Professional Documents
Culture Documents
Lin 2005
Lin 2005
N
CON
instruments, on the out-
Do procedural errors
IO
come of endodontic
T
T
A
N
I
C
therapy. U
A ING EDU 4
cause endodontic Types of Studies
Reviewed. Filling the root
R TICLE
E of pulpal infection in the root canal system. Results. Endodontic procedural errors
The classic study by Kakehashi and are not the direct cause of treatment
colleagues1 showed that periapical inflamma- failure; rather, the presence of pathogens in
tion developed in conventional laboratory rats the incompletely treated or untreated root
but not in germ-free rats with surgically exposed pulps. canal system is the primary cause of peri-
In conventional laboratory rats, oral microorganisms radicular pathosis. Procedural errors typi-
entered the pulpal cavity and caused inflammation and cally are due to several factors. Among
necrosis, as well as subsequent peri- them is a lack of understanding of the root
radicular tissue destruction. In germ- canal anatomy, the principles of mechanical
The primary instrumentation and tissue wound healing.
free rats, even when the canals were
cause of packed with sterile food debris, neither Clinical Implications. Procedural
periradicular pulpal necrosis nor periradicular inflam- errors impede endodontic therapy, thus
increasing the risk of treatment failure,
pathosis is mation developed.
In a clinical study, Sundqvist2 showed especially in teeth with necrotic pulps and
bacterial
periradicular lesions. However, procedural
infection in the that bacteria could be cultured from the errors often are preventable.
canals of traumatized necrotic teeth
root canal Key Words. Endodontic procedural
with intact crowns if periapical lesions
system. were present, but could not be cultured errors; bacteria; treatment outcomes.
However, from necrotic teeth if periradicular
procedural lesions were absent. Many studies have
errors impede shown that factors such as pulpal and
endodontic periradicular status, underfilling, over-
filling, root perforations, separated failure. However, procedural errors by
therapy.
instruments and ledge formation affect themselves do not jeopardize the out-
the prognosis for endodontic therapy. come of treatment unless a concomitant
However, only two factors—root canal infection at the infection is present. A procedural acci-
time of root filling and a preoperative periradicular dent often impedes therapy or makes it
lesion—have been shown clearly to have a direct impact impossible for therapy to be completed
on the outcome of endodontic therapy.3-8 (for instance, by preventing thorough
Clinicians generally believe that endodontic pro- mechanical débridement or a bacteria-
cedural errors, such as underfilling, overfilling, sepa- tight seal of the root canal system). An
rated instruments, root perforations and ledge forma- increased risk of failure exists when a
tion, are the direct cause of endodontic treatment procedural accident occurs during treat-
ment of infected teeth.9 The purpose of this From about 1930 to the early 1960s, clinicians
article is to review critically the effect of pro- assumed that apical percolation and subsequent
cedural errors on the outcome of endodontic diffusion stasis of tissue fluid or blood compo-
therapy. nents in the unfilled canal space could cause per-
sistent periradicular inflammation.17 The so-
UNDERFILLING OR INCOMPLETE FILLING called “hollow tube” concept has been
OF ROOT CANALS
disproved.18,19 Studies involving polyethylene tube
Underfilling or incomplete filling of the root implants in animals demonstrated clearly that
canals (more than 2 millimeters short of the blood components or tissue fluid stagnating inside
radiographic apex) often occurs as the result of the lumen of the tubes did not induce persistent
incomplete instrumentation or ledge formation of inflammation in the tissue at the open ends of the
the root canal during mechanical instrumenta- tubes.18,19 In contrast, if the polyethylene tubes
tion. Incomplete instrumentation commonly is contained bacteria from the test animal’s oral
caused by inaccurate measurement of the cavity, moderate-to-intense inflammation was
working length or inadequate irrigation and reca- observed at the open ends of the tubes.20
pitulation of canal patency and working length Davis and colleagues21 demonstrated that when
during instrumentation, thus leading to the accu- the canals of vital teeth in dogs were instru-
mulation of dentin filings and canal blockage. mented with a no. 80 file to within 1 mm of the
Ledge formation can be caused by the following: radiographic apex and underfilled by 3 mm, some
dinadequate straight-line access to the apical underfilled canal spaces became filled with viable
portion of the canal; connective tissue that was continuous with the
dinadequate irrigation, lubrication or both; periodontium one year after endodontic therapy.
