Chapter 13
OUTCOME OF ENDODONTIC
TREATMENT AND RE-TREATMENT
John I. Ingle, James H. Simon, Pierre Machtou, and Patrick Bogaerts
A question that should be asked of any discipline or tech-
nique in dentistry is, “What degree of success should be
expected?” Success, in turn, should be measured longitu-
dinally in time—long-range success as opposed to
short-term success. The beautiful resin restoration turn-
ing an ugly yellow in 1 year is not an unqualified success.
By the same token, the denture “worn” in the bureau
drawer is far from successful, nor is the well-fitting partial
denture successful if it leads to clasp caries in 6 months.
Moreover, the endodontically treated tooth with a large
periradicular lesion that does not show signs of healing 2
years after treatment cannot be considered a success.
To answer the question, “How successful is
endodontic therapy?” a study was undertaken at the
University of Washington School of Dentistry to evalu-
ate endodontically treated teeth to determine their rate
of success. More important to the study, the rate of fail-
ure was also established, and the causes of failure were
carefully examined. Analysis of the failures led to mod-
ifications in technique and treatment. Finally, the entire
discipline of endodontic therapy was re-examined, and
definitive improvements were made as a result. The
improvements in treatment are reflected in the
improvement in success, which increased to 94.45%
from a former success rate of 91.10%, an improvement
of 3.35 percentage points. In other words, nearly 95%
of all endodontically treated teeth were successful.
There was also a hidden agenda to the Washington
study—to prove ourselves to a profession that, at that
time, was skeptical of root canal therapy. In light of
today’s knowledge, the project had some design flaws
and misinterpretations and was not that well con-
trolled, even though each phase was subjected to statis-
tical analysis. The null hypothesis was ignored in an
effort to prove a point: root canal therapy could be
successful if properly done. On the other hand, the fig-
ures of the Washington study compared favorably with
other reports of success.1–13
A group at Temple University, for example, reported
a 95.2% success rate at the end of 1 year with 458 canals
filled by the gutta-percha-euchapercha method.5 They
found that teeth that started with vital inflamed pulps
had more success (98.2%) than teeth with nonvital
pulps (93.1%). Contrary to other reports, however, they
were far less successful with short-filled canals (71.1%)
than with flush-filled or overfilled canals (100%).
(Reports of 100% success must be questioned.)
South African researchers enjoyed a success rate
similar to that of the Temple University group: 89%
success at the end of 1 year.6 Also, as with the Temple
group, they were successful 92% of the time in teeth
filled to the apex and 91% of the time if the canals were
overfilled. Filling short of the apex reduced their suc-
cess rate to 82%.6
The poorest reported rate of success dealt with 845
Dutch military servicemen.7 After 17 years, 45% of the
endodontically treated teeth had failed in nonaviators,
whereas only 7% had failed in aviator patients. There is
a simple explanation for this wide discrepancy in fail-
ure rate. The aviators were usually treated with
gutta-percha or silver point fillings, whereas the non-
aviators were more frequently treated by “therapy with
special chemical compounds.” Furthermore, the avia-
tors’ teeth were more frequently crowned.7
Hession, a highly respected endodontist in Australia,
reported the highest rate of success: 98.7% of 151
teeth.8 Nelson reported lower rates in England: 81.9%
of 299 teeth. With re-treatment, however, Nelson sal-
vaged 11 of the treatment failures, raising the success
rate to 85.6%.9 Kerekes and Tronstad, using the stan-
dardized technique recommended in this text, had a
success rate similar to the Washington study,10 as did
Sjögren and his associates from Sweden.11 Their
remarkable study of 356 endodontic patients, re-exam-
ined 8 to 10 years later, reported a 96% success rate if
the teeth had vital pulps prior to treatment. The success
748 Endodontics
rate dropped to 86% if the pulps were necrotic and the
teeth had periradicular lesions and dropped still lower
to 62% if the teeth had been re-treated. They conclud-
ed by stating that “teeth with pulp necrosis and peri-
radicular lesions and those with periradicular lesions
undergoing re-treatment constitute major therapeutic
problems…” They surmised that bacteria in “sites inac-
cessible” might be the cause of increased failure.11
Worldwide, most controlled studies seem to agree
that a lower success rate is associated with overfilled
canals, teeth with preexisting periradicular lesions, and
teeth not properly restored after root canal thera-
py.11–15 A Swedish group reported a high failure rate if
canals were not totally obturated.13 Sjögren et al., quot-
ed above, also noted a direct correlation between suc-
cess and the point of termination of the root filling.11
As Figure 13-1 shows, teeth filled within 0 to 2 mm
from the apex enjoyed a 94% success rate, which fell to
76% if the teeth were overfilled and fell further to 68%
if they were filled more than 2 mm short.
In reported re-treatment of initial endodontic fail-
ures, success figures have been unacceptably low. Only
50% of the overfilled teeth were acceptable (Figure 13-
2). Similarly, a Japanese group reported a much high-
er failure rate if root fillings were overextended.14
Surprisingly, a Dutch group enjoyed as high a healing
rate whether or not the canals were filled.16 The Dutch
report was only a 2-year study. Unfilled canals had not
been followed over a long period of time (such as 10 to
20 years). Most endodontically treated teeth should
last as long as other teeth. Vire examined 116
root-filled teeth that were extracted because of failure
and found that only 8.6% failed for endodontic rea-
sons compared with 59.4% restorative failures and
32% periodontal failures.17
Figure 13-1 Outcome of treatment according to the level of the
root filling in relation to the root apex in cases with preoperative
pulp necrosis and apical periodontitis. Number of healed
lesions/number of preoperative lesions. Reproduced with permis-
sion from Sjögren U.11
Figure 13-2 Results of re-treatment of previously filled roots with
apical periodontitis with regard to the level of the final root filling
in relation to the root apex. Number of healed lesions/number of
preoperative lesions. Reproduced with permission from Sjögren
U.11
The Washington Study
The figures above from the University of Washington
are only a few from an exhaustive study encompassing
many aspects of endodontic therapy. The modifica-
tions in treatment mentioned above were instituted
following a pilot study of endodontic success and fail-
ure. Even with the limited number of patients in the
pilot study, the causes of failure became apparent.
Clinical techniques were then changed in an effort to
overcome failure. Patients were recalled for follow-up
at 6 months, 1 year, 2 years, and 5 years, and the recall
radiographs were carefully evaluated for improvement
or lack of improvement. Teeth included in the success
group were those that demonstrated decided periradic-
ular improvement (Figures 13-3 and 13-4) and those
with continuing periradicular health (Figure 13-5).
The failures were made up of those teeth that initially
demonstrated periradicular damage and that had not
improved (Figure 13-6), as well as those that had dete-
riorated since treatment (see Figure 13-6). As soon as a
statistically significant group of cases built up in the
file, the material was ready to be analyzed.
The 2-year recall series was found to be ideal for this
study because a statistically significant sample devel-
oped within this group. The 5-year recall sample was
also analyzed but in understandably smaller, though
significant, numbers. The study did not take into con-
sideration any illnesses or systemic differences between
patients.
Two-Year Recall Analysis. Of a total population of
3,678 patients who could have returned for 2 years,
1,229 actually did return, a recall rate of 33.41%—a
statistically significant cohort. Before improvements in
technique and case selection were instituted, there was
 Outcome of Endodontic Treatment and Retreatment 749

