Is endodontic re-treatment mandatory for

every relatively old temporary restoration?: A

narrative review
David Keinan, Joshua Moshonov and Ami Smidt
J Am Dent Assoc 2011;142;391-396

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 CLINICAL PRACTICE

Is endodontic re-treatment
mandatory for every relatively
old temporary restoration?
A narrative review

Downloaded from jada.ada.org on April 1, 2011

David Keinan, DMD, MSc, PhD, MHA; Joshua Moshonov, DMD; Ami Smidt, DMD, MSc

ndodontists long have con-

E sidered the success of

endodontic treatment to be
influenced by the quality of
the coronal restoration. Researchers
have recommended sealing of
AB STRACT
Objectives and Background. In this review, the authors
examine whether there is any decisive evidence to support the revi-
sion of root fillings that have been exposed to the oral environment
for more than three months, undertaken solely because of suspicions
coronal restorations to prevent
of microleakage. Researchers in numerous endodontic studies have
microorganisms in the oral environ-
addressed the evaluation of coronal microleakage by using different
ment from recolonizing the canal
tracers and techniques. The need to achieve a tight, permanent
system and to bar nutrients in the
coronal seal as soon as possible after the completion of endodontic
oral environment from supporting
treatment is obvious. However, the clinical importance of
microorganisms left in the canal
microleakage studies recently has been questioned because of their
system after treatment.1 A possible wide range and even contradictory results, and findings from only a
association between coronal leakage few clinical investigations have demonstrated a clear relationship
and endodontic failure was first between the endodontic success rate and failure rate owed to coronal
reported by Marshall and Massler2 microleakage in cases involving high-quality endodontic therapy.
in their radioisotope leakage study Methods. The authors analyzed commonly cited articles
of extracted endodontically treated regarding the clinical relevance of microleakage studies and the suc-
teeth. The interest in microleakage cess rate of teeth with compromised restorations.
subsequently developed into a major Conclusions. In a review of the literature, the authors found no
thrust of endodontic research, and clear evidence to support immediate replacement of well-obturated
by the 1980s, almost 20 percent of endodontic treatment that has lasted more than three months solely
the articles published in Journal of because of suspicions of microleakage. It may be prudent in such
Endodontics dealt with this issue. cases to make a new coronal restoration immediately and to observe
However, the majority of these the tooth for at least three months before placing the permanent
studies were conducted as short crown.
research projects by graduate stu- Key Words. Microleakage; coronal restoration; endodontic
dents who used a diverse array of success.
methods, thereby making compari- JADA 2011;142(4):391-396.
sons difficult. Indeed, the studies
Dr. Keinan is an instructor, Department of Endodontics, School of Dental Medicine, The Hebrew University-Hadassah, Jerusalem. He also is head,
Department of Endodontics, Medical Corps, Dental Center, Sheba Medical Center, Tel-Hashomer, Israel. Address reprints to Dr Keinan at the Department of
Endodontics, School of Dental Medicine, The Hebrew University-Hadassah, Jerusalem, Israel 91120, e-mail “iendo4u@gmail.com”.
Dr. Moshonov is the acting chairman, Department of Endodontics, School of Dental Medicine, The Hebrew University-Hadassah, Jerusalem.
Dr. Smidt is the head, The Center for Graduate Studies in Prosthodontics, Department of Prosthodontics, School of Dental Medicine, The Hebrew University-
Hadassah, Jerusalem.

