SUCCESS AND FAILURES IN

ENDODONTICS

Guided by : Dr. Vibha Hegde

Dr. Sharad Kokate.
Presented by :Dr. Esha Chandawalla
(M.D.S III) 1
Contents
1. What is success?
2. What is failure?
3. Interpretation of success & failure
4. Success rates
5. Variability of treatment results
6. Prognosis
7. Factors influencing prognosis
8. Advantages of understanding prognosis

2
9. When to prognosticate?
10. How to prognosticate?
11. Factors influencing success & failures
12. When to evaluate success and failure?
13. Methods of evaluation
14. Causes of endodontic failures
15. Summary
16. References

3
 Pre-operative

Pre-operative

Post-operative
ENDODONTIC TREATMENT 3 month follow
VERSUS EXTRACTION ???? up

Post-operative- 2 month follow up

4
 Current, relevant knowledge on the outcome of
endodontic therapy is key to clinical decision
making, particularly when endodontic treatment is
weighed against tooth extraction and
replacement.

 A specific goal set out by the individual patient

may either be healing/prevention of disease
(apical periodontitis) or just functional retention
of the tooth.

5
 A question that should be asked of any
discipline or technique in dentistry is, “ What
degree of success should be expected?”

 Success in turn should be measured

longitudinally in time – long range success as
opposed to short – term success.

6
WHAT IS SUCCESS??
Definition of success – accomplishment of an
aim; favorable outcome (Oxford Dictionary)
 Objectives of Non-surgical RCT –
1. Prevent adverse signs or symptoms
2. Remove all the etiological contents
3. Create a radiographic appearance of well
obturated RC system
4. Promote healing & repair of PR tissues
5. Prevent further breakdown of PR tissues
(AAE Quality Assurance Guidelines)

7
 Definition of success - Clinical symptoms
originating from an endodontically – induced
apical periodontitis should neither persist nor
develop after RCT & the contours of the PDL
space around the root should radiographically
be normal. (European Soc. Endodontology – 1994 IEJ)

8
WHAT IS FAILURE??

 Failure - lack of success; non-performance;

breaking down or ceasing to perform; running
short of supply (Oxford Dictionary)

 Failure - Cases of unresolving post-treatment

periapical radiolucencies are commomly
referred to as ‘endodontic failures’. (P.N.R Nair
2004 - Pathogenesis of apical periodontitis and the causes of
endodontic failures 15(6):348-381 (2004)     Crit Rev Oral Biol
Med)

9
 NON VITAL
TOOTH

VITAL TOOTH
Success- RCT eliminates or
significantly reduces the
bacteria in the root canal
system so that associated an
Success- RCT prevents peri-radicular lesion heals.
bacteria from entering the
canal system thereby
preventing the formation of
a peri-radicular lesion.

10
 Not all RCTs are successful

 Historically – success rate for RCT is between

80% - 95%.

 Each case should be assessed individually - %

probability of success

 Predict outcome – existing situation, current

knowledge – inform patient

 Status & prediction to be assessed – before and

immediately after treatment & at intervals.
11
 HOW TO
INTERPRET
SUCCES IN
LENIENT CRITERIA : ENDODONTICS?

of
nce s-
b se om
A p t AL
sym INIC LCY
CL RMA o f
s in
nce sign
NO b se ry es-
A ato su D
m m tis AN
n f la P A
A L HI C
i the IC AP
L IN OGR LCY
C DI A
M
RA OR
N

STRICT CRITERIA :
12
 Successful treatment based on strict criteria was defined as
Absence of pain, clinical evidence of inflammation or swelling and
Conventional radiographic measures of complete healing/presence
of a normal periodontal ligament space.

 Successful treatment based on loose criteria was defined as

Absence of pain, clinical evidence of inflammation or swelling and
conventional radiographic measures of complete healing (presence
of a normal periodontal ligament space) or incomplete healing (if
there was reduction in size of the lesion without return to normal
periodontal ligament space width).

-Outcome of nonsurgical root canal treatment

Ng et al. IEJ 2011
13
 To resolve this long-lasting dilemma, one should
remember that “success” is invariably defined
by the goal(s) established to be achieved.

 The usual goal of endodontic therapy is to

prevent or heal disease- ANY FORM of peri-
radicular lesion.

14
 Accordingly, endodontic treatment outcomes
should be classified in reference to healing
and disease as follows:

A) Healed: Both the clinical and radiographic

presentations are normal.

1 YEAR FOLLOW-UP
15
 B) Healing: Because healing is a dynamic process,
reduced radiolucency combined with normal clinical
presentation can be interpreted as healing in
progress.

1 YEAR FOLLOW-UP

16
 C) Disease: Radiolucency has emerged or persisted
without change, even when the clinical presentation is
normal, or clinical signs or symptoms are present,
even if the radiographic presentation is normal.

1 YEAR FOLLOW-UP
17
 Although curing of disease is the ultimate goal of
therapy, patients are autonomous to set less demanding
goals for therapy, such as prevention or elimination of
symptoms, or retention of the tooth.

 IN some cases where prognosis is unfavourable but

patient is motivated to an attempt to retain the
tooth, the endodontic treatment outcome can be
defined as tooth retention, as follows:

D) Functional retention: The clinical presentation is

normal, while radiolucency may be absent or present —
Newly emerged or persisting

18
 Outcome classified as
“functional.”

Pre-operative radiograph
of a mandibular first molar
with extensive apical
periodontitis.

Follow-up radiograph and

clinical view at six months;
the radiolucency is
considerably reduced and
the gingival tissue appears
to be healed.
Prognosis still poor.
19
 E) “Survival of teeth after root canal
treatment” is a similar but more lenient outcome
measure than “functional retention”, as it
ignores the clinical condition of teeth at recall.

 The perceived “threat” to endodontic

treatment from the competing treatment
option (extraction & implant supported
prosthesis) has popularized the study of “tooth
Survival.
20
SUCCESS RATES

What is the anticipated

outcome of root canal
treatment??

