Endodontic retreatment decisions: no consensus
S. Aryanpour1, J.-P. Van Nieuwenhuysen1 & W. D'Hoore2
1
Department of Operative Dentistry, School of Dental Medicine and Stomatology; and 2Department of Hospital Administration,
Universite Catholique de Louvain, Belgium
Abstract
Aryanpour S, Van Niewenhuysen J-P, D'Hoore W.
Endodontic retreatment decisions: no consensus. International
Endodontic Journal, 33, 208±218, 2000.
Aim The objectives of the present study were to: (i)
evaluate the consensus, if any, amongst dental schools,
students and their instructors managing the same
clinical cases, all of which involved endodontically
treated teeth; and (ii) determine the predominant
proposed treatment option.
Methodology Final year students, endodontic
staff members and instructors of 10 European
dental schools were surveyed as decision makers.
Fourteen different radiographic cases of root canal
treated teeth accompanied by a short clinical
history were presented to them in a uniform
format. For each case the decision makers were
requested to: (i) choose only one out of nine
treatment alternatives proposed, from `no treatment'
to `extraction' via `retreatment' and `surgery' (ii)
assess on two 5-point scales: the difficulty of
Introduction
There are substantial differences in endodontic
treatment outcomes between controlled studies
conducted by specialists or supervised trainees and epi-
demiological studies based on various population
groups treated in general dental practice. Controlled
studies have reported success rates as high as 96%
(Kerekes & Tronstad 1979, SjoÈgren et al. 1990),
whereas longitudinal studies of endodontic treatment
in the general dental services have shown large
Correspondence: Dr S. Aryanpour, Universite Catholique de Louvain,
Department of Dental Medicine and Stomatology, Avenue Hippocrate
15, 1200 Brussels, Belgium (fax: ‡32 (0)2 7645727).
208 q 2000 Blackwell Science Ltd
making a decision, and the technical complexity of the
retreatment procedure.
Results The results indicate wide inter- and also
intra-school disagreements in the clinical
management of root canal treated teeth. Analysis of
variance showed that the main source of variation
was the `school effect', explaining 1.8% (NS) to
18.6% (P < 0.0001) of the treatment variations. No
other factor explained as much variance. Decision
difficulty was moderately correlated to technical
complexity (Pearsons' r ranging from 0.19 to 0.35,
P < 0.0001).
Conclusions No clear consensus occurred amongst
and within dental schools concerning the clinical
management of the 14 cases. The lack of consensus
amongst schools seems to be due mainly to chance or
uncertainty, but can be partly explained by the `school
effect'.
Keywords: behavioural science, decision making,
endodontic retreatment.
Received 14 October 1998; accepted 17 June 1999
numbers of inadequate root fillings associated with
periapical disease (Petersson et al. 1986, Eckerbom
et al. 1987, Eriksen et al. 1988, Petersson et al. 1989,
Imfeld 1991, de Cleen et al. 1993, Buckley &
SpaÊngberg 1995, Saunders et al. 1997). These results
suggest that poor technical standard affects the
outcome of treatment in general practice and results in
a growing demand for retreatment.
To improve and audit the quality of endodontic
treatment, guidelines have been provided to simplify
endodontic retreatment decision making (British
Endodontic Society 1983, American Association of En-
dodontists 1987, European Society of Endodontology
1994). The presence or absence of a periapical radiolu-
International Endodontic Journal, 33, 208±218, 2000