JADA 142(4) http://jada.ada.org April 2011 391

Copyright © 2011 American Dental Association. All rights reserved.
CLINICAL PRACTICE
never were validated as clinically relevant,3
leading to increasing doubts about their impor-
tance and clinical applicability.4-7
Important questions raised by the editorial
board of Journal of Endodontics8 in a 2008 edito-
rial include the following:
dAre laboratory-based leakage studies of any
clinical relevance?
dCan the quality of endodontic fillings and
sealing of coronal restorations be assessed on
the basis of radiographs?
To these, Wu and colleagues9 added another
question: are radiographic films capable of
revealing the presence of periapical pathosis?
To answer these questions, we conducted
a review with the aim of determining whether
there is a definite need for endodontic re-
treatment in cases of well-conducted treatment
of root canals involving a temporary restoration
of more than three months’ duration, solely on
the basis of suspected microleakage.
IN VITRO MICROLEAKAGE STUDIES:
TECHNIQUES AND LIMITATIONS
To understand the difficulties encountered in
extrapolating to clinical practice the findings
from in vitro studies of microleakage, it is
important to bear in mind the wide range of
parameters in study design. We have identified
the following limitations of in vitro micro-
leakage studies.
Tracer characteristics. Three main charac-
teristics of tracers are relevant to leakage
studies: size, type and penetrating ability. How-
ever, no tracer can mimic the clinical conditions
and the presence of mixed flora precisely. The
various tracers used in endodontics are not of
constant size, type or shape, yet one can gener-
ally conclude that the larger the tracer, the
smaller the anticipated leakage.10 Most studies in
which researchers used dye tracers, such as
methylene blue or India ink, could show only the
leakage filling spaces along the root canal. Other
researchers resorted to use of radioactive tracers,
such as sodium 22 (22Na),11 to demonstrate the
microleakage.
In the 1990s, investigators used bacteria or
bacterial particles of known size and pene-
trating ability as a tracer for microleakage. The
main limitation of the bacterial model is the
ability to mimic clinically only leakage of bac-
teria of the same size. Torabinejad and col-
leagues,12 using a bacterial coronal leakage
model of single-rooted root-filled teeth to eval-
uate the rate of leakage, found that one-half of
the teeth were contaminated along the entire
length of the root after 19 days (motile bacteria)
392 JADA 142(4) http://jada.ada.org April 2011
Copyright © 2011 American Dental Association. All rights reserved.
or 42 days (nonmotile bacteria). The penetration
of Proteus vulgaris, a motile bacterium, was
slower than that of Staphylococcus epidermidis,
although the latter is nonmotile. Malone and
Donnelly13 failed to demonstrate the penetration
of any bacterium from fresh human saliva
through an apical foramen sealer, even when
tested with single-cone gutta-percha during a
60-day period. Investigators in other studies
attempted to detect microleakage by means of
bacterial component, which is known to cause
periapical disease. Alves and colleagues14
showed that purified andotoxin penetrated root-
filled teeth faster than did bacteria, whereas
Carratù and colleagues15 did not find evidence
of such penetration. The unclear clinical impor-
tance of these bacterial models also may be
related to the fact that endodontic infection is
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based on the mixed size and shape of micro-
organisms and on biofilm development,16 neither
of which a tracer can mimic.
Measurement methods. Several methods
exist for measuring leakage, most of them quali-
tative. Leakage commonly is determined by depth
of marker penetration,17 turbidity (as assessed by
means of spectrophotometry),12 fluid transport,18
glucose penetration18 and radioactivity.11
Experimental conditions. Most studies2,11,17
have dealt with the existence of positive or neg-
ative pressure, yet far fewer involved the use of
thermocycling19,20 and repeated loading.21 These
important parameters actually mimic conditions
in the mouth that cause degradation of coronal
restorations in general and especially tempo-
rary ones.22
Measurement time. The time elapsed
between the start of the experiment and the
first evidence of leakage is a critical parameter
for demonstrating the presence of leakage.17 One
can assume that a longer observation period
will result in a greater potential for leakage.
However, this is not always the case, as
Shemesh and colleagues18 showed in a fluid
transport model. Magura and colleagues23
demonstrated that salivary penetration was
greater after three months than that observed
after shorter periods. Their results indicated
that secondary endodontic treatment should be
undertaken if obturated root canals were
exposed for at least three months. However,
researchers have demonstrated contamination
of the root canal even within 30 days, regardless
of obturation technique.24 Friedman and col-
leagues,11 using a 22Na radiotracer, found that
temporary fillings were effective for only up to
ABBREVIATION KEY. 22Na: Sodium 22.