Figure 13-3 Special mount for radiographs

taken of each case. Note that recall films are
exposed at 6 months, 1 year, 2 years, and 5 years
following therapy. Figures at the top of the card
indicate that complete healing had occurred at 6
months and was maintained for 5 years.

a 91.10% success rate—104 failures of 1,067 cases.
After these improvements were instituted, the success
rate rose to 94.45%—9 failures of 162 cases.
Five-Year Recall Analysis. From the beginning of
the study, enough 5-year recalls had returned to make a
statistically valid analysis of these cases. Of the 302 5-
year recalls, 281 teeth were successful—a success rate of
93.05%; 21 teeth were considered failures—a failure
rate of 6.95%. These figures compare favorably with the
2-year recall analysis.
Two-Year Recall Analysis by Age of Patient.
Reference is frequently made to age as a criterion for

A B C
Figure 13-4 A, “Before” radiograph, with large periradicular lesion. B, “Treatment” radiograph immediately following periradicular sur-
gery. Also note the fractured root tip of a central incisor (arrow) that tests vital. C, Two-year postoperative radiograph of successfully treat-
ed case. Lack of total periradicular repair (moderate repair) is related to extensive surface of filling material over which cementum cannot
grow. Also note fracture repair (arrow) of vital central incisor.
750 Endodontics
A B
Figure 13-5 A, Pulpless mandibular lateral incisor with no periradicular lesion. B, Constant periradicular health is revealed in a 2-year post-
operative radiograph, a successful case.
Figure 13-6 Two failure cases demonstrated in a single radi-
ograph. Curved arrow (right) points to a lesion that has failed to
heal 2 years following endodontic treatment. Straight arrow (left)
points to a lesion that has grown worse 2 years following therapy.
Lack of total obturation of canals is revealed by the fuzzy appear-
ance of root canal fillings. Defective amalgam restoration (open
arrow) contributes to an interproximal periodontal lesion.
endodontic treatment. The youngest patient treated in
the study was 21⁄2 years old; the oldest patient was 92
years old. There was a fairly consistent rate of success
and failure according to age as shown by statistical
analysis (χ2 = 2.72; p > .09). Age, of course, has a great
deal to do with the size and shape of the canal. It was
found that older teeth, with more restricted canals,
were more successfully obturated than very “young”
teeth with large-diameter canals. It also became obvi-
ous that the size and shape of the lumen of the canal, as
well as the direction of root curvature, play an impor-
tant part in the successful completion of a root canal
filling. Analysis of success, by individual tooth, will
demonstrate these points.
Two-Year Recall Analysis by Individual Tooth. No
significant difference in failure existed between any of
the teeth in either arch (χ 2 = 2.45; p > .10). Thus, no
particular tooth can be considered a higher endodontic
risk, although there was a wide discrepancy between
the mandibular second premolar with a failure rate of
4.54% and the mandibular first premolar with a failure
rate of 11.45%. Canal anatomy might account for the
greater increase in failure in the first premolar. Pucci
and Reig, in their monumental work Conductos
Radiculares, pointed out the great anatomic differences
 Outcome of Endodontic Treatment and Retreatment
between the two mandibular premolars.18 Whereas the
mandibular second premolar has two canals and two
foramina 11.5% of the time, the mandibular first pre-
molar has branching canals, apical bifurcation, and
trifurcation 26.5% of the time.18
Others have found similar discrepancies between
mandibular premolars, most recently Trope et al. at the
University of Pennsylvania.19 These researchers con-
firmed one of Pucci and Reig’s findings almost exactly:
23.2% of the mandibular first premolars examined
had two canals. They also found that 7.8% of second
premolars had two canals, a figure differing from Pucci
and Reig’s 11.5%. This discrepancy could well be
explained on an ethnic basis: the researchers at
Pennsylvania reporting on a US African American pop-
ulation and Pucci reporting on a Uruguayan popula-
tion containing some aborigines.
The Pennsylvania study also confirmed the notion
that African American patients more frequently have
two canals in lower premolars than white patients. In
the first premolars, 32.8% had two canals, compared
with 13.7% of whites. In the second premolars, 7.8% of
African Americans had two canals, compared with
2.8% of whites. Nearly 40% of the African Americans
in the study had at least one premolar with two canals
and 16% of the time presented two separate roots in
mandibular first premolars.19
Failures in the maxillary lateral incisor may also be
explained by anatomic differences. Pucci and Reig
showed extensive distal curvature of the maxillary lat-
eral incisor root 49.2% of the time.18 Here again, poor
judgment and preparation frequently prevent adequate
instrumentation and obturation, with root perforation
at the curvature a common occurrence (Figure 13-7).
Increased failure rate in the maxillary lateral incisor is
also related to continuing root resorption following
treatment, a finding peculiar to these teeth.
The overall failure rate, mandible to maxilla, is strik-
ing but not statistically significant. Failure in the
mandibular arch was encountered 6.65% of the time
and 9.03% of the time in the maxilla.
Two-Year Recall Analysis: Nonsurgical versus
Surgical Intervention. The degree of success achieved
by surgical intervention in treated endodontic cases has
long been a contentious point. The Washington study
demonstrated that although nonsurgical treatment
appears to be slightly more successful than surgical
treatment, differences are not statistically significant
(χ2 = 3.44; p > .05).
It is tempting to indict case selection as the basis for
increased failure of surgical treatment. One of the indi-
cations for surgical intervention has been the grossly
751
Figure 13-7 Root tip biopsy from the curved apex of a maxillary
lateral incisor. Severe inflammatory reaction surrounding the root
end is related to perforation as well as failure to débride and obtu-
rate the curved portion of the canal. Reproduced with permission
from Luebke RG, Glick DH, Ingle JI. Oral Surg 1964;18:97.
involved periradicular lesion, where a lower rate of
repair might be expected. Although the 10 to 12 mm
periradicular lesion appears to heal as readily, if not
quite as rapidly, as the 2 mm lesion (Figure 13-8), this
may not always be true. Others have shown that larger
lesions, or cases with lesions versus those without, are
less successful. Nelson reported that the failure rate was
three times higher if a periradicular lesion existed
before treatment.9 In another study, the failure rate was
the same.16 The Dutch study, interestingly enough,
found that “teeth with periradicular granulomas tend
to heal less successfully than teeth showing cysts.”12
Similarly, Japanese researchers reported a wide discrep-
ancy in success between treated teeth that had no peri-
radicular rarefaction (88%) and those with a 5.0 mm or
greater rarefaction (38.5%).14 For those teeth without
periradicular lesions, Sjögren et al. reported a 96% suc-
cess rate, but this rate dropped to 86% if periradicular
lesions were present.11
Two-Year Recall Analysis of Endodontic Failures.
The final and most important portion of the
Washington study dealt with 104 failure cases as a
group. Careful analysis of these particular cases is most
revealing.
Arrangement of Failures by Frequency of
Occurrence. As Table 13-1 shows, the most striking
finding is the 58.66% of the failures caused by incom-
plete obturation of the canal (Figure 13-9). This is a
highly significant figure. This most common cause of
failure is almost 50 percentage points ahead of the next
greatest cause of failure, root perforation, which
752 Endodontics

