Prevalence of apical periodontitis of root canal–treated teeth

and retrospective evaluation of symptom-related

prognostic factors in an urban South Korean population
Seonah Kim, DDS, PhD,Seoul, Korea
KANGDONG SACRED HEART HOSPITAL

Objectives. This study aimed to investigate the prevalence of apical periodontitis among root canal–treated teeth in an
urban South Korean population and evaluate prognostic factors for periapical radiolucency and its symptoms.
Study design. The periapical status of 896 root canal–treated teeth was evaluated by using digital panoramic
radiography. Five prognostic factors were analyzed: length and density of the root filling, presence of crown
restoration, probability of unilateral bite, and presence of missing canals.
Results. The prevalence of apical periodontitis among root canal–treated teeth in the study population was 22.8%,
and 29.3% of these teeth had received dental treatment for pain relief. Evaluation of the prognostic factors indicated
that inadequacy of endodontic treatment was more predictive of apical periodontitis than the absence of a crown
restoration.
Conclusion. Inadequate root filling length appeared to be the most important prognostic factor related to apical
periodontitis and its acute symptoms among root canal–treated teeth. (Oral Surg Oral Med Oral Pathol Oral Radiol
Endod 2010;110:795-799)

The prevalence of periradicular lesions among root canal–
treated teeth is reportedly higher in cross-sectional studies
than in longitudinal studies conducted in controlled envi-
ronments at dental schools or specialist clinics.1-11 Epide-
miologic studies in many countries have revealed radio-
graphically normal apex rates as low as 35%-70% for root
canal–treated teeth.1-8 However, those studies did not in-
vestigate the association between the symptoms and the
presence of a periapical radiolucency.
Endodontic treatment is a feasible, practical, and eco-
nomical method to preserve tooth function. In an earlier
study with a large patient population, 97% of the teeth
were retained for 8 years after nonsurgical endodontic
treatment.12 Another study showed that 52% of the inves-
tigated teeth with insufficient root fillings did not need
retreatment.8 A higher odds ratio for caries than apical
periodontitis has been reported among patients seeking
emergency care for sharp dental pain, indicating that sharp
dental pain is primarily of pulpal origin.13
South Korea has a National Health Insurance (NHI)
system that is compulsory for all medical care institu-
tions. Dental services are provided to all residents un-
der the NHI system and cover dental diagnostic proce-
Assistant Professor, Department of Dentistry, Kangdong Sacred
Heart Hospital, Hallym University Medical Center.
Received for publication Jan. 20, 2010; returned for revision Jun. 11,
2010; accepted for publication Jul. 2, 2010.
1079-2104/$ - see front matter
© 2010 Mosby, Inc. All rights reserved.
doi:10.1016/j.tripleo.2010.07.004
dures, emergency care, and endodontic treatments.
However, this system does not cover prosthodontic and
implant restorations. Therefore, for economic reasons,
most South Koreans prefer to retain their teeth despite
poor prognosis. However, data on the periradicular
status in the South Korean population are inadequate.
Japan has a compulsory insurance system that some-
what differs from that followed in South Korea. Tsu-
neishi et al.3 reported that the prevalence of root-filled
teeth in Japan appeared to be higher than that in Europe
and North America, but the ratio of teeth with an apical
radiolucency to root canal–filled teeth was within the
range reported for the other countries.
Evaluation of prognostic factors is important to esti-
mate the prognosis of teeth treated endodontically and
provide evidence for endodontic retreatment of asymp-
tomatic apical periodontitis. In addition to the quality of
root filling and crown restoration, a probability of unilat-
eral bite is a prognostic factor. Although the effect of
occlusion on the periodontium has been the subject of
much debate,14,15 3-dimensional finite element analysis
of stress in the periodontium has shown a significant
increase in stress concentration at the apex with loss of
alveolar bone height.16
The aims of the present study were to determine the
prevalence of radiographically detectable apical peri-
odontitis in root canal–treated teeth and evaluate the
prognostic factors for periapical radiolucency and the
symptoms that compel the patient to seek dental treat-
ment for pain relief.

