Thomas Kvist

Editor

Apical Periodontitis
in Root-Filled Teeth

Endodontic Retreatment
and Alternative Approaches

123
Apical Periodontitis in Root-Filled Teeth
Thomas Kvist
Editor

Apical Periodontitis in
Root-Filled Teeth
Endodontic Retreatment and
Alternative Approaches
Editor
Thomas Kvist
Department of Endodontology
University of Gothenburg The Sahlgrenska Academy
Gothenburg
Sweden

ISBN 978-3-319-57248-2    ISBN 978-3-319-57250-5 (eBook)

https://doi.org/10.1007/978-3-319-57250-5

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Contents

1 Introduction��������������������������������������������������������������������������������������   1
Thomas Kvist
2 Incidence, Frequency, and Prevalence ������������������������������������������   7
Fredrik Frisk
3 Aetiology of Persistent Endodontic Infections
in Root-Filled Teeth�������������������������������������������������������������������������  21
Luis E. Chávez de Paz
4 Consequences������������������������������������������������������������������������������������  33
Fredrik Frisk and Thomas Kvist
5 Diagnosis ������������������������������������������������������������������������������������������  43
Thomas Kvist and Peter Jonasson
6 Decision Making������������������������������������������������������������������������������  55
Thomas Kvist
7 Surgical Retreatment����������������������������������������������������������������������  73
Peter Jonasson and Magnús Friðjón Ragnarsson
8 Non-surgical Retreatment ��������������������������������������������������������������  89
Charlotte Ulin
9 Prognosis ����������������������������������������������������������������������������������������  103
Thomas Kvist
10 Alternatives: Extraction and Tooth Replacement����������������������  117
Pernilla Holmberg
Index��������������������������������������������������������������������������������������������������������  133

v
List of Contributors

Luis E. Chávez de Paz, DDS, MS, PhD Division of Endodontics,

Department of Dental Medicine, Karolinska Institute, Huddinge, Sweden
Fredrik Frisk, DDS, PhD Department of Endodontology, Institute for
Postgraduate Dental Education, Jönköping, Sweden
Department of Endodontology, Institute of Odontology, University of
Gothenburg, The Sahlgrenska Academy, Göteborg, Sweden
Pernilla Holmberg, DDS  Department of Oral Prosthodontics and National
Oral Disability Centre, Institute for Postgraduate Dental Education,
Jönköping, Sweden
Peter Jonasson, DDS, PhD Department of Endodontology, Institute of
Odontology, The Sahlgrenska Academy, University of Gothenburg, Göteborg,
Sweden
Thomas Kvist, DDS, PhD Department of Endodontology, Institute of
Odontology, The Sahlgrenska Academy, University of Gothenburg, Göteborg,
Sweden
Magnús Friðjón Ragnarsson, DDS Endodontist in private practice,
Reykjavik, Iceland
Charlotte Ulin, DDS Specialist Clinic of Endodontics, Public Dental
Service Västra Götaland, Göteborg, Sweden

vii
 Introduction
1
Thomas Kvist

Our discussion will be adequate if it has as much clearness as the subject-matter admits
of, for precision is not to be sought for alike in all discussions,… for it is the mark of an
educated man to look for precision in each class of things just so far as the nature of the
subject admits.
Aristotle (350 BC) Nicomachean Ethics. Translated by W D Ross

Abstract
Diagnosis and treatment of the pathological conditions of the dental pulp
and the periradicular tissues is the primary focus of Endodontology. Over
more than 100 years, clinical experience and scientific research have gen-
erated a substantial base of critical knowledge. Reports published in jour-
nals and textbooks have indeed established the principles for endodontic
therapy. As a consequence, endodontics has become a well-established
and natural branch of restorative dentistry. Billions of teeth are saved from
extraction. However, the powerful diagnostic and treatment potential char-
acterizing endodontology, today has resulted in new clinical, scientific and
ethical challanges.

1.1 Contemporary Endodontics restorative dentistry. Billions of teeth are saved

Diagnosis and treatment of the pathological con-
ditions of the dental pulp and the periradicular
tissues is the primary focus of Endodontology.
Over more than 100 years, clinical experience
and scientific research have generated a sub-
stantial base of critical knowledge. Reports
published in journals and textbooks have
indeed established the principles for endodon-
tic therapy. As a consequence, endodontics has
become a well-­established and natural branch of
T. Kvist, PhD, DDS
Department of Endodontology, Institute of
Odontology, The Sahlgrenska Academy,
University of Gothenburg, Göteborg, Sweden
e-mail: kvist@odontologi.gu.se
from extraction and dentistry, at least in devel-
oped countries, has abandoned the “Pull and be
Damned Road” [1].
The advancement of new instruments and tech-
niques for diagnosis and treatment in endodon-
tics has been a predominant feature of research
and development over the past 25 years. By vir-
tue of the strong technological expansion in the
discipline, endodontic therapy is currently a very
feasible and attractive discipline that allows the
prudent and skillful endodontists and many gen-
eral dental practitioners to properly manage most
teeth in need of endodontic treatment.
However, in a “globalized world,” the power-
ful diagnostic and treatment potential character-
izing endodontics, as well as most other disciplines
in medicine and dentistry, today have resulted in
new clinical, scientific, and ethical challenges.

© Springer International Publishing AG 2018 1

T. Kvist (ed.), Apical Periodontitis in Root-Filled Teeth,
https://doi.org/10.1007/978-3-319-57250-5_1
2 T. Kvist
1.2  he Continued High
T including preventive measures. Saving teeth by
Prevalence of Caries
in a Growing and Aging
Population
For most of the twentieth century, the incidence
of dental caries declined in many developed
countries, but from a worldwide perspective,
dental caries remains the most prevalent human
ailment. In 2010 it was calculated that 2.4 billion
people were affected by untreated caries in the
permanent dentition. At the same time, the global
population is growing and the life expectancy is
increasing while tooth loss is decreasing.
Consequently, the need for “saving teeth” by
endodontic therapy is inexhaustible in the fore-
seeable future [2].
In many countries, people keep their teeth lon-
ger, and with increasing age, the prevalence of
the number of teeth in need of endodontic treat-
ment increases [3]. At the same time, the medical
and technical challenges and d­ ifficulties may be
very extensive for the c­ linician [4].
1.3  he Increasing Costs
T entific evidence to clinical practice. As a mat-
and Fair Distribution
of High-Quality Dental Care
Modern endodontics is associated with seem-
ingly constant pressure in increasing cost of
delivering endodontic care. During my practice
lifetime, 30 years, I have seen the necessary
armamentarium for root canal treatment go
from some hand files, gutta-percha, chloro-
form, a few spreaders, and analog X-rays to
ever more expensive technology like micro-
scopes, Ni-Ti machine driven instruments,
ultrasonics, apexlocators, and CBCT imaging
equipment. Whatever new technology the
future brings, it is unlikely to reduce the cost of
delivering care. So, one of the big challenges
in the future will be staying current with tech-
nological innovations and scientific develop-
ment while keeping costs low enough for poor,
retired, disabled, low, or flat income people to
be able to keep teeth that are in need of end-
odontic procedures. If not, fewer people can
afford the cost of high-quality dental care,
endodontic treatment risks to become a privi-
lege only for a few [5].
1.4  he Lack of Solid Evidence
T
for Many Methods
of Diagnostic and Treatment
Procedures in Endodontics
Several careful analyses of the evidence basis for
the methods that we apply in endodontics have
demonstrated extensive shortcomings. The situa-
tion is worrying for diagnostic and treatment
procedures as well as for evaluation of the results
of our methods [6]. This is not least when it
comes to the presence of apical lesions in root-
filled teeth.
1.5  he Importance of Technical
T
Skills and Good Clinical
Judgment
Endodontics is not only about applying best sci-
ter of fact, the operator’s clinical expertise and
patient’s preferences in any clinical situation are
equally important. There are different forms of
skills a good clinician must acquire. The techni-
cal skill a clinician must gain in order to render
proper treatments can only partially be gained
from research or “reading.” Therefore, practi-
cal training on models, careful implementation
of new clinical methods and watching skillful
colleagues at work, and reflecting on what has
been learned are consistently important for the
development of a skillful endodontist. The clini-
cal situation also demands that dentists exercise
good clinical judgment. This means “to do the
right thing at the right moment.” In the tradition
of the works of the Greek philosopher Aristotle,
the ability has been termed “phronesis” and can
be translated to “practical wisdom.” In order to
provide patients with proper clinical care, an
endodontist cannot rely on clinical research only
but needs also the practical skills of a craftsman,
where clinical and moral judgements are integral
components [7].
1 Introduction
1.6  he Still Large Proportion
T 1.9  he Possible Link
of Root-Filled Teeth
with Less than Entirely
Satisfactory Treatment
Results
Despite the technological developments in our
discipline, so far, there is no convincing evidence
to suggest that the overall prognosis of root canal
treatments has increased over a period of
50 years. In epidemiological studies, the preva-
lence of apical periodontitis in root-filled teeth
repeatedly is reported to be 25–50% or even
more. The gap between “what is possible to
achieve” and “what is actually achieved” has to
be analyzed from cognitive, psychological, and
ethical perspectives [8].
1.7 The Implant Threat
The history of the dental implant era is not yet
completely written, but the long-term perfor-
mance of replacements seems to be equal to
tooth-supported constructions. The technique is
nowadays spread worldwide. So far the overall
costs of replacing an endodontically involved
tooth with an implant are often higher than
those of a root canal therapy. But when more
and less expensive are brought to the market,
the implant technology may prevail over end-
odontics and, in particular, when primary root
canal treatment has failed [9].
1.8  he Internet as a Source
T inflammation and thus accommodate intraoral
of Patients’ Information
Patients’ increased abilities to retrieve informa-
tion resulted in a public that is more demanding
of better outcomes to treatment [10]. The
response from governments and authorities
could be more regulatory intervention to con-
trol perceived lapses in quality and ethics
among dentists. While the intent would be
noble, the implementation will probably lead to
an increase in administration time and less time
to devote to professional development and
patient care.
3
T
Between General Health
and Root Canal Infections
The availability of information of varying quality
has likely contributed partly to regenerate the
interest in a possible association between end-
odontic infections and general health. Our disci-
pline is facing an inevitable task to better describe
and evaluate any such connection [11].
1.10 The Awareness
of the Complexity of Biofilm
Infections
The increased understanding of the complexity and
diversity of the biofilms that are present in necrotic
root canals and many root-filled teeth has chal-
lenged the view that root canal treatment is about
getting root canals sterile. However, the essential
objective of endodontic treatment still remains, to
combat bacterial populations within the root canal,
at least to significantly reduce to levels that are com-
patible with periradicular tissue healing [12, 13].
1.11 T
 he Two Sides
of the CBCT-Coin
With new technologies, like the advent of CBCT,
it also stands clear that postoperative situations
without symptoms and even teeth-­unobjectionable
conditions, as can be assessed on an intraoral
X-ray, may still prove to have signs of residual
microorganisms. These observations put your
finger on a crucial point. What should be regarded
as a period or sick and what needs to be treated
and what does not need to be addressed? [14, 15]
To retreat or not to retreat, that’s the question?
1.12 What Is a Disease?
It has been argued that both modern medicine and
dentistry face fundamental ethical problems if too
rigorous and consistent concepts of disease prevail.
4 T. Kvist

The discussion about different concepts of disease
goes back to ancient philosophy and has bewil-
dered and engaged philosophers ever since. This
book about apical periodontitis in root-filled teeth
can only hint at the central questions. For further
reading, the interested reader should seek in books
on philosophy of medicine [16].
Two fundamentally different concepts of dis-
ease can by tradition be recognized.
The naturalist theory defines disease in terms of
biological processes. Disease is a value-free
concept, existing independently of its social
and cultural context. Disease is discovered,
studied, and described by means of science.
The normativist theory, on the other hand,
declares that there is no value-free concept of
disease. Rather than discovered, the concept
of disease is invented. It is contextual and
given by convention.
These theories address different aspects and pose
different challenges to medicine and dentistry. But
the two predominant concepts have been challenged
for several reasons. For example, they do not neither
one separately or together fully acknowledge all
important perspectives on human disorders. A dif-
ferent approach is to apply the “triad of disease, ill-
ness and sickness” [17]. The triad and its implications
on dentistry were elaborated by Hofmann and
Eriksen [18]. Kvist et al. [19] made initial attempts
to apply the theory to the problem of asymptomatic
root-filled teeth with apical periodontitis. In a
Chapter in Molar Endodontics edited by Peters
2017, I again and more profoundly discussed “the
triad” from a theoretical point of view [20].
The issue of “apical periodontitis in root-filled
teeth” is very well suited as an example of how
“the triad” can be applied to a human ailment and
give some new perspectives of this “dilemma”
that in different ways characterized and plagued
our discipline for so many years (Table 1.1).
Disease means the disorder in its’ physical form,
the biological nature, and the clinical and
paraclinical findings (histology, microbiology,
radiography, etc.).
Illness is used to describe a person’s own experi-
ence of the disease, how it feels, and what suf-
ferings it gives now or in the future. Illness
also includes anxiety and anguish.
Sickness is the third label; it tries to capture the
social role of a person who has illness or dis-
ease (or both) in a particular cultural context.
What is eligible for being “sick” can conse-
quently vary over time and between societies.

Table 1.1  An attempt to apply the triad of disease, illness, and sickness to root-filled teeth with apical periodontitis
Disease Illness Sickness
Phenomena studied Pathophysiological, Pain, swelling, or other Criteria for classification and
histological, microbiological, symptoms present now grading of disease
and radiographic events or in the future
Validity Objective Subjective Intersubjective
Purpose from the To study the medical facts of To decide upon common criteria
To identify and describe
professions’ point of apical periodontitis in order to for classification, define different
the incidence, frequency,
view improve knowledge of how to and intensity for severities of disease, and
prevent and cure construct decision aids to guide
patient-related outcomes
clinical action
(pain, swelling, spread)
Purpose from To get an explanation of the To value and accept or To understand what is regarded
patients’ point of situation not accept the situation
“sick,” respectively “healthy,” and
view to be helped to make a clinical
decision in his or her situation
Example of issues The biofilm in root-filled teeth. Factors that can predict Reassessment of the criteria for
of concern regarding The immunological response future pain or negative “success” and “failure” following
“apical periodontitis to persistent root canal impact on general health root canal treatment
in root-filled teeth” infection
The three approaches to disease do not replace but complement each other. It is also the case that they are strongly
intertwined. However, using the matrix of “disease,” “illness,” and “sickness” possibly makes it easier to understand and
to identify and rationalize the different natures of questions and discussions.
1 Introduction
1.13 The Authors
The endodontists contributing to this book about
apical periodontitis have that common denomi-
nator that they are or were in some way affiliated
with the Department of Endodontics or Oral
Microbiology at the University of Gothenburg.
This means that many of the ideas, experiences,
and knowledge conveyed in this book, for many
years and at a large number of hours, have been
worn and soaked in conjunction with lectures,
seminars, courses, and conferences.
In addition, we, who contributed as authors to
this book, have been cooperating and discussing
with many other endodontists, other specialists
(dentists and physicians), general practitioners,
philosophers, educators, and psychologists
throughout the years. No one mentioned and no
one forgotten.
However, a few people have in particular, but in
different ways over the years contributed to the
strong clinical and research environment that has
been “our school.” They have been our inspiration,
and their contribution has been particularly signifi-
cant for creating, developing, and retaining end-
odontics as a strong discipline in Gothenburg,
Sweden, Scandinavia, and the world. Late
Professor Bure Engström, late Professor Åke
Möller, Professor Gunnar Bergenholtz, Professor
Gunnar Dahlen, and Professor Claes Reit all have
been invaluable, each in his own way.
We are all grateful and proud to have been
able to pursue parts of our professional education
and training in this inspiring setting.
DDS Pernilla Holmberg is a prosthodontists
and has a background in Malmö and Jönköping,
being two other dental colleges in Sweden with
strong research and clinical environments.
1.14 The Book
I hope that the various contributions to this book
will provide both a comprehensive and in-depth
description of the issues, which from different
aspects appear when dentists or doctors, their
patients, and other dental and health services are
faced with “apical periodontitis in root-filled teeth.”
5
As for the references, it has been our ambition
not to mention all the published works that have
dealt with an issue or topic. Our objective has
instead been carving out a number of key refer-
ences. With these as a starting point, it is easy to, via
various search functions in publicly accessible data-
bases such as PubMed, search further for more ref-
erences. The general international trend with more
and more magazines and publications also means
that every reference list pretty soon tends to become
outdated. Those interested who want to keep them-
selves updated must constantly follow the develop-
ment by taking advantage of new publications.
References
1. Ingle J. “Pull and be damned Road” Preface to first
edition in “Endodontics” 1965. In: Ingle J, Bakland L,
Baumgartner C, editors. Ingle’s endodontics6, 6th ed.
PMPH-USA; 2008.
2. Kassebaum NJ, Bernabé E, Dahiya M, Bhandari B,
Murray CJ, Marcenes W. Global burden of untreated
caries: a systematic review and metaregression. J Dent
Res. 2015;94:650–8.
3. Norderyd O, Koch G, Papias A, Köhler AA, Helkimo
AN, Brahm CO, Lindmark U, Lindfors N, Mattsson A,
Rolander B, Ullbro C, Gerdin EW, Frisk F. Oral health
of individuals aged 3–80 years in Jönköping, Sweden
during 40 years (1973–2013). II. Review of clinical and
radiographic findings. Swed Dent J. 2015;39:69–86.
4. Murray CG. Advanced restorative dentistry—a prob-
lem for the elderly? An ethical dilemma. Aust Dent
J. 2015;60(Suppl 1):106–13.
5. Callahan D. Health care costs and medical technol-
ogy. In: Crowley M, editor. From birth to death and
bench to clinic: the Hastings Center bioethics briefing
book for journalists, policymakers, and campaigns.
Garrison, NY: The Hastings Center; 2008. p. 79–82.
6. Swedish Council on Health Technology Assessment.
Methods of diagnosis and treatment in endodontics—
a systematic review. Report no. 203; 2010. p. 1–491.
http://www.sbu.se
7. Bergenholtz G, Kvist T. Evidence-based endodontics.
Endod Top. 2014;31:3–18.
8. Dahlström L, Lindwall O, Rystedt H, Reit C. “It’s
good enough”: Swedish general dental practitioners
on reasons for accepting sub-standard root filling
quality. Int Endod J. 2017; https://doi.org/10.1111/
iej.12743. [Epub ahead of print].
9. Bateman G, Barclay CW, Saunders WP. Dental dilem-
mas: endodontics or dental implants? Dent Update.
2010;37:579–82. 585–6, 589–90 passim
10. Rossi-Fedele G, Musu D, Cotti E, Doğramacı
EJ. Root canal treatment versus single-tooth implant:
6 T. Kvist
a systematic review of internet content. J Endod.
2016;42:846–53.
11. Khalighinejad N, Aminoshariae MR, Aminoshariae
A, Kulild JC, Mickel A, Fouad AF. Association
between systemic diseases and apical periodontitis.
J Endod. 2016;42:1427–34.
12. Wu MK, Dummer PM, Wesselink PR. Consequences
of and strategies to deal with residual post-treatment
root canal infection. Int Endod J. 2006;39:343–56.
13. Siqueira JF Jr, Rôças IN. Clinical implications and
microbiology of bacterial persistence after treatment
procedures. J Endod. 2008;34:1291–301.
14. Wu MK, Shemesh H, Wesselink PR. Limitations of
previously published systematic reviews evaluat-
ing the outcome of endodontic treatment. Int Endod
J. 2009;42(8):656–66.
15. Haridas H, Mohan A, Papisetti S, Ealla KK. Computed
tomography: will the slices reveal the truth. J Int Soc
Prev Community Dent. 2016;6(Suppl 2):S85–92.
16. Wulff HR, Pedersen SA, Rosenberg R. Philosophy of
medicine: an introduction. 2nd ed. Oxford: Blackwell
Scientific; 1990.
17. Hofmann B. On the triad disease, illness and sickness.
J Med Philos. 2002;27:651–73.
18. Hofmann BM, Eriksen HM. The concept of disease: ethi-
cal challenges and relevance to dentistry and dental edu-
cation. Eur J Dent Educ. 2001;5:2–8. discussion 9–11.
19. Kvist T, Heden G, Reit C. Endodontic retreatment
strategies used by general dental practitioners. Oral
Surg Oral Med Oral Pathol Oral Radiol Endod.
2004;97:502–7.
20. Kvist T. The outcome of endodontic treatment. In:
Peters OA, editor. The guidebook to molar endodon-
tics. Heidelberg: Springer-Verlag Berlin Heidelberg;
2017.
 Incidence, Frequency,
and Prevalence
2
Fredrik Frisk

As our world continues to generate unimaginable amounts of data, more data lead to
more correlations, and more correlations can lead to more discoveries.
Hans Rosling (1948–2017) was a Professor of International Health,
Department of Public Health Sciences/Global Health (IHCAR),
Karolinska Institute, and founder of the Gapminder Foundation.

Abstract
Epidemiological studies may provide important information on frequency
and prevalence of apical periodontitis and root-filled teeth. They may also
present data on outcome of endodontic treatment in community dental
care along with determining factors. Results from epidemiological studies
can be used to generate hypotheses to be tried in clinical studies in which
causal relationships may be established.
The prevalence of apical periodontitis in root-filled teeth is high and
statistically determined by root filling quality and, to a lesser extent, resto-
ration quality. The long-term retention of root-filled teeth may be depen-
dent on the restoration.
Data on incidence of apical periodontitis in root-filled teeth or exacer-
bation of apical periodontitis in root-filled teeth are scarce or lacking due
to methodological difficulties.

2.1 Introduction What relevance may epidemiological data have

Wherever studied apical periodontitis is a fre-
quent finding in root-filled teeth. Epidemiological
data and research may not be seen as an impor-
tant adjunct by the clinician. Epidemiology is
concerned with groups of individuals while
the clinician focuses on the individual patient.
F. Frisk, DDS, PhD
Department of Endodontology, Institute for
Postgraduate Dental Education, Jönköping, Sweden
Department of Endodontology, Institute of
Odontology, The Sahlgrenska Academy, University
of Gothenburg, Göteborg, Sweden
e-mail: fredrik.frisk@rjl.se
for the clinician and for the patient? It may help
to answer some questions about, for example,
endodontic treatment; which prognosis is
expected and what are the determining factors? Is
the condition prevalent and which symptoms
may be expected? What are the risks involved if
treated or left untreated? Health planners and
policy makers may use data to allocate resources
in order to use them effectively. They need
answers to some questions as well; is the condi-
tion becoming more or less prevalent? Is the con-
dition becoming more difficult to treat? Is there a
need for educational efforts in order to make
treatment more effective?

© Springer International Publishing AG 2018 7

T. Kvist (ed.), Apical Periodontitis in Root-Filled Teeth,
https://doi.org/10.1007/978-3-319-57250-5_2
8 F. Frisk
Data from population surveys inform us that
there is a positive correlation between poor root
filling quality and apical periodontitis. Although
educational efforts and technical improvement
have resulted in better root filling quality, no
decrease in apical periodontitis in root filled teeth
is seen. One explanation may be that more molar
teeth are endodontically treated, and most patients
retain their own teeth when they get older, making
endodontic treatment even more challenging.
Even though crucial information is lacking in
comparison to controlled clinical studies, popula-
tion surveys are critical to investigate periapical
status and outcome of endodontic treatment in
the general population in community dental care.
Therefore, it is important that they are spread to
include as many populations as possible and
repeated to take time trends into account and ren-
der updates on disease prevalence.
2.2  opulation Surveys vs.
P (prevention and healing of apical periodontitis,
Clinical Studies
Most clinicians find endodontic treatment to be a
complicated and delicate procedure. Thus, tech-
nical difficulties may account for a high preva-
lence of apical periodontitis in root-filled teeth.
Population surveys confirm that clinicians
repeatedly fail to meet high demands on the
technical quality of the root filling as interpreted
on a radiograph. When investigated in popula-
tion surveys, the radiograph is usually the only
source of information. Nevertheless, data from
population surveys frequently confirms the
established view on root filling quality and its
impact on the periapical status. However, in
comparison to the clinical study, crucial infor-
mation about the endodontic treatment per-
formed is lacking. Clinicians contributing with
data to clinical studies most often work in educa-
tion and specialist centers with excellent facili-
ties for endodontic treatment. Moreover, they are
aware of their participation in the study which
may contribute to a higher level of motivation,
further affecting treatment quality. Consequently,
data from clinical studies may contribute to an
unrealistic expectation on the outcome of root
canal treatment. A common misconception when
comparing results from clinical studies and pop-
ulation surveys is that general practitioners fre-
quently are unsuccessful in clinical endodontics,
while endodontists are highly successful.
Available data do not support such a notion.
However, interpreted correctly, data from popu-
lation surveys may be representative for the
result of endodontic treatment in community
routine dental care (effectiveness). Data from
clinical studies may represent what can be
achieved with endodontic treatment (efficacy).
Data from contemporary population surveys
are presented as means from a population and do
not support conclusions as to which interventions
that provide effective treatment results. For
example, rotary instrumentation is widely con-
sidered as a valuable adjunct in endodontic treat-
ment and has been used, and widely spread, in
clinical practice for well over a decade. The ben-
efit on a population level in terms of outcome
tooth retention) and cost-effectiveness has yet to
be shown.
2.3 Epidemiological Study
Design
In endodontic epidemiology, mainly cross-­sectional
and longitudinal studies are used. Below, the reader
will find a brief presentation of these study designs
as well as an introduction of some terms which
may need clarification. Prevalence and frequency
are synonymous terms. In this text prevalence will
mean the percentage of individuals (with apical
periodontitis) and frequency will mean percentage
of teeth (with apical periodontitis) at a certain point
in time. Incidence will mean percentage of teeth
(getting apical periodontitis) during a determined
period of time.
2.3.1 Cross-Sectional Studies
The most common study in endodontic epidemi-
ology is the cross-sectional study. A synony-
mous term is prevalence study. It measures the
2  Incidence, Frequency, and Prevalence
prevalence (individual level) or frequency (tooth
level) of a certain entity at a given point in time.
The entity to be measured is required to be
chronic or long-lasting such as apical periodon-
titis or root-­filled teeth. Acute events, short-last-
ing conditions, or exacerbations are not eligible
for the cross-sectional study since the time for
examination may not coincide with the event or
condition to be studied. In the context of apical
periodontitis in root-filled teeth, a major draw-
back is the lack of knowledge about the end-
odontic treatments in the teeth studied. If a
certain tooth has a periapical destruction, it
should be crucial to know when the treatment
was performed and which periapical status the
tooth had at the outset of treatment. Is the peri-
apical destruction developing or healing? If a
tooth appears to have a healthy periapex, apical
periodontitis may be developing even though it
is not radiographically detectable. A longitudinal
study on this issue reported that the number of
developing and healing periapical destructions
were almost the same and thus minimizing the
problem [1] whereas another study did not sup-
port this conclusion [2]. Another drawback is
that causality cannot be studied in a cross-sec-
tional study since the relation between two vari-
ables is studied at one point in time only.
However, cross-sectional studies are frequently
used to investigate associations between differ-
ent variables such as root filling quality and peri-
apical status. Frequently, poor root filling quality
is found to be associated with periapical destruc-
tions, but in a cross-sectional study it cannot be
established as a cause, or risk factor, for apical
periodontitis. It may serve as an indicator of
poor treatment quality and/or ineffective end-
odontic treatment. Thus, poor root filling quality
may be the aggregate result of poor access prep-
aration, poor aseptic technique, poor instrumen-
tation, and poor irrigation.
Cross-sectional studies on root-filled teeth
and apical periodontitis are spread geographi-
cally uneven. A large fraction of the total num-
ber of studies has been conducted in
Scandinavia. However, during recent years sev-
eral studies from mainly European countries,
but also from other continents, have emerged.
9
This is of great importance since data from one
setting cannot be interpreted as representative
for another setting.
As can be seen in Table 2.1, the prevalence
and frequency of apical periodontitis differ
between different studies. Of course, this can be
due to varying prevalence of disease in differ-
ent populations and an indicator of poor treat-
ment quality or poor accessibility to dental care.
It may also reflect the use of different defini-
tions for a healthy and diseased periapical area,
respectively. Also, extraction frequency needs to
be taken into account. Thus, a low prevalence of
apical periodontitis in root-filled teeth may not
necessarily represent high treatment quality. It
may merely be a result of extraction of teeth with
persistent apical periodontitis. Also, selection of
teeth with prerequisites for a favorable outcome
(no preoperative apical periodontitis, no tech-
nical complications, or technically demanding
­treatment) may influence the results.
2.3.2 Longitudinal Studies
These studies follow a number of subjects over a
period of time. A synonymous term is cohort
study. In the context of population surveys, no
intervention is done—all subjects go about their
ordinary life and treatments as usual. The condi-
tion to be studied needs to be frequent enough in
order to provide a sufficient number of cases to
be compared with non-cases. A “case” is an indi-
vidual, or a tooth, with the condition under study,
for example apical periodontitis. Also, the length
of time between baseline and follow-up needs to
be adjusted in relation to what is intended to be
investigated. It needs to be long enough for the
event under study to take place and short enough
to be registered before the event is impossible to
identify. Apical periodontitis is prevalent enough
to produce a sufficient number of cases. However,
a healthy tooth may develop apical periodontitis
and be root canal treated and even extracted
between baseline and follow-up if the time span
is too long. Under such circumstances a lot of
information is lost and should warrant shorter
follow-up periods.
 10
Table 2.1  Cross-sectional studies reporting on prevalence of root-filled teeth (RF) and apical periodontitis (AP), frequency of apical periodontitis and frequency of apical peri-
odontitis in root-filled teeth.”
Prevalence Prevalence Frequency Frequency
Study Country Radiograph Sample RF (%) AP (%) AP total (%) AP RF (%)
Bergenholtz et al. [34] Sweden Apical/FMR Patient 57 6.1 30.5
Boltacz-Rzepkowska [35] Poland Apical/FMR Patient 25
Boucher et al. [36] France Apical/FMR Patient 62 7.4 29.7
Buckley and Spångberg [37] USA Apical/FMR Patient 4.1 31.3
Chen et al. [38] USA Panoramic Population 38.8 45.6 5.1 35.5
Da Silva et al. [39] Australia Panoramic Patient 21.4
De Cleen et al. [40] Netherlands Panoramic Patient 44.6 6.0 39.2
De Moor et al. [41] Belgium Panoramic Patient 63.1 6.6 40.4
Dugas et al. [42] Canada Apical/FMR Patient 34.3 3.1 45.4
Dutta et al. [6] Scotland CBCT Patient 39.2 5.8 47.4
Eckerbom et al. [43] Sweden Apical/FMR Patient 83.5 63 5.2 26.4
Eriksen and Bjertness [45] Norway Apical/FMR Population 56 3.5 36.5
Eriksen et al. [46] Norway Apical/FMR Population 24 14 0.6 38.1
Estrela et al. [47] Brazil Apical/FMR Patient 38
Georgopoulou et al. [48] Greece Apical/FMR Patient 65.6 85.5 13.6 60
Gulsahi et al. [49] Turkey Panoramic Patient 23.8 1.4 18.2
Hollanda et al. [50] Brazil Panoramic Patient 21.4
Hommez et al. [51] Belgium Apical/FMR Patient 32.5
Huumonen et al. [52] Finland Panoramic Population 61
Ilić et al. [53] Serbia Panoramic Patient 85 93.8 51.8
Jersa and Kundzina [54] Latvia Panoramic Patient 87 72 7 31
Jimenez-Pinzon et al. [55] Spain Apical/FMR Patient 40.6 61.1 4.2 64.5
Kabak and Abbott [56] Belarus Panoramic Patient 80 12 45
Kalender et al. [57] Cyprus Panoramic Patient 64 68 7 62
Kamberi et al. [58] Kosovo Panoramic Patient 12.3 46.3
Kirkevang et al. [59] Denmark Apical/FMR Population 52 42.3 3.4 52.2
Kim [60] South Korea Panoramic Patient 22.8
Loftus et al. [61] Ireland Panoramic Patient 31.8 33.1 2.0 25.0
Lupi-Pegurier et al. [62] France Panoramic Patient 7.3 31.5
Marques et al. [63] Portugal Panoramic Population 22 26 2 21.7
F. Frisk
Matijevic et al. [64] Croatia Panoramic Patient 75.9 8.5
Moreno et al. [65] Colombia Apical/FMR Patient 49
Paes da Silva et al. [5] Brazil CBCT Patient 51.4 3.4 35.4
Peciuliene et al. [66] Lithuania Apical/FMR Patient 43.1
Persic et al. [67] Croatia/Austria Panoramic Patient 47.3/62.1
Peters et al. [68] Netherlands Panoramic Patient 2.5 24.1
Petersson et al. [69] Sweden Apical/FMR Patient 93 77 8.7 26.5
Saunders et al. [71] Scotland Apical/FMR Patient 54 67.7 4.9 58.1
Sunay et al. [72] Turkey Panoramic Patient 47 4.2 53.5
Skudutyte-Rysstad et al. [73] Norway Apical/FMR Population 23 16 1.1 43
Sidaravicius et al. [74] Lithuania Apical/FMR Population 72 70 7.2 35
Tavares et al. [12] France Apical/FMR Patient 33
2  Incidence, Frequency, and Prevalence

Touré et al. [75] Senegal Apical/FMR Patient 35.5 59.6 4.6 56.1 (roots)
Tercas et al. [76] Brazil Apical/FMR Patient 67.5 5.9 42.5
Tolias et al. [77] Greece Panoramic Population 62.3
Tsuneishi et al. [78] Japan Apical/FMR Patient 86.5 69.8 40
Weiger et al. [79] Germany Panoramic/Apical Patient 3.0 61
Ödesjö et al. [80] Sweden Apical/FMR Population 43.2 2.9 24.5
Özbaş et al. [81] Turkey Apical/FMR Patient 1.6 38
11
12 F. Frisk

Longitudinal studies measuring the inci- may be examined with regard to pulpal sensitiv-
dence of apical periodontitis are scarce. They are ity to confirm the diagnosis. In an epidemiologi-
expensive to conduct and difficult to manage. A cal study exclusively based on radiographs, this
major problem is loss to follow-up. If too many information is lacking but it is usually considered
participants are prevented from participating, uncontroversial since the most probable diagno-
or choose not to, it should be questioned as to sis is apical periodontitis [3]. Older studies inves-
whether the remaining sample is representative tigating root-filled teeth and apical periodontitis,
for the population. more often than today, used apical radiographs.
During recent decades panoramic radiographs
have emerged as a simpler and more economical
2.3.3 Methodology technique. Also, and more important, it exposes
the individual with a lower radiation dose com-
2.3.3.1 Selection pared to a full mouth examination using apical
When reviewing studies in the field of endodon- radiographs. In the context of epidemiological
tic epidemiology, it is apparent that the most studies, the panoramic radiograph has been dem-
common individual studied is the one who seek onstrated as reasonably effective as the apical
dental care at a dental school and have been radiograph when apical periodontitis is studied
examined with full-mouth radiographs and/or [4]. It performs worse than the apical radiograph
panoramic x-rays. This is a convenient approach when root filling quality is studied. Cone beam
since researchers do not have to make an effort to CT (CBCT) is a rather new technique which has
invite individuals to the examination. Also, if shown to be promising as an adjunct in endodon-
individuals examined are exposed to radiation in tic diagnostics. However, it has not been used in
the context of seeking dental care, there will be a endodontic epidemiology other than in a few stud-
lesser ethical dilemma as to whether the radio- ies [5, 6]. It may be viewed as doubtful if it is jus-
logical examination was justified or not. However, tifiable to expose healthy individuals with a much
it is reasonable to assume that individuals seek- larger radiation dose (compared to a full mouth
ing dental care are not representative for the examination) when studying the prevalence and
whole population. This assumption may be espe- frequency of apical periodontitis. Apical peri-
cially true for patients seeking dental care at a odontitis is a prevalent condition and not life-­
dental school. These patients may have more threatening other than for selected patients. It
extensive treatment needs and may have smaller may thus be argued that CBCT is not suited for
financial resources than the population as a screening. Others claim that it is justifiable and
whole. Thus, in order to render samples represen- advocate the use of CBCT in epidemiological
tative for the population, researchers should con- studies, highlighting the drawbacks with two-­
sider other approaches such as studying a dimensional techniques [5].
randomized sample of individuals. If large It is acknowledged that when studying apical
enough, the randomized sample may be regarded periodontitis or root filling quality, researchers
as representative for the population from which it have to consider a variation both between observ-
was sampled. Studies using randomized samples ers and also within observers over time [7]. This
are in minority in endodontic epidemiology. is often referred to as inter- and intraobserver
Despite the methodological considerations dis- variation, respectively. In order to cope with the
cussed, the number of studies using convenience problem, two different strategies have been
sampling is still in majority. developed to reduce observer variation when
studying apical periodontitis.
2.3.3.2 Radiographic Examination Reit and Gröndahl [8] suggested that observer
Does the periapical destruction always represent variation may be reduced if the number of
apical periodontitis? In a clinical context non-­ false-­ positive findings is kept to a minimum
root-­filled teeth with a periapical destruction by instructing the observers to only register a
2  Incidence, Frequency, and Prevalence
Fig. 2.1  PAI-Reference scale with scores 1–5 and corresponding radiological and histological periapical expressions [10]
p­ eriapical destruction when certain, introducing
a five-scale index where score 1 = “periapical
destruction of bone definitely not present” and
5 = “periapical destruction of bone definitely
present.” This index is also called the PRI-index
(probability index). Reit [9] found that calibra-
tion of observers had only limited benefits in
reducing observer variation.
Örstavik et al. [10] presented the periapical
index (PAI). In contrast to Reit [9] it is proposed
that observers should be calibrated, and in con-
trast to Reit and Gröndahl [8] there is no overall
strategy to reduce false-positive findings. PAI
works as follows: observers are presented with a
five-graded scale with radiographs with differ-
ent periapical expressions ranging from periapi-
cal health (score 1) to an aggravating periapical
condition (score 2–5) (Fig. 2.1). The periapical
expressions on the radiographs have been vali-
dated with the histological periapical expression
in a previous study using biopsies from an
autopsy material [3]. For the purpose of calibra-
tion of observers to PAI, observers are instructed
to use the scale when observing 100 radio-
graphs. When in doubt, observers are instructed
to assign a higher score. The reason for this is
findings from Brynolf [3] where the histological
periapical expression always was more severe
than the radiological periapical expression. The
registrations are then compared to a “golden
standard” constructed by a panel of observers
who have assigned “true” scores to all 100
teeth. If the observer variation is low enough
13
Table 2.2  Text reference for the periapical expression
according to modified Strindberg criteria as adopted by
Reit and Hollender [7]
0 = Normal periapical condition
1 = Increased width of the periodontal membrane
space. Lamina dura continuous
2 = Increased width of the periodontal membrane
space. Lamina dura diffuse
3 = Periapical radiolucency
compared to the “golden standard,” observers
may use PAI in their study.
An alternative to PAI, when defining a healthy
and diseased periapex, modified Strindberg crite-
ria may be used [7, 11]. There is only a text refer-
ence to describe the periapical expression
(Table 2.2).
Studies evaluating the different approaches
are scarce. However, Tavares et al. [12] used both
PAI and modified Strindberg criteria. There is no
information as to which strategy that was adopted
when the modified Strindberg criteria were used.
Authors reported approximately the same preva-
lence of apical periodontitis within the same
sample regardless of method used. Tarcin et al.
[13] reported on results from comparing PAI,
PRI, and modified Strindberg criteria. PAI had
higher interobserver agreement, reflecting the
use of reference radiographs. When dichotomiz-
ing PAI and PRI, both inter- and intraobserver
agreement were higher than for the original
5-scale PAI- and PRI-indices, respectively, and
for the modified Strindberg criteria.
14
2.4  esults from Population
R rotary or reciprocating instrumentation improve
Surveys: What We Know
and What We Don’t
2.4.1 F
 requency and Prevalence
of Apical Periodontitis
and Root-Filled Teeth
A growing number of cross-sectional studies
provide us with data on apical periodontitis in
root-­filled teeth. However, longitudinal data are
scarce, and thus knowledge on the natural course
of the root-filled tooth with untoward events and
healing pattern is incomplete.
Cross-sectional studies display a wide range
in the frequency of root-filled teeth and apical
periodontitis, both on the tooth level (frequency)
as well as the individual level (prevalence). As
previously discussed this may reflect differences
between populations but also differences in
study design and definitions of outcome mea-
sures. Within the studies data often reveals an
increasing frequency of root-filled teeth and api-
cal p­ eriodontitis with increasing age. They also
report on a decreasing number of teeth. The lat-
ter may explain the increasing frequency alone
but also the number of root-filled teeth increases
with age [14].
Repeated cross-sectional studies show a trend
toward decreasing frequency of apical periodon-
titis and root-filled teeth for comparable age
groups. This is probably a result of a concomitant
decrease in caries frequency and is thus expected
and uncontroversial. A more unexpected finding
is that the frequency of apical periodontitis in
root-filled teeth is unchanged over time. Changes
in treatment protocols, new techniques and mate-
rials, and an increasing knowledge in microbiol-
ogy and immunology should be expected to
improve the results of endodontic treatment.
What may be possible reasons for this inconsis-
tency? Clinicians today probably treat more
advanced and challenging cases than in earlier
decades. Frisk et al. [14] showed that molars
were more often treated than premolars and inci-
sors in 2003. In 1973 it was the other way around.
Undeniably technically advanced systems for
F. Frisk
the treatment quality with regard to instrumenta-
tion and root filling quality. This is often high-
lighted in endodontic literature and marketing of
endodontic armamentarium. However, asepsis
and biological necessities (a complex bacterial
flora protected in a biofilm, need for copious irri-
gation with sodium hypochlorite) may need
boosted attention.
In longitudinal studies only small variations in
the frequency of apical periodontitis with increas-
ing age is seen. Results from different studies are
inconclusive [1, 15–17]. The frequency of root-­
filled teeth increases. This result is consistent
between studies. Kirkevang et al. [15] also dem-
onstrated that the increase was less marked in
younger age groups and that they received their
root fillings later in life indicating an improve-
ment in oral health. Studies reporting on changes
in the frequency of root-filled teeth with apical
periodontitis with increasing age show conflict-
ing results.
2.4.2 R
 isk Indicators for Apical
Periodontitis in Root-Filled
Teeth
2.4.2.1 Tooth-Specific Risk Indicators
Is it possible to identify a set of criteria indicating
higher risk for persisting or developing apical
periodontitis in root-filled teeth?
In epidemiological studies, the most common
predictor for apical periodontitis in root-filled
teeth is poor root filling quality. This association
is demonstrated in almost all studies pertaining to
apical periodontitis and root-filled teeth. It should
be acknowledged that poor root filling quality is
not a cause of apical periodontitis. It merely
serves as an indicator or predictor for ineffective
treatment or prevention of the root canal infec-
tion. As previously mentioned repeated cross-­
sectional studies report that the root filling quality
has improved over time without a concomitant
decrease in the frequency of apical periodontitis
in root-filled teeth. Thus, other reasons for persis-
tent apical periodontitis and ineffective treatment
2  Incidence, Frequency, and Prevalence 15

or prevention of the root canal infection must be
considered. The quality of restoration has gained
some attention as a risk indicator and has been
studied by several authors. While data are incon-
clusive as to whether poor restoration quality is
an independent risk indicator for apical periodon-
titis in root-filled teeth, the combination of ade-
quate restoration and adequate root filling
increases the chance for periapical healing [18].
Less studied is the impact of type of restoration
on periapical status in root-filled teeth. A recent
study reported that large composite fillings and
large mixed fillings (amalgam and composite)
were predictive of apical periodontitis when con-
trolling for root filling quality [19].
Results are inconclusive as to whether type and
quality of restorations in root-filled teeth predicts
a higher risk for apical periodontitis. Root filling
quality remains as the most significant predictor
for apical periodontitis in population surveys.
2.4.2.2 Individual-Specific Risk
Indicators
Is it possible to identify individuals with a spe-
cific set of risk factors or risk indicators for apical
periodontitis in root-filled teeth?
Conditions and behavioral factors have been
studied as risk indicators for apical periodontitis
in root-filled teeth in a few studies. Smoking has
repeatedly been reported as a predictor for apical
periodontitis. In a systematic review five out of
six cross-sectional studies reported a statistically
significant association between smoking and
periapical bone lesions [20]. There is no estab-
lished biological mechanism between smoking
and apical periodontitis, and present studies do
not disclose any causal relationship between
smoking and apical periodontitis. The reported
association between smoking and apical peri-
odontitis in root-filled teeth may, to some extent,
be explained by factors related to study design
and quality: small samples, misclassification of
nonsmokers, and poor control of possible con-
founders. Additionally, diabetes has been reported
to be associated with apical periodontitis on both
individual level and tooth level [21]. Also, dental
care habits may be associated with apical peri-
odontitis, whereas socioeconomic status has not
been confirmed as a predictor [22, 23].
Patients with irregular dental habits and smok-
ers may be suspected to be at higher risk for hav-
ing root-filled teeth with apical periodontitis.
There is no evidence to claim that endodontic
treatment of a specific tooth among these patients
should have a worse prognosis compared to other
groups of patients. It may be speculated that the
higher prevalence of apical periodontitis may be
explained by behavioral factors such as dental
care habits and a different attitude to health and
dental care.
2.4.3 I ncidence of Apical
Periodontitis in Root-Filled
Teeth
Is it possible to predict which root-filled teeth
that are at higher risk for developing apical
periodontitis?
In Table 2.3 incidence data for apical peri-
odontitis in root-filled teeth are listed. Those
teeth were root-filled and without radiological
evidence of apical periodontitis at base line.
Data on when the teeth were endodontically

