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Comparison of Classic Endodontic Techniques
versus 
Contemporary Techniques on Endodontic Treatment Success
Chris H. Fleming, DMD,* Mark S. Litaker, PhD,
† 
 Larry W. Alley, DMD,* and Paul D. Eleazer, DDS, MS * 
 Abstract
Introduction:
Many recent technological advance-ments have been made in the field of endodontics;however, comparatively few studies have evaluatedtheir impact on tooth survival. This study comparedthe survival rates of endodontic treatment performedby using classic techniques (eg, instrumentation withstainless steel hand files, alternating 5.25% NaOCland3%H
2
O
2
irrigation,mostlymultipletreatmentvisits,and so on) versus those performed using more contem-porary techniques (eg, instrumentation with hand androtary nickel-titanium files, frequent single-visit treat-ment, NaOCl, EDTA, chlorhexidine, H
2
O
2
irrigation,warm vertical or lateral condensation obturation, useof surgical microscopes, electronic apex locators, andso on).
Methods:
Using a retrospective chart review,clinical data were obtained for 984 endodonticallytreated teeth in 857 patients. Survival was defined asradiographic evidence ofthetreated toothbeing presentin the oral cavity 12 months or more after initial treat-ment. A mixed-model Poisson regression analysis wasused to compare failure rates.
Results:
Of the 459 teethin the classic group, there was an overall survival rate of 98% with an average follow-up time of 75.7 months. Of 525teethinthe contemporarygroup,therewas anover-all survival rate of 96%, with an average follow-up timeof 34 months. Considerably more treatments in theclassic group were completed in multiple appointments(91%) than in the contemporary group (39%). Moreteeth in the classic group underwent posttreatmentinterventions (6.7% vs 0.9%, respectively).
Conclu-sions:
No statistically significant difference was notedbetween the two technique groups or between singleor multiple visits in terms of survival.
(J Endod 2010;36:414–418)
Key Words
Endodontics outcomes, multiple-visit endodontics,temporary restorations
T
he goal of endodontic treatment is to eliminate diseased pulpal tissue and to createanenvironmentthatwillallowforhealingofperiapicaltissuesandpreventthedevel-opment of apical periodontitis. Through the removal of diseased tissue, sealing of thecanal system, and subsequent restoration of the coronal tooth structure, affected teethare retained. This maintenance of arch integrity, esthetics, and function is what most patients ultimately desire. Yet, there are other treatment options available for pulpally and or periapically diseased teeth in addition to endodontic treatment. Extraction fol-lowed by implant or removable/fixed partial denture placement are treatment optionsthatthedentistandpatientmayconsider.Extensiveliteraturehasbeenpublishedonthesuccess of endodontic treatment, but great variability exists between study protocols as well as data obtained. Differences include the length of recall, radiographic interpreta-tion, experience of practitioners, and methods of assessment of treatment outcomes.Thus, treatment outcomes and success rates differ greatly. Some studies define successbased on strict radiographic healing, whereas others consider an endodontically treated tooth a success if it remains present and functioning in the oral cavity (1–5).Inconsistency in the definition of endodontic treatment ‘‘success’’ is confusing topatients and practitioners and can cause injudicious treatment decisions. This concept has become increasingly problematic in the debate between endodontic treatment andimplant-supported single-tooth replacement. In order to more effectively comparetreatment outcomes between endodontically treated teeth and implants, several recent studies have evaluated endodontic success in terms of tooth survival rather than strict radiographic and histologic criteria for healing(6–11).Over the past few decades, huge technological advancements have been made inthe field of endodontics. Microscopes, rotary nickel-titanium files, ultrasonic instru-mentation, electronic apex locators, digital radiography, new irrigation solutions,and innovative obturation techniques have revolutionized the way in which endodonticprocedures are performed. Despite such advancements, the question exists as to whether these technologies have improved the outcome of endodontic treatment andincreased the likelihood of tooth survival. The purpose of this retrospective study  was to evaluate and compare survival rates of endodontic treatment performed by anexperienced endodontist performing classic treatment techniques versus a group per-forming more contemporary techniques.
