ENDODONTIC TREATMENT OUTCOMES-root canal therapy

CONTENTS
• Introduction
• Treatment outcome criteria
• Outcome measures for endodontic treatment
• Factors affecting treatment outcome
• Conclusion

INTRODUCTION
• Primary goals of endodontic treatment of mature and immature permanent teeth are
prevention and/or elimination of apical periodontitis and resolution of patient symptoms.
• Additional treatment specific goals are described for treatment of immature teeth with vital
and/or necrotic pulps.
• Robust criteria for outcome assessment are an essential determinant for any measure of
treatment success for both mature and immature teeth.
• Assessment of endodontic treatment outcomes has evolved from disease-based criteria to
patient-centered values emphasizing survival and function even in the presence of
inflammatory periapical disease.
• Disease-free treatment outcome should always be the goal of all endodontic treatments.
Chugal N, Mallya SM, Kahler B, Lin LM. Endodontic Treatment Outcomes. Dental Clinics. 2017 Jan 1;61(1):59-
80.

TREATMENT OUTCOMES
• Functional, asymptomatic teeth with no or minimal
radiographic periradicular (apical) pathosis
(radiolucency)
HEALED
• Nonfunctional, symptomatic teeth with or without
radiographic periradicular (apical) pathosis
(radiolucency)
NONHEALED
• Teeth with periradicular (apical) pathosis
(radiolucency),which are asymptomatic and
functional,or teeth with or without radiographic
periradicular (apical) pathosis (radiolucency),which
are symptomatic but whose intended function is
not altered
HEALING
• A treated tooth or root that is serving its intended
purpose in the dentition.
FUNCTIONAL
Eleazer P, Glickman G, McClanahan S, Webb T, Jusrman B. Glossary of endodontic terms. Editorial AAE: Chicago. 2012.

ACCORDING TO INGLE
HEALED
• Complete clinical
and radiographic
normalcy (no signs,
symptoms, residual
radiolucency)
• This category also
includes the typical
appearance of a
scar after apical
surgery
HEALING (IN
PROGRESS)
• Decrease in size of
a radiolucency and
clinical normalcy
after a follow-up
period shorter
than 4 years
DISEASE
(REFRACTORY/RECURRENT/EME
RGED APICAL PERIODONTITIS)
• Presence of
radiolucency (new,
increased,
unchanged, or
reduced after
observation
exceeding 4 years)
regardless of
clinical
presentation, or
presence of
symptoms
regardless of
radiographic
appearance
ASYMPTOMATIC
FUNCTION
• Clinical normalcy
with or without a
persistent
radiolucency,
decreased or
unchanged
Ingle JI, Baumgartner JC. Ingle's endodontics. PMPH-USA; 2008.

Complete clinical
and radiographic
normalcy (no
signs, symptoms,
residual
radiolucency)
HEALED

The typical
appearance of a
scar after apical
surgery
HEALED

Decrease in size
of a
radiolucency and
clinical normalcy
after a follow-up
period shorter
than 4 years
HEALING (IN
PROGRESS)

Presence of
radiolucency (new,
increased,
unchanged, or
reduced after
observation
exceeding 4 years)
regardless of clinical
presentation, or
presence of
symptoms regardless
of radiographic
appearance
DISEASE
(REFRACTORY/RECURRENT/
EMERGED APICAL
PERIODONTITIS)

Clinical normalcy
with or without a
persistent
radiolucency,
decreased or
unchanged
ASYMPTOMATIC
FUNCTION

STRINDBERG CRITERIA (1956)
Clinical: No symptoms
Radiographic: The contours, width, and structure of the
periodontal margin are normal OR
The periodontal contours are widened mainly around the excess
root filling OR
Lamina dura is intact
Clinical: Presence of symptoms
Radiographic: A decrease in the periradicular rarefaction OR
Unchanged periradicular rarefaction OR
An appearance of new rarefaction or an increase in the
initial rarefaction OR
Discontinuous or poorly defined lamina dura
SUCCESS
FAILURE
UNCERTAIN
Radiographic: There were ambiguous or technically
unsatisfactory control radiographs that could not, for some
reason, be repeated OR
The tooth was extracted prior to the 3-year follow-up owing to
the unsuccessful treatment of another root of the tooth
Hargreaves KM, Berman LH. Cohen's pathways of the pulp. Elsevier Health Sciences; 2015 Oct 1.

