Endodontic Topics 2002, 1, 54–78 Copyright C Blackwell Munksgaard

Printed in Denmark. All rights reserved ENDODONTIC TOPICS 2002

1601-1538

Considerations and concepts of

case selection in the management of
post-treatment endodontic disease
(treatment failure)
SHIMON FRIEDMAN

Dear Colleagues
I feel honoured and excited to participate in Endodontic Topics, the new review journal focusing on all aspects
of the science and art of endodontics, and I hope you will join me in celebrating this first issue, wherever you
are! In contrast to future issues, which will focus on one area each, this issue covers different areas, all reviewed
by my fellow Associate Editors. I selected the following review for this issue because it touches on several topics
that have been assigned to me to cover in the future. In this review, you will find reference to endodontic
treatment outcome criteria, concepts of endodontic health and disease, decision-making, treatment outcome of
apical surgery and orthograde re-treatment, post-operative pain associated with the aforementioned procedures,
removal of crowns and posts, as well as broken instruments, perforation repair, retrograde re-treatment and
more. All of these topics are dealt with in this article in the context of case selection in the management of
post-treatment disease. In the future, however, you will see the focus shifting to examining each of these topics
on their own, with many of them being reviewed in greater detail by those researchers and clinicians quoted in
this review. So, to my mind, this review is not just a review but a sign of things to come.
I look forward to working with many knowledgeable colleagues in the future to develop good quality,
comprehensive and critical reviews for your benefit. I hope you find these reviews exciting and useful.

ment techniques and methodology, the outcomes re-

Healing–disease vs. success–failure ported in these studies vary considerably (2). One of
The goal of endodontic treatment is to prevent and, the main reasons for the variability of reported out-
when required, to cure endodontic disease, apical comes is the inconsistent definition of ‘success’ (2):
periodontitis (1). To attain this goal, endodontic O combined clinical and radiographic normalcy (no
treatment is based on a sound biological rationale, signs, symptoms or radiolucency present);
consisting primarily of exclusion of microorganisms O clinical normalcy with reduced radiolucency; or
from the root canal system (1). To what extent this O clinical normalcy with persistent, stable radio-
goal is attainable has been the subject of many studies lucency.
on the outcome of endodontic treatment (2). For the Just as researchers and clinicians appear to differ in
major part, these are prospective or retrospective fol- their interpretation of endodontic treatment ‘success–
low-up studies of specific populations, in which the failure’, patients, too, may have difficulties relating to
outcome is classified into ‘success’ and ‘failure’ cate- these terms. The issue is further confused by the fact
gories. Because of differences in study material, treat- that the terms ‘success–failure’ are also being used to

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describe the outcomes of other dental treatment pro- be classified in terms of ‘healing–disease’. When
cedures; the undiscerning use of these terms may con- upon follow-up examination there are no clinical signs,
fuse the patients when they consider different treat- symptoms or radiolucency (combined clinical and
ment alternatives. One focus of attention in recent radiographic normalcy), the tooth and surrounding
years has been the implant-supported single-tooth re- tissues are classified as having healed. When the radio-
placement, for which the definition of ‘success–fail- lucency has persisted without change or a new one has
ure’ is quite different from that used in endodontics, emerged, this is an expression of disease, even when
and more consistent with the outcome category of there are no clinical signs and symptoms (clinical nor-
‘survival’ (3). Based on this definition, the reported malcy). To accommodate the fact that healing pro-
‘success’ rates for single-tooth implants are consider- cesses may require considerable time, often up to 4
ably higher than those for endodontic treatment (4). years (6), reduced radiolucency combined with clinical
The patient weighing one ‘success’ rate against the normalcy can be interpreted as a suggestion of pro-
other may erroneously assume their definitions to be gressive healing.
comparable, and select the treatment alternative that It is this author’s view that most patients can relate
appears to be offering the better chance of ‘success’. to the concept of ‘disease–therapy–healing’, unlike
Clearly, then, the term ‘success’ used in the con- the concept of ‘success–failure’. It is expected that
text of endodontic treatment outcome is ambigu- each person, be it a patient or a doctor, will bring his
ous, and it cannot be used effectively as the basis or her individual values of health and disease into this
for reliable communication among clinicians, and consideration, as illustrated by Kvist and coworkers
between clinicians and patients. (7, 8). It would appear that the individual values of
When upon the follow-up examination teeth do not patients would again result in inconsistent responses
conform to the criteria of ‘success’, they are normally to the outcome of any given endodontic treatment.
referred to as ‘treatment failure’. This term, too, is However, assigning precedence and dominance to the
problematic ª it is just as ambiguous as ‘success’, but patient’s values is consistent with the current ethical
in addition, it has a negative connotation (5). Fur- principle of patient autonomy (8), and with the cur-
thermore, it is not specific enough to imply the rent legislative principles in many modern societies,
necessity to pursue treatment or, in fact, any course which require the patient’s informed consent and au-
of action. Therefore, the term ‘failure’ also does not thorization for any treatment decisions made (9).
promote effective communication in the context of In summary, use of the terms ‘healing–disease’ to
endodontic treatment. In fact, Ørstavik (6) suggests report the outcome of endodontic treatment is advis-
that, in communication with patients, the value-laden able, as this will minimize ambiguity, facilitate com-
terms ‘success–failure’ should be substituted with munication, and conform to ethical and legislative re-
more neutral expressions, such as ‘chance of healing’ quirements. In this article, disease is used in lieu of
and ‘risk of inflammation’. ‘treatment failure’.
In the majority of endodontic treatment ‘failures’,
the radiolucency present, be it stable or reduced in
size, is an expression of apical periodontitis ª the
Post-treatment endodontic disease
same disease intended to be prevented or cured when
Epidemiology
initial endodontic treatment was performed. Giving it
a different name (treatment failure) suggests that it is In spite of the many inconsistencies, several of the
a different entity, whereas in fact it is not. aforementioned follow-up studies clearly demonstrate
It is suggested therefore that, to promote effective the excellent potential outcome of endodontic treat-
communication within the profession and, most im- ment, with apical periodontitis prevented or cured in
portantly, between clinicians and patients, the use of over 80% of treated teeth (2, 10). Apparently, how-
the terms ‘success–failure’ should be avoided when re- ever, this excellent potential of endodontic treatment
ferring to the outcome of endodontic treatment. In- has not been corroborated in the majority of cross-
stead, it is appropriate to use terms that are directly re- sectional studies, generally considered as demonstrat-
lated to the goals of treatment, prevention or curing of ing the realistic outcome of endodontic treatment
disease. Therefore, the outcome of treatment should (11). In the cross-sectional studies of general popula-