Figure 13-8 Large periradicular lesion (left) has healed completely (right) within 6 months in a patient 20 years of age.

Table 13-1 Distribution of Failures of Treated accounts for 9.61% of the failures. Thus, the two great-
Endodontic Cases: Two-Year Recall by Frequency of est causes of failure stand revealed: inadequate clean-
Occurrence ing and shaping and incomplete obturation. In other
words, over two-thirds of all of the endodontic failures
Causes of Failure Number of Failures % Failures
in the study were related to inadequate performance of
Incomplete obturation 61 58.66 two points of the endodontic triad, “canal instrumen-
Root perforation 10 9.61 tation and canal obturation.” This alone would call for
improved technique and attention to detail.
External root resorption 8 7.70
Categorical Arrangement of Causes of Failure.
Coexistent periodontal- 6 5.78 The 13 causes of endodontic failure may be arranged in
periradicular lesion three general categories of causes leading to failure: (1)
Canal grossly overfilled 4 3.85 apical percolation, (2) operative errors, and (3) errors
or overextended in case selection (Table 13-2). Actually, a clear-cut
Canal left unfilled 3 2.88 delineation of the agents of failure is difficult; apical
percolation into the canal accounts for almost all of
Developing apical cyst 3 2.88
these failures, as Table 13-2 shows.
Adjacent pulpless tooth 3 2.88 Apical Percolation. Three of the causes of failure
Silver point 2 1.92 shown in Table 13-2 lead to apical percolation and sub-
inadvertently removed sequent diffusion stasis into the canal (Figures 13-10
Broken instrument 1 0.96 and 13-11). Factor in the bacteria lurking in the region
Accessory canal unfilled 1 0.96 and these three causes together account for 63.47% of
all of the endodontic failures in the study and demon-
Constant trauma 1 0.96
strate how vital careful therapy is to success. One must
Perforation, nasal floor 1 0.96 also consider the potential of microleakage under and
Total failures 104 100.00 around coronal restorations: bacteria penetrating from
the crown to the periapex alongside poorly obturated
Distribution of 104 endodontic failures 2 years following therapy. canals.
When arranged by frequency of occurrence, note that incomplete Operative Errors. A category made up of errors in
obturation accounts for almost 60% of all failures, followed by root
perforation, which accounts for nearly 10% of 104 failures. Cause
coronal cavity preparation and canal preparation
of failure includes infrequently encountered conditions that occur accounts for almost 15% of the failures (root perfora-
less than 1% of the time. tion, 9.61%; broken instrument, 0.96%; and canal gross-
ly overfilled, 3.85%; total, 14.42% of all of the failures).
 Outcome of Endodontic Treatment and Retreatment 753

Figure 13-9 Left, Careful examination of an

initial radiograph reveals internal resorption and
widening of the canal apical to the curved arrow.
Right, In a 2-year recall radiograph, periradicular
lesion persists owing to failure to totally obliter-
ate the root canal space (arrow).