dexcessive enlargement of a curved canal with Similarly, Benatti and colleagues22 reported that
large files; when the canals of vital teeth in dogs were instru-
dpacking of debris in the apical portion of the mented 2 mm beyond the apical foramen with
canal; nos. 40, 60 or 80 files and underfilled 1 to 3 mm
dskipping of sequential file sizes.10,11 short of the apex, the unfilled canal spaces exhib-
Consequently, the clinician does not remove ited ingrowth of periodontal connective tissue 120
the infected necrotic tissue remaining in the days after endodontic therapy.
apical portion of the root canal because of incom- de Souza Filho and colleagues23 demonstrated
plete instrumentation or ledge formation. In teeth that when the canals of teeth in dogs with peri-
with necrotic pulp and a periradicular lesion, bac- radicular lesions were instrumented 2 mm
teria colonize not only within the apical few mil- beyond the apical foramen with a no. 60 file and
limeters of the canal, but also at the apical underfilled by 2 to 3 mm, healing and ingrowth of
foramen. A key aspect of endodontic treatment is connective tissue into the root canal occurred in
the elimination of bacteria from the root canal 67.8 percent of the animals 90 days after
system.12-14 Unless this is done, persistent bacte- endodontic treatment. This occurred because
rial infection in the root canal may initiate or per- intracanal bacteria were eliminated. The authors
petuate periradicular inflammation after believed that cases in which periradicular healing
endodontic therapy.12,13,15 did not occur were due to persistent root canal
Many studies have shown a poorer prognosis infection resulting from incomplete removal of
for teeth with underfillings (68 percent success bacteria during instrumentation.
rate), especially those with necrotic pulp and a Hørsted and Nygaard-Östby24 treated patients
periradicular lesion, compared with teeth with with vital teeth that were scheduled for extrac-
flush-fillings (94 percent success rate) and over- tion. They found that when pulps were extirpated
fillings (76 percent success rate).3,4,6 Chugal and to the apical foramen and the canals were
colleagues16 reported that a 1-mm loss in working enlarged up to 2 to 4 mm coronally to the radio-
length increased the chance of treatment failure graphic apex, the canal spaces between the root
by 14 percent in teeth with apical periodontitis. canal fillings and the apical foramen were occu-
However, if the unfilled canal does not contain pied by connective tissue six to 10 months after
irritants, such as bacteria or contaminated endodontic therapy. Several clinical studies also
necrotic tissue, underfilling by itself would not have shown that if the root canals were com-
cause periradicular inflammation. pletely débrided of necrotic tissue and micro-
terial contamination still plays an important role 12. Nair PN, Sjogren U, Krey G, Kahnberg KE, Sundqvist G.
Intraradicular bacteria and fungi in root-filled, asymptomatic human
in the prognosis for endodontic therapy. teeth with therapy-resistant periapical lesions: a long-term light and
Therefore, root perforations are not the direct electron microscopic follow-up study. J Endod 1990;16:580-8.
13. Lin LM, Pascon EA, Skribner J, Gangler P, Langeland K. Clin-
cause of endodontic treatment failure. Rather, the ical, radiographic, and histologic study of endodontic treatment fail-
primary cause of periradicular inflammation is ures. Oral Surg Oral Med Oral Pathol 1991;71:603-11.
14. Baumgartner JC, Falkler WA Jr. Bacteria in the apical 5 mm of
the remaining infected tissue in the uninstru- infected root canals. J Endod 1991;17:380-3.
mented portion of the canal apical to the perfora- 15. Lin LM, Gangler P. Histopathologische und histobakteriologische
untersuchung von miberfolgen der wurzelkanalbehandlung. Zahn
tion (Figure 4). Mund Kieferheilkd 1988;76:243-9.
