Endodontic Topics 2011, 18, 31–50 2011 r John Wiley & Sons A/S

All rights reserved ENDODONTIC TOPICS 2011

1601-1538

Reasons for persistent and

emerging post-treatment
endodontic disease
MARKUS HAAPASALO, YA SHEN & DOMENICO RICUCCI

This article is a critical review of the reasons for persistent and emerging post-treatment endodontic disease
(PTED). While there is a strong consensus that micro-organisms, mainly bacteria, are practically the only cause of
primary apical periodontitis, the reasons for persistent apical periodontitis lesions have been more a matter of
debate. The authors of this review focus on the role of micro-organisms in PTED, and while secondary
developments such as cholesterol crystals or foreign material in the periapical area of a tooth with apical
periodontitis may contribute to additional irritation and/or an inflammatory reaction, a detailed analysis of the
available data suggests that evidence supporting a primary role for such secondary factors without the continued
presence of bacteria is lacking. Therefore, even in PTED, elimination of micro-organisms residing within the tooth
structure, root surface, or periapical tissues remains the goal of treatment and the key to long-term success.

Received 12 June 2010; accepted 27 January 2011.

Introduction time (2–8). The persisting lesion may be smaller,

Root canal treatment of a tooth with irreversible pulp
inflammation is undertaken in order to remove the
inflamed tissue and to prevent further spread of the
infection. Criteria for successful treatment are lack of
symptoms, radiographic healing, and restored/con-
tinued functionality of the tooth. The first goal in the
treatment of apical periodontitis is to eliminate
the microbial infection from the root canal system of
the affected tooth by chemomechanical preparation
and disinfection. After this, a permanent root filling can
be placed and healing of the periapical (or lateral) lesion
can be expected. The root filling and subsequent
permanent coronal restoration will secure the tooth
against future infection. When the intra-canal infection
cannot be eliminated by conventional root canal
treatment, e.g. complex root canal anatomy, the
treatment may be completed by endodontic surgery.
In some cases, the periapical (or lateral) lesion does
not heal completely (Fig. 1) during a reasonable
follow-up time of approximately four years (1).
Persisting and recurrent apical periodontitis have been
a focus of interest in endodontic research for a long
unchanged, or even bigger than the original lesion, and
there may be occasional symptoms, although the
majority of persistent lesions are symptom-free. In
addition to persisting, non-healing lesions, it is also
possible that a new lesion may develop around the apex
of a root-filled tooth which previously did not have a
lesion or where the previous lesion had healed
completely, as judged radiographically (Fig. 2). This
review gives a summary of the various reasons for
persistent and emerging post-treatment disease.
Definition of post-treatment
endodontic disease (PTED)
In this review, post-treatment endodontic disease
(PTED) is defined as the presence of an inflammatory
periradicular lesion (periapical or lateral) in a previously
root-filled tooth when the lesion no longer can be
assumed to be undergoing healing following root canal
treatment. PTED may simply be a persistent infection,
which did not heal as a result of the root canal
treatment, but it may also be an emerging, new
infection in a previously root-filled tooth.

31
Haapasalo et al.
Epidemiology
Controlled clinical trials demonstrate a good prognosis
for root canal treatment. However, cross-sectional
epidemiological studies in various countries have
indicated that the prevalence of PTED is high. The
frequency of the presence of periapical radiolucencies
associated with root-filled teeth varies between 16%
and 65%, depending on the study population and type
of teeth included (9–13). It is likely that some of the
teeth in these studies had been treated shortly before
Fig. 1. A previously root filled tooth where the periapical
lesion has not healed. Poor quality of the treatment has
allowed bacteria to remain in the root canal space.
Fig. 2. A new periapical lesion has developed in a mandibular molar many years after root canal treatment. (a) The tooth
after root canal treatment; the root canal space seems densely filled but may be 1–2 mm short in mesial canals.
(b) Several years later the tooth is symptomatic and a periapical lesion can be seen.
32
the radiographs used in the studies were taken.
Therefore, it can be assumed that some of the lesions
are in fact undergoing healing and will disappear and
thus should not be diagnosed as PTED. The relative
proportion of the ‘‘healing in progress’’ cases cannot
be analyzed from the radiographs or from any other
information given in the studies and remains unknown.
However, based on the experience that most cases
which heal do so during the first year after treatment
(14–16), there is little doubt that the frequency of true
PTED remains disappointingly high even after deduct-
ing this group from the reported numbers. A detailed
analysis of the epidemiology of PTED is given by
Kirkevang in the next article of this volume, ‘‘Root
canal treatment and apical periodontitis: What can be
learned from observational studies?’’
Diagnosis and differential diagnosis
of PTED
Diagnostic tools and criteria
Diagnosis of PTED is based on the findings of clinical
and radiological examinations. Sensibility/vitality test-
ing of the tooth is usually of no help as the tooth is
already root-filled. The presence of a swelling open
sinus tract, tenderness to percussion and palpation, and
a careful study of the occlusion and periodontal
condition are essential components of routine exam-
 Reasons for persistent and emerging post-treatment endodontic disease
inations (Fig. 3). Evaluation of the quality of the
coronal restoration is of course important as leakage is a
potential cause for PTED. However, many of the teeth
with PTED are symptom-free, perhaps with the
exception of a slight sensitivity to percussion as
Fig. 3. A sinus tract in a previously root-filled tooth is a
sign of PTED. A gutta-percha point introduced into
an open sinus tract close to the previously root-filled
mandibular premolar teeth.
Fig. 4. Conventional periapical radiograph indicates normal bone structure surrounding the mesial root tip of a
mandibular first molar (pictures in upper row). However, CBCT image reveals inflammatory bone loss around apex
(pictures in lower row). Courtesy of Dr. Mahmoud Ektefaie.
compared to neighboring teeth. Radiographic exam-
ination is often of key importance in determining the
presence or absence of disease in previously root-filled
teeth. In addition to periapical/periradicular health,
the technical quality of the root filling must be
evaluated, together with the possibility of untreated
root canals. Unfortunately, radiographs have well-
known limitations, which are related to the quality of
the radiograph, anatomy of the bone and tooth/roots,
and the size and location of the lesion (17–20).
Inflammatory lesions which are entirely in the cancel-
lous bone and do not engage the cortex are usually not
or only faintly perceptible on conventional radiographs
(Fig. 4) (21–24). A common cause for post-treatment
endodontic disease, untreated MB2 canals of maxillary
first and second molars, are often 1–2 mm shorter than
the MB1 canal, and the lesion from this missed canal
may be superimposed (‘‘concealed’’) by the longer
buccal tip of the mesio-buccal root (Fig. 5).
PTED is often asymptomatic and therefore it is of
utmost importance to be careful when making a
diagnosis in the case of a root-filled tooth with a
radiographic periapical lesion. When a gutta-percha
point placed in a sinus tract traces the source to the
33
Haapasalo et al.
Fig. 5. A micro-CT image of the mesio-buccal root of a
maxillary first molar shows that the MB2 canal is shorter
than the MB1 canal and ‘‘hiding’’ behind the highest
point of the root. If not specifically looked for, the MB2
canal may remain undetected even during apical surgery.
Courtesy of Paul Brown, 3-D Tooth Atlas, eHuman.com.
apical periodontitis lesion of a root-filled tooth, the
diagnosis can be established easily. Also, in cases where a
root filling of poor quality is present in a root with a
clear apical periodontitis lesion and the patient experi-
ences pain or increased sensitivity to percussion, the
diagnosis of PTED can be made readily. At the other
end of the diagnostic spectrum are situations where the
root filling appears to be of high quality, the presence of
a pathosis cannot be verified reliably from the radio-
graph, and the patient’s symptoms cannot be well
localized. In addition, there are several other conditions
that may resemble or simulate apical periodontitis
radiographically and which occur at or project onto
the periapex of a tooth. These include variations of
normal anatomy (e.g. incisive canal, mental foramen),
various cysts (e.g. traumatic bone cyst), healing by scar
34
tissue (Fig. 6) (common after periapical surgery if both
cortical plates have been perforated), periapical ce-
mental dysplasia, cementoma in its early phase, fibro-
osseous lesions of the jaw, and metastatic tumors.
The introduction of cone beam computed tomogra-
phy (CBCT) to endodontic diagnostics has the
potential to greatly enhance the accuracy and sensitivity
of the diagnosis of periapical conditions. It has been
suggested that CBCT helps to detect more periapical
pathology than traditional 2D periapical films and
digital sensors (25–27). It can be expected that in the
near future CBCT will become a much more common
tool in the diagnosis of endodontic infections, includ-
ing PTED. An in-depth review of the diagnosis of
PTED is presented by Abbott in the article, ‘‘Diagnosis
and management planning for root-filled teeth with
persisting or new apical pathosis’’ in the following issue
of Endodontic Topics.
Etiology and pathogenesis of apical
periodontitis
Etiology of primary apical periodontitis
Primary apical periodontitis is caused by microbes
which have invaded the root canal space of the affected
tooth via a carious lesion, leaking filling, cracks, or
some other pathway (28, 29). Pulpal necrosis will first
develop with the advancing infection. Due to selective
pressure by the ecological environment, primary apical
periodontitis (no previous root canal treatment of the
tooth) is dominated by anaerobic bacteria, often
together with a few facultative or aerobic bacteria
(30, 31). Yeasts are uncommon in primary apical
periodontitis. The mixed infection in the root canal
interacts with the host tissue via the apical foramen
initiating an inflammatory response. The host reaction,
which can be either acute (symptomatic) or chronic
(asymptomatic), causes destruction of the bone in
the affected area. The periapical inflammatory process
and the concomitant bone resorption can usually
be seen on a radiograph as a dark, radiolucent lesion
around the apex of the tooth. Periapical pathosis
caused by a microbial infection of the necrotic
root canal of a previously untreated tooth is diagnosed
as primary apical periodontitis. Although in rare
occasions other factors such as traumatic occlusion
(severe occlusal interference) can cause widening
 Reasons for persistent and emerging post-treatment endodontic disease

