Vol. 100 No.

September 2005

ENDODONTOLOGY

ngberg Editor: Larz S. W. Spa

Periradicular status related to the quality of coronal restorations and root canal llings in a Brazilian population
F. Siqueira, Jr, DDS, MSc, PhD,a Isabela N. Ro c vio R. F. Alves, DDS,c Jose as, DDS, MSc, PhD,b Fla c s C. Campos, DDS, Rio de Janeiro, Brazil and Lu
CIO DE SA UNIVERSITY ESTA

Objective. This cross-sectional study was undertaken to determine the prevalence of periradicular lesions in root-lled teeth
from an urban adult Brazilian population, and to investigate the quality of root canal llings and coronal restorations and their association with the periradicular status of these teeth. Study design. Root canal llings from 2,051 teeth were categorized as adequate or inadequate on the basis of root canal lling length and homogeneity. Coronal restorations from the same teeth were categorized into adequate, inadequate, or absent. Results were analyzed statistically using the chi-squared test. Results. The overall success rate of root-lled teeth was 49.7%. Cases with adequate endodontic treatment and adequate restorations had a success rate of 71%. When cases with adequate treatment and inadequate restoration were evaluated, the success rate was 65%. Cases with adequate treatment and absent restoration showed a success rate of 48%. Teeth with inadequate treatment combined with adequate restoration yielded a success rate of 38%, whereas the combination of inadequate treatment and inadequate restoration resulted in a success rate of 25%. Teeth with inadequate treatment and absent restoration showed the lowest success rate of this study (18%). Data analysis revealed that when the root canal lling appeared to be adequate, the quality of the restoration did not signicantly inuence the treatment outcome. However, when a coronal restoration was absent, the success rate of adequately treated canals was signicantly reduced. The quality of the coronal restoration signicantly affected the outcome of inadequately treated teeth. Conclusions. Our results revealed a high prevalence of periradicular lesions in root-lled teeth, which was comparable to that reported in other methodologically compatible studies from diverse geographical locations. In addition, even though the coronal restoration had a signicant impact on the periradicular health, the quality of the root canal lling was found to be the most critical factor in this regard. (Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2005;100:369-74)

Longitudinal studies investigating the outcome of the endodontic treatment performed in controlled clinical environments (eg, dental schools) have demonstrated success rates up to 95% of the treated teeth.1-4

Chairman and Professor, Department of Endodontics, Faculty of cio de Sa University; Associate Researcher, LaboraDentistry, Esta tory of Oral Microbiology, Institute of Microbiology, Federal University of Rio de Janeiro. b Assistant Professor, Department of Endodontics, Faculty of Dentis cio de Sa University. try, Esta c cio de Sa Graduate student, Masters Program in Endodontics, Esta University. Received for publication Dec 9, 2004; returned for revision Mar 21, 2005; accepted for publication Mar 22, 2005. 1079-2104/$ - see front matter 2005 Mosby, Inc. All rights reserved. doi:10.1016/j.tripleo.2005.03.029

Nevertheless, epidemiological studies evaluating the outcomes of the endodontic treatment performed for the most part by general clinicians show a rather appalling picture. Irrespective of the population group and geographic location, these studies have revealed success rates as low as 35% to 60% for root-lled teeth.5-12 These epidemiologic studies point to an association between the quality of endodontic treatment and periradicular bone status, and emphasize that an improvement in the quality of root canal treatment in general dental practice is required in order to promote periradicular health.12 The attainment of a proper apical seal of the cleaned and shaped root canal is still considered as paramount in endodontic therapy, but in recent years more attention has been paid to the importance of a bacteria-tight coronal seal.13 Several in vitro investigations have revealed 369