16. Chugal NM, Clive JM, Spangberg LS. Endodontic infection: some
CONCLUSION biologic and treatment factors associated with outcome. Oral Surg Oral
Med Oral Pathol Oral Radiol Endod 2003;96(1):81-90.
The primary cause of periradicular pathosis is 17. Rickert UG, Dixon CM. The controlling of root surgery. 8th Inter-
national Dental Congress Meeting 1931(supplement 111A):15-22.
bacterial infection in the root canal system.1 18. Goldman M, Pearson AH. A preliminary investigation of the
Without the presence of bacteria, periradicular “hollow tube” theory in endodontics: studies with neo-tetrazolium. J
Oral Ther Pharmacol 1965;1:618-26.
inflammation will not develop or persist, unless 19. Torneck CD. Reaction of rat connective tissue to polyethylene
cytotoxic filling materials have been forced into tube implants, I. Oral Surg Oral Med Oral Pathol 1966;21:379-87.
20. Torneck CD. Reaction of rat connective tissue to polyethylene
the periradicular tissues.32,35 Endodontic pro- tube implants, II. Oral Surg Oral Med Oral Pathol 1967;24:674-83.
cedural errors are not the direct cause of treat- 21. Davis MS, Joseph SW, Bucher JF. Periapical and intracanal
healing following incomplete root canal fillings in dogs. Oral Surg Oral
ment failure. Rather, they increase the risk of Med Oral Pathol 1971;31:662-75.
failure because of the clinician’s inability to elimi- 22. Benatti O, Valdrighi L, Biral RR, Pupo J. A histological study of
the effect of diameter enlargement of the apical portion of the root
nate intraradicular microorganisms from the canal. J Endod 1985;11:428-34.
infected root canals. ■ 23. de Souza Filho FJ, Benatti O, de Almeida OP. Influence of the
enlargement of the apical foramen in periapical repair of contaminated
teeth of dog. Oral Surg Oral Med Oral Pathol 1987;64:480-4.
Dr. Louis Lin is a professor and director of the Advanced Education 24. Hørsted P, Nygaard-Östby B. Tissue formation in the root canal
Program in Endodontics, Department of Endodontics, New York Uni- after total pulpectomy and partial root filling. Oral Surg Oral Med Oral
versity College of Dentistry, 345 E. 24th St., New York, N.Y. 10010, Pathol 1978;46:275-82.
e-mail “lml7@nyu.edu”. Address reprint requests to Dr. Lin. 25. Dubrow H. Silver points and gutta-percha and the role of root
canal fillings. JADA 1976;93:976-80.
Dr. Rosenberg is a professor and chair, Department of Endodontics, 26. Klevant FJ, Eggink CO. The effect of canal preparation on peri-
and associate dean for graduate programs, New York University Col- apical disease. Int Endod J 1983;16(2):68-75.
lege of Dentistry, New York City. 27. Szajkis S, Tagger M. Periapical healing in spite of incomplete root
canal debridement and filling. J Endod 1983;9:203-9.
Dr. Jarshen Lin is an instructor and a director of the predoctoral 28. Donnelly JC. Resolution of a periapical radiolucency without root
endodontic program, Department of Restorative Dentistry and Bioma- canal filling. J Endod 1990;16:394-5.
terials Sciences, Harvard School of Dental Medicine, Harvard Univer- 29. Yusuf H. The significance of presence of foreign material periapi-
sity, Boston. cally as a cause of failure of root canal treatment. Oral Surg Oral Med
Oral Pathol Oral Radiol Endod 1982;54:566-74.
1. Kakehashi S, Stanley HR, Fitzgerald RJ. The effects of surgical 30. Koppang HS, Koppang R, Solheim T, Aarnes H, Stolen SO.
exposures in the dental pulps in germ-free and conventional laboratory Cellulose fibers from endodontic paper points as etiologic factor in
rats. Oral Surg Oral Med Oral Pathol 1965;20:340-9. postendodontic periapical granulomas and cysts. J Endod 1989;15:
2. Sundqvist G. Bacteriologic studies of necrotic dental pulp [odonto- 369-72.
logical dissertation no. 7]. Umeå, Sweden: Umeå University; 1976:1-94. 31. Nair PN, Sjögren U, Krey G, Sundqvist G. Therapy-resistant for-
3. Strindberg LZ. The dependence of the results of pulp therapy on eign body giant cell granuloma at the periapex of a root-filled human
certain factors: an analytic study based on radiographic and clinical tooth. J Endod 1990;16:589-95.