Fig. 6. (a) A large periapical lesion around the apex of tooth #12. Histological analysis verified the diagnosis as a
radicular cyst. (b) Follow-up radiograph taken 11 years after root canal treatment and apicoectomy shows healing
partially by scar tissue. The radiolucent area appears to be separated from the resected root apex by a layer of bone. The
original lesion perforated both buccal and palatal cortical lamellae.

of the apical periodontal ligament space of a tooth, review gives a summary and critical review of the
microbes are the only etiological factor in primary proposed reasons for persistent and emerging post-
apical periodontitis. treatment disease based on the most recent literature.

Etiology of post-treatment disease

Due to the central role of microbes in the pathogenesis
of primary apical periodontitis, it is logical that
eradication of the microbes from the infected tooth is
regarded as the key to healing (8, 32–34). The technical
and biological goal of root canal treatment is to shape
the root canal(s) in such a way that effective disinfection
can be achieved and the root canal system can be
adequately filled. When the root canal treatment is of
high quality, healing will occur in most cases. If
eradication of the infection cannot be successfully
completed and if the residual microbes (after the
treatment) communicate with host tissues, healing will
be compromised. However, the etio-pathogenesis of
PTED may be more complicated than can be simply
concluded from the above. While in primary apical
periodontitis, microbes are the only cause for the
development of the apical periodontitis lesion, in PTED
several other reasons have also been indicated as possible
causes for the persistence of the periapical pathology.
During the development of the primary apical lesion
and in the course of the root canal treatment, secondary
developments may occur which have been suggested to
prevent or interfere with the healing process. This
Microbial causes of PTED
Intraradicular microbes
Root canal treatment, even when not carried out to the
highest possible technical standard, dramatically changes
the environment in the root canal; availability of oxygen
and nutrients is different, and in many cases substances
with antimicrobial activity are introduced into the root
canal as irrigating solutions and local antimicrobial
medicaments. If the resident microflora is not completely
eradicated, the new harsher ecological environment may
in fact contribute to the development of a more resistant
facultative microflora. Post-treatment endodontic infec-
tions are dominated by environmentally tolerant bacteria
and sometimes also by yeasts, which are characterized by
higher resistance to treatment procedures and disinfect-
ing agents than the anaerobic microflora in primary
apical periodontitis (4, 31, 35–38). The microbiology of
PTED is reported in great detail by Figdor & Gulabivala
in the article ‘‘Microbiology of root canals associated
with post-treatment disease’’ later on in this volume.
The importance of the composition of the intracanal
microflora in PTED has been a subject for much

35
Haapasalo et al.

Fig. 7. (a) A radiograph showing a large apical lesion in a root-filled mandibular canine. (b) Histological section
(modified Brown and Brenn staining) passing approximately at the center of the apical root canal. Overview shows an
anticipated foramen. Dark material in the middle is the root filling. (c-d) Higher magnification images from (b)
demonstrating (the biofilm) bacterial aggregates (dark blue) intermixed with necrotic debris in the apical root canal wall
and in a cross-cut apical ramification, respectively. Reprinted modified with permission from Ricucci D. Patologia e
Clinica Endodontica. 2009; Edizioni Martina, Bologna, Italy.

speculation and discussion. The strong dominance of
Enterococcus faecalis in PTED has lead to an abundance
of studies on the role in infection and sensitivity to
disinfecting agents of this facultative Gram-positive
coccus (39–45). One should remember, however, that
the classical studies by Bergenholtz (29), Sundqvist
(46), Möller et al. (47), and Fabricius et al. (48) clearly
indicated that apparently any species or rather combi-
nation of species which are able to establish themselves
in the necrotic root canal and survive the special
ecological environment are capable of causing apical
periodontitis. The reason for using E. faecalis as a
model organism in many of the studies should
probably be seen from the following two perspectives.
First, E. faecalis is de facto the most common finding in
PTED. Second, it is more resistant to harsh environ-
mental conditions and to many medicaments, e.g.
calcium hydroxide, than most other bacteria (49, 50);
see disinfection of the root canal in PTED by Zehnder
& Paqué in the next volume (51). Therefore, the
rationale for using E. faecalis as the test organism has
been partially based on the assumption that methods
and chemicals which are effective in eliminating this
resistant and tolerant species are likely to be effective
against most other microbes as well. Until shown
otherwise, the possibility that E. faecalis is in fact one
of the microbes that play a key role in many cases of
PTED cannot be ignored.

36
 Reasons for persistent and emerging post-treatment endodontic disease

Fig. 8. (a) Persisting apical periodontitis in a root-filled mandibular incisor. A histological section of the apical canal
demonstrates bacteria/biofilm on irregularities of the apical root canal wall, untouched by instruments (b) and
penetration of bacteria into dentinal tubules (c). Black particles in (b) represent root filling material. Reprinted modified
with permission from Ricucci D. Patologia e Clinica Endodontica. 2009; Edizioni Martina, Bologna, Italy.

Localization of the resident microbes in the filled root
canal is probably much more important to the outcome
of the root canal re-treatment than the composition of
the flora. As indicated by the classical studies, most if
not all bacteria have the ability to cause apical perio-
dontitis if they can survive in the root canal. Therefore,
the ability of the residual flora to communicate with the
periapical or periradicular host tissue is what determines
the progression of the disease. When the residual
bacteria are completely entombed by the root filling,
blocking all communication with the tissues, healing
will occur and the bacteria are expected to either die or
survive but cause no harm, depending on the survival
capability of each species. However, when residual
bacteria or new invaders are located in areas with a
connection to the tissue of the host, development or
continuation of periapical inflammation is likely to
result. The main root canal, especially the most apical
part of it, and the apical delta (apical lateral canals) are
the most common sites for bacteria to remain and cause
PTED (Fig. 7). Bacteria also reside in dentinal tubules
(Fig. 8) in most teeth which have apical periodontitis
(52–54). However, the role of microbes that have
invaded deeper into the dentin has been questioned
(55, 56). Nevertheless, when root surface cementum
has been resorbed, as often happens around the apical
foramen in apical periodontitis, bacteria may more
easily invade the entire thickness of the root via dentinal
tubules (Fig. 9) and develop a biofilm on the external
root surface (57, 58). In such teeth there is a strongly
increased possibility that invasion of dentin by microbes
from the main root canal is an important factor in the
development of PTED.
In addition to the location of the microbes in various
parts of the canal system and in relation to the apical
foramen/foramina, the fact that microbes are organized
into complex structures referred to as biofilms (Figs. 9a
and b) plays a major role in the development and
resistance to treatment of endodontic infections. Biofilms
are structured microbial communities embedded in a
highly hydrated matrix of extracellular polymeric sub-
stances produced by the microbial cells (59). The
polymeric substances are partially responsible for impor-
tant biofilm functions including cellular cohesion, surface
adhesion, and nutrient dynamics (60). Generally, bacteria
in biofilms are responsible for a variety of persistent
infections (61). The difficulty in eradicating such in-
fections is caused by several factors including reduced
susceptibility of micro-organisms in biofilms to anti-
microbial agents (62, 63). Due to the central role of the
biofilm in endodontic infections, it has been suggested
that both primary apical periodontitis and PTED should
be regarded as biofilm-induced diseases (64).
The role of lateral canals in endodontic infections has
been a controversial subject. The fact that lateral canals
can contain bacteria/bacterial biofilm which cause
lateral lesions is not a matter of debate (Fig. 10).
Differences in opinion are related to the treatment:
whether it is necessary to clean (even if possible) and fill
the lateral canals to secure healing of the lateral lesion. A
recent report by Ricucci & Siqueira (56) based on
extensive clinical material indicated that eradication of