370 Siqueira et al that even with satisfactory root canal llings and regardless of the lling material or obturation technique, leakage of bacteria and bacterial products along the root canal lling is inevitable after a short-term challenge.14-18 Recent epidemiologic studies have further investigated the importance of coronal leakage and suggested that the quality of the coronal restoration may actually exert an inuence on the outcome of the endodontic treatment. However, there has been some controversy when it comes to the level of impact of the coronal restoration on the success rate of the endodontic treatment. In a study of 1,010 root-lled teeth, Ray and Trope19 found that the technical quality of the coronal restoration was even of greater importance for the periradicular status than the quality of the endodontic treatment. Other investigators10,12,20 also reported a correlation between the quality of the coronal restoration and the periradicular status of root-lled teeth, though not as pronounced as reported by Ray and Trope.19 On the other hand, Hommez et al21 reported that the quality of the coronal restoration (scored clinically and radiographically) did not have a signicant inuence on the periradicular status when it was combined with the quality of endodontic treatment. Tronstad et al22 found the quality of the coronal restoration scored radiographically only to be signicant when combined with adequate endodontic treatment and that the technical quality of the coronal restoration was signicantly less important than the technical quality of the root canal lling. Moreover, Ricucci et al23 reported that exposure of root llings to the oral microbiota was not significantly correlated with periradicular status. This study was undertaken to determine the prevalence of periradicular lesions in root-lled teeth from an urban adult Brazilian population, and to investigate the quality of root canal llings and coronal restorations and their association with periradicular status of these teeth. MATERIAL AND METHODS The sample for this cross-sectional study consisted of 1,139 patients, 478 males and 661 females, presenting consecutively as new patients seeking routine dental cio de Sa care at the Faculty of Dentistry, Esta University, Rio de Janeiro, between the years 1997 and 2002. The criterion for inclusion in the study was that the patient should be attending for the rst time. To be enrolled in the study, the patients chart had to contain a current full-mouth radiographic series or a panoramic radiograph with supplemental periapical radiographs. All periapical radiographs were taken using the paralleling technique. The radiographs of the rst 2,051 root-lled teeth were evaluated. Multirooted teeth were categorized by the root with the most inadequate

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root canal lling. The teeth were grouped according to the radiographic qualities of the root canal lling and the coronal restoration. The criteria used for evaluation were slightly modied from those described by Tronstad et al,22 as follows. Endodontic treatment: Adequate: all canals obturated. No voids present. Root canal lling ending between 2 mm short of and 1 mm beyond the radiographic apex. Inadequate: root canal lling ending more than 2 mm short of the radiographic apex or grossly overlled. Root canal lling with voids or canals not lled. Root canal lling poorly condensed. Coronal restoration: Adequate: any permanent restoration that appeared intact radiographically. Inadequate: any permanent restoration with detectable radiographic signs of overhangs, open margins, or recurrent caries, or presence of temporary coronal restoration. Absent: no coronal restoration, permanent or temporary, was present. The outcome of the endodontic treatment as radiographically evaluated was categorized as follows. Success: normal width of periodontal ligament space and normal appearance of surrounding bone. Failure: periradicular radiolucency. Two observers examined all the radiographs independently. Agreement was reached in 82.4%. When disagreement occurred, a third observer was consulted. Observers were calibrated against a set of 200 reference teeth. Data referring to the inuence exerted on the periradicular status by the different conditions of endodontic treatment and coronal restorations, including their possible combinations, were statistically analyzed by using the chi-square test. Signicant level was established at 5% (P \ .05). RESULTS Of the 2,051 root-lled teeth investigated in this study, 692 (33.7%) teeth were from males and 1,359 (66.3%) from females. Maxillary premolars were the most frequently treated teeth (20.6%), followed by maxillary central incisors (16.4%), maxillary lateral incisors (13.8%), and mandibular molars (13.4%) (Table I). Mandibular incisors were the teeth with the lowest frequency of endodontic treatment. The overall success rate of root-lled teeth was 49.7%. The endodontic treatment was rated as adequate in 1,167 teeth (56.9%). In this group the success rate was

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Siqueira et al 371

Table I. Distribution of root-lled teeth according to the tooth group (N = 2,051)

Tooth Central incisor Lateral incisor Canine Premolar Molar Total Maxillary 336 283 168 423 223 1,433 (16.4%) (13.8%) (8.2%) (20.6%) (10.9%) (69.9%) Mandibular 28 27 36 252 275 618 (1.4%) (1.3%) (1.8%) (12.3%) (13.4%) (30.1%)

Table III. Periradicular status of root-lled teeth as related to the quality of the coronal restoration combined with the quality of the endodontic treatment determined by the length and homogeneity of the root canal lling (N = 2,051)
Endodontic treatment adequate adequate adequate inadequate inadequate inadequate Coronal restoration adequate inadequate absent adequate inadequate absent n 599 377 191 359 383 142 Success 426 246 91 136 96 25 % success 71% 65% 48% 38% 25% 18%

