Matthew Hughes Word count: 1497

The causes and manifestations

of failure of non-surgical
endodontic treatment
(Endo essay)
None surgical endodontic therapy is the treatment of the tooths pulp via a crown
cavity preparation, whist surgical approaches access the pulp and root by raising
gingival flaps. Both approaches aim to; preserve healthy pulp, remove
dead/infected pulp, restore a non-vital tooth to function and to treat periapical
disease. Primary none surgical endodontic treatment has a high success rate,
ranging from 86-98% (Friedman S et al, 2003, 787-93) (Setzer FC, 2011, 37:21
5). Endodontic retreatment however has a much poorer prognosis, 27.84% to
80% (R. Stoll et al, 2005, 783-790) (S. Rahbaran, 2001, p700-709). Treatment
failure presents clinically as; tenderness on biting, swelling, increased tooth
mobility and pus. The causes of these treatment failures can be broadly dived
into procedural, post-operative and risk factors detrimental to the success of root
canal treatment (RCT). Treatment outcome is graded between survival/ success
and failure. Success is defined by the resolution of apical periodontitis, together
with asymptomatic responses. Whilst osteointegration with or without peri-
implantitis, or loss of bone is seen as survival; A term brought in through the
recent collaboration of endodontics with implantology (S. Rahbaran, 2001, p700-
709).
Procedural causes of treatment failure can be considered at each stage of root
canal treatment.
Initial cavity preparation failure is centred around perforations. Perforations can
occur laterally or at a root furcation. They are caused by; incorrect angulation of
the bur to the tooth, failed canal location and complicated access from unusual
anatomy or previous restorations. The risk of perforation can be reduced by
knowledge of tooth morphology and studying preoperative radiographs,
especially when taken at multiple angles. Clinically they present as sudden pain,
haemorrhage, the taste of irrigant during irrigation and also radiographically.
Further cavity preparation failures include treating the wrong tooth or damaging
an overlying restoration. Thoroughly checking notes pre-treatment and cavity
preperation prior to rubber dam placement will prevent incorrect tooth
treatment. Restoration damage can be avoided by using a water cooled, smooth
diamond bur and by slowly cutting the cavity.
The next stage in RCT is cleaning and shaping of the canal:
Tooth root morphology is highly variable especially within molars. The mesial
roots of maxillary and the distal roots of mandibular molars are most frequently
missed (Witherspoon DE et al). Though additional canals in lower incisors and
second canals in lower premolars are also possible. Missing canals can be
avoided by careful radiographic examination and correct cavity preparation.

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Ledge formation is when the root canal wall loses its smooth taper. This results in
endodontic files prematurely catching on the wall producing a falsely short
working length compromising both the cleaning of the canals but also the
following obturation. Inadequate straight-line access into the canal can result in a
ledge, this can be corrected by shaping the canal with a gates Glidden to help
guide the endo files. Dry canals encourage files to catch leading to ledge
formation. Teeth with excessively curved canals or those packed with debris in
their root apex can force files to catch the root canal wall. Ledging can be
prevented by ensuring straight-line access, careful monitoring of working length,
frequent lubrication of the canal, precurving files, and careful use of step backs.
Apical perforations occur when working length has been exceeded and over
instrumentation has led to the destruction of the apical constriction at the apex
of the root canal. It is indicated by haemorrhage, bleeding on the apical portion
of paper points, sudden pain, sudden loss of an apical stop and can be confirmed
radiographically. It is avoided by measuring a diagnostic working length before
filing the tooth and then maintaining this using plastic stops on the hand files.
Midroot perforations, recognised by blood spotting on the midportion of paper
points can be caused by either direct pressure and incorrect angulation of an
instrument into the canal wall or via stripping. Stripping occurs when the thin
root canal wall is eroded by over instrumentation and an excess flare in canal
shaping. it is most likely to happen on the central walls of the distal canals of the
mandibular first molars due to the thinness and curvature of this root.
cervical midroot and apical root perforations presents clinically as a shortened
working length, loss of canal patency and can be confirmed radiographically.
A further complication of cleaning a canal is instrument separation. This occurs
as a result of extreme canal morphology, over-instrumentation, excessive force
and improper activation of the instrument. It can be avoided by proper canal
lubrication, rigorously working through file sizes one step at a time and
repeatedly returning to the master hand file. Treatment initially includes the
removal of the separated instrument, then attempting to bypass it and finally by
reducing the effective working length of the canal to the point of blockage.
Extrusion of irrigant results when hydrostatic pressure in the canal becomes too
high. This can be caused by the forceful wedging of a needle into the canal and
extruding the irrigant with excessive force. Irrigant is usually a form of bleach
and damages the periradicular tissues it comes into contact with. This results in
inflammation and discomfort to the patient and on occasions bruising. Long term
effects may include paraesthesia, scarring and muscle weakness. The harm of
extrusion can be reduced by using a lower concentration of irrigant and irrigating
more frequently.
Once the canal is clean, it must be filled. Obturation is the sealing of a root canal
with a biocompatible sealant - Gutta Percha (GP). Underfilling occurs when there
is still space left unfilled within the canal. It results from ledging, insufficient
flaring and a poorly adapted master cone. Overfilling following over
instrumentation of the apex leads to apical perforation, this can also result from
excessive condensation forces. GP is very biocompatible and when this
complication occurs it can usually be managed conservatively and left to be
monitored. However, any subsequent retreatment would involve the removal of
the GP.

