JOURNAL OF ENDODONTICS
Copyright © 2004 by The American Association of Endodontists
CLINICAL RESEARCH
Levels of Evidence for the Outcome of Endodontic
Retreatment
Stephen Paik, DDS, Christopher Sechrist, DDS, Mahmoud Torabinejad, DMD, MSD, PhD
The purpose of this investigation was 2-fold: (a) to
complete a thorough search of published literature
related to clinical studies on the success and fail-
ure of nonsurgical retreatment, and (b) to assign
levels of evidence to these publications. Clinical
studies related to success and failure of retreat-
ment since 1970 were identified using both elec-
tronic and manual literature searches. After iden-
tification of pertinent literature, each article
received a level of evidence (LOE) from one (high)
to five (low). Thirty-one clinical studies and six re-
view articles related to this subject were identified.
There was no LOE 1 Randomized Control Trials
(RCT). There were three LOE 2 RCTs, one LOE 2
Cohort, and two LOE 3 Case Control Studies. Thir-
teen Case Series (LOE 4), which comprise the most
highly quoted success and failure data, were
found. Twelve Case Reports (LOE 5) and six review
articles (LOE 5) were found. Based on these find-
ings, it appears that few high level studies have
been published in the past 34 yr related to the
success and failure of endodontic retreatment.
Complete cleaning and filling of root canals should result in
resolution of periradicular lesions after nonsurgical root canal
therapy. The degree of success following root canal therapy has
been reported as high as 98.7% (1) and as low as 45% (2). The
Washington study reports a success rate of 95% (3) of all treated
endodontic cases, which compares favorably with other reports of
success. An examination of failed cases from the Washington
study (3) showed that over two-thirds of these failures were related
to incomplete cleaning and obturation of root canals. Harty et al.
have also reported that the majority of nonsurgical endodontic
procedures that fail do so because of inadequate apical seal (4).
In addition to the factors cited in the above studies, a number of
recent investigations have shown that the exposure of the coronal
parts of filled root canals to oral flora results in total contamination
745
Printed in U.S.A.
VOL. 30, NO. 11, NOVEMBER 2004
of the entire root canals in a few days (5–9). This occurs as a result
of either the presence of voids between the dentinal walls and the
filling materials used to obturate the root canal system, and/or
washing out of the root canal sealers.
The preferred treatment of failing endodontic cases is nonsur-
gical retreatment. According to Bergenholtz et al. (10), Molven
and Halse (11), Allen et al. (12), Sjogren et al. (13), and Friedman
et al. (14), this treatment usually results in successful outcomes.
The success rate of endodontic retreatment ranges between 40 to
100% (Table 1). With this wide range of data, clinicians do not
have consistent information upon which to base their clinical
treatment choices.
In an effort to provide patients with the most recent, highest
quality and predictable treatment modalities for dental care, clini-
cians must be well informed of the outcome of proposed treatment.
In cases refractory to initial root canal therapy in which a decision
is made to perform nonsurgical retreatment, the patient has the
right to know the prognosis of the proposed treatment as a com-
ponent of informed consent. Clinicians must be able to provide this
information to the patient based on the best available data.
Since the 1990s, there has been a paradigm shift to evidence-
based medicine. The Center for Evidence Based Medicine (www.
cebm.net) is an organization providing criteria for what constitutes
evidence-based research. As in medicine, dentistry has shifted to
this new thinking. The American Dental Association defines evi-
dence-based dentistry (EBD) as an approach to oral healthcare that
requires the judicious integration of systematic assessments of
clinically relevant scientific evidence, relating to the patient’s oral
and medical condition and history, with the dentist’s clinical ex-
pertise and the patient’s treatment needs and preferences (15). The
EBD process consists of four steps. The first step is the formulation
of a relevant question related to a specific clinical application.