Table II. Periradicular status of root-lled teeth in the different conditions of endodontic treatment and coronal restoration (N = 2,051)
Success Endodontic treatment adequate inadequate Total Coronal restoration adequate inadequate absent Total Failure Total

763 (65.4%) 257 (29.1%) 1,020 (49.7%)

404 (34.6%) 627 (70.9%) 1,031 (50.3%)

1,167 (56.9%) 884 (43.1%) 2,051

Table IV. Periradicular status of root-lled teeth as related to the length of the root canal lling (N = 2,051)
Coronal restoration adequate inadequate absent total Success rate Overlling 16/28 8/22 0/3 24/53 (57%) (36%) (0%) (45%) 0-2 mm 406/601 251/417 87/206 744/1224 (68%) (60%) (42%) (61%) [2 mm short 140/329 83/321 29/124 252/774 (43%) (26%) (23%) (33%)

562 342 116 1,020

(58.7%) (45%) (34.8%) (49.7%)

396 418 217 1,031

(41.3%) (55%) (65.2%) (50.3%)

958 (46.7%) 760 (37.1%) 333 (16.2%) 2,051

65.4%. The group with inadequate treatment corresponded to 43.1% of the examined cases and had a success rate of 29.1% (Table II). In general, the success rate of cases with adequate root canal treatment was signicantly higher when compared to poorly treated root canals, regardless of the quality or presence of the coronal restoration (P \ .0001). In this study, 958 teeth (46.7%) were found to have adequate coronal restorations. The endodontic success rate in this group was 58.7%. The group with inadequate restorations consisted of 760 teeth (37.1%) and the endodontic success rate in this group was 45%. A coronal restoration was absent in 333 teeth (16.2%) with a success rate of 34.8% (Table II). Signicant differences were observed for all possible comparisons among the 3 groups (P \ .01). The success rate was 71% for cases with adequate endodontic treatment and adequate restorations (426 out of 599 teeth). When cases with adequate treatment and inadequate restoration were evaluated, the success rate was 65% (246 out of 377 teeth) (Table III). The difference between the 2 groups was not statistically signicant, indicating that the outcome of adequately treated root canals was not affected by the quality of the coronal restoration (P = .06). Cases with adequate treatment and absent restoration showed a success rate of 48% (91 out of 191 teeth) (Table III). This group showed a signicantly lower success rate when com-

pared to groups of adequate treatment with adequate (P \ .0001) or inadequate restorations (P \ .0001). The teeth with inadequate treatment combined with adequate restoration yielded a success rate of 38% (136 out of 359 teeth), whereas the combination of inadequate treatment and inadequate restoration resulted in a success rate of 25% (96 out of 383 teeth) (Table III). Teeth with inadequate treatment and absent restoration showed the lowest success rate of this study, ie, 18% (25 out of 142 teeth) (Table III). Statistical analysis revealed that the success rate of inadequate endodontic treatment was signicantly affected by the quality of coronal restorations, ie, cases with adequate coronal restorations showed a signicantly higher success when compared to cases with inadequate restorations (P = .0002) or without restorations (P \ .0001). There were no signicant differences when comparing teeth with inadequate restorations to teeth without restorations (P = .09). Most of the teeth examined in this study were root-lled 0-2 mm short of the apex (1224/2051; 59.7%). Overllings occurred in only 53/2051 teeth (2.6%), whereas 774/2051 (37.7%) of the teeth were lled [2 mm short of the apex. In general, the success rate of cases treated 0-2 mm short of the apex was signicantly higher when compared with overlled (P = .03) or grossly underlled cases (P \ .0001) (Table IV). There were no signicant differences between overlled and underlled cases (P = .08).