UNCERTAIN
Radiographic :
• Ambiguous or technically unsatisfactory radiograph that could not be interpreted
with certainty
• Periradicular rarefaction less than 1 mm and disrupted lamina dura
• Tooth extracted prior to recall due to reasons not related to endodontic outcome
80.

• The highlights of the Strindberg criteria are :
1. Established criteria for evaluation of endodontic outcome,
commonly referred to as Strindberg criteria
2. Arrived at outcome rates for orthograde (conventional)
endodontic treatment
3. Related the outcome of endodontic treatment to the preoperative
periapical diagnosis
4. Defined the duration and frequency of follow-up: every 6 months
for the first 2 years and yearly thereafter up to a minimum of 4
years postoperatively
80.

• It became evident that Strindberg criteria were rigid. For example,
only teeth with complete absence of clinical signs and symptoms and
normal radiographic presentation are classified as “success”
• In contrast, an asymptomatic tooth with the appearance of broken or
poorly defined lamina dura is classified as uncertain and clinical
judgment is required for its subsequent management.
80.

Bender et al. (1966)
 Clinical :
• Absence of pain/swelling; disappearance of fistula; no loss of
function; no evidence of tissue destruction
 Radiographic :
• An eliminated or arrested area of rarefaction after a post-treatment
interval of 6 months to 2 years

Friedman & Mor (2004)
• Clinical: Normal presentation
• Radiographic: Normal presentation
HEALED
• Radiolucency has emerged or persisted without change,
even when the clinical presentation is normal OR
• Clinical signs or symptoms are present, even if the
radiographic presentation is normal
DISEASED
• Clinical: Normal presentation
• Radiographic: Reduced radiolucency
HEALING

The periapical index (PAI)
• The periapical index (PAI) is a structured scoring system for categorization of radiographic
features of apical periodontitis. It is based on a visual scale of periapical periodontitis severity
and was built on a classic study of histologic-radiologic correlations.
• It is a 5-point ordinal scale:
1.Normal periapical structures
2. Small changes in bone structure with no dimineralization
3. Changes in bone structure with some diffuse demineralization
4. Apical periodontitis with well-defined radiolucent area
5. Severe apical periodontitis, with exacerbating features

The periapical index
(PAI)
Ørstavik D, Kerekes K, Eriksen HM. The periapical index: a scoring system for radiographic assessment of apical
periodontitis. Dental Traumatology. 1986 Feb 1;2(1):20-34.

CBCT-PAI
• Cone beam CT (CBCT) has found considerable applications in endodontic diagnosis and treatment planning.
• The CBCT-PAI was developed to apply standardization in approaches to assess the severity of apical
periodontitis by CBCT.
• This index is a 6-point scale that includes a score (0–5) plus 2 variables that assess expansion and
destruction of cortical bone.
0: Intact periapical bone structures
1: Diameter of periapical radiolucency 0.5 mm to 1 mm
2: Diameter of periapical radiolucency 1 mm to 2 mm
5: Diameter of periapical radiolucency 8 mm
E: Expansion of periapical cortical bone
D: Destruction of periapical cortical bone
Chugal N, Mallya SM, Kahler B, Lin LM. Endodontic Treatment Outcomes. Dental Clinics. 2017 Jan 1;61(1):59-80.C

80.