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Friedman

tions in many countries, 20% to over 60% of endo- cal periodontitis. For simplicity, this author prefers to
dontically treated teeth present with apparent radio- use the term post-treatment disease to include all per-
lucency, suggestive of apical periodontitis (2, 12–18). sistent, recurrent and emerged apical periodontitis as-
Thus the cross-sectional studies indicate the true ex- sociated with endodontically treated teeth, while also
tent to which endodontically treated teeth in the differentiating these conditions from apical peri-
population are associated with disease, and suggest odontitis associated with untreated teeth.
the necessity to manage this condition on a far greater
scale than suggested by the follow-up studies. For ex-
Etiology
ample, one Swedish study estimated the number of
endodontically treated teeth associated with radio- Nair et al. (20) have convincingly demonstrated peri-
lucency at 2.5 million teeth (19). apical pathological lesions consistent with apical peri-
odontitis, caused by foreign bodies present within the
periapical tissues. It is critically important to put these
Definition
undisputed findings into a broad clinical perspective.
The disease associated with radiolucency about endo- In this context, it is relevant to recognize the origin of
dontically treated teeth is apical periodontitis. How- the root and periapical tissue specimens studied and
ever, as this disease has persisted despite treatment analyzed by these researchers ª they were derived from
(Fig. 1), reoccurred after having healed at first (Fig. the population studied by the Umeå, Sweden, group
2), or emerged during the follow-up period after (21). At the time of treatment, all teeth were microbio-
treatment (Fig. 3), it would appear appropriate to logically controlled with sophisticated methods, while
characterize it as persistent, recurrent or emerged api- subjected to antimicrobial intracanal procedures to

Fig. 1. Persistent disease after endodontic treatment. A. Immediate post-operative radiograph of maxillary lateral incisor
with apical periodontitis. B. Persistent disease at 1 year.

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 Post-treatment endodontic disease

eradicate root canal microorganisms. The canals were organisms in the canal. However, because exclusion of
filled only when confirmed to be free of microorgan- microorganisms is not routinely confirmed before root
isms. Twelve teeth (10%) presented with post-treat- filling, the prevalence of non-microbial etiology in the
ment disease upon follow-up, and nine were subjected general population should be much lower than that
to biopsy. Of these, in three teeth (33%) the researchers suggested by this study.
found foreign materials periapically, but not micro- In recent years, consistent and convincing evidence

Fig. 2. Recurrent disease after endodontic treatment. A. Immediate post-operative radiograph of maxillary second premolar
with apical periodontitis. B. Apparent complete healing at 1 year. C. Recurred disease at 3 years.

Fig. 3. Emerged disease after endodontic treatment. A. Immediate post-operative radiograph of maxillary second molar
without evidence of apical periodontitis. B. Emerged disease at 3 years. C. Further expansion of disease at 6 years.

