Criteria for the Ideal Treatment Option for Failed Endodontics: Surgical or Nonsurgicall

Abstract
Bekir Karabucak, DMD, MS
Assistatit Proiessor

Frank Setzer, DDS

Postgraduate Candidate Oeparttnent of Etidodontics University of Pentisylvania School of Dental Medicine Philadelphia, Pennsylvania

In case of failure of initial rool canal iherapy, modem endodonlics provides clinicians with diffrent treatment options to save the natural tooth from extraction. This article reviews the reasons for conventional treatment failure and discusses guidelines and diagnostic criteria for conventional and surgical re-treatment. The decision-making process for choosing among conventional re-treatment, surgical microendodontics, or extraction of the tooth with subsequent placement of an endosseous implant is described, and indications are illustrated by case examples.

Learning Objeccives
After reading this article, the reader should be able to:

explain the biological and technical reasons for failure of initial root canal therapy. discuss the advantages and disadvantages of conventional or surgical re-treatment.

describe the decision-making process for choosing conventional or surgical re-treatment or extraction.

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dilemma faced by many clinicians is how and when to choose between conventional and surgical re-treatment. Modem endodontic therapy can achieve success predictably But even when initial nonsurgical root canal treatment is performed to the highest standard of care, the need for re-treatment can occur. The reasons for treatment failure can be multivalent. The most common reason for true endodoniic failure is the presence of microorganisms. Procedural errors such as root perforations, separated instruments, missed canals, and anatomical difficulties (eg. calcified canals or root dilacerations) are also among the factors influencing the endodontic prognosis, and understanding these factors is essential for endodontic treatment planning.''^ This article provides guidelines and criteria to consider when planning

endodontic re-treatment versus surgical endodontics or extraction and subsequent placement of an implant.

Failure of Root Canal Therapy

Persistent Infection
Many re-treatments are performed because periapical pathology develops or persists after routine root canal therapy It has been shown that the presence of bacteria within the root canal system at the time of obturation has a negative influence on the endodontic outcome.' After bio mecha ni cal cleaning, bacteria may persist not only within the root canal system bul also in the apical regions of roots, at the apical foramen, or within a periapical lesion, which leads to endodontic failure.'*'' The presetice of bacteria in the periapical tissue does not imply periapical infection. The occurrence of bacteria in the periradicular tissue depends on a

Compendium June 2007;28(6):304-311

crical amount of bacteria within the root canal." In necrotic teeth with periapical pathology, bacterial flora become more complex, containing different species and a larger number of bacteria. Eliminating these microorgan* isms and healing become more difficult. The nature of the apical periodontitis can influence the prognosis,' Extraradicular infection may be found in symptomatic abscessed lesions, periapical actinomycosis, or infected radicular cysts. Most endodontic periapical lesions are infiammator)' and not of infectious origin or of neoplastic nature. Approximately 80% of endodontic pcriradicular lesions can beal satisfactorily after proper root canal therapy. However, the size of the periapical lesions (>5 mm) appears to be a negative factor for the prognosis."'' The incidence of periapical cysts among all inflammatory periapical lesions is approximately 15% to 20%."^'^ Pocket cysts are connected to the root apex and tbe root canal; true cysts are separate and not attached. Neither lype of cyst can be diagnosed clinically.'"" Other than periapical granuloma or pocket cysts, true cysts, extraradicular infections, reaction to foreign bodies, or residual cholesterol cr>'stals might not heal after conventional treatment, ln that instance, surgery is indicated.'"^

Inadequate Cleaning and Shaping

A clinician's primary concern is to thoroughly clean the root canal system during root canal therapy Advancements in endodontic instruments and techniques have improved the quality of biomechanical cleaning of root canals. New nickel-titanium rotary file systems and irrigation solutions have helped to clean canals faster and more predictably. These flexible and tapered files help to shape canals so that they are more centered and round. In the course of cleaning and shaping the root canal system, the initial apical size of a canal dictates the final shaping size. It has been suggested to finalize the mechanical cleaning by enlarging the apical portion by 3 International Standards Organization (ISO) file sizes.'" The initial apical size is most commonly determined by gauging consecutively larger size files until 1 binds at the canal terminus. The accuracy of this measurement depends on the root canal morphology. Severe curvatures and irregular canal walls or canal shape limit the ahility of the clinician to accurately determine the initial apical size. The purpose of apical enlargement, besides creating a space for obturation, is the mechanical debridement of remnant pulp tissue and infected dentin. Especially in infected necrotic and re-treatment cases, mechanical disinfection, in addition to chemical debridement. should be of concern to the clinician. Many morphologic studies have shown that root canals are not round and have a wide range of diameters within the canal walls.'" In most roots, the canal diameter decreases apically, and the canal becomes rounder. The minor diameter of the apical constriction is ahout 270 pm to 330 pni. In other words, the first binding file should be size 25 to 35 (ISO). Also, studies on apical cross sections (1-5 mm) revealed that most teeth have long oval canals and a buccolingual dimension that is wider than the mesiodistal dimension.'^"'' In upper premolars and mesiobuccal canals of upper molars, the buccolingual diameter of the canal could be at least 2 times larger than the mesiodistal canal diameter. '' Taking into account morphology and hacterial contamination, an ideal preparation should be a maximal apical size, retaining the original shape of the canal. However, enlarging the apical tenninus without excessively weakening the root dentin is challenging, considering the size of the minor diameter of the apical constriction (about 270330 pm) and the original oval shape. The limitation on instrumentation may prevent an optimal result."""