cency and clinical signs and/or symptoms along with
the radiographic quality of a root filling can be used as
a means of assessing the outcome of root canal
treatment. Retreatment is clearly indicated when a
periapical lesion, clinical signs and/or symptoms are
present (Friedman & Stabholz 1986, Lewis & Block
1988, Stabholz & Friedman 1988).
Several studies have shown wide inter-individual dis-
agreements in practitioners' management of periapical
lesions associated with previously root treated teeth
(Smith et al. 1981, Reit & GroÈndahl 1984, 1988,
HuÈlsmann 1994, Kvist et al. 1994). These variations
cannot be attributed solely to differences in radiographic
diagnosis of a periapical lesion or to the presence or
absence of clinical signs and/or symptoms (Reit &
GroÈndahl 1984, 1988, HuÈlsmann 1994). The
complexity of the operative procedures and the variety
of treatment alternatives introduce variation into the
choices of therapy (Smith et al. 1981, Kvist et al. 1994).
In addition to the diagnostic and technical problems,
other characteristics of practitioners (e.g. their age,
clinical experience, confidence, specialty training) may
influence their decision making (Reit et al. 1985, Reit &
GroÈndahl 1987). The large number of the relevant
factors in each study and the complexity of the decision
making process itself, make data analysis and interpre-
tation difficult (Weinstein & Fineberg 1980,
Grembowski et al. 1991, Gerrity et al. 1992).
There has been no research that includes both student
clinicians and their instructors and makes comparison of
their attitudes toward root treated teeth. Therefore, the
objectives of the present study were to: (i) evaluate the
consensus, if any, amongst dental schools, students and
their instructors in management of the same clinical
cases, all of which involve endodontically treated teeth;
(ii) determine the predominant proposed treatment
option and the influence, if any, of the `school effect' on
decision variations amongst dental schools, taking into
consideration the level of training and the country; and
(iii) analyse the relationship between the technical
complexity of the retreatment and the difficulty in
choosing a treatment option.
Materials and methods
Decision makers
Final-year students (within 1 month of graduation),
endodontic faculty members and instructors (for the
theoretical or/and clinical teaching of endodontics) of
10 European French-speaking universities and dental
q 2000 Blackwell Science Ltd
Aryanpour et al. Endodontic retreatment decisions
schools were surveyed as decision makers during 1995
and 1996.
These universities and dental schools were:
University of Geneva, University of Lille, University of
Lyon, University of Nancy, University of Nice,
University of Reims, University of Rennes, University of
LieÁge, University of Brussels and the Catholic
University of Louvain.
Clinical cases and radiographs
Radiographs of 14 different endodontically treated teeth
were carefully selected from the archives of the
Department of Operative Dentistry and Endodontics from
the Catholic University of Louvain, Brussels, Belgium.
The cases selected represented a wide range of
situations including endodontically treated teeth with:
. Subjective signs (cases 4, 7, 8, 14)
. Objective clinical signs (cases 2, 4, 8, 10, 14)
. Periapical radiolucency (cases 2±8, 10, 12, 14)
. Underfilling (cases 1±3, 5, 8, 11±14)
. Overfilling (cases 4±6, 10)
. Silver point or fractured instrument (cases 2, 4, 5,
9, 13)
. Post (cases 7, 8, 14)
. Need of coronal restoration (cases 1, 2, 5, 9, 11,
12)
Radiographs were photographed as slides and
complemented by a different clinical history concerning
each patient and tooth including: age, gender,
complaints, clinical symptoms and restorative and/or
periodontal treatment if planned. This was intended to
simulate the patient's first visit to a new dentist.
Procedure
Decision makers from each university were gathered in
the same room and, in order to standardize the
terminology used, participants had a briefing
concerning the treatment alternatives proposed.
Individual data relating to each participant were
recorded including:
. Clinical experience of decision maker: student,
endodontic staff member, teacher or instructor
. Dental degree or diploma received: graduation year
and institution
. Age and gender
. University or dental school
. Country
International Endodontic Journal, 33, 208±218, 2000 209
 Endodontic retreatment decisions Aryanpour et al.

Each case was presented to decision makers in a Table 1 Distribution of decision makers in the different
uniform format with both a radiograph and a clinical schools
history projected onto a screen in a darkened room. University Students Staff members Total
Fourteen cases were presented successively in and instructors
approximately 1 h and participants' decisions were GeneÁve 10 13 23
recorded. Lille 37 11 48
For each case, decision makers were requested to: Lyon 50 5 55
Nancy 37 10 47
(i) Choose one out of the following nine proposed Nice 23 2 25
treatment alternatives: Reims 10 6 16
Rennes 50 7 57
. No treatment necessary LieÁge 12 11 23
. Wait 6 to 12 months and re-examine (watchful Brussels (ULB) 29 13 42
Louvain (UCL) 30 12 42
waiting)
Total 288 90 378
. Selective retreatment of one or two canals
. Complete retreatment of all canals
. Apicectomy The responses were coded, verified and entered into
. Retreatment ‡ apicectomy microcomputer files. The frequency of each kind of
. Root resection decision was computed for all subjects. One way
. Retreatment ‡ root resection analysis of variance was used to assess the influence of
. Extraction the country, university, and specialization on the four
kinds of decisions. Nested models (university nested
(ii) Assess the difficulty of making a decision by using
within country, and specialization nested within
a rating scale from 1 to 5 (1 ˆ easy to make a
university) were then used to assess the relative contri-
decision, 5 ˆ difficult to make a decision).
bution of factors. Computations were made with the
(iii) Evaluate the technical complexity of the
Statistical Analysis System software 6.09 release (SAS
retreatment procedure using the hypothesis that they
Institute Inc. Cary, NC, USA).
were obliged to manage the case by a nonsurgical
retreatment, using a scale from 1 to 5 (1 ˆ procedure
will be easy, 5 ˆ procedure will be technically Results
difficult).
A total of 378 complete questionnaires were collected.
Fifty-six per cent of participants were men and 44%
Data analysis
were women. The age range was 21±63 years with a
Each case was first individually analysed. To facilitate mean of 27.7 years of age. The distribution of
reporting of results, cases were divided into four decision makers in the different schools is displayed in
categories according to presence of radiographic and Table 1.
clinical or/and subjective signs as follows:

1 Cases without clinical or radiographic signs (cases Decision makers' treatment choices
1, 9, 11, 13).
To determine the predominant proposed treatment
2 Cases with radiographically perceptible periapical
amongst participants, we analysed the frequency of
lesion but without clinical symptoms or signs
treatment choices. Table 2 presents the frequencies of
(cases 3, 5, 6, 12).
participants' treatment option selections for each
3 Cases with a radiographically perceptible periapical
category of cases. As expected, the results indicate
lesion and only one clinical symptom or sign (cases
large inter-individual disagreements in participants'
2, 7, 10).
management of endodontically treated teeth.
4 Cases with a radiographically perceptible periapical
On average, no retreatment (52.18%) and
lesion and two clinical symptoms and/or signs
nonsurgical retreatment (46.8%) were chosen most
(cases 4, 8, 14).
frequently as the appropriate alternatives for asympto-
Treatment alternatives were pooled into four groups: matic cases. For other cases, the presence of radio-
no (re)treatment proposed, nonsurgical retreatment, graphic and/or clinical signs resulted in a more
surgical retreatment, extraction. aggressive attitude, such as retreatment, surgery and

210 International Endodontic Journal, 33, 208±218, 2000 q 2000 Blackwell Science Ltd

Table 2 Mean frequencies of participants' treatment option selections for each category of cases
Category 1
Frequency
No (re)treatment 2.08 (52.18)
Nonsurgical retreatment 1.86 (46.8)
Surgical retreatment 0.03 (0.99)
Extraction (0.06)
Total 4 (100)
a
Figures in parentheses are percentages.
b
Case categories: category 1, cases without clinical or radiographic signs; category 2, cases with radiographically perceptible periapical
lesion but without other clinical symptoms or signs; category 3, cases with a radiographically perceptible periapical lesion and only one
clinical symptom or sign; category 4, cases with a radiographically perceptible periapical lesion and two clinical symptoms and/or signs.
extraction, but no relationship was noted between the
nature of the symptoms and selected treatment options.
Contributing factors
Overall, the variation in participants' treatment choice
was wide. We therefore analysed whether disagree-
ments amongst participants' treatment strategies were
related to their: (a) gender; (b) years of experience; (c)
hierarchical status (student, endodontic staff member,
teacher, instructor); (d) difficulty of making a decision;
(e) estimation of the technical complexity if a
retreatment had to be performed; (f ) university or
dental school; or (g) country.
Correlation analysis
There was no significant correlation between the
gender and the decision makers' choice. Table 3
presents correlation results for four other contributing
factors and proposed treatment strategies. None of the
tested variables was statistically significant across all
four categories of cases:
Asymptomatic cases. For asymptomatic cases, decision
makers with more experience chose nonsurgical
retreatment more often; the age and the hierarchical
status were inversely related to no (re)treatment
option, that is, no therapy or watchful waiting.
Technical complexity of retreatment had a negative
effect on no (re)treatment rate. Participants who
considered these cases as technically complex proposed
more nonsurgical retreatment (conservative
retreatment of one, two or all canals) than those who
found these cases easy to retreat.
Cases with radiographically perceptible periapical lesion but
without clinical symptoms or signs. For these cases,
q 2000 Blackwell Science Ltd
Aryanpour et al. Endodontic retreatment decisions
Category 2 Category 3 Category 4
Frequency Frequency Frequency
0.62 (15.64) 0.44 (15.04) 0.02 (0.79)
0.97 (24.53) 1.52 (50.96) 0.84 (28.31)
1.33 (33.40) 0.66 (22.38) 0.73 (24.68)
1.05 (26.33) 0.35 (11.85) 1.38 (46.27)
4 (100) 3 (100) 3 (100)
hierarchical status had a highly significant, positive
effect on nonsurgical retreatment choice and a
negative effect on surgical retreatment. Similarly, age
also had a positive effect on nonsurgical retreatment
rate and was inversely related to the choice of the
surgical retreatment option, that is, apicectomy or root
resection with or without a previous conventional
retreatment.
Difficulty of making a decision had a positive effect
on surgical retreatment rate and an inconsistent
negative effect on extraction choice.
Cases with a radiographically perceptible periapical lesion
and only one clinical symptom or sign. For these cases,
the age and the hierarchical status had a positive effect
on the extraction choice rate but a negative effect on
the surgical retreatment option.
Difficulty of making a decision had a positive effect
on no (re)treatment and surgical options rates and a
negative effect on nonsurgical retreatment choice.
Cases with a radiographically perceptible periapical lesion
and two clinical symptoms and/or signs. For these cases,
the hierarchical status had a highly significant, positive
effect on nonsurgical retreatment choice and a
negative effect on surgical retreatment and extraction
proposition rate. Age of the practitioner was not
significant in treatment decisions.
For these cases, difficulty of making a decision was
positively associated with nonsurgical retreatment and
inversely related to extraction option. Technical
complexity of retreatment had an inconsistent positive
effect on nonsurgical retreatment rate and a negative
one on the surgical option.
In general, decision makers with more experience
and higher hierarchical status chose nonsurgical
retreatment more often (except for cases with a radio-
graphically perceptible periapical lesion and only one
International Endodontic Journal, 33, 208±218, 2000 211
 Endodontic retreatment decisions Aryanpour et al.