three weeks. It is not irrational to assume that
a prudent dentist will not carry out secondary
endodontic treatment in patients with a three-
week-old temporary restoration, even though it
is clear that leakage may occur. Because
leakage can occur at any time, as shown in
various in vitro studies,11,12 the recommendation
for re-treatment undertaken solely because of
suspected microleakage is not evidence based.
Coronal restoration dimensions. The
dimensions of the coronal restoration are of great
importance, because the physical barrier against
leakage increases with filling size and because
dye penetration also can be demonstrated in sev-
eral temporary materials.25 Barthel and col-
leagues26 used a 3 × 2.5 × 4-cubic millimeter
filling size, whereas Liberman and colleagues21
used a 6 × 3 × 7-mm3 filling size. The inconsistent
dimensions of the temporary coronal restorations
in microleakage studies, and especially in clinical
practice, illustrate the difficulty in evaluating
sealing efficiency, particularly in relation to
elapsed time.
EPIDEMIOLOGIC STUDIES
Investigators in several studies have tried to
evaluate the influence of the quality of coronal
restoration on the tooth’s clinical and radio-
graphic periapical status. Safavi and colleagues27
found a higher success rate of complete peri-
radicular healing in teeth with permanent
coronal restorations than in those with tempo-
rary restorations. However, this difference was
insignificant despite the fact that the investiga-
tors observed the former teeth longer than they
did the latter teeth. Ray and Trope28 conducted a
cross-sectional study of 1,010 periapical radio-
graphs of endodontically treated teeth to eval-
uate the teeth’s periapical status in relation to
the quality of the restoration or of the endo-
dontic treatment. Although it is problematic to
evaluate the quality of coronal restoration by
using only radiographs, the authors concluded
that the quality of the coronal restoration was
substantially more important than that of the
endodontic treatment. Kirkevang and col-
leagues,29 also by using radiographic criteria,
found that adequate coronal restorations were
associated with a better periapical status than
were inadequate restorations (48.0 percent of
teeth had apical periodontitis versus 63.9 per-
cent, respectively). Hommez and colleagues,30 in
a similar study, found that the radiographic
appearance of the coronal restoration and the
homogeneity of the root fillings were equally
important, indicating an equivalent effect on the
periapical condition. They found that teeth
Copyright © 2011 American Dental Association. All rights reserved.
CLINICAL PRACTICE
restored with resin-based composite exhibited
more apical periodontitis (40.5 percent of the
cases) than did amalgam-restored teeth (28.4
percent of the cases), whereas marginal decay
did not influence the periapical status.
Siqueira and colleagues31 evaluated 2,051 radio-
graphs of endodontically filled teeth and found a
high prevalence of periradicular lesions. Coronal
restoration had an effect on the periradicular
status, albeit the researchers found the quality of
the root canal filling to be the most critical factor.
Tronstad and colleagues,32 Segura-Egea and
colleagues33 and Tavares and colleagues34 found
that the quality of the endodontic treatment had
a greater effect on the periapical status of
endodontically treated teeth than did the coronal
restorations. Ricucci and colleagues6 examined
the periapical status of endodontically filled
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teeth exposed to the oral environment because of
caries or the absence of coronal restorations.
They concluded that coronal leakage may not be
of great clinical importance, as deduced from
numerous in vitro studies, provided instrumenta-
tion and placement of root fillings were per-
formed carefully. Therefore, it is not surprising to
read a case report regarding periradicular
healing in endodontically treated teeth despite
the patient’s having had temporary restorations
for more than 2.5 years.35 Furthermore, it is
obvious that a new tight coronal seal entombs
microorganisms and nutrients and prevents their
reentry from the oral cavity, thereby preventing
the development of periradicular disease.
The explanation for the differences between
the results of these studies also may be related to
study design. In analyzing aggregate data,
Chugal and colleagues36 found that teeth with a
permanent coronal restoration had a success rate
higher than that of nonrestored teeth (80 percent
versus 60 percent). However, the results of a
stratified analysis of a key confounding factor
(preoperative periapical diagnosis) showed that
there was no significant association between per-
manent restoration and endodontic outcome.36
The inconsistent conclusions regarding the
clinical relevance of coronal restoration quality
to endodontic success, especially in cases
involving high-quality endodontic treatment, do
not lessen the need for high-quality coronal res-
toration. However, they further reinforce the
importance of high-quality endodontic treat-
ment with a tight seal. The opposite results of
some of these studies28,32 may be explained by
the fact that teeth categorized as having good
coronal or apical sealing according to radio-
graphic and clinical means actually had a
microscopically inadequate seal.
JADA 142(4) http://jada.ada.org April 2011 393
CLINICAL PRACTICE

Decision-Making Flowchart:

Asymptomatic Endodontically Treated Tooth

Well-Obturated Root Canal* Poorly Obturated Root Canal*

Compromised coronal restoration Compromised coronal restoration Compromised coronal restoration

in place < 3 months in place > 3 months to 1 year in place > 1 year

Periradicular radiolucency present? Periradicular radiolucency present? Periradicular radiolucency present?

No Yes No Yes No Yes

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Previous radiograph

Coronal Buildup
Same or
improved

3-6 months’ follow-up

Periradicular status Periradicular status

Final same or improved deteriorated Endodontic
Prosthesis Re-treatment

Figure. Flowchart to guide the clinician’s decision making regarding secondary endodontic treatment of asymptomatic teeth.
* Quality of obturation is evaluated clinically (whether gutta-percha is pinkish and firm) and according to radiographic assessment of
the filling’s homogeneity, size and length.

