JODE

10.5005/jp-journals-10047-0005
Treatment Outcomes in Endodontics
Invited review

Treatment Outcomes in Endodontics

1
Raghu Srinivasan, 2Ramya Raghu

ABSTRACT of endodontics treatment has been of great interest to

The success of endodontic treatment has been of great interest practitioners for many years now. The various causes
to practitioners for many years now. Endodontic failures, which for failure of treatment rendered may be divided
are of particular interest to us, are due to either microbial or into prosthetic, periodontal and endodontic failures.1
nonmicrobial reasons. It is often thought that procedural errors
Prosthetic failures are due to crown fracture, root fracture
like ledging, perforation, overfilling, underfilling or instrument
separation invariably result in failure. In reality, the fact is that or failure of the restorations to the extent that the tooth
such mishaps only impede the accomplishment of an ideal root is deemed unrestorable. Periodontal failures relate to
canal treatment. It is often the concomitant presence of infection extensive bone loss and mobility.1 Endodontic failures,
that ultimately results in failure.
which are of particular interest to us are due to either
Numerous studies have evaluated the success or failure of
endodontic therapy and reported a wide range of success rates microbial or nonmicrobial reasons. It is often thought that
from 40 to 93%.This wide range may be due to differences in procedural errors like ledging, perforation, overfilling,
clinical procedure, experimental design, criteria for evaluation underfilling or instrument separation invariably result
and the length of the observation period. However, most
in failure. In reality, the fact is that such mishaps only
authors conclude that the crucial factor influencing success
is the preoperative status of the tooth. Teeth with an apical impede the accomplishment of an ideal root canal
radiolucency show a 20% lower success rate than teeth without treatment. It is often the concomitant presence of infection
lesion. that ultimately results in failure.2
Till date, the main method of evaluating success is
Numerous studies have evaluated the success or
radiographic, using recall radiographs. This method, however,
is not without its own limitations due to examiner bias and failure of endodontic therapy and reported a wide range
inconsistencies. of success rates from 40 to 93%.3 This wide range may
The factors affecting treatment outcome include those be due to differences in clinical procedure, experimental
related to diagnosis, preoperative condition of the patient and
tooth, standard of care during treatment, postoperative factors
design, criteria for evaluation and the length of the
and ongoing maintenance. This paper reviews the various observation period. However, most authors conclude that
factors influencing the outcome of endodontic treatment in light the crucial factor influencing success is the preoperative
of modern thought. status of the tooth. Teeth with an apical radiolucency
Keywords: Failure, Postoperative factors, Preoperative factors, show a 20% lower success rate than teeth without lesion.3
Standard of care, Success, Treatment outcome. Till date, the main method of evaluating success is
How to cite this article: Srinivasan R, Raghu R. Treatment radiographic, using recall radiographs. This method,
Outcomes in Endodontics. J Oper Dent Endod 2016;1(1):13-17. however, is not without its own limitations due to
Source of support: Nil examiner bias and inconsistencies.1
Conflict of interest: None This paper reviews the various factors influencing the
outcome of endodontic treatment in the light of modern
Introduction thought.

Modern endodontic treatment is highly predictable DEFINING SUCCESS AND FAILURE-

with a degree of success approaching 100%. The success TRADITIONAL CONCEPTS VS CURRENT
THOUGHT
1,2
Professor and Head
The so-called ‘Strindberg concept’ defined the standards
1
for success and failure based on stringent criteria.
Department of Conservative Dentistry, AECS Maaruti College
of Dental Sciences and Research Center, Bengaluru, Karnataka According to Strindberg (1956), ‘success’ is a clinically
India symptom-free tooth with a radiologically normal periapex
2
Department of Conservative Dentistry, Bangalore Institute of after a predetermined postoperative period. This
Dental Sciences, Bengaluru, Karnataka, India implies clinical, radiologic and histologic resolution of
Corresponding Author: Ramya Raghu, Professor and Head inflammation, whereas, ‘failure’ is the presence of signs or
Department of Conservative Dentistry, Bangalore Institute symptoms indicating disease.3 This concept is perceived
of Dental Sciences, Bengaluru, Karnataka, India, e-mail: to be too dogmatic or black and white and is considered
[email protected]
inflexible for everyday clinical use.

