0099-2399/92/1812-0625/$03.

00/0 JOURNAL OF ENDOOONTICS Copyright 1992 by The American Association of Endodontists

VOL. 18, NO. 12, DECEMBER1992

Printed in U.S.A.

CLINICAL ARTICLE Factors Associated with Endodontic Treatment Failures

Louis M. Lin, BDS, DMD, PhD, Joseph E. Skribner, DDS, and Peter Gaengler, DDS, PhD

Two hundred and thirty-six cases of endodontic treatment failures, none of which had advanced periodontal disease, postperforations, or root or crown fractures were analyzed clinically, radiographically, and histobacteriologically to determine the major factor(s) for treatment failures. It was found that there was a correlation between bacterial infection in the canal system and the presence of periradicular rarefaction in endodontic failures. This report provides evidence indicating that the major factors associated with endodontic failures are the persistence of bacterial infection in the canal space and/or the periradicular area and the presence of preoperative periradicular rarefaction. The apical extent of root canal fillings, i.e underfiUed, flushfilled, or overfilled, seems to have no correlation to treatment failures.

graphic findings, clinical signs, and/or symptoms and the histobacteriological findings in endodontic treatment failures (2, 9, 10). The purpose of this report was to examine the relationship between the apical extent of root canal fillings, the preoperative status of periradicular areas, and the histobacteriological finding in endodontically treated teeth which have failed. MATERIALS AND M E T H O D S This report consisted of 236 cases of endodontic treatment failures from our previous studies (9, 10), none of which had advanced periodontal disease, postperforations, or root or crown fractures. The samples were obtained from biopsies during endodontic surgery. They were routinely processed for histopathological examination. Serial sections of 6 um were cut and stained with hematoxylin and eosin and modified Brown and Brenn. Stained bacteria were identified only when they appeared as groups of colonies in the severely inflamed or necrosed tissue. The radiographic diagnosis of preoperative periradicular status (rarefaction or nonrarefaction), the radiographic apical extent of root canal fillings (underfilled, flushfilled, and overfilled), and the histobacteriological findings of biopsied samples were recorded and correlated. Strindberg's (3) classification of radiographic periradicular status and apical extent of root canal fillings was used. The collected data were subjected to statistical analysis using the chi-square test. RESULTS Of 236 cases of endodontic failures, 83 cases were underfilled, 74 flush filled, and 79 overfilled (Table 1). Histobacteriological examination of biopsied specimens revealed that stainable bacteria were present in 157 (67%) cases. Of these, 55 cases were underfilled, 48 flush filled, and 54 overfilled (Table 2). There was no statistical difference in the frequency of stainable bacteria present among these three groups. When the preoperative periradicular status was correlated with the apical extent of root canal fillings, those cases associated with periradicular rarefaction (71%) had a significantly higher failure rate than those without (29%), whether the teeth were

The key to successful endodontic treatment is to thoroughly debride the canal system of infected or necrotic pulp tissue and microorganisms, and to completely seal the canal space, thus preventing the persistence of infection and/or reinfection of the pulp cavity. Clinically, failure of endodontic treatment is determined on the basis of radiographic findings and clinical signs and/or symptoms of the treated teeth. Numerous factors have been said to contribute to endodontic treatment failures. These include positive cultures (1), residual necrotic pulp tissue (2), broken instruments (3), root canal overfillings (13), mechanical perforations (4), root fractures (5), presence of periradicular lesions (1, 3), and peridontal disease (6). Radiographically, overfilled teeth have consistently been shown to have a less favorable prognosis than underfilled or flush-filled teeth (1-3). When teeth are overfilled, the toxic filling materials may cause necrosis of cementum, periodontal ligament, and alveolar bone (7, 8). An overhelming number of studies have also reported that endodontic treatment failures are greater in teeth that are associated with pretreatment periradicular rarefactions than in teeth without pretreatment rarefaction (1, 3). There are very few studies to correlate the radio-

625

626

Lin et al.

Journal of Endodontics

TABLE 1. Apical extent of root canal fillings in 236 cases of endodontic treatment failure

Apical Extent of Root Canal Fillings" Underfilled Flushfilled Overfilled

No. of Teeth (n = 236) 83 74 79

Underfilled, canal filled more than 1 mm short of radiographic apex; flush filled, canal filled to radiographic apex, or 1 mm short or beyond radiographic apex; and overfilled, canal filled more than 1 mm beyond radiographic apex,

TABLE 2. Relationship between apical extent of root canal fillings and histobacteriological findings in endodontic treatment failures

Bacteria Present Absent Total

No. of Teeth (%) 157 (67) 79 (33) 236 (100)

