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 Thomas Kvist
Editor

Apical Periodontitis
in Root-Filled Teeth

Endodontic Retreatment
and Alternative Approaches

123
Apical Periodontitis in Root-Filled Teeth
Thomas Kvist
Editor

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

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

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

Library of Congress Control Number: 2017957215

© Springer International Publishing AG 2018

This work is subject to copyright. All rights are reserved by the Publisher, whether the whole or
part of the material is concerned, specifically the rights of translation, reprinting, reuse of
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The use of general descriptive names, registered names, trademarks, service marks, etc. in this
publication does not imply, even in the absence of a specific statement, that such names are
exempt from the relevant protective laws and regulations and therefore free for general use.
The publisher, the authors and the editors are safe to assume that the advice and information in
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Printed on acid-free paper

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Contents

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

v
List of Contributors

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

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

vii
 Introduction
1
Thomas Kvist

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

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

1.1 Contemporary Endodontics restorative dentistry. Billions of teeth are saved

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

© Springer International Publishing AG 2018 1

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

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

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

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

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

2.1 Introduction What relevance may epidemiological data have

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

© Springer International Publishing AG 2018 7

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

Matijevic et al. [64] Croatia Panoramic Patient 75.9 8.5

Moreno et al. [65] Colombia Apical/FMR Patient 49
Paes da Silva et al. [5] Brazil CBCT Patient 51.4 3.4 35.4
Peciuliene et al. [66] Lithuania Apical/FMR Patient 43.1
Persic et al. [67] Croatia/Austria Panoramic Patient 47.3/62.1
Peters et al. [68] Netherlands Panoramic Patient 2.5 24.1
Petersson et al. [69] Sweden Apical/FMR Patient 93 77 8.7 26.5
Saunders et al. [71] Scotland Apical/FMR Patient 54 67.7 4.9 58.1
Sunay et al. [72] Turkey Panoramic Patient 47 4.2 53.5
Skudutyte-Rysstad et al. [73] Norway Apical/FMR Population 23 16 1.1 43
Sidaravicius et al. [74] Lithuania Apical/FMR Population 72 70 7.2 35
Tavares et al. [12] France Apical/FMR Patient 33
Incidence, Frequency, and Prevalence