Recurrent Injection
Even a previously completely debrided root canal system might he subject to reinfection. Most common causes are leaky restorations, ill-fitting crowns, or broken fillings as well as recurrent decay. The importance of an intact restoration after root canal therapy with regard to success and survival rates of endodontic therapy has been shown in several retrospective studies.'" Eoss of endodonticalty treated teeth is caused by multiple types of failure, mainly prosthetic failure (59.4%) and periodontal failure (32%), but less frequently by endodontic failure (8.6%).'* After exposure of debrided and obturated root canal systems to artificial and natural saliva, significant coronal dye and bacterial leakage could be demonstrated. Dye penetration of teeth that were exposed to artificial saliva in vitro showed significant leakage after 3 days.'^ ln another study, all teeth that were sealed in vivo with temporary filling material and subsequently exposed to tbe oral cavity demonstrated leakage to dye penetration after extraction.'* Bacteria in natural saliva needed <30 days to repopulate tbe entire length of root canals obturated by lateral and vertical compaction." Coronal microleakage must be considered as an important possibility of endodontic failure. The significance of an intact coronal seal must be emphasized not only during obturation and for the final restoration, but also for temporary fillings. In instances where coronal microleakage is obvious or suspected, a conventional re-treatment approach should be attempted at first to eliminate persistent or recurrent infection.

Missed Canals
After removing the existing restoration and decay, an access opening to the root canals should be established. The pulp floor should be carefully inspected to locate all calcified or missed canals. Radiographically and clinically calcified canals may appear to be completely obliterated; however, histological canal space always exists.'" These

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Case 1 : Tooth No. 4 ihe patient had a nonsurgicol root canal treolment with a crown restoration several yeors ogo. Recently, the tooth became symptomatic, The preoperative radiograph revealed periapical pathology and an untiealed canal with a post (Figure 1 A]. The existing crown morgins were ill-fitting, ond a new crown restoration was planned. Conventional re-treatment wos initiated (Figure 1B} The previousfy untreated conal was located, and the treatment was successfully completed [Figure 1C), A 1 -year recall radiograph shows the complete resolution of the periapicol radiolucency v^ith a new restoration (Figure 1 D|.

missed or nntreated canals contain necrotic tissue and bacteria contribuling to the chronic symptoms and nonhcaling periapicai lesions." Knowledge of morphology, correct inierprelation of radiographs, and careful examination under a microscope can help clinicians recognize anatomical variations, improving treatment quality of all canals.

Decision Making in Failed Root Canal Therapy

The treatment options lor root canal treated teeth with a questionable outcome include a regular followup, conventional re-lrcatment, surgical re-trcatment, or a combination of conventional and surgical re-treatment. Every treatment plan should be created individually, and several questions should be asked before making a decision. It is not necessary to re-treat because ol an unsatisfactory appearance on the radiograph only If the patient is asymptomatic, no new restoration is planned, and the periapical condition could be healing or scar tissue, a regular follow-up might be advised. However, it is important to understand the factors responsible for the failure of ihe initial therapy to select the necessary treatment. Modern endodontic surgery has evolved into endodontic microsurgery With proper inclusion and exclusion criteria and facilitating up-to-date techniques such as the use of the dental microscope, ultrasonic root-enti preparation, and the application of biologically compliant and stable filling materials (eg, mineral trioxide aggregate [MTA] or Super-EBA), the outcome of healing has become highly predictable. According to studies on

Clinical Complications
Various procedural errors can happen during the treainieni of the root canal system. Maximum effort should he made to prevent or correct such errors. Generally clinicians believe that procedural errors cause failure of the root canal treatment. Procedural errors often delay the progress of therapy or, in some situations, make it impossible to complete the course of treatment. Several studies have shown that factors such as underfilling, overfilling, root perforations, separated instruments, and ledge formations negatively affect the prognosis of root canal therapy Separated instruments, ledge formations, or root perforations may prevent thorough cleaning and shaping of the canal system. Filling material extruded into the periapical tissue may induce inflammation including a foreign body reaction despite a clinical absence of