21
 Studies vary – reported success rates as high
as 95% & as low as 53%. (Eriksen 1991,Pekruhn 1986,
Jokinen et al 1978)

 Ingle & Beveridge – 94.45% rate of success

(greatest cause of failure was interpreted to
be obturation)- WASHINGTON STUDY

 These studies have varying results due to

various factors -

22
1. Observer bias (varying criteria for success)
2. Bias in radiographic interpretation
3. Patient compliance (recall)
4. Subjectivity of patient response
5. Host variability in responding to T/t
6. Validity & reproducibility of method of
evaluation
7. Degree of control of variables (eg sample size)
8. Difference in observation period

23
The classic Washington study :
 To answer the question, “How successful is endodontic therapy?” a
study was undertaken at the University ofWashington School of
Dentistry to evaluate endodontically treated teeth to determine their
Rate of success. More important to the study, the rate of failure
was also established, and the causes of failure were carefully examined.

 Analysis of the failures led to modifications in technique and

treatment. Finally, the entire discipline of endodontic therapy was re-
examined, and definitive improvements were made as a result.

The improvements in treatment are reflected in the improvement in

success, which increased to 94.45% from a former success rate of
91.10%, an improvement of 3.35 percentage points. In other words,
nearly 95% of all endodontically treated teeth were successful.

24
 Patients were recalled for follow-up at 6 months, 1 year, 2 years, and 5
years, and the recall radiographs were carefully evaluated for
improvement or lack of improvement.

Teeth included in the success The failures were made up of

group were those that
demonstrated decided
periradicular improvement
and those with continuing
periradicular Health.
those teeth that initially
demonstrated periradicular
damage and that had not
improved as well as
those that had deteriorated
since treatment.

25
Conclusions from this study :
 AGE : It was found that older teeth, with more restricted
canals, were more successfully obturated than very “young”
teeth with large-diameter canals.

 INDIVIDUAL TOOTH : No particular tooth can be considered a

higher endodontic risk, although there was a wide discrepancy
Between the mandibular second premolar with a failure rate of
4.54% and the mandibular first premolar with a failure
rate of 11.45%. Canal anatomy might account for the
greater increase in failure in the first premolar

26
 NON-SURGICAL VERSUS SURGICAL Rx : The Washington
Study demonstrated that although nonsurgical treatment
appears to be slightly more successful than surgical
treatment, differences are not statistically significant.

 Endodontic Cases: Two-Year Recall by Frequency of Occurrence

 Causes of Failure Number of Failures % Failures
 Incomplete obturation 61 58.66
 Root perforation 10 9.61
 External root resorption 8 7.70
 Coexistent periodontal- 6 5.78
 periradicular lesion
 Canal grossly overfilled 4 3.85
 or overextended
 Canal left unfilled 3 2.88
 Developing apical cyst 3 2.88
 Adjacent pulpless tooth 3 2.88
 Silver point 2 1.92
 inadvertently removed
 Broken instrument 1 0.96
 Accessory canal unfilled 1 0.96
 Constant trauma 1 0.96
 Perforation, nasal floor 1 0.96
 Total failures 104 100.00
27
Distribution of Failures of Treated Endodontic Cases: Two-Year Recall by Category
of Cause of Failure

Causes of Failure Number of Failures % Failures

Apical percolation—total 66 63.46

Incomplete obturation 61 58.66

Unfilled canal 3 2.88
Ag point inadvertently 2 1.92
removed

Operative error—total 15 14.42

Root perforation 10 9.61

Canal grossly overfilled 4 3.85
or overextended
Broken instrument 1 0.96

Errors in case selection—total 23 22.12

External root resorption 8 7.70

Coexistent periodontal-
periradicular lesion
Developing apical cyst
Adjacent pulpless tooth
Accessory canal unfilled
Constant trauma
Perforation, nasal floor
6 5.78
3 2.88
3 2.88
1 0.96
1 0.96
1 0.96

Total failures 104 100.00 28

Sjogrens study :
 A remarkable study of 356 endodontic patients, re-examined
8 to 10 years later, reported a 96% success rate if
the teeth had vital pulps prior to treatment.

 The success rate dropped to 86% if the pulps were necrotic and
the teeth had periradicular lesions and dropped still lower to 62%
if the teeth had been re-treated.

They concluded by stating that “Teeth with pulp necrosis and

Periradicular lesions and those with periradicular lesions
undergoing re-treatment constitute major therapeutic
Problems.”

29
  They noted a direct correlation between success and the point
of termination of the root filling.

Outcome of treatment according to the

level of the root filling in relation to the
root apex in cases with preoperative pulp
necrosis and apical periodontitis. Number
of healed lesions/number of preoperative
lesions.

Results of re-treatment of previously filled

roots with apical periodontitis with regard to
the level of the final root filling in relation to
the root apex. Number of healed lesions/number
of preoperative lesions.
30
JUNE.2004.VOL.32.NO.6.CDA.JOURNAL
31
JUNE.2004.VOL.32.NO.6.CDA.JOURNAL 32
 119 articles :The estimated weighted pooled success rates of
treatments completed at least 1 year prior to review, ranged
between 68% and 85% when strict criteria were used. The
reported success rates had not improved over the last four (or
five) decades.

Four conditions :
Pre-operative absence of periapical radiolucency, Root filling with
no voids, Root filling extending to 2 mm within the
radiographic apex and satisfactory Coronal restoration were
found to improve the outcome of primary root canal treatment
Significantly.

International Endodontic Journal, 2007

International Endodontic Journal. 2008

33
 108 studies :A high success rate of 86%, 78.2% in primary and
Secondary endodontically treated teeth described in this paper
Supports the benefit of endodontic treatment and suggests that
The patients should be offered this treatment before tooth
extraction. Surgical endodontic treatment showed a success rate
of 63.4%.

 Nonsurgical retreatment should be regarded as the first

choice when primary treatment fails especially in cases
of poor root canal restorations and where renegotiation of
the root canals is possible.

International Scholarly Research Network

ISRN Dentistry, Volume 2011.
34
 Furthermore, it was reported that when nonsurgical root canal
treatment was performed in teeth that had been previously
managed with apical surgery, the success rate was lower than in
those previously endodontically treated.

Periapical surgery remains an alternative option for the

management of cases in which nonsurgical retreatment was not
possible.

International Scholarly Research Network

ISRN Dentistry, Volume 2011.
35
Endo versus Implants..
 Endodontically treated teeth are retained at about 95%-97%
after 8 years compared with implant retention of 85%-90%
during a similar time period.

 Recent literature review and meta-analysis found that natural

teeth surrounded by healthy periodontal tissues yield a very high
longevity of up to 99.5% over 50 years.

Periodontally Compromised teeth that are treated and

maintained regularly have A survival rate of 92%-93%.16 That
study concluded that oral implants, when evaluated after 10 years
of service, do not surpass the longevity of even compromised but
successfully treated natural teeth.
-OOOE 2008
36
 VARIABILITY OF T/t RESULTS
 Depends on various factors

 Some are easily identified & rest remain are

probably unknown.