372 Siqueira et al DISCUSSION A recognized limitation of cross-sectional studies like the present one refers to the fact that data to be analyzed are restricted to available information. For instance, radiographs were examined at a given point in time, and no information was available as to the time elapsed since endodontic treatment. Therefore, it is not unfair to realize that some of the radiolucencies associated with root-lled teeth and identied as persistent periradicular lesions may have been in fact lesions in a frank healing process.24 On the other hand, misinterpretations and misdiagnoses in cross-sectional studies are known to be fairly equally distributed so that the results still remain meaningful.25 It has also been assumed that crosssectional studies are less prone to be biased by the opinion of the investigators when compared to longitudinal studies.26 Furthermore, random selection of cases and large sample size are generally easier to obtain in a cross-sectional study. Using a cross-sectional study format enabled us to analyze data from 2,051 endodontically treated teeth, which is a considerably large sample size when compared to most of the previously cross-sectional or longitudinal studies related to the outcome of the endodontic treatment. Another limitation of this and other studies with a similar methodology refers to the fact that evaluations were limited to radiographs, which are allegedly of incomplete diagnostic value. It is commonly known that periradicular lesions limited to the cancellous bone usually pass undetected by conventional radiographic techniques.27 Moreover, the microbiologic conditions of the root canal system, which is a decisive factor inuencing the treatment outcome,28 cannot be inferred on the basis of radiographic examination. In the present study, one-half of the root-lled teeth were associated with a periradicular lesion. This picture was certainly a result of the high frequency of inadequate endodontic and restorative treatments in the sample investigated. Of the 2,051 root-lled teeth examined herein, 1,167 (56.9%) teeth had adequate root canal llings, and only 599 (29%) had both adequate root canal lling and restoration. It has been commonly agreed that the quality of the endodontic treatment strongly inuences the status of the periradicular tissues.1-12 In fact, the mediocre outcome observed in the present study is in accord with several epidemiologic studies from different countries. High frequencies of periradicular lesions in root-lled teeth have been reported in Belgium (40%),7 Denmark (52%),12 Lithuania (39%),20 Canada (44% and 51%),10 Germany (61%),8 Scotland (51%),6 Spain (64.5%),11 and The United States (39%).19 These daunting rates point to a need for betterment of the quality of endodontic treatment in general dental practice.

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Indeed, it has become overwhelmingly evident that the success rates of endodontic treatment carried out in controlled environments are signicantly higher than those observed in epidemiologic studies.1-12 Studies from controlled environments are usually carried out by specialists or supervised operators and reveal the potential outcome of root canal treatment rather than its realistic outcome in the general population.29 Our results showed that if the root canal lling was inadequate, it did not matter whether the coronal restoration was adequate, inadequate, or absent, the tooth would still have a poorer prognosis when compared to adequately lled tooth. For instance, teeth with adequate root llings and absent restorations (worst condition for adequately treated teeth) showed a success rate 10% higher than teeth with inadequate root llings and adequate coronal restorations (best condition for inadequately treated teeth). This clearly shows that the quality of the endodontic treatment is the most important factor with regard to the periradicular tissue health. In cases of inadequate root canal treatment, there is a higher probability that the endodontic infectionthe primary cause of periradicular diseasespersisted despite treatment. The results from the present study conrmed the ndings from other studies in that the apical level of the root canal lling is associated with the periradicular status.3,7,21 If the root lling length extended to 0-2 mm short of apex, 61% of the teeth showed no periradicular lesion, whereas for overllings and gross underllings the success rate of the treatment was 45% and 33%, respectively. The success rate of cases treated 0-2 mm short of the apex was signicantly higher when compared to overlled or underlled cases. There were no differences between the latter conditions. A poor outcome in cases of overllings is usually associated with concurrent endodontic infection.28 Failure in overlled teeth can be a result of previous overinstrumentation of an infected root canal that propelled infected dentin chips to the periradicular tissues or it can be due to a lack of apical seal that allows the trafc of tissue uids into the canal and of microorganisms and their products towards the periradicular tissues.28 In grossly underlled cases, a long segment of the root canal is highly likely to have not been cleaned and is certainly not sealed, leaving enough space for proliferation of residual microorganisms, which can have frank access to the periradicular tissues.30 Thirty-ve percent of the teeth having technically adequate endodontic llings still had periradicular lesions. Twenty-nine percent of the cases with adequate root canal lling and adequate coronal restoration showed periradicular radiolucencies. Even though some of these lesions might be actually healing at the time