OUTCOME MEASURES FOR ENDODONTIC
TREATMENT
• Outcome Measures for Vital Pulp Therapy Procedures
• Outcome Measures for Nonsurgical Root Canal Treatment and
Retreatment
• Outcome Measures for Periapical Surgery

Outcome Measures for Vital Pulp Therapy Procedures
• The surrogate outcome measures adopted in studies include
(1) Clinical success (pulp sensitivity to cold test and absence of pain, soft-tissue swelling, sinus
tract, periradicular radiolucency, or pathologic root resorption)
(2) Patient satisfaction
(3) Adverse events (pain, swelling, tooth fracture)
(4) Tooth extraction.
Although not providing a specific follow-up strategy, the quality guidelines of the European
Society of Endodontology suggests “initial review at no longer than 6 months and
thereafter at further regular intervals.”

Outcome Measures for Vital Pulp Therapy Procedures
• An initial assessment at 6 to 12 weeks, followed by a review 6 and 12 months after treatment,
seems to have been accepted and is recommended
• The process at each review consists of obtaining a history of symptoms, coupled with an
examination to determine the presence or absence of tenderness to palpation of adjacent soft
tissues, tenderness to pressure and percussion of the tooth, signs of radiographic pulpal, and
periapical changes, and responses to pulp tests.
• The accuracy of pulp tests may be limited in pulpotomized teeth because of the distance of the
remaining pulp tissue from the tooth’s surface.

• In the case of pulp capping and pulpotomy, additional tests include radiographic
verification of the presence of the calcific barrier and its integrity by removal of
the dressing and direct probing.
• If there is no evidence of complete bridge formation, the treatment is considered
failed and root canal treatment should be considered.
• In addition, in the case of incompletely formed roots there should be radiographic
evidence of continued root development

Chugal N, Mallya SM, Kahler B, Lin LM. Endodontic Treatment Outcomes. Dental Clinics. 2017 Jan 1;61(1):59-80.

Outcome Measures for Nonsurgical Root Canal Treatment and
Retreatment
• The outcome measures that quantitate healing subsequent to root canal treatment are the absence
of clinical signs and symptoms of persistent periapical disease.
• The definitive outcome measure (in conjunction with the absence of signs and symptoms), however,
is periapical healing, because the treatment is aimed at resolution of periapical disease
• Clinical judgment of the outcome of treatment is based on the absence of signs of infection and
inflammation, such as pain, tenderness to pressure/ percussion of the tooth, tenderness to palpation
of the related soft tissues, absence of swelling and sinus tract, and radiographic demonstration of
reduction in the size of the periapical lesion (if sufficient time has lapsed), with a completely normal
development of the periodontal ligament space.

• Although the majority of periapical lesions heal within 1 year, healing may
continue for up to 4 years or longer.
• Absence of signs and symptoms of periapical disease with radiographic
evidence of a persistent periapical radiolucency may indicate either fibrous
repair or persistent chronic inflammation or infection.
• Only time and acute exacerbation would identify the latter, whereas the
former should remain asymptomatic

• Longevity measures include survival of the root canal fillings or treatment and
tooth retention or survival.
• The term functional retention was coined by Friedman in 2004 to mean
retention of the tooth in the absence of signs and symptoms regardless of the
radiographic presence of a lesion.
• The term functionality should further and more specifically cover the functional
utility of the tooth—that is, some patients may complain that despite the
absence of specific signs and symptoms of infection or inflammation, they find it
impossible to use the tooth because it “feels” weak.

Outcome Measures
for Periapical Surgery
Hargreaves KM, Berman LH. Cohen's
pathways of the pulp. Elsevier Health
Sciences; 2015 Oct 1.

