concluding remarks
References

9

Clinical diagnosis of pulp necrosis and apical periodontitis
Dag Ørstavik
Introduction
Clinical features of pulp necrosis and root canal infections
Radiographic features of apical periodontitis
A strategy for the formulation of a periapical diagnosis
Diagnostic challenges during treatment
Special cases of endodontic infections
An integrated approach to endodontic diagnosis
References

Part 3
10

123
123
123
124
126
128
129
131
133
134
134
136
137

138
138
143
143
144
147
153
153
154
162
165

Endodontic Treatment Procedures

Endodontic emergencies
Peter Jonasson, Maria Pigg, and Lars Bjørndal
Introduction
General diagnostic considerations and emergency principles
The etiology and pathogenesis behind emergency scenarios
Non-endodontic tooth pain – conditions of differential diagnostic interest
Management of patients with acute dental pain
References

11

vii

Controlling the environment – the aseptic working field
Merete Markvart and Pia Titterud Sunde
Background

Preparing teeth for rubber dam isolation and the development of an aseptic
working field
Rubber dam isolation
Application of the rubber dam
Disinfection of the working field
Aseptic working procedures
References

171
171
171
171
181
182
183
185
185
186
187
189
189
190
192


viii

12

Contents

Access and canal negotiation: the first key procedural steps for successful endodontic treatment
Ove A. Peters and Ana Arias
Introduction
Principles of tooth development and tooth anatomy
Individual analysis of the tooth, preoperative radiographs, and additional CBCT scans in
complex cases
Rubber dam isolation
Access cavity preparation
Canal negotiation
References

13

Root canal instrumentation
Lars Bergmans and Paul Lambrechts
Introduction
Principles of root canal instrumentation
Root canal system anatomy
Anatomical variations in teeth
Procedural steps
Endodontic instruments
Instrumentation techniques
Limitations of root canal instrumentation
Preventing procedural mishaps
References

14

Irrigation and disinfection

Markus Haapasalo and Ya Shen
Introduction
Eradication of microorganisms from the root canal system
Microbial reduction by instrumentation
Root canal irrigation
The apical root canal – a special challenge for irrigation
Activation of irrigant flow
Use of lasers in irrigation
Wide-spectrum sound energy for cleaning the root canal system
Intracanal medicaments
Concluding remarks
References

195
195
195
196
196
197
202
203
205
205
205
206
211
213
217
221
223

225
228
231
231
231
232
232
236
237
238
239
240
241
241

15

Root canal filling

247

15.1

Root canal filling materials
Gottfried Schmalz and Birger Thonemann

248

Introduction
Requirements

Evaluation of specific materials
References

248
249
253
272

15.2

Root canal filling techniques
Amir-Taymour Moinzadeh and Hagay Shemesh
Introduction
Clinical objectives and in vitro investigations
The root canal filling–dentin interface
Root canal filling techniques
Concluding remarks
References

277
277
277
277
281
289
289


Contents

Part 4
16

The Endodontically Treated Tooth

The root canal-treated tooth in prosthodontic reconstruction
Kishor Gulabivala and Yuan-Ling Ng
Introduction
Fracture predilection of root-treated teeth
Occlusal loading
Root canal-treated teeth as abutments
Distribution of remaining tooth structure and restorability
Principles of restoration of root-treated teeth
Timing of restoration after endodontic treatment
Approach to restoration of anterior teeth
Characteristics of posts
Preparation of the post space
Approach to restoration of posterior teeth
Core materials
Modes of restoration failure in root canal-treated teeth
Conclusions
References

17

Clinical epidemiology: measuring endodontic disease and treatment outcome
Lise-Lotte Kirkevang
Introduction
Defining a “successful” outcome
Study designs commonly used in endodontic research

Treatment outcome and risk factors
Concluding remarks
References

18

19

20

ix

295
295
295
298
299
299
300
301
302
303
307
308
310
310
311
312
315
315

315
317
319
323
323

Endodontic retreatment – the decision-making process
Frank Setzer and Bekir Karabucak

327

Introduction
Why might the initial treatment be unsuccessful?
When may further intervention be considered?
Decision-making – the dentist’s perspective
Decision-making – the patient’s perspective
References