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

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

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

Table 2.3 Data from longitudinal (follow-up) studies

Follow-up Incidence of root Incidence of AP Loss of
(years) canal treatmenta in root-filled teeth root-filled teeth
Kirkevang et al. [15] 11 1.7% (140/8258) 32% (67/208) 13.9% (56/402)
Petersson et al. [24] 11 3.3% (70/2100) 12.4% (17/137) 12.4% (32/258)b
Eckerbom et al. [44] 20 5.5% (155/2825) 28.8% (113/393)
Petersson et al. [70] 20 8% (23/273) 35% (159/449)
a
Retreatments excluded
b
Root-filled teeth and pulpotomized teeth included
16
treated and on which indication is not available.
According to Petersson et al. [24] the root filling
quality was a significant predictor for develop-
ment of apical periodontitis. Kirkevang et al.
[25] did not find poor root filling quality to be
predictive for development of apical periodonti-
tis, but instead increased the risk for persistent
apical periodontitis.
As can be seen, data from population surveys
do not identify factors that consistently pre-
dict which root-filled teeth will develop apical
periodontitis.
2.4.4 Loss of Root-Filled Teeth
Longitudinal studies conclusively show that
root-­filled teeth are at higher risk to be lost
than non-­root-­filled teeth [26]. Studies investi-
gating the reasons for loss of root-filled teeth
have reported that other reasons than apical
periodontitis are more frequent. Caries, failed
restorations, amount of tooth substance, and
marginal periodontitis have been reported as
risk factors for loss of root-­filled teeth [27–29].
On an individual level, one study reported that
high age, number of lost teeth, and amount of
plaque were predictive of loss of root-filled
teeth [30]. Interestingly, endodontic factors
represent a small fraction of reasons for extrac-
tion of root-filled or endodontically treated
teeth. Several studies have reported on the ben-
efit of crown restoration on root-filled teeth.
Aquilino and Caplan [31] showed that crown
placement on molars increased survival sig-
nificantly compared to root-filled molars with-
out full crown coverage. Landys-Borén et al.
[32] reported similar results but not limited to
molars. Fransson et al. [33] also reported on
a higher survival rate for teeth with indirect
restorations compared to direct restorations.
However, the difference was small, 93.1 and
89.6%, respectively.
Root-filled teeth with substantial loss of tooth
substance and root-filled molars without full
crown coverage seem to be at higher risk of being
lost. Individuals with poor dental habits seem to
be at higher risk for loss of root-filled teeth.
F. Frisk
Take Home Lessons
• Use data from epidemiological studies
to improve endodontic treatment and
care of patients with endodontic condi-
tions. Do not use it to compare data on
outcome from clinical studies conducted
in education or specialist clinics.
• Use data from epidemiological studies
to compare with your own and your col-
leagues’ clinical experience. Is your
experience at variance with epidemio-
logical data?
• There is a great potential for improve-
ment of the outcome of endodontic
treatment. Besides adequate root canal
treatment, careful case selection and
treatment planning including choice of
adequate restoration may improve the
outcome.
Benchmark Papers
• Frisk F, Hugoson A, Hakeberg
M. Technical quality of root fillings and
periapical status in root filled teeth in
Jönköping, Sweden. Int Endod J.
2008;41:958–68. This repeated cross
sectional study reported on the fre-
quency of apical periodontitis in root
filled teeth on three occasions over a
20-year period. The results also high-
lighted that an improved root filling
quality has not resulted in a lower fre-
quency of apical periodontitis in root
filled teeth.
• Kirkevang LL, Vaeth M, Wenzel A. Ten-­
year follow-up of root filled teeth: a
radiographic study of a Danish popula-
tion. Int Endod J. 2014;47:980–8. One
of few longitudinal studies that reports
on incidence of apical periodontitis in
root filled teeth and related factors.
• Gillen BM, Looney SW, Gu LS,
Loushine BA, Weller RN, Loushine RJ,
Pashley DH, Tay FR. Impact of the
2 Incidence, Frequency, and Prevalence
quality of coronal restoration versus the
quality of root canal fillings on success
of root canal treatment: a systematic
review and meta-analysis. J Endod.
2011;37:895–902. Recommended read-
ing for anyone pondering the associa-
tion between the quality of the
restoration and apical periodontitis in
root filled teeth. The paper provides a
systematic review of the literature as
well as a meta-analysis. The authors
conclude that the combination of ade-
quate root filling and adequate restora-
tion increase the chance for a healthy
periapical condition.
• Örstavik D, Kerekes K, Eriksen
HM. The periapical index: a scoring
system for radiographic assessment of
apical periodontitis. Endod Dent
Traumatol. 1986;2:20–34. An important
paper introducing the PAI-index which
over time have found an increasing
number of users in epidemiological and
clinical studies. Recommended reading
for those who are planning a study
including evaluation of periapical sta-
tus in radiographs and wants to under-
stand how observation variation may be
handled.
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 Aetiology of Persistent Endodontic
Infections in Root-Filled Teeth
3
Luis E. Chávez de Paz

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

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

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

© Springer International Publishing AG 2018 21

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

Fig. 3.2 Schematic a Surface

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

c­olonizing species and later colonizing patho-
gens [17]. In infected root canals, the presence of
fusobacteria has been widely reported and has
been linked with the occurrence of cases with
most severe inflammatory symptoms [6]. In such
cases, fusobacteria were found in combination
with highly proteolytic organisms, e.g. Prevotella
and Porphyromonas. Hence, it is likely that the
surface receptors from fusobacteria promote the
colonization of these proteolytic pathogens in
root canals. A similar case is seen in microbio-
logical screening of sites of periodontal inflam-
mation, where fusobacteria appear just before the
pathogenic “red” complex consisting of
Porphyromonas gingivalis, Treponema denticola
and Tannerella forsythia [20].
The presence of E. faecalis in post-treatment
infected root canals has received much attention
since this is an organism that shows, among other
interesting capacities, high tolerance to alkaline
pH [21–23]. Although the majority of these obser-
vations have been made in vitro, its high tolerance
to alkaline has been clinically linked to a potential
resistance to treatment with inter-­ appointment
dressings containing calcium hydroxide [5, 7].
However, the origin of E. faecalis in infected root
canals has remained highly controversial because
this organism is not commonly found in untreated
necrotic pulps and has been until recently consid-
ered a ‘transient’ microorganism in the oral flora
[24]. E. faecalis has been isolated from teeth pre-
senting post-­treatment infections with a prevalence
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source: such of it as was not of the nature of mortification and
wounded vanity, was principally composed of childish
disappointment in the destruction of her dazzling visions of wealth
and grandeur. She had some amount of regard for Trevor himself;
she admired him, she liked his pleasant voice and gentle deference
of manner; she thought she loved him devotedly, she had long ago
made up her mind to fall in love with none but a thoroughly desirable
parti, therefore the fact of his wealth and position by no means
interfered with her belief in the genuineness of her affection for him.
That she was very thoroughly in love with the idea of marrying him,
of obtaining all the pleasant things that would certainly fall to the
share of his wife, there was not the shadow of a doubt. And the
disappointment of her hopes fell upon her with crushing weight.
There was nothing of true pathos or tragedy in her composition; her
cup was but a pretty toy, brittle as egg-shell, though, unlike egg-
shell, very capable of repair, but, such at it was, it was just now full to
the brim with the bitter draught, which no reserve of latent heroism
was at hand to render less unpalatable.
She threw herself down on the bed and sobbed.
“I wish I had never come to England I wish they had told me at
first—I wish, oh! how I wish I had never seen him,” she cried.
Then her glance fell on the little bow of red ribbon which she had
fastened to her dress that very morning.
“Naughty little ribbon, detestable little ribbon, I put you on to make
me look pretty, that he should think me pretty,” she exclaimed,
throwing the rose-coloured knot to the other end of the room, “and
now I must think of him as the fiancé of my cousin! It matters not
now that he thinks me pretty or ugly; he can never be anything more
to me. And Cicely, she who is already rich, fétée,—who could find
partis without number. Ah, but it is cruel!”
CHAPTER IV.
 MAN AND WOMAN.