Well-formulated clinical questions usually contain four elements
(PICO): the patient or the problem, the intervention, the compar-
ison of the intervention with alternative treatments, and the treat-
ment outcome (16). This process will allow the researcher or
clinician to find the best available evidence related to the treatment
of the patient. Best available evidence may include randomized
controlled clinical trials, nonrandomized controlled clinical trials,
cohort studies, case-control studies, cross over studies, cross-sec-
tional studies, case studies, or consensus opinions of experts in the
field. The second step includes gathering of the data through
746 Paik et al. Journal of Endodontics

TABLE 1. Treatment outcome following orthograde retreatment in teeth with and without periradicular lesions
Treatment Outcome
Without Periradicular
No. With Periradicular Lesions
Study Lesions
Cases
Uncertain
Success Failure No. Cases Success
(healing)
Selden 1974 52 88% 12%
Bergenholtz 1979 234 roots 48% 30% 22% 322 94%
Pekruhn 1986 36 83.4%
Molven 1988 98 71% 29% 76 89%
Allen 1989 315 72.7% 48 96%
Sjogren 1990 94 62% 38% 173 98%
Van-Nieuwenhuysen 1994 260 roots 71.8% 18.9%
Friedman 1995 86 55.8% 33.7% 10.5% 42 100%
Sundqvist 1998 50 74% 26%
Gorni 2004 167 83.8% 16.2% 83 91.6%
Gorni 2004 (Root canal 170 40% 60% 32 84.4%
morphology altered)
Fristad 2004 112 roots 97% 3% 46 roots 93.5%

queries and searches to answer the question. This data is graded on
the strength of the evidence. The third step involves the translation
of the gathered data for use by clinicians. The final step is assessing
the outcomes from the use of the data to modify treatments for
patients.
In addition to the ADAs evidence based dentistry mission,
organizations such as the Canadian Collaboration on Clinical Prac-
tice Guidelines in Dentistry (CCCD) have been established to
represent groups of practicing dentists to create evidence-based
guidelines for dentistry. The CCCD has developed a specific
methodology and process by which evidence-based clinical prac-
tice guidelines will be formulated (17). These guidelines allow
clinicians to gather new lines of evidence that may change the way
they practice.
The practice of evidence-based dentistry should integrate clin-
ical expertise with the available scientific evidence for the benefit
of the patient. In an effort to provide clinicians with an overview
of available evidence related to the treatment outcome of endodon-
tic retreatment, an extensive literature search was completed. The
purpose of this article was 2-fold: (a) to search for clinical studies
pertaining to success and failure of endodontic retreatment and (b)
to assign levels of evidence to these studies.
METHODS
Initially, a PubMed search was performed using key words such
as success and failure AND endodontic retreatment, treatment
outcome AND retreatment, revisional therapy AND endodontics,
and root canal AND retreatment. Numerous other key words were
also used to perform an exhaustive search including: failure, clin-
ical, clinical evidence, outcomes, revision, nonsurgical, and case
reports. For each reference that appeared to match the search
criteria, the article was located, photocopied, and reviewed. Then,
the reference section of each of those articles was studied to
determine if any of the references cited in the article matched our
search criteria. The references that matched our criteria were
placed on a master list. Each time a reference section was re-
viewed, the references were checked against a master list. If the
article did not appear on the master list, it was then located,
reviewed and cross-referenced. This cross-referencing process of
locating articles and studying the reference section was continued
until there were no longer any new articles located in either the
electronic databases or through manual cross-referencing.
Additional sources other than the search initiated from PubMed
were also used. They included success and failure, and retreatment
chapters in endodontic textbooks (3, 18, 19). These chapters were
reviewed and the articles that matched the search criteria were
obtained and cross-referenced until no new articles could be iden-
tified. The new references from these sources were also added to
the master list of references.