795

796 Kim
MATERIALS AND METHODS
Radiographic examination
Between January 2007 and April 2007, 742 patients
who visited the Department of Dentistry, Gangdong
Sacred Heart Hospital, Seoul, for the first time under-
went digital panoramic radiography, and the radio-
graphs were saved in a picture archiving communica-
tion system (PACS). Images were processed and saved
by using the Planmeca Dimaxis imaging software
(Planmeca USA, Roselle, IL). The inclusion criteria of
this study were permanent teeth treated endodontically
at other dental clinics. Of the 742 patients, 314 were
excluded because they did not have root canal–treated
teeth or were ⬍17 years old. Finally, 428 digital pan-
oramic radiographs showing 923 root canal–treated
teeth, including pulpotomized teeth, were included. The
study protocol was approved by the Institutional Re-
view Board (10-048), which waived the need for pa-
tient consent.
The patient’s age, gender, and tooth number were
recorded. The teeth were considered to be root canal
treated if the pulp chamber and ⱖ1 root canals were
filled with a radiopaque material. If a radiopaque ma-
terial was present only in the pulp chamber, the tooth
was categorized as a pulpotomized tooth.
The length and density of the root fillings, presence
of crown restoration, probability of unilateral bite (con-
centration of occlusal force), and presence of missing
canals were investigated as the prognostic factors.
Teeth were considered to have missing canals if they
had unfilled roots; in that case, the status of the root
filling was evaluated according to the filled root with
the poorest filling quality. The length of the root filling
was considered to be adequate if the filling material
reached ⱕ2 mm from the radiographic apex in every
canal except the missing canals and inadequate if the
filling material was ⬎2 mm short of the apex or over-
filled. The density of the root filling was categorized as
adequate if the canal was enlarged along the root shape
and filled without any voids or indadequate if not. Thus,
the quality of the root filling could be adequate even if
the tooth had missing canals. The probability of unilat-
eral bite was defined as the presence of a root canal–
treated molar without adjacent molars and with no
occluding molars on the contralateral side or of a pre-
molar without molars in the same quadrant.
The periapical status was assessed by using the peri-
apical index (PAI).17 PAI scores 1 and 2 signified a
nondiseased apex, and PAI scores 3-5 signified the
presence of apical radiolucency. Multirooted teeth were
scored according to the root with the most severe peri-
apical status.
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December 2010
Retrospective treatment record review
In addition to the PACS, an order communication
system (OCS) has been established at Gangdong Sacred
Heart Hospital. The OCS is used for reservations, pre-
scription orders, orders for radiographic examination
and treatment procedures, and receipts. Furthermore, it
is used for electronic data interchange between the
health care institution and the Health Insurance Review
and Assessment (HIRA) System. All medical care costs
covered by the NHI System require a review and as-
sessment by the HIRA system. Thus, treatment records
of the OCS are standardized regardless of the medical
practitioner. The OCS was used to confirm the details
of the treatment procedure and emergency medical
treatments performed on patients having teeth with
apical periodontitis until April 2009. If the tooth re-
ceived treatment for pain relief, such as incision and
drainage, prescription, endodontic retreatment, or ex-
traction after diagnostic panoramic imaging, it was
classified as symptomatic. If the patient having a tooth
with apical periodontitis had paid for dental treatments
on other teeth, such as extraction of third molars, treat-
ment for temporomandibular joint problems, orthodon-
tic treatment, cavity fillings, or prosthodontic and im-
plant restoration after panoramic radiography, the tooth
was considered to be asymptomatic.
Statistical analysis
The data were analyzed by using each tooth as a unit
of analysis. Root canal–treated teeth were included in
the statistical analysis, but pulpotomized teeth were
excluded. The 5 prognostic factors were investigated as
independent variables. The periapical status of the root
canal–treated teeth and presence of acute symptoms
were analyzed as dependent variables dichotomously.