Materials and Methods
This study was approved by the University of Alabama at Birmingham Institutional Review Board. Two study groups were selected for analysis: the classic group and thecontemporarygroup.Patientrecordsfromfourdifferenttreatmentlocationswereiden-tified, and data were collected by chart review. The classic group consisted of patient recordsobtainedfromthepracticeofoneendodontistwhohadbeentrainedintheearly 1970s. The ‘‘classic techniques’’ performed by this endodontist included
From the Departments of *Endodontics and
†
Diagnostic Sciences, University of Alabama at Birmingham, Birmingham, AL.AddressrequestsforreprintstoDrPaulEleazer,UniversityofAlabamaatBirminghamDepartmentofEndodontics,15303rdAvenueSouth,SDB406,Birmingham,AL35294. E-mail address:eleazer@uab.edu.0099-2399/$0 - see front matterCopyright
ª
2010 American Association of Endodontists.doi:10.1016/j.joen.2009.11.013
Clinical Research
414
Fleming et al.
JOE 
 — 
 Volume 36, Number 3, March 2010
 
instrumentation with stainless steel hand files, alternating 5.25% NaOCl and 3% H
2
O
2
irrigation, mostly multiple treatment visits, placement of calcium hydroxide and form cresol intracanal medicaments, strict adherence to confining instrumentation and obturation short of theradiographicapex,lateralcondensationobturation,andfrequentplace-ment of definitive restorations at the completion of the procedure. Thecontemporary group consisted of patient records obtained from threedifferent endodontic practices in which where the practitioners weretrained within the past 15 years. The ‘‘contemporary techniques’’used in this group included instrumentation with hand and rotary nickel-titaniumfiles,frequentsingle-visittreatment,NaOCl,EDTA,chlo-rhexidine, H
2
O
2
irrigation, warm vertical or lateral condensation obtu-ration, use of surgical microscopes, electronic apex locators, digital radiography, ultrasonic instrumentation, and placement of temporary restorations.ThetreatmenttechniquesforbothgroupsaresummarizedinTable 1. Patient records from the selected practices werereviewedinalphabetical order. If an endodontic procedure was completed ona patient, the record was further evaluated to determine if a clinical or radiographic follow-up for that tooth was available. The only criteria required for inclusion in the study was that a clinical or radiographicfollow-up of 12 or more months after endodontic treatment was avail-able. Endodontically treated teeth without a clinical or radiographicfollow-up of at least 12 months were excluded from the study. Many times follow-up radiographs were obtained at specific recall appoint-ments. Other follow-up radiographs were obtained during the courseof treatment of the adjacent teeth. Only radiographs that displayed theentire tooth including the periapex were used for evaluation. Whenavailable, treatment data obtained for the endodontically treated toothincluded the following: tooth number, patient age at treatment, sex,ethnicity, smoking habits, presence/absence of diabetes, length of time to most recent recall, tooth restored and functioning in occlusion,toothpresenceinthemouth,numberoftreatmentappointments,lengthofobturationrelativetotheradiographicapex,presenceofapost,pres-enceofapreoperativeperiapicalradiolucency,andposttreatmentinter- ventions. Amodified periapicalindex scoringsystem was createdby theauthors to evaluate pre-op radiographs for the presence of periapical lesions. This system was similar to that used by Hannahan et al (11).The parameters for the scoring system are shown inTable 2. Radio-graphs were examined by a single evaluator and no calibration wasundertaken. The periodontal ligament surrounding the treated tooth was evaluated for breaks in continuity and/or widening. Thesurrounding alveolar bone was evaluated for radiolucencies. No data  were collected on the number of roots affected, size of the lesion, or whether the lesion was well defined or diffuse. Teeth were classifiedas having a pre-op lesion if there was breakdown or widening in thePDL or radiolucency in the bone. This corresponded to a modifiedPAI score of 3 or greater. A modified PAI score of 3 or greater wasused toidentifythepresenceofaperiapicallesion.Postoperative radio-graphs were only evaluated for the presence or absence of the treatedtooth. Evaluation of periapical pathosis using the modified periapical index was not completed for postoperative recall radiographs. Survival of endodontic treatment was defined as radiographic evidence of thetreated tooth still present in the mouth 12 months or more after theinitial treatment. A tooth was classified as a failure if extracted at any time after treatment. Failure rates were compared between the twogroups using amixed-modelPoissonregressionanalysis.A term repre-senting the individual patients was included as a random effect in themodel in order to account for correlation caused by the occurrenceof multiple treatments for some patients. The analysis was implementedusing SAS statistical software (Release 9.2; SAS Institute, Inc, Cary NC).