37
Haapasalo et al.
Fig. 9. (a) Histological specimen of the root tip area of the
patient in Figure 8; section not passing through the apical
canal. (b) Higher magnification of the area indicated by
the arrow in (a). A biofilm is present on the external root
surface showing a dense network of bacteria embedded in
extracellular substance, EPS (modified Brown and Brenn
staining). Reprinted modified with permission from
Ricucci D. Patologia e Clinica Endodontica. 2009;
Edizioni Martina, Bologna, Italy.
bacteria/biofilm from the lateral canals remains a
challenge even though the canals may seem to be filled
with sealer or other root filling material as judged from
the radiographs. However, histological sections of
extracted teeth revealed that lateral canals were never
completely cleaned and, when filled with a root filling
38
material, they also contained vital or necrotic pulp tissue
and on many occasions bacteria as well (56). Never-
theless, as long as there is no method to completely clean
and disinfect the lateral canals predictably, microbes in
the lateral canals remain one possible reason for PTED.
In summary, there is a widely accepted consensus that
the microbes which are the cause of PTED usually
reside somewhere inside the root canal system of the
tooth. Key preventive measures include high-quality
chemomechanical preparation of all canals to the
correct length, effective irrigation and disinfection,
permanent root filling of optimal quality and with
antibacterial activity, and adequate coronal restoration
of the tooth to secure the root canal system against the
possibility of coronal leakage and thus re-infection.
Extraradicular microbes
While intracanal microbes remain the main cause of
PTED, extraradicular bacteria have also been claimed
to be present in some infections (41, 65–71).
Conventional root canal treatment, including instru-
mentation, disinfection, and root filling, can only affect
those microbes which are within the confines of the
root canal system. In acute apical periodontitis with an
abscess or an open sinus tract, bacteria are regularly
found in the tissue (31, 72, 73). This is not problematic
because the host defense system is expected to
eliminate these microbes quickly and effectively with
no negative impact on the long-term prognosis.
However, bacteria (or yeasts) which have succeeded
in establishing a colony/biofilm on the root surface or
in the periapical tissue are beyond the direct reach of
conservative (non-surgical) treatment methods. A
special variation of root surface biofilm is calcified root
surface biofilm. Precipitation of minerals in E. faecalis
biofilm on dentin in vitro has been described by Kishen
et al. (74), and there are some reports where calculus-
like deposits on the apical external root apex were
responsible for root canal treatment failure (75). Figure
11 shows calcified biofilm on apical root surfaces.
Traditionally, Actinomyces spp., and A. israelii in
particular, have been isolated from periapical specimens
of some persistent infections identified as periapical
actinomycosis (Fig. 12). During the last 10–15 years, a
number of studies have indicated that bacteria other
than Actinomyces spp. can also create actinomycosis-like
colonies in the periapical tissue (68–70, 76, 77). While
there is no disagreement on the presence of biofilm
 Reasons for persistent and emerging post-treatment endodontic disease

Fig. 10. (a) A histological section of a tooth shows bacterial presence (dark blue staining) in the main canal and in a large
lateral canal. (b) A higher magnification image of bacteria in the lateral canal. (c) A further magnification shows
microbial biofilm in the center of the lateral canal as well as attached to the dentin wall (modified Brown and Brenn
staining).

colonies in the periapical tissues of some persistent
infections, their independence or dependence on
intracanal infection remains a matter of debate (78).
Although it has been suggested that apical actinomycosis
represents the most typical example of extraradicular
infection independent of the intraradicular infection,
there is no strong evidence supporting this statement.
The vast majority of studies and case reports have
examined only apical periodontitis specimens taken after
periradicular surgery or extraction, but the correlation
with the bacteriological conditions of the associated root
canal has not been investigated. While the prognosis of
treatment following surgical removal of the infected
periapical tissue in periapical actinomycosis is excellent, it
should be recognized that the procedure routinely also
includes the removal of the root tip and placement of an
apical root-end filling. Therefore, the existence of apical
actinomycosis as a pathological entity independent of
the root canal infection and its involvement as the
exclusive cause of treatment failure remains to be proven.
Periapical biofilm colonies, like biofilms in general,
are assumed to be resistant to systemic antibiotic
treatment (62, 63). In addition to such biofilms inside
the periapical tissue, there are several reports of bacteria
growing in biofilms on the root surface close to the
apex (75, 79–81). There are probably two main routes
of infection resulting in root surface biofilms: one is
continuous expansion of microbial growth through the
apical foramen or through lateral canals, and the
second alternative is through dentinal tubules in an
area where root surface cementum has been resorbed
away (57, 58). The presence of a long-standing sinus
tract may also play a role in allowing bacterial
penetration from the oral cavity (75, 81). Irrespective
of the pathway of infection, when actinomycosis-like
colonies in the tissue or root surface biofilm have
developed, surgical treatment including apicoectomy
and removal of the infected hard and soft tissue has
been shown to be effective with an excellent long-term
prognosis (65, 82–84).

39
Haapasalo et al.

Fig. 11. (a) Apical section of an extracted tooth stained with modified Brown and Brenn staining reveals bacteria (dark
blue) in the root canal as well as on the apical root surface. (b) A high magnification image of the root surface shows
bacteria embedded in calculus-like structure. The tooth had no deep periodontal pockets.

Fig. 12. (a) Actinomyces-like colony (biofilm) close to the root surface in a tooth with (persistent apical lesion) primary
apical periodontitis. The bacteria are surrounded by a dense accumulation of inflammatory cells. (b) A high
magnification of Figure 12a shows several Gram-positive filamentous bacteria in the periapical biofilm.

From the point of view of treatment planning and
prevention, it would be useful to know the frequency of
extraradicular periapical infections as well as the details
of the pathogenesis of periapical actinomycosis. Un-
fortunately there is no reliable data about either. Study
populations have usually been poorly described in
reports of extraradicular infections. In addition, reli-
able diagnosis should be based on histological exam-
ination where sections have been prepared and
examined throughout the lesion. It is the opinion of
the authors that studies where only culturing or DNA
methods have been used may not always reflect the true
nature of the periapical condition/infection, and even a
temporary presence of bacteria in the tissue may be
confused with true extraradicular infection. The
possibility of true positive findings is supposed to be
higher and false positive findings lower when the
presence of the biofilm structure in tissue can be