Apical Extent of Root Canal Fillings Underfilled 55 (66) 28 (34) 83 (35) Flushfilled 48 (65) 26 (35) 74 (31) Overfilled 54 (68) 25 (32) 79 (34)

TABLE 3. Relationship between preoperative diagnosis of periradicular area and apical extent of root canal fillings in endodontic treatment failures

Apical Extent of Root Canal Fillings Under-filled Flushfilled Overfilled Total

No. of Teeth (%) 83 (35) 74 (31) 79 (34) 236 (100)

Preoperative Diagnosis of Periradicular Area No Radiolucency 25 (36) 21 (31) 23 (33) 69 (29) Radiolucency 58 (35) 53 (32) 56 (33) 167 (71)

TABLE 4. Relationship between preoperative diagnosis of periradicular area and histobacteriological findings in endodontic treatment failures

Bacteria Present Absent Total

No. of Teeth (%) 157 (67) 79 (33) 236 (100)

Preoperative Diagnosis of Periradicular Area No Radiolucency 31 (45) 38 (55) 69 (29) Radiolucency 126 (75) 41 (25) 167 (71)

underfilled, flush filled, or overfilled (Table 3). Nonetheless, the failure rate between underfilled, flush-filled, and overfilled groups was not significantly different within the catagory of no periradicular radiolucency or periradicular radiolucency (Table 3). When the preoperative periradicular status was correlated with the histobacteriological findings, stainable bacteria were present in a significantly higher percentage in the teeth associated with preoperative periradicular rarefaction (80%) than without (20%) (Table 4). DISCUSSION Clinically, when endodontic treatment has failed, it can be predicted that persisting bacterial infection caused either by

inadequate root canal debridement or incomplete root canal seal is the major factor (9-12), and apical extent or completeness of root canal fillings is not a determining factor (13, 14). Radiographically, a facial or buccal dental radiograph of a seemingly well-filled root canal does not necessarily ensure the complete cleanliness and/or filling of the three-dimensional root canal space (15). This is further supported by our biopsy study of endodontic treatment failures in which we histologically found that pan of the canal space often remained untouched during chemomechanical debridement. This untouched area frequently contained bacteria and inflamed or necrotic tissue substrate even though the root canal filling appeared to be radiographically adequate (10). Our observation that the existence of a preoperative rarefaction is a contributing factor to endodontic treatment failures regardless of apical extent of root canal fillings is not a determining factor in endodontic treatment failures (13, 14). It is a sound biological practice to avoid forcing filling materials into the periradicular tissues. Radiographic studies have showed that given time, the extruded canal filling materials would be removed from the periradicular tissues (14, t6). However, extruded filling materials, especially root canal cements may become resorbed and yet still remained in the periradicular tissues as microscopic particles (10). In this instance, they cannot be detected radiographically. Most likely the root canal filling materials are not as irritating to the periradicular tissues as microbial factors such as bacterial cell-soluble and insoluble components, toxins, enzymes, and harmful metabolic byproducts. Nevertheless, the adverse effects of canal filling materials on the periradicular tissues have been demonstrated histologically (7, 8). Also, teeth with excess root canal filling in the presence of periradicular lesions have been shown to have a poorer prognosis than teeth without excess root canal filling (1, 3). It must be emphasized that clinical success of root canal therapy (3) is much higher than histological success of endodontic therapy (17). Furthermore, not all periradicular lesions are detectable radiographically (18), and a high percentage of periradicular lesions are asymptomatic (10). Seltzer et al. (2) histologically observed that complete healing of a majority of periradicular lesions usually did not occur following nonsurgical root canal treatment. Localized granulomatous inflammation was frequently found in tissue sections of the periradicular tissues of asymptomatic, endodontically treated teeth. Our findings show that a significantly higher percentage of stainable bacteria is present in those failure cases with preoperative periradicular lesions than without. This is convincing evidence that there is a correlation between a bacterial infection in the canal system and the presence of periradicular rarefaction in endodontic failures. It has been demonstrated thai the size of the periradicular lesion is related to the number of bacterial cells in the infected root canal (19, 20). It has also been suggested that bacteria may be present in the canal system which cannot be reached by chemomechanical debridement and culturing procedure (13). Therefore, endodontically involved teeth associated with periradicular rarefactions will fail more frequently after endodontic treatment. This report further supports the findings of Engstrom et at. (1) in that the major factors associated with endodontic failures are the persistence of bacterial infection in the canal space and/or the periradicular area and the presence of preoperative periradicular rarefaction. The apical extent of root canal fillings,

Vol. 18, No. 12, December 1992

Factors Associated with Failures

627

i.e. underfilled, flush filled and overfilled, seems to have no correlation to treatment failure.
Dr. Lin is professor and director, Postgraduate Endodontic Program, Department of Endodontics, University of Medicine and Dentistry of New Jersey, Newark, NJ. Dr. Skribner is professor and chairman, Department of Endodontics, University of Medicine and Dentistry of New Jersey. Dr. Gaengler is professor and director, Department of Conservative Dentistry, Erfurt Medical Academy, Erfurt, Germany. Address requests for reprints to Dr. Louis M. Lin, Department of Endodontics, University of Medicine and Dentistry, New Jersey Dental School, 110 Bergen Street, Newark, NJ 07103.