Case categories: category 1, cases without clinical or radiographic signs; category 2, cases with radiographically perceptible periapical lesion but without other clinical symptoms or signs;
category 3, cases with a radiographically perceptible periapical lesion and only one clinical symptom or sign; category 4, cases with a radiographically perceptible periapical lesion and two
Pearson correlation coefficients for variables: age, hierarchical status, decision difficulty, technical complexity and treatment alternatives in each of the four case categories
clinical symptom or sign). For asymptomatic cases the

ÿ0.22***
age and the hierarchical status were inversely related

ÿ0.128
to the no (re)treatment option.

NS

NS
E

ÿ0.118

ÿ0.118
Analysis of variance

NS

NS
S
To assess the influence of the country, university, and

‡0.19***
‡0.22***
‡0.118
specialization (hierarchical status) on the four kinds of

NS
decisions one way analysis of variance was used.
Category 4

R
Analysis of variance showed that the `school effect',
‡0.14*
NS
could explain 1.8% (NS) to 18.6% (P < 0.0001) of the
NS
NS
N

treatment variations (Table 4). This means that

‡0.15*

therapeutic choices vary significantly amongst univer-

‡0.128

sities. Two exceptions `no (re)treatment' in category 4

NS
NS
E

and extraction in category 1 are due to a very small

ÿ0.17**
ÿ0.16**

proportion of such atypical decisions.

‡0.128

Nested (or hierarchical) models were used to assess

NS
S

the effects of country and university (Table 5), and

hierarchical status and university (Table 6). In both
ÿ0.19**
‡0.138

analyses, we considered that a local factor was nested

NS
NS
Category 3

within a more general factor. Table 5 shows that the

principal source of variation was the `university'.
‡0.14*

Treatment alternatives: N, no (re)treatment; R, nonsurgical retreatment; S, surgical retreatment; E, extraction.