 Thus, no single study has all the answers & all

studies considered as a group are, at best, only
overall indicators.

37
 Prognosis
 Prognosis – forecast; especially of the course
of a disease (Oxford Dictionary)

 Refers to prediction of whether an endodontic

treatment will prevent the development of
apical periodontitis or heal it if present.

38
Advantages of understanding prognosis

1. Development of more rational T/t plan

2. Avoiding factors that lead to failure
3. Better understanding of healing process

39
 WHEN TO PROGNOSTICATE?
 AT 3 TIMES

Before

During After

40
 HOW TO PROGNOSTICATE??

Percentage
Generalized
2 APPROACHES - Easier to
understand
Unfavourable
Favourable - status of
Questionable the tooth

- decision
making

- failure

41
To reemphasize & to repeat –
generalizations in predicting
success & failure are
inappropriate when asssessing
an individual situation;
prognosis for each clinical
case must be based on
findings and treatment
factors relevant to that case.

42
 Factors influencing outcome of
endodontic treatment

“Classic” comprehensive study by

Strindberg 1956 – 2 factors

Biologic Therapeutic

43
POTENTIAL SIGNIFICANT PROGNOSTIC FACTORS FOR
PRIMARY AND SECONDARY ROOT CANAL TREATMENT

44
CAUSES OF ENDODONTIC
FAILURES

PREOPERATIVE

OPERATIVE

POSTOPERATIVE

45
Pre-operative Factors Common To
Primary And Secondary Endo Rx :
 Gender
 Age
 General medical health
 Tooth type
 Pulpal and periapical status
 Other pre-operative clinical signs and

symptoms

46
Pre-operative Factors Common To
Secondary Endo Rx :
 Time interval between primary and re-
treatment

 Pre-operative canal contents

 Pre-operative procedural error in canal

preparation

 Quality of pre-existing root fillings

47
Prognostic Pre-operative Factor Association With Outcome
GENDER NO significant association
AGE NO significant association
GENERAL MEDICAL HEALTH DIABETES (non-insulin-dependent /
insulin-dependent) (Fouad & Burleson
2003), impaired non-specific immune
response (Marending et al. 2005) and

 SMOKING (Doyles et al. 2007)

were found to significantly reduce the
success rates of root canal treatment
on teeth with periapical lesions
TOOTH TYPE Mandibular molars were found to
have the lowest success rates.( in
terms of survival)
There was no significant difference
in the odds of success amongst the
three types of teeth: incisors/canines,
premolars and molars. 48
Prognostic pre-operative factor Association with Outcome

N
Pulpal and Periapical status CONTRADICTORY

 Vital teeth were found to have

significantly higher success rates
than non-vital teeth in some studies.
(IEJ 2008)

SIGNIFICANT ASSOCIATION-
MUST CONSISTENT FINDING.
KNOW…
Non-vitality !!
is not always
associated with root Success rate for teeth without
canal infection , whilst the periapical lesion was 28%
presence of a periapical lesion higher than that for those with
always signifies the presence periapical lesion pre-operatively.
of root canal infection.
By pooling the data for lesion size
into < 5 mm or ≥ 5 mm in diameter,
the weighted pooled success rate
for small lesions was 25% higher 49
Prognostic pre-operative factor Association with Outcome
Other clinical signs and symptoms Other conditions that may affect
root canal treatment are :

-Presence of pre-operative pain

-Presence of pre-operative sinus
tract (MOST IMP PROGNOSTIC)
-Apical resorption

Their presence has been

found to significantly reduce the
success of primary and secondary
treatments.

only ‘presence of sinus’ was found to

be a significant prognostic indicator.
(IEJ 2011)

50
Prognostic Pre-operative Factor
TIME INTERVAL BETWEEN
PRIMARY AND SECONDARY ROOT
CANAL TREATMENT
PRE-OPERATIVE CANAL
CONTENTS
Association With Outcome
By pooling the data for time interval
between primary and secondary root
canal treatment into 1 or less years or
more than 1 year,
success rates was 5% > those cases
with existing root canal treatments
of 1 or less year’s duration
The presence of pre-operative
“cement” root fillings were
associated with significantly lower
success rates than teeth with “gutta-
percha” or “silver point” root fillings
Gorni & Gagliani (2004) reported that
the success rate of treatment on
teeth with pre-operative separated
instruments was 96%, which was
within the higher end of the range of
reported success rates (88% – 97%) 51
Prognostic Pre-operative Factor
Pre-operative procedural error in
canal preparation :
The errors investigated have included:
-canal perforation,
-obstruction and
- “root canal morphology alteration by
previous treatment”: transportation,
perforation, stripping or internal
resorption.
Quality of pre-existing root fillings
Association With Outcome
success rate for teeth without
preoperative perforation was 32%
higher than that for teeth with pre-
operative perforation.
In contrast, Main et al. (2004)
reported that periradicular
radiolucencies associated with
perforations repaired with mineral
trioxide aggregate cement (MTA)
were completely resolved in all cases
with preexisting perforation
Success rates for teeth with
adequate pre-existing root fillings
(extended to 0-2 mm from the
radiographic root end with no voids)
were significantly (6%) lower than
those for teeth with inadequate pre-
operative root fillings. 52
Prognostic Intra-operative Factor
Use of rubber dam isolation during
treatment
Type of instruments for canal
preparation
Apical extent of instrumentation
Association With Outcome
NO significant association for primary
endodontic treatment but significant
lower success rates were reported
without the use of rubber dam for
secondary endodontic treatment.
NO significant association has been
assessed so far
One of the ESE guidelines is that
root canal cleaning must be extended
to the Apical constriction, or 0.5 – 2
mm from the radiographic apex, or to
the cementodentinal junction.
Instrumentation beyond the
apical foramen, without foraminal
enlargement, or transportation may
have a beneficial effect on treatment
outcome.
53
Prognostic Intra-operative Factor
Apical size of canal preparation
Taper of canal preparation
Association With Outcome
The success rate by apical size of
canal preparation smaller or larger
than ISO 30, was provided by
Hoskinson et al. (2002); the data
showed that the success rate for
small (#20-30) apical preparations
(85%) was higher than that for large
(#35-90) apical preparations (56%).
CONTRADICTORY
Smith et al. (1993) using loose criteria
for determination of success, found
that a “flared” preparation (wide
taper) resulted in a significantly
higher success rate compared with a
“conical” preparation(narrow taper);
the exact degree of taper was not
reported and the effects of
confounders were not controlled.
In contrast, Hoskinson et al. (2002) 54
 Meaningful comparison could therefore only be made between
0.05 and 0.10 tapers created by stainless steel instruments, where
an insignificant difference in success rates was found regardless
of PRIMARY OR SECONDARY treatment.