Results
Of the nearly 8,000 charts reviewed, 984 endodontically treatedteeth in 857 patients met the inclusion criteria. A summary of findingsis presented inTable 3. The classic group included 459 treated teeth in414 patients; the contemporary group consisted of 525 contemporarily treated teeth in 443 patients. In the classic group, nine teeth were ex-tracted, resulting in an overall survival rate of 98.0%. Twenty-one fail-ureswerenotedinthecontemporarygroupdatawithanoverallsurvival rateof96.0%.Molarswerethemostfrequentlytreatedgroupofteethinboth groups followed by premolars and anteriors. The patient popula-tion averaged 48.9 years of age in the classic group (standard deviation= 14.1 years) and 53.9 years in the contemporary group (standarddeviation = 15.2 years,
p
< 0.0001). Women were treated morefrequentlyinbothgroups;98.6%ofpatientstreatedintheclassicgroup were white and 1.4% black. Eighty-six percent of patients treated by theendodontists in the contemporary group were white and 12.2% black  with few Asians and Hispanics represented. The ethnic distributionsof the two groups were significantly different (
 p
< 0.0001). Ethnicity data were unavailable for 108 patients. Nearly 10% of the populationin the contemporary group reported a history of diabetes, whereasonly four patients in the entire population of the classic group reporteda history of diabetes. The average time to recall in the classic group was75.7 months, ranging from 12 to 301 months, which was over doublethat of the contemporary group (34.0 months, ranging from 12-219months). In the classic group, the average number of treatment appointments was 2.2. Most of the classic group root canal treatments werecompletedintwovisits(71.9%);anadditional19.6%weretreatedin three or more visits. Only 8.5% of the treatments were performed inasinglevisit.Rootcanaltreatmentsinthecontemporarygrouprequiredan average number of 1.41 appointments. The majority of cases in thecontemporary group were completed in a single visit (60.2%). Fewertreatments required more than one visit (39.8%). Of the teeth treatedinmorethanonesessioninthecontemporarygroup,only0.95%neces-sitated three or more visits. The number of treatments performed ina single visit was significantly different between the classic group andcontemporary group (
 p
< 0.0001). Calcium hydroxide was the most frequently placed intracanal medicament. In the classic group, form
TABLE 1.
Comparison of Treatment Techniques
Classic Group Contemporary Group
Hand SS files Hand/Rotary SS and NiTi filesMostly two or more visits Predominately one visitNaOCl and H
2
O
2
NaOCl, CHX, ETDA, H
2
O
2
Lateral condensationobturationWarm vertical, lateralcondensation obturationNo overfills More frequent obturationflush or overfilledDefinitive restoration ofaccess in most patientsMostly temporary restorationsSurgical microscopesUltrasonic instrumentationElectronic apex locatorsDigital radiography
SS, stainless steel.
TABLE 2.
Summary of Modified Periapical Index Scoring System
PAI 1 Intact PDLPAI 2 Possible broken or widened PDLPAI 3 Broken or widened PDLPAI 4 Break in PDL with possible radiolucencyPAI 5 Broken PDL with definite radiolucency
PDL, periodontal ligament. PAI scores
$
3 indicate periapical lesion.