40
 Reasons for persistent and emerging post-treatment endodontic disease
visualized in the sections. In a recent study, Ricucci &
Siqueira (64) evaluated the prevalence of bacterial
biofilms in untreated and treated root canals of teeth
with apical periodontitis. Extraradicular bacterial bio-
films were observed in six out of 100 specimens (6%),
four from teeth with untreated canals and two from
teeth with treated canals.
As previously mentioned, the development of root
surface biofilm supposedly occurs by growth of the
root canal microflora via apical foramen/foramina or
through the whole width of the infected root dentin
when root surface cementum has been resorbed.
Contrary to this, the pathogenesis of periapical
actinomycosis or actinomycosis-like extraradicular in-
fection is less obvious. Many of the species, including
Actinomyces spp., are non-motile bacteria, and yet they
are found as separate islands in the tissue. Furthermore,
how can bacteria travel in tissue and survive the host
defense before the protective biofilm is formed?
Individually, most if not all bacteria isolated so far
from periapical actinomycosis and other extraradicular
microbial lesions are sensitive to phagocytic ingestion
and killing. Although not known with certainty, one
possibility that cannot be ignored is that ready-formed
mature biofilms are transferred from the root canal into
the periapical area. This would help the bacteria avoid
the dangers of host defense as the biofilm is first formed
in the shelter of the necrotic root canal. Later, when in
the tissues, the biofilm provides the necessary protec-
tion. Kishen (85), based on measurements of liquid
movement in the apical root canal caused by occlusal
activity, suggested that this may allow transfer of
bacteria from the canal to the apical tissues. Another
possibility is that root canal biofilms are pushed into the
periapical tissue during instrumentation of the necrotic
root canal during the course of root canal treatment.
Radicular cyst
A radicular cyst develops subsequent to apical perio-
dontitis. Therefore, it can be classified under micro-
biological reasons, even though the cyst itself usually
does not contain bacteria. First, apical periodontitis
develops as a result of bacterial presence in the root
canal. Then, in some cases, epithelial cells in the
periapical area start to multiply, which may result in the
formation of a radicular cyst. While apical periodontitis
can in most cases heal by conservative root canal
treatment, the relationship between root canal treat-
ment and the healing of radicular cysts remains unclear.
Simon (86) and later Nair (7, 71) suggested that there
are two main types of radicular cysts, bay cysts
(periapical pocket cysts) and true cysts, and presented
the view that bay cysts have the better chance of healing
when only conservative root canal treatment is used.
On the contrary, in true cysts the epithelial lining is not
connected to the tooth and there is no communication
between the interior of the cyst and the root canal.
Therefore, it has been suggested that true cysts are
likely to require surgical removal to ensure healing of
the area (7). However, the hypothesis regarding the
requirements for healing of true cysts is a matter of
debate. Ricucci et al. (75) suggested that although the
use of serial sections may disclose a true cyst with no
apparent communication with the root canal, these
lesions cannot be regarded as a separate disease entity.
Lin et al. (87) argued that large cyst-like apical
periodontitis lesions or apical true cysts are formed
within an area of apical periodontitis and cannot form
by themselves. Therefore, both large cyst-like apical
periodontitis lesions and apical true cysts are of
inflammatory and not of neoplastic origin. According
to Lin et al. (87), lesions of apical periodontitis,
regardless of the histological type (granuloma, abscess,
cyst), that do not heal after conservative root canal
treatment persist for one reason: the presence of an
intraradicular and/or extraradicular infection. There
are no studies in the literature showing the absence of
microbes in the apical root canal, on the root surface, or
outside the tooth in cases of persisting radicular cysts. If
the microbial presence is terminated by the treatment,
the cystic lesions may regress by apoptosis, similar to
the resolution of inflammatory apical pocket cysts.
However, the clinical reality is that, mostly for
anatomical reasons, complete elimination of the
microflora cannot be obtained in all cases by con-
servative treatment. In situations where surgery is
performed to remove the cyst, it is important to
eliminate the areas of the tooth apex which are likely to
harbor the residual infection (87). Since clinicians are
unable to establish beforehand whether or not there is a
cyst (true or pocket) (54, 88), the effect of treatment
cannot be established in retrospect regardless of the
methods (conservative or surgical treatment) used.
The estimates of the frequency of radicular cysts
accompanying apical periodontitis show wide variation
between 6 and 55%; for review, see Nair (89). Nair et al.
(90) reported that, in a histological study of 256 apical
41
Haapasalo et al.
periodontitis lesions, 52% contained epithelial growth
but serial sectioning through the whole lesion revealed
that in fact only 15% were radicular cysts. The authors
suggested that histological analysis of only part of the
lesion may easily lead to overdiagnosis of radicular cysts
if the mere presence of epithelium is used as the
criterion (90). It should be noted that, in most studies,
lesions which are surgically removed and examined
histologically do not represent random lesions of
primary apical periodontitis as, in the great majority
of primary cases, there is no need for surgery.
Vertical root fracture
Vertical root fracture (VRF) can be regarded as a special
type of PTED (91–94). VRF can occur in teeth that
have not been endodontically treated, but it is most
common in roots which have a root filling (with or
without a post). Although VRF is not true apical
periodontitis, it causes signs and symptoms which are
often misinterpreted as persistent or emerging apical
periodontitis (Fig. 13). Vertical root fracture can occur
in any tooth (incisor, canine, premolar, or molar) and it
is always bucco-lingual. It starts in the root and is often
invisible at the beginning, both clinically and radio-
Fig. 13. Vertical root fracture in a maxillary canine. A
typical pear-shaped lesion can be seen ‘climbing’ up the
root.
42
graphically, except for the possibility of pain. Later a
narrow pocket develops all the way to the apex of the
tooth, which can be incorrectly diagnosed as a
‘‘regular’’ deep periodontal pocket or endodontic sinus
tract which mimics a pocket. The infection is caused by
bacteria residing in the fracture line, escaping from the
host defense. There is no treatment for VRF other than
extraction; therefore it is important to make an early
diagnosis in order to avoid unnecessary treatment.
Crack tooth and split tooth
Crack tooth is another type of longitudinal tooth
fracture (95). Unlike VRF, it starts in the crown, it is
mesio-distal, and occurs only in premolars and molars
(Fig. 14). Similar to VRF, it is not a true endodontic
infection. However, it often causes symptoms that can
be confused with PTED. A common consequence of
infection caused by a crack is a narrow mesial or distal
pocket. The crack itself is always invisible radio-
graphically but the bone loss caused by the infection
can often be seen. Clinically, the pocket may be difficult
to locate without careful probing. Another site of tissue
destruction caused by a crack is at the furcation, if a
deep crack extends through the pulp chamber floor. As
in VRF, bacteria remain in the crack and cannot be
eliminated without removing the dental hard tissue
surrounding the crack. In deep cracks this is not
possible and the tooth must be extracted. Split tooth is
Fig. 14. Crack tooth. A distal fracture line in a maxillary
molar. The line is stained, indicating that it is not new.
The depth of the fracture will determine the fate of the
tooth. When the fracture extends below the marginal
bone level, a narrow pocket and diffuse symptoms can be
detected.
 Reasons for persistent and emerging post-treatment endodontic disease

Fig. 15. (a-b) Split tooth. A previous crack in a mandibular molar developed further, splitting the tooth into two halves.
(c) A histological section of the distal mid-root verifies the mesio-distal direction of the fracture line. (d) Higher
magnification reveals microbial biofilm (stained blue) in the dentin wall of the fracture line. Reprinted modified with
permission from Ricucci D. Patologia e Clinica Endodontica. 2009; Edizioni Martina, Bologna, Italy.

a continuation of a crack tooth; in split tooth there are without protection by the coronal restoration in the
always two separate tooth fragments (Fig. 15). Split oral cavity for different time periods and then followed
tooth is therefore easy to diagnose; the only available for long-term prognosis after finishing the coronal seal.
treatment option is extraction.

Non-microbial causes for PTED

Coronal leakage
In many reports, coronal leakage has been suggested as a
possible cause for PTED (31, 96–100). A legion of
laboratory studies have indicated that at least some
bacteria can penetrate deeply into the root-filled canal in
only a few weeks if the canal and root filling are not
properly sealed with a coronal restoration. Most of these
studies have shown contamination of the liquid medium
at the apical end of the root by bacteria which were
placed in a coronal reservoir within a few weeks or
months, while some studies have demonstrated bacteria
between the canal wall dentin and the gutta-percha–
sealer complex using microscopic techniques (101–
106). Despite the vast amount of such information,
the true importance of coronal leakage has not been
fully demonstrated. The few studies in humans have
indicated that, although possible in teeth treated
according to less than ideal technical standards, good
fillings in optimally prepared canals may resist bacterial
penetration, even after long-standing exposure to the
oral environment (34, 107, 108). However, a new lesion
after a technically good root filling is not uncommon
either. It is therefore likely that a widely accepted
consensus regarding the clinical importance of coronal
leakage for the long-term prognosis of root-filled teeth
will remain a challenge for the future. The major reason
for this is ethical problems in conducting a clinical study
where root-filled teeth would be intentionally left
As mentioned earlier, primary apical periodontitis is
practically always caused by microbes. The situation in
PTED is to some extent different. While the primary
inflammation (inflammatory response/reaction of the
host tissues) is caused by an infection (microbial
presence in the root canal or even in the periapical
tissues), secondary developments caused either by the
inflammatory reaction itself or by treatment procedures
may contribute to the continuation of the inflamma-
tion. In the following, the most common secondary
factors and their relationship to persisting infection
within the tooth structures in PTED will be discussed.
Cholesterol crystals
Cholesterol is a steroid lipid present in human and
animal cells. Under some conditions, cholesterol can
form crystals and contribute to disease development,
e.g. atherosclerotic plaque in coronary disease (109,
110). Cholesterol crystals are also commonly found in
apical periodontitis (111–113). The origin of choles-
terol in the periapical area (Fig. 16) is most likely the
dying cells during chronic inflammation (111, 112). At
sites of inflammation, granulocytes generate reactive
oxygen metabolites which have been shown to
promote cholesterol crystal formation (114). Experi-
mental studies have shown that the presence of
cholesterol crystals in the tissue attracts accumulations