follow-up examination. Acta Odontol Scand 1956;14(supplement 21):1- 32. Bergenholtz G, Lekholm U, Milthon R, Heden G, Odesjo B,
175. Engstrom B. Retreatment of endodontic fillings. Scand J Dent Res
4. Kerekes K, Tronstad L. Long-term results of endodontic treatment 1979;87:217-24.
performed with a standardized technique. J Endod 1979;5(3):83-90. 33. Halse A, Molven O. Overextended gutta-percha and Kloropercha
5. Bystrom A, Happonen RP, Sjogren U, Sundqvist G. Healing of peri- N-O root canal fillings: radiographic findings after 10-17 years. Acta
apical lesions of pulpless teeth after endodontic treatment with con- Odontol Scand 1987;45(3):171-7.
trolled asepsis. Endod Dent Traumatol 1987;3(2):58-63. 34. Erausquin J, Muruzabal M. Tissue reactions to root canal
6. Sjögren U, Hagglund B, Sundqvist G, Wing K. Factors affecting cements in the rat molars. Oral Surg Oral Med Oral Pathol
the long-term results of endodontic treatment. J Endod 1990;16: 1968;26:360-73.
498-504. 35. Pascon A, Leonardo MR, Safavi K, Langeland K. Tissue reactions
7. Sjögren U, Figdor D, Persson S, Sundqvist G. Influence of infection to endodontic materials: criteria, assessment, and observations. Oral
at the time of root filling on the outcome of endodontic treatment of Surg Oral Med Oral Pathol Oral Radiol Endod 1991;72:222-37.
teeth with apical periodontitis. Int Endod J 1997;30:297-306. 36. Orstavik D, Mjor IA. Usage test of four endodontic sealers in
8. Chugal NM, Clive JM, Spangberg LS. A prognostic model for Macaca fasciculasris monkeys. Oral Surg Oral Med Oral Pathol 1992;
assessment of the outcome of endodontic treatment: effect of biologic 73:337-44.
and diagnostic variables. Oral Surg Oral Med Oral Pathol Oral Radiol 37. Spangberg L. Biological effects of root canal filling materials, VII:
Endod 2001;91:342-52. reaction of bone tissue to implanted root canal filling material in
9. Siqueira JF Jr. Aetiology of root canal treatment failure: why well- guinea pigs. Odontol Tidskr 1969;77(2):133-59.
treated teeth can fail. Int Endod J 2001;34(1):1-10. 38. Feldmann NG, Nyborg H. Tissue reactions to root filling
10. Frank RJ. Endodontic mishaps: their detection, correction, and materials, I: comparison between gutta-percha and silver amalgam
prevention. In: Ingle JI, Bakland LK, eds. Endodontics. 4th ed. Balti- implanted in rabbit. Odontol Revy 1962;13:1-14.
more: Williams & Wilkins; 1994:816-30. 39. Wolfson EM, Seltzer S. Reaction of oral connective tissue to some
11. Torabinejad M, Lemon RR. Procedural accidents. In: Walton R, gutta-percha formulations. J Endod 1975;1:395-402.
Torabinejad M, eds. Principles and practice of endodontics. 3rd ed. 40. Olsson B, Wennberg A. Early tissue reaction to endodontic filling
Philadelphia: Saunders; 2002:310-30. materials. Endod Dent Traumatol 1985;1(4):138-41.