Except in cases with radiographically perceptible

NS
NS

NS
N

periapical lesion but without other clinical symptoms

‡0.138

or signs; the variable `country' did not explain

NS
NS

NS

variation in treatment decisions. In Table 6, analyses

E

show again that `university' was the main source of

ÿ0.19**
ÿ0.14*

‡0.16*

variation, except in asymptomatic cases and cases

8P < 0:05; *P < 0:01; **P < 0:001; ***P < 0:0001, and NS as nonsignificant (P > 0:05).
NS

with radiographically perceptible periapical lesion but

S

without other clinical symptoms or signs, where hier-

‡0.20***

archical status explained a significant amount of

‡0.14*

variance. Within `universities' experienced and less

NS
NS
R
Category 2

experienced subjects may not make the same

‡0.13*

decisions, especially in cases where fewer signs were

NS
NS

NS

present.
N

NS
NS
NS
NS
E

Universities' treatment choices

NS
NS
NS
NS
S

Figure 1 presents an overview of the frequencies of

‡0.25***
‡0.31***

‡0.16*

different universities' treatment choices for each group

NS

of cases. As can be seen in Fig. 1. (a-d), the variations

R
Category 1

in schools' retreatment policy were large. For

ÿ0.25***
ÿ0.30***

symptomatic cases the predominant proposed strategy

ÿ0.16*

clinical symptoms and/or signs.

was intervention (nonsurgical retreatment, surgical

NS
N

retreatment, or extraction). Consensus in terms of type

Technical complexity

of treatment, however, was low.

Hierarchical status
Decision difficulty

Technical complexity and uncertainty

Table 3

Participants evaluated the technical complexity of a

Age

hypothetical retreatment case and the difficulty of

212 International Endodontic Journal, 33, 208±218, 2000 q 2000 Blackwell Science Ltd
 Aryanpour et al. Endodontic retreatment decisions

Table 4 Importance of the 'school effect` on treatment choice: percentage of variance explained by university affiliation of
participants
No (re)treatment Nonsurgical retreatment Surgical retreatment Extraction
% % % %

Category 1 9.9*** 8.3*** 5.8* 1.8 (NS)

Category 2 10.8*** 10.6*** 16.5*** 15.3***
Category 3 9.2*** 9.0*** 10.3*** 11.7***
Category 4 4.68 18.5*** 10.4*** 18.6***

Case categories: category 1, cases without clinical or radiographic signs; category 2, cases with radiographically perceptible periapical
lesion but without other clinical symptoms or signs; category 3, cases with a radiographically perceptible periapical lesion and only one
clinical symptom or sign; category 4, cases with a radiographically perceptible periapical lesion and two clinical symptoms and/or signs.
8P < 0.05, * Significant at P < 0.01,*** Significant at P < 0.0001, and NS as nonsignificant ˆ P > 0.05.

choosing an option for all 14 cases. Technical
complexity and decision difficulty were moderately
correlated (Pearsons' r ranging from 0.19 to 0.35,
P < 0.0001) (Table 7).
Analysis was made of the influence of decision
makers' characteristics (gender, years of experience,
and hierarchical status) on their ratings of difficulty on
making a decision and the technical complexity in
each of the four case categories (Table 8).
None of the decision makers' characteristics were
statistically significant across all situations. Technical
complexity was rated higher by women than by men.
Similarly, years of experience and hierarchical status
were positively correlated to ratings of technical
complexity. Female participants showed higher rates of
decision difficulties than males (except for asympto-
matic cases). Participants with high hierarchical status
reported less difficulties when making a decision than
others (except for cases with a radiographically
perceptible periapical lesion and two clinical symptoms
and/or signs).
Discussion
Considerable interindividual variations in clinical
management of endodontically treated teeth were

Table 5 Effects of country and university on treatment strategy variations (university nested within country)
Effects on variations
2
R (%) Country University

Cases without clinical or radiographic signs

No (re)treatment 8.2** NS ***
Nonsurgical retreatment 8.3** NS **
Surgical retreatment 5.9* NS *
Extraction NS NS NS

Cases with radiographically perceptible periapical lesion but without other clinical symptoms or signs
No (re)treatment 10.8*** NS ***
Nonsurgical retreatment 10.6*** *** 8
Surgical retreatment 16.5*** NS ***
Extraction 15.4*** ** ***

Cases with a radiographically perceptible periapical lesion and only one clinical symptom or sign
No (re)treatment 9.3*** 8 ***
Nonsurgical retreatment 9.1*** 8 **
Surgical retreatment 10.3*** NS ***
Extraction 11.7*** NS ***

Cases with a radiographically perceptible periapical lesion and two clinical symptoms and/or signs
No (re)treatment 4.78 8 NS
Nonsurgical retreatment 18.6*** ** ***
Surgical retreatment 10.5*** 8 ***
Extraction 18.7*** NS ***

8P < 0.05, * Significant at P < 0.01,*** Significant at P < 0.0001, and NS as nonsignificant ˆ P > 0.05.

q 2000 Blackwell Science Ltd International Endodontic Journal, 33, 208±218, 2000 213
 Endodontic retreatment decisions Aryanpour et al.