43
Haapasalo et al.

Fig. 16. A histological section (haematoxylin-eosin

staining) shows numerous cholesterol crystals and a
heavy accumulation of inflammatory cells in a specimen
obtained from a tooth with a periapical inflammation.

of host defense cells, macrophages in particular,

probably in an effort to remove the crystals by
phagocytosis (115–117). However, macrophages are
unable to eliminate the crystals, maybe partially due to
their large size as compared to the cells. The effort
nevertheless contributes to a local inflammatory
reaction via release of inflammatory mediators such as
interleukin 1a by the macrophages and other defense
cells at the site (117). In summary, cholesterol crystals
are not originally present in the periapical tissue of a
healthy tooth but, during long-standing chronic apical
periodontitis, crystals may develop locally in the tissue.
However, it should be emphasized that there are no
reports of failed cases where adequate histological
processing has shown the presence of cholesterol in
periapical tissue in the absence of infection, and a
Fig. 17. (a) A histological section of a periapical
recent histological study on failed cases did not
inflammatory lesion with foreign material. (b) A close-
describe cholesterol as responsible for the failures (8). up of the area with foreign material (dark particles,
possibly sealer) shows multinuclear giant cells next to the
material, surrounded by inflammatory cells. The reason
Foreign body reaction for persisting apical periodontitis was the intraradicular
presence of bacteria. Reprinted modified with permission
Foreign material may become lodged in the periapical
from Ricucci D. Patologia e Clinica Endodontica. 2009;
tissue and cause irritation and inflammation in the area, Edizioni Martina, Bologna, Italy.
leading to the delay or prevention of healing. Foreign
material can enter the periapical tissue (Fig. 17) from the root canal) and provide a protective platform
through the root canal when the tooth is left open for further microbial growth in the tissues. Second,
into the oral cavity or during endodontic procedures. even without any microbial contamination, foreign
Another route is by traumatic injury through the material may cause a giant cell response as the body
mucosa or during endodontic surgery. Foreign materi- tries to remove it. Giant cells and macrophages, similar
al can cause or contribute to periapical inflammation by to the situation with cholesterol crystals, secrete
at least two different mechanisms. First, it can have inflammatory mediators during their often chronic
microbes/biofilm attached to its surface (obtained effort to clear the area of foreign material.

44
 Reasons for persistent and emerging post-treatment endodontic disease
Gutta-percha is usually well tolerated if a non-
contaminated tip of a gutta-percha cone is extruded
during root filling to the periapical area. Nair et al.
(118) have shown that gutta-percha will be encapsu-
lated by multilayered collagen fibers with little or no
invasion of inflammatory cells surrounding the capsule.
In other experiments, Sjögren et al. (115) demon-
strated that when gutta-percha is processed into small
particles and introduced into vital tissue in experi-
mental animals, it is surrounded by mononuclear
inflammatory cells. A situation where gutta-percha
may be associated with continuing periapical inflam-
mation is when a piece of gutta-percha from an existing
root filling, covered with a biofilm, is left or pushed
into the periapical area during re-treatment.
Endodontic sealers are often extruded into the
periapical area during root filling, in particular with
various thermoplastic root filling techniques (119,
120). Small amounts of sealer are not expected to cause
major problems for healing. Most commercially avail-
able sealers become practically inert after some time
(34). In a histological study of 51 root-filled human
teeth healed after long-term observation periods and
extracted for various reasons, Ricucci et al. (34)
concluded that it is very unlikely that any material
toxicity would be discernible as tissue changes. No
clinical association with outcomes could be observed
when comparing the long-term treatment results of
different sealers used in this study (34). However, if the
sealer is contaminated by bacteria from a poorly
instrumented and disinfected canal, it will be a center
of continuing inflammation and thereby PTED. Also,
larger volumes of extruded sealer, even when not
contaminated, are likely to cause a foreign body reaction
by giant cells and macrophages, resulting in some
degree of continuing inflammatory reaction (121, 122).
In rare situations, even quite small amounts of either
sealer, gutta-percha, or both may be extruded outside
the root canal on the bone surface under the periosteum.
This may occur when the apical foramen is naturally
located in this area. Clinical experience has shown that
the area remains sensitive to palpation even for several
months, and spontaneous pain may also be experienced
by the patient, both an indication of PTED. Radio-
graphic examination may not reveal anything of concern,
but the irritation can only be solved by exploratory flap
operation and removal of the extruded material.
Other filling materials such as amalgam, gold,
silver, glass ionomer, composite materials, or compo-
Fig. 18. A separated piece of a silver point can be seen in
the periapical lesion of a first mandibular molar several
years after root canal treatment. However, the reason for
the unhealed lesion is persisting infection in the root canal
system of the tooth, not the silver point per se.
nents of disinfection pastes can also be found in the
periapical tissues in some cases of PTED (123). Similar
to the materials described earlier, microbial contam-
ination is possible with all of these materials, usually
from the root canal microflora, the material itself acting
in a ‘‘supporting’’ role by offering a platform for the
bacteria to form a biofilm on its surface. The continued
infection and inflammation is caused by the microbes
while the material may contribute to the inflammation
by stimulating a foreign body reaction as explained
earlier. In many occasions the filling materials present
in periapical tissues originate from a root-end filling
that was loosened or where parts of it were misplaced to
begin with during periapical surgical. Silver cones may
undergo corrosion and, if overfilled, the part in the
tissue may separate and stay in the lesion, causing a
foreign body reaction (Fig. 18). Amalgam and gold
may also originate from a restoration or a crown if the
metal powdered during burring falls into the root canal
and is pushed further into the periapical area.
Cellulose-containing materials and plant cells are
known to be able to cause a chronic inflammatory
reaction if present in the periapical tissue (71, 124,
125). Cellulose is foreign material and the human body
does not have enzymes to degrade cellulose. The above
studies have demonstrated the presence of cellulose
45
Haapasalo et al.

sometimes yeasts are regarded as the main etiological

explanation for post-treatment endodontic disease,
other reasons have also been suggested. These include
cholesterol crystals or a true cyst that may have
developed during the primary infection. However, it
has been proposed that they may become an independ-
ent reason for the persistence of the inflammation even
after the elimination of the infection. In this article the
authors critically review earlier literature and emphasize
that the evidence which would rule out the role of
residual micro-organisms is, in fact, weak or lacking.
Therefore, despite the possible contributing role of
non-microbial factors in periapical inflammation,
complete eradication of micro-organisms from the
root canal system remains the most important target of
Fig. 19. A piece of a plant (green salad) was found during
successfully eliminating PTED.
periapical surgery in the periapical abscess of a maxillary
lateral incisor. Courtesy of Dr. Stefaan Vandenwijngaert
in: Visual Endodontics, 2010.

