Clinical Research

The Influence of Different Factors on the Survival of Root Canal Fillings: A 10-Year Retrospective Study
Richard Stoll, PD, Dr.med.dent.habil.,* Kirsten Betke, Dr.med.dent., and Vitus Stachniss, Prof.Dr.med.dent.*
Abstract
The aim of the present study was to determine the survival time of root canal fillings performed in 1990 and 1991 at the Dental School, Philipps University of Marburg, Germany. Data were collected retrospectively from the dental records and control radiographs were evaluated. The survival probability was determined by Kaplan-Meier analysis. Intergroup differences were verified with the log-rank test. The 914 evaluated root canal fillings yielded an overall 10-yr cumulative survival probability of 0.74. The factors baseline periapical condition (p 0.001), length (p 0.001), condensation (p 0.001), vitality (p 0.001), and pain symptoms (p 0.005) were found to have a significant influence on the long-term success of root canal fillings. Higher survival rates were recorded for teeth with healthy periapical conditions, root canal fillings of the correct length, homogeneously condensed root canal fillings, root canal fillings in previously vital teeth, and teeth that had been asymptomatic during treatment. A nonsignificant influence was recorded for the parameters operator (p 0.606) and retreatment (p 0.196).

n recent years, opportunities for endodontic therapy have undergone a marked further development coinciding with an increase in the demand for endodontic treatment (1) and for endodontic restoration. This is due in part to a rise in the proportion of elderly persons with a relatively complete dentition and to increased dental awareness (1). Patients expectations concerning the success of endodontic restorations are accordingly high (2). Varied long-term success rates of root canal fillings have been reported by different authors; figures range from 70% (3) to more than 90% (4, 5). A survey of the relevant literature was provided by Friedman and co-workers (6), and an introduction to meta-analysis by Lewsey et al. (7). In most published studies, the analyzed collective consisted of patients who had been treated either by specially trained endodontists or by supervised dental students (4 6, 8). Most authors reported that the long-term success rate was notably higher in teeth displaying no apical radiolucency at the start of treatment (4, 6, 9 12). Moreover, the prospects of success were given a lower rating for retreatments than for initial treatments (10). The aim of the present study was to evaluate all root canal fillings performed in 1990 and 1991 at the Department of Operative Dentistry, Dental School, Philipps University of Marburg, Germany, and to calculate their survival functions in dependence on various baseline parameters, filling quality parameters and operator-related parameters.

Key Words
Root canal treatment, survival analysis

Materials and Methods

All root canal fillings performed in 1990 and 1991 at the Department of Operative Dentistry, Dental School, Philipps University of Marburg, Germany, were followed up with reference to the dental records. The patients name and date of birth were taken from the radiographic records of the respective year with reference to the control radiograph made on completion of any endodontic treatment. The unit tooth was specified as the smallest study unit. In cases where more than one tooth had undergone endodontic treatment, each tooth was evaluated individually. Only permanent teeth were investigated. Following endometric and radiographic length determination, the root canals had been prepared with standardized hand instruments (reamer, K-files and hedstroem files) and a step-back technique. All root canals had been filled with gutta-percha points and sealer (Seal-Apex, Kerr, Karlsruhe, Germany), using the lateral condensation technique. A control radiograph had been made in each case on completion of the root canal filling. The date of birth, gender and data on the affected tooth/teeth of all patients were obtained from the records. Data recorded in addition to the date of access were whether the tooth reacted positively to cold on that date, whether it was painful, and whether the root canal filling was being retreated. The date of the root canal filling was also taken from the records together with data on whether the treatment had been performed by a dental student or a qualified dentist. The criteria condensation grade, length, and periapical status according to the PRI (Table 3) (13) were assessed by one calibrated investigator with reference to the postfilling control radiograph (Tables 3, 5, and 6). In the case of multi-rooted teeth, the worst value of condensation grade, the worst PRI value and the worst value of length

From the *Department of Operative Dentistry and Endodontics, Dental School, Philipps-University of Marburg, Marburg, Germany; Private practice. Address requests for reprint to Dr. Richard Stoll, PhilippsUniversity of Marburg, Dental School, Department of Operative Dentistry and Endodontics, Georg Voigt Str. 3, D-35033 Marburg, Germany. E-mail address: stoll@mailer.uni-marburg.de. Copyright 2005 by the American Association of Endodontists