Table 6 Effects of hierarchical status and university on treatment strategy variations (hierarchical status nested within
university)
Effects on variations

R2 (%) University Hierarchical status

Cases without clinical or radiographic signs

No (re)treatment 20.5*** ** ***
Nonsurgical retreatment 20.3*** ** ***
Surgical retreatment 8.48 8 NS
Extraction NS NS NS

Cases with radiographically perceptible periapical lesion but without other clinical symptoms or signs
No (re)treatment 17.9*** ** **
Nonsurgical retreatment 18.3*** ** **
Surgical retreatment 26.5*** *** ***
Extraction 21.6*** *** ***

Cases with a radiographically perceptible periapical lesion and only one clinical symptom or sign
No (re)treatment 12.2** ** NS
Nonsurgical retreatment 11.9** ** NS
Surgical retreatment 13.6*** * NS
Extraction 18.2*** *** *

Cases with a radiographically perceptible periapical lesion and two clinical symptoms and/or signs
No (re)treatment 14.8*** *** ***
Nonsurgical retreatment 22.4*** *** NS
Surgical retreatment 13.3*** *** NS
Extraction 22.5*** *** NS

8P < 0.05, * Significant at P < 0.01,*** Significant at P < 0.0001, and NS as nonsignificant ˆ P > 0.05.

shown in the present study. Similar results have been
reported by other authors (Smith et al. 1981, Reit &
GroÈndahl 1984, 1988, HuÈlsmann 1994, Kvist et al.
1994).
As expected, the presence of radiographic and/or
clinical symptoms resulted in a more aggressive
attitude, such as retreatment, surgery and extraction,
but no relationship was noted between the nature of
the symptoms and the selected treatment options.
These results confirm the findings of other studies,
which showed that some participants chose the `nonin-
tervention' alternative not only for cases with radio-
graphic evidence of periapical disease (Reit & GroÈndahl
1988), but also for cases with clinical symptoms
(HuÈlsmann 1994).
Obviously other clinical considerations, such as the
size of the periapical radiolucency (Reit & GroÈndahl
1984, Reit et al. 1985), the quality of the previous root
canal filling, time since the placement of root filling
and the presence of a post (Kvist et al. 1994), will also
play a role in treatment selection. The symptom-based
categorization used in the present study did not take
these factors into consideration.
Practitioners' characteristics may influence
treatment decisions (Young 1987, Gerrity et al. 1992).
Studies in medicine suggested that practitioners'
personal variables, such as gender and age, do not
have a significant effect on their clinical decision
making (Goldman et al. 1990, Gerrity et al. 1992). Our
data confirmed that there was no significant
correlation between the gender and the decision
makers' choices. The factors `years of experience' (age)
and `hierarchical status' (student, endodontic staff
member, teacher or instructor) were linked in the
present study, therefore age alone was not considered
just as a personal variable.
Since in this study older practitioners were
endodontic staff members, teachers and instructors
with a high level of expertise in endodontics compared
with students, we examined the influence of their `spe-
cialization' (years of experience and hierarchical status)
on the treatment strategy.
In previous studies (Smith et al. 1981, Reit et al.
1985), general dental practitioners and endodontists'
attitudes to treatment of asymptomatic periapical
lesions in endodontically treated teeth were compared.
They demonstrated the `specialization' influence on
treatment decisions and also as an explanation for
variations in assessement of the probabilities of disease
and future complications. It was also noted that the

214 International Endodontic Journal, 33, 208±218, 2000 q 2000 Blackwell Science Ltd
 Aryanpour et al. Endodontic retreatment decisions

100 100

90 90
No retreatment No retreatment
80 Nonsurgical retreatment 80 Nonsurgical retreatment
Surgical retreatment Surgical retreatment
70 70 Extraction
Extraction

Frequencies (%)
Frequencies (%)

60 60

50 50

40 40

30 30

20 20

10 10

0 0
1 2 3 4 5 6 7 8 9 10 1 2 3 4 5 6 7 8 9 10
Universities Universities
(a) (c)

