Apical terminus location of root canal treatment procedures

Min-Kai Wu, MD, MSD, PhD, a Paul R. Wesselink, DDS, PhD, b and Richard E. Walton, DMD, MS, c Amsterdam, The Netherlands, and Iowa City, Iowa ACADEMIC CENTREFOR DENTISTRYAMSTERDAM (ACTA)AND UNIVERSITYOF IOWA, COLLEGE OF DENTISTRY
The apical termination of root canal treatment is considered an important factor in treatment success. The exact impact of termination is somewhat uncertain; most publications on outcomes are based on retrospective findings. After vital pulpectomy, the best success rate has been reported when the procedures terminated 2 to 3 mm short of the radiographic apex. With pulpal necrosis, bacteria and their byproducts, as well as infected dentinal debris may remain in the most apical portion of the canal; these irritants may jeopardize apical healing. In these cases, better success was achieved when the procedures terminated at or within 2 mm of the radiographic apex (O to 2 mm). When the therapeutic procedures were shorter than 2 mm from or past the radiographic apex, the success rate for infected canals was approximately 20% lower than that when the procedures terminated at 0 to 2 mm. Clinical determination of apical canal anatomy is difficult. An apical constriction is often absent. Based on biologic and clinical principles, instrumentation and obturation should not extend beyond the apical

foramen. (Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2000;89:99-103)

Canal instrumentation includes both cleaning and shaping. Cleaning is the significant reduction of tissue as well as micro-organisms and their by-products from the pulp system. With a vital pulp, micro-organisms would not be present in the apical part of the canal. In infected cases, bacterial contamination may reach the most apical part of the canal 1-3 and occasionally the periapex. 4-8 The purpose of shaping during instrumentation is to create a canal configuration suitable for obturation. Ideally, instrumentation should terminate at a suitable location, which is not necessarily the same for both vital and infected cases. If the termination is too short or too long, the outcome is negatively influenced. Obturation and restoration prevent the reinfection of the pulp space by micro-organisms from the oral cavity, to seal all portals of exit and to serve as a wound dressing against which healthy tissue can oppose. Sealers are toxic, and their irritative effects increase as the material/tissue contact surface area increases. 9 Because obturating materials (particularly sealers) may elicit sensitivity and immune responses when in contact with vital tissues, 10 they should remain in the canal to minimize contact surface and irritative effects. 11-14 Furthermore, theoretically, a small contact surface may reduce the risk of leakage as a result of less material/canal wall interface. aLecturer. bprofessor and Chairman, Departmentof CariologyEndodontology Pedodontology,AcademicCentre for DentistryAmsterdam(ACTA), Amsterdam, The Netherlands. cprofessor,Departmentof Endodontics, Universityof Iowa, College of Dentistry,Iowa City, Iowa. Received for publication Feb 2, 1999; returned for revision Mar 16 and June 15, 1999; acceptedfor publication July 10, 1999. Copyright 2000 by Mosby,Inc. 1079-2104/2000/$12.00 + 0 7/151101618

On the other hand, the extension of the root filling should not be too short. If the apical canal is not completely obturated, residual bacteria may survive and multiply1; tissue fluids percolating into the canal may provide nutritive substrate. The apical 3 mm of the root canal system has been considered to be a critical zone in the treatment of infected root canal. 15

PROGNOSIS STUDIES
In 1994, Stabholz et a116 summarized the factors influencing the success and failure based on a series of mainly retrospective studies. No influence was found for most therapeutic factors, such as number of treatment sessions, type of interappointment intracanal medicament, type of filling material, obturation technique, etc. All studies agreed, without exception, that the extension of the filling material indeed influenced the treatment outcome. 16 However, the analyses were based solely on radiographic findings, which may not coincide with histologic healing. 17-19 In addition, no adequate statistical tests were applied to investigate the simultaneous influence of several potential factors on treatment outcome. 2 However, these studies together form a very large sample; the influence of other factors may be similar in the subgroups of over-, under-, and flush-extended root fillings. Therefore, the same conclusion reached in all these studies is likely a correct observation: prognosis is decreased with overfill and with significant underfill.

ANATOMY OF THE APICAL CANAL The apical anatomy of the root canal system (Fig 1) is important in understanding the principles of root canal treatment (RCT). The traditional classical concept of 99

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ORAL SURGERY ORAL MEDICINE ORAL PATHOLOGY January 2000

root canal

dentin

cementum _ Apex

Fig 1. Concept of the apex. Distance between the 2 landmarks, the apical constriction (AC) and the apical foramen (AF), and the true apex varies in each root considerably. The presence, location, and relationships of the AC to the AF is more theoretical than actual.