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TABLE 1. Definition of Success
Census (functional) Loss The tooth including the original root canal filling dating from 1990 or 1991 is in situ The root canal filling has been completely or partially retreated, the tooth has been extracted, hemisected or resected at one or more root tips

TABLE 2. Classification of Individual Groups of Teeth Into Nonvital and Vital Tooth Group
Upper incisors Upper premolars Upper molars Lower incisors Lower premolars Lower molars Total

TABLE 3. Distribution of Apical Findings in Nonvital and Vital Teeth PRI

1 2 3 4 5 Total

Vital
86 71 76 60 68 58 419

Nonvital
91 95 93 35 65 116 495

Designation
Definitely no osseous involvement Probably no osseous involvement non-assessable Probably osseous involvement Definitely osseous involvement

Vital
132 163 104 16 4 419

Nonvital
20 34 73 176 191 495

PRI (Probability Index) according to Reit and Grndahl (13).

(overfilled was considered poorer than short) was registered. All radiographs were assessed individually in a radiograph viewer. The follow-up data were obtained from the patients records at the Department of Operative Dentistry and the Department of Maxillofacial Surgery, allowing both new endodontic and surgical interventions on the root-filled teeth to be registered. The criteria for functional root canal filling and loss were stipulated before baseline (Table 1). In the event of a functional root canal filling, the most recent date on which the root filling had been recorded as in situ was noted. In the event of loss, the date on which the root canal filling had been lost through retreatment, root resection or extraction was recorded. If a root canal filling had been retreated and replaced within the study period, the retreatment was included as a separate case. The interval between access and definitive root canal filling was calculated in days, and the total observation period in months. The calculations were based on the date of the definitive root canal filling and the date of the loss or last documented success. All data were first noted on a record sheet and entered into the SPSS 10.0 statistics program for evaluation by the Kaplan-Meier method (13). This method calculates the cumulative survival probability (csp) as a function of time. Csp-values and standard error were reported for the time of the last loss. The log-rank test at a significance level of p 0.05 was used for intergroup comparisons.

Results
Followed up were 965 teeth that had undergone endodontic treatment in 1990 and 1991 at the Department of Operative Dentistry, Philipps University of Marburg, Germany. Of these, 441 root canal fillings (45.7%) dated from 1990, and 524 (54.3%) from 1991. There were 51 root canal fillings (5.3%) that had been placed presurgically for planned root resections not included in the study, so that 914 root canal fillings were available for further evaluation. The gender distribution was well balanced with 474 female (49.2%) and 490 male patients (50.8%). At the time of the root canal filling, the patients ranged in age from 10 to 82 yr. Table 2 shows the distribution of the teeth according to their location. Table 3 shows the distribution of the apical findings in dependence on vitality. A classification based on the parameter interval between access and root canal filling relative to pulpal status is presented in Table 4. The lengths and condensation grades achieved in the root canal filling are shown in Tables 5 and 6. The mean observation period was 33.7 months (range: 0 to 124 months). A histogram of the observation period is presented in Fig. 1. The Kaplan-Meier survival analysis revealed 105 losses. The mean survival time calculated was 104 months (95% confidence interval: 101 784