It is suggested that over-enlarging the canal is not necessary; a

Preparation size of 30 with a 0.05 taper for stainless steel
instrumentation or 0.06 taper for NiTi instrumentation is more
than adequate and may even be optimal.

- IEJ 2011

55
Prognostic Intra-operative Factor Association With Outcome

Instrument separation during Instrument separation during primary

primary or secondary root canal or secondary root canal treatment was
treatment was found to reduce the found to reduce the success rate
success rate significantly significantly.

The corono-apical location of a

separated instrument and whether the
instrument was
successfully bypassed were found to
have no effect on treatment outcome

56
Prognostic Intra-operative Factor
Technical errors during canal
preparation
Association With Outcome
Primary root canal treatments with
iatrogenic perforations were found to
result in significantly lower success
rates. (DEPENDS on location and size
of perforation, time lapse before
repair etc)
as long as patency could be achieved at
the canal terminus, success of 2!RCTx
would not be affected by type of
foreign material whether it was
removed or bypassed.
(IEJ 2011)
The presence of root perforation at
the coronal or mid-root level was
found to significantly reduce the odds
of success by 70%, possibly
attributable to bacterial 57
Prognostic Intra-operative Factor
Irrigant
Association With Outcome
The use of a higher concentration of
sodium hypochlorite (4–5%)
made no significant improvement to
treatment outcome- in terms of
“rendering negative culture” or
“periapical healing”.
the finding that the additional use of
10% povidone-iodine for irrigation had
no accumulative influence on
treatment success.
the additional use of 0.2%
chlorhexidine solution with NaOCl for
irrigation reduced the success of
treatment, significantly.
NaOCl and 17% EDTA-Its use had a
marginal effect on the success of
primary treatment but had a profound 58
Prognostic Intra-operative Factor
Medicament
Root canal bacterial culture test
results (positive or negative) prior to the success rate (based on strict
obturation
Association With Outcome
Type of medicament
-Ca(OH)2- 69.1%
-Creosote- 90.4%
-None- 83.3%
success rate of secondary root canal
treatment using Ca(OH)2 (68.2%) was
much lower than treatments using
creosote (90.4%) as an inter-
appointment medicament.
With pre-operative periapical lesions,
criteria reported by Sundqvist et al.
1998) for teeth with negative
bacterial cultures prior to root filling
was 46% higher than that for teeth
with positive cultures
SOME STUDIES STATED no 59
Prognostic Intra-operative Factor
Root filling material and technique
Apical extent of root filling
Association With Outcome
success rate for teeth filled with gutta-
percha and sealer was 8% lower than that
for those filled with gutta-percha softened
in chloroform.
success rates for teeth filled with the
resin-based sealer (62%) was lower than
those obturated with zinc oxide eugenol-
based (75%) or glass ionomer-based (70%)
sealers.
Success rates (without stratifying the data
by pre-operative periapical status were:
Short (87%), flush (81%) and long (63%)
root.
Roots with ‘flush’ (0–2 mm from apex
locator ‘0’ reading position) root
fillings was associated with the
highest success rate, which was
followed by short and then long root
fillings
A study concluded that apical overfilling
60
per se had little influence on the long-term
Prognostic Intra-operative Factor
Quality of root filling
Apical disturbance by extruded
medicament or sealer
Association With Outcome
An unsatisfactory root filling has been
defined as “inadequate seal”, “poor
apical seal” or “radiographic presence
of voids”.
Satisfactory 41% > success
unsatisfactory
Signs for “sealer puffs” extruding through
the main and lateral/accessory canals have
been perceived as “good practice” by some
endodontists – “ CONTRADICTORY”
Friedman et al. (1995) found extrusion of
Ketac-Endo® sealer reduced success rates
significantly.
Sari & Durutűrk (2007) who reported that
extrusion of AH Plus®sealer did not
prevent but only delayed periapical healing.
Extruded glass ionomer-based (, zinc oxide
eugenol-based,silicone-based (Huumonen et
al. 2003) sealers were found not to be
61
absorbed by periapical tissues after 1 year.
Prognostic Intra-operative Factor
Apical disturbance by extruded
medicament or sealer
Association With Outcome
Extrusion of cleaning, medication or
filling materials beyond
the apical terminus into the
surrounding tissues may
result in delayed healing or even
treatment failure because of a foreign
body reaction.
Magnesium and silicon from the talc-
contaminated extruded gutta-percha
have been clinically associated
with a foreign body reaction.
Extrusion of sealer did not seem to affect
the success of 1! and 2!RCTx.
-IEJ 2011
62
Prognostic Intra-operative Factor
Acute exacerbations during
treatment- flare ups
Prognostic Intra-operative Factor
Number of treatment visits
Association With Outcome
After chemo-mechanical debridement
of the root canal system, pain or
swelling occurred in 18% of cases
and was found to significantly reduce
the success of treatment.
(IEJ 2011)
Association With Outcome
Pooled success rate for single-visit
treatment was 4.8% higher than the
success rate for
multiple-visit treatment but only one
study had contributed to the data
based on strict criteria for single-visit
treatment.
63
Prognostic POST-OPERATIVE Factor Association With Outcome
i) Type of coronal restoration Teeth with the highest survival rates
were those that were permanently
restored within ninety days following
root canal treatment (Mindiola et al.
2006).

10-year survival for crowned-teeth to

be 81%±12% which was higher
than that for teeth restored with a
direct restoration (resin composites,
amalgam, cements) (63%±15%).

teeth with prefabricated posts had a

higher chance of survival than those
with cast post & cores.