Table 2.3  Data from longitudinal (follow-up) studies

Follow-up Incidence of root Incidence of AP Loss of
(years) canal treatmenta in root-filled teeth root-filled teeth
Kirkevang et al. [15] 11 1.7% (140/8258) 32% (67/208) 13.9% (56/402)
Petersson et al. [24] 11 3.3% (70/2100) 12.4% (17/137) 12.4% (32/258)b
Eckerbom et al. [44] 20 5.5% (155/2825) 28.8% (113/393)
Petersson et al. [70] 20 8% (23/273) 35% (159/449)
a
Retreatments excluded
b
Root-filled teeth and pulpotomized teeth included
16
treated and on which indication is not available.
According to Petersson et al. [24] the root filling
quality was a significant predictor for develop-
ment of apical periodontitis. Kirkevang et al.
[25] did not find poor root filling quality to be
predictive for development of apical periodonti-
tis, but instead increased the risk for persistent
apical periodontitis.
As can be seen, data from population surveys
do not identify factors that consistently pre-
dict which root-filled teeth will develop apical
periodontitis.
2.4.4 Loss of Root-Filled Teeth
Longitudinal studies conclusively show that
root-­filled teeth are at higher risk to be lost
than non-­root-­filled teeth [26]. Studies investi-
gating the reasons for loss of root-filled teeth
have reported that other reasons than apical
periodontitis are more frequent. Caries, failed
restorations, amount of tooth substance, and
marginal periodontitis have been reported as
risk factors for loss of root-­filled teeth [27–29].
On an individual level, one study reported that
high age, number of lost teeth, and amount of
plaque were predictive of loss of root-filled
teeth [30]. Interestingly, endodontic factors
represent a small fraction of reasons for extrac-
tion of root-filled or endodontically treated
teeth. Several studies have reported on the ben-
efit of crown restoration on root-filled teeth.
Aquilino and Caplan [31] showed that crown
placement on molars increased survival sig-
nificantly compared to root-filled molars with-
out full crown coverage. Landys-Borén et al.
[32] reported similar results but not limited to
molars. Fransson et al. [33] also reported on
a higher survival rate for teeth with indirect
restorations compared to direct restorations.
However, the difference was small, 93.1 and
89.6%, respectively.
Root-filled teeth with substantial loss of tooth
substance and root-filled molars without full
crown coverage seem to be at higher risk of being
lost. Individuals with poor dental habits seem to
be at higher risk for loss of root-filled teeth.
F. Frisk
Take Home Lessons
• Use data from epidemiological studies
to improve endodontic treatment and
care of patients with endodontic condi-
tions. Do not use it to compare data on
outcome from clinical studies conducted
in education or specialist clinics.
• Use data from epidemiological studies
to compare with your own and your col-
leagues’ clinical experience. Is your
experience at variance with epidemio-
logical data?
• There is a great potential for improve-
ment of the outcome of endodontic
treatment. Besides adequate root canal
treatment, careful case selection and
treatment planning including choice of
adequate restoration may improve the
outcome.
Benchmark Papers
• Frisk F, Hugoson A, Hakeberg
M. Technical quality of root fillings and
periapical status in root filled teeth in
Jönköping, Sweden. Int Endod J.
2008;41:958–68. This repeated cross
sectional study reported on the fre-
quency of apical periodontitis in root
filled teeth on three occasions over a
20-year period. The results also high-
lighted that an improved root filling
quality has not resulted in a lower fre-
quency of apical periodontitis in root
filled teeth.
• Kirkevang LL, Vaeth M, Wenzel A. Ten-­
year follow-up of root filled teeth: a
radiographic study of a Danish popula-
tion. Int Endod J. 2014;47:980–8. One
of few longitudinal studies that reports
on incidence of apical periodontitis in
root filled teeth and related factors.
• Gillen BM, Looney SW, Gu LS,
Loushine BA, Weller RN, Loushine RJ,
Pashley DH, Tay FR. Impact of the
2  Incidence, Frequency, and Prevalence
quality of coronal restoration versus the
quality of root canal fillings on success
of root canal treatment: a systematic
review and meta-analysis. J Endod.
2011;37:895–902. Recommended read-
ing for anyone pondering the associa-
tion between the quality of the
restoration and apical periodontitis in
root filled teeth. The paper provides a
systematic review of the literature as
well as a meta-analysis. The authors
conclude that the combination of ade-
quate root filling and adequate restora-
tion increase the chance for a healthy
periapical condition.
• Örstavik D, Kerekes K, Eriksen
HM. The periapical index: a scoring
system for radiographic assessment of
apical periodontitis. Endod Dent
Traumatol. 1986;2:20–34. An important
paper introducing the PAI-index which
over time have found an increasing
number of users in epidemiological and
clinical studies. Recommended reading
for those who are planning a study
including evaluation of periapical sta-
tus in radiographs and wants to under-
stand how observation variation may be
handled.
References
1. Petersson K. Endodontic status of mandibular premo-
lars and molars in an adult Swedish population. A lon-
gitudinal study 1974–1985. Endod Dent Traumatol.
1993;9(1):13–8.
2. Kirkevang LL, Vaeth M, Hörsted-Bindslev P,
Wenzel A. Longitudinal study of periapical and
endodontic status in a Danish population. Int Endod
J. 2006;3:100–7.
3. Brynolf I. A histological and roentgenological study
of the periapical region of human upper incisors.
Odontol Revy. 1967;18(Suppl 11):1–176.
4. Ahlqwist M, Halling A, Hollender L. Rotational pan-
oramic radiography in epidemiological studies of
dental health. Comparison between panoramic radio-
graphs and intraoral full mouth surveys. Swed Dent
J. 1986;10(1–2):73–84.
17
5. Paes da Silva Ramos Fernandes LM, Ordinola-­
Zapata R, Húngaro Duarte MA, Alvares Capelozza
AL. Prevalence of apical periodontitis detected in
cone beam CT images of a Brazilian subpopulation.
Dentomaxillofac Radiol. 2013;42:80179163.
6. Dutta A, Smith-Jack F, Saunders WP. Prevalence of
periradicular periodontitis in a Scottish subpopulation
found on CBCT images. Int Endod J. 2014;4:854–63.
7. Reit C, Hollender L. Radiographic evaluation of end-
odontic therapy and the influence of observer varia-
tion. Scand J Dent Res. 1983;91:205–12.
8. Reit C, Gröndahl HG. Application of statistical deci-
sion theory to radiographic diagnosis of endodonti-
cally treated teeth. Scand J Dent Res. 1983;91:213–8.
9. Reit C. The influence of observer calibration
on radiographic periapical diagnosis. Int Endod
J. 1987;20:75–81.
10. Örstavik D, Kerekes K, Eriksen HM. The periapi-
cal index: a scoring system for radiographic assess-
ment of apical periodontitis. Endod Dent Traumatol.
1986;2:20–34.
11. Strindberg LZ. The dependence of the results of
pulp therapy on certain factors. Acta Odontol Scand.
1956;14(Suppl 21):1–175.
12. Tavares PB, Bonte E, Boukpessi T, Siqueira JF Jr,
Lasfargues JJ. Prevalence of apical periodontitis in
root canal-treated teeth from an urban French popula-
tion: influence of the quality of root canal fillings and
coronal restorations. J Endod. 2009;35:810–3.
13. Tarcin B, Gumru B, Iriboz E, Turkaydin DE,
Ovecoglu HS. Radiologic assessment of periapi-
cal health: comparison of 3 different index systems.
J Endod. 2015;41:1834–8.
14. Frisk F, Hugoson A, Hakeberg M. Technical quality
of root fillings and periapical status in root filled teeth
in Jönköping, Sweden. Int Endod J. 2008;41:958–68.
15. Kirkevang LL, Vaeth M, Wenzel A. Ten-year follow-
­up observations of periapical and endodontic status in
a Danish population. Int Endod J. 2012;45(9):829–39.
16. Eckerbom M, Andersson JE, Magnusson T. A longi-
tudinal study of changes in frequency and technical
standard of endodontic treatment in a Swedish popu-
lation. Endod Dent Traumatol. 1989;5:27–31.
17. Frisk F, Hakeberg M. A 24-year follow-up of root
filled teeth and periapical health amongst middle aged
and elderly women in Göteborg, Sweden. Int Endod
J. 2005;38(4):246–54.
18. Gillen BM, Looney SW, LS G, Loushine BA, Weller
RN, Loushine RJ, Pashley DH, Tay FR. Impact of the
quality of coronal restoration versus the quality of
root canal fillings on success of root canal treatment:
a systematic review and meta-analysis. J Endod.
2011;37:895–902.
19. Frisk F, Hugosson A, Kvist T. Is apical periodontitis
in root filled teeth associated with the type of restora-
tion? Acta Odontol Scand. 2015;73(3):169–75.
20. Walter C, Rodriguez FR, Taner B, Hecker H,
Weiger R. Association of tobacco use and peri-
apical pathosis—a systematic review. Int Endod
J. 2012;45(12):1065–73.
18
21. Segura-Egea JJ, Jiménez-Pinzón A, Ríos-Santos JV,
Velasco-Ortega E, Cisneros-Cabello R, Poyato-­Ferrera
M. High prevalence of apical periodontitis amongst
type 2 diabetic patients. Int Endod J. 2005;38:564–9.
22. Kirkevang LL, Wenzel A. Risk indicators for api-
cal periodontitis. Community Dent Oral Epidemiol.
2003;31:59–67.
23. Frisk F, Hakeberg M. Socio-economic risk indica-
tors for apical periodontitis. Acta Odontol Scand.
2006;64:123–8.
24. Petersson K, Håkansson R, Håkansson J, Olsson B,
Wennberg A. Follow-up study of endodontic status in
an adult Swedish population. Endod Dent Traumatol.
1991;7(5):221.
25. Kirkevang LL, Vaeth M, Wenzel A. Ten-year fol-
low-­up of root filled teeth: a radiographic study of a
Danish population. Int Endod J. 2014;47:980–8.
26. Zhong Y, Garcia R, Kaye EK, Cai J, Kaufman
JS, Trope M, Wilcosky T, Caplan DJ. Association
of endodontic involvement with tooth loss in the
Veterans Affairs Dental Longitudinal Study. J Endod.
2010;36:1943–9.
27. Vire DE. Failure of endodontically treated teeth: clas-
sification and evaluation. J Endod. 1991;17:338–42.
28. Zadik Y, Sandler V, Bechor R, Salehrabi R. Analysis
of factors related to extraction of endodontically
treated teeth. Oral Surg Oral Med Oral Pathol Oral
Radiol Endod. 2008;106(5):e31.
29. Touré B, Faye B, Kane AW, Lo CM, Niang B, Boucher
Y. Analysis of reasons for extraction of endodontically
treated teeth: a prospective study. J Endod. 2011;37:1512–5.
30. Caplan DJ, Weintraub JA. Factors related to loss
of root canal filled teeth. J Public Health Dent.
1997;57:31–9.
31. Aquilino SA, Caplan DJ. Relationship between crown
placement and the survival of endodontically treated
teeth. J Prosthet Dent. 2002;87:256–63.
32. Landys-Borén D, Jonasson P, Kvist T. Long-term sur-
vival of endodontically treated teeth at a public dental
specialist clinic. J Endod. 2015;41:176–81.
33. Fransson H, Dawson VS, Frisk F, Bjørndal L,
EndoReCo, Kvist T. Survival of root-filled teeth in the
Swedish adult population. J Endod. 2016;42:216–20.
34. Bergenholtz G, Malmcrona E, Milthon R. Endodontic
treatment and periapical state. I. Radiographic study
of frequency of endodontically treated teeth and fre-
quency of periapical lesions. Tandlakartidningen.
1973 Jan;65(2):64–73.
35. Bołtacz-Rzepkowska E, Pawlicka H. Radiographic
features and outcome of root canal treatment carried
out in the Łódź region of Poland. Int Endod J. 2003
Jan;36(1):27–32.
36. Boucher Y, Matossian L, Rilliard F, Machtou P.
Radiographic evaluation of the prevalence and techni-
cal quality of root canal treatment in a French sub-
population. Int Endod J. 2002 Mar;35(3):229–38.
37. Buckley M, Spångberg LS. The prevalence and tech-
nical quality of endodontic treatment in an American
subpopulation. Oral Surg Oral Med Oral Pathol Oral
Radiol Endod. 1995 Jan;79(1):92–100.
38. Chen CY, Hasselgren G, Serman N, Elkind MS,
Desvarieux M, Engebretson SP. Prevalence and qual-
F. Frisk
ity of endodontic treatment in the Northern Manhattan
elderly. J Endod. 2007 Mar;33(3):230–4.
39. Da Silva K, Lam JM, Wu N, Duckmanton P.
Cross-sectional study of endodontic treatment
in an Australian population. Aust Endod J. 2009
Dec;35(3):140–6.
40. De Cleen MJ, Schuurs AH, Wesselink PR, Wu MK.
Periapical status and prevalence of endodontic treat-
ment in an adult Dutch population. Int Endod J. 1993
Mar;26(2):112–9.
41. De Moor RJ, Hommez GM, De Boever JG, Delmé KI,
Martens GE. Periapical health related to the quality
of root canal treatment in a Belgian population. Int
Endod J. 2000 Mar;33(2):113–20.
42. Dugas NN, Lawrence HP, Teplitsky PE, Pharoah MJ,
Friedman S. Periapical health and treatment quality
assessment of root-filled teeth in two Canadian popu-
lations. Int Endod J. 2003 Mar;36(3):181–92.
43. Eckerbom M, Andersson JE, Magnusson T. Frequency
and technical standard of endodontic treatment in a
Swedish population. Endod Dent Traumatol. 1987
Oct;3(5):245–8.
44. Eckerbom M, Flygare L, Magnusson T. A 20-year
follow-up study of endodontic variables and apical
status in a Swedish population. Int Endod J. 2007
Dec;40(12):940–8.
45. Eriksen HM, Bjertness E. Prevalence of apical peri-
odontitis and results of endodontic treatment in mid-
dle-aged adults in Norway. Endod Dent Traumatol.
1991 Feb;7(1):1–4.
46. Eriksen HM, Berset GP, Hansen BF, Bjertness E.
Changes in endodontic status 1973–1993 among
35-year-olds in Oslo, Norway. Int Endod J. 1995
May;28(3):129–32.
47. Estrela C, Leles CR, Hollanda AC, Moura MS, Pécora
JD. Prevalence and risk factors of apical periodontitis
in endodontically treated teeth in a selected population
of Brazilian adults. Braz Dent J. 2008;19(1):34–9.
48. Georgopoulou MK, Spanaki-Voreadi AP, Pantazis N,
Kontakiotis EG. Frequency and distribution of root
filled teeth and apical periodontitis in a Greek popula-
tion. Int Endod J. 2005 Feb;38(2):105–11.
49. Gulsahi K, Gulsahi A, Ungor M, Genc Y. Frequency
of root-filled teeth and prevalence of apical periodon-
titis in an adult Turkish population. Int Endod J. 2008
Jan;41(1):78–85.
50. Hollanda AC, de Alencar AH, Estrela CR, Bueno
MR, Estrela C. Prevalence of endodontically treated
teeth in a Brazilian adult population. Braz Dent J.
2008;19(4):313–7.
51. Hommez GM, Coppens CR, De Moor RJ. Periapical
health related to the quality of coronal restorations
and root fillings. Int Endod J. 2002 Aug;35(8):680–9.
52.
Huumonen S, Vehkalahti MM, Nordblad A.
Radiographic assessments on prevalence and tech-
nical quality of endodontically-treated teeth in the
Finnish population, aged 30 years and older. Acta
Odontol Scand. 2012 May;70(3):234–40.
53. Ilić J, Vujašković M, Tihaček-Šojić L, Milić-Lemić
A. Frequency and quality of root canal fillings in an
adult Serbian population. Srp Arh Celok Lek. 2014
Nov–Dec;142(11–12):663–8.
2  Incidence, Frequency, and Prevalence
54. Jersa I, Kundzina R. Periapical status and quality
of root fillings in a selected adult Riga population.
Stomatologija. 2013;15(3):73–7.
55. Jiménez-Pinzón A, Segura-Egea JJ, Poyato-Ferrera
M, Velasco-Ortega E, Ríos-Santos JV. Prevalence of
apical periodontitis and frequency of root-filled teeth
in an adult Spanish population. Int Endod J. 2004
Mar;37(3):167–73.
56. Kabak Y, Abbott PV. Prevalence of apical peri-
odontitis and the quality of endodontic treatment in
an adult Belarusian population. Int Endod J. 2005
Apr;38(4):238–45.
57. Kalender A, Orhan K, Aksoy U, Basmaci F, Er F,
Alankus A. Influence of the quality of endodontic
treatment and coronal restorations on the prevalence
of apical periodontitis in a Turkish Cypriot popula-
tion. Med Princ Pract. 2013;22(2):173–7.
58. Kamberi B, Hoxha V, Stavileci M, Dragusha E, Kuçi
A, Kqiku L. Prevalence of apical periodontitis and
endodontic treatment in a Kosovar adult population.
BMC Oral Health. 2011 Nov 29;11:32.
59. Kirkevang LL, Hörsted-Bindslev P, Ørstavik D,
Wenzel A. Frequency and distribution of end-
odontically treated teeth and apical periodontitis
in an urban Danish population. Int Endod J. 2001
Apr;34(3):198–205.
60. Kim S. Prevalence of apical periodontitis of root
canal-treated teeth and retrospective evaluation of
symptom-related prognostic factors in an urban South
Korean population. Oral Surg Oral Med Oral Pathol
Oral Radiol Endod. 2010 Dec;110(6):795–9.
61. Loftus JJ, Keating AP, McCartan BE. Periapical status
and quality of endodontic treatment in an adult Irish
population. Int Endod J. 2005 Feb;38(2):81–6.
62. Lupi-Pegurier L, Bertrand MF, Muller-Bolla M,
Rocca JP, Bolla M. Periapical status, prevalence and
quality of endodontic treatment in an adult French
population. Int Endod J. 2002 Aug;35(8):690–7.
63. Marques MD, Moreira B, Eriksen HM. Prevalence of
apical periodontitis and results of endodontic treat-
ment in an adult, Portuguese population. Int Endod J.
1998 May;31(3):161–5.
64. Matijević J, Cizmeković Dadić T, Prpic Mehicic G,
Ani I, Slaj M, Jukić Krmek S. Prevalence of api-
cal periodontitis and quality of root canal fillings in
population of Zagreb, Croatia: a cross-sectional study.
Croat Med J. 2011 Dec 15;52(6):679–87.
65. Moreno JO, Alves FR, Gonçalves LS, Martinez AM,
Rôças IN, Siqueira JF Jr. Periradicular status and
quality of root canal fillings and coronal restorations
in an urban Colombian population. J Endod. 2013
May;39(5):600–4.
66.
Peciuliene V, Rimkuviene J, Maneliene R,
Ivanauskaite D. Apical periodontitis in root filled
teeth associated with the quality of root fillings.
Stomatologija. 2006;8(4):122–6.
67. Persić R, Kqiku L, Brumini G, Husetić M, Pezelj-
Ribarić S, Brekalo Prso I, Städtler P. Difference in
the periapical status of endodontically treated teeth
between the samples of Croatian and Austrian adult
patients. Croat Med J. 2011 Dec 15;52(6):672–8.
19
68. Peters LB, Lindeboom JA, Elst ME, Wesselink PR.
Prevalence of apical periodontitis relative to endodon-
tic treatment in an adult Dutch population: a repeated
cross-sectional study. Oral Surg Oral Med Oral Pathol
Oral Radiol Endod. 2011 Apr;111(4):523–8.
69. Petersson K, Lewin B, Hakansson J, Olsson B,
Wennberg A. Endodontic status and suggested treat-
ment in a population requiring substantial dental care.
Endod Dent Traumatol. 1989 Jun;5(3):153–8.
70. Petersson K, Fransson H, Wolf E, Håkansson J.
Twenty-year follow-up of root filled teeth in a
Swedish population receiving high-cost dental care.
Int Endod J. 2016 Jul;49(7):636–45.
71. Saunders WP, Saunders EM, Sadiq J, Cruickshank
E. Technical standard of root canal treatment in an
adult Scottish sub-population. Br Dent J. 1997 May
24;182(10):382–6.
72. Sunay H, Tanalp J, Dikbas I, Bayirli G. Cross-sectional
evaluation of the periapical status and quality of root
canal treatment in a selected population of urban
Turkish adults. Int Endod J. 2007 Feb;40(2):139–45.
73. Skudutyte-Rysstad R, Eriksen HM. Endodontic status
amongst 35-year-old Oslo citizens and changes over a
30-year period. Int Endod J. 2006 Aug;39(8):637–42.
74.
Sidaravicius B, Aleksejuniene J, Eriksen HM.
Endodontic treatment and prevalence of apical peri-
odontitis in an adult population of Vilnius, Lithuania.
Endod Dent Traumatol. 1999 Oct;15(5):210–5.
75. Touré B, Kane AW, Sarr M, Ngom CT, Boucher Y.
Prevalence and technical quality of root fillings in
Dakar, Senegal. Int Endod J. 2008 Jan;41(1):41–9.
76. Terças AG, de Oliveira AE, Lopes FF, Maia Filho
EM. Radiographic study of the prevalence of apical
periodontitis and endodontic treatment in the adult
population of São Luís, MA, Brazil. J Appl Oral Sci.
2006 Jun;14(3):183–7.
77. Tolias D, Koletsi K, Mamai-Homata E, Margaritis
V, Kontakiotis E. Apical periodontitis in association
with the quality of root fillings and coronal restora-
tions: a 14-year investigation in young Greek adults.
Oral Health Prev Dent. 2012;10(3):297–303.
78. Tsuneishi M, Yamamoto T, Yamanaka R, Tamaki
N, Sakamoto T, Tsuji K, Watanabe T. Radiographic
evaluation of periapical status and prevalence of end-
odontic treatment in an adult Japanese population.
Oral Surg Oral Med Oral Pathol Oral Radiol Endod.
2005 Nov;100(5):631–5.
79. Weiger R, Hitzler S, Hermle G, Löst C. Periapical
status, quality of root canal fillings and estimated end-
odontic treatment needs in an urban German popula-
tion. Endod Dent Traumatol. 1997 Apr;13(2):69–74.
80. Ödesjö B, Helldén L, Salonen L, Langeland K.
Prevalence of previous endodontic treatment, techni-
cal standard and occurrence of periapical lesions in
a randomly selected adult, general population. Endod
Dent Traumatol. 1990 Dec;6(6):265–72.
81. Özbaş H, Aşcı S, Aydın Y. Examination of the preva-
lence of periapical lesions and technical quality of
endodontic treatment in a Turkish subpopulation. Oral
Surg Oral Med Oral Pathol Oral Radiol Endod. 2011
Jul;112(1):136–42.
 Aetiology of Persistent Endodontic
Infections in Root-Filled Teeth
3
Luis E. Chávez de Paz

The 4th sort of creatures … which moved through the 3 former sorts, were incredibly
small, and so small in my eye that I judged, that if 100 of them lay one by another, they
would not equal the length of a grain of course sand; and according to this estimate, ten
hundred thousand of them could not equal the dimensions of a grain of such course sand.
There was discovered by me a fifth sort, which had near the thickness of the former, but
they were almost twice as long.
Antonie van Leeuwenhoek 1676—in a letter to about what he saw when looking to
plaque from his own teeth through one of the first microscopes.

Abstract
Post-treatment endodontic infections are caused by microorganisms form-
ing biofilm structures that remain deep-seated in root canals or extra-­
radicular surfaces. Bacteria in biofilms are difficult to eliminate as they are
protected from both the host immune response and antimicrobials. As
revealed by culture microbiological analysis and high-throughput DNA
sequencing, the microbiota in post-treatment endodontic infections is
composed by oral pathogens mixed with species that are considered
‘harmless’ or ‘transient’ commensals. However, our knowledge concern-
ing the mechanisms that lead to the survival of these mixed microbial
communities in root-filled teeth as well as the mechanisms by which they
participate in post-treatment infections have only recently begun to
advance. This chapter explores clinical and basic biological aspects to gain
deeper understanding of microbial etiological factors that play a role in
persisting infections of endodontically treated teeth.

3.1 Introduction
Endodontic treatment aims to remove bacteria
from infected root canals by mechanical instru-
mentation in combination with chemical antimi-
crobial agents. These treatment procedures apply
physical forces to remove bacteria by direct con-
tact of hand- or machine-driven instruments on
L.E. Chávez de Paz, DDS, MS, PhD
Division of Endodontics, Department of Dental
Medicine, Karolinska Institute, Huddinge, Sweden
e-mail: luis.chavez.de.paz@ki.se
the surfaces of the root canals. The use of antimi-
crobials in the form of irrigants complements the
physical action to remove root canal bacteria.
However, in spite of these mechanical/chemical
efforts and the host’s innate and adaptive defence
mechanisms, post-treatment endodontic infec-
tions occur with relative high frequency (see
Chap. 2). These persistent infections are usually
clinically silent and are characterized by chronic
inflammatory reactions taking place in the tissues
surrounding the apexes of roots.
The underlying pathogenesis of persistent
endodontic infections is associated with the

© Springer International Publishing AG 2018 21

T. Kvist (ed.), Apical Periodontitis in Root-Filled Teeth,
https://doi.org/10.1007/978-3-319-57250-5_3
22
Original root canal
microbiota
Simplification
Fig. 3.1  Ecological moments that determine the selection
of a post-treatment root canal community. Environmental
disturbances such as mechanical instrumentation, irriga-
tion with antimicrobials and inter-appointment medication
presence of microbial biofilm communities that
­
interact with host cells triggering an inflamma-
tory and immune response [1–3]. Persisting
microbial biofilm communities formed on den-
tinal walls or on extra-radicular cementum are
difficult to eliminate in part due to their high tol-
erance/resistance to host defences and antimicro-
bials. Clinical studies have established that these
microbial communities are mainly composed by
Gram-­positive facultative anaerobic bacteria [4–
7]. Streptococcus, Lactobacillus and Actinomyces
are examples of species that are considered nor-
mal inhabitants of the oral cavity and that have
been also isolated from root-filled teeth with api-
cal periodontitis. Other nonoral species such as
Enterococcus faecalis have also been found with
relatively high frequency [4–8]. Overall, the
microbiota remaining after endodontic proce-
dures is proposed to be a subpopulation of the
original root canal microbiota. Therefore, the
mechanisms by which this resistant subpopula-
tion is selected are of interest as it may reveal
important pathogenic traits included in the adap-
tation and survival of these microorganisms.
3.1.1 Ecological Scenario
There are two main ecological processes to take
into consideration that might affect the composi-
tion and function of the post-treatment microbi-
L.E. Chávez de Paz
Environmental
disturbances
Resilience
cause a simplification of the original root canal microbiota.
Further disturbances such as lack of nutrients and interac-
tions with the host’s immune cells lead to the formation of
a resilient microbiota.
ota [9]. The first process occurs directly after or
during root canal treatment, where the applica-
tion of antibacterial solutions, dressings, etc.,
triggers a simplification of the original root canal
microbiota [9]. These environmental changes
select for a subset of the microbiota with a high
resistance and tolerance (see below). The second
process comprises the resilience of the remain-
ing community, where physiological adaptive
factors play a crucial role to establish as a resil-
ient microbial community [9]. Figure 3.1 illus-
trates these ecological processes as they are
central to understand how bacteria may survive
after treatment. This chapter will describe the
main components of this ecological hypothesis
as they have a direct implication in the aetiology
of post-­treatment infections: formation of bio-
films, localization of microbial communities
beyond the reach of chemomechanical treat-
ment, interactions with the host and resistance
and tolerance of bacteria.
3.2 Root Canal Biofilms
The biofilm concept recognizes biofilm forma-
tion as a key mechanism linked to microbial
survival, and its application in endodontics has
led to the understanding of their involvement
in the pathogenesis of endodontic infections
[1–3]. In general, biofilm formation reflects an
3  Aetiology of Persistent Endodontic Infections in Root-Filled Teeth
e­ ssential mechanism of microbial adaptation to
environmental conditions. Bacteria in biofilms
are surrounded by a matrix of bacterial exopoly-
saccharides and exogenous substances (polysac-
charides, proteins, mineral crystals, extracellular
DNA) [10, 11] that protect them from the host’s
immune defences. Antibodies and phagocytes
have difficulties to penetrate into the biofilm and
may even undergo deactivation whilst inside the
matrix [10, 11]. Bacteria in biofilms are also less
susceptible to the action of antibiotics, which
may contribute to the development of chronic
infections and relapses [12, 13].
Several studies have described the presence of
biofilms formed in infected root canals [14–16].
Biofilm structures have been reported to be
formed alongside the canal walls, inside dentinal
tubules, apical deltas and periapical areas [1–3].
The presence of these microbial structures has
been associated with different clinical states
including post-treatment endodontic infections
[14–16].
Of importance is to understand the biological
basis of biofilm formation as it is possible that
various microbial genetic regulatory pathways
involved may also play a crucial role in mecha-
nisms of resistance to host immune defences and
antimicrobial treatment [12]. Notwithstanding
the characterization of biofilms in infected root
canals, the mechanisms behind their formation in
root canals have not been well established. As
most of the species found in root canals are also
found in the oral cavity, it is reasonable to specu-
late that the formation of microbial biofilms in
root canals may have similar mechanisms as oral
biofilms. Figure 3.2 depicts the main events
occurring during the formation of a biofilm.
3.2.1 Initial Adherence to Surfaces
In the oral ecosystem, the deposition of salivary
components provides a set of receptor molecules
which are primary recognized by the early colo-
nizers, such as streptococci and actinomyces
[17]. In root canals of teeth, the presence of
plasma constituents, which increase exponen-
tially due to inflammatory transudation, may
23
form the active conditioning film paving the way
for subsequent microbial colonization [18].
Plasma constituents, such as plasminogen, may
endow with primary receptors for adhesion on
root canal surfaces [18]. This previous hypothesis
is supported by the fact that several oral species
have an affinity to bind to plasminogen via very
specific lysine-dependent mechanisms. Among
the most common plasminogen-specific binding
receptors in oral species are enolase and GAPDH.
The conditioning film may not only influence
the initial adhesion of colonizing cells, but it will
also influence the production of signalling mole-
cules that control cell physiology and resistance
to antimicrobials. In a recent study, it was found
that biofilms formed by root canal bacteria on
surfaces preconditioned with collagen showed
irregular architectures, which apparently also
influenced their responsiveness to the exposure
with antimicrobials [19]. Biofilms formed on
collagen-coated surfaces by Streptococcus gor-
donii, E. faecalis and Lactobacillus paracasei
showed a much higher resistance to NaOCl than
those biofilms formed on non-coated surfaces.
Interestingly, it was found that the levels of dehy-
drogenase and esterase activities of biofilm cells
which adhered to collagen-coated surfaces were
very low, a finding which may partially explain
their high resistance to antimicrobials. The meta-
bolic downregulation of biofilm cells on surfaces
coated with collagen may give some indications
as to how the surface condition may influence
bacterial physiology and consequently resistance
to antimicrobials.
3.2.2 Secondary Colonizers
Secondary colonizers co-aggregate to adhering
cells after the first colonizers have irreversibly
adhered to the surfaces [17]. The newcomers will
form close metabolic relationships with the
adhered cells, developing microenvironments for
the establishment of bacteria with special require-
ments such as obligate anaerobes [17]. Bacteria
with plenty of receptors that are recognized by
many other organisms, such as fusobacteria, play
a key role in forming a link between primary
24 L.E. Chávez de Paz

Fig. 3.2 Schematic a Surface

depiction of the coating
temporal sequence of
biofilm formation. (a)
Clean surfaces are seconds
coated with
environmental
molecules. (b) Pioneer
microorganisms adhere b Initial
to the conditioned adhesion
surface, utilizing minutes
different cell-surface
interactions. (c)
Incorporation of
secondary colonizers by
adhesion to the pioneers
by utilizing different
c Secondary
colonization
engaging adhesins. (d)
The production of hours
extracellular polymeric
substance (matrix)
results in the formation
of mature biofilms
where intermicrobial
signalling and
intergeneric
d Growth/
maturation
co-aggregation leads to
the development of days/weeks
complex communities

c­olonizing species and later colonizing patho-
gens [17]. In infected root canals, the presence of
fusobacteria has been widely reported and has
been linked with the occurrence of cases with
most severe inflammatory symptoms [6]. In such
cases, fusobacteria were found in combination
with highly proteolytic organisms, e.g. Prevotella
and Porphyromonas. Hence, it is likely that the
surface receptors from fusobacteria promote the
colonization of these proteolytic pathogens in
root canals. A similar case is seen in microbio-
logical screening of sites of periodontal inflam-
mation, where fusobacteria appear just before the
pathogenic “red” complex consisting of
Porphyromonas gingivalis, Treponema denticola
and Tannerella forsythia [20].
The presence of E. faecalis in post-treatment
infected root canals has received much attention
since this is an organism that shows, among other
interesting capacities, high tolerance to alkaline
pH [21–23]. Although the majority of these obser-
vations have been made in vitro, its high tolerance
to alkaline has been clinically linked to a potential
resistance to treatment with inter-­ appointment
dressings containing calcium hydroxide [5, 7].
However, the origin of E. faecalis in infected root
canals has remained highly controversial because
this organism is not commonly found in untreated
necrotic pulps and has been until recently consid-
ered a ‘transient’ microorganism in the oral flora
[24]. E. faecalis has been isolated from teeth pre-
senting post-­treatment infections with a prevalence
3  Aetiology of Persistent Endodontic Infections in Root-Filled Teeth
of 24% and 70% in studies utilizing traditional
culture-­based techniques [4–7, 25, 26] and
between 66 and 77% when molecular methods
were applied [27, 28]. In a recent series of studies
[29], it was determined that E. faecalis is not
likely to be derived from the endogenous com-
mensal flora of the gastrointestinal tract and that
even the chances for nosocomial transmission
during a root canal treatment from contaminated
high-touch surfaces in dental operatory were
slight. It was stated, however, that E. faecalis in
root canal infections are most likely food-borne
since strains from root canals and food items
shared common genotypic patterns [29].
3.2.3 Growth and Maturation
During growth and maturation of the biofilm,
the concentration of chemical signals produced
by metabolism provokes a range of phenotypic
differentiations among the species forming
microbial communities [13, 30]. These different
phenotypes trigger molecular responses that are
generated as chemical signals corresponding to
secondary metabolites, also known as quorum
sensing. The quorum sensing of microbial cells
in biofilms recognizes the proximity of cells
reaching a critical number in a limited space in
the environment and that ultimately results in
the autoinduction and synthesis of the extracel-
lular matrix [10]. The biofilm matrix is mainly
composed of polysaccharides, proteins, nucleic
acids and lipids and is a key feature to the matu-
ration of biofilm formation. The matrix will
constitute the backbone of the biofilm’s three-
dimensional structure and will allow the free
circulation of metabolites and wastes among
cells and microcolonies. The structure cohesive-
ness conferred by the matrix permits that the
biofilm community to respond like a mass and
behave as a group [10].
The composition of the matrix varies depending
on the bacterial species, the environmental condi-
tions and the metabolites available. The presence
of high levels of nutrients can lead to very dense
biofilms. For instance, in oral biofilms the presence
of high levels of sucrose in the media yields very
25
dense and large biofilms [31]. This phenomenon
was explained to be due to the ability of many oral
bacteria to synthesize dextrans (including the insol-
uble 1,3-α-D-glucan mutan) and levans using
sucrose as a substrate. It has also been observed
that mixed biofilms grown on limited nutrients that
are then switched to a rich medium change consid-
erably in their structural appearance [32].
3.3 Extra-radicular Colonization
Contrary to the traditional view of extra-radicular
tissues being always free of bacteria, compelling
clinical evidence now exists on bacteria form-
ing biofilms on extra-radicular surfaces [33–36].
Although most of the studies are described as
case reports, it is reasonable to conclude from the
available information that the formation of extra-­
radicular biofilms occurs with relative frequency.
Although still unclear, the formation of extra-­
radicular biofilms seems to be a consequence of
massive infection of the root canal system associ-
ated with prolonged exposure of the canal space
to the oral environment [34]. Of interest is, how-
ever, that most cases presenting extra-radicular
biofilms are associated with sinus tracts which
may indicate inclusion of oral fluids during bio-
film formation. The latter hypothesis is sustained
with the finding of calculus-like extra-radicular
biofilms [33, 34, 36]. Figure 3.3 shows a case of
maxillary right central and lateral incisors with
deficient root canal treatments and presenting
calculus-like material covering the apexes of
roots [33]. Upon clinical inspection, an open fis-
tula was detected in the apical area of teeth 11
and 12. Both teeth were sensitive to percussion,
and the apical mucosa was sensitive to palpation.
Radiographic examination showed a large peri-
apical lesion with a thick layer of radiopaque
material covering both root tips. Treatment
included orthograde retreatment followed by api-
cal surgery. As it is visualized in the clinical pho-
tograph, during surgery both root tips presented a
calculus-like material covering the root surfaces.
Examination by scanning electron microscopy
(SEM) of the resected specimens confirmed the
presence of mineralized biofilms in the apexes,
26
a b
d e
Fig. 3.3  Case presenting extra-radicular biofilm forma-
tion in the form of calculus. (a) Preoperative radiograph
shows extensive calcifications on the apex of 12 and 11.
(b) Post-operative radiograph taken after orthograde root
canal retreatment. (c) Postsurgical radiograph. (d) Clinical
photograph during surgical procedure shows the bone
where cells were embedded in mineralized matrix
in a very similar fashion as supra- or sub-gingival
calculus. One of the possible explanations for the
occurrence of these mineralized structures is the
long-standing sinus tract which may have allowed
passage of fluids from the oral environment,
including minerals and salts that could form these
solid mineralized masses.
L.E. Chávez de Paz
c
defect and a dark calculus-like structure covering the apex
of teeth 12 and 11. (e) Representative scanning electron
microscopy (SEM) micrograph showing clusters of cells
forming extra-radicular mineralized biofilm structures.
Case is published in [33]
3.4 Host-Microbe Interactions
The presence of biofilms in root-filled teeth leads
to a chronic inflammatory reaction in the peria-
pex which is characterized by the proliferation of
macrophages, lymphocytes and plasma cells [37,
38]. Chronic apical lesions become encapsulated
in collagenous connective tissue which is stimulated
3  Aetiology of Persistent Endodontic Infections in Root-Filled Teeth
by the upregulation of connective tissue growth
factors (TGF-β) [37, 38]. In this chronic phase
which can remain symptomless for long periods
of time, activated T cells produce cytokines that
downregulate the output of pro-­ inflammatory
cytokines (IL-1, IL-6 and TNF-α), leading to the
suppression of osteoclastic activity and reduced
bone resorption [37, 38]. Upon a secondary inva-
sion of microorganisms, the lesion can spontane-
ously turn into an acute inflammatory reaction
by rapid recruitment of PMNs, a feature that is
characterized by a rapid restitution of apical
bone resorption. And the previous silent clinical
situation may suddenly turn into a symptomatic
phase.
The chronic inflammatory lesion associated
to failed-root canal treatments is in many cases
associated to the presence of well-developed
fibrous capsules consisting of dense collagenous
fibres that are firmly attached to the root surface
[37, 38]. These chronic lesions, also known as
granulomas, do not normally harbour micro-
organisms but only in special cases: (a) acute
inflammatory phase [39], (b) periapical actino-
mycosis [40–42], (c) transient contamination
during root canal instrumentation [43, 44] and
(d) infected periapical cysts with cavities open
to the root canal [45]. The main function of the
apical granuloma is thus to contain and encap-
sulate the advancement of the infection. In the
lumen of the granuloma, macrophages, including
blood-­derived macrophages, epithelioid cells and
multinucleated giant are aimed to kill bacteria.
However, complete eradication of bacteria does
not always occur. As it has been described in few
case reports [40–42], species of Actinomyces and
Propionibacterium (formerly Arachnia) have
been found forming clusters within the lumen
of the granulation mass. Although the mecha-
nisms behind clustering formation are not clear,
it may seem that clustering occurs as a micro-
bial strategy to persist within the granuloma and
perhaps to reactivate and escape under special
circumstances.
The survival of Mycobacterium tuberculosis
in granulomatous tissues is a good example for
understanding the mechanisms behind bacterial
survival within a granuloma. It has been proposed
27
that the unfavourable conditions inside the gran-
uloma, such as nutrient limitation and low oxy-
gen tension, trigger the metabolic downshift of
M. tuberculosis into dormancy [46]. Of critical
interest is, however, that under specific circum-
stances M. tuberculosis re-establishes its meta-
bolic and replicative activity by the activation of
a complex cascade of enzymes regulated by
resuscitation-promoting factors (Rpf) [46].
Although it has not been established if Rpf
orthologs are present in Actinomyces or other
endodontic pathogens, the reactivation from a
dormant state seems to be an interesting hypoth-
esis to clarify the occurrence of exacerbations of
chronic infections. This hypothesis was tested in
an experimental study, where biofilm cultures of
S. anginosus and L. salivarius were forced to
enter a state of dormancy by exposing them to
nutrient deprivation [47]. Dormant cells were
then forced to reactivate by exposure to fresh
nutrients, but even after 96 h the cells remained
metabolically inactive. This observation high-
lights the null physiological response of dormant
cells even in the presence of fresh nutrients,
which may act as a mechanism to resist further
disturbances.
3.5 Resistance vs. Tolerance
The increased survival rate of bacteria is one of
the fundamental causes of endodontic treatment
failure and because chronic infections present as
a complicated challenge [1–3]. In order to under-
stand the mechanisms by which bacteria survive,
it is important to differentiate two main concepts:
resistance and tolerance. As it is illustrated in
Fig.  3.4, resistance comprises the mechanisms
that are specifically exerted by bacteria in the
presence of antimicrobials and that are aimed to
inactivate them. Common resistance mechanisms
include physical prevention of the antimicrobials
from reaching its target (e.g. low diffusion
through the biofilm matrix), alteration of the tar-
get such that it is no longer recognized by the
antimicrobial (e.g. modification of cell receptors)
and inactivation of the antibiotic properties to
obstruct its ability to interact with its target [48].
28
Exposure to
antimicrobials
Cell death
Resistance
Tolerance
Fig. 3.4  Schematic illustrating the differences between
microbial resistance and tolerance. (a) Cell death is nor-
mally expected after treatment of a bacterial population
with an antimicrobial. (b) Resistance is regulated by
mechanisms that are specifically exerted by bacteria to
restrain the interaction of antimicrobials with cells. (c)
Tolerance comprises mechanisms of phenotypic adapta-
tion in the presence of antimicrobials upon interaction
with the cells
Tolerance is fundamentally different as it does
not affect the ability of the antimicrobial to inter-
act with its target. Although the molecular events
that lead to antimicrobial tolerance in bacteria are
not yet clear, the mechanisms that are involved
seem to be mainly controlled by phenotypic
adaptive processes (e.g. metabolic downregula-
tion or adaptation) [48]. Phenotypic tolerance is
elicited as a result of environmental factors (such
as nutrient deprivation and pH changes) that
affect antimicrobial-induced killing, whereas
genotypic tolerance can arise from specific
genetic changes within the tolerant bacteria [48].
3.5.1 R
 esistance of Endodontic
Microorganisms
The killing effect of antimicrobials (individually
or in combinations) has been thoroughly evalu-
ated in microbiological research in endodontics.
Although most of the studies have been performed
L.E. Chávez de Paz
ex vivo, it is consensus that the use of different
chemicals with antimicrobial properties for disin-
fection may be to different extents effective to
affect the root canal microbiota [49, 50].
However, it is clear that a portion of the microbi-
ota, especially those that are deep-seated in hard-­
to-­reach areas and forming multispecies biofilm
communities, may resist and remain viable after
treatment with antimicrobials [14, 36].
A key feature on antimicrobial resistance is
the differences between cells growing in plank-
tonic or in biofilm conditions. In planktonic cul-
tures, antimicrobials can gain direct access to
bacterial cells, whereas in biofilms they encoun-
ter diffusion-reaction limitations through the
matrix so that they hardly can reach the deepest
layers of the biofilm in their active form [12, 13].
For example, a recent study showed that biofilms
formed by root canal isolates L. paracasei and E.
faecalis that were exposed to chlorhexidine, cells
in the upper layers of the biofilms, were more
affected than those in the deeper layers [19]. A
similar finding has also been reported to occur in
dental plaque biofilms in which chlorhexidine
showed the highest antimicrobial effect in the
outermost layers of dental plaque but failed to
kill cells in the deeper layers of the biofilms [51].
3.5.2 T
 olerance of Endodontic
Microorganisms
The post-treatment microbiota comprises a sub-
set of species that have a high tolerance towards
environmental changes provoked by antimicrobi-
als, lack of nutrients and the host immune cells.
In this case, tolerance is distinguished by the
capacity of bacteria to adapt their phenotype in
order to endure changes in environmental condi-
tions [13]. Although most of the mechanisms of
tolerance by root canal bacteria have not been
clarified, it seems that some mechanisms maybe
coordinated concurrently from a main general
stress response with the interplay of various regu-
latory processes taking place at the same time
[21, 22].
One of the most studied characteristics among
bacterial isolates remaining in root canals after
3  Aetiology of Persistent Endodontic Infections in Root-Filled Teeth
treatment is their ability to tolerate an alkaline
environment, which is provoked after the appli-
cation of CaOH2 as an inter-appointment medica-
tion. Some members of the post-treatment
microbiota, such as E. faecalis, are well known to
have an intrinsic tolerance to alkaline, e.g. by
exertion of proton pumps [23], or release of stress
proteins [52]. Interestingly, it has been recently
demonstrated that tolerance to alkaline may be
intrinsic for a greater portion of the original root
canal population [53]. In this study by Lew et al.,
more than 60% of untreated infected root canals
harboured alkaline-tolerant bacteria with most of
them being Gram-positive organisms [53]. From
a general perspective, however, the tolerance of
root canal bacteria to alkaline stress has been
observed to be regulated by extracellular release
of housekeeping enzymes, such as phosphocar-
rier HPr, the heat shock chaperone DnaK, FBA
and GAPDH [22]. Although the physiological
role of these housekeeping enzymes outside the
cell is unknown, most of these enzymes have also
been found to be associated with the bacterial
response to other similar environmental stresses
such as acid challenge [54]. Interestingly, a recent
transcriptomic study observed that during alka-
line stress, E. faecalis expressed as much as 613
genes. From these newly expressed genes, 211
genes were found to be differentially upregu-
lated, and 402 genes were differentially down-
regulated [55]. Fifteen of these upregulated genes
were found to be involved in amino acid trans-
port, a characteristic that gives clear insights into
the metabolic demands of E. faecalis when
exposed to alkaline stress.
The ability to tolerate an environment with
scarce or limited nutrients demands an efficient
control of the mechanisms that regulate the nutri-
tional needs of root canal bacteria. These nutrient-­
adaptive capabilities have been observed in some
oral bacteria that coincidentally have been also
isolated from cases with persistent root canal
infections. For example, in the saccharolytic
organism Streptococcus oralis, a number of pro-
teolytic enzymes have been found to be upregu-
lated upon exposure to carbohydrate-deprived
environments [56]. This particular ability in S.
oralis to digest proteins could be considered as
29
an advantage for their survival in the oral com-
munity at the times of carbohydrate famine.
Similar patterns have been found also for other
oral bacteria where complementary patterns of
glycosidase and protease activities are able to
degrade glycoproteins in a synergistic manner
[57]. These complex metabolic patterns have
been proposed to play a role in the catabolism of
glycoproteins such as mucins from saliva [58] or
plasminogen from serum [18].
Specific stress-regulator mechanisms such as
‘the stringent response’ may be involved in the
regulation of the nutritional needs of root canal
bacteria [59]. The stringent response encom-
passes a massive switch in the transcription pro-
file of bacteria, which is coordinated by the
alarmones guanosine tetraphosphate (ppGpp)
and guanosine pentaphosphate ((p)ppGpp) [59].
In E. faecalis, these alarmones play an important
role in low-nutrient survival [60]. Furthermore,
the alarmone system (p)ppGpp has also a pro-
found effect on the ability of E. faecalis to form,
develop and maintain stable biofilms [60]. These
improved understandings of the alarmone mech-
anisms underlying biofilm formation and survival
by post-treatment organisms such as E. faecalis
may facilitate the identification of pathways that
could be targeted to treat chronic root canal
infections.
In general, basic research on mechanisms of
resistance and tolerance in combination with
clinical studies is expected to reveal general
mechanisms of microbial survival in order to pro-
vide a clearer understanding of the pathogenesis
of post-treatment infections and to develop more
efficient ways to treat them.
Take-Home Lessons
• Microorganisms surviving in endodon-
tically treated root canals remain assem-
bled in biofilm communities and are the
main cause of apical periodontitis in
root-filled teeth.
• In biofilms a number of factors will play
a role in microbial survival such as the
low diffusion of antimicrobial agents,
30
the entry of cells into low-energy states,
differentiation into tolerant subpopula-
tions and the expression of biofilm-­
specific antimicrobial resistance genes.
• Microbial resistance and tolerance
to antimicrobials are multifactorial,
complex and very difficult to predict
in multispecies communities where
more than one mechanism plays a part
simultaneously.
• Further research is required as for most
of the root canal bacteria we do not yet
have a minimal view of the regulatory
processes involved in biofilm formation,
phenotypic adaptation or antimicrobial
tolerance.
References
Benchmark Papers
• Molander A, Reit C, Dahlén G, Kvist
T. Microbiological status of root-filled
teeth with apical periodontitis. Int
Endod J. 1998;31:1–7. ‘This paper
includes a thorough culture-based
microbiological analysis of root filled
teeth with persistent apical periodontits.
From the 100 cases studied, 117 species
were recovered from which 47% were
Enterococcus faecalis. A relative high
frequency of other Gram-positive spe-
cies was also reported. This study brings
forward the role of a resistant flora in
post-treatment endodontic infections’.
• Chávez de Paz LE, Dahlén G, Molander
A, Möller A, Bergenholtz G. Bacteria
recovered from teeth with apical peri-
odontitis after antimicrobial endodontic
treatment. Int Endod J. 2003;36:500–8.
‘This paper yields information on the
selective process triggered by root canal
treatment on the root canal microbiota.
Based on a comprehensive microbio-
logical analysis this work indicates that
the use of antimicrobials and intracanal
medication selects for the most-resistant
L.E. Chávez de Paz
micro-organisms, many of which are
normal oral commensals’.
• Nair PN. Pathogenesis of apical periodon-
titis and the causes of endodontic failures.
Crit Rev. Oral Biol Med. 2004;15:348–81.
‘A thorough and comprehensive review
of different histo-­pathological aspects of
apical periodontitis’.
• Svensäter G, Bergenholtz G. Biofilms in
endodontic infections. Endod Topics.
2004;9:27–36. ‘A pioneer review paper
on microbial biofilms in endodontics,
which by means of sound biologically-­
based hypotheses introduces the biofilm
concept in endodontics’.
1. Chávez de Paz LE. Redefining the persistent infection
in root canals: possible role of biofilm communities.
J Endod. 2007;33:652–62.
2. Ricucci D, Siqueira JF Jr. Biofilms and apical peri-
odontitis: study of prevalence and association with
clinical and histopathologic findings. J Endod.
2010;36:1277–88.
3. Svensäter G, Bergenholtz G. Biofilms in endodontic
infections. Endod Topics. 2004;9:27–36.
4. Engström B, Hård AF, Segerstad L, Ramström G,
Frostell G. Correlation of positive cultures with the
prognosis for root canal treatments. Odontol Revy.
1964;15:257–70.
5. Möller ÅJR. Microbiological examination of
root canals and periapical tissues of human
teeth. Methodological studies. Odontol Tidskr.
1966;74(Suppl):1–380.
6. Molander A, Reit C, Dahlén G, Kvist
T. Microbiological status of root-filled teeth with api-
cal periodontitis. Int Endod J. 1998;31:1–7.
7. Sundqvist G, Figdor D, Persson S, Sjögren
U. Microbiologic analysis of teeth with failed end-
odontic treatment and the outcome of conservative
re-treatment. Oral Surg Oral Med Oral Pathol Oral
Radiol Endod. 1998;85:86–93.
8. Chávez de Paz LE, Dahlén G, Molander A, Möller
A, Bergenholtz G. Bacteria recovered from teeth with
apical periodontitis after antimicrobial endodontic
treatment. Int Endod J. 2003;36:500–8.
9. Chávez de Paz LE, Marsh PD. Ecology and physiol-
ogy of root canal microbial biofilm communities. In:
Chavez de Paz LE, Sedgley CM, Kishen A, editors.
The root canal biofilm. Heidelberg: Springer-Verlag
Berlin Heidelberg; 2015. p. 3–22.
3  Aetiology of Persistent Endodontic Infections in Root-Filled Teeth
10. Flemming HC, Wingender J. The biofilm matrix. Nat
Rev Microbiol. 2010;8:623–33.
11. Hobley L, Harkins C, MacPhee CE, Stanley-Wall
NR. Giving structure to the biofilm matrix: an over-
view of individual strategies and emerging common
themes. FEMS Microbiol Rev. 2015;39:649–69.
12. Mah TF. Biofilm-specific antibiotic resistance. Future
Microbiol. 2012;7:1061–72.
13. Stewart PS, Franklin MJ. Physiological heterogeneity
in biofilms. Nat Rev Microbiol. 2008;6:199–210.
14. Arnold M, Ricucci D, Siqueira JF Jr. Infection in
a complex network of apical ramifications as the
cause of persistent apical periodontitis: a case report.
J Endod. 2013;39:1179–84.
15. Ricucci D, Siqueira JF Jr. Recurrent apical peri-
odontitis and late endodontic treatment failure
related to coronal leakage: a case report. J Endod.
2011;37:1171–5.
16. Vieira AR, Siqueira JF Jr, Ricucci D, Lopes
WS. Dentinal tubule infection as the cause of recur-
rent disease and late endodontic treatment failure: a
case report. J Endod. 2012;38:250–4.
17. Kolenbrander PE, Palmer RJ Jr, Periasamy S,
Jakubovics NS. Oral multispecies biofilm develop-
ment and the key role of cell-cell distance. Nat Rev
Microbiol. 2010;8:471–80.
18. Kinnby B, Booth NA, Svensäter G. Plasminogen bind-
ing by oral streptococci from dental plaque and inflam-
matory lesions. Microbiology. 2008;154:924–31.
19. Chávez de Paz LE, Bergenholtz G, Svensäter G. The
effects of antimicrobials on endodontic biofilm bacte-
ria. J Endod. 2010;36:70–7.
20. Hajishengallis G, Lamont RJ. Beyond the red complex
and into more complexity: the polymicrobial synergy
and dysbiosis (PSD) model of periodontal disease eti-
ology. Mol Oral Microbiol. 2012;27:409–19.
21. Appelbe OK, Sedgley CM. Effects of prolonged
exposure to alkaline pH on Enterococcus faecalis
survival and specific gene transcripts. Oral Microbiol
Immunol. 2007;22:169–74.
22. Chávez de Paz LE, Bergenholtz G, Dahlén G,
Svensäter G. Response to alkaline stress by root canal
bacteria in biofilms. Int Endod J. 2007;40:344–55.
23.
Evans M, Davies JK, Sundqvist G, Figdor
D. Mechanisms involved in the resistance of
Enterococcus faecalis to calcium hydroxide. Int
Endod J. 2002;35:221–8.
24. Sedgley C, Buck G, Appelbe O. Prevalence of
Enterococcus faecalis at multiple oral sites in end-
odontic patients using culture and PCR. J Endod.
2006;32:104–9.
25.
Hancock HH III, Sigurdsson A, Trope M,
Moiseiwitsch J. Bacteria isolated after unsuccessful
endodontic treatment in a North American popula-
tion. Oral Surg Oral Med Oral Pathol Oral Radiol
Endod. 2001;91:579–86.
26. Pinheiro ET, Gomes BP, Ferraz CC, Sousa EL,
Teixeira FB, Souza-Filho FJ. Microorganisms from
canals of root-filled teeth with periapical lesions. Int
Endod J. 2003;36:1–11.
31
27. Rocas IN, Siqueira JF Jr. Characterization of micro-
biota of root canal-treated teeth with posttreatment
disease. J Clin Microbiol. 2012;50:1721–4.
28. Sakamoto M, Siqueira JF Jr, Rocas IN, Benno
Y. Molecular analysis of the root canal microbiota
associated with endodontic treatment failures. Oral
Microbiol Immunol. 2008;23:275–81.
29. Vidana R. Origin of intraradicular infection with
Enterococcus faecalis in endodontically treated teeth.
Stockholm, Sweden: Karolinska Institutet; 2015.
30. Wimpenny J, Manz W, Szewzyk U. Heterogeneity in
biofilms. FEMS Microbiol Rev. 2000;24:661–71.
31. Kolenbrander PE, London J. Adhere today, here
tomorrow: oral bacterial adherence. J Bacteriol.
1993;175:3247–52.
32. Möller S, Sternberg C, Andersen JB, Christensen
BB, Ramos JL, et al. In situ gene expression in
mixed-culture biofilms: evidence of metabolic inter-
actions between community members. Appl Environ
Microbiol. 1998;64:721–32.
33. Jaramillo D, Diaz A, Alonso-Ezpeleta O, Segura-
Egea JJ. Biofilm on external root surfaces associated
with persistent apical periodontitis: report of two
cases. Endodoncia. 2015;33:28–36.
34. Ricucci D, Candeiro GT, Bugea C, Siqueira JF Jr.
Complex apical intraradicular infection and extrara-
dicular mineralized biofilms as the cause of wet canals
and treatment failure: report of 2 cases. J Endod.
2016;42:509–15.
35. Su L, Gao Y, Yu C, Wang H, Yu Q. Surgical endodon-
tic treatment of refractory periapical periodontitis
with extraradicular biofilm. Oral Surg Oral Med Oral
Pathol Oral Radiol Endod. 2010;110:e40–4.
36. Wang J, Jiang Y, Chen W, Zhu C, Liang J. Bacterial
flora and extraradicular biofilm associated with the
apical segment of teeth with post-treatment apical
periodontitis. J Endod. 2012;38:954–9.
37. Nair PN. Pathogenesis of apical periodontitis and
the causes of endodontic failures. Crit Rev Oral Biol
Med. 2004;15:348–81.
38. Nair PN. On the causes of persistent apical periodon-
titis: a review. Int Endod J. 2006;39:249–81.
39. Ramachandran Nair PN. Light and electron micro-
scopic studies of root canal flora and periapical
lesions. J Endod. 1987;13:29–39.
40. Happonen RP. Periapical actinomycosis: a follow-
­up study of 16 surgically treated cases. Endod Dent
Traumatol. 1986;2:205–9.
41. Pasupathy SP, Chakravarthy D, Chanmougananda S,
Nair PP. Periapical actinomycosis. BMJ Case Rep.
2012;2012:bcr2012006218.
42. Sjögren U, Happonen RP, Kahnberg KE, Sundqvist
G. Survival of Arachnia propionica in periapical tis-
sue. Int Endod J. 1988;21:277–82.
43. Letters S, Smith AJ, McHugh S, Bagg J. A study of
visual and blood contamination on reprocessed end-
odontic files from general dental practice. Br Dent
J. 2005;199:522–5. discussion 13
44. Subramaniam P, Tabrez TA, Babu KL. Microbiological
assessment of root canals following use of rotary and
32
manual instruments in primary molars. J Clin Pediatr
Dent. 2013;38:123–7.
45. Nair PN. New perspectives on radicular cysts: do they
heal? Int Endod J. 1998;31:155–60.
46. Gengenbacher M, Kaufmann SH. Mycobacterium
tuberculosis: success through dormancy. FEMS
Microbiol Rev. 2012;36:514–32.
47. Chávez de Paz LE, Hamilton IR, Svensäter G. Oral bac-
teria in biofilms exhibit slow reactivation from nutri-
ent deprivation. Microbiology. 2008;154:1927–38.
48. Bayles KW. The biological role of death and
lysis in biofilm development. Nat Rev Microbiol.
2007;5:721–6.
49. Wang Z, Shen Y, Haapasalo M. Dental materials with
antibiofilm properties. Dent Mater. 2014;30:e1–16.
50. Xhevdet A, Stubljar D, Kriznar I, Jukic T, Skvarc
M, et al. The disinfecting efficacy of root canals
with laser photodynamic therapy. J Lasers Med Sci.
2014;5:19–26.
51. Zaura-Arite E, van Marle J, ten Cate JM. Conofocal
microscopy study of undisturbed and chlorhexidine-­
treated dental biofilm. J Dent Res. 2001;80:1436–40.
52. Flahaut S, Hartke A, Giard JC, Auffray Y. Alkaline
stress response in Enterococcus faecalis: adaptation,
cross-protection, and changes in protein synthesis.
Appl Environ Microbiol. 1997;63:812–4.
53. Lew HP, Quah SY, Lui JN, Bergenholtz G, Hoon
Yu VS, Tan KS. Isolation of alkaline-tolerant bac-
L.E. Chávez de Paz
teria from primary infected root canals. J Endod.
2015;41:451–6.
54. Svensäter G, Sjögreen B, Hamilton IR. Multiple stress
responses in Streptococcus mutans and the induction
of general and stress-specific proteins. Microbiology.
2000;146(Pt 1):107–17.
55. Ran S, Liu B, Jiang W, Sun Z, Liang J. Transcriptome
analysis of Enterococcus faecalis in response to alka-
line stress. Front Microbiol. 2015;6:795.
56. Beighton D, Smith K, Hayday H. The growth of bac-
teria and the production of exoglycosidic enzymes in
the dental plaque of macaque monkeys. Arch Oral
Biol. 1986;31:829–35.
57. Bradshaw DJ, Homer KA, Marsh PD, Beighton
D. Metabolic cooperation in oral microbial com-
munities during growth on mucin. Microbiology.
1994;140(Pt 12):3407–12.
58. Wickström C, Herzberg MC, Beighton D, Svensäter
G. Proteolytic degradation of human salivary MUC5B
by dental biofilms. Microbiology. 2009;155:2866–72.
59.
Dalebroux ZD, Swanson MS. ppGpp: magic
beyond RNA polymerase. Nat Rev Microbiol.
2012;10:203–12.
60. Chávez de Paz LE, Lemos JA, Wickström C, Sedgley
CM. Role of (p)ppGpp in biofilm formation by
Enterococcus faecalis. Appl Environ Microbiol.
2012;78:1627–30.
 Consequences
4
Fredrik Frisk and Thomas Kvist

Science is the knowledge of consequences, and dependence of one fact upon another.
Thomas Hobbes (1588–1679). English philosopher

Abstract
Persistent or emerging apical periodontitis is a common finding in root-­
filled teeth. The consequences thereof may have implications for the
patient in terms of pain, tooth loss, spread of infection and additional
costs. However, inconclusive data from several studies also suggests sys-
temic effects of apical periodontitis. Obviously, these pathologies will cor-
respondingly influence the everyday work of dentists. Also, it may have
consequences for society and third-party payers. From a cost-benefit point
of view, it is not unequivocal which should be the treatment of choice
when a root-filled tooth is diagnosed with apical periodontitis.