327
327
329
330
338
339

Nonsurgical retreatment
Thomas Kvist and Luc van der Sluis

343

Introduction
Indications
Instrumentation of the root canal
Prognosis
Summary
References

343
343
350
357
357
358

Surgical endodontics
Lise-Lotte Kirkevang, Vibe Rud, and Thomas Kvist

361

Introduction
General outline of the procedure
Local anesthesia
Flap design, incision, and raising the flap – general considerations

361
361
363
363

x

Contents

Access to the root tip
Root-end resection
Curettage of the soft-tissue lesion
Management of bleeding
Root-end preparation
Root-end filling
Repositioning and suturing of the flap
Postoperative measures
Follow-up after surgery
References

Part 5
21

Additional Considerations

Local anesthetic considerations
Nigel Foot and John Whitworth
Introduction
Fundamentals of local anesthetic action
Common local anesthetic agents in endodontics
Standard methods of local anesthesia for endodontics
Failure to secure anesthesia
Why may teeth be difficult to anesthetize?
Measures to preempt or overcome challenging local anesthesia
Supplementary injections

Sedation
Complications of local anesthesia
References

22

Complex orofacial pain conditions
Lene Baad-Hansen and Peter Svensson
Introduction
Overview of pain mechanisms
Diagnostic process
Complex orofacial pain conditions
Painful posttraumatic trigeminal neuropathy
Persistent idiopathic facial pain
Atypical odontalgia/persistent dentoalveolar pain
Trigeminal neuralgia
Trigeminal autonomic cephalalgias
Migraine/neurovascular orofacial pain
Temporomandibular disorder pain – referred pain
Summary
References

23

368
369
369
370
371
372

373
374
375
376

Endodontic complications after trauma
John Whitworth
Introduction
Common dental injuries
Dental trauma and its consequences
Consequences of pulp breakdown and infection after trauma
General considerations in the management of dental trauma
Diagnostic quandaries: to remove or review the pulp after trauma?
References

381
381
381
382
383
385
386
387
388
390
391
392
393
393
393

395
397
397
398
399
399
401
401
401
402
402
405
405
405
405
411
416
422
424


Contents

24

Medicolegal considerations
Lars Bjørndal, Shiv Pabary, and John Whitworth
Introduction
Ethical considerations – the concepts of beneficence and nonmaleficence
Defining best practice

Endodontic procedures as complex interventions with scope for imperfection,
oversight and error
Examples of errors and accidents
Do errors always lead to legal action?
Professional indemnity/malpractice insurance
Managing risks
Conclusion
References

25

Emergencies in need of urgent referral
Tara Renton
Introduction
Neurological injuries resulting from endodontic procedures and materials
Neurological injuries resulting from periapical inflammation
Chemical tissue trauma
Severe odontogenic infections that may compromise systemic health
Suspicion of locally aggressive or neoplastic lesions
Severe or persistent pain
Inhalation or aspiration of dental instruments or materials
Allergic responses that may compromise systemic health
Reporting adverse events
Summary
References

26

The transition to independent practice
Peter Musaeus

Introduction
The challenge of transition
Learning: explanations and strategies
Conclusion
Acknowledgment
References
Index

xi

427
427
427
427
428
428
430
430
431
433
434
435
435
435
440
441
443
444
445
445

445
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446
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451
451
452
454
460
461
461
463



List of contributors
Editors
Lars Bjørndal

Section of Cariology and Endodontics, Department of Odontology, Faculty of Health and
Medical Sciences, University of Copenhagen, Copenhagen, Denmark

Lise-Lotte Kirkevang

Department of Dentistry and Oral Health, Aarhus University, Aarhus, Denmark
Department of Endodontics, Institute of Clinical Dentistry, Faculty of Dentistry,
University of Oslo, Oslo, Norway

John Whitworth

School of Dental Sciences, Newcastle University/Newcastle Hospitals NHS Foundation
Trust, Newcastle, UK

Contributors
Itzhak Abramovitz

Department of Endodontics, The Hebrew University and Hadassah Faculty of Dental
Medicine, Jerusalem, Israel

Ana Arias

Department of Conservative Dentistry, School of Dentistry, Complutense University,
Madrid, Spain