“La discussion n’est vraiment possible et efficace qu’entre gens du même avis.”
Deligny.

“Perhaps, however, there is little difference between understanding and

sympathising.”
Casimir Maremma.

GENEVIÈVE came down to luncheon with hopelessly red eyes and a

general air of extreme depression. Cicely looked at her kindly, and
spoke to her gently; it was impossible not to be touched by the
contrast between her present appearance and the bright joyousness
which had attracted her cousin’s notice that very morning. Mrs.
Methvyn was more demonstratively affectionate than Geneviève had
ever known her.
“I am going to Greybridge this afternoon,” said Mrs. Methvyn,
“would you like to come with me, Geneviève? I am going in the large
carriage, so you won’t have to sit in the back seat. You cannot come,
Cicely?”
“No, mother,” said Cicely.
She got up from her chair as she spoke, for luncheon was over,
and went to the window.
“It looks so fine,” she remarked. “Don’t you think my father might
try another drive?”
Mrs. Methvyn shook her head. “I did suggest it,” she said, “but he
did not seem inclined for it. I think he might get over his nervousness
about it if Mr. Guildford could go with him once or twice.”
“I wish he could,” exclaimed Cicely. “Would it be worth while to
write and ask him if he could come some day soon early enough for
a drive?”
“You might ask your father,” answered her mother. “Well then,
Geneviève, will you come with me?”
Geneviève started. She seemed to wake out of a reverie at the
sound of her own name.
“Yes, thank you. I should like very much to go,” she said. “I will go
and get ready,” and she left the room.
“How nervous Geneviève seems!” remarked Cicely regretfully.
“And this morning she was so bright and happy! I don’t quite
understand her.”
“Not understand her, Cicely, when I have been telling you how
terribly distressed she was at the thought of losing you! It is entirely
that that has upset her. I think you should try to be a little more
demonstrative to her, poor child, a cold word or tone chills her in an
instant,” said Mrs. Methvyn reproachfully.
“Don’t say that, mother, don’t!” exclaimed Cicely in a quick tone of
pain. “I do try, I have tried to be affectionate—more so a great deal
than is natural to me—in my manner to Geneviève. But,” she
hesitated. “Mamma, it is no use struggling against it,” she went on
impetuously, “I would not say so to any one but you, but I cannot get
rid of the feeling that she is not perfectly sincere.”
“Cicely!” exclaimed her mother, “my dear child, I am surprised at
you. It is not like you to take up an unfounded prejudice. I am quite
certain Geneviève is as straightforward and genuine as possible.
Indeed, she is transparent to a fault. And her mother is the same.
When I knew her as a girl, she was the most guileless creature
living.”
“Yes,” said Cicely thoughtfully. “Yes, there is something in that. I
mean it is not likely that a girl brought up in an atmosphere of
truthfulness and simplicity would be scheming or underhand.”
“Scheming and underhand!” repeated Mrs. Methvyn. “What
dreadful words! Really, Cicely, you must not let your fancy run away
with you so. It is so unlike you.”
“Forgive me, mamma. I should not have said so much,” said
Cicely. “I have been anxious about Geneviève, and I suppose I have
grown exaggerated and fanciful. I will try to get rid of my fancies,
mother, I will indeed. And I will try to be more demonstrative to poor
Geneviève.”
“Very well,” replied her mother. “I should not recognize you,
Cicely, if you were to become prejudiced or suspicious. You will go
out a little now, won’t you? You have not been out to-day, and Trevor
will not be here just yet.”
“Yes, I will go out now,” said Cicely. “Kiss me, mother, and don’t
say I am mean and suspicious. I am cross, I think. Kiss me, dear
mother.”
She left her mother with a bright face and stood on the lawn by
the sun-dial, kissing her hand merrily in farewell as the carriage
drove away. But when it was quite out of sight, in spite of her
resolutions, her face clouded over again and her heart grew heavy.
“I ought to be glad that mother is so fond of Geneviève,” she
thought. “She will miss me the less.”
Then she felt ashamed of her own bitterness.
 “I don’t know what is coming over me,” she reflected. “I am mean
and unamiable. Can anything be meaner than for me to be jealous of
Geneviève, I who have so much, and she so little! Yet I am—I am
angry because both Trevor and mother have scolded me for being
cold to her. I am spoilt; I can’t bear being scolded—and I am vexed
with her because she has the power of showing her affection and
enlisting sympathy, whereas I seem to grow colder the more I feel.
And as for sympathy, I seem to repel it now—nobody thoroughly
sympathises with me.”