4.1 Introduction there may be many reasons to question the exact

Chapter 2 thoroughly reviewed the incidence and
prevalence of apical periodontitis in root-filled
teeth. From this it stands clear that, even though
numbers in single studies, a great many root-­
filled teeth present with signs of apical periodon-
titis. Considering the great number of root-filled
teeth in populations with access to dental care,
the condition is found in every other adult. In this
chapter we will scrutinize the consequences of
apical periodontitis in root-filled teeth.

F. Frisk, DDS, PhD (*)

Department of Endodontology,
Institute for Postgraduate Dental Education,
Jönköping, Sweden
Department of Endodontology, Institute of
Odontology, The Sahlgrenska Academy,
University of Gothenburg, Göteborg, Sweden
e-mail: fredrik.frisk@rjl.se
T. Kvist, DDS, PhD
Department of Endodontology,
Institute of Odontology, The Sahlgrenska Academy,
University of Gothenburg, Göteborg, Sweden
e-mail: kvist@odontologi.gu.se
4.2  ifferent Types of
D
Consequences and Different
Stakeholders
A fact may have different consequences and
affect different parties. Three main categories of
consequences without clear boundaries between
them may be identified in relation to apical peri-
odontitis in root-filled teeth: biological, psycho-
logical and economic. Obviously, it seems most

© Springer International Publishing AG 2018 33

T. Kvist (ed.), Apical Periodontitis in Root-Filled Teeth,
https://doi.org/10.1007/978-3-319-57250-5_4
34 F. Frisk and T. Kvist

important to investigate the consequences for 4.3.1.3 Local Spread of Disease

those directly affected by the condition, the It is well known that odontogenic infections
patients. However, also their doctors, the den- may have the potential for life-threatening
tists, will be affected, since the situation is sup- spread to other parts of the body [6]. In a study
posed to be handled with in some way or the from the United States approximately 61,000
other. Thirdly, also third-party payers like reim- hospitalizations of patients were primarily
bursement organizations, insurance companies attributed to periapical abscesses during a
or public and tax-­funded health organizations 9-year study period [7]. The mortality was
are affected by apical periodontitis in root-filled reported to be approximately 1‰ (66 patients).
teeth. In the following we will discuss the dif- In a study from Finland, Grönholm et al. [8]
ferent categories of consequences from different evaluated clinical and radiological findings in a
point of views. group of 60 patients with hospital stay due to
periapical periodontitis. They found that unfin-
ished root canal treatment was the major risk
4.3 Consequences for Patients factor for hospitalization. Root-­filled teeth with
apical periodontitis were the source only in 7
4.3.1 Biological (12%) of the 60 cases. It has been calculated
that the amount of root-filled teeth only in
4.3.1.1 Persistent Pain United States is about 420 million [9] and that
Surprisingly little is known about the frequency approximately 36% of these present with signs
of pain from root-filled teeth. From the obtain- of apical periodontitis [10]. Pooling the infor-
able data in follow-up studies from university or mation from these different sources would
specialist clinics, in a systematic review, the fre- result in an estimated risk of severe event,
quency of persistent pain >6 months after end- requiring hospitalization, because of a root-
odontic therapy was estimated to be 5% [1]. In filled tooth with apical periodontitis to be
this context it is also important to point out that a approximately 1 in 200,000 on a yearly basis.
painful condition associated with a root-filled
tooth not necessarily is due to the presence of 4.3.1.4 Loss of Tooth
apical periodontitis [2, 3]. Two longitudinal studies in Scandinavian popula-
tions found that 12–13%, respectively, of the
4.3.1.2 Flare-Ups of Asymptomatic teeth that were root filled at the base-line exami-
Lesions nation were extracted at follow-up approximately
The incidence and severity of exacerbation of 10 years later [11, 12]. In the Danish population,
apical periodontitis from root-filled teeth have it was found that teeth with apical periodontitis
met only scarce attention from researchers. A low (non-root filled and root filled) had a six times
risk of painful exacerbations (1–2%) was reported higher risk of being lost than teeth without apical
from a cohort of 1032 root-filled teeth followed periodontitis [13]. In a selected Swedish popula-
over time by Van Nieuwenhuysen et al. [4]. In a tion, the 20-year survival rate of root-filled teeth
report from a university hospital clinic in was 65% [14]. The finding of apical periodontitis
Singapore where 127 patients with 185 non-­ at baseline was among variables associated with
healed root-filled teeth were recruited [5], flare-­ low odds for tooth survival. However, it is diffi-
ups occurred only in 5.8% over a period of cult to tell whether the observed correlations are
20 years. Less severe pain was experienced by causative or a consequence of biased selection of
another 40% over the same time period. The inci- cases for extraction. Observations from other
dence of discomforting clinical events was sig- studies suggest that other causes than apical peri-
nificantly associated with female patients, odontitis such as periodontal disease, caries or
treatments involving a mandibular molar or max- root fracture are frequently present when root-­
illary premolar and preoperative pain. filled teeth are extracted [15, 16].
4 Consequences
4.3.1.5 Systemic Effects
The possible association between systemic dis-
eases and inflammatory processes of endodontic
origin has been debated for more than 100 years.
However, evidence is poor, and only a few scien-
tific studies of good quality are available [17].
A possible correlation between apical peri-
odontitis and cardiovascular disease (CVD) and
coronary heart disease (CHD), respectively, has
been of certain focus. One study found an associa-
tion between apical periodontitis and CHD in
middle-aged and younger men (<40) over a
32-year period [18]. In one cross-sectional study,
an analysis of female patients demonstrated no
increased risk of CHD among those with apical
periodontitis, after adjustment for established risk
factors [19]. Yet another study comprised analysis
of a large number of health professionals receiv-
ing medical care [20]. A weak association to CHD
was reported with respect to individuals with one
or two root fillings.
One case-controlled clinical trial showed a
positive association between the number of
inflammatory lesions of endodontic origin with
acute myocardial infarction or unstable angina
compared with healthy controls [21]. One study
evaluated whole-body computed tomography
examinations of 531 patients retrospectively. The
atherosclerotic burden of the abdominal aorta
was quantified using a calcium scoring method.
Chronic apical periodontitis correlated positively
with the aortic atherosclerotic burden. In regres-
sion models, apical lesions in teeth without end-
odontic treatment were found to be an important
factor but so did not apical radiolucencies in root-­
filled teeth [22]. One study investigated whether
an association between chronic oral infections
and the presence of an acute myocardial infarc-
tion exists. The results showed that patients, who
have experienced a myocardial infarction, had
more missing teeth and a higher number of
inflammatory processes of endodontic origin
than healthy individuals [23]. In a retrospective
study the presence of apical periodontitis and
root-filled teeth was associated with long-term
risk of incident cardiovascular events, including
cardiovascular-related mortality [24]. Finally, in
a pair-matched, cross-sectional designed study,
35
subjects with apical periodontitis were more
likely to have CVD than subjects in the final
adjusted logistic regression model [25].
Other systemic diseases that have attracted
attention are diabetes mellitus, chronic liver dis-
ease and different types of blood disorders [17].
At present time the association between end-
odontic disease and different systemic conditions
rests on shaky scientific ground. However, the
thinkable biological mechanisms behind a link
are present [26]. It is obvious that relationships
between endodontic infections and general health
and well-being should be in focus of future
research in endodontology.
4.3.2 Psychological Consequences
The psychological effects include aspects of
knowledge, beliefs, attitudes, values, preferences,
quality of life and satisfaction. Quality of life is
concerned with the degree to which a person
enjoys the important possibilities of life [27].
Surprisingly few studies have addressed these
“patient-centred” outcomes of endodontic treat-
ments [28]. Disease of pulpal origin negatively
affects quality of life primarily through physical
pain and psychological discomfort, and root canal
treatment results in distinctive improvement [29].
The impact on daily life activities (eating,
speaking, sleeping, contact with people, etc.) by
painful exacerbations of persistent periapical
lesions in root-filled teeth was reported in the
previously mentioned study from Singapore [5].
Among the 127 patients with apical periodontitis
in a root-filled tooth recruited for the study only
33 patients (38 teeth) had experienced some kind
of impact over a period 38 years. But only five
patients reported substantial impact.
The attitudes towards asymptomatic persistent
lesions among patients affected have only met
scarce attention. In two studies value judgements
towards an asymptomatic root-filled tooth with a
periapical lesion were investigated by methods
used in the context of expected utility theory [30,
31]. In both studies elicited subjective values
towards asymptomatic apical periodontitis and
root-filled teeth showed great variation.
36
4.3.3 Economic Aspects
A great many teeth with pulpitis and apical peri-
odontitis, even in countries with well-developed
dental care, often do not come under dental treat-
ment. They remain unrecognized, because they
are asymptomatic or are considered among the
ordinary discomforts of daily living. Or, the
patient may be suffering from both pain and other
symptoms for a prolonged period of time but
because of economic limitations has not been
able to seek dental care [32]. Cost is a significant
barrier to receiving dental care and a very impor-
tant factor in patients’ treatment choices. The
“willingness to pay” for root canal treatment in
order to save an asymptomatic nonvital lower
first molar was studied in a population of 503
patients in England [33]. Only, 53% of the sam-
ple wished to save the tooth with a mean “will-
ingness to pay” of £373. The variation in
willingness to pay was found to be substantial
and influenced by income. Initial cost may cap-
ture patients’ attention, but that is only the begin-
ning. The original cost of tooth retention through
root canal treatment and restoration is usually
considered to be lower than tooth replacement
using implants or fixed dental prostheses [34].
However, the lifetime cost model for different
options should also include treatment failures. In
a cost-effectiveness model from the United
Kingdom, regarding a maxillary incisor, it was
calculated that saving a tooth by root canal treat-
ment, followed by non-surgical retreatment if
indicated, was cost-effective. However, surgical
retreatment was not found to be cost-effective
[35]. On the other hand, an American cost-­
effectiveness modelling study, for a root-filled
treated molar in need of re-intervention, ranked
surgical retreatment, non-surgical retreatment,
replacement using a fixed dental prosthesis and
replacement using an implant, from the greatest
to smallest cost-effectiveness [36]. There are sev-
eral problems involved in using these data in a
clinical situation for an individual patient’s point
of view. First of all, the calculations are highly
sensitive to different care providers’ fees for the
interventions put into the algorithms. Secondly, it
is possible that the benefits available under the
F. Frisk and T. Kvist
prevailing dental care reimbursement system
encourage one of the options at the expense of the
other regardless of cost-effectiveness in the long
term. Thirdly, cost-effectiveness analyses com-
pare relative costs and outcomes but do not take
into account individual patient values. One can,
with good reason, assume that individuals who
already paid for root canal treatment once are
reluctant to pay for retreatment, in particular, if
the tooth is asymptomatic. Data from the many
epidemiological studies, showing that root-filled
teeth with persistent apical periodontitis are very
common, suggest that patients and their dentists,
in many cases, assess the cost-benefit ratio to be
too low to undertake any operation whatsoever.
4.4 Consequences for Dentists
The high prevalence of apical periodontitis
among adult patients is a challenge for dentists in
several ways. In the following, some important
issues, from the dentist’s point of view, will be
briefly mentioned. Most of these aspects are
more thoroughly addressed in the other chapters
of this book. Here, some aspects not covered
elsewhere are discussed.
4.4.1 Diagnosis
When a patient presents with a root-filled tooth
causing pain and swelling or chronic clinical
findings in the form of redness, tenderness and
fistulas, it is usually relatively straightforward to
diagnose a persistent, recurrent or arising apical
periodontitis. However, the most common situa-
tion is that the root-filled tooth is both subjective
and clinically asymptomatic but an X-ray reveals
that bone destruction remains. It is difficult to
determine how long is the time that may be
required for such a healing process in a particular
case. The diagnosis of periapical tissues based on
intra-oral radiographs has repeatedly unmasked
considerable inter- and intra-observer variation.
Besides the time aspect and observer variation,
there is also a problem of determining what
should be considered as a sufficient healing of
4 Consequences
bone destruction to constitute successful end-
odontic treatment. And as a consequence also
what establishes a “failure” and hence an indica-
tion for retreatment is far from unambiguous.
4.4.2 Liability
According to the limited data available in the lit-
erature, claims concerning endodontics are com-
mon among dental professional liability cases
[37, 38]. The high prevalence of root fillings of
poor quality, as pointed out in numerous studies,
makes this hardly surprising. However not all
claims are justified. All healthcare, including
endodontics, need to weigh the benefits of vari-
ous measures against the risks. The goal of all
dental care is of course that it will be of benefit
to those who receive it. But sometimes the pro-
cedures per definition are resulting in injuries or
damage. Some “damage” is planned, as when the
affected tooth is opened by removal of hard tis-
sue in order to get access to the root canal sys-
tem. Unnecessary injuries may occur as a result
of incompetence, negligence or by a single mis-
take. Even the most skilful, well-educated and
experienced dentist can make mistakes some-
times. Some endodontic treatments can also be
very complicated, with more built-in risk for
complications than others. These injuries are
regrettable but are an inherent risk of endodontic
procedures that one can seek to reduce over time
through improved treatments, better education
and more hands-on instruction. But injuries that
occur because of carelessness, incompetence or
because the caregiver has not complied with in
the scientific and technological developments in
the profession are avoidable in a completely dif-
ferent way and cannot be viewed as acceptable.
And as a result of quality deficiencies in the pri-
mary endodontic treatment, a suspicion or accu-
sation of malpractice may emerge when a
persistent apical periodontitis is diagnosed in a
root-filled tooth.
When treating diseases of infectious and
inflammatory disease emanating from the pulp,
unsuccessful outcome may occur despite profes-
sional excellence in every detail. It is of p­ aramount
37
importance to inform about the possible risks of
the treatment procedures and explain that treat-
ment may not always lead to a successful result,
even though it is performed in accordance with all
the rules. This should be a part of the informed
consent procedure. A malpractice claim might be
perceived as a criticism of the dentist’s compe-
tence and skills but also as a sign of a downfall in
communication with the patient.
If a root canal treatment “failure” is diagnosed
despite a reasonable high-standard treatment pro-
cedure, and the patient understands and accepts
the situation, there is also little to argue about.
The problem is limited to a decision-making
problem if and how the pathology should be
treated.
If both the patient and dentist are aware and
agree about that the initial endodontic treatment
was of poor quality, it seems appropriate to find a
way forward to rectify what can be corrected
while the patient is held economically indemni-
fied. Depending on which country, different laws
and practices set the framework for possible
insurance claims, compensation claims or other
legal procedures.
Sometimes when a patient switches dentist,
the new dental team discovers that previously
performed dental care is not of good quality. In
our particular branch of dentistry, this is almost
the rule rather than the exception when a patient
is referred from a general dental practitioner to a
specialist in endodontics, especially when it
comes to root-filled teeth. The patient, however,
may be completely unaware of the quality defi-
ciencies that exist. Perhaps it will be obvious,
also for the patient, when the examination and
possible treatment by the specialist is starting.
The question of how to act in such a situation
is difficult. Based on the principle of informed
consent and patient’s right to autonomy in health-
care, it seems, at first, as obvious quality defects
in prior treatment should be mentioned. However,
diagnosis, treatment selection and execution in
endodontics are not an exact science. It is p­ ossible
that circumstances that the patient has forgotten
or chosen to hide would put the poor quality of
treatment in a new light. Furthermore, many
­endodontic specialists’ practice depends on good
38
relations with the dentists who provide them with
the referrals. A good way can be to work to make
it natural to contact each other in a dialogue about
possible mistakes, incorrect routines and con-
structive suggestions for changes for the better in
the future. Of course, each dentist is responsible
for ensuring that the patient’s interests are put
first. However, the dentists who are considering
to criticize a colleague before a patient or to par-
ticipate in any legal process of insufficient qual-
ity of treatment performed should consider the
conditions carefully. May the poor quality be
explained by the different ways to interpret treat-
ment needs and outcome or is it obvious that the
treatment did not live up to current standards.
4.4.3 N
 eed for Training
and Armamentarium
For everyone who attended in congresses and
conferences on endodontics in recent years, it is
obvious that there are a variety of instruments
and equipment to the field of endodontic retreat-
ment. It is also offered a variety of courses, both
theoretical and hands-on to learn how these
instruments are used. Development in the area
has been almost explosive in the last 20 years.
There are also a number of published books that,
more or less in detail, describe how to perform,
both surgical and non-surgical, endodontic
retreatment procedures. The range is so wide that
it is difficult even for a specialist in the subject
endodontics to keep up with developments and
have an overview of available armamentarium.
For a general dentist, it seems almost impossible.
The situation is particularly pronounced for sur-
gical retreatment procedures where the use of the
operating microscope, ultrasonic technology and
modern cements, the MTA and similar, seems to
be a prerequisite for achieving the good results of
the operations performed. Parallel to this devel-
opment there is a wider exposure of all practitio-
ners to lectures and advertising pertaining to
implant placement. It is therefore barely surpris-
ing that general dentists and dental specialists
within other areas quite widely opt out retreat-
ment options in favour of solutions with implants,
F. Frisk and T. Kvist
while endodontists suggest tooth retention by
non-surgical or surgical retreatment.
Bigras et al. [39] compared the clinical
decision-­making choices of general dentists to
prosthodontists, endodontists, oral surgeons and
periodontists when presented with patient sce-
narios where a root-filled tooth was presented
with a need for intervention. When asked whether
to endodontically retreat or replace the specific
tooth with an implant, the retreatment option was
selected by 96% of the endodontists, 48% of the
general dentists, 36% of the prosthodontists, 31%
of the oral surgeons and 24% of the periodontists.
Similar to Di Fiore et al. [40], there was an
increase in the selection of implants, for all par-
ticipant groups, as the prosthetic and endodontic
complexities of the clinical situations increased.
On the other hand, if a clinician has endeav-
oured to develop particular skills in a limited field
of dentistry, like modern endodontic surgery,
there is a tendency for selecting this treatment
option whenever found appropriate. Hardly sur-
prising, von Arx et al. [41] settled that apical sur-
gery was the most frequently made treatment
decision in teeth referred to a specialist in apical
surgery.
4.4.4 Need for Specialists
Based on the comparison between studies of the
outcome of root canal treatment performed by
specialists and supervised dental students and, on
the other hand, epidemiologic surveys of various
populations, it is generally established that there
is a discrepancy regarding treatment outcome
between what it is possible to achieve in certain
clinical settings and what is actually achieved in
daily practice [42]. In order to improve the over-
all results of endodontic treatment rate and for
the benefit of patients in general dental practice,
it has been suggested that difficult cases should
be referred to dentists with advanced knowledge
and training [43–45].
However, surveys of referral-based endodon-
tic practices have revealed that the major propor-
tion of cases seized consists of symptomatic teeth
and teeth in need of re-intervention [46, 47].
4 Consequences
4.5  onsequences for the Third
C studies and c­ linical studies and within the dif-
Party
Dentists in most countries have been trained at
universities or dental schools. Usually training
takes several years and is considered demand-
ing. The professional role of a dentist is usu-
ally surrounded by high prestige. Knowledge
and skills in endodontology are within the
compulsory scope of each training to become
a dentist. To be able to diagnose pulpitis, pulp
necrosis and apical periodontitis and to per-
form root canal treatment are an essential
part of dentistry because diseases of the tooth
pulp and periradicular tissues are common.
Furthermore, these, many times, painful con-
ditions are common reasons that patients seek
out dental care.
From any society’s point of view, it is a funda-
mental desire that expertise in this particular field
of dentistry should be possessed by dentists.
However, studies continue to show poor tech-
nical standards of root canal treatment and high
frequency of postoperative disease [10]. Other
studies indicate that many general practitioners
lack sufficient knowledge of the fundamentals of
endodontology [48], that they often are over-
looking basic principles when performing root
canal treatment [49] and that high levels of stress
and frustration and an overall sense of lack of
control are reported in relation to root canal
treatment [42].
A limited number of countries have recog-
nized endodontics as a specialty. It is gener-
ally assumed that specialists provide better
outcomes than general practitioners. This pre-
vailing opinion is based on the constantly
repeated finding that cross-sectional epide-
miological studies which reveal high frequen-
cies of apical periodontitis in root-filled teeth
have been reported [10], while follow-up
studies of root canal treatments performed in
specialist and student clinics exhibit substan-
tially lower figures of persisting apical peri-
odontitis [50]. However, only a very limited
number of direct comparisons are available
[29, 50]. The substantial variation in the study
designs both between the cross-sectional
39
ferent types of studies warrants a critical
appraisal of this notion [51].
Also, the cost-effectiveness aspects of root
canal treatment compared to other solutions have
only been sporadically investigated [35].
What further makes it difficult for the com-
munity and third parties is the ambiguity among
academic representatives of endodontics not
completely agreeing on what should constitute a
successful treatment outcome (see Chap. 5:
Diagnosis).
There is no doubt that the vast proportion of
endodontic procedures will continue to be
undertaken by general dental practitioners.
Furthermore, it seems reasonable to assume
that even in the advent of better technical
skills, more advanced technology and wiser
clinical decisions, root canal treatments will
continue to save many teeth that otherwise
would have been extracted but also that many
of these will exhibit signs of persistent apical
periodontitis.
The cost-effectiveness of retreatment pro-
cedures has been questioned [52], and from a
third-­
party payer’s perspective, the willing-
ness to pay for further interventions if root
canal treatment is “not successful” may come
to an end.
Take-Home Lessons
• Apical periodontitis in root-filled
teeth may under unfavourable circum-
stances lead to severe local symptoms
and also that chronic infections may
have adverse consequences for gen-
eral health.
• Dentists are affected since the condition
is causing challenges both in terms of
diagnosis, decision-making and thera-
peutic interventions.
• Third-party payers and other stake-
holders are also affected because the
state is widespread and often appears to
be indirectly caused by low quality of
treatment.
40
Bench-Mark Papers
• Pak JG, Fayazi S, White SN. Prevalence
of periapical radiolucency and root canal
treatment: a systematic review of cross-
sectional studies. J Endod. 2012;38:1170–
6. The purpose of this study was to conduct
a systematic review and meta-analysis of
the prevalence of periapical radiolucency
and nonsurgical root canal treatment.
Thirty-three articles were included. Most
patient samples represented modern pop-
ulations from countries with high or very
high human development indices. Meta-­
analysis was performed on 300,861 teeth.
Of these, 5% had periapical radiolucen-
cies, and 10% were endodontically
treated. Of the root filled teeth, 36% had
periapical radiolucencies. The prevalence
of periapical radiolucency was broadly
equivalent to one radiolucency per
patient. The prevalence of teeth with root
canal treatment was broadly equivalent to
two treatments per patient.
• Nixdorf DR, Moana-Filho EJ, Law AS,
McGuire LA, Hodges JS, John
MT. Frequency of persistent tooth pain
after root canal therapy: a systematic
review and meta-analysis. J Endod.
2010;36:224–30. In this review the core
patient-­oriented outcome of persistent
pain present > or = 6 months after end-
odontic treatment, regardless of etiol-
ogy, after endodontic treatment was
evaluated with data from 26 articles. A
total of 5777 teeth were included, but
only 2996 had follow-up information
regarding pain status. The frequency
persistent tooth pain after endodontic
treatment was estimated to be 5.3%,
with higher report quality studies
suggesting > 7%.
• Khalighinejad N, Aminoshariae MR,
Aminoshariae A, Kulild JC, Mickel A,
Fouad AF. Association between sys-
temic diseases and apical periodontitis.
J Endod. 2016;42:1427–34. The rela-
F. Frisk and T. Kvist
tionships between systemic diseases and
periapical microbial infection was sys-
tematically reviewed. Sixteen articles
were identified and included. The over-
all quality of the studies and the risk of
bias were rated to be moderate. Only
three studies demonstrated a low level
of bias. The results suggested that there
may be a moderate risk and correlation
between some systemic diseases and
endodontic pathosis.
References
1. Nixdorf DR, Moana-Filho EJ, Law AS, McGuire LA,
Hodges JS, John MT. Frequency of persistent tooth
pain after root canal therapy: a systematic review and
meta-analysis. J Endod. 2010;36:224–30.
2. Polycarpou N, Ng YL, Canavan D, Moles DR,
Gulabivala K. Prevalence of persistent pain after
endodontic treatment and factors affecting its occur-
rence in cases with complete radiographic healing. Int
Endod J. 2005;38:169–78.
3. Nixdorf DR, Moana-Filho EJ, Law AS, McGuire LA,
Hodges JS, John MT. Frequency of nonodontogenic
pain after endodontic therapy: a systematic review
and meta-analysis. J Endod. 2010;36:1494–8.
4. Van Nieuwenhuysen JP, Aouar M, D’Hoore
W. Retreatment or radiographic monitoring in end-
odontics. Int Endod J. 1994;27:75–81.
5. Yu VS, Messer HH, Yee R, Shen L. Incidence and
impact of painful exacerbations in a cohort with post-­
treatment persistent endodontic lesions. J Endod.
2012;38:41–6.
6. Ferrera PC, Busino LJ, Snyder HS. Uncommon com-
plications of odontogenic infections. Am J Emerg
Med. 1996;14:317–22.
7. Shah AC, Leong KK, Lee MK, Allareddy
V. Outcomes of hospitalizations attributed to periapi-
cal abscess from 2000 to 2008: a longitudinal trend
analysis. J Endod. 2013;39:1104–10.
8. Grönholm L, Lemberg KK, Tjäderhane L, Lauhio A,
Lindqvist C, Rautemaa-Richardson R. The role of
unfinished root canal treatment in odontogenic maxil-
lofacial infections requiring hospital care. Clin Oral
Investig. 2013;17:113–21.
9. Figdor D. Apical periodontitis: a very prevalent prob-
lem. Oral Surg Oral Med Oral Pathol Oral Radiol
Endod. 2002;94:651–2.
10. Pak JG, Fayazi S, White SN. Prevalence of periapi-
cal radiolucency and root canal treatment: a sys-
tematic review of cross-sectional studies. J Endod.
2012;38:1170–6.
4 Consequences
11. Petersson K, Håkansson R, Håkansson J, Olsson B,
Wennberg A. Follow-up study of endodontic status in
an adult Swedish population. Endod Dent Traumatol.
1991;7(5):221.
12. Kirkevang LL, Vaeth M, Wenzel A. Ten-year follow-
­up observations of periapical and endodontic status in
a Danish population. Int Endod J. 2012;45:829–39.
13. Bahrami G, Væth M, Kirkevang LL, Wenzel A,
Isidor F. Risk factors for tooth loss in an adult pop-
ulation: a radiographic study. J Clin Periodontol.
2008;35:1059–65.
14. Petersson K, Fransson H, Wolf E, Håkansson
J. Twenty-year follow-up of root filled teeth in a
Swedish population receiving high-cost dental care.
Int Endod J. 2016;49:636–45.
15. Vire DE. Failure of endodontically treated teeth: clas-
sification and evaluation. J Endod. 1991;17:338–42.
16. Landys Borén D, Jonasson P, Kvist T. Long-term sur-
vival of endodontically treated teeth at a public dental
specialist clinic. J Endod. 2015;41:176–81.
17. Khalighinejad N, Aminoshariae MR, Aminoshariae
A, Kulild JC, Mickel A, Fouad AF. Association
between systemic diseases and apical periodontitis.
J Endod. 2016;42:1427–34.
18. Caplan DJ, Chasen JB, Krall EA, Cai J, Kang S,
Garcia RI, et al. Lesions of endodontic origin
and risk of coronary heart disease. J Dent Res.
2006;85:996–1000.
19. Frisk F, Hakeberg M, Ahlqwist M, Bengtsson
C. Endodontic variables and coronary heart disease.
Acta Odontol Scand. 2003;61:257–62.
20. Joshipura KJ, Pitiphat W, Hung HC, Willett WC,
Colditz GA, Douglass CW. Pulpal inflammation
and incidence of coronary heart disease. J Endod.
2006;32:99–103.
21. Pasqualini D, Bergandi L, Palumbo L, Borraccino
A, Dambra V, Alovisi M, Migliaretti G, Ferraro G,
Ghigo D, Bergerone S, Scotti N, Aimetti M, Berutti
E. Association among oral health, apical periodonti-
tis, CD14 polymorphisms, and coronary heart disease
in middle-aged adults. J Endod. 2012;38:1570–7.
22. Petersen J, Glaßl EM, Nasseri P, Crismani A, Luger
AK, Schoenherr E, Bertl K, Glodny B. The associa-
tion of chronic apical periodontitis and endodontic
therapy with atherosclerosis. Clin Oral Investig.
2014;18:1813–23.
23. Willershausen I, Weyer V, Peter M, Weichert C,
Kasaj A, Münzel T, Willershausen B. Association
between chronic periodontal and apical inflamma-
tion and acute myocardial infarction. Odontology.
2014;102:297–302.
24. Gomes MS, Hugo FN, Hilgert JB, Sant’Ana Filho M,
Padilha DM, Simonsick EM, Ferrucci L, Reynolds
MA. Apical periodontitis and incident cardiovas-
cular events in the Baltimore Longitudinal Study of
Ageing. Int Endod J. 2016;49(4):334–42.
25. An GK, Morse DE, Kunin M, Goldberger RS, Psoter
WJ. Association of radiographically diagnosed apical
periodontitis and cardiovascular disease: a hospital
records-based study. J Endod. 2016;42:916–20.
41
26. Cotti E, Dessì C, Piras A, Mercuro G. Can a chronic
dental infection be considered a cause of cardiovascu-
lar disease? A review of the literature. Int J Cardiol.
2011;148:4–10.
27. Raphael D, Brown I, Rukholm E, Hill-Bailey
P. Adolescent health: moving from prevention to
promotion through a quality of life approach. Can
J Public Health. 1996;87:81–3.
28. Hamedy R, Shakiba B, Fayazi S, Pak JG, White
SN. Patient-centered endodontic outcomes: a narra-
tive review. Iran Endod J. 2013;8:197–204.
29. Dugas NN, Lawrence HP, Teplitsky P, Friedman
S. Quality of life and satisfaction outcomes of end-
odontic treatment. J Endod. 2002;28:819–27.
30. Reit C, Kvist T. Endodontic retreatment behaviour:
the influence of disease concepts and personal values.
Int Endod J. 1998;31:358–63.
31. Kvist T, Reit C. The perceived benefit of endodontic
retreatment. Int Endod J. 2002;35:359–65.
32. Cohen LA, Harris SL, Bonito AJ, Manski RJ,
Macek MD, Edwards RR, Cornelius LJ. Coping
with toothache pain: a qualitative study of low-
income persons and minorities. J Public Health
Dent. 2007;67:28–35.
33. Vernazza CR, Steele JG, Whitworth JM, Wildman JR,
Donaldson C. Factors affecting direction and strength
of patient preferences for treatment of molar teeth
with nonvital pulps. Int Endod J. 2015;48:1137–46.
34. Moiseiwitsch J. Do dental implants toll the end of
endodontics? Oral Surg Oral Med Oral Pathol Oral
Radiol Endod. 2002;93:633–4.
35.
Pennington MW, Vernazza CR, Shackley P,
Armstrong NT, Whitworth JM, Steele JG. Evaluation
of the cost-effectiveness of root canal treatment using
conventional approaches versus replacement with an
implant. Int Endod J. 2009;42:874–83.
36. Kim SG, Solomon C. Cost-effectiveness of endodon-
tic molar retreatment compared with fixed partial den-
tures and single-tooth implant alternatives. J Endod.
2011;37:321–5.
37. Bjørndal L, Reit C. Endodontic malpractice claims in
Denmark 1995–2004. Int Endod J. 2008;41:1059–65.
38.
Pinchi V, Pradella F, Gasparetto L, Norelli
GA. Trends in endodontic claims in Italy. Int Dent
J. 2013;63:43–8.
39. Bigras BR, Johnson BR, BeGole EA, Wenckus
CS. Differences in clinical decision making: a com-
parison between specialists and general dentists.
Oral Surg Oral Med Oral Pathol Oral Radiol Endod.
2008;106:139–44.
40. Di Fiore PM, Tam L, Thai HT, Hittelman E, Norman
RG. Retention of teeth versus extraction and implant
placement: treatment preferences of dental faculty
and dental students. J Dent Educ. 2008;72:352–8.
41. von Arx T, Roux E, Bürgin W. Treatment decisions
in 330 cases referred for apical surgery. J Endod.
2014;40:187–91.
42. Dahlström L, Lindwall O, Rystedt H, Reit C.
‘Working in the dark’: Swedish general dental prac-
titioners on the complexity of root canal treatment.
42
Int Endod J. 2016; https://doi.org/10.1111/iej.12675.
[Epub ahead of print].
43. De Cleen MJ, Schuurs AH, Wesselink PR, Wu
MK. Periapical status and prevalence of endodontic
treatment in an adult Dutch population. Int Endod
J. 1993;26:112–9.
44. Saunders WP, Saunders EM, Sadiq J, Cruickshank
E. Technical standard of root canal treatment in an adult
Scottish sub-population. Br Dent J. 1997;182:382–6.
45. De Moor RJ, Hommez GM, De Boever JG, Delmé KI,
Martens GE. Periapical health related to the quality
of root canal treatment in a Belgian population. Int
Endod J. 2000;33:113–20.
46. Abbott PV. Analysis of a referral-based endodontic
practice: Part 1. Demographic data and reasons for
referral. J Endod. 1994;20:93–6.
47.
Sebring D, Dimenäs H, Engstrand S, Kvist
T. Characteristics of teeth referred to a public dental
specialist clinic in endodontics. Int Endod
J. 2017;50:629–35.
F. Frisk and T. Kvist
48. Bjørndal L, Laustsen MH, Reit C. Danish practitio-
ners’ assessment of factors influencing the outcome
of endodontic treatment. Oral Surg Oral Med Oral
Pathol Oral Radiol Endod. 2007;103:570–5.
49. Ahmed HM, Cohen S, Lévy G, Steier L, Bukiet
F. Rubber dam application in endodontic practice: an
update on critical educational and ethical dilemmas.
Aust Dent J. 2014;59:457–63.
50. Burry JC, Stover S, Eichmiller F, Bhagavatula
P. Outcomes of primary endodontic therapy provided
by endodontic specialists compared with other pro-
viders. J Endod. 2016;42(5):702.
51. Ng YL, Mann V, Rahbaran S, Lewsey J, Gulabivala
K. Outcome of primary root canal treatment: system-
atic review of the literature—Part 1. Effects of study
characteristics on probability of success. Int Endod
J. 2007;40:921–39.
52. Schwendicke F, Stolpe M. Secondary treatment
for asymptomatic root canal treated teeth: a cost-­
effectiveness analysis. J Endod. 2015;41(6):812.
 Diagnosis
5
Thomas Kvist and Peter Jonasson

Appearances to the mind are of four kinds. Things either are what they appear to be; or
they neither are, nor appear to be; or they are, and do not appear to be; or they are not,
yet appear to be. Rightly to aim in all these cases is the wise man’s task
Epictetus, 2nd century A.D.

Abstract
The diagnosis of apical periodontitis in a root-filled tooth is associated
with many difficulties. In particular, when signs of disease remain at an
X-ray but the patient and the actual tooth are otherwise free of symptoms,
the situation is cumbersome for many clinicians. In this chapter we high-
light the challenges. But we also provide arguments for a diagnostic strat-
egy that benefit of the doubt when the diagnosis is characterized of
uncertainties.

5.1 Introduction 5.2 Diagnostic Methods

For a root canal treatment to be considered 5.2.1 Clinical Examinations

wholly successful in the long term, it requires not
only that the tooth is surviving, functional, and
asymptomatic. When the root-filled tooth is
examined clinically and radiographically, it
should also be free of signs of inflammation in
surrounding bony structures. If signs of inflam-
mation persist, although presently asymptomatic,
it is likely that the root-filled tooth is containing
microorganisms and that apical periodontitis is
present.
T. Kvist, DDS, PhD (*) • P. Jonasson, DDS, PhD
Department of Endodontology, Institute of
Odontology, The Sahlgrenska Academy,
University of Gothenburg, Göteborg, Sweden
e-mail: kvist@odontologi.gu.se;
peter.jonasson@odontologi.gu.se
When root-filled teeth cause swelling or pain, it is
usually a sign of infection. Similarly, clinical find-
ings at the root-filled tooth in the form of redness,
tenderness, and fistulas are signs of presence of
microorganisms. In these situations, it is usually
relatively straightforward to diagnose a persistent,
recurrent, or arising apical periodontitis.
An intraoral radiograph (see below) usually
confirms the suspicion, and diagnostic process
quite smoothly turns into a decision-making
process.
In case of a chronic sinus tract, the diagnosis
of apical periodontitis is sometimes incidental.
The observation is discovered unintentionally
and unrelated to the treatment or diagnostic pro-
cedure undertaken at the moment, for example,
during clinical examination for caries or during a
visit for preventive professional dental hygiene