Lene Baad-Hansen

Section of Orofacial Pain and Jaw Function, Department of Dentistry and Oral Health,
Aarhus University, Aarhus, Denmark
Scandinavian Center for Orofacial Neurosciences (SCON)

Lars Bergmans

Leuven BIOMAT Research Cluster, Department of Oral Health Sciences, Section
Endodontics, KU Leuven, Leuven, Belgium

Luis E. Ch´avez de Paz

Endodontics, Department of Dental Medicine, Karolinska Institute, Huddinge, Sweden

Nigel Foot

The Briars Dental Centre, Newbury, UK
Eastman Dental Institute, University College, London, UK

Helena Fransson

¨ Sweden
Department of Endodontics, Faculty of Odontology, Malmo¨ University, Malmo,

Inge Fristad

Department of Clinical Dentistry, Endodontics, Faculty of Medicine and Dentistry,
University of Bergen, Bergen, Norway

Kishor Gulabivala

Unit of Endodontology, Department of Restorative Dental Sciences, Eastman Dental
Institute, Faculty of Medical Sciences, University College London, UK

Markus Haapasalo

Division of Endodontics, University of British Columbia Faculty of Dentistry, Vancouver,
Canada

Peter Jonasson

Department of Endodontology, Institute of Odontology, The Sahlgrenska Academy,
University of Gothenburg, Gothenburg, Sweden

xiii

xiv

List of contributors

Bekir Karabucak

Department of Endodontics, University of Pennsylvania School of Dental Medicine,
Philadelphia, PA, USA

Anda Kfir

Department of Endodontology, The Goldschleger School of Dental Medicine, Tel Aviv
University, Tel Aviv, Israel

Thomas Kvist

Department of Endodontology, Institute of Odontology at The Sahlgrenska Academy,
University of Gothenburg, Gothenburg, Sweden

Paul Lambrechts

Leuven BIOMAT Research Cluster, Department of Oral Health Sciences, Section
Endodontics, KU Leuven, Leuven, Belgium

Merete Markvart

Section of Cariology and Endodontics, Department of Odontology, Faculty of Health and
Medical Sciences, University of Copenhagen, Copenhagen, Denmark

Zvi Metzger

Department of Endodontology, The Goldschleger School of Dental Medicine, Tel Aviv
University, Tel Aviv, Israel

Amir-Taymour
Moinzadeh

Department of Endodontology, Academic Center for Dentistry Amsterdam (ACTA),
University of Amsterdam and VU University, Amsterdam, The Netherlands

Peter Musaeus

Center for Health Sciences Education (CESU), Aarhus University, Aarhus, Denmark

Matti N¨arhi

Oral Physiology, University of Eastern Finland, Department of Dentistry and Biomedicine,
Kuopio, Finland

Yuan-Ling Ng

Unit of Endodontology, Department of Restorative Dental Sciences, Eastman Dental
Institute, Faculty of Medical Sciences, University College London, UK

Dag Ørstavik

Department of Endodontics, Institute of Clinical Dentistry, Faculty of Dentistry, University
of Oslo, Oslo, Norway

Shiv Pabary

InDental Practice, Gateshead, UK
School of Dental Sciences, Newcastle University, Newcastle, UK
Postgraduate Medico-Legal Tutor, Health Education England North East

Ove A. Peters

Department of Endodontics, University of the Pacific, Arthur A. Dugoni School of
Dentistry, San Francisco, CA, USA

Kerstin Petersson

¨ Sweden
Department of Endodontics, Faculty of Odontology, Malmo¨ University, Malmo,

Maria Pigg

¨ Sweden
Department of Endodontics, Faculty of Odontology, Malmo¨ University, Malmo,

Claes Reit

Department of Endodontology, Institute of Odontology at The Sahlgrenska Academy,
University of Gothenburg, Gothenburg, Sweden

Tara Renton

Oral Surgery, King’s College London, London, UK

Vibe Rud

Private Practice, Clinic for Surgery and Endodontics, Copenhagen, Denmark

Gottfried Schmalz

Department of Conservative Dentistry and Periodontology, University of Regensburg,
Regensburg, Germany
Department of Periodontology, University of Bern, Bern, Switzerland