The chi-square test and logistic regression analysis
were used to examine the influence of the prognostic
factors associated with apical radiolucency. A second
logistic regression analysis was performed to evaluate
the joint association of the prognostic factors and pres-
ence of acute symptoms in the teeth with apical lesion.
If no treatment records were found after panoramic
radiography, the teeth were excluded from the second
analysis.
All statistical analyses were conducted by using
SPSS version 11.0 (SPSS, Chicago, IL). All tests were
2 tailed, and significance was set at the 5% probability
level.
RESULTS
Of the 923 teeth included in this study, 27 pulpoto-
mized teeth were excluded. Of the 896 root canal–
treated teeth that were statistically analyzed, 459
(51.2%) were from men and 437 (48.8%) from women.
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Volume 110, Number 6 Kim 797

Table I. Frequency of root canal–treated teeth (n ⫽ 896) Table II. Percentage frequencies of prognostic factors
Tooth Maxillary Mandibular and P values by the chi-square test
Central incisor 73 (8.1%) 6 (0.7%) Nondiseased Apical
Lateral incisor 56 (6.3%) 13 (1.5%) Total apex radiolucency
Canine 46 (5.1%) 15 (1.7%) (n ⫽ 896) (n ⫽ 692) (n ⫽ 204) P value
First premolar 46 (5.1%) 37 (4.1%) Root filling .000
Second 83 (9.3%) 81 (9.0%) length
premolar Adequate 650 (72.5%) 556 (85.5%) 94 (14.5%)
First molar 116 (12.9%) 158 (17.6%) Inadequate 246 (27.5%) 136 (55.3%) 110 (44.7%)
Second molar 73 (8.1%) 86 (9.6%) Root filling .000
Third molar 0 7 (0.8%) density
Adequate 534 (59.6%) 469 (87.8%) 65 (12.2%)
Inadequate 362 (40.4%) 223 (61.6%) 139 (38.4%)
Crown .174
restoration
The mandibular first molars were the most frequently Presence 742 (82.8%) 580 (78.2%) 162 (11.8%)
Absence 154 (17.2%) 112 (72.2%) 42 (17.8%)
treated teeth, followed by the maxillary first molars and
Unilateral bite .000
mandibular second molars. The mandibular incisors Presence 46 (5.1%) 22 (47.8%) 24 (52.2%
had the lowest frequency of endodontic treatment Absence 850 (94.9%) 670 (78.8%) 180 (21.2%)
(Table I). Missing canals .054
Among the 896 root canal-treated teeth, 204 (22.8%) Presence 52 (5.8%) 34 (65.4%) 18 (34.6%)
Absence 844 (94.2%) 658 (78.0%) 186 (22.0%)
had apical periodontitis. The length and the density of
the root filling were both adequate in 461 (51.5%)
of the 896 teeth; ⬎91% of these teeth had healthy
apices. The root filling length and density were both
Table III. Logistic regression analysis of the effect of
inadequate in 173 teeth (19.3%), and the percentage of
the prognostic factors on apical periodontitis among
normal apices among these teeth was 51.4%. Two
root canal–treated teeth
hundred sixty-two root canal–treated teeth had only
Variable 95.0% CI
adequate filling length or filling density.
Prognostic factor coding Significance OR for OR
Table II presents the statistical associations of the
Root filling length Inadequate ⫽ 1 .000 4.27 2.99-6.09
prognostic factors with the apical status of the root
Root filling density Inadequate ⫽ 1 .000 3.66 2.57-5.23
canal–treated teeth, as calculated by the chi-square test. Crown restoration Absence ⫽ 1 .060 1.53 0.98-2.37
In addition to the bivariate analysis, logistic regression Unilateral bite Presence ⫽ 1 .000 4.32 2.23-8.36
analysis revealed that root filling length, root filling Missing canals Presence ⫽ 1 .869 0.95 0.48-1.85
density, and probability of unilateral bite were signifi- OR, Odds ratio: CI, confidence interval.
cantly associated with apical periodontitis with odds
ratios of 4.3, 3.7, and 4.3, respectively (Table III). The
absence of a crown restoration and presence of missing
canals were not significantly associated with apical probability of unilateral bite, and absent crown resto-
periodontitis in either analysis. ration (Table IV).