© Springer International Publishing AG 2018 43

T. Kvist (ed.), Apical Periodontitis in Root-Filled Teeth,
https://doi.org/10.1007/978-3-319-57250-5_5
44
care. The sinus tract may exit the mucosa in
either close to or at some distance from the tooth.
When located immediately adjacent to gingival
sulcus, this can have the appearance of a deep,
narrow periodontal pocket.
5.2.2 Clinical Differential Diagnosis
There are few symptomatic pathological condi-
tions that may be present in conjunction with a
root-filled tooth and consequently be mistaken
for persistent apical periodontitis.
However, it is important for the clinician to
be familiar with these in order to be able to
make a correct diagnosis and avoid inserting
treatments that are ineffective, costly, and at
worst harmful.
5.2.2.1 Apical Fenestration
As many as 9% of teeth have shown to have small
and window-like openings or defect in the alveo-
lar plate of the bone, frequently exposing a por-
tion of the root, usually located on the facial
aspect of the alveolar process [1, 2]. These find-
ings have been confirmed by a more recent cone
beam computed tomography (CBCT) analysis on
patients with periradicular defects of endodontic
origin [3].
Pain associated with the presence of apical
fenestration may occur after root canal treatment
[4, 5]. Even slight instrumentation, irrigation or
filling beyond the apical terminus of the root
canal may irritate the periosteum and the overly-
ing mucosa. The tooth may be spontaneously
sensitive only occasionally, but pain is usually
perceived during palpation of the area and masti-
catory movements. If an apical fenestration is
diagnosed, it is difficult to separate the condition
from a painful persistent ­apical periodontitis. If
an intervention is considered, surgical retreat-
ment should be the treatment of choice. When
elevating a flap over a suspicious root tip area, the
operator hence could expect to find a root tip
without covering cortical bone. The treatment
consists of removing all pathological tissue, a
T. Kvist and P. Jonasson
root resection, an ultrasonic tip preparation, and a
root-end filling. Special attention should be done
to foreign bodies such as pieces of the bone or
root and gutta-percha or sealer that sometimes is
found embedded in the undersurface of the flap.
Successful outcome with an asymptomatic
patient after the surgical procedure confirms the
diagnosis ex juvantibus.
5.2.2.2 Vertical Root Fracture
Patients with vertical root fractures typically
present with deep depths probing in narrow or
rectangular patterns typical of cracked tooth
lesions. But the subjective symptoms are usually
only minor pain or discomfort. Sometimes the
tooth feels a little mobile. When suspecting root
fracture in teeth with more extensive restorations,
it may be necessary to remove the fillings or
crowns for inspection and better accessibility for
probing approximal pockets.
Radiographic evidence varies. Widening of
the periodontal ligament along the whole length
of the root is a rather common feature. Only
rarely will there be visible separation of the
root segments. If there is a sinus tract combined
with the narrow, isolated periodontal probing
defect in a tooth that has had root canal treat-
ment, with or without a post placement, the
findings are considered to be pathognomonic
for the presence of a vertical root fracture.
However, because vertical root fracture may
mimic periodontal disease or a persistent apical
periodontitis with an endo-perio lesion [6],
these cases often result in referral to a perio-
dontist or endodontist for evaluation.
Newer methods of analysis are currently being
studied, such as cone beam computerized tomog-
raphy (CBCT), in order to help identify longitu-
dinal fractures in a nondestructive fashion [7].
However, when there is doubt about the diagnosis
and when the fracture cannot be visualized either
on radiographs or clinically despite the use of an
operator microscope, there is an indication for an
exploratory surgery.
The only predictable treatment is removal of
the fractured root or extraction of the tooth.
5 Diagnosis
In multirooted teeth, removal of the fractured
root may be performed by root amputation (root
resection) or hemisection.
5.2.2.3 “Pulpitis” in a Root-Filled Tooth
Missed root canal during the root canal treat-
ment is a common indirect cause of persistent
apical periodontitis, especially in molar teeth
[8]. However, it may also be sometimes that a
tooth is painful because in missed canals or
part of canals vital and inflamed pulp tissue
remains [9].
5.2.2.4 Nonodontogenic Pain
Pain present in a root-filled tooth may sometimes
be of nonodontogenic origin. This is evidently
important because treatments and prognoses are
different.
Atypical Odontalgia (“Phantom Tooth
Pain”)
Persistent pain in lack of other clinical or radio-
graphic (see below) signs of pathology in a root-­
filled tooth may be caused by a peripheral nerve
damage that results in neuropathic pain, a dys-
function of the somatosensory system [10–12].
The onset of the pain may have been before the
root canal treatment was performed and conse-
quently the root canal treatment may have been
carried out following misdiagnosis. It is also pos-
sible that onset of the pain disorder is associated
with the endodontic procedures. The condition is
relatively rare [13] but challenging to dentists
because it is difficult to distinguish from pain due
to inflammation and also because inflammatory
components of pain may be present at the same
time and site. It shares many characteristics with
other chronic pain conditions, and pain perpetua-
tion mechanisms are likely to be similar. A diag-
nosis should be made only after a comprehensive
examination and assessment of patients’ self-­
reported characteristics and exclusion of odonto-
genic [9, 14] or other nonodontogenic causes,
such as temporomandibular disorders (see
below). Traditional dental diagnostic methods do
not appear to serve well, since many patients
45
report repeated care-seeking and numerous treat-
ment efforts, for example, endodontic surgery,
with little or no pain relief [11].
Referred Pain from Temporomandibular
Disorder
The most common nonodontogenic reason for
pain in a root-filled tooth is probably pain origi-
nating from temporomandibular disorders where
patients’ perception of their symptoms as “tooth”
pain can be explained within the concept of
referred pain [15, 16]. Likely, the most common
sources of referred pain to the teeth are the mas-
seter and the lateral pterygoid muscles [17].
Consequently, in lack of any objective signs of
apical periodontitis, patients experiencing a per-
sistent pain from a root-filled tooth should be
evaluated for temporomandibular disorders.
Trigeminal Neuralgia and Other
Neuropathic Pain Conditions
Multiple causes exist in neuropathic pain includ-
ing direct nerve injury, nerve injection injury,
nerve compression injury (e.g., implant, osseous
growth, neoplastic invasion), and infection-­
inflammation damage (e.g., virus) to the nerve
itself. Fortunately, these conditions are rarely
seen in a dental office, and furthermore they
either exhibit other characteristic features, like
trigger points and refractory periods in the case
of trigeminal neuralgia, or present with concur-
rently other symptoms, e.g., blizzards in case of
herpes zoster infection [18].
5.2.3 Radiographic Examination
A common situation is that the root-filled tooth
is both subjective and clinically asymptomatic,
but an X-ray reveals that bone destruction has
emerged or that the original bone destruction
remains. In cases where no bony destruction
was present when root canal treatment was
completed, and in particular in cases of vital
pulp therapy, it can be reasonably assumed that
an infection has set in the root canal system.
46
For teeth that exhibited clear bone destruction
at treatment start, there must be allowed some
time for healing and bone formation to occur.
5.2.3.1 Uncertainties in Radiographic
Diagnosis of Apical
Periodontitis
Time Passed Since Primary Root Canal
Treatment
One difficulty is to determine how long the time
that may be required for the healing process of
apical periodontitis, both in general and in the
particular case. The majority of root canal treated
teeth with bone destruction in the initial situation
shows signs of healing within 1 year [19]. In indi-
vidual cases, however, the healing process can
last a long time [20, 21]. Molven et al. [22] have
reported isolated cases requiring more than
25 years to completely heal. The notion that no
absolute time limits for healing process can be
established can also be deduced from epidemio-
logical studies [23].
Controversies of “Success” and “Failures”
of Root Canal Treatment
Besides the time aspect, there is also a problem of
determining what should be considered as a suf-
ficient healing of bone destruction to constitute
successful endodontic treatment. And as a conse-
quence also, what establishes a “failure” and
hence the diagnosis of persistent apical periodon-
titis is far from unambiguous. According to the
system launched by Strindberg [20], the only sat-
isfactory posttreatment situation, after a predeter-
mined healing period, combines a symptom-free
patient with a normal periradicular situation.
Only cases fulfilling these criteria should be clas-
sified as “successes” and all others as “failures.”
In academic environments and in clinical
research, these strict criteria set by Strindberg in
1956 have had a strong position.
However, the diagnosis of periapical tissues
based on intraoral radiographs has repeatedly
unmasked considerable inter- and intra-observer
variation [24] (see below).
The periapical index (PAI) scoring system was
presented by Ørstavik et al. in 1986 [25]. The PAI
T. Kvist and P. Jonasson
provides an ordinal scale of five scores ranging
from “healthy” to “severe periodontitis with
exacerbating features” and is based on reference
radiographs with verified histological diagnoses
originally published by Brynolf [26]. In this doc-
toral thesis, the radiographic appearance of peri-
apical tissue was compared with biopsies. The
results indicated that using radiographs, it was
possible to differentiate between normal states
and inflammation of varying severity and that the
likelihood of a correct diagnosis improved if
more than one radiograph was taken. However,
the studies were based on a limited patient spec-
trum, and the biopsy material was restricted to
upper anterior teeth. Among researchers the PAI
is well established, and it has been used in both
clinical trials and epidemiological surveys (see
Chap. 2). Researchers often transpose the PAI
scoring system to the terms of Strindberg system
by dichotomizing scores 1 and 2 to “success” (=
no apical periodontitis) and scores 3, 4, and 5 into
“failure” (=presence of apical periodontitis).
However, the “cutoff” line is arbitrary. The
Strindberg system, with its originally dichoto-
mizing structure into “success” and “failure,” has
achieved status as a normative guide to clinical
action.
As early as 1966, Bender et al. [27] suggested
that an arrested bone destruction in combination
with an asymptomatic patient should be suffi-
ciently conditions for classifying a root canal
treatment as endodontic success. More recently
Friedman and Mor [28] as well as Wu et al. [29]
have suggested similar less strict classifications
of the outcome of root canal treatment.
The Reliability of Radiographic Evaluation
Reliability is a key feature of a diagnostic test as
results should be repeatable with high interob-
server agreement. The diagnosis of periapical tis-
sues based on intraoral radiographs is subject to
considerable intra- and interobserver variation.
One of the first studies that paid attention to the
phenomenon was authored by Goldman et al. in
1972 and 1974 [30, 31]. In the first paper, six
independent examiners evaluated 253 asymptom-
atic endodontically treated cases. The examiners
agreed completely on less than 50% of the cases.
5 Diagnosis
In the later, the authors studied how well some of
the first group of examiners agreed with them-
selves when they examined the same radiographs
6–8 months later. The somewhat s­ urprising result
was they only agreed with themselves anywhere
from 72 to 88% of the time. In a classical study by
Reit and Hollender [24], three endodontists and
three radiologists interpreted periapical condi-
tions in radiographs of 119 root-­ filled roots.
Consensus on the presence of periapical lesion
was reached in 27% of cases classified as patho-
logic. The examiners agreed completely on nor-
mal periapical conditions in 37% of the cases. The
study clearly demonstrated the difficulty in defin-
ing and maintaining criteria for radiological evi-
dence of periapical disease. In order to overcome
the problems with observer variation, different
solutions have been presented. Certainly, first of
all, the quality of the different steps in the radio-
graphic process has to be no less than optimal.
Calibration programs for reducing interob-
server variation seem to have limited effect [32].
The PAI score (see Chap. 2 and above) offers a
visual reference scale for assigning a periapical
health status.
Variation between observers could basically
be explained by their different criteria of what
should constitute reporting the presence of a peri-
apical lesion. Such a view on the diagnosis of
apical periodontitis in root-filled teeth fits well
into the concept of “statistical decision analysis.”
Within this theory it is paradigmatic that an
observer reporting high true-positive percentage
also reports higher false-positive percentage and
vice versa. If the “true” state can be established,
in some way or the other, pairs of true-positive
and false-positive percentages can be plotted into
a Receiver Operating Characteristic (ROC)
curve. And variations between observers can be
explained by different positions on the ROC
curve. One key conclusion from applying this
theory is that false positive diagnoses will be
more frequent the lower the prevalence of the dis-
ease under study. Consequently, the best way to
uncover the relative difference between groups,
for example, in the research context, is to have a
strict criterion for the disease and report positive
findings only when absolutely certain [33].
47
Despite the avalanche of interest of CBCT in
recent years, the issue of observer variations
encountered only scarce interest from researchers
[34]. But data available from experimental and
cadaver studies [35, 36] suggests that both intra-
and interobservation variation are less compared
to intraoral radiographs. However, it must be kept
in mind that the use of and interpretation of
CBCT scans need particular special skills and
training.
The Validity of Radiographic Evaluation
The validity of a diagnostic test is evaluated in
terms of its ability to detect subjects with disease
as well as its capacity to exclude subjects without
disease. Uncertainties regarding the validity of
the radiographic examination [37, 38] are of con-
cern. For obvious practical and ethical reason,
only a limited number of studies have compared
the histological diagnosis in root-filled teeth with
and without radiographic signs of pathology [26,
39, 40]. In these studies, false-positive findings
(i.e., radiographic findings indicate apical peri-
odontitis, while histological examination does
not give evidence for inflammatory lesions) are
rare. False-negative findings (i.e., radiographic
findings indicate no apical periodontitis, while
histological examination does give evidence for
inflammatory lesions) vary in the different stud-
ies. However, it is well known that bone destruc-
tion and consequently apical periodontitis may
be present without radiographic signs visible in
intraoral radiographs [40, 41].
The advent of cone beam computed tomogra-
phy (CBCT) has confirmed the findings of Bender
and Seltzer [41, 42] in recent years. In vitro stud-
ies on skeletal material indicate that the method
has higher sensitivity and specificity than intra-
oral periapical radiography [34]. The higher sen-
sitivity is confirmed in clinical studies. The major
disadvantages of CBCT are greater cost and a
potentially higher radiation dose, depending on
the size of the radiation field being used. However,
one benefit of the CBCT method is that it is rela-
tively easy to apply. It provides a three-­
dimensional image of the area of interest, an
advantage when assessing the condition of multi-
rooted teeth. And the uncertainty of assessing
48
results of endodontic treatment in follow-up using
conventional intraoral radiographic technique has
been pointed out [43]. Consequently, it has been
suggested that CBCT should be used in clinical
studies, because of the risk that conventional radi-
ography underestimate the number of unsuccess-
ful endodontic treatments. However, it may be
important not to jump into conclusions. One study
examined the validity of CBCT-­diagnosed apical
periodontitis with a histological examination as a
“gold standard” [35]. The authors used jaw sec-
tions from human cadavers including 86 roots in
67 teeth. All specimens also underwent histopath-
ological examination. Different aspects of the
diagnostic accuracy of digital intraoral periapical
radiographs and cone (CBCT) were compared in
detecting apical periodontitis using histopatho-
logical findings as a reference. The study corrobo-
rated that CBCT technology is more sensitive
than intraoral radiographs, e.g., false negatives are
less frequent while a false positive only was diag-
nosed in one case (using the intraoral radiograph).
The study however did not specifically study root-
filled teeth, and the overall prevalence of apical
periodontitis was 67% which might explain the
overall high specificity for both methods.
One study [44] found that false-positive find-
ings may be a potential substantial problem using
CBCT since evidently healthy teeth (vital pulps)
showed signs of apical periodontitis in CBCT but
not on intraoral radiographs. In root-filled teeth,
long-term studies are required to investigate if
healing of periapical bone destruction may take
longer than previously assumed when evaluating
results with CBCT. For example, at 1-year post
3. Diagnostic
thinking
2. Diagnostic efficacy
accuracy
1.Technical efficacy
efficacy
Fig. 5.1  Fryback and Thornbury’s framework of the efficacy of diagnostic imaging
T. Kvist and P. Jonasson
endodontic treatment follow-up, CBCT can show
persisting bone destruction, while a conventional
intraoral radiograph shows healing [45].
The Efficacy of CT and CBCT
in Endodontics
The use of a more accurate diagnostic technology
does not necessarily lead to a different course of
action or a better outcome. A hierarchical model
of efficacy has been presented as a model for
appraisal of the literature on efficacy of diagnostic
imaging by Fryback and Thornby (Fig 5.1) [46].
Demonstration of efficacy at each lower level in
this hierarchy is logically necessary, but not suf-
ficient, to assure efficacy at higher levels. In this
model level 1 addresses technical quality of the
images. Level 2 concerns diagnostic accuracy,
sensitivity, and specificity associated with inter-
pretation of the images. Next, level 3 focuses on
whether the information produces change in the
physician’s or dentist’s diagnostic thinking. Such
a change is a logical prerequisite for level 4 effi-
cacy, which addresses effect on the patient man-
agement plan. The highest efficacy level studies
eventually concern effects on patient outcomes
and analyses of economic and societal costs and
benefits (levels 5 and 6). Few studies have investi-
gated the impact of CT or CBCT on endodontics
when making a diagnosis or selecting a treatment
option, and most importantly, even lesser have
assessed the benefit to the patient of using these
imaging modalities [34, 47, 48]. As result, the evi-
dence is still inconclusive whether the use of CT
or CBCT is warranted in the clinical decision-
making and treatment of the individual patient.
6. Societal
efficacy
5. Patient
outcome
4. Therapeutic efficacy
efficacy
5 Diagnosis
Nonendodontic Lesions Misdiagnosed
as Apical Periodontitis
There are a number of nonendontic lesions, both
benign and malign, mimicking apical periodonti-
tis in the radiograph. These include fibroosseous
lesions, ameloblastomas, nasopalatine duct cysts,
keratocystic odontogenic tumor, metastatic inju-
ries, and carcinomas [49, 50]. Some of these will
present asymptomatic, whereas others will be
present with both pain and swelling. Because the
vast majority of all periapical bone lesions are
indeed due to an infection of endodontic origin,
there may be a risk of misdiagnosing those few
who are not, as apical periodontitis. It is therefore
emphasized that the clinical and radiologic exam-
ination as well as analysis of the patients’ medical
history must be comprehensive. In root-­ filled
teeth, the usually most valuable diagnostic tool,
pulp vitality test, is not available. Therefore, the
risk of a misdiagnosis may be more pronounced.
If the medical history, clinical examination, and/
or radiographic features result in a suspicion of a
nonendodontic lesion, a biopsy and sequential
histopathological analysis are mandatory.
5.3  n Everyday Practical
A ing radiation exposure to patients, the potential
Approach to Diagnosing
Apical Periodontitis in
Root-­Filled Teeth
5.3.1 Diagnostic Strategy
The art and science of diagnosing apical periodon-
titis in root-filled teeth are hampered by several
difficulties. Misdiagnosis can therefore not be
completely avoided. A deliberate strategy may be
a mean to steer away from unwanted mistakes or
to guide to acceptable and calculated mistakes. If a
clinician, in a given situation, wants to minimize
the number of false-positive diagnoses, i.e., wants
to minimize the number of healthy wrongly diag-
nosed as being ill, the requirements for a positive
diagnosis should be kept strict, and a positive diag-
nosis should be reported only when absolutely cer-
tain. Adopting such a strategy, the patient or the
tooth “benefits of the doubt.” If, on the other hand,
the clinician wants to minimize the number of
49
false-negative diagnoses, i.e., wants to minimize
the number of sick registered as healthy, the
requirements for a positive diagnosis should be
more including, and a positive diagnosis should be
reported whenever there is a suspicion of disease.
Such a strategy in contrast to above could be char-
acterized as “trap rather than free.” A reduction of
false-positives diagnoses always brings an increase
in the number of false-negative diagnoses and vice
versa. Selection of strategy thus always has a
desired and an undesired effect [33, 51].
It is likely that a more general use of CBCT
would improve the diagnostic accuracy of apical
periodontitis in root-filled teeth. In particular, the
proportion of false-negative diagnoses could be
reduced. But it cannot be ruled out that the risk of
an increased amount of false-positive diagnoses
could also be the result, in particular in the
absence of symptoms and when then the preop-
erative appearance of the lesion is unknown.
Also, because the dynamics of the healing pro-
cess over time after root filling is undetermined,
unrestrainedly use of CBCT would bring about
risk of substantial overdiagnosis and as logical
result also overtreatment (for further reading, see
Chap. 6 “Decision Making”). As with any ioniz-
benefits should outweigh the potential risks.
5.3.2 A
 rguments for “Benefit
of the Doubt” Strategy
The high frequency of root-filled teeth with peri-
apical bone destructions seems to persist despite
the technical quality of root fillings has improved
over time [52, 53].
Millions of teeth saved to survival and asymp-
tomatic function are present in many countries all
over the world. The risks of a systemic adverse
effect on the health of untreated apical periodon-
titis may, on the basis of the evidence currently
available, considered small for healthy patients
(see Chap. 4 “Consequences”). Severe acute
infectious condition resulting from apical peri-
odontitis in root-filled teeth is also unusual and
has been estimated to less than 5% over a period
of 25 years [54]. Unfortunately, there is no
50
scientifically established method to distinguish
between different severities of periapical disease.
There is some evidence that there is a connection
between the periapical size and the amount of
involved microorganisms [21]. Many different
microorganisms, in most cases the bacteria but
sometime fungi, have been found in the biofilms
that persist in filled root canals. There are no
accepted scientifically founded clinical methods
to distinguish particularly “dangerous” or “harm-
less” biofilms from this perspective.
In many cases the root filling quality is poor,
and an apical lesion is apparent to anyone who is
observing the radiograph despite the fact the
patient is free from symptoms. In such cases
there is little or no doubt about the diagnosis; the
tooth should be diagnosed with persistent apical
periodontitis. In other situations, the periapical
radiolucency is big and shows no signs of reduc-
tion in size despite adequate root canal treatment.
It may be suspected that the periapical lesion rep-
resents a periradicular cyst without any further
healing potential without further treatment [55,
56]. The next steps are to inform the patient and
have a dialogue about how the situation should be
managed. This process is reviewed in Chap. 6.
However, if the root filling quality is reasonable
within acceptable standards, the clinician may
remain ambiguous about the periapical diagnosis.
When uncertain about the diagnosis of apical
periodontitis, it seems likely from the bulk of
available information that most patients will
“benefit from the doubt” when apical periodonti-
tis in an asymptomatic and properly root-filled
tooth is considered. In other words, false-positive
diagnoses should be avoided. This means that the
clinician deliberately should choose to refrain
from diagnosing apical periodontitis in root-filled
teeth when in doubt, rather than taking risk of
diagnosing and hence treating teeth with healed
or healing apical periodontitis.
5.3.3 E
 xceptions from the “Benefit
from the Doubt” Strategy
A careful medical history is important for all
patients under dental care. There are several med-
T. Kvist and P. Jonasson
ical conditions and medications that cause a dete-
rioration of the immune system, by the lack of
white blood cells or the inability of a patient to
produce antibodies.
In such situations, maybe that “trap rather
than free” attitude by the clinician may be the
best diagnostic strategy. However, it is unclear to
what extent medically comprised patients benefit
from diagnoses and in particular treatment of
asymptomatic apical periodontitis in a situation
of ongoing medications or disease that impede
normal function of the immune defense system.
5.3.4 S
 ome Common Situations
and Guidelines for
Determining Diagnosis
In the following we will give some typical exam-
ples where there may be an uncertainty regarding
potential residual apical periodontitis in a root-­
filled tooth. We are also suggesting a concrete
policy reaching a diagnosis in each one of the
situations.
5.3.4.1 Pain from Root-Filled Tooth
But No Sign of Apical
Periodontitis on Intraoral
Radiographs
The patient may experience soreness—pain or
discomfort from a root-filled tooth. However,
intraoral radiographs from one or two angula-
tions show no apical radiolucency. The root fill-
ing exhibits good technical quality as can be
judged from the radiographs.
Action: Suggest a CBCT scan.
If this shows that an apical radiolucency is
present, there is indication for retreatment or in
some cases extraction.
If no radiolucency, or other pathology, can be
observed, one can suspect that the endodontic treat-
ment caused a damage to sensory nerves involved.
Or that pain is projected from a TMD disorder.
There is no diagnosis of apical periodontitis and
consequently no indication for retreatment or
extraction. Instead extend the examination and
consider other diagnoses that may mimic the symp-
toms of apical periodontitis in a root-filled tooth.
5 Diagnosis
5.3.4.2 Asymptomatic Tooth
But a Widened Periapical
Contour
Another common situation is that the patient is
asymptomatic; the root filling exhibits good tech-
nical quality. But, there is a widening of the peri-
apical contour present.
Action: An expanded periodontal contour
should not be considered pathological. The diag-
nosis shows great observer variations. Great
uncertainty is present. The patient and tooth ben-
efit from the doubt if no other findings suggestive
of apical periodontitis are present.
5.3.4.3 Asymptomatic Tooth
But Clinician Is Uncertain
About a Possible Lesion
A similar common situation is that the patient is
asymptomatic. The root canal exhibits good
technical quality. However, the clinician is in
­
doubt whether a periapical lesion is present or
not.
Action: Consultation with a colleague on the
radiograph. If the uncertainty persists, consult a
radiologist who must decide.
5.3.4.4 Asymptomatic Tooth: A Lesion
Is Present But Short Time
Since Root Filling
In this scenario the patient is asymptomatic.
However, there is an apical radiolucency evident
in the intraoral radiograph. Root canal shows
good technical quality. Relatively short time
passed since the root canal treatment and root fill-
ing were performed (1–4 years).
Action: Good to fairly good healing potential
remains. The closer to the point of root filling, the
larger remaining of healing chances. Wait for
periapical healing at least 4 years.
5.3.4.5 Asymptomatic Tooth: A Lesion
Is Present Showing Reduced
Size
Our last example is equally frequent. The patient
is asymptomatic. Root filling shows good techni-
cal quality. More than 4 years have passed since
root filling was performed. There is an apical
radiolucency. However, compared with previous
51
X-ray, it shows the radiolucency clearly and con-
tinuously reduced in size.
Action: Further healing potential may remain.
Wait further healing and check again.
5.3.5 Patient Information
and the Adoption of Measures
When the diagnosis of apical periodontitis is
made, it is the dentist’s statutory obligation to
inform about the diagnosis and demonstrate the
potential of therapy. The dentist should also give
suggestions on the treatment that he/she deems
most appropriate. In addition, the dentist must
inform if the treatment is requiring a referral to a
specialist or not. It is the patient who must take
the final decision to treat or not. This process will
be further covered in Chap. 6.
Take-Home Lessons
• When pain and/or swelling or a sinus
tract from a root-filled tooth is present
and at the same time an apical radiolu-
cency can be observed on an intraoral
radiograph, the diagnosis of apical peri-
odontitis is evident.
• When pain from a root-filled tooth reg-
istered without concomitant other clini-
cal or radiographic signs of disease, a
handful of other diagnoses should be
considered, among them referred pain
from TMD and neuropathic pain
disorders.
• When clear radiographic signs of apical
periodontitis are present, the diagnosis
is usually evident because of poor-­
quality root filling giving obvious space
for microbial biofilm to persist.
• When radiographic signs of apical peri-
odontitis are uncertain, the diagnosis is
surrounded by major uncertainties,
especially if root filling quality is good.
In such situations, we argue most
patients will “benefit from doubt”—
diagnostic strategy.
52
References
Benchmark Papers
• Brynolf I. Histological and roentgeno-
logical study of periapical region of
human upper incisors. Odontologisk
Revy. 1967;18(Suppl. 11). In this classi-
cal thesis, the author studied the peri-
apical regions of root-filled teeth with
histological as well as radiographic
examinations. The studies provided data
for the PAI score.
• Reit C, Hollender L. Radiographic eval-
uation of endodontic therapy and the
influence of observer variation. Scand J
Dent Res. 1983;91:205–12. The authors
clearly and elegantly demonstrated the
intra- and interobserver variation prob-
lems involved in the diagnosis of peri-
apical lesions in intraoral radiographs.
• Reit C, Gröndahl HG. Application of
statistical decision theory to radio-
graphic diagnosis of endodontically
treated teeth. Scand J Dent Res.
1983;91(3):213–8. The study explains
why variations between the observers
could be explained by their adoption of
different criteria of periapical disease
resulting in different positions on the
ROC curve. It also explains why the best
opportunities for revealing relative dif-
ferences in disease prevalences are cre-
ated when the examiner defines a strict
criterion for disease and reported a
positive finding only when absolutely
certain.
• Strindberg LZ. The dependence of the
results of pulp therapy on certain fac-
tors. Acta Odontol Scand 1956;14(Suppl.
21). Classical study on outcome of root
canal treatment clearly demonstrating
that the number of healed cases will
increase in the long term, also after
such a long period as 4 years.
T. Kvist and P. Jonasson
1. Jorgić-Srdjak K, Plancak D, Bosnjak A, Azinović
Z. Incidence and distribution of dehiscences and
fenestrations on human skulls. Coll Antropol.
1998;22(Suppl):111–6.
2. Rupprecht RD, Horning GM, Nicoll BK, Cohen
ME. Prevalence of dehiscences and fenestra-
tions in modern American skulls. J Periodontol.
2001;72(6):722–9.
3. Yoshioka T, Kikuchi I, Adorno CG, Suda H. Periapical
bone defects of root filled teeth with persistent lesions
evaluated by cone-beam computed tomography. Int
Endod J. 2011;44:245–52.
4. Boucher Y, Sobel M, Sauveur G. Persistent pain
related to root canal filling and apical fenestration: a
case report. J Endod. 2000;26:242–4.
5. Pasqualini D, Scotti N, Ambrogio P, Alovisi M,
Berutti E. Atypical facial pain related to apical fenes-
tration and overfilling. Int Endod J. 2012;45(7):670.
6. Zehnder M, Gold SI, Hasselgren G. Pathologic
interactions in pulpal and periodontal tissues. J Clin
Periodontol. 2002;29:663–71.
7. Metska ME, Aartman IH, Wesselink PR, Özok
AR. Detection of vertical root fractures in vivo in
endodontically treated teeth by cone-beam computed
tomography scans. J Endod. 2012;38:1344–7.
8. Karabucak B, Bunes A, Chehoud C, Kohli MR, Setzer
F. Prevalence of apical periodontitis in endodontically
treated premolars and molars with untreated canal:
a cone-beam computed tomography study. J Endod.
2016;42:538–41.
9. Tidwell E, Witherspoon DE, Gutmann JL, Vreeland
DL, Sweet PM. Thermal sensitivity of endodontically
treated teeth. Int Endod J. 1999;32:138–45.
10. Marbach JJ, Hulbrock J, Hohn C, Segal AG. Incidence
of phantom tooth pain: an atypical facial neuralgia.
Oral Surg Oral Med Oral Pathol. 1982;53(2):190–3.
11. Pigg M, Svensson P, Drangsholt M, List T. Seven-­
year follow-up of patients diagnosed with atypi-
cal odontalgia: a prospective study. J Orofac Pain.
2013;27:151–64.
12. Polycarpou N, Ng YL, Canavan D, Moles DR,
Gulabivala K. Prevalence of persistent pain after
endodontic treatment and factors affecting its occur-
rence in cases with complete radiographic healing. Int
Endod J. 2005;38(3):169–78.
13. Nixdorf DR, Moana-Filho EJ, Law AS, McGuire LA,
Hodges JS, John MT. Frequency of nonodontogenic
pain after endodontic therapy: a systematic review
and meta-analysis. J Endod. 2010;36(9):1494–8.
14. Shackleton TA. Failure of root canal treatment misdi-
agnosed as neuropathic pain: case report. J Can Dent
Assoc. 2013;79:d94.
5 Diagnosis
15. Nixdorf DR, Law AS, John MT, Sobieh RM, Kohli
R, Nguyen RH, National Dental PBRN Collaborative
Group. Differential diagnoses for persistent pain
after root canal treatment: a study in the National
Dental Practice-based Research Network. J Endod.
2015;41(4):457–63.
16. Schiffman E, Ohrbach R, Truelove E, Look J,
Anderson G, Goulet JP, List T, Svensson P, Gonzalez
Y, Lobbezoo F, Michelotti A, Brooks SL, Ceusters
W, Drangsholt M, Ettlin D, Gaul C, Goldberg LJ,
Haythornthwaite JA, Hollender L, Jensen R, John
MT, De Laat A, de Leeuw R, Maixner W, van der
Meulen M, Murray GM, Nixdorf DR, Palla S,
Petersson A, Pionchon P, Smith B, Visscher CM,
Zakrzewska J, Dworkin SF, International RDC/TMD
Consortium Network, International association for
Dental Research, Orofacial Pain Special Interest
Group, International Association for the Study of
Pain. Diagnostic Criteria for Temporomandibular
Disorders (DC/TMD) for Clinical and Research
Applications: recommendations of the International
RDC/TMD Consortium Network* and Orofacial Pain
Special Interest Group†. J Oral Facial Pain Headache.
2014;28(1, Winter):6–27.
17. Wright EF. Referred craniofacial pain patterns in
patients with temporomandibular disorder. J Am Dent
Assoc. 2000;131:1307–15.
18. Benoliel R, Eliav E. Neuropathic orofacial pain. Oral
Maxillofac Surg Clin North Am. 2008;20:237–54.
19. Ørstavik D. Time-course and risk analyses of the
development and healing of chronic apical periodon-
titis in man. Int Endod J. 1996;29:150–5.
20. Strindberg LZ. The dependence of the results of
pulp therapy on certain factors. Acta Odontol Scand.
1956;14(Suppl 21):1–175.
21. Bystrom A, Happonen RP, Sjogren U, Sundqvist
G. Healing of periapical lesions of pulpless teeth after
endodontic treatment with controlled asepsis. Endod
Dent Traumatol. 1987;3:58–63.
22. Molven O, Halse A, Fristad I, MacDonald-Jankowski
D. Periapical changes following root-canal treatment
observed 20–27 years postoperatively. Int Endod
J. 2002;35:784–90.
23. Kirkevang LL, Vaeth M, Wenzel A. Ten-year follow-
­up observations of periapical and endodontic status in
a Danish population. Int Endod J. 2012;45:829–39.
24. Reit C, Hollender L. Radiographic evaluation of end-
odontic therapy and the influence of observer varia-
tion. Scand J Dent Res. 1983;91:205–12.
25. Ørstavik D, Kerekes K, Eriksen HM. The periapi-
cal index: a scoring system for radiographic assess-
ment of apical periodontitis. Endod Dent Traumatol.
1986;2:20–34.
26. Brynolf I. Histological and roentgenological study of
periapical region of human upper incisors. Odontol
Revy. 1967;18(Suppl 11):1–176.
53
27. Bender IB, Seltzer S, Soltanoff W. Endodontic suc-
cess—a reappraisal of criteria. Oral Surg Oral Med
Oral Pathol. 1966;22:780–802.
28. Friedman S, Mor C. The success of endodontic ther-
apy—healing and functionality. J Calif Dent Assoc.
2004;32:493–503.
29. Wu MK, Wesselink P, Shemesh H. New terms for
categorizing the outcome of root canal treatment. Int
Endod J. 2011;44:1079–80.
30. Goldman M, Pearson AH, Darzenta N. Endodontic
success—who’s reading the radiograph? Oral Surg
Oral Med Oral Pathol. 1972;33:432–7.
31. Goldman M, Pearson AH, Darzenta N. Reliability of
radiographic interpretations. Oral Surg Oral Med Oral
Pathol. 1974;38:287–93.
32. Reit C. The influence of observer calibration
on radiographic periapical diagnosis. Int Endod
J. 1987;20:75–81.
33. Reit C, Gröndahl HG. Application of statistical deci-
sion theory to radiographic diagnosis of endodonti-
cally treated teeth. Scand J Dent Res. 1983;91:213–8.
34. Rosen E, Taschieri S, Del Fabbro M, Beitlitum
I, Tsesis I. The diagnostic efficacy of cone-beam
computed tomography in endodontics: a systematic
review and analysis by a hierarchical model of effi-
cacy. J Endod. 2015;41:1008–14.
35. Patel S, Dawood A, Mannocci F, Wilson R, Pitt Ford
T. Detection of periapical bone defects in human jaws
using cone beam computed tomography and intraoral
radiography. Int Endod J. 2009;42:507–15.
36. Kanagasingam S, Mannocci F, Lim CX, Yong CP,
Patel S. Diagnostic accuracy of periapical radiography
and cone beam computed tomography in detecting
apical periodontitis using histopathological findings as
a reference standard. Int Endod J. 2017;50(6):417–26.
https://doi.org/10.1111/iej.12650. Epub 2016 May 18
37. Nobuhara WK, del Rio CE. Incidence of periradicular
pathoses in endodontic treatment failures. J Endod.
1993;19:315–8.
38. Carrillo C, Peñarrocha M, Bagán JV, Vera F. Relationship
between histological diagnosis and evolution of 70 peri-
apical lesions at 12 months, treated by periapical sur-
gery. J Oral Maxillofac Surg. 2008;66:1606–9.
39.
Green TL, Walton RE, Taylor JK, Merrell
P. Radiographic and histologic periapical findings of
root canal treated teeth in cadaver. Oral Surg Oral Med
Oral Pathol Oral Radiol Endod. 1997;83:707–11.
40. Barthel CR, Zimmer S, Trope M. Relationship of
radiologic and histologic signs of inflammation in
human root-filled teeth. J Endod. 2004;30:75–9.
41. Bender IB, Seltzer S. Roentgenographic and direct
observation of experimental lesions in bone: I. 1961.
J Endod. 2003;29:702–6.
42. Bender IB, Seltzer S. Roentgenographic and direct
observation of experimental lesions in bone: II. 1961.
J Endod. 2003;29:707–12. discussion 701.
54
43. Wu MK, Shemesh H, Wesselink PR. Limitations of
previously published systematic reviews evaluat-
ing the outcome of endodontic treatment. Int Endod
J. 2009;42:656–66.
44. Pope O, Sathorn C, Parashos P. A comparative inves-
tigation of cone-beam computed tomography and
periapical radiography in the diagnosis of a healthy
periapex. J Endod. 2014;40:360–5.
45. Christiansen R, Kirkevang LL, Gotfredsen E, Wenzel
A. Periapical radiography and cone beam computed
tomography for assessment of the periapical bone
defect 1 week and 12 months after root-end resection.
Dentomaxillofac Radiol. 2009;38:531–6.
46. Fryback DG, Thornbury JR. The efficacy of diagnos-
tic imaging. Med Decis Mak. 1991;11:88–94.
47. Kruse C, Spin-Neto R, Wenzel A, Kirkevang LL. Cone
beam computed tomography and periapical lesions: a sys-
tematic review analysing studies on diagnostic efficacy
by a hierarchical model. Int Endod J. 2015;48:815–28.
48. Mota de Almeida FJ, Huumonen S, Molander A,
Öhman A, Kvist T. Computed tomography (CT) in the
selection of treatment for root-filled maxillary molars
with apical periodontitis. Dentomaxillofac Radiol.
2016;45:20150391.
49. Sirotheau Corrêa Pontes F, Paiva Fonseca F, Souza de
Jesus A, Garcia Alves AC, Marques Araújo L, Silva
do Nascimento L, Rebelo Pontes HA. Nonendodontic
lesions misdiagnosed as apical periodontitis lesions:
T. Kvist and P. Jonasson
series of case reports and review of literature. J Endod.
2014;40:16–27.
50. Huang HY, Chen YK, Ko EC, Chuang FH, Chen
PH, Chen CY, Wang WC. Retrospective analysis of
nonendodontic periapical lesions misdiagnosed as
endodontic apical periodontitis lesions in a popu-
lation of Taiwanese patients. Clin Oral Investig.
2017;21:2077–82.
51. Wulff HR, Pedersen SA, Rosenberg R. Philosophy of
medicine: an introduction. 2nd ed. Oxford: Blackwell
Scientific; 1990.
52. Frisk F, Hugoson A, Hakeberg M. Technical quality
of root fillings and periapical status in root filled teeth
in Jönköping, Sweden. Int Endod J. 2008;41:958–68.
53. Pak JG, Fayazi S, White SN. Prevalence of periapi-
cal radiolucency and root canal treatment: a sys-
tematic review of cross-sectional studies. J Endod.
2012;38:1170–6.
54. Yu VS, Messer HH, Yee R, Shen L. Incidence and
impact of painful exacerbations in a cohort with post-­
treatment persistent endodontic lesions. J Endod.
2012;38:41–6.
55. Natkin E, Oswald RJ, Carnes LI. The relationship of
lesion size to diagnosis, incidence, and treatment of
periapical cysts and granulomas. Oral Surg Oral Med
Oral Pathol. 1984;57:82–94.
56. Nair PN. New perspectives on radicular cysts: do they
heal? Int Endod J. 1998;31:155–60.
 Decision Making
6
Thomas Kvist

I used to be indecisive but now I am not quite sure.

—Tommy Cooper (1921–1984). Welsh comedian and magician.

Abstract
In this chapter the complexity of any clinical decision making process is
briefly sketched out.
Descriptive as well as prescriptive projects regarding endodontic
retreatment decision making are reviewed. The inherent ethical aspects of
any prescriptive system are emphasized.
But this chapter also gives simple guidelines for the clinician’s every-
day decision making regarding persistent apical periodontitis.

6.1 Introduction compiles their own data and then constructs an

Clinical decision making is a term frequently
used to describe the fundamental role of any phy-
sician or dentist. It concerns the process where
data are gathered, interpreted and evaluated in
order to select a choice of action. Having an
understanding of the complexity and the different
approaches to the task will allow for development
and improvement in daily care of our patients.
Clinical decision making is the process by
which we determine what the patient needs and
when he or she needs it. While not arbitrary, this
exercise can be quite subjective. Each clinician
argument for a particular disease state based on
their interpretation of the “facts”. The strength of
their case will depend on the way in which they
gather and assemble information. There may then
be no single, right way of applying therapeutic
strategies to a particular case. Dentistry is not an art
like painting. But, neither is it a science like phys-
ics. It’s an applied science. Since each patient is a
unique being, it can be very tricky to decide how to
apply the science and evidence to each individual
case and situation. In this chapter I will discuss
some various aspects on clinical decision making
for root-filled teeth with apical periodontitis.

6.2 Available Options

T. Kvist, DDS, PhD
Department of Endodontology, Institute of
Odontology, The Sahlgrenska Academy,
University of Gothenburg, Göteborg, Sweden
e-mail: kvist@odontologi.gu.se
When a diagnosis of apical periodontitis in a root-
filled tooth is present, theoretically four options
are available: (1) no treatment, (2) monitoring

© Springer International Publishing AG 2018 55

T. Kvist (ed.), Apical Periodontitis in Root-Filled Teeth,
https://doi.org/10.1007/978-3-319-57250-5_6
56
Therapy
Fig. 6.1  A decision tree
logically displaying
alternative actions in the
management of
root-filled teeth with No therapy
apical periodontitis
(wait and see), (3) extraction and (4) retreatment.
If retreatment is selected, the decision maker also
has to make a choice between a (a) surgical and
(b) nonsurgical treatment (Fig. 6.1).
6.3  ariation in Endodontic
V randomly selected cohort of 1302 persons radio-
Retreatment Decision
Making
In a benchmark, experimental study, Reit and
Gröndahl [1] confronted 35 dental officers from
the Public Dental Health Organization in Sweden
with 33 endodontically treated teeth with radio-
graphic signs of persistent apical periodontitis.
In no case was the same option suggested unani-
mously by all observers. The number of teeth
selected for therapy (surgical or nonsurgical
retreatment or extraction) had an inter examiner
range of 7–26 teeth. Petersson et al. [2] scruti-
nized 1094 treatment plans including radio-
graphs submitted to the Swedish dental insurance
system by general practitioners. In 874 root-
filled teeth, a periapical radiolucency was diag-
nosed by the authors. According to the treatment
T. Kvist
No replacement
Extraction Fixed prosthesis
Implant
Surgical retreatment
Non surgical retreatment
Monitoring
No monitoring
plan, extraction, periapical surgery and conven-
tional retreatment were suggested for 23%, 3%
and 20%, respectively. However, for the remain-
ing 472 cases (54%), no intervention was pre-
scribed. In another study, Petersson et al. [3]
re-examined a sample of 351 individuals from a
graphically examined 11 years earlier. It was
found that 33 (40%) of the endodontically treated
teeth with periapical bone lesions at first exami-
nation had been retreated or extracted, while the
remaining 49 teeth had received no radiographi-
cally detectable treatment. This quandary con-
tinues to attract attention from various aspects
among researchers, and the overall conclusion is
that there is no consensus [4, 5]. In particular, the
constantly repeated observation that the mere
diagnosis of apical periodontitis does not consis-
tently lead to clinical action has attracted special
attention [6].
The implementation of dental implants to
replace a compromised tooth has made the
issue even more marked and controversial
which has been highlighted in numerous publi-
cations in recent years [7, 8].
6  Decision Making
6.4  ariation in Medical
V 6.5  linical Decision Making:
and Dental Care
Variation in health-care procedures was recog-
nized early, at the beginning of the twentieth cen-
tury. In a classical study [9] of 1000 11-year-old
schoolchildren in New York City, it was found
that 650 children had undergone tonsillectomy.
The remaining 350 children were sent to a group
of physicians. One hundred and fifty-eight chil-
dren were selected for tonsillectomy. Those
rejected (192) were sent to another group of phy-
sicians, and 88 of them were then suggested for
tonsillectomy. After that, the remaining children
were examined by a third group of physicians,
and then only 65 children remained for whom
tonsillectomy had not been suggested. At that
point the study was interrupted owing to a short-
age of physicians to consult.
Variation in care is a real challenge to many
areas within medicine and health care [10–13] as
well as dentistry [14–16].
Already in 1984 Eddy [10] condensed the
worrisome situation:
Uncertainty creeps into medical practice through
every pore. Whether a physician is defining a dis-
ease, making a diagnosis, selecting a procedure,
observing outcomes, assessing probabilities,
assigning preferences, or putting it all together,
he is walking on a very slippery terrain. It is dif-
ficult for nonphysicians, and for many physi-
cians, to appreciate how complex these tasks are,
how poorly we understand them, and how easy it
is for honest people to come to different
conclusions.
Owing to its intricacy, clinical decision making
has attracted interdisciplinary attention. In
addition to interest from health professionals,
philosophers, psychologists and economists
­ to this idea. Rawski et al. [26] applied the above-­
have also contributed [17]. Two main spheres of
research and thinking can be identified: descrip-
tive and prescriptive. Descriptive projects aim
at mapping out and explaining how clinicians
reason and make decisions. Prescriptive, or
normative, projects, on the other hand, are
involved with how decisions should or ought to
be made.
57
C
Descriptive Projects
In studies of clinical reasoning, several models
have been suggested and used [17]. Some inves-
tigators have focused on the artistic, or intuitive,
aspects of clinical practice [12, 18].
In the tradition of “judgement analysis” [19],
researchers have tried to reveal the pieces of
information or “cues”, used at conscious or
unconscious levels, that influence a person’s
decision making policy. This approach has been
applied in several domains [20] including judge-
ments of third molar removal [21]. In a series of
investigations, Kahneman and Tversky [22]
explored a proposition that people most often
rely on a small number of heuristic principles to
make decisions. Their gathered important insights
into human thinking and decision making were
admirably summarized the other year by Nobel
laureate Kahneman [23].
6.5.1 Descriptive Projects
on Endodontic Retreatment
Decision Making
Attempts have been made to explain the observed
variation in the management of periapical lesions
in endodontically treated teeth. Since several
studies have demonstrated large interindividual
variation in radiographic interpretation of the
periapical area [24], it has been hypothesized that
variation in retreatment decisions might be
regarded as a function of diagnostic variation.
However, nor studies among general practitio-
ners [25] or specialists [5, 7] have given support
mentioned “judgement analysis” model. The
complexity and multiplicity of factors present
in different studies of the phenomenon have
­rendered it difficult to present a coherent model
to explain the observed variation. But the diag-
nostic difficulties, timing and the question of
what should be regarded as healthy and diseased,
as well as several other factors, partly explain the
58
large variation among dentists regarding retreat-
ment decision making [6].
6.5.1.1 The Praxis Concept
The Strindberg [27] criterion of classifying the
results of endodontic treatment into “success” and
“failure” represents an “ideal” concept of disease.
According to Juul Jensen [28], such criterion is
demarcated and made explicit by a formal defini-
tion. However, by no way are all our concepts
defined in such a precise way. Still these concepts
exist. They exist in the sense that we use them.
Such concepts are referred to as “praxis concepts”
by Juul Jensen [28]. In search of a theory that
could, at least partly, explain the variation in retreat-
ment decision making, a “praxis concept” of peri-
apical health and disease following root canal
treatment was generated and tested in a series of
written case simulation design studies [29–31].
In this “praxis concept”, it was proposed that
dentists consider periapical health and disease, not
as either/or situations, but as states on a continuous
scale. On this scale a major lesion represents a
more serious condition than a smaller one. Variation
between decision makers could then be regarded as
the result of the individuals’ selection of differing
cut-off points on the scale for prescribing retreat-
ment. The investigations gave support to the view
that a periapical health continuum is the basis of a
praxis concept. Factors unrelated to the disease per
se (costs, technical quality of root filling, access
problems) also seemed to contribute to the final
placement of the cut-off point. These studies also
emphasized the subjective influence of personal
values on the selection of retreatment criterion.
Similar patterns among clinicians’ root canal
retreatment strategies were also found among den-
tal students in Saudi Arabia [32] and general prac-
titioners and specialists in Australia [7].
6.5.2 Personal Values
According to the praxis concept, a dentist’s values
influence the recommendation of endodontic
retreatment. The concept of value is multidimen-
sional, but it seems sound to assume that there is a
close connection between an individual’s values
T. Kvist
and his or her value judgements. It has been sug-
gested that one may apprehend values in acts of pre-
ferring [33, 34]. This means that when faced with a
choice, the values of an individual are reflected in
his preference behaviour. For example, the value of
health is given in preferring it to disease.
The subjective values of endodontic health
states in root-filled teeth were investigated among
dental students [35] and specialists in endodon-
tics [30].
In these studies, students and endodontists
were asked to judge a health state of a root-filled
incisor with no signs of periapical pathology, and
one health state where a periapical radiolucency
was diagnosed. The two health states were placed
on a utility scale extending from “perfect pulpal
and periapical health” (value = 1) to “loss of the
tooth” (value = 0). Large interindividual varia-
tions in value judgements were found for both
situations. Nevertheless, most raters assigned
higher values to a situation were no signs of
pathology were present compared to a situation
with a periapical lesion present. Nevertheless,
these studies failed to show any significant corre-
lation between the retreatment prescriptions and
the elicited values. However, the assessment of
value judgements is a complex task, and the meth-
ods of eliciting them and the reliability and valid-
ity of obtained values may be questioned [36].
6.5.3 T
 he Benefit of Endodontic
Retreatment
According to von Wright [37], something is ben-
eficial to a being when the doing or having or hap-
pening of this thing affects the good of that being
favourably. He suggests that when the being in
question is a human being, the phrase “the good
of a being” can be understood in two different
ways: in terms of welfare and in terms of health.
This means that a treatment procedure is benefi-
cial to a patient if it is in some way conducive to
his welfare (or well-being), or if it is conducive to
his (bodily or mental) health or both [38].
From a dental health point of view, a patient
will benefit from endodontic retreatment if he or
she moves from a health state with a periapical
6  Decision Making
Subjective benefit of retreatment
Patient B
Subjective benefit of retreatment
Patient A
Utility value
0
No tooth
0.35
Assessment patient A Root filled tooth
with apical periodontitis.
0.15
Assessment patient B Root filled tooth
with apical periodontitis.
Fig. 6.2  An individual may benefit from endodontic
retreatment by moving from a state with an asymptomatic
lesion to a state where the lesion has healed. The numeri-
inflammation to a post-retreatment situation where
the lesion has healed. If the health states are placed
on a utility scale, the subjective benefit of endodon-
tic retreatment can be defined as the distance
between the two states (Fig. 6.2). Presumably, end-
odontic retreatment will contribute to a person’s
well-being and health in proportion to the individ-
ual length of the distance between the health states.
In an investigation involving 16 endodontists, it
was found that the assessment of “retreatment ben-
efit” was subjected to substantial interindividual
variation [30]. This was due above all to the experts’
deviations in their judgement of the value of the
persistent periapical lesion. The findings clearly
demonstrated that the “benefit” of endodontic
retreatment varies among individuals and highlight
the necessity of “consumer” influence in clinical
decision making. From a subjective point of view,
some patients will benefit much more from end-
odontic retreatment than others. It also suggests
that the value-laden terms “success” and “failure”
are meaningful only in the clinical patient-dentist
context. Both doctors’ and patients’ values will
influence the decision making process.
59
0.75
0.30
1.0
Tooth with
healthy pulp.
0.65
Root filled tooth
without apical periodontitis.
0.90
Root filled tooth
without apical periodontitis.
cal difference in assigned utility values can be defined as
the “subjective benefit of retreatment”
Today patient autonomy is widely regarded as
a primary ethical principle, emphasizing the
importance of paying attention to the values and
preferences of the individual patient in any pre-
scriptive theories of clinical decision making.
6.6  linical Decision Making:
C
Prescriptive Projects
Prescriptive projects in clinical decision making
are fundamentally an issue of ethics. Prescriptive
ethics, or normative ethics (syn), is the branch of
philosophical ethics that investigates the set of
questions that arise when considering how one
ought to act, morally speaking. Prescriptive eth-
ics is consequently distinct from descriptive eth-
ics, as the latter is an empirical investigation of
people’s moral beliefs or values. To put it another
way, descriptive ethics would be concerned with
determining what proportion of dentists believe
that endodontic retreatment should be performed,
while prescriptive ethics is concerned with
whether it is correct or not to hold such a belief.
60
6.6.1 Ethics: What It Is
Ethics deals with that which is good or bad, what
should or should not be done and what character-
istics make us better or worse as individual
human beings. The central question in normative
ethics concerns the right procedure; its role is to
clarify how ethical questions should be managed,
i.e. what should be done in a certain situation and
what should be avoided [39]. A course of action
can be wrong on ethical grounds in two different
ways. Either there is something offensive in the
course of action itself that makes it unacceptable,
regardless of the expected consequences of the
action, e.g. because those concerned are not
treated with respect and dignity, or that it violates
basic human rights. Or the expected negative
consequences exceed the expected benefit, and
thus the action is disallowed. If there is profound
objection in principle against the course of action,
then there is no cause to reason further and weigh
the positive and negative consequences. In other
cases, these consequences should be considered.
Ethics in health care is concerned primarily
with how the individual patient should be treated,
i.e. what is beneficial and what is harmful to the
patient, respectively. Several patient-related
interests become relevant. Normally and particu-
larly issues regarding health and well-being are
central to dental ethics. But also, questions
regarding and autonomy and integrity are highly
relevant. Ethics in dentistry, however, covers
more than the individual patient. Effectiveness,
priority and fairness are also relevant aspects of
ethics, as are questions about how to weigh up
the interests of the patient against research inter-
ests (see Chapter “Consequences”).
The following four principles, which are well
established in biomedical ethics, are often pre-
sented as a basis for ethics in health and medical
(and dental) care [40]:
1. The do-good principle means that one should
try to help the patient by satisfying his or her
(medical and basic human) needs.
2. The do no harm principle means that one
should avoid harming the patient. One should,
for example, avoid taking unjustifiable risks.
T. Kvist
3. The autonomy principle means that one should
respect the patient’s right to self-­determination,
which implies that one must keep patients
informed and guarantee them the right to
decline the treatment being offered.
4. The principle of fairness or justice means that
patients with similar needs should be treated
similarly. That is, it is the patient’s treatment
need which should determine the course of
action, not—for example—the patient’s cul-
tural background, gender, financial or social
standing.
The principles in themselves do not suggest an
order of priority in cases of conflict. One can eas-
ily imagine situations where the treatment which
is most likely to improve the patient’s dental
health is at the same time associated with greater
risk than other treatment options. In such a case,
which principle should be applied, the “do-good”
or the “do no harm” principle? A similar conflict
can arise between the “do-good” principle and
the autonomy principle, in cases where the
patient does not want to accept the treatment,
which the dentist recommends. However, the
four principles are not intended as a total ethics
package for solving ethical problems. The pur-
pose is more to remind us of core ethical princi-
ples, which should be taken into account and
guide us in clinical decision making.
6.6.2 The “Strindberg System”
In endodontics, the system of dichotomizing the
outcome of root canal treatment into “success”
and “failure” launched by Strindberg [27] has
achieved paradigmatic status as a normative
guide to clinical action. According to Strindberg
[27], the only satisfactory post-treatment situa-
tion, after a predetermined healing period, com-
bines a symptom-free patient with a normal
periradicular situation. Only cases fulfilling these
criteria were classified as “successes”, and all
others as “failures”.
Consequently, when a new or persistent peri-
apical lesion is diagnosed in an endodontically
treated tooth, the Strindberg system prescribes
6  Decision Making
retreatment (or extraction). The Strindberg sys-
tem is exclusively based on biology and can be
perceived as dogmatic and inflexible. Although
generally accepted in academic institutions,
available studies and experience indicate a weak
position among general practitioners [3, 7, 31,
41, 42].
6.6.3 Expected Utility Theory
One of the most highly developed normative
decision making models is the “expected utility
theory” (EUT). For reviews see Hargreaves Heap
et al. [34] and Bacharach and Hurley [43]. The
philosophical foundation of the model is to be
found in classical utilitarianism [44, 45], while
its mathematical origins are even older [46]. The
advent of modern EUT is associated with the
influential work of von Neumann and
Morgenstern [33] which made some of the psy-
chological assumptions of utilitarianism redun-
dant. During the last 70 years, EUT has prospered
mainly in economics and the social sciences. The
theory was introduced to medicine by Ledley and
Lusted [47]. “Clinical decision analysis” has
received much attention in medicine and also in
dentistry [48].
EUT prescribes that the problem should be
structured as a “decision tree”, which (i) logically
displays available actions and their possible con-
sequences. Then (ii) the listed outcomes are
assessed regarding probabilities and subjective
values (“utility”). After this (iii) the weighed sum
(expected utility) of each strategy is computed,
and (iv) the action with the highest sum is
chosen.
Reit and Gröndahl [1] approached the man-
agement of periapical lesions in endodontically
treated teeth from a decision analytic point of
view. Even if EUT may be questioned as a nor-
mative theory, it does point out two essential
components of a basis for making clinical deci-
sions: empirical facts and subjective values. Later
these authors drew attention to the fact that the
critical information needed for the analysis were
either not available (utility values) or very uncer-
tain (outcome probabilities) [49].
61
6.6.4 Evidence-Based Decision
Making
In more recent years, the development of the con-
cept of evidence-based medicine/evidence-based
dentistry has come to supplement and to some
extent replace the formal clinical decision analy-
sis [50].
Evidence-based medicine is “the conscien-
tious, explicit and judicious use of current best
evidence in making decisions about the care of
individual patients”. This well-known definition
emanates from the highly cited report published
by David L. Sackett and collaborators in the 1996
British Medical Journal [51].
While evidence-based medicine/evidence-­
based dentistry basically is concerned with the
efficiency of the clinical procedures that we apply
to treat our patients, in order to achieve the best
possible outcome for each patient based on the
best knowledge and available resources the con-
cept has not always been generally agreed upon
and the concept has nowadays, in some instances,
been given a wider meaning and has become
something of a buzzword. However, during
recent years hundreds of books and thousands of
articles have been published using this concep-
tion. In addition, websites and various other
channels of information issued by researchers,
clinicians and organizations have been released
on this new concept in the clinical practice of
health care including dentistry.
Bergenholtz and Kvist [52] reviewed the
essence of the concepts and its impact on endodon-
tics. Like Reit and Gröndahl [49], 30 years earlier,
the authors reported that evidence-based data on
various outcomes associated with apical periodon-
titis in root-filled teeth is largely lacking, and also
patients’ preferences are difficult to estimate.
6.6.5 Autonomy and Information
The principle of autonomy is highly relevant to
diagnosis and treatment of apical periodontitis in
root-filled teeth. What should patients decide? What
information should the dentist provide and should
any information be withheld from the patient?
62
The mouth is an intimate part of the body. It is
therefore reasonable to assume that it is impor-
tant for people to make their own decisions about
their teeth, not least with respect to any treat-
ment. In order to make informed decisions about
their own dental care, patients require relevant
information. In circumstances where there is a
lack of knowledge about the expected benefits of
different treatment options, it is difficult to pro-
vide information, which offers the patient a basis
for decision making. It is also difficult to analyse
the value of different options from a general point
of view. It is therefore important from both an
individual patient and a community perspective
that research is conducted to improve our knowl-
edge of the effects of the various options for root-­
filled teeth with apical periodontitis. In the future,
this will allow the clinician to offer better infor-
mation to patients and thus for the patient to
assess various action alternatives.
As indicated by the many epidemiological
studies and the experiments on endodontic
retreatment decision making among clinicians,
asymptomatic apical periodontitis associated
with root-filled teeth is often not considered as an
indication for retreatment, and hence these teeth
are left without treatment. Is this wrong? Is the
dentist under an obligation to inform the patient
of the situation? Furthermore, a not inconsider-
able portion of the cases is a consequence from
previously improper root canal treatments.
Should the dentist inform the patient about previ-
ously inadequate treatment? From the perspec-
tive of autonomy, the answer to these questions
seems obvious. Anyone wanting such informa-
tion about their dental status should have the
right to this if the information is found during an
examination at a dental appointment.
A difficulty is that some patients do not wish to
receive such information, i.e. they prefer not to
know unless the information has a clear and direct
bearing on their health and/or well-being.
Consequently, the dentist needs to ascertain
beforehand what attitude the patient has to such
information, in order to show due consideration to
both patients who want to be fully informed and
those who do not. To ask the patient whether he
wishes to receive such information is reasonably
T. Kvist
no adequate strategy because the patient may
draw the conclusion that the dentist now has some
information or would otherwise not have asked.
It may be challenging to have to inform a
patient that previous treatment has not been suc-
cessful, as there is a risk of singling out oneself or
a colleague in a negative way. This is sometimes
unavoidable if the patient is to receive relevant
information. In the case of diagnosing someone
else’s “failure”, it is important to combine objec-
tivity in presenting the information with a
respectful attitude, since it is usually impossible
to fully appreciate under what circumstances the
treatment was accomplished.
6.6.5.1 Monitors and Blunters
Kristina is a 62-year-old teacher, and I have just
told her that the X-ray of her upper left first molar
does exhibit a periapical radiolucency and an
inadequate root filling. The root canal treatment
was done 6 years ago. I tell her that this indicates
a persisting root canal infection and that it might
become symptomatic sooner or later. I suggest a
CBCT examination for better imaging, verifying
the diagnosis and support for decision making. I
am telling her that a minor surgery might be
needed to solve the problem. Then I tell her that I
will contact her again when I have looked at the
CBCT results and suggest a treatment plan. “Will
it be painful to do a surgery?”, she asks slightly
surprised. “No it is a standard procedure done
with local anaesthesia at our clinic”, I answer.
“Do you have any further questions”, I ask. “No,
I trust you to tell me what I need to know”, she
answers before rising from chair and leaving.
In the same week, I see John, a 50-year-old
shop owner, for a check-up of a root canal treat-
ment of a lower first molar I finished 1 year ago.
The X-ray shows that the periapical radiolucency
is unchanged in size. I am telling him that no
signs of healing are yet visible but that is too
early to diagnose it as a “failure”. I suggest fur-
ther follow-up with a new X-ray for another year.
Unlike Kristina, John has a lot of questions.
“How come that healing has not occurred yet?
Are there bacteria left in the tooth than? Isn’t
dangerous? Perhaps you should have taken my
tooth out already from the beginning? Will I have
6  Decision Making
pain now? What will you suggest if you don’t see
healing at next check-up either? Will I have to go
through any further treatments?” he asks. “I
have many friends who also had root canal treat-
ments and they never said that it took so long to
heal. I'll probably ask them. Then I will go on the
Internet and search as many sites as I can about
this. My feeling is that something is wrong and I
need more information”.
It is striking how two patients facing similar
situations took two very different approaches to
gathering and processing information. Miller
[53] has categorized these two approaches to
information seeking under threat as “blunters”
and “monitors”. The blunter—Kristina—wants
just the basics, while the monitor—John—craves
more information. High monitors and low blunt-
ers chose to seek out information about its nature
and onset, whereas low monitors and high blunt-
ers chose to distract themselves. Each style has
its strengths and weaknesses. But, under unfa-
vourable conditions, both styles risk becoming
more flawed and hamper a good patient-dentist
relation.
My own clinical experience is that people react
very differently to the information about signs of
persistent apical periodontitis. Health information
is not neutral, especially when you’re the one
affected by a condition. If you, who are reading
this, have your own experience of root canal treat-
ment, you have probably experienced how differ-
ent it is when you are reading about it as a
professional, as opposed to when you had the pro-
cedures executed on your own tooth.
“We don’t see things as they are, we see them
as we are” is a quotation with several suggested
origins that captures the essence of our argument.
Most people fall somewhere in between the
two extremes of blunter and monitor. Most of our
patients want to know to appraise and understand
the options without going into too many details,
but some just want to say, “Just tell me what to
do. That’s fine”.
The notion about different psychological dis-
positions towards information and the variation
in attitudes to apical periodontitis result in con-
siderable challenge to the dentist and the decision
making process.
63
6.6.6 Informed Consent
The requirement that a medical or dental action
should be preceded by informed consent is
deemed very important in medical ethics [40].
It is important to appreciate that it is not
enough that a patient has received written or oral
information and then consented. The informed
consent has two components: information and
consent. The patient must have accepted and
understood the information and not only received
it. All the relevant aspects of the situation should
be informed about in an appropriate way. The
dentist should not only convey information but
also need to ensure that the information is cor-
rectly recognized. In order to take a position in an
independent way in a choice situation, the patient
must also be informed of the alternatives and be
free to choose, i.e. not be subjected to compul-
sion, or in such a position of dependence that the
free informed choice becomes an illusion.
In a dental surgery, there are many circum-
stances that can hamper patients’ ability to
acquire and rationally process the information
given. The environment and situation may seem
frightening and lead to both anxiety and worry,
which can confuse a generally well-functioning
sense and judgement. To ascertain that the patient
comprehends the information may thus be diffi-
cult. It is important that the dentist is attentive to
both verbal and non-verbal expressions.
At the same time, one must have realistic
expectations of the patient’s ability to under-
stand and evaluate the options. Certainly, this
can vary greatly between individuals. For
patients who want to have full control over the
decision, doctors should make sure to make this
possible, but one must also allow the patient to
hand over a part of decision making if he or she
so wishes. A professional reception of each indi-
vidual patient at the dentist’s office creates a
seedbed for a high confidence that the patient
can feel safe with both for the decision making
and forthcoming treatments.
In everyday clinical practice, an oral consent
is normal and also appears naturally. A written
agreement could be seen as well formal and
might also get the patient to wonder what kind of
64
exceptional measures that require such formali-
ties. However, in many countries and in research
contexts, it is quite common or even compulsory
with written informed consent documentation.
6.6.6.1 Information About Treatment
Patients in the dental care can hardly be expected
to have knowledge and understanding of all the
factors that can and should be taken into consider-
ation before a clinical decision about an endodon-
tic retreatment. The patient has the right to know
what the different treatment alternatives entail,
how risky and painful they are and what impact it
is likely to bring with them to undergo treatment
and to refrain from it. This implies a correspond-
ing requirement for dental staff to ensure that this
information is provided and that it is done in a
way that the patient can actually understand. In
practice, there is of course a limit on how detailed
information can be allowed to become. If patients
ask many questions about the equipment and
methods, this can be an expression of concern, or
at worst, distrust, rather than a genuine desire for
more detailed information. As important as pro-
viding answers to all the questions, then is to try
to establish or re-establish trust. The patient
should be able to rely on dentists’ knowledge
based on science and proven experience and that
they follow both the technological and scientific
developments in the field. They should also be
confident that the dentist has the best for the
patient as their primary goal.
6.6.6.2 Information About Risks
For a patient to be adequately informed, some-
thing must be said about the risks associated with
the suggested treatment but also to refrain from
treating. In our particular case, this is complicated
significantly due to the fact that evidence is lack-
ing about how the untreated apical periodontitis
affects individuals both locally and systemically.
There are two basic aspects of risk: some kind
of negative consequence and the probability that
it will occur. The negative consequence or injury
may be more or less severe. The most serious
negative consequences, death or lifelong pain or
suffering, are very unlikely as a consequence of
either leaving or treating apical periodontitis in a
root-­filled tooth. Other risks are more frequent
T. Kvist
but at the same time the consequences are not
very severe and of transient nature.
If only it had been advantages to inform, there
would have been no reason to hesitate about.
What complicates the matter is that information
in itself can cause injury. Risk information may
cause anxiety, and it can make patients refrain
from treatments because of unrest despite the
risks otherwise would be reasonable to accept.
This is why there may be reason to wonder, for
example, whether to communicate a very small
likelihood of great harm. Primarily because it is a
concern from dentist’s point of view to promote
patient’s oral health, but also from the autonomy
perspective, it is sometimes questionable whether
such information should be given. The fear of an
unlikely but serious injury may counteract the
ability of the patient to rationally reflect on the
options and come to an autonomous decision.
Exactly how much information and into what
level of detail that should be made are debatable.
Some patients prefer not to know the risks unless it
is clearly relevant. How much and what to inform
varies with the situation and who is the patient.
6.6.6.3 Information on Costs
When deciding about a tooth in possible need of
endodontic retreatment the economic aspect of
the treatment is, if not decisive, then at least a
very important factor. It is important that infor-
mation about the costs and possible reimburse-
ment by insurance are correct and that it does not
change. Also, costs for alternative strategies, i.e.
extracting the tooth with or without replacement,
should be clearly accounted for.
6.6.6.4 Information and Manipulation
When the patient is informed of the facts regard-
ing diagnoses, treatment options, risks and costs,
he or she must be allowed to choose what she
wants to do in the given situation. The individual
has a right not to be forced or manipulated to
undergo dental treatments. However, it is difficult
to imagine that the dentist can completely avoid
the influence. The positive approach to good
oral and dental health and in this particular case,
the importance of restoring periapical health is
likely to affect the patient to some degree. One
might think that it is also reasonable, since good
6  Decision Making
p­ eriapical health, in the same way as teeth without
cavities and with good periodontal health, appears
to be the intrinsic and undisputable objectives of
dental care. Here, there is an important balance to
go so that patient autonomy is not compromised.
6.6.6.5 Authorized Informed Consent
Many patients lack all or part of the capacity for
autonomous decision making. It may involve
children, mentally ill, mentally retarded or
demented individuals. It is important to remem-
ber that these patients have the right to be treated
with care and respect. A fruitful way to address
the challenge of information and consent for
these patients is to allow them to exercise their
autonomy as best they can and otherwise let them
express their willingness or unwillingness to
cooperate. In the absence of the ability to under-
stand, to take a stand and to make decisions, can
the informed consent be authorized to a close
relative or another person close to the patient?
6.7  Guide to Everyday
A ought to stick to prima facie rules. In order to
Decision Making of Root-­
Filled Teeth with Apical
Periodontitis
6.7.1 Philosophical Justification
The British philosopher RM Hare [54] makes a
distinction between two levels of moral reasoning
and hence decision making: the intuitive and the
critical. The intuitive level is the level at which
most of us make decisions about moral matters
most of the time. We rely on relatively simple,
specific and intuitive principles to guide us in rou-
tine circumstances. However, it is also possible to
reflect on those principles, to step back and to
critically assess them. This is the level of critical
thinking. At this level, empirical facts and value
judgements are considered rationally in order to
establish and select principles which can be fol-
lowed in everyday life at the intuitive level.
Social development has led to the conclusion
that we are currently seeing the patient’s right to
autonomous decision making as an integral part
of both dental care and other health services.
Consequently, a paternalistic approach to clini-
65
cal decision making must be ruled out. The
Strindberg dichotomy of post-treatment situation
into success and failure exclusively founded on
biology is neutral to different agents and clinical
situations [27]. Therefore, it cannot alone be used
on an “intuitive level” rule for clinical decisions
about endodontic retreatment.
In medical and dental decision making mat-
ters, it is often difficult to imagine all outcomes
and to assess their probabilities and elicit trust-
worthy value judgments. This holds true also for
apical periodontitis in root-filled teeth. However,
even if it was humanly possible to compute the
probabilities and utilities of all possible out-
comes, it would often be absurd, time-consuming
and counterproductive. From a critical level
­perspective, calculations should be made on the
intuitive level only if they bring about the best
consequences. If not, other decision strategies
should be used. Better overall results may come
from acting in accordance with principles or
rules. In many clinical situations, we can safely
act on well-established precepts, and in others we
achieve the best results for everyone involved, the
clinician, at the intuitive level, should probably
normally follow a few simple principles rather
than engaging in difficult and about outcomes
and preferences.
A prima facie rule is an obligation which is
initially binding until a stronger and overriding
duty emerges. The expression prima facie means
“first appearance”, and in philosophy it is associ-
ated with the reasoning initiated by Ross [55]. He
argued that we intuitively perceive a small set of
foundational prima facie duties which are the
basis of all judgements when moral issues are
involved. Ross lists the following seven prima
facie principles: promise keeping, reparation for
harm done, gratitude, justice, beneficence, self-­
improvement and non-maleficence. In the influ-
ential work on biomedical ethics of Beauchamp
and Childress [40], the prima facie idea was fur-
ther processed and the principles reduced to the
previously mentioned four: respect for autonomy,
beneficence, non-maleficence and justice.
According to Hare [54] the four principles
could be justified by the golden rule: “Therefore
all things whatsoever ye would that men should
66 T. Kvist