A comprehensive search was initiated to identify clinical studies

published in English related to the success and failure of endodon-
tic retreatment from 1970 to early 2004. The inclusion criteria were
as follows: the study must look at (a) short-term success and
failure, such as presence or absence of pain; (b) long-term success
and failure, such as periradicular healing or persistence of post-
treatment disease; (c) the success rate of endodontics in a specified
population (epidemiological study); (d) the success rate using
different materials and/or techniques; (e) the success rate of a
unique case followed over time; or (f) comprehensive clinical
review articles of success and failure. Articles that did not report
follow-up data were excluded. Animal studies and articles that
only described clinical techniques, expert opinion, or bacterial
sampling and identification of bacterial species were also ex-
cluded.
TABLE 2. Evidence level stratification of relevant study
designs*
1 Randomized control trials (RCT)
Systematic reviews of randomized control trials
2 Low quality randomized control trials
Cohort studies
Systematic review of cohort studies
3 Case control studies
Systematic reviews of case control studies
4 Poor quality cohort and case control studies
Case series
5 Case reports
Expert opinion without explicit critical appraisal
Literature reviews
* Adapted from Centre for Evidence-Based Medicine at Oxford.
Vol. 30, No. 11, November 2004 Levels of Evidence for the Outcome of Endodontic Retreatment 747

All selected articles were then examined to determine the level TABLE 3. Studies in alphabetical order by type of study and
of evidence (LOE) according to guidelines provided by The Centre level of evidence
for Evidence-Based Medicine (20). Only the broad designations of Author Year LOE Study Type
levels one through five were employed (Table 2). The type of study
was identified according to the definitions established by the ADA: Danin et al. 1996 2 Randomized Trial
(low quality)
• A Randomized Controlled Clinical Trial (RCT) is a study that Kvist, Reit 1999 2 Randomized Trial
(low quality)
randomizes a group of subjects into an experimental group and
Kvist, Reit 2000 2 Randomized Trial
a control group. The experimental group receives the new inter- (low quality)
vention and the control group receives a placebo or standard Gorni, Gagliani 2004 2 Cohort (high quality)
intervention. These groups are then followed up for the outcomes Allen et al. 1989 3 Case Control
of interest. Mattscheck et al. 2001 3 Case Control
• A Cohort Study involves identifying two groups (cohorts) of Bergenholtz et al. 1979 4 Case Series
subjects, one that receives the exposure of interest and another Bergenholtz et al. 1979 4 Case Series
that does not, and follows these cohorts forward for the outcome Friedman et al. 1995 4 Case Series
Fristad I. 2004 4 Case Series
of interest.
Imura, Zuolo 1995 4 Case Series
• Case Control Studies involve identifying subjects with a clinical Kerekes et al. 1979 4 Case Series
condition (cases) and subjects free from the condition (controls), Molven, Halse 1988 4 Case Series
and investigating if the two groups have similar or different Pekruhn 1986 4 Case Series
exposures to risk indicators or factors associated with the dis- Selden 1974 4 Case Series
ease. Sjogren et al. 1990 4 Case Series
Sundqvist et al. 1998 4 Case Series
• A Case Series is a report on a series of patients with an outcome
Van Nieuwenhuysen et al. 1994 4 Case Series
of interest. No control group is involved so they are considered Walton, Fouad 1992 4 Case Series
to be not comparative. Clark, Eleazer 2000 5 Case Report
• Case Reports are testimonials accounting one or several meth- Cohenca, et al. 1996 5 Case Report
odologies and/or their outcomes, but no analysis or comparison Fachin et al. 1995 5 Case Report
is made. Fava 2001 5 Case Report
Ida, Gutmann 1995 5 Case Report
Two endodontic residents determined the type of article and the Kleier 1984 5 Case Report
level of evidence individually. When a discrepancy existed the Koshy, Love 2003 5 Case Report
authors engaged in discussions until a general consensus was Moiseiwitsch, Trope 1998 5 Case Report
reached. This procedure was performed to minimize errors in Nair, Sjogren, Sundqvist 1993 5 Case Report
assigning levels of evidence and determining study types. An Sedgley, Wagner 2003 5 Case Report
endodontic faculty member confirmed the LOE results to help Selden 2000 5 Case Report
Tronstad et al. 1990 5 Case Report
ensure proper classification of the articles.