OUTCOME AND COMPLICATIONS OF techniques. Yet, it also is important to bear in

SECONDARY ENDODONTIC TREATMENT
Satisfactory coronal restoration clearly is among
the factors that may positively influence the
outcome of endodontic treatment.37 In a study
involving dogs, Yamauchi and colleagues38 also
showed the importance of a good coronal seal
with regard to teeth’s apical status. However,
we did not find any study results showing a
higher success rate after completion of sec-
ondary endodontic treatment in asymptomatic
cases involving properly obturated root canals
and compromised coronal restoration, carried
out solely because of suspicion of microleakage.
The finding by Hommez and colleagues30 that
marginal decay did not influence the periapical
status may be explained by the differences
between the flora causing dental caries and
those causing endodontic disease.
Endodontic re-treatment is a straightforward
procedure with a high success rate, especially
when it involves the use of modern endodontic
mind the risks of complications in the course of
endodontic treatment, although they are rare. (In
other words, “First, do no harm.”) Secondary
endodontic treatment carries with it the risk of
further loss of the residual dentin width of the
root canal walls, along with the risk of intro-
ducing defects into the root canal walls.39,40 These
defects may propagate into vertical root frac-
tures, leading to tooth loss.40 Other complications
include canal blockage,41 instrument separation,42
canal transportation,43 root perforation44,45 and
infection developing during or between appoint-
ments.46 Those aspects may support the finding
by Van Nieuwenhuysen and colleagues47 that
radiographic monitoring alone revealed no
change or even a healing process in 97.2 percent
of the canals studied, whereas the success rate of
secondary endodontic treatment was as high as
91 percent. This finding encourages the prudent
clinician to be sure before beginning treatment
that endodontic re-treatment is more likely to

394 JADA 142(4) http://jada.ada.org April 2011

Copyright © 2011 American Dental Association. All rights reserved.