41. Sjögren U, Sundqvist G, Nair PNR. Tissue reaction to gutta- epidermis slime. Infect Immun 1986;54(1):13-20.
percha particles of various sizes when implanted subcutaneously in 54. Crump MC, Natkin E. Relationship of broken root canal instru-
guinea pigs. Eur J Oral Sci 1995;103:313-21. ments to endodontic case prognosis: a clinical investigation. JADA
42. Erausquin J, Muruzabal M, Devoto FC, Rikles A. Necrosis of peri- 1970;80:1341-7.
odontal ligament in root canal overfilling. J Dent Res 1966;45:1084-92. 55. Frostell G. Factors influencing the prognosis of endodontic treat-
43. Seltzer S. Long-term radiographic and histological observations of ment. In: Grossman LI, ed. Transactions of the Third International
endodontically treated teeth. J Endod 1999;25:818-22. Conference on Endodontics. Philadelphia: University of Pennsylvania;
44. Brynolf I. A histological and roentgenological study of the peri- 1963:161-73.
apical lesions of human upper incisors. Odontol Revy 1967;18(supple- 56. Seltzer S, Bender IB, Smith J, Freedman I, Nazimov H.
ment 11):1-176. Endodontic failures: an analysis based on clinical, roentgenographic
45. Green TL, Walton RE, Taylor JK. Radiographic and histologic and histologic findings. Oral Surg Oral Med Oral Pathol 1967;23:500-
periapical findings of root canal treated teeth in cadaver. Oral Surg 30.
Oral Med Oral Pathol Oral Radiol Endod 1997;83:707-11. 57. Grossman LI. Fate of endodontically treated teeth with fractured
46. Bergenholtz G, Lekholm U, Milthon R, Engstrom B. Influence of root canal instruments. J Br Endod Soc 1968;2(3):35-7.
apical overinstrumentation and overfilling on re-treated root canals. J 58. Fox J, Moodnik RM, Greenfield E, Atkinson JS. Filling root
Endod 1979;5:310-4. canals with files: radiographic evaluation of 304 cases. N Y State Dent
47. Lin LM, Skribner JE, Gaengler P. Factors associated with J 1972;38(3):154-7.
endodontic treatment failures. J Endod 1992;18:625-7. 59. Fors UGH, Berg JO. Endodontic treatment of root canals
48. Holland R, De Souza V, Nery MJ, de Mello W, Bernabe PF, obstructed by foreign objects. Int Endod J 1968;19(1):2-10.
Otoboni Filho CD. Tissue reactions following apical plugging of the root 60. Seltzer S. Endodontology. 2nd ed. Philadelphia: Lea & Febiger;
canal with infected dentin chips. Oral Surg Oral Med Oral Pathol 1988:444-6.
1980;49:366-9. 61. Alhadainy HA. Root perforations: a review of literature. Oral
49. Noiri Y, Ehara A, Kawahara T, Takemura N, Ebisu S. Participa- Surg Oral Med Oral Pathol Oral Radiol Endod 1994;78:368-74.
tion of bacterial biofilms in refractory and chronic periapical periodon- 62. Abou-Rass M, Frank A, Glick D. The anticurvature filing method
titis. J Endod 2002;28:679-83. to prepare the curved root canal. JADA 1980;101:792-4.
50. Costerton JW, Geesey GG, Chen KJ. How bacteria stick. 63. ElDeeb ME, ElDeeb M, Tabibi A, Jensen JR. An evaluation of the
Scientific Am 1978;238(1):86-95. use of amalgam, Cavit, and calcium hydroxide in the repair of furcation
51. Costerton JW, Stewart PS, Greenberg EP. Bacterial biofilms: a perforations. J Endod 1982;10:459-66.
common cause of persistent infections. Science 1999;284:1318-22. 64. Balla R, LoMonaco CJ, Skribner J, Lin LM. Histological study of
52. Costerton JW. Effect of antibiotics on adherent bacteria. In: furcation perforations treated with tricalcium phosphate, hydroxylap-
Sabath LD, ed. Action of antibiotics in patients. Bern: Hans Huber atite, amalgam, and Life. J Endod 1991;17:234-8.
Publishers; 1982:160-76. 65. Beavers RA, Bergenholtz G, Cox CF. Periodontal wound healing
53. Johnson GM, Lee DA, Regelmann WE, Gray ED, Peters G, following intentional root perforations in permanent teeth of Macaca
Quie PG. Interference with granulocyte function by staphylococcus mulatta. Int Endod J 1986;19(1):36-44.