Briggs, Scott 1997 5 Review Article
Table 2 summarizes the type of study and the assigned level of Fleming, Dermody 2003 5 Review Article
evidence. RCTs and Cohort studies were classified as low quality Hepworth, Friedman 1997 5 Review Article
if there were deficiencies in study design such as: (a) small sample Kvist 2001 5 Review Article
size (n ⬍ 30), (b) no established criteria for standardization of Rafter 2003 5 Review Article
radiographic and clinical assessment, (c) radiographic studies with- Rakusin 1997 5 Review Article
out clinical criteria, (d) inappropriate exclusion criteria, (e) only
one radiographic evaluator, or (f) inappropriate or deficient statis-
tical analysis. nonsurgical retreatment (23). One high-level LOE 2 Cohort Stud-
All references are listed alphabetically within each LOE cate- ies was found. This recent article identified the relationship be-
gory. This format is intended to promote expeditious referencing tween initial root canal treatment deficiencies and the success and
and organization within groups. failure of retreatment (24).
Two Case Control Studies were identified. The first study com-
pared recall data of 1,300 charts to analyze for factors related to
RESULTS success and failure of surgical and nonsurgical retreatment cases
(12). The other Case Control Study compared posttreatment pain
Based on the established inclusion and exclusion criteria, the levels following retreatment with those of initial root canal therapy
literature search produced 37 publications related to the success (25).
and failure of endodontic retreatment (Table 3). No high-level Thirteen studies qualified as Case Series LOE 4 (Table 4). Ten
Randomized Control Trials were identified. There were three low- studies considered the effect of a standardized treatment method on
level RCTs. One high-level Cohort Study (LOE 2) was found and the outcome of retreatment (10, 11, 13, 14, 26 –31). Ten articles
two Case Control Studies (LOE 3) were identified. Thirteen Case evaluated the effect of periradicular lesions on the success and
Series Studies (LOE 4), 12 Case Reports (LOE 5), and six Review failure of retreatment (10, 11, 13, 14, 26 –29, 31, 32). The influence
Articles (LOE 5) were located. of over-instrumentation and overfilling was evaluated in seven
Three RCTs were identified over the past 34 yr. Two of these studies (10, 13, 14, 26, 27, 31, 32). Success and failure of retreat-
studies considered the success and failure of nonsurgical retreat- ment was critiqued based on the duration of follow-up in four
ment compared to surgical retreatment (21, 22). The remaining studies (14, 26, 27, 29). The effect of specific obturation materials
LOE 2 RCT compared postoperative pain following surgical and (11, 14, 26), single-visit therapy (14, 28), and microbial analysis
748 Paik et al.
TABLE 4. Variables impacting the success and failure of endodontic retreatment in the identified Case Series articles (LOE 4)
Variable Evaluation Criteria
Standardized retreatment methods (10, 11, 13, 14, 26–31)
The effect of periradicular lesions (10, 11, 13, 14, 26–29, 31, 32)
Influence of over-instrumentation and overfilling (10, 13, 14, 26, 27,
31, 32)
Duration of follow-up (14, 26, 27, 29)
The effect of specific obturation materials (11, 14, 26)
The effect of single visit therapy (14, 28)
Microbial analysis prior to obturation (30)
Variance of radiographic and clinical evaluation criteria (31)
Incidence of flare-up (33, 34)
(30) were also evaluated. One study examined the impact of
clinical and radiographic criteria on success and failure (31) and
two studies assessed the prevalence of endodontic flare-ups during
retreatment (33, 34). No low-level LOE 4 Cohort Studies were
found.
Twelve articles involve patient treatment reports (Case Re-
ports). They cover subjects such as retreatment of teeth with root
fractures (35), unusually long roots (36), modified instruments
(37), calcium hydroxide (38), anatomic variance (39), postsurgical
endodontic failure (40, 44), autotransplants (41), indications for
root-end surgery (42), radicular cysts (43), refractory lesions (45),
and extraradicular infections (46).