Table 13-2 Distribution of Failures of Treated These operative errors are all related to inadequate coro-
Endodontic Cases: Two-Year Recall by Category of nal cavity preparation, improper use of endodontic
Cause of Failure instruments and filling materials, and lack of standardi-
zation of endodontic equipment and material as it
Causes of Failure Number of Failures % Failures
arrives from the manufacturer. The latter problem has
Apical percolation—total 66 63.46 now been reduced through instrument standardization.
Incomplete obturation 61 58.66 On the other hand, delicate root canal instruments
must not be mistreated by the inexperienced, and one
Unfilled canal 3 2.88
of the common complaints of the neophyte is “instru-
Ag point inadvertently 2 1.92 ment breakage.” Also, improper use of the instruments
removed causing root perforation and apex perforation
Operative error—total 15 14.42 accounted for 14 of the 104 failures in the study.
Root perforation 10 9.61 Penetrating through the side of a curved root ultimate-
ly leads to incomplete instrumentation and incomplete
Canal grossly overfilled 4 3.85
obturation (Figure 13-12).
or overextended
Opening wide the apical foramen during instru-
Broken instrument 1 0.96 mentation illustrates that this is also a form of perfora-
Errors in case selection—total 23 22.12 tion and leads to gross overfilling or overextension.
Healing is delayed and often incomplete around the
External root resorption 8 7.70
grossly overfilled areas that may be caused by foreign-
Coexistent periodontal- 6 5.78 body reaction. Moreover, the perforated apical foramen
periradicular lesion has destroyed the apical “stop” and does not allow com-
Developing apical cyst 3 2.88 paction during canal filling. Although the canal may
Adjacent pulpless tooth 3 2.88 appear overfilled, it is actually incompletely obturated,
with resulting percolation and failure (Figure 13-13).
Accessory canal unfilled 1 0.96
The paucity of failures in this study owing to broken
Constant trauma 1 0.96 instruments illustrates that this is not as desperate a sit-
Perforation, nasal floor 1 0.96 uation as it is often considered to be. In analyzing the
Total failures 104 100.00 University of Washington caseload, Crump and Natkin
found that failure following instrument fragmentation
Distribution of 104 endodontic failures 2 years following therapy. was the same as in other endodontic cases.20
Causes of failure may be categorized into three general groupings: Broken instruments, however, are not favored any
apical percolation, which accounts for 63.46% of failures; operative
more than overfilling and underfilling are favored, but,
errors, which account for 14.42% of failures; and errors in case
selection, which account for 22.12% of the 104 failures. occasionally, both accidents may occur. Surgical treat-
ment is recommended in operable teeth if the instru-
ment is broken off in the apical one-third of the canal
754 Endodontics

A B
Figure 13-10 A, Although the root canal filling appears to be overextended, the fuzzy appearance indicates a lack of density necessary for
total obturation. Apical perforation destroyed the apical constriction necessary for compaction of the root canal filling. B, Root end biopsy
of this failure case shows root canal cement and cellular debris rather than well-condensed gutta-percha filling. Constant percolation into the
root canal space provides media for bacterial growth.

A B
Figure 13-11 A, Constantly draining sinus tract opposite the mesiobuccal root of a maxillary first molar (arrow) was thought to be relat-
ed to an advanced periodontal lesion. Total amputation of the mesiobuccal root is indicated. B, Amputated root reveals an error in diagno-
sis. The reamer is in an undetected second canal, whereas the arrow points to an obturated primary canal. Secondary canals in mesiobuccal
roots of first permanent molars occur about 60% of the time.
 Outcome of Endodontic Treatment and Retreatment 755

cement. Broken instruments may often be retrieved by

Figure 13-12 Failure owing to root perforation accompanied by
incomplete débridement and imperfect obturation. Note the break
in the lamina dura opposite the perforation (arrow).
and is loose in the canal and cannot be removed or
bypassed. Surgery may also be the approach if the canal
is grossly overfilled with irretrievable gutta-percha and
“floating” out the piece with an ultrasonically powered
instrument. Broken instruments, loose in the canal,
have also been seen to “rust out.” Failures associated
with underfilled canals can usually be remedied by re-
treatment rather than surgery (see Chapter 14).
All of these errors of operation may be prevented by
careful cavity preparation and canal obturation. For
example, if the operator is unsure of the instrument
position in the canal, a radiograph should be taken.
Also, more accuracy in fitting the primary or initial fill-
ing point will lead to less overfilling. In the final analy-
sis, operative error is the simplest cause of failure to
control and requires more patience, care, and under-
standing to overcome.
Errors in Case Selection. Errors in case selection are
not as easily overcome as operative errors and may often
be listed as the “bad breaks of the game” rather than
errors in judgment. Who could predict, for example, that
external root resorption would continue, an apical cyst
would develop following treatment, an adjacent tooth
would become pulpless, or an associated periodontal