Teeth with single unit crowns were

found to have a higher chance of
tooth 64
Prognostic POST-OPERATIVE Factor Association With Outcome
i) Type of coronal restoration type of coronal restoration had no
significant influence on treatment
success after adjusting the results
for other factors including the quality
of restoration.
-IEJ 2011

The placement of a GIC or zinc oxide

eugenol (IRM") cement lining coronal
to the guttapercha
filling and underneath the permanent
core in order to provide additional
antibacterial coronal seal
was found to have no additional
beneficial effect on
treatment success in the present
study.
-IEJ 2011 65
Prognostic POST-OPERATIVE Factor Association With Outcome
i) NO. OF PRXIMAL CONTACTS The number of proximal contacts may
predict the distribution of occlusal
loading imposed on a tooth. Root
treated teeth with two proximal
contacts were found to be
associated with a higher chance of
survival after treatment.
-IEJ 2008

66
 No significant difference in the odds of success
(OR = 0.83, 95% CI: 0.55, 1.23) was found
between flush and short root fillings in teeth
without a pre-operative lesion. However, when
considering teeth with a pre-operative periapical
lesion, those with flush root fillings had 1.6 times
The odds of success (OR = 1.56, 95% CI: 1.26,
1.94)compared with teeth with short root
fillings.

HEALING LESS PREDICTABLE WITH SHORTER

FILLINGS WITH PERI RADICULAR LESION.

- IEJ 2008

67
  All studies have some factors in common which
CONSISTENTLY affect the prognosis –

1. Presence of PA lesion

2. Apical extent of root canal ( flush filling)

3. Quality of RCF ( Good apical seal, No voids)

4. Satisfactory coronal seal

- IEJ 2008

68
 WHEN TO EVALUATE??

 At what level it is unlikely that your treatment

outcome will not change?

OR

 At what point one can say that the treatment is

successful or has failed or the outcome is unlikely to
change & no further recall is necessary??
69
 The European Society of Endodontology’s
Quality Guidelines for Endodontics (2006),
suggest a clinical and radiographic follow-up at
least 1 year after treatment with subsequent
annual recall for up to 4 years before a case
is judged a failure.

 The American Association of Endodontists

concurs with a suggestion of clinical and
radiographic evaluation for up to 5 years.

70
 Byström et al. (1987) had reported on the healing
dynamics and noted that the size of completely
healed lesions had decreased to about 2 mm within 2
years, regardless of the initial size.

 Orstavik (1996) – approx 76% of apical periodontitis

lesions developing post – Rx are seen within 1 yr.
therefore, 1 yr follow – up predicts long term
success.

 There is good evidence that a radiographic lesion

that is unchanged or has increased in size after 1 yr
is unlikely to resolve. - Torbinajed

71
 SO CURRENT TREND IS TO EVALUATE
FOR SUCCESS AND FAILURE IS :

 Atleast 1 yr follow up- loose criteria

 Atleast 3 years- strict criteria

72
 METHODS OF EVALUATION

RADIOGRAPHI HISTOLOGICA
CLINICAL
C L

73
Criteria for determination of periapical status
Strindberg (1956) Bender et al. Friedman & Mor (2004)
(1966a&b)

Success: Success: Healed:

Clinical: No symptoms Clinical: Clinical: Normal
Radiographic: Absence of pain / swelling presentation
The contours, width and Disappearance of fistula Radiographic: Normal
structure of the No loss of function presentation
periodontal margin were No evidence of tissue
normal, destruction
Or The periodontal Radiographic:
contours were An eliminated or arrested
widened mainly around the area of rarefaction after a
excess filling. post-treatment interval of
6 months to 2 years

a) Pre-operative radiograph (b) Follow-up radiograph 74

Strindberg (1956) Bender et al. Friedman & Mor
(1966a&b) (2004)
Failure: Diseased:
Clinical: Presence of Radiolucency has
symptoms emerged or
Radiographic: persisted without
A decrease in the change, even when
periradicular the clinical
rarefaction, or presentation is normal,
Unchanged or
periradicular Clinical signs or
rarefaction, radiographic failure symptoms are
or present, even if the
An appearance of new radiographic
rarefaction or presentation is normal.
an increase in the initial
rarefaction

75
Strindberg (1956) Bender et al. Friedman & Mor
(1966a&b) (2004)
Uncertain: Healing:
Radiographic: Clinical: Normal
There were ambiguous presentation
or technically Radiographic: Reduced
unsatisfactory control radiolucency.
radiographs
which could not for
some reason be
repeated; or
a) Pre-operative radiograph MUST
The tooth was
extracted prior to the ApicalKNOW… !! –
periodontitis which
3-year follow-up owing often a principle indication
to the failing endodontic treatmen
unsuccessful treatment is frequently asymptomatic
radiograph is the only way
of another
demonstrate the lesion!!
root of the tooth. (b) Follow-up radiograph
76
Histologic
 Routine histologic evaluation of PR tissues after
RCT is impractical & not possible without
surgery.

 Success – is indicated by reconstitution of

periradicular structures & absence of
inflammation

77
 Correlation between radiographic findings &
histologic findings – uncertain
 Brynolf 1967 human
cadavers

320 upper
No co-relation
incisors

Histologically
all treated
teeth showed XG appeared
some normal
periradicular
inflammation 78
 human
cadavers
 Green et al 1997

Corelation 74% teeth with

present- normal
sensitivity radiographic
66% findings –

no
26% XG showed no
periapical lesion–but inflammation
histologic signs of
inflammation. histologicall
y

79
  Thus, with current technology – clinical findings such
as signs, symptoms & radiographic evaluation are the
only practical means of assessing degree of healing
after RCT.

 It has been determined that 34% of lesions

associated with posterior teeth failing to be
detected by conventional periapical radiograph,
could be detected by cone beam tomography
(Low et al. 2008).

Its routine use is however, not recommended due to higher radiation (x 2-3)

80
Interpretation of outcome
 Two indices have been used to standardize
observer’s interpretation of periapical status in
epidemiological studies, they have also been used
to assess outcome of treatment.

A) The first index, THE “PROBABILITY INDEX” (RPI) was

introduced by Reit & Gröndahl (1983).

B) THE “PERIAPICAL INDEX” (PAI) was subsequently developed

by Ørstavik et al. (1986) using the radiographic material from
Brynolf’s study (1967).