this anatomy is from Kuttler. 21 He found that usually the root canal narrowed toward the apex and expanded to form the apical foramen (AF). Further, the narrowest part of the canal formed the apical constriction (AC), just short of the AE However, in another publication, 22 the "traditional" single AC was found in less than half of the teeth. Frequently, the very apical portion of root canal was tapered or parallel. 22 Other authorslS, 23 had suggested that often no AC is present, particularly with apical pathosis and root resorption.15, 23 The classic concept (Fig 1) is also that the AC forms the minor foramen (or minor diameter)24; the most apical opening of the root canal is designated the AF or major foramen or greater diameter. 24 In reality, in more than 60% of the canals, the AF is not located at the apex, and the distance between the AF and the radiographic apex varies from 0 to 3.0 mm.21,22,z4-27The conclusion is that the classic apical canal anatomy, as shown by Kuttler, 21 is more conceptual than actual. The AC is commonly advocated as the ideal termination for RCT, being a natural narrowing of the root canal and almost at the termination of the pulp. This is supposedly where an apical stop is formed, against which the obturation materials are packed. Because this constriction is usually not present, the AF may be a more useful landmark. The distance between the AC (when present) and the AF ranges from 0.5 to 1.0 m m for teeth of different ages.21,22, 24-27 When the AF is located, the position of the AC (if it exists) can be estimated; if the AC is not present, the preparation and obturation will usually be within the confines of the root. In fact, it is difficult to locate either the AC or the AF clinically. Usually visible radiographically is the root apex. Although 0.5 to 1 mm short of the radiographic apex is commonly used as the termination point, this is only an estimate. It is an attempt to debride and obtu-

rate close to the AF but hopefully, not beyond. Obviously, this will often not be the outcome.

TERMINATION POINT WITH A VITAL PULP

With an irreversible pulpitis (vital pulp), bacteria (if present) are usually limited to the chamber. Instrumentation apically is to remove the noninfected tissue and to shape the canal. For these cases, the favorable point to terminate instrumentation and to form an apical stop appears to be 2 to 3 mm short of, rather than 0 to 2 mm from, the apex. 12,28 This principle (partial pulpectomy) was originally proposed by Davis 29 in 1922. He suggested preservation of vital pulp apically, often referred to as the apical pulp stump. Following this principle, a good success rate was obtained by Kerekes and Tronstad 28 and by Sjrgren et al.12 Therefore, for vital cases, the biologic and clinical evidence indicates it is unnecessary to terminate the procedures close to the AF. When the apical pulp stump remains, extrusion of irritating filling materials into the periradicular tissues may be prevented, thereby favoring apical healing. 14 Apparently, the reaction of the pulp stump to the filling materials will not negatively influence the health of periapical tissues. The concept that the apical periodontium should not be challenged with the extrusion of root canal filling materials beyond the end of the canal is supported by many authors. 30

TERMINATION POINT FOR INFECTED CANALS

Infected canals likely differ from teeth with vital pulps. In addition to removal of necrotic tissue and debris, an important goal is to reduce or eliminate bacteria. Because it is unknown how many bacteria remaining in the apical portion of the root canal can be managed by host defenses, instrumentation length should presumably not be shorter than the apical level

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Wu, Wesselink, and Walton 101

"-:)." ~'.{

dentin debris

A
I II

Fig 2. Recapitulation to the working length with a small file. A, Dentin debris may shorten the working length and plug the canal at and beyond the working length. B, Recapitulation with a small file will aid in maintaining the full working length; the canal beyond the working length may still be plugged by debris.

of bacteria. Bacteria may remain sealed in the rootfilled canals of many radiographically successful cases. 31 As long as there is no pathway of bacteria or bacterial by-products to the periapex, a periapical response will not develop. If an avenue is later established, a nutritional (substrate) supply will develop, bacteria will proliferate and an inflammatory reaction may ensue. Canals with necrotic pulp tissue with or without periradicular pathosis are treated as infected canals. % An approach is to evaluate the correlation between the termination point and the success rate of infected canals by using the data from only those cases with pretreatment radiolucencies. These are likely the cases with infected canals32; the change in size of the lesion after treatment is assessed radiographically. A definite correlation between the radiographic and histologic findings has been reported for the teeth with pretreatment apical radiolucencies only. 33 Importantly, a tooth with no apical radiolucency before treatment may actually have an apical pathosis that is not radiographically visible. 34 Therefore, information about the change in lesion size after the treatment may not be provided by the radiographs if the lesion remains invisible. Perhaps this is why no definite correlation between the radiographic and histological findings could be found for the teeth without pretreatment apical radiolucencies. 33 The best success for treatment of teeth with necrotic pulps has been recorded when RCT was terminated at or within 2 m m of the radiographic apex (0 to 2 mm) for infected canals with visible apical pathosis. However, statistically significantly lower success was recorded