A B

Figure 13-13 A, Although this incisor appears to be grossly overfilled, careful examination (arrow) reveals failure to totally obturate the
canal. B, Tissue reaction to overfilling and underfilling in a single biopsy specimen from this failure case. Curved arrows direct attention to
a mass of cement forced into periradicular tissue. Heavy black arrow (right) indicates noninflammatory tissue capsule that has developed as
foreign-body reaction. Open arrow (bottom) points to a violent inflammatory reaction and an abscess related to bacterial products perco-
lating from the unfilled canal.
756 Endodontics
lesion would lead to failure?21 These are all factors that
led to some of the failures in the Washington study, fac-
tors that constitute 22.12% of the total failures. Some
could well have been predicted at the time of therapy,
but others were entirely unpredictable.
As Table 13-2 shows, there were also minor causes
of failure: constant occlusal trauma from bruxism,22
perforation of the nasal floor, and unfilled accessory
or lateral canals. The low incidence of failure associat-
ed with unfilled accessory canals came as a surprise
considering the degree of emphasis placed by some on
the absolute necessity of totally obliterating these lat-
eral canals.
Returning to some of the greater causes of failure,
one should note that all eight cases of continuing root
resorption were in maxillary lateral incisors. So one
should be wary in evaluating the future of these teeth if
they exhibit extensive apical resorption prior to treat-
ment. Most external apical root resorption stops in
response to successful root canal treatment!
Endodontic failure associated with periodontal
pockets is usually the fault of the dentist for not recog-
nizing the pocket’s existence. One stumbles ahead with
the endodontics before careful probing reveals the
presence of an associated pocket and that concurrent
periodontal/endodontal therapy will be necessary.23
In some cases, concurrent treatment may not solve
an unsolvable problem. Witness the destructive and
irreparable nature of some dens invaginatus or radicu-
lar lingual grooves extending to the apex24 (Figure 13-
14) or the resorptive invasion from one endodontic
lesion causing the necrosis of an adjoining tooth25
(Figure 13-15).
There are, of course, multiple causes of failure not
revealed in the Washington study: retrofilling failures,
root tip and foreign bodies left in surgical sites, root
fenestration following surgery (Figure 13-16), cracked
or split roots, or carious destruction unrelated to the
root canal treatment (Figure 13-17). Ultimately, in all
of these situations, bacteria are the final cause of fail-
ure. One must also recognize that one of the most fre-
quent causes of failure of the treated pulpless tooth is
fracture of the crown. The tooth must be carefully pro-
tected by an adequate restoration.
The Washington study has been faulted by some for
being only a radiographic study. As Brynolf pointed
out in her classic punch biopsy study of root-filled
teeth in cadavers, histologic evaluation is a much more
accurate method of determining if inflammation
remains at the apex than is radiologic evidence.26 But
her research was done on cadavers, proving the imprac-
ticality of punch biopsy on live patients. Green and
Walton followed up on Brynolf ’s approach, comparing
histologic and radiographic findings on cadavers, and
also found that 26% of the teeth with no radiolucen-
cies showed chronic inflammation histologically.27 But
that is not to say that these teeth were uncomfortable or
contributing to the patient’s poor health. How success-
Figure 13-14 Developmental defect,
invagination, and radicular lingual
groove, resulting in an unattached peri-
odontal ligament tract to the apex. The
defect at the cingulum probably com-
municated with the pulp. Endodontic
and periodontic therapy were to no
avail. Reproduced with permission
from Simon JHS, Glick DH, Frank AL.
Oral Surg 1971;37:823.
 Outcome of Endodontic Treatment and Retreatment 757

A B
Figure 13-15 A, No radiolucency is apparent on a 4-year recall radiograph following root canal filling of a first premolar. Note the anatomic defect
on the canine (arrow). B, Radiograph taken 6 years after the lesion was first noticed. Failed root canal filling in the premolar led to periradicular
lesions, inflammatory external resorption of canine, and ultimately necrosis of the canine pulp. Reproduced with permission from Frank AL.25

ful is success? Better yet, what are the criteria of suc-
cess? Comfort and function? Radiographic? Histologic?
Since histologic evaluation is impractical, if not illegal,
one would have to go with comfort and function and
the radiographic findings.
There are well over 50 studies attempting to delin-
eate how successful our treatment procedures are and
what the prognosis is for a particular form of treat-
ment.28 All in all, the studies that have been done sug-
gest the following generalizations:
1. The more extensive and severe the endodontic
pathosis, the poorer the prognosis. In other words,
Figure 13-16 Severe bony and soft tissue dehiscence extending to
the periapex of a traumatized incisor. Postoperative defects of this
type may develop following surgery in an area of osseous fenestra-
tion. Reproduced with permission from Luebke RG, Glick DH,
Ingle JI. Oral Surg 1964;18:97.
the highest percentage of success is with teeth with
vital pulps and the worst prognosis is for those with
large, long-standing periradicular lesions.
2. The more dental treatment that is done, the poorer
the prognosis. In other words, good nonsurgical
endodontic treatment has the best prognosis. The
worst prognosis lies with teeth that have been re-
treated nonsurgically and then re-treated surgically
once or twice more.
MICROBES
To further elaborate on the role bacteria play in pulpal
and periradicular disease, one must turn to the classic
research by Kakehashi and his associates at the National
Institute of Dental Research.29 They were able to show,
in a gnotobiotic study, that microorganisms alone
cause pulpal inflammation and necrosis as well as peri-
radicular infection.29 It follows that inadequate
removal of microbes (ie, bacteria, fungi, and viruses)
from the canal leads to continued infection and inflam-
mation30 and that all of the defects listed in the
Washington study are ultimately reduced to bacterial
invasion and/or colonization.
But what happens when everything is done right (ie,
cleaning, shaping, and obturation), yet failure still
occurs?31–34 Can bacteria still be present after adequate
endodontic treatment?
There is strong evidence that bacteria may not be
completely eliminated after thorough cleaning, shap-
ing, and disinfection.35–37 Moreover, when obturation
is postponed, bacteria may be able to recolonize in the
canal.38 Furthermore, try as one might, no preparation
758 Endodontics

Figure 13-17 Postoperative failure owing to

extension of dental caries rather than
endodontic therapy per se. Loss of these abut-
ment teeth led to full denture in this case.

technique can totally eliminate the intracanal irritants,
and a “critical amount” can sustain periradicular
inflammation (Figure 13-18).39,40
In addition, as stated previously, the obturated
canal may be recontaminated from coronal leak-
age.41 Indeed, gutta-percha root canal fillings do not
resist salivary contamination.42,43 As Ray and Trope
have been able to show, “long term prognosis of
treatment seems to correlate directly with the quali-
ty of the coronal seal.”44

