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JOURNAL OF ENDODONTICS Printed in U.S.A.
Copyright © 1992 by The American Association of Endodontists VOL. 18, NO. 7, JULY 1992

Are Endodontically Treated Teeth more Brittle?

Christine M. Sedgley, BDS, MDSc, FRACDS, and Harold H. Messer, MDSc, PhD

This study compared biomechanical properties extracted vital teeth and 6 teeth endodontically treated at least
(punch shear strength, toughness, hardness, and 1 yr previously. These conclusions should perhaps be viewed
load to fracture) of 23 endodontically treated teeth with caution, as Smith and Cooper (9) reported a 3-fold range
(mean time since endodontic treatment: 10.1 yr) and in punch shear strength of dentin within a single tooth de-
pending on site of sampling. In contrast to the study of Carter
their contralateral vital pairs. Analyses using paired
et al. (8), it has recently been suggested that the compressive
t tests revealed no significant differences in punch and tensile strengths of dentin from pulpless teeth are not
shear strength, toughness, and load to fracture be- significantly different from those of normal dentin (10). Also,
tween the two groups. Vital dentin was 3.5% harder Lewinstein and Grajower (11) found no difference in the
than dentin from contralateral endodontically Vickers microhardness of dentin of 16 extracted vital teeth
treated teeth (p = 0.002). The similarity between the and 32 teeth extracted at various intervals after endodontic
biomechanical properties of endodontically treated treatment (0.2 to 10 yr). Furthermore, recent research indi-
teeth and their contralateral vital pairs indicates that cated that no statistically significant differences existed in the
teeth do not become more brittle following endodon- collagen cross-link content of dentin of age- and site-matched
tic treatment. Other factors may be more critical to root-filled and normal teeth (12).
failure of endodontically treated teeth. Substantiated studies showing a reduction in elasticity and
an increase in brittleness in dentin of endodonticaUy treated
teeth are thus sparse, leaving relevant clinical questions un-
answered. This study was planned to answer the question of
whet~er loss of pulp vitality results in changes in tooth struc-
The endodontic and prosthodontic literature contains re- ture" Biomechanical properties (punch shear strength, tough-
peated references to the widely held clinical perception that ness, load to fracture, and microhardness) of the dentin of
endodontic treatment weakens teeth, resulting in increased extracted teeth with a known history of endodontic treatment
brittleness (i-4). While Rosen (1) described the dentin of were compared with those of the contralateral vital tooth from
endodontically treated teeth as "desiccated and inelastic," the same patient. In addition, because the effects of time after
Johnson et at. (2) additionally speculated that the elasticity of extraction may produce inconsistent data (13), matched-pair
dentin decreased with time following endodontic treatment. vital teeth were used to compare punch shear strength, tough-
Alternatively, it has been suggested that, rather than endodon- ness, and load to fracture measurements obtained immedi-
tic treatment, loss of tooth structure associated with restora- ately following extraction and 3 months later.
tive procedures was the major factor in weakening teeth.
Recently, it was shown that endodontic procedures reduced
the relative cuspal stiffness of premolar teeth by only 5%, in MATERIALS AND METHODS
contrast to an occlusal cavity preparation (20%) and an MOD
cavity preparation (63%) (5). Biomechanical Properties of Endodontically Treated versus
The purported brittleness of endodontically treated teeth Vital Teeth
has been attributed to decreased moisture content. The sup-
porting evidence for this is primarily a study by Heifer et al.
(6) which showed a 9% lower moisture content of pulpless
versus vital dog teeth. Very few studies have actually com- SELECTION OF TEETH
pared physical properties of endodontically treated versus vital
teeth. Stanford et al. (7) found no significant differences in Teeth were obtained from the Casualty and Oral Surgery
certain properties of dentin (modulus of elasticity, propor- Departments of the Royal Dental Hospital of Melbourne and
tional limit, and strength) from three pairs of patient-matched affiliated hospitals. Ethics approval was obtained from the
vital and pulpless incisors. However, details of previous en- Human Ethics Committee. Twenty-three matched pair teeth
dodontic treatment were not provided. Carter et al. (8) re- with relatively large, regularly shaped straight roots were
ported that the dentin of endodontically treated teeth had a selected following clinical and radiographic examination of
14% lower punch shear strength and toughness than vital patients scheduled for multiple extractions for prosthetic rea-
teeth. This was based upon a comparison between 21 freshly sons. One tooth of each pair had a history of endodontic
332
 Vol. 18, No. 7, July 1992 Brittleness of Teeth 333