Outcome Measures for Periapical Surgery

Factors Influencing Periapical Healing Following Nonsurgical Root
Canal Treatment
• The following factors are considered as having a major impact on periapical health subsequent
to root canal treatment:
• Presence and size of periapical lesion
• Patency at the canal terminus (achieving patency significantly increased the chance of success
twofold)
• Apical extent of chemomechanical preparation in relation to the radiographic apex
• Outcome of intraoperative culture test
• Iatrogenic perforation (if present, reduces the odds of success by 30%)
• Quality of root canal treatment judged by the radiographic appearance of the root filling
• Quality of the final coronal restoration

• The following factors are considered as having minimal impact on root
canal treatment outcome:
• Age of patient
• Gender of patient
• Tooth morphologic type
• Specific root canal treatment protocol and technique (preparation,
irrigation, and obturation material and technique)

Factors Influencing the Survival of Teeth Following Root Canal
Treatment
• The following conditions have been found to significantly improve tooth survival
following root canal treatment:
• Nonmolar teeth
• Teeth with both mesial and distal adjacent teeth
• Teeth not located as the distal-most tooth in the arch
• Teeth (molar) with cast restorations after treatment
• Teeth not requiring cast post and core for support and retention of restoration
• Teeth not functioning as abutments for fixed prosthesis
• Absence of preoperative deep periodontal probing defects, pain, sinus tract, or
perforation
• Achievement of patency at canal terminus and absence of root-filling extrusion
during treatment
In addition, it is important to ensure favorable distribution of occlusal forces when
designing restorations for endodontically treated teeth

• The study was designed as a randomized controlled trial to evaluate the effect of the apical
preparation size in relation to the first apical binding file (FABF) on the outcome of primary
endodontic treatment in mandibular first molars.
• One hundred sixty-seven patients met the inclusion criteria. They were randomly allocated
to 5 different endodontic treatment groups (ie, A, B, C, D, and E) in which canals were
enlarged to 2, 3, 4, 5, and 6 sizes larger than the FABF, respectively.
• One hundred twenty-nine patients were evaluated at the 12-month follow-up.
• The primary outcome measure was the change in periapical radiolucency as assessed by
periapical index (PAI) scores. The clinical finding constituted the secondary outcome
measure.
Saini HR, Tewari S, Sangwan P, Duhan J, Gupta A. Effect of different apical preparation sizes on outcome of primary
endodontic treatment: a randomized controlled trial. Journal of endodontics. 2012 Oct 1;38(10):1309-15.

• A statistically significant reduction in PAI scores was observed in all groups
(P < .001).
• The proportion of successfully healed cases increased with an increase in the
apical preparation size with 48%, 71.43%, 80%, 84.61%, and 92% successful
healing observed in groups A to E, respectively.
• However, statistical analysis revealed that only group A showed significantly
less improvement than other groups (P < .05). No significant difference was
observed between the rest of the groups.
• Regression analysis revealed a significant and positive association between the
master apical preparation size and an improvement in PAI scores
• The enlargement of the canal to 3 sizes larger than the FABF is adequate, and
further enlargement does not provide any additional benefit during
endodontic treatment.
Saini HR, Tewari S, Sangwan P, Duhan J, Gupta A. Effect of different apical preparation sizes on outcome of primary
endodontic treatment: a randomized controlled trial. Journal of endodontics. 2012 Oct 1;38(10):1309-15.

Ng YL, Mann V, Rahbaran S, Lewsey J, Gulabivala K. Outcome of primary root canal treatment: systematic review of the literature–Part 2.
Influence of clinical factors. International endodontic journal. 2008 Jan 1;41(1):6-31.

• A meta-analyses was carried out to quantify the influence of the clinical factors on the efficacy of
primary root canal treatment and (ii) to identify the best treatment protocol based on the current
evidence.
• Four conditions :
pre-operative absence of periapical radiolucency,
root filling with no voids
root filling extending to 2 mm within the radiographic apex and
satisfactory coronal restoration
were found to improve the outcome of primary root canal treatment significantly.
• Root canal treatment should therefore aim at achieving and maintaining access to apical anatomy
during chemo-mechanical debridement, obturating the canal with densely compacted material to
the apical terminus without extrusion into the apical tissues and preventing re-infection with a
good quality coronal restoration
Ng YL, Mann V, Rahbaran S, Lewsey J, Gulabivala K. Outcome of primary root canal treatment: systematic review of the literature–Part 2.
Influence of clinical factors. International endodontic journal. 2008 Jan 1;41(1):6-31.

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