She sat down on the stone at the foot of the sun-dial in a very
unusual mood of self pity—Cicely, whom at this very moment
Geneviève was thinking of as the very happiest girl in all the world!
So little do we know of the fit of each other’s garments.
From where she was sitting, Cicely could see the drive almost all
the way to the lodge. And in the light dress she wore, she herself
was easily to be distinguished, by quick eyes at least, belonging to
any one approaching, the Abbey by this front road. There came a
sound of wheels. It was too early for Mr. Fawcett, besides which it
was more than probable that he would be riding.
“Some people coming to call,” thought Cicely, groaning in the
spirit. She felt peculiarly disinclined to-day for small talk and lady-like
gossip, and wished she had not placed herself where ignorance of
the arrival was impossible. But when the carriage came fairly within
view, her fears proved to have been ill-founded. It was only the
Greybridge fly. Almost before Cicely had time to wonder who could
be its occupant, the carriage stopped and a gentleman got out. He
had evidently seen her; he came quickly across the lawn in her
direction. Cicely got up from her seat and went forward to meet him.
“Mr. Guildford!” she exclaimed. “I had no idea it was you.”
But there was welcome in her tone. Some thing in his pleasant
face, in his keen glance, in his way of shaking hands even, seemed
to dispel the cloudy atmosphere of dejection and gloom in which she
had been breathing.
 “I should have written yesterday to tell you I was coming,” he
replied,“but till to-day I was not quite sure that I could make it out. My
coming again so soon will not annoy Colonel Methvyn, will it?”
“Oh! dear no; it will please him very much,” she answered heartily.
“I was going to write to you this afternoon to ask if you could come
again some day soon in time to take papa a drive. He is nervous
about going without you; but I am sure going out the other day did
him good. Could you go with him to-day?”
“I could easily,” replied Mr. Guildford. “I am not in any hurry; but I
hardly think the day is suitable. I mean the weather. It is a good deal
colder; the wind is in the east. I noticed it this morning, and some
how it made me feel fidgety about Colonel Methvyn. I grew so
anxious to know that his drive the day before yesterday had done
him no harm that I came to see.”
“It was very kind of you,” said Cicely gratefully. “I think you will find
him very well. So the wind is in the east, is it? In June too, what a
shame! Perhaps that is why I have felt so cross all day.”
“Do you often feel cross?” asked Mr. Guildford smiling.
“I don’t know. I used not; but lately I think I have been getting into
a bad habit of feeling so from no particular cause. At least,” she
hesitated a little, “from no new cause.”
“You mean that there would have been as much excuse for you
formerly as there is now, but that it is only lately you have yielded to
the irritating influences.”
“No,” said Cicely, laughing. “I don’t think there is now or ever has
been any excuse for me. But somehow I don’t think life is as
interesting as it used to seem.”
“That is not an uncommon phase of youthful experience,” he said
drily. “Don’t you fancy sometimes that nobody understands or
sympathises with you?”
“Yes,” said Cicely, looking up in his face with a questioning in her
eyes. Was he laughing at her?
 “Ah! I thought so,” he said, shaking his head gravely. “Once upon
a time I could have sympathised with you, but now—”
“Well, what now?” she asked, eagerly.
“Now, I have grown wiser.”
“How?”
“I have come to think one can do very well without much
understanding or sympathy; that too little is better than too much.
Too much is enervating.”
“Is that true?” she said seriously.
“I think so,” he answered.
“But you are a man,” she objected.
“And you are a woman,” he replied.
“Women are more clinging than men,” she remarked somewhat
hazily.
“You are shifting your ground,” he said. “It is not the clinging—the
weak side of your nature—that is discontented just now. It is the
energetic, working side that is so.”
“Yes,” she said eagerly, with a sparkle in her eyes, “yes, I think
you are right.”
“Then satisfy it.”
“How can I?”
“Give it work to do.”
Her countenance fell. “I must say again as I did before, “I am a
woman and you are a man,” she answered dejectedly.
He looked at her with more commiseration than he had yet
shown. “I suppose it is true,” he said, at last. “It is harder for a
woman who has anything in her to find a channel for her energies.
Still, you need not despair. You don’t know what is before you.”
“Yes, I do,” she said gloomily. He glanced at her in surprise, and
she grew scarlet.
 “I mean to say,” she went on hastily, “I mean to say that I know