100 100

90 90
No retreatment No retreatment
80 Nonsurgical retreatment 80 Nonsurgical retreatment
Surgical retreatment Surgical retreatment
70 Extraction 70 Extraction
Frequencies (%)
Frequencies (%)

60 60

50 50

40 40

30 30

20 20

10 10

0 0
1 2 3 4 5 6 7 8 9 10 1 2 3 4 5 6 7 8 9 10
(b) Universities (d) Universities

Figure 1 Frequencies of universities' treatment choices in percentage for each group of cases: (a) cases without clinical or
radiographic signs; (b) cases with radiographically perceptible periapical lesion but without other clinical symptoms or signs; (c)
cases with a radiographically perceptible periapical lesion and only one clinical symptom or sign; (d) cases with a radiographically
perceptible periapical lesion and two clinical symptoms and/or signs.

endodontists did subject smaller and medium-sized
lesions to therapeutic measures more often than did
the general practitioners.
In the present study, for cases without clinical or
radiographic signs, it was noted that years of
experience and hierarchical status were inversely
related to the no (re)treatment option and also had
a positive effect on the nonsurgical retreatment
rate.
Overall it was found that decision makers with more
experience and higher hierarchical status chose
nonsurgical retreatment more often except for cases
with a radiographically perceptible periapical lesion
and only one clinical symptom. For these cases, years
of experience and hierarchical status were related to
the surgical retreatment option. These correlations
have relatively small magnitudes and demonstrate that
more experience and higher hierarchical status do not
necessarily lead to better consensus regarding the
proposed treatment.
Difficulty in making a decision and technical
complexity were not statistically significantly
correlated across all case categories. A possible
explanation for the absence of constant and statistically
significant effects of the tested variables might be that
the symptom-based categorization of cases used in this
study did not take into consideration some clinical con-
siderations contributing to the practitioner's treatment
choice. Pathology and case specifics, together with
practitioners' characteristics, interact and are
confounded with other factors, which make the clinical
decision making process so complex.
Analysis of variance showed that the main source of
variation was the `school effect', explaining 1.8% (NS)
to 18.6% (P < 0.0001) of the treatment variations, no
other factor explaining as much variance. This study

q 2000 Blackwell Science Ltd International Endodontic Journal, 33, 208±218, 2000 215
 Endodontic retreatment decisions Aryanpour et al.

Table 7 Correlation between technical complexity and decision difficulty for each of four case categories
Case categories Pearson correlation Number of
coefficients (r)* observations

Cases without clinical or radiographic signs 0.32 376

Cases with radiographically perceptible periapical lesion but without 0.19 378
other clinical symptoms or signs
Cases with a radiographically perceptible periapical lesion and only 0.19 377
one clinical symptom or sign; category
Cases with a radiographically perceptible periapical lesion and two 0.35 368
clinical symptoms and/or signs

*P < 0:0001

Table 8 Pearson correlation coefficients of three participants' variables (gender, age, hierarchical status) and technical
complexity and decision difficulty in each of the four case categories
Category 1 Category 2 Category 3 Category 4

Decision Technical Decision Technical Decision Technical Decision Technical

making complexity making complexity making complexity making complexity

Gender ÿ0.118 NS NS NS ‡0.108 NS ‡0.128 NS

Age NS NS ÿ0.18** NS NS NS NS ‡0.118
Hierarchical status NS NS ÿ0.17** NS ÿ0.15* ‡0.17** ‡0.128 ‡0.22***

Case categories: category 1, cases without clinical or radiographic signs; category 2, cases with radiographically perceptible periapical
lesion but without other clinical symptoms or signs; category 3, cases with a radiographically perceptible periapical lesion and only one
clinical symptom or sign; category 4, cases with a radiographically perceptible periapical lesion and two clinical symptoms and/or signs.
Gender: male ˆ 1, female ˆ 0.
8P < 0.05; *P < 0.01; **P < 0.001; ***P < 0.0001, and NS as nonsignificant (P > 0:05).