Of the 204 root canal–treated teeth with apical peri-
odontitis, the treatment details of 37 teeth were not DISCUSSION
found after panoramic radiography. Therefore, 167 In the urban South Korean population included in
teeth with radiographically detectable apical period- this study, 77.2% of the root canal–treated teeth did not
ontitis were included in the second logistic analysis. have apical periodontitis, which is a higher percentage
Forty-nine (29.3%) of these teeth, treated by incision than reported by epidemiologic studies from other
and drainage, prescription, endodontic retreatment, or countries.1-8 This percentage could reflect the charac-
extraction, were considered to be symptomatic. How- teristics of Seoul, a metropolis with ⬎10 million inhab-
ever, 118 (70.7%) of the 167 teeth were not adminis- itants. Seoul has 3 university-based dental colleges and
tered pain relief treatment when subsequent dental pro- is saturated with dentists and dental specialists, includ-
cedures were performed on other teeth, indicating that ing endodontists. In South Korea, patients with dental
those 118 teeth were asymptomatic at that time. pain typically visit a dentist and receive dental treat-
The second logistic regression analysis indicated that ment without an appointment. Populations from areas
the impact order of the prognostic factors associated with a high density of endodontists reportedly have a
with acute symptoms were inadequate root filling lower prevalence of apical periodontitis of root canal–
length, missing canals, inadequate root filling density, filled teeth than those from areas with fewer endodon-

798 Kim
Table IV. Logistic regression analysis of the effect of
the prognostic factors on symptomatic apical periodon-
titis among root canal–treated teeth
Variable 95.0% CI
Predisposing factor coding Significance OR for OR
Root filling length Inadequate ⫽ 1 .093 1.83 0.90-3.71
Root filling density Inadequate ⫽ 1 .662 0.84 0.39-1.82
Crown restoration Absence ⫽ 1 .960 0.98 0.42-2.29
Unilateral bite Presence ⫽ 1 .720 1.21 0.42-3.49
Missing canals Presence ⫽ 1 .173 2.13 0.72-6.29
OR, Odds ratio; CI, confidence interval
tists.6 Moreover, the subjects in the present study were
adults visiting Gangdong Sacred Heart Hospital, which
is a medical university– based hospital. These patients
might be more concerned about dental care than those
who seek private dentists in Seoul. Therefore, it is
necessary to investigate the prevalence of apical peri-
odontitis among other South Koreans who visit private
dentists.
Supporting the results of the bivariate analysis, the
first logistic regression analysis showed that root filling
length, root filling density, and probability of unilateral
bite were significantly associated with apical periodon-
titis. However, the absence of a crown restoration and
presence of missing canals were not significantly asso-
ciated with this condition. It is commonly agreed that
the quality of endodontic treatment strongly influences
the status of periradicular tissues.1-11 The results of the
present study indicate that the quality of endodontic
treatment significantly predicts the periapical status:
The length and the density of the root filling were both
adequate in 51.5% of the analyzed root canal–treated
teeth, and only 8.5% of those had apical periodontitis.
The finding that probability of unilateral bite also
appeared to be significantly associated with apical pe-
riodontitis in this study should be considered with cau-
tion, because of the limitations of the method used,
namely, radiographic assessment only, and the small
fraction of teeth (5.1%) with probability of unilateral
bite. Research interest in the effect of occlusion on the
periodontium had decreased over the years, but with an
increase in the popularity of implant dentistry, attention
has once again returned to this field.18 Although exces-
sive occlusal overloading can result in injury to the
periodontium,19 and the relation between occlusal over-
loading and apical cemental detachment has been pre-
viously reported,20 further investigations using other
methods and larger sample sizes are necessary.