Six review articles were located providing data on success and
failure of nonsurgical retreatment (47–52).
DISCUSSION
The literature search conducted in this review relied mainly on
an article’s impact on future publications. The initial PubMed
search and textbook reviews identified a core group of articles that
established a foundation for the cross-referencing procedures. The
ability of a recent article to impact textbooks is rare, so the PubMed
database was our only source for current publications. If an article
had not been quoted by another study or had not been entered into
an electronic database, it may have been missed. This limitation is
acknowledged and may result in a recent publication or a low-
impact article being omitted.
The journal impact factor, which is derived from the Science
Citation Index and published by the Institute for Scientific Infor-
mation (53) is the most common bibliometric criterion in use today
to define journal quality and prestige. Rogers (54), Coelho et al.
(55), as well as Cathey and Kader (56) have identified the potential
for the journal impact factor to influence the readership of a
particular journal. The journal impact factor did not influence our
literature search directly; however, each publication cited in this
review may have been affected by the journal impact factor at the
time each article was written.
We found no LOE 1 RCTs. There may be reasons for the lack
of LOE 1 RCTs and dominance of Case Series (LOE 4) and Case
Reports (LOE 5) in the retreatment literature. Retreatment cases
lend themselves to the latter types of studies. It is very difficult to
set up randomized double-blinded well-controlled studies for end-
odontic retreatment cases. Many pre-existing factors such as ac-
cessibility of teeth in the dental arch, pre-existing restorations, the
Journal of Endodontics
Primary Author/Year
Bergenholtz 79, Friedman 95, Fristad 04, Kerekes 79, Molven 88,
Pekruhn 86, Selden 74, Sjogren 90, Sundqvist 98, Van
Nieuwenhuysen 94.
Bergenholtz 79, Bergenholtz 79, Gorni 04, Friedman 95, Fristad
04, Kerekes 79, Molven 88, Pekruhn 86, Selden 74, Sjogren
90, Van Nieuwenhuysen 94.
Bergenholtz 79, Bergenholtz 79, Friedman 95, Fristad 04,
Kerekes 79, Sjogren 90, Van Nieuwenhuysen 94.
Friedman 95, Fristad 04, Kerekes 79, Selden 74.
Friedman 95, Fristad 04, Molven 88.
Friedman 95, Pekruhn 86.
Sundqvist 98.
Van Nieuwenhuysen 94.
Imura 95, Walton 92.
patient’s medical history, the patient’s preference and the practi-
tioner’s experience may eliminate the randomization process. In
addition, blinding the clinician and patient to radiographic and
clinical assessment can be very difficult and may violate the
informed consent process and can introduce ethical and legal
questions. LOE 1 RCT can be designed to compare the success of
retreatment to that of endodontic surgery or a combination of
retreatment and endodontic surgery. However, equalization of pre-
existing factors makes conducting these studies very difficult.
Randomized control trials and cohort studies are much easier to
conduct in retreatment cases when two aspects of retreatment are
compared to one another. For instance, for patients needing re-
treatment of a failing root canal treatment, two different techniques
for removal of filling materials or obturation of the root canals can
be randomly assigned and evaluated by examiners who are blinded
to the materials and methods used during retreatment of these
cases.
The three LOE 2 RCTs showed variable limitations related to
the success and failure of endodontic retreatment. The first RCT
compared postoperative pain following surgical and nonsurgical
retreatment (23), providing only short-term results without clinical
or radiographic criteria. The remaining two RCTs compared non-
surgical retreatment to periradicular surgery. The follow-up peri-
ods varied between studies (21, 22) and ranged between 1 and 4 yr.
Treatment modalities and assessment criteria varied, as well as the
number and experience of clinicians selected to complete treatment
(21, 22). The lack of standardization and follow-up duration makes
these studies very limited for comparison of success and failure
data.