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Siqueira et al 373

of evaluation, many cases were arguably failures and indicate that the quality of the root canal lling is not the only parameter to inuence the periradicular status. The fact that the root canal lling is radiographically classied as adequate does not necessarily imply that a 3-dimensional seal was achieved or that the intracanal procedures succeeded in eliminating or preventing the endodontic infection. Microorganisms in a persistent intraradicular infection or (less commonly) in an extraradicular infection are the major causative agents of endodontic failures even in well treated teeth.31-33 Again, an adequate root canal lling as judged by radiographs is not synonymous with a properly disinfected root canal system.28 Conicting results have been reported by different studies that investigated the impact of the endodontic treatment and the coronal restoration on the periradicular status. Ray and Trope19 suggested that the quality of the restoration had a greater impact than the quality of the root canal lling on periradicular health. Tronstad et al22 suggested that a correlation exists between the quality of the restoration and periradicular health, but concluded that the quality of the restoration was signicantly less important than the quality of the root canal lling. Other studies12,20 suggested that periradicular health of root-lled teeth depends equally on the quality of the root canal lling and the coronal restoration. The results of the present study revealed that when the root canal lling appeared to be adequate, the quality of the restoration did not signicantly affect the treatment outcome. However, when a coronal restoration was absent, the success rate of adequately treated canals was signicantly reduced. This may be explained by the missing restoration establishing a frank exposure of the root canal lling to microorganisms from saliva and a consequent pathway for microbial ingress into the root canal system. Laboratory studies have suggested that a frank exposure of the root canal lling to microorganisms and their products may allow reinfection of the root canal system in a relatively short time.14,15,17,18 The quality of the coronal restoration signicantly affected the outcome of inadequately treated teeth. Teeth with adequate restorations had a signicantly higher success rate when compared to teeth with inadequate or absent restorations. In these cases, it did not matter as to whether the restoration was inadequate or absent. The possibility exists that many of these teeth had a noninfected vital pulp before treatment and an adequate coronal restoration could have helped to prevent further microbial ingress in the root canals. Even considering this, the best outcome for inadequately treated teeth (combination with good restorations) was extremely low38% of the casesand

persistence of microorganisms within the root canal system after a poor treatment is unarguably the major cause of such a woeful outcome. Therefore, our ndings suggested that the quality of the root canal lling had a more decisive impact on the outcome of treatment than the coronal restoration, which generally concurs with the results reported by some recent studies.10,12,20,22 In the present study, the quality of the root canal lling and the quality of the coronal restoration were evaluated in relation to the periradicular status. The higher success rate was observed for teeth with both root canal lling and coronal restoration categorized as of high quality. This is in agreement with virtually all epidemiologic studies on the same subject and supports the apparently obvious assertion that the periradicular health is dependent on both endodontic and restorative treatments of high quality.
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25. Altman DG. Practical statistics for medical research. London: Chapman & Hall; 1991. p. 99-101. 26. Torabinejad M, Kettering JD, McGraw JC, Cummings RR, Dwyer TG, Tobias TS. Factors associated with endodontic interappointment emergencies of teeth with necrotic pulps. J Endod 1988;14:261-6. 27. Bender IB. Factors inuencing the radiographic appearance of bony lesions. J Endod 1982;8:161-70. 28. Siqueira JF Jr. Aetiology of the endodontic failure: why welltreated teeth can fail. Int Endod J 2001;34:1-10. 29. Eriksen HM, Kirkevang L-L, Petersson K. Endodontic epidemiology and treatment outcome: general considerations. Endod Top 2002;2:1-9. 30. Siqueira JF Jr. Ursachen endodontischer misserfolge. Endodontie 2001;10:243-57. c 31. Siqueira JF Jr, Ro as IN. Polymerase chain reactionebased analysis of microorganisms associated with failed endodontic treatment. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2004;97:85-94. c c 32. Ro as IN, Jung I-Y, Lee C-Y, Siqueira JF Jr, Ro as IN, Jung I-Y, et al. Polymerase chain reaction identication of microorganisms in previously root-lled teeth in a South Korean population. J Endod 2004;30:504-8. 33. Siqueira JF Jr. Periapical actinomycosis and infection with Propionibacterium propionicum. Endod Top 2003;6:78-95. Reprint requests: F. Siqueira, Jr Jose R. Herotides de Oliveira 61/601 , Nitero i, RJ Icara Brazil 24230-230 siqueira@estacio.br