References
from paper points in the lesion; another possible source
is cotton pellets. Contamination of paper points with
bacteria will further add to the development of a
stronger inflammatory response. The earlier practice of
using paper points as vehicles for root canal medica-
ments, leaving the points in the canal between
appointments, should be advised against because the
points may disintegrate or become fragile during the
inter-appointment period in the root canal. Periapical
surgery and careful cleaning of the bone cavity is the
best way to completely eliminate the irritation (and
PTED) from cellulose-containing materials. These
materials are not visible radiographically and therefore
they cannot be diagnosed pre-operatively.
Plant cells are probably a relatively rare reason for
PTED. However, if they find their way to the periapical
tissue of a tooth, the pathogenesis of continuing
inflammation is similar to that when cellulose-contain-
ing fibers from paper points are found in this area.
Small pieces of vegetables could be pushed down the
canal to the periapical tissues when the tooth has been
left open or a temporary filling has fallen out. Figure 19
shows a case of persistent infection where microscopic
pieces of green vegetables were found inside the lesion.
Summary and conclusions
Micro-organisms are practically the only cause of
primary apical periodontitis. Although bacteria and
1. European Society of Endodontology. Quality guide-
lines for endodontic treatment: consensus report of the
European Society of Endodontology. Int Endod J
2006: 39: 921–930.
2. Nair PNR, Schroeder HE. Periapical actinomycosis.
J Endod 1984: 10: 567–570.
3. Sjögren U, Happonen RP, Kahnberg KE, Sundqvist G.
Survival of Arachnia propionica in periapical tissue. Int
Endod J 1988: 21: 277–282.
4. Nair PNR, Sjögren U, Kahnberg KE, Krey G, 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: 580–588.
5. Figdor D, Sjögren U, Sorlin S, Sundqvist G, Nair PNR.
Pathogenicity of Actinomyces israelii and Arachnia
propionica: experimental infection in guinea pigs and
phagocytosis and intracellular killing by human poly-
morphonuclear leukocytes in vitro. Oral Microbiol
Immunol 1992: 7: 129–136.
6. Nair PNR. Non-microbial etiology: foreign body
reaction maintaining post-treatment apical periodonti-
tis. Endod Topics 2003a: 6: 96–113.
7. Nair PNR. Non-microbial etiology: periapical cysts
sustain post-treatment apical periodontitis. Endod
Topics 2003b: 6: 114–134.
8. Ricucci D, Siqueira JF Jr, Bate AL, Pitt Ford TR.
Histologic investigation of root canal-treated teeth
with apical periodontitis: a retrospective study from 24
patients. J Endod 2009b: 3: 493–502.
9. Soikkonen KT. Endodontically treated teeth and
periapical findings in the elderly. Int Endod J 1995:
28: 200–203.
10. Sidaravicius B, Aleksejūnienë J, Eriksen HM. Endo-
dontic treatment and prevalence of apical periodontitis