In the present study, inadequate length of the root
filling appears to be the most important factor in rela-
tion not only to the periapical status but also to acute
dental symptoms. The second logistic regression anal-
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December 2010
ysis, which evaluated the association between the prog-
nostic factors and the need for pain relief treatments,
revealed that the root filling length was the factor that
was most closely related to the acute symptoms in root
canal–treated teeth with apical periodontitis. Some clin-
ical aspects and symptoms, such as pain, periapical
lesions, tenderness to percussion, swelling, and sinus
tracts may be associated with primary endodontic in-
fections. Recent studies have shown that the endodontic
microbiota of asymptomatic teeth is different from that
of symptomatic teeth21,22 and that bacterial species
such as black-pigmented Prevotella and Peptostrepto-
coccus are associated with symptomatic teeth.23,24 In-
adequate length of the root filling may permit these
bacteria to play a role in the development of symptoms.
Considering that the outcome of endodontic treat-
ment is positively correlated with the hermetic seal
against bacterial ingress, the quality of the coronal
restoration affects the periapical health of root-filled
teeth.25-27 Siqueira et al.4 reported that the quality of
the coronal restoration does not significantly influence
the treatment outcome when the root canal filling is
adequate but significantly affects the outcome in the
case of inadequately treated teeth. The low P values
obtained in both the bivariate analysis (P ⫽ .174) and
the first logistic regression analysis (P ⫽ .06) of the
present study suggest the importance of a crown resto-
ration in relation to apical periodontitis. However, the
absence of a crown restoration did not appear to influ-
ence the presence of acute symptoms in the second
logistic regression analysis (P ⫽ .96).
In the present study, the retrospective review of the
symptoms was conducted via the OCS. The OCS is
more standardized and convenient than medical records
for ascertaining the details of a treatment procedure,
because medical records are differently recorded by
different practitioners. Nevertheless, some of the col-
lected information could be inaccurate, because the
degree of the symptoms cannot be confirmed through
the OCS. The subjects who were excluded in the sec-
ond logistic analysis because no treatment records were
available after panoramic radiography might have
experienced symptoms. However, ⬎70% of the root
canal–treated teeth with apical radiolucency did not
need dental treatment for acute pain relief when the
patient returned to the clinic for other dental treatments.
There were 5.5% symptomatic root canal–treated teeth
among the 896 root canal–treated teeth, indicating the
usefulness and importance of the initial endodontic
treatment.
Another limitation of this and other studies using
similar methodology is that the evaluations were lim-
ited to radiographs, and no information about the time
elapsed since endodontic treatment was available. It is
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Volume 110, Number 6
commonly known that periradicular lesions limited to
the cancellous bone usually pass undetected by conven-
tional radiographic techniques.28 Moreover, the micro-
biologic conditions of the root canal and apex cannot be
inferred on the basis of radiographic examinations
alone.
CONCLUSIONS
The prevalence of apical periodontitis among the
root canal–treated teeth in an urban South Korean pop-
ulation was found to be 22.8%. Evaluation of the prog-
nostic factors related to the diseased apex indicated that
inadequate quality of endodontic treatment was more
indicative of the periapical status than the absence of a
crown restoration. About 29.3% of the root canal–
treated teeth with apical periodontis had received pain
relief treatments, such as incision and drainage, pre-
scription, endodontic retreatment, or extraction. Inade-
quate length of the root filling appears to be the prog-
nostic factor that is most closely associated with acute
symptoms among root canal–treated teeth with apical
periodontitis.
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Reprint requests:
Seonah Kim, DDS, PhD
Department of Dentistry
Kangdong Sacred Heart Hospital
445 Gildong, Kangdonggu
Seoul 134-701
Republic of Korea
seonah23@naver.com