treatment, and vitality of the contralateral tooth was con-

i••
firmed by thermal testing or by examining the tooth for the
presence of pulp tissue when the tooth was sectioned. Those
teeth excluded had a history of periapical surgery, extensive
periodontal disease, and endodontic treatment performed less
than 1 yr previously. A history of patient age and sex, and
time since endodontic treatment was recorded. Each pair was
extracted by the same operator at the same appointment. 8 mm
Following extraction, teeth were stored in sterile-buffered
saline plus 0.05% sodium azide. During subsequent prepara-
tion and testing phases of the experiment, care was taken to
prevent dehydration. Seventeen of the matched pairs were
prepared and tested for punch shear strength, toughness, and
load to fracture immediately after extraction (within 3 to 5 FtG 1. Diagrammatic representation of preparation of root segment
h). One pair was tested 3 days after extraction, two pairs 2 for load to fracture testing. The tooth was mounted vertically in 3-
months after extraction, and three pairs 3 months after ex- mm of cold-cure acrylic resin and the crown and two cervical slices
traction. Microhardness testing was performed within 5 days (for punch shear strength, toughness, and microhardness testing)
of the other tests. All testing was done at room temperature. were removed. A 1-mm-deep seat was then cut in the coronal opening
of the 8-ram root segment (R) for seating of the loading device (L).
Using a constant crosshead speed of 0.1 mm min-1 the root segment
PREPARATION OF TEETH was loaded to fracture.

The root tip was flattened using a diamond bur in a high-

c,-, | ,~ A
speed handpiece. The tooth was then mounted vertically in
an aluminum ring by embedding the apical 3 mm in cold-
cure acrylic. The ring was then mounted in an Isomet low-
speed saw (Buehler, Lake Bluff, IL) and the crown of the
tooth was removed just below the cementoenamel junction.
Two slices 0.3 to 0.4 mm in thickness were then cut from the
cervical root dentin perpendicular to the long axis of the
tooth. Each prepared dentin slice was smoothed on 600 grit FiG 2. Diagrammatic representation of punch shear device for punch
silicon carbide abrasive paper. Both cross-sections were sub- shear strength and toughness testing. The cervical dentin sample (C)
sequently used for punch shear testing, with one section 0.3- to 0.4-ram thick was constrained between upper and lower dies
additionally used for microhardness testing. The remaining secured with two screws. A tungsten carbide rod (A) 0.993 mm in
root segment was trimmed, where necessary, to leave a seg- diameter was mounted in a tungsten carbide bush (B) located in the
center of the die. A load was applied to the rod at a crosshead speed
ment 8 mm in length, for loading to fracture (Fig. I). Using
of 0.1 mm min -1 until punching occurred.
a cone-shaped stone bur in a slow-speed handpiece, a l-ram
deep seat was then cut in the coronal opening of the root
canal for seating of the loading device. A comparator employing a micrometer reading to 0.01
mm was used to measure the thickness of each section buc-
PUNCH SHEAR TESTING cally and lingually at a distance mid-way between the root
canal and the periphery of the section. The dentin slice to be
punched was positioned over the bush of the lower die. Care
Punch shear strength (MPa) is the maximum stress that a
was taken to ensure accurate positioning of the test site over
material can withstand before failure in a punch shear mode
the punch hole. All tests were performed at least 1.0 mm from
of loading. Toughness (MJ/m -3) is defined as the energy
the specimen periphery and root canal edge on buccal and
required to fracture a material, and is measured as the area
lingual aspects. The upper die was then placed over the lower
under the elastic and plastic portions of a stress-strain curve.
die and secured so that the dentin section was constrained. A
A punch shear apparatus similar to that described by Carter
load was applied to the punch at a constant crosshead speed
et al. (8) (Fig. 2) mounted on a Shimadzu universal testing
of 0.1 mm min -~ until punching had occurred, as determined
machine (Autograph IS-5000; Shimadzu, Seisakusho Ltd.,
from the chart recording. Two tests were performed per
Kyoto, Japan) was used. The apparatus consisted of two
section. Punch shear strength and toughness values were
cylindrical steel dies aligned together with four dowels and
calculated as described by Carter et at. (8), with correction for
secured with two screws. A tungsten carbide bush was
machine compliance. The mean punch shear strength and
mounted within the central axis of the upper and lower dies,
toughness for each tooth were then calculated.
and a cylindrical tungsten carbide rod was used as a punch
(type 522; Pr~isionswerkzeuge GmhH, Ravensburg, West
Germany). The internal diameter of the upper bush was 1.000 LOAD TESTING
mm and of the lower bush 1.050 mm. Punch diameter was
0.993 mm. Concentricity between the punch and the bush of The root segment was positioned vertically on the lower
the lower die was confirmed by making an impression of the platen of the Shimadzu testing machine with the coronal face
punch and die on polyester film which was then viewed under upward. A cylindrical hardened steel rod attached to the upper
x6 magnification. crosshead was lowered until the cone-shaped point of the rod
334 Sedgley and Messer Journal of EndodonUcs