46
 Reasons for persistent and emerging post-treatment endodontic disease
in an adult population of Vilnius, Lithuania. Endod
Dent Traumatol 1999: 15: 210–215.
11. De Moor RJG, Hommez GMG, De Boever JG, Delmé
KIM, Martens GEI. Periapical health related to the
quality of root canal treatment in a Belgian population.
Int Endod J 2000: 33: 113–120.
12. Kirkevang L-L, Hõrsted-Bindslev P, Ørstavik D,
Wenzel A. A comparison of the quality of root canal
treatment in two Danish subpopulations examined 1974–
75 and 1997–98. Int Endod J 2001: 34: 607–612.
13. Dugas NN, Lawrence HP, Teplitsky PE, Pharoah MJ,
Friedman S. Periapical health and treatment quality
assessment of root-filled teeth in two Canadian
populations. Int Endod J 2003: 36: 181–192.
14. Peters LB, Wesselink PR. Periapical healing of endo-
dontically treated teeth in one and two visits obturated
in the presence or absence of detectable microorgan-
isms. Int Endod J 2002: 35: 660–667.
15. Molander A, Warfvinge J, Reit C, Kvist T. Clinical and
radiographic evaluation of one- and two-visit endo-
dontic treatment of asymptomatic necrotic teeth with
apical periodontitis: a randomized clinical trial. J Endod
2007: 33: 1145–1148.
16. Ørstavik D. Time-course and risk analyses of the
development and healing of chronic apical perio-
dontitis in man. Int Endod J 1996: 29: 150–155.
17. Bender IB, Seltzer S. Roentgenographic and direct
observation of experimental lesions in bone: I. J Am
Dent Assoc 1961: 62: 152–160.
18. Bender IB. Factors influencing the radiographic ap-
pearance of bone lesions. J Endod 1982: 8: 161–170.
19. van der Stelt PF. Experimentally produced bone
lesions. Oral Surg Oral Med Oral Pathol 1985: 59:
306–312.
20. Huumonen S, Ørstavik D. Radiological aspects of
apical periodontitis. Endod Topics 2002: 1: 3–25.
21. Shoha RR, Dowson J, Richards AG. Radiographic
interpretation of experimentally produced bony
lesions. Oral Surg Oral Med Oral Pathol 1974: 38:
294–303.
22. ElDeeb ME, Zucker KJ, Messer H. Apical leakage in
relation to radiographic density of Gutta-percha
using different obturation techniques. J Endod 1985:
11: 25–29.
23. Barbat J, Messer HH. Detectability of artificial peria-
pical lesions using direct digital and conventional
radiography. J Endod 1998: 24: 837–842.
24. Gao Y, Haapasalo M, Shen Y, Wu H, Jiang H, Zhou X.
Development of virtual simulation platform for in-
vestigation of the radiographic features of periapical
bone lesion. J Endod 2010: 36: 1404–1409.
25. de Paula-Silva FW, Wu MK, Leonardo MR, da Silva LA,
Wesselink PR. Accuracy of periapical radiography and
cone-beam computed tomography scans in diagnosing
apical periodontitis using histopathological findings as
a gold standard. J Endod 2009: 35: 1009–1012.
26. Patel S. New dimensions in endodontic imaging: Part
2. Cone beam computed tomography. Int Endod J
2009: 42: 463–475.
27. Patel S, Dawood A, Whaites E, Pitt Ford T. New
dimensions in endodontic imaging: Part 1. Conven-
tional and alternative radiographic systems. Int Endod J
2009: 42: 447–462.
28. Kakehashi S, Stanley HR, Fitzgerald RJ. The effects of
surgical exposures of dental pulps in germfree and
conventional laboratory rats. J South Calif Dent Assoc
1966: 34: 449–451.
29. Bergenholtz G. Micro-organisms from necrotic pulp of
traumatized teeth. Odontol Revy 1974: 25: 347–358.
30. Sundqvist G. Taxonomy, ecology, and pathogenicity of
the root canal flora. Oral Surg Oral Med Oral Pathol
1994: 78: 522–530.
31. Haapasalo M, Udnæs T, Endal U. Persistent, recurrent
and acquired infection of the root canal system post-
treatment. Endod Topics 2003: 6: 29–56.
32. Chugal NM, Clive JM, Spangberg LS. A prognostic
model for assessment of the outcome of endodontic
treatment: effect of biologic and diagnostic variables.
Oral Surg Oral Med Oral Pathol 2001: 91: 342–352.
33. Haapasalo M, Endal U, Zandi H, Coil JM. Eradication
of endodontic infection by instrumentation and irriga-
tion solutions. Endod Topics 2005: 10: 77–102.
34. Ricucci D, Lin LM, Spångberg LSW. Wound healing of
apical tissues after root canal therapy: a long-term
clinical, radiographic, and histopathologic observation
study. Oral Surg Oral Med Oral Pathol Oral Radiol
Endod 2009a: 108: 609–621.
35. Waltimo TMT, Siren EK, Torkko HLK, Olsen I,
Haapasalo MP. Fungi in therapy-resistant apical perio-
dontitis. Int Endod J 1997: 30: 96–101.
36. Waltimo TM, Sen BH, Meurman JH, Ørstavik D,
Haapasalo MP. Yeasts in apical periodontitis. Crit Rev
Oral Biol Med 2003: 14: 128–137.
37. Siqueira JF Jr, Rôças IN. Polymerase chain reaction-
based analysis of microorganisms associated with failed
endodontic treatment. Oral Surg Oral Med Oral Pathol
Oral Radiol Endod 2004: 97: 85–94.
38. Sakamoto M, Siqueira JF Jr, Rôças IN, Benno Y.
Molecular analysis of the root canal microbiota
associated with endodontic treatment failures. Oral
Microbiol Immunol 2008: 23: 275–281.
39. Portenier I, Waltimo TMT, Haapasalo M. Enterococcus
faecalis – the root canal survivor and ‘‘star’’ in post-
treatment disease. Endod Topics 2003: 6: 135–159.
40. 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: 429–434.
41. Nair PNR. Pathogenesis of apical periodontitis and the
causes of endodontic failures. Crit Rev Oral Biol Med
2004: 15: 348–381.
42. Reynaud Af Geijersstam AH, Ellington MJ, Warner M,
Woodford N, Haapasalo M. Antimicrobial susceptibility
and molecular analysis of Enterococcus faecalis originating
from endodontic infections in Finland and Lithuania.
Oral Microbiol Immunol 2006: 21: 164–168.
43. Reynaud Af Geijersstam A, Culak R, Molenaar L,
Chattaway M, Roslie E, Peciuliene V, Haapasalo M,
47
Haapasalo et al.
Shah HN. Comparative analysis of virulence determi-
nants and mass spectral profiles of Finnish and
Lithuanian endodontic Enterococcus faecalis isolates.
Oral Microbiol Immunol 2007: 22: 87–94.
44. Molander A, Reit C, Dahlén G, Kvist T. Microbiolog-
ical status of root-filled teeth with apical periodontitis.
Int Endod J 1998: 31: 1–7.
45. Sedgley CM, Lennan SL, Appelbe OK. Survival of
Enterococcus faecalis in root canals ex vivo. Int Endod J
2005: 38: 735–742.
46. Sundqvist G. Bacteriological Studies of Necrotic Dental
Pulps. Odontological Dissertations, No. 7. Umea:
University of Umea, 1976.
47. Möller AJR, Fabricius L, Dahlén G, Öhman AE,
Heyden G. Influence on periapical tissues of indigenous
oral bacteria and necrotic pulp tissue in monkeys.
Scandinavian J Dent Res 1981: 89: 475–484.
48. Fabricius L, Dahlén G, Öhman AE, Möller AJ.
Predominant indigenous oral bacteria isolated from
infected root canals after varied times of closure. Scand
J Dent Res 1982: 90: 134–144.
49. Evans M, Davies JK, Sundqvist G, Figdor D. Mechan-
isms involved in the resistance of Enterococcus faecalis to
calcium hydroxide. Int Endod J 2002: 35: 221–228.
50. Bergenholtz G, Spångberg L. Controversies in endo-
dontics. Crit Rev Oral Biol Med 2004: 15: 99–114.
51. Zehnder M, Paqué F. Disinfection of the root canal
system during root canal re-treatment. Endod Topics
2011: 19: 58–73.
52. Ando N, Hoshino E. Predominant obligate anaerobes
invading the deep layers of root canal dentin. Int Endod
J 1990: 23: 20–27.
53. Peters LB, Wesselink PR, Buijs JF, Van Winkelhoff AJ.
Viable bacteria in root dentinal tubules of teeth with
apical periodontitis. J Endod 2001: 27: 76–81.
54. Ricucci D, Pascon EA, Pitt Ford TR, Langeland K.
Epithelium and bacteria in periapical lesions. Oral
Surg Oral Med Oral Pathol Oral Radiol Endod 2006b:
101: 239–249.
55. Peters LB, Wesselink PR, Moorer WR. The fate and the
role of bacteria left in root dentinal tubules. Int Endod J
1995: 28: 95–99.
56. Ricucci D, Siqueira JF Jr. Fate of the tissue in lateral
canals, apical ramifications in response to pathologic
conditions and treatment procedures. J Endod 2010b:
36: 1–15.
57. Valderhaug J. A histologic study of experimentally
induced periapical inflammation in primary teeth in
monkeys. Int J Oral Surg 1974: 3: 111–123.
58. Tronstad L, Kreshtod D, Barnett F. Microbiological
monitoring and results of treatment of extraradicular
endodontic infection. Endod Dent Traumatol 1990: 6:
129–136.
59. Jain A, Gupta Y, Agrawal R, Khare P, Jain SK. Biofilms
Fa microbial life perspective: a critical review. Crit Rev
Ther Drug Carrier Syst 2007: 24: 393–443. Review.
60. Vu B, Chen M, Crawford RJ, Ivanova EP. Bacterial
extracellular polysaccharides involved in biofilm forma-
tion. Molecules 2009: 14: 2535–2554. Review.
48
61. Hall-Stoodley L, Stoodley P. Evolving concepts in
biofilm infections. Cell Microbiol 2009: 11: 1034–
1043. Review.
62. Hiby N, Bjarnsholt T, Givskov M, Molin S, Ciofu O.
Antibiotic resistance of bacterial biofilms. Int J Anti-
microb Agents 2010: 35: 322–332.
63. Lewis K. Multidrug tolerance of biofilms and persister cells.
Curr Top Microbiol Immunol 2008: 322: 107–131.
64. Ricucci D, Siqueira JF Jr. Biofilms and apical perio-
dontitis: study of prevalence, association with
clinical and histopathologic findings. J Endod 2010:
36: 1277–1288.
65. Sundqvist G, Reuterving C. Isolation of Actinomyces
israelii from periapical lesion. J Endod 1980: 6: 602–
606.
66. Haapasalo M, Ranta K, Ranta H. Mixed anaerobic
periapical infection with sinus tract. Endod Dent
Traumatol 1987: 3: 83–85.
67. Tronstad L, Barnett F, Riso K, Slots J. Extraradicular
endodontic infections. Endod Dent Traumatol 1987:
3: 86–90.
68. Sunde PT, Olsen I, Debelian GJ, Tronstad L. Micro-
biota of periapical lesions refractory to endodontic
therapy. J Endod 2002: 28: 304–310.
69. Sunde PT, Olsen I, Göbel UB, Theegarten D, Winter S,
Debelian GJ, Tronstad L, Moter A. Fluorescence in situ