81
The probability index (PRI) (Reit & Gröndahl 1983) and
periapical index (PAI) (Ørstavik et al. 1986)

82
 TOOTH SURVIVAL AFTER
ENDODONTIC TREATMENT
Pre-operative Factor Association With TOOTH LOSS
GENERAL MEDICAL HEALTH DIABETES : -associated
periodontal problems
- Persistent pain after RCT due to
neuropathy-complication of diabetes

 STEROID THERAPY
-presence of pre-operative pain
significantly increased the hazard of
tooth loss.
TOOTH TYPE  NO SIGNIFICANT
ASSOCIATION

Maxillary premolars and mandibular

molars were found to have the
highest frequency of -extraction
IEJ 2011with
83
tooth fracture being the most
 Prognostic pre-operative factor Association with Outcome

Other clinical signs and symptoms

-Presence of pre-operative pain
-Presence of pre-operative sinus
tract
-Pre-operative periodontal
probing defects of endodontic origin

REDUCE TOOTH SURVIVAL

-The presence of pre-operative pain

DID YOU KNOW had a profound effect on tooth loss
??
Endodontic problem is one of within the first 22 months
the most common reasons for after treatment.
tooth extraction following
treatment !!

- IEJ 2011
84
Intra-operative Factor Association With TOOTH SURVIVAL
A) ‘NO PATENCY AT APICAL ‘patency at canal terminus’ only
FORAMEN reduced tooth loss within 22 months
after treatment but not afterwards.
B) EXTRUSION OF GUTTA-PERCHA
ROOT FILLING In contrast, ‘extrusion of root
filling’ did not influence tooth survival
until after 22 months post-
operatively.

2 REASONS :

-Wait and watch by dentists

- compaction forces- minor root cracks
later propogate in to fracture-
DELAYED EFFECTS OF ROOT
FILLLING EXTRUSION.

- IEJ 2011
85
INGLE’S 6TH EDITION- REVIEW ARTICLE BY SOUZA 2006

2 concepts :

Apical patency OR “Cleaning of the apical

Recapitulation foramen”

 Non-vital teeth with peri-apical

 Vital pulps
lesions
 Dislodge the dentinal chips,
 Active cleaning of foramen- from a
pulpal fragments etc during
biological standpoint
cleaning and shaping before  In addition to the binding file, 1-2
proceeding to next sequential
files of greater size should be used
instrument.
for apical debridement and optimal
 An apical patency file is 2
instrumentation of the intracanal
sizes smaller than the file that
walls in this region.
binds at the apical  Instrumentation should be extended 1
constriction.- so no extrusion
to 2 mm beyond this area.
of any debris in non-vital teeth  BUT OBTURATION SHOULD
and no damage to p/a tissues in
TERMINATE 0.5-1MM SHORT OF
vital teeth
APICAL FORMAEN.
 Helps maintain working length 86
POST-OPERATIVE Factor TOOTH SURVIVAL
 Of the extracted terminal teeth,
A) ‘TERMINAL TEETH’, 68% were fractured, whilst of the
extracted non-terminal
teeth, only 38% were fractured.
B) PROXIMAL CONTACTS
 Tooth fracture was the reason for
extraction in 58% of teeth with one or
less proximal contact, compared
with 38% of extracted teeth with two
proximal contacts.

- UNFAVOURABLE OCCLUSAL FORCE

DISTRIBUTION AND HIGHER NON-
AXIAL FORCES ON TEETH WITH
LESS PROXIMAL CONTACTS

- IEJ 2011
87
POST-OPERATIVE Factor TOOTH SURVIVAL

C) PLACEMENT OF CROWNS OR  Improves survival

CAST RESTORATIONS
 Non-aesthetic and technically
demanding partial veneer onlays and
partial coverage crowns would be the
restorations of choice for root-
treated teeth.

 USE ADHESIVE RESTORATIVE

MATERIALS and crown only used if
intra-radicular aid is required.-ANT
TEETH

D) CAST POST AND COR

 Reduces excessive tooth structure
and thus survival of teeth especially in
posterior teeth.

- IEJ 201188
EVIDENCE BASED DENTISTRY 2011

 Four conditions were found to significantly

improve tooth survival. In descending order
of influence :
(i) A crown restoration after RCTx;
(ii) Tooth having both mesial and distal proximal contacts;
(iii) Tooth not functioning as an abutment for removable or fixed
prosthesis; and
(iv) Tooth type or specifically non-molar teeth

Proportion of teeth surviving over 2–10 years

following RCTx ranged between 86% and 93%.
89
 CAUSES OF ENDODONTIC
FAILURES
 If diagnosis is correct, bacterial infection is
primary cause (Lin & Pascon 1991; Cheung 1996)

 Crump 1997 – “POOR PAST”

P – perforation P – periodontal disease

O – obturation A – another tooth
O – overfill S - split
R – root canal missed T - trauma

90
 CAUSES OF ENDODONTIC
FAILURES
 Most common causes of failure are :-

1. Errors in diagnosis & T/t planning

2. Inadequate aseptic control

3. Poor access cavity design – missed canals

4. Leaking temporary or permanent fillings/coronal leakage

5. Lack of knowledge of pulp anatomy

91
6. Inadequate debridement / disinfection of root canal

7. Inadequate restorative protection

8. Operative errors

9. Obturation errors

10. Vertical root fracture

11. Resistant bacteria

92
 Even when highest standards are met & the
most careful procedures are followed – failures
still occur :-

1. Anatomical complexity

2. Factors beyond the root canals, within the

inflamed periapical tissues – interfere with
post treatment healing of the lesion.

93
 FAILURE – due to residual or resistant
intraradicular microorganisms surviving the
chemomechanical cleaning procedures or new
microorganisms invading the canals via coronal
microleakage, vertical fracture of the tooth,
perforation or accessory canals.

 In rare instances persistent

lesions may be sustained by an
established extraradicular
infection – associated with long
standing sinus, foreign body
reaction or apical true cyst.

94
CAUSES OF PERSISTENT PERI-APICAL LESIONS

Intraradicular infection

Extraradicular
actinomycosis
Other extraradicular
infections

Cystic apical periodontitis

Foreign body reactions

Scar tissue healing

95
.

Dots and associated lines

(from top to bottom)

1. True cyst

2. Foreign body reaction

3. Extra-radicular infection

4. Intra-radicular infection

96
Intraradicular infection
 Intraradicular microorganisms – essential cause
of failure.

Genetic molecular technique recently used

(Siqueira & Rocas 2004) :

 Gram +ve bacteria

 Yeasts - potential non – bacterial, microbial
cause of endodontic failure (Waltimov et al
1997; Peciuliene et al 2001)

97
Endodontic flora in root canal treated
teeth
 Gram +ve cocci, rods, & filaments
 Actinomyces
 Enterococcus
 Propionibacterium

 Intraradicular infection can also remain within

the innermost portions of infected dentinal
tubules – serve as reservoir for endodontic re-
infection – interfere with periapical healing

98
Fungi as a potential cause of endodontic
failures. (a) Low-power overview of an
axial section of a root-filled (RF) tooth
with a persisting apical periodontitis
lesion (GR). The rectangular demarcated
areas in (a) and (d) are magnified in (d)
and (b), respectively. Note the two
microbial clusters (arrowheads in b)
further magnified in (c). The oval inset in
(d) is a transmission electron microscopic
view of the organisms. Note the electron-
lucent cell wall (CW), nuclei (N), and
budding forms (BU). Magnifications: (a)
35x, (b) 130x, (c) 330x, (d) 60x, and oval
inset, 3400x.