Journal of Operative Dentistry and Endodontics, January-June 2016;1(1):13-17 13

Raghu Srinivasan, Ramya Raghu

To strike a rational middle path, considering patient mimic a periapical lesion of endodontic origin are:
comfort and function on one hand and reasonable odontogenic lesions, like lateral periodontal cyst,
evidence of healing on the other, the following guidelines ameloblastoma, cementoma, developmental lesions
proposed by Bender may be appropriate:4 like median anterior maxillary cyst, median mandibu-
• An absence of pain or swelling lar developmental cyst, globulomaxillary cyst, oral
• Disappearance of any sinus tracts tumors like giant cell granuloma (common in man-
• Radiographic evidence of resolved or arrested areas dible), neurofibroma (mimic endodontic-periodontal
of rarefaction after a post-treatment interval of 6 to lesions) and squamous cell carcinoma, physical injury
24 months like traumatic bone cyst.7
• No loss of function • Incorrect diagnosis of pain: The commonest non-
Given these guidelines, currently, terms like ‘healed’, odontogenic causes of pain that mimic pulpal and/or
‘healing’ or ‘disease’ may be better expressions of periapical pain are trigeminal neuralgia and maxillary
treatment outcome.5 sinusitis.
• Healed: Completely normal appearance clinically and
radiologically. This also includes the appearance of a Preoperative Condition of
scar after periapical surgery (radiographically). the Patient and the Tooth
• Healing (in progress): Clinically normal tooth with • Age, gender and health of the patient: Several studies
reduction in size of radiolucency for a follow-up have evaluated the role of the patient’s age and gender
period less than 4 years. on the success of endodontic treatment. They have
• Disease (refractory, recurrent apical periodontitis): not been able to find any correlation.8 Thus, age and
Clinically, symptomatic tooth regardless of radiologic gender do not influence the outcome of endodontic
appearance or presence of radiolucency (new, treatment.9 Apical periodontitis represents a balance
increased, unchanged or reduced) regardless of between intraradicular infection and host defences. In
clinical presentation. the past, it was believed that host factors supposedly
Recently, it has been suggested that the term ‘effective’ exerted a major influence on treatment outcome.10
would include the categories ‘healed’ and ‘healing’ However, this has not been found to be true. Only
and will not result in further treatment, while the term in severely immunocompromised patients and in
‘ineffective’ at 1 year would mean the emergence or uncontrolled diabetics has healing shown to be
enlargement of the periapical radiolucency and/or delayed and less predictable. Even in such cases, root
symptoms and signs that will require intervention.6 canal treatment is not contraindicated as healing is
The advantages of using ‘effective’ and ‘ineffective’ still possible.
over previous terms to describe the outcome are the • Presence of apical periodontitis: Studies evaluating the
following:6 outcome of endodontic treatment have pinpointed
• Shorten the follow-up period from 4 to 1 year, and the presence of apical periodontitis as the single
thereby increase the recall rate and reduce the number most important factor affecting healing. Teeth with
of appointments and radiographs. irreversible pulpitis have a better prognosis than
• Reduce the number of unnecessary retreatments those with pulp necrosis and apical periodontitis.
indicated by adhering to previous definitions. Sjögren et al while evaluating the long-term results
• The terms ‘effective’ and ‘ineffective’ relate directly to of endodontic treatment concluded that the presence
an indication for treatment and make clinical decisions of preoperative periapical lesions reduced the success
easier and reproducible. rate from 96 to 86%.3 Strindberg attributed this lower
success rate to difficulties in the repair potential of the
FACTORS AFFECTING TREATMENT OUTCOME periapical tissues and inability to thoroughly disinfect
the root canal system.
Related to Diagnosis
• Size of the periapical lesion: Many researchers have
A significant factor affecting treatment outcome and one, reported that teeth with periapical lesions lesser than
i.e. frequently overlooked is an erroneous diagnosis. 5 mm in diameter heal better following endodontic
Incorrect diagnosis of pain and misinterpretation of the therapy than those with larger lesions.5 But Sjögren
radiographic appearance of a bony lesion are the two et al in their 8 to 10-year follow-up of 356 cases did not
common causes for a mistake in diagnosis. find this to be true. They attributed this to two possible
• Oral pathologist Bhaskar SN has listed 38 radiolu- reasons—observation periods of earlier studies were
cent lesions of the jaw of which only three are of too short to re-establish normal periapical architecture
endodontic origin. Nonendodontic rarefactions that and larger periapical lesions may heal by soft-tissue