108 months). At the time of the last loss after 106 months, the cumulative survival probability was csp 0.74 (standard error: 0.03; Table 7). The 914 cases were divided into subgroups according to the parameters vitality, type of treatment, operator, symptoms, radiographic findings, length, and condensation grade. Each of these subgroups was then tested for verification of the survival function with the log-rank test. Before trepanation, 419 teeth had been classified as vital and 495 as nonvital. At the time of the last loss after 95 months, this yielded a cumulative survival probability of csp 0.81 for the group of teeth originally classified as vital. At the time of the last loss after 106 months, the teeth originally classified as nonvital had a cumulative survival probability of csp 0.68. The intergroup comparison revealed a significant difference (p 0.0001) in the survival function (Table 7 and Fig. 2). There had been 508 teeth classified as pain-free before treatment, and 406 as painful. The pain-free teeth yielded a cumulative survival probability of csp 0.79 after 99 months, and the painful teeth a cumulative survival probability of csp 0.67 after 106 months. The log-rank test revealed a significant intergroup difference (p 0.0047) in the survival functions (Table 7 and Fig. 3). PRI classes 1 and 2 (definitely or probably no apical lesion) and 4 and 5 (definitely or probably apical periodontitis) were combined (Table 7 and Fig. 4). Whereas the cumulative survival probability calculated after 95 months for the group with PRI classes 1 and 2 was csp 0.88, that calculated after 106 months for the group with PRI classes 4 and 5 was csp 0.64. Here too, the log-rank test revealed a significant difference (p 0.0001). Another factor influencing the survival rate of the root canal filling is its quality. To assess the influence of length, length classes 2 (root canal filling extending to within 12 mm of the apex) and 3 (root canal filling extending to within 0 1 mm of the apex) were combined (n 595, cumulative 106-month survival probability csp 0.85) and compared with classes 4 (too long, n 104, cumulative 99-month survival probability csp 0.49) and 1 (too short, n 116, cumulative 96month survival probability csp 0.41) (Table 7 and Fig. 5). This revealed significant differences in the log-rank test between the combined group and the two remaining classes (p 0.0001, respectively). The comparison of the homogeneous (n 690, cumulative 96month survival probability csp 0.84) with the inhomogeneous root fillings (n 222, cumulative 106-month survival probability csp 0.45) also revealed a statistically significant difference (p 0.0001). The kind of treatment, divided into initial treatment (n 793, cumulative 106-month survival probability csp 0.74) and retreatJOE Volume 31, Number 11, November 2005

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TABLE 4. Time Between Access and Root Canal Filling, Depending on Vitality Weeks
Vital Nonvital

0
86 55

02
122 123

24
75 87

46
35 58

68
15 34

812
29 47

1216
18 25

1620
13 29

2024
11 13

2428
3 7

2853
11 18

TABLE 5. Radiographically Detectable Condensation Grade of Root Canal Fillings Condensation Grade
1 2 3 Total

Discussion
There were 914 teeth that had undergone root canal treatment and were followed up in the present study. The number of teeth investigated in comparable studies ranges between 22 and 2298 (7), one study had access to 110,766 cases using a data-warehousing approach at an insurance company database (15). By contrast, some authors specified the number of roots; this ranged between 501 (8) and 1277 (16). In the present study, the tooth was selected as the smallest study unit. A subdivision based on roots (4, 5, 9, 16) is unfavorable in that a failure cannot always be allocated to one specific root. A failure at only one root moreover leads to loss of the entire tooth in the worst-case scenario. The high proportion of multi-rooted teeth with successful root canal fillings in the above-stated studies may have had a very positive impact on the results. A direct comparison of studies based on the tooth as the smallest unit with those based on the root as the smallest unit is thus open to criticism. Becaues of the retrospective design of the present study, the follow-up period ranged from 0 months to 10 yr. The time span of comparable studies is between 1 yr (17) and 10 yr (18). Apart from the exclusion of deciduous teeth and fillings in preparation for a surgical intervention, which was defined in the present study as a failure of the root canal filling, no exclusion criteria were formulated. The material accordingly included complex cases, e.g. teeth were severe root canal curvature, third molars, or retreatments, and thus a relatively high proportion of cases that would have fallen short of the exclusion criteria set in other studies (3, 10, 19). Nor did a sporadically reduced quality of the radiographs lead to exclusion from the study, as had been the case with Grahnen and Hansson, for example (16). The criterion of success adopted for the present study was the continued presence of the tooth with the original root canal filling dating from 1990 or 1991. By contrast, any intervention at the root canal filling (full or partial retreatment) or at the tooth (extraction, root amputation, or root resection) was regarded as a failure. Because of differences in the definition of success and failure as reported in the literature, results are not readily comparable and have to be discussed in the setting of the study design. The method used in the present study is comparable to a data warehousing approach used by studies that access large insurance company databases (15). As classification into success or failure in the present retrospective study was based solely on the patients records, clinical parameters such as lack of pain or a radiographic evaluation of the periapical status could not be applied. These clinical parameters were previously regarded as reliable criteria for determining success (20). However, the extent to which these criteria lead to different results from the more global parameters used in the present study is a matter of speculation (18). The difference between a strict criterion (complete healing of the periapex) and a more liberal one (incomplete healing is also counted as a success) for the probability of success is 0.08 (p-value) according to a meta-analysis by Lewsey et al. (7). At least when clinical symptoms occur, therapy leading to a failure rating can be expected to be initiated. If the observation period is sufficiently long, the results of the study should not be affected in such cases. No assessment was undertaken of the periapical region in comparison with the findings immediately after root canal filling, as in some 785