quite well that my life will be very smooth and easy, and that I shall
never have anything to do that—that anybody could not do. Don’t
think me conceited,” she added pleadingly. “What makes me dull just
now is that the only duties that I feel I can do specially well, that
seem my own particular business, are going to be taken from me.”
Mr. Guildford made no answer. “You don’t think women should
have such feelings, I know,” she went on, in a tone of
disappointment. “You think they should take things as they come,
and be contented to stay in their own domain.”
“No, not quite that. There are exceptional women as well as
exceptional men,” he replied. “I don’t consider myself one of the
latter, but still I understand myself. Whatever it was that I said that
you are alluding to now, referred only to my own domain. I don’t
dictate to other people. I know what is best for myself, and least
likely to interfere with the aims of my own life—that is all. And so far
as I understand you,” he went on in a different tone, “your present
trouble seems to be that you want to stay in your own domain, and
you can’t get leave to do so.”
There was a half-veiled inquiry in his tone, but Cicely did not
perceive it. He tried to believe that she was only referring to some
passing trouble, some wish of her parents, perhaps, that she should
enter more into society, or give up the more arduous of her home
duties. For Geneviève’s assurance that her cousin and Mr. Fawcett
were “like brother and sister only,” was strongly impressed upon him.
Cicely’s reply puzzled him still more.
“Perhaps it is rather that I am not sure where is my own domain,”
she said. “And you being a man, can never be troubled with doubts
of that kind,” she added more lightly.
“I don’t know that,” he answered, feeling instinctively that she
wished to turn the conversation from her own affairs. “I often doubt,
as I think I have told you, if I did well to come to Sothernbay at all.”
“But you are thinking of leaving it eventually!” she asked with
interest.
 “Yes,” he answered. “When ‘eventually’ may be I can’t say, though
things lately seem inclined to hasten it. I had a piece of good luck—
at least of great encouragement—a short time ago. But,” he stopped
for a moment, “it is very egotistical of me to talk about all this. It can’t
possibly interest a young lady.”
“Why not?” she said. “If I had a brother who was clever and
learned like you—above all, who worked as hard as you do—do you
think I should not be interested in his success? So fancy I am your
sister. You have no sister?”
“Yes, I have,” he answered. “I have a very good little sister. She is
certainly not the least like you, Miss Methvyn.”
Cicely laughed. Mr. Guildford had a rather original way of
expressing himself sometimes.
“Never mind,” she said. “Tell me about your success. I believe I
can guess what it is. You have written some learned book, which has
set all the medical authorities of Europe in an excitement. And you
are the new light of the day.”
“Not quite. Don’t laugh at me, please. I dare say my success
won’t sound much to you. It is only that some papers of mine have
attracted attention, and I have been invited to contribute a series to
one of the first scientific journals of the day. The subject is not
directly connected with my own profession, but indirectly it bears
upon the very branch of it that I have studied more than any other.
So it will be no loss of time to me in any way.”
“I do consider it a success—a great success!” exclaimed Cicely.
“And what a reward for your past labours to find that they have been
all in the right direction! How I envy you! If it were not so
commonplace, I think I should sometimes say that I wished I were a
man.”
“Don’t say it,” said Mr. Guildford; “but not because it is
commonplace. You needn’t mind that.”
“Why must I not say it, then?”
 “Because—because it isn’t womanly,” he answered, smiling at his
own words.
Cicely smiled too.
“I suspect,” she said, “that your interpretation of that word is as
arbitrary as most men’s. And your notions about women are just as
inconsistent and unreasonable as—as—”
“As theories on subjects one knows very little about usually are?”
he suggested. “Perhaps so. Please remember, however, I only make
theories for myself, not for the rest of the world.”
The stable clock in the distance struck three.
“I think papa will be pleased to see you now,” said Cicely. “I
always go to him about this time when my mother is out.”
They turned towards the house. “Did you not meet my mother and
my cousin as you came from Greybridge?” she asked.
“Yes,” he replied. “I met them about half a mile from here—Miss
Casalis is exceedingly pretty,” he remarked inconsequently.
“She is beautiful,” said Cicely.
“No, she is too small to be beautiful. She is just the perfection of
prettiness.”