when treatment terminated short of 2 mm from, or was beyond the radiographic apex. 12,28,35 When procedures were more than 2 m m short of the apex, a significant reduction in success rate was recorded. 12,26 An interpretation is that the apical canal may harbor a critical count of microorganisms that would maintain periradicular inflammation. Thus, instrumentation is preferred to a level deep enough to remove or at least significantly reduce these microorganisms. During instrumentation, dentinal debris, which may be infected, is produced and may remain within the apical canal or in the periapical tissues. 1 In the canal, this debris may reduce the working length and may hinder repair. 36,37 In a study 37 of periradicular biopsies, extruded dentin debris or other materials often was associated with surrounding inflammation. These debris or materials were related to a history of RCT or apicoect0my. Why dentin chips cause periradicular inflammation 36,37 should be further studied. Recapitulation to the working length only may maintain the working length but not remove the dentinal debris that have plugged the canal beyond the working length (Fig 2). It presumably would be preferable to prevent plugging of dentinal debris in the apical portion of the canal, although it is unknown whether this debris (infected or uninfected) constitutes a significant irritant. With the use of instrumentation, techniques that involved a rotational motion, such as the balanced force, Canal Master U, Lightspeed and ProFile techniques 38,39 and frequent irrigation in sufficiently enlarged apical canals 4 have been found to be efficient in reducing accumulated dentinal debris in the apical canal.

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Wu, Wesselink, and Walton

ORAL SURGERY ORAL MEDICINE ORAL PATHOLOGY January 2000 bacteremia often is the result of overinstrumentation of teeth with necrotic, b a c t e r i a l l y c o l o n i z e d pulp spaces. 5 Although there is no definitive evidence that introducing bacteria or antigens from infected canals into the bloodstream causes systemic diseases, it would seem prudent to avoid this situation when possible.

A n o t h e r technique to enlarge and clean the apical canal is "apical clearing?' Parris et al,41 after step-back filing, used successively larger files a few sizes larger than the master apical file with a reaming motion; this technique did indeed enlarge and further debride the apical canal with less debris accumulation. One suggested approach to solve the problem is the "apical patency" concept. This is using a very small size file (10 or 15) to 1 m m longer than the final working length in an attempt to remove the dentinal debris from the very apical portion of the canal. This concept is taught in 50% of the United States dental schools. 42 However, the efficacy o f using a small file to remove the debris remains to be evaluated. Considering the apical canal anatomy, this approach seems unreasonable. If the patency file extends to the radiographic apex, 43 usually the instrument will go beyond the A F because the A F is usually located short of the apex. 21,22,25-27 The further the deviation of the A F from the apex, the further the instrument will penetrate and damage apical periodontium. In addition, the small file will likely not remove significant amounts o f debris. Again, this apical patency concept remains untested.

SUMMARY
Because most publications on outcomes are retrospective, definitive conclusions are not possible. Based on current information, the apical termination point of root canal treatment procedures seems to be an important influence on treatment outcomes. F o r teeth with vital pulps, leaving an apical pulp stump of up to 3 m m is recommended. For the infected canals, the length of root canal instrumentation should ideally not be short of the level to which bacteria have contaminated; locating the A F is of more importance, but it is difficult to accomplish. The final length for a few cases in which root canal therapy has failed and the failure m a y be related to infection in the very apical part of the canal, is to the AF; admittedly, the exact level of the A F cannot be determined with certainty. In conclusion, b a s e d on b i o l o g i c a l principles and experimental evidence, instrumentation or obturation should not extend beyond the apical foramen. These r e c o m m e n d a t i o n s m a y change as additional wellcontrolled, outcome-assessment studies are published.

TERMINATION POINT FOR RETREATMENT

W h e n present, the AC is the narrowest diameter of the blood supply. Apically, the canal widens and m a y have a richer b l o o d supply that m a y allow better i m m u n e activities than in the pulp canal. However, bacteria m a y s o m e t i m e s persist in the canal 44 and survive b e y o n d the AC; a speculation is that these bacteria are related to R C T failures. 1 It seems that it would be preferable to clean the canal to the A F in retreatment; the downside is the possibility of overinstrumentation, which would force materials and debris into periradicular tissues. In order to reduce the introduction of irritants into the periapex, a suggestion is to clean the coronal part of the root canal first with a step-down or crown-down sequence 45 with copious irrigation. However, instrumentation extended beyond the radiographic apex, which certainly would have its apical terminus beyond the AF, has been found to hinder apical healing significantly.4648 Although instrumentation to the A F is suggested for some failure cases, usually the apical stop should be created at 1 to 2 m m short of the A F to confine the instruments, irrigants, and obturants to the canal space.

REFERENCES
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SYSTEMIC CONSIDERATIONS
Concerns have recently been raised relative to the impact o f oral conditions on systemic health. 49 The impact may be by bacterial or immunogenic seeding of distant organs or tissues v i a the vascular ( b l o o d or l y m p h a t i c ) system. It has been d e m o n s t r a t e d that a

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Reprint requests:
M-K Wu, MD, MSD, PhD Department of Cariology Endodontology Pedodontology Academic Centre for Dentistry Amsterdam (ACTA) Louwesweg 1 1066 EA Amsterdam, The Netherlands M.Wu@acta.nl