The one LOE 2 Cohort Study identified attempts to compare
success and failure of endodontic retreatment to alterations in root
canal morphology during the initial treatment (24). The presence or
absence of periradicular lesions is considered and the radiographic
and clinical follow-up period was 24 months. Unfortunately, the
materials and intracanal medicaments used were not uniformly
standardized allowing for confounding variables during treatment.
The two Case Control Studies (LOE 3) have some limitations.
The first study compared recall data of 1,300 charts to analyze the
factors related to success and failure of surgical and nonsurgical
retreatment cases (12). Success and failure data is presented, but
the study design is strictly retrospective without interventional
control of treatment and groups. The other study compared post-
treatment pain levels associated with retreatment and initial root
canal therapy (25). This study only addressed short-term pain
Vol. 30, No. 11, November 2004 Levels of Evidence for the Outcome of Endodontic Retreatment
levels, but did not address long-term radiographic and clinical
treatment outcome.
The 13 Case Series LOE 4 articles are among the most highly
quoted studies related to the success and failure of endodontic
retreatment. Based on our literature search, these reports comprise
45% of the published literature related to nonsurgical retreatment
outcomes. Unfortunately, these articles cover a broad range of
treatment variations, assessment criteria, biological philosophies
and follow-up durations, which creates confusion regarding the
predicted outcome of retreatment. These publications do not have
control groups, randomization or alternative treatments, and many
articles are retrospective without standardization of treatment
methodology or diagnostic criteria.
The inclusion of Case Reports LOE 5 in this review article is
intended to identify rather than justify. The use of Case Reports in
the formulation of success and failure data related to retreatment is
unwarranted, but the identification of unique situations and treat-
ment outcome related to these cases is informative for the clinician.
The 12 Case Reports cover a broad range of patient treatment
outcomes related to retreatment and comprises 39% of the total
studies found in the literature search.
Six Review Articles (LOE 5) were selected. These articles
present data on the success and failure of retreatment, and attempt
to establish guidelines for the etiology of failure. Comparisons are
often made relating retreatment to initial therapy. The inclusion of
these articles is intended to enhance the reader’s ability to draw on
a substantial body of literature when the success and failure of
endodontic retreatment is questioned. Review articles related to
retreatment that did not present data based on clinical studies were
not selected.
In the fields of epidemiology and medicine, Case Series and
Case Reports are not considered reasonable evidence for the for-
mulation of treatment modalities. Ideally, clinicians should not
formulate treatment decisions based on studies completed without
control groups for comparison. While a few high level studies are
available, it appears that low-level clinical studies such as Case
Series (LOE 4) and Case Reports (LOE 5) dominate the literature
on success and failure of conventional retreatment. Scientific ev-
idence by no means refers only to randomized controlled trials.
There are two important components in an evidence-based prac-
tice; the first is the systematic assessment of scientific evidence
and the second is using the findings from systematic reviews to
form clinical decisions. This step attempts to integrate the clini-
cians’ experience, the specific factors related to the patient, patient
autonomy, and the best available research into the clinical decision
making process. Because of the complexity of this process, the
Centre for Evidence Based Medicine has established Grades of
Recommendation to provide clinicians with advice relative to the
integration of these factors (20).
Based on the results of this search, it appears that few high level
studies have been published in the past 34 yr related to the success
and failure of endodontic retreatment. Our findings on the outcome
of endodontic retreatment are consistent with the findings of other
investigations related to the success and failure of initial nonsur-
gical root canal treatment (57) and surgical endodontics (58).
From the Department of Endodontics, School of Dentistry, Loma Linda
University, Loma Linda, CA.
Address request for reprints to Dr. Mahmoud Torabinejad, DMD, MSD,
PhD, Professor and Director, Endodontic Residency Program, Department of
Endodontics, School of Dentistry, Loma Linda University, Loma Linda, CA
92350; E-mail address: mtorabinejad@sd.llu.edu.
749
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