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A danger of excessive condensation forces when obturating is vertical root

fracture. This is more likely to occur when the root is excessively weakened
during cavity preparation/ decay, when subjected to high mechanical forces. In
multirooted teeth the single root may be removed, but in single rooted teeth the
whole tooth is extracted.
Post procedural failure of Endodontic treatment failure is usually characterised by
apical periodontitis, which may be persistent, emergent or recurrent. The most
common aetiology of post-treatment disease is persistent intra-radicular
infection. In some cases, secondary intra-radicular infection due from coronal
leakage or extra-radicular infection can occur (Siqueira et al. 305-312) (Ras I
N, Siqueira J F Jr. 34: 12911301). In both cases the cause of this apical
periodontitis is bacterial infection. Persistent infection is caused by bacteria
present at the time of the first treatment which were not successfully eliminated
or controlled.
Secondary infection is caused by bacteria not present in the canal before
treatment but introduced following a breach in aseptic surgical conditions, or
from failure in the coronal seal after treatment. It Is often assumed that coronal
leakage is the main cause for post-treatment apical periodontitis, however there
is increasing evidence to suggest that persistent bacteria from the root canal
system prior the initial treatment plays a larger role (Ricucci D, e.t. al. 35: 493
502). This is based on the following findings: Most teeth show only bacterial
infection in the apical rather than extending along the entire length of the canal
walls (which would be suggestive of coronal leakage); Teeth which swab for high
bacterial load immediately after treatment have a poor prognosis, indicating a
persistent infectious problem and lastly the incidence of post-treatment disease
is higher in teeth with pre-operative apical periodontitis than in teeth with no
lesion. This would not be the case if secondary infection due to coronal leakage
were the most significant cause of post-treatment disease, as failure rates for
vital and necrotic teeth would be the same (Ricucci D, e.t. al. 35: 493502).
This does not undermine the importance of an adequate coronal seal following
root canal treatment. Cross-sectional studies indicate that the best outcome is
achieved in teeth when adequate coronal restorations are performed, especially
when they are placed as soon as the root canal is finished (Moreno J O, et al. 39:
600-604). Extra-radicular have the same effect, however incident bacteria
originate from the external root surface and are independent of procedural error.

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Figure 1 - (Elemam, et al. 1-8)

As you can see from Figure 1, the top two causes for root canal failure is failed
obturation and root perforations. Both of these are procedural errors and can be
easily avoided by completing the treatment systematically. Furthermore, post
treatment radiographs can check whether these complications have occurred,
offering the dentist a chance to retreat immediately. The 3 rd and 4th most
common causes of failure cannot be assessed immediately after treatment.
Whilst they are technique sensitive, due to the anatomy of dentinal tubules and
periradicular tissues, they can never be fully excluded from the risk of treatment.

Refrences:
1. Friedman S, Abitbol S, Lawrence HP. Treatment outcome in endodontics:
the Toronto Studyphase 1: initial treatment. J Endod 2003;29:78793.
2. Setzer FC, Boyer KR, Jeppson JR, Karabucak B, Kim S. Long-term
prognosis of endodontically treated teeth: a retrospective analysis of
preoperative factors in molars. J Endod 2011;37:215.
3 R. Stoll, K. Betke, and V. Stachniss, The influence of different factors on
the survival of root canal fillings: a 10-year retrospective study, Journal of
Endodontics, vol. 31, no. 11, pp. 783 790, 2005.
4 S. Rahbaran, M. S. Gilthorpe, S. D. Harrison, K. Gulabivala, and K.
Gulabivala, Comparison of clinical outcome of periapical surgery in
endodontic and oral surgery units of a teaching dental hospital: a
retrospective study, Oral Surgery, Oral Medicine, Oral Pathology, Oral
Radiology, and Endodontics, vol. 91, no. 6, pp. 700709, 2001.

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5. Witherspoon DE, et al. "Missed Canal Systems Are The Most Likely Basis
For Endodontic Retreatment Of Molars. - Pubmed - NCBI".
Ncbi.nlm.nih.gov. N.p., 2017. Web. 30 Apr. 2017.
6. Siqueira, J. F. et al. "Causes And Management Of Post-Treatment Apical
Periodontitis". BDJ 216.6 (2014): 305-312. Web. 30 Apr. 2017.
7. Siqueira J F Jr, Ras I N. Clinical implications and microbiology of
bacterial persistence after treatment procedures. J Endod 2008; 34: 1291
1301.
8. Ricucci D, Siqueira J F Jr., Bate A L, Pitt Ford T R. Histologic investigation
of root canal-treated teeth with apical periodontitis: a retrospective study
from twenty-four patients. J Endod 2009; 35: 493502.
9. Moreno J O, Alves F R, Goncalves L S, Martinez A M, Rocas I N, Siqueira J
F Jr. Periradicular status and quality of root canal fillings and coronal
restorations in an urban Colombian population. J Endod 2013; 39: 600
604. (Moreno J O, et al. 39: 600-604)
10. Elemam, Ranya Faraj, and Iain Pretty. "Comparison Of The Success
Rate Of Endodontic Treatment And Implant Treatment". ISRN Dentistry
2011 (2011): 1-8. Web. 30 Apr. 2017.