“Rose-jacynth to the finger tips,”

he observed reflectively.
Cicely looked up quickly. Her mother’s words recurred to her
memory, but Mr. Guildford’s manner perplexed her. Was “the
perfection of prettiness” his ideal? She walked on in a reverie, and
her companion glanced at her once or twice without attracting her
attention. Then he spoke.
“Do you think it is impertinent of me to make such remarks?” he
asked with a little anxiety.
Cicely started, but the start turned into a smile.
 “Oh! dear, no,” she replied. “I was only thinking about something
that puzzled me a little about—”
“About Miss Casalis?” inquired Mr. Guildford. His tone was so
gentle that Cicely never thought of resenting the question.
“Yes,” she said; “it was partly about her.”
“But you don’t think her puzzling, do you?” said Mr. Guildford in
surprise. “She seems to me transparency itself.”
Cicely looked up in his face with some perplexity in her own.
“I am afraid I sometimes repel where I should like to win,” she
remarked with apparent irrelevance. But there was no time to say
more, for just then they were met by a servant sent by Colonel
Methvyn in quest of his daughter, and Cicely hastened in to tell her
father of Mr. Guildford’s arrival.
When Mrs. Methvyn and Geneviève drove up to the hall door on
their return from Greybridge, they were met by Mr. Guildford. He
came forward to help them out of the carriage.
“I am still here, you see,” he said to Mrs. Methvyn. “I hope you will
not think I have tired Colonel Methvyn; we have had such a pleasant
afternoon. Colonel Methvyn has been so kind as to let me look over
his portfolios.”
“I am so glad,” answered the wife. “There is nothing he enjoys
more than showing his engravings to any one who understands
them. Your coming to-day was particularly fortunate, Mr. Guildford. I
wish we could send for you by magic now and then.”
Mr. Guildford laughed brightly, and Geneviève, who was just
stepping out, smiled up in his face as if in agreement with her aunt.
“Yes,” she said, “how nice that would be when dear uncle is tired!”
And as the young man turned towards her as she spoke, he felt
half inclined to modify his verdict of that very afternoon.
“Pretty! She is more than pretty,” he thought. For Geneviève was
at her very loveliest just then. The tears and agitation of the morning
had left their traces in an increased depth and tenderness of
expression; there was a subdued softness about her face which Mr.
Guildford had never remarked before. The unconcealed admiration
of his glance caught Mrs. Methvyn’s observation. She smiled, and
the smile was not misunderstood by Geneviève.
“That is what my aunt means,” thought the girl, referring in her
own mind to something that Mrs. Methvyn had said during their
drive, in the fulness of her motherly heart, about the pleasure it
would give her to see Geneviève happy like her cousin,—happy as
she who showed such appreciation of Cicely, surely deserved to be!
And sorely as the girl was suffering, the idea was not altogether
devoid of consolation.
“Where is Cicely?” said Mrs. Methvyn, as she entered the hall.
“Have you seen her, Mr. Guildford?”
“Not very lately,” he replied. “It must be an hour and a half at least
since I went up to Colonel Methvyn’s room, and I have not seen Miss
Methvyn since then.”
“Miss Cicely is out; Mr. Fawcett called about an hour ago, and
Miss Cicely went out into the garden with him,” said the old butler, in
answer to his mistress’s inquiry.
“She will be in soon, I dare say,” said Mrs. Methvyn. “Run upstairs
and let your uncle know we have come in, Geneviève dear, and then
come and make tea for us in the library. You will not refuse a cup of
tea, Mr. Guildford?”
Somewhat to her mother’s surprise, Cicely made her appearance
in the library almost immediately. She came in by the glass door,
alone, her hat in her hand, an unusual colour in her cheeks, and a
forced brightness in her manner which did not deceive the loving
eyes.
“What have you done with Trevor?” asked Mrs. Methvyn, with a
would-be carelessness of tone. “Simmons said he had been here.”
“Yes; but he could not stay long; he had letters to write or
something, and hurried home. Had you a pleasant drive, mother?
You look all the better for it, Geneviève,” said Cicely, speaking more
quickly than usual, and making greater clatter among the tea-cups
than her wont.
“We had a very nice drive,” replied Mrs. Methvyn, and then, quick
to take her daughter’s hint, she went on to speak about the
commissions they had executed at Greybridge, the neighbours they
had met, and the news they had heard, without further allusion to Mr.
Fawcett or his call.
Geneviève had fixed her eyes on her cousin when Trevor’s name
was first mentioned. She, too, had noticed something unusual in
Cicely’s manner. “Can it be that they have quarrelled,” she said to
herself, a throb of joy passing through her at the very thought. The
mere possibility of such a thing made her feel amiable, and almost
capable of pitying her cousin. She got up from her seat and came
forward to the tea-table to help Cicely.
“Thank you, dear,” said Cicely. She glanced at Geneviève as she
spoke. Some thing in her expression smote Geneviève—a look of
distress and endurance, a pained, perplexed expression, new to the
calm, fair face. Geneviève carried a cup of tea to Mrs. Methvyn, and
then went back to her seat, feeling unhappy and bewildered and