do to you, do ye even so to them: for this is the
law and the prophets” (St Matthew 7:12).
The following principles about decision mak-
ing regarded apical periodontitis in root-filled
teeth are suggested and formulated from a den-
tist’s perspective [6].
1. First principle: Apical periodontitis in a root-­ decision making process.
filled tooth that is not expected to heal should
be retreated.
meaning of the situation will differ among patients.
Only the patient is the expert on how he or she
feels about keeping a tooth with or without retreat-
ment or perhaps extracting it, which symptoms are
tolerable, which risks are worth taking and what
costs are acceptable. These, subjective and per-
sonal values, must be allowed to influence the
(b) Retreatment risks

Motivation: It is assumed that the best overall con-
sequences are obtained if dentists’ primary sugges-
tions to patients, at the intuitive level, are to perform
endodontic retreatment when a persisting apical peri-
odontitis is diagnosed. The persistent lesion is an
expression of a root canal infection, and people ben-
efit from having their oral infections treated. Diagnosis
and treatment of oral infections belong to the central
and indispensable values of dentistry, and everybody
involved, not only patients, will benefit if prevention
and treatment of oral infections are at the core in the
dental profession. There is no solid scientific evidence
to distinguish among grades of periapical disease.
However, if the lesion is small and asymptomatic, the
probability of development of severe local symptoms
is low. Furthermore, in general, the health hazard of
an untreated persistent lesion is probably low.
Therefore, false-positive diagnoses should be avoided.
This first principle is simple but quite dog-
matic. It implies that if a retreatment is suggested
following the diagnosis of a persistent lesion and
if this is accepted, no specific arguments or fur-
ther deliberation are needed.
However, if a persistent lesion is diagnosed
and retreatment is not selected, specific argu-
ments have to be put forward. These are found in
the second principle.
2. Second principle: A persistent periapical
lesion in a root-filled tooth might not be
retreated with regard to:
(a) Respect for patient autonomy
This principle implies that the patient is fully
informed regarding the situation but does not want
retreatment to be performed. Attitudes to periapi-
cal disease vary among individuals. The subjective
The potential risks (the probability of certain
negative events) associated with a possible
retreatment procedure (e.g. root fracture associ-
ated with post removal, nerve injury as a result of
periapical surgery) are objectively assessed and
weighed against the subjectively evaluated bene-
fit resulting from retreatment. The risk/ benefit
ratio is found to be too low to be accepted.
(c) Retreatment monetary costs
Patient’s costs for retreatment are considered
(e.g. treatment fee, drugs, loss of income, suffer-
ing), and the cost/benefit ratio is subjectively
considered to be too low to be accepted.
6.8  urgical or Nonsurgical
S
Retreatment
While the clinician makes a diagnosis and
informs about and considers retreatment of a per-
sistent apical lesion to the patient, the question, if
so, how is a natural and integrated part of the
process.
There is insufficient scientific support on which
to determine whether surgical and nonsurgical
retreatment of root-filled teeth gives systemati-
cally different outcomes, both short and long term,
with respect to healing of apical ­periodontitis or
tooth survival [56, 57]. In everyday clinical prac-
tice, a number of factors influence the choice of
retreatment method. For example, the size of the
bone destruction, the technical quality of previous
treatment, accessibility to the root canal, future
restorative requirements of the tooth, the cost of
treatment, the preferences of the clinician and the
patient, m
­ edical considerations and the availability
6  Decision Making
of various types of special equipment are briefly
discussed below. More detailed discussion is avail-
able in Chaps. 7 and 8. Although future compara-
tive studies may provide valuable general
information, clinical decisions in every individual
case will still have to be made on the basis that the
conditions applying to every case are unique.
6.8.1 T
 he Size of the Bone
Destruction
Apical periodontitis may develop into cysts.
Periapical cysts are classified as “pocket cysts” or
“true cysts”. In case of a pocket cyst, the cyst cav-
ity is open to the root canal, and therefore it is
expected to heal after proper conventional root
canal treatment. The cavity of a true cyst, on the
other hand, is supposed to be entirely enfolded by
epithelial lining which may make it nonrespon-
sive to any nonsurgical root canal treatment or
retreatment. Thus, it is supposed that true radicu-
lar cysts have to be surgically resected in order to
heal [58]. There is no method to clinically deter-
mine the histological diagnosis of the periapical
tissue in general, and in particular there is no
method to discriminate between pocket cysts and
true cysts [59]. Cysts are expected to be more
prevalent among big bone destructions [60].
The clinical empiric support for how radicular
cysts are best treated is poor but rather based upon
histological findings and theoretical assumptions.
However, in cases when a big (≥ 15 mm in diam-
eter) periapical bone destruction is present and
especially if the quality of the root filling is good,
these assumptions suggest there are reasons to
suspect a “true cyst” and consequently consider
surgical retreatment as the first choice.
6.8.2 T
 he Technical Quality
of the Previous Treatment
In cases of non-healed apical periodontitis, the
quality of the initial root treatment is often inad-
equate. This is frequently reflected in the poor
technical quality of the root filling [61]. In
molars, the reason for treatment failure may be
associated with untreated canals [62]. In many
67
cases, therefore a nonsurgical retreatment should
be considered. In particular, this is the case when
access is not obstructed by a crown and post.
Since there is convincing support that the quality
of the restoration also plays a significant role for
the periapical status in root filled teeth the clini-
cian should always have a critical look at the
restoration.
The obvious objective for a nonsurgical retreat-
ment is to treat previously untreated parts of root
canal system and thus improve the quality of root
canal filling. With the help of modern endodontic
armament, this is often possible to achieve.
Studies have shown that nonsurgical retreatment
performed by skilful clinicians results in good
chances of achieving periapical healing [63, 64].
It is sometimes argued that the result of a surgi-
cal of endodontic surgery is dependent of a good
quality of the root filling and consequently that any
endodontic surgery should be preceded by a non-
surgical retreatment. The benefits of this approach
must be questioned. The evidence base is weak
[65]. And even if the procedures would show mar-
ginally better healing outcome, the cost-effective-
ness must be questioned. Moreover, if used orderly
it would lead to the execution of a not insignificant
amount of unnecessary surgeries. In many cases
the nonsurgical treatment would be sufficient to
achieve healing of the periapical tissues and conse-
quently making the surgical procedure redundant.
6.8.3 Accessibility to the Root Canal
Root-filled teeth are often restored with posts and
crowns and are frequently used as abutments for
bridges and other prosthodontic constructions
which have to be removed or passed through for a
nonsurgical approach. In cases where the quality of
restorations is adequate, therefore, the more
­complex the restoration, the more appealing an end-
odontic surgery approach. Even without hindering
restorations, a preoperative analysis of the case may
reveal intra-canal ledges or fractured instruments
that already preoperatively make the accessibility to
the site of the residual infection questionable [63].
On the other hand, access to the site of infec-
tion by endodontic surgery can also be judged to
imply major difficulties. In particular surgery
68
involving mandibular molar roots as well as pala-
tal roots of the maxillary teeth sometimes offers
significant operator challenges. Preoperative
CBCT scans help the surgeon to plan the interven-
tion or sometimes to refrain and choose a nonsur-
gical approach or even considering extraction and
a different treatment plan [66].
6.8.4 Restorative Requirements
of the Tooth
Before considering retreatment of a previously
root-filled tooth, there is a need for a careful
deliberation of the overall treatment plan. In
many cases the issue is rather straightforward. It
might concern a single tooth, restored with a post
and a crown of fully acceptable quality but with
an ensured diagnosis of persistent apical peri-
odontitis. The objective is to cure the disease and
to “save” the tooth and its restoration in the long
term. In other situations, when complete mouth
restorations are planned to “build something
new”, the strategic use of teeth, non-root filled as
well as root filled, and dental implants to mini-
mize the risk of failure of the entire restoration
must be the first priority [67]. Long-term follow-
­up studies of teeth that have undergone surgical
or nonsurgical retreatment are rare [68–70].
6.8.5 The Costs
Since surgical endodontics does not require the
dismantling of functional prosthodontics construc-
tions, it is often a less expensive alternative for the
patient. But the costs of both surgical and nonsur-
gical treatment of course vary both in different
countries between operators and between coun-
tries with different systems of reimbursement by
insurance. From a patient’s point of view, three
types of monetary costs associated with endodon-
tic retreatment may be considered: (i) direct costs
(dentist’s fees, drugs), (ii) indirect costs (patient’s
loss of income) and (iii) intangible costs (mone-
tary value of the patient’s pain and suffering) [71].
The presence of prosthodontic reconstructions
will often impede access for nonsurgical retreat-
T. Kvist
ment. Since posts and crowns have to be removed
(and replaced), a nonsurgical approach will be
expensive in such situations. Indirect and intangi-
ble costs associated with endodontic retreatment
are mainly related to postoperative sequelae such
as pain and swelling [72].
6.8.6 The Preferences
of the Clinician
and the Patient
Whether a retreatment, nonsurgical or surgical,
should be performed is a complex decision mak-
ing situation. Many factors have to be considered.
For the dentist who made the diagnosis and who is
about to suggest a treatment alternative, both bio-
logical considerations and the potential and limi-
tations of different options have to be deliberated
[73]. However, as important the professional skill
and knowledge might be the preferences of each
individual patient will also influence the final
decision. Only the patient is the expert on how he
or she feels about the pros and cons with different
retreatment options, which risks are tolerable and
what costs are agreeable.
Take-Home Lessons
• Clinical decision making of apical peri-
odontitis in root filled teeth is a complex
task and that different decision-makers
come to different decisions depending
on different circumstances in different
situations is not only understandable but
also necessary and desirable.
• In the situation of making a diagnosis,
avoid false-positive diagnoses.
• When the diagnosis of persistent apical
periodontitis is clear-cut, from the den-
tist’s and profession’s point of view, with
current available knowledge, a sugges-
tion of retreatment is the first principle.
• Include the patient in the decision making
process, and when refraining from action,
refer to any of the grounds of the second
principle, autonomy, risks or costs.
6  Decision Making
Benchmark Papers
• Reit C, Gröndahl HG. Management of
periapical lesions in endodontically treated
teeth. A study on clinical decision making.
Swed Dent J. 1984;8:1–7. In this study the
variation in clinical decision making of
root-filled teeth with apical periodontitis is
illustrated exemplary and clearly.
• Kvist T. Endodontic retreatment. Aspects
of decision making and clinical outcome.
Swed Dent J Suppl. 2001;144:1–57. In
this doctoral thesis several of the aspects
of decision making in endodontics are
elaborated.
References
1. Reit C, Gröndahl HG. Management of periapical
lesions in endodontically treated teeth. A study on
clinical decision making. Swed Dent J. 1984;8:1–7.
2. Petersson K, Lewin B, Hakansson J, Olsson B,
Wennberg A. Endodontic status and suggested treat-
ment in a population requiring substantial dental care.
Endod Dent Traumatol. 1989;5:153–8.
3. Petersson K, Håkansson R, Håkansson J, Olsson B,
Wennberg A. Follow-up study of endodontic status in
an adult Swedish population. Endod Dent Traumatol.
1991;7:221–5.
4. Çiçek E, Özsezer-Demiryürek E, Özerol-Keskin NB,
Murat N. Comparison of treatment choices among
endodontists, postgraduate students, undergradu-
ate students and general dentists for endodontically
treated teeth. Int Dent J. 2016;66:201–7.
5. Mota de Almeida FJ, Huumonen S, Molander A,
Öhman A, Kvist T. Computed tomography (CT) in the
selection of treatment for root-filled maxillary molars
with apical periodontitis. Dentomaxillofac Radiol.
2016;45:20150391.
6. Kvist T. Endodontic retreatment. Aspects of decision
making and clinical outcome. Swed Dent J Suppl.
2001;144:1–57.
7. Wenteler GL, Sathorn C, Parashos P. Factors influ-
encing root canal retreatment strategies by general
practitioners and specialists in Australia. Int Endod
J. 2015;48:417–27.
8. Torabinejad M, White SN. Endodontic treatment
options after unsuccessful initial root canal treatment:
alternatives to single-tooth implants. J Am Dent
Assoc. 2016;147:214–20.
9. American Child Health Association. Physical defects:
the pathway to correction. New York: American Child
Health Association; 1934. p. 80–96.
69
10. Eddy DM. Variations in physician practice: the role of
uncertainty. Health Aff. 1984;5:74–89.
11. Ham C. Health care variations: assessing the evi-
dence. Research report no. 2. London: King’s Fund
Institute; 1988.
12. Groopman J. How doctors think. Boston, MA:
Houghton Mifflin Co.; 2007.
13. Birkmeyer JD, Reames BN, McCulloch P, Carr
AJ, Campbell WB, Wennberg JE. Understanding
of regional variation in the use of surgery. Lancet.
2013;382:1121–9.
14. Elderton RJ, Nuttall NM. Variation among dentists in
planning treatment. Br Dent J. 1983;154:201–6.
15. Bader JD, Shugars DA. Variation, treatment out-
comes, and practice guidelines in dental practice.
J Dent Educ. 1995;59:61–95.
16. Bigras BR, Johnson BR, BeGole EA, Wenckus
CS. Differences in clinical decision making: a com-
parison between specialists and general dentists.
Oral Surg Oral Med Oral Pathol Oral Radiol Endod.
2008;106:139–44.
17. Dowie J, Elstein A. Professional judgement. A
reader in clinical decision making. Cambridge, UK:
Cambridge University Press; 1988.
18. Schön DA. The reflective practitioner: how profes-
sionals think in action. New York: Basic Books, Inc.
Publishers; 1983.
19. Brunswick E. Representative design and probabilis-
tic theory in a functional psychology. Psychol Rev.
1955;62:193–217.
20. Brehmer A, Brehmer B. What have we learned about
human judgment from thirty years of policy captur-
ing? In: Brehmer B, Joyce CRB, editors. Human judg-
ment: the SJT view. Amsterdam: Elsevier Science
Publishers BV; 1988, p. 75–114.
21. Knutsson K, Brehmer B, Lysell L, Rohlin
M. Judgement of removal of asymptomatic mandibular
molars: influence of position, degree of impaction, and
patient’s age. Acta Odontol Scand. 1996;54:348–54.
22. Kahneman D, Slovic P, Tversky A. Judgement under
uncertainty: heuristics and biases. Cambridge, UK:
Cambridge University Press; 1982.
23. Kahneman D. Thinking, fast and slow. 1st ed.
New York; London: Farrar, Straus and Giroux; Allen
Lane; 2011.
24. Petersson A, Axelsson S, Davidson T, Frisk F, Hakeberg
M, Kvist T, Norlund A, Mejàre I, Portenier I, Sandberg
H, Tranaeus S, Bergenholtz G. Radiological diagnosis
of periapical bone tissue lesions in endodontics: a sys-
tematic review. Int Endod J. 2012;45:783–801.
25. Reit C, Gröndahl HG. Endodontic retreatment deci-
sion making among a group of general practitioners.
Scand J Dent Res. 1988;96:112–7.
26. Rawski AA, Brehmer B, Knutsson K, Petersson
K, Reit C, Rohlin M. The major factors that influ-
ence endodontic retreatment decisions. Swed Dent
J. 2003;27:23–9.
27. Strindberg LZ. The dependence of the results of
pulp therapy on certain factors. Acta Odontol Scand.
1956;14(Suppl 21):1–175.
70
28. Juul Jensen U. Sjukdomsbegrepp i praktiken. Det klin-
iska arbetets filosofi och vetenskapsteori. Stockholm:
Esselte studium; 1985.
29. Kvist T, Reit C, Esposito M, Mileman P, Bianchi S,
Pettersson K, Andersson C. Prescribing endodontic
retreatment: towards a theory of dentist behaviour. Int
Endod J. 1994;27:285–90.
30. Kvist T, Reit C. The perceived benefit of endodontic
retreatment. Int Endod J. 2002;35:359–65.
31. Kvist T, Heden G, Reit C. Endodontic retreatment
strategies used by general dental practitioners. Oral
Surg Oral Med Oral Pathol Oral Radiol Endod.
2004;97:502–7.
32. Al-Ali K, Marghalani H, Al-Yahya A, Omar R. An
assessment of endodontic re-treatment decision-­
making in an educational setting. Int Endod
J. 2005;38:470–6.
33. von Neumann J, Morgenstern O. Theory of games
and economic behaviour. 2nd ed. Princeton: Princeton
University Press; 1947.
34. Hargreaves Heap S, Hollis M, Lyons B, Sugden R,
Weale A. The theory of choice. A critical guide.
Oxford, UK: Blackwell; 1992.
35. Reit C, Kvist T. Endodontic retreatment behaviour:
the influence of disease concepts and personal values.
Int Endod J. 1998;31:358–63.
36. Griffin J. Well-being. Its meaning, measurement and
moral importance. Oxford, UK: Clarendon Press; 1986.
37. von Wright GH. The varieties of goodness. London:
Routledge and Kegan Paul; 1963.
38. Brülde B. The human good (PhD Thesis). Acta
Philosophica Gothoburgiensia, Gothenburg; 1998.
39. Kagan S. Normative ethics. Boulder, CO: Westview
Press; 1998.
40. Beauchamp TL, Childress FF. Principles of biomedi-
cal ethics. 6th ed. New York: Oxford University Press;
2009.
41. Kirkevang LL, Vaeth M, Wenzel A. Ten-year follow-
­up observations of periapical and endodontic status in
a Danish population. Int Endod J. 2012;45:829–39.
42. Petersson K, Fransson H, Wolf E, Håkansson J. Twenty-
year follow-up of root filled teeth in a Swedish popula-
tion receiving high-cost dental care. Int Endod J. 2015;
https://doi.org/10.1111/iej.12495. [Epub ahead of print].
43. Bacharach M, Hurley SL. Foundations of deci-
sion theory: issues and advances. Cambridge, UK:
Blackwell; 1994.
44. Bentham J. An introduction to the principles of mor-
als and legislation. In: Burns JH, Hart DLA, editors.
London and New York: Methuen; 1982. (Original
work published 1789).
45. Mill JS Utilitarianism. Warnock M, editor. London
and Glasgow: Collins; 1962. (Original work pub-
lished 1861).
46. Schoemaker PJH. The expected utility model: its vari-
ants, purposes, evidence and limitations. J Econ Lit.
1982;20:529–63.
47. Ledley RS, Lusted LB. Reasoning foundations of
medical diagnosis. Science. 1959;130:9–21.
T. Kvist
48. Rohlin M, Mileman PA. Decision analysis in den-
tistry—the last 30 years. J Dent. 2000;28:453–68.
49. Reit C, Gröndahl H-G. Endodontic decision-making
under uncertainty: a decision analytic approach to
management of periapical lesions in endodontically
treated teeth. Endod Dent Traumatol. 1987;3:15–20.
50. Bauer J, Spackman S, Chiappelli F, Prolo P. Evidence-­
based decision making in dental practice. J Evid
Based Dent Pract. 2005;5:125–30.
51. Sackett DL, Rosenberg WM, Gray JA, Haynes RB,
Richardson WS. Evidence based medicine: what it is
and what it isn’t. BMJ. 1996;312:71–2.
52. Bergenholtz B, Kvist T. Evidence based endodontics.
Endod Top. 2014;31:3–18.
53. Miller SM. Monitoring and blunting: validation of a
questionnaire to assess styles of information seeking
under threat. J Pers Soc Psychol. 1987;52:345–53.
54. Hare RM. Moral thinking: its levels, method and
point. Oxford, UK: Oxford University Press; 1981.
55. Ross WD. The right and the good. Oxford, UK:
Oxford University Press; 1930.
56. Swedish Council on Health Technology Assessment.
Methods of diagnosis and treatment in endodontics—
a systematic review. Report no. 203; 2010. p. 1–491.
http://www.sbu.se
57. Del Fabbro M, Corbella S, Sequeira-Byron P, Tsesis
I, Rosen E, Lolato A, Taschieri S. Endodontic proce-
dures for retreatment of periapical lesions. Cochrane
Database Syst Rev. 2016;10:CD005511.
58. Nair PN. New perspectives on radicular cysts: do they
heal? Int Endod J. 1998;31:155–60.
59. Rosenberg PA, Frisbie J, Lee J, Lee K, Frommer H,
Kottal S, Phelan J, Lin L, Fisch G. Evaluation of
pathologists (histopathology) and radiologists (cone
beam computed tomography) differentiating radicular
cysts from granulomas. J Endod. 2010;36:423–8.
60. Natkin E, Oswald RJ, Carnes LI. The relationship of
lesion size to diagnosis, incidence, and treatment of
periapical cysts and granulomas. Oral Surg Oral Med
Oral Pathol. 1984;57:82–94.
61. Gillen BM, Looney SW, Gu LS, Loushine BA, Weller
RN, Loushine RJ, Pashley DH, Tay FR. Impact of the
quality of coronal restoration versus the quality of
root canal fillings on success of root canal treatment:
a systematic review and meta-analysis. J Endod.
2011;37:895–902.
62. Karabucak B, Bunes A, Chehoud C, Kohli MR, Setzer
F. Prevalence of apical periodontitis in endodontically
treated premolars and molars with untreated canal:
a cone-beam computed tomography study. J Endod.
2016;42:538–41.
63. Gorni FG, Gagliani MM. The outcome of endodontic
retreatment: a 2-yr follow-up. J Endod. 2004;30:1–4.
64. Ng YL, Mann V, Gulabivala K. A prospective study
of the factors affecting outcomes of nonsurgical root
canal treatment: part 1: periapical health. Int Endod
J. 2011;44:583–609.
65. Taschieri S, Machtou P, Rosano G, Weinstein T, Del
Fabbro M. The influence of previous non-surgical
6  Decision Making
re-treatment on the outcome of endodontic surgery.
Minerva Stomatol. 2010;59:625–32.
66. Cohenca N, Shemesh H. Clinical applications of cone
beam computed tomography in endodontics: a com-
prehensive review. Quintessence Int. 2015;46:465–80.
67. Zitzmann NU, Krastl G, Hecker H, Walter C, Waltimo
T, Weiger R. Strategic considerations in treatment
planning: deciding when to treat, extract, or replace a
questionable tooth. J Prosthet Dent. 2010;104:80–91.
68. Fristad I, Molven O, Halse A. Nonsurgically retreated
root filled teeth—radiographic findings after 20–27
years. Int Endod J. 2004;37:12–8.
69. Song M, Woncho C, Seung-Jong L, Euiseong K. Long-
term outcome of the cases classified as successes based
71
on short-term follow-up in endodontic microsurgery.
J Endod. 2012;38:1192–6.
70. Riis A, Taschieri S, del Fabbro M, Kvist T. Long-term
tooth survival after endodontic retreatment and its
relation to root canal posts. In manuscript.
71.
Torrance GW. Measurement of health state
utilities for economic appraisal. J Health Econ.
1986;5:1–30.
72. Kvist T, Reit C. Postoperative discomfort associated
with surgical and nonsurgical endodontic retreatment.
Endod Dent Traumatol. 2000;16(2):71–4.
73.
West J. Nonsurgical versus surgical endodon-
tic retreatment: “how do I choose”? Dent Today
2007;26(4): 74, 76; 78–81.
 Surgical Retreatment
7
Peter Jonasson and Magnús Friðjón Ragnarsson

It ought … to be understood that no one can be a good physician who has no idea of
surgical operations, and that a surgeon is nothing if ignorant of medicine.

—Guido Lanfranchi
Chirurgia Magna (1296, printed 1479).

Abstract
In many cases, modern surgical retreatment technique is a realistic treat-
ment option with a predictable and successful outcome. The main objec-
tive with surgical retreatment is to eliminate and prevent bacterial infection
in the root canal system from causing an inflammatory reaction in the
periradicular tissue. This chapter provides an overview of possible indica-
tions and contraindications for surgical retreatment from a technical, bio-
logical, anatomical, and medical perspective.
The concept of minimal invasive microsurgical approach is the state-­
of-­the-art for surgical retreatment. It requires certain techniques, instru-
ments, and materials. Furthermore, and perhaps most importantly, it
requires magnification and illumination either through an operating micro-
scope or loupes equipped with head-lights.
A basic prerequisite for successful treatment is the diagnosis, case
selection, and treatment planning. This is particularly important since the
primary treatment has failed, and consequently, the case may pose particu-
lar difficulties, which is exemplified in the chapter.

7.1 Introduction

Over the years, endodontic surgery has greatly ben-

P. Jonasson, DDS, PhD (*)
Department of Endodontology, Institute of
Odontology, The Sahlgrenska Academy,
University of Gothenburg, Göteborg, Sweden
e-mail: peter.jonasson@odontologi.gu.se
M.F. Ragnarsson, DDS
Endodontist in private practice, Reykjavik, Iceland
efited from a continuing technological development.
With the skilful use of the operating microscope,
ultrasonics technique, and root-end filling materials
such as MTA, tooth maintenance after endodontic
surgical procedures has become predictable, and the
success rate has improved [1, 2]. The indications for

© Springer International Publishing AG 2018 73

T. Kvist (ed.), Apical Periodontitis in Root-Filled Teeth,
https://doi.org/10.1007/978-3-319-57250-5_7
74
surgical retreatment have been extended from
being considered to be the last resort to a viable
alternative to orthograde retreatment in most
cases. The main objectives of any endodontic
retreatment procedure are long-­term survival of
an asymptomatic tooth and healing of the peri-
apical tissues. Using a surgical retreatment
approach, this is achieved by reducing the bacte-
rial load and preventing bacterial leakage from
the root canal system into the periradicular tis-
sues. Modern endodontic surgery technique has
the potential to effectively eradicate the causes of
persistent apical pathology with little postopera-
tive discomfort [3, 4].
The advantages of a surgical rather than non-­
surgical approach to persistent apical periodonti-
tis in root filled teeth include:
• Preservation of coronal tooth structure.
• No need for drilling through or removing
prosthodontic restorations.
• Root and surrounding tissues are directly
visualised for diagnosis and interventions.
• A biopsy of the pathological tissue may be
taken and sent for a histological examination.
However, there are also some obvious
disadvantages:
• Lack of control of possible coronal leakage
and carious lesions under restorations
• Limited access to the root canal full length
• Limited possibility to use chemical disinfec-
tion methods
7.2 Indications,
Contraindications,
and Treatment Planning
The goals for endodontic surgery are to retain a
tooth in function without signs and symptoms of
persistent infection. Unfortunately, there is no solid
scientific evidence to choose between surgical and
non-surgical treatment with respect neither to heal-
ing of apical periodontitis, tooth survival nor cost
P. Jonasson and M.F. Ragnarsson
effectiveness. Every case is unique and the decision
has to be made on an individual basis.
In cases where apical periodontitis persists
after conventional endodontic treatment, the first
step is, together with the patient, to evaluate the
tooth’s value from a functional and aesthetic
aspect. The individual preferences are likely to
vary greatly and may be the single most impor-
tant factor for the final decision.
The evaluation before treatment must always
include a careful weighing of the advantages and
disadvantages as well as a cost-effectiveness
analysis of the treatment options. The importance
of proper diagnosis cannot be overemphasised.
The examination comprises a thorough clinical
and radiographic examination, including adja-
cent and opposing teeth, in order to decide
whether surgical or non-surgical retreatment
should be the treatment of choice.
Trying to analyse and to understand the under-
lying mechanisms that apical periodontitis is not
healing and where the causative infection is
located is of paramount importance for the proper
management. Infections causing apical periodon-
titis can either persist after endodontic treatment
or be a recurrent infection from coronal leakage.
In some cases, an extraradicular infection may be
suspected. Large periapical lesions are likely to
be bounded by epithelium, i.e. a radicular cyst
may have been formed and a surgical retreatment
may be necessary to remove the tissue to estab-
lish a proper diagnosis and optimise the likeli-
hood of healing.
Besides these basic assessments, several other
considerations must be made by the wise clinician.
7.2.1 Technical Considerations
It is generally accepted that the healing of the perira-
dicular tissue after orthograde endodontic treatment
is positively correlated with the technical quality of
the root filling and coronal restoration [5–7].
Before evaluating the technical aspects of the
present root filling, it is of great importance to
evaluate the quality of the coronal restoration.
7  Surgical Retreatment
If the quality is poor (over- or under-extended
restorations) or if secondary carious lesions are
present, this may suggest that the origin of persis-
tent disease originates from coronal leakage. If
so, non-surgical retreatment including a replace-
ment of the restoration appears mandatory in
order to fulfil the objectives of retreatment.
However, in many situations the coronal resto-
ration is judged to be functional and without
major defects, but the quality of the root filling is
poor. Consequently, it is reasonable to assume
that the source of failure comes from a persistent
infection within the root canal system. A basic
prerequisite for successful outcome is accurate
access to the site of infection.
From this perspective, non-surgical retreat-
ment generally provides better accessibility to
treat and refill the complete root canal system.
Consequently, selecting this option seems attrac-
tive especially when the clinician judges that
quality of seal can be substantially improved.
However, to remove an existing restoration for
better accessibility for orthograde retreatment
a b
Fig. 7.1 (a) Radiograph of an upper lateral incisor with a
long parallel post showing an incomplete root canal filling
and a periapical radiolucency. Endodontic treatment
options can either be conventional retreatment after
removal of crown and post or surgical retreatment.
Considering the relative narrow root in relation to the size
of the post and possible risk for inducing root fractures,
75
can imply great differences in costs, technical
difficulties and risks to induce complications.
Even if the risks for technical complications and
inducing root fracture appear small when remov-
ing posts, on the basis of the limited data avail-
able in the literature [8], the decision must be
based on root and post dimensions, type of post
and the technique for removal [9] (Fig. 7.1). In
case the access preparation is made through the
artificial crown, it may influence the retention
and provoke loosening of the cemented crown
[10, 11] and result in a situation where the crown
and/or bridge have to be replaced. Incomplete
root fillings should as far as possible be handled
with orthograde retreatment.
On the other hand, irrespective of the quality
of the former treatment, surgical retreatment is
considered to be the first choice where ortho-
grade retreatment has failed to control the infec-
tion or cannot be undertaken due to blocked
canals caused by dystrophic calcifications and
iatrogenic errors such as ledges, broken instru-
ments and presence of posts (Figs. 7.2 and 7.3).
c
surgical retreatment is considered as the first choice of
treatment. (b) The retrograde instrumentation of the canal
was performed with hand files held in a haemostat. To
maintain the curvature of the canal flexible files can be a
better alternative than stiff ultrasonic tips when longer
instrumentations are needed. (c) Postoperative radiograph
with a retrograde filling to the level of the post
76
a b
Fig. 7.2 (a) A lower left first molar with an incomplete root
filling and periapical radiolucencies on booth roots. Surgical
retreatment was performed as an alternative to conventional
retreatment. A partly or completely obliterated mesial root
can be suspected from the radiograph that can be challenging
to treat. The patient was eager to keep the crown and post in
a b
Fig. 7.3 (a) Radiograph of the upper left first molar with
a fractured instrument in the mesiobuccal root diagnosed
with symptomatic apical periodontitis. Due to the difficul-
ties in removing instrument without extensive risks for
7.2.2 Biological Considerations
From microbial perspective, surgical retreatment
is indicated when suspecting a persistent infection
withstanding the effect of an impeccable root
canal treatment. Even though persistent infections
are mainly localised in the root canal system,
microorganisms can establish an extraradicular
infection formed as a biofilm on the root surface
adjacent to the root apex and even colonizing the
periapical tissue [12, 13]. However, to what extent
an extraradicular infection can persist without the
intraradicular infection as a reservoir is not well
understood [14] and a surgical retreatment should
therefore focus on treatment of all possible infec-
tion sites.
Most periapical lesions can be classified as
dental granulomas, root cysts and abscesses [15,
16]. Periapical lesions cannot be differentiated
based only on the radiographic observations [17].
However, a correlation has been shown between
the radiographic lesion size and the probability
P. Jonasson and M.F. Ragnarsson
c
order to reduce the costs. (b) A postoperative radiograph with
a limited retrograde preparation and filling in the mesial root.
(c) Five years postoperatively, the patient developed pain from
the area. The radiograph showed a nice bone healing on the
first molar, but the second molar had developed a periradicu-
lar bone lesion found to originate from a root fracture
c
complications when located in the apical third of the root
with a root curvature, surgical retreatment was performed.
(b) Immediately postoperatively. (c) A 1-year follow-up
for cystic lesions [18, 19]. Based on histological
criteria, two different categories of cysts have
been defined [20, 21]: True cyst which have com-
plete enclosed lumina and therefore no direct
connection to the root canal and pocket cysts that
have open connection to the root canal. True cyst,
different from pocket cysts, may therefore be
self-perpetuating and fail to heal if not treated
surgically.
Foreign body material can accidentally be dis-
placed to the periapical tissue during endodontic
treatment. The presence of a foreign body in the
periapical tissues may cause endodontic failure
by triggering an inflammatory response and a
subsequent foreign body reaction, which can be
treated successfully by surgical retreatment.
A local deep pocket is generally an aggravat-
ing factor for the prognosis (Figs. 7.4 and 7.5).
Tentative diagnoses are periodontal fistulation,
root fracture or an endo-perio lesion either
caused by primary or secondary periodontal dis-
ease. The benefits with a surgical approach are
7  Surgical Retreatment 77

a b

Fig. 7.4 (a) First lower right molar with a persistent graph shows a periradicular radiolucency on the mesial
pathology after orthograde retreatment. (b) Adjacent to root. The mesial root was surgically retreated with a ques-
the fistula a local pocket was probed to the apex. No root tionable prognosis then it is difficult to know if a second-
fracture could be found after exploration. (c) The radio- ary periodontal lesion had developed

a b c

Fig. 7.5 (a) Upper right second premolar with a deep line was found after removing the soft tissue and staining
pocket located buccal. (b) An exploration was made in with methylene blue
order to inspect the root surface. (c) A vertical fracture
78
the ­possibilities to explore the root and evaluate
for eventual fractures and supplement if neces-
sary with a periodontal treatment.
With an extensive marginal attachment loss in
periodontally compromised teeth, the possibili-
ties to perform a surgical treatment may be lim-
ited. Osteotomy for apical resection reduces
longitudinal width of the buccal bone that
increases the risk of endo-perio communication.
Moreover, with the surgical approach, the apical
part of the root is resected and the crown-to-root
ratio of the tooth may be unfavourable for the
prosthodontic prognosis. The evaluation of tooth
mobility preoperatively and the bite forces can be
crucial to the possibilities of treatment.
7.2.3 Anatomical Considerations
A preoperative judgement of the accessibility of
the site of infection is central for the successful
outcome of the procedure. Careful evaluation of
two or more periapical radiographs exposed in
different angulations is mandatory (Fig. 7.6), and
for certain cases, computed tomography is a good
complement for planning and performing the
treatment (Fig. 7.7).
Most roots are accessible for surgical treat-
ment. In the lower jaw, proximity to the mandibu-
lar nerve and/or a thick cortical bone buccal to
the tooth may limit the accessibility. Extended
a b
Fig. 7.6  An upper molar with a symptomatic apical peri-
odontitis. (a) The radiographs showing a periapical radio-
lucency and fractured instrument in the apical third of the
mesiobuccal root. (b) With a mesial eccentric radiographs,
P. Jonasson and M.F. Ragnarsson
p­ reoperative radiographic examination with cone
beam computed tomography CBCT is recom-
mended in such cases. The palatal root can either
be treated by a buccal or palatal entrance. The rela-
tion to sinus and indications for treating the buccal
roots is crucial for the decision (Fig. 7.8). A palatal
entrance is technical demanding not at least
depending on the difficulty raising the flap and get
a good insight (Fig. 7.9). In cases were the acces-
sibility to the palatal root is limited surgically
especially for the second maxillary molars, a com-
bined intervention may be considered with a con-
ventional orthograde treatment of the palate root.
The location of the lesion, root anatomy, rela-
tionships of roots and relation to neighbouring
anatomical structures and findings that indicate
untreated channels are of special interest for
treatment planning. Once again, CBCT is a pow-
erful tool that can assist when a more exact three-­
dimensional imaging of the tooth and the
periapical tissue is necessary [22] (Fig. 7.7).
For supporting the clinician in the preopera-
tive planning, a guide with different categories of
complexity of lesions has been presented [23]
where the more severe categories are demanding
and may need certain surgical skills, techniques
and equipment.
The location of the root in the alveolar process
and possible involvement of neurovascular struc-
tures may hamper the opportunities for access.
Nerve injuries and altered sensation is however
the root-filled canal in the mesiobuccal root moves from
the x-rays, not centralised in the canal, indicating a second
untreated canal
7  Surgical Retreatment
Fig. 7.7  Orthopantomogram showing a patient with need
of extensive fixed prosthodontic treatment. Evaluation of
suitability of the upper jaw for installing implants showed
poor bone conditions. The radiographic examinations
showing periapical radiolucencies on several teeth (13, 22
and 26). Thirteen and twenty-six are restored with well-­
functioning posts and not planned for removal. Surgical
79
retreatment was planned. A CBCT in axial, frontal and
sagittal view and periapical radiograph of the first left
maxillary molar showing periapical radiolucencies around
all roots. In between the roots there is a sinus recess. Only
a minor swelling can be seen in the sinus mucosa. The
postoperative radiograph showing the retrograde fillings
performed by a buccal entrance
80
a b
d e
Fig. 7.8  Surgical treatment of tooth 26 was performed by
a buccal entrance. (a) After removing the soft tissue and
performing the root resection of the buccal roots a perfo-
rated sinus membrane was found. (b) As the sinus mem-
brane was perforated, access to the palatal root could be
achieved from sinus. The arrow showing the apex of the
palatal root covered by the sinus membrane and bone. (c)
The palatal root is seen after drilling through the covering
rarely reported after surgical retreatment. It can
occur as an effect of nerve traumatised during
surgery or following local anaesthetic adminis-
tration, or indirectly caused by a postoperative
inflammation when performing treatment in the
vicinity of major nerves. The risk to injure the
inferior alveolar nerve is related to treatment of
second molar and premolars but also to some
extent first molars [24].
Surgical treatment on teeth with apex or a
periapical lesion in close apposition to the maxil-
lary sinus should be carried out with caution
(Fig. 7.8). Removal of infected tissue should be
performed carefully, in order to avoid perforation
of the sinus membrane.
Sometimes the membrane is disrupted due to
the inflammatory reaction. In such cases, spe-
cial attention has to be made to not introduce
infected material or inadvertently drop instru-
ments into the sinus. This can be prevented by
packing the sinus with gauze. A final thorough
P. Jonasson and M.F. Ragnarsson
c
f
tissue. (d) The palatal root after root resection. (e)
Inspecting the mesiobuccal root by a micro mirror. The
root filling in the canal showing a void. Parts of the isth-
mus in between the canals are seen. (f) Gauze is packed
into the sinus in order not to introduce infected material or
inadvertently drop instruments into the sinus. The canals
and the isthmus are prepared by a contra-angled ultra-
sound tip
rinsing with saline is important to ensure
removal of infected material in the sinus.
More extensive lesions that have destructed
the cortical bone plates with a through-and-­
through lesion may end up with incomplete bone
healing with fibrous tissue ingrowth (scar tissue)
[25] (Fig. 7.10). A situation that may be only
indication for where a guided tissue regeneration
technique may be indicated [26].
With larger lesions, other tissue structures dis-
tant from the tooth may be involved and can com-
plicate the treatment and certain precautions have
to be made. More teeth may be necrotic and
involved in the process and therefore the vitality
of neighbouring teeth has to be evaluated before
surgery. Due to the surgery and soft tissue curet-
tage teeth not involved in the process may be
devitalised due to the treatment.
Radiographic evaluation of the size and the
location of the bone lesion may give an indication
to where in the root the infection is localised. An
7  Surgical Retreatment 81

a b

Fig. 7.9 (a) First left maxillary molar with an apical functioning crown, a surgical retreatment was planned.
radiolucency related to the palatal root according to the (b) Showing the palatal flap and the fenestration of the
intraoral radiograph. Due to long post and a well-­ palatal bone plate

a b c

Fig. 7.10  A sequence of healing after surgical retreat- bone. (c) A 4-year follow-up showing a feature of incom-
ment of tooth 12. (a) Immediately postoperatively (b) A plete scar tissue healing with continuous periodontal liga-
1-year follow-up with a reduction of the defect in the ment and a separate lesion

important question is whether lateral canals or
untreated canals may be involved (Figs. 7.6 and
7.11), and if these are accessible for treatment
during surgery. Also, any external inflammatory
root resorption that may have occurred should
also be localised and held as a potential exit of
intra-canal infection when treating the root.
Even if the impression from the intraoral
radiographs is that the tooth has separate root
canals, anatomical studies have shown a great
variety in morphology and complexity of the
canal system [27]. Canals may branch, divide and
rejoin, end in apical ramifications and have acces-
sory canals and roots with more than one canal
having isthmuses (Fig. 7.8). All these anatomical
sites may function as a bacterial reservoir and are
crucial to properly treat.
Where there is poor supporting bone tissue
surgical retreatment may be contraindicated due
to the doubtful prognosis. Teeth with endodontic-­
periodontal lesions may exist separately and
later unite together in a combined lesion, or it
may be primarily endodontic or periodontal with
a secondary involvement of the other (Fig. 7.4).
82 P. Jonasson and M.F. Ragnarsson