hybridization (FISH) for direct visualization of bacteria
in periapical lesions of asymptomatic root-filled teeth.
Microbiology 2003: 149: 1095–1102.
70. Sunde PT, Olsen I, Lind PO, Tronstad L. Extra-
radicular infection: a methodological study. Endod
Dent Traumatol 2000: 16: 84–90.
71. Nair PNR. Pathology of apical periodontitis. In:
Ørstavik D, Pitt Ford TR, eds. Essential Endodontology.
Oxford: Blackwell, 1998c.
72. van Winkelhoff AJ, van Steenbergen TJ, de Graaff J.
The role of black-pigmented Bacteroides in human oral
infections. J Clin Periodontol 1988: 15: 145–155.
73. Trope M, Rosenberg E, Tronstad L. Darkfield micro-
scopic spirochete count in the differentiation of
endodontic and periodontal abscesses. J Endod 1992:
18: 82–86.
74. Kishen A, George S, Kumar R. Enterococcus faecalis-
mediated biomineralized biofilm formation on root
canal dentine in vitro. J Biomed Mater Res A 2006: 77:
406–415.
75. Ricucci D, Martorano M, Bate AL, Pascon EA.
Calculus-like deposit on the apical external root surface
of teeth with post-treatment apical periodontitis:
report of two cases. Int Endod J 2005: 38: 262–271.
76. Gatti JJ, Dobeck JM, Smith C, White RR, Socransky
SS, Skobe Z. Bacteria of asymptomatic periradicular
endodontic lesions identified by DNA-DNA hybridiza-
tion. Endod Dent Traumatol 2000: 16: 197–204.
77. Chan S, Mohammed N, Dobeck JM, White RR,
Socransky SS, Skobe Z. Evaluation of the whole
genome DNA-DNA hybridization technique to iden-
tify bacteria in histological sections of periradicular
lesions. J Endod 2004: 30: 518–522.
 Reasons for persistent and emerging post-treatment endodontic disease
78. Ricucci D, Siqueira JF Jr. Apical actinomycosis as a
continuum of intraradicular, extraradicular infection:
case report andcritical review on its involvement with
treatment failure. J Endod 2008: 34: 1124–1129.
79. Tronstad L, Barnett F, Cervone F. Periapical bacterial
plaque in teeth refractory to endodontic treatment.
Endod Dent Traumatol 1990: 6: 73–77.
80. Siqueira JF Jr, Lopes HP. Bacteria on the apical root
surfaces of untreated teeth with periradicular lesions: a
scanning electron microscopy study. Int Endod J 2001:
34: 216–220.
81. Ricucci D, Bergenholtz G. Histologic features of apical
periodontitis in human biopsies. Endod Topics 2004: 8:
68–87.
82. Samanta A, Malik CP, Aikat BK. Periapical actinomy-
cosis. Oral Surg 1975: 39: 458–462.
83. Wesley RK, Osborn TP, Dylewski JJ. Periapical
actinomycosis: clinical considerations. J Endod 1977:
3: 352–355.
84. Rubinstein RA, Kim S. Short-term observation of the
results of endodontic surgery with the use of a surgical
operation microscope and Super-EBA as root-end
filling material. J Endod 1999: 25: 43–48.
85. Kishen A. Periapical biomechanics and the role of cyclic
biting force in apical retrograde fluid movement. Int
Endod J 2005: 38: 597–603.
86. Simon JH. Incidence of periapical cysts in relation to
the root canal. J Endod 1980: 6: 845–848.
87. Lin LM, Ricucci D, Lin J, Rosenberg PA. Nonsurgical
root canal therapy of large cyst-like inflammatory
periapical lesions and inflammatory apical cysts. J Endod
2009: 35: 607–615.
88. Ricucci D, Mannocci F, Pitt Ford TR. A study of
periapical lesions correlating the presence of a radio-
paque lamina with histological findings. Oral Surg
Oral Med Oral Pathol Oral Radiol Endod 2006a: 101:
389–394.
89. Nair PNR. New perspectives on radicular cysts: do they
heal? Int Endod J 1998a: 31: 155–160.
90. Nair PNR, Pajarola G, Schroeder HE. Types and
incidence of human periapical lesions obtained with
extracted teeth. Oral Surg Oral Med Oral Pathol 1996:
81: 93–102.
91. Vire DE. Failure of endodontically treated teeth: classifi-
cation and evaluation. J Endod 1991: 17: 338–342.
92. Testori T, Badino M, Castagnola M. Vertical root
fractures in endodontically treated teeth: a clinical
survey of 36 cases. J Endod 1993: 19: 87–90.
93. Tamse A, Lustig J, Kaplavi J. An evaluation of
endodontically treated vertically fractured teeth.
J Endod 1999: 25: 506–508.
94. Walton RE, Michelich RJ, Smith GN. The histopathogen-
esis of vertical root fractures. J Endod 1984: 2: 48–56.
95. Rivera EM, Walton RE. Longitudinal tooth fractures:
findings that contribute to complex endodontic diag-
nosis. Endod Topics 2007: 16: 82–111.
96. Madison S, Swanson K, Chiles SA. An evaluation of
coronal microleakage in endodontically treated teeth.
II Sealer types. J Endod 1987: 13: 109–112.
97. Swanson K, Madison S. An evaluation of coronal
microleakage in endodontically treated teeth. Part I.
Time periods. J Endod 1987: 13: 56–59.
98. Torabinejad M, Ung B, Kettering JD. In vitro bacterial
penetration of coronally unsealed endodontically
treated teeth. J Endod 1990: 16: 566–569.
99. Saunders WP, Saunders EM. Coronal leakage as a cause
of failure in root-canal therapy: a review. Endod Dent
Traumatol 1994: 10: 105–108.
100. Lazarski MP, Walker WA 3rd, Flores CM, Schindler
WG, Hargreaves KM. Epidemiological evaluation of
the outcomes of nonsurgical root canal treatment in a
large cohort of insured dental patients. J Endod 2001:
27: 791–796.
101. Brosco VH, Bernardineli N, Torres SA, Consolaro A,
Bramante CM, de Moraes IG, Garcia RB. Bacterial
leakage in root canals obturated by different tech-
niques. Part 1: microbiologic evaluation. Oral Surg
Oral Med Oral Pathol Oral Radiol Endod 2008: 105:
e48–e53.
102. De-Deus G, Murad C, Paciornik S, Reis CM,
Coutinho-Filho T. The effect of the canal-filled area
on the bacterial leakage of oval-shaped canals. Int
Endod J 2008: 41: 183–190.
103. Kampfer J, Göhring TN, Attin T, Zehnder M. Leakage
of food-borne Enterococcus faecalis through temporary
fillings in a simulated oral environment. Int Endod J
2007: 40: 471–477.
104. Saleh IM, Ruyter IE, Haapasalo M, Ørstavik D.
Bacterial penetration along different root canal filling
materials in the presence or absence of smear layer. Int
Endod J 2008: 41: 32–40.
105. Siqueira JF Jr, Rôças IN, Favieri A, Abad EC, Castro AJ,
Gahyva SM. Bacterial leakage in coronally unsealed
root canals obturated with 3 different techniques. Oral
Surg Oral Med Oral Pathol Oral Radiol Endod 2000:
90: 647–650.
106. Williamson AE, Marker KL, Drake DR, Dawson DV,
Walton RE. Resin-based versus gutta-percha-based
root canal obturation: influence on bacterial leakage
in an in vitro model system. Oral Surg Oral Med Oral
Pathol Oral Radiol Endod 2009: 108: 292–296.
107. Ricucci D, Gröndahl K, Bergenholtz G. Periapical
status in root-filled teeth exposed to the oral environ-
ment by loss of restoration or caries. Oral Surg
Oral Med Oral Pathol Oral Radiol Endod 2000: 90:
354–359.
108. Ricucci D, Bergenholtz G. Bacterial status in root-filled
teeth exposed to the oral environment by loss of
restoration and fracture or cariesFa histobacteriological
study of treated cases. Int Endod J 2003: 36: 787–802.
109. Yeagle PL. The Biology of Cholesterol. Boca Raton, FL:
CRC Press, 1988.
110. Yeagle PL. Understanding Your Cholesterol. San Diego,
CA: Academic Press, 1991.
111. Shear M. The histogenesis of dental cysts. Dental
Practitioner 1963: 13: 238–243.
112. Browne RM. The origin of cholesterol in odontogenic
cysts in man. Arch Oral Biol 1971: 16: 107–113.
49
Haapasalo et al.
113. Trott JR, Chebib F, Galindo Y. Factors related to
cholesterol formation in cysts and granulomas. J Can
Dent Assoc 1973: 38: 76–78.
114. Eder MI, Miquel JF, Jongst D, Paumgartner G, von
Ritter C. Reactive oxygen metabolites promote cho-
lesterol crystal formation in model bile: role of lipid
peroxidation. Free Radic Biol Med 1996: 20: 743–749.
115. Sjögren U, Sundqvist G, Nair PNR. Tissue reaction to
gutta-percha of various sizes when implanted subcuta-
neously in guinea pigs. Euro J Oral Scien 1995: 103:
313–321.
116. Nair PNR, Sjögren U, Sundqvist G. Cholesterol
crystals as an etiological factor in non-resolving chronic
inflammation: an experimental study in guinea pigs.
Euro J Oral Scien 1998b: 106: 644–650.
117. Sjögren U, Mukohyama H, Roth C, Sundqvist G,
Lerner UH. Bone-resorbing activity from cholesterol-
exposed macrophages due to enhanced expression of
interleukin-1a. J Dent Res 2002: 81: 11–16.
118. Nair PNR, Sjögren U, Krey G, Sundqvist G. Therapy-
resistant foreign-body giant cell granuloma at the
periapex of a root filled human tooth. J Endod
1990b: 16: 589–595.
119. Gutmann JL, Saunders WP, Saunders EM, Nguyen L.
An assessment of the plastic Thermafil obturation
50
technique. Part 1. Radiographic evaluation of adapta-
tion and placement. Int Endod J 1993: 26: 173–178.
120. Da Silva D, Endal U, Reynaud A, Portenier I, Ørstavik
D, Haapasalo M. A comparative study of lateral
condensation, heat-softened gutta-percha, and a mod-
ified master cone heat-softened backfilling technique.
Int Endod J 2002: 35: 1005–1111.
121. Zmener O, Guglielmotti MB, Cabrini RL. Tissue
response to an experimental calcium hydroxide-based
endodontic sealer: a quantitative study in subcutaneous
connective tissue of the rat. Endod Dent Traumatol
1990: 6: 66–72.
122. Ricucci D, Langeland K. Apical limit of root canal
instrumentation and obturation, part 2. A histological
study. Int Endod J 1998: 31: 394–409.
123. Koppang HS, Koppang R, Stlen SØ. Identification of
common foreign material in postendodontic granulo-
mas and cysts. J Dent Assoc S Afr 1992: 47: 210–216.
124. Koppang HS, Koppang R, Solheim T, Aarnes H, Stlen
SØ. Cellulose fibers from endodontic paper points as an
etiologic factor in postendodontic periapical granulo-
mas and cysts. J Endod 1989: 15: 369–372.
125. Sedgley CM, Messer H. Long-term retention of a
paperpoint in the periapical tissues: a case report. Endod
Dent Traumatol 1993: 9: 120–123.