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Treatment Outcomes in Endodontics

scarring which cannot be distinguished from Apical true cysts in which the cystic cavity is
persistent inflammation on the radiograph.3 completely enclosed in the epithelial lining and has no
• Condition and position of the tooth: Factors that may communication with the root canal system do not heal
compromise treatment outcome include difficult following nonsurgical endodontic treatment. This is
access, coronal breakdown, anatomic complexities, because in true cysts the tissue dynamics are self-sustaining
calcifications, resorptions altering the root canal space and independent of the presence or absence of irritants in
and cracked teeth. Since these problems are more the root canal system. True cysts contain large numbers
common in posterior teeth, their treatment outcome of cholesterol crystals in the connective tissue around
may be less predictable. Studies evaluating the healing the cystic epithelial lining. These are derived from the
rate for multirooted teeth give conflicting results. breakdown of host cells like erythrocytes, lymphocytes,
Earlier studies by Strindberg and Engstrom reported plasma cells and macrophages. Multinucleated giant
a higher success rate while considering each root of cells are ineffective in removing these crystals; thus, they
a posterior as a unit. The more recent Toronto study, continue to accumulate and maintain the cyst.12
however, reports a lower success rate for posterior
teeth as they considered the tooth as a whole.11 Standard of Care during Endodontic Treatment
• Nature of the canal flora: The persistence of microbial
• Apical extent of the canal preparation and obturation:
infection in the root canal system and/or the periapical
The apical limit of preparation and obturation does
area is an important cause for endodontic failure. This
not appear to be that critical for healing following
is true even when the treatment is technically of a
nonsurgical endodontic treatment in teeth without
very high standard. During cleaning and shaping
apical periodontitis. In teeth with apical periodontitis,
procedures, instrumentation, irrigation and intracanal
healing is optimal if the preparation and obturation is
medicament are relied upon to completely eliminate
within 2 mm of the root apex. Over instrumentation
microorganisms. But, studies have demonstrated
with consequent overfilling appears to impart
that regardless of the technique or instruments
used, part of the root canal space often remains periapical healing to the greatest extent in teeth with
untouched. Also, bacteria harbored in isthmuses, apical periodontitis.3 Extrusion of infected debris into
ramifications, apical deltas and dentinal tubules may the periapical tissues rather than overextension of the
sometimes be unaffected by irrigants or medicaments. obturating material is responsible for this.
However, failure will result only when these bacteria • Apical width: In root canal infections, bacteria have
possessing pathogenicity, reach sufficient numbers been shown to penetrate to a depth of 150 to 250 µm
and communicate with the periradicular tissue.12 into the dentinal tubules. This protects them from the
If the case is poorly treated, a greater number of effect of irrigants and medicaments. Therefore, many
microbial species predominated by anaerobes similar to researchers have put forth various recommendations
that found in the primary infection is likely to be found. regarding the size of the apical preparation (apical
On the other hand, well-treated cases that have failed, width) necessary to successfully eliminate these
often show one or a few species of which E. fecalis is found bacteria. However, studies have not been able to
in 29 to 38% of the cases.2 Yeast like microorganisms have correlate the size of the apical enlargement with the
also been isolated from the canals.12 treatment outcome. Excessive apical enlargement may
Recently, there is considerable interest regarding result in iatrogenic errors like canal transportation
the role of extraradicular infection (an established and ledging while minimal apical preparation carries
infection on the external root surface forming a biofilm the risk of leaving residual infected material behind.
and persisting in the periapical tissues) in the failure of Thus, a balance between these two extremes should
well-treated cases. Such an infection is inaccessible to be achieved.5
conventional endodontic disinfection procedures, and • Single versus multivisit treatment: In recent years,
since they are in the form of a biofilm they also escape the the consensus regarding healing following one or
action of the host’s defences. Oral microorganisms, such multivisit root canal therapy in teeth without apical
as Actinomyces spp. and Propionibacterium propionicium are periodontitis is clear. There is no difference in the
implicated in extraradicular infections.2,12 healing rates. Regarding teeth associated with apical
• Type of periapical lesion: It is seen that periapical lesions periodontitis there are many studies that emphasize
considered to be granulomas often heal following the need for intracanal medication to achieve proper
routine endodontic treatment. This is also the case disinfection and a better treatment outcome. However,
with apical pocket cysts in which the cyst cavity prolonging the treatment for more than two sessions
communicates with the root canal system. does not provide any additional benefits.5,13