Fig. 7.11 (a) An upper

a
right canine with a
juxtaradicular
radiolucency. (b) A
lateral canal (arrow) was
located after exploration
and staining with
methylene blue
b

Fig. 7.12  Upper right canine with a long post and juxta- covered by a composite with a dentine bonding agent after
radicular and periapical radiolucency. An exploration drilling a minor cavity
showing a buccal post perforation. The perforation was

Due to the risk for down growth of a long junc-
tional epithelium and subsequent hindrance of a
favourable healing with bone and reattachment,
the outcome is compromised [28, 29].
In cases with long posts especially in metal,
leaving a limited canal space may influence the
possibilities to perform enough deep retrograde
filling for a proper seal and alternative techniques
may be considered. This can also be the situation
in case of post perforation with limited possibili-
ties to create a cavity preparation (Fig. 7.12).
7.2.4 Medical Considerations
Considerations of medical risks are essential for
all dental treatments but special precautions
should be taken when planning for surgery. For
every treatment, a risk assessment has to be per-
formed based on a careful medical history and in
some cases after consultation with physician. For
medically compromised patients, orthograde pro-
cedures usually expose them to less medical risks
than surgical treatment. Therefore, a non-surgical
7  Surgical Retreatment
approach to endodontic retreatment may be more
suitable. For certain medical conditions, the surgi-
cal treatment should be postponed until the patient
has recovered. However, there are no absolute
medical contraindications to endodontic surgery.
An overall estimate of the medical risk can be
made due to the physical status classification sys-
tem adopted by the American Society of
Anaesthesiologists (ASA) in 1962 with a modifi-
cation in five categories to the dental treatment
situation [30].
There are several medical conditions and
medications that cause a depressed immune sys-
tem, where surgical intervention is contraindi-
cated until white blood cells count and antibody
levels have normalised.
Patient with increased risk for bleeding needs
special attention. Medication with antiplatelet
and anticoagulant agents increases the bleeding
time intra- and postoperatively. Surgical treat-
ment is possible in most cases but needs certain
treatment protocols. Surgical treatment of
patients with haemophilia or impaired liver func-
tion should only be after consultation and in
agreement with the patient’s physician.
Previous high-dose irradiation affects the
blood vessels and reduces the blood supply to the
jawbone. An irradiated bone must be treated with
caution, as there is always a risk of reduced heal-
ing potential, developing postoperative infection
and osteoradionecrosis and surgical treatment
a b
Fig. 7.13  Single-rooted maxillary incisor treated by surgi-
cal retreatment using microsurgical technique. (a) The
resected root and canal with gutta-percha seen in the micro
83
should only be performed after careful consider-
ation of the alternatives.
Osteonecrosis is a rare condition and has mainly
been related to intravenous delivery of bisphospho-
nates in patients with bone cancer disease [31].
Invasive treatments have been shown to increase
the risk of developing this serious complication.
However, few cases have been reported and very
few guidelines are available in the endodontic lit-
erature. Even if no evidence-­based data are avail-
able, non-surgical retreatment seems to be
preferable, but as an alternative to extraction, surgi-
cal retreatment still is a less traumatic procedure.
7.3 Methods and Techniques
Endodontic surgery has developed from a surgi-
cal procedure where a curettage and removal of
the soft tissue surrounding the root apex was the
only action towards a causal oriented approach
with the aim to eradicate or closing in the root
canal infection. Untreated infected parts of the
root canal system are localised and mechanically
treated. Persistent infections in inaccessible areas
are instead entombed with a retrograde filling
preventing leakage of microorganisms and their
by-products into the periradicular tissue.
Today’s state-of-the-art is a minimal inva-
sive microsurgical approach that requires par-
ticular skills, techniques (Fig. 7.13), instruments
c
mirror and microscope (x6) with good haemostatic control.
(b) Retrograde preparation with a contra-angled ultrasonic
tip (3 mm). (c) Application of the retrograde filling (MTA)
84 P. Jonasson and M.F. Ragnarsson

and materials. Magnification with loops or most gingiva should be taken. In order to minimise the
preferable a surgical operating microscope is risk, a submarginal incision is often recom-
mandatory. mended. However, if the anatomical conditions
The surgical microscope and micro-­are not favourable or if the surgery is not well
instruments are an integral part of the up-to-date performed, such an incision may have devastat-
endodontic surgery arsenal. Its’ combination ing effects on the aesthetic outcome; that’s why
with an essentially improved illumination due to this technique should be used with caution. The
the built-in light source has improved the possi- biotype of gingiva can predict the risk for reces-
bility to see, localise and hence also treat the vari- sion. A thick and wide papilla compared to a thin
ous locations of microbes present in and on the and narrow is more likely to heal without reces-
root. As a consequence, the indications for end- sion [33]. Important factors for the healing pro-
odontic surgery have expanded [32]. With a bet- cess are also a healthy gingiva and the level of the
ter understanding of infection control and more marginal bone supporting the soft tissue during
conservative handling of the soft and hard tis- the healing process.
sues, the reported success rate has significantly
been improved.
7.3.2 Bleeding Control
During Surgery
7.3.1 Soft Tissue Management
Adequate bleeding control is crucial for inspect-
To get access to the root, the surgery commences ing the root and performing the retrograde treat-
with an incision and raising of a full-thickness ment. An important first step for bleeding control
flap. This means a soft tissue flap, which entails is to remove the highly vascularised granulation
gingival and mucosal tissues as well as perios- tissue in the bone crypt. Local anaesthesia
teum. Many different flap designs have been pro- ­containing epinephrine contributes to a certain
posed in the literature [33]. The objective is to haemostasis but must often be supplemented
provide good accessibility and view without with other medicaments. For certain patient
unnecessarily traumatise soft tissue in order to groups, epinephrine should not be used, and in
promote a predictable healing of gingival tissue. such cases, it is particularly important to have
The design of the flap should be carefully planned access to other medicaments. However, cotton
in advance and has to be adapted to each indi- pellet saturated with epinephrine for local use in
vidual and case. To be able to mobilise the flap, the bone crypt have been shown to be effective
various modes of incision can be selected, includ- for bleeding control and cause no changes in
ing horizontal incisions and vertical releasing blood pressure or heart rate [34].
incisions. The horizontal incision can either fol- Other topical haemostatic agents suggested
low and include the papilla or cut through the for controlling bone crypt haemorrhage are alu-
papilla base. The most frequent horizontal inci- minium chloride or ferric sulphate [35].
sions are either sulcular with or without involv- A relatively common surgical complication is
ing the papilla or submarginal in the attached an insult to blood vessels. In most cases, manual
gingiva with one or two vertical releasing inci- compression will have adequate effect, but if
sion. The releasing incisions are performed paral- more severe bleeding, electrocauterization may
lel to the tooth axis and subperiosteal blood be considered.
vessels in order to minimise the number of cut Taken together there are techniques to control
blood vessels. local bleeding in most cases and is bleeding from
In the aesthetic zone with artificial crowns, the site of endodontic surgery seldom a limiting
precautions to reduce the risk for recession of the factor during the surgical procedure. For certain
7  Surgical Retreatment
groups of patients, special precautions should be
taken and a contact with the patient’s physician
for a dialogue about any preoperative measures
to prevent possible risks is recommended.
7.3.3 Root Resection
and Retrograde Treatment
of the Root Canal
The root resection is performed to eliminate
infected ramifications, lateral canals and contam-
inated dentin. Moreover, the root resection allows
better overview of the canal anatomy and inspec-
tion of the resected root surface for isthmuses or
microfractures. In general, a root resection of
3 mm apically is considered to be sufficient to
remove most of infected ramifications and lateral
canals [23]. It is optimally performed in a 90°
angle to the long axis of the root to minimise any
leakage that might occur through cut dentinal
tubules.
The aim of the root-end preparation is to
remove infected material and enough intra-canal
filling material to be able to seal the root canal
system with a retrograde filling. The ideal root-­
end preparation can be defined as a cavity of least
3 mm depth [36], with walls parallel to and coin-
cident with the anatomic outline of root canal
space. Newer instruments have been designed to
prepare up to 9 mm in untreated canals or canals
with poor-quality root fillings [37]. In cases with
limited access and need of extended retrograde
instrumentation, hand files held in a haemostat
can be used as an alternative [38] (Fig. 7.1). The
purpose of the retrograde filling material is to fill
the apical canal space and to obtain a hermetic
seal and entomb microorganisms in not accessi-
ble areas. Numerous materials have been sug-
gested for root-end filling include gutta-percha,
IRM, Super EBA and dentin-bonded modified
resins [39–42].
At the present time, mineral trioxide aggre-
gate (MTA) is considered the gold standard for
root-end filling materials. But there is an emerg-
ing trend of using other bioceramic materials
85
[43]. MTA is a very appropriate material for root-­
end filling due to its good biocompatibility,
osteo- and cemento-inductive capabilities and
antibacterial and sealing properties [44–46]. The
drawbacks are long setting time and handling
difficulties.
Retrograde root-end cavities are prepared by
ultrasonic tips in exposed canal orifices that are at
least a 3 mm to provide a satisfactory thickness
and seal with MTA [47] (Fig. 7.13).
7.3.4 Suturing
After thorough irrigation with saline of the
wound surface for removal of contaminated
materials and blood clot a proper wound closure
is necessary for optimal healing. Surgical sutures
should hold the edges of a flap in apposition until
the wound has healed sufficiently to withstand
normal functional stresses and resist reopening.
Resorbable or non-resorbable threads in diame-
ters 5-0 or 6-0 and three-eighths reverse-cutting
or tapered needle are commonly used. The
sutures can in most cases be removed after
7–14 days. If resorbable sutures are used, it
should retain resorption more than 7–14 days.
7.4 Postoperative Information
and Complications
Pain and swelling may occur after surgical treat-
ment, but in most cases, only to a limited extent
[48]. The symptoms are related to the degree of
tissue trauma and inflammatory reaction. The
reaction is part of the healing process. In addi-
tion, secondary infection of the surgical site may
also occur and induce a postsurgical inflamma-
tion, which can sometimes be difficult to differ-
entially diagnose from a normal postoperative
course.
Factors that have been shown to predispose
for postoperative pain are location for surgery,
poor oral hygiene, smoking and the duration of
surgery [49]. There is some data supporting that
86
surgical procedures lasting longer than 1 h pre-
dispose for postoperative symptoms and infec-
tions [50].
The severity of the pain is usually worst the
first 24 h postoperatively [49]. The swelling is
greatest between first and second postoperative
day. The management is usually prescribing anti-­
inflammatory analgesics (NSAIDs). In case of a
secondary infection, surgical drainage may be
required and if systemic effects and risk for
spreading prescription of antibiotics may be
motivated.
7.5 Prognosis
Successful treatment is defined by the absence of
radiographically and clinical signs of apical peri-
odontitis. Within a period of 1–3 months, clinical
signs of pathology are expected to be missing,
and radiographically, a remineralisation of the
lesion and a new periodontal ligament formation
is expected to occur within 1–2 years. According
to the literature, the success rate for surgical
retreatment on accurate indications and using the
latest technical advancement can be expected to
be above 80–90% [32, 51].
Take-Home Message
• Surgical retreatment is a valid and pre-
dictable alternative for retreatment of
teeth with post-treatment apical peri-
odontitis especially when it is desirable
to preserve a restoration.
• In cases where orthograde retreatment is
judged difficult or even impossible
because of previous iatrogenic errors or
blocked canals, surgical retreatment
may be the only realistic treatment alter-
native to extraction.
• Accurate diagnosis and correct treatment
planning is prerequisite for success.
• Using a minimal invasive microsurgical
approach for surgical retreatment
requires certain techniques, instruments,
materials and work with good vision for
a reliable treatment outcome.
P. Jonasson and M.F. Ragnarsson
Benchmark Papers
• Tsesis I, Rosen E, Taschieri S, Telishevsky
Strauss Y, Ceresoli V, Del Fabbro
M. Outcomes of surgical endodontic
treatment performed by a modern tech-
nique: an updated meta-analysis of the
literature. J Endod. 2013;39(3):332–9.
This review and meta-analysis paper
gives an updated evidence base for the
excellent healing frequencies that are
possible to obtain after surgical retreat-
ment procedures in settings characterised
by extensive expertise, high clinical skills
and best available equipment.
• Kruse C, Spin-Neto R, Christiansen R,
Wenzel A, Kirkevang LL. Periapical
bone healing after apicectomy with and
without retrograde root filling with min-
eral trioxide aggregate: a 6-year follow-
­up of a randomised controlled trial. J
Endod. 2016;42:533–7. This clinical
study highlights the importance of the
retrograde filling for achieving good
healing results as well as the need for
more long-term follow-ups of surgical
retreatment procedures.
References
1. Shetzer FC, Shah SB, Kohli MR, Karabucak B, Kim
S. Outcome of endodontic surgery: a meta-analysis of
the literature—part 1: Comparison of traditional root-­
end surgery and endodontic microsurgery. J Endod.
2010;36(11):1757–65.
2. Tsesis I, Rosen E, Taschieri S, Telishevsky Strauss Y,
Ceresoli V, Del Fabbro M. Outcomes of surgical end-
odontic treatment performed by a modern technique:
an updated meta-analysis of the literature. J Endod.
2013;39(3):332–9.
3. Iqbal MK, Kratchman SI, Guess GM, Karabucak
B, Kim S. Microscopic periradicular surgery: peri-
operative predictors for postoperative clinical out-
comes and quality of life assessment. J Endod.
2007;33(3):239–44.
4. Penarrocha M, Garcia B, Marti E, Balaguer J. Pain
and inflammation after periapical surgery in 60
patients. J Oral Maxillofac Surg. 2006;64(3):429–33.
5. Ray HA, Trope M. Periapical status of endodontically
treated teeth in relation to the technical quality of the
root filling and the coronal restoration. Int Endod
J. 1995;28(1):12–8.
7  Surgical Retreatment
6. Tronstad L, Asbjornsen K, Doving L, Pedersen I,
Eriksen HM. Influence of coronal restorations on
the periapical health of endodontically treated teeth.
Endod Dent Traumatol. 2000;16(5):218–21.
7. Ng YL, Mann V, Gulabivala K. A prospective study
of the factors affecting outcomes of nonsurgical root
canal treatment: part 1: periapical health. Int Endod
J. 2011;44(7):583–609.
8. Abbott PV. Incidence of root fractures and methods
used for post removal. Int Endod J. 2002;35(1):63–7.
9. Altshul JH, Marshall G, Morgan LA, Baumgartner
JC. Comparison of dentinal crack incidence and
of post removal time resulting from post removal
by ultrasonic or mechanical force. J Endod.
1997;23(11):683–6.
10. McMullen AF III, Himel VT, Sarkar NK. An in vitro
study of the effect endodontic access preparation and
amalgam restoration have upon incisor crown reten-
tion. J Endod. 1990;16(6):269–72.
11. Mulvay PG, Abbott PV. The effect of endodontic
access cavity preparation and subsequent restorative
procedures on molar crown retention. Aust Dent
J. 1996;41(2):134–9.
12. Nair PN. On the causes of persistent apical periodon-
titis: a review. Int Endod J. 2006;39(4):249–81.
13. Wang J, Jiang Y, Chen W, Zhu C, Liang J. Bacterial
flora and extraradicular biofilm associated with the
apical segment of teeth with post-treatment apical
periodontitis. J Endod. 2012;38(7):954–9.
14. Ricucci D, Siqueira JF Jr. Apical actinomycosis as a
continuum of intraradicular and extraradicular infec-
tion: case report and critical review on its involvement
with treatment failure. J Endod. 2008;34(9):1124–9.
15. Stockdale CR, Chandler NP. The nature of the
periapical lesion—a review of 1108 cases. J Dent.
1988;16(3):123–9.
16. Nair PN. New perspectives on radicular cysts: do they
heal? Int Endod J. 1998;31(3):155–60.
17. Wood NK. Periapical lesions. Dent Clin N Am.
1984;28(4):725–66.
18. Natkin E, Oswald RJ, Carnes LI. The relationship of
lesion size to diagnosis, incidence, and treatment of
periapical cysts and granulomas. Oral Surg Oral Med
Oral Pathol. 1984;57(1):82–94.
19. Lalonde ER. A new rationale for the management of
periapical granulomas and cysts: an evaluation of his-
topathological and radiographic findings. J Am Dent
Assoc. 1970;80(5):1056–9.
20. Ramachandran Nair PN, Pajarola G, Schroeder
HE. Types and incidence of human periapi-
cal lesions obtained with extracted teeth. Oral
Surg Oral Med Oral Pathol Oral Radiol Endod.
1996;81(1):93–102.
21. Simon JH. Incidence of periapical cysts in relation to
the root canal. J Endod. 1980;6(11):845–8.
22. Fayad MI, Nair M, Levin MD, Benavides E,
Rubinstein RA, Barghan S, Hirschberg CS, Ruprecht
A. AAE and AAOMR joint position statement: use
of cone beam computed tomography in endodontics
2015 update. Oral Surg Oral Med Oral Pathol Oral
Radiol. 2015;120(4):508–12.
87
23. Kim S, Kratchman S. Modern endodontic sur-
gery concepts and practice: a review. J Endod.
2006;32(7):601–23.
24. Pogrel MA. Damage to the inferior alveolar nerve
as the result of root canal therapy. J Am Dent Assoc.
2007;138(1):65–9.
25. Molven O, Halse A, Grung B. Incomplete healing
(scar tissue) after periapical surgery—radiographic
findings 8 to 12 years after treatment. J Endod.
1996;22(5):264–8.
26. Corbella S, Taschieri S, Elkabbany A, Del Fabbro M,
von Arx T. Guided tissue regeneration using a bar-
rier membrane in endodontic surgery. Swiss Dent
J. 2016;126(1):13–25.
27. Vertucci FJ. Root canal anatomy of the human per-
manent teeth. Oral Surg Oral Med Oral Pathol.
1984;58(5):589–99.
28. Kim E, Song JS, Jung IY, Lee SJ, Kim S. Prospective
clinical study evaluating endodontic microsur-
gery outcomes for cases with lesions of endodontic
origin compared with cases with lesions of com-
bined periodontal-endodontic origin. J Endod.
2008;34(5):546–51.
29. Skoglund A, Persson G. A follow-up study of apicoec-
tomized teeth with total loss of the buccal bone plate.
Oral Surg Oral Med Oral Pathol. 1985;59(1):78–81.
30. Malamed SF. Medical emergencies in the dental
office. 5th ed. St. Louis: Mosby; 2000. p. 41–4.
31. Tsesis I. Complications in endodontic surgery. 2014.
p. 153–64. Springer-Verlag Berlin Heidelberg;2014
32. Setzer FC, Kohli MR, Shah SB, Karabucak B, Kim
S. Outcome of endodontic surgery: a meta-analysis
of the literature—Part 2: Comparison of endodontic
microsurgical techniques with and without the use of
higher magnification. J Endod. 2012;38(1):1–10.
33. Velvart P, Peters CI. Soft tissue management in end-
odontic surgery. J Endod. 2005;31(1):4–16.
34. Vickers FJ, Baumgartner JC, Marshall G. Hemostatic
efficacy and cardiovascular effects of agents used dur-
ing endodontic surgery. J Endod. 2002;28(4):322–3.
35. von Arx T, Jensen SS, Hanni S. Clinical and radio-
graphic assessment of various predictors for healing
outcome 1 year after periapical surgery. J Endod.
2007;33(2):123–8.
36. Lamb EL, Loushine RJ, Weller RN, Kimbrough
WF, Pashley DH. Effect of root resection on the
apical sealing ability of mineral trioxide aggregate.
Oral Surg Oral Med Oral Pathol Oral Radiol Endod.
2003;95(6):732–5.
37. Khayat B, Michonneau JC. Tissue conservation
in endodontic microsurgery. J Odontol Stomatol.
2008;37:275–86.
38. Reit C, Hirsch J. Surgical endodontic retreatment. Int
Endod J. 1986;19(3):107–12.
39. Chong BS, Pitt Ford TR, Hudson MB. A prospective
clinical study of mineral trioxide aggregate and IRM
when used as root-end filling materials in endodontic
surgery. Int Endod J. 2003;36(8):520–6.
40. Rud J, Rud V, Munksgaard EC. Long-term evaluation
of retrograde root filling with dentin-bonded resin
composite. J Endod. 1996;22(2):90–3.
88
41. von Arx T, Jensen SS, Hanni S, Friedman S. Five-year
longitudinal assessment of the prognosis of apical
microsurgery. J Endod. 2012;38(5):570–9.
42. Walivaara DA, Abrahamsson P, Samfors KA, Isaksson
S. Periapical surgery using ultrasonic preparation and
thermoplasticized gutta-percha with AH Plus sealer
or IRM as retrograde root-end fillings in 160 consecu-
tive teeth: a prospective randomized clinical study.
Oral Surg Oral Med Oral Pathol Oral Radiol Endod.
2009;108(5):784–9.
43. Gutmann JL. Surgical endodontics: past, present, and
future. Endod Top. 2014;30:29–43.
44. Baek SH, Plenk H Jr, Kim S. Periapical tissue
responses and cementum regeneration with amalgam,
SuperEBA, and MTA as root-end filling materials.
J Endod. 2005;31(6):444–9.
45. Fernandez-Yanez Sanchez A, Leco-Berrocal MI,
Martinez-Gonzalez JM. Metaanalysis of filler mate-
rials in periapical surgery. Med Oral Patol Oral Cir
Bucal. 2008;13(3):E180–5.
46. Lindeboom JA, Frenken JW, Kroon FH, van den
Akker HP. A comparative prospective randomized
clinical study of MTA and IRM as root-end filling
materials in single-rooted teeth in endodontic surgery.
P. Jonasson and M.F. Ragnarsson
Oral Surg Oral Med Oral Pathol Oral Radiol Endod.
2005;100(4):495–500.
47. Valois CR, Costa ED Jr. Influence of the thickness of
mineral trioxide aggregate on sealing ability of root-­
end fillings in vitro. Oral Surg Oral Med Oral Pathol
Oral Radiol Endod. 2004;97(1):108–11.
48. Garcia B, Penarrocha M, Marti E, Gay-Escodad
C, von Arx T. Pain and swelling after periapical
surgery related to oral hygiene and smoking. Oral
Surg Oral Med Oral Pathol Oral Radiol Endod.
2007;104(2):271–6.
49. Garcia B, Larrazabal C, Penarrocha M, Penarrocha
M. Pain and swelling in periapical surgery. A lit-
erature update. Med Oral Patol Oral Cir Bucal.
2008;13(11):E726–9.
50. Cruse PJ, Foord R. The epidemiology of wound infec-
tion. A 10-year prospective study of 62,939 wounds.
Surg Clin North Am. 1980;60(1):27–40.
51. Kruse C, Spin-Neto R, Christiansen R, Wenzel
A, Kirkevang LL. Periapical bone healing after
apicectomy with and without retrograde root fill-
ing with mineral trioxide aggregate: a 6-year fol-
low-up of a randomized controlled trial. J Endod.
2016;42(4):533–7.
 Non-surgical Retreatment
8
Charlotte Ulin

If a thing is worth doing, it’s worth doing well

Abstract
Non-surgical retreatment is difficult and treatment planning is essential.
Good access to the already root-filled root canals and working with good
aseptic procedures will create a possibility to render a preferable progno-
sis. The knowledge and ability in how to remove the gutta-percha and
other obstacles within the root canal will make the procedure easier and
more predictable. The microbiotic flora in the already treated root canal
system with periapical pathologies is more robust to chemical treatment
due to its ability to survive in an environment where nutrients are sparse.
This is important to understand when making the choice of and how to use
the irrigant. An inter-appointment dressing is preferably used. The proce-
dure of placing a new root filling might be as challenging as the removal
of the old one since the original form of the root canal has been changed.
Follow-ups of endodontic treatment must be made systematically and over
a longer period of time in order not to jump into conclusions or let rare
individual events distort the overall results.

8.1 Introduction The aim of non-surgical retreatment is to get

This chapter will describe a strategy in how to
treat root-filled teeth with a non-surgical
approach, what to consider, how to manage and
the expected result. The access to, the treatment
of and possible complications when treating the
root canal will be described.
C. Ulin, DDS
Specialist Clinic of Endodontics, Public Dental
Service Västra Götaland, Göteborg, Sweden
e-mail: charlotte.ulin@vgregion.se
access to and to eradicate the intracanal microor-
ganisms responsible for the persistent apical peri-
odontitis. In some cases the procedure is rather
pursued in order to improve the quality of root
filling in order to prevent apical periodontitis, for
example, prior to including the tooth in a prosth-
odontic construction.
Non-surgical retreatment challenges the clini-
cian to repeat a procedure that has already been
done but to a higher standard and benefit for the
patient. It is well established that if the root filling
reaches 0.5–2 mm from the radiographic apex, has
no voids and follows the outline of the root canal,

© Springer International Publishing AG 2018 89

T. Kvist (ed.), Apical Periodontitis in Root-Filled Teeth,
https://doi.org/10.1007/978-3-319-57250-5_8
90
the prognosis of root canal treatment is good, and
healing or prevention of apical periodontitis will
prevail [1–3]. Therefore the first question to be
considered before starting the treatment is if you
think you are up for the challenge. Do you have the
clinical skills, the necessary armamentarium and
knowledge in how to conquer the obstacles that
might come in to your way?
In a systematic review [4] by SBU (Swedish
Council on Health Technology Assessment) pub-
lished in 2010, they found that there is a lack of
evidence regarding the effect of different instru-
mental techniques, disinfection protocols or root
filling materials on periapical healing in conjunc-
tion with retreatment. Though, in essence, the
available evidence supports the current paradig-
matic premise of endodontics that healthy peri-
apical tissues are likely to be promoted if the
treatment procedures result in a successful eradi-
cation of the root canal infection.
The retreatment strategies include x-ray
examination, magnification and illumination,
coronal examination, access preparation, remov-
ing root filling material, irrigation and chemical
disinfection, placement of a new root filling res-
toration and follow-up.
8.2 X-ray Examination
Having good preoperative x-rays is crucial in cre-
ating the first attempt of creating a strategy for
non-surgical retreatment. With good x-rays the
a b
Fig. 8.1 (a) Tooth 36 is symptomatic after root canal
treatment. (b) X-ray in distal angulation suggests the pres-
ence of an untreated mesial-lingual canal. (c) Reamer 02
C. Ulin
preoperative status of the treated tooth of choice
can be studied. Are there signs of caries, posts,
untreated root canals and procedural errors such
as instrument fractures, ledges and overinstru-
mentation? The status of the root filling can be
visualized. Is it short? Are there voids or unfilled
spaces? Does it follow the original anatomy of
the root canal? The answers to these questions
will give a preview of the challenges of treatment
ahead.
Two apical intraoral x-rays in different angu-
lations are mandatory. “One x-ray makes you
interested, with two diagnosis can be made”
(Fig. 8.1). Sometimes a bitewing is necessary to
diagnose caries and status of the coronal restau-
ration. With a bitewing x-ray the risk of over- or
under-axial angulation is avoided. Hereby some
of the above questions can be answered and some
can be enlightened.
Cone beam computed tomography (CBCT) is
a very useful tool in diagnosing periapical lesions
and root canal anatomy. It has its disadvantages
in already root-filled teeth due to the creation of
artefacts from the root filling material and also if
posts are present (Fig. 8.2). The European end-
odontic society made a position statement in
2014 [5] regarding the use of CBCT in endodon-
tics. “A request for a CBCT scan should only be
considered if the additional information from
reconstructed three-dimensional images will
potentially aid formulating a diagnosis and/or
enhance the management of a tooth with an end-
odontic problem(s)”.
c
ISO 15 in mesial-lingual canal verifies the likely reason
for case being symptomatic
8  Non-surgical Retreatment
Fig. 8.2  Cone beam
computed tomography
(CBCT) has its
disadvantages in
root-filled teeth due to
the creation of artefacts
from the root filling
material and also if posts
are present
8.3 Magnification
and Illumination
Magnification and illumination in endodontic
practice is a good help within any step of the
procedures. The possibility to visualize the
tooth and root canal system will give diagnostic
information, and during treatment the surgical
microscope makes the procedures easier and
allows them to be conducted in a controlled
manner. The clinical effect of the use of the sur-
gical microscope is difficult to evaluate from a
strictly scientific point of view, and there are no
studies available that specifically investigated
the outcome of orthograde retreatment if or not
using an operating microscope, although the
possibility to enhance the quality of the access
preparation in terms of locating root canals has
been studied [6–8].
8.4  ssessment of the Coronal
A to cure a tooth by retreatment might be due to
Restoration
A root-filled tooth has usually a large coronal res-
toration or an artificial crown. The status of the
coronal restauration needs to be assessed for
­several reasons. Gaps between the filling material
and the dentine or carious lesions may be the
source of persistent apical periodontitis through
91
the mechanisms of coronal leakage. Consequently,
in such a situation, all filling materials and soft
dentine have to be removed to create aseptic con-
ditions during treatment and to allow for a suc-
cessful outcome in the long term.
In some situations the quality of the crown or
restoration is judged to be faultless, and it seems
to be safe to carry out the treatment with the
maintenance of the restoration from a microbio-
logical point of view. However, a proper access
to the root canal system may be jeopardized.
Hence a complete removal of the previous fill-
ing or artificial crown may be indicated
anyway.
After the complete removal of the restoration
and caries, the ability of the remaining tooth sub-
stance to provide support for a new restoration
must be assessed. Not surprisingly, it is common
for this appraisal to turn out negatively and the
tooth is deemed for extraction. Therefore, the
patient should be informed that the decision to try
change as treatment commences and progresses.
Another common finding is that remaining tooth
structure is compromised by cracks or fractures.
In conjunction with a local periodontal pocket, it
gives reasons to believe that a vertical root frac-
ture is present. Also under such circumstances,
the retreatment is pointless and the tooth should
rather be extracted. When only minor cracks
92
without any periodontal involvement or mobility
between s­ egments are present, the clinical deci-
sion is more difficult. There is only scarce scien-
tific documentation on the long-term outcome.
The prognosis should be considered doubtful. If
the treatment is carried on, it must be after thor-
ough deliberation and informed consent from the
patient.
The coronal examination also involves an
inspection of the pulp chamber floor. The pos-
sible presence of untreated root canals or isth-
muses can hereby be diagnosed. For example,
65–98% of the upper first molars have two root
canals in the mesiobuccal root [9, 10]. And the
most palatal of the two (MB2) has frequently
been overlooked in the primary treatment and
may be the underlying reason to treatment fail-
ure. The presence of previously made perfora-
tion in the pulp chamber can be diagnosed. If
diagnosed the prognosis is dependent on the
created damage to the periodontium and the
possibility to successfully seal the area of per-
foration [11, 12].
The type of root filling material previously
used can also be assessed. There are many dif-
ferent types of root filling materials used.
However, in most cases the clinician will find
canals filled with some type of sealer together
with a core of gutta-percha. But sometimes
only sealers or cements have been used. Core
materials other than gutta-percha such as sil-
verpoints or plastic carriers may also have
been used. Tooth colouring can sometimes
give a hint about what materials have been
administered. A pink-coloured tooth is usually
root filled with resorcinol-formaldehyde resin,
so-called Russian red [13].
8.5  emoval of Crowns, Cores
R to at a low speed remove fibre posts. The risk
and Posts
The removal of a crown will almost always
also remove some dentine since the border
between the crown and the underlying dentine
is difficult to visualize. The crown is most
C. Ulin
e­ asily removed by drilling an axial furrow on
the buccal side in to the dentine. The cemental
lock is then breakable by creating a bending
force inside the furrow with, for example, a
small and short screwdriver or a carver.
Depending upon the core material of the crown,
it will be more or less challenging. There are
today burs available that are designed to cut
through given materials such as titanium, zir-
conium, cobalt-chrome, etc. A high-speed
hand-piece should be avoided due to its low
momentum. An upregulated air-turbine-driven
hand-piece is preferable.
Sometimes a core and post might be present
inside the prosthodontic construction or even
when there is a composite resaturation. The
core is removed with burs. If a post is present,
it can be of metal or a fibre material. Depending
on the fit and retention of the post the removal
might be quick or time consuming. The aim is
to dislodge the lock of the cement surrounding
the post after which it will become loose and
easy to passively remove. This is preferably
done by ultrasonic equipment even though
other techniques are available. The coronal
part of the post, above the orifice of the root
canal, must be exposed. It is important to make
sure that the core material is removed from the
post. After choosing an ultrasound tip, designed
for the purpose, this is placed against the post,
and the ultrasonic unit is set on a high fre-
quency. Then, the clinician moves the tip
around the post in order to allow the vibrations
to be transported along the post and break the
cement. Thin ultrasonic files can be used to
remove the cement between the root canal wall
and the post. If the post does not come loose,
the possibility of drilling away the post can be
considered. There are specially designed burs
of at the same time removing dentine and
increasing the risk of root fracture or perfora-
tion has to be taken into account. Magnification,
visibility, acquaintance of the root canal anat-
omy and skill is obviously crucial for a suc-
cessful result.
8  Non-surgical Retreatment
8.6 The Access Preparation
The access preparation should give visibility and
easy access to the root canals and also allow a
complete eradication of residues of pulp tissue
and microorganisms. At the same time care
should be taken to save tooth substance.
A number of different access burs are avail-
able that have in common to cut the surface effec-
tively with as little damage to the tooth and
resaturation as possible. Before starting drilling
through a crown, its outline and its position in
relation to the root must be examined and
considered. For e­xample, the root might be
­ 8.8  emoving the Root Filling
rotated but the crown is placed in line with the
tooth arch.
The access cavity needs to be large enough
to give the operator a possibility to see and
introduce the instruments into root canal with
a “straight-line access”. Rotary or reciprocat-
ing instruments should be allowed to act freely
without touching the cavity walls. If touching
the cavity walls during instrumentation the
tapered instruments will be transported within
the root canal, and there will be a risk of creat-
ing a ledge or instrument fracture. The judi-
cious clinician also considers to reduce cusps
not only for good access but also to avoid frac-
ture of undermined tooth substance. The most
commonly needed cusps to be reduced are the
mesiobuccal on the upper molar and the buc-
cal on the lower molar.
8.7  ubber Dam and Aseptic
R possible to bring the file down in to the root fill-
Working Field
Next a rubber dam is placed to seal off the tooth
and to create an operating field with good asep-
tic properties. The rubber dam will render an
obstacle for saliva and microbes to enter into
the cavity and thereby give the operating dentist
a possibility to concentrate on eradicating the
root filling material and microorganisms within
the root canal [14]. This basic endodontic prac-
tice also enhances a good field of view and
93
comfort both for the patient and the operator.
Furthermore patient safety considerations
require the use of rubber dam in order to pre-
vent inhalation or ingestion. The isolated tooth
and the clamp and rubber dam fabric that sur-
rounds it should preferably be also be disin-
fected in order to further minimize risk of
contamination during the treatment. For exam-
ple, Möller suggests that the tooth is firstly
cleaned with 30% hydrogen peroxide and then
after disinfected with 10% iodine tincture [15].
R
Material
The aim is to remove the root filling material
together with necrotic pulp material and/or
embedded microorganisms in order to create
access to and enable a chemomechanical debride-
ment of the persisting biofilm. At the same time
the clinician must be prudent not to remove an
excess of root dentine that in turn can jeopardize
tooth survival in the long term. Depending on the
type and quality of the root filling, it will be dif-
ferences in difficulty and time for its removal. A
tooth that has been root filled with sealer and has
had excessive amount of leakage into the root
canal will be more easy to treat than a tooth root
filled with a densely compacted gutta-percha and
a hard-set sealer or one filled with a core material
such Thermafil™ or similar. It is a good clinical
practice to probe the root-filled canal with a file,
preferably a K-file 15, to feel to what extent it is
ing material. This will give an immediate indica-
tion on the quality of the seal. If the quality is
poor, the instrument will with ease penetrate into
the root canal.
8.8.1 Removing Gutta-Percha
and Sealer
The root filling removal is preferably done using
a stepwise “crown-down” strategy. It is strongly
94
recommended not to push or advance any rotary
instrument (burs, drills or root canal instruments)
beyond the length that has been first accessed by
a K-file 15 (corresponding to creating a “glide
path” in primary treatments).
A low-speed bur can be used to remove the
1–2 mm coronal part. In the next step, Gates
Glidden drills can be used to advance further
3–5 mm down the root canal. Rotary or recipro-
cating instruments may now be the perfect
choice to start to create a predetermined shape
of the root canal [16]. The file should be work-
ing in the centre of the material to avoid iatro-
genic damages. Many of the rotary file systems
have special retreatment files that are usually
stiffer and with non-cutting tip and also design
to be driven at a higher speed. However the pro-
cedure must be done with caution because of
the risk creating a ledge. By careful widening
of the coronal part of the root canal, a better
access to the apical part is created. Hand files,
preferably Hedstrom files, can be used but will
be more time consuming. Studies have shown
that rotary files remove root filling material and
prepare the root canal more quickly comparing
to hand-instrumentation. Rotary files will leave
more root filling materials behind inside the
root canal compared to hand files [17, 18].
Using rotary files often needs finishing off with
hand files to remove the middle and apical part
of the remaining gutta-percha. Ultrasonic files
may also be used for this purpose. Remnants of
sealer and cement are also easier removed by
ultrasonic without risk of removing more root
canal dentine.
8.8.2 Removing Plastic Carriers
Carriers covered by gutta-percha are easiest
removed by creating a space between the
material and root canal wall by inserting a
rotary file. The operator must be aware of the
risk that the pressure of the wall will control
the movements of the file and consequently
C. Ulin
use only light pressure in order to avoid creat-
ing a ledge or even perforation if canal is
curved.
8.8.3 Solvents
Solvents of gutta-percha and some sealers may
be a valuable adjunct in the retreatment proce-
dure when the root canal is densely packed or if
the root-filled canals are severely curved.
Guttasolv™, Endosolv™ and chloroform are
substances aimed for this purpose. Entering a few
drops of the solvent into the canal will soften the
gutta-percha, and the file can lodge in to the
material and follow its path. Since many of these
solvents contain chemicals potentially allergenic
or even carcinogenic, they should be considered a
working environmental hazard. The solvent also
creates a layer of gutta-percha on the root canal
walls that can be difficult to remove. Therefore
they should be used with caution and only when
considered necessary and not on a routine basis.
8.9 Instrumentation
of the Apical Part
When the previous root filling has been success-
fully removed the root canal instrumentation, I
made the same way as at a primary treatment.
The rotary or reciprocating instrument sequence
should be followed and working length measured
as recommended by the manufacturers. A con-
ceivable crown-root length is estimated by study-
ing the preoperative x-rays. An apex locator is
preferably used together with an intraoral x-ray.
Since the natural taper and possibly the constric-
tion of the root canal is damaged by previous
instrumentations, the apex locator will most
likely only show if inside or outside of the root
canal and not if the constriction is approaching as
normally is shown. The intraoral x-ray will add
information about the position and direction of
the file in the root canal. It will also give an idea
8  Non-surgical Retreatment
of the amount of root filling material still remain-
ing. After working length determination, the root
canal preparation continues accordingly to the
manual of the selected system and with adjust-
ments selected by the clinician for the individual
case. Preferably the apical dimension is above
ISO 20 to enable an effective removal of the
microorganisms to working length [19, 20]. If the
apical dimension needs to be enlarged, be aware
of that further enlargement gives higher risk of
perforation, zipping or transportation of the root
canal. Overinstrumentation has a negative impact
on the prognosis of endodontic retreatment and
should always be avoided [1].
8.10 O
 bstacles and Previous
Mishaps
8.10.1 Ledges
Often a ledge has been formed at the end of the
previous filling in the coronal, middle or apical
part of the root canal. Often the ledge is the
result of an inadequate angle of access to the
root canal during primary treatment. The ledge
can be passed and removed if access to the root
canal can be recreated. But, it may be very dif-
ficult or even impossible to pass a ledge.
However, the attempt should commence with a
pre-flaring of the coronal portion of the canal
giving the operator a chance to move the file in
the right direction. Usually the coronal part of
the canal needs to be widened even more but in
the opposite way of ledge. A K-10 file pre-bent
in its apical portion can be used to probe the
actual pathway. First, the file should be inserted
in the canal with the tip directed toward the
canal curvature. With very short strokes, the
clinician must search for a catch. If unsuccess-
ful, the file tip must be bended in a slightly
other way and the procedure is repeated until a
catch is felt. Then the file should be wiggled
back and forth maintaining a light apical pres-
sure. By moving the file in an up-and-­down
95
motion, the ledge is smoothed. A Hedstrom file
size 15–20 can also cautiously be used to estab-
lish a good glide path. When the block is
bypassed, copious sodium hypochlorite irriga-
tion should be used to remove debris.
8.10.2 Instrument Fractures
During the primary treatment, a root canal instru-
ment may have been fractured and left inside the
root canal. Instrument fracture occurs and it is
mostly due to a procedural error. The frequency
of instrument fracture during root canal treatment
has been reported to be 1–5% [21]. In retreatment
cases the root filling material can act as a block-
age of the file that will then not rotate freely and
as a consequence instrument fracture may also
occur during retreatment procedures. Removal of
fractured instruments can be difficult and is
depending on the location within the canal. If in
the coronal part before the apical curvature, the
instrument is more likely to be managed and
removed. The fractures occurring in the coronal
part are often due to excessive amount of apical
pressure, and if in the apical curvature, cyclic
fatigue is more likely to be the reason. Since the
file has been rotated and screwed inside the root
canal wall or root filling material, the principle is
that it has to be rotated out. The possibility to
access the coronal 1–2 mm of the broken instru-
ment needs to be assessed without major risk of
root perforation. A careful monitored preopera-
tive radiographic examination is therefore man-
datory. The access is made preferably by a blunt
instrument such as a bevelled Gates Glidden drill
which will create space for an ultrasonic thin tip
to reach in between the file and the root canal
wall. The ultrasonic tip is rotated around the bro-
ken instrument in a counterclockwise direction
removing small amounts of dentine and vibrating
the file until it comes loose. The procedure can be
very time consuming, and the necessity of its
removal and cost-benefit is to be considered [22]
(Fig. 8.3).
96 C. Ulin