succeed than is merely replacing the coronal resto-
ration. By removing the compromised coronal res-
toration, the clinician may be able to verify that
the gutta-percha is pinkish and firmly condensed.
Furthermore, in questionable cases, the use of
cone-beam computed tomography to verify the
status of the periradicular tissue may be helpful.48
Is there any justification for remaking a
crown or bridge, removing a post and core or
taking the risk of losing a clinically good abut-
ment tooth with no symptoms when there is a
chance of future failure owing to microleakage?
There is no clear answer, and one has to con-
sider the history of the treatment, the possi-
bility of monitoring and follow-up and the
option of apical surgery in those few cases
involving late failure of endodontic treatment.
To help the clinician make decisions in cases
involving asymptomatic teeth, the flowchart
(Figure) may prove useful.
CONCLUSIONS
The literature review presented here empha-
sizes the importance of good permanent coronal
restoration. In the absence of clear scientific evi-
dence, in cases involving high-quality
endodontic treatment but also a compromised
coronal restoration of more than three months’
duration, it may be prudent to resort to a per-
manent coronal restoration.
Because radiographs are of limited value in
assessing the quality of root canal obturation, it
is important to verify clinically that the gutta-
percha is pinkish and firmly condensed. The use
of cone-beam computed tomography may be
helpful in patients with an unclear periradic-
ular status. If the periradicular status is not
clear, it is important to inform the patient of the
uncertain prognosis and to monitor the tooth for
at least three months before proceeding with
the permanent crown. The clinician must bear
in mind the option of future secondary
endodontic treatment or apical surgery.
Further prospective epidemiologic studies
regarding the success rate of endodontic treat-
ment in teeth with replaced compromised
coronal restoration versus that in similar cases
involving re-treatment may be helpful. ■
Disclosure. None of the authors reported any disclosures.
The authors thank Dr. John Whitworth for his remarks and advice.
1. Friedman S. Treatment outcome and prognosis of endodontic
therapy. In: Ørstavik D, Pitt Ford TR, eds. Essential Endodontology:
Prevention and Treatment of Apical Periodontitis. Oxford, England:
Blackwell Science; 1998:367-401.
2. Marshall FJ, Massler M. The sealing of pulpless teeth evaluated
with radioisotopes. J Dent Med 1961;16(4):172-184.
3. Wu MK, Wesselink PR. Endodotic leakage studies reconsidered,
Copyright © 2011 American Dental Association. All rights reserved.
CLINICAL PRACTICE
part I: methodology, application and relevance. Int Endod J 1993;
26(1):37-43.
4. Oliver CM, Abbott PV. Correlation between clinical success and
apical dye penetration. Int Endod J 2001;34(8):637-644.
5. Pitt Ford TR. Relation between seal of root fillings and tissue
response. Oral Surg Oral Med Oral Pathol 1983;55(3):291-294.
6. Ricucci D, Gröndahl K, Bergenholtz G. Periapical status of root-
filled teeth exposed to the oral environment by loss of restoration or
caries. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2000;
90(3):354-359.
7. Susini G, Pommel L, About I, Camps J. Lack of correlation
between ex vivo apical dye penetration and presence of apical radi-
olucencies. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2006;
102(3):e19-e23.
8. Editorial Board of the Journal of Endodontics. Wanted: a base of
evidence. J Endod 2007;33(12):1401-1402.
9. Wu MK, Shemesh H, Wesselink PR. Limitations of previously
published systematic reviews evaluating the outcome of endodontic
treatment. Int Endod J 2009;42(8):656-666.
10. Michaïlesco P, Boudeville P. Calibrated latex microspheres
percolation: a possible route to model endodontic bacterial leakage.
J Endod 2003;29(7):456-462.
11. Friedman S, Shani J, Stabholtz A, Kaplawi J. Comparative
sealing ability of temporary filling materials evaluated by leakage of
radiosodium. Int Endod J 1986;19(4):187-193.
Downloaded from jada.ada.org on April 1, 2011
12. Torabinejad M, Ung B, Kettering JD. In vitro bacterial penetra-
tion of coronally unsealed endodontically treated teeth. J Endod 1990;
16(12):566-569.
13. Malone KH 3rd, Donnelly JC. An in vitro evaluation of coronal
microleakage in obturated root canals without coronal restorations.
J Endod 1997;23(1):35-38.
14. Alves J, Walton R, Drake D. Coronal leakage: endotoxin pene-
tration from mixed bacterial communities through obturated, post-
prepared root canals. J Endod 1998;24(9):587-591.
15. Carratù P, Amato M, Riccitiello F, Rengo S. Evaluation of
leakage of bacteria and endotoxins in teeth treated endodontically by
two different techniques. J Endod 2002;28(4):272-275.
16. Svensäter G, Bergenholtz G. Biofilms in endodontic infections.
Endod Topics 2004;9(1):27-36.
17. Swanson K, Madison S. An evaluation of coronal microleakage
in endodontically treated teeth, part I: time periods. J Endod 1987;
13(2):56-59.
18. Shemesh H, Wu MK, Wesselink PR. Leakage along apical root
fillings with and without smear layer using two different leakage
models: a two-month longitudinal ex vivo study. Int Endod J 2006;
39(12):968-976.