List of contributors

xv

Frank Setzer

Department of Endodontics, University of Pennsylvania School of Dental Medicine,
Philadelphia, PA, USA

Hagay Shemesh

Department of Endodontology, Academic Center for Dentistry Amsterdam (ACTA),
University of Amsterdam and VU University, Amsterdam, The Netherlands

Ya Shen

Division of Endodontics, University of British Columbia Faculty of Dentistry, Vancouver,
Canada

St´ephane Simon

School of Dentistry, Universit´e de Paris Diderot, Paris, France

Alastair J. Sloan

Cardiff Institute for Tissue Engineering & Repair, Oral and Biomedical Sciences, School of
Dentistry, College of Biomedical and Life Sciences, Cardiff, Wales, UK

Luc van der Sluis

Center of Dentistry and Oral Hygiene, University Medical Center Groningen, University of
Groningen, Groningen, The Netherlands

Pia Titterud Sunde

Department of Endodontics, Institute of Clinical Dentistry, Faculty of Dentistry, University
of Oslo, Oslo, Norway

Peter Svensson

Section of Orofacial Pain and Jaw Function, Department of Dentistry and Oral Health,
Aarhus University, Aarhus, Denmark
Scandinavian Center for Orofacial Neurosciences (SCON)
Department of Dental Medicine, Karolinska Institute, Huddinge, Sweden

Birger Thonemann

¨

Private Practice, Dusseldorf,
Germany
Department of Conservative Dentistry and Periodontology, University of Regensburg,
Regensburg, Germany



Foreword
With appreciation we, the prior editors, want to congratulate the new editors, Drs Lars Bjørndal, Lise-Lotte
Kirkevang, and John Whitworth for their hard work
and well-mannered effort in conducting the revision of
Textbook of Endodontology. By attracting both old and
new authors the latest developments in the biology,
diagnosis, and treatment of endodontic conditions are
now available. While the basic concepts and structure of the previous two editions have been retained
in terms of the Core concept, Clinical procedure and
Advanced concept text boxes, descriptions of key literature, and extensive references, several new chapters
have been commissioned and prior chapters have been
thoroughly reviewed. Overall the book gives the reader
a broad perspective on the endodontic field. All authors
originate from Europe and its neighboring countries,

including Turkey and Israel, even though some of them
have their professional sites in the United States. In
essence many of the chapters have authors from a new
generation of endodontists and they have all provided
text that is well worth studying. Therefore, we believe
that the time spent on each chapter will be very valuable. For undergraduate and postgraduate students in
particular this book provides a rich source for learning
that will show what the discipline of endodontology can

do today to preserve the original dentition.

Gunnar Bergenholtz
Preben Hørsted-Bindslev
Claes Reit
April 2018

xvii



Preface
A decade has passed since the second edition of Textbook of Endodontology, and its founding editors, Gunnar
Bergenholtz, Preben Hørsted-Bindslev, and Claes Reit,
deserve our unreserved thanks for their legacy to the
endodontic community. It is with the greatest respect,
humility, and some degree of awe that a new editorial
team steps into their shoes, to fan the flames and bring
this new edition to life.
Much has developed and changed in the last 10 years,
but core principles remain unchanged. We remain committed to the educational needs of undergraduate and
postgraduate dental students and general practitioners who wish to update their knowledge of contemporary endodontic research and practice. The third edition
remains true to the textbook’s founding principles, providing information on the biological processes of pulpal and periapical disease and how this influences clinical decision-making and practice. New line drawings
and clinical images are included and we have retained
core concept, advanced concept, clinical procedure, and
key literature boxes for ease of assimilation. We hope the
individual chapters work well together, and have signposted readers to related chapters where this may be
helpful.
Many of the original authors were enthusiastic to
revise and update their well-received chapters and we

are grateful to those who allowed the updating of their
previous work as part of a comprehensive revision. New
for this edition are distinctive chapters on local anesthesia, asepsis, access and canal negotiation, irrigation