References
1. Engstrom B, Hard AF, Segerstad L, Ramstrom G, Frostell G. Correlation of positive cultures with the prognosis for root canal therapy. Odontol Revy 1964;15:257-69. 2. Seltzer S, Bender IB, Smith J, et al. Endodontic failures: a analysis based on clinical, roentgenographic, and histologic findings. Oral Surg 1967;23:50016. 3. Strindberg LZ. The dependence of the results of pulp therapy on certain factors. Acta Odontol Scand 1956;14(supp121 ):1-175. 4. Lantz B, Persson PA. Periodontal tissue reactions after root perforations in dog's teeth. A histologic study. Odontol Tidsk 1967;75:209-20. 5. Walton RE, Michelich RJ, Smith GN. The histopathogenesis of vertical root fractures. J Endodon 1984;10:48-56. 6. Seltzer S, Endodontology. 2nd ed. Philadelphia: Lea & Febiger, 7. Erasquin J, Muruzaball M, DeVoto FCH, Rickles A. Necrosis of the periodontal ligament in root canal fillings. J Dent Res 1966;45:1084-92.

1988:458.

8. Muruzaball M, Erasquin J, DeVoto FCH. A study of periapical overfilling in root canal treatment in the molar of rat. Arch Oral Biol 1966;11:373-83. 9. Lin LM, Gangler P. Histopathologische und histobakteriologische untersuchung yon misserfolgen der wurzelkanalbehandlung. Zahn Mund Kieferheilkd 1988;76:243-9. 10. Lin L, Passcon EA, Skribner J, et al. Clinical, radiographic and histological study of endodontic treatment failures. Oral Surg 1991 ;71:603-11. 11. Fukushima H, Yamamoto K, Hirohata K, et al. Localization and identification of root canal bacteria in clinically asymptomatic periapical pathosis. J Endodon 1990;16:534-8, 12. Nair PNR, Sjogren U, Krey G, et al. Intraradicular bacteria and fungi in root-filled, a symptomatic human teeth with therapy-resistant periapical lesions: a long-term light and electron microscopic follow-up study. J Endodon 1990; 16:580-8. 13. Sjogren U, Hagglund B, Sundqvist G, Wing K. Factors affecting the long-term results of endodontic treatment. J Endodon 1990;16:498-504. 14. Halse A, Molven O. Overextended gutta-percha and Kloropercha N-o root canal fillings. Radiographic findings after 10-17 years. Acta Odontol Scand 1987 ;45:171-7. 15, Kersten HW, Wesselink PR, Thoden Van Velzen SK. The diagnostic reliability of the buccal radiograph after root canal filling. Int Ended J 1987;20:20-4. 16. Augsburger RA, Peters DD. Radiographic evaluation of extruded obturation materials. J Endodon 1990;16:492-7. 17. Brynolf I. A histological and roentgenological study of the periapical region of human upper incisors. Odontol Revy 1967;18(suppl 11):1-176. 18. Bender IB. Factors influencing the radiographic appearance of bone lesions. J Endodon 1982;8:161-70. 19. Lin L, Shovlin F, Skdbner J, Langeland K. Pulp biopsies from the teeth associated with periapical radiolucency. J Endodon 1984;10:436-48. 20. Bystrom A, Happonen R-P, Sjogren U, Sundqvist G. Healing of periapical lesions of pulpless teeth after endodontic treatment with controlled asepsis. Endod Dent Traumato11987;3:58-63.

The Way It Was

C. Edmund Kells, a renowned dentist of the early 20th century, wrote of his experiences in Three Score Years and Nine published in 1926. Of interest to endodontists is a rather comprehensive description of the use of leeches for relief of alveolar inflammation subsequent to endodontic therapy. The first sentence describing the procedure is, "Procure the leech." (Sounds like the old recipe for rabbit stew--"First, get a rabbit.") He then advises that the "best leeches come from the Dalmatian Coast, packed one hundred to a tub." Wonder if these were white leeches with black spots??

William Cornelius (Courtesy of Bob Uchin)