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Case 2: Tooth No. 19

A new coronal restorotion had been recenlly ptoced after roo) conal treatmenl. The poent was sensitive lo bifing and percussion. The preoperallve rodiograph revealed an apicol pathology oround the mesial ond the distal roots (Figufe 2A1. The patient wanted to keep the new restoration intact. Osteotomy and roo^ end sufgery were performed under o surgical micrascope (Figine 2B1. The postoperative rodiogroph shows the root-end fillings with MTA before wound closure (Figure 2C). A 1-yeaf recoil radiogiaph revealed complete bone healing [Figure 2D). The patient was free of symptoms.

endodoniic microsurgery that followed these principles, the possible clinical success rate Is around 90%.-" However, periradicular surgery, no matter how sophisticated or advanced, is not a substitute for conventional re-trcatment. If the coronal and apical access is feasible through the current restoration and the canal space is accessible, tnaximum effort should be tnade for a conventional re-trcattiient. If an original treattnent is inadequate (eg, shows poor obturation or missed eanals) or the root canal system is contaminated hy exposure to the intraoral environtnetit, conventional re-treatmeni should he the treatment of choice.

a successful restoration to gain orthograde access to the root canal systetn and if the restoration is intact or can he removed at all. Disassembly may not be reasonably safe and could lead to a nonrestorable situation. In some cases, it tnight be better to either access the root canal system through the restoration or more conservatively to corisider surgical re-treatment. However, if a restoration is lost or coronal leakage exists, the restoration should be removed to clean out all sources of infection and to prevent a possible route of entry for bacteria into the root canal system. It is key to consider conventional re-treatment first in the case of existing leakage (Cases 1 and 2). The quality of the obturation should be evaluated Conventional vs Surgical Re-treatment radiographically before treatment. Based on the authors" Two randomized controlled trials are available com- experience, it is recommended to take multiple angulation paring conventional and surgical re-treatment. In the first radiographs to gel maximum information on the root ^tudy, the difference in success rate was not statistically morphology and the previous treatment. The filling matesignificant after 1 year/'' * The secotid trial showed a sig- rial may look dense or show voids. There may be signs of " nificantly (P<.05) higher healing rate for root-end sur- perforations, ledges, separated instruments, infected latergery after I year but no difference after 4 years. *' al canals, or internal or external rsorption. The location When a decision between a conventional and a surgi- of perforations can dictate the suggested treatment. cal re-treattnent needs to be made, clinicians should eval- Zipping or perforations at the apical level more likely canttate whether the existing condition necessitates damaging not be repaired from itiside ihe root canal system. If there

Compendittm June 2007;28(6):304-311

307

Case 3: Tooth No. 14

A # 15 Hedstrom file had been separared in the distobuccol canal ot toorh No. 14 Figure 3A) Alrhough an otempl to retrieve fhe separated tile was done during conventional Ireatmeni, it could not be removed because of the location ot the tile and the curvature ot Ihe canal (Figure 3B|. A miciosurgical retrieval became necessary. The fragment was located and removed (Figure 3C). The distobuccal root was subsequently sealed v/ith MTA (Figure 3D1. The iTear recall radiograph shows complete bone healing oround the distobur.cril rr-ii (Finiirp IDl

Case 4: Tooth No. 30

Nonsurgical root canal treatment had been completed 5 yeots before. The periapical radiograph revealed periradicular radiolucencles Iperiapical and In fhe (uication area] [Figure 4A). The patient was asymptomatic, and periodontal probing depths were within normal limits; however, a new crown restoration was planned. Nonsurgical endodontic re-treatment was initiated. The intracoronal picture shows the previously treated 4 carols with infected gutta-percha filling (Figure 4B|, Under high magnification, a furcation canal (Figure 4C| and a third distol canal Figure 4D| were locoted. The postoperative radiograph shows ihe ed tooth with 5 main canals (Figure 4E|. The l^ear recall radiograph demonstrates the complete resolution of the perifadicuiar radiolucencies (Figure 4F).