Designation
Homogeneous Without radiologically detectable faults Nonassessable Inhomogeneous Radiologically detectable faults

Number Percentage
690 123 101 914 75.5 13.4 11.1 100

TABLE 6. Radiographic Length Control of Root Canal Fillings Length

1 2 3 4 5 Total

Designation
2 mm short of apex 12 mm short of apex 01 mm short of apex overfilled Nonassessable

Number
116 279 316 104 99 914

Percentage
12.7 30.5 34.6 11.4 10.8 100

Figure 1. Distribution of observation times (root filling up to last census or loss).

ment (n 121, cumulative 96-month survival probability csp 0.72) showed no significant difference (p 0.196) in the log-rank test (Table 7 and Fig. 7). Whether the treatment was carried out by dental students (n 693, cumulative 106-month survival probability csp 0.72) or by qualified dentists (n 221, cumulative 96-month survival probability csp 0.78) had no influence (p 0.606) on the survival function (Table 7 and Fig. 8).

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TABLE 7. Results of Kaplan-Meier Survival Analysis in the Total Group and the Individual Subgroups Together with the Result of the Log-Rank Test for the Same Survival Functions Group
All Initial filling Retreatment Vital Nonvital Students Dentists Pain-free Painful Condensation good Condensation poor Length short Length correct Length above apex PRI 12 PRI 45

Mean Survival Time with Confidence Interval (mo)

104 (101108) 105 (101109) 94 (85104) 111 (107115) 94 (8999) 101 (97105) 105 (99112) 108 (104113) 98 (92104) 110 (107114) 84 (7593) 77 (6490) 113 (110116) 76 (6487) 116 (113120) 93 (8699)

Cases Losses Successes

914 793 121 419 495 693 221 508 406 690 222 116 595 104 349 387 105 87 18 31 74 78 27 47 58 52 51 30 35 27 15 69 809 706 103 388 421 615 194 461 348 638 171 86 560 77 334 318

Survival Rate (last loss)

0.74 0.74 0.72 0.81 0.68 0.72 0.78 0.79 0.67 0.84 0.45 0.41 0.85 0.49 0.88 0.64

Standard Error
0.03 0.03 0.07 0.04 0.04 0.04 0.04 0.03 0.05 0.03 0.08 0.10 0.03 0.10 0.03 0.04

Last Loss (in mo)

106 106 96 95 106 106 96 99 106 96 106 96 106 99 95 106

Log-Rank p
0.196 0.0001 0.606 0.0047 0.0000 0.0000 0.0000 0.0000

Figure 2. Cumulative survival functions in dependence on the factor vitality (vital n 419, nonvital n 495); the vertical lines represent censor points.

Figure 3. Cumulative survival functions in dependence on the factor pain symptoms (no pain n 508, pain n 406); the vertical lines represent censor points.

other studies (6, 8, 10, 21). This meant that any negative changes in the periapical region were not recorded unless they were clinically evident. In addition, no distinction was made in the event of an extraction as to whether it had been performed for endodontic reasons or for other reasons such as periodontal problems or trauma. The fact that any extracted tooth was evaluated as a failure, irrespective of the reason for extraction, may have had a negative impact on the result of the study. In contrast to studies with follow-ups at specific timepoints (3, 4, 8), no fixed follow-up timepoints were required in the present study (10). The evaluation of success or failure was undertaken at each control appointment kept by the patients after the definitive root canal filling. The total observation period for the individual root canal fillings was calculated retrospectively from the interval between the date of the root canal filling and the last follow-up appointment at which success was recorded. In the event of a failure, the date on which the root canal filling was lost was regarded as the endpoint of the observation. The demand for the longest possible observation periods (22) was met with a maximum possible observation period of 10 yr. While the mean observation period of 33.7 months seems short compared with the 10-yr 786