19. Zmener O, Banegas G, Pameijer CH. Coronal microleakage of
three temporary restorative materials: an in vitro study. J Endod
2004;30(8):582-584.
20. Zaia AA, Nakagawa R, De Quadros I, et al. An in vitro evalu-
ation of four materials as barriers to coronal microleakage in root-
filled teeth. Int Endod J 2002;35(9):729-734.
21. Liberman R, Ben-Amar A, Frayberg E, Abramovitz I, Metzger
Z. Effect of repeated vertical loads on microleakage of IRM and cal-
cium sulfate-based temporary fillings. J Endod 2001;27(2):724-729.
22. Mayer T, Eickholz P. Microleakage of temporary restorations after
thermocycling and mechanical loading. J Endod 1997;23(5):320-322.
23. Magura ME, Kafrawy AH, Brown CE Jr, Newton CW. Human
saliva coronal microleakage in obturated root canals: an in vitro
study. J Endod 1991;17(7):324-331.
24. Khayat A, Lee SJ, Torabinejad M. Human saliva penetration of
coronally unsealed obturated root canals. J Endod 1993;19(9):458-461.
25. Cruz EV, Shigetani Y, Ishikawa K, Kota K, Iwaku M, Goodis
HE. A laboratory study of coronal microleakage using four temporary
restorative materials. Int Endod J 2002;35(4):315-320.
26. Barthel CR, Zimmer S, Wussogk R, Roulet JF. Long-term bacte-
rial leakage along obturated roots restored with temporary and
adhesive fillings. J Endod 2001;27(9):559-562.
27. Safavi KE, Dowden WE, Langeland. Influence of delayed
coronal permanent restoration on endodontic prognosis. Endod Dent
Traumatol 1987;3(4):187-191.
28. Ray HA, Trope M. Periapical status of endodontically treated
teeth in relation to the technical quality of the root filling and the
coronal restoration. Int Endod J 1995;28(1):12-18.
29. Kirkevang LL, Ørstavik D, Hörsted-Bindslev P, Wenzel A. Peri-
apical status and quality of root fillings and coronal restorations in a
Danish population. Int Endod J 2000;33(6):509-515.
30. Hommez GM, Coppens CR, De Moor RJ. Periapical health
JADA 142(4) http://jada.ada.org April 2011 395
CLINICAL PRACTICE
related to the quality of coronal restorations and root fillings. Int
Endod J 2002;35(8):680-689.
31. Siqueira JF Jr, Rôças IN, Alves FR, Campos LC. Periradicular
status related to the quality of coronal restorations and root canal
fillings in a Brazilian population. Oral Surg Oral Med Oral Pathol
Oral Radiol Endod 2005;100(3):369-374.
32. Tronstad L, Asbjørnsen K, Døving L, Pedersen I, Eriksen HM.
Influence of coronal restorations on the periapical health of endodon-
tically treated teeth. Endod Dent Traumat 2000;16(5):218-221.
33. Segura-Egea JJ, Jimé nez-Pinzøn A, Poyato-Ferrera M,
Velasco-Ortega E, Ríos-Santos JV. Periapical status and quality of
root fillings and coronal restorations in an adult Spanish population.
Int Endod J 2004;37(8):525-530.
34. Tavares PB, Bonte E, Boukpessi T, Siqueira JF Jr, Lasfargues
JJ. Prevalence of apical periodontitis in root canal–treated teeth
from an urban French population: influence of the quality of root
canal fillings and coronal restorations. J Endod 2009;35(6):810-813.
35. Vail MM, Guba PP. Apical healing of an endodontically treated
tooth with a temporary restoration. J Endod 2002;28(10):724-726.
36. Chugal NM, Clive JM, Spångberg LS. Endodontic treatment
outcome: effect of the permanent restoration. Oral Surg Oral Med
Oral Pathol Oral Radiol Endod 2007;104(4):576-582.
37. Ng YL, Mann V, Gulabivala K. Outcome of secondary root canal
treatment: a systematic review of the literature. Int Endod J 2008;
41(12):1026-1046.
38. Yamauchi S, Shipper G, Buttke T, Yamauchi M, Trope M. Effect
of orifice plugs on periapical inflammation in dogs. J Endod 2006;
396 JADA 142(4) http://jada.ada.org April 2011
Copyright © 2011 American Dental Association. All rights reserved.
32(6):524-526.
39. Wilcox LR, Roskelley C, Sutton T. The relationship of root canal
enlargement to finger-spreader induced vertical root fracture. J
Endod 1997;23(8):533-534.
40. Shemesh H, Bier CA, Wu MK, Tanomaru-Filho M, Wesselink
PR. The effects of canal preparation and filling on the incidence of
dentinal defects. Int Endod J 2009;42(3):208-213.
41. Fors UG, Berg JO. Endodontic treatment of root canals
obstructed by foreign objects. Int Endod J 1986;19(1):2-10.
42. Spili P, Parashos P, Messer HH. The impact of instrument frac-
ture on outcome of endodontic treatment. J Endod 2005;31(12):845-850.
43. Briseño BM, Sonnabend E. The influence of different root canal
instruments on root canal preparation: an in vitro study. Int Endod J
1991;24(1):15-23.
44. Metzger Z, Shperling I. Iatrogenic perforation of the roots of
restoration-covered teeth. J Endod 1981;7(5):232-233.
45. Kvinnsland I, Oswald RJ, Halse A, Grønningsaeter AG. A clin-
ical and roentgenological study of 55 cases of root perforation. Int
Endod J 1989;22(2):75-84.
46. Molander A, Reit C, Dahlén G, Kvist T. Microbiological status of
root-filled teeth with apical periodontitis. Int Endod J 1998;31(1):1-7.
47. Van Nieuwenhuysen JP, Aouar M, D’Hoore W. Retreatment or
radiographic monitoring in endodontics. Int Endod J 1994;27(2):75-81.
48. Estrela C, Bueno MR, Leles CR, Azevedo B, Azevedo JR. Accu-
racy of cone beam computed tomography and panoramic and peri-
Downloaded from jada.ada.org on April 1, 2011
apical radiography for detection of apical periodontitis. J Endod
2008;34(3):273-279.