A B

C D
Figure 13-18 A, The radiograph shows a mandibular cuspid that appears well obturated with a well-fitting coronal restoration. B, A sinus
tract is traced with a gutta-percha point to the apical lesion that has not responded to treatment. C, Surgical resection of the root end. D,
High-power photomicrographs show bacteria containing plaque on the external root surface.
 Outcome of Endodontic Treatment and Retreatment 759

There are also times when an irritant, such as infected respond to the irritants and inflammation and prolifer-
dentin chips, is packed at the apex or pushed through the ate into a cyst-like attempt to wall off the irritants.78
apex, there to serve as a continuing irritant45,46 that over- It has been suggested that these latent epithelial cell
whelms the body’s defense system. As stated before, the rests could be activated by the epidermal growth factor
periapical tissue could become colonized by periodontal present in saliva that contaminates canals left open for
contamination,47 the virulence of the bacteria, or extru- drainage.79,80 In the absence of treatment, or in the pres-
sion by overaggressive instrument action.48–50 ence of persistent bacteria, epithelium continues to pro-
In most cases, the host’s immune system can overcome liferate to become a bay (pocket) cyst and eventually a
these antigens.51 On the other hand, some bacteria pos- true cyst.81,82 The distinction between a bay (pocket)
sess mechanisms to resist phagocytosis such as encapsu- cyst (Figure 13-20) and a true cyst is important from a
lation or the production of proteases aimed against the clinical standpoint. Since root canal therapy can directly
immune system.52,53 Bacteria may also bury themselves affect the lumen of the bay (pocket) cyst, the environ-
in a thick matrix that acts as a sort of apical plaque (see mental change may bring resolution of the lesion.
Figure 13-18, D).54–56 There is a controversy over whether cysts heal after
Many organisms can survive in periradicular lesions: nonsurgical endodontic treatment. The true cyst is
Actinomyces, Peptostreptococcus,57–60 Propionibac- independent of the root canal system, so conventional
terium,61,62 Prevotella and Porphyromonas, 63–65 therapy may have no effect on it. The prevalence of true
Staphylococcus,66,67 and Pseudomonas aeruginosa.35 cysts is less than 10%. 65,66 Most practitioners now real-
Barnett, in fact, has stated that Pseudomonas refractory ize that true cysts, as well as some bay (pocket) cysts,
periradicular infection could be “cured” only by heavy probably do not heal with nonsurgical therapy. In spite
doses of metronidazole (Flagyl) following the failure of of good cleaning, shaping, and filling, these lesions
re-treatment and apicoectomy.68 have to be surgically removed to effect healing.
The dangers delineated above emphasize the point
FOREIGN BODIES initially stressed: if the case is carefully selected before
In spite of what has been stated above, “foreign-body treatment, if the canal is correctly instrumented and
giant cell reaction” can occur without the presence of obturated, and if the crown is properly restored, the
bacteria, but no fulminating infection will develop ultimate outcome should be successful.
without the bacteria.
A number of foreign bodies have been reported:
lentil beans,69 other vegetables,70 popcorn kernels71
(Figure 13-19), paper points, cellulose, and a variety of
unidentified materials.72 Human body defense cells are
unable to digest cellulose or cotton pellets.72,73
In addition, various lipids, cholesterols, and crystals
have also been implicated as periradicular irritants. By
their very presence, these intrinsic factors are capable of
sustaining an apical lesion despite correct endodontic
treatment.74
Root canal sealers can also act as a foreign body and
thus sustain a lesion, although, over time, extruded
sealers (and gutta-percha) may be phagocytized by
macrophages.75
The cytotoxicity of freshly mixed and unset sealers is
well documented.76 In the long term, however, obtura-
tion materials are far less irritating than microbes.75 It
can be concluded that an overfill may cause a delay in
healing but will not prevent it.77

EPITHELIUM
The role of epithelium must also be taken into account Figure 13-19 Biopsy of what was thought to be a root tip reveals
when reviewing failure to heal periapically. If the rest- columnar-like cells (arrow) of the outer husk of a popcorn kernel that
ing cells of Malassez remain in the region, they may was trapped in a fresh surgical area and served as a severe irritant.
760 Endodontics
A B
Figure 13-20 A, Periradicular lesion persisting 2 years following endodontic therapy appears to be either an apical cyst or chronic apical
periodontitis. B, Biopsy of the periapex demonstrated the epithelial lining of an apical cyst (arrow). Persistence of development of apical cysts
led to failure in three cases in study.
Measures to be Employed to Improve Success.
One may draw certain conclusions from this study and
finally list a number of procedures to improve the rate
of success of treated endodontic cases. These are the
Ten Commandments of Endodontics:
1. Use great care in case selection. Be wary of the case
that will be an obvious failure, but, at the same time,
be daring within the limits of capability.
2. Use greater care in treatment. Do not hurry; main-
tain an organized approach. Be certain of instru-
ment position and procedure before progressing.
3. Establish adequate cavity preparation of both the
access cavity, which can be improved by modifica-
tions of the coronal preparation, and the radicular
preparation, which can be improved by more thor-
ough canal débridement—cleaning and shaping.
4. Determine the exact length of tooth to the foramen
and be certain to operate only to the apical stop,
about 0.5 to 1.0 mm from the external orifice of the
foramen.
5. Always use curved, sharp instruments in curved
canals, and especially remember to clean and
reshape the curved instrument each time it is used.
This applies to stainless steel instruments.
6. Use great care in fitting the primary filling point.
One must be certain to obliterate the apical portion
of the canal. Be more exacting in the total obtura-
tion of the entire root canal. Always use a root canal
sealer cement.
7. Use periradicular surgery only in those cases for
which surgery is definitely indicated.
8. Always check the apical density of the completed
root canal filling of the patient undergoing peri-
radicular surgical treatment, and this should be
done by using a sharp right-angled explorer. If
found wanting, the apical foramen is prepared and
retrofilled.
9. Properly restore each treated pulpless tooth to pre-
vent coronal fracture and microleakage.
10. Practice endodontic techniques until the proce-
dures are as routine as the placement of an amal-
gam restoration or the extraction of a central inci-
sor. Practice on extracted teeth mounted in acrylic
blocks is especially recommended.
Careful attention to details in following the Ten
Commandments of Endodontics will ensure a degree
of success approaching 100%.
 Outcome of Endodontic Treatment and Retreatment 761