Journal of Operative Dentistry and Endodontics, January-June 2016;1(1):13-17 15

Raghu Srinivasan, Ramya Raghu

• Canal preparation and obturation techniques: The lesions can progress and quietly destroy the coronal tooth
instrumentation technique regardless of whether hand structure and reinfect the obturated root canal system.14
or rotary instruments, different rotary instrument The other reasons for eventual failure are loss of
systems or degree of taper does not influence integrity of the coronal restoration fracture of the crown
the treatment outcome. 14 At present, there is or root development of advanced periodontal disease and
insufficient data from follow-up studies to assess traumatic occlusion.8 Therefore, careful periodic clinical
the effect of intracanal medication on healing and radiographic evaluation is a must.
potential. One study has suggested that calcium
hydroxide was superior to other medicaments or no Evaluation
medicaments on the long-term retention of teeth.15 Periodic radiographic evaluation should be performed
Studies comparing the effect of different obturation to monitor post-treatment healing:
techniques suggest that the technique used for • Approximately, 90% of cases that are healing will
obturation does not influence the treatment outcome.9 demonstrate clear signs of improvement and 50%
Contemporary methods of cleaning and shaping would have healed completely within a year.
using a crown-down approach and rotary nitinol • If after a year if a periapical lesion appears reduced in
instruments, reduce the chances of procedural size, it can be safely assumed that it would continue
errors like ledging, blockages, apical transportation, to heal and should be evaluated.
extrusion of debris, etc. Thus, if a clinician employs • If a lesion does not show any change radiographically,
a scientifically accepted protocol for treatment and but the tooth is asymptomatic, radiographic evaluation
a three-dimensional obturation extending to within must be carried out for 4 years. Further healing is
2 mm of the root apex there is greater likelihood of a unlikely after 4 years at which point a final judgment
successful outcome.3 can be made.5

Postoperative Factors CONCLUSION

The following postoperative factors have been researched:5 Long-term evaluation of endodontic treatment requires
• Inadequate postendodontic restoration resulting an exhaustive analysis of various preoperative, treatment
in bacterial penetration and development of apical related and postoperative factors. In general, favorable
periodontitis outcome of endodontic treatment in terms of healing and
• Type of restoration functionality is very good for both teeth with and without
• Presence or absence of posts and prevalence of apical apical periodontitis. Considering the high success rate of
periodontitis endodontic treatment, conservative endodontic treatment
The results of these studies have been conflicting. should be the first choice for teeth with good restorative
However, a definitive restoration placed as early as and periodontal prognosis. The past few decades have
possible following root canal treatment is important for witnessed the emergence of newer techniques and devices
healing although the type of the restoration is not that that have greatly enhanced the practice of endodontics. In
critical.14 A failure rate as high as 35% has been reported the light of these advances, evaluation of current practices
by the Toronto study series due to poor postendodontic is an important parameter in treatment outcome.
restorations. The technical quality of the coronal
restoration was even more important for the periapical
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Journal of Operative Dentistry and Endodontics, January-June 2016;1(1):13-17 17