total observation period, it conforms with the results of similarly designed studies (23). In the present study, the recall rate recorded in the first year after definitive root canal filling was relatively high. However, this rate was not maintained. A study by Selden (24) showed that the number of dropouts increases with the increasing length of a study. A recall rate of approx. 50% after 6 months but of only 11% after 18 months was reported. The problem of patient compliance in clinical studies has long been known. The reasons for the increasing dropout rate in follow-up studies are certainly varied (4, 25). Survival studies have the advantage of utilizing all collected information until the endpoint of the study (26). As no fixed examination intervals were specified in the present study, the procedure proposed by Kaplan and Meier (14) was the statistical method of choice (23). The gain in the utilization of censored survival data depends on the number of probands, the relative completeness of the further examinations, and the relative size of the initial loss rate (26). It has to be borne in mind that the initial loss rate in dental studies tends to be small (23). Espe-

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Figure 4. Cumulative survival functions in dependence on the factor baseline situation of the periapex (PRI 1&2 group without chronic apical periodontitis (n 349), PRI 4&5 group with chronic apical periodontitis (n 387)); the vertical lines represent censor points.

Figure 6. Cumulative survival functions in dependence on the factor condensation (homogeneous n 690, inhomogeneous n 224); the vertical lines represent censor points.

Figure 5. Cumulative survival functions in dependence on the factor length (0 2 mm to apex n 595, too short n 116, overfilled n 104; nonassessable root canal fillings are not shown); the vertical lines represent censor points.

Figure 7. Cumulative survival functions in dependence on the factor retreatment (initial treatment n 793, retreatment n 121); the vertical lines represent censor points.

cially when censored data are used, the predictive validity of survival studies carried out over a short period is low; such studies are thus better suited to long follow-up periods (23). A large quantity of early censored data results in long-term survival figures having a high standard error and in survival probabilities being underestimated (27). The log-rank test is suitable for comparing different groups with predicted differences in loss rate. Unlike the Breslow test, for example, all losses are taken equally into account, irrespective of the timepoint. Especially in conjunction with a large quantity of censored data, the log-rank test has a higher predictive potential than the Breslow test (28). For this study, we manually modeled the test groups for each covariate. We considered this approach as advantageous compared to a general multivariate model like Cox regression.

A meta-analysis of published studies (7) calculated from the resulting pooled data a success probability of csp 0.84 (with a 95% confidence interval of 0.80 0.87). The 124-month cumulative survival probability for all cases investigated in that analysis was csp 0.74. Similar results were reported by Lo st et al. (10), Fritz and Kerschbaum (29), and Rocke et al. (18), who also calculated survival probabilities. Table 8 shows a comparison of the results of some selected studies. A number of studies (4, 22, 30) reported considerably higher success rates in part. However, the distinction was confined to success or failure, without the partially substantial fluctuations in the length of the follow-up period being taken into account. Some studies classify reasons of failure into categories. It was shown that the most common reason for failure was caries because of poor oral hygiene and loss of the restoration sealing the root canal (31). Teeth without subsequent restorations had a four times higher inci787