and disinfection, emergency management, and medicolegal considerations. Aspects of diagnosis, deep caries
management, decision-making for endodontic retreatment, orofacial pain, and clinical epidemiology also
receive greater emphasis. A final chapter provides helpful insights on the pressures facing young dentists as
they transition from dental school to independent practice and strive to remain true to core principles of training. Readers may also find single best answer questions
useful to gauge their knowledge and understanding.
We are extremely grateful to all contributing authors,
and to their long-suffering partners and families who
have supported them through the writing and editorial
process. Furthermore, we wish to express our sincere
gratitude to the entire team from Wiley, and in particular special editing and project manager Dr. Nik Prowse,
who has supported us during the process. Thank you all
very much.
As global sales of paper books once again exceed
those of electronic versions, we hope this traditional text
will provide readers with an attractive, user-friendly,
and informative resource. This project is very much
alive and we welcome the observations and constructive feedback of students and colleagues on this third
edition.
Lars Bjørndal
Lise-Lotte Kirkevang
John Whitworth
January 2018

xix

About the companion website
This book is accompanied by a companion website:
www.wiley.com/go/bjorndal/endodontology
The website includes:

r

Interactive multiple-choice questions

xxi



Chapter 1

Introduction to endodontology
John Whitworth, Lise-Lotte Kirkevang, and Lars Bjørndal

Endodontology
The word “endodontology” derives from the Greek language and can be translated as “the knowledge of what
is inside the tooth.” Thus, endodontology concerns all
structures and processes within the tooth, with particular reference to the dental pulp and the space it occupies.
But what about “knowledge”? What does it actually
mean to “know” things? Most people would probably
say that knowledge has something to do with truth
and being able to provide reasons for things. It is often
believed that dental and medical knowledge is simply
scientific knowledge – truth that is supported by scientific research to provide reasons for disease processes
and justification for clinical actions. But as practicing

dentists, scientific knowledge is not always sufficient,
and although it is important to know about the anatomy
of the pulp space and the fatigue failure of engine-driven
endodontic files, we must also develop sound judgment
and the ability to make correct clinical decisions, often
in the face of uncertainty. The knowledge required by
dental practitioners is therefore complex and multidimensional and can be considered within Aristotle’s
domains of “episteme,” “techne,” and “phronesis” [1].

Episteme
Episteme is the word for theoretical, scientifically supported knowledge, the opposite being doxa, which
refers to common beliefs or opinions that may not be
so grounded in “hard” evidence. The body of epistemic
knowledge in endodontology is enormous, spanning
from fundamental pulp biology to the clinical risk
factors associated with root canal treatment failure.
The knowledge generated by science, however, is often
less certain than we would wish, and subject to the
weakness of study design, the bias of conflicting interests, and a lack of obvious translation to the realities of

“wet-fingered” dentistry. Nevertheless, efforts are made
to present scientific knowledge in a balanced way
through lectures, articles, and textbooks, so from a
student’s point of view, learning requires ample time for
reading and opportunities for discussion and reflection.
This book, in large part, is composed of epistemic
knowledge.

Techne
A substantial element of learning endodontology must

be characterized as techne, or “knowing how,” which
embraces elements of practical skill, craft, and artistry.
It is not always possible to explain every detail of how
we perform technical acts, such as negotiating a challenging root canal with delicate tactile sense or riding a
bicycle around a corner without falling off. In this way,
it is not sufficient to teach students how to shape a root
canal solely by asking them to read a book or attend a
lecture. Their knowledge must be supplemented with
practical experiences, both observing and doing, and by
discussion and personal reflection to understand the
challenges they encounter, develop cognitive and practical strategies to overcome them, and to help them do
better next time.
It is not possible to learn all about the procedures
in endodontology by studying a textbook. Observing a
good clinical instructor, watching other dentists at work,
performing the procedures oneself, and reflecting on
what has been learnt are all important. The preclinical simulation laboratory provides an essential environment in which to embed new factual knowledge and
translate it into practical reality.

Phronesis
According to Aristotle, phronesis is the ability to think
about practical matters and then acquire the ability to act

Textbook of Endodontology, Third Edition. Edited by Lars Bjørndal, Lise-Lotte Kirkevang, and John Whitworth.
© 2018 John Wiley & Sons Ltd. Published 2018 by John Wiley & Sons Ltd.
Companion Website: www.wiley.com/go/bjorndal/endodontology

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