hopeful all at once. And as she reflected further on the position of
things, the last feeling gradually came to predominate, the shadow of
self-reproach faded away. What if Cicely and her lover had
quarrelled, and about her! She was not to blame. She had been kept
in the dark as to the true state of affairs; and even if she had known
it, could she have prevented what had happened?
“I did not make my own face,” thought Geneviève complacently. “I
cannot make myself ugly, and if people fall in love with me, it is not
my fault.”
She was quite ready to believe that Mr. Guildford, too, was fast
falling a victim to her charms. The idea was not unpleasing to her. It
brightened her eyes and added sweetness to her smile, as she
turned to speak to the young man who stood beside her, absorbed,
so it seemed to Mrs. Methvyn, in the contemplation of her lovely
face. Cicely noticed them too, and a little sigh escaped her. Was a
lovely face the one thing after all? It almost seemed so.
 Soon after Mr. Guildford left them, Geneviève went out into the
garden, and the mother and daughter were alone.
“Don’t you think that what I said is very evident now, Cicely?”
asked Mrs. Methvyn.
“What?” said Cicely absently, listlessly raising her eyes, “what was
it that you said, mother?”
“About Geneviève—about Mr. Guildford’s admiring her. Don’t you
remember?” said Mrs. Methvyn impatiently.
Oh, yes! I dare say it is so. I have no doubt he admires her.
Everybody does. It is not only her face; she is lovable and womanly
and gentle; everything I am not,” exclaimed Cicely with most
unaccustomed bitterness.
“Cicely!” ejaculated Mrs. Methvyn. In the extremity of her
amazement she could say no more.
“Oh! mother, don’t be shocked at me, said Cicely. “I am so
unhappy, so very unhappy, I don’t know what I am saying. Oh!
mother, I wish there were no such thing as marrying in the world!”
“What is it, dear? Is there anything wrong between you and
Trevor? Is he disappointed at your wishing to put off your marriage?”
asked Mrs. Methvyn, anxiously.
“Yes,” replied Cicely. “He is more than disappointed. He has
spoken very cruelly to me. He is cruel. And I don’t deserve it. I have
not put off our marriage, mother. It is Trevor that wished to hurry it on
in a way that had never been thought of. It is inconsiderate in the
extreme of him. I don’t understand him; he is quite, quite changed.”
Two or three large tears gathered in the troubled eyes and rolled
slowly down the pale face. And Cicely so seldom cried!
Her mother kissed her silently.
“I can’t bear to see you so unhappy, my darling,” she said at last.
“Tell me more about it. How is he changed? You cannot doubt his
affection; his very eagerness to hurry on things is a proof of it.”
Cicely shook her head.
 “I don’t doubt his affection,” she said, “if I did I could not marry
him. But there is something I don’t understand. A few months ago he
was so gentle and considerate—so understanding. To-day he was
quite different. When I told him that six months hence was quite as
soon as I could agree to our marriage taking place, he got quite
angry and indignant. He accused me of not caring for him, mother; of
making false excuses with the hope of delaying it indefinitely—
perhaps for ever—of all sorts of feelings and schemes that he knows
I am incapable of. In fact, he quite forgot himself. And, mother, my
reasons were right and good ones; a few months ago, yes, even a
few weeks ago, he would have completely entered into them. If I did
not know—” she hesitated and stopped.
“What, dear?” inquired her mother.
“I was going to say if I did not know Trevor to be perfectly
honourable, I could almost have fancied he was trying to provoke me
into breaking off our engagement.” She looked up into her mother’s
face with a painful doubt in her eyes.
“No,” said Mrs. Methvyn decidedly; “Trevor is incapable of such a
thing. Cicely dear, you have mistaken him. It was only a passing fit of
irritation, and he said more than he meant.”
“I hope so,” answered Cicely. “Yes, I hope so. He is not capable of
anything scheming or dishonourable. Still, mother, he is changed. He
has grown suspicious and irritable; he who used to be so sweet
tempered and gentle.”
“He will be so again, dear. I am sure he will,” said her mother
confidently. “He is only disappointed. And remember it is partly your
father’s fault; he led him to believe the marriage might be sooner.”
“But papa says he will be very glad to have me at home for six
months. Six months! It is not long, mother.”
“Your father is in better spirits again just now,” said Mrs. Methvyn.
“But a week or two ago, he seemed to wish he could see you
married at once. He was very dull about himself at that time.”
“Yes, I remember,” replied Cicely. Then she sat silent for a few
moments thinking deeply.
 “But—but it was all right again between you before Trevor went?”
asked Mrs. Methvyn somewhat timidly.
“‘All right?’ You mean we did not actually quarrel?” said Cicely,
smiling a little at her mother’s anxiety. “No, we did ‘make it up’ after a
fashion. I don’t think Trevor and I could really quarrel. Only—only—
somehow it has left a sore feeling, a feeling of not understanding him
as thoroughly as I used to do; of not feeling sure that he understands
me. But it will go off again. Forgive me for troubling you, dear
mother. I shall be all right again now. Don’t tell Geneviève that
anything was wrong.”
CHAPTER V.
 ONE OF MANY.