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main prognostic factor in initial endodontic treatment (11). In contrast to the general opinion, Peak (22) stated that root canal fillings in teeth with periapical radiographic findings had a higher survival time than those in teeth without such findings. Root canal fillings ending within 0 to 2 mm of the radiographic apex are classified as correct with respect to their length (1). For this reason the cases covered in the present study were divided for statistical analysis into three groups. This revealed that teeth whose root canal filling was of the correct length had a significantly (p 0.001) better survival function than those where the root canal filling was too short or too long. The results recorded in the present study are in agreement with those of other studies also reporting notably better results for root canal fillings of the correct length (3, 12, 19, 30, 34, 35). The hypothesis of Lin et al. (33), according to which the length of the root canal filling has no influence on its success, could not be confirmed with the findings of the present study. In the present study the proportion of homogeneous root canal fillings was notably higher than that of inhomogeneous fillings. The survival probability of teeth with homogeneous root canal fillings was significantly (p 0.0001) higher than that of teeth with inhomogeneously condensed fillings. As with length, the homogeneity of all root canal fillings was assessed only from radiographs, as this is currently the only feasible method in vivo. As this method is based on the two-dimensional representation of a three-dimensional structure, it has to be accepted that the homogeneity cannot be fully assessed with the given means in all planes. However, in the radiological assessment of homogeneity a false-positive rating is very much more likely than a falsenegative one. Similar conclusions were drawn in comparable studies (4, 9). The discrepancy is most marked in the study by Kerekes and Tronstad (9), who reported 93% success for homogeneous and 28% success for inhomogeneous root canal fillings. Only Friedman et al. (6) failed to find a significant difference in the success rate of homogeneous and inhomogeneous root canal fillings. At 13.2%, the proportion of retreatment in the present study was relatively low. In comparison, the proportions reported by Sjo gren et al. and Lo st et al. in their collectives were more than twice as high (4, 10). A comparison of the survival functions of retreatments and initial treatments in the present study yielded no significant difference (p 0.196). Contrary to these results, notably poorer results for retreatments are reported in the literature (4, 6, 10, 36). The outcome of nonsurgical retreatment depends highly significant on the alteration of root canal morphology and the presence of apical lesions. Teeth without alteration of root canal morphology and without apical lesion showed a success rate of 91.6% after a 2 yr period. Teeth with alterated morphology and with apical lesions had a success rate of 40% following retreatment (36). Other important factors are preoperative apical periodontitis (absent 97% healing, present 78%), perforation (absent 89%, present 42%), filling length and lack of definitive restoration (37). One possible explanation of the results in the present study might be that the patients investigated had all been treated at a teaching hospital, where difficult cases are generally delegated to experienced dentists in view of the training situation. A comparison of the relative percentage of retreatments in the individual groups, i.e. 12% for dental students and 17.2% for qualified dentists, reveals that this difference is verifiable but not pronounced. Another explanation might be an increased willingness under teaching hospital conditions to take special care and to invest more time in performing even protracted, less economical procedures. Approximately 75% of the investigated root canal fillings had been performed by undergraduates. However, no further subdivision was made into different terms or examination levels. Nor were treatments

Figure 8. Cumulative survival functions in dependence on the factor operator (dentists n 221, students n 693); the vertical lines represent censor points.

dence of extraction than teeth with single unit restorations (15). There were 59.4% of extractions following nonsurgical root canal treatment caused by prosthetic failure, 32% were caused by periodontal failure, and only 8.6% were caused by endodontic failure (32). In the present study, significant differences were registered in the survival probability of teeth classified as vital (csp 0.81) or nonvital (csp 0.68) at the time of access. Teeth classified preoperatively as vital thus had a higher survival probability. The cryogenic method of sensitivity testing was used in contrast to other studies where an electric pulp tester was preferred (31). Although this method is in widespread use, it has to be pointed out that it is only the sensitivity but not the vitality of the respective tooth that is tested, i.e. it is primarily the conduction response to a given stimulus. The vitality of the tooth is dependent upon an efficient flow of blood to the vessels. As it is fundamentally possible for a tooth to be vital despite a lack of sensitivity, some of the teeth classified as nonvital must be assumed to have been merely nonsensitive. Similar conclusions are drawn in various other studies (3, 4, 6, 11, 25, 30), although the distinction between vital and nonvital teeth is not equally clear in all cases. Some authors reported no differences between the success probabilities of vital and nonvital teeth (9, 13, 25). In the present study, teeth that were asymptomatic at the time of access were found to have longer survival times than those that were painful (p 0.005), i.e. the factor pain symptoms must be assumed to have an impact on the success of root canal treatment. Contrary to the frequent claim that pain has no impact on the success of root canal treatments (4, 9, 17), there is agreement in this point with findings of Friedman et al. (6), who also reported a highly significant difference between asymptomatic and painful teeth. In the group with periapical findings (PRI 4&5), the loss rate was more than four times higher than in the group without such findings (PRI 1&2). At the time of the last loss, the survival probability of the group without periapical findings was csp 0.88, while that of the group with periapical findings was only csp 0,64; this difference was statistically significant (p 0.0001). Most authors consider that the presence of a periapical lesion has a negative impact on the prospective success of root canal fillings (4, 9 12, 17, 33, 34). Friedman et al. stated that apical periodontitis is the 788