PROGNOSIS Mactou pointed out that “the quality of treatment

All of this having been said, it should be possible to
predict the outcome of endodontic treatment. With the
benefit of education and experience and some plain
luck, one should be able to choose the proper cases for
endodontic treatment and reject those that will obvi-
ously fail. But it is not quite that simple.
The practicing dentist should not be cited for faulty
judgment when even the experts tend to disagree on
prognosis. A North Carolina group, for example, found
considerable disparity in treatment choice between
general practitioners and endodontists who were
shown seven controversial cases.83 In another instance,
Holland and his collaborators reviewed 17 prognosis
studies dealing with success or failure of teeth with and
without periradicular lesions.84 In the “with lesion” col-
umn, successful outcome ranged from a low of 31.8%
to a high of 85%. On the other hand, there was general
agreement among these 17 experts that a greater suc-
cess rate may be enjoyed if there is no initial periradic-
ular lesion present. This is not to say that teeth with
periradicular lesions should be shunned. On the con-
trary, respectable success rates have been reported by
many who have treated teeth with radiolucent lesions.
All in all, one must ultimately develop confidence in
one’s own abilities. Being able to practice using a vari-
ety of techniques and not being “married” to a single
approach in every case greatly enhances one’s capabili-
ties. This is the basis of good prognosis, the result of
skill, knowledge, and self-confidence. On the other
hand, if a treated tooth does fail, it may be resurrected
by skillful re-treatment!
plays a decisive role in the successful outcome of
endodontic therapy” (Figure 13-21) (personal com-
munication, April 2000).
Fortunately, treated root canals with inadequate
results may be re-treated to improve the quality of the
treatment and heal any apical lesion. (Figure 13-22)
Bergenholtz et al., for example, reported on 556 re-
treatment cases in which 50% completely healed after
2 years, and in an additional 30%, the lesions were sig-
nificantly reduced in size.104 In a 2-year follow-up
study, Bergenholtz et al. also reported a 94% success
rate for re-treatments done for one reason only, to
improve root canal filling quality prior to prosthodon-
tic therapy.105
Friedman et al. claimed a 100% success rate in re-
treatment of endodontic cases presenting without
periradicular lesions, which suggests that if infection is
not present, and re-treatment is performed by skilled
clinicians, the success rate can be expected to be very
high (Table 13-4). On the other hand, if periradicular
lesions are present before re-treatment, the success rate
can be expected to fall to around 70% (Table 13-5).28
As many as 22 factors have been listed to affect the
prognosis of endodontic re-treatment, the preoperative

SUCCESSFUL RE-TREATMENT
One must recognize that the patients in the
Washington study were all controlled university clinic
or specialty practice patients, as were the patients in
many of the other success and failure reports, an
important consideration in evaluating these outcomes.
In marked contrast, worldwide reports of endodon-
tic success and failure in a cohort of general practice
patients is an entirely different matter.44,85–103 To make
matters worse, the periradicular lesions in these
reports were associated with previously treated
endodontic general practice cases and were much high-
er (24.5 to 46%) than the periradicular lesions in non-
treated teeth (1.4 to 10%) (Table 13-3).
There is also a very disappointing finding in a gen-
eral survey by Buckley and Spångberg at the University Figure 13-21 Apical perforation through overinstrumentation
of Connecticut; they noted that periradicular lesions leads to loss of the apical stop, gross overextension, and failure to
are found 5 to 10 times more often in endodontically compact the canal filling. Notice that instrumentation has resulted
treated teeth than for teeth without root fillings.101 in a canal that is short of the apex. (Courtesy of Dr. Pierre Mactou.)
762 Endodontics

A B C
Figure 13-22 A, Failure case with apical and lateral periradicular lesions. B, Re-treatment eliminates bacterial infection through extensive
recleaning, reshaping, and canal medication. Obturation by vertical compaction fills the lateral canal as well. C, Complete healing 1 year later.
(Courtesy of Dr. Pierre Mactou.)

state of the tooth (as above) obviously being a key fac-
tor in outcome.106 Stabholz et al.107 and Friedman108
have noted that causes of endodontic failure fall into
three categories: preoperative, intraoperative, and post-
operative causes. Of these three, intraoperative, that is,
iatrogenic, causes are the most prevalent but the most
easily controlled.109 For example, Nair has pointed out
that refractory periradicular infections are found in
acute symptomatic teeth.110 At the same time, others
have noted that these bacteria may have been “planted”
there as contaminants during previous endodontic
treatment.110–116 As previously stated, infected dentin
chips, extruded from overinstrumentation, may also be
the “root” cause of refractory infections.103 Bergenholtz
has stated that“…root filling material [per se] was not
the immediate cause of the unsuccessful cases, but that

Table 13-3 Cross-sectional Studies on the Presence of Periapical Periodontitis (PAP) in Nontreated and
Endodontically Treated Teeth and Quality of Treatment
Endodontically Endodontically Treated Technically Inadequate
Lead Author Country Teeth with PAP (%) Treated Teeth (%) Teeth with PAP (%) Treatment (%)