a b

Fig. 8.3 (a) Tooth 34 is diagnosed with a fractured completed with a root filling. (d) Tooth 36 with an instru-
instrument that is judged to be removable without major ment fracture. Excessive removal of dentine and the risk
tooth loss. (b) The instrument was removed by using a of root perforation that are evident in the attempt to
thin ultrasonic tip in an anticlockwise motion. (c) Case remove the instrument are obvious
8  Non-surgical Retreatment
Fig. 8.4  A Stropko™ irrigation needle inserted in the
mesial-buccal root canal of 36 to working length
8.10.3 Perforations
Root canal perforations may be present in all
parts of the root canal system as a consequence of
mishaps during root canal therapy, post space
preparation or as a result of the extension of an
internal resorptive defect. A perforation that is
diagnosed during retreatment procedures has to
be analysed from different aspects. The location,
the size and the time that has elapsed since its
occurrence seem to be the most important issues
in order to make a decision whether to carry on
the treatment or not.
The prevailing view is that coronal perforations
have the worse prognosis [23]. At the coronal level
the inflammatory process that develops as a
response to the perforation might easily communi-
cate with the gingival pocket and establish a peri-
odontal defect. It is therefore favourable to seal any
perforation site at an early stage. A wide perforation
will be more difficult to seal than a small one. Non-
surgical repair is less affected by the location of the
perforation than a surgical approach to treatment,
which can be impossible in certain areas of the root.
The perforation also creates difficulty in
good asepsis during treatment whereby it has
to be controlled. The perforation can occur
during the access preparation and the root
canal ­instrumentation creating different size
and access to the perforated area.
Through the years numerous techniques and
materials to repair perforations have been described.
97
The perforation can be sealed off by using different
material that has hydrophilic properties in common.
MTA (mineral trioxide aggregate) and similar bioc-
eramic materials have shown good characteristics
for this purpose [24]. The sustainability over time is
not known. To be able to seal the perforation, obser-
vation and access is necessary and can be created by
good magnification and illumination. Another con-
sideration that needs to be taken into account is the
possibility to find the root canal in the perforated
area and the ability to successfully treat the root
canal after the perforation has been sealed off.
8.10.4 Overinstrumentation
Overinstrumentation is a type of perforation that
occurs at the site or in close proximity to the api-
cal foramen. It has a negative impact on the prog-
nosis of any endodontic treatment and should be
avoided. The natural constriction of the root
canal is damaged, and the natural stop for the root
canal preparation and root filling is injured. It
creates a possibility for exudate from the periapi-
cal area to enter the root canal system, feeding
any remaining microorganisms with nutrients
and at the same time allowing their waste prod-
ucts to evade into the periapical area and sustain
apical pathology.
Overinstrumentation can be avoided by using
an apex locator and working length x-rays to
hereby control the position of the file within the
canal. Apex locators are probably better than
x-rays to establish working length [25, 26].
8.11 Chemical Disinfection
8.11.1 Irrigation
The cultivable microbiological flora within a filled
root canal with apical periodontitis is different
comparing the non-root-filled canal. The strains are
fewer and the facultative anaerobes are predomi-
nant [27]. The microbes are situated on the root fill-
ing material, between the gutta-percha and root
canal wall as well as within the dentinal tubules, as
shown by Nair et al. [28, 29]. The mechanical
98
removal of the infected root filling material is made
by different instruments which will give access to
the dentine. The microbes are colonizing the sites
in form of a biofilm that helps them to protect
themselves from any attempts to kill them by the
use of chemicals. Consequently, the instrumenta-
tion and irrigation preferably should, as far as pos-
sible, disrupt the biofilm in order to make the
microbes more susceptible for the antiseptic effect
of the irrigant. Tissue-­dissolving features are there-
fore an essential requirement. The irrigant should
also be able to reach areas that cannot possibly be
touched by the instruments. Therefore low surface
tension is an important property.
The disinfection irrigant should be able to
kill or at least permanently inactivate the micro-
biota within the root canal system. At the same
time the agent has to be minimally toxic and not
cause tissue damage if accidentally entering
beyond the root canal system. Depending on the
irrigation device used, the solution is, more or
less, able to reach to the working length without
penetrating out in to the periapical area.
None of the currently used agents is fully sat-
isfying the above requirements.
8.11.1.1 Sodium Hypochlorite
(NaOCl)
Sodium hypochlorite has the ability to disrupt the
microbiological biofilm within the root-canal and
is a potential antiseptic agent. It has been exten-
sively used within endodontics and has good evi-
dence to be effective both in vitro and in clinical
studies [30]. Sodium hypochlorite is the main
irrigant of choice. Which concentration should be
used is up for further investigation. Higher con-
centration will increase the risk of severe toxic
effects if sodium hypochlorite is flushed through
the root apex. The treatment time will increase
with lower concentration but it can be safer [31].
Lower pH and higher temperature change sodium
hypochlorite to become more effective at lower
concentrations [32]. The optimal concentration,
pH and temperature are to be investigated.
Sodium hypochlorite is quickly inactivated by
the presence of oxidizable material such as den-
tine debris and organic material [33]. Therefore it
has to be replenished consistently.
C. Ulin
8.11.1.2 EDTA
Ethylenediaminetetraacetic acid binds calcium
and is used to remove the created smear layer
while instrumenting the root canal. Removing the
smear layer will create access for other irrigants
to the root dentine. The smear layer often con-
tains bacterial residue which preferably is eradi-
cated [34].
8.11.1.3 C  hlorhexidine and Iodine-­
Potassium Iodide
The understanding of the infected root canal and
the complexity of the biofilm have increased over
the last decades. The fact that particularly resis-
tant microorganisms have been found in root-­
filled teeth has enabled clinicians and researchers
to try using alternative or complementary irriga-
tion fluids either to more effectively remove
microbes initially or to enhance chemical disin-
fection in retreatment, disinfectants that can be
more effective to yeast and enterococcus than
NaOCl [35].
Chlorhexidine is used due its biocompatible
and binding properties to hydroxyapatite. Two
percent chlorhexidine gluconate is used, but its
lack of tissue-dissolving properties makes it not
useful as a sole irrigant but in conjunction with
NaOCl. Mixing NaOCl with chlorhexidine will
give para-chloroaniline as a precipitate. This
pink-coloured residue might cover the root canal
wall and prohibit the effect of NaOCl. The effi-
cacy of iodine-potassium iodide particularly tar-
geted against species of Enterococcus has found
some support both in vitro and clinical protocols
[35, 36]. Iodine-potassium iodide may be used
preferably after EDTA.
8.11.1.4 Irrigation Methods
Irrigating the root canal with a syringe and a nee-
dle is the most common technique. Needles of
different designs and material are available. The
scope is to find a technique that reaches the whole
space of the root canal and preferably its sur-
rounding crevices, bi-canals and isthmuses. At
the same time the irrigating method used should
also prevent the irrigation solution to penetrate
the root canal foramen, thereby risking damage
to surrounding tissue.
8  Non-surgical Retreatment
Gulabivala et al. [37] describe the fluid mecha-
nism of root canal irrigation where a greater taper and
a side-vented needle design will render the s­ afest and
best effect. Needle material of Ni-Ti will give the
device a possibility to follow the curvature of the root
canal and to reach the apical area (Fig. 8.4).
The activation of the irrigation solution by an
ultrasonic device will give agitation of the fluid
and create a higher possibility of tissue dissolv-
ing and a disruption of the biofilm within the root
canal [38].
8.12 Inter-appointment Dressings
8.12.1 Calcium Hydroxide
Calcium hydroxide in aqueous solution is a
strong alkaline solution with a pH of 12.5. It dis-
sociates into calcium and hydroxyl ions, of which
the later have strong antimicrobial effect when
into direct contact with the microflora. The
tissue-­dissolving effect of the hydroxyl ions is
also helpful in the disruption of the biofilm.
A classical study by Sjögren et al. [2] has
shown that inter-appointment dressing with cal-
cium hydroxide reduces the amount of microflora
within the root canal, although the antiseptic effect
of calcium hydroxide on facultative anaerobes
such as Enterococcus faecalis and yeast, for exam-
ple, Candida albicans, has been questioned [39].
However, in a retreatment case when treat-
ment often is complicated and time consuming
and therefore split into more than one session, it
seems advantageous to use calcium hydroxide to
prohibit growth of bacteria in the root canal
between visits. By filling the root canal with cal-
cium hydroxide, the nutritional supply to
microbes by inflammatory exudates from the
periapical area is blocked.
8.13 Root Filling
The procedure of placing a new root filling may
be as challenging as removing the old one.
Often, the anatomy of the root canal has been
transformed due to the treatment, and it is no
99
longer of a form that co-inherit with the gutta-
percha points manufactured to fit to a particular
file system. The apical size will often be larger
and the taper greater. The root filling technique
to be used needs to encounter these properties.
There is no evidence to suggest that any particu-
lar method or material systematically results in
better outcome than any other. However, the
variety of situations challenges the clinician to
adapt his or her technology to the various condi-
tions prevailing in each individual case. The key
to achievement is usually to first of all fill the
apical part and as a second step fill the coronal
part of the root canal. The apical part is prefer-
ably filled with a master point that correlates, as
well as possible, to the shape of the canal in this
apical 4–5 mm from the working length and the
rest of the root canal with a warm gutta-percha
technique. If the root canal has been retreated
and enlarged to a shape that co-inherits with a
particular instrument in a particular instrumen-
tation system, the canal is easiest filled with the
corresponding gutta-percha.
It has been shown that a root filling with a thin
layer of sealer gives the best properties when it
comes to leakage [40, 41].
After the root filling it is sometime advocated
to place a bacterial-tight filling 2–3 mm in the
coronal part of the root canal. This is to prevent
coronal leakage. There are no clinical studies to
support this recommendation [42]. Also, Ricucci
et al. [43] could show that teeth that had been
optimally endodontically treated and showed
good-quality root fillings did not show apical
pathologies when exposed to the oral cavity for a
long period of time.
After the root filling is made, the resaturation of
the coronal part is due to take place. The possibility
of a good coronal resaturation after the endodontic
treatment should always be taken into consider-
ation when doing the treatment planning.
8.14 Follow-Up
One of the best ways to know if your strategy has
been successful is to do your own follow-ups.
You thereby learn what challenges you have to
100
overcome and what you have to consider when
treatment planning is made. However the follow-­
ups must be made systematically and over a lon-
ger period of time in order not to jump into
conclusions or let rare individual events distort
the overall results.
Follow-up of endodontic treatment takes time.
The way of knowing if a treatment of an apical
periodontitis has been successful is to follow the
size of the periapical destruction on an x-ray. The
time between treatment and follow-up needs to
be as long as periapical changes are likely to be
seen. A first follow-up time of 12 months is
therefore often recommended. The follow-up
includes an anamnestic report of subjective and
objective symptoms and x-rays. The x-rays
should mimic the preoperative x-rays which
gives the best opportunity to follow changes in
the periapical area (Fig. 8.5). Strindberg in his
thesis from 1956 [44] could show that the most of
the periapical lesions that where less in size after
1 year usually had healed after 4 years. However,
to be able to confirm complete healing, it requires
follow-up periods that sometimes need to be
extended to the length of an entire professional
career (Fristad et al. [45]).
a b
Fig. 8.5 (a) Preoperative x-ray with clearly visible apical lesions. (b) 12-month follow-up after retreatment, perira-
dicular tissues exhibit clear signs of a bone healing process
C. Ulin
Take-Home Lessons
• Diagnosis, case selection and treatment
planning are the keys for successful out-
come of non-surgical retreatment.
• When retreating a root canal, the down-
side is that you are bound to someone
else’s pathway within the root canal.
• Create a treatment strategy and an
objective for the procedures, and make
sure to apprise your patient and get his
or her informed consent.
• Consider the challenges in removing the
root filling material and the more robust
microbial flora in advance.
• Do follow-ups to learn and to create an
individual evidence-based database.
Benchmark Papers
• Bergenholtz G, Lekholm U, Milthon R,
Heden G, Ödesjö B, Engström B.
Retreatment of endodontic fillings. Scand
J Dent Res. 1979;87:217–24.
8  Non-surgical Retreatment
• Ng YL, Mann V, Gulabivala K. A pro-
spective study of the factors affecting
outcome of nonsurgical root canal treat-
ment: part 1: periapical health. Int
Endod J. 2011;44:583–609.
• Molander A, Reit C, Dahlén G, Kvist T.
Microbiological status of root-filled
teeth with apical periodontitis. Int
10. Vertucci FJ. Root canal anatomy of the human per-
Endod J. 1998;31:1–7.
• Nair PN, Sjögren U, Krey G, Kahnberg
KE, Sundqvist G. Intraradicular bacteria
and fungi in root-filled, asymptomatic
human teeth with therapy-resistant peri-
apical lesions: a long-term light and
electron microscopic follow-up study. J
Endod. 1990;16:580–8.
The studies show that the prognosis of
root-filled teeth and its treatment are
dependent on the quality of the previous
made endodontic treatment. The influence
of procedural errors and lack of microbial
eradication are factors to be considered
and also to be able to control while per-
forming non-surgically retreatment.
References
1. Bergenholtz G, Lekholm U, Milthon R, Heden G,
Ödesjö B, Engström B. Retreatment of endodontic
fillings. Scand J Dent Res. 1979;87:217–24.
2. Sjögren U, Hägglund B, Sundquist G, Wing K. Factors
affecting the long-term results of endodontic treat-
ment. J Endod. 1990;16:498–504.
3. Ng YL, Mann V, Gulabivala K. A prospective study
of the factors affecting outcome of nonsurgical root
canal treatment: part 1: periapical health. Int Endod
J. 2011;44:583–609.
4. Swedish Council on Health Technology Assessment.
Methods of diagnosis and treatment in endodontics—
a systematic review. Report no. 203; 2010. p. 1–491.
http://www.sbu.se.
5. European Society of Endodontology, Patel S, Durack
C, Abella F, Roig M, Shemesh H, Lambrechts P,
Lemberg K. European Society of Endodontology
position statement: the use of CBCT in endodontics.
Int Endod J. 2014;47:502–4.
6. Del Fabbro M, Taschieri S. Endodontic therapy using
magnification devices: a systematic review. J Dent.
2010;38:269–75.
101
7. Del Fabbro M, Taschieri S, Lodi G, Banfi G, Weinstein
RL. Magnification devices for endodontic therapy.
Cochrane Database Syst Rev. 2009:8(3):CD005969.
https://doi.org/10.1002/14651858.CD005969.pub2.
8. Görduysus MÖ, Görduysus M, Friedman S.
Operating microscope improves negotiation of sec-
ond mesiobuccal canals in maxillary molars. J Endod.
2001;27:683–6.
9. Kulid JC, Peter DD. Incidence and configuration of
canal systems in the mesiobuccal root of maxillary
first and second molars. J Endod. 1990;16:311–7.
manent teeth. Oral Surg Oral Med Oral Pathol.
1984;58:589–99.
11. Main C, Mirzayan N, Shabahang S, Torabinejad
M. Repair of root perforations using mineral trioxide
aggregate: a long-term study. J Endod. 2004;30:80–3.
12. Krupp C, Bargholz C, Brüsehaber M, Hülsmann
M. Treatment outcome after repair of root perfora-
tions with mineral trioxide aggregate: a retrospective
evaluation of 90 teeth. J Endod. 2013;39:1364–8.
13. Schwandt NW, Gound TG. Resorcinol-formaldehyde
resin “Russian red” endodontic therapy. J Endod.
2003;29:435–7.
14. Lin PY, Huang SH, Chang HJ, Chi LY. The effect
of rubber dam usage on the survival rate of teeth
receiving initial root canal treatment: a nationwide
population-­based study. J Endod. 2014;40:1733–7.
15. Möller ÅJR Microbiological examination if root
canals and periapical tissues of human teeth. Scand
Dent J. 1966;74(5 and 6).
16. Molander A, Caplan D, Bergenholtz G, Reit C. Improved
quality of root fillings provided by general dental prac-
titioners educated in nickel-titanium rotary instrumenta-
tion. Int Endod J. 2007;40:254–60.
17. Betti LV, Bramante CM. Quantec SC rotary instru-
ments versus hand files for gutta-percha removal in
root canal retreatment. Int Endod J. 2001;34:514–9.
18. Bernardes RA, Duarte MA, Vivan RR, Alcalde MP,
Vasconcelos BC, Bramante CM. Comparison of three
retreatment techniques with ultrasonic activation in
flattened canals using micro-computed tomography
and scanning electron microscopy. Int Endod J. 2015;
https://doi.org/10.1111/iej.12522. Epub ahead of print.
19. Huang TY, Gulabivala K, Ng YL. A bio-molecular
film ex-vivo model to evaluate the influence of canal
dimensions and irrigation variables on the efficacy of
irrigation. Int Endod J. 2008;41:60–71.
20. Clars Dalton B, Örstavik D, Philips C, Petiette M,
Trope M. Bacterial reduction with nickel-titanium
rotary instrumentation. J Endod. 1998;11:763–7.
21. Shen Y, Coil JM, McLean AG, Hemerling DL,
Haapasalo M. Defects in nickel-titanium instruments
after clinical use. Part 5: single use from endodontic
specialty practices. J Endod. 2009;10:1363–7.
22. Suter B, Lussi A, Sequeira P. Probability of remov-
ing fractured instruments from root canals. Int Endod
J. 2005;38:112–23.
23. Petersson K, Hasselgren G, Tronstad L. Endodontic
treatment of experimental root perforations in dog
teeth. Endod Dent Traumatol. 1985;1:22–8.
102
24. Guneser MB, Akbulut MB, Eldeniz AU. Effect of
various endodontic irrigants on the push-out bond
strength of biodentine and conventional root perfora-
tion repair materials. J Endod. 2013;39:380–4.
25. Ravanshad S, Adl A, Anvar J. Effect of work-
ing length measurement by electronic apex loca-
tor or radiography on the adequacy of final working
length: a randomized clinical trial. J Endod. 2010;36:
1753–6.
26. Williams CB, Joyce AP, Roberts S. A comparison
between in vivo radiographic working length deter-
mination and measurement after extraction. J Endod.
2006;32(7):624.
27.
Molander A, Reit C, Dahlén G, Kvist
T. Microbiological status of root-filled teeth with api-
cal periodontitis. Int Endod J. 1998;31:1–7.
28. Nair PN, Sjögren U, Figdor D, Sundqvist G. Persistent
periapical radiolucencies of root-filled human teeth,
failed endodontic treatments, and periapical scars.
Oral Surg Oral Med Oral Pathol Oral Radiol Endod.
1999;87:617–27.
29. Nair PN, Sjögren U, Krey G, Kahnberg KE, Sundqvist
G. Intraradicular bacteria and fungi in root-filled,
asymptomatic human teeth with therapy-resistant peri-
apical lesions: a long-term light and electron micro-
scopic follow-up study. J Endod. 1990;16:580–8.
30. Zendher M. Root canal irrigants. J Endod. 2006;32:
389–98.
31. Bystrom A, Sundqvist G. The antibacterial action of
sodium hypochlorite and EDTA in 60 cases of end-
odontic therapy. Int Endod J. 1985;18:35–40.
32. Moorer WR, Wesselink PR. Factors promoting the
tissue dissolving capability of sodium hypochlorite.
Int Endod J. 1982;15:187–96.
33. Haapasalo HK, Sirén EK, Waltimo TM, Örstavik D,
Haapsalo MP. Inactivation of local root canal medi-
caments by dentine: an in vitro study. Int Endod
J. 2000;33:126–3.
34. Sen BH, Wesselink PR, Türkün M. The smear layer:
a phenomenon in root canal therapy. Int Endod
J. 1995;28:141–8.
C. Ulin
35. Portenier I, Haapasalo H, Orstavik D, Yamauchi M,
Haapasalo M. Inactivation of the antibacterial activity
of iodine potassium iodide and chlorhexidine diglu-
conate against Enterococcus faecalis by dentin, den-
tin matrix, type-I collagen, and heat-killed microbial
whole cells. J Endod. 2002;28:634–7.
36. Peciuliene V, Reynaud AH, Balciuniene I, Haapasalo
M. Isolation of yeasts and enteric bacteria in root-­
filled teeth with chronic apical periodontitis. Int
Endod J. 2001;34:429–34.
37. Gulabivala K, Ng YL, Gilbertson M, Eames I. The
fluid mechanics of root canal irrigation. Physiol Meas.
2010;31:49–84.
38. Stojicic S, Zivkovic S, Qian W, Zhang H, Haapasalo
M. Tissue dissolution by sodium hypochlorite: effect
of concentration, temperature, agitation, and surfac-
tant. J Endod. 2010;36:1558–62.
39. Vianna ME, Gomes BP, Sena NT, Zaia AA, Ferraz
CC, de Souza Filho FJ. In vitro evaluation of the
susceptibility of endodontic pathogens to calcium
hydroxide combined with different vehicles. Braz
Dent J. 2005;16:175–80.
40. De-Deus G, Coutinho-Filho T, Reis C, Murad C,
Paciornik S. Polymicrobial leakage of four root
canal sealers at two different thicknesses. J Endod.
2006;32:998–1001.
41. Wu MK, Wesselink PR, Boersma J. A 1-year follow-
­up study on leakage of four root canal sealers at dif-
ferent thicknesses. Int Endod J. 1995;28:185–9.
42. Yamauchi S, Shipper G, Buttke T, Yamauchi M, Trope
M. Effect of orifice plugs on periapical inflammation
in dogs. J Endod. 2006;32(6):524.
43. Ricucci D, Gröndahl K, Bergenholtz G. Periapical status
of root filled teeth exposed to the oral environment by
loss of restorations or caries. Oral Surg. 2000;90:354–9.
44. Strindberg LZ. The dependence of the result of pulp
therapy on certain factors. Acta Odontol Scand.
1956;14(Suppl 21):1–175.
45.
Fristad I, Molven O, Halse A. Nonsurgically
retreated root filled teeth. Radiographic findings after
20–27 years. Int Endod J. 2004;37(1):12–8.
 Prognosis
9
Thomas Kvist

Evidence based practice must be based on practice based evidence.

—Inspired by Sackett et al.
in “Evidence based medicine—What it is—and what it isn’t.” 1996

Comparative experience is a prerequisite for experimental and scientific medicine,

otherwise the physician may walk at random and become the sport of a thousand
illusions.
Claude Bernard—“Introduction a l’étude de la medicine expérimentale.” 1866

Abstract
For any human ailment, outcome assessment is a major step. In this chap-
ter the prognosis of persistent apical periodontitis in root-filled teeth is
discussed. However, the focus is on critically examining the evidence con-
cerning this condition and giving a brief overview of the challenges the
discipline of endodontics is facing for future clinical research in order to
close some of the essential “knowledge gaps” regarding apical periodonti-
tis in root-filled teeth.

9.1 Introduction asked questions concerned with the future of a

When people are diagnosed with a disorder, they
have many questions about how this will affect
them in the future. This also holds true for apical
periodontitis in root-filled teeth. And perhaps this
diagnosis will generate extra many anxieties
since the condition is preceded by a previous
treatment attempt that has somehow “failed” in
achieving one or two of the fundamental objec-
tives of root canal treatment. Some frequently
persistent apical periodontitis in root-filled teeth
are likely to be as follows:
• How does this problem affect my risk of loos-
ening the tooth?
• Will it affect my general health?
• What different options do I have?
• How likely is it that retreatment will cure the
tooth?
• Would it be a better idea to take the tooth out?
• If so, can it and should it be replaced?

What information should the dentist provide

T. Kvist, DDS, PhD
Department of Endodontology, Institute of
Odontology, The Sahlgrenska Academy,
University of Gothenburg, Göteborg, Sweden
e-mail: kvist@odontologi.gu.se
and should any information be withheld from the
patient? This issue is more deeply discussed in
Chap. 6: Decision making. This chapter will crit-
ically discuss the present evidence base for the

© Springer International Publishing AG 2018 103

T. Kvist (ed.), Apical Periodontitis in Root-Filled Teeth,
https://doi.org/10.1007/978-3-319-57250-5_9
104
information we need to be able to convey to our
patients in the situation of facing a root-filled
tooth with persistent apical periodontitis.
9.2  linical Research: The Basis
C when it is deceiving. Therefore, studies aiming to
of Statements
About Prognosis
Prognosis is a prediction of the future course of a
condition following its onset with or without
treatment. Studies on prognosis should tackle
and give solid answers to clinical questions. A
group of patients with a condition such as apical
periodontitis in a root-filled tooth or a particular
treatment in common, such as endodontic retreat-
ment, are identified and followed forward in time.
Clinical outcomes are measured. Often, condi-
tions that are associated with a given outcome,
i.e. prognostic factors, are sought. The prognosis
of a disease without interference is termed the
natural history of disease. The term clinical
course has been used to describe the evolution
(prognosis) of disease that has come under medi-
cal or dental care and treated in a variety of ways
that might affect the subsequent course of events.
It is a difficult but indispensable task to make
clinical research on these issues. The studies may
be affected by biasses that have to be controlled
ce
en
d
vi
fe
lo
ve
Fig. 9.1  The “evidence
Le
pyramid” illustrates how
different types of studies
basically are assessed
for their potential ability
to provide different
w
levels of scientific
Lo
evidence for a specific
clinical question
T. Kvist
as far as possible. The objective is to predict the
future of individual patients and their affected
teeth as closely as possible. The intention in the
clinical setting is to avoid stating needlessly
vague prognoses and answer with confidence
answer the clinical questions must be scrutinized
for quality [1, 2].
9.2.1 Methods for Clinical Research
Assessment prognosis can be carried out in a
number of ways. Evidence-based medicine/den-
tistry seeks to prioritize information in a hierar-
chy of evidence by study design from the most
biassed to the least biassed. Knowledge about
the biology of disease, in vitro studies and stud-
ies in models, cadavers or animals are certainly
valuable to the discipline in many aspects. Yet
this kind of research, even if skilfully per-
formed, will very sparsely, if at all, contribute to
evidence-­ based answers to clinical questions.
Because of the complex biology of human
beings, the variation among individuals, the
influence of chance and the interaction between
doctors and patients, valid answers to the clini-
cal questions, must be searched for in clinical
research (Fig. 9.1).
gh
Hi
Meta-analyses of RCTS.
Randomized controlled trials.
Prospective cohort studies.
Case-control studies.
Case series.
Case reports.
Studies in models and in animals.
9 Prognosis
9.2.1.1 Case Reports
A simple way of clinical research is the descrip-
tion of clinical cases, which may show unique or
unusual features of the condition or outcome of
therapy. Such case analyses are quite common in
endodontic journals and at congresses. It is the
only mean by which specific or even unexpected
clinical events can be described and are therefore
important as further examinations may be initi-
ated. The limitation of case presentations is obvi-
ous. Information from a single case cannot be
transferred to other patients because of the wide
variation and many factors not controlled or
checked for.
9.2.1.2 Case Series
Series of cases provide better information.
Larger groups of patients with a particular dis-
ease or condition subjected to treatment are stud-
ied. The involvement of chance can be checked
by statistical analysis. Yet, the efficiency of the
clinical procedure cannot be ascertained to be
better or equal to any other method if no control
group is available. Sometimes, inclusion of data
from prior studies or other authors’ results is
used for comparison purposes. However, this
procedure will not bring particular strong evi-
dence to the report, as the conditions, under
which the studies were conducted, may not have
been very similar.
9.2.1.3 Case-Control Studies
Case-control studies also belong to the arsenal of
methods of observational studies available for
clinical research. A case-control study assesses
persons with a condition (or another outcome
variable) of interest and a suitable control group
of persons without the condition (comparison
group, reference group). The potential relation-
ship of a suspected risk factor or an attribute to
the condition is examined by comparing the
affected and non-affected subjects with regard to
how frequently the factor or attribute is present
(or, if quantitative, the levels of the attribute) in
105
each of the groups. For an example Kim et al. [3]
studied the influence of a presence of an isthmus
area when performing endodontic surgery in
maxillary and mandibular first molars. Of the 106
teeth, 72 teeth had an isthmus, and 34 did not.
The analysis revealed that the cumulative 4 years
survival rate after surgery was 61.5 and 87.4%,
respectively, when an isthmus was present and
absent.
9.2.1.4 Prospective Cohort Studies
Retrospective studies of any nature will not do
well as they suffer the risk of having limited or no
control of a number of aspects relevant to out-
come. To provide good evidence, clinical research
requires being prospective. A type of clinical
research design that has gained increased atten-
tion in recent years is the prospective cohort
observational study [4]. Cohort refers to a group
of patients. This study design implies that a large
sample of patients can be treated and then be
assembled for follow-up examinations. An
important factor of such studies is that a fairly
large number of clinics have to be included in
order for the report to gain generalizability. Yet
the study design has the advantage to allow inclu-
sion of general dentists and therefore will give
availability to aspects on endodontics at which
we have very little understanding.
Database-Based Studies
Given that a comprehensive registry of patients
under treatment currently is under way in many
countries, valuable basic information on the effi-
ciency of procedures can be gained [5]. However,
since validated data on diagnoses, treatment pro-
tocols and other essential details often are lack-
ing, this type of study cannot give answers to
more detailed clinical questions.
9.2.1.5 Randomized Controlled Trial
Randomized controlled trials (RCTs) are genu-
ine clinical experiments. Two or more groups of
subjects receive different measures, are followed
106 T. Kvist

forward in time and are compared using an out-
come assessment. The distinguishing feature of
an RCT is that patients are allocated to test and
control procedures in a strictly randomized man-
ner. This kind of study usually observes the effect
of a single variable only. All other variables (back-
ground variables, confounders) are controlled by
the chance effect in both the test and the control
group. To be appropriate RCT requires further a
precalculated minimal number of patients to be
included in order to ensure that a statistical sig-
nificant difference between the test and the con-
trol procedure can be ascertained. RCTs are
indeed powerful tools as many of the biasses that
affect nonrandomized trials can be eliminated.
In Fig. 9.2 the set-up of three different RCTs
is sketched. From a scientific perspective, these
would be highly desirable to implement in order
to provide significantly better knowledge of the
prognosis for apical periodontitis in root-filled
teeth.
Yet, the long time they require to conduct
and the high costs make RCTs difficult to per-
form. On a careful consideration, we must real-
ize that RCTs may not attain evidence-based
research very easily for important clinical
questions for endodontic retreatment. In fact,
RCTs are ideal for testing the effects of drugs
because it can use placebo and be controlled
double blinded. However, for assessment of
important aspects of surgical interventions,
such as endodontic retreatment procedures,
several predicaments occur. For example, it
would probably be difficult to enrol a sufficient
number of root-filled teeth with apical peri-
odontitis similar enough to be randomized to
extraction and implant or non-surgical retreat-
ment. But even if possible, it is likely that the
values and expectations of the patients, the
dentists and the evaluators could influence the
assessment of the outcome since neither
patients, dentists nor evaluators can be blinded

a Treatment procedure:
surgical retreatment

+ Healed

TX - Not healed

All patients with

Comparison of outcome of
the condition of
interest:
interest:
Sample Randomisation healing of apical periodontitis
root filled tooth
and apical
periodontitis

CTR + Healed

Control procedure:
non-surgical retreatment - Not healed

Fig. 9.2  Basic designs of three RCTs that should be
highly preferred to be carried out in order to increase the
level of scientific evidence for crucial questions regarding
apical periodontitis in root-filled teeth. (a) Comparing the
outcome of periapical tissues following surgical versus
non-surgical retreatment. (b) Comparing “functional
retention” following surgical retreatment versus extrac-
tion and replacement with an implant. (c) Comparing
important outcomes following retreatment versus “no
intervention”
9 Prognosis 107

b
Treatment procedure:
surgical retreatment

+ Functional
retention

TX - Loss of tooth

All patients with

the condition Comparison of outcome of
of interest: interest:
root filled tooth Sample Randomisation functional retention
and apical
periodontitis

CTR + Functional
retention

Control procedure: - Loss of implant

extraction and
replacement with an
implant

c
Treatment procedure:
retreatment

TX

Comparison of outcomes of
All patients with interest:
the condition of
interest:
root filled tooth • Tooth retention and function
Sample Randomisation
and asymptomatic • Influence of general health
apical • Pain and discomfort
periodontitis • Progression or healing of lesion
• Costs

CTR

Control procedure:
no intervention

Fig. 9.2 (continued)

to the allocated treatment (Fig. 9.2a, b). Another
concern is the long follow-­up time necessary to
a meaningful outcome comparison assessment.
If, for example, surgical or non-surgical inter-
vention is compared to extraction implant
placement in a randomized manner (Fig. 9.2b),
the crucial and interesting comparison is at
hand only after several years [6, 7].
Finally, RCTs for the most central clinical
questions have ethical challenges. For exam-
ple, perhaps the utmost important and vital
RCT would be to randomly allocate ­individuals
108
with asymptomatic apical periodontitis in root-
filled teeth to retreatment or monitoring the
condition without intervention (Fig. 9.2c). The
many difficulties involved in investigating the
most relevant clinical questions with an RCT
design have resulted in a limited number of
publications over the years. And most of them
are investigating relatively trivial issues [7] but
still without evidence-based answers even to
these.
9.2.1.6 Systematic Reviews
and Meta-Analyses
There are several approaches to summarize the
scientific basis for clinical practice. In recent
years, when thanks to developments of com-
puter and IT technology, large amounts of data
and literature can be both searched and retrieved
within a very short period of time, so-called sys-
tematic reviews have become increasingly com-
mon. By definition the review must be conducted
in a systematic way and contain at least four
components:
• Formulation of a clear question (or several
clear questions)
• Searching and identifying relevant research
• Collecting and critically analysing included
reports
• Summarizing results, making conclusions and
giving recommendations as to how to proceed
in the clinical setting
Systematic reviews are a special type of
review article, which can be considered to pro-
vide the highest level of evidence when sev-
eral similar RCTs on the same clinical question
T. Kvist
are utilized. Meta-analysis is a specialized
type of systematic review, where data are
pooled for a quantitative rather than a qualita-
tive analysis. This type of study can provide
the highest level of evidence, if the report is
limited to proper RCTs. However, a meta-
analysis cannot give a higher-quality evidence
than that which exist in the studies included in
the analysis.
9.2.2 A
 ssessing the Quality
of Available Research
In assessing the scientific quality of a clinical
research report, a number of factors are essential.
These aspects sum up into an account of internal
validity (the degree to which the results of a study
are correct for the sample of patients being stud-
ied) and the extent of external validity (generaliz-
ability) (the degree to which the results of an
observation hold true in other settings).
9.2.2.1 The PICO Concept
A good starting point to use for evaluating the
quality of a RCT is the PICO concept (Fig. 9.3).
It stands for population, intervention, control
procedure and outcome measure. The PICO
model can also be adopted for other types of
studies both for planning and for evaluating indi-
vidual studies, for example, when pursuing a
systematic review. At each “letter” there are
however many pitfalls that have to be avoided if
the study is to produce results of high internal
and external validity. PICO helps the researcher
or evaluator to systematically evaluate all the
phases of a study.
9 Prognosis 109

Population (P) Humans

• Root filled permanent teeth with asymptomatic apical
periodontitis 4 years after root canal treatment
• “Healthy” patients
• No caries or any other indication for further
intervention than persistent apical periodontitis
• Maximum one tooth/individual

Intervention (I) • Surgical root canal retreatment

• Surgical procedure using surgical microscope,
ultrasonic preparation and retro-filling with
MTA

Control (C) • No intervention

Outcome (O) 5 Years after treatment

• General health evaluation
• Tooth retention and function
• Patients’ evaluation of pain and discomfort
• Healing of apical periodontitis
• Total costs of each option

Fig. 9.3  The PICO concept applied for a RCT on important outcomes following retreatment versus “no intervention”
of root-filled teeth with asymptomatic apical periodontitis

9.2.2.2 Biasses in Clinical Research Sampling Bias

“Bias” is the term for a process at any stage of
inference tending to produce results and conclu-
sions that deviate from the true condition system-
atically. The quality of studies is subject to the
risk of being limited by numerous biasses. The
problem affects all kinds of reports including the
top articles in the evidence pyramid (prospective
cohort studies and RCTs) (Fig. 9.1). Biasses are
in four wide-ranging categories, viz. sampling
bias, selection bias, measurement bias and con-
founding bias [8].
Sampling bias arises when the sample of patients
is systematically different from those suitable for
the research question or the clinical use of the
information. For example, studies on the outcome
of endodontic retreatment have exclusively been
conducted in dental schools or specialist centres.
An important question is if these teeth are repre-
sentative of “root filled teeth with apical periodon-
titis” in general? Perhaps the teeth treated are a
sample of “suitable teeth” for referral and treat-
ment [9]. When reporting a clinical study, it is
110
always important to accurately describe the inclu-
sion and exclusion criteria for the subjects included
in the study.
Selection Bias
Selection bias arises when comparisons are
made on groups that differ in ways, other than
the factors under study. Groups of patients often
differ in many ways by age, sex, general health
and severity of disease. If we compare the out-
come of two groups that differ on a specific issue
of interest (e.g. surgical versus non-surgical
retreatment) but are dissimilar in any other way
and this difference itself is related to the out-
come of interest, the comparison between the
groups will be biassed. Thus, little can be con-
cluded from the results. In our example of surgi-
cal versus non-­ surgical retreatment, if “easy
cases with easy access” (perhaps premolars and
incisors) are more frequent in the non-surgical
group, the outcome may be systematically better
or poorer. Randomization is the best way to
overcome these difficulties. The randomization
procedures must then be performed without
manipulation and be clearly described in the
methods of the study.
Measurement Bias
Measurement bias arises, when the means or
methods of measurement are different among the
groups of patients. This is the reason why histori-
cal comparisons (data from other reports) often
are invalid. Another problem may be the lack of
common criteria for evaluating the outcome. For
example, when comparing results of non-surgical
and surgical endodontic procedures, there is no
mutually recognized way to interpret “healing
from “no healing” in radiographs. The problem
with intra- and interobserver variation must also
be handled in an appropriate way by using
blinded and independent evaluators.
Confounding Bias
Confounding bias arises when two factors are
associated with each other, and the effect of one
is confused with or distorted by the effect of
another, not measured or controlled, factor. For
T. Kvist
example, if survival of a group of teeth, which
had a surgical retreatment, is compared with a
group where non-surgical retreatment was con-
ducted. Perhaps the result showed a significantly
higher survival after 10 years in the non-­surgical
retreatment group. Yet in further analyses of the
data, it was revealed that in the non-­ surgical
group, a new crown was placed more frequently
postoperatively than in the surgical group.
Consequently, it may be that the placement of the
new crown rather than the choice of treatment
explained the observed difference in outcome.
9.2.2.3 Statistical Analysis
The observed difference between the intervention
and the control group in a clinical study cannot
be expected to represent a true difference because
of the random variation between the groups being
compared. Statistical tests help to estimate how
well the observed difference approximates the
real difference.
There are two main approaches to assess the
role of chance in clinical studies, hypothesis test-
ing and estimation. With hypothesis testing sta-
tistical tests are conducted to calculate the
probability that the observed result was by
chance. This calculation may result in both false-­
positive and false-negative statistical errors. The
type I error relates to the conclusion of an effect
of the tested procedure that does not exist in real-
ity, while a type II error means that there is a
positive effect, which data failed to show. The
acceptable size of the risk for errors of both types
is a value judgement. It is customary to set the
risk for type I errors to 1 or 5%. For type II errors,
a considerably higher risk of error is normally
accepted, and the probability is usually given at
20%.
In order to avoid statistical errors, sample
size is an important concern. A calculation
(“power analysis”) should therefore be carried
out prior to the onset of a study to analyse how
many patients should be needed to avoid a type
II error. Generally speaking more patients are
required to detect small differences than if large
differences are in centre of attention. However,
even with a proper “power analysis” and
9 Prognosis
respected in the implementation of the study,
researchers take the risk of being mistaken every
fifth time a study does not show a statistically
significant difference (type II error 20%). If a
statistically significant difference is found, the
risk of being mistaken is, however, only one
(type I error 1%) or five (type I error 5%) in
hundred instances.
These potential errors in hypothesis testing
have made many researchers and statisticians to
prefer estimation statistics [10]. This type of con-
trol for chance uses the data to define the range of
values that is likely to include the true effect.
Point estimates (the observed effect) and confi-
dence intervals are used here. They emphasize
the size of the effect and not the p-value and show
the range of plausible values.
9.2.2.4 Statistical and Clinical
Significance
It is important to realize that statistical difference
only tells if the difference observed is likely to be
true, but not that it is important or large. In clini-
cal research, it is therefore highly important to
clear the distinction between statistical and clini-
cal significance. Even with a small p-value (the
risk of a type I error), it is not necessary so that
the difference is clinically important. In fact,
completely trivial differences in well-designed
studies may be highly significant on a statistical
level, if a large number of patients were studied,
but the difference may be clinically of little or no
relevance.
9.2.2.5 Loss to Follow-Up
A serious problem in clinical research is the loss
of patients to follow-up. Numerous examples
exist in the endodontic retreatment literature,
where too many patients were unable to attend
the control. Short follow-up periods of 1 and
2 years may do well, but once extended, patient
losses increase, and the results can easily
become invalidated. Thirty per cent is a com-
mon figure used in systematic reviews as the
highest loss of patients for recall in a study to be
included in a systematic review. However, while
5 and 10 years follow-up data are highly desir-
111
able, few, if any study, have been published in
the focus area of this book that reach this high
number of attendance at this point postopera-
tively [7]. Losses of patients may be due to vari-
ous reasons. A most important, which normally
cannot be checked, is that the treatment failed
and resulted in a decision of the patient not to
attend the recall or to take the tooth out by
another dentist.
9.2.2.6 Clinically Relevant Outcomes
Because of their selection and training, dentists in
general and scholars in particular tend to prefer
the kind of precise measurements the physical and
biologic sciences provide. They discount others
especially for research. Within endodontic retreat-
ment there are numerous studies concerned with
the quality of root fillings and disappearance or
reduction of periapical radiolucencies. Yet, relief
of symptoms, retaining a functional and asymp-
tomatic tooth in the long term and the feeling of
well-being are among the important outcomes of
dental care. These are central concerns of patients
and dentists alike. To guide clinical decisions,
reports of clinical research should therefore focus
on more patient-centred outcomes.
9.2.2.7 Efficacy and Effectiveness
Results of clinical studies must be judged in rela-
tion to two broad questions. Can the diagnostic
method or treatment work under ideal circum-
stances? And does it work in ordinary settings?
The terms efficacy and effectiveness have been
applied here. It may be a question of the dentist’s
experience, ability, and attention to detail, meticu-
lousness and skill. It is seldom possible to assess
the extent such factors influence the results in
treatment studies and clinical evaluations. It is,
however, reasonable to assume that in a clinical
discipline such as endodontics, these factors are
important, because of the technically complicated
nature of many procedures. In endodontic retreat-
ment, the diagnosis and treatment is often com-
plex, and the influence of the operator on the
results cannot be overvalued. So far most clinical
studies have been conducted in academic or
­specialist settings (efficacy), where devices that
112
s­ubstantially facilitate the technical procedures
are widely spread and will affect the outcome rate
of retreatment procedures. For the future, it is
important that clinical research also is conducted in
general practice where most of teeth with persistent
apical periodontitis are managed (effectiveness).
9.2.2.8 Publication Bias
Dentists and researchers prefer good news. It is
much less appealing to author and publish an article
where the results are disappointing, negative or per-
haps much worse than previously published, than to
describe successful treatments. It must be realized
that research projects that attain publication status
are a biassed sample of all researches being con-
ducted. Hence, it is not unreasonable to assume that
our inclination for “good” and positive results leads
to a biassed publication of articles. For example,
imagine a group of clinicians, who have performed
an excellent study from a methodological point of
view about surgical endodontics. But they had a
healing rate of 50% in both the intervention and
control group. With what degree of enthusiasm will
the writing of this article begin? What will the reac-
tion be of journal editors and reviewers, if the article
after all was written and submitted?
9.3  tatements About Prognosis
S has not been able to seek further dental care.
About Apical Periodontitis
in Root-Filled Teeth
Unfortunately, in recent years, careful analyses
of the scientific basis for the methods that we
apply in endodontics as a clinical discipline
within dentistry have demonstrated extensive
shortcomings [11]. The situation is worrying for
diagnostic and treatment procedures as well as
for evaluation of the results of the methods.
It is generally acknowledged that teeth with
inflamed, necrotic and infected pulps can be
treated endodontically to achieve a healthy out-
come that can last many years. This bulk of
knowledge has repeatedly been presented in sci-
entific journals reviews and textbooks of end-
odontics. There are, however, few clinical studies
of high scientific quality [11].
T. Kvist
It also well-known that a “successful” out-
come is not always the case and that great many
patients present with asymptomatic persistent
signs of apical periodontitis. Statements of the
prognosis of this condition, which is the subject
of this book, suffer from an even greater lack of
evidence than that of primary root canal treat-
ments [7, 11–17]. And this applies both to the
effects of inaction (natural course) and the vari-
ous forms of treatment (clinical course).
9.3.1 N
 atural History of Apical
Periodontitis in Root-Filled
Teeth
The prognosis of a disease without interference
is termed the natural history of disease. Great
many root-filled teeth with apical periodontitis
will not be detected and diagnosed. They remain
unrecognized, because they are asymptomatic,
and even if detected they are not considered for
any intervention. Even, when root-filled teeth
cause mild pain, tenderness or fistulas are con-
sidered among the ordinary discomforts of daily
living. Or, the patient may be suffering both
pain and other symptoms for a prolonged period
of time but because of economic limitations, it
Remarkably little is known about the frequency
of pain and other symptoms as well as general
health hazards from root-filled teeth with apical
periodontitis (see Chap. 4: Consequences).
9.3.2 Clinical Course
The term clinical course has been used to describe
the evolution (prognosis) of disease that has
come under medical or dental care and treated in
a variety of ways that might affect the subsequent
course of events.
9.3.2.1 Retreatment
Chronic periapical asymptomatic lesions as
well as exacerbation or aggravation of persis-
tent apical periodontitis of root-filled teeth
9 Prognosis
may be cured by endodontic non-surgical or
surgical retreatment. There is insufficient sci-
entific support on which to determine whether
surgical and non-­surgical retreatment of root-
filled teeth gives systematically different out-
comes, both in the short and long term, with
respect to healing of apical periodontitis or
tooth survival [6, 7, 11].
During the last 20-year period, clinical end-
odontics has undergone a technological develop-
ment of rare unprecedented proportions. Rotary
instrumentation alloys have facilitated the pains-
taking work of removing old root fillings. Super
flexible properties of nickel-titanium instruments
allow root canals to be successfully instrumented
in a predictable way.
An equally significant addition to the end-
odontic armamentarium is the operating micro-
scope. With its help, previously untreated parts of
the root canal system can be visualized during
both surgical and non-surgical retreatment.
Parallel with the increasing use of the operating
microscope, a wide range of specialized instru-
ments have been developed, primarily in connec-
tion with surgical endodontics. In addition, the
introduction of ultrasonic instruments has further
improved treatment options.
Much effort has also been expended on trying
to develop new materials for safer retrograde
sealing of the root canal. Alternatively, techno-
logical achievements have significantly changed
the clinical routine of endodontic retreatment
procedures.
In environments of clinical excellence, non-­
surgical as well as surgical retreatment has
shown favourable outcomes on the periapical tis-
sues of “endodontic failures” [17, 18]. It is likely
that more root-filled teeth with apical periodon-
titis can be successfully treated surgically com-
pared with reports from before microsurgical
techniques were used [17, 19]. Frequency of
periapical healing after retreatment has been
reported to reach approximately 80–90% for
both methods [17, 18]. High-quality clinical
studies of long-­term follow-up of teeth that have
undergone surgical-or nonsurgical retreatment
are so far rare.
113
9.4 Endodontic Retreatment
Need for Research
In the future, there is a need for more high-­quality
research on natural as well as clinical course of
apical periodontitis in root-filled teeth.
Endodontic retreatment methods need to be eval-
uated whether they are effective in terms of pro-
moting healing of apical periodontitis and
resulting in long-term tooth survival. In this con-
text, it is also important to evaluate the alterna-
tives to retreatment, extraction and replacement
by a tooth-supporting bridge or an implant from
the perspective of quality of life and cost-­
effectiveness [9, 20].
9.5  hort Answers to Clinical
S
Questions
This chapter shows that despite a considerable
documentation gathered through the years about
the management of apical periodontitis in root-­
filled teeth, it is difficult to give evidence-based
answers to many clinical questions. However,
from the bulk of information, it can be concluded
that many individuals will not directly suffer
from the condition but also that the condition
may, in many cases, be cured and possibly save
many of root-filled teeth afflicted by a persistent
apical lesion.
Based on current best empirical and scientific
knowledge, the following general short answers
to “the clinical questions” may be appropriate:
• How does this problem affect my risk of loos-
ening the tooth?
The risk of loosening a root-filled tooth is
higher than for a healthy tooth in general.
To what extent a persistent lesion affects
the risk is not well known.
• Will it affect my general health?
With the current state of knowledge, it is
unlikely that apical periodontitis in root-­
filled teeth would constitute a significant
health risk. But it cannot be entirely ruled
out that the chronic inflammation may
114
r­ epresent a small but contributing negative
factor for poorer health in the long term.
• What different options do I have?
If the lesion is asymptomatic and small, some
prefer to do nothing or just to “follow it”
regularly and intervene only if symptoms
occur or if it expands. The other option is to
perform a retreatment. Depending on the
position of the tooth, how it is restored, the
size of lesion, the quality of root filling and
the overall treatment plan, surgical or non-­
surgical retreatment may be appropriate.
• How likely is it that retreatment will cure the
tooth?
In cases with persistent disease, surgical or
non-surgical retreatment performed by
skilled specialists using modern armamen-
tarium is able to cure the lesion in about
80–90% of the cases.
• Would it be a better idea to take the tooth out?
In most cases no. But if the tooth is afflicted
by periodontal disease or the remaining
tooth substance does not provide condi-
tions for a high-quality restoration, it might
be a better idea.
• If so, can it be replaced?
In the majority of cases, a lost tooth can be
replaced by an implant or a fixed
prosthesis.
9.6 Knowledge Gaps
There are few clinical studies of high scientific
quality within the field of endodontics.
Consequently, there are many knowledge gaps
[9]. Further clinical studies with high quality are
necessary to give our patients less vague answers
to the following questions:
• Will root-filled teeth survive long term and
what factors influence the loss of endodonti-
cally treated teeth?
T. Kvist
• How often will a root-filled tooth with persis-
tent but asymptomatic periapical inflamma-
tion result in the occurrence of pain and
swelling?
• Which are the prognostic factors to predict an
exacerbation of asymptomatic periapical
inflammation, particularly in a root-filled tooth?
• How often will retreatment of a root-filled
tooth with apical periodontitis result in overall
better consequences than leaving the condi-
tion untreated in the long term?
• What method of retreatment (surgical or non-­
surgical) will have the best results in the long
term?
• How cost-effective are retreatment methods
compared to extraction and replacement?
• Are there any risks to general health when
teeth with a periapical inflammatory process
remain untreated?
Take-Home Lessons
• From the bulk of evidence available
from many years of clinical research
and clinical experience, it stands
clear that root-filled teeth with apical
periodontitis may be successfully
­
retreated in order to give remedy to
symptoms, to establish sound periapi-
cal tissues and to promote long-term
survival.
• Few high-quality studies are available to
evidence-based answers to a number of
clinical questions.
• Prognosis for an individual case must
be based not only on the scientific lit-
erature but also in rationale and logi-
cal thinking based on basic knowledge
of biology and technology and the
conditions that are at hand in every
case.
9 Prognosis
Benchmark Papers
• Bergenholtz G, Kvist T. Evidence-based
endodontics. Endod Top. 2014;31:3–18.
This review thoroughly presents the
concept of evidence-based practice and
discusses and how the concept has been
applied to endodontics. The focus is on
treatment procedures in endodontics.
The means used in the process and how
far our knowledge base has reached are
addressed. Aspects are conveyed at the
end on what future research in clinical
endodontics should take into account.
• Swedish Council on Health Technology
Assessment. Methods of diagnosis and
treatment in endodontics—a systematic
review. 2010;Report No 203:1–491. http://
www.sbu.se. A comprehensive review on
the evidence available in Endodontics.
• Del Fabbro M, Corbella S, Sequeira-­
Byron P, Tsesis I, Rosen E, Lolato A,
Taschieri S. Endodontic procedures for
retreatment of periapical lesions.
Cochrane Database Syst Rev.
2016;10:CD005511. An updated com-
plete review on the high-quality studies
(RCT’s) available for different aspects
endodontic retreatment.
References
1. Sackett DL, Rosenberg WM, Gray JA, Haynes RB,
Richardson WS. Evidence based medicine: what it is
and what it isn’t. BMJ. 1996;312(7023):71–2.
2. Bergenholtz G, Kvist T. Evidence-based endodontics.
Endod Top. 2014;31:3–18.
3. Kim S, Jung H, Kim S, Shin SJ, Kim E. The influ-
ence of an isthmus on the outcomes of surgically
treated molars: a retrospective study. J Endod.
2016;42:1029–34.
4. Nixdorf DR, Law AS, Look JO, Rindal DB, Durand
EU, Kang W, Agee BS, Fellows JL, Gordan VV,
Gilbert GH, National Dental PBRN Collaborative
115
Group. Large-scale clinical endodontic research
in the National Dental Practice-Based Research
Network: study overview and methods. J Endod.
2012;38:1470–8.
5. Raedel M, Hartmann A, Bohm S, Walter MH. Three-­
year outcomes of apicectomy (apicoectomy): mining
an insurance database. J Dent. 2015;43(10):1218–22.
6. Kvist T, Reit C. Results of endodontic retreat-
ment: a randomized clinical study comparing
surgical and nonsurgical procedures. J Endod.
1999;25(12):814–7.
7. Del Fabbro M, Corbella S, Sequeira-Byron P, Tsesis
I, Rosen E, Lolato A, Taschieri S. Endodontic proce-
dures for retreatment of periapical lesions. Cochrane
Database Syst Rev. 2016;10:CD005511.
8. Sacket DL. Bias in analytic research. J Chronic Dis.
1979;32:51–63.
9. Sebring D, Dimenäs H, Engstrand S, Kvist
T. Characteristics of teeth referred to a public dental
specialist clinic in endodontics. Int Endod J. 2016;
https://doi.org/10.1111/iej.12671. [Epub ahead of print].
10. Braitman LE. Confidence intervals assess both clini-
cal significance and statistical significance. Ann
Intern Med. 1991;114:515–7.
11. Swedish Council on Health Technology Assessment.
Methods of diagnosis and treatment in endodontics—
a systematic review. Report no. 203; 2010. p. 1–491.
http://www.sbu.se.
12. Ng YL, Mann V, Gulabivala K. Outcome of second-
ary root canal treatment: a systematic review of the
literature. Int Endod J. 2008;41(12):1026–46.
13. Ng YL, Mann V, Gulabivala K. Tooth survival
following non-surgical root canal treatment: a
systematic review of the literature. Int Endod
J. 2010;43(3):171–89.
14. Nixdorf DR, Moana-Filho EJ, Law AS, McGuire LA,
Hodges JS, John MT. Frequency of persistent tooth
pain after root canal therapy: a systematic review and
meta-analysis. J Endod. 2010;36:224–30.
15. Torabinejad M, Corr R, Handysides R, Shabahang
S. Outcomes of nonsurgical retreatment and end-
odontic surgery: a systematic review. J Endod.
2009;35(7):930.
16.
Petersson A, Axelsson S, Davidson T, Frisk
F, Hakeberg M, Kvist T, Norlund A, Mejàre I,
Portenier I, Sandberg H, Tranaeus S, Bergenholtz
G. Radiological diagnosis of periapical bone tissue
lesions in endodontics: a systematic review. Int Endod
J. 2012;45:783–801.
17. Tsesis I, Rosen E, Taschieri S, Telishevsky Strauss Y,
Ceresoli V, Del Fabbro M. Outcomes of surgical end-
odontic treatment performed by a modern technique:
an updated meta-analysis of the literature. J Endod.
2013;39:332–9.
116
18. Ng YL, Mann V, Gulabivala K. A prospective study
of the factors affecting outcomes of nonsurgical root
canal treatment: part 1: periapical health. Int Endod
J. 2011;44:583–609.
19. Setzer FC, Shah SB, Kohli MR, Karabucak B, Kim
S. Outcome of endodontic surgery: a meta-analysis of
the literature—part 1: comparison of traditional root-­
end surgery and endodontic microsurgery. J Endod.
2010;36:1757–65.
T. Kvist
20. Torabinejad M, Anderson P, Bader J, Brown LJ,
Chen LH, Goodacre CJ, Kattadiyil MT, Kutsenko
D, Lozada J, Patel R, Petersen F, Puterman I,
White SN. Outcomes of root canal treatment
and restoration, implant-supported single crowns,
fixed partial dentures, and extraction without
replacement: a systematic review. J Prosthet Dent.
2007;98:285–311.
 Alternatives: Extraction and Tooth
Replacement
10
Pernilla Holmberg

It takes a special kind of compass in the field of dental science

and art to understand the present and to navigate the future
of clinical prosthodontics with so many options available!

Abstract
There are different prosthetic treatment options to choose amongst when a
tooth is extracted, and there are numerous factors, both evident and hid-
den, which will affect the decision-making process and finally result in a
construction best suited for each patient or no construction at all. The den-
tist must in the decision-making process combine the best available evi-
dence with clinical data, weigh all the factors against each other and in
agreement with the patient choose the best treatment. The restorative den-
tist of modern age will face an even faster progression of new techniques
and dental materials than before, thus making the prosthetic decision-­
making even more challenging.

10.1 Introduction extracted tooth or tooth loss per se may have

grave social, professional or psychological con-
When extraction of a root-filled tooth is selected sequences, and for others the loss of a tooth may
due to endodontic treatment failure or inevitable be seen as a natural consequence with no further
because of caries or fracture, the dentist must re-­ implications.
evaluate the existing information about the The intention of this chapter is to provide the
patient and also gather additional information in reader with a brief outline of available treatment
order to make a treatment decision for the miss- options when a tooth is extracted and leaves a
ing tooth. For some patients the effect of an single-tooth gap and also to present three similar
patient cases who have received three different
tooth replacements. Since there is no possible
way to cover the entire prosthodontic field in
P. Holmberg, DDS detail in one chapter, the interested reader is
Department of Oral Prosthodontics and National Oral
Disability Centre, Institute for Postgraduate Dental
referred to the extensive and excellent textbooks
Education, Jönköping, Sweden on the prosthodontic aspects in detail on replace-
e-mail: pernilla.holmberg@liv.se ment of teeth.