showed no clear consensus recorded amongst dental
schools concerning the clinical management of the 14
proposed cases, but there was a `school effect', i.e.
some consensus within dental schools. An explanation
for the `school effect' was that students from the same
university have the same undergraduate curriculum
on endodontics. This curriculum is not uniform across
countries and dental schools. Final year students with
little clinical experience manage their uncertainty of
diagnostic and treatment decision making by: deciding
not to decide, requesting more tests, adopting their
teacher's or instructor's recommendations or `school of
thought'. Clinical training by different instructors may
be a possible explanation for disagreements within
dental schools. This could explain the lack of accepted
criteria for retreatment decisions within dental schools.
As expected, participants' ratings of technical
complexity of retreatment procedures and difficulty of
making a decision were moderately correlated
(Pearsons' r ranging from 0.19 to 0.35, P < 0.0001).
None of the tested decision makers' characteristics
(gender, age, hierarchical status) was statistically
significant across all situations.
The 14 cases used in the study were carefully
selected to represent a wide range of clinical situations,
including endodontically treated teeth with or without
radiographic evidence of periapical lesions and/or
clinical symptoms and also with varying quality of root
canal filling and coronal restoration. There is no
reason to think that another selection could have led
to different results.
In order to make it possible to analyse the effects of
radiographic and clinical symptoms on participants'
decisions, it was decided to restrict the case classifica-
tion to the nature and the number of symptoms:
asymptomatic cases (without clinical or radiographic
signs); those with radiographically perceptible
periapical lesion but without clinical symptoms; those
with a radiographically perceptible periapical lesion
and only one clinical symptom; and those with a radio-
graphically perceptible periapical lesion and two
clinical symptoms and/or signs. Similar results were
observed with analysis of individual cases.
The use of radiograph-based clinical cases to
evaluate practitioners' attitudes toward root canal
treated teeth is not new. In contrast, there has been no
research that included both student clinicians and
their teachers and instructors managing the same
clinical cases, all involving endodontically treated
teeth.

216 International Endodontic Journal, 33, 208±218, 2000 q 2000 Blackwell Science Ltd

Such a radiograph-based clinical case study does not
reflect the practitioner's decision making process in
real life for two reasons (Jones et al. 1990). First, there
is a considerable difference between what is learned
from dental textbooks, what is expressed in a survey
and what is actually done in clinical practice. Incor-
poration of clinical elements in theoretical concepts is a
complex process and may explain these variations.
Secondly, clinical decision making is a multifactorial
problem. Practitioners consider several contributing
factors when prescribing treatments and a radiograph-
based clinical case does not provide all the required
elements. Multidisciplinary research is required if the
effects of these contributing factors on the decision
making process is to be understood.
This study is therefore inadequate in identifying all
of the causes of decision variations, but it provides
evidence regarding the consensus (`school effect') and
the disagreement rate amongst and within dental
schools. The quantitative analysis of the `school effect'
can be used in dental education as a tool in estimating
the impact of teachers' opinions and teaching of
endodontics on students' treatment decisions. In
addition, further comparative research is needed to
examine whether this `school effect' remains stable
over time.
The lack of consensus amongst and within dental
schools, as shown by the results of the present study,
indicates that there is an important need for uniformity
and improvement in the undergraduate curriculum on
endodontics. More emphasis should be given to
endodontic retreatment, and established guidelines for
root canal treatment must be incorporated into the un-
dergraduate curriculum.
Conclusion
In conclusion, no clear consensus was recorded
between dental schools concerning the clinical
management of the 14 proposed cases, but there was a
`school effect', i.e. some consensus within dental
schools. The lack of consensus between schools
appears to be due mainly to chance or uncertainty.
Technical complexity explained little interindividual
variation in the treatment choice and was related to
decision difficulty. The multiplicity and the complexity
of all the contributing factors which come into play
when a clinical decision is made show how difficult it
is to reduce the interindividual variation. Recently,
decisional methods based on research of the best
clinical evidence have been developed and used by
q 2000 Blackwell Science Ltd
Aryanpour et al. Endodontic retreatment decisions
health care professionals to determine the most
appropriate treatment strategy for a given clinical
problem. It is hoped that the incorporation of these
evidence-based methods and established guidelines for
root canal treatment into the undergraduate
curriculum will reduce the decision variation margins
within and between dental schools.
Acknowledgements
We acknowledge the helpful assistance and
cooperation of the endodontic staff members of the par-
ticipating universities, particularly those of Professors
B. Ciucchi (Geneva), A. Claisse (Lille), P. Farge (Lyon),
M. Panighi (Nancy), J.-P. Rocca (Nice), J.-P. Camus
(Reims), J.-M. Vulcain (Rennes), J. Charpentier (LieÁge),
and T. Charles (Brussels).
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