Bergenholtz, 1973 Sweden 6 12.7 31 —

Hansen, 1976 Norway 1.5 3.4 46 —
Petersson, 1986 Sweden 6.9 12.4 31 > 60
Allard, 1986 Sweden 10 18 27 69
Eckerbom, 1987 Sweden 5.2 13 26.4 55
Eriksen, 1988 Norway 1.4 3.4 34 59
Odesjo, 1990 Sweden 2.9 8.6 24.5 70
Imfeld, 1991 Switzerland 8 20.3 31 64
De Cleen, 1993 Netherlands 6 2.3 38 50.6
Buckley, 1995 United States 4.1 5.5 31.3 58
Soikkonen, 1995 Finland 4 21 16 75
 Outcome of Endodontic Treatment and Retreatment 763

Table 13-4 Nonsurgical Endodontic Re-treatment Table 13-5 Nonsurgical Endodontic Re-treatment
Outcome in Pulpless Teeth without Periapical Outcome in Teeth with Periapical Periodontitis
Periodontitis
Success Failure
Authors Cases Success (%) Authors Cases (%) Uncertain (%)

Strindberg, 1956 64 95 Strindberg, 123 84 — 16

Grahnon and Hansson, 1961 323 (roots) 94 1956
Engstrom et al., 1964 68 93 Grahnen and 118 (roots) 74 — 26
Hansson, 1961
Bergenhotz et al., 1979 322 (roots) 94
Engstrom et al., 85 74 — 26
Molven and Halse, 1988 76 (roots) 89
1964
Allen et al., 1989 48 96
Bergenhotz et al., 234 (roots) 48 30 22
Sjögren et al., 1990 173 (roots) 98 1979
Friedman et al., 1995 42 100 Molven and 98 (roots) 71 — 29
From Friedman.28 Halse, 1988
Sjögren et al., 94 (roots) 62 — 38
1990
unsuccessful cases were caused…by a reinfection in the
apical areas favored by overinstrumentation”105 Friedman et al., 86 56 34 10
(Figure 13-23). 1995
Mactou has laid out the important factors that must Sundqvist et al., 50 74 — 26
be adhered to if re-treatment is to be successful: first of 1998
all, complete recleaning and reshaping of the canals. From Friedman.28
This should be carried out in a step-down fashion:
early coronal enlargement and canal body shaping
prior to apical preparation (personal communication,
April 2000).

A B C
Figure 13-23 A, Failed endodontic treatment caused by overinstrumentation and failure to totally obturate the canal. Note the gross overex-
tension of sealer and that the final 6 mm of the canal are sealer only. B, Re-treatment by complete recleaning, reshaping, and canal medica-
tion before final obturation. C, Twelve-year recall shows total healing. Note recurrent decay at the distal margin of the crown (arrow) that
can lead to microleakage and potential failure. (Courtesy of Dr. Pierre Mactou.)
764 Endodontics
The canal should be cleaned segment by segment
through a coronal reservoir of 2.5% of sodium
hypochlorite. Working length at the radiographic ter-
minus is established late in treatment, when the
remainder of the canal has already been cleaned and
shaped. Maintenance of apical potency and constant
recapitulation with fine files avoids canal blockage with
dentin debris. It also allows the sodium hypochlorite to
reach this area. Great care must be exercised when
removing the previous filling material, particularly
when solvents such as chloroform are used.
It is very difficult to remove all of the sealer and
gutta-percha from the canal walls. Wilcox et al. con-
tended that the last remnants of sealer can be removed
only by vigorous reinstrumentation and reshaping of
the canal117,118 but cautioned that overenlargement
may result.119 It would appear that sealer removal is
most important since bacteria can easily “hide” under
previous sealer.
CANAL MEDICATION
Re-treatment cases are notorious for continued failure!
In all probability this is caused by the failure to remove
or kill the refractory bacteria responsible for the lesions
A B
C
in the first place. One is warned that these cases are
challenging, and this is probably not the occasion for
one-appointment therapy. Continuing failure is
undoubtedly owing to remaining bacteria, and their
elimination calls for extra effort. New data regarding
failed root canals indicate that these microflora120–122
differ from those of untreated necrotic teeth.
Enterococci, for example, are quite prevalent in previ-
ously root-filled teeth and are quite difficult to elimi-
nate. Enterococcus faecalis is the most frequent strain and,
as a monoinfection, is found in 33% of the cases.123
Entercocci are quite resistant to calcium hydroxide, so
Safaui et al. have recommended the addition of iodine
potassium iodide in these cases.124 Heling and Chandler
have recommended a mixture of 3% hydrogen peroxide
and 1.8% chlorhexidine as an alternative against E. fae-
calis.125 Staphylococcus aureus and Pseudomonos are also
notorious refractory contaminants and may require a
prescription of metronidazole and amoxicillin to rid the
periapex of these bacteria.126–128
OBTURATION AND RESTORATION
It goes without saying that total obturation is the sine
qua non of successful re-treatment.
Figure 13-24 A, Pretreatment radiograph reveals failed endodon-
tic treatment and a periradicular lesion. B, Re-treament by total
recleaning, reshaping, and canal medication. Final obturation by
vertical compaction fills the lateral canal as well. C, Six-year follow-
up. (Courtesy of Dr. Pierre Mactou.)
 Outcome of Endodontic Treatment and Retreatment
A Mactou.)
B C
For this, the reader is referred to chapter 11.
Furthermore, since many failures are believed to be
related to microleakage from around coronal restora-
tions, it is imperative that the re-treated tooth be prop-
erly restored, at once, not weeks later (Figure 13-24).
Molven and Halse have said it best: “Success depends
on the elimination of root canal infection present when
treatment starts, and the prevention of both contami-
nation during treatment and re-infection later. So suc-
cess rates reflect the standard of the cleaning, shaping
and filling of root canals”129 (Figure 13-25).
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