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Case 5: Tooth ^io. 30

The pfeoperotive lodiograph fevealed a periapical radiolucency and transponed canals in ihe mesial rool |Figure 5A). Thts procedural error may have delayed the piogress of therapy or even mode il impossible lo thoroughly clean and shape ihe conal terminus. Roa^eod surgery wos performed lo enucieote the petiapical pcrthobgy and dbride previously uncleaned parts of the canols. On the apicolt/ resected rool surface, an uncteaned portion of 1 canal and on isttimus connecltng Ihe 2 main canals became visible under high magnification (Figure 3B), whicfi wefe prepared to 1 r^rocavity using ultrosonic lips (Figure 3C| and filled with MTA (Figure 5D1.

are separated instruments or foreign objects, their location within the canal system dictates whether to retrieve or bypass the instrument. Clinicians must be familiar with techniques, instruments, and microscope use. If a separated object is beyond the canal curvature, conventional removal is not advised, but a surgical approach is preferred (Case 3). The number of previously treated canals might suggest a missed canal (Case 4). In Case 4, conventional reireatment is indicated to eradicate bacteria and tissue remnants. The apical extension of the filling can appear too short or too long. When an overfilling is obvious, surgical ireatment is often the successful approach if the condition t>r the root canal treatment cannot be significantly improved by conventional re-treatment. The suggested working length for teeth with periapical lesions is <1 mm from ihe radiographie apex, with the obturation material confined to the root canal space. Ending at or short of the apical constriction results in the most favorable histological condition,'" If patency cannot be achieved or transportations or ledges are present, the chances to clean out infection properly are minimized (Case 5). In cases with no apparent explanation for failure, the

success for conventional re-treatmeni should be questioned. In situations where a conventional re-treatment has already failed, a cystic lesion or an extraradicular infection might be the cause of resistance to healing. The nature of an existing periradicular lesion cannoi be determined radiographically In those instances, even improving the filling by conventional re-treatment might not result in healing, and a surgical approach should be preferred.

Extraction Indications
An extraction of the tooth should be considered in cases of prosthetic failure, vertical or horizontal root fractures, severe periodontitis, severe mobility, or an insufficient tooth structure. Also, a poor prognosis of the overall treatment plan can necessitate extraction. If an existing restoration has to be removed, it should be carefully assessed before treatment if the tooth is restorable at all. This includes assessing the amount of remaining tooth structure, possible fractures, the clinical crown-to-root ratio, and the periodontal condition. A total of 4.0 mm of biological width and restorative finish line with sufficient ferrule to enhance the resistance to root fracture should be given.'- If this cannot be estab-

Compendium June 2007;28(6):304-311

308

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Conclusion
The key factors to consider are whether tbe fill of the root canal can be improved, it is likely that a canal was missed, the crown is leaking, access to the root canal system is possible, and the disassembly is reasonably safe. If all of these concerns are considered, tbe correct treatment choice can he made with the correct equipment availahle and the proper skills and experience. Conventional retreatment should be the fust treatment choice, except when a canal cannot be completely negotiated because of an apical or coronal obstruction or a re-treatment attempt has already failed. Conventional re-treatment is less Invasive in most cases. Surgical treatment often can be performed after conventional re-treatment as the next step in treatment {Figure 6).

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Quizl
1. The extensive convergent afferent input patterns and the receptive fields from other structures for most of these [pain deducing] neurons may explain: a. accurate localization of specific pain. b. poor localization of deep pain. c. pain referral after NSAID administration. d. the effectiveness of COX-2 inhibitors. 2. The same inflammatory mechanisms that are initiated by tissue damage: a. also activate pain receptors. b. increase the specific immune response. c. decrease tbc specific immune response. d. increase the nonspecific immune response. The afferent barrage of pain itiput can lead to prolonged alterations in the nucleus caudalis that have been termed: a. hyperimmunogenic. b. bypoimmunogenic. c. central sensilization. d. peripheral overstimulation. 9. 4. Botb A delta and C fibers are very susceptible to: a. axon injury. b. blockade by local anesthetics. c. demyelination. d. electrical field disruption. Pretreating patietits with NSAIDs before or soon after dental surgery: a. is no longer considered the standard of care. b. blocks the COX enzymes. c. disrupts the nucleus caudalis. d. increases substance P production. 6. The profound analgesic efficacy of opioid drugs results from: a. decreasing nerve conductivity on the primary axon. b. decreasing nerve conductivity at the primary synapse. c. blockage of prostoglandin synthesis. d. tbeir ability to mimic the actions of endogenous opioid peptides. 7. Through its inhibition of prostaglandin synthesis, aspirin has been shown to affect: a. taste sensation. b. platelet function. c. auditory nerve conduction. d. neuronal cell mitosis. The mechanism of action of acetaminophen: a. inhibits prostoglandin synthesis. b. increases lipid solubility. c. offers greater protein binding. d. remains unclear. What is the only NSAID approved for parenteral (IV) administration for the shortterm management of moderate to severe pain? a. ketorolac b. piroxicam c. meclofenamate d. ketoprofen 3.

5.

10. The drug class of choice for dental pain for patients who do not have any contraindications to its use is: a. salicylates. b. acetaminophen. c. NSAIDs. d. a combination of analgesics.

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