rested in the prepared coronal root face seat (Fig. 1). Using a maining 20 pairs, 11 were from females and 9 from males.
constant crosshead speed of 0.1 m m min-~ each root segment Patient ages ranged from 21 to 72 yr with a mean of 47.2 yr.
was loaded to fracture. Time since endodontic treatment ranged from 1 to 25 yr with
a mean of 10.1 yr; only four teeth had been treated less than
MICROHARDNESS TESTING 5 yr previously. The teeth tested were maxillary central incisor
(n = 6), maxillary lateral incisor (n = 5), maxillary canine (n
One dentin slice per tooth was glued to a glass slide (Petro- = 4), maxillary first premolar (n = 2), maxillary second
graphic Slides; Buehler) with epoxy resin (Araldite Super premolar (n = 3), maxillary second molar (palatal root) (n =
Strength Epoxy Resin; Selleys Chemical Co. Pry Ltd., Pad- 1), mandibular canine (n = 1), and mandibular third molar
stow, NSW, Australia) and polished (Minimet Polisher; Bueh- (single rooted) (n = 1). All teeth were extracted for prosthetic
ler) until all scratches created by the saw were removed. The reasons. None of the endodontically treated teeth were re-
specimen was wet polished on 600 grade silicon carbide paper, moved because of failure of endodontic treatment.
followed by Texmet Cloth (Buehler) and Microcloth (Buehler) The mean punch shear strength, toughness, hardness, and
with diamond polishing paste. Microhardness of dentin was load at fracture are shown in Table 2. There were no statisti-
measured using a microhardness tester (Leitz MINILOAD- cally significant differences between endodontically treated
Hardness Tester; Ernst Leitz G m b H Wetzlar, FRG) under a and contralateral vital teeth in punch shear strength (p =
100-g load, and the Vickers Hardness Number was obtained. 0.710) and toughness (p = 0.089). Despite a difference in
Each pair was tested at identical sites. Three indentations hardness of only 3.5 %, vital teeth were highly significantly (p
were made mid-way between the root canal and the periphery = 0.002) harder than contralateral endodontically treated
of the specimen on both mesial and distal aspects, and the teeth. Two samples for load testing were lost during processing
mean value was calculated. The thickness of all slices exceeded and the data for their matched pairs were excluded from
1.5 times the length of the diagonal of the indentation pro- further analyses. The load to fracture values were not signifi-
duced. cantly different between the two groups (p = 0.149).

Effect of Storage on Physical Properties DISCUSSION

Eight matched pairs of vital teeth were obtained as before, The clinical concept of "brittle" or weakened endodonti-
but with crowns unrestored and intact. Patient age and sex cally treated teeth has been attributed to loss of tooth structure
were recorded. One tooth of each pair was tested immediately following trauma, caries, endodontic access, instrumentation
after extraction for punch shear strength, toughness, and load and irrigation procedures, and/or to changes in properties of
to fracture as described above. The contralateral tooth was teeth following endodontic treatment (3, 6, 8). Although
tested 3 months later following storage in sterile-buffered Heifer et al. (6) reported a 9% lower water content of pulpless
saline plus 0.05% sodium azide. Microhardness testing was teeth versus vital teeth, few studies have compared the bio-
not performed.
mechanical properties of dentin of endodonticaUy treated
teeth with vital teeth (7, 8, 11). The only report of a difference
Statistical Analysis

The data for each property tested were subjected to paired TABLE 1. Effect of storage on biomechanical properties of
t test analysis. For punch shear strength, toughness, and teeth*
hardness, paired t tests were performed on the mean values Immediate Three-Month
obtained for each tooth. Testing Storage P