“‘It is good when it happens,’ say the children,

‘That we die before our time.’”
E. B. Browning.

WHEN Geneviève woke the next morning, the sun—the beautiful

morning sun of an English June—was shining into her room. Her first
thought was of gladness.
“What a fine day!” she said to herself. “I shall go out as soon as
breakfast is over; I am sure Mr. Fawcett will be out early this
morning.”
But suddenly the occurrences of the previous day returned to her
recollection. Mr. Fawcett, what was he?—her own all but
acknowledged lover, the rich, handsome young Englishman, whom
long ago she had pictured as her future husband? Ah! no, all that
was at an end. What could he ever be to her now? He, the betrothed
of her cousin Cicely,—he, who she now knew had never cared for
her as she had imagined, had only been amusing himself at her
expense.
Yet she found it difficult to believe he did not care for her, she
recalled his looks and words and tones, and dwelt on them till she
almost persuaded herself that his engagement to Cicely was
repugnant to him; that she, and not her cousin, was in possession of
his heart. She knew that he admired her beauty, and she hardly
understood the difference between a feeling of this kind and a
higher, deeper devotion. She recalled the depression of Cicely’s
manner the evening before, and her own suspicion as to its cause,
and again a slight uncomfortable sensation of self-reproach passed
through her, but again she checked it quickly.
“It is not my fault,” she said to herself; “if Mr. Fawcett thinks me
prettier than Cicely I cannot help it. I have not interfered with my
cousin’s fiancé, I knew not he was engaged to her, they never told
me; it is their fault, not mine.”
And though yesterday, when she had learnt the real state of
things from her aunt, she had felt, in the first blush of her
disappointment and mortification, as if she could never speak to Mr.
Fawcett again, as if she would be thankful to go away home to
Hivèritz at once, and forget all her English experiences,—she now
began to think she would like to meet Trevor, to see how he bore
himself to her now that she knew all, perhaps even to hear his own
account of things, possibly even—who could say?—his assurance of
the depth of his hopeless regard for her, his soft whispers of regret
that they had not met till “too late.”
It was too late. Of that she now felt satisfied, not from any
scrupulous feeling of honour due to his own vows, or regard to
Cicely’s happiness,—such considerations weighed curiously little in
the scales of Geneviève’s judgment,—but she felt that in Trevor’s
place she herself would have hesitated before the sacrifice involved
by the breaking off of his engagement. Cicely was rich, well-
connected, and in every sense a partie to be desired; his parents
approved of her,—there was no saying what might not be the results
of his displeasing them in so grave a matter. “They might disinherit