99
Extraradicular actinomycosis
 Sequel to caries & are caused by Actinomyces israelli
& Propionibacterium propionicum – have been
consistently isolated from PA tissues (Happonen, 1986;
Sjögren et al., 1988)

 Because of the ability of actinomycotic organisms to

establish extraradicularly – they can perpetuate the
inflammation at the periapex, even after orthograde
root canal treatment. (Sundqvist and Reuterving, 1980;
Nair and Schroeder, 1984; Happonen et al., 1985; Happonen, 1986;
Sjögren et al., 1988).

10
0
 Ability of these bacteria to build cohesive
colonies – escape the host defense system –
enables them to establish in the periapical
tissues. (Figdor et al., 1992).

10
1
Other extraradicular infections
 In the late 1980s, there was a resurgence of
the idea of extraradicular microbes in apical
periodontitis (Tronstad et al., 1987, 1990; Iwu et al., 1990;
Wayman et al., 1992), with the controversial
suggestion that extraradicular infections are
the cause of many failed endodontic
treatments.

10
2
 In summary, extraradicular infections do occur
in:
1. Acute apical periodontitis lesions (Nair, 1987);

2. Periapical actinomycosis (Sundqvist and Reuterving, 1980;

Nair and Schroeder, 1984; Happonen et al., 1985; Happonen, 1986;
Sjögren et al., 1988);

3. Association with pieces of infected root dentin that may be

displaced into the periapex during root canal instrumentation (
Holland et al., 1980; Yusuf, 1982) or cut from the rest of the
root by massive apical resorption (Valderhaug, 1974; Laux et al.
, 2000); and

4. Infected periapical cysts , particularly in periapical pocket

cysts with cavities open to the root canal (Nair, 1987; Nair et al.
, 1996, 1999).

10
3
 There is strong evidence that bacteria may not be completely
eliminated after thorough cleaning, shaping, and disinfection.
Moreover, when obturation is postponed, bacteria may be able to
recolonize in the canal.

 Gutta-percha root canal fillings do not resist salivary

Contamination- Faulty coronal restorations

 There are also times when an irritant, such as infected dentin

chips, is packed at the apex or pushed through the
apex, there to serve as a continuing irritant.

 The periapical tissue could become colonized by periodontal

contamination, HIGHLY VIRULENT BACTERIA.

10
4
Cystic apical periodontitis
 Oral surgeons hold the view that cysts do not
heal and have to be removed by surgery. Many
endodontists, on the other hand, are of the
opinion that the majority of cysts heal after
endodontic treatment.

 True periapical cysts, particularly those

containing cholesterol crystals, are less likely
to be resolved by conventional endodontic
therapy (Nair, 1998a, 2003a).

10
5
Foreign body reactions
 Endogenous cholesterol crystals deposited in
periapical tissues (Nair et al., 1993) and exogenous
materials trapped in the periapical area (Nair et al., 1990b
; Koppang et al., 1992) can perpetuate apical periodontitis
after root canal treatment by initiating a foreign-
body reaction at the periapex (Nair, 2003).

10
6
 (1) Cholesterol crystals

 Accumulation of cholesterol crystals occurs in

apical periodontitis lesions (Shear, 1963;
Bhaskar, 1966; Browne, 1971; Trott et al., 1973; Nair et al., 1993
), with clinical significance in endodontics (Nair
et al., 1993; Nair, 1998a).

 The incidence of cholesterol

clefts in apical periodontitis
varies from 18% to 44%
(Shear, 1963; Browne, 1971;
Trott et al., 1973).

Overview of a histological section (upper inset) of an asymptomatic apical

periodontitis that persisted after conventional root canal treatmen t 10
7
 Source - The crystals are believed to be
formed from cholesterol released by:

(i) disintegrating erythrocytes of stagnant blood

vessels within the lesion (Browne, 1971)

(ii) lymphocytes, plasma cells, and macrophages

which die in great numbers and disintegrate in
chronic periapical lesions; and

(iii) the circulating plasma lipids (Shear, 1963).

10
8
 All these sources may contribute to the
concentration and crystallization of cholesterol
in the periapical area. Nevertheless, locally
dying inflammatory cells may be the major
source of cholesterol as a result of its release
from disintegrating membranes of such cells in
long-standing lesions (Seltzer, 1988; Nair et al.
, 1993).

10
9
 In an experimental study that specifically
investigated the potential association of cholesterol
crystals and non-resolving apical periodontitis lesions
(Nair et al., 1998).

 The crystals were densely surrounded by numerous

macrophages and multinucleate giant cells that
formed a well-circumscribed area of tissue reaction.

 Suggests that the crystals induced a typical foreign-

body reaction (Coleman et al., 1974; Nair et al., 1990;
Sjögren et al., 1995).

11
0
 HOST DEFENSE- Unable to degrade the crystalline cholesterol

 Major sources of apical inflammatory and bone-resorptive

mediators. (Sjögren et al., 2002).

 “The presence of vast numbers of cholesterol crystals...would be

sufficient to sustain the lesion indefinitely" (Nair et al., 1993).

111
(2) Foreign bodies

 Foreign materials trapped in periapical tissue during

and after endodontic treatment can perpetuate apical
periodontitis persisting after root canal treatment
(Nair et al., 1990; Koppang et al., 1992).

 Endodontic clinical materials (Nair et al., 1990; Koppang et al.

, 1992) and certain food particles (Simon et al., 1982) can
reach the periapex, induce a foreign-body reaction
that appears radiolucent, and remain asymptomatic
for several years (Nair et al., 1990).