Punch shear strength 64.97 __+7.91 63.63 __ 9.99 = 0.733

RESULTS (MPa)
Punch shear toughness 35.16 +_ 3.49 33.09 +_ 5.72 = 0.267
Effect of Storage on Physical Properties (MJ/m -3)
Load to fracture (N) 724 _+ 206 642 -+ 187 = 0.215
Eight matched pairs were obtained from four males and • All values represent mean -+ SD for eight matched.pairs.
three females. Patient ages ranged from 21 to 60 yr with a
mean of 40.5 yr. The teeth tested were maxillary central
incisor (n = 4), maxillary lateral incisor (n = 2), maxillary TABLE 2. Comparison of properties of endodontically treated
canine (n = 1), and mandibular canine (n = 1). There were versus contralateral vital teeth*
no significant differences between the two groups in punch Endodontically
shear strength, toughness, and load to fracture (Table 1). Treated Teeth Vital Teeth p
These results indicated that data from teeth stored for up to
3 months after extraction could be included in the subsequent Punch shear strength 70.42 _+ 12.39 69.76 ___11.69 = 0.710
(MPa)
analyses.
Punch shear toughness 42.51 + 10.38 40.08_+ 8.91 = 0.089
(MJ/m -3)
Endodontically Treated versus Vital Teeth Microhardness(Vickers 66.79__ 4.83 69.15 + 4.89 = 0.002
hardness no.)
Data on patient age, sex, and time since endodontic treat- Load to fracture (N) 611 ___148 574 ___153 = 0.149
ment were unavailable for three matched pairs. Of the re- • All values represent mean _+ SD for 23 matched pairs.
Vol. 18, No. 7, July 1992 Brittleness of Teeth 335