57
Friedman

has been accumulated to confirm that post-treatment benefits and risks of both treatment alternatives have
endodontic disease is primarily caused by infection to be weighed (9).
(22). What appears to differ, and to some extent to
stimulate a dispute, is the site in which microorganisms
Benefits
are harbored. Most frequently the microorganisms
are harbored in the root canal system (23–31), when In general terms, ‘a treatment procedure is beneficial
they have either survived the treatment and persisted to a patient if it is in some way conducive to his wel-
(32), or invaded the filled canal space after treatment, fare, health, or both’ (8). When considering treat-
possibly because of coronal leakage (33). Recent evi- ment alternatives, therefore, factors should be taken
dence has clearly demonstrated microorganisms of dif- into account that can potentially affect those two as-
ferent species harbored in the periapical tissues (34–36). pects of benefiting the patient.
This recent evidence is an important addition to pre- Retreatment and apical surgery differ significantly
vious, well-established evidence confirming that speci- in their ability to address the site where microorgan-
fic microorganisms, particularly Actinomyces israelii, isms are harbored. The following considerations are
can become established in the periapical tissues and pertinent:
sustain the post-treatment disease (37). Collectively, O For root canal infection, retreatment is an attempt
microorganisms harbored outside the root canal are re- to exclude the microorganisms, whereas apical surgery
ferred to as extraradicular (38). They may survive in is an attempt to confine the microorganisms within
cementum lacunae on the root surface (39, 40), in the canal boundaries. Retreatment therefore offers a
plaque-like microbial films on the apical root surface better chance to curtail root canal infection, and this
(38, 41–43), or in dentin debris inadvertently ex- is its main benefit. Surgery, on the other hand, has a
truded periapically during treatment (44). Clearly, limited capacity to curtail root canal infection, and
different microbial species have the ability to sur- therefore, it offers a lesser benefit.
vive in extraradicular sites, and this phenomenon O For extraradicular infection, surgery is an attempt
appears to be far more common than was recog- to exclude the microorganisms by totally removing
nized a few years ago. From the clinical perspective, the infected site, whereas retreatment is an attempt to
however, the most important consideration is whether isolate the extraradicular microorganisms by cutting
or not the extraradicular microorganisms observed in them off from possible, albeit unlikely, support from
specimens from teeth with post-treatment disease did root canal microorganisms. Surgery therefore offers a
indeed sustain the disease process without dependence better chance to curtail extraradicular infection, and
on microorganisms present in the root canal ª a few this is its main benefit. Retreatment clearly offers a
microbial species have been shown to sustain extrarad- smaller benefit in this regard; however, its benefit can-
icular infection exclusively (37), but the ability of most not be dismissed entirely, as frequently there is uncer-
other species to do so is still pending clarification. Until tainty regarding the coexistence of extraradicular in-
this aspect of exclusive extraradicular infection is eluci- fection and root canal infection.
dated, it should be regarded as a far less common oc- To summarize, root canal infection is far more
currence than root canal infection, representing the common than exclusive extraradicular infection, and
minority of teeth associated with post-treatment dis- it should be considered as representing the majority
ease. of teeth associated with post-treatment disease.
Therefore, it is appropriate to consider that gener-
ally the benefits of retreatment, the procedure
Treatment ª benefits and risks
that best curtails root canal infection, outweigh
Post-treatment disease, like other disease processes, those of apical surgery. When clinical evidence or
can be resolved only if the etiological factor is elimin- case history supports the diagnosis of extraradicu-
ated or critically curtailed. To achieve this goal with- lar infection, the benefits of apical surgery out-
out having to extract the affected tooth, either ortho- weigh those of retreatment. In either case, both
grade retreatment or apical surgery can be performed. procedures may be carried out in conjunction to ex-
In accordance with the current guidelines regarding clude microorganisms harbored in all possible sites
treatment decision making processes, the respective and thus maximize the benefit. In this manner the

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treatment outcome is better than that of either pro- treatment, the inherent risk depends on the type of
cedure alone (2) because ‘infection is eliminated restoration that is present, and the type of root canal
and re-infection is prevented’ (45). However, in filling or other obstacles that have to be eliminated.
teeth where the root canal is accessible for re- At most, the patient is at risk of losing the tooth be-
treatment, apical surgery should be avoided to pre- cause of fracture or a significant complication, such as
vent its inherent risks; therefore, the combination of an irreparable perforation (59). Other complications,
both procedures is not common (2). such as instrument breakage or marked canal trans-
The better ability of retreatment to curtail root ca- portation represent a lesser risk, although they can
nal infection should theoretically translate into the compromise the outcome of treatment. The follow-
most important benefit of all ª an improved treatment ing considerations may be used as suggestive of the
outcome. Although the respective outcomes of re- risk associated with retreatment:
treatment and apical surgery have been reported in O Coronal restoration ª Only removal of full cover-
follow-up studies of either alternative (2), the most age restorations (crowns, bridges) is associated with a
appropriate comparison between the two alternatives risk; the tooth may be rendered non-restorable if its
is on the basis of randomized controlled trials. To coronal portion is severed.
date, two such clinical trials have been reported (46, O Post restoration ª Post removal is associated with a
47), and both conclude that the outcome of both risk of root fracture, proportional to the retention of
alternatives does not differ significantly. However, it the post within the root. Post retention depends on
would be a mistake to consider these two trials in iso- its size, type and the material with which it is ce-
lation from the many other outcome studies available. mented––it is the greatest when the post is large, long
It is interesting to note that, for apical surgery, the and has parallel walls (60), and when it is cemented
complete healing rate of just under 60% reported in with dentin-bonded composite resin, such as Panavia
both trials is consistent with the weighted average rate (61). Nevertheless, when the appropriate armamen-
of 67% calculated from the outcomes in other studies tarium is used with adequate skill, the risk of root
reported in the past decade (2, 10, 48, 49). In con- fracture is very small, and should not be considered
trast, for retreatment, the healing rates of 28% (46) to exceed 1% (62) (Fig. 4). Also, post removal may
and 55% (47) fall considerably short of the weighted occasionally be avoided in multirooted teeth, when
average rate of 80% calculated from other studies re- post-treatment disease is associated with roots other
ported in the past decade (2, 50–58). It is difficult to than the one supporting the post (59, 63) (Fig. 5).
speculate why the outcome of retreatment is poorer O Root canal obstacles ª Attempts to eliminate insol-
than usual in these two trials. Possibly, the randomiza- uble materials, such as zinc-phosphate cement or
tion requirement that was the basis for the experi- broken instruments, are associated with a risk of root
mental design resulted in retreatment performed in perforation. The more apical the location of the ob-
teeth in which complicating factors were present, stacle, the greater the risk. Nevertheless, root perfor-
such as root canal obstacles, extruded filling materials ations can frequently be successfully repaired in situ
or perforations. The mention in one of the studies (64); therefore, unlike in the past, perforations should
(47) of 17% of the retreated teeth having extruded no longer result in imminent tooth loss, although
root fillings may be a hint to that effect. Comparisons they may compromise the outcome of treatment.
between the outcome of retreatment and apical For apical surgery, the inherent risk depends on the
surgery beyond these two randomized controlled tri- location of the treated tooth in proximity to sensitive
als are not appropriate; therefore, the treatment out- anatomic structures such as nerves, major blood ves-
come benefit of the two alternative procedures sels, sinuses, muscles or roots of adjacent teeth, and
cannot be clearly defined (8). on the accessibility of the roots as determined by the
thickness of the buccal alveolar bone plate and depth
of the buccal vestibule. At most, the patient is at risk
Risks
of nerve damage or sinus complications requiring ad-
Both retreatment and apical surgery require consider- ditional invasive procedures. Other complications,
able manipulation, and should be considered invasive such as perforation of the lingual alveolar bone plate
procedures associated with inherent risks. For re- or exposure of a root dehiscence, may compromise