© Springer International Publishing AG 2018 117

T. Kvist (ed.), Apical Periodontitis in Root-Filled Teeth,
https://doi.org/10.1007/978-3-319-57250-5_10
118
10.2 Decision-Making
and Evidence-Based
Dentistry
D.V Lindley, Professor in Statistics, stated in
1970: “decision-making is something which con-
cerns all of us, both as the makers of the choice
and as sufferers of consequences”. The process
of clinical decision-making within each clinician
is a complex process, and many minor decisions
both consciously and subconsciously are made
prior to reaching the final decision of which treat-
ment option to choose. Consequently, human
errors can be made during these complex pro-
cesses, and therefore a good clinician should
reflect on the alternatives, become aware of the
uncertainties, be able to modify his/her judge-
ment on the basis of accumulated evidence, bal-
ance the judgement of the risks of various kinds
and finally consider the possible consequences of
each treatment option [1].
Most clinicians have encountered patients
who have basically the same dentitions, yet
slightly different treatment options have been
prescribed. Furthermore, during a professional
life different treatment strategies and philoso-
phies will come and go. Certain will prevail over
others, and to make the context even more com-
plex, observations from medicine and dentistry
suggest that the decisions of healthcare profes-
sionals themselves may be highly variable, even
in the case of relatively simple interventions, and
influenced by a number of personal, educational
and economic considerations [2, 3].
Thus, the factors that determine treatment
selection are diverse, and clinical decision-­
making could be consistent and straightfor-
ward if there were clear and accepted
guidelines and furthermore if the recom-
mended actions were universally acceptable to
patients and care providers as well as sup-
ported by unequivocal evidence [3, 4].
Although there are few real evidence-based
guidelines in fixed and removable prosthodon-
tics, the clinician ought to have an established
practice on which to base his or her treatment
plans as well as to consciously, clearly and
wisely use the latest and best evidence as the
basis for decisions in the treatment of the
P. Holmberg
i­ndividual patient. In conclusion this implies
integrating personal clinical experience and
skills with the best possible available, exter-
nal, clinical evidence [5].
10.3 T
 o Arrive at the Correct
Prosthodontic Treatment?
“Primum non nocere”! “First do no harm” is still
very much valid and known amongst clinicians
today. It is essential that a clinician is able to
diagnose the problem before deciding on how, or
whether, to treat the patient. Failures of endodon-
tic therapies and resulting in necessary tooth
extractions can make the patients suspicious to
dental treatment. Why did the earlier treatment
result in loss of the tooth? These patients place
greater demands on the skill of the dental team. It
is essential that the clinician is able to diagnose
the problems thoroughly before deciding on how,
or whether, to treat the patient. There is no “cor-
rect” way to organize the information-gathering
process, but it is important to have a strategy or a
model in this process and clinical decision-­
making as a way to meet the patient’s expecta-
tions and treat the whole patient and not only the
single-tooth loss. The clinician who is not mind-
ful about her or his behavioural basis of care may
well find her/himself providing treatment that
may not have an optimal outcome. The best way
to arrive at a diagnosis is not to collect as much
information as possible but to reject as much as
possible irrelevant information, according to
Webber’s model [6].
The ultimate goal of restorative dentistry is the
preservation of teeth and surrounding oral struc-
tures and further to restore appropriate function
and aesthetics. This goal is not always met, and
the proposed prosthesis may not be maintainable
by either the patient or the clinical professionals,
and consequently there will be a likely significant
biological cost. Single-tooth replacement may be
achieved through no replacement at all (NRA), a
removable partial denture (RPD), the use of a
conventional fixed dental prosthesis (FDP), a
resin-bonded fixed dental prosthesis (RBFDP) or
a dental implant-supported single crown (ISSC)
(Fig. 10.1).
10  Alternatives: Extraction and Tooth Replacement 119

Temporary
Patient case
Tooth Migration Removable Trauma toothll
Decision-making
Prosthesis Endodontics fails
&
Consequences? Extraction
operator’s clinical
experience Eating
Clinical Data
No treatment & Life-style Drinking
At all Systematic Age Smoking
Resin-Bonded reviews Medical History Profession
Permanent ? Fixed dental Implant supported Economy
Cantilever
Temporary ? Prosthesis single crown Social history Perception
Dental fixed
Ability
prosthesis
2-Unit 2-Unit End- Dental history Motivation
Survival & (Two-retainer) (single-retainer) Material Abutment Expectiotions
complication selection ? Prosthetic Periapical
Survival &
rates ? Survival & assessment Remaining teeh Perio
complication
complication Rates ? Oral hygiene Caries
rates ?
Oral status Occlusion
Radiographic Force patiern
PMF All-Ceramic Panoramic - Assessment Masticatory apparatus
Ridge assessment
Laboratory Perl BTW CT
Techniques Apical
Monolithic Veneered CBCT Vertical Horizontal

New Techniques Aesthetics

Smileline
Soft tissue
Scanners CAD /CAM
contour

Fig. 10.1  A rough outline model for the prosthetic treatment options, single-tooth gap

10.4 Gathering Information d­ entistry and of their attitude or motivation for

10.4.1 Patient History
10.4.1.1 The Medical History
The patient’s general health must be comprehen-
sively recorded to make sure whether it will
affect the selection of treatment procedures or
not. The dental procedures or the restoration
itself must never be injurious to the health of the
patient. Moreover, the caregiver should make
sure that no member of the dental team or other
patients will be harmed as a consequence of pro-
viding dental care to a patient who has an infec-
tious disease.
10.4.1.2 The Social History
It is important to learn about the patient’s life-
style including eating, drinking and smoking
habits. Lifestyle factors can have a big impact on
both the treatment itself and the outcome and
maintenance of it. In most patients’ lives, the
economy plays a major part which prosthetic
treatment is affordable.
10.4.1.3 The Dental History
By listening to the patient’s own description of
previous experience, it helps the dentist to gain
an impression of the patient’s perceptions of
dental care. It also gives a hint of the patient’s
ability to maintain an acceptable standard of oral
hygiene and the previous dental care given.
10.4.2 The Oral Status
This examination encompasses the charting of
remaining teeth and their status. An evaluation of
the occlusion must be done as well as the health of
the masticatory apparatus. Furthermore, the level
of oral hygiene should be assessed. Individual teeth
may need more specific investigations such as pulp
vitality tests or a thorough assessment of the peri-
odontal status. The clinical collection of informa-
tion and assessment will be accompanied by a
more or less extensive radiologic examination.
10.4.3 Radiographic Assessments
There are different imaging techniques and each
one has its advantages and disadvantages, which
the clinician must be aware of. The patient must
not be exposed unnecessarily to ionizing radia-
tion and still there is a need to decide on the best
available means to obtain the required and neces-
sary information [7].
120 P. Holmberg

10.4.4 Ridge and Bone Assessment
When selecting between different replacement
options, an evaluation of the ridges is essential.
This may be done by using a gloved finger to
roughly estimate the outline and form. By plac-
ing a local anaesthetic and using a sterile probe
with a rubber stopper, the thickness of the mucosa
from the surface to the bone can be measured [8].
Alternatively, this may be achieved using radio-
graphs via a CT scan, but this is more expensive
and not always available for the practising den-
tist. Bone quality is usually assessed radiographi-
cally to determine relative densities.
10.4.5 Space Assessment
Is the available tooth space large enough to incor-
porate a single tooth? It could very well be that
the available space is too large for one single
tooth or too small. If it is too large, there is an
option to accept the gap as it is or to reduce the
space via orthodontics or by reshaping the neigh-
bouring teeth. If the edentulous space is too
small, there is an option of increasing the space
orthodontically or accepting the gap. Evaluation
of the vertical dimensions is mandatory before
any prosthetic restoration is placed. Lack of ver-
tical space may require an increase in the occlu-
sal vertical dimensions and can be done in many
different ways [9].
10.5 E
 xtraction and Ridge
Augmentation
v­ ertical bone loss of 11–22% after 6 months fol-
lowing tooth extraction and that the most rapid
resorption takes place in the first year. The risk of
unfavourable bone loss is particularly high in the
anterior maxilla which is commonly known to
exhibit a thin or even partially absent buccal bone
plate [10–13].
The loss of bone often leaves a condition of
poor quality and quantity of bone which many
times is inadequate for the placement of dental
implants but also changes the gingival contours.
This can also be critical in determining the use-
fulness of a tooth-borne fixed bridge. If normal
tooth morphology is to be maintained, this will
give wide embrasures at the gingiva and may
result in problems with speech or eating/drink-
ing. The alternative of blocking the embrasures
will lead to a poor aesthetic appearance since the
inciso-gingival connectors will be too long [14,
15] (Figs. 10.2 and 10.3).
Fig. 10.2  Bone deficiencies at site 22 after extraction
resulting in a long inciso-gingival line and poor aesthetic
with a tooth-borne fixed bridge. The gingival outline of
pontic 22 will be situated higher compared to the neigh-
bouring teeth. The aesthetics was solved with pre-­
prosthetic crown lengthening of the front teeth

When a tooth is extracted, it is indisputably fol-

lowed by a reduction of the alveolar ridge.
Moreover, it is well established that both hori-
zontal and vertical changes of hard- and soft-­
tissue dimensions take place at the edentulous
site. The buccal cortical plate of the alveolar pro-
cess may be resorbed even prior to tooth extrac-
tion as a result of inflammatory tooth disease,
developmental defects and trauma or a combina-
tion of these factors. Recent review studies have Fig. 10.3  Staged ridge augmentation at implant site 21
shown horizontal bone loss of 29–63% and compared to simultaneous ridge augmentation at site 11
10  Alternatives: Extraction and Tooth Replacement
Consequently, different measures have been
taken to avoid this bone modelling process such
as immediate implant placement and bone graft-
ing in order to counteract this catabolic process
and preserve the dimensions of the alveolar ridge.
Bone augmentation procedures to rebuild defi-
cient ridge contours are mandatory to enable
optimal dental implant placement and position-
ing. Sufficient bone volume, favourable three-­
dimensional implant positioning and stable
peri-implant soft-tissue conditions are consid-
ered prerequisites to achieve long-term implant
functions and aesthetics [11, 13].
Alveolar ridge rebuilding can be undertaken at
different times during treatment and is generally
categorized as simultaneous or staged. In the
staged approach, the alveolar bone is first recon-
structed in an initial surgery. Implant placement is
then carried out 2–6 months later. In contrast, in
the simultaneous approach, implant placement and
alveolar ridge reestablishment are undertaken dur-
ing the same surgery. The size of the defect affects
the healing time. The simultaneous approach is
obviously the preferred technique by the patient
and clinician alike, since it reduces treatment time
and cost. However, if the residual bone volume
precludes primary implant stability or results in
inadequate prosthodontic implant positioning, the
staged approach is recommended [16, 17].
Thus, the clinician is required to carefully
plan the extraction of a compromised tooth and to
perform the surgical intervention according to a
precise schedule and gentle touch in order to pro-
mote favourable hard- and soft-tissue conditions
at the upcoming edentulous site. In addition, it is
possible to reduce healing periods and number of
surgical interventions, especially when implant
treatment is planned [13].
The best way to treat a ridge deficiency is to pre-
vent it from occurring!
10.6 No Replacement at All (NRA)
Sometimes “less is more”! Rarely is NRA chosen
when a single tooth is missing in the aesthetic zone
or in a position which is important to load-­bearing
121
zones. Studies have shown that individuals are
usually more concerned about replacing missing
anterior teeth than posterior teeth, since a great
majority of patients find aesthetics more important
than function. In some cases, the choice of not
replacing a missing tooth could also be due to
socio-economic factors [18]. The clinician must
also be aware of that drifting and tipping of neigh-
bouring teeth to an extraction site are commonly
reported phenomena and make an assessment of
the consequences following tooth extraction. In a
study by Craddock and co-­workers, they found the
teeth mesial to the extraction site had a tendency to
tip distally. The upper teeth showed a higher
degree of tipping and also in subjects with a cusp-
to-cusp buccal occlusion. Moreover, the tipping of
the tooth distal to the extraction site was more
prevalent in individuals with a reduced overbite
and in the lower arch. The tipping of the distal
tooth could be in some cases extreme [19]. A com-
plete dentition is not always necessary, but the cli-
nician needs to evaluate the risks and consequences
with not replacing a missing tooth and explain and
inform the patient thoroughly.
10.7 R
 emovable Partial Denture
(RPD)
A removable partial denture effectively serves
temporarily to stabilize the occlusion and prevent
unwanted drifting of the adjacent and opponent
teeth into the space of the extracted tooth. The
denture is usually made of acrylic or acrylic and
metal. The overall treatment time for this option
is short and the cost can be very low. There is
always a risk of soft-tissue irritation and bone
problems. However, in younger patients, it is a
good therapy waiting for the right age to place a
fixed replacement of the extracted tooth.
Sometimes a removable denture suggested as
temporary substitute turns out to be very well tol-
erated as a final treatment and preferred option
for replacing a single missing tooth. However,
RPDs are mostly used as a temporary replace-
ment or a compromise because of severe prob-
lems with surrounding teeth and perhaps general,
health or economy.
122
10.8 F
 ixed Dental Prosthesis
(FDP)
It seems apparent that the most ancient dental
prosthetic appliances have been of fixed bridge
work and man has for many centuries tried to
hold artificial or detached natural teeth from one
mouth to another in place by means of wires or
ligatures.
10.8.1 Survival and Complication
Rates
Fixed dental prosthesis for teeth have taken a
variety of designs throughout the history. The
initial placement of a fixed dental prosthesis
is rarely the end of treatment and many times
the patient enters the “cycle of rerestoration”
leading to expansion of prostheses carrying
increased biological and technical risks and
consequently higher costs of dental care. Socio-
economic factors and better oral hygiene regi-
mens with patients included in regular recall
programmes have led to an increased number of
teeth and to a shift from fully to more partially
edentulous patients over the past decades. This
has resulted in a trend towards higher frequen-
cies of fixed dental prostheses. Fixed dental
prosthesis (FDP) are associated with the sacri-
fice of sound tooth tissue and inherent risks of
pulp injury [20–23]. One study conducted
amongst 66 practising dentists showed that
70% of treatment recommendations resulted in
an increased number of restored surfaces [22].
A considerable disadvantage with bridgework
replacing a single tooth is that the neighbouring
healthy teeth have to be involved, affected and
damaged. Owing to the variety of techniques
employed and materials used, failing reconstruc-
tions may be attributed to several causes. Some
studies attribute over 50% of failures to the den-
tists and materials used. Moreover, biological
and technical complications have been reported
in a variety of studies including secondary caries,
loss of retention and marginal defects [22].
P. Holmberg
Failure of a FDP is not particularly alarm-
ing per se, but the biologic consequences that
many times will ensue may be the cause of
great concern. Caries is the most reported
cause of prosthesis failure and results in loss
of dental hard structures, structural compro-
mises and loss of abutment teeth, while loss of
retention of the FDP was the most common
technical complication [21]. Goodacre and
Spolnik [24] reported that 3–23% of the abut-
ment teeth used requires endodontic treatment
after placement of a FDP. Abutment fractures
and endodontic failures present additional
complications to FDP since abutment teeth
that have been further weakened must support
larger prostheses [24]. In a meta-­analysis con-
ducted by Scurria et al. [25], prosthesis sur-
vival dropped to 69% at 15 years, as in
accordance of another study where Lindquist
and Karlsson [26] indicated a survival rate of
fixed partial prosthesis that drops significantly
after approximately 10 years and after 20 years
the survival rate was 65%.
10.8.2 Material Selection
The evolution in material science has led to the
introduction of new framework materials, and
the tradition with using metal-based recon-
structions for fixed dental reconstructions is
partially changing in favour for all-ceramic
materials, e.g. monolithic materials rather than
a framework with a veneer. In a recent system-
atic review (Pjetursson et al. [20]) comparing
survival rates of all types of all-ceramic FDPs
with conventional metal-ceramic FDPs, the
incidence of framework fractures was signifi-
cantly higher for reinforced glass-ceramic FDP
as well as infiltrated glass-ceramic FDPs. The
incidence for ceramic fracture and loss of
retention was significantly higher for densely
sintered zirconia FDPs compared to metal-
ceramic constructions. In conclusion, the sur-
vival rate for all-ceramic FDPs was lower than
for metal-ceramic FDPS [20].
10  Alternatives: Extraction and Tooth Replacement
10.8.3 Cantilever Fixed Dental
Prostheses
Pjetursson et al. [27] conducted a review on can-
tilever fixed partial prosthesis where the cumula-
tive failure rate was 18.2% after a 10-year
follow-up time, as compared with the results for
conventional end-abutment-supported fixed par-
tial prosthesis which showed a 10.9% failure
rate. Of the abutment teeth considered vital at
the time of cementation, 32.6% lost their pulp
vitality over a period of 10 years, and this was
the most common biological complication [27].
In an earlier study by Karlsson [28], two-thirds
of the failed cantilever fixed partial prosthesis
had a terminal root-canal-treated abutment indi-
cating that cantilever fixed partial prosthesis was
more prone to failure, if based on a nonvital ter-
minal abutment. Randow and Glantz [29] con-
ducted a study on root-canal-treated teeth and
found that the pain threshold was almost twice as
high on these nonvital teeth as compared to vital
teeth. Comparing one-cantilever pontic with
fixed partial prosthesis with multiple extensions,
there was no significant difference [27]. Another
common biological complication was caries at
the abutment teeth, and in several studies an
association between loss of retention and sec-
ondary caries was noted. This might be debat-
able which of the two conditions occurred first
and led to the other. The most frequent technical
complication was loss of retention. In conclu-
sion, it seems that there is a higher risk for bio-
logical and technical complications for the
cantilever FPP compared to the conventional
end-abutment-supported fixed partial prosthesis
after 10 years and the estimated survival rate is
81.8% after a 10-year observation period [27].
10.9 R
 esin-Bonded Fixed Dental
Prosthesis (RBFDP)
The resin-bonded fixed dental prosthesis pro-
vides a method for replacing missing teeth or
splinting periodontally weakened teeth in the
123
anterior regions of the mouth. This method has
both short-term and long-term benefits in that
prosthesis can be placed with minimal or no
tooth preparation [30]. In the early 1970s,
Rochette developed and introduced a more
complex procedure compared to the previous
bonded acrylic denture tooth. The bridge frame-
work was laboratory-­manufactured and perfo-
rated with tapering holes in order to lock the
framework in place, covering the lingual sur-
faces and with a more aesthetic pontic [30].
Livaditis and co-­workers from Maryland in the
USA extended it further to include the posterior
region and also developed the etched alloy
technique to overcome the shortcomings with
the Rochette technique.
10.9.1 Survival and Complication
Rates
The survival rates vary widely between studies,
but debonding is the most frequent occurring
technical complication. When there are no reli-
able mechanical and chemical bonds between
metal/resin and dental/resin surfaces, the reten-
tion lock will degrade faster over time being [30,
31]. Pjetursson et al. [32] has shown a cumulative
rate of 19.2% during a 5-year observation time.
The debonding was most frequent in the metal-­
ceramic RBFDPs with a perforated framework,
and the posterior bridges showed a higher rate as
well with debonding compared to the anterior.
Since the development of the first RBBs in the
1970s, there have been significant changes in the
design, the materials used and the tooth prepara-
tion to improve the longevity of the prosthesis.
10.9.2 Material Selection
The first all-ceramic RBFDPs were introduced in
the early 1990s as to benefit from the advantages
with a predictable adhesive cementation proce-
dure and debonding was seldom a complication,
but they showed a high risk for fracture due to
124
their brittleness. In order to improve their stabil-
ity, the design was changed from two-retainer to
single-retainer cantilever RBFDP, and conse-
quently the survival rates were improved. In a
retrospective study of all-ceramic single-retainer
cantilever resin-bonded fixed dental prostheses
by Sailer et al. [33], there were no problems with
debonding and no catastrophic failures, thus
100% survival after a 6-year follow-up.
10.10 Implant-Supported Single
Crown (ISSC)
The use of an implant-supported single crown
preserves the adjacent teeth and the surrounding
oral tissues. Consequently, there is no risk of
loss of vitality of abutment teeth or further
weakening of an already weak abutment tooth
due to tooth substance loss. Today, many
patients also oppose and reject treatments which
involve tooth preparations; thus, the osseointe-
gration method has opened up possibilities for
implant-supported single crowns for replacing a
missing tooth [34–36]. In the early days of
implants, the primary goal was osseointegra-
tion, but now it is taken for granted and even for
the implant to remain in function for years.
Today the focus has shifted towards the aesthet-
ics and how to augment and contour the alveolar
ridge.
10.10.1 S
 urvival and Complication
Rates
The replacement of missing teeth, especially in
the anterior zone, has always been a challenge for
the dentist, and a major challenge for the restor-
ative dentist is to provide the patient with an
implant-supported crown which is in harmony
with the neighbouring teeth and soft tissue in
order to restore function and aesthetics. It is of
great importance to place the implants in a
P. Holmberg
p­ osition to optimize the emergence profiles of the
restoration to achieve this, called currently “the
restorative-driven surgical concept” [37].
Earlier research concerning the use of dental
implants (DI) in partial edentulism and single-­
tooth replacement reported survival rates of
93.6–97.5%, respectively, during a 5-year fol-
low-­up, and the prosthetic complications were
relatively low with the most common complica-
tion being abutment or screw loosening [35, 38,
39]. In concordance, a newer systematic review
by Jung et al. [40] showed survival rates mount-
ing to 97.2% at 5 years and 89.4% after 10 years.
Biological, technical and aesthetic complications
were frequent with the highest cumulative com-
plication rate with soft-tissue complications
encompassing peri-implantitis, fistulas, gingivitis
or other signs of inflammation. Technical compli-
cations such as abutment and screw loosening
also showed a high rate, mostly due to one older
study who reported on first generation of SCs on
Brånemark implants. And if excluded from the
study, the cumulative incidence of screw loosen-
ing decreased. Fractures of components, such as
implants, abutments and occlusal screw were rare
complications.
10.11 W
 hich Prosthetic Treatment
for the Single-Tooth Gap?
Comparing Fixed Dental
Prostheses (FDPs)
and Implant-Supported
Single Crowns (ISSCs)
The question confronting each clinician is when
to apply which prosthetic treatment option and
to use these therapeutic approaches to their max-
imum benefit for the patient [34]. Today, a
greater demand is placed on the diagnostic and
treatment planning by the clinician, as a conse-
quence of the introduction of newer surgical and
restorative techniques as well as newer restor-
ative materials that has significantly expanded
10  Alternatives: Extraction and Tooth Replacement 125

the available treatment options. In an ideal pros- psychological profile of each patient. The
thetic world, the treatment decisions should be patients’ preferences as well as their willingness
based on well-­performed reviews of the avail- to pay for different alternatives will finally result
able evidence and, if possible, on formal quanti- in the “best option” in each for the particular con-
tative evidence synthesis and meta-analysis [41]. text and clinical situation.
Since there is no clear-cut percentage of survival
rates between the two options, the decision-mak-
ing process is partially based on operator’s clini- 10.12 Replacing a Single Missing
cal experience, skill and inclinations and patient Tooth—Analysis
preferences [42]. and Treatment Planning
In the daily clinical practice, patient and clini-
cian satisfaction is not only influenced by sur- These three patients have in common that they
vival rates. Survival is usually defined as the all have experienced dental trauma in relatively
implants or prostheses remaining in situ with or young age where the upper right central incisor
without modification during the observation have undergone root canal treatment but later
time, but not necessarily free of complications the tooth has been extracted. They have
[43]. Both implant-supported crowns and tooth-­ received different prosthetic treatments even
supported fixed dental prostheses exhibit a vari- though the same tooth is missing. The exam-
ety of complications. One meta-analysis of 5- and ples are given to show the reader how different
10-year survival rates of FDPs and ISSCs, per- factors in the information gathering affect the
formed by Pjetursson et al. [41], showed an esti- treatment option selected.
mated 5-year survival rate of conventional
tooth-supported fixed dental prostheses of 93.8%,
cantilevered FDPs of 91.4% and implant-­ 10.12.1 Case 1
supported single crowns of 94.5%, respectively.
After 10 years of function, the estimated survival A 19-year-old man was referred for replace-
decreased to 89.2% for conventional FDPs, ment of a missing maxillary central incisor due
80.3% for cantilever FDPs and 89.4% for to trauma and later on failed endodontics. The
implant-supported SCs. upper right lateral and central incisors were
Failures of conventional FDPs were most fre- intruded at the trauma occasion when the
quently attributed to biological factors like caries patient was 11 years old. The teeth were reposi-
and loss of pulp vitality as compared to more tioned, fixated and underwent root canal ther-
technical complications for the ISSCs such as apy. Two years later the central incisor showed
ceramic fractures or chipping, abutment or screw ankylosis, and therefore a decision was made to
loosening and loss of retention [41]. decoronate the tooth in order to preserve the
In summary, the clinician cannot solely use alveolar ridge while the patient was growing
the published estimated survival and complica- and was replaced with a temporary removable
tion rates on group level to make clinical decision denture [44]. Orthodontic treatment was per-
for the individual patient, since there is no scien- formed due to inadequate space for the upper
tific evidence for the superiority of any of the canines and a prenormal growth development.
options. The wise clinician and dental team make The treatment with a single-tooth implant was
their decision-making on the best available evi- postponed until the patient turned 20 so most of
dence together with a professional and meticu- the developmental growth would have taken
lous evaluation of the unique medical, oral and place (Figs. 10.4–10.7).
126 P. Holmberg

Fig. 10.4  The tooth gap shows a thick gingiva biotype

[45], square teeth and a low lipline (which is not shown at
these photos). Triangular teeth are supposed to pose a
greater risk for failed aesthetics, and this risk is most
likely associated with the emergence profile and tissue
support [46]. Minor vertical tissue deficiency. Surgery
was performed according to a two-stage protocol, and the
patient underwent a rigorous oral hygiene schedule

Fig. 10.5  Three months after the implant was placed, a

temporary crown with a moderate emergence profile was
fabricated by the dental technician using a titanium post
for temporary restorations in order to condition the
mucosa and attain soft-tissue stability
Figs. 10.6 and 10.7 A screw-retained all-ceramic
crown. The implant shoulder was located a bit too far
palatally due to the loss of the horizontal bone which
resulted in a restoration with a ridge—lap design.
Satisfactory aesthetics
10  Alternatives: Extraction and Tooth Replacement 127

10.12.2 Case 2

A 14-year-old girl was referred for an interim res-

toration replacing the upper right central incisor
due to an old trauma and failed endodontics and in
waiting for an implant replacement. The patient
couldn’t accept the aesthetics of the resin-­bonded
fixed restoration metal/ceramics and which also
had debonded several times. The patient was very
anxious in the dental treatment situation so all
dental treatment was performed under sedation
with nitrous oxide. A single-tooth replacement
with an implant is planned but the patient is too
young for such a treatment (Figs. 10.8–10.10).

Figs. 10.9 and 10.10  A new resin-bonded bridge in

Fig. 10.8  Note the greyish discoloration and the dis-
harmony with the adjacent teeth. Deficient horizontal
width of the hard tissue at the site. Medium gingiva bio-
type. This patient will probably need horizontal bone
augmentation prior to implant installment and/or soft-
tissue grafting
lithium disilicate glass-ceramic for the press technique
was performed and cemented according to the instructions
of the manufacturer. Only one tooth supports the resin-­
bonded bridge. Better aesthetics and harmony in the out-
line were achieved, and the young patient was satisfied.
Efforts have been made to interlock the upper right lateral
incisor with the pontic, in order to prevent it from migra-
tion with continued growth. Regular and continued check-­
ups whether orthodontic site preparation will be needed in
the future for a single-tooth implant
128 P. Holmberg

10.12.3 Case 3

A 26-year-old man was admitted for improving

the aesthetics in the frontal upper jaw. The
patient’s new girlfriend had persuaded the patient
to seek dental treatment. The upper right central
incisor was lost due to failed endodontics follow-
ing a trauma. The tooth was extracted and replaced
with a resin-bonded bridge in metal-­ceramic. He
did not wish for a prolonged and extensive dental
treatment since he suffered from dental anxiety.
He declined treatment with extraction of two pre-
molars and orthodontic site preparation for a sin-
gle-tooth implant (Figs. 10.11–10.15).

Figs. 10.13–10.15 An all-ceramic tooth-supported

fixed dental prostheses and an all-ceramic veneer were
planned for and executed to optimize the aesthetic.
Prior to treatment decision, a wax set-up was made.
Care was taken not to place the margins of the crown
subgingivally due to the already present soft-tissue
recessions. Better harmony was achieved with the mid-
line shift and tooth shape. In this particular case, the
biologic price consisted of the loss of tooth substances
Figs. 10.11 and 10.12  Not enough restorative space for when being prepared for a fixed dental prosthesis.
a dental implant at site 11. Grey discolouration of the left
maxillary central incisor. Triangular tooth shape with thin
gingival biotype at least where the snuff induced lesions
can be seen but also elsewhere. This patient is at greater
risk for soft-tissue recession. The interocclusal space for
any restoration is advantageous. Medium lip line. Midline
shift probably due to tooth migration
10  Alternatives: Extraction and Tooth Replacement
10.13 Outlook Prosthetic
Treatments in 2017
Today, the field of dental science and art have
changed dramatically, and the restorative den-
tist has a greater number of options available
for tooth preparation techniques, impression
taking and restorative materials than in the past.
It has not only changed the way dentists run
their practice but also the dental laboratory
world. Mechanical engineering, laser milling
techniques and lately 3D printing and design
have emerged and are evolving in an increasing
pace. The introduction of intraoral scanners in
2003 made it possible to switch from the ana-
logue to the digital world, and today there is a
wide use of CAD/CAM in the dental laboratory
environment and dental offices. The intraoral
scanners in 2017 can be used for almost any
indication for a ­ tooth-­
supported construction
compared to the implant-­supported construc-
tions since they do not have a periodontal liga-
ment and show less flexibility than a natural
tooth. If a construction does not show a 100%
fit, the tooth can be displaced by force but not
the implant. All new techniques and materials
have a learning curve for both the dental team
and the dental technician, and thus all dental
situations cannot be scanned which conse-
quently will lead back to more conventional
methods. Combining scanning technology and
CAD/CAM procedures makes it possible to
reduce clinical and dental laboratory working
time significantly [47].
Milling and printing of implant-supported
and tooth-borne fixed prostheses are consid-
ered to be the “golden” standard today, and the
traditional waxing up and casting in gold or
129
precious alloys has given way for these newer
techniques. Alloys having a high proportion of
precious metals in the fabrication of porce-
lain-metal fused constructions have been
slowly replaced/substituted by cobalt-chro-
mium. Increasing aesthetic demands from
patients as well as clinician have made it pos-
sible for new full-ceramic materials and sys-
tems to emerge. A paramount change of
concept was the introduction the PROCERA
system in 1993 since the white alumina cop-
ings could be produced in the dental labora-
tory using CAD/CAM. Further development
came with zirconia CAD/CAM copings which
were introduced in the late 1990s. This mate-
rial was stronger and in a sense “self-healing”
when small cracks occurred and therefore
more suitable for load-­bearing reconstructions
such as posterior FDPs. It is now possible to
stain zirconia in tooth-shade colours and use it
as a monolithic restoration to avoid veneering
material prone to chip off effects. The coloured
zirconia is milled out of the same material as
the core material. Polished zirconia is the least
abrasive dental material available [47, 48].
The field of implant therapy has evolved at
least as quickly as that of restorative dentistry in
general. The use of wider varieties of implant
diameters, lengths and morphologies and implant
surface technology has changed many of the
basic tenants of implantology. The time neces-
sary to attain osseointegration has been signifi-
cantly shortened, and the initial strength of the
osseointegrative bond is dramatically increased.
Finally, the understanding of implant capabilities
in various sites and load applications continues to
evolve and has given us better tools to maximize
treatment outcomes for our patients.
130
Take-Home Message
• Few real evidence-based guidelines exist
in fixed and removable prosthodontics.
• The best way to treat a ridge deficiency
is to prevent it from occurring!
• The clinician is required to carefully
plan the tooth extraction in order to opti-
mize the hard- and soft-tissue condi-
tions at the edentulous site.
• Failures of conventional FDP are most
frequently attributed to biological fac-
tors like caries and loss of pulp vitality.
• Cantilever FDP present higher clinical
risk compared to conventional FDP.
• Adequate retention and long-life expec-
tancy for RBFP depend on framework
material chosen, how many retainers
incorporated and precise intra-enamel-­
placed preparations that add mechanical
retention.
• Scientific evidence suggests that treat-
ment with implant-supported SCs in a
tooth gap can be considered as a safe
and predictable option.
References
Benchmark Papers
The following references are in particular
important since they are all systematic
reviews or meta-analysis of the available
evidence and contribute to the treatment
decision-making phase:
• Jung RE, Zembic A, Pjetursson BE,
Zwahlen M, Thoma DS. Systematic review
of the survival rate and the incidence of
biological, technical, and aesthetic compli-
cations of single crowns on implants
reported in longitudinal studies with a
mean follow-up of 5 years. Clin Oral
Implants Res. 2012;23(Suppl 6):2–21.
• Ken T, Pjetursson BE, Lang NP, Chan
ES. A systematic review of the survival
and complication rates of fixed partial
dentures after an observation period of
P. Holmberg
at least 5 years. Clin Oral Implants Res.
2004;15:654–66.
• Pjetursson BE, Tan K, Lang NP, Brägger
U, Egger M, Zwahlen M. A systematic
review of the survival and complication
rates of fixed partial dentures (FDPS) after
an observation period of least 5 years. IV
Cantilever or extension FDPs. Clin Oral
Implants Res. 2004;15:667–67.
• Pjetursson BE, Brägger U, Lang NP,
Zwahlen M. Comparison of survival and
complication rates of tooth-supported
(FDPs) and implant-supported FDPs and
single crowns (SCs). Clin Oral Implants
Res. 2007;18(Suppl 3):97–113.
• Pjetursson BE, Sailer I, Makarov NA,
Zwahlen M, Thoma DS. All-ceramic or
metal-ceramic tooth-supported fixed
dental prostheses (FDPs)? A systematic
review of the survival and complication
rates. Part II: Multiple-unit FDPs. Dent
Mater. 2015;31:624–39.
1. Anusavice KJ. Decision analysis in restorative den-
tistry. J Dent Educ. 1992;56:812–22.
2. McCord JF, Grant AA, Youngson CC, Watson RM,
Davis DM. What we do with the information: deci-
sion making. In: Parkinson M, comissioning editor.
Missing teeth: a guide to treatment options. London:
Churchill Livingstone, Elsevier Science Limited;
2003. p. 11–7.
3. Pennington MW, Vernazza CR, Shackley P,
Armstrong NT, Whitworth JM, Steele JG. Evaluation
of the cost-effectiveness of root canal treatment using
conventional approaches versus replacement with an
implant. Int Endod J. 2009;42:874–83.
4. Kay E, Nuttall N. Clinical decision making. London:
BDJ Books; 1997.
5. Scarlett D. Evidence based medicine. How to practice
and teach EBM. New York: Churchill-Livingstone;
1977.
6. Webber RL. Computers in dental radiography: a sce-
nario for the future. J Am Dent Assoc. 1985;111:419–24.
7. Whaites E. Essentials of dental radiography and radiol-
ogy. 2nd ed. Edinburgh: Churchill Livingstone; 1996.
8. Atwood DA. Some clinical factors related to the resorp-
tion of residual ridges. J Prosthet Dent. 2001;86:119–25.
10  Alternatives: Extraction and Tooth Replacement
9. McCord FJ, Grant AA, Youngson CC, Watson RM,
Davis DM. Information gathering. In: Parkinson
M, comissioning editor. Missing teeth. London:
Churchill Livingstone, Elsevier Science Limited;
2003. p. 1–10.
10. Hansson S, Halldin A. Alveolar ridge resorption
after tooth extraction: a consequence of a fundamen-
tal principle of bone physiology. J Dent Biomech.
2012;3:1758736012456543.
11. Tan WL, Wong TL, Wong MC, Lang NP. A system-
atic review of post-extractional alveolar hard and soft
tissue dimensional changes in humans. Clin Oral
Implants Res. 2012;23(Suppl 5):1–21.
12. Hof M, Pommer B, Strbac GD, Sütö D, Watzek
G, Zechner W. Esthetic evaluation of single-tooth
implants in the anterior maxilla following autolo-
gous bone augmentation. Clin Oral Implants Res.
2013;24(Suppl A100):88–93.
13. Kuchler U, von Arx T. Horizontal ridge augmentation
in conjunction with or prior to implant placement in
the anterior maxilla: a systematic review. Int J Oral
Maxillofac Implants. 2014;29(Suppl):14–24.
14. Kubilius M, Kubilius R, Glwiznys A. The preserva-
tion of alveolar bone ridge during tooth extraction.
Stomatologija. 2012;14:3–11.
15. McCord JF, Grant AA, Youngson CC, Watson RM,
Davis DM. Fixed prosthodontic options. In: Parkinson
M, comissioning editor. Missing teeth: a guide to
treatment options. London: Churchill Livingstone,
Elsevier Science Limited; 2003. p. 18–34.
16. von Arx T, Buser D. Horizontal ridge augmentation
using autogenous block grafts and the guided bone
regeneration technique with collagen membranes:
a clinical study with 42 patients. Clin Oral Implants
Res. 2006;17:359–66.
17. Buser D, Bornstein MM, Weber HP, Grutter L,
Schmid B, Belser UC. Early implant placement with
simultaneous guided bone regeneration following
­ observation time of at least 5 years. Clin Oral Implants
single-­tooth extraction in the esthetic zone: a cross-
sectional, retrospective study in 45 subjects with a 2–4-
year follow-up. J Periodontol. 2008;79(9):1773–81.
18. Elias AC, Sheiham A. The relationship between satis-
faction with mouth and number and position of teeth.
J Oral Rehabil. 1998;25:649–61.
19. Craddock HL, Youngson CC, Manogue M, Blance
A. Occlusal changes following posterior tooth loss
in adults. Part 2. Clinical parameters associated with
movement of teeth adjacent to the site of posterior
tooth loss. J Prosthodont. 2007;16:495–501.
20. Pjetursson BE, Sailer I, Makarov NA, Zwahlen M,
Thoma DS. All-ceramic or metal-ceramic tooth-­
supported fixed dental prostheses (FDPs)? A system-
atic review of the survival and complication rates. Part
II: Multiple-unit FDPs. Den Mater. 2015;31(6):624–39.
21. Avivi-Arber L, Zarb GA. Clinical effectiveness of
implant supported single-tooth replacement. The Toronto
study. Int J Oral Maxillofac Implants. 1996;11:311–21.
22. Brantley CF, Bader JD, Sugars DA, Nesbit SP. Does
the cycle of re-restoration lead to larger restorations?
J Am Dent Assoc. 1995;126:1407–13.
131
23. Ken T, Pjetursson BE, Lang NP, Chan ESY. A system-
atic review of the survival and complication rates of
fixed partial dentures after an observation period of at
least 5 years. Clin Oral Implants Res. 2004;15:654–66.
24. Goodacre CJ, Spolnik KJ. The prosthodontic man-
agement of endodontically treated teeth: a literature
review. Part I. Success and failure data, treatment con-
cepts. J Prosthodont. 1994;3:243–50.
25. Scurria MS, Bader JD, Shugars DA. Meta-analysis
of fixed partial denture survival: prostheses and abut-
ment. J Prosthet Dent. 1998;79:459–64.
26. Lindquist K, Karlsson S. Success rate and failure for
fixed partial dentures after 20 years of service: Part
I. Int J Prosthodont. 1998;11(2):133–8.
27. Pjetursson BE, Tan K, Lang NP, Brägger U, Egger
M, Zwahlen M. A systematic review of the survival
and complication rates of fixed partial dentures
(FDPS) after an observation period of least 5 years.
IV Cantilever or extension FDPs. Clin Oral Implants
Res. 2004;15:667–7.
28. Karlsson S. Failures and length of service in fixed
prosthodontics after long-term function. A longitudi-
nal clinical study. Swed Dent J. 1989;13:185–92.
29. Randow K, Glantz PO. On cantilever loading of vital
and non-vital teeth. An experimental clinical study.
Acta Odontol Scand. 1986;44:271–7.
30. Simonsen R, Thomson V, Barrach G. Historical devel-
opment of the etched fixed partial denture. In: Simonsen
R, editor. Etched cast restorations: clinical and labora-
tory techniques. Chicago, IL: Quintessence Publishing
Co; 1983. p. 15–32.
31. Livaditis GJ, Thomson VP. Etched casting: an
improved retentive mechanism for resin-bonded
retainers. J Prosth Dent. 1982;47:52–8.
32. Pjetursson BE, Tan WC, Tan K, Brägger U, Zwahlen
M, Lang NP. A systematic review of the survival and
complication rates of resin-bonded bridges after an
Res. 2008;19:131–41.
33.
Sailer I, Bonani T, Brodbeck U, Hämmerle
C. Retrospective clinical study of single-retainer
cantilever anterior and posterior glass-ceramic resin-­
bonded fixed dental prostheses at a mean follow-up of
6 years. Int J Prosthodont. 2013;26(5):443–50. https://
doi.org/10.11607/ijp.3368.
34. Fugazotti PA. Evidence-based decision making:
replacement of the single missing tooth. Dent Clin
North Am. 2009;53:97–129.
35. Andersson B, Ödman P, Lindvall A-M, Lithner
B. Single tooth restorations supported by osseointe-
grated implants: results and experiences from a pro-
spective study after 2–3 years. Int J Oral Maxillofac
Implants. 1995;10:702–11.
36. Albrektsson T, Zarb G, Worthington P, Eriksson
AR. The long-term efficacy of currently used dental
implants: a review and proposed criteria of success.
Int J Oral Maxillofac Implants. 1986;1:11–25.
37. Evans CDJ, Chen ST. Esthetic outcomes of imme-
diate implant placements. Clin Oral Implants Res.
2008;19:73–80.
132
38. Lindh T, Gunne J, Tillberg A, Molin M. A meta-­
analysis of implants in partial edentulism. Clin Oral
Implants Res. 1998;9:80–90.
39. Priest G. Single-tooth implants and their role in pre-
serving remaining teeth: a 10-year survival study. Int
J Oral Maxillofac Implants. 1999;14:181–8.
40. Jung RE, Zembic A, Pjetursson BE, Zwahlen M,
Thoma DS. Systematic review of the survival rate and
the incidence of biological, technical, and aesthetic
complications of single crowns on implants reported in
longitudinal studies with a mean follow-­up of 5 years.
Clin Oral Implants Res. 2012;23(Suppl 6):2–21.
41. Pjetursson BE, Brägger U, Lang NP, Zwahlen
M. Comparison of survival and complication rates of
tooth-supported (FDPs) and implant-supported FDPs
and single crowns (SCs). Clin Oral Implants Res.
2007;18(Suppl 3):97–113.
42. Bouchard P, Renouard F, Bourgeois D, Fromentin O,
Jeanneret MH, Beresniak A. Cost-effectiveness mod-
eling of dental implant vs. bridge. Clin Oral Implants
Res. 2009;20:583–7.
43. Pjetursson BE, Asgeirsson AG, Zwahlen M, Sailer
I. Improvements in implant dentistry over the last
P. Holmberg
decade: comparison of survival and complication rates
in older and newer publication. Int J Oral Maxillofac
Implants. 2014;29(Suppl):308–24.
44. Cohenca N, Stabholz A. Decoronation—a conser-
vative method to treat ankylosed teeth for preserva-
tion of alveolar ridge prior to permanent prosthetic
­reconstruction: a literature review and case presenta-
tion. Dent Traumatol. 2007;23:87–94.
45. Kois JC, Kan JY. Predictable peri-implant gingival
aesthetics: surgical and prosthodontic rationales.
Pract Proced Aesthet Dent. 2001;13(9):691–698;quiz
700, 721–2.
46. Takei HH. The interdental space. Dent Clin North
Am. 1980;24(2):169–76.
47. Derksen W, Wismeijer D, Hanssen S, Tahmaseb
A. Dental technician of the future. Forum Implantol.
2015;11(1):12–20.
48.
Ioannidis A, Reichart D, Fehmer V, Sailer
I. Benefits and current limitations of monolithic
all-ceramic implant reconstructions on titanium
implant abutments: a case presentation. Forum
Implantol. 2015;11(1):22–7.
 Index

A Bleeding control, 84
Antimicrobial resistance, 28 Bone augmentation, 121
Apical fenestration, 44 Buccal cortical plate, 120
Apical granuloma, 27 Buccal entrance, 80
Apical lesions, 100
Apical periodontitis
clinical questions, 113–114 C
endodontic epidemiology, 8 Cardiovascular disease (CVD), 35
cross-sectional studies, 8–9 CBCT. See Cone beam computed tomography (CBCT)
longitudinal studies, 9–12 Cell death, 28
methodology selection, 12 Chronic apical lesions, 26
frequency and prevalence of, 14 Chronic apical periodontitis, 35
history, 112 Chronic inflammatory lesion, 27
incidence of, 15, 16 Chronic periapical asymptomatic lesions, 112
on intraoral radiographs, 50 Clinical decision making, descriptive projects, 55
nonendodontic lesions misdiagnosed as, 49 endodontic retreatment
population surveys vs. clinical studies, 8 benefits, 58–59
prevalence of, 36 decision making, 57–58
prognosis, 112–113 praxis concept, 58
radiographic examination, 12–13 personal values, 58
risk indicators Clinical decision making, prescriptive projects, 59
individual-specific, 15 autonomy and information, 61–62
tooth-specific, 14–15 monitors and blunters, 62–63
Asymptomatic lesions, 34, 35 ethics, 60
Asymptomatic tooth evidence-based decision making, 61
lesion, 51 expected utility theory, 61
widened periapical contour, 51 informed consent, 63–64
Atypical odontalgia, 45 authorized, 65
information about risks, 64
information about treatment, 64
B information on costs, 64
Biofilm. See also Root canal biofilms Strindberg system, 60–61
bacteria in, 23 Clinical research, apical periodontitis
extra-radicular, 25, 26 biasses, 109
formation, 22, 24, 26 confounding, 110
growth and maturation of, 25 measurement, 110
infections, 3 sampling, 109–110
in root-filled teeth, 26 selection, 110
matrix, 25 case reports, 105

© Springer International Publishing AG 2018 133

T. Kvist (ed.), Apical Periodontitis in Root-Filled Teeth,
https://doi.org/10.1007/978-3-319-57250-5
134 Index

Clinical research, apical periodontitis (cont.) pulpitis, 45

case-control studies, 105 vertical root fracture, 44–45
clinically relevant outcomes, 111 diagnostic determination, situations
database-based studies, 105 and guidelines, 50–51
efficacy and effectiveness, 111–112 diagnostic strategy, 49
loss to follow-up, 111 exceptions from benefit from the doubt strategy, 50
methods, 104–105 options, 55–56
PICO concept, 108 radiographic diagnosis, uncertainties in, 45–49
prospective cohort studies, 105 radiographic evaluation
publication bias, 112 reliability, 46–47
randomized controlled trials, 105–108 validity, 47–48
statistical analysis, 110–111 radiographic examination, 45–49
statistical and clinical significance, 111 Disease, defined, 3–4
systemic reviews and meta-analysed, 108 Dormant cell, 27
Colonizers, 23–25
Cone beam computed tomography
(CBCT), 3, 12, 44, 48, 90, 91 E
advantages, 47 Endodontic microorganisms
disadvantages, 47 resistance of, 28
in endodontics, 48 tolerance of, 28–30
Consequences Endodontic retreatment decision making, 56, 57
for dentists Endodontics, 2, 21
diagnosis, 36–37 CBCT in, 48
liability, 37–38 contemporary, 1
specialists need, 38 infections, persistent, 21
training and armamentarium, 38 modern, 2
for third party, 39 Endosolv™, 94
Consequences for patients Enterococcus faecalis, 24, 29
biological Expected utility theory (EUT), 61
flare-ups of asymptomatic lesions, 34 Extraction
local spread of disease, 34 and ridge augmentation, 120
loss of tooth, 34 of root-filled tooth, 117
persistent pain, 34 Extra-radicular colonization, 25–26
systemic effects, 35
economic aspects, 36
psychological consequences, 35
Contemporary endodontics, 1 F
Coronary heart disease (CHD), 35 Fixed dental prosthesis (FDP), 122, 124, 125
cantilever, 123
material selection, 122
D survival and complication rates, 122
Decision making. See also Clinical decision making
and evidence-based dentistry, 118
evidence-based, 61 G
philosophical justification, 65–66 Granulomas, 27
Dental care Granulomatous tissues,
high-quality, 2 Mycobacterium tuberculosis in, 27
medical and, variation in, 57 Guttasolv™, 94
Dental implants (DI), 3, 124
Dentistry
decision making and evidence-based, 118 H
goal of restorative, 118 Health-care procedure, variation in, 57
Dentists, 51, 62–64, 68, 117, 119 High-quality dental care, 2
consequences for, 36–38 Host-microbe interactions, 26–27
role, 39
Diagnostic methods, apical periodontitis
arguments for benefit of doubt strategy, 49–50 I
clinical differential diagnosis Implant-supported single crown (ISSC), 124
apical fenestration, 44 Intraoral radiographs, apical periodontitis on, 50
nonodontogenic pain, 45 ISSC. See Implant-supported single crown (ISSC)
Index 135

J P
Juxtaradicular radiolucency, 82 PAI. See Periapical index (PAI)
Patient
dental history, 119
L
medical history, 119
Lesion
social history, 119
asymptomatic, 34, 35
Periapical expressions, radiological and histological, 13
chronic apical, 26
Periapical index (PAI), 13, 46
chronic inflammatory, 27
Periapical lesions, 76
chronic periapical asymptomatic, 112
Periapical radiolucency, 82
nonendodontic, 49
Persistent endodontic infections, 21
periapical, 76
Phantom tooth pain. See Atypical odontalgia
Phenotypic tolerance, 28
M PICO concept, 108, 109
Microbial biofilm communities, 22 PICO model, 108
Microbial resistance vs. tolerance, 27 PMNs, 27
Microbiota, 22 Prosthetic treatment, 2017, 129
Mineral trioxide aggregate (MTA), 85 Prosthodontic treatment, 118–119
Modern endodontics, 2 single-tooth gap, 124
Mycobacterium tuberculosis, 27 Pulpitis, 45

N
Q
Naturalist theory, 4
Quorum sensing, 25
Neuralgia, trigeminal, 45
Neuropathic pain, 45
No Replacement at All (NRA), 121
R
Nonendodontic lesions, misdiagnosed as apical
Radiographic assessments, 119
periodontitis, 49
Randomized controlled trials (RCTs), 105
Nonodontogenic pain, 45
design, 106
Non-surgical retreatment, apical periodontitis
PICO concept for, 109
access preparation, 93
RBFDP. See Resin-bonded fixed dental prosthesis
chemical disinfection
(RBFDP)
chlorhexidine and iodine-potassium iodide, 98
RCTs. See Randomized controlled trials (RCTs)
EDTA, 98
Receiver Operating Characteristic (ROC) curve, 47
irrigation, 97–99
Referred pain, from temporomandibular disorder, 45
sodium hypochlorite, 98
Removable partial denture (RPD), 121
coronal restoration assessment, 91–92
Resin-bonded fixed dental prosthesis (RBFDP), 123
crowns, cores and posts removal, 92
material selection, 123–124
follow-up, 99–101
survival and complication rates, 123
gutta-percha and sealer removal, 93–94
Resistance vs. tolerance, 27–29
instrument fractures, 95–97
Resuscitation-promoting factors (Rpf), 27
instrumentation of apical part, 94–95
Ridge and bone assessment, 120
inter-appointment dressings, calcium hydroxide, 99
Ridge augmentation, 120
ledges, 95
extraction and, 120–121
magnification and illumination, 91
Risk indicators, for apical periodontitis
overinstrumentation, 97
individual-specific, 15
perforations, 97
tooth-specific, 14
plastic carriers removal, 94
Root canal biofilms, 22–24
root filling material removal, 93
growth and maturation, 25
root filling procedure, 99
initial adherence to surfaces, 23
rubber dam and aseptic working field, 93
secondary colonizers, 23
solvents removal, 94
Root canal infections, 14, 15, 83, 90
X-ray examination, 90–91
chronic, 29
Normativist theory, 4
Enterococcus faecalis in, 25
NRA. See No Replacement at All (NRA)
health and, 3
Root canal perforations, 97
O Root canal treatment
Oral status, patient, 119 controversies of success and failures of, 46
Orthopantomogram, 79 time passed since primary, 46
136 Index

Root-filled tooth soft tissue management, 84

cross-sectional studies reporting on, 10–11 suturing, 85
extraction of, 117 technical considerations, 74–76
frequency and prevalence of, 14 Surgical/nonsurgical retreatment,
loss of, 16 apical periodontitis, 66–67
pain from, 50 accessibility to root canal, 67–68
pulpitis in, 45 costs, 68
RPD. See Removable partial denture (RPD) preferences of clinician and patient, 68
restorative requirement of tooth, 68
size of bone destruction, 67
S
technical quality of previous treatment, 67
Single missing tooth replacement, 125–128
Single-rooted maxillary incisor, 83
Single-tooth gap, prosthodontic treatment, 119, 124
Single-tooth replacement, 118 T
Soft tissue management, 84 Temporomandibular disorder, referred pain from, 45
Streptococcus oralis, 29 Tissue growth factors (TGF-β), 27
Stress-regulator mechanism, 29 Tooth. See also specific types of tooth
Strindberg system, 60 loss of, 34
Stropko™ irrigation needle, 97 space assessment, 120
Surgical retreatment, apical periodontitis, 73–74 Trigeminal neuralgia, 45
anatomical considerations, 78–82
biological considerations, 76–78
bleeding control during surgery, 84–85
U
indications, contraindications, and treatment
Upper lateral incisor, 75
planning, 74
Upper right canine, 82
medical considerations, 82–83
postoperative information and complications, 85–86
prognosis, 86
root resection and retrograde treatment V
of root canal, 85 Vertical root fracture, 44