in properties between endodontically treated and vital teeth supply to dentin, could lead to progressive changes in the
(8) was based on six endodontically treated teeth. Stanford et biomechanical properties of dentin. The results of this and
al. (7) reported no difference in compressive properties (mod- other investigations suggest that this is not the case (10, 12).
ulus of elasticity, proportional limit, and strength) of three The similarity between the biomechanical properties of en-
matched pairs, hut details of previous endodontic treatment dodontically treated teeth and their contralateral vital pairs
were unavailable. Although not eliminating all dissimilarities, suggests that other factors may be more critical to failure of
the use of matched pairs in our study allowed a reduction in endodontically treated teeth. Reeh et al. (5) showed that the
certain variables usually associated with testing extracted hu- endodontic access cavity produced only a 5% decrease in
man teeth. Additionally, the larger number of matched pairs stiffness, in contrast to an MOD preparation which decreased
and the range of tooth type compared with previous studies tooth stiffness by 63%. We suggest that it is rather the cu-
provided the opportunity to make a broader assessment. The mulative loss of tooth structure from caries, trauma, and
mean time since endodontic treatment (10.1 yr) should have restorative and endodontic procedures that leads to suscepti-
been sufficient for any structural changes in dentin to have bility to fracture. Another possibility that has been suggested
occurred. but never extensively explored is that loss of pressoreception
Punch shear strength and toughness values were in the (19), or an elevated pain threshold (20) allows larger loads on
lower range of what has been previously reported (8, 9, 14). endodontically treated teeth without triggering a protective
Differences between our study and previous work with respect response.
to sample thickness, punch diameter, and the use of con- This project was supported by a grant from the National Health and Medical
strained samples could account for these differences, although Research Council of Australia and was based on a thesis submitted to the
Carter et al. (8) reported an increase in values of samples University of Melbourne in partial fulfillment of the requirements for the MDSc
degree.
constrained during testing. The microhardness measurements
obtained in this study agree well with those of previous The authors gratefully acknowledge the technical assistance of David Chea-
die and Koren Mitchell of the School of Dental Science, University of Melbourne,
investigators (11, 15, 16). Although we found that microhard- Melbourne, Australia.
ness values for vital teeth were statistically significantly higher
than those for contralateral endodontically treated teeth (p = Dr. Sedgley is a graduate student in endodontics, School of Dental Science,
University of Melbourne, Melbourne, Australia. Dr. Messer is professor of
0.002), this small difference (3.5%) is unlikely to be clinically Restorative Dentistry, School of Dental Science, University of Melbourne.
significant.
A comparison of vertical load to fracture of endodonticatly
treated teeth and contralateral vital teeth has not been previ-
References
ously reported. Clinically, vertical root fractures are a com-
mon means of failure of endodontically treated teeth and are 1. Rosen H. Operative procedures on mutilated endodontically treated
teeth. J Prosthet Dent 1961;11:972-86.
thought to result from the trauma associated with lateral 2. Johnson JK, Schwartz NL, Blackwell RT. Evaluation and restoration of
condensation procedures and pin/post placement in endo- endodontically treated posterior teeth_ J Am Dent Assoc 1976;93:597-605.
dontically treated teeth (17). An in vitro study by Pitts et al. 3. Greenfeld RS, Marshall FJ. Factors affecting dowel (post) selection and
use in endodontically treated teeth. J Can Dent Assoc 1983;49:777-83.
(18) found that vertical root fractures occurred using large 4. Radke RA Jr, Eissmann HF. Postendodontic restoration. In: Cohen S,
spreaders under minimum loads of 7.2 kg in maxillary central Burns RC, eds. Pathways of the pulp. 5th ed. St. Louis: CV Mosby, 1991.
incisors. The testing procedure of our study attempted to 5. Reeh ES, Messer HH, Douglas WH. Reduction in tooth stiffness as a
result of endodontic and restorative procedures. J Endodon 1989;15:512-6.
simulate vertical root fracture by applying a wedging load to 6. Heifer AR, Me/nick S, Schilder H. Determination of the moisture content
the coronal face of the root segment until longitudinal fracture of vital and pulpless teeth. Oral Surg Oral Meal Oral Patho11972;34:661-70.
7. Stanford JW, Weigal KV, Paffenbarger GC, Sweeney WT. Compressive
occurred. properties of hard tooth tissue. J Am Dent Assoc 1960;60:746-56.
There are several problems associated with the mechanical 8. Carter JM, Sorenson SE, Johnson RR, Teitelbaum RL, Levine MS. Punch
testing of dentin. These include obtaining sound develop- shear testing of extracted vital and endodontically treated teeth. J Biomech
1983; 16:841-8.
mentally normal teeth that have not been damaged during 9. Smith DC, Cooper WEG. The determination of shear strength. A method
extraction, cutting small pieces of dentin from the tooth using a micro-punch apparatus. Br Dent J 1971 ;130:333-7.
10. Huang TG, Schilder H, Nathanson D. Effects of moisture content and
without creating thermal or mechanical damage, and the endodontic treatment on some mechanical properties of human dentin [Ab-
unknown effects of storage media and time. The effects of stract]. J Endodon 1991 ;17:194.
storage on biomechanical testing of dentin have not been 11. Lewinstein I, Grajower R. Root dentin hardness of endodontically
treated teeth. J Endodon 1981;7:421-2.
extensively reported. Carter et al. (8) found that different 12. Rivera E, Yamauchi M. Dentin collagen cross-links of root-filled and
storage media (tap water or mineral oil) did not affect shear normal teeth. [Abstract]. J Endodon 1990;16:190.
strength and toughness results but that dry storage signifi- 13. Causton BE, Johnson NW. Changes in the dentin of human teeth
following extraction and their implication for in vivo studies of adhesion to tooth
cantly increased values for mandibular incisors. In our study substance. Arch Oral Bio11979;24:229-32.
it was apparent that 3-month storage in sterile saline did not 14. Roydhouse RH. Punch shear test for dental purposes. J Dent Res
1970;49:131-6.
affect the values obtained. Other testing procedures may be 15. Craig RG, Peyton FA. The microhardness of enamel and dentin. J Dent
more sensitive to potential postextraction changes. Causton Res 1958;37:661-8.
et al. (13) found that storage affected the bond shear strength 16. Renson CE, Braden M. The experimental deformation of human dentin
by indenters. Arch Oral Bio) 1971 ;16:563-72.
between polycarboxylate cement and human dentin and sub- 17. Tamse A. latrogenic vertical root fractures in endodontically treated
sequently suggested that testing of dentin should take place teeth. Ended Dent Traumato11988;4:190-6.
18. Pitts DL, Matheny HE, Nicholls Jl. An in vitro study of spreader loads
within 20 min of tooth extraction. However, the preparation required to cause vertical root fracture during lateral condensation. J Endodon
procedures necessary for testing of dental tissues may require 1983;9:544-50.
longer working times. 19. Lowenstein NR, Rathkamp R. A study on the pressoreceptive sensibility
of the tooth. J Dent Res 1955;34:287-94.
We have attempted to answer the question of whether the 20. Randow K, Glantz P-O. On cantilever loading of vital and non-vital
loss of a vital pulp, resulting in subsequent loss of the nutrient teeth. Acta Odontol Scand 1986;44:271-7.