59
Friedman

Fig. 4. Retreatment in posterior tooth with a cast post. A. Cast post and crown in maxillary first premolar with post-
treatment disease. B. Crown was removed reversibly, the post was extracted with the Gonon device, and retreatment is
underway. C. Completed retreatment with the original crown recemented in place. D. Complete healing at 4 years.

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Fig. 5. Retreatment through crown without post removal. A. Large prefabricated post in distal root of mandibular first molar
with post-treatment disease associated with mesial root. Removal of the post and retreatment of the distal canals would have
the benefit of preventing potential disease and the risk of root crack; therefore, it is avoided. B. Access to mesial canals was
prepared through the crown and core without disturbing the post and distal aspect of core; retreatment is in progress. C. Com-
pleted retreatment of mesial canals. D. Complete healing at 6 months. (Reprinted with permission from (63)).

61
Friedman

the outcome of treatment (45). Minor sinus exposure having some swelling after 1 week, compared to 66%
usually represents a lesser risk, because its sequelae are of patients that had apical surgery. The pertinence of
either transient in nature or treatable (65, 66). An- these findings is subject to individual interpreta-
other treatable complication is an inadvertent resec- tion by each and every patient – some may consider
tion of an adjacent root tip. Although the textbooks this critical, while others may not. It should be noted,
on apical surgery do not elaborate on potential risks, however, that the postoperative discomfort may in-
the following considerations may suggest risks associ- directly influence another consideration that is key to
ated with apical surgery: the selection between retreatment and apical surgery,
O Proximity to the inferior alveolar nerve ª Operation that of cost. For example, in the same study (68), 23%
on mandibular premolars and molars is associated with of the patients who received apical surgery, but none
a risk of paresthesia or dysesthesia, mainly resulting of those who received retreatment, required sick leave
from manipulation and inadvertent nerve damage. because of swelling. This may have resulted in loss of
This risk is greatest when the mandibular canal or the income, thus increasing the indirect cost associated
mental foramen is radiographically observed in close with apical surgery (68).
proximity to the surgery site. Although the altered sen-
sation is often transient, it may be permanent.
O Proximity to the maxillary sinus ª Depending on
Unique dilemmas
their proximity to the sinus, operation on maxillary
premolars and molars, and less frequently, on maxil- As explained above, without clear evidence of extra-
lary canines, may be associated with the risk of mispla- radicular infection, it is appropriate to consider re-
cing the resected root apex into the sinus (67), which treatment as the principal treatment of choice in the
may necessitate further surgical intervention. To a management of post-treatment disease, unless the
large extent this risk is avoidable, but it is not entirely foreseen risks of retreatment of the specific tooth in
preventable. Another risk is development of sinusitis question appear to outweigh those of apical surgery.
after the surgical procedure (66). In most cases, the Accordingly, apical surgery is a compromise, unless in-
sinusitis can be resolved by an antibiotic regimen; fection is assumed to be extraradicular, retreatment
lasting complications or necessity to extract the tooth is unfeasible or restricted, or a previous retreatment
are uncommon (66). attempt has not resulted in healing (5). According
O Accessibility ª Operation on difficult to access teeth to this rationale, retreatment should be much more
is associated with a greater risk of procedural compli- frequently performed than apical surgery. However,
cations, such as lingual bone plate perforation or in- apical surgery appears to be as prevalent as re-
advertent resection of an adjacent root, than is oper- treatment, and, in some parts of the world, even more
ation in easily accessible areas. Although procedural prevalent (69). The reasons for this disparity between
complications may compromise the prognosis (45), theory and practice appear to be founded in the
to a large extent they are treatable. unique dilemmas that affect clinicians’ decisions when
To summarize, it is impossible to generalize they are required to manage teeth with post-treat-
whether the risks associated with either alternative ment disease.
outweigh those associated with the other. This as- One complicating factor is the considerable differ-
sessment can only be made by taking in account ence between retreatment and the more ‘routine’ ini-
the characteristics of the individual tooth that re- tial endodontic treatment. Although these two root
quires management of post-treatment disease. canal treatment procedures share similar biologic
Another potential risk associated with treatment are principles and objectives, the following considerations
the postoperative sequelae of pain and swelling. Ac- are unique to retreatment (70):
cording to Kvist & Reit (68), retreatment provoked O An extensive restoration may have to be sacrificed
postoperative pain and swelling in 26% and 15% of and later remade, which considerably increases the
patients, respectively, whereas apical surgery pro- overall cost of the entire treatment.
voked similar reactions in 90% and 100% of the pa- O Morphologic alterations resulting from the pre-
tients, respectively. The symptoms subsided faster vious treatment may present unusual technical and
after retreatment, with only 4% of the patients still therapeutic challenges (71).