Clinical Research
 JOE 
 — 
 Volume 36, Number 3, March 2010 Classic Endodontic Techniques
versus
Contemporary Techniques on Treatment Success
415
 
cresol was placed in many vital cases. Obturation in the classic group was confined within the tooth in all cases, with lengths ranging from0 to 5 mm inside the radiographic apex. Most of the obturation lengths were confined within 2 mm from the radiographic apex. No gross over-fills were noted. The contemporary group had more overfills (3.8%);however,most ofthefillswerelessthan2mmshortof theradiographicapex. A larger percentage of teeth with pretreatment lesions (PAI scoreof 
$
3)(31.2%)occurredintheclassicgroupversusthecontemporary group (28.0%) although the difference was not statistically significant (
 p
= 0.3796). Although no specific data were recorded, most of theaccesspreparations inthe classicgroup wererestored bythe endodon-tist with a definitive restoration. All teeth that did not require multisur-face buildups were restored with amalgam or composite at thecompletion of endodontic treatment. When temporary restorations were placed, cotton pellets were seldomly used. Almost all teeth inthe contemporary group were restored with a temporary restoration.Cotton pellets were more frequently placed. A significantly greater number of teeth underwent posttreatment interventions in the classic group (6.7%) than in the contemporary group(0.9%,
 p
=0.0141).Onlyoneoftheteeththatreceivedposttreat-ment intervention was subsequently extracted. A summary of data onposttreatment interventions is presented inTable 4. Most of the post-treatment interventions in both groups were performed on molarsand on teeth with pretreatment periapical radiolucencies. The most frequent posttreatment intervention performed in the classic group was retreatment, whereas apicoectomy was marginally more frequent in the contemporary group. Most of the interventions in the classicgroup were performed on teeth originally treated in multiple visits.The average obturation lengths of intervention teeth were similar tothose of the nonintervention teeth in both groups.
TABLE 3.
Summary of Data 
Classic Group (%) Contemporary Group (%)
Treated teeth 459 525Anteriors 88 (19.2) 106 (20.2)Premolars 149 (32.5) 129 (24.6)Molars 222 (48.4) 290 (55.2)Avg treatment age*48.9 (SD = 14.1) 53.9 (SD = 15.2)
p
< 0.0001Females 267 (58.2) 299 (56.9)Males 192 (41.8) 226 (43.1)Ethnicity*White: 98.6% White: 86%
p
< 0.0001Black: 1.4% Black: 12.2%Smoker NA N: 340 of 401 (84.8)Y: 61 of 401 (15.2)Diabetes N: 455 (99.1) N: 361 of 401 (90.0)Y: 4 (0.9) Y: 40 of 401 (10.0)Avg recall time 75.73 months 34.07 monthsAvg number visits 2.2 1.411 visit*39 (8.5) 316 (60.2)
p
< 0.00012 visits 330 (71.9) 204 (38.9)3+ visits 90 (19.6) 5 (0.95)Overfills 0 21Post present N: 402 (87.6) N: 445 (84.8)Y: 57 (12.4) Y: 80 (15.2)Preoperative lesion N: 317 (69.1) N: 378 (72.0)Y: 142 (30.9) Y: 147 (28.0)Post Tx interventions*31 (6.7) 5 (0.9)
p
= 0.0141Apico: 10 Apico: 3Retreat- 20 Retreat: 2Hemisection: 1 NAFailures (extractions) 9 21Success 98.03% 96.00
 Y, yes; N, no; NA, not applicable; SD, standard deviation.*Indicates statistical significance.
TABLE 4.
Characteristics of Post Treatment Interventions
Classic Group (%)ContemporaryGroup (%)
Interventions 31/459 5/525Percentage 6.70% 0.90%Anteriors 7 (22.6) 1 (20.0)Premolars 6 (19.4) 1 (20.0)Molars 18 (58.1) 3 (60.0)Diabetes 1 (3.2) 1 (20.0)1 visit 1 (3.2) 2 (40.0)2 visit 20 (64.5) 3 (60.0)3+ visits 10 (32.3) 0 (0.0)Overfills/flush fills 0 (0.0) 3 (60.0)Post present 3 (9.7) 2 (40.0)Preoperative area 19 (61.3) 3 (60.0)
TABLE 5.
Characteristics of Failures
Classic Group (%)ContemporaryGroup (%)
Failures 9/459 21/525Percentage 1.96% 4.00%Anteriors 1 (11.1) 0 (0.0)Premolars 1 (11.1) 13 (61.9)Molars 7 (77.8) 8 (38.1)Diabetes 1 (11.1) 1 (0.05)1 visit 0 (0.0) 12 (57.1)2 visit 3 (33.3) 7 (33.3)3+ visits 6 (66.7) 2 (9.5)Overfills/flush fills 0 (0.0) 9 (42.9)Post present 0 (0.0) 8 (38.1)Preoperative area 4 (44.4) 10 (47.6)Post Tx intervention 1 (11.1) 0 (0.0)
Clinical Research
416
Fleming et al.
JOE 
 — 
 Volume 36, Number 3, March 2010
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