11
2
   (a) Gutta percha

 The widely held view that it is

biocompatible with and well-
tolerated by human tissues is
inconsistent with the clinical
observation that extruded
gutta percha is associated with
delayed healing of the periapex
(Strindberg, 1956; Seltzer
et al., 1963;
Kerekes and Tronstad, 1979;
Nair et al., 1990b; Sjögren
et al., 1990).
Disintegrated gutta-percha as potential cause of
endodontic failures. As clusters of fine particles (a),
they induce intense circumscribed tissue reaction
11
(TR) around the particles 3
 It has been experimentally shown, in guinea pigs
:–
1. Large pieces of gutta percha - are well
encapsulated in collagenous capsules

2. Fine particles of gutta percha induce an

intense, localized tissue response
characterized by the presence of
macrophages and giant cells (Sjögren et al., 1995).

11
4
(b) Plant materials
 Vegetable food particles, particularly
leguminous seeds (pulses), and endodontic
clinical materials of plant origin can get lodged
in the periapical tissue before and/or during
endodontic treatment and cause treatment
failures

11
5
 Oral pulse granuloma is a distinct histopathological
entity

 Periapical pulse granulomas are associated with tooth

damaged by caries and with the antecedence of
endodontic treatment (Simon et al., 1982; Talacko and
Radden, 1988).

 The pulse granulomas are clinically significant

because particles of vegetable food materials can
reach the periapical tissue via root canals of teeth
exposed to the oral cavity by trauma, caries damage,
or endodontic procedures (Simon et al., 1982).

11
6
 Apical periodontitis developing against particles
of predominantly cellulose-containing materials
that are used in endodontic practice (White, 1968;
Koppang et al., 1987, 1989; Sedgley and Messer, 1993) has
been denoted as ‘cellulose granuloma’.

11
7
 Endodontic paper points are utilized for
microbial sampling and drying of root canals.

 Sterile and medicated cotton wool has been

used as an apical seal.

 Particles of these materials

can dislodge or get pushed
into the periapical tissue
(White, 1968) to induce a
foreign-body reaction
at the periapex. The tip of the paper point (FB) projecting into the
apical periodontitis lesion and the bacterial plaque
(BP) adhering to the surface of the paper point 11 8
 The endodontic paper points and cotton wool consist
of cellulose that cannot be degraded by human body
cells. They remain in tissues for long periods of time (
Sedgley and Messer, 1993) and induce a foreign-body
reaction around them.

 Infected paper points can protrude through the

apical foramen and allow a biofilm to grow around it.
This will sustain and even intensify the apical
periodontitis after root canal treatment, which
eventually can result in treatment failure.

11
9
 (c) Other foreign materials
 These include amalgam, endodontic sealants,
and calcium salts derived from periapically
extruded Ca(OH)2. In a histological and x-ray
microanalytical investigation of 29 apical
biopsies, 31% of the specimens were found to
contain materials and endodontic sealer
components (Koppang et al., 1992).     

12
0
SCAR-TISSUE HEALING
 There is evidence that unresolved periapical
radiolucencies may occasionally be due to
healing of the lesion by scar tissue that may be
mistaken as a radiographic sign of failed
endodontic treatment (Penick, 1961; Bhaskar, 1966;
Seltzer et al., 1967; Nair et al., 1999).

12
1
 It must be emphasized that of all these
factors, microbial infection persisting in the
apical portion of the root canal system is the
major cause of endodontic failures in properly
treated cases.

 Failures due to extraradicular actinomycosis,

cystic lesions, foreign-body reaction, and scar-
tissue healing are rare.

12
2
Measures to be Employed to Improve Success : Ten
Commandments of Endodontics
 Use great care in case selection.
 Use greater care in treatment.
 Establish adequate cavity preparation of the access cavity- enables
thorough cleaning and shaping.
 Determine the exact length of tooth to the foramen and be certain
to operate only to the apical stop, about 0.5 to 1.0 mm from the
external orifice of the foramen.
 Always use curved, sharp instruments in curved canals.
 Use great care in fitting the primary filling point.
 Use periradicular surgery only in those cases for which surgery is
definitely indicated.
 Always check the apical density of the completed root canal filling
of the patient undergoing periradicular surgical treatment, and this
should be done by using a sharp right-angled explorer. If found wanting,
the apical foramen is prepared and retrofilled.
 Properly restore each treated pulpless tooth to prevent coronal
fracture and microleakage.
 Practice endodontic techniques until the procedures are as routine as
the placement of an amalgam restoration 12
3
Re-treatment cases :
 Periradicular lesions are found 5 to 10 times more often in
Endodontically treated teeth than for teeth without root fillings.

 If re-treatment is to be successful: first of all, complete recleaning

and reshaping of the canals. This should be carried out in a step-down
fashion: early coronal enlargement and canal body shaping prior to apical
Preparation.

 Working length at the radiographic terminus is established late in

treatment, when the remainder of the canal has already been cleaned and
shaped. Maintenance of apical potency and constant recapitulation with
fine files avoids canal blockage with dentin debris.

 sealer removal is most important since bacteria can easily “hide” under
previous sealer.

12
4
Re-treatment cases :
 One is warned that these cases are challenging, and this is probably
not the occasion for one-appointment therapy.

 Heling and Chandler have recommended a mixture of 3% hydrogen

Peroxide and 1.8% chlorhexidine as an alternative against E. faecalis.

Staphylococcus aureus and Pseudomonos are also notorious refractory

contaminants and may require a prescription of metronidazole and
amoxicillin to rid the periapex of these bacteria

12
5
SUCCESS IS A MARATHON
NOT A SPRINT!!

12
6
References
1. Principles & practice of endodontics – Mahmoud
Torabinejad
2. Endodontics – Ingles 6th edition
3. Pathways of the pulp - Stephen Cohen – 9th edition
4. Pathogenesis of apical periodontitis & the causes of
endodontic failure – P.N.R Nair
5. A prospective study of the factors affecting

outcomes of nonsurgical root canal treatment: part 1:

periapical health : IEJ 2011

6. Outcome of primary root canal treatment:
systematic review of the literature – Part 1. Effects
of study characteristics on probability of success:
IEJ 2008
12
7
6. Endodontics – Stock, Walker, Gulabivala 3rd
edition
7. Root canal retreatment : 1. Case assesment &
treatment planning – Pitt Ford – dental update
jan 2004
8. Endodontic failures – changing the approach –
SP Cheung – international dental journal –
1996, 46, 131 – 138
9. Evidence b – endodontic based dentistry :
endodontic failure – how should it be managed
– Briggs – BDJ, sept 1997 (183) 5

12
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THANK YOU
12
9