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O Root filling and possibly restorative materials must ment (retreatment/surgery) relative to persistent dis-
be removed from the root canals, increasing the as- ease.
sociated risk. All of the above result in considerable intra- and inter-
O The healing rate is generally recognized to be individual variations in decision making among clini-
lower than after initial treatment (2), undermining cians, observed even in surveys referring to radio-
the confidence of both the patient and the clinician. graphs or drawings and case histories, but not involv-
O Patients may be more apprehensive than with the ing actual treatment of patients (8, 75–85). It is
‘routine’ initial treatment. amazing to note that, although there were neither pa-
tients to treat nor real risks to be concerned about,
the ‘treatment’ prescribed by the surveyed clinicians
varied considerably ª retreatment in 25% of the teeth,
Inconsistent management
apical surgery in 15–20%, but no treatment in 53–
The unique dilemmas highlighted above may be the 60% of the teeth (76, 80).
main reason for the inconsistent management of post- Such apparent reluctance of clinicians to implement
treatment endodontic disease, as demonstrated in sev- treatment indicates unease with the management of
eral studies (72–74). After having reviewed treatment post-treatment disease. The unease of the clinicians is
plans submitted for a Swedish population of 1094 pa- frequently confounded by the patient’s reluctance to
tients, which included 874 teeth with post-treatment accept retreatment, a procedure interpreted as a rep-
endodontic disease, Petersson et al. (74) report that etition of the ‘same thing’. In contrast, apical surgery
extraction was planned in 23% of the teeth, apical may be interpreted as a different procedure, thus not
surgery in 3% and retreatment in 20%, but in the re- stirring similar sentiments. To foster confidence and
maining 54% of the teeth, no intervention was appropriate management, definitive criteria are re-
planned. In another report (73), 351 patients were quired to select cases for extraction, retreatment and
examined in successive cross-sectional studies per- apical surgery.
formed 11 years apart; it was revealed that 22% of the
teeth that presented with post-treatment disease in the
Diagnosis
first study were extracted and 18% were subjected to re-
treatment or apical surgery, but 60% remained un- Presence or absence of endodontic disease is deter-
treated in spite of the evident pathosis. A comparable mined according to clinical and radiographic find-
distribution was observed by Friedman et al. (72) in a ings. As mentioned above, opinions regarding diag-
long-term follow-up study after apical surgery: 31% of nosis have varied among clinicians and even re-
the teeth in which healing had not occurred were ex- searchers from as far back as some 70 years ago
tracted and 16% were treated again, while 53% re- (86). This variability is greatest when symptoms are
mained unattended from one follow-up period to the absent (2). However, apical periodontitis is fre-
next, and remained in limbo up to 8 years in some quently asymptomatic and diagnosed primarily by
cases. the radiographic appearance. The rather low preva-
The inconsistent management is not unique to lence of clinical signs and symptoms in conjunction
post-treatment endodontic disease; it has been docu- with apical periodontitis has been suggested by a
mented in other disciplines of dentistry and in medi- number of treatment outcome studies. For example,
cine (8). Nevertheless, its foundations require explo- of all the teeth with periapical radiolucency included
ration, in an attempt to more consistently provide pa- in two studies on the outcome of endodontic treat-
tients with the best treatment and greatest benefit. ment, only 18% (87) and 24% (10) also presented
It appears from the extensive research efforts of the clinical symptoms.
Gothenburg, Sweden, group (8) that the inconsistent Clearly then, the absence of symptoms at a fol-
management stems from: low-up examination of endodontically treated
O weak evidence base to support decisions; teeth is immaterial when the radiographic ap-
O subjective, unreliable and unstable values of peri- pearance is suggestive of post-treatment disease;
apical health and disease; therefore, it should not be used as an argument to
O subjective values of the utility, or benefit of treat- defer treatment or to avoid it altogether (2). Fur-