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TABLE 8. Study Design and Results of Comparable Studies Author(s) (year)
Grahnen & Hansson (1961) Heling & Tamshe (1970) Kerekes & Tronstad (1979) Swartz et al. (1983) Pekruhn (1986) Sjgren et al. (1990) Smith et al. (1993) Peak (1994) Friedman et al. (1995) Lst et al. (1995) Rocke et al. (1997) Fritz & Kerschbaum (1999) Lewsey et al. (2001) Lazarski et al. (2001) Benenati et al. (2002) Dammaschke et al. (2003) Friedman et al. (2003) Present study

n
1277 213 501 1770 925 849 821 136 378 161 485 504 343 38 110766 894 190 450 914

Unit
Root Tooth Root Root Tooth Root Tooth Tooth Tooth Tooth Tooth Tooth Studies Tooth Tooth Tooth Tooth Tooth

Duration (yr)
45 15 35 1 1 810 min. 5 0.56 0.51.5 0.53.5 10 9 10 0.57 10 46 10

Design
F F F F F F F F F S S S M S F S F S

X-ray
x x x x x x x x x x x x

Result
82.8% 70% 91% 89.7% 94.8% 91% 84.3% 84.6% 78.3% csp 0.61 csp 0.81 76.5% 78.5% csp 0.84 94.44% 91.05% 85.1% 81% csp 0.74

The column headed X-ray shows whether the follow-ups were based on radiographs. Studies are classified as a classical follow-up study (F), a survival study (S), or a meta-analysis (M). The column headed Result shows the recorded survival rate or the cumulative survival probability (csp).

carried out by qualified dentists differentiated according to the length of their vocational experience or to their specialty. There was no significant intergroup difference in survival function (p 0.61). The concern that fillings performed by students might have poorer survival rates than those performed by qualified dentists was not confirmed in the present study. Kerekes and Tronstad (9) and Sjo gren et al. (4) reported a success rate of more than 90% in student work, while Hellwig et al. reported a failure rate of 5% after 3 yr (8). The suspicion arises that this favorable result may be a result of the distribution of problem cases, which tend to be delegated to qualified dentists after the initial clinical examinations. A slightly uneven distribution was registered in the present study for retreatments. However, this did not apply to the treatment of molars. A comparison of the relative percentages of molars treated in the individual groups shows that the proportion treated by students (39%) was, in fact, slightly higher than that treated by qualified dentists (35%). A significantly higher patient satisfaction and quality of life outcome assessed in patients treated by endodontists may be explained by the increased skill and proficiency of specialists (38). In the present study, the long-term results of root canal fillings performed with the lateral condensation technique were investigated. The results were found to be in good conformity with those published in the literature. It could also be shown that good successes can be achieved with retreated root canal fillings. It thus seems perfectly justified to give tooth retention through sometimes resource-intensive retreatment preference over extraction with its consequences of implantation or prosthetic cover. The results of treatment under quality-controlled training conditions are no poorer than those of treatment by experienced dentists. Both the baseline state of pulpal tissue and periapex and the quality of the root canal filling itself could be shown to have a crucial influence on the long-term prognosis of the filling. It is thus possible for the operator to evaluate the prospects of success in the treatment of individual teeth by analyzing the baseline situation and adapting the therapy accordingly. At the same time, the patients expectations can be directed from the very outset into realistic channels to avert potential disappointments or misunderstandings. Irrespective of the initial situation, the dentist has a crucial influence on the treatment outcome with the quality of his work. The operator has to be constantly aware of his responsibility and to be correspondingly critical of his own work. Meticulous length

determination and an adequate condensation technique are the crucial factors shown in this study within the limitation of the study design.

References
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