63
Friedman

thermore, when infected teeth present with apical son may be the reluctance to remove posts, primarily
periodontitis for initial endodontic treatment they to avoid the risks, but also because of previously ex-
are consistently treated because of radiographic perienced unsuccessful attempts at post removal (69).
signs of disease, although the majority are not Friedman & Stabholz (70) were the first to suggest
symptomatic. If radiographs still suggest the same systematic criteria for case selection in the management
disease post-treatment, this should not be con- of post-treatment disease. At that time, society ex-
sidered a satisfactory outcome, even if symptoms pected clinicians to assume a paternalistic approach to
are absent (2). clinical decision making (8); it was the clinician’s re-
This dilemma of disease vs. symptoms can be re- sponsibility to select and then provide the most appro-
solved simply by asking the patient upon consul- priate treatment; therefore, for the most part, the out-
tation whether he/she expects healing of the disease, lined criteria referred to the case history and the tooth
or only relief of the symptoms? The specific answer under consideration. The patient was mentioned brief-
may serve as a guideline for the clinician and the ly, to suggest he/she ‘should be informed about alter-
patient as to which expectation is the most im- native treatments and possibly be allowed to partici-
portant. pate in deciding the choice of treatment’ (70). The cli-
Non-endodontic disease, vertical root fracture or nician, too, was mentioned briefly, and advised to
healing in progress should all be carefully con- ‘evaluate each case according to his capability’ and, in
sidered as a differential diagnosis (88). In this re- doubtful cases, to ‘consult an endodontist whom he
gard, the case history is reviewed, noting previous may consider more experienced than himself’ (70).
radiographs when these are available, past occur- Perhaps the weakest aspect of this case selection system
rences of symptoms, the time elapsed since previous was the assessment of the ‘feasibility’ of gaining a co-
treatment (to recognize healing in progress and ronal access to the root canals; this introduced subjec-
thus avoid premature diagnosis) and previous tivity and bias at the most critical juncture of deciding
attempts at retreatment or apical surgery (may be between retreatment and apical surgery. Nevertheless,
suggestive of vertical fracture) (70, 89). this system has gained wide acceptance, possibly be-
cause it categorically regarded retreatment as a pre-
ferred treatment alternative, and focused on identify-
Selection of treatment
ing clinical conditions, that would justify an alternative
Selection of extraction, retreatment or apical surgery treatment such as tooth anatomy, root filling, iatro-
appears to be an area that has not been clearly de- genic factors and potential complications.
scribed in articles and textbooks until fairly recently. Reit and coworkers (7, 8, 47, 68, 77–84, 91) have
Almost uniformly, this area had been referred to by systematically studied the decision making process
outlining indications for apical surgery, as follows (5, with regards to the management of post-treatment dis-
71, 89, 90): ease in an attempt to understand the various factors
O persistence of symptoms after endodontic treat- that underlie this process and to develop a decision
ment; making strategy. They suggest that this process in-
O poor or suspect quality of the root filling (assessed volves the interaction of scientific, psychological and
radiographically or upon clinical inspection); sociological considerations and that it relies mostly on
O presence of post-supported restorations, inaccess- the associated values of the utility of treatment (re-
ible canals and irretrievable root filling materials; treatment or surgery) for a disease that is not life threat-
O procedural complications during endodontic treat- ening (80). Thus far it appears that the monumental
ment; work of these researchers has been extremely helpful in
O diagnostic procedures such as biopsy and verifi- underscoring the many factors involved, from timing
cation of a fracture or crack. and interpretation of follow-up radiographs to per-
The approach to retreatment had been mostly intuit- sonal ethical and utility values. They suggest a follow-
ive and subjective, which may be one of the reasons up strategy, whereby patients should be assessed for the
why clinicians educated during that period demon- outcome of treatment 1 year postoperatively and, if in
strate such variability and inconsistency in selecting doubt, recalled again 3 years later (91). However, they
between retreatment and apical surgery. Another rea- have not yet been able to suggest a systematic strategy

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that, if universally taught to clinicians, would facilitate modified benefit–risk balance may no longer outweigh
the selection between retreatment and apical surgery that of apical surgery. These considerations focus on:
and would make it more consistent. O the patient,
As stated above, the current ethical and legislative O the tooth in question,
requirements of the society dictate that the patient O the clinician,
selects the treatment; the clinician’s responsibility has O the previous treatment attempts.
evolved from making treatment decisions to com-
municating the pertinent information and thus facilit-
Patient considerations
ating the patient’s decision making process, and pro-
viding the treatment selected by the patient. The fol- The attitude of patients and clinicians towards peri-
lowing case selection strategy, suggested by Friedman apical disease and the utility of treating it differ sig-
(63), is consistent with this modern concept. nificantly (83). Moreover, the motivation to retain
every tooth and to pursue the best long-term treat-
ment outcome may vary, as do the motivation and
Case selection ability to allocate time and finances. All these general
Retreatment and apical surgery are usually performed attitudes influence the patient’s treatment prefer-
to treat existing disease, presenting with definitive ences; therefore, they are primary considerations in
radiographic changes and possibly clinical signs and the case selection process (Table 1).
symptoms. However, even in the absence of disease,
retreatment may be indicated to prevent the potential
Motivation to retain the tooth
emergence of disease in the future (5, 70).
The considerable effort associated with both re-
treatment and apical surgery is justifiable only by the
Treatment of existing disease
potential to retain the diseased tooth. For the unmo-
As explained above, whenever post-treatment dis- tivated patient, extraction is recommended.
ease is diagnosed and treatment (tooth retention) is
preferred over extraction, both orthograde re-
Motivation to pursue the best long-term outcome
treatment and apical surgery should be considered.
Because retreatment appears to offer a greater bene- For the patient who is receptive to a compromise in
fit ª better ability to eliminate the disease’s etiology terms of the long-term outcome, the easier apical
(root canal infection) with minimal invasion, and a surgery procedure is recommended when retreatment
lesser risk ª significantly less postoperative dis- is expected to be very elaborate, unless surgery is
comfort (68) and less chance of injuring anatomic contraindicated on the grounds of health, anatomy or
structures, it should be generally considered the accessibility.
principal treatment of choice; however, it is not al-
ways feasible. At times, retreatment can be more
Critical time concerns
time-consuming and costly than surgery, particularly
when an extensive restoration must be replaced. For the time-restricted patient who is receptive to a
Also, the ability to materialize the full benefit of re- compromise in order to minimize his or her time
treatment may be restricted by a variety of clinical commitment, the quicker apical surgery procedure is
factors (70). Moreover, clinicians’ capability to per- recommended. However, the associated postopera-
form retreatment and surgery varies considerably. tive discomfort and recovery may impose loss of work
To summarize, orthograde retreatment is generally time and income (68), and therefore should be taken
selected because of its greater benefit and lesser risk into account.
in comparison with apical surgery. Therefore, the case
selection strategy suggested below is based on con-
Critical financial concerns
siderations that either preclude retreatment alto-
gether, or restrict it in a way that may decrease the For the financially restricted patient who is receptive
potential benefits and increase the risks; the resulting to a compromise in order to minimize cost, apical

65
Friedman

surgery is recommended when the combined cost of mycosis, more than one sinus tract (37), and that of a
retreatment and restoration is considered prohibitive. vertical root crack/fracture, an isolated, narrow defect
Again, the potential loss of income resulting from along the root (92). Comparison of older and recent
postoperative discomfort and recovery should be radiographs may also be helpful in some cases (70, 89).
taken into account (68).
Following the simple strategy described above, the
patient is prompted to relate the treatment alterna-
Root canal obstacles
tives to some of his or her values and priorities. This
may be helpful in preparing the patient to make a To materialize the full benefit of retreatment, elimin-
decision regarding the selected treatment. ation of root canal infection, the canal must be re-
negotiated throughout. Obstacles that restrict the cli-
nician’s ability to totally renegotiate the canal de-
Tooth considerations
crease the potential benefit of retreatment, while
When, following the above, the patient indicates a pref- attempts to overcome the obstacles increase the risk
erence for retreatment, the tooth and surrounding of procedural complications (transportation, perfor-
tissues are scrutinized with the aim of identifying clin- ation). The main obstacles that should be considered
ical conditions that might adversely affect the prog- are (Fig. 6):
nosis. Particular attention should be directed towards O calcification;
the recognition of obstacles that might limit the clini- O diverging root canal system;
cian’s ability to materialize the full benefit of re- O suspected ledge;
treatment, or that might increase the level of risk when O hard-setting cement;
attempts are made to overcome obstacles. In specific O broken instrument.
cases, the modified benefit–risk balance no longer justi- The feasibility of overcoming these obstacles must be
fies the preference of retreatment over surgery. assessed; consequently, the benefit–risk balance may
or may not change in favor of the surgical alternative.
In many teeth the canals are obstructed with posts.
‘Site of infection’
In the past, presence of a post was the main indication
As explained above, infection by root canal micro- for apical surgery (5, 71, 89, 90). Currently, however,
organisms is best eliminated by retreatment (2), cumulative clinical experience (62) and research data
whereas infection by extraradicular (periapical) micro- (60, 61) have helped establish confidence among
organisms is best eliminated by apical surgery (43). In many clinicians that posts can be removed predictably
contrast, infection associated with a vertical root crack with minimal risk (Fig.s 4 and 7). Therefore, presence
or fracture cannot be predictably eliminated by either of a post should not be considered to change the
procedure (92). A diagnostic process is therefore re- benefit–risk balance in favor of apical surgery. This
quired to differentially establish the likely ‘site of infec- recognition represents the most drastic departure
tion’. To facilitate this process, one should recognize from previous approaches to case selection and in-
the frequent manifestation of extraradicular actino- dications for apical surgery.

Table 1. Patient considerations governing case selection in the management of existing disease after root canal
treatment (adapted from 63)
Consideration No Yes
Motivation to retain tooth in question extraction retreatment or surgery
Motivation to pursue the best long-term outcome surgery retreatment
Critical time concerns retreatment surgery
Critical financial concerns retreatment surgery

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 Post-treatment endodontic disease

Fig. 6. Root canal obstacles considered to assess feasibility of retreatment. A. Calcific metamorphosis. B. Complex mor-
phology. C. Suspected ledge. D. Broken instrument. These obstacles restrict the clinican’s ability to renegotiate the canal
and increases the risk of canal perforation. (Reprinted with permission from (63)).

67
Friedman

Fig. 7. Retreatment and post removal through the crown. A. Three prefabricated posts in mandibular molar with post-
treatment disease. B. Access was prepared through the crown and posts were removed; the canals are dressed with calcium
hydroxide. C. Completed retreatment. D. Progressive healing at 6 months. (Reprinted with permission from (63)).

68
 Post-treatment endodontic disease

Perforation Capability
In the past, the presence of a perforation was con- Capability is a combination of training, skill and ex-
sidered an indication for surgical intervention aimed perience. Specialist endodontists usually are more
at external repair (5, 71, 90), because of a doubtful capable of treating post-treatment disease than the
prognosis of internal repair (93, 94). Currently, how- non-specialist dentists. Occasionally, however, even a
ever, it is recognized that a perforation of the pulp specialist may not be equally adept at retreatment and
chamber or root impairs the prognosis only when it apical surgery. When there is not an option of referral,
has become a pathway of infection (95). Therefore, the procedure that can be performed best by the at-
retreatment in conjunction with internal repair of the tending clinician (specialist or not) is recommended.
perforation is usually warranted in an attempt to cur-
tail the infection, and surgery is not the primary treat-
ment of choice (Fig. 8) (64, 95, 96). Nevertheless,
Armamentarium
when healing is unlikely or does not occur, surgery
may be required as an adjunct. The surgical pro- Use of special instruments can optimize the benefit–
cedure may include external repair of the perforation risk balance of both retreatment and apical surgery.
and an attempt at guided tissue regeneration (Fig. 9). Without a referral option, if only the instruments re-
quired to perform one of the procedures are available
to the attending clinician, that procedure is recom-
Restorative, periodontal and aesthetic factors
mended.
Teeth considered to have a hopeless restorative or
periodontal prognosis should be extracted (70). With
compromised periodontal support, apical surgery may
Time availability
result in an unfavorable crown–root ratio; therefore,
retreatment is recommended. In teeth presenting In specific circumstances (remote areas, community
with an oro-facial sinus tract, surgery may have to be clinics), an excessive practice load may prevent the cli-
performed as an adjunct to retreatment to minimize nician from undertaking an elaborate retreatment of
scarring associated with the healing of the sinus. one complex case. In these circumstances only, and
without a referral option, surgery is recommended
rather than the complex retreatment.
Clinician considerations
Clinicians vary with regards to capability, availability
Previous treatment attempts
of armamentarium and latitude regarding the time
they can (or are willing to) spend on an elaborate If a previous orthograde retreatment or apical surgery
treatment of one tooth. All of the above determine procedure did not result in healing, the quality of that
a clinician’s ‘comfort zone’, or confidence regarding procedure should be evaluated. If the initial case
specific treatment procedures. In the past, this com- selection is considered to have been appropriate but
fort zone played a major role in the selection between the quality improvable, the same procedure is recom-
retreatment and apical surgery (71). Currently, how- mended again (Fig. 10). Otherwise, the alternative
ever, when the clinician does not feel comfortable procedure is recommended, as it may better address
performing the treatment procedure selected by the the site of the infection and capacitate healing (Fig.s
patient, it is considered appropriate to refer the pa- 11 and 12).
tient to another clinician who can perform the se-
lected procedure. It is appropriate for the clinician’s
‘comfort zone’ to influence the selection only in the
Prevention of potential disease
rare situations when referral is unfeasible (remote
areas); in these situations, the selected treatment is Endodontically treated teeth may appear to be free of
that with which the clinician is most confident. any signs of disease and yet harbor microorganisms in

69
Friedman

Fig. 8. Retreatment in conjunction with an internal perforation repair. A. Distal root perforation into a furcation in a
mandibular molar with post-treatment disease. B. Access to the distal canal was established through the crown without
disturbing the mesial root, and retreatment is in process. C. Completed retreatment and perforation seal with MTA. D.
Complete healing at 1 year. (A, B and C reprinted with permission from (63)).

70
 Post-treatment endodontic disease

Fig. 9. Retreatment followed by an external perforation repair. A. Distal root perforation into the furcation of a mandibular
molar with post-treatment disease. B. Access to the distal canal was established through the crown, the post extracted and
the perforation sealed with MTA. However, a sinus tract persists at 3 months. C. The bone defect was accessed surgically,
the perforation repaired externally with MTA, a bovine-derived bone substitute was placed, and a resorbable membrane
inserted. D. Complete healing of the perforation site at 2 years, accompanied by loss of the marginal bone in the furcation.

71
Friedman

Fig. 10. Persistent disease after apical surgery. A. Post-treatment disease persists 2 years after apical surgery in the maxillary
lateral incisor. Note the gutta-percha cone tracing the sinus tract. The patient selected to have apical surgery performed again.
B. Repeated apical surgery, with an attempt to improve upon the quality of the previous procedure - the canal was retreated
through the apex all the way to the post, and filled with MTA. C. Complete healing at 3 years.

the canal (28). The apparent absence of disease sug-

Post restoration
gests that a balance exists between the root canal
microorganisms, their specific environment and the In addition to the above, there is a risk of root canal
host; if this balance is altered by changes in oxygen contamination during the post space preparation,
tension, supply of substrate or decreased host re- temporary restoration, and final post cementation.
sistance, this can result in infection and disease (1).
Another distinct risk that has to be considered is
Compromised host resistance
coronal leakage. If microorganisms are allowed to in-
vade and colonize the pulp chamber space, they can Theoretically, weakened host resistance can modify
propagate to invade the filled canal and establish in- the balance and prompt infection. This factor, how-
fection and disease within weeks or months, even if ever, has not been thoroughly investigated.
the root canal appears to be well filled (33). To summarize, the considerations governing pre-
The factors that may affect emergence of post-treat- vention of potential post-treatment disease include:
ment endodontic disease are listed below: O the adequacy of the root filling;
O the adequacy of the coronal seal;
O the need for a new restoration.
Coronal restoration
Post-retained crown or bridge restorations represent
When the endodontic system (pulp chamber, canals) a particular concern, because they will restrict the op-
has been exposed to coronal leakage or secondary tion of orthograde retreatment should disease emerge
caries, closure of this system by change of the restora- in the future. The likelihood of emerging post-treat-
tion, even a simple filling, can modify the canal en- ment disease appears to be highest when both the
vironment (availability of oxygen and substrate) to root filling and the coronal seal are suspect, and a new
favor pathogenic microbial strains that may establish restoration is needed. In these cases retreatment is in-
infection and disease. dicated, as it offers the benefit of preventing post-

72
 Post-treatment endodontic disease

Fig. 11. Persistent disease after retreatment. A. Post-treatment disease in maxillary lateral incisor. B. Completed retreatment.
Note apical patency and extensive apical enlargement. C. Disease persists at 1 year; because healing is unlikely following
another retreatment, apical surgery is indicated. D. Complete healing at 6 months after apical surgery. (Reprinted with
permission from (63)).

73
Friedman

Fig. 12. Persistent disease after apical surgery. A. Post-treatment disease in maxillary first premolar. Because canals are
assumed to be the site of infection, retreatment is indicated rather than repeated surgery. B. Access was prepared through
the crown, the post was removed, and retreatment is underway. C. Completed retreatment. D. Progressive healing at 6
months. The crown is being replaced. (Courtesy Dr. David Campbell).

74
 Post-treatment endodontic disease

treatment disease. However, when a new restoration more experienced in performing the particular pro-
is not needed and only the root filling is suspect, cedure selected by the patient.
emergence of post-treatment disease is less likely, and
retreatment offers a lesser or no benefit. In these cases
only follow-up is indicated; retreatment, and associ-
ated possible complications, can be avoided (5, 70). References
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